Faculty Bibliography

BACKGROUND: Obstructive sleep apnea syndrome (OSAS) is often found in children affected by congenital or acquired craniomaxillomandibular malformations. This disease carries different levels of risk, ranging from attention problems at school to growth problems and serious disorders, such as cor pulmonale or sudden infant death. The examination that is most commonly used to evaluate the severity of OSAS is polysomnography, and the therapeutic course is often determined by the disease state. Considering the discrepancy between clinical history and polysomnographic findings, we felt the need to identify an instrument for evaluating OSA to be used as a support for polysomnography. MATERIALS AND METHODS: This study was carried out on pediatric patients affected by congenital or acquired craniomaxillofacial malformations. We selected 34 pediatric patients, including 15 boys and 19 girls, aged between 1 and 16 years, with a mean age of 7.3 years. The study consisted of individuation of common clinical history data obtained from each patient and associating those data with the level of OSA severity identified by polysomnography. We were able to isolate certain symptoms and signs that can be predictive of OSA from research in the literature and our clinical experience with pediatric patients. In the clinic, we have found that the clinical history, given by the parents, often differs significantly from the instrumental findings obtained with polysomnography. From the previously expressed considerations and comparison of clinical history data and questionnaires, we have extracted the most significant questions for our questionnaire, which are present in the literature but formulated for adults. RESULTS AND CONCLUSIONS: The obstructive airway child test was found to be a very efficient method to evaluate and diagnose OSA. In all patients, it consistently revealed the pathology and never underestimated OSA severity. The examination focuses on clinical signs and symptoms because, in our opinion, clinical history, reported by the parents, can be more accurate than any instrumental examination.

BACKGROUND: : The senior author routinely performs primary nasal reconstruction with every cleft lip repair. This addresses the nasal tip asymmetry and simplifies the definitive secondary rhinoplasty in adolescence. METHODS: : A retrospective chart review was completed of all unilateral cleft secondary rhinoplasties performed by the senior author. The indications for secondary rhinoplasty were examined, anatomical features of the nose at the time of operation were documented, and the reconstructive techniques used were recorded. RESULTS: : From 2001 to 2009, the senior author performed 116 secondary rhinoplasties in patients with a previously repaired unilateral cleft lip. The senior author performed 44 of the initial cleft lip repairs (group A). A Dibbell rhinoplasty was required in 26 percent, a Potter rhinoplasty was required in 5 percent, a Tajima inverted-U incision was required in 70 percent, and an alar base resection was required in 53 percent. For those patients who did not undergo cleft lip repair with primary rhinoplasty by the senior author, 60 percent required a Dibbell rhinoplasty, Potter rhinoplasty was not used, 76 percent required a Tajima inverted-U incision, and 64 percent required an alar base resection. Group A had significantly greater dome symmetry when comparing the cleft side to the noncleft side (p = 0.001). Nostril apex height was also more symmetrical in group A (p = 0.105). CONCLUSION: : Primary nasal reconstruction performed with cleft lip repair as described by the senior author makes the nasal tip more symmetric and requires less complex intervention at the time of definitive secondary rhinoplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

A 6-year-old girl presented with a large recalcitrant oronasal fistula after bilateral cleft lip and palate repair and numerous secondary attempts at fistula closure. Incomplete palmar arches precluded a free radial forearm flap. A free vastus lateralis muscle flap was successfully transferred. No fistula recurrence was observed at 18 months. There was no perceived thigh weakness. The surgical scar healed inconspicuously. Free flaps should no longer be considered the last resort for treatment of recalcitrant fistulas after cleft palate repair. A free vastus lateralis muscle flap is an excellent alternative, and possibly a superior option, to other previously described free flaps.

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.

BACKGROUND: Clinical vascularized composite allografts (VCA), although performed with good success, have been characterized by rejection episodes and postoperative graft edema. We investigated lymphatic donor-recipient reconstitution and lymphatic regeneration in a nonhuman primate facial VCA model. METHODS: Heterotopic partial face (n = 9) VCAs were performed in cynomolgus macaques. Grafts were monitored for rejection episodes and response to immunosuppressive therapies as previously described. Donor and recipient lymphatic channels were evaluated using a near-infrared handheld dual-channel light-emitting diode camera system capable of detecting fluorescence from indocyanine green injections. Graft lymphatic channels were serially evaluated from postoperative day 0 to 364. RESULTS: Preoperative imaging demonstrated superficial lymphatic anatomy similar to human anatomy. Initial resolution of facial allograft swelling coincided with superficial donor-recipient lymphatic channel reconstitution. Reconstitution occurred despite early acute rejection episodes in 2 animals. However, lymphatic channels demonstrated persistent functional and anatomic pathology, and graft edema never fully resolved. No differences in lymphatic channels were noted between grafts that developed transplant vasculopathy (n = 3) and those that did not (n = 6). Dynamic changes in patterns of lymphatic drainage were noted in 4 animals following withdrawal of immunosuppression. CONCLUSIONS: Donor-recipient lymphatic channel regeneration following VCA did not result in resolution of edema. Technical causes of graft edema may be overcome with alternative surgical techniques, allowing for direct investigation of the immunologic relationship between VCA graft edema and rejection responses. Mechanisms and timing of dynamic donor-recipient lymphatic channel relationships can be evaluated using fluorescent imaging systems to better define the immunologic role of lymphatic channels in VCA engraftment and rejection responses, which may have direct clinical implications.

BACKGROUND:: Despite increasing specialization of craniofacial surgery, certain craniofacial techniques are widely applicable. The authors identified five such craniofacial techniques and queried American Society of Plastic Surgeons members and plastic surgery program directors regarding their comfort level with the procedures and their opinion on resident training for these selected procedures. METHODS:: First, a select group of senior craniofacial surgeons discussed and agreed on the top five procedures. Second, active American Society of Plastic Surgeons were surveyed regarding their opinion on training and their comfort level with each procedure. Third, plastic surgery residency program directors were studied to see which of the top five procedures are taught as part of the plastic surgery residency curriculum. RESULTS:: The top five widely applicable craniofacial procedures are technically described and include the following: (1) cranial or iliac bone graft for nasal reconstruction, (2) perialar rim bone graft, (3) lateral canthopexy, (4) osseous genioplasty, and (5) bone graft harvest for orbital floor defects. For practicing plastic surgeons, comfort level in all procedures increased with advancing years in practice (except those with <5 years). A majority of plastic surgeons (>75 percent), especially those with craniofacial fellowship training, felt competent in all procedures except osseous genioplasty (53 percent). Plastic surgery program directors agreed that all top five procedures should be mastered by graduation. CONCLUSIONS:: Although program directors felt that all five selected craniofacial procedures should be taught and mastered during residency training, plastic surgeons without craniofacial fellowship training were less comfortable with the techniques. Residency training goals should include competence in core craniofacial techniques.

The present investigation hypothesized that the reliability of reduced-thickness monolithic lithium disilicate crowns is high relative to that of veneered zirconia (Y-TZP) and comparable with that of metal ceramic (MCR) systems. CAD/CAM first mandibular molar full-crown preparations were produced with uniform thicknesses of either 1.0-mm or 2.0-mm occlusal and axial reduction, then replicated in composite for standard crown dies. Monolithic 1.0-mm (MON) and 2.0-mm CAD/CAM lithium disilicate crowns, the latter with a buccal thin veneer (BTV) of 0.5 mm, were fabricated and then sliding-contact-fatigued (step-stress method) until failure or suspension (n = 18/group). Crack evolution was followed, and fractography of post mortem specimens was performed and compared with that of clinical specimens. Use level probability Weibull calculation (use load = 1,200 N) showed interval overlaps between MON and BTV. There was no significant difference between the Weibull characteristic failure loads of MON and BTV (1,535 N [90% CI 1,354-1,740] and 1,609 N [90% CI 1,512-1,712], respectively), which were significantly higher than that of Y-TZP (370 N [90% CI 322-427]) and comparable with that of MCR (1,304 N [90% CI 1,203-1,414]), validating the study hypothesis.