Douglas J. Courtemanche

Treatment of cystic lymphatic vascular malformations with OK-432 sclerotherapy.

Background: Cystic lymphatic vascular malformations are benign lesions that can cause disfigurement and functional impairment. Complete surgical resection is often difficult, and clinical recurrence is common. Sclerotherapy has been used as an alternative to excision. OK-432 is a lyophilized mixture of Streptococcus pyogenes and benzylpenicillin which, when injected into a lesion, has shown significant ability to reduce its size or obliterate it completely. Methods: The authors report a series of 12 patients treated in this fashion at the Vascular Anomalies Clinic, British Columbia Childrens Hospital, between 1999 and 2004. All patients underwent imaging of the lesion: 10 had magnetic resonance imaging, one had a computed tomographic scan, and one had ultrasound examination. Six patients had macrocystic malformations (cysts ≥ 2 cm) and six had microcystic or combined lymphaticovenous malformations. Patients were treated with intralesional injection of OK-432. The position of the injection was confirmed by angiography and/or ultrasound in 10 cases. Response to treatment was assessed clinically. Results: All patients with macrocystic malformations had complete resolution or good response to treatment. None required any additional treatment. In contrast, those with microcystic or combined malformations responded poorly. All of these patients underwent subsequent excision without adverse consequences. The size and location of the lesion did not correlate with response to treatment. Seventy-five percent of patients experienced pyrexia. Local swelling is an expected phenomenon and must be anticipated, particularly for lesions near the airway. Conclusions: OK-432 is an excellent treatment for patients with macrocystic lymphatic malformations. However, it is ineffective for microcystic lesions.

Plate removal in traumatic facial fractures: 13-year practice review.

Various complications can result from titanium plate internal fixation, including infection, exposure, pain, cold intolerance, and palpability. The incidence of such complications has become a topic of recent interest with the advent of resorbable plating. We undertook a retrospective review to determine complication rates of titanium fixation in a facial fracture population. Out of 266 patients with operative management of traumatic facial fracture between 1991 and 2004, 135 patients had titanium plate fixation. We evaluated 16 panfacial fractures, 22 zygomatic-orbital complex fractures, 49 midface fractures, and 48 fractures of the mandible. Overall, 33.3% (45/135) of patients had plates removed; 64.4% (29/45) of plate removals were for complications, ie, discomfort, exposure, and infection; 35.6% (16/45) were removed during secondary reconstruction. The most common complication was discomfort related to palpability, cold intolerance, and pain. This constituted 72.4% (21/29) of all plate removals for complications. Higher rates of plate discomfort were noted near the supraorbital, infraorbital, and mental foramina.

Pediatric hand fractures: A review

Objective To identify the incidence, causes, and details of hand fractures in children. Design A retrospective chart review. Methods Records of children under 16 years of age who had sustained a hand fracture within the last 5 years were collected from the patient population of British Columbia’s Children’s Hospital. A total of 242 hand fractures in 232 patients were documented. These patients were reviewed for age at time of injury, gender, location of the incident, mechanism of injury, number of radiographs taken, and fracture specifics. Radiographs with obscure details or incomplete folders were excluded. Results The patients consisted of 57 (24.6%) females and 175 (75.4%) males, with a mean age of 11.1 ± 3.3 years. Incidence was low in early childhood but rose sharply after age 9 and peaked at 12 years of age. Sporting activities were the most common cause in both sexes. The fifth metacarpal was the most frequently involved bone (21.1% of total). Nonepiphyseal fractures accounted for 60.2% of the fractures, and the remaining 39.8% were epiphyseal fractures, predominantly Salter-Harris type II (90.4%). Fractures with comminution, severe displacement, intraarticular involvement, and condylar involvement were seen in 12.4%, 12.4%, 20.5%, and 15.1%, respectively. An average of 4.2 radiographs were taken per patient. Conclusion Almost all fractures healed in 2 to 3 weeks with excellent functional outcome. Knowledge of epidemiology and etiology of hand fractures can serve as an essential first step in devising strategies to reduce the incidence of these hand injuries. It is hoped that studies such as the present study may serve as a first step in planning measures to reduce the occurrence of hand fractures.

Robin Sequence: Clearing Nosologic Confusion

OBJECTIVE To gather evidence surrounding the confusion in the classification of Robin sequence and inform those who have the power to make the changes in defining this symptom complex. METHOD A questionnaire was sent to all participating cleft palate teams (N=204) of the American Cleft Palate-Craniofacial Association. The questionnaire identified the precise, different characteristics for diagnosing Robin sequence and evaluated whether the difference between a retrognathia and micrognathia influenced the diagnosis process. We subsequently also investigated whether the cleft type (i.e., U-shaped versus V-shaped) had any influence in the decision-making process. A PubMed literature review of the 50 most recent manuscripts about Robin sequence was evaluated also. RESULTS Seventy-three questionnaires were received. This 35% response rate revealed 14 different definitions of Robin sequence. A PubMed literature review of 50 consecutive manuscripts revealed 15 different descriptions. CONCLUSION This study confirms that nosologic confusion is widespread with regard to defining Robin sequence. This has implications for evaluating Robin sequence, giving advice about the prognosis and genetic counseling, and refining treatment options.

Facial fractures - association with ocular injuries: A 13-year review of one practice in a tertiary care centre.

BACKGROUND The incidence of ocular injury associated with facial fractures has been reported to be between 0.8% and 30%. OBJECTIVE Because of this wide range of incidences, a system to stratify the risk of ocular injury by type of facial fracture was sought. METHODS The present study reviewed 266 patients with facial fractures to determine the risk factors for ocular injury. The anatomy of each facial fracture was classified using an orbit-centred approach according to the number of orbital walls fractured. Patients were then grouped using this classification system. Charts documenting follow-up for each patient over a minimum of one year were examined and initial emergency room presentations of patients with subsequent visual impairment were recorded. RESULTS The incidence of severe visual impairment and blindness was 4.5% overall. Although all facial fractures (including isolated fractures of the mandible) had a notable incidence of ocular injury, an increased number of orbital wall fractures were correlated with an increased incidence of permanent visual disability. One of 147 (0.68%) patients without an orbital wall fracture sustained permanent severe ocular injury or blindness, while 13.5% (five of 37) of three-wall orbital fracture patients and 25% (four of 16) of four-wall orbital fracture patients sustained the same injury. CONCLUSIONS The risk of ocular injury in complex facial fractures can be stratified by the degree of orbital wall involvement. However, because all patients with persistent visual impairment had ocular findings on initial examination, it is proposed that oculovisual testing is a more sensitive indicator of lasting ocular injuries than the type of facial fracture.

Vascular resistance in human muscle flaps.

Important differences in free muscle flap survival have been reported in the setting of long arterial and venous vein grafts. The authors provide insight into the etiology of flap failure by addressing the following question: Do differences in flap type result in clinically significant different vascular resistances and consequently anastomotic patency? A total of 15 human flaps were studied intraoperatively: 9 gracilis, 3 rectus abdominis, and 3 latissimus dorsi. The muscle was isolated on a single pedicle and hemodynamic stability was ensured. The venous pedicle was then divided. A timed collection of effluent was used to determine flow. Vascular resistance was calculated by dividing the change in pressure by the flow, and standardizing this for temperature and hematocrit. Average vascular resistance and standard deviation for the gracilis, rectus, and 2latissimus flaps was 10.34 ± 7.77 mmHg per milliliter per minute, 2.79 ± 1.50 mmHg per milliliter per minute, and 3.17 ± 1.05 mmHg per milliliter per minute respectively. An inverse relationship between muscle vascular resistance and flap mass was found (p < 0.001). This indicates that larger muscles have less vascular resistance. The decreased resistance gives rise to higher flow rates and, as a result, potentially improved vein graft patency. The clinical implication is that a larger flap should be used when high flow-through is critical. The role of flap vascular territory makeup continues to be pursued.

Lipoma of the Cleft Soft Palate: A Case Report of a Rare Congenital Anomaly

OBJECTIVE Congenital tumors of the oral cavity are extremely uncommon. The teratoid tumors (epiganthi, dermoid, and hairy polyps) account for almost all of the reported cases and are not infrequently associated with cleft of the soft palate. Of the remaining tumors in the pediatric cleft palate population, infantile lipoma of the oral cavity is exceedingly rare. A case of a congenital lipoma associated with a cleft of the soft palate is presented. The review of the literature, the description of the lesion, the diagnosis, and the management of this finding are outlined.

Complicated infantile hemangioma of the lip: outcomes of early versus late resection.

Background: Lip hemangiomas have traditionally been approached with expectant management. However, intervention is warranted for associated complications, including facial disfigurement, feeding difficulties, speech impairment, and psychosocial manifestations. The authors evaluated outcomes of complicated lip hemangiomas resected during the proliferative as compared with the involutional phase. Methods: A retrospective review of patients with complicated lip hemangiomas managed with resection in the proliferative or involutional phase from 2005 to 2011 was performed. A transverse elliptical vermilion-mucosal resection technique was used. Review parameters included demographics, lesion size and location, growth phase, hemangioma-related complications, and preoperative management (corticosteroid or pulsed dye laser). Evaluated outcomes included surgical complications, recurrence, and patient- and surgeon-reported aesthetics. Results: Twenty-one patients underwent surgical resection of a lip hemangioma (10 proliferative and 11 involutional), with a mean follow-up of 21.4 and 23.3 months, respectively. The two groups were comparable with respect to lesion size and location. Patients in the involutional group experienced higher rates of hemangioma-related complications (bleeding, 45 percent versus 10 percent; speech impairment, 82 percent versus 0 percent; feeding difficulties, 82 percent versus 20 percent; and psychosocial issues, 100 percent versus 80 percent). There were no postoperative aesthetic concerns. One recurrence in the proliferative group was treated with reresection. Speech therapy was required for 82 percent of patients in the involutional group. Conclusions: Surgical resection is efficacious treatment for hemangiomas of the lip and yields acceptable aesthetic results during both the proliferative and involutional phases. Resection in the proliferative phase should be considered to prevent complications associated with delayed treatment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Role of platelet gel and calcium-coated Lactosorb membranes in healing critical calvarial defects.

We evaluated the efficacy of coating Lactosorb (Biomet Inc, Warsaw, IN) membranes with calcium hydroxyapatite in critical-size defects in rabbits. We also evaluated whether platelet gel affects calvarial bone healing. Fifteen adult New Zealand white rabbits were divided into 5 groups. Each animal underwent a surgical procedure in which 2 critical-size (15 mm) calvarial defects were created in the parietal bones. Group A was control. Group B was a control in 1 defect and Lactosorb in the other defect. Group C was treated with Lactosorb in 1 defect and Lactosorb coated with calcium hydroxyapatite in the other defect. Group D was treated with Lactosorb in 1 defect and coated Lactosorb without calcium hydroxyapatite in the other defect. Group E was treated with platelet gel in 1 defect and control in the other. The animals were killed at 1, 3, and 6 months. The bones were excised and evaluated by clinical observation, radiography, and histology. None of the defects were closed at 6 months. Defects treated with platelet gel healed in a similar fashion as control. All defects treated with a barrier (Lactosorb, Lactosorb coated, Lactosorb coated with hydroxyapatite) showed clinical, radiographic, and histologic evidence of increased healing compared with control. The addition of hydroxyapatite did not augment healing. We concluded that the healing of critical-size defects in rabbits can be augmented by the addition of Lactosorb membranes. There is no evidence that platelet gel augments the healing of critical defects in rabbits.

What Is the Best Way to Measure Surgical Quality? Comparing the American College of Surgeons National Surgical Quality Improvement Program versus Traditional Morbidity and Mortality Conferences.

Background: Morbidity and mortality conferences have played a traditional role in tracking complications. Recently, the American College of Surgeons National Surgical Quality Improvement Program Pediatrics (ACS NSQIP-P) has gained popularity as a risk-adjusted means of addressing quality assurance. The purpose of this article is to report an analysis of the two methodologies used within pediatric plastic surgery to determine the best way to manage quality. Methods: ACS NSQIP-P and morbidity and mortality data were extracted for 2012 and 2013 at a quaternary care institution. Overall complication rates were compared statistically, segregated by type and severity, followed by a subset comparison of ACS NSQIP-P-eligible cases only. Concordance and discordance rates between the two methodologies were determined. Results: One thousand two hundred sixty-one operations were performed in the study period. Only 51.4 percent of cases were ACS NSQIP-P eligible. The overall complication rates of ACS NSQIP-P (6.62 percent) and morbidity and mortality conferences (6.11 percent) were similar (p = 0.662). Comparing for only ACS NSQIP-P–eligible cases also yielded a similar rate (6.62 percent versus 5.71 percent; p = 0.503). Although different complications are tracked, the concordance rate for morbidity and mortality and ACS NSQIP-P was 35.1 percent and 32.5 percent, respectively. Conclusions: The ACS NSQIP-P database is able to accurately track complication rates similarly to morbidity and mortality conferences, although it samples only half of all procedures. Although both systems offer value, limitations exist, such as differences in definitions and purpose. Because of the rigor of the ACS NSQIP-P, we recommend that it be expanded to include currently excluded cases and an extension of the study interval.