Repair of an Occipital Meningocele and Scalp Soft-tissue Reconstruction in a Newborn Patient.

The differential diagnosis of large congenital scalp defects includes aplasia cutis and encephalocele, among others. Treatment includes conservative management with dressings or operative management with dermal substitutes, skin grafting, local flaps, and free flaps. This case report discusses the technical considerations and reconstructive strategies for repair of a meningocele in a newborn with a large 5.5-cm scalp defect. The key strategies include preemptive cerebrospinal fluid (CSF) diversion with external ventricular drain to reduce the risk of CSF leak and mitigate wound-healing complications; careful identification and avoidance of key anatomic structures, such as the superior sagittal sinus, as anatomy may be significantly distorted due to the presence of a meningocele and after CSF diversion; and careful, thoughtful design of the local scalp flaps to maximize blood supply and to avoid tension on the final reconstruction.

Intraoperative Anaphylaxis to Gelatin during Alveolar Bone Grafting for Cleft Palate.

Intraoperative anaphylaxis can be life threatening. Anaphylaxis to gelatin-based topical hemostatic agents is an underrecognized hypersensitivity. To date, only 21 cases of intraoperative anaphylaxis have been reported for gelatin-based hemostatic agents. In this article, we report the case of a 10-year-old male patient who sustained anaphylaxis after the use of Gelfoam during harvest of a bone graft. Rapid diagnosis and treatment of intraoperative anaphylaxis is imperative to prevent adverse outcomes. Referral to an allergist for identification of the allergen and appropriate notation in the medical record are paramount to avoid future anaphylactic events. Surgeons should avoid gelatin-based hemostatic agents, such as Gelfoam, in patients with reported intolerance of gelatin-based foods and medicines.

Geometric learning and statistical modeling for surgical outcomes evaluation in craniosynostosis using 3D photogrammetry.

BACKGROUND AND OBJECTIVE: Accurate and repeatable detection of craniofacial landmarks is crucial for automated quantitative evaluation of head development anomalies. Since traditional imaging modalities are discouraged in pediatric patients, 3D photogrammetry has emerged as a popular and safe imaging alternative to evaluate craniofacial anomalies. However, traditional image analysis methods are not designed to operate on unstructured image data representations such as 3D photogrammetry. METHODS: We present a fully automated pipeline to identify craniofacial landmarks in real time, and we use it to assess the head shape of patients with craniosynostosis using 3D photogrammetry. To detect craniofacial landmarks, we propose a novel geometric convolutional neural network based on Chebyshev polynomials to exploit the point connectivity information in 3D photogrammetry and quantify multi-resolution spatial features. We propose a landmark-specific trainable scheme that aggregates the multi-resolution geometric and texture features quantified at every vertex of a 3D photogram. Then, we embed a new probabilistic distance regressor module that leverages the integrated features at every point to predict landmark locations without assuming correspondences with specific vertices in the original 3D photogram. Finally, we use the detected landmarks to segment the calvaria from the 3D photograms of children with craniosynostosis, and we derive a new statistical index of head shape anomaly to quantify head shape improvements after surgical treatment. RESULTS: We achieved an average error of 2.74 ± 2.70 mm identifying Bookstein Type I craniofacial landmarks, which is a significant improvement compared to other state-of-the-art methods. Our experiments also demonstrated a high robustness to spatial resolution variability in the 3D photograms. Finally, our head shape anomaly index quantified a significant reduction of head shape anomalies as a consequence of surgical treatment. CONCLUSION: Our fully automated framework provides real-time craniofacial landmark detection from 3D photogrammetry with state-of-the-art accuracy. In addition, our new head shape anomaly index can quantify significant head phenotype changes and can be used to quantitatively evaluate surgical treatment in patients with craniosynostosis.

Analysis of postoperative complications related to cannabis and tobacco usage in patients undergoing mandible facial fracture surgeries.

BACKGROUND: Cannabis is the third most used controlled substance in the world. Despite its widespread use, minimal research investigates cannabis usage in patients undergoing facial fracture surgeries. This study aimed to evaluate patterns of postoperative complications related to cannabis and tobacco usage after mandible fracture surgeries. MATERIALS AND METHODS: PearlDiver™, a commercially available healthcare database, was used to identify patients endorsing the use of cannabis, tobacco, or both who underwent mandible fracture surgeries for cross-sectional analysis. The study population was categorized into groups using the Classification of Diseases, 9th revision (ICD-9), ICD-10, and Current Procedural Terminology (CPT) codes. A chi-square analysis was performed to assess the influence of cannabis and tobacco use on postoperative complications. RESULTS: A total of 8288 patients met the inclusion criteria, with 72 patients with cannabis-only usage, 914 patients with cannabis and tobacco usage, 3236 patients with tobacco-only usage, and 4066 in the control group. For patients using only cannabis, there was not an increased risk of developing postoperative complications compared with the control population. Patients with concurrent cannabis and tobacco usage and those with tobacco-only usage had an increased risk of surgical site infection, facial nonunion, facial abscess, debridement, and malocclusion after surgical repair of mandibular facial fracture. CONCLUSION: Patients with tobacco-only as well as cannabis and tobacco usage had an increased risk of all postoperative complications, except malocclusion, compared with cannabis-only. Based on the results of this study, it is recommended that healthcare providers consider a patient's history of tobacco use when planning and performing surgical treatment for traumatic mandible fractures.

Wound infection: A review of qualitative and quantitative assessment modalities.

Surgical site infections (SSI) and chronic wounds represent a burden to patients and the health care system. One in 24 surgical patients will develop an SSI, making SSI the most common nosocomial infection in the USA. Early detection and monitoring of wound infection are critical for timely healing and return to normal function. However, the mainstay of wound infection diagnostic entails subjective clinical examination and semi-quantitative, invasive microbiological tests. In this review, we present current wound infection assessment modalities in the clinical and translational fields. There is a need for a point-of-care assessment tool that provides fast, accurate, and quantitative information on wound status, with minimal to no contact with the patient. In the next ten years, the evolution of wound diagnostic tools reported here may allow medical providers to optimize patient care while minimizing patient discomfort.

Alveolar Bone Graft Timing in Patients With Cleft Lip & Palate.

ABSTRACT: Cleft lip with or without cleft palate (CLP) is the most common craniofacial condition. Alveolar clefts are present in approximately 75% of patients with a cleft lip or CLP and often do not have sufficient support of surrounding teeth. Alveolar bone graft is commonly performed to reconstruct alveolar ridge in patient with osseous defects. Objective of this review is to critically analyze the literature to provide recommendations on appropriate timing for orthodontic preparation and surgical correction of alveolar clefts in the setting of unilateral or bilateral CLP. Search of PubMed database, MEDLINE, and EMBASE was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, 15 studies were included. Majority of studies used chronological age to classify patients versus dental age. Most studies reported orthodontic treatment concomitant with surgery (12/15; 80.0%), and used orthodontics before alveolar bone grafting (8/12; 66.7%). No consensus on the best method to evaluate the success of alveolar bone grafting. Alveolar bone grafting with pre- and post-operative orthodontics is currently the standard of care for treatment of alveolar defects in patients with CLP. Authors recommend grafting during early mixed dentition phase, just before the eruption of the permanent central incisors, typically between 6 and 8 years old. Preoperative orthodontics for appropriate incisor alignment around cleft, and may be resumed 6 months postoperative.

Multilayered and Flap Closure Technique for Pediatric Spinal Deformity Surgery.

Wound complications after pediatric spinal deformity surgery are a relatively common and challenging complication that results in emotional, physical, and monetary costs to the patients, families, and healthcare providers. The role of wound closure techniques for the prevention of wound complications is being increasingly explored. Interdisciplinary care by spinal surgeons and plastic surgeons has been recently found to decrease wound complication rates in patients with nonidiopathic scoliosis.

Evolution of Bandeau Shape, Orbital Morphology, and Craniofacial Twist after Fronto-Orbital Advancement for Isolated Unilateral Coronal Synostosis: A Case-Control Study of 2-Year Outcomes.

BACKGROUND: The authors' purpose was to quantify the change in unicoronal synostosis symmetry between presentation (time 0), after fronto-orbital advancement (time 1), and 2 years later (time 2). METHODS: Bandeau/orbital symmetry ratios and skull base/midface twists were measured on computed tomographic scans of consecutive isolated unicoronal synostosis patients. Comparisons were made across three time points and against normal controls. RESULTS: Forty-three unicoronal synostosis patients and 36 controls were included. The mean bandeau ratio (symmetry = 1) changed from 0.76 (time 0), to 1.13 (time 1), and then to 1.01 (time 2). The median bandeau ratio change from time 1 to time 2 was -9.1 percent and was impacted by the degree of time 1 asymmetry. The odds of a desired symmetric or overcorrected result (bandeau ratio > 1.0) at time 2 were increased in patients with less severe preoperative asymmetry (OR, 4.2; p = 0.04) and in those who obtained symmetry or overcorrection at surgery (OR, 4.9; p = 0.02). Craniofacial twist did not significantly change after surgery but decreased at time 2. Orbital height ratios were 1.08, 1.00, and then 1.02 at time 2, respectively. The orbital width ratio was not significantly impacted by surgery, remaining at 0.89 at time 2. CONCLUSIONS: Overcorrection of the unicoronal synostosis bandeau resulted in these patients being five times more likely to have a desired result at time 2. Patients with a more severe brow presentation were four times more likely to be asymmetric at time 2. Orbital height was improved, but attention should be directed at addressing orbital width. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Custom CAD/CAM implants for complex craniofacial reconstruction in children: Our experience based on 136 cases✰.

BACKGROUND: CAD-CAM patient-specific implants offer cerebral protection and improved facial balance without the disadvantages of autologous bone grafting such as donor site morbidity and unpredictable resorption. Several alloplastic materials are available, but titanium, polymethylmethacrylate (PMMA), and polyetheretherketone (PEEK) are the current popular choices. We reviewed our experience of applying different alloplastic CAD-CAM materials in the reconstruction of complex pediatric craniofacial deformities. METHODS: A retrospective review was performed of all pediatric patients who underwent a complex inlay or onlay implant craniofacial reconstruction using CAD-CAM PEEK, PMMA, or titanium implants at a single institution. Demographics, cost, operative time, complications, and outcomes were assessed. RESULTS: Between 2003 and 2014, 136 patients (69 male; 67 female; mean age 11.5 years (3-22 years); mean follow-up 30 months) had custom patient-specific craniofacial reconstruction with PEEK (n = 72), PMMA (n = 42), and titanium (n = 22) implants (inlay = 93; onlay = 43). Indications included congenital anomalies (26.5%), decompressive craniectomies (25.0%), craniofacial syndromes (25.7%), tumor defects (14.0%), and post-trauma (6.6%). Implant cost varied significantly for PEEK ($7703 CAD) and PMMA ($8328 CAD) compared with that for titanium ($11,980 CAD) (p < 0.0005). Six patients (4.4%) required surgery due to infection consisting of irrigation and antibiotic administration with successful implant salvage in three patients. All infections occurred in the PEEK group. Five patients (3.7%) ultimately had implants removed due to infection (n = 3), late exposure (titanium; n = 1), or late fracture (PMMA; n = 1). CONCLUSIONS: CAD-CAM alloplast reconstruction in the management of complex pediatric craniofacial deformities is effective although expensive. Implant infection does not always require explantation. A reconstruction algorithm is presented.

Surgical management of a nasal AVM in a pediatric patient: A case report.

Arteriovenous malformations (AVMs) are a type of high-flow vascular malformation that are characterized by abnormal capillary communications between the arterial and venous systems. While they are most commonly located in the head and neck region, their appearance in the nose is considerably rare, resulting in a paucity of literature regarding the surgical management of these lesions. We present the case of a 13-year-old male with a 6.5 × 6 cm AVM of the nose with a history of frequent nosebleeds since early childhood, often requiring aggressive measures, such as silver nitrate cauterization for control. Use of nasal decongestants and aminocaproic acid provided only transient improvement. After determination of arterial supply, AVM was approached with a combination of preoperative selective embolization and surgical excision with subsequent forehead flap defect coverage. Due to the size and complexity of this AVM, extra precautions were taken to avoid severe intraoperative bleeding, and femoral sheaths were placed prior to excision. The patient tolerated the procedure well, and with subsequent debulking surgery and Laser Hair Removal achieved an acceptable cosmetic outcome.

Designing a Fibular Flow-Through Flap with a Proximal Peroneal Perforator-Free Flap for Maxillary Reconstruction.

Reconstruction of a composite maxillary defect is frequently performed with a fibular osteocutaneous free flap to address both the bony and mucosal defect. If during the harvest of the fibula a distal skin perforator is not present due to vascular variations, reconstruction can potentially be done using the soleus muscle for filling of the palatal mucosal defect. An additional challenge arises when the accompanying skin paddle that has been harvested is not perfused, but the fibula remains viable. This case report describes salvage following loss of the skin paddle in an osteocutaneous fibular free flap by designing a fibular flow-through flap using a proximal peroneal perforator free flap. The use of this second free flap allows a skin paddle to be positioned on the distal fibular segment, provides a surgical backup, and limits the donor sites to the same extremity.

Identical Twins with Crouzon Syndrome: Eight-Year Follow-up, Genetic Considerations, and Operative Management.

A case report of monozygotic (MZ) twins with Crouzon syndrome was previously published to highlight variables in clinical presentation. The postnatal and epigenetic causes for this variation are not well understood. An 8-year follow-up discusses their pertinent clinic course with consideration of genetic and nongenetic variables. The phenotypic and symptomatic obstacles encountered since their initial assessment are reviewed, and the use of three-dimensional Medical Modeling (Golden, CO) as a preoperative planning strategy is addressed. Analyzing the longitudinal clinical course of MZ twins with syndromic craniosynostosis will help better predict and provide optimal treatment.

Surgical Outcomes for Speech Surgery in 22q11.2 Deletion Syndrome: The Dilemma of Persistent Velopharyngeal Insufficiency After Pharyngeal Flap Operation.

INTRODUCTION: The majority of patients with 22q11.2 deletion syndrome suffer from velopharyngeal insufficiency (VPI). Patients with 22q11.2 deletion syndrome (22qDS) commonly present with a large central velopharyngeal gap in the setting of poor velar and pharyngeal wall motion. The posterior pharyngeal flap is considered the most effective technique to treat VPI in this complex patient group. This study aims to critically evaluate success rates of surgical management of VPI in 22qDS patients and discuss options for management of a failed posterior pharyngeal flap (PPF) with persistent VPI. METHODS: A systematic review was performed through MEDLINE and Scopus to examine the outcomes of PPF surgery to treat VPI in patients with 22qDS. Complications were defined as persistent VPI, hyponasal speech, and obstructive sleep apnea. To demonstrate an approach to management, the authors outline a recent patient with a failed PPF in this patient population at the authors' institution. RESULTS: The authors comprehensively reviewed 58 articles, 13 of which contained relevant information with extractable data. Of the 159 patients with 22qDS who underwent PPF to treat VPI, successful outcomes were reported in 135 patients (80%; range: 0%-100%). Complications were reported in 14% of patients, with need for revision operations in 3%. DISCUSSION: Surgical management of VPI in patients with 22qDS is challenging, with variable success rates reported in the literature. If unsuccessful, the surgeon faces additional challenges with the revision surgery including a scarred PPF donor site, distorted palatal recipient site, and further medialization of internal carotid arteries. Surgical revision of a failed PPF requires meticulous preoperative planning and technical execution.

Hemisacrectomy with preservation of the contralateral sacral nerve roots and sacroiliac joint for pelvic neurofibrosarcoma in a 7-year-old child: case report with 2-year follow-up.

Neurofibrosarcoma is rare in the pediatric age group. A malignant tumor of the sacrum presents significant challenges, especially if the goals are to resect with wide and clean surgical margins and to achieve acceptable functional outcomes. The authors report a case of this rare tumor affecting the sacrum and sacral nerve roots of a 7-year-old girl and review the role of total hemisacrectomy sparing the contralateral sacral nerve roots and lumbopelvic reconstruction in the treatment of this disease. This patient is, to the best of the authors' knowledge, the youngest to be treated in this manner.

Separation of Thoraco-Omphalo-Ischiopagus Conjoined Twins: Surgical Planning, Management, and Outcomes.

BACKGROUND: Conjoined twins are a rare medical phenomenon that offers a unique challenge for medical professionals. The complex anatomy of conjoined twins dictates their survival and amenability to separation, making each case different in terms of medical management, surgical planning, and patient outcomes. Thoraco-omphalo-ischiopagus twins, joined from the thorax to the pelvis, are one of the rarest orientations recorded in the medical literature, and successful separation of this subset of conjoined twins has not been documented. This report presents a novel case of thoraco-omphalo-ischiopagus tetrapus twins who were successfully separated at 10 months of age. The preoperative planning, operative details, and postoperative course are discussed as they relate to the reconstructive effort. METHODS: Three-dimensional medical modeling was pursued early in the planning process and was used to estimate the soft-tissue requirements for reconstruction and to design custom tissue expanders. RESULTS: The reconstructive effort required postponement until respiratory status was optimized. Even with elaborate preoperative planning, primary closure of the abdomen was limited because of tissue edema and other less predictable patient factors. Delayed closure of the abdominal wall was made possible with negative-pressure wound therapy and secondary flap advancements. CONCLUSION: Preoperative coordination with necessary vendors, a multidisciplinary surgical effort, and optimal timing of the surgical intervention all contribute to the successful separation and long-term survival of thoraco-omphalo-ischiopagus conjoined twins. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Review of quantitative outcome analysis of cranial morphology in craniosynostosis.

Outcome measures in craniosynostosis surgery have progressed from those based on the need for surgical revision to linear anthropometric measurements, 2D CT vector analysis and 3D CT vector analysis. However, finding an objective means to assess postoperative cranial morphological improvement remains challenging. A critical review of previous studies used to measure craniosynostosis surgery outcomes is presented. We also introduce and briefly discuss the key features of the computational algorithm that is being utilized in our center for evaluating craniosynostosis surgical outcomes. This has addressed a number of the previous challenges encountered in quantitative measurement of cranial morphological change. Point cloud representation and 3D stereophotogrammetry have made it possible to compare pre and post-operative images of children undergoing surgical correction for craniosynostosis. These pre- and post-operative images can also be compared to age, sex and race-matched controls throughout the patient's lifetime allowing longitudinal changes to be measured on follow up.

Cranial Fasciitis: A Systematic Review and Diagnostic Approach to a Pediatric Scalp Mass.

Cranial fasciitis is an uncommon, benign fibroproliferative condition of the scalp or skull that arises in children. Clinically, it manifests as a firm, nontender, subcutaneous, enlarging mass. The purpose of our study was to review the literature on cranial fasciitis to create a diagnostic algorithm using the latest patient at our institution as an example. The authors conducted a systematic review examining all published cases of cranial fasciitis in English literature. The authors then created a diagnostic algorithm to help distinguish cranial fasciitis from other similarly presenting cranial masses. To demonstrate this algorithm, the authors detailed the latest patient with cranial fasciitis at our institution. The authors extracted data from 53 published reports documenting 72 patients of cranial fasciitis. Our patient presented similarly to what was reported in the literature. A 7-week-old boy presented with 2 small parietal scalp masses that were noted shortly after birth. After noncontrast computed tomography imaging, the enlarging masses were resected and found to have eroded the outer cranial vault cortex. Histological analysis revealed cranial fasciitis. The differential diagnosis for an enlarging scalp mass in an infant or child is broad. Cranial fasciitis cannot be diagnosed based on clinical presentation alone. Imaging is usually employed to further characterize lesions after initial examination but histopathological analysis is essential for diagnosis. The locally invasive nature of cranial fasciitis makes it difficult to distinguish from malignant conditions such as sarcomas. However, if the diagnosis of cranial fasciitis is considered early, patients can achieve prompt clinical resolution following simple resection.

Prenatal Identification of Pierre Robin Sequence: A Review of the Literature and Look towards the Future.

Fetal ultrasonography is an important tool used to prenatally diagnose many craniofacial conditions. Pierre Robin sequence (PRS) is a rare congenital deformation characterized by micrognathia, glossoptosis, and airway obstruction. PRS can present as a perinatal emergency when the retropositioned tongue obstructs the airway leading to respiratory compromise. More predictable and reliable diagnostic studies could help the treating medical team as well as families prepare for these early airway emergencies. The medical literature was reviewed for different techniques used to prenatally diagnose PRS radiologically. We have reviewed these techniques and suggested a possible diagnostic pathway to consistently identify patients with PRS prenatally.

Cephalometric outcomes of orthognathic surgery in hemifacial microsomia.

Hemifacial microsomia is a hypoplastic disorder of the first and second branchial arches that significantly impacts on the development of the jaws, leading to malocclusion and facial asymmetry. There is little in the literature regarding the application of orthodontic/orthognathic approaches to the correction of these deformities and the stability of the surgical results. To address this, a retrospective chart review of 10 patients with complete orthodontic records and greater than 1 year of follow-up was performed. Posteroanterior cephalograms were assessed by modified Grummons analysis to determine mandibular offset (deviation of the chin point from the skeletal midline) and occlusal cant. These measurements were performed at 3 time points (T1: preoperative, T2: immediate postoperative, T3: follow-up) to elucidate the surgical movement (T2-T1), the postoperative relapse (T3-T2), and the net gain movement (T3-T1). Maxillary movements were quantified, and the occlusal cant was expressed as a ratio between vertical heights of the maxilla at the first molar on each side. One sample t test demonstrated statistically significant surgical movement and net gain. Relapse was statistically insignificant. Repeated-measures analysis of variance demonstrated similar results for chin point position relative to the putative midline. Our results suggest that a combined orthodontic/orthognathic approach at skeletal maturity delivers improved occlusal outcomes in the long term as assessed by chin point deviation and occlusal cant, but secondary surgery rates are higher than those for orthognathic surgery in other patient groups. We advocate limiting surgery to skeletal maturity whenever possible to achieve stable long-term results while limiting morbidity and number of procedures.

History of synthetic materials in alloplastic cranioplasty.

When faced with calvarial defects, surgeons have long searched for repair materials. General criteria include ease of use, low cost, availability, cosmetic shape, and osteointegrative potential. While autologous bone is widely used and favored in contemporary reconstructive procedures, synthetic alternatives have been used throughout history and are necessary in current practice for select cases when autograft reconstruction is not an option (such as cases with severe bony comminution, bone graft resorption, infection, and limited donor site options). For centuries, surgeons have experimented with metals, ceramics, plastics, and later, resorbable polymers. This paper provides a tour of the materials that have been used and experimented with throughout the history of alloplastic cranioplasty.