Extended Release Liposomal Bupivacaine Injection (Exparel) for Early Postoperative Pain Control Following Palatoplasty.

INTRODUCTION: Liposomal bupivacaine (LB) is a long-acting local anesthetic reported to decrease postoperative pain in adults. The authors demonstrate the safe use of LB in pediatric patients with improved pain control following palatoplasty. MATERIALS AND METHODS: Retrospective patient series of all single-surgeon palatoplasty patients treated at a tertiary craniofacial center from August 2014 to December 2015 were included. All patients received 1.3% LB intraoperatively as greater palatal nerve and surgical field blocks in 2-flap V-Y pushback palatoplasty. Postoperative oral intake, opioids administered, duration of hospitalization, and FLACC (face, legs, activity, cry, consolability) pain scores were measured. RESULTS: Twenty-seven patients (16 males and 11 females, average age of 10.8 months, weight 8.8 kg) received 2.9 ±â€Š0.9 mL (2.6 ±â€Š1.9 mg/kg) 1.3% LB. Average FLACC scores were 2.4 ±â€Š2.2/10 in the postanesthesia care unit and 3.8 ±â€Š1.8/10 while inpatients. Oral intake was first tolerated 10.3 ±â€Š11.5 hours postoperatively and tolerated 496.4 ±â€Š354.2 mL orally in the first 24 hours postoperatively. Patients received 8.5 ±â€Š8.4 mg hydrocodone equivalents (0.46 ±â€Š0.45 mg/kg per d hydrocodone equivalents) and were discharged 2.1 ±â€Š1.3 days postoperatively. Opioid-related adverse events included emesis in 7.4% and pruritis in 3.7% of patients. CONCLUSIONS: The LB may be used safely in pediatric patients. Intraoperative injection of LB during palatoplasty can yield low postoperative opioid use and an early and adequate volume of oral intake over an average hospital stay. Further cost-efficacy studies of LB are needed to assess its value in pediatric plastic surgery.

Applications of Computer Technology in Complex Craniofacial Reconstruction.

BACKGROUND: To demonstrate our use of advanced 3-dimensional (3D) computer technology in the analysis, virtual surgical planning (VSP), 3D modeling (3DM), and treatment of complex congenital and acquired craniofacial deformities. METHODS: We present a series of craniofacial defects treated at a tertiary craniofacial referral center utilizing state-of-the-art 3D computer technology. All patients treated at our center using computer-assisted VSP, prefabricated custom-designed 3DMs, and/or 3D printed custom implants (3DPCI) in the reconstruction of craniofacial defects were included in this analysis. RESULTS: We describe the use of 3D computer technology to precisely analyze, plan, and reconstruct 31 craniofacial deformities/syndromes caused by: Pierre-Robin (7), Treacher Collins (5), Apert's (2), Pfeiffer (2), Crouzon (1) Syndromes, craniosynostosis (6), hemifacial microsomia (2), micrognathia (2), multiple facial clefts (1), and trauma (3). In select cases where the available bone was insufficient for skeletal reconstruction, 3DPCIs were fabricated using 3D printing. We used VSP in 30, 3DMs in all 31, distraction osteogenesis in 16, and 3DPCIs in 13 cases. Utilizing these technologies, the above complex craniofacial defects were corrected without significant complications and with excellent aesthetic results. CONCLUSION: Modern 3D technology allows the surgeon to better analyze complex craniofacial deformities, precisely plan surgical correction with computer simulation of results, customize osteotomies, plan distractions, and print 3DPCI, as needed. The use of advanced 3D computer technology can be applied safely and potentially improve aesthetic and functional outcomes after complex craniofacial reconstruction. These techniques warrant further study and may be reproducible in various centers of care.

Correction of a Posttraumatic Orbital Deformity Using Three-Dimensional Modeling, Virtual Surgical Planning with Computer-Assisted Design, and Three-Dimensional Printing of Custom Implants.

We describe a case of complex, posttraumatic skull and orbital deformities that were evaluated and treated with advanced computer technology, including virtual surgical planning, three-dimensional (3D) modeling, and printed patient custom implants (PCI) fabricated by 3D printing. A 50-year-old man presented to our craniofacial referral center 1 year after failed reduction of complex left orbital, zygomatic, and frontal bone fractures due to a motorcycle collision. The patient's chief complaint was debilitating diplopia in all fields of gaze. On examination, he had left enophthalmos, left canthal displacement, lower eyelid ectropion, vertical orbital dystopia, and a laterally and inferiorly displaced, comminuted zygoma with orbital rim and frontal bone defects. The normal orbit was mirrored to precisely guide repositioning of the globe, orbital reconstruction, and cranioplasty. Preinjury appearance with normal globe position was restored with complete resolution of diplopia. Modern 3D technology allows the surgeon to better analyze complex orbital deformities and precisely plan surgical correction with the option of printing a PCI. These techniques were successfully applied to resolve a case of debilitating diplopia and aesthetic deficits after facial trauma. Further application of advanced 3D computer technology can potentially improve the results of severe orbital and craniofacial trauma reconstruction.

Extended Release Liposomal Bupivacaine Injection (Exparel) for Early Postoperative Pain Control Following Pharyngoplasty.

BACKGROUND: Liposomal bupivacaine (LB, Exparel) is a long-acting local anesthetic reported to decrease postoperative. The authors demonstrate the first safe use of LB in pediatric patients with improved pain control following pharyngoplasty. METHODS: Retrospective case-control of all the patients who underwent pharyngoplasty at a tertiary craniofacial center from March 2010 to June 2016. Treatment group (TG) administered 1.3% LB and 0.5% bupivacaine and 1:200,000 epinephrine. Control group (CG) administered 0.5% lidocaine with 1:200,000 epinephrine. Pain scores, oral intake, opioids administered, and duration of hospitalization were measured. RESULTS: Sixty patients (30 males, 30 females; average age 6.2 ±â€Š2.4 years, weight 20.9 ±â€Š6.8 kg) were evenly divided into a TG that received 3.5 ±â€Š2.1 mL (2.6 ±â€Š1.9 mg/kg) LB and 2.0 ±â€Š2.3 mL 0.5% bupivacaine and a CG that received 2.7 ±â€Š3.2 mL lidocaine. Treatment group patients had lower initial face, legs, activity, cry, consolability pain scale scores (0.1 ±â€Š0.55/10, P = 0.0049; CG 4.5 ±â€Š1.1/10, P = 0.00061) and no significant inpatient pain score difference 0 to 36 hours postoperative (P = 0.32-0.53). Oral intake was tolerated 0.21 ±â€Š0.12 days (P < 0.0001) earlier by the TG and with greater first 24-hour average volume (377.6 ±â€Š351.9 cc, P < 0.0001). Treatment group patients were discharged 1.8 ±â€Š0.87 days (P = 0.00023) earlier and required lower average opioids (15.1 ±â€Š11.2 mg hydrocodone-equivalents) than CG (27.5 ±â€Š19.1 mg hydrocodone-equivalents; P = 0.0017). CONCLUSIONS: Liposomal bupivacaine is safe in pediatric patients, associated with less opioids, increased and earlier oral intake, and shorter hospital stay.

Progressive Surgical Autonomy in a Plastic Surgery Resident Clinic.

BACKGROUND: Resident clinics are thought to catalyze educational milestone achievement through opportunities for progressively autonomous surgical care, but studies are lacking for general plastic surgery resident clinics (PSRCs). We demonstrate the achievement of increased surgical autonomy and continuity of care in a PSRC. METHODS: A retrospective review of all patients seen in a PSRC from October 1, 2010, to October 1, 2015, was conducted. Our PSRC is supervised by faculty plastic surgery attendings, though primarily run by chief residents in an accredited independent plastic surgery training program. Surgical autonomy was scored on a 5-point scale based on dictated operative reports. Graduated chief residents were additionally surveyed by anonymous online survey. RESULTS: Thousand one hundred forty-four patients were seen in 3,390 clinic visits. Six hundred fifty-three operations were performed by 23 total residents, including 10 graduating chiefs. Senior resident autonomy averaged 3.5/5 (SD = 1.5), 3.6/5 (SD = 1.5), to 3.8/5 (SD = 1.3) in postgraduate years 6, 7, and 8, respectively. A linear mixed model analysis demonstrated that training level had a significant impact on operative autonomy when comparing postgraduate years 6 and 8 (P = 0.026). Graduated residents' survey responses (N = 10; 100% response rate) regarded PSRC as valuable for surgical experience (4.1/5), operative autonomy (4.4/5), medical knowledge development (4.7/5), and the practice of Accreditation Council of Graduate Medical Education core competencies (4.3/5). Preoperative or postoperative continuity of care was maintained in 93.5% of cases. CONCLUSION: The achievement of progressive surgical autonomy may be demonstrated within a PSRC model.

Palate Fracture Repair With Light-Cured Resin Splint: Technical Note.

Palate fractures are rare, and their treatment is a matter of debate. Although some investigators have favored rigid plate fixation, others have reported successful treatment without it. Sagittal split and comminuted fractures can require rigid fixation to reduce the maxillary width; however, additional stabilization is needed. Also, palate repair without a splint is complicated by prolonged intermaxillary fixation (IMF), causing stiffness to the temporomandibular joint. We introduce a technique using a rapid light-cured resin (TRIAD TranSheet) frequently used by orthodontists for making dental retainers. Its use is similar to the splints traditionally created preoperatively, but obviates the need for making impressions, a model, and a molded splint. A series of 13 patients treated with this technique during a 5-year period is presented. The average duration of IMF was 4.7 weeks (range 3 to 6). The average duration of the palate splint was 8.4 weeks (range 5 to 12). One patient had malocclusion, but none had malunion, infection, or oronasal fistula. Our series has demonstrated a simple, cost-effective, and successful technique. It can be used alone or combined with rigid fixation and allows for a shortened duration of maxillomandibular fixation.

Surgical management of Gorlin syndrome: a 4-decade experience using local excision technique.

Basal cell nevus syndrome (aka Gorlin syndrome, Gorlin-Goltz syndrome, nevoid basal cell carcinoma syndrome, and fifth phacomatosis) is a rare but well-described autosomal dominant condition with variable penetrance. We present a female patient who has been successfully treated using local surgical excision and diligent skin surveillance for more than 4 decades, demonstrating that simple local incision is an efficacious and reasonable surgical alternative that may circumvent the specialization and expense of Mohs technique.

Orbital reconstruction for pulsatile exophthalmos secondary to sphenoid wing dysplasia.

Sphenoid wing dysplasia or absence of the greater sphenoid wing is a rare condition that is considered pathopneumonic for neurofibromatosis type 1 (NF1). It occurs in 4% to 11% of NF1 patients, and its precise cause is unclear. Some cases appear to be congenital, while others have demonstrated it to be a progressive degeneration of the orbital wall. In about half of cases, associated adjacent neurofibromas are described. Consistently, however, the clinical sequelae is herniation of the temporal lobe into the orbit, causing progressive proptosis and pulsatile exophthalmos. Reconstruction of the orbit has traditionally been with bone grafts, but due to problems with bone resorption and recurrence, titanium plates in conjunction with bone grafts have been reported. We present a case of a 6-year-old male patient who was first diagnosed with NF1 and associated absence of the greater sphenoid wing at the age of 2. Four years later, he was referred for reconstruction after the development of pulsatile exophthalmos. Surgical management included dissection of the dura of the temporal lobe off of the periorbita and skull base reconstruction with a combination of radial-shaped titanium mesh and split calvarial bone grafts. Postoperatively, there was near immediate resolution of the pulsatile exophthalmos, and follow-up at 1 year showed no recurrence.

Paramedian forehead flap to treat chronically infected base of skull defect in a posttraumatic patient.

Frontal sinus cranialization with obliteration of the frontal sinus outflow tracts is rarely needed but may be required with extensive comminution of the anterior and posterior walls of the frontal sinus. There is little in the literature about treatment of chronic larger defects of the anterior cranial fossa that communicate with the nose and drain externally after cranialization. We present a 49-year-old man who experienced extensive facial trauma requiring cranialization of the frontal sinus. Three years later, the patient presented with a chronic draining forehead wound that extended into the previously cranialized frontal sinus space with communication of the anterior cranial fossa and the internal nose. After thorough irrigation and debridement, the remaining dead space was found to be large and communicated with the nose, making autologous grafts a poor choice. A pericranial flap was not an option due to the previous soft tissue trauma. A paramedian forehead flap was deepithelialized and rotated into the space, obliterating the dead space and closing the communication between the nose and the anterior cranial fossa. Six months postoperatively, there are no signs of recurrence. The deepithelialized paramedian forehead flap should be considered for obliterating large dead spaces and closing off the communication between the cranial base and the nose.

Use of osteogenesis distractors in cloverleaf skull reconstruction.

Cloverleaf skull deformity (Kleeblattschädel-Syndromen, trilobular skulls) results from synostosis of multiple cranial sutures. The number of sutures involved, the pathogenesis of the synostosis, and the associated anomalies and syndromes are variable. All forms of cloverleaf skull are associated with a high morbidity and mortality. Management of surviving infants requires multiple decompressive and reconstructive operative procedures. Maximal advancement of the forehead/brow at the initial surgery is usually not enough to correct the associated proptosis and a second brow advancement must be done. We present a patient with Apert syndrome and cloverleaf skull deformity that required early (1 month old) cranial vault decompression due to severe proptosis and papilledema. Our management included the placement of osteogenesis distracters on the forehead/brow to gain additional advancement and expand the soft tissue.

Changes in airflow dynamics after creation of pharyngeal flaps in nonsyndromic children.

Velopharyngeal insufficiency is a common problem in the cleft palate population that may require a pharyngeal flap. Sleep disordered breathing is a common complication of this surgery and a baseline sleep study is often performed before undergoing the procedure. Few postoperative sleep studies are ever done and little is known about the effects that pharyngeal flaps have on airflow dynamics.Preoperative and postoperative nasometry and polysomnographic data were reviewed and compared from nonsyndromic children requiring pharyngeal flap since 2009. Eighteen children having undergone pharyngeal flap were identified. Of those 18, Nadir oxygen saturations were worsened in 10, improved in 7, and remained the same in 1. Snoring was caused or made worse in 8. Sleep efficiency was worse in 11, improved in 6, and remained the same in 1. Apnea/hypopnea events increased in 9 and decreased in the other 9. Hypernasality was improved in varying degrees in 17 patients, but all required additional speech therapy. Diagnosed preoperative sleep apnea remained in 1 patient. No patient's postpharyngeal flap had any significant sleep disturbance that would warrant continuous positive airway pressure. No flaps required division or takedown.This preliminary study suggests that pharyngeal flaps may increase snoring and apnea/hypopnea events without causing diagnosable sleep disordered breathing and the resultant clinical sequelae. Nasometry shows evidence of nasal airway diversion without complete obstruction. Speech improves more subjectively than nasometry would predict after pharyngeal flap.

Cornu cutaneum in a patient of African descent: implications and management of an uncommon lesion.

Cornu cutaneum, or giant cutaneous horn (GCH), is an uncommon but disfiguring lesion that may cause the patient considerable distress. The aesthetic implications of such lesions are obvious. The etiology and treatment of GCH are more obscure, both to patients and physicians alike. We present a female patient of African descent with a GCH of the scalp, which represents the first such case to our knowledge outside Africa. The etiology and management of GCH in all races are reviewed.

Incidence and management of zygomatic fractures at a level I trauma center.

PURPOSE: The purpose of this study is to evaluate current treatment of zygomatic fractures presenting at a level I trauma center. METHODS: Radiology records over a 1-year period were retrospectively reviewed to determine all patients diagnosed with fractures through the zygoma. A total of 1049 computed tomography maxillofacial scans were reviewed which identified 243 patients with fractures through the zygoma. Of these, 200 patients were identified as clinically relevant zygomatic fractures defined as having 3 or more major buttress fractures. RESULTS: Among the 200 patients identified with zygomatic fractures, 132 patients were treated nonoperatively and 68 patients required operative management. In the operative group 31% were treated with a limited (one-buttress) approach. CONCLUSIONS: Review of our management of zygomatic fractures at a level I trauma center found a high incidence of zygomatic fractures (66%) that can be managed nonoperatively without significant complications. There is a select group of zygomatic fractures that can be successfully managed by the experienced surgeon with a limited one-buttress approach.

Congenital granular cell tumour of the newborn: A case report and literature review.

A congenital granular cell tumour is rare, and presents in newborns as a mass arising from the alveolus. While its pathogenesis is unclear, it has no malignant potential and may, occasionally, spontaneously regress postpartum. Successful treatment usually consists of conservative simple excision.

Nasoethmoid orbital fractures: diagnosis and treatment.

Blunt trauma to the midface frequently results in fractures of the nasoethmoid orbital skeleton. These complex injuries are often misdiagnosed or inadequately treated and are perhaps the most difficult of all facial fractures to treat. The purpose of this article is to describe the author's technique for the diagnosis and treatment of these complex fractures. Presented is an organized approach to the diagnosis and surgical management of nasoethmoid orbital fractures that has evolved in the author's treatment of over 450 nasoethmoid fractures. Early diagnosis is confirmed by computed tomographic scan using the simple classification system described. Fractures that demonstrate displacement or movement on examination require open reduction and stabilization. Identifying the extent and type of fracture pattern and associated injuries determines the exposure and method of fixation needed. Wide exposure with meticulous reduction is necessary, with stabilization of the medial orbital rim fragment using a transnasal wire technique. Plate-and-screw fixation of the superior and inferior rim is performed with bone graft reconstruction of the nose as needed. Attention to redraping of soft tissue in the naso-orbital valley with the use of nasal compression bolsters is a crucial step in the repair. Multiple clinical cases are used to illustrate the different fracture patterns, soft-tissue injuries, and surgical technique recommended. This organized approach has proven effective in restoring preinjury appearance. Early diagnosis combined with the aggressive surgical techniques described will optimize results and minimize the late posttraumatic deformity.

Giant basal cell carcinoma surgical management and reconstructive challenges.

Basal cell carcinoma is exceedingly common, but tumors >5 cm in size or giant basal cell carcinomas (GBCCs) are rare. We retrospectively review 10 GBCCs in 8 patients treated by aggressive surgical excision and reconstruction in a single operative procedure. With the exception of 1 chest lesion, all GBCCs involved the face or scalp. The 10 large defects were reconstructed with 5 free-tissue transfers, 2 pedicled musculocutaneous flaps, and 3 rotational skin flaps. There has been no evidence of local recurrence or metastasis in a mean follow-up of 29 months. Neglect has a well-established role in the presence of GBCCs, with undiagnosed preexisting medical problems also common. Surgical excision and reconstruction is the treatment of choice and can be readily accomplished in a single procedure with few complications, good oncologic control, and acceptable cosmetic results.

The specialized wound care center: a 7-year experience at a tertiary care hospital.

Multidisciplinary wound care centers have proliferated as a result of an increasing need for care of nonhealing wounds. Information regarding types of wounds treated, length of treatment, compliance with treatment, and rates of healing was collected from a tertiary care hospital-based wound center over a 7-year period. Venous stasis ulcers were the most common type of wound treated (21%) and were also the most likely to heal. Pressure ulcers (20%), diabetic neuropathic ulcers (14%), ischemic ulcers (6%), and postsurgical wounds (6%) comprised the remainder of wounds treated. The success of treating wounds varied greatly with the wound's etiology. Despite the chronic nature of these wounds, most patients did not become long-term patients of the wound center. This study provides baseline outcome measures, which can serve as the basis for the comparison of treatment protocols and the development of prospective clinical trials.

Management of a circumferential lower extremity degloving injury with the use of vacuum-assisted closure.

A 58-year-old male presented with a large circumferential degloving injury and was immediately taken to the operating room for further assessment of his wound. At that time, a plastic surgeon was consulted to manage the wound due to its size and significant soft tissue loss. The decision was made to manage the patient's wound with the vacuum-assisted closure (VAC) device to prepare the wound bed for grafting. After three weeks of VAC therapy, the wound bed was revascularized with granulation tissue and was ready for grafting. The patient underwent a successful split thickness skin graft on hospital Day 23 and was discharged home. Follow-up visits revealed no scar contracture or functional limitations.

Necrobiotic xanthogranuloma of the chest wall.

Necrobiotic xanthogranuloma is a rare disease that usually presents with indurated yellow red nodules or plaques in the dermis or subdermal tissues. The pathogenesis of this disease is unknown and the limited number of cases has made long-term studies difficult. We report the case of a 61-year-old woman seen in our office for a 5 x 5-cm lesion of her chest wall. Biopsies established a diagnosis of necrobiotic xanthogranuloma. The patient received 4 months of intralesional steroid injections without change in the lesion. The patient was also treated with colchicine for several months without improvement. Therefore, the lesion was surgically excised and the area was reconstructed with local advancement skin flaps. The patient has been followed for 2 years with no evidence of recurrence.

Ablepharon-macrostomia syndrome.

We report three new cases of ablepharon-macrostomia syndrome (AMS) and give a 10-year follow-up on a newborn reported in an abstract. These four patients, as well as those previously reported, all had absent hair, brows, and lashes, absent or short eyelids, macrostomia, ear anomalies, redundant skin, and abnormal genitalia. Many have persistent visual problems, often related to early corneal exposure. Hearing loss, poor hair growth, finger contractures, and growth retardation were also chronic problems. Developmental impairment was present in two-thirds of patients but was usually mild. This report contributes to our knowledge regarding the natural history of AMS and includes the first report of an adult patient. It also adds further evidence that AMS is distinct from Barber-Say syndrome, which has similar features.