Davinder J. Singh

Aesthetic considerations in nasal reconstruction and the role of modified nasal subunits.

&NA; In 1985, Burget and Menicks landmark article on the nasal subunit principle popularized the technique of reconstructing the specific topographic subunits that they identified as the dorsum, tip, and columella and the paired alae, sidewalls, and soft triangles. In patients with more than 50 percent of subunit loss, Burget and Menick proposed removing the remaining portion of the subunit and reconstructing the entire subunit with a skin graft or flap. They further supported the placement of incisions for local flaps along borders of aesthetic subunits to maximize scar camouflage. Although the concept of nasal subunits is important in planning the reconstruction, other aesthetic considerations, such as skin texture, color, contour, and actinic damage, are also crucial in achieving an optimal result. Often, focusing on these aspects with the goal of nasal symmetry in mind leads to the violation of the subunit principle but provides a pleasing result of both the defect and the donor site. The purpose of this study was to demonstrate when and how the modification of the nasal subunit principle is used to achieve coverage of nasal skin defects. A retrospective analysis of patients who underwent nasal reconstruction after skin cancer ablation surgery by one surgeon at the Hospital of the University of Pennsylvania from 1987 to 2000 was performed. During this 13‐year period, 219 patients underwent 245 nasal reconstructions. Seventy‐four patients with 76 reconstructions (31 percent) had procedures that violated the classic nasal subunit principle. Eight of these 74 patients (11 percent) had complications, and eight (11 percent) had 10 revisions performed. The aesthetic and functional results were graded as excellent, good, and fair. The results for the 74 patients who underwent modification of the subunit were excellent in 85 percent, good in 13 percent, and fair in 2 percent. Case reports were selected to illustrate situations in which the nasal subunit was altered. (Plast. Reconstr. Surg. 111: 639, 2003.)

The diagnosis and treatment of single-sutural synostoses : Are computed tomographic scans necessary?

Background: Computed tomographic scan evaluation is the current standard of care for diagnosing craniosynostosis. Recent publications, and the National Cancer Institute, have raised concerns about ionizing radiation associated with computed tomographic scans in children (e.g., developmental delays, tumor induction). The authors sought to ascertain the diagnostic accuracy of the physical examination in evaluating single-sutural craniosynostosis and assess the need for computed tomographic scans in surgical correction. Methods: This prospective, multicenter, outcome assessment included children clinically diagnosed with a single-sutural synostosis by craniofacial surgeons (with 1 to 18 years’ experience) at four centers over a 1-year period. Clinical diagnoses were compared with computed tomographic scan evaluations. All surgeons scored the utility of computed tomographic scans during surgical repair. Results: Sixty-seven patients were clinically diagnosed with single-sutural craniosynostosis (mean age, 7 months; range, 1 week to 48 months). Sixty-six of 67 patients were diagnosed with craniosynostosis by computed tomographic scan (sagittal, 40 percent; metopic, 31 percent; right unilateral coronal, 16 percent; left unilateral coronal, 6 percent; and right lambdoid, 6 percent), for a diagnostic accuracy exceeding 98 percent. One patient with suspected lambdoid synostosis was radiologically diagnosed with positional plagiocephaly. Three of four craniofacial surgeons scored computed tomographic scans as “unnecessary” for surgical correction; one scored scans as “sometimes helpful.” Conclusions: Craniofacial surgeons with various experience levels were able to accurately diagnose single-sutural synostosis by physical examination alone. Considering potential side effects from ionizing radiation, risks of sedation, and costs, surgeons may wish to reserve computed tomographic scans only for infants with suspected single-sutural craniosynostosis in whom the physical examination is not clearly diagnostic.

True lambdoid craniosynostosis : Long-term results of surgical and conservative therapy

Background: True lambdoid synostosis is a rare malformation. Few clinical reports have examined the efficacy of conservative or surgical management in the care of these patients. Methods: All patients with a diagnosis of true lambdoid synostosis treated by the senior author (S.P.B.) at The Children’s Hospital of Philadelphia between 1990 and 2005 were included in the study. Both qualitative and quantitative assessments of craniofacial growth were performed following either conservative or surgical management. Qualitative assessments were made based on preoperative and postoperative photographs, computed tomographic scans, and a review of patient charts. A quantitative assessment of ear position was performed using craniometric analysis and the appropriate statistical tests. Results: The study included nine patients—six who underwent surgical intervention and three who did not undergo transcranial surgery to date. The authors’ analysis of patient data revealed a predictable craniofacial dysmorphism manifest as occipital flattening, an ipsilateral occipitomastoid bulge, and a pronounced hemifacial deficiency. Generally, these malformations improved following operative management. A quantitative analysis of preoperative and postoperative ear position displayed no statistically significant vertical or anteroposterior displacement. In one untreated patient, true lambdoid synostosis resulted in persistent severe asymmetry of the cranial vault and facial skeleton. Conclusions: True lambdoid synostosis, if left untreated, results in pronounced craniofacial asymmetry. Although a diversity of clinical presentations exists, diagnostic features include occipital flattening, an ipsilateral occipitomastoid bulge, and a contralateral hemifacial deficiency. Posterior vault switch cranioplasty is an effective treatment for true lambdoid synostosis when performed in the first year of life.

Nonsynostotic occipital plagiocephaly : Radiographic diagnosis of the sticky suture

Background: While the clinical differences between nonsynostotic occipital plagiocephaly and lambdoid craniosynostosis have been described, the radiographic differentiation between the two remains obscure. The aim of this study was to characterize morphological differences in the lambdoid suture between nonsynostotic occipital plagiocephaly and lambdoid craniosynostosis. Methods: Computed tomography scans of children clinically diagnosed with nonsynostotic occipital plagiocephaly (n = 26) were compared with computed tomography scans from children diagnosed with lambdoid craniosynostosis (n = 7). Suture and cranial morphology, ear position, and endocranial base angles were qualitatively and quantitatively compared. Results: Nonsynostotic occipital plagiocephaly sutures demonstrated areas of focal fusion (25 percent), endocranial ridg-ing (78 percent), narrowing (59 percent), sclerosis (19 percent), and changes from overlapping to end-to-end orientation (100 percent). No sutures demonstrated ectocranial ridging. All cases of nonsynostotic occipital plagiocephaly presented with ipsilateral occipital flattening, 85 percent with ipsilateral frontal, and 95 percent with contralateral occipital bossing producing parallelogram morphology. In contrast, a greater frequency of sutures in lambdoid craniosynostosis patients demonstrated nearly complete obliteration (p < 0.001) with ectocranial ridging (p < 0.001); significantly more of these patients presented with ipsilateral occipital flattening with compensatory ipsilateral mastoid (p < 0.001) and contralateral parietal (p < 0.01) bossing, producing a trapezoid morphology. Sutures from nonsynostotic occipital plagiocephaly patients showed endocranial ridging, focal fusions, and narrowing, previously reported as lambdoid craniosynostosis. Conclusions: In contradiction to previous reports, lambdoid craniosynostosis is not radiographically unique among suture fusions. This work establishes the radiographic diagnosis of nonsynostotic occipital plagiocephaly.

Aesthetic management of the ear as a donor site.

Background: The ear is a frequently used donor site for facial reconstruction. It serves as an ideal source for skin, cartilage, and composite grafts because of its color and texture match. However, because of the prominent location of the ears, the prevention of donor-site problems such as scarring and resultant asymmetries is equally important in creating an overall aesthetic facial reconstruction. The purpose of this review was to describe surgical techniques of minimizing ear donor-site morbidity as a consequence of harvesting of composite chondrocutaneous grafts. Methods: A retrospective analysis was performed of all patients who underwent nasal reconstruction performed by the senior surgeon (D.J.S.) between 1987 and 2003, to identify those patients in whom a composite chondrocutaneous auricular graft was used. Photographs, surgical technique, and aesthetic outcomes were reviewed for those patients identified as having donor auricular composite grafts. Results: Three hundred fifty-seven nasal reconstructions were performed. Of the 357 reconstructions, 67 involved harvest of preauricular or postauricular full-thickness skin graft, and 79 involved use of auricular cartilage. Sixteen of the 79 involved harvesting of auricular composite grafts. For these 16 patients, defect size, donor site, and closure of donor site are described and indications for certain techniques are delineated. Conclusions: The harvest of composite grafts is challenging in technical design and in closure of the defect. In this patient series, the donor defects were closed primarily in one of six ways, depending on the size of the cartilage and skin graft required. These techniques allowed adequate harvest of donor tissue while preserving the aesthetics of the ear.

Squamosal suture synostosis: a cause of atypical skull asymmetry.

Background: The squamosal suture is markedly different from the major calvarial sutures of the human skull. The unique properties of the suture are a result of the complex developmental biology of the temporal bone and biomechanical force exerted by surrounding structures. The dysmorphic effects of premature fusion of the suture, and possible treatment strategies in cases of synostosis, have received only brief description in the literature. Methods: A retrospective case series was performed. The study included patients evaluated by one of the senior authors (S.P.B., R.R.R., and D.J.S.) between 1993 and 2009. All pertinent patient data including inpatient and outpatient charts, photographic records, and radiographic scans were reviewed. Any management performed under the direction of a craniofacial surgeon was documented—including orthotic helmet therapy and operative management. Results: The study included 14 patients. Synostosis of the squamosal suture was noted to occur either in an isolated fashion or in the setting of other craniofacial malformations. Patients with isolated squamosal synostosis often suffered from a deformity that was mild in severity and tended to improve with time. However, when occurring in the setting of other forms of craniosynostosis, the deformity was often progressive, and transcranial surgery was frequently required. Conclusions: Synostosis of the squamosal suture can result in, or contribute to, significant craniofacial dysmorphism. The optimal form of therapy for this disorder is evolving.

Pediatric Cranial Vault Defects: Early Experience With β-Tricalcium Phosphate Bone Graft Substitute

Pediatric calvarial defects may result from numerous causes. Availability of bone is often limited because of the childs age, and bone substitutes may be needed to reconstruct the defects. A bone substitute composed of ultraporous &bgr;-tricalcium phosphate (Orthovita, Malvern, PA) is an osteoconductive product successfully used in orthopedic surgery. However, its application in cranial vault reconstruction is largely unstudied. The purpose of this investigation was to determine the healing rate of bone defects with the use of this product.A retrospective review was performed of patients in whom &bgr;-tricalcium phosphate was used. Patient population consisted of 23 patients. Mean surgical age was 35 months. Reconstructions consisted of 20 craniosynostosis corrections and 3 posttraumatic repairs. The average defect size was 37 cm2 (range, 4.6-210 cm2). Average follow-up was 12.7 months.At 2 months, 19 (79%) of 23 patients achieved healing of their defect, defined as the absence of persistent bone gaps. Persistent areas of bone weakness occurred in 3 patients at 4 months and 2 patients at 6 months. By 9 months, only 1 patient had not healed. This patient had the largest original defect of 210 cm2. Defects taking longer than 2 months to heal measured 83 cm2, whereas healed defects were 32 cm2. No patients required treatment for graft-related problems such as infection or exposure.Early experience with &bgr;-tricalcium phosphate bone substitute shows good healing of pediatric calvarial vault defects by 2 months, with no graft-associated complications. It seems most effective in the repair of smaller defects less than 40 cm2.

Surgical reconstruction of pediatric pressure sores: Long-term outcome

&NA; Learning Objectives: After studying this article, the participant should be able to: 1. Define the staging system for pressure sores. 2. Describe the controversy surrounding the surgical repair of pressure sores given the recurrence rates documented in the adult population. 3. Distinguish between pediatric and adult pressure sore recurrence rates after surgical repair. 4. Identify patient characteristics and management strategies that would lead to greater long‐term success in surgical repair. The long‐term outcome after the surgical repair of pressure sores in the adult population has been well studied. Recurrence rates from 25 to 80 percent have been reported, despite improvements in surgical repair and mechanical support devices. Such high recurrence rates have led many investigators to question the rationale for the surgical closure of pressure sores. There are no published long‐term data that document pressure sore recurrence after surgical treatment in the pediatric population. A retrospective analysis of all patients who underwent surgical reconstruction of grade III and IV pressure sores at the Childrens Hospital of Philadelphia from 1987 to 1999 was performed. During this 12‐year period, 19 consecutive patients with a mean age of 16.2 years were operated on for 25 pressure sores. Follow‐up was obtained for 15 patients (79 percent), who underwent repair for 20 pressure sores. Mean postoperative follow‐up was 5.3 years (range, 11 months to 11 years). Mean age at the time of surgery was 16.5 years. The overall pressure sore recurrence rate was 5 percent (1 of 20 sores). Overall patient recurrence (previous patient who developed a new sore) was 20 percent (3 of 15 patients). In contrast to the recurrence rates reported for the surgical repair of pressure sores in the adult population, the recurrence rate of 5 percent in the pediatric population is significantly lower. This demonstrates that the surgical reconstruction of pressure sores in the pediatric patient can be successful and provide long‐term skin integrity. (Plast. Reconstr. Surg. 109: 265, 2002.)

Mandibular deformities: single-vector distraction techniques for a multivector problem.

Single-vector distraction devices have been criticized for creating a malocclusion in an attempt to correct a three-dimensional mandibular deficiency, resulting in the evolution of a multiplanar device. Although there are indications for the use of a multiplanar device, a vast number of patients with mandibular hypoplasia can be effectively treated with a single-vector device, producing a normal occlusion and an aesthetic result while minimizing facial scarring and simplifying postoperative care. The purpose of this review was to describe surgical techniques whereby a single-vector device is effectively used in treating a multivector mandibular deficiency. A retrospective analysis of all patients who underwent mandibular distraction at the Childrens Hospital of Philadelphia between 1996 and 2005 with a semiburied, uniplanar device was conducted. Charts, photographs, graphs, operative reports, computed tomography scans, and cephalometrograms were reviewed for those patients undergoing uniplanar mandibular distraction. Ten unilateral and 4 bilateral distractions were performed. In these 14 patients, causes included hemifacial microsomia, Treacher Collins syndrome, posttraumatic hypoplasia, and temporomandibular joint ankylosis with hypoplasia. The average device distraction was 29 mm (range, 18-34 mm). The average age at distraction was 8.4 years (range, 4-15 years). Surgical techniques for these patients will be described in detail. The single-vector, semiburied device can be effectively used to aesthetically correct a three-dimensional problem and to produce or maintain a class I occlusion while simplifying postoperative management and minimizing facial scarring.

Tranexamic Acid Reduces Blood Loss in Craniosynostosis Surgery

Methods: The authors retrospectively reviewed 79 patients with craniosynostosis who underwent either bifrontal or biparietal-occipital calvarial vault remodeling before institution of tranexamic acid (TXA) administration (non-TXA group) and 35 patients after institution of TXA administration (TXA group). The patients were analyzed in 2 groups: all open calvarial vault remodeling patients (anterior and posterior) as a whole, and anterior vaults only as a subset analysis. Primary outcomes accessed were: total intraoperative blood transfused, postoperative blood transfused, and estimated blood loss (EBL). Secondary outcomes evaluated were length of stay in the pediatric intensive care unit and hospital length of stay. Results: When comparing all open calvarial vault remodeling patients, patients who received TXA required significantly less total blood transfusion during their operation (264 cc TXA group versus 428 cc non-TXA, P < 0.0001). Patients who received TXA required no blood transfusions postoperatively, compared with the non-TXA group, in which 45% of patients required postoperative blood transfusion. Weight-based EBL was also significantly lower in those patients receiving TXA (25 cc/kg in the TXA group versus 34 cc/kg in the non-TXA group [P = 0.0143]). All patients required transfusion intraoperatively. Pediatric intensive care unit length of stay was shorter in the TXA group, but there was no significant difference in total hospital length of stay. These findings also reached statistical significance when comparing only the anterior vault patients. Conclusion: Intraoperative TXA administration has a correlation with reduced blood transfusion requirements, as well as EBL, in patients undergoing open calvarial vault remodeling. There were no adverse events related to TXA administration.