My personal evolution of caring for patients with congenital cleft malformations: a joyous, but humbling career.

The evaluation and treatment of patients with congenital orofacial clefting is a challenging task. Successful treatment requires a concerted effort by the cleft surgeon and cleft team to maximize the appearance and function of the cleft patient. To become a competent cleft surgeon, a facial plastic surgeon must be dedicated to a lifelong pursuit of technical excellence through continual evaluation, self-criticism, and improvement of surgical techniques and approaches. The contemporary cleft surgeon must integrate the knowledge gained by mentors that have years of expert experience and evidence-based information demonstrated by careful study. This information should help guide the young cleft surgeon as experience is gained and expertise developed through years of careful observation and evaluation of patients. This article is a discussion of the art and science of cleft surgery. It outlines the timetable associated with cleft repairs, the resources necessary to provide superior cleft care, and exposes the weaknesses and frailties of all cleft surgeons. It is designed to aid cleft surgeons in their pursuit of perfection.

Building a sustainable free flap program in a resource-limited setting: A 12-year humanitarian effort.

BACKGROUND: We present a sustainable complex reconstructive program built through 12 years of surgical outreach work at Kijabe Hospital in Kenya. METHODS: Retrospective chart review and anecdotal experiences. RESULTS: In 2011, surgeons from a US-medical center performed Kijabe Hospital's first 3 successful free flap surgeries. Since then, they have returned 7 times, performing a total of 31 tumor excisions with microvascular reconstruction. One flap failure occurred that was reconstructed on a subsequent trip. In 2013, a US-trained missionary surgeon and a Kenyan-trained general surgeon began working with the visiting team with the goal of performing these surgeries independently. In 2016 they performed their first independent free flap reconstruction and have since performed 32 independent cases with only three flap losses. Establishing infrastructure, staff education, selective patient criteria, and continuous communication are the factors that enabled the success of this program. CONCLUSIONS: Establishing a successful microvascular reconstruction program in a resource-limited setting is feasible.

Management of locally invasive well-differentiated thyroid cancer.

Thyroid carcinoma invasion of the aerodigestive tract and recurrent laryngeal nerve (RLN) are important factors with increase in morbidity and mortality. Primary treatment is surgery; the decision about the extent of surgery is difficult, because preserving function is as essential as removal of the tumor. This article discusses the literature relating to the assessment of disease, surgical management, and adjuvant therapy for invasive thyroid cancer of the aerodigestive tract and RLN and makes suggestions based on the authors' experience.

Revision rates and speech outcomes following pharyngeal flap surgery for velopharyngeal insufficiency.

IMPORTANCE: Velopharyngeal insufficiency in children with cleft palate (and other causes) contributes to difficulty with communication and quality of life. The pharyngeal flap is a workhorse to address hypernasality and nasal air escape. However, there is a paucity of literature on the characteristics of cases that require revision. OBJECTIVE: To measure the revision rate of pharyngeal flaps, compare the preperceptual and postperceptual speech scores, and identify the characteristics of those patients who required revision. DESIGN, SETTING, AND PARTICIPANTS: A retrospective medical record review was completed for patients who underwent pharyngeal flap surgery from June 1, 2008, through January 31, 2013, at a tertiary academic center. MAIN OUTCOMES AND MEASURES: Perceptual speech analyses and surgical revision rates. Perceptual speech patterns before and after surgery were compared using nasal air emission and resonance scores. The association between requiring revision surgery and covariates was analyzed using multivariable mixed-effects logistic regression. RESULTS: Sixty-one patients were identified, including 24 boys (39%) and 37 girls (61%). The mean (SD) patient age at the time of pharyngeal flap surgery was 8.2 (6.8) years (range, 3-55 years). Velopharyngeal insufficiency was associated with cleft palate in 51 patients (84%), and 17 patients (28%) had a syndrome. The mean (SD) time to surgery after the speech evaluation was 225 (229) days (range, 14-1341 days). The mean (SD) nasal air emission scores decreased by -1.1 (2.0 [1.1] preoperatively to 0.8 [1.1] postoperatively). The mean (SD) resonance score decreased by -1.5 (2.4 [1.1] preoperatively to 0.9 [1.1] postoperatively; P < .001). Flaps were revised in 12 patients (20%), including port revision in 9, complete flap revision in 2, and flap takedown in 1. The only covariate that was significantly associated with revision rates was increased age at surgery, which was associated with a higher probability of revision surgery (odds ratio, 1.31; 95% CI, 1.03-1.66; P = .04). CONCLUSIONS AND RELEVANCE: Pharyngeal flap surgery, when appropriately selected, was effective at improving speech with a revision rate of 20%, which is comparable to previously published studies. Increased age at the time of the pharyngeal flap surgery was associated with an increased need for revision surgery, supporting evidence that cleft centers should encourage early childhood speech evaluations with consistent documentation and prompt treatment. LEVEL OF EVIDENCE: 3.

Considerations in non-Caucasian facial rejuvenation.

Aging of the face is inevitable and undeniable. This process includes a loss of skeletal support, soft tissue volume depletion, and a decrease in skin elasticity. The contribution of these 3 factors varies between individuals with noticeable hereditary influence. Characteristic ethnic features have been described in the literature, but as societies have changed, many of these ethnic variations have blended together. Facial cosmetic procedures must to be tailored to address these variations in anatomy, and consideration must be given to enhancing the facial skeleton, adequately lifting the soft tissues, and planning careful incisions to be closed under no tension.

Comparison of complications in free flap reconstruction for osteoradionecrosis in patients with or without hyperbaric oxygen therapy.

BACKGROUND: Hyperbaric oxygen (HBO) therapy induces native tissue oxygenation. The hypothesis was patients with mandibular osteoradionecrosis (ORN) and a history of HBO therapy would have less free flap reconstruction complications than patients without HBO therapy. METHODS: We conducted a multisite retrospective review involving radical debridement and free flap reconstruction for ORN between January 1, 1995 and June 30, 2011. Patients were stratified based on receiving prior HBO therapy or not. RESULTS: Thirty-nine of 89 patients (43.8%) had HBO therapy whereas 50 of 89 (56.2%) did not. The HBO therapy group had significantly less patients with diabetes. There was no statistical difference in overall complication in patients between groups (p = .5478). However, there was marginal significance of increased infections in the patients with a history of HBO therapy (p = .0545). CONCLUSION: Although no significant differences in free flap reconstruction complication rates were observed between these 2 patient cohorts, there was marginal significance of increased infections in the patients with a history of HBO therapy. A prospective multi-institutional randomized study examining issues of infection would address issues inherent in this retrospective study.