What's New in Cleft Palate and Velopharyngeal Dysfunction Management: An Update.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: (1) Describe the pathology of velopharyngeal dysfunction (VPD) as it relates to patients with a cleft palate. (2) Use the perceptual speech assessment and objective diagnostic tools to determine the presence or absence of VPD. (3) Describe the surgical options available for the treatment of patients with VPD. (4) Develop an evidence-based, customized treatment plan for VPD founded on objective considerations. SUMMARY: To treat patients with cleft palate effectively, the surgeon must understand the diagnosis and surgical management of cleft-associated velopharyngeal dysfunction. The authors review diagnostic modalities including perceptual speech assessment, video nasendoscopy, fluoroscopy, magnetic resonance imaging, and nasometry. Surgical treatments including palatal lengthening with buccal myomucosal flaps, conversion Furlow palatoplasty, sphincter pharyngoplasty, and pharyngeal flap are discussed. Selection of an optimal surgical treatment is addressed.

Malignant Melanoma in Older Adults: Different Patient or Different Disease?

Objective In this study, we aimed to compare the clinical outcomes between older and younger patients with melanoma and to evaluate for differences in tumor genetic makeup that might explain differences in clinical behavior between older and younger cohorts. Materials and methods A consecutive sample of patients diagnosed with melanoma at a single institution from 1984 to 2019 was categorized by age into younger, middle, and older cohorts. Tumor characteristics, melanoma-specific survival, and recurrence-free survival were assessed while accounting for differential follow-up and death from other causes using Kaplan-Meier analysis with log-rank testing. Results A total of 4378 patients were included in the study. Older patients presented with a higher incidence of T3 and T4 tumors, and a lower incidence of T1 tumors (p<0.001). The same group of patients had a lower nodal positivity at any given Breslow thickness (p<0.01). Melanoma-specific survival was lower for older patients with T2 tumors (p=0.046). There was no difference in recurrence-free survival among all age groups and tumor thicknesses (p>0.05). For patients with a given genetic profile, the melanoma-specific survival and recurrence-free survival were equivalent across ages. BRAF was the most common driver in the younger group, while NRAS and other mutations increased in prevalence as age rose. Conclusions Older adults have decreased melanoma-specific survival for T2 tumors and lower nodal positivity, suggesting a different pattern of metastatic progression. The mutational drivers of cutaneous melanoma change with age and may play a role in the different metastatic progression as well as the differential melanoma-specific survival across all age cohorts.

A Preliminary Management Algorithm for Velopharyngeal Insufficiency in Cleft-Orthognathic Patients.

PURPOSE: Patients born with a cleft palate often suffer from velopharyngeal insufficiency (VPI) due to the soft palate musculature's abnormal structure. Surgical correction of the palate at a young age can hinder maxillary growth, requiring surgical correction of the maxillomandibular discrepancy at skeletal maturity. Orthognathic surgery can then cause or further exacerbate VPi in these patients. The purpose of this paper is to assess cleft-orthog-nathic patients under the lens of persistent or newly-developed VPi, to understand outcomes and generate a targeted management algorithm. METHODS: A retrospective study was performed inspecting cleft-orthognathic patients presenting to a single surgeon. Patients with sufficient follow-up were placed into predefined algorithmic cohorts by their VPi development pattern in relation to orthognathic surgery. They were further stratified into groups by level of adherence to our algorithm to evaluate VPi outcomes. Demographic factors, risk factors, and outcomes were compared between groups via Welch t test and Fisher exact test. RESULTS: Fifty-one patients were examined, including 16 with VPI. Velopharyngeal insufficiency fully resolved amongst all algorithmically adherent patients and remained in nonadherent patients ( P  < 0.001). CONCLUSIONS: Our targeted algorithm may improve symptoms and the management of VPI in cleft-orthognathic patients. Multi-centered studies with larger sample sizes and prospective studies are encouraged to validate our proposed treatment algorithm further.

Aesthetic Repair of Unilateral Cleft Lip using the Modified Inferior Triangle and Adjunctive Techniques.

SUMMARY: Surgical management of unilateral cleft lip is challenging. Correction requires a comprehensive approach to ensure optimal aesthetic outcomes. Various techniques have been proposed for the repair of cleft lip. This article and video vignette highlight the senior author's (D.S.) preferred method for repair of a unilateral cleft lip using a modified inferior triangle technique, a Noordhoff triangular flap for vermillion augmentation, orbicularis oris chemodenervation to reduce tension at the repair site, and autologous fat grafting for lip sculpting.

Treacher Collins Mandibular Distraction.

Treacher Collins syndrome (TCS) is a genetic disorder that presents with a variety of craniofacial deformities. One classic feature of TCS is a steep, counterclockwise rotation of the occlusal plane, and microretrognathia with bony deficiencies in both the body and ramus of the mandible. This morphology commonly necessitates reconstruction by the craniofacial surgeon. This article discusses strategies and considerations for surgically correcting the mandibular deformity associated with TCS using mandibular distraction osteogenesis and other related techniques. The proper implementation of these techniques can yield excellent results that greatly improve quality of life in this challenging patient population.

Hospital Volume Improves Primary, Revision, and Delayed Cleft Palate Repair.

BACKGROUND: High volume centers (HVC) is commonly associated with increased resources and improved patient outcomes. This study assesses efficacy and outcomes of high volume centers in cleft palate repair. METHODS: Cleft palate procedures were identified in the Kids' Inpatient Database from 2003-2009. Demographics, perioperative factors, co-morbidities, and complications in HVC (90th percentile, >48 cases/year) and non-high volume centers (NHVC) were compared across various cohorts of cleft repair. RESULTS: Four thousand five hundred sixty-three (61.7%) total cleft palate surgeries were performed in HVC and 3388 (38.3%) were performed in NHVC. The NHVC treated a higher percentage of Medicaid patients (P = 0.005) and patients from low-income quartiles (P = 0.018). HVC had larger bedsizes (P <0.001), were more often government/private owned (P <0.001), and were more often teaching hospitals (P <0.001) located predominantly in urban settings (P <0.001). The HVC treated patients at younger ages (P = 0.008) and performed more concurrent procedures (P = 0.047). The most common diagnosis at HVC was complete cleft palate with incomplete cleft lip, while the most common diagnosis at NHVC was incomplete cleft palate without lip. Overall, length of stay and specific complication rates were lower in HVC (P = 0.048, P = 0.042). Primaries at HVCs showed lower pneumonia (P = 0.009) and specific complication rates (P = 0.023). Revisions at HVC were associated with older patients, fewer cardiac complications (P = 0.040), less wound disruption (P = 0.050), but more hemorrhage (P = 0.040).

Body mass index as a continuous predictor of outcomes after expander-implant breast reconstruction.

BACKGROUND: Studies show that obesity is a risk factor for complications after expander/implant breast reconstructions. However, reports vary on the precise threshold of body mass index (BMI) as a predictor of heightened risk. We endeavored to link BMI as a continuous variable to overall complications in a single-surgeon series of expander-implant reconstructions. METHODS: From 399 patients undergoing expander-implant reconstruction, 551 breasts were stratified to normal weight, overweight, and obese groups for analysis and comparison with previous studies. Logistic regression was performed to predict changes to risk profile per increment of BMI. RESULTS: Complication rates for obese and overweight patients were significantly greater than for normal weight patients, that is, 21.1% and 24.0% versus 10.4%, respectively (P < 0.005). A unit increase in BMI predicted a 5.9% increase in the odds of a complication occurring, and 7.9% increase in the odds of reconstruction ending in failure. CONCLUSIONS: By expanding the analysis of BMI to include patients who do not meet the traditional definition of obesity (BMI ≥ 30 kg/m), we demonstrated that simply overweight patients (25 ≤ BMI < 30 kg/m) had an elevated complication rate. Moreover, through regression analysis, we established that BMI as a continuous variable predicts outcomes from expander-based breast reconstruction.

The impact of body mass index on reduction mammaplasty: a multicenter analysis of 2492 patients.

BACKGROUND: Reduction mammaplasty is commonly performed in women who are considered obese by the body mass index (BMI) classification of the World Health Organization. OBJECTIVES: The authors compare complication rates among breast reduction patients, stratified by BMI, across multiple institutions. METHODS: A retrospective analysis was performed of all reduction mammaplasties in the database of the National Surgical Quality Improvement Program for 2006 through 2010. Demographic, comorbidity, and BMI data were collected. Data on medical and surgical complications, reoperation, and mortality were collected through 30 days postsurgery. RESULTS: Of 2492 patients, 55% were considered obese (BMI >30). The overall rate of surgical complications was 4.0%, increasing from 2.4% for BMI <25 to 7.1% for BMI >45 (P = .006), with an adjusted odds ratio of 2.97 for BMI >45 versus BMI <25. The most common surgical complication was superficial surgical site infection; it was found in 2.9% of patients, increasing from 2.1% for BMI <25 to 5.1% for BMI >45 (P = .03). The medical complication rate was 0.6%, and the reoperation rate was 2.1%. There were no deaths. A maximal point analysis showed that BMI ≥39 was associated with a significantly higher complication rate, with an odds ratio of 2.38. CONCLUSIONS: Reduction mammaplasty is a safe surgical procedure, even when performed on obese patients. However, patients with higher BMI have a greater risk of surgical site complications. This risk should be discussed preoperatively with obese patients.

Comparing thirty-day outcomes in prosthetic and autologous breast reconstruction: a multivariate analysis of 13,082 patients?

BACKGROUND: There is a paucity of multi-institutional data that directly compares short term outcomes of autologous and prosthetic breast reconstruction. The National Surgical Quality Improvement Program provides a unique data platform for evaluating peri-operative outcomes of these two main categories of breast reconstruction. It has detailed data from nearly 250 hospitals and over 13,000 patients. We performed risk-adjusted analysis of prosthetic and autologous breast reconstruction to compare 30-day morbidity outcomes. METHODS: Patients who underwent prosthetic breast reconstruction or autologous tissue reconstruction from 2006 to 2010 were identified using operation descriptions. Over 240 tracked variables were extracted for patients undergoing breast reconstruction. Thirty-day postoperative outcomes were compared, and subgroup analysis was performed on the autologous population to describe outcomes of specific flap procedures. Reconstruction was analyzed as an independent risk factor for specific complications, with propensity scores used to help standardize compared patient populations. Regression analyses were performed using SPSS (version 20.0, Chicago, IL). RESULTS: A total of 13,082 patients underwent breast reconstruction; 9786 patients received prosthetic reconstruction and 3296 received autologous reconstruction. Within the autologous cohort, 1608 (48.8%) patients underwent a pedicle TRAM flap, 1079 (32.7%) had a LD flap, and 609 (18.5%) received a free flap. Autologous reconstruction patients had higher rates of overall complications (12.47% vs 5.38%, p<.001), wound infection (5.46% vs 3.45%, p<.001), prosthesis/flap failure (3.13% vs 0.85%, p<.001), and reoperation (9.59% vs 6.76%, p<.001). Risk-adjusted multivariate analysis also showed autologous reconstruction to be a significant independent predictor of specific short term outcomes. CONCLUSIONS: Using risk-adjusted models of a large multi-institutional database, we found that--relative to prosthetic reconstruction--autologous reconstruction had higher rates of 30-day overall complications, wound infection, prosthesis/flap failure, and reoperation. This may be due, in part, to a concomitant increase in operative time and higher case complexity. Taken with other reports such as NMBRA, this study helps to educate patients and surgeons alike on potential, comparative complications during the perioperative period.

Autologous options for postmastectomy breast reconstruction: a comparison of outcomes based on the American College of Surgeons National Surgical Quality Improvement Program.

BACKGROUND: The postmastectomy patient faces a plethora of choices when opting for autologous breast reconstruction; however, multi-institutional data comparing the available techniques are lacking. The National Surgical Quality Improvement Program (NSQIP) database provides a robust patient cohort for comparing outcomes and determining independent predictors of complications for each autologous method. STUDY DESIGN: The NSQIP database was retrospectively reviewed from 2006 to 2010, identifying 3,296 autologous breast reconstruction patients. Univariate analyses compared complication and reoperation rates. Multivariable logistic regression analyses of 4 cohorts (free flaps, pedicled transverse rectus abdominis myocutaeous (TRAM) flaps, latissimus, and all flaps in aggregate) determined complication rates and independent risk factors for complications and specific outcomes of interest (surgical site infection [SSI], flap failure, reoperation) in all flap types. RESULTS: American Society of Anesthesiologists (ASA) classification ≥ 3, body mass index > 30 kg/m(2), recent surgery, delayed reconstruction, and prolonged operative times are significant predictors of increased complications in autologous reconstructions. Rates of complications, flap failure, and reoperation were highest in the free tissue transfer group (p < 0.001). Latissimus flaps showed significantly lower rates of complications than other autologous methods (p < 0.001). Pedicled TRAM patients had the highest incidences of venous thromboembolic disease and SSI. CONCLUSIONS: This large-scale, multicenter evaluation of outcomes in autologous breast reconstruction found that free flaps have the highest captured 30-day complication and reoperation rates of any autologous reconstructive method; complications in latissimus flaps were surprisingly few. Pedicled TRAM and latissimus flaps remain the most commonly used autologous reconstructive methods. In addition to providing statistically robust outcomes data, this study contributes significantly to patient education and preoperative planning discussions.

Esthetic Outcomes of ADM-Assisted Expander-Implant Breast Reconstruction.

OBJECTIVE: Adjunct acellular dermal matrices (ADM) are thought to improve esthetic outcomes of breast reconstruction but the existing evidence is largely anecdotal. In this study, we provide comparative data on esthetic outcomes of expander-implant breast reconstruction with and without ADM. METHODS: Chart review was performed on a consecutive series of expander-implant reconstructions by the senior author. Demographic, oncologic, surgical, and photographic data were obtained for each patient. Photographic data were scored using a 3-point (0-1-2) breast-specific esthetic scale by 3 blinded, independent reviewers not involved in patient care. RESULTS: ADM-assisted breast reconstructions had significantly higher scores than the non-ADM reconstructions for breast mound volume (1.38 vs 1.11; P = .0102), breast mound placement (1.57 vs 1.39; P = .0217), and the inframammary fold (1.39 vs 1.23; P = .0458). CONCLUSIONS: ADM may improve breast volume, placement, and inframammary fold definition. These specific findings may help plastic surgeons better utilize ADM to improve outcomes for breast reconstruction.

The relationship between relative value units and outcomes: a multivariate analysis of plastic surgery procedures.

INTRODUCTION: Relative value units (RVUs) were developed as a quantifier of requisite training, knowledge, and technical expertise for performing various procedures. In select procedures, increasing RVUs have been shown to substitute well for increasing surgical complexity and have been linked to greater risk of complications. The relationship of RVU to outcomes has yet to be examined in the plastic surgery population. METHODS: This study analyzed nearly 15,000 patients from a standardized, multicenter database to better define the link between RVUs and outcomes in this surgical population. The American College of Surgeons' National Surgical Quality Improvement Program was retrospectively reviewed from 2006 to 2010. RESULTS: A total of 14,936 patients undergoing primary procedures of plastic surgery were identified. Independent risk factors for complications were analyzed using multivariable logistic regression. A unit increase in RVUs was associated with a 1.7% increase in the odds of overall complications and 1.0% increase in the odds of surgical site complications but did not predict mortality or reoperation. A unit increase in RVUs was also associated with a prolongation of operative time by 0.41 minutes, but RVUs only accounted for 15.6% of variability in operative times. CONCLUSIONS: In the plastic surgery population, increasing RVUs correlates with increased risks of overall complications and surgical site complications. While increasing RVUs may independently prolong operative times, they only accounted for 15.6% of observed variance, indicating that other factors are clearly involved. These findings must be weighed against the benefits of performing more complex surgeries, including time and cost savings, and considered in each patient's risk-benefit analysis.