Gingivoperiosteoplasty in Children with Cleft Lip and Palate: The Need for Alveolar Bone Grafting.

OBJECTIVE: This study aimed to determine the efficacy of gingivoperiosteoplasty (GPP) in preventing alveolar bone grafting (ABG) among children with cleft lip and palate (CLP). DESIGN/SETTING: Retrospective university hospital single center study. PATIENTS: Children with CLP treated with GPP from 2000-2015 were included. Those under eight years of age, without definitive conclusions regarding need for ABG or with incomplete data were excluded. INTERVENTIONS: Included patients were analyzed for demographics, cleft type, age at GPP, associated cleft surgery, use of nasoalveolar molding (NAM), indication for ABG, operating surgeon and presence of residual alveolar fistula. T-tests and Fisher's exact tests were utilized for statistical analysis. MAIN OUTCOME MEASURE: The need for ABG. RESULTS: Of the 1682 children identified with CLP, 64 underwent GPP and met inclusion criteria. 78% of patients with CLP who underwent GPP were recommended for ABG. Those who received GPP at a younger age (P = .004) and at the time of initial cleft lip repair (P = .022) were less likely to be recommended for ABG. Patients with complete CLP were more likely to be recommended for ABG than patients with cleft lip and alveolus only (P = .015). The operating surgeon impacted the likelihood of ABG (P = .004). Patient gender, race, ethnicity, laterality, and NAM were not significantly associated with recommendation for ABG. CONCLUSION: GPP does not preclude the need for ABG. Therefore, the success of ABG after GPP and maxillary growth restriction should be analyzed further to determine if GPP is a worthwhile adjunct to ABG in cleft care.

American Indian and Alaska Native Accessibility to Comprehensive Cleft Lip and Palate Treatment.

American Indians and Alaska Natives (AI/AN) have the highest incidence of cleft lip and palate (orofacial clefts [OFCs]) when compared to other ethnic groups. We aim to determine the AI/AN populations' proximity and accessibility to American Cleft Palate-Craniofacial Association accredited centers (ACPA centers) for treatment of OFCs. Our hypothesis is an unacceptable proportion of the AI/AN population lacks reasonable accessibility to ACPA centers and comprehensive craniofacial care.A cross-sectional study of ACPA centers and AI/AN populations were analyzed for possible disparities.ACPA centers were mapped using Geographic Information Systems (GIS) and compared with 2018 census population data and 2017 Tribal Census Tract data to visually display possible disparities. Total annual potential pediatric cleft care need for selected high-density AI/AN populated lands were estimated.GIS mapping demonstrates geographical isolation of AI/AN populations from ACPA centers. Two states with high AI/AN populated lands (ND, WY) have no ACPA centers. 47.1% of ACPA centers in high AI/AN populated lands have no craniofacial trained surgeons versus 78.9% craniofacial staffed ACPA centers nationally. The potential unmet cleft and craniofacial care need in selected high-density AI/AN populated lands is 1042 children.AI/AN populations are likely underserved by ACPA centers and by craniofacial fellowship-trained staffed centers. Not addressing OFCs with comprehensive care can lead to worsened outcomes and further marginalization of these children. With future studies, we will be capable of making data-driven, informed decisions to more effectively ensure AI/AN access to comprehensive cleft and craniofacial care.

Orthognathic Surgery Rate in Cleft Care.

PURPOSE: To determine the true need for orthognathic surgery in patients with repaired cleft lip and/or palate (CL/P) at a high-volume craniofacial center. METHODS: An institutional retrospective review of patients with CL/P born between 1975 and 2008 was performed. Patients with adequate documentation reflecting cleft care who were ≥ 18 years at the time of last craniofacial/dentistry follow-up were included. Patients with non-paramedian clefts or a comorbid craniofacial syndrome were excluded. Primary outcome variable was the total proportion of patients with CL/P who either underwent or were referred for orthognathic surgery Le Fort I (LF1) to correct midface hypoplasia. Secondary outcome variables were associations between cleft phenotype, midface hypoplasia severity, and number of cleft related surgeries with the eventual LF1 referral/recipiency. RESULTS: One hundred seventy-seven patients with CL/P met inclusion criteria. A total of 90/177 (51%) patients underwent corrective LF1; however, 110/177 (62%) of patients were referred for surgery. Patients with secondary cleft palate involvement were referred for and underwent LF1 at significantly greater rates than those without secondary palate involvement (referred: 65% versus 13%, P = 0.001; underwent: 55% versus 0%, P < 0.001). Patients with bilateral cleft lip/palate were referred for and underwent LF1 at significantly higher rates than those with unilateral cleft lip/palate (referred: 71.0% versus 50.4%, P= 0.04; underwent: 84% versus 71%, P = 0.02). Number of secondary palate surgeries was positively correlated with increased LF1 referral (P = 0.02) but not LF1 recipiency (P = 0.15). CONCLUSIONS: The incidence of orthognathic surgery redundant in patients with repaired CL/P was 51% at our institution, marginally above the higher end of previously reported rates. However, this number is an underrepresentation of the true requirement for LF1 as 62% of patients were referred for surgical intervention of midface hypoplasia. This distinction should be considered when counseling families.

Postoperative helmet therapy following fronto-orbital advancement and cranial vault remodeling in patients with unilateral coronal synostosis.

Out of all the synostotic corrective surgeries, fronto-orbital advancement and cranial vault remodeling for patients with unilateral coronal synostosis is one of the hardest to maintain symmetric and proportional correction without some amount of relapse. Over the course of 20 years operating on these patients, the senior author has made multiple adjustments to compensate for relapse asymmetry, including overcorrection on the affected side, increased points of fixation, periosteal release, and scalp expansion with galeal scoring to minimize tension of the closure. As a result of these interventions, we have seen improved immediate results following surgery. However, we have continued to note clinically significant relapse postoperatively. As such, we have started to implement postoperative helmet therapy (PHT) to help maintain the surgical correction, improve secondary brachycephaly, and increase overall symmetry. PHT is a reasonable low-risk complement to fronto-orbital advancement and cranial vault remolding. Clinically, PHT appears to help minimize relapse and improve overall head symmetry. Further investigation and increased patient enrollment are required to determine the true benefits of PHT in this patient population.

Is Le Fort I Distraction Enough to Treat Severe Midface Hypoplasia?

BACKGROUND: In severe cases of maxillary hypoplasia, Le Fort I distraction may be required for treatment. This study describes our experience with internal distraction devices and assesses our outcomes in patients with a negative overjet on average >15 mm. METHODS: A retrospective review of patients with a history of cleft lip and/or palate who underwent Le Fort I distraction at our institution from 11/2007-11/2017 was performed. Data regarding demographics, procedural details and outcomes were collected and analyzed. RESULTS: Twenty patients, 13 (65.0%) male and 7 (30.0%) female, were included. All (100%) patients had a history of cleft lip and/or palate and 2 (10.0%) of them had associated syndromes. All 20 patients underwent internal distraction. The average age at surgery was 17.8 years (range 15.2-20.7, SD 1.6 years). The average preoperative negative overjet was 19.27 mm (range 10-30, SD 5.63 mm). The mean total distraction length was 15.3 mm (range 0-30, SD 6.72 mm). There were no intraoperative complications, however, there were a total of 4 (20.0%) postoperative complications, 2 of which required reoperation due to device malfunction or displacement. 14 (70.0%) patients had repeat procedures to complete occlusal correction or correct relapse. CONCLUSIONS: Maxillary distraction alone was insufficient for correction of maxillary discrepancies averaging >15 mm. Instead, it's utility may be in positioning the maxilla for a more viable final advancement and fixation procedure, rather than being solely responsible for achieving normal occlusion during distraction.

Nasoalveolar Molding: Assessing the Burden of Care.

ABSTRACT: Over the last 3 years a shift at our institution has taken place in which patients who would have been offered nasoalveolar molding (NAM) as an adjunct to cleft lip repair (repair after 3 months) have instead undergone early cleft lip repair (ECLR) (2-5 weeks of life) without NAM. This study sought to examine the financial and social impact of the transition away from NAM to ECLR. The efficacy of NAM is limited by patient compliance to a rigorous treatment schedule requiring weekly visits for appliance adjustments. Nasoalveolar molding patients required an average of 11 dental visits, accounting for $2132 in indirect lost income per family. Average direct charges for NAM totaled $12,290 for the hospital, physician, and appliance costs. Over the entire study period, the cumulative direct cost of NAM separate from the surgical repair of the lip was $970,910. Following the introduction of ECLR as an alternative to NAM with standard lip repair, NAM usage decreased by 48% and unilateral cleft lip patients undergoing NAM decreased by 86%. Those diverted from NAM to ECLR resulted in a decreased healthcare cost burden of $368,700 ($111,727 per year). In addition to the time burden, the financial burden of NAM is significant. Early cleft lip repair without NAM is more cost effective. Nasoalveolar molding has significantly decreased utilization since the implementation of ECLR. We believe that ECLR, with increased experience, long-term data, and increased awareness, has the potential to decrease the burden of health care costs in the United States.

A Meta-Analysis of Palatal Repair Timing.

ABSTRACT: Developing midface hypoplasia is common after palatoplasty and has been hypothesized to be influenced by the timing of hard palate repair. This meta-analysis assesses the risk of developing midface hypoplasia based on age at hard palate repair. A Pubmed PRISMA systematic review and meta-analysis was completed for literature focused on palatoplasty and midface hypoplasia published between 1970 and 2019. Cephalometric data were extracted and categorized by age at hard palate repair: <6, 7 to 12, 13 to 18, 19 to 24, and 25 to 83 months. Analysis of these groups and a control were compared using independent T-tests and Spearman correlation coefficients. SNA angles for each group were 77.9 ±â€Š3.1° (<6 months), 77.7 ±â€Š4.2° (7-12 months), 78.7 ±â€Š4.2° (13-18 months), 75.1 ±â€Š4.2° (19-24 months), 75.5 ±â€Š4.8° (25-83 months), and were statistically different than the control group 82.4 ±â€Š3.5° (P < 0.0001). Hard palate repair at 13 to 18 months had a statistically significant greater SNA angle than all other groups except for the repair at <6 months group (P = 0.074). As age at hard palate closure increased beyond 18 months, the SNA decreased, corresponding to a more hypoplastic maxilla (Spearman's correlation coefficient -0.381, P = 0.015). Analysis suggests that younger age at the time of repair is less likely to create in midface hypoplasia in adulthood. Minimizing midface hypoplasia in cleft palate patients by optimizing algorithms of care is a practical way to decrease the burden of disease on patients, families and medical systems. Further studies are needed to evaluate the role of technique on outcomes.Level of Evidence: IV.

Assessing the Safety of a Novel Neonatal Anesthesia Protocol: A Review of 101 Patients With Early Cleft Lip Repair.

PURPOSE: Our study introduces a novel anesthetic protocol for neonates without using volatile agents with the goal to minimize potentially neurotoxic and pro-apoptotic agents. The authors evaluated the short-term safety and efficacy of our anesthetic protocol in patients undergoing early cleft lip repair (ECLR). METHODS: A retrospective review of ECLR patients who underwent repair before 2.5 months of age within the last 4.3 years was performed. This sample was comprised of 2 groups, those who received either a standard volatile gas-based regimen or a dexmedetomidine-based neonatal anesthetic protocol (DBNAP). Patient demographics, medication dosing, anesthetic time (induction to extubation), major and minor complications, and medication side effects were compared between the 2 cohorts. RESULTS: A total of 101 patients underwent ECLR. All patients were American Society of Anesthesiologists class 1 or 2. Mean age at surgery was 31 ±â€Š13 days and mean anesthetic time was 179 ±â€Š36 minutes. DBNAP was used in 65 patients while the standard anesthetic protocol was used in 36 patients. Patient weight was significantly lower in the DBNAP group (4.01 ±â€Š0.61 versus 4.38 ±â€Š0.72 kg, P  = 0.007). There were no significant differences between the 2 cohorts when comparing anesthetic time, emergence time, complication rate, or medication side effects. CONCLUSION: For patients undergoing ECLR, DBNAP is perioperatively equivalent to the anesthetic standard of care, demonstrating no major complications and acceptable rates of minor complications and medication side effects.

A Review of Hand Feminization and Masculinization Techniques in Gender Affirming Therapy.

INTRODUCTION: Anatomical characteristics that are incongruent with an individual's gender identity can cause significant gender dysphoria. Hands exhibit prominent dimorphic sexual features, but despite their visibility, there are limited studies examining gender affirming procedures for the hands. This review is intended to cover the anatomical features that define masculine and feminine hands, the surgical and non-surgical approaches for feminization and masculinization of the hand, and to adapt established aesthetic hand techniques for gender affirming care. METHODS: The authors performed a comprehensive database search of PubMed, Embase OVID and SCOPUS to identify articles on the characterization of masculine or feminine hands, hand treatments related to gender affirmation, and articles related to techniques for hand masculinization and feminization in the non-transgender population. RESULTS: From 656 possibly relevant articles, 42 met the inclusion criteria for the current literature search. There is currently no medical literature specifically exploring the surgical or non-surgical options for hand gender affirmation. The available techniques for gender affirming procedures discussed in this paper are appropriated from those more commonly used for hand rejuvenation. CONCLUSION: There is a dearth of literature addressing the options for transgender individuals seeking gender affirming procedures of the hand. Though established procedures used for hand rejuvenation may be utilized in gender affirming care, further study is required to determine relative salience of various hand features to gender dysphoria in transgender patients of various identities, as well as development of novel techniques to meet these needs. LEVEL OF EVIDENCE III: 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266. .

An Expert Consensus Study for Informed Consent in Primary Breast Augmentation Surgery.

BACKGROUND: What constitutes adequate information for decision-making and informed consent is a practical question appropriately answered with deference to expertise. OBJECTIVES: The aims of this study were: (1) to establish consensus on a procedure-specific core information set of essential informed consent information by relevant medical experts for primary breast augmentation surgery; and (2) to define from the clinical perspective the data source and imminence elements of evidence-based risk communication. METHODS: The study followed a modified Delphi expert consensus model. Active members of The Aesthetic Society were identified as the relevant clinician experts and were recruited by email. Survey round 1 was informed by a scoping review of the relevant scientific and gray literature. Round 2 was informed by the initial survey round. Consensus was defined a priori as a 75% majority rating. RESULTS: Expert consensus of essential information was achieved for 16 risk items, 1 risk factor, and 8 expectations-including benefits and burdens-along with clarification of clinically appropriate options to present to all patients considering primary implant-based breast augmentation surgery. A basic, procedure-specific, structure for evidence-based risk data is also described. CONCLUSIONS: This paper reports results for the first phase of a larger pilot study aiming to develop a patient decision aid to replace traditional informed consent documents for the specified procedure. Implications for practice are encouraging in terms of reducing unwanted variation in disclosure practices and information overload.

Vertical Distraction for the Treatment of Congenital Syngnathia.

Congenital syngnathia is a very rare condition that presents with several unique challenges. There is no consensus on the best operative approach to manage this condition. Readhesion of surgically separated tissues is a relatively common occurrence. The authors propose that the use of a vertical distraction technique helps maintain adequate separation to prevent relapse of the bony fusion. Long-term follow-up will be required to follow mandibular growth and implications of this treatment option.

Sebaceous Nevus of the Scalp.

Excisions of scalp nevus sebaceous (NS) presents a unique challenge due to limited soft tissue laxity, hair-bearing skin, and convex surfaces which often leave the surgeon and patient underwhelmed with the reconstructive outcome. In this study, the authors conducted an institutional review board-approved retrospective review of patients who underwent excision of pathologically proven scalp primary NS from 2003 to 2017 at our institution to better define the reconstructive outcomes and options for treatment of pediatric scalp NS. 92 patients were included in the study, 54 males (58.7%) and 38 females (41.3%). The average age at surgery was 7.24 years (0.5-16.0; SD 4.7). Local tissue undermining/galeal scoring with primary closure (LTUGS) was used for lesions with average surface area of 3.6 cm, rotational or transposition flaps (RF/TF) for lesions averaging 4.3 cm, completed serial excision for lesions averaging 13.9 cm, and tissue expansion (TE) for lesions averaging 21 cm (P <0.001). One or more poor outcomes were experienced by 35 patients (38%), with a significant difference between the surgical groups; LTUGS 37.2% (29/78), RF/TF 60% (3/5), serial excision 100% (3/3), TE 0% (0/6) (P = 0.022). Univariant binary regression analysis within the LTUGS and RF/TF groups showed that lesion size was a significant predictor of poor outcomes (P = 0.012). All specimens in this study were negative for carcinoma. Therefore, most pediatric nevus sebaceous of the scalp can be managed by a single-phase procedure though risk of poor outcomes increase with nevus size with high rates of poor outcomes even with small lesions.

Safety/Efficacy of New Topical Silicone Formulation with Selective Growth Factors for Treating Striae Distensae.

Striae distensae (SD) are linear dermal scars that arise from progressive stretching or tearing of the dermal layer. This study tests the safety and efficacy of a topical formulation of silicone-based scar cream containing selective synthetic recombinant human growth factors, hyaluronic acid, and vitamin C to improve overall appearance and texture of SD. Twenty-two subjects with SD alba were recruited and randomized to apply the topical formula to half of their SD laterally twice a day for 1 month. Patient surveys were obtained at 1 month for overall appearance, texture, and tolerability. Three-dimensional imaging was obtained at baseline and at 1 month and submitted to independent evaluators for grading on overall appearance. Subjects reported improved texture and appearance in 86.4% of SD. Subjects reported 100% of untreated SD to have no change in overall appearance or texture. 90.9% of subjects reported no tolerability issues. 9.1% of the treated group reported mild issues such as slight itching or redness the first day of application, which subsided in 2 days for all patients. Independent evaluators indicated improvement in 72.7% of SD in comparison to improvement in 36.3% of untreated SD. This study demonstrates that the investigated topical formulation is safe and effective to use for SD.

Attitudes, Beliefs, and Practices of Aesthetic Plastic Surgeons Regarding Informed Consent.

BACKGROUND: Best practice for informed consent in aesthetic plastic surgery is a process of shared decision-making, yet evidence strongly suggests this is not commonly reflected in practice nor is it supported by traditional informed consent documents (ICD). Falsely held beliefs by clinicians about shared decision-making may contribute to its lack of adoption. OBJECTIVE: The authors sought to understand the baseline attitudes, beliefs, and practices of informed consent among board-certified plastic surgeons with a primarily aesthetics practice. METHODS: A 15-question online survey was emailed to active members of the American Society for Aesthetic Plastic Surgery. Items included demographics, Likert scales, free-text, acceptability, and 1 question seeking consensus on general information all patients must understand before any surgery. RESULTS: This survey yielded a 13% response rate with a 52% completion rate across 10 countries and 31 US states. A total of 69% were very or extremely confident that ICD contain evidence-based information, but 63% were not at all or not so confident in ICD effectiveness of prompting patients to teach-back essential information. A total of 50% believed surgical ICD should be reviewed annually. Eighty-six percent reported assistance with patient education during informed consent. Members of professional plastic surgery societies should be a source of evidence for content (free-text). A total of 64% were somewhat to very satisfied with the survey and 84% will probably to definitely participate in future related surveys. CONCLUSIONS: The findings echo concerns in the literature that ICD are focused on disclosure instead of patient understanding. There is notable concern regarding information overload and retention but less regarding the quality and completeness of information. Current culture suggests key clinician stakeholders are amenable to change.

Optimal Timing of Secondary Alveolar Bone Grafting: A Literature Review.

PURPOSE: Secondary alveolar bone grafting (SABG) during mixed dentition is the standard of care for alveolar clefts. However, early SABG at 4 to 7 years of age before the eruption of lateral incisors versus late SABG at 8 to 12 years of age before the eruption of maxillary permanent canines is still debated. The purpose of this study was to perform a systematic review of the literature to evaluate the outcomes of early SABG in residual bone volume or degree of bone resorption, maxillary canine movement or impaction rate, complications, and esthetic outcomes and to compare outcomes of early versus late SABG. MATERIALS AND METHODS: A comprehensive search of the PubMed database was performed according to PRISMA guidelines. Keywords for alveolar cleft repair and inclusion criteria were used to screen articles for final review. RESULTS: The initial search yielded 6,278 articles, of which 4 retrospective and 4 prospective studies were chosen for final review. Of these, 7 studies compared outcome variables between early and late SABG and 1 looked at bone formation of patients who underwent only early SABG. For outcome variables, 3 studies assessed bone volume with radiographic evaluation, 2 estimated maxillary permanent canine impaction rate, 1 evaluated surgical complications, operative time, and length of hospital stay, and 1 looked at anterior incisor crown length. Overall, 6 studies concluded that early SABG provides a better outcome than late SABG and 2 found comparable results across the aforementioned variables. CONCLUSIONS: This review suggests that the existing data support the concept of early SABG; however, the data are not sufficient for a definitive conclusion. A well-planned prospective study is needed to further investigate the rationale for early SABG.

Cosmetically Challenging Congenital Melanocytic Nevi.

BACKGROUND: Congenital melanocytic nevi (CMN) have a 1% to 5% lifetime risk for malignant transformation, with 50% of transformations occurring before the age of 5 years.The aim of this study is to assess the risk of melanoma development in pediatric patients with facial CMN involving the eyebrows, eyelid margins, and nasal alae where a margin of CMN was not excised to preserve these structures. METHODS: A retrospective chart review of all pediatric patients with CMN from 1986 to 2014 was performed to review demographic information, diagnosis, and number of surgeries. Patients' clinical photographs were evaluated for residual nevi after completion of the treatment. RESULTS: More than 950 medical charts of patients with CMN of the face area were reviewed. We identified 32 patients (13; 41% male) that met the study criteria with pathology-confirmed diagnosis of facial CMN with an average age of 4.4 years (3.3 months-15.8 years) at the time of initial surgery. The CMNs were classified into small (1; 3%), medium (14; 44%), large (14; 44%), and giant (3; 9%) based on their projected adult sizes. No patients developed melanoma within the small residual lesions left over the eyebrows and eyelids and inside nostrils at an average follow-up time of 5.6 (1.0-14.4) years and average age of 9.6 (1.8-19.2) years at the time of last follow-up. CONCLUSIONS: Although a lifelong risk of malignant transformation of the residual CMN cannot be concluded, our results found no transformation in follow-up visits at an average age beyond the highest risk of melanoma development in childhood. We feel that leaving residual lesions on the face in areas of important anatomic structures for better cosmetic outcome is an acceptable risk.

Less Is More in Congenital and Pediatric Nasal Lesions.

Congenital and pediatric nasal lesion resection and their reconstructive outcomes are not well studied. A surgeon must consider the site, size, depth, etiology, age, and effect on future function (including growth). As such, it is important to contrast the differences between the adult's and child's nose. The authors propose that more conservative resection and reconstructive methods may better serve congenital and pediatric nasal lesions. An Internal Review Board approved study of congenital and pediatric nasal lesions using a defect only approach from 2005 to 2017 was performed. Lesions, type of surgeries, complications, aesthetic outcome, and additional interventions were reviewed. One hundred twenty-seven patients met the study criteria with a median age at surgery of 5.4 years with follow-up of 1.4 years (1 week-11.3 years). The most common diagnosis was congenital melanocytic nevus (47, 37%). The lesions were located on more than 1 subunit in 34 (27%) patients with an average surface area of 3.7 (0.04-32) cm. The most common primary procedure was excision and primary closure with adjacent tissue undermining/rearrangement (73, 57.4%) followed by full-thickness skin graft (23, 18.1%). The aesthetic outcome was considered acceptable in a high number of patients 117 (92%), while 10 (8%) patients had unacceptable aesthetic outcomes, mostly due to scarring. The authors' data supports the concept of minimal healthy tissue excision or lesion only excision when treating pediatric and congenital nasal lesions.

EC-IC bypass for cerebral revascularization following skull base tumor resection: Current practices and innovations.

Complex skull base tumors can involve critical vessels of the head and neck. To achieve a gross total resection, vessel sacrifice may be necessary. In cases where vessel sacrifice will cause symptomatic cerebral ischemia, surgical revascularization is required. The purpose of this paper is to review cerebral revascularization for skull base tumors, the indications for these procedures, outcomes, advances, and future directions.

Impact of the Distance of Maxillary Advancement on Horizontal Relapse After Orthognathic Surgery.

BACKGROUND: The maxillary horizontal relapse following Le Fort I advancement has been estimated to be 10% to 50%. This retrospective review examines the direct association between the amounts of maxillary advancement and relapse. We hypothesize that the greater the advancement, the greater the relapse amount. METHOD: Patients with class III skeletal malocclusion underwent maxillary advancement with either a Le Fort I or a Le Fort I with simultaneous mandibular setback (bimaxillary surgery) from 2008 to 2015. Patients were assessed for a history of cleft lip or cleft palate. Patients with known syndromes were excluded. Cephalometric analysis was performed to compare surgical and postsurgical changes. RESULTS: Of 136 patients, 47.1% were males and 61.8% had a history of cleft. The mean surgery age was 18.9 (13.8-23) years and 53.7% underwent a bimaxillary procedure. A representative subgroup of 35 patients had preoperative, immediate postoperative, and an average of 1-year postoperative lateral cephalograms taken. The mean maxillary advancement was 6.3 mm and the horizontal relapse was 1.8 mm, indicating a 28.6% relapse. A history of cleft and amount of maxillary advancement were directly correlated, whereas bone grafting of the maxillary osteotomy sites was inversely correlated with the amount of relapse ( P < .05). CONCLUSIONS: Our data suggest positive correlation between amount of maxillary advancement and horizontal relapse as well as a positive correlation between history of cleft and horizontal relapse. Bone grafting of the maxillary osteotomy sites has a protective effect on the relapse.

Combined Direct and Indirect Cerebral Revascularization Using Local and Flow-Through Flaps.

BACKGROUND: Extracranial-intracranial bypass is indicated in ischemic disease such as moyamoya, certain intracranial aneurysms, and other complex neurovascular diseases. In this article, we present our series of local and flow-through flaps for cerebral revascularization as an additional tool to provide direct and indirect revascularization and/or soft tissue coverage. METHODS: A retrospective review of a prospectively maintained database was performed identifying nine patients. Ten direct arterial bypass procedures with nine indirect revascularization and/or soft tissue reconstruction were performed. RESULTS: Indications for arterial bypass included intracranial aneurysm (n = 2) and moyamoya disease (n = 8). Indications for soft tissue transfer included infected cranioplasty (one) and indirect cerebral revascularization (eight). Four flow-through flaps and five pedicled flaps were used including a flow-through radial forearm fasciocutaneous flap (one), flow-through radial forearm fascial flaps (three), and pedicled temporoparietal fascial (TPF) flaps with distal end anastomosis (five). The superficial temporal vessels (seven) and facial vessels (two) were used as the vascular inflow. Arterial bypass was established into the middle cerebral artery (six) and anterior communicating artery (three). There were no intraoperative complications. All flaps survived with no donor-site complications. In one case of flow-through TPF flap, the direct graft failed, but the indirect flap remained vascularized. CONCLUSION: Local and flow-through flaps can improve combined direct and indirect revascularization and provide soft tissue reconstruction. Minimal morbidity has been encountered in early outcomes though long-term results remain under investigation for these combined neurosurgery and plastic surgery procedures. LEVEL OF EVIDENCE: The level of evidence is IV.