Bone Graft Substitutes and Enhancement in Craniomaxillofacial Surgery.

Critical-sized bone defects are a reconstructive challenge, particularly in the craniomaxillofacial (CMF) skeleton. The "gold standard" of autologous bone grafting has been the work horse of reconstruction in both congenital and acquired defects of CMF skeleton. Autologous bone has the proper balance of the protein (or organic) matrix and mineral components with no immune response. Organic and mineral adjuncts exist that offer varying degrees of osteogenic, osteoconductive, osteoinductive, and osteostimulative properties needed for treatment of critical-sized defects. In this review, we discuss the various mostly organic and mostly mineral bone graft substitutes available for autologous bone grafting. Primarily organic bone graft substitutes/enhancers, including bone morphogenic protein, platelet-rich plasma, and other growth factors, have been utilized to support de novo bone growth in setting of critical-sized bone defects. Primarily mineral options, including various calcium salt formulation (calcium sulfate/phosphate/apatite) and bioactive glasses have been long utilized for their similar composition to bone. Yet, a bone graft substitute that can supplant autologous bone grafting is still elusive. However, case-specific utilization of bone graft substitutes offers a wider array of reconstructive options.

Current trends in unilateral cleft lip repair.

The purpose of this review is to provide an in-depth look at the current perioperative and intraoperative practices for unilateral cleft lip repair. The contemporary literature reveals trends towards incorporation of curvilinear and geometric hybrid lip repairs. Perioperative practices are trending in new directions as well with the use of enhanced recovery after surgery (ERAS) protocols to reduce morbidity and length of stay, continued use of nasoalveolar molding, and a tendency to favor outpatient repair with more utilization of same day surgery centers. There is much room for growth, with new and exciting technologies on the horizon to improve upon cosmesis, functionality, and the operative experience.

Reducing Risks for Midface and Mandible Fracture Repair.

The midface skeleton provides structural scaffolding to the middle third of the face. Complications associated with fracture repair in these regions can result from incomplete, inaccurate, or delayed assessment, poor initial and subsequent reduction and fixation, infection, uncontrolled hemorrhage, hardware failure and associated soft tissue injuries. A systematic approach to managing the patient with facial trauma that includes Acute Trauma Life Support principles, early reconstruction, and precise reduction and fixation is essential to reducing the short-term and long-term risks of complications.

Enhanced Recovery after Surgery (ERAS) protocols in craniomaxillofacial surgery: an evidence-based review.

PURPOSE OF REVIEW: Enhanced Recovery after Surgery (ERAS) refers to a patient centered, multidisciplinary team developed pathway aimed at reducing the surgical stress response and facilitating expedited patient postoperative recovery. These protocols have been largely developed in the general surgery literature and have led to vast improvements in the patient experience. With a growing shortage of hospital resources during the height of the COVID-19 pandemic there has been a growing push to apply these principles to a wide variety of specialties. RECENT FINDINGS: ERAS protocols are generally substantiated on three phases along the continuum of surgical care: preadmission optimization, intraoperative treatment, and postoperative management. In this article, the evidence for ERAS development in craniomaxillofacial surgery will be reviewed, and recommendations from prior studies for enhanced recovery will be outlined. SUMMARY: ERAS protocols have been proven effective in many surgical arenas, however, modification is needed for the craniomaxillofacial population. The implications for widespread implementation of ERAS protocols during these procedures are a potentially shortened length of stay, expedited early return to function, reduction in narcotic dependence, and reduction in postdischarge complications necessitating additional intervention.

Otitis Media and Hearing Loss in Patients With Nonsyndromic Craniosynostosis: A Multicenter Study.

OBJECTIVES: The objectives of this study were to: (1) determine the prevalence of otitis media with effusion in patients with nonsyndromic craniosynostosis; (2) determine the prevalence of hearing loss in patients with nonsyndromic craniosynostosis; and (3) identify potential patterns and outcomes in patients with nonsyndromic craniosynostosis. METHODS: A retrospective chart review was conducted at 2 academic institutions, St Christopher's Hospital for Children and SUNY Upstate Medical University, from January 2015 through August 2018, to identify patients having nonsyndromic craniosynostosis with a concurrent diagnosis of otitis media and/or hearing loss. The demographic data and categorical variables were analyzed using descriptive statistics and chi-square testing, respectively. RESULTS: In the entire cohort of patients (N = 113, age range 0-123 months), 36% had otitis media with effusion on either history, physical examination, tympanometry, and/or imaging. Half (50%) of patients with coronal synostosis had otitis media with effusion compared to sagittal (40.7%), metopic (26.3%), multiple (25%), and lambdoid (0%). However, these differences were not statistically significant (P = .190). Most patients had normal hearing (91%), while a minority had either conductive (7%) or sensorineural (2%) hearing loss. CONCLUSION: The presence of otitis media in our cohort of patients with nonsyndromic craniosynostosis appears to be at the upper limit of normal when compared to historical rates in normocephalic children. Synostosis subtype did not appear to predict the presence of otitis media. Only 9% of patients with nonsyndromic craniosynostosis were found to have a hearing loss.

Prevention and management of oronasal fistulas.

PURPOSE OF REVIEW: The aim of this article is to present the current opinion on the prevention and management of oronasal fistulas in cleft palate patients. RECENT FINDINGS: Though cleft palate repair has seen numerous modifications and improvements, oronasal fistulas remain one of the most common complications of palatoplasty. There are various techniques available for preventing and managing this complication. SUMMARY: Oronasal fistulas can be minimized by employing proper principles for palatoplasty. Once a fistula occurs, the repair technique should be appropriate for the fistula type. Oronasal fistula classifications, various repair techniques, tissue adjuncts, and biomaterials used in both the primary palate repair and oronasal fistula repair are discussed in this review.

The unilateral cleft lip repair.

OBJECTIVE: To determine if there is a benefit of 2-stage cleft lip repair in regard to improving facial symmetry and facilitating definitive lip, nose, and palate repair. STUDY DESIGN: Retrospective chart review of patients born with complete, unilateral cleft lip deformity that underwent a two-stage repair described as a stage 1 straight line repair and a stage 2 modified Millard repair, for which a complete set of records, and peri-operative and post-operative photos were available. All cases were performed by a single surgeon. SETTING: Tertiary care center craniofacial team. METHODS: Measurements were taken from intraoperative, perioperative, and postoperative images of patients before and after each stage. Ratios were then created comparing the affected size to the unaffected side, and these were averaged between observers. RESULTS: A 19% increase in the width of area of the presumptive C flap was obtained between the unrepaired and the post-stage I images. The nostril width of the cleft side was 1.2× the width of the unaffected side, demonstrating a 140% decrease in nostril width at the completion of stage II. The cleft side nostril width was maintained slightly larger than the noncleft side as desired. Symmetry of the upper lip length was achieved, as the length of the cleft side lateral lip after stage II was 92% of the unaffected side. CONCLUSION: We believe this study provides evidence for our observations that a two-stage repair can be performed with functionally and aesthetically pleasing outcomes as an alternative to presurgical nasoalveolar molding.

Comparing Caliper versus Computed Tomography Measurements of Cranial Dimensions in Children.

OBJECTIVES/HYPOTHESIS: We have found no study assessing the accuracy of caliper cranium measurements compared to computed tomography (CT) measurements of the head. The objective of this study was to assess the reliability of caliper measurements in comparison to CT measurements. STUDY DESIGN: Retrospective chart review. METHODS: This study includes all patients evaluated for head shape abnormality between 2010 and 2019 at a single academic medical center. Eighty-nine patients who had CT head scans were identified, and their caliper measurements of anterior-posterior and transverse head dimensions were documented. RESULTS: There was no statistically significant difference between the CT and caliper measurements. CONCLUSION: Caliper measurements are a simple and reliable way to assess cranial vault proportionality with growth after cranial vault reconstruction. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:773-775, 2021.

The Art of Teaching, Training, and Putting the Scalpel in Residents' Hands.

Surgical education is under tremendous pressure due to ever-increasing medical knowledge and demands on trainees' time. They must continually learn more in less time due to work hour limitations, regulations, and electronic medical record demands. Surgical training must become more efficient. There is an unprecedented array of education and training opportunities for resident preparation. The preparation for each case has to be maximal. Preoperative, intraoperative, and postoperative simulation and discussions improve the educational benefit of the trainee experience. For the teaching surgeon, putting a scalpel in residents' hands requires patience, knowledge, judgment, and a leap of faith in the resident.

Update on evidence in craniomaxillofacial surgery.

PURPOSE OF REVIEW: Evidence-based medicine underpins clinical practice. Ideally, our clinical decision-making stems from systematic reviews of randomized controlled trials. However, in practice, this is not often the case, and we must instead rely on the best available evidence. RECENT FINDINGS: We review the history of evidence-based research, the development of the levels of evidence, and the relationship of evidence and bias present in craniomaxillofacial surgery. We also discuss the recent trends in CMF publications and identify areas for improvement. SUMMARY: Because of inherent challenges, the quality of evidence in craniomaxillofacial surgery lags behind other surgical and medical specialties. However, over recent years this has improved significantly, with better reporting of data and a higher rate of randomized controlled trials.

Risk factors for velopharyngeal dysfunction following orthognathic surgery in the cleft population.

PURPOSE OF REVIEW: This article highlights important trends in speech outcomes following orthognathic surgery in the cleft lip and palate populations. The geometric changes in the velopharyngeal port caused by maxillary advancement by standard means and distraction are only one consideration in predicting speech outcomes. Myriad and variable preoperative risk factors, both anatomic and functional, have been identified in the literature because of weaknesses in experimental design and small patient populations. Therefore, elucidating risk factors for postoperative velopharyngeal dysfunction remains a challenge in our field. RECENT FINDINGS: Recent pharyngeal morphologic studies using computed tomography demonstrate volumetric discrepancies in the unilateral and bilateral cleft lip and palate populations before and after orthognathic surgery, suggesting differing requirements of velar adaptation among these two populations. Perceptual and instrumental speech evaluation studies and cephalometric correlates revisit 'borderline' velopharyngeal insufficiency and isolate preoperative velar length as a risk factor for velopharyngeal dysfunction following orthognathic surgery. SUMMARY: Research design heterogeneity, small patient populations, and inherent risk of bias of retrospective reviews obscure velopharyngeal dysfunction risk factor identification prior to orthognathic surgery. However, recent reports on the volumetric changes in the pharyngeal airway and preoperative 'borderline' velopharyngeal insufficiency and velar length offer improved predictive value in anticipating postoperative velopharyngeal dysfunction.

Frontal Sinus Fractures: Evolving Clinical Considerations and Surgical Approaches.

Frontal sinus fractures are an uncommon injury of the maxillofacial skeleton, and account for 5-15% of all maxillofacial fractures. As the force of impact increases, fractures may extend beyond the anterior table to involve adjacent skull, posterior table and frontal sinus outflow tract (FSOT). Fractures at these subsites should be evaluated independently to assess the need for and type of operative intervention. Historically, these fractures were managed aggressively with open techniques resulting in obliteration or cranialization. With significant injuries, these approaches are still indispensable. However, the treatment of frontal sinus fractures has changed dramatically over the past half-century, and recent case series have demonstrated favorable outcomes with conservative management. Concurrently, there has been an increasing role of minimally invasive endoscopic techniques, both for primary and expectant management, with a focus on sinus preservation. Here, we review the diagnosis and management of frontal sinus fractures, with an emphasis on subsite evaluation. Following a detailed assessment, an appropriate treatment strategy is selected from a variety of open and minimally invasive approaches available in the surgeon's armamentarium.

Location of the euryon in scaphocephalic vs. non-scaphocephalic controls: A novel assessment of cranial vault remodeling outcomes.

We describe a novel measurement of cranial morphology in pre- and post-operative scaphocephalic patients to complement the cephalic index. This will better describe restoration of normal skull and head shape, further defining the nuances of the corrected skull. In this retrospective comparative study the location of the euryon on the skull was statistically significantly different in preoperative scaphocephalic patients versus non-scaphocephalic controls. This difference was resolved with surgical cranial vault remodeling, indicating restoration of a normal skull profile. Additional measurements of the location of the euryon in relation to the forehead prominence, combined with validated cephalic index measurements, can further describe postoperative outcomes in scaphocephaly. More sensitive clinical measurements such as these can aid the craniofacial surgeon in assessing outcomes in cranial vault remodeling. Further, large-scale study is needed to determine if additional anterior skull metric points may be useful in documenting skull shape restoration.

Skull Base Trauma: Clinical Considerations in Evaluation and Diagnosis and Review of Management Techniques and Surgical Approaches.

Traumatic injuries to the skull base can involve critical neurovascular structures and present with symptoms and signs that must be recognized by physicians tasked with management of trauma patients. This article provides a review of skull base anatomy and outlines demographic features in skull base trauma. The manifestations of various skull base injuries, including CSF leaks, facial paralysis, anosmia, and cranial nerve injury, are discussed, as are appropriate diagnostic and radiographic testing in patients with such injuries. While conservative management is sometimes appropriate in skull base trauma, surgical access to the skull base for reconstruction of traumatic injuries may be required. A variety of specific surgical approaches to the anterior cranial fossa are discussed, including the classic anterior craniofacial approach as well as less invasive and newer endoscope-assisted approaches to the traumatized skull base.

Incidence of Secondary Surgery after Modified Furlow Palatoplasty: A 20-Year Single-Surgeon Case Series.

Objective To determine the occurrence of velopharyngeal insufficiency (VPI) requiring surgery and fistula repair after primary palatoplasty using a "modified" Furlow technique. Study Design Case series with chart review. Setting Academic multidisciplinary cleft and craniofacial center. Subjects and Methods Children younger than 18 years at presentation, with unrepaired cleft palate, with or without cleft lip, including submucous clefts, who underwent palatoplasty were included. No cleft patients having primary repair were excluded. All operations were conducted by a single surgeon from March 1994 through December 2013. Charts were reviewed for demographics, cleft type, genetic syndrome, operations performed, and complications, including VPI and oronasal fistula. Results In total, 312 consecutive patients underwent primary palatoplasty (160 [51.3%] male) with a median age of repair of 0.95 (range, 0.47-17.6) years and followed for 6.49 (range, 4.0-20.2) years. Robin sequence was diagnosed in 109 (34.9%), 104 (33.4%) had alveolar clefts, and 27 (8.7%) had concomitant gingivoperiosteoplasty. A modified Furlow was performed in 289 (92.6%). Overall, 16 (5.1%) required subsequent pharyngeal flap for VPI, and 48 (15.4%) required oronasal fistula repair. Veau class II had higher pharyngeal flap rates ( P = .033). Fistula repair was lower in Veau I ( P < .001) but higher in Veau II ( P < .001) and IV ( P = .002). Older age ( P = .034) and Robin sequence ( P = .017) were associated with higher rates of oronasal fistula repair. Conclusions The modified Furlow palatoplasty yields acceptable rates of secondary surgery for VPI without selection based on cleft width. While our oronasal fistula repair rate is high, it is concordant with previous reports and is likely related to our rare use of lateral relaxing incisions.

Long-Term Otologic and Audiometric Outcomes in Patients with Cleft Palate.

Objective Describe longitudinal audiometric and otologic outcomes in patients with cleft palates. Study Design Case series with chart review. Setting Single academic medical center. Methods Charts of 564 patients with a diagnosis of cleft palate (59% syndromic etiology, 41% nonsyndromic) from 1998 to 2014 were reviewed. Patients without at least 1 audiometric follow-up were excluded from analysis. Patient demographics, surgeries, audiometric tests, and otologic data were recorded for 352 patients. Results Forty-five percent had isolated cleft palates, 34% had unilateral cleft lip and palate, and 21% had bilateral cleft lip and palate. Patients were followed for a mean of 50.3 months with a mean of 3.2 separate audiograms performed. Patients received a mean of 2.93 pressure equalization tubes. Increased number of pressure equalization tubes was not associated with incidence of cholesteatoma, which was identified in only 4 patients. Nine patients underwent eventual tympanoplasty with an 89% closure rate. Analysis of mean air-bone gap by cleft type did not reveal significant differences ( P = .08), but conductive losses and abnormal tympanometry persisted into teenage years. Conclusions Patients with cleft palates have eustachian tube dysfunction, which, in our cohort, resulted in persistent conductive hearing loss, highlighting the importance of long-term follow-up. Cholesteatoma incidence was low and not associated with number of tubes, which at our institution were placed prophylactically. Tympanoplasty was successful in those with persistent perforations.

Controversies in the Management of Patients with Cleft Lip and Palate.

Cleft lip and palate is one of the most common congenital anomalies. For many years, surgeons have been attempting to reduce the severity of the deformity before the surgical repair to achieve a better outcome. The nasoalveolar molding technique uses acrylic nasal stents attached to the vestibular shield of an oral molding plate to mold the nasal alar cartilages into a more normal form and position during the presurgical period. Proponents of nasoalveolar molding claim several benefits, including improved aesthetic outcome, reduced overall costs, and a psychosocial benefit to the family. Research on these outcomes is not conclusive.