Scar Outcome in Unilateral Complete Cleft Lip Repair: A Comparative Analysis of Vertical Lip Lengthening Strategies Using the Rotation-Advancement Concept.

OBJECTIVE: To assess the differences in scar outcomes between modified rotation-advancement techniques proposed by Drs. Mohler and Noordhoff, designed to address issues such as inadequate vertical lip length and scarring on the upper third of the lip in the original rotation-advancement technique. DESIGN: Retrospective single-surgeon (RD) study. PATIENTS: Consecutive non-syndromic children (n = 68) with unilateral complete cleft lip and palate. INTERVENTIONS: Modified Mohler (columellar backcut reconstructed with C flap; n = 34) and modified Noordhoff (lower, medially-created backcut reconstructed with laterally-based triangular skin flap; n = 34) repairs. MEAN OUTCOME MEASURES: Using 12-month postoperative frontal photographs, scar evaluations (overall and superior, middle, and inferior portions of the lip) were appraised by an assessment panel composed by independent professional and nonprofessional raters employing four validated qualitative scar assessment scales: Manchester Scar Scale, modified Scar-Rating Scale, Stony Brook Scar Evaluation Scale, and Visual Analog Scale. Quantitative computerized photogrammetric scar widths of the superior, middle, and inferior portions of the upper lip were also measured. RESULTS: The modified Noordhoff method showed significantly (all P < .001) better scar quality for the overall scar and superior portion of the scar in all four scales compared to the modified Mohler method, with no significant (all P > .05) difference for the middle and lower portions. No significant difference (all P > .05) was observed for photogrammetric scar width measurements. CONCLUSION: The modified Noordhoff technique provided better qualitative results for unilateral complete cleft lip-related scars compared to the modified Mohler technique.

Two-flap technique with interpositional dermofat graft for anterior oronasal fistula closure in patients with cleft: A case series.

BACKGROUND: Oronasal fistula at the anterior hard palate is one of the common sequelae after cleft surgery, and the leakage negatively affects the patient's quality of life. Although several surgical techniques have been proposed for reconstruction, it remains challenging because of the scarred regional tissue with a high rate of fistula recurrence. In this study, we present the anterior oronasal fistula repair using a two-flap technique with an interpositional dermofat graft (DFG). METHODS: A retrospective review of anterior oronasal fistula repair performed by the senior author between April 2018 and August 2022 at the Craniofacial Center was conducted. Patients who underwent a fistula repair using the technique were further identified and investigated. RESULTS: Thirty-four operations were performed using the technique, and 31 fistulas were completely closed, with a success rate of 91.2%. The fistula symptom improved but persisted postoperatively in 3 patients, of whom 2 patients underwent a second fistula repair using the same procedure, resulting in successful closure. Fistula recurrence was significantly correlated with fistula size (p = 0.04). The DFG was simultaneously utilized for nasal dorsum and/or vermillion reconstruction in 28 cases. CONCLUSION: The two-flap technique enabled tension-free approximation, and the interpositional DFG facilitated watertight closure of the fistula, resulting in a high success rate of anterior oronasal fistula repair. The fistula closure could be combined with other revisional procedures for cleft-related deformities, where the DFG was simultaneously utilized.

Secondary Bilateral Cleft Rhinoplasty: Achieving an Aesthetic Result.

BACKGROUND: Secondary rhinoplasty in patients with bilateral cleft lip poses ongoing challenges and requires a reliable method for achieving optimal outcomes. OBJECTIVES: The purpose of this study was to establish a safe and effective method for secondary bilateral cleft rhinoplasty. METHODS: A consecutive series of 92 skeletally matured patients with bilateral cleft lip and nasal deformity were included. All had undergone secondary open rhinoplasty, performed by a single surgeon, with the use of bilateral reverse-U flap and septal extension graft between 2013 and 2021. Medical records of these 92 patients were reviewed to assess the clinical course. The three-dimensional anthropometric analysis and panel assessment of 32 patients were performed to evaluate the aesthetic improvement using an age-, sex-, and ethnicity-matched normal control group for comparisons. RESULTS: The methods showed statistically significant improvement in addressing short columella (columellar height), short nasal bridge (nasal bridge length), de-projected nasal tip (nasal tip projection, nasal dorsum angle), poorly defined nasal tip (nasal tip angle, dome height, and panel assessment), and transversely oriented nostrils (columellar height, alar width, nostril type). Importantly, these improvements were accompanied by a low complication rate of 4%. However, upper lip deficiency over the upper lip angle and labial-columellar angle remains without significant improvement. CONCLUSIONS: This study described the effective secondary rhinoplasty that was composed of bilateral reverse-U flap and septal extension graft with acceptable outcome. The 3D anthropometric analysis and panel assessment clarified that our rhinoplasty procedure could bring the nasal morphology in the patients closer to the normal data.

Validating the Modified Small Double Opposing Z-Plasty for Palatal Lengthening in Primary Palatoplasty.

OBJECTIVE: To appraise the degree of intraoperative palatal lengthening with the modified Furlow small double-opposing Z-plasty (sDOZ). DESIGN: Retrospective single-surgeon (R.D.) study. PATIENTS: Nonsyndromic children (n = 167) with Veau types I to IV cleft palates who underwent primary sDOZ palatoplasty. INTERVENTIONS: Intraoperative measurements of palatal lengths and widths were collected using calipers, paper rulers, and metal rulers before the administration of local anesthetic solution and before the removal of the mouth gag (initial and final palatal dimensions, respectively). MAIN OUTCOME MEASURES: Assessment of the intraoperative percentage change (difference between final and initial values) in surface palatal length, straight palatal length, and soft palatal length. Bivariate and multivariate analyses were performed to identify independent predictors (sex, age at surgery, Veau, Kernahan/ Stark, and Randall classifications, widest cleft width, presence of lateral relaxing incision, type of coverage with buccal fat flap, and postoperative complications) of soft palatal lengthening. RESULTS: Surface palatal, straight palatal, and soft palatal lengths had an intraoperative increase of 8%, 14.7%, and 27.7%, respectively. The degree of intraoperative soft palatal lengthening significantly varied among Veau cleft types (I = II < III = IV). Veau type III and cleft lip/palate were independent positive predictors (P < .001) of soft palatal lengthening, while other tested variables were not correlated (P > .05) with this outcome. CONCLUSIONS: Overall intraoperative palatal lengthening occurs with the modified sDOZ palatoplasty, with differences within the spectrum of cleft palate deformity.

Primary rhinoplasty in patients with bilateral cleft lip: Longitudinal results and comparison between closed and semi-open approaches.

BACKGROUND: Although several studies have shown that primary rhinoplasty in patients with cleft lip provides good outcomes with limited effect on nasal growth, the surgical procedure remains to be standardized. The purpose of this study was to evaluate the long-term outcome of primary semi-open rhinoplasty with Tajima reverse-U incision, compared with that of closed rhinoplasty. METHODS: Consecutive nonsyndromic patients with complete bilateral cleft lip and palate (n = 52) who underwent primary semi-open rhinoplasty between 2001 and 2016 were reviewed. Patients who underwent primary closed rhinoplasty (n = 61) and control group individuals were recruited for comparison. Computer-based standardized measurements of 2D photographs and panel assessments by laypersons were collected and statistically analyzed. RESULTS: In the comparative analysis at preschool age, semi-open rhinoplasty significantly improved the typical nasal deformities, including transversely oriented wide nostrils, short columella, and de-projected nasal tip, more effectively than closed rhinoplasty. Without major drawbacks, these parameters in the semi-open group were well maintained closer to those in the control group till skeletal maturity. After primary rhinoplasty, 54% of patients in the closed group and 4% in the semi-open group underwent intermediate rhinoplasty at preschool age. CONCLUSION: This study showed that the patients who underwent primary semi-open rhinoplasty achieved long-term and persistent outcomes that were closer to the normal nasal morphology compared with the patients treated with closed rhinoplasty, while avoiding intermediate rhinoplasty during the preschool to adolescent periods.

Chang Gung Forum: An Exemplary Strategy for Implementing a Multidisciplinary Network of Experts in Craniofacial Anomalies.

INTRODUCTION: The Chang Gung Forum has been dedicated to the care of craniofacial anomalies since 2000. This annual continuing medical education program focuses on orofacial cleft and surgery-first orthognathic surgery by providing up-to-date information and management guidelines. This study explored how the Chang Gung Forum has influenced medical perspectives, decisions, and practices in a multidisciplinary craniofacial team. METHODS: Between 2000 and 2022, 20 Chang Gung Forums have been held. A questionnaire was distributed among 170 attendees who had participated in the forum more than once. The questionnaire collected information on the participants' experiences and levels of satisfaction with the educational program and whether or how it had influenced their clinical practice. RESULTS: Valid responses from 86 attendees (response rate, 50.6%) who had participated more than once were collected and analyzed. The overall satisfaction rate of the Chang Gung Forum based on the respondents' most recent visits was 4.28 ± 0.63 out of 5. Of the respondents, 90.9% acknowledged changes in their clinical practice, with modifications in surgery plans and decisions being the most notable (48.5%). In addition, comprehension increased throughout years of attending the annual forum (P < 0.001). CONCLUSION: The Chang Gung Forum has contributed markedly to the community of congenital craniofacial anomalies. The program will continue providing updated information and influencing the clinical decision-making of health care professionals.

Modified Furlow palatoplasty using small double-opposing Z-plasty: Long-term outcome and comparison with two-flap palatoplasty.

BACKGROUND: The post-palatoplasty velopharyngeal function needs to be evaluated through long-term follow-up, but such reports are limited in the literature and there has been no consensus as to which surgical technique yields optimal velopharyngeal function with minimum complication rate. This study aimed to evaluate the long-term outcome of the modified Furlow palatoplasty using small double-opposing Z-plasty (small-DOZ). METHODS: A retrospective review of consecutive patients who received palatoplasty performed by the senior author between January 2000 and March 2014 was conducted. Non-syndromic patients who underwent palatoplasty before the age of 18 months and followed-up until at least 9 years of age were included. Comparisons between the small-DOZ and two-flap methods for soft palate repair were made. RESULTS: A total of 196 small-DOZ and 167 two-flap palatoplasty patients were eligible in the study. Among the small-DOZ palatoplasty patients, 1 patient (0.5%) developed oronasal fistula, and 18 patients (9.2%) received velopharyngeal insufficiency (VPI) surgery (10 patients at preschool age and 8 at nine years of age). Compared with the small-DOZ palatoplasty, the oronasal fistula rate, VPI surgery rate, and the need for myringotomy tube insertion were significantly higher in the two-flap group (p =0.01, <0.01, <0.01, respectively). Patients who developed oronasal fistula had significantly higher likelihood of having velopharyngeal insufficiency (p < 0.01). CONCLUSION: The small-DOZ provided successful palatal repair with low rates of oronasal fistula and VPI in the long-term. Wound closure under minimal tension facilitated to avoid oronasal fistula. Reconstruction of the functional muscle sling enabled to achieve normal velopharyngeal function with favorable speech outcome and middle ear function.

Septal extension graft in cleft rhinoplasty: Patients with secondary unilateral cleft lip nasal deformity.

BACKGROUND: Tip refinement procedure is still controversial in secondary unilateral cleft rhinoplasty. The aim of this study was to assess whether septal extension graft improved nasal and tip deformity and achieved a normal profile with clinical and 3D morphometric analyses. METHODS: A consecutive series of 194 skeletally mature patients with unilateral cleft were included and analyzed. All had undergone secondary open rhinoplasty, performed by a single surgeon, with the use of septal extension graft between 2013 and 2021. Clinical data were collected, and 3D morphometric measurements were performed. An age-, sex-, and ethnicity-matched normal group was included for comparisons. RESULTS: Our standard procedures included open approach combining reverse U incision, septal extension graft, dorsal augmentation, lip revision, and vermilion augmentation. The postoperative outcome showed significantly increased numerical values (nasal bridge length, nasal height, nasal tip projection, nasal dorsum angle, columellar angle, columellar-lobule angle, nostril height ratio, nasal surface area, nasal volume) and decreased numerical values (alar width, tip/middle deviation, nasal tip angle, labial-columellar angle) than the preoperative morphology. The postoperative measurement showed significantly higher numerical values (nasal protrusion, tip/middle deviation, nasal dorsum angle), and lower numerical values (columellar-lobule angle, nostril height ratio, alar width ratio) than the control group. CONCLUSION: This study revealed that our secondary cleft rhinoplasty significantly improved the under-projected, up-rotated, deviated, and poorly defined tip as well as short nasal bridge deformities. The technique could result in the nose of the patients with cleft lip nasal deformity being closer to that of the normative profile.

The Rise of Online Medical Education in Craniofacial Surgery.

BACKGROUND: International travel had been radically disrupted by coronavirus disease 2019 (COVID-19), leaving traditional medical conferences on a 2-year hiatus. The International Craniofacial Chang Gung Group (ICC) was thus created to disseminate knowledge related to craniofacial surgery. This study aimed to reveal how webinars fundamentally transformed the traditional format of medical conferences. MATERIALS AND METHOD: In total, 64 ICC webinars held between December 13, 2020, and May 21, 2023, were documented and reviewed. A questionnaire was designed and sent to ICC members. The questionnaire collected information on attitudes and habits relating to videoconferencing in general before and after the start of COVID-19 and on the ICC webinars specifically. Responses were analyzed to inform our understanding of respondents' experience and satisfaction with the webinars. RESULTS: The webinars covered a variety of topics related to craniofacial surgery. In total, 64 webinars were included for analysis. The mean number of attendees at each webinar was 86.7. In total, 111 respondents were more satisfied (4.25 ± 0.72 out of 5) with ICC webinars than with other media of online meetings ( P < 0.001). In total, 89.2% of respondents were willing to continue attending ICC webinars after COVID-19 restrictions have been lifted. CONCLUSIONS: Webinars are an effective format for imparting knowledge, especially in the ICC, and will become key in continuing medical education.

Effective correction of columellar base deviation in primary unilateral cleft lip repair: A muscle-driven method.

SUMMARY: Columellar base deviation is a common and challenging deformity in patients with unilateral cleft lip. Debate still continues on its surgical correction without sufficient studies to establish an effective management. This article presents our experience in correcting the columellar base deviation with the muscle-driven method in primary lip repair. The key is to perform extensive muscle dissection and reconstruction. In the medial lip segment, muscle dissection is performed subcutaneously up to the contralateral nostril floor for effective lengthening and rotation. In the lateral lip segment, muscle dissection is executed in both submucosal and subcutaneous planes, and muscle component is extensively separated from the lip skin and buccal mucosa. The lateral muscle flap is advanced and reattached to the contralateral nostril floor and columellar base using a subcutaneous sustaining suture. Cinching suture between columellar base and alar base is performed. These two sutures help to centralize and over-correct the columellar base. Bilateral muscle components are re-oriented and approximated in a Z-plasty format for lengthening of the lip. The patients were followed up for at least 3 years. Quantitative measurements of deviation in columellar base angulation were executed, which revealed 55.8±2.6° (before nasoalveolar molding), 29.6±1.7° (after nasoalveolar molding), and 2.8±0.4° (postoperative follow-up), respectively. The muscle-driven method represents a safe and effective technique to correct columellar base deviation in patients with unilateral cleft lip.

Risk of Dry Eye Syndrome in Patients with Orbital Fracture: A Nationwide Population-Based Cohort Study.

This study aimed to investigate whether orbital fracture increases the risk of dry eye syndrome (DES) and identified the profile of prognostic factors. We studied a cohort from the Taiwan National Health Insurance Research Database (NHIRD). Overall, 46,179 and 184,716 participants were enrolled in the study and control groups, respectively. Each patient in the case group was age- and gender-matched to four individuals without orbital fracture that served as the control group. Cox proportional hazards analysis regression was used to estimate the risks of incident DES. During the follow-up period, the case group was more likely to develop incident DES (0.17%) than the control group (0.11%) (p = 0.001). Multivariate Cox regression analysis demonstrated that the case group had a 4.917-fold increased risk of DES compared to the controls. In the stratified age group, orbital fracture had the highest impact on patients aged 18-29 years. Furthermore, patients with orbital roof fracture have a greater risk of developing DES. Regardless of whether having received surgery or not, the patients with orbital fracture have higher risks of DES. Our study demonstrated that orbital fracture increases the risk of developing subsequent DES. Early recognition by thorough examinations with raised awareness in the clinical setting could preserve visual function and prevent further complications.

Workflow and Strategies for Recruitment and Retention in Longitudinal 3D Craniofacial Imaging Study.

Longitudinal epidemiological studies are considered the gold standard for understanding craniofacial morphologic development, but participant recruitment and retention can be challenging. This study describes strategies used to recruit and maintain a high level of participation in a longitudinal study involving annual three-dimensional (3D) craniofacial soft-tissue imaging from healthy Taiwanese Chinese elementary school students aged 6 to 12 years. The key aspects for project delineation, implementation, and the initial three-year practical experiment are portrayed in an integrated multistep workflow: ethics- and grant-related issues; contact, approval, and engagement from partners of the project (school stakeholders and parents); a didactic approach to recruit the students; research staff composition with task design; three station-based data collection days with two educative activities (oral hygiene and psychosocial interaction stations) and one 3D craniofacial imaging activity; and reinforcement tactics to sustain the longitudinal annual participation after the first enrollment. Randomly selected students and teachers answered an experience satisfaction questionnaire (five-point Likert scale ranging from one to five) designed to assist in understanding what they think about the data collection day. Measures of frequency (percentage) and central tendency (mean) were adopted for descriptive analysis. Six of seven contacted schools accepted participation in the project. All parents who attended the explanatory meetings agreed to join the project. A cohort of 676 students (336 girls) participated at baseline enrollment, with a follow-up rate of 96% in the second data collection. The average questionnaire-related scores were 4.2 ± 0.7 and 4.4 ± 0.6 for teachers and students, respectively. These 3D craniofacial norms will benefit multidisciplinary teams managing cleft-craniofacial deformities in the globally distributed ethnic Chinese population, particularly useful for phenotypic variation characterization, conducting quantitative morphologic comparisons, and therapeutic planning and outcome assessment. The described pathway model will assist other groups to establish their own age-, sex-, and ethnic-specific normative databases.