Publications by authors named "Sanjay Naran"

61 Publications

Hyperbaric Oxygen Therapy for Large Composite Grafts: An Alternative in Pediatric Facial Reconstruction.

J Plast Reconstr Aesthet Surg 2020 Dec 21;73(12):2178-2184. Epub 2020 May 21.

Division of Plastic Surgery, Section of Pediatric Plastic Surgery. Albany Medical Center and Bernard and Millie Duker Children's Hospital at Albany Medical Center. Albany, New York.

Background: Management of pediatric facial defects can be challenging, as reattachment of large composite grafts is usually unsuccessful. Hyperbaric oxygen therapy (HBO) has been researched to augment composite graft survival, but clinical use for this application remains anecdotal. The authors present their successful experience managing select cases with large composite grafts and HBO as an adjunct.

Methods: A retrospective chart review identified children presenting with facial defects and managed operatively with large composite grafts (≥1.5 × 1.5 cm) and HBO therapy. Records were reviewed for defect characteristics, management details, and outcomes at last follow-up.

Results: Nine children (avg. 8.4 years, range 1.6-15.1) presented with ear or nose defects secondary to dog bites (n=7), falls (n=1), or congenital causes (n=1). Three experienced ear amputations, and six suffered nasal avulsions of varying degrees. All avulsed ears were reattached. Three cases of nose avulsions were reattached; the other three underwent secondary reconstruction with composite ear grafts. HBO was initiated immediately and continued for 8-10 days. All grafts survived at least 80% with no postoperative complications. At last follow-up (avg. 30.1 months; 0.8-63.9), all patients demonstrated good cosmetic results with minimal residual deformity.

Conclusion: When reconstruction of pediatric facial defects warrants a large chondrocutaneous graft, immediate postoperative HBO therapy can increase survival. Particularly when reattaching amputated segments, if successful, this approach offers an anatomically ideal result without donor site morbidity. If unsuccessful, it does not "burn bridges" and decreases the extent of secondary reconstruction. The authors present their HBO protocol along with a review of available literature.
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http://dx.doi.org/10.1016/j.bjps.2020.05.028DOI Listing
December 2020

Airway Obstruction Risk in Unique Infant Cleft Phenotype: PSIO Protocol Modification Recommendations.

Cleft Palate Craniofac J 2020 02 30;57(2):245-248. Epub 2019 Jul 30.

Department of Plastic Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA.

Patients presenting with a unique unilateral cleft phenotype may be at risk of nasal airway obstruction which can be exacerbated by presurgical infant orthopedic (PSIO) appliance therapy and lip taping. Four patients presented to the UPMC Children's Hospital of Pittsburgh Cleft-Craniofacial Center with a cleft phenotype characterized by: An anteriorly projected greater alveolar segment and medial collapse of the lesser segment posteriorly, leading to cleft alar base displacement posteromedial to the anteriorly projected greater segment. Resultant bilateral nasal airway obstruction: cleft ala drape over the leading edge of the greater segment's alveolus (cleft side obstruction) and caudal septum displacement secondary to attachments to the orbicularis oris from the noncleft side (noncleft side obstruction). The patient described presented at 3 months old from an outside institution, where PSIO therapy was undertaken. A second opinion was sought due to concern of significant difficulty in breathing and feeding with the PSIO oral plate. Lip-nose adhesion (LNA) was elected and airway obstruction was immediately relieved after this intervention. Lip-nose adhesion releases the tethered cleft side alar base from the pyriform rim of the posteromedially collapsed lesser segment and unites the superior lip and nostril sill-relieving the cleft side nostril obstruction. During the LNA, the caudal septum is surgically released from the anterior nasal spine and is uprighted, relieving the obstructed noncleft nostril. In this cleft anatomy, the treatment alternatives of modification to the PSIO appliance or LNA should be carefully considered in consultation with the surgeon, PSIO provider, and the infant's caretakers.
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http://dx.doi.org/10.1177/1055665619866354DOI Listing
February 2020

A Craniometric Analysis of the Posterior Cranial Base After Posterior Vault Distraction.

J Craniofac Surg 2019 Sep;30(6):1692-1695

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

Background: Posterior vault distraction osteogenesis (PVDO) has been demonstrated to effectively increase intracranial volume, treat increased intracranial pressure, and improve head shape in syndromic patients. The purpose of this study is to compare changes along the posterior cranial base before and after distraction.

Methods: A retrospective review was completed of subjects who underwent PVDO with computed tomography scans at 2 time-points: within 3 months preoperatively and 1 to 6 months postoperatively. Using Mimics software, craniometric landmarks were identified and surface area of the foramen magnum was calculated. A comparison of pre- to postoperative measurements was completed using Wilcoxon matched-paired signed rank tests and linear regression.

Results: A total of 65 PVDO subjects were identified, 12 subjects met inclusion criteria. Mean operative age was 3.0 ± 4.0 years. The cranial vault was distracted on average 25.0 ± 6.0 mm, with those < 12 months of age distracted 29.5 ± 4.9 mm and >12 months of age distracted 22.0 ± 4.9 mm (P = 0.0543). There was a significant increase in pre- to postoperative foramen magnum surface area (52.1 ± 63.2 mm, P = 0.002), length (0.9 ± 1.4 mm, P = 0.050), and width (0.6 ± 1.0 mm, P = 0.050). Similarly, linear distances between nasion and posterior cranial base landmarks such as foramen magnum (3.4 ± 4.2 mm, P = 0.010), and occipital protuberance (9.1 ± 9.6 mm, P = 0.003) were increased. Subjects under 12 months had a greater percentage increases in posterior vault length than those over 12 months.

Conclusion: Posterior vault distraction osteogenesis is associated with an increase in size of the foramen magnum, and lengthening of the posterior cranial base, both of which may be beneficial in patients with turribrachycephaly.
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http://dx.doi.org/10.1097/SCS.0000000000005496DOI Listing
September 2019

Balancing Distraction Forces in the Mandible: Newton's Third Law of Distraction.

Plast Reconstr Surg Glob Open 2018 Sep 14;6(9):e1856. Epub 2018 Sep 14.

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

Vertical mandibular distraction results in translation of both proximal and distal segments. The force exerted on the condylar segment not only places unwanted force on the joint but also rotates the coronoid process into the cranial base. To prevent these sequelae, we investigate the use of a "check plate" on the condylar segment in an attempt to decrease force at the Temporomandibular joint (TMJ) and prevent unwanted rotation of the coronoid. Patients with hemifacial microsomia, seen at our Children's Hospital from 2012 to 2016 having undergone unilateral vertical mandibular distraction with placement of check plate were compared with a sample of those similarly having undergone distraction without use of the plate. Preoperative and postoperative cephalometric measures and 3-dimensional computed tomography imaging were analyzed. Three subjects were identified in each group. Age and Pruzansky-Kaban classification did not differ between groups. Vertical distance from the coronoid process perpendicular to the Frankfort Horizontal did not differ between groups ( < 0.07); however, postoperative distance significantly differed with the coronoid process rotating upward into the cranial base in subjects without a check plate ( < 0.005). Preoperative angle of the coronoid process based on the Frankfort Horizontal did not differ ( < 0.06); however, postoperative angle significantly changed, confirming upward rotation into the cranial base ( < 0.01). Total regenerate did not differ ( < 0.08). Vertical mandibular distraction results in undesirable upward rotation of the proximal segment into the cranial base and superior displacement of regenerate. This can be prevented with the use of a check plate.
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http://dx.doi.org/10.1097/GOX.0000000000001856DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6191224PMC
September 2018

Sphenoid Dysplasia in Neurofibromatosis: Patterns of Presentation and Outcomes of Treatment.

Plast Reconstr Surg 2018 10;142(4):518e-526e

From the Division of Pediatric Plastic and Reconstructive Surgery, Advocate Children's Hospital; and the Division of Plastic and Reconstructive Surgery and the Section of Neuro-Oncology, Division of Oncology, Children's Hospital of Philadelphia.

Background: Sphenoid wing dysplasia in patients with neurofibromatosis type 1 may result in challenging and significant changes, including ultimately vision loss. The authors describe the radiographic patterns of sphenoid dysmorphology with time and age, and the impact of surgical intervention on preservation of vision.

Methods: A retrospective study was performed at a single pediatric hospital, identifying subjects with neurofibromatosis type 1. Records were reviewed in their entirety for each subject, with attention to ophthalmologic evaluation. Radiographic images were digitally analyzed and scored for sphenoid transformations on a grade of 0 to 3.

Results: Fifty-two subjects were identified. On initial imaging, 42.31 percent had a normal sphenoid (grade 0), 32.69 percent had an abnormal contour (grade 1), 11.54 percent had thinning (grade 2), and 13.46 percent had a gross defect (grade 3). Among the 45 subjects with serial imaging, 55.56 percent demonstrated progression of the deformity of at least one grade. Deformity progression correlated with length of imaging interval. Enucleation was noted to occur more often in subjects with a gross sphenoid defect (p < 0.0001). Of subjects identified as having a gross sphenoid defect, 26.7 percent were managed using orbitosphenoid reconstruction with titanium mesh and cranial bone graft, and 33.3 percent were managed with soft-tissue debulking and canthopexy only. Vision was more likely to be preserved with early orbitosphenoid reconstruction (p < 0.05).

Conclusions: Sphenoid dysplasia is a progressive disease. Loss of vision is associated with a gross defect, and appears to be better preserved with early orbitosphenoid reconstruction with titanium mesh and cranial bone graft.
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http://dx.doi.org/10.1097/PRS.0000000000004779DOI Listing
October 2018

Current Concepts in Orthognathic Surgery.

Plast Reconstr Surg 2018 06;141(6):925e-936e

Park Ridge, Ill.; New Haven, Conn.; and Philadelphia, Pa.

Learning Objectives: After studying this article, the participant should be able to: 1. Identify skeletal differences that are treated with orthognathic surgery; describe the goals of orthognathic surgery; and understand modern virtual surgical planning of orthognathic movement of the mandible, maxilla, and chin. 2. Appreciate the surgical principles of maxilla- versus mandible-first surgery, and orthognathic surgery before orthodontic correction; and understand when an osseous genioplasty may be beneficial, and the potency of this bony movement. 3. Appreciate the utility of fat grafting as an adjunct to orthognathic bony movements, and demonstrate understanding of the utility of orthognathic surgery in the treatment of obstructive sleep apnea. 4. Be aware of associated complications and be able to critically assess outcomes following orthognathic surgery.

Summary: This CME article outlines the goals of orthognathic surgery, highlighting advances in the field and current controversies. The principles of the sequencing of osteotomies are discussed and literature is reviewed that may assist in decision-making as to maxilla-first versus mandible-first surgery. The emergence of "surgery first," in which surgery precedes orthodontics, is discussed and important parameters for patient candidacy for such a procedure are provided. The emerging standard of virtual surgical planning is described, and a video is provided that walks the reader through a planning session. Soft-tissue considerations are highlighted, especially in the context of osseous genioplasty and fat grafting to the face. The utility of orthognathic surgery in the treatment of obstructive sleep apnea is discussed. The reader is provided with the most current data on complications following orthognathic surgery and advice on avoiding such pitfalls. Finally, outcome assessment focusing on the most current trend of patient-reported satisfaction and the psychological impact of orthognathic surgery are discussed.
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http://dx.doi.org/10.1097/PRS.0000000000004438DOI Listing
June 2018

Incidence of Cranial Base Suture Fusion in Infants with Craniosynostosis.

Plast Reconstr Surg 2018 04;141(4):559e-570e

Philadelphia, Pa.; and Winston-Salem, N.C.

Background: Cranial base sutures are important drivers of both facial and cranial growth. The purpose of this study was to compare the incidence and location of cranial base suture fusion among three groups: nonaffected controls, patients with nonsyndromic craniosynostosis, and patients with syndromic craniosynostosis.

Methods: Patients and computed tomographic scans were accrued from the authors' prospective craniofacial database. Computed tomographic scans were graded on the frequency of cranial vault and cranial base suture/synchondrosis fusion (0, open; 1, partially/completely fused) by an attending craniofacial surgeon and neuroradiologist. Statistical comparisons were conducted on location and rates of fusion, age, and diagnosis.

Results: One hundred forty patients met inclusion criteria: 55 syndromic, 64 nonsyndromic, and 21 controls. Average age at computed tomography of syndromic patients (3.6 ± 3.1 months) was younger than that of nonsyndromic patients (5.4 ± 3.1 months; p = 0.001) and control subjects (5.1 ± 3.2 months; p = 0.058). Syndromic craniosynostotic patients had over three times as many cranial base minor sutures fused (2.2 ± 2.5) as nonsyndromic craniosynostosis patients (0.7 ± 1.2; p < 0.001) and controls (0.4 ± 0.8; p = 0.002), whose rates of fusion were statistically equivalent (p = 0.342). Syndromic craniosynostosis patients had a greater frequency of cranial base suture fusion in the coronal branches, squamosal arch, and posterior intraoccipital synchondrosis (p < 0.05).

Conclusions: Patients with syndromic craniosynostosis have higher rates of cranial base suture fusion in infancy, especially in the coronal arches, and this may have significant implications for both cranial and facial growth. In contrast, patients with nonsyndromic craniosynostosis have similar rates and sites of cranial base suture fusion as controls. Interestingly, there is a low, "normal," rate of cranial base suture/synchondrosis closure in infancy, the implications of which are unknown.

Clinical Question/level Of Evidence: Risk, III.
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http://dx.doi.org/10.1097/PRS.0000000000004238DOI Listing
April 2018

Quality of Life in Adults with Nonsyndromic Craniosynostosis.

Plast Reconstr Surg 2018 06;141(6):1474-1482

Philadelphia, Pa.

Background: Although studies have analyzed quality of life in children with nonsyndromic craniosynostosis, to date nobody has investigated long-term quality of life in adults with nonsyndromic craniosynostosis. The purpose of this study was to compare quality of life in adult nonsyndromic craniosynostosis patients with a cohort of unaffected controls.

Methods: The authors queried their institution's prospectively maintained craniofacial registry for nonsyndromic craniosynostosis patients aged 18 years and older, and administered the validated World Health Organization Quality of Life Biomedical Research and Education Foundation questionnaire. Responses were compared, using a two-sample t test, to an age-matched U.S. normative database provided by the World Health Organization.

Results: One hundred fifty-one adults met inclusion criteria: 52 were successfully contacted and 32 completed the questionnaire. Average age of respondents was 23.0 ± 6.1 years (range, 18.1 to 42.1 years). Nonsyndromic craniosynostosis patients had a superior quality of life compared with comparative norms in all domains: physical health (17.8 ± 2.7 versus 15.5 ± 3.2; p < 0.001), psychological (16.3 ± 2.9 versus 13.8 ± 3.2; p < 0.001), social (16.9 ± 2.6 versus 13.2 ± 3.6; p < 0.001), and environmental (17.2 ± 2.5 versus 11.7 ± 2.7; p < 0.001). Comparison between single-suture subtypes revealed no difference in any quality-of-life domain (p > 0.05).

Conclusions: Adult patients previously treated for nonsyndromic craniosynostosis perceive their quality of life to be high, superior to that of a normative U.S.

Sample: Future work will seek to analyze additional patients and better understand the reasons behind these findings.
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http://dx.doi.org/10.1097/PRS.0000000000004408DOI Listing
June 2018

Craniometric Analysis of Frontal Cranial Morphology Following Posterior Vault Distraction.

J Craniofac Surg 2018 Jul;29(5):1169-1173

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

Background: Posterior vault distraction osteogenesis (PVDO) is believed to improve frontal contour in infants with syndromic craniosynostosis and turribrachycephaly. This study provides an objective craniometric analysis to determine how PVDO affects anterior cranial morphology.

Methods: A retrospective chart review of patients who underwent PVDO was performed. Inclusion criteria included pre- and postoperative computed tomography (CT) scans within 3 months before surgery and another 1 to 6 months after device removal. Volumetric and craniometric data were derived using Mimics software and compared using paired t-test and Wilcoxon rank-sum test.

Results: About 65 patients underwent PVDO, and 13 patients met inclusion criteria. Mean age at intervention was 3.4 ± 4.2 years. Total cranial volume increased 249 ± 159 cm in all patients (P = 0.0001) and 380 ± 128 cm in patients younger than 1 year of age (n = 6, P =0 .0008). Supraorbital retrusion decreased from 5.44 ± 3.89 to 4.54 ± 3.91 mm postoperatively (P = 0.0004), decreasing significantly in patients without previous frontal surgery and not in those with previous frontal surgery (P = 0.2115; comparison P = 0.0047). Basofrontal angle decreased by 2.92 ± 2.16 degrees (P = 0.0004) with a greater decrease of 3.33±2.68 degrees in those younger than 12 months (P = 0.0289) and 2.58±1.74 degrees in those older (P = 0.0079). No change was found in anterior cranial height and anterofrontal angle (P > 0.05).

Conclusion: PVDO improves frontal contour by decreasing supraorbital retrusion and reducing frontal bossing in syndromic craniosynostosis patients with turribrachycephaly. When combined with its demonstrated efficacy for cranial expansion, these frontal changes likely reinforce PVDO's ability to influence the timing of, and to a degree, the need for frontal surgery in this group.
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http://dx.doi.org/10.1097/SCS.0000000000004473DOI Listing
July 2018

Spring-Mediated Cranioplasty in Sagittal Synostosis: Does Age at Placement Affect Expansion?

J Craniofac Surg 2018 May;29(3):632-635

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

Purpose: The aim of this study is to evaluate the effect of timing of surgery and spring characteristics on correction of scaphocephalic deformity in patients undergoing spring-mediated cranioplasty (SMC) for sagittal craniosynostosis.

Methods: The authors conducted a review of patients with sagittal craniosynostosis who underwent SMC at a tertiary referral center between July 2011 and March 2017, with a primary outcome measure of head shape, both preoperatively and postoperatively, determined by cephalic index (CI). Patient demographics and operative details including timing of surgery and spring characteristics were collected. Differences in CI preoperation and postoperation were compared using Wilcoxon signed-rank test. Ordinary least-squares linear regression was used to assess the impact of timing, number of springs, maximum single spring force, and total spring force on postoperative change in CI.

Results: Thirty-six subjects (12 males and 24 females) were included in the study. Mean age at spring placement was 3.9 months (range: 1.9-9.2) with a mean follow-up of 1.4 years (range: 0.3-5.2). The mean number of springs used was 3 (range: 2-4). The mean maximum single spring force was 9.9 Newtons (N) (range: 6.9-13.0) and the mean total spring force was 24.6 N (range: 12.7-37.0). Mean CI increased from 70 ± 0.9 preoperatively to 77 ± 1.0 postoperatively (P < 0.001). Age at spring placement was significantly associated with change in CI: for every month increase in age, the change in CI decreased by 1.3 (P = 0.03). The number of springs used, greatest single spring force, and total spring force did not correlate with changes in CI (P = 0.85, P = 0.42, and P = 0.84, respectively).

Conclusion: In SMC, earlier age at time of surgery appears to correlate with greater improvement in CI, at least in the short-term. While spring characteristics did not appear to affect head shape, it is possible that the authors were underpowered to detect a difference, and spring-related variables likely deserve additional study.
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http://dx.doi.org/10.1097/SCS.0000000000004233DOI Listing
May 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

Cleft-Palate Repair: Does Hospital Case-Volume Impact Outcomes or Cost?

Plast Reconstr Surg 2018 05;141(5):1193-1200

Philadelphia, Pa.

Background: How hospital case-volume affects operative outcomes and cost continues to grow in importance. The purpose of this study was to examine the relationship of case volume with operative outcomes and cost in cleft palate repair.

Methods: Subjects undergoing cleft palate repair between 2004 and 2015 were identified in the Pediatric Health Information System. Outcomes were compared between two groups: those undergoing treatment at a high-volume institution, and those undergoing treatment at a low-volume institution. Primary outcomes were as follows: any complication, prolonged length of stay, and increased total cost.

Results: Over 20,000 patients (n = 20,320) from 49 institutions met inclusion criteria. On univariate analysis, those subjects who underwent treatment at a high-volume institution had a lower rate of overall complications (3.4 percent versus 5.1 percent; p < 0.001), and lower rates of prolonged length of stay (4.5 percent versus 5.8 percent; p < 0.001) and increased total cost (48.6 percent versus 50.9 percent; p = 0.002). In multivariate regression analyses, subjects treated in high-volume centers were less likely to experience any complication (OR, 0.678; p < 0.001) and were less likely to have an extended length of stay (OR, 0.82; p = 0.005). Subjects undergoing palate repair at a high-volume institution were no less likely to incur increased total cost (OR, 1.01; p = 0.805).

Conclusion: In institutions performing a high volume of cleft palate repairs, subjects had significantly decreased odds of experiencing a complication or prolonged length of stay.

Clinical Question/level Of Evidence: Therapeutic, III.
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http://dx.doi.org/10.1097/PRS.0000000000004292DOI Listing
May 2018

Components Separation for Abdominal Wall Reconstruction in the Recalcitrant, High-Comorbidity Patient: A Review of 311 Single-Surgeon Cases.

Ann Plast Surg 2018 Mar;80(3):262-267

Purpose: Components separation of the abdominal musculature remains a mainstay for closure of complicated midline and paramedian abdominal wall defects. The authors critically analyzed their experience with this technique to identify prognosticators affecting long-term clinical outcomes.

Methods: A retrospective review was performed of patients undergoing components separation by a single senior surgeon (J.M.R.) between 2000 and 2010. Numerous perioperative patient characteristics were collected and analyzed to determine their effects on long-term clinical outcomes. Multivariable logistic regression was used to predict hernia recurrence and other adverse clinical outcomes.

Results: A total of 311 patients were identified (male, 51.1%). Mean age was 53.1 ± 14.0 years, preoperative body mass index was 33.1 ± 8.2 kg/m, and defect width was 11.4 ± 7.5 cm. Patients who had prior hernia repair were 97.4%, with 38.3% having prior mesh placement. Average follow-up was 2.9 ± 2.4 years. Overall hernia recurrence rate was 18.3%. Postoperative complications included seroma (9.3%), superficial wound infection (9.0%), skin dehiscence (4.82%), hematoma (3.2%), deep vein thrombos or pulmonary emolbus (3.2%), and skin flap ischemia (1.0%). Respiratory comorbidity (odds ratio, [OR], 2.02; P < 0.029), prior failed mesh repair (OR, 1.86; P < 0.045), and occurrence of any postoperative complication (OR, 2.02; P < 0.034) significantly increased the risk of eventual hernia recurrence. Preoperative body mass index was not associated with hernia recurrence (P < 0.351) or increased incidence of any aforementioned postoperative complications.

Conclusions: This study provides a comprehensive review of one of the largest single-surgeon experiences using components separation to date. Patients with respiratory comorbidities, prior failed mesh repair, and the occurrence of any postoperative complication are at significantly increased risk for hernia recurrence.
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http://dx.doi.org/10.1097/SAP.0000000000001275DOI Listing
March 2018

More Than Meets the Eye: The Effect of Intercanthal Distance on Perception of Beauty and Personality.

J Craniofac Surg 2018 Jan;29(1):40-44

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

In judging normalcy, surgeons rely on established facial anthropometric measures and proportions. However, there exists a range of "normal," and a degree of disproportion may be considered more attractive. The authors set out to determine how changes in only intercanthal distance affect the layperson's perception of beauty and personality traits of a face. The authors used Amazon.com's Mechanical Turk (MTurk), a crowdsourcing tool, to determine how changes in intercanthal distance affect overall perception of beauty and personality. MTurk respondents provided demographic information and were asked to survey 16 female subjects, each digitally edited to be hypoteloric or hyperteloric. Data were collected from 490 MTurk crowd raters. Paired t test analysis found that respondents perceived subjects to be more submissive, friendly, and attractive with increased intercanthal distance (P < 0.05). Women respondents were less likely to perceive change in regards to how unthreatening and how intelligent the subject appeared upon intercanthal widening (P < 0.05). Compared with Caucasian respondents, minorities (Asian- and African-American) were more likely to perceive difference in submissiveness, threat, intelligence, and attractiveness with increased intercanthal distance (P < 0.05). All respondents >46 years of age were less likely to perceive a change in any of the 7 traits upon intercanthal widening, compared with respondents between 18 and 25 years of age (P < 0.05). The layperson perceives significant increases in a female subject's submissivness, friendliness, and attractiveness with an intercanthal distance increase of 10% from normal. Surgeons should be aware of this when correcting hypertelorism, given the potential positive impact of a slightly increased intercanthal distance on perceived beauty and personality.
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http://dx.doi.org/10.1097/SCS.0000000000004072DOI Listing
January 2018

Craniosynostosis Surgery: Does Hospital Case Volume Impact Outcomes or Cost?

Plast Reconstr Surg 2017 Nov;140(5):711e-718e

Philadelphia, Pa.

Background: The relationships between hospital/surgeon characteristics and operative outcomes and cost are being scrutinized increasingly. In patients with craniosynostosis specifically, the relationship between hospital volume and outcomes has yet to be characterized.

Methods: Subjects undergoing craniosynostosis surgery between 2004 and 2015 were identified in the Pediatric Health Information System. Outcomes were compared between two exposure groups, those undergoing treatment at a high-volume institution (>40 cases per year), and those undergoing treatment at a low-volume institution (40 cases per year). Primary outcomes were any complication, prolonged length of stay, and increased total cost.

Results: Over 13,000 patients (n = 13,112) from 49 institutions met inclusion criteria. In multivariate regression analyses, subjects treated in high-volume centers were less likely to experience any complication (OR, 0.764; p < 0.001), were less likely to have an extended length of stay (OR, 0.624; p < 0.001), and were less likely to have increased total cost (OR, 0.596; p < 0.001). Subjects undergoing strip craniectomy in high-volume centers were also less likely to have any complication (OR, 0.708; p = 0.018) or increased total cost (OR, 0.51; p < 0.001). Subjects undergoing midvault reconstruction in high-volume centers were less likely to experience any complications (OR, 0.696; p = 0.002), have an extended length of stay (OR, 0.542; p < 0.001), or have increased total cost (OR, 0.495; p < 0.001).

Conclusion: In hospitals performing a high volume of craniosynostosis surgery, subjects had significantly decreased odds of experiencing a complication, prolonged length of stay, or increased total cost compared with those undergoing treatment in low-volume institutions.

Clinical Question/level Of Evidence: Therapeutic, III.
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http://dx.doi.org/10.1097/PRS.0000000000003763DOI Listing
November 2017

Orthognathic Surgery Has a Significant Effect on Perceived Personality Traits and Emotional Expressions.

Plast Reconstr Surg 2017 Nov;140(5):971-981

Philadelphia, Pa.

Background: The effects of orthognathic surgery go beyond objective cephalometric correction of facial and dental disproportion and malocclusion, respectively. The authors hypothesized that there is tangible improvement following surgery that alters publicly perceived personality traits and emotions.

Methods: The authors used Amazon.com's Mechanical Turk (MTurk), a crowdsourcing tool, to determine how preoperative and postoperative images of orthognathic surgery patients were perceived on six personality traits and six emotional expressions based on posteroanterior and lateral photographs. Blinded respondents provided demographic information and were randomly assigned to one of two sets of 20 photographs (10 subjects before and after surgery).

Results: Data on 20 orthognathic surgery patients were collected from 476 individuals. The majority of participants were female (52.6 percent), 18 to 39 years old (67.9 percent), Caucasian (76.6 percent), had some college or technical training or graduated college (72.7 percent), and had an annual income between $20,000 and $99,999 (74.6 percent). A paired t test analysis found that subjects were perceived significantly more favorably after orthognathic surgery in 12 countenance categories: more dominant, trustworthy, friendly, intelligent, attractive, and happy; and also less threatening, angry, surprised, sad, afraid, and disgusted (p < 0.05). Raters with the highest annual income perceived a greater magnitude of dominance after surgery than those earning less (p < 0.001).

Conclusions: There is significant improvement in the countenance of patients after orthognathic surgery, with both perceived personality traits and emotions deemed more favorable. Additional work is needed to better understand the physiologic underpinnings of such findings. Crowdsourcing technology offers a unique opportunity for surgeons to gather data regarding laypeople's perceptions of surgical outcomes in areas such as orthognathic surgery.
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November 2017

A Craniometric Analysis of Cranial Base and Cranial Vault Differences in Patients With Metopic Craniosynostosis.

J Craniofac Surg 2017 Nov;28(8):2030-2035

*Division of Plastic and Reconstructive Surgery †Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA.

Purpose: The effect of synostosis is not confined to the immediate vicinity of the suture. The authors hypothesized metopic craniosynostosis results in migration of lateral structures from midline, and differences in segmental volume of the cranial fossa.

Methods: A retrospective case-controlled cohort analysis of patients with nonsyndromic metopic craniosynostosis was performed. Craniometric angles, distances to landmarks from midline, cephalic index, and segmented volume ratios were calculated. A comparison group consisted of patients without cranial pathology or with mild positional plagiocephaly.

Results: Twenty patients with metopic craniosynostosis and 19 controls were identified. The bifrontal angle was significantly more acute in metopic patients. Distance from midline to the medial carotid, the foramen ovale, and the hypoglossal canal were all significantly longer in metopic patients. Ratio of anterior third to total cranial vault volume was significantly smaller in metopic patients; however, ratio of middle third to total cranial vault volume was significantly larger. As the bifrontal angle decreased by 1°, the volume of the anterior third of the cranial vault was observed to decrease by 0.17% (P < 0.001).

Conclusions: Patients with metopic craniosynostosis show a distinct and significant transverse lateralization of structures of the anterior skull base relative to midline, significant restriction of the anterior third of the cranial vault, and compensatory expansion of the middle third. There is a linear relationship between the bifrontal angle and the subsequent change in anterior third cranial vault volume.

Level Of Evidence: IV; Therapeutic.
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November 2017

A Volumetric and Craniometric Analysis of Cranial Base Differences in Unicoronal Craniosynostosis.

J Craniofac Surg 2017 Oct;28(7):1725-1729

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

Background: The authors hypothesized that patients with unicoronal craniosynostosis (UCS) have deviation of the vault, cranial base, and face resulting in significant differences in skull base morphology and segmental cranial vault volume relative to nonaffected controls.

Methods: Unicoronal craniosynostosis patients were collected from the authors' IRB-approved, prospective, craniofacial registry; controls were from a trauma registry. Mimics software was used to compare those with UCS to controls for a series of standardized craniometric angles and distances. A segmented volumetric analysis of anterior, middle, and posterior cranial fossae was performed, as well.

Results: The study included 18 patients with UCS and 19 controls. Nearly all angles measured were statistically different in UCS versus controls. Overall cranial vault volume did not differ between UCS and controls (P = 0.250). Three volumetric ratios comparing the synostosed side to the contralateral were significantly less than controls: anterior (0.44 ± 0.03 versus 0.5 ± 0.01, P < 0.001), middle (0.45 ± 0.02 versus 0.5 ± 0.02, P < 0.001), posterior (0.46 ± 0.02 versus 0.50 ± 0.02, P < 0.001). The ratio of total middle volume to total cranial volume was larger in UCS patients versus controls, but the posterior ratio was smaller: anterior (0.13 ± 0.02 versus 0.12 ± 0.02, P = 0.545), middle (0.50 ± 0.05 versus 0.42 ± 0.04, P = 0.001), posterior (0.37 ± 0.05 versus 0.45 ± 0.03, P = 0.001).

Conclusions: This study provides quantitative evidence of the degree of angulation and torsion of the cranial base in UCS and its profound effect on volumetric differences in the cranial vault, with significant restriction on the synostosed side and compensatory expansion on the nonsynostosed side. Future work will focus on the effects of volumetric differences on cerebral architecture and postoperative volumetric changes.
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October 2017

Asymmetric Multisutural Craniosynostosis: an Algorithm of Early Intervention to Prevent Evolving Deformity.

J Craniofac Surg 2017 Jul;28(5):1211-1219

Department of Pediatric Plastic Surgery, Children's Hospital of Pittsburgh, Pittsburgh, PA.

Background: Asymmetric multisutural craniosynostosis (AMC) is characterized by fusion of a midline suture combined with unilateral fusion of at least 1 nonmidline suture. Due to its rarity, complexity, and high rate of reoperation, the purpose of this study is to evaluate outcomes of our staged approach to AMC.

Methods: Patients treated for craniosynostosis between January 2004 and December 2013 were identified retrospectively. Only patients with AMC and a minimum follow-up of 2 years were included. The 3-staged algorithm includes: extended strip craniectomy of fused sutures; postoperative helmet molding; and fronto-orbital advancement versus a touch-up procedure. Morphologic, aesthetic, and functional outcomes were evaluated.

Results: Nine patients (6.8% of cases) were treated for AMC (mean follow-up: 4.1 years). Sixty-seven percent of patients (6 of 9) demonstrated signs of elevated intracranial pressure. Patients were divided into 2 groups: "Group A" included patients treated according to the staged algorithm (n = 5); "Group B" included those treated by traditional techniques (n = 4). Group A underwent their first calvarial vault procedure earlier than those from Group B (2.7 vs. 13.2 months; P < 0.02). Postoperatively, no Group A patients had developmental delay, signs of elevated intracranial pressure, or reoperation. Three of 5 patients (60%) were rated Whitaker Classification II and the others (40%) rated Whitaker Classification III.

Conclusions: Asymmetric multisutural synostosis results in a complex and evolving deformity involving the entire craniofacial complex. However, when asymmetric multisutural synostosis is approached in stages with early intervening helmet therapy, acceptable functional and appearance-related outcomes can be obtained with minimal complications.

Level Of Evidence: III.
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July 2017

Nonsyndromic Craniosynostosis and Associated Abnormal Speech and Language Development.

Plast Reconstr Surg 2017 Jul;140(1):62e-69e

Pittsburgh and Philadelphia, Pa.

Background: Although many metrics for neurodevelopment in children with nonsyndromic craniosynostosis have been analyzed, few have directly examined early language acquisition and speech development. The authors characterized language acquisition and speech development in children with nonsyndromic craniosynostosis.

Methods: The authors' institutional database was queried for nonsyndromic craniosynostosis from 2000 to 2014. Patients with an identified syndrome were excluded. Specific data elements included age, gender, velopharyngeal adequacy by means of the Pittsburgh Weighted Speech Scale, evaluation for anatomical motor delay, language acquisition delay/disorder, articulation or speech sound production delays/disorders, and whether speech therapy was recommended. Diagnosis of a submucous cleft palate was noted.

Results: One hundred one patients met inclusion criteria, of which 57.4 percent were male. Average age at the time of the most recent speech evaluation was 6.1 years (range, 2.31 to 17.95 years); 43.6 percent had normal speech/language metrics and 56.4 percent had one or more abnormalities, including anatomical motor delay/disorder (29.7 percent), language acquisition delay/disorder (21.8 percent), articulation or speech production delay/disorder (4.0 percent), hypernasality (15.8 percent), and velopharyngeal insufficiency or borderline competency (23.8 percent). Average Pittsburgh Weighted Speech Scale score was 1.3 (range, 0 to 5), and 29.7 percent (n = 30) of patients were recommended to have speech therapy. In addition, 25.8 percent of patients were diagnosed with a submucous cleft palate.

Conclusions: One in four patients with nonsyndromic craniosynostosis carried a diagnosis of submucous cleft palate. The authors found that abnormal speech and language development occurs in one in 1.7 patients with nonsyndromic craniosynostosis, and that speech therapy for such abnormal development is warranted in one in 3.4 of them-a prevalence two to five times higher compared with the general pediatric population.
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http://dx.doi.org/10.1097/PRS.0000000000003423DOI Listing
July 2017

The Whitaker Classification of Craniosynostosis Outcomes: An Assessment of Interrater Reliability.

Plast Reconstr Surg 2017 Oct;140(4):579e-586e

Philadelphia, Pa.

Background: The Whitaker classification is a simple and widely used system for describing aesthetic outcomes after craniosynostosis surgery. The purpose of this study is to evaluate its interrater reliability for patients who have undergone fronto-orbital surgery.

Methods: A retrospective review of patients with craniosynostosis who underwent surgical intervention at a tertiary referral center was conducted. Inclusion criteria were as follows: single-suture craniosynostosis, surgical intervention before age 2 years, and photographs taken before revisions between 5 and 20 years of age. Thirteen craniofacial surgeons independently reviewed the subjects' photographs and assigned Whitaker classifications. Interrater reliability was assessed with the Cohen kappa statistic.

Results: Twenty-nine subjects were included. Average ages at surgery and at the time of postoperative photography were 0.8 year and 12.8 years, respectively. The κ value for all 13 raters was 0.1567 (p < 0.0001), indicating "slight agreement." Pairwise comparisons demonstrated κ values ranging from 0.0384 to 0.5492. The average rating for the set of 29 photographs differed significantly across the 13 raters (p = 0.0020) and ranged from 1.79 ± 0.68 to 2.79 ± 0.77. Finally, we found that average Whitaker classification did not differ significantly between subjects who subsequently underwent cranioplasty and/or fronto-orbital advancement and those who did not (subsequent procedures, 2.45 ± 0.55; no subsequent procedures, 1.88 ± 0.78; p = 0.1087).

Conclusions: The Whitaker classification exhibits low interrater reliability and does not predict future treatment. It may benefit craniofacial surgeons to create new evaluation tools with greater precision, to improve the quality of patient care and craniofacial outcomes research.
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October 2017

Nasal Root Deviation in Unicoronal Craniosynostosis: A Craniometric Analysis of Early and Late Postoperative Outcomes.

J Craniofac Surg 2017 Jul;28(5):1220-1223

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

Purpose: Current operative techniques for correcting unicoronal craniosynostosis (UCS) leave the nasal bones untouched, resulting in an unclear long-term impact on nasal root deviation. The purpose of this study is to quantify nasal root deviation in the preoperative and late postoperative setting in patients who have undergone conventional single-staged UCS correction.

Methods: The authors performed a retrospective, craniometric analysis of nasal root deviation comparing preoperative computed tomography scans, with those of the early, and late postoperative period. Three vectors were analyzed to measure nasal root deviation, one extending from the nasion to the rhinion (nasal bone vector), the second from the rhinion to the anterior nasal spine (nasal aperture vector), and the third from the nasion to the anterior nasal spine (nasal longitudinal vector).

Results: Twenty-five subjects were included in the study. Average ages at the time of preoperative, early, and late postoperative imaging were 0.6 ± 0.3, 0.9 ± 0.6, and 9.3 ± 2.7 years, respectively. Improvement of angular deviation of both the nasal aperture vector and nasal longitudinal vector was observed. Mean angular deviation of the nasal aperture vector was 6.0 ± 1.9 degrees preoperatively, 6.0 ± 2.1 degrees early postoperatively (P = 0.952), and 2.4 ± 2.1 in the late postoperative period (P = 0.013). Mean angular deviation of the nasal longitudinal vector was 5.7+2.0 degrees preoperatively, 5.8 ± 2.3 degrees early postoperatively (P = 0.948), and 3.7 ± 1.6 degrees in the late postoperative period (P = 0.019).

Conclusion: Nasal root deviation decreased significantly only in the late postoperative period, lending credence to the notion that though UCS correction does not directly address nasal root deviation, this pathology improves significantly over time.
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July 2017

What's New in Cleft Palate and Velopharyngeal Dysfunction Management?

Plast Reconstr Surg 2017 Jun;139(6):1343e-1355e

Pittsburgh, Pa.

Learning Objectives: After studying this article, the participant should be able to: 1. Have a clear understanding of the evolution of concepts of velopharyngeal dysfunction, especially as it relates to patients with a cleft palate. 2. Explain the subjective and objective evaluation of speech in children with velopharyngeal dysfunction. 3. On the basis of these diagnostic findings, be able to classify types of velopharyngeal dysfunction. 4. Develop a safe, evidence-based, patient-customized treatment plan for velopharyngeal dysfunction founded on objective considerations.

Summary: Velopharyngeal dysfunction is improper function of the dynamic structures that work to control the velopharyngeal sphincter. Approximately 30 percent of patients having undergone cleft palate repair require secondary surgery for velopharyngeal dysfunction. A multidisciplinary team using multimodal instruments to evaluate velopharyngeal function and speech should manage these patients. Instruments may include perceptual speech analysis, video nasopharyngeal endoscopy, multiview speech videofluoroscopy, nasometry, pressure-flow, and magnetic resonance imaging. Velopharyngeal dysfunction may be amenable to surgical or nonsurgical treatment methods or a combination of each. Nonsurgical management may include speech therapy or prosthetic devices. Surgical interventions could include palatal re-repair with repositioning of levator veli palatini muscles, posterior pharyngeal flap, sphincter pharyngoplasty, or soft palate or posterior wall augmentation. Treatment interventions should be based on objective assessment and rating of the movement of lateral and posterior pharyngeal walls and the palate to optimize speech outcomes. Treatment should be tailored to specific anatomical and physiologic findings and the overall needs of the patient.
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http://dx.doi.org/10.1097/PRS.0000000000003335DOI Listing
June 2017

Biomechanical Integrity in Craniofacial Surgery: Calvarial Reconstruction in Favorable and Infected Defects with Bone Morphogenetic Protein 2.

Plast Reconstr Surg 2017 May;139(5):1141-1150

Pittsburgh, Pa.; and Augusta, Ga.

Background: The limitations of autologous and alloplastic reconstruction for craniofacial bone defects have created a clinical need for viable tissue-engineering strategies. Recombinant human bone morphogenetic protein-2 (rhBMP-2) has shown promise in this setting. The aim of this study was to determine the long-term biomechanical properties of rhBMP-2-mediated calvarial reconstruction.

Methods: Twelve-week-old New Zealand White rabbits underwent subtotal calvarectomy. Defects were repaired in one of several groups: immediate reconstruction with autologous graft, immediate reconstruction with cryopreserved bone graft, immediate reconstruction with rhBMP-2 (favorable), and delayed reconstruction with rhBMP-2 following infection and subsequent débridement (unfavorable). Cryopreserved reconstructions were measured at 6 weeks; autologous reconstructions were measured at 6 weeks and 6 months; and both favorable and unfavorable rhBMP-2 reconstructions were assessed at 6 weeks, 6 months, and 1 year after reconstruction. Healing was assessed with computed tomography. An unconfined compression test was performed for biomechanical analysis. Stress at 20 percent strain, percentage relaxation, tangent modulus, and final strain at 1800 N were compared between groups.

Results: Nearly complete radiographic coverage was achieved by 6 months for autologous reconstruction and by 6 weeks for rhBMP-2 reconstruction. Favorable rhBMP-2 reconstruction demonstrated a larger final strain at 1800 N through 1 year compared with native bone. Bone in unfavorable rhBMP-2 reconstruction was more compressible than native bone, with a larger final strain at 1800 N at 1 year. There were no significant differences between favorable and unfavorable groups.

Conclusions: Despite providing radiographic coverage, the biomechanical properties of rhBMP-2 bone differ from those of native bone. Further studies are warranted to determine how these properties affect overall strength and structural integrity.
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May 2017

Pediatric Dog Bite Prevention: Are We Barking Up the Wrong Tree or Just Not Barking Loud Enough?

Pediatr Emerg Care 2019 Sep;35(9):618-623

From the Department of Pediatric Plastic Surgery.

Objectives: The objectives of this study were (1) to evaluate dog bite-related injuries and associated medical documentation and (2) to compare these results with a study of dog bites from the same institution 10 years prior.

Methods: Data were retrospectively collected from a pediatric emergency department from July 2007 to July 2011 for patients treated for dog bites. These data were then compared with data from the same institution from 10 years prior.

Results: A total of 1017 bite injuries were treated (average, 254.25 bites/year), which represents a 25% increase compared with 10 years prior. Comparing the 1997 and 2007 to 2011 cohorts, patient demographics, bite rate among children less than 5 years old, rate of dog breed documentation, and setting of injury were similar. Dog breed was reported in 47% (95% confidence interval [CI], 40.2-53.9) and 41% (95% CI, 38.0-44.0) of cases, respectively, in the 2 cohorts. Bites to the craniofacial region were most common (face only reported for 1997: 43.2%; 95% CI, 36.4-50 versus 2007-2011: 66.1%; 95% CI, 63.2-69.0). In both cohorts, the child's home was the most frequent setting, accounting for 43% of bites (1997: 95% CI, 30.2-55.9 and 2007-2011: 95% CI, 39.3-46.7).

Conclusions: Pediatric dog bites continue to occur frequently, and the associated factors did not change over the 10-year period: young age of child, bites to the craniofacial region, and dogs familiar to the child. Although accurate medical documentation of dog bites is a prerequisite to develop effective prevention strategies, current medical documentation of dog bites may be misguided.
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September 2019

Case Report: 35-Year Follow-up for Nonvascularized Toe Phalangeal Transfer for Multiple Digit Symbrachydactyly.

Hand (N Y) 2016 12 28;11(4):NP38-NP40. Epub 2016 Jul 28.

University of Pittsburgh, PA, USA; Hand & UpperEx Center, Wexford, PA, USA.

A case is discussed in which a young girl was born with symbrachydactyly of multiple digits in whom nonvascularized proximal toe phalanges were transferred to the aphalangic digits at the age of four. At 39 years of age, she presented incidentally to our clinic and was observed to have a very functional hand with mobile metacarpophalangeal joints in all reconstructed digits. We present a case report which is discussed in the context of long-term follow-up, and phalangeal growth in the absence of distraction, and a review of the current literature in regards to outcomes for this modality of treatment. We document growth of the transplanted phalanges, despite surgery occurring after the reported optimum age of before 18 months, and the patient not undergoing distraction. The patient reported no donor site morbidity in regards to function or psychosocial impact. Furthermore, we observed active function at the metacarpophalangeal joints of all operated digits. We report the longest follow-up (35 years) following nonvascularized proximal toe phalangeal transfer for short finger type symbrachydactyly. We highlight the long-term functional outcome of nonvascularized toe phalangeal transfers, and present an overview of the current outcome literature for this type of procedure, advocating that nonvascularized toe phalangeal transfers remain a viable treatment option for select cases of symbrachydactyly.
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http://dx.doi.org/10.1177/1558944716658748DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5256662PMC
December 2016

Titanium versus Stainless-Steel Plating in the Surgical Treatment of Distal Radius Fractures: A Randomized Trial.

J Hand Microsurg 2016 Dec 12;8(3):155-158. Epub 2016 Oct 12.

Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States; Division of Hand and Upper Extremity Surgery, Department of Orthopedic Surgery, Technion Israel Institute of Technology School of Medicine, Haifa, Israel.

Our purpose was to compare postoperative complications and rate of plate removal in titanium and stainless-steel plating of distal radius fractures (DRF). Patients following DRF were randomly fixed with titanium or stainless-steel plates using the same plating system. Complications, second surgeries, and plate prominence were documented. A total of 41 patients were treated with stainless-steel and 22 with titanium plates. Average follow-up was 60 ± 5.6 months. There was no difference in demographics, fracture characteristics, or follow-up between the groups. Plate prominence was found in 50% of radiographs (mean distance: 1.4 mm). Four titanium plates and three stainless-steel plates were removed (11%). Mean time to plate removal was 18.4 ± 4.6 months. There was no difference in removal rates between the groups. Plate material and prominence, age, fracture comminution and smoking status were not associated with plate removal. Our results support using volar and dorsal plates regardless of the plate material.
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http://dx.doi.org/10.1055/s-0036-1593731DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5167617PMC
December 2016

Simonart's Band: Its Effect on Cleft Classification and Recommendations for Standardized Nomenclature.

Cleft Palate Craniofac J 2017 11 12;54(6):726-733. Epub 2016 Sep 12.

Objective: Accurate classification of cleft lip plays an important role in communication, treatment planning, and comparison of outcomes across centers. Although there is reasonable consensus in defining cleft types, the presence of Simonart's band can make classification challenging. Our objective was to survey cleft care providers to determine what all consider to be Simonart's band, how its presence effects cleft lip classification, and to provide recommendations for standardized nomenclature.

Design: A multiple-choice survey was e-mailed to 1815 members of the American Cleft Palate-Craniofacial Association, assessing each respondent's definition of Simonart's band and its effect on cleft classification. Cleft classification was drawn from the ICD system diagnosis billing codes. Descriptive analysis was performed.

Results: Three hundred seventy-three providers completed the survey (20.5% response), the majority of whom were surgeons (61.5%); 87.1% agreed with the definition that a Simonart's band is "any soft tissue bridge located at the base of the nostril or more internally, between the segmented ridges." However, only 41.8% felt that the presence of a Simonart's band rendered a cleft lip incomplete; 54.4% felt that an alveolar cleft was the defining difference between a complete and an incomplete cleft lip. When asked to define the child with a cleft involving the upper lip that extends into the naris but interrupted by a soft tissue bridge located only at the base of the nostril or more internally, without a cleft of the alveolar ridge and palate, 61.4% classified this as an incomplete cleft lip, 32.7% as a complete cleft lip, and 5.9% as an unspecified cleft lip.

Conclusions: Responses revealed wide discrepancy in the classification of cleft phenotypes and in the interpretation of the significance of anatomical components in the classification of a cleft lip. We discuss the difficulty in aligning classification based on unclear definition of terms and variable anatomic parameters. We highlight this issue in the face of a need for comparability in clinical evidence-based practices. To ensure precision and uniformity in cleft classification, we recommend that use of the term "Simonart's band" be abandoned while incorporating a notation of the integrity of the nasal sill into the LAHSHAL system. We propose a uniform definition of incomplete versus complete cleft lip, wherein a cleft lip will be classified as complete in the presence or absence of narrow bands of tissue present at the base of the nasal sill or more internally.
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November 2017

Pediatric Craniofacial Fractures: Trajectories and Ramifications.

J Craniofac Surg 2016 Sep;27(6):1535-8

*Department of Plastic Surgery, University of Pittsburgh, Pittsburgh †Division of Plastic Surgery, University of Pennsylvania, Philadelphia ‡Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA.

Background: The pediatric craniofacial skeleton fractures in patterns distinct from those typical in adults; this has implications pertinent to management that may go unrecognized. The authors reviewed multilevel pediatric craniofacial fractures presenting to their institution, surmising that they would display an oblique trajectory of fracture patterns, and would be at increased risk of growing skull fractures (GSFs), compared with adults.

Methods: A retrospective review was performed of pediatric patients presenting with multilevel craniofacial fractures between 2004 and 2010. Demographics, cause of injury, fracture patterns, associated injuries, management, and follow-up information were gathered. Computed tomography scans were reviewed to characterize fracture length, displacement, and trajectory. Adverse outcomes were documented, with particular attention to GSFs.

Results: One hundred fifty-one patients met our inclusion criteria, which included a follow-up of >3 years. Average age at injury was 9.5 ± 4.7 years. Patterns of fracture displayed near consistent obliquity, with only 4 patients (2.6%) displaying a LeFort-type facial fracture. LeFort patterns were associated with older patients over the age of 12, but without statistical significance (P = 0.07). Five patients (3.3%) died as a result of their injuries. 3.3% of patients developed a GSF. All craniofacial fracture patients demonstrated radiographic and/or clinical evidence of healed fractures at their last follow-up.

Conclusions: This series of pediatric craniofacial fractures near consistently demonstrated oblique fracture patterns, in contrast to the typical adult fracture patterns described by LeFort. Pediatric craniofacial fractures are also at increased risk of GSFs. Understanding of these principles is fundamental to successful therapy in this population.
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September 2016

Repair of a Complicated Calvarial Defect: Reconstruction of an Infected Wound With rhBMP-2.

Ann Plast Surg 2016 Feb;76(2):205-10

From the *Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA; †Georgia Health Sciences University, Augusta, GA; ‡Division of Plastic Surgery, University of Wisconsin, Madison, WI; §Department of General Surgery, St Louis University, St Louis, MO; ∥Department of Oral Biology, and ¶Departments of Anthropology and Orthodontics, University of Pittsburgh, Pittsburgh, PA.

Background: Management of the previously infected craniofacial defect remains a significant clinical challenge, posing obstacles such as wound healing complications, lack of donor site availability, and predisposition to failure of the repair. Optimal therapy would reconstruct like with like, without donor site morbidity. The purpose of this study was to compare the efficacy of recombinant human bone morphogenetic protein-2 (rhBMP-2)-mediated bone regeneration with the current standard of autologous bone graft for repair of previously infected calvarial defects.

Methods: Nineteen adult New Zealand white rabbits underwent subtotal calvariectomy. Bone flaps were inoculated with Staphylococcus aureus and replanted. After 1 week of infection, bone flaps were removed, and wounds were debrided, followed by 10 days of antibiotic treatment. After 6 weeks, animals underwent scar debridement followed by definitive reconstruction in 1 of 4 groups: empty control (n = 3), vehicle control (buffer solution on absorbable collagen sponge [ACS], n = 3), autologous bone graft (n = 3), or rhBMP-2 repair (rhBMP-2/ACS, n = 10). Animals underwent computed tomography imaging at 0, 2, 4, and 6 weeks postoperatively, followed by euthanization and histological analysis. Percent healing was determined by 3-dimensional analysis. A (time × group) 2-way analysis of variance was performed on healing versus treatment group and postoperative time.

Results: At 6 weeks postoperatively, rhBMP-2/ACS and autologous bone graft resulted in 93% and 68% healing, respectively, whereas the empty and vehicle control treatment resulted in 27% and 26% healing (P < 0.001). Histologically, compared to autologous bone graft, bone in the rhBMP-2/ACS group was more cellular and more consistently continuous with wound margins.

Conclusions: The rhBMP-2 therapy is effective in achieving radiographic coverage of previously infected calvarial defects.
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http://dx.doi.org/10.1097/SAP.0000000000000515DOI Listing
February 2016