Calcium phosphate and titanium cranioplasty after total angular craniopagus separation.

Craniopagus separation requires careful planning and a multi-staged surgical approach, managed by a multidisciplinary team. Despite growing experience on surgical management, the long-term restoration of the cranial defect has been rarely discussed so far. Several alloplastic materials have been proposed as effective and safe solutions for cranioplasty even for pediatric patients, allowing for bone generation, good aesthetic results, and low complication rates. We report, for the first time, on a separated craniopagus child who underwent successful implant of a tailor-made system based on the combination of calcium phosphate ceramic reinforced with a titanium mesh.

Safety and Efficacy of Mek Inhibitors in the Treatment of Plexiform Neurofibromas: A Retrospective Study.

INTRODUCTION: Plexiform neurofibromas (PN) represent the main cause of morbidity in patients affected by Neurofibromatosis Type 1 (NF1). Until recently, surgery has been the main treatment option in these patients, but it is burdened with a low efficacy rate and a high incidence of side effects as well as recurrence. In recent years, MEK inhibitors (MEKi) such as selumetinib and trametinib have shown great promise. METHODS: We retrospectively describe a single center cohort of NF1 patients affected by PN1 and treated with MEKi since 2019 to 2021. Patients recruited in the study were affected by PN that were not eligible to complete surgical excision, symptomatic or with major cosmetic deformation or functional neurological deficits. RESULTS: Most patients experienced improvement in clinical symptoms and quality of life, with reduction or stabilization of lesions. However, no complete response was achieved. The most common adverse effects involved the skin, affecting every patient. Importantly, no life-threatening adverse effects occurred. CONCLUSIONS: In our experience, MEKi treatment has been shown to be both safe and effective in improving symptomatology and quality of life.

Vascular lesions of the pediatric orbit: A radiological walkthrough.

Vascular anomalies of the pediatric orbit represent a heterogeneous group that include both vascular tumors and vascular malformations. The disorder may initially be silent and then associated with symptoms and/or function damage, depending on the type of vascular anomaly and its extension. Vascular tumors include benign, locally aggressive (or borderline) and malignant forms while vascular malformations are divided into "simple", "combined" and syndromic, or "low flow" or "high flow". Both entities can arise in isolation or as part of syndromes. In this review, we describe the imaging findings of the vascular lesions of the orbit in the pediatric population, which are key to obtain a correct diagnosis and to guide the appropriate treatment in the light of the new genetic and molecular discoveries, and the role of the radiologist in their multidisciplinary management. We will also touch upon the main syndromes associated with orbital vascular abnormalities.

25-year Follow-up of Primary Tibial Periosteal Graft for Hard Palate Repair in Cleft Lip and Palate: Outcomes, Concerns and Controversies.

OBJECTIVE: This study evaluates long-term outcomes in adults with Unilateral and Bilateral Cleft Lip and Palate (UCLP/BCLP) treated during the period 1992 to 1995 with tibial periosteal graft in primary repair. DESIGN: Retrospective study. SETTING: Department of Plastic and Maxillofacial Surgery, Children's Hospital Bambino Gesù (Italy). PATIENTS: The study included 52 patients with non-syndromic BCLP/UCLP who met the inclusion criteria. INTERVENTIONS: All patients underwent a standardized surgical protocol using a tibial periosteal graft as primary repair of the hard palate. MAIN OUTCOME MEASURE(S): Long-term outcomes on maxillary growth, residual oronasal fistula, and leg length discrepancy. RESULTS: About <2% of patients showed oral-nasal communication. Mean value of maxillary depth was 86° ± 4.5°. The lower value for maxillary retrusion was 76.8° in relation to the Frankfurt plane. At the x-ray control, 12.2% of patients showed leg discrepancy with a difference of always <2 cm. CONCLUSIONS: The rate of maxillary retrusion obtained was the same if compared to other techniques. Tibial periosteal graft reduces the risk of fistula and the need for reintervention after secondary bone graft. The study did not observe negative impacts on leg growth after 25 years.

The clinical effectiveness of an integrated multidisciplinary evidence-based program to prevent intraoperative pressure injuries in high-risk children undergoing long-duration surgical procedures: A quality improvement study.

The prevention of hospital-acquired pressure injuries (HAPIs) in children undergoing long-duration surgical procedures is of critical importance due to the potential for catastrophic sequelae of these generally preventable injuries for the child and their family. Long-duration surgical procedures in children have the potential to result in high rates of HAPI due to physiological factors and the difficulty or impossibility of repositioning these patients intraoperatively. We developed and implemented a multi-modal, multi-disciplinary translational HAPI prevention quality improvement program at a large European Paediatric University Teaching Hospital. The intervention comprised the establishment of wound prevention teams, modified HAPI risk assessment tools, specific education, and the use of prophylactic dressings and fluidized positioners during long-duration surgical procedures. As part of the evaluation of the effectiveness of the program in reducing intraoperative HAPI, we conducted a prospective cohort study of 200 children undergoing long-duration surgical procedures and compared their outcomes with a matched historical cohort of 200 children who had undergone similar surgery the previous year. The findings demonstrated a reduction in HAPI in the intervention cohort of 80% (p < 0.01) compared to the comparator group when controlling for age, pathology, comorbidity, and surgical duration. We believe that the findings demonstrate that it is possible to significantly decrease HAPI incidence in these highly vulnerable children by using an evidence-based, multi-modal, multidisciplinary HAPI prevention strategy.

Use of acellular intact fish skin grafts in treating acute paediatric wounds during the COVID-19 pandemic: a case series.

OBJECTIVE: More specific strategies are needed to support children requiring skin grafting. Our goal was to identify procedures that reduce operating times, post-operative complications, pain and length of hospital stay. Patient safety, optimal wound bed support and quick micro-debridement with locoregional anaesthesia were prioritised. Ultimately, a novel acellular fish skin graft (FSG) derived from north Atlantic cod was selected for use. METHOD: We admitted consecutive paediatric patients with various lesions requiring skin grafting for definitive wound closure. All FSGs were applied and bolstered in the operating room following debridement. RESULTS: In a cohort of 15 patients, the average age was 8 years and 9 months (4 years 1 month-13 years 5 months). Negative pressure wound therapy (NPWT) was given to 12 patients. Rapid wound healing was observed in all patients, with a wound area coverage of 100% and complete healing in 95% of wounds. Time until engraftment in patients receiving NPWT was reduced by about a half (to an average 12 days) from our standard experience of 21 days. Ten patients received locoregional anaesthesia and were discharged after day surgery. The operating time was <60 minutes, and no complications or allergic reactions were reported. Excellent pliability of the healed wound was achieved in all patients, without signs of itching and scratching in the postoperative period. This case series is the first and largest using FSG to treat paediatric patients with different wound aetiologies. We attribute the rapid transition to acute wound status and the good pliability of the new epidermal-dermal complex to the preserved molecular components of the FSG, including omega-3. CONCLUSION: FSG represents an innovative and sustainable solution for paediatric wound care that results in shorter surgery time and reduced hospital stays, with accelerated wound healing times.

Case report of anesthesia for free fibula flap reconstruction in Ewing sarcoma: Safety and efficacy of continuous popliteal sciatic nerve block and very low doses of intravenous heparin.

A child with a maxillary Ewing sarcoma was operated for tumor asportation and reconstruction with free fibula flap. Adequate anticoagulation was achieved with lower doses of heparin and monitored with multiple ACT values. We used NIRS monitoring to avoid hypoperfusion. Post-operative pain relief was guarantited by local anestethic continous infusion.

Successful staged separation of total angular craniopagus.

BACKGROUND: Total craniopagus is an exceedingly rare condition in which surgical treatment is complex and potentially fatal. Over the last decades, a multistep surgical approach, which allows development of venous collateral circulation, has fostered a dramatic improvement of successful separation rates and neurological outcomes. Most of the experience derives from management of vertical craniopagus, the angular form being rarer and less amenable to successful surgical separation. METHODS: We present a case of total angular craniopagus twins observed at our Institution. Specific features included a large occipital fusion area with a bone defect, complete separation of brain and arterial vessels and a complex configuration of dural venous sinuses. The superior sagittal sinus of each twin preferentially drained to a single transverse sinus through a shared torcular. RESULTS: After an extensive diagnostic phase, including neuroimaging, tridimensional and virtual reality modelling, neurological, neurophysiological and rehabilitation assessment, a detailed multistep surgical plan, was proposed to a wide multidisciplinary team. The venous system was managed by taking advantage of the fact each twin's superior sagittal sinus was drained preferentially by the transverse sinus on the twin's left. The transverse sinuses were thus separated accordingly. CONCLUSIONS: Successful separation was achieved in three surgical steps over one year, with an excellent outcome for both twins.

Vascular Birthmarks as a Clue for Complex and Syndromic Vascular Anomalies.

Vascular birthmarks are common in neonates (prevalence: 20-30%) and mostly incidental findings sometimes with spontaneous regression (salmon patch and nevus simplex). Capillary malformations are found in about 1% and infantile hemangiomas are found in 4% of mature newborns. Vascular malformations are classified according to their most prominent vessel type. The term "capillary malformation" (port wine stain) includes a wide range of vascular lesions with different characteristics; they may be isolated or part of specific syndromic conditions. Part of the infantile hemangiomas and of the vascular malformations may require treatment for functional or cosmetic reasons, and in rare cases, investigations are also necessary as they represent a clue for the diagnosis of complex vascular malformation or tumors associated with extracutaneous abnormalities. Complex vascular malformations are mostly mosaicism due to early somatic mutations. Genetic advances have led to identify the main pathogenic pathways involved in this disease group. Diffuse capillary malformation with overgrowth, Klippel-Trenaunay syndrome, CLAPO syndrome, CLOVES syndrome, and megalencephaly-capillary malformation belong to the PIK3CA-related overgrowth. Capillary malformation-arteriovenous malformation underlies a fast-flow vascular malformation, sometimes manifesting as Parkes-Weber syndrome. Recognition of these different types of capillary vascular stains is sometimes difficult; however, associated findings may orient the clinicians while genetic testing may confirm the diagnosis. Lymphatic malformation frequently manifests as large masses that compress and/or infiltrate the surrounding tissues, representing a neonatal emergency when airways are involved. Infantile hemangiomas may cause functional and/or permanent esthetical damage, depending on their localization (such as periorbital area, lip, nose); large (more than 5 cm) infantile hemangiomas with a segmental distribution can be associated with obstruction or malformations of the underneath organs with complications: PHACE syndrome, LUMBAR/SACRAL syndrome, and beard infantile hemangioma. In our review, we discuss controversies regarding the international classification and emerging concepts in the field of vascular anomalies. Finally, we discuss potential developments of new, non-invasive diagnostic techniques and repurposing of target therapies from oncology. Complex and/or life-threatening vascular tumors and malformations are extremely rare events and they represent a considerable therapeutic challenge. Early recognition of clinical signs suggestive for a specific disease may improve therapeutic outcomes and avoid severe complications.

Optimal care for rhino-orbital mucormycosis in child with myeloblastic leukemia. Case report and literature review.

Mucormycosis is an opportunistic and aggressive fungal infection that mainly affects immunocompromised patients who generally suffer from diabetes mellitus, immune impairment, hematological disease. It is a life-threatening infection and the management is not standardized. The literature proposes aggressive and early surgical approach, even at the expense of mutilation. We report a case of rhino-orbital mucormycosis in a child with myeloblastic leukemia and the successful treatment using the instill negative pressure wound therapy combined with reconstructive surgery in order to reduce mortality and to avoid disfigurement. KEY WORDS: Amphotericin B, Apex syndrome, Forehead flap, Instill NPWT, Myeloaplasia Mucormycosis.

The Versatility of the Free Vastus Lateralis Muscle Flap: Orbital Reconstruction After Removal of Complex Vascular Malformation in a Pediatric Patient.

Introduction: Vascular orbital lesions in pediatric population represent a demanding therapeutic challenge which requires a multidisciplinary team. In severe cases, orbital enucleation can be considered. Surgical management of enucleated orbital region in children, differently from the adults, represents a challenging procedure owing to the intrinsic relation between volume replacement and normal orbital growth. Many reconstructive options have been proposed, and many donor sites have been utilized for this purpose but each one have demonstrated potential disadvantages. Despite its well-known versatility, no report of the vastus lateralis free flap in children requiring orbital reconstruction exists in literature. Herein, we propose this surgical strategy as a valid option for the reconstruction of an extended orbital defect in a pediatric patient suffering from a mixed type of vascular malformation. Material and Methods: A patient was referred from a foreign country with an unclear medical history, presenting exorbitism and exophthalmos, proptosis of the eyeball, visus 4/10, and limited ocular motility. We made clinical-instrumental investigations with a diagnosis of complex vascular malformation. It expanded in intraorbital and retrorbital space with bulb anterior dislocation and optic nerve involvement. We performed an emptying of the orbital content via transconjunctival and via coronal incision with eyelid preservation. A free vastus lateralis muscle flap was used for reconstruction, filling the orbital cavity. We anastomosed the flap on the superficial temporal artery. An ocular conformator was then positioned. Results: We report the result at 12 months, showing a good orbital rehabilitation with an adequate prosthetic cavity, a good recovery of volume and facial symmetry, guaranteeing balanced orbital and periorbital growth. There were no major or minor complications associated with the procedure. Discussion: The reconstruction of the orbit remains a "surgical challenge" both in adults, whose goal is the restoration of volume, adequate symmetry and facial esthetics, and children, in which correcting the asymmetry has the additional objective to balance orbital growth. Many reconstructive techniques have been proposed, including the use of free flaps. The versatility of the free vastus lateralis muscle flap is well-known. It offers adequate amount of tissue with minimal morbidity to the donor site, provides a long pedicle, gives the possibility of simultaneous work in a double team, and has a constant anatomy and a safe and rapid dissection. There are no descriptions of its use for pediatric orbital reconstructions. Conclusions: In our opinion, the free vastus lateralis flap should be included as one of the best option for orbital pediatric reconstruction after enucleation.

Volumetric analysis of cleft lip deformity using 3D stereophotogrammetry.

PURPOSE: To quantify and compare pre-operative and post-operative volumetric adjustments of the upper lip tissues in patients with cleft lip. METHODS: The authors performed an anthropometric study and a quantitative analysis of the differences based on three-dimensional morphology of the nasolabial area. Twenty facial images using the three-dimensional stereophotogrammetry were taken from ten selected subjects on two separate occasions, sitting in natural head position. Facial landmarks were marked and measurements recorded, in order to calculate the volumetric adjustments in the soft tissues of the upper lip, comparing the preoperative and postoperative results. Student test and p-Value were performed for statistical analysis. RESULTS: The analysis of the 3D images showed variability with the pre- and postoperative volumes of the nasolabial area with: an increase of upper lip volume all patients; a complete view of the severity in the preoperative; and an improvement of the appearance in the postoperative. The amount of increase of the upper lip volume was established about 29,7%. For all measurements, the variability between pre- and post-operative was significant (p < 0.01). CONCLUSION: The 3D stereophotogrammetry technique allows a detailed preoperative evaluation and an accurate assessment of the surgical outcomes. The study provides a value of volumetric variation of the upper lip in individuals with cleft lip. KEY WORDS: Cleft lip, Nasolabial area, 3D Morphological Analysis, 3D Stereophotogrammetry, Upper lip volume.

Lay People Esthetic Evaluation of Primary Surgical Repair on Three-Dimensional Images of Cleft Lip and Palate Patients.

Background and Objectives: Previous literature has disclosed that facial attractiveness affects the esthetic evaluation of nose and lip deformity on frontal and lateral photographs. However, it has never been debated if the removal of the external facial features on three-dimensional (3D) models ("cropped assessment bias") could provide a considerable usefulness in the interpretation and comparison of the results. Additionally, it has been assumed on two-dimensional (2D) studies that esthetic assessment biases with respect to observer gender, and it is not acknowledged if and to the extent that "gender assessment bias" may be influenced by a three-dimensional layout. The aim of this study is to investigate if facial traits and observers' gender may affect the esthetic ratings of unilateral cleft lip and palate (UCLP) patients after soft tissue reconstruction. Materials and Methods: Three-dimensional images of ten UCLP patients' images were acquired before the intervention (T0), one-month (T1) and six-months (T2) postoperative. Geomagic® software (version 2014; 3D Systems, Rock Hill, SC, USA) was used to remove the external facial features of 3D surface models. Five-point scale developed by Asher-McDade et al. was used to rate both nasolabial attractiveness and impairment for full-face (FF) and cropped-face (CF) 3D images. Forty-three judges (21 males, 22 females) were enrolled for the esthetic evaluation. Intraclass correlation coefficient (ICC) was used to test intra- and inter-examiner reliability; a value of 0.7 was set as the minimum acceptable level of reliability. Results: When comparing the 2 sets of observations (FF and CF), the ICC ranged from 0.654 to 0.823. Concerning gender assessment bias, the ICC ranged from 0.438 to 0.686 and from 0.722 to 0.788 for males and females, respectively. Concerning inter-examiner reliability, ICC for questions 2-7 ranged from 0.448 to 0.644 and from 0.659 to 0.817 at T0 and T2, respectively. Conclusions: The removal of external facial features provides subtle differences on the esthetic assessment of UCLP patients. Moreover, based on our data, examiners' gender differences may affect esthetic assessment of UCLP patients. Despite the subjectivity of esthetic judgments, a reliable, validated and reproducible scoring protocol should consider the influence of gender differences on 3D esthetic assessment of UCLP patients.

How to eliminate bilateral cleft lip stigmata 30 year experience.

PURPOSE: To report a surgical algorithm for the treatment of bilateral cleft lip stigmata. METHODS: The investigators designs a retrospective study composed of patients with bilateral cleft lip stigmata. The surgical approach is on the basis of the severity of the deformity and of course the age of the patient. It consists in Simple scar revision with orbicularis muscle synthesis; Two dermal flaps tunneled in the central vermilion; Abbe flap. The investigators analyzes early and late complications, and performs the evaluation of the cosmetic appearance by a parent or patient himself/herself, a surgeon and a blinded third party observer. RESULTS: The sample was composed of 351 patients. At short-term follow-up, viability of the flaps, function and morphology are good. At long-term follow-up, we observed significant improvement of the characteristics and profile of the patient's face and a normal function of the lips. We recorded a good scarring and a high satisfaction rate by evaluation of patients/ surgeon/ blinded third party observer. CONCLUSION: The results of this study suggest that a surgical algorithm on the basis of the severity of the deformity and of course the age of the patient can represent an option of choice for most patients with bilateral cleft lip stigmata. KEY WORDS: Abbe flap, Bilateral cleft lip stigmata, Cleft lip, Dermal flaps, Orbicularis muscles.

Early surgical excision of giant congenital hemangiomas of the scalp in newborns: clinical indications and reconstructive aspects.

BACKGROUND: Infantile hemangioma is the most common vascular tumor in newborns, with an incidence from 12 to 23% among preterm infants with low weight at birth and a female to male ratio of 3:1. The head and neck is the most frequently affected area (60%), and the scalp is a typical site for such large lesions. OBJECTIVE: We describe some clinical and medical aspects in comparison with the surgical approach to giant infantile hemangioma of the scalp. METHODS: The indications to treatment are discussed. An outcome basis evaluation, by reviewing some clinical cases, is provided to help readers better understand when and how to undergo surgery safely. CONCLUSION: Early excision of huge infantile hemangioma of the scalp is the treatment of choice if feasible within 5 months of age.

Minor salivary gland neoplasm in children.

In this article, we present a review of the literature, and we focus on 2 particular cases of cancer of the salivary glands accessory in pediatric patients The accessory parotid is the site of congenital and acquired lesions. In adults, the acquired lesions are often neoplastic and are usually similar to those seen in the main parotid gland. The disorders in children are less well defined, as only a few cases have been reported.The accessory parotid gland, or accessory parotid, is a nodule of normal salivary tissue separated from the main parotid gland, located on the masseter muscle, to which it is bound by an extension of the masseteric fascia and connected to the Stensen duct at that level. In contrast to the extensive literature on acquired lesions of the accessory parotid in adults, very few cases of malignant or benign lesions of the accessory parotid in children could be found in the literature. A review of several articles reporting lesions of the accessory parotid in adult patients, reporting 3 or more cases each for a total of 71 patients, showed 24 malignant neoplasms, 39 benign neoplasms, and 8 nonneoplastic lesions. Lesions of the accessory parotid are quite rare in children but should be considered when facing mass located in the cheek.

Congenital myxoid and pigmented dermatofibrosarcoma protuberans: a case report.

Dermatofibrosarcoma protuberans (DFSP) is a low-grade, mesenchymal, spindle cell tumor. In addition to the classical form characterized by a storiform pattern of tumor cells, pigmented (Bednar's tumor) and myxoid variants can be observed. Classical DFSP and Bednar's tumor are easily diagnosed. The myxoid variant represents a diagnostic challenge. Pigmented and myxoid variants are rare and thus far have never been reported in association in congenital DFSP. We came across a unique DFSP that was, at the same time, congenital, pigmented, and myxoid. The tumor was surgically excised with broad free margins and no recurrence. The differential diagnosis with other entities such as giant cell fibroblastoma, CD34-positive plaque-like dermal fibroma, superficial plaque-like CD34 DFSP, and neurocristic hamartoma is discussed. The recognition of this hybrid variant of congenital DFSP is important to avoid under- or overtreatment.