Impact of socioeconomic status on psychological functioning in survivorship following breast cancer and reconstruction.

Socioeconomic status (SES) remains an important population health risk factor and impacts a patient's experience of care during breast cancer. This study explored the relationship between SES and quality of life and satisfaction in survivorship following breast cancer and reconstruction. All patients underwent breast reconstruction at a single academic center from 2013 to 2017. Patients completed the five quality of life and satisfaction domains of the BREAST-Q, a validated patient-reported outcome measure. Estimated home value using a web-based real estate website was used to approximate a patient's socioeconomic status. Correlations were evaluated using Pearson's correlation methods, where appropriate, as well as analysis of covariance. Data were stratified for comparison utilizing t tests and linear regression models. Significance was defined as P ≤ .05. Four hundred patients underwent 711 breast reconstructions during the study time period. Satisfaction with the breast (P = .038) and psychosocial well-being (P = .012) had significant positive correlations with increasing socioeconomic status. When stratifying patients' socioeconomic status into thirds, the upper third had significantly higher psychosocial well-being (P = .001), satisfaction with breasts (P = .010), and physical well-being of the chest (P = .001) than the lower third. Significance persisted even after controlling for cancer stage, treatment, complications, and baseline comorbidities. Higher socioeconomic status is associated with greater satisfaction with breast reconstruction and psychosocial well-being following breast cancer treatment. Providing added social, psychological, and emotional support networks may be beneficial long after the initial cancer treatment and reconstruction are complete. Patients of lower socioeconomic status may benefit from additional resources.

Patients with psychiatric illness report worse patient-reported outcomes and receive lower rates of autologous breast reconstruction.

Psychiatric well-being impacts on general satisfaction and quality of life. This study explored how the presence of psychiatric diagnoses affects patient-reported outcomes in breast reconstruction and on selection of reconstructive modality. Patients who received breast reconstruction at a tertiary hospital between 2013 and 2018 and completed the BREAST-Q survey were included. BREAST-Q module scores were compared between patients who had a psychiatric diagnosis at presentation and the remaining cohort using t tests. General linear models (GLMs) were used to control for confounding factors. A chi-squared test was used to assess the effect on reconstructive modality, and binary logistic regression was used to control for confounding factors. Of the 471 patients included, 93 (19.7%) had at least one psychiatric diagnosis. Cohorts did not differ significantly by age, BMI, race, ASA classification, or insurance status. Patients with a psychiatric diagnosis experienced a decrease in BREAST-Q scores for the Psychosocial Wellbeing (B = 9.16, P = .001) and Sexual Wellbeing (B = 9.29, P = .025) modules. On binary logistic regression, patients with a psychiatric diagnosis were less likely to receive autologous reconstruction compared with implant reconstruction (OR = 0.489, P = .010). The presence of psychiatric diagnoses is an independent predictor of decreased BREAST-Q. Furthermore, there is a significant disparity in modality of reconstruction given to patients with psychiatric diagnoses. Further study is needed to evaluate interventions to improve satisfaction among at-risk populations and evaluate the reason for low autologous reconstruction in this population.

Assessing Facial Asymmetry in Postoperative Patients With Unilateral Coronal Craniosynostosis.

BACKGROUND: Despite surgical correction of unilateral craniosynostosis (ULC), complex cranial base angulation can result in partial reversion to preoperative deformity with growth and time. Using 3-dimensional imaging, dysmorphic facial features of ULC in school-age patients were quantified and related to how they contribute to overall facial asymmetry and patient-reported outcomes. METHODS: Children who underwent surgical correction of ULC were recruited from Yale University and Children's Hospital of Philadelphia. The 3D photographs were analyzed utilizing a Procrustes analysis of shape. Pearson's correlation was used to determine dysmorphic features' impact on overall asymmetry. Patients were stratified into "moderate" and "severe" asymmetry. Finally, asymmetry was correlated to patient-reported outcome scores. Statistical analysis was performed with SPSS-25 with P < 0.05 as statistically significant. RESULTS: Twenty-one patients were included with average age at analysis of 12.3 years. Fifty-seven percent of patients had right-sided fusion. The overall Procrustes analysis indicated a root mean square difference of 2.21 mm. Pearson's correlation indicated that the facial middle 3rd (P ≤ 0.001), orbital dystopia (P < 0.001), chin point deviation (P = 0.011), and nasal root angulation (P = 0.019) contributed most to overall asymmetry. Patients in the severe asymmetry cohort had greater facial middle-third asymmetry (P < 0.001) and orbital dystopia (P < 0.001). Asymmetry did not correlate with patient-reported outcomes. CONCLUSION: Patients with ULC have persistent facial asymmetry at school-age with the greatest levels of asymmetry in the facial middle-third, orbit, and nasal root. Beyond the cranial dysmorphology, initial skull base angulation in unilateral coronal craniosynostosis manifests in long-term mid and lower-third facial asymmetry.

Outcomes of Endoscopic Versus Open Spring Assisted Surgery for Sagittal Craniosynostosis.

Spring-assisted surgery (SAS) has been shown to be an effective technique for correction of isolated sagittal craniosynostosis in patients less than 6 months of age. At their institution, the authors adopted a minimally invasive technique in 2010, using a shorter incision and an endoscope. A retrospective chart review of 101 patients with isolated, nonsyndromic, sagittal craniosynostosis, who underwent SAS, was performed in order to compare perioperative and clinical outcomes of the open (n = 51) and minimally-invasive (n = 50) approaches. Surgeries were performed by 2 neurosurgeons and 3 plastic surgeons, between 2005 and 2018. The pre and postoperative cephalic indices were not significantly different in both groups. Minimally-invasive spring placement required a longer operative time than the open approach, with the mean minimally-invasive operative time at 65 minutes, compared to 53 minutes (P < 0.0001). Spring removal operative time was not significantly different, with the minimally-invasive operative time at 31 minutes versus 29 minutes (P = 0.48). There were no significant differences in major or minor complications when comparing the open and minimally-invasive approaches. In conclusion, both the open and the minimally-invasive SAS techniques are effective for early correction of isolated sagittal craniosynostosis, although the minimally-invasive approach requires a longer operative time for spring placement.

Spring-Assisted Strip Craniectomy Versus Cranial Vault Remodeling: Long-Term Psychological, Behavioral, and Executive Function Outcomes.

BACKGROUND: Controversy exists regarding the optimal surgical approach for non-syndromic sagittal synostosis. This study provides the first comparative analysis of the long-term behavioral, psychological, and executive function outcomes for patients who underwent either cranial vault remodeling (CVR) or spring-assisted strip craniectomy (SAS). METHODS: Thirty-six CVR patients and 39 SAS patients were evaluated. Parents and caregivers completed the Behavior Rating Inventory of Executive Function (BRIEF) and the Behavior Assessment System for Children, Second Edition (BASC-2) to evaluate behavioral, emotional, social, adaptive, and executive functioning skills. RESULTS: There were no statistically significant differences between the CVR and the SAS groups (P > 0.05) in any of the BRIEF areas of function. Furthermore, the BASC-2 battery illustrated no significant differences in all areas analyzed except one. Among the 2 groups, the CVR group was rated as having fewer social withdrawal symptoms on the BASC-2 (47.00 ±â€Š10.27) compared to the SAS cohort (54.64 ±â€Š10.96), F = 6.79, P = 0.012, Cohen d = 0.688. However, both means were still within the normal range. CONCLUSIONS: Children undergoing SAS and CVR procedures for isolated sagittal synostosis were not rated as having clinically significant behavioral, emotional, social, adaptive, or executive functioning problems on parental forms.

Secondary Cleft Rhinoplasty in 1720 Patients: Are National Practices Consistent With Guidelines?

OBJECTIVE: To assess the timing, type, and associated adjunct procedures for secondary cleft rhinoplasty nationally. DESIGN: Data were extracted from a national database of all secondary cleft rhinoplasty procedures (Current Procedural Terminology [CPT] codes 30460 and 30462). Frequency statistics were utilized to analyze demographics, comorbidities, surgical procedures, and timing. Chi-squared analysis and Fisher exact test were used for analysis. SETTING: National Surgical Quality Improvement Program-Pediatric Database. PARTICIPANTS: A total of 1720 patients met inclusion criteria for secondary cleft rhinoplasty repair. INTERVENTIONS: No relevant intervention. MAIN OUTCOMES AND MEASURES: Age, demographics, comorbidities, and associated procedures. RESULTS: Over 5 consecutive years, 1720 patients underwent secondary cleft lip rhinoplasty nationally. Mean patient age was 9.3 ± 5.3 years. Unilateral cleft rhinoplasty patients were older (9.0 years) than bilateral patients (7.8 years; P = .001). Rib grafting was performed in 6.3% of patients at a mean age of 10.6 years with a higher proportion of Asian and female patients. Auricular grafts were more commonly performed by otolaryngology than plastic surgery. The most common adjunct procedures included secondary cleft lip revision (33.1%) and tympanostomy tube placement (10.2%). When subdividing by type of cleft rhinoplasty, tip rhinoplasty was performed at a mean age of 7.3 years compared to rhinoplasty with osteotomies and a major septal component at 12.1 years (P < .001). CONCLUSIONS: This study reveals that a large proportion of cleft rhinoplasties are performed in skeletally immature patients. Although patients undergoing rib grafting, nasal osteotomies, and a major septal component were older, these procedures are still performed in a large proportion of patients who are younger than expected.

Veau III and Veau IV Cleft Palate: Do Peri-Operative Complications Differ?

OBJECTIVE: The Veau classification represents the most commonly used system for characterizing cleft palate severity. Conflicting evidence exists as to how increasing Veau classification affects outcomes. This study compared perioperative outcomes between Veau III and IV cleft palate repairs. METHODS: The National Surgical Quality Improvement Program Pediatric (NSQIP-P) database was used to identify cleft palate repairs between 2012 and 2016 using CPT codes. Patients with alveolar bone grafts were excluded. Veau III (unilateral) and Veau IV (bilateral) cleft palate repairs were identified using International Classification of Disease code 9 and 10 (ICD-9 and -10 codes. Patient demographics, comorbidities, and adverse events were compared between the cohorts. RESULTS: A total of 5026 patients underwent cleft palate repair between 2012 and 2016. Of the 2114 patients with identifiable Veau classification, 1302 had Veau III cleft palates and 812 had Veau IV cleft palates.The Veau IV cleft palate patient population was older (377.8 versus 354.1 days, P < 0.001) and had significantly more comorbidities including a higher incidence of chronic lung disease (P = 0.014), airway abnormalities (P = 0.001), developmental delay (P = 0.018), structural central nervous system deformities (P < 0.001), and nutritional support (P < 0.001). Veau IV cleft palate repairs also had longer operative times (153.2 versus 140.2 minutes, P < 0.001). Despite significant differences in comorbidities and perioperative factors, there were no differences in 30-day complications, readmissions, or reoperation rates between Veau III and IV cleft palate repairs. CONCLUSIONS: Patients undergoing Veau IV cleft palate repair have a significantly greater number of comorbidities than Veau III cleft palate repairs. Despite differences in patient populations, 30-day surgical outcomes are comparable between the cohorts.

National Longitudinal Comparison of Patients Undergoing Surgical Management of Craniosynostosis.

PURPOSE: Limited cross-institutional studies compare strip craniectomy versus cranial vault remodeling (CVR) for craniosynostosis management. Given competing surgical preferences, the authors conducted a large-scale analysis of socioeconomic differences, costs, and complications between treatment options. METHODS: Nonsyndromic craniosynostosis patients receiving strip craniectomies or CVR were identified in the Kids' Inpatient Database for years 2000 to 2009. Demographics, socioeconomic background, hospital characteristics, charge, and outcomes were tabulated. Univariate and multivariate analyses were performed for comparison. RESULTS: Two hundred fifty-one strip craniectomies and 1811 CVR patients were captured. Significantly more strip craniectomy patients were White while more CVR patients were Hispanic or Black (P < 0.0001). Strip craniectomy patients more often had private insurance and CVR patients had Medicaid (P < 0.0001). Over time, CVR trended toward treating a higher proportion of Hispanic and Medicaid patients (P = 0.036). Peri-operative charges associated with CVR were $27,962 more than strip craniectomies, and $11,001 after controlling for patient payer, income, bedsize, and length of stay (P < 0.0001). Strip craniectomies were performed more frequently in the West and Midwest, while CVR were more common in the South (P = 0.001). Length of stay was not significant. Postsurgical complications were largely equivocal; CVR was associated with increased accidental puncture (P = 0.025) and serum transfusion (P = 0.002). CONCLUSION: Our national longitudinal comparison demonstrates widening socioeconomic disparities between strip craniectomy and CVR patients. Cranial vault remodeling is more commonly performed in underrepresented minorities and patients with Medicaid, while strip craniectomy is common in the White population and patients with private insurance. While hospital charges and complications were higher among CVR, differences were smaller than expected.

Dynamic regulation of ß1 subunit trafficking controls vascular contractility.

Ion channels composed of pore-forming and auxiliary subunits control physiological functions in virtually all cell types. A conventional view is that channels assemble with their auxiliary subunits before anterograde plasma membrane trafficking of the protein complex. Whether the multisubunit composition of surface channels is fixed following protein synthesis or flexible and open to acute and, potentially, rapid modulation to control activity and cellular excitability is unclear. Arterial smooth muscle cells (myocytes) express large-conductance Ca(2+)-activated potassium (BK) channel α and auxiliary ß1 subunits that are functionally significant modulators of arterial contractility. Here, we show that native BKα subunits are primarily (∼95%) plasma membrane-localized in human and rat arterial myocytes. In contrast, only a small fraction (∼10%) of total ß1 subunits are located at the cell surface. Immunofluorescence resonance energy transfer microscopy demonstrated that intracellular ß1 subunits are stored within Rab11A-postive recycling endosomes. Nitric oxide (NO), acting via cGMP-dependent protein kinase, and cAMP-dependent pathways stimulated rapid (≤1 min) anterograde trafficking of ß1 subunit-containing recycling endosomes, which increased surface ß1 almost threefold. These ß1 subunits associated with surface-resident BKα proteins, elevating channel Ca(2+) sensitivity and activity. Our data also show that rapid ß1 subunit anterograde trafficking is the primary mechanism by which NO activates myocyte BK channels and induces vasodilation. In summary, we show that rapid ß1 subunit surface trafficking controls functional BK channel activity in arterial myocytes and vascular contractility. Conceivably, regulated auxiliary subunit trafficking may control ion channel activity in a wide variety of cell types.

Biology of Bone Formation, Fracture Healing, and Distraction Osteogenesis.

Distraction osteogenesis is a bone-regenerative process in which an osteotomy is followed by distraction of the surrounding vascularized bone segments, with formation of new bone within the distraction gap. Distraction osteogenesis is efficacious for reconstructing critical sized bony defects in the appendicular and craniofacial skeleton. To provide opportunity to expand applications of distraction osteogenesis, it is important to have a thorough understanding of the underlying molecular biology and physiology of bone development and fracture healing. To accomplish these objectives a review of the literature was performed using search terms "endochondral ossification, intramembranous ossification, craniofacial skeleton, appendicular skeleton, fracture healing, bone development, and distraction osteogenesis." Bones of the craniofacial and appendicular skeleton have distinct mechanisms of embryonic development. The former develops from growth centers of mesenchymal precursors through intramembranous ossification. The latter forms though endochondral ossification in growth plates. However, both endochondral and intramembranous bone share similar master regulatory transcription factors and downstream growth factors. Fracture healing mirrors the pathway by which these bones developed embryonically. In contrast, bone formed by distraction osteogenesis does so by intramembranous ossification, regardless of whether it occurs within the appendicular or craniofacial skeleton. Understanding molecular pathway differences between bone formation by these mechanisms may allow for optimization and expansion of skeletal reconstruction by distraction osteogenesis.

Smooth muscle cell transient receptor potential polycystin-2 (TRPP2) channels contribute to the myogenic response in cerebral arteries.

Intravascular pressure-induced vasoconstriction is a smooth muscle cell-specific mechanism that controls systemic blood pressure and organ regional blood flow. Smooth muscle cell polycystin-1 and -2 (TRPP1 and -2) proteins modulate the myogenic response in mesenteric arteries, but involvement in other vascular beds is unclear. Here, we examined TRPP2 expression, cellular distribution, cation currents (ICat), and physiological functions in smooth muscle cells of rat and human cerebral arteries. We demonstrate that TRPP2 is the major TRPP isoform expressed in cerebral artery smooth muscle cells, with message levels higher than those of TRPP1. Arterial biotinylation and immunofluorescence indicated that TRPP2 is located primarily (∼88%) in the smooth muscle cell plasma membrane. RNA interference reduced TRPP2 expression by ∼55% compared to control, but did not alter levels of TRPP1, TRPC1, TRPC3, TRPC6, TRPM4, ANO1/TMEM16A, or voltage-dependent Ca(2+) (CaV1.2) channels, other ion channel proteins that modulate myogenic tone. Cell swelling induced by hyposmotic (250 osmol (l solution)(-1)) bath solution stimulated Gd(3+)-sensitive ICat in smooth muscle cells that were reduced by selective TRPP2 knockdown. TRPP2 knockdown did not alter myogenic tone at 20 mmHg but reduced tone between ∼28 and 39% over an intravascular pressure range between 40 and 100 mmHg. In contrast, TRPP2 knockdown did not alter depolarization-induced (60 mmol l K(+)) vasoconstriction. In summary, we show that TRPP2 is expressed in smooth muscle cells of resistance-size cerebral arteries, resides primarily in the plasma membrane, and contributes to the myogenic response. Data also suggest that TRPP2 differentially regulates the myogenic response in cerebral and mesenteric arteries.

The voltage-dependent L-type Ca2+ (CaV1.2) channel C-terminus fragment is a bi-modal vasodilator.

Voltage-dependent L-type Ca(2+) channels (CaV1.2) are the primary Ca(2+) entry pathway in vascular smooth muscle cells (myocytes). CaV1.2 channels control systemic blood pressure and organ blood flow and are pathologically altered in vascular diseases, which modifies vessel contractility. The CaV1.2 distal C-terminus is susceptible to proteolytic cleavage, which yields a truncated CaV1.2 subunit and a cleaved C-terminal fragment (CCt). Previous studies in cardiac myocytes and neurons have identified CCt as both a transcription factor and CaV1.2 channel inhibitor, with different signalling mechanisms proposed to underlie some of these effects. CCt existence and physiological functions in arterial myocytes are unclear, but important to study given the functional significance of CaV1.2 channels. Here, we show that CCt exists in myocytes of both rat and human resistance-size cerebral arteries, where it locates to both the nucleus and plasma membrane. Recombinant CCt expression in arterial myocytes inhibited CaV1.2 transcription and reduced CaV1.2 protein. CCt induced a depolarizing shift in the voltage dependence of both CaV1.2 current activation and inactivation, and reduced non-inactivating current in myocytes. Recombinant truncated CCt lacking a putative nuclear localization sequence (92CCt) did not locate to the nucleus and had no effect on arterial CaV1.2 transcription or protein. However, 92CCt shifted the voltage dependence of CaV1.2 activation and inactivation similarly to CCt. CCt and 92CCt both inhibited pressure- and depolarization-induced vasoconstriction, although CCt was a far more effective vasodilator. These data demonstrate that endogenous CCt exists and reduces both CaV1.2 channel expression and voltage sensitivity in arterial myocytes. Thus, CCt is a bi-modal vasodilator.

A comparison of perioperative safety for breast augmentation in cis- vs. trans patients.

BACKGROUND: Gender-affirming surgery provides a psychosocial benefit to transgender women. However, increased medical complexity within the transgender population has limited access for some transgender women. This study compared patient population comorbidities and 30-day peri-operative safety following primary augmentation mammoplasty between cis- and transgender women. METHODS: Data were extracted from the National Surgical Quality Improvement Program (NSQIP) database between 2007 and 2016. Transgender patients were identified using ICD-9 &10 codes for gender dysphoria. Categorical variables were compared using chi-squared and Fisher's exact tests while independent t-tests were used for continuous variables. Statistical significance was set at P<0.05. RESULTS: There were 4,234 breast augmentations identified in cisgender women and 137 in transgender women. Transgender women had a higher frequency of ASA-II and ASA-III patients (P<0.001), diabetes (P<0.001), hypertension (P=0.006), and active smoking status (P<0.001). Despite the higher comorbidity burden and routine use of hormonal therapy, there were no significant differences between populations in major or minor peri-operative complication rates. CONCLUSIONS: Top surgery improves quality of life in transgender women. Despite the more complex pre-operative risk profile in the transgender population, there is no difference in peri-operative safety profiles. Plastic surgeons treating this patient population should consider more liberal surgical indications for reconstructive top surgery compared with cosmetic breast augmentation.

Comparison of Autologous Breast Reconstruction Complications by Type of Neoadjuvant Chemotherapy Regimen.

BACKGROUND: Neoadjuvant chemotherapy before mastectomy helps reduce tumor burden and pathologic response in breast cancer. Limited evidence exists regarding how neoadjuvant chemotherapy impacts outcomes following microvascular breast reconstruction. This study examines the effects of neoadjuvant chemotherapy regimens and schedules on microvascular breast reconstruction complication rates and also assesses the effects of neoadjuvant chemotherapy on circulating immune cells related to wound healing. METHODS: Patients who underwent neoadjuvant chemotherapy and microvascular breast reconstruction at Yale New Haven Hospital between 2013 and 2018 were identified. Demographic variables, oncologic history, chemotherapy regimens, and complication profiles were collected. Chemotherapy regimens were stratified by inclusion of anthracycline and order of taxane administration. Chi-square, Fisher's exact, and t tests were used for univariate analysis. Multivariate binary logistic regression was used to control for covariates. RESULTS: One hundred patients met inclusion criteria. On multivariate analysis, the administration of taxane first in an anthracycline-containing chemotherapy sequence was associated with increased complications (OR, 3.521; p = 0.012), particularly fat necrosis (OR, 2.481; p = 0.040). In the logistic regression model evaluating the effect of the taxane-first regimen on complication rates, the area under the curve was estimated to be 0.760 (p < 0.0001), particularly fat necrosis 0.635 (p < 0.05). The dosage of chemotherapy, number of days between neoadjuvant chemotherapy completion and surgery, and number of circulating immune cells did not significantly differ among patients who experienced complications. CONCLUSIONS: Taxane-first, anthracycline-containing neoadjuvant chemotherapy regimens were associated with increased complications, particularly fat necrosis. The increased postreconstruction complication risk must be weighed against the benefits of taxane-first regimens in improving tumor outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A Comparison of BREAST-Q Scores between Prepectoral and Subpectoral Direct-to-Implant Breast Reconstruction.

BACKGROUND: Subpectoral breast implant placement has in recent history predominated in breast reconstruction, but there has been more recent adoption of prepectoral implant reconstruction. There has been limited study to date of patient-reported outcomes comparing the two techniques. METHODS: Patients who underwent direct-to-implant breast reconstruction between 2013 and 2018 were included in this retrospective cohort study. Eligible patients were asked to complete BREAST-Q domains comparing quality of life and satisfaction. Descriptive, t test, chi-square test, and multivariate linear regression analyses were performed to compare BREAST-Q scores. Significance was defined as p ≤ 0.05. RESULTS: There were 64 patients (114 breasts) who underwent prepectoral reconstruction and 37 patients (68 breasts) who underwent subpectoral reconstruction. Among the 101 women (182 breasts), there were no significant differences between BREAST-Q scores and implant position for the Satisfaction with Breasts domain (adjusted p = 0.819), Psychosocial Well-being domain (adjusted p = 0.206), or Physical Well-being Chest domain (adjusted p = 0.110). The subpectoral implant cohort was associated with higher scores, 53 versus 47, for the Sexual Well-being module (adjusted p = 0.001). CONCLUSIONS: Patients undergoing direct-to-implant breast reconstruction had comparable BREAST-Q satisfaction scores for most modules regardless of implant plane. The subpectoral implant cohort scored higher for sexual well-being.

Long-Term Neurocognitive Outcomes of Spring-Assisted Surgery versus Cranial Vault Remodeling for Sagittal Synostosis.

BACKGROUND: A long-term neurocognitive comparison of patients with sagittal synostosis who underwent spring-assisted surgery or cranial vault remodeling has not been performed. METHODS: Patients with sagittal synostosis who underwent spring-assisted surgery or cranial vault remodeling were recruited from Wake Forest School of Medicine and Yale School of Medicine, respectively. Cognitive tests administered included an abbreviated intelligence quotient, academic achievement, and visuomotor integration. An analysis of covariance model compared cohorts controlling for demographic variables. RESULTS: Thirty-nine spring-assisted surgery and 36 cranial vault remodeling patients were included in the study. No significant differences between cohorts were found with respect to age at surgery, sex, race, birth weight, family income, or parental education. The cranial vault cohort had significantly older parental age (p < 0.001), and mean age at testing for the spring cohort was significantly higher (p = 0.001). After adjusting for covariates, the cranial vault cohort had significantly higher verbal intelligence quotient (116.5 versus 104.3; p = 0.0024), performance intelligence quotient (109.2 versus 101.5; p = 0.041), and full-scale intelligence quotient (114.3 versus 103.2; p = 0.0032). When included patients were limited to intelligence quotients from 80 to 120, the cranial vault cohort maintained higher verbal (108.0 versus 100.4; p = 0.036), performance (104.5 versus 97.7; p = 0.016), and full-scale (107.6 versus 101.5; p = 0.038) intelligence quotients. The cranial vault cohort had higher visuomotor integration scores than the surgery group (111.1 versus 98.1; p < 0.001). There were no significant differences in academic achievement. CONCLUSIONS: Sagittal synostosis patients who underwent cranial vault remodeling had higher intelligence quotient and visuomotor integration scores. There were no differences in academic achievement. Both cohorts had intelligence quotient scores at or above the normal range. Further studies are warranted to identify factors that may contribute to cognitive outcome differences. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Radiographic Severity of Metopic Craniosynostosis Correlates with Long-Term Neurocognitive Outcomes.

BACKGROUND: Reports of neurodevelopmental delays in adolescents with metopic craniosynostosis have ranged from 15 to 61 percent. Previously, event-related potentials have correlated preoperative radiographic severity with language deficiencies in infancy. This study sought to characterize neurocognitive testing at cranial maturity and correlate outcomes to preoperative radiographic severity. METHODS: Patients diagnosed with metopic craniosynostosis who underwent surgical correction in infancy completed a neurodevelopmental battery evaluating age-normalized intelligence quotient, academic achievement, and visuomotor integration. Data were stratified by preoperative endocranial bifrontal angle (moderate, >124 degrees; severe, <124 degrees). Multiple variable regression was used to control measured intelligence and achievement for age at surgery, age at testing, parental education, and income. Significance was set at p < 0.05. RESULTS: Twenty patients completed neurodevelopmental testing. Mean intelligence quotient was 111.7 ± 13 and academic achievement was similar to national averages (word reading, 53.4 percent; reading comprehension, 53.4 percent; reading composite, 53.5 percent; spelling, 44 percent; and math, 52.9 percent). Radiographic measurements revealed 36 percent of patients with moderate phenotype and 64 percent with severe. Patients with severe phenotypes had lower intelligence quotient measures and scored more poorly in every academic measure tested. Word reading (113 versus 95; p = 0.035) and reading composite (109 versus 98; p = 0.014) reached significance. CONCLUSIONS: Overall, cranial mature patients with metopic craniosynostosis had above average intelligence quotient and academic achievement near the national mean. Long-term neurocognitive function was correlated to preoperative radiographic severity in metopic craniosynostosis, with more severe cases performing worse. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Impact of Insurance Payer on Type of Breast Reconstruction Performed.

BACKGROUND: The impact of insurance and socioeconomic status on breast reconstruction modalities when access to care is controlled is unknown. METHODS: Records for patients who underwent breast reconstruction at an academic medical center between 2013 and 2017 were reviewed and analyzed using chi-square analysis and logistic regression. RESULTS: One thousand six hundred eighty-three breast reconstructions were analyzed. The commercially insured were more likely to undergo microvascular autologous breast reconstruction (44.4 percent versus 31.3 percent; p < 0.001), with an odds ratio of 2.22, whereas patients with Medicare and Medicaid were significantly more likely to receive tissue expander/implant breast reconstruction, with an odds ratio of 1.42 (41.7 percent versus 47.7 percent; p = 0.013). Comparing all patients with microvascular reconstruction, the commercially insured were more likely to receive a perforator flap (79.7 percent versus 55.3 percent versus 43.9 percent), with an odds ratio of 4.23 (p < 0.001). When stratifying patients by median household income, those in the highest income quartile were most likely to receive a perforator flap (82.1 percent) (p < 0.001), whereas those in the lowest income quartile were most likely to receive a muscle-sparing transverse rectus abdominis myocutaneous flap (36.4 percent) (p < 0.001). CONCLUSIONS: Patients at the same academic medical center had significantly different breast reconstruction modalities when stratified by insurance and household income. Despite similar access to care, differences in insurance types may favor higher rates of perforator flap breast reconstruction among the commercially insured. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

National Patterns in Surgical Management of Syndactyly: A Review of 956 Cases.

Purpose: Being one of the most common congenital hand malformations, syndactyly is repaired by orthopedic, plastic, and fellowship-trained general surgeons. Limited multi-institutional outcomes analyses regarding incidence, timing, and type of repair exist. Methods: All syndactyly cases performed over a 5-year period from 2012-2016 were isolated from the National Surgical Quality Improvement Program Pediatric database. Patient demographics, surgical factors, perioperative outcomes, and risk factors were analyzed using χ2, Fisher exact, and t-test analysis. Results: A total of 956 patients who underwent syndactyly repair were identified. Most cases were simple syndactyly with nearly even case distribution among plastic and orthopedic surgeons. Most patients were men and Caucasian. Mean age at the time of surgery was 2.6 years. Most cases were performed as outpatient surgery. Patients of plastic surgeons had significantly more airway abnormalities and shorter operative times. Patients with complex syndactyly had significantly more ventilator dependence, tracheostomy, and comorbidities when compared with those with simple syndactyly. Cases with complex syndactyly also had longer operative times and a higher rate of superficial surgical site infections. Conclusions: Syndactyly repair is a safe procedure with few major or minor reconstructive complications regardless of the surgical specialty or syndactyly type. Patients with complex syndactyly have significantly more preoperative comorbidities with comparable outcomes. orthopedic surgeons have significantly longer operative times than plastic surgeons, likely due to caring for increased number of patients with complex syndactyly.

Comparison of Neurocognitive Outcomes in Postoperative Adolescents with Unilateral Coronal Synostosis.

Unilateral coronal nonsyndromic craniosynostosis is associated with asymmetric skull growth, which may influence cerebral long-term function. Twenty affected adolescents who underwent cranial vault remodeling at a mean age of 8.2 months (12 from the Yale Craniofacial Clinic and eight from the Children's Hospital of Philadelphia) all completed a double-blinded neurodevelopmental assessment at an average age of 12.1 years. The study cohort included 55 percent female and 50 percent right-sided craniosynostosis. Mean verbal intelligence quotient was highest at 117.3, and mean performance intelligence quotient was 106.4, for a mean full-scale intelligence quotient of 112.5. Patients performed above the national average on all academic achievements except for numerical operations, which was significantly lower than word reading (p = 0.022). Patients performed below average on all Beery-Buktenica visual motor tests; motor-coordination was poorer than both visual motor integration and visual perception (p = 0.027 and p = 0.005). Significant positive correlations existed between paternal education/visual perception (r = 0.450; p = 0.046) and household income/verbal intelligence quotient (r = 0.628; p = 0.004). Patients with right unilateral coronal nonsyndromic craniosynostosis had improved spelling compared with left-sided patients on multivariate regression (p = 0.033). Female patients had higher motor coordination (p = 0.024). Breast-fed patients had better performance intelligence quotient (p = 0.024), visual motor integration (p = 0.014), and visual perception (p = 0.031). Adolescents who underwent cranial vault remodeling at two institutions had above average intelligence quotient scores, but worse mathematical and visual motor achievement compared with control subjects. Left-side craniosynostosis patients performed worse in spelling than right-side patients. Breast-feeding was an independent predictor for improved performance intelligence quotient, visual motor achievement, and visual perception performance. Study findings are limited by the cohort size. A larger population study is required, which could validate or modify the study conclusions.