AI-based Cleft Lip and Palate Surgical Information is Preferred by Both Plastic Surgeons and Patients in a Blind Comparison.

INTRODUCTION: The application of artificial intelligence (AI) in healthcare has expanded in recent years, and these tools such as ChatGPT to generate patient-facing information have garnered particular interest. Online cleft lip and palate (CL/P) surgical information supplied by academic/professional (A/P) sources was therefore evaluated against ChatGPT regarding accuracy, comprehensiveness, and clarity. METHODS: 11 plastic and reconstructive surgeons and 29 non-medical individuals blindly compared responses written by ChatGPT or A/P sources to 30 frequently asked CL/P surgery questions. Surgeons indicated preference, determined accuracy, and scored comprehensiveness and clarity. Non-medical individuals indicated preference. Calculations of readability scores were determined using seven readability formulas. Statistical analysis of CL/P surgical online information was performed using paired t-tests. RESULTS: Surgeons, 60.88% of the time, blindly preferred material generated by ChatGPT over A/P sources. Additionally, surgeons consistently indicated that ChatGPT-generated material was more comprehensive and had greater clarity. No significant difference was found between ChatGPT and resources provided by professional organizations in terms of accuracy. Among individuals with no medical background, ChatGPT-generated materials were preferred 60.46% of the time. For materials from both ChatGPT and A/P sources, readability scores surpassed advised levels for patient proficiency across seven readability formulas. CONCLUSION: As the prominence of ChatGPT-based language tools rises in the healthcare space, potential applications of the tools should be assessed by experts against existing high-quality sources. Our results indicate that ChatGPT is capable of producing high-quality material in terms of accuracy, comprehensiveness, and clarity preferred by both plastic surgeons and individuals with no medical background.

US air pollution is associated with increased incidence of non-syndromic cleft lip/palate.

Maternal cigarette use is associated with the fetal development of orofacial clefts. Air pollution should be investigated for similar causation. We hypothesize that the incidence of non-syndromic cleft lip with or without palate (NSCLP) and non-syndromic cleft palate (NSCP) would be positively correlated with air pollution concentration. METHODS: The incidence of NSCLP and NSCP per 1000 live births from 2016 to 2020 was extracted from the Centers for Disease Control and Prevention Vital Statistics Database and merged with national reports on air pollution using the Environmental Protection Agency Air Quality Systems annual data. The most commonly reported pollutants were analyzed including benzene, sulfur dioxide (SO2), particulate matter (PM) 2.5, PM 10, ozone (O3), and carbon monoxide (CO). Multivariable negative binomial and Poisson log-linear regression models evaluated the incidence of NSCLP and NSCP as a function of the pollutants, adjusting for race. All p-values are reported with Bonferroni correction. RESULTS: The median NSCLP incidence was 0.22/1000 births, and isolated NSCP incidence was 0.18/1000 births. For NSCLP, SO2 had a coefficient estimate (CE) of 0.60 (95% CI [0.23, 0.98], p < 0.007) and PM 2.5 had a CE of 0.20 (95% CI [0.10, 0.31], p < 0.005). Among isolated NSCP, no pollutants were found to be significantly associated. CONCLUSION: SO2 and PM 2.5 were significantly correlated with increased incidence of NSCLP. The American people and perinatal practitioners should be aware of the connection to allow for risk reduction and in utero screening.

A Retrospective Review of Outcomes and Complications after Infant Ear Molding at a Single Institution.

Background: The purpose of this study was to evaluate outcomes and complications associated with infant ear molding at a single institution. Methods: We conducted a retrospective chart review of all infants who underwent ear molding using the EarWell Infant Ear Correction System with pediatric plastic surgery from October 2010 to March 2021. Types of ear anomalies, age at initiation, duration of treatment, gaps in treatment, comorbidities, and complications were extracted for included patients. The primary outcomes assessed were degree of ear anomaly correction and incidence of skin complications. Parents were also sent a questionnaire regarding their long-term satisfaction with the ear molding treatment process. Results: A total of 184 ears of 114 patients meeting inclusion criteria were treated during the study period. Mean age at treatment initiation was 21 days, and average duration of treatment was 40 days. Helical rim deformities (N = 50 ears) and lop ear (N = 40 ears) were the most common anomalies. A total of 181 ears (98.4%) achieved either a complete (N = 125 ears, 67.9%) or partial correction (N = 56 ears, 30.4%). The most common complications were eczematous dermatitis (N = 27 occurrences among 25 ears, 13.6%) and pressure ulcers (N = 23 occurrences among 21 ears, 12.5%). Infants who experienced a complication were 3.36 times more likely to achieve partial relative to complete correction (P < 0.001; 95% confidence interval 1.66-6.81). Conclusion: Ear molding is an effective treatment strategy for infant ear anomalies, with most patients achieving complete correction.

Disruptive Therapy Using a Nonsurgical Orthodontic Airway Plate for the Management of Neonatal Robin Sequence: 1-Year Follow-up.

We recently published the 3-month follow-up of 2 neonates with Robin sequence whose mandibular hypoplasia and restricted airway were successfully treated with an orthodontic airway plate (OAP) without surgical intervention. Both infants were successfully weaned off the OAP after several months of continuous use. We present the course of OAP treatment in these patients with a focus on breathing, feeding, and facial growth during their first year of life. Both infants demonstrated stable mandibular projection, resolution of obstructive sleep apnea, and normal development.

Nonsurgical Orthodontic Airway Plate Treatment for Newborns With Robin Sequence.

Despite promising outcomes for >50 years, nonsurgical orthodontic airway plates (OAP) are only infrequently offered for babies with Robin sequence in a few parts of the world. This article demonstrates possibility of providing functional improvement using an OAP to help these babies overcome their functional and structural difficulties on their own. Two consecutively treated cases are presented exemplifying that OAP treatment that had originated from Europe is reproducible and effective in an institution in the United States.

Readability of Online Patient Information Relating to Cleft Palate Surgery.

OBJECTIVE: It is important for health care education materials to be easily understood by caretakers of children requiring craniofacial surgery. This study aimed to analyze the readability of Google search results as they pertain to "Cleft Palate Surgery" and "Palatoplasty." Additionally, the study included a search from several locations globally to identify possible geographic differences. DESIGN: Google searches of the terms "Cleft Palate Surgery" and "Palatoplasty" were performed. Additionally, searches of only "Cleft Palate Surgery" were run from several internet protocol addresses globally. MAIN OUTCOME MEASURES: Flesch-Kincaid Grade Level and Readability Ease, Gunning Fog Index, Simple Measure of Gobbledygook (SMOG) index, and Coleman-Liau Index. RESULTS: Search results for "Cleft Palate Surgery" were easier to read and comprehend compared to search results for "Palatoplasty." Mean Flesch-Kincaid Grade Level scores were 7.0 and 10.11, respectively (P = .0018). Mean Flesch-Kincaid Reading Ease scores were 61.29 and 40.71, respectively (P = .0003). Mean Gunning Fog Index scores were 8.370 and 10.34, respectively (P = .0458). Mean SMOG Index scores were 6.84 and 8.47, respectively (P = .0260). Mean Coleman-Liau Index scores were 12.95 and 15.33, respectively (P = .0281). No significant differences were found in any of the readability measures based on global location. CONCLUSIONS: Although some improvement can be made, craniofacial surgeons can be confident in the online information pertaining to cleft palate repair, regardless of where the search is performed from. The average readability of the top search results for "Cleft Palate Surgery" is around the seventh-grade reading level (US educational system) and compares favorably to other health care readability analyses.

A Systematic Review of Mandibular Distraction Osteogenesis Versus Orthodontic Airway Plate for Airway Obstruction Treatment in Pierre Robin Sequence.

OBJECTIVE: Mandibular distraction osteogenesis (MDO) is frequently performed to address airway obstruction in patients with Pierre Robin sequence (PRS), though more recently the technique of orthodontic airway plating (OAP) has gained traction. We aimed to evaluate OAP compared to MDO for airway obstruction in PRS. DESIGN: A systematic literature search across PubMed, Embase, and Google Scholar identified all studies published in English, which involved MDO or any form of OAP as treatments for PRS. All relevant articles were reviewed in detail and reported on, adhering to PRISMA guidelines. MAIN OUTCOME MEASURES: Airway (tracheostomy avoidance, decannulation rate), feeding (full oral feeding tolerance). RESULTS: Literature search identified 970 articles, of which 42 MDO studies and 9 OAP studies met criteria for review. A total of 1159 individuals were treated with MDO, and 322 individuals were treated with OAP. Primary outcomes appear similar for MDO and OAP at face value; however, this must be interpreted with different pretreatment contexts in mind. CONCLUSIONS: Orthodontic airway plating may be considered for airway obstruction in PRS, as some airway-related and feeding-related outcomes appear similar with MDO, per existing evidence in the literature. However, since PRS severity differed between studies, OAP cannot be uniformly considered a replacement for MDO. Further research is required to more comprehensively assess these treatment modalities inclusive of metrics that allow for direct comparison.

Rates of Revision and Obstructive Sleep Apnea after Surgery for Velopharyngeal Insufficiency: A Longitudinal Comparative Analysis of More Than 1000 Operations.

BACKGROUND: The purpose of this study was to evaluate the comparative incidence of obstructive sleep apnea following velopharyngeal insufficiency surgery in the United States. METHODS: A retrospective analysis of cleft and noncleft pediatric patients who underwent velopharyngeal insufficiency surgery was performed using the IBM MarketScan Commercial Database. Patients were tracked longitudinally from 2007 to 2016 to evaluate the incidence of obstructive sleep apnea. Multivariable regression was used to evaluate predictors of postoperative obstructive sleep apnea and surgical revision. RESULTS: A total of 1098 patients underwent a pharyngeal flap (61.0 percent), sphincter pharyngoplasty (22.2 percent), or palatal lengthening with or without island flaps (16.8 percent). Diagnoses were predominantly cleft lip and/or palate (52.8 percent) and congenital oropharyngeal anomalies (42.6 percent). Eighty patients (7.3 percent) developed obstructive sleep apnea at an average of 10.2 months postoperatively. Predictors of obstructive sleep apnea included older age (p = 0.014) and head and neck neoplasm (p = 0.011). The obstructive sleep apnea rate following sphincter pharyngoplasty was 11.1 percent, compared to 7.2 percent after pharyngeal flap surgery. Compared to sphincter pharyngoplasty, pharyngeal flap surgery was associated with a lower risk of further surgery (OR, 0.43; p = 0.010). Of patients with cleft lip and/or palate, 35 developed obstructive sleep apnea (6.0 percent) without a significant association with procedure type. CONCLUSIONS: In this national claims database analysis of cleft and noncleft pediatric patients, the rate of obstructive sleep apnea following velopharyngeal insufficiency surgery was not significantly different for pharyngeal flap compared to sphincter pharyngoplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Nationwide Perioperative Analysis of Endoscopic Versus Open Surgery for Craniosynostosis: Equal Access, Unequal Outcomes.

ABSTRACT: The purpose of this study is to evaluate national differences in inpatient outcomes and predictors of treatment type for endoscopic versus open surgery for craniosynostosis, with particular consideration of racial, socioeconomic, and geographic factors. The 2016 Kids' Inpatient Database was queried to identify patients aged 3 years or younger who underwent craniectomy for craniosynostosis. Multivariable regression modeled treatment type based on patient-level (gender, race, income, comorbidities, payer) and facility-level (bed size, region, teaching status) variables, and was used to assess outcomes. The weighted sample included 474 patients, of whom 81.9% (N = 388) of patients underwent open repair and 18.1% (N = 86) underwent endoscopic repair. A total of 81.1% of patients were under 1 year of age and 12.0% were syndromic. Patients were more likely to be treated open if they were older (odds ratio [OR] 3.07, P = 0.005) or syndromic (OR 8.56, P = 0.029). Patients who underwent open repair were more likely to receive transfusions (OR 2.86, P = 0.021), and have longer lengths of stay (OR 1.02, P < 0.001) and more costly hospitalizations (OR 5228.78, P = 0.018). Complications did not significantly vary between procedure type. The authors conclude that United States national data confirm benefits of endoscopic surgery, including a lower risk of transfusion, shorter hospital stay, and lower hospital costs, without a significant change in the rate of inpatient complications. Racial, socioeconomic, and geographic factors were not significantly associated with treatment type or perioperative surgical outcomes. Future studies are needed to further investigate the influence of such variables on access to craniofacial care.

Adult Cranioplasty and Perioperative Patient Safety: Does Plastic Surgery Facility Volume Matter?

ABSTRACT: Cranioplasty lies at the intersection of neurosurgery and plastic surgery, though little is known about the impact of plastic surgery involvement. The authors hypothesized that adult cranioplasty patients at higher volume plastic surgery facilities would have improved inpatient outcomes. Adult cranioplasty encounters were extracted from the National Inpatient Sample from 2012 to 2014 based on International Classification of Diseases, Ninth Revision (ICD-9) codes. Regression models included the following variables: age, gender, race/ethnicity, Elixhauser Comorbidity Index, payer, hospital size, region, and urban/teaching status. Outcomes included odds of receiving a flap, perioperative patient safety indicators, and mortality. The weighted sample included 49,305 encounters with diagnoses of neoplasm (31.2%), trauma (56.4%), infection (5.2%), a combination of these diagnoses (3.9%), or other diagnoses (3.2%). There were 1375 inpatient mortalities, of which 10 (0.7%) underwent a flap procedure. On multivariable regression, higher volume plastic surgery facilities and all diagnoses except uncertain neoplasm were associated with an increased likelihood of a flap procedure during the admission for cranioplasty, using benign neoplasm as a reference (P < 0.001). Plastic surgery facility volume was not significantly associated with likelihood of a patient safety indicator event. The highest volume plastic surgery quartile was associated with lower likelihood of inpatient mortality (P = 0.008). These findings support plastic surgery involvement in adult cranioplasty and suggest that these patients are best served at high volume plastic surgery facilities.

Erratum: Improvements in Cleft Lip Aesthetics with the Fisher Repair Compared to the Mohler Repair: Erratum.

[This corrects the article DOI: 10.1097/GOX.0000000000002919.].

Improvements in Cleft Lip Aesthetics with the Fisher Repair Compared to the Mohler Repair.

BACKGROUND: The extended Mohler rotation-advancement repair and the Fisher anatomic subunit repair are commonly used for the surgical correction of unilateral cleft lip. The rotation-advancement repair was the initial technique of choice by the senior surgeon. However, due to recurring suboptimal aesthetic results, the senior surgeon transitioned to the anatomic subunit repair. This study was performed to compare the outcomes of the rotation-advancement repair and the anatomic subunit repair. METHODS: A retrospective study of all consecutive patients undergoing unilateral cleft lip repair by the senior author between 2009 and 2016 was conducted. Demographic data, the presence of scar shortening/contraction, hypertrophy, widening, and revision rates were recorded. RESULTS: There were 68 patients identified for inclusion. Thirty-four patients had a rotation-advancement repair and 35 had an anatomic subunit repair. Twelve patients (36%) with the rotation-advancement repair and 1 patient (2.9%) with the subunit repair required anterior lip revision (P < 0.001). Conversely, 2 patients (6.1%) with the rotation-advancement repair and 13 patients (37.1%) with the subunit repair required minor debulking of excess red vermilion fullness (P < 0.005). CONCLUSIONS: Transitioning from the rotation-advancement repair to the anatomic subunit repair has resulted in improved lip aesthetics with decreased incidence of scar contracture, hypertrophy, and widening as evidenced by a decrease in the revision rate for these suboptimal scars. However, the rate of debulking procedures of the red vermilion did increase early in the adoption of the anatomic subunit repair, requiring minor modifications in the technique.

Applied Online Crowdsourcing in Plastic and Reconstructive Surgery: A Comparison of Aesthetic Outcomes in Unilateral Cleft Lip Repair Techniques.

BACKGROUND: Aesthetic outcomes of unilateral cleft lip repairs have important psychosocial implications for patients who are heavily influenced by social perceptions. Online crowdsourcing offers the unique potential to efficiently recruit large numbers of laypeople to assess public perception. The aim of this study was to use the online crowdsourcing platform Mechanical Turk to compare the postoperative outcomes of Fisher, Millard, and Mohler cleft lip repair techniques. METHODS: Two hundred fifty-four participants were recruited through Mechanical Turk to evaluate 29 cropped and deidentified photographs of children, 8 photographs were controls without cleft lips and 21 were children with unilateral cleft lips who had undergone Fisher, Millard, or Mohler repairs (7 in each group). Respondents were asked whether a scar was present, whether they would be personally satisfied with the surgical result and used a Likert scale from 1 to 5 to rate overall appearance, scar severity, and nasal symmetry. RESULTS: Fewer respondents reported that a scar was present when assessing postoperative photographs of Fisher repairs (70.3 ± 8.6%) compared with Millard (92.0 ± 1.5%) or Mohler (88.8 ± 3.1%) repairs. Average rating of scar severity was also lower for Fisher (1.9) compared with Millard (2.6) or Mohler (2.6) repairs. Average ratings of nose symmetry, general appearance, and satisfaction with operative result were not statistically significantly different between the repair groups. CONCLUSIONS: This study demonstrates the potential of online crowdsourcing to assess public perception of plastic surgery outcomes. The Mechanical Turk platform offers a reduction in selection bias, ease of study design, and enhanced efficiency of large-scale participant recruitment. Results indicate that the Fisher repair led to the most favored aesthetic outcomes compared with the Millard and Mohler techniques, particularly with regard to scar severity. Crowdsourcing is a powerful tool to assess layperson perception of plastic surgery outcomes and can be used to better guide surgical decision-making.

Descriptive Overview of Primary Cleft Palate Surgeries in the Low- and Middle-Income Countries.

OBJECTIVE: To increase access to high-quality and multiregional databases in global epidemiology of cleft surgeries through partnership with an NGO. DESIGN: The study retrospectively analyzes 34 801 primary palate surgeries in 70+ countries from the 2016 electronic health records of an non-governmental organization (NGO). The study also utilizes the Kids' Inpatient Database to compare the epidemiology of primary cleft palate surgeries in the United States. PARTICIPANTS: Patient records of those undergoing primary cleft palate surgeries only. MAIN OUTCOME MEASURES: Region, age, sex, type of cleft, laterality of cleft. RESULTS: Key findings show that average age of those receiving primary cleft palate surgery in the low- and middle-income countries (LMICs) was 1.95 years. The distribution of males and females receiving surgery corresponds to the US national data. More hard cleft palates were on the left side (66.18%) than the right side (33.82%), independent of gender and region. CONCLUSIONS: Databases from an established NGO can be used to enhance our understanding of the disease characteristics in these regions. By increasing the information available regarding cleft surgeries in the LMIC, we hope to increase awareness of the similarities and differences in surgeries across various regions, as part of an effort to inform the goals set by Global Surgery 2030 initiative by the Lancet Commission.

Phase 1/2a clinical trial of gene-corrected autologous cell therapy for recessive dystrophic epidermolysis bullosa.

BACKGROUNDRecessive dystrophic epidermolysis bullosa (RDEB) patients have mutations in the COL7A1 gene and thus lack functional type VII collagen (C7) protein; they have marked skin fragility and blistering. This single-center phase 1/2a open-label study evaluated the long-term efficacy, safety, and patient-reported outcomes in RDEB patients treated with gene-corrected autologous cell therapy.METHODSAutologous keratinocytes were isolated from participant skin biopsies. Epidermal sheets were prepared from cells transduced with a retrovirus carrying the full-length human COL7A1 gene. These gene-corrected autologous epidermal sheets measured 5 × 7 cm (35 cm2) and were transplanted onto 6 wound sites in each of 7 adult participants (n = 42 sites total) from 2013 to 2017. Participants were followed for 2 to 5 years.RESULTSNo participants experienced any serious related adverse events. Wound healing of 50% or greater by Investigator Global Assessment was present in 95% (36 of 38) of treated wounds versus 0% (0 of 6) of untreated control wounds at 6 months (P < 0.0001). At year 1, 68% (26 of 38) of treated wounds had 50% or greater healing compared with 17% (1 of 6) of control wounds (P = 0.025). At year 2, 71% (27 of 38) of treated wounds had 50% or greater healing compared with 17% (1 of 6) of control wounds (P = 0.019).CONCLUSIONC7 expression persisted up to 2 years after treatment in 2 participants. Treated wounds with 50% or greater healing demonstrated improvement in patient-reported pain, itch, and wound durability. This study provides additional data to support the clinically meaningful benefit of treating chronic RDEB wounds with ex vivo, C7 gene-corrected autologous cell therapy. This approach was safe and promoted wound healing that was associated with improved patient-reported outcomes.TRIAL REGISTRATIONClinicaltrials.gov identifier: NCT01263379.FUNDINGEpidermolysis Bullosa Research Partnership, Epidermolysis Bullosa Medical Research Foundation, NIH R01 AR055914, Office of Research and Development at the Palo Alto Veteran's Affairs Medical Center, and the Dermatology Foundation.

Retrospective cohort-based comparison of intraoperative liposomal bupivacaine versus bupivacaine for donor site iliac crest analgesia during alveolar bone grafting.

INTRODUCTION: Bone grafting of alveolar clefts is routinely performed with cancellous bone harvested from the iliac crest. Graft site morbidity is frequently seen, with early postoperative pain being one of the most common complaints. Liposomal bupivacaine (LB) has been demonstrated to provide improvement in postoperative pain for patients undergoing bunionectomy or hemorrhoidectomy, which may translate to patients requiring iliac crest bone graft harvest. METHODS: Thirty-eight patients undergoing iliac crest bone harvest were included in the study. Twenty-one patients underwent open iliac crest bone graft harvest with administration of 0.25% bupivacaine at the hip donor site, while 17 patients received local infiltration of 1.3% liposomal bupivacaine. Patient-reported pain scores, total narcotic use, length of stay, and postoperative steps were monitored. RESULTS: There were no significant differences in age, weight, distribution of clefts, or choice of donor hip between the two groups. There were no significant differences in length of hospitalization stay. However, differences were noted in average postoperative pain scores at five of six time points in the first 24 h, total oral morphine equivalents administered (4.7 ±â€¯5.3 vs. 14.3 ±â€¯12.0), and steps at postoperative days one to three (p < 0.001, for all three days) for patients receiving 1.3% LB versus 0.25% bupivacaine, respectively. CONCLUSION: Reduced pain scores and increased postoperative activity highlight the potential of LB to improve postoperative pain management in children undergoing iliac crest bone harvest for alveolar bone grafting.

Assessing the Fisher, Mohler, and Millard Techniques of Cleft Lip Repair Surgery With Eye-Tracking Technology.

BACKGROUND: Cleft lip repair is essential to restoring physiologic function and ensuring social and psychological well-being in children with orofacial clefts. It is important to critically study various techniques to understand the elements of the lip and nasal repair that contribute to favorable results. Here, we use eye-tracking technology to evaluate how viewers analyze images of cleft lips repaired by the Fisher, Millard, or Mohler techniques. METHODS: Thirty viewers were shown 5 images without deformity and 5 images each of unilateral cleft lips repaired by the Fisher, Millard, or Mohler techniques. Viewers assessed the esthetic quality of images on a Likert scale while eye-tracking technology analyzed their gaze patterns. RESULTS: Of the 3 repair techniques, viewers found Fisher repairs most esthetically pleasing (mean ± standard error, 6.91 ± 0.13). Mohler repairs were next most attractive at (6.47 ± 0.13), followed by Millard repairs at (5.60 ± 0.14). The proportion of time spent in fixed gaze on the nose and upper lip was greatest for Millard repairs (58.3% ± 0.4%) and least for Fisher repairs (51.9% ± 0.5%). Viewers fixated most frequently on the nose and upper lip in Millard repairs (83.2% ± 0.5%) and least frequently in Fisher repairs (75.3% ± 0.5%). When examining the Millard compared with Fisher and Mohler repairs, viewers spent more time and fixations on the ipsilateral lip, nose, and repair scar than on the contralateral lip. CONCLUSIONS: The esthetics of the Fisher repair appear to be favored as measured by Likert scores and gaze data. Eye-tracking technology may be a useful tool to assess outcomes in plastic surgery.

Management of Complex Arteriovenous Malformations Using a Novel Combination Therapeutic Algorithm.

Importance: Current therapeutic options for patients with extracranial head and neck arteriovenous malformations are limited. Surgical intervention, such as sclerotherapy or resection, often result in rapid recurrence and progression of disease. Objective: To assess the efficacy and tolerability of sirolimus as an adjuvant therapy for endovascular embolization in the management of complicated extracranial head and neck arteriovenous malformations. Design, Setting, and Participants: This case series examined 6 patients with extracranial head and neck arteriovenous malformations treated from January 1, 2013, to December 31, 2017, at a multidisciplinary vascular anomalies clinic within Stanford Hospital and Clinics. Intervention: Initiation of sirolimus at least 1 month prior to endovascular embolization, targeting a trough level of 10 to 15 ng/mL throughout the course of the endovascular embolization series and continued for at least 1 month after the series. Main Outcomes and Measures: Clinical manifestations; disease progression and overall response to treatment were assessed via clinical evaluation and radiographic imaging. Results: All 6 patients (4 male and 2 female patients; mean age, 24.5 years [range, 9-44 years]) responded favorably to the combination of sirolimus therapy followed by endovascular embolization, and 4 patients exhibited a near-complete response. The median duration of follow-up was 19 months (range, 6-40 months). One patient discontinued sirolimus soon after embolization and experienced regrowth of the arteriovenous malformation after 1 year. Sirolimus was resumed, which has stabilized his disease for more than 2 years. Mild adverse effects were noted in 4 patients. The combination therapy was well tolerated in all patients. One patient developed skin ulceration after embolization and required surgical debridement. Another patient developed pulmonary microthrombi after embolization with cyanoacrylate glue that resolved with a brief course of anti-inflammatory therapy. Conclusions and Relevance: Although further prospective trials are needed, this report suggests the benefit of a mammalian target of rapamycin inhibitor as an adjuvant therapy for surgical embolization of complex, extracranial head and neck arteriovenous malformations. The optimal dosing and therapeutic duration of sirolimus treatment before and after embolization remain to be determined.

Anatomical Nasal Lining Flaps for Closure of the Nasal Floor in Unilateral and Bilateral Cleft Lip Repairs Reduce Fistulas at the Alveolus.

BACKGROUND: Techniques vary for addressing the nasal floor during cleft lip repair in patients with a cleft lip and palate. Sometimes, no closure is performed, leaving a symptomatic alveolar fistula until the time of alveolar bone grafting. Often, medial and lateral skin flaps are used, but these are often thin and unreliable. Anatomical nasal lining flaps are used to improve closure with robust, well-vascularized flaps that anatomically close the nasal floor. METHODS: A retrospective chart review was performed to identify patients with a unilateral or bilateral cleft lip and palate who underwent primary cleft lip repair with nasal lining flaps or with medial and lateral flaps. The primary outcome was presence of a symptomatic and/or visible oronasal fistula. RESULTS: Sixty-four patients were included. Thirty-seven underwent closure with nasal lining flaps, whereas 27 underwent closure using Millard medial and lateral flaps. The rate of symptomatic/visible fistulas after cleft palate repair was 19 percent (seven of 37) for patients with nasal lining flaps and 44 percent (12 of 27) for patients with medial and lateral flaps (p = 0.0509, Fisher's exact test). The alveolar fistula rate was 3 percent (one of 37) for patients with nasal lining flaps and 30 percent (eight of 27) for patients with medial and lateral flaps (p = 0.0032, Fisher's exact test). CONCLUSIONS: Nasal lining flaps at the time of cleft lip repair effectively close the anterior nasal floor in patients with a unilateral or bilateral cleft lip and palate. Decreasing the presence of alveolar fistulas after cleft palate repair improves the quality of life for patients with cleft deformities. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Teaching Palatoplasty Using a High-Fidelity Cleft Palate Simulator.

BACKGROUND: Cleft palate repair is a challenging procedure for cleft surgeons to teach. A novel high-fidelity cleft palate simulator has been described for surgeon training. This study evaluates the simulator's effect on surgeon procedural confidence and palatoplasty knowledge among learners. METHODS: Plastic surgery trainees attended a palatoplasty workshop consisting of a didactic session on cleft palate anatomy and repair followed by a simulation session. Participants completed a procedural confidence questionnaire and palatoplasty knowledge test immediately before and after the workshop. RESULTS: All participants reported significantly higher procedural confidence following the workshop (p < 0.05). Those with cleft palate surgery experience had higher procedural confidence before (p < 0.001) and after (p < 0.001) the session. Palatoplasty knowledge test scores increased in 90 percent of participants. The mean baseline test score was 28 ± 10.89 percent and 43 ± 18.86 percent following the workshop. Those with prior cleft palate experience did not have higher mean baseline test scores than those with no experience (30 percent versus 28 percent; p > 0.05), but did have significantly higher scores after the workshop (61 percent versus 35 percent; p < 0.05). All trainees strongly agreed or agreed that the simulator should be integrated into training and they would use it again. CONCLUSIONS: This study demonstrates the effective use of a novel cleft palate simulator as a training tool to teach palatoplasty. Improved procedural confidence and knowledge were observed after a single session, with benefits seen among trainees both with and without previous cleft experience.