The Implications of Laterality in Unilateral Cleft Lip Reconstruction: A Global Survey of Cleft Surgeons.

OBJECTIVE: To explore the impact of directional laterality in complete Unilateral Cleft Lip (UCL) amongst the global cleft surgeon community. DESIGN: Cross-sectional survey study. SETTING: Global distribution of online survey distributed in English and Spanish. PARTICIPANTS: Cleft surgeons from around the world. MAIN OUTCOME MEASURES: Survey participant perception of the impact of laterality on: (1) cleft presentation (2) surgical challenge and (3) surgical outcomes. RESULTS: Responses were received from 453 cleft surgeons located in 54 countries around the world. 221 (49%) had previously considered differences in patients presenting with a left- versus right-sided UCL. 95 (21%) considered right-sided clefts more difficult to reconstruct, 37 (8%) reported left-sided clefts to be more difficult and 321 (71%) reported no difference in difficulty between the cleft sides. Higher volume cleft surgeons, characterised by those reporting cleft as their principal area of practice and performing >20 cleft operations per year, were more likely to have both previously considered differences in laterality in cleft and to report right-sided unilateral cleft lip to be more difficult to primarily reconstruct. 395 (87%) did not consider surgical outcomes to be influenced by cleft laterality. CONCLUSIONS: This survey reports perceptions on cleft laterality from a large body of global surgeons and suggests a trend for increased difficulty in right-sided compared to left-sided cleft lip reconstruction, where such laterality-associated difficulty is perceived.

Sidedness in Unilateral Orofacial Clefts: A Systematic Scoping Review.

OBJECTIVE: An overview of the literature relating to the sidedness of unilateral cleft lip with or without cleft palate to map current knowledge on the cause and impact of directional asymmetry. DESIGN: Scoping review with a systematic search of Medline and Embase from inception to May 2023. PATIENTS, PARTICIPANTS: Humans born with a left or right unilateral cleft lip with or without a cleft palate. MAIN OUTCOME MEASURES: Cleft sidedness as a co-occurrence, an outcome or an exposure. RESULTS: Forty studies were eligible for inclusion and confirmed the predilection for the occurrence of left sided cleft lips; 12 studies reported cleft sidedness co-occurring with another phenotype, 11 studies report sidedness as an outcome and 17 studies as an exposure. Phenotypes which were reported to co-occur with either left or right sided clefts included congenital dental anomalies, handedness and additional congenital anomalies. Variables investigated as a potential cause of left or right sided clefts as an outcome included chromosomal anomalies, genetic variants and environmental factors. Outcomes investigated in relation to cleft sidedness as an exposure included facial anatomical features, facial growth, educational attainment, functional and psychological characteristics. More studies showed worse outcomes in right sided clefts versus left sided clefts than vice versa, although studies were inconsistent, and a quality assessment was not performed. CONCLUSIONS: The field of cleft sidedness research is expanding and there are promising early findings to differentiate cause and outcome by sidedness of the cleft.

The Cleft Multidisciplinary Collaborative: Establishing a Network to Support Cleft Lip and Palate Research in the United Kingdom.

BACKGROUND: As a growing paradigm of health research, trainee collaboratives can influence clinical practice through the generation of cost-effective multicenter audit and research projects. The aims of the present article are to outline and discuss the establishment of a multidisciplinary collaborative in the context of cleft lip and/or palate (CL/P). METHODS: The Cleft Multidisciplinary Collaborative (CMC) was formed in April 2016 under the overarching supervision of the National Institute for Health Research. Membership of the CMC is open to all members of the CL/P multidisciplinary team, who are encouraged to submit ideas for new research projects that will benefit clinical practice. RESULTS: To date, 48 clinical participants are involved in the CMC. These participants represent all 17 cleft teams from the United Kingdom and encompass a wide range of disciplines. The CMC has undertaken 2 major projects so far. The first involved collection of phenotype data to support a national cohort study. The second, still in progress, is a systematic review investigating factors associated with outcomes for velopharyngeal competence following cleft palate repair. CONCLUSIONS: The concept of a multidisciplinary collaborative in CL/P has been demonstrated through the generation of a United Kingdom-wide network of committed clinicians and researchers and the effective undertaking of 2 large research projects. As the CMC gathers momentum, it hopes to attract funding to support its activities, to promote more involvement from the allied health and nursing professions, to encourage a more ingrained research culture within the CL/P community, and to promote the wider ambition of a global collaborative.

Electronic Follow-Up of Developing World Cleft Patients: A Digital Dream?

OBJECTIVE: To identify potential access to telemedicine follow-up of children with clefts operated on a humanitarian mission. METHODS: A cross-sectional study of parents of children presenting to a humanitarian cleft lip and palate mission in a Provincial Hospital in the Philippines. A purpose designed questionnaire was used to assess access to electronic and digital resources that could be used to aid follow-up. Forty-five (N = 45) parents of children having primary cleft lip and or palate surgery participated. There were no interventions. Access to the Internet was through Parent Perceived Affordability of Internet Access and Parent Owned Devices. RESULTS: Thirty-one (N = 31) respondents were female. There was 93% mobile phone ownership. The mean distance traveled to the clinic was 187 km. Majority (56%) were fluent in English. Thirty-one percent accessed the Internet daily. Sixteen percent reported use of e-mail. Fifty-one percent accessed the Internet on a mobile device, and short message service use was the most affordable means of communication. CONCLUSIONS: Due to perceived unaffordability and low levels of access to devices with cameras and the Internet, as well as issues with privacy, we cannot recommend relying on electronic follow-up of patients in the developing world.

A Diagnostic Conundrum: Ectopic Nasal Ossification, Submucosal Alveolar Cleft, Absent Posterior Atlantal Arch, and Corpus Callosum Lipoma.

A 19-year-old woman was referred for nasal breathing and aesthetic concerns regarding her nose. A computed tomography scan revealed a massive osseous shield anterior to the piriform aperture. Furthermore, there was a submucosal median alveolar cleft, and the posterior arch of C1 was missing. The magnetic resonance imaging brain scan revealed a curvilinear lipoma of corpus callosum. The ectopic nasal bone was removed by open rhinoplast,y and nasal function and aesthetics were restored. The described features defy conventional clinical diagnosis and severity classifications and present a diagnostic conundrum somewhere between a mild form of frontonasal dysplasia, oculoauriculofrontonasal syndrome, and Pai syndrome.

Are NHS cleft services in England ready for delegation to integrated care systems?

Cleft care services in the UK have been nationally funded since centralisation 25 years ago and during this time have been able to demonstrate improved clinical outcomes. Integrated care systems have been introduced into legislature as part of the Health Care Act of 2022 and will be responsible for the paradigm shift of allocating funds on a regional basis for cleft care services in England from 2024. The proposed population-based funding formulas present an opportunity to improve current inequities in cleft care, including access to speech therapy and adult services. However, the regional footprint of integrated care systems does not align with that of the centralised cleft service system and represents a threat to the standardised patient-centred care that has taken two decades to build. Awareness needs to be raised so that cleft care providers can proactively adapt to this mandatory change to service funding to ensure that clinical standards are maintained and continue to improve.

Academic Training in Oral and Maxillofacial Surgery - when and how to enter the pathway.

Entering into surgical academia can seem a daunting prospect for an oral and maxillofacial surgery (OMFS) trainee. However, the streamlining of academic training by the NIHR to create the integrated academic training (IAT) pathway has simplified academic training and more clearly defined academic positions and entry points for trainees. In this article we review the current NIHR IAT pathway and the various grades and entry points available to OMF surgeons, both pre- and post-doctoral. We highlight the unique challenges facing OMF trainees and provide advice and insight from both junior and senior OMFS academics. Finally, we focus on the planning and application for a doctoral research fellowship - discussing funding streams available to OMF surgeons.

Rapid inactivation of SARS-CoV-2 by titanium dioxide surface coating.

Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission occurs via airborne droplets and surface contamination. Titanium dioxide (TiO 2) coating of surfaces is a promising infection control measure, though to date has not been tested against SARS-CoV-2. Methods: Virus stability was evaluated on TiO 2- and TiO 2-Ag (Ti:Ag atomic ratio 1:0.04)-coated 45 x 45 mm ceramic tiles. After coating the tiles were stored for 2-4 months before use. We tested the stability of both SARS-CoV-2 Spike pseudotyped virions based on a lentiviral system, as well as fully infectious SARS-CoV-2 virus. For the former, tile surfaces were inoculated with SARS-CoV-2 spike pseudotyped HIV-1 luciferase virus. At intervals virus was recovered from surfaces and target cells infected. For live virus,  after illuminating tiles for 0-300 min virus was recovered from surfaces followed by infection of Vero E6 cells. % of infected cells was determined by flow cytometry detecting SARS-CoV-2 nucleocapsid protein 24 h post-infection. Results: After 1 h illumination the pseudotyped viral titre was decreased by four orders of magnitude. There was no significant difference between the TiO 2 and TiO 2-Ag coatings. Light alone had no significant effect on viral viability. For live SARS-CoV-2, virus was already significantly inactivated on the TiO 2 surfaces after 20 min illumination. After 5 h no detectable active virus remained. Significantly, SARS-CoV-2 on the untreated surface was still fully infectious at 5 h post-addition of virus. Overall, tiles coated with TiO 2 120 days previously were able to inactivate SARS-CoV-2 under ambient indoor lighting with 87% reduction in titres at 1h and complete loss by 5h exposure. Conclusions: In the context of emerging viral variants with increased transmissibility, TiO 2 coatings could be an important tool in containing SARS-CoV-2, particularly in health care facilities where nosocomial infection rates are high.

Non-Interventional Factors Influencing Velopharyngeal Function For Speech In Initial Cleft Palate Repair: A Systematic Review Protocol.

BACKGROUND: This systematic review aims to inform the development of a screening tool which pre-operatively predicts which children are likely to develop velopharyngeal insufficiency, one of the causes of poor speech outcomes, following cleft palate repair. This would be highly beneficial as it would inform pre-operative counselling of parents, allow targeted speech and language therapy, and enable meaningful comparison of outcomes between surgeons, techniques, and institutions. Currently, it is unclear which factors influence speech outcomes. A systematic review investigating the non-interventional factors which potentially influence speech outcomes following cleft palate repair is warranted. This may be illuminating in itself or provide foundations for future studies. METHODS: A systematic review will be carried out according to Cochrane methodology and reported according to PRISMA guidelines (PLoS Med 6: e1000097, 2009). Systematic review software will be used to facilitate three-stage screening by two independent reviewers experienced in cleft lip and palate. Thereafter, data extraction and GRADE assessment will be performed in duplicate by five independent reviewers experienced in cleft lip and palate. Studies reporting the proportion of patients who were recommended or underwent secondary speech surgery for velopharyngeal insufficiency following primary surgery for cleft palate will be included. The study findings will be tabulated and summarised. The primary outcome measure will be further speech surgery (either recommended or performed). The secondary outcome measure will be perceptual speech assessment for the presence of velopharyngeal insufficiency. A meta-analysis is planned. However, if this is not possible, due to the anticipated marked heterogeneity of study characteristics, pre-operative assessment, and the recorded outcome measures, a narrative synthesis will be undertaken. DISCUSSION: This systematic review may provide sufficient data to inform the development of a screening tool to predict the risk of velopharyngeal insufficiency prior to cleft palate repair. However, it is anticipated that these findings will provide the foundation for future studies in this area. SYSTEMATIC REVIEW REGISTRATION: Registered on 19 December 2016 with PROSPERO CRD42017051624.

A survey of the career-defining determinants of prospective UK oral and maxillofacial surgical trainees.

Increasing numbers of medics are applying to dental school to pursue a career in oral and maxillofacial surgery (OMFS), particularly in the aftermath of Modernising Medical Careers (MMC), but their perspectives, experience, and training up to this point differ widely. We aimed to characterise these differences in the light of MMC and beyond by doing a survey of 20 dentists and 24 medics who were applying for their second degree. They were questioned about factors that influenced their choice of career and university, the motivation to pursue specialty training, and were asked for their opinions on suggested measures for workforce planning. The medics were subdivided into those who had trained before MMC (n=18), and those who had not (n=6). Dentists had considerably more OMFS experience than medics (mean 22 months compared with 4.2 months), and 46% (11/24) of medics had no substantive OMFS experience. Of those who had trained before MMC 3/18 considered OMFS as their first choice of career, compared with 4/6 who have trained since, and 15/20 of dentists. Eighty-three percent (20/24) of medics admitted that MMC had influenced their choice of career, and 54% (13/24) had applied for training in a specialty other than OMFS, notably otolaryngology. The most favoured method of workforce planning among all respondents (25/44) was "roughly matching" places on a second degree to projected OMFS training posts.