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1.
J Craniofac Surg ; 31(1): 265-268, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31821213

RESUMO

PURPOSE: Pedestrian trauma due to motor vehicle crashes can be especially destructive to the pediatric population as the facial skeleton is immature and developing. Almost half of crashes resulting in pedestrian death involved alcohol consumption, and children are often victims of irresponsible driving. The objective of this study was to examine the prevalence of facial fractures in this patient population in order to analyze management strategies that optimize functional recovery. METHODS: A retrospective chart review was performed for all facial fractures resulting from motor vehicle collisions with pedestrians in the pediatric population at a level 1 trauma center in an urban environment (University Hospital in Newark, NJ). Patient demographics were collected, as well as location of fractures, concomitant injuries, and surgical management strategies. RESULTS: During the time period examined, 55 patients were identified as 18 years of age or younger and having sustained a facial fracture as the result of being struck by a motor vehicle. The mean age was 11.3 (range 1-18) years, with a male predominance of 69.0%. There were a total of 125 fractures identified on radiologic imaging via CT or X-ray. The most common fractures were those of the orbit (20.0%), mandible (19.2%), and nasal bone (10.4%). The mean Glasgow Coma Scale on arrival was 12.1 (range 4-15). Fifteen patients were intubated on, or prior to, arrival to the trauma bay. The most common concomitant injuries were intracranial hemorrhage, long bone fractures, and cervical spine fractures. The mean operative time was 216.9 (range 63-515) minutes. Surgery was required in 36 patients, with most undergoing open reduction and internal fixation with titanium plates and screws. Two patients required resorbable plates, and one required Medpor implants. The mean hospital length of stay was 9.9 (range 1-59) days. Two patients expired. CONCLUSIONS: There is currently a dearth of literature regarding the management and patterns of injury for pediatric pedestrian injuries due to motor vehicle collisions. The impact of these injuries can be devastating with concomitant life-threatening complications, and may influence the future development of the facial skeleton after healing of the bone and soft tissue. The authors hope this study can provide insight and further investigation regarding prevention and management.

2.
Plast Reconstr Surg ; 144(4): 932-940, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31568307

RESUMO

BACKGROUND: Patients with syndromic craniosynostosis have an increased incidence of progressive hydrocephalus and Chiari malformations, with few data on the relative benefit of various surgical interventions. The authors compare the incidence and resolution of Chiari malformations and hydrocephalus between patients undergoing posterior vault distraction osteogenesis (PVDO) and patients undergoing conventional cranial vault remodeling. METHODS: Patients with syndromic craniosynostosis who underwent cranial vault surgery from 2004 to 2016 at a single academic hospital, with adequate radiographic assessments, were reviewed. Demographics, interventions, the presence of a Chiari malformation on radiographic studies and hydrocephalus requiring shunt placement were recorded. Mann-Whitney U and Fisher's exact tests were used as appropriate. RESULTS: Forty-nine patients underwent PVDO, and 23 patients underwent cranial vault remodeling during the study period. Median age at surgery (p = 0.880), sex (p = 0.123), and types of syndrome (p = 0.583) were well matched. Patients who underwent PVDO had a decreased incidence of developing Chiari malformations postoperatively compared with the cranial vault remodeling cohort (2.0 percent versus 17.4 percent; p = 0.033). Not surprisingly, no significant difference was found between the groups with regard to the incidence of postoperative hydrocephalus requiring shunt placement (PVDO, 4.1 percent; cranial vault remodeling, 4.3 percent; p = 0.999). CONCLUSIONS: As expected, PVDO did not significantly affect intracranial hydrodynamics to the extent that hydrocephalus shunting rates were different for patients with syndromic craniosynostosis. However, PVDO was associated with a reduced risk of developing a Chiari malformation; however, prospective evaluation is needed to determine causality. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.


Assuntos
Malformação de Arnold-Chiari/etiologia , Craniossinostoses/complicações , Craniossinostoses/cirurgia , Hidrocefalia/etiologia , Osteogênese por Distração/métodos , Crânio/cirurgia , Feminino , Humanos , Lactente , Masculino , Indução de Remissão , Estudos Retrospectivos , Síndrome
3.
Surg J (N Y) ; 5(4): e146-e149, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31602397

RESUMO

Objective Sports-related injuries, such as facial fractures, are potentially debilitating and may lead to long-term functional and aesthetic deficits in a pediatric patient. In this study, we analyze sports-related facial fractures in the urban pediatric population in an effort to characterize patterns of injury and improve management strategies and outcomes. Methods Retrospective chart review was performed for all facial fractures resulting from sports injuries in the pediatric population at a level-1 trauma center (University Hospital, Newark, NJ). Results Seventeen pediatric patients were identified as having sustained a fracture of the facial skeleton due to sports injury. Mean age was 13.9 years old. A total of 29 fractures were identified. Most common fracture sites included the orbit ( n = 12), mandible ( n = 5), nasal bone ( n = 5), and zygomaticomaxillary complex ( n = 3). The most common concomitant injuries included skull fracture ( n = 3), intracranial hemorrhage ( n = 4), and traumatic brain injury ( n = 4). One patient was intubated upon arrival to the emergency department. Hospital admission was required in 13 patients, 4 of which were admitted to an intensive care setting. Nine patients required operative intervention. Mean length of hospital stay was 2.4 days. No patients were expired. Conclusions Sports-related facial fractures are potentially debilitating injuries in the pediatric population. Analysis of fracture pattern and concomitant injuries is imperative to develop effective management strategies and prevention techniques.

4.
Am Surg ; 85(7): 730-732, 2019 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-31405417

RESUMO

There is an absence of literature regarding nasoorbitoethmoid (NOE) facial fractures. Although NOE fractures are uncommon, there are a significant number in the pediatric population. These fractures also often occur in conjunction with other facial fractures because the NOE region adjoins the nose, orbit, maxilla, and cranium. They can also be a harbinger for more serious concerns such as traumatic brain injury and intracranial hemorrhage. For this reason, NOE fractures can be highly complicated and a challenge to manage. We aim to define the etiologies and patterns of NOE fractures to guide hospital and surgical management strategies. From 2001 to 2014, 15 pediatric patients were identified as having sustained an NOE fracture. Four (26.7%) of the patients were female and 11 (68.8%) were male. Average age was 11.40. The most common etiologies recorded were motor vehicle accident (n = 8), pedestrian struck (n = 3), and assault (n = 2). Orbital fracture (n = 13), nasal fracture (n = 13), and frontal sinus fracture (n = 10) were the most commonly associated facial fractures sustained alongside NOE fracture. Several patients sustained traumatic brain injury (n = 11) and loss of consciousness (n = 13). The mean Glasgow Coma Score was 10.5. In addition, eight required intubation and five required a surgical airway. Thirteen of the patients were admitted to the ICU and eight required surgical management for their fractures. Titanium plates were most commonly used (n = 4) for surgical management. Alternatively, resorbable implants were used for two patients. The remaining two were treated with closed reduction.


Assuntos
Osso Etmoide , Ossos Faciais/lesões , Fixação de Fratura/métodos , Osso Nasal/lesões , Fraturas Orbitárias , Fraturas Cranianas , Adolescente , Criança , Pré-Escolar , Osso Etmoide/lesões , Osso Etmoide/cirurgia , Traumatismos Faciais/etiologia , Traumatismos Faciais/cirurgia , Feminino , Humanos , Lactente , Tempo de Internação , Masculino , Fraturas Orbitárias/etiologia , Fraturas Orbitárias/cirurgia , Fraturas Cranianas/etiologia , Fraturas Cranianas/cirurgia , Centros de Traumatologia
6.
J Craniofac Surg ; 30(7): 2026-2029, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31261348

RESUMO

BACKGROUND: The purpose of this study was to examine a level 1 trauma center's 12-year experience treating frontal sinus fractures with regards to patient demographics, management strategies, and treatment outcomes. METHODS: An institutional review board-approved retrospective review of all facial fractures at a level 1 trauma center was performed for the years 2000 to 2012. Patient demographics, location of fractures, concomitant injuries, use of antibiotics, surgical management strategies and outcomes were collected for all frontal sinus fractures. A significance value of 5% was used. RESULTS: There were 291 frontal sinus fractures treated at our institution. The mean age of patients was 34.4 years with a male predominance (90%). The most common mechanisms of injury were assault in 82 (28.2%) and motor vehicle accidents in 80 (27.5%). Anterior table fractures were seen in 261 patients (89.7%) and posterior table fractures were seen in 181 (62.2%). Treatment included ORIF with sinus preservation in 18 (6.2%), ORIF with sinus obliteration in 20 (6.9%), and cranialization in 18 (6.2%). Antibiotics were started on admission in 152 patients (52.2%). Fatality occurred in 9.3% of patients and complications included meningitis (1%), frontal sinusitis (1%), early wound infection (0.3%), and mucopyelocele (0.3%). CONCLUSIONS: Frontal sinus fractures in our center are most often caused by interpersonal violence. Anterior table fractures were more common than posterior table fractures and ORIF with sinus obliteration was the most common surgical intervention. Most frontal sinus fractures at our institution (82%) were treated conservatively with no surgical intervention and we observed a low rate of long term complications.


Assuntos
Fraturas Cranianas/cirurgia , Acidentes de Trânsito , Adulto , Traumatismos Faciais/complicações , Traumatismos Faciais/cirurgia , Feminino , Seio Frontal/cirurgia , Humanos , Masculino , Estudos Retrospectivos , Fraturas Cranianas/complicações , Resultado do Tratamento , Violência
7.
Plast Reconstr Surg ; 2019 Jul 02.
Artigo em Inglês | MEDLINE | ID: mdl-31274746

RESUMO

PURPOSE: Patients with syndromic craniosynostosis have an increased incidence of progressive hydrocephalus and Chiari malformations (CM), with little data on relative benefit of various surgical interventions. The authors compare the incidence and resolution of CM and hydrocephalus between patients undergoing posterior vault distraction osteogenesis (PVDO) versus conventional cranial vault remodeling (CVR). METHODS: Patients with syndromic craniosynostosis who underwent cranial vault surgery from 2004 - 2016 at a single academic hospital with adequate radiographic assessments were reviewed. Demographics, interventions, the presence of a CM on radiographic studies and hydrocephalus requiring shunt placement were recorded. Mann-Whitney U and Fisher's exact tests were used as appropriate. RESULTS: 49 patients underwent PVDO, and 23 patients underwent CVR during the study period. Median age at surgery (p=0.880), sex (p=0.123), and types of syndrome (p=0.583) were well-matched. Patients who underwent PVDO had a decreased incidence of developing CM post-operatively compared to the CVR cohort (2.0% vs 17.4%, p=0.033). Not surprisingly, no significant difference was found between the groups with regards to the incidence of post-operative hydrocephalus requiring shunt placement (PVDO: 4.1% vs CVR: 4.3%, p=0.999). CONCLUSION: As expected, PVDO did not significantly affect intracranial hydrodynamics to the extent that hydrocephalus shunting rates were different for patients with syndromic craniosynostosis. However, PVDO was associated with a reduced risk of developing a CM, though prospective evaluation is needed to determine causality.

8.
Plast Reconstr Surg ; 143(6): 1725-1736, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31136491

RESUMO

BACKGROUND: The frequency of respiratory events in the perioperative period, and optimal duration of intubation during early mandibular distraction osteogenesis activation, are poorly understood. This study assesses potential risk factors associated with perioperative respiratory events, particularly the need for reintubation, following mandibular distraction osteogenesis surgery. METHODS: A retrospective review was conducted for infants (younger than 1 year) undergoing mandibular distraction osteogenesis for tongue-based airway obstruction between November of 2010 and December of 2017. Univariate and multivariate analyses of sentinel events and outcomes were performed. RESULTS: Ninety infants (median age, 35 days) were included (50 percent were syndromic). Twenty-seven subjects (30 percent) experienced a respiratory event requiring intervention before discharge, including 14 subjects who failed initial extubation. Subjects extubated earlier than postoperative day 5 failed extubation more frequently (33%) compared to those extubated later (9%; p = 0.005). Respiratory events occurred more frequently when extubation was attempted at distraction lengths of 5 mm or less (42 percent) compared to greater than 5 mm (21 percent; p = 0.032). Logistic regression modeling showed that syndromic status (OR, 14.8) and secondary airway anomaly (OR, 6.1) were significant predictors for respiratory events, whereas greater length of distraction at the time of extubation was protective (OR, 0.8; p < 0.05). CONCLUSIONS: Postoperative intubation of at least 5 days with associated mean distraction of 5 mm appears to be associated with successful extubation trial following mandibular distraction osteogenesis surgery. Patients with congenital syndromes and secondary airway anomalies are more likely to experience perioperative respiratory events. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.


Assuntos
Micrognatismo/cirurgia , Osteogênese por Distração/efeitos adversos , Assistência Perioperatória/métodos , Síndrome de Pierre Robin/cirurgia , Insuficiência Respiratória/fisiopatologia , Obstrução das Vias Respiratórias/etiologia , Obstrução das Vias Respiratórias/fisiopatologia , Estudos de Coortes , Feminino , Seguimentos , Humanos , Incidência , Lactente , Intubação Intratraqueal/métodos , Modelos Logísticos , Masculino , Avanço Mandibular/efeitos adversos , Avanço Mandibular/métodos , Micrognatismo/diagnóstico por imagem , Análise Multivariada , Osteogênese por Distração/métodos , Período Perioperatório , Síndrome de Pierre Robin/diagnóstico por imagem , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/terapia , Insuficiência Respiratória/epidemiologia , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/terapia , Estudos Retrospectivos , Medição de Risco , Resultado do Tratamento
9.
J Craniofac Surg ; 30(2): 503-507, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31137452

RESUMO

BACKGROUND: Posterior cranial vault distraction osteogenesis (PVDO) has gained popularity as the initial intervention in patients with syndromic craniosynostosis. Patients may require secondary frontal orbital advancement (FOA) following PVDO, but little is known about the perioperative risks associated with this staged management. The purpose of this study is to compare the perioperative morbidity profile of secondary FOA (study) to that of primary FOA (control). METHODS: A retrospective review was conducted for patients with syndromic or complex craniosynostosis undergoing FOA between 2004 and 2017. Univariate and multivariate analysis of demographic and perioperative data were performed. RESULTS: Forty-three subjects met inclusion criteria, 17 in the study cohort and 26 in the control cohort. The 2 cohorts were similar with regards to diagnosis and suture involvement, as well as weight-adjusted estimated blood loss, blood transfusion volume, and length of hospital stay (P > 0.050). Secondary FOA procedures required longer operating time (231 ±â€Š58 versus 264 ±â€Š62 min, P = 0.031) and anesthesia time (341 ±â€Š60 versus 403 ±â€Š56 min, P = 0.002). The secondary FOA cohort had a significantly greater proportion of procedures with difficult wound closure (19% versus 59%, P = 0.008). Two subjects in the study cohort developed a wound dehiscence, compared with 1 subject in the control cohort (P = 0.552). Frontal orbital advancement as a secondary procedure after PVDO was a predictor variable in multivariate analysis for wound difficulties (odds ratio 8.6, P = 0.038). CONCLUSION: Syndromic and complex craniosynostosis may safely be managed with initial PVDO followed by FOA, with some increased wound closure difficulty.


Assuntos
Craniossinostoses/cirurgia , Osso Frontal/cirurgia , Órbita/cirurgia , Osteogênese por Distração/métodos , Criança , Pré-Escolar , Feminino , Seguimentos , Humanos , Lactente , Masculino , Análise Multivariada , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Síndrome , Resultado do Tratamento
10.
Ann Plast Surg ; 82(4S Suppl 3): S179-S184, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30855385

RESUMO

PURPOSE: Facial fractures are a harbinger when it comes to airway management. Facial fractures can cause airway obstruction or preclude the use of intubation. We aim to examine the etiologies, types of facial fractures, and the risk factors that may lead to requirement of an advance airway. METHODS: A retrospective chart review was performed of all facial fractures in the adult population in a level 1 trauma center in an urban environment (University Hospital in Newark, NJ). Patient demographics were collected, as well as location of fractures, concomitant injuries, and course of hospital stay. RESULTS: During the period examined, 2626 patients were identified as 18 years or older and with facial fracture. Among these patients, 443 received airway management. Mean age was 34.21 years (range, 18-95 years), with a male predominance of 91.9%. One hundred nineteen patients were intubated on, or before, arrival to the trauma bay. One hundred three patients required surgical airways on arrival to the trauma bay, and 91 of these patients were also reported to have been intubated before arrival. There were a total of 741 fractures identified on radiologic imaging. The most common fractures observed were orbital fractures, frontal sinus fractures, and nasal fractures. Mean Glasgow Coma Scale score on arrival was 9.45 (range, 3-15). Gunshot wound was also the most common etiology among those who were intubated and those who received a surgical airway. The most common concomitant injuries were traumatic brain injury, intracranial hemorrhage, and skull fracture. Forty-one patients died, most of which were intubated during their hospital course. CONCLUSIONS: There is a dearth of literature detailing standardization of airway management for patients who present with facial fractures. The difference between intubation and surgical airway is often a subjective judgment call, but the authors believe that a more streamlined process can be elucidated after analyzing previous trends as well as variabilities in patient survival and prognosis.

11.
Clin Plast Surg ; 46(2): 185-195, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30851750

RESUMO

Orbital hypertelorism represents lateralization of the orbits, meaning increased interorbital and outer orbital distances. Interorbital hypertelorism represents a failure of medial orbital wall medialization in the setting of normally positioned lateral orbital walls. The etiology and type of hypertelorism influence selection of an operative procedure, whereas the severity of deformity dictates surgical need. Choice of surgical procedure is dictated by anatomic considerations, such as degree of orbital hypertelorism, midfacial proportions, and occlusal status.


Assuntos
Hipertelorismo/cirurgia , Osteotomia/métodos , Procedimentos Cirúrgicos Reconstrutivos/métodos , Face/cirurgia , Feminino , História do Século XX , Humanos , Hipertelorismo/classificação , Hipertelorismo/embriologia , Hipertelorismo/história , Masculino , Procedimentos Cirúrgicos Reconstrutivos/efeitos adversos
12.
Ann Plast Surg ; 82(4S Suppl 3): S195-S198, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30730318

RESUMO

PURPOSE: Falls are a leading cause of nonfatal injury in the pediatric population, resulting in numerous hospitalizations. Children may not have fully developed reflexive and balancing abilities, rendering them more susceptible to traumatic falls. Here the authors present their findings regarding patterns of facial fracture and concomitant injury seen in the pediatric population secondary to falls. METHODS: A retrospective chart review was performed of all facial fractures as a result of falls in the pediatric population in a level 1 trauma center in an urban environment (University Hospital in Newark, NJ). Patient demographics were collected, as well as location of fractures, concomitant injuries, and surgical management strategies. RESULTS: Fifty-five patients were identified as 18 years or younger and having sustained a facial fracture as the result of a fall. This cohort was compared with 418 pediatric patients with facial fractures due to nonfall etiologies. The mean age was 9.6 years (range, 0-18 years), with a male predominance of 67.3%. There were a total of 70 fractures identified on radiological imaging. The most frequently fractured bones were the orbit (n = 27), nasal bone (n = 15), and mandible (n = 11). Orbital and frontal sinus fractures each occurred more frequently due to falls compared with all other causes of injury. Patients with orbital fractures were significantly more likely to present with an additional facial fracture compared with those without (P < 0.01). The most common concomitant injuries were traumatic brain injury, skull fracture, and intracranial hemorrhage. Patients who suffered a facial fracture due to a fall were significantly more likely to sustain a concomitant skull fracture (P < 0.05) and intra-abdominal injury (P < 0.05) compared with all other etiologies. Fourteen patients required surgical intervention. One patient died. CONCLUSIONS: Pediatric facial fractures are a unique entity. The general plasticity of the pediatric anatomy can predispose patients to significant injury without obvious external signs. A high level of clinical suspicion is required to avoid misdiagnosis and delay of treatment. The authors hope this study can address a preventable issue in child safety, educate caregivers, and provide insight towards fracture management that fosters functional and aesthetic recovery.

13.
J Craniofac Surg ; 30(1): 105-109, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30376505

RESUMO

BACKGROUND: Hospital resource overutilization can significantly disrupt patient treatment such as cancelling surgical patients due to a lack of intensive care unit (ICU) space. The authors describe a clinical pathway (CP) designed to reduce ICU length of stay (LOS) for nonsyndromic single-suture craniosynostosis (nsSSC) patients undergoing cranial vault reconstruction (CVR) in order to minimize surgical disruptions and improve patient outcomes. METHODS: A multidisciplinary team implemented a perioperative CP including scheduled laboratory testing to decrease ICU LOS. Hospital and ICU LOS, interventions, and perioperative morbidity-infection rate, cerebrospinal fluid (CSF) leaks, and unplanned return to the operating room (OR)-were compared using Mann-Whitney U, Fisher exact, and t tests. RESULTS: Fifty-one ICU admissions were managed with the standardized CP and compared to 49 admissions in the 12 months prior to pathway implementation. There was a significant reduction in ICU LOS (control: mean 1.84 ±â€Š0.93, median 1.89 ±â€Š0.94; CP: mean 1.15 ±â€Š0.34, median 1.03 ±â€Š0.34 days; P < 0.001 for both). There were similar rates of hypotension requiring intervention (CP: 2, control: 1; P = 0.999), postoperative transfusion (CP: 3, control: 0; P = 0.243), and artificial ventilation (CP: 1, control: 0; P = 0.999). Perioperative morbidity such as infection (CP: 1, control: 0; P = 0.999), return to the OR (CP: 1, control: 0; P = 0.999), and CSF leak (no leaks; P = 0.999) was also similar. CONCLUSION: Implementation of a standardized perioperative CP for nsSSC patients resulted in a significantly shorter ICU LOS without a measured change in perioperative morbidity. Pathways such as the one described that improve patient throughput and decrease resource utilization benefit craniofacial teams in conducting an efficient service while providing high-quality care.


Assuntos
Protocolos Clínicos , Craniossinostoses/cirurgia , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Procedimentos Cirúrgicos Reconstrutivos , Adolescente , Adulto , Criança , Pré-Escolar , Procedimentos Clínicos , Feminino , Recursos em Saúde/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória , Procedimentos Cirúrgicos Reconstrutivos/efeitos adversos , Adulto Jovem
14.
Plast Reconstr Surg ; 143(2): 521-530, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30531617

RESUMO

BACKGROUND: This study characterizes the perioperative morbidity of a large cohort of subjects with syndromic craniosynostosis who underwent transcranial or subcranial midface distraction. METHODS: Demographic and perioperative data were compared between those who underwent transcranial or subcranial midface distraction osteogenesis between July of 1999 and December of 2017. Univariate analysis was conducted using chi-square and Fisher's exact tests for categorical variables and the Mann-Whitney U test for continuous variables. Multivariate analysis was conducted using logistic regression modeling. Complications were graded using the Clavien-Dindo classification. RESULTS: Sixty-four subjects underwent a total of 71 midface distraction procedures. There was a total of 28 complications (39 percent). The trans cranial cohort had a significantly higher frequency of complications (58 percent) compared with the subcranial cohort (29 percent; p = 0.017), with a significantly greater proportion of infection-related complications in the transcranial cohort (80 percent versus 54 percent; p = 0.028). Transcranial complications included cranial contamination, whereas most subcranial cohort infections were superficial or limited facial abscesses. The only significant predictor variable for complications in a multivariate analysis was whether the osteotomy approach was transcranial as opposed to subcranial, with an odds ratio of 5.80 (p = 0.013). CONCLUSIONS: Complication rates in midface distraction remain high, with transcranial procedures having significantly higher complication rates, infection-related complications, and notably greater severity of complications. Although the goals of surgery often dictate choice of osteotomy, the risks associated with transcranial procedures must be thoroughly understood by surgeon and patient alike. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.


Assuntos
Abscesso/epidemiologia , Craniossinostoses/cirurgia , Face/patologia , Osteogênese por Distração/efeitos adversos , Infecção da Ferida Cirúrgica/epidemiologia , Abscesso/etiologia , Adolescente , Criança , Pré-Escolar , Face/cirurgia , Feminino , Humanos , Masculino , Período Perioperatório , Estudos Prospectivos , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Crânio/cirurgia , Infecção da Ferida Cirúrgica/etiologia , Síndrome
16.
Cleft Palate Craniofac J ; 56(2): 177-186, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-29698113

RESUMO

OBJECTIVE: To characterize the epidemiology and risk factors for nasal obstruction among subjects with cleft lip and/or cleft palate (CL/P) utilizing the well-validated Nasal Obstruction Symptom Evaluation (NOSE) survey. DESIGN: Retrospective cross-sectional study. SETTING: Cleft Lip and Palate Program, Children's Hospital of Philadelphia. PATIENTS, SUBJECTS: One thousand twenty-eight surveys obtained from 456 subjects (mean age: 10.10 (4.48) years) with CL/P evaluated between January 2015 and August 2017 with at least 1 completed NOSE survey. INTERVENTIONS: Nasal Obstruction Symptom Evaluation surveys completed at each annual visit. MAIN OUTCOME MEASURES: Composite NOSE and individual symptom scores. RESULTS: Sixty-seven percent of subjects had nasal obstruction at some point during the study period, with 49% reporting nasal obstruction at latest follow-up. subjects aged 14 years and older reported the most severe symptoms ( P = .002). Subjects with cleft lip and alveolus (CL+A) and unilateral cleft lip and palate (CLP) reported more severe nasal blockage than other phenotypes ( P = .021). subjects with a history of either posterior pharyngeal flap (PPF) or sphincter pharyngoplasty (SP) had significantly higher NOSE scores than subjects with no history of speech surgery ( P = .006). There was no significant difference ( P > .050) in NOSE scores with regard to history of primary tip rhinoplasty, nasal stent use, or nasoalveolar molding. CONCLUSIONS: There are more severe nasal obstructive symptoms among subjects older than 14 years of age, with CL+A or unilateral CLP, and with a history of PPF or SP. Future studies utilizing the NOSE are needed to evaluate and address this prevalent morbidity in the CLP population.


Assuntos
Fenda Labial , Fissura Palatina , Obstrução Nasal , Rinoplastia , Adolescente , Criança , Humanos , Estudos Retrospectivos , Avaliação de Sintomas , Resultado do Tratamento
17.
Plast Reconstr Surg ; 142(5): 1285-1293, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30511982

RESUMO

BACKGROUND: Controversy exists regarding the treatment of mandibular hypoplasia in craniofacial microsomia patients, notably the role of mandibular distraction osteogenesis. The authors compared the need for orthognathic surgery in skeletally mature craniofacial microsomia subjects who either did (study group) or did not (control group) undergo early mandibular distraction osteogenesis. METHODS: A retrospective review was conducted of all craniofacial microsomia patients evaluated between January of 1993 and March of 2017. This study included patients with a Kaban-Pruzansky grade I to III mandible, and who were at least 14 years old at the time of the latest follow-up. RESULTS: Thirty-eight subjects met inclusion criteria: 17 who underwent mandibular distraction osteogenesis and 21 who did not (mean age, 18.95 ± 2.82 years versus 17.95 ± 2.14 years, respectively; p = 0.246). The degree of mandibular deformity was matched (distraction, 29.4 percent Kaban-Pruzansky grade IIb and 5.9 percent grade III; no distraction, 23.8 percent grade IIb and 9.5 percent grade III; p = 0.788). No significant difference was noted between the distraction and no-distraction cohorts with regard to need for orthognathic surgery [distraction, n = 10 (58.8 percent); no distraction, n = 8 (38.1 percent); p = 0.203]. CONCLUSIONS: The results seem to suggest that there is no significant difference in orthognathic surgery rates at skeletal maturity between craniofacial microsomia subjects who underwent early mandibular distraction osteogenesis and those who did not. Subjects who undergo distraction may still ultimately require orthognathic surgery to correct facial asymmetry. Additional studies are required to determine the optimal timing and technique of distraction, the importance of orthodontic management during and after distraction, and the early psychosocial benefits of improved facial symmetry. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.


Assuntos
Síndrome de Goldenhar/cirurgia , Reconstrução Mandibular/métodos , Osteogênese por Distração/métodos , Adolescente , Transplante Ósseo/métodos , Criança , Feminino , Seguimentos , Humanos , Masculino , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Reoperação , Costelas/transplante , Resultado do Tratamento
18.
Plast Reconstr Surg ; 142(4): 1012-1022, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30020234

RESUMO

BACKGROUND: Facial scarring and disharmony caused by clefting are associated with psychosocial stress, which may be improved by orthognathic surgery. The authors examine how clefting influences change in layperson perception of a patient following orthognathic surgery. METHODS: One thousand laypersons were recruited through Mechanical Turk to evaluate patient photographs before and after orthognathic surgery. Nineteen patients-five with unilateral and five with bilateral clefting-were included. Respondents assessed six personality traits, six emotional expressions, and likelihood of seven interpersonal experiences on a scale from 1 to 7. RESULTS: Changes in all aspects of social perception after the procedure differed significantly between cleft versus noncleft cohorts (p < 0.01 for all). Respondents evaluated the change for the cleft cohort compared with the noncleft cohort as more trustworthy, friendly, sad, and afraid; more likely to feel lonely, be teased or bullied by others, or feel anxious around others; less angry, disgusted, threatening, dominant, intelligent, happy, and attractive; and less likely to have romantic relationships, friends, or be praised by others. For unilateral versus bilateral cleft cohorts, change in social perception was significantly different in four of the 19 items (p < 0.05 for all). Social perception change for the unilateral cohort was less surprised, sad, dominant, or happy compared with the bilateral cohort (p < 0.05 for all). CONCLUSIONS: Despite significant improvements in social perception following orthognathic surgery, cleft patients benefit less than noncleft patients. These findings may be useful to counsel postsurgical expectations for cleft patients undergoing orthognathic surgery.


Assuntos
Fenda Labial/cirurgia , Fissura Palatina/cirurgia , Procedimentos Cirúrgicos Ortognáticos/psicologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Atitude Frente a Saúde , Estudos Controlados Antes e Depois , Emoções , Expressão Facial , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fotografação , Cuidados Pós-Operatórios , Cuidados Pré-Operatórios , Percepção Social , Adulto Jovem
19.
Plast Reconstr Surg ; 142(2): 480-509, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29870511

RESUMO

There is a paucity of literature directly comparing tongue-lip adhesion versus mandibular distraction osteogenesis in surgical treatment of patients with Pierre Robin sequence. This study comprehensively reviews the literature for evaluating airway and feeding outcomes following mandibular distraction osteogenesis and tongue-lip adhesion. A search was performed using the MEDLINE and Embase databases for publications between 1960 and June of 2017. English-language, original studies subjects were included. Extracted data included prevention of tracheostomy (primary airway outcome) and ability to feed exclusively by mouth (primary feeding outcome). A total of 67 studies were included. Ninety-five percent of subjects (657 of 693) treated with mandibular distraction osteogenesis avoided tracheostomy, compared to 89% of subjects (289 of 323) treated with tongue-lip adhesion. Eighty-seven percent of subjects (323 of 370) treated with mandibular distraction osteogenesis achieved full oral feeds at latest follow-up. Seventy percent of subjects (110 of 157) treated with tongue-lip adhesion achieved full oral feeds at latest follow-up. The incidence of second intervention for recurrent obstruction ranged from 4 to 6 percent in mandibular distraction osteogenesis studies, compared to a range of 22 to 45 percent in tongue-lip adhesion studies. Variability of patient selection, surgical techniques, outcomes measurement methods, and follow-up length across studies precluded meta-analysis of the data. Both mandibular distraction osteogenesis and tongue-lip adhesion are effective alternatives to tracheostomy for patients who fail conservative management and improve feeding. Mandibular distraction osteogenesis may be superior to tongue-lip adhesion in long-term resolution of airway obstruction and avoidance of gastrostomy, but is associated with notable complications.


Assuntos
Lábio/cirurgia , Mandíbula/cirurgia , Osteogênese por Distração/métodos , Síndrome de Pierre Robin/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Língua/cirurgia , Humanos , Resultado do Tratamento
20.
Eplasty ; 18: e16, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29713397

RESUMO

Purpose: Gunshot injuries to the face that result in fractures of the underlying skeleton present a challenge in management. The goal of this study was to evaluate patterns of facial fractures as a result of gunshot injuries and strategies for management. Methods: A retrospective review of facial fractures resulting from gunshot injuries in a level 1 trauma center was performed for the years 2000 to 2012. Data were collected for patient demographics, fracture distribution, concomitant injuries, and surgical management strategies. Results: A total of 190 patients sustained facial fractures from a gunshot injury. The average age was 29.9 years, and 90% were male. Sixteen injuries were self-inflicted. The most common fractures were of the mandible and the orbit. Uncontrolled hemorrhage was noted on presentation in 68 patients; 100 patients were intubated on arrival. The average Glasgow Coma Scale score on arrival was 11.9. Concomitant injuries included skull fracture, intracranial hemorrhage, and intrathoracic injury. Surgical management was required in 89 patients. Nine patients required soft-tissue coverage. Thirty patients expired. Conclusion: Gunshot injuries to the face resulting in fractures of the underlying skeleton have high instances of morbidity and mortality. Life-threatening concomitant injuries can complicate management of facial fractures in this population.

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