Michael A. Marschall

Immediate unrestricted feeding of infants following cleft lip and palate repair.

Postoperative feeding regimens after cleft lip and palate repair continue to be a controversial issue. This study was designed to test the feasibility of immediate unrestricted feeding after lip and palate closure with attention to operative outcome or complications. A retrospective analysis of two feeding protocols involved 80 infants with both unilateral and bilateral defects. Protocol A utilized tube and syringe feedings, and protocol B utilized unrestricted bottle or breast feedings. There were no instances of lip or palate wound complications in the unrestricted group. We conclude that immediate unrestricted feeding may be instituted safely, thus improving and simplifying postoperative management after cleft lip and/or palate repair.

Long-term effects of rigid fixation on the growing craniomaxillofacial skeleton.

&NA; Fixation of craniomaxillofacial bones with plates and screws is becoming an increasingly popular method of managing patients with maxillofacial fractures, congenital anomalies, and skeletal defects after tumor extirpation. The effects of rigid fixation on growth, however, are not well defined and remain controversial. This experimental work was designed to evaluate the effects of rigid fixation on the growing craniomaxillofacial skeleton. Eight 2‐month‐old beagle dogs were divided into two groups. Cephalometric analysis and computed tomography were obtained preoperatively to establish a baseline of the craniomaxillofacial skeleton. Rigid fixation using plates and screws was applied across the intact coronal and nasofrontal sutures. The contralateral side served as the control. The periosteum was elevated over the contralateral suture and replaced without any surgical intervention. The animals were killed one year after application of rigid fixation, when they had achieved full and mature skeletal growth. The skulls were evaluated both grossly and cephalometrically. There was bony growth over some of the plates, as well as sclerosis of the plated suture lines. Cephalometric analysis demonstrated consistent asymmetry between the plated and nonplated sides, with deviation of the midline toward the plated side in all of the animals. Although further studies are necessary to clarify this issue fully, we conclude from our study that rigid fixation during skeletal development can potentially alter the growth patterns of the craniomaxillofacial skeleton and should be used with caution.

Postoperative Mydriasis After Repair of Orbital Floor Fracture

Mydriasis after operative repair of orbital floor fracture has been attributed to manipulation of the inferior oblique muscle. We treated two patients with mydriasis, one with an isolated mydriatic pupil and the other with a tonic pupil, which followed posterior orbital floor injuries and repair. The posterior location of the fractures suggests that surgical manipulation of or near the ciliary ganglion may account for these phenomena. Patients should be warned before posterior orbital floor repair about possible mydriatic or tonic pupils as a complication.

Early, aggressive management of postoperative oropharyngocutaneous fistulas.

Oropharyngocutaneous fistulas remain a serious and potentially lethal complication. Advantages from surgical repair and the use of musculocutaneous flaps have been demonstrated. Timing of the procedure, however, has not been adequately addressed or emphasized. This report presents our experience with early, aggressive management of postoperative orocutaneous fistulas. Patients were reoperated at an average of 12 days after the initial surgery and underwent exploration, debridement of all devitalized tissues, and closure by reelevation of previously used flaps or with additional flaps. All wounds healed without further problem. We conclude that as long as the patients general condition permits, early, aggressive management of fistulas should be the procedure of choice to reduce hospital stay and costly wound care and to avoid maceration and partial or complete necrosis of flaps and the potential rupture of the carotid artery. Timely radiotherapy can then be delivered, and quality of life can be significantly improved.

Craniofacial approach for the reconstruction of severe facial injuries

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Repair of Right Ventricular Free Wall Defect with a Pedicled Muscle Flap

A unique case of repair of a full-thickness cardiac defect and simultaneous reconstruction of an infected median sternotomy wound is presented. A right ventricular defect, 6 cm in diameter, was closed with a fascia lata graft and reinforced with a rectus abdominis muscle flap. The superior portion of the mediastinum was obliterated with a pectoralis major muscle flap. The patient tolerated the procedure well and remains free of cardiac symptoms seven months postoperatively, with no evidence of residual infection.

Tissue expansion for the reconstruction of burn defects.

Tissue expansion has emerged recently as an alternative reconstructive procedure and has been used for the treatment of a variety of defects. This paper presents our experience with the use of tissue expansion exclusively for the treatment of secondary burn defects. The technique was used in 22 consecutive patients. The technical aspects of the procedure are described. The advantages of tissue expansion, including the superior quality of reconstruction, cost effectiveness, and absence of donor site scar are presented. The disadvantages, including the need for two stages, multiple office visits, its application for relatively small defects, and the objectionable temporary appearance, are discussed. Finally, patient selection, and refinements of the technique and tailoring of the expanded flaps to achieve the best possible reconstructive and esthetic results and limit the possibility of complications are discussed.

The role of tissue expansion in the reconstruction of secondary burn defects

Tissue expansion has become firmly established as an acceptable and useful modality in the treatment of various soft tissue defects. This article relates our experience with this technique for the reconstruction of secondary burn deformities in 26 patients. Details of expander placement and use are discussed, as well as the results and complications in this series. The advantages of this method, including a superior quality reconstruction, limited donor site morbidity, and cost-effectiveness, are discussed. The disadvantages of several operative steps, multiple office visits, and the objectionable appearance during expansion are enumerated. Guidelines for patient selection and technique refinements are also considered to reduce complications and to achieve an optimal functional and aesthetic result.