The Forgotten Flap: The Pedicled Trapezius Flap's Utility in Pediatric Head and Neck Reconstruction-A Systematic Review.

BACKGROUND: When free tissue transfer is precluded or undesired, the pedicled trapezius flap is a viable alternative for adults requiring complex head and neck (H&N) defect reconstruction. However, the application of this flap in pediatric reconstruction is underexplored. This systematic review aimed to describe the use of the pedicled trapezius flap and investigate its efficacy in pediatric H&N reconstruction. METHODS: A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles describing the trapezius flap for H&N reconstruction in pediatric patients were included. Patient demographics, surgical indications, wound characteristics, flap characteristics, complications, and functional outcomes were abstracted. RESULTS: A systematic review identified 22 articles for inclusion. Studies mainly consisted of case reports (n = 11) and case series (n = 8). In total, 67 pedicled trapezius flaps were successfully performed for H&N reconstruction in 63 patients. The most common surgical indications included burn scar contractures (n = 46, 73.0%) and chronic wounds secondary to H&N masses (n = 9, 14.3%). Defects were most commonly located in the neck (n = 28, 41.8%). The mean flap area and arc of rotation were 326.4 ± 241.7 cm2 and 157.6 ± 33.2 degrees, respectively. Most flaps were myocutaneous (n = 48, 71.6%) and based on the dorsal scapular artery (n = 32, 47.8%). Complications occurred in 10 (14.9%) flaps. The flap's survival rate was 100% (n = 67). No instances of functional donor site morbidity were reported. The mean follow-up was 2.2 ± 1.8 years. CONCLUSION: This systematic review demonstrated the reliability of the pedicled trapezius flap in pediatric H&N reconstruction, with a low complication rate, no reports of functional donor site morbidity, and a 100% flap survival rate. The flap's substantial surface area, bulk, and arc of rotation contribute to its efficacy in covering soft tissue defects ranging from the proximal neck to the vertex of the scalp. The pedicled trapezius flap is a viable option for pediatric H&N reconstruction.

"Healthcare Disparities in the Care of Children with Craniosynostosis in the United States: A Systematic Review".

BACKGROUND: Healthcare inequity is a pressing concern in pediatric populations with craniofacial conditions. Little is known about the barriers to care affecting children with craniosynostosis. This systematic review investigates disparities impacting care for children with craniosynostosis in the U.S. METHODS: A comprehensive literature search was performed in the following databases from inception to December 2022: Ovid MEDLINE, Ovid EMBASE, and The Cochrane Library. Studies were screened for eligibility by two authors. All original articles that focused on disparities in access, treatment, or outcomes of craniosynostosis surgery were included. Studies describing disparities in other countries, those not written English, and review articles were excluded (Figure 1). RESULTS: An initial database search revealed 607 citations of which 21 met inclusion criteria (Figure 1). All included studies were retrospective reviews of databases or cohorts of patients. The results of our study demonstrate that barriers to access in treatment for craniosynostosis disproportionally affect minority children, children of non-English speaking parents and those of lower socioeconomic status or with Medicaid. Black and Hispanic children, non-English speaking patients, and children without insurance or with Medicaid were more likely to present later for evaluation, ultimately undergoing surgery at an older age. These patients were also more likely to experience complications and require blood transfusions compared to their more privileged, white peers. CONCLUSIONS: There is a discrepancy in treatment received by minority patients, patients with Medicaid, and those who are non-English speaking. Further research is needed to describe the specific barriers that prevent equitable care for these patients.

Delayed, dramatic breast swelling in a transgender woman: a case report.

Background: As the number of gender-affirming procedures performed in the United States increases, physicians caring for gender-nonconforming patients, regardless of practice location and focus, will likely encounter transgender women with breast implants. Increasingly, transgender women are seeking breast feminization. However, this population is less consistently receiving surveillance and routine breast care than cisgender women. Aim: This report aims to add to the growing body of knowledge addressing breast augmentation complications in transgender women and to highlight disparities in healthcare. Methods: A case of breast implant-associated seroma at our institution was analyzed through chart review. A literature review was conducted using PubMed to gather all articles discussing breast implant-associated fluid collections in transgender patients. Prior to publication of this report, a Waiver of Consent was granted by the E.R.'s Institutional Review Board for the study under which this article was prepared. Results: Our patient was an African American transgender woman presenting initially at age 60 with significant asymmetry due to dramatic swelling of her left breast. The patient underwent bilateral breast augmentation outside of the United States 2 decades prior. The patient noted a gradual painless increase in her left breast size starting 3 years prior. She admitted that she was hesitant to seek a second opinion after being treated dismissively by another surgeon. Subsequent management included mammography and mirrored recommendations for late breast implant-associated seromas in cisgender patients: ultrasound, aspiration for cytology and culture, and removal of the implant and capsule. Outcomes: The fluid collection in our patient was determined to be a chronic hematoma and was managed surgically. Though this patient eventually achieved a good outcome, treatment was delayed due to barriers she faced as a transgender woman. Clinical Implications: Literature demonstrates that recommended management of late-onset breast-implant-associated seroma does not differ based on gender identity; however, transgender and GNC adults are more likely to receive less thorough care than cisgender women. Any patients undergoing breast augmentation with implants should be routinely evaluated for late complications, including seromas, which require prompt attention and methodical evaluation due to their potentially malignant nature. Strengths and Limitations: This article is limited in that it is a single report of breast seroma. It is strengthened by a PubMed review gathering all articles discussing breast-implant-associated fluid collections in transgender patients. Conclusion: We propose better education of physicians on how to care for transgender and gender-diverse patients should help mitigate the neglect and late presentation of such medical conditions in this vulnerable and marginalized population.

Risk Factors for Delayed Diagnosis of Positional Plagiocephaly: A Review of 25,322 Patients.

OBJECTIVE: This study identifies risk factors for late positional plagiocephaly (PP) diagnosis and impact on helmet therapy. DESIGN: We conducted a retrospective review of all patients diagnosed with PP over 10 years at five Southern California hospitals. SETTING: Patients diagnosed with PP at an included hospital. PATIENTS: 25,332 patients were diagnosed with PP over 10 years. INTERVENTIONS: Patients diagnosed with PP early (< = 6 months) and late (>6 months) were compared. MAIN OUTCOME MEASURES: Cohorts were evaluated for demographics, gestational history, associated conditions, and hospitalizations through direct comparison, logistic regression, and correlation analyses. Rates of referrals and helmet orders were compared. RESULTS: Of patients reviewed, 4.8% (n = 1216) were diagnosed late. On multivariate analysis, late diagnoses were more likely Hispanic or Black/African-American. Early gestational age, hydrocephalus, and VP shunt were more frequent in late diagnoses. Patients diagnosed late had longer NICU and overall hospital stays. Earlier gestational age, longer NICU or overall hospital stay correlated with later age at PP diagnosis. 8.9% of patients were referred for helmet therapy evaluation. Patients diagnosed late were 2.63 and 1.64 times as likely to be referred and require helmet therapy, respectively. CONCLUSIONS: Patients who are Hispanic or Black/African-American, premature, have hydrocephalus, or VP shunt have higher rates of delayed PP diagnosis. Shorter gestational age or longer NICU or hospital stay correlates with later diagnosis, which increases helmet therapy requirements. Additional interventions are needed for at risk patients to routinely evaluate for and minimize the risk of developing PP.

Identifying Populations at Risk for Difficulty Managing Emotions and Social Interactions After Burn Injury.

There has been conflicting data on the relationship between burn severity and psychological outcomes. The present study aims to characterize the baseline psychosocial disposition of adults attending outpatient burn clinic at a large urban safety net hospital, as well as the impact of clinical course on self-reported psychosocial well-being. Adult patients attending outpatient burn clinic completed survey questions from the National Institutes of Health Patient-Reported Outcomes Measurement Information System Managing Chronic Conditions: Self-Efficacy for Managing Social Interactions (SEMSI-4) and Managing Emotions (SEME). Sociodemographic variables were collected from surveys and retrospective chart review. Clinical variables included total body surface area burned, initial hospital length of stay, surgical history, and days since injury. Poverty level was estimated by U.S. census data using patient's home ZIP code. Scores on SEME-4 and SEMSI-4 were compared to the population mean by one-sample T-test, and independent variables evaluated for associations with managing emotions and social interactions by Tobit regression while adjusting for demographic variables. The 71 burn patients surveyed had lower scores in SEMSI-4 (mean = 48.0, P = .041) but not SEME-4 (mean = 50.9, P = .394) versus the general population. Marital status and neighborhood poverty level were associated with SEMSI-4, while length of stay and % total body surface area burned were associated with SEME-4. Patients who are single or from poorer neighborhoods may have difficulty interacting with their environment after burn injury and need extra social support. Prolonged hospitalization and increased severity of burn injury may have more impact on emotional regulation; these patients may benefit from psychotherapy during recovery.

Tympanostomy Tubes: Are They Necessary? A Systematic Review on Implementation in Cleft Care.

OBJECTIVE: To understand the indication for and the effects of early ventilation tube insertion (VTI) on hearing and speech for patients with cleft lip and/or palate (CLP). DESIGN: We conducted a Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)-guided systematic review of relevant literature. SETTING: Setting varied by geographical location and level of clinical care across studies. PATIENTS, PARTICIPANTS: Patients with CLP who underwent VTI were included. INTERVENTIONS: No interventions were performed. MAIN OUTCOME MEASURE(S): Primary outcome measures were hearing and speech following VTI. Secondary outcome measures were tube-related and middle ear complications. Early VTI occurred before or at time of palatoplasty while late VTI occurred after palatoplasty. RESULTS: Twenty-three articles met inclusion criteria. Articles varied among study design, outcome measures, sample size, follow-up, and quality. Few studies demonstrated support for early VTI. Many studies reported no difference in hearing or speech between early and late VTI. Others reported worse outcomes, greater likelihood of complications, or needing repeat VTI following early tympanostomy placement. Several studies had significant limitations, including confounding variables, small sample size, or not reporting on our primary outcome. CONCLUSIONS: No consistency was found regarding which patients would benefit most from early VTI. Given the aforementioned variability and sub-optimal methodologies, additional studies are warranted to provide stronger evidence regarding VTI timing in cleft care.

Rethinking the Rule of 10s: Early Cleft Lip Repair Improves Weight Gain.

OBJECTIVE: This study compares patients undergoing early cleft lip repair (ECLR) (<3-months) and traditional lip repair (TLR) (3-6 months) with/without nasoalveolar molding (NAM) to evaluate the effects of surgical timing on weight gain in hopes of guiding future treatment paradigms. DESIGN: Retrospective review. SETTING: Children's Hospital of Los Angeles, California. PATIENT, PARTICIPANTS: A retrospective chart review evaluated patients who underwent ECLR or TLR ± NAM from November 2009 through January 2020. INTERVENTIONS: No intervention was performed. MAIN OUTCOME MEASURE(S): Patient demographics, birth and medical history, perioperative variables, and complications were collected. Infant weights and age-based percentiles were recorded at birth, surgery, 8-weeks, 6-months, 12-months, and 24-months postoperatively. The main outcomes were weight change and weight percentile amongst ECLR and TLR ± NAM groups. RESULTS: 107 patients met inclusion criteria: ECLR, n = 51 (47.6%); TLR + NAM, n = 35 (32.7%); and TLR-NAM, n = 21 (19.6%). ECLR patients had significantly greater changes in weight from surgery to 8-weeks and from surgery to 24-months postoperatively compared with both TLR ± NAM (P < .05). Age-matched weights in the ECLR group were significantly greater than TLR ± NAM at multiple time points postoperatively (P < .05). CONCLUSIONS: ECLR significantly increased patient weights 24-months postoperatively when compared to TLR ± NAM. Specifically compared to TLR-NAM, ECLR weights were significantly greater at all time points past 6-months postoperatively. The results of this study demonstrate that ECLR can mitigate feeding difficulties and malnutrition traditionally seen in patients with cleft lip.

Peer Support Groups: Identifying Disparities to Improve Participation.

Disparities in psychosocial outcomes after burn injury exist in patients from racial or ethnic minority groups in the United States. Peer support groups can help patients with many psychosocial aspects of recovery from burns; however, access to such support among patients of racial and ethnic minority or low socioeconomic groups are unknown. The present study examined participation rates in outpatient peer support within this patient population. Patients attending outpatient clinic at an urban safety-net hospital and regional burn center with a majority minority patient population were asked about participation in burn survivor group, interest in joining a group, and given validated survey questions about managing emotions and social interactions since injury. Current or past participation in peer support was low (4.2%), and 30.3% of patients not already in support group were interested in joining. Interest in future participation in peer support was highest among Hispanic patients (37.0%) and lowest among Black patients (0%). Logistic regression models demonstrated that increased total body surface area burned, hospital length of stay, and need for surgical intervention were associated with interest in joining or having joined a peer support group. Effectiveness of management of emotions and social interactions were not associated with interest in joining peer support in the future. These findings demonstrate a considerable difference between levels of interest and participation in peer support within this population. Improving access to and education about benefits of peer support in underresourced communities may help to address the variation in psychosocial outcomes of patients across racial or ethnic minority groups recovering from burns.

Increased Distraction Magnitude Leads to Greater Reduction in the Apnea-Hypopnea Index in Infants With Robin Sequence.

PURPOSE: Upper airway obstruction seen in Robin Sequence (RS) is commonly treated with mandibular distraction osteogenesis (MDO). The purpose of this study is to evaluate the impact of distraction distance on sleep study outcomes in patients with obstructive sleep apnea (OSA) secondary to RS. METHODS: A retrospective cohort study was conducted for patients with isolated RS who underwent MDO at Children's Hospital Los Angeles between January 2006-September 2021. The predictor variable was distraction distance (maximal distraction using a 30 mm device vs sub-maximal distraction), and the primary outcome variable was OSA scores. Relationships between covariates, including demographic characteristics, preoperative sleep variables, and postoperative OSA outcomes using polysomnography, were also analyzed. Descriptive statistics and tests of statistical significance were performed using the Statistical Package for Social Sciences (SPSS) (version 28.0), including Student's t-test, proportions testing, multiple linear regression, and correlation analysis. RESULTS: Seventy-one patients met inclusion criteria (39.4% female, 60.6% male). Average age at MDO was 3.0 ± 10.2 months. Fifty-six patients were distracted maximally with a 30 mm distractor, while the remaining 15 patients experienced shorter distraction due to distractor limitations (25 mm distractor), persistent infection or family request. Looking at absolute values of postoperative sleep study variables, there were no significant differences between patients who were maximally and sub-maximally distracted across apnea-hypopnea index (AHI), highest carbon dioxide, lowest oxygen saturation, and oxygen requirement. However, both cohorts demonstrated significant improvements in lowest oxygen saturation, AHI, highest carbon dioxide level, and highest oxygen requirement compared to their pre-distraction levels. Compared with patients distracted <30 mm, maximal distraction had a significantly greater improvement in AHI when controlling for preoperative sleep study variables (P = .047). CONCLUSION: Patients with isolated RS who have more severe OSA experienced greater improvements in AHI, oxygen requirement, and oxygen saturation after MDO. Two-thirds of patients no longer had oxygen requirements after MDO. Our results suggest that MDO is helpful in treating patients with RS regardless of distraction distance. However, our study provides evidence that increasing the distraction distance may further improve AHI, which is particularly beneficial to patients with a significant preoperative AHI.

High prevalence of deleterious mutations in concomitant nonsyndromic cleft and outflow tract heart defects.

Our previous work demonstrating enrichment of outflow tract (OFT) congenital heart disease (CHD) in children with cleft lip and/or palate (CL/P) suggests derangements in common underlying developmental pathways. The current pilot study examines the underlying genetics of concomitant nonsyndromic CL/P and OFT CHD phenotype. Of 575 patients who underwent CL/P surgery at Children's Hospital Los Angeles, seven with OFT CHD, negative chromosomal microarray analysis, and no recognizable syndromic association were recruited with their parents (as available). Whole genome sequencing of blood samples paired with whole-blood-based RNA sequencing for probands was performed. A pathogenic or potentially pathogenic variant was identified in 6/7 (85.7%) probands. A total of seven candidate genes were mutated (CHD7, SMARCA4, MED12, APOB, RNF213, SETX, and JAG1). Gene ontology analysis of variants predicted involvement in binding (100%), regulation of transcription (42.9%), and helicase activity (42.9%). Four patients (57.1%) expressed gene variants (CHD7, SMARCA4, MED12, and RNF213) previously involved in the Wnt signaling pathway. Our pilot analysis of a small cohort of patients with combined CL/P and OFT CHD phenotype suggests a potentially significant prevalence of deleterious mutations. In our cohort, an overrepresentation of mutations in molecules associated with Wnt-signaling was found. These variants may represent an expanded phenotypic heterogeneity within known monogenic disease genes or provide novel evidence of shared developmental pathways. The mechanistic implications of these mutations and subsequent developmental derangements resulting in the CL/P and OFT CHD phenotype require further analysis in a larger cohort of patients.

The influence of an all-female healthcare environment on mentorship and empowerment of female healthcare professionals.

Low- and middle-income countries (LMICs) have the greatest need for additional healthcare providers, and women outside the workforce help address the need. Women in healthcare need more mentorship and leadership training to advance their careers due to systemic barriers. This study evaluates how women working together on a medical team influences mentorship, leadership and empowerment. A single all-female volunteer team participating in a cleft surgery mission in Oujda, Morocco were surveyed before and after the mission. Statistical analysis with student's t-test or chi-squared were performed. 95 female volunteers from 23 countries participated on this team and 85% completed surveys. Volunteers from high-income countries (32%) and LMICs (68%) had similar mission roles (p = 0.58). Experience as a mission volunteer (p = 0.47), team leader (p = 0.28), and educator (p = 0.18) were equivalent between cohorts. 73% of women had previously received mentorship but 98% wanted more. 75% had previously mentored others, but 97% wanted to be mentors. 73% of volunteers who had no prior mentorship found their first mentor during the mission. All participants found a long-term peer relationship and felt motivated to mentor women at home. 95% were inspired to pursue leadership positions, advance professionally, and continue working with other women. This population of female healthcare professionals overwhelmingly desired more mentorship than is felt to be available. An all-female healthcare environment appears to provide opportunities for mentorship and create lasting motivation to teach, lead, and advance professionally. Findings raise the potential that increasing visibility of female professionals may effectively empower women in healthcare.

Midface Growth Potential in Unoperated Clefts: A Systematic Review and Meta-Analysis.

ABSTRACT: Competing hypotheses for the development of midface hypoplasia in patients with cleft lip and palate include both theories of an intrinsic restricted growth potential of the midface and extrinsic surgical disruption of maxillary growth centers and scar growth restriction secondary to palatoplasty. The following meta-analysis aims to better understand the intrinsic growth potential of the midface in a patient with cleft lip and palate unaffected by surgical correction. A systematic review of studies reporting cephalometric measurements in patients with unoperated and operated unilateral cleft lip and palate (UCLP), bilateral cleft lip and palate (BCLP), and isolated cleft palate (iCP) abstracted SNA and ANB angles, age at cephalometric analysis, syndromic diagnosis, and patient demographics. Age and Region-matched controls without cleft palate were used for comparison. SNA angle for unoperated UCLP (84.5 ±â€Š4.0°), BCLP (85.3 ±â€Š2.8°), and ICP (79.2 ±â€Š4.2°) were statistically different than controls (82.4 ±â€Š3.5°), (all P ≤ 0.001). SNA angles for operated UCLP (76.2 ±â€Š4.2°), BCLP (79.8 ±â€Š3.6°), and ICP (79.0 ±â€Š4.3°) groups were statistically smaller than controls (all P ≤ 0.001). SNA angle in unoperated ICP (n = 143) was equivalent to operated ICP patients (79.2 ±â€Š4.2° versus 79.0 ±â€Š4.3° P = 0.78). No unoperated group mean SNA met criteria for midface hypoplasia (SNA < 80). Unoperated UCLP/BLCP exhibit a more robust growth potential of the maxilla, whereas operated patients demonstrate stunted growth compared to normal phenotype. Unoperated ICP demonstrates restricted growth in both operated and unoperated patients. As such, patients with UCLP/BCLP differ from patients with ICP and the factors affecting midface growth may differ.Level of Evidence: IV.

Impact of an All-Female Surgical Team on Moroccan Patient Perspectives of Female Healthcare Providers.

INTRODUCTION: Increasing numbers of women in medicine could address Morocco's 5.5-fold deficit in surgical providers. Cultural perceptions towards women limit female advancement in healthcare. This study evaluates the impact of an all-female surgical team on Moroccan attitudes. OBJECTIVE: This study aimed to evaluate how attitudes towards female healthcare professionals changed for Moroccan patients after exposure to a unique, all-female medical environment. METHODS: Cleft patients were surveyed after a surgery mission with all-female volunteers in Oujda, Morocco. Analysis included quantitative, qualitative, and mixed-methods approaches. RESULTS: Of 121 respondents (94%), 85% and 77% had prior exposure to a female nurse or doctor, respectively. 94% of respondents strongly agreed to receiving high-quality care. 75% developed increased confidence in female providers. 68% and 69% of respondents, regardless of gender (p = 0.950), felt that having a female nurse or doctor did not impact care. Female patients were more likely than male patients to strongly encourage female relatives to pursue medical careers (p = 0.027). Respondents without prior exposure to female nurses were more likely to: pursue medical careers (p = 0.034), believe female relatives could pursue medical careers (p = 0.006), and encourage them to do so (p = 0.011). CONCLUSIONS: Increased visibility of women improved patient attitudes towards female providers, especially in patients without prior exposure. Initiatives that increase female representation in healthcare may have greater effects in cultures with more gender inequity.

Factors Associated With Delay in Cleft Surgery at a Tertiary Children's Hospital in a Major US Metropolitan City.

OBJECTIVE: To identify factors associated with late cleft repair at a US tertiary children's hospital. DESIGN: Retrospective study of children with CL/P using Children's Hospital Los Angeles (CHLA) records. SETTING: US tertiary children's hospital. PATIENTS/PARTICIPANTS: Patients undergoing primary CL or CP repair at CHLA from 2009 to 2018. MAIN OUTCOME MEASURES: Proportion of children who had delayed primary CL repair or CP repair using CHLA and American Cleft Palate-Craniofacial Association (ACPA) guidelines and factors associated with late surgery. RESULTS: In total, 805 patients-503 (62.5%) who had CL repair, 302 (37.5%) CP repair-were included. Using CHLA protocol, 14.3% of patients seeking CL repair had delayed surgery. Delay was significantly associated with female gender, non-Hispanic ethnicity, Spanish primary language, government insurance, bilateral cleft, cleft lip and palate (CLP), and syndromic diagnosis. Using ACPA guidelines, 5.4% had delayed surgery. Female gender and syndromic diagnosis were significantly associated with delay and remained significant after adjustment for confounders in multivariate models. For CP repair, 60.3% of patients had delayed surgery using CHLA protocol. Cleft lip and palate diagnosis, complete cleft, syndromic diagnosis, and longer travel distance were significantly associated with delay. Using ACPA guidelines, 28.5% had delayed surgery; however, significant association with patient variables was not consistently observed. CONCLUSIONS: Delay in cleft surgery occurs most often for patients seeking CP repair and is associated with female gender, non-Hispanic ethnicity, Spanish language, government insurance, and bilateral CL, CLP, or syndromic diagnoses. Initiatives should aim to optimize cleft surgery delivery for these subpopulations.

The Evolution of Unilateral Cleft Lip Repair.

ABSTRACT: The understanding of cleft lip etiology and approaches for surgical repair have evolved over time, allowing for improved ability to restore form and function. The variability of cleft lip presentations has necessitated a nuanced surgical approach with multidisciplinary cleft care. The earliest documentation of unilateral cleft lip repair predates the 19th century, with crude outcomes observed before the advent of curved incisions and advancement flaps. In the 20th century, straight line, quadrilateral flap, and triangular flap repairs were introduced to mitigate post-repair surgical scarring, increase lip length, and restore the symmetry of the Cupid's bow. Towards the latter part of the century, the development of rotation-advancement principles allowed for improved functional and aesthetic outcomes. Future technical improvements will continue to address the goals of lip and nasal symmetry, muscular continuity, precise scar concealment, and improved patient satisfaction in an increasing range of cleft phenotypes and during subsequent years of growth.

A Meta-Analysis of Palatal Repair Timing.

ABSTRACT: Developing midface hypoplasia is common after palatoplasty and has been hypothesized to be influenced by the timing of hard palate repair. This meta-analysis assesses the risk of developing midface hypoplasia based on age at hard palate repair. A Pubmed PRISMA systematic review and meta-analysis was completed for literature focused on palatoplasty and midface hypoplasia published between 1970 and 2019. Cephalometric data were extracted and categorized by age at hard palate repair: <6, 7 to 12, 13 to 18, 19 to 24, and 25 to 83 months. Analysis of these groups and a control were compared using independent T-tests and Spearman correlation coefficients. SNA angles for each group were 77.9 ±â€Š3.1° (<6 months), 77.7 ±â€Š4.2° (7-12 months), 78.7 ±â€Š4.2° (13-18 months), 75.1 ±â€Š4.2° (19-24 months), 75.5 ±â€Š4.8° (25-83 months), and were statistically different than the control group 82.4 ±â€Š3.5° (P < 0.0001). Hard palate repair at 13 to 18 months had a statistically significant greater SNA angle than all other groups except for the repair at <6 months group (P = 0.074). As age at hard palate closure increased beyond 18 months, the SNA decreased, corresponding to a more hypoplastic maxilla (Spearman's correlation coefficient -0.381, P = 0.015). Analysis suggests that younger age at the time of repair is less likely to create in midface hypoplasia in adulthood. Minimizing midface hypoplasia in cleft palate patients by optimizing algorithms of care is a practical way to decrease the burden of disease on patients, families and medical systems. Further studies are needed to evaluate the role of technique on outcomes.Level of Evidence: IV.

Clinical Importance of Concomitant Cleft Lip/Palate in the Surgical Management of Patients With Congenital Heart Disease.

BACKGROUND: Congenital heart disease (CHD) frequently occurs in conjunction with extracardiac developmental anomalies, including cleft malformations. The clinical impact of concomitant cleft disease on the surgical management of CHD has not been studied. We evaluated cardiac surgical outcomes in patients with concomitant CHD and cleft lip and/or palate (CL/P). METHODS: Patients with CHD + CL/P managed at our institution between January 2004 and December 2018 were included. Demographic, operative, and follow-up data were retrospectively collected and analyzed using SAS 9.4. Chi-square tests were used for categorical variables and t test or Wilcoxon rank sum tests for continuous variables. Significance of P < .05 was used. RESULTS: There were 127 patients with CHD + CL/P; 63 (50%) were boys. Compared to the general CHD population, patients with CHD + CL/P demonstrated an enrichment of atrial septal defects (10.5% vs 34%), tetralogy of Fallot/double outlet right ventricle (6.4% vs 15.7%), arch defects (4.5% vs 10.2%), truncus arteriosus (1.2% vs 3.1%), and total anomalous pulmonary venous return (1.0% vs 2.4%). Of 63 patients who underwent CHD repair, 58 (92%) did so prior to CL/P repair at 21.5 (6-114) days of age. Compared to CHD lesion-matched patients undergoing cardiac surgical repair at our institution, patients with CL/P had a 2- to 3.7-fold longer intensive care stay, 1.8- to 2.6-fold longer hospital stay, and 6- to 13.5-fold increase in major morbidity, without a significant difference in mortality. CONCLUSIONS: Cardiac outflow tract defects are particularly overrepresented in CL/P patients. The presence of CL/P increases the complexity of postoperative care after CHD surgery, without a significant impact on mortality.

The Local Mission: Improving Access to Surgical Care in Middle-Income Countries.

BACKGROUND: Billions of people lack access to quality surgical care. Short-term missions are used to supplement the delivery of surgical care in regions with poor access to care. Traditionally known for using international teams, Operation Smile has transitioned to using a local mission model, where surgical service is delivered to areas of need by teams originating within that country. This study investigates the proportion and location of Operation Smile missions that use the local mission model. METHODS: A retrospective review was performed of the Operation Smile mission database for fiscal years 2014 to 2019. Missions were classified into local or international missions. Countries were also classified by their income levels as well as their specialist surgical workforce (SAO) density. As no individual patient or provider data was recorded, ethics board approval was not warranted. RESULTS: Between 2014 and 2019, Operation Smile held an average of 144.8 (range 135-154) surgical missions per year. Local missions accounted for 97 ± 5.6 (67%) of the missions. Of the 34 program countries, 26 (76%) used local missions. Of the countries that had only international missions, six (75%) were low-income countries and the average SAO density was 1.54 (range 0.19-5.88) providers per 100,000 people. Of the countries with local missions, 24 (92%) were middle-income, and the average SAO density was 30.9 (range 3.4-142.4). CONCLUSION: International investments may assist in the creation of local surgical teams. Once teams are established, local missions are a valuable way to provide specialized surgical care within a country's own borders.

The Likelihood of Orthognathic Surgery After Orofacial Cleft Repair.

ABSTRACT: Midface hypoplasia is one of the most significant sequelae of cleft lip and/or palate surgery. A complete understanding of the rate of orthognathic surgery across varying cleft phenotypes is a powerful tool for educating patients and families as to the treatment course that the patient will incur during their lifetime. Understanding the average rates of orthognathic intervention also can act to develop metrics for outcome evaluation with different treatment protocols. Attempting to identify the average rates of orthognathic intervention, the authors conducted a systematic review and meta-analysis by combining studies from 1987 to 2016 describing the frequency of orthognathic intervention on the different cleft phenotypes as the primary outcome. Secondary outcomes included identification of surgical protocol, age of patient at orthognathic intervention, and the method by which patients were evaluated for orthognathic intervention. The rate of orthognathic surgery was 38.1% for bilateral cleft lip and palate (BCLP), 30.2% for unilateral cleft lip and palate (UCLP), 4.4% for isolated cleft palate (ICP), and 1.8% for patients with isolated cleft lip (ICL). 71% (n = 10) reported using lateral cephalograms for orthognathic surgery evaluation and only one of those studies reported specific objective cephalometric measurements for orthognathic intervention. Our findings demonstrated that BCLP possessed the highest rate of orthognathic intervention followed by UCLP, ICP, and ICL. ICP and ICL both possessed low rates of orthognathic intervention. By sharing our findings, the authors hope to provide a useful tool for informing patients' families as to their risk of needing orthognathic intervention.