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Pediatric Plastic and Craniomaxillofacial Surgery

The Laboratory for Pediatric Plastic and Craniomaxillofacial Surgery, aka the “Peds-CMF Lab,” focuses on the study of anatomic and surgical aspects and outcomes related to various pediatric plastic surgical, craniofacial, and oral/maxillofacial conditions. Present work is related to the following conditions:

  • Craniomaxillofacial trauma
  • Cleft lip/palate
  • Cleft lip nasal deformity
  • Craniosynostosis
  • Craniofacial microsomia
  • Myelomeningocele
  • Rhinoplasty
  • Facial paralysis
  • Brachial plexus palsy

Methods employed in these investigations span the gamut from anatomic dissection, to image analysis (e.g., CT-based cephalometry, stereophotogrammetry), to case-control and cohort studies, to population-based survey studies.

The lab also has a strong interest in methods for medical education and has several projects related to video-based and workshop-based education to improve learning by medical students and surgical residents.

Lab Members (Faculty)

Current and Past Research Fellows

  • 2016 — Peter Bittar, Jason Green
  • 2015 — Adam Glener, Ronni Shammas
  • 2014 — Danielle Sobol
  • 2012 — Ryan Kellogg, Irene Pien
  • 2008 — Leahthan Domeshek

Selected Contributions

A sample of recent projects is described below:

Interfrontal Angle for Trigonocephaly from Metopic Synostosis

Surgical intervention for metopic synostosis is largely based on a subjective impression of the presence and severity of trigonocephaly. Several objective methods have been proposed to characterize phenotypic severity, but these methods are imprecise or impractical. The purpose of this investigation was to develop a practical and reliable quantitative method to assess trigonocephaly using existing computed tomographic (CT) data. This project spanned two phases:

In the first phase, we developed a tool that could discriminate reliably between trigonocephaly and normal calvarial shape. Clinical and administrative databases were queried to identify sequential patients referred for evaluation of possible metopic synostosis. Age-matched comparative controls were selected from a previously described pediatric craniofacial normative database. Craniofacial CT data were assessed as two-dimensional axial series, three-dimensional reconstructions, and multiplanar reconstructions. Six methods were then evaluated for quantifying the shape of the frontal region. Each method was critically appraised with respect to accuracy, precision, and practicality. The best method was defined as the interfrontal angle (IFA), and it was shown to have great sensitivity and specificity for diagnosis of trigonocephaly. Cf. Kellogg R et al. J Craniofac Surg. 2012 May;23(3):799-804.
In the second phase, we demonstrated that the interfrontal angle can be used to further characterize the severity of trigonocephaly (as minor, moderate, or severe) and further served to narrow the “gray zone” of “moderate” trigonocephaly. It also correlated with expert decision-making for operative versus nonoperative management. This tool may be used as an adjunct to clinical decision-making when the decision to proceed with surgery may not be straightforward. Cf. Anolik RA et al. Plast Reconstr Surg. 2016 May;137(5):1548-55.

3D Vector Analysis

The purpose of this project is the application of three-dimensional vector analysis (3DVA) to patients with craniofacial conditions. Preoperative and postoperative analysis of craniofacial morphology has previously relied on traditional anthropometric indices, which are primitive. 3DVA uses modern graphical software to analyze head CT scan information to form a 3-D representation of skull morphology. Using a set of vectors emanating at prescribed angles from a predetermined single fixed point, 3DVA provides a finite, yet comprehensive, dataset of defined cranial surface points. The "cranial fingerprint" that is generated is a 3-D representation of skull morphology that is far more complex than can be represented by an interpretation of several measurements.

Comparison of craniosynostosis patients with age-matched data sets from a normative database showed that 3DVA can detect a difference between normal and abnormal cranial morphology with a high degree of precision. When applied to preoperative CT imaging of the craniosynostosis patient, it enables automated analysis of diagnosis and severity. Comparison of preoperative datasets to a normative database facilitates preoperative planning. Furthermore, postoperative data sets can be either paired with the preoperative or normative datasets to assess outcomes in a quantitative manner. The prerequisite of the 3DVA project is the development of a robust normative CT database. The database currently is one of the largest collections of pediatric cranial CT data in the world. The accruement of normative datasets is an ongoing project within the lab. Cf. Marcus JR et al. Plast Reconstr Surg. 2009 Dec;124(6):2076-84.

Craniomaxillofacial Trauma

Our Lab has focused on many aspects related to craniomaxillofacial trauma. Selected publications appear below:

Moses H et al. Opportunity cost of surgical management of craniomaxillofacial trauma. Craniomaxillofac Trauma Reconstr. 2016 Mar;9(1):76-81.

Atisha DM et al. Facial fractures in the aging population. Plast Reconstr Surg. 2016 Feb;137(2):587-93.

Cahill TJ 3rd et al. Hardware removal in craniomaxillofacial trauma: a systematic review of the literature and management algorithm. Ann Plast Surg. 2015 Nov;75(5):572-8.

Powers DB and Delo RI. Characteristics of ballistic and blast injuries. Atlas Oral Maxillofac Surg Clin North Am. 2013 Mar;21(1):15-24.

Cleft Lip/Palate and Cleft Lip Nasal Deformity

Our Lab has a particular interest in orofacial clefting, its surgical treatment, and other aspects of care for children affected by this condition. Selected publications appear below:

Sobol DL et al. Nasal airway dysfunction in children with cleft lip/palate: results of a cross-sectional population-based study, with anatomic and surgical considerations.

Pien IJ et al. Long-term clinical and holistic outcomes in children with cleft lip and/or palate: a multidisciplinary, mixed-methods approach. Plast Reconstr Surg. 2015 Oct;136(4 Suppl).

Watkins S, Meyer RE, Aylsworth AS, Marcus JR, Allori AC, Pimenta L, Lipinski RJ, and Strauss RP. Academic achievement among children with nonsyndromic orofacial clefts: a population-based study. ACCEPTED to Cleft Palate Craniofac J.

Allori AC and Mulliken JB. Secondary correction of cleft lip nasal deformity. ACCEPTED to Plast Reconstr Surg.

Allori AC and Marcus JR. Principalization of cleft lip repair: conventions, commonalities, and controversies. ACCEPTED to Plast Reconstr Surg.

Sitzman T et al. Reliability of oronasal fistula classification. ACCEPTED to Cleft Palate Craniofac J.

Advanced Training

Opportunities for working with the Lab are open to Duke University medical students and residents. These opportunities include basic collaboration on research projects, as well as longer-term 1- or 2-year associations as part of a formal research sabbatical.

Contact Us

Are you interested in surgical research, especially as it pertains to pediatric plastic surgery, craniofacial surgery, or oral/maxillofacial surgery? Would you like to propose a collaboration? Please get in touch!

Jeffrey R. Marcus, MD
jeffrey.marcus@duke.edu