Evaluation of predictive factors of septic wrist to avoid overdiagnosis.

BACKGROUND: The existing diagnostic criteria for septic wrist are nonspecific, exposing patients with noninfectious etiologies to surgical morbidity. This study aimed to identify predictors differentiating septic wrist from other etiologies. METHODS: An institutional review board-approved retrospective review was conducted on patients with a presumed diagnosis of septic wrist (2003-2022). Bivariate and multiple regression analyses were performed to identify correlation between confirmed septic wrist and comorbidities (autoimmune diseases, immunosuppression, crystalline arthropathy, intravenous [IV] drug use, smoking), penetrating trauma, fever, multi-joint involvement, inflammatory markers (erythrocyte sedimentation rate [ESR]/C-reactive protein [CRP]/white blood cells [WBC]), serum uric acid level, blood cultures, imaging findings, and synovial fluid analysis. Categorical data were reported as median [interquartile range]. RESULTS: Hundred and sixty-eight (58 females and 110 males) patients were included. The median length of hospitalization and follow-up were 6[7] days and 1[3] months. Eighty-nine (53%) patients had septic wrist confirmed with Gram stain/culture, 48 (29%) patients received alternative diagnoses, and 31 (18%) patients had undetermined diagnoses. Concomitant septic wrist and crystalline arthropathy were identified in 9 patients (6.6% of total patients). Out of the 48 patients who received alternative diagnoses, 12 (25%) underwent open drainage. Elevated synovial WBC count (95,409.4 ± 85,926.2) showed a trend of association with septic wrist (p = 0.08). Negative synovial crystals (p = 0.01), positive blood culture (p = 0.04), negative history of crystalline arthropathy (p = 0.08), and multi-joint involvement (p = 0.05) were identified as predictors of septic wrist with a combined sensitivity of 87.5%, specificity of 86.2%, and area under the curve 0.93. CONCLUSIONS: Current diagnostic criteria for septic wrist have low specificity. Negative history of crystalline arthropathy, multi-joint involvement, absence of synovial crystals, and positive blood culture are helpful indicators for predicting septic wrist in patients presenting with a painful, erythematous, and swollen wrist.

Intracranial Pressure Patterns in Children with Sagittal Craniosynostosis.

BACKGROUND: Elevated intracranial pressure (ICP) in sagittal craniosynostosis has a wide spectrum of reported incidence, and patterns are not well understood across infancy and childhood. Characterizing the natural history of ICP in this population may clarify risks for neurocognitive delay and inform treatment decisions. METHODS: Infants and children with sagittal craniosynostosis and unaffected control subjects were prospectively evaluated with spectral-domain optical coherence tomography (OCT) from 2014-2021. Elevated ICP was determined based on previously validated algorithms utilizing retinal OCT parameters. RESULTS: Seventy-two patients with isolated sagittal craniosynostosis, and 25 control subjects were evaluated. Overall, 31.9% (n=23) of patients with sagittal craniosynostosis had evidence of ICP ≥15 mmHg, and 27.8% (n=20) of patients had ICP ≥20 mmHg.Children with sagittal craniosynostosis younger than 6 months of age were more likely to have normal intracranial pressure (88.6% <15 mmHg, 91.4% <20 mmHg) than those between 6-12 months of age (54.5%, p=.013; 54.5%, p=.005) and than those older than 12 months of age (46.2%, p<.001; 53.8%, p=.001). Intracranial pressure was directly correlated with severity of scaphocephaly (p=.009). No unaffected control subjects at any age exhibited retinal thickening suggestive of elevated ICP. CONCLUSIONS: Elevated ICP is rare in isolated sagittal craniosynostosis below 6 months of age, but becomes significantly more common after 6 months of age, and may correlate with severity of scaphocephaly.

A Longitudinal Study of Improvement in Nasal Airway Obstruction after Secondary Cleft Rhinoplasty.

BACKGROUND: Nasal airway obstruction is an increasingly recognized phenomenon in patients with cleft lip and/or palate and has the potential to significantly affect quality of life in this patient population. To date, the effect of secondary cleft rhinoplasty on cleft-related nasal airway obstruction has not been studied. METHODS: Patients undergoing secondary cleft rhinoplasty at the Children's Hospital of Philadelphia from 2015 to 2021 were identified. Preoperative and postoperative Nasal Obstruction Symptom Evaluation scores were recorded. Alterations in scores were evaluated for variation depending on patient characteristics, operative maneuvers, and postoperative nasal stenting. RESULTS: Nasal airway obstruction was present in mild to moderate severity in patients before secondary cleft rhinoplasty. Postoperatively, obstruction improved or resolved in the domains of nasal blockage/obstruction, trouble breathing through the nose, and ability to get enough air through the nose during exertion (P < 0.05). Overall composite Nasal Obstruction Symptom Evaluation scores improved (P < 0.05). Lateral crural strut grafting was associated with improvement in nasal blockage, whereas alar revision and tip sutures were associated with worsening in specific nasal symptoms. Patients who underwent nasal stenting were found to report less trouble breathing after surgery than patients who did not (P < 0.05). CONCLUSIONS: Nasal airway obstruction is present in mild to moderate severity in patients with cleft lip and/or palate, and the subjective severity of obstruction is decreased by secondary cleft rhinoplasty. Specific operative maneuvers are associated with alterations in nasal airway obstructive symptoms, and nasal stenting is associated with an improvement in trouble breathing after secondary cleft rhinoplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Speech Outcomes following Mandibular Distraction Osteogenesis for Robin Sequence: Midchildhood Results.

BACKGROUND: The aim of this study was to compare midchildhood speech outcomes in patients with nonsyndromic Robin sequence with cleft palate (RSCP) treated with mandibular distraction osteogenesis (MDO) to patients with nonsyndromic Veau class I and Veau class II cleft palate (CP). METHODS: The authors performed a retrospective review of patients with nonsyndromic Robin sequence from 2000 to 2017, comparing those who underwent MDO to patients with nonsyndromic CP. Demographics, operative details, length of hospital stay, complications, and Pittsburgh Weighted Speech Scale scores were collected. RESULTS: Thirty-three patients met inclusion criteria in the MDO group with 127 patients as controls. Despite similar median age (RSCP, 4.5 years; CP only, 4.6 years) and Veau cleft type at early evaluation, there was a significant increase in composite Pittsburgh Weighted Speech Scale score within the MDO cohort ( P ≤ 0.002); specifically, with worse visible nasal emission ( P ≤ 0.007), hypernasality ( P ≤ 0.001), and compensatory articulation ( P ≤ 0.015). However, these differences were not present at age-matched midchildhood evaluation (median, RSCP, 6.5; CP only, 7.1; P ≥ 0.092). Median age-matched follow-up was 6.4 years in the MDO group and 7.1 years in the control group ( P ≥ 0.136). There was also no difference in the rate of secondary speech surgery at midchildhood evaluation ( P ≥ 0.688). CONCLUSIONS: The authors' retrospective comparison of speech outcomes in RSCP versus CP only demonstrates no difference in midchildhood speech, conflicting with recent reports. Although patients with Robin sequence treated with MDO had worse visible nasal emission, hypernasality, and compensatory articulation in early childhood, this appears to have resolved in the interim without additional intervention. Longitudinal follow-up is needed to fully understand the speech ramifications of RSCP. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Socioeconomic Disparities in Cleft Lip Care.

OBJECTIVE: The purpose of this study was to utilize a multicenter dataset to elucidate whether socioeconomic factors were associated with access to cleft lip surgery, treatment by higher-volume providers, and family choice for higher-volume centers. DESIGN: Retrospective cohort study. SETTING: Hospitals participating in the Pediatric Health Information System. PATIENTS: Primary cleft lip repair performed in the United States between 2010 and 2020. OUTCOMES: Travel distance, hospital volume, hospital choice. RESULTS: During the study interval, 8954 patients underwent unilateral (78.4%, n = 7021) or bilateral (21.6%, n = 1933) primary cleft lip repair. Patients with unilateral cleft lip were repaired significantly earlier if they were White (P < .001) and significantly later if they lived in an urban community (P = .043). Similarly, patients with bilateral cleft lip were repaired significantly earlier if they were White (P < .001). Patients from above-median income households (P = .011) and living in urban communities (P < .001) were significantly more likely to be treated at high-volume hospitals, whereas those living in underserved communities (P < .001) were significantly less likely to be treated at high-volume hospitals. White patients were significantly more likely to be treated by high-volume surgeons (P < .001). Patients with White race were significantly more likely to choose a higher-volume hospital than the one most locally available (P < .001). CONCLUSIONS: Patients with White race are more likely to travel farther and be treated by high-volume surgeons although at smaller hospitals. Patients from underserved areas travel significantly farther for cleft care and are treated at lower-volume hospitals. Patients in urban communities have shorter travel distances and are treated at higher-volume hospitals.

Narcotic Utilization After Cleft Lip Repair: Does Local Anesthetic Choice Matter?

To analyze whether the choice of intraoperative local anesthetic for cleft lip repair is associated with the amount of perioperative narcotic utilization.Retrospective cohort study.Hospitals participating in the Pediatric Health Information System.Primary cleft lip repairs performed in the United States from 2010 to 2020.Local anesthesia injected-treatment with lidocaine alone, bupivacaine alone, or treatment with both agents.Perioperative narcotic administration.During the study interval, 8954 patients underwent primary cleft lip repair. Narcotic utilization for unilateral (P < .001) and bilateral (P = .004) cleft lip repair has decreased over the last 5 years. Overall, 21.8% (n = 1950) of infants were administered perioperative narcotics for cleft lip repair, such that 14.3% (n = 1282) required narcotics on POD 0, and 7.2% (n = 647) required narcotics on POD 1.In this study, 36.5% (n = 3269) patients received lidocaine, 22.0% (n = 1966) patients received bupivacaine, and 19.7% (n = 1762) patients received both local anesthetics. Administration of any perioperative narcotic was significantly lower in patients receiving both lidocaine and bupivacaine than those receiving only lidocaine (P = .001, 17.5% vs 21.7%) or only bupivacaine (P < .001, 17.5% vs 22.9%). Narcotic utilization on the day of surgery was significantly lower in patients receiving both lidocaine and bupivacaine than those receiving only lidocaine (P < .001, 11.5% vs 15.1%) or only bupivacaine (P = .004, 11.5% vs 14.6%). Narcotic utilization on the first postoperative day was significantly lower in patients receiving both lidocaine and bupivacaine than those receiving only bupivacaine (P = .009, 5.9% vs 8.1%). CONCLUSIONS: In children undergoing cleft lip repair, local anesthetic combination of lidocaine and bupivacaine is associated with decreased perioperative narcotic use compared to lidocaine or bupivacaine alone.

Facial Scars: Do Position and Orientation Matter?

BACKGROUND: This study tested the core tenets of how facial scars are perceived by characterizing layperson response to faces with scars. The authors predicted that scars closer to highly viewed structures of the face (i.e., upper lip and lower lid), scars aligned against resting facial tension lines, and scars in the middle of anatomical subunits of the face would be rated less favorably. METHODS: Volunteers aged 18 years and older from the United States were recruited through Amazon's Mechanical Turk to complete a face rating survey. Scars were digitally added in different locations and orientations for a total of 14 unique scars added to each face. Each participant rated 50 different faces on confidence, friendliness, and attractiveness. Data were analyzed using linear mixed effects models. RESULTS: A total of 88,850 ratings [82,990 scarred (93.4 percent)] for attractiveness, friendliness, and confidence were analyzed. In univariate linear mixed effects models, the presence of a facial scar did not significantly impact attractiveness (ß = 0.016, SE = 0.014, z = 1.089, p = 0.276). A second set of linear mixed effects models identified interactions between location, subunit placement, and orientation to facial tension lines. Scars located on the lower lid mid subunit perpendicular to facial tension lines were rated less attractive (ß = -0.065, SE = 0.028, z = -2.293, p = 0.022). CONCLUSIONS: On average, a single well-healed facial scar does not negatively affect first impressions of attractiveness, confidence, or friendliness. Specific scar location and orientation combinations, however, such as a perpendicular scar at the mid-lower eyelid, may result in lower perceived attractiveness, confidence, and friendliness. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Cleft Rhinoplasty: Does Timing and Utilization of Cartilage Grafts Affect Perioperative Outcomes?

BACKGROUND: The purpose of this study was to evaluate the epidemiology and perioperative complications of different reconstructive strategies to correct cleft nasal deformity, with particular attention paid to type and timing of cartilage grafting. METHODS: Retrospective cohort study was conducted of cleft rhinoplasty performed between 2012 and 2017 in North America utilizing the American College of Surgeons National Surgical Quality Improvement Program- Pediatric hospital network. Medical/surgical complications, reoperations, and readmissions within 30 days postoperatively were analyzed with appropriate statistics. RESULTS: During the study interval, 3317 pediatric patients underwent cleft rhinoplasty, with 8.0% involving the use of cartilage grafts. Ear cartilage was significantly more commonly used for intermediate repair, whereas rib cartilage was more commonly used for late repair (P=0.006). Overall, rhinoplasties with ear cartilage grafts had shorter procedure durations than those without cartilage grafts (P=0.005), whereas those with rib cartilage grafts had increased procedure duration (P<0.001). The use of cartilage grafts was not associated with increased complications in either intermediate or late cleft rhinoplasty. Patients with bilateral clefts were more likely to undergo rhinoplasty with cartilage grafts overall (P=0.047) and with cartilage grafts for late reconstruction (P=0.039). CONCLUSIONS: Ear cartilage is most frequently utilized for intermediate repair, whereas rib cartilage is most frequently utilized for late repair during cleft rhinoplasty. Ear cartilage grafts are associated with significantly decreased procedure duration, whereas rib cartilage grafts are associated with significantly increased procedure duration. Not surprisingly, cleft rhinoplasty is relatively safe, with a 2% overall short-term complication rate.

How Low Should We Go? Safety and Craniometric Impact of the Low Occipital Osteotomy in Posterior Vault Remodeling.

BACKGROUND: A larger volume cranial vault expansion is likely facilitated by a low posterior cranial osteotomy beneath the torcula; however, this may impart an increased risk of venous bleeding. The authors compared the safety of infratorcular versus supratorcular osteotomy in patients undergoing posterior vault reconstruction or posterior vault distraction osteogenesis and analyzed volumetric changes. METHODS: Patients undergoing initial posterior vault reconstruction or distraction osteogenesis between 2009 and 2021 at the authors' institution were grouped by occipital osteotomy location and analyzed retrospectively. Craniometric analysis was performed if patients had high-resolution computed tomography scans available within 180 days preoperatively and postoperatively. RESULTS: A total of 187 patients were included: 106 (57 percent) who underwent posterior vault distraction osteogenesis and 81 (43 percent) who underwent posterior vault reconstruction. Infratorcular osteotomy was more common in reconstruction [ n = 65 (80 percent)] than in distraction osteogenesis [ n = 61 (58 percent); p < 0.002]. Blood transfused was similar between low and high osteotomy cohorts in the distraction osteogenesis ( p = 0.285) and reconstruction ( p = 0.342) groups. However, median transfused blood volume per kilogram of patient weight was greater in the low versus high osteotomy distraction osteogenesis ( p = 0.010) and reconstruction ( p = 0.041) cohorts. Intraoperative venous sinus injury was rare. In the distraction osteogenesis cohort, there was increased median intracranial volumetric gain in the low (263 ml) compared with the high osteotomy cohort (127 ml; p = 0.043); however, when controlled for distraction distance, only a trend was observed ( p = 0.221). Patients undergoing distraction osteogenesis showed a larger median intracranial volume increase (168 ml) compared with those undergoing reconstruction (73 ml; p < 0.001). CONCLUSION: Infratorcular osteotomy can be performed safely in most patients undergoing cranial vault remodeling and does not appear to be associated with greater hemodynamic instability or sinus injury. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Endoscope-Assisted Fronto-Orbital Distraction Osteogenesis.

SUMMARY: Anterior cranial vault fronto-orbital distraction osteogenesis is a promising treatment modality for children with unicoronal craniosynostosis. A minimally invasive, endoscope-assisted approach offers the additional potential benefits of less scalp scarring, decreased blood loss, and decreased scalp dissection. In this article, the authors present a novel technique for minimally invasive, endoscope-assisted fronto-orbital distraction osteogenesis.

Utility of Preoperative Helmet Molding Therapy in Patients With Isolated Sagittal Craniosynostosis.

ABSTRACT: The purpose of this study was to review our institution's experience using helmet molding therapy in children with isolated non-syndromic sagittal craniosynostosis before placement of cranial springs and provide objective measurements of craniometric changes to help determine its role in treatment.Patients who underwent preoperative helmet molding therapy for sagittal craniosynostosis were retrospectively reviewed. Three-dimensional surface tomography scans were used to measure head circumference, cranial width, cranial length, cranial index (CI), and cranial vault asymmetry.Seventeen patients underwent orthotic helmeting therapy before spring mediated cranial vault expansion. Patients spent a median of 48 days (interquartile range [IQR] 32, 57) in preoperative orthotic helmeting therapy. There were increases in both cranial width and length post-helmeting (median: 107.5 mm [IQR 104.8, 110.4] versus 115.6 mm [IQR 114.5, 119.3]; P < 0.001) (median: 152.8 mm [IQR 149.2, 154.9] versus 156.8 mm [IQR 155.0, 161.5]; P < 0.001), respectively. There was a greater increase in cranial width (P = 0.015). Consequently, patients' CI improved after preoperative helmeting (median: 0.702 [IQR 0.693, 0.717] versus 0.739 [0.711, 0.752]; P < 0.001). There was no evidence of growth restriction from helmeting (pre-helmeting Head circumference [HC]: median 96.8 percentile [IQR 90.6, 99.9] versus post-helmeting HC: 98.7 percentile [IQR 94.7, 99.8]; P = 0.109).Preoperative helmeting in patients with non-syndromic isolated sagittal craniosynostosis can be used to improve CI before surgical correction. Significant benefits can be achieved in shorter preoperative helmeting durations than previously reported with no evidence of cranial growth restriction, which supports its feasibility and utility in children undergoing spring mediated cranial vault expansion.

Geographic Financial Analysis of Craniosynostosis Surgery in the United States.

BACKGROUND: The purpose of this study was to investigate the financial implications of demographic and socioeconomic factors upon the cost of surgical procedures for craniosynostosis. METHODS: A retrospective cohort study was conducted of admissions for craniosynostosis surgery in the United States from 2015 through 2020 using the Pediatric Health Information System. Patient demographics, case volume, and surgical approach were analyzed in context of hospital charges. RESULTS: During the study interval, 3869 patients were admitted for surgery for craniosynostosis. In multivariate regression accounting for demographic and socioeconomic factors, hospital admission charges were significantly higher in patients with longer hospital length of stay ( P < 0.001), longer ICU length of stay ( P < 0.001), living in an underserved area ( P = 0.046), preoperative risk factors ( P = 0.016), and those undergoing open procedures ( P < 0.001); hospital admission charges were significantly lower in patients with White race ( P = 0.020) and those treated at high-volume centers ( P < 0.001). In multivariate regression, ICU length of stay was significantly higher in patients with preoperative risk factors ( P < 0.001), undergoing open procedures ( P < 0.001), government insurance ( P = 0.018), and not treated at high-volume centers ( P = 0.005). There were significant differences in admission charges ( P < 0.001), charge-to-cost ratios ( P < 0.001), and likelihood of being treated at high-volume craniofacial centers ( P < 0.001) across geographic regions of the country. CONCLUSIONS: In the United States, there is significant sociodemographic variability in charges for craniosynostosis care, with increased hospital charges independently associated with non-White race, preoperative risk factors, and living in an underserved area.

Surgical and Nonsurgical Factors Associated with Salvaging Exposed Vertical Expandable Prosthetic Titanium Rib Hardware.

BACKGROUND: Vertical expandable prosthetic titanium rib (VEPTR) devices were designed to treat childhood scoliosis and thoracic insufficiency syndrome. Although they have drastically reduced patient mortality, they present a profound subcutaneous hardware burden. The authors examined the surgical and nonsurgical factors associated with salvage of VEPTR hardware exposures. METHODS: Between 2014 and 2020, a prospective institutional database was queried for patients with VEPTR hardware complications who required soft-tissue reconstruction. Hardware salvage was considered successful if reconstruction allowed the hardware to be retained until the next VEPTR expansion. RESULTS: Fifty-eight patients required VEPTR hardware salvage. Hardware complications were successfully salvaged in 62.1 percent of patients at 60.0 percent of operative sites. Neuromuscular scoliosis (p = 0.041) and nonambulatory status (p = 0.018) were factors associated with VEPTR hardware salvage failure, whereas congenital scoliosis was associated with successful hardware salvage (p = 0.012) and preventing need for immediate hardware removal (p = 0.049). Exposed hardware, as compared to threatened exposure, was more likely to require immediate removal (p = 0.045) and result in unsuccessful hardware salvage (p = 0.015). CONCLUSIONS: Local and regional muscle flaps were able to prevent VEPTR hardware removal in the majority of patients, even in the setting of infection, immobility, incontinence, and multiple systemic comorbidities. Patients with neuromuscular scoliosis and nonambulatory status were at increased risk for failure, whereas those with incontinence and low body mass index trended toward increased risk of failure. Threatened exposure was associated with higher rates of salvage than exposed hardware, and thus earlier referral to plastic surgeons for soft-tissue salvage may be advised. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Transverse Distraction Osteogenesis for Posterior Narrowing of the Cranial Vault.

SUMMARY: Although conventional posterior vault distraction osteogenesis is known to achieve the greatest improvement in intracranial volume, anteroposterior expansion of the cranial vault is not always ideal in certain head shapes. Transverse posterior vault distraction osteogenesis is an alternative reconstructive strategy in patients presenting with recalcitrant multisuture craniosynostosis resulting in scaphocephaly with posterior narrowing. The authors present a multimedia demonstration of placing the cranial hinge points at the superior anterior aspect of the bone segments in order to achieve increased intracranial volume and significant improvement in posterior head shape, while preserving normal anterior skull dimensions.

A Quantification of Scalp Thickness before and after Posterior Vault Distraction Osteogenesis.

SUMMARY: Previous literature has documented craniometric changes of the bony calvaria, increases in intracranial volume, and resolution of Chiari malformations following posterior vault distraction osteogenesis. No studies have analyzed changes to the soft-tissue envelope after posterior vault distraction osteogenesis. In this study, the authors aimed to provide objective measurements of scalp thickness in patients undergoing posterior vault distraction osteogenesis, utilizing facial soft-tissue thickness as a proxy to control for growth. The authors hypothesized that the soft tissues of the scalp are not made thinner by the distraction process, either in the region of distraction or in neighboring areas. Subjects who underwent posterior vault distraction osteogenesis for a craniosynostosis diagnosis who had high-resolution predistraction and post-distractor removal computed tomographic scans within 100 days of each operation were included. The scans were analyzed on Materialise Mimics version 21 software (Materialise, Ghent, Belgium). Six key craniometric landmarks (glabella, pogonion, zygion, vertex, euryon, and opisthocranium) were identified on the three-dimensional bone masks in the Frankfort horizontal plane. The points were overlaid onto soft-tissue thickness masks and thicknesses were recorded. Percent change in postoperative facial soft-tissue thickness was used to control for growth of the craniofacial soft-tissue envelope during the study interval. The preoperative and postoperative posterior vault distraction osteogenesis cohorts did not differ significantly at the glabella, pogonion, opisthocranium, vertex, and zygion. The corrected median thickness at the euryon was significantly increased in the post-posterior vault distraction osteogenesis cohort [2.67 mm (IQR, 2.49 mm to 4.02 mm) versus 5.26 mm (IQR, 3.83 mm to 7.82 mm), p = 0.002]. This is the first study to quantify changes in soft-tissue thicknesses preoperatively and postoperatively in patients undergoing posterior vault distraction osteogenesis, demonstrating maintenance of scalp thickness. . CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

What is the Role of Midfacial Sutures in the Development of Maxillary Hypoplasia in Children With Cleft Palate?

ABSTRACT: Maxillary hypoplasia is common in patients with cleft lip and palate (CL/P), and its etiology is incompletely understood. The purpose of this study is to evaluate facial suture patency in patients with CL/P and maxillary hypoplasia. The authors hypothesize that patients with CL/P will demonstrate higher rates of premature midfacial suture fusion in comparison to unaffected controls. Skeletally mature patients with CL/P and midface hypoplasia were identified, along with a cohort of unaffected age- and sex-matched controls. High-resolution facial computed tomography scans were evaluated for the presence of facial suture fusion. Utilizing a previously published suture fusion grading scale, the facial sutures were classified as open, partially open, closed, or pathologically absent. Thirty-one CL/P patients with midface hypoplasia were identified, with age and sex-matched controls. The frequency of intermaxillary suture fusion did not differ between patients with CL/P and unaffected controls (P  > 0.05.) Pathologic absence of the midpalatal suture was more commonly present in patients with CL/ P and midface hypoplasia in comparison to unaffected controls (P < 0.05.) The role of midfacial sutures in the development of midfacial hypoplasia seen in CLP has not previously been studied or described. Our data show that the midpalatal suture is frequently pathologically absent in patients with CL/P and maxillary hypoplasia. The authors did not identify statistically significant differences in other midfacial sutures between patients with CL/P and controls, leading us to conclude that midfacial sutures may not play a key role in the development of midfacial hypoplasia.

Does the Geographical Distribution of Facial Trauma Surgeons Correspond to Facial Trauma Burden? A Nationwide Population-Level Analysis.

ABSTRACT: It is unknown if craniofacial trauma services are inequitably distributed throughout the US. The authors aimed to describe the geographical distribution of craniofacial trauma, surgeons, and training positions nationwide. State-level data were obtained on craniofacial trauma admissions, surgeons, training positions, population, and income for 2016 to 2017. Normalized densities (per million population [PMP]) were ascertained. State/ regional-level densities were compared between highest/lowest. Risk-adjusted generalized linear models were used to determine independent associations. There were 790,415 craniofacial trauma admissions (x? = 2330.6 PMP), 28,004 surgeons (x? = 83.5 PMP), and 746 training positions (x? = 1.9 PMP) nationwide. There was significant state-level variation in the density PMP of trauma (median 1999.5 versus 2983.5, P   <  0.01), surgeon (70.8 versus 98.8, P  < 0.01), training positions (0 versus 3.4, P  < 0.01) between lowest/highest quartiles. Surgeon distribution was positively associated with income and training positions density ( P  < 0.01). Subanalysis revealed that there was an increase of 6.7 plastic and reconstructive surgeons/PMP for every increase of 1000 trauma admissions/PMP ( P  < 0.01). There is an uneven state-level distribution of facial trauma surgeons across the US associated with income. Plastic surgeon distribution corresponded closer to craniofacial trauma care need than that of ENT and OMF surgeons. Further work to close the gap between workforce availability and clinical need is necessary.

Endoscopic-Assisted Fronto-Orbital Distraction Osteogenesis: Initial Patient Report.

BACKGROUND: The purpose of this manuscript is to introduce a novel endoscopic-assisted approach for creation of osteotomies and distractor hardware placement for unicoronal craniosynostosis. METHODS: Only three small incisions are performed, one at the anterior fontanelle, pterional region, and upper lateral blepharoplasty location. Unicoronal strip craniectomy and osteotomies in temporal bone, nasofrontal junction, lateral orbital rim, sphenoid wing, orbital roof, and contralateral frontal bone are performed through these incisions with the assistance of a 30° 5-mm endoscope. One linear cranial distractor is inserted through the pterional incision and fixated across the unicoronal suturectomy. RESULTS: Endoscopic-assisted fronto-orbital distraction osteogenesis has been performed on 3 patients with unicoronal craniosynostosis. Median age at surgery was 5.4 months (95%CI 5.0-6.1). Median operative duration was 98 minutes (95%CI 91-112), and estimated blood loss was 25 mL (95%CI 15-150). Median length of distraction achieved was 25.7 mm (95%CI 21.9-28.0), based on lateral skull x-rays obtained on the last day of activation. Distractors were removed 2.3 months postoperatively (95%CI 2.1-3.1), and operative duration of distractor removal was 20 minutes (95%CI 19-29). There was 1 complication, a transient cerebrospinal fluid leak thought to have been caused by a pinpoint injury to the dura at the nasofrontal junction, which was managed expectantly and resolved spontaneously by the fourth postoperative day. CONCLUSIONS: Endoscopic-assisted fronto-orbital distraction osteogenesis is a promising treatment modality for children with unicoronal craniosynostosis combining the benefits of distraction osteogenesis with a minimally invasive approach. Additional experience and follow-up are needed to determine its utility, safety, and longevity.

Risk Factors for Occipital Step-Off Deformities in Posterior Vault Distraction Osteogenesis.

PURPOSE: The goal of this study was to investigate patient specific factors and surgical techniques that affect occipital step-off deformity in children undergoing posterior vault distraction osteogenesis (PVDO). METHODS: Patients who underwent PVDO were retrospectively reviewed and included if a high resolution three-dimensional computed tomography scan was available 1-year post-distractor removal. Two craniofacial surgeons were blinded to individual subjects and presented with 3 still images of three-dimensional bone reconstructions and asked to rate the degree of step off: none, mild, moderate, or severe. The data were analyzed with multinomial logistic regressions and other appropriate statistics. RESULTS: Forty-one patients met inclusion criteria. All patients had multisuture or bicoronal craniosynostosis. Multinomial logistic regression identified age at PVDO (Cox and Snell = 0.487, P < 0.001) as a predisposing factor and one potentially protective factor, height of osteotomy (Cox and Snell = 0.394, P = 0.004) in univariate models. Post-hoc pairwise Mann-Whitney U test revealed there was decreased step-off rating when comparing osteotomy below torcula (median 0, [IQR 0, 3]) and above torcula (median 3 [IQR 1, 4]; P = 0.036) as well as a decreased step-off when below inion (median 0 [IQR 0, 1]; P = 0.001) was compared to above the torcula. CONCLUSIONS: Older age at PVDO predict increased risk of developing an occipital step-off deformity after PVDO, while design of the occipital osteotomy below the inion is protective. Barrel staves with greenstick outfracture did not lower the risk of occipital step-off in this sample, the reasons for which are unclear.

Mandibular Distraction Osteogenesis for Tongue-Based Airway Obstruction Without Micrognathia.

PURPOSE: Mandibular distraction osteogenesis (MDO) effectively treats tongue-based airway obstruction (TBAO) in micrognathic patients with Robin Sequence. Mandibular distraction osteogenesis may also address TBAO in certain nonmicrognathic patients who have severe obstructive apnea, although there is no current literature to guide MDO use in these atypical patients. This study describes outcomes of MDO in a series of patients with TBAO without micrognathia. METHODS: Patients who underwent MDO for TBAO from 2013-20 were reviewed, and patients with micrognathia were excluded. Study subjects received baseline/follow up polysomnography. Polysomnography variables, including Obstructive Apnea Hypopnea Index, oxyhemoglobin saturation nadir (SpO2 nadir), percent sleep time end tidal CO2 greater than 50 mm Hg (%ETCO2 > 50), and respiratory-related arousals were compared before and after MDO. Demographics, syndromic/cleft palate status, airway anomalies, respiratory support, and feeding outcomes were collected. RESULTS: One hundred and twenty-four patients underwent MDO during this study period; 5 were nonmicrognathic and included in analysis. Sixty percent (n = 3) of the cohort was syndromic: 1 patient each had Trisomy 9, Beckwith Wiedemann syndrome, and duplicated pituitary gland plus syndrome. Forty percent (n = 2) of patients had a cleft palate, 60% (n = 3) had laryngomalacia, and 40% had tracheomalacia. Median (range) age at MDO was 53 days (47-167 days), and median length of distraction was 16 mm (14-20 mm). After MDO, median Obstructive Apnea Hypopnea Index decreased from x̃ = 60.7/h (11.6-109.4) to x̃ = 5.3/h (3.5-19.3) (P = 0.034). SpO2 nadir increased (69% [58-74] to 85% [80-88], P = 0.011), and median %ETCO2 > 50 mm Hg decreased (5.8% [5.2-30.1] to 0.0% [0.0-1.3], P ≤ 0.043). Continuous positive airway pressure was used by all patients immediately after MDO, and at 6 months postoperatively, 1 patient remained on continuous positive airway pressure and 1 patient required supplemental oxygen. At last follow up, no patients had significant residual airway obstruction or required a tracheostomy. CONCLUSIONS: Mandibular distraction osteogenesis can effectively treat severe TBAO in some patients without micrognathia that would otherwise be candidates for tracheostomy. When used in select patients, MDO significantly improves obstructive sleep apnea and reduces need for ventilatory support, although feeding support is still needed in most patients at 6 months. Further study in a larger cohort will help identify appropriate candidates for MDO and characterize outcomes of unique patient populations.