Comparison of Outpatient and Inpatient Pediatric Rhinoplasty: Results From National Surgical Quality Improvement Program-Pediatric, 2012-2014.

INTRODUCTION: Outpatient management of patients undergoing elective surgical procedures has been associated with significantly decreased health care costs compared with inpatient management. This study investigates current practices in outpatient versus inpatient management of pediatric rhinoplasty patients. METHODS: A query was performed of the 2012 to 2014 National Surgical Quality Improvement Program-Pediatric data sets. Patients age 17 or younger undergoing rhinoplasty as the primary surgical procedure were included. Clinical characteristics and complications were compared among patients managed as inpatients versus outpatients using both univariate and multivariate logistic regression analyses. RESULTS: Among 938 pediatric rhinoplasty patients, 199 (21.2%) were managed as inpatients. Multivariate analysis revealed multiple variables significantly associated with an increased odds of inpatient management, including young patient age, presence of a congenital malformation, neurologic or nutritional disease, lengthy procedure time, management by a plastic surgeon compared with an otolaryngologist, and certain procedure types including cleft septorhinoplasty, secondary rhinoplasty with intermediate or major revision, and rib cartilage grafting. Complications among both inpatients and outpatients were rare, with the most common complication being readmission among 15 patients (1.6%). CONCLUSIONS: This study indicates that multiple subgroups of pediatric patients undergoing rhinoplasty procedures have a significantly increased likelihood of inpatient management without any significantly increased likelihood of a complication or need for readmission. Future efforts to manage appropriately selected children on an ambulatory basis may be safe, while improving costs and quality of care.

The Imperative of Academia in the Globalization of Plastic Surgery.

Although vertical health care delivery models certainly will remain a vital component in the provision of surgery in low-and-middle-income countries, it is clear now that the sustainability of global surgery will depend on more than just surgeons operating. Instead, what is needed is a comprehensive approach, that is, a horizontal integration that develops sustainable human resources, physical infrastructure, administrative oversight, and financing mechanisms in the developing world. We propose that such a strategy for development would necessarily involve an active role by academic institutions of high-income countries.

Endoscopic changes in the upper airway after mandibular distraction osteogenesis.

INTRODUCTION: Children with micrognathia secondary to craniofacial disorders can experience significant airway and feeding difficulties. Mandibular distraction osteogenesis (MDO) is one treatment of severe micrognathia. We examined endoscopic images for upper airway (UA) soft tissue changes after MDO. We hypothesized that MDO produces consistent changes in UA soft tissue, which correlate with symptom resolution. MATERIALS AND METHODS: This retrospective chart review included 16 patients undergoing MDO from 2002 to 2007. Demographic data, symptom information, and preoperative and early and late postoperative endoscopic images were collected. Blinded randomized images of UA soft tissues were quantitatively analyzed using ImageJ. To compare nonstandardized images, ratios of UA dimensions were made. Preoperative and early and late postoperative ratios were statistically analyzed with Student's t-test. RESULTS: Sixteen patients with a mean age of 237 days were included. Mean distance distracted was 12 mm. There were significant changes in relative dimensions of the supraglottic space in the early postoperative period, which were not maintained in the late postoperative period. Nevertheless, all experienced complete relief of airway obstruction. DISCUSSION: Our study showed a significant increase in supraglottic space dimensions after MDO that was not maintained over time. This is likely because of the limitation of images and measurement methods. Despite this, significant clinical improvement was seen in all patients, with resolution of airway obstruction. This suggests supraglottic changes as well as tongue base alterations are related to clinical improvement. Further investigation of alterations in UA after MDO is needed to continue characterizing these changes.

A case of congenitally absent left internal carotid artery: vascular malformations in 22q11.2 deletion syndrome.

Our report is on a Hispanic boy for whom, shortly after birth, clinical suspicion of 22q11.2 deletion syndrome (22q11.2DS) was raised as a result of his characteristic features, including facial dysmorphisms and hypotonia. The 22q11.2DS was confirmed by fluorescence in situ hybridization (FISH), noting a 22q11.2 deletion. Further evaluation revealed complete congenital absence of the left internal carotid artery and focal pachygyria of the left hemisphere. Multiple cardiac and vascular anomalies have been previously described in 22q11 deletion syndrome, but congenital absence of the internal carotid has not been previously reported in the literature. We present a clinical case report in detail of this unique 22q11.2 deletion syndrome associated finding.

University of Wisconsin Guidelines for Treatment of Facial Trauma While Minimizing the Risk of COVID-19 Transmission.

BACKGROUND: The COVID-19 pandemic has forced many practices to completely change the interface between health care providers and patients. Patients presenting with facial trauma present a special risk for COVID-19 transmission, as contact with respiratory and ocular secretions is common, and so special precautions must be taken in managing them. METHODS: We created guidelines and a triage/management algorithm for patients presenting with facial trauma to decrease the risk of COVID-19 transmission. CONCLUSIONS: In this paper, we present a set of guidelines and a triage algorithm we have successfully implemented to mitigate the spread of COVID-19 while managing facial trauma. We believe that these guidelines can help other providers restructure their practices during this pandemic.

A Competency Assessment Tool for Unilateral Cleft Lip Repair.

Objective evaluation of operative performance is increasingly important in surgical training. Evaluation tools include global rating scales of performance and procedure-specific skills checklists. For unilateral cleft lip repair, the numerous techniques make universal evaluation challenging. Thus, we sought to create a unilateral cleft lip evaluation tool agnostic to specific repair technique. METHODS: Four surgeons with expertise in 3 common cleft lip repair techniques participated in a 3-round Delphi process to generate consensus evaluation points spanning all techniques. Items were categorized as marking the repair, performing the repair, and final result. Two blinded raters then scored videos of simulated cleft lip repairs using both the 21-item novel checklist and the modified Objective Structured Assessment of Technical Skills. Kappa and T values were calculated for both scales to determine level of agreement. RESULTS: Ten videos of repairs performed by novice residents through experienced craniofacial fellows were scored. Moderate (κ = 0.41-0.60) to substantial (κ = 0.61-0.80) interrater reliability was seen for the majority of questions in both the novel tool and the Objective Structured Assessment of Technical Skills. A single question in the novel tool had almost perfect agreement (κ = 0.81-1.00), 8 had moderate agreement, and 6 had substantial agreement. Poorly scoring questions were discarded from the final 18-item tool. CONCLUSIONS: Despite variations in unilateral cleft lip repair technique, common themes exist that can be used to assess performance and outcome. A universal evaluation tool has potential implications for trainee assessment, surgeon credentialing, and screening for surgical missions.

Pediatric Obstructive Sleep Apnea: Consensus, Controversy, and Craniofacial Considerations.

Pediatric obstructive sleep apnea, characterized by partial or complete obstruction of the upper airway during sleep, is associated with multiple adverse neurodevelopmental and cardiometabolic consequences. It is common in healthy children and occurs with a higher incidence among infants and children with craniofacial anomalies. Although soft-tissue hypertrophy is the most common cause, interplay between soft tissue and bone structure in children with craniofacial differences may also contribute to upper airway obstruction. Snoring and work of breathing are poor predictors of obstructive sleep apnea, and the gold standard for diagnosis is overnight polysomnography. Most healthy children respond favorably to adenotonsillectomy as first-line treatment, but 20 percent of children have obstructive sleep apnea refractory to adenotonsillectomy and may benefit from positive airway pressure, medical therapy, orthodontics, craniofacial surgery, or combined interventions. For children with impairment of facial skeletal growth or craniofacial anomalies, rapid maxillary expansion, midface distraction, and mandibular distraction have all been demonstrated to have therapeutic value and may significantly improve a child's respiratory status. This Special Topic article reviews current theories regarding the underlying pathophysiology of pediatric sleep apnea, summarizes standards for diagnosis and management, and discusses treatments in need of further investigation, including orthodontic and craniofacial interventions. To provide an overview of the spectrum of disease and treatment options available, a deliberately broad approach is taken that incorporates data for both healthy children and children with craniofacial anomalies.

The Current State of Global Surgery Training in Plastic Surgery Residency.

BACKGROUND: The current state of global surgery training in U.S. plastic surgery residency programs remains largely undefined. METHODS: An electronic survey was distributed to Accreditation Council for Graduate Medical Education-certified plastic surgery residency programs. Programs with global health curricula were queried regarding classification, collaboration details, regions visited, conditions/procedures encountered, costs, accreditation, and personal sentiment. Residencies without global health curricula were asked to select barriers. RESULTS: Sixty-four of 81 residency programs returned questionnaires (response rate, 79 percent). Twenty-six programs (41 percent) reported including a formal global health curriculum; 38 did not (59 percent). When asked to classify this curriculum, most selected clinical care experience [n = 24 (92 percent)], followed by educational experience [n = 19 (73 percent)]. Personal reference was the most common means of establishing the international collaboration [n = 19 (73 percent)]. The most commonly encountered conditions were cleft lip-cleft palate [n = 26 (100 percent)], thermal injury [n = 17 (65 percent)], and posttraumatic reconstruction [n = 15 (57 percent)]. Dominant funding sources were primarily nonprofit organizations [n = 14 (53 percent)]. Although the majority of programs had not applied for residency review committee accreditation [n = 23 (88 percent)], many considered applying [n = 16 (62 percent)]. Overall, 96 percent of programs (n = 25) supported global health training in residency, choosing exposure to different health systems [n = 22 (88 percent)] and surgical education [n = 17 (68 percent)] as reasons. Programs not offering a global health experience most commonly reported lack of residency review committee/plastic surgery operative log recognition of cases performed abroad [n = 27 (71 percent)], funding for trip expenses [n = 25 (66 percent)], and salary support [n = 24 (63 percent)] as barriers. CONCLUSIONS: Residencies incorporating global health training describe the experience positively. Funding and case accreditation are the major obstacles to implementing these curricula.

Effects of reduction mammaplasty on pulmonary function and symptoms of macromastia.

A number of studies have documented subjective improvement in somatic and psychological symptoms following breast reduction surgery. Objective data demonstrating improved postoperative function have been more difficult to assess, and particularly with respect to pulmonary function, the results have been contradictory. In this prospective study, patients completed a comprehensive preoperative questionnaire modified from the American Thoracic Society Division of Lung Diseases Epidemiology Standardization Project (1978). This questionnaire noted subjective pulmonary symptoms and pulmonary medical history. In addition, subjective symptoms related to breast size, including back and neck pain and shoulder pain and grooving, and a subjective evaluation of body image, were evaluated. All subjects received preoperative pulmonary function testing, including spirometry, lung volume measurements, and measurement of peak inspiratory and expiratory flow rates and pressures. Eight weeks after breast reduction, a repeat questionnaire and pulmonary function testing were administered. Preoperative and postoperative pulmonary function values were compared using Cochran-Mantel-Haenszel tests, and correlations were tested between changes in pulmonary function test values and subjective symptom improvement. Forty-four patients underwent an average of 2228-g bilateral reduction. All of these patients had their surgical procedures preauthorized as medically necessary by their insurance carriers. All subjective parameters examined were statistically significantly improved following breast reduction (p < 0.001). Of the 17 patients with preoperative complaints of shortness of breath, all noted significant improvement following breast reduction surgery (p < 0.001). Of the objective pulmonary criteria evaluated, inspiratory capacity, peak expiratory flow rate, and maximal voluntary ventilation showed a statistically significant improvement following surgery (p < 0.05). These changes correlated with body mass index; the greater the index, the greater the change in maximal voluntary ventilation and peak expiratory flow rate. Smokers in this group had the largest change in maximal voluntary ventilation (p < 0.008). No correlation could be found between preoperative pulmonary symptoms, a single subjective symptom, or grams of breast weight reduction and changes in pulmonary function tests. The results show that pulmonary parameters, related primarily to work of breathing (inspiratory capacity, maximal voluntary ventilation, peak expiratory flow rate), were statistically improved following breast reduction surgery, and these changes correlated with body mass index.

Pediatric feeding disorder and growth decline following mandibular distraction osteogenesis.

BACKGROUND: Mandibular distraction osteogenesis has proven to be an effective treatment for upper airway obstruction related to micrognathia. Changes in the aerodigestive space can help facilitate tracheostomy removal in children and prevent tracheostomy in newborns. However, this may also precipitate changes in the ability to orally feed. There are few data on early postoperative feeding and growth rate following mandibular lengthening. The authors found evidence of growth rate decline and feeding difficulty in pediatric patients following mandibular distraction osteogenesis. METHODS: Ten pediatric patients underwent mandibular distraction osteogenesis for treatment of upper airway obstruction. Outcomes in resolution of upper airway obstruction, oral feeding success, and growth rate were analyzed. Follow-up ranged from 12 to 28 months. RESULTS: All 10 patients had complete resolution of upper airway obstruction. The length of distraction ranged from 10 to 17 mm. Three patients demonstrated a feeding disorder after mandibular distraction osteogenesis, defined as requiring a long-term (>1 month) alternate feeding method (gastric tube in two patients and gastric gavage in one). Seven of 10 patients exhibited an early decline in growth rate following distraction. Data used to determine growth rate changes were weight measurements at the time of distraction, at the time of distractor removal (6 to 8 weeks after distraction), and at 6 and 12 months after the date of distraction initiation. CONCLUSION: These results suggest that infants and children undergoing mandibular lengthening by distraction osteogenesis should be carefully monitored for postdistraction feeding disorder and growth rate disturbance.

Management of mandible fractures.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Review the incidence and etiology of mandible fractures. 2. Discuss indications and techniques for closed and open treatment of mandible fractures. 3. Review complications of mandible fractures. BACKGROUND: Mandible fractures are among the most common types of facial fractures treated by plastic surgeons. They must be managed carefully to maintain the function of the mandible, reestablish proper occlusion, and minimize secondary complications. METHODS: Current methods of management include combinations of soft diet, intermaxillary fixation, open reduction with plate fixation, and, rarely, external fixation. RESULTS: Decision-making depends on the age of the patient, type of fracture identified, and concomitant medical conditions or injuries. CONCLUSION: The authors review the diagnosis and current trends in management of mandible fractures.