The Repair of International Clefts in the Current Surgical Landscape

The Implementation of International Electives for Plastic Surgery Residents: Current State and Future Directions

INTRODUCTION

Interest in international surgical missions has been rising exponentially, with the plastic surgery community being a leader in this endeavor. The role of residents in such missions remains a topic of debate. This systematic review aims to consolidate the literature relevant to the inclusion of plastic surgery residents on international surgical missions to devise an algorithm to facilitate resident participation.

MATERIALS AND METHODS

A comprehensive search of PubMed, Medline, and EMBASE was performed to identify studies relevant to plastic surgery resident involvement in the context of surgical missions. Relevant conclusions were retrieved from each study and compiled according to category.

RESULTS

Of 418 initial studies, 26 were retained for the qualitative synthesis. These were grouped into 3 categories: surveys (n=12), reflections (n=7), and reviews (n=7). The survey studies addressed the perceived value, educational impact, and long-term effect on participating residents. Three reflection studies were from the perspective of residents and 4 from staff, while all recounted the many benefits gained for participating residents. Review studies addressed the issue of accreditation and the ethics surrounding resident involvement.

CONCLUSION

This systematic review highlights the overwhelming support from residents and staff, the highly regarded educational value, and the positive global health effects associated with plastic surgery resident participation in international surgical missions. The authors hope this will encourage and facilitate the implementation of formal opportunities for residents within residency training programs.

The Effect of Surgical Timing on 30-Day Outcomes in Cleft Palate Repair

BACKGROUND

The optimal age for cleft palate repair continues to be debated, with little discussion of surgical risk related to operative timing. This study of 3088 cleft palate patients analyzed the impact of surgical timing on perioperative and 30-day postoperative outcomes.

METHODS

Primary cleft palate repairs were identified in the National Surgical Quality Improvement Program database from 2012 to 2015. Data were combed for total postoperative complications, rates of readmission and reoperation, operating room time, and length of stay. Bivariate analyses were performed comparing 3-month periods from months 6 to 18, and months 0 to 5, 18 to 23, 24 to 29, and 30 to 59.

RESULTS

Despite a higher proportion of isolated soft palate closure, children operated on before 6 months had a higher complication rate than children at other ages (7.1 percent versus 3.2 percent; OR, 2.4; p = 0.04), and higher rates of both readmission (3.6 percent versus 1.4 percent; OR, 3.6; p = 0.02) and reoperation (2.4 percent versus 0.5 percent; OR, 4.7; p = 0.04). There were no differences in short-term outcomes for any other age group younger than 5 years, and no differences in hospital length of stay among any age groups.

CONCLUSIONS

The authors' findings suggest a relative contraindication to operation before 6 months. As there were no differences between any other age groups, long-term speech optimization should continue to be the primary consideration for operative planning. These findings improve the current rationale for palatoplasty timing, and can aid surgeons and parents in the surgical decision-making process.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

The Geographic Availability of Certified Cleft Care in the United States: A National Geospatial Analysis of 1-Hour Access to Care

PURPOSE

Children with cleft lip and/or palate (CLP) require longitudinal multidisciplinary care. Travel distance to comprehensive cleft centers may be a barrier for some families. This study evaluated the geospatial availability of certified cleft teams across the United States.

MATERIALS AND METHODS

A geographic catchment area within a 1-hour travel radius of each American Cleft Palate-Craniofacial Association-certified cleft center was mapped using TravelTime distance matrix programming. The proportion of children located within each catchment area was calculated using county-level data from the National Kids Count Data Center, with aggregate estimates of patients with CLP based on state-level data from the Centers for Disease Control and Prevention. One-hour access was compared across regions and based on urbanization data collected from the US Census.

RESULTS

There were 182 American Cleft Palate-Craniofacial Association-certified centers identified. As per study estimates, 28,331 (27.3%) children with CLP did not live within 1-hour travel distance to any center. One-hour access was highest in the Northeast (84.2% of children, P < .001) and lowest in the South (65.7%) and higher in states with the greatest urbanization in comparison with more rural states (85.1 vs 37.4%, P < .001). Similar patterns were seen for access to 2 or more cleft centers. The number of CLP children-per-center was highest in the West (775) and lowest in the Northeast (452).

CONCLUSIONS

Travel distances of more than 1 hour may affect more than 25,000 (1 of 4) CLP children in the US, with significant variation across geographic regions. Future studies should seek to understand the impact of and provide strategies for overcoming geographic barriers.

Primary Cleft Palate Repair Among Older-Age Children and Adolescents in the United States

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.

Validation of the Hubli Grading System for Assessing Unilateral and Bilateral Cleft Lip Outcomes

BACKGROUND

When determining whether a cleft lip repair outcome is acceptable, the severity of a patient's cleft at initial presentation must be considered. Currently, there is not a widely agreed upon scale for grading the pre-operative severity or post-operative surgical outcome for patients with unilateral and/or bilateral cleft lip. The aim of this study is to validate the Hubli grading system as a reliable and reproducible system for characterizing cleft lip repair outcomes.

METHODS

Craniofacial surgeon graders independently evaluated 2489 patients from 56 different countries undergoing both unilateral and bilateral cleft lip repair from April 2004 to December 2018. Preoperative severity and postoperative surgical results were assessed, and these grades were combined to determine surgical outcome acceptability based on initial cleft severity. Intrarater and interrater reliability were calculated as percentages of agreement.

RESULTS

Intrarater and interrater acceptability scores had an agreement of 94.50% and 87.04%, respectively. These results indicate that using the Hubli grading system, independent raters are able to reliably and reproducibly measure the acceptability of a cleft lip repair.

CONCLUSIONS

This study validates the use of the Hubli grading system to evaluate the acceptability of unilateral and bilateral cleft lip repairs. This is the largest study to date to evaluate cleft lip severity and repair outcomes, and the Hubli grading system is the only scale to determine the acceptability of surgical outcomes based on initial cleft severity. This system is designed to identify surgeons with sub-optimal outcomes in order to implement timely, individualized training on a global scale.

The History and Mission of Smile Train, a Global Cleft Charity

Cleft lip and/or palate (CLP) is a common congenital anomaly with a global impact. One organization attempting to decrease global burden of CLPs is Smile Train. Since 1999, Smile Train has empowered local medical providers to provide comprehensive and sustainable cleft care. Partner surgeons have performed more than 1.5 million operations for patients with CLPs in more than 90 countries. This article outlines the history and mission of Smile Train and details the organization's efforts to increase hospital-wide safety, provide education and training opportunities for partners, and use technology to improve the delivery of cleft care on a global scale.

Impact of short-term reconstructive surgical missions: a systematic review

Introduction

Short-term missions providing patients in low-income countries with reconstructive surgery are often criticised because evidence of their value is lacking. This study aims to assess the effectiveness of short-term reconstructive surgical missions in low-income and middle-income countries.

Methods

A systematic review was conducted according to PRISMA guidelines. We searched five medical databases from inception up to 2 July 2018. Original studies of short-term reconstructive surgical missions were included, which reported data on patient safety measurements, health gains of individual patients and sustainability. Data were combined to generate overall outcomes, including overall complication rates.

Results

Of 1662 identified studies, 41 met full inclusion criteria, which included 48 546 patients. The overall study quality according to Oxford CEBM and GRADE was low. Ten studies reported a minimum of 6 months’ follow-up, showing a follow-up rate of 56.0% and a complication rate of 22.3%. Twelve studies that did not report on duration or follow-up rate reported a complication rate of 1.2%. Fifteen out of 20 studies (75%) that reported on follow-up also reported on sustainable characteristics.

Conclusions

Evidence on the patient outcomes of reconstructive surgical missions is scarce and of limited quality. Higher complication rates were reported in studies which explicitly mentioned the duration and rate of follow-up. Studies with a low follow-up quality might be under-reporting complication rates and overestimating the positive impact of missions. This review indicates that missions should develop towards sustainable partnerships. These partnerships should provide quality aftercare, perform outcome research and build the surgical capacity of local healthcare systems.

PROSPERO registration number

CRD42018099285.

Frontoethmoidal meningoencephalocele: appraisal of a craniofacial surgical teaching program in Cambodia

OBJECTIVE The treatment of frontoethmoidal meningoencephaloceles (fMECs) in Cambodia was not possible before the development of a program that taught some Khmer surgeons (working at the Children's Surgical Centre in Phnom Penh) how to surgically correct these deformities without any foreign help. The results of that teaching program are discussed in this paper. METHODS Between 2004 and 2009, both local and visiting foreign neurosurgical and craniofacial surgeons (the visitors coming twice a year) worked together to operate on 200 patients, and a report on those cases was published in 2010. In subsequent years (2010-2016), the Khmer surgeons operated on 100 patients without the presence of the visiting surgeons. In this study, the authors compare the second case series with the previously published series and the literature in terms of results and complications. The operations were performed with limited surgical materials and equipment, using a combined bicoronal and transfacial approach in most cases. Most of the patients came from very poor families. RESULTS Organizing the postoperative follow-up of these low-income patients (mean age 12 years) was probably the most challenging part of this teaching program. Nine of the patients were lost to surgical follow-up. In the other cases, cosmetic results were judged by the surgeons as worse than the patient's preoperative appearance in 1 case, poor in 12 cases, average in 27, and good in 51-data that are significantly less encouraging than the results reported by the joint local/visiting teams in 2010 (p = 0.0001). Nevertheless, patients and parents tended to have a better overall opinion about the surgical results (rating the results as good in 84% of the 80 cases in which parent or patient ratings were available). Twenty postoperative complications were observed (the most common being temporary CSF leaks). The rate of immediate postoperative complications directly related to fMEC surgery was less than that in the previous series, but the difference was not statistically significant (20% vs 28.5%, p = 0.58). No death was noted in this case series (in contrast to the previous series). Social questionnaire results confirmed that fMEC correction partially improved the adverse social and educational consequences of fMEC in affected children. CONCLUSIONS In the current state of this program, the local surgeons are able to correct fMECs in their own country, without foreign assistance, with good results in a majority of patients. Such humanitarian teaching programs generally take years to achieve the initial aims.

Ethical and Surgical Dilemmas in Patients with Neglected Surgical Diseases Visiting a Field Hospital in a Zone of Recent Disaster

OBJECT

The massive typhoon Haiyan (Yolanda) ripped across the central Philippines on November 8, 2013, and damaged infrastructure including hospitals. The Israeli Defense Forces field hospital was directed by the Philippine authorities to Bogo City in the northern part of the island of Cebu, to assist the damaged local hospital. Hundreds of patients with neglected diseases sought for medical treatment which was merely out of reach for them. Our ethical dilemmas were whether to intervene, when the treatment we could offer was not the best possible.

METHODS

Each patient had an electronic medical record that included diagnosis, management and aftercare instructions. We retrospectively reviewed all charts of patients.

RESULTS

Over 200 patients presented with neglected chronic diseases (tuberculosis, goiter, hypertension and diabetes). We limited our intervention to extreme values of glucose and blood pressure. We had started anti-tuberculosis medications, hoping that the patients will have an option to continue treatment. We examined 85 patients with a presumed diagnosis of malignancy. Without histopathology and advanced imaging modality, we performed palliative operations on three patients. Eighteen patients presented with inguinal hernia. We performed pure tissue repair on seven patients with large symptomatic hernias. We examined 12 children with cleft lip/palate and transferred two of them to Israel. We operated on one child with bilateral club feet. Out of 37 patients with pterygium, our ophthalmologist repaired the nine patients with the most severe vision disturbance.

CONCLUSION

Medical delegations to disaster areas should prepare a plan and appropriate measures to deal with non-urgent diseases.