Pediatric facial fractures, although uncommon, have a significant impact on public health and the... more Pediatric facial fractures, although uncommon, have a significant impact on public health and the US economy by the coexistence of other injuries and developmental deformities. Violence is one of the most frequent mechanisms leading to facial fracture. Teaching hospitals, while educating future medical professionals, have been linked to greater resource utilization in differing scenarios. This study was designed to compare the differences in patient characteristics and outcomes between teaching and non-teaching hospitals for violence-related pediatric facial fractures. Using the 2000-2009 Kids' Inpatient Database, 3881 patients younger than 18 years were identified with facial fracture and external cause of injury code for assault, fight, or abuse. Patients admitted at teaching hospitals were compared to those admitted at non-teaching hospitals in terms of demographics, injuries, and outcomes. Overall, 76.2% of patients had been treated at teaching hospitals. Compared to those treated at non-teaching hospitals, these patients were more likely to be younger, non-white, covered by Medicaid, from lower income zip codes, and have thoracic injuries; but mortality rate was not significantly different. After adjusting for potential confounders, teaching status of the hospital was not found as a predictor of either longer lengths of stay (LOS) or charges. There is an insignificant difference between LOS and charges at teaching and non-teaching hospitals after controlling for patient demographics. This suggests that the longer LOS observed at teaching hospitals is related to these institutions being more often involved in the care of underserved populations and patients with more severe injuries.
Fronto-orbital advancement and remodeling (FOAR) remains the most widely practiced treatment of u... more Fronto-orbital advancement and remodeling (FOAR) remains the most widely practiced treatment of unicoronal craniosynostosis (UCS) despite recent studies of ocular dysfunction and aesthetic shortcomings in the long-term. The aim of the study was to compare perioperative morbidity and short-term outcomes of a recently developed, nondevascularizing, distraction-based treatment of UCS with conventional FOAR. To do so, the authors compared the first 6 patients who were treated with a new osteotomy/distraction approach to the last 6 patients who underwent traditional FOAR for the treatment of UCS with regards to demographics, operative details, perioperative morbidity, and short-term outcomes.Between July 2012 and June 2014, 6 patients underwent each procedure. Duration of surgery and length of hospital stay in the distraction group were on average 2 hours 7 minutes and 3.4 days, respectively, significantly less than in the traditional FOAR group (P = 0.039, P = 0.032, respectively). Peri...
The authors present a new and unique pattern of sutural fusion "peace sign synostosis" ... more The authors present a new and unique pattern of sutural fusion "peace sign synostosis" (PSS) characterized by synostosis of the metopic, bicoronal, and sagittal sutures and associated with abnormalities of the TWIST1 gene known to be associated with Saethre-Chotzen syndrome (SCS). To do so, we performed a retrospective review of patients with bicoronal, metopic, and at least partial anterior sagittal synostoses at the Children's Hospital of Philadelphia and Seattle Children's Hospital. Patients' demographics, genetic analysis, perioperative and clinic notes were reviewed. Five patients were identified with PSS and abnormalities of TWIST1 consistent with SCS. One patient, with the longest follow-up of 7 years, underwent 5 intracranial procedures and required a ventriculoperitoneal (VP) shunt. The remaining 4 patients underwent posterior cranial vault distraction as the initial procedure, followed by anterior cranial vault remodeling. Two patients required a VP s...
The aim of this study is to evaluate the efficacy, safety profile and the complications associate... more The aim of this study is to evaluate the efficacy, safety profile and the complications associated with mandibular distraction osteogenesis (MDO) performed in infants < 4kg with Robin sequence (RS). A 11-year retrospective review of all infants (< 6 months) with MDO treated RS was performed. Patients < 4 kg (experimental) and ≥ 4 kg (control) who underwent MDO were compared. Demographics, medical comorbidities, improvement in apnea/hypopnea index (AHI), need for tracheostomy, repeat distraction, and complications were evaluated. One hundred twenty-one patients underwent MDO. 81 patients were < 4 kg while 40 were ≥ 4 kg. The mean follow up was 2.8 years in patients < 4 kg and 3.0 years in the control group. Mean age and weight at time of distraction were 23 days old / 3.1 kg and 2.7 years / 11 kg; respectively. There was no significant difference in success of MDO to treat airway obstruction in the < 4 kg group versus the control group (92.6% vs. 88.9%; p = 0.49). T...
Journal of cranio-maxillo-facial surgery : official publication of the European Association for Cranio-Maxillo-Facial Surgery, Jan 8, 2015
Robin sequence (RS) is defined as the triad of micrognathia, glossoptosis and airway obstruction.... more Robin sequence (RS) is defined as the triad of micrognathia, glossoptosis and airway obstruction. A popular surgical treatment is mandibular distraction osteogenesis (MDO). In this study, it is demonstrated that the associated variables change, dependent on the manner in which failure is defined. These multiple failure outcomes are used to construct a scoring system to predict MDO failure. A retrospective database of neonatal MDO patients was constructed. Failure outcomes studied included tracheostomy; a decrease in the apnea-hypopnea index (AHI) but an AHI >20; and death. A combination of bivariate and regression analysis was used to produce significantly associated variables and a scoring system. Statistical analysis demonstrated the association of gastroesophageal reflux; age >30 days; neurologic anomaly; airway anomalies, other than laryngomalacia; an intact palate; and pre-operative intubation on the outcome variables studied. Multiple scoring systems were produced with r...
Facial paralysis is a debilitating condition. Dynamic and static facial reanimation remains a cha... more Facial paralysis is a debilitating condition. Dynamic and static facial reanimation remains a challenge for plastic surgeons and requires important resources. Our objective was to quantify the health state utility assessment (ie, utility score outcomes) of living with unilateral facial paralysis. Utility assessments using visual analog scale, time trade-off, and standard gamble were used to obtain utility outcome scores for unilateral facial paralysis from a prospective sample of the general population and medical students. A total number of 123 individuals prospectively participated in the study. All measures (visual analog scale, time trade-off, and standard gamble) for unilateral facial paralysis [0.56 ± 0.18, 0.78 ± 0.21, and 0.79 ± 0.21 respectively] were significantly different (P < 0.0001) from the corresponding outcome scores for monocular blindness [0.61 ± 0.21, 0.83 ± 0.21, and 0.85 ± 0.18, respectively] and binocular blindness [0.33 ± 0.18, 0.65 ± 0.28, and 0.65 ± 0.29...
Patients with multisutural craniosynostosis can develop anomalous venous connections between the ... more Patients with multisutural craniosynostosis can develop anomalous venous connections between the intracranial sinuses and cutaneous venous system through enlarged emissary veins. Cranial vault remodeling in this subset of patients carries the risk of massive intraoperative blood loss and/or occlusion of collateral draining veins leading to intracranial venous hypertension and raised intracranial pressure, increasing the morbidity of cranial expansion. The authors report the use of spring-mediated expansion as a technique for cranial reconstruction in which the collateral intracranial venous drainage system can be preserved. A patient with bilateral lambdoid, sagittal, and unicoronal synostosis presented for cranial reconstruction. A tracheostomy and ventriculoperitoneal shunt were placed prior to intervention. At the time of reconstruction, a Luckenschadel skull abnormality and Chiari malformation Type I were present. A preoperative CT venogram demonstrated large collateral superfic...
The Canadian journal of plastic surgery = Journal canadien de chirurgie plastique, 2013
Exposure to plastic surgery during medical school is limited. Most interested applicants form the... more Exposure to plastic surgery during medical school is limited. Most interested applicants form their perceptions of careers in this surgical specialty during elective rotations. To investigate the perceptions of Canadian medical students considering a career in plastic surgery. The results obtained were then compared with current Canadian plastic surgery residents' perceptions. The data were collected via two separate self-administered online surveys that were distributed to either Canadian plastic surgery residents or medical students. The questionnaires were similar and focused on three aspects: applicant details; driving force behind interest in the field; and essential character traits and competencies related to successful matching. Fifty-nine plastic surgery residents and 477 medical students participated in the online survey. The most commonly reported driving forces for interest in a plastic surgery career in both groups were variety of career choice, complexity of the fi...
Journal of plastic, reconstructive & aesthetic surgery : JPRAS, 2014
Craniofacial malformations including cleft lip and/or palate (CL/P) increase risk for obstructive... more Craniofacial malformations including cleft lip and/or palate (CL/P) increase risk for obstructive sleep apnea (OSA). While 30% of CL/P occurs in the context of underlying genetic syndromes, few studies have investigated the prevalence of OSA in this high-risk group. This study aims to determine the incidence and risk factors of positive screening for OSA in this complex patient population. The Pediatric Sleep Questionnaire (PSQ) was prospectively administered to all patients cared for by the cleft lip and palate clinic at the Children's Hospital of Philadelphia between January 2011 and August 2013. The PSQ is a 22-item, validated screening tool for OSA with a sensitivity and specificity of 0.83 and 0.87 in detecting an apnea-hypopnea index (AHI) >5/hour in healthy children. The Fisher exact and Chi-square tests were used for purposes of comparison. 178 patients with syndromic CL/P completed the PSQ. Mean cohort age was 8.1 ± 4.4 years. Patients were predominately female (53.9...
The Canadian journal of plastic surgery = Journal canadien de chirurgie plastique, 2014
To determine the incidence of obstructive sleep apnea (OSA) in children with isolated cleft lip a... more To determine the incidence of obstructive sleep apnea (OSA) in children with isolated cleft lip and/or palate (CL/P). The present prospective study was performed at a pediatric tertiary care centre. Consecutive patients evaluated at the cleft clinic from January 2011 to August 2013 were identified. Patients' families prospectively completed the Pediatric Sleep Questionnaire (PSQ), a validated tool used to predict moderate to severe OSA. Patients with CL/P and an underlying syndrome or other craniofacial diagnosis were excluded. A positive OSA screen was recorded if the ratio of positive to total responses was >0.33. Risk factors associated with a positive screen were identified using the Student's t or ANOVA test. A total of 867 patients completed the PSQ, 489 of whom with isolated CL/P met inclusion criteria. The mean age was 8.4 years. The overall incidence of positive screening was 14.7%. The most commonly reported symptoms among positive screeners were 'fidgets wi...
The aims of this study were to document the incidence of new-onset craniosynostosis (NOC) after p... more The aims of this study were to document the incidence of new-onset craniosynostosis (NOC) after posterior vault distraction osteogenesis (PVDO), to determine risk factors for the development of NOC, and to deduce the cranial ramifications of NOC. An institutional review board-approved retrospective review of all patients who underwent PVDO at the Children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Hospital of Philadelphia was performed. Demographics, perioperative data, as well as preoperative and postoperative three-dimensional computed tomographic scans were analyzed. Suture patency preoperatively and postoperatively was recorded.Thirty patients underwent PVDO for suspected increased intracranial pressure and/or severe turribrachicephaly from 2008 to 2013. Twenty-four patients had syndromic diagnoses. The average age at the time of PVDO was 2.03 years. Distraction distances ranged from 19 to 40 mm, with an average of 28.7 mm. Among the 19 patients who had patent lambdoid sutures before PVDO, new-onset lambdoid fusion was seen in 17 patients after PVDO (89.5%), whereas the suture remained open in 2 patients (10.5%). New-onset lambdoid fusion was not significantly associated with age at distraction (P = 0.28), sex (P = 0.47), length of distraction (P = 0.93), or diagnosis (P = 0.61). Similarly, new-onset sagittal synostosis was not associated with age at distraction (P = 0.06), sex (P = 0.64), length of distraction (P = 0.83), or diagnosis (P = 0.25). None of the patients who developed NOC had characteristic head shape changes such as mastoid bulges or scaphocephaly. New-onset lambdoid and sagittal synostoses occur frequently after PVDO. Although the diagnosis of NOC is obvious radiographically, the clinical importance of the diagnosis morphometrically, neurodevelopmentally, and in cranial growth has yet to be fully investigated.
While there is a clear correlation between unilateral coronal synostosis (UCS) and ocular motilit... more While there is a clear correlation between unilateral coronal synostosis (UCS) and ocular motility abnormalities, the literature provides little information as to the true epidemiology of strabismus, or the underlying etiology of these paralleled pathologies. The purpose of this study is to investigate the rate of oculomotor abnormalities associated with UCS and its management. A retrospective review of all patients identified to have single-suture, nonsyndromic UCS treated by fronto-orbital advancement at a tertiary craniofacial referral center from 1977 to 2013 was performed. Inclusion criteria mandated complete medical, surgical, and ophthalmological records. Patients were evaluated for strabismus both preoperatively and postoperatively, and as to whether eye muscle surgery was performed. A total of 181 patients underwent treatment for UCS at our institution during the study period, of which 79 met the inclusion criteria. Twenty-nine patients had strabismus prior to any craniofacial surgical intervention. Following fronto-orbital advancement, 23 patients (46 %) developed a new onset strabismus. Fifty-five patients had no change in their preoperative ocular examination, and one patient had resolution of preoperative strabismus. Of the 51 patients who had postoperative strabismus, 30 went on to have eye muscle surgery. There were no statistically significant differences in gender (p = 0.477), race (p = 0.395), sidedness of suture involvement (p = 0.552), or age at intervention (p = 0.66) in comparing the group with new postoperative strabismus and those without. This study sheds new light on the prevalence of strabismus in UCS, and more importantly, the risk of developing strabismus in the setting of conventional fronto-orbital advancement. This data will allow more accurate preoperative counseling and reinforces the important role of ophthalmologists as members of the multidisciplinary craniofacial team.
Within the diagnosis &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;craniosyno... more Within the diagnosis &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;craniosynostosis,&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; there is a subset of patients who present with isolated, nonsyndromic, single-suture involvement. This study evaluates perioperative complications in this specific subset of patients over 4 decades at a single institution. To do so, we performed a retrospective review on consecutive patients undergoing correction of single-suture synostosis from May 1977 to January 2013 at a tertiary pediatric craniofacial center. Demographic information, operative details, and perioperative course were collected. Complications were categorized as either major or minor. A χ(2) test and Fisher exact test were used to compare all categorical variables. Continuous variables were analyzed using Wilcoxon rank-sum and Kruskal-Wallis tests.Seven hundred forty-six patients underwent surgical correction of nonsyndromic craniosynostosis. Of these, there were 307 (41.2%) sagittal, 201 (26.9%) metopic, and 238 (31.9%) unicoronal. Thirty-four patients had complications (4.6%). Eight were considered major (1.1%), including one postoperative mortality in a patient with hypoplastic left-sided heart syndrome. Minor complications occurred in 26 patients (3.5%) and included subgaleal hematoma (n = 3), seroma (n = 4), and superficial wound infection (n = 5). Metopic and sagittal suture involvement was significantly associated with a higher complication rate (P = 0.04). A child with isolated single suture synostosis and any comorbidity had a significantly greater risk of any complication (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001; odds ratio, 3.8) and specifically an increased risk of major complication (P = 0.031; odds ratio, 6.0). Subclassification of patients by time period yielded no statistically significant changes in perioperative morbidity. To conclude, these data allow us to counsel families more accurately with regard to morbidity and mortality and may potentially serve as a benchmark for future quality improvement work.
Three-dimensional virtual surgical planning using computer-aided design and modeling (CAD/CAM) ha... more Three-dimensional virtual surgical planning using computer-aided design and modeling (CAD/CAM) has gained popularity in planning complex orthognathic and osteocutaneous free flap reconstructions of the head and neck because of its ability to guide complex geometric planning in three-dimensional space and save time in the operating room. The purpose of this study was to review our experience using CAD/CAM concepts in periorbital osteotomies. Three complex periorbital osteotomies were planned and performed: 1 case of bilateral vertical and horizontal orbital dystopia, 1 case of a Monobloc-Le Fort II in an Apert patient, and 1 case of recurrent hypertelorism in a patient with craniofrontal nasal dysplasia. The patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; charts were reviewed, including photographs, medical records, and CAD/CAM plans. The CAD/CAM planning sessions were held 3 to 6 weeks preoperatively and lasted approximately 1 hour. Both cutting guides and positioning guides were used, translating to significant precision of both the osteotomy as well as the final position of the orbits. Qualitatively, the cutting and positioning guides were easy to use and improved operating room efficiency. To conclude, in our hands, CAD/CAM virtual surgical planning is safe and effective in the performance of complex periorbital osteotomies. More work is needed to more clearly define surgical indications for this costly, new technology.
Craniofacial microsomia encompasses a spectrum of diagnoses associated with variable degrees of m... more Craniofacial microsomia encompasses a spectrum of diagnoses associated with variable degrees of mandibular hypoplasia, facial asymmetry, chin deviation, occlusal abnormalities, and potential airway compromise. This study presents one surgeon&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s experience with costochondral rib grafting for mandibular reconstruction in children with Pruzansky/Kaban type 2B and type 3 mandibular hypoplasia. An institutional review board-approved retrospective chart review was performed of all patients with craniofacial microsomia who underwent costochondral rib grafting for mandibular reconstruction performed by the senior author (S.P.B.) at The Children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Hospital of Philadelphia from January of 1998 to September of 2013. Demographic information, surgical history, operative details, postoperative complications, and outcomes were recorded. Plain radiographs and preoperative and postoperative three-dimensional computed tomographic scans were reviewed. Two hundred fifty-five patients were diagnosed with craniofacial microsomia, and 22 patients met inclusion criteria. Twelve boys and 10 girls underwent grafting at an average age of 7.2 years. Thirty-three costochondral rib grafts were performed, 11 unilateral reconstructions and 11 bilateral reconstructions. Twelve hemimandibles were type 2B and 21 were type 3. No intraoperative complications were reported, and no incidence of graft resorption was noted. No additional procedures were required in 27 reconstructed hemimandibles (81.8 percent), whereas six (18.2 percent) required secondary distraction osteogenesis. Only one patient developed postoperative ankylosis. No malunion or nonunion was noted. The approach described in this article allowed the authors to obtain reliably good results with costochondral rib grafting for type 2B and type 3 mandibular hypoplasia associated with craniofacial microsomia. Therapeutic, IV.
Le Fort II and III distraction osteogenesis (DO) is a powerful tool in the craniofacial armamenta... more Le Fort II and III distraction osteogenesis (DO) is a powerful tool in the craniofacial armamentarium that is most often employed to treat patients with craniofacial syndromes such as Crouzon, Apert, or Pfeiffer syndrome who present with midfacial retrusion, shallow orbits, exorbitism, malocclusion, obstructive sleep apnea and facial imbalance. In this article, the authors will provide the reader with an update on techniques for the treatment of various forms of midfacial retrusion.
Distraction osteogenesis is an effective technique for elongating the deficient mandible. The aut... more Distraction osteogenesis is an effective technique for elongating the deficient mandible. The authors specifically evaluated its effectiveness in the treatment of airway obstruction in pediatric patients with mandibular hypoplasia. A comprehensive literature review of the National Library of Medicine (PubMed) database was performed. English-language studies involving isolated distraction of the pediatric mandible (younger than 18 years) with descriptive reporting of airway changes were included. Extracted data included demographics, initial diagnosis, distractor type, distraction protocol, predistraction and postdistraction airway status, and complications. Seventy-four articles met the inclusion criteria, resulting in 711 patients with craniofacial abnormalities who underwent mandibular distraction osteogenesis. Mean age at the time of distraction was 18.1 months. The most common diagnoses were isolated Pierre Robin sequence (52.9 percent), syndromic Pierre Robin sequence (7 percent), and Treacher Collins syndrome (6.8 percent). Mandibular distraction osteogenesis successfully treated airway obstruction in 89.3 percent of cases. Success was defined as either decannulation of tracheostomy, avoidance of tracheostomy or continuous positive airway pressure, or alleviation or significant improvement of obstructive sleep apnea symptoms. One hundred seventy-one (84.2 percent) of the 203 tracheostomy-dependent patients were successfully decannulated. Among the 181 patients with obstructive sleep apnea, mandibular distraction osteogenesis successfully allowed for either complete resolution or significant improvement of symptoms in 95.6 percent. A 23.8 percent overall complication rate was noted. The mean follow-up time was 28.7 months. In addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients.
Journal of Plastic, Reconstructive & Aesthetic Surgery, 2011
Pyogenic granuloma (PG) is a common benign vascular proliferation that commonly occurs on the ski... more Pyogenic granuloma (PG) is a common benign vascular proliferation that commonly occurs on the skin. Various treatment options exist in the literature with no clear consensus. Our objective was to review the literature associated with PGs and their management, and based on recurrence rates, suggest management options. A retrospective literature review examining the treatment of cutaneous PG and their associated recurrence rates was conducted. A total of 34 manuscripts were included in our review; with 1162 PGs managed using 19 different treatment modalities with 53 recurrences observed. Among the surgical management options, surgical excision offers the lowest overall recurrence rates (2.94%). Of the medical treatments, cryotherapy offered the lowest overall recurrence rate (1.62%). We concluded that surgical excision and primary closure should be the treatment of choice for small cutaneous PGs in non-cosmetically sensitive areas; however if non-surgical management is undertaken, cauterization with silver nitrate should be the first line treatment. When comparing recurrence rates of surgical excision vs. cauterization, we found no statistical difference between the two (p-value 0.426).
Pediatric facial fractures, although uncommon, have a significant impact on public health and the... more Pediatric facial fractures, although uncommon, have a significant impact on public health and the US economy by the coexistence of other injuries and developmental deformities. Violence is one of the most frequent mechanisms leading to facial fracture. Teaching hospitals, while educating future medical professionals, have been linked to greater resource utilization in differing scenarios. This study was designed to compare the differences in patient characteristics and outcomes between teaching and non-teaching hospitals for violence-related pediatric facial fractures. Using the 2000-2009 Kids&amp;amp;amp;amp;amp;amp;#39; Inpatient Database, 3881 patients younger than 18 years were identified with facial fracture and external cause of injury code for assault, fight, or abuse. Patients admitted at teaching hospitals were compared to those admitted at non-teaching hospitals in terms of demographics, injuries, and outcomes. Overall, 76.2% of patients had been treated at teaching hospitals. Compared to those treated at non-teaching hospitals, these patients were more likely to be younger, non-white, covered by Medicaid, from lower income zip codes, and have thoracic injuries; but mortality rate was not significantly different. After adjusting for potential confounders, teaching status of the hospital was not found as a predictor of either longer lengths of stay (LOS) or charges. There is an insignificant difference between LOS and charges at teaching and non-teaching hospitals after controlling for patient demographics. This suggests that the longer LOS observed at teaching hospitals is related to these institutions being more often involved in the care of underserved populations and patients with more severe injuries.
Fronto-orbital advancement and remodeling (FOAR) remains the most widely practiced treatment of u... more Fronto-orbital advancement and remodeling (FOAR) remains the most widely practiced treatment of unicoronal craniosynostosis (UCS) despite recent studies of ocular dysfunction and aesthetic shortcomings in the long-term. The aim of the study was to compare perioperative morbidity and short-term outcomes of a recently developed, nondevascularizing, distraction-based treatment of UCS with conventional FOAR. To do so, the authors compared the first 6 patients who were treated with a new osteotomy/distraction approach to the last 6 patients who underwent traditional FOAR for the treatment of UCS with regards to demographics, operative details, perioperative morbidity, and short-term outcomes.Between July 2012 and June 2014, 6 patients underwent each procedure. Duration of surgery and length of hospital stay in the distraction group were on average 2 hours 7 minutes and 3.4 days, respectively, significantly less than in the traditional FOAR group (P = 0.039, P = 0.032, respectively). Peri...
The authors present a new and unique pattern of sutural fusion "peace sign synostosis" ... more The authors present a new and unique pattern of sutural fusion "peace sign synostosis" (PSS) characterized by synostosis of the metopic, bicoronal, and sagittal sutures and associated with abnormalities of the TWIST1 gene known to be associated with Saethre-Chotzen syndrome (SCS). To do so, we performed a retrospective review of patients with bicoronal, metopic, and at least partial anterior sagittal synostoses at the Children's Hospital of Philadelphia and Seattle Children's Hospital. Patients' demographics, genetic analysis, perioperative and clinic notes were reviewed. Five patients were identified with PSS and abnormalities of TWIST1 consistent with SCS. One patient, with the longest follow-up of 7 years, underwent 5 intracranial procedures and required a ventriculoperitoneal (VP) shunt. The remaining 4 patients underwent posterior cranial vault distraction as the initial procedure, followed by anterior cranial vault remodeling. Two patients required a VP s...
The aim of this study is to evaluate the efficacy, safety profile and the complications associate... more The aim of this study is to evaluate the efficacy, safety profile and the complications associated with mandibular distraction osteogenesis (MDO) performed in infants < 4kg with Robin sequence (RS). A 11-year retrospective review of all infants (< 6 months) with MDO treated RS was performed. Patients < 4 kg (experimental) and ≥ 4 kg (control) who underwent MDO were compared. Demographics, medical comorbidities, improvement in apnea/hypopnea index (AHI), need for tracheostomy, repeat distraction, and complications were evaluated. One hundred twenty-one patients underwent MDO. 81 patients were < 4 kg while 40 were ≥ 4 kg. The mean follow up was 2.8 years in patients < 4 kg and 3.0 years in the control group. Mean age and weight at time of distraction were 23 days old / 3.1 kg and 2.7 years / 11 kg; respectively. There was no significant difference in success of MDO to treat airway obstruction in the < 4 kg group versus the control group (92.6% vs. 88.9%; p = 0.49). T...
Journal of cranio-maxillo-facial surgery : official publication of the European Association for Cranio-Maxillo-Facial Surgery, Jan 8, 2015
Robin sequence (RS) is defined as the triad of micrognathia, glossoptosis and airway obstruction.... more Robin sequence (RS) is defined as the triad of micrognathia, glossoptosis and airway obstruction. A popular surgical treatment is mandibular distraction osteogenesis (MDO). In this study, it is demonstrated that the associated variables change, dependent on the manner in which failure is defined. These multiple failure outcomes are used to construct a scoring system to predict MDO failure. A retrospective database of neonatal MDO patients was constructed. Failure outcomes studied included tracheostomy; a decrease in the apnea-hypopnea index (AHI) but an AHI >20; and death. A combination of bivariate and regression analysis was used to produce significantly associated variables and a scoring system. Statistical analysis demonstrated the association of gastroesophageal reflux; age >30 days; neurologic anomaly; airway anomalies, other than laryngomalacia; an intact palate; and pre-operative intubation on the outcome variables studied. Multiple scoring systems were produced with r...
Facial paralysis is a debilitating condition. Dynamic and static facial reanimation remains a cha... more Facial paralysis is a debilitating condition. Dynamic and static facial reanimation remains a challenge for plastic surgeons and requires important resources. Our objective was to quantify the health state utility assessment (ie, utility score outcomes) of living with unilateral facial paralysis. Utility assessments using visual analog scale, time trade-off, and standard gamble were used to obtain utility outcome scores for unilateral facial paralysis from a prospective sample of the general population and medical students. A total number of 123 individuals prospectively participated in the study. All measures (visual analog scale, time trade-off, and standard gamble) for unilateral facial paralysis [0.56 ± 0.18, 0.78 ± 0.21, and 0.79 ± 0.21 respectively] were significantly different (P < 0.0001) from the corresponding outcome scores for monocular blindness [0.61 ± 0.21, 0.83 ± 0.21, and 0.85 ± 0.18, respectively] and binocular blindness [0.33 ± 0.18, 0.65 ± 0.28, and 0.65 ± 0.29...
Patients with multisutural craniosynostosis can develop anomalous venous connections between the ... more Patients with multisutural craniosynostosis can develop anomalous venous connections between the intracranial sinuses and cutaneous venous system through enlarged emissary veins. Cranial vault remodeling in this subset of patients carries the risk of massive intraoperative blood loss and/or occlusion of collateral draining veins leading to intracranial venous hypertension and raised intracranial pressure, increasing the morbidity of cranial expansion. The authors report the use of spring-mediated expansion as a technique for cranial reconstruction in which the collateral intracranial venous drainage system can be preserved. A patient with bilateral lambdoid, sagittal, and unicoronal synostosis presented for cranial reconstruction. A tracheostomy and ventriculoperitoneal shunt were placed prior to intervention. At the time of reconstruction, a Luckenschadel skull abnormality and Chiari malformation Type I were present. A preoperative CT venogram demonstrated large collateral superfic...
The Canadian journal of plastic surgery = Journal canadien de chirurgie plastique, 2013
Exposure to plastic surgery during medical school is limited. Most interested applicants form the... more Exposure to plastic surgery during medical school is limited. Most interested applicants form their perceptions of careers in this surgical specialty during elective rotations. To investigate the perceptions of Canadian medical students considering a career in plastic surgery. The results obtained were then compared with current Canadian plastic surgery residents' perceptions. The data were collected via two separate self-administered online surveys that were distributed to either Canadian plastic surgery residents or medical students. The questionnaires were similar and focused on three aspects: applicant details; driving force behind interest in the field; and essential character traits and competencies related to successful matching. Fifty-nine plastic surgery residents and 477 medical students participated in the online survey. The most commonly reported driving forces for interest in a plastic surgery career in both groups were variety of career choice, complexity of the fi...
Journal of plastic, reconstructive & aesthetic surgery : JPRAS, 2014
Craniofacial malformations including cleft lip and/or palate (CL/P) increase risk for obstructive... more Craniofacial malformations including cleft lip and/or palate (CL/P) increase risk for obstructive sleep apnea (OSA). While 30% of CL/P occurs in the context of underlying genetic syndromes, few studies have investigated the prevalence of OSA in this high-risk group. This study aims to determine the incidence and risk factors of positive screening for OSA in this complex patient population. The Pediatric Sleep Questionnaire (PSQ) was prospectively administered to all patients cared for by the cleft lip and palate clinic at the Children's Hospital of Philadelphia between January 2011 and August 2013. The PSQ is a 22-item, validated screening tool for OSA with a sensitivity and specificity of 0.83 and 0.87 in detecting an apnea-hypopnea index (AHI) >5/hour in healthy children. The Fisher exact and Chi-square tests were used for purposes of comparison. 178 patients with syndromic CL/P completed the PSQ. Mean cohort age was 8.1 ± 4.4 years. Patients were predominately female (53.9...
The Canadian journal of plastic surgery = Journal canadien de chirurgie plastique, 2014
To determine the incidence of obstructive sleep apnea (OSA) in children with isolated cleft lip a... more To determine the incidence of obstructive sleep apnea (OSA) in children with isolated cleft lip and/or palate (CL/P). The present prospective study was performed at a pediatric tertiary care centre. Consecutive patients evaluated at the cleft clinic from January 2011 to August 2013 were identified. Patients' families prospectively completed the Pediatric Sleep Questionnaire (PSQ), a validated tool used to predict moderate to severe OSA. Patients with CL/P and an underlying syndrome or other craniofacial diagnosis were excluded. A positive OSA screen was recorded if the ratio of positive to total responses was >0.33. Risk factors associated with a positive screen were identified using the Student's t or ANOVA test. A total of 867 patients completed the PSQ, 489 of whom with isolated CL/P met inclusion criteria. The mean age was 8.4 years. The overall incidence of positive screening was 14.7%. The most commonly reported symptoms among positive screeners were 'fidgets wi...
The aims of this study were to document the incidence of new-onset craniosynostosis (NOC) after p... more The aims of this study were to document the incidence of new-onset craniosynostosis (NOC) after posterior vault distraction osteogenesis (PVDO), to determine risk factors for the development of NOC, and to deduce the cranial ramifications of NOC. An institutional review board-approved retrospective review of all patients who underwent PVDO at the Children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Hospital of Philadelphia was performed. Demographics, perioperative data, as well as preoperative and postoperative three-dimensional computed tomographic scans were analyzed. Suture patency preoperatively and postoperatively was recorded.Thirty patients underwent PVDO for suspected increased intracranial pressure and/or severe turribrachicephaly from 2008 to 2013. Twenty-four patients had syndromic diagnoses. The average age at the time of PVDO was 2.03 years. Distraction distances ranged from 19 to 40 mm, with an average of 28.7 mm. Among the 19 patients who had patent lambdoid sutures before PVDO, new-onset lambdoid fusion was seen in 17 patients after PVDO (89.5%), whereas the suture remained open in 2 patients (10.5%). New-onset lambdoid fusion was not significantly associated with age at distraction (P = 0.28), sex (P = 0.47), length of distraction (P = 0.93), or diagnosis (P = 0.61). Similarly, new-onset sagittal synostosis was not associated with age at distraction (P = 0.06), sex (P = 0.64), length of distraction (P = 0.83), or diagnosis (P = 0.25). None of the patients who developed NOC had characteristic head shape changes such as mastoid bulges or scaphocephaly. New-onset lambdoid and sagittal synostoses occur frequently after PVDO. Although the diagnosis of NOC is obvious radiographically, the clinical importance of the diagnosis morphometrically, neurodevelopmentally, and in cranial growth has yet to be fully investigated.
While there is a clear correlation between unilateral coronal synostosis (UCS) and ocular motilit... more While there is a clear correlation between unilateral coronal synostosis (UCS) and ocular motility abnormalities, the literature provides little information as to the true epidemiology of strabismus, or the underlying etiology of these paralleled pathologies. The purpose of this study is to investigate the rate of oculomotor abnormalities associated with UCS and its management. A retrospective review of all patients identified to have single-suture, nonsyndromic UCS treated by fronto-orbital advancement at a tertiary craniofacial referral center from 1977 to 2013 was performed. Inclusion criteria mandated complete medical, surgical, and ophthalmological records. Patients were evaluated for strabismus both preoperatively and postoperatively, and as to whether eye muscle surgery was performed. A total of 181 patients underwent treatment for UCS at our institution during the study period, of which 79 met the inclusion criteria. Twenty-nine patients had strabismus prior to any craniofacial surgical intervention. Following fronto-orbital advancement, 23 patients (46 %) developed a new onset strabismus. Fifty-five patients had no change in their preoperative ocular examination, and one patient had resolution of preoperative strabismus. Of the 51 patients who had postoperative strabismus, 30 went on to have eye muscle surgery. There were no statistically significant differences in gender (p = 0.477), race (p = 0.395), sidedness of suture involvement (p = 0.552), or age at intervention (p = 0.66) in comparing the group with new postoperative strabismus and those without. This study sheds new light on the prevalence of strabismus in UCS, and more importantly, the risk of developing strabismus in the setting of conventional fronto-orbital advancement. This data will allow more accurate preoperative counseling and reinforces the important role of ophthalmologists as members of the multidisciplinary craniofacial team.
Within the diagnosis &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;craniosyno... more Within the diagnosis &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;craniosynostosis,&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; there is a subset of patients who present with isolated, nonsyndromic, single-suture involvement. This study evaluates perioperative complications in this specific subset of patients over 4 decades at a single institution. To do so, we performed a retrospective review on consecutive patients undergoing correction of single-suture synostosis from May 1977 to January 2013 at a tertiary pediatric craniofacial center. Demographic information, operative details, and perioperative course were collected. Complications were categorized as either major or minor. A χ(2) test and Fisher exact test were used to compare all categorical variables. Continuous variables were analyzed using Wilcoxon rank-sum and Kruskal-Wallis tests.Seven hundred forty-six patients underwent surgical correction of nonsyndromic craniosynostosis. Of these, there were 307 (41.2%) sagittal, 201 (26.9%) metopic, and 238 (31.9%) unicoronal. Thirty-four patients had complications (4.6%). Eight were considered major (1.1%), including one postoperative mortality in a patient with hypoplastic left-sided heart syndrome. Minor complications occurred in 26 patients (3.5%) and included subgaleal hematoma (n = 3), seroma (n = 4), and superficial wound infection (n = 5). Metopic and sagittal suture involvement was significantly associated with a higher complication rate (P = 0.04). A child with isolated single suture synostosis and any comorbidity had a significantly greater risk of any complication (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001; odds ratio, 3.8) and specifically an increased risk of major complication (P = 0.031; odds ratio, 6.0). Subclassification of patients by time period yielded no statistically significant changes in perioperative morbidity. To conclude, these data allow us to counsel families more accurately with regard to morbidity and mortality and may potentially serve as a benchmark for future quality improvement work.
Three-dimensional virtual surgical planning using computer-aided design and modeling (CAD/CAM) ha... more Three-dimensional virtual surgical planning using computer-aided design and modeling (CAD/CAM) has gained popularity in planning complex orthognathic and osteocutaneous free flap reconstructions of the head and neck because of its ability to guide complex geometric planning in three-dimensional space and save time in the operating room. The purpose of this study was to review our experience using CAD/CAM concepts in periorbital osteotomies. Three complex periorbital osteotomies were planned and performed: 1 case of bilateral vertical and horizontal orbital dystopia, 1 case of a Monobloc-Le Fort II in an Apert patient, and 1 case of recurrent hypertelorism in a patient with craniofrontal nasal dysplasia. The patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; charts were reviewed, including photographs, medical records, and CAD/CAM plans. The CAD/CAM planning sessions were held 3 to 6 weeks preoperatively and lasted approximately 1 hour. Both cutting guides and positioning guides were used, translating to significant precision of both the osteotomy as well as the final position of the orbits. Qualitatively, the cutting and positioning guides were easy to use and improved operating room efficiency. To conclude, in our hands, CAD/CAM virtual surgical planning is safe and effective in the performance of complex periorbital osteotomies. More work is needed to more clearly define surgical indications for this costly, new technology.
Craniofacial microsomia encompasses a spectrum of diagnoses associated with variable degrees of m... more Craniofacial microsomia encompasses a spectrum of diagnoses associated with variable degrees of mandibular hypoplasia, facial asymmetry, chin deviation, occlusal abnormalities, and potential airway compromise. This study presents one surgeon&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s experience with costochondral rib grafting for mandibular reconstruction in children with Pruzansky/Kaban type 2B and type 3 mandibular hypoplasia. An institutional review board-approved retrospective chart review was performed of all patients with craniofacial microsomia who underwent costochondral rib grafting for mandibular reconstruction performed by the senior author (S.P.B.) at The Children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Hospital of Philadelphia from January of 1998 to September of 2013. Demographic information, surgical history, operative details, postoperative complications, and outcomes were recorded. Plain radiographs and preoperative and postoperative three-dimensional computed tomographic scans were reviewed. Two hundred fifty-five patients were diagnosed with craniofacial microsomia, and 22 patients met inclusion criteria. Twelve boys and 10 girls underwent grafting at an average age of 7.2 years. Thirty-three costochondral rib grafts were performed, 11 unilateral reconstructions and 11 bilateral reconstructions. Twelve hemimandibles were type 2B and 21 were type 3. No intraoperative complications were reported, and no incidence of graft resorption was noted. No additional procedures were required in 27 reconstructed hemimandibles (81.8 percent), whereas six (18.2 percent) required secondary distraction osteogenesis. Only one patient developed postoperative ankylosis. No malunion or nonunion was noted. The approach described in this article allowed the authors to obtain reliably good results with costochondral rib grafting for type 2B and type 3 mandibular hypoplasia associated with craniofacial microsomia. Therapeutic, IV.
Le Fort II and III distraction osteogenesis (DO) is a powerful tool in the craniofacial armamenta... more Le Fort II and III distraction osteogenesis (DO) is a powerful tool in the craniofacial armamentarium that is most often employed to treat patients with craniofacial syndromes such as Crouzon, Apert, or Pfeiffer syndrome who present with midfacial retrusion, shallow orbits, exorbitism, malocclusion, obstructive sleep apnea and facial imbalance. In this article, the authors will provide the reader with an update on techniques for the treatment of various forms of midfacial retrusion.
Distraction osteogenesis is an effective technique for elongating the deficient mandible. The aut... more Distraction osteogenesis is an effective technique for elongating the deficient mandible. The authors specifically evaluated its effectiveness in the treatment of airway obstruction in pediatric patients with mandibular hypoplasia. A comprehensive literature review of the National Library of Medicine (PubMed) database was performed. English-language studies involving isolated distraction of the pediatric mandible (younger than 18 years) with descriptive reporting of airway changes were included. Extracted data included demographics, initial diagnosis, distractor type, distraction protocol, predistraction and postdistraction airway status, and complications. Seventy-four articles met the inclusion criteria, resulting in 711 patients with craniofacial abnormalities who underwent mandibular distraction osteogenesis. Mean age at the time of distraction was 18.1 months. The most common diagnoses were isolated Pierre Robin sequence (52.9 percent), syndromic Pierre Robin sequence (7 percent), and Treacher Collins syndrome (6.8 percent). Mandibular distraction osteogenesis successfully treated airway obstruction in 89.3 percent of cases. Success was defined as either decannulation of tracheostomy, avoidance of tracheostomy or continuous positive airway pressure, or alleviation or significant improvement of obstructive sleep apnea symptoms. One hundred seventy-one (84.2 percent) of the 203 tracheostomy-dependent patients were successfully decannulated. Among the 181 patients with obstructive sleep apnea, mandibular distraction osteogenesis successfully allowed for either complete resolution or significant improvement of symptoms in 95.6 percent. A 23.8 percent overall complication rate was noted. The mean follow-up time was 28.7 months. In addition to its positive effect on facial appearance, mandibular distraction osteogenesis is an effective procedure for the treatment of airway obstruction associated with congenital craniofacial defects involving mandibular hypoplasia in appropriately selected patients.
Journal of Plastic, Reconstructive & Aesthetic Surgery, 2011
Pyogenic granuloma (PG) is a common benign vascular proliferation that commonly occurs on the ski... more Pyogenic granuloma (PG) is a common benign vascular proliferation that commonly occurs on the skin. Various treatment options exist in the literature with no clear consensus. Our objective was to review the literature associated with PGs and their management, and based on recurrence rates, suggest management options. A retrospective literature review examining the treatment of cutaneous PG and their associated recurrence rates was conducted. A total of 34 manuscripts were included in our review; with 1162 PGs managed using 19 different treatment modalities with 53 recurrences observed. Among the surgical management options, surgical excision offers the lowest overall recurrence rates (2.94%). Of the medical treatments, cryotherapy offered the lowest overall recurrence rate (1.62%). We concluded that surgical excision and primary closure should be the treatment of choice for small cutaneous PGs in non-cosmetically sensitive areas; however if non-surgical management is undertaken, cauterization with silver nitrate should be the first line treatment. When comparing recurrence rates of surgical excision vs. cauterization, we found no statistical difference between the two (p-value 0.426).
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Papers by Youssef Tahiri