Faculty Bibliography

BACKGROUND: This article presents a real-time surgical simulator for teaching three- dimensional local flap concepts. Mass-spring based simulators are interactive, but they compromise accuracy and realism. Accurate finite element approaches have traditionally been too slow to permit development of a real-time simulator. METHODS: A new computational formulation of the finite element method has been applied to a simulated surgical environment. The surgical operators of retraction, incision, excision, and suturing are provided for three-dimensional operation on skin sheets and scalp flaps. A history mechanism records a user's surgical sequence. Numerical simulation was accomplished by a single small-form-factor computer attached to eight inexpensive Web-based terminals at a total cost of $2100. A local flaps workshop was held for the plastic surgery residents at the University of Wisconsin hospitals. RESULTS: Various flap designs of Z-plasty, rotation, rhomboid flaps, S-plasty, and related techniques were demonstrated in three dimensions. Angle and incision segment length alteration advantages were demonstrated (e.g., opening the angle of a Z-plasty in a three-dimensional web contracture). These principles were then combined in a scalp flap model demonstrating rotation flaps, dual S-plasty, and the Dufourmentel Mouly quad rhomboid flap procedure to demonstrate optimal distribution of secondary defect closure stresses. CONCLUSIONS: A preliminary skin flap simulator has been demonstrated to be an effective teaching platform for the real-time elucidation of local flap principles. Future work will involve adaptation of the system to facial flaps, breast surgery, cleft lip, and other problems in plastic surgery as well as surgery in general.

Background & Purpose: The aim of this study was to compare 3D symmetry of the nose in patients with UCLP, subsequent to rotation advancement (Millard) without primary nasal repair and the NAM/Cutting primary nasal repair. Methods & Description: Nasal casts were made for 12 consecutively appearing patients with UCLP, in each of two groups. Group 1 patients had a Millard repair without primary nasal repair (Bardach) while Group 2 patients had NAM and primary nasal repair. Patients were 6 to 18 years of age (mean=12.04). Surgery was performed at the mean age of 3.8 months. None of patients in Group 1 had primary nasal surgery as it was believed at the time by the surgeon that nasal growth might be inhibited. A two flap palatoplasty was performed at 12-24 months (mean age 19.75). All operations were performed by one surgeon in Group 1 and another surgeon in Group 2. Nasal casts were scanned using the 3Shape e scanner. All noses were scaled to the same size prior to evaluation. Procrustes analysis of 3D nasal symmetry was performed using 3dMD Vultus software. The Procrustes technique, determines nasal symmetry by performing a superimposition of its surface with its mirror image (ref Maull 1999). 4 linear measurements including columellar height, nasal dome height, alar base and nasal projections were performed on cleft and non-cleft side in both groups (ref Cutting 1984). For 3D analysis, student's t-test was used to determine the difference between the mean asymmetry index for each group. If symmetry is perfect the asymmetry index is zero. For linear analysis, student's T test was utilized to compare the differences. SPSS was used to perform a descriptive analysis of the groups. Results: The mean asymmetry index in the Millard rotation advancement repair was 4.41 and the NAM plus primary nasal repair was 2.45. The difference was statistically significant (P=0.006). In linear measurements, columellar length and alar base were significantly different when cleft side was compared to non-cleft side in Millard group (P=0.04 and 0.005). There was no significant difference in columellar length, nasal dome height, alar base and nasal projection in cleft versus non-cleft side in NAM group. Inter-group analysis showed that alar base in cleft and non-cleft side is significantly different in Millard versus NAM group (P=0.02). Conclusions: To our knowledge this is the first long-term, quantitative 3D study to analyze the asymmetry of the nose in the Millard rotation advancement versus NAM plus primary nasal repair in patients with complete UCLP. This study shows that the NAM plus primary nasal repair results in significantly less asymmetry of the nose compared to the Millard rotation advancement without nasal correction

Background & Purpose: We have produced a freely available, web-based, multimedia surgical simulator in partnership with Smile Train which demonstrates the cardinal procedures in primary cleft surgery. This tool is intended to help surgeons in developing countries care for their local cleft populations. Limitations of Internet access and local technology may hinder use in the developing world. We report on the international utilization of the world's first internet-based cleft simulator. Methods & Description: The Smile Train Virtual Surgery Simulator contains an internal tracking system which records the unique Internet Protocol (IP) addresses all users. Using these IP addresses, each country accessing the Simulator was identified over a one year period. All users accessing the Simulator for less than 5 minutes were eliminated. The countries were analyzed based upon economic factors such as Gross Domestic Product (GDP) and per capita income (PCI) as well as health metrics such as health expenditures and underweight children. Results: There were 849 novel users of the Simulator from 78 countries were recorded over the one-year study period. Those countries represent 6.28 billion persons or 88.5% of the global population. Of the countries utilizing the simulator 54 were classified as developing economies, representing 5.3 billion people. The developing countries average GDP was $467.4 +/- 147 billion and PCI was $8,281 +/- 815. The poorest developing countries accessing the Simulator in terms of PCI were Congo ($400), Ethiopia ($1,200), and Nepal ($1,300). In terms of percent population living below the poverty line, the poorest countries accessing the simulator were Haiti (80%) Congo (71%) and Nigeria (70%). In developing countries, the health expenditures as a percentage of GDP averaged 6.1%. The nations with the lowest healthcare expenditures as a percentage of GDP were Myanmar 2%, Pakistan 2.2%, and Indonesia 2.6%. Penetration into advanced economies was also extensive including 24 countries representing 979 million people and an aggregate GDP of $40.98 Trillion. In the United States the simulator was used in 40 states from both academic and community Internet service providers. Surprisingly, the simulator was used in 21 countries with active armed conflicts and 28 where the US State Department advises against travel including Ukraine, Egypt, Yemen, Iraq and Nigeria. Conclusions: The presented internet-based surgical simulator is accessible globally and has quickly gained use in 78 countries representing 88% of the global population including 5.3 billion of the worlds developing population. Over 2/3rds of the countries accessing the simulator are developing nations and include regions experiencing severe poverty. Projects directed towards international education of cleft care in the developing world should strongly consider the use of web-based digital technology as a means to immediately access and educate caregivers, particularly in countries with significant economic and political constraints. Disclosure: Receipt of Intellectual Property Rights/Patent Holder-Aaron Oilker holds the intellectual property rights for the biodigital surgery simulator

The present study aims to determine the risk of early secondary nasal revisions in patients with complete unilateral and bilateral cleft lip and palate (U/BCLP) treated with and without nasoalveolar molding (NAM) and examine the associated costs of care. A retrospective cohort study from 1990 to 1999 was performed comparing the risk of early secondary nasal revision surgery in patients with a CLP treated with NAM and surgery (cleft lip repair and primary surgical nasal reconstruction) versus surgery alone in a private practice and tertiary level clinic. The NAM treatment group consisted of 172 patients with UCLP and 71 patients with BCLP, whereas the non-NAM-prepared group consisted of 28 patients with UCLP and 5 with BCLP. The risk of secondary nasal revision for patients with UCLP was 3% in the NAM group and 21% in the non-NAM group. The risk of secondary nasal revision for patients with BCLP was 7% in the NAM group compared with 40% in the non-NAM group. Using multicenter averages, the non-NAM revision rates were calculated at 37.8% and 48.5% for U/BCLP, respectively. Applying these risks of revision, NAM treatment led to an estimated savings of between $491 and $4893 depending on the type of cleft. In conclusion, NAM can reduce the number of early secondary nasal revision surgeries and, therefore, reduce the overall cost of care.

ABSTRACT: Preoperative nasoalveolar molding (NAM) in combination with primary gingivoperiosteoplasty (GPP) reduces the need for secondary alveolar bone grafting by 60% in patients with unilateral cleft lip and palate (CL/P). Herein, we investigate the efficacy of NAM and primary GPP in patients with bilateral CL/P. All patients (n = 38) with bilateral CL/P who underwent NAM and primary GPP from 1988 to 1998 with at least 14 years of follow-up were included in this study. Panoramic and periapical radiographs were used to assess dentoalveolar bone formation. A total of 38 patients were identified with median follow-up of 18 years (range 14-26 years). Of the 27 patients who underwent bilateral GPP, 14 (51%) patients had successful dentoalveolar bone formation bilaterally and 13 (49%) had unilateral bone formation. No patient had a bilateral failure. Of the 11 patients who underwent unilateral GPP, 7 (63%) patients had successful dentoalveolar bone formation. Bilateral successful dentoalveolar bone formation following primary bilateral GPP has a dependent probability of 52% and a conditional probability of 82%.

ABSTRACT: Despite significant advances in cleft lip and palate treatment, anatomical controversies remain. Some have proposed that the width of the cleft is due to alveolar segmental displacement. Others suggest that the width is due to palatoalveolar hypoplasia. Improving our understanding of cleft anatomy may have implications for presurgical orthopedics and tissue engineering therapies. Palatoalveolar impressions of 17 noncleft children and 11 children with complete (alveolar, primary, and secondary) unilateral cleft palates were taken. Maxillary tuberosity positions and maxillary volumes were compared. Tuberosity position was determined by facebow transfer of palatoalveolar casts into geodetic datum boxes, and identification of the Cartesian coordinates (x, y, z) of the tuberosities relative to the box surfaces and Frankfurt horizontal. Maxillary volume was determined by immersing the palatoalveolar casts and measuring sand displacement. A significant difference was noted in the average tuberosity to contralateral tuberosity distance between cleft and noncleft cohorts. On average, cleft palate tuberosities were laterally displaced 8.7 mm compared with noncleft palates (P < 0.05). There was neither statistically significant alveolar segment elevation nor retroversion. A significant difference was noted in the average palatoalveolar volumes. The cleft palatoalveolar volume was 5.7 cm, and the noncleft palatoalveolar volume was 7.2 cm (P < 0.05). A palatal cleft is due to both alveolar tissue displacement and deficiency. Therefore, ideal cleft palate care should involve the correction of a displaced and deficient alveolus.

ABSTRACT: The incidence of postoperative complications in cleft care is low. In this 19-year retrospective analysis of cleft lip and palate patients treated with preoperative nasoalveolar molding, we examine the incidence of postoperative oronasal fistulae. The charts of 178 patients who underwent preoperative nasoalveolar molding by the same orthodontist/prosthodontist team and primary cleft lip/palate repair by the same surgeon over a 19-year period were reviewed. Millard, Mohler, Cutting, or Mulliken-type techniques were used for cleft lip repairs. Oxford-, Bardach-, or von Langenbeck-type techniques were used for cleft palate repairs. One nasolabial fistula occurred after primary cleft lip repair (0.56% incidence) and was repaired surgically. Four palatal fistulae (3 at the junction between soft and hard palate and 1 at the right anterior palate near the incisive foramen) occurred, but 3 healed spontaneously. Only 1 palatal fistula (0.71%) required surgical repair. All 5 fistulae occurred within the first 8 years of the study period, with 4 (80%) of 5 occurring within the first 3 years. Although fistula rate may be related to surgeon experience and the evolution of presurgical techniques, nasoalveolar molding in conjunction with nasal floor closure contributes to a low incidence of oronasal fistulae.

ABSTRACT: Nearly 60 years ago, Joseph Murray described several advancements to Bradford Cannon's Abbe flap reconstruction of secondary bilateral cleft lips in order to simplify the technique and improve results. Unlike their predecessors, Drs. Cannon and Murray modified the Abbe flap by splitting its apex in order to obtain a symmetrical correction of the upper lip and allow the 2 suture lines to extend vertically and laterally past the base of the columella and disappear within the floor of the nose. Eighteen years later, Dr. Murray reviewed the evolution of his own secondary cleft lip reconstruction experience to include a new approach to advance the maxilla rather than set back the mandible. In this Signature Issue, we reflect on contemporary innovations in secondary bilateral cleft lip Abbe flap reconstruction. Today, we approach the secondary reconstruction of the bilateral cleft lip in 3 stages. First, we establish normal anatomic positioning of the midface. Second, we perform secondary cleft nasal surgery as necessary. Finally, only after the midfacial skeleton and nose have been treated do we proceed with Abbe flap reconstruction of the upper lip. We inset the Abbe flap a quarter of the way out on the columella and wrap the Abbe darts around the sides of the columella. We find that designing the Abbe flap this way avoids the saber cut-like notching at the lip-columella junction, redundant vermilion, and excess flap length, and it also reduces or eliminates the need for upper or lower lip scar revision.

In 1971, Micheal Hogan introduced the Lateral Port Control Pharyngeal Flap (LPCPF) which obtained good results with elimination of VPI. However, there was a high incidence of hyponasality and OSA. We hypothesized that preoperative assessment with videofluoroscopy and nasal endoscopy would enable modification and customization of the LPCPF and result in improvement in the result in both hyponasality and obstructive apnea while still maintaining results in VPI. Thirty consecutive patients underwent customized LPCPF. All patients had preoperative diagnosis of VPI resulting from cleft palate. Patient underwent either videofluoroscopy or nasal endoscopy prior to the planning of surgery. Based on preoperative velar and pharyngeal movement, patients were assigned to wide, medium, or narrow port designs. Patients with significant lateral motion were given wide ports while patients with minimal movement were given narrow ports. There was a 96.66% success rate in the treatment of VPI with one patient with persistent VPI (3.33%). Six patients had mild hyponasality (20 %). Two patients had initial OSA (6.67%), one of which had OSA which lasted longer than six months (3.33%). The modifications of the original flap description have allowed for success in treatment of VPI along with an acceptably low rate of hyponasality and OSA.

The pediatric dentist plays a crucial role in the treatment and management of infants born with cleft deformities of the lip, alveolus, and palate. At New York University Langone Medical Center in New York City, 70% of infants with cleft lip/cleft palate (CLCP) are detected on prenatal ultrasound analysis. Thus, the role of the pediatric dentist can start as early as prenatal counseling. Nasoalveolar molding (NAM) is delivered during the first 3 to 5 months of life. During this stage of treatment, the pediatric dentist establishes the foundation of the "cleft dental" home and initiates the first stage of anticipatory guidance. Consequently, parents are educated and motivated to initiate oral hygiene care upon eruption of the first primary teeth. The purpose of this paper was to describe the role of the pediatric dentist in performing nasoalveolar molding and also describe its indications, appliance design, fabrication, biomechanics, complications, and patient management.