Lisa R. David

Velopharyngeal insufficiency (VPI) occurs in more than 20% of patients with a cleft palate after primary palatoplasty. Surgical treatment focuses on pharyngoplasty to narrow the nasopharyngeal space and to decrease the distance needed for palatal closure. Persistent VPI after pharyngoplasty affects more than 20% of patients. From September 2007 to December 2009, 16 children (10 boys and 6 girls) with a mean age of 9.5 years (4–15 years) underwent surgical revision using an AlloDerm sling for persistent VPI after at least 1 previous failed pharyngoplasty. Ten children had previous sphincter pharyngoplasties, and 6 had previous pharyngeal flaps. Surgical technique involves creation of a submucosal tunnel through the limbs of the previous pharyngoplasty or pharyngeal flap. A strip of AlloDerm is threaded circumferentially, and the port is adjusted to the desired aperture. All patients underwent preoperative and postoperative analysis of VPI, including oral pharyngeal and perceptual speech examination by speech pathology with a mean follow-up of 441 days. Acoustic nasometry was used to objectively compare preoperative and postoperative nasalance values. A significant improvement in perceptual resonance was seen in 93.8% of patients, and 87.5% of patients improved to normal or mild resonance (P < 0.001). There was a significant mean reduction of nasalance using the MacKay-Kummer Simplified Nasometric Assessment Procedure test (P < 0.001). Two patients developed postoperative flap dehiscence, with one being revised ultimately to have normal speech resonance. Revision pharyngoplasty using an AlloDerm sling can safely and effectively improve speech in patients with persistent VPI after failed pharyngoplasty. Long-term follow-up studies are ongoing.

Metopic craniosynostosis has traditionally been reported to be the third most common form of single-suture synostosis. The purposes of this article were to analyze the relationship between metopic craniosynostosis and positional plagiocephaly and to define more clearly the differences between the changes seen with true suture fusion compared with metopic abnormalities secondary to positional changes. This is an institutional review board-approved retrospective review of three-dimensional computed tomographic scans for abnormalities of the metopic suture in all children treated at our institution for positional plagiocephaly between 1997 and 2007. We also independently reviewed the images of all patients treated for metopic synostosis for evidence of positional plagiocephaly during the same period. Among the positional plagiocephaly group, 39% were noted to have some form of metopic suture abnormality. Of the children treated for metopic craniosynostosis, a much smaller percentage also was noted to have evidence of positional plagiocephaly. Between 1997 and 2007, we treated 93 patients (50%) for sagittal synostosis, 41 patients (22%) for unicoronal, 41 patients (22%) for metopic, 4 patients (2%) for lamdoid, and 7 patients (4%) with multiple-suture involvement. This study demonstrates an increasing trend toward metopic suture abnormalities during the past 10 years, which corresponds to the same time interval of an increased incidence of positional abnormalities. It is postulated that some of these abnormalities are related to deformational forces resulting from posterior pressure. Altered mechanical forces from supine infant positioning may be associated with early metopic suture ridging and dysmorphology distinct from true craniosynostosis.

Matching into an integrated plastic surgery program has become highly competitive. As a result it has become more difficult for both the applicants and the residency programs to determine which attributes are most important to match in plastic surgery and, more importantly, to make a surgeon who will contribute to the future of our specialty. This study was conducted to analyze potential associations between a successful match into plastic surgery and the number of interviews offered and attended, Alpha Omega Alpha (AOA) membership, and participation in away rotations. Increased competitiveness of the specialty also has required that the applicant spend significant time and money on the match process to improve his chances. Therefore, we looked at the financial impact of the interview process as well as at compliance with the new communication mandate by the Plastic Surgery Residency Review Committee designed to decrease some of the time and monetary costs associated with the match process. An anonymous 30-item survey was e-mailed to all the applicants to our institution last year. The survey consisted of questions addressing applicant profile with specific questions regarding the interview process. Descriptive statistics, including frequencies and proportions for each of the questions, were calculated. To assess the relationship between categorical outcomes, a Fisher exact test was used. Results with a P value less than 0.05 were considered to be statistically significant. Considering matching as the primary outcome measure, a statistically significant relationship was found with the number of plastic surgery interview invitations received and attended (P < 0.0001 for both), as well as with AOA membership (P = 0.018), with 89% (32/36) of the responders in AOA matching into plastic surgery. Although doing an away rotation did not have a significant association with match rate, one-third of responders matched where they did an away rotation. Gender was not found to influence match rate. This study supports with hard data the assumptions regarding matching into a competitive specialty: the more interview invitations received and interviews attended, and the more academically competitive the applicant, the more likely the applicant is to match. By applying this data, more precise guidelines may be developed to advise applicants concerning preparation for a successful match.

Spring-assisted surgery (SAS) has demonstrated promising results for the treatment of sagittal craniosynostosis. The purpose of this study was to assess the outcomes of the first 75 cases compared with a prospectively collected group of patients treated with cranial expansion (cranial vault remodeling [CVR]). Seventy-five children with scaphocephaly have completed this institutional review board-approved study. Patients underwent cranial surgery with removal of a 1-cm strip of sagittal suture and insertion of a mean of 2 spring distractors. Clinical outcome assessment included analysis of changes in cephalic index, shape, and volume on three-dimensional laser scans for both the SAS and the CVR treatments. Perioperative variables for both techniques were also compared. All patients successfully underwent SAS without significant complications with a mean follow-up of 46 months. Perioperative variables including odds ratio, time, blood loss, transfusion requirements, intensive care unit and hospital stay lengths, and hospital costs differed significantly in favor of SAS. The mean cephalic index improved from 69 preoperatively to 75.4 after SAS, comparable with the change from 66 to 72.5 for CVR. This correction was maintained at 3- and 5-year follow-ups. Anterior frontal bossing was corrected on three-dimensional scan volume measurements. Spring-assisted surgery is a safe, effective, minimally invasive treatment of scaphocephaly. It combines the low morbidity and the operative time of a strip craniectomy with dynamic reshaping techniques while the implanted spring gradually distracts the skull, improving head shape. Our 7 years of experience has shown that SAS effectively corrected cranial shape including frontal bossing with maintained results over time.

Background and Purpose: Spring-assisted surgery has been used for the treatment of craniofacial deformities since its 1997 inception in Sweden by Dr Lauritzen (Scand J Plast Reconstr Surg Hand Surg 1998;32:331-338). Initial applications have focused on the treatment of patients with single-suture craniosynostosis. Recently, indications and applications have expanded to include patients with syndromic craniosynostosis, multiple-suture synostosis, and midface hypoplasia. The advancement of spring-assisted surgery in this country has been hindered by the need for patient-specific spring fabrication because few surgeons understand how to make the springs for each application. We will review our spring design and treatment algorithms to facilitate wider use of this innovative treatment modality. Methods: This is a retrospective institutional review board-approved analysis of the spring design for our first 90 cases of spring-assisted surgery used to treat sagittal synostosis at the North Carolina Center for Cleft and Craniofacial Deformities. Outcome analysis was done to generate a treatment algorithm based on diagnosis, patient age, spring design, number of springs, spring force and expansion, and clinical outcome. Results: Ninety children with sagittal craniosynostosis (64 males, 26 females) were treated during an 8-year period (2001-2009) with spring-assisted surgery. Mean age at treatment was 4.4 months and mean age at spring removal was 8.8 months. Mean number of springs used was 2 (range, 1-3). Mean spring force used in sagittal synostosis was 5.5-9.5 (range) for the anterior spring and 5.5-9.5 (range) for the posterior spring with a mean posttreatment expansion of 6.65 cm. Analysis of the results shows that spring force and expansion required for optimal correction is dependent on the age at surgery, type of the deformity, and severity of the deformity. Specifically, the younger the child, the weaker the spring needed for surgical correction. General principles for spring application for scaphocephaly include (1) the longer the anterior posterior dimension of the skull deformity, the more likely a third spring is necessary; (2) the narrower the posterior occiput, the stronger the posterior spring required; and (3) if a postcoronal band is seen in the calvarium, a stronger anterior spring is needed. Conclusions: Long-term experience with spring-assisted surgery has facilitated the development of standardized, reproducible techniques allowing spring design modifications to optimize clinical outcome.

Scaphocephaly is an important but incompletely defined entity resulting from premature fusion of the sagittal suture. Our goal was to use the clarity afforded by three-dimensional computed tomographies (CTs) to discern what characteristics of this disease are most representative and singular. Furthermore, we sought to define a classification system wherein the dominant physical trait, as it results from varied sites of premature fusion, determines the type of scaphocephaly in a particular patient. All patients with CT-diagnosed isolated single-suture sagittal craniosynostosis seen by a single craniofacial surgeon and a single pediatric neurosurgeon over a 5-year period are included (N = 76). Patients were stratified into anterior, central, posterior, or complex subtypes dependent upon the presence of a single dominant characteristic as seen on CT scan. Anterior type features a transverse retrocoronal band; central type has a heaped sagittal ridge; posterior type has an especially prominent occiput; and complex type includes those patients in whom a single dominant feature is not present. Forty-eight patients fit into anterior, central, or posterior types. Thirteen percent (N = 7) lack a single dominant feature and are complex. Incidence and prevalence for each type in this population are the following: anterior, 13/24%; central, 16/29%; posterior, 19/35%; and complex, 7/13%. Heterogeneous points of initial fusion may be responsible for the differing representations. Clinical applications using this classification system are ongoing and may allow us to individualize surgical intervention to optimize clinical outcome.

The gold standard for closing small cranial defects is autogenous bone: iliac crest, rib, or split calvarial grafts. Autogenous grafts result in donor site morbidity, increased operative time, blood loss, and additional cost, and they are limited in quantity. Hydroxyapatite cements are alternative bone substitutes that eliminate these restrictions. Although the use of hydroxyapatite is well accepted in completely developed crania, its use in the growing pediatric skull is limited. The purpose of the current study was to address the safety and long-term efficacy of this bone substitute for the repair of craniofacial bone defects in the growing pediatric skull. Safety is measured dually by resistance of bone substitute to infection and its tolerability by lack of a foreign body reaction. Efficacy is evaluated as structural skull integrity, volume stability with time, aesthetic quality, and most importantly, the ability to integrate adequately into a growing cranium without subsequent deformity or complications. This is a retrospective review of all pediatric patients at the authors' institution who underwent reconstruction of cranial defects using hydroxyapatite cement between May 1997 and March 2001. Eight patients who underwent 11 operations between the ages of 25 and 100 months (mean, 55 months) were followed up between 23 and 72 months (mean, 38 months). No mortalities or significant morbidities were encountered in the study population. It has been the authors' experience that hydroxyapatite cement is both biocompatible and resistant to infection when used in sites not contiguous with sinus mucosa; and that it is a good alternative to autogenous bone in pediatric craniofacial reconstruction.

The evolution of modern craniofacial surgery has come full circle from the early strip craniectomies to the complete calvarial remodeling and now back to attempts at minimally invasive surgical interventions. The goal of the craniofacial surgeon has always been the correction of form and function with minimization of associated morbidity and mortality. Particularly problematic has been the ability to maintain the anatomical correction beyond the result seen on the operating room table secondary to changes with growth. The ability to improve the clinical result in a growing and developing child has been the impetus for dynamic treatment modalities. Dr Claes Lauritzen’s pioneering work in this area has been particularly successful using internal springs to correct craniofacial deformities. The purpose of this study is to assess this treatment modality clinically in terms of safety and efficacy and to develop a methodology for the spring formation that would be easily reproducible. This is an institutional review board-approved prospective study of 15 children (11 male, 4 female) with non-syndromic sagittal suture synostosis. All patients were treated with a sagittal strip craniectomy and placement of 2 omega-shaped stainless steel springs at a mean age of 3.9 months. Patients were followed clinically and with cephalograms; after reossification of the intervening bone, the springs were removed at a mean age of 8.2 months. The mean force applied at initial placement of the springs was 6.9 N, and the mean spring deflection at formation was 6.87 cm. All patients completed the study protocol without any significant morbidity or any mortality. Perioperative variables, including blood loss, transfusion rate, operative time, intensive care unit stay, hospital stay, and hospital charges, were all significantly less (P < 0.05) in this study group compared with children with the same diagnosis treated with cranial vault reshaping during the same period. Furthermore, the preoperative mean cephalic index of 64.3 corrected to 77.6 after surgery and was maintained over time. Spring-mediated cranial reshaping is efficacious and safe for the treatment of sagittal synostosis. Long-term study of cranial development and clinical morphology are ongoing to validate further the effectiveness of this treatment modality.