Faculty Bibliography

Background/Purpose: Cleft deformities of the lip and palate affect nearly one in 500 to 700 births and lead to increased morbidity and mortality if untreated. Nevertheless, significant global disparities in access to timely and appropriate care still exist. The relatively basic infrastructure required to surgically correct these deformities and large unmet disease burden have resulted in a significant number of foundation-based cleft care initiatives focused toward developing countries. In this study, we evaluate the peer-reviewed literature generated by these foundations in an attempt to assess their clinical, scientific, educational, and economic impact. Methods/Description: A comprehensive review of the literature was performed using key search terms, and the level of evidence of identified articles was determined. Data were then analyzed to determine the different models of foundation-based cleft care in developing countries, as well as their clinical, scientific, educational, and economic impact.
Result(s): A total of 244 articles were identified through our search and reviewed. The levels of evidence of these articles were also determined, and included 3 (1.2%) level I, 62 (25.4%) level II, 11 (4.5%) level III, 59 (24.2%) level IV, 53 (21.7%) level V, and 56 (23.0%) articles that were not gradable. Foundation-based cleft care initiatives in developing countries have significantly contributed to a better understanding of disease epidemiology, barriers to care, safety considerations, complications and outcomes, as well as international and local cleft surgery education. The cleft care center model is more cost-effective than the surgical mission model and provides more sustainable care.
Conclusion(s): Foundation-based cleft care prevents significant morbidity in developing countries and has provided valuable resources for capacity building. The surgical mission model should be considered as a transitory conduit for establishing the more effective and sustainable cleft care center model of care

Background/Purpose: Despite the increasing trend toward ambulatory surgery rate in general, for cleft lip repair, 72.1% of patients in the United States are still hospitalized. Multiple centers have been studying this and with the very recent publishing of 2 large volume studies published in Plastic and Reconstructive Surgery supporting the safety of outpatient cleft lip surgery, it has become a high-profile debatable topic in cleft management. Last year at ACPA in the plastic surgery breakout session there was a heated debate on the topic between surgeons. And just this summer, one of the authors articles was featured as the PRS Journal Club article of the month via Social media, where there were 68 comments, 11 shares, and 40 likes, which placed the article in the TOP 15 most viewed article in PRS Journal's website. So this is a topic that more and more surgeons and craniofacial teams are thinking about and considering changing practice management but that deserves being brought into the spotlight to discuss all the pros and cons. The goal of the presentation are to present a literature review up to date on inpatient versus outpatient cleft lip surgery and have members of the panel share their and data behind their approach to postoperative cleft lip management. We would like to focus on what has been studied and reported versus what people practice because "that is how they were trained" or that is how they "historically" have always done it. Methods/Description: We will start with an overview of the literature surrounding inpatient versus outpatient cleft lip surgery and epidemiology about the numbers of institutions that do inpatients versus outpatient. If possible, we would like to include an audience poll to get an idea of practice patterns in the room. Then based on the recent published studies, each panelist will share different protocols that have been successful for outpatient cleft lip management and how that could be implemented if a center wants to consider outpatient cleft lip surgery. This includes: preoperative education that can be done by the team or nurse managers, perioperative management before, during, and after the operation, and postoperative care after they go home. All are very key components to a successful outpatient cleft lip management. We will also discuss the barriers to doing outpatient cleft lip surgery as well as having a panelist who consistently does inpatient cleft lip surgery to present the rationale behind their practice management and also their barriers to outpatient cleft lip surgery. I have reached out to a few people and will be discussing with them at the upcoming ASPS meeting to see who may be interested in joining the panel to discuss that. We will discuss the economic impact overall of practice changes to a predominantly outpatient surgery and also potential insurance policy impact. We think this will be a very useful topic for any team member participating in the care of a cleft lip patient

Background/Purpose: Alveolar cleft surgery is the most common bone reconstruction performed in patients with a cleft. Osteogenic agents such as BMP-2 have been used to restore the bony cleft without the morbidity of bone graft, but concerns remain regarding premature fusion of sutures, exuberant bone formation, and malignant degeneration. We have recently demonstrated that dipyridamole-coated, 3D printed bio-ceramic (3DPBC) scaffolds generate comparable bone amounts to BMP2 and significantly greater bone compared to negative controls in short-term growing animal model studies. No detrimental effects to growth sutures were noted in any animals. This study investigates the long-term osteogenic properties, degradation kinetics, and effects on facial growth of these tissue engineering constructs in growing animal models. Methods/Description: Twenty-two 1-month-old (immature) New Zealand white rabbits underwent creation of unilateral 3.5 x 3.5 mm alveolar defects. Each alveolar defect was repaired with either 3DPBC scaffolds coated with 1000 muM dipyridamole (n = 14) or with autogenous bone graft from the radius (n = 8). Six rabbits from the 3DPBC scaffold group were sacrificed at 8 weeks. The remaining rabbits (n = 8 each group) were euthanized following completion of craniofacial growth (6 months). Bone regeneration, scaffold degradation, and maxillary suture patency were calculated using CT images reconstructed and analyzed in Amira software. Facial symmetry was evaluated using dense-surface 3D modeling and validated with bilateral cephalometric measurements of maxillary projection. Bone growth and suture patency were qualitatively evaluated through histologic analysis.
Result(s): After 6 months, animals with defects repaired with 3DPBC scaffolds regenerated an average of 52.9% +/- 3.3% bone (mean +/- SEM), compared to 40.7%+/-4.0% in defects repaired with bone graft (P = .02). This is compared to unoperated alveolus occupied by 39.3% +/- 1.6% bone. Scaffolds showed significant degradation at 6 months (6.7% +/- 1.6%) compared to at 8 weeks (27.1% +/- 1.9%; P >= .001). Morphometric analysis using dense surface modeling showed similar symmetry indices of 55.0 +/- 3.3 for scaffold animals and 61.7% +/- 1.6% for bone graft animals (P = .10). Comparative measurements of operated and unoperated sides showed no significant differences in asymmetry between scaffold and bone graft animals (P = .86). Histologic analysis of scaffold samples revealed vascularized, organized bone within scaffold interstices without evidence of ectopic bone, excess inflammatory cells, or suture fusion.
Conclusion(s): In a growing animal model, dipyridamole-coated 3DPBC scaffolds can regenerate bone comparable to autogenous bone graft by radiographic and histologic analysis. Over 6 months, scaffolds show significant, favorable degradation and do not result in premature suture fusion or disruption of facial growth compared to bone graft. These results support long-term safety and efficacy of this tissue engineering strategy in the repair of alveolar cleft defects

The surgical treatment of nonsyndromic craniosynostosis is one of the most common procedures performed by craniofacial surgeons. However, for residents and fellows, the high degree of difficulty and complex anatomy may result in slow progress along a steep learning curve. This is particularly important in the context of contemporary academic practice, where work-hour limits and other factors restrict operative exposure and opportunities for trainees to learn. These issues have prompted the development of surgical simulation modalities that, while prevalent in other surgical specialties, have not been fully adopted in reconstructive surgery.Among these resources is the Craniofacial Interactive Virtual Assistant - Professional Edition (CIVA-Pro), a procedural cognition simulator that is free of charge. By integrating 3-dimensional virtual animation, voice over, and high-definition intraoperative video, CIVA-Pro describes cardinal craniofacial surgery procedures in an engaging platform. In this study, a detailed, step-by-step description of the fronto-orbital advancement surgical technique to complement the corresponding CIVA-Pro module was presented. This synergistic combination of multimedia educational resources provides a unique didactic option for current trainees to prepare for surgery.

BACKGROUND:Single-stage primary cleft lip and palate (PCLP) repair is controversial in the United States, and most patients are treated with a staged approach. In this study, early postoperative complications of the single-stage approach as compared to primary cleft lip (PCL) or primary cleft palate (PCP) alone were evaluated. This study represents the largest cohort of patients undergoing combined cleft lip and palate repair. METHODS:The American College of Surgeons National Surgical Quality Improvement Program-Pediatric database was used to identify patients undergoing single-stage PCLP, PCL, or PCP repairs. Preoperative factors and postoperative outcomes were compared between the 3 groups, as well as within the PCLP group between patients with and without complications. Univariate and multivariate analyses were performed. RESULTS:A TOTAL OF:: 181 patients were included in the single-stage PCLP group, 1007 in the PCP group and 783 in the PCL group. There was no difference in the rates of early complications between the 3 groups. Within the PCLP group, cardiac risk factors (β = 35.19; 95% confidence interval [CI] 7.88-75.21; P = 0.04) and complications (β = 77.31; 95% CI 35.82-118.79; P < 0.001) were significant risk factors for longer operative time. CONCLUSION/CONCLUSIONS:Analysis of a national database showed that single-stage PCLP repair is not associated with increased risk of early postoperative complications as compared to primary lip or palate repair alone. In-depth long-term analyses of craniofacial morphology, fistulae rate, speech, and dental outcomes are essential for a comprehensive assessment of the effects of combined cleft lip and palate repair.

Background/UNASSIGNED:Rhinoplasty relies on clear patient communication and precise execution of a three-dimensional (3D) plan to achieve optimal results. As 3D imaging and printing continue to grow in popularity within the medical field, rhinoplasty surgeons have begun to leverage these resources as an aid to preoperative planning, patient communication, and the technical performance of this challenging operation. Objective/UNASSIGNED:Utilizing departmentally-available resources and open access 3D imaging platforms, we have developed an affordable, reproducible protocol for rapid in-house virtual surgical planning (VSP) and subsequent manufacture of 3D-printed rhinoplasty models. Methods/UNASSIGNED:Preoperative 3D photographic images underwent virtual rhinoplasty using a freely-available 3D imaging and sculpting program (BlenderTM [Version 2.78, Amsterdam, The Netherlands]). Once the ideal postoperative result was digitally achieved, scaled, sterilizable and patient-specific 3D models of the preoperative and ideal postoperative result were manufactured in-house using a departmentally-owned 3D printer. Results/UNASSIGNED:3D-printed models have successfully been manufactured and employed for 12 patients undergoing rhinoplasty. The average time to prepare a set of pre- and postoperative models was 3 hours, while the printing process required 18-24 hours per model. Each set of surgical models can be manufactured at a total materials cost of approximately $5.00. Conclusions/UNASSIGNED:We describe an affordable means to construct sterilizable, scaled, patient-specific 3D-printed models for rhinoplasty. This technique may become of increasing interest to academic and cosmetic centers as hardware costs of 3D printers continues to fall.