Burn Patients and Mental Health: A Matched Cohort Study.

OBJECTIVE: To determine the association between burns and hospitalization for mental health disorders up to three decades later. SUMMARY BACKGROUND DATA: Burns are associated with pain, disability, and scarring, but the long-term impact on mental health is unclear. METHODS: We analyzed a cohort of 23,726 burn patients aged ≥10 years who were matched to 223,626 controls from Quebec, Canada, between 1989 and 2022. The main exposure was admission for a burn. We followed patients during 3,642,206 person-years of follow-up to identify future hospitalizations for psychiatric disorders, substance use disorders, and suicide attempts. We estimated adjusted hazard ratios (HR) with 95% confidence intervals (CI) for the association between burns and subsequent mental health hospitalization using Cox proportional hazards regression. RESULTS: Burn patients had 1.76 times greater risk of mental health hospitalization over time (95% CI 1.72-1.81), compared with controls. Associations were present regardless of burn site, but were greatest for burns covering ≥50% of the body (HR 3.29, 95% CI 2.61-4.15), third degree burns (HR 2.04, 95% CI 1.94-2.14), and burns requiring skin grafts (HR 2.00, 95% CI 1.90-2.10). Compared with controls, burn patients had more than two times the risk of hospitalization for eating disorders (HR 3.14, 95% CI 2.50-3.95), psychoactive substance use disorders (HR 2.27, 95% CI 2.17-2.39), and suicide attempts (HR 2.42, 95% CI 2.23-2.62). Risks were particularly elevated within 5 years of the burn, but persisted throughout follow-up. CONCLUSIONS: Burns are associated with an increased risk of hospitalization for mental health disorders up to 30 years later.

Determination of Novel, Cranium-Based Relationships for Construct Placement in Microtia Reconstruction for Hemifacial Microsomia Patients.

OBJECTIVE: Determine if the ideal location of the construct in microtia reconstruction for hemifacial microsomia (HFM) can be more accurately derived from measurements on the cranium. DESIGN: High-resolution computerized tomography (CT) images were analyzed through craniometric linear relationships. SETTING: Our tertiary care institution from 2000 to 2021. PATIENTS/PARTICIPANTS: Patients diagnosed with HFM and microtia, who had high-resolution craniofacial CT scans, yielding 36 patients accounting for 44 CT scans. MAIN OUTCOME MEASURE(S): First, the integrity of the posterior cranial vault among HFM patients was determined. If proven to be unaffected, it could be used as a reference in the placement of the construct. Second, the position of the ear in relation to the cranium was assessed in healthy age-matched controls. Third, if proven to be useful, the concordance of these cranium-based relationships could be validated among our HFM cohort. RESULTS: The posterior cranial vault is unaffected in HFM (P > .001). Further, craniometric relationships between the tragus and the Foramen Magnum, as well as between the tragus and the posterior cranium, have been shown to be highly similar and equally precise in predicting tragus position in healthy controls (P > .001). These relationships held true across all age groups (P > .001), and importantly among HFM patients, where the mean absolute difference in predicted tragus position never surpassed 1.5 mm. CONCLUSIONS: Relationships between the tragus and the cranium may be used as an alternative to distorted facial anatomy or surgeon's experience to assist in pre-operative planning of construct placement in microtia reconstruction for HFM patients.

Face transplantation: anesthesia and other organizational considerations.

In 2005, the first facial vascularized composite allotransplant was performed in France. In May 2018, our team at Maisonneuve-Rosemont Hospital, Montreal, Quebec, had the privilege to participate in the first facial transplant in Canada. Interdisciplinary collaboration, coordination, and communication formed the cornerstone of this medical undertaking and, ultimately, its success. This report details the anesthetic and organizational considerations of our experience.

RéSUMé: En 2005, la première allogreffe de tissu composite vascularisée faciale était réalisée en France. En mai 2018, notre équipe à l'Hôpital Maisonneuve-Rosemont, à Montréal, au Québec, a eu le privilège de participer à la première greffe faciale au Canada. La collaboration, la coordination et la communication interdisciplinaires ont constitué les pierres angulaires de ce projet médical et, ultimement, de son succès. Ce compte-rendu détaille les considérations anesthésiques et organisationnelles de notre expérience.

Breast Implant-Associated Anaplastic Large Cell Lymphoma: Immediate or Delayed Implant Replacement?

INTRODUCTION: Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a rare and recently described type of peripheral T-cell lymphoma. Fewer than 550 cases have been reported worldwide. Although BIA-ALCL is usually indolent, early diagnosis and treatment have been shown to improve outcome. CASE DESCRIPTION: This case report describes the management of a 50-year-old healthy Caucasian woman presenting with rapid painful enlargement of the left breast. Imaging revealed findings consistent with BIA-ALCL. This diagnosis was confirmed by fine needle aspiration cytology and subsequent pathological analysis. Bilateral removal of implants, complete left capsulectomy and immediate bilateral implant exchange were performed. CONCLUSION: No consensus currently exists regarding optimal time of implant exchange and management of the contralateral capsule. The immediate replacement with smooth implants was thoroughly discussed with the patient and endorsed by expert opinion, given complete removal of the disease. There was no sign of recurrence at 6 months. Close clinical and radiological visits are planned for the next years. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Revisiting the anatomic relationship of the marginal mandibular nerve and the posterior facial vein: a cadaveric study.

In preparation for the donor and recipient facial vascularized composite allotransplant (VCA), the marginal mandibular nerve branch should be identified and co-apted to the recipient's nerve to allow for re-innervation. We describe a method to identify the marginal mandibular branch of the facial nerve in facial VCA donors and recipients. Through cadaver dissections, the posterior facial vein was traced posteriorly to identify the marginal mandibular branch of the facial nerve. In cases where we were unable to use this relationship, we found the posterior facial venous system to be diminutive. This technique is useful for finding the marginal mandibular branch when dissecting anterograde to the parotid gland.

The role of computer-assisted design and modeling in an edentulous mandibular malunion reconstruction.

Mandibular trauma is a common problem encountered by the craniofacial surgeon. Fractures in the edentulous mandible represent only 3% of these injuries, and optimal management is controversial. This problem is further compounded by malunion and malocclusion when fracture lines heal in incorrect positions. Even with recent advances in imaging and hardware systems, they remain difficult problems that often require multiple operations to obtain satisfactory results. We present a 69-year-old man with an edentulous mandibular fracture and concomitant malocclusion after a series of unsuccessful operations. By using computer-assisted design and manufacturing technology, we were able to plan osteotomies for correct anatomic positioning, which restored dental occlusion and facial aesthetics. A follow-up at 6 months postoperatively revealed a stable and anatomic reconstruction.

Computer-aided design and manufacturing in craniosynostosis surgery.

BACKGROUND: Considerable operative time is expended during the planning, shaping, and reconfiguring of the cranial vault in the pursuit of symmetry during open craniosynostosis surgery. Computer-aided design and manufacturing has recently been implemented in orthognathic surgery and complex craniomaxillofacial reconstruction as a means of optimizing operative accuracy and efficiency. In this report, we highlight our growing experience with this promising modality for the preoperative planning and intraoperative execution of cranial vault remodeling in patients with both simple and complex forms of craniosynostosis. METHODS: Computer-assisted surgical planning begins with acquisition of high-resolution computed tomography scans of the craniofacial skeleton. An Internet-based teleconference is then held between the craniofacial and biomedical engineering teams and provides a forum for virtual manipulation of the patient's preoperative three-dimensional computed tomography with real-time changes and feedback. Through virtual surgical planning, osteotomies are designed and calvarial bones reconfigured to achieve the desired cranial vault appearance. Cutting and positioning guides are manufactured to transform the virtual plan into a reality. RESULTS: From February to March 2012, 4 children (aged 9 months to 6 years) with craniosynostosis underwent computer-assisted simulation and surgery. Diagnoses included metopic, unicoronal (n = 2), and multisutural synostoses (sagittal and left unicoronal). Open craniofacial repairs were performed as virtually planned, including front o-orbital remodeling, fronto-orbital advancement, and anterior two-thirds calvarial remodeling, respectively. Cutting and final positioning guides demonstrated excellent fidelity and ease of use. CONCLUSIONS: Computer-aided design and manufacturing may offer a platform for optimizing operative efficiency, precision, and accuracy in craniosynostosis surgery, while accelerating the learning curve for future trainees.

How Big Is Too Big? Exploring the Relationship between Breast Implant Volume and Postoperative Complication Rates in Primary Breast Augmentations.

There is no consensus regarding implant size as an independent risk factor for complications in primary breast augmentation. Choosing appropriate implant volume is an integral part of the preoperative planning process. The current study aims to assess the relationship between implant size and the development of complications following augmentation mammaplasty. Methods: A retrospective chart review of patients undergoing primary breast augmentation at the Westmount Institute of Plastic Surgery between January 2000 and December 2021 was conducted. Demographics, implant characteristics, surgical technique, postoperative complications, and follow-up times were recorded. Univariate logistic regression was used to identify independent predictors, which were then included in multivariate logistic regressions of implant volume and implant volume/body mass index (BMI) ratio regarding complications. Results: A total of 1017 patients (2034 breasts) were included in this study. The average implant volume used was 321.4 ± 57.5 cm3 (range: 110-605). Increased volume and volume/BMI ratio were associated with a significant increase in risk of implant rupture (odds ratio = 1.012, P < 0.001 and 1.282, P < 0.001 respectively). Rates of asymmetry were significantly associated with increases in implant volume and volume/BMI ratio (odds ratio = 1.005, P = 0.004 and 1.151, P < 0.001, respectively). No single implant volume or volume/BMI ratio above which risks of complications significantly increase was identified. Conclusions: Implant rupture and postoperative asymmetries are positively correlated with bigger implant volumes. Implant size could likely be a useful independent predictor of certain complications, especially in patients with high implant to BMI ratios.

Subperiosteal release of the floor of the mouth to correct airway obstruction in pierre robin sequence: review of 31 cases.

OBJECTIVE: The purpose of this study was to evaluate subperiosteal release of the floor of the mouth (SRFM) musculature to correct neonatal airway obstruction in children with Pierre Robin sequence and to compare this procedure with other surgical options available. METHODS: A retrospective chart review of patients who underwent a SRFM for neonatal severe airway obstruction unresponsive to conservative management was performed. Preoperative and postoperative oxygenation parameters, sleep studies, feeding difficulties, and long-term evolution were documented. RESULTS: Thirty-one consecutive patients between 1995 and 2009, 19 boys and 12 girls, had an SRFM procedure to alleviate severe neonatal airway obstruction. Eight children were syndromic, 15 had associated malformations, and eight had an isolated Pierre Robin sequence. The airway obstruction was corrected with SRFM alone in 26 children (84%), three patients remained dependent on nasopharyngeal airway, and two required subsequent mandibular osteogenic distraction procedures following the SRFM to manage persistent obstruction. No patient required a tracheostomy. The average age at SRFM was 33 days, and the patients were kept intubated for an average of 6 days postoperatively. Average hospital stay after the surgery was 45 days, and 10 patients went home with gavage feeding. CONCLUSIONS: The SRFM is effective for the treatment of severe airway obstruction in patients with Pierre Robin sequence. The procedure is simple and has fewer complications and secondary procedures than other surgical options for correction of the airway obstruction.

Validating a Novel Device to Improve Skin Color Matching for Face Transplants.

Facial vascularized composite allotransplantation (VCA) offers an added layer of complexity when compared to solid organ transplantation. VCAs must account for aesthetic variables such as skin tone and color. The goal of this study is to validate the Nix Color Sensor as a novel tool to be added to the plastic surgeon's armamentarium for evaluating skin color match of the donor and recipient. Methods: A prospective study of 100 individuals was conducted. All participants were photographed and scanned with the Nix Color Sensor. Sixty pairwise comparisons were randomly generated. Skin color analysis was performed using photographs and the Nix Color Sensor. Delta E2000 values were compared to mean evaluator ratings using a Spearman correlation analysis. Results: One hundred patients were included. A Spearman's correlation demonstrated a strong inverse correlation between Delta E2000 values and the mean evaluator ratings. The higher the mean evaluator rating for likeness, the lower the delta. A correlation coefficient of -0.850 demonstrates a statistically significant relationship (P < 0.01). Conclusions: When the Delta E2000 rises above 5 there is a significant drop in the mean evaluator ratings. As mean evaluator ratings of 5 and above would be considered adequate for face transplant amongst most plastic surgeons, an E2000 value of 5 or lower should be targeted when matching donors with recipients for face transplant. The Nix Color Sensor positively correlates to the plastic surgeon's perception of skin color and can serve as an adjunct in donor selection for facial VCAs.

Surgical Microtia Reconstruction in Hemifacial Microsomia Patients: Current State and Future Directions.

Background: Hemifacial microsomia (HFM) is one of the most common congenital craniofacial disorders. Among many other features, microtia is present in the large majority of these patients. However, mainly due to the unilateral hypoplastic anatomy, microtia reconstruction among this patient population remains a reconstructive challenge for plastic surgeons. Given that no clear standards exist, an evidence-based synthesis of the literature was devised. Methods: A systematic search of Pubmed, Medline, and Embase was carried out, in accordance with the PRISMA guidelines. Studies discussing surgical microtia reconstruction for HFM patients were retained. Qualitative data regarding study design, challenges addressed, specific recommendations, and their respective strengths/limitations were extracted from each. Retrieved recommendations were consolidated and assigned a level of evidence grade. Results: Although only 11 studies were included in this review, these provided 22 main recommendations regarding the eight HFM-specific challenges identified, which were of either grade C (n = 5) or D (n = 17). Included studies addressed construct location (n = 7), the low hairline (n = 6), soft tissue construct coverage (n = 6), earlobe reconstruction (n = 6), construct projection (n = 5), anomalies of the relevant neurovascular systems (n = 2), retroauricular construct coverage (n = 2), and sizing of the construct (n = 2). Conclusions: Given the many persisting reconstructive challenges regarding surgical microtia reconstruction for HFM patients, the authors present a comprehensive and evidence-based consolidation of recommendations specific to these challenges. The authors hope this systematic review can appropriately guide plastic surgeons and will ultimately improve care for this patient population.

Expanding the Classic Facial Canons: Quantifying Intercanthal Distance in a Diverse Patient Population.

Background: The intercanthal distance (ICD) is central to our perception of facial proportions, and it varies according to gender and ethnicity. Current standardized reference values do not reflect the diversity among patients. Therefore, the authors sought to provide an evidence-based and gender/ethnicity-specific reference when evaluating patients' ICD. Methods: As per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search of PubMed, Medline, and Embase was carried out for studies reporting on the ICD. Demographics, study characteristics, and ICDs were extracted from included studies. ICD values were then pooled for each ethnicity and stratified by gender. The difference between men and women, and that across ethnicities and measurement types were compared by means of independent sample t-test and one-way ANOVA (SPSS v.24). Results: A total of 67 studies accounting for 22,638 patients and 118 ethnic cohorts were included in this pooled analysis. The most reported ethnicities were Middle Eastern (n = 6629) and Asian (n = 5473). ICD values (mm) in decreasing order were: African 38.5 ± 3.2, Asian 36.4 ± 1.6, Southeast Asian 32.8 ± 2.0, Hispanic 32.3 ± 2.0, White 31.4 ± 2.5, and Middle Eastern 31.2 ± 1.5. A statistically significant difference (P < 0.05) existed between all ethnic cohorts, between genders among most cohorts, and between most values stratified by measurement type. Conclusions: Our standards of craniofacial anthropometry must evolve from the neoclassical canons using White values as references. The values provided in this review can aid surgeons in appreciating the gender- and ethnic-specific differences in the ICD of their patients.

Fine Details That Improve Nasal Reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Identify common negative outcomes that arise with conventional nasal reconstruction. 2. Understand the technical refinements that help avoid and reduce negative outcomes in nasal reconstruction. 3. Learn about the utility of regional axial island flaps for nasal reconstruction, in particular, the lateral nasal artery flap. SUMMARY: Nasal reconstruction has been a preoccupation of surgeons dating to before 600 bc. The nose is the central focal point of the face and a key identifying facial feature, and surgery to the nose can prove to be challenging to even the most experienced surgeon. The objective of this CME article is to outline the most commonly used surgical options for each nasal aesthetic subunit, and the specific complications observed for each. The best surgical options and technical refinements are highlighted, and principles that may help restore the nose are outlined.

Utility Outcome Measures for the Treatment of Ameloblastomas during Childhood.

Our objective was to determine the potential impact of the surgical treatment of ameloblastoma in children through validated health state utility outcome measures. METHODS: A survey-based preference health utility assessment using the visual analog scale, time trade-off, and standard gamble methods was undertaken among a general population sample. Quality-adjusted life years were derived from these measures. A one-way ANOVA was used for statistical analysis, with a mean (P) value of 0.05 considered significant. Demographic parameters were individually assessed as possible predictors of each utility score. RESULTS: In total, 86 participants took part in this study, with a mean age of 29.9 years. Greater utility scores were observed among participants reporting no religious beliefs (P = 0.025, t = 2.28). No other demographic parameters showed statistically significant prediction of utility score. From the mean utility scores (± SD) (visual analog scale = 0.60 ± 0.17; time trade-off = 0.65 ± 0.22; standard gamble = 0.64 ± 0.20), a gain of 30.0, 32.3, and 32.1 quality-adjusted life years may be derived, respectively. All utility outcome measures suggested that an ameloblastoma during childhood is perceived as more burdensome than several debilitating conditions, such as cleft lip and palate. CONCLUSIONS: To attain perfect health, participants would theoretically undergo surgical treatment of an ameloblastoma during childhood, with willingness to trade off 28.2 years of life and accepting a 35.7% risk of death. The objective assessment of the perceived burden of an ameloblastoma affliction during childhood may inspire cost-utility or cost-effectiveness analyses at broader societal levels.

The Pediatric Arterialized Venous Flow-through Flap.

Arterialized venous flow-through flaps are solely vascularized through the venous plexus. The flaps were first described 40 years ago; however, reports of venous congestion and ischemia discouraged surgeons from adopting them into their armamentarium. Nevertheless, recent studies have demonstrated a resurgence of venous flow-through flaps for reconstruction of small to medium defects of the hand and digits. Although current data report variable levels of success in adults, no case reports have been published in the pediatric population for this type of flap. In this study, an arterialized venous flow-through flap from the medial forearm was used to reconstruct a volar hand defect in a young child. Flap markings, surgical technique, and aftercare are described. The surgery was uncomplicated, and the postoperative outcomes were aesthetically and functionally excellent. Venous flow-through flaps restore full-thickness defects, are relatively easy to perform, allow an early return to daily activities, and have almost no morbidity. These flaps offer excellent options for pediatric hand and finger defects.

Facial Transplantation in a Nationalized Health System: The Canadian Experience.

Facial transplantation (FT) is recognized as the ultimate reconstruction for severely disfigured patients. The substantial cost of these procedures in a nationalized health system has not been extensively published. The first Canadian FT performed in May 2018 was a great opportunity to address this subject and evaluate the viability of such a program. METHODS: A detailed patient chart review was performed and a cost per unit approach was used to estimate the procedure cost. The preoperative, operative, and the postoperative periods up to 1-year after the surgery were analyzed. Financial support from private sponsors and Hospital Fund donations were considered. The literature on international FT and national solid organ transplantation was reviewed. RESULTS: The overall 1-year cost was estimated at $440,224 (2018 CAD). The costs are explained by a long hospital length of stay, costly immunosuppressive therapy, and high immunosuppression-related complications. Those findings are consistent with international FT literature. The societal impact of the surgery was minimized with a $36,921 (2018 CAD) grant obtained from an external contributor. Interestingly, the hospital foundation sustained a 794% increase in donations ($1,787,148; 2019 CAD) the year following the surgery. CONCLUSION: Our experience confirmed that the combination of private funding, with positive goodwill and hospital donations, is a workable model for innovative surgery in the setting of a nationalized health system with financial restrictions.

Microsurgical and Endovascular Management of Congenital Iliac Aneurysms in the Neonatal Period: Two Cases and a Literature Review.

INTRODUCTION: Congenital aneurysms of major arteries are very rare diagnoses and prognosis can be poor if treatment is not initiated rapidly. This is the presentation of two cases of infants with congenital iliac aneurysms who underwent treatment in the neonatal period. The report then proceeds with a literature review of paediatric iliac aneurysms. REPORT: Case 1: A female neonate was diagnosed antenatally with right common iliac (CIA) and internal iliac (IIA) artery aneurysms. Embolisation on day of life (DOL) eight was impossible because of partial thrombosis. The infant was subsequently observed for several months and the aneurysm was injected percutaneously with thrombin on DOL 78. A small residual aneurysm was coil embolised at five months of age. Satisfactory results were observed at one year follow up. Case 2: A female neonate was diagnosed antenatally on routine third trimester ultrasound with voluminous, bilateral CIA aneurysms. The patient underwent surgery on DOL 9 for aneurysm resection and microsurgical vascular reconstruction. The intervention was successful with triphasic flow through the anastomoses on colour Doppler ultrasound at six week follow up. DISCUSSION: Ten cases of congenital iliac aneurysms have been reported previously, with just two diagnosed in the neonatal period and eight undergoing surgical intervention. Definitive management to avoid aneurysm rupture or thrombosis should be timed carefully, and sometimes delayed with watchful waiting, to maximise success and minimise complications. Surgery is the key treatment modality, but endovascular intervention can be considered in selected cases. Congenital iliac aneurysms should be addressed at the safest time for the patient. Following resection, primary microvascular anastomosis is the ideal reconstructive technique, but other options for neonates have been described. Endovascular treatment should be considered for anatomically amenable saccular aneurysms.

Face Transplant: Current Update and First Canadian Experience.

SUMMARY: Facial vascularized composite allotransplantation has emerged as a groundbreaking reconstructive solution for patients with severely disfiguring facial injuries. The authors report on the first Canadian face transplant. A 64-year-old man sustained a gunshot wound, which resulted in extensive midface bony and soft-tissue damage involving the lower two-thirds of the face. In May of 2018, he underwent a face transplant consisting of Le Fort III and bilateral sagittal split osteotomies in addition to skin from the lower two-thirds of the face and neck. Virtual surgical planning was used to fabricate osteotomy guides and stereolithographic models. Microsurgical anastomoses of the facial (three branches) and infraorbital nerves were performed bilaterally. At 18-month follow-up, the aesthetic outcome was excellent. Partial restoration of light touch sensation had been observed over the majority of the allograft. Although significantly affected, animation, speech, mastication, and deglutition were continuously improving with intensive therapy. Nevertheless, the patient was now tracheostomy and gastrostomy free. Despite these limitations, he reported a high degree of satisfaction with the procedure and had reintegrated into the community. Four grade I episodes of acute rejection with evidence of endotheliitis were successfully treated. Postoperative complications were mainly infectious, including mucormycosis of the left thigh, treated with surgical resection and antifungal therapy. Undoubtedly, immunosuppression represents the greatest obstacle in the field and limits the indications for facial vascularized composite allotransplantation. Continuous long-term follow-up is mandatory for surveillance of immunosuppression-related complications and functional assessment of the graft.

Velopharyngeal Space Assessment in Patients Undergoing Le Fort 1 Maxillary Advancement.

The effects of maxillary advancement on velopharyngeal anatomy have primarily been studied using lateral cephalometric radiographs. However, with recent advances in orthognathic surgery, there is an increased need for more detailed and precise imaging such as computerized tomographic (CT) scan reconstructions, to help in surgical planning and to measure outcomes. The purpose of this study was to compare the pre- and post-operative velopharyngeal anatomic configuration modifications as measured on CT scans. METHODS: This is a retrospective cohort study of 44 patients with and without cleft palate who were treated with maxillary advancement. The pre- and post-operative CT scans were compared with respect to pre-established landmarks. Linear distances, cross-sectional areas, and volumes were measured using 3-dimensional CT scan reconstructions. RESULTS: For the linear distances measured, a statistically significant difference was found when comparing the pre- and post-operative measures of the narrowest part of the nasopharynx and the narrowest part of the retropalatal airway space (P = 0.001 and 0.026, respectively). Retropalatal cross-sectional areas, nasopharyngeal cross-sectional areas, and the volumetric assessment of the nasopharyngeal space showed no statistically significant differences when comparing pre- and post-operative scans (P < 0.05). Mean changes in the measures did not differ over time (pre- and post-operative) depending on whether there was a prior history of cleft palate repair. CONCLUSIONS: Although structural modifications of the pharyngeal space are inherent to maxillary advancement, its surface area and volume do not significantly change. The use of 3-dimensional reconstruction using CT scans should be the first choice for evaluation of the upper airway.

The Use of Virtual Surgical Planning for Reduction Cranioplasty.

Hydrocephalic macrocephaly may occur as a result of untreated hydrocephalus. Reduction cranioplasty is the treatment of choice for these patients when the weight of their head interferes with normal development and negatively impacts quality of life. However, this procedure has several associated risks, including prolonged anesthesia, significant blood loss, and death. Virtual surgical planning (VSP) has been shown to be a useful adjunct for orthognathic and craniofacial surgery. The following report details the application and advantages of this technology in the setting of a reduction cranioplasty. We report the case of a 2-year-old girl with severe hydrocephalic macrocephaly who underwent a reduction cranioplasty guided by VSP with computer-aided design and manufacturing (CAD/CAM). Prefabricated cutting guides and a concave assembly bowl were used for precise fixation of bony segments. Our patient underwent a successful reduction cranioplasty using VSP and CAD/CAM. This technology allowed precise remodeling of the cranial vault with minimal bony gaps in the final construct. Head circumference and intracranial volume were reduced from 70 cm and 4,575 cm3 to 62 cm and 2,645 cm3, respectively. VSP with CAD/CAM can serve as a useful adjunct in complex cases of cranioplasty allowing for an increase in the precision, the efficacy, and the esthetic result.