Current Trends in Unilateral Cleft Lip Care: A 10-Year Update on Practice Patterns.

BACKGROUND: The care of unilateral cleft lip (UCL) patients is extremely variable. Historical benchmarks for perioperative and intraoperative choices by cleft surgeons were produced by Sitzman et al (Plast Reconstr Surg. 2008;121:261e-270e) in 2005. However, emerging data and cleft lip repair methods around this period were not captured by this study. The aim of this study was to update the current practice patterns of cleft lip surgeons. METHODS: An electronic survey was distributed to surgeons in the American Cleft Palate Association. Demographic data about the surgeon were collected as well as their choices regarding perioperative and intraoperative cleft lip care. RESULTS: Eighty-six surgeons responded to the survey. Nearly 40% of surgeons have changed their technique for UCL repair with Fisher anatomical subunit repair gaining significant popularity. Nasoalveolar molding is also being used more frequently (41% vs 22%). At the time of the cleft lip repair, closure of the nasal floor is occurring in 83.1% of patients and primary cleft rhinoplasty is being performed routinely 57% of the time. CONCLUSIONS: Over the last 10 years, there has been an increase in the use of modified rotation advancement repairs and Fisher anatomic subunit approximation technique for treatment of UCL. There continues to be a lack of evidence regarding superiority of specific repair techniques or the benefits of adjunct procedures, which results in varying practice patterns. Educating all cleft surgeons on practices that are well supported is important to improve care to cleft patients.

Sparing a Craniotomy: The Role of Intraoperative Methylene Blue in Management of Midline Dermoid Cysts.

BACKGROUND: Midline nasal dermoid cysts are rare congenital anomalies that extend intracranially in approximately 10 percent of cases. Cysts with intracranial extension require a craniotomy to avoid long-term complications, including meningitis, abscesses, and cavernous sinus thrombosis. Current guidelines recommend preoperative imaging with either magnetic resonance imaging or computed tomography to determine appropriate management. METHODS: Patients who underwent excision of a midline nasal dermoid cyst between January 1995 and September 2016 were identified using Current Procedural Terminology codes. In cases with equivocal imaging findings or uncertain stalk extent during surgical dissection, methylene blue was used intraoperatively. Demographics, preoperative imaging findings, intraoperative dye findings, surgical approach, and complications were collected. RESULTS: A total of 66 midline dermoid cyst excisions were identified; 17 (25.8 percent) had intracranial extension requiring craniotomy. Preoperative imaging showed a subcutaneous cyst in 41 (62.1 percent), intraosseous tracking in three (4.5 percent), and intracranial extension in 15 (22.7 percent). Twelve patients (18.2 percent) had preoperative imaging that was inconsistent with intraoperative findings. Methylene blue was used in 17 cases and indigo carmine was used in one case. Intraoperative dye findings changed management in five cases, and in three cases a craniotomy was avoided without evidence of cyst recurrence. CONCLUSIONS: This report is the largest published series of midline dermoid cysts with intracranial extension. In almost 20 percent of cases, preoperative imaging was not consistent with intraoperative findings. Given disparate radiographic and intraoperative findings, methylene blue is a valuable tool that can facilitate appropriate, morbidity-sparing management of midline dermoid cysts. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Evolution of Fibroblastic Connective Tissue Nevus in an Infant.

Fibroblastic connective tissue nevus (FCTN) is a rare and recently described neoplasm of fibroblastic/myofibroblastic lineage. We report a case of a 1-month-old healthy male infant who presented with a dermal plaque on the upper chest since birth. A punch biopsy demonstrated a dermal spindle-cell neoplasm with variable smooth muscle actin positivity and negative staining for CD34, consistent with myofibroma. Over the course of the next year, the remaining lesional tissue exhibited clinical softening and a surgical excisional specimen revealed histologic findings distinct from the original biopsy. These included a poorly circumscribed proliferation of bland spindle cells arranged in short fascicles centered in the dermis and extending into the subcutis with positivity for CD34, and absence of staining with smooth muscle actin features diagnostic of FCTN. Our case allowed the opportunity to see this unusual neoplasm at different stages, and we hypothesize that FCTN may undergo an early cellular phase and that time is required for these lesions to "mature" and demonstrate the more characteristic features of FCTN.

Orbital Expansion for Congenital Anophthalmia May Be Achievable in Infancy But Not in Childhood.

BACKGROUND: Congenital anophthalmia is a rare anomaly that results in micro-orbitism and craniofacial microsomia. Treatment with static conformers is labor-intensive and provides minimal stimulation for orbital growth that requires eventual reconstruction with orbital osteotomies after skeletal maturity. METHODS: A protocol for the treatment of congenital anophthalmia is presented. Patients underwent a preoperative low-dose radiation computed tomography (CT) scan of the facial bones to assess orbital volume. An intraorbital expander was placed and was filled on a monthly basis. Quantitative changes in the affected and unaffected orbits were assessed by a repeat CT scan obtained 1 year postoperatively. RESULTS: Two patients with left unilateral congenital anophthalmia were prospectively followed. In a 4-month-old, the affected orbital width and height increased by 171.6% and 116.7% respectively compared with the unaffected orbit. In a 4-year-old, the affected orbital width increased by 36.1% but the height decreased by 35.3% compared with the unaffected orbit. At 18 months follow-up, no complications, ruptures, infections, or extrusions have been observed. CONCLUSIONS: Our results support that accelerated expansion can be achieved in a 4-month-old orbit reversing the effects of anophthalmia. However, in a 4-year-old, minimal growth was observed. The lack of accelerated growth in this study may be explained by synostosis of the orbital sutures. As such, expansion should be initiated at the earliest age possible. Further longitudinal study is ongoing to determine if sustained catch-up growth will obviate or reduce the complexity of a secondary correction.

A Multidisciplinary Evaluation of Prescribing Practices for Prophylactic Antibiotics in Operative and Nonoperative Facial Fractures.

BACKGROUND: Evidence supports short-term perioperative prophylaxis for facial fractures. It is unknown, however, whether there is any professional consensus on how to manage these injuries. No multidisciplinary evaluation of the prophylactic antibiotic prescribing patterns for neither operative nor nonoperative facial fractures has been performed. AIM: To evaluate the prophylactic antibiotic prescribing patterns of multiple specialties in operative and nonoperative facial fractures. METHODS: A 14 question anonymous online-based survey was distributed to members of the American Society of Maxillofacial Surgeons (ASMS) and the American Association of Facial Plastic Surgeons to evaluate current practices. RESULTS AND CONCLUSIONS: 205 respondents, including 89 plastic surgeons, 98 otolaryngologists, 12 oral and maxillofacial surgeons, and 7 with double board certification practicing throughout the United States with ranging experience from 11 to 30 years. As expected, preoperative, perioperative, or postoperative prophylactic antibiotics are either "always" or "sometimes" prescribed, 100% of the time with more varied practice upon further inspection. A total of 85.1% either "always" or "sometimes" use antibiotics while awaiting surgery. Dentate segment fractures are the most frequent type of facial fractures to receive prophylactic antibiotics for both operative (90.5%) and nonoperative (84.1%) fractures. Duration of antibiotic use is more varied with the majority providing 3 to 7 days despite current evidence. First generation cephalosporins alone are prescribed by 49% of respondents, which may not adequately cover oral flora. There is no multidisciplinary consensus for prophylactic antibiotics for specific operative fracture types or nonoperative facial fractures, an area with little published evidence.

Challenges of Organizing Mission Surgery in Resource Limited Environments.

Interest in global burden of disease that can be surgically treated is on the rise, and plastic surgeons, with a wide scope of practice, have the tools that make them integral in providing much of the needed surgical support in the world. Since the 1950 s, plastic surgeons have been closely involved in volunteer surgery, and it is through the success and growth of organizations such as Interplast and Operation Smile that we are able to take part in the current paradigm shift to local empowerment and self-sufficiency instead of service delivery alone. This kind of growth started with medical mission work that fostered international partnerships and that remain an important aspect of addressing the unmet surgical burden of disease. Building a mission comprised of an international team of volunteers that travels to a resource-limited environment and provides top-quality surgical care is not without challenges. The aim of this article is to discuss some of these challenges and how they might be overcome.