Kyle J. Chepla

Clinical outcomes following supraorbital foraminotomy for treatment of frontal migraine headache.

Background: Although 92 percent of patients who undergo surgical decompression of the supraorbital nerve for treatment of frontal migraine headaches through resection of the glabellar muscle group achieve at least 50 percent improvement, only two-thirds demonstrate complete resolution of symptoms. The authors investigated the role of additional decompression methods by comparing surgery outcomes between patients who underwent glabellar myectomy alone and patients who also underwent supraorbital foraminotomy. Methods: Outcome measures including migraine headache frequency, severity, and duration; Migraine Headache Index score; and forehead pain were reviewed retrospectively and analyzed statistically for 43 age-matched control patients who underwent glabellar myectomy for release of the supraorbital nerve and 43 patients who underwent glabellar myectomy with supraorbital foraminotomy from 2002 to 2010. Results: The myectomy group statistically matched the myectomy with foraminotomy group for age, number of surgical sites, and preoperative headache characteristics (p > 0.05). For the myectomy and myectomy with foraminotomy groups, postoperative migraine frequency was 7.8 per month versus 4.1 per month, severity was 5.6 versus 4.4, Migraine Headache Index score was 26.5 versus 11.1, and persistent forehead pain was 48.8 percent versus 25.6 percent, respectively. These differences were all statistically significant (p < 0.05). Duration of headache was unchanged (p = 0.17). Conclusions: The supraorbital foramen is a potential site of supraorbital nerve compression that can trigger frontal migraine headache. If it is present, the authors strongly recommend foraminotomy to ensure complete release of the supraorbital nerve to optimize outcomes. Their results also support consideration of release of any fibrous bands across the supraorbital notch. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

An anatomical study of the lesser occipital nerve and its potential compression points: implications for surgical treatment of migraine headaches.

Background: This study maps the course of the lesser occipital nerve and its potential compression sites in the posterior scalp. Methods: Twenty sides of 10 fresh cadaveric heads were dissected. Two fixed anatomical landmarks were used: the y axis was the vertical midline in the posterior scalp through the midline of the cervical spine. The x axis was a horizontal line drawn between the most anterosuperior points of the external auditory meatus. A topographic map of the lesser occipital nerve and its potential compression points was created. Results: The lesser occipital nerve emerged from the posterior border of the sternocleidomastoid muscle at an average of 6.4 ± 1.4 cm lateral to the y axis and 7.5 ± 0.9 cm caudal to the x axis. Branches of the occipital artery were found to interact with the lesser occipital nerve in 11 of the 20 hemiheads (55 percent). The mean location of the artery-nerve interaction was 5.1 ± 0.9 cm lateral to the y axis and 2 ± 1.45 cm caudal to the x axis. Two patterns of artery-nerve interaction were seen: a single site of artery crossing over the nerve in nine of 20 hemiheads (45 percent) and a helical intertwining relationship in two of 20 of hemiheads (10 percent). A fascial band was identified to compress the lesser occipital nerve in four of 20 hemiheads (20 percent). Conclusion: This anatomical study traced the lesser occipital nerve as it courses through the posterior scalp and mapped its potential decompression sites.

Evidence-based medicine: cleft palate.

Learning Objectives: After reading this article, the participant should be able to: 1. Describe recent changes in treatment of cleft palate. 2. Compare the efficacy of different surgical treatments. 3. Assess their own knowledge of cleft palate repair. 4. Determine where further individual in-depth study and development are warranted. Summary: The Maintenance of Certification in Plastic Surgery series is designed to ensure professional development and measure continued competency within a specialty or subspecialty. The present article provides an evaluation of the interval studies regarding the management of cleft palate with a specific focus on craniofacial growth, speech outcomes, and obstructive sleep apnea since the last Maintenance of Certification in Plastic Surgery article on the subject published in 2010. This purpose of this article is to update plastic and craniomaxillofacial surgeons on recent changes in treatment of cleft palate, provide a means for accurate self-assessment, and guide further individual in-depth study and development.

Maxillary artery pseudoaneurysm after le fort i osteotomy: Treatment using transcatheter arterial embolization

Life-threatening hemorrhage is a rare complication after Le Fort I osteotomy. However, owing to the gravity of this complication, all surgeons who perform Le Fort I osteotomy should be aware of the potential for this complication and options for its resolution. The following case report describes an episode of subacute, life-threatening bleeding, after a Le Fort I osteotomy for the treatment of midface hypoplasia. Emergent angiographic evaluation demonstrated an internal maxillary artery pseudoaneurysm with fistulous drainage via the cavernous sinus. This was treated by arterial embolization in which the pseudoaneurysm was packed with microcoils. This report reaffirms the importance of maintaining a high clinical suspicion for pseudoaneurysm as a possible etiology of delayed postoperative bleeding in patients after craniomaxillofacial surgery.

Use of intraoral miniplates to control postoperative occlusion after high condylectomy for the treatment of condylar hyperplasia

AbstractMandibular condylar hyperplasia is a rare disorder, characterized by unilateral mandibular overgrowth with overeruption of the dentition on the affected side. Although the etiology is unclear, multiple surgical techniques have been described to correct the associated mandibular bone, occlusal, and soft tissue deformities. Often a condylectomy, to arrest mandibular growth, is combined with various orthognathic procedures to restore occlusion and facial harmony. Here we report our technique of isolated high condylectomy with simultaneous intraoral placement of maxillary and mandibular miniplates. Each plate has an intraoral extension that allows our orthodontists to develop vertical force vectors to intrude the maxillary and mandibular molar segments. Using this combined surgical and orthodontic technique, we were able to postoperatively control the occlusal cant, restore the dental midline, improve facial aesthetics, and resolve the patient’s contralateral temporomandibular joint dysfunction without concomitant orthognathic surgery. As a result of our findings, we are currently using, and would recommend, this technique for patients requiring surgical-orthodontic intervention for other conditions.

Primary correction of nasal asymmetry in patients with unilateral coronal synostosis.

Background: The optimal strategy for correction of significant nasal angulation in patients with unilateral coronal synostosis remains controversial. The authors report a novel technique for correction of significant nasal angulation in these patients, in which dissection of the nasal bones is limited to the site of the osteotomy, maintaining continuity with the soft-tissue envelope and the nasal cartilages. Methods: Seven successive patients with unilateral coronal synostosis and nasal deviation of greater than 6 degrees by computed tomographic analysis were evaluated. Three patients were treated using ex vivo repositioning in which the nasal bones were freed completely from the surrounding soft-tissue envelope, and four patients were treated with in vivo repositioning by performing a subperiosteal dissection only where required for lateral nasal osteotomies without separating the nasal bones from the cartilaginous framework of the nose. Nasal angulation was calculated using clinical photographs and three-dimensional computed tomography preoperatively and at 1-year follow-up. Results: Mean nasal angulation was reduced from 9.5 degrees to 2.5 degrees by computed tomographic analysis (p < 0.001) and from 6.9 degrees to 1.9 degrees by photographic analysis (p < 0.01) 1 year postoperatively. There was no significant difference in outcome between patients who underwent ex vivo or in vivo repositioning. Conclusions: Primary surgical correction of significant nasal angulation in patients with unilateral coronal synostosis can be achieved with less dissection and disruption of soft-tissue relationships than previously described without compromise in efficacy. The authors’ technique for osteotomy of the nasal bones preserves nasal architecture, minimizes periosteal dissection, and may theoretically reduce the potential for growth disruption. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Interstitial pneumonitis after betadine aspiration.

Disinfection of the face and mucosa lined surfaces of the nose and mouth using a povidone-iodine (PI) or Betadine solution is common practice among head and neck surgeons. Povidone-iodine, which is a highly effective broad-spectrum antibiotic effective against bacteria, viruses, fungi, and protozoa, decreases the risk of postoperative surgical wound infection. We report a case of PI aspiration causing an acute chemical pneumonitis after preoperative disinfection of the oral cavity and nasopharynx in preparation for cleft palate repair. As a result of the inflammatory response, the patient required positive pressure mechanical ventilation and a prolonged stay in the pediatric intensive care unit. The patient was safely extubated on hospital day 7 and discharged on hospital day 10 without any long-term sequelae on follow-up. We also review the 3 other reported cases of PI aspiration pneumonitis. Based on our case report and literature review, we conclude that PI aspiration is associated with a high rate of morbidity; however, this should not preclude the use of PI before surgery, given its effectiveness as an oral disinfectant and the exceedingly low incidence of aspiration.

Discussion: How "successful" is calvarial reconstruction using frozen autologous bone?

D craniectomy creates a large bony defect that is often not amenable to immediate repair because of underlying cerebral edema. Definitive management of these defects requires stable coverage of the underlying brain tissue and support of the overlying soft-tissue envelope to prevent parenchymal injury, restore calvarial contour, and normalize cerebrospinal fluid dynamics. Although many autologous and alloplastic materials have been used, there have been no formal randomized controlled studies to date that support one material or technique. This important retrospective analysis of 156 patients demonstrates a high failure rate (29 percent) when frozen autologous calvarial bone was used for craniectomy reconstruction on long-term follow-up and excludes three immediate postoperative patient deaths (1 percent) attributable to cerebral edema. The authors have defined simple, reproducible criteria for definitive success (absence of infection and no evidence of bone resorption on clinical or radiographic examination at 6 months), probable success (absence of infection and no evidence of absorption on clinical examination at 6 months), and failure (infection requiring explanation or significant resorption on clinical or radiographic examination). They have also expanded the definition of resorption to include loss of bicortical integrity on radiographic examination as a criterion for failure. Although they do not address whether this is of any clinical significance, it may be useful for future studies. Resorption of the nonvascularized autologous bone was the most common complication (21 percent) and is expected, given the large size of what should only be considered an architectural guide for osteoconduction and creeping substitution. The size and functionality of these defects are unique, and in very few other clinical situations would such a large piece of avascular bone be used. Infection (8 percent) was the second most common cause of failure and again can be explained by the large amount of avascular implanted material. Of importance, the incidence of infection did not correlate with time to reconstruction, suggesting that it should be performed as soon as possible. One drawback to this study is that, of the reported 71 percent success rate, 50 percent were only “probable” successes, with no evidence of resorption on clinical analysis without corresponding radiographic evaluation. Radiographs of these patients would be useful to ascertain how effective clinical examination is compared with computed tomography and would likely further increase the reported failure rate. The authors also fail to discuss outcomes of, and whether there were additional complications in, the 18 patients with either clinically or radiographically significant resorption managed conservatively compared with patients who underwent secondary titanium mesh implantation. The question that remains is how best to handle such defects. We have addressed this question in a recent review of biomaterials for craniofacial reconstruction in the pediatric population.1 Reconstruction of calvarial defects in the pediatric population is a more complex problem because of the added dimension of calvarial growth, for which the majority of reconstructive options that do not incorporate into bone are inadequate. The population treated by the present authors has mature calvaria, for which nonautologous materials are more acceptable if they provide protection. The first question one must address is whether frozen native bone will fare better than alternaFrom the Department of Plastic and Reconstructive Surgery, University Hospital–Case Medical Center, and the Division of Pediatric Plastic Surgery. Northwestern University Feinberg School of Medicine, Lurie Children’s Hospital. Received for publication June 13, 2012; accepted June 18, 2012. Copyright ©2012 by the American Society of Plastic Surgeons