A Retrospective Review on the Effects of Nasoalveolar Molding on Infant Weight Gain and Time to Primary Lip Repair in Unilateral and Bilateral Cleft Lip and Palate.

BACKGROUND: In patients with severe cleft deformities, nasoalveolar molding (NAM) can improve long-term lip and nasal symmetry by reducing the size of the cleft, better aligning the alveolus, lip, and nose, and making the primary lip repair more predictable. Despite the increasing number of published studies on modified NAM techniques, the effects of NAM on weight gain and time to primary lip repair remain less studied. PURPOSE: This study aims to evaluate the effect of NAM on feeding, weight gain, growth velocity, and time to primary lip repair in patients with complete unilateral and bilateral cleft lip and palate (BCLP). METHODS: A retrospective, single-institution review was conducted to identify patients with complete unilateral and BCLP treated between January 2005 and June 2020. The following outcomes were measured: age at the time of lip and palate repairs; weight, height, and BMI on the date of lip repair; and growth velocity. Crude and standardized morbidity ratio-weighted differences in outcome means and 95% confidence intervals were estimated using t tests. RESULTS: Seventy-one patients were included in the study, 30 of whom underwent NAM. On average, patients treated with preoperative NAM underwent lip repair later than patients who were not treated with NAM. They also had a greater growth velocity and BMI when compared to their non-NAM counterparts. These differences, however, were not statistically significant. CONCLUSION: This study explores the relationships between the use of NAM and preoperative weight gain, as well as time to lip repair in patients with complete unilateral and BCLP. Additional studies may be needed to better elucidate the effect of NAM on weight gain and the time required for surgical repair of the cleft lip and palate.

Cost-Effectiveness Analysis of Virtual Surgical Planning in Mandibular Reconstruction.

BACKGROUND: Because of the complex nature of osteocutaneous free flap mandibular reconstruction, modern technologies such as virtual surgical planning have become popularized to refine the procedure. Compared with usual care, virtual surgical planning has been suggested to reduce operative time and improve accuracy of outcomes. The aim of this study was to examine the cost-effectiveness of virtual surgical planning versus usual care in mandibular reconstruction. METHODS: A decision-analytic model was constructed to comparatively understand cost-effectiveness of virtual surgical planning and usual care treatments based on additional costs of virtual surgical planning, and costs attributed to probabilities of postoperative complications. Model structure was informed through qualitative clinical interviews from the University of North Carolina, and supported through University of North Carolina clinical data and literature. Costs and complication probabilities were estimated from the literature. Sensitivity analyses of all uncertain model parameters were performed, and distributional parameters were selected based on best practices. RESULTS: Results of base-case analysis indicated that virtual surgical planning was more costly by a difference of $7099 per person and did not reduce the risk of complications or flap loss. Virtual surgical planning cases had an increased incidence of flap loss by 0.6 percent and an increased incidence of mandibular infection by 6.5 percent. CONCLUSIONS: Virtual surgical planning has upfront expenses that do not necessarily translate into downstream reduction in complications or improved outcomes. Clinical decision-makers would benefit from future research to identify thresholds whereby virtual surgical planning may result in more cost-savings for particular types of patients.

Co-occurrence of frameshift mutations in SMAD6 and TCF12 in a child with complex craniosynostosis.

Non-syndromic craniosynostosis (CS) affects 1 in 2350 live births. Recent studies have shown that a significant fraction of cases are caused by de novo or rare transmitted mutations that promote premature osteoblast differentiation in cranial sutures. Rare heterozygous loss-of-function (LOF) mutations in SMAD6 and TCF12 are highly enriched in patients with non-syndromic sagittal and coronal CS, respectively. Interestingly, both mutations show striking incomplete penetrance, suggesting a role for modifying alleles; in the case of SMAD6, a common variant near BMP2 drastically increases penetrance of sagittal CS. Here, we report a proband presenting with both sagittal and coronal craniosynostosis with the highly unusual recurrence of CS within two months of initial surgery, requiring a second operation to re-establish suture patency at six months of age. Exome sequencing revealed a rare transmitted frameshift mutation in SMAD6 (p. 152 fs*27) inherited from an unaffected parent, absence of the common BMP2 risk variant, and a de novo frameshift mutation in TCF12 (p.E548fs*14). SMAD6 and TCF12 independently inhibit transcriptional targets of BMP signaling. The findings are consistent with epistasis of these mutations, increasing penetrance and severity of CS in this proband. They also add to the list of composite phenotypes resulting from two Mendelian mutations, and support the utility of exome sequencing in atypical CS cases.

Trends in medical malpractice claims in patients with cleft or craniofacial abnormalities in the United States.

OBJECTIVE: To describe medical malpractice trends in patients with cleft and/or craniofacial abnormalities. METHODS AND MATERIALS: A modified Delphi approach was used to gather search terms. Search settings included "all jury verdicts and settlements", with jurisdiction of "all states" and "all federal courts" (by court and circuit). A retrospective review of WestLawNext legal database was conducted. Cases were excluded if they did not have a direct association from the patient's craniofacial anomaly or if they were not related to malpractice. RESULTS: Forty-two cases met inclusion criteria. Cases closed between 1981 and 2014 were included. The mean payment among claims with an indemnity payment was $3.9 million. Of cases brought to trial, 62% were in favor of the plaintiff. Amongst physicians named as co-defendants, pediatricians were most commonly named (24%), followed by plastic surgeons (16%), obstetricians (7.8%), and radiologists (7.8%). "Missed diagnosis" was the most common type of negligent claim (45%), followed by "surgical error" (21%), and "medication error" (17%). "Anoxic brain injury" resulted in the highest median indemnity payment for complication of patient management ($3.5 million), followed by "wrongful birth" ($1.03 million), and "minor physical injury" ($520,000). No specific type of negligent claim (p = 0.764) nor complication of patient management (p = 0.61) was associated with a greater indemnity payment. Mean indemnity payment was $920,000 prior to 2001 and $4.4 million after 2001 (p = 0.058). CONCLUSIONS: Mean indemnity payments were fourteen-fold greater in patients as compared to those in the overall population ($3.9 million versus $274,887) and seven-fold greater than those in the average pediatric population ($3.9 million versus $520,923). All healthcare providers should be aware of the associated medical malpractice claims that may be incurred when treating patients at risk for these conditions.

Comparison of different methods to assess alveolar cleft defects in cone beam CT images.

OBJECTIVES: This study aimed to evaluate the accuracy of three different methods for assessing the volume of cleft defects in CBCT images. The influence of field of view (FOV) and voxel sizes was also assessed. METHODS: Using three radio-opaque plastic skulls, unilateral defects were created to mimic alveolar clefts and were filled with wax following the contralateral side contours. They were scanned in a CBCT unit using four different acquisition protocols, varying FOV and voxel sizes. Using three different methods, the defect/wax volume was evaluated on the images by defining: (1) the width, height and facial-palatal length of the defect in maximum intensity projection; (2) the areas of the defect on axial slices; and (3) the threshold and segmentation of the region of interest. The values obtained from each method using different acquisition protocols were compared with the real volume of the wax (gold standard) using ANOVA and Tukey's test. RESULTS: Methods 2 and 3 did not differ from the gold standard (p > 0.05). Conversely, Method 1 presented statistically significant overestimated values (p < 0.01). No differences were found among the different FOV and voxel sizes (p > 0.05). CONCLUSIONS: CBCT volumes proved reliable for the volumetric assessment of alveolar cleft defects, when using Methods 2 and 3 regardless of FOV and voxel sizes. It may be possible to improve surgical planning and outcomes by knowing the exact volume of grafting material needed prior to the surgical intervention.

All That You Can't Leave Behind: Professionalism as the Focus of Mentoring and Modeling.

Mentoring serves a critical and necessary role not only in the advancement of plastic surgery, but also in maintaining the health of our specialty. In addition to providing a driving force for innovation--which remains the core competency of plastic surgery--mentoring is a powerful, educational tool that helps us teach the critical skills of communication and model the tenets of professionalism. Our identity as innovators, healers, and providers of hope is dependent on conferring what it means to be a professional, from those who are just beginning their journey as surgeons, to those who are still on that odyssey.

The Use of Brainlab Navigation in Le Fort III Osteotomy.

Le Fort III osteotomy is commonly used in the surgical correction of midface hypoplasia, specifically in patients with syndromic craniosynostosis. These osteotomies can be associated with significant complications, which are often the result of incomplete or inaccurate osteotomies. Brainlab, a technology first developed for neurosurgery, has been applied to numerous surgical subspecialties. The aim of this study was to report our initial experience using the Brainlab VectorVision2 and Brainlab Curve (Brainlab, Westchester, IL) as an intraoperative guidance system for osteotomy placement during Le Fort III advancement. Three pediatric patients with syndromic craniosynostosis and midface hypoplasia scheduled to undergo Le Fort III advancement were scanned preoperatively with 0.6-mm computed tomography cuts, which were then uploaded to the Brainlab system. All surgeries commenced with rigid fixation of the Brainlab registration device to the patient's skull. The navigation system was used intraoperatively to accurately determine osteotomy sites and trajectories. External distractors were placed without complication. Mean length of surgery was 331 minutes, and mean estimated blood loss was 500 mL. No transfusion was required with a mean postoperative hemoglobin of 8.3 g/dL. The application of Brainlab technology to Le Fort III advancement proved useful in establishing precise osteotomy lines and trajectories. Looking forward, this technology could be applied to a minimal dissection technique in order to avoid extensive blood loss. Further study would be needed to determine possible benefits such as reduced complications or operative time when using an intraoperative navigation system for image-guided osteotomy placement during Le Fort III advancement.

Juvenile Swine Surgical Alveolar Cleft Model to Test Novel Autologous Stem Cell Therapies.

Reconstruction of craniofacial congenital bone defects has historically relied on autologous bone grafts. Engineered bone using mesenchymal stem cells from the umbilical cord on electrospun nanomicrofiber scaffolds offers an alternative to current treatments. This preclinical study presents the development of a juvenile swine model with a surgically created maxillary cleft defect for future testing of tissue-engineered implants for bone generation. Five-week-old pigs (n=6) underwent surgically created maxillary (alveolar) defects to determine critical-sized defect and the quality of treatment outcomes with rib, iliac crest cancellous bone, and tissue-engineered scaffolds. Pigs were sacrificed at 1 month. Computed tomography scans were obtained at days 0 and 30, at the time of euthanasia. Histological evaluation was performed on newly formed bone within the surgical defect. A 1 cm surgically created defect healed with no treatment, the 2 cm defect did not heal. A subsequently created 1.7 cm defect, physiologically similar to a congenitally occurring alveolar cleft in humans, from the central incisor to the canine, similarly did not heal. Rib graft treatment did not incorporate into adjacent normal bone; cancellous bone and the tissue-engineered graft healed the critical-sized defect. This work establishes a juvenile swine alveolar cleft model with critical-sized defect approaching 1.7 cm. Both cancellous bone and tissue engineered graft generated bridging bone formation in the surgically created alveolar cleft defect.

Craniosynostosis incision: scalpel or cautery?

There is an ongoing debate regarding the optimal instrument for scalp incisions: the scalpel or electrocautery. The argument generally focuses on improved healing after an incision made with a knife and decreased bleeding when using electrocautery. This study compares the use of scalpel and electrocautery in making coronal incisions for patients undergoing surgical correction of craniosynostosis. The outcome metric used is wound healing within 6 months after surgery. All patients presenting to the University of North Carolina Children's Hospital with craniosynostosis between July 1, 2007 and January 1, 2010 requiring a coronal incision for surgical correction were prospectively enrolled. In all of these patients, half of the coronal incision was made with knife; the other half, with needle tip cautery. Side of the incision was specified at the time of surgery in the operative report. Patients were excluded from the study if the instrument for incision was not specified or if only 1 modality was used for the entire incision. Sixty-eight patients underwent cranial vault reconstruction, of which 58 met inclusion criteria. Of the 58 matched pairs, 55 were analyzed statistically. The 3 excluded cases were those who had midline complications. There were 17 wound complications (15%): 8 in the knife group, 6 in the cautery group, and 3 at midline (with indeterminate side for the problem). We found no statistically significant difference in wound healing between incisions made with a knife or with electrocautery.

Outcome analysis of factors impacting the plastic surgery match.

Matching into an integrated plastic surgery program has become highly competitive. As a result it has become more difficult for both the applicants and the residency programs to determine which attributes are most important to match in plastic surgery and, more importantly, to make a surgeon who will contribute to the future of our specialty. This study was conducted to analyze potential associations between a successful match into plastic surgery and the number of interviews offered and attended, Alpha Omega Alpha (AOA) membership, and participation in away rotations. Increased competitiveness of the specialty also has required that the applicant spend significant time and money on the match process to improve his chances. Therefore, we looked at the financial impact of the interview process as well as at compliance with the new communication mandate by the Plastic Surgery Residency Review Committee designed to decrease some of the time and monetary costs associated with the match process. An anonymous 30-item survey was e-mailed to all the applicants to our institution last year. The survey consisted of questions addressing applicant profile with specific questions regarding the interview process. Descriptive statistics, including frequencies and proportions for each of the questions, were calculated. To assess the relationship between categorical outcomes, a Fisher exact test was used. Results with a P value less than 0.05 were considered to be statistically significant. Considering matching as the primary outcome measure, a statistically significant relationship was found with the number of plastic surgery interview invitations received and attended (P < 0.0001 for both), as well as with AOA membership (P = 0.018), with 89% (32/36) of the responders in AOA matching into plastic surgery. Although doing an away rotation did not have a significant association with match rate, one-third of responders matched where they did an away rotation. Gender was not found to influence match rate. This study supports with hard data the assumptions regarding matching into a competitive specialty: the more interview invitations received and interviews attended, and the more academically competitive the applicant, the more likely the applicant is to match. By applying this data, more precise guidelines may be developed to advise applicants concerning preparation for a successful match.