Surgical Approach to Hemipalatal Discrepancy in Tessier 7 Reconstruction: Review of Literature and Case Series.

OBJECTIVE: The authors present findings and techniques to address hemipalatal discrepancy in patients with Tessier 7 cleft and associated cleft palate during cleft palatoplasty. DESIGN: The authors report 2 cases of pediatric patients with Tessier 7 facial clefts and associated cleft palate. One patient presents on the broader oculo-auriculo-vertebral spectrum and the other is has isolated Tessier cleft 7. Additionally, a PubMed search was performed using the MeSH terms "tessier 7," "cleft palate", "macrostomia," "tessier 7 AND cleft palate," "macrostomia AND cleft palate," AND "hemipalatal discrepancy." All relevant literature was identified and underwent full review for qualitative analysis. RESULTS: Two patients met criteria for inclusion in this article. The surgical techniques utilized to mitigate the hemipalatal length discrepancy are detailed, and intraoperative photographs are provided. The results of the literature review are also presented. Tessier 7 craniofacial cleft and palatal clefts, when occurring in combination, is noted to result in discrepant hemipalatal length with short maxillary palate length on the affected side as well hypoplasia of the associated speech musculature. The postoperative palatal length after palatoplasty in both patients was longer than the preoperative hypoplastic palatal length. CONCLUSIONS: When occurring in combination, Tessier 7 craniofacial cleft and concomitant palatal cleft results in discrepant hemipalatal length, and deficiency of the bony maxillary palatal shelves, and associated speech musculature and soft tissues. The techniques described in this article may assist in maximizing postoperative palatal length.

Efficacy of Staged Oronasal Fistula Reconstruction and Improved Bone Graft Survival in Cleft Patients Undergoing Secondary Reconstruction.

OBJECTIVE: To evaluate the efficacy of the senior author's technique of staged reconstruction in patients with recalcitrant oronasal fistulas. DESIGN: A retrospective review of the Pediatric Plastic Surgery Cleft & Craniofacial Surgery Database of cases from September 2013 to December 2018 was conducted. PATIENTS: A total of 31 patients who had previously undergone >1 surgical attempt to repair a fistula or patients who have failed >1 attempt at bone graft were included in this study. All patients were referrals from outside facilities. MAIN OUTCOME MEASURES: Primary outcomes examined included fistula recurrence, infection rates, ability to proceed with second stage bone grafting after first stage fistula takedown and reconstruction, and bone graft loss. RESULTS: Charts of 1053 patients were reviewed and 31 (2.94%) cases met inclusion criteria for this study. Nineteen (61.3%) of these patients proceeded with the second stage of reconstruction and 100% did not experience any graft loss. Seven patients who completed the first stage are undergoing orthodontic optimization prior to bone grafting. The remaining 5 are adult patients not interested in pursuing bone grafting. All 31 patients with recurrent and recalcitrant fistulas had successful fistula reconstruction with our approach, despite multiple previous failed reconstructions. CONCLUSIONS: The 2-staged reconstructive approach described herein effectively resulted in resolution of prior recurrent recalcitrant fistulas and resulted in eventual bone grafting. By employing this technique, we report successful fistula repair and bone grafting in patients who had previously undergone multiple surgical reconstructions.

Diagnosis and Treatment of Scalp Arteriovenous Malformations With Intracranial Extension.

Scalp arteriovenous malformations (AVMs) are rare entities that may present as large, tortuous vascular lesions with resultant craniofacial deformity. Radiologic findings include feeding arteries and veins associated with dilated tortuous vessels. Intracranial extension is rare. A 5-year-old African American male presented with an occipital mass presumed to be a dermoid cyst on referral. Further workup revealed the presence of a scalp AVM that demonstrated extension into the left sigmoid sinus. Radiologic and intraoperative images are presented. Literature search revealed only 4 patients with scalp AVM extending intracranially into the sagittal sinus, 2 of which were managed with coagulation and division of the feeding vessels and the other 2 underwent preoperative embolization. Our patient is the 1st to be reported to have sigmoid sinus extension. Scalp AVMs with intracranial extension are rare, and require further preoperative workup. Following ultrasound evaluation, computed tomography angiography, magnetic resonance angiography, magnetic resonance imaging, or cerebral angiography can be considered. Treatment entails resection, but preoperative embolization is increasingly used, mirroring patients without intracranial extension. Further studies are needed to evaluate the efficacy and risk profile of these treatments.

Cranial Erosion Associated With Non-Midline Dermoid Cysts in the Pediatric Population.

BACKGROUND: While the risk for intracranial extension of midline nasoglabellar dermoid cysts is well-described, the risk in non-midline dermoid cysts and role of preoperative imaging in these lesions is less understood. This study aims to address this gap and provide preoperative recommendations. MATERIALS AND METHODS: A retrospective review was performed evaluating patients who underwent excision of craniofacial dermoid cysts by a single surgeon. Findings on preoperative physical examination and imaging modalities were compared to intraoperative findings to assess effectiveness of each in predicting bony erosion. A treatment algorithm is proposed. RESULTS: Twenty-eight patients were included and 50% had intraoperatively confirmed bony erosion. Bony erosion was identified in 100% of lesions immobile on examination, compared to 30% of mobile lesions (P = 0.001). Bony erosion was identified in 40.9% of lateral brow cysts compared to 83.3% of lesions located elsewhere (P = 0.03), in 60% of patients with periorbital sequelae compared to 47.8% without periorbital sequelae, and in 66.7% of patients with reported change in cyst size with Valsalva compared to 48.0% without change with Valsalva. Sensitivities for preoperative identification of bony erosion were as follows: physical examination 57.1%, US 11.1%, MRI 66.7%, and CT 100%. CONCLUSIONS: A management algorithm for non-midline dermoid cysts is presented. CT or MRI is recommended for lesions that are immobile, in atypical locations, or have associated periorbital sequelae or change with Valsalva. The authors feel there is no role for ultrasound and don't recommend routine imaging in patients with non-midline dermoid cysts without features suggestive of bony erosion.

Cranial Suture Anchor Temporalis Resuspension: A New Technique to Reconstruct Temporal Hollowing After Craniotomy.

INTRODUCTION: Proper temporalis resuspension following craniotomy or craniectomy is necessary to prevent significant temporofacial deformity. Several methods of temporalis reconstruction have been described with varying success; currently there are no reports of suture anchor utilization. METHODS: A patient is presented displaying successful temporalis resuspension using suture anchor fixation. An incision was made in the temporal hair-bearing scalp to access and lengthen the retracted temporalis under direct visualization. Stab incisions were then made in the scalp to expose the superior temporal line, where suture anchors were placed for muscle fixation. After confirming appropriate vectors for muscle resuspension, 1 suture arm was passed through a subgaleal tunnel to capture the temporalis and the other was fixated to the temporoparietal skull. The suture anchors were secured and the incisions were closed in layers. RESULTS: A 36-year-old female with history of decompressive craniectomy for hemorrhagic stroke presented with significant temporal hollowing. Her temporalis was retracted with a noticeable defect on frontal view and bulging over the zygomatic arch. The patient underwent temporalis resuspension as described with durable correction resembling her premorbid state. The buried suture anchors were nonpalpable. CONCLUSION: Temporal hollowing after craniotomy is a difficult contour deformity to correct. In the presented patient, reconstruction with temporalis elevation and suture anchor resuspension was found to be an effective technique with excellent cosmetic outcome. The efficiency of suture anchor placement, postoperative maintenance of muscle tension, and nonpalpable profile of the buried suture anchors suggest comparable efficacy to plate fixation and suture-only techniques.

Surgical Management of Pediatric Lymphedema: A Systematic Review.

BACKGROUND: Lymphedema is a rare, progressive, and debilitating condition caused by failure of the lymphatic system to adequately drain the protein-rich fluid exiting the capillaries. Conservative management is often emphasized in pediatric patients, resulting in a paucity of literature describing surgical treatment in this population. METHODS: A systematic review was performed using PubMed, ScienceDirect, and Google Scholar to identify all studies describing surgical management of lymphedema in the pediatric population. RESULTS: Of the 343 relevant articles identified, 14 met the criteria for full review. Articles were divided into the following treatment categories: genital lymphedema, excisional procedures for extremity lymphedema, and physiologic procedures for extremity lymphedema. Outcomes for genital lymphedema were overall positive. For extremity lymphedema, excisional procedures yielded good results overall and included the majority of patients in this study. Physiologic procedures had mixed outcomes in the small population included in this study, but definitive conclusions cannot be drawn due to the paucity of existing data. CONCLUSION: While conservative management of pediatric lymphedema is well described, the literature remains sparse regarding surgical treatment. Further studies are needed to evaluate efficacy and outcomes in all three categories in this population.

Craniosynostosis and Guanine Nucleotide-binding Protein Alpha Stimulating Mutation: Risk of Bleeding Diathesis and Circulatory Collapse in Patients Undergoing Cranial Vault Reconstruction.

Reconstruction of the craniosynostosis deformity is a relatively safe operation with low overall complication risks. Despite expected risk of significant blood loss, life-threatening bleeding is relatively rare, and there is a low incidence of reported deaths in the literature. Several modalities have been described for perioperative mitigation of blood loss and transfusion requirements. Due to the low overall risk of life-threatening bleeding and circulatory collapse, it is judicious that any potential causes of such unusual but potentially significant fatal bleeding complication be evaluated and reported to increase awareness for craniofacial surgeons treating these conditions. In this report and literature review, the authors present a highly unusual patient with significant bone bleeding and circulatory collapse in a metopic craniosynostosis patient with guanine nucleotide-binding protein alpha stimulating (GNAS) mutation; perform a literature review regarding bleeding diathesis in craniosynostosis patients with GNAS mutations; and suggest guidelines to potentially prevent mortality in such patients.

Improving Functional and Aesthetic Outcomes in Syndromic Patients With Webbed Neck Deformity: Utilizing a Staged Endoscopic-Assisted Approach to Improve the Posterior Hairline and Decrease Scar Burden.

INTRODUCTION: Webbed neck deformity (WND) can have significant functional and psychosocial impact on the developing child. Surgical correction can be challenging depending on the extent of the deformity, and patients often also have low posterior hairlines requiring simultaneous correction. Current surgical techniques include various methods of single-stage radical excision that often result in visible scar burden and residual deformity. There is currently no general consensus of which technique provides the best outcomes. METHODS: A modified approach to WND was designed by the senior author aimed to decrease scar burden. Endoscopic-assisted fasciectomy was performed with simultaneous posterior hairline reconstruction with local tissue rearrangement camouflaged within the hair-bearing scalp. Staged surgical correction was planned rather than correction in a single operation. A retrospective review was performed to evaluate all patients who underwent this approach over a 2-year period. RESULTS: Two patients underwent the modified approach, a 17-year-old female with Noonan syndrome and a 2-year-old female with Turner syndrome. Both patients showed postoperative improvement in range of motion, contour of the jaw and neckline, and posterior hairline definition. Patients were found to have decreased scar burden compared with traditional techniques. DISCUSSION: A staged, combination approach of endoscopic-assisted fasciectomy and strategic local tissue reconstruction of the posterior hairline to correct WND achieves good functional and aesthetic results and good patient satisfaction. This modification should be considered when managing WND.

Perioperative Safety in Plastic Surgery: Is the World Health Organization Checklist Useful in a Broad Practice?

INTRODUCTION: In October 2007, the World Health Organization (WHO) introduced the Safe Surgery Saves Lives Program, the cornerstone of which was a 19-item safe-surgery checklist (SSC), in 8 selected hospitals around the world. After implementation, death rates decreased significantly from 1.5% to 0.8% (P = 0.003), inpatient complications reduced from 11% to 7% (P < 0.001), as did rates of surgical site infection (P < 0.001) and wrong-sided surgery (P < 0.47), across all sites. On the basis of these impressive reductions in complications and mortality, our institution adopted the WHO SSC in April 2009, with a few additional measures included, such as assuring presence of appropriate implants and administration of preoperative antibiotics and thromboembolic prophylaxis. Our purpose was to evaluate the efficacy and applicability of the surgical safety checklist in a multisurgeon plastic surgery hospital-based practice, by analyzing its effect on morbidity and outcomes. METHODS: A retrospective review of the morbidity and mortality data from the Department of Plastic Surgery at Loma Linda University Medical Center was conducted from January 2006 to July 2012. Data on morbidity and mortality before and after implementation of the surgical safety checklist were analyzed. RESULTS: The most common complications were wound related, including infection, seroma and/or hematoma, dehiscence, and flap-related complications. No significant decrease in the measured complications, neither total nor each specific complication, occurred after the implementation of the SSC. Although verifying appropriate administration of antibiotic, presence of appropriate equipment and materials, performing a preoperative formal pause, and verifying the execution of the other measures included in the SSC is critical, untoward outcomes after implementation of the checklist did not measurably decrease. In its current form as this time, the checklist does not seem to be efficacious in Plastic Surgery. CONCLUSIONS: Although certain elements of the WHO SSC checklist are universal and should be adopted, certain specific aspects require modification to improve applicability in a plastic surgery-specific practice. This necessitates the creation of a surgical safety checklist specifically for plastic surgery as other surgical specialties have proposed.

A Meta-analysis of Outcomes Using Acellular Dermal Matrix in Breast and Abdominal Wall Reconstructions: Event Rates and Risk Factors Predictive of Complications.

BACKGROUND: The use of acellular dermal matrix (ADM) has gained acceptance in breast and abdominal wall reconstructions. Despite its extensive use, there is currently a wide variation of reported outcomes in the literature. This study definitively elucidates the outcome rates associated with ADM use in breast and abdominal wall surgeries and identifies risk factors predisposing to the development of complications. METHODS: A literature search was conducted using the Medline database (PubMed, US National Library of Medicine) and the Cochrane Library. A total of 464 articles were identified, of which 53 were eligible for meta-analysis. The endpoints of interest were the incidences of seroma, cellulitis, infection, wound dehiscence, implant failure, and hernia. The effects of various risk factors such as smoking, radiation, chemotherapy, and diabetes on the development of complications were also evaluated. RESULTS: A majority of the studies were retrospective (68.6%) with a mean follow-up of 16.8 months (SD ± 10.1 months) in the breast group and 14.2 months (SD ± 7.8 months) in the abdominal wall reconstructive group. The overall risks and complications were as follows: cellulitis, 5.1%; implant failure, 5.9%; seroma formation, 8%; wound dehiscence, 8.1%; wound infection, 16.1%; hernia, 27.6%; and abdominal bulging, 28.1%. Complication rates were further stratified separately for the breast and abdominal cohorts, and the data were reported. This provides additional information on the associated abdominal wall morbidity in patients undergoing autologous breast reconstruction in which mesh reinforcement was considered as closure of the abdominal wall donor site. Radiation resulted in a significant increase in the rates of cellulitis (P = 0.021), and chemotherapy was associated with a higher incidence of seroma (P = 0.014). CONCLUSION: This study evaluates the overall complication rates associated with ADM use by conducting a meta-analysis of published data. This will offer physicians a single comprehensive source of information during informed consent discussions as well as an awareness of the risk factors predictive of complications.

Pediatric Cranial Vault Fractures: Analysis of Demographics, Injury Patterns, and Factors Predictive of Mortality.

BACKGROUND: Pediatric cranial vault fractures are a unique subset of injuries that pose distinct management and treatment challenges. They are anatomically distinct from their adult counterparts with potential implications on the development of the brain and craniofacial skeleton, and require unique considerations for management and treatment outcomes.A detailed analysis of the characteristics and outcomes of pediatric cranial vault fractures remains understudied in this population. Thus, the aim of this study was to characterize the demographics, injury patterns, operative interventions, concomitant injuries, and factors predictive of mortality in pediatric patients sustaining cranial vault fractures. METHODS: A retrospective review of patients less than 18 years of age presenting to the emergency department of a pediatric level I trauma center between 2000 and 2005 with skull fractures was performed. All patients were included regardless of treating specialty, treatment modality, or inpatient status. Patients were stratified into 3 groups (age < = 5 yrs, 5.1-11 yrs, and >11 yrs). ZIP codes were mapped using ArcGIS 10.2 Software (ESRI Inc, Redlands, CA) with ZIP code shapefiles from ESRI's ArcGIS Online. Socioeconomic and demographic variables at the ZIP code level were linked to each geocoded location using the United States Census Bureau summary files, and spatial clusters of injury were performed using GeoDa to conduct a test of local indicator of spatial autocorrelation. Statistical analysis was performed using the SPSS version 17 (SPSS Inc, Chicago, IL). RESULTS: A total of 923 consecutive patients met the inclusion criteria for the study. Caucasian (P < 0.001) males (P = 0.055) were most likely to sustain cranial vault fractures. The average age at injury was 5.97 years. Falls (53.7%) were the most common cause of injury across all age groups, followed by collisions (20.8%), with falls being more common in the youngest age group (< = 5 yrs), and collisions being more common in the older age groups. Direct objects to the head had the highest rate of surgical intervention (P < 0.001). Parietal bone fractures were more frequent in the youngest age group, while frontal and temporal bone fractures were more common in the older age groups. Increasing age was an independent predictor of the need for surgical intervention (P < 0.0001). The overall incidence of blindness and hearing loss was low, and increased with increasing age. Patients with fractures as a result of violent mechanisms were more likely to come from highly impoverished zip codes, compared with patients with nonviolent mechanisms of injury (19.6% versus 8%). Overall mortality was low (2.9%). Temporal bone fractures had the greatest risk of mortality (P < 0.001) with age > = 5 years being an independent predictor of mortality (P < 0.001). Victims of falls, and patients with associated gastrointestinal or musculoskeletal injuries, had a statistically significant increased chance of survival, whereas victims of collisions and patients with concomitant cervical spine, cardiothoracic, or respiratory injuries had a significantly increased risk of death. CONCLUSIONS: Pediatric cranial vault fracture injury patterns are significantly correlated with demographics, mechanisms of injury, presence and type of concomitant injuries, need for surgical intervention, and mortality. Although the need for operative intervention and overall mortality is low, these variables play significant roles in portending prognosis, and an understanding of the metrics presented herein will enable practitioners optimize management and treatment in this unique patient population.

Retrospective analysis of never events in panniculectomy and abdominoplasty patients and their financial implications.

In 2008, the Centers for Medicare and Medicaid Service adapted a list from the National Quality Forum consisting of 10 hospital-acquired conditions, also known as never events. Deeming such events as preventable in a safe-hospital setting, reimbursement is no longer provided for treatments arising secondary to these events. A retrospective chart review identified 90 panniculectomy and abdominoplasty patients. The hospital-acquired conditions examined include surgical-site infections (SSI), vascular-catheter associated infections, deep venous thrombosis/pulmonary embolism, retained foreign body, catheter-related urinary tract infection, manifestations of poor glycemic control, falls and trauma, air embolism, pressure ulcers (stages III and IV), and blood incompatibility. Information regarding age, American Society of Anesthesiologists (ASA) classification, body mass index, smoking, and chemotherapy were collected. Patients were divided into 2 groups, namely, those who developed never events and those with no events. Of the 90 patients, 14 (15.5%) developed never events because of SSI. No events occurred in the remaining 9 categories. Statistically significant risk factors included American Society of Anesthesiologists classification, age, and diabetes mellitus. The most common never event was SSI. In light of the obvious prevalence of the risk factors in patients who develop these events, the question of whether never events are truly unavoidable arises. Despite this, awareness of the impact on patient care, health care and hospital reimbursement is vital to understanding the new paradigm of the "one size fits all."

A unique case of tessier 30 and bilateral cleft lip and palate: a new clinical syndrome?

Background : Tessier 30 cleft is rare and sparsely reported in the literature. A unique case of an infant with a Tessier 30 cleft, bilateral cleft lip and palate, and other anomalies is presented. In addition to craniofacial anomalies, he had cardiac, gastrointestinal, and genitourinal defects. The constellation of these findings suggests the possibility of a new clinical syndrome. We present these findings and postoperative results following surgical treatment. Patient and Methods : A 37-week gestational male infant with multiple congenital anomalies is presented. Findings on clinical exam were notable for Tessier 30 median mandibular cleft, bilateral cleft of the lip and palate, and bifid tongue. Further workup revealed levocardia, perimembranous moderate-to-large ventricular septal defect, patent foramen ovale, double outlet right ventricle, intestinal malrotation, and bilateral undescended testicles. There were no extremity anomalies, and cytogenetic studies for 22q deletion were negative. Results : The preoperative, intraoperative, and postoperative findings and images are discussed. Conclusion : We present a unique case of a child with a Tessier 30 cleft associated with bilateral cleft lip and palate in the absence of intraoral masses or limb anomalies. Previous reports of median facial clefts have occurred either in the presence of intraoral hamartomas, suggesting the palatal defects are a result of sequence abnormalities, or in association with extremity findings consistent with the spectrum of orofaciodigital syndrome. The case we present is distinct and may represent a new clinical syndrome.

The use of intra-abdominal tissue expansion for the management of giant omphaloceles: review of literature and a case report.

Giant omphaloceles present a reconstructive challenge in planning, management, and eventual closure of the abdominal wall defect. The goal of reconstruction is to recreate a functional abdominal wall domain and return the extra-anatomically placed viscera into the peritoneal cavity in a safe manner. Traditionally, placement of tissue expanders has been in the subcutaneous and intramuscular planes. Recently, however, there have been reports of intra-abdominal placement of expanders. We present a detailed review of the literature regarding the use of tissue expanders in the management of giant omphaloceles with specific emphasis on the intra-abdominal technique of placement. We also present a case report with the longest follow-up till date in which the patient underwent staged reduction using the intra-abdominal approach. Initial reports of this modality are promising both as a primary strategy and in patients in whom conventional techniques have failed. Results from our review of literature and case report suggest that this technique appears to be durable and effective with successful functional and cosmetic outcomes.

Demographics of cleft care providers in Africa and reported experience in training and practice: direct analysis of continent-based practitioners.

OBJECTIVE: To elucidate the impact of several geographic, cultural, and socioeconomic variables on cleft care delivery in Africa, and to investigate the current status of cleft care delivery in Africa. DESIGN: Survey of practitioners attending the second Pan-African Congress on Cleft Lip and Palate (PACCLIP). SETTING: The annual PACCLIP conference in Ibadan, Nigeria, West Africa, February 2007. MAIN OUTCOME MEASURE: To provide an analysis of the demographics and training experience of cleft care providers in Africa by collating information directly from the continent-based practitioners. RESULTS: Plastic surgeons and oral and maxillofacial surgeons provide the majority of cleft care. Most of the participants reported availability of formal training programs in their respective countries. The predominant practice settings were university and government-based. During training, half of the providers had encountered up to 30 cleft cases, and a quarter had managed more than 100 cases. Representation of visiting surgeons were equally distributed between African and non-African countries. CONCLUSIONS: This study provides initial and detailed analysis crucial to understanding the underlying framework of cleft care composition teams, demographics of providers, and training and practice experience. This awareness will further enable North American and other non-African plastic surgeons to effectively partner with African cleft care providers to have a further reaching impact in the region.

An Effective, Reproducible, and Cost-Effective Approach for Achieving Symmetry in Bicoronal Incisions in Pediatric Patients Undergoing Craniofacial Surgery.

SUMMARY: Bicoronal incisions are frequently used for exposure and access to the craniofacial skeleton. A zigzag design is often used to camouflage the resultant scar. Often, free-hand zigzag drawings require several correction attempts to ensure symmetry because of the need for replication of multiple limbs of the bicoronal incision that need to be similar lengths, distance, and angles from each other. The authors present a novel technique using a template that rapidly and consistently achieves symmetric zigzag bicoronal incisions. The device is a hairstyling device that is inherently geometric in its design. Retrospective results of pediatric craniofacial patients from 2010 to 2018 are presented. Patients undergoing endoscopic reconstructions and patients who had prior operations at other institutions were excluded from the study. Fifty-two patients met inclusion criteria, with age at surgery ranging from 3 to 207 months (mean, 17 months). Follow-up ranged from 1 to 66 months (mean, 26 months). Data collected included demographics, type of surgery, and operative outcomes, including incision-related complications. Using this dynamic hairstyling device in a novel application as a template results in a fast, effective, and easily reproducible symmetric bicoronal zigzag incision in all cases. This technique eliminates the need for adjusting the length and angles of bicoronal incisions, and it can be adapted across a variety of head sizes and shapes in both pediatric and adult populations.