Clinical Factors Affecting Length of Stay After 100 Consecutive Cases of Primary Cleft Lip Repair.

OBJECTIVE: To analyze the hospital course of 100 consecutive infants after primary cleft lip repair (PCLR) and identify factors related to length of stay (LOS). DESIGN: Retrospective analysis of 100 consecutive infants who were routinely admitted after PCLR. SETTING: Tertiary care center. PATIENTS: One hundred consecutive infants undergoing PCLR. Demographic and perioperative data were collected and analyzed. MAIN OUTCOME MEASURE: LOS, planned before data collection. RESULTS: Male:female ratio was 65:35. Seventy-two infants had unilateral cleft lip; syndromic association was documented in 15 patients. Mean age and weight at PCLR were 5.6 ± 4.0 months and 6.7 ± 1.3 kg, respectively. Mean duration of surgery was 2.5 ± 0.9 hours, and mean duration of general anesthesia was 3.4 ± 0.9 hours. A total of 3.3 ± 1.5 mL of intraoperative local anesthetic was used per patient. Intravenous fluids were necessary after transfer from the post-anesthesia care unit to the general ward in 98% of patients. Almost half (44%) of all patients received intravenous morphine 23 hours or more after hospital admission. Mean LOS was 35.8 ± 13.9 hours. No association was identified between patient demographic factors and LOS. Multivariate linear regression models identified significant positive correlation between LOS and duration of general anesthesia (P = .002). Greater volume of postoperative oral intake (P = .000) and higher acetaminophen dosage on the floor (P = .000) correlated with decreased LOS. CONCLUSIONS: This study identifies perioperative factors associated with LOS. Our findings question the safety of routine outpatient or short-stay observation after PCLR.

Atypical expanded-spectrum hemifacial microsomia: a case report.

Objective : To present the case report of a patient with expanded hemifacial microsomia (HFM) that illustrates the complex interactions of these embryogenic factors and to review current theories and mechanism regarding the etiopathogenesis of HFM. Design and Method : We present the case of an African American girl who was born at full term by cesarean section and transferred to our institution for systemic malformations. Her craniofacial findings include holoprosencephaly, cleft lip and palate, low set and posteriorly rotated ears, flat midfacial features, micrognathia, left HFM with grade 1 microtia, hypoplastic mandible, and a small preauricular pharyngeal arch remnant. Systemic anomalies included ectopic kidney, atrial-septal defect, bilateral hip dysplasia, bilateral humeroradial fusion, bilateral club feet, and bilateral low-set thumbs with the right side also being triphalangeal. Genetic evaluation did not identify a molecular diagnosis or other known syndrome. Conclusions : Although vasculogenic disruption of the stapedial artery during early fetal gestation has been implicated in the etiology of HFM, the grouping and bilateral findings seen in our patient argue against this relatively simple and localized phenomenon. Instead, such diverse and widespread anomalies in the setting of expanded spectrum HFM seem to support the theory of a disorder in blastogenesis as the cause of HFM.

Incidental findings on preoperative computed tomography for nonsyndromic single suture craniosynostosis.

Although the diagnosis of nonsyndromic single suture craniosynostosis (NSSC) can usually be made by clinical examination, computed tomography (CT) is still commonly used in preoperative evaluation. This practice has been questioned in light of recent studies that document a small, but measurable, increased risk of malignancy from CT-associated radiation. The purpose of this study was to examine whether preoperative CT for patients with NSSC provided clinically important information beyond confirmation of craniosynostosis. We performed a retrospective analysis of all patients with NSSC undergoing cranial vault remodeling at our center from March 1999 to March 2011. Only patients with complete preoperative CT scans available for review were included. Staff pediatric neurosurgeons were blinded to patient diagnosis and official radiology report, analyzed the CT images, and documented the site of synostosis and any other findings. Of the 231 patients, 80 met the inclusion criteria. Sites of synostosis included sagittal (51 patients), coronal (17 patients), metopic (11 patients), and frontosphenoidal (1 patient). Clinical diagnosis correlated with radiographic site of fusion in all patients except the patient with frontosphenoidal synostosis. Incidental findings were documented in more than 50% of the patients including prominent extra-axial cerebrospinal fluid (n = 36, 45%), ventriculomegaly (n = 5, 6.25%), choroid fissure cyst (n = 2), cavum septum pellucidum (n = 2), Chiari malformation (n = 1), and prominent perivascular space (clinically nonsignificant finding, n = 1). Incidental findings required additional follow-up or management in 5 patients (6.25%). Our findings support the use of preoperative imaging in this population to identify intracranial anomalies that cannot be discerned by clinical examination. Whereas many findings were not clinically important, some required additional attention.

Sonographic assessment of suture artifact obscuring visualization of the digital nerve.

INTRODUCTION: The purpose of this study was to grade the severity of sonographic artifact produced by four suture materials and to determine whether these artifacts affect visualization of a digital nerve. METHODS: A needle was placed into a pig foot to mimic a normal volar digital nerve. Incisions superficial to the needle were closed with different suture types, specifically nylon (N), chromic (C), vicryl (V), and prolene (P). Sonographic images were obtained using a high-frequency transducer. Twenty radiology residents and attending physicians graded the severity of artifact and nerve obscuration. Two image types were shown: one suture type per image and a composite image of each suture type, adjacent to one another. RESULTS: Severity of nerve obscuration was as follows: composite image: P = N = V > C; individual images: P > N > V > C. Severity of artifact was: composite image: V = N > P > C; individual image: P > N > V > C. CONCLUSION: Although all sutures produced artifact, only C produced mild artifact, which did not significantly obscure visualization of the nerve model.

Sonographic assessment of volar digital nerve injury in the context of penetrating trauma.

OBJECTIVE: The purpose of this article was to report our experience using ultrasound to assess digital nerve integrity after penetrating hand trauma with sensory deficit. Ultrasound was performed in the long axis on 22 digital nerves in 11 patients using a 12-14-MHz linear array hockey stick transducer. CONCLUSION: Of 22 volar digital nerves evaluated by sonography, six were transected. All imaging findings were confirmed surgically. High-frequency ultrasound permits accurate imaging of intact and transected volar digital nerves.

Treating facial soft tissue deficiency: fat grafting and adipose-derived stem cell tissue engineering.

The authors outline the limitations of fat grafting. They then describe the currently available fat culturing technique and explain how options incorporating adipose-derived stem cell technologies and growth factors will provide new modalities in treating facial soft tissue deficiency.

Radiation following surgery for oral cancer: impact on local control.

OBJECTIVES: The use of postoperative radiation therapy (RT) is commonly used in the treatment of patients with high-risk squamous cell carcinoma of the head and neck. However, few data exist that quantitate the incremental benefit of RT when administered following surgery. The retrospective study was designed to measure the incremental benefit of adjuvant RT after surgery on control of the primary lesion when compared with patients undergoing surgical therapy alone for squamous cell carcinoma of the oral cavity. STUDY DESIGN: Retrospective chart. METHODS: Previously untreated patients with squamous cell carcinoma of the floor of mouth or oral tongue who were treated between 1974 and 1998 were eligible for study. A minimum follow-up of 2 years was required. Tumor site, stage, and RT data were correlated with local control. RESULTS: Patients with missing or incomplete data and those lost to follow-up or dead as a result of intercurrent disease with follow-up of less than 2 years were censored. A group of 211 patients who could be evaluated was available for the study. Radiation therapy was administered postoperatively to 58 patients, and 153 patients were treated with surgery alone. In the group treated with combined therapy, the average irradiation dose was 5850 cGy; this group included 35 patients who received more than and 16 who received less than 5700 cGy. CONCLUSIONS: The incremental benefit in terms of control of tumor at the primary site for patients receiving postoperative RT was between 0% and 7%. Surgery alone controlled 80% to 85% of primary tumors. The dose of postoperative RT did not correlate with local control.