Sequential free fibula transfers: Quality of life and systematic review.

BACKGROUND: Successive osteoseptocutaneous fibula transfers for jaws reconstruction are rare but important options. This study contributes patient-reported and clinical outcomes, as well as systematically reviews all existing reports. METHODS: All sequential fibula transfers performed by the senior author were reviewed from a prospectively managed database, including University of Washington quality of life (UWQoL). Systematic review was conducted in PubMed and Cochrane databases for similar publications. RESULTS: Eighteen patients (average age 51.5 years) received sequential fibulas (mean 4.7 years between reconstructions). Secondary fibulas more often had benign indications (72.2% vs. 33.3%, p = .04), most commonly osteoradionecrosis (38.9%). At a mean follow-up of 30.5 months, the average interincisal distance increased from 21.8 to 27.6 mm, and 92.3% tolerated an oral diet following the second fibula. Eight patients completed the UW-QoL before and after the second fibula, and three prior to the first fibula. Composite physical function was significantly decreased from 96.7 prefibula reconstruction to 63.3 following the first (p < .001) and 64.2 after the second fibula (p < .001). There were no differences in other domains. The systematic review yielded six articles reporting 56 patients (mean 39 months between fibulas). Secondary fibulas were performed for repeat malignancy (45%) and osteoreadionecrosis (39%), resulting in elevated tube feeding from 20% following the first to 39% following the second, but overall high quality of life in two studies. CONCLUSIONS: Sequential osteoseptocutaneous fibula reconstructions of jaws are often performed for benign indications such as osteoradionecrosis. Overall function and QoL are comparable with those following the first fibula transfer.

ChatGPT in head and neck scientific writing: A precautionary anecdote.

PURPOSE: To evaluate the accuracy of ChatGPT references in scientific writing relevant to head and neck surgery. MATERIALS AND METHODS: Five commonly researched keywords relevant to head and neck surgery were selected (osteoradionecrosis of the jaws, oral cancer, adjuvant therapy for oral cancer, TORS, and free flap reconstruction in oral cancer). The AI chatbot was then asked to provide ten complete citations for each of the keywords. Two independent authors reviewed the results for accuracy and assigned each article a numerical score based on pre-selected criteria. RESULTS: Among 50 total references provided by ChatGPT, only five (10 %) were found to have the correct title, journal, authors, year of publication, and DOI. Merely 14 % of the presented references had correct DOI. References regarding free flap reconstruction for oral cancer were the least accurate from all the five categories, with no correct DOI. Complete inter-rater agreement was noted while evaluating the citations. CONCLUSION: Only 10 % of the articles provided by ChatGPT, relevant to head and neck surgery, were correct. A high degree of academic hallucination was noted.

Persistent Cranial Defects After Endoscopic Sagittal Synostosis Surgery.

INTRODUCTION: Incomplete cranial ossification is a rare complication of calvarial-vault remodeling for sagittal synostosis often requiring reoperation. Studies show an incidence ranging from 0.5% to 18%. METHODS: Infants with sagittal synostosis who underwent endoscopic sagittal synostectomy and barrel stave osteotomies with postoperative orthotic helmeting between 2003 and 2021 were included with minimum follow-up until the completion of helmeting. RESULTS: Of 90 patients, 86 met inclusion; 3 had defects (3.5%). Patients with and without cranial defects had no difference in age of surgery (113 versus 131 d), duration helmeting (6.6 versus 7.0 mo), or perioperative/postoperative complications. Two underwent reoperation for recurrence. Patients with cranial defects manifested the evidence of developmental concerns more than patients without (100% versus 16.9%).The average cranial defect size was 19.33 cm 2 and age at surgery 4.29 years. All were managed with cranial particulate bone grafting with addition of bone matrix and SonicWeld plate. The first had 6×6 cm posterior defect requiring cranioplasty at 4.86 years with excellent healing. The second had a 3×6 cm posterior and 1×1 cm anterior defect, underwent cranioplasty at 4.14 years with persistent 4×6 defect, requiring repeat cranioplasty at 5.3 years. The third had a 3×5 cm posterior defect and underwent cranioplasty at 3.88 years with continued defect, planning for repeat intervention. CONCLUSIONS: This is the largest documented series of reoperations for incomplete ossification after endoscopic sagittal synostectomy with postoperative helmet treatment. The authors report a 3.5% rate of cranial defects, managed with bone grafting, bone matrix, and absorbable plates. Patients with poor ossification may have a propensity toward developmental concerns.

Labiaplasty: Analysis of the National Surgical Quality Improvement Program Database.

BACKGROUND: Labiaplasty is an increasingly popular procedure performed for both cosmetic and pathologic etiologies. Questions have been raised regarding the efficacy of the procedure, especially for cosmetic etiologies. OBJECTIVES: The aim of this study was to examine the complication profiles of labiaplasties for both cosmetic and pathologic etiologies. METHODS: The 2005 to 2017 National Surgical Quality Improvement Program database was analyzed for patients who, according to the relevant Current Procedural Terminology code, had undergone labiaplasties. Our cohort was further separated into cosmetic and pathologic groups based on International Classification of Diseases codes. Information was collected on patient demographic characteristics, patient comorbidities, and operative variables. Outcomes of interest included surgical complications and delayed length of stay (DLOS). A univariate analysis and multivariate logistic regression were applied to determine statistically significant predictors of our outcomes of interest for both etiologies. RESULTS: There were 640 patients in the cosmetic cohort and 1919 patients in the pathologic cohort. There were no significant differences in rates of surgical complications between the 2 groups, but there was a statistically significant increase in length of stay for the pathologic group. Univariate analysis revealed operative time and plastic surgeon specialty to be predictive of DLOS in the cosmetic cohort. No covariates were implicated with multivariate analysis for either surgical complications or for DLOS in the cosmetic cohort. CONCLUSIONS: Our findings suggest that cosmetic labiaplasty is a safe and efficacious procedure with low complication rates and no predictors of adverse outcomes.

Primary Cleft Palate Repair Among Older-Age Children and Adolescents in the United States.

PURPOSE: Older age cleft palate (CP) repair in international settings has been associated with increased surgical morbidity. This study assesses the prevalence and risks associated with late-age CP repair (age > 5 years) in the United States. METHODS: Primary CP repair patients less than the age of 18 years were identified in the National Surgical Quality Improvement pediatric database from 2012 to 2018. Total postoperative complications, readmissions, reoperations, duration of surgery, and length of stay were recorded. T-tests and χ2 analyses were used to compare variables between age groups 0-5, 6-10, and 11-17. RESULTS: A total of 10,022 primary CP procedures were identified from 2012 to 2018, of which 868 (8.6%) received repair at age > 5 years. Hispanic patients constituted a larger proportion of CP repair from ages 11 to 17 years than repair at other ages (P < .001). In comparison with children treated from ages 0 to 5 years, children operated on between ages 6 and 10 or 11 and 17 years experienced no increases in unplanned readmissions, reoperations, or complication rates after surgery. Patients of ages 6-10 years and 11-17 years had decreased operating room time (P < .001) compared with younger patients. Patients of ages 11-17 years also had decreased hospital length of stay (P = .04). CONCLUSIONS: Many children in the United States received primary CP repair after the age of 5 years likely due to late treatment of submucosal clefts or delayed care among international immigrants/adoptees. Old age procedures were not associated with increased short-term surgical morbidity in comparison with surgery at earlier time points. The causes and implications of older age primary surgery warrant further study.

Assessing Facial Asymmetry in Postoperative Patients With Unilateral Coronal Craniosynostosis.

BACKGROUND: Despite surgical correction of unilateral craniosynostosis (ULC), complex cranial base angulation can result in partial reversion to preoperative deformity with growth and time. Using 3-dimensional imaging, dysmorphic facial features of ULC in school-age patients were quantified and related to how they contribute to overall facial asymmetry and patient-reported outcomes. METHODS: Children who underwent surgical correction of ULC were recruited from Yale University and Children's Hospital of Philadelphia. The 3D photographs were analyzed utilizing a Procrustes analysis of shape. Pearson's correlation was used to determine dysmorphic features' impact on overall asymmetry. Patients were stratified into "moderate" and "severe" asymmetry. Finally, asymmetry was correlated to patient-reported outcome scores. Statistical analysis was performed with SPSS-25 with P < 0.05 as statistically significant. RESULTS: Twenty-one patients were included with average age at analysis of 12.3 years. Fifty-seven percent of patients had right-sided fusion. The overall Procrustes analysis indicated a root mean square difference of 2.21 mm. Pearson's correlation indicated that the facial middle 3rd (P ≤ 0.001), orbital dystopia (P < 0.001), chin point deviation (P = 0.011), and nasal root angulation (P = 0.019) contributed most to overall asymmetry. Patients in the severe asymmetry cohort had greater facial middle-third asymmetry (P < 0.001) and orbital dystopia (P < 0.001). Asymmetry did not correlate with patient-reported outcomes. CONCLUSION: Patients with ULC have persistent facial asymmetry at school-age with the greatest levels of asymmetry in the facial middle-third, orbit, and nasal root. Beyond the cranial dysmorphology, initial skull base angulation in unilateral coronal craniosynostosis manifests in long-term mid and lower-third facial asymmetry.

Spring-Assisted Strip Craniectomy Versus Cranial Vault Remodeling: Long-Term Psychological, Behavioral, and Executive Function Outcomes.

BACKGROUND: Controversy exists regarding the optimal surgical approach for non-syndromic sagittal synostosis. This study provides the first comparative analysis of the long-term behavioral, psychological, and executive function outcomes for patients who underwent either cranial vault remodeling (CVR) or spring-assisted strip craniectomy (SAS). METHODS: Thirty-six CVR patients and 39 SAS patients were evaluated. Parents and caregivers completed the Behavior Rating Inventory of Executive Function (BRIEF) and the Behavior Assessment System for Children, Second Edition (BASC-2) to evaluate behavioral, emotional, social, adaptive, and executive functioning skills. RESULTS: There were no statistically significant differences between the CVR and the SAS groups (P > 0.05) in any of the BRIEF areas of function. Furthermore, the BASC-2 battery illustrated no significant differences in all areas analyzed except one. Among the 2 groups, the CVR group was rated as having fewer social withdrawal symptoms on the BASC-2 (47.00 ±â€Š10.27) compared to the SAS cohort (54.64 ±â€Š10.96), F = 6.79, P = 0.012, Cohen d = 0.688. However, both means were still within the normal range. CONCLUSIONS: Children undergoing SAS and CVR procedures for isolated sagittal synostosis were not rated as having clinically significant behavioral, emotional, social, adaptive, or executive functioning problems on parental forms.

Segmental Maxillary Osteotomy to Close Wide Alveolar Clefts.

Wide alveolar clefts are challenging to treat and are often associated with a higher chance of failure requiring repeated bone grafts. Even if successful, an excessively large cleft leads to a wide edentulous space, and patients are faced with prolonged orthodontic treatment. We present a series of large alveolar clefts closed with the aid of segmental maxillary osteotomies. Cases of alveolar clefts treated by segmental maxillary osteotomy from 2014 to 2016 were reviewed. Preoperative and postoperative computed tomography scans were analyzed to assess the alveolar gap and bone filling. Demographic characteristics, diagnoses, and operative techniques were reviewed and described. A total of 10 alveolar fistulae were addressed, using 6 segmental osteotomies in 6 patients. Of the cases, 66% were bilateral. There were 4 female and 2 male patients with an average age of 12.6 years. The average preoperative cleft width was 14.2 mm on computed tomography scans. Postoperatively, all clefts were successfully closed and no adverse effects were observed. Segmental maxillary osteotomy with concurrent bone grafting and fistula closure is an effective approach to treat excessively wide alveolar clefts. This enables a prudent dental substitution or prosthodontic plan while minimizing prolonged orthodontia, in addition to achieving the traditional goals of alveolar bone grafting (stabilizing the maxillary arch, closing fistulae, and permitting canine eruption).

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

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

National Longitudinal Comparison of Patients Undergoing Surgical Management of Craniosynostosis.

PURPOSE: Limited cross-institutional studies compare strip craniectomy versus cranial vault remodeling (CVR) for craniosynostosis management. Given competing surgical preferences, the authors conducted a large-scale analysis of socioeconomic differences, costs, and complications between treatment options. METHODS: Nonsyndromic craniosynostosis patients receiving strip craniectomies or CVR were identified in the Kids' Inpatient Database for years 2000 to 2009. Demographics, socioeconomic background, hospital characteristics, charge, and outcomes were tabulated. Univariate and multivariate analyses were performed for comparison. RESULTS: Two hundred fifty-one strip craniectomies and 1811 CVR patients were captured. Significantly more strip craniectomy patients were White while more CVR patients were Hispanic or Black (P < 0.0001). Strip craniectomy patients more often had private insurance and CVR patients had Medicaid (P < 0.0001). Over time, CVR trended toward treating a higher proportion of Hispanic and Medicaid patients (P = 0.036). Peri-operative charges associated with CVR were $27,962 more than strip craniectomies, and $11,001 after controlling for patient payer, income, bedsize, and length of stay (P < 0.0001). Strip craniectomies were performed more frequently in the West and Midwest, while CVR were more common in the South (P = 0.001). Length of stay was not significant. Postsurgical complications were largely equivocal; CVR was associated with increased accidental puncture (P = 0.025) and serum transfusion (P = 0.002). CONCLUSION: Our national longitudinal comparison demonstrates widening socioeconomic disparities between strip craniectomy and CVR patients. Cranial vault remodeling is more commonly performed in underrepresented minorities and patients with Medicaid, while strip craniectomy is common in the White population and patients with private insurance. While hospital charges and complications were higher among CVR, differences were smaller than expected.

Evolution of free flap reconstruction in the upper extremity: perspective from a tertiary plastic and reconstructive institution.

Soft tissue reconstruction of the upper extremity requires consideration of wound bed status, varied anatomic composition, future function and tissue match, whether in thickness, pliability or involvement of other tissue components. Of the options available, microvascular free tissue flaps allow maximal customizability with the avoidance of long-term donor site morbidity. Free tissue transfers have evolved, given increased surgical proficiency, from direct vessel-based flaps to septocutaneous vessel-based flaps, to musculocutaneous perforator flaps, and most recently to free-style free flaps. With increases in technical complexity come limitless alternatives. We documented the progression of free flap upper extremity reconstruction in recreating form and function of the upper extremity. The foundations laid should allow surgeons the freedom and versatility to choose the most faithful restoration of the defect and produce the best functional and aesthetic results.

National trends in revision procedures in post-mastectomy breast reconstruction: Autologous vs implant-based approaches.

BACKGROUND: Breast reconstruction involves collaborative decision-making between patients and surgeons, but the need for multiple revisions after the initial reconstructive surgery process can burden patients and the healthcare system. This study explored how the type of breast reconstruction (autologous [ABR], immediate implant-based reconstruction [IBR], or two-stage IBR) impacts postreconstruction revision rates. METHOD: Using MarketScan Databases, a retrospective database study (2007-2021) was conducted, identifying revision procedures through Current Procedural Terminology codes. Statistical analysis with linear models, adjusted for patient characteristics and surgical factors, used a significance threshold of p < 0.05. RESULTS: Among 58,264 patients, 6.2% of ABR patients, 3.8% of immediate IBR patients, and 3.6% of two-stage IBR patients underwent future revisions. IBR had a 51% lower incidence rate of revision operations than ABR (incidence rate ratio = 0.49, p < 0.001). Within IBR, there was no significant difference in the number of operations between immediate IBR (0.06 ± 0.32) and two-stage IBR (0.05 ± 0.32, p = 0.95). Immediate IBR demonstrated 12% (OR = 0.88, p = 0.0022) and 70% (OR = 0.30, p < 0.001) lower odds of requiring breast revision and fat grafting compared to ABR, respectively. Two-stage reconstruction had 66 % lower odds of requiring only fat grafting than ABR (OR = 0.34, p < 0.001). CONCLUSION: ABR necessitated a higher number of total revision procedures after completion of the initial reconstruction. These findings will better equip providers and patients to counsel patients in understanding their reconstructive journey, planning their reconstructions and timing, and provide more accurate estimates of the number of procedures that will be required to reach their aesthetic goals and final outcome.

Impact of post-operative infection on revision procedures in breast reconstruction: A marketscan database analysis.

BACKGROUND: Esthetic complications, such as capsular contracture and soft-tissue contour defects, hinder the desired outcomes of breast reconstruction. As subclinical infection is a prevailing theory behind capsular contracture, we investigated the effects of post-operative infections on these issues and revision procedures. METHODS: We conducted a retrospective database study (2007-2021) on breast reconstruction patients from the MarketScan® Databases. Esthetic complications were defined by their associated revision procedures and queried via CPT codes. Severe capsular contracture (Grade 3-4) was defined as requiring capsulotomy or capsulectomy with implant removal or replacement. Moderate and severe soft-tissue defects were determined by the need for fat grafting or breast revision, respectively. Generalized linear models were used, adjusting for comorbidities and surgical factors (p < 0.05). RESULTS: We analyzed the data on 62,510 eligible patients. Post-operative infections increased the odds of capsulotomy (OR 1.59, p < 0.001) and capsulectomy (OR 2.30, p < 0.001). They also raised the odds of breast revision for severe soft-tissue defects (OR 1.21, p < 0.001). There was no significant association between infections and fat grafting for moderate defects. Patients who had post-operative infections were also more likely to experience another infection after fat grafting (OR 3.39, p = 0.0018). In two-stage reconstruction, infection after tissue expander placement was associated with greater odds of infection after implant placement. CONCLUSION: Post-operative infections increase the likelihood of developing severe soft-tissue defects and capsular contracture requiring surgical revision. Our data reinforce the role of infections in the pathophysiology of capsular contracture. Additionally, infections elevate the risk of subsequent infections after fat grafting for moderate defects, further increasing patient morbidity.

Differential Pulley Release in Trigger Finger: A Prospective, Randomized Clinical Trial.

BACKGROUND: The palmar aponeurosis or "A0 pulley" may play a role in trigger finger pathology. This study assesses the involvement of the A0 pulley in patients receiving trigger finger release. METHODS: This single-surgeon, prospective, randomized clinical trial was conducted among consenting patients with symptomatic trigger finger. Intraoperative coin toss was used to randomize initial release of either the A0 or A1 pulley. Following release, active flexion and extension of the affected digit were examined. The remaining pulley was then released in sequence, and clinical trigger status was recorded. RESULTS: Thirty fingers from 24 patients were released; 17 fingers received A0 release first, and 13 received A1 release. Following initial A0 release, 8 fingers (47%) demonstrated complete resolution of symptoms, 4 (24%) demonstrated improvement but incomplete resolution of triggering, and 5 (29.4%) demonstrated no improvement. Following initial A1 release, 6 fingers (46%) demonstrated complete resolution, 3 (23%) demonstrated improvement but incomplete resolution of triggering, and 4 (31%) demonstrated no improvement. All patients demonstrated complete resolution after surgical release of both sites. Neither initial A1 release nor initial A0 release was statistically associated with complete, incomplete, or failed symptom resolution. CONCLUSIONS: These data implicate the A0 pulley as the primary cause of 31% to 47% of trigger fingers in our study. Although larger trials are needed to validate these results, our study suggests that release of both A0 and A1 pulleys may offer greater symptom resolution than release of the A1 pulley alone.

Virtual Neurocognitive Testing in Craniofacial Surgery.

SUMMARY: Digital communication platforms have had an impact on plastic surgery research. Although neurocognitive testing is an important tool for understanding the long-term developmental outcomes of congenital craniofacial conditions, testing has been geographically limited because of its interactive nature. Virtual neurocognitive testing is a facsimile version of in-person testing that allows researchers to overcome this limitation with high fidelity. Ten school-age subjects completed a neurocognitive assessment battery measuring intelligence quotient, academic achievement, and visuomotor skills at an average age of 7.8 ± 1.4 years. The subjects then retook the same battery through an identical virtual testing method approximately 1 year after the initial test. There were no significant differences in verbal intelligence quotient (p = 0.878), performance intelligence quotient (p = 0.813), and full-scale intelligence quotient (p = 0.982) scores obtained through in-person and virtual tests. There were no significant differences between academic achievement letter and word recognition (p = 0.999), math computation (p = 0.619), reading comprehension (p = 0.963), and spelling (p = 0.344) scores. There were no significant differences in visuomotor integration (p = 0.158), visual perception (p = 0.798), and motor coordination (p = 0.796) scores obtained through the two methods. The median at-home time to set up study equipment for the virtual testing was 5.0 minutes (interquartile range, 2.3 minutes). Seventy percent of participants reported that they preferred participating in research from home. All participants stated that the virtual research study was an overall positive experience. Virtual neurocognitive testing is an effective method of performing high-fidelity neurocognitive assessments while overcoming geographic barriers.

The Effect of Surgical Timing on 30-Day Outcomes in Cleft Palate Repair.

BACKGROUND: The optimal age for cleft palate repair continues to be debated, with little discussion of surgical risk related to operative timing. This study of 3088 cleft palate patients analyzed the impact of surgical timing on perioperative and 30-day postoperative outcomes. METHODS: Primary cleft palate repairs were identified in the National Surgical Quality Improvement Program database from 2012 to 2015. Data were combed for total postoperative complications, rates of readmission and reoperation, operating room time, and length of stay. Bivariate analyses were performed comparing 3-month periods from months 6 to 18, and months 0 to 5, 18 to 23, 24 to 29, and 30 to 59. RESULTS: Despite a higher proportion of isolated soft palate closure, children operated on before 6 months had a higher complication rate than children at other ages (7.1 percent versus 3.2 percent; OR, 2.4; p = 0.04), and higher rates of both readmission (3.6 percent versus 1.4 percent; OR, 3.6; p = 0.02) and reoperation (2.4 percent versus 0.5 percent; OR, 4.7; p = 0.04). There were no differences in short-term outcomes for any other age group younger than 5 years, and no differences in hospital length of stay among any age groups. CONCLUSIONS: The authors' findings suggest a relative contraindication to operation before 6 months. As there were no differences between any other age groups, long-term speech optimization should continue to be the primary consideration for operative planning. These findings improve the current rationale for palatoplasty timing, and can aid surgeons and parents in the surgical decision-making process. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Long-Term Neurocognitive Outcomes of Spring-Assisted Surgery versus Cranial Vault Remodeling for Sagittal Synostosis.

BACKGROUND: A long-term neurocognitive comparison of patients with sagittal synostosis who underwent spring-assisted surgery or cranial vault remodeling has not been performed. METHODS: Patients with sagittal synostosis who underwent spring-assisted surgery or cranial vault remodeling were recruited from Wake Forest School of Medicine and Yale School of Medicine, respectively. Cognitive tests administered included an abbreviated intelligence quotient, academic achievement, and visuomotor integration. An analysis of covariance model compared cohorts controlling for demographic variables. RESULTS: Thirty-nine spring-assisted surgery and 36 cranial vault remodeling patients were included in the study. No significant differences between cohorts were found with respect to age at surgery, sex, race, birth weight, family income, or parental education. The cranial vault cohort had significantly older parental age (p < 0.001), and mean age at testing for the spring cohort was significantly higher (p = 0.001). After adjusting for covariates, the cranial vault cohort had significantly higher verbal intelligence quotient (116.5 versus 104.3; p = 0.0024), performance intelligence quotient (109.2 versus 101.5; p = 0.041), and full-scale intelligence quotient (114.3 versus 103.2; p = 0.0032). When included patients were limited to intelligence quotients from 80 to 120, the cranial vault cohort maintained higher verbal (108.0 versus 100.4; p = 0.036), performance (104.5 versus 97.7; p = 0.016), and full-scale (107.6 versus 101.5; p = 0.038) intelligence quotients. The cranial vault cohort had higher visuomotor integration scores than the surgery group (111.1 versus 98.1; p < 0.001). There were no significant differences in academic achievement. CONCLUSIONS: Sagittal synostosis patients who underwent cranial vault remodeling had higher intelligence quotient and visuomotor integration scores. There were no differences in academic achievement. Both cohorts had intelligence quotient scores at or above the normal range. Further studies are warranted to identify factors that may contribute to cognitive outcome differences. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

A Comparison of BREAST-Q Scores between Prepectoral and Subpectoral Direct-to-Implant Breast Reconstruction.

BACKGROUND: Subpectoral breast implant placement has in recent history predominated in breast reconstruction, but there has been more recent adoption of prepectoral implant reconstruction. There has been limited study to date of patient-reported outcomes comparing the two techniques. METHODS: Patients who underwent direct-to-implant breast reconstruction between 2013 and 2018 were included in this retrospective cohort study. Eligible patients were asked to complete BREAST-Q domains comparing quality of life and satisfaction. Descriptive, t test, chi-square test, and multivariate linear regression analyses were performed to compare BREAST-Q scores. Significance was defined as p ≤ 0.05. RESULTS: There were 64 patients (114 breasts) who underwent prepectoral reconstruction and 37 patients (68 breasts) who underwent subpectoral reconstruction. Among the 101 women (182 breasts), there were no significant differences between BREAST-Q scores and implant position for the Satisfaction with Breasts domain (adjusted p = 0.819), Psychosocial Well-being domain (adjusted p = 0.206), or Physical Well-being Chest domain (adjusted p = 0.110). The subpectoral implant cohort was associated with higher scores, 53 versus 47, for the Sexual Well-being module (adjusted p = 0.001). CONCLUSIONS: Patients undergoing direct-to-implant breast reconstruction had comparable BREAST-Q satisfaction scores for most modules regardless of implant plane. The subpectoral implant cohort scored higher for sexual well-being.

Radiographic Severity of Metopic Craniosynostosis Correlates with Long-Term Neurocognitive Outcomes.

BACKGROUND: Reports of neurodevelopmental delays in adolescents with metopic craniosynostosis have ranged from 15 to 61 percent. Previously, event-related potentials have correlated preoperative radiographic severity with language deficiencies in infancy. This study sought to characterize neurocognitive testing at cranial maturity and correlate outcomes to preoperative radiographic severity. METHODS: Patients diagnosed with metopic craniosynostosis who underwent surgical correction in infancy completed a neurodevelopmental battery evaluating age-normalized intelligence quotient, academic achievement, and visuomotor integration. Data were stratified by preoperative endocranial bifrontal angle (moderate, >124 degrees; severe, <124 degrees). Multiple variable regression was used to control measured intelligence and achievement for age at surgery, age at testing, parental education, and income. Significance was set at p < 0.05. RESULTS: Twenty patients completed neurodevelopmental testing. Mean intelligence quotient was 111.7 ± 13 and academic achievement was similar to national averages (word reading, 53.4 percent; reading comprehension, 53.4 percent; reading composite, 53.5 percent; spelling, 44 percent; and math, 52.9 percent). Radiographic measurements revealed 36 percent of patients with moderate phenotype and 64 percent with severe. Patients with severe phenotypes had lower intelligence quotient measures and scored more poorly in every academic measure tested. Word reading (113 versus 95; p = 0.035) and reading composite (109 versus 98; p = 0.014) reached significance. CONCLUSIONS: Overall, cranial mature patients with metopic craniosynostosis had above average intelligence quotient and academic achievement near the national mean. Long-term neurocognitive function was correlated to preoperative radiographic severity in metopic craniosynostosis, with more severe cases performing worse. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Concurrent Platysmaplasty and Genioplasty Using a Novel Intraoral Approach.

Facial aging patients frequently seek improved neck and jawline definition. Microgenia, or lack of chin support, is often overlooked or underdiagnosed in these patients. The authors propose a simultaneous genioplasty, in addition to platysmaplasty and face/neck lift, to address both soft-tissue and bony components, and enhance the cervicomental area. The platysmaplasty is performed in a novel fashion using the intraoral genioplasty incision. The operative sequence includes intraoral incision, platysmal exposure, fat excision, platysmal tightening, genioplasty osteotomy/fixation, and external skin redraping (face/neck lift). Case examples are shown to illustrate appropriate candidate selection and results. Parameters for success include increased chin-throat distance and definition, improved cervicomental angle, and soft-tissue rejuvenation. The novel approach the authors describe enables discrete access to the platysmal and submental region and provides bony definition to help optimize the soft-tissue drape and definition. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.