Novel Design of Interlocking 3-Dimensional Miniplate in Mandibular Angle Fractures: An In Vitro Study.

The evolution of osteosynthesis has led to the development of novel miniplate designs, including 3-dimensional (3D) miniplates, which offer improved biomechanical stability. However, mandible fractures resulting from the high impact have a complex fracture configuration. Hence, the authors developed interlocking 3D miniplate to overcome the difficulty in miniplate and screw placement to avoid critical anatomic structures, that is, dental roots and nerve, while still providing stability for the fracture fragments. The interlocking 3D miniplates can be formed according to the specific needs by adjusting the horizontal and vertical cross struts configuration. This study describes a design process of interlocking 3D miniplates and evaluates biomechanical performance compared to standard miniplates. Finite element analysis was performed to evaluate the design's stress state using human and goat mandible models under various loading conditions. After the authors, established that our design was feasible for fabrication, the authors developed the prototype for biomechanical testing. Biomechanical testing was conducted on 10 goat mandibles to compare stability and displacement under various load between the interlocking 3D miniplate and the standard miniplate configuration. Biomechanical testing revealed reduced displacement in all directions with the interlocking 3D miniplate compared to the standard miniplate. Furthermore, there was a significant difference in all loads in the buccal-lingual displacement (P<0.05). The novel interlocking 3D miniplate design shows an adequate ability to provide stability for fixation for mandibular fractures, as evidenced by finite element analysis and biomechanical testing. Further research is necessary to validate these findings and explore the clinical application of interlocking 3D miniplates in mandibular fracture management.

Biomechanical Property and Biocompatibility of a New Silicone Rubber Nasal Retainer (Nostriloo).

Nasal retainers have been utilized to maintain the position of the nose after primary rhinoplasty in cleft lip patients. However, commercial nasal retainers made from silicone are quite expensive. To address this issue, the authors designed an alternative nasal retainer that is affordable, safe, and has similar biomechanical and biocompatibility properties to other commercial nasal retainers. Three types of nasal retainers were tested: our own (Nostriloo), a commercial nasal retainer from Turkey, and another one from Taiwan. There were 3 samples on each group, with a total sample of 9 retainers. Each sample was tested for biomechanical property and biocompatibility. Elasticity modulus, tensile strength, and direct and indirect toxicity were analyzed. Nostriloo had the least durable tensile strength but showed similar elastic modulus (2.76 ± 0.41 MPa) compared with human lower lateral cartilage (2.09 ± 0.81 MPa). On the basis of direct and indirect toxicity tests, Nostriloo is considered nontoxic. Nostriloo can be utilized for small-scale production and use. Further experiment is needed to produce higher-quality nasal retainers.

Bilateral Cleft Lip and Palate in Ring Chromosome 7 Syndrome: A Case Report and Review of Clinical Characteristics.

This report presents a case of ring chromosome 7 syndrome with bilateral cleft lip and palate. A four-year-old boy presented with bilateral cleft lip and palate, microcephaly, clenched toes, cafe-au-lait spots, a history of epilepsy, and severe intellectual disability. Genetic karyotyping revealed 46 XY r(7) (p22q36). His cheiloplasty and delayed palatoplasty were successful. A review of 22 previous r(7) patients revealed that 22.7% had cleft lip and/or palate. This case demonstrates the importance of a multidisciplinary evaluation for cleft patients, particularly those with syndromic features and global developmental delay.

The misconception of plastic surgery scope amongst general practitioners in East Nusa Tenggara, Indonesia.

BACKGROUND: The scope of plastic reconstructive and aesthetic surgery is often misunderstood amongst both public and professionals, including the general practitioners (GP) who play vital roles in referring patients. Unlike other subspecialties, which are circumscribed by subgroup patients, specific organs, or diseases, the versatility of plastic surgery is driven by the principle of the surgical technique being malleable to each clinical case. This study aimed to demonstrate how well general practitioners in Kupang City acknowledge the scope of plastic surgery. METHODS: The 30-Question electronic survey was filled out by GPs in several hospitals, PHCs, and clinics whose certificate of registration is based in Kupang City. Respondents should match the given cases to one subspecialist surgeon that the GPs think fits best. RESULTS: In total, 83 GPs participated; 63.9% (n = 53) were female, aged 27.95 (±3.53 years), 77.1% (n = 64) practised in a hospital, and 67.5% (n = 56) graduated from medical school in Java. Only 2.4% (n = 2) chose a plastic surgeon whom they will refer to among three hand cases, 6% (n = 5) in four craniomaxillofacial cases, and 10.8% (n = 9) in five reconstructive cases. CONCLUSION: The GPs tend to associate cosmetic procedures with plastic surgeons, while reconstructive surgery cases like hand or craniomaxillofacial cases were correlated with non-plastic surgeons. The scope of plastic surgery needs to be further introduced in the medical student curriculum; thus, GP can be more exposed to the field and refer patients accurately.

Translation, Validation, and Cultural Adaptation of CLEFT-Q© for use in Indonesia.

OBJECTIVE: To translate and validate CLEFT-Q©, patient-reported outcome measure for patients with cleft lip and/or palate (CL and/or P), into Indonesian. CLEFT-Q© covers the domains of appearance, facial function, health-related quality of life and consists of scales describing outcomes after cleft surgery. DESIGN: The CLEFT-Q© instrument was translated according to the International Society of Pharmacoeconomics and Outcomes Research guidelines, including translation, cognitive debriefing, and field-testing. SETTING: Dr. Cipto Mangunkusumo Hospital, Indonesia; independent CL and/or P support groups. PATIENTS: Patients ages 8-29 with a history of repaired CL and/or P were grouped based on age. Those unable to complete the questionnaire independently were excluded. INTERVENTIONS: The primary objective was reliable translation of the CLEFT-Q® instrument. Each scale was assessed for its internal consistency (Cronbach's alpha) and validity (inter-item correlation), and sub-group analyses were performed based on age group. RESULTS: Forward and back translation revealed 25(13.3%) and 12(6.3%) of items were difficult to translate. Cognitive debriefing revealed 10(5.3%) items were difficult to understand, with the lowest reliability on the facial appearance scale (α=0.27). Other scales demonstrated acceptable to excellent reliability (α=0.53-0.68). Field testing revealed acceptable reliability and validity of the translation (α = 0.74-0.92; 69% ideal range of inter-item correlation). Sub-group analyses revealed patients in the <11y.o. and >18y.o. groups had the lowest scores on the "cleft lip scar" scale while those 11-18y.o. had the lowest scores on the "nostrils" scale. CONCLUSION: Iterative translation and cultural adaptation of CLEFT-Q© into Indonesian demonstrated reliability and validity of the tool, supported by acceptable to excellent internal consistency and ideal inter-item correlation.

Limited Access to Alveolar Bone Graft Surgery Following Primary Cleft Lip and Palate Repair in Indonesia: A Questionnaire-Based Qualitative Study.

INTRODUCTION: Cleft Lip and Palate is the most common craniofacial anomaly, and cleft lip and palate repair is widely performed. Alveolar cleft accompanies 75% of cleft lip cases and requires alveolar bone graft (ABG) surgery at mixed dentition age. However, studies on rates of ABG surgery are scarce. OBJECTIVE: This study aims to investigate the low popularity of ABG and orthodontic care among patients with ABG history at Cleft and Craniofacial Centre, Cipto Mangunkusumo Hospital, Jakarta. METHOD: A total of 771 patients had orofacial cleft surgeries throughout 2015 to 2021. A descriptive analysis of labioplasty, palatoplasty, and ABG surgeries was presented. Questionnaire-based qualitative analysis of ABG was obtained from the patient's guardians to evaluate the limitation and experience of conducting the surgery at our institution. RESULTS: We distributed questionnaires to 13 patients with a history of ABG. ABG accounted for only 5% of total orofacial cleft surgeries. The average age of ABG surgery and orthodontic care initiation was 11 and 11.8 years old, respectively. About 82% had access to preoperative and postoperative orthodontic care; however, only 11% received PSO before 9 years old. The satisfaction rate was 100% and 75% in ABG patients with and without orthodontic care, respectively, reporting improved feeding, speech, teeth alignment, and esthetic result. CONCLUSION: Orofacial cleft management requires a multistage, comprehensive, and multidisciplinary approach. The number of ABG surgeries is low in developing countries, attributed to unequal access to ABG and orthodontic care, suggesting that limitations of knowledge, geography, and economy play a big role in Indonesian healthcare.

Global Burden of Orofacial Clefts and the World Surgical Workforce.

BACKGROUND: Orofacial clefts are one of the most common congenital anomalies, but this disease burden is unevenly distributed worldwide. The authors hypothesize that this burden falls disproportionately on the countries with the smallest surgical workforce or lowest Socio-Demographic Index, rather than those with the highest prevalence of disease. METHODS: The authors estimated the prevalence and disease burden of orofacial clefting from 1990 to 2017 in 195 countries using the Global Burden of Disease methodology. Prevalence and disability-adjusted life-years were compared geographically, temporally, and against the size of the national surgical workforce, Socio-Demographic Index, and income status. Linear and logarithmic regressions were performed. RESULTS: In 2017, the prevalence of orofacial clefting was estimated to be 10.8 million people, representing a disease burden of 652,084 disability-adjusted life-years, with most of this disease burden experienced by low- and middle-income countries (94.1%). From 1990 to 2017, there was a decrease in disease burden (-70.2%) and prevalence (-4.9%). There was negative logarithmic association between surgical workforce size and disease burden, with a surgical workforce of greater than six providers per 100,000 population (3.6 disability-adjusted life-years versus 22.4 disability-adjusted life-years per 100,000 population; p < 0.0001). CONCLUSIONS: Burden of orofacial clefting has a strong negative association with the size of the surgical workforce, suggesting that strengthening the surgical workforce will help alleviate this burden. Epidemiologic data on countries and regions with inadequate surgical workforces and high disease burden should guide future research efforts and allocation of resources, and guide the treatment and educational goals of international charitable organizations.

Use of local perforator flaps for closure of a thoraco-omphalopagus conjoined twin defect after separation during the COVID-19 pandemic.

INTRODUCTION: Conjoined twins are a rare medical phenomenon that poses unique challenges for surgeons. Separation of conjoined twins involves multidisciplinary teamwork, complex medical management and surgical planning, and multi-stage operations and often still has a high mortality and morbidity rate. In the times of the COVID-19 pandemic, separation of conjoined twins pose even greater challenges. Aiming for the best outcome possible, while minimizing the risk of COVID transmission and ensuring the safety of the personnel, is paramount. This case report presents thoraco-omphalopagus twins who were successfully separated at 4 months of age. The preoperative planning, operative details, postoperative follow-ups, and outcomes are discussed. METHODS: The absence of a tissue expander and the inability to acquire it due to travel restrictions from COVID-19 further complicated the management on this patient. A Routine Polymerase Chain Reaction (PCR) swab test was performed on the patients and personnel. Standardized personnel protective equipment (PPE) was worn during ward and surgical care. After separation of the twins by cardiothoracic and pediatric surgeons, one twin underwent immediate skin closure using a double keystone perforator island flap and a lower abdominal perforator flap. Due to extensive defects, closure was delayed for the second twin. After a series of dressing changes, eventually local perforator flaps could be raised to close the defect using staged tension sutures and skin grafts for secondary defects. RESULTS: Both twins were discharged with no significant morbidity, and no personnel were exposed to COVID-19 infection during the management. CONCLUSION: Preoperative coordination and planning, multidisciplinary effort, adherence to screening protocols for COVID, and strict use of standardized PPE all contributed to the successful separation of thoraco-omphalopagus conjoined twins during the COVID-19 pandemic.

The effectiveness of oral propranolol for infantile hemangioma on the head and neck region: A case series.

INTRODUCTION: Infantile hemangioma is the most common tumor in infancy, with 60% occurring on the face and neck. A large tumor involving the facial region will cause significant aesthetic and functional impairment and isn't always easy to treat surgically. A non-invasive treatment is needed for this condition. Propranolol has recently been used as a choice of treatment in infantile hemangioma. PRESENTATION OF CASE: We presented two cases of large problematic infantile hemangioma that were successfully managed with oral propranolol. DISCUSSION: Large problematic lesions that ulcerate and bleed often need surgery; however, a substantial defect resulting from surgery is tricky to reconstruct and can cause significant scar. Propranolol is used because of its efficacy and low risk characteristics. CONCLUSION: Propranolol is an effective treatment to reduce the need of surgical intervention in problematic hemangioma.

Efficacy of intra-lesional alcohol injection as alternative and/or complementary treatment of vascular malformations: a systematic review.

INTRODUCTION: The purpose of this article is to discuss whether intra-lesional alcohol injection is beneficial in the treatment of vascular malformations. METHODS: A systematic review through literature search was conducted for English-language studies in PubMed. This search was conducted in April 2007 using EndNote 7.0 with keywords: 'vascular malformation*' and 'sclerotherapy'. Both retrospective and prospective studies on the efficacy of intra-lesional alcohol injection in the treatment of vascular malformations in the head and neck and/or upper extremity region published from 1997 to 2006 are included. Exclusion criteria are letters to editor, article, comment, discussion, literature research, publication review, prevalence study, animal study and lecture. Evaluation is aimed at level of clinical improvement or cure, number of injections required to achieve the desired clinical result and local or other complications. RESULTS: Thirty publications with usable information were retrieved. In 25 publications, a total of 567 patients (mean age: 18.6 years; 43.4% male, 56.6% female) received intra-lesional absolute alcohol injection, either as an independent therapy or as an adjunctive to other treatment modalities. From 13 publications, the clinical results are as follows: excellent 74 (22.3%), good 224 (67.5%) and poor 34 (10.2%). Mean number of injections required is 2.63. Minor complications are predominantly skin damage (21.1%). Major complications are mostly tissue fibrosis (1.9%). DISCUSSION: Intra-lesional alcohol injection as an independent treatment or in combination with other treatment modalities has good-to-excellent results. This intervention applied in fast-flow malformations is as effective as in slow-flow malformations. Preoperative and/or postoperative embolo/sclerotherapy provides substantial improvement on the overall results of the therapy. Intra-lesional alcohol injection is a relatively safe treatment modality with minor complications mostly involving the skin and some, but relatively rare, major complications.