Faculty Bibliography

Background/Purpose: Craniofacial surgery remains a challenging field to learn and master. We present a freely-available internet-based multimedia simulator for craniofacial surgery designed as a resource of surgeons in craniofacial fellowship training. Methods/Descriptions: Previously constructed digital animations of craniofacial surgery were upgraded in Maya 10 (Autodesk, San Rapheal, CA) in preparation for web-based simulation. These animations were exported into an internet cloud-based, surgical simulator produced by BioDigital Systems Inc. (New York, NY). High-definition intra-operative video recordings of all procedures were edited in Adobe Premiere CS5.5 (Adobe, San Jose, CA) and exported into the simulator with the addition of voiceover. Test questions were produced for each surgical module. Results: Nine craniofacial surgery procedures are demonstrated in this interactive surgical simulator. Through a customized digital interface the user can manipulate the 3D simulations in real-time including the ability to alter perspective, pace and order of the virtual operation. High-definition intra-operative video footage compliments the critical steps of each procedure demonstrated in the simulation. A voiceover and text guides the user through each tutorial. A test is included at the end of each simulation. As the simulator is internet-based, there is no need for specialized software or downloads and simulator upgrades are immediately available to all users. Access is zero cost and the tutorial can be viewed on a modern laptop or desktop computer with a current web-browser. Conclusions: We present the first internet-based surgical simulator of craniofacial surgery. This freely available resource capitalizes on recent improvements in internet capability to produce an interactive virtual surgical environment for students and teachers of craniofacial surgery. This free simulator is designed as an educational resource for the next generation of craniofacial surgeons

Background/Purpose: The complicated nature of craniofacial procedures can be difficult for patients and families to understand. Patients and families undergoing treatment for facial differences may, understandably, find the process overwhelming, as consultations are often scheduled with multiple members of the Craniofacial Team. Furthermore, a plethora of online (mis)information, commonly turns the consultation into a clarification session, rather than an opportunity to educate and address concerns. In order to provide a dependable resource for patients and families, we introduce a multi-media education portal for craniofacial surgical procedures. Methods/Descriptions: Postoperative interviews of adult-aged patients and parents of school-aged patients were performed to determine specific information that would have been useful upon consultation regarding their craniofacial surgery and the recovery process. Based on interview responses, the authors developed a free, multimedia educational portal. Previously constructed craniofacial digital animations were edited and upgraded in Maya 10 (Autodesk, San Rapheal, CA) and uploaded into the cloud-based multimedia portal. Voice-over, text and video were also created based on patient and parent instruction. Patient feedback was obtained on preliminary versions to further refine the portal. Results: An online portal has been designed to describe six common and complex craniofacial surgery procedures: Le Fort I, Le Fort III, Bilateral Sagittal Split Osteotomy, Monobloc, Genioplasty, Fronto- Orbital Advancement with Cranial Vault Remodeling. For each procedure, a brief text/voice-over description of the objectives of the surgery is followed by a schematic, yet anatomically accurate, threedimensional animation of the operation with voice-over narration. Then, a detailed description of the recovery process precedes video interviews of patients and families discussing their experiences. A portable document format (PDF) file is available for download with more detaied reading material related to each procedure. Conclusions: We introduce an online multimedia education portal containing scrutinized, sound, and procedure-specific information for patients and families undergoing craniofacial surgery. This freely available resource is intended to supplement preoperative consultation with the craniofacial team and may prove a powerful tool for patients and families undergoing the stressful process of facial reconstruction

Background/Purpose: Patients with cleft lip and palate commonly require an alveolar bone graft (ABG) at approximately 8 years old to allow for tooth descent in the location of the alveolar cleft. This procedure was previously performed with at least one post-operative overnight stay due to hip pain. Upon transitioning from an open iliac crest bone harvesting technique to an Acumed drill, we observed that most patients had limited hip pain and were treatable as outpatients. We report feasibility and cost analysis of performed ABG surgery as an outpatient using the Acumed drill technique. Methods/Descriptions: Under IRB-approval, a 3-year retrospective review was conducted of all subjects born with a cleft lip/palate (CLP) and who had an alveolar bone graft performed between 2012 and 2015. Patients were categorized based upon hospital stay: inpatient (overnight stay), observation (23-hour), or outpatient. Prior to April 2013, patients underwent ABG surgery as a planned inpatient procedure (Group 1). After April 2013, patients underwent ABG surgery as a planned outpatient procedure (Group 2). Cost data acquired included: total direct cost (costs associated directly with patient care), total variable direct cost (costs which vary according to the needs of each patient), fixed direct cost (charges that do not fluctuate depending on what is done), and the sum of total direct costs for both medical/surgical supplies and operating room costs. T-tests were used to determine differences in various cost categories between groups of patients. Results: 58 patients were enrolled with a total of 62 procedures (4 patients had 2 ABGs), and with a mean age of 10 years at the time of surgery. 7 procedures were inpatient, 16 were observation, and 39 were outpatient. 7 of 14 Group 1 patients (50%) were admitted as inpatients, whereas 0 of 48 Group 2 patients were inpatients. The total direct costs averaged $4,536 for inpatients, $3,222 for the observation group, and $3,340 for the outpatient group. These inpatient and outpatient costs were significantly different (p<.001). There were significantly reduced total variable direct costs (p<0.05) and fixed direct costs (p<0.001) when comparing the outpatient to inpatient groups. Costs for the observation group were significantly lower in all three cost categories than inpatient costs, but were not significantly different than outpatient costs. Of the 39 outpatient procedures, no patients visited urgent care within 30 days postoperatively, and observation group had two patients visit urgent care. None were readmitted in any group. Conclusions: In ABG surgery done on patients born with a CLP, the costs for an inpatient stay are significantly higher than those of patients discharged the same day or who stay in the hospital for less than 23 hours on observational status. The Acumed drill technique results in improved pain control with no appreciable harms to the outpatient group, allowing for same day discharge

BACKGROUND: Titanium cranioplasty is commonly used for surgical closure of skull defects post craniectomy. Superficial implantation of the mesh can result in discomfort, palpability, and in extreme patients, exposure of the mesh. Exposed titanium mesh can be complicated by infections and often requires implant revision or removal. Generally, the contour of the titanium mesh is camouflaged in the hairline of the patient and any aesthetic complication can remain inconspicuous. However, in the frontal bone position the thin hairless forehead skin often may not easily hide the contour of the underlying titanium mesh. OBJECTIVES: The goal of this study was to demonstrate the usage of an alloderm covering over the titanium cranioplasty to possibly minimize the contour irregularities of titanium. SURGICAL TECHNIQUE: Our index patient, a 22-year-old woman, was operated for left frontal craniectomy for frontal bone tumor extending to brain parenchyma. This resulted in a surgical defect that was repaired with titanium mesh cranioplasty and dural patch. It was felt that the patient would potentially feel and see the titanium mesh cranioplasty under the thin frontalis muscle. Therefore, over top of the titanium mesh a remnant piece of AlloDerm unused after the dural patch was placed to buffer the potential contour deformity. Postoperatively, the contour appears natural and the patient does not report any complaints of discomfort or mesh palpability. CONCLUSION: In a thin-skinned patient undergoing titanium mesh cranioplasty, the risk of mesh palpability or exposure can be significant, especially in areas of non-hair-bearing scalp and the protruding areas of the skull. Alloderm covering over the titanium mesh can provide improved aesthetic outcomes by minimizing contour deformity and may serve as an additional buffer in thin scalp.

Background/Purpose: NasoAlveolar molding (NAM) is employed to reduce the severity of nasolabial deformity in the weeks prior to the primary surgical repair of patients with UCLP and BCLP. There is considerable interest among clinicians as to the impact that NAM may have on mid face growth. The purpose of this study was to determine the effect of NAM on growth of the mid face in patients with nonsyndromic UCLP at approximately 9 years of age. Methods/Descriptions: This retrospective cohort study includes 61 consecutive non syndromic Caucasian patients with UCLP, ages 6-11 years, treated with NAM. 28 cephalometric hard and soft tissue landmarks were identified and measured by two examiners. For comparison, cephalometric measurements were obtained from the Eurocleft centers (n=56) that did not utilize pre-surgical infant orthopedics (Non-PSIO). Meta-analysis was used to derive an average expected result from these trials. Student's t-tests were used to compare means from NAM-prepared patients with meta-analytic averages derived from the Eurocleft centers that did not utilize presurgical infant orthopedics (n=56). Results: On average, no significant differences were found between the NAM-prepared group and the Eurocleft centers that did not utilize NAM on the following hard and soft tissue cephalometric relationships: SNA, ANB, A'N'B' (soft tissue), nasolabial angles (CT-Sn-LS), and ANS-Me/N-Me% measurements. Conclusions: On average, no significant differences were found between the NAM prepared group and the Eurocleft centers that did not utilize presurgical infant orthopedics in the SNA, ANB, A'N'B', nasolabial angles (CT-Sn-LS), and ANS-Me/N-Me% measurements. An in depth comparison of all corresponding variables for the NAM and Non-PSIO groups will be reported. In conclusion, NAMhas no apparent long-term (age 9 years) negative or positive effect on skeletal or soft tissue facial growth in this comparison to the outcomes of Eurocleft non-PSIO treatment centers for children with non-syndromic UCLP

Background/Purpose: Septal deviation is a common finding in skeletally mature patients with cleft lip and palate (CL/P), however the contribution of the cartilaginous and bony septum to airway obstruction is poorly defined. This study characterizes the septal and airway anatomy in skeletally mature patients with CL/P utilizing cone beam computed tomography (CBCT) and will help guide airway management of this patient population at the time of definitive rhinoplasty. Methods/Descriptions: This is a retrospective single institution review of all CL/P patients over the age of 15 who have undergone CBCT analysis. Septal deviation was measured in coronal sections of CBCT scans at the cartilaginous septum [anterior nasal spine (ANS)], and bony septum [posterior nasal spine (PNS) and midpoint between the ANS and PNS (MID)]. Airway obstruction was defined as the smallest linear distance between nasal septum and adjacent turbinate and was similarly measured at all three points. Superior (perpendicular plate of ethmoid) and inferior (vomer) bony septal displacement was measured as an angle from vertical at the coronal slice of maximal septal deviation. CL/P patients were compared to age-matched controls using Student's t-test. Stepwise multivariable linear regression was used to compare septal deviation to obstruction. Measurements were performed by two separate raters and interrater reliability was assessed using Pearson's r coeffecient. Statistical significance was held at p<0.05. Results: 24 CL/P patients and 16 age-matched controls were identified for the study. Interrater reliability for 210 independent measurements was r=0.94 (p<0.0001). Results are reported as CL/P versus control. Septal deviation was significantly increased at the ANS (2.1+/-2.2 mm vs 0.7+/-1.0 mm, p=0.03), MID (4.6+/-3.1 mm vs 2.2+/-1.2 mm, p=0.01), and PNS (2.9+/-1.8 mm vs 1.0+/-0.6 mm, p=0.0002). The airway was significantly obstructed at the ANS (1.8+/-0.8 mm vs 2.3+/-0.6 mm, p=0.03). Maximal septal deviation occurred at the bony septum in 39 of 40 patients. Both the perpendicular plate of the ethmoid (14+/-7.8degree vs 8.0+/-5.4degree, p=0.01) and vomer (25+/-15degree vs 9.0+/-7.9degree, p=0.0006) were significantly displaced from vertical. Midpoint bony septal deviation was a good predictor of anterior nasal airway obstruction (r=-0.525, p=0.008). Conclusions: Skeletally mature patients with a cleft demonstrate severe septal deviation which includes both cartilage and bone. Resection of the bony and cartilaginous septum should be considered at time of definitive rhinoplasty in CL/P patients

Background/Purpose: Treacher Collins (TC) and Robin Sequence (RS) are both associated with a retrognathic mandible, glossoptosis, and airway obstruction. TC is associated with aberrations of the lower jaw, upper jaw and nasal airway in a manner distinct from RS. Although in both TC and RS, airway obstructions in severe cases may benefit from mandibular distraction (MDO), the different pathophysiology suggests MDO to be less successful in TC compared to the current literature on RS. The purpose of this study is to report on the clinical outcomes of tracheostomy removal utilizing MDO in the TC patient population. Methods/Descriptions: A single center, twenty-year retrospective review (1991-2010) was conducted of all patients with TC treated with MDO. Recorded variables included: age of MDO, number of MDO procedures, presence of tracheostomy and complications. Literature review of clinical outcomes of MDO in the RS population demonstrates age of MDO of under one year, average on distraction per patient and avoidance of tracheostomy in over 90% of patients. Results: 24 patients with TC who underwent MDO were included in our analysis. The follow up time was 9.2 years (range1.7-17 years). The mean age of the first MDO was 4.97 years. The mean number of distractions was 1.42 with 46% of patients who had more than onedistraction attempted. The distraction devices used were external in 67% and internal in 33% of cases. 19 patients (79%) had a tracheostomy prior to MDO and only 9 (47%) patients were decannulated within one year of distraction. An additional 5 patients were decannulated several years later after further distraction and other airway procedures. Complications were divided into major (ankylosis, device failure) moderate and minor (pin infection, hypertrophic scar). Overall, 67% of TC patients had at least one complication with 41% having major complications. There was a 20% incidence of TMJ ankylosis. Conclusions: Compared to the RS population, TC patients undergo MDO at a later age, require more distraction and have less successful decannulation. Further surgery is required to effectively treat airway obstruction. The incidence of major complications

PURPOSE: To describe an unusual case of pediatric iris melanocytoma with pigment dispersion glaucoma that resolved after resection of the primary tumor. METHODS: Retrospective case review of the clinical record, ultrasonographic images, and histopathology. RESULTS: A 6-year-old Asian girl, with a dark iris tumor, pigment dispersion, and secondary glaucoma, was initially treated with topical antiglaucoma medication and observation. Rapid growth prompted biopsy, revealing melanocytoma. As the tumor continued to grow, excision of the primary tumor was performed. Surgery proved curative in that the pigment dispersion slowly reabsorbed and her glaucoma resolved. CONCLUSIONS: In this case, rapid growth did not indicate malignant transformation. Initial observation for growth and judiciously timed surgical intervention prevented progression, loss of vision, and potentially the loss of the eye.

OBJECTIVE: There exist inherent problems with previously described classification schemes for head and neck lymphatic malformations in children and lack of guidance for management. An organization scheme and management recommendations are proposed to improve communication between health care providers. STUDY DESIGN: Consecutive patient series with a chart review of children with head and neck lymphatic malformations. SETTING: Tertiary-care, academic children's hospital. METHODS: Children with lymphatic malformations of the head and neck were included. A proposed organization system for head and neck lymphatic malformations in children was developed and compared to 2 others currently predominantly used, de Serres and Cologne Disease Score. RESULTS: Seventeen patients were identified, 7 boys and 10 girls. The mean age was 64.4 months (range 0.89-185.5). Nine patients (52.9%) were managed expectantly, 5 (29.4%) with sclerotherapy with 1 awaiting treatment (5.9%), and 2 (11.8%) with surgical excision. All children who underwent active treatment with surgery or sclerotherapy were managed successfully. No treatment-related complications were encountered, and no children managed with watchful waiting/expectant management experienced failure. The proposed staging system differed from the de Serres stage in 11 children (64.7%), with 9 (81.8%) being down staged and 2 (18.2%) up staged. Cologne Disease Score ranged from 2 to 10, with only 1 (5.9%) patient with a score of 3 or less (severe disease). CONCLUSIONS: Treatment recommendations in children with head and neck lymphatic malformations should be individualized. Weaknesses of currently used staging systems are discussed as well as considerations for management decisions.