Fat grafting in patients with cleft lip and palate: A systematic review.

This systematic review aims to compare different fat-grafting techniques for cleft lip and palate repair. A search was conducted in PubMed, Embase, Cochrane Library, gray literature and reference lists of selected articles. A total of 25 articles were included, 12 on closure of palatal fistula and 13 on cleft lip repair. The rate of complete resolution of palatal fistula ranged from 88.6% to 100% in studies with no control group, whereas in comparative studies patients receiving a fat graft showed better outcomes than those not receiving a graft. Evidence suggests that fat grafting can be indicated for the primary and secondary repair of cleft palate, with good results. The use of dermis-fat grafts in lip repair was associated with gains in surface area (11.5%), vertical height (18.5%-27.11%), and lip projection (20%). Fat infiltration was associated with increased lip volume (6.5%), vermilion show (31.68% ± 24.03%), and lip projection (46.71% ± 31.3%). The available literature suggests that fat grafting is a promising autogenous option for palate and fistula repair and for improvement of lip projection and scar aesthetics in patients with cleft. However, to develop a guideline, further studies are needed to confirm whether one technique is superior to the other.

Perceived Age and Personality Profiling after Orthognathic Surgery.

BACKGROUND: Recent studies suggest that orthognathic surgery can improve facial age and personality profiling. The authors expand on these findings by assessing the role of patient facial profile and sociodemographics on perceived changes following surgery. METHODS: Preoperative and postoperative images of 65 patients operated on by a single surgeon were randomly assorted and rated by 30 respondents. Patient facial profiles were categorized as convex, concave, or straight. Paired and unpaired t tests were used to assess differences preoperatively and postoperatively. Multivariate regression and post hoc receiver operating characteristic curve analyses were used to quantify the influence of various patient factors. RESULTS: Significant decreases in perceived age were seen following orthognathic surgery overall (-1.31 years; p < 0.01) and in the straight (-1.10 years; p = 0.02) and convex (-1.80 years; p ≤ 0.01) subgroups. After controlling for patient sociodemographics, there were no significant differences in age change based on facial profile. Older age at the time of surgery was independently associated with greater perceived age changes ( p = 0.04); older patients (>26.5 years, determined by receiver operating characteristic curve) experienced greater net decreases in perceived age in comparison to younger patients (-2.0 years versus -1.2 years; p < 0.01). Improvements were seen in overall attractiveness ( p < 0.01) and in each tested personality characteristic following surgery ( p < 0.01). These differences were not significantly associated with different patient sociodemographics or facial profile. CONCLUSIONS: The authors' data add to the growing base of evidence that orthognathic surgery improves patient-perceived age and personality. Significant decreases in perceived age are more likely to be gained by patients undergoing surgery at an older age. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Mandibular Distraction Osteogenesis in Robin Sequence Using Three-Dimensional Analysis and Planning.

SUMMARY: The optimal management of patients with Robin sequence may include neonatal mandibular distraction osteogenesis, which has been used to achieve excellent functional and aesthetic outcomes in appropriate patients. This article and video vignette depict the treatment of micrognathia and airway obstruction secondary to Robin sequence, demonstrating the planning and surgical approach of the senior author (D.M.S.) using mandibular distraction osteogenesis.

Perceived Age and Attractiveness Using Facial Recognition Software in Rhinoplasty Patients: A Proof-of-Concept Study.

ABSTRACT: Artificial intelligence (Al)-based analyses may serve as a more objective tool for measuring cosmetic improvements following aesthetic plastic surgery. This preliminary proof-of-concept study utilized a novel commercial facial recognition software to assess perceived changes in age and attractiveness among patients receiving rhinoplasty.This study was a retrospective evaluation of three-dimensional photographs of patients who underwent rhinoplasty by the senior author (DS). Both pre- and post-operative (> 12-month follow-up) Vectra three-dimensional images (Canfield Scientific, Parsippany, NJ) were assessed using Haystack AI Software (Haystack AI, New York, NY). Facial attractiveness (score 1-10) and apparent age were predicted. A retrospective chart review of demographic variables was additionally performed. Paired t tests were used to compare age and attractiveness scores before and after surgery. Multivariate linear regression was performed to identify factors associated with age and attractiveness scores.One hundred twenty-four patients receiving rhinoplasty met the study criteria (average age: 35.58). Overall, rhinoplasty was associated with increases in Al-rated attractiveness (+0.28, P = 0.03) and decreases in perceived age relative to the patient's true age (-1.03 years, P = 0.03). Greater decreases in postoperative perceived age were achieved in patients who appeared older than their actual age preoperatively ( P < 0.001).Facial recognition software was successfully used to evaluate improvements in perceived age and attractiveness in patients undergoing aesthetic rhinoplasty. Patients were perceived by the software as younger and more attractive following rhinoplasty. Age reversal was greatest among patients who appeared much older than their actual age at the time of surgery.Level of Evidence: IV.

Trends in industry-sponsored research in plastic surgery since implementation of the Sunshine Act.

Financial contributions from industry for physician-led research have been historically challenging to study in plastic surgery. However, as mandated by the Physician Payments Sunshine Act of 2013, the Open Payments Database (OPD) has increased transparency in payments from industry to physicians. This study aimed to analyze trends in industry-sponsored research funding for plastic surgeons. Using the OPD, research payments from industry made to plastic surgeons from 2014 to 2018 were examined. Total payments and number of payments were recorded by recipient's census region (e.g., Northeast, Midwest, South, West) and therapeutic area (e.g., breast prosthetics/reconstruction, wound healing/tissue engineering, software/instrumentation, biologics, cosmetics/injectables). Payments totaled across 5 years in each therapeutic area for each region were also analyzed. Location of company U.S. headquarters and therapeutic area were recorded. Statistical analyses were performed using SAS 9.4. Brown-Mood test, t test, Kruskal-Wallis, Mann-Whitney, and linear regression tests were used. Aggregated over 5 years, the greatest payment value was allocated to wound healing/tissue engineering, whereas the number of payments was highest in breast prosthetics/reconstruction. Private plastic surgeons receive significantly higher payments compared to academic plastic surgeons. With such findings, greater transparency and additional years of OPD data may provide further insight into industry influence on physician-led research in plastic surgery.

Outcomes in Pediatric Maxillofacial Reconstruction With Vascularized Fibular Flaps: A Systematic Review.

BACKGROUND: The purpose of this study was to examine the complications and outcomes after maxillofacial reconstruction using the free fibular flap in the pediatric population. METHODS: A systematic review and descriptive analysis were conducted using data variables, including study characteristics; patient characteristics; postoperative complications (major and minor); surgical revision; and dental rehabilitation. RESULTS: The systematic review resulted in 1622 articles, 55 of which met inclusion criteria for this study. The 55 articles consisted of 17 case series and 38 case reports with level III/IV and level V of evidence, respectively. Of the 155 identified pediatric patients, the rate of major complications was 13.5% and minor complications was 24.5%. The most common complication was mild growth distortion (n = 7) at the recipient site. Complications at the donor site were less common. During follow-up, 29 patients (18.7%) underwent or awaited surgical revision, and 43 patients (27.7%) underwent or awaited dental rehabilitation. CONCLUSIONS: Our study suggests that the free fibular flap for pediatric maxillofacial reconstruction is safe and reliable. Additionally, surgical revision to correct the functional impairments resulting from primary reconstruction using the free fibular flap is relatively common.

Race-Based Differences in the Utilization and Timing of Secondary Cleft Procedures in the United States.

Primary CL/P repair, revisions, and secondary procedures-cleft rhinoplasty, speech surgery, and alveolar bone grafting (ABG)-performed from 2014-2018 were identified from the Pediatric National Surgical Quality Improvement Program (NSQIP) database. Utilization estimates were derived via univariable and multivariable logistic regression. A Kruskal-Wallis rank-sum test and multivariable linear regression were used to assess differences in timing for each procedure cohort.The primary outcome measures were the odds of a patient being a certain race/ethnicity, and the age at which patients of different race/ethnicity receive surgery.There were 23 780 procedures analyzed. After controlling for sex, diagnosis, and functional status, there were significant differences in utilization estimates across procedure groups. Primarily, utilization was lowest in patient who were Black for cleft rhinoplasty (OR = 0.70, P = .023), ABG (OR = 0.44, P < .001) and speech surgery (OR = 0.57, P = .012), and highest in patients who were Asian patients in all surgery cohorts (OR 2.05-4.43). Timing of surgery also varied by race, although differences were minimal. CONCLUSIONS: Estimates of utilization and timing of secondary cleft procedures varied by race, particularly among patients who were Black (poor utilization) or Asian (high utilization). Further studies should identify the causes and implications of underutilized and/or delayed cleft care.

Clinical Practice Trends and Postoperative Outcomes in Primary Cleft Rhinoplasty.

PURPOSE: Optimal correction of the cleft nasal deformity remains challenging. The purpose of this study was to examine the practice patterns and postoperative course of patients undergoing cleft lip repair with rhinoplasty compared to those who have primary lip repair without rhinoplasty. METHODS AND MATERIALS: A retrospective cohort study was conducted based on the Kids' Inpatient Database. Data were collected from January 2000 to December 2011 and included infants aged 12 months and younger who underwent cleft lip repair. The predictor variable was the addition of rhinoplasty at primary cleft lip repair. Primary outcome variables included hospital setting, year, and admission cost, while secondary outcome variables included length of stay and postoperative complication rate. Independent t-tests and chi-squared tests were performed. Continuous variables were analyzed by multiple linear regression models. RESULTS: The study sample included 4559 infants with 1422 (31.2%) who underwent primary cleft rhinoplasty. Over time, there was a significant increase in the proportion of cleft lip repairs accompanied by a rhinoplasty (p < .01). A greater proportion of patients with unilateral cleft lips received simultaneous rhinoplasty with their lip repairs (33.8 vs 26.0%, p < .01). This cohort had a significantly shorter length of stay (1.6 vs 2.8 days, p < .01) when compared to children that underwent cleft lip repair alone. CONCLUSIONS: Performing primary cleft rhinoplasty is becoming more common among cleft surgeons. Considering comparable costs and complication rates, a rhinoplasty should be considered during the surgical treatment planning of patients with cleft nasal deformities.

A Comprehensive Single-Center Analysis of Postoperative Nausea and Vomiting Following Orthognathic Surgery.

BACKGROUND: Postoperative nausea and vomiting (PONV) remains a major clinical end-point for directing enhanced recovery after surgery (ERAS) protocols in facial plastic surgery. This study aimed to identify risk factors for PONV and evaluate strategies for PONV reduction in orthognathic surgery patients. METHODS: A retrospective cohort study was performed among patients receiving orthognathic surgery at our institution from 2011 to 2018. Patient demographics, surgical operative and anesthesia notes, medications, and nausea/vomiting were assessed for each patient. The amount of opioid analgesia given both perioperatively and postoperatively was recorded and converted into morphine equivalents (MEQ). Stepwise regression analysis was used to identify significant risk factors for PONV. Post hoc analyses were employed to compare PONV among patients based on MEQ dosage and antiemetic prophylaxis regimes. RESULTS: A total of 492 patients were included; mean age was 23.0 years (range: 13-60); 54.4% were female. The majority of patients received concurrent Le Fort I osteotomy, BSSO, and genioplasty (70.1%). During hospitalization, 59.4% of patients experienced nausea requiring antiemetic medications and 28.4% experienced emesis. Stepwise regression yielded Apfel scores (P = 0.003) and postoperative opioids (P = 0.013) as the strongest predictors of PONV. Post hoc analyses showed that undertreatment with prophylactic antiemetics (based on Apfel) predicted increased PONV (+12.9%, P = 0.020), and that lower postoperative MEQs (<28.0) predicted decreased PONV (-11.8%, P = 0.01). CONCLUSIONS: The study findings confirm the high incidence of PONV among orthognathic surgical patients and stratify previously reported PONV risk factors. More aggressive utilization of antiemetic medications and decreased dependence on opioid analgesia may decrease nausea/vomiting following orthognathic surgery.

Does Initial Cleft Lip Width Predict Final Aesthetic Outcome?

A natural aesthetic appearance of the lip and a favorable scar are essential goals of cleft lip repair. Wider clefts intuitively pose a greater technical challenge; however, the relationship between initial width and aesthetic outcome remains controversial. The current study aimed to determine whether lip adhesion can help wider clefts achieve safe, consistent aesthetic outcomes. METHODS: A retrospective cohort study was conducted on unilateral cleft lip patients who underwent lip repair within a 2-year period by the senior author. Subjects were divided into three groups based on cleft severity: (1) wide complete clefts that required lip adhesion before definitive repair, (2) narrower complete clefts that did not require lip adhesion, and (3) incomplete clefts. Aesthetic outcomes related to the vermillion and upper lip scar were rated by 48 blinded observers. Statistical analysis was performed using Kruskal-Wallis and Mann-Whitney tests. Nasal outcomes were not assessed. RESULTS: Seventeen patients were included in the study: five in group 1, six in group 2, and six in group 3. Patients with the widest clefts did not have inferior results compared with the other groups. In fact, they had statistically significantly higher aesthetic scores in all scar-related outcomes compared with those in groups 2 and 3 (P < 0.0001). CONCLUSIONS: This study suggests that a wide cleft does not necessarily foreshadow a poor surgical outcome. In fact, wide clefts may have pleasing results, and the use of a staged lip adhesion approach can be useful for achieving the desired outcome in wider clefts.

Decreasing Inpatient Opioid Use Following Orthognathic Surgery.

PURPOSE: Strategies to decrease postoperative opioid use are important for mitigating the immediate and long-term risks associated with their use. We aimed to investigate the impact of perioperative various factors on inpatient opioid needs for patients undergoing orthognathic surgery. METHODS: This was a retrospective cohort study of all patients who underwent orthognathic surgery performed by the senior author from 2012 to 2018. Patients were grouped into intravenous (IV) acetaminophen and no-IV acetaminophen cohorts. Opioid medications received by patients during hospital stay were converted to mean morphine equivalents (MME) for comparison. Additional factors that influenced opioid consumption, such as transexamic acid (TXA) and postoperative nausea and vomiting (PONV), were identified using univariate analysis. Factors found to have statistical significance were added to a multivariate linear regression model. RESULTS: 319 patients were included. Those who received IV acetaminophen had lower rates of total opioid use (57.3 versus 74.8 MME; P = 0.002) and postoperative opioid use (24.0 versus 37.7 MME; P < 0.001). Perioperative prothrombotic agents, such as TXA, were associated with lower total and postoperative MME (P = 0.005, P = 0.002). Multivariate regression analysis showed that increased PONV resulted in increased postoperative opioid use, whereas perioperative acetaminophen lowered total and postoperative quantities. CONCLUSIONS: Perioperative IV acetaminophen is an effective method for decreasing inpatient opioid analgesia after orthognathic surgery. Intravenous TXA and PONV control may provide additional benefit to decreasing inpatient opioid consumption. More research as to the mechanisms and ideal clinical applications for both IV acetaminophen and TXA are warranted.

Spatial Analysis of the Temporomandibular Joint and Condyle Following Mandibular Distraction in Robin Sequence.

ABSTRACT: To comprehensively assess changes in temporomandibular joint and mandibular condyle morphology in Robin sequence (RS) patients undergoing mandibular distraction osteogenesis (MDO). A retrospective analysis of pediatric patients with RS and functional temporomandibular joints who underwent MDO by a single surgeon was performed. Preoperative and postoperative computed tomography (CT) scans were morphometrically analyzed three-dimensional in 3-matic and Mimics (Materialise). Comparative analysis was performed using Wilcoxon signed-rank tests. Fourteen RS patients were included (28 condyles, 56 CT scans), 78% male and 22% females. The mean age at surgery was 9.4 weeks (range 1.6-46.7 weeks). The average age at initial CT was 5.3 days (range 0-11 days). The mean time interval for CT scan before MDO and after hardware removal were 8.8 ±â€Š6.4 days and 11.2 ±â€Š25.8 days, respectively. Rotatory changes of the condyle revealed a significantly decreased horizontal angle following MDO (-7.55°, 95% confidence interval -11.13° to -3.41°; P < 0.001). Anteroposteriorly, the angle between condylar process and ramus (incline) increased significantly (14.14°, 95% confidence interval 10.71°-19.59°; P < 0.001). Intragroup analysis revealed no difference between left versus right condylar position measurements. The condyle itself increased in size and length and the intercondylion distance increased post-MDO. There were no complications and all patients achieved relief of airway obstruction without tracheostomy. Morphologic and positional changes of the mandibular condyle following MDO in RS patients parallel changes that occur during normal development in non-RS patients. As a result, MDO may facilitate normal condylar morphology and function in RS patients.

Orthognathic Surgery to Improve Facial Profile: Assessment, 3-Dimensional Planning, and Technique.

A concave profile with class III malocclusion is most often due to a combination of maxillary hypoplasia and mandibular hyperplasia. Surgical correction entails normalization of jaw positions and is more challenging in the setting of concurrent asymmetry and open bite. Treatment should optimize both facial harmony and occlusion. Orthognathic surgery for class III deformities occurs at skeletal maturity and should address all aspects of the condition while preventing unnecessary emotional stress from delayed treatment. In this article, the authors describe the 3-jaw orthognathic surgery technique to address maxillary hypoplasia, mandibular prognathism, open bite, and mandibular asymmetry in a single procedure. The process of preoperative 3-dimensional (3D) virtual surgical planning, detailed surgical technique, fat grafting, and a comparison of preoperative and postoperative 3D aesthetic outcomes is presented. Additionally, a retrospective review of postoperative outcomes of 54 patients who received 3-jaw orthognathic surgery is presented as well.

Aesthetic Rhinoplasty: Technique, 3-Dimensional Simulation, and Outcome Assessment.

Communication of goals and realistic expectations between the surgeon and patient is a crucial step of aesthetic rhinoplasty. Three-dimensional (3D) imaging technology allows for sharing of simulated outcomes in the office setting, thereby facilitating this process. This article highlights the use of 3D rhinoplasty simulation in preoperative assessment and the senior author's preferred surgical technique in open rhinoplasty.

Crushed Cartilage and Autologous Fat for Dorsal Nasal Refinement.

BACKGROUND: Dorsal contour irregularities remain a potential undesirable sequela of rhinoplasty. Use of dorsal onlay grafts can camouflage such irregularities. In this article, a novel technique for dorsal onlay grafting utilizing crushed cartilage mixed with autologous fat is described. This study aims to assess long-term graft retention and aesthetic outcomes with this technique. METHODS: Patients with >18-month follow-up who underwent primary open rhinoplasty with the described technique were reviewed. Three-dimensional photographs taken at multiple timepoints were overlaid with volumetric subtraction used to quantify graft retention. The Rhinoplasty module of the FACE-Q was completed by each patient, and the Rhinoplasty Assessment Scale Photographic (RASP) was completed by surgeon reviewers. Pre- and postoperative changes in dorsal height as well as RASP scores were compared with paired t-tests. Changes in BMI, dorsal volume, and dorsal height were compared with linear regression. P values <0.05 were considered significant. RESULTS: Fourteen patients were included, mean age 32. Mean intermediate and final follow-up was 17.8 months and 28.9 months, respectively. There were no statistically significant dorsal height change (mean = 0.0 mm, p = 0.91) and minimal dorsal volume change (mean = 0.02 cm3, range:  0.08 to 0.13). Patients reported a high degree of satisfaction with facial/nasal appearance and psychological/social functioning. There was a statistically significant improvement in RASP scores (p < 0.001) postoperatively. CONCLUSION: Crushed septal cartilage mixed with autologous fat is an effective option for dorsal nasal onlay in rhinoplasty and is associated with excellent graft retention, patient satisfaction, and nasal aesthetics. LEVEL OF EVIDENCE IV: 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.

Conformity of the Virtual Surgical Plan to the Actual Result Comparing Five Craniofacial Procedure Types.

BACKGROUND: The "accuracy" of virtual surgical planning across multiple procedure types is not known. The authors aimed to compare the planned outcome from virtual surgical planning to the actual postoperative outcome for five craniofacial procedure types performed by a single surgeon: implant cranioplasty, cranial vault remodeling, orthognathic surgery, mandible reconstruction, and mandibular distraction. METHODS: Stereolithography formats were obtained from virtual surgical planning and compared to postoperative computed tomographic scans for consecutive patients who underwent one of the five procedure types. Volumetric renderings of the operated bony region of interest were overlaid and compared using a Boolean operation to compute conformity (as a percentage of the region of interest). Conformity across procedure type was analyzed using analysis of variance and post hoc Bonferroni analysis, where appropriate. RESULTS: One hundred thirty patients were included (51.5 percent male and 49.5 percent female; mean age, 27 years; 59 orthognathic surgery, 32 cranial vault remodeling, 16 mandible reconstruction, 12 mandibular distraction, and 11 implant cranioplasty patients). The highest tier of conformity was obtained for implant cranioplasty (median, 76.8 ± 10.3 percent) and mandible reconstruction (mean, 69.4 ± 11.2 percent), followed by orthognathic surgery (mean, 55.0 ± 7.3 percent) and mandibular distraction (median, 41.9 ± 20.3 percent), followed by cranial vault remodeling (mean, 22.2 ± 12.1 percent) (p < 0.001 between tiers and p > 0.05 among tiers). CONCLUSIONS: Virtual surgical planning resulting in custom permanent implants and intraoperative guides provides more predictable results compared to virtual surgical planning used for procedures involving higher degrees of skeletal repositioning and postoperative movement (i.e., mandibular distraction and nonrigid cranial vault remodeling). In cases with expectedly lower conformity, excellent outcomes can be achieved with sound intraoperative judgment.