Atypical facial clefts: Tessier number 3 and 4 clefts.

PURPOSE OF REVIEW: Tessier number 3 and 4 clefts result from failed fusion of facial processes during embryogenesis, and cause functional, psychosocial, and cosmetic morbidity. Given their rarity and heterogeneity, they present a unique challenge to the reconstructive surgeon, with limited literature for guidance. The purpose of this update is to summarize Tessier number 3 and 4 clefts with a focus on recent literature and expert opinion. RECENT FINDINGS: The incidence of atypical facial clefts has been estimated between 1.4 and 4.9 per 100 000 live births. Several retrospective chart reviews have been published in recent years; however, the epidemiologic data remains limited. Surgical management must be individualized and guided by classic reconstructive principles. The goal of surgery is to return the three soft tissue components (lip, nasomalar, and eyelid) to their proper anatomical location. SUMMARY: Tessier number 3 and 4 clefts are rare, demonstrate a wide spectrum of clinical presentation, and remain challenging to gain a breadth of experience for any single surgeon. They are classified based on their location along well defined anatomical axes. Component repair is performed with attention to the lip, nasomalar, and eyelid regions to restore facial symmetry and function.

Perspectives on the state of cleft lip and cleft palate patient care in Africa.

PURPOSE OF REVIEW: As the most common congenital craniofacial defect, patients with cleft lip -palate (CLP) experience morbidity and social stigma, particularly in low-income and middle-income countries (LMICs) such as those of sub-Saharan Africa (SSA). Delays in treatment secondary either to lack of awareness, skills, equipment and consumables; poor health infrastructure, limited resources or a combination of them, has led to SSA having the highest rates of death and second highest rates of disability-adjusted life years in patients with CLP globally. Here we review current perspectives on the state of comprehensive cleft lip and palate repair in Africa. RECENT FINDINGS: To bridge gaps in government health services, nongovernmental organizations (NGOs) have emerged to provide care through short-term surgical interventions (STSIs). These groups can effect change through direct provision of care, whereas others strengthen internal system. However, sustainability is lacking as there continue to be barriers to achieving comprehensive and longitudinal cleft care in SSA, including a lack of awareness of CLP as a treatable condition, prohibitive costs, poor follow-up, and insufficient surgical infrastructure. With dedicated local champions, a comprehensive approach, and reliable partners, establishing sustainable CLP services is possible in countries with limited resources. SUMMARY: The replacement of CLP 'missions' with locally initiated, internationally supported capacity building initiatives, integrated into local healthcare systems will prove sustainable in the long-term.

Geospatial evaluation of radiologic access in Rwanda.

BACKGROUND: Rwanda has aimed to rebuild its health care system since the Rwandan genocide against the Tutsis in 1994, though one of the challenges has been a scarcity of radiologic resources. OBJECTIVE: To assess the location and accessibility of radiologic facilities in Rwanda using geospatial mapping and population-based data. METHODS: A cross-sectional study was conducted in May 2023 using location and radiologic modality data provided by the Department of Radiology at the University Teaching Hospital of Kigali and the WorldPop database, a publicly available database providing open-access geospatial population data. Radiologic equipment included magnetic resonance (MR), computed tomography (CT), positron emission tomography (PET), radiotherapy, X-ray, mammography, and fluoroscopy machines. Geospatial analysis was performed using ArcGIS Pro 2.8.6 software. RESULTS: Fifty-six radiologic facilities were identified, including 5 MR, 7 CT, 1 radiotherapy, 52 X-ray, 5 mammography, 5 fluoroscopy, and 0 PET machines. There were 0.4 MR, 0.5 CT, 0 PET, 0.1 radiotherapy, 3.9 X-ray, 0.4 mammography, and 0.4 fluoroscopy units per 1 million people. CONCLUSION: Rwanda is one of the countries with the lowest radiologic access in East Africa; however, there is evidence of progress, particularly in more advanced diagnostic imaging techniques such as computed tomography and magnetic resonance imaging. CRITICAL RELEVANCE STATEMENT: This study provides a 10-year update on current radiologic resources and access in Rwanda, identifying areas of progress and ongoing scarcity, serving as a guide for future direction of growth. KEY POINTS: • As Rwanda works on rebuilding its health care system, this study provides an assessment of the current radiologic resources within the country. • There is less than one radiologic unit for every million of the Rwandan population for every imaging modality other than X-ray. • While radiologic access in Rwanda lags behind that of its neighbors, there has been growth focused on advanced imaging modalities and the training of human resources.

Prospective Outcomes of Noma Facial Reconstructive Surgery in Sokoto, Nigeria.

Background: Noma is a gangrenous infection of the face that results in severe facial deformity, occurring primarily in malnourished and impoverished populations. Objective: To assess clinician- and patient-reported outcomes (PROs) before and after reconstructive surgery for patients with noma in northwest Nigeria. Methods: Objective outcomes were recorded using the noma-specific NOITULP (nose, outer cheek, inner cheek, trismus, upper/lower lip, particularities) classification system. PROs were recorded using a locally developed tool. Postsurgical changes were assessed by Wilcoxon signed-rank testing. Linear regression was used to look for associated risk factors. The inter-rater reliability (IRR) of the NOITULP score was assessed using the weighted kappa statistic. Results: Forty-nine patients (median age 25 years, 71% male) underwent local/regional flap reconstruction and/or trismus release. Twelve complications were reported. Univariate analysis showed a 3.20 change in PRO score (95% confidence interval 0.59 to 5.81, p = 0.018) per kilogram the patient underwent at time of surgery. The NOITULP score improved from a presurgery median of 3.5 to 2.3 (p < 0.0001), however, the IRR was poor (kappa = 0.0894, p < 0.0001). The PRO score also improved from a median of 7.0 to 12.0 (p < 0.0001). Conclusions: Facial reconstructive surgery improves the NOITULP score and PROs in patients with noma in northwest Nigeria. Clinical Trial Registration: OCA017-63.

Wire Osteosynthesis in the Treatment of Mandible Fractures in Low Resource Settings: A Force Study.

Study Design: Cadaveric investigation. Objective: Rigid internal fixation (RIF) using plates and screws is often not feasible in low and middle-income countries due to limited resources. Interosseous wiring to achieve semi-rigid fixation is often used, but lacks biomechanical force data. Herein we aim to quantitatively compare interosseous wiring to RIF. Methods: Cadaveric mandibles were fractured at the parasymphysis and angle. Fixation was achieved using interosseous wiring in both single wire loop and figure-of-eight formations, as well as plate and screw fixation (n = 5 for each fixation type at each fracture site). A force gauge was used to measure the number of Newtons (N) required to achieve diastasis and complete failure at the fixation site. Results: For angle fractures, the mean force required for initial diastasis was 4.1, 5.9, and 10.9 N for single wire, figure-of-eight wiring, and plating respectively (P < .001). Complete failure was achieved with 152.9, 168.9, and 237.6 N of force for the three methods, respectively (P < .001). Complete failure was achieved for parasymphyseal fractures with 197.7, 263.0, and 262.8 N of force for single wire, figure-of-eight wiring, and plating respectively (P = .002). Forces to achieve initial diastasis for parasymphyseal fractures were not statistically significant among the three fixation methods (P = .29). Conclusions: Figure-of-eight interosseous wiring resists comparable forces across mandibular fractures compared to the gold standard of plating. In resource-limited settings when plates and screws are not available, this technique can be considered to achieve semi-rigid fixation of mandibular fractures.

Quantifying Facial Distortion in Modern Digital Photography.

BACKGROUND: Advancements in digital cameras and the advent of smartphones have magnified the importance of clinical photography in facial plastic surgery. Here, we aim to examine the effect of different camera types, focal lengths, and distances from subjects on facial distortion. METHODS: Twelve subjects underwent a series of frontal photographs using a smartphone camera and a full-frame digital single-lens reflex camera. Photos were captured at six distances from the subject. Seven focal lengths were used at each distance for the full-frame camera. Measurements of facial landmarks were made for each photo, with those made at 60 inches using the full-frame camera considered the gold standard and used for comparison. RESULTS: Distortion of facial features using the full-frame camera occurred when photos were captured 8 inches away using short focal lengths. A 12%-19% increase in vertical stretching of the midface occurred when using focal lengths of 24, 35, and 50 mm (p < 0.05 for all). The same features were distorted when a smartphone camera was used at 8 inches (18% increase, p < 0.01) and 12 inches (12% increase, p < 0.03). CONCLUSIONS: Distortion of midfacial features using both smartphones and full-frame cameras occurs with short, 'selfie' distances between the camera and subject. LEVEL OF EVIDENCE: 2 Laryngoscope, 134:1234-1238, 2024.

Factors Influencing Delay in Diagnosis of Head and Neck Cancer in Rwanda.

OBJECTIVE: Head and neck cancer is a significant contributor to global otolaryngologic disease burden, with a disproportionate impact on low- and middle-income countries. This study investigates the factors contributing to delays in head and neck cancer diagnosis at the University Teaching Hospital of Kigali (CHUK). METHODS: Cross-sectional study of all patients with a pathologic diagnosis of head and neck cancer presenting to CHUK between January 2021 and June 2022. Sociodemographic data, tumor characteristics, and reasons for delay were collected. Univariate and multivariable analyses were undertaken to evaluate risk factors for delays. RESULTS: Eighty-one patients met criteria for inclusion. Median duration from patient first reported symptoms to initial medical consultation was 52 weeks, from initial medical consultation to referral to CHUK was 4 weeks, and from referral to final pathologic diagnosis was 6 weeks. The most common reason for delay to referral to CHUK was financial (37.04%). Patients who visited traditional healers had higher odds of delay between symptom onset and medical consultation (OR 3.51, CI 1.05-11.70). Delays in final diagnosis after referral were most commonly due to OR availability for biopsy (37.04%) and time for pathology results after biopsy (35.80%). OR availability had a significant impact on duration to final diagnosis (OR 59.48, CI 7.17-493.67). Stage 4 disease had the shortest time to final diagnosis (OR 0.05, CI 0.01-0.45). CONCLUSION: Understanding the reasons for delayed diagnosis of head and neck cancer may help guide improvements in care, with the goal of reducing global head and neck burden of disease. LEVEL OF EVIDENCE: 3; prospective non-random follow-up study Laryngoscope, 134:1663-1669, 2024.

Cost Burden of Rigid Internal Fixation in Craniomaxillofacial Trauma Care in Low- and Middle-Income Countries.

Fractures of the craniomaxillofacial (CMF) skeleton cause significant morbidity and mortality in low- and middle-income countries (LMICs). Despite this, quality CMF trauma care is lacking for the majority of the world's population. There is a paucity of literature describing the costs of standard-of-care open reduction internal fixation (ORIF) for CMF fractures in LMICs. We consider the cost of a six-hole plate with six screws (SHPS), standard materials used in ORIF for CMF fractures, as a percentage of gross domestic product (GDP) per capita to ascertain the cost burden to patients. Hospital pricing catalog data at 14 LMIC institutions were queried. On average, the SHPS cost represented 10.2% of the GDP per capita in sampled LMICs. We highlight manufacturing costs, import taxes, and lack of subsidized health care as factors contributing to the significant cost burden of ORIF in these areas. Future work should characterize additional financial and socioeconomic barriers to optimal CMF care.

Variations in Payer-Negotiated Prices for Head and Neck Reconstructive Surgery.

OBJECTIVE: Little is known about pricing for reconstructive procedures of the head and neck. As of January 2021, the Centers for Medicare and Medicaid Services requires hospitals to disclose payer-negotiated prices for services, offering new insight into prices for privately insured patients. STUDY DESIGN: Cross-sectional analysis. SETTING: Turquoise database. METHODS: Payer-negotiated facility fees for 41 reconstructive surgeries were grouped by procedure type: primary closure, skin grafts, tissue rearrangement, locoregional flaps, or free flaps. Prices were normalized to account for local labor costs, then calculated as percent markup in excess of Medicare reimbursement. The mean percent markup between procedure groups was compared by the Kruskal-Wallis test. Subset analyses were performed to compare mean percent markup using a Student's t test. We also assessed price variation by calculating the ratio of 90th/10th percentile mean prices both across and within hospitals. RESULTS: In total, 1324 hospitals (85% urban, 81% nonprofit, 49% teaching) were included. Median payer-negotiated fees showed an increasing trend with more complex procedures, ranging from $379.54 (interquartile range [IQR], $230.87-$656.96) for Current Procedural Terminology (CPT) code 12001 ("simple repair of superficial wounds ≤2.5 cm") to $5422.60 ($3983.55-$8169.41) for CPT code 20969 ("free osteocutaneous flap with microvascular anastomosis"). Median percent markup was highest for primary closure procedures (576.17% [IQR, 326.28%-1089.34%]) and lowest for free flaps (99.56% [37.86%-194.02%]). Higher mean percent markups were observed for rural, for-profit, non-Northeast, nonteaching, and smaller hospitals. CONCLUSION: Wide variation in private payer-negotiated facility fees exists for head/neck reconstruction surgeries. Further research is necessary to better understand how pricing variation may correlate with out-of-pocket costs and quality of care.

Otolaryngology Training in Uganda: The Mbarara University of Science and Technology Experience.

Sub-Saharan Africa has a high otolaryngologic disease burden exacerbated by an inadequate number of otolaryngologists. The Otolaryngology department at Mbarara University of Science & Technology in Uganda is addressing this problem by having created Uganda's second national residency training program in 2010. We chronicled an early period in the program's development by reporting surgical case quantity and complexity, as defined by "key indicator procedure" classification per the United States Accreditation Council for Graduate Medical Education, and interpreting it with respect to a timeline of significant events. Procedure complexity, but not total number per year, increased over the study period-KIPs increased from 3% in 2012 (6 of 175 total procedures) to 29% in 2016 (35 of 135 total procedures). During this period of complexity increase, operating room capacity expanded, faculty received advanced training and increased in number, and operative equipment improved.

Noma, a neglected disease: prevention is better than cure.

PURPOSE OF REVIEW: There is a need for concerted effort to increase Global awareness about noma (cancrum oris). This paper aims to summarize the recent literature on noma and provide suggestions that could be implemented to raise awareness about this neglected disease. RECENT FINDINGS: Noma has been recognized, diagnosed and reported for centuries. Despite significant progress in scientific methods over time, the published literature on noma has predominantly been of low level clinical and scientific evidence. Recent studies have reported on noma's global distribution and its predisposing risk factors, its treatment, its knowledge and beliefs and has included a number of literature reviews. Noma cases are being reported from an increasingly diverse set of geographical locations. SUMMARY: Noma has largely been neglected in the research sphere. Noma is a preventable disease and its progression can be halted if patients are recognized and treated in the early stages of disease. Treatment for late stage noma survivors remains complex and time consuming, requiring substantial human and financial resources most commonly not achieving functional and cosmetic anatomy. The ultimate aim is therefore prevention, initiatives should be integrated into existing health programs.

Effect of Delay of Care for Patients with Craniomaxillofacial Trauma in Rwanda.

Objectives: Craniomaxillofacial (CMF) trauma represents a significant proportion of global surgical disease burden, disproportionally affecting low- and middle-income countries where care is often delayed. We investigated risk factors for delays to care for patients with CMF trauma presenting to the highest-volume trauma hospital in Rwanda and the impact on complication rates. Study Design: This prospective cohort study comprised all patients with CMF trauma presenting to the University Teaching Hospital of Kigali, Rwanda, between June 1 and October 1, 2020. Setting: Urban referral center in resource-limited setting. Methods: Epidemiologic data were collected, and logistic regression analysis was undertaken to explore risk factors for delays in care and complications. Results: Fifty-four patients (94.4% men) met criteria for inclusion. The mean age was 30 years. A majority of patients presented from a rural setting (n = 34, 63%); the most common cause of trauma was motor vehicle accident (n = 18, 33%); and the most common injury was mandibular fracture (n = 28, 35%). An overall 78% of patients had delayed treatment of the fracture after arrival to the hospital, and 81% of these patients experienced a complication (n = 34, P = .03). Delay in treatment was associated with 4-times greater likelihood of complication (odds ratio, 4.25 [95% CI, 1.08-16.70]; P = .038). Conclusion: Delay in treatment of CMF traumatic injuries correlates with higher rates of complications. Delays most commonly resulted from a lack of surgeon and/or operating room availability or were related to transfers from rural districts. Expansion of the CMF trauma surgical workforce, increased operative capacity, and coordinated transfer care efforts may improve trauma care.

Mobile Surgical Scouts Increase Surgical Access for Patients with Cleft Lip and Palate in Nepal.

Background: In Nepal's remote regions, challenging topography prevents patients with cleft lip and palate (CLP) from seeking care. Objective: To measure the effect of a mobile surgical scout program on CLP surgical care in remote regions of Nepal. Methods: Forty-four lay people were trained as mobile surgical scouts and over 5 months traversed remote districts of Nepal on foot to detect and refer CLP patients for surgical care. Surgical patients from remote districts were compared with matched time periods in the year before intervention. Diagnostic accuracy of the surgical scouts was assessed. Findings: Mobile surgical scouts accurately diagnosed (90%) and referred (82%) patients for cleft surgery. Before the intervention, CLP surgeries from remote districts represented 3.5% of cleft surgeries performed. With mobile surgical scouting, patients from remote districts comprised 8.2% of all cleft surgeries (p = 0.007). When transportation and accompaniment was provided in addition to mobile surgical scouts, patients from remote districts represented 13.5% (p ≤ 0.001) of all cleft surgeries. Conclusion: Task-shifting the surgical screening process to trained scouts resulted in accurate diagnoses, referrals, and increased access to cleft surgery in remote districts of Nepal.

The history of nasal reconstruction.

PURPOSE OF REVIEW: Total nasal reconstruction is a unique plastic surgery challenge of the highest order. The history of nasal reconstruction dates back to ancient times and it remains a fundamental challenge today. This article reviews the historical context of nasal reconstruction, and highlights how the essential tenets of this art have been conserved over millennia. RECENT FINDINGS: The disfiguring and brutal practice of nasal amputation created a demand for 'nosemakers' in India since 1500 BC. In 600 BC, Sushruta described the use of a leaf to make a template of the wound, and a cheek flap to supply tissue. In the 1400-1500s, the Italians relied on similar flap concepts, but employed a pedicled arm flap for soft tissue coverage. Eventually, the forehead flap, or 'Indian method' of nasal reconstruction, made its way to Europe in the 1800s. Its use has been a fundamental component of nasal reconstruction to this day. SUMMARY: Knowledge of the unique history of nasal reconstruction permits appreciation of this surgical integration of art and science. The story of nasal reconstruction has been one of global contribution and creativity that has stood the test of time.

The digital doctor: telemedicine in facial plastic surgery.

PURPOSE OF REVIEW: In the setting of the COVID-19 global pandemic, the demand for and use of telemedicine has surged in facial plastic and reconstructive surgery. This review aims to objectively review and summarize the existing evidence for the use of telemedicine within facial plastic surgery. RECENT FINDINGS: Telemedicine has been successfully implemented among subsets of facial plastic surgery patients, with high patient and provider satisfaction. Although the technology to facilitate telemedicine exists and preliminary studies demonstrate promise, multiple technological, financial, and medical barriers may persist in the postpandemic era. SUMMARY: Telemedicine will likely continue to grow and expand within facial plastic surgery moving forward, and we should continue to critically evaluate patient selection, access to care, and strategies for effective implementation to enhance current clinical practices.