Robert J. Havlik

Resorbable Plla-pga Plate and Screw Fixation in Pediatric Craniofacial Surgery: Clinical Experience in 1883 Patients

The need to provide rigid bony fixation in the surgical treatment of craniofacial deformities has inspired an ongoing evolution of surgical innovations and implants. Because of the young age of many treated craniosynostosis patients and the unique pattern of cranial vault growth, the extensive implantation of metal devices is potentially problematic. The use of resorbable plate and screw devices offers all of the benefits of rigid fixation without many of their potential risks. Since the introduction of resorbable plate and screw devices in 1996, tens of thousands of craniofacial patients have received implants, but long-term results from a large series have yet to be reported. A combined prospective and retrospective analysis was done on 1883 craniosynostosis patients under 2 years of age treated by 12 surgeons from seven different geographic locations over a 5-year period who used the same type of resorbable bone fixation devices (poly-L-lactic-polyglycolic copolymer). Specifically, the incidence of postoperative infection, fixation device failure, occurrence of delayed foreign-body reactions, and the need for reoperation resulting from device-related problems were determined. Technical difficulties and trends in device use were also noted. From this series, significant infectious complications occurred in 0.2 percent, device instability primarily resulting from postoperative trauma occurred in 0.3 percent, and self-limiting local foreign-body reactions occurred in 0.7 percent of the treated patients. The overall reoperation rate attributable to identifiable device-related problems was 0.3 percent. Improved bony stability was gained by using the longest plate geometries/configurations possible and bone grafting any significant gaps across plated areas that were structurally important. The specific types of plates and screws used evolved over the study period from simple plates, meshes, and threaded screws to application-specific plates and threadless push screws whose use varied among the involved surgeons. This report documents the safety and long-term value of the use of resorbable (LactoSorb) plate and screw fixation in pediatric craniofacial surgery in the infant and young child. Device-related complications requiring reoperation occurred in less than 0.5 percent of the implanted patients, which is less frequent than is reported for metallic bone fixation. Resorbable bone fixation for the rapidly growing cranial vault has fewer potential complications than the traditional use of metal plates, screws, and wires.

Resorbable plate fixation in pediatric craniofacial surgery.

&NA; Resorbable bone plates composed of a copolymer of polylactic and polyglycolic acids stabilized into position with metallic microscrews were used in the reconstruction of pediatric craniofacial deformities. In 100 patients between 4 and 15 months of age, a total of 912 resorbable plates were implanted over a 21/2‐year period. Their application was simple and rapid and required no special instrumentation. Currently, 85 patients are more than 1 year postimplantation, which is the known time for complete resorption of this copolymeric compound. No complications have been seen with this use, including infection, overlying soft‐tissue reactions, reconstructive instability, or underlying osteolysis around the screws, as determined by postoperative plain radiographs at 6 months and 1 year postoperative time periods. Four patients have had screws removed due to either palpability or secondary reconstructive surgery between 9 and 18 months postoperatively, all of whom exhibited complete polymer resorption and normal bone healing. These clinical results demonstrate the safety and effectiveness of this copolymeric material for pediatric craniofacial applications. (Plast. Reconstr. Surg. 100: 1, 1997.)

Midface distraction following Le Fort III and monobloc osteotomies: Problems and solutions

&NA; Distraction osteogenesis has been used increasingly for midfacial advancement in patients with syndromic craniosynostosis and in severe developmental hypoplasia of the midface. In these patients, the degree of advancement required is often so great that restriction of the adjacent soft tissues may preclude stable advancement in one stage. Whereas distraction is an ideal solution by which to gradually lengthen both the bones and the soft tissues, potential problems remain in translating the distraction forces to the midface. In these patients, severe developmental hypoplasia may be associated with weak union between the zygoma and the maxilla, increasing the chance of zygomaticomaxillary dysjunction when using internal devices that translate distraction force to the maxilla through the zygoma. Eight cases are reported in which either internal or external distraction systems were used for midface advancement following Le Fort III (n = 7) or monobloc (n = 1) osteotomies. Cases of patients in whom hypoplasia at the zygomaticomaxillary junction altered or impaired plans for midface distraction were reported from three host institutions. Seven patients had midface hypoplasia associated with syndromic craniosynostosis, and one patient had severe developmental midface hypoplasia. The distraction protocol was modified to successfully complete midface advancement in light of weakness at the zygomaticomaxillaryjunction in seven patients. Modifications included change from an internal to an external distraction system in two patients, rigid fixation and bone graft stabilization of the midface in one patient, and plate stabilization of a fractured or unstable zygomaticomaxillary junction followed by resumption of internal distraction in four patients. Previous infection and bone loss involving both malar complexes precluded one patient from being a candidate for an internal distraction system. Using a problem‐based approach, successful advancement of the midface ranging from 9 to 26 mm at the occlusal level as measured by preoperative and postoperative cephalograms was undergone by all patients. Advantages and disadvantages of the respective distraction systems are reviewed to better understand unique patient characteristics leading to the successful use of these devices for correction of severe midface hypoplasia. (Plast. Reconstr. Surg. 109: 1797, 2002.)

The Spectrum of Orofacial Clefting

LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Describe the differing types of congenital clefting defects that extend outward from the perioral region. 2. Define the sites of anatomical disruption and deformities that these types of facial clefts cause. 3. Describe the cause and incidence, if known, of orofacial clefts and their inheritance/transmission risks. BACKGROUND Clefts of the orofacial region are among the most common congenital facial defects. The clinical presentation is usually that of a lateral cleft of the lip through the philtrum with or without extension through the palatal shelves. However, atypical forms of clefts with lip involvement also occur in a variety of patterns, some of which are embryologically predictable; others are not. METHODS An overview of the embryology, cause, and incidence of this diverse and interesting group of congenital orofacial clefts is presented. RESULTS Clefts involving the lateral upper lip; median upper lip; and oblique facial, lateral facial, and median mandibular regions are reviewed. CONCLUSIONS This review of orofacial malformations describes clefting anomalies that emanate from the mouth and lips. As the causes of orofacial clefts are better understood, it is becoming clear that a complex interplay between genetic and environmental variables causes these clefts. Future study of orofacial clefts will require increasingly sophisticated methods of elucidating these subtle interactions.

Timing of palatal surgery and speech outcome.

Objective: To examine the impact of age and lexical status at the time of primary palatal surgery on speech outcome of preschoolers with cleft palate. Participants: Forty children (33 to 42 months) with nonsyndromic cleft palate participated in the study. Twenty children (Group 1) were less lexically advanced and younger (mean age  =  11 months) and 20 children (Group 2) were more lexically advanced and older (mean age  =  15 months) when palatal surgery was performed. Main Outcome Measures: Samples of the childrens spontaneous speech were compared on 11 speech production measures (e.g., size of consonant inventory, total consonants correct, % correct for manner of articulation categories, compensatory articulation usage, etc.). Next, listeners rated a 30-second sample of each childs connected speech for articulation proficiency and hypernasality, separately, using direct magnitude estimation (DME). Results: Group differences were noted for 4 of the 11 speech production measures. Children in Group 1 exhibited larger consonant inventories (and true consonant inventories) and more accurate production of nasals and liquids compared to children in Group 2. On the DME task, significant group differences were found for ratings of articulation proficiency and hypernasality. Children in Group 1 exhibited better articulation and less hypernasality than children in Group 2. Conclusions: The findings suggested that children who were less lexically advanced and younger at the time of palatal surgery exhibited better articulation and resonance outcomes at 3 years of age.

Sentinel lymph node biopsy for melanoma: experience with 234 consecutive procedures.

Sentinel lymph node biopsy is increasingly used to identify occult metastases in regional lymph nodes of patients with melanoma. Selection of patients for sentinel lymph node biopsy and subsequent lymphadenectomy is an area of debate. The purpose of this study was to describe a large clinical series of these biopsies for cutaneous melanoma and to identify patients most likely to gain useful clinical information from sentinel lymph node biopsy. The Indiana University Melanoma Program computerized database was queried to identify all patients who underwent this procedure for clinically localized cutaneous melanoma. It was performed using preoperative technetium Tc 99m lymphoscintigraphy and isosulfan blue dye. Pertinent demographic, surgical, and histopathologic data were recorded. Univariate and multivariate logistic regression and classification table analyses were performed to identify clinical variables associated with sentinel node and nonsentinel node positivity. In total, 234 biopsy procedures were performed to stage 291 nonpalpable regional lymph node basins. Mean Breslow’s thickness was 2.30 mm (2.08 mm for negative sentinel lymph node biopsy, 3.18 mm for positive). The mean number of sentinel nodes removed was 2.17 nodes per basin (range, 1 to 8). Forty-seven of 234 melanomas (20.1 percent) and 50 of 291 basins (17.2 percent) had a positive biopsy. Positivity correlated with AJCC tumor stage: T1, 3.6 percent; T2, 8.1 percent; T3, 27.4 percent; T4, 44 percent. By univariate logistic regression, Breslow’s thickness (p = 0.003, continuous variable), ulceration (p = 0.003), mitotic index ≥ 6 mitoses per high power field (p = 0.008), and Clark’s level (p = 0.04) were significantly associated with sentinel lymph node biopsy result. By multivariate analysis, only Breslow’s thickness (p = 0.02), tumor ulceration (p = 0.02), and mitotic index (p = 0.02) were significant predictors of biopsy positivity. Classification table analysis showed the Breslow cutpoint of 1.2 mm to be the most efficient cutpoint for sentinel lymph node biopsy result (p = 0.0004). Completion lymphadenectomy was performed in 46 sentinel node-positive patients; 12 (26.1 percent) had at least one additional positive nonsentinel node. Nonsentinel node positivity was marginally associated with the presence of multiple positive sentinel nodes (p = 0.07). At mean follow-up of 13.8 months, four of 241 sentinel node-negative basins demonstrated same-basin recurrence (1.7 percent). Sentinel lymph node biopsy is highly reliable in experienced hands but is a low-yield procedure in most thin melanomas. Patients with melanomas thicker than 1.2 mm or with ulcerated or high mitotic index lesions are most likely to have occult lymph node metastases by sentinel lymph node biopsy. Completion therapeutic lymphadenectomy is recommended after positive biopsy because it is difficult to predict the presence of positive nonsentinel nodes.

Mandibular Distraction Lengthening in the Severely Hypoplastic Mandible: A Problematic Case with Tongue Aplasia

Distraction lengthening is a technique that was initially developed for correction of lower limb length discrepancies. It has recently been adapted to maxillofacial problems and has gained increasing popularity in this application. This report illustrates the principles involved in mandibular distraction lengthening and offers possible solutions to potentially Limiting clinical problems. First, conventional technique dictates that a distinct periosteal sleeve is necessary for distraction osteogenesis to occur. However, in this case, distraction was performed through an area of scar tissue in which the native periosteum was destroyed. The ability to extend the use of the technique of distraction successfully to suboptimal clinical situations may broaden the indications for its use. Second, fixator instability is a potentially common problem in these cases because of the forces involved in distraction osteogenesis and the duration of the process. However, mechanical rigidity is essential for the period of mineralization and bony consolidation (typically requiring twice as long as the distraction phase). Fixator instability can be successfully salvaged during the mineralization phase of bony healing through the use of an onlay corticocancellous bone “plate,” which resorbs as the distraction gap gains strength. This report highlights one of the main advantages of the distraction process: the expansion of the soft-tissue matrix of the face.

Parameters of Care for Craniosynostosis

Background A multidisciplinary meeting was held from March 4 to 6, 2010, in Atlanta, Georgia, entitled “Craniosynostosis: Developing Parameters for Diagnosis, Treatment, and Management.” The goal of this meeting was to create parameters of care for individuals with craniosynostosis. Methods Fifty-two conference attendees represented a broad range of expertise, including anesthesiology, craniofacial surgery, dentistry, genetics, hand surgery, neurosurgery, nursing, ophthalmology, oral and maxillofacial surgery, orthodontics, otolaryngology, pediatrics, psychology, public health, radiology, and speech-language pathology. These attendees also represented 16 professional societies and peer-reviewed journals. The current state of knowledge related to each discipline was reviewed. Based on areas of expertise, four breakout groups were created to reach a consensus and draft specialty-specific parameters of care based on the literature or, in the absence of literature, broad clinical experience. In an iterative manner, the specialty-specific draft recommendations were presented to all conference attendees. Participants discussed the recommendations in multidisciplinary groups to facilitate exchange and consensus across disciplines. After the conference, a pediatric intensivist and social worker reviewed the recommendations. Results Consensus was reached among the 52 conference attendees and two post hoc reviewers. Longitudinal parameters of care were developed for the diagnosis, treatment, and management of craniosynostosis in each of the 18 specialty areas of care from prenatal evaluation to adulthood. Conclusions To our knowledge, this is the first multidisciplinary effort to develop parameters of care for craniosynostosis. These parameters were designed to help facilitate the development of educational programs for the patient, families, and health-care professionals; stimulate the creation of a national database and registry to promote research, especially in the area of outcome studies; improve credentialing of interdisciplinary craniofacial clinical teams; and improve the availability of health insurance coverage for all individuals with craniosynostosis.

Lymphoscintigraphy with sentinel lymph node biopsy in cutaneous merkel cell carcinoma

Merkel cell carcinoma (MCC) is a rare cutaneous malignancy characterized by an aggressive clinical behavior with high rates of locoregional and systemic recurrence. Regional disease and distant metastases are associated with poor prognosis. Despite a predisposition of MCC to spread via the lymphatics, prophylactic lymph node dissection in the absence of clinically apparent lymph node involvement is controversial. The value of lymphoscintigraphy in cutaneous melanoma is established in lesions with ambiguous lymphatic drainage patterns. When used with sentinel lymph node biopsy (SLNB), it can identify subjects with occult regional node metastasis. The authors present 2 patients with MCC who underwent regional node staging with lymphoscintigraphy-directed SLNB. Both patients had sentinel nodes that were positive for metastatic disease. In patients with MCC, minimally invasive regional node staging SLNB may be useful in limiting the sequelae of routine lymphadenectomies. Whether early identification and treatment of patients with occult regional node disease can influence survival in MCC is not known.

The surgical correction of pierre robin sequence: Mandibular distraction osteogenesis versus tongue-lip adhesion

Background: The authors present an outcomes analysis of mandibular distraction osteogenesis versus tongue-lip adhesion in the surgical treatment of Pierre Robin sequence. Methods: A retrospective, 15-year, single-surgeon review was undertaken of all nonsyndromic neonates with Pierre Robin sequence treated with mandibular distraction osteogenesis (2004 to 2009; n = 24) or tongue-lip adhesion (1994 to 2004; n = 15). Outcomes included time of extubation, length of intensive care unit stay, incidence of tracheostomy, and surgical complications. Polysomnography data were collected 1 month and 1 year postoperatively. Sleep study data included changes in oxygen saturation and apnea-hypopnea index. Results: There were no postprocedure tracheostomies in the mandibular distraction osteogenesis group and four tracheostomies in the tongue-lip adhesion group. The preoperative oxygen saturations were significantly lower in the mandibular distraction osteogenesis group compared with tongue-lip adhesion (76.5 percent versus 82 percent; p < 0.05). Preoperative apnea-hypopnea index was significantly higher in the mandibular distraction osteogenesis group compared with the tongue-lip adhesion group (47 versus 37.6; p < 0.05). Despite these preoperative differences, patients undergoing mandibular distraction osteogenesis demonstrated significantly higher oxygen saturation levels at 1 month (98.3 percent versus 87.5 percent; p < 0.05) and 1 year postoperatively (98.5 percent versus 89.2 percent; p < 0.05) and lower apnea-hypopnea index at 1 month (10.9 versus 21.6; p < 0.05) and 1 year postoperatively (2.5 versus 22.1; p < 0.05) compared with tongue-lip adhesion. Surgical complications were comparable between the two groups. Conclusions: In nonsyndromic patients with Pierre Robin sequence, mandibular distraction osteogenesis demonstrates superior outcome measures regarding oxygen saturation, apnea-hypopnea index, and incidence of tracheostomy compared with tongue-lip adhesion. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.