Tina M. Sauerhammer

Helmet treatment of deformational plagiocephaly: The relationship between age at initiation and rate of correction

Background: The purpose of this study was to evaluate the relationship between age at initiation of helmet therapy for deformational plagiocephaly and the rate of correction. Methods: Infants treated for deformational plagiocephaly with a helmet orthosis between 2009 and 2010 were included. Patients were stratified prospectively by the age at which treatment was initiated: group 1, younger than 20 weeks (n = 26); group 2, 20 to 23.9 weeks (n = 59); group 3, 24 to 27.9 weeks (n = 82); group 4, 28 to 31.9 weeks (n = 62); group 5, 32 to 35.9 weeks (n = 45); group 6, 36 to 40 weeks (n = 29), and group 7, older than 40 weeks (n = 43). Pretreatment and posttreatment calvarial asymmetry was measured using direct anthropometry and reported as a transcranial difference. Results: Three hundred forty-six infants were included; initial transcranial difference was equivalent on all paired-group comparisons. Duration of helmet therapy positively correlated with age at initiation (r = 0.89, p < 0.05). The rate of change in transcranial difference correlated negatively with age at treatment onset (r = –0.88, p < 0.05): group 1, 0.93 mm/week; group 2, 0.64 mm/week; group 3, 0.59 mm/week; group 4, 0.56 mm/week; group 5, 0.41 mm/week; group 6, 0.42 mm/week; and group 7, 0.42 mm/week). At the conclusion of therapy, all groups had improved calvarial symmetry, albeit less completely in groups 6 and 7. Conclusions: The correction rate of plagiocephaly with helmet therapy decreases with increasing infant age; after 32 weeks, there is a slow and relatively constant rate of change. Improvement can still be achieved in infants older than 12 months. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Craniectomy gap patency and neosuture formation following endoscopic suturectomy for unilateral coronal craniosynostosis.

Background: The combination of endoscope-assisted suturectomy and postoperative helmet therapy has been advocated to treat unilateral coronal synostosis. However, surgical outcomes can vary. One possible explanation for this inconsistency is early closure of the craniectomy gap. The authors examined short-term postoperative patency of the craniectomy gap and its relationship to phenotypic improvement. Methods: A retrospective review was performed that included patients who (1) underwent endoscope-assisted suturectomy and postoperative helmet therapy for isolated unilateral coronal synostosis and (2) had preoperative and postoperative (>7 months) computed tomographic imaging. High-resolution computed tomographic images were analyzed for craniectomy gap patency. Results: Seventeen patients met the inclusion criteria. Mean age at operation was 2.5 months (range, 1.1 to 4.7 months). Mean duration of follow-up was 32.9 months (range, 10.6 to 64.9 months) and age at latest postsurgical computed tomography was 16.8 months (range, 7.5 to 40.9 months). Fifteen patients demonstrated “neosuture” formation and coronal patency on postoperative computed tomography. Three patients (17.6 percent) had complete formation of a normal-appearing coronal suture, whereas 12 patients (70.6 percent) had areas composed of both reformed suture and persistent craniectomy gap. These 15 patients demonstrated satisfactory phenotypic improvement and did not require subsequent procedures. The remaining two patients (11.8 percent) exhibited focal areas of refusion interspersed with areas of neosuture formation and persistent craniectomy gap. Both had poor phenotypic improvement; one underwent fronto-orbital advancement. Conclusion: Persistence of a craniectomy gap and neosuture formation are common early findings after endoscope-assisted suturectomy and postoperative helmet therapy and appear to correlate with better phenotypic improvement. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Analysis of routine intensive care unit admission following fronto-orbital advancement for craniosynostosis.

Background: Intensive care unit admission following fronto-orbital advancement for craniosynostosis is routine at most institutions. The authors determined the frequency of postoperative events requiring intensive care unit care that justify this practice. Methods: Infants with craniosynostosis who underwent primary fronto-orbital advancement at a single institution from 1997 to 2011 were included. Patient demographics, operative factors, and hemodynamic outcomes were recorded. Adverse postoperative events/interventions were graded as none (group I); minor (group II), easily managed on a surgical floor; or major (group III), requiring intensive care unit care. Results: One hundred seven infants were included. Average length of hospitalization was 3.7 ± 1.6 days, with 1.3 ± 1.0 days in the intensive care unit and 2.4 ± 1.0 days on the floor. Seventy-eight patients (72.9 percent) were categorized into group I, 24 (22.4 percent) into group II, and five (4.7 percent) into group III. Major events/interventions included prolonged intubation (n = 2), reintubation (n = 2), and continuous positive airway pressure support (n = 1). Preexisting end-organ dysfunction was significantly associated with group III patients, who also had significantly higher intraoperative blood loss requiring greater resuscitation. Mean daily charges were

Reflections on the mating pool for women in plastic surgery.

7652.33 (10.9 percent of total charges) for intensive care unit care and

Incidental findings on preoperative computed tomography for nonsyndromic single suture craniosynostosis.

2470.62 (6.9 percent of total charges) for floor care. Conclusions: In this study, 4.7 percent of patients had event/interventions requiring intensive care unit care after fronto-orbital advancement. Predictors included preexisting end-organ dysfunction and higher intraoperative blood loss requiring greater resuscitation. Financial savings from selective postoperative intensive care unit admission may not outweigh the potential cost of an emergent event on the surgical floor. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Clinical Factors Affecting Length of Stay After 100 Consecutive Cases of Primary Cleft Lip Repair

Background: Almost three times as many board-certified female plastic surgeons are unmarried compared with male colleagues. The purpose of this study was to determine why women in plastic surgery are less likely to be married. Methods: A 52-question survey was sent to all female members of the American Society of Plastic Surgeons. Questions focused on type of training and practice; marital status; age at marriage; spousal education, financial, and professional status; relational goals, values, and satisfaction. A total of 729 questionnaires were sent via e-mail; responses were anonymous. Results: Response rate was 34 percent (n = 250). Respondents were either married (64 percent), engaged (2 percent), in a “serious” relationship (11 percent), or not in a committed relationship (23 percent). Of unmarried respondents, 56 percent wanted to marry, 44 percent did not wish marriage at the time of the survey, and 42 percent had deliberatively postponed marriage. The most frequently cited reasons for being single were perceived lack of desirable partners (45 percent), job constraints (14 percent), and personality differences (13 percent). Female plastic surgeons who married later than 36 years of age were more likely to choose a spouse with a lower income, less education, and lower financial success compared with female plastic surgeons who married at a younger age. Conclusions: Women in surgical practice who marry later are less likely to find a partner with equal educational level, financial resources, and professional success. Hence, a shift occurs from hypergamy toward hypogamy. These findings are not unique to plastic surgery.

Combined metopic and unilateral coronal synostoses: A phenotypic conundrum

Abstract Although the diagnosis of nonsyndromic single suture craniosynostosis (NSSC) can usually be made by clinical examination, computed tomography (CT) is still commonly used in preoperative evaluation. This practice has been questioned in light of recent studies that document a small, but measurable, increased risk of malignancy from CT-associated radiation. The purpose of this study was to examine whether preoperative CT for patients with NSSC provided clinically important information beyond confirmation of craniosynostosis. We performed a retrospective analysis of all patients with NSSC undergoing cranial vault remodeling at our center from March 1999 to March 2011. Only patients with complete preoperative CT scans available for review were included. Staff pediatric neurosurgeons were blinded to patient diagnosis and official radiology report, analyzed the CT images, and documented the site of synostosis and any other findings. Of the 231 patients, 80 met the inclusion criteria. Sites of synostosis included sagittal (51 patients), coronal (17 patients), metopic (11 patients), and frontosphenoidal (1 patient). Clinical diagnosis correlated with radiographic site of fusion in all patients except the patient with frontosphenoidal synostosis. Incidental findings were documented in more than 50% of the patients including prominent extra-axial cerebrospinal fluid (n = 36, 45%), ventriculomegaly (n = 5, 6.25%), choroid fissure cyst (n = 2), cavum septum pellucidum (n = 2), Chiari malformation (n = 1), and prominent perivascular space (clinically nonsignificant finding, n = 1). Incidental findings required additional follow-up or management in 5 patients (6.25%). Our findings support the use of preoperative imaging in this population to identify intracranial anomalies that cannot be discerned by clinical examination. Whereas many findings were not clinically important, some required additional attention.

Endocortical plating of the bandeau during fronto-orbital advancement provides safe and effective osseous stabilization.

Objective To analyze the hospital course of 100 consecutive infants after primary cleft lip repair (PCLR) and identify factors related to length of stay (LOS). Design Retrospective analysis of 100 consecutive infants who were routinely admitted after PCLR. Setting Tertiary care center. Patients One hundred consecutive infants undergoing PCLR. Demographic and perioperative data were collected and analyzed. Main Outcome Measure LOS, planned before data collection. Results Male:female ratio was 65:35. Seventy-two infants had unilateral cleft lip; syndromic association was documented in 15 patients. Mean age and weight at PCLR were 5.6 ± 4.0 months and 6.7 ±1.3 kg, respectively. Mean duration of surgery was 2.5 ± 0.9 hours, and mean duration of general anesthesia was 3.4 ± 0.9 hours. A total of 3.3 ±1.5 mL of intraoperative local anesthetic was used per patient. Intravenous fluids were necessary after transfer from the post-anesthesia care unit to the general ward in 98% of patients. Almost half (44%) of all patients received intravenous morphine 23 hours or more after hospital admission. Mean LOS was 35.8 ± 13.9 hours. No association was identified between patient demographic factors and LOS. Multivariate linear regression models identified significant positive correlation between LOS and duration of general anesthesia (P = .002). Greater volume of postoperative oral intake (P = .000) and higher acetaminophen dosage on the floor (P = .000) correlated with decreased LOS. Conclusions This study identifies perioperative factors associated with LOS. Our findings question the safety of routine outpatient or short-stay observation after PCLR.

Correction of deformational plagiocephaly in early infancy using the plagio cradle orthotic

BackgroundMost types of craniosynostosis cause predictable changes in cranial shape. However, the phenotype of combined metopic and unilateral coronal synostoses is anomalous. The purpose of this observational study was to better clarify the clinical and radiographic features of this rare entity. MethodsA retrospective review of a craniofacial database was performed. Patients with combined metopic and unilateral coronal synostoses were included in this study. Data collected included demographic information, physical and radiographic findings, genetic evaluation, treatment, and operative outcomes. ResultsOf 687 patients treated between 1989 and 2010, only 3 patients had combined metopic and unilateral coronal synostoses. All patients were diagnosed through computed tomography on the first day of life. Phenotypic features included the following: (1) narrowed forehead with a prominent midline ridge, (2) severe bilateral brow retrusion with an acute indentation on the side of the patient coronal suture, (3) facial and nasal angulation similar to isolated unilateral coronal synostosis, and (4) anterior displacement of the ear on the fused side. In addition, the cranial vertex was deviated toward the side of the open coronal suture. Two patients had a head circumference below the 25th percentile; 2 of the 3 had a TWIST gene mutation consistent with Saethre-Chotzen syndrome. One patient was managed through fronto-orbital advancement and required a revision. The other 2 patients had early endoscopic release, followed by postoperative helmet therapy; one improved but still required open cranial remodeling. The other has near-normal phenotype, and no further surgery is planned. ConclusionsCombined metopic and unilateral coronal synostoses present a rare and unusual phenotype. Although early intervention improves the deformity, revisional procedures are usually required.

An Unconventional Presentation of Branchio-Oculo-Facial Syndrome.

Background Ectocortical resorbable plate fixation has become a standard method of fixation during fronto-orbital advancement (FOA) in young children. Plate hydrolysis occurs slowly and can cause visible prominences, sterile abscesses, and osseous depressions that can persist after complete resorption. Although endocortical placement avoids contour issues, the safety and effectiveness of this technique are undocumented. Methods A review of our prospectively collected craniofacial database was performed. All patients undergoing FOA by a single craniofacial team at a single institution from 1997 to 2011 were examined. Inclusion criteria were as follows: (1) unicoronal, bicoronal, or metopic synostosis; (2) resorbable endocortical fixation of the bandeau; and (3) follow-up for 1 year or longer. Evaluation included patient demographic data, postoperative clinical course, and computed tomography imaging when available. Results Seventy-three patients met the inclusion criteria. Fusion involved the unicoronal (n = 26), bicoronal (n = 19), and metopic (n = 28) sutures. Mean age at operation was 8.3 months (range, 2.7–35.5 mo), and follow-up was 4.5 years (range, 1.0–9.9 y). No endocortical or ectocortical sterile abscesses were documented in our series. Postoperative complications included hematoma (n = 2), infection (n = 2), wound breakdown (n = 3), cerebral contusion (n = 2), and cerebrospinal fluid leak (n = 1); none of these issues were related to endocortical absorbable fixation. Fifty-eight patients (80%) were categorized as Whitaker classification I/II; and 15 patients (20%), Whitaker classification III/IV. Postoperative computed tomography (mean follow-up, 4.6 y) was obtained in 34 patients (47%). All plates were completely resorbed, and there were no bone or soft tissue irregularities in the region where the plates were placed. Conclusions Endocortical resorbable fixation is a safe and effective method of osseous stabilization during FOA for craniosynostosis in young children.