Cameron S. Francis

Neonatal and infant mandibular distraction as an alternative to tracheostomy in severe obstructive sleep apnea.

Context Surgical management for severe obstructive sleep apnea has been tracheostomy, which has significant morbidity. Objective To determine the efficacy of internal mandibular distraction in treating severe obstructive sleep apnea in infants and neonates. Design Retrospective review of medical records of 29 patients who underwent internal mandibular distraction for obstructive sleep apnea secondary to micrognathia. Setting Nonprofit, academic, pediatric medical center. Patients A total of 29 infants with obstructive sleep apnea were studied. Nine were included in the respiratory failure group requiring intubation prior to distraction surgery. The other 20 were included in the respiratory distress group and underwent preoperative polysomnography that assessed the severity of obstructive sleep apnea as measured by the apnea-hypopnea index. One patient expired following surgery; the remaining 28 underwent postoperative polysomnography determining their postoperative apnea-hypopnea index. Interventions Bilateral mandibular distraction with internal microdistractors. Main Outcome Measure Improvement in the apnea-hypopnea index or extubation. Results The nine respiratory failure patients avoided tracheostomy and were successfully extubated postdistraction. Eight in this group had postoperative polysomnographies showing a mean apnea-hypopnea index of 3.13 (range, 0 to 13.9). All 20 patients in the respiratory distress group underwent polysomnography and showed improved apnea-hypopnea indices (p < .001). The mean pre-op apnea-hypopnea index was 39.7 (range, 4.5 to 177), and the mean post-op apnea-hypopnea index was 5.8 (range, 0 to 34). Average improvement in the apnea-hypopnea index was 33.9. The mean follow-up period was 18.7 months (1.6 to 45.2 months). Conclusions Infants with micrognathia and obstructive sleep apnea may avoid tracheostomy and its inherent risks and complications by undergoing internal mandibular distraction, which is a viable alternative to tracheostomy.

rhBMP-2 with a demineralized bone matrix scaffold versus autologous iliac crest bone graft for alveolar cleft reconstruction.

Background: Secondary alveolar cleft reconstruction using autologous iliac crest bone graft is currently the standard treatment for alveolar clefts. Although effective, harvesting autologous bone may result in considerable donor-site morbidity, most commonly pain and the potential for long-term sensory disturbances. In an effort to decrease patient morbidity, a novel technique using recombinant human bone morphogenetic protein (rhBMP)-2 encased in a demineralized bone matrix scaffold was developed as an alternative to autografting for secondary alveolar cleft reconstruction. Methods: A chart review was conducted for the 55 patients who underwent secondary alveolar cleft reconstruction over a 2-year period with a mean follow-up of 21 months. Of these, 36 patients received rhBMP-2/demineralized bone matrix scaffold (including 10 patients with previously failed repairs using iliac crest bone grafting) and 19 patients underwent iliac crest bone grafting. Postoperatively, bone stock was evaluated using occlusal radiographs rated according to the Bergland and Chelsea scales. Results: Alveolar clefts repaired using rhBMP-2/demineralized bone matrix scaffold were 97.2 percent successful compared with 84.2 percent with iliac crest bone grafting. Radiographically, initial repairs with rhBMP-2/demineralized bone matrix scaffold were superior to iliac crest bone grafting according to both Bergland and Chelsea scales, and significantly more patients in the rhBMP-2/demineralized bone matrix scaffold group had coronal bridging. The postoperative intraoral infection rate following iliac crest bone grafting was significantly greater than for rhBMP-2/demineralized bone matrix scaffold. The cost of rhBMP-2/demineralized bone matrix scaffold products was offset by cost savings associated with a reduction in operative time averaging 102 minutes. Conclusions: rhBMP-2 encased in a demineralized bone matrix scaffold appears to be a viable alternative for secondary alveolar cleft repair. Patients are spared donor-site morbidity and achieve excellent results, decreasing operative time, and increasing operating room use. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Variation in the Absence of the Palmaris Longus in a Multiethnic Population of the United States: An Epidemiological Study

The absence of the palmaris longus (PL) has been shown to vary based on body side, gender, and ethnicity. In prior studies, homogenous ethnic populations have been shown to have differences in rates of absence. However, no study thus far has analyzed the differences in palmaris longus prevalence in a multiethnic population. We prospectively collected data on 516 patients visiting the outpatient hand clinics at LAC+USC Medical Center and Keck Medical Center. Analysis of the data was then performed for variables including ethnicity, laterality, and gender. There were no differences in the absence of the PL based on laterality or gender. Ethnically, there was no difference between white (non-Hispanic) and white (Hispanic) patients, with prevalence of 14.9% and 13.1%, respectively. However, African American (4.5%) and Asian (2.9%) patients had significantly fewer absences of the PL than the Caucasian, Hispanic reference group (P = 0.005 and P = 0.008, resp.). African Americans and Asians have a decreased prevalence of an absent PL. The Caucasian population has a relatively greater prevalence of an absence of the PL. This epidemiological study demonstrates the anatomic variation in this tendon and may be taken into account when planning an operation using tendon grafts.

Trends in the incidence and treatment of necrotizing soft tissue infections: an analysis of the National Hospital Discharge Survey.

Necrotizing soft tissue infections are a rare but potentially fatal condition of the soft tissues caused by virulent, toxin-producing bacteria. In the United States, there is an estimated annual incidence of 0.04 cases per 1000 annually, but previous estimates of the Centers for Disease Control and Prevention had the incidence at 500 to 1500 cases yearly. Early reports of mortality were variable with rates ranging from 46 to 76% but outcomes have been improving over time. The National Hospital Discharge Survey was analyzed to study current trends in the demographics, incidence, use, and mortality of patients diagnosed with necrotizing soft tissue infections. The authors analyzed the 1999, 2002, and 2007 National Hospital Discharge Survey by using a sampling weighting method. A total of 13,648 cases of necrotizing soft tissue infections were identified in 2007. This represents an increase from 12,153 cases in 2002 and 6612 cases in 1999. In the 9 years from 1999 to 2007 the gross incidence of necrotizing soft tissue infections more than doubled. Hospital stay was essentially unchanged within study years, at 16 days. Mean age increased from approximately 50 years in 1999 to 54 years in 2007. Further, mortality went from 10.45% in 1999 to 9.75% in the 2007 survey. The population-adjusted incidence rate increased 91% in the studied years. Rising use of immunosupression, exponential growth in the incidence of obesity, and type 2 diabetes could be a major contributing factor. The mortality rate is far below the rate in reports published from as early as 20 years ago, and at 9.75% compares with modern case series, but is a more accurate measure of mortality in this condition.

Hypertrophic scarring in cleft lip repair: a comparison of incidence among ethnic groups

Background Although hypertrophic scar (HTS) formation following cleft lip repair is relatively common, published rates vary widely, from 1% to nearly 50%. The risk factors associated with HTS formation in cleft patients are not well characterized. The primary aim of this retrospective study of 180 cleft lip repairs is to evaluate the frequency of postoperative HTS among various ethnic groups following cleft lip repair. Methods A retrospective chart view of patients undergoing primary cleft lip repair over a 16-year period (1990–2005) by the senior surgeon was performed. The primary outcome was the presence of HTS at 1 year postoperatively. Bivariate analysis and multivariable logistic regression were used to evaluate potential risk factors for HTS, including ethnicity, type and laterality of cleft, and gender. Results One hundred and eighty patients who underwent cleft lip repair were included in the study. The overall rate of postoperative HTS formation was 25%. Ethnicity alone was found to be an independent predictor of HTS formation. Caucasian patients had the lowest rate of HTS formation (11.8%) and were used as the reference group. HTS rates were significantly higher in the other ethnicities, 32.2% in Hispanic patients (odds ratio [OR]: 3.51; 95% confidence interval [CI]: 1.53–8.85), and 36.3% for Asian patients (OR 4.27; 95% CI: 1.36–13.70). Sex, cleft type, and cleft laterality were not associated with increased rates of HTS. Conclusions Differences in ethnic makeup of respective patient populations may be a major factor influencing the wide variability of reported HTS rates. Consideration should be given to potential prophylactic treatments for HTS in susceptible ethnic populations.

Limited-incision surgical debulking of lymphatic malformations using ultrasound-assisted liposuction.

the distal interphalangeal joint into four categories. Based on the classification of Moiemen and Elliot, the new surgical technique led to excellent or good results in 25 cases, two with fair results. No further treatment was needed. All wounds healed primarily and the scar on the pulp and dorsa was noted to be comfortable without sensation and apparent appearance disorder. There was no tendon avulsion or rupture, no infection or suture reaction, and no nail deformities (Table 1). The new technique with palmaris longus tendon to rebuild the flexor digitorum profundus tendon is a reliable alternative method for the treatment of isolated acute or chronic rupture of flexor tendons in zone 1. DOI: 10.1097/PRS.0b013e31826d172e

A rare case of accessory maxilla and bilateral Tessier no. 7 clefts, a 10-year follow-up

A Tessier no. 7 cleft is a lateral facial cleft which originates from the oral cavity and extends towards the tragus, involving both soft-tissue and skeletal components. A male patient presenting with both maxillary jaw duplication and bilateral Tessier no. 7 clefts, which has been reported only twice in the literature, is described. Bilateral facial clefts, macrostomia and chondro-cutaneous remnants were noted, which were repaired and resected. With further growth, facial asymmetry and asymmetric facial nerve dysfunction became apparent. Radiographic examination showed an accessory maxillary jaw and a flattened and hypoplastic right coronoid process. A maxillary alveolar cleft was also present between the left second bicuspid and the second permanent molar. This case may represent an under-recognized phenotype with an unusual combination of maxillary jaw duplication, macrostomia, Tessier no. 7 clefts, and chondro-cutaneous remnants. A long-term follow-up of these patients is recommended as they often develop craniofacial deformities later in life.

In situ fronto-orbital advancement with medial orbital osteotomies for trigonocephaly-associated hypotelorism.

In treating trigonocephaly, the value of direct surgical correction of orbital hypotelorism is controversial. In many cases of hypotelorism, the distance between the orbits increases over time after traditional fronto-orbital advancement. Still, more severe hypotelorism is not fully corrected and may benefit from a more definitive surgical intervention. We describe an in situ fronto-orbital advancement that improves severe hypotelorism and simplifies the surgical treatment of trigonocephaly. The key modification to traditional fronto-orbital advancement is an in situ medial orbital osteotomy that extends along the medial orbit, posterior to the medial canthus, and then across the inferior orbital rim into the piriform aperture. The procedure is indicated only in patients with more severe hypotelorism on physical examination. Rather than creating a freely removable bandeau during the operation, the bone segment composed of the supraorbital bar and superior orbits remains attached at the medial canthi. A midline osteotomy allows the respective orbital segments to be independently mobilized with the medial canthi left attached, and the space between them widened with gentle lateral traction and placement of an interpositional bone graft. Concomitantly, the lateral orbits and lateral supraorbital bar are contoured, advanced, and fixed with resorbable plates and screws. Representative results are shown. In situ fronto-orbital advancement with medial orbital osteotomies is a safe, efficient, and relatively simple technique that results in immediate improvement of hypotelorism and may be a worthwhile maneuver to consider in selected cases.

Neural sheath tumors of the brachial plexus: a multidisciplinary team-based approach.

AbstractPeripheral tumors of the brachial plexus, although rare, provide an opportunity for the plastic surgeon to coordinate a multidisciplinary team and achieve excellent outcomes. Most of the case series are reported from the neurosurgical literature. We report on the experience of the Kaiser Permanente Brachial Plexus Clinic over a recent 2-year period. A retrospective review was conducted to examine the medical records, radiographic images, operative reports, and pathologic findings of 13 consecutive patients with peripheral nerve sheath tumors of brachial plexus origin. Of the 10 patients requiring surgical exploration, 90% had significant improvement or resolution of pain, with sensory and motor recovery showing mixed results. Average follow-up consisted of 2 years with occupational therapy beginning shortly after operative intervention. Our results are similar to or better than those published in the literature. The plastic surgeon with subspecialty training can safely and successfully treat tumors of the brachial plexus by implementing a multidisciplinary approach.

Scalp erosion in ankyloblepharon-ectodermal defect-cleft lip and/or palate (AEC syndrome): treatment with acellular dermal matrix.

Ankyloblepharon-ectodermal defect-cleft lip and/or palate (AEC syndrome, also known as Hay-Wells syndrome) is an autosomal dominant disease caused by mutation in the p63 gene that is primarily characterized by facial clefting, presence of ankyloblepharon, ectodermal dysplasia, and scalp erosion. Scalp erosion is perhaps the most debilitating manifestation of AEC due to its problematic treatment that is fraught with failure given the underlying pathology of the p63 mutation causing dysfunctional wound healing. Management is often targeted in a stepwise fashion, beginning with daily baths, light debridement, and emollients and progressing to extensive skin excision. Skin grafting has limited success and, inevitably, infections requiring aggressive debridement and antibiotic therapy result from dysfunctional healing. The use of acellular dermal matrix for treatment of scalp erosion is a novel approach attempted in a patient with severe scalp disease. Here we report her case and the failure of treatment, along with possible explanations and suggestions for future therapy.