Claire Sanger

Spring-assisted cranioplasty vs pi-plasty for sagittal synostosis--a long term follow-up study.

Spring-assisted cranioplasty (SAS) has been used for the treatment of selected cases of sagittal synostosis at our unit routinely since 1998. In order to assess the long-term outcomes of this procedure, we compared the clinical data and morbidity with the pi-plasty technique, our previous standard procedure for the treatment of such children. The first 20 consecutive patients who underwent SAS for isolated sagittal synostosis with complete records, and who were 3 years old at the time of this study, were included. Twenty patients with a pi-plasty performed in the period immediately preceding the spring group acted as a control group. Cephalograms (preoperative, 1-year and 3-year), clinical examination, medical record data, medical photography, and a questionnaire (spring-group only) were used to evaluate and compare these two groups. The mean age of the spring group was 3.5 months (2.5-5.5) and the pi-plasty group 7.1 months (4-15.5) of age at surgery. There were no deaths in either group. There was a higher rate of complications in the pi-plasty group. The skull morphology was similar preoperatively in both groups but slightly different at the 3-year follow-up. The mean cephalic index (CI) in the spring group was 72 at 1 year of age and 71 at 3 years of age, indicating a minor relapse. The pi-plasty group had a mean CI of 73 at 3 years of age. The length was the same in both groups however the pi-plasty group had a lower height (mean 2 mm) and wider biparietal distance (mean 5 mm). All parents of the spring group were highly satisfied with the aesthetic results achieved, would undergo the operation again, and would recommend it to others with scaphocephaly. It was concluded that the two groups of surgery resulted in a quite similar morphologic outcome. The pi-plasty group had a cephalic index marginally closer to the normal range at 3 years of age. The spring group was superior with respect to blood loss, transfusion requirements, operative time, ICU time, recovery time, and total hospital stay.

Impact of significant weight loss on outcome of body-contouring surgery.

Morbid obesity in the United States has reached startling proportions, with serious physical and psychosocial ramifications. As the number of patients undergoing bariatric surgery increases to treat this problem, it is expected there will be an increase in the number of patients presenting to plastic surgery offices for body contouring after weight loss. It is imperative that plastic surgeons prepare patients with extreme weight loss as to the risks and complications as compared with the general population undergoing body contouring. In this retrospective chart review, 26 patients undergoing body contouring from May 2001 to November 2004 were reviewed. Only patients who had extreme weight loss, defined as losing greater than 50 pounds, were included in this study. The age, gender, amount of weight lost, comorbidities, tobacco use, and weight-loss method were recorded. Additionally, the type of body-contouring procedure and presence of complications were collected from the records. The percentage of complications in our patient population is significantly higher than reported in the literature for the general population undergoing an abdominoplasty. We believe the increased wound complications seen in our patients can be attributed to the inherent complications seen with obese patients.

Aplasia Cutis Congenita: Clinical Management of a Rare Congenital Anomaly

Background:Aplasia cutis congenita (ACC) is a rare congenital disorder characterized by absence of skin and adjacent tissue that usually affects the scalp, but any part of the body may be affected. Although ACC is more often superficial and small, it can be large and involve the underlying structures such as skull and dura, thus increasing the risk of hemorrhage, infection, and mortality. Controversy exists regarding nonsurgical versus surgical intervention for this condition. This study reviews indications and modalities for treatment of this rare congenital anomaly. Results:Management of this anomaly depends on size, location, and structures at risk. Small lesions with intact underlying structures and lesions affecting extremities are treated in a conservative fashion with dressings and ointments followed by delayed scar excision. Aplasia cutis congenita scar excision often requires complex tissue rearrangement, tissue expansion, or skin grafting. Larger ACC lesions or lesions with exposure of vital structures require early surgical intervention. Initially, exposed vital structures and bony ridges can be protected using conservative measures. Delayed definitive repair can then be performed using scalp flaps, split- and full-thickness skin grafts, cultured epithelial autografts, delayed split rib cranioplasty, tissue expansion, and composite cranioplasty. Conclusions:Aplasia cutis congenita should be individually evaluated based on size, depth, location, and tissues involved. Using conservative and surgical modalities, one can achieve complete closure of the defect, thus avoiding risks of infection, hemorrhage, and further trauma.

Dynamic spring-mediated cranioplasty in a rabbit model.

Since the beginning of craniofacial surgery, there has been an ongoing search for surgical techniques to enhance outcome while, at the same time, decreasing the invasiveness of the surgical treatment of craniofacial deformities. The purpose of this study was to test a recently reported minimally invasive treatment modality, the dynamic spring, in a rabbit calvarial model for efficacy and safety. Specifically, the results of spring cranioplasty on skull growth, the underlying brain, and adjacent bone were to be assessed. The study population consisted of 36 7-week-old New Zealand white rabbits. The rabbits were divided into four treatment groups (9 rabbits each): control, sham surgery, stainless steel springs, and memory metal springs. Postoperative analysis included weekly radiographs to evaluate movement of amalgam markers placed at standardized locations. Additionally, 16 rabbits (4 from each group) were killed at 14 days after surgery, and postmortem histological analysis was done. The remaining rabbits were followed until they were adults and were then killed and similarly analyzed. No morbidity or mortality occurred in the immediate perioperative period secondary to the surgery. Postmortem histological analysis of all study animals revealed no intracranial, subcutaneous, or skin infections and no technical complications related to the surgery. Statistical analysis using ANOVA and pair-wise comparisons between treatment groups revealed a statistically significant difference (P < 0.05) between the marker movement in the spring groups versus the sham and control groups. There were no significant differences between the sham and control groups or between the two spring groups. In conclusion, this study confirms the efficacy and safety of the dynamic spring in a rabbit model.

Spring-assisted surgery-a surgeon's manual for the manufacture and utilization of springs in craniofacial surgery.

Background and Purpose: Spring-assisted surgery has been used for the treatment of craniofacial deformities since its 1997 inception in Sweden by Dr Lauritzen (Scand J Plast Reconstr Surg Hand Surg 1998;32:331-338). Initial applications have focused on the treatment of patients with single-suture craniosynostosis. Recently, indications and applications have expanded to include patients with syndromic craniosynostosis, multiple-suture synostosis, and midface hypoplasia. The advancement of spring-assisted surgery in this country has been hindered by the need for patient-specific spring fabrication because few surgeons understand how to make the springs for each application. We will review our spring design and treatment algorithms to facilitate wider use of this innovative treatment modality. Methods: This is a retrospective institutional review board-approved analysis of the spring design for our first 90 cases of spring-assisted surgery used to treat sagittal synostosis at the North Carolina Center for Cleft and Craniofacial Deformities. Outcome analysis was done to generate a treatment algorithm based on diagnosis, patient age, spring design, number of springs, spring force and expansion, and clinical outcome. Results: Ninety children with sagittal craniosynostosis (64 males, 26 females) were treated during an 8-year period (2001-2009) with spring-assisted surgery. Mean age at treatment was 4.4 months and mean age at spring removal was 8.8 months. Mean number of springs used was 2 (range, 1-3). Mean spring force used in sagittal synostosis was 5.5-9.5 (range) for the anterior spring and 5.5-9.5 (range) for the posterior spring with a mean posttreatment expansion of 6.65 cm. Analysis of the results shows that spring force and expansion required for optimal correction is dependent on the age at surgery, type of the deformity, and severity of the deformity. Specifically, the younger the child, the weaker the spring needed for surgical correction. General principles for spring application for scaphocephaly include (1) the longer the anterior posterior dimension of the skull deformity, the more likely a third spring is necessary; (2) the narrower the posterior occiput, the stronger the posterior spring required; and (3) if a postcoronal band is seen in the calvarium, a stronger anterior spring is needed. Conclusions: Long-term experience with spring-assisted surgery has facilitated the development of standardized, reproducible techniques allowing spring design modifications to optimize clinical outcome.

Cost-effective management of isolated facial fractures.

The purpose of this study was to evaluate the subset of costs incurred for surgical treatment of isolated midface and mandible fractures of patients admitted directly from the emergency department compared with those admitted as outpatients after evaluation and discharge from the emergency department. After institutional review board approval, the records of patients admitted to Wake Forest University Baptist Medical Center were studied retrospectively for patients who underwent surgical repair of an isolated facial fracture between July 1, 1999 and June 30, 2000. Patients were placed into one of two groups: admission from the emergency department versus admission as an out-patient. Total hospital charges were compared, and complications were evaluated. Mechanism of injury, age, and gender were recorded within each group. Forty-two patients met the study criteria. Twenty-eight patients were admitted directly from the emergency department (Group A), and 14 were admitted as outpatients after elective scheduling for operative repair (Group B). Operative charges based on utilization of time and materials showed no statistical significance between Group A (P = 0.275) and Group B (P = 0.393). Patients admitted directly from the emergency department had a mean hospital charge of

Advances in hemangioma evaluation and treatment.

3,556.66 higher (P≤0.001) and stayed 2 days longer in the hospital as compared with the outpatient group. No differences were noted in complications between the study groups. The results of this study reveal a significant decrease in cost for patients with isolated facial fractures admitted as outpatients on scheduling surgery as compared with immediate admission from the emergency department.

Proboscis lateralis: a rare craniofacial anomaly, reconstruction, and long-term evaluation.

In 1979, the late Dr. William Grabb after chairing a symposium Vascular Malformations stated, Bwithin the next decade, vascular malformations will cease to be a debilitating scourge for our children.[ Unfortunately, time has proven him wrong. Fortunately, however, many significant advances have been made in the diagnosis classification, and treatment of vascular anomalies, particularly hemangiomas. In addition, the application of biomolecular analysis techniques has led to a better understanding of the pathology and prognostic indicators for these lesions. The clinician, when faced with a vascular lesion in an infant, must quickly make the diagnosis as to whether the lesion is a hemangioma, a true vascular malformation, or one of a large number of unusual, less clearly defined clinical entities. Initial diagnosis for most lesions can be made using the basic tools of a history, physical exam and experience. In 1982, Mulliken classified vascular lesions into two main categories: tumors and true arteriovenous malformations. This was a biological classification based on physical findings, clinical evolution and cellular features. Unfortunately, the window for optimal treatment often passed while the physician observed clinical evolution. Newer techniques assist in making a more expedited diagnosis. The treatment of true vascular malformations in 2001, when indicated, is surgical. Hemangioma treatment is less welldefined and depends on many factors. The remainder of this paper will be restricted to hemangioma diagnosis and treatment as practiced in our vascular malformation clinic in 2005. CLASSIFYING THE VASCULAR LESION

Congenital pyriform aperture stenosis.

Proboscis lateralis is a rare spontaneous congenital anomaly that results from a failure of normal embryological nasal development. The ensuing deformity consists of imbrication of the nasal soft tissues into a tubelike proboscis and can be associated with ipsilateral heminasal aplasia, choanal atresia, and multiple other abnormalities. A case report of a patient with proboscis lateralis is presented, with a 27-year follow-up detailing the complexities of long-term surgical management. After 15 major surgical interventions, there is relatively normal facial symmetry, but abnormalities remain with the underlying craniofacial skeleton and nasopharyngeal airway. Proboscis lateralis is not an isolated soft tissue abnormality but is a craniofacial defect that requires a long-term multidisciplinary approach to the surgical timing and treatment with lifelong follow-up.

Difficulties of delayed treatment of craniosynostosis in a patient with Crouzon, increased intracranial pressure, and papilledema.

Neonates rely on the nasal airway for their source of air; thus, any compromise in the ability to inhale will dramatically alter their ability to breathe. Congenital nasal pyriform aperture stenosis is a rare yet serious form of airway obstruction due to overgrowth of the maxilla at the medial nasal process. Infants typically present with difficulty feeding and obvious difficulty breathing. Radiologic imaging aids in confirming the diagnosis and assists in operative planning to open the medial nasal process to reduce airway resistance. Further corrective surgery is often needed and is planned commensurate with facial growth. We present a novel case of a child diagnosed with congenital nasal pyriform aperture stenosis who has performed extraordinarily well intellectually and has achieved an excellent cosmetic and physiological reconstruction of the nose and airway.