Sebaceous Nevus of the Scalp.

Excisions of scalp nevus sebaceous (NS) presents a unique challenge due to limited soft tissue laxity, hair-bearing skin, and convex surfaces which often leave the surgeon and patient underwhelmed with the reconstructive outcome. In this study, the authors conducted an institutional review board-approved retrospective review of patients who underwent excision of pathologically proven scalp primary NS from 2003 to 2017 at our institution to better define the reconstructive outcomes and options for treatment of pediatric scalp NS. 92 patients were included in the study, 54 males (58.7%) and 38 females (41.3%). The average age at surgery was 7.24 years (0.5-16.0; SD 4.7). Local tissue undermining/galeal scoring with primary closure (LTUGS) was used for lesions with average surface area of 3.6 cm, rotational or transposition flaps (RF/TF) for lesions averaging 4.3 cm, completed serial excision for lesions averaging 13.9 cm, and tissue expansion (TE) for lesions averaging 21 cm (P <0.001). One or more poor outcomes were experienced by 35 patients (38%), with a significant difference between the surgical groups; LTUGS 37.2% (29/78), RF/TF 60% (3/5), serial excision 100% (3/3), TE 0% (0/6) (P = 0.022). Univariant binary regression analysis within the LTUGS and RF/TF groups showed that lesion size was a significant predictor of poor outcomes (P = 0.012). All specimens in this study were negative for carcinoma. Therefore, most pediatric nevus sebaceous of the scalp can be managed by a single-phase procedure though risk of poor outcomes increase with nevus size with high rates of poor outcomes even with small lesions.

Cosmetically Challenging Congenital Melanocytic Nevi.

BACKGROUND: Congenital melanocytic nevi (CMN) have a 1% to 5% lifetime risk for malignant transformation, with 50% of transformations occurring before the age of 5 years.The aim of this study is to assess the risk of melanoma development in pediatric patients with facial CMN involving the eyebrows, eyelid margins, and nasal alae where a margin of CMN was not excised to preserve these structures. METHODS: A retrospective chart review of all pediatric patients with CMN from 1986 to 2014 was performed to review demographic information, diagnosis, and number of surgeries. Patients' clinical photographs were evaluated for residual nevi after completion of the treatment. RESULTS: More than 950 medical charts of patients with CMN of the face area were reviewed. We identified 32 patients (13; 41% male) that met the study criteria with pathology-confirmed diagnosis of facial CMN with an average age of 4.4 years (3.3 months-15.8 years) at the time of initial surgery. The CMNs were classified into small (1; 3%), medium (14; 44%), large (14; 44%), and giant (3; 9%) based on their projected adult sizes. No patients developed melanoma within the small residual lesions left over the eyebrows and eyelids and inside nostrils at an average follow-up time of 5.6 (1.0-14.4) years and average age of 9.6 (1.8-19.2) years at the time of last follow-up. CONCLUSIONS: Although a lifelong risk of malignant transformation of the residual CMN cannot be concluded, our results found no transformation in follow-up visits at an average age beyond the highest risk of melanoma development in childhood. We feel that leaving residual lesions on the face in areas of important anatomic structures for better cosmetic outcome is an acceptable risk.

Less Is More in Congenital and Pediatric Nasal Lesions.

Congenital and pediatric nasal lesion resection and their reconstructive outcomes are not well studied. A surgeon must consider the site, size, depth, etiology, age, and effect on future function (including growth). As such, it is important to contrast the differences between the adult's and child's nose. The authors propose that more conservative resection and reconstructive methods may better serve congenital and pediatric nasal lesions. An Internal Review Board approved study of congenital and pediatric nasal lesions using a defect only approach from 2005 to 2017 was performed. Lesions, type of surgeries, complications, aesthetic outcome, and additional interventions were reviewed. One hundred twenty-seven patients met the study criteria with a median age at surgery of 5.4 years with follow-up of 1.4 years (1 week-11.3 years). The most common diagnosis was congenital melanocytic nevus (47, 37%). The lesions were located on more than 1 subunit in 34 (27%) patients with an average surface area of 3.7 (0.04-32) cm. The most common primary procedure was excision and primary closure with adjacent tissue undermining/rearrangement (73, 57.4%) followed by full-thickness skin graft (23, 18.1%). The aesthetic outcome was considered acceptable in a high number of patients 117 (92%), while 10 (8%) patients had unacceptable aesthetic outcomes, mostly due to scarring. The authors' data supports the concept of minimal healthy tissue excision or lesion only excision when treating pediatric and congenital nasal lesions.

A Single Lab Test to Aid Pierre Robin Sequence Severity Diagnosis.

OBJECTIVE: The workup of patients with Pierre Robin sequence (PRS) consists of a physical examination, O2 saturation, and polysomnography to determine the severity of respiratory obstruction and need for surgery. We suggest that capillary blood gas (CBG) may be a better physiologic representation of airway obstruction and should be routinely used in the management of patients with PRS. DESIGN: This is a multicenter study based on a retrospective review of medical records. SETTING: The study was performed at tertiary care centers. INTERVENTIONS: Patients with PRS <1 year old underwent mandibular distraction osteogenesis. MAIN OUTCOME MEASURE: Using successful treatment outcome as a reference standard, receiver operating characteristic (ROC) curve was used to determine the accuracy of the diagnostic test and values for the best sensitivity and specificity to determine the need for surgical intervention. RESULTS: Of 73 patients, 48 had sporadic PRS, 23 had syndromes, 2 had micrognathia, not otherwise specified. Mandibular distraction osteogenesis was performed in 62 patients at a mean age of 39 days. The mean initial Apnea-Hypopnea Index (AHI) in nonsurgical versus surgical groups was 10 versus 31 ( P = .063), pH 7.41 versus 7.34 ( P = .003), pCO2 43 versus 56 ( P < .001), and HCO3 27 versus 30 ( P = .022). The ROC curve showed that pCO2 of 49.5 has the best specificity (100%) and sensitivity (72.6%) profile in terms of need for definitive airway. CONCLUSION: A simple CBG heel stick may better predict the physiologic effects of obstructive apnea; therefore, it should be added to the algorithm of PRS workup.

Optimal Timing of Secondary Alveolar Bone Grafting: A Literature Review.

PURPOSE: Secondary alveolar bone grafting (SABG) during mixed dentition is the standard of care for alveolar clefts. However, early SABG at 4 to 7 years of age before the eruption of lateral incisors versus late SABG at 8 to 12 years of age before the eruption of maxillary permanent canines is still debated. The purpose of this study was to perform a systematic review of the literature to evaluate the outcomes of early SABG in residual bone volume or degree of bone resorption, maxillary canine movement or impaction rate, complications, and esthetic outcomes and to compare outcomes of early versus late SABG. MATERIALS AND METHODS: A comprehensive search of the PubMed database was performed according to PRISMA guidelines. Keywords for alveolar cleft repair and inclusion criteria were used to screen articles for final review. RESULTS: The initial search yielded 6,278 articles, of which 4 retrospective and 4 prospective studies were chosen for final review. Of these, 7 studies compared outcome variables between early and late SABG and 1 looked at bone formation of patients who underwent only early SABG. For outcome variables, 3 studies assessed bone volume with radiographic evaluation, 2 estimated maxillary permanent canine impaction rate, 1 evaluated surgical complications, operative time, and length of hospital stay, and 1 looked at anterior incisor crown length. Overall, 6 studies concluded that early SABG provides a better outcome than late SABG and 2 found comparable results across the aforementioned variables. CONCLUSIONS: This review suggests that the existing data support the concept of early SABG; however, the data are not sufficient for a definitive conclusion. A well-planned prospective study is needed to further investigate the rationale for early SABG.

To Admit or Not to Admit: That is the Cleft Lip Question. Confirming the Safety of Outpatient Cleft Lip Repair.

BACKGROUND: There is no accepted protocol for inpatient versus ambulatory cleft lip surgery. The aim of this study was to review the safety of outpatient repair and develop guidelines. METHODS: A retrospective review of patients younger than 2 years undergoing primary cleft lip repair from 2008 to 2015 at six centers was performed. Patients were divided into two groups: predominantly ambulatory (discharged or admitted for specific concerns) and inpatient (admitted due to surgeon's preference). The impact of independent variables on admission, emergency department visits, and readmission within 1 month of discharge was analyzed. RESULTS: Of 546 patients, 68.1 percent were boys, 4.4 percent had syndromes, and 23.6 percent had comorbidities. One hundred forty-two patients were admitted postoperatively. Forty-nine admissions were attributable to the surgeon's preference. After excluding this subset, our ambulatory surgery rate was 81 percent. There was no difference in emergency department visits (3 percent versus 2.2 percent; p = 0.6) or readmissions (0 percent versus 1.45 percent; p = 0.5) between groups. None of the ambulatory surgery patients were readmitted within 36 hours, for a successful ambulatory surgery rate of 100 percent. Female sex; surgical time; prematurity and/or postconceptional age younger than 52 weeks; and cardiac, respiratory, central nervous system, gastrointestinal, genitourinary, and other congenital comorbidities had significant impact on admission rates in the predominantly ambulatory group (p < 0.05). Respiratory comorbidities and syndromes were risk factors for readmission if patients presented to the emergency department (p < 0.05). CONCLUSIONS: Ambulatory cleft lip repair can be performed safely in most patients with no difference in emergency department visits or readmission. Patients with comorbidities should be admitted for observation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

External Port Tissue Expansion in the Pediatric Population: Confirming Its Safety and Efficacy.

BACKGROUND: External filling ports in tissue expander-based reconstruction have the advantages of being associated with less pain and emotional distress. However, among practicing surgeons using tissue expansion, a theoretical concern remains regarding higher risk of infection. The authors' goal was to evaluate external port safety in the pediatric population by looking at the complications and overall success rate of reconstruction. METHODS: A retrospective review of all patients undergoing tissue expansion using external ports at Children's Hospital Los Angeles between January of 2008 and June of 2016 was conducted. Patient demographic and perioperative data were collected and analyzed. RESULTS: Two hundred forty-one expanders were placed in 100 pediatric patients, resulting in 123 procedures for congenital and acquired conditions, with an average age at the time of surgery of 7.1 years (range, 1 month to 19.9 years) and average follow-up length of 2.5 years (range, 2.8 months to 8.8 years). The overall complication rate was 29.9 percent, and the infection rate was 17 percent. The majority of these cases were treated conservatively without additional need for surgery. Of 123 cases, 25 required premature expander removal because of complications. Despite early intervention, 21 of these cases underwent successful completion of their reconstruction according to the preoperative plan, resulting in an overall 96.7 percent success rate of tissue expander reconstruction. CONCLUSIONS: In children, who are often less tolerant of the pain and distress associated with internal port expansion, the authors encourage the use of external ports. This study found a high success rate in terms of successful reconstruction, with the majority of complications being treated conservatively. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Predictors of Failure in Infant Mandibular Distraction Osteogenesis.

PURPOSE: Mandibular distraction osteogenesis (MDO) has been shown to be successful in treating upper airway obstruction caused by micrognathia in pediatric patients. The purpose of this study was to assess the success rate of MDO and possible predictors of failure. PATIENTS AND METHODS: The records of all neonates and infants who underwent MDO from 2008 to 2015 were retrospectively reviewed. Procedural failure was defined as patient death or the need for tracheostomy postoperatively. Details of distraction, length of stay, and failures were captured and elucidated. RESULTS: Of the 82 patients, 47 (57.3%) were male; 46 (56.1%) had sporadic Pierre Robin sequence; 33 (40.3%) had syndromic Pierre Robin sequence; and 3 (3.7%) had micrognathia, not otherwise specified. The average distraction length was 27.5 mm (range, 15 to 30 mm; SD, 4.4 mm), the average age at operation was 63.3 days (range, 3 to 342 days; SD, 71.4 days), and the average length of post-MDO hospital stay was 43 days (range, 9 to 219 days; SD, 35 days) with an average follow-up period of 4.3 years (range, 1.1 to 9.6 years; SD, 2.6 years). There were 7 failures (8.5%) (5 tracheostomies and 2 deaths) resulting in a 91.5% success rate. Regression analysis showed that the predicted probability of the need for tracheostomy was 45% (P = .02) when the patient had a central nervous system (CNS) anomaly. The predicted probability of the need for tracheostomy and death combined was 99.6% when the patient had laryngomalacia and a CNS anomaly and was preoperatively intubated (P < .05). CONCLUSIONS: This review confirms that MDO is an effective method of treating the upper airway obstruction caused by micrognathia with a high success rate. In our sample the presence of CNS abnormalities, laryngomalacia, and preoperative intubation had a significant impact on the failure rate.

Impact of the Distance of Maxillary Advancement on Horizontal Relapse After Orthognathic Surgery.

BACKGROUND: The maxillary horizontal relapse following Le Fort I advancement has been estimated to be 10% to 50%. This retrospective review examines the direct association between the amounts of maxillary advancement and relapse. We hypothesize that the greater the advancement, the greater the relapse amount. METHOD: Patients with class III skeletal malocclusion underwent maxillary advancement with either a Le Fort I or a Le Fort I with simultaneous mandibular setback (bimaxillary surgery) from 2008 to 2015. Patients were assessed for a history of cleft lip or cleft palate. Patients with known syndromes were excluded. Cephalometric analysis was performed to compare surgical and postsurgical changes. RESULTS: Of 136 patients, 47.1% were males and 61.8% had a history of cleft. The mean surgery age was 18.9 (13.8-23) years and 53.7% underwent a bimaxillary procedure. A representative subgroup of 35 patients had preoperative, immediate postoperative, and an average of 1-year postoperative lateral cephalograms taken. The mean maxillary advancement was 6.3 mm and the horizontal relapse was 1.8 mm, indicating a 28.6% relapse. A history of cleft and amount of maxillary advancement were directly correlated, whereas bone grafting of the maxillary osteotomy sites was inversely correlated with the amount of relapse ( P < .05). CONCLUSIONS: Our data suggest positive correlation between amount of maxillary advancement and horizontal relapse as well as a positive correlation between history of cleft and horizontal relapse. Bone grafting of the maxillary osteotomy sites has a protective effect on the relapse.

An Unusual Complication of Bone Wax Utilization.

Bone wax is a commonly used hemostatic agent with minimal complications. Some of the known complications include inflammation, granuloma formation, infection, and impaired osteogenesis. Several clinical reports of bone wax migration have also been reported. In this paper, the authors present a rare patient of bone wax migration intracranially in a 6-year-old patient who initially underwent craniotomy for the evacuation of subdural hematoma and repair of depressed skull fracture. The patient then underwent craniotomy scalp scar revision several months later. Postoperatively he developed short-term memory loss, apraxia, and word finding difficulties. The imaging findings were consistent with the presence of a foreign body centered in the posterior aspect of the left middle temporal gyrus, which was surgically removed and found to be bone wax. The patient recovered well with complete improvement of his neurologic symptoms.

Updates on the Management of Non-Melanoma Skin Cancer (NMSC).

Non-melanoma skin cancers (NMSCs) are the most common malignancy worldwide, of which 99% are basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) of skin. NMSCs are generally considered a curable diseases, yet they currently pose an increasing global healthcare problem due to rising incidence. This has led to a shift in emphasis on prevention of NMSCs with development of various skin cancer prevention programs worldwide. This article aims to summarize the most recent changes and advances made in NMSC management with a focus on prevention, screening, diagnosis, and staging.