Simultaneous second-stage Fowler-Stephens Orchiopexy and microvascular testicular autotransplantation in a patient with prune belly syndrome with cryptorchidism.

We present a case of simultaneous second-stage Fowler-Stephens Orchiopexy (FSO) with microvascular testicular autotransplantation for cryptorchidism and in a patient with prune belly syndrome. At 5 months old, the patient underwent laparoscopic bilateral first-stage FSO with the right testicle located 1 cm from the liver and the left slightly more caudal. An ultrasound on postoperative Day 72 following second-stage FSO and microvascular autotransplantation showed patent testicular vasculature. Our experience shows that this combination technique is safe and effective to supercharge the testicle and augment collateral vessels if clinical suspicion for monotherapy failure is high.

The Role of Nasal Sill Correction in Secondary Cleft Rhinoplasty.

BACKGROUND: Evaluating outcomes after cleft rhinoplasty can be challenging because of the lack of objective measures that would lead to a more desirable outcome. METHODS: This study is a 10-year retrospective review of 30 consecutive patients who underwent secondary unilateral cleft rhinoplasty performed by a single surgeon. Subjective ratings were made using the Unilateral Cleft Lip Surgical Outcomes Evaluation (UCL SOE), which rates 4 components (nose, cupid's bow, lateral lip, and free vermillion) with a score of 0 to 2. Multiple anthropometric measurements (nostril height ratio, width ratio, medial » height ratio, sill ratio, nostril area ratio, columellar angle, tip projection ratio, and nasolabial angle) were taken using a free National Institutes of Health program, ImageJ. Standardized photographs were compared at T0 (preoperatively), T1 (<6 weeks postoperatively), and T2 (>6 weeks postoperatively). RESULTS: There were 30 patients who met our inclusion criteria: 10 males (66.7%) and 20 females (66.7%). Of these patients, 26 (86.7%) had a complete cleft lip and 4 (13.3%) had an incomplete cleft lip. The patients' average age at time of surgery was 16.2 years with a mean follow-up of 17.9 months. Subjective scores in both nasal and overall UCL SOE ratings improved from T0 to T1, 0.7 to 1.2 (P ≤ 0.001) and 3.6 to 4.7 (P ≤ 0.001), respectively. Visual analog scores in nasal and overall UCL SOE ratings improved between T0 and T2, 0.7 to 0.9 (P = 0.023) and 3.6 to 4.8 (P = 0.002), respectively. Of all the objective measures, nasal sill ratio and cleft height to width ratio correlated with improved subjective ratings across multiple time points. CONCLUSIONS: Our study shows that objective measures such as nasal sill and nostril shape (cleft height to width ratio) correlate with improved subjective visual analog scale using the UCL SOE. The nasal sill is an often overlooked, yet essential, part of creating an aesthetically pleasing nose during cleft rhinoplasty.

Square-root Palatoplasty: Comparing a Novel Modified-Furlow Double-opposing Z-palatoplasty Technique to Traditional Straight-line Repair.

The purpose of this study was to introduce a modification of the Furlow double-opposing Z-plasty (DOZ)-the square-root palatoplasty (SRP)-and critically evaluate outcomes compared to children who underwent straight-line repair (SLR). METHODS: A retrospective review was performed of all nonsyndromic children undergoing primary cleft palate closure either by SRP or SLR at our institution between 2009 and 2017. Outcomes of interest included rates/location of oronasal fistula, secondary surgery, speech delay/deficits, resonance, nasal air emission (NAE), articulation errors, and velopharyngeal function. Logistic regression was used to assess for the effect of surgery type on outcomes while controlling for Veau cleft type, age, and gender. RESULTS: Seventy-eight patients were included; 46 (59%) underwent SRP, and 32 (41%) underwent SLR. The mean follow-up was 4.07 years. When compared to SLR, children who underwent SRP were less likely to have oronasal fistula [odds ratio (OR) 4.8, P = 0.0159], speech delay/deficits (OR 7.7, P < 0.001), NAE (OR 9.7, P < 0.001), articulation errors (OR 10.2, P < 0.001), or need for secondary speech surgery (OR 13.2, P < 0.0002). Patients who underwent SRP were also more likely to have normal resonance (78.26% versus 43.75%, respectively; P = 0.0043) and good VP function (84.78% versus 56.25%, respectively; P = 0.0094). CONCLUSIONS: This study describes and evaluates outcomes following a modified-Furlow DOZ technique-the SRP. After adjusting for Veau classification, age, and gender in nonsyndromic children, SRP is associated with significantly less speech delay/deficits, NAE, articulation errors, and need for secondary speech surgery when compared to children who underwent SLR.

Ethanol treatment of nanoPGA/PCL composite scaffolds enhances human chondrocyte development in the cellular microenvironment of tissue-engineered auricle constructs.

A major obstacle for tissue engineering ear-shaped cartilage is poorly developed tissue comprising cell-scaffold constructs. To address this issue, bioresorbable scaffolds of poly-ε-caprolactone (PCL) and polyglycolic acid nanofibers (nanoPGA) were evaluated using an ethanol treatment step before auricular chondrocyte scaffold seeding, an approach considered to enhance scaffold hydrophilicity and cartilage regeneration. Auricular chondrocytes were isolated from canine ears and human surgical samples discarded during otoplasty, including microtia reconstruction. Canine chondrocytes were seeded onto PCL and nanoPGA sheets either with or without ethanol treatment to examine cellular adhesion in vitro. Human chondrocytes were seeded onto three-dimensional bioresorbable composite scaffolds (PCL with surface coverage of nanoPGA) either with or without ethanol treatment and then implanted into athymic mice for 10 and 20 weeks. On construct retrieval, scanning electron microscopy showed canine auricular chondrocytes seeded onto ethanol-treated scaffolds in vitro developed extended cell processes contacting scaffold surfaces, a result suggesting cell-scaffold adhesion and a favorable microenvironment compared to the same cells with limited processes over untreated scaffolds. Adhesion of canine chondrocytes was statistically significantly greater (p ≤ 0.05) for ethanol-treated compared to untreated scaffold sheets. After implantation for 10 weeks, constructs of human auricular chondrocytes seeded onto ethanol-treated scaffolds were covered with glossy cartilage while constructs consisting of the same cells seeded onto untreated scaffolds revealed sparse connective tissue and cartilage regeneration. Following 10 weeks of implantation, RT-qPCR analyses of chondrocytes grown on ethanol-treated scaffolds showed greater expression levels for several cartilage-related genes compared to cells developed on untreated scaffolds with statistically significantly increased SRY-box transcription factor 5 (SOX5) and decreased interleukin-1α (inflammation-related) expression levels (p ≤ 0.05). Ethanol treatment of scaffolds led to increased cartilage production for 20- compared to 10-week constructs. While hydrophilicity of scaffolds was not assessed directly in the present findings, a possible factor supporting the summary data is that hydrophilicity may be enhanced for ethanol-treated nanoPGA/PCL scaffolds, an effect leading to improvement of chondrocyte adhesion, the cellular microenvironment and cartilage regeneration in tissue-engineered auricle constructs.

No Longer a Pain in the Neck: Use of Operating Microscope for Palatoplasty.

For craniofacial surgeons, cleft palate repair is an intricate and difficult operation positionally. Historically, use of loupe magnification and a headlight can cause significant strain to the surgeon's neck and, at times, subpar optics for both the operator and the assistant. The use of an operating microscope was first advocated by Sommerlad in 2003. By using the operating microscope for cleft palate closure, there are improved ergonomics for the surgeon and assistant by allowing for straight in-line back and neck posture with excellent visualization of the surgical field for the entire surgical team. The available zoom and focus improve the ability to isolate and repair the levator veli palatini muscle. Proper posture with a neutral cervical spine will help prolong a surgeon's career and ability to care for their patients.

An analytical study of neocartilage from microtia and otoplasty surgical remnants: A possible application for BMP7 in microtia development and regeneration.

To investigate auricular reconstruction by tissue engineering means, this study compared cartilage regenerated from human chondrocytes obtained from either microtia or normal (conchal) tissues discarded from otoplasties. Isolated cells were expanded in vitro, seeded onto nanopolyglycolic acid (nanoPGA) sheets with or without addition of bone morphogenetic protein-7 (BMP7), and implanted in nude mice for 10 weeks. On specimen harvest, cartilage development was assessed by gross morphology, histology, and RT-qPCR and microarray analyses. Neocartilages from normal and microtia surgical tissues were found equivalent in their dimensions, qualitative degree of proteoglycan and elastic fiber staining, and quantitative gene expression levels of types II and III collagen, elastin, and SOX5. Microarray analysis, applied for the first time for normal and microtia neocartilage comparison, yielded no genes that were statistically significantly different in expression between these two sample groups. These results support use of microtia tissue as a cell source for normal auricular reconstruction. Comparison of normal and microtia cells, each seeded on nanoPGA and supplemented with BMP7 in a slow-release hydrogel, showed statistically significant differences in certain genes identified by microarray analysis. Such differences were also noted in several analyses comparing counterpart seeded cells without BMP7. Summary data suggest a possible application for BMP7 in microtia cartilage regeneration and encourage further studies to elucidate whether such genotypic differences translate to phenotypic characteristics of the human microtic ear. The present work advances understanding relevant to the potential clinical use of microtia surgical remnants as a suitable cell source for tissue engineering of the pinna.

Low incidence of maxillary hypoplasia in isolated cleft palate.

BACKGROUND: The cause of maxillary growth restriction in patients with cleft lip and palate remains controversial. While studies have investigated the effects surgical technique and timing have on maxillary growth, few focus on patients with isolated cleft palate (ICP). The purpose of this study was to determine the impact palate repair and its associated complications may have on maxillary growth. METHODS: A retrospective chart review of ICP patients who underwent palatoplasty from 1962 to 1999 at Akron Children's Hospital was performed. Patient demographics, Veau type, age at primary repair, closure technique, presence of fistula or velopharyngeal insufficiency (VPI), number of palatal operations, maxillary hypoplasia (MH) frequency, and follow-up were recorded. Exclusion criteria included patients with cleft lip, submucous cleft, or syndromes. RESULTS: Twenty-nine non-syndromic ICP patients were identified; 62% (n = 18) had Veau type 1 and 38% (n = 11) had Veau type 2. All patients underwent 2-flap or Furlow palatoplasty with mobilization of mucoperiosteal flaps. Vomerine flaps were used in all Veau 2 cleft palate closures. Palatoplasty was performed at a mean age of 19.9 ± 8.2 months. Average follow-up was 209 ± 66.5 months. The rate of VPI was 59% (n = 17) and the rate of oronasal fistula was 14% (n = 4). CONCLUSIONS: There was a low incidence of MH despite complications after initial palate closure. Our results seem to suggest that age at palate closure, type of cleft palate, and type of surgical technique may not be associated with MH. Additionally, subsequent procedures and complications after primary palatoplasty such as VPI and palatal fistula may not restrict maxillary growth.

Risk Factors Associated With Allogenic Blood Transfusion in Primary Infant Cranial Vault Remodeling.

INTRODUCTION: Cranial vault remodeling is commonly associated with high blood loss and high transfusion rates. Blood management protocols have recently been developed to minimize blood loss and reduce transfusion requirements. We sought to determine risk factors associated with blood product transfusion for infants undergoing primary cranial vault remodeling after the implementation of a blood management protocol. METHODS: A retrospective review of patients who underwent cranial vault remodeling at a single center was performed. Patients under 18 months of age who underwent cranial vault remodeling after the establishment of a blood management protocol were included. RESULTS: Thirty-five patients were identified. Eleven patients (31%) received allogenic blood transfusions. Patients who received allogenic blood transfusions had a lower absolute weight (8.8 kg versus 9.6kg P = 0.04), longer procedure times (337 minutes versus 275 minutes P < 0.01), and were more likely to have undergone fronto orbital advancement (91% versus 46% P = 0.02). There were no significant differences in age, weight percentile, and patient diagnosis between patients who received allogenic blood transfusions and those that did not (P > 0.05). CONCLUSION: Low weight, longer operative times, and fronto orbital advancement are associated with allogenic blood transfusion despite the use of a blood management protocol. Attempts to modify these factors may further improve outcomes.

Intermediate Follow-up and Management of Previously Reported Malignant Peripheral Nerve Sheath Tumor of the Penis.

Malignant peripheral nerve sheath tumors (MPNSTs) are soft tissue sarcomas that arise from peripheral nerve fibers and primarily occur in the setting of neurofibromatosis (NF1). MPNST arising from the penis is very rare and may require mutilating surgery to achieve surgical cure. We previously reported a case of MPNST involving the penis in a 14-month-old boy treated with neoadjuvant chemotherapy, total penectomy, and adjuvant radiation. Here we report intermediate follow-up of the same patient, describe his subsequent genitourinary reconstruction, and discuss management dilemmas that arise following treatment of penile MPNST.

Photogrammetric Outcomes of Primary Nasal Correction in Unilateral Cleft Lip Patients: Early Childhood Results From a Single Surgeon's Experience.

BACKGROUND: Concerns of nonlasting results and potential nasal growth damage precluded cleft nasal correction at the time of initial cleft lip repair. Our goal was to evaluate the outcome of primary cleft nasal correction in our patients with unilateral cleft lip. METHODS: A retrospective review of patients with complete and incomplete unilateral cleft lip who underwent primary cleft nasal correction from 2010 to 2017 by the same surgeon was performed. The cleft-to-noncleft nostril height, width, one-fourth medial part of nostril height, nasal sill height, and nostril area ratios, as well as inner nostril height-to-width ratios were determined from standard basilar view photographs taken in different time points (T1, <3 months; T2, 3-12 months; T3, 12-36 months; and T4, >36 months after surgery). A 5-point visual analog scale (1 = worst, 5 = best) was used to assess each patient's nose appearance. RESULTS: Seventy-two patients were identified (66.7% male, 51.3% with a complete cleft lip). Average visual analog scale scores T1-T4 were 3.88 ± 0.85, 3.72 ± 0.93, 3.54 ± 0.99, and 3.40 ± 0.71, respectively. Intraclass correlation ranged from 0.61 to 0.94. A significant decrease [mean difference (SD)] was found for cleft-to-noncleft nostril width ratio [0.15 (0.18)] from T1 to T2, and an increase for one-fourth medial height ratio [-0.09 (0.07)] and for inner nostril height-to-width ratio in the noncleft side [-0.23 (0.25)] from T1 to T3. Thirteen patients required secondary surgical revision. CONCLUSION: Based on photogrammetry, primary cleft nasal correction in our patients with unilateral cleft lip achieved acceptable and stable outcomes during early childhood.

Postoperative Ketorolac Administration Is Not Associated with Hemorrhage in Cranial Vault Remodeling for Craniosynostosis.

Nonsteroidal anti-inflammatory drugs have been used as part of multimodal postoperative analgesic regimens to reduce the necessity of opioids. However, due to its effect on platelet function, there is a hesitation to utilize ketorolac postoperatively. The goal of this study is to analyze our experience utilizing ketorolac in patients who underwent major cranial vault remodeling (CVR) for craniosynostosis with an emphasis on postoperative hemorrhage and complications. METHODS: A retrospective review was performed for all patients undergoing CVR for craniosynostosis from 2013 to 2017. Primary outcomes were hemorrhagic complications. Secondary outcomes included length of stay, emesis, and doses of pain medication. RESULTS: Seventy-four consecutive patients met inclusion criteria. Forty-three (58.1%) received ketorolac. Seven in the ketorolac group (16%) and 9 in the control group (29%) received intraoperative blood transfusion (P = 0.25). One in the ketorolac group (2.3%) and 2 in the control group (3.1%) necessitated postoperative transfusion (P = 0.56). Patients who received ketorolac required less morphine doses (2.1 versus 3.3 doses; P = 0.02) and had a reduced length of stay (2.1 versus 2.6 nights; P = 0.04). CONCLUSIONS: This is the first study to demonstrate that postoperative ketorolac is not associated with an increase in hemorrhagic complications or transfusion risk in children who underwent CVR for craniosynostosis. Patients administered ketorolac required less morphine and had a hospital length of stay. We hope this study stimulates more well-done prospective trials analyzing the role that ketorolac can play in an effective and safe postoperative analgesia regimen.

Isolated Post-Shunt Metopic Synostosis and Neural Tube Defects.

BACKGROUND: Craniosynostosis is an uncommon complication after shunting procedures for congenital hydrocephalus. We report a case of a child with myelomeningocele and normocephaly at the time of birth. She underwent ventricular shunting for Chiari malformation and hydrocephalus at 3 days of age. An immediate postoperative CT scan confirmed all sutures were open. Serial CT scans document an open metopic suture at 2 months, closed metopic suture at 5 months, and trigonocephaly at 11 months with concomitant slit ventricle syndrome, and collapsed lateral and third ventricles. METHODS: An Ovid MEDLINE search within the dates of 1948 through 2017, using the keywords "synostosis AND shunt" was carried out. A tabulation of all patients and their respective synostosis patterns were recorded. RESULTS: We identified 8 case series and 2 case reports during 43 years (1966-2017). Seventy-eight patients with 79 suture synostosis patterns were identified (one patient underwent a second cranial reconstruction for identification of a separate, newly formed synostosis). Eighteen (30.5%) cases were associated with a neural tube defect (NTD). Patients with NTD and secondary craniosynostosis had on average earlier age of shunt placement (P = 0.001), craniosynostosis presentation (P = 0.146), and cranioplasty (P = 0.325) than secondary craniosynostosis patients without NTD. CONCLUSIONS: Ventricular shunt drainage in treating hydrocephalus rarely may lead to early synostosis and cranial deformity, especially in patients with NTDs. Early shunt placement poses significant risk in patients with NTD. Close follow-up may be necessary to evaluate overdrainage and cranial deformity after shunting procedures.

Management of a Dentigerous Cyst in a Child with Robin Sequence.

This is a brief clinical report describing an 18-month-old female with Robin sequence found to have an incidental mandibular cystic lesion on a head computed tomography scan in the preoperative workup before performing mandibular distraction. She underwent enucleation of the tumor, which was found to be a dentigerous cyst. One year following cyst enucleation, mandibular distraction was performed in order to alleviate her tongue-based obstruction. This case demonstrates the ability of the mandibular bone to successfully regenerate after undergoing cyst enucleation.

Long-Term Comparison between Human Normal Conchal and Microtia Chondrocytes Regenerated by Tissue Engineering on Nanofiber Polyglycolic Acid Scaffolds.

BACKGROUND: Previous regeneration studies of auricle-shaped cartilage by tissue engineering leave unresolved whether the chondrocyte phenotype from human auricular chondrocytes seeded onto polymeric scaffolds is retained over the long term and whether microtia remnants may be a viable cell source for auricular reconstruction. METHODS: Chondrocytes were isolated from human ears, either normal conchal ear or microtia cartilage remnants, expanded in vitro, and seeded onto nanoscale-diameter polyglycolic acid sheets. These tissue-engineered constructs were implanted into athymic mice for up to 40 weeks. At harvest times of 5, 10, 20, and 40 weeks, samples were documented by gross morphology, histology, and reverse transcription-quantitative polymerase chain reaction analysis. RESULTS: Neocartilages generated from the two types of surgical tissues were similar in appearance of their extracellular matrices and positive staining for elastin and proteoglycans. In the 5- to 40-week time interval, there was an increasing trend in gene expression for type II collagen, elastin, and sex determining region Y box 5, important to normal cartilage phenotype, and a decreasing trend in gene expression for type III collagen, a fibroblast and dedifferentiation marker. Over 40 weeks of implantation, the original nanoscale-diameter polyglycolic acid scaffold dimensions (1 cm × 1 cm × 80 µm) were generally maintained in tissue-engineered cartilage length and width, and thickness was statistically significantly increased. CONCLUSIONS: Auricular cartilage can be regenerated over the long term (40 weeks) from surgical remnants by tissue-engineering techniques incorporating nanoscale-diameter polyglycolic acid scaffolds. Based on the present assays, microtia neocartilage very closely resembles tissue-engineered cartilage regenerated from chondrocytes isolated from normal conchal cartilage.

Overview of Wound Healing and Management.

Wound healing is a highly complex chain of events, and although it may never be possible to eliminate the risk of experiencing a wound, clinicians' armamentarium continues to expand with methods to manage it. The phases of wound healing are the inflammatory phase, the proliferative phase, and the maturation phase. The pathway of healing is determined by characteristics of the wound on initial presentation, and it is vital to select the appropriate method to treat the wound based on its ability to avoid hypoxia, infection, excessive edema, and foreign bodies.

Propranolol Therapy for Problematic Infantile Hemangioma.

BACKGROUND: Infantile hemangioma (IH) is a common, benign tumor occurring in up to 10% of white infants. Propranolol has emerged as a front-line therapy for IH. The retrospective study examined the response of propranolol therapy on hemangioma size. METHODS: Twenty-seven children (4 to 20 weeks old) with IH were enrolled into the study of oral propranolol solution 2 mg/kg per day divided 3 times daily for 10 months. Response was assessed by size measurements at pretreatment and posttreatment. Scoring was stratified into no response, plateau, and regression groups. Secondary outcomes measured were drug compliance and complications. RESULTS: Twenty-seven consecutive patients with IH were treated with propranolol, of whom 67% completed a 6-month therapy. No correlation was demonstrated between tumor size and age at therapy initiation or patient (P = 0.7 and P = 0.7, respectively). A large number of infants responded to therapy (85.2%). Response was first observed sooner in the regression group compared to plateau responders (15.15 ± 8.06 and 20.5 ± 18.42 days, respectively). A significant difference in median pretreatment and posttreatment tumor size was noted (4.50 vs 1.55 cm, P = 0.02). Attrition was secondary to drug-induced side effects, no response, and dosing noncompliance. CONCLUSIONS: Propranolol is a safe and effective first-line therapy for problematic IHs. Therapy should show significant response by 2 weeks. If no response is observed by 3 weeks, then other treatment should be sought.

M to T rearrangement: an approach to correct webbed neck deformity.

For the Noonan syndrome patient, the most concerning physical defect is often congenital webbing of the neck or pterygium colli. We present a patient with pterygium colli and a low and laterally displaced nuchal hairline. Since its description, various surgical approaches have been implemented to correct the deformity. Previously reported posterior and lateral approaches have notable disadvantages with regard to hairline displacement and recurrence. In order to address these disadvantages, a new surgical technique was used on this patient. We have termed this technique an M to T rearrangement. Using a lateral approach, the M and T incisions are made and the trapezial fascial web is directly visualized and able to be completely excised. This prevents the recurrence seen with the use of posterior techniques. Inferolateral displacement of hair-bearing skin can be removed with resection of the superior intervening triangle and improves the appearance of the low nuchal hairline. The excision of excess skin along with the zig-zag closure also prevents postoperative scar contraction and recurrence. An important effect of this technique is the prevention of anterior displacement of hair bearing skin. M to T rearrangement is an effective technique for the correction of webbed neck deformities seen in Noonan and Turner syndromes.

Effects of FGF-2 and OP-1 in vitro on donor source cartilage for auricular reconstruction tissue engineering.

OBJECTIVE: Microtia is a congenital partial or total loss of the external ear with current treatment approaches involving autologous construction from costal cartilage. Alternatively, tissue engineering provides possible use of normal or microtia auricular chondrocytes harvested from patients. This study investigated effects in vitro of basic fibroblast growth factor (FGF-2) and osteogenic protein 1 (OP-1) on human pediatric normal and microtia auricular chondrocytes and their potential proliferation and differentiation for cellular expansion. A working hypothesis was that FGF-2 promotes proliferation and OP-1 maintains an auricular phenotype of these cells. METHODS: Two patients, one undergoing otoplasty and one an ear construction, yielded normal and microtia auricular chondrocytes, respectively. The two donor sets of isolated chondrocytes were equally divided into four experimental cell groups. These were controls without added growth factors and cells supplemented with FGF-2, OP-1 or FGF-2/OP-1 combined. Cells were cultured 3, 5, 7, and 10 days (3 replicates/time point), counted and assayed by RT-qPCR to determine elastin and types II and III collagen gene expression. RESULTS: Compared to control counterparts, normal and microtia chondrocytes with OP-1 alone were similar in numbers and varied in elastin and types II and III collagen expression over all culture times. Compared to respective controls and chondrocyte groups with OP-1 alone, normal and microtia cell groups with FGF-2 had statistically significant (p<0.05) enhanced proliferation and statistically significant (p<0.05) decreased elastin and types II and III collagen expression over 10 days of culture. CONCLUSIONS: FGF-2 effects on normal and microtia chondrocytes support its use for increasing cell numbers while OP-1 maintains a chondrocyte phenotype, otherwise marked by increasing type III collagen expression and cellular dedifferentiation to fibroblasts in culture.

2.5D constructs for characterizing phase separated polymer blend surface morphology in tissue engineering scaffolds.

Previously, we used 2D films to identify an annealed PCL-PDLLA phase-separated blend morphology which provided nanoscale surface texture and patterning that stimulated osteoblast differentiation. In order to translate these 2D surface nanopatterning effects to the walls of 3D salt-leached scaffolds, the blend phase morphology of scaffold walls must be characterized. For salt-leached scaffolds, NaCl is used as a porogen, which may affect phase separation in PCL-PDLLA blends. However, it is not possible to characterize the surface blend morphology of 3D scaffold walls using standard approaches such as AFM or optical microscopy, since scaffolds are too rough for AFM and do not transmit light for optical microscopy. We introduce a 2.5D approach that mimics the processing conditions of 3D salt-leached scaffolds, but has a geometry amenable to surface characterization by AFM and optical microscopy. For the 2.5D approach, PCL-PDLLA blend films were covered with NaCl crystals prior to annealing. The presence of NaCl significantly influenced blend morphology in PCL-PDLLA 2.5D constructs causing increased surface roughness, higher percent PCL area on the surface and a smaller PCL domain size. During cell culture on 2.5D constructs, osteoblast (MC3T3-E1) and dermal endothelial cell (MDEC) adhesion were enhanced on PCL-PDLLA blends that were annealed with NaCl while chondrogenic cell (ATDC5) adhesion was diminished. This work introduces a 2.5D approach that mimicked 3D salt-leached scaffold processing, but enabled characterization of scaffold surface properties by AFM and light microscopy, to demonstrate that the presence of NaCl during annealing strongly influenced polymer blend surface morphology and cell adhesion.

Speech outcome after palatal repair in nonsyndromic versus syndromic Robin sequence.

BACKGROUND: The authors' purpose was to document speech outcome after cleft palate repair in patients with syndromic versus nonsyndromic Robin sequence. Results of secondary correction of velopharyngeal insufficiency using a superiorly based pharyngeal flap or double-opposing Z-palatoplasty are also reported. METHODS: Charts of patients with Robin sequence and cleft palate between 1980 and 2007 were reviewed. Data collected included date of birth, sex, syndrome/association, cleft palatal type (Veau I or II), age at palatoplasty, incidence of palatal fistula, postoperative speech assessment, videofluoroscopic results, need for secondary operation for velopharyngeal insufficiency, and type of secondary operation (pharyngeal flap or double-opposing Z-palatoplasty). RESULTS: The authors identified 140 patients with Robin sequence who had palatal closure. Postoperative speech evaluation was available for 96 patients (69 percent). A syndrome or association was identified in 42 patients (30 percent). Primary palatoplasty was successful in 74 patients (77 percent); speech was characterized as competent and competent to borderline competent. The authors found a significantly higher incidence of velopharyngeal insufficiency following palatal repair for syndromic (38 percent) than nonsyndromic Robin sequence (16 percent). (p = 0.039). In patients with velopharyngeal insufficiency, competent or borderline competent speech was determined after double-opposing Z-palatoplasty (two of five patients) or pharyngeal flap (eight of 10 patients). CONCLUSIONS: The rate of velopharyngeal insufficiency in syndromic Robin sequence is significantly greater than in nonsyndromic Robin sequence. The authors prefer pharyngeal flap for velopharyngeal insufficiency in patients with Robin sequence, whether syndromic or nonsyndromic, without retrognathism or signs/symptoms of obstructive sleep apnea.