Predictors of Adverse Outcomes Following Cleft Palate Repair: An Analysis of Over 2500 Patients Using International Smile Train Data

OBJECTIVE

The objective of this study was to use data from Smile Train's global partner hospital network to identify patient characteristics that increase odds of fistula and postoperative speech outcomes.

DESIGN

Multi-institution, retrospective review of Smile Train Express database.

SETTING

1110 Smile Train partner hospitals.

PATIENTS/PARTICIPANTS

2560 patients.

INTERVENTIONS

N/A.

MAIN OUTCOME MEASURE(S)

Fistula occurrence, nasal emission, audible nasal emission with amplification (through a straw or tube) only, nasal rustle/turbulence, consistent nasal emission, consistent nasal emission due to velopharyngeal dysfunction, rating of resonance, rating of intelligibility, recommendation for further velopharyngeal dysfunction assessment, and follow-up velopharyngeal dysfunction surgery.

RESULTS

The patients were 46.6% female and 27.5% underweight by WHO standards. Average age at palatoplasty was 24.7 ± 0.5 months and at speech assessment was 6.8 ± 0.1 years. Underweight patients had higher incidence of hypernasality and decreased speech intelligibility. Palatoplasty when under 6 months or over 18 months of age had higher rates of affected nasality, intelligibility, and fistula formation. The same findings were seen in Central/South American and African patients, in addition to increased velopharyngeal dysfunction and fistula surgery compared to Asian patients. Palatoplasty technique primarily involved one-stage midline repair.

CONCLUSIONS

Age and nutrition status were significant predictors of speech outcomes and fistula occurrence following palatoplasty. Outcomes were also significantly impacted by location, demonstrating the need to cultivate longitudinal initiatives to reduce regional disparities. These results underscore the importance of Smile Train's continual expansion of accessible surgical intervention, nutritional support, and speech-language care.

Reducing drain use with paraspinal muscle flaps for spinal closures: A retrospective cohort study

BACKGROUND

Paraspinal muscle (PSM) flaps can be mobilized with superficial undermining and lateral release from the thoracolumbar fascia and/or deep undermining and medial release from the transverse processes and ribs. The objective of the study was to compare the effect of the PSM flap technique on drain use, retention, and complication rates.

METHODS

A retrospective chart review was performed for patients who underwent spinal coverage with PSM flaps at a single institution from April 2020 to June 2021. Patient demographics, preoperative comorbidities, surgical technique, drain usage, and postoperative complications were analyzed to compare the effects of different PSM flap surgical techniques on postoperative drain use and complications.

RESULTS

Sixty patients were included. Both superficial and deep releases were performed in half (47%) of the cases, while the remainder was split between superficial (25%) and deep (28%) releases. Drains were used less frequently for the deep release (35%) than the superficial (93%) or both releases (96%, p < 0.01). The deep release had shorter mean drain retention time (5.8 days) than the superficial (30.3 days) or both releases (24.8 days, p < 0.01). There were no significant differences between the techniques in terms of complications. For the deep release, the use of drains was not associated with a reduction in complications (odds ratio 0.91 [0.84 - 0.98], p = 0.97).

CONCLUSIONS

In a selected patient population, a "deep release only" PSM flap technique may allow for drainless spinal closure without an increased risk of seroma or other complications.

Changes in Subspecialty Interest of Plastic Surgery Residents With Progression of Training: Impact on Academic Attrition

BACKGROUND

Plastic surgery residency applicants often express interest in academic subspecialties, but only a small percentage of graduating residents pursue academic careers. Identifying reasons for academic attrition may help training programs address this discrepancy.

METHODS

A survey was sent to plastic surgery residents through the American Society of Plastic Surgeons Resident Council to assess interest in 6 plastic surgery subspecialties during junior and senior years of training. If a resident changed their subspecialty interest, the reasons for change were recorded. The importance of different career incentives over time were analyzed with paired t tests.

RESULTS

Two hundred seventy-six plastic surgery residents of 593 potential respondents (46.5% response rate) completed the survey. Of 150 senior residents, 60 residents reported changing interests from their junior to senior years. Craniofacial and microsurgery were identified as the specialties with the highest attrition of interest, while interest in esthetic, gender-affirmation, and hand surgery increased. For residents who left craniofacial and microsurgery, the desire for higher compensation, to work in private practice, and the desire for improved job opportunities significantly increased. The desire for improved work/life balance was a prominent reason for subspecialty change among senior residents who changed to esthetic surgery.

CONCLUSIONS

Plastic surgery subspecialties associated with academia, such as craniofacial surgery, suffer from resident attrition due to a variety of factors. Increased retention of trainees in craniofacial surgery, microsurgery, and academia could be improved through dedicated mentorship, improved job opportunities, and advocacy for fair reimbursement.

The personal impact of involvement in international global health outreach: A national survey of former Operation Smile student volunteers

BACKGROUND

Humanitarian surgical organizations such as Operation Smile provide global health opportunities for students and medical trainees. Prior studies have shown a positive benefit for medical trainees. This study aimed to determine if the international global health experiences of young student volunteers impact their career choices as adults.

METHODS

A survey was sent to adults who were involved with Operation Smile as students. The survey elicited information about their mission trip experience, education, career, and current volunteer and leadership activities. Data were summarized with descriptive statistics and qualitative analysis.

RESULTS

114 prior volunteers responded. The majority participated in leadership conferences (n = 110), mission trips (n = 109), and student clubs (n = 101) while in high school. Many graduated from college (n = 113, 99%) and completed post-graduate degrees (n = 47, 41%). The most highly represented occupational industry was healthcare (n = 30, 26%), including physicians and medical trainees (n = 9), dentists (n = 5), and other healthcare providers (n = 5). Three-fourths reported that their volunteer experience impacted their career choice, and half reported that their experience allowed them to connect with career mentors. Their experience was associated with the development of leadership skills, including public speaking, self-confidence, and empathy, and increased awareness of cleft conditions, health disparities, and other cultures. Ninety-six percent continued to volunteer. Narrative responses revealed that the volunteer experiences impacted their inter- and intrapersonal development into adulthood.

CONCLUSIONS

Participation in a global health organization as a student may encourage a long-term commitment to leadership and volunteerism and foster interest in a healthcare career. These opportunities also encourage development of cultural competency and interpersonal skills.

LEVEL OF EVIDENCE

III, Cross-Sectional Study.

Outcomes of Tibial Nerve Repair and Transfer: A Structured Evidence-Based Systematic Review and Meta-Analysis

Although nerve transfer and repair are well-established for treatment of nerve injury in the upper extremity, there are no established parameters for when or which treatment modalities to utilize for tibial nerve injuries. The objective of our study is to conduct a systematic review of the effectiveness of end-to-end repair, neurolysis, nerve grafting, and nerve transfer in improving motor function after tibial nerve injury. PubMed, Cochrane, Medline, and Embase libraries were queried according to the PRISMA guidelines for articles that present functional outcomes after tibial nerve injury in humans treated with nerve transfer or repair. The final selection included Nineteen studies with 677 patients treated with neurolysis (373), grafting (178), end-to-end repair (90), and nerve transfer (30), from 1985 to 2018. The mean age of all patients was 27.0 ± 10.8 years, with a mean preoperative interval of 7.4 ± 10.5 months, and follow-up period of 82.9 ± 25.4 months. The mean graft repair length for nerve transfer and grafting patients was 10.0 ± 5.8 cm, and the most common donor nerve was the sural nerve. The most common mechanism of injury was gunshot wound, and the mean MRC of all patients was 3.7 ± 0.6. Good outcomes were defined as MRC ≥ 3. End-to-end repair treatment had the greatest number of good outcomes, followed by neurolysis. Patients with preoperative intervals less than 7 months were more likely to have good outcomes than those greater than 7 months. Patients with sport injuries had the highest percentage of good outcomes in contrast to patients with transections and who were in MVAs. We found no statistically significant difference in good outcomes between the use of sural and peroneal donor nerve grafts, nor between age, graft length, and MRC score.

Targeted muscle reinnervation at the time of amputation in the management of complex regional pain syndrome of the lower extremity

BACKGROUND

Complex regional pain syndrome (CRPS) is a chronic, posttraumatic condition defined by severe pain and sensorimotor dysfunction. In cases of severe CRPS, patients request amputation, which may cause phantom limb pain (PLP) and residual limb pain (RLP). Targeted muscle reinnervation (TMR) reduces the risk of PLP and RLP. This report describes the use of TMR at the time of amputation in a series of patients with CRPS.

PATIENTS AND METHODS

Four patients (ages 38-71 years) underwent TMR at the time of amputation for CRPS between April 2018 and January 2019. Three patients had a history of trauma and surgery to the affected limb. All patients attempted pharmacologic and interventional treatments for 1-7 years before requesting amputation. Three patients underwent below-knee amputations (BKA) and one had an above-knee amputation (AKA). Target muscles included the soleus, gastrocnemius, and flexor hallucis longus (BKA), and semitendinosus, biceps femoris, and vastus medialis (AKA). Postoperative phantom and residual limb pain symptoms were collected via a telephone survey adapted from the Patient-Reported Outcomes Measurement Information System (PROMIS).

RESULTS

There were no complications related to the TMR procedure. Average follow-up time was 12.75 months. Patients reported varied outcomes: two had RLP and PLP, one had RLP only, and one had PLP only. All patients reported successful prosthetic use.

CONCLUSION

TMR may be performed at the time of amputation for CRPS. Further study is necessary to determine the effect of TMR on pain, pain medication use, prosthesis use, and other domains of function.

Off-Label Use of Topical Minoxidil in Alopecia: A Review

Topical minoxidil is a well-known and often-utilized drug in dermatological practice for the treatment of alopecia. It was approved by the United States Food and Drug Administration for the treatment of androgenetic alopecia in 1988. Since its approval, minoxidil has been used off-label for the treatment of many other types of alopecia, with minimal formal evidence of efficacy. Conditions for which the use of topical minoxidil has been reported include telogen effluvium, alopecia areata (AA), scarring alopecia, eyebrow hypotrichosis, monilethrix, and chemotherapy-induced alopecia (CIA). The evidence for the use of minoxidil in each condition is derived from a variety of studies, including clinical trials, case series, and case reports. A comprehensive review of the literature indicates that while minoxidil is routinely used in the management of many alopecic conditions, there is mixed evidence for its efficacy. For certain conditions, including AA and most scarring alopecias, the evidence seems to be inconclusive. For others, such as eyebrow hypotrichosis, monilethrix, early traction alopecia, and CIA, there is more support for the efficacy of minoxidil. Although the favorable safety profile of minoxidil is established in adults, its use in the treatment of pediatric alopecia may require heightened monitoring and patient education.

Enhanced Survival with Implantable Scaffolds That Capture Metastatic Breast Cancer Cells In Vivo

The onset of distant organ metastasis from primary breast cancer marks the transition to a stage IV diagnosis. Standard imaging modalities often detect distant metastasis when the burden of disease is high, underscoring the need for improved methods of detection to allow for interventions that would impede disease progression. Here, microporous poly(ε-caprolactone) scaffolds were developed that capture early metastatic cells and thus serve as a sentinel for early detection. These scaffolds were used to characterize the dynamic immune response to the implant spanning the acute and chronic foreign body response. The immune cell composition had stabilized at the scaffold after approximately 1 month and changed dramatically within days to weeks after tumor inoculation, with CD11b(+)Gr1(hi)Ly6C(-) cells having the greatest increase in abundance. Implanted scaffolds recruited metastatic cancer cells that were inoculated into the mammary fat pad in vivo, which also significantly reduced tumor burden in the liver and brain. Additionally, cancer cells could be detected using a label-free imaging modality termed inverse spectroscopic optical coherence tomography, and we tested the hypothesis that subsequent removal of the primary tumor after early detection would enhance survival. Surgical removal of the primary tumor following cancer cell detection in the scaffold significantly improved disease-specific survival. The enhanced disease-specific survival was associated with a systemic reduction in the CD11b(+)Gr1(hi)Ly6C(-) cells as a consequence of the implant, which was further supported by Gr-1 depletion studies. Implementation of the scaffold may provide diagnostic and therapeutic options for cancer patients in both the high-risk and adjuvant treatment settings. Cancer Res; 76(18); 5209-18. ©2016 AACR.