Evidence-Based Practices in Cleft Palate Surgery.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: (1) Understand the embryologic origins, cause, and incidence of cleft palate. (2) Review the anatomy and common classifications of cleft palate and associated defects. (3) Describe surgical techniques for palatoplasty and understand their respective indications. (4) Gain an awareness of general perioperative care considerations, timing of repair, and risk factors for and operative mitigation of complications. SUMMARY: Cleft palate affects 0.1 to 1.1 per 1000 births, with a higher incidence in certain ethnic groups but affecting both sexes equally. Cleft palate may occur in isolation or in combination with cleft lip or in association with other congenital anomalies including various syndromes. The goals of cleft palate repair are to anatomically separate the oral and nasal cavities for normal feeding and improved speech and minimize the risk of oronasal fistulas, velopharyngeal dysfunction, and disruption of facial growth. This review discusses the incidence, causes, and classification of cleft palate; surgical techniques for palatoplasty and perioperative patient management; and complications of palatoplasty.

Prolonged Inflammatory Reaction to Fractured Calcium Phosphate Cement Cranioplasty Secondary to Sequestration Within the Diploe.

Calcium phosphate cement remains the choice biomaterial for cranial reconstruction and augmentation in pediatric patients after 90% completion of cranial growth, especially compared with other nonallograft alternatives. While trauma to the site of calcium phosphate augmentation is a known risk for cement fracture, subsequent micro-fragmentation and sequestration of the cement beneath the fracture site can produce a localized inflammatory reaction that requires surgical intervention to adequately address. The authors present the course of a patient undergoing a prolonged inflammatory reaction to calcium phosphate micro-fragmentation after trauma to the site of previous augmentation performed to mend bitemporal hollowing. Cement microfragmentation and migration through an associated nondisplaced fracture of the outer table required extensive debridement of the underlying diploe before the resolution was achieved. This case illustrates the need for appropriate evaluation in cases of trauma to areas with cement to mitigate the need for extensive surgical management.

Revisiting the U-Shaped Elevator for Zygomaticomaxillary Fracture: Study and Comparison of Elevators for Zygomaticomaxillary Fracture Reduction.

The authors present the case of a 15-year-old male who sustained a unilateral zygomaticomaxillary complex fracture and underwent open reduction and rigid internal fixation, for which a U-shaped elevator was utilized. The authors discuss techniques in reduction and fixation of zygomaticomaxillary complex fractures, focusing on the use of various elevators during reduction, including straight-type and curved elevators. The U-shaped elevator is a handheld tool with bilateral symmetrically curved ends that is seldom used, despite its specific benefits including nonslip serrated tips, symmetrical nature that allows for direct loading needed for accurate reduction, visualization of the fracture site, and avoidance of tissue compression during elevation.

Palliative lower leg reconstruction.

Palliative care is a multidisciplinary field that aims to relieve physical pain and psychological suffering with the goal of improving quality of life rather than focusing on curing or prolonging life. Plastic surgeons may have a role in this near end-of-life care through palliative reconstruction. The use of palliative reconstruction has been frequently described in the setting of head and neck and thoracic malignancies However, there is a paucity in the literature about the role of palliative reconstruction in the lower extremity. In this review, we provide a summary of the current literature in support of the benefits of palliative reconstruction in the lower extremity as well as three case examples to demonstrate scenarios in which palliative lower extremity reconstruction may be used for select patients. In order to determine whether a patient may benefit from palliative reconstruction to merit its risks, the treatment goals and limitations must be assessed on a case-by-case basis in collaboration with the patient. Careful patient selection, focus on patient's ambulatory and personal goals, and minimizing donor site morbidity are important considerations in palliative reconstruction of the lower extremity. Together with a multidisciplinary approach, plastic surgeons can provide valuable contributions to improve the quality of life for certain palliative oncological patients by providing palliative reconstruction of the lower extremity.

Evidence-Based Practices in Facial Reanimation Surgery.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Describe the causes and preoperative evaluation of facial paralysis. 2. Discuss techniques to restore corneal sensation and eyelid closure, elevation of the upper lip for smile, and depression of the lower lip for lip symmetry. 3. Outline treatment goals, surgical treatment options, timing of repair, and other patient-specific considerations in appropriate technique selection. SUMMARY: Congenital facial paralysis affects 2.7 per 100,000 children; Bell palsy affects 23 per 100,000 people annually; and even more people are affected when considering all other causes. Conditions that impair facial mimetics impact patients' social functioning and emotional well-being. Dynamic and static reconstructive methods may be used individually or in concert to achieve adequate blink restoration, smile strength and spontaneity, and lower lip depression. Timing of injury and repair, patient characteristics such as age, and cause of facial paralysis are all considered in selecting the most appropriate reconstructive approach. This article describes evidence-based management of facial paralysis.

Practice Management in Plastic Surgery: A Survey Comparing Skills Acquired During Residency and Those Applied in Independent Practice.

BACKGROUND: Understanding the extent of practice management education within plastic surgery residency may serve to enhance elements of current curricular training. METHODS: A survey was sent to private practice plastic surgeons who completed training between 2008 and 2020. The survey elicited opinions about their practice management training during residency and experiences as attendings. RESULTS: Forty-nine private practice plastic surgeons completed the survey with a mean of 5 years in practice. 96% of respondents entered private practice immediately following their final training program. 48% of respondents cited "autonomy" as the primary reason for pursuing private practice. Surgeon's narrative responses regarding practice management skills learned outside of residency revealed the most grouped into the following themes: "Finance, Marketing, Accounting, Human Resources (HR), Operations" (n = 19), "Hiring, Firing, Employee Management" (n = 17), "Insurance Coverage, Billing, Coding" (n = 13), "General Skills" (n = 12), and "Starting & Running a Practice" (n = 11). 71.4% of respondents reported that they learned practice management skills from on-the-job training. Almost all respondents felt that there should be formal training in practice management (n = 35), with "Finance & Accounting" and "Management" cited as the most important skills to learn as a plastic surgeon. 51% of current surgeons felt allowing senior residents additional opportunities to rotate in private practices was the best way to enhance residency curricula. CONCLUSION: Incorporating practice management skills into training curricula will address the demonstrated knowledge gap and accelerate plastic surgeons' career growth. LEVEL OF EVIDENCE V: 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 .

Hostile Scalp Wound Reconstruction Using Acellular Dermal Matrix for Soft Tissue Augmentation.

The use of acellular dermal matrix (ADM) is well established in scalp burn reconstruction. However, its application in at-risk patients and hostile scalp wounds remains controversial and only described in the pediatric setting. This study aims to describe the pre-operative factors leading to the decision to use ADM in adult patients undergoing complex scalp reconstruction, and to describe the postoperative outcomes including wound breakdown and need for reoperation. This is a retrospective case series of patients undergoing scalp reconstruction with use of ADM. Data was collected from operations performed by a single surgeon over a period from January 2017 to October 2018. Nine patients underwent scalp reconstruction including placement of ADM during the study period. Seven patients were female, and median age was 64 years. Six patients had undergone prior craniotomies and three had undergone prior craniectomies for a variety of etiologies including neoplastic disease (n = 4), aneurysmal disease (n = 2), and trauma (n = 3). Wound breakdown or delayed wound healing necessitated reconstructive operations in all patients, 4 of whom had exposed/infected hardware that required removal. The median area of soft tissue defects was 30 cm. Two of the 4 patients with both benign and malignant tumors had been treated with radiation therapy, compromising the quality of the remaining adjacent scalp. Acellular dermal matrix was used in each setting to augment or buttress thin scalp. In 4 patients cranioplasty implants, hardware, or mesh were replaced concurrently. Two patients proceeded onto staged alloplastic cranioplasty without complication. Median follow up was 115 days. During follow up, only 1 patient suffered a major complication requiring reoperation to explant an osteomyelitic bone flap. Acellular dermal matrix can serve as an adjunct in hostile scalp reconstruction. Augmenting the areas of compromised scalp, especially over alloplastic cranioplasty material, can minimize the likelihood of future hardware exposure. Our study demonstrates its use in high-risk scalp wounds defined by frequent operation, chronic infection, and radiation.