Patrick A. Gerety

A Systematic Review and Head-to-Head Meta-Analysis of Outcomes following Direct-to-Implant versus Conventional Two-Stage Implant Reconstruction.

Background: Innovative approaches to reconstruction have ushered in an era of breast reconstruction in which direct-to-implant procedures can provide an immediately reconstructed breast. Balancing the benefits against its technical challenges is vital. The authors evaluated the safety and efficacy of using direct-to-implant versus conventional two-stage reconstruction through a systematic meta-analysis. Methods: A literature search identified all articles published after 1999 involving prosthetic-based breast reconstruction as a two-stage tissue expander/implant or direct-to-implant technique. The primary outcomes of interest, including implant loss, capsular contracture, reoperation, and infection, were analyzed by means of head-to-head meta-analysis. Results: Thirteen studies involving 5216 breast reconstructions were included. The average patient age was 47.2 ± 1.0 years, the average body mass index was 24.9 ± 0.8 mg/k2, and the average follow-up was 40.8 months. Wound infection, seroma, and capsular contracture risk were similar between groups. However, direct-to-implant reconstruction was associated with a higher risk for skin flap necrosis (OR, 1.43; p = 0.01; I2 = 51 percent) and reoperation (OR, 1.25; p = 0.04; I2 = 43 percent). Ultimately, the risk for implant loss was nearly two-fold higher with direct-to-implant reconstruction compared with tissue expander/implant reconstruction (OR, 1.87; p = 0.04; I2 = 33 percent). Conclusions: Although direct-to-implant and two-stage tissue expander/implant reconstruction are successful approaches, this meta-analysis demonstrates significantly greater risk of flap necrosis and implant failure with direct-to-implant reconstruction. The authors’ findings suggest that the critical component of patient selection is judgment of mastectomy flap tissue quality. These findings can enhance the risk counseling process and highlight the need for additional investigations to optimize outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Differential closure of the spheno-occipital synchondrosis in syndromic craniosynostosis

Background: The spheno-occipital synchondrosis is a driver of cranial base and facial growth. Its premature fusion has been associated with midface hypoplasia in animal models. The authors reviewed computed tomographic scans of patients with Apert and Muenke syndrome, craniosynostosis syndromes with midface hypoplasia, to assess premature fusion of the spheno-occipital synchondrosis when compared with normal controls. Methods: Ninety head computed tomographic scans of Apert syndrome patients and 31 head scans of Muenke syndrome patients were assessed, in addition to an equal number of control scans. Spheno-occipital synchondrosis fusion on axial images was graded as open, partially closed, or closed. Analysis focused on ages 7 to 14 years, as no control patient fused before age 7 or had failed to fuse after age 14. Results: All 38 Apert syndrome patients aged 7 to 14 had some degree of spheno-occipital synchondrosis closure, compared with 29 of 38 matched controls (p = 0.0023). Seventeen of 20 Muenke syndrome patients showed closure, compared with 14 of 20 matched controls (p = 0.4506). Partial fusion was seen as early as age 2 in Apert syndrome and age 6 in Muenke syndrome patients; the earliest fusion was seen at age 7 in the control group. Conclusions: Compared with matched controls, the spheno-occipital synchondrosis closes significantly earlier in patients with Apert syndrome but not Muenke syndrome. This correlates well to reported incidences of midface hypoplasia in these syndromes. Although causality cannot be concluded from this study, an association exists between midface phenotype and degree of spheno-occipital synchondrosis closure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Operative Management of Nonsyndromic Sagittal Synostosis: A Head-to-Head Meta-analysis of Outcomes Comparing 3 Techniques.

Background:The timing and surgical technique for the treatment of sagittal synostosis remain controversial. Calvarial vault remodeling (CVR), strip craniectomy (SC), and spring-mediated cranioplasty (SMC) are currently in use. We perform a meta-analysis of the literature to compare these 3 techniques. Methods:A literature search identified articles involving operative management of nonsyndromic sagittal synostosis. Comparison of 2 operative techniques was required, and methodology was assessed via the American Society of Plastic Surgeons’ Levels of Evidence. Three techniques were considered: CVR, SC, and SMC. Meta-analysis was conducted for change in cephalic index (CI), reported as weighted mean difference (WMD). Pooled subgroup comparisons were performed for operative time, length of stay, blood loss, and cost. Results:Twelve studies providing level 2 or 3 evidence were included. All studies involved CVR (n = 187), 8 involved SC (n = 299), and 7 involved SMC (n = 158). Head-to-head comparison of change in CI demonstrated a greater, yet statistically insignificant change for CVR versus SMC, WMD = 0.94 (−0.23 to 2.11) (P = 0.12, I2 = 55%). Calvarial vault remodeling showed a statistically greater change in CI versus SC, WMD = 1.47 (0.47–2.48) (P = 0.004, I2 = 66%). Compared with SMC/SC, CVR had longer operative length (170 vs 97 minutes), higher blood loss (238 vs 47 mL), longer length of stay (5.1 vs 2.9 days), and higher costs (

Application of a robotic telemanipulator to perform posterior pharyngeal flap surgery: a feasibility study.

35,280 vs

Sustained delivery of rhBMP-2 by means of poly(lactic-co-glycolic acid) microspheres: cranial bone regeneration without heterotopic ossification or craniosynostosis.

13,147), all with P < 0.0001. Conclusions:This study, the first meta-analysis comparing 3 primary operations for correcting nonsyndromic sagittal synostosis, demonstrates no difference in CI for CVR versus SMC and a small but statistically greater improvement in CI favoring CVR over SC. Secondary outcomes favored SC/SMC procedures over CVR. However, long-term studies are still needed to adequately assess the risk-benefit ratios.

An international survey of craniofacial surgeons: current trends in practice.

Background: The instrumentation used during surgery to address velopharyngeal dysfunction has changed little over the past century. Recent advances in the use of robotic surgical systems in transoral surgery have expanded the use of these instruments beyond their traditional laparoscopic applications. The purpose of this study was to evaluate the feasibility of performing superiorly based, “Hogan”-style posterior pharyngeal flaps using a robotic surgical telemanipulator system. The authors hypothesize that use of this surgical platform provides equivalent safety, improved exposure, and more comfortable surgeon ergonomics compared with traditional methods of flap harvest and inset. Methods: A pilot study was performed using three fresh cadaveric human heads. Superiorly based posterior pharyngeal flaps were successfully performed in all specimens. The technical aspects of the procedure, including telemanipulator setup, positioning, surgical instrumentation, and timing, are described in detail. Results: All three subjects underwent successful transfer of posterior pharyngeal flaps. Mean surgical time was 113 minutes. Using a 30-degree angled endoscope, the area of the operative field was nearly doubled, and this allowed for easy visualization of the flap ports, an advantage when tailoring the flap. Technically, the learning curve for using the robot telemanipulator was steep, and both operating surgeons (J.M.S. and J.A.T.) felt that the instrumentation and setup were ergonomic. There was no damage to adjacent structures. Conclusions: Transoral robotic surgery for velopharyngeal dysfunction is feasible and may offer improved exposure and ergonomics compared with traditional methods. As the use of robotic surgical systems becomes more widespread, their use in intraoral cleft surgery warrants further investigation.

Impact of Fronto-orbital Advancement on Frontal Sinus Volume, Morphology, and Disease in Nonsyndromic Craniosynostosis

Background: Commercially available recombinant human bone morphogenetic protein 2 (rhBMP2) has demonstrated efficacy in bone regeneration, but not without significant side effects. The authors used rhBMP2 encapsulated in poly(lactic-co-glycolic acid) (PLGA) microspheres placed in a rabbit cranial defect model to test whether low-dose, sustained delivery can effectively induce bone regeneration. Methods: The rhBMP2 was encapsulated in 15% PLGA using a double-emulsion, solvent extraction/evaporation technique, and its release kinetics and bioactivity were tested. Two critical-size defects (10 mm) were created in the calvaria of New Zealand white rabbits (5 to 7 months of age, male and female) and filled with a collagen scaffold containing either (1) no implant, (2) collagen scaffold only, (3) PLGA-rhBMP2 (0.1 &mgr;g per implant), or (4) free rhBMP2 (0.1 &mgr;g per implant). After 6 weeks, the rabbits were killed and defects were analyzed by micro–computed tomography, histology, and finite element analysis. Results: The rhBMP2 delivered by means of bioactive PLGA microspheres resulted in higher volumes and surface area coverage of new bone than an equal dose of free rhBMP2 by micro–computed tomography (p = 0.025 and p = 0.025). Finite element analysis indicated that the mechanical competence using the regional elastic modulus did not differ with rhBMP2 exposure (p = 0.70). PLGA-rhBMP2 did not demonstrate heterotopic ossification, craniosynostosis, or seroma formation. Conclusions: Sustained delivery by means of PLGA microspheres can significantly reduce the rhBMP2 dose required for de novo bone formation. Optimization of the delivery system may be a key to reducing the risk for recently reported rhBMP2-related adverse effects.

A Sustainable Model for Patient Follow-Up Following an International Cleft Mission: A Proof of Concept

Background Craniofacial surgery is a diverse subspecialty of plastic surgery that focuses on a wide range of head and neck pathology in children and adults. The purpose of this study was to define the characteristics of this group of surgeons and to compare subgroups within the specialty. Methods A 36-question, anonymous, electronic survey was sent to 403 craniofacial surgeons; the response rate was 30% (121). Distribution was to members of the International Society of Craniofacial Surgeons and to graduates of fellowships recognized by the American Society of Craniofacial Surgeons. Data were collected and analyzed for surgeon demographics, geography, practice setting (academic vs private), case mix and volume, and career satisfaction. Comparisons were made between US and international surgeons, males and females, and surgeons of different ages. Results The craniofacial surgeons in this study ranged in age from 29 to 75 years (mean, 53 years); 92% were male, and 8% were female. They are largely academic (69%), high in academic rank (54% full professors), predominantly male (92%), and actively practicing craniofacial surgery. There are significant differences between international and domestic surgeons in terms of training background (64% vs 36% plastic surgery residency, P = 0.003) and volume of craniofacial surgery (56% vs 26% performing more than 5 complex craniofacial procedures per year, P = 0.002). Conclusions Craniofacial surgeons are a highly successful academic group with high career satisfaction. There are significant differences between US and international craniofacial surgeons in terms of demographics and practice, with more US surgeons performing fewer major craniofacial osteotomies. There is a significant gender disparity, which warrants further study.

Gelfoam Interposition Minimizes Risk of Fistula and Postoperative Bleeding in Modified-Furlow Palatoplasty.

Background: Fronto-orbital advancement for nonsyndromic craniosynostosis has been thought to injure frontal sinus buds, lead to chronic sinus disease, and influence final forehead shape. This study investigates the effect of fronto-orbital advancement in infancy on subsequent frontal sinus volume, morphology, and disease. Methods: The authors conducted a retrospective review of nonsyndromic craniosynostosis patients treated with fronto-orbital advancement in infancy with a head computed tomographic scan obtained at age 7 to 18 years. Facial trauma patients served as age-matched controls. Frontal sinus characteristics were determined using three-dimensional reconstructions. Results: The study included 33 nonsyndromic craniosynostosis patients who underwent fronto-orbital advancement (n = 20 unicoronal; n = 13 metopic) and 20 control patients. The incidence of at least unilateral pneumatization was 94 percent for fronto-orbital advancement subjects and 95 percent for control subjects. Mean frontal sinus volumes for unicoronal synostosis, metopic synostosis, and control groups were 3427 ± 2294, 4576 ± 3510, and 4157 ± 3963 mm3, respectively (p = 0.598). Asymmetry scores were as follows: unicoronal synostosis, 56 ± 35 percent; metopic synostosis, 36 ± 33 percent; and control, 23 ± 24 percent (p = 0.010). Unicoronal subjects displayed prominent asymmetry, with increased pneumatization on the unaffected side. Frontal sinus volume correlated with age at computed tomography but not with age at fronto-orbital advancement. Interrater reliability was 0.997. One fronto-orbital advancement subject and zero control subjects demonstrated computed tomographic evidence of frontal sinus disease. Conclusions: Frontal sinus volume, morphology, and disease do not differ significantly between control subjects and nonsyndromic craniosynostosis subjects following fronto-orbital advancement, but subtle differences such as increased asymmetry in the unicoronal synostosis group can be appreciated. Further research with syndromic craniosynostosis patients undergoing multiple procedures may help elucidate the association between surgical disruption and frontal sinus development. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Robotic Approaches to Palatoplasty and the Treatment of Velopharyngeal Dysfunction.

Purpose: Patient follow-up after cleft missions is imperative if we are to critically assess the quality of care provided in these settings. The adoption of mobile telephones among disadvantaged families abroad may enable such an undertaking in a cost-effective manner. This project aimed to assess the efficacy of cellular phone-based follow-up in a developing country following a cleft mission to Thailand. Methods: Changing Childrens Lives Inc. performed a cleft surgical mission to Udon Thani, Thailand, in January 2013. Telephone numbers collected at that time were used to survey the patients or their parents 1.5 years postoperatively. Results: Of the 56 patients who underwent cleft lip and/or palate surgery during the mission, more than 50% (n = 30, 54%) were reachable by telephone; all chose to participate in the study. The cost for families was U.S.