A Rare Case of Sagittal Sinus Obstruction Following Posterior Cranial Vault Distraction Osteogenesis.

Posterior cranial vault distraction osteogenesis (PCVDO) is a relatively new paradigm in the treatment of syndromic craniosynostosis, having first been introduced in 2009. PCVDO directly addresses the underdeveloped cranial vault and appears to allow for a larger increase in intracranial volume when compared to traditional techniques. Although reported as safe in the literature, critical appraisal is still required as PCVDO is a relatively uncommon procedure that may require greater numbers to detect true complication rates. The overall reported incidence of serious complications in PCVDO to date is low. This presentation highlights a rare case of sagittal sinus obstruction following posterior cranial vault distraction and raises questions as to the safest technical considerations when planning the operation.

Management of Unicoronal and Metopic Synostoses: Minimally Invasive Approaches.

Early endoscopic-assisted correction of unicoronal and metopic synostosis is an excellent, safe, cost-effective, and highly effective option for affected patients. Although open calvarial remodeling has a place in the armamentarium of the craniofacial team, the skull base changes seen in endoscopic-assisted techniques are unparalleled. The procedures are associated with low morbidity and no mortality. There is minimal blood loss, decreased operating time, significantly reduced blood transfusion rates, decreased hospitalization length, decreased cost, and less pain and swelling. Early diagnosis and referral for surgical evaluation are critical to obtaining these results.

The Use of Allogeneic Cartilage for Grafting in Functional and Reconstructive Rhinoplasty.

PURPOSE: Allogeneic cartilage grafting has multiple uses in rhinoplasty. Autogenous cartilage is frequently used in cases of nasal obstruction or reconstruction, but harvesting grafts can cause complications or might be contraindicated. Rhinoplasties on the patient with a cleft might require costochondral grafts. Allogeneic rib is an effective and safe alternative to autogenous grafts, prevents complications, and obviates postoperative admission after rib harvest. MATERIALS AND METHODS: Patients who had allogeneic cartilage placed during functional or reconstructive rhinoplasty were studied from 2 institutions, including 19 who had functional rhinoplasty using allogeneic Cartiform patellar cartilage grafts and 15 patients who underwent reconstructive cleft rhinoplasty with allogeneic rib cartilage. Postoperative follow-up was at least 6 months, and graft handling characteristics and improvement in breathing were assessed. Internal and external nasal valve (INV and ENV, respectively) patencies were evaluated in patients who received the Cartiform grafts, and cosmetic outcomes were rated for patients with reconstructed clefts. RESULTS: The average age of patients who underwent functional rhinoplasty was 57.3 years, and all were men with compromised nasal breathing. Cartiform cartilage was used to repair INV or ENV collapse. Postoperatively, all patients had patent INVs and ENVs and reported improved nasal breathing. Patients who received the rib allograft had an average age of 18 years and 40% were male; all had severe nasal deformities secondary to cleft or craniofacial conditions. Patients rated their preoperative nasal breathing as 4 of 10 on average and cosmetic appearance as 3 of 10; postoperatively, these were rated as 9 of 10. Complications were not noted, except for 1 superficial infection (unrelated to the graft) and 1 hypertrophic scar. There were no postoperative admissions. The mechanical and handling properties of the Cartiform and allogeneic rib were appropriate. CONCLUSION: Allogeneic cartilage is an acceptable alternative to autologous cartilage in functional and reconstructive rhinoplasty.

GoPro HERO 4 Black recording of scleral buckle placement during retinal detachment repair.

OBJECTIVE: GoPro and Google Glass technology have previously been used to record procedures in ophthalmology and other medical fields. In this manuscript, GoPro's latest HERO 4 Black edition camera (GoPro Inc, San Mateo, Calif.) will be used to record the placement of a scleral buckle during retinal detachment surgery. METHODS: GoPro HERO 4 Black edition camera, which records 4K-quality video with a resolution of 3840 (pixels) x 2160 (lines), was mounted on a head strap to record placement of a scleral buckle for a retinal detachment. RESULTS: Excellent video quality was achieved with the 4K SuperView setting. Bluetooth connection with an Apple iPad (Apple Inc, Cupertino, Calif.) provided live streaming and use of the GoPro App. Zoom, horizontal/vertical alignment, exposure, and contrast adjustments were made with postproduction editing on GoPro Studio software. CONCLUSIONS: Video recording with the GoPro HERO 4 Black edition camera is an excellent way to document extraocular procedures to improve medical education, self-training, or medicolegal documentation.

Cranium Bifidum Occultum Associated with Hypertelorism Treated with Posterior Vault Reconstruction and Orbital Box Osteotomies: Case Report and Technical Note.

Cranium bifidum occultum is a disorder of skull ossification presenting as an enlarged posterior fontanelle in the upper posterior angle of the parietal bone near the intersection of the sagittal and lambdoid sutures. The standard treatment for cranium bifidum occultum is observation. We present a case of a 5-year-old boy who presented with a 15 × 4.5 cm midline posterior cranial vault defect consistent with diagnosis of cranium bifidum occultum associated with orbital hypertelorism and a widened nose. The patient underwent posterior vault reconstruction for correction of cranium bifidum occultum defect followed by bifrontal craniotomy and orbital box osteotomies for correction of orbital hypertelorism and nasal deformity. To our knowledge, this is the first reported case describing surgical treatment for cranium bifidum occultum associated with orbital hypertelorism.

Problems and complications of full-face carbon dioxide laser resurfacing for pathological lesions of the skin.

OBJECTIVE: Facial resurfacing with a CO2 laser has been used for treatment of pathologic lesions and for cosmetic purposes. Postoperative complications and problems after laser resurfacing include infections, acneiform lesions, and pigment changes. This retrospective study describes the most common problems and complications in 105 patients and assesses postoperative pain in 38 patients. STUDY DESIGN: All patients received CO2 laser resurfacing for treatment of malignant/premalignant lesions and had postoperative follow-up to assess problems and complications. Some had follow-up to assess postoperative pain. All patients had Fitzpatrick I-III skin types and underwent the same perioperative care regimen. RESULTS: There were 11 problems and 2 complications. Problems included infection, acneiform lesion/milia, and uncontrolled postoperative pain. Complications included hyperpigmentation. Among the postoperative pain group, 53% reported no pain and the rest had mild or moderate pain. CONCLUSION: Complications are rare. Infection and acneiform lesions/milia were the most common problems, as previously reported. Most patients do not experience postoperative pain.

Factors Determining Outcome After Trigeminal Nerve Surgery for Neuropathic Pain.

PURPOSE: Most patients who seek relief from trigeminal neuropathic pain by trigeminal microneurosurgery techniques do not show permanent pain relief after surgery. However, a small number of patients have permanent relief after surgery. The objective of this study was to determine factors that might be associated with the resolution, decrease, or recurrence of neuropathic pain after trigeminal nerve surgery in those patients who present with neuropathic pain before surgery. PATIENTS AND METHODS: An ambispective study design was used to assess patients who underwent trigeminal nerve repair of the inferior alveolar and lingual nerve who had documented neuropathic pain before surgery from 2006 through 2014. The primary endpoint was the difference in pain intensity at 3, 6, and 12 months after surgery compared with presurgical intensity levels. Explanatory variables, including age at surgery, gender, site of nerve injury, etiology of nerve injury, classification of nerve injury, duration from injury to repair, health comorbidities, and type of repair performed, were evaluated as potential factors in the outcomes. Wilcoxon signed rank analysis was used to compare demographic and injury characteristics of patients who had pain relief, partial pain relief, and no pain relief after surgery. Two-way analysis of variance and logistic regression analysis were used to evaluate the association between neuropathic pain and the explanatory variables. RESULTS: Twenty-eight patients met the inclusion criteria. Three cohorts of patients were identified and analyzed. The no-recurrence cohort included 7 patients who had neuropathic pain before surgery that was resolved with surgery. The complete-recurrence (CR) cohort included 10 patients who had neuropathic pain before surgery and complete recurrence of pain intensity after surgery. The incomplete-recurrence (ICR) cohort included 11 patients who had neuropathic pain before surgery and partial recurrence of pain intensity after surgery. There was no statistical difference in preoperative pain intensity levels among the 3 cohorts (P = .16), but there were statistical differences at 3 months (P = .007), 6 months (P < .0001), and 12 months (P < .0001). There were no statistical differences between the CR and ICR cohorts at 3 months (P = .502), 6 months (P = .1), and 12 months (P = .2). There was no effect by age, gender, injury type, Sunderland classification, injury etiology, duration from injury to repair, health comorbidity, or repair type on the outcome. CONCLUSIONS: The recurrence of neuropathic pain after trigeminal nerve repair for neuropathic pain is likely multifactorial and might not depend on factors that normally affect sensory recovery in patients who have no neuropathic pain (ie, age, duration of injury, type of injury, or repair type) and undergo trigeminal nerve surgery. These differences indicate that the understanding of trigeminal neuropathic pain is incomplete. Predictive outcomes of treatment will probably improve when the etiology is better defined to allow target- and site-specific treatment. In the meantime, trigeminal nerve surgery is a treatment option that offers a chance of decreasing or resolving pain intensity.

Course of the mandibular incisive canal and its impact on harvesting symphysis bone grafts.

PURPOSE: To characterize the anatomic course of the mandibular incisive canal to define parameters for harvesting autogenous bone from the symphysis of the mandible. MATERIALS AND METHODS: A series of osteotomies were completed between the mental foramina in the anterior mandibles of 19 cadavers. Methylene blue dye was used to help identify the incisive canal. From the canal, distances to key adjacent landmarks were measured with a Boley gauge to 0.1 mm. Measurements included distances from the mandibular incisive canal to the buccal cortex, the lingual cortex, the inferior border of the mandible, the apices of the teeth, and the buccal cementoenamel junction (CEJ) of the teeth. RESULTS: The canal decreased in diameter from lateral to medial. It tended to be closer to the buccal cortical bone than to the lingual cortex (P < .001) and was, at times, directly abutting the buccal cortex (average distance to buccal cortex, 3.5 mm). The canal maintained a relatively constant distance from the apices of the teeth (approximately 7 to 8 mm), coursing inferiorly under the longer canines bilaterally. The canal became increasingly difficult to identify toward the midline, likely dispersing into microscopic tributaries. CONCLUSIONS: The authors suggest several modifications to the standard surgical approach to the symphysis area during the harvest of bone grafts. When the goal is to avoid the mandibular incisive canal, osteotomies should not exceed a depth of 4 mm, should be at least 5 mm anterior to the mental foramen, and 9 mm below the root apices (or 23 mm below the lowest facial CEJ) and should maintain the contour of the mandible's inferior border. Alternatively, some degree of canal compromise can be accepted and larger grafts can be obtained by increasing the depth of the harvest in the horizontal dimension or decreasing the distance from the osteotomy to the root apices (or the CEJ) in the vertical dimension.

The presence of neuropathic pain predicts postoperative neuropathic pain following trigeminal nerve repair.

PURPOSE: The risk for the continuation or recurrence of neuropathic pain following trigeminal nerve repair has never been examined. The objective of this study was to determine which risk factors might be associated with the continuation or recurrence of neuropathic pain following trigeminal nerve microneurosurgery. PATIENTS AND METHODS: An ambispective study design was used to assess subjects who underwent trigeminal nerve repair of the inferior alveolar nerve and lingual nerve between 2000 and 2010. The primary outcome was the presence or absence of neuropathic pain at 3, 6, and 12 months after surgery. Explanatory variables, including age at surgery, gender, presence of neuropathic pain before surgery, site of nerve injury, etiology of nerve injury, classification of nerve injury, duration of nerve injury, and type of repair performed, were abstracted from patient charts. Fisher exact tests were used to compare the demographic and injury characteristics of patients who presented with pain before surgery and those who did not. The McNemar test was used to assess whether there was a significant change in neuropathic pain report from before to after surgery. The level of significance was set at .50. RESULTS: Of the 65 patients analyzed, two-thirds were women; the average age was 36±16.1 years, and the median time between the injury and surgery was 6.4 months (interquartile range, 6.7 months). Lingual nerve injury type was the most frequent (62%). There was no statistically significant change in pain status from before to after surgery (P=.104). Only 1 patient had pain after surgery who had not had pain before surgery, while 67% of those with pain before surgery continued to have pain after surgery. Pain prior to surgery as a predictor of pain after had sensitivity of 91%, specificity of 88%, positive predictive value of 67%, and negative predictive value 97%. CONCLUSIONS: The presence of neuropathic pain prior to trigeminal microneurosurgery is the major risk factor for the continuation or recurrence of postoperative neuropathic pain. These findings suggest that trigeminal nerve surgery is not a risk factor for developing neuropathic pain in the absence of neuropathic pain before surgery.

Comparison of intraoral harvest sites in the edentulous versus dentate specimen.

OBJECTIVE: The aim of this study was to compare the edentulous vs dentate specimen intraoral bone harvest sites. We wished to identify if there were any sites that yielded similar quantities of bone regardless of the status of the dentition. STUDY DESIGN: There were 59 cadavers in the study. Three continuous outcomes (area, thickness, and volume) were measured for each cadaver at 4 sites (zygoma, symphysis, ramus, and coronoid). RESULTS: Status of the dentition was not a factor in the quantity of harvested bone in regard to surface area and volume. The only difference noted between the dentate and edentulous groups was the thickness in the symphysis and zygomaticomaxillary buttress, with the dentate group, on average, having greater thickness. CONCLUSIONS: There appeared to be similar amounts of bone available in dentate and edentulous specimens in our study. This information should encourage clinicians to consider intraoral bone harvest for augmentation of an edentulous ridge regardless of the status of the dentition.

Comparison of intraoral harvest sites for corticocancellous bone grafts.

PURPOSE: The aim of this study is to quantify and compare the amount of bone that can be harvested from the mandibular symphysis, ascending ramus/body, coronoid process, and the zygomatic-maxillary buttress using a within-subject study design. MATERIALS AND METHODS: Three continuous outcomes (area, thickness, and volume) were measured at 4 sites (zygomatic-maxillary buttress symphysis, ramus, coronoid) from each of the 59 cadavers used in this study. The explanatory variables were age, gender, and site. To account for the within-subject research design, a linear mixed-effects model was performed separately for each of the 3 outcomes to compare the sites controlling for age and gender. Level of significance was set at 0.05. RESULTS: For all 3 outcomes, there was a statistically significant difference among the average values of the 4 sites (P < 0.0001). The ramus had the highest average cortical bone area and volume harvested, while the symphysis had the highest average thickness. CONCLUSIONS: The characteristics among different potential intraoral donor sites vary greatly regarding thickness, volume, and cortical surface area. Using the estimates of the various yields derived from these grafts, a surgeon will be more adequately equipped to confront the reconstructive challenges of the maxillofacial region.