Global Smile Foundation's Cleft Surgical Outreach Program: Clinical and Economic Impact During the Past 14 Years.

Clefts of the lip and/or palate can result in significant morbidity as well as economic and psychosocial distress for patients and families. Global Smile Foundation is a non-profit organization committed to providing comprehensive cleft care to patients with cleft of the lip/palate around the world. Primary cleft lip and primary cleft palate repairs performed by the Global Smile Foundation in the last decade were reviewed. Averted disability-adjusted life years were estimated and assessed for their economic value. A total of 15,310 disability-adjusted life years were averted. The financial gain was estimated between $78,323,624 and $152,906,604, with an average financial benefit of $48,021 to $93,750 per patient.

Unilateral Cleft Lip Repair: A Quantitative Scale Assessment of Postoperative Lip and Nose Scars Across 2 Operative Techniques.

BACKGROUND: There is no quantitative evidence supporting one unilateral cleft lip (UCL) repair technique over the other with regard to scarring. We sought to evaluate the difference between the extended Mohler and Millard techniques, using 3 scar assessment scales. METHODS: Postoperative frontal and basal photographs of patients undergoing UCL repair were reviewed. Three validated scar assessment scales were used: the Manchester Scar Scale (MSS), modified scar-rating scale (MSRS), and Stony Brook Scar Evaluation Scale. Lip and nose scars were rated by 5 independent raters using each of the scales. Interrater reliability was assessed using the intraclass correlation coefficient (ICC). RESULTS: Assessment of 116 images for 58 consecutive patients undergoing UCL repair (36 extended Mohler, 22 Millard) was performed. Interrater reliability was excellent for lip scars (ICCs, 0.903 [0.857-0.938] for MSS, 0.913 [0.872-0.944] for MSRS, and 0.850 [0.775-0.902] for SBES) and moderate for nose scar assessment (ICCs, 0.714 [0.579-0.816] for MSS, 0.693 [0.548-0.802] for MSRS, and 0.565 [0.359-0.720] for SBES). No statistically significant difference was found between the extended Mohler and Millard repairs in mean lip scar scores (MSS, 6.983 ± 1.469 vs 6.772 ± 1.175, P = 0.571; MSRS, 5.433 ± 1.530 vs 5.481 ± 1.290, P = 0.902; SBES, 3.633 ± 0.977 vs 3.446 ± 0.995, P = 0.483) or nose scar scores (MSS, 5.644 ± 1.131 vs 5.491 ± 0.689, P = 0.523; MSRS, 4.233 ± 0.987 vs 3.991 ± 0.705, P = 0.320; SBES, 3.933 ± 0.750 vs 4.018 ± 0.486, P = 0.603). CONCLUSIONS: Using 3 validated scar assessment scales, no significant difference was found between the extended Mohler and Millard techniques in terms of lip or nose scars.

How to Integrate Lived Experience Into Quality-of-Life Assessment in Patients Considering Facial Transplantation.

Facial transplantation has gained increasing acceptance as a treatment option to improve quality of life (QoL) for persons suffering from severe facial disfigurement. Despite its growth, the field has yet to establish a consistent approach to assessing QoL in face transplant candidates and recipients that includes integration of meaningful patient-reported outcomes. The published literature suggests that face transplant programs currently use a wide variety of assessment tools and strategies. Moreover, confusion remains as to how best to weigh patients' lived experiences and incorporate them into QoL assessments. Qualitative research can illuminate the dimensions of QoL that are meaningful to face transplant candidates and recipients. Coupled with collaboration and data sharing across face transplant programs, qualitative research will help to bring conceptual clarity and transparency to the assessment process.

Qualitative Assessment of Columella Scar Quality After Extended Mohler Unilateral Cleft Lip Repair.

BACKGROUND: The Extended Mohler cleft lip repair restores upper lip form using a columellar flap to fill the defect created by the downward rotation of Cupid's bow. The resulting columella incision is mentioned as a potential drawback. This study seeks to evaluate the morbidity of the resulting scar. MATERIALS AND METHODS: This retrospective study enrolled 50 unilateral cleft lip patients treated using the Extended Mohler repair. 5 reviewers examined post-operative images. Three validated scar assessment scales were utilized: Manchester Scar Scale (MSS), Modified Scar-Rating Scale (MSRS), and Stony Brook Scar Evaluation Scale (SBSES). A scar score for the lip and columellar portion of each patient was determined. RESULTS: Three different scar scales demonstrated significantly better scar quality for the columellar portion of the scar compared to the lip portion. The average score for the lip and columella using the MSS was 7.0 ±â€Š1.4 and 5.7 ±â€Š1.1 (P <0.001). The average score for the lip and columella using the MSRS was 5.5 ±â€Š1.4 and 4.3 ±â€Š0.9 (P <0.001). The average score for the lip and columella using the SBSES was 3.5 ±â€Š1.1 and 3.9 ±â€Š0.7 (P = 0.014). The intraclass correlation coefficient for lip scar assessments was 0.901 (MSS), 0.91 (MSRS), and 0.873 (Stony Brook Evaluation Scale [SBES]). The intraclass correlation coefficient for columellar scar assessment was 0.786 (MSS), 0.761 (MSRS), and 0.726 (SBES). CONCLUSION: The Extended Mohler unilateral cleft lip columellar scar is of superior quality compared to the lip portion. This analysis ameliorates one of the major concerns regarding the Extended Mohler cleft lip repair.

Comprehensive Assessment of Vascularized Composite Allotransplantation Patient-Oriented Online Resources.

INTRODUCTION: Online resources have become a major source of medical information for the general public. To date, there has not been an assessment of patient-oriented online resources for face and upper extremity transplantation candidates and patients. The goal of this study is to perform a comprehensive assessment of these resources. METHODS: Our analysis relied on 2 dimensions: comprehensiveness and readability. Comprehensiveness was evaluated using 14 predetermined variables. Readability was evaluated using 8 different readability scales through the Readability Studio Professional Edition Software (Oleander Software, Ltd, Vandalia, Ohio). Data were also collected from solid organ transplantation (SOT), specifically kidney and liver, programs for comparison. RESULTS: Face and upper extremity transplantation programs were significantly more likely to list exclusion criteria (73.9% vs 41.2%; P = 0.02), the need for life-long immunosuppression (87.0% vs 58.8%; P = 0.02), and benefits of transplantation (91.3% vs 61.8%; P = 0.01) compared with SOT programs. The average readability level of online resources by all face and upper extremity transplantation programs exceeded the sixth grade reading level recommended by the National Institutes of Health and the American Medical Association. The average reading grade level of online resources by these programs was also significantly higher than those of SOT with both exceeding the recommended reading level (13.95 ± 1.55 vs 12.60 ± 1.65; P = 0.003). CONCLUSIONS: Future efforts in face and upper extremity transplantation should be directed toward developing standardized, comprehensive, and intelligible resources with high-quality content and simple language.

Nasolabial Aesthetics Following Cleft Repair: An Objective Evaluation of Subjective Assessment.

OBJECTIVE: Assess the weight and contribution of each of the parameters of the Asher-McDade Scale to overall subjective assessment of nasolabial aesthetics following cleft lip repair. DESIGN: Retrospective cohort evaluation. SETTING: Cleft and craniofacial center. PARTICIPANTS: Forty-one patients who underwent unilateral cleft lip repair. INTERVENTIONS: Unilateral cleft lip repair. MAIN OUTCOME MEASURES: Nasolabial rating using the Asher-McDade scale and overall subjective assessment of nasolabial aesthetics using a rank score following unilateral cleft lip repair. RESULTS: Strong interrater reliability was observed between the 3 raters. Significant association was determined on bivariate analysis between nasal form score (ß = 27.06; P < .001), nasal symmetry score (ß = 26.41; P < .001), nasal profile score (ß = 28.75; P < .001), vermilion border score (ß = 13.40; P = .012), and the ranking score. Adjusted ß coefficients obtained from multivariate regression analysis were used to develop a modified nasolabial appearance score (over 5), that is, weighted for each of the 4 parameters: nasal form (over 8, adjusted ß = 14.33), nasal symmetry (over 5, adjusted ß = 7.96), nasal profile (over 5, adjusted ß = 9.44), and vermilion (over 2, adjusted ß = 3.31). Regression analysis between our modified nasolabial appearance score and patient ranking score demonstrated superior goodness of fit when compared to the Asher-McDade overall nasolabial appearance score (R2 = .80; P < .001 vs R2 = .69; P < .001). CONCLUSION: The parameters evaluated in the Asher-McDade scale have different weights and contribute differently to overall subjective assessment of nasolabial aesthetic outcomes following cleft lip repair. Adjusting for their weights results in a modified score that demonstrates superior correlation with overall subjective assessment of nasolabial aesthetic outcomes.

Assessment of American Cleft Palate-Craniofacial Association-Approved Teams' Websites for Patient-Oriented Content and Readability.

OBJECTIVE: Informed decision-making relies on available information, including online resources. We evaluated the content and readability of websites published by American Cleft Palate-Craniofacial Association (ACPA)-approved cleft lip and/or palate (CLP) teams in the United States. DESIGN: Team websites were reviewed, and teams with no accessible website or <30 sentences of content were excluded. Website content was scored by presence/absence of 20 variables derived from ACPA approval standards. Readability was evaluated with 8 scales. Readability was then compared to American Medical Association (AMA) recommendations. The relationship between website content and readability was assessed. MAIN OUTCOME MEASURE(S): Content and readability of team websites. RESULTS: From 167 reviewed teams, 47 (28.1%) had nonfunctional links, 17 (10.2%) had no accessible website, and 39 (23.4%) had <30 sentences. The average content score for all 111 team websites included was 14.5 (2.6) of 20. The combined average reading level across all scales (10.7 [1.9]) exceeded the AMA-recommended sixth-grade reading level; this finding held true for each individual website. Children's Hospital-affiliated teams (n = 86) had a significantly higher content score (14.8 vs 13.5; P = .03) and better readability as evidenced by lower reading grade level (10.5 vs 11.4; P = .04). On linear regression, a higher content score significantly predicted better readability (ß = -0.226; P < .001). CONCLUSIONS: Websites published by ACPA-approved CLP teams vary in accessibility and content and exceed the recommended reading level. These findings could inform future efforts to improve patient-oriented resources.

Three-Dimensional Affordable Stone Models for Cleft Lip Markings: A Prospective Study of Learner Satisfaction.

INTRODUCTION: Knowledge of surgical markings for unilateral cleft lip (UCL) repair is critical for surgical competency. However, few appropriate models are accessible to residents and affordable and accurately reproduce this 3-dimensional (3D) deformity. We propose that cleft care units have the capability of creating affordable 3D stone models to teach UCL markings. METHODS: Polyvinyl siloxane and SnapStone were used to create UCL stone models. Thirteen plastic surgery residents were prospectively recruited, provided with a textbook chapter and online module for studying surgical markings for UCL repair, and then asked to perform the markings on a UCL stone model and standardized patient photograph. Learner satisfaction was evaluated using a modified survey based on the Student Evaluation of Educational Quality survey. RESULTS: The production time of each model was 10 minutes, whereas the cost was $1.84. Participants reported that the stone model was more stimulating (4.77 ± 0.44 vs 3.92 ± 0.86; U = 38.0; P = 0.008), increased their interest more (4.70 ± 0.48 vs 3.53 ± 1.20; U = 33.5; P = 0.005), allowed better learning (4.61 ± 0.51 vs 3.08 ± 0.86; U = 10.0; P < 0.001), was clearer (4.62 ± 0.51 vs 3.15 ± 0.90; U = 12.5; P < 0.001), and was more effective for learning cleft lip markings (4.77 ± 0.44 vs 3.08 ± 1.04; U = 9.0; P < 0.001). They were also more likely to recommend it (4.85 ± 0.38 vs 3.15 ± 1.07; U = 7.0; P < 0.001). CONCLUSIONS: Plastic surgery residents report that 3D cleft lip stone models are superior training tools to learn cleft lip markings compared with patient photographs. These educational tools have the potential to overcome significant financial, logistic, and time constraints in teaching cleft lip surgery markings.

Foundation-Based Cleft Care in Developing Countries.

BACKGROUND: Cleft deformities of the lip and palate affect nearly one in 500 to 700 births, and lead to increased morbidity and mortality if untreated. Nevertheless, significant global disparities in access to timely and appropriate care still exist. The relatively basic infrastructure required to surgically correct these deformities and large unmet disease burden have resulted in a significant number of foundation-based cleft care initiatives focused on developing countries. In this study, the authors evaluate the peer-reviewed literature generated by these foundations in an attempt to assess their clinical, scientific, educational, and economic impact. METHODS: A comprehensive review of the literature was performed using key search terms, and the level of evidence of identified articles was determined. Data were then analyzed to determine the different models of foundation-based cleft care in developing countries, and their clinical, scientific, educational, and economic impact. RESULTS: A total of 244 articles were identified through the authors' search and reviewed. Foundation-based cleft care initiatives in developing countries have significantly contributed to a better understanding of disease epidemiology, barriers to care, safety considerations, complications and outcomes, and international and local cleft surgery education. The cleft care center model is more cost-effective than the surgical mission model and provides more sustainable care. CONCLUSIONS: Foundation-based cleft care prevents significant morbidity in developing countries and has provided valuable resources for capacity building. The surgical mission model should be considered as a transitory conduit for establishing the more effective and sustainable cleft care center model of care.

Three-Dimensional Analysis of Donor Masks for Facial Transplantation.

BACKGROUND: Face transplant teams have an ethical responsibility to restore the donor's likeness after allograft procurement. This has been achieved with masks constructed from facial impressions and three-dimensional printing. The authors compare the accuracy of conventional impression and three-dimensional printing technology. METHODS: For three subjects, a three-dimensionally-printed mask was created using advanced three-dimensional imaging and PolyJet technology. Three silicone masks were made using an impression technique; a mold requiring direct contact with each subject's face was reinforced by plaster bands and filled with silicone. Digital models of the face and both masks of each subject were acquired with Vectra H1 Imaging or Artec scanners. Each digital mask model was overlaid onto its corresponding digital face model using a seven-landmark coregistration; part comparison was performed. The absolute deviation between each digital mask and digital face model was compared with the Mann-Whitney U test. RESULTS: The absolute deviation (in millimeters) of each digitally printed mask model relative to the digital face model was significantly smaller than that of the digital silicone mask model (subject 1, 0.61 versus 1.29, p < 0.001; subject 2, 2.59 versus 2.87, p < 0.001; subject 3, 1.77 versus 4.20, p < 0.001). Mean cost and production times were $720 and 40.2 hours for three-dimensionally printed masks, and $735 and 11 hours for silicone masks. CONCLUSIONS: Surface analysis shows that three-dimensionally-printed masks offer greater surface accuracy than silicone masks. Greater donor resemblance without additional risk to the allograft may make three-dimensionally-printed masks the superior choice for face transplant teams. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Internet-Based Digital Simulation for Cleft Surgery Education: A 5-Year Assessment of Demographics, Usage, and Global Effect.

BACKGROUND: In October 2012, a freely available, internet-based cleft simulator was created in partnership between academic, nonprofit, and industry sectors. The purpose of this educational resource was to address global disparities in cleft surgery education. This report assesses demographics, usage, and global effect of our simulator, in its fifth year since inception. OBJECTIVE: Evaluate the global effect, usage, and demographics of an internet-based educational digital simulation cleft surgery software. SETTING AND PARTICIPANTS: Simulator modules, available in five languages demonstrate surgical anatomy, markings, detailed procedures, and intraoperative footage to supplement digital animation. Available data regarding number of users, sessions, countries reached, and content access were recorded. Surveys evaluating the demographic characteristics of registered users and simulator use were collected by direct e-mail. RESULTS: The total number of simulator new and active users reached 2865 and 4086 in June 2017, respectively. By June 2017, users from 136 countries had accessed the simulator. From 2015 to 2017, the number of sessions was 11,176 with a monthly average of 399.0 ± 190.0. Developing countries accounted for 35% of sessions and the average session duration was 9.0 ± 7.3 minutes. This yields a total simulator screen time of 100,584 minutes (1676 hours). Most survey respondents were surgeons or trainees (87%) specializing in plastic, maxillofacial, or general surgery (89%). Most users found the simulator to be useful (88%), at least equivalent or more useful than other resources (83%), and used it for teaching (58%). CONCLUSIONS: Our internet-based interactive cleft surgery platform reaches its intended target audience, is not restricted by socioeconomic barriers to access, and is judged to be useful by surgeons. More than 4000 active users have been reached since inception. The total screen time over approximately 2 years exceeded 1600 hours. This suggests that future surgical simulators of this kind may be sustainable by stakeholders interested in reaching this target audience.