Gary F. Rogers

Validity and Reliability of Craniofacial Anthropometric Measurement of 3D Digital Photogrammetric Images

Background: Direct anthropometry performed during a patient examination is the standard technique for quantifying craniofacial dysmorphology, as well as for surgical planning and outcome assessment. Several new technologies have been designed to computerize anthropometric measurements, including three-dimensional (3D) digital photogrammetry. These digital systems have the advantage of acquiring patient craniofacial surface images quickly and noninvasively. Before morphometry using digital photogrammetry can be applied in clinical and research practice, it must be assessed against direct anthropometry. Objective: To evaluate the validity and reliability of facial anthropometric linear distances imaged by 3D digital photogrammetry with respect to direct anthropometry. Design, Setting, Participants, Measures: Standard craniofacial distances were directly measured twice on 20 normal adult volunteers. Craniofacial surfaces were also imaged using the 3dMDface digital photogrammetry system, and distances were digitally measured twice for each subject. Validity measures of accuracy and bias (for direct versus digital measurements) and reproducibility measures of precision and test-retest reliability (for repeated sets of digital measurements) were computed. Results: Seventeen of the 18 direct measurements correlated highly with digital values (mean r = 0.88). The correlation for one measurement (upper prolabial width) was not statistically significant. The overall precision of all 17 digital measurements was less than 1 mm, and the reliability was high (mean r = 0.91). Conclusions: Craniofacial anthropometry using the 3dMDface System is valid and reliable. Digital measurements of upper prolabial width may require direct marking, prior to imaging, to improve landmark identification.

Efficacy of Tranexamic Acid in Pediatric Craniosynostosis Surgery: A Double-blind, Placebo-controlled Trial

Background:Extensive blood loss is common in pediatric craniosynostosis reconstruction surgery. Tranexamic acid (TXA) is increasingly used to reduce perioperative blood loss in various settings, but data on its efficacy are limited in children. The purpose of this randomized, double-blind, placebo-controlled, parallel trial was to evaluate the efficacy of TXA in pediatric craniosynostosis correction surgery. The primary and secondary outcome variables were reduction in perioperative blood loss and reduction in blood transfusion, respectively. Methods:Forty-three children, ages 2 months to 6 yr, received either placebo or TXA in a loading dose of 50 mg·kg−1, followed by an infusion of 5 mg·kg−1·h−1 during surgery. TXA plasma concentrations were measured. Results:The TXA group had significantly lower perioperative mean blood loss (65 vs. 119 ml·kg−1, P < 0.001) and lower perioperative mean blood transfusion (33 vs. 56 ml· kg−1, P = 0.006) compared to the placebo group. The mean difference between the TXA and placebo groups for total blood loss was 54 ml·kg−1 (95% CI for the difference, 23–84 ml·kg−1) and for packed erythrocytes transfused was 23 ml·kg−1 (95% CI for the difference, 7–39 ml·kg−1). TXA administration also significantly diminished (by two thirds) the perioperative exposure of patients to transfused blood (median, 1 unit vs. 3 units; P < 0.001). TXA plasma concentrations were maintained above the in vitro thresholds reported for inhibition of fibrinolysis (10 &mgr;g·ml−1) and plasmin-induced platelet activation (16 &mgr;g·ml−1) throughout the infusion. Conclusions:TXA is effective in reducing perioperative blood loss and transfusion requirement in children undergoing craniosynostosis reconstruction surgery.

Circular Excision of Hemangioma and Purse-string Closure: The Smallest Possible Scar

&NA; Localized cutaneous infantile hemangioma acts like a tissue expander. This rapidly growing tumor can destroy elastic fibers or cause ulceration resulting in telangiectases, cutaneous laxity, scarring, and fibrofatty residuum. Although surgeons may dispute indications and timing, most would agree that the scar of resection should be minimized. For this reason, circular excision and pursestring closure is particularly applicable for hemangioma at any stage of its evolution. The purposes of this study were to: (1) analyze the results of circular excision/purse‐string closure in all three phases of the life cycle of hemangioma; (2) quantify dimensional changes after resection; and (3) compare the scars after theoretical single‐stage lenticular excision with those after staged circular excision/pursestring closure. The authors retrospectively analyzed their experience in 25 children with localized hemangioma who underwent circular excision/purse‐string closure from 1997 to 2000. Each hemangioma was measured preoperatively and the scars were measured at most recent follow‐up (minimum, 6 months). Preoperative and postoperative dimensions were analyzed using SPSS statistical software. The study included 22 girls and three boys, with an average time to follow‐up evaluation of 13.1 months. Twenty‐one lesions were in the face and scalp, and five were in the extremity. Five tumors were resected in the proliferative phase (either because of ulceration, bleeding, or visual complications) and 21 were excised in the involuting or involuted phase. Six patients had a secondstage procedure: three had another circular excision and three had later lenticular excision. After single circular excision/purse‐string closure, the mean long‐axial diameter (length) decreased by 45 percent, the mean shortaxial width (width) decreased by 73 percent, and the mean scar area was only 15 percent of the original area. All these differences were statistically significant (p = 0.001). The average width/length ratio decreased by 50 percent, indicating a tendency for scars to linearize. There was no difference in linearization for the three phases of hemangioma (p > 0.05); extremity scars became more linear that those on the face (p = 0.01). The authors devised a formula for scar length after lenticular excision/linear closure, assuming a conventional excisional ratio of 3:1 for a circular lesion. Using this equation, the authors predicted that mean scar length after circular excision, followed by lenticular excision, would be 72 percent shorter than the calculated scar that would result from conventional lenticular excision. In three patients who underwent this two‐stage approach, the resultant scar was 69 percent shorter. Circular excision of hemangioma and purse‐string closure reduces both the longitudinal and transverse dimensions and converts a large circular lesion into a small ellipsoid scar. If subsequent revision to a linear scar is desirable, its length will be the same or slightly less than the diameter of the original lesion. No other excision and closure technique results in a smaller scar. Another advantage of this method is minimal distortion of surrounding structures. (Plast. Reconstr. Surg. 109: 1544, 2002.)

Autogenous bone graft: basic science and clinical implications.

No single biomaterial is optimum for every craniomaxillofacial application. Instead, surgeons should consider the advantages and disadvantages of each alternative in a given clinical situation, and select the material with lowest overall cost and morbidity, and the highest likelihood of success. Autogenous bone is still considered the gold standard for most applications; it becomes vascularized and osseointegrates with surrounding bone, thus minimizing the risk of infection, dislodgement, or break-down. Limitations include added operative time for graft harvest, donor site morbidity, graft resorption, molding challenges, and limited availability, especially in the pediatric population. Numerous alternatives to bone graft have become available to address these limitations; unfortunately, most of these products are expensive, do not osseointegrate, and have unpredictable biologic activity. Understanding the physiologic behavior of autogenous bone graft can help clarify the indications for its use and provide a conceptual framework for achieving the best possible outcome when this alternative is chosen.

The Role of Congenital Muscular Torticollis in the Development of Deformational Plagiocephaly

Background: Numerous risk factors have been associated with the development of deformational plagiocephaly, although the etiology remains unclear. Torticollis and sternocleidomastoid imbalance are implicated, but reporting is variable. The authors sought to determine the incidence of torticollis/sternocleidomastoid imbalance in deformational plagiocephaly. Methods: The authors prospectively evaluated 371 infants with cranial asymmetry between 2002 and 2003. Demographic data and medical history were recorded, and a questionnaire was administered. Cranial asymmetry and head rotation were assessed, and variables were statistically analyzed. Results: Two-hundred two patients were included. Mean age at initial evaluation was 6.1 months (range, 3 to 16 months). Sixty-eight percent (n = 138) were male; 74 percent (n = 149) were flat on the right occiput; 14 percent (n = 28) were from a multiple pregnancy (24 twins, four triplets); 27 percent (n = 54) were premature; and four percent (n = 8) were syndromic. Ninety-three percent (n = 188) of parents did not notice flattening at birth. Ninety-two percent (n = 186) recalled a preferential head position after birth, and in 95 percent of these infants (n = 177 of 186) this improved with age. Only 24 percent (n = 48) of infants had been previously diagnosed or treated for torticollis. Mean cranial asymmetry was 12.5 mm (range, 8 to 25 mm). Ninety-seven percent (n = 195) of infants had head rotational asymmetry of 15 degrees or greater, with more rotation to the flat side. The mean rotational difference was 24 degrees (range 0 to 60; SD 9.8). There was a negative correlation (p = 0.004) between age and head rotational asymmetry (i.e., younger patients exhibited greater asymmetry) and a positive correlation (p = 0.043) between cranial asymmetry and head rotational asymmetry. Conclusions: The incidence of torticollis/sternocleidomastoid imbalance in deformational plagiocephaly is underreported. Because this condition improves rapidly during early infancy, the findings may be subtle and evidenced only by a history of preferential head rotation. The major cause of deformational plagiocephaly is limited head mobility in early infancy secondary to cervical imbalance.

Palatoplasty outcomes in nonsyndromic patients with cleft palate: a 29-year assessment of one surgeon's experience.

The primary objective of cleft palate repair is velopharyngeal competence without fistula. The reported incidence of fistula and velopharyngeal insufficiency (VPI) is variable. Our purpose was to assess the senior surgeons 29-year palatoplasty experience with respect to incidence of fistula and VPI. Our hypotheses were that VPI is related to (1) age at palatoplasty, (2) cleft palate type, and (3) VPI and palatal fistula incidence decrease with the surgeons experience. We reviewed the records of all children with cleft palate treated by the senior author between 1976 and 2004. Cleft palate was categorized according to Veau. Palatoplasty was performed on 449 patients, using a 2-flap technique with muscular retropositioning. The mean age at palatoplasty was 11.6 ± 4.9 months (range, 7.0-46.4 months). The incidence of palatal fistula was 2.9%, and velopharyngeal sufficiency was found in 85.1% of patients. We found a significant association between age at palatoplasty and VPI (P = 0.009, odds ratio, 1.06 [95% confidence interval, 1.02-1.10]). Velopharyngeal insufficiency was also associated with the Veau hierarchy (P = 0.001). Incidence of VPI was independent of surgeon experience (P = 0.2). In conclusion, the incidence of palatal fistula was low. Velopharyngeal insufficiency was associated with increasing age at palatoplasty and with the Veau hierarchy.

Management of parotid hemangioma in 100 children.

Most problematic infantile hemangiomas are successfully treated with pharmacological therapy. However, there are reports that hemangioma of the parotid gland responds poorly to corticosteroid and interferon. To better clarify the management of parotid hemangioma, the authors retrospectively studied the records of 100 consecutive patients, seen between 1975 and 2002. The characteristics of the tumor, including sex ratio, presence at birth, size, side, complications, and involvement of adjacent structures, were recorded. The indications for and response to treatment and the need for surgical procedures were documented and statistically analyzed. The female-to-male ratio was 4.5:1. Forty percent of parotid hemangiomas were on the right side, 36 percent were on the left, and 24 percent were bilateral. Forty-five percent of patients had a premonitory cutaneous lesion at birth. Fifty-nine percent of parotid hemangiomas ulcerated during the early proliferative phase. Eighty-eight percent involved nearby structures (ear, 70 percent; lip, 34 percent; subglottic region, 21 percent; eye, 18 percent; and nose, 3 percent). Seven percent of patients required tracheostomy, and 3 percent had signs of congestive heart failure. Seventy infants received pharmacological treatment. Sixty-seven patients were initially managed with corticosteroids; regression or stabilization was noted in 83 percent of tumors (56 of 67 tumors). Twenty-one patients received interferon: 11 in whom corticosteroid therapy had failed, seven in whom the tumor stabilized with corticosteroid therapy but further regression was needed, and three who had interferon as primary therapy. Ninety-five percent of the lesions that were resistant to corticosteroid subsequently responded to interferon alfa-2a or −2b. The overall response rate to pharmacological therapy was 98 percent. A reconstructive procedure was necessary during the involuting or involuted phase in 66 percent of patients: 92 percent had preauricular excision of redundant skin and/or fibrofatty tissue and 37 percent of patients had auricular revision. In summary, drug therapy was effective in the majority of infants with parotid hemangioma, whether given because the tumor was large, deforming, ulcerated, or involved nearby structures with functional consequences. Infantile hemangioma in the parotid gland responded to pharmacological treatment in a similar manner as hemangioma in other locations.

The management of sagittal synostosis using endoscopic suturectomy and postoperative helmet therapy.

OBJECT Suturectomy as a treatment for craniosynostosis was largely replaced in the late twentieth century by more extensive, but predictable, cranial remodeling procedures. Recent technical innovations, such as using the endoscope combined with postoperative orthotic reshaping, have led to a resurgence of interest in suturectomy as a safer, less invasive method. METHODS A retrospective chart review was performed for all cases of sagittal synostosis treated with endoscopic sagittal suture strip craniectomy and helmet therapy between 2004 and 2008. Data collected included gestational age, genetic evaluations and syndromic status, age at operation, duration of procedure, need for blood transfusions, length of hospital stay, preoperative and postoperative head circumference percentile and cranial index, duration of helmet use, length of follow-up, complications, and revisions. RESULTS Fifty-six patients with isolated sagittal synostosis were treated using endoscopic suturectomy and completed helmet therapy. Mean age at time of procedure was 3.24 months. Mean operative duration was 45.32 minutes. Mean hospital stay was 1.39 days. There were 2 transfusions and no deaths. The mean length of follow-up was 2.34 years. Helmet therapy was instituted for a mean of 7.47 months. Head circumference percentile increased from 61.42% to 89.27% over 2 years of follow-up. Cranial index increased from a preoperative mean of 0.69 to 0.76 over 2 years of follow-up. Reoperations for synostosis included 1 sagittal suture refusion and 2 cases in which other sutures fused. CONCLUSIONS Sagittal synostosis can be safely treated with endoscopic suturectomy and helmet therapy. Improvements in cranial volume and shape are comparable to open procedures and are enduring.

Parameters of Care for Craniosynostosis

Background A multidisciplinary meeting was held from March 4 to 6, 2010, in Atlanta, Georgia, entitled “Craniosynostosis: Developing Parameters for Diagnosis, Treatment, and Management.” The goal of this meeting was to create parameters of care for individuals with craniosynostosis. Methods Fifty-two conference attendees represented a broad range of expertise, including anesthesiology, craniofacial surgery, dentistry, genetics, hand surgery, neurosurgery, nursing, ophthalmology, oral and maxillofacial surgery, orthodontics, otolaryngology, pediatrics, psychology, public health, radiology, and speech-language pathology. These attendees also represented 16 professional societies and peer-reviewed journals. The current state of knowledge related to each discipline was reviewed. Based on areas of expertise, four breakout groups were created to reach a consensus and draft specialty-specific parameters of care based on the literature or, in the absence of literature, broad clinical experience. In an iterative manner, the specialty-specific draft recommendations were presented to all conference attendees. Participants discussed the recommendations in multidisciplinary groups to facilitate exchange and consensus across disciplines. After the conference, a pediatric intensivist and social worker reviewed the recommendations. Results Consensus was reached among the 52 conference attendees and two post hoc reviewers. Longitudinal parameters of care were developed for the diagnosis, treatment, and management of craniosynostosis in each of the 18 specialty areas of care from prenatal evaluation to adulthood. Conclusions To our knowledge, this is the first multidisciplinary effort to develop parameters of care for craniosynostosis. These parameters were designed to help facilitate the development of educational programs for the patient, families, and health-care professionals; stimulate the creation of a national database and registry to promote research, especially in the area of outcome studies; improve credentialing of interdisciplinary craniofacial clinical teams; and improve the availability of health insurance coverage for all individuals with craniosynostosis.

Comparison of a modifiable cranial cup versus repositioning and cervical stretching for the early correction of deformational posterior plagiocephaly.

Background: Deformational occipital flattening is the most common cause of abnormal head shape. Current treatment calls for repositioning and cervical stretching in infants younger than 5 months. The authors assessed the effectiveness of a modifiable cranial cup compared to repositioning and cervical stretching to correct early deformational plagiocephaly. Methods: This nonrandomized, prospective clinical trial used historical controls. The treatment and control groups consisted of infants, younger than 4 months, referred for deformational posterior plagiocephaly. The control children were managed by repositioning and cervical stretching exercises. An adjustable concave cranial cup was used in the treated group. Infants were examined at the initial and final visits by a single examiner. Calvarial asymmetry was measured using a large cranial caliper. Active head rotation and degree of rotational asymmetry were estimated to the nearest 10 degrees. Results: There were no statistically significant differences between the control (n = 23) and treatment groups (n = 24) with respect to gestational age at birth, age at initial visit, initial head rotational asymmetry, initial transcranial difference, final head rotational asymmetry, and age at final evaluation. Mean time between initial and final evaluation was 56.3 days for the treatment group and 61.6 days for the control group. The mean transcranial difference decreased from 11.2 to 3.5 mm in the treatment group, and from 9.0 to 8.0 mm in the control group (p = 0.000). Conclusion: The cranial cup, a modifiable concave resting surface, is significantly more effective than repositioning and physical therapy for correcting early deformational plagiocephaly.