Andrew L. Greensmith

Long-term experience with methylmethacrylate cranioplasty in craniofacial surgery

Cranioplasty is a procedure commonly performed by plastic surgeons involved in craniofacial surgery, in which it is generally accepted that the ideal reconstructive material is autogenous bone. When this is not available or when its use is inappropriate, alloplastic materials are the next best option. A retrospective analysis was carried out to review the senior authors experience of 98 cranioplasties with methylmethacrylate (MM) from 1980 to 2001. The site and size of the implant and complications thereof were recorded and an assessment of the quality of the final result made. The patients were divided into two groups: Group 1: Methylmethacrylate as a full thickness inlay. Group 2: Methylmethacrylate as an onlay only. In group 1 there were 32 patients for whom the average follow up was 8.2 years (range 2-16 years). In group 2 there were 66 patients with an average follow up of 7.1 years (range 2-20 years). After a minimum follow up of 2 years, 89 out of 98 of the patients retained their implants. Nine implants in total were removed. Of the 89 patients retaining their implants, 85 had excellent or good results at long-term follow up. The infection and implant removal rate was very high if nasal or frontal sinus tissue was in direct contact with the implant during the operative procedure. The keys to the successful use of methylmethacrylate are discussed and representative case examples are presented. There is increasing evidence that the long term results of newer alternatives to methylmethacrylate for cranioplasty such as hydroxyapatite cement are disappointing and do not justify their expense. Methylmethacrylate is cheap, readily available and easy to use and it remains the alloplastic material of choice for cranioplasty in our hands.

Analysis of morbidity and mortality in surgical management of craniosynostosis.

Abstract Multidisciplinary care involving plastic surgery and neurosurgery is generally accepted as optimal to manage craniosynostosis to avoid complications and to identify patients at risk. We conducted a retrospective 30-year review of craniosynostosis surgery at a single major craniofacial institute to establish the rate and predictors of complications. Medical records of 796 consecutive patients who underwent primary surgery for craniosynostosis from 1981 to 2010 at our institute were analyzed for complications. Complications were defined as intraoperative and postoperative adverse events requiring changed management. Reoperation was defined as a repeat transcranial procedure. Multivariate logistic regression was used to identify predictors for complications or revision. Across the years, the procedures evolved from technically simple to complex, which increased complications but better outcomes. Complications occurred in 111 patients (14%), and 33 (5.4%) needed major revision. Multivariate analysis identified multisuture and syndromic craniosynostosis, more recent surgeries, younger age (<9 months), spring-assisted cranioplasty, longer surgery, and greater transfusion as predictors of complications. Patients with syndromic and multisutural craniosynostosis and those operated on younger than 9 months had increased risk of major revision surgery for regression to phenotype. Our experience over 30 years indicates that pediatric transcranial craniosynostosis surgery can be safely carried out in our tertiary referral center. There were no deaths from primary surgery, and complication and reoperation rates mirror those of other published studies. Syndromic and complex craniosynostosis predicted both complications and need for major revision. Spring cranioplasty was associated with higher complications. Overall results support a recommended age for craniosynostosis surgery between 9 and 12 months.

Complete correction of severe scaphocephaly: the Melbourne method of total vault remodeling.

Background: A new method of total calvarial remodeling for correcting significant scaphocephaly is described, and experience with the first 30 consecutive patients is presented. Methods: Thirty consecutive patients (22 boys and eight girls) with moderate to severe scaphocephaly who underwent total calvarial remodeling using the Melbourne technique were analyzed retrospectively. Mean age at surgery was 7.5 months (range, 4 to 18 months). All had significant frontal and occipital deformities, bitemporal narrowing, a low cranial index, an anteriorly located vertex, and a narrow posteroinferiorly sloping posterior cranium. Clinical photographs, computed tomographic imaging, and cranial index were evaluated preoperatively and postoperatively. A sufficient follow-up period in 17 patients enabled the measurement of changes in cranial indices. Results: A dramatic improvement in head shape was confirmed subjectively by clinical examination and photographs and, in 17 patients, objectively by analyses of the cranial indices. In these 17 patients, mean preoperative cranial index was 64.6 percent preoperatively (range, 56 to 69.3 percent) and increased to a mean of 77.5 percent postoperatively (range, 72 to 81 percent). The mean increase in cranial index was 12.9 percent (range, 9.5 to 19 percent). Among the 30 patients, overall complications were major in one patient (3.3 percent) (presumed air embolus) and minor in three (10 percent). Conclusions: The Melbourne technique of total vault remodeling consistently achieves a virtually normal head shape. After analysis of the first 30 cases, the authors recommend this as their technique of choice for severe scaphocephaly when the full constellation of deformities is present.

Measuring cranial vault volume with three-dimensional photography: a method of measurement comparable to the gold standard.

The gold standard for measuring cranial vault volume is a computed tomography (CT) scan. Computed tomography scans in the pediatric population carry the significant risk of inducing a malignancy later in life. In a novel study, we show that a three-dimensional (3D) photograph can be used to measure and track cranial vault volume changes in craniosynostosis patients. In a study of adequate power as determined by pre hoc analysis, we demonstrate a greater than 0.91 correlation coefficient between volume as measured by CT and 3D photograph in more than 70 patients presenting to a tertiary craniofacial center (P < 0.001). Volume above a plane running through the lateral canthus (ex) and tragus (t) sag-ex-t on the digital 3D photograph differs from CT by a mean percentage difference of 31.9% (SD, 14.0%; 95% confidence interval, P < 0.0001). A linear regression model was used to determine the equation describing the relationship between volume as measured by 3D photograph and CT; with this equation, the absolute volume of the cranial vault is easily determined using only the 3D image. Interrater reliability is high (>0.99, ICC). The ability to measure cranial vault volume from the 3D photograph adds an important dimension to the complete and objective analysis of skull growth and postoperative change.

Changing epidemiology of nonsyndromic craniosynostosis and revisiting the risk factors.

Abstract Recent studies in Europe and the United States report increased incidence of metopic synostosis. Whether a similar trend had occurred in Australia remains unknown. This research aimed to determine changes in incidence and subtypes of craniosynostosis in Victoria and to identify perinatal risk factors. A retrospective audit of patients (n = 522) presenting to the Royal Children’s Hospital in Melbourne with nonsyndromic craniosynostosis from 1982 to 2008 was undertaken. Perinatal data were sourced from the Victorian Perinatal Data Collection. The changes in incidence of craniosynostosis subtypes were calculated based on Poisson regression, and risk factors for craniosynostosis and subtypes were analyzed by univariate logistic regression analysis. The prevalence of nonsyndromic craniosynostosis was 3.1 in 10,000 live births in Victoria. On average, the incidence of nonsyndromic craniosynostosis increased by 2.5% per year among Victorian live births. Over 25 years, metopic synostosis incidence significantly increased by 7.1% per year in the population of Victoria, outpacing other subtypes. The risk factors for metopic synostosis include being male, multiple births (ie, twins), preterm gestation, low birth weight, high maternal age, and emergency cesarean birth. This study revealed a true increase in incidence of metopic synostosis in Victoria, which could be a result of increased frequency of multiple births, preterm gestation, low birth weight, and high maternal age in the Victorian population from 1982 to 2008. The incidence of other nonsyndromic craniosynostoses, which include sagittal, unicoronal, and multisutural craniosynostoses, however, has remained unchanged.

Prospective analysis of the outcome of surgical management of drooling in the pediatric population: a 10-year experience.

Background: Sialorrhea is a common problem in the neurologically impaired pediatric patient and surgery is the mainstay of treatment for severely affected patients refractory to conservative or medical treatment. Methods: The results of the surgical protocol used since 1993 at the Royal Children’s Hospital in Melbourne, Australia, are reported. Seventy-two patients underwent bilateral submandibular duct transposition combined with bilateral sublingual gland excision. Patients were analyzed prospectively and reviewed at 1, 6, and 12 months, then at 2 and 5 years postoperatively. Results: Of 67 patients with 2 years of complete follow-up, the median score for the frequency of drooling fell from 4.0 to 2.9 (p < 0.001) and the median severity-of-drooling score decreased from 4.8 to 3.0 (p < 0.001). There was a fall in the number of clothing/bib changes from a median of four per day to zero (p < 0.0001). Of 41 patients followed to 5 years, both the median frequency and severity of drooling scores remained at 3. Overall the majority of patients benefited from surgery. Thirteen patients (18 percent) experienced complications which were major in 9 percent. Conclusion: We have found bilateral sublingual gland excision in combination with bilateral submandibular duct transposition to be superior to bilateral submandibular duct transposition plus parotid duct ligation. The surgical treatment of sialorrhea continues to be a rewarding experience for our multidisciplinary team.

Long-term Outcomes of Surgical Tongue Reduction in Beckwith–wiedemann Syndrome

Background: Surgical tongue reduction is often performed in Beckwith–Wiedemann syndrome when macroglossia results in abnormal tongue function or cosmesis; however, no published studies have examined the long-term outcomes of this procedure. Methods: Patients older than 18 years with Beckwith–Wiedemann syndrome who had previously undergone surgical tongue reduction at the Royal Children’s Hospital in Melbourne underwent assessment of speech and tongue function, mobility, sensation, and cosmesis. These assessments were performed by questionnaire on 11 subjects and by formal medical and speech pathology review in four of these 11 subjects. Results: Eleven patients aged 19 to 31 years completed responses by means of questionnaire. The most common self-reported abnormalities were continued disproportionate tongue bulk (91 percent), abnormal tongue appearance (82 percent), specific speech sound errors (73 percent), and a short tongue tip (55 percent). Formal assessments investigated speech, swallowing, taste, and tongue mobility in four quite different subjects. One of these four subjects had no detectable deficits in tongue function. All 11 patients were of normal intelligence and did not report significant difficulties in their day-to-day life that were attributable to their macroglossia or tongue reduction surgery. Conclusions: Pediatric patients with symptomatic macroglossia requiring surgical tongue reduction may not achieve complete normality in tongue function and appearance in adulthood. It is important that surgical tongue reduction addresses the global nature of the macroglossia and aims to retain a tapered tongue tip with length sufficient to permit normal tongue movements.

Quantitative morphometric outcomes following the Melbourne method of total vault remodeling for scaphocephaly.

The Melbourne method of total vault remodeling was developed at The Royal Childrens Hospital (Melbourne) to address all phenotypic aspects of scaphocephaly. To quantitatively evaluate this technique, a retrospective analysis was performed on 33 consecutive patients who underwent the Melbourne procedure between October 2004 and June 2007. To monitor outcomes, three-dimensional digital surface photography was used, obtaining 4 anthropometric measurements (cranial length, cranial width, head circumference, auricular head height) preoperatively and postoperatively. To assess the effect on continuing cranial vault development, cranial volume was calculated with computed tomography. Anthropometric measurements were obtained in 27 patients (81.8%), with a mean postoperative follow-up of 8.9 months. Cranial index (width/length) demonstrated an 11.1% improvement. The mean head circumference in the scaphocephaly group preoperatively remained larger than the normative population postoperatively, although the magnitude of difference was decreased, whereas the mean auricular head height demonstrated a 10.5% increase postoperatively, remaining higher than the normative population. Cranial volume was calculated in 30 patients (91%), with a mean postoperative follow-up of 7.9 months. This demonstrated that the mean intracranial volume was significantly higher in the scaphocephaly group preoperatively, and this difference was maintained postoperatively. These results support our belief that the Melbourne procedure is a technique that may be used to correct all phenotypic aspects of scaphocephaly, with no apparent evidence for a detrimental effect on cranial growth.

Submucous cleft palate: an often-missed diagnosis.

AbstractThis study aimed to investigate the age at diagnosis, palatal characteristics, and symptoms of submucous cleft palate (SMCP) and to compare the speech outcomes between 3 operative techniques for primary repair of SMCP.It was a retrospective review of 92 patients diagnosed with SMCP between 1994 and 2008, where patients were treated with 1 of 3 surgical procedures: double opposing z-palatoplasty, radical intravelar veloplasty, or pharyngeal flap.The need for a second procedure was considered a primary outcome measure, with operative failure defined by the need for a secondary operation. Postoperative speech was evaluated perceptually using the Great Ormond Street Speech Assessment.We found that SMCP was diagnosed at a mean age of 3.6 years. At diagnosis, 8% were asymptomatic, 67% had abnormal speech, 49% had recurrent otitis media with effusions, and 47% had hearing loss. Ear, nose, and throat surgery was performed on 37% without the diagnosis of SMCP being made. Subjective impression of a short palate was a predictor for secondary surgery (P < 0.02). Age at repair did not affect velopharyngeal insufficiency outcome; however, repair after 18 months of age led to a higher likelihood of developing articulatory speech errors resulting in the need for more speech therapy.In conclusion, the triad of features of SMCP is well recognized, but our study reveals that a high percentage is seen by physicians who have failed to make the diagnosis despite signs and symptoms being evident. Surgical correction is successful regardless of technique and age, but earlier recognition to prevent speech impairment should be sought.

Fatty hypertrophy cause obstructive sleep apnea after fat injection for velopharyngeal incompetence.

Intervention Soft tissue augmentation of the posterior pharyngeal wall and the soft palate is reported to reduce velopharyngeal incompetence, and fat grafting in selected patients has shown effective and lasting results for restoring normal resonance. Potential complications of soft tissue augmentation for velopharyngeal incompetence include obstructive sleep apnea. Patient An 8-year-old boy with velopharyngeal incompetence and a small velopharyngeal gap underwent a fat injection procedure and subsequently developed obstructive sleep apnea concomitant with a significant weight gain. Videofluoroscopy and nasendoscopy showed a remarkable enlargement of the grafted fat areas that required a soft palate debulking procedure, significantly improving obstructive sleep apnea. Conclusion This is an unusual case where alteration in volume of grafted fat at the recipient site is suspected of causing obstructive sleep apnea. It is also an example of long-term fat graft survival and fat graft overgrowth.