Mandibular distraction osteogenesis in very young patients to correct airway obstruction.

The purpose of this study was to measure changes in the airway cross-sectional area of pediatric patients with micrognathia and obstructive airway symptoms after treatment by mandibular distraction. The measurements obtained were correlated with the clinical outcomes.Ten patients, ranging in age from 3 months to 8 years, underwent measurement and distraction. Eight patients were under 30 months of age. Six were diagnosed with Pierre Robin sequence, two with Treacher Collins syndrome, and two with Nager syndrome. All patients had retrognathia of greater than 8 mm and obstructive airway symptoms while awake that had resulted in tracheostomy (3), repeated apnea monitor triggering (5), or abnormal sleep study (2). Cephalometric analysis was performed pretreatment and posttreatment by distraction. The effective airway space was defined with the following boundaries: a horizontal line from the tip of the odontoid to the velum, the uvula tip to the tongue base along the shortest line, the tongue base down to the base of the epiglottis, and the horizontal line to the posterior pharynx. These lines were traced for each cephalogram, the outline was digitized, and the area was calculated by computer. An analysis of the square area change was done by paired t test. The range of distraction was 8 to 22 mm; the mean effective airway increase was 67.5 percent, with a range of 26 to 120 percent. Measurable airway increase occurred in all patients who underwent distraction, and all patients showed clinical improvement. Six patients with Pierre Robin sequence became asymptomatic, with normal sleep, feeding, and weight gain. Two patients with Nager syndrome and tracheostomies were decannulated and were asymptomatic postdistraction. One patient with Treacher Collins syndrome without tracheostomy became asymptomatic after mandibular distraction; one patient failed to distract because of premature consolidation and continued to require a cannula. Mandibular distraction seems to provide a consistent change in tongue base position that improves obstructive airway symptoms by increasing measured effective airway space. The potential for mandibular distraction exceeds the simple correction of malocclusion also by eliminating soft-tissue obstruction of the micrognathic airway. Airway improvement is independent of the syndrome diagnosed. Mandibular distraction osteogenesis may be useful to avoid or decannulate existing tracheostomy in infants with micrognathia.

Efficacy of preoperative decontamination of the oral cavity.

This two-part study consisted of: (1) a survey to assess current practice patterns, and (2) an experiment designed to assess the results of varying intraoral preparations. A 48 percent response rate was obtained from the survey of the 318 active members of the American Society of Maxillofacial Surgeons. This survey demonstrated that significant controversy continues regarding the efficacy of preoperative decontamination of the oral cavity. This prospective, randomized experimental study of 30 patients (saline, 10; povidone-iodine, 10; no preparation, 10) demonstrates a significant and sustained reduction of both anaerobic and aerobic bacteria after intraoral preparation with povidone-iodine solution but not saline. The patient's age, use of preoperative intravenous cephalosporin, and type and length of procedure did not influence the postoperative bacterial counts. Although none of the patients in this study developed an infection, recommendations are provided for standardized preoperative treatment of the oral cavity.

A management strategy for palatal fractures: a 12-year review.

Fractures of the palate are frequently associated with the more common and well-described Le Fort fractures. Palatal fractures may present diagnostic and exposure challenges and, if not satisfactorily treated, will result in occlusal problems after surgery. From 1986 through 1998, 116 complex maxillary fractures were treated at the authors' center. Among these, 13 patients were diagnosed with fracture of the palate. Patients with gunshot wounds to the face were excluded from the present study. Open reduction and internal fixation of the palatal fractures were achieved through elevation of the entire palatal mucoperiosteal flap to avoid late hardware exposure. This paper presents a unique approach to visualizing the whole bony palatal surface for accurate reduction and internal fixation of fractures.

A prospective evaluation of the prevalence of submucous cleft palate in patients with isolated cleft lip versus controls.

Although there is an established relationship between cleft lip and overt cleft palate, the relationship between isolated cleft lip and submucous cleft palate has not been investigated. To test the hypothesis that patients with isolated cleft lip have a greater association with submucous cleft palate, a double-armed prospective trial was designed. A study group of 25 consecutive children presenting with an isolated cleft lip, with or without extension through the alveolus but not involving the secondary palate, was compared with a control group of 25 children with no known facial clefts. Eligible patients were examined for the presence of physical criteria associated with classic submucous cleft palate, namely, (1) bifid uvula, (2) absence of the posterior nasal spine, and (3) zona pellucida. Nasoendoscopy was subsequently performed just after induction of general anesthesia, and the findings were correlated with digital palpation of the palatal muscles. Patients who did not satisfy all three physical criteria and in whom nasoendoscopy was distinctly abnormal relative to the control group were classified as having occult submucous cleft palate. Classic submucous cleft palate was found in three study group patients (12 percent), all of whom had flattening or a midline depression of the posterior palate and musculus uvulae on nasoendoscopy and palpable diastasis of the palatal muscles under general anesthesia. An additional six study group patients (24 percent) had similar nasoendoscopic criteria and palpable diastasis of the palatal muscles; they were classified as having occult submucous cleft palate. No submucous cleft palate was identified in the control group. Seventeen patients in the study group had an alveolar cleft with a 53 percent (9 of 17) prevalence of submucous cleft palate. In the present study, classic submucous cleft palate in association with isolated cleft lip was 150 to 600 times the reported prevalence in the general population. All children with an isolated cleft lip should undergo peroral examination and speech/resonance assessment no later than the age of 3 years. Any child with an isolated cleft lip with velopharyngeal inadequacy or before an adenoidectomy should be assessed by flexible nasal endoscopy to avoid missing an occult submucous cleft palate.

Secondary alveolar bone grafting using milled cranial bone graft: a retrospective study of a consecutive series of 100 patients.

OBJECTIVE: The purpose of this study was to evaluate the outcome of secondary bone grafting of alveolar clefts using milled cranial bone graft. PATIENTS: The study included a consecutive series of 100 patients who were operated on between 1986 and 1995 by a single senior surgeon. MEASUREMENTS: The patients were divided into four groups; (1) unilateral alveolar cleft or (2) bilateral alveolar cleft, (3) before eruption of the canine teeth or (4) after eruption. Follow-up ranged from a minimum of 12 months to 10 years, and evaluation included a physical examination, medical photography, orthodontic reports, and a panorex X-ray and/or a three-dimensional computed tomography scan of the maxilla produced using Denta-scan software. Patient outcomes were judged to be good, acceptable, or poor. Patients who developed any fistula or required regrafting were defined as poor outcomes. RESULTS: The combined good and acceptable outcomes represented 83% of the entire consecutive series. These two groups were defined as successful outcomes. In patients with unilateral and bilateral clefts who were under 12 years old, the success rate was 90% and 88%, respectively. In patients grafted following full canine eruption (>12 years old), success rate decreased to 83% in patients with unilateral and 66% in bilateral clefts, respectively. CONCLUSIONS: Our results support the use of milled cranial bone graft, which produces a stable closure of the alveolar cleft with good contour and support for adjacent tooth eruption. Our data further support the conclusion by others that outcomes of early secondary grafting are superior to delayed grafting. The experience presented here, including the success rate, ease of harvesting, and minimal morbidity, makes the cranium our preferred donor site for alveolar cleft grafting.

Frontofacial osteotomies, advancement, and remodeling by distraction: an extended application of the technique.

The purpose of this clinical report is to present the distraction technique for advancement of the frontofacial skeleton as a unit. Our 14-year-old patient was diagnosed with Carpenter's syndrome and kleblattschädel deformity at birth. At other centers the patient underwent corrective surgeries, including repeated fronto-orbital advancement in an attempt to correct the residual deformity. This has resulted in bony malunion and recurrent deformity, and it has left the patient with no available donor sites for harvesting of bone graft. The patient had class III malocclusion, severe midfacial and frontal deficiency, and relative turricephaly. We performed frontofacial osteotomies and placement of the distraction devices. Distraction of 20 mm was accomplished, correcting the exophthalmos and midface retrusion and producing class I dental occlusion. We conclude that distraction is an optional surgical method that can be applied in selected cases for advancement of the entire frontofacial skeleton.

Modified orticochea pharyngoplasty for treatment of unilateral velopharyngeal incompetence.

Unilateral nasopharyngeal paralysis is a relatively rare cause of velopharyngeal incompetence. Few therapeutic modalities for this problem have been described. A modification of the orticochea sphincter pharyngoplasty was developed using only a unilateral flap for treatment of the symptoms of hypernasality and nasal reflux. This preliminary report summarizes the operative approach and the successful outcomes in 2 patients.

Cleft cluster: a strategy for concurrent correction of multiple secondary clefting deformities.

We have developed a strategy for concurrent correction of multiple secondary clefting deformities based on the model proposed by Henderson and Jackson [1] which combines several cleft-related procedures. We have expanded this concept significantly to include as many as eleven procedures. The selected procedures are dictated individually by patients' needs. The constellation of corrective cleft-related surgeries has been given the name "cleft cluster" in the interest of simplicity. We are reporting on our experience with 85 consecutive patients using this approach. All patients in this series received bone grafting of the alveolar cleft as the primary procedure, plus multiple additional procedures as necessary. None of the patients reported received primary lip or palate surgery by the authors. The average number of procedures performed was 7.2. The average hospitalization was 4.1 days. The patients have been followed from 1 to 7 yrs. The fistula recurrence rate was 8%. Average patient age was 16.8 yrs with a range of 8 to 54 yrs. This approach eliminates multiple hospitalizations and outpatient procedures, allows flexibility to individualize patient care, provides consistent results, and is cost-effective.

Le Fort type III osteotomy for midface deficiency in selected cleft palate patients.

The comprehensive treatment of cleft lip and palate continues to evolve as understanding of the pathogenesis of this malformation and refinement of surgical techniques for its treatment have improved. The malformation, although varying in severity from individual to individual, is now considered an abnormality of the entire maxilla. Our experience indicates that a finite minority of cleft patients exists with significant malar and midfacial projection deficiency in addition to class III malocclusion who will benefit from a more extensive midfacial advancement. We have treated 10 patients with a diagnosis of cleft lip and palate as well as malar and midfacial retrusion with a Le Fort type III advancement. In this group of patients, there were two early postoperative complications. Two patients (20%) experienced late occlusal changes; 4 patients underwent orthodontic correction; and the other required a Le Fort type I osteotomy. Three patients (30%) experienced predicted velopharyngeal insufficiency requiring a pharyngeal flap for correction. All patients demonstrated both subjective and objective improvement in facial aesthetics and Angle's class I occlusion after surgery. In patients with cleft lip and palate who also have midfacial retrusion, the Le Fort type III advancement provides a more complete correction of the facial deformity as well as the malocclusion. This approach should be integrated into the comprehensive management of this deformity by individuals trained in craniofacial techniques.

Clostridial infection following severe facial trauma.

Severe posttraumatic wound infections are uncommon occurrences in the craniofacial region. Although most reported cases have occurred following an odontogenic infection or minor soft-tissue trauma, the potential for the development of this type of infection exists following complex facial fractures. We report a case with clostridial infection in the temporalis fascia complicating a complex facial fracture. The implications regarding antibiotic usage and delay of surgical treatment are discussed.

The effect of frostbite on the reconstructed ear.

A 17-year-old patient whose left ear was reconstructed using a lateral arm fascia and skin graft had done well until one episode of cold exposure approximately two years after the reconstruction. This thermal injury resulted in a localized area of composite tissue loss demonstrating that the reconstructed ear had a higher susceptibility to cold temperatures. The transferred fascia did, however, allow a stable base for granulation and reepithelialization, showing the continued vascularity and regenerative capacity of the transferred tissue. A discussion is provided regarding the susceptibility of free transferred fascia and its regenerative capacity.

Malar augmentation by osteotomy and advancement.

We developed a modification of Tessier's zygoma plasty to increase anterior and lateral projection of the malar eminences in 8 patients with malar hypoplasia. The four steps of our modification are: (1) access solely through an intraoral upper sulcus incision; (2) osteotomy of the inferior orbital rim at a more medial site and of the lateral orbital rim more cephalad; (3) careful preservation of both the zygomaticomaxillary buttress and the zygomatic arch; and (4) use of a cranial bone graft alone, as a wedge, to stabilize the rotated zygoma, without the need for plate or screw fixation. Eight patients have undergone this procedure. Follow-up ranged from 4 to 15 months. There have been no complications. All 8 patients have achieved excellent accentuation of their malar eminences, with maintenance of symmetry. The increase in malar eminence projection has improved overall facial form in these patients. The modified Tessier zygoma plasty offers a stable and predictable technique for improving facial form. It provides a very natural correction for deficient malar projection, without introducing visible scars.

Immediate reconstruction of complex cranioorbital fractures in children.

Six principles of craniofacial surgery were applied to the treatment of 7 consecutive pediatric patients who sustained complex cranioorbital fractures. These principles are (1) accurate assessment of the deformity, (2) early reconstruction, (3) complete exposure of the involved craniofacial skeleton, (4) accurate anatomical reduction of the fracture fragments, (5) use of rigid internal fixation, and (6) autogenous cranial bone grafting. Patient follow-up ranged from 6 to 52 months; evaluation included serial photographs, three-dimensional computed tomographic imaging, and cephalometric analysis. Application of these 6 craniofacial surgical principles provided definitive management in one operation, with optimal anatomical and functional reconstruction, and resulted in no detectable impairment to subsequent craniofacial growth.

Correction of velopharyngeal insufficiency by pharyngeal augmentation using autologous cartilage: a preliminary report.

Twenty patients with velopharyngeal insufficiency (VPI) were treated with autologous costal bone or cartilage implants. Videofluoroscopy and videonasopharyngoscopy studies were used to identify candidates for the procedure. The specific size and shape of the gap as well as an appropriate location for the implant were determined in those patients for whom videonasopharyngoscopy was used. A piece of costal bone or cartilage was implanted into a preselected site in the posterior pharynx. Speech and voice evaluation were conducted preoperatively and 8 weeks postoperatively. Hypernasality and audible nasal emissions were completely eliminated in five patients. Four patients had no postoperative change in speech quality. In the remaining patients, improvement occurred without elimination of VPI. The use of costal bone was discontinued after the ninth patient. One infection occurred with complete resorption of the costal bone graft. Resorption has not been a problem with costal cartilage. No extrusion has occurred, and there have been no infections. Overall speech improvement in this group of children (80%) compared favorably with other reports on pharyngeal augmentation. Costal cartilage appears to be a superior choice for implant material.

Comprehensive correction of the craniofacial deformity in achondroplastic dwarfism.

The treatment of this patient serves to demonstrate a craniofacial team approach to a unique and moderately severe problem. By the modification and careful combination of standard techniques, i.e., frontofacial advancement, and Le Fort I and vertical mandibular osteotomy, a good correction has been obtained. Analysis of the problem clearly indicated the need for moving multiple components of the facial skeleton into new positions to provide correction. The upper and lower midface required simultaneous movements in exactly opposite directions to normalize the skeletal deformity. To address the excess forehead height and projection, a modification of the usual frontofacial advancement was necessary. Rotation of the frontofacial segment forward inferiorly allowed correction of the orbital deficiency while also allowing shortening of the vertical forehead dimension. This is a deviation from the straight linear advancement usually dissected. Simultaneous retroposition and rotation of the maxilla allowed correction of the plane of occlusion while lengthening the midface. The unique combination and application of standard techniques of craniofacial surgery in this patient allowed a very good result.

Self-inflicted midline facial gunshot wounds: the case for a combined craniofacial and microvascular team approach.

Self-inflicted gunshot wounds to the face are extremely complex and difficult to manage. In the past, these patients have been treated by debridement, hemostasis, and soft tissue closure with reconstruction deferred to a later time. This approach consigned the patient to significant facial contracture and scarring, which is impossible to adequately correct secondarily. As a result of this traditional approach, patients had substantial disfigurement as well as dysfunction. At the Medical College of Wisconsin, we have begun an aggressive multispecialty team approach in which the maximum possible reconstruction is performed acutely. This has resulted in superior aesthetic and functional results, and in a substantially lower number of hospitalizations, surgical procedures, and hospital days. This approach includes the spectrum of current plastic surgical techniques including the craniofacial approach using open reduction with accurate miniplate reconstruction and acute bone grafting as well as soft tissue reconstruction and replacement using composite multiple-stacked free tissue transfer. We believe the overall approach provides a superior result and we will continue a program of aggressive and acute intervention.

Expanded midline forehead flap for coverage of nonnasal facial defects.

A 13-month-old infant with a giant hairy nevus of the superior portion of the right cheek, which measured 3.5 x 5.5 cm, was treated by excision and coverage using expanded midline forehead flap. This approach stands in contrast both to the standard technique of excision and full-thickness grafting for large facial defects as well as to the use of the midline forehead flap for nonnasal reconstruction. Although this approach did necessitate the placement of a midline forehead scar, the overall result was sufficiently superior to justify its use. The child has good, stable, soft coverage with no contour or landmark distortion. The child is presented in an 18-month follow-up with photographic documentation.

Early repair of complex orbital fractures.

Complex orbital fractures consist of fractures of the orbital rim and walls in two or more places and may be associated with more extensive facial fractures. Previously, delayed repair was the standard approach. Techniques of craniofacial surgery allow earlier reconstruction with more accuracy and stability. Enophthalmus, dystopia and facial contour deformities are avoided, and the final result improved. A new standard has been established. Three factors are important in attaining improved results. Three-dimensional CT scanning is used to obtain a comprehensive assessment of the injury, to plan reconstruction pre-operatively, and to assess the reconstruction post-operatively. Secondly, complete exposure of the facial skeleton is necessary and is achieved by the use of a coronal incision, frontal flap, infraorbital incision, and intraoral upper sulcus incision. Thirdly, cranial bone grafting is used to reconstruct orbital floors and severely comminuted or missing bones. Finally, the use of mini-plates and lag screws provides improved accuracy and stability of the reconstruction.

A preliminary report on the spray application of topical silver sulfadiazine to burn wounds.

A simple, flexible system for spray application of topical antimicrobials has been developed in the Burn Unit at Hennepin County Medical Center. In contrast to previous attempts, this method allows spray application of silver sulfadiazine without dilution. Because of the viscosity of the micronized cream, aerosol spread is minimal. Inexpensive commercially available components are used without modification. This system can be readily adapted to most hospital situations and provides rapid topical antimicrobial application. Time required for dressing changes has been reduced in our Burn Unit by 75% and fewer nursing personnel are required. Spray application avoids direct physical contact with burn wounds, eliminating potential contamination and greatly reducing pain associated with dressing changes. Patient acceptance is high.