A. Michael Sadove

Resorbable Plla-pga Plate and Screw Fixation in Pediatric Craniofacial Surgery: Clinical Experience in 1883 Patients

The need to provide rigid bony fixation in the surgical treatment of craniofacial deformities has inspired an ongoing evolution of surgical innovations and implants. Because of the young age of many treated craniosynostosis patients and the unique pattern of cranial vault growth, the extensive implantation of metal devices is potentially problematic. The use of resorbable plate and screw devices offers all of the benefits of rigid fixation without many of their potential risks. Since the introduction of resorbable plate and screw devices in 1996, tens of thousands of craniofacial patients have received implants, but long-term results from a large series have yet to be reported. A combined prospective and retrospective analysis was done on 1883 craniosynostosis patients under 2 years of age treated by 12 surgeons from seven different geographic locations over a 5-year period who used the same type of resorbable bone fixation devices (poly-L-lactic-polyglycolic copolymer). Specifically, the incidence of postoperative infection, fixation device failure, occurrence of delayed foreign-body reactions, and the need for reoperation resulting from device-related problems were determined. Technical difficulties and trends in device use were also noted. From this series, significant infectious complications occurred in 0.2 percent, device instability primarily resulting from postoperative trauma occurred in 0.3 percent, and self-limiting local foreign-body reactions occurred in 0.7 percent of the treated patients. The overall reoperation rate attributable to identifiable device-related problems was 0.3 percent. Improved bony stability was gained by using the longest plate geometries/configurations possible and bone grafting any significant gaps across plated areas that were structurally important. The specific types of plates and screws used evolved over the study period from simple plates, meshes, and threaded screws to application-specific plates and threadless push screws whose use varied among the involved surgeons. This report documents the safety and long-term value of the use of resorbable (LactoSorb) plate and screw fixation in pediatric craniofacial surgery in the infant and young child. Device-related complications requiring reoperation occurred in less than 0.5 percent of the implanted patients, which is less frequent than is reported for metallic bone fixation. Resorbable bone fixation for the rapidly growing cranial vault has fewer potential complications than the traditional use of metal plates, screws, and wires.

The Spectrum of Orofacial Clefting

LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Describe the differing types of congenital clefting defects that extend outward from the perioral region. 2. Define the sites of anatomical disruption and deformities that these types of facial clefts cause. 3. Describe the cause and incidence, if known, of orofacial clefts and their inheritance/transmission risks. BACKGROUND Clefts of the orofacial region are among the most common congenital facial defects. The clinical presentation is usually that of a lateral cleft of the lip through the philtrum with or without extension through the palatal shelves. However, atypical forms of clefts with lip involvement also occur in a variety of patterns, some of which are embryologically predictable; others are not. METHODS An overview of the embryology, cause, and incidence of this diverse and interesting group of congenital orofacial clefts is presented. RESULTS Clefts involving the lateral upper lip; median upper lip; and oblique facial, lateral facial, and median mandibular regions are reviewed. CONCLUSIONS This review of orofacial malformations describes clefting anomalies that emanate from the mouth and lips. As the causes of orofacial clefts are better understood, it is becoming clear that a complex interplay between genetic and environmental variables causes these clefts. Future study of orofacial clefts will require increasingly sophisticated methods of elucidating these subtle interactions.

Management of Alveolar Cleft Bone Grafting—State of the Art

Bone grafting of the alveolus is an essential step in the reconstruction of the orofacial cleft deformity. Secondary grafting with iliac marrow consistently produces trabecular bone to unify the maxilla and provide odontogenic support. It requires preoperative maxillary alignment, well designed mucoperiosteal flaps, and good oral hygiene to be optimally successful. Its high success rate currently makes it the preferred approach at most centers. Primary grafting with rib results in a unified maxilla, eliminates the oronasal fistula, and does not adversely affect midfacial growth. It assists in preventing maxillary segmental collapse, particularly in the bilateral cleft patient. Whether it can produce enough alveolar bone to support long-term odontogenic needs awaits further clinical documentation in the limited numbers of centers that routinely perform this procedure.

Congenital and acquired pediatric breast anomalies : A review of 20 years' experience

Background: The purpose of this article was to review the senior author’s 20 years of experience in the treatment of pediatric breast abnormalities, to propose a classification system for their treatment, and to provide a synopsis of treatment options. Methods: Congenital and acquired breast anomalies were identified in a retrospective chart review (n = 66). Breast abnormalities were classified as hyperplastic (n = 44), deformational (n = 11), or hypoplastic (n = 11). Hyperplastic abnormalities included gynecomastia, hyperplasia, polythelia, polymastia, and giant fibroadenoma. Deformational abnormalities were categorized as either iatrogenic (previous thoracostomy, thoracotomy, or tumor excision) or traumatic (thermal or penetrating injuries). Hypoplastic abnormalities included athelia, unilateral and bilateral hypoplasia, tuberous breast, and Poland syndrome. Type of surgery, age at initial operation, and number of operations were recorded for all patients. Results: Hyperplastic abnormalities were treated with breast reduction techniques and required the fewest operations per patient (1.14), followed by iatrogenic breast injury (2.1 per patient). The average number of procedures required for hypoplastic abnormalities was 2.45 per patient. The highest reoperation rates were seen in patients with burn injuries to the breast and patients with Poland syndrome. Mean age at initial operation was highest in the deformational group (18.5 years) and lowest in the hyperplastic group (17.4 years). Conclusion: Classification of pediatric breast abnormalities and considerations about timing for surgery and the likely need for staged operations aid in anticipating and optimizing clinical outcomes.

Experimental effects of graft revascularization and consistency on cervicofacial fat transplant survival.

An experimental study evaluating the contributions of graft composition (particulate vs. whole) and revascularization (immediate reanastomosis vs. delayed) to cervicofacial fat transplantation was conducted in rats. Distant (inguinal fat) grafts were bilaterally transplanted to a muscular bed in the cervicofacial region as a free flap (anastomosis to carotid and jugular vessels) or as a free graft (either particulate or whole). Postoperative assessment was made by comparison of pre- and post-operative weights and histologic examination of all specimens, and by acrylic microangiography in select animals of each group. The fat flaps exhibited minimal loss of tissue volume, and showed a normal histologic appearance of the adipocytes and extensive vascular elements within the grafts. Conversely, considerable volume loss occurred in both the particulate and whole fat grafts. Histologically, the free graft was characterized by cellular disruption, atrophic adipocytes, and areas of acellularity. Whole grafts had histologic evidence of vessels located primarily at the periphery, whereas particulate grafts had increased intragraft vessels. Only the fat flaps showed observable intragraft vasculature by microangiography. These findings suggest that reduction of fat grafts into smaller components, eg, by liposuction harvesting, does not improve graft survival or decrease posttransplant resorption.

Effects of Resorbable Fixation on Craniofacial Skeletal Growth: A Pilot Experimental Study

The effects of fixation composed of resorbable polymers on craniofacial development was investigated in an animal model. Fourteen rabbits had amalgam markers placed bilaterally at the lambdoid, coronal, and frontonasal sutures at 28 days of age. Seven animals (group I) were not plated and served as controls. The other 7 animals (group II) were fixed across the left coronal suture with a 4-hole, compressive resorbable plate. After 6 months, intermarker distances (growth) were measured radiographically, and the amount of fixation degradation was determined by extracted plate weights. Resorbable plating across the coronal suture resulted in local marker constriction adjacent to fixation. Compensatory lengthening of the distal aspect of the frontal bone occurred, however resulting in unaltered total cranionasal lengths compared with that of control animals. Plate degradation occurred with a mean decrease of 7% from their original weights. Molecular weight analysis of the plate differences, however, was not done. This initial study indicates that a large plate size and slow resorption properties of polymer fixation can have a similar restrictive effect on bone growth as that of metal fixation. Whether thinner plates or more rapidly resorbing polymers will permit normal growth in this animal model awaits further testing.

Cleft palate repair: art and issues

Caring for the child with cleft palate requires a multidisciplinary approach that begins with evaluation for other possible congenital anomalies, decisions about timing of repair, and choice of techniques. Postoperative follow-up similarly requires a team approach and should include an otolaryngologist, an orthodontist, and a speech therapist. The art of cleft palate repair has enjoyed a decade rich in new developments. New techniques have been developed, and standard techniques have been refined. Most importantly, the need for prospective, randomized trials to objectively compare surgical techniques has been recognized. Initiation and completion of these trials will improve outcomes for patients with cleft palate repairs.

Effects of a positively charged biomaterial for dermal and subcutaneous augmentation

Based on previous experimental connective tissue work, the use of a positively charged dextran-based biomaterial in subcutaneous tissue sites was evaluated. After hydration with saline, the biomaterial was injected beneath the abdominal skin in rats. A robust macrophage response was initially seen at 30 days without acute inflammation. By one year postoperatively, extensive intermaterial fibroblast and collagen ingrowth had occurred. No evidence of a foreign-body or chronic inflammatory response was seen. These preliminary findings suggest good tissue compatibility of this biomaterial and suggests that when combined with a biocompatible liquid medium, the potential for development of a bioactive dermal and subcutaneous injectable substance exists.

Computer-generated Patient Models for Reconstruction of Cranial and Facial Deformities

The use of three-dimensional, computer-generated anatomic models can be used in the diagnosis and reconstruction of a variety of craniofacial problems. They are readily manufactured from computed tomography scans at a reasonable cost with only several weeks of preparation and delivery time. Their contemporary value is in the preoperative treatment planning, intraoperative implant fashioning, and preoperative implant fabrication in appropriately selected patients.

Pediatric chest wall and breast deformities.

Pediatric chest wall and breast deformities present as a wide spectrum of anomalies, and often occur coincidentally. Chest wall abnormalities fall into two categories, congenital (which are largely hypoplastic) and deformational (including both chest wall malignancies and postoperative abnormalities). Breast abnormalities can be categorized into three groups, including hypoplastic, hyperplastic, and deformational anomalies. Hypoplastic breast anomalies require reconstruction with augmentation techniques and are often associated with significant reoperative rates, as are deformational anomalies; hyperplastic abnormalities require reduction techniques and are less likely to require reoperation. Considerations about surgical correction of pediatric chest wall and breast deformities often require coordinated efforts between pediatric and pediatric plastic surgeons with anticipation of continued growth of the child and careful timing for treatment to maximize functional and aesthetic outcomes.