Relationship of a Metopic Ridge and Anterior Cranial Volume Measured by a Noninvasive Laser Shape Digitizer.

Cranial dysmorphology observed in patients with metopic craniosynostosis varies along a spectrum of severity including varying degrees of metopic ridging, bitemporal narrowing, and trigonocephaly. Management has been based upon the subjective clinical impression of presence and severity of trigonocephaly. Severity of cranial dysmorphology does not predict the occurrence or severity of associated abnormal neurodevelopment, as children with mild-to-moderate trigonocephaly may also experience developmental delays. The authors sought to determine the relationship between mild-to-moderate trigonocephaly and anterior cranial volume using a noninvasive laser shape digitizer (STARscanner) in patients with abnormal head shape.An IRB-approved retrospective review of a prospectively maintained database and medical records was performed. Two hundred three patients less than 1 year of age with abnormal head shape were categorized as having a metopic ridge with mild-to-moderate trigonocephaly, metopic ridge without trigonocephaly, or no ridge. Measurements of cranial volume, circumference, and symmetry were calculated by the STARscanner, which quantifies three-dimensional shape of the cranial surface. Measures were analyzed using a series of analyses of variance and post-hoc Tukey honest significant difference.The authors results showed ACV was significantly reduced in patients with mild-to-moderate trigonocephaly compared with those without metopic ridge (P = 0.009), and trended toward significance compared with those with a ridge but without trigonocephaly (P = 0.072). The ratio of anterior-to-posterior cranial volume was significantly reduced in those with mild-to-moderate trigonocephaly compared with those without metopic ridge (P = 0.036).In conclusion, patients with milder anterior cranial deformities demonstrated an association between a metopic ridge with mild-to-moderate trigonocephaly and reduced anterior cranial volume.

Use of the On-Q Pain Pump in Alveolar Bone Grafting: Effect on Hospital Length of Stay.

OBJECTIVE: Alveolar bone grafting (ABG) with iliac crest bone graft can be associated with significant pain at the donor site. The On-Q pain pump has been shown to be efficacious in treating postsurgical pain. The aim of this study was to compare the length of postoperative hospital stay in patients undergoing ABG who received the On-Q pain pump at the iliac crest donor site (On-Q+) with that of patients who did not receive the On-Q pain pump (On-Q-). DESIGN: A retrospective, cohort study, approved by institutional review board, was performed. Thirty-one consecutive patients in the On-Q- group were compared with 38 consecutive patients in the On-Q+ group. The two cohorts were assessed for length of stay. Statistical analysis was performed using the Fisher exact probability test. SETTING: Tertiary care academic medical center. PATIENTS: Sixty-nine patients with cleft lip and/or cleft palate (CL/P) undergoing secondary ABG with iliac crest bone graft were operated on between May 1993 and January 2014. MAIN OUTCOME MEASURE: Length of postoperative hospital stay. RESULTS: Mean length of stay in the On-Q- patients was 0.52 days versus 0.37 days for the On-Q+ patients. This difference between the two cohorts was not statistically significant (P = .234). CONCLUSION: Although there is a trend toward a shorter length of stay in our patients who received the On-Q pump, this finding was not statistically significant. Given the expense and additional burden of care associated with the device, we have become more selective in its utilization.

Intraoperative tissue expansion in the surgical correction of craniosynostosis.

BACKGROUND: Wound healing complications can occur after calvarial vault expansion due to tension on the scalp flaps. OBJECTIVES: To compare wound healing outcomes in patients with craniosynostosis undergoing calvarial vault expansion with and without intraoperative tissue expansion of the scalp. METHODS: The present analysis was an institutional review board-approved, retrospective cohort study involving 40 consecutive patients at the University of Missouri Hospitals and Clinics (Columbia, Missouri, USA) who underwent calvarial vault expansion for nonsyndromic craniosynostosis between June 1, 2009 and June 30, 2012. Patients were divided into two sequential cohorts: the first 20 underwent calvarial vault expansion without intraoperative tissue expansion; the second 20 underwent calvarial vault expansion with intraoperative tissue expansion. The main outcome measures included presence or absence of wound healing complications (persistent scabbing or slow-healing wounds, hardware exposure, need for operative wound revision or healed but widened scars), with documented postoperative follow-up of at least three months. The primary end point was the presence of a well-healed scar; the secondary end point was the need for an operative revision. RESULTS: Patients in the intraoperative tissue expansion group had a higher percentage of well-healed scars (73.6%) than those in the nonexpansion group (42.1%) (P=0.0487). This difference was primarily due to scar widening in the nonexpansion group. CONCLUSIONS: The present study demonstrated that the use of intraoperative tissue expansion in patients with nonsyndromic craniosynostosis who underwent calvarial vault expansion resulted in a greater likelihood of a well-healed incision with a lower rate of poor scarring.

HISTORIQUE: Après une expansion de la calotte crânienne, la cicatrisation peut être compliquée par la tension exercée sur les lambeaux du cuir chevelu. OBJECTIFS: Comparer les résultats de la cicatrisation chez des patients ayant une craniosténose soignée par expansion de la calotte crânienne accompagnée ou non d'une expansion peropératoire des tissus du cuir chevelu. MÉTHODOLOGIE: La présente analyse, une étude de cohorte rétrospective approuvée par le conseil d'examen de l'établissement, a été réalisée auprès de 40 patients consécutifs des hôpitaux et des cliniques de l'université du Missouri (Columbia, Missouri, États-Unis) qui ont été soignés pour une craniosténose non syndromique au moyen d'une expansion de la calotte crânienne entre le 1er juin 2009 et le 30 juin 2012. Les chercheurs ont divisé les patients en deux cohortes séquentielles. Les 20 premiers ont subi une expansion de la calotte crânienne sans expansion peropératoire des tissus et les 20 suivants, une expansion de la calotte crânienne accompagnée d'une expansion peropératoire des tissus. Les principales mesures de résultats incluaient la présence ou l'absence de complications de la cicatrisation (gales persistantes ou guérison ralentie, exposition à un corps étranger, nécessité d'une chirurgie corrective ou guérison, mais élargissement des cicatrices), étayée par un suivi postopératoire d'au moins trois mois. Le paramètre primaire était la présence d'une cicatrice bien guérie et le paramètre secondaire, la nécessité de procéder à une chirurgie corrective. RÉSULTATS: Les patients faisant partie du groupe soigné par expansion peropératoire des tissus présentaient un pourcentage plus élevé de cicatrices bien guéries (73,6 %) que ceux du groupe n'ayant pas subi cette expansion (42,1 %) (P=0,0487). Cette différence était surtout attribuable à l'élargissement des cicatrices dans le groupe n'ayant pas subi cette expansion. CONCLUSIONS: La présente étude démontre que l'expansion peropératoire des tissus chez les patients ayant une craniosténose non syndromique soignés par expansion de la calotte crânienne était plus susceptible de présenter une incision qui guérissait bien et qui cicatrisait mieux.

Prenatal counseling's effect on rates of neonatal intensive care admission for feeding problems cleft lip/palate infants.

Prenatal counseling and feeding instruction is standard at our institution for parents of cleft lip and palate patients. We studied this intervention's effect on Neonatal Intensive Care Unit (NICU) admission solely for feeding. Ten percent (2/20) of patients whose parents received counseling were admitted to the NICU for feeding issues alone compared to 21% (5/24) of the non-counseling group. Prenatal counseling and feeding instruction appears to decrease NICU admission, duration and health care costs.

Endoscopy-assisted wide-vertex craniectomy, barrel stave osteotomies, and postoperative helmet molding therapy in the management of sagittal suture craniosynostosis.

OBJECT: Endoscopic techniques were introduced 7 years ago for the surgical management of patients with sagittal synostosis. In this study of 139 patients with sagittal synostosis, the authors assessed the efficacy, safety, complications, and outcomes after performing endoscopy-assisted wide-vertex craniectomies with bitemporal and biparietal barrel stave osteotomies. METHODS: The sample population consisted of a total of 99 boys and 40 girls who ranged in age from 0.4 to 9.2 months (mean 3.6 months). Two small incisions were made near the lambda and vertex. Using endoscopic visualization, wide-vertex craniectomies with bilateral temporal and parietal barrel stave osteotomies were performed. Postoperative treatment included custom-made surlyn cranial orthotic devices for cranial reshaping and maintenance. The mean craniectomy width was 5.4 cm and the length was 10 cm. The overall blood transfusion rate was 9% (two intraoperative and 12 postoperative transfusions). The mean estimated blood loss was 29 ml (range 5-150 ml). The mean preoperative hematocrit was 32%, whereas the postoperative level was 27%. One hundred thirty-two patients were discharged the morning following surgery. The majority of patients did not experience facial swelling, and none suffered postoperative fevers. Anthropometric cephalic index measurements indicated that excellent results were obtained in 87% of the patients (cephalic index > 75); good results in 8.7% (cephalic index 70-75); and poor results in 4.3% (cephalic index > 70). There were no cases of intraoperative death, infection, hemorrhage, or venous sinus injury. CONCLUSIONS: Analysis of the results indicates that use of the aforedescribed procedure in the early treatment of infants with sagittal synostosis provides excellent outcomes and that the morbidity rate is lower than that associated with traditional cranial vault reconstruction. Detailed anthropometric and radiographic analyses demonstrated that with adequate helmet therapy in our patients normocephaly was achieved and maintained without the need for secondary operations.