Videofluoroscopy Versus Nasopharyngoscopy of Lateral Pharyngeal Wall Movement for Assessment of Velopharyngeal Insufficiency.

BACKGROUND: Competent speech requires closure of the velopharyngeal sphincter by dynamic apposition of the velum and posterior and lateral pharyngeal walls. An accurate estimation of lateral pharyngeal wall motion is an important determinant in the planning and the outcome of any operation to correct velopharyngeal insufficiency (VPI). The purpose was to compare the assessment of lateral pharyngeal wall movement by videofluoroscopy (VP) versus nasopharyngoscopy (NP). METHODS: The authors retrospectively reviewed the charts of 269 consecutive patients in our cleft lip/palate clinic from 1982 to 2008 and culled those treated with a pharyngeal flap for VPI. The authors included patients who were evaluated preoperatively by both VP and NP, and had studies of suitable quality. Percentage of lateral pharyngeal wall motion was estimated with each technique and compared for each patient. RESULTS: The authors identified 25 patients who underwent both VP and NP at the same median age (4.7 years). The estimated percentage of lateral pharyngeal wall motion between the 2 techniques was significantly different ( P <0.001). Average lateral pharyngeal wall motion was estimated to be 59±25% (range: 5%-90%) by VP and only 40%±25% (range: 0%-95%) during NP. CONCLUSIONS: VP and NP are complementary, but assessment of lateral pharyngeal wall motion can vary between the 2 methods. The surgeon should be aware of the difference in estimated lateral pharyngeal wall movement when planning a procedure to correct VPI.

Prenatal Diagnosis of Craniosynostosis Using Ultrasound.

BACKGROUND: Craniosynostosis is typically diagnosed postnatally. Prenatal diagnosis would allow for improved parental counseling and facilitate timely intervention. Our purpose was to determine whether prenatal ultrasound can be used to diagnose nonsyndromic craniosynostosis. METHODS: The authors reviewed 22 prenatal ultrasounds of infants known to have nonsyndromic craniosynostosis and 22 age-matched controls. Cross-sectional images at the plane used to measure biparietal diameter were selected and cranial shape of each participant was parameterized and used to discriminate affected patients from controls. The results from quantitative shape analysis were compared with results from a blinded visual inspection alone. RESULTS: Among the 22 patients, the most common diagnosis was sagittal synostosis ( n = 11), followed by metopic synostosis ( n = 6). The average gestational age at time of ultrasound of controls and synostotic patients was 26 weeks and 6.8 days at the junction of the second and third trimesters. The controls and synostotic cases segregated into statistically different populations by their shape profiles ( p < 0.001). An automatic shape classifier using leave-one-out cross-validation correctly classified the 44 images as normal versus synostotic 85 percent of the time (sensitivity, 82 percent; specificity, 87 percent). Cephalic index was a poor indicator of sagittal synostosis (45 percent sensitivity). Visual inspection alone demonstrated only a fair level of accuracy (40 to 50 percent agreement) in identifying cases of synostosis (kappa, 0.09 to 0.23). CONCLUSIONS: Craniosynostosis can be identified on prenatal ultrasound with good sensitivity using formal shape analysis. Cephalic index and visual inspection alone performed poorly. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

A Quantitative Analysis of Facial Asymmetry in Torticollis Using 3-Dimensional Photogrammetry.

OBJECTIVE: To assess whether children with torticollis have quantifiably greater facial asymmetry than their age-matched controls using 3-dimensional (3D) photogrammetry. DESIGN: We retrospectively analyzed patients diagnosed with torticollis and age-matched volunteers who underwent 3D photogrammetry of their faces. We calculated the root mean square deviation (RMSD) between native and reflected facial images, as a measure of asymmetry. Two observers independently measured RMSD values for all study participants. The Spearman correlation coefficient evaluated interobserver reliability. The Wilcoxon rank-sum test with Bonferroni adjusted P values for multiple comparisons. SETTING: Institutional. PARTICIPANTS: Twenty patients diagnosed with torticollis and 12 age-matched volunteers. Patients were analyzed on a computer database and volunteers were selected and consented in the hospital. We excluded patients with a history of facial trauma, facial operations, or other craniofacial diagnoses. INTERVENTIONS: Facial surface scans were obtained using the Canfield Vectra stereophotogrammetry system. The technology captures surface anatomy without radiation. MAIN OUTCOME MEASURES: RMSD comparisons between patients with torticollis and age-matched controls. RESULTS: Compared to controls, patients with torticollis had statistically significant greater full face, upper third, and middle third facial asymmetry. There was a trend toward greater asymmetry of the lower facial third. CONCLUSIONS: We used 3D photogrammetry to quantitate facial asymmetry from torticollis. We found greater asymmetry in patients with torticollis than in their unaffected peers. All areas of the face appeared to be affected, though the asymmetry in the lower facial third just failed to reach significance.

Revisiting the Resolution of Chiari Malformation in Nonsyndromic Craniosynostosis: A Case of Posterior Cranial Vault Reconstruction in Secondary Pan-Suture Synostosis.

BACKGROUND: While commonly seen in syndromic craniosynostosis, the incidence of Chiari malformation (CM) in nonsyndromic craniosynostosis has been reported at 5% and there is a lack of understanding of the pathophysiology and management of CM in this patient population. CASE DESCRIPTION: We present a 5-year-old male patient who underwent a sagittal craniosynostosis repair at the age of 5 months and returned at the age of 5 years with daily headaches associated with behavioral changes. He was found to have pan-synostoses and radiographic evidence of increased intracranial pressure, including a Chiari malformation. Neurologic and genetic workup was unremarkable. A cranial vault reconstruction was performed, and subsequent imaging demonstrated resolution of previously noted Chiari malformation. CONCLUSIONS: In our case, we provided a unique window into the underlying pathophysiology for CM in patients with concurrent nonsyndromic craniosynostosis that we hope will add to the current foundation of literature supporting the intricate relation between cranial vault compliance and Chiari malformation or hindbrain herniation. Furthermore, we provide insight into the management of acquired CM and support isolated cranial vault reconstruction in those who do not appear to have symptomatic suboccipital compression.

Recurrent Orbital Trauma Following Repaired Orbital Floor Fracture.

A study of a 22-year-old male who was assaulted and sustained a left orbital floor blowout fracture was presented in this study. The orbital floor was repaired with a titanium-reinforced porous polyethylene implant. Two years postoperatively, the patient sustained repeated left orbital trauma. The orbital floor implant remained stable while the medial wall blew out.

The Natural History of Treated and Untreated Zygomatic Arch Fractures.

The authors present the case of a 32-year-old patient treated for a left, isolated zygomatic fracture following assault. The injury was reduced without fixation via the Keene approach. The same patient presented to the emergency room 16 months later with a right-sided fracture similar to the previous contralateral injury. This fracture was left untreated. Repeated assaults over a 4-year period provide us with a natural history of both injuries, allowing for comparison between the 2 approaches. The authors found that reduction of the arch without fixation led to an outcome without palpable or visible deformity and no impaired mastication. Additionally, considering etiology of injury, such as alcohol or drug use, treatment may provide an important point of intervention to prevent recurrence.

Langerhans Cell Histiocytosis in the Pediatric Population: Treatment of Isolated Craniofacial Lesions.

Langerhans cell histiocytosis (LCH) commonly affects the craniofacial skeleton and prognosis depends on location, extension, and recurrence of the disease. The aim of our study is to better define the treatment of single craniofacial lesions, as to date different treatment modalities have been suggested and recurrence rates for both unifocal and multifocal bony lesion range between 10% and 70%. Between 2000 and 2014, we retrospectively reviewed clinical findings, anatomic location, extent of the disease, therapy, and outcomes in 24 pediatric patients with histologically confirmed LCH. Seventeen patients (67%) had craniofacial involvement, of which 13 had single system involvement and 4 had multisystem involvement. Eight patients (33%) had no craniofacial involvement. Eleven patients affected by unifocal cranial lesions were treated with resection and reconstruction. One patient with a unifocal mastoid lesion was treated with chemotherapy alone (vinblastine and prednisone). Four patients with mandible lesions were treated with curettage alone.There were no recurrences in patients treated with excision alone. One patient (25%) treated with curettage recurred. Two patients with diffuse disease manifested organ dysfunction and diabetes insipidus. Chemotherapy was tolerated in 12 patients treated.Our findings suggest that resection of isolated LCH lesions of the cranium is safe and chemotherapy is effective and well tolerated for nonsurgical cases.

Surgical Treatment for Palatoglossal Arch Cicatrix and Velopharyngeal Insufficiency After Adenotonsillectomy.

Postadenotonsillectomy velopharyngeal incompetence/insufficiency/dysfunction (VPI) is an uncommon but potentially surgically challenging problem. We report a child without cleft palate who developed severe palatoglossal arch cicatrix and VPI after adenotonsillectomy, and describe bilateral palatoglossal arch z-plasty to restore palatal function and speech.

Quantitative 3-dimensional Geometry of the Aging Eyelids.

Although facial aging is a well-known phenomenon, it has not been comprehensively characterized in 3 dimensions. This study introduces a novel technique for capturing periorbital structures across age groups using 3-dimensional (3D) imaging and point cloud data collection. METHODS: Forty-six white women were divided into 3 age groups: 20-39 years, 40-59 years, and 60+ years. Patients were scanned with the Canfield 3D photogrammetry system, and data files were exported to the point cloud processing software CloudCompare. Manually selected points specifying eyelid margins, creases, and 5 key periorbital features provided the basis for a fitted model and principal component analysis (PCA). Potential statistical significance across age groups was assessed for PCA values corresponding to each subject's eyelid geometry. RESULTS: Three tendencies emerged with respect to increasing age and eyelid anatomy: the width and height of the palpebral fissure decreases, with the width decreasing more rapidly; the depth of the lateral canthus relative to the medial canthus decreases; and the superior crease becomes more variable. Analyses of variance of PCA values across age groups show statistically significant differences between the youngest and oldest groups. CONCLUSIONS: Three-dimensional photogrammetry enables rigorous and reliable evaluation of the aging eyelid. Results suggest age-induced changes to eyelid margin, crease, and lateral canthus positions, which have been noted anecdotally but poorly quantified until now.

Surgical Correction of Metopic Craniosynostosis: A 3-D Photogrammetric Analysis of Cranial Vault Outcomes.

OBJECTIVE: To evaluate 3-dimensional (3-D) photogrammetry as a tool for assessing the postoperative head shape of patients who had undergone cranial vault remodeling for metopic synostosis. DESIGN: We prospectively analyzed images of patients with metopic craniosynostosis who had undergone anterior cranial vault remodeling and age-matched controls. To ensure standardized facial orientation, each 3-D image was positioned to "best fit" the preoperative face by aligning 6 soft tissue landmarks. Forehead measurements were taken from a standardized position behind the surface of the face to landmarks placed in a ray configuration across the forehead. SETTING: Academic teaching hospital. PATIENTS, PARTICIPANTS: Thirteen pediatric patients with metopic craniosynostosis who had undergone anterior cranial vault remodeling and age-matched controls. INTERVENTIONS: Images were taken preoperatively, immediately postoperatively, and over 1-year postoperatively. MAIN OUTCOME MEASURES: Forehead contours preoperatively and postoperatively, with statistics performed using a multivariate analysis of variance shape analysis. RESULTS: Mean postoperative follow-up was 1.8 (0.6) years. The average distance from the origin to forehead landmarks was 55.1 (3.4) mm preoperatively, 59.3 (0.7) mm immediate postoperatively, 59.1 (1.0) mm 1-year postoperatively, and 59.4 (0.6) mm in controls. Postoperative metopic forehead contours varied significantly from preoperative contours ( P < .01), while there was no statistical difference between the 2 postoperative time points ( P = .70). One-year postoperative patients were not significantly different from their age-matched controls ( P > .99). CONCLUSIONS: Preoperative metopic forehead contours varied significantly from postoperative contours. Cranial reconstructions approximated the foreheads of normal controls, and reconstructions were stable at more than 1-year follow-up.

The Relationship between Age and Facial Asymmetry.

BACKGROUND: Facial symmetry is a fundamental goal of plastic surgery, yet some asymmetry is inherent in any face. Three-dimensional photogrammetry allows for rapid, reproducible, and quantitative facial measurements. With this tool, the authors investigated the relationship between age and facial symmetry. METHODS: The authors imaged normal subjects using three-dimensional photogrammetry. Facial symmetry was calculated by identifying the plane of maximum symmetry and the root-mean-square deviation. Regression analysis was used to assess the relationship between age and symmetry. Subgroup analyses were performed among facial thirds. RESULTS: The authors imaged 191 volunteers with an average age of 26.7 ± 22.2 years (range, 0.3 to 88 years). Root-mean-square deviation of facial symmetry clustered between 0.4 and 1.3 mm (mean, 0.8 ± 0.2 mm). The authors found a significant positive correlation between increasing age and asymmetry (p < 0.001; r = 0.66). The upper, middle, and lower facial third's average root-mean-square deviations were 0.5 ± 0.2 mm (range, 0.2 to 1.2 mm), 0.6 ± 0.2 mm (range, 0.2 to 1.4 mm), and 0.6 ± 0.2 mm (range, 0.2 to 1.2 mm), respectively. Asymmetry also increased with age across all facial thirds (p < 0.001). CONCLUSIONS: Facial asymmetry increases with age in each facial third, with a greater asymmetry and increase in asymmetry in the lower two-thirds. Contributing factors may include asymmetric skeletal remodeling along with differential deflation and descent of the soft tissues. The observed correlation between increasing facial asymmetry and age may be a useful guide in plastic surgery to produce age-matched features.

Craniosynostosis as the Presenting Feature of X-linked Hypophosphatemic Rickets.

Craniosynostosis is the premature closure of cranial sutures. Primary, or congenital, craniosynostosis is often sporadic but may be associated with genetic or chromosomal abnormalities. Secondary craniosynostosis presents after gestation, and can occur in metabolic bone diseases, including rickets. We describe the first reported cases of primary craniosynostosis in 2 unrelated, term infants with X-linked hypophosphatemic rickets (XLH). The diagnosis of XLH in both patients was confirmed by genetic testing. At the time craniosynostosis was detected, the patient in the first case did not have any other clinical features of XLH. The second patient developed clinical findings of craniosynostosis, followed by rickets. These are the earliest reported cases of craniosynostosis in XLH and demonstrate that craniosynostosis may be a presenting feature of this disease.

Improving Pressure Ulcer Reconstruction: Our Protocol and the COP (Cone of Pressure) Flap.

BACKGROUND: Surgical treatment of pressure ulcers is challenging for high recurrence rates. Deepithelialized flaps have been used previously with the aim to eliminate shearing forces and the cone of pressure (COP) effect. The goal of this study is to adopt a standardized protocol and evaluate if 2 different flap techniques affect outcomes. METHODS: The novel COP flap is illustrated. Twenty patients were prospectively treated with flap coverage over a 36-month period. According to the flap type, patients were assigned to 2 groups: group 1 with 11 patients treated with the COP flap and group 2 with 9 patients treated with conventional flap without anchoring technique. We adopted a standardized protocol of debridement, tissue cultures, and negative-pressure wound therapy. Rotation fasciocutaneous flaps were used for both groups and mean follow-up was 19 months. The COP flap is a large deepithelialized rotation flap inset with transcutaneous nonabsorbable bolster sutures. The 2 groups were comparable for demographics and ulcer location and size (P < 0.05). Five patients showed positive cultures and were treated with antibiotics and negative-pressure therapy before surgery. RESULTS: Recurrence rates were 12% in the COP flap group and 60% in the conventional flap coverage group (P < 0.001). Results were compared at 16-month follow-up. CONCLUSIONS: The COP flap significantly reduces recurrences and eliminates shearing forces, suture ripping, and tension on superficial soft-tissue layers. The technique can be applied to both ischial and sacral pressure sores. The flap provides padding over bony prominence without jeopardizing flap vascularity.

Interdisciplinary Management of Minimally Displaced Orbital Roof Fractures: Delayed Pulsatile Exophthalmos and Orbital Encephalocele.

Traumatic orbital roof fractures are rare and are managed nonoperatively in most cases. They are typically associated with severe mechanisms of injury and may be associated with significant neurologic or ophthalmologic compromise including traumatic brain injury and vision loss. Rarely, traumatic encephalocele or pulsatile exophthalmos may be present at the time of injury or develop in delayed fashion, necessitating close observation of these patients. In this article, we describe two patients with minimally displaced blow-in type orbital roof fractures that were later complicated by orbital encephalocele and pulsatile exophthalmos, prompting urgent surgical intervention. We also suggest a management algorithm for adult patients with orbital roof fractures, emphasizing careful observation and interdisciplinary management involving plastic surgery, neurosurgery, and ophthalmology.

Three-Dimensional Analysis of Nasal Symmetry Following Primary Correction of Unilateral Cleft Lip Nasal Deformity.

OBJECTIVE: To evaluate nasal symmetry using three-dimensional photogrammetry following primary tip rhinoplasty with or without an internal splint in patients with unilateral complete cleft lip/palate. DESIGN: We captured three-dimensional images of patients with unilateral complete cleft lip/palate who underwent nasolabial repair by rotation-advancement of the lip and primary tip rhinoplasty, either with or without an internal resorbable splint, and normal control subjects. We assessed nasal symmetry by identifying the plane of maximum symmetry and the root-mean-square deviation between native and reflected surfaces. PATIENTS/PARTICIPANTS: We imaged 38 controls and 38 subjects with repaired unilateral complete cleft lip/palate (20 with, 18 without an internal splint). RESULTS: Nasal asymmetry root-mean-square deviation clustered between 0.19 and 0.50 mm (median = 0.24 ± 0.08 mm) for controls; whereas, those with repaired unilateral complete cleft lip/palate ranged from 0.4 to 1.5 mm (median = 0.75 ± 0.40 mm). Although root-mean-square deviation ranges overlapped, patients with repaired unilateral complete cleft lip/palate had significantly greater asymmetry than controls (P < .001). We found no difference in asymmetry between patients with or without an internal splint (P = .5). CONCLUSIONS: Three-dimensional photogrammetry was used to successfully compare symmetry among different patient and control groups. Although "normal" nasal symmetry was attained in some patients following cleft lip/nasal repair, most had persistent asymmetry compared with normal controls. Placement of a resorbable internal splint did not improve symmetry in patients with unilateral complete cleft lip/palate.

Management of Craniosynostosis at an Advanced Age: Controversies, Clinical Findings, and Surgical Treatment.

BACKGROUND: The natural history of unrepaired craniosynostosis is not well defined. Delayed surgical intervention carries greater risk of postoperative complications and its functional benefits for older patients are poorly characterized. The authors reviewed patients in whom children presented beyond 1 year of age to better understand the natural history of craniosynostosis, and the risk-benefit relationship for delayed reconstruction. METHODS: After institutional IRB approval the authors conducted a retrospective review of patients who presented after 1 year of age with craniosynostosis. Type of craniosynostosis, age at evaluation, medical history, surgical findings, developmental abnormalities, ophthalmologic findings, and clinical course were reviewed. RESULTS: Ten patients with delayed presentation for craniosynostosis were identified. The mean age at presentation was 6.8 years ±â€Š4.2 years (range, 3-17 years). Seven of 10 patients presented with developmental delay. Five patients presented with debilitating headaches. Five patients presented with comorbid Chiari malformations, 3 of whom required surgical decompression. Two patients had papilledema. Four patients underwent intracranial pressure monitoring, with elevated pressures found in 3 patients. Six patients underwent delayed cranial vault remodeling. There were no peri- or postoperative complications, including infection or residual bony defects, in those undergoing delayed operation. CONCLUSIONS: Children who present in a delayed fashion with unrepaired craniosynostosis have high rates of debilitating headaches, developmental delays, head shape anomalies, and Chiari malformation. Five patients reporting preoperative headaches noted subjective improvements in headaches following delayed operation. Cranial reconstruction can be safely performed at an older age and is appropriate to consider in carefully selected patients for aesthetic and/or functional concerns.

Pediatric Orbital Depth and Growth: A Radiographic Analysis.

BACKGROUND: Orbital reconstruction requires knowledge of orbital depth in order to prevent optic nerve injury. Numerous analyses of adult orbital dimensions have been undertaken previously in order to characterize this measurement, including skull specimen and computerized tomography studies. However, there is a paucity of information regarding the pediatric orbit. METHODS: The authors used pediatric magnetic resonance imaging (MRI) studies in order to quantify the change in orbital depth in relationship to patient age, and to develop methods to estimate and calculate orbital depth for individual pediatric patients. MRIs of the head in normal pediatric patients were reviewed retrospectively. Orbital depths were measured and correlated with age and cephalometric dimensions. In a randomly selected subgroup of patients, measurements were repeated by an independent investigator to determine interobserver reliability. RESULTS: Measurements were obtained in 72 patients ranging from 3 months to 18 years of age (mean=7.8 years). There was a significant exponential relationship between orbital depth and patient age (r=0.81, F(2,69)=143.97, P<0.001). Depth increased more rapidly in the first 6 years of life, but leveled off in the early teen years toward a horizontal asymptote of approximately 45 mm. There was also a significant relationship between orbital depth and the sum of the biparietal width plus the anterior-posterior length (r=0.72, F(2,69)=87.44, P<0.0001). There was high interobserver reliability in measurements between 2 independent investigators (r=0.79, P<0.0001). CONCLUSION: In children, orbital depth increases predictably with rising age and increasing head size. Knowledge of this growth curve and the relationship between head size and orbital depth can complement careful surgical dissection to improve safety and efficacy in pediatric orbital reconstructions.

Armadillo cranioplasty for expansion and remodeling in craniosynostosis.

UNLABELLED: Craniosynostosis is typically treated in the first year of life, when osteogenic potential is high and residual obligate skull defects heal. Delayed reconstruction can result in persistent skull defects because of diminished osteogenic potential. Adequately expanding the cranium yet minimizing residual skull defects in older patients presents a conundrum. Although secondary cranioplasty can be performed, primary cortical bone coverage is preferred. The authors present a technique of cranial expansion by sliding stairstep osteotomies, thus preventing residual skull defects when treating craniosynostosis at an advanced age. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Use of intraoperative computed tomography in complex craniofacial trauma: an example of on-table change in management.

The primary goals in repairing complex craniofacial fractures are restoration of occlusion and mastication, and anatomic reconstruction of a symmetric facial skeleton. Failure to accomplish these goals may result in the need for secondary operations. Recognition of malreduction may not be appreciated until review of a postoperative computed tomographic (CT) scan. Intraoperative CT scanning enables immediate on-table assessment of reduction and fixation, allowing alteration of the surgical plan as needed. We report using intraoperative CT scanning while repairing a panfacial injury in which malreduction was appreciated intraoperatively and corrected. Intraoperative CT can be used to improve outcomes and quality of complex facial fracture repair.