The Rise of Online Medical Education in Craniofacial Surgery.

BACKGROUND: International travel had been radically disrupted by coronavirus disease 2019 (COVID-19), leaving traditional medical conferences on a 2-year hiatus. The International Craniofacial Chang Gung Group (ICC) was thus created to disseminate knowledge related to craniofacial surgery. This study aimed to reveal how webinars fundamentally transformed the traditional format of medical conferences. MATERIALS AND METHOD: In total, 64 ICC webinars held between December 13, 2020, and May 21, 2023, were documented and reviewed. A questionnaire was designed and sent to ICC members. The questionnaire collected information on attitudes and habits relating to videoconferencing in general before and after the start of COVID-19 and on the ICC webinars specifically. Responses were analyzed to inform our understanding of respondents' experience and satisfaction with the webinars. RESULTS: The webinars covered a variety of topics related to craniofacial surgery. In total, 64 webinars were included for analysis. The mean number of attendees at each webinar was 86.7. In total, 111 respondents were more satisfied (4.25 ± 0.72 out of 5) with ICC webinars than with other media of online meetings ( P < 0.001). In total, 89.2% of respondents were willing to continue attending ICC webinars after COVID-19 restrictions have been lifted. CONCLUSIONS: Webinars are an effective format for imparting knowledge, especially in the ICC, and will become key in continuing medical education.

Use of Fractional CO2 Laser in Cleft Lip Scars: Does It Make a Difference?

BACKGROUND: Whatever the technique of the surgical repair, the scar remains and it is the most common cause for parent's and patient's dissatisfaction. We aimed in this work to evaluate the efficacy of the fractional CO2 (FCO2) laser on the later appearance of cleft lip scars in general and to compare between the early and late use of this tool to know its ideal application time in particular. To our knowledge, there are no published reports about this objective with regard to the number of patients and the concerned designated study. PATIENTS AND METHODS: One hundred twenty patients complaining of cleft lip scar were divided into 3 groups. Group 1 started FCO2 application 3 weeks postoperatively, group 2 started it 3 months postoperatively, and group 3 applied local creams only as a control group. Fractional CO2 laser had been applied for 5 to 7 sessions. Vancouver scar scale was used for scar evaluation determining vascularity, pigmentation, pliability, and height. Visual analog scale was also used depending on 5 independent physicians and nonmedical personnel to rate results on a graded scale from 0 to 10. Moreover, the scar width had been assessed through studying the final images by Photoshop CS5 Extended Version, in 2 fixed points of the scar width. RESULTS: Patients showed a great degree of improvement in their lip scar after FCO2 laser sessions. Vancouver Scar Scale score had insignificant differences between studied groups at the baseline before applying either FCO2 or local cream, whereas after their applications, it was significantly lower in group 1 (1.92 ± 0.88) in comparison with group 2 (3.70 ± 1.11) and group 3 (4.05 ± 1.29). Regarding scar width assessment, it was significantly lower in group 1 (2.51 ± 0.64) in comparison with groups 2 (3.17 ± 0.54) and 3 (3.27 ± 0.48). The visual analog scale by the participating medical personnel indicated that the FCO2-induced improvement in the lip scar appearance in group 1 more than groups 2 and 3 with a mean score of 44.17 ± 3.45, 36.53 ± 4.43, and 30.40 ± 5.22, respectively. The same assessment by the participating nonmedical personnel was significantly higher in group 1 (43.52 ± 4.20) in comparison with group 2 (37.52 ± 4.73) and group 3 (33.55 ± 4.85). CONCLUSIONS: We proved that using FCO2 is significantly better than using local creams in the postoperative management of cleft lip scars. More in depth, the early application of this tool is also significantly better than its delayed use.Clinical Trials Registration Name: Assessment of Fractional CO2 Laser in Treatment of Post-surgical Scarring of Cleft LipURL:https://clinicaltrials.gov/ct2/show/NCT03277287?cond=Assessment+of+Fractional+CO2+Laser+in+Treatment+of+Post-surgical+Scarring+of+Cleft+Lip&draw=2&rank=1Clinical Trials ID: NCT03277287Registration Date: June 9, 2017, retrospectively registered.

Primary Pharyngeal Flap With Palate Repair Improves Speech Outcome in Older Children and Adults: A Comparative Study.

BACKGROUND: Repair of cleft palate after 6 years of age is controversial in regard to the surgical procedure and the speech outcome. Primary repair alone may not be considered sufficient to achieve intelligible speech. The authors consider addition of pharyngeal flap at the time of primary repair to be a significant factor in improving speech. METHODS: Prospectively maintained data of all cleft palate patients operated from 2013 to 2017 (5 years) was analyzed to identify patients older than 6 years. Complete cleft palate, incomplete cleft palate, and cleft of the soft palate were further stratified according to different Randall types. They were divided into 2 main types: primary palate repair only and primary palate repair with pharyngeal flap. Speech was assessed preoperatively and 12 months postoperatively by Pittsburgh weighted speech scale. RESULTS: A total of 139 patients were analyzed. There were 78 males and 61 females. Their ages ranged from 6 to 60 years (mean age, 12.5 years). The overall preoperative speech score in palate repair-only group was 12.15, whereas the postoperative score was 7.32. In patients who underwent primary pharyngeal flap along with palate repair, the preoperative speech score was 11.3, and the postoperative score was 3.76. CONCLUSIONS: In select group of patients who report late for palate repair, addition of pharyngeal flap along with the primary palate repair improves the speech outcome in all Randall groups.

Pakistan Comprehensive Fistula Classification: A Novel Scheme and Algorithm for Management of Palatal Fistula/Dehiscence.

BACKGROUND: It is not easy to find a management-based classification of palatal fistula in the literature. A few attempts have been made to classify the wide variety of fistulae that do not describe the fistula details comprehensively and guide toward its management. The authors have come across a wide variety of fistulae that could not be classified according to any of the prevailing classification systems. The presented classification gives a clear and exact understanding of location and size of fistula/dehiscence. Palatal function has been included as one of the important determinants for devising a management plan. Based on this classification, the authors have proposed an algorithm that encompasses clear guidelines for surgical treatment of these fistulae. METHODS: Over the past 15 years, the authors' team operated on 2537 palatal fistula patients. The medical records of these patients were reviewed to determine the location, size, and velopharyngeal competence. A new classification and algorithm were developed. RESULTS: Of 2537 patients, 2258 had midline fistulae, 208 had lateral fistulae, and 53 had subtotal fistulae. There were 18 patients with dehiscence. Recurrence developed in 181 patients. CONCLUSION: The authors believe that this classification and algorithm can help follow a practical approach to manage palatal fistulae and dehiscence.

Continuous Versus Interrupted Sutures for Primary Cleft Palate Repair.

BACKGROUND: Cleft palate is a common congenital problem. It is traditionally surgically repaired with interrupted sutures between the ages of 6 and 18 months, with the aim of achieving closure of both nasal and oral layers. In various fields of surgery, continuous, rather than interrupted, sutures are the norm. There are no reports, however, of continuous suture repair for cleft palate. METHODS: A comparative study was designed at Clapp Hospital Lahore, to compare the effectiveness of 2 techniques. A total of 152 patients were included in the study over a period of 3 years. Per-operatively, the duration of surgery (time for nasal and oral layer closure) and the number of suture materials used were noted and compared between the 2 groups. Postoperatively, we compared the rate of wound dehiscence and fistula formation between the 2 groups. RESULTS: Out of 152 patients, 84 patients were operated on by continuous technique and 68 patients by interrupted technique. The mean duration of nasal layer closure in group A was 7.08 minutes, whereas that in group B was 11.50 minutes. The mean number of sutures required for the continuous suture group was 2.12, whereas that for the interrupted suture group was 4.59 (P < 0.05). There were no differences seen in either of the 2 postoperative outcomes compared in this study. CONCLUSION: A continuous closure technique can be utilized in palate repair, as it us more cost-effective and time-efficient.

Radical Dissection of Greater Palatine Artery and Dynamic Reconstruction of Cleft Palate.

BACKGROUND: Restoration of proper anatomy and physiology is an integral part of cleft palate repair. The senior author has devised a new technique of radical release of greater palatine vessels, which helps in achieving tension-free closure of palatal cleft. In addition, release and transposition of palatal muscles is performed without the use of operative microscope, resulting in improved palatal function. This technique is applicable to all types of clefts of the palate and can be performed on adult patients as well. MATERIALS AND METHODS: This is a retrospective case series of cleft palate repairs performed over a period of 3 years. Single-stage repair with modified Bardach's technique for complete cleft palate and von Langenbeck's technique for incomplete cleft palate with radical release of greater palatine vessels and levator complex retropositioning was performed. The outcome measures were closure of palatal defect and speech production. A follow-up of at least 6 months was completed in each patient. RESULTS: A total of 1568 patients were included in the study. Their age ranged from 9 months to 54 years. The overall fistula rate was 6.1%. Improvement of speech was observed even in adult patients. CONCLUSIONS: Radical release of greater palatine artery and levator complex transposition can dramatically improve results of cleft palate repair. This technique helps in dynamic reconstruction of cleft palate and can be effectively applied in all age groups.

A model humanitarian cleft mission: 312 cleft surgeries in 7 days.

BACKGROUND: There are many countries in the world where patients with cleft lip and palate cannot get access to specialized cleft care units. Cleft missions play an important role in providing surgical care to the areas of the world with limited resources. This article presents a model of cleft missions that can be adopted in many countries where expertise is available but resources are limited. Through proper utilization of local human resource, this type of mission can be a cost-effective and robust way of treating patients with cleft in countries with approximately 52% of the world's population. METHODS: We present a case series of patients of one of our cleft missions carried out in Khairpur, Pakistan, in March 2014 over a period of 7 days. Specific details concerning the organization of mission, gathering of patients, preparation for surgery, and carrying out surgical procedures in a safe and swift manner are presented. RESULTS: A total of 312 patients were operated on in 7 days. There were 145 patients with cleft lip and 167 patients with cleft palate. There were 187 male and 125 female patients with mean age of 7 years. Contemporary operative techniques were utilized to repair different types of cleft lip and palate. Of 167 patients, only 16 developed fistula. CONCLUSION: A locoregional cleft team can be more effective to care for the patients with cleft in countries where surgical and other expertise can be utilized by proper organization of cleft missions on a national level.

Evaluation of the antibacterial activity of selected Pakistani honeys against multi-drug resistant Salmonella typhi.

BACKGROUND: The development of resistance to conventional anti-typhoid drugs and the recent emergence of fluoroquinolone resistance have made it very difficult and expensive to treat typhoid fever. As the therapeutic strategies become even more limited, it is imperative to investigate non-conventional modalities. In this context, honey is a potential candidate for combating antimicrobial resistance because it contains a broad repertoire of antibacterial compounds which act synergistically at multiple sites, thus making it less likely that the bacteria will become resistant. The in vitro antibacterial activity of 100 unifloral honey samples against a blood culture isolate of multi-drug resistant (MDR) Salmonella typhi were investigated. METHODS: All honey samples were evaluated for both total (acidity, osmolarity, hydrogen peroxide and non-peroxide activity) and plant derived non-peroxide antibacterial activity by agar well diffusion assay at 50% and 25% dilution in sterile distilled water and 25% in catalase solution. Manuka (Unique Manuka Factor-21) honey was used for comparison. The phenol equivalence of each honey sample from 2% to 7% (w/v) phenol was obtained from regression analysis. The antibacterial potential of each honey sample was expressed as its equivalent phenol concentration. The honey samples which showed antibacterial activity equivalent to or greater than manuka honey were considered therapeutically active honeys. RESULTS: Nineteen honey samples (19%) displayed higher hydrogen peroxide related antibacterial activity (16-20% phenol), which is more than that of manuka honey (21-UMF). A total of 30% of the honey samples demonstrated antibacterial activity between 11 and 15% phenol similar to that of manuka honey while 51% of the honey samples did not exhibit any zone of inhibition against MDR-S. typhi at 50% (w/v) dilution. None of the indigenous honey samples displayed non-peroxide antibacterial activity. Only manuka honey showed non-peroxide antibacterial activity at 25% dilution (w/v) in catalase solution. CONCLUSIONS: The honey samples which displayed antibacterial activity equal to or greater than manuka honey may be useful in the clinical conditions where higher hydrogen peroxide related antibacterial activity is required. Manuka honey, which is known to possess non-peroxide antibacterial activity, warrants further evaluation in a suitable typhoid animal model.

Frequency of oronasal fistulae in complete cleft palate repair.

OBJECTIVE: To determine the frequency of oro-nasal fistula in patients undergoing complete cleft palate repair by two flappalatoplasty. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Department of Plastic Surgery, Services Hospital, Lahore, from January to December 2013. METHODOLOGY: Patients admitted to the study place for repair of cleft palate after informed consent obtained were included. Cleft palate was repaired by two-flap palatoplasty, using Bardach technique. Patients were discharged on the second postoperative day and followed-up at third week postoperatively. During follow-up visits, fistulae formation and their sites were recorded on pre-designed proforma. RESULTS: Among the total 90 patients, 40 patients (44.4%) were male and 50 patients (55.6%) were female. The mean age was 6.4 ± 5.7 years ranging from 9 months to 20 years. At third week follow-up, 5 patients (5.6%) had fistulae formation. Four patients (80%) had anterior fistulae and one patient (20%) had posterior fistula. CONCLUSION: With two-flap palatoplasty Bardach procedure for repair of cleft palate, the complication of fistula formation was uncommon at 5.6%, provided the repair was tension free and multi-layered.