Incidence, Characteristics, and Outcomes of Robin Sequence: A Population-Based Analysis in the United States.

INTRODUCTION: While the literature is replete of clinical studies reporting on the Robin sequence (RS), population-based analyses are scarce with significant variability within the literature in terms of reported incidence, demographic parameters, and outcomes. The authors have conducted a 20-year population-based analysis to guide clinical practice. METHODS: A birth cohort was created from the available datasets in the Healthcare Cost and Utilization Project-Kids' Inpatient Database (HCUP-KID; 2000-2019). Robin sequence patients were identified and further stratified by syndromic status. Incidence, demographic parameters, and outcomes including mortality and tracheostomy rates were computed. A subset analysis comparing the isolated and syndromic cohorts was conducted. Data was analyzed through a χ 2 or t test. RESULTS: The incidence of RS was 5.15:10,000 (95% CI: 4.99-5.31) from a birth cohort of 7.5 million. Overall, 63.3% of the cohort was isolated RS and 36.7% had syndromic RS. Robin sequence patients had a significantly higher rate of cardiac (25.9%) and neurological (8.6%) anomalies compared with the general birth cohort and were most commonly managed in urban teaching hospitals ( P <0.0001). The pooled mortality and tracheostomy rates were 6.6% and 3.6%, respectively. Syndromic status was associated with a longer length of hospital stay (27.8 versus 13.6 d), tracheostomy rate (6.2% versus 2.1%), and mortality (14.1% versus 2.2%) compared with isolated RS ( P <0.0001). CONCLUSIONS: The true incidence of RS is likely higher than previously reported estimates. Isolated RS patients have a low associated mortality and tracheostomy rate and are typically managed in urban teaching hospitals. Syndromic status confers a higher mortality rate, tracheostomy rate, and length of stay compared with nonsyndromic counterparts.

The Effect of Tranexamic Acid Administration During Liposuction on Bleeding Complications and Ecchymosis: A Systematic Review.

Liposuction is the most frequently performed cosmetic procedure. Tranexamic acid (TXA) has emerged as a promising blood loss reducing agent in plastic surgery, but its value in liposuction is still being studied. This systematic review investigates the safety and efficacy of TXA in reducing blood loss during liposuction procedures. A systematic review of PubMed (US National Library of Medicine, Bethesda, MD), MEDLINE (US National Library of Medicine), EMBASE (Elsevier, Amsterdam, the Netherlands), and Cochrane databases (Wiley, Hoboken, NJ) from inception to June 2023 was performed. The primary objective was to compare blood loss, hematoma rate, and ecchymosis from liposuction procedures in patients who received TXA versus those who did not. The secondary objective was to assess the incidence of TXA-related complications. A total of nine studies were included, published between 2018 and 2023 of which eight were prospective and one was retrospective. A total of 345 intervention versus 268 control arms were compared. Follow-up time ranged from 1-14 days. Mean age, and mean BMI ranged from 33 - 50 years, 23 to 30 kg/m2, respectively. Blood loss in aspirate was significantly less with TXA administration assessed by five studies (p < 0.05). Of the five studies that assessed the incidence of ecchymosis, all reported less bruising with TXA use. Among all the studies, only one found post-operative complications with five patients requiring transfusion in the control group (without TXA). The evidence provided in the literature suggests that TXA use in liposuction is safe and effective for reducing blood loss and ecchymosis with IV and local administration.

Utility and Comparative Performance of Current Artificial Intelligence Large Language Models as Postoperative Medical Support Chatbots in Aesthetic Surgery.

BACKGROUND: Large language models (LLMs) have revolutionized the way plastic surgeons and their patients can access and leverage artificial intelligence (AI). OBJECTIVES: The present study aims to compare the performance of 2 current publicly available and patient-accessible LLMs in the potential application of AI as postoperative medical support chatbots in an aesthetic surgeon's practice. METHODS: Twenty-two simulated postoperative patient presentations following aesthetic breast plastic surgery were devised and expert-validated. Complications varied in their latency within the postoperative period, as well as urgency of required medical attention. In response to each patient-reported presentation, Open AI's ChatGPT and Google's Bard, in their unmodified and freely available versions, were objectively assessed for their comparative accuracy in generating an appropriate differential diagnosis, most-likely diagnosis, suggested medical disposition, treatments or interventions to begin from home, and/or red flag signs/symptoms indicating deterioration. RESULTS: ChatGPT cumulatively and significantly outperformed Bard across all objective assessment metrics examined (66% vs 55%, respectively; P < .05). Accuracy in generating an appropriate differential diagnosis was 61% for ChatGPT vs 57% for Bard (P = .45). ChatGPT asked an average of 9.2 questions on history vs Bard's 6.8 questions (P < .001), with accuracies of 91% vs 68% reporting the most-likely diagnosis, respectively (P < .01). Appropriate medical dispositions were suggested with accuracies of 50% by ChatGPT vs 41% by Bard (P = .40); appropriate home interventions/treatments with accuracies of 59% vs 55% (P = .94), and red flag signs/symptoms with accuracies of 79% vs 54% (P < .01), respectively. Detailed and comparative performance breakdowns according to complication latency and urgency are presented. CONCLUSIONS: ChatGPT represents the superior LLM for the potential application of AI technology in postoperative medical support chatbots. Imperfect performance and limitations discussed may guide the necessary refinement to facilitate adoption.

Patient-Specific Implants and Fat Grafting for Contour Deformities Post Craniosynostosis Reconstruction: A Therapeutic Approach.

BACKGROUND: Contour deformities after fronto-orbital advancement for craniosynostosis reconstruction are commonly encountered. There is a paucity of literature describing secondary procedures to correct such deformities with reported outcomes. An approach to defect analysis and procedure selection is lacking. The authors present our experience utilizing fat grafting (FG) and patient-specific implant (PSI) reconstruction as management strategies for this population. METHODS: A retrospective analysis of consecutive patients who underwent secondary onlay PSI or FG for contour deformities after primary craniosynostosis reconstruction was carried out. Patient demographics, defect analysis, surgical approach, postoperative complications, and esthetic outcomes were recorded. Data were pooled across the entire cohort and presented in a descriptive manner. RESULTS: Fourteen patients (36% syndromic and 64% isolated) were identified that either underwent PSI (n = 7) with a mean follow-up of 56.3 weeks, FG (n = 5) with a mean follow-up of 36 weeks or a combination of both (n = 2) for deformities postcraniosynostis surgery. Supraorbital retrusion and bitemporal hollowing were the most common deformities. There were no intraoperative or postoperative complications. All patients achieved Whitaker class I esthetic outcomes and there were no additional revisions during the defined study period. The presence of a significant structural component or large (>5 mm) depression typically necessitated a PSI. CONCLUSIONS: Contour deformities after fronto-orbital advancement reconstruction can be successfully managed using FG and PSI either as a combination procedure or in isolation. The authors have proposed anatomical criteria based on our experience to help guide procedure selection. Future prospective studies would be beneficial in providing more objective assessment criteria.

Description of a Novel Web-Based Liposuction System to Estimate Fat Volume and Distribution.

BACKGROUND: Preoperative planning for liposuction is vital to ensure safe practice and patient satisfaction. However, current standards of fat assessment before surgery are guided by subjective methods such as visual inspection, skin-pinch tests, and waist circumference measurements. OBJECTIVES: This study aimed to develop an inexpensive software-based tool that utilizes ultrasound (US) imaging and an online platform to accurately simulate regional subcutaneous adipose tissue (SAT) distribution and safe volume estimation for liposuction procedures. METHODS: The authors present a web-based platform with integrated 2-dimensional (2D) and 3-dimensional (3D) simulations of SAT to support liposuction planning and execution. SAT-Map was constructed using multiple sub-applications linked with the python framework programming language (Wilmington, DE). RESULTS: The SAT-Map interface provides an intuitive and fluid means of generating patient-specific models and volumetric data. To further accommodate this, an operational manual was prepared to achieve consistent visualization and examination of estimated SAT content. The system currently supports static 2D heatmap simulation and 3D interactive virtual modelling of the SAT distribution. Supplementary clinical studies are needed to evaluate SAT-Map's clinical performance and practicality. CONCLUSIONS: SAT-Map revolutionizes the concept of preoperative planning for liposuction by developing the first combined web-based software that objectively simulates fat distribution and measures safe liposuction volume. Our software approach presents a cost-efficient, accessible, and user-friendly system offering multiple advantages over current SAT assessment modalities. The immediacy of clinically accurate 3D virtual simulation provides objective support to surgeons towards improving patient conversation, outcomes, and satisfaction in liposuction procedures.

Ultrasound Calculation of Fat Volume for Liposuction: A Clinical Software Validation.

BACKGROUND: Fat manipulation procedures such as liposuction contain a degree of subjectivity primarily guided by the surgeon's visual or tactile perception of the underlying fat. Currently, there is no cost-effective, direct method to objectively measure fat depth and volume in real time. OBJECTIVES: Utilizing innovative ultrasound-based software, the authors aimed to validate fat tissue volume and distribution measurements in the preoperative setting. METHODS: Eighteen participants were recruited to evaluate the accuracy of the new software. Recruited participants underwent ultrasound scans within the preoperative markings of the study area before surgery. Ultrasound-estimated fat profiles were generated with the in-house software and compared directly with the intraoperative aspirated fat recorded after gravity separation. RESULTS: Participants' mean age and BMI were 47.6 (11.3) years and 25.6 (2.3) kg/m2, respectively. Evaluation of trial data showed promising results following the use of a Bland Altman agreement analysis. For the 18 patients and 44 volumes estimated, 43 of 44 measurements fell within a confidence interval of 95% when compared with the clinical lipoaspirate (dry) volumes collected postsurgery. The bias was estimated at 9.15 mL with a standard deviation of 17.08 mL and 95% confidence interval between -24.34 mL and 42.63 mL. CONCLUSIONS: Preoperative fat assessment measurements agreed significantly with intraoperative lipoaspirate volumes. The pilot study demonstrates, for the first time, a novel companion tool with the prospect of supporting surgeons in surgical planning, measuring, and executing the transfer of adipose tissues.

Ethics of Facial Transplantation: The Effect of Psychological Trauma Associated With Facial Disfigurement on Risk Acceptance and Decision Making.

OBJECTIVE: This study examines and contrasts the effect of risk disclosure on risk acceptance and perceived changes in quality of life (QoL) among individuals with and without facial disfigurement. SUMMARY OF BACKGROUND DATA: Psychological distress has been previously shown to alter patients' perception of certain treatments. Due to the grave risks and complications of FT, it is important to understand whether the psychological trauma associated with facial disfigurement alters their perception of FT and its associated risks. METHODS: Participants with and without facial disfigurement were recruited to complete a questionnaire about their perceived QoL, sense of identity, and willingness to proceed with FT in the context of 3 different hypothetical scenarios involving facial disfiguration. RESULTS: Four hundred nine nonfacially disfigured and 74 facially disfigured participants were included. When both healthy and facially disfigured individuals were presented with the risks and benefits of a FT, they both perceived their QoL to be as low, or significantly lower, than if they had severe facial disfigurement. Furthermore, presenting the risks of FT significantly altered the decision making and risk acceptance of healthy individuals with no facial disfigurement. However, risk disclosure did not affect the decision making among facially disfigured individuals. CONCLUSION: This study highlights that presenting the complication profile of FT decreases risk acceptance of FT in healthy individuals but has no significant effects on facially disfigured individuals. The psychological impact of facial disfigurement and its influence on accepting the significant risks of FT should be considered and warrants further investigation.

Efficacy and Complications of Mandibular Distraction Osteogenesis for Airway Obstruction in the Robin Sequence Population: A Comprehensive Literature Review.

INTRODUCTION: Mandibular distraction osteogenesis (MDO) is becoming the procedure of choice for patients with Robin Sequence (RS) as it offers superior long-term respiratory outcomes in avoidance of tracheostomy. Lacking, is an analysis of the short- and long-term complications. To that end, we have conducted a comprehensive review focusing on complications of MDO. MATERIALS AND METHODS: A systematic review of primary clinical studies reporting outcomes and complications of MDO in RS patients. Outcomes included tracheostomy avoidance and decannulation rate. Complications included dental trauma, nerve injury, surgical site infection and hardware failure. Complications were stratified according to distractor type (internal versus external) and age (>2 months versus <2months). RESULTS: A total of 49 studies yielded 1209 patients with a mean follow-up of 43.78 months. The tracheostomy avoidance rate was 94% (n = 817/870) and the mortality rate was 0.99% (n = 12/1209). The complication rate was 28.9% (n = 349/1209) with surgical site infections (10.5%) being most common. Dental and nerve injuries occurred in 7.9% and 3.2% of patients, respectively. Hardware replacement occurred in 1.2% of patients. internal distractors had higher rates of dental injury whereas external distractors had higher technical failure rates. There were no differences in complication rates ( P= 0.200), mortality ( P = 0.94) or tracheostomy avoidance ( P = 0.058) between patients >2months or <2months of age. CONCLUSION: Mandibular distraction osteogenesis is highly reliable and effective with a low mortality and high tracheostomy avoidance rate. There are important complications including nerve and dental injuries which require long-term follow-up. Neonatal patients do not appear to be at higher risk of complications reinforcing the safety of MDO in this population.

Decreasing Incidence of Palatoplasty in the United States.

INTRODUCTION: Cleft palate is amongst the most common birth defect across the world. Although its etiology is multifactorial, including genetic and environmental contributors, the investigators were interested in exploring whether its incidence was changing over time. METHODS: The Nationwide Inpatient Sample database, the largest publically available healthcare database in the United States, was used to identify all primary palatoplasties performed under 2 years of age and births which occurred over a 17-year period from 1999 to 2015. The change in rate of palatoplasties and overall maternal demographics were assessed longitudinally using the chi-squared test. Significance level was set at P < 0.001. RESULTS: A total of 13,808,795 pregnancies were reviewed during the time period, from 1999 to 2015, inclusively. A total of 10,567 primary palatoplasties were performed in that period of time reflecting an overall rate of 7.7 palatoplasties per 10,000 deliveries. Palatoplasty rates decreased across the study period from 9.5 per 10,000 in 1999 to 7.1 per 10,000 died/delivered pregnancies in 2015 which corresponds to an average compounded year-to-year decrease of 1.76%, P < 0.001. CONCLUSIONS: The rate of primary palatoplasties, as a proxy for the rate of cleft palate prevalence, has been significantly decreasing over the last 2 decades and may represent improvements in early diagnosis in pregnancy, changing genetic or racial demographics, and/or environmental factors such as decreased maternal smoking in the US population. Future research may be directed at better understanding the definitive etiology of this decreasing prevalence of children undergoing primary cleft palate repairs in the United States.

Cost-Effectiveness Analysis, Psychosocial, and Utility Outcomes of Early Mandibular Distraction in Craniofacial Microsomia.

BACKGROUND: The cost-effectiveness, utility outcomes, and most optimal timing of mandibular distraction osteogenesis (MDO) in craniofacial microsomia (CFM) continue to be a topic of debate, especially in the population of patients with mild or nonsignificant functional issues. The objective of this study was to quantitatively assess the burden of mandibular asymmetry in CFM, and to accurately evaluate the impact of early MDO on patients' perceived quality of life and social acceptance, in addition to examining the cost-effectiveness of early MDO in CFM. METHODS: A validated crowdsourcing platform was utilized to recruit participants. Psychosocial acceptance and utility outcomes were assessed for patients with CFM. Participants were presented with health-state scenarios supplemented with pre- and postoperative images. Quality-adjusted life years (QALYs) were subsequently calculated and costs were estimated based on Medicare fee schedules using the Current Procedural Terminology codes. Incremental cost-effectiveness ratios for early MDO were calculated and plotted against a $100,000/QALY threshold. RESULTS:: A total of 463 participants were included in the study. The mean visual analog scale score for untreated mandibular hypoplasia in CFM was 0.48 ±â€Š0.24, which improved significantly (P < 0.0001) to 0.63 ±â€Š0.20 following early MDO. Time trade-off scores for an imaginary surgery leading to perfect health with no complications were not statistically different from undergoing early MDO (P = 0.113). Early mandibular distraction decreased social distance in all 8 social situations assessed. Incremental cost-effectiveness ratios varied by the duration of time between early MDO and a potential second intervention, ranging from $148,142.09 per QALY gained at an interval of 1 year to $9876.14 per QALY gained after 15 years. Using a willingness-to-pay threshold of $100,000/QALY, early MDO in CFM becomes cost-effective when patients enjoy an improved health-state post-MDO for more than 1.48 years before a potential second intervention, if deemed necessary. CONCLUSION: Early mandibular distraction may lead to tangible positive gains in CFM patients based on utility outcome scores, psychosocial acceptance, and social distance. Therefore, although further interventions may be needed at skeletal maturity, early MDO can improve the psychological well-being of CFM patients during their crucial developmental years in a cost-effective manner. The incremental cost per QALY gained post-early MDO correlates negatively with time until a second potential surgical intervention.