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Midface hypoplasia (MFH) is a long-term sequela of cleft lip and palate repair, and is poorly understood. No study has examined the aggregate data on sagittal growth restriction of the midface following repair of the lip, but not palate, in these patients.A systematic review of 3780 articles was performed. Twenty-four studies met inclusion criteria and 11 reported cephalometric measurements amenable to meta-analysis. Patients with Veau class I-III palatal clefts were included so long as they had undergone only lip repair. Groups were compared against both noncleft and unrepaired controls.Cephalometrics were reported for 326 patients (31.3% female). Noncleft controls had an average SNA angle of 81.25° ± 3.12°. The only patients demonstrating hypoplastic SNA angles were those with unilateral CLP with isolated lip repair (77.4° ± 4.22°). Patients with repaired CL had SNA angles similar to noncleft controls (81.4° ± 4.02°). Patients with unrepaired CLP and CL tended toward more protruding maxillae, with SNA angles of 83.3° ± 4.04° and 87.9° ± 3.11°, respectively. Notably, when comparing SNA angles between groups, patients with CLP with isolated lip repair had significantly more hypoplastic angles compared to those with repaired CL (P < .0001). Patients with CLP with isolated lip repair were also more hypoplastic than noncleft controls (P < .0001). In contrast, there was no significant difference between the SNA of patients with repaired CL and controls (P = .648).We found that cleft lip repair only appeared to contribute to MFH in the setting of concurrent cleft palate pathology, suggesting that scarring from lip repair itself is unlikely to be the predominant driver of MFH development. However, studies generally suffered from inadequate reporting of timing, technique, follow-up time, and cleft severity.
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Labio Leporino , Fisura del Paladar , Humanos , Femenino , Masculino , Labio Leporino/cirugía , Labio Leporino/patología , Fisura del Paladar/cirugía , Fisura del Paladar/patología , Cara , Maxilar , Cefalometría/métodosRESUMEN
OBJECTIVE: The influence of different surgical techniques on maxillary growth remains unclear. This study investigates the long-term impact of Furlow double-opposing Z-plasty versus straight-line repair (SLR) techniques on midface growth and subsequent orthognathic surgery. DESIGN: Retrospective cohort study. SETTING: Tertiary children's hospital. PATIENTS/PARTICIPANTS: This study evaluated patients who underwent primary palatoplasty with Furlow or SLR techniques from 1994-2023. Patients were >14 years old at their most recent follow-up. INTERVENTIONS: No interventions were performed. MAIN OUTCOME MEASURE(S): Primary outcomes were orthognathic surgery and orthognathic surgery recommendation rates to correct midface hypoplasia (MFH). Cephalometrics at the time of orthognathic surgery recommendation were traced to validate MFH. RESULTS: In total, 1857 patients underwent palatoplasty, of which 335 met inclusion criteria (49 SLR, 286 Furlow). Average age at last follow-up was 18.5±2.6 years. Patients who underwent Furlow versus SLR showed no significant difference in orthognathic surgery rates (p=0.428) or recommendation for orthognathic surgery rates (p=0.900). Patients recommended to undergo orthognathic surgery had more negative ANB angles (p<0.001) and smaller SNA angles (p<0.001) than patients not recommended for orthognathic surgery, demonstrating maxillary hypoplasia. Upon multivariate regression, patients with Veau III and IV clefts had an increased need for orthognathic surgery, p=0.047 and p=0.008, respectively. CONCLUSIONS: Our findings suggest that higher cleft severity contributes to future orthognathic surgery. However, palatoplasty technique did not influence orthognathic surgery rates. Our results provide valuable data when surgeons are considering the impact of palatoplasty technique on sagittal growth restriction.
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Cleft palate is among the most common congenital disorders worldwide and is correctable through surgical intervention. Sub-optimal surgical results may cause velopharyngeal insufficiency (VPI). When symptomatic, VPI can cause hypernasal or unintelligible speech. The postoperative risk of VPI varies significantly in the literature but may be attributed to differences in study size, cleft type, surgical technique, and operative age. To identify the potential impact of these factors, a systematic review was conducted to examine the risk of VPI after primary palatoplasty, accounting for operative age and surgical technique. A search of PubMed, Embase, and Web of Science was completed for original studies that examined speech outcomes after primary palatoplasty. The search identified 4740 original articles and included 35 studies that reported mean age at palatoplasty and VPI-related outcomes. The studies included 10,795 patients with a weighted mean operative age of 15.7 months (range: 3.1-182.9 mo), and 20% (n=2186) had signs of postoperative VPI. Because of the heterogeneity in reporting of surgical technique across studies, small sample sizes, and a lack of statistical power, an analysis of the VPI risk per procedure type and timing was not possible. A lack of data and variable consensus limits our understanding of optimal timing and techniques to reduce VPI occurrence. This paper presents a call-to-action to generate: (1) high-quality research from thoughtfully designed studies; (2) greater global representation; and (3) global consensus informed by high-quality data, to make recommendations on optimal technique and timing for primary palatoplasty to reduce VPI.
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Fisura del Paladar , Procedimientos de Cirugía Plástica , Insuficiencia Velofaríngea , Humanos , Fisura del Paladar/cirugía , Incidencia , Insuficiencia Velofaríngea/epidemiología , Insuficiencia Velofaríngea/cirugía , ConsensoRESUMEN
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 (84.5â±â4.0°), BCLP (85.3â±â2.8°), and ICP (79.2â±â4.2°) were statistically different than controls (82.4â±â3.5°), (all P ≤ 0.001). SNA angles for operated UCLP (76.2â±â4.2°), BCLP (79.8â±â3.6°), and ICP (79.0â±â4.3°) groups were statistically smaller than controls (all P ≤ 0.001). SNA angle in unoperated ICP (nâ=â143) was equivalent to operated ICP patients (79.2â±â4.2° versus 79.0â±â4.3° Pâ=â0.78). No unoperated group mean SNA met criteria for midface hypoplasia (SNAâ<â80). 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.
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Labio Leporino , Fisura del Paladar , Cefalometría , Labio Leporino/complicaciones , Labio Leporino/cirugía , Fisura del Paladar/complicaciones , Fisura del Paladar/cirugía , Humanos , Maxilar/cirugíaRESUMEN
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.
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Países en Desarrollo , Misiones Médicas , Humanos , Renta , Estudios RetrospectivosRESUMEN
ABSTRACT: Crowd sourcing has been used in multiple disciplines to quickly generate large amounts of diverse data. The objective of this study was to use crowdsourcing to grade preoperative severity of unilateral cleft lip phenotype in a multiethnic cohort with the hypothesis that crowdsourcing could efficiently achieve similar rankings compared to expert surgeons. Deidentified preoperative photos were collected for patients with primary, unilateral cleft lip with or without cleft palate (CLâ±âP). A platform was developed with C-SATS for pairwise comparisons utilizing Elo rankings by crowdsource workers through Amazon Mechanical Turk. Images were independently ranked by 2 senior surgeons for comparison. Seventy-six patients with varying severity of unilateral (CLâ±âP) phenotype were chosen from Operation Smile missions in Bolivia, Madagascar, Vietnam, and Morocco. Patients were an average of 1.2 years' old, ranging from 3 months to 3.3 years. Each image was compared with 10 others, for a total of 380 unique pairwise comparisons. A total of 4627 total raters participated with a median of 12 raters per pair. Data collection was completed in <20âhours. The crowdsourcing ranking and expert surgeon rankings were highly correlated with Pearson correlation coefficient of Râ=â0.77 (Pâ=â0.0001). Crowdsourcing provides a rapid and convenient method of obtaining preoperative severity ratings, comparable to expert surgeon assessment, across multiple ethnicities. The method serves as a potential solution to the current lack of rating systems for preoperative severity and overcomes the difficulty of acquiring large-scale assessment from expert surgeons.
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Labio Leporino , Fisura del Paladar , Colaboración de las Masas , Labio Leporino/cirugía , Fisura del Paladar/cirugía , Humanos , Tecnología , VietnamRESUMEN
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 77.9â±â3.1° (<6 months), 77.7â±â4.2° (7-12 months), 78.7â±â4.2° (13-18 months), 75.1â±â4.2° (19-24 months), 75.5â±â4.8° (25-83 months), and were statistically different than the control group 82.4â±â3.5° (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 (Pâ=â0.074). 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, Pâ=â0.015). 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.
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Labio Leporino , Fisura del Paladar , Procedimientos de Cirugía Plástica , Adulto , Biometría , Cefalometría , Labio Leporino/cirugía , Fisura del Paladar/cirugía , Humanos , Maxilar/cirugía , Paladar Duro/cirugíaRESUMEN
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% (nâ=â10) 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.
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Labio Leporino , Fisura del Paladar , Cirugía Ortognática , Procedimientos Quirúrgicos Ortognáticos , Cefalometría , Labio Leporino/cirugía , Fisura del Paladar/cirugía , Humanos , Estudios RetrospectivosRESUMEN
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.
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Labio Leporino , Procedimientos de Cirugía Plástica , Labio Leporino/cirugía , Estética Dental , Humanos , Labio/cirugía , Colgajos QuirúrgicosRESUMEN
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.
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Labio Leporino , Fisura del Paladar , Niño , Labio Leporino/cirugía , Fisura del Paladar/cirugía , Femenino , Hospitales Pediátricos , Humanos , Estudios Retrospectivos , Centros de Atención TerciariaRESUMEN
PURPOSE: An intracranial approach to the craniomaxillofacial skeleton can be effective for correcting complex craniofacial dystoses such as frontofacial hypoplasia, hypertelorism, and orbital dystopia. However, the significant morbidity resulting from the high complication rates has limited intracranial use. Given the need for intracranial approaches for certain clinical indications, the present study reevaluated intracranial frontofacial procedures to determine their safety and outcomes. PATIENTS AND METHODS: A retrospective review was performed of all frontofacial procedures completed between 2007 and 2017 at a single institution. Patients who had undergone monobloc distraction alone or with facial bipartition, facial bipartition alone, or box osteotomy were included in the intracranial cohort. Those who had undergone Le Fort III distraction, advancement, or a combination with Le Fort I were included in the subcranial cohort. The recorded data included demographics, previous craniofacial surgery, and operative events. The complications rates were compared between the 2 cohorts. RESULTS: The present study included 65 patients-35 subcranial and 30 intracranial. The rates of previous craniomaxillofacial (P = .193) and intracranial (P = .340) surgery were equivalent between the 2 cohorts. Of the 30 intracranial and 35 subcranial patients, 26.7% and 34.3% experienced complications (P = .218). The intracranial patients experienced more dural tears (53.3 vs 5.7%; P < .0001); however, no significant differences were observed in cerebrospinal fluid leakage. Reintubations (n = 3; 4.5%) occurred exclusively in the subcranial group. No significant differences in the major and minor complication rates were observed between the 2 cohorts. CONCLUSIONS: Intracranial and subcranial frontofacial procedures are associated with an equal risk of major and minor complications. Given the lack of an increase in risk, intracranial frontofacial procedures should be considered for the management of complex craniofacial dystoses.
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Disostosis Craneofacial , Osteogénesis por Distracción , Hueso Frontal/cirugía , Humanos , Maxilar , Osteotomía , Osteotomía Le Fort , Estudios RetrospectivosRESUMEN
BACKGROUND: Although combined monobloc facial bipartition with distraction (MFBD) may simultaneously correct multiple facial dimensions in patients with syndromic craniosynostoses, complication risks limit its use. This study reassesses MFBD complications and outcomes to compare safety and efficacy to monobloc distraction (MD) and facial bipartition (FB) alone. METHODS: A retrospective review of MFBD, MD, and FB cases for 10 years at a tertiary children's hospital was performed. Patient demographics and surgical variables were compared between cohorts. Distraction distance was compared between MFBD and MD. Correction of interdacryon distance in MFBD compared with FB was measured on preoperative and postoperative computed tomographic scans. SPSS 17 was used for data analysis. RESULTS: Twenty-two total patients, 11 MFBD, 4 MD, and 7 FB, met the inclusion criteria. Three MFBD (27.3%) patients experienced complications, including 1 osteomyelitis and 2 hardware displacements. One MD patient (25%) experienced a postoperative complication consisting of a wound infection. Three FB patients (42.9%) experienced either cerebrospinal fluid leak, seroma, mucocele, hardware exposure, and/or orbital dystopia (n = 1 each). Patients with MFBD had significantly longer intensive care unit stay (P ≤ 0.05), but no difference in hospital stay (P = 0.421). Mean distraction length was similar between MFBD and MD (P = 0.612). There was no significant difference in final (P = 0.243) or change (P = 0.189) in interdacryon distance between MFBD and FB patients. CONCLUSIONS: In our experience, MFBD has similar complication rates compared with MD and FB alone. Given equivalent safety and postoperative correction of facial dimensions, MFBD could be more widely considered for select patients.
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Disostosis Craneofacial , Craneosinostosis , Osteogénesis por Distracción , Niño , Cara , Huesos Faciales , Humanos , Estudios RetrospectivosRESUMEN
Normocephalic pancraniosynostosis is a rare form of craniosynostosis that usually presents later in life secondary to a delayed onset of symptoms and the presence of a normal head shape. Since its initial description in the literature in 2010, normocephalic pancraniosynostosis remains a rare clinical entity that has only been reported in 6 patients. Surgical treatment in the 2 published reports has been by staged total calvarial reconstruction or anterior cranial vault remodeling with bilateral frontoorbital advancement. In this case report, the authors present 1 patient with normocephalic pancraniosynostosis and propose surgical treatment by anterior cranial vault expansion with distraction osteogenesis.
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Craneosinostosis/cirugía , Osteogénesis por Distracción/métodos , Procedimientos de Cirugía Plástica/métodos , Cráneo/cirugía , Preescolar , Craneosinostosis/diagnóstico , Femenino , Humanos , Cráneo/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
Surgical training is facing new obstacles. As advancements in medicine are made, surgeons are expected to know more and to be able to perform more procedures. In the western world, increasing restrictions on residency work hours are adding a new hurdle to surgical training. In low-resource settings, a low attending-to-resident ratio results in limited operative experience for residents. Advances in telemedicine may offer new methods for surgical training. In this article, the authors share their unique experience using live video broadcasting of surgery for educational purposes at a comprehensive cleft care center in Guwahati, India.
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Labio Leporino/cirugía , Educación de Postgrado en Medicina/métodos , Procedimientos de Cirugía Plástica/educación , Telemedicina/métodos , Grabación en Video , Humanos , India , Internado y ResidenciaRESUMEN
Humanitarian cleft surgery has long been provided by teams from resource-rich countries traveling for short-term missions to resource-poor countries. After identifying an area of durable unmet need through surgical missions, Operation Smile constructed a permanent center for cleft care in Northeast India. The Operation Smile Guwahati Comprehensive Cleft Care Center (GCCCC) uses a high-volume subspecialized institution to provide safe, quality, comprehensive, and cost-effective cleft care to a highly vulnerable patient population in Assam, India. The purpose of this study was to profile the expenses of several cleft missions carried out in Assam and to compare these to the expenditures of the permanent comprehensive cleft care center. We reviewed financial data from 4 Operation Smile missions in Assam between December 2009 and February 2011 and from the GCCCC for the 2012-2013 fiscal year. Expenses from the 2 models were categorized and compared. In the studied period, 33% of the mission expenses were spent locally compared to 94% of those of the center. The largest expenses in the mission model were air travel (48.8%) and hotel expenses (21.6%) for the team, whereas salaries (46.3%) and infrastructure costs (19.8%) made up the largest fractions of expenses in the center model. The evolution from mission-based care to a specialty hospital model in Guwahati incorporated a transition from vertical inputs to investments in infrastructure and human capital to create a sustainable local care delivery system.
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Altruismo , Labio Leporino/cirugía , Fisura del Paladar/cirugía , Atención Integral de Salud/economía , Hospitales Especializados/economía , Misiones Médicas/economía , Análisis Costo-Beneficio , Costos de los Medicamentos , Educación Profesional/economía , Equipos y Suministros/economía , Equipos y Suministros de Hospitales/economía , Gastos en Salud , Administración Hospitalaria/economía , Hospitales Especializados/organización & administración , Humanos , India , Inversiones en Salud , Salarios y Beneficios , Transportes/economía , Viaje/economía , Poblaciones VulnerablesRESUMEN
Frontofacial surgery, encompassing the monobloc with or without facial bipartition and the box osteotomy, can treat the frontal bone and midface simultaneously, providing comprehensive improvement in facial balance. Complex pediatric patients with genetic syndromes and craniosynostosis are most optimized by an interdisciplinary team of surgeons, pediatricians, geneticists, speech pathologists, audiologists, dietitians, pediatric dentists, orthodontists, and psychosocial support staff to manage the myriad of challenges and complications throughout early childhood and beyond. Despite early treatment of the anterior and posterior cranial vault, these patients frequently have resultant frontal and/or midface hypoplasia and orbital abnormalities that are best managed with simultaneous surgical treatment.
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Craneosinostosis , Osteogénesis por Distracción , Niño , Preescolar , Craneosinostosis/cirugía , Hueso Frontal/cirugía , Humanos , OsteotomíaRESUMEN
BACKGROUND: Unilateral cleft palates have a large spectrum of variability. Key morphologic factors such as cleft width and palatal length are not represented in current classification systems. Palate length and velopharyngeal port size are clinically linked to speech outcomes, as the soft palate must close the posterior pharynx for proper phonation. This study investigates the relationship between objective preoperative measures and postoperative velopharyngeal port size, to define a reproducible severity scale. METHODS: Surgical data were prospectively collected from unilateral cleft palate patients in Morocco, Bolivia, Vietnam, and Madagascar. Key measurements were cleft width and palate width at the hard-soft palate junction, alveolar cleft width, vertical alveolar discrepancy, velopharyngeal port size. Cleft width ratio (CWR) was defined as the width of the cleft at the hard-soft junction, divided by the palate width. RESULTS: Seventy-six patients were evaluated. Thirty-one had complete clefts and average age at surgical repair was 2.9 years. Mean CWR was 0.50 ± 0.12. Palate length was increased by an average of 2.2 mm (11%) after palatoplasty. Multivariate analysis determined greater CWR and larger preoperative velopharyngeal ports were significantly correlated with a smaller percent change in palate length after palatoplasty (P < 0.01). CONCLUSIONS: A wider palatal cleft decreases the surgeon's ability to decrease velopharyngeal port size through palatoplasty. Given the ease of measurement even in low-resource settings, CWR may be a valuable tool for setting expectations for speech results, modifying surgical technique, and correlating future speech outcomes in evidence-based cleft care.
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OBJECTIVE: Short-term, high-volume surgical training experiences can lead to successful skills transfer and be an effective method of training surgical providers in low-resource settings. However, immediate skills acquisition does not guarantee long-term performance of surgical procedures by trainees. This study aims to determine the long-term impact of a short-term plastic surgery training rotation (STR) on general surgeon contribution to plastic surgery capacity building in Rwanda. DESIGN: A retrospective survey study was conducted. Surveys were distributed to credentialed general surgeons who previously participated in the Operation Smile STR in Rwanda. Questions focused on exposure to procedures during the rotation and current practice demographics. The percentage of current practice volumes dedicated to plastic surgery was mapped to demonstrate participant contribution to plastic surgery capacity in the country. SETTING: Surveys were distributed remotely. Surgeon respondents previously participated in the STR at the Rwinkwavu District Hospital, a primary level hospital in eastern Rwanda. PARTICIPANTS: All 8 prior participants of the STR who completed residency and are currently practicing as general surgeons in Rwanda were included. RESULTS: Six out of 8 prior participants completed the survey (75.0%). All respondents work as general surgeons in governmental hospitals around the country. Up to 75% of surgeon caseloads are dedicated to plastic surgery procedures. Half of respondents work in regions without a credentialed plastic surgeon. Exposure to cleft and congenital hand surgery during the rotation did not lead to durable performance in practice. All participants felt the rotation improved their performance in multiple core competencies. CONCLUSION: Participation in a short-term plastic surgery training experience in Rwanda was associated with increased long-term surgical capacity in the country through a task-sharing model. A mission-based rotation may provide sufficient exposure for basic plastic surgery procedures, but does not provide enough volume or time to durably teach more complicated surgeries such as cleft repair. Further studies are needed to determine how longer durations of training exposure impacts long-term performance of plastic surgery procedures.
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Cirugía General , Internado y Residencia , Cirugía Plástica , Creación de Capacidad , Cirugía General/educación , Humanos , Estudios Retrospectivos , Rotación , Rwanda , Cirugía Plástica/educaciónRESUMEN
Radioulnar heterotopic ossification is a rare occurrence found in approximately 2% of all forearm injuries. Treatment is complicated by relatively high recurrence rates. Strategies to decrease recurrence have included the range of motion exercises and the interposition of inert or autogenous barriers. We report on the interposition of human acellular dermal matrix (ADM) for the treatment of distal radioulnar synostosis. We report a novel technique for the treatment of distal radioulnar heterotopic ossification. After resection, ADM in a cigar-shaped construct is interposed between the radius and ulna. Patients are followed clinically and radiographically. Two female patients were treated. Both patients had significant improvement in the range of motion in supination and pronation of the affected wrist postoperatively with an average follow-up of 36 months. There were no postoperative complications. Neither patient had recurrent disease. We describe the successful treatment of 2 patients with distal radioulnar heterotopic ossification with the use of human ADM. The ADM provides a barrier between the radius and ulna to prevent the recurrent formation of heterotopic ossification. ADM usage results in no donor site morbidity and is theoretically more resistant to infection when compared with nonbiologic barriers such as silicone and Integra. This technique is a simple, safe, and effective way to treat and prevent the recurrence of radioulnar heterotopic ossification.