Craniofacial Surgery

Implementation of a Modified Enhanced Recovery Protocol in Cleft Palate Repairs Aims: Enhanced Recovery after Surgery (ERAS) protocols have been shown to improve patient outcomes in numerous adult surgical populations, but there are few known standards for their use in pediatric patients. To assess the effectiveness in pediatric craniofacial surgery, we present our results following the application of a modified ERAS protocol for patients undergoing primary palatoplasty. Methods: A modified ERAS program was developed and implemented in a multidisciplinary manner. The primary components of the protocol included: (1) administration of gabapentinoids, (2) minimal perioperative narcotic use, and (3) post-operative pain control using nonnarcotic first-line agents. Fifty patients were collected prospectively, assigned to the modified ERAS protocol and compared to historic controls. We reviewed patient demographics, narcotic use, length of stay (LOS), oral intake, and complication rates. Results: Between April 2017 and June 2018, 50 patients underwent palatoplasty under the modified ERAS protocol. The mean age (control: 9.7 ± 2.3 months; ERAS: 9.9 ± 1.6 months), weight (8.8 ± 1.3 kg; 8.6 ± 1.3 kg), and comorbidities did not vary between the groups. ERAS patients evidenced an increase in oral intake normalized per LOS (22.3 mL/h vs 15.4 mL/h). Total narcotic usage (morphine equivalents) during each phase of care was greater in the controls compared with ERAS (Intraop: 3.71 mg vs 0.12 mg; PACU: 0.51 mg vs 0.05 mg; Postop: 2.6 mg vs 0.07 mg). The implementation of this protocol led to a 36.6% decrease in LOS (1.83 days vs 1.16 days) without an increase in perioperative complications. Conclusions: Implementation of a modified ERAS protocol provided effective perioperative pain control allowing narcotic minimization, increased post-operative oral intake, and a shorter LOS without an increased complication rate. Address correspondence and reprint requests to Colin M. Brady, MD, Children's Healthcare of Atlanta, 975 Johnson Ferry Road, NE, Suite 100, Atlanta, GA 30342; E-mail: colinbrady8@gmail.com Received 7 October, 2018 Accepted 26 April, 2019 The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

Use of Unsintered Hydroxyapatite and Poly-L-lactic Acid Composite Sheets for Management of Orbital Wall Fracture Although unsintered hydroxyapatite and poly-L-lactic acid (u-HA/PLLA) composite sheets have various applications, such as in craniomaxillofacial fractures, orthognathic surgery, and orthopedic surgery, and have been proven to be safe and effective, no studies have reported the use of u-HA/PLLA composite sheets for orbital wall reconstruction with long-term follow-up. This study reports our preliminary results using the u-HA/PLLA composite sheet for orbital wall fractures. The SuperFIXSORB MX sheet (u-HA/PLLA composite sheet; Takiron, Tokyo, Japan), with size of 30 × 50 mm and thickness of 0.5 mm, was used in all cases of hard reconstruction of the orbital bone defect. Seventy-two patients with acute orbital wall fractures (within 2 weeks after sustaining the injury) treated at the Jikei University between January 2014 and August 2016 were included. The authors evaluated the postoperative complications and the operability of the material. The authors did not observe any postoperative complications, such as infection, postoperative diplopia, or enophthalmos, due to the use of the u-HA/PLLA composite sheet. In pure orbital fractures (orbital fractures only), the mean (±standard deviation) operation time was significantly longer with combined inferior and medial wall fractures (201.1 ± 36.6 minutes; n = 11) than with inferior wall or medial wall fractures only (135.0 ± 54.4 minutes; n = 51) (Mann–Whitney U test, P < 0.001). The U-HA/PLLA composite sheet is safe and can be used for orbital wall fracture reconstruction. Further long-term functional and aesthetic assessments for infection, ocular movement disorder, enophthalmos, and any other complication are necessary. Address correspondence and reprint requests to Shinya Tsumiyama, MD, Jikei University School of Medicine, Plastic and Reconstructive Surgery, 3-25-8 Nishishimbashi Minato-ku Tokyo, Japan 105-8461; E-mail: h24md-tsumiyama@jikei.ac.jp Received 25 October, 2018 Accepted 25 April, 2019 The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

Surgical Feasibility of Curtler-Beard Reconstruction for Large Upper Eyelid Defect Purpose: To report long-term surgical outcomes of Cutler-Beard reconstructive surgery in patients with large full-thickness upper eyelid defects following malignant tumor excision. Methods: The medical records of 5 consecutive patients with full-thickness upper eyelid defects following tumor resection who underwent Cutler-Beard surgery were reviewed retrospectively between April 2005 and November 2018. Surgical procedure comprises 2 stages: first, complete tumor resection followed by bridged full-thickness lower eyelid advancement flap; second, separation of the closed eyelid with eyelid margin repair 7 to 9 weeks later. Postoperative anatomical, functional and cosmetic outcomes, and complications were evaluated during follow-up at 22 to 77 months. Results: Patients were in the age group of 49 to 75 years, including 3 (60%) females and 2 (40%) males. Three of the 5 patients (60%) exhibited sebaceous cell carcinoma and 2 (40%) showed squamous cell carcinoma. Three patients (60%) underwent Cutler-Beard surgery after recurrence of primary carcinoma following previous operation. Three patients underwent revision surgery with entropion, 2 underwent correction for wound dehiscence and 1 was treated with symblepharon lysis. No serious or permanent ocular complications were observed during the operation or follow-up with the patients. The procedure resulted in good aesthetic quality and acceptable sequelae at the donor site. Conclusions: Cutler-Beard procedure for the reconstruction of large and full-thickness upper eyelid defects is an effective procedure with satisfactory long-term results, although a few patients may require minor revision surgery. Address correspondence and reprint requests to Suk-Woo Yang, MD, Department of Ophthalmology and Visual Science, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 505 Banpo-dong, Seocho-ku, Seoul 137-701, Republic of Korea; E-mail: yswoph@catholic.ac.kr Received 31 January, 2019 Accepted 15 May, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

The Mandibular Ramus: An Alternative Donor Site for Secondary Alveolar Bone Grafting in Clefts of the Alveolus The authors describe the use of the mandibular ramus as an autologous bone graft material for secondary alveolar bone grafting in cleft patients. This technique represents a safe and effective alternative to currently used donor sites. Furthermore, it allows to minimize patient discomfort, so that they can be treated as outpatients. Address correspondence and reprint requests to Jeannine Blatter, MD, Division of Oral and Maxillofacial Surgery, CHUV, 46 rue du Bugnon, 1011 Lausanne, Switzerland; E-mail: Jeannine.blatter@chuv.ch Received 1 February, 2019 Accepted 25 April, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Osteoplastic Anterior Transoral Approach for Tumors of the Middle Cranial Fossa Surgical access to tumors involving the midline skull base remains a considerable challenge for surgeons. Various surgical approaches for treating these tumors like transnasal, transantral, and endoscopic approaches sometimes have anatomical limitations. This paper describes a transoral approach with a Lefort I osteotomy that allows a great visualization, not only the center of the skull base but also the infratemporal fossa. This technique may be used for the surgical resection of extracranial and intracranial benign tumors, and non-neoplastic intradural pathology, which does not require dural resection. The authors will review proper patient selection, surgical exposure, operative procedure, and complications. Address correspondence and reprint requests to Rivera Ejusmar, Encirclement # 1, the Hills Park, Maracaibo, Zulia State, Venezuela; E-mail: ejusmar12@gmail.com Received 24 February, 2019 Accepted 24 April, 2019 The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

Cervical Stenosis in Non-Syndromic Pierre Robin Sequence Pierre Robin sequence is a triad of micrognathia, glossoptosis, and airway obstruction that has reported associations with numerous birth defects and anomalies including craniocervical pathologies. Given the number of airway assessments and neck manipulations these neonates experience, undetected cervical instability can result in detrimental consequences. The authors present a case of a neonate with non-syndromic Pierre Robin sequence planned for mandibular distraction osteogenesis that developed abnormal motor activity following intubation. The patient was eventually diagnosed with cervical spine stenosis and craniocervical instability after radiologic investigation. This paper demonstrates the significance of preoperative cervical spine evaluation and the importance of maintaining high level of suspicion when performing neck manipulations in those high-risk infants. Address correspondence and reprint requests to Laura A. Monson, MD, Division of Plastic Surgery, Department of Surgery, Baylor College of Medicine, 6701 Fannin St, Suite 610.00, Houston, TX 77030; E-mail: Laura.Monson@bcm.edu Received 1 March, 2019 Accepted 9 May, 2019 The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

The Risk Factors for Facial Numbness After Microvascular Decompression in Patients With Trigeminal Neuralgia Object: Microvascular decompression (MVD) is the most popular surgical procedure for treating Trigeminal neuralgia (TN). In this article, the authors conducted a large case series in which patients underwent MVD for TN, and focus on surgical outcomes, intraoperative findings, complications and risk factors. Methods: From January 2017 to June 2017, a total of 84 patients with TN were treated with MVD in our department. The authors retrospectively analyzed the surgical outcomes and postoperative complications of these patients. Risk factors were analyzed by binary logistic regression analysis. Results: Of the 84 patients, 69 had complete postoperative symptom relief (BNI I-II). A total of 28 patients developed postoperative facial numbness (BNI III-IV) and 1 patient died intraoperatively. With binary logistic regression analysis, significant risk factors for postoperative Facial numbness (FN) were longer operation time (odds ratio [OR] 1.153, P <0.05) and longer hospital stay (OR 1.371, P <0.05). The patients’ age, the length of the disease, the gender, and the side of the disease did not affect the occurrence of postoperative FN. Conclusions: The study found that patients with TN treated with MVD had a good response rate after surgery. The incidence of FN after surgery is not low, and longer duration of surgery and longer hospital stay are risk factors for FN. In the case of ensuring the success rate of surgery, reducing unnecessary operations, reducing the operation time, will help to reduce the occurrence of FN. Address correspondence and reprint requests to Xiao-Qiang Wang, Department of Neurosurgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China; E-mail: wangxiaoqiang@xinhuamed.com.cn Received 5 April, 2019 Accepted 28 April, 2019 The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

First Demonstration Water-Filled Vesicles of Choroid Plexus Tumors Objective: Choroid plexus cysts are the most common neuro-epithelial cysts. Methods: The authors describe 2 cases. The first case is a 1-year-old child presenting with hydrocephalus and cyst of the choroid plexus. The child was treated with endoscopic fenestration of the cysts. Results: The histological examination of the cyst wall was consistent with choroid epithelium and water-filled vesicles. The second case is 63 years old male with a highly vascularized tumor extending to choroid plexus. A quaductus Silvius was obstructed by the tumor. The histopathologic examination of choroid plexus showed a low number, water-vesicles. Conclusions: According to our knowledge, there are no previous reports of water-filled vesicles with choroid plexus cyst causing hydrocephalus. The firstcase is a good example of over secretion of cerebrospinal fluid (CSF) with the waterfilled vesicle. The second case with low number of water filled vesicle shows that the cause of hydrocephalus is not over production of CSF, it is blockage of the CSF pathway in Aquaductus Silvius by the tumor itself. These 2 cases are illustrative and more importantly highlights the need to study for water-filled vesicles in this kind of cases. Address correspondence and reprint requests to Ayhan Kanat, MD, RecepTayyipErdogan University, Medical Faculty, Department of Neurosurgery, Rize-Turkey; E-mail: ayhankanat@yahoo.com Received 28 April, 2019 Accepted 11 May, 2019 The authors report no conflicts of interest. © 2019 by Mutaz B. Habal, MD.

Timing of Tracheotomy in Patients With Severe Traumatic Brain Injury Background: Tracheotomy has played an important role in the treatment of patients with severe traumatic brain injury (TBI), the appropriate tracheotomy time will affect the prognosis of patients. However, the timing of tracheostomy after severe TBI remains controversial. To find the optimal time for tracheostomy, the authors compared the effects of early tracheostomy (ET) versus late tracheostomy (LT) on TBI-related outcomes and prognosis. Methods: The clinical data of 98 patients with severe TBI treated by tracheotomy at NICU, First Affiliated Hospital of Xi’an Medical University, January 2017 to January 2018, were analyzed retrospectively. According to the time of the tracheotomy during the treatment, the patients were divided into ET group (after admission <3 days) and LT group (>3 days after admission). The NICU stay, hospital stay, long duration of antibiotic use, pneumonia rates, mortality rates, improvement of nerve function, complications of tracheotomy, and treatment cost were compared between the 2 groups. Results: The NICU stay, hospitalization stay, and antibiotic use time of patients in the ET group were shorter than those in the LT group (P < 0.05). The pneumonia rates and the cost of hospitalization in the ET group were lower than those in the LT group (P < 0.05). The complications of the tracheostomy, mortality, and neurologic function improvements were not statistically significant in the 2 groups (P > 0.05). Conclusion: For severe TBI, ET can reduce the NICU stay, hospitalization stay, length of antibiotic use, and reduce the incidence rates of pneumonia and the cost of hospitalization compared with LT, but there is no significant improvement in the mortality rates and neurologic function of patients during hospitalization. Address correspondence and reprint requests to Wenchao Lu, MD, Department of Neurosurgery, The First Affiliated Hospital of Xi’an Medical University, No 48 Fenghao West Road, Xi’an, 710077 Shaanxi Province, China; E-mail: luwenchao1985@163.com Received 12 March, 2019 Accepted 8 May, 2019 All authors of this study and the manuscript were employed by the First Affiliated Hospital of Xi’an Medical University, China. The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.

Integra in Scalp Reconstruction After Tumor Excision: Recommendations From a Multidisciplinary Advisory Board Integra is a dermal regeneration template used in the reconstruction of burns, traumatic injuries, or excision lesions in patients who present particular risk factors for traditional surgical procedures. A multidisciplinary advisory board of expert dermatologists and plastic surgeons have discussed the use of Integra in the reconstruction of scalp defects after tumor excision, focusing on the evidence derived from literature and on their experience in the treatment of approximately 400 patients. In this position paper, the authors summarize the main evidence discussed during the board, and the common practice guidelines proposed by the experts. The use of Integra is recommended in elderly patients with multiple comorbidities who have a higher risk for potential complications in traditional surgery; these patients may in fact benefit from a lower anesthetic risk, a less complicated postsurgical care and limited morbidity at the donor site obtained with the dermal template. Integra should also be used in the reconstruction of large and complex wounds and in case of bone exposure, as it helps to overcome the challenges related to wound healing in difficult areas. Notably, Integra has proven to be effective in patients who have undergone previous surgical procedures or adjuvant radiation therapy, in which previous incisions, scarring and radiation damages may hamper the effectiveness of traditional procedures. Finally, Integra is recommended in patients with recurrent and aggressive tumors who need closer tumor surveillance, as it gives easy access to the tumor site for oncologic follow-up examination. Address correspondence and reprint requests to Cristina Magnoni, MD, Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy; E-mail: magnoni.cristina@gmail.com Received 28 March, 2019 Accepted 20 April, 2019 AP received personal fees from Integra LifeScience. Editorial assistance was provided by Ambra Corti, and Aashni Shah (Polistudium srl) funded by internal funds. The remaining authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcraniofacialsurgery.com). © 2019 by Mutaz B. Habal, MD.