Lower Extremity Pediatric Tissue Expansion: A Single Surgeon's 16-Year Experience.

BACKGROUND: Tissue expansion is a well-established approach to soft tissue reconstruction in the pediatric population for lower extremity pathologies. Unfortunately, complication rates range from 19% to 40% in literature, including infection and implant extrusion, leading to delays in reconstruction. These challenges have prompted investigation toward categorizing risk factors for lower extremity tissue expander placement. METHODS: A retrospective study of pediatric patients who underwent lower extremity tissue expander placement by the senior author (R.J.R.) was performed over a 16-year period. Patient charts were reviewed to categorize baseline and operative characteristics. Primary outcome variables were surgical-site infection, expander extrusion, and expander deflation. Univariate and multivariate logistic regressions were performed ( α < 0.05). RESULTS: There were 59 tissue expanders in our cohort. The overall complication rate was 27.1% with a 77.2% successful reconstruction rate. Greater number of expanders placed during 1 operation is associated with 2.5 increased odds of having any complication and is associated with 0.4 decreased odds of having a successful reconstruction. Incisions made in scar tissue for expander placement appear to be associated with a greater than 7 times increased odds of readmission. CONCLUSIONS: Reconstruction of soft tissue pathologies using lower extremity tissue expanders in the pediatric population is an effective yet challenging technique. This study identified that the number of expanders inserted during 1 operation, incisions made over scar tissue, and expanders placed in the anterior thigh were correlated with having a negative impact on reconstructive outcomes. Extra care should be taken with patients who require multiple expanders during 1 operation and with choosing the location and incision of expander placement.

Socioeconomic Disparities in Postoperative Outcomes of Osteocutaneous Fibula Free Flaps for Head and Neck Reconstruction.

BACKGROUND: Osteocutaneous fibula free flaps (FFFs) are a fundamental component of reconstructive surgery in the head and neck region, particularly after traumatic injuries or oncologic resections. Despite their utility, FFFs are associated with various postoperative complications, such as infection, flap failure, and donor site morbidity, impacting up to 54% of cases. This study aimed to investigate the influence of socioeconomic variables, with a particular focus on median household income (MHI), on the incidence of postoperative complications in FFF reconstruction for head and neck cancer. METHODS: A retrospective analysis of 80 patients who underwent FFF reconstruction for head and neck cancer at a single center from 2016 to 2022 was conducted. Demographic and patient characteristics, including race, MHI, insurance type, history of radiation therapy, and TNM (tumor, node, metastasis) cancer stage, were evaluated. Logistic regression, controlling for comorbidities, was used to assess the impact of MHI on 30-, 90-, and 180-day postoperative complications. RESULTS: The patient population was predominantly male (n = 51, 63.8%) and White (n = 63, 78.8%), with the majority falling within the $55,000 to $100,000 range of MHI (n = 51, 63.8%). Nearly half of the patients had received neoadjuvant radiation treatment (n = 39, 48.75%), and 36.25% (n = 29) presented with osteoradionecrosis. Logistic regression analysis revealed that the $55,000-$100,000 MHI group had significantly lower odds of developing complications in the 0- to 30-day postoperative period when compared with those in the <$55,000 group (odds ratio [OR], 0.440; 95% confidence interval [CI], 0.205-0.943; P = 0.035). This trend persisted in the 31- to 90-day period (OR, 0.136; 95% CI, 0.050-0.368; P < 0.001) and was also observed in the likelihood of flap takeback. In addition, the $100,000-$150,000 group had significantly lower odds of developing complications in the 31- to 90-day period (OR, 0.182; 95% CI, 0.035-0.940; P = 0.042). No significant difference was found in the >$150,000 group. CONCLUSIONS: Median household income is a significant determinant and potentially a more influential factor than neoadjuvant radiation in predicting postoperative complications after FFF reconstruction. Disparities in postoperative outcomes based on income highlight the need for substantial health care policy shifts and the development of targeted support strategies for patients with lower MHI.

Complications Following Tissue Expander-Based Reconstruction in Pediatric Burn Injuries: A Retrospective Analysis.

BACKGROUND: Tissue expansion has been widely used to reconstruct soft tissue defects following burn injuries in pediatric patients, allowing for satisfactory cosmetic and functional outcomes. Factors impacting the success of tissue expander (TE)-based reconstruction in these patients are poorly understood. Herein, we aim to determine the risk factors for postoperative complications following TE-based reconstruction in pediatric burn patients. METHODS: A retrospective review of pediatric patients who underwent TE placement for burn reconstruction from 2006 to 2019 was performed. Primary outcomes were major complications (TE explantation, extrusion, replacement, flap necrosis, unplanned reoperation, readmission) and wound complications (surgical site infection and wound dehiscence). Descriptive statistics were calculated. The association between primary outcomes, patient demographics, burn characteristics, and TE characteristics was assessed using the chi-squared, Fisher's exact, and Mann-Whitney U tests. RESULTS: Of 28 patients included in the study, the median [interquartile range (IQR)] age was 6.5 (3.3-11.8) years, with a follow-up of 12 (7-32) months. The majority were males [n = 20 (71%)], Black patients [n = 11 (39%)], and experienced burns due to flames [n = 78 (29%)]. Eleven (39%) patients experienced major complications, most commonly TE premature explantation [n = 6 (21%)]. Patients who experienced major complications, compared to those who did not, had a significantly greater median (IQR) % total body surface area (TBSA) [38 (27-52), 10 (5-19), P = 0.002] and number of TEs inserted [2 (2-3), 1 (1-2), P = 0.01]. Ten (36%) patients experienced wound complications, most commonly surgical site infection following TE placement [n = 6 (21%)]. Patients who experienced wound complications, compared to those who did not, had a significantly greater median (IQR) %TBSA [35 (18-45), 19 (13-24), P = 0.02]. CONCLUSION: Pediatric burn injuries involving greater than 30% TBSA and necessitating an increasing number of TEs were associated with worse postoperative complications following TE-based reconstruction.

Optimal Treatment Order With Fibula-Free Flap Reconstruction, Oncologic Treatment, and Dental Implants: A Systematic Review and Meta-Analysis.

Head and neck cancer (HNC) patients benefit from craniofacial reconstruction, but no clear guidance exists for rehabilitation timing. This meta-analysis aims to clarify the impact of oncologic treatment order on implant survival. An algorithm to guide placement sequence is also proposed in this paper. PubMed, Embase, and Web of Science were searched for studies on HNC patients with ablative and fibula-free flap (FFF) reconstruction surgeries and radiotherapy (RTX). Primary outcomes included treatment sequence, implant survival rates, and RTX dose. Of 661 studies, 20 studies (617 implants, 199 patients) were included. Pooled survival rates for implants receiving >60 Gy RTX were significantly lower than implants receiving < 60 Gy (82.8% versus 90.1%, P =0.035). Placement >1 year after RTX completion improved implant survival rates (96.8% versus 82.5%, P =0.001). Implants receiving pre-placement RTX had increased survival with RTX postablation versus before (91.2% versus 74.8%, P <0.001). One hundred seventy-seven implants were placed only in FFF with higher survival than implants placed in FFF or native bone (90.4% versus 83.5%, P =0.035). Radiotherapy is detrimental to implant survival rates when administered too soon, in high doses, and before tumor resection. A novel evidence-based clinical decision-making algorithm was presented for utilization when determining the optimal treatment order for HNC patients. The overall survival of dental prostheses is acceptable, reaffirming their role as a key component in rehabilitating HNC patients. Considerations must be made regarding RTX dosage, timing, and implant location to optimize survival rates and patient outcomes for improved functionality, aesthetics, and comfort.

Orbital Fracture Characteristics and Outcomes in Baltimore.

Fracture characteristics and postoperative outcomes of patients presenting with orbital fractures in Baltimore remain poorly investigated. The purpose of our study was to determine the fracture patterns, etiologies, and postoperative outcomes of patients treated for orbital fractures at 2 level I trauma centers in Baltimore. A retrospective cohort study was conducted on patients who underwent orbital fracture repair at the R Adams Cowley Shock Trauma Center and the Johns Hopkins Hospital from January 2015 to December 2019. Of 374 patients, 179 (47.9%) had orbital fractures due to violent trauma, 252 (67.4%) had moderate to near-total orbital fractures, 345 (92.2%) had orbital floor involvement, and 338 (90.4%) had concomitant neurological symptoms/signs. Almost half of the patients had at least one postoperative ocular symptom/sign [n = 163/333 (48.9%)]. Patients who had orbital fractures due to violent trauma were more likely to develop postoperative ocular symptoms/signs compared with those who had orbital fractures due to nonviolent trauma [n = 88/154 (57.1%), n = 75/179 (41.9%); P = 0.006]. After controlling for factors pertaining to injury severity, there was no significant difference in patient throughput or incidence of any postoperative ocular symptom/sign after repair between the two centers. Timely management of patients with orbital fractures due to violent trauma is crucial to mitigate the risk of postoperative ocular symptoms/signs.

A Geospatial Analysis of Barriers to Cleft Lip and Palate Care in the United States.

OBJECTIVE: This study evaluates the geospatial distribution of cleft lip and/or cleft palate (CL/P) care in the United States, assesses disparities between families with and without one-hour proximity to CL/P care, and recommends interventions for improving access. DESIGN: We identified American Cleft Palate Craniofacial Association-approved CL/P teams and calculated a one-hour driving radius around each clinic. We then used census data to compare risk factors for developing cleft (i.e., incidence risk factors) and obstacles to care (i.e., access risk factors) between counties with and without one-hour proximity. RESULTS: We identified 187 CL/P teams in 45 states. Most were in the South (n = 60, 32.0%), though children in the Middle Atlantic had the greatest access to care. Alabama, Mississippi, Tennessee, and Kentucky had the least access. Children without access were 39% more likely to have gestational tobacco exposure, 8% more likely to have gestational obesity exposure, and 28% less likely to have health insurance (p < 0.01). Children without access in the South were 29% more likely to have a low birth weight and 46% more likely to be living below the poverty line (p < 0.01). Children with access were twice as likely to live in immigrant families and 7-times more likely to speak English as a second language. CONCLUSIONS: Pronounced disparities affect patients with and without one-hour access to CL/P care. Interventions should address care costs for patients living furthest without access and language barriers for patients with access that speak English as a second language.

Skull and Scalp En-Bloc Harvest Protects Calvarial Perfusion: A Cadaveric Study.

BACKGROUND: Calvarial defects are severe injuries that can result from a wide array of etiologies. Reconstructive modalities for these clinical challenges include autologous bone grafting or cranioplasty with biocompatible alloplastic materials. Unfortunately, both approaches are limited by factors such as donor site morbidly, tissue availability, and infection. Calvarial transplantation offers the potential opportunity to address skull defect form and functional needs by replacing "like-with-like" tissue but remains poorly investigated. METHODS: Three adult human cadavers underwent circumferential dissection and osteotomy to raise the entire scalp and skull en-bloc. The vascular pedicles of the scalp were assessed for patency and perfused with color dye, iohexol contrast agent for computed tomography (CT) angiography, and indocyanine green for SPY-Portable Handheld Imager assessment of perfusion to the skull. RESULTS: Gross changes were appreciated to the scalp with color dye, but not to bone. CT angiography and SPY-Portable Handheld Imager assessment confirmed perfusion from the vessels of the scalp to the skull beyond midline. CONCLUSION: Calvarial transplantation may be a technically viable option for skull defect reconstruction that requires vascularized composite tissues (bone and soft tissue) for optimal outcomes.

Mentorship is Critical: An Analysis of the 2022 Plastic Surgery Match.

BACKGROUND: As the second cycle impacted by COVID-19, the 2022 Plastic and Reconstructive Surgery (PRS) Match maintained virtual interviews while offering a modest lift of subinternship restrictions. The residency application process continues to evolve, with changes such as pass/fail United States Medical Licensing Examination Step 1 reporting prompting programs to reconsider metrics of applicant success. It is critical to address the impact of board scores, mentorship, and resource availability on a diverse applicant population in the PRS Match. METHODS: A survey was electronically administered to students applying to a single institutional PRS residency program. The survey inquired about demographics, application statistics, mentorship experience, and match outcomes. Logistic regressions were modeled to assess for odds of matching into plastic surgery. RESULTS: In total, 151 responses were analyzed, a 49.7% response rate. Most participants were female (52.3%), White (68.9%), and not Hispanic/Latino (84.8%). The largest percentage of respondents had a faculty mentor only from their home institution (55.0%) and a resident mentor from only their home institution (32.3%). Participants with a faculty mentor from both a home and outside institution had 7.4 times the odds of matching into PRS ( P = 0.02) than students with no faculty mentorship. Students with dual-institution resident mentorship had 18.5 times higher the odds of matching compared with students with no resident mentorship ( P < 0.001). CONCLUSIONS: Subjective metrics, rather than objective scores, had the most influence on successfully matching into plastic surgery. As the PRS Match continues to become increasingly competitive, it behooves programs to provide equitable access to resources such as mentorship.

The Impact of Socioeconomic Factors on the 2022 Plastic Surgery Match.

BACKGROUND: In 2022, the plastic and reconstructive surgery (PRS) match faced unprecedented system-wide transitions that have redefined conventional measures of applicant success. This challenges the equitable assessment of student competitiveness and diversity in the field. METHODS: A survey of demography, application content, and 2022 match outcomes was distributed to applicants to a single PRS residency program. Comparative statistics and regression models were performed to assess the predictive value of factors in match success and quality. RESULTS: A total of 151 respondents (response rate 49.7%) were analyzed. Although step 1 and step 2 CK scores were significantly higher among matched applicants, neither examination predicted match success. Most respondents (52.3%) were women, although gender was also not significantly associated with match success. Underrepresented in medicine applicants made up 19.2% of responses and 16.7% of matches, and the plurality of respondents (22.5%) were raised with a household income ≥$300,000. Both Black race and household income ≤$100,000 were associated with lower odds of scoring above a 240 on either step 1 or step 2 CK (Black: OR, 0.03 and 0.06; P < 0.05 and P < 0.001; income: OR, 0.07-0.47 and 0.1 to 0.8, among income subgroups), receiving interview offers (OR, -9.4; P < 0.05; OR, -11.0 to -5.4), and matching into PRS (OR, 0.2; P < 0.05; OR, 0.2 to 0.5), compared with White and high-income applicants, respectively. CONCLUSIONS: Systemic inequities in the match process disadvantage underrepresented in medicine candidates and those from lower household incomes. As the residency match continues to evolve, programs must understand and mitigate the impacts of bias in various application components.

Do Racial and Ethnic Disparities Exist in Management of Pediatric Mandible Fractures? A 30-Year Outcome Analysis.

BACKGROUND: Mandibular fractures are the most common of pediatric facial fractures. The effect of race on management/outcomes in these injuries has not been previously studied. Given the significant association between race and healthcare outcomes in many other pediatric conditions, an in-depth study of race as related to mandibular fractures in the pediatric patient population is warranted. METHODS: This was a 30-year retrospective, longitudinal study of pediatric patients who presented to a single institution with mandibular fractures. Patient data were compared between patients of different races and ethnicities. Demographic variables, injury characteristics, and treatment variables were analyzed to find predictors of surgical treatment and posttreatment complications. RESULTS: One hundred ninety-six patients met inclusion criteria, of whom 49.5% were White, 43.9% were Black, 0.0% were Asian, and 6.6% were classified as "other." Black and "other" patients were more likely than their White counterparts to be injured as pedestrians (P = 0.0005). Black patients were also more likely than White patients or "other" patients to be injured by assault than by sports-related injuries or animal-related accidents (P = 0.0004 and P = 0.0018, respectively). Race or ethnicity were not found to be a predictor of receiving surgical treatment (ORIF) or of posttreatment complications. The posttreatment rates for all the complications observed were comparable among all race and ethnic groups. Higher mandible injury severity score (odds ratio [OR], 1.25), condyle fracture (OR, 2.58), and symphysis fracture (OR, 3.20) were positively correlated with receiving ORIF as treatment. Mandible body fracture (OR, 0.36), parasymphyseal fracture (OR, 0.34), bilateral mandible fracture (OR, 0.48), and multiple mandibular fractures (OR, 0.34) were negatively correlated with receiving ORIF as treatment. Only high mandible injury severity score (OR, 1.10) was identified as an independent predictor of posttreatment complications. Lastly, Maryland's transition to an all-payer model in 2014 also had no impact on treatment modality; treatment of fractures among race and ethnicity were not significantly different pre- and post-2014. CONCLUSIONS: There is no difference in how patients are treated (surgically vs nonsurgically) and no difference in outcomes for patients based on race at our institution. This could be due to institutional ideology, services provided by a tertiary care center, or simply the more diverse patient population at baseline.

Treatment Delays in Nonsyndromic Craniosynostosis: A 30-Year Retrospective Case-Control Analysis of the Impact of Socioeconomic and Family Status on Access to Care.

BACKGROUND: Patients with nonsyndromic craniosynostosis (NSC) generally undergo corrective surgery before 1 year of age to the mitigate morbidities and risks of delayed repair. The cohort of patients who receive primary corrective surgery after 1 year and factors associated with their gaps to care is poorly characterized in literature. METHODS: A nested case-control study was conducted for NSC patients who underwent primary corrective surgery at our institution and affiliates between 1992 and 2022. Patients whose surgery occurred after 1 year of age were identified and matched 1:1 by surgical date to standard-care control subjects. Chart review was conducted to gather patient data regarding care timeline and sociodemographic characteristics. RESULTS: Odds of surgery after 1 year of age were increased in Black patients (odds ratio, 3.94; P < 0.001) and those insured by Medicaid (2.57, P = 0.018), with single caregivers (4.96, P = 0.002), and from lower-income areas (+1% per $1000 income decrease, P = 0.001). Delays associated with socioeconomic status primarily impacted timely access to a craniofacial provider, whereas caregiver status was associated with subspecialty level delays. These disparities were exacerbated in patients with sagittal and metopic synostosis, respectively. Patients with multisuture synostosis were susceptible to significant delays related to familial strain (foster status, insurer, and English proficiency). CONCLUSIONS: Patients from socioeconomically strained households face systemic barriers to accessing optimal NSC care; disparities may be exacerbated by the diagnostic/treatment complexities of specific types of craniosynostosis. Interventions at primary care and craniofacial specialist levels can decrease health care gaps and optimize outcomes for vulnerable patients.

Evaluation of Complications and Outcomes in Craniosynostosis by Age of Operation: Analysis of the National Surgical Quality Improvement Program-Pediatric.

Considerable controversy exists around the optimal age on which to operate for craniosynostosis. This study aims to use data from the American College of Surgeons National Surgical Quality Improvement Program-Pediatric to assess the impact of operative age on hospital stay and outcomes. After excluding patients who underwent endoscopic cranial vault remodeling, a total of 3292 patients met inclusion criteria in the National Surgical Quality Improvement Program-Pediatric between 2012 and 2019. Median age at surgery was 300 days (interquartile range: 204-494). Patients between 0 and 6 months underwent the highest proportion of complex cranial vault remodeling, Current Procedural Terminology 61,558 ( n =44, 7.7%) and Current Procedural Terminology 61,559 ( n =317, 55.1%). White blood cell counts peaked in the 12 to 18 months group, and were lowest in the 24± months group. Hematocrit was lowest in the 0 to 6 months group and rose steadily to the 24± months group; the inverse pattern was found in platelet concentration, which was highest in the youngest patients and lowest in the oldest. Prothrombin time, international normalized ratio, and partial thromboplastin time were relatively consistent across all age groups. Younger patients had significantly shorter operating room times, which increased with patient age ( P <0.001). Younger patients also had significantly shorter length of stay ( P =0.009), though length of stay peaked between 12 and 18 months. There was a significantly lower rate of surgical site infection in younger patients, which occurred in 0.7% of patients 0 to 12 months and 1.0 to 3.0% in patients over 12 to 24± months. There was no significant difference in the average number of transfusions required in any age group ( P =0.961).

Skull and Scalp En-Bloc Harvest Protects Calvarial Perfusion: A Cadaveric Study.

BACKGROUND: Calvarial defects are severe injuries that can result from a wide array of etiologies. Reconstructive modalities for these clinical challenges include autologous bone grafting or cranioplasty with biocompatible alloplastic materials. Unfortunately, both approaches are limited by factors such as donor site morbidly, tissue availability, and infection. Calvarial transplantation offers the potential opportunity to address skull defect form and functional needs by replacing "like-with-like" tissue but remains poorly investigated. METHODS: Three adult human cadavers underwent circumferential dissection and osteotomy to raise the entire scalp and skull en-bloc. The vascular pedicles of the scalp were assessed for patency and perfused with color dye, iohexol contrast agent for computed tomography (CT) angiography, and indocyanine green for SPY-Portable Handheld Imager assessment of perfusion to the skull. RESULTS: Gross changes were appreciated to the scalp with color dye, but not to bone. CT angiography and SPY-Portable Handheld Imager assessment confirmed perfusion from the vessels of the scalp to the skull beyond midline. DISCUSSION/CONCLUSION: Calvarial transplantation may be a technically viable option for skull defect reconstruction that requires vascularized composite tissues (bone and soft tissue) for optimal outcomes.

The Impact of Virtual Surgical Planning on Orthognathic Surgery: Contributions From Two Specialties.

BACKGROUND: Virtual surgical planning (VSP) has gained popularity for preoperative orthognathic surgery planning and is increasingly being employed by surgeons trained in plastic and reconstructive surgery (PRS) or oral and maxillofacial surgery (OMS). This review assesses the introduction of VSP as a new technology and its impact on orthognathic surgery research and practices based upon surgeon training. METHODS: Two PubMed literature reviews were conducted. The first classified publications on VSP for orthognathic surgery by training (OMS- or PRS-trained surgeons) and compared focuses, timing, and journals of publications from each group of surgeons. The second evaluated how orthognathic surgery publication volumes changed with VSP introduction. English articles published from inception until January 2020 (first review) and November 2020 (second review) were included. RESULTS: The first literature review retrieved 419 unique publications, with 188 studies selected for inclusion: 162 were published by OMS-trained principal investigators (OMS-authored) and 26 by PRS-trained principal investigators (PRS-authored). Plastic and reconstructive surgery-authored publications regarding VSP use in orthognathic surgery increased after the first publication in 2000, but at a significantly slower rate (0.2 new publications/year) than OMS-authored publications ( P < 0.01). Aesthetics was discussed in significantly more PRS-authored publications (76.9% compared to 28.4% of OMS-authored publications). The second review revealed that over 80.6% of orthognathic surgery literature was published after 2008, the year VSP was first integrated into orthognathic surgery workflow. CONCLUSIONS: Following the introduction of VSP, orthognathic surgery research output has differed between PRS and OMS based on publication speed, volume, and research focuses.Further research is necessary to evaluate how VSP has impacted PRS and OMS clinical practice.

Surgical Versus Nonsurgical Lower Face Contouring: Layperson Perceptions of Attractiveness and Personality Traits.

BACKGROUND: Traditional approaches to lower face contouring involve ostectomy of the mandibular angle or body. More recently, nonsurgical techniques have gained popularity, including neurotoxin injection to the masseter muscle. This study aims to evaluate layperson perceptions of patient attractiveness and personality traits following lower face contouring using either surgical or nonsurgical treatment. METHODS: In this survey study distributed via Amazon's Mechanical Turk, respondents viewed a series of 14 patient images obtained in clinic before and after surgical or nonsurgical jawline slimming, or without any facial aesthetic procedure. Respondents rated changes in attractiveness and personality trait scores between the before and after image (score: -50 to 50, with 50 representing the greatest posttreatment increase and 0 representing no change). We used descriptive statistics and multivariable regression to determine differences in respondent ratings between patient images. RESULTS: A total of 415 respondents (mean age 38 years, 50.6% female) successfully completed the survey. Compared to patients who underwent nonsurgical treatment, those who received surgery had significantly greater increases in perceived attractiveness (P < 0.001), femininity (P < 0.001), friendliness (P < 0.001), intelligence (P < 0.001), trustworthiness (P < 0.001), financial wealthiness (P < 0.001), dominance (P < 0.01), and self-esteem (P < 0.001). Gonial angles increased and jaw widths decreased following both surgical and nonsurgical intervention, with no statistically significant difference between treatment groups. CONCLUSIONS: From the layperson perspective, surgical compared to nonsurgical jawline contouring offers greater improvements in perceptions of attractiveness and favorable personality traits.

Caregiver Preferences for Three-Dimensional Printed or Augmented Reality Craniosynostosis Skull Models: A Cross-Sectional Survey.

BACKGROUND: Recent advances in three-dimensional (3D) printing and augmented reality (AR) have expanded anatomical modeling possibilities for caregiver craniosynostosis education. The purpose of this study is to characterize caregiver preferences regarding these visual models and determine the impact of these models on caregiver understanding of craniosynostosis. METHODS: The authors constructed 3D-printed and AR craniosynostosis models, which were randomly presented in a cross-sectional survey. Caregivers rated each model's utility in learning about craniosynostosis, learning about skull anatomy, viewing an abnormal head shape, easing anxiety, and increasing trust in the surgeon in comparison to a two-dimensional (2D) diagram. Furthermore, caregivers were asked to identify the fused suture on each model and indicate their preference for generic versus patient-specific models. RESULTS: A total of 412 craniosynostosis caregivers completed the survey (mean age 33 years, 56% Caucasian, 51% male). Caregivers preferred interactive, patient-specific 3D-printed or AR models over 2D diagrams (mean score difference 3D-printed to 2D: 0.16, P < 0.05; mean score difference AR to 2D: 0.17, P < 0.01) for learning about craniosynostosis, with no significant difference in preference between 3D-printed and AR models. Caregiver detection accuracy of the fused suture on the sagittal model was 19% higher with the 3D-printed model than with the AR model (P < 0.05) and 17% higher with the 3D-printed model than with the 2D diagram (P < 0.05). CONCLUSIONS: Our findings indicate that craniosynostosis caregivers prefer 3D-printed or AR models over 2D diagrams in learning about craniosynostosis. Future craniosynostosis skull models with increased user interactivity and patient-specific components can better suit caregiver preferences.

Personality, Success, and Beyond: The Layperson's Perception of Patients With Facial Transplantation.

BACKGROUND: While the goal of facial vascularized composite allotransplantation (FVCA) is to provide patients with improved physical and social function, no study has evaluated layperson perception of social acceptance and perceived career success of patients with FVCA. The purpose of this study was to determine how FVCA changes social acceptance and perceived career success of patients with facial disfiguration. METHODS: Eight hundred fifteen laypersons were surveyed through Mechanical Turk to evaluate their perceptions of patients with FVCA. Respondents were shown facial photographs of patients pre-FVCA, post-FVCA, and matched controls and evaluated these photos on 26 items of perceived social acceptance and career success. Responses were analyzed using descriptive statistics and the Wilcoxon signed-rank test. RESULTS: Both male and female post-FVCA photos were perceived as significantly more socially accepted and professionally successful than their pre-FVCA photos in at least 21 out of 26 items (P < 0.001 for all), but the posttransplant patients scored lower than their control in at least 25 out of 26 items (P < 0.001 for all). Additionally, there were discrepancies in findings based on patient gender. CONCLUSIONS: This study suggests that while FVCA has a significantly positive impact on social acceptance and perceived professional success, it does not fully reinstate these qualities. Furthermore, varying surgical outcomes and/or cognitive biases (such as gender) may impact perceptions of the individual by the public. Our findings suggest a need to standardize practices to better predict and improve outcomes and encourage surgeons to consider patient factors such as gender when planning these procedures.

Characterizing the Impact of Socioeconomic Status on Orbital Floor Reconstruction: A National Inpatient Sample (NIS) Analysis.

ABSTRACT: Orbital floor fractures result in posterior globe displacement known as enophthalmos, and diplopia due to extraorbital soft tissue impingement. Surgical repair may involve the use of autolo-gous or synthetic materials. Previous studies have demonstrated a higher prevalence of orbital floor fractures among lower socioeconomic status (SES) populations. The authors aimed to characterize the impact of socioeconomic status on surgical management, outcomes, and use of synthetic orbital implant. The authors conducted a cross-sectional study of adult orbital floor fracture patients from 2002 to 2017 using the National Inpatient Sample. Among patients who underwent surgical treatment, our study found decreased synthetic orbital implant use among uninsured and Black patients and decreased home discharge among Medicare patients. There were no differences in orbital reconstruction. Further research is needed to elucidate possible mechanisms driving these findings.

Craniofacial Fellowship Applicant Perceptions of Virtual Interviews.

INTRODUCTION: The 2021 interview cycle for craniofacial fellowship applicants was the first to be held virtually due to the coronavirus disease 2019 pandemic. Here, we detail the craniofacial fellowship applicant perceptions and experience on the virtual interview process. MATERIALS AND METHODS: An institutional review board-approved 35-question survey study on the perception of the virtual interview process among craniofacial fellowship applicants was conducted. Surveys were distributed to individuals who had applied through the match, overseen by the American Society of Craniofacial Surgeons (ASCFS). RESULTS: Ten surveys were fully completed with a corresponding response rate of 48%. The average number of interviews completed was 12.7±7.7 and 50% of applicants interviewed at >1 program in a single day. Overall, 90% of respondents preferred in-person interviews before the interview season, however, only 10% preferred the in-person format afterwards. Preference for a virtual-only format increased from 10% to 70%. Applicants cited cost (100%), ease of scheduling (90%), and ability to participate in more interviews (70%) as the primary strengths of the virtual platform; none reported difficulties with self-advocacy. After the interview cycle, 90% stated they would recommend virtual interviews. CONCLUSIONS: The greatest strengths of virtual interviews were the ability to participate in more interviews, the ease of scheduling, and the cost benefits. Most applicants reported the same or increased ability for self-advocacy with virtual interviews. Following the index interview cycle for 2021, the majority of fellowship applicants now appear to prefer a virtual-only or hybrid format and would recommend virtual interviews in the future.

Pediatric Orthognathic Surgery: A NSQIP-P Comparison of Peri-Operative Factors and Outcome Differences Between Cleft and Noncleft Patients.

OBJECTIVE: The present study aimed to investigate the risk factors, complication profiles, and clinical outcomes of cleft and noncleft patients undergoing single jaw (mandibular or LeFort 1) and bimaxillary (BSSO + LeFort 1). DESIGN: Retrospective Cross-sectional Study Setting: National Surgical Quality Improvement Program database 2018-2019. PATIENTS: Pediatric patients. INTERVENTIONS: Outcomes for mandibular, LeFort 1, and bimaxillary osteotomy were retrospectively evaluated for cleft and noncleft patients. MAIN OUTCOME MEASURES: Multivariate logistic regression was used to determine the odds of complications and length of stay for cleft and noncleft patients undergoing single jaw and double jaw surgery. RESULTS: 669 pediatric patient underwent orthognathic surgery in the study period; the majority received LF1 only (n = 385; 58.3%), followed by mandible only (n = 179; 27.1%), and bimaxillary (n = 105; 15.9%%). Cleft differences were present in 56% of LFI patients, 32% of mandibular patients, and 22% of bimaxillary patients. After multivariate adjustment, ASA class III was associated with nearly 400% increased odds of any complication including readmission and reoperation (OR = 5.99; CI [[1.54-23.32]], p < 0.01, and 65% increased LOS (ß-coefficient = 1.65, CI [1.37-1.99], p < 0.01). Presence of cleft was not significantly associated with odds of any complication (p = 0.69) nor increased LOS (p = 0.46) in this population. CONCLUSION: Complications remained low between surgery types among cleft and noncleft patients. The most significant risk factor in pediatric orthognathic surgery was not the presence of cleft but rather increased ASA class. Though common in patients seeking orthognathic surgery, cleft differences did not cause additional risk after adjustment for other variables.