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For patients with an ostomy, a poor fitting appliance may cause leakage, peristomal dermatitis, and frequent appliance changes. PURPOSE: The purpose of this case study was to report the outcome of fat grafting to augment peristomal soft tissue and improve appliance fit. CASE STUDY: A 57-year-old woman with a history of Crohn's disease presented with soft-tissue deficiency and uneven contour around her ileostomy site. She was unable to properly fit an ostomy appliance, which resulted in leakage, chronic skin irritation, and frequent appliance changes. The patient underwent 2 rounds of fat grafting using fat harvested from her medial thighs and knees infused with dilute lidocaine with epinephrine. The patient noted immediate improvement after 34 cc of processed fat was injected in the first round. Appliance change frequency decreased from daily to every 3 to 4 days. A second graft of 32 cc provided 3 months later further improved appliance fit, reducing appliance change frequency to every 5 to 7 days and obviating the need to use adjustment rings and glue. Pre- and postoperative computed tomography showed increased thickness of abdominal wall subcutaneous tissues. CONCLUSION: Fat grafting around an ostomy site presents a viable option to improve contour and appliance fit with reduced skin irritation and leakage.

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BACKGROUND: Candidates for otoplasty have variable anatomy that may result in an aesthetically suboptimal appearance. The authors describe an algorithm to obtain ideal aesthetic position of the ear using a standardized suturing only technique. METHODS: A retrospective review was conducted at a major children's hospital. Pre- and postoperative distances from the mastoid to the posterior lateral helical rim were measured at 3 consistent points (upper helix, mid helix, and lobule). Cosmetic outcomes were determined by visual analog cosmetic score (VACS), assigned by 3 independent reviewers. RESULTS: A total of 26 patients underwent otoplasty for prominent ear (average age 8.2 years). Duration of follow-up was an average of 32 weeks postoperatively. Pre- and postoperative VACSs were determined for all patients: overall-appearance, 25.8 versus 71.3; overall-ear appearance, 25.7 versus 70.0; shape, 24.4 versus 72.6; and projection, 23.7 versus 73.9 (P < 0.05 for all). There was no inter-rater difference between scores. There was greater symmetry between ears postoperatively (P < 0.05). Measurements were significantly improved pre- versus postoperatively: upper-helix 2.04 versus 1.20 cm, mid-helix 2.22 versus 1.18 cm, and lobule 1.85 versus 1.49 cm (P < 0.05.) Postoperative measurements are in accordance with established norms for ideal ear position (1.0-1.2 cm upper third of the ear). Two patients recurred, and 1 experienced a spitting suture (11.5%). CONCLUSION: Aesthetic ideal was established on the operating table based on the appearance of the ear. Postoperative measurements fell within aesthetic ideal for a normal ear, suggesting that the use of intraoperative measurements are not needed to obtain an aesthetically acceptable outcome.

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BACKGROUND: Many infants with congenital muscular torticollis (CMT) have deformational plagiocephaly (DP), and a small cohort also demonstrate mandibular asymmetry (MA). The aim of this retrospective study was to evaluate mandibular changes in these infants with previous computed tomography (CT) scans who underwent physical therapy (PT) to treat CMT. METHODS: A retrospective study included patients presenting to a pediatric plastic surgery clinic from December 2010 to June 2012 with CMT, DP, and MA. A small subset of these patients initially received a 3D CT scan due to concern for craniosynostosis. An even smaller subset of these patients subsequently received a second 3D CT scan to evaluate for late-onset craniosynostosis. Patients were treated with PT for at least 4 months for CMT. Initial CT scans were retrospectively compared to subsequent CT scans to determine ramal height asymmetry changes. Clinical documentation was reviewed for evidence of MA changes, CMT improvement, and duration of PT. RESULTS: Ten patients met inclusion criteria. Ramal height ratio (affected/unaffected) on initial CT was 0.87, which significantly improved on subsequent CT to 0.93 ( P < .05). None of the patients were diagnosed with craniosynostosis on initial CT. One patient was diagnosed with late-onset coronal craniosynostosis on subsequent CT. CONCLUSIONS: We identified a small cohort of infants with MA, CMT, and DP. These patients uniformly demonstrated decreased ramal height ipsilateral to the affected sternocleidomastoid muscle. Ramal asymmetry measured by ramal height ratios improved in all infants undergoing PT.

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BACKGROUND: The pediatric craniofacial skeleton fractures in patterns distinct from those typical in adults; this has implications pertinent to management that may go unrecognized. The authors reviewed multilevel pediatric craniofacial fractures presenting to their institution, surmising that they would display an oblique trajectory of fracture patterns, and would be at increased risk of growing skull fractures (GSFs), compared with adults. METHODS: A retrospective review was performed of pediatric patients presenting with multilevel craniofacial fractures between 2004 and 2010. Demographics, cause of injury, fracture patterns, associated injuries, management, and follow-up information were gathered. Computed tomography scans were reviewed to characterize fracture length, displacement, and trajectory. Adverse outcomes were documented, with particular attention to GSFs. RESULTS: One hundred fifty-one patients met our inclusion criteria, which included a follow-up of >3 years. Average age at injury was 9.5 ±â€Š4.7 years. Patterns of fracture displayed near consistent obliquity, with only 4 patients (2.6%) displaying a LeFort-type facial fracture. LeFort patterns were associated with older patients over the age of 12, but without statistical significance (P = 0.07). Five patients (3.3%) died as a result of their injuries. 3.3% of patients developed a GSF. All craniofacial fracture patients demonstrated radiographic and/or clinical evidence of healed fractures at their last follow-up. CONCLUSIONS: This series of pediatric craniofacial fractures near consistently demonstrated oblique fracture patterns, in contrast to the typical adult fracture patterns described by LeFort. Pediatric craniofacial fractures are also at increased risk of GSFs. Understanding of these principles is fundamental to successful therapy in this population.

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BACKGROUND: Management of the previously infected craniofacial defect remains a significant clinical challenge, posing obstacles such as wound healing complications, lack of donor site availability, and predisposition to failure of the repair. Optimal therapy would reconstruct like with like, without donor site morbidity. The purpose of this study was to compare the efficacy of recombinant human bone morphogenetic protein-2 (rhBMP-2)-mediated bone regeneration with the current standard of autologous bone graft for repair of previously infected calvarial defects. METHODS: Nineteen adult New Zealand white rabbits underwent subtotal calvariectomy. Bone flaps were inoculated with Staphylococcus aureus and replanted. After 1 week of infection, bone flaps were removed, and wounds were debrided, followed by 10 days of antibiotic treatment. After 6 weeks, animals underwent scar debridement followed by definitive reconstruction in 1 of 4 groups: empty control (n = 3), vehicle control (buffer solution on absorbable collagen sponge [ACS], n = 3), autologous bone graft (n = 3), or rhBMP-2 repair (rhBMP-2/ACS, n = 10). Animals underwent computed tomography imaging at 0, 2, 4, and 6 weeks postoperatively, followed by euthanization and histological analysis. Percent healing was determined by 3-dimensional analysis. A (time × group) 2-way analysis of variance was performed on healing versus treatment group and postoperative time. RESULTS: At 6 weeks postoperatively, rhBMP-2/ACS and autologous bone graft resulted in 93% and 68% healing, respectively, whereas the empty and vehicle control treatment resulted in 27% and 26% healing (P < 0.001). Histologically, compared to autologous bone graft, bone in the rhBMP-2/ACS group was more cellular and more consistently continuous with wound margins. CONCLUSIONS: The rhBMP-2 therapy is effective in achieving radiographic coverage of previously infected calvarial defects.

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BACKGROUND: Velopharyngeal insufficiency affects as many as one in three patients after cleft palate repair. Correction using a posterior pharyngeal flap (PPF) has been shown to improve clinical speech symptomatology; however, PPFs can be complicated by hyponasality and obstructive sleep apnea. The goal of this study was to assess if speech outcomes revert after clinically indicated PPF takedown. METHODS: The cleft-craniofacial database of the Children's Hospital of Pittsburgh at the University of Pittsburgh Medical Center was retrospectively queried to identify patients with a diagnosis of velopharyngeal insufficiency treated with PPF who ultimately required takedown. Using the Pittsburgh Weighted Speech Score (PWSS), preoperative scores were compared to those after PPF takedown. Outcomes after 2 different methods of PPF takedown (PPF takedown alone or PPF takedown with conversion to Furlow palatoplasty) were stratified and cross-compared. RESULTS: A total of 64 patients underwent takedown of their PPF. Of these, 18 patients underwent PPF takedown alone, and 46 patients underwent PPF takedown with conversion to Furlow Palatoplasty. Patients averaged 12.43 (range, 3.0-22.0)(SD: 3.93) years of age at the time of PPF takedown, and 58% were men. Demographics between groups were not statistically different. The mean duration of follow-up after surgery was 38.09 (range, 1-104) (SD, 27.81) months. For patients undergoing PPF takedown alone, the mean preoperative and postoperative PWSS was 3.83 (range, 0.0-23.0) (SD, 6.13) and 4.11 (range, 0.0-23.0) (SD, 5.31), respectively (P = 0.89). The mean change in PWSS was 0.28 (range, -9.0 to 7.0) (SD, 4.3). For patients undergoing takedown of PPF with conversion to Furlow palatoplasty, the mean preoperative and postoperative PWSS was 6.37 (range, 0-26) (SD, 6.70) and 3.11 (range, 0.0-27.0) (SD, 4.14), respectively (P < 0.01). The mean change in PWSS was -3.26 (range, -23.0 to 4.0) (SD, 4.3). For all patients, the mean preoperative PWSS was 5.66 (range, 0.0-26) (SD, 6.60) and 3.39 (range, 0.0-27) (SD, 4.48), respectively (P < 0.05). The mean change in PWSS was -2.26 (range, -23.0 to 7) (SD, 5.7). There was no statistically significant regression in PWSS for either surgical intervention. Two patients in the PPF takedown alone cohort demonstrated deterioration in PWSS that warranted delayed conversion to Furlow palatoplasty. Approximately 90% of patients, who undergo clinically indicated PPF takedown alone, without conversion to Furlow Palatoplasty, will show no clinically significant reduction in speech. CONCLUSIONS: Although there is concern that PPF takedown may degrade speech, this study finds that surgical takedown of PPF, when clinically indicated, does not result in a clinically significant regression of speech.

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BACKGROUND: The safety, efficacy, and direct comparison of various surgical treatments for velopharyngeal insufficiency (VPI) associated with occult submucous cleft palate (OSMCP) are poorly characterized. The aim of this study was to report and analyze the safety and efficacy of Furlow palatoplasty (FP) versus radical intravelar veloplasty (IVV) for treatment of VPI associated with OSMCP. METHODS: A retrospective review of one institution's experience treating VPI associated with OSMCP using IVV (group 1) or FP (group 2) during 24 months was performed. Statistical significance was determined by Wilcoxon matched-pair, Independent-Samples Mann-Whitney U, and analysis of variance (SPSS 20.0.0). RESULTS: In group 1 (IVV), 18 patients were identified from August 2010 to 2011 (12 male and 6 female patients; average age, 5.39 years). Seven patients were syndromic and 11 were nonsyndromic. In group 2 (FP), 17 patients were identified from August 2009 to 2011 (8 male and 9 female patients; average age, 8.37 years). Three patients were syndromic and 14 patients were nonsyndromic. There was statistical significance between the average pretreatment Pittsburgh Weighted Speech Score (PWSS) of the 2 groups (group 1 and 2 averages 19.06 and 11.05, respectively, P=0.002), but there was no statistical significance postoperatively (group 1 and 2 averages 4.50 and 4.69, respectively, P=0.405). One patient from each group required secondary speech surgery. Average operative time was greater for FP (140 minutes; range, 93-177 minutes) compared to IVV (95 minutes; range, 58-135 minutes), P<0.001. Average hospital stay was 3.9 days for IVV (range, 2-9 days) and 3.2 days for FP (range, 2-6 days), with no significant difference (P=0.116). There were no postsurgical wound infections, oral-nasal fistulas, postoperative bleeding complications, or mortalities. CONCLUSIONS: Nonsyndromic patients with hypernasal speech are treated effectively and safely with either IVV or FP. Intravelar veloplasty trended toward lower speech scores than FP (76% IVV, 58% FP PWSS absolute reduction). Syndromic patients with OSMCP may be more effectively treated with FP (72% IVV vs 79% FP PWSS absolute reduction). Intravelar veloplasty is associated with shorter operative times. Both techniques are associated with low morbidity, improved speech scores, and low reoperative rates.

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BACKGROUND: Dermal regenerate templates are currently widely used in both adult and pediatric burn reconstruction. Despite this, the safety and efficacy of regenerate templates combined with full-thickness skin grafts for the reconstruction of pediatric facial defects traditionally treated with local flaps is not widely published. The aim of this study is to report the safety and efficacy of pediatric nasal defect reconstruction using regenerative templates/full-thickness skin grafts. METHODS: A retrospective review of one institution's experience with pediatric nasal defects treated with regenerative templates was performed. All patients (n = 4) were treated with a multistage protocol. Two reviewers independently assigned Visual Analogue Cosmetic Scale (VACS) scores: 1 surgeon and 1 nonsurgical researcher not involved in patient care. Standardized photographs (anteroposterior, oblique, lateral, and worm's eye view) were assigned VACS scores according to a 100-point scale: "abhorrent," 0-24; "poor," 25-49; "moderate," 50-74; and "excellent," 75-100. Statistical analysis was performed using Mann-Whitney U and Wilcoxon paired signed-rank tests. RESULTS: Four patients (2 boys and 2 girls, average age 6.8 yr) who met the inclusion criteria were identified. A total of 5 nasal lesions (2 spitz nevi, 1 vascular lesion, and 2 congenital nevi) were removed. The preoperative VACS score was 45.2 (range, 5-70), compared with 84.5 (range, 45-100) postoperatively (P <0.000). There was no significant difference between raters (preoperative, P = 0.346; postoperative, P = 0.678). CONCLUSIONS: The reconstruction of complex pediatric nasal lesions using dermal regenerative templates and full-thickness postauricular skin grafts is safe and effective, and associated with low morbidity and significant improvement in VACS scores.