Thoracic Duct Lymphovenous Bypass: A Preliminary Case Series, Surgical Techniques, and Expected Physiologic Outcomes.

In patients with recalcitrant mechanical thoracic duct obstruction, microsurgical lymphovenous bypass is an emerging therapeutic option. We herein discuss the preoperative workup, share our current operative technique, and evaluate preliminary outcomes with an emphasis on changes in physiology. Methods: A retrospective review of adult patients who underwent thoracic duct lymphovenous bypass by a single surgeon and interventional radiologist from 2019 to 2022 was performed. Demographics, comorbidities, perioperative data, and postoperative outcomes were collected. Results: Nine patients were included in the study. Immediate postoperative heart rate increased significantly among this heterogeneous patient population, but within 4-6 hours the change in heart rate was no longer significant. Mean arterial pressure and oxygen requirement were not significantly different before and after bypass. Conclusions: Thoracic duct lymphovenous bypass seem to be well tolerated in the short-term even in patients with cardiopulmonary comorbidities. Further data are necessary to continue to better understand the resulting physiologic changes and to optimize patient outcomes.

The financial impact of COVID-19 on a surgical department: The effects of surgical shutdowns and the impact on a health system.

BACKGROUND: The COVID-19 pandemic resulted in sweeping shutdowns of surgical operations to increase hospital capacity and conserve resources. Our institution, following national and state guidelines, suspended nonessential surgeries from March 16 to May 4, 2020. This study examines the financial impact of this decision on our institution's health system by comparing 2 waves of COVID-19 cases. METHODS: The total revenue was obtained for surgical cases occurring during the first wave of the pandemic between March 1, 2020 and July 31, 2020 and the second wave between October 1, 2020 and February 29, 2021 for all surgical departments. During the same time intervals, in the prepandemic year 2019, total revenue was also obtained for comparison. Net revenue and work relative value units per month were compared to each respective month for all surgical divisions within the department of surgery. RESULTS: Comparing the 5-month first wave period in 2020 to prepandemic 2019 for all surgical departments, there was a net revenue loss of $99,674,376, which reflected 42% of the health system's revenue loss during this period. The department of surgery contributed to a net revenue loss of $58,368,951, which was 24.9% of the health system's revenue loss. Within the department of surgery, there was a significant difference between the net revenue loss per month per division of the first and second wave: first wave median -$636,952 [interquartile range: -1,432,627; 26,111] and second wave median -$274,626 [-781,124; 396,570] (P = .04). A similar difference was detected when comparing percent change in work relative value units between the 2 waves (wave 1: median -13.2% [interquartile range: -41.3%, -1.8%], wave 2: median -7.8% [interquartile range: -13.0%, 1.8%], P = .003). CONCLUSION: Stopping elective surgeries significantly decreased revenue for a health system. Losses for the health system totaled $234,839,990 during the first wave, with lost surgical revenue comprising 42% of that amount. With elective surgeries continuing during the second wave of COVID-19 cases, the health system losses were substantially lower. The contribution surgery has to a hospital's cash flow is essential in maintaining financial solvency. It is important for hospital systems to develop innovative and alternative solutions to increase capacity, offer comprehensive care to medical and surgical patients, and prevent shutdowns of surgical activity through a pandemic to maintain financial security.

Posterior Vault Distraction Osteogenesis: Rates of Ossification in Bone Gaps After Consolidation.

ABSTRACT: The authors observe significant bone gaps upon distractor removal in posterior vault distraction osteogenesis (PVDO). The purpose of this study was to quantify bone gaps upon distractor removal, determine whether they close over time, determine if they predispose to relapse, and investigate whether age affects rate and degree of re-ossification. The authors performed a retrospective review of PVDO patients and included those with computed tomography (CT) scans at 2 timepoints: 1 at completion of consolidation and another at least 4 months later. Using Mimics software, bone gaps were traced to calculate total surface area. A paired t test and linear regression were used to compare size of bone gaps, presence of relapse, and rates of re-ossification. Sixty-nine patients were identified, with 7 meeting inclusion criteria. Three were under 1 year. Consolidation began 28.3 ± 6.0 days after surgery and continued for 64.9 ± 14.5 days. Length of time between CT scans was 7.5 ± 2.7 months. A significant decrease in bone gaps occurred between scans (33.4 ± 14.6 cm2 versus 19.2 ± 17.2 cm2, P = 0.005). After consolidation, ossification occurred at a rate of 2.4 cm2/month (P = 0.046). The rate of bony regeneration in patients under and over 1 year was 4.3 cm3/month (P = 0.025) and 1.5 cm3/month (P = 0.552), respectively. Despite differential bony regeneration rates, no patient demonstrated relapse. From this study, the authors conclude the following. Calvarial bone gaps are present after PVDO consolidation. These gaps undergo re-ossification at a rate that appears to be faster in infants. Overall, they decrease in size over time. The presence of bone gaps does not correlate with relapse of cranial expansion.

Forces Exerted in Craniofacial Distraction Osteogenesis.

BACKGROUND: The purpose of this study was to develop a methodology for quantifying linear forces of distraction osteogenesis, and thereafter apply this methodology to measure and compare distraction force magnitudes between cranial vault distraction osteogenesis (CVDO) and mandibular distraction osteogenesis (MDO). METHODS: Patients undergoing CVDO or MDO as inpatients had distraction forces acquired with a digital torque-measuring screwdriver. Torque measurements were then converted into linear distraction force values, which were then compared across distraction types and protocols with appropriate statistics. RESULTS: CVDO was performed on 7 patients (41.2%), and MDO was performed on 10 patients (58.8%). Across the entire cohort, the average maximum force per activation was 27.0 N, and the average elastic force was 10.7 N. Maximum force (CVDO: 52.9 N versus MDO: 12.9 N; P < 0.001) and elastic force (CVDO: 22.0 N versus MDO: 4.5 N; P < 0.001) were significantly higher in patients undergoing CVDO than MDO. Multivariate regression demonstrated that maximum activation force was significantly associated with sequential days of distraction (B= + 1.1 N/day; P < 0.001), distraction rate (B= + 8.9 N/mm/day; P = 0.016), distractor hardware failure (B= + 10.3 N if failure; P = 0.004), and distraction type (B= + 41.4 N if CVDO; P < 0.001). CONCLUSIONS: Cranial vault distraction requires significantly more linear distraction force than mandibular distraction. Maximum forces increase with each day of distraction, as well as with increased distraction rates. Linear distraction force methodology from this study may provide the foundation for future development of optimized procedure-specific or patient-specific distraction protocols.

Ear Molding Therapy: Laypersons' Perceptions, Preferences, and Satisfaction with Treatment Outcome.

This study investigates laypersons' perceptions of congenital ear deformities and preferences for treatment, particularly with ear molding therapy-an effective, noninvasive, yet time-sensitive treatment. METHODS: Laypersons were recruited via crowdsourcing to view photographs of normal ears or one of the following ear deformities, pre- and post-molding: constricted, cryptotia, cupped/lopped, helical rim deformity, prominent, and Stahl. Participants answered questions regarding perceptions and treatment preferences for the ear. Statistical analyses included multiple linear and logistic regressions and Wilcoxon signed-rank tests. RESULTS: A total of 983 individuals participated in the study. All deformities were perceived as significantly abnormal, likely to impair hearing, and associated with lower psychosocial quality of life (all P < 0.001). For all deformities, participants were likely to choose ear molding over surgery despite the logistical and financial implications of ear molding (all P < 0.02). Participants were significantly more satisfied with the outcome of ear molding in all deformities compared with control, except constricted ears (all P < 0.002, except Pconstricted = 0.073). Concern for hearing impairment due to ear deformity was associated with increased likelihoods of seeing a physician (P < 0.001) and choosing ear molding despite treatment logistics and costs (all P < 0.001). CONCLUSIONS: Laypersons perceived all ear deformities as abnormal and associated with low psychosocial quality of life. Despite logistical and financial implications, laypersons generally desired molding therapy for ear deformities; treatment outcomes were satisfactory for all deformities except constricted ears. Timely diagnosis of this condition is crucial to reaping the benefits of ear molding therapy.

Craniometric and Volumetric Analyses of Cranial Base and Cranial Vault Differences in Patients With Nonsyndromic Single-Suture Sagittal Craniosynostosis.

PURPOSE: How different from "normal" are the cranial base and vault of infants with nonsyndromic, single-suture sagittal synostosis (NSSS)? This study quantitatively addresses this question utilizing computed tomography (CT) analytic technology. METHOD: Head CT scans of infants with NSSS and normocephalic controls were analyzed using Mimics to calculate craniometric angles, distances, and segmented volumes. Craniometric measurements and asymmetry indices were compared between NSSS and control groups using linear regressions controlling for age. Ratios of anterior-, middle-, and posterior-to-total cranial vault volume were compared between groups using beta regressions controlling for age. RESULTS: Seventeen patients with NSSS and 19 controls were identified. Cranial index and interoccipital angle were significantly smaller in NSSS compared with controls (P = 0.003 and <0.001, respectively). Right-but not left-external acoustic meatus angle and internal acoustic meatus-to-midline distance were significantly greater in NSSS than in controls (P = 0.021 and 0.016, respectively). NSSS patients and controls did not significantly differ in any asymmetry indices, except for the articular fossa angle asymmetry index (P = 0.016). Anterior vault volume proportion was greater in NSSS relative to controls (proportion ratio = 1.63, P < 0.001). NSSS trended toward a smaller posterior vault volume proportion (P = 0.068) yet did not differ in middle vault volume proportion compared with controls. CONCLUSION: In this small study, patients with nonsyndromic, single-suture sagittal craniosynostosis had relatively similar cranial base measurements, and larger anterior vault volumes, when compared with controls. Further work is needed to confirm the possibility of rightward asymmetry of the anterior cranial base.

Public Perception of Helical Rim Deformities and Their Correction With Ear Molding.

BACKGROUND: Among congenital ear deformities, helical rim deformities are most common. Non-surgical ear molding has emerged as an effective option to treat helical rim deformities and could reduce the need for surgery later in a child's life. Despite this, there has never been a study examining how the general public rates corrections after ear molding. METHODS: A retrospective chart review was conducted of all consecutive patients with helical rim deformities treated with InfantEar TM Molding System. Amazon Mechanical Turk (MTurk) was used to survey blinded respondents using photographs of patients' ears to determine the degree of normalcy on a scale of 1 (not normal) to 10 (completely normal) before and after molding. Ratings of ears were compared using a paired t test and percent improvement from baseline. RESULTS: A total of 59 ears met criteria for evaluation by 497 MTurk respondents. Average age of patients at the time of treatment was 34.2 ±â€Š16.8 days and mean therapy duration was 31.3 ±â€Š13.1 days. A paired t test analysis found that MTurk respondents identified significant improvement in 91.5% of ears (n = 54) (P < 0.05). The percent improvement in observed helical rim change was on average 82.7 ±â€Š61.1%. CONCLUSION: Ear molding is an effective and safe way to address helical rim deformities early in the neonatal period. The general public is able to recognize ears with rim deformities as abnormal, and appreciate the difference in architecture after molding. Crowdsourcing technology offers an opportunity to measure laypeople's perceptions regarding outcomes after ear molding.

An Update on Social Media in Academic Plastic Surgery Training Programs: The Rising Trend of Likes, Shares, and Retweets.

BACKGROUND: Increasing in popularity, social media provides powerful marketing and networking tools for private practice plastic surgeons. The authors sought to examine social media utilization by academic plastic surgery training programs. METHODS: Facebook, Instagram, and Twitter were queried for plastic surgery training program, program director, and chief/chair accounts. Training program posts were categorized as educational, operative, social, informational, self-promotional, visiting lecturer, research-related, and other. Factors influencing total number of followers were analyzed including number of accounts followed, frequency, total number, and types of posts as well as duration of account. Other variables included geographic location, 2018 to 2019 Doximity residency ranking, and US News and World Report rankings of affiliated hospital systems and medical schools. Social media accounts were analyzed using Kruskal-Wallis, Wilcoxon rank sum, and regression analysis. RESULTS: Facebook is the most popular social media platform among chiefs/chairs (34, 35.7%), followed by Instagram (20, 21.1%) and Twitter (19, 20.0%). Facebook is used more by program directors (31, 32.6%) followed by Instagram (22, 23.1%) and Twitter (15, 15.7%). The majority of Facebook and Twitter leadership accounts are for personal use (62%-67%), whereas Twitter is used primarily for professional purposes (60%-84%). Training program social media use is rising, with Instagram and Twitter presence growing at exponential rates (R = 0.97 and 0.97, respectively). Of 95 training programs evaluated, 54 (56.8%) have Instagram accounts, 29 (30.5%) have Facebook accounts, and 27 (28.4%) have Twitter accounts. Most training programs using social media have 2 or more accounts (37, 67.3%). West coast programs have more Instagram followers than other geographic regions, significantly more than Southern programs (P = 0.05). Program accounts with more followers are affiliated with top-ranked hospitals (P = 0.0042) or top-ranked Doximity training programs (P = 0.02). CONCLUSIONS: Similar to its adoption by private practice plastic surgery, social media use in academic plastic surgery is growing exponentially. Now, over half of residency programs have Instagram accounts. Program leaders are using Facebook and Instagram primarily for personal use and Twitter for professional use. Programs affiliated with a top-ranked hospital or ranked highly by Doximity have more followers on social media.

Comparison of Lengthening Temporalis Myoplasty and Free-Gracilis Muscle Transfer for Facial Reanimation in Children.

BACKGROUND: Lengthening temporalis myoplasty (LTM) and cross-face nerve graft with free gracilis muscle transfer (CFNG-FGMT) are the 2 most common procedures used to restore dynamic facial animation and improve facial symmetry. There has not been direct comparison or consensus. Here, the authors compare our experience with respect to muscle activity, symmetry, and excursion. METHODS: A retrospective review was performed of patients with facial palsy who had CFNG-FGMT or LTM from 2008 to 2016 at a single institution. Postoperative surface EMG was recorded at maximum open smile. Normal and paralyzed sides of the face were analyzed with Facial Assessment by Computer Evaluation software. Commissure excursion and symmetry was assessed. RESULTS: Six patients with LTM and 10 with CFNG-FGMT met inclusion criteria. Muscle activity was 1st identified in LTM patients after 3 months (47.42 mV, P < 0.001) and CFNG-FGMT patients after 3 months (28.30 mV, P < 0.001) compared to immediate postoperative period. Relative to preoperative excursion, there was significant increase of 3.33 mm in commissure excursion seen at the 0 to 3 month period for LTM patients (P = 0.04). Commisure excursion for CFNG-FGMT was seen later, in the 3- to 6-month postoperative period (4.01, P = 0.024). During smile, CFNG-FGMT patients had better symmetry than unilateral LTM patients. In bilateral LTM patients, there was no significant change in symmetry. CONCLUSION: Dynamic facial animation improved in both surgical groups. The LTM demonstrates a faster rate of muscle recruitment compared to CFNG-FGMT. After 3 months, both LTM and CFNG-FGMT groups had comparable excursions. A decision-making algorithm is presented.

A Craniometric Analysis of the Posterior Cranial Base After Posterior Vault Distraction.

BACKGROUND: Posterior vault distraction osteogenesis (PVDO) has been demonstrated to effectively increase intracranial volume, treat increased intracranial pressure, and improve head shape in syndromic patients. The purpose of this study is to compare changes along the posterior cranial base before and after distraction. METHODS: A retrospective review was completed of subjects who underwent PVDO with computed tomography scans at 2 time-points: within 3 months preoperatively and 1 to 6 months postoperatively. Using Mimics software, craniometric landmarks were identified and surface area of the foramen magnum was calculated. A comparison of pre- to postoperative measurements was completed using Wilcoxon matched-paired signed rank tests and linear regression. RESULTS: A total of 65 PVDO subjects were identified, 12 subjects met inclusion criteria. Mean operative age was 3.0 ±â€Š4.0 years. The cranial vault was distracted on average 25.0 ±â€Š6.0 mm, with those < 12 months of age distracted 29.5 ±â€Š4.9 mm and >12 months of age distracted 22.0 ±â€Š4.9 mm (P = 0.0543). There was a significant increase in pre- to postoperative foramen magnum surface area (52.1 ±â€Š63.2 mm, P = 0.002), length (0.9 ±â€Š1.4 mm, P = 0.050), and width (0.6 ±â€Š1.0 mm, P = 0.050). Similarly, linear distances between nasion and posterior cranial base landmarks such as foramen magnum (3.4 ±â€Š4.2 mm, P = 0.010), and occipital protuberance (9.1 ±â€Š9.6 mm, P = 0.003) were increased. Subjects under 12 months had a greater percentage increases in posterior vault length than those over 12 months. CONCLUSION: Posterior vault distraction osteogenesis is associated with an increase in size of the foramen magnum, and lengthening of the posterior cranial base, both of which may be beneficial in patients with turribrachycephaly.

Influence of Repaired Cleft Lip and Palate on Layperson Perception following Orthognathic Surgery.

BACKGROUND: Facial scarring and disharmony caused by clefting are associated with psychosocial stress, which may be improved by orthognathic surgery. The authors examine how clefting influences change in layperson perception of a patient following orthognathic surgery. METHODS: One thousand laypersons were recruited through Mechanical Turk to evaluate patient photographs before and after orthognathic surgery. Nineteen patients-five with unilateral and five with bilateral clefting-were included. Respondents assessed six personality traits, six emotional expressions, and likelihood of seven interpersonal experiences on a scale from 1 to 7. RESULTS: Changes in all aspects of social perception after the procedure differed significantly between cleft versus noncleft cohorts (p < 0.01 for all). Respondents evaluated the change for the cleft cohort compared with the noncleft cohort as more trustworthy, friendly, sad, and afraid; more likely to feel lonely, be teased or bullied by others, or feel anxious around others; less angry, disgusted, threatening, dominant, intelligent, happy, and attractive; and less likely to have romantic relationships, friends, or be praised by others. For unilateral versus bilateral cleft cohorts, change in social perception was significantly different in four of the 19 items (p < 0.05 for all). Social perception change for the unilateral cohort was less surprised, sad, dominant, or happy compared with the bilateral cohort (p < 0.05 for all). CONCLUSIONS: Despite significant improvements in social perception following orthognathic surgery, cleft patients benefit less than noncleft patients. These findings may be useful to counsel postsurgical expectations for cleft patients undergoing orthognathic surgery.

Incidence of Cranial Base Suture Fusion in Infants with Craniosynostosis.

BACKGROUND: Cranial base sutures are important drivers of both facial and cranial growth. The purpose of this study was to compare the incidence and location of cranial base suture fusion among three groups: nonaffected controls, patients with nonsyndromic craniosynostosis, and patients with syndromic craniosynostosis. METHODS: Patients and computed tomographic scans were accrued from the authors' prospective craniofacial database. Computed tomographic scans were graded on the frequency of cranial vault and cranial base suture/synchondrosis fusion (0, open; 1, partially/completely fused) by an attending craniofacial surgeon and neuroradiologist. Statistical comparisons were conducted on location and rates of fusion, age, and diagnosis. RESULTS: One hundred forty patients met inclusion criteria: 55 syndromic, 64 nonsyndromic, and 21 controls. Average age at computed tomography of syndromic patients (3.6 ± 3.1 months) was younger than that of nonsyndromic patients (5.4 ± 3.1 months; p = 0.001) and control subjects (5.1 ± 3.2 months; p = 0.058). Syndromic craniosynostotic patients had over three times as many cranial base minor sutures fused (2.2 ± 2.5) as nonsyndromic craniosynostosis patients (0.7 ± 1.2; p < 0.001) and controls (0.4 ± 0.8; p = 0.002), whose rates of fusion were statistically equivalent (p = 0.342). Syndromic craniosynostosis patients had a greater frequency of cranial base suture fusion in the coronal branches, squamosal arch, and posterior intraoccipital synchondrosis (p < 0.05). CONCLUSIONS: Patients with syndromic craniosynostosis have higher rates of cranial base suture fusion in infancy, especially in the coronal arches, and this may have significant implications for both cranial and facial growth. In contrast, patients with nonsyndromic craniosynostosis have similar rates and sites of cranial base suture fusion as controls. Interestingly, there is a low, "normal," rate of cranial base suture/synchondrosis closure in infancy, the implications of which are unknown. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Quality of Life in Adults with Nonsyndromic Craniosynostosis.

BACKGROUND: Although studies have analyzed quality of life in children with nonsyndromic craniosynostosis, to date nobody has investigated long-term quality of life in adults with nonsyndromic craniosynostosis. The purpose of this study was to compare quality of life in adult nonsyndromic craniosynostosis patients with a cohort of unaffected controls. METHODS: The authors queried their institution's prospectively maintained craniofacial registry for nonsyndromic craniosynostosis patients aged 18 years and older, and administered the validated World Health Organization Quality of Life Biomedical Research and Education Foundation questionnaire. Responses were compared, using a two-sample t test, to an age-matched U.S. normative database provided by the World Health Organization. RESULTS: One hundred fifty-one adults met inclusion criteria: 52 were successfully contacted and 32 completed the questionnaire. Average age of respondents was 23.0 ± 6.1 years (range, 18.1 to 42.1 years). Nonsyndromic craniosynostosis patients had a superior quality of life compared with comparative norms in all domains: physical health (17.8 ± 2.7 versus 15.5 ± 3.2; p < 0.001), psychological (16.3 ± 2.9 versus 13.8 ± 3.2; p < 0.001), social (16.9 ± 2.6 versus 13.2 ± 3.6; p < 0.001), and environmental (17.2 ± 2.5 versus 11.7 ± 2.7; p < 0.001). Comparison between single-suture subtypes revealed no difference in any quality-of-life domain (p > 0.05). CONCLUSIONS: Adult patients previously treated for nonsyndromic craniosynostosis perceive their quality of life to be high, superior to that of a normative U.S. SAMPLE: Future work will seek to analyze additional patients and better understand the reasons behind these findings.

Craniometric Analysis of Frontal Cranial Morphology Following Posterior Vault Distraction.

BACKGROUND: Posterior vault distraction osteogenesis (PVDO) is believed to improve frontal contour in infants with syndromic craniosynostosis and turribrachycephaly. This study provides an objective craniometric analysis to determine how PVDO affects anterior cranial morphology. METHODS: A retrospective chart review of patients who underwent PVDO was performed. Inclusion criteria included pre- and postoperative computed tomography (CT) scans within 3 months before surgery and another 1 to 6 months after device removal. Volumetric and craniometric data were derived using Mimics software and compared using paired t-test and Wilcoxon rank-sum test. RESULTS: About 65 patients underwent PVDO, and 13 patients met inclusion criteria. Mean age at intervention was 3.4 ±â€Š4.2 years. Total cranial volume increased 249 ±â€Š159 cm in all patients (P = 0.0001) and 380 ±â€Š128 cm in patients younger than 1 year of age (n = 6, P =0 .0008). Supraorbital retrusion decreased from 5.44 ±â€Š3.89 to 4.54 ±â€Š3.91 mm postoperatively (P = 0.0004), decreasing significantly in patients without previous frontal surgery and not in those with previous frontal surgery (P = 0.2115; comparison P = 0.0047). Basofrontal angle decreased by 2.92 ±â€Š2.16 degrees (P = 0.0004) with a greater decrease of 3.33±2.68 degrees in those younger than 12 months (P = 0.0289) and 2.58±1.74 degrees in those older (P = 0.0079). No change was found in anterior cranial height and anterofrontal angle (P > 0.05). CONCLUSION: PVDO improves frontal contour by decreasing supraorbital retrusion and reducing frontal bossing in syndromic craniosynostosis patients with turribrachycephaly. When combined with its demonstrated efficacy for cranial expansion, these frontal changes likely reinforce PVDO's ability to influence the timing of, and to a degree, the need for frontal surgery in this group.

Spring-Mediated Cranioplasty in Sagittal Synostosis: Does Age at Placement Affect Expansion?

PURPOSE: The aim of this study is to evaluate the effect of timing of surgery and spring characteristics on correction of scaphocephalic deformity in patients undergoing spring-mediated cranioplasty (SMC) for sagittal craniosynostosis. METHODS: The authors conducted a review of patients with sagittal craniosynostosis who underwent SMC at a tertiary referral center between July 2011 and March 2017, with a primary outcome measure of head shape, both preoperatively and postoperatively, determined by cephalic index (CI). Patient demographics and operative details including timing of surgery and spring characteristics were collected. Differences in CI preoperation and postoperation were compared using Wilcoxon signed-rank test. Ordinary least-squares linear regression was used to assess the impact of timing, number of springs, maximum single spring force, and total spring force on postoperative change in CI. RESULTS: Thirty-six subjects (12 males and 24 females) were included in the study. Mean age at spring placement was 3.9 months (range: 1.9-9.2) with a mean follow-up of 1.4 years (range: 0.3-5.2). The mean number of springs used was 3 (range: 2-4). The mean maximum single spring force was 9.9 Newtons (N) (range: 6.9-13.0) and the mean total spring force was 24.6 N (range: 12.7-37.0). Mean CI increased from 70 ±â€Š0.9 preoperatively to 77 ±â€Š1.0 postoperatively (P < 0.001). Age at spring placement was significantly associated with change in CI: for every month increase in age, the change in CI decreased by 1.3 (P = 0.03). The number of springs used, greatest single spring force, and total spring force did not correlate with changes in CI (P = 0.85, P = 0.42, and P = 0.84, respectively). CONCLUSION: In SMC, earlier age at time of surgery appears to correlate with greater improvement in CI, at least in the short-term. While spring characteristics did not appear to affect head shape, it is possible that the authors were underpowered to detect a difference, and spring-related variables likely deserve additional study.

More Than Meets the Eye: The Effect of Intercanthal Distance on Perception of Beauty and Personality.

In judging normalcy, surgeons rely on established facial anthropometric measures and proportions. However, there exists a range of "normal," and a degree of disproportion may be considered more attractive. The authors set out to determine how changes in only intercanthal distance affect the layperson's perception of beauty and personality traits of a face. The authors used Amazon.com's Mechanical Turk (MTurk), a crowdsourcing tool, to determine how changes in intercanthal distance affect overall perception of beauty and personality. MTurk respondents provided demographic information and were asked to survey 16 female subjects, each digitally edited to be hypoteloric or hyperteloric. Data were collected from 490 MTurk crowd raters. Paired t test analysis found that respondents perceived subjects to be more submissive, friendly, and attractive with increased intercanthal distance (P < 0.05). Women respondents were less likely to perceive change in regards to how unthreatening and how intelligent the subject appeared upon intercanthal widening (P < 0.05). Compared with Caucasian respondents, minorities (Asian- and African-American) were more likely to perceive difference in submissiveness, threat, intelligence, and attractiveness with increased intercanthal distance (P < 0.05). All respondents >46 years of age were less likely to perceive a change in any of the 7 traits upon intercanthal widening, compared with respondents between 18 and 25 years of age (P < 0.05). The layperson perceives significant increases in a female subject's submissivness, friendliness, and attractiveness with an intercanthal distance increase of 10% from normal. Surgeons should be aware of this when correcting hypertelorism, given the potential positive impact of a slightly increased intercanthal distance on perceived beauty and personality.

Orthognathic Surgery Has a Significant Effect on Perceived Personality Traits and Emotional Expressions.

BACKGROUND: The effects of orthognathic surgery go beyond objective cephalometric correction of facial and dental disproportion and malocclusion, respectively. The authors hypothesized that there is tangible improvement following surgery that alters publicly perceived personality traits and emotions. METHODS: The authors used Amazon.com's Mechanical Turk (MTurk), a crowdsourcing tool, to determine how preoperative and postoperative images of orthognathic surgery patients were perceived on six personality traits and six emotional expressions based on posteroanterior and lateral photographs. Blinded respondents provided demographic information and were randomly assigned to one of two sets of 20 photographs (10 subjects before and after surgery). RESULTS: Data on 20 orthognathic surgery patients were collected from 476 individuals. The majority of participants were female (52.6 percent), 18 to 39 years old (67.9 percent), Caucasian (76.6 percent), had some college or technical training or graduated college (72.7 percent), and had an annual income between $20,000 and $99,999 (74.6 percent). A paired t test analysis found that subjects were perceived significantly more favorably after orthognathic surgery in 12 countenance categories: more dominant, trustworthy, friendly, intelligent, attractive, and happy; and also less threatening, angry, surprised, sad, afraid, and disgusted (p < 0.05). Raters with the highest annual income perceived a greater magnitude of dominance after surgery than those earning less (p < 0.001). CONCLUSIONS: There is significant improvement in the countenance of patients after orthognathic surgery, with both perceived personality traits and emotions deemed more favorable. Additional work is needed to better understand the physiologic underpinnings of such findings. Crowdsourcing technology offers a unique opportunity for surgeons to gather data regarding laypeople's perceptions of surgical outcomes in areas such as orthognathic surgery.

A Volumetric and Craniometric Analysis of Cranial Base Differences in Unicoronal Craniosynostosis.

BACKGROUND: The authors hypothesized that patients with unicoronal craniosynostosis (UCS) have deviation of the vault, cranial base, and face resulting in significant differences in skull base morphology and segmental cranial vault volume relative to nonaffected controls. METHODS: Unicoronal craniosynostosis patients were collected from the authors' IRB-approved, prospective, craniofacial registry; controls were from a trauma registry. Mimics software was used to compare those with UCS to controls for a series of standardized craniometric angles and distances. A segmented volumetric analysis of anterior, middle, and posterior cranial fossae was performed, as well. RESULTS: The study included 18 patients with UCS and 19 controls. Nearly all angles measured were statistically different in UCS versus controls. Overall cranial vault volume did not differ between UCS and controls (P = 0.250). Three volumetric ratios comparing the synostosed side to the contralateral were significantly less than controls: anterior (0.44 ±â€Š0.03 versus 0.5 ±â€Š0.01, P < 0.001), middle (0.45 ±â€Š0.02 versus 0.5 ±â€Š0.02, P < 0.001), posterior (0.46 ±â€Š0.02 versus 0.50 ±â€Š0.02, P < 0.001). The ratio of total middle volume to total cranial volume was larger in UCS patients versus controls, but the posterior ratio was smaller: anterior (0.13 ±â€Š0.02 versus 0.12 ±â€Š0.02, P = 0.545), middle (0.50 ±â€Š0.05 versus 0.42 ±â€Š0.04, P = 0.001), posterior (0.37 ±â€Š0.05 versus 0.45 ±â€Š0.03, P = 0.001). CONCLUSIONS: This study provides quantitative evidence of the degree of angulation and torsion of the cranial base in UCS and its profound effect on volumetric differences in the cranial vault, with significant restriction on the synostosed side and compensatory expansion on the nonsynostosed side. Future work will focus on the effects of volumetric differences on cerebral architecture and postoperative volumetric changes.