Long-Term Control of Nasal Tip Position: Quantitative Assessment of Caudal Septal Extension Graft.

BACKGROUND: Control of nasal tip position is critical to final rhinoplasty outcomes. Two frequent methods of exerting tip control are columellar strut and caudal septal extension graft (SEG). Past work has demonstrated that SEG are better able to preserve tip position. However, there is no quantitative data describing long-term projection and rotation. The purpose of this study was to analyze long-term maintenance of tip projection and rotation following SEG. METHODS: A retrospective study of adult patients undergoing open rhinoplasty was conducted. Three-dimensional photogrammetric evaluation of nasal tip position was performed. Anthropometric points were analyzed preoperatively and postoperatively. Outcome variables were tip projection, tip rotation, and nasal length. RESULTS: Twenty patients were included with an average follow-up time of 3.3 years (2.0 - 6.6 years). From postoperative week 1 to 6, there was a statistically significant decrease in rotation (-4.3%, p<0.01). There were no statistically significant decreases in projection, rotation, or nasal length from 6 weeks postoperative to 2 years postoperative, or from 6 weeks postoperative to final follow-up (2.0 - 6.6 years). CONCLUSIONS: Nasal tip projection and rotation appear to decrease from the immediate postoperative position, likely due to resolving edema. In this study, patients that underwent open rhinoplasty with SEG experienced modest loss of projection and rotation until 6 weeks postoperative, but projection and rotation were maintained from 6 weeks postoperative to 2 years and beyond. This study provides evidence that SEG maintains long-term changes in tip projection and rotation. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A National Assessment of Racial and Ethnic Disparities in Cleft Lip Repair.

PURPOSE: This study examined the impact of patient race/ethnicity on the likelihood of experiencing delays to surgery, post-operative surgical complications, and prolonged hospital length of stay (LOS) following primary cleft lip (CL) repair. METHODS: Patients who underwent CL repair were identified in the 2006-2012 Kids' Inpatient Database. Primary outcomes were defined as treatment after 6-months-old, presence of any surgical complication, LOS >1 day, and total hospital charges. Multivariable analyses were performed to adjust for sociodemographic and clinical characteristics that might account for differences in outcomes. RESULTS: There were 5927 eligible patients with cleft lip: 3724 White, 279 Black, 1316 Hispanic, 277 Asian/Pacific-Islander, and 331 other race/ethnicity. Across all outcomes, there were significant unadjusted differences (p<0.001) by race/ethnicity, with White children having the lowest odds of delayed surgery, complications, and prolonged LOS, and the lowest charges. Multivariable analyses suggested that differences in baseline health status may account for much of this disparity in combination with factors such as income, insurance type, and location. Even after adjusting for co-variates, significantly increased odds of delayed surgery and higher charges remained for Hispanic and Asian/PI patients. CONCLUSION: There are significant differences in the odds of delays, complications, prolonged hospital stays, and total charges among CL patients of different race/ethnicity. Advocacy efforts to ameliorate disparity in early infant health may subsequently improve equity in cleft outcomes.

Health Equity and Healthcare Disparities in Plastic Surgery: What We Can Do.

Amidst the unexpected losses and challenges of 2020, healthcare disparities and health equity have presided as noteworthy topics of national discussion among healthcare workers, governmental officials, and society at large. Health equity, defined as the opportunity for everyone to be as healthy as possible, may be achieved through the alleviation of healthcare disparities. Healthcare disparities are defined as "preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations." While these concepts may be perceived as a departure from the core responsibility of plastic surgeons, it is of paramount importance to recognize how race, socioeconomic status (SES), and physical environment impact access to care, surgical outcomes, and postoperative recovery for vulnerable populations. In this communication, our purpose is two-fold: 1) to elucidate the existent healthcare disparities and associations with race and SES in craniofacial, trauma, breast, hand, and gender-affirming reconstruction; and 2) provide tangible recommendations to incorporate the concepts of health equity and healthcare disparities in clinical, research, community, and recruitment settings for plastic surgeons. Through such knowledge, plastic surgeons may glean important insights that may enhance the delivery of equitable and accessible care for patients.

Orthognathic Surgery to Improve Facial Profile: Assessment, 3-Dimensional Planning, and Technique.

A concave profile with class III malocclusion is most often due to a combination of maxillary hypoplasia and mandibular hyperplasia. Surgical correction entails normalization of jaw positions and is more challenging in the setting of concurrent asymmetry and open bite. Treatment should optimize both facial harmony and occlusion. Orthognathic surgery for class III deformities occurs at skeletal maturity and should address all aspects of the condition while preventing unnecessary emotional stress from delayed treatment. In this article, the authors describe the 3-jaw orthognathic surgery technique to address maxillary hypoplasia, mandibular prognathism, open bite, and mandibular asymmetry in a single procedure. The process of preoperative 3-dimensional (3D) virtual surgical planning, detailed surgical technique, fat grafting, and a comparison of preoperative and postoperative 3D aesthetic outcomes is presented. Additionally, a retrospective review of postoperative outcomes of 54 patients who received 3-jaw orthognathic surgery is presented as well.

Aesthetic Rhinoplasty: Technique, 3-Dimensional Simulation, and Outcome Assessment.

Communication of goals and realistic expectations between the surgeon and patient is a crucial step of aesthetic rhinoplasty. Three-dimensional (3D) imaging technology allows for sharing of simulated outcomes in the office setting, thereby facilitating this process. This article highlights the use of 3D rhinoplasty simulation in preoperative assessment and the senior author's preferred surgical technique in open rhinoplasty.

The Geographic Availability of Certified Cleft Care in the United States: A National Geospatial Analysis of 1-Hour Access to Care.

PURPOSE: Children with cleft lip and/or palate (CLP) require longitudinal multidisciplinary care. Travel distance to comprehensive cleft centers may be a barrier for some families. This study evaluated the geospatial availability of certified cleft teams across the United States. MATERIALS AND METHODS: A geographic catchment area within a 1-hour travel radius of each American Cleft Palate-Craniofacial Association-certified cleft center was mapped using TravelTime distance matrix programming. The proportion of children located within each catchment area was calculated using county-level data from the National Kids Count Data Center, with aggregate estimates of patients with CLP based on state-level data from the Centers for Disease Control and Prevention. One-hour access was compared across regions and based on urbanization data collected from the US Census. RESULTS: There were 182 American Cleft Palate-Craniofacial Association-certified centers identified. As per study estimates, 28,331 (27.3%) children with CLP did not live within 1-hour travel distance to any center. One-hour access was highest in the Northeast (84.2% of children, P < .001) and lowest in the South (65.7%) and higher in states with the greatest urbanization in comparison with more rural states (85.1 vs 37.4%, P < .001). Similar patterns were seen for access to 2 or more cleft centers. The number of CLP children-per-center was highest in the West (775) and lowest in the Northeast (452). CONCLUSIONS: Travel distances of more than 1 hour may affect more than 25,000 (1 of 4) CLP children in the US, with significant variation across geographic regions. Future studies should seek to understand the impact of and provide strategies for overcoming geographic barriers.

Racial Disparities in Complications, Length of Stay, and Costs Among Patients Receiving Orthognathic Surgery in the United States.

INTRODUCTION: Black and Hispanic/Latino patients in the United States often experience poorer health outcomes in comparison to White patients. We aimed to assess the impact of race on complications, length of stay, and costs after orthognathic surgery. METHODS: Pediatric and young adult orthognathic surgeries (age <21) were isolated from the Kids Inpatient Database from 2000-2012. Procedures were grouped into cohorts based on the preoperative diagnosis: apnea, malocclusion, or congenital anomaly. T tests and χ2 analyses were employed to compare complications, length of stay (LOS), and costs among Black, Hispanic, Asian/Pacific Islander, and other patients in comparison to White patients. Multivariable regression was performed to identify associations between sociodemographic variables and the primary outcomes. Post-hoc χ2 analyses were performed to compare proportions of patients of a given race/ethnicity across the 3 surgical cohorts. RESULTS: There were 8,809 patients identified in the KID database (mean age of 16.3 years). Compared to White patients, complication rates were increased among Hispanic patients (2.1 vs 1.3%, P = .037) and other patients treated for apnea (8.7 vs 0.83%, P = .002). Hospital LOS was increased in both Black (3.3 vs 2.1 days, P < .001) and Hispanic (2.9 days, P < .001) patients. Costs were higher than Whites ($35,633.47) among Hispanic ($48,029.15, P < .001), Black ($47,034.41, P < .001), and Asian/Pacific-Islander ($44,192.49, P < .001) patients. White patients comprised a larger proportion of the malocclusion group (77.8%) than apnea (66.9%, P < .001) or congenital anomaly (59.1%, P < .001), while the opposite was true for Black, Hispanic, and Asian/Pacific-Islander patients. CONCLUSION: There are significant differences in complications, LOS, and costs after orthognathic surgery among patients of different race/ethnicity. Further studies are needed to better understand the causes of disparity and their clinical manifestations.

Control of Nasal Tip Position: Quantitative Assessment of Columellar Strut versus Caudal Septal Extension Graft.

BACKGROUND: Control and maintenance of nasal tip position are critical in rhinoplasty. Two frequent methods of exerting tip control are columellar strut and caudal septal extension graft. However, no quantitative data exist comparing the two methods over time. The purpose of this study was to analyze maintenance of tip projection and rotation following either columellar strut or septal extension graft. METHODS: A retrospective cohort study of patients undergoing rhinoplasty was reviewed. Three-dimensional photogrammetric evaluation of patients with either columellar strut or septal extension graft to increase tip projection was performed. Anthropometric points were analyzed in a blinded fashion. Outcome variables were tip projection, nasal length, the Goode ratio, and tip rotation. Results were stratified based on technique and compared statistically. RESULTS: One hundred six patients were included. Overall, 66 percent were female, with an average age of 34.5 years. A columellar strut was used in 42 percent of cases (n = 45), and a septal extension graft was used in 57 percent (n = 61). Analysis showed greater maintenance of tip rotation over time with the septal extension graft compared with the columellar strut [-1.01 percent change (p = not significant versus -5.08 percent change (p = 0.009)]. Tip projection, nasal length, and the Goode ratio decreased over time for both groups, but the differences were not statistically different. CONCLUSIONS: Nasal tip projection and rotation appear to decrease from the immediate postoperative position. In this study, both septal extension graft and columellar strut exhibit similar changes in tip projection with time; however, septal extension graft is better able to preserve tip rotation compared with the columellar strut. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Hospital Volume Improves Primary, Revision, and Delayed Cleft Palate Repair.

BACKGROUND: High volume centers (HVC) is commonly associated with increased resources and improved patient outcomes. This study assesses efficacy and outcomes of high volume centers in cleft palate repair. METHODS: Cleft palate procedures were identified in the Kids' Inpatient Database from 2003-2009. Demographics, perioperative factors, co-morbidities, and complications in HVC (90th percentile, >48 cases/year) and non-high volume centers (NHVC) were compared across various cohorts of cleft repair. RESULTS: Four thousand five hundred sixty-three (61.7%) total cleft palate surgeries were performed in HVC and 3388 (38.3%) were performed in NHVC. The NHVC treated a higher percentage of Medicaid patients (P = 0.005) and patients from low-income quartiles (P = 0.018). HVC had larger bedsizes (P <0.001), were more often government/private owned (P <0.001), and were more often teaching hospitals (P <0.001) located predominantly in urban settings (P <0.001). The HVC treated patients at younger ages (P = 0.008) and performed more concurrent procedures (P = 0.047). The most common diagnosis at HVC was complete cleft palate with incomplete cleft lip, while the most common diagnosis at NHVC was incomplete cleft palate without lip. Overall, length of stay and specific complication rates were lower in HVC (P = 0.048, P = 0.042). Primaries at HVCs showed lower pneumonia (P = 0.009) and specific complication rates (P = 0.023). Revisions at HVC were associated with older patients, fewer cardiac complications (P = 0.040), less wound disruption (P = 0.050), but more hemorrhage (P = 0.040).

Racial Disparities in Cleft Palate Repair.

BACKGROUND: Various factors can influence outcomes in cleft palate care. This study sought to determine the impact of race on admissions, hospital costs, and short-term complications in cleft palate repair. METHODS: Cleft palate operations were identified in the Kids' Inpatient Database data, from 2000 to 2009. Data were combed for demographics, perioperatives, complications, and hospital characteristics. Bivariate and multivariate analyses were performed between races in total, primary, and revision cohorts. RESULTS: There were 3464 white, 1428 Hispanic, 413 black, 398 Asian/Pacific-Islander, and 470 patients of other races captured. Black patients experienced more emergent admissions (p = 0.005) and increased length of stay (p = 0.029). Hospital charges were highest for black and Hispanic patients and lowest for white patients (p = 0.019). Black patients had more total complications than non-black patients (p = 0.039), including higher rates of postoperative fistula (p = 0.020) and nonspecific complications among revision repairs (p = 0.003). Asian/Pacific Islander in the primary cohort experienced higher rates of accidental puncture (p = 0.031) and fistula (p < 0.001). Other patients had the highest rates of wound disruption (p = 0.013). After controlling for race, diagnosis, Charlson Comorbidity Index score, region, elective/nonelective, payer, and income quartile, length of stay (p < 0.001) and age (p < 0.001) were associated with increases in both total complications and costs. CONCLUSIONS: Race may play a significant role in cleft palate repair, as white patients had fewer complications, shorter length of stay, and lower costs following repair. Delayed age at treatment may predispose patients to adverse sequelae in minority populations, in terms of influencing length of stay and costs. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Postoperative Edema Resolution following Rhinoplasty: A Three-Dimensional Morphometric Assessment.

BACKGROUND: The final result of rhinoplasty may be masked for several months after surgery because of postoperative edema; however, no objective evidence supports this time estimate. The purpose of this study was to three-dimensionally quantify the decrease in postsurgical nasal edema following rhinoplasty over the first postoperative year. METHODS: This was a retrospective, three-dimensional, morphometric study of primary, open rhinoplasty patients. Subjects with at least three postoperative three-dimensional images up to 1 year were included. Patients were excluded for closed or secondary procedures or cleft deformities. Images were assessed using three-dimensional stereophotogrammetry (Vectra) and volumetric analysis (Geomagic). Baseline nasal volume (time 0) occurred at the first postoperative visit at 1 to 2 weeks. All subsequent nasal volume measurements were calculated as a percentage of baseline values. Data points from all patients were pooled, and a six-point moving average was used to create an inverse function line of best fit. RESULTS: Forty patients were included, with 146 three-dimensional photographs quantified. The equation for the inverse function line of best fit of the six-point moving average was y = 1.484 (1/x) + 0.844 (R = 0.85, p < 0.01). According to this equation, approximately two-thirds of edema resolves within the first month, 95 percent after 6 months, and 97.5 percent after 1 year. A plateau is reached at 84.4 percent of the original postoperative volume. CONCLUSIONS: This study provides quantitative evidence to predict decrement of rhinoplasty edema with time. Three-dimensional morphometric assessment demonstrated a two-thirds decrease in edema at 1 month, a 95 percent decrease at 6 months, and a 97.5 percent decrease at 1 year. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Improved Short-Term Outcomes following Orthognathic Surgery Are Associated with High-Volume Centers.

BACKGROUND: Previous studies assessing outcomes following orthognathic surgery rely primarily on single-center/surgeon experience. In addition to issues of generalizability, these studies are limited in evaluating the effect of operative volume on patient outcomes. METHODS: Orthognathic procedures were identified in the 1999 to 2011 Healthcare Cost and Utilization Project Nationwide Inpatient Sample. Outcomes included occurrence of any in-hospital complication, extended length of stay (>2 days), and increased costs (>$10,784). High-volume hospitals were defined as the 90th percentile of case volume or higher (>31 cases/year). Univariate and multivariate analyses were conducted to identify independent predictors of outcomes. Trend analyses were performed to assess changes in the annual rate of patients treated at high-volume hospitals over the study period. RESULTS: Among 101,692 orthognathic surgery patients, 19.6 percent underwent concurrent ancillary procedures (i.e., genioplasty, rhinoplasty, or septoplasty), and 37.6 percent underwent double-jaw surgery. Fifty-three percent were treated at high-volume hospitals. High-volume hospitals more often performed ancillary procedures (21.4 percent versus 17.4 percent; p < 0.001) and double-jaw surgery (41.3 percent versus 33.4 percent; p < 0.001). After adjustments for clinical and hospital characteristics, patients treated at high-volume hospitals were less likely to experience any complication (OR, 0.75; 95 percent CI, 0.70 to 0.81; p < 0.001) and extended length of stay (OR, 0.71; 95 percent CI, 0.68 to 0.75; p < 0.001). There was a 2 percent annual increase in the rate of patients treated at high-volume hospitals over the study period (incidence rate ratio, 1.02; 95 percent CI, 1.01 to 1.03; p < 0.001). CONCLUSIONS: The majority of orthognathic cases nationwide are performed at a small number of high-volume hospitals. These hospitals discharge patients earlier, perform more complex procedures, and have fewer complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The Repair of International Clefts in the Current Surgical Landscape.

Cleft lip and palate (CLP) constitute a significant global disease burden. There are two general models that exist to deliver cleft care: surgical missions and comprehensive cleft centers (CCC). While surgical missions offer high quality surgical care to patients who would be unlikely to ever receive treatment, they may fail to provide sustainable solutions. The development of CCC is growing in popularity worldwide. CCC are permanent centers that offer a multidisciplinary team approach to the treatment of cleft lip and palate. Operation Smile has adopted the concept of specialized surgical care centers. These centers are shown to be safe, cost-effective, and provide sustainable solutions for cleft care. The authors discuss some of the benefits and drawbacks of the classic mission-based model and highlight why there may be a paradigm shift towards CCC.

Assessment of three-dimensional nasolabial response to Le Fort I advancement.

BACKGROUND: Le Fort I advancement induces soft tissue changes to the nasolabial region. The correlation of sagittal skeletal movement to soft tissue alteration has been studied using 2D methods. However, the influence of maxillary advancement has not been adequately assessed using three-dimensional means. The purpose of this study is to analyze nasolabial changes following Le Fort I advancement using 3D photometric measurements. METHODS: Patient demographic information and their amount of advancement were tabulated. Pre- and postoperative 3D photographs (3D VECTRA photosystem, Canfield, Fairfield, NJ) were recorded. Nasolabial anthropometric measurements were performed using the corresponding 3D post-processing software (Mirror). Six month minimum follow-up elapsed before final evaluation. RESULTS: Forty-four 3D photo data sets were included. Mean maxillary advancement was 5.5 (±1.9) mm. Male/female ratio was 0.7 with a mean age of 16.7 years. Significant increases (p < 0.0001) were seen in the alar base, alar widths, nostril width, and in the soft triangle and lateral alar angles. Significant decreases (p < 0.0001) were noted in the nasofrontal angle and in nostril height. A significant (p < 0.05) increase of the nasal tip, columella and upper lip projection was seen. Philtral height showed no significant changes (p > 0.05) after maxillary advancement. No significant correlation (p > 0.05) between the degree of soft tissue changes and the amount of maxillary advancement was found. CONCLUSION: Le Fort I advancement significantly impacts the nasolabial soft tissue envelope. The 3D soft tissue changes are predictable and similar for any advancement up to 10 mm.

Bridge of bone canthopexy: technique and morphologic assessment.

INTRODUCTION: Malposition of the lower eyelid may disrupt facial aesthetics and impair proper eyelid function. Multiple techniques have been proposed to restore lower eyelid position. The purpose of this study is to report on a modified bridge of bone canthopexy technique and assess its effect on lower eyelid and palpebral fissure restoration. METHODS: A retrospective chart review was conducted. Pre- and post-operative photographs of patients were evaluated by a blinded observer. Pair-wise and chi-square tests were conducted with an observed p-value of 0.05 or less considered statistically significant. RESULTS: 12 patients (7 females) with a mean age of 42 (range = 7-87) were included. Canthal tilt and scleral show decreased significantly following surgery (p = 0.05), and the eye fissure index and inferior coverage of the iris approached significance (p = 0.16 and p = 0.07, respectively). Two minor complications were encountered in our series. CONCLUSION: The modified bridge of bone canthopexy is a safe and effective technique for alteration of the lower eyelid and is broadly applicable to all causes of negative canthal angulation. Further studies are necessary to test the longevity and stability of this procedure.