Diagnostic accuracy of maxillofacial trauma two-dimensional and three-dimensional computed tomographic scans: comparison of oral surgeons, head and neck surgeons, plastic surgeons, and neuroradiologists.

BACKGROUND: The authors' objectives were to study differences in diagnostic accuracy between two- and three-dimensional computed tomographic scans and among the specialties of plastic surgery, head and neck surgery, oral surgery, and neuroradiology, since this had not previously been done. METHODS: Four groups of subspecialists completed time-proctored tests of 20 maxillofacial trauma scans with zygomatic arch, zygomatic complex, orbital, Le Fort I, II, III, mandibular and panfacial fractures from five institutions (n = 40). Accuracy of diagnosis and indication for surgery, efficiency, and preference were assessed. Comparison between two- and three-dimensional scans, between expert (experienced attending) versus novice (resident/fellow), and among the four subspecialties was performed. RESULTS: For two- and three-dimensional scans, two-dimensional was more accurate for orbital floor/medial wall (40 percent and 34 percent) and frontal sinus (26 percent for diagnostic) fractures. Two-dimensional examinations took 2.3 times longer but were preferred (85 percent). Experts and novices had similar accuracy with three-dimensional scanning, but experts were more accurate with the two-dimensional scanning. Experts were 3.3 times faster with two-dimensional scanning but not with three-dimensional scanning. Accuracy of diagnosis among subspecialists was similar, except that oral surgery was less accurate with orbitozygomatic fractures (79 percent versus 90 to 92 percent); neuroradiology was less accurate with indications for surgery (65 percent versus 87 to 93 percent). CONCLUSIONS: Differences in diagnostic accuracy exist between two- and three-dimensional maxillofacial scans and between expert and novice readers but not between subspecialties. Combined modalities are preferred.

Microform cleft lip repair with intraoral muscle interdigitation.

BACKGROUND: With a microform (forme fruste) cleft lip, obtaining an optimal functional and esthetic result is a challenge to a reconstructive surgeon. We describe modifications to existing techniques by Mulliken, Furlow, and Cutting that provides an optimal functional result with correction of the cleft furrow, vermillion notch, and cleft nose deformity. METHODS: Sequential unilateral microform cleft lip patients underwent our microform cleft lip repair modified from the following 3 techniques: the Mulliken microform cleft lip repair with no cutaneous scar, the Furlow complete cleft lip repair with interdigitating muscle, and the Cutting cleft nose repair (n = 12). From follow-up (1 year) examinations, photographs (and 3-dimensional images), and video, 3 reviewers scored esthetic and functional outcomes using a 0 to 4-point scale. In addition, parental surveys were obtained. RESULTS: For our microform cleft lip repair, there were no infections, bleeding, or other complications. Esthetic outcome score, evaluating the cutaneous scar, symmetry of philtral columns, alignment of lip line and vermillion border, and nasal tip symmetry was a mean of 3.7 (+/-0.3). Thus, the reviewers' scored the cleft lip and nose repair as "Very Good" (minor cleft lip/nose deformity but no need for revision) to "Excellent" (Imperceptible cleft lip or nose deformity). The functional outcome score, based on the ability to smile, pucker their lips, and whistle, was a mean of 3.8 (+/-0.2). The parental survey, including postoperative course, functional, and cosmetic outcome, demonstrated a high level of satisfaction with a score of 3.9 (+/-0.2). CONCLUSIONS: The modified microform cleft lip and nose technique provided very good to excellent esthetic and functional results in a series of patients with this rare deformity.

Pfeiffer syndrome twins: despite improved correction in one twin, growth disturbance results in similar need for subsequent monobloc advancement.

BACKGROUND: Twins with Pfeiffer syndrome (or acrocephalosyndactyly) had a similar phenotypic appearance with findings of classic or type 1 Pfeiffer syndrome, including bicoronal and sagittal craniosynostoses, midface hypoplasia, and broad thumbs/toes. We document their treatment with 2 monobloc advancements and discuss growth disturbances in craniofacial dysostosis. METHODS: At 6 months, both twins underwent release of multisuture (bilateral coronal and sagittal) fusions for improvement of scaphocephalic shape and multisuture release; however, one twin had a more aggressive procedure with advancement of the frontal-orbital region. Despite improved initial correction by one twin, at 5 years of age, both twins presented with midface hypoplasia and exorbitism and underwent a monobloc distraction procedure with similar 20-mm advancements. Comparative analysis by our craniofacial multidisciplinary team included perioperative reports, computed tomographic scans, cephalograms, parent questionnaires, and physician surveys. RESULTS: Both twins had an improved confidence interval scores from 84 to 68 and 82 to 69 postoperatively. In 6-month follow-up, the Whitaker score of the first twin was 2.8, whereas that for the second twin with the frontal-orbital advancement was 1.2. Preschool expressive and receptive tests yielded 97 and 95, and 97 and 98, and developmental testing was similar between the twins. Global evaluations were equivalent to age-matched controls, and memory and attention skills were within normal limits. Parental surveys showed a high level of satisfaction after all procedures in both twins. CONCLUSIONS: Our study demonstrates that the phenotypic outcome for both twins remained unchanged when comparing a more aggressive surgery to less aggressive surgery as an infant. The genetic mutation may have overridden the different surgical interventions. Both twins ultimately required 2 subsequent monobloc corrections.

Three tenets for staged correction of Kleeblattschädel or cloverleaf skull deformity.

BACKGROUND: Patients with cloverleaf skull deformity are known to have high morbidity and poor outcome. Physical anomalies include a misshapen, trilobar skull, with a high "bossed" forehead, a bulging temporal region, and a flat posterior skull from multiple cranial suture fusion. METHODS: Patients with cloverleaf skull deformity treated at the University of California, Los Angeles from 1990 to 2006 (n = 14) underwent early cranial vault remodeling (group 1) or staged correction with ventriculoperitoneal shunt (neonate), fronto-orbital advancement (3 to 6 months), and posterior vault remodeling (1 year) (group 2). Morbidity, necessary revisions, and neurologic (developmental testing) and aesthetic (Whitaker score) outcomes were assessed at follow-up. RESULTS: Diagnoses included Apert syndrome, Crouzon syndrome, Pfeiffer syndrome, Saethre-Chotzen syndrome, and nonsyndromic. Early cranial vault remodeling patients had more complications than staged correction patients [pneumonia, meningitis, and excessive bleeding (each 66 percent versus 9 percent); wound infection (66 percent versus 18 percent); and seizure (100 percent versus 0 percent)]. Early cranial vault remodeling patients had prolonged intensive care unit and hospital stays compared with staged correction patients (13 versus 2 days and 27 versus 5 days, respectively). The Whitaker score showed acceptable results at 18 months in group 2 (1.4, no revisions necessary) but not in group 1 (2.8, minor to major bony recontouring). Developmental tests showed that all early cranial vault remodeling patients had lower scores in both preschool tests and global evaluations compared with normative data (mean preschool receptive scores, 95 versus 85; mean preschool expressive scores, 94 versus 87). CONCLUSION: Staged correction of cloverleaf skull provided acceptable neurologic and aesthetic outcomes in the authors' series of patients.

Roman arch, keystone fixation for facial bipartition with monobloc distraction.

BACKGROUND: Patients with craniofacial dysostosis may require correction for hypertelorbitism and midface hypoplasia. Traditionally, these procedures were sequential or staged, and used acute advancement with bone grafting and rigid fixation. The authors reviewed a series of combined, one-stage facial bipartition and monobloc distraction procedures using internal devices. They describe the Roman arch, keystone fixation modification to maximize the stability of the bipartition segments and support the vertical load of the distraction forces. METHODS: Patients diagnosed at the University of California, Los Angeles as having craniofacial dysostosis with hypertelorbitism and midface hypoplasia who underwent the Roman arch, keystone fixation procedure were included in the study (n = 13). Reduction of interdacryon and intercanthal distances and the lateral cephalometric horizontal change of the forehead, midface, and maxilla were studied postoperatively and at 1-year follow-up. RESULTS: There were no serious complications (e.g., cerebrospinal fluid leak, meningitis, frontal bone loss); there was a 10 percent rate of total complications (wound infection). Facial bipartition successfully narrowed the interdacryon distance by a mean of 55 percent (21 mm), with only a 3-mm relapse. The mean distraction advancement/relapse was as follows: forehead, +16 mm/-2 mm; midface, 14 mm/-1 mm; and maxilla, 13 mm/-1 mm. Only one of 13 patients required a repeated monobloc procedure. Of the seven patients who reached skeletal maturity, 86 percent underwent a subsequent Le Fort I and/or III procedure. CONCLUSION: The Roman arch, keystone fixation modification of a combined facial bipartition with monobloc distraction using internal devices provided a stable construct for advancement, with minimal relapse.