Faculty Bibliography

PURPOSE: Currently, surgeons approach autogenous microtia repair by creating a two-dimensional (2D) tracing of the unaffected ear to approximate a three-dimensional (3D) construct, a difficult process. To address these shortcomings, this study introduces the fabrication of patient-specific, sterilizable 3D printed auricular model for autogenous auricular reconstruction. METHODS: A high-resolution 3D digital photograph was captured of the patient's unaffected ear and surrounding anatomic structures. The photographs were exported and uploaded into Amira, for transformation into a digital (.stl) model, which was imported into Blender, an open source software platform for digital modification of data. The unaffected auricle as digitally isolated and inverted to render a model for the contralateral side. The depths of the scapha, triangular fossa, and cymba were deepened to accentuate their contours. Extra relief was added to the helical root to further distinguish this structure. The ear was then digitally deconstructed and separated into its individual auricular components for reconstruction. The completed ear and its individual components were 3D printed using polylactic acid filament and sterilized following manufacturer specifications. RESULTS: The sterilized models were brought to the operating room to be utilized by the surgeon. The models allowed for more accurate anatomic measurements compared to 2D tracings, which reduced the degree of estimation required by surgeons. Approximately 20 g of the PLA filament were utilized for the construction of these models, yielding a total material cost of approximately $1. CONCLUSION: Using the methodology detailed in this report, as well as departmentally available resources (3D digital photography and 3D printing), a sterilizable, patient-specific, and inexpensive 3D auricular model was fabricated to be used intraoperatively. This technique of printing customized-to-patient models for surgeons to use as 'guides' shows great promise.

BACKGROUND: Tongue-lip adhesion (TLA), mandibular distraction osteogenesis (MDO), and subperiosteal release of the floor of the mouth (SPRFM) are the most commonly performed surgical procedures to treat severe airway obstruction in infants born with Pierre Robin sequence (PRS). OBJECTIVES: To determine the rate of failure of each type of procedure, in terms of mortality and the need for tracheostomy, and to determine what proportion of infants have significant airway obstruction postoperatively as determined by polysomnography (PSG) and compare the data by procedure type. METHOD: A comprehensive literature search (1981 through June 2015) was done of the National Library of Medicine database using PubMed. Extracted data included diagnosis, type of surgery, and outcome including mortality, need for postoperative tracheostomy and details of PSG. Persistence of significant airway obstruction was defined as an apnea-hypopnea index >15 events/h on PSG. RESULTS: Both mortality rate and need for tracheostomy were low for all procedures. Many studies lacked sufficient detail to identify significant airway obstruction postoperatively. In studies with sufficient data, MDO was associated with the lowest percentage of significant airway obstruction postprocedure (3.6%) compared to 50% for infants who underwent TLA. Insufficient PSG data was available for patients who were treated with SPRFM. CONCLUSIONS: There is a paucity of objective PSG data to definitively assess postoperative airway outcomes for PRS. MDO appears to be the most effective technique based on the available PSG data. Standardized use of PSG may lead to better identification and treatment of patients at risk for suboptimal airway outcomes postoperatively.

BACKGROUND: Cleft and craniofacial centers require significant investment by medical institutions, yet variables contributing to their academic productivity remain unknown. This study characterizes the elements associated with high academic productivity in these centers. METHODS: The authors analyzed cleft and craniofacial centers accredited by the American Cleft Palate-Craniofacial Association. Variables such as university affiliation; resident training; number of plastic surgery, oral-maxillofacial, and dental faculty; and investment in a craniofacial surgery, craniofacial orthodontics fellowship program, or both, were obtained. Craniofacial and cleft-related research published between July of 2005 and June of 2015 was identified. A stepwise multivariable linear regression analysis was performed to measure outcomes of total publications, summative impact factor, basic science publications, total journals, and National Institutes of Health funding. RESULTS: One hundred sixty centers were identified, comprising 920 active faculty, 34 craniofacial surgery fellowships, and eight craniofacial orthodontic fellowships; 2356 articles were published in 191 journals. Variables most positively associated with a high number of publications were craniofacial surgery and craniofacial orthodontics fellowships (beta = 0.608), craniofacial surgery fellowships (beta = 0.231), number of plastic surgery faculty (beta = 0.213), and university affiliation (beta = 0.165). Variables most positively associated with high a number of journals were craniofacial surgery and craniofacial orthodontics fellowships (beta = 0.550), university affiliation (beta = 0.251), number of plastic surgery faculty (beta = 0.230), and craniofacial surgery fellowship (beta = 0.218). Variables most positively associated with a high summative impact factor were craniofacial surgery and craniofacial orthodontics fellowships (beta = 0.648), craniofacial surgery fellowship (beta = 0.208), number of plastic surgery faculty (beta = 0.207), and university affiliation (beta = 0.116). Variables most positively associated with basic science publications were craniofacial surgery and craniofacial orthodontics fellowships (beta = 0.676) and craniofacial surgery fellowship (beta = 0.208). The only variable associated with National Institutes of Health funding was craniofacial surgery and craniofacial orthodontics fellowship (beta = 0.332). CONCLUSION: Participation in both craniofacial surgery and orthodontics fellowships demonstrates the strongest association with academic success; craniofacial surgery fellowship, university affiliation, and number of surgeons are also predictive.

BACKGROUND:Postoperative airway obstruction is a feared complication following cleft palate repair. The aim of this study was to evaluate the effectiveness of tongue stitches and nasal trumpets that have been used in an attempt to prevent this complication. METHODS:An 8-year (2005 to 2013) retrospective review of palatoplasties performed at a tertiary care center was conducted. Patients were divided into three groups: those with no airway protective measure, those with a tongue stitch only, and a group with nasal trumpet and tongue stitch. Recorded variables included sex, age, Veau classification, and comorbidities. Primary outcomes measured were postoperative respiratory distress, readmission, and reoperation rates. RESULTS:Fifty-eight patients underwent palatoplasties with no airway protective measure, 252 patients had tongue stitch only, and 87 had tongue stitch and nasal trumpet. There were no significant differences between groups with respect to comorbidities except that cleft lip was more prevalent in the no-airway protection group than in the other two groups (p = 0.04). There was no significant difference in the incidence of reintubation, intensive care unit transfer, surgery-related readmissions, or reoperation. Respiratory complications were significantly increased in the nasal trumpet group even after adjusting for age and weight. Length of stay was also significantly (p < 0.01) shortened when comparing no airway protection to those who underwent both nasal trumpet and tongue suture placement. CONCLUSIONS:The use of a tongue stitch, with or without nasal trumpet, did not correlate with improved safety and outcomes. Patients without these airway protective measures had a shorter hospital stay. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, III.

Contemporary plastic surgery residents are increasingly challenged to learn a greater number of complex surgical techniques within a limited period. Surgical simulation and digital education resources have the potential to address some limitations of the traditional training model, and have been shown to accelerate knowledge and skills acquisition. Although animal, cadaver, and bench models are widely used for skills and procedure-specific training, digital simulation has not been fully embraced within plastic surgery. Digital educational resources may play a future role in a multistage strategy for skills and procedures training. The authors present two virtual surgical simulators addressing procedural cognition for cleft repair and craniofacial surgery. Furthermore, the authors describe how partnerships among surgical educators, industry, and philanthropy can be a successful strategy for the development and maintenance of digital simulators and educational resources relevant to plastic surgery training. It is our responsibility as surgical educators not only to create these resources, but to demonstrate their utility for enhanced trainee knowledge and technical skills development. Currently available digital resources should be evaluated in partnership with plastic surgery educational societies to guide trainees and practitioners toward effective digital content.

Background/Purpose: Patients with cleft lip and palate commonly require an alveolar bone graft (ABG) at approximately 8 years old to allow for tooth descent in the location of the alveolar cleft. This procedure was previously performed with at least one post-operative overnight stay due to hip pain. Upon transitioning from an open iliac crest bone harvesting technique to an Acumed drill, we observed that most patients had limited hip pain and were treatable as outpatients. We report feasibility and cost analysis of performed ABG surgery as an outpatient using the Acumed drill technique. Methods/Descriptions: Under IRB-approval, a 3-year retrospective review was conducted of all subjects born with a cleft lip/palate (CLP) and who had an alveolar bone graft performed between 2012 and 2015. Patients were categorized based upon hospital stay: inpatient (overnight stay), observation (23-hour), or outpatient. Prior to April 2013, patients underwent ABG surgery as a planned inpatient procedure (Group 1). After April 2013, patients underwent ABG surgery as a planned outpatient procedure (Group 2). Cost data acquired included: total direct cost (costs associated directly with patient care), total variable direct cost (costs which vary according to the needs of each patient), fixed direct cost (charges that do not fluctuate depending on what is done), and the sum of total direct costs for both medical/surgical supplies and operating room costs. T-tests were used to determine differences in various cost categories between groups of patients. Results: 58 patients were enrolled with a total of 62 procedures (4 patients had 2 ABGs), and with a mean age of 10 years at the time of surgery. 7 procedures were inpatient, 16 were observation, and 39 were outpatient. 7 of 14 Group 1 patients (50%) were admitted as inpatients, whereas 0 of 48 Group 2 patients were inpatients. The total direct costs averaged $4,536 for inpatients, $3,222 for the observation group, and $3,340 for the outpatient group. These inpatient and outpatient costs were significantly different (p<.001). There were significantly reduced total variable direct costs (p<0.05) and fixed direct costs (p<0.001) when comparing the outpatient to inpatient groups. Costs for the observation group were significantly lower in all three cost categories than inpatient costs, but were not significantly different than outpatient costs. Of the 39 outpatient procedures, no patients visited urgent care within 30 days postoperatively, and observation group had two patients visit urgent care. None were readmitted in any group. Conclusions: In ABG surgery done on patients born with a CLP, the costs for an inpatient stay are significantly higher than those of patients discharged the same day or who stay in the hospital for less than 23 hours on observational status. The Acumed drill technique results in improved pain control with no appreciable harms to the outpatient group, allowing for same day discharge

Background/Purpose: The complicated nature of craniofacial procedures can be difficult for patients and families to understand. Patients and families undergoing treatment for facial differences may, understandably, find the process overwhelming, as consultations are often scheduled with multiple members of the Craniofacial Team. Furthermore, a plethora of online (mis)information, commonly turns the consultation into a clarification session, rather than an opportunity to educate and address concerns. In order to provide a dependable resource for patients and families, we introduce a multi-media education portal for craniofacial surgical procedures. Methods/Descriptions: Postoperative interviews of adult-aged patients and parents of school-aged patients were performed to determine specific information that would have been useful upon consultation regarding their craniofacial surgery and the recovery process. Based on interview responses, the authors developed a free, multimedia educational portal. Previously constructed craniofacial digital animations were edited and upgraded in Maya 10 (Autodesk, San Rapheal, CA) and uploaded into the cloud-based multimedia portal. Voice-over, text and video were also created based on patient and parent instruction. Patient feedback was obtained on preliminary versions to further refine the portal. Results: An online portal has been designed to describe six common and complex craniofacial surgery procedures: Le Fort I, Le Fort III, Bilateral Sagittal Split Osteotomy, Monobloc, Genioplasty, Fronto- Orbital Advancement with Cranial Vault Remodeling. For each procedure, a brief text/voice-over description of the objectives of the surgery is followed by a schematic, yet anatomically accurate, threedimensional animation of the operation with voice-over narration. Then, a detailed description of the recovery process precedes video interviews of patients and families discussing their experiences. A portable document format (PDF) file is available for download with more detaied reading material related to each procedure. Conclusions: We introduce an online multimedia education portal containing scrutinized, sound, and procedure-specific information for patients and families undergoing craniofacial surgery. This freely available resource is intended to supplement preoperative consultation with the craniofacial team and may prove a powerful tool for patients and families undergoing the stressful process of facial reconstruction

Background/Purpose: Multidisciplinary Cleft and Craniofacial Centers require significant investment and maintenance by medical schools and/or departments, and yet the variables contributing to their academic productivity remain unknown. This study characterizes the elements that result in high academic productivity in Cleft and Craniofacial Centers. Methods/Descriptions: All cleft and craniofacial centers accredited by American Cleft Palate-Craniofacial Association were included. Vari-ables such as university affiliation (UNI); resident training (RES); number of active surgical and orthodontic faculty (FAC); and investment in a craniofacial surgery (CF) or craniofacial orthodontics (CO) fellowship program, or both (CF+CO), were obtained for each center. All craniofacial and cleft-related research published between July 2005 and June 2015 was identified using the National Library of Medicine database; for each article, journal of publication and impact factor were also recorded. A stepwise multivariable linear regression analysis was performed on the listed variables to outcome measures of total publications, summative impact factor, and basic science publications. Results: A total of 160 centers were identified, comprising 690 active faculty, 29 craniofacial fellowships and 9 orthodontic fellowships; 2,093 articles were published in 199 journals within the study period. Variables most positively associated to a high number of publications were, in order: CF+CO (beta, CF+CO = 0.555, p < 0.001), CF (beta, CF= 0.248, p < 0.001), RES (beta, RES = 0.198, p = 0.003). Variables most positively associated to a high summative impact factor are, in order: CF+CO (beta, CF+CO = 0.551, p < 0.001), CF (beta, CF = 0.313, p < 0.001), FAC (beta, FAC = 0.183, p = 0.006). Variables most positively associated to basic science publications are, in order: CF+CO (beta, CF+CO=0.491, p < 0.001), CF (beta, CF=0.322, p < 0.001), and RES (beta, RES = 0.164, p = 0.032). Conclusions: Participation in both craniofacial surgery and orthodontic fellowships demonstrate the strongest association with academic success; craniofacial fellowship alone, residency programs and number of active faculty are also predictive. Cleft and Craniofacial Centers interested in academic performance should allocate funds and resources into these variables, particularly interdisciplinary partnerships between surgery and dentistry