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OBJECTIVEThe objective of this study was to present the authors’ 19-year experience treating metopic craniosynostosis by using an endoscopy-assisted technique and postoperative cranial orthotic therapy. The authors also aimed to provide a comprehensive, comparative statistical analysis of minimally invasive surgery (MIS) versus open surgery in reports previously published in the literature (through 2014) regarding only patients with metopic synostosis.METHODSA total of 141 patients with single-suture metopic nonsyndromic craniosynostosis sutures were treated between 1998 and 2017 by endoscopically resecting the synostosed bone followed by postoperative custom cranial orthosis use. All data used in the case series were collected prospectively and stored in a secure database. A comprehensive literature review was performed that included all previous case series reporting common surgical performance measures. A statistical comparison of traditional open methods versus MIS techniques was performed with regard to age, length of hospital stay (LOS), surgical time, estimated blood loss (EBL), and transfusion rate.RESULTSThe mean age at the time of surgery in the current series was 4.1 months. The mean EBL was 33 ml (range 5–250 ml). One patient underwent an intraoperative blood transfusion and 5 underwent postoperative blood transfusion for a total transfusion rate of 4.3%. The mean operating time was 56 minutes. Ninety-eight percent of patients were discharged on the 1st postoperative day. The median size of the removed synostosed bone was 0.6 cm × 10 cm. The primary goal of achieving correction of the forehead deformity was obtained in 94% of the patients. One hundred eight patients presented with hypotelorism (76.6%). Those with a minimum 1-year follow-up achieved 99% correction (n = 97). Six patients younger than 1 year had not achieved correction at the time of follow-up (6%). There were no intra- or postoperative deaths. One patient had a temporary contact dermatitis to the helmet materials and 2 patients developed pseudomeningoceles, which were successfully treated with a lumbar drain and/or spinal tap. No patient required nor underwent a second surgical procedure. Regarding the previously published literature through 2014, the reported EBL in patients who underwent MIS versus traditional open methods was 54.7 ml versus 224 ml, respectively. The reported average age for patients undergoing MIS versus traditional open methods was 3.8 months versus 11.5 months. The average LOS for patients undergoing MIS versus traditional open methods was 1.7 days versus 3.7 days. The average reported surgical time for those undergoing MIS versus traditional open methods was 66.7 minutes versus 223.7 minutes. The transfusion rate for patients undergoing MIS versus traditional open methods was 22% versus 77%. All of the above differences demonstrated statistical significance.CONCLUSIONSThe authors’ team has safely and effectively performed 141 metopic craniosynostosis corrections over the past 19 years, with excellent outcomes. Literature review comparing metrics such as LOS, EBL, operating time, and transfusion rate demonstrates a statistically significant improvement in all commonly reported measurements. MIS techniques are safe and effective and should be offered to parents and patients as an option at craniofacial centers treating this condition.

Object The objective of this study was to present the authors' 16-year experience treating coronal craniosynostosis in infants using endoscopy-assisted techniques and postoperative cranial orthoses. Methods A total of 128 synostosed coronal sutures in 115 patients were treated between 1996 and 2012 by endoscopically resecting a strip of bone containing the stenosed suture via a 2–3 cm incision made at the ipsilateral stephanion. Data were obtained from a prospective database. Following surgery, patients were fitted with custom cranial orthoses to help correct preoperative craniofacial deformities. All patients were followed closely with cranial anthropometric measurements and photographs. Results The estimated mean blood loss was 20 ml (range 5–120 ml) and the estimated mean strip size was 0.6 cm × 10.7 cm. The mean surgical duration was 55 minutes (range 22–150 minutes). One patient underwent an intraoperative blood transfusion and 1 had a postoperative blood transfusion, for a total transfusion rate of 1.7%. Ninety-seven percent of patients were discharged on the first postoperative day. There were no deaths. Vertical dystopia correction of more than 80% from baseline was obtained in almost two-thirds of patients, with 51% achieving 100% correction. Nasal and sagittal craniofacial deviation (vertex-nasion-gnathion) correction greater than 80% was achieved in 80% of patients, with 77% achieving 100% correction. Supraorbital rim advancement of the ipsilateral eye was obtained in 98% of cases, with correction of frontal plagiocephaly the last deformity to achieve correction. Conclusions Early treatment of coronal synostosis with endoscopy-assisted craniectomy and postoperative molding helmets leads to significant correction of craniofacial abnormalities, including vertical dystopia, nasal deviation, sagittal misalignment, and ipsilateral proptosis. This treatment method is associated with minimal trauma, blood loss, and transfusion rates, and typically only requires 1 overnight stay. This surgical approach is safe, effective, and associated with excellent results.

Patients with Apert syndrome commonly present with ocular proptosis due to bilateral coronal craniosynostosis and midfacial hypoplasia. Severe proptosis can cause visual compromise and damage, which is most commonly treated with bilateral orbital frontal advancement. The authors present the case of a patient who was treated at 8 weeks of age with endoscope-assisted bilateral coronal craniectomies followed by treatment with a custom-made postoperative cranial orthosis. The patient underwent the procedure without any complications. Over the ensuing months, the patient's proptosis corrected, the forehead and orbital rims advanced without the need for an orbital frontal advancement and craniotomies. This approach may provide an alternative treatment modality for these patients.

This study aimed to present a 16-year experience of treating sagittal synostosis with endoscopic-assisted techniques and postoperative cranial orthotic therapy. In 1996, we introduced the use of endoscopes for the management of sagittal synostosis in four young infants. During the subsequent years, we have treated a total of 256 patients with great success and long-term follow-up. Presented herein are the techniques and results of such clinical experience.A total of 256 patients with sagittal synostosis have been treated between May 1996 and April 2012. There were 187 males and 69 females. Mean age at time of surgery was 3.9 months. A wide-vertex craniectomy with bilateral barrel stave osteotomies of the temporal and parietal bones using small scalp incisions and endoscopic viewing techniques was performed. Instruments have been developed to assist with the operation. All patients were placed in postoperative molding cranial orthosis.Mean estimated blood loss was 27 cc. Mean transfusion rate was 7 %. Mean surgical time was 57 min. Mean length of stay was 1.1 days. Using cephalic index (CI) as an anthropometric measurement to judge head shape, our results were classified as excellent (CI80), good (CI 80-70), or poor (CI70). A total of 87 % were classified as excellent, 9 % as good, and 4 % as poor.Endoscopic-assisted management of sagittal synostosis is a safe, efficacious, and excellent option for treating this condition with long-lasting, superb results. It is associated with minimal morbidity and complications and improved results over traditional procedures.

This paper aims to present a 15-year experience treating coronal craniosynostosis with endoscopic-assisted techniques and postoperative cranial orthotic therapy. A total of 100 patients with coronal craniosynostosis were treated between 1996 and 2010. There were 36 males and 64 females. A single 2-cm incision was made halfway between anterior fontanelle and the squamosal on the affected side. Using endoscopic-assisted visualization, a strip of bone was removed between the aforementioned points. Following surgery, all patients were placed in cranial orthoses to assist in the correction of the craniofacial deformity. Mean estimated blood loss was 20 cm3; only one patient required a transfusion. Mean length of stay was 1 day. Mean surgery time was 54 min. There were no mortalities. There was significant correction of vertical dystopia (66 % from baseline) and midsagittal plane deviation (80 % from baseline). Endoscopic-assisted craniectomy for treatment of coronal craniosynostosis in very young infants followed by cranial molding is associated with excellent long-lasting results and minimal morbidity and no mortality.

Object The authors present the results of treating infants with multiple-suture nonsyndromic craniosynostosis in whom the authors used minimally invasive endoscopy-assisted techniques and postoperative cranial molding over an 11-year period. Methods A total of 21 patients who presented with multiple-suture (nonsyndromic) craniosynostosis were treated using minimally invasive endoscopy-assisted craniectomies. Surgery was followed by treatment with custommade cranial orthoses for up to 12 months. A total of 48 sutures were treated. The most common was the coronal suture (38 cases) and this was followed by the sagittal (11 cases), metopic (6 cases), and lambdoid (3 cases) sutures. There were 13 male and 8 female pediatric patients. Their ages ranged between 3 weeks and 9 months (mean 3.2 months, median 2.5 months). The sagittal suture was treated with a wide vertex craniotomy via 2 incisions located behind the anterior fontanel and in front of the lambda. The metopic suture underwent a suturectomy as did the coronal and lambdoid sutures. Results The mean follow-up duration was 61 months (range 3–135 months). There were no deaths. In patients with bicoronal synostosis, brachycephaly was corrected. Patients presenting with vertical dystopia or nasal deviation had these deformities corrected as well. The mean blood loss was 42 ml (range 10–120 ml). The mean hospital length of stay was 1 day. The intraoperative transfusion rate was 0%. The results indicate that nonsyndromic multiple-suture synostosis can be safely and effectively treated using endoscopic techniques. Conclusions Early treatment of complex multiple-suture synostosis with endoscopic techniques provides an excellent surgical alternative. The results of the present study indicate marked correction of skull base and craniofacial deformities. Endoscopy provides a safe and effective way to treat these patients.

Object A relationship has been found between peripheral thermal injury and cerebral complications leading to injury and death. In the present study, the authors examined whether tumor necrosis factor–α (TNF-α) and matrix metalloproteinase–9 (MMP-9) play a causative role in blood-brain barrier (BBB) disruption after peripheral thermal injury. Methods Thirty-two male Sprague-Dawley rats were subjected to thermal injury. One hour later, 8 rats were injected with TNF-α neutralizing antibody, and 8 were injected with doxycycline, an inhibitor of the MMP family proteins; 16 rats did not receive any treatment. Brain tissue samples obtained 7 hours after injury in the treated animals were examined for BBB function by using fluorescein isothiocyanate–dextran and by assessing parenchymal water content. Protein expression of basement membrane components (collagen IV, laminin, and fibronectin) was quantified on Western blot analysis, and MMP-9 protein expression and enzyme activity were determined using Western blot and gelatin zymography. Thermally injured rats that did not receive treatment were killed at 3, 7, or 24 hours after injury and tested for BBB functioning at each time point. Histological analysis for basement membrane proteins was also conducted in untreated rats killed at 7 hours after injury. Results of testing in injured rats were compared with those obtained in a control group of rats that did not undergo thermal injury. Results At 7 hours after thermal injury, a significant increase in the fluorescein isothiocyanate–dextran and water content of the brain was found (p < 0.05), but BBB dysfunction was significantly decreased in the rats that received TNF-α antibody or doxycycline (p < 0.05). In addition, the components of the basal lamina were significantly decreased at 7 hours after thermal injury (p < 0.01), and there were significant increases in MMP-9 protein expression and enzyme activity (p < 0.05). The basal lamina damage was reversed by inhibition of TNF-α and MMP-9, and the increase in MMP-9 protein was reduced in the presence of doxycycline (p < 0.05). The authors found that MMP-9 enzyme activity was significantly increased after thermal injury (p < 0.01) but decreased in the presence of either TNF-α antibody or doxycycline (p < 0.01). Conclusions The dual, inhibitory activity of both TNF-α and MMP-9 in brain injury suggests that a TNF-α and MMP-9 cascade may play a key role in BBB disruption. These results offer a better understanding of the pathophysiology of burn injuries, which may open new avenues for burn treatment beyond the level of current therapies.

Background: A number of breast reduction techniques have been developed over the years, but debate over which technique is better for patients continues to grow. The authors' goal was to survey members of the American Society of Plastic Surgeons to identify their preferences and practices and report their opinion regarding issues related to the various breast reduction techniques. Methods: In the fall of 2006, a one-page anonymous survey was sent to 5112 plastic surgeons who were members of the American Society of Plastic Surgeons. A follow-up survey was sent 2 weeks after the first mailing as a friendly reminder. The questionnaires were then collected over a 6-week period. Results: Of the 5112 plastic surgeons surveyed, 2665 (52 percent) responded to the survey. The majority of the respondents (69 percent) use the inferior pedicle breast reduction technique. Ninety-two percent of the respondents use intraoperative deep venous thrombosis prophylaxis. Sixty-one percent of respondents performed over 75 percent of their cases on an outpatient basis and 97 percent of respondents use general anesthesia. Ninety-three percent of the respondents use preoperative antibiotics. Over 70 percent of the respondents do not think breast reduction should be a cosmetic procedure. Conclusions: In conclusion, the inferior pedicle technique has traditionally been the procedure of choice and remains so today. However, there has been an increase in the use of the newer techniques. Plastic surgeons are becoming more cognizant of the risk of deep venous thrombosis among their patients. The majority of breast reductions are now performed as outpatient procedures.

A total of 100 patients who presented with synostosis of the metopic or coronal suture were consecutively treated during a 6-year period using minimally invasive endoscopic-assisted suturectomies. After surgery, all patients were fitted with custom-made cranial helmets for up to 12 months. The coronal group consisted of 50 patients, 26 females and 23 males with a mean age of 3.78 months. Surgery was done through a single 2-mm incision at the ipsilateral stephanion. After endoscopic-assisted dissection, a craniectomy of the involved suture was done (mean width, 6 mm, and mean length, 10 cm). The metopic group consisted of 50 patients, 35 males and 16 females with a mean age of 4.1 months. A single 2- to 3-cm incision was placed on the midline behind the hairline. A suturectomy of the suture from anterior fontanelle to nasofrontal suture was performed (mean width, 7 mm, and mean length, 9.8 cm). For the entire cohort, the mean estimated blood loss was 34 cc (5–250 cc). The mean estimated percent of blood volume lost was 5.2% (1–26%). There were no intraoperative blood transfusions and five postoperative for a total transfusion rate of 6.7%. The mean surgical time was 56 min. All but one patient (99%) was discharged on the first postoperative day. Complications included two dural tears and four pseudomeningoceles. There were two cases of incomplete reossification of the craniectomy. There were no infections, mortalities, hematomas, or visual injuries. There were no complications related to helmet therapy except three superficial skin breakdowns that cleared immediately with helmet non-use for 3–4 days. Using anthropometric measurements and extensive photographic and physical assessments, excellent results were obtained in 84%, good results in 9%, and poor results in 7% of patients. Early treatment of infants with coronal or metopic craniosynostosis using endoscopic assisted minimally invasive suturectomies is a safe and efficacious treatment alternative associated with excellent results in a large portion of these patients.

It is unclear whether Filipinos with sincipital encephaloceles have true orbital hypertelorism or just telecanthus. Knowing this determines whether orbital osteotomies or medial canthoplasty are more appropriate corrective procedures. To evaluate this, 56 sequential Filipino sincipital encephalocele patients (28 female and 28 male, average age 66.6 months, age range 4 days to 21.8 years) were evaluated for orbital width. Soft tissue measurements of inner and outer canthal position and CT measurements of medial and lateral orbital wall position were obtained. Normative data curves by age and sex for orbital bony and soft tissue distances in normal Filipino children were developed. Data was plotted on these curves and analyzed to determine if encephaloceles were associated with medial widening alone or true hypertelorism. Inner canthal measurements for male were approximately +2.8 standard deviation (SD) and female +2.3 SD wider than average. Medial orbital wall dimensions were wider for male +1.5 SD and female +1.4 SD. Lateral orbital measurements for both male and female clustered around the normative mean (males -0.5 SD and females -0.8 SD). Female outer canthal measurements also clustered around the normative mean (+0.6 SD wider) while male outer canthal measurements averaged approximately +1.1 SD wider than mean. As expected, measurements were wider medially when compared to normative data. However, lateral bony and soft tissue widening was minimal or approached normative averages. This suggests the problem is medial widening only and less invasive procedures such as medial canthoplasty or nasal bony contouring may be the most appropriate surgical management.

Mortality after serious systemic thermal injury may be linked to significant increases in cerebral vascular permeability and edema due to blood-brain barrier (BBB) breakdown. This BBB disruption is thought to be mediated by a family of proteolytic enzymes known as matrix metalloproteinases (MMPs). The gelatinases, MMP-2 and MMP-9, digest the endothelial basal lamina of the BBB, which is essential for maintaining BBB integrity. The current study investigated whether disruption of microvascular integrity in a rat thermal injury model is associated with gelatinase expression and activity. Seventy-two adult Sprague-Dawley rats were anesthetized and submerged horizontally, in the supine position, in 100 degrees C (37 degrees C for controls) water for 6 s producing a third-degree burn affecting 60-70% of the total body surface area. Brain edema was detected by calculating water content. Real time PCR, Western blot, and zymography were used to quantify MMP mRNA, protein, and enzyme activity levels. Each group was quantified at 3, 7, 24, and 72 h post thermal injury. Brain water content was significantly increased 7 through 72 h after burn. Expression of brain MMP-9 mRNA was significantly increased as early as 3 h after thermal injury compared to controls, remained at 7 h (p

Previous studies have shown that the cerebral complications associated with skin burn victims are correlated with brain damage. The aim of this study was to determine whether systemic thermal injury induces inflammatory responses in the brain. Sprague Dawley rats (n=28) were studied in thermal injury and control groups. Animals from the thermal injury (n=14) and control (n=14) group were anesthetized and submerged to the neck vertically in 85 degrees C water for 6 s producing a third degree burn affecting 60-70% of the animal body surface area. The controls were submerged in 37 degrees C water for 6 s. Early expression of tumor necrosis factor-alpha (TNF-alpha), interleukin 1-beta (IL-1beta), and intracellular cell adhesion molecules (ICAM-1) protein levels in serum were determined at 3 (n=7) and 7 h (n=7) by enzyme-linked immunoabsorbent assay (ELISA). mRNA of TNF-alpha, IL-1beta, and ICAM-1 in the brain was measured at the same time points with a real-time reverse transcriptase-polymerase chain reaction (RT-PCR). An equal animal number was used for controls. Systemic inflammatory responses were demonstrated by dramatic up-regulations (5-50 fold) of TNF-alpha, IL-1beta, and ICAM-1 protein level in serum at 7 h after the thermal injury. However, as early as 3 h after peripheral thermal injury, a significant increase (3-15 fold) in mRNA expression of TNF-alpha, IL-1beta and ICAM-1 was observed in brain homogenates, with increased levels remaining at 7 h after injury. This study demonstrated an early inflammatory response in the brain after severe peripheral thermal injury. The cerebral inflammatory reaction was associated with expression of systemic cytokines and an adhesion molecule.

Seventy-two patients who presented with nonsyndromic coronal craniosynostosis were treated using endoscopic-assisted techniques. Release of the stenosed suture was accomplished with the creation of a 5-mm osteotomy extending from the anterior fontanelle to the pterion. All patients tolerated the procedure well with no mortalities, morbidities, or need for blood transfusions. Correction of the vertical dystopia, nasal deviation, and orbital resection was accomplished in most cases. This approach offers a viable alternative for the early treatment of coronal craniosynostosis.

Since 1997, the authors have instituted the use of custom-made helmets to correct craniofacial deformities associated with craniosynostosis following endoscopic-assisted craniectomies of the stenosed sutures in infants. This article presents their experience and results using helmet therapy in their patient population.

Object. Endoscopic techniques were introduced 7 years ago for the surgical management of patients with sagittal synostosis. In this study of 139 patients with sagittal synostosis, the authors assessed the efficacy, safety, complications, and outcomes after performing endoscopy-assisted wide-vertex craniectomies with bitemporal and biparietal barrel stave osteotomies. Methods. The sample population consisted of a total of 99 boys and 40 girls who ranged in age from 0.4 to 9.2 months (mean 3.6 months). Two small incisions were made near the lambda and vertex. Using endoscopic visualization, wide-vertex craniectomies with bilateral temporal and parietal barrel stave osteotomies were performed. Postoperative treatment included custom-made surlyn cranial orthotic devices for cranial reshaping and maintenance. The mean craniectomy width was 5.4 cm and the length was 10 cm. The overall blood transfusion rate was 9% (two intraoperative and 12 postoperative transfusions). The mean estimated blood loss was 29 ml (range 5‐150 ml). The mean preoperative hematocrit was 32%, whereas the postoperative level was 27%. One hundred thirty-two patients were discharged the morning following surgery. The majority of patients did not experience facial swelling, and none suffered postoperative fevers. Anthropometric cephalic index measurements indicated that excellent results were obtained in 87% of the patients (cephalic index � 75); good results in 8.7% (cephalic index 70‐75); and poor results in 4.3% (cephalic index � 70). There were no cases of intraoperative death, infection, hemorrhage, or venous sinus injury. Conclusions. Analysis of the results indicates that use of the aforedescribed procedure in the early treatment of infants with sagittal synostosis provides excellent outcomes and that the morbidity rate is lower than that associated with traditional cranial vault reconstruction. Detailed anthropometric and radiographic analyses demonstrated that with adequate helmet therapy in our patients normocephaly was achieved and maintained without the need for secondary operations.

Traditionally, surgical correction of craniosynostosis involves calvarial remodeling, large blood losses necessitating transfusions, hospital stays of several days, and less-than-satisfactory results. In this study, outcomes from a minimally invasive technique called endoscopic strip craniectomy, along with a postoperative molding helmet, to correct craniosynostosis in young infants were evaluated. The endoscopic strip craniectomy was performed on 185 patients with clinical signs of craniosynostosis, with the following distribution: 107 sagittal, 42 coronal, 37 metopic, and 7 lambdoid, for a total of 198 sutures. The mean blood loss was 29.4 cc, and only two patients underwent intraoperative blood transfusion. Fourteen patients underwent postoperative blood transfusion; none was life-threatening. There were no deaths, complications, neurological injuries, or infections. All but six patients were discharged on the first postoperative day. A majority of the patients achieved or approached normocephaly, and there were no complications. Neuroscience nurses need to be aware of this technique when they discuss treatment options with the families of infants with craniosynostosis.

Six hundred and seventy seven radiographs were selected from the logs of films taken in a major hospital in Metro Manila, Philippines over the course of the previous year. Two hundred and eighty-eight female and 389 male, healthy Filipinos between the ages of birth and twenty years were selected based on the availability of a modified Waters' projection and lateral skull film taken at the same time. Measurements for the lateral orbital wall were made at the site of the suture on the medial surface of the zygomatic bone. The medial orbital wall measurement was the distance between the dacrya using a correction factor formula of CF = D-d/D where D is the target film distance and d is the object film distance (1). The actual bony measurements were calculated. The data was gathered and plotted according to sex and in age in years. Graphs were generated using SAS over a graph software. Lines were smooth using cubic spline technique developed by Reinsch with the smoothest value of 75 (2). The mean plus two, four, and six standard deviations were included in each of the curves.

We present a model used to describe the effects of systemic thermal injury in cerebral permeability with the use of an open, acute pial window technique. Sprague-Dawley rats were anesthetized, and an open pial window was constructed. The area was then bathed with artificial cerebrospinal fluid with a pH adjusted to 7.4 that was heated to a constant temperature of 37°C, which was allowed to circulate into a reservoir at a rate of 2 cc/min. The fluid was infused with a gas mixture of 5% carbon dioxide and 95% nitrogen. A warming blanket was placed under the animal's ventral surface, and the animal's temperature was maintained at 37°C and monitored with a rectal thermal probe. Experimental animals were submerged to the xiphoid process in 100°C water bath for a total of 6 seconds, which produced a 70% total body surface area third degree burn. Control animals were submerged in 37°C water for 6 seconds. The animals were then injected with a constant infusion of bovine albumin coupled with fluorescein isothiocyanate. Recordings were taken every 15 minutes for 6 hours. The vascular albumin leakage was determined from the ratio of interstitium to vascular fluorescence and expressed as a percentage. The percent albumin leakage in the control group was found to be significantly different from that in the experimental group at all periods measured. The mean increase in permeability ranged from 20% at 15 minutes to 104% at 6 hours. These changes were found to be statistically significant with the use of unpaired t test at a P value of .0001. The model presented is the first to demonstrate changes in cerebral permeability after acute severe systemic thermal injury. (J Burn Care Rehabil 2000;21:20-5)

To facilitate the passive feeding requirements of children with cleft lip and palate deformities, as well as children with neurological deformities, a modification has been adapted to the Playtex nurser (Playtex, Dover, DE). It consists of removing the lower plastic portion of the bottle to allow passive delivery via a squeeze bag technique. This modification has been quite successful with these patients. We have found this bottle to be less expensive as well as easy to purchase compared with other available bottles. This bottle also has the capability of having multiple nipple variety types that can be adapted to it

To determine the efficacy of lumbar intrathecal (i.t.) morphine in a dose of 0.02 mg/kg in providing analgesia following repair of frontal encephaloceles.Prospective, open-label investigation of i.t. morphine with secondary comparison to a retrospective cohort.Metropolitan hospital in the Philippines.24 ASA physical status I and II children undergoing frontal encephalocele repair.Following induction of general anesthesia. I.t. morphine (Group 1) was administered via single-shot technique or through a lumbar i.t. drain placed for cerebrospinal fluid drainage during the surgical procedure. Postoperative analgesia was assessed by visual analog score in patients greater than 5 years of age or a behavioral score in patients less than 5 years of age. The retrospective cohort received postoperative analgesia with intermittent doses of intravenous nalbuphine (Group 2).Group 1 had decreased postoperative analgesic requirements, decreased intraoperative inhalational anesthetic requirements, and a longer time to the first request for postoperative analgesia than Group 2. The time to the first request for postoperative analgesia was 16.0 +/- 9.1 hours in Group 1 and 1.6 +/- 1.2 hours in Group 2 (p0.0001). Six of 12 patients in Group 1 required no analgesic drugs during the first 24 postoperative hours while all 12 patients in Group 2 (p = 0.02) did require analgesic drugs during this period. The patients in Group 1 who did not require supplemental analgesic drugs maintained pain scores of 2 or less throughout the first 24 postoperative hours.Lumbar IT morphine provides effective analgesia following repair of frontal encephaloceles in children and adolescents.

The objective of this study was to present the authors' 16-year experience treating coronal craniosynostosis in infants using endoscopy-assisted techniques and postoperative cranial orthoses.A total of 128 synostosed coronal sutures in 115 patients were treated between 1996 and 2012 by endoscopically resecting a strip of bone containing the stenosed suture via a 2-3 cm incision made at the ipsilateral stephanion. Data were obtained from a prospective database. Following surgery, patients were fitted with custom cranial orthoses to help correct preoperative craniofacial deformities. All patients were followed closely with cranial anthropometric measurements and photographs.The estimated mean blood loss was 20 ml (range 5-120 ml) and the estimated mean strip size was 0.6 cm × 10.7 cm. The mean surgical duration was 55 minutes (range 22-150 minutes). One patient underwent an intraoperative blood transfusion and 1 had a postoperative blood transfusion, for a total transfusion rate of 1.7%. Ninety-seven percent of patients were discharged on the first postoperative day. There were no deaths. Vertical dystopia correction of more than 80% from baseline was obtained in almost two-thirds of patients, with 51% achieving 100% correction. Nasal and sagittal craniofacial deviation (vertex-nasion-gnathion) correction greater than 80% was achieved in 80% of patients, with 77% achieving 100% correction. Supraorbital rim advancement of the ipsilateral eye was obtained in 98% of cases, with correction of frontal plagiocephaly the last deformity to achieve correction.Early treatment of coronal synostosis with endoscopy-assisted craniectomy and postoperative molding helmets leads to significant correction of craniofacial abnormalities, including vertical dystopia, nasal deviation, sagittal misalignment, and ipsilateral proptosis. This treatment method is associated with minimal trauma, blood loss, and transfusion rates, and typically only requires 1 overnight stay. This surgical approach is safe, effective, and associated with excellent results.

In an attempt to obtain objective analysis of outcome in reduction mammaplasty patients, a retrospective study was done for women having elective bilateral reduction mammaplasty. Participants were chosen from a pool of over 200 consecutive reduction mammaplasty patients at the University of Missouri-Columbia. Of those eligible for inclusion, 72 met the criteria and were available for long-term follow-up. These patients answered a panel of questions regarding weight change, brassiere size, exercise, activity level, symptoms, and a personal appraisal of appearance. Statistical analysis was done to evaluate the change in each variable in relationship to the time of surgery, i.e., before surgery, 6 months after surgery, and at the present time. The findings revealed a significant stable reduction of breast mass. The women reported a significant reduction of symptoms that had been associated with their macromastia. They also reported a significant increase in exercise and other physical and social activities.

Posterior plagiocephaly secondary to lambdoid suture stenosis requires surgical release and repair to prevent progressive deformational changes associated with a suture stenosis. A surgical technique is described for release of the stenosed lambdoid suture and asterion region, followed by occipital reconstruction. This technique provides excellent cosmetic results. Using a standard biparietal incision, most of the occipital bone is removed en bloc. The asymmetric occiput is then reconstructed using an autologous bone bandeau and Marchac forehead template graft. The remaining bone is cut into longitudinal strips and placed in a centrifugal fashion around this construct. This technique creates a stable unit that provides immediate symmetry to the occipital area. The operative time and blood loss are comparable to that of similar procedures. With this technique there have been no complications or need for reoperation.

Patients with Apert syndrome commonly present with ocular proptosis due to bilateral coronal craniosynostosis and midfacial hypoplasia. Severe proptosis can cause visual compromise and damage, which is most commonly treated with bilateral orbital frontal advancement. The authors present the case of a patient who was treated at 8 weeks of age with endoscope-assisted bilateral coronal craniectomies followed by treatment with a custom-made postoperative cranial orthosis. The patient underwent the procedure without any complications. Over the ensuing months, the patient's proptosis corrected, the forehead and orbital rims advanced without the need for an orbital frontal advancement and craniotomies. This approach may provide an alternative treatment modality for these patients.

A retrospective analysis of 29 patients who sustained perioral electrical burns was undertaken. Children were divided into three groups: (group 1) no surgery and no splint (n = 21), (group 2) nonsurgical management with splint appliance (n = 8), and (group 3) commissuroplasty (n = 9). Mean age was 3 years, and minimum follow-up was 1 year. Subjective evaluation of standard photographs was performed by six surgeons. Group 2 had a less noticeable scar and more normal lip parameters. Group 3 and group 1 had similar percent scar involvement and overall poor subjective scores. All evaluators felt that commissuroplasty (group 3) improved patients' appearance compared with no surgery and no splint (group 1). Therefore the application of our easily constructed splint alone yielded the best cosmetic results.

Nine patients (7 men, 2 women) with external nasal deviation underwent corrective procedures using a monobloc nasal osteotomy technique. The deformities ranged from mild to severe. Eight patients had post-traumatic deviations, whereas 1 had a unilateral cleft nasal deformity. For this monobloc technique, osteotomies were performed at unequal levels to correct the height difference, no periosteal undermining was performed, and septal dissection was undertaken only after monobloc repositioning. There was no need for grafts or microplate fixation. Minimum follow-up was 8 months. All patients had improvement in their external deviation, 1 patient was mildly undercorrected, and only 1 patient (cleft nasal) required a radical submucosal resection.

Twenty-one consecutive patients who had earlier superiorly based pharyngeal flap surgery and persistent velopharyngeal insufficiency were seen between 1976 and 1991. Patients were divided into two treatment groups, depending on the results of videofluoroscopic and nasopharyngoscopic assessment. The first group consisted of 18 patients who had bilateral port insufficiency and required a complete reconstruction of a new superiorly based pharyngeal flap that was elevated from a scarred posterior pharyngeal wall. After an average follow-up of 6.2 years, 15 patients had normal resonance, 2 patients had improvement but continued hypernasality, and 1 patient was hyponasal. The second group consisted of 3 patients who had «patch» flaps to a unilateral port insufficiency

Achondroplasia, the most common type of dwarfism, Involves several physical characteristics that can cause pre- and intraoperative respiratory problems. The characteristics Include rib-cage deformities, midface hypoplasia, choanal stenosis, muscular hypotonia, foramen magnum compression, and cervical abnormalities. Specific pre- and postoperative strategies for dealing with achondroplastic dwarfs are discussed.

Distraction of the frontal bone outside the cranial plane using the Ilizarov principle was performed in 17 22-week-old New Zealand white rabbits. Five rabbits had frontal bone osteotomy only and were in the control group; 5 rabbits were placed in the sham control group and had frontal bone osteotomy plus application of a customized headgear appliance; and 7 rabbits were placed in the experimental group, which underwent frontal bone osteotomy application of the headgear and distraction. The frontal bone was elevated 1 mm every other day for a period of 8 weeks, and the animals were then killed. Cephalometry was performed both preoperatively and at the end of the 8-week period. Histological examination of the skulls was also performed. The experimental group showed a significantly elevated frontal bone compared to the sham control group (p < 0.05). Callous bone filled the distracted segment, which united the frontal bone with the cranial plane. Therefore, frontal bone advancement by distraction osteogenesis is possible using this rabbit model.

Presented are 2 patients with abnormal craniofacial region, limbs, and abdomen, features that may be consistent with Pfeiffer syndrome, type 3. Both patients had bicoronal and bisphenoidal synostosis, extreme exophthalmic midface hypoplasia, and hydrocephalus. The limbs had a fixed flexion deformity of the elbows with broad thumbs which were radiopalmarly deviated; the toes were broad with a varus deformity and syndactyly of toes 2–5. Both patients developed bowel obstruction secondary to midgut malrotation, and one of the patients had prune belly syndrome. Review of the literature disclosed an additional patient who, in retrospect, had Pfeiffer syndrome type 3 and midgut malrotation. These patients suggest that intestinal malrotation with or without prune belly syndrome may be a common component of this entity. © 1993 Wiley-Liss, Inc.

Background Various studies have reported an incidence of venous air embolism (VAE) as high as 82.6% during surgical procedures for craniosynostosis. There has been an increase in the use of minimally invasive, endoseopie surgical procedures, including applications for endoscopic strip craniectomy. The current study prospectively evaluated the incidence of VAF during endoscopic strip craniectomy. Methods Continuous, intraoperative monitoring for VAE was performed using precordial Doppler monitoring. A recording was made of the Doppler tones and later reviewed to verify its accuracy. Results The cohort for the study included 50 consecutive neonates and infants ranging in age from 3.5 to 36 weeks and ranging in weight from 3 to 9 kg. Surgical time varied from 31 to 95 min for a total of 2,701 mm of operating time, during which precordial Doppler tones were auscultated. In 46 patients, there was no evidence of VAE. In four patients, there was a single episode of VAE. Two of the episodes of VAE were grade I (change in Doppler tones), and two were grade H (change in Doppler tones and decrease in end-tidal carbon dioxide). No grade III (decrease in systolic blood pressure by 20% from baseline) VAF was noted. Conclusion In addition to previously reported benefits of decreased blood loss, decreased surgical time, and improved postoperative recovery time, the authors noted a low incidence of VAF during endoscopic strip craniectomy in neonates and infants.

The authors present the results of treating infants with multiple-suture nonsyndromic craniosynostosis in whom the authors used minimally invasive endoscopy-assisted techniques and postoperative cranial molding over an 11-year period.A total of 21 patients who presented with multiple-suture (nonsyndromic) craniosynostosis were treated using minimally invasive endoscopy-assisted craniectomies. Surgery was followed by treatment with custommade cranial orthoses for up to 12 months. A total of 48 sutures were treated. The most common was the coronal suture (38 cases) and this was followed by the sagittal (11 cases), metopic (6 cases), and lambdoid (3 cases) sutures. There were 13 male and 8 female pediatric patients. Their ages ranged between 3 weeks and 9 months (mean 3.2 months, median 2.5 months). The sagittal suture was treated with a wide vertex craniotomy via 2 incisions located behind the anterior fontanel and in front of the lambda. The metopic suture underwent a suturectomy as did the coronal and lambdoid sutures.The mean follow-up duration was 61 months (range 3-135 months). There were no deaths. In patients with bicoronal synostosis, brachycephaly was corrected. Patients presenting with vertical dystopia or nasal deviation had these deformities corrected as well. The mean blood loss was 42 ml (range 10-120 ml). The mean hospital length of stay was 1 day. The intraoperative transfusion rate was 0%. The results indicate that nonsyndromic multiple-suture synostosis can be safely and effectively treated using endoscopic techniques.Early treatment of complex multiple-suture synostosis with endoscopic techniques provides an excellent surgical alternative. The results of the present study indicate marked correction of skull base and craniofacial deformities. Endoscopy provides a safe and effective way to treat these patients.

The purpose of this study was to determine the solidification rates for BoneSource (hydroxyapatite cement) mixed with sterile water versus BoneSource mixed with 0.25 ml of sodium phosphate. The average time for cure for BoneSource mixed with sterile water was 99 minutes, with a SD of 5.3 minutes. The average time for cure for BoneSource and sodium phosphate was 43 minutes, with a SD of 3.6 minutes (P < 0.0003). The average temperature for BoneSource in sterile water was 19.1 degrees C with a SD of 0.082, and the average temperature of BoneSource in sodium phosphate was 20.1 degrees C, with a SD of 0.1. Therefore, sodium phosphate shows that there is a significantly decreased amount of time required to solidify BoneSource and it remains isothermic throughout this reaction.

A relationship has been found between peripheral thermal injury and cerebral complications leading to injury and death. In the present study, the authors examined whether tumor necrosis factor-alpha (TNF-alpha) and matrix metalloproteinase-9 (MMP-9) play a causative role in blood-brain barrier (BBB) disruption after peripheral thermal injury.Thirty-two male Sprague-Dawley rats were subjected to thermal injury. One hour later, 8 rats were injected with TNF-alpha neutralizing antibody, and 8 were injected with doxycycline, an inhibitor of the MMP family proteins; 16 rats did not receive any treatment. Brain tissue samples obtained 7 hours after injury in the treated animals were examined for BBB function by using fluorescein isothiocyanate-dextran and by assessing parenchymal water content. Protein expression of basement membrane components (collagen IV, laminin, and fibronectin) was quantified on Western blot analysis, and MMP-9 protein expression and enzyme activity were determined using Western blot and gelatin zymography. Thermally injured rats that did not receive treatment were killed at 3, 7, or 24 hours after injury and tested for BBB functioning at each time point. Histological analysis for basement membrane proteins was also conducted in untreated rats killed at 7 hours after injury. Results of testing in injured rats were compared with those obtained in a control group of rats that did not undergo thermal injury.At 7 hours after thermal injury, a significant increase in the fluorescein isothiocyanate-dextran and water content of the brain was found (p0.05), but BBB dysfunction was significantly decreased in the rats that received TNF-alpha antibody or doxycycline (p0.05). In addition, the components of the basal lamina were significantly decreased at 7 hours after thermal injury (p0.01), and there were significant increases in MMP-9 protein expression and enzyme activity (p0.05). The basal lamina damage was reversed by inhibition of TNF-alpha and MMP-9, and the increase in MMP-9 protein was reduced in the presence of doxycycline (p0.05). The authors found that MMP-9 enzyme activity was significantly increased after thermal injury (p0.01) but decreased in the presence of either TNF-alpha antibody or doxycycline (p0.01).The dual, inhibitory activity of both TNF-alpha and MMP-9 in brain injury suggests that a TNF-alpha and MMP-9 cascade may play a key role in BBB disruption. These results offer a better understanding of the pathophysiology of burn injuries, which may open new avenues for burn treatment beyond the level of current therapies.

Emerging data suggests the serine proteases, tissue plasminogen activator (tPA), and urokinase plasminogen activator (uPA), may play a detrimental role in traumatic states leading to compromise of the blood brain barrier (BBB). The purpose of our study was to define the role of endogenous tPA and uPA on the BBB following peripheral burn injuries. Adult male Sprague-Dawley rats (n=46) were studied in control and thermal injury groups. Rats were anesthetized and submerged in 100 degrees C water for 6s producing a third degree burn affecting 60-70% of the total body surface area. BBB dysfunction was then evaluated by measuring the amount of Evans blue and by calculating the water content in the brain. Levels of tPA and uPA mRNA in the brain were determined with real-time polymerase chain reaction (PCR) at 3 and 7h post-injury. Results showed an increase in the brain water content and the presence of Evans blue in the brain tissue of thermally injured rats, temporally associated with an increased expression of endogenous tPA and uPA. Our study demonstrates that peripheral thermal injury does induce an increase in the permeability of the BBB. A possible mechanism may be an increased expression of tPA and uPA.

Since abdominoplasty has been shown to have a positive impact on patient's self-image and quality of life, it is no surprise that the annual number of these procedures performed has continued to increase. Historically, because of concerns with patient safety the majority of these operations have been performed on an inpatient basis. The breast reduction experience has shown that with proper patient selection and operative technique, this procedure can be performed on an outpatient basis without compromising safety. We retrospectively reviewed the senior author's experience to see if abdominoplasties can be safely performed as an outpatient procedure. Forty-five patients underwent abdominoplasties as an outpatient with only 1 patient required operative reexploration; the other complications were minor wound problems that did not require operative intervention. Proper patient selection and operative technique can allow a successful abdominoplasty with minimal morbidity.

Background: Since the National Surgical Adjuvant Breast and Bowel Project B06 (NSABP-B06) trial demonstrated equivalent survival outcomes between patients with breast cancer undergoing modified radical mastectomy versus lumpectomy and radiation, an increasing number of patients are seeking breast conservation therapy. Traditionally, only patients who have undergone total mastectomy have been referred for reconstruction. Objective: The purpose of the study was to determine the number of dissatisfied patients treated with breast conservation therapy who have suboptimal cosmesis and should be referred for reconstruction. Methods: After obtaining approval from the Institutional Review Board and patient consent, patients identified as more than 1 year posttreatment from breast conservation therapy (1999–2004) were interviewed and photographed. Data were gathered by use of a questionnaire that included patient aesthetic score, patient satisfaction, and change in body image. Photographs were shown to a surgical oncologist, a general surgeon, and a plastic surgeon for a physician aesthetic score. Results: Thirteen of 46 patients (28.3%) were dissatisfied with their cosmetic result. Women who were dissatisfied with their cosmetic result were more likely to have a negative change in their body image when compared with patients who were satisfied with their cosmetic result (46.2 % vs 6.1%, P = .02). Additionally, dissatisfied patients were more likely to rate their cosmetic result as poor (15.4 % vs 0%, P = .007) and were more likely to consider reconstruction (46.2% vs 9.1%, P = .01) when compared with satisfied patients. Risk factors to predict dissatisfaction in our patient population included age younger than 52 years and the resection of tumor from the upper inner quadrant. Conclusions: Twenty-eight percent of patients in this study were dissatisfied with their cosmetic result. Furthermore, a large portion of these patients would consider reconstruction if it were offered. Although this study only identified a few broad risk factors for suboptimal cosmetic outcome, it confirms our hypothesis that many patients who have undergone breast conservation therapy should be referred for plastic surgery consultation.

High mortality incidence after serious systemic thermal injury is believed to be linked to significant increases in cerebral permeability, ultimately leading to irreversible blood-brain barrier (BBB) breakdown. The aim of this study was to investigate whether disruption of microvascular integrity in a rat thermal injury model is associated with early matrix metalloproteinase (MMP) expression. A total of 35 Sprague-Dawley rats were studied in thermal injury and control groups, each group containing two subgroups, one for brain edema and Evans blue analysis and another for MMP mRNA analysis. Thermally injured animals were anesthetized and submerged vertically in 85 degrees C water to the neck for 6 seconds producing a third degree burn affecting 70% of the total body surface area. BBB integrity was determined by measuring amount of Evans blue after 7 hours of injury with a spectrophotometer. Brain edema was detected by calculating water content. Brain mRNA levels were determined with real-time PCR 3 and 7 hours post-injury. Brain water content was significantly increased after peripheral injury at hour 7. Evans blue leakage was also significantly increased at the same time, suggesting an impaired BBB function after injury. Expressions of MMP-2 and MMP-9 mRNA in brain were increased as early as 3 hours after injury and remained at hour 7. Our study demonstrated a significant increase in cerebral permeability that occurs after serious systemic thermal injury. The underlying mechanisms could be related to early expression of MMPs.

Background Extended abdominoplasty in the patient with massive weight loss has traditionally been performed as an inpatient procedure. To date, there has been no report on the safety of outpatient extended abdominoplasty in the patient with massive weight loss. Objective The authors sought to evaluate the safety of outpatient abdominoplasty in this growing population of patients. Methods A retrospective chart review was performed of all the senior author's (C.M.B.) patients with massive weight loss who underwent extended abdominoplasty from November 2004 to August 2006. Each case was evaluated for demographic information, patient weight (pre-gastric bypass, pre-contour), body mass index (pre-gastric bypass, pre-contour), weight of specimen, anesthesia type, estimated blood loss, operating room time, length of stay, and drain management. The complications were compared with historical control subjects. Results A total of 19 patients, 16 female and 3 male, underwent extended abdominoplasty after massive weight loss. The average weight loss was 142 pounds. The average pre-gastric bypass body mass index was 52 kg/m 2 . The average pre-contour body mass index was 29 kg/m 2 . The average operative findings were as follows: estimated blood loss, 130 mL; specimen weight, 3288 g; and operative time, 132 minutes. There was no perioperative blood transfusion. All patients (100%) were discharged the same day. Overall complications in 5 patients (26%) included stitch abscess (5%), partial umbilical necrosis (5%), superficial wound dehiscence (10%), and seroma and bleeding (5%) in the same patient. Conclusions With appropriate patient selection and operative techniques, outpatient extended abdominoplasty can be performed safely in the patient with massive weight loss.

Object The purpose of this study was to assess the efficacy, safety, associated complications, and outcome in patients with sagittal suture craniosynostosis in whom endoscopy-assisted wide-vertex craniotomy and “barrel-stave” osteotomy were performed. Methods During a 4-year period, 59 patients with sagittal suture synostosis underwent endoscopy-assisted wide-vertex craniectomies, barrel stave–like osteotomies, and postoperatively were fitted with custom-made molding helmets. Data on operative time, blood loss, transfusion rates, hospital length of stay, complications, and hospital charges were collected prospectively. The mean patient age at the time of surgery was 3.7 months. The average blood loss was 31.8 ml; and only one patient required an intraoperative blood transfusion. Nine patients received transfusions of donor blood postoperatively. The mean operative time was 50 minutes, and all but three patients were discharged from the hospital the morning following surgery. There were no intraoperative complications. Normocephaly as well as normal cephalic indices were observed at latest follow up. Conclusions The authors conclude that early treatment of infants with sagittal suture craniosynostosis by using minimally invasive, endoscopy-assisted wide-vertex craniectomies provides excellent results and a significantly lower morbidity rate than traditional calvarial vault reconstructive procedures.

Objective. To assess the safety, efficacy, and results of the early treatment of infants with craniosynostosis using minimally invasive endoscopic strip craniectomies and postoperative helmet molding therapy.Methods. A total of 100 patients with documented diagnosis of craniosynostosis were prospectively studied and treated with endoscopic strip craniectomies. A total of 106 stenosed sutures were operated on with the following distribution: 61 sagittal, 23 coronal, 18 metopic, and 4 lambdoid sutures. Sixty-three patients were treated under 16 weeks of age. After surgery, all patients were treated with custom-made molding helmets for up to 7 months. Follow-up ranged between 4 months and 50 months.Results. All patients underwent the surgical procedures successfully and without complications. The mean surgical operative time was 52.7 minutes. The mean estimated blood loss was 26.2 mL; only 1 patient underwent intraoperative blood transfusion, and 10 patients had a non- life-threatening postoperative blood transfusion. All but 3 patients were discharged on the first postoperative day. There were no infections, dural sinus tears, cerebrospinal fluid leaks, or neurologic injuries, and there were no significant complications related to the use of helmet therapy. Most patients have achieved or are in the process of reaching normalization of their craniofacial deformities.Conclusions. The results indicate that the early treatment of craniosynostosis with minimally invasive endoscopic strip craniectomies is a safe, efficacious, and valuable therapeutic alternative to the current extensive surgical treatment modalities. The significantly less blood loss, need for blood transfusions, and length of stay and decreased costs make this procedure an excellent early option for treating infants who present with craniosynostosis.

The child with an excessive drooling problem often faces similar social deprivation to those with severe craniofacial malformations. Many of these children have other “strikes against them” (such as cerebral palsy) that, when coupled with drooling, isolate them from social interaction. Many methods have been employed to control drooling but surgery has been most consistently successful. The most popular of these has been the Wilke procedure or a modification of It. Several series have been reported, but a detailed correlation of mechanical success with the effects on social activity has not been reported. We reviewed a series of 23 cases of Wilke-type surgery. Analysis of the results showed a convincing Improvement in social activity after successful surgery. The Wilke procedure enjoys a relatively high rate of success In preventing excessive drooling, which seems to offer a dramatic improvement in social contact enjoyment.

The posteriorly based tongue flap can be very useful to close difficult palatal fistulas, especially because the palatal sling prevents dehiscence of the tongue flap. However, special techniques may need to be employed with very large palatal fistulas or severely scarred palates. This technique has been used successfully in 5 patients. A detailed case report is presented, for which refinements of the tongue flap technique was required.