The unilateral cleft lip repair is one of the most rewarding and challenging of plastic surgery procedures. Surgeons have introduced a variety of straight line, geometric, and rotation-advancement designs, while in practice the majority of North American surgeons have been using hybrids of the rotation-advancement techniques. The anatomic subunit approach was introduced in 2005 by Fisher and has gained popularity, with early adopters of the design touting its simplicity and effectiveness. The objectives of this article are to summarize the basic tenets of respecting the philtral subunit, accurate measurement and planning, and tips for transitioning to this subunit approach.

There is a lack of consensus regarding preferred implant materials for orbital floor fracture reconstruction, leading to surgeon- and institution-dependent preferences. A variety of implants are used for orbital floor fracture reconstruction, each with their own complication profile. Knowledge of different implant materials is critical to identifying complications when they present. We report a delayed periorbital abscess 5 years after orbital floor reconstruction using a silicone implant.

Purpose of review

The purpose of this article is to review and evaluate the surgical options for treating patients with facial paralysis, covering primary neurorrhaphy to facial reanimation, with microvascular free tissue transfer.

Recent findings

In recent years, free tissue transfer has been increasingly common for rehabilitating the paralyzed face, providing a more dynamic and aesthetic outcome, than has been possible prior to microvascular surgery in facial plastic and head and neck surgery.

Summary

Although primary facial nerve repair attains the best results, nerve grafting with the sural nerve and commercially available motor nerve allografts can be used alone, or in combination with masseteric nerve grafts to attain facial tone and protect eyelid function. The workhorse for reanimation is the gracilis free tissue transfer innervated by the masseteric nerve or contralateral facial nerve using a cross-face nerve graft. The orthodromic temporalis tendon transfer has minimal donor site morbidity and acceptable reported outcomes. Static procedures continue to be used alone and in combination with other paradigms for facial nerve reanimation.

Congenital anomalies of the nose range from complete aplasia of the nose to duplications and nasal masses. Nasal development is the result of a complex embryologic patterning and fusion of multiple primordial structures. Loss of signaling proteins or failure of migration or proliferation can result in structural anomalies with significant cosmetic and functional consequences. Congenital anomalies of the nose can be categorized into four broad categories: (1) aplastic or hypoplastic, (2) hyperplastic or duplications, (3) clefts, and (4) nasal masses. Our knowledge of the embryologic origin of these anomalies helps dictate subsequent work-up for associated conditions, and the appropriate treatment or surgical approach to manage newborns and children with these anomalies.

The repair of an infant with cleft lip includes treatment of the nasal deformity using surgical repositioning of the nasal cartilages. In some cases, the nose is molded before surgery, termed nasoalveolar molding, and in others, postoperatively with nostril stents for a variable amount of time. This best practice evaluation fails to make a definitive evidence-based conclusion, yet the benefits of stenting seem to outweigh the risks.

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.

Purpose of review

Near-miss investigations in high reliability organizations (HROs) aim to mitigate risk and improve system safety. Healthcare settings have a higher rate of near-misses and subsequent adverse events than most high-risk industries, but near-misses are not systematically reported or analyzed. In this review, we will describe the strategies for near-miss analysis that have facilitated a culture of safety and continuous quality improvement in HROs.

Recent findings

Near-miss analysis is routine and systematic in HROs such as aviation. Strategies implemented in aviation include the Commercial Aviation Safety Team, which undertakes systematic analyses of near-misses, so that findings can be incorporated into Standard Operating Procedures (SOPs). Other strategies resulting from incident analyses include Crew Resource Management (CRM) for enhanced communication, situational awareness training, adoption of checklists during operations, and built-in redundancy within systems.

Summary

Health care organizations should consider near-misses as opportunities for quality improvement. The systematic reporting and analysis of near-misses, commonplace in HROs, can be adapted to health care settings to prevent adverse events and improve clinical outcomes.