Cephalometric Improvement of Severe Microretrognathia With an Anterior Open Bite Using Curvilinear Mandibular Distraction Osteogenesis.

Curvilinear mandibular distraction osteogenesis (MDO) provides for multidimensional augmentation and rotation in mandibles with complex, abnormal morphology. This study aims to demonstrate cephalometric changes after curvilinear MDO.A prospectively maintained craniofacial database was queried for patients undergoing curvilinear MDO from 2009 to 2015. Demographic and operative data were collected. Cephalometric measurements were obtained from preoperative and postdistraction imaging, including sella-nasion-B point angle (SNB), mandibular plane angle (MPA), occlusal plane angle (OPA), and gonial angle (GA). Measurements were compared using a paired t test.Nine patients exhibiting microretrognathia and an anterior open-bite deformity had a mean age of 8.4 ±â€Š6.0 years and a mean follow-up of 23.2 ±â€Š25.3 months. Mean distance distracted was 32.6 ±â€Š7.2 mm, with augmentation in length and height, and rotatory closure of anterior open bites. Preoperative SNB versus postdistraction was 66.9 ±â€Š4.2 versus 78 ±â€Š9.1° (P = 0.0029). MPA, OPA, and GA all decreased (61.0 ±â€Š10.7 vs. 45.7 ±â€Š11.1°, P = 0.0066, 37.3 ±â€Š8.9 vs. 25.7 ±â€Š6.0°, P = 0.0025, 140.3 ±â€Š16.1 vs. 127.3 ±â€Š13.2°, P = 0.0019, MPA, OPA, and GA, respectively), trending toward normalization. Airway diameter increased by 7.1 ±â€Š2.8 mm. Anterior bite improved by 7.2 ±â€Š1.9 mm. Complications arose in 2 subjects including device malfunction and wound infection.Curvilinear MDO results in dramatic cephalometric improvement in patients with severe microretrognathia and anterior open-bite. The procedure is associated with a high rate of complications, and long-term stability of movement has yet to be documented.

Gelfoam Interposition Minimizes Risk of Fistula and Postoperative Bleeding in Modified-Furlow Palatoplasty.

Failure to accomplish a tension-free, watertight closure predisposes the palatoplasty patient to fistula formation. Perioperative bleeding also places the patient at risk for adverse airway events (AAE). This study introduces the incorporation of a hemostatic gelatin sponge (Gelfoam) into layered palatoplasty to minimize adverse postoperative bleeding and fistula formation. A retrospective chart review was performed to identify subjects who underwent Furlow palatoplasty with insertion of Gelfoam from 2010 to 2015. Exclusion criteria include age >3 years, prior palate surgery, <30-day follow-up, immunosuppressive state, and diagnosis of Treacher-Collins or Apert Syndrome. Demographic data include age, sex, cleft laterality, prior surgeries, Veau classification, Pierre Robin status, and tracheostomy dependence. Primary outcome was fistula formation. Secondary outcomes included perioperative metrics and AAE.One hundred subjects met criteria, 45% female. Average age was 14.6 months. Subjects with syndromes comprised 28%, with 16% diagnosed with Pierre Robin. Two subjects were tracheostomy-dependent. Prior cleft and mandibular procedures were performed in 55%. Isolated palatal defects were seen in 46%, unilateral lip and palate in 41%, and bilateral lip and palate in 13%. The majority of defects were Veau II and III (35% and 34%, respectively). Adverse airway events occurred in 2%, one of which resulted in reintubation. One subject (1%) was found to have a postoperative fistula.The incorporation of Gelfoam in the modified-Furlow palatoplasty results in a low rate of oronasal fistula (1%) and low perioperative risk of AAE. Further prospective comparison of this method to others will be the focus of future work.

Frontal Sinus Volume and Frontal Bar Position Are Associated in Unicoronal Craniosynostosis.

BACKGROUND: Frontal sinus pneumatization plays an important role in brow protrusion, and absence of frontal sinus development may be associated with brow retrusion. Using unicoronal craniosynostosis as a model, the authors studied the relationship among frontal sinus volume, supraorbital retrusion, and brow position. METHODS: The authors conducted a retrospective review of unicoronal craniosynostosis patients with head computed tomographic scans and photographs taken from ages 5 to 18 years. Frontal sinus volume and supraorbital retrusion were calculated using three-dimensional computed tomographic reconstructions. A "brow score" from 0 to 3 was assigned to each patient's photographs by a consensus of two craniofacial surgeons; sinus morphology and brow scores were compared. RESULTS: The study included 20 unicoronal craniosynostosis patients. The affected side demonstrated increased retrusion (7.1 ± 3.7 mm versus 3.0 ± 3.1 mm; p < 0.001) and decreased frontal sinus volume (0.8 ± 0.9 cc versus 2.6 ± 1.8 cc; p < 0.001). Qualitative brow retrusion scores differed between affected and unaffected sides (score of 0, 17 percent affected versus 78 percent unaffected; score of 1, 28 percent versus 22 percent; score of 2, 39 percent versus 0 percent; and score of 3, 17 percent versus 0 percent; p < 0.001). Brow scores trended with retrusion measurements (score of 0, 2.7 ± 2.9 mm retrusion; score of 1, 6.1 ± 3.5 mm; score of 2, 8.9 ± 3.2 mm; and score of 3, 9.7 ± 2.8 mm; p < 0.001). Subjects with brow scores of 0 or 1 had larger frontal sinus volumes than subjects with brow scores of 2 or 3 (p = 0.018). CONCLUSIONS: Qualitative brow retrusion correlates strongly with both quantitative supraorbital retrusion and frontal sinus volume. Although this retrospective study cannot prove causality, which is likely multifactorial, its strong correlation with frontal sinus pneumatization highlights the importance of the frontal sinus in brow position in unicoronal craniosynostosis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Assessing Risk Factors for Hospital-Based, Acute Care Within Thirty Days of Craniosynostosis Surgery Using the Healthcare Cost and Utilization Project.

While in-hospital outcomes and long-term results of craniosynostosis surgery have been described, no large studies have reported on postoperative readmission and emergency department (ED) visits. The authors conducted this study to describe the incidence, associated diagnoses, and risk factors for these encounters within 30 days of craniosynostosis surgery.Using 4 state-level databases, the authors conducted a retrospective cohort study of patients <3 years of age who underwent surgery for craniosynostosis. The primary outcome was any hospital based, acute care (HBAC; ED visit or hospital readmission) within 30 days of discharge. Multivariate logistic regression modeling was used to identify factors associated with this outcome.The final sample included 1120 patients. On average, patients were ages 4.6 months with the majority being male (67.3%) and having Medicaid (52%) or private (48.0%) insurance. Ninety-nine patients (8.8%) had at least 1 HBAC encounter within 30 days and 13 patients (1.2%) had 2 or more. The majority of encounters were managed in the ED without hospital admission (56.6%). In univariate analysis, age, race, insurance status, and initial length of stay significantly differed between the HBAC and non-HBAC groups. In multivariate analysis, only African-American race (adjusted odds ratio [AOR] = 5.98 [1.49-23.94]) and Hispanic ethnicity (AOR = 5.31 [1.88-14.97]) were associated with more frequent HBAC encounters.Nearly 10% of patients with craniosynostosis require HBAC postoperatively with ED visits accounting for the majority of these encounters. Race is independently associated with HBAC, the cause of which is unknown and will be the focus of future research.

Impact of Fronto-Orbital Advancement on Frontal Sinus Volume, Morphology, and Disease in Nonsyndromic Craniosynostosis.

BACKGROUND: Fronto-orbital advancement for nonsyndromic craniosynostosis has been thought to injure frontal sinus buds, lead to chronic sinus disease, and influence final forehead shape. This study investigates the effect of fronto-orbital advancement in infancy on subsequent frontal sinus volume, morphology, and disease. METHODS: The authors conducted a retrospective review of nonsyndromic craniosynostosis patients treated with fronto-orbital advancement in infancy with a head computed tomographic scan obtained at age 7 to 18 years. Facial trauma patients served as age-matched controls. Frontal sinus characteristics were determined using three-dimensional reconstructions. RESULTS: The study included 33 nonsyndromic craniosynostosis patients who underwent fronto-orbital advancement (n = 20 unicoronal; n = 13 metopic) and 20 control patients. The incidence of at least unilateral pneumatization was 94 percent for fronto-orbital advancement subjects and 95 percent for control subjects. Mean frontal sinus volumes for unicoronal synostosis, metopic synostosis, and control groups were 3427 ± 2294, 4576 ± 3510, and 4157 ± 3963 mm, respectively (p = 0.598). Asymmetry scores were as follows: unicoronal synostosis, 56 ± 35 percent; metopic synostosis, 36 ± 33 percent; and control, 23 ± 24 percent (p = 0.010). Unicoronal subjects displayed prominent asymmetry, with increased pneumatization on the unaffected side. Frontal sinus volume correlated with age at computed tomography but not with age at fronto-orbital advancement. Interrater reliability was 0.997. One fronto-orbital advancement subject and zero control subjects demonstrated computed tomographic evidence of frontal sinus disease. CONCLUSIONS: Frontal sinus volume, morphology, and disease do not differ significantly between control subjects and nonsyndromic craniosynostosis subjects following fronto-orbital advancement, but subtle differences such as increased asymmetry in the unicoronal synostosis group can be appreciated. Further research with syndromic craniosynostosis patients undergoing multiple procedures may help elucidate the association between surgical disruption and frontal sinus development. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A Perioperative Risk Comparison of Posterior Vault Distraction Osteogenesis in an Older Pediatric Population.

There is a growing literature on the advantages of posterior cranial vault distraction osteogenesis (PVDO) in infants, particularly those with syndromic and multisuture craniosynostosis. This study aims to compare perioperative outcomes of PVDO in older patients to those of infants. A prospective craniofacial database was queried for patients aged 5 and older undergoing PVDO; controls were diagnosis-matched infants. Demographic, perioperative, and distraction data was compared using a 2-sample t test and Fisher exact test.Twenty patients met inclusion criteria, and all had syndromic craniosynostosis. Mean age was 9.2 years for the older group, and 0.7 years for the younger. Older children had less weight-based blood loss (mean 58.6 ±â€Š38.8 versus 14.6 ±â€Š7.0 cc/kg, control versus older, P = 0.0092) and weight-based transfusion (mean 70.1 ±â€Š37.2 versus 21.2 ±â€Š9.9 cc/kg, control versus older, P = 0.0023); other perioperative variables were similar including duration of surgery, length of stay, distance distracted, time in consolidation, and length of follow-up. All patients in both groups successfully completed PVDO, and all older patients had resolution of papilledema and/or headaches. One from each group developed a wound infection that was treated with oral antibiotics.Posterior cranial vault distraction osteogenesis is a safe and efficacious for cranial vault expansion in syndromic craniosynostosis, with similar perioperative outcomes in older children as compared to infants. Posterior cranial vault distraction osteogenesis may be a reasonable alternative in older syndromic patients with acceptable frontal morphology and concerns for increased intracranial pressure.

An Algorithmic Approach to the Surgical Treatment of Chronic Ischemia of the Hand: A Systematic Review of the Literature.

BACKGROUND: Chronic ischemia of the hand can lead to intractable pain, cold intolerance, and digital necrosis, affecting up to 4.8 percent of patients undergoing vascular surgery. Treatment of patients suffering from chronic hand ischemia, in particular, the subset of patients with a nonreconstructible distal arterial tree, can be a significant challenge for hand surgeons. The purpose of this systematic review is to analyze the outcomes of surgical therapies in an effort to define the efficacy of each intervention. The authors also revisit the treatment algorithm for nontraumatic chronic hand ischemia. METHODS: A systematic search of the literature published since 1990 in the PubMed/MEDLINE database was performed using keywords. Articles were eligible if they described clinical studies of human patients with nontraumatic chronic hand ischemia who underwent sympathectomy, arterial bypass, or venous arterialization. Pain improvement, wound healing, and new ulcerations were primary outcome measures. Primary patency rates and limb salvage data were also collected as primary outcome measures in the bypass and arterialization study arms. RESULTS: For sympathectomy, arterial bypass, and venous arterialization, pain relief was achieved in 89, 100, and 100 percent of patients, respectively; whereas wound healing occurred in 74, 93, and 75 percent, respectively. Postoperative ulcerations were 0, 3, and 8 percent, respectively. No secondary amputations were reported in these 33 studies. Complication rates were moderately high (2.1 to 30.8 percent). CONCLUSION: This systematic review confirms that sympathectomy, arterial bypass, and venous arterialization are efficacious treatments, and allows for an algorithmic approach to the surgical treatment of chronic hand ischemia. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.