Objective: The purpose of this study was to determine the anatomical differences among selected individuals with a cleft palate repaired using "The Buccal Flap Approach" during primary palatoplasty compared to aged-matched participants without cleft palate.Design: Observational, prospective.Setting: Two regional hospitals.Participants: A total of 30 adult males consisting of 15 adults born with cleft palate who received the Double Opposing Z-Plasty plus Buccal Flaps (DOZP + BF) repair at the time of primary palatoplasty and no history of secondary speech surgery or orthognathic surgery and 15 adults without a history of cleft palate.Interventions: All participants underwent MRI to visualize anatomy.Main outcome measures: Ten velopharyngeal and craniofacial anatomical measures.Results: No statistically significant differences between groups were observed for velar thickness, velar length, pharyngeal depth, NSBa angle, SNB angle, or levator veli palatini length. Individuals with the DOZP + BF presented with a greater effective velar length (p < .001), greater effective VP ratio (p < .001), smaller SNA angle (p < .001), and smaller maximal velar stretch (p < .001) compared to the control participants.Conclusions: This study suggests that adult males who received the DOZP + BF repair at the time of primary palatoplasty and no history of secondary speech surgery or orthognathic surgery present with a longer effective velar length and larger effective VP ratio in comparison to the non-cleft group. Future research is needed to compare patients with and without favorable outcomes from multiple surgical types to fully understand how surgical techniques alter the anatomy.

Objective Describe the first hybrid global simulation-based comprehensive cleft care workshop, evaluate impact on participants, and compare experiences based on in-person versus virtual attendance.Design Cross-sectional survey-based evaluation.Setting International comprehensive cleft care workshop.Participants Total of 489 participants.Interventions Three-day simulation-based hybrid comprehensive cleft care workshop.Main Outcome Measures Participant demographic data, perceived barriers and interventions needed for global comprehensive cleft care delivery, participant workshop satisfaction, and perceived short-term impact on practice stratified by in-person versus virtual attendance.Results The workshop included 489 participants from 5 continents. The response rate was 39.9%. Participants perceived financial factors (30.3%) the most significant barrier and improvement in training (39.8%) as the most important intervention to overcome barriers facing cleft care delivery in low to middle-income countries. All participants reported a high level of satisfaction with the workshop and a strong positive perceived short-term impact on their practice. Importantly, while this was true for both in-person and virtual attendees, in-person attendees reported a significantly higher satisfaction with the workshop (28.63 +/- 3.08 vs 27.63 +/- 3.93; P = .04) and perceived impact on their clinical practice (22.37 +/- 3.42 vs 21.02 +/- 3.45 P = .01).Conclusion Hybrid simulation-based educational comprehensive cleft care workshops are overall well received by participants and have a positive perceived impact on their clinical practices. In-person attendance is associated with significantly higher satisfaction and perceived impact on practice. Considering that financial and health constraints may limit live meeting attendance, future efforts will focus on making in-person and virtual attendance more comparable.

Purpose: Primary palatoplasties using the Anatomic Cleft Restoration Philosophy uses the buccinator myomucosal flap (buccal flap) as the major tissue replacement flap to correct the tissue deficiency within the cleft palate malformation. The surgical approach aims to close the palate without tension, lengthen the palate, reconstruct the levator muscular sling, not inhibit craniofacial growth and achieve proper resonance for speech. The purpose of this study is to present preliminary data on velopharyngeal variables to demonstrate the muscle and tissue morphology in adults with cleft palate who have not received a secondary surgery for speech or orthognathic surgery. Methods: Magnetic resonance imaging was used to analyze velopharyngeal variables for 2 individuals with the buccal flap approach and 2 individuals who received a traditional cleft palate repair. Linear measurements were obtained and 2 velopharyngeal ratios were calculated. Results: All variables were compared to previously published normative data of velopharyngeal variables for individuals with non-cleft anatomy who are of the same race, sex, and of similar age. The individuals with the buccal flap approach presented with a similar velar length and levator length in comparison to individuals with non-cleft anatomy. The individuals with the buccal flap approach presented with a longer effective velar length and velar length in comparison to individuals with a traditional cleft palate repair. Visually, the individual with the buccal flap presents with a thicker tissue mass between the hard and soft palate junction. Conclusions: In this case study, individuals who received a primary palatoplasty with the buccal flap approach presented with a longer velum and effective velar length in comparison to individuals with a traditional cleft palate repair and those with non-cleft anatomy. This study highlights the utility of using magnetic resonance imaging to quantify the changes that occur to the velopharyngeal anatomy following the buccal flap surgical approach.

OBJECTIVE:Evaluate simulation-based comprehensive cleft care workshops as a reproducible model for education with sustained impact.DESIGN:Cross-sectional survey-based evaluation.SETTING:Simulation-based comprehensive cleft care workshop.PARTICIPANTS:Total of 180 participants.INTERVENTIONS:Three-day simulation-based comprehensive cleft care workshop.MAIN OUTCOME MEASURES:Number of workshop participants stratified by specialty, satisfaction with the workshop, satisfaction with simulation-based workshops as educational tools, impact on cleft surgery procedural confidence, short-term impact on clinical practice, medium-term impact on clinical practice.RESULTS:The workshop included 180 participants from 5 continents. The response rate was 54.5%, with participants reporting high satisfaction with all aspects of the workshop and with simulation-based workshops as educational tools. Participants reported a significant improvement in cleft lip (33.3 ± 5.7 vs 25.7 ± 7.6; P < .001) and palate (32.4 ± 7.1 vs 23.7 ± 6.6; P < .001) surgery procedural confidence following the simulation sessions. Participants also reported a positive short-term and medium-term impact on their clinical practices.CONCLUSION:Simulation-based comprehensive cleft care workshops are well received by participants, lead to improved cleft surgery procedural confidence, and have a sustained positive impact on participants' clinical practices. Future efforts should focus on evaluating and quantifying this perceived positive impact, as well reproducing these efforts in other areas of need.

BACKGROUND: Primary palatoplasties using the Anatomic Palate Restoration Concept use the buccinator myomucosal flap (buccal flap) to correct the tissue deficiency within the cleft palate malformation. Buccal flaps are used to replace the missing tensor veli palatini aponeurosis and mucus membrane. The surgical approach aims to close the palate without tension, lengthen the palate, reconstruct the levator muscular sling, not inhibit craniofacial growth and achieve proper oral-nasal resonance for speech.1,2 To the best of our knowledge, this is the first study to use magnetic resonance imaging (MRI) to demonstrate the changes that occur to the velopharyngeal anatomy following the surgical repair. The purpose of this study is to present preliminary data on velopharyngeal variables to demonstrate the muscle and tissue morphology in adults with cleft palate who have not received a secondary surgery for speech or orthognathic surgery. METHODS: MRI was used to analyze velopharyngeal variables for a single participant. The participant was a 19-year-old Caucasian male with a unilateral cleft lip and palate who received primary palatoplasty using the buccal flap approach. MRI data were viewed in Amira 6.5.0 Visualization Modeling software. Velopharyngeal measurements were obtained on the midsagittal image. RESULTS: All variables were compared to previously published normative data of velopharyngeal variables for individuals with noncleft anatomy who are of the same race, sex, and of similar age.3 Velar length and velar thickness were both greater in the individuals with the buccal flap repair, in comparison to the individuals with noncleft anatomy. Levator length and the distance from the PNS to PPW were both shorter in the individual with the buccal flap repair. Visually, the individual with the buccal flap presents with a thicker and longer velum. CONCLUSIONS: This study is the first to demonstrate the velopharyngeal muscle and tissue arrangement following primary palatoplasty using the buccal flap approach. The individual presents with a longer and thicker velum in comparison to age- and sex-matched individuals with noncleft anatomy. This study highlights the utility of using MRI to quantify the changes that occur to the velopharyngeal anatomy following the buccal flap surgical approach. Future studies should assess how these anatomical changes impact speech and compare data to Z-Plasty without the use of the buccal flap repair and to individuals with noncleft anatomy. Our research team is currently investigating this line of research and specifically seeking to improve our understanding of the functional impact of this surgical method on speech. REFERENCES: 1. Mann RJ, Fisher DM. Bilateral buccal flaps with double opposing Z-plasty for wider palatal clefts. Plast Reconstr Surg. 1997;100:1139–1143. 2. Mann RJ, Martin MD, Eichhorn MG, et al. The double-opposing Z-plasty plus or minus buccal flap approach for repair of cleft palate: a review of 505 consecutive cases. Plast Reconstr Surg. 2017;139:735e–744e. 3. Perry JL, Kollara L, Sutton BP, et al. Growth effects on velopharyngeal anatomy from childhood to adulthood. J Speech Lang Hear Res. 2019;62:682–692.

OBJECTIVE:It is well known that patients with oral clefts have challenges with feeding. Enteral feeding access, in the form of gastrostomy, is often utilized to supplement or replace oral intake. Although commonly performed, these procedures have reported complication rates as high as 83%. We intend to discover rates of enteral access in patients with oral clefts and report-related outcomes.DESIGN:The Healthcare Cost Utilization Project Kids' Inpatient Database from 2000 to 2012 was analyzed using patients with oral clefts and enteral access procedures. The χ2 test was used for univariate analyses of proportions, and linear regression was used to analyze trends. Multivariate logistic regression was used to analyze odds ratios.RESULTS:Of the 46 617 patient admissions included, 14.6% had isolated cleft lip (CL), 51.7% cleft lip and palate (CLP), and 43.7% isolated cleft palate. The rates of enteral access in the oral cleft population increased from 3.7% in 2000 to 5.8% in 2012 ( P < .001). Increased rates were identified in patients with ( P = .019) and without ( P < .001) complex conditions. A significant increase in the rate of enteral access was seen in patients with CLP ( P < .001) and isolated cleft palate ( P < .001). No difference was seen in the isolated CL group ( P = .096). Patients with complex conditions were at a 4.4-fold increased risk and those admitted to urban, teaching hospitals were at a 4.7-fold risk of enteral access placement.CONCLUSIONS:The rates for enteral feeding access increased significantly from 2000 to 2012. The reasons for the increased incidence are unclear. Invasive enteral access procedures have been shown to have a multitude of complications. Careful patient selection should be done before placement of invasive enteral access.

Nasal stenosis is an uncommon and challenging deformity. Most common etiologies for nasal stenosis include congenital, iatrogenic, trauma, and infection. Repair techniques typically include tissue replacement with grafts or flaps with subsequent stent placement. These procedures often require general anesthesia and carry high rates of restenosis. We describe a case of a 10-year-old girl with Teebi syndrome and iatrogenic nasal stenosis who underwent successful nasal dilation with inexpensive, minimally invasive steel gauge earrings.

Purpose: Failure to thrive is seen in up to 49% of patients with orofacial clefts. Enteral feeding access (EFA) is often necessary to supplement or replace nutrition. EFA is associated with significant complications and morbidity. This study evaluates the incidence and risk factors associated with EFA in patients with orofacial clefts. Methods: The HCUP KID database from 2000 to 2012 was analyzed for patients with orofacial clefts, comorbidities, and EFA using ICD-9-CM diagnosis and procedure codes. Chromosome abnormalities and congenital heart defects were analyzed as comorbidities. Results: A total of 46,617 patients with orofacial clefts were identified, 14.6% with isolated cleft lip (CL), 51.7% with cleft lip and palate (CLP), and 33.7% with isolated cleft palate (CP). The incidence of patients requiring EFA increased from 2000 (3.7%) to 2012 (5.8%) (p<0.001). After controlling for comorbidities, the incidence was again found to increase throughout the study period (3.3% to 5.0%, p<0.001). Patients with comorbidities were noted to have higher rates of EFA that increase significantly between 2000 and 2012 (12.8% to 18.6%, p=0.019). Treatment in an urban teaching hospital was an independent risk factor for EFA (OR 4.65). Race and income were not independent risk factors. Conclusion: The rates of EFA in patients with orofacial clefts increased substantially between 2000 and 2012, even after controlling for comorbidities. Patients with CP comprised the majority, which is consistent with a higher incidence of comorbidities in this population. The use of EFA is associated with a multitude of complications. Unnecessary use should be minimized.

INTRODUCTION: Pediatric craniofacial procedures are complex and require intensive preoperative, intraoperative, and postoperative care. Transfusions are often required due to both the invasive nature of the procedure as well as the inherently lower blood volume in pediatric patients. We report here our experience with a multidisciplinary Blood Management Team in complex craniofacial surgery. OBJECTIVES: To determine if a Pediatric Blood Management (PBM) program with multimodal approach can reduce transfusion requirements in pediatric patients undergoing craniofacial surgery. METHODS: A collaborative protocol was developed by the PBM team, plastic surgery and anesthesia clinicians in 2016, which involved the pre-operative optimization of hemoglobin levels, the intraoperative use of tranexamic acid and CellSaver™ technology, as well as blood sparing operative techniques. Additionally, patients were preoperatively screened for altered coagulation including hypofibrinogenemia and von Willebrand’s disease. Prospective monitoring of these 17 patients in the intervention arm was collected. Retrospective data on 20 consecutive patients who underwent craniofacial surgery prior to the initiation of the program were used as a control group. The primary endpoint was the transfusion volume of blood products. RESULTS: Groups at baseline were similar in age, weight and reported intraoperative estimated blood loss. Patients post-intervention had a higher mean ASA classification. The rate of transfusion decreased from 80% pre-intervention to 65% post-intervention. Post-intervention, patients received a mean of 106 mL of intraoperative PRBC, while pre-intervention, patients received a mean of 224 mL. (p=0.024). Postoperative hemoglobin measurements were similar, with the control group 10.9 g/dL and the intervention arm 10.5 g/dL (p=0.64). Discharge hemoglobin concentrations also were similar with 9.6 g/dL and 10.6 g/dL in the control and PBM group, respectively (p=0.196). Furthermore, 3 patients were found to have von Willebrand’s disease preoperatively. CONCLUSION: We found that the institution of a Pediatric Blood Management team significantly reduced the transfusion burden of patients undergoing craniofacial procedures, including in complex patients with von Willebrand’s disease. The use of a multimodal approach to hematologic management optimized patients for their procedures and helped minimize exposure to transfusion associated complications.

Suraj Jaisinghani, MS,a Nicholas S. Adams, MD,b,c Robert J. Mann, MD,b,c,d John W. Polley, MD,b,c,d , and John A. Girotto, MD, MMAb,c,d aChicago Medical School at Rosalind Franklin University; Chicago, Ill; bMichigan State University, Grand Rapids, Mich; cGrand Rapids Medical Education Partners, Plastic and Reconstructive Surgery Residency, Grand Rapids, Mich; and dPediatric Plastic and Craniofacial Surgery, Helen DeVos Children’s Hospital, Grand Rapids, Mich

BACKGROUND:Motorcycle helmet legislation has been a contentious topic for over a half-century. Benefits of helmet use in motorcycle trauma patients are well documented. In 2012, Michigan repealed its universal motorcycle helmet law in favor of a partial helmet law. The authors describe the early clinical effects on facial injuries throughout Michigan.METHODS:Retrospective data from the Michigan Trauma Quality Improvement Program trauma database were evaluated. Included were 4643 motorcycle trauma patients presenting to 29 Level I and II trauma centers throughout Michigan 3 years before and after the law repeal (2009 to 2014). Demographics, external cause of injury codes, International Classification of Diseases, Ninth Revision diagnosis codes, and injury details were gathered.RESULTS:The proportion of unhelmeted trauma patients increased from 20 percent to 44 percent. Compared with helmeted trauma patients, unhelmeted patients were nearly twice as likely to sustain craniomaxillofacial injuries (relative risk, 1.90), including fractures (relative risk, 2.02) and soft-tissue injuries (relative risk, 1.94). Unhelmeted patients had a lower Glasgow Coma Scale score and higher Injury Severity Scores. Patients presenting after helmet law repeal were more likely to sustain craniomaxillofacial injuries (relative risk, 1.46), including fractures (relative risk, 1.28) and soft-tissue injuries (relative risk, 1.56). No significant differences were observed for age, sex, Injury Severity Score, or Glasgow Coma Scale score (p > 0.05).CONCLUSIONS:This study highlights the significant negative impact of relaxed motorcycle helmet laws leading to an increase in craniomaxillofacial injuries. The authors urge state and national legislators to reestablish universal motorcycle helmet laws.

Summary Oropharyngeal stenosis (OPS) is a rare postoperative complication of adenotonsillectomy that can be a source of considerable patient distress and morbidity. Circumferential scarring of the soft palate and tonsillar pillars leads to narrowing of the oropharyngeal aperture. This case report describes the novel use of bilateral buccal myomucosal flaps for the repair of postoperative OPS in a 20-year-old woman presenting with dysphagia, odynophagia, dyspnea, and intermittent hypernasal speech. Postoperatively, the patient noted immediate improvement of her symptoms. At 1-month follow-up, she noted complete resolution of her symptoms with no dysphagia, nasal regurgitation, speaking difficulty, dyspnea, or gagging. The buccal flaps were well healed and completely intact, maintaining appropriate height of the tonsillar pillars. The buccal myomucosal flap is an effective tool for numerous palatal and oropharyngeal abnormalities and, as described in this case study, is a reliable, safe, and effective technique that can be considered for the reconstruction of postsurgical OPS.

Deformities of the cranium in patients with nonsyndromic single-suture synostosis occur because of growth restriction at fused sutures and growth over compensation at normal sutures. Traditional surgery includes ostectomies of the synostotic suture to release these restricted areas and osteotomies to enable immediate cranial remodeling. In the process of reshaping the cranium, traditional approaches usually involve obliteration of both the normal functioning suture and the pathologic suture. The directive growth approach (DGA) is a new, simpler, more natural way to repair deformities caused by single-suture cranial synostosis. The DGA works by reversing the original deforming forces by temporarily restricting growth in areas of over compensation and forcing growth in areas of previous synostotic restriction. Most importantly, it preserves a normal functioning suture to allow for improved future cranial growth. Eighteen consecutive nonsyndromic patients with unilateral coronal synostosis were used to illustrate the efficacy of the DGA. Ten patients who underwent DGA treatment were compared with a control group of 8 patients treated with traditional frontal orbital advancement. Postoperative three-dimensional computed tomography (CT) comparison measurements were taken, including bilateral vertical and transverse orbital dimensions, lateral orbital rim to external auditory canal, and forehead measurements from the superior aspect of the orbital rim to the pituitary fossa. The traditional treatment group showed absence of the coronal sutures bilaterally on long-term CT scans. The DGA group showed normal coronal sutures on the unaffected sides. Postoperative CT measurements showed no statistical difference between the 2 techniques (P < 0.05).

BACKGROUND:Standard methods of cleft palate repair rely on existing palatal tissue to achieve closure. These procedures often require relaxing incisions, causing scars and growth restriction, and may result in insufficient palatal length and suboptimal positioning of the velar musculature. The Furlow double opposing Z-plasty improves palatal length and repositions the velar musculature; however, relaxing incisions may still be needed. The addition of buccal flaps to the Furlow repair obviates the need for relaxing incisions and allows the Furlow repair to be used in wide clefts.METHODS:A retrospective review was performed on 505 patients; all patients were treated with the double opposing Z-plasty plus or minus buccal flap approach. Outcomes included nasal resonance, secondary speech surgery, and postoperative complications. A comparison was made between patients treated with double opposing Z-plasty alone and those treated with double opposing Z-plasty plus buccal flaps.RESULTS:The average nasal resonance score was 1.38 and was equivalent in both the double opposing Z-plasty alone and with buccal flap groups, despite significantly more wide clefts in the buccal flap group (56 percent versus 8 percent). The secondary surgery rate for velopharyngeal insufficiency was 6.6 percent and the fistula rate was 6.1 percent. The large fistula rate (>2 mm) was 2.7 percent.CONCLUSIONS:The double opposing Z-plasty plus or minus buccal flap approach is a useful alternative to standard palate repairs. Speech outcomes were excellent, even in wider clefts, and postoperative complications were minimal. Buccal flaps allow the benefits of the Furlow repair to be applied to any size cleft, without the need for relaxing incisions.CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, III.

Wound healing inevitably leads to scarring, which leads to functional and cosmetic defects. It is the goal of this study to investigate the immediate use of ablative fractional CO2 lasers to reduce post‐operative scarring secondary to surgical wounds.

Peter M. DeJong, BS,a Nicholas S. Adams, MD,a,b Robert J. Mann, MD,a,b,c John W. Polley, MD,a,b,c and John A. Girotto, MD, MMAa,b,c aMichigan State University College of Human Medicine, Grand Rapids, Mich; bPlastic and Reconstructive Surgery Residency, Grand Rapids Medical Education Partners, Grand Rapids, Mich; and cPediatric Plastic and Craniofacial Surgery, Helen DeVos Children’s Hospital, Grand Rapids, Mich

Reconstruction for single sutural synostosis typically involves cranial reshaping to correct for compensatory growth changes. Current remodeling techniques involve obliteration of both pathologic and normal sutures. Presented here is a case report describing a new approach to the treatment of single cranial synostosis. The concept involves excision of the offending suture and transient plating of the remaining functional sutures. Compensatory sutures are then allowed to direct the growth forces to the area of the synostosis, leading to the reversal of the compensatory shape deformity. This more natural approach leaves functioning sutures intact and allows for their active participation in the reshaping process.

Reconstruction for single sutural synostosis typically involves cranial reshaping to correct for compensatory growth changes. Current remodeling techniques involve obliteration of both pathologic and normal sutures. Presented here is a case report describing a new approach to the treatment of single cranial synostosis. The concept involves excision of the offending suture and transient plating of the remaining functional sutures. Compensatory sutures are then allowed to direct the growth forces to the area of the synostosis, leading to the reversal of the compensatory shape deformity. This more natural approach leaves functioning sutures intact and allows for their active participation in the reshaping process.