The Severity of Initial Unilateral Cleft Lip and Nasal Deformity Predicts Long-Term Postoperative Esthetic Outcome.

BACKGROUND: Infantile cleft lip and nasal severity influence the final esthetic result of the repair. Although various authors have described methods of cleft lip and nasal repair, there is a paucity of data that correlates cleft severity with esthetic outcomes. The aim of this study was to examine the correlation between presurgical severity of unilateral cleft deformity and long-term postoperative esthetic outcomes. METHODS: This retrospective study, based at a single institution, investigated patients with complete unilateral cleft lip, with or without cleft palate, who underwent repair by a single surgeon, had preoperative infantile facial casts, and had postoperative facial photographs at 6 to 11 years of age (N=31). Preoperative nostril width ratio and columellar angle measurements were taken from facial casts. Postoperative, long-term nasolabial appearance was rated by 5 blinded observers used a modified Kuijpers-Jagtman scale. Linear regression was used to determine the relationship between preoperative cleft severity and postoperative ratings. RESULTS: Preoperative nostril width ratio directly correlated with postoperative nasal form score (r=0.40; P=0.026); likewise, preoperative columellar angle predicted postoperative nasal form score (r=0.37; P=0.040). Preoperative cleft severity was not significantly correlated with vermillion border appearance. Cronbach α values of 0.91 (nasal form) and 0.79 (vermillion border) indicated good inter-rater reliability. Kappa values of 0.87 (nasal form) and 0.70 (vermillion border) indicated good intrarater reliability. CONCLUSIONS: Preoperative unilateral cleft nose severity directly correlates with long-term postoperative nasal appearance in childhood. Outcome studies should present and control for preoperative severity to allow more accurate assessment of repair techniques.

Surgical Guide Splint Fabrication via Virtual Surgical Planning for Complex Mandible Fractures in the Trauma Setting.

INTRODUCTION: In cases of significantly displaced or comminuted mandible fractures, surgical guide splints can be developed to create the normal preinjury occlusion rather than placing patients in maxillomandibular fixation. Standard fracture fixation involves bending of plates intraoperatively based on surgeon-constructed dental splints which is prone to error. METHODS: A 38-year-old male experienced a gunshot wound to the face that resulted in mandibular angle fractures bilaterally causing severely deranged occlusion and free-floating anterior mandible segment. Virtual surgical planning (VSP) software was used to recreate the injury-induced anatomy and anticipated postoperative anatomy. It also provided a surgical guide splint and a framework to preoperatively bend reconstruction plates to assist in achieving proper occlusion. RESULTS: He underwent open reduction internal fixation of comminuted mandible fractures with lingual guide splint placement 10 days after injury. Following lingual splint application, the reconstruction plate was applied from angle to angle. The lingual splint was maintained for 3 weeks postoperatively to support the stabilization, and he was able to tolerate a regular diet and showed no evidence of wound breakdown. DISCUSSION: Virtual surgical planning has had important implications in craniofacial surgery, orthognathic surgery, maxillomandibular reconstruction, and orbital reconstruction after tumor resection, temporomandibular joint surgery, and others. However, there have only been isolated reports describing the role of VSP in the facial trauma setting. In this technical study, the authors demonstrate the benefits of VSP and surgical guide splinting in trauma settings.

Pott Puffy Tumor Secondary to Cranial Vault Reconstruction in a Patient With Metopic Craniosynostosis.

Pott puffy tumor (PPT) is defined as a subperiosteal abscess of the anterior wall of the frontal sinus associated with underlying frontal osteomyelitis. PPT affects all age groups but occurs predominantly in adolescents. The potential etiologies include rhinosinusitis, a history of direct trauma to the forehead, odontogenic disease, intranasal drug abuse, diabetes, or other immunocompromised states. We introduce a case of a 6-year-old boy with a medical history of anterior cranial vault remodeling presenting with localized forehead swelling. Computed tomography imaging demonstrated mucosal thickening and a region of dehiscence in the wall of the frontal sinus; the presence of midline subperiosteal abscess was consistent with a diagnosis of PPT. Due to concerns for intracranial involvement, we utilized removal and replacement of the anterior wall of the frontal sinus, complete removal of sinus mucosa, and frontal sinus obliteration with bilateral peri-cranial flaps. To the best of our knowledge, this is the first case description of a PPT secondary to cranial vault reconstruction in a patient with metopic craniosynostosis.

Orofacial Clefting in Van der Woude's Syndrome.

What is the etiology based on the history and physical examination?Describe the embryology associated with orofacial clefts.What kind of treatment team is needed for orofacial clefts, and how do the team members work together?Describe the surgical treatment timeline and goals for orofacial clefts.

Creating a Spaced Repetition Model to Supplement Education in Plastic Surgery.

Plastic surgery encompasses a wide spectrum of material involving comprehensive anatomy, physiology, microbiology, biomaterials, complex surgical techniques, and many nonsurgical interventions. The core disciplines overlap extensively with the foundational knowledge of many other surgical specialties. With the ever-expanding knowledge base required to become a competent plastic surgeon, spaced repetition is a means to optimize learning in plastic surgery and help trainees master new concepts while retaining other facts that are easily forgotten. Platforms for spaced repetition are user-friendly and can be synchronized between devices to streamline progress and make efficient use of the limited free time that exists throughout the workday. Flashcard decks can be imported to these platforms to follow a spaced repetition algorithm. Currently, no publicly available comprehensive deck exists for education in plastic and reconstructive surgery. Creation of flashcard decks covering lectures, textbooks, or old examination questions can reinforce the foundational concepts of our field. Additionally, there is potential to improve resident performance on the Plastic Surgery In-service Training Examination. Once created, this comprehensive flashcard deck can be distributed to plastic surgery residency programs to pave the way for a uniform curriculum.

Opioid Prescribing Practices in Cleft Lip and Cleft Palate Reconstruction.

INTRODUCTION: Currently, there is no consensus regarding the role of opioids in the management of perioperative pain in children undergoing cleft lip/palate repair. METHOD: The present study evaluated opioid prescribing patterns of surgeon members within the American Cleft Palate-Craniofacial Association surgeons utilizing an anonymous survey. RESULTS: Respondents performing cleft lip repair typically operate on patients 3 to 6 months of age (86%), admit patients postoperatively (82%), and discharge them on the first postoperative day (72%). Comparatively, respondents performed palatoplasty between the ages of 10 and 12 months (62%), almost always admit the patients (99%), and typically discharge on the first postoperative day (78%). Narcotics were more frequently prescribed after palatoplasty than after cleft lip repair, both for inpatients (66%; 49%) and at discharge (38%; 22%). Oxycodone was the most prescribed narcotic (39.1%; 41.4%), typically for a duration of 1 to 3 days (81.5%; 81.2%). All surgeons who reported changing their narcotic regimen (34.4% dose, 32.8% duration) after cleft lip repair, decreased both parameters from earlier to later in their career. Similarly, surgeons who changed the dose (32.2%) and duration (42.5%) of narcotics after palatoplasty, mostly decreased both parameters (96%). Additionally, physicians with >15 years of practice were less likely to prescribe opioids in comparison with colleagues with ≤15 years of experience. Ninety-two percent of respondents endorsed prescribing nonopioid analgesics after prescribing cleft surgery, most commonly acetaminophen (85.7%; 85.4%). CONCLUSION: Cleft surgeons typically prescribe opioids to inpatients and rarely upon discharge. Changes to opioid-prescribing patterns typically involved a decreased dose and duration.

Microsurgery in the era of COVID-19.

The COVID-19 pandemic has presented new challenges to microsurgeons. The virus is highly transmissible, with increased risk during operations that involve the aerodigestive tract. It is important to be able to identify high-risk operations and scenarios to guide management decisions and selection of personal protective equipment. Preoperative testing is a key element in identifying high-risk scenarios, and preoperative testing protocols are essential to maintaining safety in the COVID-19 era. Because COVID-19 can be transmitted via the conjunctiva, adaptations to loupes and microscopes are necessary to safely perform microsurgery in high-risk scenarios. We outline a potential risk stratification algorithm, as well as precautions for each scenario. Potential areas for innovation are also discussed.

A Protocol for Safe Head and Neck Reconstructive Surgery in the COVID-19 Pandemic.

The COVID-19 pandemic has had significant implications for citizens globally and for the healthcare system, including plastic surgeons. Operations of the upper aerodigestive tract, including head and neck reconstruction and craniomaxillofacial procedures, are of particularly high risk because they may aerosolize the virus and lead to severe surgeon and surgical team illness. Until the virus is eradicated or widespread vaccination occurs, we recommend certain precautions to safely perform these operations. We propose evolving algorithms for head and neck reconstruction and facial trauma surgeries to maintain provider safety. Central to these guidelines are preoperative COVID-19 testing, appropriate personal protective equipment, and operative techniques/principles that minimize operative time and aerosolization of the virus. We aim to provide efficient care to our patients throughout this pandemic, while maintaining the safety of plastic surgeons and other healthcare providers.

Reexploring the Anatomy of the Distal Humerus for its Role in Providing Vascularized Bone.

BACKGROUND: The lateral arm flap is used for composite defects in need of vascularized soft tissue, skin, and bone. From its original description, the distal humeral metaphysis can be included with the flap, supplied by the periosteal extensions of the posterior branch of the radial collateral artery. We sought to reexplore the anatomy of the lateral arm to determine its utility as a donor site for vascularized bone. METHODS: Twelve fresh, silicone-injected cadaver dissections were performed. Arteriovenous anatomy, pedicle length and diameter, and anatomic variability as well as photo documentation was recorded. RESULTS: The distal extent of the deltoid, lateral intermuscular septum and lateral humeral epicondyle were identified before the dissection. A septocutaneous perforator was consistently located 10 cm proximal to the lateral humeral epicondyle, which could be used for a skin paddle to monitor. Harvest of a 1.5 cm × 2 cm corticocancellous bone graft was performed. Average pedicle length was 9.1 ± 1.1 cm, and average pedicle diameter was 1.74 ± 0.52 mm. The inferior lateral cutaneous nerve of the arm and the posterior cutaneous nerve of the forearm were consistently identified and preserved. CONCLUSION: The predictable anatomy of the lateral distal humerus make it an ideal donor site for small segments of vascularized bone.

A Multidisciplinary Evaluation of Prescribing Practices for Prophylactic Antibiotics in Operative and Nonoperative Facial Fractures.

BACKGROUND: Evidence supports short-term perioperative prophylaxis for facial fractures. It is unknown, however, whether there is any professional consensus on how to manage these injuries. No multidisciplinary evaluation of the prophylactic antibiotic prescribing patterns for neither operative nor nonoperative facial fractures has been performed. AIM: To evaluate the prophylactic antibiotic prescribing patterns of multiple specialties in operative and nonoperative facial fractures. METHODS: A 14 question anonymous online-based survey was distributed to members of the American Society of Maxillofacial Surgeons (ASMS) and the American Association of Facial Plastic Surgeons to evaluate current practices. RESULTS AND CONCLUSIONS: 205 respondents, including 89 plastic surgeons, 98 otolaryngologists, 12 oral and maxillofacial surgeons, and 7 with double board certification practicing throughout the United States with ranging experience from 11 to 30 years. As expected, preoperative, perioperative, or postoperative prophylactic antibiotics are either "always" or "sometimes" prescribed, 100% of the time with more varied practice upon further inspection. A total of 85.1% either "always" or "sometimes" use antibiotics while awaiting surgery. Dentate segment fractures are the most frequent type of facial fractures to receive prophylactic antibiotics for both operative (90.5%) and nonoperative (84.1%) fractures. Duration of antibiotic use is more varied with the majority providing 3 to 7 days despite current evidence. First generation cephalosporins alone are prescribed by 49% of respondents, which may not adequately cover oral flora. There is no multidisciplinary consensus for prophylactic antibiotics for specific operative fracture types or nonoperative facial fractures, an area with little published evidence.

Challenges of Organizing Mission Surgery in Resource Limited Environments.

Interest in global burden of disease that can be surgically treated is on the rise, and plastic surgeons, with a wide scope of practice, have the tools that make them integral in providing much of the needed surgical support in the world. Since the 1950 s, plastic surgeons have been closely involved in volunteer surgery, and it is through the success and growth of organizations such as Interplast and Operation Smile that we are able to take part in the current paradigm shift to local empowerment and self-sufficiency instead of service delivery alone. This kind of growth started with medical mission work that fostered international partnerships and that remain an important aspect of addressing the unmet surgical burden of disease. Building a mission comprised of an international team of volunteers that travels to a resource-limited environment and provides top-quality surgical care is not without challenges. The aim of this article is to discuss some of these challenges and how they might be overcome.