Faculty Bibliography

Background/Purpose: Financial constraints are driving hospitals toward shortening patient stay and favoring outpatient surgery when appropriate. This study compares perioperative complications between the outpatient and inpatient settings in patients undergoing primary cleft lip surgery (PCLS) and identifies risk factors associated with complications and longer lengths of stay. Methods/Description: The American College of Surgeons National Surgical Quality Improvement Program Pediatric database (ACS NSQIP-Pediatric) was reviewed from 2012 to 2015 using Current Procedure Terminology (CPT) codes for PCLS. Patients older than 5 years or undergoing concurrent cleft palate surgery were excluded. The objective of our study was to compare perioperative complications following outpatient vs inpatient PCLS. Statistical analyses were performed using SPSS (version 21.0; IBM Corp, Armonk, NY).
Result(s): We identified 3142 (1721 inpatient vs 1421 outpatient) eligible patients. The majority of patients were males (63.0%) and underwent unilateral PCLS (78.5%). Plastic surgeons were the most frequent providers (85.1%) performing these procedures followed by otolaryngologists (14.0%). The most commonly performed concurrent procedures were cleft lip rhinoplasty (24.2%) and tympanostomy tube insertion (4.7%). Tissue grafting and gingivoperiosteoplasty were each performed in 1.2% of patients. Mean age in days and weight in kilograms at surgery were 200.8+/-223.3 and 7.0+/-3.2, respectively. Mean age (222.6+/-258.7 vs 182.9+/-187.7; P < .001) and weight (7.1 +/- 3.2 vs 6.9 +/- 3.5; P = .03) were significantly higher in the outpatient group. The inpatient group included a significantly higher proportion of patients with cardiac risk factors (12.9% vs 9.4%; P = .002) and oxygen dependence (1.1% vs 0.4%; P = .02). Rates of surgical site infections, wound dehiscence, reoperation, readmission, 30-day mortality, cardiac arrest, transfusion requirements, reintubation and operative time were comparable between groups on univariate analysis. Multivariate regression showed that an underlying structural pulmonary abnormality was significantly associated with a longer hospital length of stay (B = 4.94, P = .001, 95% CI [2.21,7.66]). No other significant associations were identified on multivariate analysis.
Conclusion(s): Surgical site infections, wound dehiscence, reoperation, readmission, 30-day mortality, and other perioperative complications are comparable in patients undergoing outpatient and inpatient PCLS. Patient selection remains the cornerstone for safe practice. Increasing health care fiscal constraints warrant considering outpatient PCLS for appropriate candidates

Background/Purpose: Gingivoperiosteoplasty (GPP) performed concurrent with lip repair is an option for treating bony alveolar deficiency in patients with orofacial clefts. GPP has been demonstrated to produce bony continuity, eliminating the need for alveolar bone grafting (ABG) in two-thirds of treated cleft sites. The purpose of this study was to assess if early bone formation as produced by successful GPP influences maxillary canine eruption. Methods/Description: A retrospective chart review was conducted to identify patients born between January 1, 2000, and December 31, 2007, with unilateral complete cleft lip and alveolus, with or without cleft palate. Patients were included if they had successful GPP or ABG, and had panoramic or maxillary CBCT radiographs available at age 5 to 9 (T1) and 9 to 12 (T2) years, with a minimum of 6 months between radiographs. Panoramic images were excluded if a head positioning error produced an occlusal plane greater than 15degree from perpendicular to midline. Panoramic images were used to assess maxillary canine sector, angulation relative to midline and ipsilateral occlusal plane, and cusp tip height from ipsilateral occlusal plane. CBCT images were used to assess the horizontal distance between the canine cusp tip and the maxillary arch form. Clinical charts were reviewed to determine if canines erupted successfully or required intervention. Finally, canine mesial-distal and labio-lingual position after eruption was assessed using occlusal photographs. Outcomes in GPP and ABG groups were compared, and results were stratified by ipsilateral lateral incisor presence or absence.
Result(s): Seventy-nine patients met inclusion; 24 had successful bone fill after GPP, and 55 after ABG. In patients with cleft-side lateral incisors present, no significant differences were found between GPP and ABG groups in canine angulation, height, sector, eruptive outcome, or timing of eruption. When spontaneous canine eruption occurred, there was a statistically nonsignificant trend to more mesial eruptive position in patients who were treated with GPP. In patients with cleft-side lateral incisor agenesis, initial canine angulation did not differ. Patients who were treated with GPP demonstrated 10.8degree +/- 11.1degree spontaneous canine uprighting from T1 to T2, while canine angulation was maintained in the ABG group; this difference was statistically significant (P = .001). The GPP group demonstrated greater canine descent from T1 to T2, resulting in significantly less distance from the occlusal plane (5.8 +/- 4.8 mm) compared to the ABG group (9.4+/-4.2 mm). Horizontal distance to arch did not differ between the groups. In the GPP group, 75% of patients demonstrated successful spontaneous canine eruption, compared to 41% in the ABG group, though this did not reach statistical significance (P = .146).
Conclusion(s): Gingivoperiosteoplasty favorably influenced the angulation, height, and eruptive success of cleft-side canines in patients. These benefits were predominantly noted in patients with congenital absence of lateral incisors

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.

INTRODUCTION/BACKGROUND:Parallel to worldwide disparities in patient access to health care, the operative opportunities of surgical trainees are increasingly restricted across the globe. Efforts have been directed toward enhancing surgical education outside the operating room and reducing the wide variability in global trainee operative experience. However, high costs and other logistical concerns may limit the reproducibility and sustainability of nonoperative surgical education resources. METHODS:A partnership between the academic, nonprofit, and industry sectors resulted in the development of an online virtual surgical simulator for cleft repair. First year global access patterns were observed. RESULTS:The simulator is freely accessible online and includes 5 normal and pathologic anatomy modules, 5 modules demonstrating surgical markings, and 7 step-by-step procedural modules. Procedural modules include high-definition intraoperative footage to supplement the virtual animation in addition to include multiple-choice test questions. In its first year, the simulator was accessed by 849 novel users from 78 countries; 70% of users accessed the simulator from a developing nation. CONCLUSION/CONCLUSIONS:The Internet shows promise as a platform for surgical education and may help address restrictions and reduce disparities in surgical training. The virtual surgical simulator presented may serve as the foundation for the development of a global curriculum in cleft repair.

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: The aim of this study was to investigate the effect of infant orthopedics on transversal, sagittal and vertical dimensions of maxillary and mandibular dentoalveolar measurements in patients with unilateral cleft lip and palate (UCLP) and to compare them to patients without cleft at the age of 5. Methods/Description: Forty-five dental casts of nonsyndromic patients with completeUCLP were assessed for this retrospective study (age range: 4.5-6.5 years). These patientswere divided into 2 groups based onwhether infant orthopedics were applied (IO) or not (NIO). Maxillary andmandibular dental casts were available for 25 patients in the IOgroup and 20 in the NIO group 20. These 2 cleft groups were compared to a control group of age-matched patients with class I occlusion and without a cleft (n = 48). Maxillary and mandibular anterior and posterior arch widths, arch lengths, and palatal depths were measured with a ruler and digital caliper. Lesser segment canine position and the amount of cleft gap were evaluated as well. For statistical analysis, ANOVA was used for comparisons between groups.
Result(s): Maxillary anterior (III-III) and posterior arch widths (V-V) were similar in the subgroups of patientswith clefts, whereas they were narrower than the noncleft control group (P < .01). There was no significant difference in mandibular arch dimensions between samples from patients with and without a cleft (P >= .05). Lesser segment arch perimeter did not differ between groups (P <= .336), while greater segment arch perimeter was found to be higher in the control group when compared to the groups with a cleft (P <= .01). Posterior palatal depth, measured from the occlusal surfaces of the second primary molars, was found to be higher in noncleft samples (P <= .001) and the difference between patients in the IO and NIO groups were not significant. However, measurement of anterior palatal depth revealed no significant difference between patients with a cleft and the control group (P >= .05). The maxillary deciduous canine at the lesser segmentwas located more palatinally in theNIO group than in the IOgroup (P < .05). Regarding the amount of cleft gap, the NIO group exhibited a bigger cleft width (3.98 +/- 2.65 mm) and depth (2.12 +/- 2.63 mm) than those of the IO group (2.36 +/- 2.48 mm, 0.78 +/- 1.14 mm, respectively) significantly (P <= .05).
Conclusion(s): Maxillary transverse measurements were decreased in groups of patients with a cleft both with/without IO when compared to a noncleft control group. The IO and NIO groups exhibited similar arch widths. Cleft depth and width were found to be higher in the NIO group

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

Background/Purpose: LeFort III distraction osteogenesis is commonly recommended for children with syndromic craniosynostosis to reduce exorbitism, improve airway function, and decrease dysmorphism. This purpose of this study is to report on the long-term clinical outcomes of patients with syndromic craniosynostosis patients who have undergone early primary subcranial LeFort III distraction osteogenesis and who have been followed longitudinally through skeletal maturity. Methods/Description: Retrospective review of all patients who underwent LeFort III distraction osteogenesis between the ages of 3 and 11 years and were followed throughout development with longitudinal dental, medical, radiographic, and photographic evaluations conducted through skeletal maturity and beyond. Inclusion criteria entailed having preoperative medical photographs and cephalometric studies at 6 months and 1, 5, and 10 years postoperatively after the primary LeFort III distraction osteogenesis as well as cephalometric documentation 6 months and 1 year after the secondary midface advancement after skeletal maturity.
Result(s): Seventeen patients fulfilled inclusion criteria, with a mean age of 5.7 years at the time of initial LeFort III distraction. The mean advancement of point A was 14.9 mm anteriorly and 2.7 mm inferiorly along the x- and y-axis, respectively. Orbitale moved 10.5 mm anteriorly and 2.2 mm inferiorly along the x- and y-axis, respectively. At 10 years postoperatively, point A moved 3.4 mm anterior along the xaxis and 4.7 mm inferiorly along the y-axis, while orbitale moved 0.4 mm posteriorly and 3 mm inferiorly along the x- and y-axis, respectively. At the time of skeletal maturity, there was a return of occlusal disharmony from normal mandibular growth and a return of proptosis owing to remodeling of orbitale inferiorly, and the lateral orbital rim posteriorly, while the globe continued to grow in the anterior vector. All but 1 study patient underwent or is scheduled to undergo a secondary midface advancement at the LeFort III and LeFort I level after skeletal maturity was attained.
Conclusion(s): The data demonstrate that patients who undergo early LeFort III distraction osteogenesis before the age of mixed dentition will still most likely need a secondary midface advancement after skeletal maturity is reached given that there is a small degree of anterior growth at the level of the maxilla and no anterior growth at orbitale over time

Background/UNASSIGNED:Amniotic Band Syndrome is a clinical constellation of congenital anomalies characterized by constricting rings, tissue synechiae and amputation of body parts distal to the constriction bands. Involvement of the hand with loss of multiple digits not only leads to devastating deformities but also loss of functionality. Methods/UNASSIGNED:In this series, utilizing microvascular transfer of the second toe from both feet, along with local tissue reconfiguration, a tetra-digital hand with simile of normal cascade was reconstructed. A consecutive series of eight children with Amniotic Band Syndrome, younger than two years in age operated on by single surgeon over a twenty five year interval was reviewed. Results/UNASSIGNED:There was no flap loss. The hands were sensate with effective simple prehensile function. Conclusion/UNASSIGNED:Application of Microvascular toe-to-hand transfer for well selected, albeit severe hand deformity in Amniotic Band Syndrome is a valid surgical concept.

BACKGROUND:Gingivoperiosteoplasty can avoid secondary alveolar bone grafting in up to 60 percent of patients with a cleft. However, preoperative predictors of success have not been characterized. This study reports on the preoperative alveolar segment position most favorable for successful gingivoperiosteoplasty. METHODS:The authors performed a single-institution, retrospective review of patients with a unilateral cleft who underwent nasoalveolar molding. Alveolar segment morphology was directly measured from maxillary dental models created before and after nasoalveolar molding. Statistical analysis was performed to identify parameters associated with the decision to perform gingivoperiosteoplasty and its success, defined as the absence of an eventual need for alveolar bone grafting. RESULTS:Fifty patients with a unilateral cleft who received nasoalveolar molding therapy were included in this study (40 underwent gingivoperiosteoplasty and 10 did not). Eighteen alveolar morphology and position characteristics were tested, including cleft gap width, horizontal and vertical positions of the alveolar segments, alveolar stepoff, and degree of alveolar segment apposition. Post-nasoalveolar molding vertical rotation of the greater segment and the percentage of segment alignment in the correct anatomical zone were statistically significant predictors of the decision to perform gingivoperiosteoplasty (86 percent predictive power). Cleft gap, greater/lesser segment overlap, alveolar segment alignment, greater segment horizontal rotation, and alveolar segment width following nasoalveolar molding were significant predictors of gingivoperiosteoplasty success (86.5 percent predictive power). CONCLUSIONS:Greater segment vertical rotation and proper alveolar segment anatomical alignment are positive predictors of the decision to perform gingivoperiosteoplasty. Post-nasoalveolar molding evidence of proper alignment and direct contact between the alveolar segments were significant predictors of successful gingivoperiosteoplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Risk, III.