Expanding Accessibility in Cleft Care: The Role of Artificial Intelligence in Improving Literacy of Alveolar Bone Grafting Information.

OBJECTIVE: The American Medical Association (AMA) recommends patient education materials (PEMs) be written at or below a sixth grade reading level. This study seeks to determine the quality, readability, and content of available alveolar bone grafting (ABG) PEMs and determine if artificial intelligence can improve PEM readability. DESIGN: Review of free online PEMs. SETTING: Online ABG PEMs were retrieved from different authoring body types (hospital/academic center, medical society, or private practice). PATIENTS, PARTICIPANTS: None. INTERVENTIONS: Content was assessed by screening PEMs for specific ABG-related topics. Quality was evaluated with the Patient Education Material Assessment Tool (PEMAT), which has measures of understandability and actionability. Open-access readability software (WebFX) determined readability with Flesch Reading Ease, Flesch-Kincaid Grade Level, and Gunning-Fog Index. PEMs were rewritten with ChatGPT, and readability metrics were reassessed. MAIN OUTCOME MEASURE(S): Quality, readability, and content of ABG PEMs. RESULTS: 34 PEMs were analyzed. Regarding quality, the average PEMAT-understandability score was 67.0 ± 16.2%, almost at the minimum acceptable score of 70.0% (p = 0.281). The average PEMAT-actionability score was low at 33.0 ± 24.1%. Regarding readability, the average Flesch Reading Ease score was 64.6 ± 12.8, categorized as "standard/plain English." The average Flesch-Kincaid Grade Level was 8.0 ± 2.3, significantly higher than AMA recommendations (p < 0.0001). PEM rewriting with ChatGPT improved Flesch-Kincaid Grade Level to 6.1 ± 1.3 (p < 0.0001). CONCLUSIONS: Available ABG PEMs are above the recommended reading level, yet ChatGPT can improve PEM readability. Future studies should improve areas of ABG PEMs that are most lacking, such as actionability.

Postoperative Feeding in Cleft Surgery: A Systematic Review.

INTRODUCTION: Postoperative feeding is crucial for the recovery of children after cleft surgery. The literature outlines diverse feeding methods with varying recommendations on the duration of non-nipple feeding postsurgery. This study aims to explore reported postoperative feeding modalities for infants undergoing primary cleft lip/palate repair, concentrating on their influence on feeding improvement and complication reduction. METHODS: PubMed, Cochrane, and Web of Science databases were queried for original English articles without any date restrictions. This review was conducted in accordance with the 2020 PRISMA. The MINORS criteria was used to assess quality of studies. RESULTS: Of 696 abstracts, 9 full-text articles were included, consisting of 459 children with cleft lip (n = 221) & cleft lip/palate (n = 238). Feeding modalities included bottle, breastfeeding, spoon, syringe, and nasogastric tube. Two studies found a significant increase in weight with breastfeeding compared to spoon or cup. Two studies found partial wound dehiscence using spoons, and two studies reported dehiscence using bottles. Post-palatoplasty, two studies showed a decrease in hospital stay in infants breastfed (2.1 & 5.8 days) vs spoon-fed (6 days). Analgesia was reduced in the breastfed group vs spoon/nasogastric tube. CONCLUSION: This review highlights the importance of postoperative feeding in the recovery of infants with cleft lip/palate. Evidence suggests that breastfeeding may offer advantages in terms of weight gain and reduced hospital stay, while potentially minimizing the need for postoperative analgesia. The limited number of studies and variability in their outcomes underscore the need for further research to establish evidence-based guidelines for postoperative feeding.

Establishment and validation of a nomogram for predicting the risk of syncope after craniomaxillofacial surgery.

PURPOSE: To explore the influencing factors of syncope in patients after plastic surgery, establish a syncope risk prediction model, and verify its accuracy. METHODS: A total of 265 patients undergoing craniomaxillofacial surgery were included and divided into a syncope group and non-syncope group. Multivariate logistic regression analysis was used to screen for risk factors of syncope, and R language was used to establish a risk prediction nomogram of syncope in craniomaxillofacial surgery patients. The Hosmer-Lemeshow goodness-of-fit test was used to evaluate the fit of the model, and the receiver operating characteristic (ROC) curve was used to analyze the predictive value of the model. RESULTS: Syncope occurred in 87 of 265 patients (32.8%), and no syncope occurred in 178 patients (67.8%). Multivariate logistic regression analysis revealed statistical differences in age, orthostatic heart rate, orthostatic diastolic blood pressure, syncope history, weight loss history, and medication history between the 2 groups (P < 0.05). A nomogram was constructed for predicting the risk of syncope after craniomaxillofacial surgery, and the Hosmer-Lemeshow goodness-of-fit test proved that the nomogram fitted well (P = 0.431). The results of ROC curve analysis showed that the alignment graph model had high prediction accuracy; the area under the curve was 0.886 (95% confidence interval, 0.8381-0.9332). CONCLUSION: Evaluating the risk of syncope after craniomaxillofacial surgery is helpful and provides guidance for the formulation of preventive strategies.

Rare craniofacial clefts: Surgical management protocols.

BACKGROUND: Standardization of surgical protocols is an evolving issue owing to the low incidence of rare craniofacial clefts. In this article, we present our surgical management technique for repair of rare craniofacial clefts and evaluate the postoperative results. METHODS: This study was conducted from 2013 to 2022 and included patients who presented with craniofacial clefts. The results were assessed based on parents' satisfaction and objective evaluations by two independent observers. RESULTS: A total of 3679 patients presented with cleft anomalies; of these, 61 patients with 89 rare craniofacial clefts were observed with a prevalence of 2.42/100. The male to female ratio was 1:1.35. Craniofacial cleft "4" and "5" were the most common, with 17 (19.1%) and 16 (17.98%) patients, respectively. Multiple craniofacial clefts were observed in 37.7% of the patients. Associated craniofacial anomalies were found in 39.34% of the patients. The parents of 71.6% of the patients were very satisfied with the results. Based on the scores of two independent observers, 70.27% of the patients showed good results. CONCLUSION: The rare nature of craniofacial clefts and involvement of various structures make the standardization of surgical procedures very challenging. Our experience with these clefts will help new surgeons both in didactics and in technical aspects of patient management. KEY POINTS: 1. We share our experience with rare craniofacial clefts. 2. Each cleft presents with its own unique reconstructive challenges. The literature describes many techniques for each type of cleft, all with multiple permutations. We present a simplified technique that has worked for us over the years for all Tessier clefts.

Using the SCAR-Q to Evaluate Morbidity of Scars in Craniosynostosis Repair.

OBJECTIVE: While previous literature has investigated the psychosocial impact and aesthetic satisfaction associated with post-operative scarring for certain pediatric craniofacial conditions, the impact of the scar burden resulting from craniosynostosis surgery has not been adequately studied. PARTICIPANTS: SCAR-Q was shared with patients ages 8 and older. Thirty-two complete patient responses were recorded. INTERVENTIONS: SCAR-Q is a PROM that consists of three independent scales - appearance, symptoms, and psychosocial impact - associated with a scar. MAIN OUTCOME MEASURES: Mann-Whitney U, linear regression, and Pearson correlation tests were used to evaluate associations between the scales, in addition to patient characteristics such as sex and suture involvement. RESULTS: Mean ages at time of surgery and survey completion were 9.65 ± 10.10 months and 12.10 ± 3.92 years, respectively. Mean scale scores were 81.5 ± 17.9 for appearance, 86.8 ± 12.4 for symptoms, and 79.3 ± 25.7 for psychosocial impact. Higher patient dissatisfaction with scar appearance correlated with more scar-related symptoms (r = 0.389; p = 0.028) and a greater psychosocial impact (r = 0.725; p < 0.001). SCAR-Q scales did not significantly correlate with age at surgery, age at survey completion, type of synostosis, or type of surgery; however, female patients reported lower mean appearance (65.4 vs. 86.0; p = 0.012) and psychosocial impact (57.3 vs. 85.5; p = 0.010) scores when compared to their male counterparts. CONCLUSIONS: It is vital that surgeons discuss patients' aesthetic satisfaction following craniosynostosis surgery in order to appropriately address and limit deleterious, long-term physical and psychosocial outcomes.

Morphological description of the temporomandibular joint ligaments in domestic pigs.

The temporomandibular joint (TMJ) ligaments play crucial roles in its function or dysfunction. The objective of this study was to describe the macro and microscopic morphology of these ligaments in domestic pigs, aiming to: (1) expand knowledge about the species; (2) provide anatomical references for advancing veterinary therapy and utilizing pigs as animal models in craniofacial research. Heads of young Sus scrofa domesticus were dissected to identify TMJ ligaments. Fragments of these ligaments were collected and processed for subsequent histological analysis with Haematoxylin and eosin staining. The results were qualitatively described. Pigs exhibited a TMJ reinforced by three individualized capsular ligaments: a lateral ligament, attaching to the ventral margin of the zygomatic process of the temporal bone and the lateral margin of the mandibular neck; a caudomedial ligament, attaching to the retroarticular process of the squamous part of the temporal bone and the caudomedial margin of the mandibular neck and a caudolateral ligament, attaching to the ventral margin of the base of the zygomatic process of the temporal bone and the caudal margin of the mandibular neck. The lateral ligament exhibited a greater constitution of dense irregular connective tissue, while the caudomedial and caudolateral ligaments showed a greater constitution of dense regular connective tissue. It is concluded that the TMJ of pigs presents one more ligament than horses, cattle, dogs, cats and what has been described for pigs themselves. We believe these results may contribute to the improvement of veterinary clinical and surgical therapy overall, as well as provide essential morphological information for a better interpretation and application of interspecies results in craniofacial research using pigs as an experimental model, as in the case of humans.

Optic nerve elongation during fronto-facial surgery for Crouzon syndrome: 3D quantification and clinical implications.

OBJECTIVE: Fronto-facial monobloc advancement with internal distraction (FFMBA) is a key procedure in the management of syndromic craniosynostoses. FFMBA involves circumferential dissection and linear enlargement of the orbit, potentially leading to mechanical stress on the optic nerve (ON). Several reports of transient vision loss during the distraction process led us to investigate ON shape modifications during facial advancement, with the aim to potentially refine current clinical guidelines on postoperative management and the distraction schedule. METHODS: Twenty-six patients with Crouzon syndrome were included in this study. ONs were segmented on pre- and postoperative CT scans. Distraction amplitudes, linear and curved lengths, and cross-section diameters of the ON were assessed along the main axis of the nerve. A two-level hierarchical multivariate linear model was used to screen for factors associated with ON morphology. RESULTS: The mean age at FFMBA was 4.4 ± 3.8 years. Two patients presented with transient impaired vision during distraction. The final mean fronto-orbital and temporo-zygomatic distraction amplitudes were 18 ± 4 mm and 18 ± 6 mm, respectively. At the end of distraction, ONs were elongated (+1.8 mm for curved lengths, p = 0.013), and their mean cross-section was reduced (-1.9 mm2, p < 0.001) in the proximal intraorbital portion (first 15 mm). In the 2 patients with visual symptoms, functional impairment was associated with ON area reduction (OR 0.487, p < 0.001) and increased temporo-zygomatic distraction amplitude (OR 2.240, p < 0.001). CONCLUSIONS: ON was elongated during FFMBA, with proximal diameter reduction. Transient visual impairment with normal fundus examination during distraction seemed to have a morphological basis, based on 2 cases. These results suggest the importance of vision monitoring associated with fundus examination during distraction, and advocate for early extubation after FFMBA to allow clinical follow-up.

Practical Considerations in Computerized Surgical Planning for Frontofacial Surgery.

The field of frontofacial surgery has advanced considerably, building on the pioneering techniques of Paul Tessier, with computerized surgical planning (CSP) emerging as a critical component. CSP has enhanced the precision and efficiency of surgeries for craniofacial dysostoses and hypertelorism, resulting in improved outcomes. This review delves into the importance of understanding orbital anatomy and the crucial bony and soft tissue landmarks essential to the application of CSP in frontofacial procedures, encompassing Le Fort III and monobloc advancements, as well as the correction of hypertelorism.

Publication Trends and Surgeon Perceptions: A Comprehensive Analysis of Gender Disparities in Craniofacial Surgery.

In academic craniofacial surgery, gender disparities exist across various metrics including faculty positions, leadership roles, and conference representation. This study benchmarks the academic productivity of craniofacial surgeons in 2022 and surveys their perspectives regarding diversity, equity, and inclusion (DEI).Total, first author, and senior author PubMed publications in 2022 were recorded for 193 craniofacial attendings and fellows. Craniofacial surgeons were also surveyed regarding academic experience, leadership roles, and DEI perceptions.Electronic.26 craniofacial attendings.Total, first author, and senior author publication counts in 2022.Women comprised 27% (n = 53) of the craniofacial surgeon cohort. Men led total publications (81% vs 19%, p < 0.001), senior-author publications (84% vs 16%, p < 0.001), average total publications (6.6 vs 4.0, p = 0.043), and average senior-author publications (3.1 vs 1.5, p = 0.02). Sub-analysis of craniofacial fellows showed a higher proportion of women (65%) with no statistical difference in total or average publication counts. Survey responses (n = 26) included a perceived lack of female representation in academic and leadership roles. Barriers included inadequate support from current leadership, systemic issues, and biases. Recommendations for improvement included mentorship programs, targeted recruitment, and equitable conference speaker selection.Ongoing gender disparities are evident in craniofacial surgery, particularly in academic metrics. However, trends in younger cohorts exhibit more balanced gender representation, publication records, and leadership positions, indicating potential improvements. Further studies are needed to examine these cohorts more comprehensively and longitudinally. Sustained commitment, including mentorship programs and enhanced DEI efforts, is needed to continue this progress.

Cleft Lip Repair Comparison Between Inpatient and Outpatient Surgeries: A Multi-Surgeon Experience.

OBJECTIVE: Great variability exists as to whether cleft lip (CL) repair is performed as an inpatient or outpatient surgery. This study's aim is to investigate the authors' institutional experience to see if there is an increase in complications, emergency department (ED) visits, or readmissions to the hospital when performed as outpatient. DESIGN: This study reviewed patients who underwent CL repair between 2012 and 2023 at the authors' institution. Data collected included patient demographics, perioperative details, ED visits and readmissions within thirty days of surgery, and complications. RESULTS: One hundred forty-five patients met inclusion measures. When the surgery was performed as outpatient, there was no significant difference in returning to the ED (p = 0.767) or readmission to the hospital (p = 0.447) within thirty days as compared to inpatient surgeries. Outpatients did not have more postoperative complications (p = 0.698). Bilateral cleft lips were more likely to be performed as inpatient (p = 0.001). Inpatients had a lower weight at time of repair (p = 0.033). Patients with a respiratory (p = .006), gastrointestinal (p = 0.003), or hematologic (p = 0.013) comorbidity had a higher readmission rate. Patients were more likely to be readmitted if they had a younger gestational age (p = 0.005). CONCLUSION: There was no increased return to the ED or readmission for patients undergoing inpatient versus outpatient CL repair. CL repair can be performed safely in an outpatient setting with careful patient selection.

Quantitative analysis of surgical landmarks of the face in fixed cadaveric heads: clinical and anatomical implications.

PURPOSE: This study aimed to examine and analyze the presence of sexual dimorphism and symmetry/asymmetry in fixed cadaveric heads and their contributions to clinical practice. METHODS: Measurements were conducted on 6 cadavers and 24 fixed cadaveric heads (n = 30) using a digital microcaliper to assess cranial dimensions, including surgical landmarks, facial index (FI), orbital index (OI), and the danger triangle of the face, offering crucial references for surgeons during surgical interventions. RESULTS: Analyses were conducted on cadavers consisting of 10 females (33.3%) and 20 males (66.7%). Males demonstrated significantly higher values than females in terms of Zy-Zy (Zy = Zygion), nasal body, and width/length of the columella. Hyperleptoprosop types were the most frequently observed, followed by the leptoprosop type. Females exhibited megaseme characteristics according to OI on both sides. Additionally, the danger triangle of the face was greater in males compared than in females, suggesting a higher risk of infection in this region among males. CONCLUSION: The observed sex differences in facial and nasal dimensions, along with facial indices, are crucial for customizing surgical procedures to individual patients. For example, the greater distance in the danger triangle among males highlights the importance of considering anatomical variations to avoid complications, such as septic cavernous sinus thrombosis. Integrating these measurements into preoperative planning can enhance the precision of facial reconstruction and aesthetic surgeries, thereby improving patient outcomes and safety.

The Effect of Barrel-Stave Osteotomy Length in Sagittal Strip Craniectomy.

OBJECTIVE: In managing sagittal craniosynostosis, strip craniectomy of the affected suture is commonly paired with barrel-stave osteotomies to allow for additional cranial remodeling. However, the effect of these osteotomies is not well-established. This study aimed to evaluate the effect of the length of barrel-stave osteotomies on outcomes in patients with sagittal craniosynostosis. DESIGN: A retrospective review of operative records and pre-operative and one-year post-operative three-dimensional images. SETTING: Tertiary care pediatric institution. PATIENTS: Forty-five patients with sagittal craniosynostosis. INTERVENTIONS: Sagittal strip craniectomy and either long, medium, or short barrel-stave osteotomy lengths followed by helmet therapy. MAIN OUTCOME MEASURES: Operative and three-dimensional craniometric outcomes. RESULTS: Operative time, estimated blood loss, and hospital length of stay were significantly decreased in the short group (P = .003; 0.002; 0.027). The cranial index was normalized in all groups, but the long group was significantly lower (P = .007; 0.025). Head circumference was similar between groups. All indexes were within the normal percentiles in all groups. The medium group had a significantly decreased scaphocephalic index (P = .031; .035). The short group had significantly greater occipital bulleting than the medium group (P = .001). The long group had significantly greater narrowing than the short group (P = .036). CONCLUSIONS: Strip craniectomy with the addition of long, medium, or short barrel staves all resulted in clinically successful outcomes. Our findings suggest that increased barrel-stave osteotomy length may not be necessary for a successful outcome while avoiding more extensive dissection, potential risk, increased operative time, and hospital length of stay.

Impact of COVID-19 Pandemic on Cleft Lip/Palate Surgery in Brazil: Assessing the Current Landscape.

OBJECTIVE: This study aims to evaluate the impact of COVID-19 and the current situation for cleft lip/palate treatment surgeries within Brazil's public health system. DESIGN: Our retrospective study analyzed CL/P corrective surgeries in Brazil's health system using DATASUS TabNet data from March 2020 to December 2022, with historical data from January 2016 to February 2020. We employed ARIMA analysis to estimate pandemic-related surgery cancellations. RESULTS: In 2020, 1992 (CI 95%: 989-2995) CL/P surgeries were not conducted due to pandemics, a 44.1% (CI 95%: 28.1-54.2%) decrease compared to expectations for march to December 2020. Between the onset of the pandemic in Brazil and the end of 2022, 10,643 surgeries were performed in the country, representing a 33.8% shortfall compared to the expected number for the period (16,076; 95% CI: 9697-22,456). CONCLUSION: The study highlights COVID-19's impact on CL/P surgeries in Brazil. Post-pandemic, surgeries increased but regional disparities remain, urging collaborative efforts to improve services and support affected patients.

[The MASK lift]. / Le MASK lift.

The MASK lift or subperiosteal lift of the upper and middle thirds of the face is a procedure that can be performed alone for aesthetic purposes, but can also be combined with reconstructive surgery of this region to improve the result. This procedure will enable the overall result to be enhanced in the management of complex pathologies. The aim of this article is to present the MASK lift surgical technique in detail, to explain its indications and to show that this surgical technique still has a place in our practice.

The Effect of Palatoplasty on Growth.

OBJECTIVES: To assess the effect of palatoplasty on growth velocity in undernourished and nourished orally fed children with cleft palate. METHODS: A retrospective chart review was conducted using a data query with cleft-associated ICD-10 and ICD-9 codes to identify children who underwent cleft palate repair between 2006 and 2022 at a tertiary pediatric hospital. Data gathered included demographics, admission variables, weight gain, and weight percentile as per the WHO growth chart data. Inclusion was limited to patients with complete growth data and without parenteral feeding support. Nutritional status was defined as undernourished (≤3rd percentile) and nourished (>3rd percentile). Between and within-group comparisons were made using nonparametric tests. RESULTS: A total of 192 patients met the study criteria. Among undernourished patients, the median pre- and postsurgical weekly weight gain was 0.09 kg and 0.05 kg (p = <0.0001), and the median growth percentiles were 0.67% and 1.1%, respectively (p = 0.03). Among nourished patients, the median pre- and postsurgical weekly weight gain was 0.12 kg and 0.07 kg (p = <0.0001), and the median growth percentiles were 25.4% and 29.5%, respectively (p = <0.0001). The postsurgical reduction in weight gain per week was similar across nutritional status (p = 0.43), however, the nourished group demonstrated a larger increase in median growth percentile (3.3% vs. 0.23%; p = 0.03). CONCLUSION: This study demonstrates that palatoplasty does not independently improve growth velocity in children who were able to maintain an oral preoperative diet. In the case of undernourished children, there was no clinically significant improvement in postoperative growth percentiles. LEVEL OF EVIDENCE: 3 Laryngoscope, 2024.

Metopic craniosynostosis: Dynamic cranioplasty for trigonocephaly versus fronto-orbital remodeling and advancement - A retrospective study.

The aim of this study was to compare a traditional fronto-orbital remodeling and advancement (FORA) with the dynamic cranioplasty for trigonocephaly (DCT). The authors analyzed patients who underwent surgery for trigonocephaly. Perioperative data were compared. Parents were asked to use a visual analog scale to evaluate the pre- and postoperative distance between the eyes, the forehead shape, and the global appearance of the face. A panel of observers was asked to grade pre- and postoperative photographs using a similar visual analog scale. Pre- and postoperative anthropometric data were collected and analyzed in a subset of the study population aged 9 years or older. The total sample size was 51 patients (DCT n = 39; FORA n = 12). Durations of surgery and anesthesia were shorter in the DCT group (115 vs 194 min, p = 0.001; 226 vs 289 min, p = 0.001). Patients in the DCT group received similar preoperative ratings to those in the FORA group, but significantly higher postoperative ratings by parents for all three questions. There were no significant differences in postoperative ratings by the panel or postoperative anthropometric data. DCT is safe and effective. It is preferred over FORA because it is associated with shorter durations of surgery and anesthesia, while providing higher degrees of parental satisfaction and similar aesthetic and anthropometric outcomes.

Implementation of an Enhanced Recovery After Surgery Protocol for Cranial Vault Remodeling Procedures.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols have been implemented across surgical disciplines, including cranial vault remodeling for craniosynostosis. The authors aim to describe the implementation of an ERAS protocol for cranial vault remodeling procedures performed for patients with craniosynostosis at a tertiary care hospital. DESCRIPTION: Institutional review board approval was received. All patients undergoing a cranial remodeling procedure for craniosynostosis at the authors' institution over a 10-year period were collected (n = 168). Patient and craniosynostosis demographics were collected as well as operative details. Primary outcome measures were intensive care unit length of stay (ICU LOS) and narcotic usage. Chi squared and independent t-tests were employed to determine significance. A significance value of 0.05 was utilized. RESULTS: During the time examined, there were 168 primary cranial vault remodeling procedures performed at the authors' institution - all of which were included in the analysis. Use of the ERAS protocol was associated with decreased initial 24-hour morphine equivalent usage (p < 0.01) and decreased total morphine equivalent usage (p < 0.01). Patients using the ERAS protocol experienced a shorter ICU LOS (p < 0.01), but the total hospital length of stay was unchanged. CONCLUSION: This study reiterates the benefit of developing and implementing an ERAS protocol for patients undergoing cranial vault remodeling procedures. The protocol resulted in an overall decreased ICU LOS and a decrease in narcotic use. This has implications for ways to maximize hospital reimbursement for these procedures, as well as potentially improve outcomes.

Distractor position and distraction amplitude in fronto-facial monobloc advancement : A case series.

Fronto-facial monobloc advancement with internal distraction (FFMBA) is a central procedure in the management of faciocraniosynostoses. In techniques with internal distraction, two sets of devices are generally positioned: bilateral fronto-orbital and temporo-zygomatic distractors, using a temporal tongue and groove osteotomy design. It is believed that distractors must be positioned as parallel as possible in the horizontal and sagittal planes to avoid mechanical conflicts between the sliding bone fragments of the tongue and groove during distraction, and thus optimize the advancement amplitude. Several approaches involving surgical planification and guides for distractor positioning have thus been proposed to monitor distractor placement. To explore the need for surgical planification in distractor placement, the parallelism of the position of the 4 distractors was assessed in 19 FFMBA procedures and we correlated a set of 10 distractor angles with the degree of advancement. We report that the horizontal cut of the tongue and groove can be used as a landmark for the positioning of the lower, temporo-zygomatic, distractor in fronto-facial monobloc advancement. Other parameters (relative position of the two homolateral and the two contralateral distractors and the orientations of the vertical and horizontal cuts of the tongue and groove) do not interfere with distraction, other things being equal. Our results indicate that distractor orientation is not a critical issue in fronto-facial monobloc advancement when devices are positioned as parallel as possible based on visual monitoring.

Maximizing Patient Satisfaction in Facial Feminizing Rhinoplasty.

Background: Although facial feminizing rhinoplasty can reduce gender dysphoria, there is limited evidence on approaches to maximize transgender patient satisfaction. In a retrospective cohort of transfeminine patients who underwent feminizing rhinoplasty, we compare pre- and postoperative nasal metrics and postoperative satisfaction. Methods: Records were retrospectively reviewed to identify transfeminine patients who had feminizing rhinoplasty and cisgender females who had aesthetic rhinoplasty at least 8 weeks post-rhinoplasty. Transgender patients were contacted to rate their aesthetic and functional rhinoplasty satisfaction. Patients with 75% or greater of the total survey score were "very satisfied," those between 50% and 75% were "satisfied," and those below 50% were "less satisfied." The Vectra 3D imaging software was utilized to measure each patient's pre- and post-rhinoplasty dorsal lengths; tip projection ratios; and nasolabial, nasofrontal, and nasofacial angles. Relative percent changes for each patient between pre- and post-rhinoplasty measurements were compared between transgender and cisgender females using descriptive statistics. Results: Twenty-five transgender patients met the inclusion criteria; 19 answered the survey with 12 very satisfied, 7 satisfied, and 0 less satisfied patients. The median age of surveyed patients was 35, and 42.1% identified as Hispanic. Between very satisfied and satisfied patients, median relative percent changes in dorsal length (-1.2% vs 5.7%, P = .043), tip projection ratio (2.4% vs 8.1%, P = .038), and nasolabial angle (-2.5% vs 9.7%, P = .026) significantly differed; median relative changes in nasofrontal angles (4.2% vs -0.6%, P = .071) and nasofacial angles (-0.7% vs -3.6%, P = .703) were insignificantly different. Satisfied transgender patients and cisgender patients (n = 5) had significant differences in median relative changes in dorsal length (5.7% vs 0.7%, P = .047), tip projection ratio (8.1% vs -3.5%, P = .033), and nasolabial angles (9.7% vs -5.4%, P = .042). Very satisfied transgender and cisgender females had no significant differences in relative metric changes. Conclusions: Very satisfied transgender patients had decreases in dorsal length, smaller increases in tip projection ratio, and decreases in the nasolabial angle compared with satisfied patients. These data can help focus feminizing rhinoplasty approaches to maximize satisfaction. Further, very satisfied transgender patients had similar changes as cisgender females, reaffirming the utility of applying cisgender female rhinoplasty considerations to feminizing rhinoplasty.

A Nationwide Analysis of the Impact of Cardiopulmonary Anomalies on Cleft Palate Surgical Outcomes.

OBJECTIVE: To increase awareness and improve perioperative care of patients with cleft palate (CP) and coexisting cardiopulmonary anomalies. DESIGN: Retrospective cohort. SETTING: Multi-center. PATIENTS/PARTICIPANTS: Patients who underwent surgical repair of CP between 2012-2020 identified in the American College of Surgeons National Surgical Quality Improvement Program Pediatric Data File. Chi-squared analysis and Student's t-test were implemented to make associations between congenital heart disease (CHD) and congenital pulmonary disease (CPD) and postoperative complications. Multiple logistic regression was performed to identify associations between CP and CHD/CPD while controlling for age, gender, and ASA class. C2 values were used to assess the logistic regressions, with a significance level of 0.05 indicating statistical significance. MAIN OUTCOMES MEASURES: Length of stay (LOS), perioperative complications (readmission, reoperation, reintubation, wound dehiscence, cerebrovascular accidents, and mortality). RESULTS: 9 96 181 patients were identified in the database, 17 786 of whom were determined to have CP, of whom 16.0% had congenital heart defects (CHD) and 13.2% had congenital pulmonary defects (CPD). Patients with CHD and CPD were at a significantly greater risk of increased LOS and all but one operative complication rate (wound dehiscence) relative to patients with CP without a history of CHD and CPD. CONCLUSION: This study suggests that congenital cardiopulmonary disease is associated with increased adverse outcomes in the setting of CP repair. Thus, heightened clinical suspicion for coexisting congenital anomalies in the presence of CP should prompt referring providers to perform a comprehensive and multidisciplinary evaluation to ensure cardiopulmonary optimization prior to surgical intervention.