Quantitative Evaluation of Palatal Lengthening After Cleft Palate Repair When a Buccal Flap Is Routinely Combined With Furlow's Z-Plasty.

INTRODUCTION: The use of a buccinator myomucosal flap in combination with Furlow's Z-plasty during primary and secondary palatal repairs has been proposed by many authors to overcome some of the limitations of Furlow's technique. However, there have been no studies that quantitatively measured the effective palatal lengthening when the buccal flap is added. PATIENTS AND METHODS: The buccal flap is routinely used during primary palate repair in order to fill the gap between the hard palate and reoriented palatal muscle sling. The soft palatal length was measured in the midline from the posterior edge of the hard palate to the base of the uvula. All patients were measured before starting the surgery and just after palatal closure in the standard position for cleft palate repair. RESULTS: Seventy-three patients with cleft palate who were candidates for primary repair were included. The mean age at the time of operation was 11.4 ± 3.5 months. The mean preoperative palatal length was 21.36 ± 3.529 mm, whereas the mean postoperative palatal length was 29.64 ± 4.171) mm. The mean palatal length change was 8.29 ± 2.514 mm (P < 0.000). CONCLUSIONS: The Combined use of a buccinator myomucosal flap with modified Furlow's Z-plasty in primary cleft palate repair has proven effective for palatal lengthening and achieved tensionless closure without the need for relaxing incision. It also provided a pliable soft tissue attachment of the palatal muscles to the hard palate allowing for better muscle function and mobility.

Versatility of Hard Occlusal Splints in Optimizing Outcomes in Patients with Old Pan-facial Fractures.

Pan-facial fracture repair is considered one of the most challenging complex reconstructive procedures to perform. It is always better to treat facial fractures as soon as possible. A delay of several days or weeks makes an ideal anatomic reduction difficult, if not impossible. METHODS: Patients presenting late with noncompound pan-facial fractures and interrupting maxillary and mandibular arches who were candidates for ORIF were included. Patients had been divided randomly into two groups: group A was managed by the ordinary sequence of repair, and group B was managed with the aid of occlusal dental splint. RESULTS: In total, 20 patients presented late (3-9 weeks post insult) due to serious injuries that required previous intervention. The time until obtaining optimal occlusion ranged between 80 and 120 minutes in the study group, whereas in the control group, the time ranged between 120 and 180 minutes (P < 0.0001). Postoperative malocclusion was noticed to be less frequent in the splint group than in the control group: only one patient with residual malocclusion in the study group versus two patients in the control group. CONCLUSIONS: Occlusal splints could be a good modality for restoring the pre-morbid occlusion in patients with delayed pan-facial fractures. It is a simple, reliable technique that could be easily integrated into our daily practice, and could help decrease the intraoperative time needed for restoration of optimal occlusion and decrease the postoperative malocclusions.

Lower Pole Breast Reconstruction Using Muscle-sparing Latissimus Dorsi Flap in Postburn Breast Deformity.

BACKGROUND: Full-thickness burns of the anterior chest wall during childhood are a devastating problem that results in significant distortion of the developing breast. This deformed burnt breast represents a serious aesthetic problem, and can lead to functional impairment as well as severe emotional trauma for patients. METHODS: Patients with postburn scarring affecting the lower pole of the breast were included. Only patients with small to medium-sized breasts were targeted. The lower breast pole was reconstructed using muscle-sparing latissimus dorsi flap. All patients had been subjectively assessed, including overall patient satisfaction regarding breast aesthetics, donor site morbidity, and functional deficits of latissimus dorsi muscle, 3 months postoperatively. RESULTS: Six patients (seven breasts) were included in this study. Muscle-sparing latissimus dorsi flap was used to reconstruct lower breast pole in all patients. A horizontally-oriented skin paddle was used in five patients, whereas a vertically oriented skin paddle was used in one patient. Average patient satisfaction was 9.1 (SD 0.6) for the reconstructed lower breast pole. For the donor site, average overall satisfaction was 9.1 (SD 0.8). Latissimus dorsi muscle function was objectively confirmed in 90% of cases after 3 months postoperatively. Patients had an average score of 3.9 (SD 0.4) for the activity score as well. CONCLUSIONS: The muscle-sparing latissimus dorsi flap is a good reconstructive tool for lower breast pole in postburn breast reconstruction. It has a reliable versatile skin paddle that can resurface the whole lower breast pole, while avoiding many of the latissimus flap morbidities.

Topical Corticosteroids Decrease IL-25 Expression by Immunohistochemistry.

BACKGROUND: Interleukin-25 (IL-25) is an important contributing factor in the pathogenesis of allergic rhinitis. It leads to increasing peripheral and infiltrating eosinophilia as well as serum IgE, IgG, and Th2 cytokines (IL-4, IL-5, IL-13), which are responsible for the allergic symptoms. Intranasal steroids (INS) are effective in treating allergic rhinitis, but their effect on IL-25 release has not been studied. We aimed to study the link between IL-25 and the pathophysiology of allergic rhinitis as well as the effect of INS on its release. METHODOLOGY: This was a cohort, prospective, nonrandomized study that included 60 patients, 35 allergic rhinitis patients and 25 controls. We studied the effect of INS on IL-25 release. RESULTS: Of allergic rhinitis patients 68.6% had strong cytoplasmic stain of IL-25 in the epithelial layer, while 25.7% had intermediate stain. INS caused significantly reduced IL-25 stain as only 14.3% of patients had intermediate stain and 85.7% had weak stain. Moreover, a correlation was found between nasal smear eosinophilia and the degree of IL-25 staining in the epithelial layer. CONCLUSION: Intranasal corticosteroids appear to be effective in the downregulation of IL-25, which may explain some of the utility of intranasal corticosteroid treatment in improving allergic rhinitis symptoms.

Demographic characteristics of craniosynostosis patients in Asia.

PURPOSE: Craniosynostosis (CRS) is a congenital condition resulting premature fusion of one or more cranial sutures. CRS is classified according to the involved sutures into sagittal, metopic, unicoronal, unilambdoid, bicoronal, and multiple-suture CRS, with sagittal suture fusion known to be the most common type. Although multiple studies have presented demographic characteristics of CRS patients, to date, there is no study representing an Asian population. We sought to compare the demographic characteristics of Asian patients to those of Western patients, considering previous reports. MATERIALS AND METHODS: A total of 266 CRS patients treated in a single institution from 1996 to 2016 were retrospectively reviewed. Data from the patients was collected regardless of whether they underwent operation. Patients' age at the time of presentation, sex, and maternal and paternal age at birth were reviewed. Patients were routinely investigated for abnormal genes (FGFR2 and FGFR3). The Bayley Scales of Infant Development, Second Edition (BSID-II), was used to assess the patients' cognitive and psychomotor development. One-way analysis of variance or the Kruskal-Wallis test was used to compare continuous variables. A p value of <0.05 was considered statistically significant. RESULTS: Our study included 157 males (59.02%) and 109 females (40.98%), with an age ranging from 0.1 to 10.5 years. The mean age at the time of diagnosis was 2.01 ± 2.57 years, and the mean age at operation was 2.16 ± 2.61 years. Of the patients, 27 (10.15%) were bicoronal, 28 patients (10.53%) were metopic, 48 patients (18.04%) were unicoronal, 50 patients (18.80%) were unilamboid, and 67 patients (25.19%) were sagittal. Patients with multiple-suture CRS totaled 46 (17.29%). Investigation of abnormal genes revealed six patients (2.20%), including two patients with abnormal FGFR2 and four patients with abnormal FGFR3. Maternal and paternal ages at the patients' birth were 32.18 ± 4.56 years and 34.71 ± 4.72 years, respectively. The mean BSID-II scores were 84.96 ± 22.77 for the Mental Development Index and 84.19 ± 25.62 for the Psychomotor Development Index. To examine the trend of diagnosis of CRS type, we also evaluated the number of new patients diagnosed with nonsyndromic CRS per year at our institution. New diagnoses of CRS generally increased from the year 2009, although variations continued. CONCLUSION: The mean age of our patients is relatively high compared to previous, Western studies. Through this research, we recognized that cultural discrepancies regarding the expectations of Asian parents may lead to prolonged diagnosis of CRS patients, and yet even relatively older CRS infants can successfully be treated with surgical intervention. The prevalence of CRS types and BSID-II development scores varied compared to those in previous Western studies. Further investigations at the genetic level are required to compare the different populations. To diagnose CRS in an effective and timely manner, a physician must be aware of the general characteristics and understand the variations between Western and Eastern populations.

Cervical Spine Dysmorphism in Congenital Muscular Torticollis.

BACKGROUND: Congenital muscular torticollis is a common childhood musculoskeletal anomaly that might result in permanent craniofacial deformity, facial asymmetry, and changes in the cervical vertebrae, if not treated during early childhood. Although there have been many studies on cervical vertebral changes, their onset in children has not been previously studied. METHODS: Fifteen patients (aged <8 years) with a confirmed diagnosed of torticollis were included. Three-dimensional computed tomography scans were obtained, and segmentation of the cervical vertebrae was done. Division of the atlas and axis across the midsagittal plane was done to compare the anatomical changes. The volumes of each halves of the atlas and axis were measured. RESULTS: An apparent change was observed in the axis of the vertebral column when compared with that of the skull. There were progressive anatomical changes affecting the upper cervical vertebrae, which started to develop around the age of 8 months and became more evident in older children. The axis vertebra was the first to be affected. Rotational and bending deformities were the most likely changes to occur. Pearson correlation analysis showed a statistically significant trend in the volume and height changes for both halves of the atlas and axis (P < 0.001 and P < 0.001). CONCLUSIONS: Children with untreated congenital muscular torticollis show progressive anatomical changes of the cervical vertebrae which started at the age of 8 months. The severity of the deformity increased with the advance of age as well as with the severity of sternocleidomastoid tightness, which might result in permanent deformities.

Analysis of the correlation between deformational plagiocephaly and neurodevelopmental delay.

BACKGROUND: Deformational plagiocephaly (DP) refers to cranial asymmetry resulting from uneven external forces. A strong association exists between DP and developmental delay. We investigated the effect of DP severity on developmental delay. METHODS: Between 2010 and 2016, data from 155 patients with DP were reviewed retrospectively. Two indices were used to evaluate the deformation quantitatively: cranial index (CI) and cranial vault asymmetry index (CVAI). The Bayley Scales of Infant Development-II was used to evaluate the neurodevelopment of patients. RESULTS: According to the CI of the study population, 2 patients showed scaphocephaly, 12 showed mesocephaly, and 141 showed brachycephaly. For CVAI, 10 patients showed values of <3.5, 10 patients showed mild deformity (3.5-6.25), 27 patients showed moderate deformity (6.25-8.75), and 108 patients showed severe deformity. The means of the mental development index (MDI) and psychomotor development index (PDI) were 91.69 ± 16.8 and 92.28 ± 17.59, respectively; after the exclusion of patients with confounding factors, the values were 96.26 and 92.9, respectively. The Spearman correlation coefficients between MDI and CI and CVAI were -0.019662 and 0.118916, respectively, whereas for PDI, the values were -0.195428 and -0.012386, respectively. CONCLUSIONS: There was a statistically significant neurodevelopmental delay in patients with DP. However, accelerated neurodevelopment was also encountered in many patients. MDI was found to be more affected by multiple confounding factors than PDI, whereas PDI was only affected by congenital anomalies. There was no definitive relationship between the severity of DP and the degree of developmental delay in our study group.

Craniofacial Fibrous Dysplasia: Retrospective Study on the Relationship Between the Tumor Volume Changes and the Circulating Serum Calcitonin and Serum Alkaline Phosphatase.

BACKGROUND: The purpose of this study was to determine the usefulness of serum alkaline phosphatase (ALP) and calcitonin in the follow-up of tumor volume changes in patients with craniofacial fibrous dysplasia. METHODS: Twenty patients with isolated craniofacial fibrous dysplasia were included, who met our criteria for long-term follow-up. Three-dimensional computed tomography scans were obtained, and tumor segmentation was performed. The tumor volume was measured preoperatively, immediate postoperative and during long-term follow-up. Serum ALP and calcitonin levels were obtained at the same times to assess their correlation with tumor volumes. RESULTS: Preoperative calcitonin levels were correlated with the presence of tumor (P = 0.0442), whereas ALP levels were not (P = 0.1125). There were no significant associations between tumor volume and ALP or calcitonin levels in the preoperative or postoperative periods. During long-term follow-up, serum ALP was significantly associated with tumor recurrence (P = 0.0096), but serum calcitonin was not (P = 0.4760). However, serum levels of ALP did not reflect the tumor volume changes. CONCLUSIONS: Serum ALP may be useful as a laboratory test for follow-up of patients with isolated craniofacial fibrous dysplasia. However, it cannot represent the tumor's volume changes and 3-dimensional computed tomography scans with tumor volume measurement are mandatory for detecting significant volume changes during follow-up. Investigation of the serum calcitonin in the preoperative period is also recommended on a large scale because it was related to the presence of the tumor.

Cervical Spine Deformity in Long-Standing, Untreated Congenital Muscular Torticollis.

BACKGROUND: Congenital muscular torticollis (CMT) is a benign condition. With early diagnosis and appropriate management, it can be cured completely, leaving no residual deformity. However, long-standing, untreated CMT can lead to permanent craniofacial deformities and asymmetry. METHODS: Four adult patients presented to the author with long-standing, untreated CMT. Initial clinical assessment demonstrated tightness of the sternocleidomastoid muscle on the affected side. Investigation of cervical spine using 3-dimensional computed tomography scans with cervical segmentation allowed a 3-dimensional module to be separately created for each vertebra to detect any anatomical changes. RESULTS: A change in the axis of the vertebral column was noted when compared to that of the skull. Also, there were apparent anatomical changes affecting the vertebrae, which were most noticeable at the level of the atlas and axis vertebrae. These changes decreased gradually till reaching the seventh cervical vertebra, which appeared to be normal in all patients. The changes in the atlas vertebra were mostly due to its intimate relation with the skull base. The changes of the axis were the most significant, affecting mainly the superior articular facet, the lamina, and the body. CONCLUSIONS: There were seemingly permanent changes along the cervical spine region in the adult patients with long-standing, untreated CMT in the form of bending and rotation deformities that might result in residual torticollis postoperatively.