Faculty Bibliography

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

Background/Purpose:Management of patientswith cleft lip and palate is complex and requires a multidisciplinary team with several treatment interventions. Proper sequencing and timing of orthodontic and surgical treatment is important for successful long-term outcome and reducing the burden of care on the families. This presentation will focus on orthodontic management of patients born with cleft lip and palate from infancy to skeletal maturity. Methods/Description: The management of patients with cleft lip and cleft palate requires extended orthodontic treatment and an interdisciplinary approach in providing these patients with optimal aesthetics, function, and stability. Orthodontic or orthopedic management in infancy, primary, mixed, and permanent dentition and after the completion of facial growth will be discussed with a proper interdisciplinary approach to treatment planning and treatment sequencing during each phase of orthodontic and surgical treatment. This presentation will discuss the presurgical infant orthopedic, pre and post bone graft orthodontics, phase II comprehensive orthodontic treatment, and LeFort I distraction and orthognathic surgery at skeletal maturity. Long-term outcome of treatment will be presented of patients treated from birth to adulthood

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.

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.

OBJECTIVE:To compare continuous infusion preperitoneal wound catheters (CPA) versus continuous epidural analgesia (CEA) after elective colorectal surgery. METHODS:An open-label equivalence trial randomizing patients to CPA or CEA. Primary outcomes were postoperative pain as determined by numeric pain scores and supplemental narcotic analgesia requirements. Secondary outcomes included incidence of complications and patient health status measured with the SF-36 Health Survey (Acute Form). RESULTS:98 patients were randomized [CPA (N = 50, 51.0%); CEA (N = 48, 49.0%)]. 90 patients were included [ CPA 46 (51.1%); CEA 44 (48.9%)]. Pain scores were significantly higher in the CPA group in the PACU (p = 0.04) and on the day of surgery (p < 0.01) as well as supplemental narcotic requirements on POD 0 (p = 0.02). No significant differences were noted in postoperative complications between groups, aggregate SF-36 scores and SF-36 subscale scores. CONCLUSIONS:Continuous epidural analgesia provided superior pain control following colorectal surgery in the PACU and on the day of surgery. The secondary endpoints of return of bowel function, length of stay, and adjusted SF-36 were not affected by choice of peri-operative pain control.

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

Autologous fat grafting is an important tool for plastic surgeons treating the aging face. Malar augmentation with fat is often targeted to restore the youthful facial contour and provides support to the lower eyelid. The existence of distinct facial fat compartments suggests that a stepwise approach may be appropriate in this regard. The authors describe a three-step approach to malar augmentation using targeted deep malar fat compartmental augmentation, termed the "boomerang lift." Clinical patients undergoing autologous fat grafting for malar augmentation were injected in three distinct deep malar fat compartments: the lateral sub-orbicularis oculi fat, the medial sub-orbicularis oculi fat, and the deep medial cheek (n = 9). Intraoperative three-dimensional images were taken at baseline and following compartmental injections (Canfield VECTRA H1). Images were overlaid between the augmented and baseline captures, and the three-dimensional surface changes were analyzed, which represented the resulting "augmentation zone." Three-dimensional analysis demonstrated a unique pattern for the augmentation zone consistent across patients. The augmentation zone resembled a boomerang, with the short tail supporting the medial lower lid and the long tail extending laterally along the zygomatic arch. The upper border was restricted by the level of the nasojugal interface, and the lower border was defined medially by the nasolabial fold and laterally by the level of the zygomaticocutaneous ligament. Lateral and medial sub-orbicularis oculi fat injections defined the boundaries of the boomerang shape, and injection to the deep medial cheek provided maximum projection. This is the first description of deep malar augmentation zones in clinical patients. Three-dimensional surface imaging was ideal for analyzing the surface change in response to targeted facial fat grafting. The authors' technique resulted in a reproducible surface shape, which they term the boomerang lift.

Background/Purpose: In October 2012, a freely available, Internetbased cleft simulator was created in partnership among academic, nonprofit, and industry sectors. The purpose of this educational resource was to address disparities in surgical education resulting from resident work-hour restraints in developed countries and limited resources in developing nations. This report assesses demographics, utilization, and global impact of our simulator, in its fifth year since inception. Methods/Description: Simulator modules demonstrate surgical anatomy, markings, detailed procedures, and intraoperative footage to supplement digital animation. Available data regarding number of users, sessions, countries reached, and content access was collected. Surveys evaluating the demographic characteristics of registered users and simulator utility were collected by direct e-mail.
Result(s): The total number of simulator new and active users reached 2865 and 4086 in June 2017, respectively. A steady increase in number of new users (217-327), active users (407-555), and sessions (1956-2304) was noted from January 2016 to June 2017. From March 2015 to June 2017, our simulator was accessed in an increasing number of countries (85-136). In the same time frame, the number of sessions was 11 176, with a monthly average of 399.0 +/- 190.0. Developing countries accounted for 35% of sessions. New users generated the majority of sessions (59.8% +/- 8.5%), and the average session duration was 9.0 +/- 7.3 minutes. This yields a total simulator screen time of 100 584 minutes (1676 hours) and an average of 3725 minutes (62 hours) per month. A total of 151 users responded to our survey, the majority of whom were surgeons or trainees (87%) specializing in plastic, maxillofacial or general surgery (89%). Most users found the simulator to be useful (88%), at least equivalent or more useful than other resources (83%), and used it for teaching (58%).
Conclusion(s): Internet-based distribution of a freely available cleft surgery simulator can deliver an interactive teaching platform that reaches the intended target audience, is not restricted by socioeconomic barriers to access, and is judged to be useful by surgeons. Our simulator has reached more than 4000 active users since inception. The great majority of users are surgeons or surgical trainees. The total screen time over approximately 2 years exceeded 1600 hours. This suggests that future educational simulators of this kind may be sustainable by stakeholders interested in reaching this target audience

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