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OBJECTIVE In the last several decades, there has been much debate regarding the ideal treatment for sagittal synostosis. The purpose of this study was to compare perioperative, anthropometric, and subjective assessments of cosmetic outcomes between open and endoscopic management of isolated sagittal synostosis. METHODS At their routine postoperative follow-up, pediatric patients with sagittal craniosynostosis were recruited to undergo digital cranial measurement and standardized photography for objective and subjective assessments of perioperative outcomes. Age-normalized z-scores for cephalic index, head circumference, euryon-euryon diameter (Eu-Eu), and glabella-opisthocranion diameter (G-Op) were calculated for each patient. Faculty surgeons, surgical trainees, nurses, and laypersons were asked to rate the normalcy of craniofacial appearances using a 5-point Likert scale. Outcomes were compared between patients treated with endoscopic correction and those treated with open repair. RESULTS A total of 50 patients were included in the study. Thirty-one had undergone open surgical correction, and 19 had undergone endoscopic treatment. Endoscopic repair involved significantly lower operative time, blood loss, transfusion rate, and hospital length of stay than those with open repair (p < 0.001). There was no significant difference between groups in terms of z-scores for head circumference (p = 0.22), cephalic index (p = 0.25), or Eu-Eu (p = 0.38). Endoscopic treatment was associated with a significantly lower G-Op (p = 0.009). Additionally, the average subjective rating of head shape was higher for endoscopic treatment when corrected for age, gender, and ethnicity (p = 0.02). CONCLUSIONS The study findings suggest that patients who are treated endoscopically may have an overall more normal appearance in skull morphology and cosmesis, although these results are limited by poor reliability.

PurposeThe authors seek to stimulate and strengthen learning for both institutional and corporate leadership to transform society toward sustainability and resilience. The authors use sustainability in the broader socioecological sense, rather than meaning merely financial survival. Based upon experiences by various parties in dealing with coronavirus disease 2019 (COVID-19) or (C-19) during 2020 and into 2021, we are all driven to ask, “Which lessons shall we learn?”Design/methodology/approachBased upon a brief review of environmental and management literature, the authors compare experiences with C-19 and those of socio-ecological sustainability to-date and distill both sources for optimism as well as pessimism in the face of technical and socio-political challenges.FindingsHistorical experiences are not particularly encouraging, but there are many opportunities for great improvements if institutional and corporate leaders choose to learn from both C-19 experiences and earlier efforts toward sustainability.Practical implicationsProcrastination by major industrialized economies in not taking major positive actions to control and reduce carbon pollution and other environmental damage is leading to human crises–hunger and thirst followed by migration, conflicts and healthcare system collapses. Organizational executives need to develop flexibility and embrace precautionary principles regarding many stakeholders if humanity is going to have a good chance of flourishing in the future.Originality/valueThe authors adapt the “wedding cake” model of Sustainability Development Goals (SDGs) and their relationships to the concept of “dynamic materiality” in both an organizational as well as a macro perspective. In addition, the authors introduce the wordsustilienceto describe an organization's combined ability to achieve “sustainability” through relatively stable conditions as well as the “resilience” to rebound after major external shocks.

Introduction: Epidural/subgaleal abscesses in craniosynostosis surgery are rare but serious complications that may compromise neurological functioning in pediatric craniofacial populations. We evaluated the risk and evolution of management of post-operative subgaleal/epidural abscesses in craniosynostosis patients treated over 20 years by a single surgeon. Methods: Pediatric patients who underwent transcranial procedures for craniosynostosis by a single surgeon from 1997 to 2018 were included. The patients were stratified into groups based on the development of post-op abscess. The primary outcome measure was bone salvage success. Post-op abscesses were drained in the following manner: either open packing with delayed closure or no elevation of the scalp flap, followed by copious irrigation and deep (epidural) drain placement plus long-term intravenous antibiotics. Results: A total of 384 patients underwent 413 cases in this period: 177 sagittal, 85 unicoronal, 49 metopic, 4 lambdoid, and 69 cases of multiple suture synostosis. In this cohort, epidural/subgaleal abscess were found in 6 patients (1.5%) who all had bilateral fronto-orbital advancement ( P = .03). Bone salvage was attempted in all 6 patients with only minor bone resorption seen in 3 of the patients who presented with abscess. Conclusion: This study found that patients undergoing bilateral fronto-orbital advancement were at increased risk of a deep space infections, while those undergoing clavarial vault remodeling with barrel staves alone, were not. We were able to salvage the bone grafts and prevent neurological sequela with surgical washout, placement of drains and intravenous antibiotic therapy.

Introduction In the last decade, we have seen a steady increase in the incidence of frontal sinus trauma due to gunshot wounds and a decrease in motor vehicle trauma. Penetrating gunshot wounds to the frontal sinus present a unique challenge to the reconstructive surgeon because they require careful consideration of the management principles of plastic surgery. Despite previous reviews on frontal sinus trauma, there are no studies examining the management techniques of frontal sinus fractures due specifically to gunshot wounds. In this study, we aim to retrospectively evaluate the use of a variety of tissue flaps in intervention and associated outcomes. Methods A retrospective chart review was completed on all patients with gunshot wound(s) to the frontal sinus from January 2010 to January 2018 at a single institution. The patients were classified based on the fracture pattern (anterior vs posterior table vs both), degree of displacement, presence of nasofrontal outflow tract injury, and evidence of cerebrospinal fluid leak. Patients were then stratified according to the type of reconstruction performed (cranialization, obliteration and need for free flap) and evaluated for major and minor complications after reconstruction. Results In this study, we present outcome data from 28 cases of frontal sinus trauma due to gunshot wounds. There was a statistically significant difference (P = 0.049) in the type reconstructive strategy employed with each type of flap, with pericranial flaps primarily used in cranialization, temporal grafts were more likely to be used in obliteration, and free flaps were more likely to be used in cranialization. The overall major complication rate was 52% (P = 0.248), with the most common acute major complication was cerebrospinal fluid leak (39%) and major chronic was abscess (23.5%). Conclusions This report explores the management of frontal sinus trauma and presents short-term outcomes of treatment for penetrating gunshot wounds at a tertiary referral center.

Comorbidity trends after median sternectomy were studied at our institution by Vasconze et al (Comorbidity trends in patients requiring sternectomy and reconstruction. Ann Plast Surg. 2005;54:5). Although techniques for sternal reconstruction have remained unchanged, the patient population has become more complex in recent years. This study offers insight into changing trends in this patient population.A retrospective review was performed of patients who underwent median sternectomy followed by flap reconstruction at out institution between 2005 and 2020. Comorbidities, reconstruction method, average laboratory values, and complications were analyzed.A total of 105 patients were identified. Comorbidities noted were diabetes (27%), immunosuppression (16%), hypertension (58%), renal insufficiency (23%), chronic obstructive pulmonary disease (16%), and tobacco utilization (24%). The most common reconstruction methods were omentum (45%) or pectoralis major flaps (34%). Thirty-day mortality rates were 10%, and presence of at least 1 complication was 34% (hematoma, seroma, osteomyelitis, dehiscence, wound infection, flap failure, and graft exposure). Univariate analysis demonstrated that sex (P = 0.048), renal insufficiency, surgical site complication, wound dehiscence, and flap failure (P0.05) had statistically significant associations with mortality. In addition, body mass index, creatinine, and albumin had a significant univariate association with mortality (P0.05).Similar to the original study, there is an association between renal insufficiency and mortality. However, the mortality rate is decreased to 10%, likely because of improved medical management of patients with increasing comorbidities (80% with greater than one comorbidity). This has led to the increased use of omentum as a first-line option. Subsequent wound dehiscence and flap failure demonstrate an association with mortality, suggesting that increasingly complex patients are requiring a method of reconstruction once used a last resort as a first-line option.

Introduction Although the literature contains reports of the risks and complications of calvarial vault reconstruction for acquired defects, there are few publications addressing the specific patient population who require such reconstructions in cases preceded by prior infection, radiation, massive associated soft tissue trauma, and so on. We define such clinical presentations as a hostile environment for large surface area reconstruction. Our objective is to compare the safety and efficacy of autologous bone and alloplastic reconstruction in hostile cranial defects. Methods An institutional review board-approved retrospective review of patients who underwent cranioplasty of a hostile site at the University of Alabama at Birmingham between January 2008 and December 2018 was performed. The patients were stratified into 3 groups based on the type of implant used: autogenous (bone), alloplastic (polyetheretherketone [PEEK], titanium, polymethyl methacrylate), or mixed (combination of bone and prosthetic). The primary outcome metric was a complication in the year after cranioplasty, identified by implant failure, necrosis, or infection. Statistical analysis included t tests and χ2 tests where appropriate using SPSS. Results There were 55 total cases in this period: 27 autogenous, 23 alloplastic, and 5 mixed. The purely autogenous group had the highest complication rate (44%), and the alloplastic group had the lowest complication rate (38%), which was not statistically different between the 3 groups (P = 0.121). When stratified by specific material used for reconstruction (27 bone, 14 PEEK, 10 titanium, and 5 polymethyl methacrylate), overall complication rate was statistically significant (P = 0.009, χ2 test), with PEEK implants having the lowest complication rate (21%). Conclusions This analysis interestingly found that in the setting of hostile cranial defects, cranioplasties would benefit from the use of prosthetic implants instead of autologous bone grafts, not only for avoidance of donor site morbidity but also for a decrease in overall complications.

BACKGROUND Despite advances in surgical treatments and assessments of objective outcomes in surgery for sagittal synostosis, there is no agreement regarding the optimal assessment of postoperative outcomes. Additionally, few studies have evaluated subjective assessments of cranial morphology after surgical correction. This study sought to evaluate the utility of subjective aesthetic outcome assessment and compare these assessments to established craniometric outcomes in patients undergoing surgery for isolated sagittal synostosis. METHODS Nineteen raters (5 parents, 4 surgeons, 5 trainees and 5 nurses) evaluated fifty patients who underwent surgical correction of isolated sagittal synostosis using standardized postoperative patient photos and a five-point Likert scale. Previously established anthropomorphic measurements were recorded postoperatively in these same patients and comparisons were made between the objective anthropomorphic and subjective outcome evaluations. RESULTS There were no statistically significant correlations between age-controlled cephalic index, head circumference, or euryon-euryon diameter and subjective aesthetic scores. Lay persons assigned a significantly lower proportion of scores (37.9%) as middle values (2, 3, or 4) compared with faculty (64.8%). There was a statistically significant association between high scores given by surgical faculty and laypersons (P

Summary Objectives Palatal re-repair aims to improve velar function by retro-positioning the levator veli palatini muscles. The surgery includes extensive dissection, leading to tissue edema and scar formation which may need time to remodel. Together with the change of muscle orientation and tension, it is expected that a period of time is needed to reach the final functional performance. This study attempts to determine how much time is required to reach the optimum performance of the palate after re-repair. Methods A retrospective chart review identified consecutive cleft patients with VPI who underwent palate re-repair procedure by a single surgeon from 2000 to 2015 and achieved normal or borderline normal VP function. Only patients who had regular postoperative follow-up visits for speech assessments until resolution of speech abnormalities were included. The percent of patients cured at each time point following surgery was recorded. Results Forty-five patients met the inclusion criteria. The mean age at surgery was 6.6 ± 3.2 years. Speech abnormalities had resolved in 44.5% of patients within the first 6 months after surgery, 62.2% after up to 1 year, 75.6% after up to 2 years and 88.9% after up to 3 years post re-repair palatoplasty. The remaining 11.1% continued to improve after 3 years up to 6 years. Conclusions Re-repair procedures may take a longer time than previously thought for the final outcome to manifest. Close monitoring of improvement with continued speech therapy is recommended before deciding to move to the next surgical step in management.

BACKGROUND Palatal re-repair aims to improve velar function by retropositioning the levator muscles. Although it has become a popular procedure, very few studies document its efficacy. To date, this is the largest series reported to clarify its indications and efficacy. METHODS One hundred eighty-three consecutive cleft patients presenting with velopharyngeal incompetence and evidence of abnormally oriented levator muscles underwent palate re-repair (regardless of the gap size) performed by a single surgeon from 2000 to 2015. Perceptual speech assessment was performed using the Pittsburgh Weighted Speech Score. Other patients' demographic data were collected. RESULTS Complete records of 111 patients were available. Eighteen cases were syndromic (18.9 percent). Postoperatively, there was highly significant improvement (p < 0.001) in nasal emission (from 2.24 to 0.64), nasality (from 3.44 to 1.27), articulation (from 5.32 to 2.01), and total score (from 11.29 to 4.11). Speech became normal/borderline normal, improved or did not improve in 66.7, 24.3, and 9 percent of patients, respectively. An initial diagnosis of isolated cleft palate, Caucasians, intravelar veloplasty in the primary repair, older patients, and nonsyndromic cases were associated with better outcome. There were no reported cases of postoperative fistula or new obstructive sleep apnea. CONCLUSIONS This large series study provides confirmatory evidence of the effectiveness and safety of the re-repair procedure. It is recommended as a first-line procedure in all velopharyngeal incompetence cases with abnormally oriented levator muscles regardless of gap size, even if the primary operation included prior muscle dissection. The pharyngoplasty rate could be significantly reduced with the current protocol. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.

Objective: This study aims to examine the importance of the uvula as a part of palatoplasty outcome and to assess the aesthetic results of the conventional versus a new technique for uvuloplasty. Design/Participants: The study included 2 groups of patients undergoing palatoplasty. Group I consisted of 20 cleft palate patients repaired with the conventional uvula repair, combining the 2 hemi-uvulae. Group II consisted of 20 patients repaired with our new technique, sacrificing one hemi-uvula and centralizing the remaining one. The aesthetic outcome was assessed in both groups. A questionnaire was distributed to the families of both groups to assess their concern about the uvula after palate repair. Setting: Cleft unit at a tertiary care center. Results: Sixty-five percent of parents considered the uvula as important functionally and aesthetically after palate repair whereas 35% either did not care or were not sure about its importance. Results of the aesthetic outcome of the 2 techniques for uvula reconstruction showed that uvula was absent in 4 cases in group I versus 1 in group II ( P > .05), small in 8 cases of group I versus 4 in group II ( P > .05), bifid in 5 cases of group I versus none in group II ( P < .05), became deviated in no case of group I versus 4 in group II ( P > .05), and was satisfactory in 3 cases of group I versus 11 in group II ( P < .05). Conclusions: Among the respondents, the uvula was a significant concern to the parents of cleft patients and should be given more attention during repair. The described technique had better aesthetic outcome over the conventional one of combining the 2 hemi-uvulae.

Backgrounds The success rate of the surgical repair of palatal fistula after palatoplasty is often unsatisfactory. This study is a review of 15 years of single surgeon's experience with the evolution of a reliable surgical technique with high success rate. Methods This is a retrospective chart review of consecutive cleft cases undergoing repair of palatal fistula from 2000 to 2015. The study included 37 consecutive fistula repair cases with wide elevation and mobilization of the palatal tissues and nasal and oral layer repair. Group 1 (n = 20) were treated earlier in the study using either midline, von Langenbeck, or 2-flap palatoplasty with 3-layer suturing. Group 2 (n = 17) were treated through a Dorrance-type incision and additional repair of the oral periosteum for a total of 4-layer suturing. Results The overall fistula closure rate was 94.6% (90% in group 1 and 100% in group 2). The difference in outcome between the 2 groups was statistically insignificant (P > 0.05). Most patients (83.8%) had concomitant velar muscle retropositioning for treatment of velopharyngeal incompetence. Conclusions Fistula repair using wide mobilization of the entire palate through previous repair incisions and multilamellar suturing technique has a very low fistula recurrence rate. Addition of the fourth layer of suturing and the use of a Dorrance-type incision further improves the outcome. This approach provides wide tissue release and access to tissue layers for better repair and tension-free closure. Combining intravelar veloplasty with fistula repair is safe and allows management of the fistula and its possible consequences on palatal function in a single procedure.

This is a response to a letter replying to our paper discussing the significance of the uvula during palatoplasty and our surgical technique of uvula repair. The hemi-uvula repair technique was developed independently in our department. In our publication, we fully cited the 2 studies by Rossell-Perry et al about uvula repair and acknowledged them to be the first to publish the concept of using one hemi-uvula. Upon further study, the mistake of omitting 2 references from the list, although they were cited in the text, was found to have occurred during the transition between publishers of this journal (corrected in Erratum). We highlighted some of the differences in the studies and techniques, which are already discussed in our paper, for further clarification.

Significantly worse speech outcomes and higher complication rates are reported among internationally adopted cleft patients. We evaluated our cohort to provide more accurate counseling to adoptive parents.We reviewed internationally adopted children with unrepaired cleft palate who had 2-flap palatoplasty with radical intravelarveloplasty from 2003 to 2015 in a single-surgeon, consecutive series.Seventy-two children adopted with unrepaired cleft palate were identified, 2 with syndromic association. The average age at palatoplasty was 28.1 months. Meaningful speech assessment was available in 58 patients. Successful speech was defined by a competent or borderline-competent velopharyngeal mechanism (Pittsburgh Weighted Speech Score2). Twenty-five patients (43%) had successful speech outcomes. Twenty-nine patients (50%) were recommended secondary operation for nasality. Nonfistula repair secondary operation was performed using the following: fat grafting (9 patients, 43%), intravelarveloplasty (8 patients, 38%), and sphincter pharyngoplasty (4 patients, 19%). The average Pittsburgh Weighted Speech Score improved 5.8 to 1.3 (P = 1.3E-6); 4.8 to 1.0 (P = 0.0009) with fat grafting alone. After all interventions, normal speech was achieved in 43 (74%) of 58 patients. Palatal fistula (9.2% vs 0.9%, P = 0.001) and velopharyngeal insufficiency (50% vs 6.7%, P = 0.0004) rates were both significantly higher in the internationally adopted cohort than our nonadopted population data. The need for secondary surgery was independent of cleft type (P = 0.89), age (P = 0.78), or presence of a "wide" cleft (P = 1).Our results demonstrate higher fistula and secondary surgery rates. Successful speech outcomes were achieved in most patients with minimally invasive secondary procedures.

Delayed intracranial hypertension (DIH) occurs most frequently in children with syndromic or multi-suture synostosis after surgical correction. The rarity of DIH in children with isolated non-syndromic sagittal synostosis (ISS) warrants follow-up evaluation by large craniofacial centers until skeletal maturity. This study reports the incidence of DIH in children following open repair for ISS by our center’s craniofacial team. A single-center retrospective study of patients who underwent open calvarial vault remodeling (CVR) for ISS at our institution between November 2000 and November 2012 was performed. Syndromic and multi-suture synostosis patients were excluded. Demographic and follow-up data were extracted from the medical record for analysis until July 2017. One hundred five patients with ISS were identified who had undergone CVR in the aforementioned timeframe. Average age at initial surgery was 11.7 ± 15.32 months. Mean follow-up in our craniofacial clinic was 4.94 ± 3.53 years, with 69 patients (65.7%) having follow-up in craniofacial clinic ≥ 3 years and 74 (70.5%) having follow-up ≥ 3 years in any clinic at our institution. Four patients (3.8%) had intracranial pressure (ICP) monitors placed for symptoms concerning for DIH, one of which (0.95%) had confirmed DIH and underwent a second surgical procedure at 7.4 years of age. The patient presented late initially, having his first operation at 1.56 years of age. One patient out of 105 (0.95%) developed DIH, confirmed by ICP monitoring, and required reoperation. The occurrence of DIH, albeit rare, remains an important topic to include in parental discussions and mandates long-term follow-up in this population.

IMPACT: Current practice guidelines offer a variety of treatment options for sternal reconstruction but complications and infections remain a serious surgical problem. This work seeks to provide a comprehensive picture of the com-morbidities and reconstructive methods that lead to success and improve patient outcomes. OBJECTIVES/GOALS: Patients that undergo cardiac surgery via the median sternotomy approach are at risk of wound complications that require repair. We seek to evaluate how outcomes of sternal reconstruction are influenced by patient comorbidities, flap usage and internal mammary artery grafts and methods of sternal closure. METHODS/STUDY POPULATION: We identified patients between 2005 and 2020 who underwent sternotomy followed by debridement and flap coverage at our institution. Comorbidities, method of reconstruction, demographic data, surgical history, and other factors pertaining to mortality and morbidity were collected. The data will then be analyzed to identify population characteristics using logistic regression variables to determine univariate and adjusted multivariable measures of association with mortality. We present the pre-liminary data analyzed using chi-square and one-way anova in R. RESULTS/ANTICIPATED RESULTS: In this study we present a preliminary characterization of one institution’s sternal reconstruction patient outcomes with a variety of reconstruction methods including pectoralis advancement flaps, omental flaps and latissumus dorsi flaps. Notable preoperative comorbidities include 50% of patients > age 60, 18% with diabetes mellitus, 18 % with diagnosed hypertension, 18% with COPD, and 9% with a smoking history DISCUSSION/SIGNIFICANCE OF FINDINGS: In an evolving cardiothoracic landscape, clinical characteristics of patients being treated for sternal reconstructive surgery present a moving target. Understanding current risk factors, preoperative management and timing for aggressive surgical treatment offers an opportunity to update treatment protocol and maximize successful outcomes.

In a retrospective review of patients seen at the University of Alabama at Birmingham Cleft and Craniofacial Center, four patients with rare interrupted clefting were identified who had undergone genetic testing. Each of these patients had a typical cleft lip, with intact hard palate and cleft of the soft palate. Given this picture of mixed clefting, IRF6 sequencing was done and was negative for mutations in all four patients. As genetic testing for single-gene mutations and exome sequencing become clinically available, it may be possible to identify novel mutations responsible for this previously unreported type of interrupted clefting.

Background: Unlike developed countries where adult primary cleft lip and palate cases are barely nonexistent, developing countries still have a backlog of adults with unrepaired cleft lip and palate. Method: A retrospective review of adult/adolescent cleft lip repair under local anesthesia was performed between 2012 and 2015. Results: Fifty six (56) adolescent and adults were seen comprising 35 females and 21 males. Forty two patients presented with unrepaired unilateral cleft lip of which only 6 were complete; 4 were unrepaired bilateral cleft lip and 10 were revisions. The lowest age was 13 years (two patients) and the highest age was 66 years (one patient). The mean weight was 54 kg. The mean anaesthetic time including waiting time was 12.94 minutes and mean operation time was 56.52 minutes. Majority of the patients were discharged same day except for five who needed to stay overnight because of distance from their home. There were no reported early postoperative complications and wound healing was uneventful for all the patients. Conclusion: Cleft lip repair in adults under local anesthesia is safe, effective and less expensive. A modification in technique with minimal dissection and efficiency is essential in such cases.

The purpose of this hands-on “ABC” (Academic, Business, Consulting) panel symposium is to share and discuss eight different approaches to organizational strategizing for tackling the most pressing ...

The authors report on an infant with a bifrontal encephalocele that was associated with multisuture craniosynostosis, spasticity, and a progressively severe epilepsy. They describe the initial presentation, genetic screening results, staged multidisciplinary operative plans, clinical course, complications, and long-term surgical and developmental follow-up. To their knowledge, the comprehensive surgical management of this type of complicated congenital cranial anomaly has not been previously described. Surgical management was staged and multidisciplinary and required careful attention to all 3 components of the condition: 1) hydrocephalus, 2) frontal meningoencephalocele, and 3) epilepsy.

Orofacial clefting is a common condition found in 1 per 700 to 1 per 1000 births. Although most cases are isolated, a subset is caused by a specific genetic mutation. Specific gene tests have been used for recognizable syndromes such as velocardiofacial syndrome or van der Woude syndrome, where the cleft is associated with other anomalies. However, many cleft lip and palate patients have other anomalies but do not fit in to a recognizable syndrome. For these patients, chromosome analysis has been a first-line genetic test; however, in the past few years, a new form of genetic testing has become available for these patients: array comparative genome hybridization (aCGH). We present a 7-month-old male infant with cleft palate, developmental delay, and a family history of velopharyngeal insufficiency in whom aCGH array was used to identify a small deletion on the short (p) arm of chromosome 7. This defect, which was also found in the mother, was undetected by chromosome analysis. In summary, this case demonstrates that aCGH is a new diagnostic tool that is useful in the evaluation of select cases of orofacial clefting. Array comparative genome hybridization should be considered when the suspicion for a genetic etiology of the clefting remains strong despite a normal cytogenetic analysis.

Purpose The purpose of the present review was to evaluate the protocol and technique used in a large population of patients with cleft lip and palate when secondary grafting is performed during the early mixed dentition stage, as determined by eruption of the central incisor. In the United States, most investigators have recommended alveolar grafting at the 9- to 11-year age range or before eruption of the permanent canines. Materials and Methods An institutional review board-approved chart review of 99 patients undergoing alveolar cleft bone grafting during a 7-year period at a single institution was performed. Data were collected regarding demographics, operative time, length of hospitalization, follow-up time, complications, and additional procedures performed. The cases were divided by patient age into 2 groups: group 1, aged 6 to 8 years (n = 61); and group 2, aged 9 years and older (n = 38). Statistical analysis was performed for various comparisons in the study. Results The average operative time for groups 1 and 2 was 86 and 103 minutes, respectively. The complication rate, length of stay, and follow-up time between the 2 groups was not statistically significant at the P = .05 significance level. Conclusions We recommend earlier bone grafting at or before the eruption of the central incisor, rather than delaying until the cuspid tooth root is 25% formed. We believe this will provide better bone support for the dentition, a decreased burden of treatment for the patient, and improved quality of life. Performing the procedure at this time can lead to decreased operative times, with comparable postoperative outcomes.

With the advent of resorbable systems, most surgeons have stopped using wires for craniofacial fixation. Although numerous large retrospective reports regarding craniofacial surgery have been published, no documentation exists regarding the disadvantages or complications associated with wires. We review our experience with 47 consecutive patients with bicoronal and unicoronal craniosynostosis where wire osteosynthesis alone was used. Nine patients (19.1%) developed wire-related complications, but only 5 patients (10.6%) required reoperations. No other complications were observed including growth restrictions, implant migration, or interference with radiographic imaging. These results are comparable to those reported in the literature for other fixation systems and demonstrate that wires are a safe means of fixation of the cranial vault in infancy.

Inadequate ethics education has a high price tag in the world of business, burdensome rules and enforcement across global economies and costly consequences for society.

Posterior pharyngeal augmentation is an accepted method of treating velopharyngeal insufficiency (VPI). Techniques using autologous fat harvest, preparation, and grafting are well described. Based on the complications from retropharyngeal injection, we performed augmentation of the nasal surface of the palate to reduce hypernasality with decreased risks.After Institutional Review Board approval, a chart review from 2010 to 2013 identified 46 patients with cleft palate, subjective and nasoendoscopic evidence of VPI treated with autologous fat grafting to the soft palate. Speech evaluation of velopharyngeal function was compared before and after autologous fat grafting.A total of 61 autologous fat grafting procedures were performed in 46 patients. The average age of the study population is 5.59 ± 2.05 years. The majority underwent a single procedure (32/46 or 69.6%), 13 of 46 patients (28.2%) had 2 fat grafting procedures and only 1 patient (2.2%) had 3 fat grafting procedures. The fat was injected primarily in the soft palate. The recorded volume of fat grafted averaged 2.4 ± 1.1 mL. Average operative time was 39 ± 12.55 minutes. There were no local or donor site complications. Four patients were lost to follow-up. Of 34 patients with adequate speech follow-up, including Pittsburgh Weighted Speech Scale (PWSS) assessment, the average preoperative score of 8.17 ± 3.59 was reduced to 5.17 ± 3.14 postoperatively. Although 26 of 34 patients (76.5%) had an improvement in their PWSS score, only 13 of 34 patients (38.23%) saw an improvement in their PWSS category.Autologous fat grafting to the soft palate is a safe operation with minimal risks. Speech outcomes are subjectively enhanced in the majority of patients, with a full PWSS category improvement seen in 40% of the cases. Patient selection criteria to optimize results are provided.

By adopting a cognitive perspective, we examine ways in which knowledge creation processes within organizations effectively enhance organizational knowledge via the cognitive processes of organizational members. We identify two distinct yet complementary learning processes—informational and interactive—and argue that these processes contribute to the creation of organizational knowledge in different ways. We use cognitive mapping to examine changes in knowledge and use a research design involving pre‐test and post‐test of cognitive maps. Results suggest that organizational knowledge generally improves as organizations engage in the knowledge creation processes and that the effectiveness of such processes in creating knowledge depends on the context. The conceptual arguments and methods developed in this paper should encourage researchers to conduct additional empirical research and help managers change the mix of the informational and interactive learning processes for effective learning as their firm's competitive environment becomes more volatile.

The purpose of this review was to evaluate the utility of the 20 MHz microvascular implantable Doppler probe for free-tissue transfer, both intra- and postoperatively. Over a 15-month period, the Doppler probe was used in a total of 260 anastomoses, including 118 arterial and 142 venous microanastamoses. In these 260 anastomoses, there were six false positive results and eight true positives, resulting in one flap loss. The free flap success rate was 99 percent, the re-exploration rate was 8 percent, and the salvage rate was 83 percent. The internal Doppler offers an easy and reliable way to monitor microvascular free-tissue transfer both intra- and postoperatively. This study demonstrates the continued increase in survival, as well as salvage, of free-tissue transfer.

Objective: The primary purpose of this study was to evaluate the long-term result of an onlay bone graft augmentation of the supraorbital ridge at the time of primary correction of coronal suture synostosis. Design: The study is a retrospective review of 62 consecutive patients treated for coronal synostosis from June 1991 through February 1997. The surgical technique utilized involved a standard bilateral fronto-orbital advancement and calvarial reshaping with the addition of an onlay bone graft in the supraorbital region. Setting: All patients were treated at a tertiary care craniofacial center. Results and Conclusion: A total of 62 patients were treated by this technique. Fifty patients underwent primary correction as infants (mean age 9.8 months). An additional 12 patients were older (mean age 8.2 years) and were treated for residual deformity having previously undergone correction by another technique. Results with follow-up as long as 7 years demonstrate stable forehead and orbital symmetry. Complications identified by chart review were minimal and not directly attributable to this modification in surgical technique.

Objective: To document an evidence based evolution of VPI management over an 18 year period with the goal of optimizing speech while minimizing complications and need for re-operation. Design: An institutional review board approved, retrospective 18-year single surgeon, single-center series of 370 patients undergoing surgery for velopharyngeal incompetence (VPI). Methods: A review of our database between the years of 1997 and 2015 identified 370 patients who underwent surgical procedures for VPI. Records were reviewed for types of procedures performed each year. Procedures were evaluated for safety and efficacy as regards to speech outcome. The study population was divided into an earlier period (1997–2009) and a later period (2010–2015). Results: We demonstrated a reduction in the use of airway obstructive procedures such as sphincter pharyngoplasty from 25.2% of VPI surgeries in the early period to 10.4% in the late period. There has been a progressive shift toward more physiologic procedures such as re-repair with intravelar veloplasty (IVVP). The extent of IVVP has become more aggressive over the time period of the study. In our re-repair population, 89.7% of patients had improvement of the speech scores with 64.5% of all the re-repair patients achieving normal speech postoperatively. Autologous fat augmentation of the palate was introduced in the second period and represents about half of the procedures in the later period. Focused autologous fat augmentation of the palate resulted in statistically significant improvement in speech in 75.7% of cases. Conclusion: This study demonstrates an evidence-based evolution in management, shifting away from potentially airway obstructive procedures and toward a more physiologic approach to velopharyngeal competence. We outline the steps taken to reach the author's current approach to VPI management based on periodic outcome audits, specific anatomic findings, and goal-directed surgical interventions. With correct diagnosis and patient selection, VPI can be safely eliminated in over 70% of patients with a single procedure. We believe that this anatomic and physiologic approach improves safety while minimizing risks of airway obstruction.

The recent report of a transforming growth factor-beta 3 (TGF-beta 3) knock-out mouse in which 100 percent of the homozygous pups have cleft palate raised the question as to the potential usefulness of these animals as a model for cleft palate research. The specific aim in this study was to carefully document the anatomy of the cleft palate in the TGF-beta 3 knock-out mice as compared with wild type controls. Special attention was paid to the levator veli palatini muscle, the tensor veli palatini muscle, and their respective innervation. Because the TGF-beta 3 knock-out is lethal in the early perinatal period and because the heterozygotes are phenotypically normal, polymerase chain reaction was required to genotype the animals before mating. Time-mated pregnancies between proven heterozygotes were then delivered by cesarean section at gestational day 18.5 to prevent maternal cannibalism of homozygote pups. All delivered pups were killed and their tails processed by polymerase chain reaction to verify genotype. The heads were then fixed and sectioned in axial, coronal, or sagittal planes. Sections were stained with hematoxylin and eosin or processed for immunohistochemistry with nerve specific protein gene product 9.5 and calcitonin gene-related peptide antibodies. Sections were analyzed in a serial fashion. Nine wild type control animals were analyzed along with nine TGF-beta 3 knock-out homozygotes. Time matings between proven heterozygotes yielded wild type pups, heterozygote pups, and homozygote knock-out pups in the expected mendelian ratios (28 percent to 46 percent to 26 percent; n = 43). The results demonstrated 100 percent clefting in the homozygous TGF-beta 3 knock-out pups. Complete clefting of the secondary palate was seen in four of nine and incomplete clefting was seen in five of nine. The levator veli palatini and tensor veli palatini muscles were demonstrated coursing parallel to the cleft margin in all cleft mice. The orientation of these muscles differs from the normal transverse sling of the levator veli palatini muscle and the normal palatine aponeurosis of the tensor veli palatini muscle at the soft palate in control animals. Innervation of the levator veli palatini muscle by cranial nerve IX and the tensor veli palatini muscle by cranial nerve V were demonstrated in both cleft and control animals by use of immunohistochemistry with nerve-specific antibodies. Demonstration of a teratogen-free, reproducible animal model of clefting of the palate with a known, single-gene etiology is an important step in the systematic understanding of a congenital defect whose multifactorial etiology has hampered previous research efforts. This study presents a detailed anatomic description of such a model, including a description of the muscular anatomy and the innervation of the muscles of the palate. Because of early perinatal mortality, this model has limited applications for postnatal studies.

The Kapur-Toriello syndrome (KTS) is a rare multiple congenital anomaly syndrome, with presumed autosomal recessive inheritance based on the initial report of affected siblings. Here we report on a female with multiple anomalies, including cleft lip and palate, coloboma, mental retardation with cerebral atrophy, and imperforate anus who, upon re-evaluation at 30 months, was recognized to have a columella that extended below the nares. This distinctive finding prompted the diagnosis of KTS. This is the 5th report of KTS, and the second female. Interestingly, both female cases also manifest an ano/rectal malformation, suggesting that this should be considered a component manifestation of this rare syndrome.

Background: Vitamin A and its metabolites have been shown to be teratogenic in animals and humans producing defects of neural crest derived structures that include abnormalities of the craniofacial skeleton, heart, and thymus. Our prior studies with retinoic acid have established that gestational day (gd) 9 is a sensitive embryonic age in the mouse for inducing craniofacial and thymic defects. Methods: We exposed pregnant mice to variable doses of vitamin A (retinyl acetate) on gd 9 and embryos were evaluated for changes in developing pharyngeal arch and pouch morphology, neural crest cell migration and marker gene expression. Additionally, we investigated whether a single organ system was more sensitive to low doses of vitamin A and could potentially be used as an indicator of vitamin A exposure during early gestation. Results: High (100 mg/kg) and moderate (50 and 25 mg/kg) doses of vitamin A resulted in significant craniofacial, cardiac outflow tract and thymic abnormalities. Low doses of vitamin A (10 mg/kg) produced craniofacial and thymic abnormalities that were mild and of low penetrance. Exposed embryos showed morphologic changes in the 2nd and 3rd pharyngeal arches and pouches, changes in neural crest migration, abnormalities in cranial ganglia, and altered expression of Hoxa3. Conclusions: These animal studies, along with recent epidemiologic reports on human teratogenicity with vitamin A, raise concerns about the potential for induction of defects (perhaps subtle) in offspring of women ingesting even moderate to low amounts of supplemental vitamin A during the early gestational period.

We report the case of a 3-month-old girl with Down's syndrome, who sustained a deep and massive extravasation of dopamine, resulting in segmented, full-thickness skin necrosis and transient brachial plexus palsy of her left upper extremity. The patient was managed conservatively, including wound care, de-bridement of necrotic tissue, secondary wound healing and intensive physical therapy. The patient showed a satisfactory outcome with complete secondary closure of her wounds and full brachial plexus recovery after 1 year of follow-up. The mechanism of action of dopamine in the deep soft tissue, the difficulties of an adequate diagnosis of a deep dopamine extravasation and alternative treatments are presented in this article.

Pressure sore closure is frequently a reconstructive challenge. This challenge is particularly evident in cases of multiply recurrent sores. In such settings, there are often opportunities to manage the recurrent wounds either by repeated advancement of previous flaps or by design of alternative ones. However, these interventions are not always feasible, and limb amputation with total thigh flap closure must be considered. A review of operative experience with seven such complex pressure sores in seven patients is presented. Each patient had previously suffered a permanent thoracic-level spinal cord injury. Prior attempts at wound closure were unsuccessful. Despite consideration of all described locoregional flaps, no limbsparing procedure could be designed satisfactorily. As an alternative to either hip disarticulation and total thigh flap coverage or distant free-tissue transfer, we reconstructed the debrided ulcer beds with inferiorly based rectus abdominis myocutaneous flaps. Six of the seven wounds healed primarily, whereas one required repeated debridement and the addition of a gracilis muscle flap to achieve complete closure. Postoperative follow-up has ranged from 6 to 45 months. Each patient has returned to his baseline preoperative activity level with no clinical compromise of abdominal wall function. All wounds have healed. Successful application of the inferiorly based vertical rectus abdominis myocutaneous flap for cases of both recalcitrant ischial and trochanteric pressure sores is demonstrated and its consideration is advocated if no reconstructive options short of extremity amputation and total thigh flap coverage exist for such challenging sores. (Plast. Reconstr. Surg. 102: 111, 1998.)

This paper examines how organizational knowledge is created and used in organizations. A rich organizational simulation was used to study relationships among organizational learning processes, deci...

Despite the growing body of literature on both organizational learning (OL) and corporate venture development (CVD), very few attempts have been made to establish connections between these two literature streams. While existing literature provides some evidence that OL may facilitate the process of CVD, several interesting research issues remain unexamined. We know very little about (a) what type of learning processes are effective at various stages of CVD; and (b) whether and how knowledge created through various OL processes enhances venture performance. These research issues are examined in this paper by integrating the literature from OL and CVD. We develop a conceptual model that integrates organizational learning with the antecedents and outcomes of CVD. We argue that (a) organizational learning in CVD occurs through two distinct and yet complementary processes; (b) productive organizational learning occurs when organizations vary their emphases on different types of learning depending upon the stages of CVD; and (c ) different types of learning are associated with different types of venture outcomes. Propositions are developed and implications are discussed to facilitate empirical research.

Why do so many firms have difficulty improving their strategic management processes, even though many of their operating departments gain benefits from the “experience curve”? For example, an impressively successful midwestern bank improves the performance of acquired banks in contiguous markets but struggles with acquisitions in more remote parts of the country. A large diversified Asian manufacturer invests substantial sums of money annually documenting and distributing knowledge among top executives who are being transferred between countries, but the company cannot effectively use marketing data bases that are available across various divisions.

The notion that ‘success breeds failure’ is well known to management scholars and practitioners. Gulf Oil Corporation was among the largest corporations in the world. In 1984, its management was forced to seek a white knight to avoid a hostile takeover. The $13·3bn merger with Chevron is among the largest deals in corporate history. This research explores ‘how’ and ‘why’ this event occurred through case research. Strategic decision processes across eight critical events during 30 years were examined. Data was collected through interviews with forty senior corporate executives. The case analysis suggests that inertia and political processes stifled innovation. Also, there is evidence that Gulf's ‘downward spiral’ began 10 years prior to the takeover battle. The data reveal the internal dynamics of decline, the complexities of organizational life, and paradoxical situations which challenge executives. The continuing challenges in the oil industry, as recently exemplified at British Petroleum, underscore the importance of acting promptly to avoid such downward spirals.

The purpose of this study was to compare the two-flap palatoplasty technique for cleft palate repair, with and without radical intravelar veloplasty, with special emphasis on the fistula rate and speech outcome.A retrospective, time-series cohort of 213 consecutive patients with primary two-flap palatoplasty before and after the introduction of a radical intravelar veloplasty was studied. The main outcome measures were immediate postoperative complications, oronasal fistula rate, and speech. A perceptual speech evaluation was performed by two speech pathologists and included hypernasality, nasal emission, articulation, intelligibility, and overall velopharyngeal competence. The need for secondary palate surgery for velopharyngeal insufficiency was also analyzed.There were no differences in postoperative complications between the two study groups. Postoperative morbidity occurred in six patients (2.8 percent) and consisted of two patients with respiratory compromise, two patients who required reoperation for bleeding, and two patients with oronasal fistula. Perceptual speech evaluation demonstrated significantly better speech outcomes (81.9 percent versus 49.5 percent, p0.001) and a significantly lower rate of secondary palate surgery for velopharyngeal insufficiency (29 percent versus 6.7 percent, p = 0.008) in the radical intravelar veloplasty group. The most important predictive factor of speech outcome was the addition of a radical intravelar veloplasty (odds ratio, 0.175; 95 percent confidence interval, 0.039 to 0.785).Despite study design limitations, such as experience bias and follow-up differences, this study demonstrates that radical intravelar veloplasty may enhance the functional results of the two-flap palatoplasty without increasing postoperative morbidity. A novel classification of the muscle repair is proposed based on the amount of muscle dissection and retropositioning.

Facial asymmetry is a common finding in infants and can be the result of a number of distinctive conditions such as hemifacial microsomia, overgrowth syndromes, a soft tissue tumor, and a vascular malformation. However, overgrowth syndromes such as Beckwith-Wiedemann syndrome (BWS) typically manifest more extensive involvement; it rarely presents as isolated facial overgrowth.Here, we present a 7-year-old boy who presented with facial asymmetry. He was found to have isolated facial hemihyperplasia, involving his right cheek and teeth. No abnormalities were seen in the rest of his examination. The diagnosis of BWS was considered and was confirmed by detection of a methylation abnormality in H19 (DMR1). This case demonstrates that BWS should be considered, even with isolated facial involvement. This is important, as affected patients are predisposed to certain malignancies, especially in the first 5 to 8 years of life. Therefore, specialized surveillance is recommended as the part of management.

This study examines the short- and long-term implications of investment intensity and identifies appropriate strategies during expansionary and recessionary phases of the business cycle, based on a...

This report was originally commissioned in 1988 by the Executive Committee of the Business Policy and Planning Division of the Academy of Management. At that time, the Executive Committee, concerned about a number of issues connected with doctoral education, appointed The Committee on the Future of Doctoral Education to study these issues. There had been, in the last 15 years, a veritable explosion of literature in the field of Business Policy and Strategy. This trend was accompanied by a growth in the number of doctoral programs being established in American universities.As with any evolving field, questions were being raised not only by "outsiders" (faculty in other departments of a business school, curriculum and administrative officers in business schools) but also by "insiders" (professors, students, prospective students in the field itself). What is the nature of the field? What are its boundaries? What are the major streams of literature in the field? What kind of research is most promising?

This study examines the degree of autonomy provided by acquiring companies to the management of acquired firms in the managing of post-acquisition operations as well as the relationships between such autonomy and the perceived success of the acquisition. Results show that in unrelated acquisitions the extent of autonomy is significantly greater than in related acquisition. Also, autonomy is positively associated with superior performance in unrelated acquisitions, but the relationship is not significant in related acquisitions. Implications for future research and management practice are discussed.