Smooth versus Textured Tissue Expanders: Comparison of Outcomes and Complications in 536 Implants.

Background Increasing concerns regarding the safety of textured surface implants have resulted in surgeons transitioning from textured tissue expanders (TEs) to smooth TEs. Given this change has only recently occurred, this study evaluated outcomes between smooth and textured TEs. Methods Women who underwent two-stage breast reconstruction using TEs from 2013 to 2022 were included. TE-specific variables, perioperative information, pain scores, and complications were collected. Chi-squared, t -test, and linear regression analyses were performed. Results A total of 320 patients received a total of 384 textured and 152 smooth TEs. Note that 216 patients received bilateral reconstruction. TEs were removed in 9 cases. No significant differences existed between groups regarding comorbidities. Smooth TEs had a higher proportion of prepectoral placement ( p < 0.001). Smooth TEs had less fills (3 ± 1 vs. 4 ± 2, p < 0.001), shorter expansion periods (60 ± 44 vs. 90 ± 77 days, p < 0.001), smaller expander fill volumes (390 ± 168 vs. 478 ± 177 mL, p < 0.001), and shorter time to exchange (80 ± 43 vs. 104 ± 39 days, p < 0.001). Complication rates between textured and smooth TEs were comparable. Smooth TE had a greater proportion of TE replacements ( p = 0.030). On regression analysis, pain scores were more closely associated with age ( p = 0.018) and TE texture ( p = 0.046). Additional procedures at time of TE exchange ( p < 0.001) and textured TE ( p = 0.017) led to longer operative times. Conclusion As many surgeons have transitioned away from textured implants, our study shows that smooth TEs have similar outcomes to the textured alternatives.

Impact of Nicotine Replacement Therapy on Breast Surgery Outcomes.

BACKGROUND: Smoking cessation therapy, including nicotine replacement therapy (NRT), is used perioperatively to assist patients to reduce their tobacco smoke intake and consequently decrease their risk of smoking-associated complications. There are, however, theoretical concerns that nicotine-induced peripheral vasoconstriction could impair wound healing. This study investigated the effect of NRT on postoperative outcomes in patients undergoing breast surgery. METHODS: A retrospective chart review of patients undergoing breast surgery within the Yale New Haven Health System from the years 2014 to 2020 was performed. Documented smoking status within 6 months before surgery, use or prescription of NRT, type of surgery, and surgical complications of infection, wound dehiscence, tissue necrosis, hematoma, seroma, fat necrosis, and return to operating room within 30 days were recorded. Demographic and complication data were compared between patients with NRT usage and those without using t-tests and chi-square analyses. Multivariable logistic regression models were created to predict the effect of NRT usage on the occurrence of any complication. RESULTS: A total of 613 breast procedures met inclusion criteria, of which 105 (17.2%) had documented NRT use. The NRT cohort and the non-NRT cohort were well balanced with respect to demographics and procedural variables. Upon multivariable modeling for risk of any surgical complication, NRT was not a significant predictor (odds ratio [OR]: 1.199, p = 0.607 and OR: 0.974, p = 0.912, respectively), whereas procedure type, increased body mass index, and increased age were. CONCLUSION: NRT use was not associated with an increased risk of postoperative complications compared with not using NRT as part of smoking cessation therapy prior to operation.

Seminars in Plastic Surgery: Pediatric Ear Anomalies and Reconstruction.

Congenital ear anomalies affect 15 to 20% of neonates and can be categorized as either auricular deformations or malformations. Deformations involve a fully developed, albeit abnormally shaped, chondrocutaneous framework, which makes them amenable to correction with ear molding within the first few months of life. Malformations involve hypoplastic or fully absent auricular structures that require augmentation with alloplastic and/or autogenous reconstruction. The goal of this article is to outline the various auricular deformities and malformations, followed by a description of the latest clinical management options, both nonsurgical and surgical, by auricular anomaly.

Quantifying the Impact of Genetics on Neurocognition in Nonsyndromic Sagittal Craniosynostosis.

BACKGROUND: Previous work has identified an association between de novo and transmitted loss-of-function mutations in genes under high evolutionary constraint with neurodevelopmental delays in nonsyndromic craniosynostosis (NSC). The authors sought to quantify the neurocognitive effect of these genetic lesions. METHODS: In a prospective, double-blinded cohort study, demographic surveys and neurocognitive tests were administered to patients recruited from a national sample of children with sagittal NSC. Scores for academic achievement, Full-Scale Intelligence Quotient (FSIQ), and visuomotor skills were directly compared between patients with and without damaging mutations in genes with a high probability of loss of function intolerance using two-tailed t tests. Analysis of covariance was also used to compare test scores while controlling for surgery type, age at surgery, and sociodemographic risk. RESULTS: Fifty-six patients completed neurocognitive testing, 18 of whom had a mutation in a highly constrained gene. There was no significant difference between groups in any sociodemographic factors. After controlling for patient factors, patients with high-risk mutations had poorer performance compared with patients without high-risk mutations in every testing category, with significant differences in FSIQ (102.9 ± 11.4 versus 110.1 ± 11.3; P = 0.033) and visuomotor integration (100.0 ± 11.9 versus 105.2 ± 9.5; P = 0.003). There were no significant differences in neurocognitive outcome when stratifying groups based on type of surgery or age at time of surgery. CONCLUSIONS: Even after controlling for exogenous factors, the presence of mutations in high-risk genes led to poorer neurocognitive outcomes. High-risk genotypes may predispose individuals with NSC to deficits, particularly in FSIQ and visuomotor integration. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Role of State Insurance Policy in Orthotic Helmet Access for Deformational Plagiocephaly.

BACKGROUND: Helmet therapy for deformational plagiocephaly has an ideal window for treatment, and timely access to care is vital to achieving optimal benefit. The authors evaluated the hypothesis that patients insured through Medicaid experience decreased access to helmet therapy. METHODS: This was a retrospective analysis of referrals for helmet therapy to Cranial Technologies, Inc. between 2014 and 2020 across 21 states. Outcome measures were likelihood of receiving a helmet, receiving a second helmet, receiving delayed treatment, and having delayed presentation. RESULTS: From 2014 to 2020, a total of 219,869 patients were referred and 141,513 of these received a helmet. Patients with Medicaid were less likely to receive treatment (OR, 0.63; P < 0.001) and more likely to present late (OR, 1.55; P < 0.001) or receive delayed treatment (OR, 3.24; P < 0.001) compared with the commercially insured. Patients with Medicaid were less likely to receive helmet therapy in nine states, with the strongest association in Texas (OR, 0.32; P < 0.001), and more likely to receive helmet therapy in five states, with the strongest association in Colorado (OR, 1.89; P < 0.001). Medicaid was associated with late presentation and delayed treatment in all states. CONCLUSIONS: Patients with Medicaid presented later and were less likely to receive helmet therapy. Findings reflected state-specific Medicaid policies, with patients in some states more likely to receive a helmet with Medicaid than with commercial insurance. However, late presentation and delays in treatment with Medicaid were observed across all states. State-specific Medicaid restrictions are likely a driving factor in determining access to helmet therapy.

Racial/Ethnic and Gender Disparities Over the Last Decade Within Microsurgery and Craniofacial Fellowship Training.

BACKGROUND: Racial/ethnic and gender disparities persist in plastic surgery at nearly all levels of training, becoming more pronounced at each stage. Recent studies have demonstrated that the proportion of female plastic surgery residents has increased to nearly 40%, yet only 11% of full professors of plastic surgery are female. Other studies have identified severe declines in underrepresented minority plastic surgery representation between plastic surgery residents and academicians with only 1.6% of Black/African American and 4.9% of Hispanic/Latinx full professors of plastic surgery. Often, residents seek fellowship for advanced training before seeking an academic professorship. This study aims to describe the racial/ethnic and gender representation of microsurgery and craniofacial fellows. METHODS: Names and photos of graduated fellows for the past 10 years (2012-2021) were extracted from microsurgery and craniofacial fellowship Web sites. Using a 2-person evaluation method, race/ethnicity and gender were primarily determined by photographic and surname and verified, when possible, through online confirmation methods (articles, social media). Distributions were analyzed with descriptive statistics and compared with the US population. RESULTS: Among 30 microsurgery fellowships, 180 graduated fellows (52.7%) were identified, resulting in 66 female fellows (36.7%) and the following racial/ethnic distribution: 113 (62.8%) White, 49 (27.2%) Asian, 12 (6.7%) Hispanic/Latinx, and 6 (3.3%) Black/African American. Among 31 craniofacial fellowships, 136 graduated fellows (45.0%) were identified, resulting in 38 female fellows (27.9%) and the following racial/ethnic distribution: 75 (55.1%) White, 45 (33.1%) Asian, 8 (5.9%) Hispanic/Latinx, and 8 (5.9%) Black/African American. The intersection between race/ethnicity and gender revealed the most disproportionately low representation among Black women. Relative to the US population, Hispanic/Latinx (0.31-fold) and Black/African American (0.48-fold) fellows were underrepresented, White (0.90-fold) fellows were nearly equally represented, and Asian (5.42-fold) fellows are overrepresented relative to the US population. Furthermore, despite pursuing fellowships at a greater rate, Asian and Black fellows are not reaching adequate representation among academic plastic surgeons. CONCLUSION: This study demonstrates that female racial/ethnic minorities are disproportionately underrepresented among microsurgery and craniofacial fellowships. Efforts should be made to improve the recruitment of fellows of underrepresented backgrounds and thus improve the pipeline into academic careers.

"Validation of Artificial Intelligence Severity Assessment in Metopic Craniosynostosis".

OBJECTIVE: Several severity metrics have been developed for metopic craniosynostosis, including a recent machine learning-derived algorithm. This study assessed the diagnostic concordance between machine learning and previously published severity indices. DESIGN: Preoperative computed tomography (CT) scans of patients who underwent surgical correction of metopic craniosynostosis were quantitatively analyzed for severity. Each scan was manually measured to derive manual severity scores and also received a scaled metopic severity score (MSS) assigned by the machine learning algorithm. Regression analysis was used to correlate manually captured measurements to MSS. ROC analysis was performed for each severity metric and were compared to how accurately they distinguished cases of metopic synostosis from controls. RESULTS: In total, 194 CT scans were analyzed, 167 with metopic synostosis and 27 controls. The mean scaled MSS for the patients with metopic was 6.18 ± 2.53 compared to 0.60 ± 1.25 for controls. Multivariable regression analyses yielded an R-square of 0.66, with significant manual measurements of endocranial bifrontal angle (EBA) (P = 0.023), posterior angle of the anterior cranial fossa (p < 0.001), temporal depression angle (P = 0.042), age (P < 0.001), biparietal distance (P < 0.001), interdacryon distance (P = 0.033), and orbital width (P < 0.001). ROC analysis demonstrated a high diagnostic value of the MSS (AUC = 0.96, P < 0.001), which was comparable to other validated indices including the adjusted EBA (AUC = 0.98), EBA (AUC = 0.97), and biparietal/bitemporal ratio (AUC = 0.95). CONCLUSIONS: The machine learning algorithm offers an objective assessment of morphologic severity that provides a reliable composite impression of severity. The generated score is comparable to other severity indices in ability to distinguish cases of metopic synostosis from controls.

Disparities in Access to Cranial Remodeling Orthosis for Deformational Plagiocephaly.

OBJECTIVE: Moderate to severe cases of deformational plagiocephaly (DP) may be treated with cranial remolding orthoses (CRO). This study investigated the socioeconomic disparities in access to care for CRO for DP correction. DESIGN: This was a retrospective review of medical records from a single CRO company in Connecticut from 2014 to 2020. METHODS: Demographic variables were collected from all patients. Univariable logistic regressions were used to identify differences for presenting age at consultation, whether CRO was pursued, and length of CRO treatment by insurance payor and household income quartile. RESULTS: Of the 5620 patients identified, 4100 (73.0%) received CRO, with 674 (12.0%) receiving a second helmet. Of those receiving CRO, 1536 (37.5%) had Medicaid insurance while 2558 (62.4%) were commercially insured. Patients on Medicaid were 1.30 times more likely to have delayed presentation (P = .017), while patients from the lowest income quartile were 1.26 1.50 (P < .001) and 1.58 (P < .001) times more likely to have a delayed presentation relative to those in the highest and second-highest income quartiles, respectively. Patients in the highest and second-highest income quartiles were also 1.55 (P < .001) and 1.45 (P < .001) more likely, respectively, to receive CRO after consultation than those from the lowest income quartile. CONCLUSIONS: Lower income and Medicaid-insured patients had delayed presentation for CRO consultation. Those from the lowest income quartile were more likely to never receive CRO than those from wealthier backgrounds. Low socioeconomic status and Medicaid insurance, which can have more restrictive coverage policies for CRO, may result in the delayed treatment of DP.

Evaluation of Complication Rates of Free Flap Reconstruction in Pediatric Patients.

Introduction: While there is extensive literature investigating surgical outcomes in free flaps for adults, there is a dearth of information on the efficacy of flap use in the pediatric population. This study is the first to measure complication rates following pediatric free flap reconstruction on a national level. Methods: All pediatric free flap cases between 2012 and 2018 were identified and stratified by type of flap using current procedural terminology codes assigned to the primary procedure in the National Surgical Quality Improvement Program database. Each entry included the recipient location of the flap, postoperative complications, and demographics. Chi-square analysis was used to compare complication rates across various flap groupings. In addition, univariate and multivariate analyses were used to identify independent predictors of flap complications or failure. Results: Multivariate regression analysis demonstrated that compared to bone flaps, there is increased risk of nonbleeding complications in skin (Odds Ratio (OR) =7.7, P = 0.029), muscle (OR = 10.6, P = 0.012), and osteocutaneous flaps (OR = 10.8, P = 0.018). Flap of the trunk (OR = 40.9, P = 0.003) and upper extremities (OR = 32.9, P = 0.041) had a higher odds of bleeding complications compared to head-and-neck flaps. Regression analysis also showed that older age is associated with bleeding complications, with patients aged 5-11 years (OR = 38.5, P = 0.027) and 12-17 years (OR = 30.6, P = 0.038) having greater rates compared to patients under the age of 2. The pediatric flap reoperation rate was found to be 3.6%-4.7%, with the highest flap anastomotic complication rate in the head-and-neck region (6.9%-8.0%). Conclusion: Free flap reconstruction across flap type, anatomic location, and age ranges are safe and efficacious in the pediatric population.

Racial and geographic disparities in reconstructive procedures following melanoma resection.

INTRODUCTION: Melanoma occurs most commonly in non-Hispanic White patients; however, Black and Hispanic patients experience greater morbidity and mortality. This study assesses how race and socioeconomic factors influence rates of reconstructive procedures and hospital-based outcomes in melanoma patients. METHODS: Data were extracted from the National Inpatient Sample database from the years 2010-2015. Patients with melanoma who underwent a reconstructive procedure were identified. Univariate and multivariate logistic regression analysis was used to identify the relationship between dependent variables and various patient/hospital components for patients undergoing reconstructive procedures. RESULTS: Black and Hispanic patients had a greater length of stay (LOS) than non-Hispanic White patients (OR: 2.252, p = 0.0307, and OR: 2.592, p = 0.0014), and Hispanic patients were less likely to receive more complex reconstructive procedures (OR: 0.449, p = 0.0487). Patients living in rural areas were less likely to receive complex reconstructive procedures than those in both urban teaching and non-teaching hospitals (OR: 3.313, p = 0.0135, and OR: 3.505, p = 0.0074). Pedicled or rotational flaps were less likely to be performed at medium- or large-sized hospitals (OR: 0.610, p = 0.0296, and OR: 0.496, p = 0.0002). CONCLUSION: Race and socioeconomic factors are important predictors of access to complex reconstructive procedures and hospital-based outcomes following extirpation in melanoma patients.

Influence of Nonsyndromic Bicoronal Synostosis and Syndromic Influences on Orbit and Periorbital Malformation.

BACKGROUND: Oculoorbital disproportion in patients with craniosynostosis has similarities and dissimilarities between syndromic and nonsyndromic cases. The authors hypothesized that these two conditions have specific individual influences as they relate to development of the orbital and periorbital skeletons. METHODS: A total of 133 preoperative computed tomography scans (nonsyndromic bicoronal synostosis, n = 38; Apert syndrome bicoronal synostosis subtype, n = 33; Crouzon syndrome bicoronal synostosis subtype, n = 10; controls, n = 52) were included. Craniometric and volumetric analyses related to the orbit and periorbital anatomy were performed. RESULTS: Orbital cavity volume was mildly restricted in nonsyndromic bicoronal synostosis (7 percent, p = 0.147), but more so in Apert and Crouzon syndromes [17 percent (p = 0.002) and 21 percent (p = 0.005), respectively]. The sphenoid side angle in Apert syndrome was wider than when compared to Crouzon syndrome (p = 0.043). The ethmoid side angle in Apert patients, however, was narrower (p = 0.066) than that in Crouzon patients. Maxilla anteroposterior length was more restricted in Apert syndrome than Crouzon syndrome (21 percent, p = 0.003) and nonsyndromic cases (26 percent, p < 0.001). The posterior nasal spine position was retruded in Crouzon syndrome (39 percent, p < 0.001), yet the anterior nasal spine position was similar in Apert and Crouzon syndromes. CONCLUSIONS: Orbit and periorbital malformation in syndromic craniosynostosis is likely the combined influence of syndromic influences and premature suture fusion. Apert syndrome expanded the anteriorly contoured lateral orbital wall associated with bicoronal synostosis, whereas Crouzon syndrome had more infraorbital rim retrusion, resulting in more severe exorbitism. Apert syndrome developed maxillary hypoplasia, in addition to the maxillary retrusion, observed in Crouzon syndrome and nonsyndromic bicoronal synostosis patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Orbitofacial morphology changes with different suture synostoses in Crouzon syndrome.

This study aims to investigate the influence of different cranial vault suture synostoses on orbital and periorbital morphological development in Crouzon syndrome. Computed tomography (CT) scans of Crouzon syndrome patients who had not undergone operation were subgrouped as follows: type I: bicoronal synostosis; type II: sagittal synostosis; type III: pansynostosis; type IV: perpendicular combinations of suture synostoses; and type V: bilateral squamosal synostosis. CT scans were measured using Materialise software. CT scans of 80 Crouzon syndrome patients and 72 normal controls were included. Orbital bony cavity volume was reduced in all subgroups (16-24%), including type V bilateral squamosal synostosis (16%, p = 0.003), although the reduction in type II sagittal synostosis Crouzon patients failed to reach statistical significance (p = 0.071). Globe volume was reduced only in type I bicoronal synostosis (9%, p = 0.018), while the retrobulbar soft tissue volume decreased in type III pansynostosis group by 11% (p = 0.005). Globe volume projection beyond the orbital rim was increased in all groups (p < 0.001), with the greatest increase in type IV perpendicular combination of sutures synostoses, by 100% (p < 0.001). The anteroposterior length of maxilla was significantly shortened in type I (10%, p = 0.028) and type III (9%, p = 0.022) but developed normally in other groups, although the maxilla was posteriorly displaced in all groups (all p ≤ 0.026). The influence of squamosal synostosis on craniofacial malformation is not equivalent to that of a major vault suture. Therefore, subtype suture fusion individualized surgical interventions, after initial occipital expansion, likely provide additional benefits in mitigating oculo-orbital disproportion.

Extended Scalp Expansion for Larger Defects During Staged Cranioplasty.

BACKGROUND: Secondary cranioplasty is often required following trauma, infection, radiation, or oncologic care, but is complicated by soft-tissue deficits with limited regional options. Scalp tissue expanders can provide hair-bearing, vascularized tissue for tension- free closure yielding optimal aesthetic results. However, the upper limit of safe scalp expansion has not been explored. This study sought to evaluate the efficacy of extended scalp tissue expansion for challenging cranioplasties in a consecutive series. METHODS: Patients who underwent scalp tissue expansion before cranioplasty were retrospectively identified from a single institution between the years 2017 and 2020. Patient demographics, tissue expansion characteristics, and complications during expansion and after cranioplasty were collected. RESULTS: Six patients were identified who underwent staged scalp expansion for cranioplasty; 5 were male (83.3%) with a mean age of 43.8 ±â€Š12.5 years. Indications for cranioplasty included 2 epilepsy- related procedures, 1 oligodendroglioma, 2 infectious processes, and 1 traumatic incident. A single expander was used in 5 cases, whereas 2 were used in the remaining case. The average expander fill volume was 434.3 ±â€Š115 ccs with a mean expansion time of 3.3 ±â€Š1.4  months. Expander infection occurred in 1 case and expander exposure in another, but adequate scalp expansion was still achieved in both. Successful closure over cranioplasty was obtained in 5 cases (83.3%); 1 patient ultimately required free flap reconstruction for soft-tissue coverage. CONCLUSIONS: In cases of extended scalp defects, scalp tissue expansion remains the preferred method for recruiting large quantities of like tissue before implant cranioplasty.

Stepwise Reconstruction of a Large, Self-Inflicted Calvarial Defect.

BACKGROUND AND IMPORTANCE: Scalp expansion ensures that tissue similar in color, texture, thickness, and most importantly, hairbearing quality, is available to resurface the scalp. It is a critical option for reconstruction of large calvarial defects. CLINICAL PRESENTATION: Over 6months, a 55-year-old male patient excoriated his scalp into a full-thickness scalp and calvarial wound resulting in dural violation and meningitis. The patient presented with altered mental status and methicillin-susceptible staphylococcus aureus (MSSA) bacteremia, cranial osteomyelitis, and an intracranial abscess secondary to the large scalp defect. The patient underwent immediate debridement and dural coverage with a scalp rotational flap. Several months later he began delayed stepwise cranioplasty with multiple scalp tissue expanders given the deficiency of soft tissue. CONCLUSIONS: This case is presented to highlight the unusual mechanism of injury and the complex reconstructive approach in surgical management.

Postoperative Edema Resolution Post-Orthognathic Triple Jaw Surgery: A Three-Dimensional Volumetric Analysis.

PURPOSE: The final result following orthognathic surgery may be hidden for months due to postoperative swelling. However, no substantial evidence supports this time estimate. Our study aims to three-dimensionally quantify volumetric changes in facial edema following triple-jaw surgery. MATERIALS AND METHODS: This was a retrospective, three-dimensional (3D) study of patients who underwent primary orthognathic triple jaw surgery (Le Fort I, Bilateral Sagittal Split Osteotomy (BSSO), and osseous genioplasty) by the senior author (DMS). Vectra 3D Software (Canfield, Fairfield, NJ) was used to assess and quantify volumetric changes between serial 3D photos. An inverse line of best-fit was plotted to assess reduction in postoperative facial edema. The effects of gender, age, body mass index, and tranexamic acid administration on swelling resolution were analyzed through mixed linear model analysis. RESULTS: A total of 46 patients (198 images) met the study criteria. The equation for the inverse function line of best fit was y = -13.14ln (x) + 39.54 (P < 0.01). On average, 60% of the swelling resolved in 1 month, 84% after 6 months, and nearly 93% after 12 months. There were no significant differences in the rate of swelling resolution when accounting for age, gender, body mass index, or tranexamic acid administration. CONCLUSIONS: Most facial edema resolved during the first month following triple jaw surgery, with significant reduction in swelling between 6 and 12 months postoperatively. After 1 year, approximately 10% of the initial edema remained.

Non-Surgical Correction of Congenital Ear Anomalies: A Critical Assessment of Caretaker Burdens and Aesthetic Outcomes.

INTRODUCTION: Congenital ear anomalies result from cartilage and skin compression in utero. They can be corrected in infancy before the cartilage hardens and loses its malleability. Caretaker burden of ear molding and its impact on esthetic outcomes has not been studied. METHODS: Demographic and procedural variables were retrospectively collected for infants who underwent ear molding. Parents were surveyed regarding their experience, caretaker burden, and esthetic outcome. Outside physicians were provided with pre- and post-treatment photographs and asked to rate outcomes. A Likert scale was developed for responses and converted to a numeric score from 1 to 5 with 5 as the most desirable. RESULTS: Seventy-four patients comprising 121 ears were included. Mean age at treatment was 20.1 ± 21.4 days with treatment duration of 21.1 ± 7.7 days. Parental participation in the survey was 70.1%. Questions that queried parents' experiences revealed a "very positive" experience with minor burden related to bathing and cleaning (Mean Likert Score 4.1, Range 1-5). Favorable parent-reported outcomes were obtained regarding anticipated social distress (4.28, 1-5), satisfaction with results (4.27, 1-5), and perception of final appearance (4.18, 1-5). Physician assessments of esthetic outcomes were slightly lower, but favorable between "somewhat effective" and "very effective" (3.46, 1-5). Earlier treatment trended favorably, but did not reach significance. Ear malformations had higher parent-reported satisfaction than ear deformations (4.75 ± 0.46 vs 4.21 ± 1.25, p = 0.025). CONCLUSION: Despite the additional obligation for new parents, infant ear molding is rated low in terms of caretaker burden. Esthetic outcomes are excellent as assessed by parents and physicians. However, caretakers reported higher esthetic outcomes than physician evaluations. LEVEL OF EVIDENCE IV: 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.

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.

Utilizing Age of Menarche to Optimize Pediatric Rhinoplasty.

BACKGROUND/PURPOSE: Pediatric septorhinoplasty has sparked controversial debate amongst craniofacial surgeons, particularly due to its potential growth disturbances of the face and nose. The purpose of this study is (1) to conduct a systematic literature review that explores unique considerations and limitations associated with performing rhinoplasty in the pediatric population; (2) to discuss objective indicators for determining craniofacial skeleton maturation; (3) to perform a case series to further understand whether the age of menarche serves as a good proxy for estimating the time of facial growth maturation, and by extension, whether a post-menarchal patient is a suitable candidate for rhinoplasty. METHODS: Systematic literature review was performed in order to assess unique considerations and limitations of pediatric rhinoplasty. Retrospective chart review and anthropometric (9 linear, 3 angular, 6 indices) measurements were performed for ten pediatric female patients who underwent open septo-rhinoplasty. Follow-up times ranged from 66 to 103 weeks. Patients were separated into 2 cohorts according to age at the time of menarche. Cohort 1 consisted of patients who had undergone menses for longer than 2 years at the time of rhinoplasty, whereas Cohort 2 comprised of patients who either had menses within 2 years of rhinoplasty or did not have menses at the time of rhinoplasty. Data included demographic factors, procedural variables, revision surgeries, and complications. Measurements were conducted using VECTRA software (Canfield Scientific, Parsippany, NJ). Differences in measurements between the 2 postoperative timepoints were compared. RESULTS: Literature review yielded 17 articles, which had conflicting opinions regarding pediatric rhinoplasty and ultimately, highlighting the need for a more objective tool for guiding the decision to perform rhinoplasty.Patients in Cohort 1 had minimal deviations in measurements over time, within the exception of an increase in nasal tip projection and a decrease in nasolabial angle and facial width. Patients in Cohort 2 had decreases in facial height, upper facial height, nasal tip angle, and nasofrontal angle. Nasolabial angle decreased for both cohorts. Of the ten patients, 1 in Cohort 2 underwent revision rhinoplasty. CONCLUSIONS: Our case series suggests that anthropometric measurements remain relatively more stable for patients who have undergone menses for more than 2 years, compared to those who have not. Although this study has limitations, further investigation is warranted in order to determine whether age of menarche may serve as a useful tool for craniofacial surgeons in guiding the decision to perform rhinoplasty.

Socioeconomic Disparities in the Surgical Management of Craniosynostosis.

BACKGROUND: The updated ICD-10 coding system introduced partway through 2015 offers codes with increased granularity for disease and procedure types. This is the first study to use ICD-10 codes to investigate disparities in the surgical management for craniosynostosis. METHODS: Using the Kids' Inpatient Database univariable analyses were performed to compare the relative odds of undergoing strip craniectomy, either endoscopic (ESC) or open (OSC), or calvarial vault remodeling (CVR) based on a variety of demographic and hospital-level variables. RESULTS: Of the 2,874 patients identified, 2,352 underwent CVR while 522 underwent SC. Of those undergoing SC, 295 and 228 had an endoscopic and open procedure, respectively. A greater proportion of patients who had private insurance (58.14% versus 47.49%) or were self-pay (8.06% versus 6.28%) underwent SC, whereas a higher percentage who were covered under Medicaid (46.23% versus 32.8%; P < 0.001) received CVR. ESC patients were 2.16 times more likely to have private insurance and 2.07 times more likely to be from the highest income quartile compared to OSC patients. However, there were no differences in terms of insurance type or income level between those undergoing CVR compared to OSC. CONCLUSIONS: Our study found that the difference between CVR and SC can be attributed to the difference in the endoscopic versus open approaches to SC. Although the socioeconomic disparities persisted in the comparison between ESC and OSC, with patients receiving ESC coming from wealthier and commercially insured families, the same differences were not observed when comparing CVR with OSC.