Further construct validation of the CLEFT-Q: Ability to detect differences in outcome for four cleft-specific surgeries.

BACKGROUND: The CLEFT-Q is a patient-reported outcome measure developed for use in patients with cleft lip and/or palate. A significant indicator of the CLEFT-Q's validity relates to its ability to detect differences between the impact of specific aspects of clefting before and after surgery. This study compares relevant sub-scale scores of the CLEFT-Q for patients requiring four specific surgical treatments against those who either have had surgery or never needed surgery. METHODS: CLEFT-Q scores and clinical information regarding the past and future need for jaw surgery, lip revision, rhinoplasty, and speech surgery were obtained from the CLEFT-Q field-test data. Eight one-way analysis of variance (ANOVA) models were developed to compare mean scores of relevant CLEFT-Q scales between those who needed surgery, those who have had surgery, and those who never needed surgery. Only patients from high-income countries were included to minimize the impact of any economic confounders that could result in treatment variation. In the rhinoplasly and lip revision models, patients without a cleft lip were excluded. In the jaw surgery and speech surgery models, patients without a cleft palate or alveolus were excluded. RESULTS: The CLEFT-Q field test included 1938 participants from high-income countries. Participants who needed surgery scored significantly lower (worse) than those who have had surgery in each of the eight relevant CLEFT-Q scales (p < 0.001 in each ANOVA). CONCLUSION: The ability of the CLEFT-Q to detect differences between groups based on surgical status further supports its validity.

A Comparative Study of the Aesthetic Outcome of Two Techniques for Unilateral Complete Cleft Lip Repair.

BACKGROUND: Cleft lip repair aims to create symmetric nasolabial morphology with minimal scarring. Poor aesthetic outcomes may have damaging psychosocial implications. Determining the optimal method of recreating lip symmetry is a major goal of applied cleft clinical research. This study aims to determine whether subjective assessment could differentiate aesthetic outcome between two surgeons who use two different surgical techniques for unilateral cleft lip repair. METHODS: Surgeon A uses a modified rotation-advancement technique incorporating a supra-white roll flap and Noordhoff-style vermilion flap. Surgeon B uses an upper and lower triangle technique. Neither surgeon used presurgical orthopedics. Five-year postoperative frontal photographs (cropped according to the Asher-McDade aesthetic index) were analyzed by a panel of 40 blinded surgical and lay reviewers using a five-point Likert scale. The assessments were repeated after a 2-week interval to assess intrarater reliability. RESULTS: Thirty-nine consecutive complete unilateral cleft lip and palate patients were assessed for each surgeon. The mean Likert score for surgical/lay assessors was 3.07/3.00 for surgeon A and 2.67/2.61 for surgeon B. This difference was statistically significant (p < 0.05). The interrater reliability was excellent and the intrarater reliability was fair. There was good correlation between lay and surgical assessors. CONCLUSION: Subjective assessment of clinical photography provides a reliable method of differentiating aesthetic outcome after unilateral cleft lip repair and presents a rapid and straightforward clinically relevant method of comparing surgical outcomes.

Trans-oral robotic cleft surgery (TORCS) for palate and posterior pharyngeal wall reconstruction: A feasibility study.

BACKGROUND/AIM: Robot-assisted surgery has become increasingly routine, replacing open and laparoscopic techniques in certain domains, with recent extension to head and neck surgery through trans-oral access. Some advantages of the robot-assisted surgery include the ability to access confined spaces, enhanced dexterity instrumentation with intuitive movement, motion scaling, tremor elimination and three-dimensional (3D) endoscopic viewing with true depth perception. The aim of this study was to investigate the technical feasibility of trans-oral robotic cleft surgery (TORCS) to access the posterior pharyngeal wall and palate for potential use in the cleft population. METHODS: All possible permutations of patient and robotic instrument configurations were used with the daVinci Si Surgical System® (Intuitive Surgical, USA) 0° and 30° 3D endoscopes and 8-mm training instruments to determine the optimal visualization and surgical access to the palate and posterior pharynx in a paediatric airway manikin, and to simulate posterior pharyngeal wall surgery. A full robot-assisted cadaveric Hynes pharyngoplasty was performed using 5-mm training instruments. Experiments were recorded with still and video photography. RESULTS: TORCS is technically feasible in the paediatric cleft population. We predict a short learning curve due to the intuitive instrumentation, easier dissection and the potential to limit secondary insult compared with traditional surgery, as well as improved ergonomics for the operating surgeon. CONCLUSIONS: The as-yet unreported use of robotic-assisted cleft palate surgery may considerably enhance a surgeon's ability to perform difficult procedures of the palate and posterior pharynx in selected patients with limited access as well as lay the foundation for potential novel techniques.

Use of autologous fat grafting for breast reconstruction: a systematic review with meta-analysis of oncological outcomes.

BACKGROUND: There is growing interest in the use of autologous fat grafting (AFG) for breast reconstruction. Concerns have been raised regarding its effectiveness and safety. OBJECTIVE: The primary objective was to determine the oncological, clinical, aesthetic and functional, patient reported, process and radiological outcomes of AFG. METHODS: A protocol was published on PROSPERO (CRD42013005254). Types of studies: All original studies. TYPES OF PARTICIPANTS: Women undergoing reconstruction after surgery for breast cancer. Types of Interventions: AFG techniques for reconstruction. Types of outcome measures: Oncological, clinical, aesthetic and functional, patient reported, process and radiological. Search terms and keywords: The search strategy was devised to find papers regarding AFG for breast reconstruction. DATA SOURCES: Electronic databases were searched from 1st January 1986 to 31st March 2014 including: PubMed, MEDLINE, EMBASE, SCOPUS, The Cochrane Library, and clinical trial registries. Identification and selection of studies: Title and abstract screening and full text assessment undertaken separately by independent researchers. Data extraction, collection and management: Data extracted by two researchers and stored in a standardised database. RESULTS: 35 studies were included (3624 patients) with a high degree of patient and surgeon satisfaction over a mean of 1.9 sessions at 18 month follow-up. Fat necrosis was the commonest reported complication (4.4%), biopsy of a subsequent breast lump was required in 2.7% and an interval mammogram in 11.5%. The weighted mean recurrence rate was 4.4% at 24.6 months. Meta-analysis of comparative studies showed no significant difference in oncological event rates between AFG and non-AFG groups (p=0.10). CONCLUSION: AFG is a potentially useful reconstructive tool, has a relatively low complication rate, with the majority of patients and clinicians satisfied or very satisfied with the results. Long term clinical and radiological follow-up is required. Further research is necessary to confirm oncological ramifications.

Measuring outcomes in craniofacial and pediatric plastic surgery.

This article discusses the measurement of outcomes in craniofacial and pediatric plastic surgery, using examples of craniosynostosis and cleft lip and/or palate (CLP). The challenges in measuring the standard outcomes of function, aesthetics, and health-related quality of life are discussed, along with the importance of developing evidence and studying quality improvement in this specialty. The need to define specific and comprehensive goals is discussed with a focus on patient-reported outcomes (PROs). Examples from the development of the CLEFT-Q, a PRO instrument for patients with CLP, are provided to support the need to seek the patient perspective.

Does repairing a cleft lip neonatally have any effect on the longer-term attractiveness of the repair?

OBJECTIVE: To determine whether attractiveness and success of surgical outcome differ according to the timing of cleft lip repair. DESIGN: Three experiments were conducted: (1) surgeons rated postoperative medical photographs of infants having either neonatal or 3-month lip repair; (2) lay panelists rated the same photographs; (3) lay panelists rated dynamic video displays of the infants made at 12 months. Normal comparison infants were also rated. The order of stimuli was randomized, and panelists were blind to timing of lip repair and the purposes of the study. SETTING: Four U.K. regional centers for cleft lip and palate. PARTICIPANTS: Infants with isolated clefts of the lip, with and without palate. INTERVENTION: Early lip repair was conducted at median age 4 days (interquartile range [IQR] = 4), and late repair at 104 days (IQR = 57). MAIN OUTCOME MEASURES: Ratings of surgical outcome (Experiment 1 only) and attractiveness (all experiments) on 5-point Likert scales. RESULTS: In Experiment 1 success of surgical outcome was comparable for early and late repair groups (difference = -0.08; 95% confidence interval [CI] = -0.43 to 0.28; p = .66). In all three experiments, attractiveness ratings were comparable for the two groups. Differences were, respectively, 0.10 (95% CI = -2.3 to 0.44, p = .54); -0.11 (95% CI = -0.42 to -0.19, p = .54); and 0.08 (95% CI = -0.11 to 0.28, p = .41). Normal infants were rated more attractive than index infants (difference = 0.38; 95% CI = 0.24 to 0.52; p < .001). CONCLUSION: Neonatal repair for cleft of the lip confers no advantage over repair at 3 months in terms of perceived infant attractiveness or success of surgical outcome.