Characterizing Olfactory Dysfunction in Patients with Unilateral Cleft Lip Nasal Deformities

Background: Unilateral cleft lip nasal deformity (uCLND) is associated with olfactory dysfunction, but the underlying etiology remains poorly understood. Objective: To investigate the etiology of uCLND-associated olfactory dysfunction using clinical, computational, and histologic assessments. Methods: Inclusion criteria: uCLND patients >16 years undergoing septorhinoplasty. Exclusion criteria: prior septoplasty or rhinoplasty, pregnancy, sinusitis. Measured outcomes: patient-reported scores, rhinomanometry, smell identification and threshold tests, computational fluid dynamics (CFD) airflow simulations, and histologic analysis of olfactory epithelium. Results: Five uCLND subjects were included: 18-23 years, three male and two female, four left-sided cleft and one right-sided cleft. All subjects reported moderate to severe nasal obstruction. Smell identification and threshold tests showed varying degrees of hyposmia. Nasal resistance was higher on the cleft side versus noncleft side measured by rhinomanometry (median 3.85 Pa-s/mL, interquartile range [IQR] = 21.96, versus 0.90 Pa-s/mL, IQR = 5.17) and CFD (median 1.04 Pa-s/mL, IQR = 0.94 vs. 0.11 Pa-s/mL, IQR = 0.12). Unilateral olfaction varied widely and was dependent on unilateral percentage olfactory airflow. Biopsies revealed intact olfactory neuroepithelium. Conclusions: uCLND-associated olfactory dysfunction appears to be primarily conductive in etiology and highly susceptible to variations in nasal anatomy. Clinical Trial Registration number: NCT04150783.

Relevance of cleft palatal width in short-term otologic outcomes

OBJECTIVE

Children with cleft palate are at increased risk for Eustachian tube dysfunction (ETD) and conductive hearing loss from chronic otitis media. While it has been proposed that the severity of ETD is related to the severity of cleft palate, data are lacking to support this hypothesis. An improved understanding of the relevance of cleft width may have prognostic value that could inform decisions on the timing of tympanostomy tube placement and choice of tympanostomy tube design. The objective of this study was to assess severity of ETD in children with narrow, moderate, and wide cleft palate, with examination of hearing outcomes, number of tympanostomy procedures, and incidence of otologic complications.

METHODS

Retrospective chart review was conducted on 58 patients with primary palatoplasty performed at a single academic medical center from January 1, 2016-December 31, 2019. The primary outcome was the number of otologic procedures performed after the initial palatoplasty. Secondary outcomes included audiometric findings, number of tympanostomy tube placements, presence of effusion at the time of myringotomy, and occurrence of any postoperative otologic complication. Outcomes were compared for patients with narrow (<10 mm), moderate (10-15 mm), and wide (>15 mm) cleft palate. Analysis included consideration of cleft palatal morphology (Veau I - IV), presence of Robin sequence or syndromes, and risk factors for otitis media.

RESULTS

Patients with moderate and wide cleft palate underwent higher mean numbers of otologic procedures [narrow: 1.3 (95% confidence interval [CI] 0.9, 1.7); moderate: 1.6 (95% CI 1.1, 2.1); wide: 1.8 (95% CI 1.2, 2.4)]. Moderate and wide cleft palate were less likely to have normal hearing after their first tympanostomy (narrow: 50%, 10/20; moderate: 25%, 6/24; wide: 36%, 5/14). Patients with a wide cleft palate had a shorter median time between first and second tympanostomy procedures (median, IQR; narrow: 27.0, 20.8-35.7; moderate 20.4, 16.3-25.9; wide 17.3, 11.5-23.4).

CONCLUSION

Our findings suggest that patients with wider cleft palate may be more susceptible to severe ETD. Further large-scale study may help to allow for more informed and personalized clinical decision making for management of cleft palate, incorporating cleft width for prognosis of risks for persistent middle ear dysfunction.

Cutaneous Reconstruction of the Nasal Distal Third: Alternative Local Flaps for a Complex Region

Small-to-medium cutaneous defects of the distal nose pose a significant challenge to reconstructive surgeons, and commonly described reconstructive techniques have their limitations. As the skin of this region is characteristically rigid and sebaceous, care must be taken to avoid introducing unfavorable tension vectors that can result in functional or anatomic distortion of the nasal free margins. With this in mind, the authors discuss 3 alternative reconstructive options, the East-West, nasalis sling, and trilobed flaps, which have wide utility in the repair of distal nasal cutaneous defects and can result in excellent cosmesis. The indications, surgical technique, and limitations of each are discussed in detail, and are compared with several of the more commonly described options in the context of distal nasal reconstruction.

Dorsal Hump Reduction and Midvault Reconstruction

Dorsal hump reduction is one of the most common techniques used in modern rhinoplasty, yet it carries a high propensity for untoward aesthetic and functional sequelae, as evidenced by a nontrivial revision rate. Component dorsal hump reduction with stepwise deconstruction and manipulation of component parts allows for an adaptable and precise approach to variances in anatomy and in desired aesthetic result. Secondary changes must be anticipated and addressed at the index operation to avoid negative results and prevent the need for revision. Adequate reconstruction of the midvault is paramount to achieving optimal aesthetic and functional outcomes.

Analysis of nasal air conditioning in subjects with unilateral cleft lip nasal deformity

This study evaluated the impact of unilateral cleft lip nasal deformity (uCLND) on the ability of the nasal passages to warm and humidify inspired environmental air using computational fluid dynamics (CFD) modeling. Nasal air conditioning was simulated at resting inspiration in ten individuals with uCLND and seven individuals with normal anatomy. The overall heat and water transfer through nasal mucosa was significantly greater (p = 0.02 for both heat and moisture fluxes) on the non-cleft side than on the cleft side. Unilateral median and interquartile range (IQR) for heat flux (W/m²) was 190.3 (IQR 59.9) on the non-cleft side, 160.9 (IQR 105.0) on the cleft side, and 170.7 (IQR 87.8) for normal subjects. For moisture flux (mg/(s·m²), they were 357.4 (IQR 112.9), 298.7 (IQR 200.3) and 320.8 (IQR 173.0), respectively. Significant differences of SAHF50 between cleft side of uCLND and normal existed except for anterior region. Nevertheless, air conditioning ability in subjects with uCLND was generally comparable to that of normal subjects.

Tip Ligament Preservation and Suspension: Why and How?

This issue of Clinics explores the concept of "preservation" rhinoplasty. At present, this topic is gaining considerable attention. As proponents of preservation suggest, a great number of problems we encounter in rhinoplasty are problems that were not present before the surgery; therefore, they can often be attributable to the deconstruction and reconstruction that took place. Preservation rhinoplasty should be viewed generally as a mindset to limit deconstructive steps in rhinoplasty when possible, understanding that these steps and those to later reconstruct provide the potential to create new problems that did not previously exist.

Special education use in elementary school by children with nonsyndromic orofacial clefts

BACKGROUND

Children with nonsyndromic orofacial clefts (NS OFCs) may require exceptional children's (EC) services for academic delays. We examined EC service use of children with and without NS OFCs in NC in elementary school.

METHODS

We included 559 children with NS OFCs and 6,822 children without birth defects who had NC educational records. We estimated prevalence ratios, trends in enrollment, and characteristics of eligibility classification using descriptive statistics and logistic regression by cleft subtype and race/ethnicity. We estimated the odds of third grade retention by EC enrollment using logistic regression with inverse probability of treatment weights.

RESULTS

Children with NS OFCs were 3.02 (95% CI: 2.50, 3.64) times as likely to receive third grade special education (SE) services compared to unaffected peers. The prevalence odds was highest among children with CL+P (OR: 4.61, 95% CI: 3.49, 6.09) declining by 54% by fifth grade. The prevalence odds of SE for white children was approximately 1.50 times that for African American children in fourth and fifth grades. Approximately 33% of children with NS OFCs within each racial/ethnic group received SE in third grade. African American children were twice as likely to receive services under specific learning disability. Children with NS OFCs receiving EC services were 44% (OR: 0.56; 95% CI: 0.13, 2.38) less likely to be retained in third grade compared to children with NS OFCs who were not receiving services.

CONCLUSIONS

Children with NS OFCs are more likely to receive SE services in elementary school compared to their unaffected peers. The eligibility category differed by racial/ethnic group.

Implementation of a Standardized Data-Collection System for Comprehensive Appraisal of Cleft Care

OBJECTIVE

Our objective is to describe the process of adapting a conceptual framework into a practical toolkit for one cleft team.

DESIGN

This is a single-arm implementation study in a single institution.

SETTING

Implementation took place at a mid-sized multidisciplinary clinic for patients with cleft lip and/or palate (CL/P) from urban/suburban and rural areas across North Carolina and neighboring states.

PARTICIPANTS

Eligible participants were patients with CL/P from English-speaking families. Sixty patients entered and finished the study.

INTERVENTIONS

The implementation of a prospective data collection system based on the International Consortium for Health Outcomes Measurement (ICHOM) standard set of outcome measures for CL/P was accomplished in multiple stages. Patient- and clinician-reported forms and protocols for gathering data were created. Team members were trained and the system was tested; finally, the system was deployed.

MAIN OUTCOME MEASURES

Success was appraised using the RE-AIM framework to assess reach, effectiveness, adoption, implementation, and maintenance.

RESULTS

Ninety-eight percent of patients and all team members agreed to participate. Ninety-four percent of required data were captured. Adaptations to friction points were made; specifically, visible reminders were affixed to charts, primary clinicians were required to assume data entry responsibility, and e-mail reminders were instituted. Development cost was US$7707; average time cost per clinician was 21 min/wk.

CONCLUSIONS

Conceptual frameworks for outcomes studies must be tailored to their environments; otherwise, they cannot be practically implemented and sustained. We present this process for a cleft team using the ICHOM standard set. The process may help other teams implement the standard set or other conceptual frameworks.

Reliability of Oronasal Fistula Classification

OBJECTIVE

Oronasal fistula is an important complication of cleft palate repair that is frequently used to evaluate surgical quality, yet reliability of fistula classification has never been examined. The objective of this study was to determine the reliability of oronasal fistula classification both within individual surgeons and between multiple surgeons.

DESIGN

Using intraoral photographs of children with repaired cleft palate, surgeons rated the location of palatal fistulae using the Pittsburgh Fistula Classification System. Intrarater and interrater reliability scores were calculated for each region of the palate.

PARTICIPANTS

Eight cleft surgeons rated photographs obtained from 29 children.

RESULTS

Within individual surgeons reliability for each region of the Pittsburgh classification ranged from moderate to almost perfect (κ = .60-.96). By contrast, reliability between surgeons was lower, ranging from fair to substantial (κ = .23-.70). Between-surgeon reliability was lowest for the junction of the soft and hard palates (κ = .23). Within-surgeon and between-surgeon reliability were almost perfect for the more general classification of fistula in the secondary palate (κ = .95 and κ = .83, respectively).

CONCLUSIONS

This is the first reliability study of fistula classification. We show that the Pittsburgh Fistula Classification System is reliable when used by an individual surgeon, but less reliable when used among multiple surgeons. Comparisons of fistula occurrence among surgeons may be subject to less bias if they use the more general classification of "presence or absence of fistula of the secondary palate" rather than the Pittsburgh Fistula Classification System.

Academic Achievement Among Children With Nonsyndromic Orofacial Clefts : A Population-Based Study

OBJECTIVE

Children with orofacial clefts (OFCs) may experience poor reading proficiency, learning disabilities, and academic underachievement. We examined the association between nonsyndromic (NS) OFCs and end-of-grade (EOG) performance in reading and math from third through eighth grade in a sample subgroup.

PARTICIPANTS

We identified a cohort of 559 children with NS-OFCs and 6822 children without birth defects, classifying cleft type by cleft lip alone, with or without cleft alveolar ridge (CL); cleft lip with cleft palate (CL+P); and cleft palate only (CP).

MAIN OUTCOME MEASURES

Using logistic regression, we estimated the odds of not meeting grade-level standards among children with NS-OFCs compared to unaffected peers. Using longitudinal analyses, we estimated the odds of not meeting grade-level standards and average change in test scores through eighth grade.

RESULTS

Children with NS-OFCs were 1.22 (95% CI: 0.96, 1.83) times as likely not to meet grade-level standards in reading compared to unaffected peers. The effect was similar for math (OR: 1.17; 95% CI: 0.92, 1.48). Children with CL+P were 1.33 (95% CI: 0.86, 1.83) and 1.74 (95% CI: 1.19, 2.56) times as likely not to meet grade-level standard in reading and in both subjects, respectively, compared to unaffected peers. The average rate of change in both scores was similar for children with and without OFCs.

CONCLUSIONS

Poor academic performance appears greatest for children with CL+P, a finding compatible with previous observations and hypothesized mechanisms associating orofacial clefts with subtle abnormalities in brain development. Academic performance monitoring and referral for academic assistance is warranted.

Classification of Cleft Lip/Palate: Then and Now

Cleft lip and/or palate (CL/P) is phenotypically diverse, making classification difficult. This article explores the evolution of ideas regarding CL/P classification and includes the schemes described by Davis and Ritchie (1922) , Brophy (1923) , Veau (1931) , Fogh-Andersen (1943), Kernahan and Stark (1958) , Harkins et al. (1962) , Broadbent et al. (1968), Spina (1973) , and others. Based on these systems, a longhand structured form is proposed for describing CL/P in a way that is clear, comprehensive, and consistent. A complementary shorthand notation is also described to improve the utility and convenience of this structured form.

Survey of Current Practice Patterns in the Management of Frontal Sinus Fractures

The management of frontal sinus fractures has evolved in the endoscopic era. The development of functional endoscopic sinus surgery (FESS) has been incorporated into management algorithms proposed by otolaryngologists, but the extent of its influence on plastic surgeons and oral and maxillofacial surgeons is heretofore unknown. A cross-sectional survey was performed to assess the practice pattern variations in frontal sinus fracture management across multiple surgical disciplines. A total of 298 surveys were reviewed. 33.5% were facial plastic surgeons with otolaryngology training, 25.8% general otolaryngologists, 25.5% plastic surgeons, and 15.1% oral and maxillofacial surgeons. 74.8% of respondents practiced in an academic setting. 61.7% felt endoscopic sinus surgery changed their management of frontal sinus fractures. 91.8% of respondents favored observation for uncomplicated, nondisplaced frontal sinus outflow tract fractures. 36.4% favored observation and 35.9% favored endoscopic sinus surgery for uncomplicated, displaced frontal sinus outflow tract fractures. For complicated, displaced frontal sinus outflow tract fractures, obliteration was more frequently favored by plastic surgeons and oral and maxillofacial surgeons than those with otolaryngology training. The utility of FESS in managing frontal sinus fractures appears to be recognized across multiple surgical disciplines.

Clinician's Primer to ICD-10-CM Coding for Cleft Lip/Palate Care

On October 1,2015, the United States required use of the Clinical Modification of the International Classification of Diseases, 10th Revision (ICD-10-CM) for diagnostic coding. This primer was written to assist the cleft care community with understanding and use of ICD-10-CM for diagnostic coding related to cleft lip and/or palate (CL/P).

Early Postoperative Complications following Gracilis Free Muscle Transfer for Facial Reanimation: A Systematic Review and Pooled Data Analysis

BACKGROUND

Multiple studies have detailed promising smile restoration following gracilis free muscle transfer for facial reanimation but information detailing the potential complications is lacking. The aim of this study is to systematically review the literature to evaluate the reported complication rate associated with this procedure. We also aim to determine the most common occurring complications.

METHODS

The PubMed, Embase, and Web of Science databases were queried with multiple search strategies for published articles between January 1950 and February 2013 that detailed gracilis free muscle transfer for facial reanimation. Title, abstract, and full text review was performed. Complications were defined as any reported, identifiable adverse outcome that required an alteration in treatment for correction.

RESULTS

The literature search yielded 62 studies of gracilis free muscle transfer for facial reanimation. Overall, 36 articles (58%) reported whether or not a complication had occurred. The overall complication rate based on pooled proportions was 9.6% and the most commonly occurring complications were postoperative hematoma (3.6%) and infection (3.5%).

CONCLUSIONS

Our data suggests that complications after gracilis free muscle transfer for facial reanimation may be underreported and this complex procedure may in fact be associated with significant adverse outcomes as high as 9.6%.

Modern tenets for repair of bilateral cleft lip

The understanding of the bilateral cleft lip and associated nasal deformity has evolved over the last 30 years to a point where there now exists general agreement regarding the goals, principles, and strategies for operative repair. This article presents modern tenets for repair of bilateral cleft lip and describes a logical approach to correction of the different possible subtypes.

Video-Assisted Palatopharyngeal Surgery: A Model for Improved Education and Training

Objective

The learning process for intraoral procedures is arguably more difficult than for other surgical procedures because of the assistant's severely limited visibility. Consequently, trainees may not be able to adequately see and follow all steps of the procedure, and attending surgeons may be less willing to entrust trainees with critical portions of the procedure. In this report, we propose a video-assisted approach to intraoral procedures that improves lighting, visibility, and potential for effective education and training.

Design

Technical report (idea/innovation).

Setting

Tertiary referral hospital.

Patients

Children with cleft palate and velopharyngeal insufficiency requiring surgery.

Interventions

Video-assisted palatoplasty, sphincteroplasty, and pharyngoplasty.

Main Outcome Measures

Qualitative and semiquantitative educational outcomes, including learner perception regarding “real-time” (video-assisted surgery) and “non–real-time” (video-library–based) surgical education.

Results

Trainees were strongly in favor of the video-assisted modality in “real-time” surgical training. Senior trainees identified more opportunities in which they had been safely entrusted to perform critical portions of the procedure, corresponding with satisfaction with the learning process scores, and they showed greater comfort/confidence scores related to performing the procedure under supervision and alone.

Conclusions

Adoption of the video-assisted approach can be expected to markedly improve the learning curve for surgeons in training. This is now standard practice at our institution. We are presently conducting a full educational technology assessment to better characterize the effect on knowledge acquisition and technical improvement.

Correction of the cleft nasal deformity: from infancy to maturity

The cleft nasal deformity remains the most likely stigma of the cleft to remain plainly visible despite vigorous and repeated attempts at correction. This deformity is present at birth, but evolves over time. Certain aspects can be treated early, but some, such as the dorsal and septal deformity continue to develop as facial growth proceeds through adolescence. This article presents a conceptual mechanism and a philosophy of conservative reliable gains starting at the primary operation, with the long-term view of achieving definitive correction at maturity. Cogent planning of longitudinal care of the deformity from infancy leads to solid, predictable results.

Pediatric head contours and inertial properties for ATD design

Child head trauma in the United States is responsible for 30% of all childhood injury deaths with costs estimated at $10 billion per year. The common tools for studying this problem are the child anthropomorphic test devices (ATDs). The headform sizes and structural properties of child ATDs are based on various anthropometric studies and scaled Hybrid III mass and center of gravity (CG) properties. The goals of this study were to produce pediatric head and skull contours, provide estimates of pediatric head mass, mass moment of inertia and CG locations, and compare the head contours with the current child ATD head designs. To that end, computer tomography (CT) scans from one hundred eighty-five children in twelve age groups were analyzed to develop three-dimensional head and skull contours. The contours were averaged to estimate head and skull contours for children aged 1-month to 10-years. Inertial properties were estimated from a small sample of post- mortem human subjects (PMHSs). This paper provides new equations for estimating the moments of inertia and anatomical landmarks in the head. There were reasonable agreement between the estimates for head masses obtained from analysis of the CT scans of the PMHS heads and the estimates obtained using the volumetric scaling rule used in ATD design work. The regression of the pediatric head sizes was found to be non-linear, with different regression slope for ages 1M to 18M and 18M to 120M. The 12M CRABI and 36M Hybrid III heads were found to be different by 10 and 18mm, respectively, from the average human CT contours due to the differences in the occipital condyle placement relative to the nasion.

Healthy baboon with no upper jaw or nose: an extreme case of adaptability in the Kibale National Park, Uganda

We describe and document with digital images an adult female baboon (Papio anubis) from the Kibale National Park, Uganda, who was missing all but the basal part of her upper jaw and nose, i.e., no premaxilla and very little of the maxilla and nasal bones. She appeared otherwise healthy, well integrated into a social group, and apparently reproducing, based on the fact that she was grooming a juvenile who suckled from her and that she appeared to be pregnant. Her extreme deformity raises numerous questions and demonstrates the highly adaptable capabilities of wild baboons.

A technique to perfuse cadavers that extends the useful life of fresh tissues: the Duke experience

The demand for laboratory-based teaching and training is increasing worldwide as medical training and education confront the pressures of shorter training time and rising costs. This article presents a cost-effective perfusion technique that extends the useful life of fresh tissue. Refrigerated cadavers are preserved in their natural state for up to 45 days with a daily working period of ten hours. Tissues maintain their color and natural consistency throughout this period. This new process for preservation of tissue opens the door to improved surgical training and to numerous research opportunities.

Total scapholunate dislocation with complete scaphoid extrusion: case report

A case of complete dislocation of the lunate and scaphoid resulting from a fall is reported. We are unaware of any previously reported case of simultaneous dislocation with the scaphoid completely extruded from the wrist at the time of injury. The patient was treated with a proximal row carpectomy.

Current surgical practices in cleft care: cleft palate repair techniques and postoperative care

BACKGROUND

The purpose of this study was to objectively report practices commonly used in cleft palate repair in the United States. This study investigates current surgical techniques, postoperative care, and complication rates for cleft palate repair surgery.

METHODS

All 803 surgeon members of the American Cleft Palate-Craniofacial Association were sent online and/or paper surveys inquiring about their management of cleft palate patients.

RESULTS

Three-hundred six surveys were received, a 38 percent response rate. This represented responses of surgeons from 100 percent of American Cleft Palate-Craniofacial Association registered cleft teams. Ninety-six percent of respondents perform a one-stage repair. Eighty-five percent of surgeons perform palate surgery when the patient is between 6 and 12 months of age. The most common one-stage repair techniques are the Bardach style (two flaps) with intravelar veloplasty and the Furlow palatoplasty. After surgery, 39 percent of surgeons discharge patients within 24 hours. Another 43 percent discharge patients within 48 hours. During postoperative management, 92 percent of respondents implement feeding restrictions. Eighty-five percent of physicians use arm restraints. Surgeons' self-reported complications rates are minimal: 54 percent report a fistula in less than 5 percent of cases. The reported need for secondary speech surgery varies widely.

CONCLUSIONS

The majority of respondents repair clefts in one stage. The most frequently used repair techniques are the Furlow palatoplasty and the Bardach style with intravelar veloplasty. After surgery, the majority of surgeons discharge patients in 1 or 2 days, and nearly all surgeons implement feeding restrictions and the use of arm restraints. The varying feeding protocols are reviewed in this article.

Spontaneous resolution of a 13-mm Chiari malformation Type I in relation to differential growth of the posterior fossa volume

The case of a 3-year-old patient with tuberous sclerosis and a 13-mm Chiari malformation Type I that spontaneously disappeared over the course of 4 years is presented. Using morphometric measurements of the posterior fossa and cerebellum in this patient, the authors show that the volume of the posterior fossa at the time of initial evaluation was consistent with that reported as normal in the literature (180.24 cm3; normal volume 132-198 cm3). Moreover, the patient showed a normal rate of growth of his posterior fossa over the period of observation (201.05 cm3; normal range 153-230 cm3). Cerebellar volumes were found to increase only minimally during this time period, which is compatible with observations in healthy controls. The posterior fossa volume, on the other hand, was shown to increase significantly more than that of the cerebellum (p=0.0185). This differential growth may permit the tonsils to ascend back up into the posterior fossa. Therefore, pediatric patients with normal posterior fossa volumes and normal development may have a spontaneous resolution of their asymptomatic Chiari malformation Type I.

[Facial allograft transplantation: fiction or reality? Surgical techniques in a fresh human cadaver model]

BACKGROUND

The aim of this study was to describe two methods of face-harvesting techniques -- a skin and soft tissue flap and a combined osteocutaneous flap -- and to demonstrate the compatibility between donor and recipient in a human fresh cadaver model.

METHODS

In fresh human cadavers the skin and soft tissue of the face (type 1) and a combined osteocutaneous flap (including a le Fort III segment, type 2) were harvested. The faces were subsequently exchanged among the donor crania, simulating full-face transplantation.

RESULTS

Both flaps are based on the external blood supply of the faciotemporal vessels and the external jugular vein. The end branches of the trigeminal nerve could potentially be used for restoration of sensation (type 1 flap). With type 2 flaps the facial expression may be restored with the inclusion of the facial nerve. Four morphological parameters determine the donor/recipient compatibility: skin color and texture, anthropometric head dimensions, specific soft tissue components (nose, lip, cheek, and eyebrow), and gender.

CONCLUSION

Apart from ethical considerations, long-term immunosuppression will remain the limiting factor of full facial transplantation in the near future.

Objective three-dimensional analysis of cranial morphology

OBJECTIVE

The lack of adequate means to objectively characterize cranial shape contributes to ongoing controversies in the surgical management of craniosynostosis. Cranial shape analysis must address relevant clinical questions objectively and thoroughly and must be broadly applicable across the spectrum of normal and abnormal. Herein, we demonstrate and statistically validate an automated computed tomography (CT)-based application for 3-dimensional characterization of skull morphology. The technology is intended for application to diagnostic imaging, surgical planning, and outcomes assessment.

METHODS

Three-dimensional vector analysis (3DVA) was applied to craniofacial CT data, generating three-dimensional cranial surface point clouds.

VALIDATION

To assess accuracy, measurements derived from the 3DVA analysis of a CT scan of a skull phantom were compared to those made directly from the Digital Imaging and Communications in Medicine data on a Vitrea workstation. To assess reproducibility, 3 readers independently analyzed human head CT scans using 3DVA.

APPLICATION

A normative database of 86 age-incremental pediatric patients was created. Preoperative craniosynostosis case datasets were analyzed using 3DVA and were compared with age-matched normative datasets.

RESULTS

Accuracy and reproducibility of less than 1% mean error and less than 0.5 mm standard error in all cases validated 3DVA-derived distances. Three-dimensional vector analysis point clouds provide qualitative and quantitative representations of morphology. Regional dysmorphology in craniosynostosis cases is demonstrated graphically.

CONCLUSIONS

Three-dimensional vector analysis generated accurate, reproducible, and comprehensive craniofacial morphometric data. 3DVA may be used for paired data analysis (eg, a single subject undergoing surgical correction), comparative group data analysis, and craniofacial data archiving. The technique can provide objective characterization of craniofacial morphology previously not possible.

[Near-total ear amputation: anatomical bases and management]

BACKGROUND

In cases of near-total ear avulsions, replantation is often successful without microsurgery. The purpose of our study was to investigate the relevant vascular anatomy associated for ear survival.

PATIENTS AND METHODS

Four cases of successful surgical intervention in near-total ear avulsions are presented. Injection studies using latex were performed to identify the blood supply to the auricle on 13 cadaveric ears.

RESULTS

A small superior branch of the superficial temporal artery above the tragus was identified extending along the upper border of the auricle and connecting with the helical arcade. Below the tragus, a second small horizontal branch of the superficial temporal artery was identified.

CONCLUSION

The auricle can survive near-total amputation based on a skin bridge above or below the tragus. One of the auricular branches of the superficial temporal artery seems sufficient for the blood supply to the ear and allows for a successful non-microsurgical operative repair.

A clinically applicable reporting system for the diagnosis of facial fractures

A clinically applicable, comprehensive reporting system for the diagnosis of facial fractures was developed with three guiding principles: (1) preservation of classical anatomical terminology and nomenclature, (2) facilitation of uniform interpretation of radiographs between radiologists and (3) non-redundant diagnostic descriptions of complex fractures, in a manner that correlates with treatment modality. Twenty-two fracture types (17 simple fracture types and 5 complex fracture types) are included in the system. Each patient's fracture pattern is described by listing the component fractures present. A short narrative (modifying description) is provided after each fracture listed. Simple fractures that help to comprise more complex fractures are not listed separately, but are described within the modifying description of the complex fracture they help to comprise. When components of multiple complex fractures are present, a hierarchy of complex fractures dictates which fracture is described first. Additional complex fractures are only described separately when they do not share common components. In all other cases, the second (lower order) complex fracture is best described by simply listing the component (simple or complex) fractures that are not accounted for in the higher order complex fracture. Adoption of this reporting system should improve communication between emergency medicine physicians, radiologists and surgeons.

Fascio-subcutaneous extension of a free radial forearm flap for frontonasal duct obliteration

Frontonasal duct injury is a critical factor in the treatment of frontal sinus fractures. We present the case of a 43-year-old man who sustained multiple comminuted fractures of the anterior table of the frontal sinus and of the orbital roof as the result of a gunshot. After adequate debridement, the combined bone and soft tissue defect was reconstructed with a titanium mesh and a free radial forearm flap. The frontonasal duct injury was treated by surgical obliteration with a custom designed fascio-subcutaneous extension of the free radial forearm flap. The postoperative course was uneventful with good functional and aesthetic results. No early or late complications have occurred.

Quantitative and qualitative assessment of morphology in sagittal synostosis: mid-sagittal vector analysis

Consensus remains lacking regarding the optimal surgical treatment modality for sagittal synostosis. There is, however, wide agreement that objective analytical methods are required to demonstrate the characteristic morphology of the condition and to substantiate the benefits of specified surgical techniques. Simple calculated anthropomorphic indices, such as the cranial index, are commonly used but fail to provide satisfactory representation of morphology, which is far more complex than can be represented by its simple length-width ratio. Techniques to provide more comprehensive, yet practical, assessment of morphology are needed for analytic purposes. Herein, we introduce vector analysis as an objective, computed tomography (CT)-based morphometric technique for assessment of cranial morphology; this work represents the first application of the technique mid-sagittal vector analysis (MSVA). MSVA is a single plane application that was devised to address dysmorphology in sagittal synostosis. It was our hypothesis that MSVA would quantitatively and qualitatively depict preoperative morphology and postoperative correction in specific regions. Sixteen patients undergoing cranial reshaping surgery for sagittal synostosis were included in the study. All patients underwent routine preoperative and 1 year postoperative CT scans, from which the MSVA was derived. MSVA is a radial vector analysis in which distances to the cranial surface are measured from a single reference point origin in the sagittal plane. Preoperative morphology, characterized by respective vectors, was analyzed in three regions: the frontal, vertex, and occipital regions. Comparison with postoperative paired data was conducted for each patient. The analysis of postoperative change demonstrated (1) decrease in prominence in the frontal and occipital regions, (2) increase in height and forward translation of the vertex, and (3) ability to distinguish and qualify frontal versus occipital bossing and correction thereof. We conclude that the longitudinal differences associated with scaphocephaly are well characterized and differentiated by MSVA. Quantitative and qualitative assessment identifies three relevant regions affected by the condition and its treatment: the frontal, vertex, and occipital regions. The transverse dimension is not addressed in this single plane analysis; a more comprehensive application will require additional planes of analysis and the development of a normative database.

A Pilot Study in Sub-SMAS Face Transplantation: Defining Donor Compatibility and Assessing Outcomes in a Cadaver Model

BACKGROUND

Face transplantation may become a viable alternative in the treatment of patients with severe acquired facial deformity. In this study, the authors investigate morphological compatibility between donor and recipient by assessing chimeric outcomes in a human cadaver model.

METHODS

Four faces were harvested from fresh human cadaver specimens in a surgical plane deep to the galea, to the superficial musculoaponeurotic system, and to the platysma. The faces were subsequently exchanged among the four donor crania, simulating full-face transplantations. Eight cranium-face chimera complexes were created and analyzed with standardized photography and with volumetric computed tomographic radiography.

RESULTS

Four morphological parameters to consider in determining donor/recipient compatibility were defined: (1) skin color and texture, (2) head size, (3) soft-tissue features, and (4) gender.

CONCLUSION

Careful selection of face donors based on compatibility criteria will aid in ensuring that the posttransplant outcome is morphologically similar to the recipient's native face.

Technical and Anatomical Considerations of Face Harvest in Face Transplantation

Total face transplantation may become a reconstructive option in the treatment of patients with acquired facial deformity. Here, 2 face-harvesting techniques are presented in a fresh human cadaver model. In technique 1, the skin and soft tissue of the face is harvested by dissecting in a subgaleal, sub-SMAS, subplatysmal plane. In technique 2, the entire soft tissue and the bony structures of the midface are harvested by dissecting in a subperiosteal plane and performing a Le Fort III osteotomy. Each face was harvested successfully as a bipedicled flap based on the external carotid arteries, the external jugular veins, and the facial veins. Each of these 2 techniques is a theoretically viable approach to face harvest for composite allograft transplantation. These techniques represent the 2 extremes of which tissues can be harvested while maintaining vascular integrity. Each will address different reconstructive needs.

No evidence for maternal-fetal microchimerism in infantile hemangioma: a molecular genetic investigation

In this study, using the placental origin theory as a basis, we set out to explore whether hemangioma endothelial cells (HEC) were maternal in origin. We rigorously addressed this hypothesis using several molecular genetic techniques. Fluorescent in situ hybridization on surgical specimens of proliferating hemangiomas (n=8) demonstrated no XX-labeled HEC from resected tumors of male infants. This analysis was followed by PCR genotyping of HEC (n=11) using microsatellite markers where cellular components were genotyped and compared to genomic DNA of corresponding mother-child pairs. In the seven informative mother-child pairs, HEC matched the genotype of the child and not the maternal genotype. Concerned that HEC represented a mixed population of cells, we subsequently enriched for cells using the placental-specific endothelial cell (EC) marker, Fc gammaRII. Three informative mother-child pairs exhibited only the genotype of the child in our enriched cell population. Using sequence analysis, we identified an informative single nucleotide polymorphism in an exon of the placental-EC-specific protein, GLUT1. When comparing GLUT1 complementary DNA (cDNA) with mother-child DNA, the genotype of the cDNA matched the constitutional DNA of the child. Our results indicate that hemangiomas are not microchimeric in origin. This study provides further insight into the origin of a tumor whose pathogenesis remains elusive.