Background: Deformational plagiocephaly is cranial asymmetry caused by external forces on the skull. Deformational plagiocephaly is seen in 5% to 48% of healthy newborns. Incomplete uvular fusion, in contrast, is one of many uvular malformations. The incidence of all degrees of incomplete uvular fusion is approximately 1% in healthy children. Bifid uvula is a malformation that is often considered a microform cleft palate or a marker for submucous cleft palate. Methods: This is a retrospective study of patients with deformational plagiocephaly seen at the Upstate Cleft and Craniofacial Center between January 1, 2006, and September 30, 2011. Patients were identified by the International Classification of Diseases, Ninth Revision code for plagiocephaly. Seventy-nine patients were excluded with craniosynostosis and syndromic diagnoses. One hundred forty-six patients with deformational plagiocephaly were included in the study. Data were collected for sex, age at presentation, parity, multiple births, delivery, oligohydramnios, cephalohematoma, uterine abnormalities, fetal position, and intrauterine growth restriction. Clinical findings were collected including location of cranial flattening and uvular malformations. Results: Twenty-four of 146 patients with deformational plagiocephaly had incomplete fusion of the uvula ranging from complete bifid uvula to a notched uvular tip (16.4%). This association was statistically significant (odds ratio, 18; 95% confidence interval, 11.1–28.9). Most patients (62.3%) were male. We recorded primiparity (44.5%), multiple births (17.1%), vacuum-assisted delivery (6.2%), cesarean section (36.3%), oligohydramnios (4.1%), uterine abnormalities (2.1%), abnormal fetal position (3.4%), and intrauterine growth restriction (1.4%). Ten of the 24 patients with plagiocephaly and uvular malformation were seen for an initial consultation only in our chart system. Of the remaining 14 patients with follow-up, none had recorded signs or symptoms of velopharyngeal insufficiency. Conclusions: The incidence of incomplete uvular fusion in infants with deformational plagiocephaly is 16.4%, which is significantly higher than the approximate 1% incidence reported in the general population. This is the first report of uvular malformation in the presence of deformational plagiocephaly.
A preteen boy presented with a 1-year history of right-sided nasal obstruction and a 4-day history of intermittent right-sided epistaxis following blunt trauma to the nose. The epistaxis occurred 3 to 4 times a day and resolved with pressure. He did not have facial pain, facial paresthesia, or visual changes. There was no family or personal history of bleeding disorders. Nasal endoscopy revealed a large, well-vascularized, polypoid mass filling the right anterior nasal cavity. A computed tomographic scan showed a right nasal cavity mass (4.5 × 1.7 cm) extending to the posterior choana with opacification and bony remodeling of the right maxillary sinus. The mass had heterogeneous intermediate signal intensity on T2-weightedmagnetic resonance imaging (Figure, A). The patient was taken to the operating room for biopsy and possible excision of the nasal mass. As the lesion was biopsied, there was brisk bleeding. However, the lesion was found to have a narrow pedicle of attachment and was resected in its entirety. The mass was based on the superior aspect of the nasal septum and cribriform plate. Hematoxylin-eosin stain showed a sheet-like proliferation of epithelioid and polygonal cells with pale eosinophilic granular cytoplasm and relatively uniform vesicular nuclei (Figure, B). The cells were arranged in nests. Branching, staghorn-like blood vessels were scattered throughout the tumor. The tumor cells stained positive for smooth muscle actin (Figure, C), muscle specific actin, Bcl-2, INI-1, and transcription factor E3 (Figure, D). A B
Objectives: 1) Explain the pros and cons of using arch bars for mandible fracture stabilization. 2) Compare and contrast the outcomes of mandible fractures treated with and without arch bars. Methods: A retrospective review was performed of mandible fractures treated at a Level 1 trauma center between 2001 and 2011. Two‐hundred forty‐two patients met inclusion criteria. Patients were categorized into those treated with or without arch bars. Major complications were malocclusion, infection, and malunion. Independent variables of age, sex, trauma, and dental status were collected. Exclusion criteria included lack of follow‐up, greenstick fractures, mid‐facial fractures, and subcondylar fractures. Data were analyzed using Fisher's exact test. Results: Eighty‐four patients had one mandible fracture, and 158 patients had two fractures. Overall, patients treated with arch bars had a complication rate of 13%, and those treated without arch bars had a rate of 16%. This was statistically insignificant ( P = 0.58). When separated by number of fractures, the differences remained insignificant (12% and 10% complication rates with and without arch bars in single fracture cases ( P = 0.74); 14% and 19% in two fracture cases ( P = 0.37)). Conclusions: The use of arch bars did not have a significant effect on major complications in this series. This trend was consistent for cases of one and two mandible fractures. These data suggest that many patients with mandible fractures may be safely treated without arch bars.
Abstract Laser technology continues to increase in popularity and expand treatment options for patients with common but challenging skin conditions including facial telangiectasias, facial aging, striae distensae, and acne scars. Facial telangiectasias have been estimated to occur in tens of millions of people worldwide. The 585-nm laser was the first to follow the principle of selective photothermolysis for the treatment of cutaneous vascular lesions, but it caused significant postoperative purpura. Newer diode lasers target superficial and deep telangiectasias without the side effects of the 585-nm laser. Ablative resurfacing was introduced in the 1990s with the carbon dioxide laser to address facial rhytids and photoaging. While effective, the risks and downtime were significant. The newest fractionated nonablative lasers are demonstrating impressive results, with decreased risks and downtime. This new generation of lasers is being used extensively and in unique combinations for facial aging, striae, and acne scars.
Ayoung boywithmild developmental delay and autism presentedwith a 1-week history of progressive left periorbital swelling. His parents reported that he complained of left orbital pain just before they noticed the swelling, and he was treated with cold compresses with only slight improvement. He had never experienced these symptoms before. The patient had not experienced diplopia, change in visual acuity, nasal obstruction, change in oral intake, weight loss, recent upper respiratory infection, sick contacts, fevers, or chills. At the time of presentation, the patient was breathing comfortably and was afebrile. Findings from his head and neck examination were significant for a firm mass over the left zygoma and lateral infraorbital rim, 2 × 3 cm in diameter. The mass was nontender, nonerythematous, and fixed to the underlying zygoma and lateral infraorbital rim. There was no cervical lymphadenopathy. Ophthalmology examination revealed intact extraocular movements, bilateral visual acuity of 20/50, and no evidence of afferent papillary defect. Computed tomographic (CT) images showed a round, soft-tissue mass with osseous destruction and erosion into the zygoma, infratemporal fossa, inferolateral orbit, and maxillary sinus (Figure, A and B). Concern for orbital involvement prompted magnetic resonance imaging (MRI) of the maxillofacial region (Figure, C and D). He was taken to the operating room the following day for open biopsy. A B
Anterior plication ptosis repair is a well-recognized technique but there is a paucity of literature using this technique in a Facial Plastic Surgery private practice where the majority of ptosis patients are having their repair in conjunction with other major cosmetic facial surgery under general anesthesia. The objective is to evaluate revision rates of combined aesthetic upper blepharoplasty with anterior plication ptosis repair in this practice setting. This study is a retrospective review of patients between 2010 and 2015 in a private practice Facial Plastic Surgery office who underwent primary upper blepharoplasty with and without anterior plication ptosis repair by the senior author (S.W.P). Patients were identified by Current Procedural Terminology (CPT) code. Average follow-up was 15 months with a range of 3 months to 63 months. Main outcome measure was need for skin pinch revision and/or ptosis revision. Three hundred twenty-six patients were identified. Patients were excluded who had previous upper blepharoplasty (n = 48) and less than 3 months of follow-up (n = 53). Patients were categorized into 2 groups: upper blepharoplasty with anterior plication ptosis repair (33 eyelids, 23 patients) and upper blepharoplasty without ptosis repair (402 eyelids, 202 patients). Of patients who underwent upper blepharoplasty with anterior plication ptosis repair, 15% of eyelids (5/33 eyelids) required revision ptosis repair for abnormal eyelid contour. Seventy percent of patients who underwent this technique were under general anesthesia for multiple procedures. Overall, there was a 7% dermatochalasis revision rate (31/435 eyelids). There was no significant difference in dermatochalasis revision rates of upper blepharoplasty with or without anterior plication ptosis repair ( P = .07). In our Facial Plastic Surgery private practice, upper blepharoplasty with anterior plication ptosis repair may be safely and effectively performed in conjunction with major cosmetic facial surgery under general anesthesia to address aging dermatochalasis and ptosis.
Objective There is continued debate as to whether to perform a neck dissection as a planned vs “wait and see” procedure in patients with head and neck cancer treated with chemoradiotherapy. In this study we aimed to review our results to help with the decision making process. Method A retrospective review of 140 oropharyngeal cancer cases treated with chemoradiotherapy was performed. Demographic data and treatment outcomes were extracted. The patients who underwent neck dissections were selected and evaluated as to how the decision was made; this included clinical examination, imaging studies, and fine needle aspiration biopsy. Results Of the 140 patients, 19 underwent ND for persistent disease. This included 9 patients with tonsil and 10 with base of tongue cancer. The decision for a ND was made according to CT scan findings in 7 patients, FNAB in 2 patients, PET imaging in 3 patients, clinical examination in 4 patients, and the combination of imaging and clinical findings in three patients. The dissections were performed at an average of 10 weeks (range, 4‐20 weeks). Seven patients (37%) had no viable cancer in the ND specimen. The pre‐treatment neck staging showed no significant difference. Conclusion Head and neck surgeons are in search of reliable methods to determine patients at risk of persistent disease. In this series, 37% of the patients had no viable tumor in the ND specimen. Further studies are needed to identify patients who are not in need of a ND.
Abstract Facial aging is a combination of descent of facial tissues, atrophy of fat compartments, bony remodeling, and chronological and photoaging changes of the skin. A rhytidectomy will address the aging changes due to gravity on facial tissues but will do little to improve skin texture, thickness, and pigmentation. To address collagen loss, rhytids, and dyspigmentation, surgeons are incorporating resurfacing techniques including carbon dioxide/erbium ablative and fractionated lasers, 35% trichloroacetic acid chemical peel pretreated with Jessner's solution, phenol 88% chemical peel, Baker's solution chemical peel, and dermabrasion. More recently, surgeons are approaching facial aging with a more comprehensive approach to address both gravity and collagen changes by a combination of rhytidectomy with resurfacing. Technique and modality selection are keys to maximum single treatment results and therefore the greatest patient satisfaction.
