Does the Children's Hospital of Philadelphia Modification Improve the Fistula Rate in Furlow Double-Opposing Z-Plasty?

PURPOSE: Oronasal fistulas (ONFs) have been the most common complication of primary cleft palatoplasty. The present study evaluated the incidence of ONFs after primary standard Furlow and modified Furlow palatoplasty and a buccal fat pad flap (BFPF) as a viable tissue layer to facilitate wound healing. PATIENTS AND METHODS: A retrospective cohort study was conducted. The data from all the patients who had met the criteria for primary palatoplasty from 2003 to 2016 and had undergone surgery by a single surgeon were retrospectively reviewed from an established cleft databank. An initial group of patients (2003 to 2007; standard Furlow palatoplasty) and a subsequent group (2008 to 2016; modified Furlow palatoplasty), all of whom had received the BFPF, were evaluated. The primary outcome variable was the development of palatal fistula. An additional outcome predictor included single versus staged palatoplasty. A χ2 analysis using a 1-tailed Fisher exact test was used, with statistical significance established at P ≤ .05 to determine the difference in ONF development using different operative techniques. RESULTS: A total of 49 patients had undergone standard Furlow palatoplasty, with an ONF rate of 22.4%. Of the 49 patients, 28 had had isolated cleft palate (ICP; 6 ONFs), 12 had had unilateral cleft lip/palate (UCLP; 2 ONFs), 9 had had bilateral cleft lip/palate (BCLP; 3 ONFs). A total of 65 patients had undergone modified Furlow palatoplasty with a BFPF, with a total ONF rate of 3%. Of the 65 patients, 40 had had ICP (1 ONF), 18 had had UCLP, and 7 had had BCLP (1 ONF). This difference in the ONF rate was statistically significant (P = .0015). The staged repairs resulted in an ONF rate (22.6%) that was significantly greater (P = .029) than the rate with nonstaged repairs (7.1%). The occurrence of ONFs tended to be greater in the patients with BCLP, syndromic patients, after staged repairs, and patients with wide cleft defects. CONCLUSIONS: A reduced ONF rate appeared to be associated with the modified Furlow palatoplasty and single-stage palatoplasty. Among the cleft types, BCLP showed a tendency to an increased postoperative ONF rate.

Dog-Bite Injuries to the Craniofacial Region: An Epidemiologic and Pattern-of-Injury Review at a Level 1 Trauma Center.

PURPOSE: The purpose was to determine the incidence, etiologic factors leading to injury, and demographic composition of patients sustaining dog-bite injuries of the craniofacial region at a regional referral level 1 trauma center. These findings may assist primary and affiliated health care providers, educators, and policy makers in developing and implementing strategies to prevent serious dog-bite injuries, particularly in the individuals most vulnerable-children and elderly persons. PATIENTS AND METHODS: We performed a retrospective observational and descriptive review of dog bite-related injuries solely managed by the Section of Maxillofacial Surgery at Charleston Area Medical Center in West Virginia. Patient information was derived from an existing database on dog-bite injuries of the craniofacial region, electronic health records, and animal encounter records. RESULTS: We reviewed 182 patient records distributed among several breed categories. The results showed a disturbing trend toward more severe injuries, especially in younger children, and a reversal in gender, with girls bitten more than boys. Young children incurred more extensive facial injuries, including fractures. The data showed that compared with other dog breeds, pit bull terriers inflicted more complex wounds, were often unprovoked, and went off property to attack. Other top-biting breeds resulting in more unprovoked and complex wounds included German shepherds, Rottweilers, and huskies. Management of facial wounds took place more often in the operating room, especially in younger children, with increased hospital stays. Of the patients, 19 (10.4%) had fractures and 22 (12%) underwent a rabies vaccination protocol. CONCLUSIONS: This study showed a disturbing trend toward more severe dog-bite injuries in young children and a greater incidence of bites in girls than in boys among several biting breeds of dogs. The public health implications of aggressive biting breeds and risks of severe injury in the home environment were discussed.

First Case of Cutaneous Orbital Abscess Caused by Gemella: A Case Report and Review of the Literature.

This is the first report of an orbital abscess caused by Gemella bergeri, uncommonly identified in cardiac valvular infections. Through matrix-assisted laser desorption-ionization time-of-flight mass spectrometry (MALDI-TOF MS), microbial identification and speciation resulted in timely identification and appropriate management. Successful management includes accurate microbial identification, incision and drainage, and broad-spectrum antibiotics.

Nodular fasciitis of the tongue: A case report in an infant.

Nodular fasciitis is a benign lesion uncommonly found in the head and neck region. Although described previously in adults, there have been no reports of nodular fasciitis in a child's tongue. A 4 month old male infant was referred for evaluation of a rapidly growing tongue lesion. He underwent excisional biopsy of the lesion. Initial pathology suggested a spindle cell tumor. Subsequent outside facility molecular testing was obtained and Nodular Fasciitis was confirmed. Nodular fasciitis is a rare benign tumor that can be often mistaken for malignancy. Special histochemical and molecular testing is required to obtain final diagnosis.

Evaluation of Pain Syndromes, Headache, and Temporomandibular Joint Disorders in Children.

After a thorough review of the history and presentation of a child's facial pain, a targeted head and neck examination is critical to the appropriate diagnosis of facial pain and temporomandibular joint disorders. It is critical to distinguish between the structural (trauma, degenerative disease, and tumor) and nonstructural (neurogenic, myogenic, and psychological) causes of pain, which will allow for incorporation of appropriate strategies of medical, psychological, dental, and surgical therapies.

Panfacial fractures: an approach to management.

Panfacial fractures are defined as fractures involving the lower, middle, and upper face. Treatment can be challenging and requires an individualized treatment plan. A firm understanding of the treatment principles of each individual fracture is necessary before attempting to tackle the patient with panfacial fractures. Advances in rigid fixation, wide exposure, primary bone grafting, and attention to soft tissue reattachment have significantly improved the treatment of the patient with panfacial fractures.

Pediatric head injuries.

Head injuries in children are common, comprising more than half of all injuries sustained. The mortality and morbidity associated with traumatic head injury in children is staggering, and the cumulative effect of such on the pediatric and general populations is propagated through related health care measures and subsequent socioeconomic burden. The majority of deaths due to trauma in children are caused by brain injury. This article reviews the evaluation and management of scalp injuries in the pediatric patient. The second portion addresses skull fractures, the specter of child abuse, management of acute fracture, and the phenomenon of growing skull fractures.

Facial dermatologic lesions in children.

This article briefly reviews some of the most common skin lesions in the head and neck of a child. Benign "lumps and bumps" are very common in children and it is prudent for the pediatric maxillofacial surgeon to be familiar with their presentation, workup (including radiographic studies), and definitive surgical management. Inflammatory and infectious lesions require prompt treatment to avoid more serious sequelae of progressive infection and scarring.

Child maltreatment.

Oral and maxillofacial surgeons are in a unique position to identify and report child abuse. In the career of any practitioner, maltreated children (both physically abused and neglected) will present for management of injuries and infections. There must be a high level of vigilance for, and understanding of, mechanisms of injury and skill in sorting out inflicted injuries or evidence of neglect. Because of this, the medical community, society, state law, and the legal system place oral and maxillofacial surgeons in a position of expertise and accountability in the care of children.

Dog bites of the face, head and neck in children.

Dog bites of the facial region are increasing in children according to the Center for Disease Control. To evaluate the epidemiology of such injuries in our medical provider region, we undertook a retrospective review of those children treated for facial, head and neck dog bite wounds at a level 1 trauma center. Most dog bites occurred in or near the home by an animal known to the child/family. Most injuries were soft tissue related, however more severe bites and injuries were observed in attacks from the pit-bull and Rottweiler breeds. Younger (under five years) children sustained more of the injuries requiring medical treatment. Injury Severity Scales were determined as well as victim and payer mix demographics, type and characteristics of injury, and complications from the attack.

All-terrain vehicle-related maxillofacial trauma in the pediatric population.

PURPOSE: Nearly 40% of all-terrain vehicle (ATV) crash-related fatalities involve pediatric patients, with many of these patients dying from head and neck injuries. West Virginia is in a unique position to examine these injuries because of its high rate of ATV use. This study examines craniofacial ATV-related trauma in children. PATIENTS AND METHODS: We conducted a single-center, retrospective, descriptive study of 26 children presenting with a craniofacial injury(ies) resulting from an ATV crash from January 2001 to December 2004. RESULTS: Twenty-six children (65% boys) with a mean age of 13.1 years presented with craniofacial injuries during the study period. Two patients were helmeted. Mortality was 3.8% (n = 1, head injury related, postinjury day 3). Patients were most often drivers of the ATV (65%), although girls were more likely to be passengers (P = .03). Facial contusions, lacerations, and abrasions were highly prevalent (62%, 69%, 65%, respectively), as were fractures of the facial bones and skull (77%). Thirty-five percent sustained closed head injuries, which were significantly associated with mandible fractures (odds ratio 12.8%; 95% CI, 1.15-143). Mean length of hospital stay was 4.6 +/- 5 days, and 36% required an ICU stay (mean, 5.1 +/- 3 days). Twenty-four percent required ventilator support (mean, 107 +/- 43 hours; range, 48 to 168 hours). Operative intervention was required in 72% of patients (n = 18). CONCLUSION: Maxillofacial injury patterns from ATV-related crashes in children suggest a high percentage of significant facial injuries and closed head injuries. As new ATV legislation that addresses operator use is enacted, a decrease in the number and severity of craniofacial injuries may be seen.

Soft tissue pediatric facial trauma: a review.

Facial soft tissue injuries are common in pediatric trauma patients. Early diagnosis and definitive treatment as well as good postoperative wound care are important when dealing with soft tissue injuries, such as facial nerve and parotid injuries, animal bites, avulsive skin wounds and eyelid and ear lacerations. Children heal quickly, but they also tend to develop hypertrophic scars. Proper wound management during the healing period can help to minimize the risk of adverse scar formation. Dentists may be involved in the initial assessment of these patients. Knowledge of the diagnosis and management of soft tissue trauma is useful when dealing with pediatric patients and their parents postoperatively.

Hard tissue pediatric facial trauma: a review.

Although hard tissue injuries are uncommon in the pediatric patient, dentists may be involved in the initial assessment of these patients. In this paper, we review fractures of the facial skeleton with a focus on dentoalveolar injuries. Minimally displaced fractures in pediatric patients can be managed conservatively, while displaced fractures may require open approaches and rigid fixation. New fixation stratagems are presented, and possible facial growth disturbances resulting from trauma are discussed.

Secondary procedures in maxillofacial dermatology.

Dermatologic secondary procedures involve careful preoperative planning and patient preparation, skillful execution of the appropriate procedure, and thorough postoperative wound care. Many modalities of treatment are used, including skin preparation through elimination of inflammatory conditions, resurfacing of skin, and improvement of patient health. Proper selection of incisional design, local or regional flaps, and grafting techniques is key to successful revisional surgery. Care of the revised lesion or wound through medications, dressings and resurfacing techniques will optimize the end result.