Publications by authors named "Ian Hoppe"

59 Publications

Pediatric Palate Fractures: An Assessment of Patterns and Management at a Level 1 Trauma Center.

Craniomaxillofac Trauma Reconstr 2021 Mar 7;14(1):23-28. Epub 2020 Jul 7.

Division of Plastic and Reconstructive Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.

Study Design: Literature discussing palate fractures in the pediatric population is limited. We performed a retrospective review of pediatric palatal fractures at our institution to better understand the impact of this fracture pattern in the pediatric patient.

Objectives: The goal of our study is to analyze our institutional experience with pediatric palate fractures, focusing on epidemiology, concomitant injuries, and fracture management.

Methods: Records were collected for all palatal fractures in pediatric patients diagnosed between 2000 and 2016 at an urban Level I trauma center. Patient imaging was reviewed. Demographic characteristics and inpatient clinical data were recorded.

Results: Nine pediatric patients were diagnosed with fracture of the bony palate. Average age was twelve with male predominance (66%). Pedestrian struck injuries (33%) and motor vehicle accidents (33%) were the most common etiologies. Five patients sustained skull fractures. Three patients were found to have intracranial hemorrhage, two required emergent bolt placement. Two patients sustained cervical spine injury. One patient had severe facial hemorrhage requiring embolization. According to the Hendrickson classification, there were three type I fractures, two type II fractures, one type III fracture, one type IV fracture, and one type V fracture. Lefort I and/or alveolar fracture was present in every patient. Four patients underwent surgical treatment with open reduction and restoration of facial height with maxillomandibular fixation. Three patients underwent concomitant mandible fracture repair.

Conclusions: Pediatric palatal fractures are rare and are usually accompanied by devastating concomitant injuries. Surgical repair of the palate in the pediatric patient is often necessary to restore facial height.
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http://dx.doi.org/10.1177/1943387520935013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7868506PMC
March 2021

How to Treat a Tongue-tie: An Evidence-based Algorithm of Care.

Plast Reconstr Surg Glob Open 2021 Jan 25;9(1):e3336. Epub 2021 Jan 25.

Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia; Philadelphia, Pa.

Ankyloglossia, or tongue-tie, is characterized by a short or thickened lingual frenulum; this can be associated with impaired breastfeeding, speech, and dentofacial growth. The indications for performing frenotomy, frenuloplasty, or other operative interventions are unclear.

Methods: A meta-analysis was performed to identify the extent of the benefit from frenotomy in breastfeeding measures, degree of tongue-tie, and maternal pain during feeding in randomized controlled trials. A structured literature review analyzed the optimal type and timing of repair. An algorithm was developed to incorporate this evidence into a management pathway.

Results: Among 424 studies reviewed, 5 randomized controlled trials met inclusion criteria for meta-analysis. Frenotomy significantly improved the degree of tongue-tie, with a 4.5-point decrease in Hazelbaker Assessment Tool for Lingual Frenulum Function score compared with a decrease of 0 in those who did not undergo frenotomy ( < 0.00001). This was associated with improved self-reported breastfeeding (relative risk [RR] = 3.48, < 0.00001) and decreased pain (Short-Form McGill Pain Questionnaire, < 0.00001); however, Breastfeeding Self-Efficacy-Short Form and Latch, Audible Swallowing, Type of Nipple, Comfort, Hold scores did not significantly improve. Multiple studies demonstrated significant improvements following frenuloplasty when compared with frenotomy but demonstrated mixed results as to the effect of timing of tongue-tie division.

Conclusions: Frenotomy is associated with breastfeeding improvements that vary individually but trend toward significance collectively during a critical time in infant development. Among patients with a severe Hazelbaker Assessment Tool for Lingual Frenulum Function score or difficulty breastfeeding, we conclude that simple frenotomy without anesthetic is generally indicated in infancy and frenuloplasty under general anesthesia for older children.
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http://dx.doi.org/10.1097/GOX.0000000000003336DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7859174PMC
January 2021

Facial Fractures and Mixed Dentition - What Are the Implications of Dentition Status in Pediatric Facial Fracture Management?

J Craniofac Surg 2021 Jan 7;Publish Ahead of Print. Epub 2021 Jan 7.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ Division of Plastic and Reconstructive Surgery, Department of Surgery, The University of Mississippi Medical Center, Jackson, MS.

Introduction: The stage of maturation of the pediatric facial skeleton at the time of injury has a significant impact on both facial fracture patterns and management strategies. For instance, the relative prominence of the pediatric cranium during the early years of life affords protection to the structures of the midface, whereas delayed aeration of the frontal sinuses may predispose younger patients to frontal bone fractures. The dentition status of a pediatric patient may have similar implications in the setting of facial fracture. In this study, the authors examine the effect of dentition status on facial fracture patterns and management strategies at an urban, level 1 trauma center.

Methods: A retrospective chart review was performed for all cases of facial fracture occurring in the pediatric patient population at a level 1 trauma center (University Hospital in Newark, NJ) between 2002 and 2014. A database including patient demographics, facial fracture, and concomitant injury patterns, and operative management data was constructed and analyzed.

Results: A total of 72 patients with mixed dentition met inclusion criteria for our study and were compared against patients with primary (n = 35) and permanent (n = 349) dentition. The mean age at presentation was 9.2 years, with a male predominance of 68%. The most common fracture etiology was pedestrian struck accident (n = 23), fall (n = 21), motor vehicle collision (n = 12), and assault (n = 9). The most frequently identified facial fractures were that of the orbit (n = 31), mandible (n = 21), nasal bone (n = 19), and frontal sinus (n = 14). Additionally, 8 Le Fort and 4 nasoorbitoethmoid fractures were identified. Twenty-one patients (29%) required operative management for 1 or more facial fractures. Operative intervention was required in 38% of mandibular fractures, with 6 patients requiring only maxillomandibular fixation and 2 requiring open reduction and internal fixation with titanium plating. Nine cases of orbital fracture (29%) were managed operatively - 4 with absorbable plates, 3 with Medpor implants, and 8 with titanium plating. Management of all nasal fractures requiring operative intervention was accomplished through closed reduction. Concomitant injuries included traumatic brain injury (TBI) (n = 35), skull fracture (n = 24), intracranial hemorrhage (ICH) (n = 20), and long bone fracture (n = 12). Seventeen patients required admission to the intensive care unit. Patients with mixed dentition were significantly more likely to sustain frontal sinus and Le Fort fractures (P < 0.01), as well as skull fracture, ICH, and TBI (P < 0.01) as compared to those with permanent dentition.

Conclusions: The dentition status of a pediatric patient may have significant implications in both patterns of injury and operative management strategies in the setting of acute facial trauma. Our study finds that Le Fort and frontal sinus fractures were significantly more common in patients with mixed dentition. Severe concomitant injuries such as ICH and TBI were also significantly more likely in this cohort. A patient's dentition status may also play a role in the decision for ridged fixation of mandibular and orbital fractures, as well as the method of maxillomandibular fixation in maxillary and mandibular alveolar fracture.
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http://dx.doi.org/10.1097/SCS.0000000000007424DOI Listing
January 2021

Rigid External Distractors in Midface Fractures: A Review of Relevant and Related Literature.

Eplasty 2020 19;20:e11. Epub 2020 Oct 19.

Division of Plastic and Reconstructive Surgery, Rutgers New Jersey Medical School, Newark, NJ.

Introduction: Literature discussing the use of rigid external distraction devices in midfacial trauma is limited. Rigid external distraction devices have been described for use in craniofacial surgery, allowing for distraction and stabilization of bony segments. In complex facial trauma, bony fragments are often comminuted and unstable, making traditional approaches with internal fixation difficult. Moreover, these approaches require subperiosteal dissection, limiting blood supply that is important for bone healing.

Objective: The goal of this study was to evaluate the role of rigid external distraction devices for the treatment of complex facial trauma.

Methods: We performed a literature review of rigid external distraction devices, as relevant both for facial trauma and for other craniofacial indications, to better elucidate their use and efficacy in complex facial fractures.

Results: The review revealed only 2 articles explicitly describing rigid external distraction devices for facial trauma, while 6 other articles describing its use for other craniofacial cases. An important benefit associated with the use of rigid external distraction devices is their ability to provide controlled traction of bony segments while also allowing for movement as needed for fracture reduction. Various articles describe performing internal fixation following rigid external distraction device usage, while others emphasize that internal fixation is not necessarily indicated if the rigid external distraction device is left intact long enough to ensure bony healing. One potential setback described is unfamiliarity with using the rigid external distraction device, which can preclude its use by many surgeons. In addition, the literature review did not provide any uniform guidelines or recommendations about how long rigid external distraction devices should remain intact.

Conclusion: Based on relevant literature, rigid external distraction devices have been shown to be useful in the stabilization and treatment of complex facial fractures. Further studies should be conducted to better elucidate the specific indications for rigid external distraction devices in complex facial trauma.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7656155PMC
October 2020

Motor Vehicle Collision Injuries: An Analysis of Facial Fractures in the Urban Pediatric Population.

J Craniofac Surg 2020 Oct;31(7):1910-1913

Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ.

Purpose: Motor vehicle collisions (MVC) are a leading cause of unintentional death and injury in the US pediatric population. Compliance with prevention measures such as seatbelts and child safety seats varies considerably with patient demographics. In this study, the authors examine facial fracture secondary to MVC in an urban pediatric population.

Methods: A retrospective chart review was performed of all facial fractures as a result of MVC in the pediatric population in a level 1 trauma center in an urban environment (University Hospital in Newark, NJ). Patient demographics were collected, as well as location of fractures, concomitant injuries, and surgical management strategies.

Results: Seventy-five patients met inclusion criteria for the authors' study. Mean age was 14 years old. Common fracture sites included orbital, mandible, nasal bone, and frontal sinus. Patients were more likely to incur fracture of the zygoma, orbit, nasal bone, frontal sinus, and nasoorbitoethmoid (NOE) if involved in an MVC compared to all other etiologies. Common concomitant injuries included traumatic brain injury, intracranial hemorrhage, and skull and long bone fractures. Open reduction and internal fixation with titanium plates was the most common surgical procedure indicated.

Conclusion: Motor vehicle collisions related injury has significant health implications in the urban pediatric population. Orbital, zygoma, and nasal facial fractures and TBI are injuries commonly associated with MVC. The facial fractures are likely due to lack of proper utilization of safety equipment and airbags. Development of effective prevention techniques relies heavily on analysis of injury patterns and management strategies.
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http://dx.doi.org/10.1097/SCS.0000000000006671DOI Listing
October 2020

Mentorship Through Research: A Novel Approach to Increasing Resident and Medical Student Research Competency Through an Institutional Database.

J Surg Educ 2020 Nov - Dec;77(6):1331-1333. Epub 2020 Jun 3.

Rutgers - New Jersey Medical School, Division of Plastic and Reconstructive Surgery, Newark, New Jersey. Electronic address:

Background: We describe a novel research database development project to increase resident and medical student scholarly ability and mentorship skills. We collected data on 3147 facial fractures treated at our institution over a 12-year period. This data was used to publish novel research on multiple types of facial fractures and outcomes.

Methods: We learned about key database aspects that led to its high level of research quality and output volume through over 6 years of database development and expanded research output. A retrospective review was completed to compile the total research produced during this time period.

Results: Research resulted in 20 manuscripts, 17 podium presentations, and 11 posters. 16 medical students, 5 residents and 3 faculty members were authors on at least one project. The average number of published manuscripts was 5.17 overall and 2.9, 7.0, and 14.0 for medical students, residents, and faculty, respectively. Four residents matched into fellowship, 7 medical students matched into residency, and one faculty member was promoted academically.

Conclusions: A database focused on a common and under-researched pathology can result in a high volume of novel research output. Additional program benefits include increased scholarly and mentorship ability in engaged residents and medical students.
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http://dx.doi.org/10.1016/j.jsurg.2020.04.010DOI Listing
June 2020

Pediatric Pedestrian Facial Fracture Patterns and Management Following Motor Vehicle Collisions.

J Craniofac Surg 2020 Jan/Feb;31(1):265-268

Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ.

Purpose: Pedestrian trauma due to motor vehicle crashes can be especially destructive to the pediatric population as the facial skeleton is immature and developing. Almost half of crashes resulting in pedestrian death involved alcohol consumption, and children are often victims of irresponsible driving. The objective of this study was to examine the prevalence of facial fractures in this patient population in order to analyze management strategies that optimize functional recovery.

Methods: A retrospective chart review was performed for all facial fractures resulting from motor vehicle collisions with pedestrians in the pediatric population at a level 1 trauma center in an urban environment (University Hospital in Newark, NJ). Patient demographics were collected, as well as location of fractures, concomitant injuries, and surgical management strategies.

Results: During the time period examined, 55 patients were identified as 18 years of age or younger and having sustained a facial fracture as the result of being struck by a motor vehicle. The mean age was 11.3 (range 1-18) years, with a male predominance of 69.0%. There were a total of 125 fractures identified on radiologic imaging via CT or X-ray. The most common fractures were those of the orbit (20.0%), mandible (19.2%), and nasal bone (10.4%). The mean Glasgow Coma Scale on arrival was 12.1 (range 4-15). Fifteen patients were intubated on, or prior to, arrival to the trauma bay. The most common concomitant injuries were intracranial hemorrhage, long bone fractures, and cervical spine fractures. The mean operative time was 216.9 (range 63-515) minutes. Surgery was required in 36 patients, with most undergoing open reduction and internal fixation with titanium plates and screws. Two patients required resorbable plates, and one required Medpor implants. The mean hospital length of stay was 9.9 (range 1-59) days. Two patients expired.

Conclusions: There is currently a dearth of literature regarding the management and patterns of injury for pediatric pedestrian injuries due to motor vehicle collisions. The impact of these injuries can be devastating with concomitant life-threatening complications, and may influence the future development of the facial skeleton after healing of the bone and soft tissue. The authors hope this study can provide insight and further investigation regarding prevention and management.
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http://dx.doi.org/10.1097/SCS.0000000000006034DOI Listing
March 2020

Sports-Related Pediatric Facial Trauma: Analysis of Facial Fracture Pattern and Concomitant Injuries.

Surg J (N Y) 2019 Oct 9;5(4):e146-e149. Epub 2019 Oct 9.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey.

 Sports-related injuries, such as facial fractures, are potentially debilitating and may lead to long-term functional and aesthetic deficits in a pediatric patient. In this study, we analyze sports-related facial fractures in the urban pediatric population in an effort to characterize patterns of injury and improve management strategies and outcomes.  Retrospective chart review was performed for all facial fractures resulting from sports injuries in the pediatric population at a level-1 trauma center (University Hospital, Newark, NJ).  Seventeen pediatric patients were identified as having sustained a fracture of the facial skeleton due to sports injury. Mean age was 13.9 years old. A total of 29 fractures were identified. Most common fracture sites included the orbit (  = 12), mandible (  = 5), nasal bone (  = 5), and zygomaticomaxillary complex (  = 3). The most common concomitant injuries included skull fracture (  = 3), intracranial hemorrhage (  = 4), and traumatic brain injury (  = 4). One patient was intubated upon arrival to the emergency department. Hospital admission was required in 13 patients, 4 of which were admitted to an intensive care setting. Nine patients required operative intervention. Mean length of hospital stay was 2.4 days. No patients were expired.  Sports-related facial fractures are potentially debilitating injuries in the pediatric population. Analysis of fracture pattern and concomitant injuries is imperative to develop effective management strategies and prevention techniques.
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http://dx.doi.org/10.1055/s-0039-1697627DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6785318PMC
October 2019

Onset and Resolution of Chiari Malformations and Hydrocephalus in Syndromic Craniosynostosis following Posterior Vault Distraction.

Plast Reconstr Surg 2019 10;144(4):932-940

From the Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia.

Background: Patients with syndromic craniosynostosis have an increased incidence of progressive hydrocephalus and Chiari malformations, with few data on the relative benefit of various surgical interventions. The authors compare the incidence and resolution of Chiari malformations and hydrocephalus between patients undergoing posterior vault distraction osteogenesis (PVDO) and patients undergoing conventional cranial vault remodeling.

Methods: Patients with syndromic craniosynostosis who underwent cranial vault surgery from 2004 to 2016 at a single academic hospital, with adequate radiographic assessments, were reviewed. Demographics, interventions, the presence of a Chiari malformation on radiographic studies and hydrocephalus requiring shunt placement were recorded. Mann-Whitney U and Fisher's exact tests were used as appropriate.

Results: Forty-nine patients underwent PVDO, and 23 patients underwent cranial vault remodeling during the study period. Median age at surgery (p = 0.880), sex (p = 0.123), and types of syndrome (p = 0.583) were well matched. Patients who underwent PVDO had a decreased incidence of developing Chiari malformations postoperatively compared with the cranial vault remodeling cohort (2.0 percent versus 17.4 percent; p = 0.033). Not surprisingly, no significant difference was found between the groups with regard to the incidence of postoperative hydrocephalus requiring shunt placement (PVDO, 4.1 percent; cranial vault remodeling, 4.3 percent; p = 0.999).

Conclusions: As expected, PVDO did not significantly affect intracranial hydrodynamics to the extent that hydrocephalus shunting rates were different for patients with syndromic craniosynostosis. However, PVDO was associated with a reduced risk of developing a Chiari malformation; however, prospective evaluation is needed to determine causality.

Clinical Question/level Of Evidence: Therapeutic, III.
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http://dx.doi.org/10.1097/PRS.0000000000006041DOI Listing
October 2019

Patterns of Nasoorbitalethmoid Fractures in the Pediatric Population.

Am Surg 2019 Jul;85(7):730-732

There is an absence of literature regarding nasoorbitoethmoid (NOE) facial fractures. Although NOE fractures are uncommon, there are a significant number in the pediatric population. These fractures also often occur in conjunction with other facial fractures because the NOE region adjoins the nose, orbit, maxilla, and cranium. They can also be a harbinger for more serious concerns such as traumatic brain injury and intracranial hemorrhage. For this reason, NOE fractures can be highly complicated and a challenge to manage. We aim to define the etiologies and patterns of NOE fractures to guide hospital and surgical management strategies. From 2001 to 2014, 15 pediatric patients were identified as having sustained an NOE fracture. Four (26.7%) of the patients were female and 11 (68.8%) were male. Average age was 11.40. The most common etiologies recorded were motor vehicle accident (n = 8), pedestrian struck (n = 3), and assault (n = 2). Orbital fracture (n = 13), nasal fracture (n = 13), and frontal sinus fracture (n = 10) were the most commonly associated facial fractures sustained alongside NOE fracture. Several patients sustained traumatic brain injury (n = 11) and loss of consciousness (n = 13). The mean Glasgow Coma Score was 10.5. In addition, eight required intubation and five required a surgical airway. Thirteen of the patients were admitted to the ICU and eight required surgical management for their fractures. Titanium plates were most commonly used (n = 4) for surgical management. Alternatively, resorbable implants were used for two patients. The remaining two were treated with closed reduction.
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July 2019

Management of Frontal Bone Fractures.

J Craniofac Surg 2019 Oct;30(7):2026-2029

Division of Plastic and Reconstructive Surgery, Department of Surgery.

Background: The purpose of this study was to examine a level 1 trauma center's 12-year experience treating frontal sinus fractures with regards to patient demographics, management strategies, and treatment outcomes.

Methods: An institutional review board-approved retrospective review of all facial fractures at a level 1 trauma center was performed for the years 2000 to 2012. Patient demographics, location of fractures, concomitant injuries, use of antibiotics, surgical management strategies and outcomes were collected for all frontal sinus fractures. A significance value of 5% was used.

Results: There were 291 frontal sinus fractures treated at our institution. The mean age of patients was 34.4 years with a male predominance (90%). The most common mechanisms of injury were assault in 82 (28.2%) and motor vehicle accidents in 80 (27.5%). Anterior table fractures were seen in 261 patients (89.7%) and posterior table fractures were seen in 181 (62.2%). Treatment included ORIF with sinus preservation in 18 (6.2%), ORIF with sinus obliteration in 20 (6.9%), and cranialization in 18 (6.2%). Antibiotics were started on admission in 152 patients (52.2%). Fatality occurred in 9.3% of patients and complications included meningitis (1%), frontal sinusitis (1%), early wound infection (0.3%), and mucopyelocele (0.3%).

Conclusions: Frontal sinus fractures in our center are most often caused by interpersonal violence. Anterior table fractures were more common than posterior table fractures and ORIF with sinus obliteration was the most common surgical intervention. Most frontal sinus fractures at our institution (82%) were treated conservatively with no surgical intervention and we observed a low rate of long term complications.
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http://dx.doi.org/10.1097/SCS.0000000000005720DOI Listing
October 2019

Perioperative Outcomes of Secondary Frontal Orbital Advancement After Posterior Vault Distraction Osteogenesis.

J Craniofac Surg 2019 Mar/Apr;30(2):503-507

Division of Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA.

Background: Posterior cranial vault distraction osteogenesis (PVDO) has gained popularity as the initial intervention in patients with syndromic craniosynostosis. Patients may require secondary frontal orbital advancement (FOA) following PVDO, but little is known about the perioperative risks associated with this staged management. The purpose of this study is to compare the perioperative morbidity profile of secondary FOA (study) to that of primary FOA (control).

Methods: A retrospective review was conducted for patients with syndromic or complex craniosynostosis undergoing FOA between 2004 and 2017. Univariate and multivariate analysis of demographic and perioperative data were performed.

Results: Forty-three subjects met inclusion criteria, 17 in the study cohort and 26 in the control cohort. The 2 cohorts were similar with regards to diagnosis and suture involvement, as well as weight-adjusted estimated blood loss, blood transfusion volume, and length of hospital stay (P > 0.050). Secondary FOA procedures required longer operating time (231 ± 58 versus 264 ± 62 min, P = 0.031) and anesthesia time (341 ± 60 versus 403 ± 56 min, P = 0.002). The secondary FOA cohort had a significantly greater proportion of procedures with difficult wound closure (19% versus 59%, P = 0.008). Two subjects in the study cohort developed a wound dehiscence, compared with 1 subject in the control cohort (P = 0.552). Frontal orbital advancement as a secondary procedure after PVDO was a predictor variable in multivariate analysis for wound difficulties (odds ratio 8.6, P = 0.038).

Conclusion: Syndromic and complex craniosynostosis may safely be managed with initial PVDO followed by FOA, with some increased wound closure difficulty.
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http://dx.doi.org/10.1097/SCS.0000000000005220DOI Listing
August 2019

Risk Factors for Perioperative Respiratory Failure following Mandibular Distraction Osteogenesis for Micrognathia: A Retrospective Cohort Study.

Plast Reconstr Surg 2019 06;143(6):1725-1736

From the Division of Plastic Surgery, Children's Hospital of Philadelphia.

Background: The frequency of respiratory events in the perioperative period, and optimal duration of intubation during early mandibular distraction osteogenesis activation, are poorly understood. This study assesses potential risk factors associated with perioperative respiratory events, particularly the need for reintubation, following mandibular distraction osteogenesis surgery.

Methods: A retrospective review was conducted for infants (younger than 1 year) undergoing mandibular distraction osteogenesis for tongue-based airway obstruction between November of 2010 and December of 2017. Univariate and multivariate analyses of sentinel events and outcomes were performed.

Results: Ninety infants (median age, 35 days) were included (50 percent were syndromic). Twenty-seven subjects (30 percent) experienced a respiratory event requiring intervention before discharge, including 14 subjects who failed initial extubation. Subjects extubated earlier than postoperative day 5 failed extubation more frequently (33%) compared to those extubated later (9%; p = 0.005). Respiratory events occurred more frequently when extubation was attempted at distraction lengths of 5 mm or less (42 percent) compared to greater than 5 mm (21 percent; p = 0.032). Logistic regression modeling showed that syndromic status (OR, 14.8) and secondary airway anomaly (OR, 6.1) were significant predictors for respiratory events, whereas greater length of distraction at the time of extubation was protective (OR, 0.8; p < 0.05).

Conclusions: Postoperative intubation of at least 5 days with associated mean distraction of 5 mm appears to be associated with successful extubation trial following mandibular distraction osteogenesis surgery. Patients with congenital syndromes and secondary airway anomalies are more likely to experience perioperative respiratory events.

Clinical Question/level Of Evidence: Risk, III.
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http://dx.doi.org/10.1097/PRS.0000000000005651DOI Listing
June 2019

Implications of Facial Fracture in Airway Management of the Adult Population: What Is the Most Effective Management Strategy?

Ann Plast Surg 2019 04;82(4S Suppl 3):S179-S184

Division of Craniofacial and Reconstructive Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, MS.

Purpose: Facial fractures are a harbinger when it comes to airway management. Facial fractures can cause airway obstruction or preclude the use of intubation. We aim to examine the etiologies, types of facial fractures, and the risk factors that may lead to requirement of an advance airway.

Methods: A retrospective chart review was performed of all facial fractures in the adult population in a level 1 trauma center in an urban environment (University Hospital in Newark, NJ). Patient demographics were collected, as well as location of fractures, concomitant injuries, and course of hospital stay.

Results: During the period examined, 2626 patients were identified as 18 years or older and with facial fracture. Among these patients, 443 received airway management. Mean age was 34.21 years (range, 18-95 years), with a male predominance of 91.9%. One hundred nineteen patients were intubated on, or before, arrival to the trauma bay. One hundred three patients required surgical airways on arrival to the trauma bay, and 91 of these patients were also reported to have been intubated before arrival. There were a total of 741 fractures identified on radiologic imaging. The most common fractures observed were orbital fractures, frontal sinus fractures, and nasal fractures. Mean Glasgow Coma Scale score on arrival was 9.45 (range, 3-15). Gunshot wound was also the most common etiology among those who were intubated and those who received a surgical airway. The most common concomitant injuries were traumatic brain injury, intracranial hemorrhage, and skull fracture. Forty-one patients died, most of which were intubated during their hospital course.

Conclusions: There is a dearth of literature detailing standardization of airway management for patients who present with facial fractures. The difference between intubation and surgical airway is often a subjective judgment call, but the authors believe that a more streamlined process can be elucidated after analyzing previous trends as well as variabilities in patient survival and prognosis.
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http://dx.doi.org/10.1097/SAP.0000000000001883DOI Listing
April 2019

State-of-the-Art Hypertelorism Management.

Clin Plast Surg 2019 Apr 9;46(2):185-195. Epub 2019 Jan 9.

Division of Plastic Surgery, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA. Electronic address:

Orbital hypertelorism represents lateralization of the orbits, meaning increased interorbital and outer orbital distances. Interorbital hypertelorism represents a failure of medial orbital wall medialization in the setting of normally positioned lateral orbital walls. The etiology and type of hypertelorism influence selection of an operative procedure, whereas the severity of deformity dictates surgical need. Choice of surgical procedure is dictated by anatomic considerations, such as degree of orbital hypertelorism, midfacial proportions, and occlusal status.
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http://dx.doi.org/10.1016/j.cps.2018.11.004DOI Listing
April 2019

Traumatic Falls in the Pediatric Population: Facial Fracture Patterns Observed in a Leading Cause of Childhood Injury.

Ann Plast Surg 2019 04;82(4S Suppl 3):S195-S198

University of Mississippi Medical Center, Jackson, MS.

Purpose: Falls are a leading cause of nonfatal injury in the pediatric population, resulting in numerous hospitalizations. Children may not have fully developed reflexive and balancing abilities, rendering them more susceptible to traumatic falls. Here the authors present their findings regarding patterns of facial fracture and concomitant injury seen in the pediatric population secondary to falls.

Methods: A retrospective chart review was performed of all facial fractures as a result of falls in the pediatric population in a level 1 trauma center in an urban environment (University Hospital in Newark, NJ). Patient demographics were collected, as well as location of fractures, concomitant injuries, and surgical management strategies.

Results: Fifty-five patients were identified as 18 years or younger and having sustained a facial fracture as the result of a fall. This cohort was compared with 418 pediatric patients with facial fractures due to nonfall etiologies. The mean age was 9.6 years (range, 0-18 years), with a male predominance of 67.3%. There were a total of 70 fractures identified on radiological imaging. The most frequently fractured bones were the orbit (n = 27), nasal bone (n = 15), and mandible (n = 11). Orbital and frontal sinus fractures each occurred more frequently due to falls compared with all other causes of injury. Patients with orbital fractures were significantly more likely to present with an additional facial fracture compared with those without (P < 0.01). The most common concomitant injuries were traumatic brain injury, skull fracture, and intracranial hemorrhage. Patients who suffered a facial fracture due to a fall were significantly more likely to sustain a concomitant skull fracture (P < 0.05) and intra-abdominal injury (P < 0.05) compared with all other etiologies. Fourteen patients required surgical intervention. One patient died.

Conclusions: Pediatric facial fractures are a unique entity. The general plasticity of the pediatric anatomy can predispose patients to significant injury without obvious external signs. A high level of clinical suspicion is required to avoid misdiagnosis and delay of treatment. The authors hope this study can address a preventable issue in child safety, educate caregivers, and provide insight towards fracture management that fosters functional and aesthetic recovery.
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http://dx.doi.org/10.1097/SAP.0000000000001861DOI Listing
April 2019

Discussion: Craniometric Analysis of Endoscopic Suturectomy for Bilateral Coronal Craniosynostosis.

Plast Reconstr Surg 2019 01;143(1):197-198

From the Division of Plastic Surgery, University of Pennsylvania and the Children's Hospital of University of Pennsylvania.

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http://dx.doi.org/10.1097/PRS.0000000000005120DOI Listing
January 2019

Retrospective Review of the Complication Profile Associated with 71 Subcranial and Transcranial Midface Distraction Procedures at a Single Institution.

Plast Reconstr Surg 2019 02;143(2):521-530

From the Division of Plastic Surgery, Children's Hospital of Philadelphia.

Background: This study characterizes the perioperative morbidity of a large cohort of subjects with syndromic craniosynostosis who underwent transcranial or subcranial midface distraction.

Methods: Demographic and perioperative data were compared between those who underwent transcranial or subcranial midface distraction osteogenesis between July of 1999 and December of 2017. Univariate analysis was conducted using chi-square and Fisher's exact tests for categorical variables and the Mann-Whitney U test for continuous variables. Multivariate analysis was conducted using logistic regression modeling. Complications were graded using the Clavien-Dindo classification.

Results: Sixty-four subjects underwent a total of 71 midface distraction procedures. There was a total of 28 complications (39 percent). The trans cranial cohort had a significantly higher frequency of complications (58 percent) compared with the subcranial cohort (29 percent; p = 0.017), with a significantly greater proportion of infection-related complications in the transcranial cohort (80 percent versus 54 percent; p = 0.028). Transcranial complications included cranial contamination, whereas most subcranial cohort infections were superficial or limited facial abscesses. The only significant predictor variable for complications in a multivariate analysis was whether the osteotomy approach was transcranial as opposed to subcranial, with an odds ratio of 5.80 (p = 0.013).

Conclusions: Complication rates in midface distraction remain high, with transcranial procedures having significantly higher complication rates, infection-related complications, and notably greater severity of complications. Although the goals of surgery often dictate choice of osteotomy, the risks associated with transcranial procedures must be thoroughly understood by surgeon and patient alike.

Clinical Question/level Of Evidence: Therapeutic, IV.
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http://dx.doi.org/10.1097/PRS.0000000000005280DOI Listing
February 2019

Early Mandibular Distraction in Craniofacial Microsomia and Need for Orthognathic Correction at Skeletal Maturity: A Comparative Long-Term Follow-Up Study.

Plast Reconstr Surg 2018 11;142(5):1285-1293

From the Division of Plastic Surgery, Children's Hospital of Philadelphia.

Background: Controversy exists regarding the treatment of mandibular hypoplasia in craniofacial microsomia patients, notably the role of mandibular distraction osteogenesis. The authors compared the need for orthognathic surgery in skeletally mature craniofacial microsomia subjects who either did (study group) or did not (control group) undergo early mandibular distraction osteogenesis.

Methods: A retrospective review was conducted of all craniofacial microsomia patients evaluated between January of 1993 and March of 2017. This study included patients with a Kaban-Pruzansky grade I to III mandible, and who were at least 14 years old at the time of the latest follow-up.

Results: Thirty-eight subjects met inclusion criteria: 17 who underwent mandibular distraction osteogenesis and 21 who did not (mean age, 18.95 ± 2.82 years versus 17.95 ± 2.14 years, respectively; p = 0.246). The degree of mandibular deformity was matched (distraction, 29.4 percent Kaban-Pruzansky grade IIb and 5.9 percent grade III; no distraction, 23.8 percent grade IIb and 9.5 percent grade III; p = 0.788). No significant difference was noted between the distraction and no-distraction cohorts with regard to need for orthognathic surgery [distraction, n = 10 (58.8 percent); no distraction, n = 8 (38.1 percent); p = 0.203].

Conclusions: The results seem to suggest that there is no significant difference in orthognathic surgery rates at skeletal maturity between craniofacial microsomia subjects who underwent early mandibular distraction osteogenesis and those who did not. Subjects who undergo distraction may still ultimately require orthognathic surgery to correct facial asymmetry. Additional studies are required to determine the optimal timing and technique of distraction, the importance of orthodontic management during and after distraction, and the early psychosocial benefits of improved facial symmetry.

Clinical Question/level Of Evidence: Therapeutic, III.
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http://dx.doi.org/10.1097/PRS.0000000000004842DOI Listing
November 2018

A Standardized Perioperative Clinical Pathway for Uncomplicated Craniosynostosis Repair Is Associated With Reduced Hospital Resource Utilization.

J Craniofac Surg 2019 Jan;30(1):105-109

Division of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA.

Background: Hospital resource overutilization can significantly disrupt patient treatment such as cancelling surgical patients due to a lack of intensive care unit (ICU) space. The authors describe a clinical pathway (CP) designed to reduce ICU length of stay (LOS) for nonsyndromic single-suture craniosynostosis (nsSSC) patients undergoing cranial vault reconstruction (CVR) in order to minimize surgical disruptions and improve patient outcomes.

Methods: A multidisciplinary team implemented a perioperative CP including scheduled laboratory testing to decrease ICU LOS. Hospital and ICU LOS, interventions, and perioperative morbidity-infection rate, cerebrospinal fluid (CSF) leaks, and unplanned return to the operating room (OR)-were compared using Mann-Whitney U, Fisher exact, and t tests.

Results: Fifty-one ICU admissions were managed with the standardized CP and compared to 49 admissions in the 12 months prior to pathway implementation. There was a significant reduction in ICU LOS (control: mean 1.84 ± 0.93, median 1.89 ± 0.94; CP: mean 1.15 ± 0.34, median 1.03 ± 0.34 days; P < 0.001 for both). There were similar rates of hypotension requiring intervention (CP: 2, control: 1; P = 0.999), postoperative transfusion (CP: 3, control: 0; P = 0.243), and artificial ventilation (CP: 1, control: 0; P = 0.999). Perioperative morbidity such as infection (CP: 1, control: 0; P = 0.999), return to the OR (CP: 1, control: 0; P = 0.999), and CSF leak (no leaks; P = 0.999) was also similar.

Conclusion: Implementation of a standardized perioperative CP for nsSSC patients resulted in a significantly shorter ICU LOS without a measured change in perioperative morbidity. Pathways such as the one described that improve patient throughput and decrease resource utilization benefit craniofacial teams in conducting an efficient service while providing high-quality care.
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http://dx.doi.org/10.1097/SCS.0000000000004871DOI Listing
January 2019

Influence of Repaired Cleft Lip and Palate on Layperson Perception following Orthognathic Surgery.

Plast Reconstr Surg 2018 10;142(4):1012-1022

From the Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia; and the Department of Psychiatry and the Center for Human Appearance, Department of Surgery, University of Pennsylvania Perelman School of Medicine.

Background: Facial scarring and disharmony caused by clefting are associated with psychosocial stress, which may be improved by orthognathic surgery. The authors examine how clefting influences change in layperson perception of a patient following orthognathic surgery.

Methods: One thousand laypersons were recruited through Mechanical Turk to evaluate patient photographs before and after orthognathic surgery. Nineteen patients-five with unilateral and five with bilateral clefting-were included. Respondents assessed six personality traits, six emotional expressions, and likelihood of seven interpersonal experiences on a scale from 1 to 7.

Results: Changes in all aspects of social perception after the procedure differed significantly between cleft versus noncleft cohorts (p < 0.01 for all). Respondents evaluated the change for the cleft cohort compared with the noncleft cohort as more trustworthy, friendly, sad, and afraid; more likely to feel lonely, be teased or bullied by others, or feel anxious around others; less angry, disgusted, threatening, dominant, intelligent, happy, and attractive; and less likely to have romantic relationships, friends, or be praised by others. For unilateral versus bilateral cleft cohorts, change in social perception was significantly different in four of the 19 items (p < 0.05 for all). Social perception change for the unilateral cohort was less surprised, sad, dominant, or happy compared with the bilateral cohort (p < 0.05 for all).

Conclusions: Despite significant improvements in social perception following orthognathic surgery, cleft patients benefit less than noncleft patients. These findings may be useful to counsel postsurgical expectations for cleft patients undergoing orthognathic surgery.
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http://dx.doi.org/10.1097/PRS.0000000000004778DOI Listing
October 2018

Surgical Management and Outcomes of Pierre Robin Sequence: A Comparison of Mandibular Distraction Osteogenesis and Tongue-Lip Adhesion.

Plast Reconstr Surg 2018 08;142(2):480-509

From the Division of Plastic Surgery, Children's Hospital of Philadelphia.

There is a paucity of literature directly comparing tongue-lip adhesion versus mandibular distraction osteogenesis in surgical treatment of patients with Pierre Robin sequence. This study comprehensively reviews the literature for evaluating airway and feeding outcomes following mandibular distraction osteogenesis and tongue-lip adhesion. A search was performed using the MEDLINE and Embase databases for publications between 1960 and June of 2017. English-language, original studies subjects were included. Extracted data included prevention of tracheostomy (primary airway outcome) and ability to feed exclusively by mouth (primary feeding outcome). A total of 67 studies were included. Ninety-five percent of subjects (657 of 693) treated with mandibular distraction osteogenesis avoided tracheostomy, compared to 89% of subjects (289 of 323) treated with tongue-lip adhesion. Eighty-seven percent of subjects (323 of 370) treated with mandibular distraction osteogenesis achieved full oral feeds at latest follow-up. Seventy percent of subjects (110 of 157) treated with tongue-lip adhesion achieved full oral feeds at latest follow-up. The incidence of second intervention for recurrent obstruction ranged from 4 to 6 percent in mandibular distraction osteogenesis studies, compared to a range of 22 to 45 percent in tongue-lip adhesion studies. Variability of patient selection, surgical techniques, outcomes measurement methods, and follow-up length across studies precluded meta-analysis of the data. Both mandibular distraction osteogenesis and tongue-lip adhesion are effective alternatives to tracheostomy for patients who fail conservative management and improve feeding. Mandibular distraction osteogenesis may be superior to tongue-lip adhesion in long-term resolution of airway obstruction and avoidance of gastrostomy, but is associated with notable complications.
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http://dx.doi.org/10.1097/PRS.0000000000004581DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6502235PMC
August 2018

Evaluation of parental and surgeon stressors and perceptions of distraction osteogenesis in pediatric craniofacial patients: a cross-sectional survey study.

Childs Nerv Syst 2018 09 11;34(9):1735-1743. Epub 2018 May 11.

Division of Plastic Surgery, Children's Hospital of Philadelphia, The University of Pennsylvania, Colket Translational Research Building, 9th Floor, Philadelphia, PA, 19104, USA.

Purpose: There is a paucity of literature on how limitations of distraction osteogenesis (DO) are perceived by physicians and parents of pediatric patients. Specifically understanding which features of DO are most concerning to these two groups may better inform parent education, as well as direct improvements in distraction protocols and devices.

Method: Parents/guardians of patients (between January 2016 and October 2017) being treated with craniofacial distraction were recruited to complete a survey regarding level of stress (1 = not stressful, 9 = maximally stressful) associated with eight features of DO. Craniofacial surgeons completed a survey asking them to report (1) their personal level of stress and (2) their perceptions of parental stress regarding these same eight features of DO.

Results: Thirty-five parents and 15 craniofacial surgeons completed the survey. The risk of the device getting infected was perceived as most stressful by parents (5.5 ± 2.3) followed by the device sticking through the skin (4.9 ± 2.6) and the second operation for removal (4.7 ± 2.3). These same three features also elicited the highest level of stress among surgeons. Surgeon-perceived parental stress regarding turning of the distractor (5.8 ± 1.5) was significantly higher than parent self-reported stress (4.2 ± 2.8, p = 0.042).

Conclusions: Both parents and surgeons perceive risk of device-associated infection, the protrusion of the device through the skin, and the requirement of a second operation for removal as the most stressful drawbacks of distraction. Infection reduction protocols, less obtrusive devices, and devices that do not require removal are potential targets for stress reduction.
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http://dx.doi.org/10.1007/s00381-018-3827-5DOI Listing
September 2018

A Single-Center Review of Facial Fractures as the Result of High-Speed Projectile Injuries.

Eplasty 2018 9;18:e16. Epub 2018 Apr 9.

Division of Plastic Surgery, Department of Surgery, New Jersey Medical School, Rutgers Biomedical Health Sciences, Newark.

Gunshot injuries to the face that result in fractures of the underlying skeleton present a challenge in management. The goal of this study was to evaluate patterns of facial fractures as a result of gunshot injuries and strategies for management. A retrospective review of facial fractures resulting from gunshot injuries in a level 1 trauma center was performed for the years 2000 to 2012. Data were collected for patient demographics, fracture distribution, concomitant injuries, and surgical management strategies. A total of 190 patients sustained facial fractures from a gunshot injury. The average age was 29.9 years, and 90% were male. Sixteen injuries were self-inflicted. The most common fractures were of the mandible and the orbit. Uncontrolled hemorrhage was noted on presentation in 68 patients; 100 patients were intubated on arrival. The average Glasgow Coma Scale score on arrival was 11.9. Concomitant injuries included skull fracture, intracranial hemorrhage, and intrathoracic injury. Surgical management was required in 89 patients. Nine patients required soft-tissue coverage. Thirty patients expired. Gunshot injuries to the face resulting in fractures of the underlying skeleton have high instances of morbidity and mortality. Life-threatening concomitant injuries can complicate management of facial fractures in this population.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5896170PMC
April 2018

Nasal Obstruction in Children With Cleft Lip and Palate: Results of a Cross-Sectional Study Utilizing the NOSE Scale.

Cleft Palate Craniofac J 2019 02 26;56(2):177-186. Epub 2018 Apr 26.

1 Division of Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA.

Objective: To characterize the epidemiology and risk factors for nasal obstruction among subjects with cleft lip and/or cleft palate (CL/P) utilizing the well-validated Nasal Obstruction Symptom Evaluation (NOSE) survey.

Design: Retrospective cross-sectional study.

Setting: Cleft Lip and Palate Program, Children's Hospital of Philadelphia.

Patients, Subjects: One thousand twenty-eight surveys obtained from 456 subjects (mean age: 10.10 (4.48) years) with CL/P evaluated between January 2015 and August 2017 with at least 1 completed NOSE survey.

Interventions: Nasal Obstruction Symptom Evaluation surveys completed at each annual visit.

Main Outcome Measures: Composite NOSE and individual symptom scores.

Results: Sixty-seven percent of subjects had nasal obstruction at some point during the study period, with 49% reporting nasal obstruction at latest follow-up. subjects aged 14 years and older reported the most severe symptoms ( P = .002). Subjects with cleft lip and alveolus (CL+A) and unilateral cleft lip and palate (CLP) reported more severe nasal blockage than other phenotypes ( P = .021). subjects with a history of either posterior pharyngeal flap (PPF) or sphincter pharyngoplasty (SP) had significantly higher NOSE scores than subjects with no history of speech surgery ( P = .006). There was no significant difference ( P > .050) in NOSE scores with regard to history of primary tip rhinoplasty, nasal stent use, or nasoalveolar molding.

Conclusions: There are more severe nasal obstructive symptoms among subjects older than 14 years of age, with CL+A or unilateral CLP, and with a history of PPF or SP. Future studies utilizing the NOSE are needed to evaluate and address this prevalent morbidity in the CLP population.
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http://dx.doi.org/10.1177/1055665618772400DOI Listing
February 2019

Intracranial Migration of Hardware 16 Years Following Craniosynostosis Repair.

Eplasty 2018 15;18:e2. Epub 2018 Jan 15.

Craniofacial and Pediatric Plastic Surgery, Department of Plastic Surgery, Hackensack University Medical Center, Hackensack, NJ.

The techniques used to fixate osteotomized segments of bone have evolved alongside the treatment of craniosynostosis. The use of nonresorbable metal plates and screws offered a method of rigidly stabilizing repositioned segments of bone. Several reports specify the tendency for these fixation systems to "migrate" transcranially. We present a unique case of a patient who initially underwent treatment of multisuture craniosynostosis utilizing titanium miniplates at 6 months of age. At 16 years of age, the patient was returned to the operating room with complaints of pain and contour irregularities, and intracranial migration of the screws and plates was observed. The hardware was extracted and the cranium reconstructed. Symptoms resolved and bony contour was improved. The craniofacial surgeon considering metal plate fixation in the pediatric population should be aware of the possibility for transcranial plate and screw migration.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5773937PMC
January 2018

Posterior Vault Distraction Osteogenesis in Nonsyndromic Patients: An Evaluation of Indications and Safety.

J Craniofac Surg 2018 May;29(3):566-571

Division of Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA.

Purpose: The purpose of this study was to evaluate the indications, safety, and short-term outcomes of posterior vault distraction osteogenesis (PVDO) in patients with no identified acrocephalosyndactyly syndrome (study) and to compare those to a syndromic cohort (controls).

Methods: Demographic and perioperative data were recorded and compared across the study and control groups for those who underwent PVDO between January 2009 and December 2016. Univariate analysis was conducted using χ and Fisher exact tests for categorical variables, and Mann-Whitney U test for continuous variables.

Results: Sixty-three subjects were included: 19 in the nonsyndromic cohort, 44 in the syndromic cohort. The cohorts had similar proportion of subjects exhibiting pansynostosis (42.1% of nonsyndromic versus 36.4% of syndromic, P = 0.667). The nonsyndromic cohort was significantly older (4.04 ± 3.66 years versus 2.55 ± 3.34 years, P = 0.046) and had higher rate of signs of raised intracranial pressure (68.4% versus 25.0%, P = 0.001) than the syndromic cohort. There was no significant difference in perioperative variables or rate of complications (P > 0.05). The mean total advancement distance achieved was similar, 27 ± 6 mm in the nonsyndromic versus 28 ± 8 mm in the syndromic cohort (P = 0.964). All nonsyndromic subjects with signs of raised intracranial pressure demonstrated improvement at an average follow-up of 22 months.

Conclusion: As in the syndromic patient, PVDO is a safe and, in the short-term, effective modality for cranial vault expansion in the nonsyndromic patient. The benefits and favorable perioperative profile of PVDO may therefore be extended to patient populations other than those with syndromic craniosynostosis.
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http://dx.doi.org/10.1097/SCS.0000000000004230DOI Listing
May 2018

Pediatric Facial Fractures: An Assessment of Airway Management.

J Craniofac Surg 2017 Nov;28(8):2004-2006

Rutgers New Jersey Medical School, Newark, NJ.

Pediatric facial fractures present unique and challenging management considerations, especially with regards to airway management. Anatomical differences in children increase both airway resistance and the difficulty of intubation. A surgical airway may be required if intubation is unable to be performed. The purpose of this study was to examine a single center's experience with pediatric facial fractures to determine the frequency of advanced airway use, as well as the risk factors that may predispose a patient to requiring an advanced airway. A retrospective review of all facial fractures at a level 1 trauma center was performed from 2000 to 2012. Patients age 18 years and younger were included. Patient demographics were collected, as well as location of fractures, concomitant injuries, services consulted, and surgical management strategies. Information was collected regarding the need for an advanced airway, including intubation and the need for a surgical airway. A total of 285 patients met inclusion criteria. Of these, 57 patients (20%) required emergency intubation and 5 (1.8%) required a surgical airway. Intubation was significantly related to fractures of the midface, frontal sinuses, spine, skull, and pelvis, as well as depressed Glasgow coma scores and traumatic brain injury. The need for a surgical airway is extremely uncommon (1.8%), and tracheostomy was only needed in the setting of penetrating head trauma. Both emergent intubation and tracheostomy are associated with complications, but these complications must be weighed against the potentially life-saving measure of securing an airway.
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http://dx.doi.org/10.1097/SCS.0000000000004036DOI Listing
November 2017

A Single-Center Review of Palatal Fractures: Etiology, Patterns, Concomitant Injuries, and Management.

Eplasty 2017 14;17:e20. Epub 2017 Jun 14.

Division of Plastic Surgery, Department of Surgery, Rutgers Biomedical Health Sciences, New Jersey Medical School, Newark.

Palatal fractures are frequently associated with facial trauma and Le Fort fractures. The complex anatomy of the midfacial skeleton makes diagnosing and treating these injuries a challenge. The goal of this study was to report our experience with the presentation, concomitant injuries, and management of palatal fractures at a level I trauma center in an urban environment. Data were collected for all palatal fractures diagnosed between January 2000 and December 2012 at the University Hospital in Newark, NJ. Data on patient demographics, Glasgow Coma Scale score on presentation, concomitant facial fractures, extrafacial injuries, and management strategies were collected from these records. Of the 3147 facial fractures treated at our institution during this time period, 61 were associated with a palatal fracture following blunt trauma. There was a strong male predominance (87%) and a mean age of 35.6 years in this subset of patients. The most common causes of injury were assault and motor vehicle accident. The most common fracture patterns were alveolar, parasagittal, and para-alveolar, whereas sagittal and transverse fractures were rare. The most frequently encountered facial and extrafacial injuries were orbital fractures and intracranial hemorrhage, respectively. There was a significant association between type II sagittal fractures and traumatic brain injury ( < .05). Our study examines a single center's experience with palatal fractures in terms of presentation, concomitant injuries, and management strategies. Palatal fractures are most often associated with high-energy mechanisms, and the severity of injury appears to correlate with the type of palatal fracture.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5475306PMC
June 2017