Long-Term Incisal Relationships After Palatoplasty in Patients With Isolated Cleft Palate.

PURPOSE: Various palatoplasty techniques have limited incisions in the hard palate due to concerns that these incisions may limit maxillary growth. There is little convincing long-term evidence to support this. Our purpose is to determine incisal relationships, an indicator for future orthognathic procedure, in patients after repair of an isolated cleft of the secondary palate. METHODS: Our craniofacial database was used to identify patients aged 10 years or greater with an isolated cleft of the secondary palate who underwent palatoplasty between 1985 and 2002. Data collected included age at palatoplasty and follow-up, cleft type, associated syndrome, Robin sequence, surgeon, repair technique, number of operations, and occlusion. Incisal relationship was determined through clinical observation by a pediatric dentist and orthodontist. RESULTS: Seventy eligible patients operated on by 9 surgeons were identified. Class III incisal relationship was seen in 5 patients (7.1%). Palatoplasty techniques over the hard palate (63 of 70 patients) included 2-flap palatoplasty, VY-pushback, and Von Langenbeck repair. There was an association between class III incisal relationship and syndromic diagnosis (P <0.001). Other study variables were not associated with class III incisal relationships. CONCLUSION: In patients with an isolated cleft of the secondary palate, there was no association between class III incisal relationship and surgeon, age at repair, cleft type, palatoplasty technique, or number of operations. Increased likelihood of class III incisal relationship was associated primarily with syndromic diagnosis.

Anatomical study of the effects of five surgical maneuvers on palate movement.

The anatomy of the palate has been extensively described, with a predominant focus on palatal musculature. There are no biomechanical studies investigating the effects of surgical maneuvers on the palate to aid cleft closure. This study aims to describe the soft tissue attachments at different zones and quantify the movement following their release. Fourteen adult cadaver heads were dissected. The palates were split in the midline and five maneuvers described: Step 1, over the hard palate; Step 2, around the greater palatine pedicle; Step 3, over the palatine aponeurosis; Step 4, over the hamulus; and Step 5, resulting in a hamulus fracture. The movements across the midline at the posterior nasal spine following each maneuver were measured. The age range of the 14 heads was between 60 -75 years. Completion of steps 1 and 2 over the hard palate obtained a mean release of 2.6 and 2.0 mm, respectively. The largest movements occurred at Step 3 (5.7 mm) and Step 4 (3.5 mm), after releasing attachments at the posterior hard palate and palatine aponeurosis. Steps 3 and 4 dissections exhibited cumulative release, with a maximum movement with Step 3 (p < 0.05). Isolated fracture of the hamulus (Step 5) yielded a mean movement of 1.4 mm. Individual steps of dissection are described with respect to releasing soft tissue attachments. Medial movement of the oral mucosa is quantified with each step of dissection. The greatest release occurred with dissection overlying the palatine aponeurosis posterior to the hard/soft palate junction. Additional dissection along the hamulus (without fracture) added significantly to this release.

Anatomical study of the medial crura and the effect on nasal tip projection in open rhinoplasty.

BACKGROUND: Common variations in morphology of the medial crura have been described. The authors' observation is that changes in nasal tip projection depend on the shape and strength of the medial crura. The authors investigated how differences in medial crura shape affect tip projection after surgical intervention. METHODS: Seventeen cadaver heads were dissected with an open rhinoplasty approach. Nasal tip projection and columellar length and width were measured. Medial crura shape was noted and classified. Anthropometric measurements were made preoperatively and after each of the following procedures: (1) elevation of skin envelope and closure of the columellar incision, (2) interdomal and medial crural sutures, and (3) placement and fixation of a floating columellar strut. RESULTS: Three anatomical variations of the medial crura were noted: type 1, asymmetric parallel (n = 7); type 2, flared symmetric (n = 5); and type 3, straight symmetric (n = 5). A significant difference in tip projection after elevation of the skin envelope and closure was discovered between types 1 and 3 (p = 0.004). Type 2 medial crura were found to have a mean reduction of 1.0 mm. Suture techniques resulted in return to baseline tip projection for types 1 and 2. Columellar strut placement increased tip projection in all types. CONCLUSIONS: Changes in tip projection after an open rhinoplasty depend on the shape of the medial crura. Straight symmetric (type 3) cartilages can maintain tip projection without any additional intervention during an open rhinoplasty. Asymmetric parallel (type 1) or flared symmetric (type 2) variants will require interdomal and medial crural sutures to maintain baseline tip projection.

Beta blockers for peripheral arterial disease.

BACKGROUND: Beta (ß) blockers are indicated for use in coronary artery disease (CAD). However, optimal therapy for people with CAD accompanied by intermittent claudication has been controversial because of the presumed peripheral haemodynamic consequences of beta blockers, leading to worsening symptoms of intermittent claudication. This is an update of a review first published in 2008. OBJECTIVES: To quantify the potential harmful effects of beta blockers on maximum walking distance, claudication distance, calf blood flow, calf vascular resistance and skin temperature when used in patients with peripheral arterial disease (PAD). SEARCH METHODS: For this update, the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched March 2013) and the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, 2013, Issue 2). SELECTION CRITERIA: Randomised controlled trials (RCTs) evaluating the role of both selective (ß1) and non-selective (ß1 and ß2) beta blockers compared with placebo. We excluded trials that compared different types of beta blockers. DATA COLLECTION AND ANALYSIS: Primary outcome measures were claudication distance in metres, time to claudication in minutes and maximum walking distance in metres and minutes (as assessed by treadmill).Secondary outcome measures included calf blood flow (mL/100 mL/min), calf vascular resistance and skin temperature (ºC). MAIN RESULTS: We included six RCTs that fulfilled the above criteria, with a total of 119 participants. The beta blockers studied were atenolol, propranolol, pindolol and metoprolol. All trials were of poor quality with the drugs administered over a short time (10 days to two months). None of the primary outcomes were reported by more than one study. Similarly, secondary outcome measures, with the exception of vascular resistance (as reported by three studies), were reported, each by only one study. Pooling of such results was deemed inappropriate. None of the trials showed a statistically significant worsening effect of beta blockers on time to claudication, claudication distance and maximal walking distance as measured on a treadmill, nor on calf blood flow, calf vascular resistance and skin temperature, when compared with placebo. No reports described adverse events associated with the beta blockers studied. AUTHORS' CONCLUSIONS: Currently, no evidence suggests that beta blockers adversely affect walking distance, calf blood flow, calf vascular resistance and skin temperature in people with intermittent claudication. However, because of the lack of large published trials, beta blockers should be used with caution, if clinically indicated.

Comparative study of cranial anthropometric measurement by traditional calipers to computed tomography and three-dimensional photogrammetry.

Craniofacial anthropometry by direct caliper measurements is a common method of quantifying the morphology of the cranial vault. New digital imaging modalities including computed tomography and three-dimensional photogrammetry are similarly being used to obtain craniofacial surface measurements. This study sought to compare the accuracy of anthropometric measurements obtained by calipers versus 2 methods of digital imaging.Standard anterior-posterior, biparietal, and cranial index measurements were directly obtained on 19 participants with an age range of 1 to 20 months. Computed tomographic scans and three-dimensional photographs were both obtained on each child within 2 weeks of the clinical examination. Two analysts measured the anterior-posterior and biparietal distances on the digital images. Measures of reliability and bias between the modalities were calculated and compared.Caliper measurements were found to underestimate the anterior-posterior and biparietal distances as compared with those of the computed tomography and the three-dimensional photogrammetry (P < 0.001). Cranial index measurements between the computed tomography and the calipers differed by up to 6%. The difference between the 2 modalities was statistically significant (P = 0.021). The biparietal and cranial index results were similar between the digital modalities, but the anterior-posterior measurement was greater with the three-dimensional photogrammetry (P = 0.002). The coefficients of variation for repeated measures based on the computed tomography and the three-dimensional photogrammetry were 0.008 and 0.007, respectively.In conclusion, measurements based on digital modalities are generally reliable and interchangeable. Caliper measurements lead to underestimation of anterior-posterior and biparietal values compared with digital imaging.

Pierre robin sequence.

Pierre Robin sequence (PRS) is classically described as a triad of micrognathia, glossoptosis, and airway obstruction. Infants frequently present at birth with a hypoplastic mandible and difficulty breathing. The smaller mandible displaces the tongue posteriorly, resulting in obstruction of the airway. Typically, a wide U-shaped cleft palate is also associated with this phenomenon. PRS is not a syndrome in itself, but rather a sequence of disorders, with one abnormality resulting in the next. However, it is related to several other craniofacial anomalies and may appear in conjunction with a syndromic diagnosis, such as velocardiofacial and Stickler syndromes. Infants with PRS should be evaluated by a multidisciplinary team to assess the anatomic findings, delineate the source of airway obstruction, and address airway and feeding issues. Positioning will resolve the airway obstruction in ~70% of cases. In the correct position, most children will also be able to feed normally. If the infant continues to show evidence of desaturation, then placement of a nasopharyngeal tube is indicated. Early feeding via a nasogastric tube may also reduce the amount of energy needed and allow for early weight gain. A proportion of PRS infants do not respond to conservative measures and will require further intervention. Prior to considering any surgical procedure, the clinician should first rule out any sources of obstruction below the base of the tongue that would necessitate a tracheostomy. The two most common procedures for treatment, tongue-lip adhesion and distraction osteogenesis of the mandible, are discussed.

Venous malformations of the limbs: the Birmingham experience, comparisons and classification in children.

The management of vascular anomalies in upper and lower limbs is complex. The current practice at Birmingham Children's Hospital is based on a multidisciplinary approach, involving plastic surgeons, interventional radiologists, vascular surgeons, dermatologists and laser specialists. This study reviews the management strategies for peripheral venous malformations (VMs) and proposes a simple classification system to aid treatment. A retrospective review was undertaken involving all paediatric patients presenting with (VMs) of the upper and lower limbs, managed by the same multidisciplinary team over a period of 3 years. A total of 33 patients were identified, of whom 19 had lesions located in the upper limb. Treatment modalities included surgery, sclerotherapy, a combination of the two and conservative management. The indications for treatment included: (1) worsening pain, (2) increased swelling, (3) reduced function, (4) bleeding or ulceration and finally, (5) cosmetic deformity. Following treatment, outcome measures with regards to the symptoms were graded into (1) improved, (2) worsened and (3) unchanged. Based on magnetic resonance imaging, we were able to apply our classification to separate the lesions into Type 1a (superficial localised): nine, Type 1b (superficial diffused): five, Type 2 (Fascia/muscle infiltration): nine, Type 3 (Bone/joint infiltration): seven and Type 4 (Extensive whole-limb infiltration): three. In patients with upper limb VMs (n=19), eight lesions (42%) were superficial and localised (Type 1a) while the rest were diffused lesions. In contrast, in the lower limb (n=14), only one lesion (7%) was superficial while the rest were diffused lesions. Lower success rate for treatment was noted in lower limb malformations (p<0.05). In eight patients with recurrence of symptoms, six had Type 3 (intra-articular) lesions. There was one major and three minor complications following treatment. An outline of the management strategies for VMs in peripheral limbs is discussed in this article. An anatomical classification is described which aids in management and communication.

Negative-pressure wound therapy: a snapshot of the evidence.

Topical negative pressure (TNP) is a mode of therapy used to encourage wound healing. It can be used as a primary treatment for chronic/complex wounds or as an adjunct to surgery. Based on the evidence to date, the clinical effectiveness of negative-pressure therapy is still unclear. Although case reports and retrospective studies have demonstrated enhanced wound healing in acute/traumatic wounds, chronic wounds, infected wounds, wounds secondary to diabetes mellitus, sternal wounds and lower limb wounds, there are very few randomised controlled trials, with unclear results. The evidence is lacking for the use of TNP therapy for other indications to enhance wound healing such as patients with decubitus ulcers, diabetes and peripheral vascular disease and to improve skin graft take. There have been, as yet, no quality-of-life studies available for negative-pressure therapy. Despite this, the usage of TNP has increased. This review provides an overview of clinical studies using TNP and proposes avenues for further research to elucidate the exact mechanism of TNP, in addition to large randomised controlled clinical trials of patients undergoing this therapy.

Vacuum-assisted closure to aid wound healing in foot and ankle surgery.

BACKGROUND: Although vacuum-assisted closure (VAC) is a well-established technique in other surgical specialties, its use has not been established in the foot and ankle. The aims of this study were to determine if vacuum-assisted closure therapy (VAC) helps assist closure in diabetic foot ulcers and wounds secondary to peripheral vascular disease, if it helps debride wounds, and if it prevents the need for further surgery. METHODS: We retrospectively reviewed 15 patients (18 wounds or ulcers) with primary diagnoses of diabetes (10 patients), chronic osteomyelitis (two patients), peripheral vascular disease (two patients), and spina bifida (one patient). Eleven of the 15 patients had serious comorbidities, such as peripheral neuropathy, renal failure, and wound dehiscence. All wounds were surgically debrided before VAC therapy was applied according to the manufacturer's instructions. The main outcome measures were time to satisfactory wound closure, changes in the wound surface area, and the need for further surgery. RESULTS: Satisfactory healing was achieved in 13 of the 18 wounds or ulcers at an average of 2.5 months. VAC therapy failed in five patients (five class III ulcers), three of whom required below-knee amputations. Wound or ulcer size decreased from an average of 7.41 cm(2) before treatment to an average of 1.58 cm(2) after treatment. CONCLUSION: VAC therapy is a useful adjunct to the standard treatment of chronic wound or ulcers in patients with diabetes or peripheral vascular disease. Its use in foot and ankle surgery leads to a quicker wound closure and, in most patients, avoids the need for further surgery.