Trends in Craniofacial Fellowship Career Outcomes: A Call for Expanding Professional Opportunities in Craniofacial Surgery.

PURPOSE: Limited available pediatric plastic surgery positions fail to accommodate the increasing number of craniofacial fellows trained annually. However, many adult indications have increased the demand for craniofacial expertise. Given new opportunities available to craniofacial surgeons, the authors aim to evaluate career prospects for recent craniofacial graduates and explore additional career opportunities. METHODS: Upon approval from the American Society of Craniofacial Surgeons (ASCFS), an anonymous online survey invitation was sent to craniofacial fellows who graduated from 2016 to 2021. Respondents were queried regarding their craniofacial fellowship and subsequent career prospects. RESULTS: A total of 124 eligible participants were identified, of which 30 (24.2%) responded. Craniomaxillofacial case distribution at respondents' current practices varied, with 42.3% reporting a 50% to 75% craniofacial caseload and 38.5% reporting less than 25%. Craniofacial trauma reconstruction was performed most at current positions (92.3%), followed by general reconstruction (92.3%) and breast surgery (69.2%); the least commonly performed was facial feminization (23.1%). Most respondents desired an increased craniomaxillofacial caseload (65.4%). However, 26.9% were unable to secure their current position before fellowship completion, and 80.0% cited limited craniofacial job availability. Recommendations to improve fellowship comprehensiveness and increase candidate competitiveness included increased facial feminization, facial esthetic, and microsurgical experience. CONCLUSION: To adapt to trends in craniomaxillofacial surgery, ASCFS should encourage developing fellowships that increase exposure to gender-affirming, adult craniofacial reconstruction, orthognathic, and skeletal facial esthetic surgery. Expanding training beyond congenital deformities can provide additional employment opportunities while maintaining excellence and innovation in facial plastic surgery.

Same-Admission Microvascular Maxillofacial Ballistic Trauma Reconstruction Using Virtual Surgical Planning: A Case Series and Systematic Review.

Study Design: Retrospective case series; systematic review. Objective: It is unknown whether the use of virtual surgical planning (VSP) to facilitate same-admission microsurgical reconstruction of the mandible following acute maxillofacial ballistic trauma (MBT) is sufficient to achieve definitive reconstruction and functional occlusion. Methods: A single-center retrospective analysis was conducted for patients who underwent microsurgical reconstruction of the mandible using VSP after acute MBT. The PubMed/MEDLINE, Embase, ScienceDirect, and Scopus databases were systematically reviewed using blinded screening. Studies were evaluated via thematic analysis. Results: Five patients were treated by same-admission and microsurgical reconstruction of the mandible using VSP. We observed an average of 16.4 ± 9.1 days between initial presentation and reconstruction, an average length of stay of 51.6 ± 17.9 days, 6.2 ± 2.8 operations, and 1.6 ± 0.9 free flaps per patient. Four types and 8 total flaps were employed, most commonly the anterior lateral thigh flap (37.5%). Care yielded complete flap survival. Each patient experienced at least 1 minor complication. All patients achieved centric occlusion, oral nutrition, and an approximation of their baseline facial aesthetic. Follow up was 191.0 ± 183.9 weeks. Systematic review produced 8 articles that adhered to inclusion criteria. Consensus themes in the literature were found for clinical goal and function of VSP when practicing MBT reconstruction, yet disagreement was found surrounding optimal treatment timeline. Conclusions: Same-admission microsurgical reconstruction after MBT is safe and effective to re-establish mandibular form and function. VSP did not delay reconstruction, given the need for preparation prior to definitive reconstruction.

Advanced Three-Dimensional Technologies in Craniofacial Reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Describe the evolution of three-dimensional computer-aided reconstruction and its current applications in craniofacial surgery. 2. Recapitulate virtual surgical planning, or computer-assisted surgical simulation, workflow in craniofacial surgery. 3. Summarize the principles of computer-aided design techniques, such as mirror-imaging and postoperative verification of results. 4. Report the capabilities of computer-aided manufacturing, such as rapid prototyping of three-dimensional models and patient-specific custom implants. 5. Evaluate the advantages and disadvantages of using three-dimensional technology in craniofacial surgery. 6. Critique evidence on advanced three-dimensional technology in craniofacial surgery and identify opportunities for future investigation. SUMMARY: Increasingly used in craniofacial surgery, virtual surgical planning is applied to analyze and simulate surgical interventions. Computer-aided design and manufacturing generates models, cutting guides, and custom implants for use in craniofacial surgery. Three-dimensional computer-aided reconstruction may improve results, increase safety, enhance efficiency, augment surgical education, and aid surgeons' ability to execute complex craniofacial operations. Subtopics include image analysis, surgical planning, virtual simulation, custom guides, model or implant generation, and verification of results. Clinical settings for the use of modern three-dimensional technologies include acquired and congenital conditions in both the acute and the elective settings. The aim of these techniques is to achieve superior functional and aesthetic outcomes compared to conventional surgery. Surgeons should understand this evolving technology, its indications, limitations, and future direction to use it optimally for patient care. This article summarizes advanced three-dimensional techniques in craniofacial surgery with cases highlighting clinical concepts.

Pediatric Diffuse Large B-Cell Lymphoma of the Frontal Sinus: A Case Report.

An 11-year-old male presented with right proptosis, bulbar conjunctivitis, and diplopia. Computerized tomography (CT) and magnetic resonance imaging revealed an enhancing mass involving the superio-medial orbit, ethmoids, frontal sinus, and anterior cranial fossa with skull base destruction. Diffuse large B-cell lymphoma was diagnosed via CT-guided biopsy. As a component of multidisciplinary care, the patient underwent frontal sinus cranialization, with orbital and skull base reconstruction. Trauma reconstructive principles guided recreation of orbital, frontal sinus, and anterior skull base anatomy. This rare primary location is undescribed in the pediatric literature.

Improving Care of Cleft-Related Velopharyngeal Incompetence on Humanitarian Missions Using a Multidisciplinary Team Approach.

BACKGROUND: Proper evaluation and analysis of speech surgery outcomes for cleft-related velopharyngeal incompetence in children and young adults performed on humanitarian missions is poorly characterized. The aim of this study is to examine the effect of using a multidisciplinary team on cleft-related humanitarian missions. The effect on patient selection, velopharyngeal mechanism imaging, and speech outcomes after surgery will be highlighted. METHODS: A review of the Medical Readiness Training Exercise database for craniofacial missions to the Dominican Republic from 2009 to 2011 was performed. A speech pathologist and a craniofacial surgeon evaluated all patients with a diagnosis of cleft palate and speech abnormalities. Patients were screened using speech analysis and selective nasal endoscopy. Data collected included sex, age, diagnosis, speech scores, date, and type of surgical procedure-that is, pharyngeal flap (PF) versus sphincter pharyngoplasty (SP), morbidity, and mortality. RESULTS: One hundred twenty-six patients with cleft palate were screened during the study period by a craniofacial surgeon and secondarily by a speech pathologist. Twenty-eight patients were identified with nasal quality speech of whom 12 patients (12/126 = 9.5% of total surgical cases) underwent PF/SP surgery after previous primary repair of a cleft palate defect. The 16 remaining patients (16/28 = 57%) with nonsurgical speech abnormalities were determined that surgery was not going to be beneficial and they were spared unnecessary surgery after speech pathology evaluation and nasal endoscopy. Eight patients were female and 4 patients were male; average age was 13.3 years (range 4-27 years). Seven pharyngeal flaps (58%) and 5 (42%) sphincter pharyngoplasty procedures were performed. The average presurgical speech score was 11.4 (range 6-24). There was a significant decrease in postsurgical speech scores with the average postsurgical speech score of 5.2 (range 0-21, P value = 0.0028). Follow-up evaluation averaged 18 months (range 6-24). Average hospital stay was 2 days for PF/SP surgery. Two patients, both with developmental delay, retained speech scores greater than 6. There were no major complications or reoperations. CONCLUSIONS: Pharyngeal flap/sphincter pharyngoplasty surgery in young adults resulted in improved speech scores and comprehensibility after speech surgery on Medical Readiness Training Exercise military humanitarian missions. Speech surgery in older patients in relatively austere environments is safe and effective. After comprehensive multidisciplinary team evaluation, 43% of the patients who were screened to have velopharyngeal incompetence were identified as surgical candidates. Fifty-seven percent of patients evaluated by speech pathologist were recommend nonsurgical solution toward improving speech scores sparing them unnecessary surgery. The incorporation of a speech pathologist to the humanitarian mission resulted in identifying surgical candidates who would benefit the most from intervention and improved speech surgery outcomes.

Use of Technological Aids in the Resection of a Rare Maxillofacial Tumor of Infancy.

Melanotic neuroectodermal tumor of infancy is a rare maxillofacial tumor, usually presenting within the first year of life, often a benign locally aggressive lesion, with wide local excision providing the best opportunity of cure. In past reports, direct tissue visualization guided resection, with occasional need for reoperation to clear margins. In this case report, a method is presented to achieve clear margins in surgery using virtual surgical planning and surgical stealth navigation.

Total Ear Reconstruction Using Porous Polyethylene.

Total ear reconstruction has been approached by several techniques involving autologous graft, prosthetic implant, and alloplastic implant options. Recent studies have shown the superiority of porous polyethylene (Medpor, Porex Surgical) reconstruction over autologous reconstruction based on improved aesthetic results, earlier age of intervention, shorter surgery times, fewer number of required procedures, and a simpler postoperative recovery process. A durable and permanent option for total ear reconstruction, like Medpor, can help alleviate the cosmetic concerns that patients with auricular deformities may be burdened with on a daily basis. In this article, the authors discuss the advantages of Medpor-based ear reconstruction and discuss recent advances in the surgical techniques involved, such as harvesting a temporoparietal fascia flap and full-thickness skin graft to adequately cover the Medpor framework and decrease extrusion rates.

Hypophosphatemic rickets and craniosynostosis: a multicenter case series.

OBJECTIVE This study examines a series of patients with hypophosphatemic rickets and craniosynostosis to characterize the clinical course and associated craniofacial anomalies. METHODS A 20-year retrospective review identified patients with hypophosphatemic rickets and secondary craniosynostosis at 3 major craniofacial centers. Parameters examined included sex, age at diagnosis of head shape anomaly, affected sutures, etiology of rickets, presenting symptoms, number and type of surgical interventions, and associated diagnoses. A review of the literature was performed to optimize treatment recommendations. RESULTS Ten patients were identified (8 males, 2 females). Age at presentation ranged from 1 to 9 years. The most commonly affected suture was the sagittal (6/10 patients). Etiologies included antacid-induced rickets, autosomal dominant hypophosphatemic rickets, and X-linked hypophosphatemic (XLH) rickets. Nine patients had undergone at least 1 cranial vault remodeling (CVR) surgery. Three patients underwent subsequent surgeries in later years. Four patients underwent formal intracranial pressure (ICP) monitoring, 3 of which revealed elevated ICP. Three patients were diagnosed with a Chiari Type I malformation. CONCLUSIONS Secondary craniosynostosis develops postnatally due to metabolic or mechanical factors. The most common metabolic cause is hypophosphatemic rickets, which has a variety of etiologies. Head shape changes occur later and with a more heterogeneous presentation compared with that of primary craniosynostosis. CVR may be required to prevent or relieve elevated ICP and abnormalities of the cranial vault. Children with hypophosphatemic rickets who develop head shape abnormalities should be promptly referred to a craniofacial specialist.

Cleft and Craniofacial Care During Military Pediatric Plastic Surgery Humanitarian Missions.

BACKGROUND: Military pediatric plastic surgery humanitarian missions in the Western Hemisphere have been initiated and developed since the early 1990 s using the Medical Readiness Education and Training Exercise (MEDRETE) concept. Despite its initial training mission status, the MEDRETE has developed into the most common and advanced low level medical mission platform currently in use. The objective of this study is to report cleft- and craniofacial-related patient outcomes after initiation and evolution of a standardized treatment protocol highlighting lessons learned which apply to civilian plastic surgery missions. METHODS: A review of the MEDRETE database for pediatric plastic surgery/cleft and craniofacial missions to the Dominican Republic from 2005 to 2009 was performed. A multidisciplinary team including a craniofacial surgeon evaluated all patients with a cleft/craniofacial and/or pediatric plastic condition. A standardized mission time line included predeployment site survey and predeployment checklist, operational brief, and postdeployment after action report. Deployment data collection, remote patient follow-up, and coordination with larger land/amphibious military operations was used to increase patient follow-up data. Data collected included sex, age, diagnosis, date and type of procedure, surgical outcomes including speech scores, surgical morbidity, and mortality. RESULTS: Five hundred ninety-four patients with cleft/craniofacial abnormalities were screened by a multidisciplinary team including craniofacial surgeons over 4 years. Two hundred twenty-three patients underwent 330 surgical procedures (cleft lip, 53; cleft palate, 73; revision cleft lip/nose, 73; rhinoplasty, 15; speech surgery, 24; orthognathic/distraction, 21; general pediatric plastic surgery, 58; fistula repair, 12). Average follow-up was 30 months (range, 1-60). The complication rate was 6% (n = 13) (palate fistula, lip revision, dental/alveolar loss, revision speech surgery rate). The average pre-surgical (Pittsburgh Weighted Speech Score) speech score was 12 (range, 6-24). The average postsurgical speech score was 6 (range, 0-21). Average hospital stay was 3 days for cleft surgery. There were no major complications or mortality, 1 reoperation for bleeding or infection, and 12 patients required secondary operations for palatal fistula, unsatisfactory aesthetic result, malocclusion, or velopharygeal dysfunction. CONCLUSIONS: Military pediatric plastic surgery humanitarian missions can be executed with similar home institution results after the initiation and evolution of a standardized approach to humanitarian missions. The incorporation of a dedicated logistics support unit, a dedicated operational specialist (senior noncommissioned officer), a speech language pathologist, remote internet follow up, an liaison officer (host nation liaison physician participation), host nation surgical resident participation, and support from the embassy, Military Advisory Attachment Group, and United States Aid and International Development facilitated patient accurate patient evaluation and posttreatment follow-up. Movement of the mission site from a remote more austere environment to a centralized better equipped facility with host nation support to transport patients to the site facilitated improved patient safety and outcomes despite increasing the complexity of surgery performed.

Orbital necrotizing fasciitis and osteomyelitis caused by arcanobacterium haemolyticum: a case report.

The facial region is infrequently affected by necrotizing infections. Orbital necrotizing infections are even rarer, seen following trauma, local skin infection, and sinusitis. The authors report a unique case of orbital necrotizing fasciitis and osteomyelitis resulting from Arcanobacterium Haemolyticum ethmoid sinusitis. No prior occurrences of Arcanobacterial species orbital necrotizing fasciitis/osteomyelitis have been reported.A 16-year-old boy presented to the ER with a 3-day history of fever, chills, headache, and sinus pressure. CT scan revealed soft tissue swelling of the right orbit, forehead, and ethmoid sinusitis. Within 24 hours of admission, he suffered rapidly progressive swelling and erythema of the right orbit and forehead with diminished visual acuity, despite broad-spectrum antibiotics. Orbital exploration revealed frankly necrotic fascia and periosteum along the superior aspect. Lateral canthotomy, cantholysis, decompression of the optic nerve, and soft tissue debridement with bone biopsy was performed. Operative specimens isolated Arcanobacterium Haemolyticum. Pathologic examination revealed right orbital osteomyelitis.

Posterior cranial vault distraction osteogenesis: evolution of technique.

The rapid growth of the brain in the first few years of life drives the expansion of the cranial vault. This expansion occurs primarily at the cranial sutures; premature fusion of these results in growth restriction perpendicular to the axis of the suture. The result of this is physical deformation of the cranial and facial skeleton, as well as the distortion of the underling brain and its physiology. These patients can present with symptoms of raised intracranial pressure, neurodevelopmental delay, as well as the morphological features of craniosynostosis. Acquired conditions such as the slit ventricle syndrome may also result in cephalocranial disproportion with these clinical features. Traditional vault remodeling surgery is able to correct the physical abnormalities as well as correcting cephalocranial disproportion. Its limitations include the degree of scalp expansion achievable as well as resulting defects in the bone. The use of distraction osteogenesis of the cranial vault permits a controlled expansion in a predetermined vector in a gradual manner. When used in the calvarium, this combines the benefits of tissue expansion on the scalp, as well as stimulating the production of new bone, reducing the defects resulting from expansion. In this review, the authors describe some of the surgical considerations important to the use of this technique. This includes the relevant anatomy and technical aspects illustrated with the use of clinical cases. Finally, they present a summary of their experience and discuss the complications associated with cranial vault distraction osteogenesis.

Le fort I maxillary advancement using distraction osteogenesis.

Treatment of maxillary hypoplasia has traditionally involved conventional Le Fort I osteotomies and advancement. Advancements of greater than 10 mm risk significant relapse. This risk is greater in the cleft lip and palate population, whose anatomy and soft tissue scarring from prior procedures contributes to instability of conventional maxillary advancement. Le Fort I advancement with distraction osteogenesis has emerged as viable, stable treatment modality correction of severe maxillary hypoplasia in cleft, syndromic, and noncleft patients. In this article, the authors provide a review of current data and recommendations concerning Le Fort I advancement with distraction osteogenesis. In addition, they outline their technique for treating severe maxillary hypoplasia with distraction osteogenesis using internal devices.

Orthodontic considerations for maxillary distraction osteogenesis in growing patients with cleft lip and palate using internal distractors.

The orthodontist plays a key role in the selection of the optimal treatment for patients followed by a craniofacial team. For patients with cleft lip and palate, the need for multidisciplinary treatment planning and sequentially staged treatment is essential for successful patient outcomes. The technique of Le Fort I distraction osteogenesis of the maxilla using an internal device is potentially a predictable, stable, and convenient option for the correction of severe maxillary hypoplasia. It is an alternative option for treatment of maxillary hypoplasia in growing patients. In this article, the authors describe the orthodontist's approach to the management of cleft patients with severe maxillary deficiency with the use of an internal distraction device. The information is presented with a focus on the clinical aspects of treatment, using case illustrations and appropriate literature.

Treatment of cephalocranial disproportion in shunt-induced slit ventricle syndrome with cranial vault distraction osteogenesis.

BACKGROUND: Slit ventricle syndrome (SVS) is a known late complication of shunting procedures. Some patients develop cephalocranial disproportion (CCD) that will require surgical treatment to increase craniocerebral compliance. METHODS: We performed cranial vault distraction osteogenesis to treat 2 teenage patients who presented with SVS, increased intracranial pressure and CCD. Bilateral temporo-parieto-occipital craniotomies were performed. RESULTS: Both patients successfully completed distraction and consolidated without the need for bone grafting. Postoperatively, both patients showed an increase in intracranial and intraventricular volume, as well as decreased shunt revisions. One patient had improvement of her headaches, while the other continues to have chronic headaches. CONCLUSION: Distraction osteogenesis is an option to expand the cranial vault in older children with SVS and CCD, in which the traditional cranial vault expansion would be a challenge and may or may not provide adequate expansion.

Resorption of PDLLA plates as a nidus for recurrent langerhans cell histiocytosis.

Resorbable plating systems have been adapted into routine use for craniofacial reconstruction in children. After implantation in some patients, the area around the plates can develop palpable and visible fibrous capsules, with underlying bone resorption and a significant foreign-body giant cell reaction. The reaction is usually self-limited. We report a case in which Langerhans cell histiocytosis was resected, and then recurred at the sites of resorbing plate and screw placement in association with a foreign-body giant cell reaction.

Warfare-related craniectomy defect reconstruction: early success using custom alloplast implants.

BACKGROUND: Cranial bone defects secondary to decompression craniectomy associated with the Global War on Terror pose a unique reconstructive challenge. The objective of this study was to evaluate the outcome of alloplastic reconstruction using custom-designed implants for large craniectomy defects from warfare-related cranial trauma. METHODS: A review of injured personnel who underwent decompression craniectomy reconstruction and subsequent alloplastic cranial reconstruction in the National Capital Region was performed from 2003 to 2008 (n = 99). Collected data included mechanism of injury, evacuation time, Glasgow Coma Scale score, decompression craniectomy type, and implant type. Outcomes included complications and retention of implants. RESULTS: Average patient age was 25 years (range, 18 to 53 years). All patients were men. Follow-up was 2.4 years. Improvised explosive device blasts were responsible for 46 percent of injuries. The initial Glasgow Coma Scale score was 7. On arrival to the continental United States, it was 9. Time for evacuation to the continental United States was 6 days. Eighty-eight percent had hemicraniectomies and 12 percent had bifrontal craniectomies. Successful reconstruction with retention of the implant occurred in 95 percent. Five (three hemicraniectomy and two bifrontal) patients underwent implant removal because of infection. Seventy-three patients were complication-free. The reoperation rate with recontouring, drainage, or removal was 18 percent. After reconstruction, seven patients developed hematomas/hygromas, three patients developed seizures, and 10 percent had contour abnormalities (temporal hollowing) requiring revisions. CONCLUSIONS: Despite war wound contamination, massive cranial defects can be successfully reconstructed using custom alloplastic implants. However, reconstruction of frontal cranial defects in proximity to the airways and orbits was associated with infection and implant removal.

Blood-conservation techniques in craniofacial surgery.

Attempts at reducing exposure to allogeneic transfusions, using blood conservation techniques such as controlled hypotension and normovolemic hemodilution, have met with mixed results and are not always practical in small infants. Recombinant human erythropoietin (RHE), a hormone that stimulates RBC production, increases the hematocrit when administered to infants. A retrospective chart review of all patients undergoing fronto-orbital advancement for craniosynostosis by the same plastic surgeon between January 2002 and December 2002 was conducted. A subgroup of patients (10/19) received RHE as a blood-conservation strategy. Transfusion requirements were lower in the RHE group (5/10) versus the control group (9/9). Total volume of blood products transfused was statistically lower in the RHE group (154 mL RHE group versus 421 mL control) (P < 0.03). RHE combined with blood-conservation techniques was associated with a decreased need for blood transfusion, thus exposing the patient to fewer risks associated with allogeneic transfusion.