Visual Attention, Bias, and Social Dispositions Toward People With Facial Anomalies: A Prospective Study With Eye-Tracking Technology.

BACKGROUND: Facial attractiveness influences our perceptions of others, with beautiful faces reaping societal rewards and anomalous faces encountering penalties. The purpose of this study was to determine associations of visual attention with bias and social dispositions toward people with facial anomalies. METHODS: Sixty subjects completed tests evaluating implicit bias, explicit bias, and social dispositions before viewing publicly available images of preoperative and postoperative patients with hemifacial microsomia. Eye-tracking was used to register visual fixations. RESULTS: Participants with higher implicit bias scores fixated significantly less on the cheek and ear region preoperatively (P = 0.004). Participants with higher scores in empathic concern and perspective taking fixated more on the forehead and orbit preoperatively (P = 0.045) and nose and lips (P = 0.027) preoperativel. CONCLUSIONS: Participants with higher levels of implicit bias spent less visual attention on anomalous facial anatomy, whereas participants with higher levels of empathic concern and perspective taking spent more visual attention on normal facial anatomy. Levels of bias and social dispositions such as empathy may predict layperson gaze patterns toward those with facial anomalies and provide insights to neural mechanisms underlying the "anomalous is bad" paradigm.

Prenatal Diagnosis of Cleft and Craniofacial Conditions: An International Analysis of Practice Patterns.

ABSTRACT: Prenatal diagnosis of congenital anomalies is associated with increased parental stress. Surgical prenatal counseling for parents expecting a child with an orofacial cleft has been shown to reduce parental anxiety through education and expectation setting. Despite the prevalence and significance of these conditions throughout the world, little is known of international counseling practices as they pertain to clefts and other craniofacial conditions, specifically regarding topics of counseling and discussions of ethical issues including interruption of pregnancy (IOP).In this study, 50 members of the International Society of Craniofacial Surgery, representing 18 countries, were surveyed. The questionnaire included questions about the number of consultations performed, for which conditions, setting of practice, and regional regulations pertaining to IOP. The authors report that the most frequent topics of discussion included initial treatment of clefts (89%), future surgeries (89%), and speech/language difficulties (85%). North American surgeons more frequently discussed cleft appearance (100%) thansurgeons from Central/SouthAmerica (64%) or Europe (64%, P = 0.019). Overall, 46% of surgeons surveyed believe it is ethical to give parents their opinion on IOP when asked. European surgeons were more likely to report that parents want to receive information about IOP at prenatal consultations (82%), compared to 25% from North America and 8% from Central/South America ( P < 0.001). The authors conclude that despite a lack of standard guidelines on conducting prenatal counseling appointments for cleft and craniofacial conditions, discussion topics were similar across country, practice type, and surgeon experience.

Wound location is independently associated with adverse outcomes following first-time revascularization for tissue loss.

OBJECTIVE: Few studies adequately evaluate the impact of wound location on patient outcomes after lower extremity revascularization. Consequently, we evaluated the relationship between lower extremity wound location and long-term outcomes. METHODS: We reviewed all patients at our institution undergoing any first-time open surgical bypass or percutaneous transluminal angioplasty with or without stenting for tissue loss between 2005 and 2014. We categorized wounds into three distinct groups: forefoot (ie, toes and metatarsal heads), midfoot (ie, dorsal, plantar, lateral, medial surfaces excluding toes, metatarsal heads, or heel), and heel. Limbs with multiple wounds were excluded from analyses. We compared rates of perioperative complications, wound healing, reintervention, limb salvage, amputation-free survival, and survival using χ2, Kaplan-Meier, and Cox regression analyses. RESULTS: Of 2869 infrainguinal revascularizations from 2005 to 2014, 1126 underwent a first-time revascularization for tissue loss, of which 253 patients had multiple wounds, 197 had wounds proximal to the ankle, 100 had unreliable wound information, and 576 (forefoot, n = 397; midfoot, n = 61; heel, n = 118) fit our criteria and had a single foot wound with reliable information regarding wound specifics. Patients with forefoot, midfoot, and heel wounds had similar rates of coronary artery disease, hypertension, diabetes, and smoking history (all P > .05). Conversely, there were significant differences in patient age (71 vs 69 vs 70 years), prevalence of gangrene (41% vs 5% vs 21%), and dialysis dependence (18% vs 17% vs 30%) (all P < .05). There were no statistically significant differences in perioperative mortality (1.3% vs 4.9% vs 4.2%; P = .06) or postoperative complications among the three groups. Between forefoot, midfoot, and heel wounds, there were significant differences in unadjusted 6-month rates of complete wound healing (69% vs 64% vs 53%), 3-year rates of amputation-free survival (54% vs 57% vs 35%), and survival (61% vs 72% vs 41%) (all P < .05). After adjustment, compared with forefoot wounds, heel wounds were associated with higher rates of incomplete 6-month wound healing (hazard ratio [HR], 1.6; 95% confidence interval [CI], 1.1-2.]), major amputation or mortality (HR, 1.7; 95% CI, 1.1-2.7), and all-cause mortality (HR, 1.8; 95% CI, 1.1-3.0), but not major amputation alone (HR, 2.1; 95% CI, 0.9-4.5). In open surgical bypass-first patients, heel wounds were solely associated with an increased risk of all-cause mortality (HR, 1.7; 95% CI, 1.1-2.8), whereas heel wounds in percutaneous transluminal angioplasty-first patients were associated with an increased risk of incomplete wound healing (HR, 2.2; 95% CI, 1.3-3.7), major amputation or mortality (HR, 2.3; 95% CI, 1.1-5.4), and all-cause mortality (HR, 2.8; 95% CI, 1.1-7.2). CONCLUSIONS: Heel wounds confer considerably higher short- and long-term morbidity and mortality compared with midfoot or forefoot wounds in patients undergoing any first-time lower extremity revascularization.

What is the Impact of Prenatal Counseling on Postnatal Cleft Treatment? Multidisciplinary Pathway for Prenatal Orofacial Cleft Care.

ABSTRACT: In the pediatric general surgery literature, it has been shown that prenatal diagnosis of a congenital anomaly is an independent predictor of parental psychological distress. Surgical prenatal counseling can decrease parental anxiety by helping families understand the surgical needs and potential outcomes of their infant. In this retrospective analysis (n = 440), the authors sought to present our care pathway for prenatally diagnosed cleft lip and palate (CL/P) and explore the impact of cleft lip and palate-specific prenatal counseling on patient care by comparing the timing of clinical and surgical care between a cohort of patients who received prenatal CL/P consultation and a cohort of patients only seen postnatally. The authors hypothesize that our multidisciplinary prenatal care intervention is associated with earlier postnatal clinic visits and surgical repair. The care of all patients whose mother's presented for prenatal CL/P consultation (prenatal cohort, n = 118) was compared to all new CL/P patients without prenatal consultation at our institution (postnatal cohort, n = 322) from January 2015 through August 2019. 81.4% (n = 96) of the prenatal cohort returned for care postnatally while 2 pregnancies were interrupted, four neonates died, and 15 patients did not return for care. Prenatal consultation was associated with earlier postnatal clinic appointments (P < 0.001) as well as a shorter time to CL repair in patients with CL only (P = 0.002) and CLP (P = 0.047). Our described pre- and postnatal CL/P pathway is a multidisciplinary model associated with high retention rates from the prenatal period through complete surgical repair.

Globalization of The Journal of Craniofacial Surgery Over The Last Decade: A Continent, Country, and State Level Analysis.

ABSTRACT: Craniofacial surgery continues to be a rapidly evolving field, due in part to interdisciplinary collaboration that has allowed for sharing of knowledge and methodologies, which has expanded greatly due to online journals and publications. The Journal of Craniofacial Surgery (JCS) is a highly regarded journal that has attracted attention for its mission to increase diversity and global representation in manuscript submissions and research publications. The purpose of this study is to provide an objective measurement of global participation in craniofacial research specifically as it pertains to the JCS. Through a bibliometric analysis, the country of origin of all articles published in the JCS from 2010 to 2019 was analyzed. In line with its mission, the JCS increased its overall production 1.9 times during the past decade and increased its global representation 1.6 times, as represented by the number of countries contributing (78). The journal produced 8147 articles with Turkey (1424), USA (1397), China (1178), South Korea (1023), and Italy (644) being the top producers. The highest represented states were Florida (156), New York (130), California (117), Massachusetts (112), and Pennsylvania (106). The Journal of Craniofacial Surgery has the greatest diversity of country representation of the major plastic and reconstructive journals compared. Overall the JCS has stayed true to its mission to foster craniofacial research and is a valuable resource for craniofacial surgeons across the world. This study provides an analysis of trends in global contributions to craniofacial research and highlights areas for further increasing global contributors to the field of craniofacial surgery.

Is Risk of Secondary Surgery for Oronasal Fistula Following Primary Cleft Palate Repair Associated With Hospital Case Volume and Cost-to-Charge Ratio?

OBJECTIVE: This study assesses the association between risk of secondary surgery for oronasal fistula following primary cleft palate repair and 2 hospital characteristics-cost-to-charge ratio (RCC) and case volume of cleft palate repair. DESIGN: Retrospective cohort study. SETTING: This study utilized the Pediatric Health Information System (PHIS) database, which consists of clinical and resource-utilization data from >49 hospitals in the United States. PATIENTS AND PARTICIPANTS: Patients undergoing primary cleft palate repair from 2004 to 2009 were abstracted from the PHIS database and followed up for oronasal fistula repair between 2004 and 2015. MAIN OUTCOME MEASURE(S): The primary outcome measure was whether patients underwent oronasal fistula repair after primary cleft palate repair. RESULTS: Among 5745 patients from 45 institutions whom met inclusion criteria, 166 (3%) underwent oronasal fistula repair within 6 to 11 years of primary cleft palate repair. Primary palatoplasty at high-RCC facilities was associated with a higher rate of subsequent oronasal fistula repair (odds ratio [OR] = 1.84 [1.32-2.56], adjusted odds ratio [AOR] = 1.81 [1.28-2.59]; P ≤ .001). Likelihood of surgery for oronasal fistula was independent of hospital case volume (OR = 0.83 [0.61-1.13], P = .233; AOR = 0.86 [0.62-1.20], P = .386). Patients with complete unilateral or bilateral cleft palate were more likely to receive oronasal fistula closure compared to those with unilateral-incomplete cleft palate (AOR = 2.09 [1.27-3.56], P = .005; AOR = 3.14 [1.80-5.58], P < .001). CONCLUSIONS: Subsequent need for oronasal fistula repair, while independent of hospital case volume for cleft palate repair, increased with increasing hospital RCC. Our study also corroborates complete cleft palate and cleft lip as risk factors for oronasal fistula.

Pediatric Otoplasty: Does Surgical Specialty Training Affect Safety and Rates of Adverse Perioperative Events?

BACKGROUND: Otoplasty remains an overlapping clinical domain of plastic surgery and otolaryngology. The purpose of this study is to objectively analyze the safety of otoplasty and determine if there are any risk factors, such as surgical training, associated with increased patient morbidity. METHODS: Retrospective cohort study was conducted of otoplasty procedures performed in North America by plastic surgeons and otolaryngologists between 2012 and 2017 using the American College of Surgeons National Surgical Quality Improvement Program Pediatric dataset. Statistical analysis was performed to analyze the relationships between comorbidities, congenital malformations, and postoperative complications. RESULTS: There were 777 otoplasty procedures performed during the study period. Median age at time of surgery was 8.3 years (95% CI 7.9-8.7 years). Plastic surgeons performed 75.8% (n = 589) procedures and otolaryngologists performed 23.4% (n = 182). No significant (P = 0.952) difference in the occurrence of postoperative complications between surgical specialties was appreciated despite the fact that operative time was significantly longer in procedures performed by otolaryngologists (121 minutes versus 94 minutes, P < 0.001). Overall, 1.3% (n = 10 of 777) children experienced a complication, with the most common complication being superficial surgical site infection, occurring in 0.9% (n = 7 of 777) patients. There was no association of comorbidities (P all > 0.324) or congenital malformations (P all > 0.382) contributing to postoperative complications. Reoperation (0.8%, n = 6 of 777) and readmission (0.4%, n = 3 of 777) were uncommon; nevertheless, these adverse events were significantly associated with multiple inherent patient risk factors on multivariate regression. CONCLUSIONS: Otoplasty is a relatively safe surgical procedure with similarly low complication and readmission rates when performed by plastic surgeons and otolaryngologists. Surgical site infection remains the most prevalent complication after otoplasty. Readmission and reoperation after otoplasty were significantly correlated to prematurity, structural pulmonary abnormality, alimentary tract disease, and seizure disorder.

Trends in Utilization of Virtual Surgical Planning in Pediatric Craniofacial Surgery.

INTRODUCTION: While the use of virtual surgical planning (VSP) has been well described in the adult craniofacial literature, there has been little written about pediatric uses or trends. The purpose of this study is to evaluate the evolving utilization of VSP for pediatric craniofacial procedures. METHODS: The authors' prospective institutional review board-approved craniofacial registry was queried for index craniofacial procedures from January 2011 through December 2018. Data was collected regarding utilization of traditional surgical planning versus VSP, as well as the extent of VSP's influence on the operative procedure. These data were analyzed for trends over time and compared using appropriate statistics. RESULTS: During the study period, a total of 1131 index craniofacial cases were performed, of which 160 cases (14.1%) utilized VSP. Utilization of VSP collectively increased over time, from 2.0% in 2011 to 18.6% in 2018 (P < 0.001). Utilization rates of VSP varied across procedures from 0% of craniosynostosis cases and fronto-orbital advancement cases to 67% of osteocutaneous free tissue transfers (P < 0.001). The most profound contributor to increase in VSP utilization was orthognathic surgery, utilized in 0% of orthognathic procedures in 2011 to 68.3% of orthognathic procedures in 2018 (P < 0.001). CONCLUSIONS: Utilization of virtual surgical planning for pediatric craniofacial procedures is increasing, especially for complex orthognathic procedures and osteocutaneous free tissue transfers. Utilization patterns of individual components of the VSP system demonstrate unique footprints across the spectrum of craniofacial procedures, which reinforces the specific and variable benefits of this workflow for treating pediatric craniofacial disorders.

Value-Based Analysis of Virtual Versus Traditional Surgical Planning for Orthognathic Surgery.

BACKGROUND: In orthognathic surgery, virtual surgical planning (VSP) is gaining popularity over traditional surgical planning (TSP); however, concerns about cost of VSP have slowed adoption of this technology. This study investigates the clinical value of VSP versus TSP over the entire clinical care continuum. METHODS: Retrospective cohort study was conducted for patients undergoing maxillomandibular surgery between 2005 and 2016 at a tertiary pediatric hospital. Clinical value, defined as patient outcomes per unit cost, was analyzed between the 2 groups with appropriate statistics. RESULTS: The VSP (n = 19) and TSP (n = 10) cohorts had statistically similar hospital lengths of stay, rates of complications, readmissions, and duration of postoperative orthodontic treatment (P = 0.518, P > 0.999, P > 0.999, P = 0.812, respectively). VSP maxillomandibular procedures trended towards shorter operative times (P = 0.052). Total hospital charges were statistically similar between the TSP and VSP cohorts (P = 0.160). Medication, laboratory and testing, and room charges were also statistically similar between the TSP and VSP cohorts (P = 0.169, P = 0.953, and P = 0.196 respectively). CONCLUSIONS: Indexed patient outcomes and costs incurred for maxillomandibular procedures were statistically similar between those utilizing TSP or VSP leading us to conclude that these 2 methods are associated with similar clinical value. This retrospective analysis should be followed with prospective data to give patients and insurers the best estimate of clinical value utilizing TSP and VSP.

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.

Long Term Speech Outcomes Following Midface Advancement in Syndromic Craniosynostosis.

Midface advancement by distraction osteogenesis (DO) is commonly performed in patients with craniosynostosis for indications including midface hypoplasia, exorbitism, obstructive sleep apnea, class III malocclusion, and overall aesthetic facial deficiency. There is evidence to suggest that maxillary LeFort I advancement increases the risk of velopharyngeal dysfunction in the cleft palate population, yet few studies have investigated changes in speech following LeFort III or monobloc midface advancement in patients with syndromic craniosynostosis. The purpose of this study was to examine the effect of midface DO on speech as indicated by the Pittsburgh Weighted Speech Score in patients with Apert, Crouzon, and Pfeiffer Syndrome. Among 73 midface advancement cases performed during the study period, 19 cases met inclusion criteria. Overall, the highest post-advancement Pittsburgh Weighted Speech Score (PWSS) was significantly higher than the pre-advancement PWSS (0.52 versus 2.42, P = 0.01), indicating an acute worsening of VPI post-advancement. Specifically, the PWSS components nasal emission and nasality were significantly higher post-advancement than pre-advancement (nasal emission: 1.16 versus 0.21, P = 0.02) (nasality: 0.68 versus 0.05, P = 0.04). However, there was no significant difference between pre-advancement PWSS and the latest post-advancement PWSS (P = 0.31). Midface distraction is associated with an acute worsening of VPI post-operatively that is followed by improvement, and often resolution over time. Future work with additional patient accrual is needed to determine the effect of different advancement procedures and syndromes on VPI rates and profundity.

Perceptions and Preferences of Laypersons in the Management of Positional Plagiocephaly.

BACKGROUND: Uncertain clinical evidence for treating positional plagiocephaly, especially with helmet therapy, creates difficulties in counseling parents of patients. This study investigates layperson perceptions and treatment preferences for positional plagiocephaly to provide patient-oriented evidence for management. METHODS: Adult laypersons were recruited through crowdsourcing to view digitally-modified images of normal, mildly, moderately, or severely plagiocephalic infant heads. Participants provided demographic information and rated the infant's head shape and potential related social difficulties, likelihood of consulting a physician for treatment options, and likelihood of seeking helmeting treatment for the infant. RESULTS: Nine hundred forty-five individuals participated in the study. Perception of head shape, prediction of future embarrassment and social difficulties, likelihood of seeking physician evaluation, likelihood of choosing helmet therapy, and willingness-to-pay for helmet therapy were pairwise-different between 4 plagiocephaly severities (corrected-P < 0.001 for all), except between normocephaly (n = 194) and mild (n = 334) plagiocephaly or between moderate (n = 203) and severe (n = 214) plagiocephaly. Younger respondents were more likely to consult a physician (uncorrected-P = 0.016) and choose helmet therapy (uncorrected-P = 0.004) for infants with normocephaly or mild plagiocephaly. Parents of children with physical disabilities were 6 times as likely as other participants to choose helmet therapy for mild plagiocephaly (corrected-P = 0.036). CONCLUSIONS: Laypersons perceived moderate and severe plagiocephaly as equally abnormal and mild plagiocephaly as normal, consistent with their treatment preferences. Parents of physically disabled children were significantly more likely than other participants to choose helmet therapy. Our findings provide medical professionals with lay perspectives on positional plagiocephaly that may facilitate effective counseling of parents.

Outcomes after first-time lower extremity revascularization for chronic limb-threatening ischemia in insulin-dependent diabetic patients.

OBJECTIVE: Historically, open surgical bypass provided a durable repair among diabetic patients with chronic limb-threatening ischemia (CLTI). In the current endovascular era, however, the difference in long-term outcomes between first-time revascularization strategies among patients with insulin-dependent diabetes mellitus (IDDM) is poorly understood. METHODS: We reviewed the records of all patients with IDDM undergoing a first-time infrainguinal bypass graft (BPG) or percutaneous transluminal angioplasty with or without stenting (PTA/S) for CLTI at our institution from 2005 to 2014. We defined IDDM as use of chronic insulin administration at baseline to control blood glucose levels and recorded the most recent glycated hemoglobin value available within 3 months before the procedure and fasting blood glucose level on the day of the procedure. We compared rates of wound healing, restenosis, reintervention, major amputation, and mortality between BPG and PTA/S in our population using χ2, Kaplan-Meier, and Cox regression analyses. As a sensitivity analysis, we calculated propensity scores and employed inverse probability weighting to account for nonrandom assignment to BPG vs PTA/S. RESULTS: Of 2869 infrainguinal revascularizations from 2005 to 2014, 655 limbs (316 BPG, 339 PTA/S) in 580 patients fit our criteria and underwent a first-time revascularization for CLTI. Patients undergoing BPG, compared with PTA/S, were similar in age (69 vs 68 years; P = .55), had similar rates of tissue loss (87% vs 91%; P = .07) and dialysis dependence (26% vs 28%; P = .55), were less likely to be hypertensive (84% vs 92%; P < .001), and were more likely to be current smokers (21% vs 14%; P = .02). There were no differences between BPG and PTA/S patients in mean glycated hemoglobin levels (8.1% vs 8.0%; P = .51) or mean fasting blood glucose levels (158 vs 150 mg/dL; P = .18). Although total hospital length of stay was significantly longer among BPG patients (11 vs 8 days; P < .001), perioperative complications did not differ, including acute kidney injury (19% vs 23%; P = .24), hematoma (6.0% vs 3.8%; P = .20), acute myocardial infarction (1.3% vs 2.1%; P = .43), and mortality (3.8% vs 3.0%; P = .55). BPG-first patients had significantly lower unadjusted 6-month rates of incomplete wound healing (49% vs 57%) and 5-year rates of restenosis (53% vs 72%) and reintervention (47% vs 58%; all P < .05). After adjustment, multivariable analysis suggested PTA/S-first intervention to be significantly associated with higher risk of restenosis (hazard ratio, 1.9; 95% confidence interval, 1.3-2.7) and reintervention (1.9 [1.2-2.7]). These results remained robust after inverse probability weighting. CONCLUSIONS: Among patients with IDDM and CLTI, a bypass-first strategy is associated with similar 30-day outcomes and lower restenosis and reintervention rates. These data suggest that a bypass-first approach may best serve appropriately selected, anatomically suitable patients with IDDM and pedal ischemia that requires revascularization.

Visual Attention Toward Patients with Hemifacial Microsomia Reconstruction: A Prospective Eye-Tracking Study.

BACKGROUND: Facial areas attracting the most visual attention in Hemifacial Microsomia (HFM) are poorly understood. Further, it is not clear if and how visual attention changes from pre- to post-operatively. This study characterized layperson visual attention to pre- and post-reconstruction hemifacial microsomia (HFM) using eye-tracking technology. METHODS: Visual fixations (Tobii Pro Nano) were recorded in four areas of interest from sixty participants completing two consecutive trials of 68 total images in each hemi-face of 17 patients with HFM pre- and post- orthognathic jaw reconstruction. Linear mixed effect models evaluated if visual fixations were affected by surgical reconstruction. RESULTS: 47,354 visual fixations were captured over 120 trials within defined AOIs. Linear mixed effect models revealed significantly decreased postoperative visual fixations in the mandible and chin region [716 (54.8%) pre-reconstruction, 591 (45.2%) post reconstruction; ß = -0.198, SE = 0.056, z = -3.550, p < 0.001]. Analysis also revealed significantly increased postoperative visual fixations in the forehead and orbit region [11350 (48.6%) pre-reconstruction, 12000 (51.4%) post-reconstruction; ß = 0.086, SE = 0.015, z = 5.664, p < 0.00001]. CONCLUSIONS: Following corrective jaw surgery for HFM, laypersons demonstrated significantly less visual attention to the mandible and chin and increased visual attention to the forehead and orbit. These findings suggest postoperative improvement towards aesthetic normalcy may reduce visual attention to previously anomalous anatomy.

Ten Years of Posterior Cranial Vault Expansion by Means of Distraction Osteogenesis: An Update and Critical Evaluation.

BACKGROUND: The goal of this study was to describe the 10-year evolution of the authors' surgical technique and institutional perioperative outcomes using posterior vault distraction osteogenesis (PVDO) in patients with syndromic and multisuture craniosynostosis. METHODS: The authors performed a retrospective cohort study of patients who underwent PVDO for treatment of syndromic and multisuture craniosynostosis at a single institution over a 10-year period. Demographic data, perioperative outcomes, distraction patterns, and complications were analyzed. Outcomes of patients in the first 5 years (early cohort) were compared with those of the latter 5 years (late cohort). RESULTS: One hundred ten patients underwent a total of 118 PVDO procedures. Patients with a syndromic diagnosis represented 83.6 percent of the cohort ( n = 92) and were significantly younger than patients with a nonsyndromic diagnosis at the time of first PVDO (median [25th percentile, 75th percentile] 14.1 [6.6, 40.1] versus 42.7 [15.2, 59.6] months; p = 0.014). Mean distraction distance in the anterior-posterior direction was 30.8 mm (SD, 7.4). Compared with the early cohort, PVDO in the late cohort had faster median operative times (144.0 [123.0, 189.0] minutes versus 161.0 [138.0, 199.0] minutes; p = 0.038), lower estimated blood loss as a percentage of blood volume (28.5 [20.6, 45.3] versus 50.0 [31.1, 95.8]; p < 0.001), and lower blood replacement as percentage of blood volume (39.5 [23.8, 59.1] versus 56.3 [37.8, 110.1]; p = 0.009). CONCLUSIONS: This 10-year experience with PVDO demonstrates continued overall safety and efficacy with improved perioperative outcomes over time. Although PVDO has become the authors' first line of expansion in syndromic craniosynostosis, shortcomings such as need for device removal, infection concerns, and potential for cerebrospinal fluid leak merit attention by the craniofacial community. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Postnatal outcomes and risk factor analysis for patients with prenatally diagnosed oropharyngeal masses.

OBJECTIVES: To describe our experience treating prenatally diagnosed oropharyngeal masses in a novel, multidisciplinary collaboration. To identifying outcomes and risk factors associated with adverse postnatal outcomes. METHODS: This is a sixty-two patient case series at an academic referral center. Patients with prenatally diagnosed oropharyngeal masses were identified through a programmatic database and confirmed in the electronic health record. RESULTS: Sixty-two patient with prenatally diagnosed oropharyngeal mass were identified, with prenatal imaging at our institution confirming this diagnosis in fifty-seven patients, short term outcomes analysis conducted on forty-four patients, and long-term outcomes analysis conducted on seventeen patients. The most common pathology was lymphatic malformations (n = 27, 47.4%), followed by teratomas (n = 22, 38.6%). The median mass volume from all available patient imaging (n = 57) was 60.54 cm3 (range 1.73-742.5 cm3). Thirteen pregnancies were interrupted, six infants expired, and thirteen cases had an unknown fetal outcome. Confirmed mortality was 6/57 patients with imaging-confirmed oropharyngeal masses (10.5%). Fourteen (56%) of the surviving patients (n = 25) were delivered by Ex Utero Intrapartum Treatment (EXIT) procedure and the median NICU stay was thirty-six days (range: 3-215 days). There was no association between airway compression/deviation/displacement, stomach size, polyhydramnios, or mass size and mortality. Seventeen patients had more than one year of follow-up (mean 5.3 ± 2.4 years). These seventeen patients underwent general anesthesia a total of ninety-two times (mean 5.4 ± 4.3) and had a total of twenty-three mass-related surgeries. The great majority of patients required an artificial airway at birth, feeding support, and speech/swallow therapy. CONCLUSIONS: Oropharyngeal mass involvement of key anatomic structures-the neck, upper thorax, orbit, and ear, has a greater association with mortality than mass size. Regardless of the size and involved structures, oropharyngeal masses are associated with a high burden of intensive medical care and surgical care beginning at or before birth.

Poverty and Risk of Cleft Lip and Palate: An Analysis of United States Birth Data.

BACKGROUND: The relationship between poverty and incidence of cleft lip and cleft palate remains unclear. The authors investigated the association between socioeconomic status and cleft lip with or without cleft palate and cleft palate only in the United States after controlling for demographic and environmental risk factors. METHODS: The U.S. 2016 and 2017 natality data were utilized. Proxies for socioeconomic status included maternal education, use of the Special Supplemental Nutrition Program for Women, Infants, and Children, and payment source for delivery. Multiple logistic regression controlled for household demographics, prenatal care, maternal health, and infant characteristics. RESULTS: Of 6,251,308 live births included, 2984 (0.05 percent) had cleft lip with or without cleft palate and 1180 (0.02 percent) had cleft palate only. Maternal education of bachelor's degree or higher was protective against, and delayed prenatal care associated with, cleft lip with or without cleft palate (adjusted ORs = 0.73 and 1.14 to 1.23, respectively; p < 0.02). Receiving assistance under the Special Supplemental Nutrition Program for Women, Infants, and Children was associated with cleft palate only (adjusted OR = 1.25; p = 0.003). Male sex, first-trimester tobacco smoking, and maternal gestational diabetes were also associated with cleft lip with or without cleft palate (adjusted ORs = 1.60, 1.01, and 1.19, respectively; p < 0.05). Female sex, prepregnancy tobacco smoking, and maternal infections during pregnancy were associated with cleft palate only (adjusted ORs = 0.74, 1.02, and 1.60, respectively; p < 0.05). CONCLUSIONS: Increased incidence of orofacial clefts was associated with indicators of lower socioeconomic status, with different indicators associated with different cleft phenotypes. Notably, early prenatal care was protective against the development of cleft lip with or without cleft palate. CLIINCAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

A Nationwide Analysis of Cleft Palate Repair: Impact of Local Anesthesia on Operative Outcomes and Hospital Cost.

BACKGROUND: This study investigates the associations between local anesthesia practice and perioperative complication, length of stay, and hospital cost for palatoplasty in the United States. METHODS: Patients undergoing cleft palate repair between 2004 and 2015 were abstracted from the Pediatric Health Information System database. Perioperative complication, length of stay, and hospital cost were compared by local anesthesia status. Multiple logistic regressions controlled for patient demographics, comorbidities, and hospital characteristics. RESULTS: Of 17,888 patients from 49 institutions who met selection criteria, 8631 (48 percent), 4447 (25 percent), and 2149 (12 percent) received epinephrine-containing lidocaine, epinephrine-containing bupivacaine, and bupivacaine or ropivacaine alone, respectively. The use of epinephrine-containing bupivacaine or bupivacaine or ropivacaine alone was associated with decreased perioperative complication [adjusted OR, 0.75 (95 percent CI, 0.61 to 0.91) and 0.63 (95 percent CI, 0.47 to 0.83); p = 0.004 and p = 0.001, respectively]. Only bupivacaine- or ropivacaine-alone recipients experienced a significantly reduced risk of prolonged length of stay on adjusted analysis [adjusted OR, 0.71 (95 percent CI, 0.55 to 0.90); p = 0.005]. Risk of increased cost was reduced in users of any local anesthetic (p < 0.001 for all). CONCLUSIONS: Epinephrine-containing bupivacaine or bupivacaine or ropivacaine alone was associated with reduced perioperative complication following palatoplasty, while only the latter predicted a decreased postoperative length of stay. Uses of epinephrine-containing lidocaine, epinephrine-containing bupivacaine, and bupivacaine or ropivacaine alone were all associated with decreased hospital costs. Future prospective studies are warranted to further delineate the role of local anesthesia in palatal surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Biliary atresia liver histopathological determinants of early post-Kasai outcome.

BACKGROUND: A retrospective chart review of liver histologies in Kasai biliary atresia BA patients operated 1/2017- 7/2019 at our institution was conducted to identify histologic prognostic factors for biliary outcome. METHODS: Patients with wedge liver biopsies and portal plate biopsies (n = 85) were categorized into unfavorable and favorable outcome, based on a 3-month serum total bilirubin level of <34 µM or mortality. Hepatocellular histologies, presence of ductal plate malformation (DPM) and of large bile duct of ≥ 150 µm diameter size at the portal plate were evaluated. RESULTS: Total Bilirubin levels> 34 µM correlates with worse 1-year survival. Age at surgery, histologic fibrosis or inflammation does not predict outcome. Potential adverse predictors are severe hepatocellular swelling, severe cholestasis, presence of DPM (n = 24), and portal plate bile duct size < 150 µm (n = 28). In multivariate analyses adjusting for age at Kasai and postop cholangitis, bile duct size and severe hepatocellular swelling remain independent histologic prognosticators (OR 3.25, p = 0.039 and OR 3.26, p = 0.006 respectively), but not DPM. CONCLUSION: Advanced histologic findings of portal plate bile duct size of <150 µm and severe hepatocellular damage predict poor post-Kasai jaundice clearance and short-term survival outcome, irrespective of Kasai timing. LEVEL OF EVIDENCE: Level III.

Physiologic Timeline of Cranial-Base Suture and Synchondrosis Closure.

BACKGROUND: Fusion of cranial-base sutures/synchondroses presents a clinical conundrum, given their often unclear "normal" timing of closure. This study investigates the physiologic fusion timelines of cranial-base sutures/synchondroses. METHODS: Twenty-three age intervals were analyzed in subjects aged 0 to 18 years. For each age interval, 10 head computed tomographic scans of healthy subjects were assessed. Thirteen cranial-base sutures/synchondroses were evaluated for patency. Partial closure in greater than or equal to 50 percent of subjects and complete bilateral closure in less than 50 percent of subjects defined the fusion "midpoint." Factor analysis identified clusters of related fusion patterns. RESULTS: Two hundred thirty scans met inclusion criteria. The sutures' fusion midpoints and completion ages, respectively, were as follows: frontoethmoidal, 0 to 2 months and 4 years; frontosphenoidal, 6 to 8 months and 12 years; and sphenoparietal, 6 to 8 months and 4 years. Sphenosquamosal, sphenopetrosal, parietosquamosal, and parietomastoid sutures reached the midpoint at 6 to 8 months, 8 years, 9 to 11 months, and 12 years, respectively, but rarely completed fusion. The occipitomastoid suture partially closed in less than or equal to 30 percent of subjects. The synchondroses' fusion midpoints and completion ages, respectively, were as follows: sphenoethmoidal, 3 to 5 months and 5 years; spheno-occipital, 9 years and 17 years; anterior intraoccipital, 4 years and 10 years; and posterior intraoccipital, 18 to 23 months and 4 years. The petro-occipital synchondrosis reached the midpoint at 11 years and completely fused in less than 50 percent of subjects. Order of fusion of the sutures, but not the synchondroses, followed the anterior-to-posterior direction. Factor analysis suggested three separate fusion patterns. CONCLUSIONS: The fusion timelines of cranial-base sutures/synchondroses may help providers interpret computed tomographic data of patients with head-shape abnormalities. Future work should elucidate the mechanisms and sequelae of cranial-base suture fusion that deviates from normal timelines.