Superiorly Based Posterior Pharyngeal Flaps: Using A Care Pathway to Optimize Speech and Airway Outcomes.

BACKGROUND: Pharyngeal flap (PF) surgery is effective at improving velopharyngeal sufficiency, but historical literature shows a concerning prevalence rate of obstructive sleep apnea (OSA), reported as high as 20%. Our institution has developed a protocol to minimize risk of postoperative obstructive complications and increase safety of PF surgery. We hypothesize that (1) preoperative staged removal of significant adenotonsillar tissue along with (2) multiview videofluoroscopy to guide patient-specific surgical approach via appropriately sized PFs can result in excellent speech outcomes while limiting occurrence of OSA. METHODS: This was a retrospective chart review of all patients with velopharyngeal insufficiency (VPI) (aged 2-20 years) seen at the University of Rochester from 2015 to 2022 undergoing PF surgery to correct VPI. Nasopharyngoscopy was used for surgical planning and airway evaluation. Patients with tonsillar and adenoid hypertrophy underwent staged adenotonsillectomy at least 2 months before PF. Multiview videofluoroscopy was used to identify anatomic causes of VPI and to determine PF width. Patients underwent polysomnography and speech evaluation before and at least 6 months after PF surgery. RESULTS: Forty-one children aged 8.5 ± 4.1 years (range, 4 to 18 years) who underwent posterior PF surgery for VPI were identified. This included 10 patients with 22q11.2 deletion and 4 patients with Pierre Robin sequence. Thirty-nine patients had both pre- and postoperative speech data and underwent both a pre- and postoperative sleep study. Polysomnography showed no significant difference in obstructive apnea-hypopnea index after posterior PF surgery (obstructive apnea-hypopnea index preop, 1.3 ± 1.2 events per hour; postop, 1.7 ± 2.1 events per hour; P = 0.111). Significant improvements in speech outcome were seen in patients who underwent PF (modified Pittsburgh score preop, 11.52 ± 1.37; postop, 1.09 ± 2.35; P < 0.05). CONCLUSIONS: Use of preoperative staged adenotonsillectomy as well as patient-specific PF dimensions results in effective resolution of VPI and a low risk of OSA.

An Updated Analysis of Body Contouring Malpractice Cases.

INTRODUCTION: Body contouring procedures are commonly performed in the United States for patients seeking to sculpt specific areas of their bodies. The aim of this study was to provide an updated analysis of the factors that influence medical malpractice litigation surrounding body contouring surgery. METHODS: The following terms were used to search the Westlaw Campus Legal research Database for cases with earliest documentation after January 2013: ("contouring" OR "abdominoplasty" OR "liposuction" OR "tummy tuck" OR "body lift" OR "thigh lift" OR "arm lift" OR "brachioplasty" OR "thighplasty" OR "lipectomy" OR "panniculectomy") AND "surgery" AND "medical malpractice." Cases were only included if there was a complaint of medical malpractice subsequent to a body contouring procedure, and details of the cases were provided. Information was collected on the location of the lawsuit, the earliest year of available case documentation, patient demographics, procedure(s) performed, alleged injury, specialty involvement, and verdicts. RESULTS: A total of 32 cases were included in the study. Most of the patients involved in the cases were women (n = 30, 93.8%) and alive (n = 28, 87.5%). New York state had the most cases (n = 7, 21.9%). Abdominoplasty (56.3%), liposuction (53.1%), and buttock augmentations (15.6%) were the most common procedures. Plastic surgeons were involved in 93.8% (n = 30) of the cases, and anesthesia, emergency medicine, dermatology, and oncology were also involved. Claims of malpractice most often discussed negligent technique (71.9%) and poor postoperative management (62.5%). Common postoperative complications were infection/sepsis (40.6%), scarring (31.3%), and emotional distress/prolonged pain (31.3%). One available ruling was in favor of the plaintiff. CONCLUSION: Although many of the cases in this analysis cited negligent technique, none were founded in their argument. Because involvement in these cases can place a burden on attending physicians, clear expectations of postoperative infections, scarring, and prolonged pain should be addressed during the informed consent process.

Simultaneous Furlow Palatoplasty and Tonsillectomy for the Treatment of Velopharyngeal Insufficiency and Tonsillar Hypertrophy.

OBJECTIVE: To determine whether performing tonsillectomy at the time of Furlow palatoplasty for the treatment of cleft palate related velopharyngeal insufficiency (VPI) incurs increased surgical complications or compromises speech outcomes. DESIGN: A retrospective review of patients who had Furlow palatoplasty and the outcomes of surgery in the treatment of cleft palate related VPI. SETTING: A single academic center between January 2015 and January 2022. PARTICIPANTS: Patients with submucous cleft (SMC) palate or patients with prior straight line primary palatoplasty presenting with VPI. INTERVENTIONS: Simultaneous conversion Furlow palatoplasty and tonsillectomy. MAIN OUTCOME MEASURE(S): Primary outcome measures include preoperative and postoperative Modified Pittsburgh Weighted Speech Scale (mPWSS), and postoperative surgical complications. RESULTS: Eight patients (25%) underwent Furlow palatoplasty and concomitant tonsillectomy, while 24 patients (75%) underwent Furlow palatoplasty alone. A significantly lower median postoperative mPWSS score, corresponding to better velopharyngeal function, was reported for patients in the Furlow-tonsillectomy group (0, IQR 0-0) compared to the Furlow only group (1, IQR 0-9, p = 0.046). No surgical complications were encountered in either group. Five patients (20.8%) in the Furlow only group required subsequent surgery for persistent VPI. No patients in the Furlow-tonsillectomy group required additional surgical treatment for VPI (0%, p = 0.16). CONCLUSIONS: Tonsillectomy at time of Furlow palatoplasty is utilized in patients with both VPI and baseline tonsillar hypertrophy to lessen the risk of postoperative obstructive breathing. Tonsillectomy performed concurrently with Furlow palatoplasty is safe, without increased risk of surgical complications, and does not compromise post-Furlow palatoplasty speech outcomes.

Experimental Models and Practical Simulators for Supermicrosurgery: An Updated Systematic Review and Meta-Analysis.

BACKGROUND: Supermicrosurgical simulators and experimental models promote test viability, a faster learning curve, technical innovations, and improvements of the surgical dexterities. The authors aimed to present a systematic review and meta-analysis of preclinical experimental models and simulation platforms used for supermicrosurgery. METHODS: An electronic search was conducted across the PubMed MEDLINE, Embase, Web of Science, and Scopus databases in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Data collection included the types of experimental models and outcomes. Pooled estimates were calculated with a random-effect meta-analysis using the DerSimonian-Laird model. RESULTS: Thirty-eight articles were incorporated in the qualitative synthesis. Twenty-three articles reported the use of in vivo models (60.5%), 12 used ex vivo models (31.5%), and three used synthetic models (7.9%). The superficial inferior epigastric system of rats was the most common in vivo model, whereas chicken wings and hindlimbs were the most common methods used in ex vivo models. The most common methods to evaluate patency of anastomoses were gross inspection, passage of nylon thread into the lumen, and intravascular flow of an injected dye. Nineteen studies were incorporated in the meta-analysis. The overall rate of a successful anastomosis was 94.9% (95% CI, 92.3 to 97.5%). The success rate of in vivo models using rats was 92.5% (95% CI, 88.8 to 96.3%). The success rate of ex vivo models was 97.7% (95% CI, 94.6 to >99%). CONCLUSION: Simulators that have high fidelity concerning the dissection of the vascular pedicle, flap elevation, supermicrovascular anastomosis, and adequate assessment of a successful anastomosis possess adequate predictive validation to evaluate and simulate the supermicrosurgical technique. CLINICAL RELEVANCE STATEMENT: Supermicrosurgical simulators are designed to reproduce specific clinical scenarios; therefore, these should be implemented sequentially to develop specific competencies. Supermicrosurgical models must be regarded as mutually inclusive learning platforms to optimize the learning curve.

Applications of three-dimensional surgical planning in facial feminization surgery: A systematic review.

BACKGROUND: Despite some reports that have shown an increase in safety, efficiency, and accuracy during feminizing craniofacial procedures utilizing three-dimensional (3D) technology, there are no reports summarizing the available evidence on this matter for facial feminization surgery (FFS). Here, we aimed to systematically review the application of 3D technology on FFS. METHODS: We conducted a comprehensive search across PubMed, SCOPUS, Ovid MEDLINE®, Web of Science, and ScienceDirect looking for studies reporting the use of 3D surgical planning in the setting of FFS following the PRISMA guidelines. We extracted data on photographic assessment, imaging, surgical application, and surgical technique and outcomes. RESULTS: This review included 10 studies comprising 1473 transgender female patients and 50 cadaveric cranial specimens. Four studies employed virtual surgical planning (VSP) and the concomitant use of prefabricated cutting guides. One study reported the implementation of 3D VSP using a female skull as a reference. One study used computer-aided design cutting guides and custom plates for FFS. Standardized incorporation of 3D printed models allowed for preoperative planning in three studies. Three studies reported VSP using 3D reconstruction of CT images, but without the use of 3D printing. Three studies used 3D photography with specialized camera technology to enrich clinical documentation and provide a comprehensive facial analysis of soft tissue. Accuracy ranged from 85.7% to 97%. Morbidity ranged from 0% to 12.5%. CONCLUSION: Based on this data, we believe 3D VSP has promising outcomes in terms of accuracy and low morbidity, encouraging its implementation in FFS. However, further prospective double-arm cohort studies are required.

BMPR1A maintains skeletal stem cell properties in craniofacial development and craniosynostosis.

Skeletal stem cells from the suture mesenchyme, which are referred to as suture stem cells (SuSCs), exhibit long-term self-renewal, clonal expansion, and multipotency. These SuSCs reside in the suture midline and serve as the skeletal stem cell population responsible for calvarial development, homeostasis, injury repair, and regeneration. The ability of SuSCs to engraft in injury site to replace the damaged skeleton supports their potential use for stem cell-based therapy. Here, we identified BMPR1A as essential for SuSC self-renewal and SuSC-mediated bone formation. SuSC-specific disruption of Bmpr1a in mice caused precocious differentiation, leading to craniosynostosis initiated at the suture midline, which is the stem cell niche. We found that BMPR1A is a cell surface marker of human SuSCs. Using an ex vivo system, we showed that SuSCs maintained stemness properties for an extended period without losing the osteogenic ability. This study advances our knowledge base of congenital deformity and regenerative medicine mediated by skeletal stem cells.

Laryngoscopy Grade Improvement and Difficult Airway Resolution in Infants With Robin Sequence Undergoing Mandibular Distraction Osteogenesis: A Multi-Institutional Study.

OBJECTIVE: Mandibular distraction osteogenesis (MDO) aims to relieve tongue-based airway obstruction in Robin Sequence (RS). We investigated direct laryngoscopy grade (DLG) improvement and difficult airway (DA) resolution following MDO. DESIGN: Retrospective cohort analysis. SETTING: Three tertiary care institutions. PATIENTS: Sixty-four infants with RS who underwent a single MDO procedure in their first year of life were identified from January 2010 to January 2019. MAIN OUTCOME MEASURES: The primary outcome was DLG pre- and post-MDO. Secondary outcomes included DA designation, pre- and post-MDO polysomnographic assessment for obstructive sleep apnea (OSA), length of stay, need for gastrostomy, and major/minor adverse events. RESULTS: Median DLG improved from II pre-MDO to I at the time of distractor removal (n = 43, P < .001). No significant change was seen in patients with a third recorded time point (eg, palatoplasty; n = 78, P = .52). Twenty-six (47%) of 55 patients were designated as DA pre-MDO, and 10 (18%) of 55 patients retained the label post-MDO (P < .01). Five (50%) of these 10 patients appeared to be inappropriately retained. Median obstructive apnea-hypopnea index improved from 38.6 (range 31.2-62.8) pre-MDO to 2.9 (range 1-3.9) post-MDO (n = 12; P = .002). CONCLUSION: Mandibular distraction osteogenesis allowed for DLG improvement that was stably maintained as well as functional improvement in OSA, with minimal morbidity. Difficult airway designation persisted in the electronic record of some infants despite clinical resolution.

Outcomes Following Orbital Floor Fractures in the Elderly.

BACKGROUND: Orbital floor fractures in the elderly are controversial, with varying guidelines on indications for operative and nonoperative management. Morbidity includes changes to ocular position, inferior rectus muscle injury, and damage to the neurovascular bundle as it traverses the orbital floor. Across all facial fractures, the elderly are less frequently operated on, albeit longer hospital stays and more probably ICU admission. This study's purpose is to describe our experience with orbital floor fractures and the role of operative versus nonoperative management in the context of patient age. METHODS: Retrospective review of orbital floor fracture coronal and sagittal CT images between 2015 and 2018 in those aged 20 to 40 (controls) or over 65 (cases). Patients were excluded if imaging revealed additional complex fractures of the upper third of the face or the midface. RESULTS: Twenty-five subjects met inclusion criteria for the elderly cohort (mean age of 79.4 years) compared to 48 subjects included in the control cohort (mean age 29.9). In the elderly population the most common mechanisms of injury were mechanical fall (72%) and syncope (8%), compared to assault (69%) and MVC (13%) in the controls. Two elderly patients (8%) required operative repair of their injury, whereas fourteen had surgery (29%) in the control cohort. Overall, the mean elderly fracture size was 3.19 cm (SD 1.18) and the mean control fracture size was 2.83 cm (SD 1.67) (P = 0.37). Within the elderly group, the mean fracture size for those who underwent surgery was 3.5 cm compared to 3.2 cm in those treated non-operatively (P = 0.27). Within the control group, the mean fracture size for those who underwent surgery was 2.9 cm compared to 2.8 cm in those treated non-operatively (P = 0.25). CONCLUSIONS: Orbital floor fractures in the elderly do not require operative intervention in most instances for management.

Ewing Sarcoma Presenting as a Congenital Scalp Mass.

Ewing sarcoma is a locally aggressive, highly malignant tumor most commonly seen in the skeletal system. The "Ewing family of tumors" also includes other tissue types that are not common, such as soft tissue origin classified as extraosseous Ewing sarcoma (EES) or primitive neuroendocrine origin. Age of onset most often occurs within the first 2 decades of life. Congenital presentation of EES is exceedingly rare. We report the first described case to our knowledge of congenital EES originating from the scalp.

The Relationship between Age and Facial Asymmetry.

BACKGROUND: Facial symmetry is a fundamental goal of plastic surgery, yet some asymmetry is inherent in any face. Three-dimensional photogrammetry allows for rapid, reproducible, and quantitative facial measurements. With this tool, the authors investigated the relationship between age and facial symmetry. METHODS: The authors imaged normal subjects using three-dimensional photogrammetry. Facial symmetry was calculated by identifying the plane of maximum symmetry and the root-mean-square deviation. Regression analysis was used to assess the relationship between age and symmetry. Subgroup analyses were performed among facial thirds. RESULTS: The authors imaged 191 volunteers with an average age of 26.7 ± 22.2 years (range, 0.3 to 88 years). Root-mean-square deviation of facial symmetry clustered between 0.4 and 1.3 mm (mean, 0.8 ± 0.2 mm). The authors found a significant positive correlation between increasing age and asymmetry (p < 0.001; r = 0.66). The upper, middle, and lower facial third's average root-mean-square deviations were 0.5 ± 0.2 mm (range, 0.2 to 1.2 mm), 0.6 ± 0.2 mm (range, 0.2 to 1.4 mm), and 0.6 ± 0.2 mm (range, 0.2 to 1.2 mm), respectively. Asymmetry also increased with age across all facial thirds (p < 0.001). CONCLUSIONS: Facial asymmetry increases with age in each facial third, with a greater asymmetry and increase in asymmetry in the lower two-thirds. Contributing factors may include asymmetric skeletal remodeling along with differential deflation and descent of the soft tissues. The observed correlation between increasing facial asymmetry and age may be a useful guide in plastic surgery to produce age-matched features.

The Evolution of Iliac Bone Graft Donor Site Analgesia in Cleft Patients: Transversus Abdominis Plane Block Is Safe and Efficacious.

BACKGROUND: The transversus abdominis plane (TAP) block has been increasingly used as a means of abdominal wall analgesia. This study aims to determine if TAP block analgesia provides a benefit in cleft patients undergoing alveolar bone grafting with iliac crest cancellous bone graft. METHODS: Two groups of 20 consecutive patients undergoing alveolar bone grafting with iliac crest cancellous bone with either TAP block or indwelling catheter pain pump were examined in a retrospective fashion. Demographic data, pharmacologic use, and hospital length of stay were examined. RESULTS: Mean lengths of stay were identical between both groups. Patients in both groups received similar cumulative doses of morphine equivalents, codeine, ibuprofen, and ondansetron at 6 and 24 hours postoperatively. Transversus abdominis plane block patients received greater amounts of Tylenol at both 6 and 24 hours (P = 0.0015 and P = 0.0106). Pain scores did not differ significantly across our groups at 6 or 24 hours postoperatively. No adverse events were reported with the TAP block procedure. CONCLUSIONS: Patients undergoing TAP blocks receive the benefit of a single stage procedure without an indwelling catheter and similar 6- and 24-hour morphine usage. Given the safety profile of the procedure, its effectiveness and comfort without indwelling catheter, we advocate for TAP block analgesia as an adjunct therapy in the management of postoperative pain in this population.

Novel computer vision analysis of nasal shape in children with unilateral cleft lip.

BACKGROUND: Optimization of treatment of the unilateral cleft lip nasal deformity (uCLND) is hampered by lack of objective means to assess initial severity and changes produced by treatment and growth. The purpose of this study was to develop automated 3D image analysis specific to the uCLND; assess the correlation of these measures to esthetic appraisal; measure changes that occur with treatment and differences amongst cleft types. METHODS: Dorsum Deviation, Tip-Alar Volume Ratio, Alar-Cheek Definition, and Columellar Angle were assessed using computer-vision techniques. Subjects included infants before and after primary cleft lip repair (N = 50) and children aged 8-10 years with previous cleft lip (N = 50). Two expert surgeons ranked subjects according to esthetic nose appearance. RESULTS: Computer-based measurements strongly correlated with rankings of infants pre-repair (r = 0.8, 0.75, 0.41 and 0.54 for Dorsum Deviation, Tip-Alar Volume Ratio, Alar-Cheek Definition, and Columellar Angle, p < 0.01) while all measurements except Alar-Cheek Definition correlated moderately with rankings of older children post-repair (r âˆ¼ 0.35, p < 0.01). Measurements were worse with greater severity of cleft type but improved following initial repair. Abnormal Dorsum Deviation and Columellar Angle persisted after surgery and were more severe with greater cleft type. CONCLUSIONS: Four fully-automated measures were developed that are clinically relevant, agree with expert evaluations and can be followed through initial surgery and in older children. Computer vision analysis techniques can quantify the nasal deformity at different stages, offering efficient and standardized tools for large studies and data-driven conclusions.

#Cleft: The use of Social Media Amongst Parents of Infants with Clefts.

INTRODUCTION: Many societies and organizations are using social media to reach their target audience. The extent to which parents of patients with craniofacial anomalies use social media has yet to be determined. The goal of this study is to characterize and describe the use of social media by the parents of children with cleft lip and palate as it pertains to the care of their child. MATERIALS AND METHODS: Parents or guardian of all patients presenting for initial consultation regarding a child's congenital cleft anomaly were contacted by phone or mail to complete a survey regarding their use of social media vis-à-vis their child's cleft anomaly. Participants were asked to answer a 19-question survey. RESULTS: Thirty-two families were contacted and 25 surveys were completed. Ninety-two percent of respondents used social media to learn about their child's diagnosis. Facebook (76%) and blogs (24%) were the most commonly accessed social media outlets, followed by Instagram (8%). Education about the diagnosis and treatment of cleft pathology (87%) was the most common reason for accessing social media, followed by companionship and support (56%), and advice about perioperative care (52%). Almost half (43%) of parents used social media to obtain information on their caregiver and treatment team, and 26% of parents used information gained on social media to guide their decision on where to seek care. CONCLUSION: Social media is a readily available resource, one that will certainly shape the experiences of our patients and families for years to come.

Measuring Symmetry in Children With Unrepaired Cleft Lip: Defining a Standard for the Three-Dimensional Midfacial Reference Plane.

OBJECTIVE: Quantitative measures of facial form to evaluate treatment outcomes for cleft lip (CL) are currently limited. Computer-based analysis of three-dimensional (3D) images provides an opportunity for efficient and objective analysis. The purpose of this study was to define a computer-based standard of identifying the 3D midfacial reference plane of the face in children with unrepaired cleft lip for measurement of facial symmetry. PARTICIPANTS: The 3D images of 50 subjects (35 with unilateral CL, 10 with bilateral CL, five controls) were included in this study. INTERVENTIONS: Five methods of defining a midfacial plane were applied to each image, including two human-based (Direct Placement, Manual Landmark) and three computer-based (Mirror, Deformation, Learning) methods. MAIN OUTCOME MEASURE: Six blinded raters (three cleft surgeons, two craniofacial pediatricians, and one craniofacial researcher) independently ranked and rated the accuracy of the defined planes. RESULTS: Among computer-based methods, the Deformation method performed significantly better than the others. Although human-based methods performed best, there was no significant difference compared with the Deformation method. The average correlation coefficient among raters was .4; however, it was .7 and .9 when the angular difference between planes was greater than 6° and 8°, respectively. CONCLUSIONS: Raters can agree on the 3D midfacial reference plane in children with unrepaired CL using digital surface mesh. The Deformation method performed best among computer-based methods evaluated and can be considered a useful tool to carry out automated measurements of facial symmetry in children with unrepaired cleft lip.

Pediatric Orbital Depth and Growth: A Radiographic Analysis.

BACKGROUND: Orbital reconstruction requires knowledge of orbital depth in order to prevent optic nerve injury. Numerous analyses of adult orbital dimensions have been undertaken previously in order to characterize this measurement, including skull specimen and computerized tomography studies. However, there is a paucity of information regarding the pediatric orbit. METHODS: The authors used pediatric magnetic resonance imaging (MRI) studies in order to quantify the change in orbital depth in relationship to patient age, and to develop methods to estimate and calculate orbital depth for individual pediatric patients. MRIs of the head in normal pediatric patients were reviewed retrospectively. Orbital depths were measured and correlated with age and cephalometric dimensions. In a randomly selected subgroup of patients, measurements were repeated by an independent investigator to determine interobserver reliability. RESULTS: Measurements were obtained in 72 patients ranging from 3 months to 18 years of age (mean=7.8 years). There was a significant exponential relationship between orbital depth and patient age (r=0.81, F(2,69)=143.97, P<0.001). Depth increased more rapidly in the first 6 years of life, but leveled off in the early teen years toward a horizontal asymptote of approximately 45 mm. There was also a significant relationship between orbital depth and the sum of the biparietal width plus the anterior-posterior length (r=0.72, F(2,69)=87.44, P<0.0001). There was high interobserver reliability in measurements between 2 independent investigators (r=0.79, P<0.0001). CONCLUSION: In children, orbital depth increases predictably with rising age and increasing head size. Knowledge of this growth curve and the relationship between head size and orbital depth can complement careful surgical dissection to improve safety and efficacy in pediatric orbital reconstructions.

Use of intraoperative computed tomography in complex craniofacial trauma: an example of on-table change in management.

The primary goals in repairing complex craniofacial fractures are restoration of occlusion and mastication, and anatomic reconstruction of a symmetric facial skeleton. Failure to accomplish these goals may result in the need for secondary operations. Recognition of malreduction may not be appreciated until review of a postoperative computed tomographic (CT) scan. Intraoperative CT scanning enables immediate on-table assessment of reduction and fixation, allowing alteration of the surgical plan as needed. We report using intraoperative CT scanning while repairing a panfacial injury in which malreduction was appreciated intraoperatively and corrected. Intraoperative CT can be used to improve outcomes and quality of complex facial fracture repair.