Developing the Aesthetic Postoperative Complication Score (APeCS) for Detecting Major Morbidity in Facial Aesthetic Surgery.

BACKGROUND: Facial aesthetic surgery encompasses a variety of procedures with complication rates that are difficult to estimate due to a lack of published data. OBJECTIVES: We sought to estimate major complication rates in patients undergoing facial aesthetic procedures and develop a risk assessment tool to stratify patients. METHODS: We utilized the Tracking Operation and Outcomes for Plastic Surgeons (TOPS) database from 2003-2018. The analytic database included major facial aesthetic procedures. Univariate analysis and a backward stepwise multivariate regression model identified risk factors for major complications. Regression coefficients were utilized to create the score. Performance robustness was measured with area under receiver operating characteristic curves and sensitivity analyses. RESULTS: A total of 38,569 patients were identified. The major complication rate was 1.2% (460). The regression model identified risk factors including over 3 concomitant surgeries, BMI ≥25, ASA class ≥2, current or former smoker status, and age ≥45 as the variables fit for risk prediction (n = 13,004; area under curve: 0.68, standard error: 0.013, [0.62-0.67]). Each of the 5 variables counted for 1 point, except over 3 concomitant surgeries counting for 2, giving a score range from 0 to 6. Sensitivity analysis showed the cutoff point of ≥3 to best balance sensitivity and specificity, 58% and 66%, respectively. At this cutoff, 65% of cases were correctly classified as having a major complication. CONCLUSIONS: We developed an acceptable risk prediction score with a cutoff value of ≥3 associated with correctly classifying approximately 65% of those at risk for major morbidity when undergoing face and neck aesthetic surgery.

Predicting the Ideal Patient for Ambulatory Cleft Lip Repair.

BACKGROUND: The utilization of ambulatory surgical centers (ASCs) for cleft lip repair is increasing to reduce costs. This study better defines the patient population appropriate for ambulatory cleft repair with uplift modeling, a predictive analytics technique. METHODS: Pediatric patients who underwent cleft lip repair were identified in the 2007 to 2011 California Healthcare Cost and Utilization Project State Inpatient Database and State Ambulatory Surgery and Services Database. The 2-model uplift approach was utilized using multivariate logistic regressions fit to assess the effect of ASCs, age, comorbidities, and procedure type on mortality or 30-day readmission. RESULTS: Of the pediatric cleft lip repairs in California between 2007 and 2011, 2383 (83%) were conducted in inpatient facilities and 498 (17%) in ASCs. The 30-day readmission rates were 2.01% and 1.93% for ASC repairs and inpatient repairs, respectively ( P = .909). Uplift modeling predicts that of the 2881 patients, approximately 40% of patients would have benefit from an ASC repair and an ASC repair would have had no effect on the remaining 60%. Patients likely to benefit from an ASC repair were more likely younger than 1 year old, nonsyndromic, not to have a respiratory or neurologic diagnosis, have less number of procedures, and to have undergone an isolated cleft lip repair. CONCLUSION: Uplift modeling predicts that approximately 40% of patients would benefit from an ASC cleft lip repair. Targeting patients younger than 1 year old, nonsyndromic, with no respiratory or neurologic diagnosis for ASC cleft lip repair, may be a safe and cost-saving endeavor.

Age at Time of Craniosynostosis Repair Predicts Increased Complication Rate.

OBJECTIVE: This study uses administrative data to assess the optimal timing for surgical repair of craniosynostosis and to identify factors associated with risk of perioperative complications. DESIGN: Statistical analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database (2006, 2009, 2012). SETTING: KID-participating hospitals in 44 states. PATIENTS: Children 0 to 3 years of age with ICD-9 codes for surgical correction of craniosynostosis (756 and 0124, 0125, 0201, 0203, 0204, or 0206). MAIN OUTCOME MEASURE: Age-based cohorts were assessed for perioperative complications. We performed a multivariable analysis to determine characteristics associated with increased risk of complications. RESULTS: 21 million admissions were screened and 8417 visits met criteria for inclusion. Seventy-five percent of procedures occurred before age 1. Complications occurred in 8.6% of patients: 6.6% of patients at age 0 to 6 months, 10.3% of patients aged 7 to 12 months, and 13.9% of patients 12 to 36 months. Patients with acrocephalosyndactyly or associated congenital anomalies experienced complications in 22.9% of cases (OR = 3.07, 95% CI = 2.33, 4.03). CONCLUSION: Craniosynostosis repair is safe; however, the risk of complications increases with age at intervention. Presence of a syndromic congenital deformity at any age carries the greatest increased risk of perioperative complications. This suggests that optimal timing of intervention is within the first year of life, especially in those cases with additional factors increasing perioperative risk. These data support the importance of counseling patients of the increased risk associated with delaying craniosynostosis repair.

Le Fort III Distraction With Internal vs External Distractors: A Cephalometric Analysis.

OBJECTIVE: This study compares the change in midface position following Le Fort III advancement using either rigid external distraction (group 1) or internal distraction (group 2). We hypothesized that, with reference to right-facing cephalometry, internal distraction would result in increased clockwise rotation and inferior displacement of the midface. DESIGN: Le Fort III osteotomies and standardized distraction protocols were performed on 10 cadaveric specimens per group. Right-facing lateral cephalograms were traced and compared across time points to determine change in position at points orbitale, anterior nasal spine (ANS), A-point, and angle ANB. SETTING: Institutional. PATIENTS, PARTICIPANTS: Twenty cadaveric head specimens. INTERVENTIONS: Standard subcranial Le Fort III osteotomies were performed from a coronal approach and adequately mobilized. The specified distraction mechanism was applied and advanced by 15 mm. MAIN OUTCOME MEASURE(S): Changes of position were calculated at various skeletal landmarks: orbitale, ANS, A-point, and ANB. RESULTS: Group 1 demonstrated relatively uniform x-axis advancement with minimal inferior repositioning at the A-point, ANS, and orbitale. Group 2 demonstrated marked variation in x-axis advancement among the 3 points, along with a significant inferior repositioning and clockwise rotation of the midface ( P < .0001). CONCLUSION: External distraction resulted in more uniform advancement of the midface, whereas internal distraction resulted in greater clockwise rotation and inferior displacement. External distraction appears to provide increased vector control of the midface, which is important in creating a customized distraction plan based on the patient's individual occlusal and skeletal needs.

Customized "In-Office" Three-Dimensional Printing for Virtual Surgical Planning in Craniofacial Surgery.

BACKGROUND: Virtual surgical planning using three-dimensional (3D) printing technology has improved surgical efficiency and precision. A limitation to this technology is that production of 3D surgical models requires a third-party source, leading to increased costs (up to $4000) and prolonged assembly times (averaging 2-3 weeks). The purpose of this study is to evaluate the feasibility, cost, and production time of customized skull models created by an "in-office" 3D printer for craniofacial reconstruction. METHODS: Two patients underwent craniofacial reconstruction with the assistance of "in-office" 3D printing technology. Three-dimensional skull models were created from a bioplastic filament with a 3D printer using computed tomography (CT) image data. The cost and production time for each model were measured. RESULTS: For both patients, a customized 3D surgical model was used preoperatively to plan split calvarial bone grafting and intraoperatively to more efficiently and precisely perform the craniofacial reconstruction. The average cost for surgical model production with the "in-office" 3D printer was $25 (cost of bioplastic materials used to create surgical model) and the average production time was 14  hours. CONCLUSIONS: Virtual surgical planning using "in office" 3D printing is feasible and allows for a more cost-effective and less time consuming method for creating surgical models and guides. By bringing 3D printing to the office setting, we hope to improve intraoperative efficiency, surgical precision, and overall cost for various types of craniofacial and reconstructive surgery.

Pediatric frontal sinus fractures: outcomes and treatment algorithm.

Pediatric frontal sinus fractures are a rare clinical entity. Owing to the large amount of force required to fracture the frontal sinus, it is often associated with severe intracranial and craniofacial injuries. The treatment of frontal sinus fractures is controversial, with many different established algorithms based mainly on the adult population. The authors present their experience with pediatric frontal sinus fractures; they also present a treatment algorithm. A retrospective review of the Cincinnati Children's Hospital Medical Center trauma database was performed. From 1998 to 2010, the authors identified patients between the ages of 0 and 18 with frontal sinus fractures and analyzed demographics, fracture pattern, associated injuries, methods of treatment, and complications. Descriptive statistics and univariate analyses were performed.A total of 39 patients were included in the study with a mean follow-up of 31.2 months. Fractures of the anterior and posterior table with displacement greater than one table width were significantly associated with higher hospital costs, higher velocity mechanism of injuries, lower Glasgow Coma Scale scores, nasofrontal outflow tract (NFOT) involvement, and cerebrospinal fluid leak. There were no differences in short- and long-term complications. Additionally, these patients were more likely to be treated surgically in the form of obliteration or cranialization.Patients without NFOT involvement can be managed with observation only. Patients with NFOT involvement or persistent cerebrospinal fluid leak should be treated with obliteration or cranialization, respectively, to reduce the risk of severe complications.

Comparative Study of Early Secondary Nasal Revisions and Costs in Patients With Clefts Treated With and Without Nasoalveolar Molding.

The present study aims to determine the risk of early secondary nasal revisions in patients with complete unilateral and bilateral cleft lip and palate (U/BCLP) treated with and without nasoalveolar molding (NAM) and examine the associated costs of care. A retrospective cohort study from 1990 to 1999 was performed comparing the risk of early secondary nasal revision surgery in patients with a CLP treated with NAM and surgery (cleft lip repair and primary surgical nasal reconstruction) versus surgery alone in a private practice and tertiary level clinic. The NAM treatment group consisted of 172 patients with UCLP and 71 patients with BCLP, whereas the non-NAM-prepared group consisted of 28 patients with UCLP and 5 with BCLP. The risk of secondary nasal revision for patients with UCLP was 3% in the NAM group and 21% in the non-NAM group. The risk of secondary nasal revision for patients with BCLP was 7% in the NAM group compared with 40% in the non-NAM group. Using multicenter averages, the non-NAM revision rates were calculated at 37.8% and 48.5% for U/BCLP, respectively. Applying these risks of revision, NAM treatment led to an estimated savings of between $491 and $4893 depending on the type of cleft. In conclusion, NAM can reduce the number of early secondary nasal revision surgeries and, therefore, reduce the overall cost of care.

Unilateral Craniofacial Microsomia: Unrecognized Cause of Pediatric Obstructive Sleep Apnea.

Bilateral craniofacial microsomia causes obstructive sleep apnea (OSA). We hypothesize that unilateral craniofacial microsomia (UCFM) is an underappreciated cause of OSA. The records of all pediatric UCFM patients from 1990 to 2010 were reviewed; only complete records were included in the study. UCFM patients with OSA (apnea hypopnea index >1/hr) were compared to UCFM patients without OSA. Univariate and multivariate Fisher and χ(2) tests were performed. Of the 62 UCFM patients, 7 (11.3%) had OSA. All OSA patients had Pruzansky IIB or III mandibles. OSA patients presented with snoring (71.4%), failure to thrive (FTT) (57.1%), and chronic respiratory infections (42.8%). Snoring (P < 0.001), Goldenhar syndrome (P = 0.001), and FTT (P = 0.004) were significantly associated with OSA, but race, obesity, clefts, respiratory anomalies, adenotonsillar hypertrophy, and laterality were not. The prevalence of OSA in UCFM patients is up to 10 times greater than in the general population. Snoring, Goldenhar syndrome, and FTT are significantly associated with the presence of OSA.

Tissue expander complications in the pediatric burn patient: a 10-year follow-up.

BACKGROUND: This study is a 10-year follow-up to our previous publication reviewing the complication rates of tissue expansion in the pediatric burn population. The purpose of this study was to determine if our institutional experience with tissue expanders had remained stable during the subsequent 10 years. METHODS: There were 240 patients who were identified at a major pediatric burn center who underwent reconstruction with a tissue expander (256 tissue expanders) from 1996 to 2006. Data were obtained retrospectively by reviewing patient medical records. Complications were categorized into absolute and relative complications. RESULTS: Absolute complications occurred in 36 (14.1%) of 256 expanders placed and relative complications occurred in 26 (10.2%) of 256 expanders placed. There was no statistical difference between this study and our previous study for overall complication rates and complications for all sites. The highest complication rate occurred when the scalp was a surgical site. Betadine skin preparation was associated with a 10% reduction in infection-related complications compared to other skin preparations. The operating surgeon or age of patient was not found to be associated with increased complication rates. CONCLUSIONS: After changing our tissue expander protocol, the complication rates at our institution have remained stable during the 10-year follow-up period. Tissue expansion in the pediatric burn population continues to be a safe and effective reconstructive option with acceptable complication rates.

Thoracic outlet syndrome in the pediatric population: case series.

We present 4 patients, 4 months to 10 years of age, with thoracic outlet syndrome. All were referred to the brachial plexus clinic. Three patients were diagnosed with vascular thoracic outlet syndrome after clinical evaluation and diagnostic imaging. Three had a cervical rib and 1 had an anomalous first rib. All patients were treated surgically through a supraclavicular approach and had resolution of the symptoms. No postoperative complications were noted.

Maxillary mucocele with proptosis and visual impairment: a late complication of Le Fort III distraction.

Maxillary mucoceles are a relatively rare entity especially following surgical procedures involving osteotomies of the maxilla. The etiology of maxillary mucoceles has been ascribed to facial trauma (fractures), sinus surgery, and chronic inflammatory diseases or infections. Mucoceles can follow injury to the sinus mucosa and/or sinus outflow tract with a resulting expansile cystic mass. The clinical presentation ranges from swelling, pain, a palpable mass, proptosis, enophthalmos, and diplopia. The treatment involves either open or endoscopic incision and drainage of the cyst, mucosal resection, and an antrostomy for drainage.We report the case of a patient with Pfeiffer syndrome who underwent Le Fort III distraction osteogenesis and developed a symptomatic mucocele 15 years postoperatively.

Extended composite temporoparietal fascial flap: clinical implications for tissue engineering in mandibular reconstruction.

BACKGROUND: The authors have expanded upon a well-described and widely used flap in the head and neck region. The purpose of the cadaver study was to determine the feasibility, angiosome, and the potential application of this pedicled flap in bone tissue engineering of the mandible. METHODS: A total of 6 fresh human cadaver heads were dissected for a total of 12 flaps. The extended composite temporoparietal fascial flap, based on the superficial temporal artery (STA) and including cranial periosteum, was dissected and the dimensions were measured. Through a combined submandibular and preauricular incision, the mandible was exposed and the dimensions were measured from the sigmoid notch to the gonion angle and from the gonion angle to the symphysis. CT angiography and silicone injections were performed to identify the vascular anatomy of the flap. RESULTS: The combined distance from the sigmoid notch to the gonion and the gonion to the symphysis, plotted versus the cranial apex to tragus length, demonstrated adequate flap dimensions in all specimens for hemi-mandibular reconstruction. The average flap length was 16.5 ± 1.40 cm and the average flap width was 11.4 ± 0.98 cm, resulting in an average flap surface area of 94.5 ± 13.08 cm. Radiographic images and silicone injections confirmed STA perfusion of the cranial periosteum. CONCLUSIONS: The extended composite temporoparietal fascial flap with periosteum can be a viable option for providing vascularized periosteum in tissue-engineered craniofacial reconstruction.

External fixation in a low-velocity gunshot wound to the mandible.

Low-velocity gunshot wounds to the mandible are complex injuries that can be aesthetically and functionally devastating. Despite advances in plating systems and surgical techniques, repair of such injuries remains a challenging endeavor. Traditionally, external fixation has resulted in longer treatment times and the need for revision surgery. Rigid fixation has many proponents because of shorter postoperative treatment times and fewer complications. We report a case of a low-velocity gunshot injury to the mandible with comminution and a full-thickness soft tissue wound treated definitively with maxillomandibular fixation and an external fixation device.

National Trends in Venous Thromboembolism in the Adult Craniofacial Trauma Population.

Venous thromboembolism (VTE), specifically deep vein thrombosis (DVT) and pulmonary embolism (PE), is a major complication in plastic surgery; however, there is a paucity of evidence about the incidence of VTE in the craniofacial subpopulation. We investigated the incidence and risk factors for VTE in the adult craniofacial trauma population. Methods: This retrospective review identified patients from the 2016 and 2017 Healthcare Cost and Utilization Project's National Inpatient Sample with a diagnosis for an initial encounter of a facial fracture. International Classification of Disease codes identified patients with DVT or PE. Groups were identified: adult craniofacial patients with and without a VTE diagnosis. The groups were analyzed to determine risk factors for developing a VTE during inpatient admissions. Results: A total of 203,240 patients were identified based on a diagnosis for an initial encounter of a facial fracture. Among those, 3350 (1.65%) were diagnosed with a DVT and 1455 (0.72%) with a PE. Risk factors for VTE were male sex (P = 0.011), longer hospital stay (P = 0.000), and higher Elixhauser comorbidity index (P = 0.000). Additionally, PE was an independent predictor of mortality [odds ratio (OR), 2.129] but DVT was not (OR, 1.148). Cranial and frontal fractures were independently associated with an increase in DVT (OR, 2.481) and PE (OR, 1.489). Conclusions: This study demonstrates that craniofacial trauma patients are at risk for VTE and should be risk-stratified for chemoprophylaxis therapy. Further studies in thromboembolism prophylaxis for facial fractures are warranted as the data are limited.

American Society of Plastic Surgeons Evidence-Based Clinical Practice Guideline: Eyelid Surgery for Upper Visual Field Improvement.

BACKGROUND: A group of experts from different disciplines was convened to develop guidelines for the management of upper visual field impairments related to eyelid ptosis and dermatochalasis. The goal was to provide evidence-based recommendations to improve patient care. METHODS: A multidisciplinary group of experts representing their specialty organizations was selected. A systematic literature review was performed including topics regarding documentation of the underlying cause for visual field impairment, selection of an appropriate surgical repair, assessment of the type of anesthesia, the use of adjunctive brow procedures, and follow-up assessments. The Grading of Recommendations, Assessment, Development, and Evaluation methodology process was used to evaluate the relevant studies. Clinical practice recommendations were developed using BRIDGE-Wiz (Building Recommendations In a Developers' Guideline Editor) software. RESULTS: Each topic area was assessed. A clinical recommendation was made, and the relevant literature was discussed. CONCLUSIONS: The review of the literature revealed varied complication rates and diverse treatment modalities for the correction of upper visual field deficit. Strong recommendations could not be made in most topic areas because of a paucity of methodologically sound studies in the literature. More rigorously designed studies are needed to measure outcomes of interest, with fewer sources of potential error or bias. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Five-Year Follow-Up of Midface Distraction in Growing Children with Syndromic Craniosynostosis.

BACKGROUND: Maxillary position in patients with syndromic craniosynostosis after midface distraction has been shown to be stable 1 year postoperatively. The purpose of this study is to assess midfacial position in the growing child with craniosynostosis 5 years after Le Fort III advancement with a rigid external device. METHODS: Seventeen consecutive patients were identified to have the diagnosis of syndromic craniosynostosis and had undergone midface advancement [corrected]. There were 10 boys and seven girls, seven patients had Crouzon syndrome, five had Apert syndrome, and five had Pfeiffer syndrome. A standard subcranial Le Fort III osteotomy was performed. Cephalometric analysis was performed to assess the position of the maxilla. RESULTS: After device removal, orbitale advanced 13.67 mm along the x axis and downward 1.70 mm along the y axis. The A point advanced 15.97 mm along the x axis and downward 1.14 mm along the y axis. At 1 year after distraction, both orbitale and A point had advanced an additional 0.47 mm and 0.24 mm along the x axis and downward 0.58 mm and 1.78 mm along the y axis, respectively. At 5 years after distraction, the orbitale moved posterior 0.58 mm and the A point advanced an additional 2.08 mm along the x axis. Orbitale and A point descended 3.23 mm and 5.2 mm along the y axis, respectively. CONCLUSION: After Le Fort III advancement with distraction, the maxillary position remains stable and continues to advance minimally along the x axis and demonstrates more growth along the y axis over the long term. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Heads-up 3D Microscopy: An Ergonomic and Educational Approach to Microsurgery.

Traditional microsurgery can lead surgeons to use postures that cause musculoskeletal fatigue, leaving them more prone to work-related injuries. A new technology from TrueVision transmits the microscopic image onto a 3-dimensional (3D) monitor, allowing surgeons to operate while sitting/standing in a heads-up position. The purpose of this study was to evaluate the feasibility of performing heads-up 3D microscopy as a more ergonomic alternative to traditional microsurgery. A feasibility study was conducted comparing heads-up 3D microscopy and traditional microscopy by performing femoral artery anastomoses on 8 Sprague-Dawley rats. Operative times and patency rates for each technology were compared. The 8 microsurgeons completed a questionnaire comparing image quality, comfort, technical feasibility, and educational value of the 2 technologies. Rat femoral artery anastomoses were successfully carried out by all 8 microsurgeons with each technology. There was no significant difference in anastomosis time between heads-up 3D and traditional microscopy (average times, 34.5 and 33.8 minutes, respectively; P = 0.66). Heads-up 3D microscopy was rated superior in neck and back comfort by 75% of participants. Image resolution, field of view, and technical feasibility were found to be superior or equivalent in 75% of participants, whereas 63% evaluated depth perception to be superior or equivalent. Heads-up 3D microscopy is a new technology that improves comfort for the microsurgeon without compromising image quality or technical feasibility. Its use has become prevalent in the field of ophthalmology and may also have utility in plastic and reconstructive surgery.