Comparison of Presurgical Anthropometric Measures of Right and Left Complete Unilateral Cleft Lip and/or Palate.

BACKGROUND: Left clefts occur twice as frequently as right ones. The sidedness has been suggested to influence certain outcomes. Some surgeons consider a right cleft more challenging to repair. This is often attributed to their reduced prevalence. The authors question whether this may be caused by morphologic differences. The authors' hypothesis is that there are anthropometric differences between left and right complete cleft lips. METHODS: Patients with complete unilateral cleft lip, with or without cleft palate, operated on at the age of 3 to 6 months, between 2000 and 2018, by a single surgeon, were included. Eight standardized anthropometric measurements of the cleft lip, collected just before cleft lip repair, compare lip and vermillion dimensions and ratios between left and right clefts. RESULTS: One hundred thirty-nine left and 80 right unilateral cleft lips were compared. A significant difference was found between left and right clefts for cleft-side to non-cleft-side ratios comparing the lateral lip element vertical heights and vermillion heights. CONCLUSIONS: Patients with right cleft lips have a greater degree of lateral lip element hypoplasia, demonstrating greater deficiencies of lateral lip element vertical height and vermillion height when compared to patients with left clefts. This has clinical implications for preoperative assessment, choice of surgical technique, and postoperative and long-term outcomes.

Fat Embolism After Autologous Facial Fat Grafting.

BACKGROUND: Autologous facial fat grafting has gained popularity in recent years and is considered to be safe. This paper presents the case of a patient who died due to massive cerebral microfat embolism after facial fat grafting. OBJECTIVES: The aim of this study was to raise awareness and provide more evidence on the prevention and treatment of this potentially lethal complication of facial fat grafting. METHODS: A detailed report was made of the case. Two online databases were searched for similar cases of facial fat embolism resulting in neurologic and/or visual symptoms. Thereafter a literature search was conducted to verify the etiology, current treatment options, and preventive measures. RESULTS: Forty-nine cases with similar events were found in the literature. The most common injected area was the glabella (36.1%), and an average of 16.7 mL fat was injected. The main complications were visual impairment, with 88.5% of cases resulting in permanent monocular blindness, and neurologic symptoms, some of which never fully recovered. Including the present patient, 7 cases were fatal. Fat embolism can occur in the veins and arteries of the face. Two possible pathways for fat embolism exist: the macroscopic, mechanical pathway with immediate signs, and the microscopic, biochemical pathway with delayed symptoms. Mechanical embolectomy and corticosteroids are suggested treatment options but evidence for their efficacy is lacking. Several different preventive measures are described. CONCLUSIONS: Although facial fat grafting is considered a safe procedure, one should be aware of the risk of fat embolism. Underreporting of this adverse event is likely. With no effective treatment and often detrimental outcomes, preventive measures are of utmost importance to improve patient safety.

The LDI Enigma, Part I: So much proof, so little use.

INTRODUCTION: Laser Doppler imaging (LDI) is still not an ubiquitous part of burn care worldwide despite reported accuracy rates of more than 95%, which is significantly higher than clinical assessment alone (50-75%). The aims of Part I of this survey study are: to identify the most important barriers for the use of LDI and to provide useful recommendations for efficient implementation in routine burn care. The actual interpretation and use of LDI measurements is discussed in the Enigma Part II article. MATERIAL AND METHODS: 1. Informative interviews with 15 representatives of burn centers without LDI. 2. A survey among 51 burn centers with LDI by means of an extensive questionnaire. 3. In-depth interviews with 21 of the participating centers. RESULTS: 1. All 15 centers without LDI indicated that cost of purchase in combination with maintenance of the LDI device, as well as personnel costs were the reason for not buying, while 12 (80%) also rated the current scientific evidence as insufficient. 2. Twenty-seven burn centers with an LDI (53%) participated and filled in almost the entire questionnaire. In 5 centers, cost delayed the purchase of LDI. The hospital/department paid for the LDI device in 62% of the burn centers and in 88% also for maintenance and salaries. The LDI operators were mainly surgeons (47%) or nurses (42%). In more than half of the burn centers (52%), between 2 and 5 people were trained and certified to use an LDI. In 50% of burn centers, the interpretation of the LDI scan was done by the same person doing the actual measurements. Eighty-nine percent of the burn centers considered the accuracy of the LDI scan as mainly to almost completely accurate. In case of real discrepancy between clinical diagnosis and LDI, in 48% of the burn centers (13/27) the surgeon still relied more on the clinical diagnosis despite reporting this high or almost complete accuracy rate of the LDI. CONCLUSIONS: Barriers for the routine implementation of LDI were: 1. cost of purchasing and using an LDI combined with health care systems that inadequately reimburse non-surgical management; 2. lack of awareness of or ongoing skepticism towards the scientific evidence supporting LDI use; and 3. organizational constraints combined with logistical limitations. Our recommendations for wider use of LDI technology include: 1. a cost-effective reimbursement of LDI use combined with a more appropriate valuation of expert conservative management compared to surgical therapy; 2. increased use of LDI for every mixed depth burn and; 3. specialized LDI teams to improve burn procedural flexibility and to enable embedding LDI use in the burn care routine. Implementing these measures would promote the highest standards for LDI measurements and interpretation resulting in optimal care with mutual benefits for the hospital, for burn care teams and, most importantly, for the patients.

Reducing the Cleft Nose Deformity in Bilateral Cleft Lip Repair.

Repair of a bilateral cleft lip and nose deformity remains a challenge. The nose remains the main persisting stigma for patients, deserving an equal amount of attention as the lip during the repair. We share 3 technical principles to help achieve the optimal nasolabial result and minimize cleft nose deformity after bilateral cleft lip repair. Firstly, cephalad rotation of C-flaps from the prolabium is used to define the nasolabial angle. Secondly, the nasal base and contour is set before the lip repair, as the vectors and tension of nasal repair differ from the vector and tension of the orbicularis oris muscle closure. Thirdly, different suspension and shaping stitches are used to define alar shape and position after lower lateral cartilage release, avoiding additional scars.