Mirko S. Gilardino

The Effectiveness of Mandibular Distraction in Improving Airway Obstruction in the Pediatric Population

Background: Distraction osteogenesis is an effective technique for elongating the deficient mandible. The authors specifically evaluated its effectiveness in the treatment of airway obstruction in pediatric patients with mandibular hypoplasia. Method: A comprehensive literature review of the National Library of Medicine (PubMed) database was performed. English-language studies involving isolated distraction of the pediatric mandible (younger than 18 years) with descriptive reporting of airway changes were included. Extracted data included demographics, initial diagnosis, distractor type, distraction protocol, predistraction and postdistraction airway status, and complications. Results: Seventy-four articles met the inclusion criteria, resulting in 711 patients with craniofacial abnormalities who underwent mandibular distraction osteogenesis. Mean age at the time of distraction was 18.1 months. The most common diagnoses were isolated Pierre Robin sequence (52.9 percent), syndromic Pierre Robin sequence (7 percent), and Treacher Collins syndrome (6.8 percent). Mandibular distraction osteogenesis successfully treated airway obstruction in 89.3 percent of cases. Success was defined as either decannulation of tracheostomy, avoidance of tracheostomy or continuous positive airway pressure, or alleviation or significant improvement of obstructive sleep apnea symptoms. One hundred seventy-one (84.2 percent) of the 203 tracheostomy-dependent patients were successfully decannulated. Among the 181 patients with obstructive sleep apnea, mandibular distraction osteogenesis successfully allowed for either complete resolution or significant improvement of symptoms in 95.6 percent. A 23.8 percent overall complication rate was noted. The mean follow-up time was 28.7 months. Conclusion: In addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients.

Long-term follow-up experience with carbonated calcium phosphate cement (Norian) for cranioplasty in children and adults.

Background: Despite the growing popularity of calcium-based bone cements as a cranioplasty material, the long-term success and complication rates of these materials remain largely controversial. The authors reviewed their extended experience with Norian, a carbonated calcium phosphate bone cement, for cranioplasty. Methods: A retrospective chart review of all patients who underwent cranioplasty using Norian over the past 9 years was conducted. Patients with less than 1 year of follow-up were excluded. Results: Forty-six patients were studied. Follow-up averaged 43.9 months (range, 12.1 to 109.8 months). The overall complication rate was 26 percent, and included infection (n = 9), seroma (n = 1), or a chronically draining sinus (n = 2). Average time to onset of a complication was 20.2 months (range, 2.3 to 89.2 months). Two of nine infections resolved with oral antibiotics; the remaining complications required surgical intervention for definitive treatment. Factors associated with a statistically increased risk of complications were amounts of Norian used (p < 0.01) and onlay application with a high probability for bacterial contamination (p = 0.001), whereas reconstruction of full-thickness cranial defects larger than 25 cm2 trended toward worse outcomes (p > 0.05). Conclusions: Norian is well suited for cranioplasty when used in moderate amounts for onlay applications, as evidenced by acceptable complication rates and contouring ability in this setting. Its use in large amounts as an onlay, inlay full-thickness cranial reconstruction of large defects or areas with potential bacterial contamination should be avoided. Complications or construct failure may occur months or even years after implantation, even under ideal circumstances.

Level of evidence in plastic surgery research.

Background: There has been a recent shift toward evidence-based medicine in the medical and surgical literature. The objective of this study was to determine the level of evidence of published plastic surgery articles. Methods: A review of the following four major plastic surgery journal publications was performed to determine the level of evidence utilized in the published studies: Plastic and Reconstructive Surgery (PRS), Annals of Plastic Surgery (Annals), Journal of Plastic, Reconstructive, and Aesthetic Surgery (JPRAS), and American Journal of Aesthetic Surgery (Aesthetic) from January 1 to December 31, 2007. Results: Of the 1759 articles reviewed, 726 (41 percent) were included (animal studies, cadaver studies, basic science studies, review articles, instructional course lectures, and correspondence were excluded). The articles were ranked according to their level [level I (highest evidence, e.g., randomized-controlled trials) to level IV (lowest evidence, e.g., case reports)]. The average level of evidence in each journal was as follows: PRS, 3.05; Aesthetic, 3.11; JPRAS, 3.35; and Annals, 3.31. The evidence differed significantly between journals (p < 0.05), except when JPRAS was compared with the Aesthetic journal. Only 2.2 percent of articles were level I evidence. Conclusions: The average level of evidence in four major plastic surgery journals was 3.2 (level III). In order for the plastic surgery profession to become a participant in higher-level evidence-based medicine, greater emphasis must be placed on prospective randomized blinded trials.

Acellular dermal matrix in cleft palate repair: an evidence-based review.

Background: The repair of wide cleft palates and secondary palatal fistulas remains a challenge for pediatric plastic surgeons. To reduce the incidence of fistulization, use of acellular dermal matrix to facilitate closure has been reported in the literature. A review of the literature was performed to assess whether sufficient evidence exists to recommend the routine use of acellular dermal matrix for either primary palatoplasty or secondary palatal fistula repair. Methods: A literature search for the period between 1970 and 2011 was performed. All articles with clinical application of acellular dermal matrix in primary palatoplasty or palatal fistula repair were included. Data were analyzed using weighted averages to compare fistula rates between repairs performed with and without acellular dermal matrix (historical controls) for each repair type (primary versus secondary fistula repairs). Results: Four studies examined the use of acellular dermal matrix in primary palatoplasty (n = 92) with a mean cleft width of 14.2 mm. The overall fistula rate was 5.4 percent compared with 10.6 percent in the non–acellular dermal matrix historical control group. Five studies used acellular dermal matrix in palatal fistula repair (n = 74). The overall recurrent fistula rate was 8.1 percent compared with 12.9 percent in the historical control group. Conclusions: Based on the available data, the results imply that acellular dermal matrix may have a potential benefit in reducing fistula formation/persistence in palate surgery. However, the authors did not find sufficient prospective randomized (level II or better) evidence to recommend the routine use of acellular dermal matrix for cleft palate repair.

Evolving trends in the management of orbital floor fractures.

BackgroundThe management of orbital floor fractures is diverse and continues to evolve. The purpose of the current study was to provide an updated summary of the literature, with a focus on interspecialty differences, and contrast that with current treatment strategies of actively practicing plastic surgeons. MethodsA survey was conducted of surgeons who currently manage orbital floor fractures. The results are summarized and compared with a 10-year literature review (2002–2012) of surgical approaches, indications and timing of surgery, and implant selection in various surgical disciplines. Inclusion criteria included studies in English language with 10 or more patients. ResultsThe survey response rate was 56%, of which 86 surgeons were identified to currently manage orbit fractures. A third of participants reported they are less likely to operate on these fractures relative to earlier in their career. Six factors were found to have the greatest influence on surgeon’s operative decision: enophthalmos, hypophthalmos, positive forced duction, defect size, motility restriction, and persistent diplopia. The most common preferred approach to the orbit is midlid/infraorbital (45%) followed by transconjunctival (31%) and subciliary (24%). Medpor and titanium are the most preferred implants (83%) compared with autologous bone (5%). ConclusionsSignificant interdisciplinary and intradisciplinary differences in the management of orbital fractures exist. The most significant trends are the growing popularity of alloplastic versus autogenous materials for orbital floor reconstruction and the fact that one-third of surgeons are more likely to opt for a nonoperative (conservative) approach compared with earlier in their careers.

Novel nitric oxide producing probiotic wound healing patch: preparation and in vivo analysis in a New Zealand white rabbit model of ischaemic and infected wounds.

The treatment of chronic wounds poses a significant challenge for clinicians and patients alike. Here we report design and preclinical efficacy of a novel nitric oxide gas (gNO)‐producing probiotic patch for wound healing. Specifically, a wound healing patch using lactic acid bacteria in an adhesive gas permeable membrane has been designed and investigated for treating ischaemic and infected full‐thickness dermal wounds in a New Zealand white rabbit model for ischaemic wound healing. Kaplan–Meier survival curves showed increased wound closure with gNO‐producing patch‐treated wounds over 21 days of therapy (log‐rank P = 0·0225 and Wilcoxon P = 0·0113). Cox proportional hazard regression showed that gNO‐producing patch‐treated wounds were 2·52 times more likely to close compared with control patches (hazard P = 0·0375, score P = 0·032 and likelihood ratio P = 0·0355), and histological analysis showed improved wound healing in gNO‐producing patch‐treated animals. This study may provide an effective, safe and less costly alternative for treating chronic wounds.

Choice of internal rigid fixation materials in the treatment of facial fractures.

The surgical treatment of craniomaxillofacial trauma involves the restoration of both form and function via a complex interplay between the facial bony skeleton and its soft tissue envelope. However, it was not until the introduction of open reduction and internal rigid fixation techniques for the facial skeleton that the basic orthopedic principles of accurate fracture reduction, bone fixation, and healing could be applied. The latter introduced the unprecedented ability to repair unstable and/or displaced bony fractures of the face, providing a stable foundation upon which to reestablish preinjury soft tissue contour. Advances in the science of internal fixation, improvements in available plating materials and equipment, refinements in exposures to the facial skeleton, and an increase in the volume of facial trauma all fueled the rapid expansion of use of rigid internal fixation for facial fractures in the 1980s.1 With growing experience, surgeons came to appreciate the utility of metallic internal rigid fixation systems, along with the potential pitfalls and complications.2,3,4,5 In addition, the permanence of metallic implants spawned questions of long-term safety,2,5,6,7,8 rates and need for removal,3,9,10 and risks in the growing pediatric skeleton.11,12,13,14,15 Aimed at addressing these concerns, manufacturers began research and development of resorbable rigid fixation systems, which more recently are gathering interest in the management of facial trauma. With this in mind, the authors have attempted to summarize and compare the current data describing use of either metallic or resorbable fixation systems for the treatment of facial fractures in an effort to educate surgeons faced with selecting between these two options. Factors such as complication rates, cost, efficacy, and availability are all considered and summarized in this article.

Preoperative diplopia: the most important prognostic factor for diplopia after surgical repair of pure orbital blowout fracture.

Background: No consensus exists in the literature regarding the risk factors associated with new or residual diplopia after pure orbital blowout fracture (BOF) repair. Objective: To assess and evaluate the risk factors associated with diplopia after surgical repair of pure BOF. Methods: Patients with pure BOF who were managed surgically were identified in an 11-year period at the McGill University Health Center. The association between new or residual diplopia postsurgical repair and various risk factors was assessed using &khgr;2 and Fisher exact tests, and multivariate analysis was conducted using logistic regression. Results: A total of 61 patient charts were reviewed. Results demonstrated the presence of preoperative diplopia and radiologic evidence of extraocular muscle (EOM) swelling to be strongly associated with diplopia at 6 months after repair (P < 0.05). Patients who presented preoperatively with diplopia had a 9.91 times greater probability of developing diplopia postoperatively (P = 0.035; 95% confidence interval, 1.17-83.80). Conclusions: Preoperative diplopia is the best predictor of the presence of postoperative diplopia after BOF repair. Initial injury to the EOM leading to EOM swelling and preoperative diplopia seems to be the origin of diplopia after surgical repair of pure BOF.

A comparison and cost analysis of cranioplasty techniques: autologous bone versus custom computer-generated implants.

BackgroundCranioplasty can be performed either with gold-standard, autologous bone grafts and osteotomies or alloplastic materials in skeletally mature patients. Recently, custom computer-generated implants (CCGIs) have gained popularity with surgeons because of potential advantages, which include preoperatively planned contour, obviated donor-site morbidity, and operative time savings. A remaining concern is the cost of CCGI production. The purpose of the present study was to objectively compare the operative time and relative cost of cranioplasties performed with autologous versus CCGI techniques at our center. MethodsA review of all autologous and CCGI cranioplasties performed at our institution over the last 7 years was performed. The following operative variables and associated costs were tabulated: length of operating room, length of ward/intensive care unit (ICU) stay, hardware/implants utilized, and need for transfusion. ResultsTotal average cost did not differ statistically between the autologous group (n = 15;

Competency-based medical education for plastic surgery: where do we begin?

25,797.43) and the CCGI cohort (n = 12;