Brianne T. Mitchell

Perioperative Complications in Posterior Pharyngeal Flap Surgery: Review of the National Surgical Quality Improvement Program Pediatric (NSQIP-PEDS) Database

Background Posterior pharyngeal flap (PPF) surgery is effective for treating velopharyngeal insufficiency but has historically been associated with risk of airway compromise. This study aims to identify risk factors for complications from and readmission after PPF using a national database. Methods Patients who underwent PPF surgery were selected from the 2012 American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-PEDS) database. Patient characteristics, comorbidities, and complication/readmission data were analyzed. Results Among 225 study patients, 12 (5.3%) suffered perioperative complications. The most common complications were pulmonary in nature (5 patients, 2.2%), including prolonged postoperative mechanical ventilation (3 patients, 1.3%). Underlying asthma (P = .024) or any cardiac risk factor (P = .047) conveyed significant complication risk. Further, severe cardiac risk factors were associated with postoperative bleeding (P = .024). Readmission (4 patients, 1.7%) and reoperation (3 patients, 1.3%) occurred at mean intervals of 9 and 10 days after the original procedure. Seventy-nine patients (35%) were discharged postoperatively on an outpatient basis, and this subgroup included only one patient (1.2%) with a complication (P = .038). Conclusions The overall perioperative complication rate for PPF surgery is low at 5.3%. Patients with underlying cardiac risk factors, severe American Society of Anesthesiologists Physical Status class, and asthma should prompt greater attention given their heightened risk profiles.

An Algorithm for Managing Syndromic Craniosynostosis Using Posterior Vault Distraction Osteogenesis

Background: The authors hypothesize that early posterior vault distraction osteogenesis safely confers considerable cranial vault remodeling, sufficient to enable fronto-orbital advancement to be delayed to a later age, with improved outcomes. Methods: The authors conducted a retrospective cohort study of children with syndromic craniosynostosis treated before (2003 to 2008) or after (2009 to 2014) implementation of posterior vault distraction osteogenesis. Results: Sixty children with syndromic craniosynostosis presented during the study period. Forty met inclusion criteria with care continuity and complete records: 22 before and 18 after implementation of posterior vault distraction osteogenesis. Only 11 patients (61 percent) who underwent initial posterior vault distraction osteogenesis required frontal advancement, at a mean follow-up of 4.0 years of age, compared with 22 patients (100 percent) before implementation of posterior vault distraction osteogenesis. Kaplan-Meier survival analysis indicated significant delay of first fronto-orbital advancement in the posterior vault distraction osteogenesis cohort compared with the pre–posterior vault distraction osteogenesis cohort (p = 0.011). Comparing treatment in the first 5 years of life among posterior vault distraction osteogenesis versus non–posterior vault distraction osteogenesis subcohorts of patients older than 5 years, there were significantly fewer fronto-orbital advancements performed (0.6 versus 1.5 per patient; p = 0.023). Conclusion: Using early posterior vault distraction osteogenesis for patients with syndromic craniosynostosis significantly reduces the average number of fronto-orbital advancement procedures in the first 5 years of life, delays initial fronto-orbital advancement, and is likely to reduce the total number of major craniofacial procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Effect of Furlow Palatoplasty Timing on Speech Outcomes in Submucous Cleft Palate

Background Because some patients with submucous cleft palate (SMCP) are asymptomatic, surgical treatment is conventionally delayed until hypernasal resonance is identified during speech production. We aim to identify whether speech outcomes after repair of a SMCP is influenced by age of repair. Methods We retrospectively studied nonsyndromic children with SMCP. Speech results, before and after any surgical treatment or physical management of the palate were compared using the Pittsburgh Weighted Speech Scoring system. Results Furlow palatoplasty was performed on 40 nonsyndromic patients with SMCP, and 26 patients were not surgically treated. Total composite speech scores improved significantly among children repaired between 3 and 4 years of age (P = 0.02), but not older than 4 years (P = 0.63). Twelve (86%) of 14 patients repaired who are older than 4 years had borderline or incompetent speech (composite Pittsburgh Weighted Speech Scoring ≥3) compared with 2 (29%) of 7 repaired between 3 and 4 years of age (P = 0.0068), despite worse prerepair scores in the latter group. Resonance improved in children repaired who are older than 4 years, but articulation errors persisted to a greater degree than those treated before 4 years of age (P = 0.01.) Conclusions Submucous cleft palate repair before 4 years of age appears associated with lower ultimate rates of borderline or incompetent speech. Speech of patients repaired at or after 4 years of age seems to be characterized by persistent misarticulation. These findings highlight the importance of timely diagnosis and management.

An Evidence-Based Algorithm for Managing Syndromic Craniosynostosis in the Era of Posterior Vault Distraction Osteogenesis.

RESULTS: Age at initial evaluation ranged from 3-12 months. Complete correction was achieved in 75% of patients with conservative treatment (n=3186). 25% transitioned to helmet therapy (n=1062). Average helmet treatment duration was 5 months with 95% having complete correction of deformity with a single helmet. 5% of patients required a second helmet for additional correction (n=49) with 0.01% requiring a third helmet to achieve complete correction (n=8). Risk factors for failure of conservative therapy included advanced age, torticollis, and severity of cephalic ratio and diagonal difference.

The Effects of Molding Helmet Therapy on Spring-Mediated Cranial Vault Remodeling for Sagittal Craniosynostosis.

AbstractThere is no clear consensus for the optimal treatment of sagittal craniosynostosis; however, recent studies suggest that improved neurocognitive outcomes may be obtained when surgical intervention imparts active cranial expansion or remodeling and is performed before 6 months of age. The authors consider spring-mediated cranioplasty (SMC) to optimally address these imperatives, and this is an investigation of how helmet orthoses before or after SMC affect aesthetic outcomes.The authors retrospectively evaluated patients treated with SMC and adjunct helmeting for sagittal synostosis. Patients were stratified into 4 cohorts based on helmet usage: preop, postop, both, and neither. The cephalic index (CI) was used to assess head shape changes and outcomes. Twenty-six patients met inclusion criteria: 6 (23%) had preop, 11 (42%) had postop, 4 (15%) had preop and postop, and 5 (19%) had no helmeting. Average age at surgery was 3.6 months. Overall, CI improved from a mean 69.8 to 77.9 during an average 7-month course of care. Mean preoperative change in CI showed greater improvement with preop helmet (1.3) versus not (0.0), (P = 0.029), despite similar initial CI in these cohorts (70.4 and 69.6 respectively, P = 0.69). Nonetheless, all patient cohorts regardless of helmeting status achieved similar final CIs (range 76.4–80.4; P = 0.72).In summary, preoperative molding helmet therapy leads to improved CI at the time of spring-mediated cranioplasty. However, this benefit does not necessarily translate into overall improved CI after surgery and in follow-up, calling into question the benefits of molding helmet therapy in this setting.

A New, Single-Stage, Distraction-Mediated, Cranial Vault Expansion Technique for the Multisuture Deformity.

Abstract Multisuture craniosynostosis with a mild cloverleaf deformity is rare but associated with high morbidity and mortality. Conventional treatment to alleviate intracranial hypertension in a young infant involves multisuturectomy and relies on passive correction of the deformity followed by additional staged reconstruction later in infancy. Early regional craniectomy and rigid reconstruction have been described, but the cranial bone has limited stability to tolerate plate fixation and extensive dissection of the bone–dura interface may devascularize the cranial bone flap and limit its durability. The authors report an interesting technique to treat a mild form of cloverleaf skull deformity using early, nondevascularizing osteotomies followed by application of semiburied cranial distractors in multiple planes to increase intracranial volume and treat the deformity, and its attendant volumetric constriction, in a single stage.

Abstract: Trends in Fat Grafting

M oday, O cber 1, 2018 with Fitzpatrick Skin Types II and III. Subjects received 3 combination treatments completed 30 days apart. Standardized photographs were taken at baseline and each followup. Improvement in wrinkles, texture and pigmentation was determined by masked, qualitative assessment of photographs at 90 days after last treatment compared to baseline. Clinician and Subject Global Aesthetic Improvement Scales (CGAIS, PGAIS), and a Patient Satisfaction Questionnaire were completed at 90 days after last treatment.

Abstract: Congenital Syndactyly Reconstruction of 391 Webspaces

INtROdUCtION: Congenital syndactyly occurs in isolated and syndromic forms; method of reconstruction must be tailored to the type of syndactyly and postoperative function will depend on the preoperative state of the hand in addition to the method of reconstruction selected. We present the 18 year experience of surgical reconstruction of congenital syndactyly in all of its forms at a high throughput children’s hospital.

Long-Term Growth of Costochondral Rib Grafts in Mandibular Reconstruction for Craniofacial Microsomia.

INTRODUCTION: Costochondral rib grafting is the most common surgical technique for reconstructing the Pruzansky-Kaban 2b/3a mandibular deformity in craniofacial microsomia (CFM). However, graft growth is thought to be unpredictable, with possible overor undergrowth with time. Secondary procedures, including mandibular distraction osteogenesis (DO), may be utilized to augment graft growth. We seek to understand the intrinsic growth properties of costochondral grafts in CFM and the role of mandibular distraction to refine symmetry of the grafted mandible.

Optical Coherence Tomography Can Detect Intracranial Hypertension in Young Children with Craniosynostosis.

Detecting intracranial hypertension (ICH) in children with craniosynostosis may enable timely intervention to prevent neurocognitive impairment, but is invasive and often equivocal with conventional methods. Optical coherence tomography (OCT) can noninvasively quantify retinal thickness using high-resolution ultrasound. We study whether OCT can reliably measure retinal thickness in children with craniosynostosis, and whether findings correlate with intracranial hypertension.