Factors Associated with Delayed Palatoplasty Before, During, and After the COVID-19 Pandemic.

BACKGROUND: Cleft palatoplasty is typically performed around 10 to 12 months of age in the US, and delays can negatively affect speech development. Early during COVID-19, elective surgeries were canceled. The aims of this study were to (1) identify overall risk factors for greater age at palatoplasty and (2) analyze delays in palatoplasty during COVID-19. METHODS: This study was part of a larger prospective, multicenter comparative study of speech outcomes in palatoplasty. Participants underwent palatoplasty between March 2019 and September 2022 at 18 pediatric hospitals in the United States. Ages were corrected for prematurity. Dates of palatoplasty were divided into 4 periods corresponding to different phases of the pandemic. Factors analyzed included region, language, adoption status, sex, ethnicity, race, rurality, health insurance type, and cleft type. Analyses were performed using ANOVA, Student's test, and multivariable linear regression, with a P value of ≤0.05 being significant. RESULTS: Nine hundred twenty-eight participants were included. Average corrected age at palatoplasty was 374 days. In univariable analysis, palatoplasty was performed later in children who were Hispanic (P=0.003), of a race other than White, Black, or Asian (P<0.001), and without private insurance (P<0.001). On multivariable regression, predictors of delayed palatoplasty were Hispanic ethnicity (P=0.015), from other race (P<0.001), and without private insurance (P<0.001). During COVID-19, disproportionate delays occurred in patients who were female, of other races, from nonrural areas, and on Medicaid. CONCLUSIONS: Palatoplasty was performed later in vulnerable populations. Some of these populations were also disproportionately affected by COVID-19 delays. Providers should be aware of these differences as they pertain to equitable access to craniofacial care. LEVEL OF EVIDENCE: III.

Prospective Evaluation of Health-Related Quality-of-Life in Children with Craniosynostosis.

OBJECTIVE: To investigate health-related quality of life (HRQL) in children aged 2 to 7 years, who have undergone surgery for craniosynostosis. DESIGN: Cross-sectional survey. SETTING: A tertiary pediatric academic medical center. PARTICIPANTS: Children with craniosynostosis who underwent surgical correction, and who were 2-7 years old at the time of the study. Children from families that did not speak English were excluded. INTERVENTIONS: Caregivers were asked to fill out the Pediatric Quality of Life Inventory (PedsQL) Core Parent Report and the PedsQL Cognitive Functioning Scale. MAIN OUTCOME MEASURES: PedsQL: Psychosocial Health Summary Score, Physical Health Summary Score, Total Core Score, Cognitive Functioning Scale Score. Scores range from 0 to 100, with higher scores reflecting greater QoLSubject factors: comorbidities, syndromic status, type of craniosynostosis, type of surgery. RESULTS: The study included 53 subjects, of whom 13.2% had a syndrome. Core and cognitive scores did not depend on presence of a syndrome or suture involved. Subjects who underwent posterior cranial distraction achieved higher Total Core Scores than subjects who underwent open vault remodeling. Among subjects with sagittal craniosynostosis, there was a tendency for higher scores among children who underwent minimally-invasive surgery compared to those who underwent open vault remodeling. CONCLUSIONS: This study demonstrates similar HRQL among children with and without a syndrome, higher HRQL among children undergoing posterior cranial distraction than those undergoing open vault remodeling, and trends towards higher HRQL in children with sagittal craniosynostosis who underwent minimally-invasive surgery compared to those who underwent open vault remodeling.

Functional outcomes between headache surgery and targeted botox injections: A prospective multicenter pilot study.

Introduction: Chronic migraine headaches (MH) are a principal cause of disability worldwide. This study evaluated and compared functional outcomes after peripheral trigger point deactivation surgery or botulinum neurotoxin A (BTA) treatment in patients with MH. Methods: A long-term, multicenter, and prospective study was performed. Patients with chronic migraine were recruited at the Ohio State University and Massachusetts General Hospital and included in each treatment group according to their preference (BTA or surgery). Assessment tools including the Migraine Headache Index (MHI), Migraine Disability Assessment Questionnaire (MIDAS) total, MIDAS A, MIDAS B, Migraine Work and Productivity Loss Questionnaire-question 7 (MWPLQ7), and Migraine-Specific Quality of Life Questionnaire (MSQ) version 2.1 were used to evaluate functional outcomes. Patients were evaluated prior to treatment and at 1, 2, and 2.5 years after treatment. Results: A total of 44 patients were included in the study (surgery=33, BTA=11). Patients treated surgically showed statistically significant improvement in headache intensity as measured on MIDAS B (p = 0.0464) and reduced disability as measured on MWPLQ7 (p = 0.0120) compared to those treated with BTA injection. No statistical difference between groups was found for the remaining functional outcomes. Mean scores significantly improved over time independently of treatment for MHI, MIDAS total, MIDAS A, MIDAS B, and MWPLQ 7 (p<0.05). However, no difference in mean scores over time was observed for MSQ. Conclusions: Headache surgery and targeted BTA injections are both effective means of addressing peripheral trigger sites causing headache pain. However, lower pain intensity and work-related disabilities were found in the surgical group.

Posterior Cranial Distraction in Craniosynostosis: A Systematic Review of the Literature.

OBJECTIVE: Posterior cranial distraction (PCD) is a surgical technique to address craniosynostosis, especially in syndromic patients. The technique has the ability to significantly expand the cranium, while requiring minimal dural dissection, compared to cranial remodeling. Our goals were to determine the patient characteristics and surgical outcomes of PCD. The two questions that we sought to answer were: 1) What is the average published complication rate and the most common complications of PCD? and 2) How much intracranial volume expansion can one expect with PCD? DESIGN: A PubMed database search of articles on PCD was performed. Case reports and articles with overlapping patients were excluded. A systematic review was performed using the remaining articles. MAIN OUTCOME MEASURES: Patient data were extracted in order to determine the total number of patients, patients with a syndrome, types of syndromes, mean age at surgery, mean distraction distance, mean increase in intracranial volume, and complications. RESULTS: 18 articles representing 325 patients were analyzed. A syndrome was present in 68.6% of patients. The mean age at time of surgery was 22.1 months. Mean distraction amount was 24.7 mm. Mean increase in intracranial volume was 253.2 cm3. The overall complication rate was 32.2%, with the most common complications being surgical-site infection, hardware-related complications and delayed wound healing. CONCLUSIONS: PCD is a powerful technique in the management of syndromic craniosynostosis, although complication rates are significantly higher than traditional remodeling techniques. Future studies should compare the effects of supratorcular and infratorcular osteotomies on intracranial volume, cosmesis and complications.

Abdominal Wall Reconstruction with Retrorectus Self-Adhering Mesh: A Single-Center Long-Term Follow-Up.

BACKGROUND: Mesh repair has been demonstrated to be superior to suture alone in ventral hernia repair. In a previous short-term pilot study, the authors found lower postoperative narcotic requirements with self-adhering mesh. The aim of this study was to follow-up on that pilot study, using long-term data. METHODS: This is a retrospective review of a prospectively collected database. All patients who underwent ventral hernia repair with retrorectus mesh and who had at least a 12-month follow-up were reviewed. Comparisons were performed between patients who received self-adhering mesh and those who received transfascially sutured mesh, using matched-pair analysis, examining perioperative outcomes, surgical-site occurrences, and hernia recurrence/bulge. RESULTS: Forty-two patients were included in the study, with 21 patients undergoing repair with transfascially sutured mesh and 21 patients receiving self-adhering mesh. Average length of follow-up was 1078 days. There were no significant differences between the two groups in baseline characteristics. Patients receiving self-adhering mesh had significantly shorter surgery, and a shorter hospital length of stay. They also had a tendency toward lower narcotic requirements. There were no significant differences in the rate of surgical-site occurrences, hernia recurrences, or bulge between the two groups. CONCLUSIONS: This long-term study shows that self-adhering mesh in ventral hernia repair results in similar long-term outcomes to transfascially sutured mesh, with shorter surgery, shorter length of stay, and a tendency toward improved pain control. These findings mirror the known advantages of self-adhering mesh in inguinal hernia repair. Further research is needed to study the incidence of chronic pain and the cost-effectiveness of self-adhering mesh. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Airway and Feeding Outcomes in Pierre Robin Sequence: A Comparison of Three Management Strategies.

BACKGROUND: Controversy remains regarding optimal management of Pierre Robin sequence (PRS). The goal of this study was to compare airway and feeding outcomes in infants with PRS who underwent surgical intervention, specifically mandibular distraction osteogenesis (MDO) or tongue-lip adhesion (TLA), or who had conservative management (CM) without surgery. METHODS: All consecutive patients treated for PRS at a pediatric academic medical center, with at least one year follow-up, were included. Patients who underwent tracheostomy as an index procedure were excluded. Patients were divided into those who underwent MDO, TLA or CM. Feeding status and data from initial and follow-up polysomnograms were collected. Comparisons between groups were made using the Kruskal-Wallis test, followed by Mann-Whitney pairwise comparison with a Bonferroni correction, when appropriate. RESULTS: 67 neonates were included. 19 underwent TLA, 29 underwent MDO and 19 underwent CM. The proportions of syndromic patients were similar between groups. Patients undergoing CM had the lowest baseline AHI (9.1), but there were no significant differences between TLA (20.1) and MDO (25.4). At follow-up, the three groups had similar mean AHI (MDO 1.3, TLA 4.2, CM 4.5). A similar proportion of patients achieved AHI 5 or less (TLA 89.5%, MDO 96.6%, CM 84.2%). At one year, there were no significant differences in weight percentiles or in risk of failure-to-thrive between groups. One patient from the TLA group required a tracheostomy. CONCLUSION: The three treatment modalities achieved high airway and feeding success rates. All three modalities should have a place in the armamentarium of the craniofacial surgeon.

Coping and Recovery in Surgical Residents after Adverse Events: The Second Victim Phenomenon.

The second victim phenomenon is the distress felt by healthcare providers after a medical error. Although the phenomenon is a significant risk factor for burnout, little has been written about it in surgery, especially among residents. Methods: After institutional review board approval, a 27-question anonymous online survey was sent to plastic surgery residents throughout the United States, and to residents from all surgical specialties at our institution, for a total of 435 residents. Residents were asked to describe any adverse events they had experienced, and subsequent emotional sequelae. Results: The survey was returned by 125 residents (response rate 28.7%), of whom 53 were plastic surgery residents (42.4%) and 72 were from other surgical specialties (57.6%). In total, 110 (88%) described having been part of a medical error. An estimated 74 residents (34 from plastic surgery, 40 from other surgical specialties) provided a detailed description of the event. Sixty-four of them (86.5%) had subsequent emotional sequelae, most commonly guilt, anxiety, and insomnia. Only 24.3% of residents received emotional support. They rated other residents as the most important source of support, followed by faculty members and then family/friends. Conclusions: The second victim phenomenon seems to be common among surgical residents. The most important source of support for affected residents in our cohort was other residents. Given these findings, institutions should focus on fostering camaraderie among residents, building effective second victim response teams and training peer support specialists.

A Primer for Success as an Early Career Academic Plastic Surgeon.

The early career academic plastic surgeon strives to be an expert surgeon, an innovative researcher, and an impactful educator. Navigating these challenges is difficult in a healthcare landscape with diminishing public research funding, increasing demand from institutions for clinical productivity, and decreased value of surgical education. To help the junior academic plastic surgeon, this article discusses the fundamental aspects of developing an early academic plastic surgery practice, rooted in clinical care, research, and education. METHODS: Using published literature, expert opinion, and faculty interviews, the authors prepared this primer for education and guidance of plastic surgery residents considering a career in academic plastic surgery and early career academic plastic surgeons. RESULTS: This primer highlights elements important to succeeding as a junior academic plastic surgeon including defining goals and priorities, institutional and financial support, mentorship, education of students and residents, developing a practice niche, promotion and tenure, and social support and burnout. CONCLUSION: The early career academic plastic surgeon can create an environment for academic success with appropriate institutional support, mentorship, personal, and social support, to progress toward promotion while minimizing burnout and professional exhaustion.

Pediatric Lawnmower Injuries: a 25-year Review.

BACKGROUND: Despite regulations currently in place, the incidence of lawnmower injuries in children has not decreased for several decades in the United States. In fact, studies in several countries show that the incidence of riding lawnmower injuries are actually on the rise worldwide. Those injuries tend to be devastating and limb-threatening. The purpose of this study was to evaluate a pediatric trauma center's experience with those injuries over the past 25 years. METHODS: All patients who presented to a level I pediatric trauma center with injuries from lawnmowers between 1994 and 2019 were reviewed. Date of birth, gender, date of injury, mechanism of injury, type of lawnmower, and type of injury (including whether an open fracture, soft tissue defect, and/or amputation were present) were recorded. RESULTS: A total of 142 pediatric patients were treated over the study period. The average age was 7.5 years. The three most common mechanisms of injury were being hit by a riding lawnmower moving forward, falling off a riding lawnmower, and being hit by a riding lawnmower moving backward. Of all patients, 68.3% sustained an open fracture and 38% required an amputation. Riding lawnmowers resulted in more operative procedures, longer hospital stays, and more soft tissue defects that require reconstruction than push mowers. Younger patients were at a higher risk to sustain proximal amputations (wrist/ankle or proximal) than older patients. CONCLUSION: Lawnmower injuries are devastating and largely avoidable. There are currently recommendations and regulations in the United States, which if followed, would prevent the vast majority of pediatric lawnmower injuries. Unfortunately, the incidence of these injuries has not decreased despite the current regulations. Broader public education is essential to decrease the incidence of serious lawnmower injuries in children.Level of Evidence: IV.

A Case Series of the Use of Piezosurgery Instrument for Minimally Invasive Metopic Suturectomy.

BACKGROUND: Minimal invasive suturectomy is one of the many surgical approaches to treat isolated single suture craniosynostosis. This approach can be technically challenging in metopic craniosynostosis given the narrow corridor and steep angle of the forehead. New instruments such as the Piezosurgery device (Mectron) have the potential to improve the ability to safely perform minimal invasive surgery in metopic craniosynostosis. OBJECTIVE: To demonstrate the safety and efficacy of Piezosurgery technology in minimal invasive suturectomy for nonsyndromic metopic suture craniosynostosis and to describe our technique. METHODS: A retrospective chart review was performed of all the single metopic suturectomies performed at our single institution from March 2018 to November 2019. Pre-, intra-, and postoperative data were collected to assess the safety of Piezosurgery. RESULTS: The cohort consisted of 12 patients with an average of 95.25 d old and an average weight of 6.2 kg. A total of 91.7% were male, and 91.7% were Caucasian. There were no intraoperative or postoperative Piezosurgery device-related complications in the entire cohort. CONCLUSION: The use of the Piezosurgery instrument was safe in this cohort of minimal invasive metopic suturectomy. This device has greatly increased the ease of this procedure in our hands.

Strategies for Mesh Fixation in Abdominal Wall Reconstruction: Concepts and Techniques.

SUMMARY: Ventral hernias have numerous causes, ranging from sequelae of surgical procedures to congenital deformities. Patients suffering from these hernias experience a reduced quality of life through pain, associated complications, and physical disfigurement. Therefore, it is important to provide these patients with a steadfast repair that restores functionality and native anatomy. To do this, techniques and materials for abdominal wall reconstruction have advanced throughout the decades, leading to durable surgical repairs. At the cornerstone of this lies the use of mesh. When providing abdominal wall reconstruction, a surgeon must make many decisions with regard to mesh use. Along with the type of mesh and plane of placement of mesh, a surgeon must decide on the method of mesh fixation. Fixation of mesh provides an equal distribution of tension and a more robust tissue-mesh interface, which promotes integration. There exist numerous modalities for mesh fixation, each with its own benefits and drawbacks. This Special Topic article aims to compare and contrast methods of mesh fixation in terms of strength of fixation, clinical outcomes, and cost-effectiveness. Methods included in this review are suture, tack, fibrin glue, mesh strip, and self-adhering modes of fixation.

Outcomes in Velopharyngeal Dysfunction Treatment: Comparing Two Approaches for Pharyngeal Flaps.

BACKGROUND: The most common surgical intervention to treat velopharyngeal dysfunction in the US is the posterior pharyngeal flap (PPF). In this retrospective study, the authors compare surgical and speech outcomes across 2 PPF surgical approaches: the palatal split (PS) and fish mouth (FM) techniques. METHODS: An Institutional Review Board approved retrospective chart review was performed for PPF cases performed by a single surgeon between 2008 and 2016. Overall, 40 patients received the PS technique and 47 received the FM technique. Age at surgery, operative length, length of stay (LOS), revisional surgery, and pain medication administration were measured. Speech outcomes were measured based on the Universal Parameters for Reporting Speech Outcomes and included Speech Language Pathologist ratings of hypo- and hypernasality, speech acceptability, and audible nasal emission. Two sample t-tests and multivariable-mixed effects logistic regression were used to analyze the data. RESULTS: Comparing the 2 groups (PS versus FM), there were statistically significant differences among the operative approaches across multiple measures: LOS (32.86 hours versus 26.20 hours, P = 0.01), acetaminophen use (1523.54 mg versus 805.74 mg, P = 0.01), revisional surgery rate (17.5% versus 2.10%, P = 0.02), and degree of postoperative hypernasality (0.61 versus 0.29, P = 0.03). Syndromic patients were more likely to receive the FM technique (PS: 15% versus FM: 29.8%; P = 0.05). The odds ratio for revision surgery with the FM technique was -2.32 (CI: -4.32 to -0.35, P = .04). CONCLUSIONS: In this study, the FM technique offered a shorter LOS, lower revision rate, less acetaminophen administration, and more favorable speech outcomes when compared to the PS technique.

Spring Cranioplasty: Incorporation Into Practice.

OBJECTIVE: The aim of this paper is to discuss ways to incorporate spring-assisted cranioplasty into the surgical armamentarium for craniosynostosis. BACKGROUND: Spring-assisted cranioplasty after cranial suturectomy for craniosynostosis was popularized in the literature by Dr Lauritzen in 2008 after reporting the results of the first 100 cases. Since that time, more craniofacial surgeons and neurological surgeons have incorporated this surgical technique for treatment of patients presenting with craniosynostosis. This paper will discuss how the team at Nationwide Children's Hospital has incorporated spring-assisted cranioplasty into the care of patients presenting with sagittal synostosis. METHODS: In this article, the authors review our previous protocol for the treatment of children with sagittal synostosis prior to the introduction of spring cranioplasty. The authors then describe the impetus for incorporating spring-assisted cranioplasty for sagittal synostosis into our practice, and barriers we encountered during this implementation. The authors then discuss their current, comprehensive protocol for treating children with sagittal craniosynostosis. Finally, the authors review the expected and unexpected advantages that our craniofacial program has experienced as they implemented spring-assisted cranioplasty. CONCLUSION: Incorporation of spring-assisted cranioplasty for sagittal synostosis offers an additional minimally invasive technique, which presents great advantages for many families, and is rewarding for both craniofacial and neurological surgeons.

Simultaneous Midface Advancement and Orthognathic Surgery: A Powerful Technique for Managing Midface Hypoplasia and Malocclusion.

BACKGROUND: Midface hypoplasia dramatically affects the normative facial cascade. Simultaneous Le Fort III and Le Fort I procedures (Le Fort III/I) provide a powerful tool for achieving significant midface advancement. This study presents the authors' approach for addressing midface hypoplasia in the setting of class III malocclusion using Le Fort III/I advancement. METHODS: This was an institutional review board-approved retrospective review of patients who underwent Le Fort III/I advancement at the authors' institution from 2009 to 2019. Demographic, surgical, and postoperative data were recorded. The authors' operative technique and surgical pearls are described. RESULTS: Twenty-five patients met inclusion criteria, 15 male patients (60 percent) and 10 female patients (40 percent). Patient age ranged from 14.9 to 21.6 years. Diagnoses included Crouzon syndrome, nonsyndromic developmental skeletal dysplasia, cleft lip/palate, Klippel-Feil syndrome, Apert syndrome, Van den Ende-Gupta syndrome, and Pfeiffer syndrome. Le Fort III advancements averaged 6.18 ± 1.38 mm and Le Fort I advancements averaged 6.70 ± 2.48 mm. Thirteen patients underwent simultaneous bilateral sagittal split osteotomy with average movement of 5.85 ± 1.21 mm. Average follow-up was 1.3 ± 1.0 years. One patient experienced intraoperative cerebrospinal fluid leak that resolved with expectant management. Three patients experienced major complications (12 percent) postoperatively necessitating repeated orthognathic operations. Ten patients experienced minor complications (40 percent). Average length of stay was 10 days, with all patients achieving improvement of their facial profile. CONCLUSIONS: The authors' experience reaffirms the relative safety of simultaneous Le Fort III/I advancement. This technique should be considered in select patients with global midface retrusion and class III malocclusion. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Cost-Effectiveness of Long-Term, Targeted OnabotulinumtoxinA versus Peripheral Trigger Site Deactivation Surgery for the Treatment of Refractory Migraine Headaches.

BACKGROUND: Chronic migraines affect approximately 2 percent of the U.S. population and cost an estimated $17 billion per year. OnabotulinumtoxinA (botulinum toxin type A) is a U.S. Food and Drug Administration-approved prophylactic medication for chronic migraine headaches and is best injected in a targeted fashion into specific trigger sites. The purpose of this study was to determine the cost-effectiveness of long-term, targeted botulinum toxin type A versus peripheral trigger site deactivation surgery for the treatment of migraine headaches. METHODS: A Markov model was constructed to examine long-term, targeted botulinum toxin type A versus peripheral trigger site deactivation surgery. Costs, utilities, and other model inputs were identified from the literature. One-way and probabilistic sensitivity analyses were performed. An incremental cost-effectiveness ratio under $50,000 per quality-adjusted life-year was considered cost-effective. RESULTS: The mean cost of peripheral trigger site deactivation surgery was $10,303, with an effectiveness of 7.06; whereas the mean cost of long-term, targeted botulinum toxin type A was $36,071, with an effectiveness of 6.34. Trigger-site deactivation surgery is more effective and less costly over the time horizon of the model. One-way sensitivity analysis revealed that surgery is the most cost-effective treatment in patients requiring treatment for greater than 6.75 years. CONCLUSIONS: Based on this model, peripheral trigger site deactivation surgery is the more cost-effective option for treating refractory migraine headaches requiring treatment beyond 6.75 years. The model reveals that peripheral trigger-site deactivation surgery is more effective and less costly than long-term, targeted botulinum toxin type A over the course of a patient's lifetime.

Practical Management of Pilonidal Disease.

Pilonidal disease is a common problem across the globe, with a wide variety of options for management, ranging from healing by secondary intention to flap closure. As new techniques have been introduced, the ideal method to reduce complications and limit recurrence has become unclear. In this review, we highlight the most common methods used to treat pilonidal disease, as well as the senior author's preferred technique for management. Ideally, surgeons are able to choose the optimal procedure for each patient and maximize outcomes with minimal patient care burden and morbidity.

Silver in Wound Care-Friend or Foe?: A Comprehensive Review.

Due to its strong antimicrobial activity, silver is a commonly used adjunct in wound care. However, it also has the potential to impair healing by exerting toxic effects on keratinocytes and fibroblasts. The published literature on the use of silver in wound care is very heterogeneous, making it difficult to generate useful treatment guidelines. METHODS: A search of high-quality studies on the use of silver in wound care was performed on PubMed. A detailed qualitative analysis of published articles was performed to evaluate the evidence for the use of silver in infected wounds, clean wounds, burns, and over closed surgical incisions. RESULTS: Fifty-nine studies were included in this qualitative analysis. We found that, overall, the quality of the published research on silver is poor. While there is some evidence for short-term use of dressings containing nanocrystalline silver in infected wounds, the use of silver-containing dressings in clean wounds and over closed surgical incisions is not indicated. Negative-pressure wound therapy accelerates the healing of contaminated wounds, especially when silver is used as an adjunct. For burns, silver sulfadiazine slows healing and should not be used. Instead, nanocrystalline silver, or alternatives such as octenidine and polyhexanide, lead to less infection and faster healing. CONCLUSIONS: In infected wounds, silver is beneficial for the first few days/weeks, after which nonsilver dressings should be used instead. For clean wounds and closed surgical incisions, silver confers no benefit. The ideal silver formulations are nanocrystalline silver and silver-coated polyurethane sponge for negative-pressure wound therapy. Silver sulfadiazine impairs wound healing. Proper use of silver-containing dressings is essential to optimize wound healing.