Faculty Bibliography

Presurgical lip, alveolus, and nose approximation (PLANA) is a novel form of presurgical infant orthopedics (PSIO) designed without an intraoral molding plate. While early studies on PLANA have demonstrated improvements in nasolabial morphology, its impact on infant feeding and weight gain has not been assessed. A single-institution, retrospective review of all patients with cleft lip and palate (CL±P) treated with PLANA over a 1-year period was therefore performed. Weight values at baseline and at surgery were compared with World Health Organization (WHO) Child Growth Standards, and weight-for-age z-scores (WAZ) as well as changes in weight-for-age z-scores (WAZ) were obtained. A cohort of patients who underwent PSIO with NasoAlveolar Molding (NAM) was evaluated as a reference group. The PLANA (n=19) and NAM (n=25) groups were comparable in age (15.63 versus 21.16 d, P=0.2), weight (3.38 versus 3.50 kg, P=0.2), and WAZ (-0.80 versus -0.94, P=0.8) at baseline, and in age (103.11 versus 113.04 d, P=0.06), weight (5.82 versus 5.68 kg, P=0.3), and WAZ (-0.92 versus -1.47, P=0.2) at surgery. Both groups had similar weight gain (2.44 versus 2.18 kg, P=0.1) and WAZ (-0.12 versus -0.53, P=0.2). The PLANA group exhibited statistically significant greater daily weight gain (0.028 versus 0.024 kg/d, P=0.04). None of the patients experienced surgical delays due to insufficient weight gain. PLANA did not interfere with presurgical weight gain in infants with CL±P.

Strict trainee work-week hour restrictions, increased complexities of surgical care, and shifting hospital policies have posed challenges to operating room training for residents in high-resource regions. A shortage of cleft-trained surgeon educators and inconsistent training curricula further limit exposure to cleft operative education in low-resource settings. Furthermore, teaching cleft surgery can be difficult given the confined space of the infant oral cavity and the small, delicate flaps used for reconstruction. In the face of these challenges, the role of simulation has expanded in surgical education to supplement intraoperative training and increase resident preparedness. Smile Train, a nonprofit cleft-focused organization, in partnership with the technology companies BioDigital (New York, NY) and Simulare Medical (Toronto, Ontario, Canada), and academic plastic surgeons, has developed and globally distributed a variety of simulation resources for cleft surgery. This work provided a comprehensive review of Smile Train-distributed simulator modalities, including surgical training videos, a digital simulation platform, high-fidelity physical simulators, and virtual reality models. This review described the evolution of these models, the effects on learner experience, knowledge, and surgical performance, as well as directions for future development.

BACKGROUND:This study evaluates the Presurgical Lip, Alveolus, and Nose Approximation (PLANA) technique as a novel alternative to NasoAlveolar molding (NAM). The study hypothesizes that PLANA can achieve comparable Nasolabial outcomes to NAM while addressing its limitations, particularly by reducing the burden of care. METHODS:A retrospective review was conducted on 50 patients with non-syndromic unilateral or bilateral cleft lip and palate (CLP) treated with either NAM (n=28, including 2 treatment discontinuations) or PLANA (n=22). The overall physical burden of care was assessed in the full cohort. A subset of 25 patients with complete unilateral CLP (PLANA n=12; NAM n=13) was further analyzed to assess changes in nasolabial anthropometric ratios between cleft and non-cleft side using standardized 2D photographs taken pre-treatment (T1) and post-treatment (T2). RESULTS:The physical burden of care was significantly lower in the PLANA group, with 61.2 % fewer total office visits (5.2 vs. 13.4; p<0.001). The PLANA group also showed 72.19 % reduction in transient reversible side effects, such as oral, nasal, and cheek irritations (18.18% [n=4] vs. 65.38% [n=17]; p<0.001). PLANA achieved a significantly greater improvement in the columellar length ratio (0.53 vs. 0.37; p = 0.026), while NAM demonstrated a greater increase in the nostril height ratio (0.29 vs. 0.39; p = 0.04). No significant differences were observed in nostril width and alar base width ratios, or columellar deviation angle between the groups. CONCLUSION/CONCLUSIONS:These findings suggest that PLANA significantly reduces the burden of care for patients with cleft lip and palate and may offer comparable nasolabial outcomes to NAM.

Patients with unilateral cleft lip and palate (UCLP) often exhibit asymmetric paranasal flatness of soft tissues. Despite clinical recognition of this asymmetry, skeletal paranasal asymmetry remains poorly quantified. Measuring skeletal landmark asymmetries can aid in planning surgical maxillary yaw corrections that simultaneously enhance paranasal symmetry and maxillary dental midline position. This study aims to quantify skeletal paranasal asymmetry in patients with UCLP. Skeletally mature patients with complete UCLP who were orthodontically prepared for orthognathic surgery between 2014 and 2023 were included in this study. Presurgical CBCTs were analyzed using Dolphin 3D. Anterior-posterior discrepancies between affected and unaffected sides were measured at the most lateral point of piriform aperture (PA) and 15 mm lateral to PA (15PA). A one-sample t test was conducted. Analysis of 30 patients (mean age 18-8 y, 17 male, 13 female, 20 left-sided, 10 right-sided) was completed. On the affected side, PA and 15PA were positioned 3.8 mm (P<0.05) and 2.4 mm (P<0.05) more posteriorly, respectively. These results suggest that skeletal paranasal asymmetry should be assessed during the pretreatment stage, as presurgical orthodontics should maintain a maxillary midline deviation toward the affected side when yaw correction is indicated. This approach facilitates simultaneous correction of piriform projection and midline alignment during surgery and may reduce the need for secondary procedures, such as malar implants or fat injections, which add cost and morbidity. This study confirms skeletal paranasal asymmetry in patients with UCLP and establishes a standardized method for measuring these deficiencies using CBCT-based skeletal landmarks.

BACKGROUND/UNASSIGNED:Virtual reality (VR) has not been tested for cleft surgery training in low-resource settings where the surgical instructor provides the lesson from another continent. METHODS/UNASSIGNED:Fifty-one plastic and maxillofacial surgery trainees in India participated in a VR simulation of the Furlow palatoplasty given by a New York-based cleft surgeon. Participants completed pre- and postsurveys, which included a knowledge assessment regarding the Furlow technique, confidence in VR as an educational tool, and opinions on the use of VR in surgical education. Satisfaction and acceptance of the technology were assessed with learning measures postsimulation. RESULTS/UNASSIGNED:< 0.001). The opinion that VR should be included in surgical education began high and remained high. Learners reported that the simulation was stimulating (4.63 ± 0.49), increased interest (4.51 ± 0.67), was clear (4.45 ± 0.67), and was effective for teaching (4.78 ± 0.47), and they would recommend the lecture to others (4.78 ± 0.46). VR simulation increased control and active learning (4.73 ± 0.49), facilitated comprehension (4.76 ± 0.51), allowed for reflective thinking (4.59 ± 0.57), had high fidelity (3.98 ± 0.93), was easy to use (4.29 ± 0.73), and was enjoyable (4.78 ± 0.42). CONCLUSIONS/UNASSIGNED:VR cleft simulation can be effectively used in low- to emerging-resource settings. Surgical instructors can provide real-time, immersive surgical experiences to trainees across the world.

BACKGROUND:The severity of unilateral cleft lip significantly influences surgical outcomes, yet no standardized system exists to classify cleft severity or assess the impact of presurgical infant orthopedics (PSIO). This study proposes an objective classification system integrating anthropometric measurements with expert evaluations. METHODS:Deidentified pre- and post-PSIO photographs of 50 infants with unilateral cleft lip from the Smile Train Express database were analyzed. Three anthropometric parameters-nostril width ratio (NWR), columellar angle (CA), and subnasale lateral displacement (SN)-were measured. An expert panel of orthodontists and surgeons independently rated cleft severity and PSIO outcomes in a structured three-stage process. Severity thresholds were established through consensus, and interrater agreement was analyzed using weighted kappa. RESULTS:Consensus-derived thresholds categorized NWR, CA, and SN into four severity levels. Interrater agreement for cleft severity improved across stages, reaching near-perfect levels in Stage 3 (weighted kappa = 0.91 pre-PSIO, 0.93 post-PSIO). While pre-PSIO agreement was similar between surgeons and orthodontists, post-PSIO assessments showed greater variability. PSIO had a disproportionate effect on nasal morphology (CA) compared to maxillary segments (NWR, SN), with severe NWR and SN frequently coexisting with mild CA. The proposed classification system demonstrated substantial reliability, aligning at least two parameters within the same severity subclassification. CONCLUSIONS:This study introduces a standardized classification system for cleft severity and PSIO outcomes, demonstrating strong interrater reliability. By integrating anthropometric data with expert assessments, it provides a reproducible framework for clinical and research applications. Further refinements, including intraoral measurements and 3D imaging, may enhance its precision and applicability.

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.

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.

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.