Faculty Bibliography

Facial disfigurement can significantly affect personal identity and access to social roles. Although conventional reconstruction can have positive effects with respect to identity, these procedures are often inadequate for more severe facial defects. In these cases, facial transplantation (FT) offers patients a viable reconstructive option. However, FT's effect on personal identity has been less well examined, and ethical questions remain regarding the psychosocial ramifications of the procedure. This article reviews the literature on the different roles of the face as well as psychological and social effects of facial disfigurement. The effects of facial reconstruction on personal identity are also reviewed with an emphasis on orthognathic, cleft, and head and neck surgery. Finally, FT is considered in this context, and future directions for research are explored.

BACKGROUND:Enhanced recovery pathway programs have demonstrated improved perioperative care and shorter length of hospital stay in several surgical disciplines. The purpose of this study was to compare outcomes of patients undergoing autologous tissue-based breast reconstruction before and after the implementation of an enhanced recovery pathway program. METHODS:The authors retrospectively reviewed consecutive patients who underwent autologous tissue-based breast reconstruction performed by two surgeons before and after the implementation of the enhanced recovery pathway at a university center over a 3-year period. Patient demographics, perioperative data, and 45-day postoperative outcomes were compared between the traditional standard of care (pre-enhanced recovery pathway) and enhanced recovery pathway patients. Multivariate logistic regression was performed to identify risk factors for length of hospital stay. Cost analysis was performed. RESULTS:Between April of 2014 and January of 2017, 100 consecutive women were identified, with 50 women in each group. Both groups had similar demographics, comorbidities, and reconstruction types. Postoperatively, the enhanced recovery pathway cohort used significantly less opiate and more acetaminophen compared with the traditional standard of care cohort. Median length of stay was shorter in the enhanced recovery pathway cohort, which resulted in an extrapolated $279,258 savings from freeing up inpatient beds and increase in overall contribution margins of $189,342. Participation in an enhanced recovery pathway program and lower total morphine-equivalent use were independent predictors for decreased length of hospital stay. Overall 45-day major complication rates, partial flap loss rates, emergency room visits, hospital readmissions, and unplanned reoperations were similar between the two groups. CONCLUSION/CONCLUSIONS:Enhanced recovery pathway program implementation should be considered as the standard approach for perioperative care in autologous tissue-based breast reconstruction because it does not affect morbidity and is associated with accelerated recovery with reduced postoperative opiate use and decreased length of hospital stay, leading to downstream health care cost savings. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, III.

Background/Purpose: Presurgical infant orthopedics has been employed since 1950 as an adjunctive neonatal therapy for the correction of cleft lip and palate. Most of these therapies did not address deformity of the nasal cartilage in unilateral and bilateral cleft lip and palate as well as the deficiency of the columella tissue in infants with a bilateral cleft. The nasoalveolar molding (NAM) technique is a unique approach to presurgical infant orthopedics to reduce the severity of the initial cleft of the alveolar and the nasal deformity, particularly in patients with bilateral cleft lip and palate. Methods/Description: In infants with bilateral cleft lip and palate, the premaxilla may be protrusive, mobile, and may show varying degree of asymmetrical displacement and rotation. In some instances, the premaxilla may be everted placed on top of the nasal tip with a very short columella length. Protruded premaxilla and the associated nasal deformity present a special challenge for the surgeon in achieving optimal repair during primary reconstructive surgery. This study session will demonstrate the NAM technique to treat patients with severe bilateral cleft lip and palate. The technique of correcting the protruded and asymmetrically displaced premaxilla, molding the alar cartilage and nonsurgical columella elongation will be discussed. Appliance design and weekly adjustment of the NAM appliance to accomplish the desired result will be presented. Special emphasis will be placed on leveling the premaxilla in asymmetric cases; retracting premaxilla in incomplete bilateral clefts and management of complications during the course of the NAM therapy will be discussed. For the successful outcome, the surgeon has to take the advantage of the NAM therapy during the primary repair. Surgical technique of 1-stage lip nose and alveolus surgery utilizing the presurgical preparation of infants with bilateral cleft lip and palate with NAM therapy will be discussed in detail. Long-term outcome of patients treated with NAM and primary reconstruction of nose lip and alveolus will be presented

Vascular malformations (VMs) of the head and neck can lead to aesthetic problems as well as cranial nerve damage, airway compromise, and vision loss. Large VMs are typically managed surgically, with sclerotherapy or embolization performed in the perioperative period to decrease the risk of excessive blood loss and minimize the size of the VM. However, this initial treatment is frequently insufficient leading to excessive blood loss intraoperatively, poorer margin visualization for the surgeon, and decreased likelihood of complete resection. As a result, resections of large VMs are often performed in a multistage approach. This article introduces a new hybrid approach for the management of head and neck VMs entailing the use of an endovascular operating room where a neuroendovascular surgeon performs embolization or sclerotherapy intraoperatively as needed in conjunction with surgical excision. Three patients with large VMs in the facial region underwent successful use of the hybrid approach. The hybrid approach improved visualization, leading to complete resection in 1 patient and nearly complete resections (70% and 90%) in the other patients. The technique also helped minimize blood loss because only the youngest patient (23 months old) required a blood transfusion. Implications of these findings include the transition from a multistaged approach for large VMs to a single-stage approach. In addition, decreases in blood loss may allow for the development and use of minimal access techniques, leading to a decrease in visible scarring for patients. We suggest the consideration of the hybrid approach for large head and neck VMs.

Background/Purpose: Gingivoperiosteoplasty (GPP) performed with lip repair has been shown to eliminate the need for alveolar bone grafting in two-thirds of treated cleft sites. In patients who have received GPP and subsequently require alveolar bone grafting (ABG), bone fill may be more favorable than in patients treated by ABG alone. However, some reports have suggested that GPP increases the risk of dental anomalies. This study aimed to assess the prevalence of dental anomalies in patients who were treated by GPP compared to those treated by ABG without GPP. Methods/Description: A retrospective chart review was conducted to identify patients born January 1, 2000, to December 31, 2007, with unilateral complete cleft lip and alveolus, with or without cleft palate. Patients were included if they received GPP or ABG at our center, and had adequate panoramic radiographs and clinical images at ages 5 to 9 and 10 to 12 years. Clinical records were assessed for missing or malformed teeth by a blinded examiner. Cleft side lateral incisors were classified as absent, present, extracted, and supernumerary; cleft side lateral incisor morphology was classified as normal, undersized/ peg shaped, or severely malformed; cleft side central incisors were classified as absent, normal, or anomalous; and the number of cleft side premolars was recorded. Dental anomalies were compared between the GPP and no-GPP groups using the chi-square test.
Result(s): Ninety-four patients met inclusion criteria: 46 treated with GPP, and 48 patients who did not receive GPP. Among patients who received GPP, cleft-side lateral incisors were absent in 54% of patients, compared to 50% of patients who did not receive GPP. Two patients in the GPP group and 4 in the no-GPP group required lateral incisor extraction. Two patients in the GPP group and one in the no- GPP group had supernumerary lateral incisors. These differences were statistically nonsignificant (P = .919). The majority of lateral incisors were undersized or peg shaped in both the no-GPP (20, 83.3%) and GPP (15, 71.4%) groups. One patient in the GPP group had a severely malformed lateral incisor. These differences were not statistically significant (P = .442). Cleft side central incisors were present in the majority of patients. In the GPP group, 5 patients (10.9%) exhibited central incisor agenesis, and a further 3 had significant hypoplasia. In the no-GPP group, 4 patients (8.3%) exhibited central incisor agenesis, and 5 (10.5%) significant hypoplasia. There were no intergroup differences (P = .937). Eight patients in the GPP group and 14 in the no- GPP group were missing cleft side premolars; the difference was not statistically significant (P = .937).
Conclusion(s): In this sample, gingivoperiostoplasty was not associated with increased prevalence of agenesis or malformation of cleft side incisors or premolars. When performed appropriately, gingivoperiosteoplasty is a safe treatment technique that does not increase the risk of dental anomalies

Background/Purpose: Outpatient primary cleft palate surgery (PCPS) has been implemented in many cleft centers; however, the prevalence of this procedure is unknown and its safety has been called into question. We queried the American College of Surgeons National Surgical Quality Improvement Program Pediatric database (ACS NSQIPPediatric) to evaluate perioperative complications associated with PCPS. Methods/Description: The ACS NSQIP-Pediatric database was reviewed from 2012 to 2015 using Current Procedure Terminology (CPT) codes for PCPS. Patients undergoing concurrent bone grafting or cleft lip surgery were excluded. Patients aged 5 years or younger were included. The goal of our study was to compare 30-day perioperative complications following outpatient vs inpatient PCPS. Statistical analyses were carried out using SPSS (Version 21.0. Armonk, NY: IBM Corp).
Result(s): We identified 4191 (2760 inpatient vs 1431 outpatient) eligible patients. The majority of patients were males (52.6%). Plastic surgeons performed these procedures most frequently (80.3%) followed by otolaryngologists (18.7%). Tympanostomy tube insertion was the most common concurrent procedure (17.1%). Mean age in days and weight in kilograms at surgery were 485.5 +/- 319.2 and 9.7 +/- 3.8, respectively. Mean age (509.3 +/- 346.9 vs 473.2 +/- 303.1; P < .001) and weight (9.9 +/- 4.0 vs 9.6 +/- 3.8; P = .01) were significantly higher in the outpatient group. The inpatient group included a significantly higher proportion of patients with congenital abnormalities (25.0% vs 21.2%; P = .01), history of stroke (1.0% vs 0.3%; P = .02), cardiac risk factors (14.4% vs 11.7%; P = .02) and oxygen dependence (1.8%vs 0.8%; P = .01). Univariate analysis showed that rates of superficial (3.5% vs 2.0%; P = .01) and deep (2.2% vs 1.0%; P = .003) wound dehiscence were significantly higher in the outpatient group. The rates of reoperation (1.2 vs 0.4; P = .02) and readmission (3.2 vs 1.5; P = .01) were significantly higher in the inpatient group. Mortality at 30 days was comparable between groups. After controlling for confounders, rates of superficial (OR = 1.99, P = .01, 95% CI [1.22, 3.24]) and deep (OR = 2.22, P = .01, 95% CI [1.25, 3.95]) wound dehiscence remained significantly higher in the outpatient group, whereas reoperation (OR = 2.8, P=.04, 95%CI [1.04, 7.14]) and readmission (OR=1.92, P= .02, 95% CI [1.14, 3.23]) rates were significantly higher in the inpatient group.
Conclusion(s): Outpatient PCPS is a common practice and appears to have an acceptable safety profile in appropriately selected patients. Outpatient surgery has a higher risk for wound complications. Inpatient surgery is associated with greater reoperation and readmission. Preoperative evaluation of patient risk factors and comorbidities is critical for optimal outcomes