Plastic and Reconstructive Surgery • July 2014 correction is the goal, rather than occlusion. The authors argue that they achieved a desired counterclockwise rotation with significantly more advancement at the dentoalveolar level than at the nasion level, analogous to a Le Fort I/III procedure. This is only possible if the advancement was quite small or if the occlusal plane was extraordinarily steep such that the rotation actually leveled the occlusal plane. Although helpful in internal midface distraction, perioperative elastics would likely only impact the advancement at the nasion level and actually limit additional rotation advancement at the occlusion. The most likely explanation, in our opinion, is that an open bite is being created and orthodontic compensations, such as upper incisor proclination, occur. Finally, it would be beneficial in the study to separate skeletally mature patients from growing patients because the therapeutic goals and treatment strategies are different. In the skeletally mature patient, it is important to achieve a class I occlusion, whereas in a growing patient, overcorrection into a class II occlusion is the goal. DOI: 10.1097/PRS.0000000000000298
Justine C. Lee, M.D., Ph.D. James P. Bradley, M.D. Division of Plastic and Reconstructive Surgery University of California, Los Angeles Los Angeles, Calif. Correspondence to Dr. Bradley Division of Plastic and Reconstructive Surgery University of California, Los Angeles 200 Medical Plaza, Suite 465 Los Angeles, Calif. 90095-6960 [email protected]
PATIENT CONSENT Parents or guardians provided written consent for use of the patient’s images. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCE 1. Kumar A, Gabbay JS, Nikjoo R, et al. Improved outcomes in cleft patients with severe maxillary deficiency after Le Fort I internal distraction. Plast Reconstr Surg. 2006;117:1499–1509.
type of repair (particularly with the excision of large parts of the prolabium) lacks the normal fullness and projection to have it lie anterior to the lower lip, as is normal. The lip repair shown is essentially that espoused by Ralph Millard, my teacher, but with the fabrication of a narrower philtrum. Dr. Millard insisted that the columella be lengthened with forked flaps, but I agree with John that an adequate columella and tip can be obtained simply by cartilage reshaping and repositioning. Years ago, I found myself unhappy with the lip and nose results that I was obtaining with the one-stage repair. The lips were in my opinion tight and short. The columellae were quite adequate, but the lobule was often deficient. I switched to staged rotation advancements, where virtually no tissue is discarded, which gave a longer, fuller lip, and normal noses, using the McComb technique. This was used first for incomplete clefts,2 and more recently for complete bilateral clefts.3 Showing that the anthropometric normals described by Leslie Farkas can be re-created in the reconstructed lip on frontal view is of interest, but we need to see the lateral view as well.4 I would personally rather have a philtrum that is wider than the norms described by Farkas if it provides a full, pouting lip. Often in orthognathic surgery, we have a better result if sella, nasion, A-point and sella, nasion, B-point are not precisely on the money. I think the same holds for philtral width and length in bilateral cleft repair (Fig. 1). Also, in the incomplete bilateral cleft, with staged repairs, we can maintain the normal white roll across the base of the philtrum, achieve a good muscle repair (because there is muscle in the prolabium), and often even obtain a philtral dimple, a lovely structure that disappears if the prolabial skin is elevated to allow muscle closure beneath it. Dr. Millard felt that the prolabial vermillion should never be used, because it had a different texture and color, but we have not seen that keeping it in place is a problem (Fig. 2). It is not unreasonable to postulate that a tight upper lip can exert a negative effect on maxillary growth. Yes, James Barrett Brown did feel that bilateral clefts were twice as hard as unilateral clefts. However, if we think of them as simply two unilateral clefts, and treat each side with a rotation advancement precisely as is done for the unilateral clefts, they no longer are twice as hard, and the results may be just as good. DOI: 10.1097/PRS.0000000000000307
S. Anthony Wolfe, M.D.
Repair of Bilateral Incomplete Cleft Lip: Techniques and Outcomes Sir: read with interest John Mulliken’s treatise on the repair of incomplete bilateral clefts.1 I would have very much appreciated seeing lateral views of the two patients presented because, in my experience, the upper lip after this
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Division of Plastic Surgery Miami Children’s Hospital 3100 SW 62nd Avenue, Suite 2230 Miami, Fla. 33155 [email protected]
PATIENT CONSENT The patient and parents or guardians provided written consent for use of patients’ images.
Volume 134, Number 1 • Letters
Fig. 1. A young woman with attractive upper lip, with a philtral width of 20 mm.
Fig. 2. Patient with incomplete and complete clefts, before and after staged rotation advancements. The philtrum is wide, but the lip is full and loose, and there is a native white roll and Cupid’s bow.
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Plastic and Reconstructive Surgery • July 2014 DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Mulliken JB, Kim DC. Repair of bilateral incomplete cleft lip: Techniques and outcomes. Plast Reconstr Surg. 2013;132:923–932. 2. Wolfe SA, Ghurani R, Mejia M. Use of staged rotation-advancement procedures for the treatment of incomplete bilateral clefts of the lip. Ann Plast Surg. 2004;52:263–268; discussion 269. 3. Wolfe SA, Mejia ML. Staged rotation advancements provide improved nasal results compared to 1-stage repairs in patients with complete bilateral cleft lip and palate. Ann Plast Surg. 2014;72:307–311. 4. Farkas LG. Anthropometry of the Head and Face. New York: Raven; 1994.
Assessing Risk Factors of Respiratory Complications following Abdominal Wall Reconstruction Sir: n a retrospective study by Fischer et al.1 assessing associations of perioperative factors with postoperative respiratory morbidity in patients undergoing abdominal wall reconstruction, they had attempted to control most of the known factors that could affect postoperative respiratory complications, such as age, body mass index, smoking status, American Society of Anesthesiologists physical status, preoperative comorbidities, use of steroids, intraoperative blood loss and transfusion, and others. Furthermore, they used appropriate methods to determine risk factors for postoperative respiratory complications. However, this study is a retrospective analysis with observational designs, which are inevitably subject to uncontrolled and unmeasured confounding. In our view, several important issues of this study were not well addressed. First, the authors did not describe use of opioid drugs or neuromuscular blocking agents during surgery, the duration of postoperative assessment, or methods of postoperative analgesia. Fair evidence suggests that intraoperative short-acting rather than long-acting neuromuscular blocking agents reduce the risk of postoperative respiratory complications.2 It has been shown that the first 24 hours after surgery represent the highest risk of unanticipated respiratory failure because of opioid drugs, whereas postoperative hypoxemia is most common by the third night after major surgery.3 Thus, assessment of postoperative respiratory complications is frequently focused on the early postoperative period of 3 days after surgery. Following abdominal surgery, moreover, pain is recognized as being the most frequent postoperative problem, and inadequate postoperative analgesia may result in splinting, with rapid and shallow breathing. As a result, ensuring adequate analgesia in the postoperative period is of great importance, not only for patient comfort but also for improvement of pulmonary function and a reduction in the risk of respiratory complications.4
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Second, in this study, 67.2 percent of patients had at least one defined comorbidity preoperatively. Moreover, the most common comorbid condition was hypertension (53.0 percent), and 9.7 percent of patients suffered from coronary artery disease. Thus, preoperative assessment of cardiac function should be included in the study design. Good-quality evidence identifies preoperative cardiac insufficiency as a significant risk factor for postoperative pulmonary complications.2 To exclude the possible influence of existing lung lesions on the postoperative respiratory outcome, preoperative chest radiography is required, especially for patients with new or unstable cardiopulmonary signs or symptoms and patients at increased risk of postoperative pulmonary complications.2 Finally, ventilator-induced lung injury is a possible confounding factor. It is generally believed that use of large tidal volume or high pressure during general anesthesia may adversely influence postoperative pulmonary complications. In this study, the authors assessed the effects of inspiratory pressure on postoperative respiratory morbidities, and showed that the highest peak intraoperative airway pressure was associated with postoperative respiratory complications. We would like to know whether an identical ventilation strategy, with the same settings of ventilation mode, ventilation rate, and tidal volume, was used in all patients. A randomized clinical trial in patients undergoing elective laparotomy confirms that, compared with standard ventilation strategy, a protective ventilation strategy with lower tidal volumes, positive end-expiratory pressure, and recruitment maneuvers during anesthesia improves postoperative respiratory function and reduces the clinical signs of postoperative pulmonary infection.5 In addition, transfusion-related acute lung injury is a well-known issue. To assess associations of intraoperative transfusions with postoperative respiratory morbidity, transfusion indications during surgery should at least be provided. We believe that addressing the above confounding factors would further clarify the transparency of this retrospective study. DOI: 10.1097/PRS.0000000000000297
Fu S. Xue, M.D. Shi Y. Wang, M.D. Xin L. Cui, M.D. Rui P. Li, M.D. Department of Anesthesiology Plastic Surgery Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing, People’s Republic of China Correspondence to Dr. Xue Department of Anesthesiology Plastic Surgery Hospital Chinese Academy of Medical Sciences and Peking Union Medical College 33 Ba-Da-Chu Road Shi-Jing-Shan District Beijing 100144, People’s Republic of China [email protected]
Justine C. Lee, M.D., Ph.D. James P. Bradley, M.D. Division of Plastic and Reconstructive Surgery University of California, Los Angeles Los Angeles, Calif. Correspondence to Dr. Bradley Division of Plastic and Reconstructive Surgery University of California, Los Angeles 200 Medical Plaza, Suite 465 Los Angeles, Calif. 90095-6960 [email protected]
PATIENT CONSENT Parents or guardians provided written consent for use of the patient’s images. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCE 1. Kumar A, Gabbay JS, Nikjoo R, et al. Improved outcomes in cleft patients with severe maxillary deficiency after Le Fort I internal distraction. Plast Reconstr Surg. 2006;117:1499–1509.
type of repair (particularly with the excision of large parts of the prolabium) lacks the normal fullness and projection to have it lie anterior to the lower lip, as is normal. The lip repair shown is essentially that espoused by Ralph Millard, my teacher, but with the fabrication of a narrower philtrum. Dr. Millard insisted that the columella be lengthened with forked flaps, but I agree with John that an adequate columella and tip can be obtained simply by cartilage reshaping and repositioning. Years ago, I found myself unhappy with the lip and nose results that I was obtaining with the one-stage repair. The lips were in my opinion tight and short. The columellae were quite adequate, but the lobule was often deficient. I switched to staged rotation advancements, where virtually no tissue is discarded, which gave a longer, fuller lip, and normal noses, using the McComb technique. This was used first for incomplete clefts,2 and more recently for complete bilateral clefts.3 Showing that the anthropometric normals described by Leslie Farkas can be re-created in the reconstructed lip on frontal view is of interest, but we need to see the lateral view as well.4 I would personally rather have a philtrum that is wider than the norms described by Farkas if it provides a full, pouting lip. Often in orthognathic surgery, we have a better result if sella, nasion, A-point and sella, nasion, B-point are not precisely on the money. I think the same holds for philtral width and length in bilateral cleft repair (Fig. 1). Also, in the incomplete bilateral cleft, with staged repairs, we can maintain the normal white roll across the base of the philtrum, achieve a good muscle repair (because there is muscle in the prolabium), and often even obtain a philtral dimple, a lovely structure that disappears if the prolabial skin is elevated to allow muscle closure beneath it. Dr. Millard felt that the prolabial vermillion should never be used, because it had a different texture and color, but we have not seen that keeping it in place is a problem (Fig. 2). It is not unreasonable to postulate that a tight upper lip can exert a negative effect on maxillary growth. Yes, James Barrett Brown did feel that bilateral clefts were twice as hard as unilateral clefts. However, if we think of them as simply two unilateral clefts, and treat each side with a rotation advancement precisely as is done for the unilateral clefts, they no longer are twice as hard, and the results may be just as good. DOI: 10.1097/PRS.0000000000000307
S. Anthony Wolfe, M.D.
Repair of Bilateral Incomplete Cleft Lip: Techniques and Outcomes Sir: read with interest John Mulliken’s treatise on the repair of incomplete bilateral clefts.1 I would have very much appreciated seeing lateral views of the two patients presented because, in my experience, the upper lip after this
I
166e
Division of Plastic Surgery Miami Children’s Hospital 3100 SW 62nd Avenue, Suite 2230 Miami, Fla. 33155 [email protected]
PATIENT CONSENT The patient and parents or guardians provided written consent for use of patients’ images.
Volume 134, Number 1 • Letters
Fig. 1. A young woman with attractive upper lip, with a philtral width of 20 mm.
Fig. 2. Patient with incomplete and complete clefts, before and after staged rotation advancements. The philtrum is wide, but the lip is full and loose, and there is a native white roll and Cupid’s bow.
167e
Plastic and Reconstructive Surgery • July 2014 DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. REFERENCES 1. Mulliken JB, Kim DC. Repair of bilateral incomplete cleft lip: Techniques and outcomes. Plast Reconstr Surg. 2013;132:923–932. 2. Wolfe SA, Ghurani R, Mejia M. Use of staged rotation-advancement procedures for the treatment of incomplete bilateral clefts of the lip. Ann Plast Surg. 2004;52:263–268; discussion 269. 3. Wolfe SA, Mejia ML. Staged rotation advancements provide improved nasal results compared to 1-stage repairs in patients with complete bilateral cleft lip and palate. Ann Plast Surg. 2014;72:307–311. 4. Farkas LG. Anthropometry of the Head and Face. New York: Raven; 1994.
Assessing Risk Factors of Respiratory Complications following Abdominal Wall Reconstruction Sir: n a retrospective study by Fischer et al.1 assessing associations of perioperative factors with postoperative respiratory morbidity in patients undergoing abdominal wall reconstruction, they had attempted to control most of the known factors that could affect postoperative respiratory complications, such as age, body mass index, smoking status, American Society of Anesthesiologists physical status, preoperative comorbidities, use of steroids, intraoperative blood loss and transfusion, and others. Furthermore, they used appropriate methods to determine risk factors for postoperative respiratory complications. However, this study is a retrospective analysis with observational designs, which are inevitably subject to uncontrolled and unmeasured confounding. In our view, several important issues of this study were not well addressed. First, the authors did not describe use of opioid drugs or neuromuscular blocking agents during surgery, the duration of postoperative assessment, or methods of postoperative analgesia. Fair evidence suggests that intraoperative short-acting rather than long-acting neuromuscular blocking agents reduce the risk of postoperative respiratory complications.2 It has been shown that the first 24 hours after surgery represent the highest risk of unanticipated respiratory failure because of opioid drugs, whereas postoperative hypoxemia is most common by the third night after major surgery.3 Thus, assessment of postoperative respiratory complications is frequently focused on the early postoperative period of 3 days after surgery. Following abdominal surgery, moreover, pain is recognized as being the most frequent postoperative problem, and inadequate postoperative analgesia may result in splinting, with rapid and shallow breathing. As a result, ensuring adequate analgesia in the postoperative period is of great importance, not only for patient comfort but also for improvement of pulmonary function and a reduction in the risk of respiratory complications.4
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Second, in this study, 67.2 percent of patients had at least one defined comorbidity preoperatively. Moreover, the most common comorbid condition was hypertension (53.0 percent), and 9.7 percent of patients suffered from coronary artery disease. Thus, preoperative assessment of cardiac function should be included in the study design. Good-quality evidence identifies preoperative cardiac insufficiency as a significant risk factor for postoperative pulmonary complications.2 To exclude the possible influence of existing lung lesions on the postoperative respiratory outcome, preoperative chest radiography is required, especially for patients with new or unstable cardiopulmonary signs or symptoms and patients at increased risk of postoperative pulmonary complications.2 Finally, ventilator-induced lung injury is a possible confounding factor. It is generally believed that use of large tidal volume or high pressure during general anesthesia may adversely influence postoperative pulmonary complications. In this study, the authors assessed the effects of inspiratory pressure on postoperative respiratory morbidities, and showed that the highest peak intraoperative airway pressure was associated with postoperative respiratory complications. We would like to know whether an identical ventilation strategy, with the same settings of ventilation mode, ventilation rate, and tidal volume, was used in all patients. A randomized clinical trial in patients undergoing elective laparotomy confirms that, compared with standard ventilation strategy, a protective ventilation strategy with lower tidal volumes, positive end-expiratory pressure, and recruitment maneuvers during anesthesia improves postoperative respiratory function and reduces the clinical signs of postoperative pulmonary infection.5 In addition, transfusion-related acute lung injury is a well-known issue. To assess associations of intraoperative transfusions with postoperative respiratory morbidity, transfusion indications during surgery should at least be provided. We believe that addressing the above confounding factors would further clarify the transparency of this retrospective study. DOI: 10.1097/PRS.0000000000000297
Fu S. Xue, M.D. Shi Y. Wang, M.D. Xin L. Cui, M.D. Rui P. Li, M.D. Department of Anesthesiology Plastic Surgery Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing, People’s Republic of China Correspondence to Dr. Xue Department of Anesthesiology Plastic Surgery Hospital Chinese Academy of Medical Sciences and Peking Union Medical College 33 Ba-Da-Chu Road Shi-Jing-Shan District Beijing 100144, People’s Republic of China [email protected]
