Autologous Cranioplasty Using a Dental SafeScraper Device.

SUMMARY: Conventional methods to reconstruct cortical bone defects introduced by pediatric cranial vault remodeling (CVR) procedures have shortcomings. Use of bone burr shavings as graft material leads to variable ossification, and harvesting split-thickness cortical grafts is time-intensive and often not possible in thin infant calvaria. Since 2013, the authors' team has used the SafeScraper, originally developed as a dental instrument, to harvest cortical and cancellous bone grafts during CVR. The authors assessed the effectiveness of this technique by analyzing postoperative ossification using computed tomography scans of 52 patients, comparing cohorts treated with the SafeScraper versus those who received conventional methods of cranioplasty during fronto-orbital advancement. The SafeScraper cohort had a greater reduction in total surface area of all defects (-83.1% ± 14.9 versus -68.9% ± 29.8; P = 0.034), demonstrating a greater and more consistent degree of cranial defect ossification compared with conventional methods of cranioplasty, suggesting potential adaptability of this tool. This is the first study that describes the technique and efficacy of the SafeScraper in reducing cranial defects in CVR. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

How does CLEFT-Q change the way we practice? A prospective study integrating patient-reported outcomes.

OBJECTIVE: The CLEFT-Q is a validated instrument designed to elicit patient-reported outcomes among people affected by cleft lip and/or palate. However, it has not been reported how use of CLEFT-Q data alters routine cleft care. This study analyzed the impact of CLEFT-Q data integration on patient care and clinical decision making. METHODS: Patients were sequentially, prospectively evaluated during scheduled cleft team visits. The CLEFT-Q was completed prior to the clinic encounter but results were initially masked from the surgeon and family. In the encounter, a study observer characterized patients' verbalized attitudes across seven specific domains of appearance and function and the provisional assessment and plan was noted. CLEFT-Q data was then introduced in the clinical encounter and discussed. Discordance between patients' initially verbalized attitudes and their self-reported scores on the CLEFT-Q was documented along with any resultant modifications to their care plan. RESULTS: Seventy patient visits were observed; mean patient age was 12.7 years (range 8-19). Forty-one patients (59%) had cleft lip and palate/alveolus and 29 (41%) had isolated cleft palate. Discordance was observed in 36% of visits and in 9.2% of specific domains assessed. Highest discordance rates were observed in domains of psychosocial function (12.5%,) speech function/distress (11.6%,) and lips/lip scar appearance (11.6%). No age group or gender was associated with increased discordance. Integration of CLEFT-Q results altered the assessment and plan in 11 (16%) visits. CONCLUSIONS: The CLEFT-Q provides clinically-relevant insight into patient perspectives that are not captured by routine interview and examination alone, and regularly leads to a change in the management plan.

Integration of the Cleft-Q Patient Reported Outcome Tool into a Multidisciplinary Cleft and Craniofacial Clinic: A Proof of Concept.

SUMMARY: Implementation of patient reported outcome (PRO) tools has increased internationally in a variety of clinical settings, with emerging evidence suggesting benefits for patient satisfaction, improved patient-provider communication, and management of chronic conditions. However, integrating PROs into clinical workflow remains a barrier to implementation, with common challenges including patient completion, provider review of results, and future accessibility of data. Cleft lip and/or palate (CL/P) presents with a variety of aesthetic, functional, and psychosocial sequelae optimally managed by a multidisciplinary team, and Cleft-Q is a validated twelve-module PRO that captures patient perception in these domains. Given the emerging proven benefits of using PROs in a clinical setting, the authors integrated the Cleft-Q PRO at a multidisciplinary cleft and craniofacial clinic at a large, urban, tertiary care center. We collaborated with our institution's EHR Clinical Informatics Team to automatically identify eligible CL/P patients and generate the Cleft-Q PRO prior to weekly multidisciplinary cleft and craniofacial clinic days. Patient results were automatically scored, compared to age-based normative data, and populated into the EHR patient note. Cleft-Q results were viewed by clinicians during patient visits to initiate module-specific discussion in relation to patient age-based normative results. Patient-specific Cleft-Q data were also discussed during multidisciplinary cleft and craniofacial team discussions to aid in clinical decision making. This experience may have applicability to other PRO tools in plastic surgery and other medical specialties where integrating PROs may yield superior patient experience and outcomes.

Spinal pseudomeningocele closure: capsulofascial interposition technique.

INTRODUCTION: The development of a spinal pseudomeningocele is a complication of dural repair or reconstruction that carries significant morbidity for pediatric patients. In addition to cerebrospinal fluid (CSF) hypotension and positional headaches, CSF leaking into the extradural space increases the risk for incisional breakdown, meningitis, and cosmetic deformity. Spinal pseudomeningocele management is challenging, and reported techniques range from local wound revisions/exploration to shunt placement for permanent CSF diversion. METHODS: At our institution, we have recently implemented a multidisciplinary approach of capsulofascial interposition for the surgical repair of the symptomatic spinal pseudomeningocele with a combined neurosurgery-plastic surgery team. To our knowledge, this technique has not previously been characterized, and we describe the technical aspects of this surgery here. RESULTS: Among 10 patients treated with this technique, none required reoperation or developed infections following pseudomeningocele closure; 2 patients received postoperative transfusions; and 2 patients underwent CSF diversion procedures. CONCLUSION: We propose that this capsulofascial interposition technique should be employed in the surgical treatment of symptomatic spinal pseudomeningoceles.

Crowdsourcing in Plastic and Reconstructive Surgery: A Systematic Review with Reporting Recommendations.

BACKGROUND: Crowdsourcing uses online platforms to collect large data from laypersons and has been increasingly used over the past 5 years to answer questions about aesthetic and functional outcomes following plastic and reconstructive surgery. This systematic review evaluates crowdsourcing articles in plastic and reconstructive surgery based on study topic, participants, and effect size in the hopes of describing best practices. METHODS: A systematic search strategy was developed with a licensed librarian and attending plastic surgeon to query all articles using crowdsourcing in plastic and reconstructive surgery. Covidence systematic review manager was used by two independent reviewers to import articles, screen abstracts, evaluate full texts, and extract data. RESULTS: A search run on October 8, 2021, yielded 168 studies, of which 45 were ultimately included. Craniofacial surgery and aesthetic surgery collectively constituted over half of studies. Participants in plastic surgery crowdsourcing studies are more commonly from the United States, female, straight, 25 to 35 years old; have completed college; and earn $20,000 to $50,000 per year. Studies typically assessed aesthetic perceptions, cost approximately $350, ran a median of 9 days, included approximately 60 unique survey items, and included approximately 40 unique human images. CONCLUSIONS: Crowdsourcing is a relatively new, low-cost method of garnering high-volume data from laypersons that may further our understanding of public perception in plastic and reconstructive surgery. As with other nascent fields, there is significant variability in number of subjects used, subject compensation, and methodology, indicating an opportunity for quality improvement.

How Low Should We Go? Safety and Craniometric Impact of the Low Occipital Osteotomy in Posterior Vault Remodeling.

BACKGROUND: A larger volume cranial vault expansion is likely facilitated by a low posterior cranial osteotomy beneath the torcula; however, this may impart an increased risk of venous bleeding. The authors compared the safety of infratorcular versus supratorcular osteotomy in patients undergoing posterior vault reconstruction or posterior vault distraction osteogenesis and analyzed volumetric changes. METHODS: Patients undergoing initial posterior vault reconstruction or distraction osteogenesis between 2009 and 2021 at the authors' institution were grouped by occipital osteotomy location and analyzed retrospectively. Craniometric analysis was performed if patients had high-resolution computed tomography scans available within 180 days preoperatively and postoperatively. RESULTS: A total of 187 patients were included: 106 (57 percent) who underwent posterior vault distraction osteogenesis and 81 (43 percent) who underwent posterior vault reconstruction. Infratorcular osteotomy was more common in reconstruction [ n = 65 (80 percent)] than in distraction osteogenesis [ n = 61 (58 percent); p < 0.002]. Blood transfused was similar between low and high osteotomy cohorts in the distraction osteogenesis ( p = 0.285) and reconstruction ( p = 0.342) groups. However, median transfused blood volume per kilogram of patient weight was greater in the low versus high osteotomy distraction osteogenesis ( p = 0.010) and reconstruction ( p = 0.041) cohorts. Intraoperative venous sinus injury was rare. In the distraction osteogenesis cohort, there was increased median intracranial volumetric gain in the low (263 ml) compared with the high osteotomy cohort (127 ml; p = 0.043); however, when controlled for distraction distance, only a trend was observed ( p = 0.221). Patients undergoing distraction osteogenesis showed a larger median intracranial volume increase (168 ml) compared with those undergoing reconstruction (73 ml; p < 0.001). CONCLUSION: Infratorcular osteotomy can be performed safely in most patients undergoing cranial vault remodeling and does not appear to be associated with greater hemodynamic instability or sinus injury. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Relating Metopic Craniosynostosis Severity to Intracranial Pressure.

PURPOSE: A subset of patients with metopic craniosynostosis are noted to have elevated intracranial pressure (ICP). However, it is not known if the propensity for elevated ICP is influenced by the severity of metopic cranial dysmorphology. METHODS: Children with nonsyndromic single-suture metopic synostosis were prospectively enrolled and underwent optical coherence tomography to measure optic nerve head morphology. Preoperative head computed tomography scans were assessed for endocranial bifrontal angle as well as scaled metopic synostosis severity score (MSS) and cranial morphology deviation score determined by CranioRate, an automated severity classifier. RESULTS: Forty-seven subjects were enrolled between 2014 and 2019, at an average age of 8.5 months at preoperative computed tomography and 11.8 months at index procedure. Fourteen patients (29.7%) had elevated optical coherence tomography parameters suggestive of elevated ICP at the time of surgery. Ten patients (21.3%) had been diagnosed with developmental delay, eight of whom demonstrated elevated ICP. There were no significant associations between measures of metopic severity and ICP. Metopic synostosis severity score and endocranial bifrontal angle were inversely correlated, as expected ( r =-0.545, P <0.001). A negative correlation was noted between MSS and formally diagnosed developmental delay ( r =-0.387, P =0.008). Likewise, negative correlations between age at procedure and both MSS and cranial morphology deviation was observed ( r =-0.573, P <0.001 and r =-0.312, P =0.025, respectively). CONCLUSIONS: Increased metopic severity was not associated with elevated ICP at the time of surgery. Patients who underwent later surgical correction showed milder phenotypic dysmorphology with an increased incidence of developmental delay.

Pediatric Dog Bite Injuries: A 5-Year Nationwide Study and Implications of the COVID-19 Pandemic.

INTRODUCTION: Although single institution studies have analyzed various animal attacks, there has not been multicenter investigation into dog bites in children. The purpose of this study was to characterize national trends and investigate the characteristics of pediatric dog bites. METHODS: Aretrospective cohort study was conducted of pediatric dog bite injuries in the United States from 2015 to 2020 using the Pediatric Health Information System national database. Patient characteristics, injury locations, and need for intervention were analyzed. Mann-Whitney U test, Pearson chi-square, and Fisher exact test, and linear multivariate regressions were performed for statistical analysis of data values; statistical significance was maintained at P < 0.05. RESULTS: A total of 56,106 patients were included, majority male (55.1%) with a median age 6.8 years (interquartile range 3.5-10.6). Incidence peaked in July (median =1217) with nadirs in February (median = 760). A substantial increase in bites was seen per overall Emergency Department presentations during the pandemic. Most common bite location was the head (62.1%), followed by the upper extremity (25.1%). Relative proportions of dog bites to the face gradually decreased with age (B = -3.4%/year, P< 0.001), whereas proportions to the upper extremities (B = + 1.9%/year, P < 0.001) and lower extremities (B = + 1.6%/year, P = 0.002) gradually increased with age. Overall, 8.0% patients required repair in the operating suite. injuries isolated to the head (OR= 2.6, P < 0.001) and those to multiple anatomic regions were more likely to require operative intervention [operating room (OR= 2.6, P < 0.001)]. CONCLUSIONS: Dog bites most commonly occur during the summer in school-aged boys. Toddlers disproportionately suffer injuries to the head, with a trend towards upper extremity bites in teenagers. The coronavirus disease 2019 pandemic ushered a spike in dog bite presentations among Emergency Department visits, further underscoring the need for targeted educational initiatives to halt the persistence of these preventable injuries.

Making the Diagnosis in Sagittal Craniosynostosis-It's Height, Not Length, That Matters.

INTRODUCTION: This study assesses the diagnostic reliability of a novel photogrammetric measurement to distinguish sagittal craniosynostosis (SS) from control and false positive cases (SNS). METHODS: Head CTs from 2014-2020 were reviewed for patients with sagittal synostosis (SS, n = 177), presumed sagittal synostosis with normal imaging (SNS, n = 30), and controls (n = 100). Using preoperative clinical photographs and CTs, a measurement reflecting the anterior-posterior location of the vertex was measured using an angle drawn between the cranial vertex, nasion, and opisthocranion (VNO) in profile view, with the head in a neutral position. RESULTS: Mean age at pre-operative head CT was 9.5 months for the SS cohort, 4.2 months for the SNS cohort, and 8.9 months for controls (p = .327). Mean age at pre-operative clinical photograph was 9.5 months for the SS cohort and 4.2 months for the SNS cohort (p = .149). Pearson correlations revealed no significant association between age and VNO angle. The average VNO angle measured on clinical photographs was 54.7° ± 3.8° for the SS group, 43.1° ± 2.2° for the SNS group, and 41.1° ± 3.7° for controls (p < .001). Receiver operating characteristic (ROC) analysis yielded a cut-off of ≥ 50° to identify SS. Diagnostic sensitivity and specificity were 96.6% and 99.2%, respectively. Three-rater analysis yielded an average ICC of 0.742 (p = .004). CONCLUSIONS: Measurement of the VNO angle is a reliable screening tool to diagnose sagittal craniosynostosis, with an angle of 50° or more suggesting suture synostosis. This method relies on the relationship between the anterior displacement of the vertex and occipital bulleting to approach the diagnostic accuracy of CT imaging.

Utility of Preoperative Helmet Molding Therapy in Patients With Isolated Sagittal Craniosynostosis.

ABSTRACT: The purpose of this study was to review our institution's experience using helmet molding therapy in children with isolated non-syndromic sagittal craniosynostosis before placement of cranial springs and provide objective measurements of craniometric changes to help determine its role in treatment.Patients who underwent preoperative helmet molding therapy for sagittal craniosynostosis were retrospectively reviewed. Three-dimensional surface tomography scans were used to measure head circumference, cranial width, cranial length, cranial index (CI), and cranial vault asymmetry.Seventeen patients underwent orthotic helmeting therapy before spring mediated cranial vault expansion. Patients spent a median of 48 days (interquartile range [IQR] 32, 57) in preoperative orthotic helmeting therapy. There were increases in both cranial width and length post-helmeting (median: 107.5 mm [IQR 104.8, 110.4] versus 115.6 mm [IQR 114.5, 119.3]; P < 0.001) (median: 152.8 mm [IQR 149.2, 154.9] versus 156.8 mm [IQR 155.0, 161.5]; P < 0.001), respectively. There was a greater increase in cranial width (P = 0.015). Consequently, patients' CI improved after preoperative helmeting (median: 0.702 [IQR 0.693, 0.717] versus 0.739 [0.711, 0.752]; P < 0.001). There was no evidence of growth restriction from helmeting (pre-helmeting Head circumference [HC]: median 96.8 percentile [IQR 90.6, 99.9] versus post-helmeting HC: 98.7 percentile [IQR 94.7, 99.8]; P = 0.109).Preoperative helmeting in patients with non-syndromic isolated sagittal craniosynostosis can be used to improve CI before surgical correction. Significant benefits can be achieved in shorter preoperative helmeting durations than previously reported with no evidence of cranial growth restriction, which supports its feasibility and utility in children undergoing spring mediated cranial vault expansion.

Update: Diversity and Practice Patterns of International Craniomaxillofacial Surgeons.

BACKGROUND: The authors' group characterized the cranio-maxillo-facial workforce 10 years ago, revealing high levels of career satisfaction but significant gender disparity. This study provides an updated profile of the international cranio-maxillo-facial workforce. METHODS: A 30-question electronic survey was distributed to 387 cranio-maxillo-facial surgeons with membership in the American Society of Craniofacial Surgeons, American Society of Maxillofacial Surgeons, and international Society of Craniofacial Surgery. Questions related to demographics, training background, practice setting, surgical volume, career satisfaction, and perceived discrimination. Independent samples t test was used to compare continuous variables. RESULTS: The authors received 91 responses (response rate = 23.5%). The majority of respondents were White (n = 73, 80.2%), non-Hispanic (n = 85, 93.4%), heterosexual (n = 72, 79.1%), cisgender males (n = 74, 81.3%). Practice setting was primarily academic, 65.9% (n = 60) and group/hospital-based 88.3% (n = 68), with two-thirds of respondents practicing in the United States. Female surgeons reported earlier planned retirement (66 versus 70 years, P = 0.012) and more personal encounters with discrimination of any kind (69% versus 29%, P = 0.033). US craniofacial surgeons reported more racial and sexual orientation-based discrimination compared with non-US surgeons ( P = 0.049 and P = 0.048, respectively). Older surgeons (>55 years old) reported less perceived gender discrimination ( P = 0.041). There was no difference between subgroups in career satisfaction or likelihood of repeating/recommending a cranio-maxillo-facial fellowship. CONCLUSIONS: Female representation in cranio-maxillo-facial surgery on an international scale has increased over the past decade, but this study demonstrates persistent, disparate perception of workplace discrimination by gender, practice region, and age.

Parietal bone thickness for predicting operative transfusion and blood loss in patients undergoing spring-mediated cranioplasty for nonsyndromic sagittal craniosynostosis.

OBJECTIVE: Variables that can predict outcomes in patients with craniosynostosis, including bone thickness, are important for surgical decision-making, yet are incompletely understood. Recent studies have demonstrated relative risks and benefits of surgical techniques for correcting head shape in patients with nonsyndromic sagittal craniosynostosis. The purpose of this study was to characterize the relationships between parietal bone thickness and perioperative outcomes in patients who underwent spring-mediated cranioplasty (SMC) for nonsyndromic sagittal craniosynostosis. METHODS: Patients who underwent craniectomy and SMC for nonsyndromic sagittal craniosynostosis at a quaternary pediatric hospital between 2011 and 2021 were included. Parietal bone thickness was determined on patient preoperative CT at 27 suture-related points: at the suture line and at 0.5 cm, 1.0 cm, 1.5 cm, and 2.0 cm from the suture at the anterior parietal, midparietal, and posterior parietal bones. Preoperative skull thickness was compared with intraoperative blood loss, need for intraoperative transfusion, and hospital length of stay (LOS). RESULTS: Overall, 124 patients with a mean age at surgery ± SD of 3.59 ± 0.87 months and mean parietal bone thickness of 1.83 ± 0.38 mm were included in this study. Estimated blood loss (EBL) and EBL per kilogram were associated with parietal bone thickness 0.5 cm (ρ = 0.376, p < 0.001 and ρ = 0.331, p = 0.004; respectively) and 1.0 cm (ρ = 0.324, p = 0.007 and ρ = 0.245, p = 0.033; respectively) from the suture line. Patients with a thicker parietal bone 0.5 cm (OR 18.08, p = 0.007), 1.0 cm (OR 7.16, p = 0.031), and 1.5 cm (OR 7.24, p = 0.046) from the suture line were significantly more likely to have undergone transfusion when controlling for age, sex, and race. Additionally, parietal bone thickness was associated with hospital LOS (ß 0.575, p = 0.019) when controlling for age, sex, and race. Patient age at the time of surgery was not independently associated with these perioperative outcomes. CONCLUSIONS: Parietal bone thickness, but not age at the time of surgery, may predict perioperative outcomes including transfusion, EBL, and LOS. The need for transfusion and EBL were most significant for parietal bone thickness 0.5 cm to 1.5 cm from the suture line, within the anticipated area of suturectomy. For patients undergoing craniofacial surgery, parietal bone thickness may have important implications for anticipating the need for intraoperative transfusion and hospital LOS.