Faculty Bibliography

OBJECTIVE:The purpose of this research was to build on previous work regarding predictive factors of acute skin failure (ASF) in the critically ill population. METHODS:Researchers conducted a retrospective case-control study with a main and validation analysis. Data were extracted from the New York Statewide Planning and Research Cooperative System. For the main analysis, there were 415 cases with a hospital-acquired pressure injury (HAPI) and 194,872 controls without. Researchers then randomly selected 100 cases with a HAPIs and 300 controls without for the validation analysis. A step-up logistic regression model was used. Researchers generated receiver operating characteristic curves for both the main and validation analyses, assessing the overall utility of the regression model. RESULTS:Eleven variables were significantly and independently related to ASF: renal failure (odds ratio [OR], 1.4, P = .003), respiratory failure (OR, 2.2; P = < .001), arterial disease (OR, 2.4; P = .001), impaired nutrition (OR, 2.3; P = < .001), sepsis (OR, 2.2; P = < .001), septic shock (OR, 2.3; P = < .001), mechanical ventilation (OR, 2.5; P = < .001), vascular surgery (OR, 2.2; P = .02), orthopedic surgery (OR, 3.4; P = < .001), peripheral necrosis (OR, 2.5; P = .003), and general surgery (OR, 3.8; P = < .001). The areas under the curve for the main and validation analyses were 0.864 and 0.861, respectively. CONCLUSIONS:The final model supports previous work and is consistent with the current definition of ASF in the setting of critical illness.

Background/Purpose: Our goal is to present to mental health professionals and craniofacial center providers a Panel Workshop on helping parents/caregivers learn how to best advocate for their school age children with craniofacial conditions who experience academic and social challenges. Information about various types of schools, choosing a school, enrollment and school placement, in-school special services, parent-teacher conferences, how to transfer to another school, at home tutoring following surgery, and other related topics will be discussed. In addition, we will address academic stress, developing a realistic schedule, bullying interventions, technology and social media guidelines, and provide families with relevant resources. Methods/Description: The panelists focused on topics including: academic advocacy, academic testing, neuropsychological and behavioral assessments, IEP's(Individual Educational Plans), optimal classroom placement, academic modifications and accommodations, in-school special services, how to ease the burden of academic stress, and providing information on available services. Social advocacy focused on issues such as how to help children feel comfortable starting school, transitions to grades and new schools, return to school after surgery, and ways to cope with social issues including bullying. Panelists included the craniofacial team psychologist, senior social worker, nurse practitioner, a nonprofit organization's director of family programs, as well as the parent of a school age child, an adult patient, a school administrator, and an educational/advocacy representative from a community organization

Background/Purpose: Our study quantifies changes in skeletal, soft tissue profile, and globe position in patients with syndromic craniosynostosis after Le Fort I + III (LF I + III) surgery. Methods/Description: Patients with syndromic craniosynostosis who underwent LF I + III at the time of facial maturity were followed for at least 1 year. Each lateral cephalometric radiograph was traced using Dolphin Imaging software and superimposed at the sella. Changes in positions of the different landmarks at T0 (preoperatively), T1 (immediate postoperatively), and T2 (1 year postoperatively) were measured by the software. Sixty-seven soft tissue and skeletal landmarks were digitized and measured. LF III skeletal changes were measured by changes in lateral orbit and orbitale. LF I skeletal changes were measured at the A point and U1. Corresponding soft tissue profile and globe position were studied. All data were measured along the x-axis.
Result(s): Twelve patients included in our study have the following syndromes: Crouzon (n = 6), Pfeiffer (n = 2), Apert (n = 1), Antley-Bixler (n = 1), cleidocranial dysplasia (n = 1) and frontonaso dysplasia (n = 1). Nine patients had previous history of LF III distraction. Standard descriptive statistics was used. Data were analyzed using paired T test. Lateral orbit advanced 5.49 mm (T0-T1) on average, with a P value of 1.3-5, and 5.94 mm (T0-T2) on average; 0.45 mm (T1-T2) change with a P value of .96 suggests the lateral orbit is stable. Similar advancement at orbitale is observed at 5.68 mm (T0-T1) and 6.42 mm (T0-T2). The globe moved anteriorly by 1.98 mm (T0-T1) with a P value of .025 and anteriorly by 0.944mm(T0-T2). The change between T2 and T1 is 1.04 mm (P value: .26), which suggests the globe moved backward after postsurgical swelling subsided. The ratios of movement (globe to lateral orbit) between T0-T1 and T0-T2 are 31% and 16%, respectively. The decrease in ratio can be attributed to the reduction in soft tissue swelling at T2. Restoring position of the globe relative to the lateral orbit decreases the risk of exposure keratitis, keratoconjunctivitis sicca, and corneal ulceration. Anterior nasal spine and point A were advanced by 9.38 and 10.08 mm, respectively, between T0 and T1, and 9.01 mm and 8.51 mm, respectively, between T1 and T2. At the occlusal level, U1 advanced 10 mm and L1 moved back 1.45 mm between T0 and T1. Menton moved back 1.25 mm (T0-T1) but advanced by 2.48 mm (T0-T2). This change in direction is due to splint use at T1 as it rotates mandible clockwise.
Conclusion(s): In our cohort, LFI + III surgery improved both midface deficiency and proptosis in those with syndromic craniosynostosis.Combined Le Fort I + III surgery allows surgeons to perform differential corrections of the midface at the orbital and the dentition level. This is ideal for proptosis correction and establishing optimal jaw relationship

Background/Purpose: Temporomandibular joint (TMJ) ankylosis is an uncommon but debilitating condition which can affect feeding, speech, dental health, facial growth, and quality of life. We present an institutional experience treating congenital and acquired TMJ ankylosis, detailing outcomes and potential risk factors of recurrence. Methods/Description: Patients with ankylosis of the TMJ were identified through retrospective chart review (1976-2019). Clinical records, operative reports, and imaging studies were reviewed for demographics, surgical operations, and ankylosis including mean interincisal opening (MIO) and reankylosis.
Result(s): Forty-four TMJs with bony ankylosis were identified in 28 patients, 27(96.4%) of whom had syndromes. Mean age at any initial mandibular surgery was 3.7+/-3.6 (range: 0-14 years). Follow-up was 13.7 +/- 5.9 years. Sixteen (57.1%) patients had bilateral ankylosis. Nine cases of ankylosis were congenital, 16 were iatrogenic (4.5 +/- 3.7 years from initial distraction osteogenesis or autologous mandibular reconstruction) referred from outside institutions in 6 cases, and 3 were postinfectious. Patients having their first mandibular operation at a younger age had more frequent reoperations for recurrent TMJ ankylosis, although this did not reach statistical significance. Improvement in MIO was 21.4 +/- 7.3 mm. Ankylosis recurred in 21(75%) cases, 11 of which were iatrogenic, requiring an average of 2 reoperations (range: 1-8). Five patients with congenital TMJ ankylosis required gastrostomy and remained at least partially dependent. Five patients had tracheostomy at the time of TMJ ankylosis surgery: 2 were eventually decannulated and 3 required repeat tracheostomy after ankylosis recurrence and remained tracheostomy-dependent.
Conclusion(s): Craniofacial anomalies, younger age at mandibular surgery, and number of operations portend to increased risk of TMJ ankylosis as well as tracheostomy and gastrostomy dependence. Despite initial improvement in postoperative MIO, pediatric TMJ ankylosis is associated with high recurrence and multiple reoperations

Background/Purpose: The evolution of primary unilateral cleft lip repair represents a series of incremental modifications pioneered by a distinct group of master surgeons. It is through understanding the purpose of each evolutionary step, the limits and compromises of these steps, and the subsequent modifications which followed, can a greater understanding of the art of cleft lip repair be realized. This course will trace the conceptual development of unilateral cleft lip repair over the past 70 years using a novel, real-time computer-based cleft lip simulator. A first order accurate biophysics implementation within the simulator will be used to demonstrate the cleft lip repair techniques described to reveal the strengths and weaknesses of each stage of unilateral lip repair development. The course will begin with the Tennison Randall lower triangular lip repair, as it is still in common use today. This will be followed by Skoog, Wynn, and Mustarde adding an upper triangle to the lip repair. The various stages in the progression of the Millard repair will then be carefully traced along with the biophysics which are likely responsible for why Millard altered his original design. The modifications of the Millard design by other surgeons, and the reasons for them, will then be carefully traced. The modifications covered will be those of Noordhoff, Mohler, Cutting, Fisher, and others. The interaction between lip repair technique and primary correction of the cleft-lip nasal deformity will be discussed in detail. Simulator-based demonstrations will be augmented with patient examples from the senior author's clinical practice which illustrate the conceptual difficulties encountered at various stages in the historical development of primary unilateral cleft lip and nose repair. Methods/Description: The principal method used in this course will be real-time computer-based surgical simulation. A unilateral cleft lipnose model involving skin, mucosa, muscle, bone, cartilage, and teeth was derived from an MR scan of an adolescent with an unrepaired unilateral cleft. Alterations in the model are illustrated with first-order accurate biophysics using a new software base called projective dynamics. Surgical tools provided are scalpel, suture, hook, and undermine of both skin/mucosa and bone/cartilage. Surgical "'history" files are used to step through a succession of cleft lip repairs in the surgical eclectic. The presentation will be augmented with photographs from the senior author's long career further illustrating why successive alterations in technique were made

Background/Purpose: Global Smile Foundation (GSF) is a not for profit foundation whose founders and volunteers have been providing cleft care to underserved communities around the world for 32 years. In 2012, GSF incorporated nasoalveolar molding (NAM) into its treatment model in Guayaquil, Ecuador. We present an evaluation of nasolabial aesthetic outcomes and scarring in patients treated with NAM prior to primary cleft lip repair versus patients who were not, in similar outreach settings. Methods/Description: The Cleft Aesthetic Rating Scale (CARS) used frontal photographs taken at least 1-year post primary cleft lip repair to assess the nose: tip, nostrils (symmetry, size, flaring), and upper lip (vermillion symmetry and continuity and length of the philtrum), ranging from 1 (very good) to 5 (very poor). Photos were standardized to reveal only the nasolabial area and excluded any time points after any additional surgical revision to the nasolabial area. Each NAM time point was matched to a control time point based on their age at primary cleft lip repair (maximum of 3 months) and their time postoperative from primary cleft lift repair (maximum of 6 months). All included NAM and control patients had unilateral cleft lip and palate, and were from Ecuador. Patients with congenital syndromes other than cleft lip and palate (CLCP) affecting facial appearance were excluded. Twelve independent raters including 3 surgeons, 3 orthodontist, 3 pediatric dentists, and 3 medical students rated the photographs. As a modification to CARS, raters were also asked to assess scar quality utilizing a previously developed scar subtype scoring system.
Result(s): Of the 189 patients treated with NAM in Guayaquil since 2012, 96 patients had long-term follow-up, and 27 patients with 34 photographic time points qualified for inclusion, 15 (55.56%) male, 12 (44.44%) female. The average time post primary cleft lip repair was 2.19 +/- 1.65 months (range: 0.98-7.37 months). Matched to the patients who had received NAM were 31 control patients with 34 photographic time points, 26 (83.87%) male, 5 (16.13%) female with an average time post primary cleft lip repair of 2.19 +/- 1.63 months (range: 0.93-6.98 months) The average rating of Nasal aesthetics was significantly lower in patients who had received NAM compared to nasal controls (2.60 +/- 1.05 vs 2.82 +/- 1.12; P< .01).The average rating for lip aesthetics showed similar differences between patients who had received NAM and matched controls (2.23+/-0.96 vs 2.56+/- 1.07; P < .01). Similarly, the average rating of scar quality was significantly lower among patients who had received NAM (1.82+/-0.93 vs 2.03 +/- 0.89; P < .01).
Conclusion(s): Using the CARS and a modified scar rating scale, patients who had received NAM were found to have superior nose and lip aesthetic outcomes in comparison to non-NAM controls. This suggests that NAM is not only feasible in an outreach setting, but it is also associated with improved lip, nose, and scar outcomes