The Current Incidence and Future Projection of Acetabular Fractures in Korea.

BACKGROUND: As one of the most challenging fractures to orthopedic surgeons, acetabular fractures show a wide range of incidence among countries and regions with even more variance in the treatment modalities. In this study, we aimed to investigate the epidemiology of acetabular fractures, and to compare the rate of subsequent total hip arthroplasty (THA) between nonoperative and operative treatments in South Korea using a medical claims database. METHODS: This was a retrospective study using the Korean Health Insurance Review and Assessment database. Patients admitted for acetabular fractures from January 2007 to December 2018 were identified using International Classification of Diseases-10 codes. Kaplan-Meier survival analysis was used to compare the cumulative incidence of THA between two groups. We also evaluated the survivorship of operative group according to the type of institutions. RESULTS: The incidence rate of acetabular fractures increased by 28% between 2007 and 2018. Acetabular fractures were more common in men (62%) than women (38%), and most common in the patients older than 80 years. The number of acetabular fractures was estimated to increase 1.7-fold in 2030 compared to 2018. Operative treatment accounted for 16% of cases, and nonoperative treatment for 84%. The incidence of subsequent THA was higher in the operative treatment group than in the nonoperative group (P < 0.001). The higher rate in the operative treatment group is probably related with the severity of the fracture type. The rate of subsequent THA was higher in patients who initially treated in general hospitals compared with those who were initially treated in tertiary hospitals. CONCLUSION: The incidence of acetabular fractures is increasing in South Korea, in line with global trends. Most acetabular fractures are treated conservatively, and those who receive surgery are more likely to require a subsequent THA. Patients who were operated in general hospitals had highest possibility of subsequent THA after acetabular fractures.

Pulsed-Mode Metalorganic Vapor-Phase Epitaxy of GaN on Graphene-Coated c-Sapphire for Freestanding GaN Thin Films.

We report the growth of high-quality GaN epitaxial thin films on graphene-coated c-sapphire substrates using pulsed-mode metalorganic vapor-phase epitaxy, together with the fabrication of freestanding GaN films by simple mechanical exfoliation for transferable light-emitting diodes (LEDs). High-quality GaN films grown on the graphene-coated sapphire substrates were easily lifted off by using thermal release tape and transferred onto foreign substrates. Furthermore, we revealed that the pulsed operation of ammonia flow during GaN growth was a critical factor for the fabrication of high-quality freestanding GaN films. These films, exhibiting excellent single crystallinity, were utilized to fabricate transferable GaN LEDs by heteroepitaxially growing InxGa1-xN/GaN multiple quantum wells and a p-GaN layer on the GaN films, showing their potential application in advanced optoelectronic devices.

Molecular-level chemical composition of aerosol and its potential source tracking at Antarctic Peninsula.

Marine organic aerosols play crucial roles in global climatic systems. However, their chemical properties and relationships with various potential organic sources still need clarification. This study employed high-resolution mass spectrometry to investigate the identity, origin, and transportation of organic aerosols in pristine Antarctic environments (King Sejong Station; 62.2°S, 58.8°W), where complex ocean-cryosphere-atmosphere interactions occur. First, we classified the aerosol samples into three clusters based on their air mass transport history. Next, we investigated the relationship between organic aerosols and their potential sources, including organic matter dissolved in the open ocean, coastal waters, and runoff waters. Cluster 1 (C1), in which the aerosols mainly originated from the open ocean area (i.e., pelagic zone-influenced), exhibited a higher abundance of lipid-like and protein-like organic aerosols than cluster 3 (C3), with ratios 1.8- and 1.6-times higher, respectively. In contrast, C3, characterized by longer air mass retention over sea ice and land areas (i.e., inshore-influenced), had higher lignin- and condensed aromatic structures (CAS)-like organic aerosols by 2.2- and 3.4-times compared to C1. Cluster 2 (C2) has intermediate characteristics between C1 and C3 concerning the chemical properties of the aerosols and air mass travel history. Notably, the chemical properties of the aerosols assigned to C1 are closely related to those of phytoplankton-derived organics enriched in the open ocean. In contrast, those of C3 are comparable to those of terrestrial plant-derived organics enriched in coastal and runoff waters. These findings help evaluate the source-dependent properties of organic aerosols in changing Antarctic environment.

"Validation of Artificial Intelligence Severity Assessment in Metopic Craniosynostosis".

OBJECTIVE: Several severity metrics have been developed for metopic craniosynostosis, including a recent machine learning-derived algorithm. This study assessed the diagnostic concordance between machine learning and previously published severity indices. DESIGN: Preoperative computed tomography (CT) scans of patients who underwent surgical correction of metopic craniosynostosis were quantitatively analyzed for severity. Each scan was manually measured to derive manual severity scores and also received a scaled metopic severity score (MSS) assigned by the machine learning algorithm. Regression analysis was used to correlate manually captured measurements to MSS. ROC analysis was performed for each severity metric and were compared to how accurately they distinguished cases of metopic synostosis from controls. RESULTS: In total, 194 CT scans were analyzed, 167 with metopic synostosis and 27 controls. The mean scaled MSS for the patients with metopic was 6.18 ± 2.53 compared to 0.60 ± 1.25 for controls. Multivariable regression analyses yielded an R-square of 0.66, with significant manual measurements of endocranial bifrontal angle (EBA) (P = 0.023), posterior angle of the anterior cranial fossa (p < 0.001), temporal depression angle (P = 0.042), age (P < 0.001), biparietal distance (P < 0.001), interdacryon distance (P = 0.033), and orbital width (P < 0.001). ROC analysis demonstrated a high diagnostic value of the MSS (AUC = 0.96, P < 0.001), which was comparable to other validated indices including the adjusted EBA (AUC = 0.98), EBA (AUC = 0.97), and biparietal/bitemporal ratio (AUC = 0.95). CONCLUSIONS: The machine learning algorithm offers an objective assessment of morphologic severity that provides a reliable composite impression of severity. The generated score is comparable to other severity indices in ability to distinguish cases of metopic synostosis from controls.

A safe and sustainable bacterial cellulose nanofiber separator for lithium rechargeable batteries.

Bacterial cellulose nanofiber (BCNF) with high thermal stability produced by an ecofriendly process has emerged as a promising solution to realize safe and sustainable materials in the large-scale battery. However, an understanding of the actual thermal behavior of the BCNF in the full-cell battery has been lacking, and the yield is still limited for commercialization. Here, we report the entire process of BCNF production and battery manufacture. We systematically constructed a strain with the highest yield (31.5%) by increasing metabolic flux and improved safety by introducing a Lewis base to overcome thermochemical degradation in the battery. This report will open ways of exploiting the BCNF as a "single-layer" separator, a good alternative to the existing chemical-derived one, and thus can greatly contribute to solving the environmental and safety issues.

Characteristics and Patterns of Facial Fractures in the Elderly Population in the United States Based on Trauma Quality Improvement Project Data.

ABSTRACT: With the increase in the elderly population in the United States, the number of people seeking care for trauma injuries is expected to increase. However, nationwide studies on epidemiological profile of elderly facial fractures remain sparse. The authors present the epidemiological measures of elderly facial fractures on national scale. Characteristics of facial fractures among younger adults (18-64 years old) and the elderly population (65-74 years old, 75-84 years old and 85 years and above) have been examined using the 2016 American College of Surgeons-Trauma Quality Improvement Program databank. Variables studied included facial fracture patterns, mechanisms of injury, treatment variables, and demographic descriptive data. Of 104,183 elderly trauma patients, 3415 presented with facial fractures, making up 3.3% (versus 6.5% in younger adults). Majority of facial fractures in 85 and over group (60.7%) were experienced by females, compared to only 19.5% in the younger adult group. Most common mechanism of injury in the elderly was falls, versus motor vehicle trauma in younger adults. The most common type of facial fractures among both groups were nasal fractures. Elderly patients presented with fewer zygoma, mandibular and nasal fractures when compared to younger adults, whereas showing more maxillary/malar and orbital bone fractures. Elderly patients experienced less operative management (4.3%-8.2%) compared to younger adults (15.6%). Concurrently, mortality rates were higher in the elderly patients (9.9%-11.8%) when compared to the younger adults (8.0%). Elderly patients presented with different causes of injury, distribution of fractures, and rates of operative management compared to younger adults.

A Comprehensive Single-Center Analysis of Postoperative Nausea and Vomiting Following Orthognathic Surgery.

BACKGROUND: Postoperative nausea and vomiting (PONV) remains a major clinical end-point for directing enhanced recovery after surgery (ERAS) protocols in facial plastic surgery. This study aimed to identify risk factors for PONV and evaluate strategies for PONV reduction in orthognathic surgery patients. METHODS: A retrospective cohort study was performed among patients receiving orthognathic surgery at our institution from 2011 to 2018. Patient demographics, surgical operative and anesthesia notes, medications, and nausea/vomiting were assessed for each patient. The amount of opioid analgesia given both perioperatively and postoperatively was recorded and converted into morphine equivalents (MEQ). Stepwise regression analysis was used to identify significant risk factors for PONV. Post hoc analyses were employed to compare PONV among patients based on MEQ dosage and antiemetic prophylaxis regimes. RESULTS: A total of 492 patients were included; mean age was 23.0 years (range: 13-60); 54.4% were female. The majority of patients received concurrent Le Fort I osteotomy, BSSO, and genioplasty (70.1%). During hospitalization, 59.4% of patients experienced nausea requiring antiemetic medications and 28.4% experienced emesis. Stepwise regression yielded Apfel scores (P = 0.003) and postoperative opioids (P = 0.013) as the strongest predictors of PONV. Post hoc analyses showed that undertreatment with prophylactic antiemetics (based on Apfel) predicted increased PONV (+12.9%, P = 0.020), and that lower postoperative MEQs (<28.0) predicted decreased PONV (-11.8%, P = 0.01). CONCLUSIONS: The study findings confirm the high incidence of PONV among orthognathic surgical patients and stratify previously reported PONV risk factors. More aggressive utilization of antiemetic medications and decreased dependence on opioid analgesia may decrease nausea/vomiting following orthognathic surgery.

Predictors for Prolonged Drain Use Following Autologous Breast Reconstruction.

BACKGROUND: Surgical drains are routinely used following autologous reconstruction, but are often cited as the leading cause of peri-operative discomfort. This study defined routine drain use duration and assessed the risk factors for prolonged breast and abdominal drain use during microvascular breast reconstruction, measures which have never previously been defined. METHODS: Patients who underwent an abdominal microvascular free flap were included. Demographics, comorbidities, and operation-related characteristics were retrospectively collected in a prospectively maintained database. Statistical analysis utilized chi-square independent t-test, and linear regression analyses. RESULTS: One hundred forty-nine patients comprising 233 breast flaps were included. Average breast and abdominal drain duration were 12.9 ± 3.9 and 17.7 ± 8.2 days, respectively. Prolonged breast and abdominal drain duration were defined as drain use beyond the 75th percentile at 14 and 19 days, respectively. Multivariable regression revealed hypertension was associated with an increased breast drain duration by 1.4 days (p = 0.024), axillary dissection with 1.7 days (p = 0.026), African-American race with 3.1 days (p < 0.001), Hispanic race with 1.6 days (p = 0.029), return to the OR with 3.2 days (p = 0.004), and each point increase in BMI with 0.1 days (p = 0.028). For abdominal drains, each point increase in BMI was associated with an increased abdominal drain duration by 0.3 days (p = 0.011), infection with 14.4 days (p < 0.001), and return to the OR with 5.7 days (p = 0.007). CONCLUSION: Elevated BMI, hypertension, and axillary dissection increase risk for prolonged breast drain requirement in autologous reconstruction. African-American and Hispanic populations experience prolonged breast drain requirement after controlling for other factors, warranting further study.

Survey of Bacterial Phylogenetic Diversity During the Glacier Melting Season in an Arctic Fjord.

To understand bacterial biogeography in response to the hydrographic impact of climate change derived from the Arctic glacier melting, we surveyed bacterial diversity and community composition using bacterial 16S rRNA gene metabarcoding in the seawaters of Kongsfjorden, Svalbard, during summer 2016. In the present study, bacterial biogeography in the Kongsfjorden seawaters showed distinct habitat patterns according to water mass classification and habitat transition between Atlantic and fjord surface waters. Moreover, we estimated phylogenetic diversity of bacterial communities using the net relatedness, nearest taxon, and beta nearest taxon indices. We found the influence of freshwater input from glacier melting in shaping bacterial assemblage composition through the stochastic model. We further evaluated bacterial contributions to phytoplankton-derived dimethylsulfoniopropionate (DMSP) using a quantitative PCR (qPCR) measurement with demethylation (dmdA) and cleavage (dddP) genes of two fundamentally different processes. Our qPCR results imply that bacterial DMSP degradation follows the Atlantic inflow during summer in Kongsfjorden. These findings suggest that the Atlantic inflow and glacial melting influence bacterial community composition and assembly processes and thus affect the degradation of phytoplankton-derived organic matter in an Arctic fjord.

Racial Disparities in Complications, Length of Stay, and Costs Among Patients Receiving Orthognathic Surgery in the United States.

INTRODUCTION: Black and Hispanic/Latino patients in the United States often experience poorer health outcomes in comparison to White patients. We aimed to assess the impact of race on complications, length of stay, and costs after orthognathic surgery. METHODS: Pediatric and young adult orthognathic surgeries (age <21) were isolated from the Kids Inpatient Database from 2000-2012. Procedures were grouped into cohorts based on the preoperative diagnosis: apnea, malocclusion, or congenital anomaly. T tests and χ2 analyses were employed to compare complications, length of stay (LOS), and costs among Black, Hispanic, Asian/Pacific Islander, and other patients in comparison to White patients. Multivariable regression was performed to identify associations between sociodemographic variables and the primary outcomes. Post-hoc χ2 analyses were performed to compare proportions of patients of a given race/ethnicity across the 3 surgical cohorts. RESULTS: There were 8,809 patients identified in the KID database (mean age of 16.3 years). Compared to White patients, complication rates were increased among Hispanic patients (2.1 vs 1.3%, P = .037) and other patients treated for apnea (8.7 vs 0.83%, P = .002). Hospital LOS was increased in both Black (3.3 vs 2.1 days, P < .001) and Hispanic (2.9 days, P < .001) patients. Costs were higher than Whites ($35,633.47) among Hispanic ($48,029.15, P < .001), Black ($47,034.41, P < .001), and Asian/Pacific-Islander ($44,192.49, P < .001) patients. White patients comprised a larger proportion of the malocclusion group (77.8%) than apnea (66.9%, P < .001) or congenital anomaly (59.1%, P < .001), while the opposite was true for Black, Hispanic, and Asian/Pacific-Islander patients. CONCLUSION: There are significant differences in complications, LOS, and costs after orthognathic surgery among patients of different race/ethnicity. Further studies are needed to better understand the causes of disparity and their clinical manifestations.

Morphological Basis for Airway Surgical Intervention in Apert Syndrome.

OBJECTIVE: Previous studies have explored the restricted nasopharyngeal airway in Apert syndrome patients. This study aims to investigate the segmented airway volume changes with age and directly analyze their correlations with subcranial dimensions and angulations. METHODS: Ninety-seven preoperative computed tomography scans (Apert, n = 44; control, n = 53) were included in this study, and divided into 5 age-related subgroups. Computed tomography scans were measured using Mimics and 3-matics software. RESULTS: Before 6 months of age, the nasal cavity in Apert syndrome is reduced by 47% (P = 0.002), which gradually approximates normal thereafter; however, there remained a 30% reduction, compared with controls. It is highly correlated with the anteroposterior length of subcranial space, and the position of maxilla and palate. The pharyngeal airway volume in Apert syndrome patients, younger than 6 months, was larger than normal by 129% (P = 0.013). However, between 2 and 6 years of age, the pharyngeal airway becomes smaller than normal, with a 57% (P = 0.010) reduction in childhood and 52% (P = 0.005) in adolescence. It is closely correlated with the intercondylar and intergonial widths. CONCLUSIONS: Airway compromise in Apert syndrome patients is attributable more to the nasal cavity in infants, but in the older child, it is the pharyngeal region. The restricted nasal airway in Apert syndrome is correlated with the subcranial space length and width, but independent of cranial base flexion. The pharyngeal airway volume in Apert syndrome is not as highly correlated with craniofacial morphology. Rather, it is impacted by the growth of mandible, which often requires surgical intervention later in childhood.

Neurological Functional Connectivity in Unilateral Coronal Synostosis: A Side-Based Comparison.

PURPOSE: Unicoronal synostosis (UCS) has been associated with reading, language, and social dysfunction. Limited brain function connectivity studies exist for UCS with none devoted to comparing outcomes by side of synostosis (left versus right-sided UCS). METHODS: Twelve patients with surgically treated UCS, 7 right-sided and 5 left-sided, were age matched to healthy controls. Resting state functional MRI was acquired in a 3T Siemens TIM Trio scanner (Erlangen, Germany). Data was collected with intrinsic connectivity distribution and seed-connectivity analysis using BioImage Suite (Yale School of Medicine). Region of interest analysis was performed based on Brodmann areas related to emotional, executive, language, motor, and visuo-spatial function. Significance was set at P < 0.05. RESULTS: Compared to controls, all UCS patients demonstrated decreased connectivity in areas of the parietal and temporal cortices responsible for visuo-motor coordination and language function. Right UCS patients demonstrated decreased intrinsic connectivity in regions related to complex motor movement and proprioception relative to control subjects. Left UCS patients demonstrated decreased seed connectivity between regions of the parietal lobe and occipital lobe related to motor coordination, visual function, and language compared to right UCS patients. CONCLUSION: Unicoronal synostosis had decreased functional connectivity in regions associated with memory, visual information processing, and motor function. Moreover, left-sided UCS had decreased connectivity in circuits for motor coordination and language when compared to right-sided UCS. This study provides data suggestive of long-term sequelae of UCS that varies by sidedness, which may be responsible for neurocognitive impairments found in previous cognitive analyses.

Does Surgical Specialty Impact Mandibular Fracture Outcomes?

PURPOSE: Maxillofacial trauma is treated by two medical specialties, plastic surgery (PRS) and otolaryngology (ENT). Differences in training exposure and practice patterns exist between specialties, but their respective outcomes have never been compared. METHODS: Mandible fracture data were reviewed from the National Surgical Quality Improvement Program from 2005 to 2016. Demographics variables, repair types, and adverse outcomes were compared between PRS and ENT. RESULTS: From 2005 to 2016, one thousand two hundred eighty-two cases were identified with 756 cases managed by ENT and 526 cases managed by PRS. Mean patient age was 34.6 years for both specialties (P = 0.95). Patient demographics between both cohorts were not statistically different except for higher rates of hypertension among ENT patients (10.2% for ENT versus 6.7% for PRS, P = 0.027) and higher rates of smoking history among PRS patients (46.8% versus 52.3%, P = 0.055). Mean operative time (131.3 versus 124.0 min, P = 0.090) had a trend toward being longer for ENT and mean length of stay (1.3 versus 2.0, P = 0.002) was significantly longer for PRS. Despite a greater proportion of high ASA class patients in the ENT group (P = 0.012) and patients with dirty/infected wounds in the PRS group (P = 0.013), there were no significant differences in 30-day readmission rates, 30-day reoperation rates, or wound infection rates. CONCLUSIONS: No significant differences in 30-day readmission rates, reoperation rates, or wound infection rates for mandible fracture management exist between specialties. Despite differences in training between PRS and ENT, both specialties have comparable perioperative outcomes for mandible fracture management.

Zygoma Fractures Are Associated With Increased Morbidity and Mortality in the Pediatric Population.

BACKGROUND: Trauma involving the facial bones has been shown to be associated with high severity in previous studies. Characteristics of facial fractures in adults have been well described in the adult population, less so in the pediatric literature. Our investigation aims to define these epidemiological measures and risk factors for poor outcomes using the most recent data. METHODS: The 2016 Trauma Quality Improvement Program data bank was examined to study facial fracture pattern, mechanism of injury, and demographic descriptive data to characterize pediatric trauma patients. Multivariable regression analysis was performed to assess risk factors for morbidity and mortality in pediatric facial fracture patients. RESULTS: Of 51,168 total pediatric trauma patients, 2917 (5.7%) presented with facial fractures. Motor vehicle trauma was the most common mechanism of injury. Maxillary/malar fractures was the most common fracture type overall. Mandibular fractures were most common in the 0 to 1 age category while nasal bone fractures were more common in older patients. Patients with mandible fractures experienced the highest rate of operative management. Zygoma fracture was highly associated with concomitant traumatic brain injury. Multivariable regression analysis showed that fracture of the zygoma, concomitant traumatic brain injury, and cervical spine injury were risk factors for increased mortality. CONCLUSION: Facial fractures are a rare but significant form of trauma in the pediatric population. Our data suggests a slight change in fracture patterns compared to previous studies. Zygoma fractures, traumatic brain injury, and cervical spine injury are risk factors of increased mortality that clinicians should be aware of.

Distinguishing Craniomorphometric Characteristics of Unilateral Lambdoid Craniosynostosis.

BACKGROUND: Unilateral lambdoid synostosis (ULS) represents the rarest form of single suture nonsyndromic craniosynostosis. Differentiating between posterior deformational plagiocephaly (DP) and ULS has been difficult due to overlapping clinical findings. Past analyses have been limited by sample size. This study was undertaken to clarify anatomical features of ULS. METHODS: A multiinstitution study was undertaken, analyzing CT imaging from patients with documented ULS to determine clinical and pathological characteristics. Similar analyses were performed on DP patients to differentiate the 2 conditions. RESULTS: Twenty-seven ULS patient scans and 10 DP scans were included. For ULS patients mean age was 6.6 months, majority male (75%), and majority left-sided ULS (71%). The synostosed side ear was anteriorly displaced in 100% of ULS patients, mean difference of 9.6° (P < 0.001), and inferiorly in 96.3% of patients, mean difference of 4.4 mm, relative to the nonsynostosed side. The posterior fossa deflection (PFD) was deviated 5.9° toward the synostosed side relative to the anterior midline. In DP, there was no significant difference between sides in EAC measurements. The PFD and EAC displacements were significantly smaller in DP relative to ULS (P < 0.001 for each). An ipsilateral mastoid bulge was found in 100% of ULS and 0% of DP on CT imaging. CONCLUSION: Contrary to some previously published findings, the ear is more anteriorly displaced ipsilateral to the fused lambdoid suture in 100% of ULS patients. Ear position alone is not a reliable indicator to differentiate between DP and ULS. A mastoid bulge is a more reliable indicator of ULS.

Cephalocranial Disproportionate Fossa Volume and Normal Skull Base Angle in Pfeiffer Syndrome.

BACKGROUND: Pfeiffer syndrome is a rare syndromic craniosynostosis disorder, with a wide range of clinical manifestations. This study aims to investigate the structural abnormalities of cranial fossa and skull base development in Pfeiffer patients, to provide an anatomic basis for surgical interventions. METHOD: Thirty preoperative CT scans of Pfeiffer syndrome patients were compared to 35 normal controls. Subgroup comparisons, related to differing suture synostosis, were performed. RESULTS: Overall, the volume of anterior and middle cranial fossae in Pfeiffer patients were increased by 31% (P < 0.001) and 19% (P = 0.004), versus controls. Volume of the posterior fossa in Pfeiffer patients was reduced by 14% (P = 0.026). When only associated with bicoronal synostosis, Pfeiffer syndrome patients developed enlarged anterior (68%, P = 0.001) and middle (40%, P = 0.031) fossae. However, sagittal synostosis cases only developed an enlarged anterior fossa (47%, P < 0.001). The patients with solely bilateral squamosal synostosis, developed simultaneous reduced anterior, middle and posterior cranial fossae volume (all P ≤ 0.002). The overall skull base angulation, measured on both intracranial and subcranial surfaces, grew normally. CONCLUSION: Enlarged anterior cranial fossae in Pfeiffer syndrome children is evident, except for the squamosal synostosis cases which developed reduced volume in all fossae. Volume of the middle cranial fossa is influenced by associated cranial vault suture synostosis, specifically, sagittal synostosis cases develop normal middle fossa volume, while the bicoronal cases develop increased middle fossa volume. Posterior cranial fossa development is restricted by shortened posterior cranial base length. Surgical intervention in Pfeiffer syndrome patients optimally should be indexed to different suture synostosis.

Decreasing Inpatient Opioid Use Following Orthognathic Surgery.

PURPOSE: Strategies to decrease postoperative opioid use are important for mitigating the immediate and long-term risks associated with their use. We aimed to investigate the impact of perioperative various factors on inpatient opioid needs for patients undergoing orthognathic surgery. METHODS: This was a retrospective cohort study of all patients who underwent orthognathic surgery performed by the senior author from 2012 to 2018. Patients were grouped into intravenous (IV) acetaminophen and no-IV acetaminophen cohorts. Opioid medications received by patients during hospital stay were converted to mean morphine equivalents (MME) for comparison. Additional factors that influenced opioid consumption, such as transexamic acid (TXA) and postoperative nausea and vomiting (PONV), were identified using univariate analysis. Factors found to have statistical significance were added to a multivariate linear regression model. RESULTS: 319 patients were included. Those who received IV acetaminophen had lower rates of total opioid use (57.3 versus 74.8 MME; P = 0.002) and postoperative opioid use (24.0 versus 37.7 MME; P < 0.001). Perioperative prothrombotic agents, such as TXA, were associated with lower total and postoperative MME (P = 0.005, P = 0.002). Multivariate regression analysis showed that increased PONV resulted in increased postoperative opioid use, whereas perioperative acetaminophen lowered total and postoperative quantities. CONCLUSIONS: Perioperative IV acetaminophen is an effective method for decreasing inpatient opioid analgesia after orthognathic surgery. Intravenous TXA and PONV control may provide additional benefit to decreasing inpatient opioid consumption. More research as to the mechanisms and ideal clinical applications for both IV acetaminophen and TXA are warranted.

Sphenoid Bone Structure and Its Influence on the Cranium in Syndromic Versus Nonsyndromic Craniosynostosis.

BACKGROUND: Little is known about the detailed growth of the sphenoidal and temporal bones, even though they contribute significantly to the cranial base and cranial fossa skeletons. They also serve to connect the cranial vault with facial structure. This study details their morphologic development in isolated bicoronal synostosis and associated syndromes. METHODS: Eighty-one CT scans were included (nonsyndromic bicoronal synostosis, n = 28; Apert syndrome associated with bicoronal synostosis, n = 19; Crouzon syndrome associated with bicoronal synostosis, n = 8; and controls, n = 26), and measured using Materialize software. RESULTS: Sphenoidal and temporal bone volumes in nonsyndromic bicoronal synostosis are reduced 23% (P = 0.005) and 24%(P = 0.003) at 6 months of age, compared to controls. Apert and Crouzon syndrome patients developed similar reduced volumes. The greater wing of the sphenoid and pterygoid processes in nonsyndromic bicoronal synostosis are initially inferiorly rotated at 2 months of age, by 9.60° (P = 0.002) and 4.33° (P = 0.023), respectively. In Apert syndrome, these rotations were reduced by 4.82° (P = 0.003) and 12.60° (P < 0.001), (like Crouzon syndrome). However, in Apert syndrome, the length of pterygoid processes is shortened by 11% (P = 0.018) compared to nonsyndromic bicoronal synostosis. Crouzon syndrome skulls did not develop a statistically significant shortening relative to nonsyndromic bicoronal synostosis. Mediolateral expansion of the sphenoid in nonsyndromic bicoronal synostosis was less than normal (P = 0.023), and it was further reduced in syndromic skulls. CONCLUSION: Isolated bicoronal synostosis tends to reduce the volume of sphenoidal and temporal bones, and inferior and posterior rotation of the entire sphenoid. Syndromic conditions restrict sphenoidal rotation, and limit the expansion of sphenoidal greater wing and pterygoid plate.

Crushed Cartilage and Autologous Fat for Dorsal Nasal Refinement.

BACKGROUND: Dorsal contour irregularities remain a potential undesirable sequela of rhinoplasty. Use of dorsal onlay grafts can camouflage such irregularities. In this article, a novel technique for dorsal onlay grafting utilizing crushed cartilage mixed with autologous fat is described. This study aims to assess long-term graft retention and aesthetic outcomes with this technique. METHODS: Patients with >18-month follow-up who underwent primary open rhinoplasty with the described technique were reviewed. Three-dimensional photographs taken at multiple timepoints were overlaid with volumetric subtraction used to quantify graft retention. The Rhinoplasty module of the FACE-Q was completed by each patient, and the Rhinoplasty Assessment Scale Photographic (RASP) was completed by surgeon reviewers. Pre- and postoperative changes in dorsal height as well as RASP scores were compared with paired t-tests. Changes in BMI, dorsal volume, and dorsal height were compared with linear regression. P values <0.05 were considered significant. RESULTS: Fourteen patients were included, mean age 32. Mean intermediate and final follow-up was 17.8 months and 28.9 months, respectively. There were no statistically significant dorsal height change (mean = 0.0 mm, p = 0.91) and minimal dorsal volume change (mean = 0.02 cm3, range:  0.08 to 0.13). Patients reported a high degree of satisfaction with facial/nasal appearance and psychological/social functioning. There was a statistically significant improvement in RASP scores (p < 0.001) postoperatively. CONCLUSION: Crushed septal cartilage mixed with autologous fat is an effective option for dorsal nasal onlay in rhinoplasty and is associated with excellent graft retention, patient satisfaction, and nasal aesthetics. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Management of recurrent bilateral multifocal pseudoangiomatous stromal hyperplasia (PASH).

Pseudoangiomatous stromal hyperplasia (PASH) is a benign hyperplastic condition of the breast that can lead to macromastia. The standard treatment for PASH is focal excision or rarely reduction mammoplasty. We present a rare case of postpartum bilateral rapid breast enlargement and axillary growth that was refractory to reduction mammoplasty. Ultimately, the patient required bilateral mastectomy and two-stage implant-based breast reconstruction. This more extensive form along with its management represents one of the few reported cases in the literature. The decision to pursue bilateral mastectomy was undertaken after exhausting more conservative options. Excellent aesthetic outcome and pain relief was obtained following definitive extirpative and reconstructive surgery.