The Asymmetry Within: A Renewed Look at Cupids Bow in Unilateral Cleft Lip.

The purpose of this study is to analyze the angular variations within Cupid's bow in patients with unoperated unilateral cleft lip (UCL). Angular features of Cupid's bow were quantified in standardized presurgical photographs of children with UCL by 5 medical professionals specializing in craniofacial anomalies. The peaks and valley of Cupid's bow were identified. A cleft side (CSA) and a noncleft side angle (NCSA) were delineated and measured by each expert. The data was pooled, and the angles were analyzed for symmetry. Cupid's bow asymmetry was defined as a difference between NCSA and CSA ≥3°. Of the 37 patients studied, 29 were found to have asymmetry of Cupid's bow with an average angle difference of 8.0° (95% CI: 6.6°-9.5°). Within this group,15 patients were found with acute asymmetry and 14 with obtuse asymmetry. Geometric analysis was performed on an example of a patient with acute asymmetry to demonstrate how correction of asymmetry can be considered during surgical repair. There is an asymmetry that exists in the Cupid's bow of a significant number of patients with unoperated UCL. This finding not only adds to our understanding of UCL but may also have important implications when selecting the method/technique of surgical repair.

Monobloc Differential Distraction Osteogenesis.

ABSTRACT: Midface advancement at the monobloc level can be the seminal life event for patients with craniofacial dysostosis. Monobloc reconstruction, when planned appropriately, can simultaneously and definitively address multiple functional and aesthetic deficiencies in these patients. The application of distraction has reduced the morbidity experienced with traditional monobloc surgery. The purpose of this study is to report on the outcomes, stability, and growth in younger patients after monobloc advancement in syndromic craniosynostosis patients. The authors report a consecutive series of thirty patients with craniofacial dysostosis treated through monobloc differential distraction osteogenesis. Detailed history, photographic, and long-term radiographic data are reviewed, including a subset of patients who were skeletally immature at the time of their treatment. Differential distraction allows control of midface pitch, roll, and yaw, optimizing functional and aesthetic outcomes. There were no infectious complications requiring reoperation. The average surgical age for all patients was 12.5 years. For the 7 patients age <7 years, average age was 6 years. For all patients, the mean horizontal movement was 12 mm at nasion and 10 mm at A-point. At mean follow-up (4.8 years entire group and 6.2 years age <7 years group) a positive horizontal advancement of 1.1 mm at nasion and 0.8 mm at A-point was observed. More pronounced positive horizontal changes were seen in the age <7 years group. Monobloc differential distraction osteogenesis affords safe and precise repositioning of the midface. The advancement is skeletally stable and young patients show moderate continued growth.

Pediatric Blood Management Protocol in Cranial Vault Surgery.

BACKGROUND: Cranial vault surgeries are invasive, extensive procedures with blood transfusions being frequently required. Previous interventions have been described to attempt to decrease the transfusion burden. The objective of this study is to determine if a Pediatric Blood Management (PBM) team can reduce transfusion requirements in children undergoing cranial vault surgery. METHODS: A protocol was developed which involved preoperative optimization of hemoglobin (Hb), intraoperative use of tranexamic acid, cell saver technology, and blood sparing operative techniques. Patients were preoperatively screened with basic laboratory testing. Retrospective data on 20 consecutive patients who underwent craniofacial surgery prior were used as controls. Prospective data on patients was collected. RESULTS: Groups were similar in age and weight. Postoperative Hb measurements were similar, with the control group 10.9 ±â€Š2.2 g/dL and the intervention arm 9.6 + 2.7 g/dL. Discharge Hb concentrations also were similar with 9.6 ±â€Š1.6 g/dL and 9.7 ±â€Š2.5 g/dL in the control and PBM group, respectively. The rate of transfusion decreased from 80% to 42% after protocol implementation (P = 0.007). During the last 6 months of data collection, the transfusion rate decreased further to 17%. Furthermore, 4 patients were found to have von Willebrand disease preoperatively with only 1 requiring a transfusion. CONCLUSIONS: The authors found that the institution of a PBM team reduced the transfusion burden of patients, including complex patients with von Willebrand disease. The use of a multimodal approach to hematologic management optimized patients for their procedures and helped minimize exposure to transfusion associated complications.

Trends in Enteral Access Placement Among Patients With Oral Clefts: Evaluation of 46 617 Patient Admissions.

OBJECTIVE: It is well known that patients with oral clefts have challenges with feeding. Enteral feeding access, in the form of gastrostomy, is often utilized to supplement or replace oral intake. Although commonly performed, these procedures have reported complication rates as high as 83%. We intend to discover rates of enteral access in patients with oral clefts and report-related outcomes. DESIGN: The Healthcare Cost Utilization Project Kids' Inpatient Database from 2000 to 2012 was analyzed using patients with oral clefts and enteral access procedures. The χ2 test was used for univariate analyses of proportions, and linear regression was used to analyze trends. Multivariate logistic regression was used to analyze odds ratios. RESULTS: Of the 46 617 patient admissions included, 14.6% had isolated cleft lip (CL), 51.7% cleft lip and palate (CLP), and 43.7% isolated cleft palate. The rates of enteral access in the oral cleft population increased from 3.7% in 2000 to 5.8% in 2012 ( P < .001). Increased rates were identified in patients with ( P = .019) and without ( P < .001) complex conditions. A significant increase in the rate of enteral access was seen in patients with CLP ( P < .001) and isolated cleft palate ( P < .001). No difference was seen in the isolated CL group ( P = .096). Patients with complex conditions were at a 4.4-fold increased risk and those admitted to urban, teaching hospitals were at a 4.7-fold risk of enteral access placement. CONCLUSIONS: The rates for enteral feeding access increased significantly from 2000 to 2012. The reasons for the increased incidence are unclear. Invasive enteral access procedures have been shown to have a multitude of complications. Careful patient selection should be done before placement of invasive enteral access.

Salvage or Solution: Alloplastic Reconstruction in Hemifacial Microsomia.

INTRODUCTION: Skeletal reconstruction in severe grades of hemifacial microsomia (HFM) continues to be challenging. Traditional techniques of autografts and osseous distraction for reconstruction of the glenoid fossa, condyle, and ramus can fall short of expectations and can create new problems. This intercontinental study analyzes the role of alloplastic skeletal rehabilitation in severe HFM. METHODS: Ten consecutive patients with Pruzansky grade III HFM were reconstructed between October 2014 and July 2017 at 2 craniofacial centers following the same protocol. Data were gathered retrospectively from the medical records, including photographs and virtual planning records. Pre and postoperative photos were taken to compare occlusal status, interincisal opening, sagittal mandibular projection, and posterior facial height. Alloplastic reconstruction was accomplished using a custom designed titanium implant. RESULTS: Ten consecutive skeletally mature patients with HFM with failed traditional reconstructions were successfully treated with virtually planned alloplastic reconstructions (11 joints) and simultaneous orthognathic surgery. The glenoid fossa, condyle, and ramus on the affected sides were reconstructed with custom designed titanium implants. All patients achieved occlusal stabilization, normalization of posterior facial height and sagittal mandibular projection, and maintenance or improved inter-incisal opening. There were no major complications or repeated surgeries. Follow-up ranges from 6 to 50 months. CONCLUSION: Alloplastic reconstruction allows for precise vertical reconstruction of the ramus and condyle and sagittal repositioning of the mandibular body. The glenoid fossa component is firmly anchored to the skull base assuring a stable centric relation on the reconstructed side. Consistent and acceptable results can be achieved in skeletally mature patients.

A Novel Treatment of Nasal Stenosis Using Steel Gauging Earrings.

Nasal stenosis is an uncommon and challenging deformity. Most common etiologies for nasal stenosis include congenital, iatrogenic, trauma, and infection. Repair techniques typically include tissue replacement with grafts or flaps with subsequent stent placement. These procedures often require general anesthesia and carry high rates of restenosis. We describe a case of a 10-year-old girl with Teebi syndrome and iatrogenic nasal stenosis who underwent successful nasal dilation with inexpensive, minimally invasive steel gauge earrings.

The Directive Growth Approach for Nonsyndromic, Unicoronal Craniosynostosis: Patient and Clinical Outcomes.

Deformities of the cranium in patients with nonsyndromic single-suture synostosis occur because of growth restriction at fused sutures and growth over compensation at normal sutures. Traditional surgery includes ostectomies of the synostotic suture to release these restricted areas and osteotomies to enable immediate cranial remodeling. In the process of reshaping the cranium, traditional approaches usually involve obliteration of both the normal functioning suture and the pathologic suture. The directive growth approach (DGA) is a new, simpler, more natural way to repair deformities caused by single-suture cranial synostosis. The DGA works by reversing the original deforming forces by temporarily restricting growth in areas of over compensation and forcing growth in areas of previous synostotic restriction. Most importantly, it preserves a normal functioning suture to allow for improved future cranial growth. Eighteen consecutive nonsyndromic patients with unilateral coronal synostosis were used to illustrate the efficacy of the DGA. Ten patients who underwent DGA treatment were compared with a control group of 8 patients treated with traditional frontal orbital advancement. Postoperative three-dimensional computed tomography (CT) comparison measurements were taken, including bilateral vertical and transverse orbital dimensions, lateral orbital rim to external auditory canal, and forehead measurements from the superior aspect of the orbital rim to the pituitary fossa. The traditional treatment group showed absence of the coronal sutures bilaterally on long-term CT scans. The DGA group showed normal coronal sutures on the unaffected sides. Postoperative CT measurements showed no statistical difference between the 2 techniques (P < 0.05).

The Effects of Motorcycle Helmet Legislation on Craniomaxillofacial Injuries.

BACKGROUND: Motorcycle helmet legislation has been a contentious topic for over a half-century. Benefits of helmet use in motorcycle trauma patients are well documented. In 2012, Michigan repealed its universal motorcycle helmet law in favor of a partial helmet law. The authors describe the early clinical effects on facial injuries throughout Michigan. METHODS: Retrospective data from the Michigan Trauma Quality Improvement Program trauma database were evaluated. Included were 4643 motorcycle trauma patients presenting to 29 Level I and II trauma centers throughout Michigan 3 years before and after the law repeal (2009 to 2014). Demographics, external cause of injury codes, International Classification of Diseases, Ninth Revision diagnosis codes, and injury details were gathered. RESULTS: The proportion of unhelmeted trauma patients increased from 20 percent to 44 percent. Compared with helmeted trauma patients, unhelmeted patients were nearly twice as likely to sustain craniomaxillofacial injuries (relative risk, 1.90), including fractures (relative risk, 2.02) and soft-tissue injuries (relative risk, 1.94). Unhelmeted patients had a lower Glasgow Coma Scale score and higher Injury Severity Scores. Patients presenting after helmet law repeal were more likely to sustain craniomaxillofacial injuries (relative risk, 1.46), including fractures (relative risk, 1.28) and soft-tissue injuries (relative risk, 1.56). No significant differences were observed for age, sex, Injury Severity Score, or Glasgow Coma Scale score (p > 0.05). CONCLUSIONS: This study highlights the significant negative impact of relaxed motorcycle helmet laws leading to an increase in craniomaxillofacial injuries. The authors urge state and national legislators to reestablish universal motorcycle helmet laws.

Repair of Oropharyngeal Stenosis With Bilateral Buccal Myomucosal Flaps.

Oropharyngeal stenosis (OPS) is a rare postoperative complication of adenotonsillectomy that can be a source of considerable patient distress and morbidity. Circumferential scarring of the soft palate and tonsillar pillars leads to narrowing of the oropharyngeal aperture. This case report describes the novel use of bilateral buccal myomucosal flaps for the repair of postoperative OPS in a 20-year-old woman presenting with dysphagia, odynophagia, dyspnea, and intermittent hypernasal speech. Postoperatively, the patient noted immediate improvement of her symptoms. At 1-month follow-up, she noted complete resolution of her symptoms with no dysphagia, nasal regurgitation, speaking difficulty, dyspnea, or gagging. The buccal flaps were well healed and completely intact, maintaining appropriate height of the tonsillar pillars. The buccal myomucosal flap is an effective tool for numerous palatal and oropharyngeal abnormalities and, as described in this case study, is a reliable, safe, and effective technique that can be considered for the reconstruction of postsurgical OPS.

The Double Opposing Z-Plasty Plus or Minus Buccal Flap Approach for Repair of Cleft Palate: A Review of 505 Consecutive Cases.

BACKGROUND: Standard methods of cleft palate repair rely on existing palatal tissue to achieve closure. These procedures often require relaxing incisions, causing scars and growth restriction, and may result in insufficient palatal length and suboptimal positioning of the velar musculature. The Furlow double opposing Z-plasty improves palatal length and repositions the velar musculature; however, relaxing incisions may still be needed. The addition of buccal flaps to the Furlow repair obviates the need for relaxing incisions and allows the Furlow repair to be used in wide clefts. METHODS: A retrospective review was performed on 505 patients; all patients were treated with the double opposing Z-plasty plus or minus buccal flap approach. Outcomes included nasal resonance, secondary speech surgery, and postoperative complications. A comparison was made between patients treated with double opposing Z-plasty alone and those treated with double opposing Z-plasty plus buccal flaps. RESULTS: The average nasal resonance score was 1.38 and was equivalent in both the double opposing Z-plasty alone and with buccal flap groups, despite significantly more wide clefts in the buccal flap group (56 percent versus 8 percent). The secondary surgery rate for velopharyngeal insufficiency was 6.6 percent and the fistula rate was 6.1 percent. The large fistula rate (>2 mm) was 2.7 percent. CONCLUSIONS: The double opposing Z-plasty plus or minus buccal flap approach is a useful alternative to standard palate repairs. Speech outcomes were excellent, even in wider clefts, and postoperative complications were minimal. Buccal flaps allow the benefits of the Furlow repair to be applied to any size cleft, without the need for relaxing incisions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Combined maxillary and mandibular distraction osteogenesis in patients with hemifacial microsomia.

INTRODUCTION: Hemifacial microsomia is a deformity of variable expressivity with unilateral hypoplasia of the mandible and the ear. In this study, we evaluated skeletal soft tissue changes after bimaxillary unilateral vertical distraction. METHODS: Eight patients (4 preadolescents 4 adolescents) each with a grade II mandibular deformity underwent a LeFort I osteotomy and an ipsilateral horizontal mandibular ramus osteotomy. A semiburied distraction device was placed over the ramus, and intermaxillary fixation was applied. Anteroposterior cephalometric and frontal photographic analyses were conducted before and after distraction. Statistics were used to analyze the preoperative and postoperative changes. RESULTS: Cephalometrically, the nasal floor and the occlusal and gonial plane angles decreased. The ratios of affected-unaffected ramus and gonial angle heights improved by 15% and 20%, respectively. The position of menton moved toward the midline. The photographic analysis showed a decrease of the nasal and commissure plane angles, and the chin moved to the unaffected side. The parallelism between the horizontal skeletal and soft tissue planes improved, with an increase in the affected side ramus height and correction of the chin point toward the midline. CONCLUSIONS: Simultaneous maxillary and mandibular distraction improved facial balance and symmetry. Patients in the permanent dentition with fixed orthodontic appliances and well-aligned dental arches responded well to this intervention.

Treatment of midfacial hypoplasia in syndromic and cleft lip and palate patients by means of a rigid external distractor (RED).

INTRODUCTION: Distraction Osteogenesis (DO) became an alternative for the treatment of severe craniofacial skeletal dysplasias. The rigid external distraction device (RED) is successfully used to advance the maxilla and all the maxillary-orbital-frontal complex (monobloc) in children, adolescents and adults. This approach provides predictable and stable results, and it can be applied alone or with craniofacial orthognathic surgical procedures. OBJECTIVE: In the present article, the technical aspects relevant to an adequate application of the RED will be described, including the planning, surgical and orthodontic procedures.

Treatment of midfacial hypoplasia in syndromic and cleft lip and palate patients by means of a rigid external distractor (RED)

INTRODUCTION: Distraction Osteogenesis (DO) became an alternative for the treatment of severe craniofacial skeletal dysplasias. The rigid external distraction device (RED) is successfully used to advance the maxilla and all the maxillary-orbital-frontal complex (monobloc) in children, adolescents and adults. This approach provides predictable and stable results, and it can be applied alone or with craniofacial orthognathic surgical procedures. OBJECTIVE: In the present article, the technical aspects relevant to an adequate application of the RED will be described, including the planning, surgical and orthodontic procedures.

INTRODUÇÃO: a Distração Osteogênica (DO) tornou-se uma alternativa para o tratamento das displasias craniofaciais esqueléticas severas. O aparelho distrator externo rígido (RED) é utilizado com êxito para avançar a maxila e todo o complexo maxilar-orbital-frontal (monobloco) em crianças, adolescentes e adultos. Essa abordagem proporciona resultados previsíveis e estáveis, podendo ser aplicada isoladamente ou junto a procedimentos cirúrgicos ortognáticos craniofaciais. OBJETIVO: no presente artigo, serão descritos os aspectos técnicos pertinentes a uma adequada aplicação do RED, incluindo o planejamento, procedimentos cirúrgicos e ortodônticos.

Orthognathic positioning system: intraoperative system to transfer virtual surgical plan to operating field during orthognathic surgery.

PURPOSE: To introduce the concept and use of an occlusal-based "orthognathic positioning system" (OPS) to be used during orthognathic surgery. MATERIALS AND METHODS: The OPS consists of intraoperative occlusal-based devices that transfer virtual surgical planning to the operating field for repositioning of the osteotomized dentoskeletal segments. The system uses detachable guides connected to an occlusal splint. An initial drilling guide is used to establish stable references or landmarks. These are drilled on the bone that will not be repositioned adjacent to the osteotomy line. After mobilization of the skeletal segment, a final positioning guide, referenced to the drilled landmarks, is used to transfer the skeletal segment according to the virtual surgical planning. The OPS is digitally designed using 3-dimensional computer-aided design/computer-aided manufacturing technology and manufactured with stereolithographic techniques. CONCLUSIONS: Virtual surgical planning has improved the preoperative assessment and, in conjunction with the OPS, the execution of orthognathic surgery. The OPS has the possibility to eliminate the inaccuracies commonly associated with traditional orthognathic surgery planning and to simplify the execution by eliminating surgical steps such as intraoperative measuring, determining the condylar position, the use of bulky intermediate splints, and the use of intermaxillary wire fixation. The OPS attempts precise translation of the virtual plan to the operating field, bridging the gap between virtual and actual surgery.

Nasal changes after presurgical nasoalveolar molding (PNAM) in the unilateral cleft lip nose.

PURPOSE: Nasal reconstruction for patients with unilateral cleft lip and palate (UCLP) is a challenge for the reconstructive surgeon. Presurgical nasoalveolar molding (PNAM) was introduced to reshape the cleft nasal structures prior to lip repair. This study analyzed two-dimensional nasal changes before and after PNAM in patients with complete UCLP. METHODS: Thirty UCLP patients (19 males; 11 females) who received PNAM before lip repair were included in this study. PNAM was applied for 100 days. Nasal casts were obtained before and after PNAM. Frontal and 45° standardized digital photographs were taken from all casts, and a photogrammetric analysis (16 linear, six angular, and two area measurements) was performed. Paired Student's t tests were used to search for differences by time, and time versus side (cleft versus noncleft). RESULTS: Significant reduction of cleft columella deviation with an increase in columella length, nostril height, and axial inclination on the cleft side were recorded. This resulted in an increase in the projection of the nasal tip. The noncleft measurements remained without significant changes. The cleft nostril area increased significantly more than the noncleft side by 90% with PNAM treatment. Significant normal growth changes were observed in nasal width and nasal height. CONCLUSION: A favorable reshaping of the nose after PNAM was achieved, resulting in an improvement in form before lip surgery. These changes lead to improved nasal symmetry before primary lip and nasal reconstruction in UCLP patients.

Biomechanical considerations for distraction of the monobloc, Le Fort III, and Le Fort I segments.

BACKGROUND: Distraction osteogenesis is effective for correction of severe maxillary and midface hypoplasia. The vectors controlling the segment to be moved must be planned. This requires knowledge of the physical characteristics of the osteotomized bone segment, including the location of the center of mass (free body) and the center of resistance (restrained body). The purpose of this study was to determine the center of mass of the osteotomized monobloc, Le Fort III, and Le Fort I bone segments. METHODS: A dry human skull was used to sequentially isolate three bone segments: monobloc, Le Fort III, and Le Fort I. Each segment was suspended from three different points, and digital photographs were obtained from each suspension. The photographs were digitally superimposed. The center of mass was determined by calculating the intersection of the suspension lines. RESULTS: The center of mass for the monobloc segment was located at a point 43.5 percent of the total height from the occlusal plane to the superior edge of the frontal bone supraorbital osteotomy. For the Le Fort III, it was located 38 percent of the total height from the occlusal plane to the superior edge of the osteotomized base of the nasal bones. For the Le Fort I, it was 53 percent of the total height from the occlusal plane to the superior edge of the osteotomized maxillary bone. CONCLUSION: Knowledge of the location of the center of mass in the monobloc, Le Fort III, and Le Fort I segments provides a starting point for the clinician when planning vectors for advancement with distraction.

Evaluation of maxillary permanent molars in patients with syndromic craniosynostosis after monobloc osteotomy and midface advancement with rigid external distraction (RED).

OBJECTIVE: This retrospective study was conducted to analyze changes in the maxillary permanent molars after monobloc advancement with rigid external distraction (RED). SETTING: University hospital-based craniofacial center. MATERIALS AND METHODS: Fourteen patients, three in primary, eight in mixed, and three in permanent dentition underwent monobloc advancement with RED. After a latency period of 6 days, distraction was carried out for 18 days. Lateral cephalometric radiographs were taken before surgery (T1) and an average of 3.72 months after the removal of the distractor (T2). Panoramic radiographs were taken at T1, T2, and T3 (an average of 14.87 months after RED removal), to search for surgical tooth trauma, arrested crown/root development, impaction, tooth germ displacement, dilacerations, and other possible dental abnormalities. Vertical and horizontal displacement and angulations of the permanent maxillary molars were evaluated before and after surgery. STATISTICS: A paired t test was used to analyze significant changes in molar position after distraction. RESULTS AND CONCLUSIONS: Distraction created posterior arch length with significant horizontal forward movement of the first and second molars (p<.05) and minimal vertical displacement (p>.05). The procedure disrupted the development of one of the first molars, three of the second molars, and two of the third molars. Incidence of molar damage was increased in patients operated on during primary dentition. Careful surgical technique during pterygomaxillary disjunction, especially in young children, and long-term radiographic follow-up of maxillary molars is strongly recommended.

Introduction of a new removable adjustable intraoral maxillary distraction system for correction of maxillary hypoplasia.

Distraction osteogenesis has become a treatment alternative to treat severe craniofacial skeletal dysplasias. A rigid external distraction device has been successfully used to advance the maxilla as well as the maxillary, orbital, and forehead complex (monobloc) in children as young as 2 years, adolescents, and adults. For this severe group of patients, the technique has been found to be simpler and safer than traditional surgical methods. Maxillary and midfacial advancement through distraction has been found to be extremely stable in the patients in whom the technique was used.The authors introduce an intraoral distractor for those patients requiring a moderate maxillary advancement. The advantages of the device include ease of insertion, vector adjustability, reactivation capabilities, and no need for second procedure for its removal.The above approaches have provided predictable and stable results. A detailed description of the device, necessary orthodontic and surgical procedures, case reports, and cephalometric outcomes are presented. The techniques can be applied alone or as an adjunct to traditional orthognathic and craniofacial surgical procedures.