Videofluoroscopy Versus Nasopharyngoscopy of Lateral Pharyngeal Wall Movement for Assessment of Velopharyngeal Insufficiency.

BACKGROUND: Competent speech requires closure of the velopharyngeal sphincter by dynamic apposition of the velum and posterior and lateral pharyngeal walls. An accurate estimation of lateral pharyngeal wall motion is an important determinant in the planning and the outcome of any operation to correct velopharyngeal insufficiency (VPI). The purpose was to compare the assessment of lateral pharyngeal wall movement by videofluoroscopy (VP) versus nasopharyngoscopy (NP). METHODS: The authors retrospectively reviewed the charts of 269 consecutive patients in our cleft lip/palate clinic from 1982 to 2008 and culled those treated with a pharyngeal flap for VPI. The authors included patients who were evaluated preoperatively by both VP and NP, and had studies of suitable quality. Percentage of lateral pharyngeal wall motion was estimated with each technique and compared for each patient. RESULTS: The authors identified 25 patients who underwent both VP and NP at the same median age (4.7 years). The estimated percentage of lateral pharyngeal wall motion between the 2 techniques was significantly different ( P <0.001). Average lateral pharyngeal wall motion was estimated to be 59±25% (range: 5%-90%) by VP and only 40%±25% (range: 0%-95%) during NP. CONCLUSIONS: VP and NP are complementary, but assessment of lateral pharyngeal wall motion can vary between the 2 methods. The surgeon should be aware of the difference in estimated lateral pharyngeal wall movement when planning a procedure to correct VPI.

The Relationship between Age and Facial Asymmetry.

BACKGROUND: Facial symmetry is a fundamental goal of plastic surgery, yet some asymmetry is inherent in any face. Three-dimensional photogrammetry allows for rapid, reproducible, and quantitative facial measurements. With this tool, the authors investigated the relationship between age and facial symmetry. METHODS: The authors imaged normal subjects using three-dimensional photogrammetry. Facial symmetry was calculated by identifying the plane of maximum symmetry and the root-mean-square deviation. Regression analysis was used to assess the relationship between age and symmetry. Subgroup analyses were performed among facial thirds. RESULTS: The authors imaged 191 volunteers with an average age of 26.7 ± 22.2 years (range, 0.3 to 88 years). Root-mean-square deviation of facial symmetry clustered between 0.4 and 1.3 mm (mean, 0.8 ± 0.2 mm). The authors found a significant positive correlation between increasing age and asymmetry (p < 0.001; r = 0.66). The upper, middle, and lower facial third's average root-mean-square deviations were 0.5 ± 0.2 mm (range, 0.2 to 1.2 mm), 0.6 ± 0.2 mm (range, 0.2 to 1.4 mm), and 0.6 ± 0.2 mm (range, 0.2 to 1.2 mm), respectively. Asymmetry also increased with age across all facial thirds (p < 0.001). CONCLUSIONS: Facial asymmetry increases with age in each facial third, with a greater asymmetry and increase in asymmetry in the lower two-thirds. Contributing factors may include asymmetric skeletal remodeling along with differential deflation and descent of the soft tissues. The observed correlation between increasing facial asymmetry and age may be a useful guide in plastic surgery to produce age-matched features.

Predictive value of weight gain and airway obstruction in isolated Robin sequence.

OBJECTIVE: Treatment of airway obstruction and feeding difficulties among newborns with isolated Robin sequence is challenging. The lack of clear guidelines may lead to prolonged hospital stays and delays in treatment. Appropriate risk stratification can facilitate treatment planning. We aim to identify factors that prognosticate prolonged hospital stay in children with isolated Robin sequence. SETTING: We used a retrospective multivariate analysis of 46 patients admitted with isolated Robin sequence at the Hospital for Sick Children, in Toronto, between 2000 and 2007. During the initial 4 weeks following admission, data regarding duration of hospital stay, management of airway obstruction, respiratory rate, management of feeding difficulties, and reflux therapy were collected. RESULTS: Correlation between length of hospital stay, airway management, and weight gain during the initial 4 weeks was noted. No correlation was found between length of hospital stay and respiratory rate, supplemental oxygen requirement, or reflux therapy. CONCLUSIONS: Risk stratification is possible in children with isolated Robin sequence. Delayed weight gain in Robin sequence correlates with the degree of airway obstruction. The need for a nasopharyngeal tube and weight gain during the initial 4 weeks of life in newborns with Robin sequence reliably predict length of hospital stay. These prognosticators should contribute to parent and physician expectations, as well as assist in treatment and discharge planning.

Lip replantation and delayed inset after a dog bite: a case report and literature review.

Dog bites to the face are common in children and often involve amputation of the lip or cheek resulting in a devastating facial injury. When feasible, replantation of the amputated lip segment provides the optimal cosmetic outcome. Here, we present the case of a partial upper lip replantation with delayed inset as a new treatment option. Revascularization of the central upper lip segment was enabled by anastomosis to a single labial artery. Inset compression at the time of initial closure caused arterial insufficiency. Therefore, a delayed, sequential inset was performed over the following 2 weeks resulting in an esthetically and functionally successful replantation. A comprehensive review of the literature on published lip replantation techniques is also provided and discussed. We add delayed inset to the armamentarium of the microsurgeon when faced with these difficult injuries.

Nasal reconstruction after severe facial burns using a local turndown flap.

Reconstruction of the nose after severe burn injury is a challenging problem. There are usually associated facial burns, which limits the availability of local flaps. Reconstruction with unburned distant tissue is often not appropriate because of the resulting mismatch in color and texture. Successful nasal reconstruction can be accomplished in this group of challenging patients using a simple, inferiorly based flap from the nasal dorsum with subsequent skin grafting to the resulting defect. We have used an inferiorly based nasal turndown flap to reconstruct severe nasal deformities after burn injury in 28 patients. The flap tissue consists of the dorsal surface of the nose, which is usually made up of skin graft and scar. The flap base is the scar transition zone between the dorsum of the nose and the lining mucosa. This is turned over to provide nasal length, projection, and to stimulate alar lobules. The resulting defect on the dorsum of the nose is then skin grafted. If further length or refinement is required, the procedure may be repeated. The records of all patients who underwent this procedure were reviewed for demographics, age at burn, percentage of total body surface area burned (%TBSA), availability of the forehead, number of procedures, and complications. Twenty-eight patients underwent nasal reconstruction in our series using this local turndown flap. Most of these patients had severe burns, with an average %TBSA of 46%. The procedure was initially applied to patients with devastating injuries and %TBSA of 80%-95%, with extremely limited donor sites. As the success of the procedure was established, less severely burned patients were included in the series, thereby lowering the mean %TBSA. All patients had partial or complete destruction of their forehead donor site. All patients presented for multiple hospitalizations, with an average of 17 hospital admissions. Using this local turndown flap, adequate nasal length and projection could be achieved. There were few complications. All of the flaps survived, although there were 2 cases of necrosis of the distal edge of the flaps (0.7%). This resulted in decreased length and projection but this problem was successfully addressed with additional staged procedures. Contraction of local scar tissue created bulk and support, eliminating the need for distant tissue transfer or cartilage grafting. Twelve of the 28 patients required repeat turndown flaps to achieve sufficient nasal length and projection. These results were durable over a follow-up period of up to several decades. A simple, multistaged dorsal nasal flap can be used to reconstruct severe nasal deformities after facial burn injury. This can obviate the need for distant tissue transfer. Even in patients with subtotal nasal amputation and complete absence of cartilaginous support, the opportunistic use of scar tissue can restore nasal tip projection and alar lobule architecture without cartilage grafting. The resulting nasal reconstruction blends well into the surrounding facial appearance. This simple technique has been remarkably successful in this selected group of patients with challenging nasal deformities.

Infantile digital fibromatosis.

Infantile digital fibromas are rare benign neoplasms that occur principally in children and are usually confined to the digits. These lesions are similar in appearance to several benign and malignant lesions, and biopsy is often required to confirm the diagnosis. The tumor is composed of myofibroblasts, which contain pathognomonic intracellular inclusion bodies. There is a strong tendency for recurrence after excision. We present a 2-year-old who developed extensive involvement of all 4 extremities after syndactyly release. This case is unusual in that the lesions occurred postsurgically and were substantially more extensive than those previously described.

Patency of the descending branch of the lateral circumflex femoral artery in patients with vascular disease.

BACKGROUND: Although the anatomy of the descending branch of the lateral circumflex femoral artery has been well described, the reliability of this vessel in patients with vascular disease has not been established. The authors sought to determine the patency of this vessel in patients with suspected lower extremity vascular disease by studying a series of lower extremity angiograms. METHODS: The authors retrospectively reviewed 72 angiograms and medical records of 49 patients with suspected lower extremity vascular disease. The degree of stenosis in each of the major lower extremity arteries including the descending branch of the lateral circumflex femoral artery was measured using an established scoring system. A nonparametric Mann-Whitney test was used to determine any correlation between vessel stenosis and comorbid conditions. RESULTS: The most common comorbidities were peripheral vascular disease (86 percent), hypertension (80 percent), and diabetes (59 percent). Mean stenosis of the descending branch of the lateral circumflex femoral artery was 10 percent. Other vessels demonstrated mean percentage stenoses greater than 50 percent, except for the profunda femoris (12.5 percent). The descending branch showed no atherosclerotic changes in 87 percent, mild changes in 4.5 percent, moderate changes in 1.5 percent, and severe disease in 7 percent. Stenosis of this vessel was not predicted by any particular patient demographic. CONCLUSIONS: The descending branch of the lateral circumflex femoral artery appears to be relatively spared from atherosclerosis, providing the reconstructive surgeon with multiple flap choices based on the versatility of this system. The yield of preoperative angiography for discovering severe stenosis in patients with multiple comorbidities is low, approximately 7 percent.