Antonio Jorge Forte

Analysis of midface retrusion in Crouzon and Apert syndromes.

Background: Midface retrusion is the hallmark of the syndromic dysostoses (i.e., Crouzon and Apert). Lack of forward projection and/or structural deficiency could be responsible, but neither has been adequately assessed three-dimensionally. The authors examined both the cranial base/facial interface and the midface volume to provide an understanding of the etiopathogenesis of midface deficiency. Methods: Children with computed tomographic scans in the absence of any surgical intervention were included. Demographic information was recorded for three groups: Apert, Crouzon, and control. Scans were digitized and manipulated using Materialise software (Surgicase CMF). Craniometric data relating to the midface and sphenoid were collected. Volumetric assessment of the midface was tabulated. Statistical analysis was performed using the t test. Results: Thirty-six scans were included (control, n = 17; Crouzon/Apert, n = 19). All children were in the early mixed dentition stage. The anterior cranial fossa proved to be shorter and wider in Crouzon/Apert patients compared with controls. The cranial base angles (N-S-BA, N-S-SO, N-SO-BA, S-SO-BA, and N-S-AR) were not statistically different across the groups. The Crouzon/Apert group showed angles more obtuse between the greater wings of the sphenoid, and more obtuse (more splayed) between the pterygoid plates. Nasion-sella-pterygomaxillary fissure angle was more obtuse (flatter) in the Crouzon/Apert group. There was no volumetric difference in the maxilla, zygoma, and sphenoid comparing the Crouzon/Apert group to controls. Conclusions: Midface retrusion in the Crouzon/Apert group is associated with altered sphenoid morphology (widened and retruded pterygoid plates), with a flatter and wider maxilla, suggesting diminished growth inferiorly and anteriorly. There is no volumetric deficiency in Crouzon/Apert patients compared with controls. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Reduced three-dimensional airway volume is a function of skeletal dysmorphology in Treacher Collins syndrome.

Background: Children with Treacher Collins syndrome frequently present with obstructive sleep apnea and respiratory insufficiency. The purpose of this study was to three-dimensionally calculate upper airway volume in these patients. The authors also assessed the correlation between bony craniofacial morphology and spatial position with airway volume. Methods: Thirty Treacher Collins syndrome patients who have not been operated on were compared with a sample of 35 age- and sex-matched unaffected controls. Upper airway volume was stratified into retropalatal and retroglossal aspects. Three-dimensional craniometric findings were compared between patients and controls. Among Treacher Collins syndrome patients, the authors assessed the relationship of craniofacial morphology and spatial positioning to airway volume. Statistical analyses included independent sample t tests and Pearson correlation coefficient analyses. Results: Decreased total upper airway volume (p = 0.034) was found in the Treacher Collins syndrome group, attributable primarily to a decrease in retroglossal airway volume (p = 0.009). Regarding three-dimensional craniometric variables, maxillary and mandibular length (r = 0.76, p < 0.001; and r = 0.68, p < 0.001), and the anterior and posterior cranial base (r = 0.61, p < 0.001; and r = 0.77, p < 0.001) were positively correlated with airway volume in Treacher Collins syndrome patients. Transverse internal diameters of the upper airway were also positively correlated with airway volume (r = 0.635, p = 0.001; and r = 0.511, p = 0.006); however, no correlation was shown for the anteroposterior airway diameters. Conclusions: Three-dimensional analysis revealed diminished upper airway volume in Treacher Collins syndrome, with the retroglossal region being the most severely constricted. Maxillomandibular dysmorphologies, and their relationship to the cranial base, correlated significantly with airway findings.

Perception of Age, Attractiveness, and Tiredness After Isolated and Combined Facial Subunit Aging.

BackgroundPatients often seek help to redress aging that affects various regions of the face (subunits). The purpose of this study was to determine how aging of different facial subunits impacts perception of age, attractiveness, and tiredness.MethodFrontal and lateral view facial photographs of a middle-aged woman were modified using imaging software to independently age different facial features. Sixty-six subjects were administered with a questionnaire, and presented with a baseline unmodified picture and others containing different individual or grouped aging of facial subunits. Test subjects were asked to estimate the age of the subject in the image and quantify (0–10 scale) how “tired” and “attractive” they appeared. Facial subunits were organized following rank assignment regarding impact on perception of age, attractiveness, and tiredness.ResultsThe correlation coefficient between age and attractiveness had a strong inverse relationship of approximately −0.95 in both lateral and frontal views. From most to least impact in age, the rank assignment for frontal view facial subunits was full facial aging, middle third, lower third, upper third, vertical lip rhytides, horizontal forehead rhytides, jowls, upper eyelid ptosis, loss of malar volume, lower lid fat herniation, deepening glabellar furrows, and deepening nasolabial folds. From most to least impact in age, the rank assignment for lateral view facial subunits was severe neck ptosis, jowls, moderate neck ptosis, vertical lip rhytides, crow’s feet, lower lid fat herniation, loss of malar volume, and elongated earlobe.ConclusionThis study provides a preliminary template for further research to determine which anatomical subunit will have the most substantial effect on an aged appearance, as well as on the perception of tiredness and attractiveness.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Reduced three-dimensional nasal airway volume in treacher collins syndrome and its association with craniofacial morphology.

Background: Airway insufficiency decreases quality of life and may be life threatening in patients with Treacher Collins syndrome. The authors calculated the three-dimensional nasal airway volume in patients with Treacher Collins syndrome to identify correlations between nasal airway volume and craniofacial morphology and provide guidance for surgical planning. Methods: Thirty nonoperated patients with Treacher Collins syndrome were compared with 35 unaffected age- and gender-matched controls. Anatomic variables of the cranial base, the maxilla complex, and internal diameters of nasal airway were compared between patients and control subjects using three-dimensional craniometric analyses. In the Treacher Collins group, the relation of craniofacial morphology to nasal airway volume was assessed separately. Statistical analyses were performed using independent sample t tests and Pearson correlation coefficient analyses. Results: Nasal airway volume was decreased 38.6 percent in patients with Treacher Collins syndrome relative to controls (p = 0.001). A positive correlation of maxillary position and nasal airway volume was shown in Treacher Collins patients (r = +0.463, p = 0.013). Maxillary, nasal bone, and orbitale width were also positively correlated with nasal airway volume (r = +0.582, p = 0.001; r = +0.408, p = 0.035; and r = +0.677, p < 0.001, respectively). Shortened internal diameters of the nasal airway all positively correlated with nasal airway volume. Conclusions: Nasal airway volume is reduced in patients with Treacher Collins syndrome. Reduced projection of the maxilla and transverse maxillary deficiency are correlated with reduced nasal airway volume and are primarily responsible for obstruction of the nasal airway. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Use of Three-Dimensional Computed Tomography to Classify Filling of Alveolar Bone Grafting

Several authors have proposed classifications to analyze the quality over time of secondary alveolar bone grafting. However, little discussion has been held to quantitatively measure the secondary bone grafting for correction of nasal deformity associated to cleft palate and lip. Twenty patients with unilateral alveolar cleft, who underwent secondary alveolar bone grafting, were studied with 3D computer tomography. The height between the inferior portion of the pyriform aperture and the incisal border of the unaffected side (height A) and the affected side (height B) was measured using a software Mirror. A percentage was then obtained dividing the height B by the height A and classified into grades I, II, and III if the value was greater than 67%, between 34% and 66%, or less than 33%. Age, time of followup, initial operation, and age of canine eruption were also recorded. All patients presented appropriate occlusion and function. Mean time of followup was 7 years, and mean initial age for operation was 10 years old. 16 patients were rated as grade I and 4 patients as grade II. No cases had grade III. We present a new grading system that can be used to assess the success of secondary bone grafting in patients who underwent alveolar cleft repair.

Combined metopic and sagittal craniosynostosis: is it worse than sagittal synostosis alone?

OBJECT Combined metopic and sagittal craniosynostosis is a common variant of the nonsyndromic, multiplesuture synostoses. It is unknown whether this combined form causes reduced intracranial volume (ICV) and potentially more brain dysfunction than sagittal synostosis alone. This study is a volumetric comparison of these 2 forms of craniosynostosis. METHODS The authors conducted a retrospective chart and CT review of 36 cases of isolated sagittal synostosis or combined metopic and sagittal synostosis, involving patients seen between 1998 and 2006. Values were obtained for the intracranial compartment, brain tissue, CSF space, and ventricular volumes. Patients with craniosynostosis were then compared on these measures to 39 age- and sex-matched controls. RESULTS In patients with isolated sagittal synostosis and in those with combined metopic and sagittal synostosis, there was a trend toward smaller ICV than in controls (p < 0.1). In female patients older than 4.5 months of age, there was also a trend toward smaller ICV in patients with the combined form than in those with sagittal synostosis alone (p < 0.1), and the ICV of patients with the combined form was significantly smaller than the volume in controls in the same age group (p < 0.05). Brain tissue volume was significantly smaller in both patient groups than in controls (p < 0.05). Ventricular volume was significantly increased (compared with controls) only in the patients with isolated sagittal synostosis who were younger than 4.5 months of age (p < 0.05). Overall CSF space, however, was significantly larger in both patient groups in patients younger than 4.5 months of age (p < 0.05). CONCLUSIONS These findings raise concerns about intracranial and brain volume reduction in patients with sagittal and combined metopic and sagittal synostoses and the possibility that this volume reduction may be associated with brain dysfunction. Because the ICV reduction is greater in combined metopic and sagittal synostosis in patients older than 4.5 months of age than in sagittal synostosis in this age group, the potential for brain dysfunction may be particularly true for these younger infants.

Cadaveric Study of Breast Measurements during Augmentation with Implants

Background: The goal of this study was to compare immediate changes in breast shape and nipple position using different implant shapes and volumes, with variable release of the pectoralis major muscle in fresh cadavers. Methods: Seventeen fresh cadaveric breasts were analyzed. Six different augmentation procedures were performed, including pocket dissection in the submuscular and subglandular planes, and partial and full release of the pectoralis major muscle insertion. Round and contoured implant volumes of 200, 300, 400, 500, and 600 ml were used, resulting in a total of 30 procedures per breast. Results: Projection was greater when subjects received contoured implants versus round implants in all volumes both in submuscular and in subglandular pockets (p < 0.001). For implants larger than 200 ml, projection was greater when a subglandular pocket was chosen (p < 0.02), for both round and contoured implants. Nipple-to–inframammary fold distance was increased with contoured implants compared with round implants in both subglandular and submuscular pockets for all implant volumes (p < 0.05). Conclusions: Implant shape, volume, and pocket location influence projection, causing it to increase in a linear fashion. Partial pectoralis major release seems to affect projection only for small volumes, but does not influence nipple position in the immediate setting. As projection increases with augmentation volume, cephalad movement of the nipple is produced by a relative increase in nipple-to–inframammary fold distance compared with the midclavicular point–to-nipple distance in our cadaveric sample.

The Sentinel Fat Pads: The Relationship of the ROOF and SOOF to the Temporal Nerve in Facial Rejuvenation

BACKGROUND A great number of studies have reported on the temporal branch anatomy and its relationship to the fascial layers and various fat pads of the temporal region, but no article has included information on the relationship of the temporal nerve to the retro-orbicularis oculi fat (ROOF) and/or the suborbicularis oculi fat (SOOF). OBJECTIVES The authors report the results of a series of human cadaver temporal nerve dissections, with particular attention paid to its relation to the ROOF and the SOOF. The results of a literature review and a subsequent open browlift are also reported to confirm the results of the cadaver study. METHODS Dissection was performed on 15 fresh human cadavers, for a total of 29 hemifaces. The course and relationships of the temporal nerve branch to the fascia, fat pads, and landmarks in the temporal region were noted and detailed. A thorough review was also performed for 23 articles, to compare the authors anatomical findings with data in the previous literature. RESULTS During cadaver dissection, the temporal branch was found to lie on the undersurface of the superficial temporal fascia. In the supraorbital area, the ROOF existed in the loose areolar plane or deep layer of the superficial temporal fascia, with the temporal nerve branch directly superficial to it. The temporal branch passed lateral to the SOOF in its superiomedial course at the level of the zygoma. These findings were later confirmed during an in vivo open browlift as well. CONCLUSIONS The ROOF was formerly unrecognized as an important sentinel marker for possible injury to the temporal nerve branch during browlift. However, this cadaver study and its accompanying literature comparisons show that browlift dissection, whether endoscopic or open, should aim to keep the ROOF fat in the superficial plane, ensuring that the nerve branch is safe from iatrogenic injury.

Muscle-flap salvage of prosthetic dural repair

OBJECTIVE A critical element in the prevention of wound and cerebrospinal fluid (CSF) infections after craniotomies is the prevention of postprocedural CSF leaks. The salvage of infected prosthetic dural material in this milieu is not adequately addressed in the literature and is the subject of this study. METHODS We performed a 7-year retrospective review of the Yale-New Haven Hospital patient records to identify successful salvage strategies in patients with relentless CSF leaks. Twenty data points were collected, including original diagnosis, nature of the procedure, presence of dural graft, definitive treatment of the leak, culture results and pre- and postoperative antibiotics. RESULTS Thirteen patients experienced post-craniotomy CSF leaks that required surgical intervention. The most common cause of the original craniotomy (54% of patients) was an oncological aetiology, followed by ruptured aneurysms or haemorrhage in 31% of the patients. Of the 13 patients experiencing CSF leaks, 76% involved the posterior skull base, and therefore a trapezius muscle flap was used in 38% of the cases. The Bovine pericardial graft (10 our of 13), a nonautologous graft, was left intact, and CSF drainage procedures were employed in most patients Growth of gram-positive organisms on cultures was found in 76% of the cases. The most frequent offenders were Staphylococcus aureus (five of the 13), coagulase-negative staphylococcal species (two out of 13), and methicillin-resistant S. aureus (two out of 13). Vancomycin was administered in all cases preoperatively. All 13 patients who underwent open surgery for CSF leak had complete resolution of the leak without need for additional reconstructive surgical intervention. CONCLUSION Comprehensive method of treating CSF leaks in conjunction with the salvage of bovine pericardial dural grafts may be a viable clinical option.

Hysterectomy with Concurrent Panniculectomy: A Propensity-Matched Analysis of 30-Day Outcomes.

Background: The goal of this multicenter study was to examine 30-day outcomes following combined hysterectomy and panniculectomy compared with hysterectomy alone at a national level. Methods: Female patients who underwent hysterectomy with or without concurrent panniculectomy were identified in the 2005 through 2012 American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files. Propensity scores were used to match patients who underwent combined surgery to a sample of similar patients who underwent hysterectomy alone. Results: A total of 24,893 patients who underwent hysterectomy alone and 174 patients who underwent hysterectomy with concurrent panniculectomy were identified. Patients who underwent combined surgery were more often obese (body mass index ≥30 kg/m2), with diabetes mellitus, and cardiovascular/pulmonary comorbidities. Unadjusted outcomes for the total cohort showed that patients who underwent both procedures more often experienced venous thromboembolism (2.9 percent versus 1.0 percent; p = 0.015) and length of stay greater than 3 days (48.3 percent versus 29.2 percent; p < 0.001). In the propensity-matched sample, there were no differences shown in the proportion of patients who experienced wound complications, surgical-site infections, venous thromboembolism, medical complications, or total complications. However, patients who underwent both procedures were twice as likely to experience length of stay greater than 3 days (OR, 2.06; 95 percent CI, 1.28 to 3.31). Conclusions: Combined hysterectomy and panniculectomy procedures appear to be performed infrequently among American College of Surgeons National Surgical Quality Improvement Program–participating hospitals. After propensity matching, only differences in length of stay were identified. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.