Pediatric Facial Fractures: Demographics, Injury Patterns, and Associated Injuries in 3334 Patients.

Pediatric craniofacial fractures are fundamentally distinct from their adult counterparts because of unique injury patterns and effects on future growth. Understanding patterns and injury context informs management and risk mitigation. Previous studies include only inpatients, operative patients, or are specialty-specific. In contrast, our study presents a comprehensive assessment of all pediatric facial fracture patients seen at a single institution. Patients under 18 years old who were evaluated for facial fractures at a level I pediatric trauma center between 2006 and 2021 were reviewed. Subanalysis was performed for groups defined by age. Variables studied included demographics, etiology, fracture pattern, associated injuries, management, and outcomes. Three thousand thirty-four patients were included. Mean age at presentation was 11.5 to 4.9 years. The majority were Caucasian (82.6%) and male (68.4%). Sports were the leading cause of injury in older patients (42.2% of patients over 12 y), compared with activities of daily living in patients under 6 years (45.5%). Thirty-two percent of patients were hospitalized, 6.0% required ICU care, and 48.4% required surgery. Frequency of ICU admission decreased with age (P<0.001), whereas operative intervention increased with age (P<0.001). Zygomaticomaxillary complex (P=0.002) and nasal fractures (P<0.001) were common in older patients, whereas younger patients experienced more skull (P<0.001) and orbital fractures (P<0.001). The most associated injuries were soft tissue (55.7%) and neurologic (23.6%). This large-scale study provides updated characterization of craniofacial fractures in the pediatric population, providing a necessary framework for future studies on outcomes assessments and preventative care.

A Longitudinal Analysis of Pre- and Post-Operative Dysmorphology in Metopic Craniosynostosis.

OBJECTIVE: The purpose of this study is to objectively quantify the degree of overcorrection in our current practice and to evaluate longitudinal morphological changes using CranioRateTM, a novel machine learning skull morphology assessment tool.  . DESIGN: Retrospective cohort study across multiple time points. SETTING: Tertiary care children's hospital. PATIENTS: Patients with preoperative and postoperative CT scans who underwent fronto-orbital advancement (FOA) for metopic craniosynostosis. MAIN OUTCOME MEASURES: We evaluated preoperative, postoperative, and two-year follow-up skull morphology using CranioRateTM to generate a Metopic Severity Score (MSS), a measure of degree of metopic dysmorphology, and Cranial Morphology Deviation (CMD) score, a measure of deviation from normal skull morphology. RESULTS: Fifty-five patients were included, average age at surgery was 1.3 years. Sixteen patients underwent follow-up CT imaging at an average of 3.1 years. Preoperative MSS was 6.3 ± 2.5 (CMD 199.0 ± 39.1), immediate postoperative MSS was -2.0 ± 1.9 (CMD 208.0 ± 27.1), and longitudinal MSS was 1.3 ± 1.1 (CMD 179.8 ± 28.1). MSS approached normal at two-year follow-up (defined as MSS = 0). There was a significant relationship between preoperative MSS and follow-up MSS (R2 = 0.70). CONCLUSIONS: MSS quantifies overcorrection and normalization of head shape, as patients with negative values were less "metopic" than normal postoperatively and approached 0 at 2-year follow-up. CMD worsened postoperatively due to postoperative bony changes associated with surgical displacements following FOA. All patients had similar postoperative metopic dysmorphology, with no significant association with preoperative severity. More severe patients had worse longitudinal dysmorphology, reinforcing that regression to the metopic shape is a postoperative risk which increases with preoperative severity.

Squamosal Suture Synostosis: An Under-Recognized Phenomenon.

INTRODUCTION: The squamosal suture (SQS) joins the temporal to the parietal bones bilaterally and is a poorly described site of craniosynostosis. SQS fusion is thought to occur as late as the fourth decade of life and beyond; however, we have incidentally noted its presence among our pediatric patients and hypothesize that it may occur earlier in life and more frequently than previously believed. METHODS: A retrospective review of imaging performed on pediatric patients was completed to identify patients with SQS synostosis. This included a review of clinical notes as well as computed tomography (CT) images obtained by our craniofacial clinic. Relevant patient data and imaging were reviewed. RESULTS: Forty-seven patients were identified with SQS synostosis, 21 were female (45%). Age at the time of radiographic diagnosis was 10.1 ± 8.4 years (range 17 days to 27 years). A majority of patients had bilateral SQS synostosis (57%), with a relatively even distribution of unilateral right (23%) versus left (19%). SQS was an isolated finding (no other suture involvement) in 15 patients (32%), all of whom were normocephalic and did not require surgical intervention. Thirty-two patients (68%) had concomitant craniosynostosis of other sutures, most commonly sagittal and coronal. Nine patients (19%) underwent surgery to correct cranial malformations-all these patients had multi-suture synostosis (P = 0.012). Twenty-seven patients (57%) had SQS synostosis diagnosed incidentally compared to 20 (43%) who were imaged with suspicion for synostosis. In those who were symptomatic, common findings included developmental delay, elevated intracranial pressure, hydrocephalus, seizures, and visual/hearing impairments. Ten patients (21%) were syndromic, the most frequent of which was Crouzon syndrome. No single pattern of calvarial malformation could be definitively described for SQS synostosis. CONCLUSION: Given that most isolated SQS synostosis cases were normocephalic, asymptomatic, and discovered incidentally, it is likely that there are many cases of unidentified SQS synostosis. The significance of SQS synostosis is currently unclear, and warrants further investigation into this phenomenon, its natural course, and its potential presence in the spectrum of normal development.

Review of Diet Protocols Following Orthognathic Surgery and Analysis of Postoperative Weight Loss.

INTRODUCTION: Orthognathic surgery is routinely practiced, yet little comparative data exists to evaluate post-orthognathic surgery diet protocols. OBJECTIVE: To evaluate which postoperative diet protocols are recommended and to quantify post-orthognathic surgery weight changes in our institutional cohort. METHODS: An internet search was carried out on Google for "orthognathic surgery diet" and the postoperative diet recommendations from centers worldwide were quantified. Additionally, a retrospective analysis of patients that underwent orthognathic surgery at our institution was performed, and their preoperative and postoperative weights were recorded. RESULTS: The internet search yielded 58 centers that met our inclusion criteria. Most centers were in the United States (n = 37, 63.8%) and were oral and maxillofacial surgeon (OMFS)-led centers (n = 39, 67.2%). Postoperative diets were categorized into 7 distinct protocols, ranging from most to least restrictive-the most popular was liquid diet for 2 to 4 weeks followed by soft diet for 2 to 6 weeks. There were no significant patterns observed across different geographical regions or specialties.In our institution, 135 patients were identified. Overall, there was an average maximum weight loss of 4.1 kg by week 4, followed by a gradual increase in weight. Linear regression analysis showed that patients with greater preoperative body mass index (BMI) lost more weight postoperatively than patients with lower BMI (R2 = 0.25, P < .001). CONCLUSION: There is a significant variability in recommended postoperative diets following orthognathic surgery. Following a moderately restrictive diet at our institution, patients returned to their preoperative weight after approximately 4 months.

A Preliminary Management Algorithm for Velopharyngeal Insufficiency in Cleft-Orthognathic Patients.

PURPOSE: Patients born with a cleft palate often suffer from velopharyngeal insufficiency (VPI) due to the soft palate musculature's abnormal structure. Surgical correction of the palate at a young age can hinder maxillary growth, requiring surgical correction of the maxillomandibular discrepancy at skeletal maturity. Orthognathic surgery can then cause or further exacerbate VPi in these patients. The purpose of this paper is to assess cleft-orthog-nathic patients under the lens of persistent or newly-developed VPi, to understand outcomes and generate a targeted management algorithm. METHODS: A retrospective study was performed inspecting cleft-orthognathic patients presenting to a single surgeon. Patients with sufficient follow-up were placed into predefined algorithmic cohorts by their VPi development pattern in relation to orthognathic surgery. They were further stratified into groups by level of adherence to our algorithm to evaluate VPi outcomes. Demographic factors, risk factors, and outcomes were compared between groups via Welch t test and Fisher exact test. RESULTS: Fifty-one patients were examined, including 16 with VPI. Velopharyngeal insufficiency fully resolved amongst all algorithmically adherent patients and remained in nonadherent patients ( P  < 0.001). CONCLUSIONS: Our targeted algorithm may improve symptoms and the management of VPI in cleft-orthognathic patients. Multi-centered studies with larger sample sizes and prospective studies are encouraged to validate our proposed treatment algorithm further.

A Comprehensive Single-Center Analysis of Postoperative Nausea and Vomiting Following Orthognathic Surgery.

BACKGROUND: Postoperative nausea and vomiting (PONV) remains a major clinical end-point for directing enhanced recovery after surgery (ERAS) protocols in facial plastic surgery. This study aimed to identify risk factors for PONV and evaluate strategies for PONV reduction in orthognathic surgery patients. METHODS: A retrospective cohort study was performed among patients receiving orthognathic surgery at our institution from 2011 to 2018. Patient demographics, surgical operative and anesthesia notes, medications, and nausea/vomiting were assessed for each patient. The amount of opioid analgesia given both perioperatively and postoperatively was recorded and converted into morphine equivalents (MEQ). Stepwise regression analysis was used to identify significant risk factors for PONV. Post hoc analyses were employed to compare PONV among patients based on MEQ dosage and antiemetic prophylaxis regimes. RESULTS: A total of 492 patients were included; mean age was 23.0 years (range: 13-60); 54.4% were female. The majority of patients received concurrent Le Fort I osteotomy, BSSO, and genioplasty (70.1%). During hospitalization, 59.4% of patients experienced nausea requiring antiemetic medications and 28.4% experienced emesis. Stepwise regression yielded Apfel scores (P = 0.003) and postoperative opioids (P = 0.013) as the strongest predictors of PONV. Post hoc analyses showed that undertreatment with prophylactic antiemetics (based on Apfel) predicted increased PONV (+12.9%, P = 0.020), and that lower postoperative MEQs (<28.0) predicted decreased PONV (-11.8%, P = 0.01). CONCLUSIONS: The study findings confirm the high incidence of PONV among orthognathic surgical patients and stratify previously reported PONV risk factors. More aggressive utilization of antiemetic medications and decreased dependence on opioid analgesia may decrease nausea/vomiting following orthognathic surgery.

Neurological Functional Connectivity in Unilateral Coronal Synostosis: A Side-Based Comparison.

PURPOSE: Unicoronal synostosis (UCS) has been associated with reading, language, and social dysfunction. Limited brain function connectivity studies exist for UCS with none devoted to comparing outcomes by side of synostosis (left versus right-sided UCS). METHODS: Twelve patients with surgically treated UCS, 7 right-sided and 5 left-sided, were age matched to healthy controls. Resting state functional MRI was acquired in a 3T Siemens TIM Trio scanner (Erlangen, Germany). Data was collected with intrinsic connectivity distribution and seed-connectivity analysis using BioImage Suite (Yale School of Medicine). Region of interest analysis was performed based on Brodmann areas related to emotional, executive, language, motor, and visuo-spatial function. Significance was set at P < 0.05. RESULTS: Compared to controls, all UCS patients demonstrated decreased connectivity in areas of the parietal and temporal cortices responsible for visuo-motor coordination and language function. Right UCS patients demonstrated decreased intrinsic connectivity in regions related to complex motor movement and proprioception relative to control subjects. Left UCS patients demonstrated decreased seed connectivity between regions of the parietal lobe and occipital lobe related to motor coordination, visual function, and language compared to right UCS patients. CONCLUSION: Unicoronal synostosis had decreased functional connectivity in regions associated with memory, visual information processing, and motor function. Moreover, left-sided UCS had decreased connectivity in circuits for motor coordination and language when compared to right-sided UCS. This study provides data suggestive of long-term sequelae of UCS that varies by sidedness, which may be responsible for neurocognitive impairments found in previous cognitive analyses.

Distinguishing Craniomorphometric Characteristics of Unilateral Lambdoid Craniosynostosis.

BACKGROUND: Unilateral lambdoid synostosis (ULS) represents the rarest form of single suture nonsyndromic craniosynostosis. Differentiating between posterior deformational plagiocephaly (DP) and ULS has been difficult due to overlapping clinical findings. Past analyses have been limited by sample size. This study was undertaken to clarify anatomical features of ULS. METHODS: A multiinstitution study was undertaken, analyzing CT imaging from patients with documented ULS to determine clinical and pathological characteristics. Similar analyses were performed on DP patients to differentiate the 2 conditions. RESULTS: Twenty-seven ULS patient scans and 10 DP scans were included. For ULS patients mean age was 6.6 months, majority male (75%), and majority left-sided ULS (71%). The synostosed side ear was anteriorly displaced in 100% of ULS patients, mean difference of 9.6° (P < 0.001), and inferiorly in 96.3% of patients, mean difference of 4.4 mm, relative to the nonsynostosed side. The posterior fossa deflection (PFD) was deviated 5.9° toward the synostosed side relative to the anterior midline. In DP, there was no significant difference between sides in EAC measurements. The PFD and EAC displacements were significantly smaller in DP relative to ULS (P < 0.001 for each). An ipsilateral mastoid bulge was found in 100% of ULS and 0% of DP on CT imaging. CONCLUSION: Contrary to some previously published findings, the ear is more anteriorly displaced ipsilateral to the fused lambdoid suture in 100% of ULS patients. Ear position alone is not a reliable indicator to differentiate between DP and ULS. A mastoid bulge is a more reliable indicator of ULS.

Radiographic Predictors of FACE-Q Outcomes Following Non-Operative Orbital Floor Fracture Management.

BACKGROUND: Orbital floor fractures are common injuries treated by multiple surgical subspecialties. Controversy exists regarding the operative indications. This study sought to correlate radiographic characteristics of orbital floor fractures with validated patient reported outcome measures following non-operative management. MATERIALS AND METHODS: Patients who underwent non-operative management of an orbital floor fracture at Yale New Haven Hospital from 2013 to 2018 were queried retrospectively. Patients with GCS < 15 and/or distracting facial soft tissue or bony injuries were excluded from analysis. CT images, demographic information, and FACE-Q patient reported outcomes (Satisfaction with Eyes, Psychological Function, Social Function, and Appearance Related Psychosocial Distress) were reviewed. Statistical analysis was performed with SPSS with statistical significance set at P < .05. RESULTS: Eighteen patients were included in the study. The mean time between injury and completion of the survey was 3.6 years. Fifty-six percent of patients had a right-sided fracture. The mean fracture area was 73.6 mm (Range:15-172 mm), and 913 mm (Range: 0-3106) was the mean volume displaced into the maxillary sinus. The unaffected inferior rectus muscle shape (height/width) was 0.5 (Range: 0.2-0.98) compared to 0.8 (Range 0.4-1.6) for the affected inferior rectus. After controlling for the time interval between survey and injury, gender, income, and education, rounding of the inferior rectus muscle was a significant predictor of appearance related psychosocial distress (P = 0.006). Inferior rectus rounding was stratified into "severe" (75%) and "moderate" (25%) categories. Severe rounding was associated with a larger orbital floor fracture area (110 versus 64 mm; P = 0.074), volume displaced into the maxillary sinus (1,716 versus 610 mm; P = 0.024), and worse appearance-related psychosocial distress (70 versus 25; P = 0.013). Sixty-one percent of patients followed up in clinic with a mean duration of 194 days. CONCLUSION: Prior studies have correlated presenting radiographic findings to follow-up clinical findings. However, this study is the first to assess long-term outcomes using validated patient-reported questionnaires. Inferior rectus muscle belly rounding significantly correlated with appearance related psychosocial distress. This radiographic finding may be valuable to consider in orbital floor fracture management.

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.

Hospital Volume Improves Primary, Revision, and Delayed Cleft Palate Repair.

BACKGROUND: High volume centers (HVC) is commonly associated with increased resources and improved patient outcomes. This study assesses efficacy and outcomes of high volume centers in cleft palate repair. METHODS: Cleft palate procedures were identified in the Kids' Inpatient Database from 2003-2009. Demographics, perioperative factors, co-morbidities, and complications in HVC (90th percentile, >48 cases/year) and non-high volume centers (NHVC) were compared across various cohorts of cleft repair. RESULTS: Four thousand five hundred sixty-three (61.7%) total cleft palate surgeries were performed in HVC and 3388 (38.3%) were performed in NHVC. The NHVC treated a higher percentage of Medicaid patients (P = 0.005) and patients from low-income quartiles (P = 0.018). HVC had larger bedsizes (P <0.001), were more often government/private owned (P <0.001), and were more often teaching hospitals (P <0.001) located predominantly in urban settings (P <0.001). The HVC treated patients at younger ages (P = 0.008) and performed more concurrent procedures (P = 0.047). The most common diagnosis at HVC was complete cleft palate with incomplete cleft lip, while the most common diagnosis at NHVC was incomplete cleft palate without lip. Overall, length of stay and specific complication rates were lower in HVC (P = 0.048, P = 0.042). Primaries at HVCs showed lower pneumonia (P = 0.009) and specific complication rates (P = 0.023). Revisions at HVC were associated with older patients, fewer cardiac complications (P = 0.040), less wound disruption (P = 0.050), but more hemorrhage (P = 0.040).

Body mass index as a continuous predictor of outcomes after expander-implant breast reconstruction.

BACKGROUND: Studies show that obesity is a risk factor for complications after expander/implant breast reconstructions. However, reports vary on the precise threshold of body mass index (BMI) as a predictor of heightened risk. We endeavored to link BMI as a continuous variable to overall complications in a single-surgeon series of expander-implant reconstructions. METHODS: From 399 patients undergoing expander-implant reconstruction, 551 breasts were stratified to normal weight, overweight, and obese groups for analysis and comparison with previous studies. Logistic regression was performed to predict changes to risk profile per increment of BMI. RESULTS: Complication rates for obese and overweight patients were significantly greater than for normal weight patients, that is, 21.1% and 24.0% versus 10.4%, respectively (P < 0.005). A unit increase in BMI predicted a 5.9% increase in the odds of a complication occurring, and 7.9% increase in the odds of reconstruction ending in failure. CONCLUSIONS: By expanding the analysis of BMI to include patients who do not meet the traditional definition of obesity (BMI ≥ 30 kg/m), we demonstrated that simply overweight patients (25 ≤ BMI < 30 kg/m) had an elevated complication rate. Moreover, through regression analysis, we established that BMI as a continuous variable predicts outcomes from expander-based breast reconstruction.

Individuals with Cleft Lip and/or Palate Demonstrated Improved Self-Reported Psychosocial Functioning Following the Onset of the COVID-19 Pandemic.

Objective: To evaluate the impact of the COVID-19 pandemic on the psychosocial functioning of individuals with cleft lip and/or palate (CL/P). Methods: Patients with CL/P ≥ 6 years old were prospectively recruited from the Cleft and Craniofacial Clinic of a tertiary children's hospital. From July-October 2021, eligible patients (or their parent/guardian) were sent a survey regarding their psychosocial functioning before and after the start of the pandemic. Main Outcome Measure: The difference between prepandemic and intrapandemic patient-reported outcome scores. Results: Thirty-six patients (20 female, age: 15.9 ± 9.8 years) responded. Most had cleft lip and palate (77.8%), responded online (69.4%), interacted remotely via both voice- and video-conferencing (62.9%), and wore masks routinely (77.1%). Similar numbers of patients responded independently (27.8%), responded with the help of a parent/guardian (36.1%), or had a parent/guardian respond on their behalf (36.1%). General social-emotional well-being (p = 0.004, r rb = 0.659) and satisfaction with facial appearance (p = 0.044, r rb = 0.610) significantly improved after the start of the pandemic. Compared to their general intrapandemic social-emotional well-being scores, patients reported higher scores while wearing a mask (r rb = 0.827) and lower scores while interacting remotely (r rb = 0.605), although all were still significantly improved compared to their prepandemic scores (p ≤ 0.010). Patients also reported significant improvement in social functioning while wearing a mask (p = 0.036, r rb = 0.519), whereas they did not when considering their general intrapandemic feelings/experiences (p = 0.269, r rb = 0.211). Conclusion: Patients with CL/P demonstrated significant improvement in overall social-emotional well-being, satisfaction with facial appearance, and social functioning after the start of the COVID-19 pandemic, particularly when wearing a mask.

A Road Map to Creating a High-Quality Clinical Database in Plastic Surgery.

BACKGROUND: Detailed in-house databases are a staple of surgical research and a crucial source of data for many studies from which clinical guidelines are built. Despite the importance of generating a clear and thorough developmental design, the literature on database creation and management is limited. In this article, the authors present their stepwise single-institution process of developing a clinical facial fracture database. METHODS: The authors outline the process of development of a large single-institution clinical pediatric facial fracture database. The authors highlight critical steps from conception, regulatory approval, data safety/integrity, human resource allocation, data collection, quality assurance, and error remediation. The authors recorded patient characteristics, comorbidities, details of the sustained fracture, associated injuries, hospitalization information, treatments, outcomes, and follow-up information on Research Electronic Data Capture. Protocols were created to ensure data quality assurance and control. Error identification analysis was subsequently performed on the database to evaluate the completeness and accuracy of the data. RESULTS: A total of 4451 records from 3334 patients between 2006 and 2021 were identified and evaluated to generate a clinical database. Overall, there were 259 incorrect entries of 120,177 total entries, yielding a 99.8% completion rate and a 0.216% error rate. CONCLUSIONS: The quality of clinical research is intrinsically linked to the quality and accuracy of the data collection. Close attention must be paid to quality control at every stage of a database setup. More studies outlining the process of database design are needed to promote transparent, accurate, and replicable research practices.

CranioRate: An Image-Based, Deep-Phenotyping Analysis Toolset and Online Clinician Interface for Metopic Craniosynostosis.

BACKGROUND: The diagnosis and management of metopic craniosynostosis involve subjective decision-making at the point of care. The purpose of this work was to describe a quantitative severity metric and point-of-care user interface to aid clinicians in the management of metopic craniosynostosis and to provide a platform for future research through deep phenotyping. METHODS: Two machine-learning algorithms were developed that quantify the severity of craniosynostosis-a supervised model specific to metopic craniosynostosis [Metopic Severity Score (MSS)] and an unsupervised model used for cranial morphology in general [Cranial Morphology Deviation (CMD)]. Computed tomographic (CT) images from multiple institutions were compiled to establish the spectrum of severity, and a point-of-care tool was developed and validated. RESULTS: Over the study period (2019 to 2021), 254 patients with metopic craniosynostosis and 92 control patients who underwent CT scanning between the ages of 6 and 18 months were included. CT scans were processed using an unsupervised machine-learning based dysmorphology quantification tool, CranioRate. The average MSS was 0.0 ± 1.0 for normal controls and 4.9 ± 2.3 ( P < 0.001) for those with metopic synostosis. The average CMD was 85.2 ± 19.2 for normal controls and 189.9 ± 43.4 ( P < 0.001) for those with metopic synostosis. A point-of-care user interface (craniorate.org) has processed 46 CT images from 10 institutions. CONCLUSIONS: The resulting quantification of severity using MSS and CMD has shown an improved capacity, relative to conventional measures, to automatically classify normal controls versus patients with metopic synostosis. The authors have mathematically described, in an objective and quantifiable manner, the distribution of phenotypes in metopic craniosynostosis.

True Incidence of Marginal Mandibular Nerve Palsy Following Neonatal Mandibular Distraction Osteogenesis.

INTRODUCTION: In children with PRS, MDO is routinely performed to alleviate airway obstruction; however, it involves risk of injury to the MMN. We hypothesize that MMN palsy incidence following MDO, reported at 1-15%, is underestimated. This study investigates the true incidence of MMN palsy after MDO to better guide follow-up care and improve treatment of this complication. METHODS: A retrospective review of PRS patients who underwent MDO at a single, tertiary pediatric hospital between September 2007 and March 2021 was conducted. Patients who underwent MDO under one year of age and had postoperative clinical evaluations detailing MMN function were included. Logistic regression analysis was performed to investigate predictors of MMN injury. RESULTS: Of 93 patients who underwent MDO, 59.1% met inclusion criteria. 56.4% were female, 43.6% were syndromic, and average age at MDO was 1.52 ± 2.04 months. The average length of mandibular distraction was 17.3 ± 4.36mm, average duration of intubation was 6.57 ± 2.37 days, and average time until hardware removal was 111.1 ± 23.6 days. Sixteen patients (29.1%) presented with permanent MMN dysfunction, comprised of 8 patients with bilateral weakness and 8 with unilateral weakness. An additional five patients (9.1%) presented with transient MMN weakness that resolved within a year. Average length of follow-up postoperatively was 6.02 years, and no significant predictors of nerve injury were found. CONCLUSION: In this 14-year review of patients with PRS who underwent MDO, 38.2% demonstrated evidence of MMN palsy (29.1% permanent, 9.1% transient), which is much greater than previously described.

The impact of body mass index on reduction mammaplasty: a multicenter analysis of 2492 patients.

BACKGROUND: Reduction mammaplasty is commonly performed in women who are considered obese by the body mass index (BMI) classification of the World Health Organization. OBJECTIVES: The authors compare complication rates among breast reduction patients, stratified by BMI, across multiple institutions. METHODS: A retrospective analysis was performed of all reduction mammaplasties in the database of the National Surgical Quality Improvement Program for 2006 through 2010. Demographic, comorbidity, and BMI data were collected. Data on medical and surgical complications, reoperation, and mortality were collected through 30 days postsurgery. RESULTS: Of 2492 patients, 55% were considered obese (BMI >30). The overall rate of surgical complications was 4.0%, increasing from 2.4% for BMI <25 to 7.1% for BMI >45 (P = .006), with an adjusted odds ratio of 2.97 for BMI >45 versus BMI <25. The most common surgical complication was superficial surgical site infection; it was found in 2.9% of patients, increasing from 2.1% for BMI <25 to 5.1% for BMI >45 (P = .03). The medical complication rate was 0.6%, and the reoperation rate was 2.1%. There were no deaths. A maximal point analysis showed that BMI ≥39 was associated with a significantly higher complication rate, with an odds ratio of 2.38. CONCLUSIONS: Reduction mammaplasty is a safe surgical procedure, even when performed on obese patients. However, patients with higher BMI have a greater risk of surgical site complications. This risk should be discussed preoperatively with obese patients.

A multi-institutional perspective of complication rates for elective nonreconstructive breast surgery: an analysis of NSQIP data from 2006 to 2010.

BACKGROUND: As elective nonreconstructive breast surgery increases in popularity, there is greater demand for accurate multi-institutional data on minor and major postoperative complications. OBJECTIVE: The authors utilized a multi-institutional database to compare 30-day morbidities and reoperation rates among the different types of elective nonreconstructive breast surgery. METHODS: Patients in the National Surgical Quality Improvement Program (NSQIP) participant use file who underwent elective nonreconstructive breast surgery between 2006 and 2010 were identified. Twenty defined morbidities were compared among mastopexy, reduction mammaplasty, and augmentation mammaplasty patients using analysis of variance and χ(2) tests for continuous variables and categorical variables, respectively. Logistic regression modeling was employed to identify preoperative risk factors for complications. RESULTS: Of the 3612 patients identified, 380 underwent mastopexy, 2507 underwent reduction mammaplasty, and 725 underwent augmentation mammaplasty. Complication rates were low in all cohorts, and patients undergoing augmentation mammaplasty had the lowest overall complication rate compared with mastopexy and reduction mammaplasty (1.24%, 2.37%, and 4.47%). Patients undergoing reduction mammaplasty had a modestly elevated incidence of overall morbidity, superficial surgical site infections, and wound disruptions (P < .05). Moreover, 30-day reoperation rates for mastopexy, reduction mammaplasty, and augmentation mammaplasty were low (1.58%, 2.07%, and 0.97%), as were the rates of life-threatening complications (0%, 0.16%, and 0%). One death was observed for all 3612 procedures (0.03%). CONCLUSIONS: Elective breast surgery is a safe procedure with an extremely low incidence of life-threatening complications and mortality. Comprehensive data collated from the NSQIP initiative add to the literature, and the findings of this multi-institutional study may help further guide patient education and expectations on potentially deleterious outcomes.

The Aesthetics of Digit Amputation.

Background: The goal of surgery, when treating a patient with a traumatized hand, is to restore function. The importance of the aesthetics on a patient's psychological well-being should also be considered. The biomechanical ideals for creating a useful hand after digit amputation have been defined; however, ideal aesthetic levels for finger amputation have not been elucidated. The purpose of this study was to determine the general population's visual preferences for different levels of digit amputation in the hand. Methods: In all, 310 participants were surveyed to identify preferences of different levels of single digit amputations in dorsal and volar views. A normal hand was digitally manipulated to simulate various levels of digit amputation. The aesthetics of amputation at the distal interphalangeal (DIP) joint, proximal interphalangeal (PIP) joint, metacarpophalangeal (MCP) joint, and ray amputation were compared to one another via rank order. Average rank for each level of amputation for a digit was determined. Results: Amputation at the DIP was favored over all other levels; however, ray amputation was the second most aesthetic, particularly in the middle and ring fingers even when compared to amputation at the PIP level. Conclusion: When presented a choice at which level to perform a completion amputation or a primary amputation of a digit, and functionality at multiple levels of amputation is equivocal, aesthetic outcomes should be considered. Amputation at the DIP joint is preferable, but ray amputation is aesthetically more pleasing than amputation at the PIP or MCP joints in the index, middle, ring, and small fingers.