Faculty Bibliography

BACKGROUND: Frontal sinus cranialization is commonly indicated for posterior table fractures with significant comminution, displacement, or cerebrospinal fluid leaks. This study assessed the clinical outcomes of conservative management. METHODS: A 10-year retrospective review of all frontal sinus fractures treated at a level 1 trauma center was performed using medical records and radiographic images. RESULTS: A total of 875 patients with frontal sinus fractures were identified, and 68 had posterior table involvement. Nine died within the first 48 hours from other injuries. The remaining 59 patients constituted the study population. Average follow-up approached 1 year (342 days). The more common mechanisms of injury were blunt interpersonal violence (29 percent) and motor vehicle accidents (27 percent). Concurrent central nervous system injury was common (73 percent), and the average Glasgow Coma Scale score was 12.7. Posterior wall fracture pattern was nondisplaced and noncomminuted in 33 patients (54 percent) and comminuted and/or displaced in 27 (46 percent). Cerebrospinal fluid leak was recorded in 11 patients (19 percent). Conservative management was the more common strategy (78 percent), followed by open reduction and internal fixation with sinus preservation (12 percent), obliteration (8 percent), and cranialization (2 percent). Of the 27 patients with comminuted and/or displaced fractures, 16 (59 percent) underwent conservative management, and 11 (41 percent) underwent surgical management, but only one patient (2 percent) underwent cranialization. There was no incidence of intracranial infection, except for one patient who died from encephalitis secondary to a gunshot wound to the head. CONCLUSION: The vast majority of frontal sinus fractures involving the posterior table, including those with comminution, displacement, or cerebrospinal fluid leaks, can be safely managed without cranialization. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

We review the literature on medial orbital wall fractures and perform a meta-analysis on outcomes with the transcaruncular approach. The reported incidence for this injury ranges widely, although diagnosis can be made effectively with clinical examination and computed tomography. Clinical sequelae can include rectus entrapment or herniation, enophthalmos, and diplopia. Local injuries occurring in high concordance include concomitant fractures of the orbital floor and nasal fractures, although anterior cranial fossa extension, ocular trauma, other craniofacial injuries, and polytrauma must be ruled out. Indications for operative intervention include large defects, early or persistent enophthalmos particularly if causing diplopia, and rectus muscle entrapment.Various surgical approaches to the medial orbit have been described; however, the transcaruncular approach offers direct, reliable access without creating a cutaneous scar on the central face. A meta-analysis was performed on all studies reporting outcomes of the transcaruncular approach. A total of 228 cases were pooled, finding a favorable overall complication rate of 2.6%. Half of these complications required surgical correction and half resolved nonoperatively.Medial orbital wall fractures are an increasingly appreciated injury requiring clinical and radiologic assessments. When indicated, reconstruction of the medial orbital wall can be safely and effectively performed with the transcaruncular approach. Additional prospective outcomes studies are required to elucidate (1) the incidence of medial orbital wall fractures, (2) indications for operative versus nonoperative management, and (3) outcomes analysis of the transcaruncular approach compared with other approaches.

BACKGROUND: Syndromic craniosynostosis is associated with a high incidence of elevated intracranial pressure. The most common treatment paradigm is to perform anterior cranial vault reconstruction in infancy followed later by possible expansion of the posterior cranial vault and midface advancement. Recently, however, posterior cranial vault expansion has been advocated as an initial step in treatment. We sought to quantify volumetric changes with anterior versus posterior cranial vault surgery in these patients. MATERIALS AND METHODS: We reviewed patients with syndromic brachycephalic craniosynostosis treated in our unit from 2002 to 2009 with existing preoperative fine-cut computed tomographic scans. Using computer software (Analyze; Mayo Clinic, Rochester, MN) and computed tomographic data, the senior author simulated both anterior and posterior cranial vault expansions. Expansion was simulated with a series of translational advancements of the separated segments. Volumetric data were compared for each simulated procedure. RESULTS: Thirteen patients underwent simulated cranial vault reconstructions. At 2, 10, and 20 mm of anterior advancement, the mean increase in intracranial volume was 1.8%, 8.8%, and 17.7%, respectively, whereas posterior advancements achieved 2.4%, 11.9%, and 23.9%, respectively. On average, posterior cranial vault reconstruction created 35% more relative expansion than anterior expansion at equivalent degrees of advancement (P < 0.001). In all simulations, posterior cranial vault reconstruction created greater intracranial volume changes than anterior reconstructions. CONCLUSIONS: This simulation demonstrates that, in syndromic brachycephalic craniosynostosis, posterior cranial vault advancement achieves approximately 35% greater intracranial volume expansion compared with equivalent degrees of anterior cranial vault advancement. This may help guide decisions in treatment sequencing of patients with syndromic craniosynostosis.

BioDigital Systems, LLC in collaboration with New York University Langone Medical Center Department of Reconstructive Plastic Surgery has created a complex, real-time, step-based simulation platform for plastic surgery education. These simulators combine live surgical footage, interactive 3D visualization, text labels, and voiceover as well as a high-yield, expert-approved testing mode to create a comprehensive virtual educational environment for the plastic surgery resident or physician.

BACKGROUND: Flexor tendon injuries are common problems faced by hand surgeons. To minimise the surgical trauma associated with localisation and retrieval of the proximal tendon end, we investigated the use of surgeon-performed ultrasound in the evaluation of injured flexor tendons in a cadaver model. Our goal was to use surgeon-performed ultrasound: (1) to correctly diagnose flexor tendon injuries and (2) to correctly localise the proximal tendon ends within 1cm. METHODS: Flexor tendon injuries with varying degrees of retraction were randomly created in individual digits of cadaver upper extremities, with a number of tendons left uninjured. A surgeon, blinded to the injury status of each digit, imaged each tendon by ultrasound. Predicted injury status of each tendon and localisation of the proximal stump was recorded. A total of 81 tendons were studied. FINDINGS: Correct diagnosis of flexor tendon injury was made in 78 of 81 tendons (96.2% success). Correct localisation of the proximal tendon stump was made in 39 of 50 lacerated tendons (78% success). Small finger injuries were most difficult to assess (66.7% success). With the small finger excluded from our analysis, the localisation success rate increased to 86.8%. The average time taken to image each digit was just under 2.5min. CONCLUSIONS: Surgeon-performed ultrasound evaluation of the hand is a reliable means to diagnose flexor tendon injuries and to accurately localise the proximal tendon ends. This imaging modality may limit the need for extensive surgical exploration during flexor tendon repair. We do not recommend using this technique to image flexor tendon injuries of the small finger at this time

BACKGROUND:: Three-dimensional digital animation can enable surgeons to create anatomically accurate, virtual models of normal and pathologic human anatomy. From these models, surgical procedures can be digitally performed, recorded, and distributed as a teaching tool or as a virtual surgical atlas. The idea of a virtual surgical atlas has recently become a part of contemporary surgical teaching. In the field of craniofacial surgery, no such educational tool exists. Presented is the first part of the creation of a virtual atlas of craniofacial surgical procedures: the three-dimensional digital modeling of pathologic deformities commonly treated by craniofacial surgeons. METHODS:: Three-dimensional craniofacial models were constructed using Maya 8.5. A skeletally 'normal' craniofacial skeleton was first produced from a preexisting digital skull using Bolton tracings as a reference. The remaining soft-tissue elements were then added to create an anatomically complete three-dimensional face. The 'normal' model was then deformed in Maya to produce specific craniofacial deformities using computed tomographic scans, cephalograms, and photographs as a reference. One of the craniofacial deformity models was created directly from computed tomographic data. RESULTS:: One model of the normal face and eight pathologic models of craniofacial deformities were created: microgenia, micrognathia, prognathia, temporomandibular joint ankylosis, maxillary hypoplasia, Crouzon syndrome with and without the need for cranial vault expansion, and bicoronal craniosynostosis. CONCLUSIONS:: For the first time, anatomically accurate three-dimensional digital models of craniofacial deformities have been created. The models are the first step in the creation of a virtual surgical atlas of craniofacial procedures

BACKGROUND:: Craniofacial surgery can be challenging to teach and learn. To augment the intraoperative learning experience for surgical trainees and to provide a resource for practicing craniofacial surgeons to review uncommonly performed procedures before entering the operating room, a series of three-dimensional animations were created encompassing the most commonly performed craniofacial procedures. METHODS:: Previously created three-dimensional craniofacial digital models were used to create digital animations of craniofacial surgical procedures using Maya 8.5. Digital models were altered systematically within Maya to recreate the ordered steps of each craniofacial procedure. Surgical tools were imported into Maya for use in the animations using computer-aided manufacturing files obtained directly from the manufacturer. RESULTS:: Nine craniofacial procedures were animated: genioplasty, bilateral sagittal split osteotomy, intraoral vertical ramus osteotomy, Le Fort I osteotomy, unifocal mandibular distraction, mandibular transport distraction, fronto-orbital advancement with cranial vault remodeling, Le Fort III advancement/distraction, and monobloc advancement/distraction. All major surgical steps are demonstrated, including exposure, execution of the osteotomy, displacement of the bone composite, and the predicted morphologic changes to the craniofacial contour. Throughout the surgical animation, the view of the surgeon in the operating room is incorporated to reproduce the vantage of the surgeon, and the overlying tissue is rendered transparent to illustrate critical underlying anatomical relationships. CONCLUSIONS:: The first virtual surgical atlas of craniofacial procedures is presented. These animations should serve as a resource for trainees and practicing surgeons in preparation for craniofacial surgical procedures

BACKGROUND: During cleft palate repair, levator sling palatoplasty with tensor veli palatini tendon transection significantly improves speech results. However, the procedure may pose a risk to eustachian tube function. This study assesses the impact of three types of palatoplasty techniques on eustachian tube function: no tensor transection, tensor transection alone, and a new addition to the palatoplasty technique, tensor tenopexy. METHODS: A retrospective review was conducted of all patients undergoing cleft palate repair at two institutions between 1997 and 2001. Three cleft palate repair groups were studied: no tensor transection (n = 64), tensor transection alone (n = 31), and tensor tenopexy (n = 52). The percentages of patients requiring myringotomy tubes at each year of age were compared among the three groups. RESULTS: By 7 years of age, there was a significantly decreased need for myringotomy tubes in patients who underwent no tensor transection compared with patients who underwent tensor transection alone (38 percent versus 61 percent, respectively; p = 0.05), as well as for patients who underwent tensor tenopexy compared with patients who underwent tensor veli palatini tendon transection (23 percent versus 61 percent, respectively; p < 0.001). Also, by the age of 7, there was a trend toward a decreased need for myringotomy tubes in patients who underwent tensor tenopexy compared with patients who underwent no tensor transection (23 percent versus 38 percent, respectively; p = 0.11). CONCLUSIONS: No tensor transection and tensor tenopexy significantly decrease the need for myringotomy tubes compared with tensor transection alone. There is a small decrease in the need for myringotomy tubes when comparing tensor tenopexy with no tensor transection

BACKGROUND:: The authors assessed the safety and efficacy of a novel cleft rhinoplasty procedure that combines an open rhinoplasty with the Dibbell and Tajima techniques. METHODS:: A single-surgeon, 10-year, retrospective review was conducted of all unilateral cleft lip rhinoplasties (n = 157). Nonsyndromic patients undergoing a combined open incision/Dibbell/Tajima procedure and who had follow-up of greater than 8 months were included. Thirty-five patients were identified. Standardized patient photographs were studied in 18 patients who had both preoperative and 1-year postoperative photographs. Farkas normal values were applied to the medial canthal distance; from this value, metric measurements of changes in alar base width, columellar height, and nostril apex height were derived. RESULTS:: There were no complications secondary to skin envelope ischemia or cartilage graft infection. The revision rate was 11 percent for alar base position, 3 percent for depressed lower lateral cartilage, and 3 percent for nostril apex overhang. After the procedure, there was a statistically significant decrease in alar base width (19.9 mm versus 18.2 mm; p < 0.01) and an increase in columellar height (8.37 mm versus 9.59 mm; p = 0.02) and nostril apex height (4.70 mm versus 5.44 mm; p = 0.02) on the affected side. The differences in alar base width, columellar height, and nostril apex height between the affected and nonaffected sides all decreased significantly postoperatively. CONCLUSIONS:: The combined open rhinoplasty/Dibbell/Tajima procedure is safe, has a low revision rate, and is associated with a statistically significant decrease in alar base width, an increase in columellar height and nostril apex height, and a greater symmetry of nasal form