Clinical Focus


  • Craniofacial Abnormalities
  • Pediatric Plastic Surgery
  • Facial Fractures
  • Rhinoplasty
  • Skin cancer reconstruction
  • Mohs reconstruction
  • Cleft Lip
  • Cleft Palate
  • Craniosynostoses
  • Ear pinning (Otoplasty)
  • Nose surgery
  • Aesthetic Surgery
  • Facial rejuvination
  • Brow lift
  • Eyelid surgery (Blepharoplasty)
  • Facelift
  • Facial implants
  • Chin augmentation
  • Neck lift
  • Liposuction
  • Liposculpture
  • Fat grafting
  • Tummy tuck (Abdominoplasty)
  • Facial Bones
  • Facial Trauma
  • Craniofacial trauma
  • Craniomandibular Disorders
  • Osteogenesis, Distraction
  • Hemangioma
  • Vascular Malformations
  • Nevus
  • Acquired Nasal Deformities
  • Nasal Reconstruction
  • Facial Paralysis
  • Facial Reanimation
  • Facial Asymmetry
  • Gynecomastia
  • Abdominoplasty
  • Cosmetic Surgery
  • Infant ear molding
  • Cosmetic Reconstructive Surgical Procedures
  • Nasal Septum
  • septoplasty
  • craniofacial surgery
  • Plastic and Reconstructive Surgery
  • Microsurgery

Academic Appointments


Administrative Appointments


  • Surgical Director, Cleft & Craniofacial Center, Lucile Packard Children's Hospital, Stanford (2014 - Present)

Professional Education


  • Medical Education: University of Connecticut School of Medicine Registrar (2002) CT
  • Board Certification: American Board of Plastic Surgery, Plastic and Reconstructive Surgery (2009)
  • Fellowship: University of Washington (2008) WA
  • Residency: University of Texas Southwestern Medical Center (2007) TX
  • Residency: University of Texas Southwestern Medical Center (2005) TX

2021-22 Courses


All Publications


  • Rates of Revision and Obstructive Sleep Apnea after Surgery for Velopharyngeal Insufficiency: A Longitudinal Comparative Analysis of More Than 1000 Operations. Plastic and reconstructive surgery Rochlin, D. H., Sheckter, C. C., Khosla, R. K., Lorenz, H. P. 2021; 148 (2): 387-398

    Abstract

    BACKGROUND: The purpose of this study was to evaluate the comparative incidence of obstructive sleep apnea following velopharyngeal insufficiency surgery in the United States.METHODS: A retrospective analysis of cleft and noncleft pediatric patients who underwent velopharyngeal insufficiency surgery was performed using the IBM MarketScan Commercial Database. Patients were tracked longitudinally from 2007 to 2016 to evaluate the incidence of obstructive sleep apnea. Multivariable regression was used to evaluate predictors of postoperative obstructive sleep apnea and surgical revision.RESULTS: A total of 1098 patients underwent a pharyngeal flap (61.0 percent), sphincter pharyngoplasty (22.2 percent), or palatal lengthening with or without island flaps (16.8 percent). Diagnoses were predominantly cleft lip and/or palate (52.8 percent) and congenital oropharyngeal anomalies (42.6 percent). Eighty patients (7.3 percent) developed obstructive sleep apnea at an average of 10.2 months postoperatively. Predictors of obstructive sleep apnea included older age (p = 0.014) and head and neck neoplasm (p = 0.011). The obstructive sleep apnea rate following sphincter pharyngoplasty was 11.1 percent, compared to 7.2 percent after pharyngeal flap surgery. Compared to sphincter pharyngoplasty, pharyngeal flap surgery was associated with a lower risk of further surgery (OR, 0.43; p = 0.010). Of patients with cleft lip and/or palate, 35 developed obstructive sleep apnea (6.0 percent) without a significant association with procedure type.CONCLUSIONS: In this national claims database analysis of cleft and noncleft pediatric patients, the rate of obstructive sleep apnea following velopharyngeal insufficiency surgery was not significantly different for pharyngeal flap compared to sphincter pharyngoplasty.CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

    View details for DOI 10.1097/PRS.0000000000008193

    View details for PubMedID 34398089

  • A Systematic Review of Mandibular Distraction Osteogenesis Versus Orthodontic Airway Plate for Airway Obstruction Treatment in Pierre Robin Sequence. The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association Abbas, D. B., Lavin, C., Fahy, E. J., Choo, H., Truong, M. T., Bruckman, K. C., Khosla, R. K., Lorenz, H. P., Momeni, A., Wan, D. C. 2021: 10556656211011886

    Abstract

    OBJECTIVE: Mandibular distraction osteogenesis (MDO) is frequently performed to address airway obstruction in patients with Pierre Robin sequence (PRS), though more recently the technique of orthodontic airway plating (OAP) has gained traction. We aimed to evaluate OAP compared to MDO for airway obstruction in PRS.DESIGN: A systematic literature search across PubMed, Embase, and Google Scholar identified all studies published in English, which involved MDO or any form of OAP as treatments for PRS. All relevant articles were reviewed in detail and reported on, adhering to PRISMA guidelines.MAIN OUTCOME MEASURES: Airway (tracheostomy avoidance, decannulation rate), feeding (full oral feeding tolerance).RESULTS: Literature search identified 970 articles, of which 42 MDO studies and 9 OAP studies met criteria for review. A total of 1159 individuals were treated with MDO, and 322 individuals were treated with OAP. Primary outcomes appear similar for MDO and OAP at face value; however, this must be interpreted with different pretreatment contexts in mind.CONCLUSIONS: Orthodontic airway plating may be considered for airway obstruction in PRS, as some airway-related and feeding-related outcomes appear similar with MDO, per existing evidence in the literature. However, since PRS severity differed between studies, OAP cannot be uniformly considered a replacement for MDO. Further research is required to more comprehensively assess these treatment modalities inclusive of metrics that allow for direct comparison.

    View details for DOI 10.1177/10556656211011886

    View details for PubMedID 34075816

  • Readability of Online Patient Information Relating to Cleft Palate Surgery. The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association Lavin, C. V., Fahy, E. J., Abbas, D. B., Griffin, M., Deleon, N. M., Lee, D. K., Khosla, R. K., Bruckman, K., Lorenz, H. P., Wan, D. C. 2021: 10556656211013177

    Abstract

    OBJECTIVE: It is important for health care education materials to be easily understood by caretakers of children requiring craniofacial surgery. This study aimed to analyze the readability of Google search results as they pertain to "Cleft Palate Surgery" and "Palatoplasty." Additionally, the study included a search from several locations globally to identify possible geographic differences.DESIGN: Google searches of the terms "Cleft Palate Surgery" and "Palatoplasty" were performed. Additionally, searches of only "Cleft Palate Surgery" were run from several internet protocol addresses globally.MAIN OUTCOME MEASURES: Flesch-Kincaid Grade Level and Readability Ease, Gunning Fog Index, Simple Measure of Gobbledygook (SMOG) index, and Coleman-Liau Index.RESULTS: Search results for "Cleft Palate Surgery" were easier to read and comprehend compared to search results for "Palatoplasty." Mean Flesch-Kincaid Grade Level scores were 7.0 and 10.11, respectively (P = .0018). Mean Flesch-Kincaid Reading Ease scores were 61.29 and 40.71, respectively (P = .0003). Mean Gunning Fog Index scores were 8.370 and 10.34, respectively (P = .0458). Mean SMOG Index scores were 6.84 and 8.47, respectively (P = .0260). Mean Coleman-Liau Index scores were 12.95 and 15.33, respectively (P = .0281). No significant differences were found in any of the readability measures based on global location.CONCLUSIONS: Although some improvement can be made, craniofacial surgeons can be confident in the online information pertaining to cleft palate repair, regardless of where the search is performed from. The average readability of the top search results for "Cleft Palate Surgery" is around the seventh-grade reading level (US educational system) and compares favorably to other health care readability analyses.

    View details for DOI 10.1177/10556656211013177

    View details for PubMedID 33960204

  • Nonsurgical Orthodontic Airway Plate Treatment for Newborns With Robin Sequence. The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association Choo, H., Khosla, R. K., Meister, K. D., Wan, D. C., Lin, H. C., Feczko, R., Bruckman, K., Hopkins, E., Truong, M. T., Lorenz, H. P. 2021: 10556656211007689

    Abstract

    Despite promising outcomes for >50 years, nonsurgical orthodontic airway plates (OAP) are only infrequently offered for babies with Robin sequence in a few parts of the world. This article demonstrates possibility of providing functional improvement using an OAP to help these babies overcome their functional and structural difficulties on their own. Two consecutively treated cases are presented exemplifying that OAP treatment that had originated from Europe is reproducible and effective in an institution in the United States.

    View details for DOI 10.1177/10556656211007689

    View details for PubMedID 33845627

  • Nationwide Perioperative Analysis of Endoscopic Versus Open Surgery for Craniosynostosis: Equal Access, Unequal Outcomes. The Journal of craniofacial surgery Rochlin, D. H., Sheckter, C. C., Lorenz, H. P., Khosla, R. K. 2020

    Abstract

    The purpose of this study is to evaluate national differences in inpatient outcomes and predictors of treatment type for endoscopic versus open surgery for craniosynostosis, with particular consideration of racial, socioeconomic, and geographic factors. The 2016 Kids' Inpatient Database was queried to identify patients aged 3 years or younger who underwent craniectomy for craniosynostosis. Multivariable regression modeled treatment type based on patient-level (gender, race, income, comorbidities, payer) and facility-level (bed size, region, teaching status) variables, and was used to assess outcomes. The weighted sample included 474 patients, of whom 81.9% (N = 388) of patients underwent open repair and 18.1% (N = 86) underwent endoscopic repair. A total of 81.1% of patients were under 1 year of age and 12.0% were syndromic. Patients were more likely to be treated open if they were older (odds ratio [OR] 3.07, P = 0.005) or syndromic (OR 8.56, P = 0.029). Patients who underwent open repair were more likely to receive transfusions (OR 2.86, P = 0.021), and have longer lengths of stay (OR 1.02, P < 0.001) and more costly hospitalizations (OR 5228.78, P = 0.018). Complications did not significantly vary between procedure type. The authors conclude that United States national data confirm benefits of endoscopic surgery, including a lower risk of transfusion, shorter hospital stay, and lower hospital costs, without a significant change in the rate of inpatient complications. Racial, socioeconomic, and geographic factors were not significantly associated with treatment type or perioperative surgical outcomes. Future studies are needed to further investigate the influence of such variables on access to craniofacial care.

    View details for DOI 10.1097/SCS.0000000000007178

    View details for PubMedID 33055558

  • Adult Cranioplasty and Perioperative Patient Safety: Does Plastic Surgery Facility Volume Matter? The Journal of craniofacial surgery Rochlin, D. H., Sheckter, C. C., Khosla, R. K., Lorenz, H. P. 2020

    Abstract

    Cranioplasty lies at the intersection of neurosurgery and plastic surgery, though little is known about the impact of plastic surgery involvement. The authors hypothesized that adult cranioplasty patients at higher volume plastic surgery facilities would have improved inpatient outcomes. Adult cranioplasty encounters were extracted from the National Inpatient Sample from 2012 to 2014 based on International Classification of Diseases, Ninth Revision (ICD-9) codes. Regression models included the following variables: age, gender, race/ethnicity, Elixhauser Comorbidity Index, payer, hospital size, region, and urban/teaching status. Outcomes included odds of receiving a flap, perioperative patient safety indicators, and mortality. The weighted sample included 49,305 encounters with diagnoses of neoplasm (31.2%), trauma (56.4%), infection (5.2%), a combination of these diagnoses (3.9%), or other diagnoses (3.2%). There were 1375 inpatient mortalities, of which 10 (0.7%) underwent a flap procedure. On multivariable regression, higher volume plastic surgery facilities and all diagnoses except uncertain neoplasm were associated with an increased likelihood of a flap procedure during the admission for cranioplasty, using benign neoplasm as a reference (P < 0.001). Plastic surgery facility volume was not significantly associated with likelihood of a patient safety indicator event. The highest volume plastic surgery quartile was associated with lower likelihood of inpatient mortality (P = 0.008). These findings support plastic surgery involvement in adult cranioplasty and suggest that these patients are best served at high volume plastic surgery facilities.

    View details for DOI 10.1097/SCS.0000000000007177

    View details for PubMedID 33055559

  • Improvements in Cleft Lip Aesthetics with the Fisher Repair Compared to the Mohler Repair PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN Mittermiller, P. A., Martin, S., Johns, D. N., Perrault, D., Jablonka, E. M., Khosla, R. K. 2020; 8 (6)
  • Applied Online Crowdsourcing in Plastic and Reconstructive Surgery: A Comparison of Aesthetic Outcomes in Unilateral Cleft Lip Repair Techniques. Annals of plastic surgery Suchyta, M., Azad, A., Patel, A. A., Khosla, R. K., Lorenz, H. P., Nazerali, R. S. 2020; 84 (5S Suppl 4): S307–S310

    Abstract

    BACKGROUND: Aesthetic outcomes of unilateral cleft lip repairs have important psychosocial implications for patients who are heavily influenced by social perceptions. Online crowdsourcing offers the unique potential to efficiently recruit large numbers of laypeople to assess public perception. The aim of this study was to use the online crowdsourcing platform Mechanical Turk to compare the postoperative outcomes of Fisher, Millard, and Mohler cleft lip repair techniques.METHODS: Two hundred fifty-four participants were recruited through Mechanical Turk to evaluate 29 cropped and deidentified photographs of children, 8 photographs were controls without cleft lips and 21 were children with unilateral cleft lips who had undergone Fisher, Millard, or Mohler repairs (7 in each group). Respondents were asked whether a scar was present, whether they would be personally satisfied with the surgical result and used a Likert scale from 1 to 5 to rate overall appearance, scar severity, and nasal symmetry.RESULTS: Fewer respondents reported that a scar was present when assessing postoperative photographs of Fisher repairs (70.3 ± 8.6%) compared with Millard (92.0 ± 1.5%) or Mohler (88.8 ± 3.1%) repairs. Average rating of scar severity was also lower for Fisher (1.9) compared with Millard (2.6) or Mohler (2.6) repairs. Average ratings of nose symmetry, general appearance, and satisfaction with operative result were not statistically significantly different between the repair groups.CONCLUSIONS: This study demonstrates the potential of online crowdsourcing to assess public perception of plastic surgery outcomes. The Mechanical Turk platform offers a reduction in selection bias, ease of study design, and enhanced efficiency of large-scale participant recruitment. Results indicate that the Fisher repair led to the most favored aesthetic outcomes compared with the Millard and Mohler techniques, particularly with regard to scar severity. Crowdsourcing is a powerful tool to assess layperson perception of plastic surgery outcomes and can be used to better guide surgical decision-making.

    View details for DOI 10.1097/SAP.0000000000002389

    View details for PubMedID 32282397

  • Descriptive Overview of Primary Cleft Palate Surgeries in the Low- and Middle-Income Countries. The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association Min, J. G., Khosla, R. K., Curtin, C. 2020: 1055665620911556

    Abstract

    OBJECTIVE: To increase access to high-quality and multiregional databases in global epidemiology of cleft surgeries through partnership with an NGO.DESIGN: The study retrospectively analyzes 34 801 primary palate surgeries in 70+ countries from the 2016 electronic health records of an non-governmental organization (NGO). The study also utilizes the Kids' Inpatient Database to compare the epidemiology of primary cleft palate surgeries in the United States.PARTICIPANTS: Patient records of those undergoing primary cleft palate surgeries only.MAIN OUTCOME MEASURES: Region, age, sex, type of cleft, laterality of cleft.RESULTS: Key findings show that average age of those receiving primary cleft palate surgery in the low- and middle-income countries (LMICs) was 1.95 years. The distribution of males and females receiving surgery corresponds to the US national data. More hard cleft palates were on the left side (66.18%) than the right side (33.82%), independent of gender and region.CONCLUSIONS: Databases from an established NGO can be used to enhance our understanding of the disease characteristics in these regions. By increasing the information available regarding cleft surgeries in the LMIC, we hope to increase awareness of the similarities and differences in surgeries across various regions, as part of an effort to inform the goals set by Global Surgery 2030 initiative by the Lancet Commission.

    View details for DOI 10.1177/1055665620911556

    View details for PubMedID 32207319

  • Erratum: Improvements in Cleft Lip Aesthetics with the Fisher Repair Compared to the Mohler Repair: Erratum. Plastic and reconstructive surgery. Global open Khosla, R. K. 2020; 8 (8): e3098

    Abstract

    [This corrects the article DOI: 10.1097/GOX.0000000000002919.].

    View details for DOI 10.1097/GOX.0000000000003098

    View details for PubMedID 32983819

    View details for PubMedCentralID PMC7489696

  • Improvements in Cleft Lip Aesthetics with the Fisher Repair Compared to the Mohler Repair. Plastic and reconstructive surgery. Global open Mittermiller, P. A., Martin, S. n., Johns, D. N., Perrault, D. n., Jablonka, E. M., Khosla, R. K. 2020; 8 (6): e2919

    Abstract

    The extended Mohler rotation-advancement repair and the Fisher anatomic subunit repair are commonly used for the surgical correction of unilateral cleft lip. The rotation-advancement repair was the initial technique of choice by the senior surgeon. However, due to recurring suboptimal aesthetic results, the senior surgeon transitioned to the anatomic subunit repair. This study was performed to compare the outcomes of the rotation-advancement repair and the anatomic subunit repair.A retrospective study of all consecutive patients undergoing unilateral cleft lip repair by the senior author between 2009 and 2016 was conducted. Demographic data, the presence of scar shortening/contraction, hypertrophy, widening, and revision rates were recorded.There were 68 patients identified for inclusion. Thirty-four patients had a rotation-advancement repair and 35 had an anatomic subunit repair. Twelve patients (36%) with the rotation-advancement repair and 1 patient (2.9%) with the subunit repair required anterior lip revision (P < 0.001). Conversely, 2 patients (6.1%) with the rotation-advancement repair and 13 patients (37.1%) with the subunit repair required minor debulking of excess red vermilion fullness (P < 0.005).Transitioning from the rotation-advancement repair to the anatomic subunit repair has resulted in improved lip aesthetics with decreased incidence of scar contracture, hypertrophy, and widening as evidenced by a decrease in the revision rate for these suboptimal scars. However, the rate of debulking procedures of the red vermilion did increase early in the adoption of the anatomic subunit repair, requiring minor modifications in the technique.

    View details for DOI 10.1097/GOX.0000000000002919

    View details for PubMedID 32766066

    View details for PubMedCentralID PMC7339201

  • Phase 1/2a clinical trial of gene-corrected autologous cell therapy for recessive dystrophic epidermolysis bullosa. JCI insight Eichstadt, S., Barriga, M., Ponakala, A., Teng, C., Nguyen, N. T., Siprashvili, Z., Nazaroff, J., Gorell, E. S., Chiou, A. S., Taylor, L., Khuu, P., Keene, D. R., Rieger, K., Khosla, R. K., Furukawa, L. K., Lorenz, H. P., Marinkovich, M. P., Tang, J. Y. 2019; 4 (19)

    Abstract

    BACKGROUNDRecessive dystrophic epidermolysis bullosa (RDEB) patients have mutations in the COL7A1 gene and thus lack functional type VII collagen (C7) protein; they have marked skin fragility and blistering. This single-center phase 1/2a open-label study evaluated the long-term efficacy, safety, and patient-reported outcomes in RDEB patients treated with gene-corrected autologous cell therapy.METHODSAutologous keratinocytes were isolated from participant skin biopsies. Epidermal sheets were prepared from cells transduced with a retrovirus carrying the full-length human COL7A1 gene. These gene-corrected autologous epidermal sheets measured 5 * 7 cm (35 cm2) and were transplanted onto 6 wound sites in each of 7 adult participants (n = 42 sites total) from 2013 to 2017. Participants were followed for 2 to 5 years.RESULTSNo participants experienced any serious related adverse events. Wound healing of 50% or greater by Investigator Global Assessment was present in 95% (36 of 38) of treated wounds versus 0% (0 of 6) of untreated control wounds at 6 months (P < 0.0001). At year 1, 68% (26 of 38) of treated wounds had 50% or greater healing compared with 17% (1 of 6) of control wounds (P = 0.025). At year 2, 71% (27 of 38) of treated wounds had 50% or greater healing compared with 17% (1 of 6) of control wounds (P = 0.019).CONCLUSIONC7 expression persisted up to 2 years after treatment in 2 participants. Treated wounds with 50% or greater healing demonstrated improvement in patient-reported pain, itch, and wound durability. This study provides additional data to support the clinically meaningful benefit of treating chronic RDEB wounds with ex vivo, C7 gene-corrected autologous cell therapy. This approach was safe and promoted wound healing that was associated with improved patient-reported outcomes.TRIAL REGISTRATIONClinicaltrials.gov identifier: NCT01263379.FUNDINGEpidermolysis Bullosa Research Partnership, Epidermolysis Bullosa Medical Research Foundation, NIH R01 AR055914, Office of Research and Development at the Palo Alto Veteran's Affairs Medical Center, and the Dermatology Foundation.

    View details for DOI 10.1172/jci.insight.130554

    View details for PubMedID 31578311

  • Retrospective cohort-based comparison of intraoperative liposomal bupivacaine versus bupivacaine for donor site iliac crest analgesia during alveolar bone grafting. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Patel, R. A., Jablonka, E. M., Rustad, K. C., Pridgen, B. C., Sorice-Virk, S. S., Borrelli, M. R., Khosla, R. K., Lorenz, H. P., Momeni, A., Wan, D. C. 2019

    Abstract

    INTRODUCTION: Bone grafting of alveolar clefts is routinely performed with cancellous bone harvested from the iliac crest. Graft site morbidity is frequently seen, with early postoperative pain being one of the most common complaints. Liposomal bupivacaine (LB) has been demonstrated to provide improvement in postoperative pain for patients undergoing bunionectomy or hemorrhoidectomy, which may translate to patients requiring iliac crest bone graft harvest.METHODS: Thirty-eight patients undergoing iliac crest bone harvest were included in the study. Twenty-one patients underwent open iliac crest bone graft harvest with administration of 0.25% bupivacaine at the hip donor site, while 17 patients received local infiltration of 1.3% liposomal bupivacaine. Patient-reported pain scores, total narcotic use, length of stay, and postoperative steps were monitored.RESULTS: There were no significant differences in age, weight, distribution of clefts, or choice of donor hip between the two groups. There were no significant differences in length of hospitalization stay. However, differences were noted in average postoperative pain scores at five of six time points in the first 24h, total oral morphine equivalents administered (4.7 ± 5.3 vs. 14.3 ± 12.0), and steps at postoperative days one to three (p<0.001, for all three days) for patients receiving 1.3% LB versus 0.25% bupivacaine, respectively.CONCLUSION: Reduced pain scores and increased postoperative activity highlight the potential of LB to improve postoperative pain management in children undergoing iliac crest bone harvest for alveolar bone grafting.

    View details for DOI 10.1016/j.bjps.2019.09.026

    View details for PubMedID 31648962

  • Assessing the Fisher, Mohler, and Millard Techniques of Cleft Lip Repair Surgery With Eye-Tracking Technology ANNALS OF PLASTIC SURGERY Kwong, J. W., Cai, L. Z., Azad, A. D., Lorenz, H., Khosla, R. K., Lee, G. K., Nazerali, R. S. 2019; 82: S313–S319
  • Anatomical Nasal Lining Flaps for Closure of the Nasal Floor in Unilateral and Bilateral Cleft Lip Repairs Reduce Fistulas at the Alveolus PLASTIC AND RECONSTRUCTIVE SURGERY Mittermiller, P. A., Sethi, H., Morbia, R. P., Johns, D., Baylan, J., Lorenz, H., Khosla, R. K. 2018; 142 (6): 1549–56
  • Management of Complex Arteriovenous Malformations Using a Novel Combination Therapeutic Algorithm. JAMA dermatology Chelliah, M. P., Do, H. M., Zinn, Z., Patel, V., Jeng, M., Khosla, R. K., Truong, M., Marqueling, A., Teng, J. M. 2018; 154 (11): 1316–19

    Abstract

    Importance: Current therapeutic options for patients with extracranial head and neck arteriovenous malformations are limited. Surgical intervention, such as sclerotherapy or resection, often result in rapid recurrence and progression of disease.Objective: To assess the efficacy and tolerability of sirolimus as an adjuvant therapy for endovascular embolization in the management of complicated extracranial head and neck arteriovenous malformations.Design, Setting, and Participants: This case series examined 6 patients with extracranial head and neck arteriovenous malformations treated from January 1, 2013, to December 31, 2017, at a multidisciplinary vascular anomalies clinic within Stanford Hospital and Clinics.Intervention: Initiation of sirolimus at least 1 month prior to endovascular embolization, targeting a trough level of 10 to 15 ng/mL throughout the course of the endovascular embolization series and continued for at least 1 month after the series.Main Outcomes and Measures: Clinical manifestations; disease progression and overall response to treatment were assessed via clinical evaluation and radiographic imaging.Results: All 6 patients (4 male and 2 female patients; mean age, 24.5 years [range, 9-44 years]) responded favorably to the combination of sirolimus therapy followed by endovascular embolization, and 4 patients exhibited a near-complete response. The median duration of follow-up was 19 months (range, 6-40 months). One patient discontinued sirolimus soon after embolization and experienced regrowth of the arteriovenous malformation after 1 year. Sirolimus was resumed, which has stabilized his disease for more than 2 years. Mild adverse effects were noted in 4 patients. The combination therapy was well tolerated in all patients. One patient developed skin ulceration after embolization and required surgical debridement. Another patient developed pulmonary microthrombi after embolization with cyanoacrylate glue that resolved with a brief course of anti-inflammatory therapy.Conclusions and Relevance: Although further prospective trials are needed, this report suggests the benefit of a mammalian target of rapamycin inhibitor as an adjuvant therapy for surgical embolization of complex, extracranial head and neck arteriovenous malformations. The optimal dosing and therapeutic duration of sirolimus treatment before and after embolization remain to be determined.

    View details for PubMedID 30326494

  • Teaching Palatoplasty Using a High-Fidelity Cleft Palate Simulator PLASTIC AND RECONSTRUCTIVE SURGERY Cheng, H., Podolsky, D. J., Fisher, D. M., Wong, K. W., Lorenz, H., Khosla, R. K., Drake, J. M., Forrest, C. R. 2018; 141 (1): 91E–98E

    Abstract

    Cleft palate repair is a challenging procedure for cleft surgeons to teach. A novel high-fidelity cleft palate simulator has been described for surgeon training. This study evaluates the simulator's effect on surgeon procedural confidence and palatoplasty knowledge among learners.Plastic surgery trainees attended a palatoplasty workshop consisting of a didactic session on cleft palate anatomy and repair followed by a simulation session. Participants completed a procedural confidence questionnaire and palatoplasty knowledge test immediately before and after the workshop.All participants reported significantly higher procedural confidence following the workshop (p < 0.05). Those with cleft palate surgery experience had higher procedural confidence before (p < 0.001) and after (p < 0.001) the session. Palatoplasty knowledge test scores increased in 90 percent of participants. The mean baseline test score was 28 ± 10.89 percent and 43 ± 18.86 percent following the workshop. Those with prior cleft palate experience did not have higher mean baseline test scores than those with no experience (30 percent versus 28 percent; p > 0.05), but did have significantly higher scores after the workshop (61 percent versus 35 percent; p < 0.05). All trainees strongly agreed or agreed that the simulator should be integrated into training and they would use it again.This study demonstrates the effective use of a novel cleft palate simulator as a training tool to teach palatoplasty. Improved procedural confidence and knowledge were observed after a single session, with benefits seen among trainees both with and without previous cleft experience.

    View details for PubMedID 29280875

  • Body Contouring in Massive-Weight-Loss Patients ESSENTIALS OF AESTHETIC SURGERY Chang, J., Khosla, R. K., Hunstad, J., Janis, J. E. 2018: 869–86
  • Liposuction ESSENTIALS OF AESTHETIC SURGERY Hunter, C. L., Khosla, R. K., Claiborne, J. R., Wall, S. H., Janis, J. E. 2018: 799–817
  • Cleft Lip Standardized Patient Examinations: The Role in Plastic Surgery Resident Education CLEFT PALATE-CRANIOFACIAL JOURNAL Wright, E. J., Khosla, R. K., Howell, L., Luan, A., Lee, G. K. 2016; 53 (6): 634-639

    Abstract

      Our institution has incorporated the use of objective structured clinical examinations (OSCE) in our residency curriculum. The OSCE provides trainee education and evaluation while addressing the six Accreditation Council for Graduate Medical Education (ACGME) core competencies required within training programs. We report our program's experience with the first cleft OSCE ever conducted.  A validated method for administration of OSCEs currently used at our medical school was utilized for residents in postgraduate years (PGYs) 3 through 6. The video-recorded patient encounter involved a 1-month-old newborn with a unilateral cleft lip and palate and used standardized patient actors as parents. A post-encounter written exam assessed medical knowledge. A questionnaire regarding the utility of the exercise was administered to residents after the OSCE. Results were evaluated using analysis of variance (P < .05).  There was a positive correlation with increasing level of training in terms of medical knowledge (P < .04). Residents in PGY-3 and PGY-4 demonstrated lower understanding of the surgical markings and details of the lip repair compared with those in PGY-5 and PGY-6 (P < .03). All residents performed similarly on evaluation of the remaining ACGME core competencies. All residents agreed that this was a realistic and useful encounter.  Results of our cleft OSCE demonstrate that medical knowledge regarding the evaluation, management, and surgical repair of patients is less in midlevel residents. All residents expressed an interest in earlier exposure to pediatric patients in the training period. Although a cleft OSCE does not replace clinical rotations, it is a valuable adjunct to training and evaluation of trainees, particularly for junior residents.

    View details for DOI 10.1597/15-121

    View details for Web of Science ID 000388005700004

    View details for PubMedID 26720521

  • Rhinoplasty Education Using a Standardized Patient Encounter. Archives of plastic surgery Wright, E. J., Khosla, R. K., Howell, L., Lee, G. K. 2016; 43 (5): 451-456

    Abstract

    Comprehensive aesthetic surgery training continues to be a challenge for residency programs. Our residency program developed a rhinoplasty-based objective structured clinical examination (OSCE) based upon validated methods as part of the residency education curriculum. We report our experience with the rhinoplasty-based OSCE and offer guidance to its incorporation within residency programs.The encounter involved resident evaluation and operative planning for a standardized patient desiring a rhinoplasty procedure. Validated OSCE methods currently used at our medical school were implemented. Residents were evaluated on appropriate history taking, physical examination, and explanation to the patient of treatment options. Examination results were evaluated using analysis of variance (statistical significance P<0.05).Twelve residents completed the rhinoplasty OSCE. Medical knowledge assessment showed increasing performance with clinical year, 50% versus 84% for postgraduate year 3 and 6, respectively (P<0.005). Systems-based practice scores showed that all residents incorrectly submitted forms for billing and operative scheduling. All residents confirmed that the OSCE realistically represents an actual patient encounter. All faculty confirmed the utility of evaluating resident performance during the OSCE as a useful assessment tool for determining the Next Accreditation System Milestone level.Aesthetic surgery training for residents will require innovative methods for education. Our examination showed a program-educational weakness in billing/coding, an area that will be improved upon by topic-specific lectures. A thoroughly developed OSCE can provide a realistic educational opportunity to improve residents' performance on the nonoperative aspects of rhinoplasty and should be considered as an adjunct to resident education.

    View details for DOI 10.5999/aps.2016.43.5.451

    View details for PubMedID 27689053

  • Use of regenerative tissue matrix as an oral layer for the closure of recalcitrant anterior palatal fistulae: a pilot study JOURNAL OF THE KOREAN ASSOCIATION OF ORAL AND MAXILLOFACIAL SURGEONS Richardson, S., Hoyt, J. S., Khosla, R. K., Khandeparker, R., Sukhadia, V. Y., Agni, N. 2016; 42 (2): 77–83

    Abstract

    To evaluate the effectiveness of regenerative tissue matrix (Alloderm) as an oral layer for difficult anterior palatal fistula closure.The authors have tested the feasibility of a novel surgical technique of adding a regenerative tissue matrix (Alloderm) as an oral layer for closure of recalcitrant large anterior palatal fistulae and report the outcome of the first 12 patients in this pilot study. Patients with recurrent large fistula who otherwise would require either a local pedicled flap, free flap, or an obturator were treated with this technique and followed up for at least 6 months to monitor the progress of healing.Of the 12 patients, 8 patients (66.7%) had complete closure of the fistula, and 2 patients (16.7%) showed reduction in size of the fistula to the extent that symptoms were eliminated, for an overall success rate of 83.3% (10/12 patients). Premature graft loss and recurrence of the fistula were noted in 2 patients (16.7%).Alloderm provided an adequate barrier allowing healing to occur unimpeded and allowed closure of the palatal fistula. In our experience, this new technique using regenerative tissue matrix as an adjunct to the oral layer in large anterior palatal fistula has an advantage compared to other more invasive complex procedures and has been shown to provide satisfactory results.

    View details for PubMedID 27162747

  • Facial Twist (Asymmetry) in Isolated Unilateral Coronal Synostosis: Does Premature Facial Suture Fusion Play a Role? JOURNAL OF CRANIOFACIAL SURGERY Miri, S., Mittermiller, P., Buchanan, E. P., Khosla, R. K. 2015; 26 (3): 655-657

    Abstract

    Unilateral coronal synostosis (UCS) often causes notable facial twist in affected patients. This condition occurs when the midface deviates toward the synostotic side, and the lower face deviates away from the synostotic side. The exact underlying mechanism for this phenomenon remains unclear. It has been proposed that premature fusion of facial sutures may play a role in the formation of facial twist. The purpose of this study was to determine whether asymmetrical facial suture fusion is present in patients with UCS.A single-center retrospective study was designed. Our study group consisted of 23 patients with a confirmed diagnosis of isolated UCS. Our control group consisted of 17 age-matched patients with deformational plagiocephaly and 11 normocephalic control subjects. The computed tomography scans of the faces were examined for the presence of facial suture fusions on both synostotic and nonsynostotic sides. All results with P < 0.05 were considered statistically significant.We found an increased incidence of fusion of the frontomaxillary, nasofrontal, and nasomaxillary sutures on the side of synostosis in UCS when compared with the nonsynostotic side and when compared with patients with deformational plagiocephaly or normocephalic patients.Asymmetrical premature fusion of facial sutures can potentially be contributing to the facial twist that is seen in patients with UCS.

    View details for DOI 10.1097/SCS.0000000000001436

    View details for PubMedID 25974768

  • Chondromyxoid Fibroma of the Mandible in an Adolescent: Case Report and Microsurgical Reconstructive Option CLEFT PALATE-CRANIOFACIAL JOURNAL Khosla, R. K., Nguyen, C., Messner, A. H., Lorenz, P. 2015; 52 (2): 223-228

    Abstract

    Chondromyxoid fibroma is a rare bony tumor that usually presents in the lower extremities of middle-aged adults. Involvement of the craniofacial skeleton is extremely rare. We present the unique case of an adolescent boy with a chondromyxoid fibroma of the mandible. The chondromyxoid fibroma in this patient recurred after initial treatment with curettage. We treated the recurrence with resection of the involved mandible and immediate reconstruction using a vascularized musculo-osseus seventh rib flap ("Eve procedure"). Despite complex reconstruction in adolescents due to skeletal immaturity, the rib flap has successfully grown with the patient up to 3 years postoperatively. Therefore, we believe the musculo-osseus rib flap is a feasible solution for complex ramus and condyle reconstruction of the growing mandible in the adolescent patient.

    View details for DOI 10.1597/13-243

    View details for Web of Science ID 000352143500015

    View details for PubMedID 24625223

  • Cleft palate surgery: an evaluation of length of stay, complications, and costs by hospital type. Cleft palate-craniofacial journal Nguyen, C., Hernandez-Boussard, T., Davies, S. M., Bhattacharya, J., Khosla, R. K., Curtin, C. M. 2014; 51 (4): 412-419

    Abstract

    Objective : The purpose of this study was to assess length of stay (LOS), complication rates, costs, and charges of cleft palate repair by various hospital types. We hypothesized that pediatric hospitals would have shorter LOS, fewer complications, and lower costs and charges. Methods : Patients were identified by ICD-9-CM code for cleft palate repair (27.62) using databases from the Agency for Health Research and Quality Healthcare Cost and Utilization Project Kids' Inpatient Database from 1997, 2000, 2003, and 2006. Patient characteristics (age, race, gender, insurer, comorbidities) and facility resources (hospital beds, cleft palate surgery volume, nurse-to-bed ratio, pediatric intensive care unit [PICU], PICU intensivist, burn unit) were examined. Hospitals types included pediatric hospitals, general hospitals, and nonaccredited children's hospital. For each hospital type, mean LOS, extended LOS (LOS > 2), and complications were assessed. Results : A total of 14,153 patients had cleft repair with a mean LOS of 2 days (SD, 0.04), mortality 0.01%, transfusion 0.3%, and complication <3%. Pediatric hospitals had fewer patients with extended hospital stays. Patients with an LOS >2 days were associated with fourfold higher complications. Comorbidities increased the relative rate of LOS >2 days by 90%. Pediatric hospitals had the highest comorbidities, yet 35% decreased the relative rate of LOS >2 days. Median total charges of $10,835 increased to $15,104 with LOS >2 days; median total costs of $4367 increased to $6148 with a LOS >2 days. Conclusion : Pediatric hospitals had higher comorbidities yet shorter LOS. Pediatric resources significantly decreased the relative rate of LOS >2 days. Median costs and charges increased by 41% with LOS >2 days. Further research is needed to understand additional aspects of pediatric hospitals associated with lower LOS.

    View details for DOI 10.1597/12-150

    View details for PubMedID 24063682

  • Current Concepts for Eyelid Reanimation in Facial Palsy ANNALS OF PLASTIC SURGERY Momeni, A., Khosla, R. K. 2014; 72 (2): 242-245

    Abstract

    ABSTRACT: The treatment of facial palsy is a complex and challenging area of plastic surgery. Two distinct anatomical regions and functions are the focus of interest when managing facial palsy: (1) reanimation of the eyelids and (2) reconstruction of the smile. This review will focus on the treatment of ocular manifestations of facial palsy. The principles of eyelid rehabilitation will be presented along with a discussion of surgical and nonsurgical treatment options.

    View details for DOI 10.1097/SAP.0b013e318264fcba

    View details for Web of Science ID 000338013700025

  • A National Study on Craniosynostosis Surgical Repair CLEFT PALATE-CRANIOFACIAL JOURNAL Christine Nguyen, C., Hernandez-Boussard, T., Khosla, R. K., Curtin, C. M. 2013; 50 (5): 555-560

    Abstract

    Objective :  Our study aimed to use national data to assess the perioperative outcomes of craniosynostosis surgical repair. Design :  Data were obtained from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project Kids Inpatient Database from 1997, 2000, 2003, and 2006. Setting :  Community hospitals in the United States. Patients :  The cohort was identified using the ICD-9-CM procedure codes for craniosynostosis surgical repair (2.01, 2.03, 2.04, 2.06). Main Outcome Measures(s) :  We determined patient and hospital characteristics. We clustered patients by age group (<7 months, 7 to 12 months, 1 to 3 years) and assessed mortality, comorbidities, mean length of stay (LOS), and total charge. We performed logistic regression with our dependent variable being longer average hospital stay: LOS >4.2 days. Results :  We found 3426 patients. Average age at the time of surgery was 181 days (SD 84). Average length of stay was 4.2 days. The majority of the patients were boys (66%), white (71%), and insured (93%). Nearly all patients underwent surgery in a teaching hospital (98%) in urban centers (99%). Approximately 10% of patients experienced an acute complication, most commonly hemorrhages or hematomas and airway or respiratory failure. Patients ages 1 to 3 years had the highest rates of comorbidities and a longer LOS. Mortality rate was <1%. Conclusions :  Craniosynostosis surgery is safe with low rates of mortality and acute complications. LOS >4.2 appears to be associated more with comorbidities than with complications. Higher rates of comorbidities and LOS >4.2 days for patients age 1 to 3 years warrant addition research to assess potential barriers to care.

    View details for DOI 10.1597/11-324

    View details for Web of Science ID 000327536100011

  • Emergency surgical treatment of an ulcerative and hemorrhagic congenital/infantile fibrosarcoma of the lower leg: case report and literature review JOURNAL OF PEDIATRIC ORTHOPAEDICS-PART B Kraneburg, U. M., Rinsky, L. A., Chisholm, K. M., Khosla, R. K. 2013; 22 (3): 228-232

    Abstract

    Fibrosarcomas are rare malignant soft-tissue tumors occurring mostly in infants younger than 1 year of age. Fibrosarcomas can ulcerate and cause various complications, which could threaten a fetus in utero or a child in the early neonatal period. We report a unique case of congenital infantile fibrosarcoma of the lower leg, its treatment and pathology. The large expansive and destructive lesion was not appreciated on routine prenatal ultrasound exams at 20 and 33 weeks gestation. The newborn required immediate emergency surgical intervention after delivery to prevent death by hemorrhagic shock. Initial debulking of the tumor was performed and hemostasis was attained on the day of birth. The child was resuscitated and definitive treatment of the leg was deferred until a pathologic diagnosis was obtained. Given the extent of the fibrosarcoma, the lower leg was not salvageable and the patient received a through-the-knee amputation in the neonatal period. The patient is free of disease at 2 years of age.

    View details for DOI 10.1097/BPB.0b013e3283536908

    View details for Web of Science ID 000316801200010

    View details for PubMedID 22568962

  • Microsurgical reconstruction of the smilecontemporary trends MICROSURGERY Momeni, A., Chang, J., Khosla, R. K. 2013; 33 (1): 69-76

    Abstract

    The treatment of facial palsy is a complex and challenging area of plastic surgery. Microsurgical innovation has introduced the modern age of dynamic reconstruction for facial palsy. This review will focus on microsurgical reconstruction for smile restoration in patients with long-standing facial palsy. The most common donor muscles and nerves will be presented. The advantages and disadvantages of single-stage versus multi-stage reconstruction will be discussed. Contemporary trends will be highlighted and the authors' preferred practice outlined.

    View details for DOI 10.1002/micr.22042

    View details for PubMedID 22976539

  • Contemporary concepts for the bilateral cleft lip and nasal repair. Seminars in plastic surgery Khosla, R. K., McGregor, J., Kelley, P. K., Gruss, J. S. 2012; 26 (4): 156-163

    Abstract

    The bilateral cleft lip and nasal deformity presents a complex challenge for repair. Surgical techniques continue to evolve and are focused on primary anatomic realignment of the tissues. This can be accomplished in a single-stage or two-stage repair early in infancy to provide a foundation for future growth of the lip and nasal tissue. Most cleft surgeons currently perform a single-stage repair for simplifying patient care. Certain institutions utilize presurgical orthopedics for alignment of the maxillary segments and nasal shaping. Methods for the bilateral cleft lip repair are combined with various open and closed rhinoplasty techniques to achieve improved correction of the primary nasal deformity. There is recent focus on shaping the nose for columellar and tip support, as well as alar contour and alar base position. The authors will present a new technique for closure of the nasal floor to prevent the alveolar cleft fistula. Although the alveolar fistula is closed, alveolar bone grafting is still required at the usual time in dental development to fuse the maxilla. It is paramount to try and minimize the stigmata of secondary deformities that historically have been characteristic of the repaired bilateral cleft lip. A properly planned and executed repair reduces the number of revisions and can spare a child from living with secondary deformities.

    View details for DOI 10.1055/s-0033-1333885

    View details for PubMedID 24179448

  • Nonsyndromic craniosynostosis. Seminars in plastic surgery Garza, R. M., Khosla, R. K. 2012; 26 (2): 53-63

    Abstract

    Nonsyndromic craniosynostosis is more commonly encountered than syndromic cases in pediatric craniofacial surgery. Affected children display characteristic phenotypes according to the suture or sutures involved. Restricted normal growth of the skull can lead to increased intracranial pressure and changes in brain morphology, which in turn may contribute to neurocognitive deficiency. Management has primarily focused on surgical correction of fused sutures prior to 12 months of age to optimize correction of the deformity and to ameliorate the effects of increased intracranial pressure. However, emphasis has recently shifted to better understanding the pathogenesis of neurocognitive impairment observed in these children, along with genetic mutations that contribute to premature suture fusion. Such understanding will provide opportunities for earlier and more specific neurocognitive interventions and for the development of targeted genetic therapy to prevent pathologic suture fusion. The authors review the common types of nonsyndromic craniosynostosis and the epidemiological, genetic, and neurodevelopmental details that are currently known from the literature. In addition, they present the rationale for surgical correction, offer suggestions for timing of intervention, and present some nuances of techniques that they find important in producing consistent results.

    View details for DOI 10.1055/s-0032-1320063

    View details for PubMedID 23633932

  • Combination Jessner's Solution and Trichloroacetic Acid Chemical Peel: Technique and Outcomes PLASTIC AND RECONSTRUCTIVE SURGERY Herbig, K., Trussler, A. P., Khosla, R. K., Rohrich, R. J. 2009; 124 (3): 955-964

    Abstract

    Trichloroacetic acid is a commonly utilized agent for chemical resurfacing of the face. Jessner's solution in combination with trichloroacetic acid has been previously described for the treatment of facial rhytids in the dermatology literature. The purpose of this study was to describe the application technique and examine the clinical results of Jessner's solution in combination with trichloroacetic acid in a diverse plastic surgery patient population.A retrospective chart evaluation of 105 patients undergoing combination Jessner's and 35% trichloroacetic acid facial peel procedures by the senior author was performed. Patient demographics, anatomic location of peel, concomitant surgical procedures, and postoperative complications were noted. Technique and endpoints are described.Between January of 2000 and April of 2007, 115 chemical peels were performed by the senior author. All patients were female, ranging in age from 32 to 83 years (mean, 54 years). Of the 115 chemical peels performed, 104 were done with concomitant procedures. Eleven peels were performed alone. The most significant complications related to the combination peel were fungal infections (7.8 percent overall rate). In addition, the senior author performed 27 face/neck lifts with superficial musculoaponeurotic system (SMAS)-ectomy or SMAS plication along with full face combination peel, with minimal postoperative complications and no evidence of hypertrophic scarring.The combination of Jessner's solution and 35% trichloroacetic acid is an effective, safe resurfacing tool that can treat superficial to moderate rhytids. Despite the apparent simplicity of the procedure, there is a significant learning curve to understand the intricacies of chemical penetration in the skin. Consistency in results is achieved with experience and proper preoperative patient evaluation and selection.

    View details for DOI 10.1097/PRS.0b013e3181addcf5

    View details for Web of Science ID 000269485200033

    View details for PubMedID 19730318

  • Bilateral cleft lip and nasal repair PLASTIC AND RECONSTRUCTIVE SURGERY Byrd, H. S., Ha, R. Y., Khosla, R. K., Gosman, A. A. 2008; 122 (4): 1181-1190

    Abstract

    The bilateral cleft lip and nasal repair has remained a challenging endeavor. Techniques have evolved to address concerns over unsatisfactory features and stigmata of the surgery. The authors present an approach to this complex clinical problem that modifies traditional repairs described by Millard and Manchester. The senior author (H.S.B.) has developed this technique with over 25 years of surgical experience dealing with the bilateral cleft lip. This staged lip and nasal repair provides excellent nasal projection, lip function, and aesthetic outcomes. Lip repair is performed at 3 months of age. Columellar lengthening is performed at approximately 18 months of age. A key component of this repair focuses on reconstruction of the central tubercle. A triangular prolabial dry vermilion flap is augmented by lateral lip vermilion flaps that include the profundus muscle of the orbicularis oris. This minimizes lateral lip segment sacrifice and provides improved central vermilion fullness, which is often deficient in traditional repairs. The authors present the surgical technique and examples of their clinical results.

    View details for DOI 10.1097/PRS.0b013e3181858f33

    View details for Web of Science ID 000259811700025

    View details for PubMedID 18827654