Brian T. Andrews

Vascular considerations in composite midfacial allotransplantation.

Background: Advances in microsurgery and immunosuppression have allowed for facial reconstruction at a qualitatively new level with facial composite tissue allografts. Although donor tissue recovery is unique for each patient, transplantation of the maxilla and overlying soft tissues will be a frequent indication. Vascularity of the maxilla and palate, supplied by facial arteries alone, has been a concern. Based on cadaver dissections and a clinical case, vascular considerations for transplantation of the entire midface are discussed. Methods: To prepare for central facial transplantation in an identified patient, a preclinical dissection was completed on four cadavers. In April of 2009, an extended midfacial allotransplantation was performed. The flap included the entire group of facial mimetic muscles with overlying skin, sensory and motor nerves, nose, upper lip, maxilla, teeth, and hard palate. Results: The preclinical study identified key anatomical structures for inclusion in the composite tissue allograft. Moreover, dissections showed that the facial and angular blood vessels were connected to branches of the maxillary vessels through an anastomotic network organized around the periosteum and bony canals of the midfacial skeleton. Transplantation of a central face allograft including the maxilla and palate was anticipated to be feasible. A technically successful clinical case was completed. Conclusions: Anatomical and clinical observations elucidated several technical points related to composite tissue transplantation of the midface. Careful graft harvest, appropriate selection of donor and recipient vessels, complete allograft revascularization, and restoration of sensory and motor function are critical to making face transplant surgery safe and functional.

Incidence of concomitant airway anomalies when using the university of California, Los Angeles, protocol for neonatal mandibular distraction.

Background: In newborns with micrognathia and severe upper airway obstruction, understanding potential airway lesions is important for determining appropriate treatment: observation, mandibular distraction, or tracheostomy. When concomitant airway anomalies are present, mandibular distraction is often unsuccessful at alleviating causes of obstruction, mandating the need for tracheostomy. The first part of this study evaluates 10-year results using the University of California, Los Angeles, algorithm for surgical candidacy to identify patients who will benefit from neonatal mandibular distraction. The second part describes the concomitant airway abnormalities found at the time of diagnostic laryngoscopy/bronchoscopy and how these anomalies affect neonatal distraction candidacy of these patients. Methods: Newborns admitted to the neonatal intensive care unit with micrognathia and upper airway obstruction (n = 133) were subjected to a decision tree model protocol formulated by a multidisciplinary team at the University of California, Los Angeles, to decide on appropriate treatment. Concomitant airway abnormalities were recorded and outcomes were documented for the first 5 years of life. Results: Fifty-five percent of patients underwent internal mandibular distraction with 97 percent success. Home observation with a nasopharyngeal tube was chosen in 11 percent of patients, and 34 percent had tracheostomies. On endoscopic examination, 51.7 percent of the nondistracted patients had concomitant airway anomalies: laryngomalacia (53.3 percent), tracheal web (20.0 percent), vocal cord paralysis (13.3 percent), epiglottal collapse (6.7 percent), and infraglottal narrowing (6.7 percent). Conclusions: For the management of neonatal upper airway obstruction with micrognathia, a decision tree algorithm is useful to determine candidates for mandibular distraction. Diagnostic laryngoscopy/bronchoscopy is an important component of this algorithm because a multitude of airway anomalies may be present. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Positioning the caudal septum during primary repair of unilateral cleft lip.

Background:Since 1995, the senior surgeon has straightened the deviated anterocaudal septum in all infants undergoing primary repair of unilateral complete cleft lip/palate. Methods:A retrospective assessment was done on 17 patients who did not have septal correction and 17 patients who did have septal correction at the time of nasolabial repair. Operative reports were reviewed, and secondary procedures on the nose were documented.Posterior-anterior cephalograms were used to measure septal deviation from the midline, angle of septal deviation, and width of the inferior turbinate on the noncleft side. The angle subtended by the superior and inferior segments of the cartilaginous septum was measured at the point of maximal septal deviation. Results:The uncorrected group had a mean maximal septal deviation from the midline of 5.8 mm compared with 4.1 mm in the corrected group (P < 0.01). The uncorrected group had a mean width of the contralateral inferior turbinate of 12.7 mm compared with 10.2 mm in the corrected group (P < 0.01). The uncorrected group had a mean subtended angle of 137.8 degrees compared with 147.9 degrees in the corrected group (P < 0.01). Conclusions:Positioning the anterior caudal septum during primary repair of unilateral complete cleft lip results in less septal deviation and a smaller contralateral turbinate as documented by posteroanterior cephalometry in adolescence.

Fibrous dysplasia of the zygomaticomaxillary region: outcomes of surgical intervention.

Background: Fibrous dysplasia is the most common craniofacial tumor, presenting in both monostotic and polyostotic forms with varying degrees of severity. No consensus exists regarding the surgical management of craniofacial fibrous dysplasia, particularly in the zygomaticomaxillary region. The present study compared long-term outcomes of limited reduction burring versus radical resection of zygomaticomaxillary fibrous dysplasia. Methods: Patients with craniofacial fibrous dysplasia at the University of California, Los Angeles, Craniofacial Center from 1982 to 2008 were studied based on demographics, treatment, and follow-up data, including examinations, computed tomographic scans, photographs, physician Whitaker scoring, and patient surveys (n = 97). Outcomes were compared for zygomaticomaxillary disease treated with radical resection with cranial bone graft reconstruction or limited reduction burring (n = 58). Results: Thirty-four percent of patients had monostotic disease, 66 percent had polyostotic disease, 3 percent had McCune-Albright syndrome, and 2.1 percent had malignant degeneration into osteosarcoma. Most patients had surgical treatment (84.5 percent). Of the patients that required optic nerve decompression for vision changes (11.4 percent), most (75 percent) had vision stabilization postoperatively. Differences were recorded in zygomaticomaxillary disease treated with radical resection (63.8 percent) versus reduction burring (36.2 percent) according to age (19.6 versus 14.2 years), complications (13.5 percent versus 4.8 percent), recurrence (66.7 percent versus 24.3 percent), and number of subsequent procedures (2.8 versus 4.0). There were similarities in Whitaker outcome score (1.3 ± 0.3 versus 1.5 ± 0.6) and patient satisfaction (2.7 ± 0.4 versus 2.8 ± 0.3). Conclusions: Although different approaches have been advocated to treat fibrous dysplasia, the authors’ data support a more aggressive management for zygomaticomaxillary disease with radical resection and cranial bone graft reconstruction, especially for more involved disease. CLINICAL QUESTION OF EVIDENCE: Therapeutic, III.

Abstract 51: Decreased Secondary Bone Grafting but Poorer Midface Growth after Primary Alveolar Cleft Repair with Gingivoperiosteoplasty and rhBMP-2.

975 Volume 133, Number 4 (Supplement) • AAPS Abstract Supplement M on d y, A p il 7, 2014 CONCLUSION: These data represent the largest complications evaluation of nonsyndromic, single suture synostosis treatment to date. We characterize the complications and reoperation rates in this population of patients, demonstrating statistically lower risk for those patients without additional comorbidity. These data allow us to counsel families more accurately with regards to morbidity and mortality associated with this select group of patients. 4 Decreased Secondary Bone Grafting but Poorer Midface Growth after Primary Alveolar Cleft Repair with Gingivoperiosteoplasty and rhBMP-2

Orthognathic surgery for obstructive sleep apnea: applying the principles to new horizons in craniofacial surgery.

AbstractThis article is dedicated to the senior author Dr. Henry K. Kawamoto, Jr, who pioneered the use of orthognathic surgery to treat severe obstructive sleep apnea in 1981. Since that time, his techniques for maxillomandibular advancement have been revised and expanded for improved surgical success. Obstructive sleep apnea is a growing public health concern because it can cause hypertension, cardiac arrhythmias, heart attack, stroke, and, in rare circumstances, sudden death if untreated. When less invasive options fail such as weight loss or dental devices for mandibular repositioning, maxillomandibular advancement is a valuable treatment option for severe obstructive sleep apnea.

Experiential learning in aesthetic surgery training: a quantitative comparison among surgical subspecialties.

BACKGROUND The specialty of plastic surgery has evolved to encompass a wide breadth of both reconstructive and aesthetic surgery. Practitioners in other specialties have increasingly advanced on procedures and areas that have traditionally been served by plastic surgeons. To date, no evaluation and comparison of the operative experience of graduating residents from various specialties has been performed. METHODS The authors review the case log statistical reports of the Accreditation Council for Graduate Medical Education. For each specialty, this annual report highlights the average number of cases performed for all graduating residents. The national case log reports were reviewed for dermatology, ophthalmology, otolaryngology, and plastic surgery. Four procedures (i.e., blepharoplasty, face lift, liposuction, and rhinoplasty) were compared for residents graduating in the 2006 to 2010 academic years. The hypothesis that no difference exists between the average numbers of aesthetic procedures performed by various specialty residency training was tested using a two-sample t statistic. RESULTS For blepharoplasty, face lift, and liposuction, the higher number of cases performed by graduating plastic surgery residents was statistically significant (p < 0.00001) for all years examined. Although plastic surgery trainees graduating from 2006 to 2010 had a higher number of recorded rhinoplasties, this difference in case logs was statistically significant only for plastic surgery residents graduating in 2008. CONCLUSIONS The quantitative operative experience of graduating plastic surgery residents for selected aesthetic surgery cases exceeds that of other surgical subspecialties. Given the exposure and strength of plastic surgery training, plastic surgeons should remain at the forefront of aesthetic surgery.

Assessment of Deformational Plagiocephaly Severity and Neonatal Developmental Delay.

Deformational plagiocephaly (DP) in infants has been associated with developmental delay that can last until adolescence. Despite this association and a 5-fold increase in incidence of DP over the past 2 decades, there are currently no guidelines regarding screening for developmental delay or identification of which infants with DP are at the greatest risk of delay. A prospective, nonrandomized study was performed. Infants diagnosed with DP who had no prior intervention were eligible for enrollment. Cranial deformity was measured by cross-cranial measurements using calipers, and developmental delay was measured using the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III). Correlation between cranial deformity and developmental delay was analyzed using a linear regression. Twenty-seven infants, ages 4.0 to 11.0 months (mean = 6.61 months) diagnosed with DP were studied. Developmental delay was observed on the composite language (n = 3 of 27, 11%), and composite motor (n = 5 of 23, 22%) scales, but not the cognitive scale. Severity of cranial deformity did not correlate with scores on any Bayley-III scales (cognitive R = 0.058, P = 0.238; composite language R = 0.03, P = 0.399; composite motor R = 0.0195, P = 0.536). This study demonstrates that severity of cranial deformity cannot be used to predict presence or degree of developmental delay. Craniofacial surgeons should be aware of this risk and consider developmental screening based on clinical suspicion.AbstractDeformational plagiocephaly (DP) in infants has been associated with developmental delay that can last until adolescence. Despite this association and a 5-fold increase in incidence of DP over the past 2 decades, there are currently no guidelines regarding screening for developmental delay or identification of which infants with DP are at the greatest risk of delay. A prospective, nonrandomized study was performed. Infants diagnosed with DP who had no prior intervention were eligible for enrollment. Cranial deformity was measured by cross-cranial measurements using calipers, and developmental delay was measured using the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III). Correlation between cranial deformity and developmental delay was analyzed using a linear regression. Twenty-seven infants, ages 4.0 to 11.0 months (mean = 6.61 months) diagnosed with DP were studied. Developmental delay was observed on the composite language (n = 3 of 27, 11%), and composite motor (n = 5 of 23, 22%) scales, but not the cognitive scale. Severity of cranial deformity did not correlate with scores on any Bayley-III scales (cognitive R2 = 0.058, P = 0.238; composite language R2 = 0.03, P = 0.399; composite motor R2 = 0.0195, P = 0.536). This study demonstrates that severity of cranial deformity cannot be used to predict presence or degree of developmental delay. Craniofacial surgeons should be aware of this risk and consider developmental screening based on clinical suspicion.

Audiologic findings in Saethre-Chotzen syndrome.

Background: Hearing loss has been described in Apert syndrome but is poorly documented in other craniosynostosis disorders. Methods: The authors retrospectively reviewed the audiologic and otologic records of patients with Saethre-Chotzen syndrome to define the incidence, type, and extent of hearing loss. Only patients with documented audiologic examinations were included. Hearing loss was categorized by American Speech-Language-Hearing Association guidelines (i.e., mild, 26 to 40 dB; moderate, 41 to 55 dB; moderate/severe, 56 to 70 dB; severe, 71 to 90 dB; and profound, >90 dB). Results: Twenty-nine patients met inclusion criteria. Mean age at initial audiologic evaluation was 6.7 years (range, 0.7 to 24.5 years). Seventeen patients (59 percent) had at least one abnormal audiogram; in 15 patients, the deficit was mild. Eight patients demonstrated sensorineural hearing loss. Five cases resolved and, thus, had been mischaracterized. Six patients had conductive hearing loss on at least one examination; follow-up testing in four patients revealed normal hearing. Two patients had unspecified hearing loss by sound field method. One patient had mixed hearing loss on consecutive audiograms. Twenty-one patients (72 percent) had normal hearing on their last audiogram. Conclusions: Most patients with Saethre-Chotzen syndrome had hearing loss at some point during childhood. This was typically mild and correlated with middle ear abnormality and eustachian tube dysfunction. Usually, the hearing deficit resolved. Early mischaracterization of mixed hearing loss or conductive hearing loss as sensorineural hearing loss was common.

Surgical Management of Obstructive Sleep Apnea.

Summary: Surgical management of snoring and obstructive sleep apnea is indicated when a surgically correctable abnormality is believed to be the source of the problem. Many patients opt for surgical treatment after noninvasive forms of treatment have been proven ineffective or difficult to tolerate. With increasing frequency, functional rhinoplasty, septoplasty, turbinoplasty, palatal surgery, and orthognathic surgery are being used in the management of snoring and obstructive sleep apnea. Plastic surgeons’ experience with aesthetic nasal surgery, nasal reconstruction, palatal surgery, and craniofacial surgery puts them at the forefront of performing surgery for snoring and sleep apnea. The role of functional septorhinoplasty, turbinoplasty, palatal surgery, genioglossal advancement, and orthognathic surgery is indispensable in the surgical management of obstructive sleep apnea. Multidisciplinary management of these patients is critical, and plastic surgeons are encouraged to work collaboratively with sleep medicine clinicians and centers.