Travis T. Tollefson

Global surgical initiatives to reduce the surgical burden of disease.

A 12-YEAR-OLD GIRL INVOLVED IN A MOTOR VEHICLE crash is transported to a district hospital in subSaharan Africa with a femur fracture and splenic laceration. Because resources and surgical personnel are limited, resuscitation efforts for the injured girl are inadequate. However, governments, the World Health Organization (WHO), funding agencies, and international nongovernmental organizations (NGOs) are beginning to reassess the importance of surgical services in developing countries and to prioritize the support, resources, training, and workforce required. Global surgical initiatives are hindered by the lack of data reflecting the magnitude of the unmet need. In this Viewpoint, we (1) describe the progress of global surgery initiatives, (2) delineate research priorities, (3) review metrics that assess the cost-effectiveness of surgical services, and (4) discuss approaches to building surgical capacity to reduce the global surgical burden of disease.

Pediatric facial trauma.

Purpose of reviewTo review the epidemiology, evaluation, and treatment of pediatric facial trauma, with emphasis on the unique challenges encountered in the pediatric patient. Current controversies in management will be discussed. Recent findingsMuch of the current literature relating to pediatric facial trauma focuses on the etiology and epidemiology of these injuries, with few studies concentrating on the management. In general, treatment of pediatric maxillofacial fractures is more conservative than in adults. When open reduction and internal fixation is necessary, either temporary placement of permanent titanium plating systems or absorbable plating is recommended. Increasing use of resorbable plating systems in rigid fixation of pediatric fractures is noted; however, these have not become the standard of care. ConclusionPediatric facial fractures are relatively uncommon, but can cause significant short-term and long-term morbidity. A thorough understanding of the unique characteristics in the growing maxillofacial skeleton is a requisite for surgeons encountering these injuries.

Advances in facial reanimation.

Purpose of reviewFacial paralysis often has a significant emotional impact on patients. Along with the myriad of new surgical techniques in managing facial paralysis comes the challenge of selecting the most effective procedure for the patient. This review delineates common surgical techniques and reviews state-of-the-art techniques. Recent findingsThe options for dynamic reanimation of the paralyzed face must be examined in the context of several patient factors, including age, overall health, and patient desires. The best functional results are obtained with direct facial nerve anastomosis and interpositional nerve grafts. In long-standing facial paralysis, temporalis muscle transfer gives a dependable and quick result. Microvascular free tissue transfer is a reliable technique with reanimation potential whose results continue to improve as microsurgical expertise increases. Postoperative results can be improved with ancillary soft tissue procedures, as well as botulinum toxin. SummaryThe paper provides an overview of recent advances in facial reanimation, including preoperative assessment, surgical reconstruction options, and postoperative management.

Advances in the treatment of microtia

Purpose of reviewCreating the fine details of the ear in a patient with a congenital absent ear is extremely challenging. Each component of the multidisciplinary team that manages the ear reconstruction, hearing restoration, and associated craniofacial anomalies of these patients has seen recent progress. Recent findingsPopulation studies have provided new insights into the etiology of microtia. Novel techniques for costal cartilage harvest, implantation, and positioning add to the techniques of Brent and Nagata, which remain the gold standard for microtia repair. Advances in the use of alloplasts and tissue-engineered cartilage appear promising. SummaryTechnical advances in combined aural atresia/microtia reconstruction, bone-anchored prosthetics, bone-anchored hearing aides, and use of alloplastic implants provide numerous options to patients and practitioners. Implantable, tissue-engineered auricular frameworks appear to be a promising option for the future.

Pediatric tracheotomy: Indications and decannulation outcomes

The objective of this study was to determine if there are differences in decannulation rates and duration of cannulation between pediatric patients undergoing tracheotomy for different indications.

Efficacy of Crosseal Fibrin Sealant (Human) in Rhytidectomy

OBJECTIVE To examine the potential efficacy of Crosseal (the human protein, bovine component-free fibrin sealant) (OMRIX Biopharmaceuticals, Ltd, Brussels, Belgium) to reduce ecchymoses and hematoma formation in patients undergoing rhytidectomy. METHODS Before initiation of the study, approval was obtained from the US Food and Drug Administration for an Investigational New Drug Application and off-label use of Crosseal and from the Institutional Review Board of the University of California, Davis. Patients undergoing rhytidectomy with or without concomitant procedures were voluntarily enrolled without compensation in the study (N = 9). Patients were randomized according to which side of the rhytidectomy the tissue sealant was placed. In all patients in the study, 1 side of the rhytidectomy was treated with Crosseal; the other, untreated side was used as a control. Before closure of the skin, 2 mL of Crosseal was sprayed through a pressure regulator under the skin flap of the dissected area of the rhytidectomy only on 1 side. The skin was pretrimmed before placement and closed in standard fashion. A pressure dressing was left in place for 3 days before removal. Nine patients were originally enrolled in the study. On postoperative days 3 and 7, photographs were taken of the patients. The photographs were judged by 5 independent reviewers who were blinded as to which side had been treated with Crosseal. The judges rated the degree of ecchymoses on a scale of 1 (minimal) to 10 (severe) and were asked their opinion as to which side of the facelift had been treated with Crosseal. These results were compared using statistical analysis. Also on days 3 and 7, patients were examined for seroma or hematoma formation on each side of the face. RESULTS Our study demonstrated efficacy of Crosseal in reducing ecchymoses and swelling in all patients. The mean score for ecchymosis on the Crosseal-treated side was 4.5 and on the untreated (control) side was 6.2 (P < .01, Wilcoxon rank sum test). The rate of hematoma or seroma formation was 22% (2 of 9 patients) for the untreated side vs 0% (0 of 9 patients) for the treated side. This did not reach statistical significance (P = .43, Fisher exact test). Small hematomas developed in 2 patients on the control side, which were needle aspirated. There were no known long-term complications from either the use of Crosseal or the rhytidectomy. CONCLUSION Crosseal is efficacious in reducing ecchymoses after rhytidectomy.

Mandibular Distraction Osteogenesis Used to Treat Upper Airway Obstruction

OBJECTIVE To evaluate whether mandibular distraction osteogenesis relieves tongue-based airway obstruction in patients with severe micrognathia. DESIGN Retrospective medical review spanning a 7-year period in a tertiary care hospital. The inclusion criterion was defined as micrognathia associated with a severe tongue-based obstruction. The patients included 11 neonates and infants (mean age, 4.3 months) and 2 pediatric patients (mean age, 5.4 years). Two patients had already received tracheotomies, 11 had not. The intervention was bilateral mandibular osteotomies with distraction osteogenesis. The outcome measures were avoidance of tracheotomy and decannulation. RESULTS Ten of 11 patients avoided tracheotomy. Two of 2 patients who had already undergone tracheotomies were successfully decannulated. CONCLUSION Mandibular distraction osteogenesis is an acceptable treatment alternative to tracheotomy in select pediatric patients with micrognathia and severe tongue-based obstruction.

Recent advances in presurgical molding in cleft lip and palate

Purpose of reviewAlthough many protocols for treating infants with cleft lip and palate have been successful, the severely wide deformities often require a multidisciplined team approach. Maxillary appliances have been used for 50 years; however, nasal molding is a relatively recent development that has shown progress but not without stalwart criticism. Recent findingsPresurgical nasal alveolar molding is an evolving technique in the treatment of cleft lip and palate. Used properly, molding can create improved nasal symmetry in unilateral cases and columellar lengthening in bilateral cases. Some regression of improvement is often seen in the following years due to differential growth patterns within the nasal subunits. The nasal septal and columellar deviation seen in unilateral cleft lip and palate can also be improved with a novel device. SummaryAlthough traditional repair of the cleft lip and nasal deformity is often adequate, severely wide clefts are amenable to a variety of presurgical measures. Presurgical nasal alveolar molding in children with cleft lip and palate allows repositioning of the maxillary alveolus and surrounding soft tissues in hopes of reducing wound tension and improving results. These techniques can be extremely challenging but an excellent addition to a cleft lip and palate teams armamentarium.

Force requirements for artificial muscle to create an eyelid blink with eyelid sling.

OBJECTIVE To determine the force requirements, optimal vector, and appropriate materials of a novel eyelid sling device that will be used to rehabilitate eyelid closure (blink) in congenital or acquired permanent facial paralysis with an artificial muscle. METHODS The force required to close the eyelids in human cadavers (n = 6) were measured using a load cell system. The eyelid sling using either expanded polytetrafluoroethylene (ePTFE) or temporalis muscle fascia was implanted. The ideal vector of force and placement within the eyelid for a natural eyelid closure were compared. RESULTS The eyelid sling concept was successful at creating eyelid closure in a cadaver model using an upper eyelid sling attached to the distal tarsal plate. Less force was necessary to create eyelid closure using a temporalis muscle fascia sling (627 +/- 128 mN) than for the ePTFE eyelid sling (1347 +/- 318 mN). CONCLUSIONS The force and stroke required to close an eyelid with the eyelid sling are well within the attainable range of the electroactive polymer artificial muscle (EPAM). This may allow the creation of a realistic and functional eyelid blink that is symmetric and synchronous with the contralateral, normally functioning blink. Future aims include consideration of different sling materials and development of both the EPAM device and an articulation between the EPAM and sling. The biocompatibility and durability studies of EPAM in a gerbil model are under way. The successful application of artificial muscle technology to create an eyelid blink would be the first of many potential applications.

Use of intraoperative computed tomography for maxillofacial reconstructive surgery.

IMPORTANCE Intraoperative computed tomography (CT) provides surgeons with real-time feedback during maxillofacial trauma and reconstructive surgery, which can affect intraoperative decision making. OBJECTIVES To evaluate the time needed to perform intraoperative CT scans during maxillofacial surgery, determine any trend toward shorter total scan times as experience is gained with the technique, and identify the characteristics of cases that required intraoperative revision based on the results of intraoperative CT scanning. DESIGN, SETTING, AND PARTICIPANTS A retrospective review was completed for all maxillofacial reconstruction procedures that used intraoperative CT between January 1, 2012, and March 31, 2014. INTERVENTIONS Patients were cared for by the routine practice pattern of the authors. Intraoperative CT scans were obtained for all patients. MAIN OUTCOMES AND MEASURES Time needed for intraoperative CT scan was measured and trends were analyzed. Covariates included age, sex, complexity of fracture, procedure type, total scan time, surgeon, and need for intraoperative revision based on intraoperative CT findings. RESULTS Thirty-eight cases were identified, including 30 males (79%) and 8 females (21%). The mean (SE) age was 37.4 (16.0) years (range, 7-75 years). Cases were defined as routine (18 [47%]) or complex (20 [53%]). Isolated orbital fractures were the most common fracture (23 [61%]) in both the routine (14 [78%]) and complex (9 [45%]) cases. The mean (SE) total scan time was 14.5 (4.9) minutes (range, 6-27 minutes) and did not differ based on complexity (P = .34). Intraoperative revisions were performed in 9 patients (24%) and were more common in complex (n = 8) than routine (n = 1) cases (P = .004). There was no reduction in total scan time during the study period (P = .22). The mean (SE) scan time for the most experienced surgeon was 3.78 (1.53) minutes shorter than for the other surgeons as a group (P = .02). CONCLUSIONS AND RELEVANCE Current intraoperative CT scanning techniques are rapid, averaging 14.5 minutes per case. No decrease in total scan time was noted during the study; however, the surgeon most experienced with the CT software had the shortest total scan times. Intraoperative revisions were most common in complex cases. We recommend surgeons consider the use of intraoperative CT imaging for maxillofacial reconstruction, particularly in complex procedures. LEVEL OF EVIDENCE NA.