David A. Shaye

Use of intraoperative computed tomography for maxillofacial reconstructive surgery.

IMPORTANCE Intraoperative computed tomography (CT) provides surgeons with real-time feedback during maxillofacial trauma and reconstructive surgery, which can affect intraoperative decision making. OBJECTIVES To evaluate the time needed to perform intraoperative CT scans during maxillofacial surgery, determine any trend toward shorter total scan times as experience is gained with the technique, and identify the characteristics of cases that required intraoperative revision based on the results of intraoperative CT scanning. DESIGN, SETTING, AND PARTICIPANTS A retrospective review was completed for all maxillofacial reconstruction procedures that used intraoperative CT between January 1, 2012, and March 31, 2014. INTERVENTIONS Patients were cared for by the routine practice pattern of the authors. Intraoperative CT scans were obtained for all patients. MAIN OUTCOMES AND MEASURES Time needed for intraoperative CT scan was measured and trends were analyzed. Covariates included age, sex, complexity of fracture, procedure type, total scan time, surgeon, and need for intraoperative revision based on intraoperative CT findings. RESULTS Thirty-eight cases were identified, including 30 males (79%) and 8 females (21%). The mean (SE) age was 37.4 (16.0) years (range, 7-75 years). Cases were defined as routine (18 [47%]) or complex (20 [53%]). Isolated orbital fractures were the most common fracture (23 [61%]) in both the routine (14 [78%]) and complex (9 [45%]) cases. The mean (SE) total scan time was 14.5 (4.9) minutes (range, 6-27 minutes) and did not differ based on complexity (P = .34). Intraoperative revisions were performed in 9 patients (24%) and were more common in complex (n = 8) than routine (n = 1) cases (P = .004). There was no reduction in total scan time during the study period (P = .22). The mean (SE) scan time for the most experienced surgeon was 3.78 (1.53) minutes shorter than for the other surgeons as a group (P = .02). CONCLUSIONS AND RELEVANCE Current intraoperative CT scanning techniques are rapid, averaging 14.5 minutes per case. No decrease in total scan time was noted during the study; however, the surgeon most experienced with the CT software had the shortest total scan times. Intraoperative revisions were most common in complex cases. We recommend surgeons consider the use of intraoperative CT imaging for maxillofacial reconstruction, particularly in complex procedures. LEVEL OF EVIDENCE NA.

Cleft Lip and Palate An Evidence-Based Review

The current article reviews the pertinent literature on the management of cleft lip and palate. We review the commonly used surgical techniques for repair, adjunctive options for treatment, clinical outcomes, complications, and concerns to consider. Throughout the discussion, we state the level of evidence where applicable and identify areas for future study.

Update on outcomes research for cleft lip and palate.

Purpose of reviewThe purpose of this review is to summarize the recent evidence-based literature focusing on cleft lip and palate outcomes research. Recent findingsThe findings of recently published literature focus on cleft lip and palate outcomes research, patient-based outcomes measurement tools, nasoalveolar molding, and how speech outcomes relate to palatoplasty timing, technique, and intravelar veloplasty. Studies have investigated the relationship between palatoplasty timing and facial development. SummaryThe literature lacks any evidence-based consensus to support a superior method of cleft lip repair. A majority of North American surgeons, however, utilize a rotation-advancement technique and perform cleft rhinoplasty at the time of primary lip repair, with the idea that this could decrease the number of revision surgeries needed over the long term. Most cleft surgeons perform a single-stage palatoplasty at 9–12 months of age for improved early speech outcomes. There is insufficient evidence to support a two-stage palatoplasty with the intention of improved maxillary growth. Controversy persists on the relationship between early palatal surgery and its deleterious effects on facial development. A shift toward patient-reported outcomes is called for; however, this remains difficult, as there are few validated, cleft-specific outcome measurement tools.

Cleft lip-cleft palate in Zimbabwe: estimating the distribution of the surgical burden of disease using geographic information systems.

To evaluate the prevalence and unmet need for cleft lip–cleft palate reconstructive surgery by using incidence. Our hypotheses were that the age of presentation to screening clinics will decrease between 2006 and 2012, and the geospatial distribution of cases will expand to a more rural catchment area.

Improving Posttraumatic Facial Scars

Posttraumatic soft-tissue injuries of the face are often the most lasting sequelae of facial trauma. The disfigurement of posttraumatic scarring lies in both their physical deformity and psychosocial ramifications. This review outlines a variety of techniques to improve facial scars and limit their lasting effects.

Expanding Roles and Broader Goals for Global Surgery

47. Campbell A, Restrepo C, Mackay D, et al. Scalable, sustainable cost-effective surgical care: a model for safety and quality in the developing world, part III: impact and sustainability. J Craniofac Surg. 2014;25(5):1685-1689. 48. Campbell A, Restrepo C, Mackay D, et al. Scalable, sustainable cost-effective surgical care: a model for safety and quality in the developing world, part II: program development and quality care. J Craniofac Surg. 2014;25(5):1680-1684.

Cleft lip and cleft rhinoplasty complications.

Complications resulting from cleft lip and cleft rhinoplasty surgery are usually due to errors in surgical planning and technique. The various secondary deformities resulting from cleft lip and cleft rhinoplasty surgeries are reviewed and management options discussed.

Advances in nasal reconstruction.

Purpose of reviewRecent advances in nasal reconstruction are provided within the framework of traditional reconstructive principles. Recent findingsRecent advances build upon and challenge the established tenets and principles of nasal reconstruction. Advances focus on achieving perfection in restoration of form and function with the absolute minimum of donor site morbidity. Specifically, advances in tissue engineering show promise in recreating cartilaginous framework. SummaryThis article summarizes the most recent developments in nasal reconstruction. The focus of recent advances in nasal reconstruction centers on minimizing morbidity while achieving an inconspicuous result.

Global surgery: current evidence for improving surgical care

Purpose of review The field of global surgery is undergoing rapid transformation, owing to several recent prominent reports positioning it as a cost-effective means of relieving global disease burden. The purpose of this article is to review the recent advances in the field of global surgery. Recent findings Efforts to grow the global surgical workforce and procedural capacity have focused on innovative methods to increase surgeon training, enhance international collaboration, leverage technology, optimize existing health systems, and safely implement task-sharing. Computer modeling offers a novel means of informing policy to optimize timely access to care, equitably promote health and financial protection, and efficiently grow infrastructure. Tools and checklists have recently been developed to enhance data collection and ensure methodologically rigorous publications to inform planning, benchmark surgical systems, promote accurate modeling, track key health indicators, and promote safety. Creation of institutional partnerships and trainee exchanges can enrich training, stimulate commitment to humanitarian work, and promote the equal exchange of ideas and expertise. Summary The recent body of work creates a strong foundation upon which work toward the goal of universal access to safe, affordable surgical care can be built; however, further collection and analysis of country-specific data is necessary for accurate modeling and outcomes research into the efficacy of policies such as task-sharing is greatly needed.

Global Cleft Surgery.

Surgery has recently been properly recognized as an essential component of global health. Global cleft surgery, often performed by visiting surgical teams in many parts of the world, has evolved with the recent surge in interest in global surgery. This article explores that evolution.