Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
All teeth were vital. A 4-year follow-up shows no evidence of recurrence (Figs. 3A–E).
Cysts increase in size because of osmotic pressure and pressure resorption. This force over the bone causes bone resorption while
the malignancy expands.3 Mitigating the pressure by using a draining system is an applied physical principle that relieves intracystic pressure, changes its environment, and stimulates bone formation.4Resection, which is neither recommended nor contra- indicated, should be considered when it is impossible to maintain a long-term follow-up. Therefore, it takes a lot of judgment before deciding whether to resect. In our case, the patient’s young age, the easy access to our institution, and the unusual size of the lesion that would have required resection of at least 70% of the mandible were the principal factors that made us give her the chances for a conservative method. Long-term follow-up is mandatory.
Javier Delgado-Rueda, DDS Division of Oral and Maxillofacial Surgery Hospital del Occidente de Kennedy Bogota´, Colombia Oral and Maxillofacial Surgery Department Hospital Cardiovascular del Nin˜o de Cundinamarca Soacha, Colombia Alfonso Ayala-Go´mez, DDS Oral and Maxillofacial Surgery Department Clı´nica Fundadores Oral and Maxillofacial Surgery Department Clı´nica Federma´n Universidad El Bosque School of Dentistry Bogota´, Colombia Jaime Castro-Nu´n˜ez, DMD Research Department Institucio´n Universitaria Colegios de Colombia Oral and Maxillofacial Surgery Department Clı´nica Nueva Universidad El Bosque School of Dentistry Bogota´, Colombia Universidad Evange´lica de El Salvador School of Dentistry San Salvador, El Salvador [email protected] REFERENCES
1. Barnes L, Eveson JW, Reichart P, et al. World Health Organization Classification of Tumours. Pathology and Genetics of Head and Neck Tumours. Lyon, France: IARC Press; 2005:306
2. Pogrel MA. Treatment of keratocysts: the case for decompression and marsupialization.J Oral Maxillofac Surg2005;63:1667–1673 3. Toller PA. The osmolality of fluids from cysts of the jaws.
Br Dent J1970;129:275–278
4. Blanas N, Freund B, Schwartz M, et al. Systematic review of the treatment and prognosis of odontogenic keratocyst.Oral Surg Oral Med Oral Pathol Oral Radiol Endod2000;90:553–558
Do We Need to Apply Antiseptics? A Review of Antiseptics Use in Cleft Lip Repair Procedure to Prevent Surgical Site Infection
To the Editor:Through the years, surgeons have used antiseptics as the standard skin preparation in surgical procedure. Many
FIGURE 1.An extensive radiolucency ranging from the left sigmoid notch to the mesial aspect of tooth 30. The pressure exerted by the entity rejected distally and upward tooth 17. Tooth 27 was rejected distally and downward, creating the risk of a pathologic fracture. Vitality test performed on the anterior lower teeth was positive.
FIGURE 2.Marsupialization and decompression of the cyst by placing 2 no. 5 anesthesia tubes.
FIGURE 3. A, Three-month follow-up radiography. The asterisks show the main sites of osteogenesis. While the bony walls at the left persisted, tooth 18 started the eruption process, and root formation of tooth 27 is seen by comparing it with FIGURE 1. B, Steady reduction of the cyst by March 2011. Tooth 18 represented a matter of concern as it developed a periodontic-endodontic lesion that prevented bone formation around (arrows). It was extracted to eliminate the risk of infection. Tooth K was extracted to allow for proper eruption of tooth 20. C, A panoramic radiography of late June 2011 proved the extraction of tooth 18 to be successful in terms of bone formation. Tooth 27 started to move medially as osteogenesis occurred around it. Anesthesia tubes were removed. D, At 29 months after marsupialization and decompression, the pathology had faded virtually in its entirety. E, In July 2013, only a small, circled, and well-defined radiolucency persisted apical to tooth 22 (arrow). All teeth were vital.
The Journal of Craniofacial Surgery Volume 26, Number 5, July 2015 Correspondence
#2015 Mutaz B. Habal, MD
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
guidelines also promote the use of antiseptics to prevent surgical site infection (SSI). Nonetheless, until now, there is no consensus among the surgeons regarding the efficacy of antimicrobial pro- phylaxis in cleft lip and palate repair procedure. On the contrary, some studies mentioned that the use of antiseptics does not sig- nificantly reduce SSI. Moreover, the SSI rate in cleft lip repair is low (1.3%). By considering these facts, it could be the time to reconsider the antiseptics’ application in cheiloplasty procedure.
Cleft of lip and palate (CLP) is one of the congenital anomalies that occurs in about 1.7 per 1000 live born babies.1For achieving the best result, the first reconstructive surgery is carried out in their first year of age or right after the patients meet the rule of 10 s criteria.2– 4 Undergoing surgery in their early age makes the babies have high risk of infection during the procedure, which commonly refers to SSI.
Infection control, including health care-associated infection (HAI) control, has become one of the highlighted issues for health care providers. Based on Centers for Disease Control and Preven- tion guidelines, there are 4 types of HAI, namely central line- associated bloodstream infection, catheter-associated urinary tract infection, SSI, and ventilator-associated pneumonia.5Among all, SSI holds responsibility for 14% to 16% of HAI and likely the most common HAI in surgical patients.6Regarding the infection risk, some guidelines have been established to minimalize the incidence of infection; however, most of the guidelines are established based on experts’ opinions and they are not proven by reliable clinical study; especially in pediatric cases.6,7
In intention to prevent SSI, the guidelines suggest the use of antibiotic prophylactic and antiseptics before surgical pro- cedure6,8– 10; however, the surgeons have not established any con- sensus regarding the efficacy of antimicrobial prophylaxis in cleft lip and palate repair; more research and controlled trial study are needed to explore antimicrobial efficacy on the procedure.7
SURGICAL SITE INFECTION
Surgical site infection is an infection of the operative area, which occurs within 30 days after the surgical procedure. Commonly, SSI is divided into 3 categories, namely superficial incisional SSI, deep incisional SSI, and organ space SSI.11The first category involves the superficial part, only the skin or subcutaneous tissue of the operative area. Deep incisional SSI is assessed if one of these criteria is present: purulent drainage from the deep incision, spon- taneous dehiscence of the incision site and the presence of signs or symptoms of infection, abscess or other manifestation of infection, and assessment by the surgeon or attending physician. Meanwhile, organ space SSI relates to surgical intervention to organ or space, which lies deeper than deep incision. According the criteria, patients who undergo cleft lip repair may have risk of getting superficial and deep incisional SSI.
There are some guidelines and studies as well that elaborate the antiseptics and antibiotic prophylaxis efficacy in preventing SSI.6 – 8,12,13
Preoperative skin antiseptic is still recommended to reduce the risk of SSI. Nonetheless, some recent studies also show that preoperative bathing by using routine antiseptics (chlorhex- idine and povidone-iodine [PVP-I]) show no significant reduction of bacteria compared with using nonmedicated soap and water.12,14,15Thus, it leads to a critical thinking that it might not be the chemical role of antiseptics themselves, which holds the important role, but the dilution effect. Moreover, a study mentioned that sufficient saline irrigation (>2000 mL/h) could reduce SSI incidence on surgical procedure.16
CLEFT LIP AND PALATE REPAIR
Cleft lip and palate repair is classified as clean-contaminated surgery. It is stated that the incidence of SSI after CLP repair is
1.3%.7The infection rate is low, compared with surgical procedure on other parts of the body. The fact leads to a query; if the infection rate is low and there is no consensus about the antimicrobial efficacy on cleft lip and palate procedure, why should we apply the antimicrobial prophylaxis routinely? Antimicrobial agents that we refer to are either antiseptic or antibiotics.
Based on clinical practice guideline on antimicrobial prophylaxis, SSI rates for clean procedures without antimicrobial prophylaxis on the head and neck area is<1%.7,17,18The SSI risk will increase when the surgical procedure is done in cancer cases.7 Meanwhile, the antimicrobial prophylaxis shows no effect on lowering SSI risk in adenoidectomy, tonsillectomy, and septoplasty.7Other guideline for antibiotic prophylaxis in surgery stated that antibiotic prophylaxis is only recommended for major cleft palate surgery.19
In addition to the studies about antimicrobial efficacy and avail- able guidelines for SSI prevention, we can scrutinize the application of antiseptics in surgical procedure, including cleft lip repair. Cleft lip repair involves oral cavity, which is continuously contaminated by normal flora because the intraoral cavity is never cleansed completely with antiseptic. Thus, operative area on cleft lip repair procedure will never be free from microflora. In addition to the fact, the PVP-I, which is intentionally applied to minimize the risk of SSI, will not give maximal effect because of the short duration of application.
POTENTIAL OF RESISTANCE
Antibiotics resistance has become an issue in clinical practice.
Although, microbial resistance is rarely reported in antiseptics appli- cation, some researchers do worry about this issue because of the widespread use of antiseptics. Moreover, antiseptics are well known for its broad-spectrum activity, which enlarge the resistant potency.
Povidone-iodine is a chemical mixture of polyvinylpyrrolidone (PVP) complex and iodine (I). The common commercial form of this antiseptic is 10% solution in water, which contains 1% of iodine.20A study shows that PVP-I yields complete inhibition on bacterial growth when its concentration is 3% to 7.5%. The study used gram-negative bacteria as well as gram-positive bacteria to observe the efficacy of PVP-I.21
There is still no report about PVP-I resistance, yet there is a report of elevated resistance toward local antiseptics, which use polyhex- amethylene biguanide base. The methicillin-resistantStaphylococcus aureusstrains used in that study show 160-fold (the maximum limit is 400-fold) increased resistance toward polyhexamethylene biguanide- based antiseptics compared with the control strains.21
According to some studies that were done on humans, PVP-I is commonly known to be effective in controlling bacterial growth22; however, there are some other studies that show that PVP-I gives no significant reduction in bacterial colony compared with saline12,22 and yield no significant effect in preventing SSI. Meanwhile, some recent studies show that preoperative skin antiseptics have no significant effect in reducing SSI risk,12,23and a prospective study has shown that there was no SSI incidence, although the patients did not get antiseptics for skin preparation before surgical procedure.24 Moreover, the routine use of antiseptics has raised an awareness among the experts about growing problem of resistance.25
Based on these recent studies, senior author’s experiences, and our critical thinking, we need to investigate the use of antiseptics in cleft lip repair procedure. If dilution of bacterial colony is the one that holds important role in preventing SSI, we should consider it as a reliable method to prevent SSI instead of antiseptic application.
Thus, saline solution might be enough to replace antiseptics for skin preparation in cleft lip surgery. Besides, the low incidence of SSI in cleft lip repair should be a good reason to reconsider the routine use of antiseptics in cleft lip repair procedure. Nonetheless, this critical thinking needs to be proved through a well-designed clinical trial.
Correspondence The Journal of Craniofacial Surgery Volume 26, Number 5, July 2015
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#2015 Mutaz B. Habal, MDCopyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Theddeus O.H. Prasetyono, MD Division of Plastic Surgery, Department of Surgery Cipto Mangunkusumo Hospital/Faculty of Medicine University of Indonesia [email protected] Debby K.A. Saputra, MD Jakarta, Indonesia REFERENCES
1. Mossey PA, Little J, Munger RG, et al. Cleft lip and palate.Lancet 2009;374:1773–1785
2. Hopper RA, Cutting C, Grayson B. Cleft lip and palate. In: Thorne CH, Beasley RW, eds.Grabb and Smith’s Plastic Surgery.6th ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2007:201–225 3. Fillies T, Homann C, Meyer U, et al. Perioperative complications in
infant cleft repair.Head Face Med2007;3:9. doi: 10.1186/1746-160X-3-9 4. Nahai FR, Williams JK, Burstein FD, et al. The management of cleft lip and palate: pathways for treatment and longitudinal assessment.Semin Plast Surg2005;19:275–285
5. CDC. Type of healthcare-associated infections. http://www.cdc.gov/
HAI/infectionTypes.html. [Accessed August 5, 2014].
6. Junker T, Mujagic E, Hoffmann H, et al. Prevention and control of surgical site infections: review of the Basel Cohort Study.Swiss Med Wkly2012;142:w13616
7. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery.Am J Health Syst Pharm 2013;70:195–283
8. Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of surgical site infection.Infect Control Hosp Epidemiol1999;20:250–278 9. Downs LA. Preventing surgical site infections.Healthy Skin2012;10:
58–62
10. Bunn F, Cunningham, Handscomb K. Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery.Cochrane Database Syst Rev2006;2:CD005360. doi: 10.1002/14651858.CD005360.pub2 11. Ameh EA, Cox S, Nasir AA. Surgical site infection. In: Ameh EA,
Bickler SW, Lakhoo K, Nwomeh BC, Poenaru D, eds.Paediatric Surgery: A Comprehensive Text for Africa.Seattle, WA: Global HELP;
2011:98–102
12. Kamel C, McGahan L, Polisena J, et al. Preoperative skin antiseptic preparations for preventing surgical site infections: a systematic review.
Infect Control Hosp Epidemiol2012;33:608–617
13. Lee I, Agarwal RK, Lee BY, et al. Systematic review and cost analysis comparing use of chlorhexidine with use of iodine for preoperative skin antisepsis to prevent surgical site infection.Infect Control Hosp Epidemiol2010;31:1219–1229
14. Reichman DE, Greenberg JA. Reducing surgical site infections:
a review.Rev Obstet Gynecol2009;2:212–221
15. Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection (Review).Cochrane Database Syst Rev2006;2: CD004985. doi: 10.1002/14651858.
CD004985.pub2
16. Watanabe M, Sakai D, Matsuyama D, et al. Risk factors for surgical site infection following spine surgery: efficacy of intraoperative saline irrigation.J Neurosurg Spine2010;12:540–546
17. Avenia N, Sanguinetti A, Cirocchi R, et al. Antibiotic prophylaxis in thyroid surgery: a preliminary multicentric Italian experience.Ann Surg Innov Res2009;3:10. doi: 10.1186/1750-1164-3-10
18. Johnson JT, Wagner RL. Infection following uncontaminated head and neck surgery.Arch Otolaryngol Head Neck Surg1987;113:368–369 19. SIGN. Antibiotic prophylaxis in surgery: a national clinical guideline.
2008. http://www.sign.ac.uk/pdf/sign104.pdf. [Accessed September 23, 2013].
20. Burks RI. Povidone-iodine solution in wound treatment. Phys Ther 1998;78:212–218
21. Hirsch T, Seipp HM, Jacobsen F, et al. Antiseptics in surgery.Eplasty 2010;10:320–326
22. Drosou A, Falabella A, Kirsner RS. Antiseptics on wounds: an area of controversy.Wounds2003;15:149–166
23. Meier DE, Nkor SK, Aasa D, et al. Prospective randomized comparison of two preoperative skin preparation techniques in a developing world country.World J Surg2001;25:441–443
24. Kalantar-Hormozi AJ, Davami B. No need for preoperative antiseptics in elective outpatient plastic surgical operations: a prospective study.
Plast Reconstr Surg2005;116:529–531
25. Selvaggi G, Monstrey S, Van Landuyt K, et al. The role of iodine in antisepsis and wound management: a reappraisal.Acta Chir Belg 2003;103:241–247
A Simple Technique to Repair a Large Thoracolumbar
Myelomeningocele
To the Editor:Severe neural tube defects (NTDs) are often incom- patible with life. In the case of survival, early repair of myelome- ningocele (MMC) to avoid infection is mandatory. Although large MMC often require more aggressive techniques such as myocuta- neous flaps,1we present here a case of a neonate with complex NTD and extraordinarily poor prognosis in which a large thoracolumbar MMC was repaired by a simple technique: bilateral bipedicled cutaneous flaps combined with paraspinal musculofascial turnover flaps. This simple approach added to an interdisciplinary manage- ment allowed him to survive for 10 months.
A newborn boy was diagnosed via prenatal sonographic monitoring at 23 weeks with hydrocephalus, type III Chiari mal- formation, cervical-dorsal-lumbar dysraphism, thoracolumbar mye- lomeningocele, and thoracic diastematomyelia. He was born by caesarean section at 35 weeks of gestation (Apgar score 7; birth weight 2200 g). His physical examination showed a thoracolumbar MMC, a lumbar tuft of hair and foot deformities. Neurological examination showed present, but diminished, upper and lower limb movements and lack of the normal spontaneous writhing move- ments of the neonate. He had perianal anesthesia and anal sphincter dysfunction. Skin sensitivity to touch was preserved in L4 to L5 regions and absent in S1 to S2. Hip flexion and abduction were preserved and he could extend the knees against gravity. He needed oxygen to maintain blood oxygen saturation >90%. He also required Bilevel Positive Airway Pressure during sleep for several days.
Repair of the dysraphism was carried out in the first hours of life.
A midline incision extended the cutaneous defect from the cervical to the sacral region to expose the termination of the dural defect since there was an absence of fusion of all posterior vertebral arcs of the spine. The spinal cord appeared longitudinally split up to the mid-thoracic region. The neural plaque was isolated after dissection of the arachnoid from the placode in its entirety (from lumbosacral to upper thoracic region). Another incision following the circum- ferential white line formed by the junction of the skin and the arachnoid allowed this membrane to be removed. Spinal cord decompression was achieved through partial removal of the her- niated cerebellar tissue that appeared in the upper thoracic and cervical region. The dura mater was isolated by lateral dissection of a dural plane. The lateral edges of the placode were then folded and sutured in the midline to reconstitute the plaque into a tubular configuration with 6-0 absorbable monofilament (Monocryl, Ethicon, Johnson and Johnson, LTD., Leeds, UK).
After restoring the continuity of the dural sac, the final defect size was 127 cm. Bilaterally, paraspinous muscular fascia was harvested from laterally to medially, turned over the midline, and sutured with interrupted 4-0 braided absorbable sutures (Vicryl,
The Journal of Craniofacial Surgery Volume 26, Number 5, July 2015 Correspondence
#2015 Mutaz B. Habal, MD
