Clarifying "meaning" in the context of cancer research: a systematic literature review

OBJECTIVES

This article synthesizes the published literature related to the construct of meaning in the adult cancer population.

METHODS

The databases CancerLit, CINAHL, Medline, PsychINFO, and the Journal of Psychosocial Oncology and PsychoOncology were searched to identify all studies related to meaning. The methodological aspects of all studies are described and the conceptual aspects are summarized only from those studies that met criteria for methodological rigor and validity of findings. The definitions for global meaning, appraised meaning, search for meaning, and meaning as outcome as proposed by Park and Folkman were used to interpret the findings.

RESULTS

Of 44 studies identified, 26 met the criteria for methodological rigor. There is strong empirical and qualitative evidence of a relationship between meaning as an outcome of and psychosocial adjustment to cancer.

SIGNIFICANCE OF RESULTS

The qualitative findings are considered useful for the development of psychosocial interventions aimed at helping cancer patients cope with and even derive positive benefit from their experience. However, variations in the conceptual and operational definitions, frequent reliance on homogeneous and convenience sampling, and the lack of experimental designs are considered to be methodological limitations that need to be addressed to advance the study of meaning in the context of cancer.

Sequence Dependence of Charge Transport Properties of DNA

The electrical conduction through three short oligomers (26 base pairs, 8 nm long) with differing numbers of GC base pairs was measured. One strand is poly(A)-poly(T), which is entirely devoid of GC base pairs. Of the two additional strands, one contains 8 and the other 14 GC base pairs. The oligomers were adsorbed on a gold substrate on one side and to a gold nanoparticle on the other side. Conducting atomic force microscope was used for obtaining the current versus voltage curves. We found that in all cases the DNA behaves as a wide band-gap semiconductor, with width depending on the number of GC base pairs. As this number increases, the band-gap narrows. For applied voltages exceeding the band-gap, the current density rises dramatically. The rise becomes sharper with increasing number of GC base pairs, reaching more than 1 nA/nm2 for the oligomer containing 14 GC pairs.

Using the Patient Generated Index to evaluate response shift post-stroke

BACKGROUND

Individualized measures allow for the assessment of health-related quality of life (HRQL) based on areas that are relevant to the person and may prove to be useful for evaluating response shift (reconceptualization of HRQL and change in values).

OBJECTIVE

The objective of this study was to assess reconceptualization of HRQL and change of individual values among persons with stroke during the first six months of recovery.

METHODS

The data collection for this study was incorporated into a randomized trial of acute post-stroke care. Individualized HRQL was evaluated at 6 and 24 weeks post-stroke using the Patient Generated Index (PGI). At 24 weeks a semi-structured interview was administered to assess whether verbalizations given by subjects indicated that they had experienced a response shift.

RESULTS

Ninety two subjects (61%) had complete PGI information at the 6- and 24-week evaluations, and of these, 46 completed the semi-structured interview. Between the 6- and 24-week evaluations, the domains selected were: the same for 10 (11%) subjects, reduced for 27 (29%), expanded for 11 (12%), and completely different for 44 (48%) subjects. Twenty eight percent (n = 13) of subjects recovering from stroke experienced a response shift as evidenced by the semi-structured interviews.

CONCLUSION

The PGI provides valuable information regarding changes in person's conceptualization of HRQL and values, but the feasibility of using an individualized measure during the first six months post-stroke is limited by the added complexity of completing and interpreting such a measure.

The structural equation modeling technique did not show a response shift, contrary to the results of the then test and the individualized approaches

BACKGROUND AND OBJECTIVE

Persons experiencing changes in their physical health may change their values and rerate the importance of basic elements of health-related quality of life (HRQL), a process known as response shift. Developing an estimator of HRQL that differentiates between objective change and response shift is essential for the interpretation of the results. The purpose of the present article was to contrast three methodologic approaches for evaluating response shift to develop a proposed set of HRQL measurement recommendations under circumstances where response shift is expected to occur.

METHODS

The three approaches compared were a structural equation modeling (SEM) technique, the then test, and an individualized approach. The data collection procedures for these methods were incorporated into a poststroke randomized controlled trial.

RESULTS

The SEM did not show a response shift, contrary to the results of the then test and the individualized approaches. We discuss factors that effect the selection of a methodologic approach including feasibility, subjects' memory and more advanced cognitive tasks, and whether response shift was evaluated at the group or individual level.

CONCLUSION

The evaluation of response shift is an integral part of HRQL evaluations, and further comparisons between methodologic approaches are needed.

Parental perspectives on hospital staff members' acts of kindness and commemoration after a child's death

OBJECTIVES

Acts of kindness and commemoration by staff members often follow the death of a patient. Acts include attending funerals, sending sympathy cards, sending cards on birthdays/anniversaries, telephoning/visiting family homes, and attending memorial services. This study explores the significance of these acts for bereaved parents.

METHODS

Twelve parents whose children died in the ICU of a tertiary care pediatric hospital were interviewed, to explore their experiences of the death. Investigators reviewed transcripts and observational field notes. Multidisciplinary team triangulation was used to corroborate themes, with cross-case analysis.

RESULTS

Three themes emerged regarding parental experiences of staff members' acts, ie, (1) parents placed great importance on the hospital's memorial service and on staff members' presence at the service; (2) parents found it difficult to return to the hospital after the child's death but all attended the memorial service, finding some closure in the return; and (3) parents appreciated receiving cards and greatly valued staff members' efforts to telephone/visit and to attend the funeral. Months later, parents remembered positively which staff members engaged in which activities. Conversely, parents expressed disappointment when staff members did not engage in these activities and/or were absent from memorial/funeral services.

CONCLUSIONS

Efforts to support families and to commemorate deceased children are appreciated by bereaved parents. Staff members' absences at commemorative events and a lack of supportive acts are noticed and regretted by families. Staff members and program administrators should attempt to arrange workloads to ensure meaningful contact between staff members and parents during the bereavement period.

Response shift influenced estimates of change in health-related quality of life poststroke

OBJECTIVE

The interpretability of changes in perceived health status over time is threatened if people experience a response shift. This study assessed whether the recovery process following stroke altered individuals' perceptions of past health status and the impact that change in internal standards (response shift) had on ratings over time. We hypothesized that individuals with stroke would experience changes in internal standards, not experienced by the control group. Two other hypotheses related to objective criterion measures also were tested.

STUDY DESIGN AND SETTING

Individuals were recruited through a randomized trial of acute poststroke care. Health status was evaluated at baseline (within the first week poststroke), 6 and 24 weeks later using the EQ VAS. At 6 and 24 weeks, subjects were asked to retrospectively re-evaluate their health status for the preceding evaluation using the then test technique.

RESULTS

The pattern of mean scores was indicative of changes in internal standards among individuals with stroke but not for the control group. Memory had an impact on estimates of response shift. Hypotheses related to the objective criterion measures were not supported.

CONCLUSION

The results suggest that there was a change in internal standards, and that measures of improvement in health status are different based on prospective as compared to retrospective ratings. Further understanding of the impact of recall on the assessment of response shift using the then test is needed to validate the use of this technique.

What determines the quality of life of terminally ill cancer patients from their own perspective?

BACKGROUND

Although several instruments have been developed to measure the quality of life (QOL) of palliative care patients, a rigorous research study has not specifically asked patients themselves what is important to their QOL. It is, therefore, not clear whether these instruments measure what is most important to these patients' QOL.

PURPOSE

To understand the primary determinants of the QOL of palliative care patients with cancer.

METHOD

The study used a qualitative paradigm. Participants were interviewed concerning what was important to their QOL. A systematic content analysis of the transcripts was carried out by all the investigators.

RESULTS

Five broad domains were found to be importnat determinants of patient QOL: (1) the patient's own state, including physical and cognitive functioning, psychological state, and physical condition; (2) quality of palliative care; (3) physical environment; (4) relationships; and (5) outlook.

CONCLUSIONS

Existing instruments cover many of these domains, but no single instrument includes all of the relevant content. The McGill Quality of Life Questionnaire, which we developed previously, has been revised based on these data.

A classification of facial wrinkles

An increasing number of injectable filler materials for facial wrinkles and folds points to the need for objective measurements of their effectiveness. Patient satisfaction is the goal, but proof of the value of a particular product requires objective measurement. A wrinkle assessment scale was developed as a simple tool for use by plastic surgeons, dermatologists, and aesthetic surgeons who want to assess the changes resulting from injecting filler materials in their patients. By correlating the grade of the wrinkle in the reference photographs with the wrinkle in a patient's face, a classification of 0 to 5 is assigned. Reliability of the scale was assessed by "live" judgment of 76 wrinkles by nine observers. The same rating was given to 92.7 percent of all wrinkles. In a second trial, photographs from 130 wrinkles were presented to eight observers who rated 89.4 percent of all wrinkles equally. A significant correlation of 87 percent was found between subjective ratings and objective wrinkle depth measured by profilometry on 40 silicone impressions. Manufacturers, monitors of clinical trials, health authorities, and most important, patients will benefit from objective data on current and new injectable materials.

Tacks: a new technique for craniofacial fixation

Biodegradable fixation in craniofacial surgery provides secure fixation while eliminating much of the concern over intracranial migration of metallic plates and screws. One limitation of present biodegradable systems, however, is the need for tapping the drill hole before screw insertion. Herein, a new method of rigid, biodegradable fixation with tacks (Macrapore, Inc., San Diego, CA) is described. The tacks are made of a 70:30 ratio of the L and DL form of polylactic acid (L,DL-PLA). Degradation times range from 18 to 36 months. Newer prototypes are nearly developed for more rapid dissolution times. From April 1999 to February 2000, tack fixation has been applied in 100 patients (51 males, 49 females aged 3 months to 61 years). Indications for operation were craniosynostosis (n = 33); craniofacial trauma or post-traumatic deformities (n = 11); cleft lip and palate (n = 13); craniofacial syndromes (n = 18); other diagnoses (n = 11). Patients underwent fronto-orbital advancement with cranial reshaping; monobloc osteotomy, open reduction-internal fixation of fractures; hypertelorbitism repair; cranioplasty; stabilization of grafts; major cranial reconstruction; zygomatic advancement; alveolar cleft repair; and iliac bone graft donor site protection. Tacks were also used for temporalis muscle and lateral canthal suspension. Follow-up ranged from 16 to 28 months. Complications occurred in 7 patients, 4 of whom had infections and during debridement had biodegradable implants removed. None of the complications appeared to be related to the use of tacks. The tacks are carried in a specially designed holder and may be placed by hand or with the light tap of a mallet on the tack driver. An automatic driver has been developed. Overall, the performance of the tacks has been excellent. They are easily handled by the nursing personnel and rapidly inserted by the surgeon. Stability appears to be excellent. At this time, it is probably preferable to employ tap and screws for orthognathic surgery or other osteotomies with substantial load bearing.

Outcome analysis for correction of single suture craniosynostosis using resorbable fixation

A retrospective review was performed on 63 patients at Childrens Healthcare of Atlanta at Scottish Rite who underwent correction of single-suture craniosynostosis using a resorbable fixation system. Included in the series were 24 patients with metopic synostosis, 15 with sagittal synostosis, and 24 with unicoronal synostosis. The average age at operation was 22.7 months (range: 2.8 months-18 years), and mean follow-up time was 30.7 months (range: 7.1-10 years). Reoperation equal to or exceeding the magnitude of the original procedure occurred in 4.76% of the patients. This was comparable to the reoperation rate observed at our institution using traditional fixation systems. Minor complications related to the use of resorbable plates were also identified, and the final outcome for single-suture synostosis was favorable. Results suggest that resorbable plates and screws are as effective as titanium-based systems in the treatment of single-suture synostosis.

Changes in quality of life following admission to palliative care units

The primary goal of palliative care is to improve the quality of life (QOL) of people with a terminal illness. Previous studies of the impact of hospice/palliative care have documented improvement in physical and psychological symptoms, but not in overall QOL, due in part to the difficulties of measuring QOL. The McGill Quality of Life Questionnaire (MQOL) was developed to assess QOL in persons with advanced illness. MQOL scores were determined on admission and 7-8 days later for sequential eligible and willing patients admitted to five palliative care units. These 88 patients represented 8% of those admitted to the units during the study period. Following the final MQOL completion, patients were interviewed and asked to describe the nature of the changes in QOL they had experienced since admission. Significant improvements were found in the MQOL total score and subscale scores reflecting physical, psychological and existential well-being. In the interviews patients indicated that they had experienced changes in physical, emotional and interpersonal status, in spiritual outlook, and in their preparation for death. They also described the impact of the palliative care unit environment. This is the first study to demonstrate that hospice/palliative care can improve existential well-being in addition to psychological and physical symptoms. It provides evidence in the patients' own words that improvements in QOL go beyond symptom control following admission to a palliative care unit. However, the study results are generalizable only to those few patients admitted who are well enough to complete a questionnaire 1 week after admission.

Lymphedema: strategies for management

An important sequela of cancer treatment is lymphedema. Management of this condition must be based on the physiologic functioning of the lymphatic system and tailored to the individual patient's presentation of the disease. Early diagnosis and treatment are essential to prevent worsening of the condition and to help assuage the psychologic impact of the disease. A review of the normal and impaired lymphatic system is presented in this article. Current assessment and treatment options are described, including education of patients in precautions, positioning, exercise, compression garments and bandages, pneumatic pumps, and lymphatic massage. Also included is a discussion of the psychologic impact of the disease as well as management of psychologic symptoms. Various strategies for management of the physical aspects of lymphedema are available. Studies have shown that use of physical treatments such as exercise, compression, and lymphatic massage are effective in reducing the amount of swelling in affected limbs. The specific type, amount, and combination of these treatments continues to be debated. The development of lymphedema is commonly associated with significant psychologic distress that can impact on compliance with physical treatments. Because there is no consensus as to the optimal treatment approach for management of lymphedema, additional research must ensue to determine the efficacy of existing treatments and to develop new management techniques. Clinicians must be attuned to the signs and symptoms of lymphedema in order to make prompt referrals for treatment.

Internal Le Fort III Distraction with Biodegradable Devices

Shortly after the initial application of distraction osteogenesis to the human mandible by McCarthy, distraction osteogenesis was used for gradual lengthening of the midface in children with syndromic craniosynostosis, cleft lip and palate, hemifacial microsomia, and midface hypoplasia from other causes. Both external and internal devices are available for midface distraction. In spite of the many advantages of internal metallic distraction devices, they can be more difficult to remove. By substituting the metallic fixation plates of the Stryker-Leibinger Modular Internal Distraction system, with resorbable MacroPore fixation mesh, only the distractor screw and cable drive need to be removed. Moreover, by using a resorbable stabilizer, the screw and cable components are not needed for the consolidation phase, and can be removed at the completion of active distraction. In this case report of a 4-year-old girl with Crouzon's syndrome, contouring of the resorbable distraction devices was performed using a sterilizable model, 20 mm of distraction was achieved, and 4 days later the distractor screw was replaced with a resorbable stabilizer, resulting in an excellent correction of her midface hypoplasia.

Living with cancer: "good" days and "bad" days--what produces them? Can the McGill quality of life questionnaire distinguish between them?

BACKGROUND

To determine the impact of care on quality of life (QOL), or to detect a change in QOL over time, measures of QOL must remain stable when QOL is stable (test-retest reliability) and change when QOL changes (responsiveness). This study addresses these issues for the McGill Quality of Life Questionnaire (MQOL). Unlike other studies that use disease status to indicate whether QOL has remained stable or changed, in this study the patient determines QOL stability or change. The authors also sought to clarify the determinants of "good" and "bad" days for oncology patients.

METHODS

Patients attending an oncology outpatient clinic or who were being treated by a palliative care service were asked to complete MQOL 4 times: on days they judged to be "good," "average," and "bad" and 2 days after the first completion. They also were asked to directly rate the change in their QOL during the intervals between MQOL completion and to report the most important determinants of their good and bad days.

RESULTS

The test-retest reliability of MQOL as measured by an intraclass correlation coefficient ranged from 0.69 to 0.78. All MQOL scores were significantly different on good, average, and bad days, except for the support subscale, in both clinical settings. Five domains were determinants of QOL: physical symptoms, physical functioning, psychologic well-being, existential well-being, and relationships.

CONCLUSIONS

MQOL's reliability and responsiveness suggest it can be used to determine changes in the QOL of groups. The results allow interpretation of changes in MQOL scores with respect to meaning of the change to oncology patients. This in turn is helpful to determine the sample size required in future studies. Some of the domains important to the QOL of oncology patients are not included in widely used measures of QOL.

Chiari malformation, cervical spine anomalies, and neurologic deficits in velocardiofacial syndrome

The purpose of this investigation was to evaluate the prevalence of Chiari malformation, cervical spine anomalies, and neurologic deficits in patients with velocardio-facial syndrome. This study was a prospective evaluation of 41 consecutive patients with velocardiofacial syndrome, documented by fluorescence in situ hybridization, between March of 1994 and September of 1998. The 23 girls and 18 boys ranged in age from 0.5 to 15.2 years, with a mean age of 6.7 years. Nineteen patients were assessed with magnetic resonance imaging, 39 underwent lateral cephalometric radiography, and all patients were examined for neurologic deficits. Eight of 19 patients (42 percent) had anomalies of the craniovertebral junction, including Chiari type I malformations (n = 4), occipitalization of the atlas (n = 3), and narrowing of the foramen magnum (n = 1). One patient with Chiari malformation required suboccipital craniectomy with laminectomy and decompression. Fourteen of 41 patients (34 percent) had demonstrated neurologic deficits; 10 patients (24 percent) had velar paresis (6 unilateral and 4 bilateral). Chiari malformations, cervical spine anomalies, and neurologic deficits are common in velocardiofacial syndrome. Because these findings may influence the outcome of surgical intervention, routine assessment of patients with velocardiofacial syndrome should include careful orofacial examination, lateral cephalometric radiography, and magnetic resonance imaging of the craniovertebral junction.

Internal craniofacial distraction with biodegradable devices: early stabilization and protected bone regeneration

Internal craniofacial distraction has several advantages over distraction with external devices. The scars may be less conspicuous; the devices are buried and therefore easier for patients to tolerate; and the devices are more rigidly secured to bone, preventing uncontrolled rotation of the advancing segments. There are several types of internal devices. The Modular Internal Distraction System developed by one of the authors (S.R.C.) and Stryker-Leibinger, Inc. has had widespread use for midface distraction, but requires a substantial surgical procedure for device removal. This is justified in selected children with syndromic craniosynostosis, who frequently need secondary orbitocranial reconstruction at the conclusion of distraction with any type of device. It would be preferable to develop a device that would retain the positive characteristics of the Modular Internal Distraction system, while allowing easy removability. Moreover, the entire distraction procedure would benefit from a technique that would assist in bone regeneration within the distraction gap. Such a biodegradable, stabilizing device may enable early explanation, accelerating the recovery period, while providing fixation of the distraction gap and protected bone regeneration. Accordingly, we have developed a new, biodegradable distraction device with Macropore, Inc. that may be used with the Modular Internal Distraction system to permit easy removability of the device without the need for a large operation for exposure. Second, we have developed a biodegradable stabilizer that permits earlier removal of the distraction device while providing simultaneous fixation and protected bone regeneration. Last, we have demonstrated the feasibility of midcourse correction of the distraction procedure, should this be necessary for whatever reason.

Intralesional laser therapy of extensive hemangiomas in 100 consecutive pediatric patients

The authors have treated 100 consecutive pediatric patients with capillary/cavernous hemangiomas (age range, 1.3 months to 16 years; mean age, 26.6 months; 30 male and 70 female patients) with intralesional laser therapy during a 3-year period. All patients have been followed for a minimum of 6 months after treatment (range, 6-36 months; mean, 18 months). Indications for intralesional laser treatment included interference with vision, blockage of the nose or mouth, ulceration, bleeding, and rapid, uncontrollable growth. The Nd:YAG laser was used in 70 patients, and the Potassium, Titanyl, Phosphate (KTP) laser was used in 30 patients. Fifty-five hemangiomas were in the head and neck region, excluding the orbit; 25 were in the trunk or extremities; 10 were periorbital; and 10 involved multiple sites. Seventy patients (70%) received one treatment, 20 patients (20%) received two treatments, 7 patients (7%) received three treatments, and 3 patients (3%) received four or more treatments. No appreciable differences were noted between treatment with the Nd:YAG and KTP lasers. Forty-six patients had more than a 90% reduction in the overall size of the hemangiomas whereas 54 patients had a 50% to 90% reduction in the size of the hemangioma. After maximal reduction in size of the cavernous component was achieved, the external capillary component, found in 68 patients, was treated with a tunable dye laser. Seventy-six patients underwent surgical resection after maximal lesion involution. Residual induration due to lesion fibrosis was treated with local steroid injections in 13 patients. There were four operative complications attributable to intralesional laser therapy. Two patients had residual midfacial weakness, and two patients had punctuated skin burns after intralesional treatment. The authors have found intralesional laser therapy to be a valuable tool in the treatment of large capillary/cavernous hemangiomas, often rendering an inoperable lesion safely resectable, or markedly decreasing the size and functional impact of the lesion.

Iliac crest bone graft harvesting techniques: a comparison

This study was undertaken to compare the morbidity of traditional iliac bone graft harvesting techniques for grafting alveolar clefts to minimally invasive techniques. Fifty-five age-matched patients, ages 6.5 to 16 years (mean, 11.2 years), 22 girls and 33 boys, were divided into three groups. The traditional bone window open harvesting technique served as the control group. Two different minimally invasive techniques, one that used a bone grinder and another that used a trephine, for bone harvesting were compared with the control. Both invasive techniques were statistically superior, p < 0.05, in terms of total time pain medication was necessary (mean of 12.0 hours for bone grinder, 17.6 hours for trephine, 26.0 hours for control), operative time for bone harvest (mean of 11 minutes for bone grinder and trephine, 20 minute for control), and mean incision length (2 cm for bone grinder and trephine, 5 cm for control). Patients exposed to the minimally invasive techniques had fewer complications, a trend toward earlier ambulation, and shorter hospital stays when compared with the bone grinder technique. The patients exposed to the bone grinder demonstrated earlier ambulation and fewer requirements for analgesia when compared with the trephine technique, although these results did not reach statistical significance. The trephine technique was useful when maxillary osteotomies were combined with alveolar bone grafting, because it provided structural bone grafts and cancellous bone. On the basis of these findings, the bone grinder is the preferred technique for harvesting alveolar bone grafts when no structural support is required. These authors no longer use the traditional bone window open harvesting technique.

The use of hydroxyapatite cement in secondary craniofacial reconstruction

Sixty-one patients underwent secondary craniofacial reconstruction for contour defects using hydroxyapatite cement over a 3-year period (20-month mean follow-up). There were 56 children, aged 2.2 to 18 years (mean, 10.7 years), 21 boys and 35 girls. This is the first series of pediatric patients in whom the use of hydroxyapatite cement has been reported. There were five adults aged 21 to 46 years (mean, 32 years), 3 men and 2 women. Thirty-one patients underwent reconstruction for secondary orbitocranial defects after surgery for synostosis, 7 after surgery for hypertelorism, 10 for posttraumatic skull defects, and 13 for a variety of other facial skeletal defects. There were seven complications (11 percent), ranging from a retained drain to postoperative seromas, all of which required reoperation without loss of the contour correction. All of the complications occurred in the first 18 months of our study. There has been excellent retention of implant volume with no recurrence of contour defects to date. We have not found any visible evidence of interference with craniofacial growth over the study period. We conclude that hydroxyapatite cement is a versatile and safe biomaterial when used for the correction of secondary craniofacial contour defects in children and adults. The coupling of antibiotics with this biomaterial may have applications in the treatment of osteomyelitis.

The role of distraction osteogenesis in the management of craniofacial disorders

Since its introduction in the medical literature in 1992 by McCarthy, distraction osteogenesis of the craniofacial skeleton has become a standard surgical therapy. The present report attempts to trace the development of craniofacial distraction from the perspective of one of the early proponents of the technique. Although the earliest application of distraction was in children with severe unilateral or bilateral mandibular deficiency, its use for functional abnormalities such as apnoea were especially appealing. Distraction osteogenesis for the midface began with external appliances that were attached to the teeth. Newer, buried devices have eliminated the need for external devices in all LeFort III and monobloc cases. For LeFort I and mandibular cases, the ideal internal device has not been manufactured.

An anatomic evaluation of the furlow double opposing Z-plasty technique of cleft palate repair

The aim of this investigation was to examine velar anatomy following the Furlow double opposing Z-plasty in order to analyse the theoretical effects of this technique. Thirty patients with cleft lip and/or cleft palate who underwent primary Furlow palatoplasties between 1989 and 1994 were reviewed. The mean age at the time of surgery was 6.4 months. Evaluation was performed at a mean time of 2.9 years postoperatively, and consisted of oral examination of the position of the velar dimple and measurements of velar dimensions from standard lateral cephalograms. A comparative statistical analysis of velar length (n = 17) and thickness (n = 14) was performed using 2 historical control groups (non-cleft norms and non-Furlow cleft palate repairs). The Furlow procedure produced posterior dimples in 19 of 26 patients adequately rated on oral examination, suggesting successful repositioning of the velar musculature in transverse orientation. The mean velar length was not significantly different from that of norms (being 0.72 mm less), suggesting that the Furlow Z-plasty results in the attainment of near normal velar length. In contrast, the mean velar length was 0.46 mm greater compared to non-Furlow repairs. Although this difference was not statistically significant, it suggests that the Furlow Z-plasty may be more effective in increasing velar length compared to non-Furlow palatoplasty techniques. Velar thickness was significantly greater compared to both norms (P = 0.002) and non-Furlow repairs (P = 0.001). These data suggest that the Furlow double opposing Z-plasty repositions the velar muscles in transverse orientation, and increases both velar length and thickness, lending weight to the theoretical effects of this procedure. The anatomic basis of these changes and their functional implications are discussed.

Monobloc and facial bipartition distraction with internal devices

Distraction osteogenesis (DO) permits gradual lengthening of the craniofacial skeleton. With the advent of new internal devices, monobloc (M) and facial bipartition (FB) DO are feasible. The rationale behind M and FB distraction is (1) gradual advancement of the M segment is not associated with a substantial retrofrontal dead space; (2) because 5 to 7 days elapse prior to distraction, the nasofrontal opening, in theory, is allowed to remucosalize; (3) gradual expansion of the soft tissues takes advantage of skin creep, potentially limiting relapse; (4) the procedure appears to be less invasive with decreased blood loss and operative time, enabling its use in infants; (5) overdistraction may eliminate or reduce the frequency of subsequent procedures; and (6) the procedure may be combined with FB and skull vault remodeling to provide excellent results in more complex craniofacial dysostosis problems. Five children underwent M advancement (N = 3) and M with FB (N = 2) at 9 months to 5 years of age to correct functional abnormalities such as corneal exposure, increased intracranial pressure, and apnea, as well as severe craniofacial disfigurement. Each patient underwent from 22 to 30 mm of distraction with the Modular Internal Distraction (MID) system, developed by the first author (SRC). There was one infection late in the series along the DO cable track. There were no cases of epidural abscess. In conclusion, MDO, with and without FB, appears to be a safe and effective technique for transcranial frontofacial advancement. The morbidity of the procedure appears to be less than that of conventional M advancement.

Craniofacial distraction with a modular internal distraction system: evolution of design and surgical techniques

The present report summarizes the evolution of design for a modular internal distraction system that is applicable throughout the craniofacial region. Eleven patients (5 boys, 6 girls), whose ages ranged from 4 months to 10 years at the time of distraction, constitute the basis for this study. The clinical indications for distraction were exorbitism with corneal exposure (n = 1), obstructive sleep apnea (n = 4), tracheostomy decannulation (n = 1), severe maxillary hypoplasia with class III malocclusion (n = 3), severe vertical and sagittal maxillary deficiency with anophthalmia (n = 1), and relapse following frontoorbital advancement in a case of rare craniofacial clefting (n = 1). Twenty-two distraction devices were used in these 11 patients. Two initial prototypes were tested (prototype 1 = 8 devices; prototype 2 = 2 devices) until the modular internal distraction system (MIDS, Howmedica-Leibinger, Inc.) was developed (n = 12 devices). The craniofacial osteotomies used were Le Fort III (n = 4), monobloc (n = 3), mandibular (n = 3), Le Fort I (n = 2), and cranial (n = 1). The distraction distances ranged from 11 to 28 mm. One patient undergoing mandibular distraction developed transient swelling in the left mandibular region, which responded to antibiotics. There were no other complications. Depending on the age of the patient and the length of distraction, the distraction gap was allowed to consolidate from 6 weeks to 3 months. The devices were then removed on either an outpatient or a 23-hour-stay basis. The modular internal distraction system permits widespread application of easily customizable, buried distraction devices throughout the craniofacial region.