Demystifying Velopharyngeal Dysfunction for Plastic Surgery Trainees Part 2: Speech Fundamentals and Perceptual Speech Assessment.

Velopharyngeal dysfunction (VPD) is the inability to achieve proper closure of the velopharyngeal (VP) port, affecting speech and swallowing. The gold standard for diagnosis is auditory-perceptual speech evaluation by a specialized speech-language pathologist. This 3-part series provides a comprehensive discussion on (1) the anatomy and physiology of the velopharyngeal mechanism, (2) fundamental speech terminology and principles of perceptual speech assessment for VPD, and (3) techniques for objective evaluation of the VP port and surgical decision-making process. In part 2, the authros begin with the concepts and terminology required to understand the perceptual speech assessment of VPD, including resonance, articulation, and the differentiation between consonants and vowels. We review the types of speech samples used for evaluation such as single-word articulation tests, syllable repetition, sentence repetition, and spontaneous connected speech. Finally, we discuss the auditory-perceptual speech assessment for VPD, including the assessment of resonance, nasal air emission, articulation, and voice quality. The use of rating scales like the Pittsburgh Weighted Speech Scale (PWSS) and the Cleft Audit Protocol for Speech-Augmented-Americleft Modification (CAPS-A-AM) is highlighted. In addition, the significance of intraoral examinations, visual-tactile-auditory evaluations, and the assessment of voice quality are covered. Most textbook chapters discussing this topic assume a foundational knowledge of speech-language pathology, which a surgical trainee may lack. This study aimed to bridge the gap between surgical training and speech pathology, providing a comprehensive resource to enhance the understanding and management of VPD.

Demystifying Velopharyngeal Dysfunction for Plastic Surgery Trainees-Part 1: Anatomy and Physiology.

The velopharyngeal (VP) port separates the nasopharynx from the oropharynx and is bordered by the velum, lateral pharyngeal walls, and posterior pharyngeal wall. Velopharyngeal dysfunction (VPD) is the inability to achieve proper closure of the VP port, affecting speech and swallowing. This 3-part series provides a comprehensive discussion on (1) the anatomy and physiology of the velopharyngeal mechanism; (2) fundamental speech terminology and principles of perceptual speech assessment for VPD; and (3) techniques for objective evaluation of the VP port and surgical decision-making process. In part 1, the authors focus on the anatomy and physiology of the velopharyngeal port, the anatomy of cleft palate, and the causes of VPD. There are 3 types of VPD: velopharyngeal insufficiency, involving structural deficits; velopharyngeal incompetence, resulting from neuromuscular issues; and velopharyngeal mislearning, due to maladaptive speech habits. VPD is commonly associated with cleft palate due to anatomic disruptions that impair velopharyngeal function. However, there are numerous causes of noncleft VPD, including congenital or acquired structural defects, neuromuscular conditions, and developmental/behavioral factors. Diagnosis and management of VPD require a multidisciplinary approach involving, at a minimum, surgeons and speech-language pathologists. Plastic surgery trainees often receive education on the surgical treatment of VPD, but without a foundational knowledge of the disease spectrum and speech pathology, the complex terminology can impede a thorough understanding of its diagnosis and management. This series serves as an accessible resource, providing the foundational knowledge required for surgical trainees new to this topic.

Demystifying Velopharyngeal Dysfunction for Plastic Surgery Trainees Part 3: Objective Assessment and Surgical Decision-Making.

Velopharyngeal dysfunction (VPD) is the inability to achieve proper closure of the velopharyngeal (VP) port, affecting speech and swallowing. After an auditory-perceptual speech evaluation by a speech-language pathologist, objective assessment of the VP port is required to determine the need for surgical intervention. This 3-part series provides a comprehensive discussion on (1) the anatomy and physiology of the velopharyngeal mechanism; (2) fundamental speech terminology and principles of perceptual speech assessment for VPD; and (3) techniques for objective evaluation of the VP port and surgical decision-making process. In part 3, the authors focus on the modalities for objective VP port assessment, including both direct and indirect methods. Direct imaging techniques such as videofluoroscopy, nasoendoscopy, and MRI are detailed for their strengths and limitations in visualizing VP port function and preoperative planning. Indirect assessments, including nasometry and aerodynamic measurements, are also briefly discussed. The decision-making process for surgical intervention is explored, emphasizing factors such as the severity and etiology of VPD, VP closure patterns, palatal length, orientation of the levator veli palatini, and other patient-specific considerations. The authors review the surgical options for repair including palatoplasty procedures (Furlow palatoplasty, straight-line intravelar veloplasty, and palatal lengthening buccal myomucosal flaps) and pharyngoplasty procedures (posterior pharyngeal flaps and sphincter pharyngoplasty), highlighting their indications, techniques, and potential complications. This series serves as an accessible resource, providing the foundational knowledge required for surgical trainees new to this topic.

Management of Pediatric Type III Tibial Shaft Fractures: A Cohort Study Utilizing the Trauma Quality Improvement Program Database.

BACKGROUND: Pediatric open tibial fractures represent a challenging subset of injuries with limited literature to guide management. For children, the epidemiology, management, and outcomes of tibial-shaft fractures have not been fully described. METHODS: A retrospective analysis of the Trauma Quality Improvement Program Data Bank from 2017-2020 was used to query demographics, injury patterns, and management strategies in pediatric open tibial fractures. Fractures were compared by age group (0-5, 6-12, 13-17 years) and type (I/II vs type III). A subgroup analysis was performed on patients with type III open fractures. RESULTS: A total of 3480 open tibial fractures were identified, 3049 were type I/II, and 431 were type III. Motor vehicle accidents (48%) were the most common mechanism of injury (P < 0.001). Subanalysis of 128 type IIIb/c tibial fractures revealed local flap reconstruction (25%) skin graft (25%), and free tissue transfer were the most common management strategies and soft-tissue coverage was achieved after 162 hours (interquartile range = 109-231). Negative pressure wound therapy was utilized in 63% of cases but used in isolation in only 23% of cases. Immediate fixation with intramedullary nailing was more frequently used in the 13-17 age group while plate fixation was more commonly used in younger age groups. CONCLUSIONS: Soft-tissue management patterns following open tibial shaft fractures mirror those seen in adult cohorts. The median time to achieve soft-tissue coverage exceeds the traditional 72-hour target advocated by Godina. Age-based variation is seen in orthopedic management of these fractures based on growth maintenance concerns.

What to do with an incidental finding of a fused sagittal suture: a modified Delphi study.

OBJECTIVE: As many as 5% of normocephalic children may have a prematurely fused sagittal suture, yet the clinical significance and best course of management of this finding remain unclear. Providers in the Synostosis Research Group were surveyed to create a multicenter consensus on an optimal treatment and monitoring algorithm for this condition. METHODS: A four-round modified Delphi method was utilized. The first two rounds consisted of anonymous surveys distributed to 10 neurosurgeons and 9 plastic surgeons with expertise in craniosynostosis across 9 institutions, and presented 3 patients (aged 3 years, 2 years, and 2 months) with incidentally discovered fused sagittal sutures, normal cephalic indices, and no parietal dysmorphology. Surgeons were queried about their preferred term for this entity and how best to manage these patients. Results were synthesized to create a treatment algorithm. The third and fourth feedback rounds consisted of open discussion of the algorithm until no further concerns arose. RESULTS: Most surgeons preferred the term "premature fusion of the sagittal suture" (93%). At the conclusion of the final round, all surgeons agreed to not operate on the 3- and 2-year-old patients unless symptoms of intracranial hypertension or papilledema were present. In contrast, 50% preferred to operate on the 2-month-old. However, all agreed to utilize shared decision-making, taking into account any concerns about future head shape and neurodevelopment. Panelists agreed that patients over 18 months of age without signs or symptoms suggesting elevated intracranial pressure (ICP) should not undergo surgical treatment. CONCLUSIONS: Through the Delphi method, a consensus regarding management of premature fusion of the sagittal suture was obtained from a panel of North American craniofacial surgeons. Without signs or symptoms of ICP elevation, surgery is not recommended in patients over 18 months of age. However, for children younger than 18 months, surgery should be discussed with caregivers using a shared decision-making process.

Spectrum of Disease in Hospitalized Newborns with Congenital Micrognathia: A Cohort of 3,236 Infants at North American Tertiary-Care Intensive Care Units.

OBJECTIVE: To describe the spectrum of disease and burden of care in infants with congenital micrognathia from a multicenter cohort hospitalized at tertiary care centers. STUDY DESIGN: The Children's Hospitals Neonatal Database was queried from 2010 through 2020 for infants diagnosed with micrognathia. Demographics, presence of genetic syndromes, and cleft status were summarized. Outcomes included death, length of hospitalization, neonatal surgery, and feeding and respiratory support at discharge. RESULTS: Analysis included 3,236 infants with congenital micrognathia. Cleft palate was identified in 1266 (39.1%). A genetic syndrome associated with micrognathia was diagnosed during the neonatal hospitalization in 256 (7.9%). Median (IQR) length of hospitalization was 35 (16, 63) days. Death during the hospitalization (n = 228, 6.8%) was associated with absence of cleft palate (4.4%, P < .001) and maternal Black race (11.6%, P < .001). During the neonatal hospitalization, 1289 (39.7%) underwent surgery to correct airway obstruction and 1059 (32.7%) underwent gastrostomy tube placement. At the time of discharge, 1035 (40.3%) were exclusively feeding orally. There was significant variability between centers related to length of stay and presence of a feeding tube at discharge (P < .001 for both). CONCLUSIONS: Infants hospitalized with congenital micrognathia have a significant burden of disease, commonly receive surgical intervention, and most often require tube feedings at hospital discharge. We identified disparities based on race and among centers. Development of evidence-based guidelines could improve neonatal care.

Aesthetic Outcomes in Cleft Care: Exploring Patterns in Patient-Reported Outcomes Across Adolescence.

BACKGROUND: For patients with cleft lip/palate, adolescence is a time of maxillofacial growth and complex psychosocial stressors. The personal significance of facial differences may change, making patient-reported outcomes measures (PROMs) invaluable. In this study, we use several scales from CLEFT-Q™ and FACE-Q™ to explore how aesthetic outcomes differ by age and by sex among patients with unilateral cleft lip/palate. MATERIALS AND METHODS: This was a multi-center, cross-sectional study that prospectively collected CLEFT-Q™ and FACE-Q™ data across six cleft treatment centers during clinical appointments from 2019-2022. Subjects were aged 8-22y with unilateral cleft lip, alveolus, and palate who had not undergone tertiary operative care (maxillary advancement or septorhinoplasty) at the time of survey response. Data cross-sections were prepared by age (8-10y, 11-13y, 14y+), by sex, and by age and sex together. RESULTS: Older age groups reported poorer aesthetic outcomes and worse appearance-related distress compared to younger groups. Although male and female subjects reported similar aesthetic outcomes, female subjects reported more appearance-related distress. When considered simultaneously, age and sex appear to have an intersectional impact on perceived aesthetic outcome and appearance-related distress during adolescence. CONCLUSIONS: This exploratory project suggests that patients with cleft lip/palate may perceive worsening of facial aesthetic throughout the course of adolescence, the exact pattern of which may be dependent on sex. Future work will evaluate this hypothesis using longitudinal cohorts. It will be important to investigate psychosocial factors that may impact these outcomes, and also to quantify the impact of tertiary operative care on these outcomes.

Surgical outcome and treatment trends in 1289 infants with micrognathia: a multicenter cohort.

BACKGROUND: Studies of infants with micrognathia, especially Robin Sequence (RS), are limited by its rarity and both phenotypic and diagnostic variability. Most knowledge of this condition is sourced from small, single-institution samples. METHODS: This is a cross-sectional study including infants with micrognathia admitted to 38 Children's Hospital Neonatal Consortium centers from 2010-2020. Predictor variables included demographic data, birth characteristics, cleft and syndrome status. Outcome variables included length of stay (LOS), death, feeding or respiratory support, and secondary airway operations. RESULTS: 1289 infants with micrognathia had a surgery to correct upper airway obstruction. Mean age and weight at operation were 34.8±1.8 weeks and 3515.4±42 grams, respectively. A syndromic diagnosis was made in 150 (11.6%) patients, with Stickler (5.4%) and Treacher Collins Syndromes (2.2%) most common. Operations included: mandibular distraction osteogenesis (MDO), 66.3%; tracheostomy, 25.4%; and tongue-lip adhesion (TLA), 8.3%. Tracheostomy patients had a lower birth weight, head circumference, gestational age, and APGAR scores. MDO patients were less likely to need a second airway operation compared to TLA patients (3.5%vs17.8%,p<0.001). The proportion of infants feeding exclusively orally at hospital discharge differed significantly, from most to least: MDO, TLA, tracheostomy. Hospital LOS was not statistically different for patients that had MDO and TLA, but was longer for those with primary tracheostomy. Mortality was low for all operations (0.5%). CONCLUSION: In this 1289 surgical patient cohort, MDO was associated with shorter hospital stay, improved oral feeding, and lower rates of secondary airway operations. Prospective multi-center studies are necessary to support these conclusions.

Cleft Palate Fistula: A Review.

Background: The development of postoperative oronasal fistulae (ONF) is a complication that plagues all cleft surgeons to varying degrees. There is extensive literature discussing the incidence, functional impact, and treatment of ONF. The goal of this article is to provide an extensive review of the literature discussing the incidence, causative factors, functional impact, classification systems, and treatment of ONF. Methods: A literature review was performed using PubMed using the Medical Subject Heading terms "cleft palate" AND "fistula" OR "palatal fistula" OR "oronasal fistula". After review, a total of 356 articles were deemed relevant for this study. Results: Information regarding ONF care, prevention, and management in patients with cleft palate was collected from the articles included in this review. Treatment of ONF remains a challenging problem as there is not a consensus in the available literature on the best palatoplasty techniques for their prevention and treatment. A myriad of reconstructive options and adjunctive therapies exist, and their use is guided by the size and location of the fistula. Conclusions: Fistula treatment should be tailored to the specific needs of the patient, and consideration must be given to not only the ONF itself but also the patient's stage of growth and development. Large-scale, multicenter studies are needed in which ONF are described using standardized nomenclature, and improved outcomes reporting is necessary to better define an algorithm for a truly holistic approach to palate surgery and reduce the incidence of palatal fistula.

Design and Validation of a 3D Printed Cranio-Facial Simulator: A Novel Tool for Surgical Education.

OBJECTIVE: To assess the ability of current 3D printing technology to generate a craniofacial bony and soft tissue anatomical model for use in simulating the performance of a fronto-orbital advancement (FOA) osteotomy and then to further assess the value of the model as an educational tool. DESIGN: Anatomic models were designed with a process of serial anatomic segmentation/design, 3D printing, dissection, and device refinement. A validation study was conducted with 5 junior and 5 senior plastic surgery residents. The validation study incorporated a multiple-choice Knowledge Assessment test (KA), an Objective Structured Assessment of Technical skills (OSATs), a Global Rating Scale (GRS) and a Michigan Standard Simulation Experience Scale (MiSSES). We compared the scores of both the junior and senior residents and compared junior resident scores, before and after viewing a lecture/demonstration. RESULTS: MiSSES showed high face validity with a score of 85.1/90, signifying high satisfaction with the simulator learning experience. Simulation and the lecture/demonstration improved the junior resident average KA score from 5.6/10 to 9.6/10 (P = .02), OSATs score from 32.4/66 to 64.4/66 (P < .001) and GRS score from 13.9/35 to 27.5/35 (P < .001). The senior residents OSATs score of 56.3/66 was higher than the pre-lecture juniors (32.4/66) (P < .001), but lower than the post-lecture juniors (64.4/66) (P < .001). CONCLUSION: We have successfully fabricated a 3D printed craniofacial simulator capable of being used as an educational tool alongside traditional surgical training. Next steps would be improving soft tissue realism, inclusion of patient and disease specific anatomy and creation of models for other surgical specialties.

The Incidence of Thromboembolic Events During Hospitalizations Following Surgical Resection of Lower Extremity Sarcomas in Children: Utilizing the Pediatric Health Information System Database.

BACKGROUND: Venous thromboembolism (VTE) is a frequent occurrence during treatment for adults with sarcoma. The incidence and underlying risk factors of postsurgical VTE in children and adolescents undergoing resection of sarcoma are unknown. METHODS: Using International Classification of Disease revision-9 diagnostic and procedure codes, the Pediatric Health Information System database was queried for patients aged 18 years and younger, discharged from 2004 to 2015 with a diagnosis of lower extremity malignant neoplasm who had a tumor resection or amputation performed during the encounter. Malignant neoplasms of the pelvic bones and soft tissues were categorized as "pelvis tumors", whereas malignant neoplasms of bone and soft tissues of the lower limbs were categorized as "lower limb tumors". Hospitalizations were evaluated for the occurrence of VTE. Demographic characteristics (age at admission, sex, race, and race/ethnicity) and incidence of VTE were reported. RESULTS: There were 2400 patients identified. Of these, 19 experienced VTE (0.79%) during their surgical hospitalization encounter. By anatomic group, the rate of VTE was 1.4% (CI: 0.5%-3.2%) for tumors in the pelvis and 0.6% (CI: 0.3%-1.0%) in lower limb tumors. Categorizing by age, the incidence of VTE was 1.2% in patients aged zero to 5, 0.3% in patients 6 to 13, and 1.2% in patients 14 to 18 years old. (Table 1). The extremely low rate of VTE occurrence precluded further analysis of risk factors. CONCLUSIONS: In this analysis, postsurgical VTE during hospitalization after pelvic and lower extremity sarcoma resection was an uncommon event in children and adolescents. There seemed to be an increased incidence of postsurgical VTE in pelvic tumors when compared with lower limb tumors, however, the rarity of all events precluded formal statistical analysis. A more robust data set would be required to determine if there are subsets of children and adolescents with sarcoma at higher risk of VTE that could benefit from thromboprophylaxis in the postoperative setting. LEVEL OF EVIDENCE: Level II.

An Algorithmic Approach for Deploying Buccal Fat Pad Flaps and Buccal Myomucosal Flaps Strategically in Primary and Secondary Palatoplasty.

OBJECTIVE: Recent publications have introduced the use of buccal myomucosal and fat pad flaps to augment palatal repairs with autologous tissue. We propose a workflow for intraoperative decision-making to introduce these adjuncts into standard palatoplasty procedures. DESIGN/PATIENTS: A retrospective chart review of a single-surgeon series of patients undergoing primary and secondary palatoplasties performed between October 2017 and November 2020 was completed after Institutional Review Board approval. MAIN OUTCOME MEASURES: Patient demographics, phenotype, operative details, and postoperative complications were recorded. RESULTS: Fifty-eight patients were included in a review. For those undergoing primary repair, 23.3% underwent a Furlow palatoplasty alone, 46.3% had a Furlow palatoplasty accompanied with acellular dermal matrix (ADM) and/or a buccal fat flap (BFF). A unilateral buccal myomucosal flap (BMMF) with or without augmentation with BFF or ADM was employed in 16.3% of the cases. Fourteen percent required a bilateral BMMF+/- ADM. Fistula occurrence was 2.3% (n = 1). For revisions, 27% underwent only a conversion Furlow palatoplasty, 26% had a conversion Furlow palatoplasty accompanied with ADM and/or a BFF, 33% had a unilateral BMMF or BMMF/ADM, and 14% required a bilateral BMMF+/- ADM. CONCLUSIONS: In severe phenotypes or complicated cases, buccal fat flaps and myomucosal flaps may be utilized. This approach has mostly replaced the use of ADM over time. An algorithmic approach to palatoplasty allows surgeons to tailor the extent of surgery to the needs of each patient.

Laryngoscopy Grade Improvement and Difficult Airway Resolution in Infants With Robin Sequence Undergoing Mandibular Distraction Osteogenesis: A Multi-Institutional Study.

OBJECTIVE: Mandibular distraction osteogenesis (MDO) aims to relieve tongue-based airway obstruction in Robin Sequence (RS). We investigated direct laryngoscopy grade (DLG) improvement and difficult airway (DA) resolution following MDO. DESIGN: Retrospective cohort analysis. SETTING: Three tertiary care institutions. PATIENTS: Sixty-four infants with RS who underwent a single MDO procedure in their first year of life were identified from January 2010 to January 2019. MAIN OUTCOME MEASURES: The primary outcome was DLG pre- and post-MDO. Secondary outcomes included DA designation, pre- and post-MDO polysomnographic assessment for obstructive sleep apnea (OSA), length of stay, need for gastrostomy, and major/minor adverse events. RESULTS: Median DLG improved from II pre-MDO to I at the time of distractor removal (n = 43, P < .001). No significant change was seen in patients with a third recorded time point (eg, palatoplasty; n = 78, P = .52). Twenty-six (47%) of 55 patients were designated as DA pre-MDO, and 10 (18%) of 55 patients retained the label post-MDO (P < .01). Five (50%) of these 10 patients appeared to be inappropriately retained. Median obstructive apnea-hypopnea index improved from 38.6 (range 31.2-62.8) pre-MDO to 2.9 (range 1-3.9) post-MDO (n = 12; P = .002). CONCLUSION: Mandibular distraction osteogenesis allowed for DLG improvement that was stably maintained as well as functional improvement in OSA, with minimal morbidity. Difficult airway designation persisted in the electronic record of some infants despite clinical resolution.

Factors Influencing Timely Preparation of Alveolar Bone Grafting: A Survey of the ACPA.

OBJECTIVE: To identify factors that are commonly felt to impact a team's ability to ensure patients are orthodontically and dentally prepared for alveolar bone grafting at the appropriate time. DESIGN: Cross-sectional survey. SETTING: American Cleft Palate-Craniofacial Association (ACPA)-approved multidisciplinary cleft teams. PARTICIPANTS: Cleft team coordinators. INTERVENTIONS: Cleft team coordinators were asked to complete the survey. RESULTS: Fifty-three team coordinators from the 167 ACPA-certified cleft teams completed the survey (response rate = 32%). The majority (83.02%) of cleft teams feel having a case manager increases or would increase the rate of timely bone graft preparation. Orthodontic and dental coverage varied greatly between teams with university/hospital employed dentists and volunteer private practice orthodontists representing the most frequent models. The reported percentage of patients seeking regular dental and orthodontic care with providers affiliated with the team did not correlate with the likelihood of timely bone graft preparation (P = .17; P = .43). Great variability was noted in the manner and frequency of team communication with families during orthodontic bone graft preparation. The presence of a designated case manager on the team was not significantly associated with the percentage of patients who were reported to be orthodontically prepared for bone graft surgery (P = .25). CONCLUSION: Within our survey data, there is great variability noted in factors that may potentially impact orthodontic bone graft preparation. The majority of teams felt that a case manager did or would help with this process, however, our study does not support this fact. Significant recall bias concerning the success of bone graft preparation may affect these results.

Le Fort 1 and Bimaxillary Osteotomies Increase the Length of Stay but not Postoperative Morbidity Compared to Mandibular Osteotomies and Single Jaw Procedures.

PURPOSE: The purpose of this study is to examine the association between type of facial osteotomies performed during orthognathic surgery and postoperative outcomes including complications, length of stay, and readmission. METHODS: A retrospective review of orthognathic surgery cases from the Pediatric Health Information System (PHIS) database from 2004 to 2014 was undertaken. Osteotomy procedures were classified as Le Fort 1 (LF 1), Mandibular osteotomy, Genioplasty or their combinations. Primary outcome variable was major complications. Secondary outcomes included postoperative LOS > 1 day and 90-day readmission. Random-intercept logistic regression models were utilized to assess the association between the type of osteotomy performed and the outcomes. Bonferroni approach was used to account for multiple comparisons. RESULTS: The sample included 5413 patients, with a mean age of 17.1 ±â€Š1.68 years and 60.65% were female. The most common procedures were LF1 (39.4%), followed by bimaxillary surgery (23%). Major complications occurred in 8.57% of patients, postoperative LOS > 1 day in 52.4% and 90-day all-cause readmission in 11.16%. In adjusted analyses comparing LF1 compared to mandibular osteotomies, there were no significant differences for major complications (OR = 0.78), 90-day readmission rate (OR = 0.98). However, LF1 was associated with an increased odds for LOS compared to mandibular osteotomies (OR = 1.42). Addition of osteotomies is associated with a significant increase in LOS (P < 0.001). CONCLUSIONS: Patients undergoing orthognathic surgery demonstrated increased length of stay for LF1 or bimaxillary osteotomies. Osteotomy type did not impact the odds of readmission or complications. The trends revealed should be helpful for patient counseling.

Maxillomandibular Advancement for the Treatment of Obstructive Sleep Apnea in Patients With Normal or Class I Malocclusion.

BACKGROUND: Maxillomandibular advancement is an effective surgical option for obstructive sleep apnea (OSA) that achieves enlargement of the upper airway by physically expanding the facial skeleton. The authors sought to determine whether an advancement of 10 mm predicts surgical success and if any correlation existed between the magnitude of mandibular/maxillary advancement and improvement in polysomnography metrics using aggregated individual patient data from multiple studies. METHODS: A search of the PubMed database was performed to identify relevant articles that included preoperative and postoperative polysomnography data and measurements of the advancement of both the maxillary and mandibular portions of the face in patients with normal or class I malocclusion. Each patient was stratified into "Success" or "Failure" groups based on criteria defining a "Success" as a 50% preoperative to post-operative decrease in AHI or RDI and a post-operative AHI or RDI <20. RESULTS: A review of the PubMed database yielded 162 articles. Review of these resulted in 9 manuscripts and a total of 109 patients who met the inclusion criteria. There was no statistically significant difference in the amount of anterior advancement of either the mandible (P = 0.96) or the maxilla (P = 0.23) between the "Success" or "Failure" groups. CONCLUSIONS: While there is a paucity of individual data available, the current data does not support an ideal amount of maxillary or mandibular advancement that is required to obtain a surgical success in the treatment of OSA. Until a multicenter, prospective, randomized trial is performed, surgical planning should be tailored to patient-specific anatomy to achieve the desired result.

The Use of Prophylactic Antibiotics before Primary Palatoplasty Is Not Associated with Lower Fistula Rates: An Outcome Study Using the Pediatric Health Information System Database.

BACKGROUND: Previous attempts to study the effect of prophylactic antibiotics on the outcomes of cleft palate surgery have been hampered by the need for a very large sample size to provide adequate power to discern a potentially small therapeutic effect. This limitation can be overcome by querying large databases created by health care governing bodies. METHODS: Data from the Pediatric Health Information System database were used for this analysis. Patients, aged 6 to 18 months, who had undergone primary palatoplasty (International Classification of Diseases, Ninth Revision, code 27.62) between 2004 and 2009 were included. Subsequent repair of an oronasal fistula between 2004 and 2015 was identified by International Classification of Diseases, Ninth Revision, procedure code 21.82. Pharmacy billing records were used to determine antibiotic administration. Associations between antibiotic administration and fistula repair were assessed using random-intercept logistic regression adjusting for age, sex, race, and cleft type. RESULTS: Seven thousand one hundred sixty patients were available for analysis; of these, 460 (6.4 percent) had a subsequent repair of an oronasal fistula. Fistula rates were 5.9, 11.4, and 5.2 percent among patients given preoperative antibiotics, only postoperative antibiotics, and no antibiotics, respectively (p < 0.001). Multivariable analysis results showed that the odds of having an oronasal fistula among patients who were administered preoperative antibiotics did not differ significantly (statistically) from patients who did not receive antibiotics (OR, 0.88; 95 percent CI, 0.59 to 1.31). CONCLUSIONS: The treatment goal of primary palatoplasty is the successful repair of the cleft without an oronasal fistula. Administration of preoperative antibiotics did not significantly reduce the odds of subsequent fistula repair within the same Pediatric Health Information System institution following primary palatoplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Adding Depth to Cephalometric Analysis: Comparing Two- and Three-Dimensional Angular Cephalometric Measurements.

INTRODUCTION: Lateral cephalometric radiographs (LCR) have been the standard tool used for cephalometric analysis in craniofacial surgery. Over the past decade, a three-dimensional (3D) revolution in cephalometric analysis and surgical planning has been underway. To date, research has not validated whether cephalometric measurements taken from two-dimensional (2D) and 3D data sources are equivalent and interchangeable. The authors sought to compare angular cephalometric measurements taken with 2D and 3D modalities. METHODS: Sixty-two head CT scans (36 females, 26 males) with an average age of 63 ±â€Š20 years were studied. Twelve cephalometric angular measurements were taken from 3D reconstructed skulls using the software package Mimics 19.0 (Materialize; Leuven, Belgium). These same facial angles were measured from 2D lateral cephalograms reconstructed from the original CT scans using Dolphin 11.9. Measurements taken with both techniques were compared for agreement using a paired t test. Intra-class correlation coefficient assessment was used to determine inter-rater reliability. Statistical significance was set at P < 0.05. RESULTS: Five of the 12 angular measurements (SNA, SNB, MP-FH, U1-SN, and U1-L1) demonstrated statistically significant differences (P < 0.05) between the 2D and 3D analyses. All of these differences were less than the standard deviations for the respective measure. CONCLUSION: The differences between angular cephalometric values obtained from 2D LCRs and 3D CT reconstructions are small. This supports the practices of using 2D and 3D cephalometric data interchangeably in most applications. Clinicians must be selective in which measures they employ to maximize accuracy and care must be taken when measuring dental inclination with lateral cephalograms.

Alveolar soft-part sarcoma: Case demonstrating principles for uncommon vascular lesions.

BACKGROUND: Alveolar soft-part sarcoma (ASPS) is an uncommon malignancy that may present in a manner similar to benign vascular tumors. METHODS: A 6-year-old boy with autism spectrum disorder was referred to the Johns Hopkins All Children's Hospital vascular anomalies clinic for the evaluation of a tongue mass. RESULTS: Prior to the presentation, at 5 years of age, neck computed tomography (CT) was performed. This showed a well circumscribed, enhancing mass at the anterior aspect of the tongue. The radiologic impression was that this lesion was most likely a hemangioma. Two years later, the patient was evaluated in the vascular anomalies clinic. At that examination a 2-3 cm swelling was noted on the dorsal aspect of the tongue. The mass was fleshy and firm with discrete borders. Handheld Doppler examination indicated a high-flow lesion. The patient underwent an excisional biopsy. The lesion was identified as an alveolar soft-part sarcoma based on pathologic characteristics. CONCLUSION: Familiarity with common vascular tumors and malformations allows providers to diagnose the majority of these lesions on a combination of clinical history and physical examination. Atypical and combined lesions do benefit from imaging to help characterize and aid in the differential diagnosis. Biopsy enables definitive diagnosis but is necessary in the minority of cases. When in doubt, referral to a specialized, multidisciplinary vascular anomalies clinic will ensure that these patients receive management for this challenging collection of conditions.

Comprehension of Online Educational Material Regarding Orofacial Clefts.

BACKGROUND: Cleft lip and palate are among the common birth defects in the United States. Management is complex and may be difficult for parents and patients to understand. The goal of this study was to evaluate the readability of online educational material provided by the American Society of Plastic Surgeons (ASPS) and the American Cleft Palate-Craniofacial Association (ACPA) websites regarding cleft lip and palate and to assess parents' comprehension. METHODS: Parents of children younger than 10 years of age presenting to the plastic and reconstructive surgery clinic at Johns Hopkins All Children's Hospital for conditions other than cleft lip and palate were recruited for participation. Parents were given the literature published on the ASPS and ACPA web sites to review and were asked to complete a 5-question test specifically targeted to the content of the passage they reviewed. We tested the readability of the 2 online passages using Readability Studio software (Oleander Software Solutions Ltd). RESULTS: Sixty parents completed the study. Across all groups, the mean score was 4.35 of a possible 5. The mean score was 4.4 for the ASPS web site and 4.29 for the ACPA web site. Fifty-three percent of participants answered all questions correctly. No significant difference in scores was noted between web sites (P = .48). CONCLUSIONS: Despite containing content of varying reading-level difficulty, the literature posted on the ACPA and ASPS web sites concerning cleft lip and palate conveyed information equally well to the target parent demographic with high levels of comprehension.