- Craniofacial Abnormalities
- Pediatric Plastic Surgery
- Facial Fractures
- Skin cancer reconstruction
- Mohs reconstruction
- Cleft Lip
- Cleft Palate
- Ear pinning (Otoplasty)
- Nose surgery
- Aesthetic Surgery
- Facial rejuvination
- Brow lift
- Eyelid surgery (Blepharoplasty)
- Facial implants
- Chin augmentation
- Neck lift
- Fat grafting
- Tummy tuck (Abdominoplasty)
- Facial Bones
- Facial Trauma
- Craniofacial trauma
- Craniomandibular Disorders
- Osteogenesis, Distraction
- Vascular Malformations
- Acquired Nasal Deformities
- Nasal Reconstruction
- Facial Paralysis
- Facial Reanimation
- Facial Asymmetry
- Cosmetic Surgery
- Infant ear molding
- Cosmetic Reconstructive Surgical Procedures
- Nasal Septum
- craniofacial surgery
- Plastic and Reconstructive Surgery
Clinical Associate Professor, Surgery - Plastic & Reconstructive Surgery
Surgical Director, Cleft & Craniofacial Center, Lucile Packard Children's Hospital, Stanford (2014 - Present)
Medical Education: University of Connecticut School of Medicine Registrar (2002) CT
Board Certification: American Board of Plastic Surgery, Plastic and Reconstructive Surgery (2009)
Fellowship: University of Washington (2008) WA
Residency: University of Texas Southwestern Medical Center (2007) TX
Residency: University of Texas Southwestern Medical Center (2005) TX
- Improvements in Cleft Lip Aesthetics with the Fisher Repair Compared to the Mohler Repair PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8 (6)
Applied Online Crowdsourcing in Plastic and Reconstructive Surgery: A Comparison of Aesthetic Outcomes in Unilateral Cleft Lip Repair Techniques.
Annals of plastic surgery
2020; 84 (5S Suppl 4): S307–S310
BACKGROUND: Aesthetic outcomes of unilateral cleft lip repairs have important psychosocial implications for patients who are heavily influenced by social perceptions. Online crowdsourcing offers the unique potential to efficiently recruit large numbers of laypeople to assess public perception. The aim of this study was to use the online crowdsourcing platform Mechanical Turk to compare the postoperative outcomes of Fisher, Millard, and Mohler cleft lip repair techniques.METHODS: Two hundred fifty-four participants were recruited through Mechanical Turk to evaluate 29 cropped and deidentified photographs of children, 8 photographs were controls without cleft lips and 21 were children with unilateral cleft lips who had undergone Fisher, Millard, or Mohler repairs (7 in each group). Respondents were asked whether a scar was present, whether they would be personally satisfied with the surgical result and used a Likert scale from 1 to 5 to rate overall appearance, scar severity, and nasal symmetry.RESULTS: Fewer respondents reported that a scar was present when assessing postoperative photographs of Fisher repairs (70.3 ± 8.6%) compared with Millard (92.0 ± 1.5%) or Mohler (88.8 ± 3.1%) repairs. Average rating of scar severity was also lower for Fisher (1.9) compared with Millard (2.6) or Mohler (2.6) repairs. Average ratings of nose symmetry, general appearance, and satisfaction with operative result were not statistically significantly different between the repair groups.CONCLUSIONS: This study demonstrates the potential of online crowdsourcing to assess public perception of plastic surgery outcomes. The Mechanical Turk platform offers a reduction in selection bias, ease of study design, and enhanced efficiency of large-scale participant recruitment. Results indicate that the Fisher repair led to the most favored aesthetic outcomes compared with the Millard and Mohler techniques, particularly with regard to scar severity. Crowdsourcing is a powerful tool to assess layperson perception of plastic surgery outcomes and can be used to better guide surgical decision-making.
View details for DOI 10.1097/SAP.0000000000002389
View details for PubMedID 32282397
Descriptive Overview of Primary Cleft Palate Surgeries in the Low- and Middle-Income Countries.
The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association
OBJECTIVE: To increase access to high-quality and multiregional databases in global epidemiology of cleft surgeries through partnership with an NGO.DESIGN: The study retrospectively analyzes 34 801 primary palate surgeries in 70+ countries from the 2016 electronic health records of an non-governmental organization (NGO). The study also utilizes the Kids' Inpatient Database to compare the epidemiology of primary cleft palate surgeries in the United States.PARTICIPANTS: Patient records of those undergoing primary cleft palate surgeries only.MAIN OUTCOME MEASURES: Region, age, sex, type of cleft, laterality of cleft.RESULTS: Key findings show that average age of those receiving primary cleft palate surgery in the low- and middle-income countries (LMICs) was 1.95 years. The distribution of males and females receiving surgery corresponds to the US national data. More hard cleft palates were on the left side (66.18%) than the right side (33.82%), independent of gender and region.CONCLUSIONS: Databases from an established NGO can be used to enhance our understanding of the disease characteristics in these regions. By increasing the information available regarding cleft surgeries in the LMIC, we hope to increase awareness of the similarities and differences in surgeries across various regions, as part of an effort to inform the goals set by Global Surgery 2030 initiative by the Lancet Commission.
View details for DOI 10.1177/1055665620911556
View details for PubMedID 32207319
Improvements in Cleft Lip Aesthetics with the Fisher Repair Compared to the Mohler Repair.
Plastic and reconstructive surgery. Global open
2020; 8 (6): e2919
The extended Mohler rotation-advancement repair and the Fisher anatomic subunit repair are commonly used for the surgical correction of unilateral cleft lip. The rotation-advancement repair was the initial technique of choice by the senior surgeon. However, due to recurring suboptimal aesthetic results, the senior surgeon transitioned to the anatomic subunit repair. This study was performed to compare the outcomes of the rotation-advancement repair and the anatomic subunit repair.A retrospective study of all consecutive patients undergoing unilateral cleft lip repair by the senior author between 2009 and 2016 was conducted. Demographic data, the presence of scar shortening/contraction, hypertrophy, widening, and revision rates were recorded.There were 68 patients identified for inclusion. Thirty-four patients had a rotation-advancement repair and 35 had an anatomic subunit repair. Twelve patients (36%) with the rotation-advancement repair and 1 patient (2.9%) with the subunit repair required anterior lip revision (P < 0.001). Conversely, 2 patients (6.1%) with the rotation-advancement repair and 13 patients (37.1%) with the subunit repair required minor debulking of excess red vermilion fullness (P < 0.005).Transitioning from the rotation-advancement repair to the anatomic subunit repair has resulted in improved lip aesthetics with decreased incidence of scar contracture, hypertrophy, and widening as evidenced by a decrease in the revision rate for these suboptimal scars. However, the rate of debulking procedures of the red vermilion did increase early in the adoption of the anatomic subunit repair, requiring minor modifications in the technique.
View details for DOI 10.1097/GOX.0000000000002919
View details for PubMedID 32766066
View details for PubMedCentralID PMC7339201
Phase 1/2a clinical trial of gene-corrected autologous cell therapy for recessive dystrophic epidermolysis bullosa.
2019; 4 (19)
BACKGROUNDRecessive dystrophic epidermolysis bullosa (RDEB) patients have mutations in the COL7A1 gene and thus lack functional type VII collagen (C7) protein; they have marked skin fragility and blistering. This single-center phase 1/2a open-label study evaluated the long-term efficacy, safety, and patient-reported outcomes in RDEB patients treated with gene-corrected autologous cell therapy.METHODSAutologous keratinocytes were isolated from participant skin biopsies. Epidermal sheets were prepared from cells transduced with a retrovirus carrying the full-length human COL7A1 gene. These gene-corrected autologous epidermal sheets measured 5 * 7 cm (35 cm2) and were transplanted onto 6 wound sites in each of 7 adult participants (n = 42 sites total) from 2013 to 2017. Participants were followed for 2 to 5 years.RESULTSNo participants experienced any serious related adverse events. Wound healing of 50% or greater by Investigator Global Assessment was present in 95% (36 of 38) of treated wounds versus 0% (0 of 6) of untreated control wounds at 6 months (P < 0.0001). At year 1, 68% (26 of 38) of treated wounds had 50% or greater healing compared with 17% (1 of 6) of control wounds (P = 0.025). At year 2, 71% (27 of 38) of treated wounds had 50% or greater healing compared with 17% (1 of 6) of control wounds (P = 0.019).CONCLUSIONC7 expression persisted up to 2 years after treatment in 2 participants. Treated wounds with 50% or greater healing demonstrated improvement in patient-reported pain, itch, and wound durability. This study provides additional data to support the clinically meaningful benefit of treating chronic RDEB wounds with ex vivo, C7 gene-corrected autologous cell therapy. This approach was safe and promoted wound healing that was associated with improved patient-reported outcomes.TRIAL REGISTRATIONClinicaltrials.gov identifier: NCT01263379.FUNDINGEpidermolysis Bullosa Research Partnership, Epidermolysis Bullosa Medical Research Foundation, NIH R01 AR055914, Office of Research and Development at the Palo Alto Veteran's Affairs Medical Center, and the Dermatology Foundation.
View details for DOI 10.1172/jci.insight.130554
View details for PubMedID 31578311
Retrospective cohort-based comparison of intraoperative liposomal bupivacaine versus bupivacaine for donor site iliac crest analgesia during alveolar bone grafting.
Journal of plastic, reconstructive & aesthetic surgery : JPRAS
INTRODUCTION: Bone grafting of alveolar clefts is routinely performed with cancellous bone harvested from the iliac crest. Graft site morbidity is frequently seen, with early postoperative pain being one of the most common complaints. Liposomal bupivacaine (LB) has been demonstrated to provide improvement in postoperative pain for patients undergoing bunionectomy or hemorrhoidectomy, which may translate to patients requiring iliac crest bone graft harvest.METHODS: Thirty-eight patients undergoing iliac crest bone harvest were included in the study. Twenty-one patients underwent open iliac crest bone graft harvest with administration of 0.25% bupivacaine at the hip donor site, while 17 patients received local infiltration of 1.3% liposomal bupivacaine. Patient-reported pain scores, total narcotic use, length of stay, and postoperative steps were monitored.RESULTS: There were no significant differences in age, weight, distribution of clefts, or choice of donor hip between the two groups. There were no significant differences in length of hospitalization stay. However, differences were noted in average postoperative pain scores at five of six time points in the first 24h, total oral morphine equivalents administered (4.7 ± 5.3 vs. 14.3 ± 12.0), and steps at postoperative days one to three (p<0.001, for all three days) for patients receiving 1.3% LB versus 0.25% bupivacaine, respectively.CONCLUSION: Reduced pain scores and increased postoperative activity highlight the potential of LB to improve postoperative pain management in children undergoing iliac crest bone harvest for alveolar bone grafting.
View details for DOI 10.1016/j.bjps.2019.09.026
View details for PubMedID 31648962
- Assessing the Fisher, Mohler, and Millard Techniques of Cleft Lip Repair Surgery With Eye-Tracking Technology ANNALS OF PLASTIC SURGERY 2019; 82: S313–S319
- Anatomical Nasal Lining Flaps for Closure of the Nasal Floor in Unilateral and Bilateral Cleft Lip Repairs Reduce Fistulas at the Alveolus PLASTIC AND RECONSTRUCTIVE SURGERY 2018; 142 (6): 1549–56
Management of Complex Arteriovenous Malformations Using a Novel Combination Therapeutic Algorithm.
2018; 154 (11): 1316–19
Importance: Current therapeutic options for patients with extracranial head and neck arteriovenous malformations are limited. Surgical intervention, such as sclerotherapy or resection, often result in rapid recurrence and progression of disease.Objective: To assess the efficacy and tolerability of sirolimus as an adjuvant therapy for endovascular embolization in the management of complicated extracranial head and neck arteriovenous malformations.Design, Setting, and Participants: This case series examined 6 patients with extracranial head and neck arteriovenous malformations treated from January 1, 2013, to December 31, 2017, at a multidisciplinary vascular anomalies clinic within Stanford Hospital and Clinics.Intervention: Initiation of sirolimus at least 1 month prior to endovascular embolization, targeting a trough level of 10 to 15 ng/mL throughout the course of the endovascular embolization series and continued for at least 1 month after the series.Main Outcomes and Measures: Clinical manifestations; disease progression and overall response to treatment were assessed via clinical evaluation and radiographic imaging.Results: All 6 patients (4 male and 2 female patients; mean age, 24.5 years [range, 9-44 years]) responded favorably to the combination of sirolimus therapy followed by endovascular embolization, and 4 patients exhibited a near-complete response. The median duration of follow-up was 19 months (range, 6-40 months). One patient discontinued sirolimus soon after embolization and experienced regrowth of the arteriovenous malformation after 1 year. Sirolimus was resumed, which has stabilized his disease for more than 2 years. Mild adverse effects were noted in 4 patients. The combination therapy was well tolerated in all patients. One patient developed skin ulceration after embolization and required surgical debridement. Another patient developed pulmonary microthrombi after embolization with cyanoacrylate glue that resolved with a brief course of anti-inflammatory therapy.Conclusions and Relevance: Although further prospective trials are needed, this report suggests the benefit of a mammalian target of rapamycin inhibitor as an adjuvant therapy for surgical embolization of complex, extracranial head and neck arteriovenous malformations. The optimal dosing and therapeutic duration of sirolimus treatment before and after embolization remain to be determined.
View details for PubMedID 30326494
Teaching Palatoplasty Using a High-Fidelity Cleft Palate Simulator
PLASTIC AND RECONSTRUCTIVE SURGERY
2018; 141 (1): 91E–98E
Cleft palate repair is a challenging procedure for cleft surgeons to teach. A novel high-fidelity cleft palate simulator has been described for surgeon training. This study evaluates the simulator's effect on surgeon procedural confidence and palatoplasty knowledge among learners.Plastic surgery trainees attended a palatoplasty workshop consisting of a didactic session on cleft palate anatomy and repair followed by a simulation session. Participants completed a procedural confidence questionnaire and palatoplasty knowledge test immediately before and after the workshop.All participants reported significantly higher procedural confidence following the workshop (p < 0.05). Those with cleft palate surgery experience had higher procedural confidence before (p < 0.001) and after (p < 0.001) the session. Palatoplasty knowledge test scores increased in 90 percent of participants. The mean baseline test score was 28 ± 10.89 percent and 43 ± 18.86 percent following the workshop. Those with prior cleft palate experience did not have higher mean baseline test scores than those with no experience (30 percent versus 28 percent; p > 0.05), but did have significantly higher scores after the workshop (61 percent versus 35 percent; p < 0.05). All trainees strongly agreed or agreed that the simulator should be integrated into training and they would use it again.This study demonstrates the effective use of a novel cleft palate simulator as a training tool to teach palatoplasty. Improved procedural confidence and knowledge were observed after a single session, with benefits seen among trainees both with and without previous cleft experience.
View details for PubMedID 29280875
Cleft Lip Standardized Patient Examinations: The Role in Plastic Surgery Resident Education
CLEFT PALATE-CRANIOFACIAL JOURNAL
2016; 53 (6): 634-639
Our institution has incorporated the use of objective structured clinical examinations (OSCE) in our residency curriculum. The OSCE provides trainee education and evaluation while addressing the six Accreditation Council for Graduate Medical Education (ACGME) core competencies required within training programs. We report our program's experience with the first cleft OSCE ever conducted. A validated method for administration of OSCEs currently used at our medical school was utilized for residents in postgraduate years (PGYs) 3 through 6. The video-recorded patient encounter involved a 1-month-old newborn with a unilateral cleft lip and palate and used standardized patient actors as parents. A post-encounter written exam assessed medical knowledge. A questionnaire regarding the utility of the exercise was administered to residents after the OSCE. Results were evaluated using analysis of variance (P < .05). There was a positive correlation with increasing level of training in terms of medical knowledge (P < .04). Residents in PGY-3 and PGY-4 demonstrated lower understanding of the surgical markings and details of the lip repair compared with those in PGY-5 and PGY-6 (P < .03). All residents performed similarly on evaluation of the remaining ACGME core competencies. All residents agreed that this was a realistic and useful encounter. Results of our cleft OSCE demonstrate that medical knowledge regarding the evaluation, management, and surgical repair of patients is less in midlevel residents. All residents expressed an interest in earlier exposure to pediatric patients in the training period. Although a cleft OSCE does not replace clinical rotations, it is a valuable adjunct to training and evaluation of trainees, particularly for junior residents.
View details for DOI 10.1597/15-121
View details for Web of Science ID 000388005700004
View details for PubMedID 26720521
Rhinoplasty Education Using a Standardized Patient Encounter.
Archives of plastic surgery
2016; 43 (5): 451-456
Comprehensive aesthetic surgery training continues to be a challenge for residency programs. Our residency program developed a rhinoplasty-based objective structured clinical examination (OSCE) based upon validated methods as part of the residency education curriculum. We report our experience with the rhinoplasty-based OSCE and offer guidance to its incorporation within residency programs.The encounter involved resident evaluation and operative planning for a standardized patient desiring a rhinoplasty procedure. Validated OSCE methods currently used at our medical school were implemented. Residents were evaluated on appropriate history taking, physical examination, and explanation to the patient of treatment options. Examination results were evaluated using analysis of variance (statistical significance P<0.05).Twelve residents completed the rhinoplasty OSCE. Medical knowledge assessment showed increasing performance with clinical year, 50% versus 84% for postgraduate year 3 and 6, respectively (P<0.005). Systems-based practice scores showed that all residents incorrectly submitted forms for billing and operative scheduling. All residents confirmed that the OSCE realistically represents an actual patient encounter. All faculty confirmed the utility of evaluating resident performance during the OSCE as a useful assessment tool for determining the Next Accreditation System Milestone level.Aesthetic surgery training for residents will require innovative methods for education. Our examination showed a program-educational weakness in billing/coding, an area that will be improved upon by topic-specific lectures. A thoroughly developed OSCE can provide a realistic educational opportunity to improve residents' performance on the nonoperative aspects of rhinoplasty and should be considered as an adjunct to resident education.
View details for DOI 10.5999/aps.2016.43.5.451
View details for PubMedID 27689053
Use of regenerative tissue matrix as an oral layer for the closure of recalcitrant anterior palatal fistulae: a pilot study
JOURNAL OF THE KOREAN ASSOCIATION OF ORAL AND MAXILLOFACIAL SURGEONS
2016; 42 (2): 77–83
To evaluate the effectiveness of regenerative tissue matrix (Alloderm) as an oral layer for difficult anterior palatal fistula closure.The authors have tested the feasibility of a novel surgical technique of adding a regenerative tissue matrix (Alloderm) as an oral layer for closure of recalcitrant large anterior palatal fistulae and report the outcome of the first 12 patients in this pilot study. Patients with recurrent large fistula who otherwise would require either a local pedicled flap, free flap, or an obturator were treated with this technique and followed up for at least 6 months to monitor the progress of healing.Of the 12 patients, 8 patients (66.7%) had complete closure of the fistula, and 2 patients (16.7%) showed reduction in size of the fistula to the extent that symptoms were eliminated, for an overall success rate of 83.3% (10/12 patients). Premature graft loss and recurrence of the fistula were noted in 2 patients (16.7%).Alloderm provided an adequate barrier allowing healing to occur unimpeded and allowed closure of the palatal fistula. In our experience, this new technique using regenerative tissue matrix as an adjunct to the oral layer in large anterior palatal fistula has an advantage compared to other more invasive complex procedures and has been shown to provide satisfactory results.
View details for PubMedID 27162747
Facial Twist (Asymmetry) in Isolated Unilateral Coronal Synostosis: Does Premature Facial Suture Fusion Play a Role?
JOURNAL OF CRANIOFACIAL SURGERY
2015; 26 (3): 655-657
Unilateral coronal synostosis (UCS) often causes notable facial twist in affected patients. This condition occurs when the midface deviates toward the synostotic side, and the lower face deviates away from the synostotic side. The exact underlying mechanism for this phenomenon remains unclear. It has been proposed that premature fusion of facial sutures may play a role in the formation of facial twist. The purpose of this study was to determine whether asymmetrical facial suture fusion is present in patients with UCS.A single-center retrospective study was designed. Our study group consisted of 23 patients with a confirmed diagnosis of isolated UCS. Our control group consisted of 17 age-matched patients with deformational plagiocephaly and 11 normocephalic control subjects. The computed tomography scans of the faces were examined for the presence of facial suture fusions on both synostotic and nonsynostotic sides. All results with P < 0.05 were considered statistically significant.We found an increased incidence of fusion of the frontomaxillary, nasofrontal, and nasomaxillary sutures on the side of synostosis in UCS when compared with the nonsynostotic side and when compared with patients with deformational plagiocephaly or normocephalic patients.Asymmetrical premature fusion of facial sutures can potentially be contributing to the facial twist that is seen in patients with UCS.
View details for DOI 10.1097/SCS.0000000000001436
View details for PubMedID 25974768
Chondromyxoid Fibroma of the Mandible in an Adolescent: Case Report and Microsurgical Reconstructive Option
CLEFT PALATE-CRANIOFACIAL JOURNAL
2015; 52 (2): 223-228
Chondromyxoid fibroma is a rare bony tumor that usually presents in the lower extremities of middle-aged adults. Involvement of the craniofacial skeleton is extremely rare. We present the unique case of an adolescent boy with a chondromyxoid fibroma of the mandible. The chondromyxoid fibroma in this patient recurred after initial treatment with curettage. We treated the recurrence with resection of the involved mandible and immediate reconstruction using a vascularized musculo-osseus seventh rib flap ("Eve procedure"). Despite complex reconstruction in adolescents due to skeletal immaturity, the rib flap has successfully grown with the patient up to 3 years postoperatively. Therefore, we believe the musculo-osseus rib flap is a feasible solution for complex ramus and condyle reconstruction of the growing mandible in the adolescent patient.
View details for DOI 10.1597/13-243
View details for Web of Science ID 000352143500015
View details for PubMedID 24625223
Cleft palate surgery: an evaluation of length of stay, complications, and costs by hospital type.
Cleft palate-craniofacial journal
2014; 51 (4): 412-419
Objective : The purpose of this study was to assess length of stay (LOS), complication rates, costs, and charges of cleft palate repair by various hospital types. We hypothesized that pediatric hospitals would have shorter LOS, fewer complications, and lower costs and charges. Methods : Patients were identified by ICD-9-CM code for cleft palate repair (27.62) using databases from the Agency for Health Research and Quality Healthcare Cost and Utilization Project Kids' Inpatient Database from 1997, 2000, 2003, and 2006. Patient characteristics (age, race, gender, insurer, comorbidities) and facility resources (hospital beds, cleft palate surgery volume, nurse-to-bed ratio, pediatric intensive care unit [PICU], PICU intensivist, burn unit) were examined. Hospitals types included pediatric hospitals, general hospitals, and nonaccredited children's hospital. For each hospital type, mean LOS, extended LOS (LOS > 2), and complications were assessed. Results : A total of 14,153 patients had cleft repair with a mean LOS of 2 days (SD, 0.04), mortality 0.01%, transfusion 0.3%, and complication <3%. Pediatric hospitals had fewer patients with extended hospital stays. Patients with an LOS >2 days were associated with fourfold higher complications. Comorbidities increased the relative rate of LOS >2 days by 90%. Pediatric hospitals had the highest comorbidities, yet 35% decreased the relative rate of LOS >2 days. Median total charges of $10,835 increased to $15,104 with LOS >2 days; median total costs of $4367 increased to $6148 with a LOS >2 days. Conclusion : Pediatric hospitals had higher comorbidities yet shorter LOS. Pediatric resources significantly decreased the relative rate of LOS >2 days. Median costs and charges increased by 41% with LOS >2 days. Further research is needed to understand additional aspects of pediatric hospitals associated with lower LOS.
View details for DOI 10.1597/12-150
View details for PubMedID 24063682
Current Concepts for Eyelid Reanimation in Facial Palsy
ANNALS OF PLASTIC SURGERY
2014; 72 (2): 242-245
ABSTRACT: The treatment of facial palsy is a complex and challenging area of plastic surgery. Two distinct anatomical regions and functions are the focus of interest when managing facial palsy: (1) reanimation of the eyelids and (2) reconstruction of the smile. This review will focus on the treatment of ocular manifestations of facial palsy. The principles of eyelid rehabilitation will be presented along with a discussion of surgical and nonsurgical treatment options.
View details for DOI 10.1097/SAP.0b013e318264fcba
View details for Web of Science ID 000338013700025
A National Study on Craniosynostosis Surgical Repair
CLEFT PALATE-CRANIOFACIAL JOURNAL
2013; 50 (5): 555-560
Objective : Our study aimed to use national data to assess the perioperative outcomes of craniosynostosis surgical repair. Design : Data were obtained from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project Kids Inpatient Database from 1997, 2000, 2003, and 2006. Setting : Community hospitals in the United States. Patients : The cohort was identified using the ICD-9-CM procedure codes for craniosynostosis surgical repair (2.01, 2.03, 2.04, 2.06). Main Outcome Measures(s) : We determined patient and hospital characteristics. We clustered patients by age group (<7 months, 7 to 12 months, 1 to 3 years) and assessed mortality, comorbidities, mean length of stay (LOS), and total charge. We performed logistic regression with our dependent variable being longer average hospital stay: LOS >4.2 days. Results : We found 3426 patients. Average age at the time of surgery was 181 days (SD 84). Average length of stay was 4.2 days. The majority of the patients were boys (66%), white (71%), and insured (93%). Nearly all patients underwent surgery in a teaching hospital (98%) in urban centers (99%). Approximately 10% of patients experienced an acute complication, most commonly hemorrhages or hematomas and airway or respiratory failure. Patients ages 1 to 3 years had the highest rates of comorbidities and a longer LOS. Mortality rate was <1%. Conclusions : Craniosynostosis surgery is safe with low rates of mortality and acute complications. LOS >4.2 appears to be associated more with comorbidities than with complications. Higher rates of comorbidities and LOS >4.2 days for patients age 1 to 3 years warrant addition research to assess potential barriers to care.
View details for DOI 10.1597/11-324
View details for Web of Science ID 000327536100011
Emergency surgical treatment of an ulcerative and hemorrhagic congenital/infantile fibrosarcoma of the lower leg: case report and literature review
JOURNAL OF PEDIATRIC ORTHOPAEDICS-PART B
2013; 22 (3): 228-232
Fibrosarcomas are rare malignant soft-tissue tumors occurring mostly in infants younger than 1 year of age. Fibrosarcomas can ulcerate and cause various complications, which could threaten a fetus in utero or a child in the early neonatal period. We report a unique case of congenital infantile fibrosarcoma of the lower leg, its treatment and pathology. The large expansive and destructive lesion was not appreciated on routine prenatal ultrasound exams at 20 and 33 weeks gestation. The newborn required immediate emergency surgical intervention after delivery to prevent death by hemorrhagic shock. Initial debulking of the tumor was performed and hemostasis was attained on the day of birth. The child was resuscitated and definitive treatment of the leg was deferred until a pathologic diagnosis was obtained. Given the extent of the fibrosarcoma, the lower leg was not salvageable and the patient received a through-the-knee amputation in the neonatal period. The patient is free of disease at 2 years of age.
View details for DOI 10.1097/BPB.0b013e3283536908
View details for Web of Science ID 000316801200010
View details for PubMedID 22568962
Microsurgical reconstruction of the smilecontemporary trends
2013; 33 (1): 69-76
The treatment of facial palsy is a complex and challenging area of plastic surgery. Microsurgical innovation has introduced the modern age of dynamic reconstruction for facial palsy. This review will focus on microsurgical reconstruction for smile restoration in patients with long-standing facial palsy. The most common donor muscles and nerves will be presented. The advantages and disadvantages of single-stage versus multi-stage reconstruction will be discussed. Contemporary trends will be highlighted and the authors' preferred practice outlined.
View details for DOI 10.1002/micr.22042
View details for PubMedID 22976539
Contemporary concepts for the bilateral cleft lip and nasal repair.
Seminars in plastic surgery
2012; 26 (4): 156-163
The bilateral cleft lip and nasal deformity presents a complex challenge for repair. Surgical techniques continue to evolve and are focused on primary anatomic realignment of the tissues. This can be accomplished in a single-stage or two-stage repair early in infancy to provide a foundation for future growth of the lip and nasal tissue. Most cleft surgeons currently perform a single-stage repair for simplifying patient care. Certain institutions utilize presurgical orthopedics for alignment of the maxillary segments and nasal shaping. Methods for the bilateral cleft lip repair are combined with various open and closed rhinoplasty techniques to achieve improved correction of the primary nasal deformity. There is recent focus on shaping the nose for columellar and tip support, as well as alar contour and alar base position. The authors will present a new technique for closure of the nasal floor to prevent the alveolar cleft fistula. Although the alveolar fistula is closed, alveolar bone grafting is still required at the usual time in dental development to fuse the maxilla. It is paramount to try and minimize the stigmata of secondary deformities that historically have been characteristic of the repaired bilateral cleft lip. A properly planned and executed repair reduces the number of revisions and can spare a child from living with secondary deformities.
View details for DOI 10.1055/s-0033-1333885
View details for PubMedID 24179448
Seminars in plastic surgery
2012; 26 (2): 53-63
Nonsyndromic craniosynostosis is more commonly encountered than syndromic cases in pediatric craniofacial surgery. Affected children display characteristic phenotypes according to the suture or sutures involved. Restricted normal growth of the skull can lead to increased intracranial pressure and changes in brain morphology, which in turn may contribute to neurocognitive deficiency. Management has primarily focused on surgical correction of fused sutures prior to 12 months of age to optimize correction of the deformity and to ameliorate the effects of increased intracranial pressure. However, emphasis has recently shifted to better understanding the pathogenesis of neurocognitive impairment observed in these children, along with genetic mutations that contribute to premature suture fusion. Such understanding will provide opportunities for earlier and more specific neurocognitive interventions and for the development of targeted genetic therapy to prevent pathologic suture fusion. The authors review the common types of nonsyndromic craniosynostosis and the epidemiological, genetic, and neurodevelopmental details that are currently known from the literature. In addition, they present the rationale for surgical correction, offer suggestions for timing of intervention, and present some nuances of techniques that they find important in producing consistent results.
View details for DOI 10.1055/s-0032-1320063
View details for PubMedID 23633932
Changes in Frontal Morphology after Single-Stage Open Posterior-Middle Vault Expansion for Sagittal Craniosynostosis
89th Annual Meeting of the American-Association-of-Plastic-Surgeons
LIPPINCOTT WILLIAMS & WILKINS. 2012: 504–16
There is controversy regarding whether the frontal bossing associated with sagittal synostosis requires direct surgical correction or spontaneously remodels after isolated posterior cranial expansion. The authors retrospectively measured changes in frontal bone morphology in patients with isolated sagittal synostosis 2 years after open posterior and midvault cranial expansion and compared these changes with those occurring in age-comparable healthy control groups.Forty-three patients age 1 year or younger (mean, 6 months) with sagittal synostosis underwent computed tomography scan digital analysis immediately after and 2 years after posterior-middle cranial vault expansion. Quantitative angular and linear measures were taken along the midsagittal and axial planes to capture both aspects of frontal bossing. The change in values over the 2 years were compared with healthy controls with normal computed tomography scans taken to rule out head trauma.All measures indicative of frontal bossing decreased significantly from the time of posterior-middle vault expansion to 2 years postoperatively. Whereas the majority of patients at time of the operation had frontal bossing measures greater than two standard deviations outside the age-comparable control mean, almost all patients were within two standard deviations of the norm 2 years later. Lateral forehead bossing and anterior cranial growth was greater the older the patient was at the time of the operation, suggesting that the more time that passed before the operation, the more compensatory anterior fossa growth occurred. Central forehead position relative to the anterior cranial base was greatest in the younger patients at the time of operation, suggesting that a central forehead bulge was an early compensatory response to premature sagittal fusion.As a group, patients with sagittal synostosis start to normalize their forehead morphology within 2 years if an isolated posterior operation is performed at 1 year of age or younger, and this occurs by a combination of restriction of growth and reduction relative to patients without synostosis. This protocol decreases the risks of intraoperative positioning, forehead contour deformities, and two-stage operations.Therapeutic, III.
View details for DOI 10.1097/PRS.0b013e31823aec1d
View details for Web of Science ID 000300240000086
View details for PubMedID 22286431
Combination Jessner's Solution and Trichloroacetic Acid Chemical Peel: Technique and Outcomes
PLASTIC AND RECONSTRUCTIVE SURGERY
2009; 124 (3): 955-964
Trichloroacetic acid is a commonly utilized agent for chemical resurfacing of the face. Jessner's solution in combination with trichloroacetic acid has been previously described for the treatment of facial rhytids in the dermatology literature. The purpose of this study was to describe the application technique and examine the clinical results of Jessner's solution in combination with trichloroacetic acid in a diverse plastic surgery patient population.A retrospective chart evaluation of 105 patients undergoing combination Jessner's and 35% trichloroacetic acid facial peel procedures by the senior author was performed. Patient demographics, anatomic location of peel, concomitant surgical procedures, and postoperative complications were noted. Technique and endpoints are described.Between January of 2000 and April of 2007, 115 chemical peels were performed by the senior author. All patients were female, ranging in age from 32 to 83 years (mean, 54 years). Of the 115 chemical peels performed, 104 were done with concomitant procedures. Eleven peels were performed alone. The most significant complications related to the combination peel were fungal infections (7.8 percent overall rate). In addition, the senior author performed 27 face/neck lifts with superficial musculoaponeurotic system (SMAS)-ectomy or SMAS plication along with full face combination peel, with minimal postoperative complications and no evidence of hypertrophic scarring.The combination of Jessner's solution and 35% trichloroacetic acid is an effective, safe resurfacing tool that can treat superficial to moderate rhytids. Despite the apparent simplicity of the procedure, there is a significant learning curve to understand the intricacies of chemical penetration in the skin. Consistency in results is achieved with experience and proper preoperative patient evaluation and selection.
View details for DOI 10.1097/PRS.0b013e3181addcf5
View details for Web of Science ID 000269485200033
View details for PubMedID 19730318
Bilateral cleft lip and nasal repair
PLASTIC AND RECONSTRUCTIVE SURGERY
2008; 122 (4): 1181-1190
The bilateral cleft lip and nasal repair has remained a challenging endeavor. Techniques have evolved to address concerns over unsatisfactory features and stigmata of the surgery. The authors present an approach to this complex clinical problem that modifies traditional repairs described by Millard and Manchester. The senior author (H.S.B.) has developed this technique with over 25 years of surgical experience dealing with the bilateral cleft lip. This staged lip and nasal repair provides excellent nasal projection, lip function, and aesthetic outcomes. Lip repair is performed at 3 months of age. Columellar lengthening is performed at approximately 18 months of age. A key component of this repair focuses on reconstruction of the central tubercle. A triangular prolabial dry vermilion flap is augmented by lateral lip vermilion flaps that include the profundus muscle of the orbicularis oris. This minimizes lateral lip segment sacrifice and provides improved central vermilion fullness, which is often deficient in traditional repairs. The authors present the surgical technique and examples of their clinical results.
View details for DOI 10.1097/PRS.0b013e3181858f33
View details for Web of Science ID 000259811700025
View details for PubMedID 18827654