Preoperative Frontal and Parietal Bone Thickness Assessment to Predict Blood Loss and Transfusion During Extended Suturectomy for Isolated Sagittal Craniosynostosis.

OBJECTIVE: To predict the morbidity of sagittal suturectomy using preoperative computer tomographic measurement of frontal and parietal bone thickness in osteotomy sites. DESIGN: Retrospective analysis. SETTING: Tertiary children's hospital. PATIENTS: Fifty infants with nonsyndromic, isolated sagittal craniosynostosis who underwent extended sagittal suturectomy from 2015-2022. METHODS: Mean thickness of the frontal and parietal bone in regions of osteotomies were determined for each patient from preoperative CT images obtained within 30 days prior to suturectomy. The relationship between bone thickness (mm) and estimated blood loss (mL) was evaluated using Spearman's correlation and a multivariable model that adjusted for patient weight and surgery duration. The association between bone thickness and perioperative blood transfusion was evaluated using a multivariable logistic model controlling for patient weight and surgery duration. MAIN OUTCOME MEASURES: Estimated blood loss, perioperative blood transfusion. RESULTS: Frontal and parietal bone thickness in the region of osteotomies were positively correlated with estimated blood loss (p < 0.01). After adjusting for patient weight and duration of operation, both parietal and frontal bone thickness were associated with intraoperative blood loss (R2 = 0.292, p = 0.002 and R2 = 0.216, p = 0.026). Thicker frontal and parietal bone in the line of osteotomies resulted in significantly higher odds of blood transfusion. Bone thickness in the line of parietal osteotomies was 76% accurate at identifying patients who would require blood transfusion (p = 0.004). CONCLUSIONS: Frontal and parietal bone thickness in the line of osteotomies is associated with blood loss and perioperative blood transfusion for sagittal suturectomy operations.

Perioperative Morbidity of Secondary Frontal Orbital Advancement After Initial Frontal Orbital Advancement.

Frontal orbital advancement (FOA) is frequently performed for patients with syndromic and/or multisuture craniosynostosis. A small proportion of patients who undergo FOA have unfavorable growth and subsequently require a second FOA later in life; however, the perioperative risks associated with this second procedure are not well studied. We report results from a retrospective review of FOAs conducted from 2007 to 2022 at a single site with the same craniofacial surgeon. A total of 33 patients were included. Perioperative outcomes were compared between primary and secondary FOA procedures. The two groups were similar in regard to suture involvement and diagnosis, although the secondary FOA group was older at the time of their FOA (1.23 versus 7.07 y, P <0.001). There was no significant difference between groups in operating time, volume of blood transfusion by weight, or in the incidence of postoperative wound complications ( P >0.05). Primary FOA procedures had significantly higher weight-adjusted blood loss (28 versus 18 mL/kg, P =0.014), with a higher proportion of patients receiving a blood transfusion (95% versus 62%, P =0.025). There was no significant difference between groups in the incidence of intraoperative dural injury (50% versus 84%, P =0.067). Our findings suggest that secondary procedures appear to impose less of a surgical risk relative to primary FOA traditionally performed in infancy, likely because of the advanced age at the time of secondary FOA.

Rethinking Global Health Education in Plastic Surgery Residency.

Surgical disease is now among the most common, preventable, and growing contributors to the global burden of disease. The attitudes of trainees toward global surgery and the viability of a global surgery as an academic track have blossomed. More optimized experiences within residency education are necessary, however, to prepare the next generation of global surgeons. The field of plastic surgery is thus at an important crossroads in the effort to incorporate global surgery into training programs in a uniform fashion across the country. The recent American Council of Academic Plastic Surgeons meeting in February 2020 was dedicated to identifying strategies that will enhance the adoption of global surgery practices within plastic surgery. In this article, we discuss the principles, themes, and ideas that emerged from this session, and further develop concrete initiatives believed to be potentially fruitful. Some have been discussed in other surgical disciplines or presented in isolation to the plastic surgery community, but never as a cohesive set of recommendations that take into account the background and shortfalls of the current model for global health education in the 21st century. We then introduce five recommendations to optimize learner education: (1) clarification of learner expectations and roles; (2) domestic teaching for optimization of field experiences; (3) expansion of longitudinal, formal rotations; (4) strengthening of the role of research; and (5) integration of program financing.

A Comparative Assessment of Nasal Appearance following Nasoalveolar Molding and Primary Surgical Repair for Treatment of Unilateral Cleft Lip and Palate.

BACKGROUND: Although many cleft teams have adopted nasoalveolar molding to improve nasal form, few comparative studies have assessed the postoperative benefits of this treatment. Given that reported outcomes have been contradictory and that treatment involves considerable burden to families, the purpose of this study was to assess objective and subjective changes from nasoalveolar molding at approximately 5 years of age. METHODS: All patients with complete unilateral cleft lip and palate who underwent primary cheiloplasty performed by a single surgeon over a 7-year period were reviewed. Patient results were grouped into nasoalveolar molding or no-nasoalveolar molding. Cleft severity and aesthetic outcomes were assessed by panels of raters who independently ranked subject images at presentation, immediately preoperative (after molding), and at 5-year follow-up. Objective symmetry was measured using standard anthropometric analysis on three-dimensional images. RESULTS: Among 41 patients included, 16 successfully completed nasoalveolar molding. Both groups were similar at presentation; however, the nasoalveolar molding group had improved appearance following molding (p < 0.05). After surgery, at 5 years of age, the nasoalveolar molding group had better rank scores for overall appearance (p < 0.05), cleft nostril height, and cleft medial lip height (p < 0.05). Regression analysis revealed that nasoalveolar molding treatment was the most significant predictor of overall nasal appearance at 5 years, but that treatment team experience and initial severity were also significant predictors (p < 0.05). Qualitative audit following analysis identified favorable and unfavorable features of nasoalveolar molding. CONCLUSION: In children with complete unilateral cleft lip and palate, nasoalveolar molding was associated with better overall nasal aesthetics and improved cleft nostril height and cleft medial lip height at approximately 5 years of age. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Magnitude of Horizontal Advancement is Associated With Apnea Hypopnea Index Improvement and Counter-Clockwise Maxillary Rotation After Subcranial Distraction for Syndromic Synostosis.

PURPOSE: Subcranial midface distraction is used to treat central midface deficiency in syndromic synostosis. Our aim was to determine which maxillary movements were associated with improvement in measures of obstructive sleep apnea. METHODS: This was a retrospective cohort study that reviewed patients with syndromic midface retrusion and documented sleep apnea who underwent subcranial midface distraction via either Le Fort 3 osteotomy or Le Fort 2 osteotomy with zygomatic repositioning. The predictor variables measured on cephalograms were the magnitude and direction of midface and mandibular movements. The primary outcome was the change in the apnea hypopnea index (AHI) from polysomnography before and after surgery. The secondary outcomes were volumes of upper airway containing bone spaces calculated from computed tomography scans. Data analysis included linear regression to estimate the effect of distraction vectors on bone space volumes and AHI changes. RESULTS: We included 18 patients primarily with Crouzon or Apert syndrome. The magnitude of distraction in a horizontal direction was the most significant factor for AHI improvement and primarily expanded the nasopharyngeal space, but with a smaller impact on the oral cavity space. Clockwise palate rotation was most influenced by a downward direction of distraction, with 24° below horizontal creating a neutral advancement. The greater the magnitude of advancement, the more likely a counterclockwise rotation was observed. CONCLUSIONS: Horizontal magnitude of advancement had the greatest impact on AHI improvement. Vertical lengthening and closure of anterior open bite deformities can be done without compromising airway results as long as total advancement is not compromised. Palate rotation is best controlled by a downward distraction vector, but counterclockwise rotation increases with greater advancement.

Accessory Cranial Suture Leading to Abnormal Head Shape.

ABSTRACT: Accessory cranial sutures have been described in the literature and are most commonly associated with the parietal bone. These sutures are typically identified incidentally and there have been no reported cases of accessory cranial sutures leading to abnormal head shape.The authors present the case of a 3-month-old patient with multiple congenital anomalies and an accessory parietal suture leading to abnormal head shape. The patient was successfully treated with cranial orthotic therapy. To our knowledge, this is the first reported case of an accessory cranial suture leading to abnormal head shape.

Ablepharon Macrostomia Syndrome: Rib Cartilage and Fat Grafting for Lower Lid Reconstruction.

ABSTRACT: Ablepharon macrostomia syndrome (AMS) is a rare condition with fewer than 20 cases being reported in the literature. Features of AMS include ablepharon, hypertelorism, macrostomia, dysplastic ears, sparse body hair, and ambiguous genitalia. The most significant phenotypic presentation is rudimentary eyelids resulting in exposure keratopathy, corneal abrasions, and potential blindness. Numerous methods including primary full thickness skin grafting, conjunctival sutures followed by full thickness skin grafting, and a combination of skin grafting and local flaps have been described for definitive eyelid reconstruction in these patients. The authors report the first case of autologous rib cartilage grafting and fat grafting for lower eyelid reconstruction in a patient with AMS.

The Effectiveness of Palate Re-Repair for Treating Velopharyngeal Insufficiency: A Systematic Review and Meta-Analysis.

BACKGROUND: Palate re-repair has been proposed as an effective treatment for velopharyngeal insufficiency (VPI) with a low risk of obstructive sleep apnea (OSA). The authors conducted a systematic review and meta-analysis to determine the proportion of patients achieving normal speech resonance following palate re-repair for VPI, the proportion developing OSA, and the criteria for patient selection that are associated with increased effectiveness. METHODS: PubMed, Embase, and Scopus were searched from inception through April 2018 for English language articles evaluating palate re-repair for the treatment of VPI in patients with a repaired cleft palate. Inclusion criteria included reporting of hypernasality, nasal air emission, nasometry, additional VPI surgery, and/or OSA outcomes. Meta-analysis was conducted using random effects models. Risk of bias was assessed regarding criteria for patient selection, blinding of outcome assessors, and validity of speech assessment scale. RESULTS: Eighteen studies met inclusion criteria. The incidence of achieving no consistent hypernasality follow palate re-repair was 61% (95% confidence interval [CI]: 44%-75%). The incidence of additional surgery for persistent VPI symptoms was 21% (95% CI: 12%-33%). The incidence of OSA was 28% (95% CI: 13%-49%). Criteria for selecting patients to undergo re-repair varied, with anterior/sagittal position of palatal muscles (33%) and small velopharyngeal gap (22%) being the most common. No specific patient selection criteria led to superior speech outcomes (P = .6572). CONCLUSIONS: Palate re-repair achieves normal speech resonance in many but not all patients with VPI. Further research is needed to identify the specific examination and imaging findings that predict successful correction of VPI with re-repair.

Long-Term Outcomes for Adult Patients With Cleft Lip and Palate.

The purpose of this study was to evaluate a single center's experience with adult patients who had cleft lip, cleft palate, or both. The authors aimed to identify common long-term needs in this patient population and evaluated the relationship of team-based care in meeting those needs. To do so, the authors retrospectively reviewed chart records from a single private practice and tertiary referral cleft center for all patients who were ≥15 years of age and who had a history of clefts of the lip or palate, or both, from January 1, 2013, to June 30, 2014. The authors compared the concerns of the patients who received cleft-team-based care by a single, multidisciplinary cleft team; multiple multidisciplinary cleft teams; or no formal cleft team. The authors analyzed data for 142 patients. The most common patient concerns were lip aesthetics (64%), nose aesthetics (61%), septal deviations (47%), nasal obstruction (44%), malocclusion (32%), oronasal fistulas (29%), and speech (21%). Oronasal fistulas were more commonly reported in the group of patients who had care by multiple teams (42.9%; P < .001). Malocclusion was more commonly reported in the group of patients who had care by multiple teams (50%; P = .001). The authors found that adult patients who have undergone rehabilitation for cleft lip and palate appear to have a common set of long-term needs. Multidisciplinary cleft-team-based care appears to be the most effective way to address these needs.

Craniosynostosis Surgery and the Impact of Tranexamic Acid Dosing.

Consensus does not exist regarding the best dosage regimen for using tranexamic acid (TXA) for patients undergoing open calvarial vault remodeling in craniosynostosis surgery. The purpose of this study was to evaluate 2 dosing protocols, as well as the cost of using TXA. Previously, the institutional protocol was to give patients undergoing open calvarial vault remodeling a loading infusion of TXA (10 mg/kg) at the start of their procedure, after which intravenous TXA (5 mg/kg/h) was given throughout surgery and for 24 hours postoperatively. In July 2015, the protocol changed to a reduced postoperative infusion time of 4 hours. A retrospective review was conducted of records of 30 patients who had surgery before the protocol change (24-hour group) and 23 patients whose surgery occurred after the protocol change (4-hour group). The following data were collected: blood volume transfused, hemoglobin levels, estimated blood loss, and intensive care days; and costs of TXA and blood transfusion. Results showed a 4-hour infusion was as effective as a 24-hour infusion for reducing blood loss in patients undergoing craniosynostosis. Transfusion requirements, hemoglobin and hematocrit levels, and estimated blood loss were not significantly different for the groups. The cost of TXA and transfusion in the 4-hour group was significantly less (P < 0.001) than in the 24-hour group. No significant difference in cost existed for patients who received blood transfusion alone versus patients who received the 4-hour TXA infusion.

Open Craniosynostosis Surgery: Effect of Early Intraoperative Blood Transfusion on Postoperative Course.

Correction of craniosynostosis can result in blood loss when the patient already has physiologic anemia. The aim of this study was to determine whether patients benefit from early blood transfusion and whether the timing of blood transfusion affects metabolic disturbances and the postoperative course. In this retrospective review, 71 patients who underwent open calvarial vault remodeling for correction of craniosynostosis were separated into 2 groups according to whether they received blood transfusions early (within the first 30 minutes of surgery) or later (after the first 30 minutes of surgery). Patients were further separated into nonsyndromic and syndromic cohorts. Tracked variables included hemoglobin, hematocrit, arterial blood gas values, lactate level, length of stay, estimated blood loss, and amount of blood transfused in the operating room, amount transfused postoperatively, and total amount transfused.Among all patients, the early transfusion group had a higher hemoglobin nadir overall and received less postoperative blood. Within the nonsyndromic cohort, the early transfusion group had a higher estimated blood loss and received more transfused blood. In the syndromic cohort, the early transfusion group had a hemoglobin nadir that was significantly higher than in the late transfusion group and a lower estimated blood loss, shorter pediatric intensive care unit stay, and less postoperative blood transfused. Syndromic patients also received significantly more blood overall. For syndromic patients undergoing open calvarial vault remodeling, transfusion within the first 30 minutes of surgery should be considered.

Tranexamic Acid Reduces Blood Loss in Craniosynostosis Surgery.

METHODS: The authors retrospectively reviewed 79 patients with craniosynostosis who underwent either bifrontal or biparietal-occipital calvarial vault remodeling before institution of tranexamic acid (TXA) administration (non-TXA group) and 35 patients after institution of TXA administration (TXA group). The patients were analyzed in 2 groups: all open calvarial vault remodeling patients (anterior and posterior) as a whole, and anterior vaults only as a subset analysis. Primary outcomes accessed were: total intraoperative blood transfused, postoperative blood transfused, and estimated blood loss (EBL). Secondary outcomes evaluated were length of stay in the pediatric intensive care unit and hospital length of stay. RESULTS: When comparing all open calvarial vault remodeling patients, patients who received TXA required significantly less total blood transfusion during their operation (264 cc TXA group versus 428 cc non-TXA, P < 0.0001). Patients who received TXA required no blood transfusions postoperatively, compared with the non-TXA group, in which 45% of patients required postoperative blood transfusion. Weight-based EBL was also significantly lower in those patients receiving TXA (25 cc/kg in the TXA group versus 34 cc/kg in the non-TXA group [P = 0.0143]). All patients required transfusion intraoperatively. Pediatric intensive care unit length of stay was shorter in the TXA group, but there was no significant difference in total hospital length of stay. These findings also reached statistical significance when comparing only the anterior vault patients. CONCLUSION: Intraoperative TXA administration has a correlation with reduced blood transfusion requirements, as well as EBL, in patients undergoing open calvarial vault remodeling. There were no adverse events related to TXA administration.