Michael T. Friel

Outcomes analysis of mandibular distraction osteogenesis for the treatment of pierre robin sequence

Summary: Mandibular distraction osteogenesis is an established technique used to treat infants with Pierre Robin sequence associated with severe airway obstruction. The authors present a 7-year retrospective review of all patients with Pierre Robin sequence treated with mandibular distraction osteogenesis. Recorded variables included improvements in apnea/hypopnea index and postintervention tracheostomy. Multiple preoperative variables were assessed for association with successful mandibular distraction osteogenesis or tracheostomy. Fifty patients were identified for this study. Four patients (8 percent) required tracheostomy after distraction. A Fisher’s exact test demonstrated no statistical association of tracheostomy with prematurity, low birth weight, preoperative intubation, late intervention, genetic syndromes, cardiac abnormalities, pulmonary abnormalities, or gastrostomy tube. The absence of a cleft palate, gastroesophageal reflux disease, and need for Nissen fundoplication were associated with failure of distraction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Complications associated with neonatal mandibular distraction osteogenesis in the treatment of Robin sequence.

BackgroundRobin sequence (RS) is defined as a triad of retrognathia, glossoptosis, and airway obstruction. Although several studies have reported on the efficacy of mandibular distraction, the risks associated with this operation remain unclear. An outcomes analysis focusing on complications is reported here. MethodsA 7-year retrospective review of all patients with RS treated with mandibular distraction was performed. Recorded variables included associated medical comorbidities, improvement in apnea/hypopnea index, need for tracheostomy, repeat distraction, and complications. Complications associated with mandibular distraction were categorized as major, moderate, or minor. They included surgical site infection (SSI), device failure, temporomandibular joint ankylosis, facial nerve injury, hypertrophic scarring, self-extubation premature ossification, and fibrous nonunion. ResultsFifty patients were identified. Four patients (8%) required tracheostomy following distraction, and 3 required repeat distraction. There were 0% major, 12% moderate, and 18% minor complications. Moderate complications were device failure (2%), SSI requiring return to the operating room (2%), and SSI requiring intravenous antibiotics (8%). Minor complications were SSI managed with oral antibiotics (12%), self-extubation (4%), and transient facial nerve palsy (2%). The most common complication was SSI (22%), of which 90.9% were successfully treated by antibiotics alone. There was a 0% rate of temporomandibular joint ankylosis. ConclusionsMandibular distraction is a safe and effective treatment option for infants with RS and severe airway obstruction. The most common complication is infection; the majority of cases are successfully treated with antibiotics alone.

Airway Obstruction and the Unilateral Cleft Lip and Palate Deformity: Contributions by the Bony Septum.

BackgroundPatients with unilateral cleft lip and palate (CLP) deformities commonly develop nasal airway obstruction, necessitating septoplasty at the time of definitive rhinoplasty. We assessed the contribution of the bony septum to airway obstruction using computed tomography (CT) and cone beam CT (CBCT). MethodsA 2-year retrospective review of all subjects with unilateral CLP who underwent CBCT imaging (n = 22) and age-matched controls (n = 9) who underwent CT imaging was conducted. Control CT scans were used to determine the segment of nasal septum comprised almost entirely of bone. The CBCT of the nasal airway was assessed using Dolphin software to determine the contribution of the bony septum to septal deviation and airway obstruction. ResultsThe nasal septum posterior to the midpoint between anterior and posterior nasal spine is comprised of 96% bone. The nasal airway associated with this posterior bony segment was 43.1% (P < 0.001) larger by volume on the non–cleft side in patients with unilateral CLP. The average septal deviation within the posterior bony segment was 5.4 mm, accounting for 74.4% of the maximal deviation within the nasal airway. The average airway stenosis within the posterior bony nasal airway was 0.45 mm (0–2.2 mm). ConclusionsIn patients with unilateral CLP, the bony nasal septum can demonstrate significant deviation and airway stenosis. Surgeons should consider a bony septoplasty in their treatment algorithm in unilateral CLP patients who have reached skeletal maturity.

The Use of Glabrous Skins Grafts in the Treatment of Pediatric Palmar Hand Burns.

BackgroundAn often overlooked, yet useful, technique in the treatment of palmar hand burns is the use of glabrous skin grafting, particularly in dark-skinned individuals. Pediatric palmar burns are a particularly unique subset of burns. The typical split-thickness or full-thickness skin grafts leave a notably different skin texture and pigmentation. It is also known that the psychological aspects of a pediatric burn can be quite burdensome for a child as he or she progresses through childhood and adolescence. For a dark-skinned patient the placement a standard full-thickness skin graft in a nonpigmented palm provides for a constant reminder of a traumatic event. We report a case series of pediatric patients who were managed with glabrous skin grafting from the plantar aspect of the foot. MethodsA retrospective review of palmar skin burns requiring grafting at a single pediatric burn center experience over a 2 and a half year time period was performed. Seventeen patients were identified. Our treatment algorithm for deep partial thickness burns first relies on a combination of operative and nonoperative measures to expedite the demarcation of the burn injury. If the burn is full thickness in nature or if a lack of progression of healing is identified within the first 14 days of injury, then skin grafting is recommended. Our technique for performing the graft is described. ResultsThe average age at time of surgery was 2.05 years (6 months to 6.8 years). Fourteen of the 17 patients had darker skin types (Fitzpatrick Type III–VI) and identified themselves as either Hispanic or African American. The average size of the area requiring skin graft after debridement was 0.94% total body surface area (0.5%–2.0%). Of the patients that were not lost to follow-up, 1 patient required additional grafting after developing a finger contracture for splint noncompliance. Aesthetically, the wounds went on to heal with an excellent pigment match and an inconspicuous donor site. ConclusionsIn the management of deep-partial or full-thickness palmar skin burns in the pediatric population that require grafting, the use of plantar glabrous skin grafts offers a reliable option for coverage. The aesthetic and functional results are improved over standard techniques.

Low-cost, high-definition video documentation of corrective cleft surgeries using a fixed laparoscope

Critical to the treatment of children affected with cleft lip and palate is the training future surgeons to perform corrective cleft surgeries. Current educational resources include: textbook, intraoperative video, and computer animations. High quality video footage can be particularly useful as detailed information of surgical technique can be readily studied in ways that would be difficult to convey through a textbook. Intraoperative video recordings are traditionally obtained by professional videographers. These professionals usually produce high quality video footage but at a significant monetary cost. In addition, there are challenges to surgical video recording when the camera is placed far from the operative field, as head, hands, and surgical instruments can frequently obstruct the camera’s view. Overhead lights with video cameras suffer from these same limitations. In addition, recording intraoral cleft procedures such as soft palate repair and pharyngeal flap through the above methods can be limited as detailed images must be captured from the depth of the mouth. Currently, there is increasing popularity of high definition (HD) video which provides a sharper and more realistic capture of the recorded event. Professional HD cameras, however, are costly and intraoperative video recordings using these cameras suffer the same listed limitations. We present a cost-effective approach for high definition video documentation of corrective cleft surgery using readily available operating room technology. An 1188 HD 3Chip Camera was attached to a sterile 10-mm, 0-degree laparoscope (Stryker Endoscopy, San Jose, CA) for cleft lip repair and rhinoplasty repair and to a sterile 30-degree laparoscope for cleft palate and pharyngeal flap reconstruction. The camera was then fixed, and held in place using a Strong Arm clamp (Unique Surgical, Pittsboro, IN)

Office-Based Post-Axial Polydactyly Excision in Neonates, Infants, and Children.

Background: In adult hand surgery literature, there are multiple publications highlighting the successful use of office-based hand surgery in the treatment of hand conditions. There are few instances of office-based hand surgery in the pediatric population present in the literature. Polydactyly of the hand is one of the most common congenital hand malformations. The authors present a case series of successfully performed in-office surgical excision of the type B postaxial polydactylous digit in infants and children. The added health care utilization improvements by performing this in the office, as well as lack of exposure to general anesthesia are reviewed. Methods: A retrospective review of the patients treated was completed and the technique of in-office excision documented. Results: Over a 15 month period, a total of twenty-six children were treated in the office for postaxial polydactyly. The average age of the child at the time of excision was 3.3 months old, with a median of 1.4 months with a range of 9 days–4.2 years. There were no postprocedure complications in function or sensation. Conclusions: The authors report a case series of successful surgical excision of type B postaxial polydactyly in newborns, infants, and children in an office setting with the use of lidocaine with epinephrine. This technique is a cost-conscious approach to the condition without the need for general anesthesia. This demonstrates excellent results with improved safety without sacrificing quality. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Molecular Mechanism of the “Babysitter” Procedure for Nerve Regeneration and Muscle Preservation in Peripheral Nerve Repair in a Rat Model

Objective To investigate the molecular mechanism of nerve “babysitter” for nerve regeneration and muscle preservation in peripheral nerve repair. Methods Eighty rats were equalized into 4 groups: peroneal nerve transected, group A received no treatment; group B underwent end-to-end repair; group C underwent end-to-side “babysitter” with donor epineurial window; group D underwent end-to-side “babysitter” with 40% donor neurectomy. During second-stage procedure, end-to-end neurorrhaphies were executed in groups A, C, and D. Expression of Insulin-like growth factor (IGF)-1 in spinal cord and IGF-1, TNF-like weak inducer of apoptosis (TWEAK), and Fn14 in anterior tibial muscles were evaluated by histopathology at 4-, 8-, 12-, and 24-week timepoints postoperatively. Results At 4 weeks, group D expressed comparable IGF-1 with group B, and greater value than groups A and C in spinal cord. By 24 weeks, groups B and D showed higher values than groups A and C. Insulin-like growth factor 1 in muscles were greater in groups C and D than in groups A and B at 4 weeks, and comparable in all groups at 24 weeks. At 4 weeks, immunoreactive scores of TWEAK were 9.00 ± 0, 3.00 ± 0, 6.75 ± 0.75, and 6.75 ± 0.75, respectively. No differences were noticed in all groups by 24 weeks. At 4 weeks, Fn14 were similar in groups A, C, and D, but lower in group B. Group D showed comparable Fn14 with groups B and C, but lower value than group A at 24 weeks. Conclusions End-to-side nerve “babysitter” in peripheral nerve could promote fiber regeneration and muscle preservation by regulating expression of IGF-1 and TWEAK-Fn14. End-to-side “babysitter” with partial donor neurectomy could achieve comparable effects with end-to-end repair.

Resection of Nasal Glial Heterotopia Using a Nasal Subunit Approach

Background: In the subunit principle of nasal reconstruction, the valleys and low ridges of the nose are designated as topographic subunits. Surgical scars can be located at the borders of subunits to hide their appearance. Case Report: A 30-month-old female presented with an obstructing nasal glial heterotopia (nasal glioma). Using the nasal subunit approach, the mass was exposed using an incision along the subunit borders of the nose. The nasal glioma was completely resected, and the internal nasal valve and the deformed lower lateral cartilages were reconstructed through the subunit approach access incision. The final scar was placed along the subunit borders of the nose. At 6-month follow-up, the patient demonstrated no airway obstruction, adequate nasal contour, and an esthetic nasal scar. Conclusion: The subunit approach for a large, obstructing nasal glial heterotopia allows direct exposure for tumor resection, framework reconstruction, placement of the incision in an esthetic location, and excision of the expanded skin for recontouring of the skin envelope.

Iatrogenic Intradiploic Epidermoid Cyst Following Strip Craniectomy for Sagittal Craniosynostosis

Introduction: The increased incidence and success of strip craniectomy with postoperative helmet therapy in the treatment of sagittal craniosynostosis has been documented by multiple centers throughout the country and world. The authors report a child with a postoperative implantation intradiploic epidermoid cyst following a strip craniectomy, a complication, that to our knowledge, has not been reported. Methods: This clinical report involves a 3-year-old boy with a scaphocephalic appearance who was transferred to our center following an interstate adoption. He underwent a strip craniectomy with helmet therapy in infancy. On presentation to our facility the chief complaint was a scaphocephalic appearance. Preop computed tomography scans showed areas of bone gaps along the sagittal suture. Results: The child was brought to the operating room for a mid-vault expansion. At surgery, a large intradiploic epidermoid cyst was noted on the posterior aspect of the area of the sagittal suture, immediately beneath to posterior incision for the strip craniectomy. The cyst extended through the inner table of the skull and necessitated split cranial grafts to aid in the reconstruction. Conclusion: The authors present a patient with an iatrogenic intradiploic epidermoid cyst of the posterior skull following strip craniectomy, which has not been previously been described in association with strip craniectomy. This patient underlies the importance of a strong working relationship between craniofacial surgery and neurosurgery.

Book Review: “Comprehensive Cleft Care Family Edition”

T here is a multitude of textbooks for surgeons and those who care for cleftaffected children. This book is a first of its kind, with the focus on educating the family of a cleft-affected child. As the editors highlight, families play an equally important role as the medical team in ensuring the greatest possible quality of life, and it is refreshing to read a work dedicated to educating the family of cleft-affected children. The authors include international experts in cleft care and parents of cleft-affected children. The book is divided into 6 sections, totaling 30 chapters and 325 pages. Its size allows for portability, easily fitting in a briefcase or woman’s purse. The first section of the book is dedicated to the Fundamentals of Cleft Care. In these 8 chapters, the makeup of cleft teams, prenatal diagnosis, genetic counseling, and the role of the pediatrician are presented in a manner that is straightforward. Two chapters in this segment that would typically fall out of the realm of a cleft textbook are those focusing on advocacy in cleft care and that of adopting a cleft-affected child. This information simply has not been included in previous cleft textbooks and resources. There is an excellent chapter included on nursing care spanning