Jordan P. Steinberg

Reply: Effectiveness of Conservative Therapy and Helmet Therapy for Positional Cranial Deformation

Background: The authors investigated the effectiveness of conservative (repositioning therapy with or without physical therapy) and helmet therapy, and identified factors associated with treatment failure. Methods: A total of 4378 patients evaluated for deformational plagiocephaly and/or deformational brachycephaly were assigned to conservative (repositioning therapy, n = 383; repositioning therapy plus physical therapy, n = 2998) or helmet therapy (n = 997). Patients were followed until complete correction (diagonal difference <5 mm and/or cranial ratio <0.85) or 18 months. Rates of correction were calculated, and independent risk factors for failure were identified by multivariate analysis. Results: Complete correction was achieved in 77.1 percent of conservative treatment patients; 15.8 percent required transition to helmet therapy (n = 534), and 7.1 percent ultimately had incomplete correction. Risk factors for failure included poor compliance (relative risk, 2.40; p = 0.009), advanced age (relative risk, 1.20 to 2.08; p = 0.008), prolonged torticollis (relative risk, 1.12 to 1.74; p = 0.002), developmental delay (relative risk, 1.44; p = 0.042), and severity of the initial cranial ratio (relative risk, 1.41 to 1.64; p = 0.044) and diagonal difference (relative risk, 1.31 to 1.48; p = 0.027). Complete correction was achieved in 94.4 percent of patients treated with helmet therapy as first-line therapy and in 96.1 percent of infants who received helmets after failed conservative therapy (p = 0.375). Risk factors for helmet failure included poor compliance (relative risk, 2.42; p = 0.025) and advanced age (relative risk, 1.13 to 3.08; p = 0.011). Conclusions: Conservative therapy and helmet therapy are effective for positional cranial deformation. Treatment may be guided by patient-specific risk factors. In most infants, delaying helmet therapy for a trial of conservative treatment does not preclude complete correction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Application of finite element modeling to optimize flap design with tissue expansion

Background: Tissue expansion is a widely used technique to create skin flaps for the correction of sizable defects in reconstructive plastic surgery. Major complications following the inset of expanded flaps include breakdown and uncontrolled scarring secondary to excessive tissue tension. Although it is recognized that mechanical forces may significantly impact the success of defect repair with tissue expansion, a mechanical analysis of tissue stresses has not previously been attempted. Such analyses have the potential to optimize flap design preoperatively. Methods: The authors establish computer-aided design as a tool with which to explore stress profiles for two commonly used flap designs, the direct advancement flap and the double back-cut flap. The authors advanced both flaps parallel and perpendicular to the relaxed skin tension lines to quantify the impact of tissue anisotropy on stress distribution profiles. Results: Stress profiles were highly sensitive to flap design and orientation of relaxed skin tension lines, with stress minimized when flaps were advanced perpendicular to relaxed skin tension lines. Maximum stresses in advancement flaps occurred at the distal end of the flap, followed by the base. The double back-cut design increased stress at the lateral edges of the flap. Conclusions: The authors conclude that finite element modeling may be used to effectively predict areas of increased flap tension. Performed preoperatively, such modeling can allow for the optimization of flap design and a potential reduction in complications such as flap dehiscence and hypertrophic scarring.

Ascending necrotizing fasciitis of the face following odontogenic infection.

Necrotizing fasciitis (NF) of the face is a rare but extremely dangerous complication of dental infection associated with a nearly 30% mortality rate. This infection spreads rapidly along the superficial fascial planes of the head and neck and can lead to severe disfigurement. Reports in the literature of cases of NF of the face caused by dental infection are few. We report such a case in a 36-year-old woman and review the current standards of diagnosis and management. The patient initially presented with pain and severe swelling in the left side of her face subsequent to a dental infection. The symptoms had progressed quickly and had not improved with administration of oral antibiotics in the outpatient setting. The patient had no palpable crepitus despite its classic association with NF. The infection also took a rare, ascending route of spread with involvement of the temporalis muscle. Cultures taken during debridement grew Streptococcus anginosus and Bacteroides. Biopsies of involved muscle showed histologic evidence of necrosis. Through early surgical intervention including aggressive debridement, and the adjunctive use of appropriate antibiotics, the patient recovered with minimal loss of facial mass and no skin loss. Although NF of the face is rare, the surgeon must maintain a high index of suspicion with any patient presenting after a dental infection with rapid progression of swelling and a disproportionate amount of pain that is unresponsive to antibiotics.

Mid-term Dental and Nerve-related Complications of Infant Distraction for Robin Sequence

BACKGROUND Mandibular distraction is effective for relieving airway obstruction in Robin sequence; however, mid-term dental and nerve-related complications have not been adequately studied. METHODS Records were reviewed for patients with a single distraction in infancy using internal devices. Follow-up was 5 years or longer. Craniofacial dysmorphic syndromes and those affecting facial nerve function were excluded. Part I involved a review of dental records, whereas Part II involved assessment of inferior alveolar and marginal mandibular nerve function in returning patients with the use of 1,1,1,2-tetrafluoroethane cold stimulation and photography, respectively. RESULTS Eighty-five patients met inclusion criteria. Dental records were complete in 44 patients (median follow-up, 7.3 years; range, 5.4 to 13.2 years). First permanent molar injury was seen in 42 of 88 half-mouths (48 percent); 32 of 42 (76 percent) were restorable. Primary second molar damage and ankylosis were observed in 12 of 88 (14 percent) and one of 88 half-mouths (1 percent), respectively. Mandibular second premolar absence was noted unilaterally in eight of 36 patients (22 percent) and bilaterally in six of 36 patients (17 percent). A mean 1.2 ± 0.95 operative rehabilitations were required. Nerve testing was completed in 20 patients (median follow-up, 8.7 years; range, 5.5 to 13.2 years). Complete absence of cold sensation was noted in one of 40 half-mouths (2.5 percent), whereas lower lip depressor weakness was seen in six of 40 half-mouths (15 percent). CONCLUSIONS Infant distraction is highly successful in averting tracheostomy; however, dental and nerve-related complications remain underreported. Regular follow-up with a pediatric dentist and early recognition of injury is essential. Although inferior alveolar nerve injury appears infrequent (2.5 percent), permanent lower lip depressor weakness is more common than previously reported (15 percent of sides). CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.

Thirty Years of Prenatal Cleft Diagnosis: What Have We Learned?

Prenatal ultrasound diagnosis of cleft lip with or without cleft palate has received little attention in the plastic surgery literature despite its initial description more than 30 years ago. With more families presenting in the prenatal period, it is critical for plastic surgeons to understand the techniques in use today for prenatal cleft diagnosis as well as their associated limitations. Moreover, it is incumbent on surgeons to understand the implications of the diagnosis as well as how to appropriately counsel affected families, including how to handle questions pertaining to termination. A comprehensive review was initiated to educate plastic surgeons with respect to these aims. The following points may be inferred: (1) Based on the rates of associated anomalies in low-risk screened populations, as opposed to the high-risk groups in previous reports, prenatally detected clefts do not appear intrinsically different from historically described cohorts; (2) in the absence of structural anomalies, chromosomal anomalies in prenatally detected cleft patients are rare; (3) ultrasound detection rates are highly variable across studies (10 percent to 90 percent); (4) reporting errors range from 10 percent to 60 percent and largely relate to characterization of the secondary palate; (5) accuracy is improving with the adoption of newer technologies, including three-dimensional ultrasound; and (6) prenatal diagnosis enables counseling and a sense of preparedness for the majority of affected families and only rarely results in termination for isolated clefts.

Evaluating the effects of subclinical, cyclic ischemia-reperfusion injury on wound healing using a novel device in the rabbit ear

ObjectiveThis study aimed to evaluate the effect of cyclic ischemia-reperfusion (IR) injury on wound healing using a novel rabbit ear model. Materials and MethodsA lightweight clamp apparatus was developed for reversible occlusion of the central ear artery. Ventral ear wounds were analyzed postoperatively for epithelialization and granulation as well as gene expression after 3 consecutive days of IR cycling. ResultsBy postoperative day #7, ears showed no gross tissue necrosis, but histologic analysis of wounds confirmed a significant impairment in epithelial and granulation tissue gaps as well as total epithelial and granulation tissue areas (P < 0.001). Quantitative polymerase chain reaction analysis of IR wounds indicated significant up-regulation of heat shock protein-70 and down-regulation of superoxide dismutase 1 relative to sham controls (P < 0.05). ConclusionsA novel rabbit ear model for the induction of subclinical, cyclic IR injury in cutaneous tissue has been developed that will serve as a valuable tool for the testing of new therapeutics.

Functionally stable fixation for an infected mandibular angle fracture associated with third molar extraction during pregnancy.

To the Editor: Removal of impacted and partially erupted third molars remains the most common surgical procedure performed in dentistry. A reported, but seldom considered, complication of third molar extraction is that of mandibular angle fracture. We present and discuss the case of a pregnant patient with an occult, infected fracture of the mandibular angle after the extraction of a lower third molar that was successfully treated through functionally stable plate fixation. An 18-year-old woman who was in the 12th week of gestation was seen by her general dentist for a primary complaint of pain around an impacted tooth number 17 (Fig. 1). The tooth was removed in the general dentist’s office under local anesthesia. On the third day after this procedure, the patient presented to the emergency department with continued pain and progressive swelling of the left side of the face around the extraction site. She complained of an inability to open her mouth widely and to eat since the procedure. Significant edema in the left lower side of the face was appreciated with loss of the left inferior border of the mandible to palpation, V3 hypesthesia, trismus, and drainage from the extraction cavity. Her temperature was noted to be 100.1-F, and the white blood cell count was elevated at 14,600/mm. A computed tomographic (CT) scan with intravenous contrast revealed a significant osseous defect corresponding to the extraction cavity with marked surrounding inflammation. Loculated air and fluid were seen adjacent to the extraction site (Fig. 2A). The patient was admitted to the hospital and started on intravenous clindamycin. Consent was obtained for operative incision and drainage. The submandibular and submasseteric spaces were entered bluntly via a 1.5-cm extraoral incision and then drained and irrigated copiously. A displaced fracture of the mandibular angle was unexpectedly noted. This fracture extended through the thin buccal and lingual cortices of the extraction cavity. A decision was made to perform open reduction and plate fixation of the angle fracture using the Champy technique (Fig. 3) in combination with extraoral drainage. At 6 weeks, the patient was noted to be healing well with no complications. Her relative left-sided V3 hypesthesia was improved and her extraoral incision showed complete healing. At 3 months, the patient was admitted to the labor ward for induction with no residual complications from her mandibular surgery noted at that time. Long-term outpatient follow-up at 11 months indicated excellent clinical healing and complete osseous union on a panoramic radiograph (Fig. 4). Biomechanical weakness of the mandibular angle and its proneness to fracture in the presence of impacted lower third molars is an oft-cited factor in support of ‘‘prophylactic’’ removal of such teeth. The mechanism for the decrease in mandible strength seems to relate to the volume of bone occupied by the impacted teeth. Partially erupted third molars have been shown to occupy more osseous space than fully impacted third molars do and are therefore associated with a higher risk for angle fracture. It is important to note, however, that, although the simple presence of impacted lower third molars increases the risk for mandibular angle fracture, their surgical removal may also cause this as a complication. Although the incidence of this complication in large surgical series has generally been reported to be less than 0.1%, the risk is elevated when a greater trough of bone is drilled to extract the tooth, when preoperative infection is present, when roots are long, when the tooth is distoangulated, and when the surgeon is less experienced. In the patient presented here, only very thin lingual and buccal cortices remained at the extraction site, indicating a large osseous defect. Infection before the third molar removal was also likely, although the extent of any clinical pericoronitis was not documented in this case. Finally, the procedure described here was performed by a general dentist with less experience in the extraction of impacted third molars. FIGURE 2. Preoperative CT scan. A, Soft tissue windows showing enlarged left lower facial contour (asterisk) and inflammatory stranding within the soft tissue adjacent to the left mandibular third molar extraction site. Note the large osseous defect associated with the extraction site. B, Bone windows demonstrating subtle disruption of the lingual cortex of the extraction cavity (arrow). C, Bone windows demonstrating subtle disruption of the buccal cortex (arrow).

Plastic Surgery Review: A Study Guide for the In-Service, Written Board, and Maintenance of Certification Exams

Key Features:Focuses only on what residents, fellows, and practicing plastic surgeons need to know to score well and pass their exams, helping them make efficient use of study timeWritten in a style similar to a cheat sheet, with buzzwords, mnemonics, diagrams, drawings, tables, and bullet pointsEach chapter has been reviewed by experts in plastic surgery, ensuring that the information is current and accurateResidents, fellows, and practicing plastic surgeons will find this book to be an invaluable resource throughout their training and careers.

Management of soft tissue injuries

Soft tissue injuries represent the most common manifestation of craniomaxillofacial trauma seen and evaluated by emergency medical as well as surgical personnel. These soft tissue injuries of the head and neck frequently pose challenging reconstructive problems for the craniomaxillofacial surgeon, and their management entails careful evaluation and planning for optimal treatment. This chapter provides an overview of craniomaxillofacial soft tissue injuries and highlights the major considerations in their management. The reader is provided with a basic framework for analysis of the respective injuries by anatomic region as well as a guiding set of principles for repair. The chapter concludes with special considerations for bite wounds, pediatric soft tissue injuries, and soft tissue injuries associated with craniomaxillofacial fractures to give the reader additional information on these commonly encountered entities.