The Road Less Traveled: The Marham National Health Institute's Journey on Cleft Lip and Palate Surgery Missions.

Congenital cleft lip and palate represent the prevailing craniofacial birth anomalies on a global scale. Notably, a substantial proportion of patients within remote regions of Iran defer corrective surgery until later stages of life, often in childhood or adulthood, primarily due to intricate financial and cultural constraints. In response to this pressing healthcare challenge, a dedicated collective of volunteer plastic surgeons was established in 2009 with the explicit aim of providing medical care to these underserved patients. Over the subsequent years, this compassionate team embarked on 31 meticulously planned missions to underprivileged areas scattered across the country. Through these organized endeavors, a remarkable total of 20,579 medical visits were conducted, coupled with the performance of 2,303 essential surgeries, thus offering a lifeline of healthcare to these disadvantaged individuals.

Surgical Treatment of Anterior Plagiocephaly With Limited Calvarial Osteotomy.

OBJECTIVE: Anterior plagiocephaly is a condition in which the unicoronal suture is prematurely fused and the skull shape will change due to asymmetric growth. METHODS: This is a retrospective study describing the unilateral limited frontal osteotomy for remodeling deformed areas in the frontal and orbital bone and its pros and cons. RESULTS: Twenty-eight patients were included in the study, with a mean age of 16.8 (±11.7) months. Mean intraoperative bleeding was 78.1 (±23.6) mL. One (3.57%) patient developed postoperative bleeding, around 200 mL. After 12 months, all patients (100%) had grade I Whitaker. CONCLUSION: The described technique is safe and may have promising short-term outcomes for the correction of anterior plagiocephaly.

Surgical Treatment of Trigonocephaly, Simplified Technique for Moderate Cases.

BACKGROUND: The prevalence of trigonocephaly has increased worldwide over the past 2 decades. Early identification and appropriate treatment are critical. The aim of this study is to evaluate the outcomes and the effect of metopic suture excision, perisutural frontal bone shave, and bilateral pericranial flap method on the shape of the forehead after surgical correction in infants with moderate trigonocephaly. METHODS: The present study was performed as a cross-sectional study on 40 infants of 3 to 12 months old with trigonocephalus who underwent metopic suture excision and pericardial flap surgery in Mofid Pediatric Hospital from 2016 to 2022. The definitive diagnosis of patients' trigonocephaly was made based on clinical signs and computed tomography scan findings by a plastic surgeon. RESULTS: Overall in 40 patients operated by this technique, 23 (57.5%) of cases were males, and 17 (42.5%) were females. The mean age of patients was 7.86 ± 2.22 months. Hospital stay was 2 to 4 days (mean: 3 d), intensive care unit admission was in 33 cases for 24 hours, and no intensive care unit admission for 7 cases. Blood was transfused during surgery for 25 patients, and 15 patients did not require blood transfusion use. Results were evaluated in 6 to 12 months after surgery by 3 independent plastic surgeons, with pre and postoperative photos. Satisfaction with the results of forehead shape was excellent for 60% of patients, good for 37.5%, and moderate for 2.5%. Only one female patient had a recurrence after the surgery. CONCLUSION: This study showed that the pericranial flap method after full metopic suture excision and frontal shave was very effective in the treatment of infants with moderate trigonocephaly.

Eyebrow Reconstruction in Craniofacial Clefts by Abnormal Hairline Extention.

The absence of eyebrows, whether complete or partial, has been observed in specific types of craniofacial clefts, primarily occurring in Tessier clefts numbers 9 to 13. To address this defect, several techniques have been used to improve eyebrow appearance, such as the island scalp flap and scalp strip grafting technique. However, these methods did not yield satisfactory esthetic results. In this study, the authors present findings from 7 patients with craniofacial clefts, in whom the eyebrows were completely reconstructed through the rotation flap technique, using abnormal frontal hairline extension, in 1 or 2 stages. The result was natural-looking and highly satisfactory, with no associated morbidity.

Assessing Long-Term Neurodevelopment among Children with Non-Syndromic Single Suture Craniosynostosis.

Background: Single suture craniosynostosis (SSC) is a disorder, affecting brain growth. Reviewing literature reveals controversialists of papers in this field. Methods: This prospective study was conducted from 2014 to 2016. All the individuals, aged 2 to 16 years, whose medical records files were complete, with SSC from 1999 to 2013 were included. All patients had undergone cranial vault remodeling at Mofid Hospital, Tehran, Iran. Wechsler questionnaires, WPPSI-III and WISC-IV, were completed for each child based on his/her age. Results: Seventy children were included, with the mean age of 6.7 (±2.9) years. Forty-six (65.7%) children were boys while 24 (34.3%) were girls. Mean FSIQ for all of children was 95.5 (±13.2). Mean verbal IQ, performance IQ, verbal comprehension, perceptual reasoning, processing speed, and working memory are 93.4 (±14.1), 96.1 (±13.3), 97.5 (±13.9), 102.2 (±12.5), 94.5 (±9.8), and 97.5 (±12.9), respectively. There was statistically significant difference between FSIQ of children with SSC and that of unaffected children (P-value<0.05). There was significant difference between verbal IQ of children with SSC and that of unaffected ones (P-value< 0.007). There was significant difference between in processing speed between affected children and unaffected children (P-value<0.012). Conclusion: Children, aged 2 to 6 years, with SSC had a significantly lower Verbal IQ, and children, aged 6 to 16 years, with SSC had a significantly lower processing speed than their healthy counterparts. Though FSIQ of children with SSC falls within normal range, it is a little lower than healthy peers.

The Effect of Using In Vitro Fertilization (IVF) on Increasing the Prevalence of Craniosynostosis.

BACKGROUND: Craniosynostosis, a malformation caused by premature closure of one or more cranial sutures, is a rare congenital disability usually of unknown cause; however, it is often associated with assisted reproductive technology. Given the increasing prevalence of craniosynostosis and the use of the in vitro fertilization (IVF) method, the authors evaluated the association between IVF and the prevalence of craniosynostosis. METHODS: This retrospective study reviewed records of patients with nonsyndromic craniosynostosis who underwent surgery in Mofid Hospital, a tertiary children's hospital affiliated to Shahid Beheshti University of Medical Sciences, between 2010 and 2019. RESULTS: A total of 200 patients aged one month to 7 years old, were evaluated. Out of 200 patients, 43% were plagiocephalic, 39% trigonocephalic, 8.5% scaphocephalic, 8% brachiocephalic, and 1.5% were mixed. Nine (4.5%) patients had received clomiphene citrate. Eight (4%) mothers had become pregnant under IVF, and they all had used clomiphene citrate for ovulation stimulation. No use of artificial insemination was reported. Of the eight patients whose mother had become pregnant through IVF, three were trigonocephalic, and five were plagiocephalic. CONCLUSIONS: Without a control group, we are not able report the statistical results confirming or denying a link between craniosynostosis and infertility treatment. However, 4% prevalence of IVF use among craniosynostosis patients is significant. Further studies with a broader statistical community are suggested in this regard.

Impact of COVID-19 pandemic on plastic surgery activities and residency programs in a tertiary referral centre in Iran.

Background: On March 11, 2020, the World Health Organization (WHO) announced the COVID-19 outbreak as a new pandemic. In the meantime, plastic surgeons postponed their appointments due to the fair and rational allocation of medical supplies. These limitations made all junior and senior residents perform operations only on traumatic patients rather than those needing reconstructive procedures. This study aims to determine the effects of the COVID-19 pandemic on plastic surgery training programs in Iran. Also, the number of canceled surgeries will be determined to see the effects of the pandemic on the patients. Methods: This retrospective case study considers a six-month timeframe in two consecutive years before and after the COVID-19 pandemic. For this purpose, the researchers evaluated the number of surgeries, types of procedures, age distribution, and gender distribution. The training program data of plastic surgery residents were collected from their logbooks and then analyzed in IBM SPSS Statistics 26. Differences were considered significant if p < 0.05 at a 95% confidence level. Results: The total number of surgeries decreased by 23.5% after the COVID-19 outbreak (p < 0.05). There was a 29.9% reduction in trauma cases, -78.9% in aesthetic surgeries, -17.7% in reconstructive surgeries, -51.8% in craniofacial surgeries, and -59.5%in microscopic surgeries for each resident. Conclusions: This study provides an insight into the severity of the pandemic effects on the plastic surgery training programs and the patients. The reduced number of surgeries led to a depletion in surgical skills training. These effects will not wear off immediately after the pandemic; therefore, it is necessary to observe whether the pandemic will have any lasting effects on this subspecialty.Level of evidence: Level IV, risk/prognostic study.

Introducing A Family With Tens of Rare Craniofacial Clefts.

BACKGROUND: Craniofacial clefts are one of the rarest congenital malformations. When it comes to genetic inheritance patterns of craniofacial clefts, there are few studies on this subject due to the rarity and sporadic nature. In this study an extended family whose members have multiple craniofacial clefts has been introduced. METHODS: The authors haphazardly found a family whose members have craniofacial clefts, either Tessier no. 0 or both Tessier nos. 0 and 14, and, consequently, they were categorized into 3 groups based on the severity of clefts. RESULTS: Forty-two craniofacial clefts were noticed within the family. Twenty-two (52.3%) of patients were females and 20 (47.6%) were males. Twenty-three (54.8%) members had isolated Tessier no. 0 cleft, whereas 19 (45.2%) members had both Tessier nos. 0 and 14. Of all 42 patients, 18 (42.8%), 3 (7.1%), and 21 (50%) patients had severe, intermediate, and mild clefts, respectively. CONCLUSION: The present study reveals that in some patients genetic background is likely to be the cause of clefts.

Role of Autologous Fat Injection in Neglected Patients With Anterior Plagiocephaly.

Anterior plagiocephaly is a type of non-syndromic craniosynostosis requiring surgery. In this study, the authors have presented 15 neglected patients with anterior plagiocephaly. Two of patients had moderate plagiocephaly whereas others had mild plagiocephaly. A total of 38 procedures (fat injections) were performed on these patients. Following procedures, 2 of patients were under corrected, 2 of who were over corrected, and others were adequate corrected. One of the patients developed fat necrosis. None of them showed persistent over correction. Authors believe that autologous fat transplantation is a safe and effective method, in patients with anterior plagiocephaly who have not been operated, to improve patients' appearance and, subsequently, their self-esteem as well as their social function.

Incidence of Familial Craniosynostosis Among Patients With Nonsyndromic Craniosynostosis.

BACKGROUND: Craniosynostosis has an incidence of 1 in 2000 to 2500 live births, and is categorized into syndromic and nonsyndromic types. Nonsyndromic ones can be familial in which more than one of the family members are involved. METHODS: This is a prospective study which is carried out from April 2015 to January 2018 in 2 academic hospitals. Those patients who had nonsyndromic craniosynostosis and completed medical follow-up were included in the study as well as their 1st degree relatives. Age of patients, gender, existing consanguineous marriage, type of deliveries, type of pregnancy (assisted reproductive technologies [ART] versus sexual intercourse), severity and type of craniosynostosis were gathered. RESULTS: Ninety-four (46.0%), 58 (28.4%), 28 (13.7%), 16 (7.8%), and 8 (3.9%) of patients had trigonocephaly, scaphocephaly, anterior plagiocephaly, complex, and brachycephaly, respectively. A total number of 204 patients were included in the study. Of all 204 families which were included, 30 (14.7%) families had positive familial history. Familial patients were determined in 10, 15, 8, 1, and 5 patients with scaphocephaly, trigonocephaly, anterior plagiocephaly, rachycephaly, and mixed type. Male to female ratio was 2:1, 1.9:1, 1.3:1, 1:1, and 1:1 for scaphocephaly, trigonocephaly, anterior plagiocephaly, brachycephaly, and mixed craniosynostosis. Twelve (5.9%) women had applied ART. CONCLUSION: Present study reveals that metopic suture is the most frequent craniosynostosis within nonsyndromic types. All the types of nonsyndromic craniosynostosis had male prevalence but for complex one which was equal in both gender. Nonsyndromic craniosynostosis in about 14.7% of patients was familial.

Prefabricated Skin Excision in Face Lift: A Simplified Technique.

BACKGROUND: The demand for facial plastic surgery has dramatically been increased in recent years. Over the last decade, numerous methods have been improved for facelift surgery. Despite these modifications, skin excision technique has not changed significantly. In this study, authors have tried to introduce a new technique regarding skin excision at the initial step of facelift surgery. METHODS: A prospective study from 2012 to 2017 on 52 patients was carried out to apply a new technique for facelift ''Prefabricated skin excision method'' for all eligible patients undergoing facelift surgery. The skin calling for excision was marked by the surgeon, and then, an analgesic drug was administered. Then, excision of the marked part of the skin was performed and afterward the dissection of the superficial musculoaponeurotic system (SMAS) was performed with the direct exposure. RESULTS: All patients were female, and 50 (96.1%) cases were primary face lift and 2 (3.9%) cases were secondary. There were no complications among the patients. CONCLUSION: Facilitating the manipulation of deep layer, using this technique led to the further exposure of the surgical site, and more preferable hemostasis was achieved as well.

The Impact of Cosmetic Surgery on Women's Marital Satisfaction and Self-Concept.

BACKGROUND: Today, cosmetic surgery is one of the most common procedures worldwide, and its use is increasing. This study aimed to identify the impact of cosmetic surgery on married women's marital satisfaction and self-concept. METHODS: From January 1st, 2015 to June 6th, 2015, 44 married women operated in a plastic surgery clinic or seeking for a cosmetic surgery and 55 non-applicants as general population were enrolled. ENRICH marital satisfaction questionnaire and Rogers' Self-concept Inventory were used to compare groups. RESULTS: Operated applicants revealed a significant higher level of satisfaction in comparison with other groups regarding personality, conflict and leisure. Compared to control group, the surgical group had significantly higher satisfaction in marital and familial relationship, friendship, and financial management. CONCLUSION: It can be drawn that expectation for postoperative positive outcome probably is an important factor affecting high level of marital satisfaction in cosmetic surgery applicants. Furthermore, the self-concept is significant predictor of applying for cosmetic surgery.

The Impact of Cosmetic Surgery on Married Women's Marital Satisfaction and Self-Concept.

BACKGROUND: This study aimed to identify the impact of cosmetic surgery on married women's marital satisfaction and self-concept in Tehran. METHODS: This study was causal-comparative research. The study population consisted of all women having or applying for cosmetic surgery in Tehran over the second half of 2015. Convenient random sampling was used to select the participants. Enriching and Nurturing Relationship Issues Communication and Happiness (ENRICH) marital satisfaction questionnaire and Rogers' Self-concept Inventory were used to collect data. RESULTS: The study sample included 44 individuals having facial cosmetic procedures, 51 individuals applying for cosmetic surgery and 55 non-applicants (ordinary people). There were significant differences in terms of marital satisfaction and its components between the cosmetic surgery applicants and surgery group and control group. The cosmetic surgery applicants revealed higher levels of satisfaction in comparison with the surgery and control groups regarding the components' personality, conflict and leisure. Considering the component marital relationship, the applicant group had higher satisfaction than control group. With regard to the components financial management and relatives and friends, the applicant group had higher satisfaction, in comparison to the control group. The control group had better self-concept than the surgery and applicant groups. CONCLUSION: Expectation for postoperative positive outcome is an important factor affecting high level of marital satisfaction in surgery applicants. Furthermore, the component self-concept is also a significant predictor of having or applying for cosmetic surgery.

Various Colored Splints for Each Type of Rhinoplasty.

In rhinoplasty, one of the most popular aesthetic surgical procedures worldwide, several different techniques are utilized when performing a rhinoplasty procedure. Many complications can arise postoperatively depending on the surgical approach and technique utilized. A method to reduce immediate postoperative complications has been identified. The use of different colored nasal splints for various surgical procedures could assist in identifying high-risk patients to the postsurgical recovery team and the clinical staff. In this prospective 10-year study, patients were divided into 2 groups. In Group I, the green-colored splint was applied to all patients, whereas in Group II, patients were divided into 3 subgroups. Patients undergoing rhinoplasty and septoplasty, rhinoplasty, and minimally invasive rhinoplasty were placed in Subgroup I, Subgroup II, and Subgroup III, respectively. Different survey questionnaires were designed for patients, the surgical team, the postsurgical recovery team, the follow-up care team, and the clinical staff. A total of 2,680 (88%) patients were females, whereas 332 (12%) patients were males. There was no significant difference in surgeon's responses between 2 groups (p > .05). Between the 2 groups, there was a significant difference in the postsurgical recovery team and the follow-up care staff (p < .001). Patients in Group II were significantly more aware of their conditions and possible complications (p < .001). The current study reveals that patients undergoing rhinoplasty should be identified through colored splints, particularly patients whose surgery accompanies a high possibility of complications. In such patients, colored splint is a red flag for surgical and postsurgical nurses and staff who are providing health care to patients.

Teenage Rhinoplasty.

BACKGROUND: Rhinoplasty is among the most popular aesthetic surgical procedures selected by teenagers. When it comes to teenagers' rhinoplasty, almost all surgeons believe that modified techniques should be considered because the nose is still growing. In this article, we prospectively followed teenagers who had undergone septorhinoplasty to assess the safety of procedure and its possible complications. METHODS: All the patients who were under 18 years old but for those who had a bleeding disorder, allergic rhinitis, and cleft lip nose were included in the study. All the patients were operated by the Senior author through closed rhinoplasty. Age, gender, indication for surgery, postoperative complications, need for revision surgery, postoperative satisfaction, and disturbance in facial growth until puberty were gathered for each of patients. RESULTS: Of all 40 patients, 38 (95%) patients were female and 2 (5%) patients were male. Mean age and follow up of patients was 16.1±0.8 years and 29.5±12.1 months, respectively. Fourteen (35%) patients had some degrees of nasal obstruction. Thirty-five (87.5%) patients expressed complete satisfaction with their rhinoplasty outcome. None of patients underwent revision rhinoplasty. CONCLUSION: The study indicates that patients' craniofacial growth was not affected by the procedure, and it seems that septorhinoplasty is safe in teenagers.

Surgical Treatment of Unicoronal Synostosis: A Simplified Technique without Orbital Osteotomy.

BACKGROUND: Although referrals for nonsyndromic frontal plagiocephaly have been increased during the past several years, successful surgical repair of unicoronal synostosis (UCS) remains a challenge for craniofacial surgeons. Most surgical techniques followed to correct supraorbital rim elevation and temporal constrictions are being noticed less and often require a secondary revision. But this new technique consists of correcting the affected ipsilateral frontal, temporal, and superior orbital rim areas in the first operation. METHODS: From 1995 to 2016, a total of 154 cases of UCS were operated by first author. A total of 91 patients were operated with standard technique, whereas the new technique was applied on 63. Whitaker scoring system was used for evaluation of patients after surgery. RESULTS: Data analysis shows a significant difference between 2 operation techniques results (P = 0.007). None of the patients from the new technique group required revision surgery. CONLUSIONS: We believe that our new technique have less invasive osteotomy on the frontal bone and no manipulation of the orbital bone, so provide sufficient bone graft and is applicable even for younger patients (<6 months).

Surgical Outcome of Simplified Horse-Shoe Technique With the Traditional Procedure in Children With Trigonocephaly.

Trigonocephaly is one of the most common types of craniosynostosis leading to triangular-shaped head and neurodevelopmental complications. Several surgical techniques have been suggested for its correction, but the newly suggested technique seems to have optimal outcomes compared with the traditional methods. Thus, the authors retrospectively evaluated the outcomes of the simplified horse-shoe technique with previous procedures performed on 169 children severe trigonocephaly during 1996 to 2015 at Mofid Hospital, Tehran, Iran. Demographic data of the patients and the surgical outcomes and complications and the need for reoperation were recorded and scored using the Whitaker system. The male-to-female ratio was 2.75:1. The mean ±â€Š standard deviation age of all the patients at the time of surgery was 7.09 ±â€Š7.5, 9.95 ±â€Š7.71, 10.53 ±â€Š6.57, and 10.59 ±â€Š7.96 months for the traditional, horse-shoe, and simplified horse-shoe techniques, respectively. The total reoperation rate was 6.5% (4.7% in the traditional technique, 1.2% in the horse-shoe, and 0.6% in the simplified horse-shoe technique) (P < 0.001). The main reason for reoperation was hardware removal (in the traditional technique). Whitaker scoring showed no patients of class IV in any of the groups and no patients of class III and IV in simplified horse-shoe technique, but the difference in the Whitaker scores among the 3 groups was not statistically significant (P = 1.176). The new surgical technique is easier and simpler with fewer complications than the traditional technique and is suggested to be recommended for surgical treatment in children with trigonocephaly, especially in younger children.

Prevalence of Rare Craniofacial Clefts.

BACKGROUND: Craniofacial clefts are extremely rare congenital malformations that have adverse functional, psychosocial, and aesthetic effects on patients' life. Although the exact incidence is unclear, it is estimated between 1.4 and 4.9 per 100,000 live births. Prevalence of the rare craniofacial clefts is imprecise due to the paucity of literature as well as their etiologies. METHODS: All the patients with rare craniofacial clefts during 10 years in a plastic surgery tertiary referral hospital were included, and Tessier craniofacial clefting classification was used for classifying the clefts. RESULTS: Of 964 patients with craniofacial clefts, 80 (8.29%) patients were identified with rare craniofacial clefts. There were 39 (48.7%) males and 41 (51.3%) females. Family history was determined positive in 30 (37.5%) patients. Tessier number 0 (58.7%) was the most common cleft in the authors' study. Tessier numbers 8, 13, and 30 were the rarest clefts. There was no patient with Clefts numbers 5, 6, or 9. Maternal smoking during pregnancy was observed in 1 (1.3%) of the women and 3 of the women had used drugs, 1 of them used the dexamethasone tablets and 2 of them could not remember name of the used drug. CONCLUSIONS: Tessier number 0 was the most common cleft and Tessier numbers 8, 13, and 30 were the rarest types. The precise etiology of rare craniofacial clefts remained undetermined in this study. Women should be educated about the risk factors and subsequent ways of preventing from these risk factors.

Effect of Perioperative Management on Outcome of Patients after Craniosynostosis Surgery.

BACKGROUND: Craniosynostosis results from premature closure of one or more cranial sutures, leading to deformed calvaria and craniofacial skeleton at birth. Postoperative complications and outcome in intensive care unit (ICU) is related to surgical method and perioperative management. This study determined the perioperative risk factors, which affect outcome of patients after craniosynostosis surgery. METHODS: In a retrospective study, 178 patients with craniosynostosis who underwent primary cranial reconstruction were included. Postoperative complications following neurosurgical procedures including fever in ICU, level of consciousness, re-intubation, and blood, urine, and other cultures were also performed and their association with the main outcomes (length of ICU stay) were analyzed. RESULTS: Factors independently associated with a longer pediatric ICU stay were fever (OR=1.59, 95% CI=1.25-4.32; p=0.001), perioperative bleeding (OR=2.25, 95% CI=1.65-3.65; p=0.01), age (having surgery after the first 5 years) (OR=1.59, 95% CI=1.33-3.54, p=0.016) and infection (OR=2.17, 95% CI=1.83-7.46; p=0.002). Mean blood loss during surgery was significantly higher in patients whose duration of ICU was longer than 4 days compare to less than 4 day (p=0.026). Amount of bleeding significantly was correlated to duration of surgery (r=0.70, p=0.001) and patient's age (r=0.23, p=0.44). CONCLUSION: perioperative management particularly blood loss could deteriorate patients outcome and length of stay in ICU and hospital. Infections in ICU could deteriorate outcomes.

A Rare Patient with Facial Duplication.

Facial duplication, in whole or in part, is a very rare malformation. It may be symmetrical or asymmetric. Those cases that have been reported in the literature constitute a spectrum extending from simple nasal duplication to complete separation of 2 faces. Up to now there are some reports of eye, nose, mandible, or maxilla duplication separately. But there is no report of oral orifice or lips duplication. The present article reports a case of a newborn girl who presented with 2 mouths and also duplication of zygoma and maxilla. Then, we describe her stages of treatment from birth through now that she has 20 years.