Faculty Bibliography

A 3-year-old patient sustained a tripartite mandibular fracture, including bilateral condylar fractures with lateral dislocation of the left condyle and symphyseal fracture. Staged lower jaw reconstruction with closed reduction of the laterally dislocated condyle, transfacial pinning between the mandibular angles, MMF using circummandibular wiring and intermaxillary fixation screws was performed.

To compare lower lip changes after Le Fort I advancement surgery in patients with a cleft. Single institution, retrospective review. Academic tertiary referral hospital. Skeletally mature patients with a cleft who underwent one-piece Le Fort I advancement surgery who had a lateral cephalogram or cone-beam computed tomography (CBCT) scan preoperatively and at least 6 months postoperatively. Patients who underwent concomitant mandibular surgery or genioplasty were excluded. 64 patients were included: 45 male and 19 female, 25 with BCLP and 39 with UCLP. The mean age at surgery was 18.4 years. Single jaw one-piece Le Fort I advancement surgery. Standard lateral cephalometric landmarks of the bony skeleton and soft tissue were compared before and after Le Fort I advancement. Pearson correlation coefficients (r) were calculated to measure the correlation between lower lip position and other soft and hard tissue changes. After comparable maxillary advancements [BCLP: 7.2 mm (95% CI: 6.2-8.3 mm), UCLP: 6.4 mm (95% CI: 5.7-7.0 mm)] the horizontal upper-to-lower lip discrepancy significantly improved in both groups. The lower lip became thinner and more posteriorly positioned. Changes in lower lip position correlated strongly with mandibular bony landmarks and moderately with upper lip position, but poorly with maxillary landmarks. Le Fort I advancement results in posterior displacement of the lower lip and better lip competence, thereby improving facial harmony. This lower lip change is not predictable by degree of maxillary advancement, and does not differ in patients with BCLP vs. UCLP.

As medicine becomes more complex, there is pressure for new and more innovative educational methods. Given the economic burden associated with in-person simulation, healthcare, including the realm of surgical education, has begun employing virtual reality (VR). Potential benefits of the addition of VR to surgical learning include increased pre-operative resident exposure to surgical techniques and procedures and better patient safety outcomes. However, these new technological advances, such as VR, may not replicate organic tissues or accurately simulate medical care and surgical scenarios, creating unrealistic pseudo-environments. Similarly, while advancements have been made, there are ongoing disparities concerning the utilization of these technologies. These disparities include aspects such as the availability of stable internet connections and the cost of implementing these technologies. In accordance with other innovative technologies, VR possesses upfront economic costs that may preclude equitable use in different academic centers around the world. As such, VR may further widen educational quality between high- and low-resource nations. This analysis integrates recent innovations in VR technology with existing discourse on global health and surgical equality. In doing so, it offers preliminary guidance to ensure that the implementation of VR occurs in an equitable, safe, and sustainable fashion.

OBJECTIVE:To define "high osteotomy" and determine the feasibility of performing this procedure. DESIGN/METHODS:Single institution, retrospective review. SETTING/METHODS:Academic tertiary referral hospital. PATIENTS, PARTICIPANTS/METHODS:34 skeletally mature, nonsyndromic patients with unilateral CLP who underwent Le Fort I osteotomy between 2013 and 2020. Patients with cone-beam computed tomography (CBCT) scans completed both pre- (T1) and post-operatively (T2) were included. Patients with bilateral clefts and rhinoplasty prior to post-operative imaging were excluded. INTERVENTIONS/METHODS:Single jaw one-piece Le Fort I advancement surgery. MAIN OUTCOME MEASURES/METHODS:Measurements of the superior ala and inferior turbinates were taken from the post-operative CBCT. RESULTS:The sample included 26 males and 8 females, 12 right- and 22 left-sided clefts. The inferior turbinates are above the superior alar crease at a rate of 73.53% and 76.48% on the cleft and non-cleft sides, respectively. One (2.9%) osteotomy cut was above the level of the cleft superior alar crease, and no cuts were above the level of the non-cleft superior ala. On average, the superior ala was 2.63 mm below the inferior turbinates. The average vertical distances from the superior alar crease and the inferior turbinates to the base of the non-cleft side pyriform aperture were 12.17 mm (95% CI 4.00-20.34) and 14.80 mm (95% CI 4.61-24.98), respectively. To complete a "high osteotomy," with 95% confidence, the cut should be 20.36 mm from the base of the pyriform aperture. CONCLUSIONS:A "high" osteotomy is not consistently possible due to the relationship between the superior alar crease and the inferior turbinate.

BACKGROUND:The long-term effects of nasoalveolar molding (NAM) on patients with bilateral cleft lip and palate (BCLP) are unknown. The authors report clinical outcomes of facially mature patients with complete BCLP who underwent NAM and gingivoperiosteoplasty (GPP). METHODS:A single-institution retrospective study of nonsyndromic patients with complete BCLP who underwent NAM between 1991 and 2000 was performed. All study patients were followed to skeletal maturity, at which time a lateral cephalogram was obtained. The total number of cleft operations and cephalometric measures was compared with a previously published external cohort of patients with complete and incomplete BCLP in which a minority (16.7%) underwent presurgical orthopedics before cleft lip repair without GPP. RESULTS:Twenty-four patients with BCLP comprised the study cohort. All patients underwent GPP, 13 (54.2%) underwent alveolar bone graft, and nine (37.5%) required speech surgery. The median number of operations per patient was five (interquartile range, two), compared with eight (interquartile range, three) in the external cohort ( P < 0.001). Average age at the time of lateral cephalogram was 18.64 years (1.92). There was no significant difference between our cohort and the external cohort with respect to sella-nasion-point A angle (SNA) [73 degrees (6 degrees) versus 75 degrees (11 degrees); P = 0.186] or sella-nasion-point B angle (SNA) [78 degrees (6 degrees) versus 74 degrees (9 degrees); P = 0.574]. Median ANB (SNA - SNB) was -3 degrees (5 degrees) compared with -1 degree (7 degrees; P = 0.024). Twenty patients (83.3%) underwent orthognathic surgery. CONCLUSION:Patients with BCLP who underwent NAM and GPP had significantly fewer total cleft operations and mixed midface growth outcomes at facial maturity compared with patients who did not undergo this treatment protocol. CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, III.

BACKGROUND:Commercial payer-negotiated rates for cleft lip and palate surgery have not been evaluated on a national scale. The aim of this study was to characterize commercial rates for cleft care, both in terms of nationwide variation and in relation to Medicaid rates. METHODS:A cross-sectional analysis was performed of 2021 hospital pricing data from Turquoise Health, a data service platform that aggregates hospital price disclosures. The data were queried by CPT code to identify 20 cleft surgical services. Within- and across-hospital ratios were calculated per CPT code to quantify commercial rate variation. Generalized linear models were used to assess the relationship between median commercial rate and facility-level variables and between commercial and Medicaid rates. RESULTS:There were 80,710 unique commercial rates from 792 hospitals. Within-hospital ratios for commercial rates ranged from 2.0 to 2.9 and across-hospital ratios ranged from 5.4 to 13.7. Median commercial rates per facility were higher than Medicaid rates for primary cleft lip and palate repair ($5492.20 versus $1739.00), secondary cleft lip and palate repair ($5429.10 versus $1917.00), and cleft rhinoplasty ($6001.00 versus $1917.00; P < 0.001). Lower commercial rates were associated with hospitals that were smaller ( P < 0.001), safety-net ( P < 0.001), and nonprofit ( P < 0.001). Medicaid rate was positively associated with commercial rate ( P < 0.001). CONCLUSIONS:Commercial rates for cleft surgical care demonstrated marked variation within and across hospitals, and were lower for small, safety-net, or nonprofit hospitals. Lower Medicaid rates were not associated with higher commercial rates, suggesting that hospitals did not use cost-shifting to compensate for budget shortfalls resulting from poor Medicaid reimbursement.

Defects characterized as large osseous voids in bone, in certain circumstances, are difficult to treat, requiring extensive treatments which lead to an increased financial burden, pain, and prolonged hospital stays. Grafts exist to aid in bone tissue regeneration (BTR), among which ceramic-based grafts have become increasingly popular due to their biocompatibility and resorbability. BTR using bioceramic materials such as β-tricalcium phosphate has seen tremendous progress and has been extensively used in the fabrication of biomimetic scaffolds through the three-dimensional printing (3DP) workflow. 3DP has hence revolutionized BTR by offering unparalleled potential for the creation of complex, patient, and anatomic location-specific structures. More importantly, it has enabled the production of biomimetic scaffolds with porous structures that mimic the natural extracellular matrix while allowing for cell growth-a critical factor in determining the overall success of the BTR modality. While the concept of 3DP bioceramic bone tissue scaffolds for human applications is nascent, numerous studies have highlighted its potential in restoring both form and function of critically sized defects in a wide variety of translational models. In this review, we summarize these recent advancements and present a review of the engineering principles and methodologies that are vital for using 3DP technology for craniomaxillofacial reconstructive applications. Moreover, we highlight future advances in the field of dynamic 3D printed constructs via shape-memory effect, and comment on pharmacological manipulation and bioactive molecules required to treat a wider range of boney defects.

INTRODUCTION/BACKGROUND:Treacher Collins syndrome is a rare congenital disease characterized by the multiple craniofacial malformations. Although the deformities affecting patients with Treacher Collins syndrome have been well characterized, the effects of these malformations to clinical severity of the syndrome are not well understood. OBJECTIVE:To determine the association of specific Treacher Collins mandibular malformations with clinical severity. DESIGN/METHODS: SETTING/METHODS:Study conducted at a single institution, a quaternary craniofacial care center. PATIENTS/METHODS:54 patients with Treacher Collins syndrome. INTERVENTIONS/METHODS:Computed tomography (CT), clinical photographs and medical history were included in this analysis. Mandibles were isolated from CT data and reconstructed in three dimensions using Mimics software. Cephalometric measurements were performed on CT data. Clinical severity was determined by Teber and Vincent scores. Association of craniofacial dysmorphology to clinical severity was determined by Spearman rank coefficient. MAIN OUTCOME MEASURES/METHODS:The main results obtained were the measurements of the mandibles and the quantification of the malformations of the evaluated patients. RESULTS:Among the most frequent findings in the sample are hypoplasia of the zygomatic complex, descending palpebral cleft and mandibular hypoplasia. Patients with a lower ramus/corpus ratio had a higher (more severe) Teber and Vincent classification. CONCLUSION/CONCLUSIONS:Patients with the most compromised mandible are also the patients with the highest number of malformations, thus, the most severe patients.

OBJECTIVE:The purpose of this study is to assess cleft rhinoplasty terminology across phases of growth.Design/Setting: A systematic review was performed on cleft rhinoplasty publications over 20 years.Interventions: Studies were categorized by age at surgical intervention: infant (<1 year); immature (1 to 14 years); mature (>15 years).Main Outcome Measures: Collected data included terminology used and surgical techniques. RESULTS:The 288 studies included demonstrated a wide range of terminology. In the infant group, 51/54 studies used the term "primary." In the immature group, 7/18 studies used the term "primary," 3/18 used "secondary." In the mature group, 2/33 studies used the term "primary," 16/33 used "secondary," 2/33 used "definitive," 5/33 used terms such as "mature," "adult," and "late," and 8/33 did not use terminology.Surgical technique assessment demonstrated: cleft rhinoplasty at infancy used nostril rim or no nasal incision, immature rhinoplasty used closed and open rhinoplasty incisions; and mature rhinoplasty used a majority of open rhinoplasty. Infant and immature cleft rhinoplasty incorporated septal harvest or spur removal in <10% of cases, whereas these procedures were common in mature rhinoplasty. No studies in infants or immature patients used osteotomies or septal grafts, common techniques in mature rhinoplasty. CONCLUSIONS:Current terminology for cleft rhinoplasty is varied and inconsistently applied across stages of facial development. However, cleft rhinoplasty performed at infancy, childhood, and facial maturity are surgically distinct procedures. The authors recommend the terminology "infant," "immature," and "mature" cleft rhinoplasty to accurately describe this procedure within the context of skeletal growth.

BACKGROUND:Relative value units (RVUs) are broadly used for billing and physician compensation; however, the accuracy of RVU assignments has not been scientifically evaluated for craniofacial surgery. The authors hypothesize that unbalanced RVU allocation creates inappropriate disparities in value among procedures performed by cleft and craniofacial surgeons. METHODS:The National Surgical Quality Improvement Program Pediatric database was queried to identify all cleft and craniofacial surgery cases performed by plastic surgeons from 2012 to 2019 based on CPT code. Microsurgical cases and CPT codes with a case count of fewer than 10 were excluded. Efficiency was defined as total RVUs divided by total operative time (ie, RVUs/hour). Mean efficiency per CPT code was ranked and compared by quartile using t tests. RESULTS:The sample consisted of 69 CPT codes with 50,450 cases. In the top quartile, most CPT codes were craniofacial procedures including frontofacial procedures (23.53%) and craniectomies for craniosynostosis or bony lesions (35.29%) (mean, 15.65 ± 4.22 RVUs/hour). The lowest quartile was composed mainly of CPT codes for cleft procedures including operations for velopharyngeal insufficiency (17.65%), cleft palate repair (23.53%), and cleft septoplasty (5.88%) (mean, 7.39 ± 0.98 RVUs/hour; P < 0.001). It was 2.5 times more efficient for a cleft and craniofacial surgeon to perform a local skin flap (15.18 RVUs/hour) than a secondary palatal lengthening for cleft palate (6.09 RVUs/hour). CONCLUSIONS:The current RVU allocation to cleft and craniofacial procedures creates arbitrary disparities in physician efficiency, with cleft procedures disproportionately negatively affected. RVU assignments should be reevaluated to avoid disincentivizing cleft surgical care.