Lefort I Osteotomy With and Without Osteogenic Distraction in Cleft Lip and Palate Patients: Experience at Hospital Universitario Infantil De San José.

INTRODUCTION: Cleft lip and cleft palate (CLP) are congenital diseases that lead to several secondary craniofacial anomalies, such as hypoplasia of the middle third of the face, which can be treated with different surgical techniques to help improve functional and esthetic alterations associated with the maxilla. This article reports the results of patients managed with LeFort I osteotomy in the same craniofacial surgery center for 10 years. OBJECTIVE: To determine the postoperative results regarding recurrence rates, malocclusion, and speech status after surgical treatment, in patients with retrusion of the midface with CLP, who underwent LeFort I osteotomy with or without osteogenic distraction (OD). METHODS: A descriptive cohort study was performed at the Hospital Infantil Universitario de San José in Bogotá, Colombia, between 2010 and 2020, evaluating 38 patients with CLP who met the inclusion criteria, all managed by LeFort I osteotomy with and without OD. The authors reported the sociodemographic information, as well as data related to speech before and after surgery, recurrence, complications, and cephalometric characteristics. The recurrence of the patients was described at 6 and 12 months after the surgical procedure. RESULTS: A total of 43 patients met the inclusion criteria, of which 20 patients were managed with conventional LeFort I osteotomy, and 23 with LeFort I osteotomy with OD; 5 patients were excluded due to lack of data in the medical records, with a final sample of 38 patients. The distribution based on sex was: 57.8% men and 42.1% women. Regarding laterality, we have 7 patients with right CLP (18.42%), 11 patients with left CLP (28.9%), and 20 patients with bilateral CLP (52.63%), 100% of patients with a class III bite in Angle's classification. In group 1 (OD), 55% of the patients did not present changes in speech before surgery, 30% presented improvement in speech, and 15% worsened it. In group 2 (conventional advancement), 66% of the patients did not present changes in speech, 5.5% presented improvement, and 27.7% presented worsening of speech based on the preoperative condition, with a clinical recurrence at 6 months of 15% for group 1 and of 33% for group 2, and at 1 year of 20% for group 1 and 16% for group 2. CONCLUSIONS: Osteogenic distraction is a safe method that can be applied in patients with CLP depending on the clinical characteristics. According to what is described in the literature, those patients who require advancement of up to 6 mm treated without OD have obtained good results, showing esthetic improvement by increasing the projection of the middle third of the face, without worsening of velopharyngeal insufficiency and achieving an adequate occlusal class (Angle I) in the immediate postoperative period or after the postoperative orthodontic management. However, in patients who require advances ≥7 mm, it is clear that OD is the best option, given its association with a lower recurrence rate, minimal changes in the speech, achieving occlusion edge-to-edge at the end of the distraction or Angle's class I, which is corroborated by the results obtained in this study.

Tongue Flap for Closure of Complex Oronasal Fistula.

Complex oronasal fistula is one of the most frequent secondary complications of cleft palate correction and is considered a reconstructive challenge. Tongue flaps are one of the procedures for the treatment of complex fistulas associated or not with multiple previous procedures, offering a high success rate, few complications, and problems during its development. This study evaluates the efficacy in terms of functionality, esthetic, donor area morbidity and clarifies surgical technique steps. Descriptive cohort study was performed between August 2011 to August 2021 where an anteriorly based dorsal tongue flap was performed in 30 patients with complex palatal fistulas, evaluating outcomes in terms of technique reproducibility and flap viability, correction of oronasal regurgitation, speech, donor site morbidity, complications, and esthetics. The senior author has used this technique with consistent clinical outcomes to improve complex oronasal fistula with minimal complications, with a good success rate in terms of correction of the palatal defect with imperceptible alteration of the lingual donor area. In addition, establishes a specific definition of persistence and recurrence of oronasal fistula. The tongue flap is considered the gold standard in complex oronasal fistula reconstructions with satisfactory outcomes, and it offers an adequate amount of vascularized tissue achieving fistula closure without functional or esthetic impairment of the donor area and is a highly reproducible technique.

The First Hybrid International Educational Comprehensive Cleft Care Workshop.

OBJECTIVE: Describe the first hybrid global simulation-based comprehensive cleft care workshop, evaluate impact on participants, and compare experiences based on in-person versus virtual attendance. DESIGN: Cross-sectional survey-based evaluation. SETTING: International comprehensive cleft care workshop. PARTICIPANTS: Total of 489 participants. INTERVENTIONS: Three-day simulation-based hybrid comprehensive cleft care workshop. MAIN OUTCOME MEASURES: Participant demographic data, perceived barriers and interventions needed for global comprehensive cleft care delivery, participant workshop satisfaction, and perceived short-term impact on practice stratified by in-person versus virtual attendance. RESULTS: The workshop included 489 participants from 5 continents. The response rate was 39.9%. Participants perceived financial factors (30.3%) the most significant barrier and improvement in training (39.8%) as the most important intervention to overcome barriers facing cleft care delivery in low to middle-income countries. All participants reported a high level of satisfaction with the workshop and a strong positive perceived short-term impact on their practice. Importantly, while this was true for both in-person and virtual attendees, in-person attendees reported a significantly higher satisfaction with the workshop (28.63 ± 3.08 vs 27.63 ± 3.93; P = .04) and perceived impact on their clinical practice (22.37 ± 3.42 vs 21.02 ± 3.45 P = .01). CONCLUSION: Hybrid simulation-based educational comprehensive cleft care workshops are overall well received by participants and have a positive perceived impact on their clinical practices. In-person attendance is associated with significantly higher satisfaction and perceived impact on practice. Considering that financial and health constraints may limit live meeting attendance, future efforts will focus on making in-person and virtual attendance more comparable.

Complication After Mandibular Reconstruction With Fibula Free Flap in a Patient With Hemifacial Microsomia.

ABSTRACT: Hemifacial microsomia is the second most frequent pathology in craniofacial malformations. Clinical findings are broad, mainly affecting the mandible. Several classifications of mandibular compromise exist that guide the best treatment option in each patient. The authors present a case of an unusual complication following fibular free flap mandibular reconstruction in a patient with hemifacial microsomia prada type IV, who presented with ankylosis at the skull base and simultaneous fibula pseudoarthrosis at the union with the residual mandible. These dual findings allowed the patient to have a functional mouth aperture, which give us time to let him grow and wait for final management. Treatment options and follow up are discussed, knowing that there is no literature to support any protocol with this patient, so we present his evolution.

Simulation-Based Comprehensive Cleft Care Workshops: A Reproducible Model for Sustainable Education.

OBJECTIVE: Evaluate simulation-based comprehensive cleft care workshops as a reproducible model for education with sustained impact. DESIGN: Cross-sectional survey-based evaluation. SETTING: Simulation-based comprehensive cleft care workshop. PARTICIPANTS: Total of 180 participants. INTERVENTIONS: Three-day simulation-based comprehensive cleft care workshop. MAIN OUTCOME MEASURES: Number of workshop participants stratified by specialty, satisfaction with the workshop, satisfaction with simulation-based workshops as educational tools, impact on cleft surgery procedural confidence, short-term impact on clinical practice, medium-term impact on clinical practice. RESULTS: The workshop included 180 participants from 5 continents. The response rate was 54.5%, with participants reporting high satisfaction with all aspects of the workshop and with simulation-based workshops as educational tools. Participants reported a significant improvement in cleft lip (33.3 ± 5.7 vs 25.7 ± 7.6; P < .001) and palate (32.4 ± 7.1 vs 23.7 ± 6.6; P < .001) surgery procedural confidence following the simulation sessions. Participants also reported a positive short-term and medium-term impact on their clinical practices. CONCLUSION: Simulation-based comprehensive cleft care workshops are well received by participants, lead to improved cleft surgery procedural confidence, and have a sustained positive impact on participants' clinical practices. Future efforts should focus on evaluating and quantifying this perceived positive impact, as well reproducing these efforts in other areas of need.

A Surgical Technique for Management of the Metopic Suture in Syndromic Craniosynostosis.

OBJECTIVES: The objective is to describe a new surgical procedure developed in the San Jose Pediatric University Hospital for the management of syndromic synostosis of the metopic suture in a patient clinically diagnosed with Saethre-Chotzen syndrome. METHODS: The diagnosis of Saethre-Chotzen syndrome, bilateral coronal sutures, and metopic suture synostoses was made through photographic, anthropometric, exophthalmometric, and computed tomography analysis. The keel-like frontal bone deformity was corrected following resection using a fusiform osteotomy, remodelling was obtained by milling the edges, and the bony fragments were repositioned and fixed on the posterior wall of the frontal bone. Additionally, a fronto-orbital advancement with a self-stabilizing bar was performed. RESULTS: The 1-year postoperative results showed improvement in the position of the fronto-orbital bar, adequate cranial expansion, satisfactory correction of the upper facial third alteration, and correction of the keel-like deformity. CONCLUSIONS: The surgical approach has not previously been described in the literature and offers an alternative management for syndromic craniosyntostosis of the metopic suture, avoiding skull irregularities.

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A New Classification Based on the Kaban's Modification for Surgical Management of Craniofacial Microsomia.

In medicine, classifications are designed to describe accurately and reliably all anatomic and structural components, establish a prognosis, and guide a given treatment. Classifications should be useful in a universal way to facilitate communication between health professionals and to formulate management protocols. In many situations and particularly with craniofacial microsomia, there have been many different classifications that do not achieve this goal. In fact, when there are so many classifications, one can conclude that there is not a clear one that accomplishes all these ends and defines a treatment protocol. It is our intent to present a new classification based on the Pruzansky's classification, later modified by Kaban, to determine treatment protocols based on the degree of osseous deficiency present in the body, ramus, and temporomandibular joint. Different mandibular defects are presented in two patients with craniofacial microsomia type III and IV according to our classification with the corresponding management proposed for each type and adequate functional results.