Constance M. Barone

Endoscopic craniectomy for early correction of craniosynostosis.

Twelve patients between 0.4 and 7.8 months of age were treated by an endoscopic approach to strip craniectomy. Nine patients had sagittal suture involvement. Two patients had a single unilateral lambdoid suture synostosis, and one patient had a combination of a right coronal synostosis and a metopic synostosis. Postoperatively, all patients were placed in cranial remodeling helmets and the results showed that the estimated blood loss ranged from 5 cc to 150 cc, with blood transfusion required in only one patient. All patients were discharged from the hospital by day 2, and all patients had an improvement in their cranial head shape. The specific technique of using the endoscope to aid in performing a strip craniectomy will be discussed. Nine endoscopically treated patients with the diagnosis of sagittal suture synostosis were compared with nine patients treated by using the Marchac remodeling techniques. The mean operative time (1.6 hours versus 3.5 hours), estimated blood loss (43 cc versus 168 cc), hospital costs (

Intraoperative Autologous Blood Transfusion in the Surgical Correction of Craniosynostosis

11,671 versus

Outcome analysis of reduction mammaplasty

36,685), and length of stay (1.16 days versus 5.1 days) were less by using the endoscopic technique. All nine patients treated by using the Marchac technique required a blood transfusion, whereas only one patient was transfused in the endoscopically treated group.

Hematomas requiring surgical evacuation following face lift surgery.

Transfusion of homologous blood is associated with significant and well-known risks. Reported transfusion rates for pediatric patients undergoing surgical correction of synostotic calvarial sutures vary between 20 and 500% of estimated blood volume. The objective of this study was to ascertain the risks, benefits, and effects on transfusion rates associated with the use of intraoperative autologous transfusion (IAT) in this patient population. The Haemonetics Cell Saver 4 (Haemonetics Corporation, Braintree, MA) autotransfusion system was used to salvage blood in 18 patients undergoing the release of stenosed calvarial sutures. In a prospective, nonrandomized study, these patients were compared with a control group of similar age, gender, weight, and surgical procedures. There were 10 male patients and 8 female patients; the mean age was 7.2 months, the mean weight was 8.67 kg, and the mean surgical time was 3.15 hours. The mean amount of homologous blood transfused to the control group was 189 ml, compared with 87.69 ml for the IAT group, which was a decrease of 46.3%. The mean amount of autologous blood transfused was 150 ml (range, 50-250 ml). Thirty-three percent of the patients in the IAT group did not require homologous blood transfusion. No complications were observed with the use of the Cell Saver in the IAT group. The use of the Cell Saver was associated with a significant decrease in the amount and rate of homologous blood transfusions. Its use appears to be safe in pediatric patients undergoing craniosynostotic surgery.

Aesthetic outcomes in breast conservation therapy.

&NA; In an attempt to obtain objective analysis of outcome in reduction mammaplasty patients, a retrospective study was done for women having elective bilateral reduction mammaplasty. Participants were chosen from a pool of over 200 consecutive reduction mammaplasty patients at the University of Missouri‐Columbia. Of those eligible for inclusion, 72 met the criteria and were available for longterm follow‐up. These patients answered a panel of questions regarding weight change, brassiere size, exercise, activity level, symptoms, and a personal appraisal of appearance. Statistical analysis was done to evaluate the change in each variable in relationship to the time of surgery, i.e., before surgery, 6 months after surgery, and at the present time. The findings revealed a significant stable reduction of breast mass. The women reported a significant reduction of symptoms that had been associated with their macromastia. They also reported a significant increase in exercise and other physical and social activities.

Venous Air Embolism during Endoscopic Strip Craniectomy for Repair of Craniosynostosis in Infants

This study evaluates hematomas requiring surgical evacuation following a face lift. Twenty-three hematomas occurred with 1236 consecutive face lifts (1.86 percent). All hematomas occurred within 48 hours. Fifty-seven percent were identified at less than 15 hours, 26 percent from 15 to 24 hours, and 17 percent from 24 to 48 hours. The incidence of hematomas for surgeons who performed more than 50 face lifts in this study varied from zero to 3.83 percent. This difference in incidence was statistically significant. A multivariant analysis of predetermined variables was done. Age, preoperative tests, medical history, gender, perioperative medications, type of anesthesia, number and combination of procedures, and treatment of the SMAS did not independently affect the incidence of hematomas. Preoperative and postoperative blood pressure did not affect the incidence. The incidence of hematomas with general anesthesia in this study was 7 of 630 (1.11 percent). In a similar 1973 study at this institution, the incidence with general anesthesia was 3.26 percent. This improvement was attributed to a change in anesthetic technique. Intraoperative hypotension was avoided in the current series. The incidence of hematoma in the local anesthesia group was 3.72 percent, and in the monitored intravenous sedation group it was 0.87 percent. Meticulous hemostasis, done with the patients blood pressure in a normotensive state, appeared to be of primary importance. (Plast. Reconstr. Surg. 93: 1185, 1994.)

Multiple-suture nonsyndromic craniosynostosis: early and effective management using endoscopic techniques

BACKGROUND Since the National Surgical Adjuvant Breast and Bowel Project B06 (NSABP-B06) trial demonstrated equivalent survival outcomes between patients with breast cancer undergoing modified radical mastectomy versus lumpectomy and radiation, an increasing number of patients are seeking breast conservation therapy. Traditionally, only patients who have undergone total mastectomy have been referred for reconstruction. OBJECTIVE The purpose of the study was to determine the number of dissatisfied patients treated with breast conservation therapy who have suboptimal cosmesis and should be referred for reconstruction. METHODS After obtaining approval from the Institutional Review Board and patient consent, patients identified as more than 1 year posttreatment from breast conservation therapy (1999-2004) were interviewed and photographed. Data were gathered by use of a questionnaire that included patient aesthetic score, patient satisfaction, and change in body image. Photographs were shown to a surgical oncologist, a general surgeon, and a plastic surgeon for a physician aesthetic score. RESULTS Thirteen of 46 patients (28.3%) were dissatisfied with their cosmetic result. Women who were dissatisfied with their cosmetic result were more likely to have a negative change in their body image when compared with patients who were satisfied with their cosmetic result (46.2 % vs 6.1%, P = .02). Additionally, dissatisfied patients were more likely to rate their cosmetic result as poor (15.4 % vs 0%, P = .007) and were more likely to consider reconstruction (46.2% vs 9.1%, P = .01) when compared with satisfied patients. Risk factors to predict dissatisfaction in our patient population included age younger than 52 years and the resection of tumor from the upper inner quadrant. CONCLUSIONS Twenty-eight percent of patients in this study were dissatisfied with their cosmetic result. Furthermore, a large portion of these patients would consider reconstruction if it were offered. Although this study only identified a few broad risk factors for suboptimal cosmetic outcome, it confirms our hypothesis that many patients who have undergone breast conservation therapy should be referred for plastic surgery consultation.

Multiple-suture nonsyndromic craniosynostosis

Background Various studies have reported an incidence of venous air embolism (VAE) as high as 82.6% during surgical procedures for craniosynostosis. There has been an increase in the use of minimally invasive, endoscopic surgical procedures, including applications for endoscopic strip craniectomy. The current study prospectively evaluated the incidence of VAE during endoscopic strip craniectomy. Methods Continuous, intraoperative monitoring for VAE was performed using precordial Doppler monitoring. A recording was made of the Doppler tones and later reviewed to verify its accuracy. Results The cohort for the study included 50 consecutive neonates and infants ranging in age from 3.5 to 36 weeks and ranging in weight from 3 to 9 kg. Surgical time varied from 31 to 95 min for a total of 2,701 min of operating time, during which precordial Doppler tones were auscultated. In 46 patients, there was no evidence of VAE. In four patients, there was a single episode of VAE. Two of the episodes of VAE were grade I (change in Doppler tones), and two were grade II (change in Doppler tones and decrease in end-tidal carbon dioxide). No grade III (decrease in systolic blood pressure by 20% from baseline) VAE was noted. Conclusion In addition to previously reported benefits of decreased blood loss, decreased surgical time, and improved postoperative recovery time, the authors noted a low incidence of VAE during endoscopic strip craniectomy in neonates and infants.

Low fistula rate in palatal clefts closed with the furlow technique using decellularized dermis

OBJECT The authors present the results of treating infants with multiple-suture nonsyndromic craniosynostosis in whom the authors used minimally invasive endoscopy-assisted techniques and postoperative cranial molding over an 11-year period. METHODS A total of 21 patients who presented with multiple-suture (nonsyndromic) craniosynostosis were treated using minimally invasive endoscopy-assisted craniectomies. Surgery was followed by treatment with custommade cranial orthoses for up to 12 months. A total of 48 sutures were treated. The most common was the coronal suture (38 cases) and this was followed by the sagittal (11 cases), metopic (6 cases), and lambdoid (3 cases) sutures. There were 13 male and 8 female pediatric patients. Their ages ranged between 3 weeks and 9 months (mean 3.2 months, median 2.5 months). The sagittal suture was treated with a wide vertex craniotomy via 2 incisions located behind the anterior fontanel and in front of the lambda. The metopic suture underwent a suturectomy as did the coronal and lambdoid sutures. RESULTS The mean follow-up duration was 61 months (range 3-135 months). There were no deaths. In patients with bicoronal synostosis, brachycephaly was corrected. Patients presenting with vertical dystopia or nasal deviation had these deformities corrected as well. The mean blood loss was 42 ml (range 10-120 ml). The mean hospital length of stay was 1 day. The intraoperative transfusion rate was 0%. The results indicate that nonsyndromic multiple-suture synostosis can be safely and effectively treated using endoscopic techniques. CONCLUSIONS Early treatment of complex multiple-suture synostosis with endoscopic techniques provides an excellent surgical alternative. The results of the present study indicate marked correction of skull base and craniofacial deformities. Endoscopy provides a safe and effective way to treat these patients.

Breast Reduction Trend among Plastic Surgeons: A National Survey

OBJECT The authors present the results of treating infants with multiple-suture nonsyndromic craniosynostosis in whom the authors used minimally invasive endoscopy-assisted techniques and postoperative cranial molding over an 11-year period. METHODS A total of 21 patients who presented with multiple-suture (nonsyndromic) craniosynostosis were treated using minimally invasive endoscopy-assisted craniectomies. Surgery was followed by treatment with custommade cranial orthoses for up to 12 months. A total of 48 sutures were treated. The most common was the coronal suture (38 cases) and this was followed by the sagittal (11 cases), metopic (6 cases), and lambdoid (3 cases) sutures. There were 13 male and 8 female pediatric patients. Their ages ranged between 3 weeks and 9 months (mean 3.2 months, median 2.5 months). The sagittal suture was treated with a wide vertex craniotomy via 2 incisions located behind the anterior fontanel and in front of the lambda. The metopic suture underwent a suturectomy as did the coronal and lambdoid sutures. RESULTS The mean follow-up duration was 61 months (range 3-135 months). There were no deaths. In patients with bicoronal synostosis, brachycephaly was corrected. Patients presenting with vertical dystopia or nasal deviation had these deformities corrected as well. The mean blood loss was 42 ml (range 10-120 ml). The mean hospital length of stay was 1 day. The intraoperative transfusion rate was 0%. The results indicate that nonsyndromic multiple-suture synostosis can be safely and effectively treated using endoscopic techniques. CONCLUSIONS Early treatment of complex multiple-suture synostosis with endoscopic techniques provides an excellent surgical alternative. The results of the present study indicate marked correction of skull base and craniofacial deformities. Endoscopy provides a safe and effective way to treat these patients.