The Preservation Technique for Incomplete Unilateral Cleft Lip Reconstruction.

The incomplete unilateral cleft lip shares many of the same phenotypic characteristics as a complete unilateral cleft lip, but key differences include an intact nasal sill, a relative excess of skin in the lateral lip element, and favorable skeletal support. Surgical techniques for incomplete unilateral cleft lips should be tailored to the specific anatomical characteristics, be simple and reliable to perform, and minimize the risk of secondary deformity. Here we describe the "preservation technique" for incomplete unilateral cleft lip reconstruction. The modified design from the anatomical subunit approximation technique uses a nasal sill flap and obviates the need for nasal sill and lateral lip excision. Tissues of the lip are opened out and reorientated to maximize the anatomical advantage.

Quantifying Changes on OCT in Eyes Receiving Treatment for Neovascular Age-Related Macular Degeneration.

Purpose: Application of artificial intelligence (AI) to macular OCT scans to segment and quantify volumetric change in anatomical and pathological features during intravitreal treatment for neovascular age-related macular degeneration (AMD). Design: Retrospective analysis of OCT images from the Moorfields Eye Hospital AMD Database. Participants: A total of 2115 eyes from 1801 patients starting anti-VEGF treatment between June 1, 2012, and June 30, 2017. Methods: The Moorfields Eye Hospital neovascular AMD database was queried for first and second eyes receiving anti-VEGF treatment and had an OCT scan at baseline and 12 months. Follow-up scans were input into the AI system and volumes of OCT variables were studied at different time points and compared with baseline volume groups. Cross-sectional comparisons between time points were conducted using Mann-Whitney U test. Main Outcome Measures: Volume outputs of the following variables were studied: intraretinal fluid, subretinal fluid, pigment epithelial detachment (PED), subretinal hyperreflective material (SHRM), hyperreflective foci, neurosensory retina, and retinal pigment epithelium. Results: Mean volumes of analyzed features decreased significantly from baseline to both 4 and 12 months, in both first-treated and second-treated eyes. Pathological features that reflect exudation, including pure fluid components (intraretinal fluid and subretinal fluid) and those with fluid and fibrovascular tissue (PED and SHRM), displayed similar responses to treatment over 12 months. Mean PED and SHRM volumes showed less pronounced but also substantial decreases over the first 2 months, reaching a plateau postloading phase, and minimal change to 12 months. Both neurosensory retina and retinal pigment epithelium volumes showed gradual reductions over time, and were not as substantial as exudative features. Conclusions: We report the results of a quantitative analysis of change in retinal segmented features over time, enabled by an AI segmentation system. Cross-sectional analysis at multiple time points demonstrated significant associations between baseline OCT-derived segmented features and the volume of biomarkers at follow-up. Demonstrating how certain OCT biomarkers progress with treatment and the impact of pretreatment retinal morphology on different structural volumes may provide novel insights into disease mechanisms and aid the personalization of care. Data will be made public for future studies. Financial Disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Diabetic retinopathy: Screening, prevention, and treatment.

Internists are integral in the multidisciplinary approach to diabetic retinopathy, contributing significantly to the management of diabetes and diabetes-related complications. Effective screening processes, timely referrals, and strategic diabetes management are imperative to prevent and mitigate the consequences of diabetic retinopathy. The evolution of treatments for diabetic retinopathy has markedly improved vision outcomes and reduced the burden on patients. Despite these advances, a collaborative approach to care is essential to prevent the progression of vision impairment and manage associated complications.

Septoplasty During Primary Cleft Lip Reconstruction: A Historical Perspective and Scoping Review.

BACKGROUND: Traditional surgical approaches excluded septoplasty at primary cleft lip reconstruction due to concerns about restricted nasal and midfacial growth. Modern opinion in the treatment of cleft lip has increasingly employed primary septoplasty; this scoping review and historical perspective aims to chronicle the evolution of septoplasty in patients born with cleft lip and palate and discuss current evidence. METHODS: The historical perspective explicitly contrasts American and European perceptions of septoplasty in cleft lip deformity and the competing anatomical theories of the role of the septum on midfacial and nasal growth. For the scoping review, articles were extracted from Embase, PubMed, and Medline, as well as manual searches of reference lists. Results were compiled, grouped, and appraised by date, outcomes, and historical significance. Inclusion criteria consisted of children who underwent primary septoplasty for any indication and were followed up on outcomes of facial growth and nasal function. Literature reviews, opinion articles, case reports, guidelines, or studies not available in English or online were excluded. RESULTS: Evolving anatomical theories relating to midfacial growth in the mid-late 20th century underpinned a progressive ideological shift on the safety and efficacy of septoplasty in children. This is supported by our scoping review, which included 23 articles mutually selected for inclusion by 2 blinded assessors. Several competing methods have been employed to measure endpoints on facial growth and nasal function, but generally indicate primary septoplasty is successful in improving nasal function and preserving midfacial growth. CONCLUSION: Perceptions towards septoplasty on facial growth in the pediatric population have transformed significantly and suggest a growing acceptance of primary septoplasty techniques in patients born with a cleft lip.

Cardiovascular risk in anti-VEGF treatment of neovascular age-related macular degeneration.

OBJECTIVE: Assess 5-year all-cause mortality (ACM), hemorrhagic stroke, ischemic stroke, and myocardial infarction (MI) risks in nAMD patients receiving anti-VEGF injections compared with controls. DESIGN: Population-based retrospective cohort study using a U.S. federated health research network, containing de-identified data of 96 million patients from 1/1/2003 to 3/6/2023. PARTICIPANTS: nAMD Patients with anti-VEGF injections. Controls included nAMD patients without anti-VEGF injections, non-exudative AMD patients, and patients without AMD. METHODS: Patients were identified using nAMD ICD-10 and anti-VEGF CPT codes and matched for age, sex, and comorbidities. Five-year relative risk of ACM (RR1), hemorrhagic stroke (RR2), ischemic stroke (RR3), and MI (RR4) in nAMD patients receiving anti-VEGF injections were calculated. RESULTS: A total of 27,609 nAMD patients (mean diagnosis age [SD], [78.2 (10.3)]) received anti-VEGF injections; 769 nAMD patients without injections (75.8 [12.2]), 27,599 non-exudative AMD patients (78.2 [10.3]), and 21,902 no-AMD patients (76.1 [10.5]) were identified. After matching, nAMD patients receiving injections did not show increased risk versus nAMD patients without injections (RR1, 0.66; 95% CI [0.53, 0.82]), (RR2, 1.00 [0.42, 2.38]), (RR3, 1.70 [0.92,3.13]), (RR4, 0.63 [0.33, 1.18]). No increased risk was found compared to non-exudative AMD patients (RR1, 0.99 [0.95, 1.03]), (RR2, 0.94 [0.83,1.07]), (RR3, 1.04 [0.96, 1.12]), (RR4, 0.99 [0.91, 1.08]). Increased risk for ACM was observed versus no-AMD patients (RR1, 1.21 [1.15, 1.27]), but no other differences were found (RR2, 0.81 [0.70, 0.93]), (RR3, 1.00 [0.92, 1.09]), (RR4, 0.986 [0.90, 1.09]). CONCLUSION: Anti-VEGF injections were not associated with major cardiovascular events in nAMD patients over 5 years.

Cleft lip Sidedness and the Association with Additional Congenital Malformations.

OBJECTIVE: To investigate the association between the sidedness of orofacial clefts and additional congenital malformations. DESIGN: Linkage of a national registry of cleft births to national administrative data of hospital admissions. SETTING: National Health Service, England. PARTICIPANTS: 2007 children born with cleft lip ± alveolus (CL ± A) and 2724 with cleft lip and palate (CLP) born between 2000 and 2012. MAIN OUTCOME MEASURE: The proportion of children with ICD-10 codes for additional congenital malformations by the sidedness (left, right or bilateral) of orofacial clefts. RESULTS: For CL ± A phenotypes, there was no evidence for a difference in the prevalence of additional anomalies between left (22%, reference), right (22%, aOR 1.02, 95% CI 0.80 to 1.28; P = .90) and bilateral clefts (23%, aOR 1.09, 95% CI 0.75 to 1.57; P = .66). For CLP phenotypes, there was evidence of a lower prevalence of additional malformations in left (23%, reference) compared to right (32%, aOR 1.54, 95% CI 1.25 to 1.91; P < .001) and bilateral clefts (33%, aOR 1.64, 95% CI 1.35 to 1.99; P < .001). CONCLUSIONS: The prevalence of additional congenital malformations was similar across sidedness subtypes with CL ± A phenotypes but was different for sidedness subtypes within CLP cases. These data support the hypothesis that CL ± A has a different underlying aetiology from CLP and that within the CLP phenotype, right sided CLP may lie closer in aetiology to bilateral CLP than it does to left sided CLP.

Congenital Syphilis and the Orthopaedic Perspective: A Case Report.

CASE: We report a case of an otherwise healthy 4-month-old male infant presenting with unexplained metaphyseal lucent bands and diaphyseal periosteal reactions in bilateral extremities upon radiograph, who was ultimately diagnosed with congenital syphilis. After subsequent workup and treatment, the patient had appropriate range of motion of all extremities within 2 weeks after discharge. CONCLUSION: The purpose of this report was to increase the awareness of the rising incidence of congenital syphilis in the United States and educate fellow orthopaedic surgeons on ways to differentiate the skeletal manifestations of congenital syphilis from other pathologies with significant bone involvement.

Analysis and Reporting of Randomized Trials in Cleft Palate Surgery: Learning from the Timing of Primary Surgery (TOPS) Trial.

The Timing of Primary Surgery (TOPS) trial was published August 2023 in the New England Journal of Medicine and is a milestone achievement for a study focused on cleft palate. Due to the complexity of outcome reporting in cleft and the rarity of such comparative trials, TOPS presents a useful opportunity to critically review the design, analysis and reporting strategies utilised. This perspective article focused on the inclusion of participants, the choice of the primary outcome measure and the analysis of ordinal data within the trial. Considerations for future comparative studies in cleft care are discussed.

Sequence-structure-function characterization of the emerging tetracycline destructase family of antibiotic resistance enzymes.

Tetracycline destructases (TDases) are flavin monooxygenases which can confer resistance to all generations of tetracycline antibiotics. The recent increase in the number and diversity of reported TDase sequences enables a deep investigation of the TDase sequence-structure-function landscape. Here, we evaluate the sequence determinants of TDase function through two complementary approaches: (1) constructing profile hidden Markov models to predict new TDases, and (2) using multiple sequence alignments to identify conserved positions important to protein function. Using the HMM-based approach we screened 50 high-scoring candidate sequences in Escherichia coli, leading to the discovery of 13 new TDases. The X-ray crystal structures of two new enzymes from Legionella species were determined, and the ability of anhydrotetracycline to inhibit their tetracycline-inactivating activity was confirmed. Using the MSA-based approach we identified 31 amino acid positions 100% conserved across all known TDase sequences. The roles of these positions were analyzed by alanine-scanning mutagenesis in two TDases, to study the impact on cell and in vitro activity, structure, and stability. These results expand the diversity of TDase sequences and provide valuable insights into the roles of important residues in TDases, and flavin monooxygenases more broadly.

Robotic-assisted surgery for left-sided colon and rectal resections is associated with reduction in the postoperative surgical stress response and improved short-term outcomes: a cohort study.

INTRODUCTION: There is growing evidence that the use of robotic-assisted surgery (RAS) in colorectal cancer resections is associated with improved short-term outcomes when compared to laparoscopic surgery (LS) or open surgery (OS), possibly through a reduced systemic inflammatory response (SIR). Serum C-reactive protein (CRP) is a sensitive SIR biomarker and its utility in the early identification of post-operative complications has been validated in a variety of surgical procedures. There remains a paucity of studies characterising post-operative SIR in RAS. METHODS: Retrospective study of a prospectively collected database of consecutive patients undergoing OS, LS and RAS for left-sided and rectal cancer in a single high-volume unit. Patient and disease characteristics, post-operative CRP levels, and clinical outcomes were reviewed, and their relationships explored within binary logistic regression and propensity scores matched models. RESULTS: A total of 1031 patients were included (483 OS, 376 LS, and 172 RAS). RAS and LS were associated with lower CRP levels across the first 4 post-operative days (p < 0.001) as well as reduced complications and length of stay compared to OS in unadjusted analyses. In binary logistic regression models, RAS was independently associated with lower CRP levels at Day 3 post-operatively (OR 0.35, 95% CI 0.21-0.59, p < 0.001) and a reduction in the rate of all complications (OR 0.39, 95% CI 0.26-0.56, p < 0.001) and major complications (OR 0.5, 95% CI 0.26-0.95, p = 0.036). Within a propensity scores matched model comparing LS versus RAS specifically, RAS was associated with lower post-operative CRP levels in the first two post-operative days, a lower proportion of patients with a CRP ≥ 150 mg/L at Day 3 (20.9% versus 30.5%, p = 0.036) and a lower rate of all complications (34.7% versus 46.7%, p = 0.033). CONCLUSIONS: The present observational study shows that an RAS approach was associated with lower postoperative SIR, and a better postoperative complications profile.

Lack of racial and ethnic diversity in pediatric ophthalmology clinical trials from 2000 to 2022.

PURPOSE: To examine the prevalence of and factors associated with racial and ethnic reporting and trends in such reporting and to assess whether categories of race and ethnicity have been under- or over-represented in pediatric ophthalmology randomized control trials (RCTs) in the United States. METHODS: We systematically searched the literature on pediatric ophthalmology RCTs in high-impact factor ophthalmology journals published between 2000 and 2022. Logistic regression was used to assess parameters linked to race/ethnicity reporting; linear regression, to gauge the relationship between publication year and race/ethnicity reporting. The racial and ethnic composition of RCTs was contrasted with 2010 US census data by calculating percentage difference. RESULTS: Of 170 eligible articles, 89 (52.4%) included race/ethnicity data. Multivariable analysis showed that academic (OR = 12.19; 95% CI, 3.34-44.44) and government (OR = 3.91; 95% CI, 1.20-12.72) funding was linked to data reporting. During the study period, publication year and race/ethnicity reporting had a nonstatistically significant 1.0% annual increase (r = 0.29, P = 0.18). White participants were over-represented, with a percentage difference of 16.7% (95% CI, 11.8%-21.7%), whereas Hispanic individuals were under-represented, with a percentage difference of -7.6% (95% CI, -11.2% to -4.1%) compared to the 2010 US census data. CONCLUSIONS: Our results indicate a gradual rise in reported race and/or ethnicity in published pediatric ophthalmology RCTs, though not statistically significant, both in the United States and globally. Notably, under-representation of Hispanic, over-representation of White, and proportional representation of Black and Asian individuals were observed in US-based studies.

The Influence of Sidedness in Unilateral Cleft Lip and Palate on Mid Facial Growth at Five Years of Age.

OBJECTIVE: To determine whether facial growth at five years is different for children with a left versus right sided cleft lip and palate. DESIGN: Retrospective cohort study. SETTING: Seven UK regional cleft centres. PATIENTS: Patients born between 2000-2014 with a complete unilateral cleft lip and palate (UCLP). MAIN OUTCOMES MEASURE: 5-Year-Old's Index scores. RESULTS: 378 children were included. 256 (68%) had a left sided UCLP and 122 (32%) had a right sided UCLP. 5-Year-Old's index scores ranged from 1 (good) to 5 (poor). There was a higher proportion of patients getting good scores (1 and 2) in left UCLP (43%) compared to right UCLP (37%) but there was weak evidence for a difference (Adjusted summary odds ratio 1.27, 95% CI 0.87 to 1.87; P = .22). CONCLUSIONS: Whilst maxillary growth may be different for left versus right sided UCLP, definitive analysis requires older growth indices and arch forms.

Stroke Strikes in Silence: Bilateral Medial Medullary Infarction in a Patient With Complete Hearing Loss.

Bilateral medial medullary infarction (BMMI) is a rare stroke subtype that accounts for less than 1% of acute strokes. Common manifestations of this stroke include quadriparesis, bilateral hypoglossal palsy, bilateral sensory loss, and respiratory failure. We present the case of a 39-year-old male with deafness and mutism who was brought to the emergency department due to acute onset of altered mental status and generalized weakness, further decompensated, and was lately diagnosed with bilateral medial medullary infarction. This case hopes to illustrate a differential diagnosis to be considered and promptly managed when a patient presents with altered mental status and quadriparesis, especially in the acute setting where tissue plasminogen activator (tPA) can still be given.

Detection and quantitative analysis of patient-ventilator interactions in ventilated infants by deep learning networks.

BACKGROUND: The study of patient-ventilator interactions (PVI) in mechanically ventilated neonates is limited by the lack of unified PVI definitions and tools to perform large scale analyses. METHODS: An observational study was conducted in 23 babies randomly selected from 170 neonates who were ventilated with SIPPV-VG, SIMV-VG or PSV-VG mode for at least 12 h. 500 breaths were randomly selected and manually annotated from each recording to train convolutional neural network (CNN) models for PVI classification. RESULTS: The average asynchrony index (AI) over all recordings was 52.5%. The most frequently occurring PVIs included expiratory work (median: 28.4%, interquartile range: 23.2-40.2%), late cycling (7.6%, 2.8-10.2%), failed triggering (4.6%, 1.2-6.2%) and late triggering (4.4%, 2.8-7.4%). Approximately 25% of breaths with a PVI had two or more PVIs occurring simultaneously. Binary CNN classifiers were developed for PVIs affecting ≥1% of all breaths (n = 7) and they achieved F1 scores of >0.9 on the test set except for early triggering where it was 0.809. CONCLUSIONS: PVIs occur frequently in neonates undergoing conventional mechanical ventilation with a significant proportion of breaths containing multiple PVIs. We have developed computational models for seven different PVIs to facilitate automated detection and further evaluation of their clinical significance in neonates. IMPACT: The study of patient-ventilator interactions (PVI) in mechanically ventilated neonates is limited by the lack of unified PVI definitions and tools to perform large scale analyses. By adapting a recent taxonomy of PVI definitions in adults, we have manually annotated neonatal ventilator waveforms to determine prevalence and co-occurrence of neonatal PVIs. We have also developed binary deep learning classifiers for common PVIs to facilitate their automatic detection and quantification.

Visual acuity changes in the preoperative period in patients undergoing cataract surgery.

OBJECTIVE: This study quantifies change in best visual acuity (BVA) over the preoperative period and assesses factors associated with postoperative outcomes. DESIGN: Retrospective chart review conducted at a single institution. PARTICIPANTS: A total of 691 patients underwent cataract surgery and had a preoperative assessment 0-30 days prior to surgery following their surgical evaluation. METHODS: Baseline demographics and past medical and clinical data were collected through electronic medical record query. BVA was noted at initial surgical evaluation, preoperative assessment, and nearest postoperative assessment. RESULTS: A total of 691 patients (911 eyes) were included with mean BVAs at the initial evaluation, preoperative assessment, and postoperative assessment of 68.3 ± 16.8, 64.6 ± 18.5, and 81.1 ± 12.0 ETDRS letters, respectively. Mean BVA was significantly higher postoperatively compared with the preoperative assessment and initial evaluation (p < 0.0001). There was a mean of 53.8 days between initial surgical evaluation and surgery date and a mean of 49.9 days between the preoperative assessment and initial surgical evaluation. The mean interval between the preoperative assessment and surgery was 11.7 days. In the preoperative period, 9.1% of eyes experienced worsening of BVA by >3 lines and 0.9% experienced improvement of BVA by >3 lines. Time to surgery was significantly associated with change in postoperative BVA (effect size, -0.03 ETDRS letters; p = 0.015) but was not significant on multiple linear regression. BVA at initial evaluation, glaucoma, and glaucoma surgery were all significantly associated with postoperative outcomes. CONCLUSION: Most eyes experienced stable vision in the preoperative period for cataract surgery. On average, patients with high BVAs at the time of initial surgical evaluation may be able to defer surgery without the risk of poorer surgical outcomes.

Outcomes for maximal bilateral lateral rectus recession in large-angle exotropia.

BACKGROUND: Surgical treatment for large-angle exotropia can be challenging. The aim of this study was to evaluate short-term surgical outcomes of patients with large-angle exotropia (≥50Δ) undergoing maximal bilateral lateral rectus muscle recession of 10 mm. METHODS: This was a retrospective study of consecutive patients at our institution who underwent maximal bilateral lateral rectus muscle recession for exodeviation ≥50Δ from January 1, 2008, to July 22, 2022. We subdivided the cohort into large-angle exotropia (largest amount of exodeviation at near and/or distance ≥50Δ and <65Δ) and very large-angle exotropia (largest exodeviation ≥65Δ). Patients with a history of prior eye muscle surgery, neurologic deficits, and three- or four-muscle surgery were excluded. RESULTS: A total of 22 patients were included. Mean preoperative exodeviation at distance was 51.9Δ in the large-angle group and 67.5Δ in the very-large-angle group (P = 0.001). Outcomes for the large-angle and very-large angle groups were, respectively, as follows: mean follow-up, 31.1 weeks and 11.8 weeks (P = 0.97); success, 75.0% and 16.7% (P = 0.02); undercorrection rates, 18.7% and 83.3% (P = 0.01); and mean postoperative exodeviation at distance, 3.7Δ ± 6.3Δ and 28.0Δ ± 13.5Δ (P = 0.001). CONCLUSIONS: Our study identified good surgical outcomes (75%) with maximal bilateral lateral rectus muscle recession of 10 mm in treating patients with large-angle exotropia between 50Δ and <65Δ. Other surgical techniques such as recession-resection and three- or four-muscle surgery may result in better outcomes when treating patients with exotropia ≥65Δ.

Sidedness in Unilateral Orofacial Clefts: A Systematic Scoping Review.

OBJECTIVE: An overview of the literature relating to the sidedness of unilateral cleft lip with or without cleft palate to map current knowledge on the cause and impact of directional asymmetry. DESIGN: Scoping review with a systematic search of Medline and Embase from inception to May 2023. PATIENTS, PARTICIPANTS: Humans born with a left or right unilateral cleft lip with or without a cleft palate. MAIN OUTCOME MEASURES: Cleft sidedness as a co-occurrence, an outcome or an exposure. RESULTS: Forty studies were eligible for inclusion and confirmed the predilection for the occurrence of left sided cleft lips; 12 studies reported cleft sidedness co-occurring with another phenotype, 11 studies report sidedness as an outcome and 17 studies as an exposure. Phenotypes which were reported to co-occur with either left or right sided clefts included congenital dental anomalies, handedness and additional congenital anomalies. Variables investigated as a potential cause of left or right sided clefts as an outcome included chromosomal anomalies, genetic variants and environmental factors. Outcomes investigated in relation to cleft sidedness as an exposure included facial anatomical features, facial growth, educational attainment, functional and psychological characteristics. More studies showed worse outcomes in right sided clefts versus left sided clefts than vice versa, although studies were inconsistent, and a quality assessment was not performed. CONCLUSIONS: The field of cleft sidedness research is expanding and there are promising early findings to differentiate cause and outcome by sidedness of the cleft.

Prenatal diagnosis of cleft lip and/or palate: What do we tell prospective parents?

Cleft lip and/or palate (CL/CP) is the most common congenital craniofacial anomaly and parents often ask, "how did this happen?" Patients and families may benefit from access to a multidisciplinary team (MDT) from prenatal diagnosis into early adulthood. Multiple factors can contribute to the development of a cleft. We discuss the epidemiology and risk factors that increase the likelihood of having a newborn with a cleft. The purpose of this article is to review the prenatal investigations involved in the diagnosis and workup of these patients in addition to postpartum treatment, prognostic factors, and counseling families regarding future recurrence risk.

Systematic Review of Postoperative Velopharyngeal Insufficiency: Incidence and Association With Palatoplasty Timing and Technique.

Cleft palate is among the most common congenital disorders worldwide and is correctable through surgical intervention. Sub-optimal surgical results may cause velopharyngeal insufficiency (VPI). When symptomatic, VPI can cause hypernasal or unintelligible speech. The postoperative risk of VPI varies significantly in the literature but may be attributed to differences in study size, cleft type, surgical technique, and operative age. To identify the potential impact of these factors, a systematic review was conducted to examine the risk of VPI after primary palatoplasty, accounting for operative age and surgical technique. A search of PubMed, Embase, and Web of Science was completed for original studies that examined speech outcomes after primary palatoplasty. The search identified 4740 original articles and included 35 studies that reported mean age at palatoplasty and VPI-related outcomes. The studies included 10,795 patients with a weighted mean operative age of 15.7 months (range: 3.1-182.9 mo), and 20% (n=2186) had signs of postoperative VPI. Because of the heterogeneity in reporting of surgical technique across studies, small sample sizes, and a lack of statistical power, an analysis of the VPI risk per procedure type and timing was not possible. A lack of data and variable consensus limits our understanding of optimal timing and techniques to reduce VPI occurrence. This paper presents a call-to-action to generate: (1) high-quality research from thoughtfully designed studies; (2) greater global representation; and (3) global consensus informed by high-quality data, to make recommendations on optimal technique and timing for primary palatoplasty to reduce VPI.

The Implications of Laterality in Unilateral Cleft Lip Reconstruction: A Global Survey of Cleft Surgeons.

OBJECTIVE: To explore the impact of directional laterality in complete Unilateral Cleft Lip (UCL) amongst the global cleft surgeon community. DESIGN: Cross-sectional survey study. SETTING: Global distribution of online survey distributed in English and Spanish. PARTICIPANTS: Cleft surgeons from around the world. MAIN OUTCOME MEASURES: Survey participant perception of the impact of laterality on: (1) cleft presentation (2) surgical challenge and (3) surgical outcomes. RESULTS: Responses were received from 453 cleft surgeons located in 54 countries around the world. 221 (49%) had previously considered differences in patients presenting with a left- versus right-sided UCL. 95 (21%) considered right-sided clefts more difficult to reconstruct, 37 (8%) reported left-sided clefts to be more difficult and 321 (71%) reported no difference in difficulty between the cleft sides. Higher volume cleft surgeons, characterised by those reporting cleft as their principal area of practice and performing >20 cleft operations per year, were more likely to have both previously considered differences in laterality in cleft and to report right-sided unilateral cleft lip to be more difficult to primarily reconstruct. 395 (87%) did not consider surgical outcomes to be influenced by cleft laterality. CONCLUSIONS: This survey reports perceptions on cleft laterality from a large body of global surgeons and suggests a trend for increased difficulty in right-sided compared to left-sided cleft lip reconstruction, where such laterality-associated difficulty is perceived.