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Asadourian P, Valenti AB, Michalowski A, Truong AY, Borys N, LaValley M, Modi V, Imahiyerobo TA. Estimated Time of Arrival: Impact of Healthcare Disparities on Access to and Outcomes of Multidisciplinary Cleft Lip and Palate Care. Cleft Palate Craniofac J 2024:10556656241259890. [PMID: 39033442 DOI: 10.1177/10556656241259890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024] Open
Abstract
OBJECTIVE To determine the impact of sociodemographic and clinical factors on patient presentation into the cleft care pathway and determine how delayed interventions may affect post-surgical outcomes. DESIGN Retrospective study. SETTING Multidisciplinary craniofacial clinics of two university hospitals. PATIENTS, PARTICIPANT 135 patients with cleft lip and/or palate. INTERVENTIONS Primary cheiloplasty, primary palatoplasty. MAIN OUTCOME MEASURES Age at initial presentation, age at first surgery, lag time, delayed surgery, rate of return to the emergency department (ED), readmission rate, reoperations, and oronasal fistula development. RESULTS Patients referred by OBGYN who underwent cheiloplasty had an earlier age at initial presentation (p < 0.01), earlier age at first surgery (p = 0.01), and a shorter lag time (p < 0.01) compared to children from other referral pathways. African American children had an older age at first surgery (p = 0.01) and a longer lag time (p = 0.02) when compared to non-African American children. Children with syndromes had an older age at first surgery (p < 0.01) and a longer lag time (p < 0.01) than children without syndromes. Patient race, cleft type, and syndromic status increased the odds of receiving delayed surgery. Patients who received delayed palatoplasty returned to the ED at a higher rate than patients who received non-delayed palatoplasty (p = 0.02). CONCLUSIONS Our data suggest that referral source, race, and syndromic status influence the timeliness of cleft care. Surgeons should develop strong referral networks with local OBGYNs and hospitals to allow for an early entry into the cleft care pathway.
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Affiliation(s)
- Paul Asadourian
- Division of Plastic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - Alyssa B Valenti
- Division of Plastic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - Alexandra Michalowski
- Division of Pediatric Otolaryngology-Head & Neck Surgery, Weill Cornell Medical Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - Albert Y Truong
- Division of Plastic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - Nell Borys
- Division of Pediatric Otolaryngology-Head & Neck Surgery, Weill Cornell Medical Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - Myles LaValley
- Division of Plastic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - Vikash Modi
- Division of Pediatric Otolaryngology-Head & Neck Surgery, Weill Cornell Medical Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
| | - Thomas A Imahiyerobo
- Division of Plastic Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
- New York Presbyterian Hospital, New York, NY, USA
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Yu V, Pham J, Lukomski L, Joseph J, Guo Y. Comorbidity and Operative Time are Stronger Predictors than Age for Palatoplasty Adverse Airway Events, A NSQIP-P Study of 6668 Cases. Cleft Palate Craniofac J 2024; 61:1149-1156. [PMID: 36786023 DOI: 10.1177/10556656231156509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Adverse airway events (AAEs) are rare but devastating complications following palatoplasty. The purpose of this study is to evaluate patient risk factors for their effect on these complications. We hypothesize that prolonged operative time and the presence of multiple medical comorbidities are risk factors for AAEs. DESIGN Retrospective cohort study. SETTING Participant hospitals in the Pediatric American College of Surgeons National Surgical Quality Improvement Program year 2016-2019. PATIENTS Cases of palatoplasty in children under 3 years of age. OUTCOMES Adverse airway events including postoperative reintubation or any requirement of postoperative mechanical ventilation. RESULTS A total of 6668 patients met inclusion criteria. The median operative time was 126 min (IQR 82). AAEs were identified in 107 (1.6%) patients. The incidence of risk factors was found to increase with age and AAEs were more prevalent in younger and older patients. Although patients in the older age groups had significantly higher burden of comorbidities, differences in age were not independently associated with AAEs. Following multivariable logistic regressions, operative times greater than 2 h, ASA class ≥3, >3 medical comorbidities, and black race were found to be significant independent risk factors. CONCLUSIONS In this large, retrospective database study in palatoplasty, increased operative time, ASA classification ≥3, multiple comorbidities, and black race were independently associated with AAEs.
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Affiliation(s)
- Victor Yu
- Eastern Virginia Medical School, Norfolk, VA, USA
| | - Jason Pham
- Eastern Virginia Medical School, Norfolk, VA, USA
| | | | - Jeremy Joseph
- Division of Plastic and Reconstructive Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Yifan Guo
- Plastic and Oral Maxillofacial Surgery, Children's Hospital of the King's Daughters, Norfolk, VA, USA
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Applebaum SA, Aronson S, Termanini KM, Gosain AK. Evidence-Based Practices in Cleft Palate Surgery. Plast Reconstr Surg 2024; 153:448e-461e. [PMID: 38266141 DOI: 10.1097/prs.0000000000011035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: (1) Understand the embryologic origins, cause, and incidence of cleft palate. (2) Review the anatomy and common classifications of cleft palate and associated defects. (3) Describe surgical techniques for palatoplasty and understand their respective indications. (4) Gain an awareness of general perioperative care considerations, timing of repair, and risk factors for and operative mitigation of complications. SUMMARY Cleft palate affects 0.1 to 1.1 per 1000 births, with a higher incidence in certain ethnic groups but affecting both sexes equally. Cleft palate may occur in isolation or in combination with cleft lip or in association with other congenital anomalies including various syndromes. The goals of cleft palate repair are to anatomically separate the oral and nasal cavities for normal feeding and improved speech and minimize the risk of oronasal fistulas, velopharyngeal dysfunction, and disruption of facial growth. This review discusses the incidence, causes, and classification of cleft palate; surgical techniques for palatoplasty and perioperative patient management; and complications of palatoplasty.
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Affiliation(s)
- Sarah A Applebaum
- From the Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine
| | - Sofia Aronson
- From the Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine
| | - Kareem M Termanini
- From the Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine
| | - Arun K Gosain
- From the Division of Plastic Surgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine
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Koh DJ, Gong JH, Sobti N, Soliman L, King V, Woo AS. The Life Cycle of Orofacial Cleft Operations. J Craniofac Surg 2023:00001665-990000000-01203. [PMID: 37973027 DOI: 10.1097/scs.0000000000009863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/09/2023] [Indexed: 11/19/2023] Open
Abstract
Patients with cleft lip and palate must undergo various surgical interventions at appropriate times to achieve optimal outcomes. While guidelines for the timing of these operations are well known, it has not yet been described if national surgical practice reflects these recommendations. This study evaluates whether orofacial operations are performed in time frames that align with advised timing. Time-to-event analyses were performed using the 2012-2020 Pediatric National Surgical Quality Improvement Program database on the ages at time of orofacial operations. Outliers with an absolute Z-score of 3.29 or greater were excluded. Cleft lip (N=9374) and palate (N=13,735) repairs occurred earliest at mean ages of 200.99±251.12 and 655.08±694.43 days, respectively. Both operations clustered along the later end of recommended timing. 69.0% of lip versus 65.1% of palate repairs were completed within the advised age periods. Cleft lip (N=2850) and palate (N=1641) revisions occurred at a mean age of 7.73±5.02 and 7.00±4.63 years, respectively. Velopharyngeal insufficiency operations (N=3026), not including palate revision, were performed at a delayed mean age of 7.58±3.98 years, with only 27.7% of operations occurring within the recommended time frame. Finally, 75.8% of alveolar bone grafting cases (N=5481) were found to happen within the advised time period, with a mean age of 10.23±2.63 years. This study suggests that, with the exception of VPI procedures, orofacial operations reliably cluster near their recommended age periods. Nevertheless, primary lip repair, palatoplasty, and velopharyngeal insufficiency procedures had a mean age that was delayed based on advised timing.
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Affiliation(s)
- Daniel J Koh
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
- Division of Plastic and Reconstructive Surgery, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Jung Ho Gong
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Nikhil Sobti
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Luke Soliman
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Victor King
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Albert S Woo
- Division of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, RI
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Abi-Rafeh J, Safran T, Winocour S, Dionisopoulos T, Davison P, Vorstenbosch J. Complications of Capsulectomies: An Analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Database. AESTHETIC SURGERY JOURNAL OPEN FORUM 2022; 4:ojac025. [PMID: 35747463 PMCID: PMC9212085 DOI: 10.1093/asjof/ojac025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Although plastic surgeons commonly perform capsulectomies for a variety of peri-prosthetic capsular conditions, the safety of capsulectomy remains unknown, and the literature lacks evidence describing its morbidity and complication rates for patients inquiring about its associated risks. Objectives The present study aims to identify and define the complication rates associated with capsulectomies. Methods An analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was performed between the years 2015 and 2018. All information pertaining to demographics, patient-related information, surgical indications, procedure-related information, outcomes, and complications were assessed. Results The study identified 2231 cases of surgeon-reported capsulectomies; indications most commonly reported included capsular contracture (n = 638, 28.6%) and breast implant rupture (n = 403, 18.1%). In total, 141 patients (6.32%) were hospitalized for longer than 1 postoperative day (range, 2-28 days), while the overall complication rate was 3.0% (n = 67/2231 patients). Incidence of minor complications, representing superficial surgical site infections, was 0.8%, while the major complication rate was 2.24%. These included 7 cases of deep surgical site infections (0.3%), 19 organ space infections (0.9%), and 8 cases of wound dehiscence (0.4%). Eight patients developed sepsis (0.4%); 6 patients required transfusions (0.3%); 1 case of postoperative pneumonia and 1 myocardial infarction were also identified (n = 1 each, 0.0%). The overall reoperation and readmission rates were 2.0%, representing a readmission rate of 66% among patients with complications. Conclusions The present study provides the first estimate of the incidence of complications associated with capsulectomies. Although the NSQIP database contains significant limitations, the data presented herein describe a complication profile that plastic surgeons can share with their patients during informed consent. Level of Evidence: 4
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Affiliation(s)
- Jad Abi-Rafeh
- Division of Plastic and Reconstructive Surgery, McGill University Health Center, Montreal, Quebec, Canada
| | - Tyler Safran
- Division of Plastic and Reconstructive Surgery, McGill University Health Center, Montreal, Quebec, Canada
| | - Sebastian Winocour
- Division of Plastic and Reconstructive Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Tassos Dionisopoulos
- Division of Plastic and Reconstructive Surgery, McGill University Health Center, Montreal, Quebec, Canada
| | - Peter Davison
- Division of Plastic and Reconstructive Surgery, McGill University Health Center, Montreal, Quebec, Canada
| | - Joshua Vorstenbosch
- Division of Plastic and Reconstructive Surgery, McGill University Health Center, Montreal, Quebec, Canada
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Discussion: The Effect of Surgical Timing on 30-Day Outcomes in Cleft Palate Repair. Plast Reconstr Surg 2021; 147:138-140. [PMID: 33370057 DOI: 10.1097/prs.0000000000007459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Peck CJ, Gowda AU, Khetpal S, Lopez J, Shultz BN, Parsaei Y, Wu RT, Steinbacher DM. Primary Cleft Palate Repair Among Older-Age Children and Adolescents in the United States. J Oral Maxillofac Surg 2021; 79:1339-1343. [PMID: 33610491 DOI: 10.1016/j.joms.2021.01.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 01/19/2021] [Accepted: 01/19/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Older age cleft palate (CP) repair in international settings has been associated with increased surgical morbidity. This study assesses the prevalence and risks associated with late-age CP repair (age > 5 years) in the United States. METHODS Primary CP repair patients less than the age of 18 years were identified in the National Surgical Quality Improvement pediatric database from 2012 to 2018. Total postoperative complications, readmissions, reoperations, duration of surgery, and length of stay were recorded. T-tests and χ2 analyses were used to compare variables between age groups 0-5, 6-10, and 11-17. RESULTS A total of 10,022 primary CP procedures were identified from 2012 to 2018, of which 868 (8.6%) received repair at age > 5 years. Hispanic patients constituted a larger proportion of CP repair from ages 11 to 17 years than repair at other ages (P < .001). In comparison with children treated from ages 0 to 5 years, children operated on between ages 6 and 10 or 11 and 17 years experienced no increases in unplanned readmissions, reoperations, or complication rates after surgery. Patients of ages 6-10 years and 11-17 years had decreased operating room time (P < .001) compared with younger patients. Patients of ages 11-17 years also had decreased hospital length of stay (P = .04). CONCLUSIONS Many children in the United States received primary CP repair after the age of 5 years likely due to late treatment of submucosal clefts or delayed care among international immigrants/adoptees. Old age procedures were not associated with increased short-term surgical morbidity in comparison with surgery at earlier time points. The causes and implications of older age primary surgery warrant further study.
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Affiliation(s)
- Connor J Peck
- Medical Student, Department of Surgery, Section of Plastic Surgery, Yale School of Medicine
| | - Arvind U Gowda
- Surgical Resident, Department of Surgery, Section of Plastic Surgery, Yale School of Medicine
| | - Sumun Khetpal
- Medical Student, Department of Surgery, Section of Plastic Surgery, Yale School of Medicine
| | - Joseph Lopez
- Craniofacial Fellow, Department of Surgery, Section of Plastic Surgery, Yale School of Medicine
| | - Blake N Shultz
- Medical Student, Department of Surgery, Section of Plastic Surgery, Yale School of Medicine
| | - Yassmin Parsaei
- Dental Resident, Department of Surgery, Section of Plastic Surgery, Yale School of Medicine; and Dental Resident, Department of Orthodontics, University of Connecticut
| | - Robin T Wu
- Surgical Resident, Department of Orthodontics, University of Connecticut, Resident, Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford Medicine
| | - Derek M Steinbacher
- Chief of Oral and Maxillofacial Surgery, Director of Craniofacial, Professor Plastic and Reconstructive Surgery, Yale New Haven Health.
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