Faculty Bibliography

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

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: 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: 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:Complications from medical tourism can be significant, requiring aggressive treatment at initial presentation. This study evaluates the effect of early surgical versus conservative management on readmission rates and costs. METHODS:A single-center retrospective review was conducted from May of 2013 to May of 2017 of patients presenting with soft-tissue infections after cosmetic surgery performed abroad. Patients were categorized into two groups based on their management at initial presentation as either conservative or surgical. Demographic information, the procedures performed abroad, and the severity of infection were included. The authors' primary outcome was the incidence of readmission in the two groups. International Classification of Diseases, Ninth Revision; International Classification of Diseases, Tenth Revision; and CPT codes were used for direct-billed cost analysis. RESULTS:Fifty-three patients (one man and 52 women) presented with complications after procedures performed abroad, of which 37 were soft-tissue infections. Twenty-four patients with soft-tissue infections at initial presentation were managed conservatively, and 13 patients were treated surgically. The two groups were similar in patient demographics and type of procedure performed abroad. Patients who were managed conservatively at initial presentation had a higher rate of readmission despite having lower severity of infections (OR, 4.7; p = 0.037). A significantly lower total cost of treatment was shown with early surgical management of these complications (p = 0.003). CONCLUSIONS:Conservative management of complications from medical tourism has resulted in a high incidence of failure, leading to readmission and increased costs. This can contribute to poor outcomes in patients that are already having complications from cosmetic surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, III.

Objective Hospital-acquired pressure injuries harm over 2.5 million patients at a U.S. cost of $26.8 billion. Sub-epidermal moisture scanning technology supports clinicians to anatomically identify locations at-risk of developing hospital-acquired pressure injuries. Our objective was to evaluate the cost-effectiveness of adopting sub-epidermal moisture scanners in comparison to existing hospital-acquired pressure injury prevention guidelines structured around subjective risk assessments. Methods A Markov cohort model was developed to analyze the cost-effectiveness of sub-epidermal moisture scanners in comparison to existing prevention guidelines, based on current clinical trial data from the U.S. health care sector perspective in the acute, acute rehabilitation and skilled nursing facility settings. A hypothetical cohort was simulated over a time horizon of one year. An incremental cost-effectiveness ratio was measured using U.S. dollars per quality-adjusted life year at a willingness-to-pay threshold of $100,000/quality-adjusted life year, and uncertainty was tested using probabilistic sensitivity analysis. Results Integration of sub-epidermal moisture scanners yielded cost-savings of $4054 and 0.35 quality-adjusted life years gained per acute care admission, suggesting that sub-epidermal moisture scanners are a dominant strategy compared to standard care and producing a net monetary benefit of $39,335. For every 1000 admissions in high-risk acute care, sub-epidermal moisture scanners could avert around seven hospital-acquired pressure injury-related deaths and decrease hospital-acquired pressure injury-related re-hospitalization by approximately 206 bed-days. Conclusions Acute care, acute rehabilitation and skilled nursing settings that adopt sub-epidermal moisture technology could achieve a return on investment in less than one year. Providers may want to consider these types of technology that aid clinical judgment with objective measures of risk in quality improvement bundles

OBJECTIVE:To assess pressure injury knowledge of Skin Care Council nursing members using the Pieper-Zulkowski Pressure Ulcer Knowledge Test (PZ-PUKT), to design an educational intervention informed by the results of the baseline assessment, and to evaluate the effect of the intervention. METHODS:This was a single-group pretest-posttest project conducted in an urban, academic, tertiary medical center from January to August 2017. Participants were measured on the pretest, received the intervention, and then were reevaluated on the posttest 3 months later. Pretest results informed the design of the intervention, which was a 1-day interactive, targeted educational program referred to as the "Skin Care Council Boot Camp." Paired-samples t tests were conducted to examine differences between pretest and posttest scores on the PZ-PUKT overall and in each test section. RESULTS:Seventy-seven participants enrolled in the project and completed the pretest. Of those, 58 (75.3%) were retained through the intervention and the posttest evaluation. Participants had a mean pretest score of 78.9 and a mean posttest score of 85.3. There were significant mean differences among pretest and posttest PZ-PUKT scores: 6.4 (t = 9.419, P < .001) overall; 4.6 (t = 5.356, P < .001) in the Prevention/Risk category; 4.1 (t = 3.668, P < .001) in the Staging category; and 10.5 (t = 7.938, P < .001) in the Wound Description category. CONCLUSIONS:By testing pressure injury knowledge before developing a program, investigators created a tailored, education program that addressed knowledge gaps. Posttest results provided insight into the program's success and opportunities for future improvement.

Skin color matching in vascularized composite allotransplantation (VCA) is an important determinant of aesthetic outcomes. The process of color matching is infrequently described in the literature. The Pantone SkinTone Guide (PSTG) is a handheld tool comprised of realistic skin tone swatches with a corresponding virtual swatch system. A color match acceptability threshold (AT) is defined as the point beyond which >50% of observers deem a given skin tone pairing as unacceptable. In this study, color match acceptability thresholds were developed using the PSTG to help standardize donor-recipient color matching. Four representative colors were chosen across the skin tone spectrum. These standard colors were used to develop a survey asking participants to determine the acceptability of color pairings. Using survey results, ATs were determined for changes in lightness, undertone, and lightness and undertone combined for each of the standard colors. Inter- and intra-rater reliability were determined using Fleiss's Kappa. Participants were more critical of skin tone pairings on the darker versus the lighter end of the spectrum, as evidenced by higher thresholds observed for lighter sample pairs. Additionally, observers were more critical of differences in skin lightness compared with differences in undertone. Intra-rater reliability was fair to substantial, and inter-rater reliability was fair to moderate. The PSTG can be used as a clinical tool to improve the aesthetic outcomes of skin-containing vascularized composite allotransplantation procedures by optimizing donor-recipient skin color matching. This can allow clinicians to complement visual judgment with quantitative reference.

Penile inversion vaginoplasty involves creation of vulva and a vaginal canal. Few studies describe techniques for creating aesthetic vulvar components, particularly the clitoral hood and labia minora. The authors present their approach to primary vulvoplasty, aiming to achieve the following: (1) labia minora that are well-defined and three-dimensional; (2) labia minora that frame the introitus; (3) sufficient clitoral hooding; (4) a patent introitus that appears closed at rest; and (5) prominent labia majora. In this technique, the labia majora are created by first pulling the superolateral scrotal skin inferiorly and medially toward the perineum. The labia majora incisions may be made laterally, medially, or both laterally and medially, dependent on the amount of penile and scrotal skin available. Initial approximating sutures are placed to anchor the labia inferiorly, and then excess skin is removed medially. The surgeon should avoid excess defatting of the labia majora, which are subject to initial edema and often atrophy with time. The preputial or distal penile shaft skin is used for the clitoral hood and medial aspect of the labia minora, with proximal penile shaft skin used for the lateral surface. The penile skin used for the lateral aspect of the labia minora must be pulled inferomedially toward the perineum, to create a narrow, tapered appearance and avoid effacement of the labia minora. Interrupted horizontal mattress quilting sutures are used to define the labia minora as distinct subunits. By considering homologous structures and anatomical subunits, we are able to create well-defined, aesthetic vulva in trans women and nonbinary individuals.