Osseous Genioplasty: Prevention of Witch's Chin Deformity with No-Degloving Technique.

BACKGROUND: Osseous genioplasty is a powerful procedure that can correct chin dysmorphology; however, traditional techniques may result in chin ptosis or a "witch's chin" deformity. Iatrogenic chin ptosis is thought to be caused by excessive degloving of soft tissue with a failure to reattach the mentalis muscle. In the authors' study, they compared the "no-degloving" technique (using a 90-degree plate with lag-screw fixation) to the "traditional" technique, for minimization of chin ptosis. METHODS: The authors compared genioplasty techniques for consecutive patients: group 1 (traditional) underwent degloving for fixation of a stair-step plate, whereas group 2 (no-degloving) underwent lag-screw fixation (n = 50; 25 patients per group). The authors compared operating room time, advancement, complications, preoperative-to-postoperative vertical height change of the pogonion and menton (obtained through cone beam computed tomographic scans), surgeons' assessment of witch's chin, and FACE-Q surveys. RESULTS: No-degloving versus traditional groups had similar age and sex distributions, horizontal/vertical change (5 mm/2 mm versus 6 mm/2 mm), length of surgery, and complication rate (5 percent). The traditional group had more deviation from expected position for both the pogonion (3.4 mm versus 1.2 mm; p ≤ 0.05) and menton (2.9 mm versus 0.8 mm; p ≤ 0.05), and more occurrences of witch's chin (six versus zero). No-degloving was superior for several FACE-Q scales, including Chin Appearance, Quality of Life, Satisfaction with Decision to Undergo Procedure, and Satisfaction with Outcome. CONCLUSION: No-degloving osseous genioplasty is a safe, reproducible technique that results in decreased soft-tissue ptosis and increased patient satisfaction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Effect of Parental English Proficiency on Psychosocial Functioning in Children with Craniofacial Anomalies.

BACKGROUND: Psychosocial distress in children with craniofacial anomalies is multifactorial. A known cause of childhood psychosocial distress is parental limited English proficiency; however, its role as a psychosocial stressor in the craniofacial anomaly population remains unknown. The current study aimed to understand the potential influence of parental English proficiency in children with craniofacial anomalies. METHODS: Two hundred ninety-six children were prospectively evaluated at the University of California, Los Angels and the Orthopaedic Institute for Children using the Pediatric Patient-Reported Outcomes Measurement Information System to assess anger, anxiety, depression, and peer relationships. Children were grouped by parental English proficiency based on the requirement or lack thereof for interpreting services during clinic appointments. Independent t tests, analyses of variance, and linear regressions were performed to compare groups and identify predictors for psychosocial functioning. RESULTS: Although comparison children did not exhibit any differences in psychosocial scores with respect to parental English proficiency, craniofacial anomaly children with parents who have limited English proficiency demonstrated higher anger, anxiety, depression, and lower peer relationships compared with those with parents who are English proficient. Linear regression analyses demonstrated that limited English proficiency in parents was a significant predictor for anger (p = 0.005), anxiety (p = 0.002), depression (p < 0.001), and poor peer relationships (p < 0.001) in children with craniofacial anomalies. CONCLUSIONS: Parental English proficiency is associated with increased psychosocial distress in children with craniofacial anomalies. Future efforts toward identification of and assistance for parents with limited English proficiency to address barriers to care may improve psychosocial function in children with craniofacial anomalies. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Discrepancies in Parent Perceptions and Patient-Reported Psychosocial Function in Children with Craniofacial Anomalies.

BACKGROUND: Understanding and optimizing psychosocial functioning in children with craniofacial anomalies are essential components of their reconstructive care. This work compared parental perceptions to pediatric self-reported psychosocial functioning in children with craniofacial anomalies. METHODS: Two hundred twenty-one children with craniofacial anomalies (aged 8 to 17 years) and their parents were prospectively evaluated at two institutions using the parent-proxy and pediatric Patient-Reported Outcomes Measurement Information System to assess anger, anxiety, depression, and peer relationships. Children were stratified into three age groups: group A, 8 to 10 years; group B, 11 to 13 years; and group C, 14 to 17 years. Pearson correlations, analyses of variance with post hoc comparisons under the Tukey criterion, and paired samples t tests were performed. RESULTS: When stratified by age, no correlations between parent and child reports were found in anxiety for group A and anger, anxiety, and peer relationships for group C. Whereas group A reported the worst psychosocial functioning, group C parents perceived their children to have the worst psychosocial functioning. Group A parents perceived lower depression and better peer relationships, whereas group C parents perceived higher anxiety and depression compared to self-reports. CONCLUSIONS: Parents perceived an inverse relationship between age and psychosocial functioning compared to self-reports by children with craniofacial anomalies. These discrepancies in the current work highlight the importance of child self-report and suggest incorporating longitudinal patient-reported and parent-proxy-reported outcomes measures for psychosocial functioning as part of standard clinical care for patients with craniofacial anomalies.

Component Restoration in the Unilateral Intermediate Cleft Tip Rhinoplasty: Technique and Long-Term Outcomes.

BACKGROUND: The intermediate cleft tip rhinoplasty is performed in childhood to address residual tip asymmetries during the most critical period of psychosocial development. The authors describe and evaluate long-term outcomes of that approach for the unilateral cleft lip and palate patient based on the concept of individual restoration of each abnormal anatomical component. METHODS: Photomorphometric analyses of unilateral cleft lip and palate patients (n = 50) who underwent intermediate cleft tip rhinoplasty using the component restoration technique were evaluated preoperatively (time 0) and postoperatively at less than 1 year (time 1), 1 to 3 years (time 2), and more than 3 years (time 3) and compared to age-matched unilateral cleft lip and palate control patients. Nasal relationships (alar symmetry, nasal tip protrusion-to-alar base width ratio, and height-to-width dimensions for the cleft and noncleft nostrils) were compared over time using a linear mixed-effect model. RESULTS: At time 0, both groups demonstrated similar nasal relationships, with the exception of a wider cleft-side nostril in relationship to height in the rhinoplasty group. The component restoration technique improved all four nasal relationships at all postoperative time points compared with time 0 in a statistically significant manner, whereas control patients did not demonstrate significant changes at the corresponding ages. Long-term differences at time 3 revealed a trend toward improved alar symmetry and cleft-side and non-cleft-side nostril dimensions, and a significant improvement in the nasal tip protrusion-to-alar base width ratio in intermediate cleft tip rhinoplasty-treated versus control patients (p = 0.002). CONCLUSION: The component restoration technique for the unilateral intermediate cleft tip rhinoplasty improves nasal relationships toward normal immediately and in a sustained manner for at least 3 years. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Bioinspired Collagen Scaffolds in Cranial Bone Regeneration: From Bedside to Bench.

Calvarial defects are common reconstructive dilemmas secondary to a variety of etiologies including traumatic brain injury, cerebrovascular disease, oncologic resection, and congenital anomalies. Reconstruction of the calvarium is generally undertaken for the purposes of cerebral protection, contour restoration for psychosocial well-being, and normalization of neurological dysfunction frequently found in patients with massive cranial defects. Current methods for reconstruction using autologous grafts, allogeneic grafts, or alloplastic materials have significant drawbacks that are unique to each material. The combination of wide medical relevance and the need for a better clinical solution render defects of the cranial skeleton an ideal target for development of regenerative strategies focused on calvarial bone. With the improved understanding of the instructive properties of tissue-specific extracellular matrices and the advent of precise nanoscale modulation in materials science, strategies in regenerative medicine have shifted in paradigm. Previously considered to be simple carriers of stem cells and growth factors, increasing evidence exists for differential materials directing lineage specific differentiation of progenitor cells and tissue regeneration. In this work, we review the clinical challenges for calvarial reconstruction, the anatomy and physiology of bone, and extracellular matrix-inspired, collagen-based materials that have been tested for in vivo cranial defect healing.

Age-Related Differences in Psychosocial Function of Children with Craniofacial Anomalies.

BACKGROUND: Age is a frequent consideration for surgical timing in pediatric craniofacial surgery for optimal psychosocial development. However, systematic evaluations of the effects of age in children under active treatment have not been thoroughly evaluated. METHODS: Ninety-nine patients (age, 8 to 17 years; 46.5 percent male) from the University of California, Los Angeles, Craniofacial Clinic were prospectively evaluated using the Pediatric Patient-Reported Outcomes Measurement Information System to assess anger, anxiety, depression, and quality of peer relationships. Patients were stratified into three age groups by years: group A, 8 to 10 years, n = 30; group B, 11 to 13 years, n = 41; and group C, 14 to 17 years, n = 28. Analyses of variance and logistic regression analyses were performed. RESULTS: Significant differences in anxiety (F2,96 = 5.1; p = 0.008), depression (F2,96 = 9.7; p < 0.001), peer relationships (F2,96 = 3.5; p = 0.03), and anger (F2,96 = 4.9; p = 0.009) were found among the age groups. Group A demonstrated the highest anxiety, highest depression, and lowest peer relationship scores overall. Although there were no differences in anger between groups A and C, group B had the lowest anger scores. Children with poor scores of higher severity, defined as greater than 1 SD worse than the national mean, were compared. Group A contributed the highest percentages of more severely affected children in all categories. A logistic regression analysis demonstrated that group A was a statistically significant predictor for scores of higher severity in both anxiety (OR, 3.8; 95 percent CI, 1.3 to 11.5; p = 0.02) and peer relationships (OR, 3.4; 95 percent CI, 1.3 to 9.3; p = 0.02). CONCLUSIONS: Children between 8 and 10 years of age with craniofacial anomalies constitute a high-risk subset for psychosocial dysfunction. The authors' work suggests that tight surveillance with family and school awareness may be necessary for this age group. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Evaluation of 4 Outcomes Measures in Microtia Treatment: Exposures, Infections, Aesthetics, and Psychosocial Ramifications.

BACKGROUND: In craniofacial microsomia, microtia and canal atresia pose formidable reconstructive challenges. We review our institutional experience in treating microtia and atresia to identify variables associated with 4 outcomes measures: complications, surgical revisions, aesthetic outcomes, and psychosocial function. METHODS: Craniofacial microsomia patients treated at the University of California Los Angeles Craniofacial Clinic between 2008 and 2014 greater than 13 years of age (n = 68) were reviewed for microtia and atresia treatment and outcomes. RESULTS: In total, 91.2% of patients diagnosed with craniofacial microsomia presented with microtia, affecting 75 ears. Both a male and right-sided predominance were observed. Fifty-six patients (90.3%) underwent autologous external ear reconstruction at an average age of 8.5 years. Age, type of incision, and size of cartilage framework did not predict total number of surgeries or complications. Severity of ear anomalies correlated with increased number of surgeries (P < 0.001) and decreased aesthetic outcomes (P < 0.001) but not complications. In total, 87.1% of patients with microtia had documented hearing loss, of which the majority were conductive and 18.5% were mixed sensorineural and conductive. Hearing deficits were addressed in 70.4% of patients with external hearing aids, bone anchored hearing aids, or canaloplasty. Of all variables, improvement of psychosocial function was correlated only to hearing loss treatment of any type (P = 0.01). CONCLUSIONS: On evaluation of surgical and patient characteristics, severity of microtia predicted the total number of surgical revisions performed and aesthetic ratings. In addition, we found that the only factor that correlated with improved patient and parent-reported psychosocial outcomes was treatment of hearing loss.