Faculty Bibliography

Tessier facial clefts are rare congenital abnormalities and among the most challenging deformities treated by craniofacial surgeons. Despite various surgical interventions, treatment outcomes remain limited, resulting in a higher burden of care and lower quality of life. PreSurgical Infant Orthopedics (PSIO) has shown benefits in cleft care, but its application to Tessier clefts is underreported. This report assesses the long-term surgical outcomes of 3 patients with Tessier clefts who underwent PSIO. The cleft width and premaxilla reduction were observed in all 3 patients.

ObjectiveTo evaluate learners' acceptance of multiuser virtual reality (VR) simulation platform while practicing the Furlow repair technique for cleft palate reconstruction.DesignNonrandomized with pre- and postsurveys.SettingTertiary care institution's Department of Surgery September 2023 through August 2024.ParticipantsTwenty plastic surgery residents from level PGY1 to PGY6 from a single institution.InterventionsMultiuser Meta Quest 2 VR simulation-based workshop with an expert surgeon demonstrating a Furlow cleft palate repair. Feedback included audio and visual.Main outcome measuresLearner confidence in using VR as a tool for surgical education, understanding of the Furlow technique, and opinion regarding the incorporation of VR into surgical and medical education. Satisfaction as measured by the Student Evaluation of Educational Quality questionnaire survey with a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree).Results20 residents participated in this study, of which 65% had previously participated in a cleft palate repair and 40% had used VR. After the simulation, trainees' confidence in using VR as a tool for surgical education, understanding of the Furlow technique, and opinion regarding the incorporation of VR into surgical and medical education significantly increased (P < .05). Trainees found the simulation stimulating (4.85 ± 0.67), interesting (4.45 ± 0.83), clear (4.60 ± 0.82), an effective teaching tool (4.75 ± 0.44) and would recommend it to others (4.90 ± 0.31). Participants reported that they would feel somewhat comfortable repeating the simulation alone (3.95 ± 1.05).ConclusionMultiuser VR-based simulation workshops can significantly increase learners' confidence and skills in the Furlow technique and promote positive opinions regarding VR as an educational tool. Learners considered this platform effective and stimulating and would recommend it as an educational tool.

Virtual surgical planning (VSP) has revolutionized orthognathic and craniomaxillofacial surgeries by enabling precise 3-dimensional analysis, detailed osteotomy planning, and custom fabrication of surgical guides and fixation hardware. However, the visualization of registration holes-critical for accurate plate fixation-remains challenging, especially in a blood-filled surgical field. This paper presents a novel technique to enhance the visibility of registration holes using Bonney's blue dye. The technique involves injecting micro-aliquots of Bonney's blue dye (a mixture of crystal violet and brilliant green) into the registration holes before performing osteotomies. This approach ensures that the holes remain clearly marked despite potential visual contamination in the surgical field. The dye helps to identify screw placements and align patient-specific fixation plates more accurately. The proposed method addresses common difficulties in aligning registration holes with patient-specific plates during surgery. Bonney's blue dye provides a clear contrast against the bone, making the registration holes more visible and easier to locate. This improvement is particularly advantageous in a bloody surgical field and benefits less experienced surgeons by offering a straightforward solution to enhance accuracy and efficiency. The technique can also reduce overall operative time by minimizing the time spent locating and aligning the registration holes. Utilizing Bonney's blue dye in virtual surgical planning significantly improves the visibility and alignment of registration holes in orthognathic surgeries. This simple, cost-effective method enhances surgical precision and efficiency and can be applied to other computer-assisted surgical procedures in craniofacial surgery.

OBJECTIVES/OBJECTIVE:To examine the feasibility of outpatient alveolar bone grafting (ABG) using Exparel (bupivacaine liposome injectable suspension) for donor site analgesia. DESIGN/METHODS:Retrospective, observational study. SETTING/METHODS:Single institution, 39-month retrospective review. PATIENTS/PARTICIPANTS/METHODS:In total, 21 patients with cleft alveolus were included in this study. INTERVENTION/METHODS:In autologous outpatient ABG procedures using a mixed open harvest and Acumed trephine method to retrieve corticocancellous bone from the iliac crest, Exparel was injected in the donor site fascia. MAIN OUTCOME MEASUREMENTS/METHODS:Postoperative data including length of stay, post anesthesia care unit narcotics delivered, and maximum pain scores were recorded. Successful outcomes were assessed by exploring 30-day complications, 30-day emergency department visits, 30-day readmissions, and ambulation at follow-up. RESULTS:The average hospital length of stay was 360.8 min. Four patients required overnight stay secondary to pain. The average doses of pain medications administered postoperatively were 198.4 mg acetaminophen, 9.3 mg ketorolac, 3.0 µg fentanyl, and 1.5 mg oxycodone. No patient reported 30-day complications secondary to donor site pain, 30-day emergency department visits, or 30-day readmissions, and there was only one case of wound dehiscence. All patients exhibited proper ambulation at follow-up and healed well from ABG. CONCLUSIONS:The use of Exparel for donor site analgesia in outpatient ABG procedures using corticocancellous grafts can result in adequate pain management and ambulation without an increased risk of complications and readmissions.

MAIN OBJECTIVE/OBJECTIVE:To analyze postoperative palatoplasty outcomes before and after systemic protocol changes to preferred bottle and arm immobilizer use after surgery. DESIGN/METHODS:Retrospective, cohort study. SETTING/METHODS:Urban, academic, tertiary medical center in New York City, NY. PARTICIPANTS/METHODS:= 39). INTERVENTIONS/METHODS:Protocols were amended over the 2018 calendar year to allow for utilization of the baby's preferred bottle (vs alternative feeding methods) and hand socks (vs arm immobilizers) in the immediate postoperative period. Data was extrapolated from electronic medical records to compare surgical outcomes. MAIN OUTCOME MEASURES/METHODS:Postoperative wound complications (fistula and dehiscence) that did not resolve within 1 month, length of stay (hours), and 30-day re-admission. Nonparametric Mann-Whitney U tests and Fisher's Exact test were utilized for statistical analysis. RESULTS: = .366). CONCLUSIONS:The findings from this study suggest relaxing postoperative protocols following palatoplasty to allow immediate bottle feedings and unrestricted arm use may be safe without compromise to surgical outcomes.

IMPORTANCE/UNASSIGNED:Catastrophic facial injury with globe loss remains a formidable clinical problem with no previous reports of reconstruction by whole eye or combined whole eye and facial transplant. OBJECTIVE/UNASSIGNED:To develop a microsurgical strategy for combined whole eye and facial transplant and describe the clinical findings during the first year following transplant. DESIGN, SETTING, AND PARTICIPANT/UNASSIGNED:A 46-year-old man who sustained a high-voltage electrical injury with catastrophic tissue loss to his face and left globe underwent combined whole eye and face transplant using personalized surgical devices and a novel microsurgical strategy at a specialized center for vascularized composite allotransplantation. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Reperfusion and viability of the whole eye and facial allografts, retinal function, and incidence of acute rejection. RESULTS/UNASSIGNED:The patient underwent a combined whole eye and face transplant from an immunologically compatible donor with primary optic nerve coaptation and conventional postoperative immunosuppression. Globe and retinal perfusion were maintained throughout the immediate postoperative period, evidenced by fluorescein angiography. Optical coherence tomography demonstrated atrophy of inner retinal layers and attenuation and disruption of the ellipsoid zone. Serial electroretinography confirmed retinal responses to light in the transplanted eye. Using structural and functional magnetic resonance imaging, the integrity of the transplanted visual pathways and potential occipital cortical response to light stimulation of the transplanted eye was demonstrated. At 1 year post transplant (postoperative day 366), there was no perception of light in the transplanted eye. CONCLUSIONS AND RELEVANCE/UNASSIGNED:This is the first report of whole eye transplant combined with facial transplant, demonstrating allograft survival including rejection-free graft survival and electroretinographic measurements indicating retinal response to light stimuli. These data highlight the potential for clinical allotransplantation for globe loss.

OBJECTIVES/OBJECTIVE:To assess surgical instrument usage in cleft lip (CL) and cleft palate (CP) surgery and create an optimized surgical tray with an associated cost-savings analysis. DESIGN/METHODS:Prospective, observational study. SETTING/METHODS:Single institution, 6-month prospective review. PATIENTS/PARTICIPANTS/METHODS:A total of 10 primary CL surgeries and 10 primary CP surgeries were included in this study. INTERVENTION/METHODS:Complete lists of surgical instruments utilized in CL and CP surgeries were collected. UNLABELLED:Utilization fractions (UFs) were calculated as the percentages of average used instruments to averaged opened instruments per case. New optimized CL and CP surgical trays were idealized by removing instruments not used in at least 20% of cases, and a cost analysis was performed to identify potential savings. Calculation of annual potential savings was also conducted based on institutional caseload. RESULTS:The average instrument UFs were 26.0% for CL and 22.6% for CP. The estimated costs were $33.15 to $290.29 for the original CL surgical tray and $10.20 to $63.80 for the optimized tray. For CP, the original tray's cost was estimated at $38.25 to $319.00, and the optimized tray at $9.18 to $57.42. This demonstrates a cost reduction of $22.95 to $226.49 for CL and $29.07 to 261.58 for CP. CONCLUSIONS:The idealized surgical instrument tray could contribute to reducing healthcare expenditures and promoting operating room efficiency, patient safety, and environmentally friendlier operating theaters.

Patients with cleft lip and palate (CLP) characteristically present with maxillary hypoplasia and class III malocclusion. Protraction headgear (PHG) is a commonly used treatment for this type of malocclusion, with the goal of reducing future surgical needs. The purpose of this study was to evaluate the long-term effects of PHG treatment and determine the pretreatment predictors of long-term PHG success in patients with CLP. Twenty-nine patients with CLP who had undergone PHG treatment from 2012 to 2017 at a single institution were retrospectively analyzed. Patients were included if they had a lateral cephalogram or CBCT before, immediately after, and at least 5 years after their PHG treatment. Patients were divided into surgery and nonsurgery groups based on their 5-year follow-up clinical presentation. Student t tests, Wilcoxon signed-rank test, and a multivariate logistic regression model were used to compare pretreatment and post-treatment changes in both groups. Immediately post-treatment, the maxilla advanced 2.6 mm, the maxillary dentition advanced 4.7 mm, and the mandible rotated downward 5.0 mm and backward 2.6 mm. At long-term follow up the maxilla advanced 0.0 mm while the mandible advanced an additional 7.5 mm. Thus, PHG treatment is effective at improving class III malocclusion in the short term, but may not prevent future surgical need for patients with more severe skeletal discrepancies. Variables predictive of future surgical need include ANB, anterior facial height, overjet, and starting age of treatment, with ANB as the most reliable early predictor.

STUDY DESIGN/UNASSIGNED:Retrospective observational study. OBJECTIVE/UNASSIGNED:This study analyzes the epidemiology of pediatric Le Fort fractures and assesses the incidence of concomitant injuries and acute-level hospital course using the largest, national pediatric trauma database to date. METHODS/UNASSIGNED:Pediatric midface and Le Fort fractures from 2016-2019 were identified in the National Trauma Data Bank. Descriptive analyses of Le Fort compared to non-Le Fort midface fractures were performed. Multivariable regression assessed whether Le Fort fractures were risk factors for ICU admission, intracranial injury, cervical spine (C-spine) fracture, tracheostomy, and mortality. RESULTS/UNASSIGNED:< 0.001). Incidence of all the above increased with higher-grade Le Fort fractures. Le Fort III fractures had higher rates of mortality than non-Le Fort midface fractures (7.6% vs 3.2%). Multivariable regression showed that all Le Fort patterns were independent risk factors for tracheostomy and ICU admission, but only Le Fort I for C-spine fractures. CONCLUSIONS/UNASSIGNED:The incidence of Le Fort fractures appears to increase with age. Higher category Le Fort fractures are associated with greater morbidity.