Impact of puberty on procedure frequency for treatment of simple head and neck lymphatic and venous malformations.

OBJECTIVE: Puberty has been shown to accelerate growth of vascular malformations, including lymphatic (LM) and venous malformations (VM). This study aims to compare the number of procedures performed before and after puberty in patients with LM and VM to assess whether the onset of puberty results in higher treatment frequency. METHODS: A retrospective review of head and neck LM and VM patients who were evaluated between January 2009 and December 2019 was performed. Patient demographics, lesion characteristics, and procedural details were recorded. For the purposes of this study, 11 years or older in females and 12 years or older in males were the established cut-offs for the onset of puberty. RESULTS: After initial screening of 357 patients, 83 patients were included in the study based on inclusion criteria. There were 34 patients with LM (41 %) and 49 with VM (59 %). The mean age at diagnosis was 6.1 ± 10.9 years (LM: 4.2 ± 7.0, VM: 7.4 ± 12.9, p = 0.489). 68 patients underwent treatments, which included sclerotherapy, surgical excision, and/or laser. For all patients, the average number of lifetime treatments when initiated before puberty was 3.78 ± 2.81 and when initiated after puberty was 2.17 ± 1.37 (p = 0.022). Patients diagnosed pre-puberty were more likely to undergo treatments vs. those diagnosed after puberty (OR 10.00, 95 % CI: 2.61-38.28, p < 0.001). CONCLUSION: We found that the number of treatments was fewer in those who started treatment after puberty. This finding suggests that providers may elect to proceed with observation in asymptomatic patients, given that waiting until after the onset of puberty has not shown an increase in the procedural load on patients.

Late-Presenting Sagittal Craniosynostosis: An Update to a Standardized Treatment Protocol.

BACKGROUND: The authors previously published their protocol to treat patients who present with sagittal craniosynostosis after the age of 1 year. The purpose of this article is to present a follow-up and update of this cohort to evaluate outcomes of their treatment protocol. METHODS: Patients with isolated sagittal craniosynostosis who presented after the age of 1 year between July of 2013 and April of 2021 were included. RESULTS: A total of 108 patients met inclusion criteria. The average age at presentation was 5.2 ± 3.4 years, and 79 patients (73.1%) were male. The indications for imaging were head shape (54.6%), headache (14.8%), trauma (9.3%), seizure (4.6%), papilledema (2.8%), and other (13.9%). Of the 108 patients, 12 (11.1%) underwent surgery following their initial consultation: five for papilledema, four for elevated intracranial pressure, two for severely scaphocephalic head shapes, and one for abnormal funduscopic findings. Two of these patients underwent additional reconstructive surgery, one for the recurrence of papilledema and headache and the other for progressive scaphocephaly. The average length of time between operations was 4.9 years. Of the 96 patients who were managed conservatively, four (4.2%) underwent surgery at an average of 1.2 ± 0.5 years later (average age, 4.4 ± 1.5 years) for brain growth restriction ( n = 2), aesthetic concerns ( n = 1), and refractory headaches ( n = 1). The average follow-up of all patients with craniofacial surgery was 2.7 ± 2.3 years (median, 2.1 years; interquartile range, 3.7 years). CONCLUSIONS: Patients with late-presenting sagittal craniosynostosis require surgical correction less often than younger patients, likely because of milder phenotype. Few patients in the conservative treatment arm ultimately required surgery (4%). CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Non-involuting congenital hemangioma with delayed hypertrophy: A case series.

BACKGROUND: Noninvoluting congenital hemangiomas (NICH) are rare and poorly understood vascular tumors that are present at birth, characterized by lack of growth after birth and lack of involution. We report uncharacteristic cases of NICH hypertrophy occurring later in life. METHODS: This is a case series describing the clinical presentation, management, and histologic characteristics of two cases of NICH hypertrophy. RESULTS: Two patients with a NICH of the scalp experienced lesion hypertrophy in teenage or early adult life. Case 1 is a 14-year-old female who presented with a flat left parietal scalp lesion that at first grew slowly with the patient; however, over the span of months grew substantially resulting in an exophytic lesion. The patient had the lesion surgically excised. Case 2 is a 26-year-old female with NICH of left occipital scalp and posterior neck who noted new nodules on the inferior border of the lesion. MRA/MRI showed extension into the occipital calvarium, level V of the neck, and paraspinal musculature. The patient elected to observe given the extent of the lesion and her minimal symptoms. CONCLUSION: Although postnatal growth of NICH have been described, cases usually occur during the pre-adolescent period where growth is usually proportional to overall growth of the patient. This study describes two cases of rapid onset NICH hypertrophy occurring later in life. Knowledge of the potential for delayed hypertrophy may lead families to seek earlier intervention or opt for more definitive interventions. Additionally, recognition of these variable distinctions will contribute to a better understanding of CH and its various subtypes.

Tissue Augmenting Palatoplasty for the Treatment of Velopharyngeal Insufficiency.

PURPOSE: Persistent velopharyngeal insufficiency (VPI) following primary palatoplasty remains a difficult problem to treat. This study evaluates speech outcomes following revision palatoplasty with tissue augmentation using buccal myomucosal flaps (BMF) as an alternative to pharyngoplasty for patients with VPI. METHODS: A retrospective single-center review of revision palatoplasty with tissue augmentation at a tertiary pediatric hospital Cleft-Craniofacial Center between January 2017 and March 2021 was conducted. Patients with a history of previous palatoplasty, a diagnosis of persistent or recurrent VPI, and comprehensive pre- and postoperative speech evaluations who underwent revision palatoplasty with BMF were included. RESULTS: Twenty patients met inclusion criteria (35% female, 20% syndromic). Mean age at the time of revision palatoplasty with BMF was 9.7 years. Preoperatively, all patients had stigmatizing speech and received the recommendation for speech surgery; the mean Pittsburgh Weighted Speech Score (PWSS) was 14.3 ± 4.9. The mean postoperative PWSS at the most recent assessment was 4.2 ± 2.3, representing a statistically significant improvement from preoperative scores (P < .001). Mean follow-up time was 8.9 months. Following revision palatoplasty with BMF, only one patient has received the recommendation for further speech surgery. No complications were noted. CONCLUSION: In patients with VPI following primary palatoplasty, revision palatoplasty with tissue augmentation offers an alternative to pharyngoplasty. This approach preserves dynamic velopharyngeal function, improves speech outcomes, and should be considered an option when treating patients with post-primary palatoplasty VPI.

Objective Analysis of Fronto-Orbital Dysmorphology in Unilateral Coronal Craniosynostosis.

ABSTRACT: Correction (and over-correction) of asymmetries of the orbital shape and brow position in unilateral coronal craniosynostosis (UCS) is critical to successful fronto-orbital advancement. Here we quantify and three-dimensionally assess fronto-orbital irregularities in UCS patients compared to controls.Twenty-three patients with UCS evaluated at the Children's Hospital of Pittsburgh between 2006 and 2016 were age and gender-matched to controls. Computed tomography scans were reconstructed and evaluated for orbital metrics. A three-dimensional heat map of orbital regions was generated and evaluated for shape differences.Brow protrusion of the orbit ipsilateral to the synostotic suture did not differ significantly from healthy controls. Orbital height was significantly increased while orbital width was decreased on the UCS ipsilateral side compared to the contralateral side and controls. The ipsilateral cornea was overprojected relative to the brow and the infraorbital rim, but similar to controls relative to the lateral rim. The contralateral orbit had increased brow protrusion with decreased orbital height. The cornea was underprojected relative to the brow, but overprojected relative to the lateral orbital rim and similar to controls at the infraorbital rim. Three-dimensional comparison demonstrated significant overprojection of the contralateral brow, with some more mild and inconsistent underprojection of the lateral aspect of the ipsilateral brow.Key orbital and brow differences exist between the affected and unaffected sides in UCS. This study provides quantitative data that further characterize the orbital dysmorphology observed in UCS and identifies unique aspects of the diagnosis that should be taken into consideration during surgical planning.

Outcomes of Furlow Double-Opposing Z-Plasty Palatoplasty for the Treatment of Symptomatic Overt and Occult Submucous Cleft Palate: A Comparison Study.

BACKGROUND: The submucous cleft palate can be overt or occult and may require surgical repair. The double-opposing Z-plasty (Furlow repair) is the authors' center's preferred approach. This study evaluated complication rates, differences in outcome between overt and occult types, and patient factors associated with surgical failure. METHODS: This retrospective study reviewed documentation on all patients who underwent Furlow Z-plasty for submucous cleft palate at a single center between 2004 and 2018. Speech pathology was quantified using the Pittsburgh Weighted Speech Score. RESULTS: A total of 351 patients were included (125 overt and 226 occult cases). Furlow Z-plasty was successful (postoperative Pittsburgh Weighted Speech Score <7 without recommendation for secondary speech surgery) in 291 patients (82.1 percent). Apart from those requiring secondary surgery, there were no documented complications. Occult-type patients were 7.5 years old at palatoplasty with a speech score of 14.1; overt-type patients were 6.5 years old with a score of 15.7. Postoperative speech scores were similar for both groups. Secondary speech surgery patients had a higher preoperative score (16.9 versus 14.2). Age at time of palatoplasty and submucous cleft palate type were not predictive of the need for secondary surgery. Syndromic patients had higher preoperative and postoperative speech scores (15.6 and 7.5, respectively) than nonsyndromic patients (14.3 and 4.3) and needed secondary surgery more often (24.4 percent versus 9.2 percent). V-shaped velar vaulting on preoperative assessment was present in 92 percent of occult-type patients. CONCLUSIONS: Furlow palatoplasty is a safe and effective means of repairing submucous cleft palate. Patients with the occult type presented later with a lower Pittsburgh Weighted Speech Score. High preoperative speech score and syndromic status were associated with the need for secondary speech surgery. V-shaped velar vaulting is a reliable sign of occult submucous cleft palate. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Pediatric Craniofacial Fractures From Canine Bites.

ABSTRACT: Craniofacial fractures from canine bites are rare, but can be devastating events that lead to complex surgical management, long-term functional deficits, and psychological sequelae. The objective of this case-control study was to identify risks associated with craniofacial fractures in pediatric dog bite victims. From 2008 to 2019 at our quaternary center, all children with craniofacial fractures from dog bites were included in this study. Controls were obtained in a 2:1 ratio via a random sample of all dog bite encounters. Logistic regression was used to calculate odds ratios (OR) with 95% confidence intervals (CI). Of 3602 dog bite encounters, 114 children were included in the study with an average age of 4.8 years (interquartile range = 2.4-9.1 years) and 51 patients (45%) were female. Seventy-four children (65%) were bitten by a family-owned dog. Thirty-eight patients with 60 craniofacial fractures were identified. The following factors were significantly associated with increased risk for craniofacial fractures: Caucasian race (OR 7.3, CI 1.6-16.7), age under five (OR 4.1, CI 1.6-10.7), rural location (OR 3.9, CI 1.3-12.3), child location on the floor (OR 6.2, CI 2.4-16.2), and dogs weighing over 30 pounds (OR 19.6, CI 5.8-82.3). Nine patients (12%) required multiple reconstructive operations, and four patients (5%) developed post-traumatic stress disorder. In conclusion, toddlers in rural households with large dogs are at high risk for sustaining craniofacial fractures from bite injuries. Craniofacial surgeons, pediatricians, and emergency department physicians should use these data to lead prevention efforts in the community.

Undiagnosed Normocephalic Pancraniosynostosis Presenting as Bilateral Abducens Nerve Palsy.

ABSTRACT: Primary pancraniosynostosis is a rare variant of craniosynostosis in which the major cranial sutures prematurely fuse. Single-suture craniosynostosis is often recognized early in life due to an abnormal head shape. In contrast, primary pancraniosynostosis may be diagnosed later in life due to a grossly normal head shape and size. As such, these children can present with symptoms related to chronically elevated intracranial pressure (eg, vision loss or cognitive impairment). This report highlights a patient with primary pancraniosynostosis associated with unique neurologic sequelae-namely, bilateral abducens nerve palsy. A 9-year-old boy presented to the ophthalmologist with a 1-month history of double vision, drifting of his right eye toward the nasal bridge, and intracranial hypertension evident with papilledema. Physical examination was notable for mild bitemporal narrowing. A computed tomography study demonstrated radiologic thumbprinting, diffuse osseous sclerosis, and fusion of the bilateral coronal, sagittal, metopic, and lambdoid sutures. The patient underwent emergent cranial vault expansion with fronto-orbital advancement. Papilledema had resolved 4 months following surgery. At 2-year follow-up, abducens nerve palsy and head shape were significantly improved. This study brings attention to an unreported presenting symptom of pancraniosynostosis (bilateral abducens nerve palsy). This information may lead to quicker diagnosis and treatment of pancraniosynostosis-induced intracranial hypertension, which is critical to prevent long-term sequelae.

Interleukin-10 Does Not Augment Osseous Regeneration in the Scarred Calvarial Defect Achieved with Low-Dose Biopatterned BMP2.

BACKGROUND: Large calvarial defects represent a major reconstructive challenge, as they do not heal spontaneously. Infection causes inflammation and scarring, further reducing the healing capacity of the calvaria. Bone morphogenetic protein-2 (BMP2) has been shown to stimulate osteogenesis but has significant side effects in high doses. BMP2 has not been tested in combination with antiinflammatory cytokines such as interleukin-10. METHODS: Sixteen New Zealand White rabbits underwent 15 × 15-mm flap calvarectomies. The flap was incubated in Staphylococcus aureus and replaced, and infection and scarring were allowed to develop. The flap was subsequently removed and the wound débrided. A 15 × 15-mm square of acellular dermal matrix biopatterned with low-dose BMP2, interleukin-10, or a combination was implanted. Computed tomographic scans were taken over 42 days. Rabbits were then killed and histology was performed. RESULTS: Defects treated with BMP2 showed significantly (p < 0.05) greater osseous regeneration than untreated controls. Interleukin-10 did not significantly augment the healing achieved with BMP2, and interleukin-10 alone did not significantly increase healing compared with controls. Histology showed evidence of bone formation in defects treated with BMP2. Untreated controls and defects treated with interleukin-10 alone showed only fibrous tissue in the defect site. CONCLUSIONS: Low-dose BMP2 delivered directly to the scarred calvarial defect augments bony healing. Interleukin-10 at the dose applied did not significantly augment healing alone or in combination with BMP2. Healing had not finished at 42 days and analysis at later time points or the use of higher doses of BMP2 may yield greater healing.

Pediatric Cranioplasty.

Historically, the approach to pediatric cranioplasty has been largely extrapolated from the treatment of adults. More recently, however, the intricacies of pediatric cranial reconstruction have become better understood, and the surgical management has been refined contemporaneously. Each patient's cranial defect bears a unique set of challenges and, as such, the choice of cranioplasty technique must be tailored accordingly.

Pediatric Dog Bite Prevention: Are We Barking Up the Wrong Tree or Just Not Barking Loud Enough?

OBJECTIVES: The objectives of this study were (1) to evaluate dog bite-related injuries and associated medical documentation and (2) to compare these results with a study of dog bites from the same institution 10 years prior. METHODS: Data were retrospectively collected from a pediatric emergency department from July 2007 to July 2011 for patients treated for dog bites. These data were then compared with data from the same institution from 10 years prior. RESULTS: A total of 1017 bite injuries were treated (average, 254.25 bites/year), which represents a 25% increase compared with 10 years prior. Comparing the 1997 and 2007 to 2011 cohorts, patient demographics, bite rate among children less than 5 years old, rate of dog breed documentation, and setting of injury were similar. Dog breed was reported in 47% (95% confidence interval [CI], 40.2-53.9) and 41% (95% CI, 38.0-44.0) of cases, respectively, in the 2 cohorts. Bites to the craniofacial region were most common (face only reported for 1997: 43.2%; 95% CI, 36.4-50 versus 2007-2011: 66.1%; 95% CI, 63.2-69.0). In both cohorts, the child's home was the most frequent setting, accounting for 43% of bites (1997: 95% CI, 30.2-55.9 and 2007-2011: 95% CI, 39.3-46.7). CONCLUSIONS: Pediatric dog bites continue to occur frequently, and the associated factors did not change over the 10-year period: young age of child, bites to the craniofacial region, and dogs familiar to the child. Although accurate medical documentation of dog bites is a prerequisite to develop effective prevention strategies, current medical documentation of dog bites may be misguided.

Reconstruction of a Calvarial Wound Complicated by Infection: Comparing the Effects of Biopatterned Bone Morphogenetic Protein 2 and Vascular Endothelial Growth Factor.

Bone morphogenetic protein 2 (BMP2) bioprinted on biological matrix induces osseous regeneration in large calvarial defects in rabbits, both uncomplicated and scarred. Healing in unfavorable defects scarred from previous infection is decreased due in part to the lack of vascularity. This impedes the access of mesenchymal stem cells, key to osseous regeneration and the efficacy of BMP2, to the wound bed. The authors hypothesized that bioprinted vascular endothelial growth factor (VEGF) would augment the osseous regeneration achieved with low dose biopatterned BMP2 alone. Thirteen New Zealand white rabbits underwent subtotal calvariectomy using a dental cutting burr. Care was taken to preserve the underlying dura. A 15 mm × 15 mm flap of bone was cut away and incubated in a 1 × 108 cfu/mL planktonic solution of S aureus before reimplantation. After 2 weeks of subsequent infection the flap was removed and the surgical wound debrided followed by 10 days of antibiotic treatment. On postoperative day 42 the calvarial defects were treated with acellular dermal matrix bioprinted with nothing (control), VEGF, BMP2, BMP2/VEGF combined. Bone growth was analyzed with serial CT and postmortem histology. Defects treated with BMP2 (BMP2 alone and BMP2/VEGF combination) showed significantly greater healing than control and VEGF treated defect (P < 0.5). Vascular endothelial growth factor treated defect demonstrated less healing than control and VEGF/BMP2 combination treatments achieved less healing than BMP2 alone though these differences were nonsignificant. Low dose BMP2-patterned acellular dermal matrix improves healing of scarred calvarial defects. Vascular endothelial growth factor at the doses applied in this study failed to increase healing.

A Multimodal Preemptive Analgesic Protocol for Alveolar Bone Graft Surgery: Decreased Pain, Hospital Stay, and Health Care Costs.

OBJECTIVE: To evaluate postoperative pain, hospital length of stay (LOS), and associated costs of multiple perioperative analgesic strategies following alveolar bone grafting (ABG). DESIGN: Retrospective comparative cohort study. SETTING: Tertiary care pediatric hospital. PATIENTS/PARTICIPANTS: Iliac crest bone graft (ICBG) harvest techniques: "Open Harvest" (n = 22), "Trephine Only" (n = 14), or "Trephine + Pain Pump" (n = 25). INTERVENTION: The "Open Harvest" group underwent open ICBG harvest with 3-walled osteotomies. For the other 2 treatment groups, a trephine drill was used to harvest iliac crest bone with a ropivacaine infusion pump into the hip donor site ("Trephine + Pain Pump") or without ("Trephine Only"). Patients who underwent ABG with only cadaveric allograft were analyzed as a comparison group ("No Harvest"). MAIN OUTCOMES MEASURES: Outcomes were planned prior to data collection: maximum pain score, hospital LOS, and associated health care costs. RESULTS: Maximum pain scores were significantly higher in the "Open Harvest" group (7.3/10) compared to "Trephine + Pain Pump" (1.8/10; P < .0001) and "No Harvest" groups (2.8/10; P < .01). Hospital LOS decreased from 2.4 days ("Open Harvest") to 0.5 days (Trephine + Pain Pump"; P < .0001). Twelve (48%) patients from "Trephine + Pain Pump" were discharged on the day of surgery. The "Trephine + Pain Pump" saved an estimated $5336 for a unilateral ABG and $7265 for a bilateral ABG compared to "Open Harvest." CONCLUSIONS: The combined use of the trephine ICBG technique and ropivacaine infusion catheter effectively decreased pain, shortened hospital stay, and improved cost saving compared to patients who have undergone other methods of ICBG.

Ceftriaxone-Resistant Aeromonas hydrophila Infection Following Leech Therapy: A New Resistant Strain.

We report a case of ceftriaxone-resistant Aeromonas hydrophila infection in a 32-year-old man after medicinal leech therapy. The patient underwent a free gracilis muscle flap for dorsal foot soft tissue reconstruction. Because of persistent congestion after venous revision, medicinal leech therapy was initiated to aid in flap salvage. Intravenous ceftriaxone was administered prior to application of leeches for prophylaxis against A. hydrophila. Leech therapy was discontinued after 1 week, and ceftriaxone was discontinued 24 hours thereafter. An infection developed despite being on appropriate antibiotics. Culture sensitivities indicated that A. hydrophila was resistant to ceftriaxone.

Ruptured Pseudoaneurysm of the Maxillary Artery and Its Branches Following Le Fort I Osteotomy: Evidence-Based Guidelines.

BACKGROUND: Although rare, pseudoaneurysms (PA) can develop following Le Fort I osteotomy and lead to life-threatening hemorrhage. However, the typical presentation of a PA following a Le Fort I osteotomy is not well characterized. Evidence-based guidelines are not currently available for evaluation of PA following Le Fort I osteotomy. METHODS: A case report is presented of a 27-year-old man who underwent Le Fort I advancement and subsequently developed a bleeding PA. A comprehensive search of journal articles was performed using the MEDLINE/PubMed database between 1964 and April 2016. Keywords and phrases used were "(osteotomy OR craniofacial OR orthognathic) AND (pseudoaneurysm OR aneurysm OR epistaxis)." Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) guidelines were followed. RESULTS: The literature search yielded 13 reports of 18 patients. All 18 patients underwent Le Fort I osteotomy and subsequently developed a delayed postoperative bleeding PA. All studies were level IV or V evidence. Twenty-eight percent (N = 5) of the cases documented "excessive" intraoperative bleeding or more than 500 mL of estimated blood loss. The average time for the first bleeding episode and time until final bleed was 17.3 ±â€Š14.3 days (range: 3-62 days) and 27.8 ±â€Š21.2 days following surgery (range: 6-77 days), respectively. Sixty-seven percent (N = 12) had multiple episodes of bleeding. The duration between the bleeding events averaged 10.6 (± 7.9 days) with a range of 1 to 35 days. Bleeding PA's were treated with image-guided embolization (15/18 patients; 83.3%) or ligation or clamping (3/18 patients; 16.7%). CONCLUSION: In the setting of recurrent and/or delayed postoperative epistaxis following Le Fort I osteotomy, surgeons should maintain a high clinical suspicion for PA. Ruptured PA's are often preceded by multiple episodes of progressively worsening epistaxis. Based on the presented case report and pooled data from the literature, angiography is recommended to evaluate for PA in the setting of recurrent epistaxis following Le Fort I osteotomy, especially within the first 4 weeks following surgery.

Dog bites in a U.S. county: age, body part and breed in paediatric dog bites.

AIM: To compare characteristics of gender, age, body part and breed in dog bites. METHODS: We reviewed 14 956 dog bites (4195 paediatric) reported to the Allegheny County Health Department, USA, between 2007 and 2015. Using predefined age groups, we performed linear regression to assess for subject age and bite frequency and used binary logistic regression to evaluate for differences in gender and body part. We used chi-squared test with Bonferroni correction to evaluate for differences in reported breeds with age. RESULTS: There was a negative correlation (-0.80, r2 = 0.64) between age and bite frequency. Children 0-3 years had a higher odds ratio (OR) of bites to the face [21.12, 95% confidence interval (CI): 17.61-25.33] and a lower OR of bites to the upper (OR: 0.14, 95% CI: 0.12-0.18) and lower (OR: 0.19, 95% CI: 0.14-0.27) extremities. 'Pit bulls' accounted for 27.2% of dog bites and were more common in children 13-18 years (p < 0.01). Shih-Tzu bites were more common in children three years of age and younger (p < 0.01). CONCLUSION: Dog bites occur with higher frequency at younger ages, and head and neck injuries are more common in younger children. Pit bull bites are more common in adolescents and Shih-Tzu bites more common in younger children.

Asymmetric Multisutural Craniosynostosis: an Algorithm of Early Intervention to Prevent Evolving Deformity.

BACKGROUND: Asymmetric multisutural craniosynostosis (AMC) is characterized by fusion of a midline suture combined with unilateral fusion of at least 1 nonmidline suture. Due to its rarity, complexity, and high rate of reoperation, the purpose of this study is to evaluate outcomes of our staged approach to AMC. METHODS: Patients treated for craniosynostosis between January 2004 and December 2013 were identified retrospectively. Only patients with AMC and a minimum follow-up of 2 years were included. The 3-staged algorithm includes: extended strip craniectomy of fused sutures; postoperative helmet molding; and fronto-orbital advancement versus a touch-up procedure. Morphologic, aesthetic, and functional outcomes were evaluated. RESULTS: Nine patients (6.8% of cases) were treated for AMC (mean follow-up: 4.1 years). Sixty-seven percent of patients (6 of 9) demonstrated signs of elevated intracranial pressure. Patients were divided into 2 groups: "Group A" included patients treated according to the staged algorithm (n = 5); "Group B" included those treated by traditional techniques (n = 4). Group A underwent their first calvarial vault procedure earlier than those from Group B (2.7 vs. 13.2 months; P < 0.02). Postoperatively, no Group A patients had developmental delay, signs of elevated intracranial pressure, or reoperation. Three of 5 patients (60%) were rated Whitaker Classification II and the others (40%) rated Whitaker Classification III. CONCLUSIONS: Asymmetric multisutural synostosis results in a complex and evolving deformity involving the entire craniofacial complex. However, when asymmetric multisutural synostosis is approached in stages with early intervening helmet therapy, acceptable functional and appearance-related outcomes can be obtained with minimal complications. LEVEL OF EVIDENCE: III.

Lateral thigh perforator flap for breast reconstruction: Computed tomographic angiography analysis and clinical series.

PURPOSE: Although abdominal-based flaps remain the first choice for autologous breast reconstruction, alternative donor sites are necessary when the abdomen is unavailable. Abdominal donor site suitability is determined, at times, according to deep inferior epigastric perforator (DIEP)-protocol computed tomographic angiography (CTA) results. CTA provides information about the pelvis/upper thigh that can be used to evaluate the suitability of other donor sites. This study aimed to examine the utility of DIEP-protocol CTA in the assessment of a lateral thigh perforator (LTP) flap. Furthermore, a small clinical LTP flap breast reconstruction series was presented. METHODS: The LTP flap anatomy was studied in 100 DIEP-protocol CT angiographies (200 thighs). Collected data included lateral circumflex femoral artery (LCFA) origin; number, type, and course of LTPs; pedicle characteristics; and reference point measurements. Relative relationships between reference point anatomy and perforator anatomy were analyzed. RESULTS: Perforators originated from the LCFA ascending branch (4.6 mm average diameter), averaging 2.6 perforators/thigh. The mean estimated pedicle length was 7.7 cm (±0.7 cm). Septocutaneous perforators were present in 97% (1.8 perforators/thigh). Musculocutaneous perforators were present in 64% (0.9 perforators/thigh). The mean distance between anterior superior iliac spine and perforator was 9.9 cm (±1.5 cm). Perforators were located 0.13 cm (±1.1 cm) below the pubic symphysis. Our LTP flap clinical series featured dissection in the supine position and primary donor site closure and highlighted the difficulty in flap design (six patients, nine LTP flaps). CONCLUSIONS: LTPs are consistent, reliably present, and radiographically appear to be suitable for microsurgical transfer. DIEP-protocol CTA is an acceptable method for imaging the pertinent LTP anatomy.

Nipple-areola complex reconstruction improves psychosocial and sexual well-being in women treated for breast cancer.

INTRODUCTION: Women choose to undergo nipple-areola complex (NAC) reconstruction as part of breast reconstruction following breast cancer treatment. However, the effect of this procedure on psychosocial and sexual well-being is not well studied. The present study aimed to evaluate how NAC reconstruction affects patient satisfaction with regard to psychosocial and sexual well-being. METHODS: A retrospective chart review was performed for all patients who underwent NAC reconstruction at Magee-Women's Hospital from January 1, 2004 to July 31, 2011. A letter and questionnaire based on the BREAST-Q were mailed to patients to request their participation in the study. Patient satisfaction and health-related quality of life were measured before and after NAC reconstruction. RESULTS: In total, 107 of 328 patients (32.6%) completed the survey. The BREAST-Q scale score for satisfaction with outcome following NAC reconstruction was 85.1 ± 15.8, with higher satisfaction scores for patients with a follow-up of <1.5 years than those with a follow-up of >2.5 years (82.5 ± 21.7 vs. 69.5 ± 19.5; p < 0.01). No significant differences were found in satisfaction with the breast mound before and after NAC reconstruction. Women scored significantly higher on the psychosocial and sexual well-being scales after NAC reconstruction (p < 0.002 and 0.00004, respectively). CONCLUSIONS: This study indicates that patients are highly satisfied after undergoing NAC reconstruction. Satisfaction with the procedure, however, may decrease over time. NAC reconstruction significantly contributes to patient psychosocial and sexual well-being, and this effect did not change over time. NAC reconstruction improves patient outcomes in those who choose to undergo the procedure.