Implementation of Mandibular Distraction Osteogenesis for Patients With Pierre Robin Sequence in a Developing Country Through International Collaboration: A Paradigm for Success.

OBJECTIVE: Though it has made significant strides, Vietnam remains a resource-constrained country of 98 million people. Vietnam National Children's Hospital (VNCH) provides tertiary care to a catchment of 40 million people and is the sole national children's hospital. As such, it is one of the few referral centers in the country equipped to take care of patients diagnosed with Pierre Robin sequence (PRS) as this requires pulmonary, critical care, otolaryngology, and plastic surgery expertise. Before 2015, the only surgical options were tongue lip adhesion or tracheostomy. Only 20% of patients successfully avoided tracheostomy, mechanical ventilation, or death. From 2015 to 2019, mandibular distraction osteogenesis (MDO) was introduced by visiting international surgeons on a short-term basis. Since 2020, local surgeons at VNCH have refined their technique and widely use MDO independently. This report seeks to capitulate their experience and identify factors leading to success. METHODS: A retrospective review was conducted of patients diagnosed with PRS at VNCH from 2015 to 2022. Paper records were digitized, translated, and reviewed for inclusion criteria, including demographics, indications, hospital course, and postoperative outcomes. RESULTS: Complete records satisfying inclusion criteria were available for 53 patients with a diagnosis of PRS who underwent MDO from 2020 to 2022. From 2015 to 2019, there were 19 cases of MDO, though records were incomplete. The median age at the time of MDO was 50 ± 43 days. Forty patients (75.5%) had isolated PRS and 13 (24.5%) were syndromic. Forty-four patients (83%) had a cleft palate. Fifty-one (96.2%) of patients required preoperative supplemental oxygen or mechanical ventilation. The active distraction and consolidation phase was 4.8 ± 1.3 months. The median days to discharge after surgery was 19.0 ± 8.3 days. Median weight at birth, at the time of surgery, and at the time of device removal were 6.8 ± 1.2, 7.7 ± 1.9, and 14.8 ± 2.8 pounds, respectively. Fifty-two patients (98.1%) had obstructive sleep apnea preoperatively with an average Apnea Hypopnea Index of 25.0 ± 10.6. Post-MDO, only 4 (7.5%) had obstructive sleep apnea and the average Apnea Hypopnea Index was 5.2 ± 0.6. No patients (0) required a tracheostomy for a 100% success rate. CONCLUSIONS: The tremendous success of the implementation of MDO by local surgeons in Vietnam after its introduction by visiting international surgeons illustrates a paradigm for capacity-enhancing global surgical endeavors. Mandibular distraction osteogenesis has replaced tongue lip adhesion as the surgical treatment of choice for PRS patients at VNCH. Surgical techniques can be transferred to operating environments with basic infrastructure through collaboration and resource optimization. These results demonstrate that global surgical engagement may be scalable and repeatable with direct benefits for patients in lower-middle-income countries.

A New Measure of Posterior Morphology in Sagittal Craniosynostosis: The Occipital Bullet Index.

INTRODUCTION: Sagittal craniosynostosis (SC) is associated with scaphocephaly, an elongated narrow head shape. Assessment of regional severity in the scaphocephalic head is limited by the use of serial computed tomographic (CT) imaging or complex computer programing. Three-dimensional measurements of cranial surface morphology provide a radiation-free alternative for assessing cranial shape. This study describes the creation of an occipital bulleting index (OBI), a novel tool using surface morphology to assess the regional severity in patients with SC. METHODS: Surface imaging from CT scans or 3D photographs of 360 individuals with SC and 221 normocephalic individuals were compared to identify differences in morphology. Cartesian grids were created on each individual's surface mesh using equidistant axial and sagittal planes. Area under the curve (AUC) analyses were performed to identify trends in regional morphology and create measures capturing population differences. RESULTS: The largest differences were located in the medial regions posteriorly. Using these population trends, a measure was created to maximize AUC. The OBI has an AUC of 0.72 with a sensitivity of 74% and a specificity of 61%. When the frontal bossing index is applied in tandem, the two have a sensitivity of 94.7% and a specificity of 93.1%. Correlation between the two scores in individuals with SC was found to be negligible with an intraclass correlation coefficient of 0.018. Severity was found to be independent of age under 24 months, sex, and imaging modality. CONCLUSIONS: This index creates a tool for differentiating control head shapes from those with SC and has the potential to allow for objective evaluation of the regional severity, outcomes of different surgical techniques, and tracking shape changes in individuals over time, without the need for radiation.

Bone Tissue Engineering (BTE) of the Craniofacial Skeleton, Part I: Evolution and Optimization of 3D-Printed Scaffolds for Repair of Defects.

Bone tissue regeneration is a complex process that proceeds along the well-established wound healing pathway of hemostasis, inflammation, proliferation, and remodeling. Recently, tissue engineering efforts have focused on the application of biological and technological principles for the development of soft and hard tissue substitutes. Aim is directed towards boosting pathways of the healing process to restore form and function of tissue deficits. Continued development of synthetic scaffolds, cell therapies, and signaling biomolecules seeks to minimize the need for autografting. Despite being the current gold standard treatment, it is limited by donor sites' size and shape, as well as donor site morbidity. Since the advent of computer-aided design/computer-aided manufacturing (CAD/CAM) and additive manufacturing (AM) techniques (3D printing), bioengineering has expanded markedly while continuing to present innovative approaches to oral and craniofacial skeletal reconstruction. Prime examples include customizable, high-strength, load bearing, bioactive ceramic scaffolds. Porous macro- and micro-architecture along with the surface topography of 3D printed scaffolds favors osteoconduction and vascular in-growth, as well as the incorporation of stem and/or other osteoprogenitor cells and growth factors. This includes platelet concentrates (PCs), bone morphogenetic proteins (BMPs), and some pharmacological agents, such as dipyridamole (DIPY), an adenosine A 2A receptor indirect agonist that enhances osteogenic and osteoinductive capacity, thus improving bone formation. This two-part review commences by presenting current biological and engineering principles of bone regeneration utilized to produce 3D-printed ceramic scaffolds with the goal to create a viable alternative to autografts for craniofacial skeleton reconstruction. Part II comprehensively examines recent preclinical data to elucidate the potential clinical translation of such 3D-printed ceramic scaffolds.

Morphology of the Occipital Bones and Foramen Magnum Resulting From Premature Minor Suture Fusion in Crouzon Syndrome.

To identify skull-base growth patterns in Crouzon syndrome, we hypothesized premature minor suture fusion restricts occipital bone development, secondarily limiting foramen magnum expansion.Skull-base suture closure degree and cephalometric measurements were retrospectively studied using preoperative computed tomography (CT) scans and multiple linear regression analysis.Evaluation of multi-institutional CT images and 3D reconstructions from Wake Forest's Craniofacial Imaging Database (WFCID).Sixty preoperative patients with Crouzon syndrome under 12 years-old were selected from WFCID. The control group included 60 age- and sex-matched patients without craniosynostosis or prior craniofacial surgery.None.2D and 3D cephalometric measurements.3D volumetric evaluation of the basioccipital, exo-occipital, and supraoccipital bones revealed decreased growth in Crouzon syndrome, attributed solely to premature minor suture fusion. Spheno-occipital (ß = -398.75; P < .05) and petrous-occipital (ß = -727.5; P < .001) suture fusion reduced growth of the basioccipital bone; lambdoid suture (ß = -14 723.1; P < .001) and occipitomastoid synchondrosis (ß = -16 419.3; P < .001) fusion reduced growth of the supraoccipital bone; and petrous-occipital suture (ß = -673.3; P < .001), anterior intraoccipital synchondrosis (ß = -368.47; P < .05), and posterior intraoccipital synchondrosis (ß = -6261.42; P < .01) fusion reduced growth of the exo-occipital bone. Foramen magnum morphology is restricted in Crouzon syndrome but not directly caused by early suture fusion.Premature minor suture fusion restricts the volume of developing occipital bones providing a plausible mechanism for observed foramen magnum anomalies.

The First Hybrid International Educational Comprehensive Cleft Care Workshop.

OBJECTIVE: Describe the first hybrid global simulation-based comprehensive cleft care workshop, evaluate impact on participants, and compare experiences based on in-person versus virtual attendance. DESIGN: Cross-sectional survey-based evaluation. SETTING: International comprehensive cleft care workshop. PARTICIPANTS: Total of 489 participants. INTERVENTIONS: Three-day simulation-based hybrid comprehensive cleft care workshop. MAIN OUTCOME MEASURES: Participant demographic data, perceived barriers and interventions needed for global comprehensive cleft care delivery, participant workshop satisfaction, and perceived short-term impact on practice stratified by in-person versus virtual attendance. RESULTS: The workshop included 489 participants from 5 continents. The response rate was 39.9%. Participants perceived financial factors (30.3%) the most significant barrier and improvement in training (39.8%) as the most important intervention to overcome barriers facing cleft care delivery in low to middle-income countries. All participants reported a high level of satisfaction with the workshop and a strong positive perceived short-term impact on their practice. Importantly, while this was true for both in-person and virtual attendees, in-person attendees reported a significantly higher satisfaction with the workshop (28.63 ± 3.08 vs 27.63 ± 3.93; P = .04) and perceived impact on their clinical practice (22.37 ± 3.42 vs 21.02 ± 3.45 P = .01). CONCLUSION: Hybrid simulation-based educational comprehensive cleft care workshops are overall well received by participants and have a positive perceived impact on their clinical practices. In-person attendance is associated with significantly higher satisfaction and perceived impact on practice. Considering that financial and health constraints may limit live meeting attendance, future efforts will focus on making in-person and virtual attendance more comparable.

Premature Fusion of the Posterior Intraoccipital Synchondrosis, A Minor Suture Mimic of Lambdoid Craniosynostosis.

ABSTRACT: The posterior intraoccipital synchondrosis (PIOS) is a cartilaginous division separating the exoccipital and supraoccipital bones, allowing for flexibility of the cranial base at birth and which later ossifies in adolescence. The authors report a case of right PIOS synostosis that resembled right lambdoid synostosis, with left occipital bossing in a healthy, six-month-old female with an unremarkable birth history and no antecedent trauma. An initial referral was made from the pediatrician to oncology because of a concern over the presence and growth of a possible mass at the left occiput. Over 8 months, this mass grew and became more firm, accompanied by left occipital bossing and right occipital flattening. A computed tomography was obtained, which demonstrated the fusion of the PIOS, prompting a referral to plastic surgery. Cranial vault remodeling with switch cranioplasty was performed at age 14 months, complicated only by a superficial infection along the suture line. There are exceedingly few reports of PIOS synostosis, with occipital osteodiastasis related to birth trauma as the only prior explanation for this condition. With no birth trauma and delayed onset, our case likely represents idiopathic PIOS synostosis. With the many similarities in presentation, the surgical approaches commonly used for lambdoid synostosis, particularly switch cranioplasty, are suitable solutions to PIO synchondrosis with optimal functional and aesthetic outcomes.

"Primary Correction of the Cleft Nasal Septum: A Systematic Review".

Patients affected by cleft lip and palate have a characteristic nasal deformity; however, the treatment timeline varies amongst providers. There has been a shift from a more conservative approach to earlier intervention in order to allow for more normal development of the nose. Form, function, and future development all must be considered. For this reason, this investigation was undertaken to present the current literature available on the effects to all aspects of primary septoplasty in the cleft nasal deformity.An initial list of 222 papers was identified, and it was determined that 16 papers fit the inclusion criteria. Studies were included in which the initial age of operation for the majority of patients was between 3 and 12 months and in which patients underwent septal repositioning at the time of cleft lip repair. These papers were all reviewed by a single author initially, and the results recorded. All results were then verified by a second author for accuracy and completeness.Symmetry was found to be improved by primary septoplasty. Growth was not found to be impaired in any study; data was insufficient to indicate that growth was improved. Obstruction was improved as determined both by imaging, endoscopy, and patient survey. Finally, reoperation rates occurred at an acceptable rate not exceeding that of primary rhinoplasty without septoplasty.Primary septoplasty leads to better aesthetic symmetry and function of the cleft nose without impairing growth. This change is maintained into adulthood often without the need for revisionary surgery.

Prepectoral Versus Subpectoral Breast Reconstruction in High-Body Mass Index Patients.

BACKGROUND: The effect of body mass index (BMI) on complication rates in prepectoral implant-based breast reconstruction is not well established. The purpose of this study was to compare complication rates between different BMI groups in subpectoral and prepectoral reconstruction. METHODS: A single-surgeon, 4-year, retrospective review was performed of consecutive prosthetic breast reconstructions. During this time, the senior author's practice shifted from a subpectoral to prepectoral technique. Patients were stratified into BMI subgroups (<25, 25-35, and >35 kg/m2) and complication rates were analyzed. A survey was administered to blinded medical personnel and patients comparing esthetic results. RESULTS: Implant-based reconstructions were performed in 195 patients (103 subpectoral and 92 prepectoral). No significant difference in major complication rate was observed between techniques. Among patients with BMI greater than 35 kg/m2, implant exposure occurred at a significantly higher rate in the prepectoral group (P = 0.04). In patients with BMI greater than 25 kg/m2, minor asymmetry was more prevalent with prepectoral reconstruction (12.3% vs 0%; P = 0.02). Regardless of technique, the odds of reoperation increased by 7% per point increase in BMI, although this did not reach statistical significance (P = 0.07; odds ratio, 1.07; 95% confidence interval, 0.99-1.15).A total of 66 survey responses were received. Physicians rated esthetic results more positively than patients did. Patients with a BMI of less than 25 kg/m2 were rated better than other BMI groups in nearly all categories. The position of submuscular reconstruction was rated significantly better than prepectoral. CONCLUSIONS: There is a trend toward higher complication rates in prepectoral versus subpectoral breast reconstruction with increasing BMI. Nonetheless, the technique appears to be safe, with comparable clinical and cosmetic results.

Utilizing 3D-Printed Orbital Floor Stamps to Create Patient-Specific Implants for Orbital Floor Reconstruction.

PURPOSE: This study seeks to test a novel technique of custom-printed midface contour models with orbital floor "stamps" to guide reconstruction of orbital floor blowout fractures, with or without concomitant zygomaticomaxillary complex injury. METHODS: A series of 4 consecutive patients with orbital floor blowout fractures (including 3 with zygomatic maxillary complex fractures) were retrospectively examined for outcomes associated with orbital floor reconstruction using 3-dimensional-printed stamps and midface models. Data collected included demographics, pre- and postoperative visual globe malposition, motility, and visual field disturbances. Three-dimensional printing methodology is reported, as well as associated costs and time required to generate the models and stamps. RESULTS: The cost of producing a midface-contour model and orbital floor stamps was $131, inclusive of labor and materials. Cases averaged 170 minutes to segment, design, and print. Patients with preoperative diplopia and motility restrictions had resolution of their symptoms. Two patients had resolution of their enophthalmos, while one patient with a concomitant zygomaticomaxillary fracture had persistent mild enophthalmos. CONCLUSIONS: Midface contour models and orbital floor stamps may be produced in a timely and cost-effective manner. Use of these "homemade" stamps allows for patient-specific custom-contoured orbital floor reconstruction. Further studies are warranted to examine long-term visual and esthetic outcomes for these patients.

Outcomes in Orbital Floor Trauma: A Comparison of Isolated and Zygomaticomaxillary-Associated Fractures.

ABSTRACT: Orbital floor fractures are common sequalae of trauma to the orbit. These fractures present as an isolated orbital floor (I-OF) fracture or with other midface fractures, typically the zygomaticomaxillary complex. The authors sought to better understand the differences in patient presentation, surgical decision-making, and outcomes in I-OF fractures compared with those associated with zygomaticomaxillary complex fractures (Z-OF). A retrospective review of patients with orbital floor fractures was conducted to generate an I-OF fracture group and a Z-OF fracture group. Demographics, preoperative symptoms, surgical choices, and postoperative complications were assessed. Complications were assessed individually and as 2 composite groups consisting of orbital complications and eyelid complications. There were 156 patients that met inclusion criteria with 75 I-OF fractures and 81 Z-OF fractures. The most common mechanism of injury for I-OF fractures was assault (34.7%) and motor vehicle accidents (39.5%) for Z-OF fractures. The I-OF group presented more often with diplopia (P = 0.01) whereas the Z-OF group had more trauma symptoms (P = 0.01), which included subconjunctival hemorrhages, retrobulbar hemorrhages, and relative afferent pupillary defects. I-OF fractures had longer preoperative observational periods (P < 0.001). Postoperatively, I-OF fractures had more motility restrictions (P = 0.002) but Z-OF fractures had higher risk for eyelid complications (P = 0.03). There was no significant difference in reoperation rates (P = 0.93). Multivariate analysis showed Z-OF fractures had reduced a rate of postoperative motility defects by 72% (P = 0.03) but had 2.6 times higher risk of eyelid complications (P = 0.04). Z-OF fractures present differently, vary in surgical management, and have complications that differ from an I-OF fracture.

Spring-Assisted Surgery for Treatment of Sagittal Craniosynostosis.

ABSTRACT: Craniosynostosis (CSS), the premature fusion of calvarial sutures, most commonly involves the sagittal suture. Cranial vault remodeling (CVR) is a traditional method of CSS correction. Minimally invasive methods are becoming widely accepted, including spring-assisted surgery (SAS). The equipment required for SAS is minimal therefore adaptable to resource challenged health systems. This paper outlines the experience of SAS in Moldova.A retrospective study was performed for patients treated with SAS for sagittal CSS from 2011 to 2018 in Moldova. Perioperative data were recorded including age, length of surgery, blood loss, volume transfused and length of stay. Four patients had pre- and post-operative computed tomography (CT) scans which were used to calculate changes in cephalic index, normative cephalic index, and intracranial volume.Thirteen patients underwent SAS. Diagnoses were made clinically and confirmed with CT. Mean age at surgery was 4.0 months, and length of surgery 62.7 minutes. All but one patient received a blood transfusion, as is standard of practice in Moldova. The mean length of post-operative recovery in ICU was 30.9 hours. No complications required surgical revision. Springs were removed after 4 to 5 months. All patients had a subjective improvement in scaphocephaly. Based on the available CT scans, an increase in cephalic index (7.3%), normative cephalic index (11.8%), and intracranial volume (38.1%) was observed. One patient underwent SAS at 11 months and required cranioplasty for asymmetry at the time of spring removal.SAS is a safe and cost-effective method of CSS correction that can be utilized in countries with limited health system resources.

Outcomes of Endoscopic Versus Open Spring Assisted Surgery for Sagittal Craniosynostosis.

Spring-assisted surgery (SAS) has been shown to be an effective technique for correction of isolated sagittal craniosynostosis in patients less than 6 months of age. At their institution, the authors adopted a minimally invasive technique in 2010, using a shorter incision and an endoscope. A retrospective chart review of 101 patients with isolated, nonsyndromic, sagittal craniosynostosis, who underwent SAS, was performed in order to compare perioperative and clinical outcomes of the open (n = 51) and minimally-invasive (n = 50) approaches. Surgeries were performed by 2 neurosurgeons and 3 plastic surgeons, between 2005 and 2018. The pre and postoperative cephalic indices were not significantly different in both groups. Minimally-invasive spring placement required a longer operative time than the open approach, with the mean minimally-invasive operative time at 65 minutes, compared to 53 minutes (P < 0.0001). Spring removal operative time was not significantly different, with the minimally-invasive operative time at 31 minutes versus 29 minutes (P = 0.48). There were no significant differences in major or minor complications when comparing the open and minimally-invasive approaches. In conclusion, both the open and the minimally-invasive SAS techniques are effective for early correction of isolated sagittal craniosynostosis, although the minimally-invasive approach requires a longer operative time for spring placement.

Spring-Assisted Strip Craniectomy Versus Cranial Vault Remodeling: Long-Term Psychological, Behavioral, and Executive Function Outcomes.

BACKGROUND: Controversy exists regarding the optimal surgical approach for non-syndromic sagittal synostosis. This study provides the first comparative analysis of the long-term behavioral, psychological, and executive function outcomes for patients who underwent either cranial vault remodeling (CVR) or spring-assisted strip craniectomy (SAS). METHODS: Thirty-six CVR patients and 39 SAS patients were evaluated. Parents and caregivers completed the Behavior Rating Inventory of Executive Function (BRIEF) and the Behavior Assessment System for Children, Second Edition (BASC-2) to evaluate behavioral, emotional, social, adaptive, and executive functioning skills. RESULTS: There were no statistically significant differences between the CVR and the SAS groups (P > 0.05) in any of the BRIEF areas of function. Furthermore, the BASC-2 battery illustrated no significant differences in all areas analyzed except one. Among the 2 groups, the CVR group was rated as having fewer social withdrawal symptoms on the BASC-2 (47.00 ±â€Š10.27) compared to the SAS cohort (54.64 ±â€Š10.96), F = 6.79, P = 0.012, Cohen d = 0.688. However, both means were still within the normal range. CONCLUSIONS: Children undergoing SAS and CVR procedures for isolated sagittal synostosis were not rated as having clinically significant behavioral, emotional, social, adaptive, or executive functioning problems on parental forms.

Provision and Utilization of Team- and Community-Based Operative Care for Patients With Cleft Lip/Palate in North Carolina.

OBJECTIVE: To characterize operative care for cleft lip and/or palate (CL/P) based on location (ie, from American Cleft Palate Craniofacial Association [ACPA]-approved multidisciplinary teams or from community providers). DESIGN: Cross-sectional analysis of Healthcare Cost and Utilization Project State Inpatient Database and State Ambulatory Surgery & Services Database databases for North Carolina from 2012 to 2015. SETTING/PATIENTS AND MAIN OUTCOME MEASURES: Clinical encounters for children with CL/P undergoing operative procedures were identified, classified by location as "Team" versus "Community," and characterized by demographic, geographic, clinical, and procedural factors. A secondary evaluation reviewed concordance of team and community practices with an ACPA guideline related to coordination of care. RESULTS: Three teams and 39 community providers performed a total of 3010 cleft-related procedures across 2070 encounters. Teams performed 69.7% of total volume and performed the majority of cleft procedures, including cleft lip repair, palate repair, alveolar bone grafting, and correction of velopharyngeal insufficiency. Community locations principally offered myringotomy and rhinoplasty. Team care was associated with higher guideline concordance. CONCLUSIONS: American Cleft Palate Craniofacial Association -approved team-based care accounts for the majority of cleft-related care in North Carolina; however, a substantial volume of cleft-related procedures was provided by community providers, with 3 providers accounting for the vast majority of community cases.

Hematoma Risks of Nonsteroidal Anti-inflammatory Drugs Used in Plastic Surgery Procedures: A Systematic Review and Meta-analysis.

BACKGROUND: The opioid crisis in America has sparked a shift toward a multimodality perioperative pain regimen. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the perioperative period decreases opioid consumption and increases efficacy. However, many plastic surgeons avoid their use because of antiplatelet effects. The purpose of this article is to systematically review the plastic surgery literature to assess the risk of intraoperative or postoperative bleeding and hematoma formation. METHODS: A systematic review of articles published in PubMed was performed in September 2018 to investigate the incidence of increased bleeding and hematoma formation with use of NSAIDs in the perioperative period in plastic surgery. All articles were reviewed for primary outcome measures, and a selective literature review was performed to examine perioperative NSAID use in other surgical subspecialties. Random-effect meta-analysis was performed. RESULTS: Our search yielded 806 total articles, with 15 meeting inclusion criteria, and this included 3064 patients (1679 with perioperative NSAIDs, 1385 with no NSAIDs). There was no significant difference in overall incidence of bleeding/hematoma in the treatment group versus control (no NSAIDs). The overall pooled odds ratio (OR) and corresponding 95% confidence interval were 1.20 and 0.73 to 1.97 (P = 0.48). When separated by drug administered across all plastic surgery procedures, there were no statistically significant differences in incidences of hematoma or increased bleeding with use of ketorolac (OR, 1.48 [0.86-2.56]; P = 0.57), ibuprofen (OR, 0.55 [0.14-2.14]; P = 0.87), or celecoxib (OR, 0.22 [0.02-2.52]; P = 0.39). When examining NSAID use in breast surgery, there was no statistically significant difference in incidence of hematoma or increased bleeding when combining all 3 drug types (OR, 1.39 [0.82-2.37]; P = 0.60). Some individual studies demonstrated trends toward increased bleeding/hematoma in reduction mammoplasties. CONCLUSIONS: Nonsteroidal anti-inflammatory drugs significantly improve pain control and decrease opioid use when used in plastic surgery. The majority of evidence in plastic surgery does not support an increased incidence of bleeding/hematoma with the use of perioperative NSAIDs.

A generalized multistage approach to oral and nasal intubation in infants with Pierre Robin sequence: A retrospective review.

BACKGROUND: Airway management in children with Pierre Robin sequence in the infantile period can be challenging and frequently requires specialized approaches. AIMS: The aim of this study was to review our experience with a multistage approach to oral and nasal intubation in young infants with Pierre Robin sequence. METHODS: After IRB approval, we reviewed 13 infants with Pierre Robin sequence who underwent a multistage approach to intubation in the operating room for mandibular distractor or gastrostomy tube placement. All patients underwent awake placement of either an LMA-Classic™ #1 or ProSeal™ laryngeal mask airway size #1. General anesthesia was induced with sevoflurane, and patients were relaxed with rocuronium. The laryngeal mask airway was replaced with an air-Q® 1.0. Children were then intubated through the air-Q® 1.0 using a flexible fiberoptic bronchoscope. In cases that required a nasotracheal tube, the oral tube was left in place while a flexible fiberoptic bronchoscope loaded with a similar internal diameter nasal Ring-Adair-Elwyn (RAE) tube was introduced into the nares. Once the scope was in proximity to the glottis, the oral tube was removed and the patient was intubated with the nasal RAE over the fiberscope. RESULTS: All 13 patients with Pierre Robin sequence were successfully intubated. We observed no periods of desaturation during placement and induction with the LMA-Classic™ or ProSeal™ laryngeal mask airway except in one patient who was in extremis in the neonatal intensive care unit and required emergent transport to the operating room with the laryngeal mask airway in place. We observed several brief periods of desaturation during the apneas associated with fiberoptic intubation. CONCLUSION: In conclusion, we were able to use a ventilation-driven, multistaged approach using the unique properties of different supraglottic airways to facilitate oral and nasal intubation in 13 infants with Pierre Robin sequence.

Digital-Facial Translocation in Amniotic Band Sequence: Evidence of the Intrinsic Theory.

Amniotic band sequence is a complex congenital anomaly in which infants with typically no known genetic mutation have bands of maternal amniotic tissue wrapped around body parts, most commonly the limbs and digits. The authors report a novel variation on this presentation in 3 patients from 2 centers with complex craniofacial clefting and amniotic band sequence. They presented with hypertelorism, different forms of complex craniofacial clefting, and bands connecting ipsilateral hands to facial clefts, with digital-facial translocation in 2 cases. These findings support a model in which complex craniofacial clefts result in areas of exposed, sticky, and temporally and spatially coincident mesenchyme within the embryo that are susceptible to adherence of ipsilateral fetal hands. This strongly supports the intrinsic and adhesion theories of the etiology of amniotic band syndrome.

The Effect of Nasoalveolar Molding on Nasal Airway Anatomy: A 9-Year Follow-up of Patients With Unilateral Cleft Lip and Palate.

OBJECTIVE: To determine the effects of nasoalveolar molding (NAM) on nasal airway architecture. DESIGN: Retrospective case-control study of patients with unilateral cleft lip treated with NAM vs without NAM. SETTING: Tertiary referral center specializing in cleft and craniofacial care. Patients, Participants, and Interventions: Thirty-six patients with complete unilateral cleft lip and alveolus: 19 with NAM therapy and 17 without NAM therapy. MAIN OUTCOME MEASURES: Cone beam computed tomography (CBCT) scans were compared in multiple coronal sections and were evaluated for linear and angular septal deviation, inferior turbinate hypertrophy, and linear and 2-dimensional airway area. RESULTS: There were no significant differences in linear or angular septal deviation, inferior turbinate area, linear stenosis, or airway area between NAM- and non-NAM-treated patients. CONCLUSIONS: NAM effectively molds the external nasal cartilage and structures but may have limited effects on internal nasal structures.

Biology of Bone Formation, Fracture Healing, and Distraction Osteogenesis.

Distraction osteogenesis is a bone-regenerative process in which an osteotomy is followed by distraction of the surrounding vascularized bone segments, with formation of new bone within the distraction gap. Distraction osteogenesis is efficacious for reconstructing critical sized bony defects in the appendicular and craniofacial skeleton. To provide opportunity to expand applications of distraction osteogenesis, it is important to have a thorough understanding of the underlying molecular biology and physiology of bone development and fracture healing. To accomplish these objectives a review of the literature was performed using search terms "endochondral ossification, intramembranous ossification, craniofacial skeleton, appendicular skeleton, fracture healing, bone development, and distraction osteogenesis." Bones of the craniofacial and appendicular skeleton have distinct mechanisms of embryonic development. The former develops from growth centers of mesenchymal precursors through intramembranous ossification. The latter forms though endochondral ossification in growth plates. However, both endochondral and intramembranous bone share similar master regulatory transcription factors and downstream growth factors. Fracture healing mirrors the pathway by which these bones developed embryonically. In contrast, bone formed by distraction osteogenesis does so by intramembranous ossification, regardless of whether it occurs within the appendicular or craniofacial skeleton. Understanding molecular pathway differences between bone formation by these mechanisms may allow for optimization and expansion of skeletal reconstruction by distraction osteogenesis.

Neonatal Mandibular Distraction Without a Consolidation Period: Is It Safe? Is it Effective?

PURPOSE: Consolidation is a standard part of most post-distraction protocols. This study aims to determine whether the deliberate omission of a consolidation period following mandibular distraction (MD) in neonates with Pierre Robin sequence (PRS) affected the airway outcomes and complication rates. PATIENTS AND METHODS: A retrospective chart review of 28 neonates with PRS who underwent MD for severe airway obstruction between 2009 and 2014 was performed. Neonates were split into 2 cohorts: those with a very short or no consolidation (no consolidation group, n = 18) and those with a traditional consolidation period (consolidation group, n = 10). RESULTS: Mean consolidation length was 25 days in the conventional consolidation group and 1.5 days in the no consolidation group (P < 0.01). Postoperatively, both groups showed equivalent improvements in their obstructive index as measured by polysomnography. Compared with the patients who underwent convention consolidation, patients in the "no consolidation" group did not require a greater number of repeat distraction, supplemental oxygen, or tracheostomy. Nor was there any significant difference in the number of complications between the 2 groups. CONCLUSION: In neonates with PRS treated with MD for severe airway obstruction, the omission of a consolidation period does not appear to significantly affect the complication rate or resolution of airway obstruction.