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Purpose: Pediatric brachial plexus injuries (BPI) are uncommon, representing about 10% of BPIs overall and 0.1% of pediatric trauma cases. These injuries often result from high-energy trauma and are unique to neonatal and adult cases. This study aims to provide a contemporary, large-scale analysis of pediatric BPI mechanisms and management patterns. Methods: The Trauma Quality Improvement Program (TQIP) database was used to identify pediatric BPI cases from 2017 to 2020. Mechanisms of injury (MOI), concomitant injuries, imaging, and treatment intervention were determined. Pediatric age groups were defined as children (0–9 years), young adolescents (10–14), and older adolescents (15–17). Results: Of the 746,817 recorded pediatric trauma cases in TQIP, 285 BPI cases were identified (0.038%), with the majority (55%) in older adolescents. Firearm injuries accounted for 23% of cases, surpassing sports (22%) and MVAs (21%) as the leading mechanisms. Children under 10 years were most affected by MVAs (20%), young adolescents by sports (32%), and older adolescents by firearms (30%). Associated injuries included orthopedic (44%), head (40%), and vascular (24%) injuries. Imaging was performed in 82% of cases, with CT (57%) and MRI (50%) being the most common. Immediate BPI repair was rare (4.3%), mainly occurring in cases with concurrent vascular injuries (91%). Discussion: Pediatric BPIs are increasingly linked to firearms and often present alongside complex polytrauma, requiring specialized care. Immediate repair is rare, typically reserved for cases with vascular injury. These findings emphasize the need for further research to refine management, particularly in high-energy and firearm-related BPIs. [ABSTRACT FROM AUTHOR]

Purpose: This study aims to explore demographic disparities, regional and institutional variations, surgical timing, narcotic use, and management trends in neonatal brachial plexus palsy (NBPP) patients due to limited published literature. Methods: We conducted a retrospective cohort study using the Pediatric Health Information System (PHIS) database of NBPP patients who underwent surgery within the first 2 years of life. Patients were stratified into two groups based on age at surgery: ≤ 8 months and > 8 months. Results: A total of 788 patients were identified, with a mean surgical age of 8.1 months. Black patients were disproportionately affected (29%), over twice their national birth rate (14%). Narcotic use was more common in younger patients (63% vs. 53%, p = 0.003), as well as in those treated in the West (71%, p = 0.001) and Northeast (73%, p = 0.004), and by plastic (74%, p < 0.0001) or orthopedic surgeons (69%, p = 0.002). Patients prescribed narcotics had longer hospital stays (1.7 vs. 1.2 days, p < 0.0001) and higher complication rates (7.9% vs. 3.1%, p = 0.009). Narcotic use decreased significantly over the study period (p = 0.002). Short-term outcomes, including complication and readmission rates, were similar across the three primary surgical specialties (plastic, orthopedic, and neurosurgery). High-volume centers had lower complication rates (1.5% vs. 5.4%, p = 0.002) and ICU admissions (5.8% vs. 18%, p < 0.0001) compared to medium-volume centers. Conclusion: While narcotic use was associated with longer stays and complications, short-term outcomes were consistent across specialties. Standardized care protocols may help improve patient outcomes. [ABSTRACT FROM AUTHOR]

Any surgeon providing care to patients with congenital, oncologic, infectious, or traumatic processes impacting the head and neck should have an intimate knowledge of the local anatomy. The complex fascial system in this region results in a series of loosely and tightly bound spaces that can both harbor and/or facilitate the rapid spread of infections through these fascial planes and potential spaces. Deep neck space infections may occur spontaneously from cutaneous, lymphatic, odontogenic, otologic, salivary gland, sinus, and hematogenous sources or develop as the result of surgical/iatrogenic manipulation. These infections are typically polymicrobial, involving a mixture of Gram-positive cocci, Gram-negative rods, and beta-lactam-resistant anaerobes commonly found in the oropharyngeal flora. Other populations, such as immunocompromised or hospitalized patients, are particularly vulnerable to infection by certain opportunistic and antibiotic-resistant pathogens. Understanding the deep neck anatomy is crucial for predicting the spread of infection and guiding treatment strategies. The superficial and deep cervical fascial planes form a series of compartments and spaces including the retropharyngeal, danger, prevertebral, carotid, parapharyngeal, submandibular, sublingual, parotid, masticator, temporal, and infrahyoid spaces. Despite their rarity in the post-antibiotic era, deep neck space infections pose a significant threat as they progress rapidly and can quickly lead to life-threatening complications. Delayed clinical presentation is common due to the compartmentalization by fascial planes, therefore early recognition requires a high index of suspicion, thorough clinical examination, and diagnostic imaging studies, typically contrast-enhanced computed tomography (CECT). Treatment requires a multidisciplinary approach, including advanced airway management, administration of empirical broad-spectrum antibiotics, and surgical drainage when indicated. This review provides a comprehensive overview of deep neck space anatomy and its defining fascial planes, as well as discussions on epidemiology, specific microbiology, clinical presentation, diagnosis, antibiotic selection, and surgical treatment options. [ABSTRACT FROM AUTHOR]

Objective: To assess the ability of current 3D printing technology to generate a craniofacial bony and soft tissue anatomical model for use in simulating the performance of a fronto-orbital advancement (FOA) osteotomy and then to further assess the value of the model as an educational tool. Design: Anatomic models were designed with a process of serial anatomic segmentation/design, 3D printing, dissection, and device refinement. A validation study was conducted with 5 junior and 5 senior plastic surgery residents. The validation study incorporated a multiple-choice Knowledge Assessment test (KA), an Objective Structured Assessment of Technical skills (OSATs), a Global Rating Scale (GRS) and a Michigan Standard Simulation Experience Scale (MiSSES). We compared the scores of both the junior and senior residents and compared junior resident scores, before and after viewing a lecture/demonstration. Results: MiSSES showed high face validity with a score of 85.1/90, signifying high satisfaction with the simulator learning experience. Simulation and the lecture/demonstration improved the junior resident average KA score from 5.6/10 to 9.6/10 (P =.02), OSATs score from 32.4/66 to 64.4/66 (P <.001) and GRS score from 13.9/35 to 27.5/35 (P <.001). The senior residents OSATs score of 56.3/66 was higher than the pre-lecture juniors (32.4/66) (P <.001), but lower than the post-lecture juniors (64.4/66) (P <.001). Conclusion: We have successfully fabricated a 3D printed craniofacial simulator capable of being used as an educational tool alongside traditional surgical training. Next steps would be improving soft tissue realism, inclusion of patient and disease specific anatomy and creation of models for other surgical specialties. [ABSTRACT FROM AUTHOR]

Introduction: Alveolar bone grafting aims to restore bony continuity of the alveolus and provide optimal periodontal support for teeth adjacent to the cleft. We created a survey of cleft surgeons to assess the current standard of care regarding this procedure. Methods: A multiple choice survey was implemented using Qualtrics software and emailed to a list of 708 surgeons from the ACPA membership directory. Correlation between various provider factors and treatment practices was assessed with Fisher's exact test and likelihood ratio tests. Results: The response rate was 17.5%. Eighty-seven percent of providers preferred to perform grafts prior to secondary canine eruption while 10% favored before central incisor eruption. Eighty-one percent favored palatal expansion prior to bone grafting. Wide variability existed regarding the time to initiate postoperative orthodontics; 43% waited 4 to 6 months. Sixty-four percent of surgeons now utilize cone beam CT to assess graft take. The majority of respondents utilized cancellous bone autograft (92%) from the anterior iliac crest (97%) as graft material. Seventy percent used three or more modalities for post-operative pain control management. Early career surgeons (0–5 years) appeared more likely to use non-autologous materials (p <.01) for grafting. Conclusion: Alveolar bone grafting prior to secondary canine eruption remains the most common strategy but other protocols are employed. Surgeons utilize multiple modalities for radiographic evaluation and most often use autologous cancellous bone as the primary grafting material. There is no true consensus on the perioperative timing and sequencing of orthodontic manipulation while principles of multimodal perioperative pain control appear widely accepted. [ABSTRACT FROM AUTHOR]

Objective: Recent publications have introduced the use of buccal myomucosal and fat pad flaps to augment palatal repairs with autologous tissue. We propose a workflow for intraoperative decision-making to introduce these adjuncts into standard palatoplasty procedures. Design/Patients: A retrospective chart review of a single-surgeon series of patients undergoing primary and secondary palatoplasties performed between October 2017 and November 2020 was completed after Institutional Review Board approval. Main Outcome Measures: Patient demographics, phenotype, operative details, and postoperative complications were recorded. Results: Fifty-eight patients were included in a review. For those undergoing primary repair, 23.3% underwent a Furlow palatoplasty alone, 46.3% had a Furlow palatoplasty accompanied with acellular dermal matrix (ADM) and/or a buccal fat flap (BFF). A unilateral buccal myomucosal flap (BMMF) with or without augmentation with BFF or ADM was employed in 16.3% of the cases. Fourteen percent required a bilateral BMMF+/− ADM. Fistula occurrence was 2.3% (n = 1). For revisions, 27% underwent only a conversion Furlow palatoplasty, 26% had a conversion Furlow palatoplasty accompanied with ADM and/or a BFF, 33% had a unilateral BMMF or BMMF/ADM, and 14% required a bilateral BMMF+/− ADM. Conclusions: In severe phenotypes or complicated cases, buccal fat flaps and myomucosal flaps may be utilized. This approach has mostly replaced the use of ADM over time. An algorithmic approach to palatoplasty allows surgeons to tailor the extent of surgery to the needs of each patient. [ABSTRACT FROM AUTHOR]

Background. Craniosynostosis repair via open complex cranial vault remodeling (OCCVR) is a complicated surgical procedure associated with morbidity and blood loss, often requiring blood transfusion. The Pediatric Craniofacial Collaborative group created the Pediatric Craniofacial Surgery Perioperative Registry (PCSPR) to capture data relating to the perioperative management of children undergoing craniofacial surgery. A tertiary pediatric hospital implemented its own quality improvement (QI) initiative with the aim of reducing blood transfusion volumes and exposures in patients undergoing OCCVR. The initiative included preoperative iron supplementation, intraoperative use of cell saver and tranexamic acid, maintenance of normothermia, and restrictive transfusion protocols. Methods. Patients were included in the study if they had a diagnosis of craniosynostosis, were younger than 18 years, and underwent OCCVR. Patient demographics, comorbidities, and perioperative data were recorded using the PCSPR. Outcomes included blood transfusion volume, number of blood donor exposures, and intra and postoperative complications. Outcomes before and after the initiative were compared. Results. The median perioperative allogenic blood transfusion volume decreased from 35 mL/kg pre-QI to 24 mL/kg post-QI (P < .001). There was a significant decrease in the number of blood donor exposures, and the number of patients who experienced a transfusion-free perioperative period increased from 10.9% to 19.6% (P = .037). There were no observed differences in perioperative complications, hospital and intensive care unit length of stay, or mortality. Conclusions. This QI initiative has resulted in reduced blood transfusion volumes and reduced blood donor exposures without an increase in perioperative complications related to blood loss. Further multi-institutional research is necessary to create national standards for the anesthetic care of all patients undergoing OCVR. [ABSTRACT FROM AUTHOR]

Objective: We aimed to assess significant ethnic variabilities in infants' nasolabial anthropometry to motivate variations in surgical correction of a synchronous bilateral cleft lip/nasal anomaly, specifically whether a long columella is a European feature, therefore accepting a short columella and/or delayed columellar lengthening suitable for reconstruction in ethnic patients. Methods: Thirty-three infants without craniofacial pathology (10 African American [AA], 7 Hispanic [H], and 16 of European descent [C]), ages 3 to 8 months, presenting to the Johns Hopkins All Children's general pediatric clinic were recruited. Four separate 3D photographs (2 submental and frontal views each) were taken using the Vectra H1 handheld camera (Canfield Imaging). Eighteen linear facial distances were measured using Mirror 3D analysis (Canfield Imaging Systems). Difference between ethnicities was measured using analysis of variance with the Bonferroni/Dunn post hoc comparisons. Pearson correlation was employed for interrater reliability. All statistical analyses were carried out using SPSS version 21.0 (IBM Corp), with statistical significance set at P <.05. Results: Nasal projection (sn-prn) and columella length (sn-c) did not differ significantly between groups (P =.9). Significant differences were seen between ethnic groups in nasal width (sbal-sbal [C-AA; P =.02]; ac-ac [C-AA; P =.00; H-AA; P =.04]; al-al [C-AA; P =.00; H-AA; P =.001]) and labial length (sn-ls [C-AA; P =.041]; sn-sto [C-AA; P =.005]; Cphs-Cphi L [C-AA; P =.013]; Cphs-Cphi R [C-AA; P =.015]). Interrater reliability was good to excellent and significantly correlated for all measures. Conclusions: African American infants exhibited wider noses and longer lips. No difference was noted in nasal projection or columella length, indicating that these structures should be corrected during the primary cleft lip and nasal repair for all patients and should not be deferred to secondary correction. [ABSTRACT FROM AUTHOR]