"Longitudinal Experience Using Pedicled Buccal Fat Pad Flaps in Cleft Palatoplasty: Mitigating Velopharyngeal Insufficiency Risk and Severity".

BACKGROUND: Cleft palatoplasty commonly results in denuded maxillary bone in the lateral gutter(s) and a posterior void between oral and nasal closures. Bony exposure of the anterior palate subjects the maxilla to scarring and growth restriction, while scar contracture of the posterior void may result in velopharyngeal insufficiency (VPI) and fistula formation. Utilization of the buccal fat pad flap (BFPF) at the time of palatoplasty provides vascularized tissue over these critical areas, thereby reducing the rate of secondary surgery for speech and fistula revision. METHODS: A single-center, retrospective review identified patients who underwent palatoplasty with or without BFPF between 1995-2015. Data collected included cleft type, surgical technique, follow-up duration, and complications. Outcomes included rate of speech surgery and palatal fistula development. Veau phenotype index was computed on a scale of 2-4 as a weighted mean to reflect the frequency of cleft type (Veau II-IV) in BFPF and non-BFPF groups. RESULTS: Charts of 866 patients were reviewed; 212 met inclusion criteria. Of these, 101 received a BFPF. Mean follow-up duration was 11.4 years. Despite a selection bias for more severe clefts, the BFPF group had lower incidence of speech surgery (9.9% vs. 36.9%, p=0.0072). The BFPF group had more mild cases treatable with fat injection (7.9% vs. 2.7%, p=0.0346) and developed fewer fistulas (6.9% vs. 18.0%, p=0.0280). CONCLUSION: Despite the presence of more severe clefts, the BFPF group had a significantly lower rate of speech surgery. The BFPF is a valuable adjunct in primary palatoplasty, reducing VPI and fistula formation.

Management of Dog Bite Injuries: Procedural Sedation, Infection, and Operative Indications at a Single-Institution Level I Pediatric Trauma Hospital.

BACKGROUND: Dog bite injuries are common within the pediatric population. Currently, there are inconclusive data on best sedation practice, antibiotic regimen, and need for plastic surgery referrals for treatment of dog bite injuries in the emergency department (ED) versus operating room (OR). This study set out to determine sedation practice, infection management, and necessity for plastic surgery referral at a level I pediatric trauma center. METHODS: A retrospective review of all pediatric (0-18 years old) dog bites documented in electronic medical records from January 1, 2010, to December 31, 2019, was performed. Bitten by dog encounters were identified by International Classification of Diseases, Ninth Revision and Tenth Revision codes E906.0 and W54.0, W54.0XXA, and W54, respectively. Data gathered included age, gender, month of injury, circumstance of injury, injury characteristics, location of repair, person performing repair, sedation (if used, then length of sedation), inpatient admission, antibiotics prescribed, dog characteristics (breed, size, sex, age, relationship to patient), and complications. Summary statistics were calculated as mean ± SD. Comparisons for nominal variables were performed using the χ2 test. All analyses were performed using Stata v.16. 1. RESULTS: A total of 1438 pediatric patients were included in this study over a 10-year period. Of injuries requiring repair (n = 846), most repairs were performed in the ED (97.1% [822/846]), whereas 24 (2.8%) required repair in the OR. Of the bites that required repair (n = 846), 81.1% (686/846) were performed by an emergency medicine physician and 147 (17.4%) by plastic surgeons. Procedural sedation in the ED was performed in 146 repairs (17.3%). Documented sedation time ranged from 10 to 96 minutes. Most patients received a prescription for antibiotics (80.5%), usually amoxicillin/clavulanate (90.8%). Infection was the most common sequela (9.5%). There was no significant difference in infection rates between repairs performed in the ED versus those in the OR. CONCLUSION: Our study indicates that pediatric patient dog bite injuries can be successfully managed in an ED. Procedural sedation has demonstrated no increased safety risks compared with the OR. Rates of infection are also not demonstrated to be significantly higher in repairs done in the ED versus those taken to operating theater.

Monobloc Differential Distraction Osteogenesis.

ABSTRACT: Midface advancement at the monobloc level can be the seminal life event for patients with craniofacial dysostosis. Monobloc reconstruction, when planned appropriately, can simultaneously and definitively address multiple functional and aesthetic deficiencies in these patients. The application of distraction has reduced the morbidity experienced with traditional monobloc surgery. The purpose of this study is to report on the outcomes, stability, and growth in younger patients after monobloc advancement in syndromic craniosynostosis patients. The authors report a consecutive series of thirty patients with craniofacial dysostosis treated through monobloc differential distraction osteogenesis. Detailed history, photographic, and long-term radiographic data are reviewed, including a subset of patients who were skeletally immature at the time of their treatment. Differential distraction allows control of midface pitch, roll, and yaw, optimizing functional and aesthetic outcomes. There were no infectious complications requiring reoperation. The average surgical age for all patients was 12.5 years. For the 7 patients age <7 years, average age was 6 years. For all patients, the mean horizontal movement was 12 mm at nasion and 10 mm at A-point. At mean follow-up (4.8 years entire group and 6.2 years age <7 years group) a positive horizontal advancement of 1.1 mm at nasion and 0.8 mm at A-point was observed. More pronounced positive horizontal changes were seen in the age <7 years group. Monobloc differential distraction osteogenesis affords safe and precise repositioning of the midface. The advancement is skeletally stable and young patients show moderate continued growth.

Salvage or Solution: Alloplastic Reconstruction in Hemifacial Microsomia.

INTRODUCTION: Skeletal reconstruction in severe grades of hemifacial microsomia (HFM) continues to be challenging. Traditional techniques of autografts and osseous distraction for reconstruction of the glenoid fossa, condyle, and ramus can fall short of expectations and can create new problems. This intercontinental study analyzes the role of alloplastic skeletal rehabilitation in severe HFM. METHODS: Ten consecutive patients with Pruzansky grade III HFM were reconstructed between October 2014 and July 2017 at 2 craniofacial centers following the same protocol. Data were gathered retrospectively from the medical records, including photographs and virtual planning records. Pre and postoperative photos were taken to compare occlusal status, interincisal opening, sagittal mandibular projection, and posterior facial height. Alloplastic reconstruction was accomplished using a custom designed titanium implant. RESULTS: Ten consecutive skeletally mature patients with HFM with failed traditional reconstructions were successfully treated with virtually planned alloplastic reconstructions (11 joints) and simultaneous orthognathic surgery. The glenoid fossa, condyle, and ramus on the affected sides were reconstructed with custom designed titanium implants. All patients achieved occlusal stabilization, normalization of posterior facial height and sagittal mandibular projection, and maintenance or improved inter-incisal opening. There were no major complications or repeated surgeries. Follow-up ranges from 6 to 50 months. CONCLUSION: Alloplastic reconstruction allows for precise vertical reconstruction of the ramus and condyle and sagittal repositioning of the mandibular body. The glenoid fossa component is firmly anchored to the skull base assuring a stable centric relation on the reconstructed side. Consistent and acceptable results can be achieved in skeletally mature patients.