Comparison of emotional and behavioral regulation between metopic and sagittal synostosis.

PURPOSE: Children with surgically corrected nonsyndromic craniosynostosis have been previously found to have neurocognitive and behavioral difficulties. Children with metopic synostosis have been described to have more difficulties than children with sagittal synostosis. This study aims to characterize the behavioral differences between children with metopic and sagittal synostosis. METHODS: Children with metopic and sagittal synostosis were recruited at school age. Parents completed four separated behavioral assessments: Conners-3 (evaluation of ADHD), Social Responsiveness Scale-2 (SRS-2: evaluation of autism), Behavior Rating Inventory of Executive Function-2 (BRIEF-2: evaluation of executive function), and Child Behavior Checklist (CBCL: evaluation of overall behavioral problems). Children underwent intelligence quotient (IQ) testing using the Wechsler Abbreviated Scale of Intelligence (WASI-II). RESULTS: There were 91 children (45 with metopic and 46 with sagittal synostosis). More children with metopic synostosis reported requiring supportive services (57.7% vs 34.7%, p = 0.02) and more reached or exceeded borderline clinical levels of two executive function subscales of the BRIEF-2 (emotion regulation index: 33.3% vs 17.4%, p = 0.05; global executive composite: 33.3% vs 17.4%, p = 0.05). Children with sagittal synostosis had higher scores on the rule-breaking and externalizing problem subscales of the CBCL. Increasing age at surgery was associated with worse executive function scores. CONCLUSIONS: A relationship between suture subtype and behavioral outcomes exists at school age. More children with metopic synostosis required social services indicating more overall difficulties. Children with metopic synostosis have more specific problems with executive function, while children with sagittal synostosis had more difficulties with externalizing behaviors.

Radiographic severity is associated with worse executive function in metopic craniosynostosis.

BACKGROUND: Children with metopic synostosis have been found to have more neurocognitive and behavioral difficulties. The variables that may affect future neurodevelopmental outcomes, including presenting morphologic severity, have not been fully studied. In the largest study to date, we aimed to assess what portends worse neurocognitive and behavioral outcomes at school age. METHODS: Children 6-18 years old with surgically corrected metopic nonsyndromic craniosynostosis underwent neurocognitive testing. Parents completed behavior rating surveys about their child: Conners-3 (ADHD), Social Responsiveness Scale-2 (autism spectrum disorder), Behavior Rating Inventory of Executive Function-2 (BRIEF-2: executive function), and Child's Behavior Checklist (overall behavior). The endocranial bifrontal angle (EBA), adjusted EBA (aEBA), frontal angle (FA), and AI-derived metopic severity score (MSS) were determined on pre-operative CT images. Multivariate linear regressions were used to evaluate the association of age at surgery and severity. RESULTS: There were 87 children who underwent neurocognitive testing (average age 10.9 ± 3.3 years) of whom 67 also completed behavioral assessments. Greater phenotypical severity of metopic synostosis (lower FA, aEBA, and EBA) was associated with worse scores on the subscales of the BRIEF-2 (executive function) and executive subscale of the Conners-3. Increasing age at surgery was associated with worse executive function subscale scores of the Conners-3 when controlling for each severity measurement and sociodemographic risk. CONCLUSION: Children with greater phenotypic severity of metopic synostosis have worse executive function at school age. The majority of children with metopic synostosis have signs of ADHD. Later surgeries (greater than 12 months) may impact executive functioning, regardless of the degree of severity. Future research should aim at identifying the direct structural changes to the brain.

Safety Profile Comparison of 2 Smooth Tissue Expander Types: Artoura and CPX4.

INTRODUCTION: With the recent transition to smooth tissue expanders (TEs), functional differences between TE subtypes have not been fully elucidated. This study evaluated the differences in TE characteristics and complications between 2 commonly used Mentor smooth TE models, Artoura and CPX4. METHODS: A retrospective review of patients who received either smooth Mentor Artoura or CPX4 TE from 2012 to 2022 was conducted. Demographic data, perioperative information, pain scores, TE variables, cancer characteristics, and complications were collected. A multivariate analysis was used to evaluate the relationship between TE subtype and complications while controlling for demographic, TE characteristics, radiation, and chemotherapy exposure. RESULTS: During the study period, 62 smooth Artoura TEs and 79 smooth CPX4 TEs were used. Patients who received CPX4 smooth implants tended to be older (51.09 vs 46.18 years old, P = 0.02) and have a higher body mass index (28.66 vs 23.50 kg/m 2 , P < 0.001). There were no differences among patient comorbidities. CPX4 required on average a greater total fill volume (422.23 vs 348.07 mL, P = 0.01) and had a greater drain duration (16.91 vs 14.33 days, P = 0.05). There were no differences in TE plane placement between Artoura and CPX4. Additionally, there were no differences in complication rates, including infection, hematomas, seromas, wound breakdown, TE replacement, and capsular contracture. When controlling for body mass index, diabetes, TE plane placement, acellular dermal matrix use, radiation exposure, and chemotherapy, there was no association between TE subtype and any individual complication. DISCUSSION: Differences in total fill volume and drain duration were significantly different between Mentor Artoura and CPX4 implants, which may influence TE subtype selection. However, Artoura and CPX4 have excellent and equivalent safety profiles with similar complication rates, even when controlling for demographic and TE characteristics.

Perceived Age and Gender Perception Using Facial Recognition Software Following Facial Feminization Surgery.

Measures of success for facial feminization surgery (FFS) have previously included improved rates of external gender perception as female and patient-reported outcome measures. In this study, we used artificial intelligence facial recognition software to objectively evaluate the effects of FFS on both perceived gender and age among male-to-female transgender patients, as well as their relationship with patient facial satisfaction. Standardized frontal preoperative and postoperative images of 27 transgender women undergoing FFS were analyzed by Amazon's AI facial recognition software to determine gender, femininity confidence score, and perceived age. Female gender-typing, improvement in gender-typing (preoperatively to postoperatively), and femininity confidence scores were analyzed. To assess patient satisfaction, FACE-Q modules were completed postoperatively. Preoperatively, FFS images were perceived as female 48.1% of the time, and postoperatively, this improved to 74.1% ( P =0.05). Femininity confidence scores improved from a mean score of 0.04 preoperatively to 0.39 postoperatively ( P =0.003). FFS was associated with a decrease in perceived age relative to the patient's true age (-2.4 y, P <0.001), with older patients experiencing greater reductions. Pearson correlation matrix found no significant relationship between improved female gender typing and patient facial satisfaction. Undergoing surgery at a younger age was associated with higher overall facial satisfaction ( r =-0.6, P =0.01). Transfeminine patients experienced improvements in satisfaction with facial appearance, perceived gender, and decreases in perceived age following FFS. Notably, patient satisfaction was not directly associated with improved AI-gender typing, suggesting that other factors may influence patient satisfaction.

Long-Term Control of Nasal Tip Position: Quantitative Assessment of Caudal Septal Extension Graft.

BACKGROUND: Control of nasal tip position is critical to final rhinoplasty outcomes. Two frequent methods of exerting tip control are columellar strut and caudal septal extension graft (SEG). Past work has demonstrated that SEG are better able to preserve tip position. However, there is no quantitative data describing long-term projection and rotation. The purpose of this study was to analyze long-term maintenance of tip projection and rotation following SEG. METHODS: A retrospective study of adult patients undergoing open rhinoplasty was conducted. Three-dimensional photogrammetric evaluation of nasal tip position was performed. Anthropometric points were analyzed preoperatively and postoperatively. Outcome variables were tip projection, tip rotation, and nasal length. RESULTS: Twenty patients were included with an average follow-up time of 3.3 years (2.0 - 6.6 years). From postoperative week 1 to 6, there was a statistically significant decrease in rotation (-4.3%, p<0.01). There were no statistically significant decreases in projection, rotation, or nasal length from 6 weeks postoperative to 2 years postoperative, or from 6 weeks postoperative to final follow-up (2.0 - 6.6 years). CONCLUSIONS: Nasal tip projection and rotation appear to decrease from the immediate postoperative position, likely due to resolving edema. In this study, patients that underwent open rhinoplasty with SEG experienced modest loss of projection and rotation until 6 weeks postoperative, but projection and rotation were maintained from 6 weeks postoperative to 2 years and beyond. This study provides evidence that SEG maintains long-term changes in tip projection and rotation. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Long-term neurocognitive outcomes in 204 single-suture craniosynostosis patients.

PURPOSE: Craniosynostosis, which describes premature fusion of one or more cranial sutures, has been associated with a variety of neurocognitive deficits. We sought to explore the cognitive profiles of the various types of single-suture, non-syndromic craniosynostosis (NSC). METHODS: A retrospective review of children 6-18 years old with surgically corrected NSC who underwent neurocognitive testing (Weschler Abbreviated Scale of Intelligence, Beery-Buktenica Developmental Test of Visuomotor Integration) from the years 2014-2022 was conducted. RESULTS: 204 patients completed neurocognitive testing (139 sagittal, 39 metopic, 22 unicoronal, 4 lambdoid suture). 110 (54%) of the cohort was male, and 150 (74%) were White. Mean IQ was 106.10±14.01 and mean age at surgery and testing were 9.0±12.2 months and 10.9±4.0 years, respectively. Sagittal synostosis was associated with higher scores than metopic synostosis, with significant differences in verbal IQ (109.42±15.76 vs 101.37±10.41), full-scale IQ (108.32±14.44 vs 100.05±11.76), visuomotor integration (101.62±13.64 vs 92.44±12.07), visual perception (103.81±12.42 vs 95.87±11.23), and motor coordination (90.45±15.60 vs 84.21±15.44). Sagittal synostosis was associated with significantly higher scores for visuomotor integration (101.62±13.64 vs 94.95±10.24) and visual perception (103.81±12.42 vs 94.82±12.75) than unicoronal synostosis. CONCLUSIONS: Compared to patients with sagittal synostosis, patients with metopic synostosis exhibited lower scores in verbal IQ, full-scale IQ, visuomotor integration, visual perception, and motor control after surgical correction. Despite surgical correction for premature metopic suture fusion, the effect on the adjacent frontal lobe and white matter connections to other regions of the brain may have a lasting functional impact. Patients with unicoronal synostosis exhibited lower visuomotor integration and visual perception scores.

How Does Reduction Mammaplasty Surgical Technique Impact Clinical, Aesthetic, and Patient-Reported Outcomes?: A Comparison of the Superomedial and Inferior Pedicle Techniques.

BACKGROUND: A comprehensive comparison of surgical, aesthetic, and quality of life outcomes by reduction mammaplasty technique does not exist. We sought to ascertain the effect of technique on clinical, aesthetic, and patient-reported outcomes. METHODS: Patients with symptomatic macromastia undergoing a superomedial or inferior pedicle reduction mammoplasty by a single surgeon were identified. BREAST-Q surveys were administered. Postoperative breast aesthetics were assessed in 50 matched-patients. Patient characteristics, complications, quality of life, and aesthetic scores were analyzed. RESULTS: Overall, 101 patients underwent reductions; 60.3% had a superomedial pedicle. Superomedial pedicle patients were more likely to have grade 3 ptosis (P < 0.01) and had significantly shorter procedure time (P < 0.01). Only the inferior pedicle technique resulted in wound dehiscence (P = 0.03) and reoperations from complications (P < 0.01). Those who underwent an inferior pedicle reduction were 4.3 times more likely to experience a postoperative complication (P = 0.03). No differences in quality of life existed between cohorts (P > 0.05). Superomedial pedicle patients received significantly better scarring scores (P = 0.03). CONCLUSIONS: The superomedial pedicle reduction mammoplasty technique provides clinical and aesthetic benefits compared with the inferior pedicle technique.

Quality and Readability of Accessible Facial Feminization Literature: Where Can We Improve?

BACKGROUND: Facial feminization surgery (FFS) consists of multiple, complex procedures. Well-informed patients have been shown to have better outcomes and expectations. However, there is limited data evaluating FFS patient-oriented material online. This study aims to evaluate the quality and readability of FFS literature online. METHODS: Facial feminization surgery-related terms were queried in Google with location, cookies, and user account information disabled. Websites were analyzed for readability using Flesch Reading Ease and Flesch-Kincaid Reading Grade Level, suitability using the suitability assessment of materials (SAM), and quality using the DISCERN scale. Unpaired t tests and χ2 tests were used to compare the websites of community-based and academic or public institutions. RESULTS: One hundred twenty websites met inclusion criteria (71 community-based and 49 academic). The average reading grade level was 11.68 ± 1.71. The average SAM score was 53.11 ± 11.75, denoting adequate readability. Only 16.67% of websites contained visual aids to assist in explaining procedures and benefits. Overall, 68.33% of websites' DISCERN score was rated very poor or poor, whereas only 8.33% were rated as good. The following DISCERN elements had the lowest scores across all graded websites: "clear source and date of information," "details of additional source of support," "refers to areas of uncertainty," and "describes risks of each treatment." Websites published by community-based institutions were significantly better in describing how FFS works and the benefits of each procedure. Academic sites overall were less biased (4.84 vs 4.62, P = 0.03) and provided additional sources of support (2.35 vs 1.32, P = <0.001). CONCLUSIONS: Online FFS patient resources should be written at a more inclusive reading level and should increase the use of pictorial aids to improve patient comprehension. Facial feminization surgery patient resources were significantly above the recommended sixth grade reading level for health literature. Academic and community-based institutions should include more information about procedural risks and limitations in surgical outcomes to ensure a broader scope of understanding.

Utilizing Computer-Assisted Design and Virtual Surgical Planning for Correction of Unilateral Lambdoid Synostosis.

Unilateral lambdoid synostosis is the rarest form of single-suture craniosynostosis. Although various surgical approaches have been described, cranial vault remodeling remains the predominant approach. To aid in surgical planning, preoperative virtual surgical modeling using a patient's presenting computed tomography scan can be used to increase reconstructive precision and to reduce operative time. Presented is a 7-month-old male with unilateral lambdoid synostosis who underwent medically modeled cranial vault reconstruction.

Virtual Surgical Planning in Craniosynostosis Reduces Operative Time and Length of Stay for Cranial Vault Remodeling.

Cranial vault remodeling (CVR) with and without frontal orbital advancement remodels the skull in craniosynostosis. Virtual surgical planning (VSP) for preoperative planning has been previously shown to be effective in CVR. In this study, the authors aimed to evaluate the impact of VSP on operative and perioperative efficiency for craniosynostosis surgery. A retrospective chart review was conducted of patients with craniosynostosis who underwent CVR. Patient demographics, perioperative variables, use of VSP, and complications were obtained. Perioperative variables collected include operative time and length of stay. An independent t test was used to compare variables from patients who had surgery with VSP and patients who did not. Records were available for 126 patients with craniosynostosis who underwent CVR of whom 79 (62.7%) utilized VSP. There was no difference in average age at surgery (9.3±5.7 mo versus 13.2±31.1 mo, P =0.39). Surgeries planned using VSP demonstrated a decreased operative time of 1.3 hours (3.7±1.1 versus 5.0±1.1 h, P <0.001) and a shorter length of stay (3.9±1.3 versus 4.6±1.7 d, P =0.01). There were no differences in complication rates of dehiscence, infection, returns to the operating room, or 30-day readmission. These trends were similar among patients who underwent fronto-orbital advancement in addition to CVR. Virtual surgical planning was associated with decreased operative time and length of stay for patients with craniosynostosis and comparable complication rates. Virtual surgical planning is an effective tool for reducing anesthetic exposure time.

Tranexamic Acid in Facial Feminization Surgery: Quantifying a High-risk Setting With Exogenous Estrogen Supplementation.

Tranexamic acid (TXA) has been increasingly utilized in orthognathic surgery, aesthetic surgery, and craniofacial surgery. However, the risk of increasing venous thromboembolic events (VTE) must be carefully considered as TXA is a prothrombotic agent. Our study aimed to investigate the safety of TXA in the setting of facial feminization surgery. These patients are at an elevated risk for VTE at baseline given their uniform history of exogenous estrogen supplementation. A retrospective review of all patients that underwent facial feminization surgery at our medical center between December 2015 and September of 2022 was performed. Demographic information, procedure type, Caprini scores, hematoma rate, VTE rate, estimated blood loss, and operative time were all studied. Unpaired t tests were used to compare patients that received TXA and those who did not. In total, there were 79 surgeries performed during our study period. There were 33 surgeries (41.77%) that used TXA intraoperatively. Ten patients (12.65%) received anticoagulation postoperatively, 5 of whom received TXA intraoperatively. Of the 33 patients who received TXA, 30 patients remained on estrogen therapy. There was no statistically significant difference in VTE rates in patients who received TXA (n=33, 41.77%) and those who did not (n=46, 58.23%). Bleeding events, Caprini scores, estimated blood loss, and operative time were also not found to be significantly different between the 2 cohorts. The authors found no significant increase in VTE in facial feminization patients undergoing estrogen supplementation when intraoperative TXA was utilized. This is the first known report investigating the safety of TXA in this higher risk patient population.

Technique for Cephalometric Analysis of the Craniofacial Skeleton Following Facial Feminization Surgery.

Facial feminization surgery (FFS) is characterized by a series of relatively diverse procedures aimed at aligning skeletal and soft tissue facial appearance with one's experienced feminine gender. Although there are several well-described outcomes from surgical techniques, there is no standardized methodology to provide reliable analyses of postoperative FFS outcomes. This paper describes the first reliable and reproducible technique to accurately and consistently measure post-FFS changes to guide surgical planning to optimize patient outcomes.

Ear Molding Therapy of Congenital Ear Anomalies: Long-Term Aesthetic Outcomes and Caretaker Satisfaction.

INTRODUCTION: Ear molding is a safe, non-surgical approach to treat newborns with congenital ear anomalies. In this study, we aimed to investigate long-term aesthetic outcomes and caretaker satisfaction from ear molding therapy. METHODS: A retrospective chart review from 2018 to 2020 was conducted for infants who underwent ear molding treatment at our institution. Patient demographics and treatment related variables were collected. Caretakers were surveyed regarding their experience, expectations, and aesthetic outcome at 1 year (short-term) and 3 years (long-term) from treatment. Independent physicians evaluated treatment efficacy. Responses were converted to a Likert scale (1-5), with 5 representing most desirable. RESULTS: Overall, 38 of 42 patients participated in our long-term study (90%) for a total of 62 ears. Average follow-up was 3.31 ± 0.50 years after completion of treatment. Mean age at treatment was 23.2 ± 19.7 days with a mean treatment duration of 21.7 ± 7.7 days. Caretakers' satisfaction regarding auricular appearance remained high (short-term: 4.18 vs. long-term: 4.17, p = 0.54) and anticipated social distress decreased over time. Physician aesthetic evaluations were favorable between "somewhat effective" and "very effective" and remained consistent over time (short term: 3.46 vs. long-term: 3.31, p = 0.31). Furthermore, physician evaluations were higher for deformations than malformations (p = 0.04) and in children who began treatment by 30 days old (p = 0.04). CONCLUSION: Caretaker satisfaction from ear molding therapy remained high after long-term follow up, and social distress from the perception of their child's ears decreased with time. Physician aesthetic ratings confirmed efficacy, with better outcomes seen in deformations than in malformations. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Orthotic Helmet Therapy for Deformational Plagiocephaly: Stratifying Outcomes by Insurance.

OBJECTIVE: Deformational Plagiocephaly (DP) is commonly treated with cranial orthosis, or helmet therapy. A large, national study on the impact of insurance status on helmet outcomes is lacking. We assessed treatment outcomes for helmet therapy based on insurance status. DESIGN: This was a retrospective data analysis of patients referred to Cranial Technologies, Inc for helmet therapy between 2014-2020 across 21 states. PATIENTS, PARTICIPANTS: There were a total of 211,417 patients referred for helmeting, of whom 141,513 received helmet therapy. MAIN OUTCOMES MEASURES: Multivariate regression was used to assess the relationship of insurance status with post-treatment residual flattening, measured by cephalic index (CI) and cranial vault asymmetry index (CVAI), and treating provider rating of success. RESULTS: Patients with Medicaid were more likely to complete treatment with residual flattening measured by CI and CVAI when compared to patients with private insurance (OR: 1.58, CI: 1.51-1.65, p < 0.001 and OR: 1.21, CI: 1.15-1.28, p < 0.001, respectively). Providers of patients with Medicaid were more likely to give a low rating of success following treatment (OR: 3.25, CI: 2.70-3.92, p < 0.001). CONCLUSIONS: Our study investigating the impact of insurance status on helmet therapy across 21 states found that patients with Medicaid were more likely to experience residual flattening and have lower provider-rated outcomes compared to those with commercial insurance. Given significant caregiver burden posed by helmet therapy, which requires frequent visits and consistent helmet use, caregivers of patients with Medicaid may require greater support to reduce outcome disparities observed here.

Flap to Mastectomy Mass: Are Higher Ratios Associated with Greater Breast Reconstruction Satisfaction?

BACKGROUND: Autologous breast reconstruction is associated with superior patient-reported outcomes compared with prosthetic techniques, but little is known about the relationship between autologous flap mass and patient satisfaction. We hypothesized that a higher differential mass (ratio of flap mass to mastectomy mass) would be associated with greater satisfaction with reconstruction. METHODS: In this retrospective study, patients who underwent autologous breast reconstruction between 2015 and 2020 with a deep inferior epigastric perforator (DIEP) flap completed the BREAST-Q survey. Multivariate linear regression models were used to examine the relationship between differential mass and patient satisfaction. Models controlled for body mass index (BMI), age at surgery, reconstruction size preference, number of surgeries, previous surgery failure, whether the patient underwent radiation therapy, and whether reconstruction was unilateral or bilateral. RESULTS: Overall, 45 patients (70 breasts) completed the BREAST-Q survey. Mean age at reconstruction was 52.2 years and mean time to survey completion following surgery was 21.1 months. Most patients (59.4%) desired a smaller breast after reconstruction. The mean differential mass was +26.3% (flap mass greater than mastectomy mass). Differential mass was positively associated with all satisfaction measures with results being significant for satisfaction with breasts scores (p=0.032). CONCLUSION: In this preliminary study, a higher ratio of autologous flap mass to mastectomy mass was associated with overall higher patient-reported satisfaction. A 1:1 flap to mastectomy mass ratio may not adequately reapproximate desired breast size or shape. Larger autologous flap mass may be favorable for long-term patient satisfaction, and future studies should investigate the relationship between differential mass and breast esthetics.

Facial Trauma Call Reimbursement Patterns Among American Society of Maxillofacial Surgery Members.

Facial trauma accounts for over 3 million emergency room encounters each year in the United States and places significant financial burden on the health care system and surgeons. However, data on facial trauma call practices among plastic surgeons are lacking. We surveyed members of the American Society of Maxillofacial Surgeons (ASMS) regarding their experience with facial trauma call. A 27-question online survey was distributed through e-mail to ASMS members. Forty-five ASMS members completed the survey, of whom 64% were required to take facial trauma call and 44% were compensated for call. Respondents in the North-East were less likely [odds ratio (OR): 0.234, confidence interval (CI), 0.054-1.015; P =0.052] to be compensated for taking call, whereas those who worked at level 1 trauma centers were more likely odds ratio: 5.42, CI, 0.892-32.89; P =0.066) to be compensated. Surgeons required to take facial trauma call were 4.646 (CI, 1.203-17.944; P =0.026) times more likely to take call ≥5 days per month. These results highlight a relatively low proportion of plastic surgeons receiving additional compensation for facial trauma call while work at a level 1 trauma center was associated with higher likelihood of compensation. Surgeons in the Northeast may be compensated less frequently than other regions. Plastic surgeons should be aware of these trends, as they decide how to incorporate facial trauma call into their practice.

Effect of a Report Template-Enabled Quality Improvement Initiative on Use of Preferred Phrases for Communicating Normal Findings in Structured Abdominal CT and MRI Reports.

OBJECTIVE. The objective of this study was to assess impact of a report template quality improvement (QI) initiative on use of preferred phrases for communicating normal findings in structured abdominal CT and MRI reports. SUBJECTS AND METHODS. This prospective QI initiative, designed to decrease use of equivocal phrases and increase use of preferred and acceptable phrases (defined by multidisciplinary experts including patient advocates) in radiology reports, was performed in an academic medical center with over 800,000 annual radiologic examinations and was exempt from institutional review board approval. The intervention populated the preferred term "normal" (default) and acceptable specified pertinent negative phrases (pick-list option) when describing abdominal organ subheadings (liver, pancreas, spleen, adrenal glands, kidneys) within the "Findings" heading of abdominal CT and MRI report templates. We tabulated frequencies of the term "normal", specified pertinent negatives, and equivocal phrases in 21,629 reports before (June 1, 2017, to February 28, 2018) and 23,051 reports after (April 1, 2018, to December 31, 2018) the intervention using natural language processing and recorded trainee participation in report generation. We assessed intervention impact using statistical process control (SPC) charts and the Fisher exact test. RESULTS. Equivocal phrases were used less frequently in abdominal CT and MRI reports for both attending radiologists and trainees after the intervention (p < 0.05, SPC). Use of the term "normal" increased for reports generated by attending radiologists alone but decreased for reports created with trainee participation (p < 0.05, SPC). Frequency of pertinent negatives increased for reports with trainee participation (p < 0.05, SPC). CONCLUSION. A QI intervention decreased use of equivocal terms and increased use of preferred and acceptable phrases when communicating normal findings in abdominal CT and MRI reports.

Technologist Productivity and Accuracy in Assigning Protocols for Abdominal CT and MRI Examinations at an Academic Medical Center: Implications for Physician Workload.

OBJECTIVE. The purpose of this study was to evaluate the technologist productivity and accuracy in assigning protocols for abdominal CT and MRI examinations compared with a standard work flow whereby protocols are assigned by physicians. MATERIALS AND METHODS. In this quality improvement project at a large academic medical center, two CT technologists and two MRI technologists assigned protocols for examinations during a 15-week study period. The primary outcome measure was mean number of protocols assigned by technologists per hour. Secondary outcome measures were proportion of examinations with protocols assigned by technologists and rate of filing of quality assurance reports for protocols completed by technologists. A two-tailed t test was used to compare mean number of protocols; a chi-square test was used to compare proportions between CT and MRI. RESULTS. The mean number of protocols assigned by technologists per hour was not different between CT and MRI (CT, 22/h; MRI, 19/h; p = 0.28). CT and MRI technologist protocols accounted for 1650 of 4867 (33.9%) CT examinations (range, 23-275 per week) and 569 of 2388 (23.8%) MRI examinations (range, 0-95 per week) (p < 0.001). Radiologist quality assurance reports on inaccurate protocols were rare: three for CT (3/1650 [0.18%]), five for MRI (5/569 [0.88%]) (p = 0.017). A retrospective review of randomly selected CT and MRI protocols revealed no errors (80/80 correct). No patients were called back for repeat imaging due to protocol error. CONCLUSION. Technologists can efficiently and accurately assign protocols for abdominal CT and MRI examinations at an academic medical center, leading to increased radiologist time spent on other value-added activities.

The role of genetics on behavioral outcomes in nonsyndromic sagittal synostosis.

OBJECTIVE: Previous work identified an association between genetics and neurodevelopmental delays in patients with nonsyndromic craniosynostosis. The authors investigated the role of genetic mutations on behavioral outcomes of patients with treated sagittal synostosis. METHODS: Parents of children aged 6-18 years with surgically corrected sagittal synostosis were recruited to complete the Child Behavioral Checklist (overall behavioral problems), Conners 3rd Edition-Parent (attention-deficit/hyperactivity disorder), Social Responsiveness Scale 2nd Edition (autism spectrum disorder [ASD]), and Behavior Rating Inventory of Executive Function 2nd Edition (executive function). Genomic analysis was completed, and patients were identified if they had mutations in high probability of loss of function intolerant (pLI) genes (high pLI vs nonhigh pLI). Genetic burden was assessed relative to controls. Multivariate linear regression determined the association of mutations in high pLI genes with behavioral scores, while controlling for sociodemographic factors, age at surgery, surgery type, and IQ. RESULTS: Sixteen of 45 patients were in the high pLI group. There were no differences between the groups in terms of sociodemographic factors. A greater proportion of children in the high pLI group scored at or above borderline clinical levels for aggression (18.8% vs 0.0%, p = 0.05) and externalizing problems (31.3% vs 3.7%, p = 0.02). Among children in the nonhigh pLI group, older age at surgery was associated with worse scores on the rule-breaking, aggression, and externalizing problems domains and four out of five ASD domains. CONCLUSIONS: Children with treated nonsyndromic sagittal synostosis and mutations in high pLI genes had worse behavioral problems in externalizing behaviors and aggression, whereas older age at surgery was a significant predictor of worse behavioral outcomes in patients without mutations in high pLI genes.

Combined Tripier and V-Y Advancement Flaps for Reconstruction of Large Lid-cheek Junction Defects.

Reconstruction of lid-cheek junction defects has a known risk of ectropion. Cervicofacial flaps require significant dissection and can still be prone to ectropion. V-Y advancement flaps have been described as less morbid, but their use is limited to moderate-size defects that do not involve the lid margin. The authors present a technique of combined Tripier and V-Y advancement flaps for reconstruction of large defects of the lid-cheek junction involving the lower eyelid. A retrospective review of patients undergoing the authors' technique was performed. A facial artery perforator flap was designed in a V-Y fashion and advanced into the cheek. An orbicularis oculi myocutaneous flap (Tripier flap) was elevated from the upper eyelid and rotated into the lower eyelid/upper cheek to meet the superior edge of the V-Y flap. A separate review of patients undergoing cervicofacial flap reconstruction was also performed. Demographics, operative details, and complications were recorded and compared. This technique was applied to five patients with large-size (19.9 ± 5.6 cm2) defects of the lid-cheek. In all cases, healing was achieved without ectropion, hematoma, infection, dehiscence, flap necrosis, or facial nerve injury. Twenty-four patients separately underwent cervicofacial flap reconstruction for defects of comparable size (15.8 ± 10.7 cm2). Two patients developed ectropion, one patient developed a hematoma, and two patients developed an infection. Combined Tripier and V-Y advancement flaps is a useful technique to reconstruct lid-cheek junction defects. This method allows for the reconstruction of large lid-cheek junction defects that involve the lid margin.