Faculty Bibliography

BACKGROUND: The application of aesthetic, craniofacial, and microsurgical principles in the execution of face transplantation may improve outcomes. Optimal soft-tissue face transplantation can be achieved by incorporating subunit facial skeletal replacement and subsequent tissue resuspension. The purpose of this study was to establish a reconstructive solution for a full face and scalp burn and to evaluate outcome precision and consistency. METHODS: Seven mock face transplants (14 cadavers) were completed in the span of 1 year. Components of the vascularized composite allograft included the eyelids, nose, lips, facial muscles, oral mucosa, total scalp, and ears; and skeletal subunits of the zygoma, nasal bone, and genial segment. Virtual surgical planning was used for osteotomy selection, and to evaluate postoperative precision of hard- and soft-tissue elements. RESULTS: Each transplant experience decreased each subsequent transplant surgical time. Prefabricated cutting guides facilitated a faster dissection of both donor and recipient tissue, requiring minimal alteration to the allograft for proper fixation of bony segments during inset. Regardless of donor-to-recipient size discrepancy, ample soft tissue was available to achieve tension-free allograft inset. Differences between virtual transplant simulation and posttransplant measurements were minimal or insignificant, supporting replicable and precise outcomes. CONCLUSIONS: This facial transplant model was designed to optimize reconstruction of extensive soft-tissue defects of the craniofacial region representative of electrical, thermal, and chemical burns, by incorporating skeletal subunits within the allograft. The implementation of aesthetic, craniofacial, and microsurgical principles and computer-assisted technology improves surgical precision, decreases operative time, and may optimize function.

BACKGROUND: Despite the increasing use of nasoalveolar molding in early cleft treatment, questions remain about its effectiveness. This study examines clinician and caregiver appraisals of primary cleft lip and nasal reconstruction with and without nasoalveolar molding in a nonrandomized, prospective, multicenter study. METHODS: Participants were 110 infants with cleft lip/palate (62 treated with and 48 treated without nasoalveolar molding) and their caregivers seeking treatment at one of six high-volume cleft centers. Using the Extent of Difference Scale, standard photographs for a randomized subset of 54 infants were rated before treatment and after surgery by an expert clinician blinded to treatment group. Standard blocked and cropped photographs included frontal, basal, left, and right views of the infants. Using the same scale, caregivers rated their infants' lip, nose, and facial appearance compared with the general population of infants without clefts before treatment and after surgery. Multilevel modeling was used to model change in ratings of infants' appearance before treatment and after surgery. RESULTS: The expert clinician ratings indicated that nasoalveolar molding-treated infants had more severe clefts before treatment, yet both groups were rated equally after surgery. Nasoalveolar molding caregivers reported better postsurgery outcomes compared with no-nasoalveolar molding caregivers (p < 0.05), particularly in relation to the appearance of the nose. CONCLUSIONS: Despite having a more severe cleft before treatment, infants who underwent nasoalveolar molding were found by clinician ratings to have results comparable to those who underwent lip repair alone. Infants who underwent nasoalveolar molding were perceived by caregivers to have better treatment outcomes than those who underwent lip repair without nasoalveolar molding. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

PURPOSE: Facial fractures in the pediatric population have a significant impact on public health. Although some demographic data exists regarding the overall epidemiology of facial fractures, little attention has been paid to the patterns of facial fractures based on the etiology of the trauma. MATERIAL AND METHODS: The Kids' Inpatient Database 2000-2009 was utilized to analyze pediatric facial fractures. A total of 21,533 patients were identified. Associations of patient characteristics with outcomes of interest were assessed. RESULTS: The top three etiologies were motor vehicle accident (MVA), intentional trauma (IT), and falls. There was a decrease in the incidence of facial fractures due to MVAs and an increase in injuries due to IT and falls. Concomitant injuries were present in 58.8% and the mortality rate was 2%. The rate of concomitant injuries increased during study period. Age was significantly associated with concomitant injury, mortality, and LOS. CONCLUSION: The increasing rate of IT and falls with concomitant injury warrants special consideration to reduce undiagnosed accompanying injuries. Further programs should be put in place to protect children younger than 5 years of age, who have increased risk of concomitant injury and mortality following intentional trauma.

BACKGROUND: The aim of this study is to evaluate the efficacy, safety profile and the complications associated with mandibular distraction osteogenesis (MDO) performed in infants < 4kg with Robin sequence (RS). METHODS: A 11-year retrospective review of all infants (< 6 months) with MDO treated RS was performed. Patients < 4 kg (experimental) and >/= 4 kg (control) who underwent MDO were compared. Demographics, medical comorbidities, improvement in apnea/hypopnea index (AHI), need for tracheostomy, repeat distraction, and complications were evaluated. RESULTS: One hundred twenty-one patients underwent MDO. 81 patients were < 4 kg while 40 were >/= 4 kg. The mean follow up was 2.8 years in patients < 4 kg and 3.0 years in the control group. Mean age and weight at time of distraction were 23 days old / 3.1 kg and 2.7 years / 11 kg; respectively. There was no significant difference in success of MDO to treat airway obstruction in the < 4 kg group versus the control group (92.6% vs. 88.9%; p = 0.49). The most common complication in each group was surgical site infection (9.9% and 20.0%; p = 0.15). Overall complication rates were similar between the two groups (17.3% vs. 25.0%; p = 0.34). The rates of repeat distraction were similar between the two groups (6.3% and 13.5%; p = 0.28). CONCLUSION: MDO is a safe and effective treatment modality for infants < 4 kg with severe airway obstruction. The efficacy, safety, and complication profiles are not significantly different from larger patients.

Agnathia-otocephaly complex (AOC) is characterized by mandibular hypo- or aplasia, ear abnormalities, microstomia, and microglossia. Though rare and often fatal, this is the first report detailing various reconstructive strategies beyond infancy as well as longitudinal follow-up into adulthood.All patients with AOC treated at our institution over a 30 year period were reviewed. Four patients were identified, one with agnathia, one with micrognathia. Two males with nanognathia (defined as a symphyseal remnant without body nor ramus) were also included. The mean follow-up was 17 years. All four underwent perinatal tracheostomy and gastrostomy-tube placement. Commissuroplasties were typically performed before 3 years of age and repeated as necessary to allow for oral hygiene. Mandibular reconstruction was most successful with rib between ages 3 and 8, after which time, free fibula transfer was utilized. Due to some resoprtion or extrusion, all patients underwent repeated bone grafting procedures. Tissue expansion of the neck was used to restore the lower third of the face, but was most successful in the teenage years. At last follow-up of the eldest patients, one was in college while another was pursuing graduate education.AOC need not be a fatal nor untreatable condition; a reasonable quality of life can be achieved. Although the lower-facial contour may be improved, and a stoma created, the lack of musculature make deglutition virtually impossible with current therapies. Just as transplantation has emerged as a modality for facial restoration following severe trauma, so too may it be a future option for congenital deformities.