Evaluation of Amniotic Multipotential Tissue Matrix to Augment Healing of Demineralized Bone Matrix in an Animal Calvarial Model.

Amniotic multipotential tissue matrix (AmnioMTM) is a membrane material derived from placental tissues and rich in growth factors that have been reported to have potential in healing bone. This study hypothesized that demineralized bone matrix (DBM) supplemented with AmnioMTM would accelerate healing and bone formation as compared with DBM alone in a critical size (10 mm) rat calvarial bone defect model. Five DBM grafts and 5 DBM supplemented with AmnioMTM grafts were implanted in a 10-mm critical sized defect in 10 rats (1 implant per rat). After 4 weeks, animals were euthanized and defects evaluated by microCT and histology. There were no statistical differences in microCT data for mineral density, percent bone fill, or bone surface to volume ratios between groups, though the bone surface to volume ratio for the amnio-supplemented group suggested increased osteoid activity as compared with the DBM alone group. Histological data also indicated active osteoid activity and induced bone formation in the center of defects implanted with AmnioMTM supplemented graft as compared with DBM graft alone suggesting some potential osteoinductive potential. However, there was no significant difference at the mean percent of newly mineralized bone in the DBM group defect as compared with the AmnioMTM supplemented graft material. These data suggest that while bone formation was not increased at this early time point, the increased osteoid activity and the induction of new bone in the middle of the defect by the AmnioMTM indicates that further study is needed to assess its potential benefit to bone healing and regeneration.

Cleft Lip Cleft Palate and Craniofacial Deformities Care: An Anesthesiologist's Perspective at the Tawanchai Center.

BACKGROUND: The increasing number of pediatric patients with cleft lip-palate and craniofacial anomalies is a nuisance problem in the Northeast of Thailand. These patients have complicated problems including physical health, psychosocial, and poor quality of life; therefore, a multidisciplinary care team was established, named Tawanchai center. This study encouraged the improvement of the quality of holistic healthcare service system to improve the quality of life the patients and their families. Anesthesiologists are important personnel in the facilitation of the surgical team, and to help improve other activities including academic, service and research. OBJECTIVE: To relate the perspective of anesthesiologist according to the role they play in the multidisciplinary team. MATERIAL AND METHOD: The database of Anesthesiology department and annual report from the period between June 2005 to July 2015 were collected and reviewed. CONCLUSION: Highly-skilled and experienced anesthesiologist in the multidisciplinary patient care team play a vital role through the provision of advanced and specific knowledge to anesthesia management. The role of anesthesiologists should be researched to enhance the quality of anesthesia management, thereby contributing to national and international patient care team development.

Challenges and Long-Term Management of Patients with Craniofacial Clefts in Thailand.

OBJECTIVE: To report challenges and long-term management of patients with craniofacial clefts, treated at Srinagarind Hospital, Khon Kaen, Thailand. MATERIAL AND METHOD: Patients who were treated at Srinagarind Hospital, between 1993 and 2001. A review of data was performed including general information, classifications, photographs, radiographic findings, dental records, reconstructive surgeries, and long-term management. RESULTS: A total of 20 patients were recruited; six males and 14 females, grouped into six median, two paramedian and 12 oblique clefts. Age of the first treatment ranged from one to 39 years, age of the last follow-up ranged from 11 to 48 years and the range of follow-ups was 11 to 24 years. The reconstructive procedures included a variety of techniques of plastic surgery for soft tissue repairs and bone grafting for facial reconstructions. Four patients with median clefts and paramedian clefts died. One patient lost to follow-up. Fifteen patients were followed-up and the results were satisfying. CONCLUSION: Diagnosis, evaluation, and treatment of clefts and craniofacial deformities are complex. The proper management is challenging because of socioeconomic, cause difficulties in follow-ups according to the planned protocol. Other associated anomalies are important. Protocols with well-co-ordination of an interdisciplinary team in Craniofacial Center and continuing evaluation at appropriate schedule and age group until completion of facial growth are critical factors. Establishment of a foundation and comprehensive care model with families, local health professionals and school will benefit the most to this group of patients.

A model for interprofessional health care: lessons learned from craniofacial teams.

Seventy-six years ago, Herbert K. Cooper, DDS, DSc, LHD, FACD, created the first interprofessional health care team in response to the frequency of craniofacial anomalies and related speech and hearing deficits in Lancaster, Pa. His experiences and those from subsequent "medical-dental-nursing-pharmacy allied health professions" craniofacial teams inform and provide "best practices" for the future of interprofessional education. This paper revisits the genesis of craniofacial teams and highlights successes, challenges and cost benefits applicable today.

Scalable, sustainable cost-effective surgical care: a model for safety and quality in the developing world, part I: challenge and commitment.

BACKGROUND: With an estimated backlog of 4,000,000 patients worldwide, cleft lip and cleft palate remain a stark example of the global burden of surgical disease. The need for a new paradigm in global surgery has been increasingly recognized by governments, funding agencies, and professionals to exponentially expand care while emphasizing safety and quality. This three-part article examines the evolution of the Operation Smile Guwahati Comprehensive Cleft Care Center (GCCCC) as an innovative model for sustainable cleft care in the developing world. METHODS: The GCCCC is the result of a unique public-private partnership between government, charity, and private enterprise. In 2009, Operation Smile, the Government of Assam, the National Rural Health Mission, and the Tata Group joined together to work towards the common goal of creating a center of excellence in cleft care for the region. RESULTS: This partnership combined expertise in medical care and training, organizational structure and management, local health care infrastructure, and finance. A state-of-the-art surgical facility was constructed in Guwahati, Assam which includes a modern integrated operating suite with an open layout, advanced surgical equipment, sophisticated anesthesia and monitoring capabilities, central medical gases, and sterilization facilities. CONCLUSION: The combination of established leaders and dreamers from different arenas combined to create a synergy of ambitions, resources, and compassion that became the backbone of success in Guwahati.

Scalable, sustainable cost-effective surgical care: a model for safety and quality in the developing world, part II: program development and quality care.

BACKGROUND: The Guwahati Comprehensive Cleft Care Center (GCCCC) is committed to free medical and surgical care to patients afflicted with facial deformities in Assam, India. A needs-based approach was utilized to assemble numerous teams, processes of care, and systems aimed at providing world-class care to the most needy of patients, and to assist them with breaking through the barriers that prohibit them from obtaining services. METHODS: A team of international professionals from various disciplines served in Guwahati full time to implement and oversee patient care and training of local counterparts. Recruitment of local professionals in all disciplines began early in the scheme of the program and led to gradual expansion of all medical teams. Emphasis was placed on achieving optimal outcome for each patient treated, as opposed to treating the maximum number of patients. RESULTS: The center is open year round to offer full-time services and follow-up care. Along with surgery, GCCCC provides speech therapy, child life counseling, dental care, otolaryngology, orthodontics, and nutrition services for the cleft patients under one roof. Local medical providers participated in a model of graded responsibility commiserate with individualized skill and progress, and gradually assumed all leadership positions and now account for 92% of the workforce. Institutional infrastructure improvements positioned and empowered teams of skilled local providers while implementing systemized perioperative processes. CONCLUSION: This needs-based approach to program development in Guwahati was successful in optimization of quality and safety in all clinical divisions.

Scalable, sustainable cost-effective surgical care: a model for safety and quality in the developing world, part III: impact and sustainability.

BACKGROUND: The Guwahati Comprehensive Cleft Care Center (GCCCC) utilizes a high-volume, subspecialized institution to provide safe, quality, and comprehensive and cost-effective surgical care to a highly vulnerable patient population. METHODS: The GCCCC utilized a diagonal model of surgical care delivery, with vertical inputs of mission-based care transitioning to investments in infrastructure and human capital to create a sustainable, local care delivery system. Over the first 2.5 years of service (May 2011-November 2013), the GCCCC made significant advances in numerous areas. Progress was meticulously documented to evaluate performance and provide transparency to stakeholders including donors, government officials, medical oversight bodies, employees, and patients. RESULTS: During this time period, the GCCCC provided free operations to 7,034 patients, with improved safety, outcomes, and multidisciplinary services while dramatically decreasing costs and increasing investments in the local community. The center has become a regional referral cleft center, and governments of surrounding states have contracted the GCCCC to provide care for their citizens with cleft lip and cleft palate. Additional regional and global impact is anticipated through continued investments into education and training, comprehensive services, and research and outcomes. CONCLUSION: The success of this public private partnership demonstrates the value of this model of surgical care in the developing world, and offers a blueprint for reproduction. The GCCCC experience has been consistent with previous studies demonstrating a positive volume-outcomes relationship, and provides evidence for the value of the specialty hospital model for surgical delivery in the developing world.

In vitro antimicrobial effects of grape seed extract on peri-implantitis microflora in craniofacial implants.

OBJECTIVE: To determine the antimicrobial effects of grape seed on peri-implantitis microflora. METHODS: The grape seed extract was tested against peri-implantitis microflora most commonly found in craniofacial implants including reference strains of Staphylococcus aureus (S. aureus), Escherichia coli (E. coli), Candida albicans (C. albicans) and clinical strains of S. aureus, Klebsiella pneumonia (K. pneumonia) and Candida parapsilosis (C. parapsilosis) by disk diffusion test. Minimum inhibitory concentrations (MIC) and minimum cidal concentrations (MCC) were determined using modified agar dilution millpore method. The extract was further combined with polyethylene glycol and propylene glycol, and was tested for antimicrobial effects. RESULTS: Grape seed extract showed positive inhibitory effects with S. aureus at MIC of 0.625 mg/mL and MCC of 1.25 mg/mL respectively. However the extracts showed minimal or no reactivity against strains of E. coli, K. pneumonia, C. parapsilosis and C. albicans. The use of grape seed extract in combination with polyethylene glycol and propylene glycol also showed dose dependent inhibitory effect on S. aureus. CONCLUSIONS: The results of the study showed that grape seed has potential antimicrobial effects which can be further studied and developed to be used in the treatment of infected skin-abutment interface of craniofacial implants.

Perioperative management of children undergoing craniofacial reconstruction surgery: a practice survey.

OBJECTIVE/AIMS: To assess current practices in the management of children undergoing craniofacial surgery and identify areas of significant practice variability with the intent to direct future research. BACKGROUND: The perioperative management of infants and children undergoing craniofacial reconstruction surgery can be challenging because of the routine occurrence of significant blood loss with associated morbidity. A variety of techniques have been described to improve the care for these children. It is presently unknown to what extent these practices are currently employed. METHODS: A web-based survey was sent to representatives from 102 institutions. One individual per institution was surveyed to prevent larger institutions from being over-represented in the results. RESULTS: Requests to complete the survey were sent to 102 institutions; 48 surveys were completed. The survey was composed of two parts: management of infants undergoing strip craniectomies, and management of children undergoing major craniofacial reconstruction. CONCLUSIONS: Significant variability exists in the management of children undergoing these procedures; further study is required to determine the optimal management strategies. Clinical trials assessing the utility of central venous pressure and other hemodynamic monitoring modalities would enable evidence-based decision-making for monitoring in these children. The development of institutional transfusion thresholds should be encouraged, as there exists a body of evidence supporting their efficacy and safety.

Evaluation of craniofacial care outside the Brazilian reference network for craniofacial treatment.

OBJECTIVE: To describe health care provided outside the Brazilian Reference Network for Craniofacial Treatment, and to inform the debate about craniofacial health care policy in Brazil. DESIGN: Observational, retrospective cohort. METHODS: Craniofacial care providers completed the same questionnaire previously used to evaluate the Brazilian Reference Network for Craniofacial Treatment (RRTDCF). RESULTS: Units outside the RRTDCF are mainly located in the southeast region of Brazil and in universities. They comprise 56 independent clinics, 22 combined clinics, and four parental associations. Services provided are variable from unit to unit and just six of them meet the American Cleft Palate-Craniofacial Association minimum team standard. Genetic evaluation and counseling is provided by clinical geneticists in 35 units; whereas, in 30 units, it is undertaken by untrained professionals. CONCLUSION: A significant number of craniofacial units work in parallel and overlap the RRTDCF. They are funded by the government but not recognized as craniofacial teams. Regional disparities and lack of coordination within and between cleft lip and/or cleft palate (CL/P) teams are unsolved problems. Non-RRTDCF units are heterogeneous concerning configuration, service provided, areas of treatment, and composition of the teams. A nationwide and voluntary database on orofacial clefts is a proposed strategy to address some of these problems. Anticipated benefits include strengthening the collaboration within and between healthcare teams and supplying health authorities with a comprehensive and population-specific source of information on this prevalent and potentially preventable group of birth defects.

Predictors of blood loss in fronto-orbital advancement and remodeling.

Fronto-orbital advancement and remodeling for craniosynostosis is extensive surgery and is associated with potential risks; the most significant of these is blood loss. We prospectively studied 116 consecutive patients undergoing fronto-orbital advancement by the same surgical team for a 5-year 6-month period to determine what factors are associated with blood loss and transfusion of blood products. The data collected on the calvarial sutures involved were whether the patient had a diagnosed syndrome, the age at operation, the length of the operation, the estimated blood volume lost during the perioperative course, the number of units of packed cells transfused (donor exposures), and the use of other blood products. The mean (SD) total blood volume lost was 116% (5.4) of the estimated preoperative volume. The median number of whole units of packed cells transfused was 2 units. Other blood products were given in 28% of the cases. There was significantly greater blood loss in those patients with recognized craniofacial syndromes, pansynostosis, an operating time longer than 5 hours, and an age of 18 months or younger at operation. The use of other blood products was associated with those patients losing a blood volume higher than the mean.

Brazil's Craniofacial Project: genetic evaluation and counseling in the Reference Network for Craniofacial Treatment.

OBJECTIVE: This study is part of Brazil's Craniofacial Project, which is the first initiative for a national characterization of craniofacial healthcare in Brazil. Our main aim was to describe the status of clinical genetics in the Brazilian Reference Network for Craniofacial Treatment. DESIGN: All services (n = 29) listed in the Brazilian Reference Network for Craniofacial Treatment until October 2003 were contacted and invited to complete a questionnaire. Information regarding the general characteristics of the services, availability of genetic services, and genetic service providers was collected. RESULTS: The response rate was 86.2% (n = 25). Thirteen responding teams had clinical geneticists. Teams were predominantly located in the southeast region and affiliated with universities. Family interest in genetic counseling was reported by 95.7% (22/23) of the services. Although 80% of the responding services reported offering genetic counseling, only 45% (9/20) provided genetic counseling guided by clinical geneticists. CONCLUSION: Availability and access to genetic evaluation and counseling are still rudimentary in Brazil. Many services report family interest in genetic counseling, but there are few teams with clinical geneticists. Inclusion of this specialist on craniofacial teams is crucial to patient care. Development of standard guidelines for genetic evaluation of selected craniofacial anomalies and for local genetic counseling (e.g., for nonsyndromic cleft lip or palate) could be an alternative for improving current deficiencies in the system. Strengthening the degree of coordination and communication among craniofacial teams represents another important goal.

Effects and noneffects of personal environmental experimentation on postnatal craniofacial growth.

Genetic makeup, as well as various environmental factors, such as gravity, temperature, disease, trauma, inflammation, radiation, and chemicals, may affect skeletal growth sites and centers, thereby causing faulty growth of bone(s). The degree of the subsequent deformity will depend not only on the type, intensity, extent, and chronology of the noxious agent but also on the site and its particular susceptibility and growth activity. Over the years, I conceived, designed, initiated, and carried out a series of experiments in regard to bone(s), in both young and adult animals. Eventually, I directed my efforts principally toward local surgical experimentation as it related to both normal and abnormal gross postnatal craniofacial growth. Because of the wide variety of different structures, their interrelated individualities, and the challenges presented in both its richness of sites of growth and complexity, the skull proved to be a most unusual source of study. The purpose of this selective, organized, and limited review, analysis, and summary of personally conducted experiments is to relate certain aspects of growth with change and nonchange to age, sites, rates, factors, and mechanisms. In many instances, there are correlations between basic research findings and clinical practice. There is no such similar report in the literature. This retrospective study brings it all together.

The team approach in the management of congenital and acquired deformities.

This article provides a summary of practices and guidelines for the design and methods used to form interdisciplinary medical teams. Education and organizational resources are discussed with regard to children with congenital anomalies, specifically craniofacial and cleft lip and palate deformities. The team format is recommended to maximize efficiencies and assure a continuum of care in the evolving managed care environment.

Influence of craniofacial surgery on the social attitudes toward the malformed and their handling in different cultures and at different times: a contribution to social world history.

A historic overview including the European, American, Asian, and African continents is given on attitudes toward and the handling of humans with congenital malformations in ancient cultures and on pertinent customs in some prehistoric peoples. Figures of early works of art showing malformed individuals are presented testifying to this worldwide and timeless problem of humankind. In parallel, analogous patient photographs from our hospital before and after reconstructive surgery are shown. Philosophies of ancient Greece, rome, and China on the subject of malformed infants essentially did not differ from the known attitudes of the less developed tribes in Europe and pre-Columbian America, although the means of elimination of unwanted offspring were rather passive (exposure) than active (manual killing). A radical change in attitudes and practices occurred with the spread of the Christian religion and its political installment in Europe. The care for the underprivileged including the malformed ones was considered a Christian duty to be performed with compassion and love. In our century, the clocks have been and apparently are turned back again. Atheistic and Darwinian influences, political atheism, and the belief in "higher ethics" issued by "superman" have led to a relapse into barbarism, also within the medical system. We, as craniofacial surgeons, are privileged to have the means to turn the clocks forward again by rehabilitating the physically most underprivileged: those with conspicuous craniofacial malformations. The necessary techniques exist and are applied, as the figures of patients from our hospital demonstrate, but the will and the emotional strength for their consequent application require more than our hands.