Faculty Bibliography

We present 6 patients who do not satisfy the criteria for inclusion into any known diagnostic group, although they share similar physical findings. All had facial findings suggestive of either mild deformational plagiocephaly or craniofacial microsomia; however, hypertrophic and occasionally hyperactive muscles of the face appear to be the unifying and distinctive feature of the group. Contraction of hypertrophic postauricular muscles on the affected side resulted in movement and contraction of the pinna. Hypertrophy of the mentalis and masseter muscles was also frequently observed. Additionally, anomalous neck musculature was seen in 4 of the 6 patients. In 2 patients, the hypertrophy of certain of these muscles produced enough deformity to warrant excision. This is the first report of such an association in the literature. Possible explanations are discussed

OBJECTIVE: The purpose of this study was to evaluate if narrowing and approximation of the alveolar cleft through presurgical alveolar molding followed by gingivoperiosteoplasty (GPP) at the time of lip repair reduces the need for a bone-grafting procedure. DESIGN: This was a retrospective blind study of patients with unilateral or bilateral alveolar clefts who underwent presurgical infant alveolar molding and GPP by a single surgeon. Alveolar bone formation was assessed prior to the eruption of the maxillary lateral incisor or canine by clinical examination, panoramic and periapical radiographs, and/or a dental CT scan. The criterion for bone grafting was inadequate bone stock to permit the eruption and maintenance of the permanent dentition. SETTING: This study was performed at the Institute of Reconstructive Plastic Surgery by the members of the Cleft Palate Team. PATIENTS: All patients with unilateral (n = 16) or bilateral (n = 2) alveolar clefts who underwent presurgical infant alveolar molding and GPP by a single surgeon from 1985 to 1988 were studied. The control population consisted of all alveolar cleft patients (n = 14) who did not undergo alveolar modeling or GPP during the same time period. INTERVENTIONS: Presurgical alveolar modeling was performed with an intraoral acrylic molding plate. This plate was modified on a weekly basis to align the alveolar segments and close the alveolar gap. The surgical intervention consisted of a modified Millard GPP. MAIN OUTCOME MEASURES: The primary study outcome measure was the elimination of the need for a secondary bone graft in patients who underwent presurgical alveolar molding and GPP. RESULTS: Of the 20 sites in the 18 patients who underwent GPP, 12 sites did not require an alveolar bone graft. Of the 8 sites requiring a bone graft, 4 presented minimal bony defects. All 14 patients in the control group required bone grafts. CONCLUSIONS: In this series of 20 alveolar cleft sites treated with presurgical orthopedics and GPP, 60% did not need a secondary alveolar bone graft in the mixed dentition

An ongoing goal of aesthetic surgery is a reduction in complications and an improvement in reproducibility and speed. Balloon dissector devices have been used in other areas of surgery to achieve these goals. This report presents early clinical experience using a balloon dissector to elevate the skin flap in facialplasty. The first step in the technique is the creation of a tunnel from a small preauricular incision toward the oral commissure using scissors dissection. The balloon device is inserted into this tunnel and inflated. Unrolling the device elevates the skin flap in the cheek and neck area. Retroauricular dissection and final adjustment of flap size and shape is completed sharply. Subsequent superficial musculoaponeurotic system flap development, skin redraping, and closure is performed in a conventional fashion after customary facialplasty incisions are made. Comparison of complications, postoperative drainage, and time required for dissection and for hemostasis was made between a balloon-dissected side and a conventionally dissected side in 10 patients undergoing facialplasty. Ten additional patients were treated with balloon dissection bilaterally. Patients ranged in age from 45 to 73 years. Mean balloon dissection time was 1.4 minutes (range, 0.75-4 minutes). This produced an even flap thickness in the correct plane with few if any bleeding points. Mean total dissection time on the balloon side was significantly shorter-13.6 minutes-compared with 27.8 minutes (p < 0.003) on the conventional side. Mean difference in time to hemostasis between conventional and balloon sides was 3.8 minutes (p < 0.001). Mean total postoperative drainage (all drains removed at 24 hours) was 13.8 cc on the balloon side and 18.8 cc on the conventional side (not significant, p=0.08). Less ecchymosis and swelling was observed on the balloon side compared with the scissors-dissected side. There were no skin losses, hematomas, infections, or nerve injuries on either side. Appearance of skin redraping was comparable on each side in all patients. Balloon dissection represents a promising alternative means of creating rapid, reproducible skin flap elevation in facialplasty, and is associated with a minimum of bleeding, ecchymosis, and swelling

We present the management challenge provided by a patient with kaposiform hemangioendothelioma associated with Kasabach-Merritt phenomenon. A female child presented at 14 months of age with an ecchymotic swelling of her right upper arm and axilla. Subsequently, she developed profound thrombocytopenia and hypofibrinogenemia (Kasabach-Merritt phenomenon). Biopsy of the lesion revealed kaposiform hemangioendothelioma, which has been reported as the predominant pathologic diagnosis associated with Kasabach-Merritt phenomenon. To achieve involution of the lesion and preserve function of the arm, the following interventions were involved: embolization, systemic interferon, cyclophosphamide, epsilon aminocaproic acid, and compression therapy. The clinical management of this patient was formidable until we arrived at the proper combination of therapies. Multimodal intervention may be required to manage fastidious hemangioendotheliomas of childhood, achieve clinical improvement, and prevent further morbidity

The influence of dura mater on adjacent cranial sutures is significant. By better understanding the mechanisms of normal suture fusion and the role of the dura mater, it may be possible to delineate the events responsible for the premature suture fusion seen in craniosynostosis. In the Sprague-Dawley rat, the posterior frontal suture normally fuses between 12 and 20 days of postnatal life and has proved to be an excellent model to describe normal suture fusion. The purpose of this study was to document the critical role that the dura mater-suture complex may play on cranial suture biology. Forty Sprague-Dawley rats at 8 days of age were divided into two groups of 20 animals each. The control group (group A) had surgical disruption of the dura mater-calvarial interface. This was accomplished by elevating a strip of cranium inclusive of the posterior frontal and sagittal sutures and replacement of the cranial strip back to its anatomic position, all with the dura mater left intact. The experimental group (group B) had the same calvarial elevation (strip craniectomy), but the sutural anatomy/alignment was rotated 180 degrees. This rotation placed the posterior frontal suture into the sagittal suture's anatomic position and the sagittal suture into the posterior frontal suture's anatomic position. All of these procedures were accomplished by leaving the underlying dura mater intact. Animals were killed at 20, 30, 40, and 50 days (12, 22, 32, and 42 days postoperatively), and tissue sections were examined with hematoxylin and eosin staining. Group A (control) showed normal but delayed suture activity. The posterior frontal suture fused, and the sagittal suture remained patent. Fusion was delayed, not beginning before 20 days (12 days postoperative) and showing complete fusion between 30 and 40 days. Group B (180-degree calvarial rotation) demonstrated that the suture in the posterior frontal anatomic position (actual sagittal suture) fused between 20 and 40 days, whereas the suture in the sagittal anatomic position (actual posterior-frontal suture) remained patent throughout the study. This study demonstrates that the location of the dura mater-suture complex is important in determining either suture patency or closure in this model. Normal closure of the suture overlying the posterior frontal dura mater demonstrates that the dura mater itself, or forces derived in specific cranial locations, determines the overlying suture biology

Regional blocking techniques as noted in dentistry, anesthesia, and anatomy texts may result in inconsistent and imperfect analgesia when needed for facial aesthetic surgery. The advent of laser facial surgery and more complicated aesthetic facial procedures has thus increased the demand for anesthesia support. Surgeons should know a fail-safe method of nerve blocks. Fresh cadaver dissections are used to demonstrate a series of eight regional nerve-blocking routes. This sequence of bilateral blocks will routinely provide profound full facial anesthesia. Certain groupings of blocks are effective for perioral or periorbital laser surgery

OBJECTIVES: Delineation of clinical characteristics affecting the airway in a cohort of craniofacially deformed children. What factors differ between patients requiring and those not requiring surgical airway intervention? What factors predispose to the need for tracheotomy? When can decannulation be expected if tracheotomy is required? What interventions aid decannulation? STUDY DESIGN: Five-year retrospective chart review at tertiary center. METHODS: Two hundred fifty-one patients met the following entry criteria: enrollment in the New York University Institute of Reconstructive and Plastic Surgery's Craniofacial Clinic and admission to Tisch Hospital in Manhattan for surgery from 1990 to 1994. Hospital, clinic, and departmental office records were reviewed. All patients had major craniofacial bony anomalies and underwent administration of general anesthesia at least once. RESULTS: Nearly 20% of all children required tracheotomy (47/251). Craniofacial synostosis patients (Crouzon, Pfeiffer, or Apert syndrome) had the highest rate of tracheotomy (48% [28/59]). Mandibulofacial dysostoses patients (Treacher Collins or Nager syndrome) had the next highest rate (41% [28/59]). Patients with oculo-auriculo-vertebral sequence were less likely to undergo tracheotomy (22% [9/41]). Children with craniosynostosis rarely required a surgical airway, unless there was marked associated facial dysmorphism (1% [1/72]). The duration of cannulation was related to the age at tracheotomy in a bimodal distribution. Generally, tracheotomies required before age 4 years remained for several years, whereas those placed after age 4 were removed after several weeks. The presence of a cleft palate correlated with reduced risk for tracheotomy, but the presence of a ventriculoperitoneal shunt correlated with an increased risk for tracheotomy. Procedures selectively used to improve the airway included midface advancement, mandibular expansion, tonsillectomy and adenoidectomy, uvulopalatopharyngoplasty, anterior tongue reduction, and endoscopic tracheal granuloma excision. CONCLUSIONS: The likelihood for surgical airway management is related to specific craniofacial diagnosis. The length of tracheal cannulation is greatest for infants and young children who manifest severe airway compromise, often because of nasal obstruction in combination with other anatomic factors. Early tracheotomy is advocated for these patients to promote optimal growth and development. Choanal atresia is often misdiagnosed in these infants; nasal obstruction is actually secondary to midface retrusion. Staged surgical interventions can allow eventual successful decannulation in nearly all cases of craniofacial syndromes

Distraction osteogenesis is the current method of choice for bone lengthening. Despite the gain in experience, various complications are reported, among them, adverse effects on peripheral-nerve function. In order to thoroughly investigate the effect of distraction on neural tissue, a distraction osteogenesis model in the rat was established, using the femur of 30 Sprague-Dawley rats. The animals were randomized in three groups, following different rates of distraction (0.5 mm, 1.0 mm, and 1.5 mm/day) for 50, 25, and 16 days, respectively, so that the final length of distraction was the same in all groups. The mean sciatic function index ranged near normal in all groups. All groups demonstrated decrease of conduction velocity and the area under the curve of the compound action potential, while morphologic alterations consisted of decrease in the number of axons and evidence of active degeneration. Animals in Groups 1 (0.5 mm/day) and 2 (1 mm/day) displayed comparable changes, while in Group 3 animals (1.5 mm/day), changes were significantly more adversely dramatic. The safest and fastest rate of distraction in this rat model was determined to be 1 mm/day