Biomechanical Performance of Biodegradable Screw Fixation in Mandibular Distraction Osteogenesis.

Internal distraction devices are commonly used in congenital micrognathia. The eventual need for device and screw removal can be challenging, requiring extensive dissection and disturbance of bone regenerate. Bioabsorbable poly-L-lactide (PLLA) screws, compared to traditional titanium screws, simplify device removal. Previous in vivo studies have found that the maximal compressive force generated by mandibular distraction is 69.4N. We hypothesized that PLLA screws could support these compressive/distraction forces. Ten mandibles were obtained from 5 canine cadavers. Paired mandibles from the same cadaver were each fixated to a mandibular distractor with eight screws (either titanium or PLLA). Devices were each set to 15 and 30 mm of distraction distance. Compression force of 80 N was then generated parallel to the axis of the distraction device. Distractor displacement was measured to detect any mechanical failure during this pre-set load. Finally, if no failure was observed at 80 N, a load-to-failure compression test was done in the PLLA group to determine the mechanical failure point. All distractors in both the titanium and PLLA screw groups withstood 80 N of compression without failure. When the load-to-failure test was performed in the PLLA group, the average device failure point was 172.8 N (range 148-196 N). Review of high-frame-rate video demonstrated that all failures occurred due to the PLLA screws breaking or falling out. Bioabsorbable PLLA screws can withstand compressive forces more than double that of the maximal in vivo forces needed during mandibular distraction. These screws may be an acceptable alternative for the fixation of internal mandibular distractors.

Reconstruction of Congenital Sternal Cleft: A Systematic Review of the Literature.

INTRODUCTION: Sternal cleft (SC) is a rare congenital deformity that results from failure of sternal bar fusion. Sternal cleft can be categorized as superior partial, inferior partial, or complete. Each form of SC can present as an isolated defect or in association with other congenital deformities, which presents a unique challenge for reconstructive surgeons. In our systematic review, we aim to summarize the published experience on repair of SCs and present a pragmatic approach to help guide reconstructive planning. METHODS: A systematic review was performed to identify all reported SC cases in literature that underwent sternal reconstruction. RESULTS: Seventy-one studies were identified from 1970 to 2019, which included a total of 115 patients. Superior partial SC was the most common SC variant, accounting for 65.2% (75/115) of all reported cases. There were 31 cases of complete SC (27.0%) and 9 cases (7.8%) of inferior partial SC; 49.6% of the patients (57/115) in our review had isolated SC without any other congenital deformities. Sixty-seven patients (60.3%) were treated with primary closure, with or without secondary maneuvers, such as chondrotomies, cartilage resection, or periosteal flaps. Alternative methods included interposition grafts, with autologous rib graft in 18 patients (15.8%), permanent mesh in 8 patients (7.0%), acellular dermal matrix in 5 patients (4.4%), sternal plate flap in 5 patients (4.4%), and nonthoracic autologous bone grafts in 4 patients (3.5%). CONCLUSIONS: Our review supports that primary closure should be attempted regardless of patient age. For wider sternal gap, reconstruction with an autologous local graft or flap should be considered. When the patient does not have sufficient autologous tissue for a successful sternal reconstruction, alloplastic or allograft interposition options are a reasonable choice.

Global Burden of Craniofacial Disorders: Where Should Volunteering Plastic Surgeons and Governments Focus Their Care?

PURPOSE: Approximately 11% of the global burden of disease is surgically treatable. When located within the head, face, and neck region, plastic surgeons are particularly trained to treat these conditions. The purpose of this study was to describe the etiology, disability, and barriers to receiving care for diseases of the head, face, mouth, and neck region across 4 low-and-middle-income countries. METHODS: The Surgeons OverSeas Assessment of Surgical Need (SOSAS) instrument is a cluster randomized, cross-sectional, national survey administered in Nepal, Rwanda, Sierra Leone, and Uganda from 2011 to 2014. The survey identifies demographic characteristics, etiology, disease timing, proportion seeking/receiving care, barriers to care, and disability. RESULTS: Across the 4 countries, 1413 diseases of head, face, mouth, and neck region were identified. Masses (22.13%) and trauma (32.8%) were the most common etiology. Nepal reported the largest proportion of masses (40.22%) and Rwanda reported the largest amount of trauma (52.65%) (P < 0.001). Rwanda had the highest proportion of individuals seeking (89.6%) and receiving care (83.63%) while Sierra Leone reported the fewest (60% versus 47.77%, P < 0.001). In our multi-variate analysis literacy and chronic conditions were predictors for receiving care while diseases causing the greatest disability predicted not receiving care (ORa .58 and .48 versus 1.31 P < 0.001). CONCLUSIONS: The global volunteering plastic surgeon should be prepared to treat chronic craniofacial conditions. Furthermore, governments should address structural barriers, such as health illiteracy and lack of access to local plastic surgery care by supporting local training efforts.

Nasal Dorsal Augmentation with Freeze-Dried Allograft Bone: 10-Year Comprehensive Review.

BACKGROUND: The aim of this study was to evaluate freeze-dried cortical allograft bone for nasal dorsal augmentation. The 42-month report on 18 patients was published in 2009 in Plastic and Reconstructive Surgery with 89 percent success at level II evidence, and this article is the 10-year comprehensive review of 62 patients. METHODS: All grafts met standards recommended by the American Association of Tissue Banks, the U.S. Food and Drug Administration, and the Centers for Disease Control and Prevention. Objective evaluation of the persistence of graft volume was obtained by cephalometric radiography, cone beam volumetric computed tomography, and computed tomography at up to 10 years. Vascularization and incorporation of new bone elements within the grafts were demonstrated by fluorine-18 sodium fluoride positron emission tomography at up to 10 years. Subjective estimation of graft volume persisting up to 10 years was obtained by patient response to a query conducted by an independent surveyor. RESULTS: The authors report objective proof of persistence of volume alone or combined with proof of neovascularization in 16 of 19 allografts. The authors report the patient's subjective opinion of volume persistence in 37 of 43 grafts. The dorsal augmentation was assessed overall to be successful in 85 percent of 62 patients evaluated between 1 and 10 years, with a mean of 4.7 years. CONCLUSIONS: Freeze-dried allograft bone is a safe and equal alternative for dorsal augmentation without donor-site morbidity. Further studies are needed to (1) confirm these findings for young patients needing long-term reconstruction, and (2) partially demineralize allograft bone to allow carving with a scalpel. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Characterization of the ocular findings in the nablus masklike facial syndrome.

Nablus masklike facial syndrome (NMLFS), characterized by tight, expressionless facial features resembling a mask, was first described in 2000. Since then, 10 cases have been identified with the same phenotype and genotype. Although detailed descriptions of the facial and external ear characteristics unique to the syndrome exist, no clear description of the ocular anatomic findings and management of ocular complications has been detailed. We present a confirmed case of NMLFS with detailed descriptions of the ocular anatomy encountered in this patient and a discussion regarding the clinical significance of these findings.

Resorbable Construct for Subtotal Cranial Vault Remodeling.

INTRODUCTION: Pansynostosis can result in markedly thin calvarial bone resulting in poor quality and quantity of allograft for cranial vault expansion. Such scenarios can result in large calvarial defects and poorly stabilized constructs. Additionally, the osteoinductive properties of neonatal dura and paracranium in cranial vault reconstruction suggest the possibility of reconstructing extensive calvarial defects using minimal native calvarium given the appropriate scaffold. We report a case of subtotal cranial vault remodeling involving greater than 50% of the cranial vault using a custom poly DL lactic acid (Sonic Weld) resorbable plate construct and underlay calvarial bone grafting. METHODS: A 4-month-old male infant presented with a diagnosis of Cruzon syndrome and pansynostosis. Staged reconstruction was performed with the initial stage involving the posterior and middle cranial vault. Given the severity of the deformity, the native cranial bone was thinned with multiple defects such that it could not be used to provide structural integrity or sufficient surface coverage for cranial vault reconstruction. Useable bone comprised only a fraction of the surface area required to expand the posterior and midcranium. Resorbable poly DL lactic acid (Sonic Weld) plates were used to create a custom construct for reconstruction of the posterior and middle cranial vault. The construct was then seeded with usable fragments of the native calvarium and secured to the cranial base with resorbable pins. RESULTS: The construct resulted in maintained cranial shape throughout the postoperative period. Postoperative computed tomography imaging demonstrated osteogenesis throughout the construct with bridging of the fragmented calvarial grafts. Examination of the construct during anterior cranial vault remodeling demonstrated near complete resorption of the construct, stable posterior cranial vault, and minimal dural adhesions to the posterior cranium. At 11 months postoperatively, the patient continues to demonstrate appropriate cranial expansion and maintenance of posterior cranial shape. CONCLUSIONS: Fully resorbable constructs can provide effective structural support and a scaffold for osteogenisis in conjunction with minimal native calvarial bone grafts during reconstruction of large cranial vault defects in the infantile period.

Autologous fat grafting for primary breast augmentation: a systematic review.

As the technique of autologous fat grafting is being refined and perfected, its clinical applications are expanding. The use of autologous fat grafting for primary breast augmentation is controversial due to a lack of clarity regarding its safety and efficacy. Most notably, concerns about interference with the detection of breast cancer have been raised, but these have not been clearly addressed in the literature. To help surgeons gain further insight, the authors conducted a systematic review of the literature, carefully comparing technique, clinical outcome, radiologic impact, and complications in all available data on this subject. Although an optimal method of autologous fat grafting for primary breast augmentation is yet to be standardized, further strong evidence-based studies are necessary to confirm the findings of this approach.

Tongue suture placement after cleft palate repair.

OBJECTIVE: Postoperative airway obstruction is a complication of cleft palate repair. A technique to control the airway is to place a suture through the tongue at the conclusion of the palate repair, but it is not uniformly adopted by surgeons. Although it has been frequently performed, the use and effectiveness of the tongue suture have not been studied. Our purpose was to determine the usefulness of tongue suture placement. DESIGN: We surveyed health care providers as to their frequency of use and the value of the tongue suture in postoperative airway management of the cleft palate patient. The survey was sent via e-mail to 2080 members of the American Cleft Palate-Craniofacial Association, with a total of 396 responders. RESULTS: Surgeons were nearly equally split on placing a tongue suture, with 41.1% responders reporting that they use a tongue suture all of the time and 41.1% of responders reporting that they never used a tongue suture. Some criterion used for placement was the complexity of the case, syndromic patients, and overseas cleft missions. CONCLUSIONS: Many cleft palate repairs are done annually without using tongue sutures, but it does not seem to affect the outcomes among surgeons, thus confounding the question of effectiveness. At this time, tongue suture placement after cleft palate repair is variable and subjective. Further studies need to be performed to assess outcomes after placing a tongue suture.

Nasal dorsal augmentation with freeze-dried allograft bone.

BACKGROUND: Properly prepared freeze-dried bone has been used with impunity by orthopedic surgeons since 1992 without a single report of disease transmission. The aim of this study was to evaluate freeze-dried cortical allograft bone for nasal dorsal augmentation. METHODS: Freeze-dried human cortical bone was obtained from DCI Donor Services, Nashville, Tennessee. Standards recommended by the American Association of Tissue Banks, the U.S. Food and Drug Administration, and the Centers for Disease Control and Prevention were followed. Objective evaluation of the persistence of graft volume was obtained by cephalometric radiography. Vascularization and incorporation of new bone elements within the grafts were demonstrated by using fluorine-18 sodium fluoride positron emission tomographic/computed tomographic scanning. RESULTS: The average persistence of projection in 18 patients was 87 percent at 6 months. Thereafter, 10 patients showed 100 percent maintenance of projection at 12 to 36 months. Vascularization and incorporation of new bone elements within the grafts were demonstrated by using fluorine-18 sodium fluoride positron emission tomographic/computed tomographic scanning in four patients. CONCLUSIONS: The initial loss of 13 percent of projection is most likely attributable to resolution of early surgical edema. The authors postulate that there are two pathways based on whether the recipient bed allows vascular access to the graft. The revascularization or inductive pathway involves stem cell conversion to eventual osteoblasts. The scar bed barrier or noninductive pathway involves the preservation of the graft as an unchanged alloimplant. This report is the first of a series that will include a 5-year and a 10-year follow-up.

Craniofacial distractor applicator.

Craniofacial distraction can be planned using cephalograms, computed tomography, medical models, and other forms of anatomic data. However, it is often difficult to translate this plan to the patient. Specifically, it is difficult to obtain true parallel placement of bilateral midface and mandibular distractors. Intraoperative translation of preoperatively determined vectors is also troublesome. One method of application uses computed tomography data with radiofrequency triangulation technology in a specially equipped room. This helps with the issue of placement on the patient but does not establish parallelism. We have developed a simple-to-use craniofacial application stabilization device that allows equal placement of bilateral distractors and measurement of distraction vectors. The applicator measures 20 cm in length in its open configuration. The terminal portion of the device has a coupler that holds the distractor during placement. The device is hinged in 3 points so that it can be easily folded into a compact and autoclavable device (7 x 3 cm). The hinges allow equal placement of bilateral distractors. Each hinge can be calibrated to determine the vector of distraction and confirm equal application. Lastly, the stabilizer can be fixed to nasion with a Steinmann pin for reference, allowing intraoperative translation of distraction vectors. We demonstrated on skull models that the craniofacial distractor applicator can accurately allow parallel intraoperative placement of craniofacial distractors. We demonstrated simultaneous placement of the distractors allowing a more precise determination of end points.

Distraction osteogenesis of the cleft maxilla.

Distraction osteogenesis is a method of enhancing bony deficiencies of the hypoplastic cleft maxilla. Whether it is the result of inherited growth deficiency or of iatrogenic causes from operative intervention, 20 to 25% of cleft maxilla patients require maxillary advancement. Traditionally, this has been done by standard orthognathic surgery at varying LeFort levels. Predictable results have been achieved with standard techniques in minor to moderate maxillary hypoplasia; however, limited advancement and relapse is common in severe cases. Distraction osteogenesis has improved results in these patients by allowing soft tissue relaxation and gradual bone generation. Therefore, greater movement of the craniofacial skeleton is possible in severe cases of maxillary retrusion with lower relapse rates.

Clinical correlation of chromosome 22q11.2 fluorescent in situ hybridization analysis and velocardiofacial syndrome.

OBJECTIVE: To identify characteristics associated with microdeletions of chromosome 22q11.2 ascertained by fluorescent in situ hybridization (FISH) analysis in patients with velopharyngeal insufficiency (VPI), cleft palate, or other clinical features of velocardiofacial syndrome (VCFS). DESIGN/SETTING: Retrospective review of all patients entered at one tertiary-level multidisciplinary cleft lip and palate and craniofacial anomalies panel from January 2000 to December 2003. PATIENTS: The study consisted of 115 patients. The presence or absence of the following clinical features was documented: cleft palate (submucous and overt), VPI, cardiac anomalies, renal anomalies, small stature, characteristic facies, developmental delay, psychiatric dysfunction, and family history. MAIN OUTCOME MEASURE: Correlation between presence or absence of clinical features of VCFS and presence or absence of 22q11.2 microdeletion by FISH analysis. RESULTS: Of the 16 patients (13.9%) who demonstrated 22q11.2 microdeletion by FISH analysis, 16 had VPI (100%), 16 had small stature (100%), 14 had cleft palate (88%), and 13 had characteristic facies (81%). Developmental delay was also present in 13 of these patients (81%), and seven had cardiac anomalies (44%). Multiple regression analysis revealed that the presence of characteristic facies and small stature statistically correlated with microdeletions of chromosome 22q11.2 by FISH studies (p < .05). CONCLUSIONS: Patients with microdeletions of chromosome 22q11.2 as demonstrated by FISH analysis were more likely to have VPI, small stature, cleft palate, characteristic facies, and developmental delay, in descending order. Statistical analysis showed that only characteristic facies and small stature correlated with 22q11.2 microdeletions.

Inframammary crease: positional relationship to the pectoralis major muscle origin.

BACKGROUND: The inframammary fold (IMF) is an important anatomic landmark in breast surgery. Despite the importance of this structure, its relationship to the pectoral muscle and its position on the chest wall are not fully understood. OBJECTIVE: The purpose of this article is to identify the positional relationship of the inframammary crease to the pectoralis major muscle. METHODS: The study included 20 female cadavers and 10 patients with breast cancer with planned mastectomies. The course of the inframammary crease was tattooed to the underlying chest wall with marking needles and methylene blue dye. Marking needles were placed along the fold at the midclavicular line, 2 cm medial to the midclavicular line and 2 cm lateral to the midclavicular line. After removal of overlying soft tissue, measurements were made between the IMF markings and the inferior origin of the pectoralis major muscle. Chest walls of the cadavers were examined bilaterally. RESULTS: The IMF was located inferior to the inferior origin of the pectoralis major muscle in all measurements of all specimens. The average distance of the IMF below the pectoralis major origin in the cadaveric group at the medial, midclavicular, and lateral locations was 1.9, 2.0, and 2.5 cm, respectively. The average distance of the IMF below the pectoralis major origin in the mastectomy patient group at the medial, midclavicular, and lateral locations was 1.5, 1.6, and 2.2 cm, respectively. CONCLUSIONS: The IMF is inferior to the inferior origin of the pectoralis major muscle. Subpectoral dissection to the level of the IMF will disrupt the attachments of the pectoralis major muscle.

Anesthetic concerns of external maxillary distraction osteogenesis.

BACKGROUND: External maxillary distractions present additional anesthetic concerns to the existing complexity of the patient with craniofacial disorder. The distraction hardware is rigidly fixed to the cranium and projects in the frontofacial midline, thus limiting oronasal airway access. METHODS: A review of 16 patients (10 male, 6 female) having external maxillary distraction was done. Patients with patent tracheostomies were excluded. In all cases, the same type of external distraction device was used (R.E.D., K.L.S. Martin, Jacksonville, FL, USA). Perioperative records were reviewed for medical history; operative diagnosis, presence of airway disease, tracheostomy, laryngoscopy grade, use of fiberoptic bronchoscope, procedure, operative time, use of intraoperative steroid, day of postoperative extubation, and need for reintubation were documented. RESULTS: The study group was subdivided into two diagnostic categories: those with syndromic craniosynostosis (n = 9) and those with cleft lip/palate (CLP) (n = 7). Patients in the craniosynostotic group had grade 1 laryngoscopy views, with the exception of a single patient with Crouzon syndrome who had a grade 3 view. This was the only patient who required fiberoptic intubation. One patient with Apert syndrome required reintubation (48 hours after surgery); successful extubation was done 96 hours later. In the cleft lip/palate group, all patients had grade 1 laryngoscopic views, except one with a grade 3 view; no patient required fiberoptic intubation. Six of the seven patients were extubated immediately after surgery, with one patient extubated the next day. No patient experienced failure of extubation. CONCLUSIONS: External maxillary distraction minimally affects anesthetic management provided certain safeguards are observed. The vertical bar can be left attached to the cranial portion of the distractor, or it can be removed for extubation or reintubation. Removal of the vertical bar allows unobstructed direct laryngoscopy. This emphasizes the importance for the emergent availability of the appropriate screwdrivers and wire cutters to remove the vertical bar and trained personnel to perform the removal.

LeFort I soft tissue distraction: a hybrid technique.

Distraction osteogenesis of the craniofacial skeleton has greatly enhanced traditional osteotomies and bone grafting techniques. The obvious drawbacks to an external distraction device are visibility and awkwardness. A hybrid technique of maxillary distraction for soft tissue expansion and formation of regenerate, combined with rigid internal fixation, is proposed. This technique permits maxillary advancement that may be unattainable by traditional methods and obviates the extended use of external hardware during latency and consolidation of the regenerate. It also allows for optimization of the dental occlusion. The study group was composed of five patients with severe skeletal class III malocclusion who had combined maxillary distraction followed by rigid internal fixation. The average age at the time of LeFort osteotomy was 17 years, with a range of 13 to 19 years. The latency period ranged from 1 to 5 days, and distraction was done at the rate of 1 mm/d in all patients. After the proposed advancement was attained, all patients had reoperation, consisting of distractor removal, optimized interdental relationships with intermaxillary fixation, and placement of rigid internal fixation. The average anterior-posterior maxillary advancement was 11.6 mm, with a range of 10 to 13 mm. Lateral cephalograms and clinical examination showed no relapse at an average follow-up of 25 months, with a range of 5 to 40 months.

Resorbable internal splint: an adjunct to primary correction of unilateral cleft lip-nasal deformity.

There is usually some relapse in position of the alar cartilage after primary repair of unilateral cleft lip. Therefore, preoperative or postoperative external splinting has been recommended to supplement either closed or open suspension of the alar cartilage. The authors present a method using a resorbable internal nostril splint to shield the positioned alar cartilage from deformational forces caused by scar, and thus avoiding the problems associated with external splinting. An internal nasal splint was placed in 15 infants during repair of unilateral complete cleft lip and nasal deformity. The nasal morphology was compared with that of 15 control patients who had the same nasolabial procedure without internal splinting. Average follow-up time was 20.4 months (range, 4 to 30 months). Photogrammetric analysis showed that asymmetry of the alar contours averaged 8.6 percent in the splinted patients, as compared with 23 percent for controls (p <0.01). Thus, alar asymmetry was decreased two-thirds in the splinted group. An internal resorbable nasal splint is an adjunct to open alar suspension in primary repair of the unilateral cleft lip nasal deformity. An internal nasal splint protects the corrected alar cartilage longer than an external splint and eliminates drawbacks, such as necrosis, cutaneous depression of the nostril sill, and patient noncompliance. This strategy of temporary internal support of healing cartilage has other applications.

Transantral endoscopic orbital floor repair using resorbable plate.

The transantral endoscopic orbital floor approach can be used to repair pure orbital floor blowout fractures, avoiding the risks of lower lid incisions. A transoral incision is made to expose the anterior maxillary wall. A 1-cm2 antral bone flap gives access to the maxillary sinus and infraorbital floor. The size and fracture configuration are defined using a 30-degree, 4-mm endoscope. Stable bony shelves are identified adjacent to the fracture. Resorbable bone plating material is cut slightly larger than the defect. The material is introduced through defect, rotated, and allowed to rest on the stable medial, lateral, and anterior orbital shelves. Fixation is not required if there is adequate stability of the bony shelves. If not, direct screw fixation can be done from below.

Air dissipation in saline breast implants.

Residual air within saline breast implants can cause patient discomfort due to the mechanical and auditory effects of sloshing. Small amounts of air have no clinical significance, but if larger quantities are present and audible, the patient is reassured that the implant shell is gas-permeable and that the air will dissipate/diffuse. This study examined the time necessary for air dissipation in saline breast implants.Twelve McGhan style #68 saline breast implants were divided into two groups: group A, which included six implants with a size of 240 cc, and group B, which included six implants with a size of 270 cc. The implants were filled with room-temperature, intravenous, normal saline to their designated volumes, plus 30 cc of overfill. All air was evacuated, and each implant was inoculated with 5 cc of air. The implants were then submerged in a single tank of normal saline at 37 degrees C, at a depth of 20.4 cm to replicate capillary pressure. Intragroup analysis showed the air bubble was absent in group A at an average of 35.3 days (variance = 4.13) and in group B at an average of 38.0 days (variance = 0). If audible intraluminal air is present in the clinical setting, the patient can be reassured that the problem will resolve in approximately 30 days or less.