ImageAssist: A Novel Smartphone Application for Standardized Clinical Photography That Implements and Automates American Society of Plastic Surgery/Plastic Surgery Foundation Photographic Guidelines With Background Deletion.

STATEMENT OF THE PROBLEM: Standardized medical photography of the face is a vital part of patient documentation, clinical evaluation, and scholarly dissemination. Because digital photography is a mainstay in clinical care, there is a critical need for an easy-to-use mobile device application that could assist users in taking a standardized clinical photograph. ImageAssist was developed to answer this need. The mobile application is integrated into the electronic medical record (EMR); it implements and automates American Society of Plastic Surgery/Plastic Surgery Research Foundation photographic guidelines with background deletion. INITIAL PRODUCT DEVELOPMENT: A team consisting of a craniofacial plastic surgeon and the Health Information Technology product group developed and implemented the pilot application of ImageAssist. The application launches directly from patients' chart in the mobile version of the EMR, EPIC Haiku (Verona, Wisconsin). Standard views of the face (90-degree, oblique left and right, front and basal view) were built into digital templates and are user selected. Red digital frames overlay the patients' face on the screen and turn green once standardized alignment is achieved, prompting the user to capture. The background is then digitally subtracted to a standard blue, and the photograph is not stored on the user's phone. EARLY USER EXPERIENCE: ImageAssist initial beta user group was limited to 13 providers across dermatology, ENT, and plastic surgery. A mix of physicians, advanced practice providers, and nurses was included to pilot the application in the outpatient clinic setting using Image Assist on their smart phone. After using the app, an internal survey was used to gain feedback on the user experience. In the first 2 years of use, 31 users have taken more than 3400 photographs in more than 800 clinical encounters. Since initial release, automated background deletion also has been functional for any anatomic area. CONCLUSIONS: ImageAssist is a novel smartphone application that standardizes clinical photography and integrated into the EMR, which could save both time and expense for clinicians seeking to take consistent clinical images. Future steps include continued refinement of current image capture functionality and development of a stand-alone mobile device application.

Surgical Complexity and Physician Workload in Craniofacial Surgery: Do RVUs Need to be Adjusted?

RVU valuations need to be revisited regularly as procedure complexity and patient care pathways continue to evolve. The NSQIP-P database was queried for craniofacial procedures performed in North America between 2012 and 2019. Multivariate regression was performed to determine correlation coefficients of perioperative variables deemed to reflect procedure severity, including procedure duration, blood transfusion, length of stay, serious adverse events, related readmission, and related reoperation. CPT 21159 Le Fort III with forehead advancement remains the craniofacial procedure with the highest RVUs using our model at 33.93 units. The most underestimated procedure is CPT 42235 Repair of anterior palate, including vomer flap, with a suggested change of +8.27 units, which is a 194% increase from current compensation. Adjusted RVUs based on quantitative and nationally representative perioperative variables that reflect procedure severity might be a better alternative for procedure valuation over current survey methods to determine appropriate insurance compensation.

Easing the Burden on Caregivers- Applications of Artificial Intelligence for Physicians and Caregivers of Children with Cleft Lip and Palate.

OBJECTIVE: Many caregivers of children with cleft lip and palate experience a high level of anxiety throughout their child's medical and surgical care. We aim to evaluate artificial intelligence (AI) as a tool to mitigate these feelings and can aid clinicians in the development of robust pediatric educational materials for caregivers and families. DESIGN: Thirteen of the most common postoperative questions following cleft lip and/or palate repair were developed by an expert panel of senior Pediatric Plastic Surgeons and were posed to ChatGPT. Professional answers from the expert panel were provided and compared to responses from ChatGPT. A literature review was also conducted to generate a new support model for caregivers with children undergoing a surgical procedure. SETTING: Department of Pediatric Plastic Surgery at a metropolitan Children's Hospital. PARTICIPANTS: Senior Pediatric Plastic Surgeons at a metropolitan Children's Hospital. INTERVENTIONS: None. MAIN OUTCOME MEASURE: The primary outcome was to determine the ability of ChatGPT to respond to common postoperative questions and to develop a model for AI assistance in family-centered perioperative care. RESULTS: ChatGPT had a postoperative question response accuracy rate of 69% when compared with subject matter expert responses, with its greatest errors being information errors. An extensive literature search revealed that AI can assist in multiple traditional perioperative strategies to reduce caregivers and patient anxiety. CONCLUSIONS: Artificial Intelligence can help to reduce the burden of generating patient education materials as well as support caregivers in multiple aspects and perioperative care.

Frontal sinus hypoplasia in unoperated older patients with craniosynostosis: a pilot study.

PURPOSE: The purpose of this study is to determine whether patients with unoperated craniosynostosis have different frontal sinus pneumatization than unaffected controls. METHODS: Retrospective review was performed between 2009 and 2020 of previously unoperated patients with craniosynostosis older than 5 years old at first presentation to our institution. Total frontal sinus volume (FSV) was calculated using 3D volume rendering tool in Sectra IDS7 PACS system. Age-matched normative FSV data was collected from 100 normal CT scans for the control group. The two groups were statistically compared using Fisher's exact test and T-test. RESULTS: Study group included nine patients, 5-39 years old, median age 7 years. Frontal sinus pneumatization was absent in 12% of the normal 7-year-old controls, while frontal sinus pneumatization was absent in 89% of the studied craniosynostosis patients (p < .001). Mean FSV of the study group (113 ± 340 mm3) was significantly different from that of age matched control mean FSV (2016 ± 2529 mm3) (p = .027). CONCLUSIONS: Frontal sinus pneumatization is suppressed in unreleased craniosynostosis and may be an intracranial space conservation phenomenon. This absent frontal sinus can have implications in future frontal region trauma and frontal osteotomies.

National Trends in Orthognathic Surgery: A Multi-Institutional Analysis of 6640 Patients.

BACKGROUND: LeFort I osteotomy (LF1) and bilateral sagittal split osteotomy (BSSO) have unique operative challenges and inherent anatomic considerations that predispose to certain adverse outcomes, yet their respective complication profiles continue to be debated given conflicting results from single-center investigations. The purpose of this study is to perform a multi-institutional analysis of complications, socioeconomic trends, and financial charges associated with orthognathic surgery. METHODS: A retrospective cohort study was conducted of orthognathic procedures performed in the United States from 2010 through 2020 using the Pediatric Health Information System. Patients younger than 12 years of age were excluded. Medical complications, surgical complications, and admission costs were compared across procedures. Socioeconomic determinants and trends across regions of the country were also analyzed. RESULTS: During the study interval, 6640 patients underwent orthognathic surgery, including LF1 (59.2%, n=3928), BSSO (14.4%, n=959), and double-jaw surgery (26.4%, n = 1753). Patients undergoing LF1 were more likely to experience overall complications ( P <0.001), infections ( P <0.001), and blood transfusions ( P <0.001) than those undergoing BSSO. High-volume hospitals were more likely to perform double-jaw procedures than other hospitals ( P <0.001), yet high-volume hospitals were less likely to have surgical complications ( P =0.014). Patient admission charges related to orthognathic operations at high-volume hospitals were less than other hospitals ( P <0.001). Household income was higher for orthognathic procedures performed at high-volume hospitals ( P <0.001). White patients were 1.5 times more likely to choose a farther, higher volume hospital for orthognathic surgery than the one locally available ( P =0.041). CONCLUSIONS: LeFort I osteotomy procedures had higher infection and transfusion rates than BSSO procedures. High-volume hospitals were more likely to perform double-jaw procedures, yet high-volume hospitals had fewer complications and decreased admission charges. Future study will be needed to further elucidate case-mix index details and socioeconomic determinants of health contributing to these disparities.

Management of an open nasofrontal encephalocele during the first day of life.

Nasofrontal encephaloceles are extremely rare craniofacial defects that present with herniation of cerebral tissue through the junction of the frontal and nasal bones. They often have a cutaneous covering which allows management to be delayed until early infancy, decreasing the risks of anesthesia and acute blood loss. Further bone development also facilitates cranial remodeling. Encephaloceles with a compromised cutaneous envelope pose an imminent threat to life due to the risk of meningitis, necessitating surgical repair in the first days of life. This report presents a patient born with an open nasofrontal encephalocele that underwent encephalocele excision, dural repair, and cranial remodeling on the first day of life. Anterior encephaloceles represent a spectrum of uncommon craniofacial dysraphias. Given the rarity of these diseases, it is important to understand their many presentations and the treatment options that exist for each. When the cutaneous covering of the encephalocele is compromised, surgical correction must be undertaken urgently to mitigate the mortality associated with neonatal meningitis. This represents the first report of an open nasofrontal encephalocele managed in the first day of life. A multidisciplinary surgical approach involving the neurosurgical and craniofacial surgical teams is paramount to the treatment and survival of such complicated patients.

Managing Bilateral Oro-Sino-Orbital Fistulae in the Setting of Bilateral Tessier IV Clefts.

ABSTRACT: The number IV orofacial cleft is extremely rare, and reports on long-term outcomes are limited. Here we present the management of a child born with bilateral Tessier number IV clefts and microphthalmia, who developed bilateral oro-sino-orbital fistulae. He presented 8 years after his index procedure with persistent ocular drainage and radiographic evidence of bilateral oro-sino-orbital fistulae. His globes maintained light perception, and in order to protect them from chemical reflux he underwent fistula obliteration with demineralized bone matrix and acellular dermal matrix. His orbits were reconstructed by Imre and conjunctival flaps. In the presence of marginally functioning globes, the importance of timely intervention is critical in order to preserve residual ocular function. Light perception vision assists in the maintenance of circadian rhythm and physiologic functions that are critical to the developing pediatric patient. This case also emphasizes the importance of a multi-disciplinary team in the correction of complex craniofacial deformities.

Resorbable Versus Titanium Hardware for Rigid Fixation of Pediatric Upper and Midfacial Fractures: Which Carries a Lower Risk Profile?

PURPOSE: Titanium associated risks have led to interest in resorbable hardware for open reduction and internal fixation (ORIF) of pediatric facial fractures. This study aims to systematically review and compare the outcomes of titanium/resorbable hardware used for ORIF of upper/midfacial fractures to determine which hardware carries a higher complication rate in the pediatric patient. METHODS: Studies published between 1990 and 2020 on the ORIF of pediatric upper/midfacial fractures were systematically reviewed. A retrospective institutional review was also conducted, and both arms were compiled for final analysis. The primary predictor value was the type of hardware used and the primary outcome was the presence of a complication. Fisher's exact test and 2-proportion 2-tailed z-test calculations were used to determine statistical significance, which was defined as a P value < .05. The low quality of published evidence precluded meta-analysis. RESULTS: Systematic review of 23 studies identified 659 patients, and 77 patients were identified in the institutional review. A total of 736 patients (299 resorbable, 437 titanium) were included in the final analysis. Total complication rate was 22.8%. The titanium group had a higher complication rate (27 vs 16.7%; P < .01), and more often underwent elective hardware removal (87.3 vs 0%, P < .01). In each hardware subgroup, the incidence of complications was analyzed by fracture site. In the titanium group, complication incidence was higher when treating maxillary fractures (32.8 vs 22.9%, P = .03). When comparing the 2 hardware groups by fracture site, maxillary fractures had a higher rate of complications when treated by titanium hardware compared with resorbable hardware (32.8 vs 18%, P < .01). CONCLUSIONS: Upper/midfacial pediatric fractures requiring ORIF, especially maxillary fractures, may be best treated with resorbable hardware. Additional hardware-specific outcomes data is encouraged.

Sport participation and related head injuries following craniosynostosis correction: a survey study.

OBJECTIVE: Craniosynostosis (CS) affects about 1 in 2500 infants and is predominantly treated by surgical intervention in infancy. Later in childhood, many of these children wish to participate in sports. However, the safety of participation is largely anecdotal and based on surgeon experience. The objective of this survey study was to describe sport participation and sport-related head injury in CS patients. METHODS: A 16-question survey related to child/parent demographics, CS surgery history, sport history, and sport-induced head injury history was made available to patients/parents in the United States through a series of synostosis organization listservs, as well as synostosis-focused Facebook groups, between October 2019 and June 2020. Sports were categorized based on the American Academy of Pediatrics groupings. Pearson's chi-square test, Fisher's exact test, and the independent-samples t-test were used in the analysis. RESULTS: Overall, 187 CS patients were described as 63% male, 89% White, and 88% non-Hispanic, and 89% underwent surgery at 1 year or younger. The majority (74%) had participated in sports starting at an average age of 5 years (SD 2.2). Of those participating in sports, contact/collision sport participation was most common (77%), and 71% participated in multiple sports. Those that played sports were less frequently Hispanic (2.2% vs 22.9%, p < 0.001) and more frequently had undergone a second surgery (44% vs 25%, p = 0.021). Only 9 of 139 (6.5%) sport-participating CS patients suffered head injuries; 6 (67%) were concussions and the remaining 3 were nondescript but did not mention any surgical needs. CONCLUSIONS: In this nationwide survey of postsurgical CS patients and parents, sport participation was exceedingly common, with contact sports being the most common sport category. Few head injuries (mostly concussions) were reported as related to sport participation. Although this is a selective sample of CS patients, the initial data suggest that sport participation, even in contact sports, and typically beginning a few years after CS correction, is safe and commonplace.

Surgical Approach in a Patient With Agnathia-Otocephaly Complex: Three-Stage Mandibular Distraction Protocol.

Agnathia-otocephaly complex (AOC) is a rare malformation complex of the first pharyngeal arch that is characterized by agnathia/dysgnathia, microstomia, aglossia/hypoglossia and variable displacement of the ears. Only 11 post-infancy patients with severe AOC have been described in the literature, and the incidence of this malformation complex is estimated to be 1 per 70,000 births. In this brief clinical study, the authors describe the case of an 18-year-old female diagnosed with AOC who underwent a 3-step mandibular distraction protocol with an external distraction device. The surgical protocol the authors used was unique in that we first placed a tissue expander in the submental area to enlarge the skin envelope in an effort to mitigate skeletal relapse from soft tissue forces. Furthermore, the way in which the authors slowed the activation of the distraction device to allow for soft tissue healing behind the pins was a novel component of the patient's treatment. The 3-step mandibular distraction protocol the authors present in this study increased the length of the mandible by 20 mm, and nearly doubled the size of the patient's mandible from an initial volume of 3.62 cm to a post-operative volume of 6.89 cm. Future surgeries will aim to improve the function of our patient's expanded mandible. Most important of all, the surgical treatment authors are presenting led to a significant improvement in our patient's physical appearance and 3d quality of life.

NAM Therapy-Evidence-Based Results.

Many orthodontists working on patients with cleft lip and palate (CLP) have shown great enthusiasm for presurgical infant orthopedics (PSIO) to improve surgical outcomes with minimal intervention. Even though every clinician aims to use the best treatment modality for their patients, PSIO effects can be confounded by surgical type and timing of the primary repair, as is discussed in many studies. In such cases, one should be cautious when evaluating the particular outcomes for patients with CLP since it is difficult to differentiate the sole effect of an individual surgical or orthodontic intervention. As with any treatment methodology, nasoalveolar molding (NAM) has both benefits and limitations. Commonly cited concerns with NAM, and PSIO in general, include increased cost, increased burden of care, and a negative impact on maxillary growth. However, NAM cannot be deemed as having apparent long-term negative or positive effects on skeletal or soft tissue facial growth, based on previous studies. A review of the literature suggests that NAM does not alter skeletal facial growth when compared with the samples that did not receive PSIO. Nevertheless, the published studies on NAM show evidence of benefits to the patient, caregivers, the surgeon, and society. These benefits include documented reduction in severity of the cleft deformity prior to surgery and as a consequence improved surgical outcomes, reduced burden of care on the care givers, reduction in the need for revision surgery, and consequent reduced overall cost of care to the patient and society.

Surgical management of craniosynostosis in the setting of a ventricular shunt: a case series and treatment algorithm.

PURPOSE: Cerebrospinal fluid diversion via ventricular shunt is a common treatment for hydrocephalus. Change in cranial morphology associated with a sutural fusion has been termed shunt-related or induced craniosynostosis (SRC) or craniocerebral disproportion (CCD). We present a series of patients with SRC who underwent cranial vault remodeling (CVR) and our treatment algorithm. METHODS: Thirteen patients were retrospectively reviewed who had SRC and CVR; 92% of patients had a ventriculoperitoneal (VP) shunt placed for largely intraventricular hemorrhage of prematurity (69% of patients) at a mean age of 2.2 months. The shunt revision rate was 38.4%, and 54% of patients had a programmable shunt placed initially. RESULTS: The mean age at time of CVR was 3.6 years old. The most commonly affected sutures (CT confirmed) were the sagittal and coronal sutures, with three patients exhibiting pancraniosynostosis. The mean time from placement of the shunt to CT evidence of sutural fusion was 2.0 years. Abnormal head shape was noted in all 13 patients; 11 of these also had either chronic headaches, papilledema, seizures, or behavioral changes in the setting of functional shunt. Mean follow-up after the initial CVR was 3.3 years. No shunt infections were attributed to the CVR. The families of all patients were contacted and reported improvement in head shape with 60% of families reporting improvement in behavior, 75% reported improvement in headaches, and 40% reported decrease in seizure frequency or intensity. Shunt setting or type was not routinely changed after CVR. CONCLUSIONS: Our threshold for CVR in SRC is met when shunt malfunction has been ruled out and there are (1) radiographic evidence of craniosynostosis, (2) signs of increased ICP clinically or radiographically, and (3) cranial dysmorphism, i.e., dolichocephaly. The majority of cases of SRC result in improved cranial morphology in addition to some abatement of the symptoms of increased intracranial pressure. Early involvement of an experienced craniofacial/neurosurgical team could allow for early diagnosis and intervention which may prevent progression to more severe deformities. SRC is a complex entity, with multiple etiologies, and a future study is needed.

Characteristics of Dog Bites in Arkansas.

OBJECTIVE: Dog bite injuries are encountered frequently in emergency departments and can cause significant morbidity. The objective of this study was to explore the associations between the multiple variables at play during these occurrences (eg, the patient's age, the bite location, the bite severity, the dog's relationship with the patient, the breed of dog). METHODS: This two-institution study collected and analyzed dog bite data from Arkansas' only Level I trauma centers. The charts of 740 patients were included in our retrospective chart review. The chart review extracted data, including each individual patient's age, sex, dog bite location, and dog bite severity, as well as the patient's relationship to the dog and the dog's breed. To determine the relation between and among variables, contingency tables were created and analyzed to determine odds ratios (ORs) and confidence intervals (CIs). In addition, standard t tests were used in statistical comparisons of means and proportions. RESULTS: Of the 740 patient charts reviewed, 574 were for patients who presented to Arkansas Children's Hospital and 166 were for patients who presented to the University of Arkansas for Medical Sciences. Of the patients across both institutions, 267 (37.1%) required some form of repair, with 225 (30.4%) receiving closure within the emergency department and 42 (6.7%) requiring an operative intervention. Among children, those younger than age 5 years were >8 times as likely to require an operative repair (OR 8.1, 95% CI 2.77-23.58, P < 0.0001), >4 times as likely to be bitten on the head and neck (OR 4.30, 95% CI 3.00-6.16, P < 0.0001), and ≤3 times as likely to be bitten by a family dog (OR 2.97, 95% CI 2.10-4.20, P < 0.0001). Conversely, children older than age 12 years were >3 times as likely to be bitten on an extremity (OR 3.43, 95% CI 2.08-5.65, P < 0.0001). CONCLUSIONS: The results of this retrospective review are aligned mostly with the general trends found in previous national and global studies, supporting the notion that family dogs represent a more significant threat than often is realized and that, among the breeds identified, pit bulls are proportionally linked with more severe bite injuries. Our data further validate previous studies that note an increased risk of bites and bite severity in children younger than 5 years. In addition, our data show that bites to the head and neck occurred more frequently among children younger than 5 years than among older children, and that boys younger than 5 years were bitten more frequently than girls.

The Arkansas Tessier Number 3 Cleft Experience: Soft Tissue and Skeletal Findings With Primary Surgical Management: Four-Step Approach.

Tessier No 3 facial cleft (oro-nasal-ocular clefts) is the rarest and most challenging of all the Tessier clefts. Reports on Tessier No 3 clinical findings, surgical techniques, and outcomes are varied due to the scarcity of patients and the wide range of phenotypic findings. The authors present our experience of 2 children born with Tessier No 3 clefts who were both managed at the Arkansas Children's Hospital. Our purpose is to add knowledge on this rare craniofacial cleft by providing detailed soft tissue findings, skeletal findings, operative techniques, early postoperative outcome, and suggestions of a treatment protocol.Both were born at 38 weeks gestation and had multiple associated anomalies including: syndactyly, limb anomalies, cardiac defects, and encephalocele in Patient 1 and hydrocephalus and dysphagia in Patient 2. While both patients had a bilateral cleft lip and palate, Patient 1 had a severe left-sided cleft and Patient 2 had a right-sided incomplete cleft. A multidisciplinary team of specialists in Plastic Surgery, Otolaryngology, and Oculoplastics were assembled to devise a top-down approach for repair. In brief, our surgical sequence for both infants was a dorsal nasal Reiger flap to level the ala, cheek advancement flap along with medial canthal repositioning, and more traditional bilateral cleft lip repair using a modified Millard technique. Postoperatively, Patient 1 experienced some early scarring, medial canthal rounding, lagophthalmos, and cicatricial retraction of the lower lid and patient 2 demonstrated under-correction of the displaced ala but had satisfactory medial canthal position.Future evaluations will include serial photography and annual 3-dimensional computed tomography scans to evaluate the soft tissue and bony growth. After these initial procedures, both infants will be followed for routine cleft clinical and surgical care.

Cerebrospinal Fluid Fistula for the Craniofacial Surgeon: A Review and Management Paradigm.

Craniofacial surgeons perform operations that involve exposure of the dura. Typical procedures include cranial vault remodeling (CVR), fronto-orbital advancement (FOA), Le Fort III, monobloc, bipartition advancement, or distraction. Cerebrospinal fluid (CSF) fistulas remain one of the most common complications encountered, occurring in up to 30% of patients. Cerebrospinal fluid fistulas can be encountered intraoperatively, acutely, or in the late postoperative period. Traditional management has been well described in the neurosurgical literature. While several studies of complications exist, there is a relative lack of adequate information for craniofacial surgeons. The authors review current literature and provide 3 patients to illustrate our management paradigm.The authors review 30 years of experience at our institution and the pertinent literature. The mean rate of CSF fistula was 11.2%; rates were lowest for FOA/CVR, 5.5%. Patients with fistulas persisting after 2 days of conservative therapy or whom were symptomatic prompted placement of a lumbar subarachnoid catheter. Failure of the leak to resolve with CSF diversion prompted exploration and therapy which could include a patch, pericranial flap, and/or endonasal repair with septal flaps. Three patients are used to illustrate the paradigm, all of which have had no recurrence thus far.Cerebrospinal fluid fistula remains one of most common complications craniofacial surgeons encounter. Although neurosurgeons are often part of the clinical team, the craniofacial surgeon should be familiar with all aspects of treatment. Prompt diagnosis and appropriate knowledgeable management may avoid morbidity and mortality.

The deepithelialized skin flap for closure of large myelomeningoceles: a common plastic surgery technique for a novel neurosurgery application.

PURPOSE: The study aims to demonstrate proof of principle of a common plastic surgery technique of deepithelialization for repair of large myelomeningoceles (MMCs). Whereas repair typically consists of a watertight dural closure followed by a muscle or fasciocutaeneous layer, excess skin, however, need not be discarded and can be deepithelialized to augment or, in selective cases, replace the muscle repair. METHODS: The study was performed through a retrospective chart review of two patients. RESULTS: Step-by-step figures illustrate the technique. Two patients each born with large MMCs measuring 10 × 11 cm and 6 × 9 cm, respectively, were reviewed. Excess skin was deepithelialized to create an additional layer of vascularized tissue over the muscle repair. There were no post-operative complications at 3-month follow-up. CONCLUSIONS: In large MMCs with excess skin, the use of a deepithelialized skin flap can potentially be an alternative or adjunct to a muscle flap to buttress the dural repair.

Parental Perceptions of Neurodevelopment in Toddlers Following Craniosynostosis Repair.

INTRODUCTION: The relationship between nonsyndromic craniosynostosis and neurodevelopment remains controversial. Beyond standardized testing, little data exist about parental perceptions of their child's development. METHODS: Parents of children who underwent cranial vault remodeling for nonsyndromic craniosynostosis from 2011 to 2015 were asked to complete an anonymous survey. RESULTS: Twenty-two parents (31%) completed the survey. Patients included 52.4% males and 47.6% females with a mean age at surgery of 9.2 months and mean follow-up time of 19.8 months. Craniosynostosis types were primarily metopic (45%) and coronal (35%).The mean score for overall satisfaction with head shape with a maximum score of 10 was 9.2 (range 5-10). When answering whether their child is different for the better other than appearance with a 5 rating as "strongly agree," the mean score was 3.8 (range 1-5). When asked whether their child's motor, speech and behavior, or attention were different following surgery, the majority responded "No" (74%, 83%, and 67%, respectively).All parents would have their child undergo surgery again or recommend surgery to another family. There were no statistically significant differences when stratifying by age at surgery or length of follow-up. When stratifying by sex, parents of males gave higher ratings for whether their children were better other than appearance compared with females, 4.8 versus 3.1 (P = 0.031). DISCUSSION: Parents rated their child's neurodevelopment as largely age-appropriate following cranial vault remodeling. These findings are concordant with the majority of formal, standardized testing for this age group. Assessing parental perceptions once children enter school age may reveal increased developmental delays.