Zoe M. MacIsaac

Nonfatal sport-related craniofacial fractures: characteristics, mechanisms, and demographic data in the pediatric population

Background: Few reports exist on sport-related craniofacial fracture injuries in the pediatric population. Most patients with craniofacial injuries are adults, and most studies on pediatric sport injuries do not focus specifically on craniofacial fractures. The authors’ goal was to provide a retrospective, descriptive review of the common mechanisms of sport-related craniofacial injuries in the pediatric population, identifying the characteristics of these injuries and providing a description of the demographics of this population. Methods: The study population included children between the ages of 0 and 18 years who were seen in the emergency department at Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center between 2000 and 2005. Of the 1508 patients identified, 167 had injuries caused by sport-related trauma (10.6 percent). Results: After evaluation in the emergency department, 45.5 percent were hospitalized, and 15.0 percent of these were admitted to the intensive care unit. The peak incidence of sport-related injuries occurred between the ages of 13 and 15 years (40.7 percent). Nasal (35.9 percent), orbital (33.5 percent), and skull fractures (30.5 percent) were most common, whereas fractures of the maxilla (12.6 percent), mandible (7.2 percent), zygomaticomaxillary complex (4.2 percent), and naso-orbitoethmoid complex (1.2 percent) were observed less frequently. Baseball and softball were most frequently associated with the craniofacial injuries (44.3 percent), whereas basketball (7.2 percent) and football (3.0 percent) were associated with fewer injuries. The most common mechanisms of injury were throwing, catching, or hitting a ball (34.1 percent) and collision with other players (24.5 percent). Conclusion: These data may allow targeted or sport-specific craniofacial fracture injury prevention strategies.

Management of failed alveolar bone grafts: improved outcomes and decreased morbidity with allograft alone.

Background: This study demonstrates the safety and efficacy of allograft alone in revision alveolar bone graft surgery. Methods: A retrospective review of the authors’ institution’s alveolar bone graft experience (from 2004 to 2012) with open iliac crest bone graft, minimal-access iliac crest bone graft plus supplemental allograft, and revision allograft alone was performed. All patients (n = 47) were treated with alveolar fistula repair with primary closure. Results: Group 1 patients (12 male, 10 female; average age, 10 years) received iliac crest bone graft alone; 17 had unilateral and five had bilateral clefts. Group 2 (eight male, six female; average age, 9 years) received an iliac crest bone graft plus allograft; six clefts were unilateral and eight were bilateral. Group 3 (six male, five female; average age, 13 years) received revision allograft alone; seven clefts were unilateral and four were bilateral. Average operative time/alveolus was shortest in group 3 compared with groups 1 and 2 (p < 0.0005). Average engraftment was better in group 3 than in group 1 (p < 0.001) and similar to that in group 2 (p < 0.079). Revision alveolar bone graft with allograft alone improved Enemark scores from 3.7 preoperatively to 1.0 postoperatively (p < 0.0001). Hospital stay was shortest in group 3 compared with groups 1 and 2 (p < 0.0001). Bone graft extrusion occurred in six patients (27.3 percent) in group 1, no complications occurred in group 2, and a single necrotic central incisor was lost at the time of revision bone grafting in group 3 (9.1 percent). Conclusion: Allograft alone is safe and effective and provides a reliable alternative when traditional alveolar bone graft with iliac crest bone graft has failed. CLINICAL QUESTIONS/LEVEL OF EVIDENCE: Therapeutic, III.

Improving speech outcomes after failed palate repair: evaluating the safety and efficacy of conversion Furlow palatoplasty.

BackgroundVelopharyngeal insufficiency occurs in a nontrivial number of cases following cleft palate repair. We hypothesize that a conversion Furlow palatoplasty allows for long-term correction of VPI resulting from a failed primary palate repair, obviating the need for pharyngoplasty and its attendant comorbidities. MethodsA retrospective review of patients undergoing a conversion Furlow palatoplasty between 2003 and 2010 was performed. Patients were grouped according to the type of preceding palatal repair. Velopharyngeal insufficiency was assessed using Pittsburgh Weighted Speech Scale (PWSS). Scores were recorded and compared preoperatively and postoperatively at 3 sequential visits. ResultsSixty-two patients met inclusion criteria and were grouped by preceding repair (straight-line repair (n = 37), straight-line repair with subsequent oronasal fistula (n = 14), or pharyngeal flap (n = 11). Median PWSS scores at individual visits were as follows: preoperative = 11, first postoperative = 3 (mean, 114.0 ± 6.7 days), second postoperative = 1 (mean, 529.0 ± 29.1 days), and most recent postoperative = 3 (mean, 1368.6 ± 76.9 days). There was a significant difference between preoperative and postoperative PWSS scores in the entire cohort (P < 0.001) with overall improvement, and post hoc analysis showed improvement between each postoperative visit (P < 0.05) with the exception of the second to the most recent visit. There were no differences between postoperative PWSS scores in the operative subgroupings (P > 0.05). Eight patients failed to improve and showed no differences in PWSS scores over time (P > 0.05). Patients with a PWSS score of 7 or greater (n = 8) at the first postoperative visit (0–6 months) displayed improvement at the most recent visit (P< 0.05). ConclusionsConversion Furlow palatoplasty is an effective means for salvaging speech. Future studies should elucidate which factors predict the success of this technique following failed palate repair.

Novel animal model of calvarial defect: part III. Reconstruction of an irradiated wound with rhBMP-2.

Background: Recombinant human bone morphogenetic protein-2 (rhBMP-2) has been shown to be an effective therapy in the acute calvarial defect wound and in calvarial defects complicated by chronic scar. The authors compared the effectiveness of rhBMP-2 with the accepted standard of autologous graft for repair of irradiated calvarial defects. Methods: Nineteen adult New Zealand White rabbits underwent subtotal calvariectomy. Four days postoperatively, animals received 15 Gy to their wound. Six weeks postoperatively, scars were débrided and defects reconstructed in one of four groups: empty (n = 3), vehicle (buffer solution/absorbable collagen sponge; n = 3), cryopreserved autograft, (n = 3), or rhBMP-2 repair (rhBMP-2/absorbable collagen sponge, n = 10). Animals underwent computed tomography imaging at 0, 2, 4, and 6 weeks, followed by euthanization and histological analysis. Percent healing was determined and a 4 × 3 mixed model analysis of variance was performed on healing versus treatment group/postoperative time. Results: According to radiopacity, rhBMP-2/sponge and autografts were statistically equivalent, with 99 and 89 percent healing at 6 weeks. Empty and vehicle treatment groups, with 35 and 34 percent healing, were inferior to the rhBMP-2/sponge and autograft groups (p < 0.05). Histologically, bone in the surgical control (autograft) group was less cellular and trabecular than bone formed after rhBMP-2/sponge treatment. Conclusions: rhBMP-2 therapy was as effective in reconstructing calvarial defects in the unfavorable irradiated wound as in the acute, favorable calvarial wound. Compared with cryopreserved autologous graft, rhBMP-2–regenerated bone resulted in equal defect coverage, similar thickness, and greater cellularity. Further studies are necessary to demonstrate the long-term viability and remodeling rhBMP-2/sponge–generated bone.

Discussion: Limited Evidence for the Effect of Presurgical Nasoalveolar Molding in Unilateral Cleft on Nasal Symmetry

V der Heijden et al. have effectively captured their argument in the title of the preceding article, “Limited Evidence for the Effect of Presurgical Nasoalveolar Molding in Unilateral Cleft on Nasal Symmetry: A Call for Unified Research.” Before offering our discussion of this article, we must report two disclosures. First, our center uses presurgical infant orthopedics in all cleft cases whenever feasible. Presurgical infant orthopedics ideally takes the form of nasoalveolar molding. When nasoalveolar molding is not possible secondary to anatomical or practical concerns, lip adhesion is used as a second-tier means of presurgical infant orthopedics. The consistent use of presurgical infant orthopedics has served as an integral part of achieving satisfactory cleft lip and nose deformity corrections at our center. Although this is an admittedly qualitative assessment, it is based on surgeon and patient satisfaction, in addition to what is believed to be a low rate of revision surgery as compared with that reported in the literature. The second disclosure is that the authors of this discussion do not claim particular expertise in evidence-based medicine. We approach this discussion as clinical pragmatists, not as statisticians. This is to say, we use nasoalveolar molding to facilitate the successful primary operation (particularly in bilateral complete clefts), and we have found it to be a powerful means to this end in our hands. We do not use it to guarantee long-term nasal symmetry, nor do we believe this to be its primary purpose. Nasoalveolar molding is a central part of the cleft care algorithm at our center. We believe the primary goal of its use is to prepare the patient for surgery by turning complete clefts into morphologically “incomplete clefts” and to lessen the cleft lip–nasal deformity (i.e., lengthen the columella). Improved long-term nasal symmetry is not the primary goal of nasoalveolar molding. The assumption is, however, that by making primary surgery less challenging (with either nasoalveolar molding or lip adhesion) and by transforming profound complete clefts into less daunting “incomplete clefts,” better outcomes can be achieved with the primary operation and thus fewer secondary operations will be necessary. From this standpoint, improved long-term nasal aesthetics (and indeed symmetry) is a positive secondary consequence of nasoalveolar molding. In the context of our experience, the pragmatic answer to the question “should nasoalveolar molding be part of the cleft lip treatment plan?” is “yes.” This is because we administer presurgical infant orthopedics with specific goals in mind: to close the alveolar gap and approximate the lip edges, to straighten the nose, and to grow the columella. These goals are routinely achieved with minimal morbidity and a high degree of patient and surgeon satisfaction at our center. There are many barriers, however, to a rigorous evidence-based assessment of this same question. Many variables must be optimized to ensure the maximal efficacious delivery and impact of presurgical infant orthopedics for any given patient. A truncated list of these factors affecting the outcomes of nasoalveolar molding might include the following: variations of technique, timing of intervention, strategies to address individual growth dynamics, the patient’s quality of tissue and response to molding, and compromises made to accommodate socioeconomic hindrances to delivery of care. These variables occur on a patient-

Speech Outcomes After Clinically Indicated Posterior Pharyngeal Flap Takedown.

BackgroundVelopharyngeal insufficiency affects as many as one in three patients after cleft palate repair. Correction using a posterior pharyngeal flap (PPF) has been shown to improve clinical speech symptomatology; however, PPFs can be complicated by hyponasality and obstructive sleep apnea. The goal of this study was to assess if speech outcomes revert after clinically indicated PPF takedown. MethodsThe cleft-craniofacial database of the Childrens Hospital of Pittsburgh at the University of Pittsburgh Medical Center was retrospectively queried to identify patients with a diagnosis of velopharyngeal insufficiency treated with PPF who ultimately required takedown. Using the Pittsburgh Weighted Speech Score (PWSS), preoperative scores were compared to those after PPF takedown. Outcomes after 2 different methods of PPF takedown (PPF takedown alone or PPF takedown with conversion to Furlow palatoplasty) were stratified and cross-compared. ResultsA total of 64 patients underwent takedown of their PPF. Of these, 18 patients underwent PPF takedown alone, and 46 patients underwent PPF takedown with conversion to Furlow Palatoplasty. Patients averaged 12.43 (range, 3.0–22.0)(SD: 3.93) years of age at the time of PPF takedown, and 58% were men. Demographics between groups were not statistically different. The mean duration of follow-up after surgery was 38.09 (range, 1–104) (SD, 27.81) months. For patients undergoing PPF takedown alone, the mean preoperative and postoperative PWSS was 3.83 (range, 0.0–23.0) (SD, 6.13) and 4.11 (range, 0.0–23.0) (SD, 5.31), respectively (P = 0.89). The mean change in PWSS was 0.28 (range, −9.0 to 7.0) (SD, 4.3). For patients undergoing takedown of PPF with conversion to Furlow palatoplasty, the mean preoperative and postoperative PWSS was 6.37 (range, 0–26) (SD, 6.70) and 3.11 (range, 0.0–27.0) (SD, 4.14), respectively (P < 0.01). The mean change in PWSS was −3.26 (range, −23.0 to 4.0) (SD, 4.3). For all patients, the mean preoperative PWSS was 5.66 (range, 0.0–26) (SD, 6.60) and 3.39 (range, 0.0–27) (SD, 4.48), respectively (P < 0.05). The mean change in PWSS was −2.26 (range, −23.0 to 7) (SD, 5.7). There was no statistically significant regression in PWSS for either surgical intervention. Two patients in the PPF takedown alone cohort demonstrated deterioration in PWSS that warranted delayed conversion to Furlow palatoplasty. Approximately 90% of patients, who undergo clinically indicated PPF takedown alone, without conversion to Furlow Palatoplasty, will show no clinically significant reduction in speech. ConclusionsAlthough there is concern that PPF takedown may degrade speech, this study finds that surgical takedown of PPF, when clinically indicated, does not result in a clinically significant regression of speech.

Novel animal model of calvarial defect: part IV. Reconstruction of a calvarial wound complicated by durectomy.

Background: Recombinant human bone morphogenetic protein-2 (rhBMP-2) has been shown to be an effective therapy in the acute calvarial defect wound and in calvarial defects complicated by chronic scar and radiation. The authors assessed the effectiveness of rhBMP-2–mediated bone regeneration in calvarial defects complicated by durectomy. Methods: Sixteen adult New Zealand White rabbits underwent subtotal calvariectomy and dural removal, followed by dural repair and reconstruction in one of four groups: empty (n = 3), vehicle (buffer solution on an absorbable collagen sponge, n = 2), autologous graft (n = 3), or rhBMP-2 repair (rhBMP-2/absorbable collagen sponge, n = 8). Animals underwent computed tomographic imaging at 0, 2, 4, and 6 weeks postoperatively, followed by euthanasia and histologic analysis. Percent healing was determined by three-dimensional analysis. A 4 × 3 mixed model analysis of variance was performed on healing versus treatment group/postoperative time. Results: The rhBMP-2/absorbable collagen sponge and autograft repair groups had 51.4 and 37.3 percent healing, respectively, at 6 weeks; empty and vehicle control groups had 7.8 and 17.9 percent healing, respectively, at 6 weeks. Compared with immediate favorable reconstruction (96.8 percent healing), rhBMP-2 in this setting was significantly less effective (p = 0.001). Bone in the rhBMP-2/absorbable collagen sponge group was compact and cellular but appeared only over the intact sagittal sinus and irregularly within the absorbable collagen sponge. Conclusions: Although promising in the acute calvarial wound and other complex defects, rhBMP-2 therapy is less effective in reconstruction following dural compromise. Future studies using additional growth factors and cell therapy may improve results in this especially difficult scenario.

Treatment for Infantile Hemangiomas: Selection Criteria, Safety, and Outcomes Using Oral Propranolol During the Early Phase of Propranolol Use for Hemangiomas.

Objective:Despite the increasing popularity of propranolol for treatment of infantile hemangioma (IH), there is need for further evidence of efficacy and safety. This study is a retrospective review of one institutions experience treating IH with propranolol using a standard protocol. Methods:Between 2009 and 2014, patients with IH were evaluated for treatment with propranolol. Exclusion criteria included a history of hypoglycemia, respiratory disorders, and cardiovascular disorders. Propranolol, 2 mg/kg/d, was initiated during 48-hour inpatient stay. Weight and complications were monitored. Appearance was assessed by Visual Analog Cosmetic Scale (VACS) via serial photography. Results:Twenty-three patients were treated with propranolol. Average age at initiation of therapy was 14.9 weeks. Twenty-two lesions were on the head and neck, and 1 was on the trunk. Average treatment duration was 54.3 weeks (range 24–148 wk). Treatment was confirmed to be complete in 23 patients at the time of review (91.3%). Two patients were lost to follow-up. Posttreatment color, size, and VACS improved significantly (P < 0.05). There was no significant difference between first and most recent weight. Two patients experienced hypoglycemia, 1 during a diarrheal illness and 1 during inpatient treatment initiation. Conclusion:The authors present a series of patients with IH safely treated with 2 mg/kg/d of propranolol. Using a strict protocol, few complications were observed. Patients achieved significant reduction in size and improvement of the overall appearance of IH.

Bilateral congenital amazia: A case report and systematic review of the literature

BACKGROUND Congenital breast anomalies present challenging management decisions to the plastic surgeon. One must consider the optimal age of reconstruction as well as the ideal surgical technique. Amazia, a very rare condition characterised by a complete lack of breast tissue in the presence of a nipple areolar complex (NAC), is one such congenital breast anomaly. METHODS A comprehensive systematic review of the literature was performed to examine the various approaches to reconstruction of congenital breast anomalies. From this review, the data compiled included patient demographics and operative details, including type of reconstruction, treatment of the contralateral breast and treatment of the NAC. A case of bilateral amazia is also reported. RESULTS Of 178 articles, 13 ultimately met the inclusion criteria and 54 individual patient reconstructions were identified from these papers. At the time of reconstruction, the patients were in the range of 13-54 years, with an average age of 27.6 years. Prosthetic and autologous reconstructions were equally represented (19 patients each, 35.2%; Table 2). Autologous reconstruction with prosthesis was slightly less common (15 patients, 27.8%). One patient was reconstructed using autologous lipo-augmentation only. Of the 36 cases in which the approach to the NAC was addressed, most (66.7%) were not reconstructed. CONCLUSIONS Amazia is a very rare congenital anomaly of the breast. This systematic review of the literature highlights the need for better reporting and examination of this type of data to allow for future study and to better advise on decision making regarding the timing of reconstruction, surgical technique and the approach to the NAC.

A comparison of speech outcomes using radical intravelar veloplasty or furlow palatoplasty for the treatment of velopharyngeal insufficiency associated with occult submucous cleft palate.

BackgroundThe safety, efficacy, and direct comparison of various surgical treatments for velopharyngeal insufficiency (VPI) associated with occult submucous cleft palate (OSMCP) are poorly characterized. The aim of this study was to report and analyze the safety and efficacy of Furlow palatoplasty (FP) versus radical intravelar veloplasty (IVV) for treatment of VPI associated with OSMCP. MethodsA retrospective review of one institution’s experience treating VPI associated with OSMCP using IVV (group 1) or FP (group 2) during 24 months was performed. Statistical significance was determined by Wilcoxon matched-pair, Independent-Samples Mann-Whitney U, and analysis of variance (SPSS 20.0.0). ResultsIn group 1 (IVV), 18 patients were identified from August 2010 to 2011 (12 male and 6 female patients; average age, 5.39 years). Seven patients were syndromic and 11 were nonsyndromic. In group 2 (FP), 17 patients were identified from August 2009 to 2011 (8 male and 9 female patients; average age, 8.37 years). Three patients were syndromic and 14 patients were nonsyndromic. There was statistical significance between the average pretreatment Pittsburgh Weighted Speech Score (PWSS) of the 2 groups (group 1 and 2 averages 19.06 and 11.05, respectively, P = 0.002), but there was no statistical significance postoperatively (group 1 and 2 averages 4.50 and 4.69, respectively, P = 0.405). One patient from each group required secondary speech surgery. Average operative time was greater for FP (140 minutes; range, 93–177 minutes) compared to IVV (95 minutes; range, 58–135 minutes), P < 0.001. Average hospital stay was 3.9 days for IVV (range, 2–9 days) and 3.2 days for FP (range, 2–6 days), with no significant difference (P = 0.116). There were no postsurgical wound infections, oral-nasal fistulas, postoperative bleeding complications, or mortalities. ConclusionsNonsyndromic patients with hypernasal speech are treated effectively and safely with either IVV or FP. Intravelar veloplasty trended toward lower speech scores than FP (76% IVV, 58% FP PWSS absolute reduction). Syndromic patients with OSMCP may be more effectively treated with FP (72% IVV vs 79% FP PWSS absolute reduction). Intravelar veloplasty is associated with shorter operative times. Both techniques are associated with low morbidity, improved speech scores, and low reoperative rates.