Faculty Bibliography

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

Background/Purpose: Treacher Collins Syndrome (TCS) produces complex deformities of the maxilla, mandible, nasal airway and palate, all of which may impact speech. Clinical outcomes of cleft palate repair in TCS have not been well-defined. Methods/Descriptions: A 35 year, single-institution retrospective review of all patients with TCS and cleft palate was performed. Variables evaluated included Veau-type palate classification, age and technique of repair, Pruzansky-type mandible classification, history of tracheostomy and age of decannulation, history of mandibular distraction, bone grafting, or orthognathic surgery, palatoplasty complications or readmissions, and presence of palatal fistula. A craniofacial speech pathologist assessed velopharyngeal dysfunction, resonance and sound production long-term. Results: 58 patients with TCS were identified of whom 25 (43%) had a cleft palate and 9 (15.5%) underwent palatoplasty at our institution. Veau-type palate classifications included Veau 1 (1/9), Veau 2 (5/9), Veau 3 (1/9), and Veau 4 (2/9). Pruzansky-type mandible classifications included IIA 1/9; IIB 6/9; III 2/9. Mean age of palatoplasty was 24.4 months (13-80), average length of stay 2.2 days (1-5), and followup time of 12.2 years (2.2-24.3). There were no peri-operative complications or unplanned re-admissions. Post-operative palatal fistula rate was 33%, including both of the Veau 4 patients. Seven patients had tracheostomies, of which three were ultimately decannulated. Seven patients had long-term follow-up with a speech pathologist 6.9-22.4 years after surgery. Three (42%) presented with sound errors related to cleft palate (2/3 had an oronasal fistula, while one presented with structurally-based velopharyngeal dysfunction requiring surgical management). Six (86%) presented with articulatory- based VPD. All seven patients presented with sound errors and resonance quality consistent with the anatomical dental-skeletal anomalies associated with TCS. Conclusions: Patients with TCS and cleft palate undergo palatoplasty at an older age and have higher incidences of palatal fistula and longterm sound and resonance disorders compared to patients with isolated cleft palate. Highest risk patients had Veau 4 cleft palates and Pruzansky-type III mandibles. Given the high incidence of articulatory- based velopharyngeal dysfunction, comprehensive speech therapy should be a critical component of long-term care in this patient population

Background/Purpose: Septal deviation is a common finding in skeletally mature patients with cleft lip and palate (CL/P), however the contribution of the cartilaginous and bony septum to airway obstruction is poorly defined. This study characterizes the septal and airway anatomy in skeletally mature patients with CL/P utilizing cone beam computed tomography (CBCT) and will help guide airway management of this patient population at the time of definitive rhinoplasty. Methods/Descriptions: This is a retrospective single institution review of all CL/P patients over the age of 15 who have undergone CBCT analysis. Septal deviation was measured in coronal sections of CBCT scans at the cartilaginous septum [anterior nasal spine (ANS)], and bony septum [posterior nasal spine (PNS) and midpoint between the ANS and PNS (MID)]. Airway obstruction was defined as the smallest linear distance between nasal septum and adjacent turbinate and was similarly measured at all three points. Superior (perpendicular plate of ethmoid) and inferior (vomer) bony septal displacement was measured as an angle from vertical at the coronal slice of maximal septal deviation. CL/P patients were compared to age-matched controls using Student's t-test. Stepwise multivariable linear regression was used to compare septal deviation to obstruction. Measurements were performed by two separate raters and interrater reliability was assessed using Pearson's r coeffecient. Statistical significance was held at p<0.05. Results: 24 CL/P patients and 16 age-matched controls were identified for the study. Interrater reliability for 210 independent measurements was r=0.94 (p<0.0001). Results are reported as CL/P versus control. Septal deviation was significantly increased at the ANS (2.1+/-2.2 mm vs 0.7+/-1.0 mm, p=0.03), MID (4.6+/-3.1 mm vs 2.2+/-1.2 mm, p=0.01), and PNS (2.9+/-1.8 mm vs 1.0+/-0.6 mm, p=0.0002). The airway was significantly obstructed at the ANS (1.8+/-0.8 mm vs 2.3+/-0.6 mm, p=0.03). Maximal septal deviation occurred at the bony septum in 39 of 40 patients. Both the perpendicular plate of the ethmoid (14+/-7.8degree vs 8.0+/-5.4degree, p=0.01) and vomer (25+/-15degree vs 9.0+/-7.9degree, p=0.0006) were significantly displaced from vertical. Midpoint bony septal deviation was a good predictor of anterior nasal airway obstruction (r=-0.525, p=0.008). Conclusions: Skeletally mature patients with a cleft demonstrate severe septal deviation which includes both cartilage and bone. Resection of the bony and cartilaginous septum should be considered at time of definitive rhinoplasty in CL/P patients

Background/Purpose: Treacher Collins (TC) and Robin Sequence (RS) are both associated with a retrognathic mandible, glossoptosis, and airway obstruction. TC is associated with aberrations of the lower jaw, upper jaw and nasal airway in a manner distinct from RS. Although in both TC and RS, airway obstructions in severe cases may benefit from mandibular distraction (MDO), the different pathophysiology suggests MDO to be less successful in TC compared to the current literature on RS. The purpose of this study is to report on the clinical outcomes of tracheostomy removal utilizing MDO in the TC patient population. Methods/Descriptions: A single center, twenty-year retrospective review (1991-2010) was conducted of all patients with TC treated with MDO. Recorded variables included: age of MDO, number of MDO procedures, presence of tracheostomy and complications. Literature review of clinical outcomes of MDO in the RS population demonstrates age of MDO of under one year, average on distraction per patient and avoidance of tracheostomy in over 90% of patients. Results: 24 patients with TC who underwent MDO were included in our analysis. The follow up time was 9.2 years (range1.7-17 years). The mean age of the first MDO was 4.97 years. The mean number of distractions was 1.42 with 46% of patients who had more than onedistraction attempted. The distraction devices used were external in 67% and internal in 33% of cases. 19 patients (79%) had a tracheostomy prior to MDO and only 9 (47%) patients were decannulated within one year of distraction. An additional 5 patients were decannulated several years later after further distraction and other airway procedures. Complications were divided into major (ankylosis, device failure) moderate and minor (pin infection, hypertrophic scar). Overall, 67% of TC patients had at least one complication with 41% having major complications. There was a 20% incidence of TMJ ankylosis. Conclusions: Compared to the RS population, TC patients undergo MDO at a later age, require more distraction and have less successful decannulation. Further surgery is required to effectively treat airway obstruction. The incidence of major complications