Kurnik, Nicole M.

Objective To compare perioperative outcomes, complications, imaging utilization, and device management following posterior vault distraction osteogenesis (PVDO) and spring-mediated cranioplasty (SMC) for multisutural craniosynostosis. Design Retrospective cohort study. Setting Single pediatric tertiary care center. Patients, Participants Twenty-three patients with multisutural craniosynostosis treated between 2017 and 2025 (PVDO, n = 18; SMC, n = 5). Interventions PVDO or SMC. Main Outcome Measure(s) Time to device removal, imaging utilization, reoperations, readmissions, device-related complications, revision surgeries, wound infections, and absolute intracranial volume change. Results PVDO was associated with earlier device removal than SMC (78.7 ± 22.1 vs. 133.0 ± 27.4 days; P = .0015) but greater postoperative imaging utilization during the first year (5.33 ± 1.28 vs. 2.80 ± 1.64 studies; P = .01). Rates of reoperation (22.2% vs. 0%), readmission (22.2% vs. 40.0%), device-related complications (11.1% vs. 0%), revision surgery (16.7% vs. 0%), and wound infection (22.2% vs. 20.0%) did not differ significantly (all P ≥ .50). Preoperative imaging utilization and postoperative intracranial volume gain were comparable between groups. Conclusions PVDO and SMC demonstrated similar safety profiles and intracranial volume expansion in patients with multisutural craniosynostosis. Compared with SMC, PVDO enabled earlier device removal but required increased postoperative imaging. These findings may inform operative planning, postoperative surveillance, and family counseling. Larger, multicenter studies with longer follow-up are needed to evaluate long-term outcomes.

Background: Tranexamic acid (TXA) is widely used in craniosynostosis surgery to reduce blood loss. Although the efficacy of TXA administration has been documented in the literature, dosing in the perioperative setting is variable and without a standard protocol. The purpose of this study is to determine the efficacy of continuing TXA postoperatively for patients undergoing suturectomy for metopic or unicoronal synostosis. Methods: We conducted a retrospective cohort study evaluating the use of postoperative TXA infusion in patients undergoing suturectomy for metopic and unicoronal craniosynostosis. All patients received a TXA bolus of 10 mg/kg at the time of surgical prep, followed by a TXA infusion at 5 mg/kg/hour during the procedure. Patients undergoing suturectomy for metopic or unicoronal synostosis in 2020 to 2021 received postoperative TXA infusion at 5 mg/kg/hour for the first 4 hours after surgery. Following a protocol change in anemia management at the institution in 2022, patients undergoing this surgery in 2022 did not receive a postoperative TXA infusion. Chart review was performed, and mean hemoglobin values were compared between patients who received postoperative TXA and those who did not, with analyses stratified by suture involvement to determine the impact of the protocol change. Results: Twenty-eight patients met the inclusion criteria: 14 patients received postoperative TXA, and 14 patients did not. Both groups included 8 patients undergoing metopic suturectomy and 6 patients undergoing unicoronal suturectomy. For patients who underwent metopic suturectomy and received postoperative TXA, the mean preoperative hemoglobin was 11.4 g/dL, and on postoperative day 1 (POD1) was 8.1 g/dL. For patients who underwent metopic suturectomy and did not receive postoperative TXA, the mean preoperative hemoglobin was 11 g/dL and on POD1 was 9.2 g/dL ( P =0.27). The differences in mean preoperative and postoperative hemoglobin were not statistically significant between the 2 cohorts, P =0.15 and P =0.20, respectively. For patients who underwent unicoronal suturectomy and received postoperative TXA, the mean preoperative hemoglobin was 12 g/dL, and on POD1 was 8.7 g/dL. For patients who underwent unicoronal suturectomy and did not receive postoperative TXA, the mean preoperative hemoglobin was 11.4 g/dL and on POD1 was 9.1 g/dL ( P =0.36). The mean preoperative and postoperative hemoglobin were not statistically different between the 2 cohorts, P =0.42 and P =0.92, respectively. Hospital length of stay averaged 1 day across both cohorts. No patient received a postoperative blood transfusion. Conclusion: In patients undergoing suturectomy for metopic or unicoronal craniosynostosis, postoperative TXA infusion made no significant difference in postoperative hemoglobin levels, length of stay, or postoperative transfusion. Discontinuing postoperative TXA could potentially decrease monitoring needs and lower hospital costs.

Objective: Describe changes in symptoms of velopharyngeal insufficiency (VPI)—hypernasality, audible nasal emission, and VPI-related quality of life—following LeFort I osteotomy in individuals with cleft palate +/- cleft lip. Design: Single-center, retrospective cohort study. Participants: Twenty-one patients with a history of cleft palate repaired in infancy were included in this study. Ten patients had no prior history of VPI surgery and eleven had a pharyngeal flap in place at the time of LeFort I osteotomy. The mean age at time of surgery was 17.2 years. Main Outcome Measure: Pre- and postoperative hypernasality severity, frequency of audible nasal emission, and total score on the VPI Effects on Life Outcomes youth questionnaire (VELO-Y) before and after LeFort osteotomy I. Fischer exact test was used to assess differences between groups for categorical variables and a t test was used for continuous variables. Results: Patients with no prior history of VPI management had a significant increase in hypernasality severity compared with those with a pharyngeal flap in place at the time of surgery ( P =0.004). Patients without a prior history of VPI management also had a significant increase in frequency of audible nasal emission, while patients with a pharyngeal flap had decreased audible nasal emission ( P =0.004). There was not a significant difference between groups for change in the total score on the VELO-Y ( P =0.16). Conclusions: Findings from this study may improve preoperative counseling provided to patients and caregivers on the risk of acquiring VPI after LeFort I osteotomy based on prior VPI surgical history.

Craniofacial surgery requires a multidisciplinary care approach in the perioperative period. In an effort to guide clinical decision making and standardize care, many institutions have implemented craniofacial surgical pathways, describing numerous variables to monitor and specific actions that must be completed by each involved discipline in the perioperative period. Adherence to these pathways can be challenging given the complexity of the protocol and the multiple disciplines involved. In an effort to improve adherence to our institution’s perioperative pathway, the authors implemented a quarterly, multidisciplinary craniofacial operative team meeting to review the pathway and improve the quality of care. The authors report results from a retrospective review of craniosynostosis suturectomy operations at a single site in the 2 years before and 2 years after the start of our team meeting to review perioperative care. A total of 141 operations were included (70 before the meeting and 71 after). Perioperative outcomes and adherence to our surgical pathway were compared. Following the start of our team meetings, there was a significant decrease in the time under anesthesia, patients requiring blood transfusion, and total hospital length of stay ( P <0.05). There was also improved adherence to the craniofacial pathway, with significantly more operations applying peripheral nerve blocks to all locations specified in our pathway with the proper drug contents ( P <0.05). Our findings suggest that craniofacial operative team meetings with a goal of reviewing the surgical pathway and discussing improvements in care plans with all involved providers can significantly improve adherence to operative pathways and surgical outcomes.

Summary: Surgical disease is now among the most common, preventable, and growing contributors to the global burden of disease. The attitudes of trainees toward global surgery and the viability of a global surgery as an academic track have blossomed. More optimized experiences within residency education are necessary, however, to prepare the next generation of global surgeons. The field of plastic surgery is thus at an important crossroads in the effort to incorporate global surgery into training programs in a uniform fashion across the country. The recent American Council of Academic Plastic Surgeons meeting in February 2020 was dedicated to identifying strategies that will enhance the adoption of global surgery practices within plastic surgery. In this article, we discuss the principles, themes, and ideas that emerged from this session, and further develop concrete initiatives believed to be potentially fruitful. Some have been discussed in other surgical disciplines or presented in isolation to the plastic surgery community, but never as a cohesive set of recommendations that take into account the background and shortfalls of the current model for global health education in the 21st century. We then introduce five recommendations to optimize learner education: (1) clarification of learner expectations and roles; (2) domestic teaching for optimization of field experiences; (3) expansion of longitudinal, formal rotations; (4) strengthening of the role of research; and (5) integration of program financing.

Background: Palate re-repair has been proposed as an effective treatment for velopharyngeal insufficiency (VPI) with a low risk of obstructive sleep apnea (OSA). The authors conducted a systematic review and meta-analysis to determine the proportion of patients achieving normal speech resonance following palate re-repair for VPI, the proportion developing OSA, and the criteria for patient selection that are associated with increased effectiveness. Methods: PubMed, Embase, and Scopus were searched from inception through April 2018 for English language articles evaluating palate re-repair for the treatment of VPI in patients with a repaired cleft palate. Inclusion criteria included reporting of hypernasality, nasal air emission, nasometry, additional VPI surgery, and/or OSA outcomes. Meta-analysis was conducted using random effects models. Risk of bias was assessed regarding criteria for patient selection, blinding of outcome assessors, and validity of speech assessment scale. Results: Eighteen studies met inclusion criteria. The incidence of achieving no consistent hypernasality follow palate re-repair was 61% (95% confidence interval [CI]: 44%-75%). The incidence of additional surgery for persistent VPI symptoms was 21% (95% CI: 12%-33%). The incidence of OSA was 28% (95% CI: 13%-49%). Criteria for selecting patients to undergo re-repair varied, with anterior/sagittal position of palatal muscles (33%) and small velopharyngeal gap (22%) being the most common. No specific patient selection criteria led to superior speech outcomes ( P = .6572). Conclusions: Palate re-repair achieves normal speech resonance in many but not all patients with VPI. Further research is needed to identify the specific examination and imaging findings that predict successful correction of VPI with re-repair.

Abstract The purpose of this study was to evaluate a single center's experience with adult patients who had cleft lip, cleft palate, or both. The authors aimed to identify common long-term needs in this patient population and evaluated the relationship of team-based care in meeting those needs. To do so, the authors retrospectively reviewed chart records from a single private practice and tertiary referral cleft center for all patients who were ≥15 years of age and who had a history of clefts of the lip or palate, or both, from January 1, 2013, to June 30, 2014. The authors compared the concerns of the patients who received cleft-team–based care by a single, multidisciplinary cleft team; multiple multidisciplinary cleft teams; or no formal cleft team. The authors analyzed data for 142 patients. The most common patient concerns were lip aesthetics (64%), nose aesthetics (61%), septal deviations (47%), nasal obstruction (44%), malocclusion (32%), oronasal fistulas (29%), and speech (21%). Oronasal fistulas were more commonly reported in the group of patients who had care by multiple teams (42.9%; P < .001). Malocclusion was more commonly reported in the group of patients who had care by multiple teams (50%; P = .001). The authors found that adult patients who have undergone rehabilitation for cleft lip and palate appear to have a common set of long-term needs. Multidisciplinary cleft-team–based care appears to be the most effective way to address these needs.

Abstract Breast implants are typically placed for cosmetic or reconstructive purposes, and are recognized to have a substantial impact on aesthetics and quality of life. In addition, the presence of a breast implant on the chest wall has a potential benefit of force diffusion or force absorption in traumatic injury. This article reports a series of three patients with preexisting breast implants who suffered penetrating chest trauma. In each case, the presence of a breast implant was potentially lifesaving. We describe the cases in detail, provide a conceptual discussion, and discuss directions for future research. Level of Evidence: 5

Abstract Consensus does not exist regarding the best dosage regimen for using tranexamic acid (TXA) for patients undergoing open calvarial vault remodeling in craniosynostosis surgery. The purpose of this study was to evaluate 2 dosing protocols, as well as the cost of using TXA. Previously, the institutional protocol was to give patients undergoing open calvarial vault remodeling a loading infusion of TXA (10 mg/kg) at the start of their procedure, after which intravenous TXA (5 mg/kg/h) was given throughout surgery and for 24 hours postoperatively. In July 2015, the protocol changed to a reduced postoperative infusion time of 4 hours. A retrospective review was conducted of records of 30 patients who had surgery before the protocol change (24-hour group) and 23 patients whose surgery occurred after the protocol change (4-hour group). The following data were collected: blood volume transfused, hemoglobin levels, estimated blood loss, and intensive care days; and costs of TXA and blood transfusion. Results showed a 4-hour infusion was as effective as a 24-hour infusion for reducing blood loss in patients undergoing craniosynostosis. Transfusion requirements, hemoglobin and hematocrit levels, and estimated blood loss were not significantly different for the groups. The cost of TXA and transfusion in the 4-hour group was significantly less (P < 0.001) than in the 24-hour group. No significant difference in cost existed for patients who received blood transfusion alone versus patients who received the 4-hour TXA infusion.