Clinton S. Morrison

An algorithmic approach to the use of gauze-based negative-pressure wound therapy as a bridge to closure in pediatric extremity trauma.

Background: The efficacy of negative-pressure wound therapy as a bridge to definitive closure of traumatic extremity wounds has been demonstrated in adults. Gauze-based negative-pressure wound therapy has been used to facilitate granulation tissue formation and promote closure in a number of wound types. In this study, the authors evaluated the efficacy of gauze-based negative-pressure wound therapy using the Chariker-Jeter technique for pediatric extremity wounds requiring delayed closure. Methods: A retrospective review was conducted of 24 pediatric patients presenting with extremity injuries involving soft-tissue defects not amenable to immediate primary closure. After initial irrigation, débridement, and antibiotic therapy, negative-pressure wound therapy using the Chariker-Jeter technique was applied and dressings were changed at 48- to 72-hour intervals before secondary closure or primary closure by skin graft, local flaps, or free tissue transfer. Results: Granulation tissue was noted in all wounds by day 4. The duration of vacuum therapy averaged 10 days in patients whose wounds were closed primarily (n = 19) and 17 days in patients who were allowed to heal by secondary intention (n = 5). Nine patients’ wounds were closed with skin grafts and local flaps, eight were closed with local flaps only, and three were closed with free tissue transfer. There was no incidence of skin graft loss or flap failure. Follow-up evaluation of the wounds averaged 24 months, during which no complications were noted. Conclusions: As a relatively atraumatic wound care technique with few complications, gauze-based negative-pressure wound therapy with the Chariker-Jeter technique provides a highly effective option for temporary soft-tissue management of extremity trauma in pediatric patients.

Quantitative facial asymmetry: using three-dimensional photogrammetry to measure baseline facial surface symmetry.

BackgroundAlthough symmetry is hailed as a fundamental goal of aesthetic and reconstructive surgery, our tools for measuring this outcome have been limited and subjective. With the advent of three-dimensional photogrammetry, surface geometry can be captured, manipulated, and measured quantitatively. Until now, few normative data existed with regard to facial surface symmetry. Here, we present a method for reproducibly calculating overall facial symmetry and present normative data on 100 subjects. MethodsWe enrolled 100 volunteers who underwent three-dimensional photogrammetry of their faces in repose. We collected demographic data on age, sex, and race and subjectively scored facial symmetry. We calculated the root mean square deviation (RMSD) between the native and reflected faces, reflecting about a plane of maximum symmetry. We analyzed the interobserver reliability of the subjective assessment of facial asymmetry and the quantitative measurements and compared the subjective and objective values. We also classified areas of greatest asymmetry as localized to the upper, middle, or lower facial thirds. This cluster of normative data was compared with a group of patients with subtle but increasing amounts of facial asymmetry. ResultsWe imaged 100 subjects by three-dimensional photogrammetry. There was a poor interobserver correlation between subjective assessments of asymmetry (r = 0.56). There was a high interobserver reliability for quantitative measurements of facial symmetry RMSD calculations (r = 0.91–0.95). The mean RMSD for this normative population was found to be 0.80 ± 0.24 mm. Areas of greatest asymmetry were distributed as follows: 10% upper facial third, 49% central facial third, and 41% lower facial third. Precise measurement permitted discrimination of subtle facial asymmetry within this normative group and distinguished norms from patients with subtle facial asymmetry, with placement of RMSDs along an asymmetry ruler. ConclusionsFacial surface symmetry, which is poorly assessed subjectively, can be easily and reproducibly measured using three-dimensional photogrammetry. The RMSD for facial asymmetry of healthy volunteers clusters at approximately 0.80 ± 0.24 mm. Patients with facial asymmetry due to a pathologic process can be differentiated from normative facial asymmetry based on their RMSDs. Clinical Question/Level of EvidenceDiagnostic, II.

Utilization of intraoperative 3D navigation for delayed reconstruction of orbitozygomatic complex fractures.

Reconstructive goals for orbitozygomaticomaxillary complex fractures include restoration of orbital volume, facial projection, and facial width. Delayed reconstruction is made more difficult by malunion, nonunion, bony absorption, loss of the soft tissue envelope, and scar. Three-dimensional intraoperative navigation, widely used in neurosurgery and sinus surgery, can improve the accuracy with which bony reduction is performed. This is particularly useful in the setting of bony absorption and comminution. We report a case of delayed reconstruction of an orbitozygomaticomaxillary complex fracture using intraoperative navigation and review this technologys utility in this setting.

The pedicled reverse-flow lateral arm flap for coverage of complex traumatic elbow injuries.

PurposeThe pedicled reverse-flow lateral arm flap has been described primarily for the reconstruction of nontraumatic elbow wounds. We describe our experience using this flap in staged operations for soft tissue coverage after elbow trauma, including acute coverage of open fractures and salvage of infected hardware. MethodsReview of patients who underwent staged pedicled reverse-flow lateral arm flap transfer for coverage of traumatic elbow defects. ResultsThree patients were identified; all underwent 2-stage repair with flap delay for coverage of traumatic elbow injuries. Each patient had stable wound coverage with this flap. The only complication was 5% distal flap necrosis in 1 patient. ConclusionsThe pedicled reverse-flow lateral arm flap provides reliable soft tissue coverage of traumatic elbow defects with minimal donor-site morbidity.

Measuring Symmetry in Children With Unrepaired Cleft Lip: Defining a Standard for the Three-Dimensional Midfacial Reference Plane

Objective Quantitative measures of facial form to evaluate treatment outcomes for cleft lip (CL) are currently limited. Computer-based analysis of three-dimensional (3D) images provides an opportunity for efficient and objective analysis. The purpose of this study was to define a computer-based standard of identifying the 3D midfacial reference plane of the face in children with unrepaired cleft lip for measurement of facial symmetry. Participants The 3D images of 50 subjects (35 with unilateral CL, 10 with bilateral CL, five controls) were included in this study. Interventions Five methods of defining a midfacial plane were applied to each image, including two human-based (Direct Placement, Manual Landmark) and three computer-based (Mirror, Deformation, Learning) methods. Main Outcome Measure Six blinded raters (three cleft surgeons, two craniofacial pediatricians, and one craniofacial researcher) independently ranked and rated the accuracy of the defined planes. Results Among computer-based methods, the Deformation method performed significantly better than the others. Although human-based methods performed best, there was no significant difference compared with the Deformation method. The average correlation coefficient among raters was .4; however, it was .7 and .9 when the angular difference between planes was greater than 6° and 8°, respectively. Conclusions Raters can agree on the 3D midfacial reference plane in children with unrepaired CL using digital surface mesh. The Deformation method performed best among computer-based methods evaluated and can be considered a useful tool to carry out automated measurements of facial symmetry in children with unrepaired cleft lip.

#Cleft: The Use of Social Media Amongst Parents of Infants with Clefts

INTRODUCTION Many societies and organizations are using social media to reach their target audience. The extent to which parents of patients with craniofacial anomalies use social media has yet to be determined. The goal of this study is to characterize and describe the use of social media by the parents of children with cleft lip and palate as it pertains to the care of their child. MATERIALS AND METHODS Parents or guardian of all patients presenting for initial consultation regarding a childs congenital cleft anomaly were contacted by phone or mail to complete a survey regarding their use of social media vis-à-vis their childs cleft anomaly. Participants were asked to answer a 19-question survey. RESULTS Thirty-two families were contacted and 25 surveys were completed. Ninety-two percent of respondents used social media to learn about their childs diagnosis. Facebook (76%) and blogs (24%) were the most commonly accessed social media outlets, followed by Instagram (8%). Education about the diagnosis and treatment of cleft pathology (87%) was the most common reason for accessing social media, followed by companionship and support (56%), and advice about perioperative care (52%). Almost half (43%) of parents used social media to obtain information on their caregiver and treatment team, and 26% of parents used information gained on social media to guide their decision on where to seek care. CONCLUSION Social media is a readily available resource, one that will certainly shape the experiences of our patients and families for years to come.

Pediatric Orbital Depth and Growth: A Radiographic Analysis.

Background: Orbital reconstruction requires knowledge of orbital depth in order to prevent optic nerve injury. Numerous analyses of adult orbital dimensions have been undertaken previously in order to characterize this measurement, including skull specimen and computerized tomography studies. However, there is a paucity of information regarding the pediatric orbit. Methods: The authors used pediatric magnetic resonance imaging (MRI) studies in order to quantify the change in orbital depth in relationship to patient age, and to develop methods to estimate and calculate orbital depth for individual pediatric patients. MRIs of the head in normal pediatric patients were reviewed retrospectively. Orbital depths were measured and correlated with age and cephalometric dimensions. In a randomly selected subgroup of patients, measurements were repeated by an independent investigator to determine interobserver reliability. Results: Measurements were obtained in 72 patients ranging from 3 months to 18 years of age (mean = 7.8 years). There was a significant exponential relationship between orbital depth and patient age (r 2 = 0.81, F(2,69) = 143.97, P < 0.001). Depth increased more rapidly in the first 6 years of life, but leveled off in the early teen years toward a horizontal asymptote of approximately 45 mm. There was also a significant relationship between orbital depth and the sum of the biparietal width plus the anterior–posterior length (r 2 = 0.72, F(2,69) = 87.44, P < 0.0001). There was high interobserver reliability in measurements between 2 independent investigators (r = 0.79, P < 0.0001). Conclusion: In children, orbital depth increases predictably with rising age and increasing head size. Knowledge of this growth curve and the relationship between head size and orbital depth can complement careful surgical dissection to improve safety and efficacy in pediatric orbital reconstructions.

Ewing Sarcoma Presenting as a Congenital Scalp Mass

Ewing sarcoma is a locally aggressive, highly malignant tumor most commonly seen in the skeletal system. The “Ewing family of tumors” also includes other tissue types that are not common, such as soft tissue origin classified as extraosseous Ewing sarcoma (EES) or primitive neuroendocrine origin. Age of onset most often occurs within the first 2 decades of life. Congenital presentation of EES is exceedingly rare. We report the first described case to our knowledge of congenital EES originating from the scalp.

A simple approach to reduction and stabilization of segmental fractures of the alveolar housing in complex facial trauma.

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