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LEARNING OBJECTIVES: After studying this article, the participant should be able to: (1) Describe the pathology of velopharyngeal dysfunction (VPD) as it relates to patients with a cleft palate. (2) Use the perceptual speech assessment and objective diagnostic tools to determine the presence or absence of VPD. (3) Describe the surgical options available for the treatment of patients with VPD. (4) Develop an evidence-based, customized treatment plan for VPD founded on objective considerations. SUMMARY: To treat patients with cleft palate effectively, the surgeon must understand the diagnosis and surgical management of cleft-associated velopharyngeal dysfunction. The authors review diagnostic modalities including perceptual speech assessment, video nasendoscopy, fluoroscopy, magnetic resonance imaging, and nasometry. Surgical treatments including palatal lengthening with buccal myomucosal flaps, conversion Furlow palatoplasty, sphincter pharyngoplasty, and pharyngeal flap are discussed. Selection of an optimal surgical treatment is addressed.
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Fisura del Paladar , Insuficiencia Velofaríngea , Humanos , Insuficiencia Velofaríngea/diagnóstico , Insuficiencia Velofaríngea/cirugía , Insuficiencia Velofaríngea/etiología , Insuficiencia Velofaríngea/fisiopatología , Fisura del Paladar/cirugía , Fisura del Paladar/complicaciones , Procedimientos de Cirugía Plástica/métodos , Colgajos Quirúrgicos/trasplanteRESUMEN
Objective: To evaluate the impact of the COVID-19 pandemic on the psychosocial functioning of individuals with cleft lip and/or palate (CL/P). Methods: Patients with CL/P ≥ 6 years old were prospectively recruited from the Cleft and Craniofacial Clinic of a tertiary children's hospital. From July-October 2021, eligible patients (or their parent/guardian) were sent a survey regarding their psychosocial functioning before and after the start of the pandemic. Main Outcome Measure: The difference between prepandemic and intrapandemic patient-reported outcome scores. Results: Thirty-six patients (20 female, age: 15.9 ± 9.8 years) responded. Most had cleft lip and palate (77.8%), responded online (69.4%), interacted remotely via both voice- and video-conferencing (62.9%), and wore masks routinely (77.1%). Similar numbers of patients responded independently (27.8%), responded with the help of a parent/guardian (36.1%), or had a parent/guardian respond on their behalf (36.1%). General social-emotional well-being (p = 0.004, r rb = 0.659) and satisfaction with facial appearance (p = 0.044, r rb = 0.610) significantly improved after the start of the pandemic. Compared to their general intrapandemic social-emotional well-being scores, patients reported higher scores while wearing a mask (r rb = 0.827) and lower scores while interacting remotely (r rb = 0.605), although all were still significantly improved compared to their prepandemic scores (p ≤ 0.010). Patients also reported significant improvement in social functioning while wearing a mask (p = 0.036, r rb = 0.519), whereas they did not when considering their general intrapandemic feelings/experiences (p = 0.269, r rb = 0.211). Conclusion: Patients with CL/P demonstrated significant improvement in overall social-emotional well-being, satisfaction with facial appearance, and social functioning after the start of the COVID-19 pandemic, particularly when wearing a mask.
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Pediatric craniofacial fractures are fundamentally distinct from their adult counterparts because of unique injury patterns and effects on future growth. Understanding patterns and injury context informs management and risk mitigation. Previous studies include only inpatients, operative patients, or are specialty-specific. In contrast, our study presents a comprehensive assessment of all pediatric facial fracture patients seen at a single institution. Patients under 18 years old who were evaluated for facial fractures at a level I pediatric trauma center between 2006 and 2021 were reviewed. Subanalysis was performed for groups defined by age. Variables studied included demographics, etiology, fracture pattern, associated injuries, management, and outcomes. Three thousand thirty-four patients were included. Mean age at presentation was 11.5 to 4.9 years. The majority were Caucasian (82.6%) and male (68.4%). Sports were the leading cause of injury in older patients (42.2% of patients over 12 y), compared with activities of daily living in patients under 6 years (45.5%). Thirty-two percent of patients were hospitalized, 6.0% required ICU care, and 48.4% required surgery. Frequency of ICU admission decreased with age (P<0.001), whereas operative intervention increased with age (P<0.001). Zygomaticomaxillary complex (P=0.002) and nasal fractures (P<0.001) were common in older patients, whereas younger patients experienced more skull (P<0.001) and orbital fractures (P<0.001). The most associated injuries were soft tissue (55.7%) and neurologic (23.6%). This large-scale study provides updated characterization of craniofacial fractures in the pediatric population, providing a necessary framework for future studies on outcomes assessments and preventative care.
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OBJECTIVE: The purpose of this study is to objectively quantify the degree of overcorrection in our current practice and to evaluate longitudinal morphological changes using CranioRateTM, a novel machine learning skull morphology assessment tool. â¯. DESIGN: Retrospective cohort study across multiple time points. SETTING: Tertiary care children's hospital. PATIENTS: Patients with preoperative and postoperative CT scans who underwent fronto-orbital advancement (FOA) for metopic craniosynostosis. MAIN OUTCOME MEASURES: We evaluated preoperative, postoperative, and two-year follow-up skull morphology using CranioRateTM to generate a Metopic Severity Score (MSS), a measure of degree of metopic dysmorphology, and Cranial Morphology Deviation (CMD) score, a measure of deviation from normal skull morphology. RESULTS: Fifty-five patients were included, average age at surgery was 1.3 years. Sixteen patients underwent follow-up CT imaging at an average of 3.1 years. Preoperative MSS was 6.3 ± 2.5 (CMD 199.0 ± 39.1), immediate postoperative MSS was -2.0 ± 1.9 (CMD 208.0 ± 27.1), and longitudinal MSS was 1.3 ± 1.1 (CMD 179.8 ± 28.1). MSS approached normal at two-year follow-up (defined as MSS = 0). There was a significant relationship between preoperative MSS and follow-up MSS (R2 = 0.70). CONCLUSIONS: MSS quantifies overcorrection and normalization of head shape, as patients with negative values were less "metopic" than normal postoperatively and approached 0 at 2-year follow-up. CMD worsened postoperatively due to postoperative bony changes associated with surgical displacements following FOA. All patients had similar postoperative metopic dysmorphology, with no significant association with preoperative severity. More severe patients had worse longitudinal dysmorphology, reinforcing that regression to the metopic shape is a postoperative risk which increases with preoperative severity.
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INTRODUCTION: In children with PRS, MDO is routinely performed to alleviate airway obstruction; however, it involves risk of injury to the MMN. We hypothesize that MMN palsy incidence following MDO, reported at 1-15%, is underestimated. This study investigates the true incidence of MMN palsy after MDO to better guide follow-up care and improve treatment of this complication. METHODS: A retrospective review of PRS patients who underwent MDO at a single, tertiary pediatric hospital between September 2007 and March 2021 was conducted. Patients who underwent MDO under one year of age and had postoperative clinical evaluations detailing MMN function were included. Logistic regression analysis was performed to investigate predictors of MMN injury. RESULTS: Of 93 patients who underwent MDO, 59.1% met inclusion criteria. 56.4% were female, 43.6% were syndromic, and average age at MDO was 1.52 ± 2.04 months. The average length of mandibular distraction was 17.3 ± 4.36mm, average duration of intubation was 6.57 ± 2.37 days, and average time until hardware removal was 111.1 ± 23.6 days. Sixteen patients (29.1%) presented with permanent MMN dysfunction, comprised of 8 patients with bilateral weakness and 8 with unilateral weakness. An additional five patients (9.1%) presented with transient MMN weakness that resolved within a year. Average length of follow-up postoperatively was 6.02 years, and no significant predictors of nerve injury were found. CONCLUSION: In this 14-year review of patients with PRS who underwent MDO, 38.2% demonstrated evidence of MMN palsy (29.1% permanent, 9.1% transient), which is much greater than previously described.
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BACKGROUND: The diagnosis and management of metopic craniosynostosis involve subjective decision-making at the point of care. The purpose of this work was to describe a quantitative severity metric and point-of-care user interface to aid clinicians in the management of metopic craniosynostosis and to provide a platform for future research through deep phenotyping. METHODS: Two machine-learning algorithms were developed that quantify the severity of craniosynostosis-a supervised model specific to metopic craniosynostosis [Metopic Severity Score (MSS)] and an unsupervised model used for cranial morphology in general [Cranial Morphology Deviation (CMD)]. Computed tomographic (CT) images from multiple institutions were compiled to establish the spectrum of severity, and a point-of-care tool was developed and validated. RESULTS: Over the study period (2019 to 2021), 254 patients with metopic craniosynostosis and 92 control patients who underwent CT scanning between the ages of 6 and 18 months were included. CT scans were processed using an unsupervised machine-learning based dysmorphology quantification tool, CranioRate. The average MSS was 0.0 ± 1.0 for normal controls and 4.9 ± 2.3 ( P < 0.001) for those with metopic synostosis. The average CMD was 85.2 ± 19.2 for normal controls and 189.9 ± 43.4 ( P < 0.001) for those with metopic synostosis. A point-of-care user interface (craniorate.org) has processed 46 CT images from 10 institutions. CONCLUSIONS: The resulting quantification of severity using MSS and CMD has shown an improved capacity, relative to conventional measures, to automatically classify normal controls versus patients with metopic synostosis. The authors have mathematically described, in an objective and quantifiable manner, the distribution of phenotypes in metopic craniosynostosis.
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Craneosinostosis , Humanos , Lactante , Craneosinostosis/diagnóstico por imagen , Craneosinostosis/genética , Cráneo , Procesamiento de Imagen Asistido por Computador , Tomografía Computarizada por Rayos X/métodosRESUMEN
BACKGROUND: Detailed in-house databases are a staple of surgical research and a crucial source of data for many studies from which clinical guidelines are built. Despite the importance of generating a clear and thorough developmental design, the literature on database creation and management is limited. In this article, the authors present their stepwise single-institution process of developing a clinical facial fracture database. METHODS: The authors outline the process of development of a large single-institution clinical pediatric facial fracture database. The authors highlight critical steps from conception, regulatory approval, data safety/integrity, human resource allocation, data collection, quality assurance, and error remediation. The authors recorded patient characteristics, comorbidities, details of the sustained fracture, associated injuries, hospitalization information, treatments, outcomes, and follow-up information on Research Electronic Data Capture. Protocols were created to ensure data quality assurance and control. Error identification analysis was subsequently performed on the database to evaluate the completeness and accuracy of the data. RESULTS: A total of 4451 records from 3334 patients between 2006 and 2021 were identified and evaluated to generate a clinical database. Overall, there were 259 incorrect entries of 120,177 total entries, yielding a 99.8% completion rate and a 0.216% error rate. CONCLUSIONS: The quality of clinical research is intrinsically linked to the quality and accuracy of the data collection. Close attention must be paid to quality control at every stage of a database setup. More studies outlining the process of database design are needed to promote transparent, accurate, and replicable research practices.
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Procedimientos de Cirugía Plástica , Cirugía Plástica , Humanos , Niño , Recolección de Datos , Hospitalización , Exactitud de los DatosRESUMEN
BACKGROUND: Mandibular fractures account for up to 48.8% of pediatric facial fractures; however, there are a wide range of available treatment modalities, and few studies describe trends in adverse outcomes of these injuries. This study describes fracture etiology, pattern, management, and treatment outcomes in pediatric mandibular fracture patients. METHODS: A retrospective review was performed of patients under 18 years of age who were evaluated for mandibular fractures at a pediatric level I trauma center between 2006 and 2021. Variables studied included demographics, etiology, medical history, associated facial fractures, other associated injuries, treatments, and outcomes. RESULTS: A total of 530 pediatric patients with 829 mandibular fractures were included in the analysis. Most isolated mandibular fractures were treated with physical therapy (PT) and rest (n=253, 47.7%). Patients with combination fractures, specifically those involving the parasymphysis and angle, were 2.63 times more likely to undergo surgical management compared to patients with a single facial fracture (p<0.0001). Older age (p<0.001), gender (p=0.042), mechanism (p=0.008) and cause of injury (p=0.002), as well as specific fractures (e.g., isolated angle (p=0.001)) were more associated with adverse outcomes. The odds of adverse outcomes were higher for patients treated with CREF or ORIF compared to conservative management (OR=1.8; 95% Cl 1.0-3.2 and OR=2.1; 95% Cl 1.2-3.5, respectively). CONCLUSION: Fracture type, mechanism of injury, and treatment modality in pediatric mandibular fractures are associated with distinct rates and types of adverse outcomes. Large scale studies characterizing these injuries are critical for guiding physicians in the management of these patients.
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Objective In this study, we aimed to compare the clinical outcomes between older and younger patients with melanoma and to evaluate for differences in tumor genetic makeup that might explain differences in clinical behavior between older and younger cohorts. Materials and methods A consecutive sample of patients diagnosed with melanoma at a single institution from 1984 to 2019 was categorized by age into younger, middle, and older cohorts. Tumor characteristics, melanoma-specific survival, and recurrence-free survival were assessed while accounting for differential follow-up and death from other causes using Kaplan-Meier analysis with log-rank testing. Results A total of 4378 patients were included in the study. Older patients presented with a higher incidence of T3 and T4 tumors, and a lower incidence of T1 tumors (p<0.001). The same group of patients had a lower nodal positivity at any given Breslow thickness (p<0.01). Melanoma-specific survival was lower for older patients with T2 tumors (p=0.046). There was no difference in recurrence-free survival among all age groups and tumor thicknesses (p>0.05). For patients with a given genetic profile, the melanoma-specific survival and recurrence-free survival were equivalent across ages. BRAF was the most common driver in the younger group, while NRAS and other mutations increased in prevalence as age rose. Conclusions Older adults have decreased melanoma-specific survival for T2 tumors and lower nodal positivity, suggesting a different pattern of metastatic progression. The mutational drivers of cutaneous melanoma change with age and may play a role in the different metastatic progression as well as the differential melanoma-specific survival across all age cohorts.
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BACKGROUND: The authors previously published their protocol to treat patients who present with sagittal craniosynostosis after the age of 1 year. The purpose of this article is to present a follow-up and update of this cohort to evaluate outcomes of their treatment protocol. METHODS: Patients with isolated sagittal craniosynostosis who presented after the age of 1 year between July of 2013 and April of 2021 were included. RESULTS: A total of 108 patients met inclusion criteria. The average age at presentation was 5.2 ± 3.4 years, and 79 patients (73.1%) were male. The indications for imaging were head shape (54.6%), headache (14.8%), trauma (9.3%), seizure (4.6%), papilledema (2.8%), and other (13.9%). Of the 108 patients, 12 (11.1%) underwent surgery following their initial consultation: five for papilledema, four for elevated intracranial pressure, two for severely scaphocephalic head shapes, and one for abnormal funduscopic findings. Two of these patients underwent additional reconstructive surgery, one for the recurrence of papilledema and headache and the other for progressive scaphocephaly. The average length of time between operations was 4.9 years. Of the 96 patients who were managed conservatively, four (4.2%) underwent surgery at an average of 1.2 ± 0.5 years later (average age, 4.4 ± 1.5 years) for brain growth restriction ( n = 2), aesthetic concerns ( n = 1), and refractory headaches ( n = 1). The average follow-up of all patients with craniofacial surgery was 2.7 ± 2.3 years (median, 2.1 years; interquartile range, 3.7 years). CONCLUSIONS: Patients with late-presenting sagittal craniosynostosis require surgical correction less often than younger patients, likely because of milder phenotype. Few patients in the conservative treatment arm ultimately required surgery (4%). CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
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Craneosinostosis , Papiledema , Humanos , Masculino , Lactante , Preescolar , Femenino , Craneosinostosis/complicaciones , Craneosinostosis/diagnóstico , Craneosinostosis/cirugía , Craneotomía/métodos , Protocolos Clínicos , Cefalea/cirugía , Estudios RetrospectivosRESUMEN
INTRODUCTION: Orthognathic surgery is routinely practiced, yet little comparative data exists to evaluate post-orthognathic surgery diet protocols. OBJECTIVE: To evaluate which postoperative diet protocols are recommended and to quantify post-orthognathic surgery weight changes in our institutional cohort. METHODS: An internet search was carried out on Google for "orthognathic surgery diet" and the postoperative diet recommendations from centers worldwide were quantified. Additionally, a retrospective analysis of patients that underwent orthognathic surgery at our institution was performed, and their preoperative and postoperative weights were recorded. RESULTS: The internet search yielded 58 centers that met our inclusion criteria. Most centers were in the United States (n = 37, 63.8%) and were oral and maxillofacial surgeon (OMFS)-led centers (n = 39, 67.2%). Postoperative diets were categorized into 7 distinct protocols, ranging from most to least restrictive-the most popular was liquid diet for 2 to 4 weeks followed by soft diet for 2 to 6 weeks. There were no significant patterns observed across different geographical regions or specialties.In our institution, 135 patients were identified. Overall, there was an average maximum weight loss of 4.1â kg by week 4, followed by a gradual increase in weight. Linear regression analysis showed that patients with greater preoperative body mass index (BMI) lost more weight postoperatively than patients with lower BMI (R2 = 0.25, P < .001). CONCLUSION: There is a significant variability in recommended postoperative diets following orthognathic surgery. Following a moderately restrictive diet at our institution, patients returned to their preoperative weight after approximately 4 months.
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Cirugía Ortognática , Procedimientos Quirúrgicos Ortognáticos , Humanos , Procedimientos Quirúrgicos Ortognáticos/métodos , Estudios Retrospectivos , Pérdida de Peso , DietaRESUMEN
Background: The goal of surgery, when treating a patient with a traumatized hand, is to restore function. The importance of the aesthetics on a patient's psychological well-being should also be considered. The biomechanical ideals for creating a useful hand after digit amputation have been defined; however, ideal aesthetic levels for finger amputation have not been elucidated. The purpose of this study was to determine the general population's visual preferences for different levels of digit amputation in the hand. Methods: In all, 310 participants were surveyed to identify preferences of different levels of single digit amputations in dorsal and volar views. A normal hand was digitally manipulated to simulate various levels of digit amputation. The aesthetics of amputation at the distal interphalangeal (DIP) joint, proximal interphalangeal (PIP) joint, metacarpophalangeal (MCP) joint, and ray amputation were compared to one another via rank order. Average rank for each level of amputation for a digit was determined. Results: Amputation at the DIP was favored over all other levels; however, ray amputation was the second most aesthetic, particularly in the middle and ring fingers even when compared to amputation at the PIP level. Conclusion: When presented a choice at which level to perform a completion amputation or a primary amputation of a digit, and functionality at multiple levels of amputation is equivocal, aesthetic outcomes should be considered. Amputation at the DIP joint is preferable, but ray amputation is aesthetically more pleasing than amputation at the PIP or MCP joints in the index, middle, ring, and small fingers.
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Traumatismos de los Dedos , Dedos , Humanos , Dedos/cirugía , Traumatismos de los Dedos/cirugía , Mano , Articulación Metacarpofalángica/cirugía , Amputación QuirúrgicaRESUMEN
INTRODUCTION: The squamosal suture (SQS) joins the temporal to the parietal bones bilaterally and is a poorly described site of craniosynostosis. SQS fusion is thought to occur as late as the fourth decade of life and beyond; however, we have incidentally noted its presence among our pediatric patients and hypothesize that it may occur earlier in life and more frequently than previously believed. METHODS: A retrospective review of imaging performed on pediatric patients was completed to identify patients with SQS synostosis. This included a review of clinical notes as well as computed tomography (CT) images obtained by our craniofacial clinic. Relevant patient data and imaging were reviewed. RESULTS: Forty-seven patients were identified with SQS synostosis, 21 were female (45%). Age at the time of radiographic diagnosis was 10.1 ± 8.4 years (range 17 days to 27 years). A majority of patients had bilateral SQS synostosis (57%), with a relatively even distribution of unilateral right (23%) versus left (19%). SQS was an isolated finding (no other suture involvement) in 15 patients (32%), all of whom were normocephalic and did not require surgical intervention. Thirty-two patients (68%) had concomitant craniosynostosis of other sutures, most commonly sagittal and coronal. Nine patients (19%) underwent surgery to correct cranial malformations-all these patients had multi-suture synostosis (P = 0.012). Twenty-seven patients (57%) had SQS synostosis diagnosed incidentally compared to 20 (43%) who were imaged with suspicion for synostosis. In those who were symptomatic, common findings included developmental delay, elevated intracranial pressure, hydrocephalus, seizures, and visual/hearing impairments. Ten patients (21%) were syndromic, the most frequent of which was Crouzon syndrome. No single pattern of calvarial malformation could be definitively described for SQS synostosis. CONCLUSION: Given that most isolated SQS synostosis cases were normocephalic, asymptomatic, and discovered incidentally, it is likely that there are many cases of unidentified SQS synostosis. The significance of SQS synostosis is currently unclear, and warrants further investigation into this phenomenon, its natural course, and its potential presence in the spectrum of normal development.
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Disostosis Craneofacial , Craneosinostosis , Humanos , Niño , Femenino , Lactante , Recién Nacido , Masculino , Suturas Craneales/diagnóstico por imagen , Suturas Craneales/cirugía , Craneosinostosis/diagnóstico por imagen , Craneosinostosis/cirugía , Craneosinostosis/complicaciones , Estudios Retrospectivos , SuturasRESUMEN
BACKGROUND: The palmar aponeurosis or "A0 pulley" may play a role in trigger finger pathology. This study assesses the involvement of the A0 pulley in patients receiving trigger finger release. METHODS: This single-surgeon, prospective, randomized clinical trial was conducted among consenting patients with symptomatic trigger finger. Intraoperative coin toss was used to randomize initial release of either the A0 or A1 pulley. Following release, active flexion and extension of the affected digit were examined. The remaining pulley was then released in sequence, and clinical trigger status was recorded. RESULTS: Thirty fingers from 24 patients were released; 17 fingers received A0 release first, and 13 received A1 release. Following initial A0 release, 8 fingers (47%) demonstrated complete resolution of symptoms, 4 (24%) demonstrated improvement but incomplete resolution of triggering, and 5 (29.4%) demonstrated no improvement. Following initial A1 release, 6 fingers (46%) demonstrated complete resolution, 3 (23%) demonstrated improvement but incomplete resolution of triggering, and 4 (31%) demonstrated no improvement. All patients demonstrated complete resolution after surgical release of both sites. Neither initial A1 release nor initial A0 release was statistically associated with complete, incomplete, or failed symptom resolution. CONCLUSIONS: These data implicate the A0 pulley as the primary cause of 31% to 47% of trigger fingers in our study. Although larger trials are needed to validate these results, our study suggests that release of both A0 and A1 pulleys may offer greater symptom resolution than release of the A1 pulley alone.
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Trastorno del Dedo en Gatillo , Humanos , Trastorno del Dedo en Gatillo/cirugía , Estudios Prospectivos , Tendones/cirugía , Dedos/cirugía , AntebrazoRESUMEN
PURPOSE: Patients born with a cleft palate often suffer from velopharyngeal insufficiency (VPI) due to the soft palate musculature's abnormal structure. Surgical correction of the palate at a young age can hinder maxillary growth, requiring surgical correction of the maxillomandibular discrepancy at skeletal maturity. Orthognathic surgery can then cause or further exacerbate VPi in these patients. The purpose of this paper is to assess cleft-orthog-nathic patients under the lens of persistent or newly-developed VPi, to understand outcomes and generate a targeted management algorithm. METHODS: A retrospective study was performed inspecting cleft-orthognathic patients presenting to a single surgeon. Patients with sufficient follow-up were placed into predefined algorithmic cohorts by their VPi development pattern in relation to orthognathic surgery. They were further stratified into groups by level of adherence to our algorithm to evaluate VPi outcomes. Demographic factors, risk factors, and outcomes were compared between groups via Welch t test and Fisher exact test. RESULTS: Fifty-one patients were examined, including 16 with VPI. Velopharyngeal insufficiency fully resolved amongst all algorithmically adherent patients and remained in nonadherent patients ( P â<â0.001). CONCLUSIONS: Our targeted algorithm may improve symptoms and the management of VPI in cleft-orthognathic patients. Multi-centered studies with larger sample sizes and prospective studies are encouraged to validate our proposed treatment algorithm further.
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Algoritmos , Fisura del Paladar , Insuficiencia Velofaríngea , Fisura del Paladar/complicaciones , Humanos , Reproducibilidad de los Resultados , Estudios Retrospectivos , Resultado del Tratamiento , Insuficiencia Velofaríngea/etiología , Insuficiencia Velofaríngea/cirugíaRESUMEN
SUMMARY: Surgical management of unilateral cleft lip is challenging. Correction requires a comprehensive approach to ensure optimal aesthetic outcomes. Various techniques have been proposed for the repair of cleft lip. This article and video vignette highlight the senior author's (D.S.) preferred method for repair of a unilateral cleft lip using a modified inferior triangle technique, a Noordhoff triangular flap for vermillion augmentation, orbicularis oris chemodenervation to reduce tension at the repair site, and autologous fat grafting for lip sculpting.
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Tejido Adiposo/trasplante , Labio Leporino/cirugía , Procedimientos de Cirugía Plástica/métodos , Colgajos Quirúrgicos/trasplante , Estética , Músculos Faciales/inervación , Humanos , Labio/cirugía , Masculino , Bloqueo Nervioso/métodos , Trasplante Autólogo/métodos , Resultado del TratamientoRESUMEN
BACKGROUND: Postoperative nausea and vomiting (PONV) remains a major clinical end-point for directing enhanced recovery after surgery (ERAS) protocols in facial plastic surgery. This study aimed to identify risk factors for PONV and evaluate strategies for PONV reduction in orthognathic surgery patients. METHODS: A retrospective cohort study was performed among patients receiving orthognathic surgery at our institution from 2011 to 2018. Patient demographics, surgical operative and anesthesia notes, medications, and nausea/vomiting were assessed for each patient. The amount of opioid analgesia given both perioperatively and postoperatively was recorded and converted into morphine equivalents (MEQ). Stepwise regression analysis was used to identify significant risk factors for PONV. Post hoc analyses were employed to compare PONV among patients based on MEQ dosage and antiemetic prophylaxis regimes. RESULTS: A total of 492 patients were included; mean age was 23.0âyears (range: 13-60); 54.4% were female. The majority of patients received concurrent Le Fort I osteotomy, BSSO, and genioplasty (70.1%). During hospitalization, 59.4% of patients experienced nausea requiring antiemetic medications and 28.4% experienced emesis. Stepwise regression yielded Apfel scores (Pâ=â0.003) and postoperative opioids (Pâ=â0.013) as the strongest predictors of PONV. Post hoc analyses showed that undertreatment with prophylactic antiemetics (based on Apfel) predicted increased PONV (+12.9%, Pâ=â0.020), and that lower postoperative MEQs (<28.0) predicted decreased PONV (-11.8%, Pâ=â0.01). CONCLUSIONS: The study findings confirm the high incidence of PONV among orthognathic surgical patients and stratify previously reported PONV risk factors. More aggressive utilization of antiemetic medications and decreased dependence on opioid analgesia may decrease nausea/vomiting following orthognathic surgery.
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Antieméticos , Cirugía Ortognática , Adulto , Analgésicos Opioides/uso terapéutico , Antieméticos/uso terapéutico , Femenino , Humanos , Morfina , Náusea y Vómito Posoperatorios/epidemiología , Náusea y Vómito Posoperatorios/prevención & control , Estudios Retrospectivos , Vómitos , Adulto JovenRESUMEN
A natural aesthetic appearance of the lip and a favorable scar are essential goals of cleft lip repair. Wider clefts intuitively pose a greater technical challenge; however, the relationship between initial width and aesthetic outcome remains controversial. The current study aimed to determine whether lip adhesion can help wider clefts achieve safe, consistent aesthetic outcomes. METHODS: A retrospective cohort study was conducted on unilateral cleft lip patients who underwent lip repair within a 2-year period by the senior author. Subjects were divided into three groups based on cleft severity: (1) wide complete clefts that required lip adhesion before definitive repair, (2) narrower complete clefts that did not require lip adhesion, and (3) incomplete clefts. Aesthetic outcomes related to the vermillion and upper lip scar were rated by 48 blinded observers. Statistical analysis was performed using Kruskal-Wallis and Mann-Whitney tests. Nasal outcomes were not assessed. RESULTS: Seventeen patients were included in the study: five in group 1, six in group 2, and six in group 3. Patients with the widest clefts did not have inferior results compared with the other groups. In fact, they had statistically significantly higher aesthetic scores in all scar-related outcomes compared with those in groups 2 and 3 (P < 0.0001). CONCLUSIONS: This study suggests that a wide cleft does not necessarily foreshadow a poor surgical outcome. In fact, wide clefts may have pleasing results, and the use of a staged lip adhesion approach can be useful for achieving the desired outcome in wider clefts.
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BACKGROUND: Chest wall masculinization is often performed for transgender men in order to address gender dysphoria. Peri-areolar and double-incision mastectomy with free nipple grafts, are the most common techniques employed in chest masculinization surgery, but are limited by their relative inconsistency and inefficiency in reconstructing a natural anterior contour that comprehensively resembles that of a cis-masculine chest. The purpose of this study is two-fold. The first is to describe the "hockey stick" approach, which expands on the widely performed double-incision mastectomy to the axilla, with an additional step of revising lateral chest wall folds of tissue excess. This technique is scalable to the degree of pre-operative excess tissue on the anterior and lateral chest wall. The second is to compare the "hockey stick" incision to existing reconstructive options, with respect to clinical outcomes and patient satisfaction. METHODS: Patients who received chest masculinization surgery at Yale-New Haven Hospital were included. A retrospective chart review, comprising demographic variables, procedural details, and post-operative events, was conducted. Selected modules from a validated survey instrument, the BODY-Q, were measured. Patients were classified by body mass index and incision, which included peri-areolar, inframammary fold, and "hockey stick" incision by date. RESULTS: Twenty-seven of 73 (37.0%) participants completed the full survey and were included in the analysis. The "hockey stick" incision had comparable patient satisfaction and post-operative outcomes, compared to peri-areolar and double-incision mastectomy with free nipple graft techniques. Greater BMI patients had a higher incidence of wound dehiscence, compared to other weight classifications. CONCLUSIONS: The "hockey stick" incision is a readily performed, effective surgical technique for building a cis-masculine appearing chest in transgender men with efficient and predictable outcomes. While performed in patients with higher BMI, the "hockey stick" confers equivalent patient satisfaction and clinical outcomes to peri-areolar and double-incision mastectomy.
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Treacher Collins syndrome (TCS) is a genetic disorder that presents with a variety of craniofacial deformities. One classic feature of TCS is a steep, counterclockwise rotation of the occlusal plane, and microretrognathia with bony deficiencies in both the body and ramus of the mandible. This morphology commonly necessitates reconstruction by the craniofacial surgeon. This article discusses strategies and considerations for surgically correcting the mandibular deformity associated with TCS using mandibular distraction osteogenesis and other related techniques. The proper implementation of these techniques can yield excellent results that greatly improve quality of life in this challenging patient population.