Krishna G. Patel

Melanotic Neuroectodermal Tumor of Infancy: A Systematic Review.

Melanotic neuroectodermal tumor of infancy (MNTI) is a rare tumor, usually diagnosed within the first year of age, with a predilection for the maxilla. Although the tumor is usually benign, its rapidly growing nature and ability to cause major deformities in surrounding structures necessitate early diagnosis and intervention. It is important that medical and dental specialists are prepared to make the diagnosis and proceed with appropriate intervention. The authors performed a systematic review of the 472 reported cases from 1918 through 2013 and provided a comprehensive update on this rare entity that can have devastating effects on young patients. This investigation uncovered age at diagnosis as an important prognostic indicator, because younger age correlated with a higher recurrence rate. The authors also present a case report of a 5-month-old girl diagnosed with MNTI and review her clinical presentation and imaging and histopathologic findings.

Evidence-Based Management of Vascular Malformations

Vascular malformations of the head and neck are complex lesions that are notoriously difficult to manage. Treatment of these lesions often requires a multispecialty and multimodal approach. In the modern era of evidence-based medicine, it has become imperative for clinicians to incorporate evidence-based treatment algorithms into their everyday practices. With general widespread inundation of the literature with levels IV and V clinical evidence, however, it is often difficult to draw meaningful conclusions that can be practically applied to the clinical question at hand. When asking how best to manage the most common vascular malformations, we are faced with this large volume of lower level studies conducted in drastically different ways without consistency in outcomes reporting, thus making direct comparison nearly impossible. Furthermore, much of the evidence shows mixed results, adding to confusion over what the optimal evidence-based treatment approaches truly are. In attempt to derive consensus from available literature discussing the management of vascular malformations, we reviewed the current literature detailing modern-day treatment approaches for lymphatic malformations, venous malformations, and arteriovenous malformations of the head and neck.

Update on primary cleft lip rhinoplasty.

Purpose of reviewThe optimal timing and techniques utilized to address the nasal deformity of the cleft lip continue to raise challenges and debate for the surgical community. There has been a shift in the paradigm addressing the nasal deformity to a more proactive approach. The goal of this article is to provide an update of the latest techniques for primary cleft rhinoplasty. Recent findingsA medical literature search was performed specifically targeting primary cleft rhinoplasty in order to review the current strategies implemented, including presurgical orthopedics, surgical incisions, reconstruction, and suture techniques. SummaryToday primary rhinoplasty is performed widely with many investigators reporting improved esthetic and functional outcomes. Both endonasal and external rhinoplasty approaches have been described for the unilateral and bilateral deformity. Goals include closure of the nasal floor and sill, symmetry of the alar base, and symmetry of the lower lateral cartilages with appropriate projection of the dome. Recent literature supports that rhinoplasty performed at the time of the primary cleft lip closure may reduce the frequency and magnitude of required intermediate and definitive rhinoplasty operations.

Characterization of Facial Paresis in Hemifacial Microsomia

Objective To provide an overview of the incidence, characteristics, and proposed etiologic mechanisms of facial paresis in patients with manifestations of hemifacial microsomia. Data Sources PubMed database for English-language studies with no date restrictions. Review Methods A comprehensive literature review was performed identifying all studies that discussed incidence, characterization, or etiologic mechanisms for facial paresis in hemifacial microsomia/oculo-auriculo-vertebral spectrum. Conclusions This review supports that the prevalence of facial weakness in the spectrum of hemifacial microsomia/oculo-auriculo-vertebral spectrum ranges from 10% to 45%. Most of these patients have involvement of all facial nerve branches or lower branches only. The most commonly involved single nerve branch has yet to be described. The 2 most common associated anomalies involve the mandible and auricle. Dysmorphogeneisis of the temporal bone and its effects on the facial nerve are most likely implicated in the cause of facial weakness. Implications for Practice There is a wide variety of facial nerve presentations seen within oculo-auriculo-vertebral spectrum for which the exact etiologic mechanism is unclear. Through a better understanding of the presentation and etiology surrounding facial paresis in hemifacial microsomia, improved treatment options may be offered in the management of the facial weakness.

Proper Care of Early Wounds to Optimize Healing and Prevent Complications

Proper wound care has broad applications for all clinicians. Much of the future direction for enhancing wound repair focuses on key cells and growth factors, which is why possessing a strong understanding of the basic physiology of wound healing is imperative. This article first provides a thorough review of the phases of wound healing followed by a discussion on the latest wound management strategies. Wound conditions and surgical techniques are important components for optimizing wound healing and preventing complications. Special consideration has been given to the unique settings of contaminated wounds, open wounds, or avulsed tissue.

Solid Implants in Facial Plastic Surgery: Potential Complications and How to Prevent Them.

Allogenic implants are an effective alternative to autologous grafts in the reconstruction of facial defects. These implants are used to reconstruct a variety of bony and soft-tissue defects, including the frontal and temporal regions; internal orbit; infraorbital rim; malar, paranasal, and nasal regions; mandible; and chin. In comparison to their autologous counterparts, alloplastic materials are more readily available, lack donor-site morbidity, decrease surgical time and cost, and still have relatively good postoperative tissue tolerance. However, these implants are not without their own spectrum of complications. Common solid implant materials include silicone, GoreTex (expanded polytetrafluorethylene; W. L. Gore & Associates Inc., Flagstaff, AZ), MedPor (high-density porous polyethylene; Porex Industries, Fairburn, GA), and Mersilene mesh (nonresorbable polyester fiber; Ethicon, Somerville, NJ). Each of these materials poses certain complication risks based on their surface contour (smooth vs. porous), pliability, and reactivity with surrounding tissue. In addition, certain implant locations within the head and neck are at risk for different postoperative complications. Although there are no evidence-based guidelines for implant reconstruction to help avoid common complications, there are several principles and techniques that are commonly employed by surgeons to help reduce complication rates. These include careful patient selection, proper choice of operative procedure, infection control practices (including pre/intraoperative systemic antibiotics, meticulous aseptic technique, impregnation/soaking of implant in antibiotic, irrigation of implant pocket with antibiotic, careful closure of tissue layers, and postoperative oral antibiotics), preoperative implant shaping, choice of surgical approach, and intraoperative surgical techniques. Larger, controlled trials are needed to confirm the efficacy of the aforementioned techniques in the reduction of postoperative complications.

Esophageal Adenocarcinoma and Urothelial Carcinoma Orbital Metastases Masquerading as Infection

Abstract Orbital metastases can masquerade as other orbital processes. We present two cases of orbital metastases, the first being the first reported adenocarcinoma of the esophagus presenting as an orbital metastasis prior to the primary being known, and the other as the first urothelial carcinoma to present as orbital cellulitis. The first patient presented with left upper eyelid pain. CT scan identified a superolateral subperiosteal fluid collection without concomitant sinus disease, which was drained in the operating room. Two weeks later repeat CT scan showed recurrent orbital subperiosteal fluid. It was drained and a biopsy showed necrotic adenocarcinoma. The second case presented with a painless right proptosis, decreased vision, and globally decreased ocular motility 3 days after bladder resection for urothelial carcinoma. CT scan demonstrated pan sinusitis with a soft tissue mass in the apex of the right orbit with extension through the superior orbital fissure. After no improvement on antibiotics endoscopic drainage was performed. Pathology revealed metastatic urothelial carcinoma within the orbital fat.

Evidence-Based Medicine in the Treatment of Infantile Hemangiomas.

Over the past decade, the treatment of infantile hemangiomas has undergone dramatic breakthroughs. This review critically evaluates the latest literature that supports the myriad treatment options for infantile hemangiomas. It chronicles the fading role of steroid therapy and evolution of propranolol use as the major treatment modality. Although propranolol is helping this disease become more of a medical disease and less of a surgical dilemma, the report also reveals a continued search to find nonsystemic treatment options. In summary, this is an evidence-based medicine review for the treatment of infantile hemangiomas.

CT Measured Normative Cartilage Growth in Children Requiring Costochondral Grafting

Objective Careful operative timing is required for children undergoing microtia repair using autologous costochondral grafting. This operation is performed as early as age 6 in efforts to treat children before school matriculation while allowing for sufficient rib growth. There remains a paucity of data regarding cartilaginous growth of the ribs and synchondrosis routinely harvested during microtia repair. This study employs CT imaging to generate normative costochondral growth characteristics in children. Study Design A population-based study was performed. Setting Tertiary care children’s hospital. Subjects and Methods Chest CTs were reviewed in 360 children ages 3 to 20 years. Measurements included: length of ribs 6, 7, and 8 and the height and width of the synchondrosis between ribs 6 and 7. Growth charts are presented for gender and laterality. Results At age 6: ribs 6, 7, and 8 measure 5.96 ± 0.69, 7.79 ± 0.84, and 6.33 ± 1.01 cm, respectively. In adulthood the mean length of ribs 6, 7, and 8 are 8.29 ± 1.00, 11.10 ± 1.19, and 8.95 ± 1.99 cm, respectively. The vertical height of the synchondrosis at years 6 and 20 are 2.42 ± 0.39 and 3.59 ± 0.53 cm, respectively. Ribs 6, 7, and 8 as well as the synchondrosis grow in a nearly linear fashion. Conclusions Cartilaginous growth of ribs 6 to 8 during early childhood is nearly linear. Synchondrosis height approaches adult auricle width at 8 years. Rib size is consistently larger in males and on the left side. These data are useful for the pediatric otolaryngologist and facial plastics and reconstructive surgeon performing microtia surgery.

Use of Safety Measures, Including the Modified World Health Organization Surgical Safety Checklist, During International Outreach Cleft Missions

International surgical outreach missions have become increasingly common within the surgery community. Untoward events in this setting, although rare, can be prevented by careful planning and the use of quality assurance guidelines designed to prevent such complications. The surgical safety checklist is widely accepted in most developed health care practices, but is used variably by international mission groups. This article outlines the quality assurance guidelines used, including a modified World Health Organization safety checklist and illustrated patient instruction forms, to provide a standardized means of delivering sound surgical care in the setting of short-term international cleft lip and/or palate missions.