Preoperative Velopharyngeal Closure Predicts Hypernasality Outcomes of Secondary Furlow Double-Opposing Z-Plasty.

OBJECTIVE: To determine if preoperative velopharyngeal closure percentage (VCP) is predictive of successful Furlow double opposing Z-plasty (DOZP) and subsequently determine the optimal velopharyngeal closure cutoff for successful DOZP. DESIGN: Retrospective study. SETTING: Tertiary academic center. PATIENTS: 110 patients with repaired cleft lip and palate having hypernasality treated with DOZP. INTERVENTIONS: Speech videofluoroscopy images were used to obtain the preoperative VCP and other measurements. MAIN OUTCOME MEASURES: Changes in hypernasality scores using the Cleft Audit Protocol for Speech-Augmented-Americleft Modification (CAPS-A-AM) rating system were used as the primary outcome measure. A successful DOZP was defined as a postoperative hypernasality score of ≤ 1 or an improvement of 2 or more scores from baseline. A receiver operating characteristic (ROC) curve was calculated to determine preoperative VCP cutoff. RESULTS: There were 110 patients who underwent DOZP for treatment of velopharyngeal insufficiency. Of these patients, 94 (85%) had successful surgery as determined by their postoperative CAPS-A-AM hypernasality score. Preoperative VCP was a statistically significant predictor of successful DOZP (P < .0001). The ROC curve with Youden index (J) determined a cutoff (c*) of 55% preoperative VCP or greater to optimize surgical success rate. Grouping by preoperative VCP showed that surgical success increases directly with preoperative VCP, and patients with low VCP had above a 50% success rate in reducing hypernasality scores. CONCLUSIONS: Preoperative VCP was significantly associated with improved hypernasality ratings postoperatively. A preoperative VCP of ≥55% may be used to help predict success of Furlow palatoplasty treatment. Patients with lower VCP can still benefit from secondary DOZP.

Multicenter comparison of head shape outcomes for three minimally invasive strip craniectomy techniques for sagittal craniosynostosis.

OBJECTIVE: A literature gap exists comparing whole head shape outcome following correction of sagittal craniosynostosis. The objective of this multicenter study was to provide an analysis of long-term results following three different endoscopic strip craniectomy techniques for correction of sagittal craniosynostosis: 1) spring-assisted strip craniectomy, 2) wide-strip craniectomy with biparietal and bitemporal barrel-stave wedge osteotomies plus helmet orthosis, and 3) narrow-strip craniectomy plus orthosis without barrel staves. METHODS: Pre- and postoperative 3D stereophotogrammetric images were collected from patients who underwent craniosynostosis surgery. Procedures were divided among institutions as follows: spring-assisted strip craniectomies were performed at Atrium Health Wake Forest Baptist Hospital; narrow-strip craniectomies were performed at St. Louis Children's Hospital by one craniofacial surgeon; and wide-vertex craniectomies were performed at St. Louis Children's Hospital prior to 2010, and then continued at Children's Medical Center Dallas. Pre- and postoperative 3D whole-head composite images were generated for each procedure to visually represent outcomes at final follow-up and compared with age-matched normal controls. RESULTS: Patients in the spring-assisted strip craniectomy group showed normalization of frontal bossing and skull height compared with age-matched controls, whereas patients undergoing wide-strip craniectomy showed greater correction of occipital protrusion. Patients in the narrow-strip craniectomy cohort had intermediate results between these outcomes. Nested aggregate head shapes showed good correction of head shapes from all techniques. CONCLUSIONS: This large, retrospective, multicenter study illustrated whole head shape outcomes from three different craniectomy procedures. Although each procedure showed some differences in loci of primary correction, all three surgical methods demonstrated good correction of primary scaphocephalic deformity.

Estimated prevalence of facial injury-related mortality in the United States pediatric population.

BACKGROUND/AIMS: In pediatric populations, the epidemiology of facial trauma, their injury patterns, distribution, and outcomes are well known, However, little is known about the risk factors and impacts of minor and moderate facial injuries on in-hospital mortality among children in the United States of America (USA). The aim of this study was to determine the prevalence and risk factors for in-hospital mortality among pediatric patients following facial injuries in the USA. MATERIAL AND METHODS: A cross-sectional study was conducted with data from the National Trauma Data Bank's pediatric hospitalized patients (<18 years) with facial injuries (International Classification of Diseases, Ninth Revision codes 802.00 to 802.9 and Tenth Revision codes S02.2 to S02.92) between January 01, 2016-December 31, 2019. A multivariable logistic regression model was utilized to identify the risk factors for in-hospital mortality. RESULTS: A total of 61,294 pediatric patients (mean age 11.9 years, 69.6% males) were included in the analysis. The estimated prevalence of in-hospital mortality following facial injuries was 2.4% (n = 1480). In terms of mortality, compared to those who sustained minor facial injuries, patients with (1) moderate injuries had 43% higher odds (OR = 1.43; 95% CI: 1.25-1.64, p < .0001), (2) serious injuries had seven times higher odds (OR = 7.81; 95% CI: 6.67-9.14, p < .0001), (3) severe injuries had 16 times higher odds (OR = 16.07; 95% CI: 12.62-20.46, p < .0001), and (4) critical/maximum injury virtually unsurvivable had 145 times higher odds (OR = 145.24; 95% CI: 113.82-185.33, p < .0001) of death after controlling for age, race, insurance status, comorbidities, and hospital complications. CONCLUSIONS: The severity of facial injury, age 5-17 years, uninsured status, and those with a mental/personality disorder were risk factors for in-hospital mortality among pediatric patients following facial injuries in this population-level analysis. A better understanding of these risk factors is needed for clinical management of pediatric patients to prevent in-hospital mortality following facial injuries.

Open Versus Minimally Invasive Approach for Craniosynostosis: Analysis of the National Surgical Quality Improvement Program-Pediatric.

OBJECTIVE: This multicenter study aimed to compare demographic, operative, and short-term outcomes data between open and minimally invasive surgical approaches for craniosynostosis repair utilizing the American College of Surgeon's National Surgical Quality Improvement Program Pediatric (NSQIP-P) database and highlight surgical disparities among races and ethnicities. DESIGN: Retrospective review of large multicenter database. SETTING: Freestanding general acute care children's hospitals, children's hospitals within a larger hospital, specialty children's hospitals, or general acute care hospitals with a pediatric wing. PATIENTS AND PARTICIPANTS: A total of 4931 pediatric patients underwent craniosynostosis correction within the NSQIP-P database from 2013 to 2019. INTERVENTIONS: None. MAIN OUTCOME MEASURE(S): Demographic information included age at surgery, sex, race, and ethnicity. Operative and outcomes measures included operative time, anesthesia time, days until discharge, postoperative complications, blood transfusions, 30-day readmission, and 30-day unplanned return to operating room. RESULTS: Patients who underwent minimally invasive surgery had significantly shorter operative and anesthesia times (p < .001; p < .001), fewer days until discharge (p < .001), fewer postoperative complications (p < .05), and less blood transfusions (p < .001). The proportion of White patients was significantly higher in the minimally invasive surgery group (p < .01), whereas Black and Hispanic patients had a significantly higher proportion in the open surgery group (p < .001; p < .001). Additionally, the percentage of patients undergoing minimally invasive surgery increased from 3.8% in 2014 to over 13% in 2019. CONCLUSIONS: This study adds to a growing consensus that minimally invasive surgery has significantly decreased operative time, anesthesia time, transfusion rates, length of hospital stay, and postoperative complications compared to open surgery. Racial and ethnic surgical disparities showed larger proportions of Black and Hispanic populations undergoing open procedures.

Pediatric Tissue Expansion: Analysis of the National Surgical Quality Improvement Program-Pediatric.

INTRODUCTION: Tissue expansion (TE) in pediatric surgery provides vascularized tissue to attain functional and esthetic goals in a broad range of reconstructive procedures. Our study evaluates the demographic, operative, and short-term outcomes of TE in pediatric patients utilizing the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database and highlights factors associated with postoperative complications. MATERIALS AND METHODS: Retrospective review of a large multicenter database of 402 pediatric patients that underwent TE within the NSQIP-P database from 2013 to 2020 at freestanding general acute care children's hospitals, children's hospitals within a larger hospital, specialty children's hospitals, or general acute care hospitals with a pediatric wing. Patient demographics, clinical risk factors, operative information, and postoperative outcomes were collected with an odds ratio analysis of risk factors. RESULTS: Patients were majority female (55.5%), White (63.2%), and non-Hispanic (67.4%). The minority were born prematurely (11.9%) and had congenital malformations (16.7%). Complications occurred in 5.7%, unplanned readmission in 4.5%, and unplanned operation in 6.5% of patients. Complications lead to readmission in 2.5% and return to the operating room in 3.2% of patients. American Society of Anesthesiology (ASA) score III-IV, congenital malformations, >1-day hospital stay, and pulmonary, neurologic, and hematologic comorbidities were associated with the greatest increase in odds of complication. CONCLUSION: This study utilizes the NSQIP-P to provide a comprehensive multicenter view of pediatric patients undergoing TE. Increased understanding of risk factors for complications allows for guidance in patient selection and helps in achieving favorable surgical outcomes.

Craniofacial Fibrous Dysplasia of the Skull Assisted by Virtual Surgical Planning.

Craniofacial fibrous dysplasia (FD) involves thickening of the skull and facial bones, causing asymmetry and distortion of overlying soft tissues. Surgical contouring is often performed with rotary bur or osteotome, with the goal of matching contralateral unaffected anatomy. This is made technically challenging by having no direct visualization of contralateral structures, and the desire to control depth of resection to match the contour of the unaffected side. In our report, a 13-year-old male presented for surgical evaluation of craniofacial FD affecting the right parietal/temporal bones. A novel virtual surgical planning approach of premade drilling template with numerous pilot guide holes was used to assist bone debulking. The pilot holes allowed precise burring of the dysplastic bone. The patient achieved excellent calvarial contour symmetry without unintended intracranial extension. We believe that virtual surgical planning and drilling depth guides are effective tools in the reconstruction of craniofacial FD.

3D imaging of vascular anomalies using raster-scanning optoacoustic mesoscopy.

OBJECTIVES: Vascular anomalies such as capillary malformations (CMs) and infantile hemangiomas (IHs) are common pediatric vascular disorders that are treated with therapeutic laser. The treatment method, however, relies on subjective evaluation of clinical findings and can have unpredictable results. Raster-scanning optoacoustic mesoscopy (RSOM) is an innovative imaging technology using pulsed-light laser to excite hemoglobin, generating ultrasound waves that are converted into three-dimensional images of tissues. RSOM can provide objective information about superficial structures such as the microvasculature of vascular anomalies. MATERIALS AND METHODS: In this study, we explore the clinical potential of RSOM to study vascular anomalies before and after laser treatment. We scanned nine patients with CM (n = 6) and IH (n = 3) who underwent laser treatment and calculated the blood vessel volume. RESULTS: Overall, there was a posttreatment volume increase in CM, and a decrease in IH. CONCLUSION: These findings support the possibility that RSOM may have a role in developing an objective method of evaluating these lesions, leading to a tailored treatment approach and avoidance of adverse outcomes.

Anterior "W" Tongue Reduction for Macroglossia in Beckwith-Wiedemann Syndrome.

INTRODUCTION: Macroglossia occurs in 80% to 99% of patients with Beckwith-Wiedemann syndrome (BWS) and a variety of surgical techniques for tongue reduction are offered by surgeons. The purpose of this study is to evaluate the postoperative outcomes of the anterior "W" tongue reduction technique in patients with BWS. METHODS: A retrospective review was conducted of all patients diagnosed with BWS that underwent an anterior "W" tongue reduction for macroglossia in the past 7 years, performed by 2 surgeons. Demographics, procedural characteristics, perioperative outcomes, and complications were assessed. RESULTS: A total of 19 patients met inclusion criteria consisting of 8 male and 11 female patients. The mean age at the time of surgery was 405 days, mean surgeon operating time was 1.06 h, and mean length of follow-up was 467 days. Postoperative oral competence was observed in 100% of patients. There was no reported history of sleep apnea or airway compromise. Speech delay was seen in 4 patients pre- and postoperatively. Feeding issues decreased from 7 patients preoperatively to 1 patient postoperatively. Preoperative prevalence of class III malocclusion (53%) and isolated anterior open bite (26%) decreased postoperatively to 37% and 16%, respectively. The only reported complications were superficial tip wound dehiscence in 3 patients treated with nystatin antifungal therapy. None of the patients required revisional surgery. CONCLUSION: Patients treated with the anterior "W" tongue reduction technique had low rates of perioperative complications and significant improvements in oral competence. Anterior "W" tongue reduction is safe and effective for the correction of macroglossia in patients with BWS.

Longitudinal composite 3D faces and facial growth trends in children 6-11 years of age using 3D cephalometric surface imaging.

BACKGROUND: Normative craniofacial anthropometry provides clinically important reference values used in the treatment of craniofacial conditions. Few objective datasets of normative data exist for children. AIM: To establish normative data regarding craniofacial morphology changes with growth in children. SUBJECTS AND METHODS: 3D surface images of the same group of healthy children aged 6 - 11 years old recruited from a Dallas school were taken annually between the years 2015 - 2020. Composite 3D cephalometric faces were created for boys and girls of each age. General and craniofacial anthropometric measurements were compared. RESULTS: Seven hundred ninety one individual stereophotogrammetric acquisitions were used (400 boys, 391 girls) taken from 180 children. Linear facial, orbital, nasal, and oral anthropometric measurements revealed a consistent increase in magnitude with age. Composite 3D face comparisons revealed prominent vertical and anteroposterior growth trends in the lower and upper facial regions. CONCLUSION: This study presents a longitudinal 3D control dataset of the same group of children over a 6-year period that can serve as reference norms for facial growth values and trends in children aged 6-11 years. The composite 3D normative faces are available for clinical and research purposes upon request, which may be interrogated and measured according to user need and preference.

Correction of Metopic Craniosynostosis Using Limited Incision Strip Craniectomy Versus Open Fronto-Orbital Reconstruction: An Assessment of Aesthetic Outcomes.

BACKGROUND: Metopic craniosynostosis is traditionally repaired with fronto-orbital advancement (FOA) or, alternatively, limited short scar strip craniectomy (LSSSC) followed by helmet therapy. There is controversy among surgeons regarding resultant head shape outcomes between the 2 methods. This study aims to assess how surgeons perceive the postoperative aesthetic results of the 2 metopic craniosynostosis repair methods. METHODS: A retrospective analysis was performed on 13 (n = 6 LSSSC; n = 7 FOA) patients who presented for surgical correction of isolated metopic craniosynostosis via either LSSSC (followed by helmet therapy) or FOA. Clinical photographs at 1 year postop were shown to 10 craniofacial surgeons who rated the aesthetic outcomes on a Likert scale of 1 (poor) to 5 (excellent) and guessed which surgical method was performed. RESULTS: Mean age at the time of the procedure was younger in LSSSC than FOA (3.1 ±â€Š1.0 versus 17.5 ±â€Š8.5 months; P < 0.001). Mean blood loss was significantly lower with LSSSC versus FOA (202.0 ±â€Š361.2 versus 371.43 ±â€Š122.9 mL; P < 0.001), as was mean blood transfusion requirement (92.5 ±â€Š49.9 versus 151.3 ±â€Š51.2 mL; P < 0.001) and mean duration of the operation (3:06 ±â€Š0:24 versus 7:53 ±â€Š0:31 hours; P < 0.001). Mean surgeon scores of aesthetic outcomes were similar between groups: LSSSC, 3.27 ±â€Š1.09; FOA, 3.51 ±â€Š0.95 (P = 0.171). When asked to identify which procedure patients had received, only 63.8% of responses were correct. CONCLUSIONS: Limited short scar strip craniectomy offers an important alternative to traditional open FOA and should be considered as an option for children diagnosed with metopic craniosynostosis.

Assessing outcomes of ear molding therapy by health care providers and convolutional neural network.

Ear molding therapy is a nonsurgical technique to correct certain congenital auricular deformities. While the advantages of nonsurgical treatments over otoplasty are well-described, few studies have assessed aesthetic outcomes. In this study, we compared assessments of outcomes of ear molding therapy for 283 ears by experienced healthcare providers and a previously developed deep learning CNN model. 2D photographs of ears were obtained as a standard of care in our onsite photography studio. Physician assistants (PAs) rated the photographs using a 5-point Likert scale ranging from 1(poor) to 5(excellent) and the CNN assessment was categorical, classifying each photo as either "normal" or "deformed". On average, the PAs classified 75.6% of photographs as good to excellent outcomes (scores 4 and 5). Similarly, the CNN classified 75.3% of the photographs as normal. The inter-rater agreement between the PAs ranged between 72 and 81%, while there was a 69.6% agreement between the machine model and the inter-rater majority agreement between at least two PAs (i.e., when at least two PAs gave a simultaneous score < 4 or ≥ 4). This study shows that noninvasive ear molding therapy has excellent outcomes in general. In addition, it indicates that with further training and validation, machine learning techniques, like CNN, have the capability to accurately mimic provider assessment while removing the subjectivity of human evaluation making it a robust tool for ear deformity identification and outcome evaluation.

A Role for Artificial Intelligence in the Classification of Craniofacial Anomalies.

ABSTRACT: Development of an objective algorithm to diagnose and assess craniofacial conditions has the potential to facilitate early diagnosis, especially for care providers with limited craniofacial expertise. Deep learning, a branch of artificial intelligence, can automatically analyze and categorize disease without human assistance. Convolutional neural networks (CNN) have excelled in utilizing medical images to automatically classify disease. In this study, the authors developed CNN models to detect and classify non-syndromic craniosynostosis (CS) using 2D images. The authors created an annotated data set of labeled CS (normal, metopic, sagittal, and unicoronal) conditions using standard clinical photography from the image repository at our center. The authors extended this dataset set by adding photographic images of children with craniofacial conditions from the internet. A total of 1076 images were used in this study. The authors developed a CNN model using a pre-trained ResNet-50 model to classify the data as metopic, sagittal, and unicoronal. The testing accuracy for the CS ResNet50 model achieved an overall testing accuracy of 90.6%. The sensitivity and precision were: 100% and 100% for metopic, 93.3% and 100% for sagittal, and 66.7% and 100% for unicoronal, respectively. The CNN model performed with promising accuracy. These results support the idea that deep learning has a role in diagnosis of craniofacial conditions. Using standard 2D clinical photography, such systems can provide automated screening and detection of these conditions. In the future, ML may be applied to prediction and assessment of surgical outcomes, or as an open-source remote diagnostic resource.

Progressive Postnatal Pansynostosis in Crouzon Syndrome.

ABSTRACT: Crouzon syndrome is a known craniosynostosis syndrome with a heterogenous presentation. Suture closure can rapidly develop postnatally and involve multiple sutures, requiring vigilant clinical monitoring to prevent delay in diagnosis and developing intracranial hypertension. The authors present the case of a male patient with Crouzon syndrome who developed postnatal pansynostosis at 18 months of age when several missed appointments led to diagnosis after complete closure of all sutures and signs of elevated intracranial pressure. Posterior cranial vault distraction was performed soon after, and the patient improved clinically. There is a need for improved monitoring and management of these patients to prevent delay in diagnosis and potential permanent sequelae as well as minimizing radiation exposure through watchful CT scanning.

Comparison of Head Shape Outcomes in Metopic Synostosis Using Limited Strip Craniectomy and Open Vault Reconstruction Techniques.

AIM: Metopic craniosynostosis (MCS), with its trigonocephalic head shape, is often treated with either limited incision strip craniectomy (LISC) followed by helmet orthotic treatment, or open cranial vault reconstruction techniques (OCVR). There is controversy regarding resultant shape outcomes among craniofacial surgeons. Those adverse to LISC claim normal head shape is never attained, while proponents believe there is gradual correction to an equivalent outcome. This study aims to quantitate, over time, the three-dimensional (3D) head shapes in patients who have undergone LISC or OCVR intervention for MCS. METHODS: Sixty-three 3D images of 26 patients with MCS were analyzed retrospectively. Head shape analyses were performed at: (1) preoperative, (2) 1-month postoperative, (3) 10 to 14 months postoperative (1 year), and (4) 2 years postoperative. Composite 3D head shapes of patients were compared at each time point. Two-dimensional (2D) standardized cross sections of the forehead were also compared. RESULTS: Composite head shapes for both groups were nested, to allow visual comparison as the child's forehead grows and expands. The difference between LISC and OCVR 2D cross sections was calculated; 108.26 mm preoperatively, 127.18 mm after 1-month postoperative, 51.05 mm after 10 to 14 months postoperative, and 27.03 mm after 2 years postoperative. CONCLUSIONS: This study found excellent head shape outcomes for both the LISC and OCVR techniques at 2 years of age. It also corroborates the slow and progressive improvement in head shape with the LISC technique. This study highlights the advantages of 3D photography for measurement of contour outcomes, utilizing both 2D vector and 3D whole head analytical techniques.

The Use of Eye Tracking to Discern the Threshold at Which Metopic Orbitofrontal Deformity Attracts Attention.

INTRODUCTION AND OBJECTIVES: Surgical treatment for trigonocephaly aims to eliminate a stigmatizing deformity, yet the severity that captures unwanted attention is unknown. Surgeons intervene at different points of severity, eliciting controversy. This study used eye tracking to investigate when deformity is perceived. MATERIAL AND METHODS: Three-dimensional photogrammetric images of a normal child and a child with trigonocephaly were mathematically deformed, in 10% increments, to create a spectrum of 11 images. These images were shown to participants using an eye tracker. Participants' gaze patterns were analyzed, and participants were asked if each image looked "normal" or "abnormal." RESULTS: Sixty-six graduate students were recruited. Average dwell time toward pathologic areas of interest (AOIs) increased proportionally, from 0.77 ± 0.33 seconds at 0% deformity to 1.08 ± 0.75 seconds at 100% deformity (P < .0001). A majority of participants did not agree an image looked "abnormal" until 90% deformity from any angle. CONCLUSION: Eye tracking can be used as a proxy for attention threshold toward orbitofrontal deformity. The amount of attention toward orbitofrontal AOIs increased proportionally with severity. Participants did not generally agree there was "abnormality" until deformity was severe. This study supports the assertion that surgical intervention may be best reserved for more severe deformity.

Kinematic Analysis of Smiles in the Healthy Pediatric Population Using 3-Dimensional Motion Capture.

INTRODUCTION: Facial normalcy, as measured with 2-dimensional or 3-dimensional photographs, has been documented in the healthy pediatric population. However, static images convey far from a complete representation of an individual's daily interactions with peers. Craniofacial surgery induces changes to soft or osseous tissues and thereby affects dynamic facial expression. To-date, there has not been rigorous, dynamic quantification of normal facial expression. In this study, we used 4-dimensional (4D) imaging to assess the facial expression of healthy children to provide a normative reference point for craniofacial surgeons. METHODS: A total of 36 healthy pediatric volunteers underwent 4D video recordings while performing a maximal voluntary smile. A face template containing 884 landmarks was registered and tracked throughout the videos using Dimensional Imaging software. Participants were divided into 2 smile groups: open-lip smile and closed-lip smile. Kinematic analysis of smiles was calculated for every landmark from its position in the resting frame to its terminal displacement. RESULTS: Composite smiles and Euclidean distance maps were generated displaying areas of greatest displacement near the oral commissures. There was significant difference between closed-lip and open-lip groups in regions of eyes and cheeks. In addition, the open-lip smile group demonstrated significantly greater displacement in the oral commissure on the left side compared to the right (P < .05); whereas, in the closed-lip group, the eyes and cheeks moved significantly more on the right side. CONCLUSION: This study presents an innovative method that can be used to evaluate facial expressions to help craniofacial surgeons restore functional movement in patients with facial anomalies.

Identifying Ear Abnormality from 2D Photographs Using Convolutional Neural Networks.

Quantifying ear deformity using linear measurements and mathematical modeling is difficult due to the ear's complex shape. Machine learning techniques, such as convolutional neural networks (CNNs), are well-suited for this role. CNNs are deep learning methods capable of finding complex patterns from medical images, automatically building solution models capable of machine diagnosis. In this study, we applied CNN to automatically identify ear deformity from 2D photographs. Institutional review board (IRB) approval was obtained for this retrospective study to train and test the CNNs. Photographs of patients with and without ear deformity were obtained as standard of care in our photography studio. Profile photographs were obtained for one or both ears. A total of 671 profile pictures were used in this study including: 457 photographs of patients with ear deformity and 214 photographs of patients with normal ears. Photographs were cropped to the ear boundary and randomly divided into training (60%), validation (20%), and testing (20%) datasets. We modified the softmax classifier in the last layer in GoogLeNet, a deep CNN, to generate an ear deformity detection model in Matlab. All images were deemed of high quality and usable for training and testing. It took about 2 hours to train the system and the training accuracy reached almost 100%. The test accuracy was about 94.1%. We demonstrate that deep learning has a great potential in identifying ear deformity. These machine learning techniques hold the promise in being used in the future to evaluate treatment outcomes.

Quantifying normal head form and craniofacial asymmetry of elementary school students in Taiwan.

BACKGROUND: Defining three-dimensional (3D) normal craniofacial morphology in healthy children could provide craniofacial surgeons a reference point to assess disease, plan surgical reconstruction, and evaluate treatment outcome. The purposes of this study were to report normal craniofacial form and quantify craniofacial asymmetry of healthy children in Taiwan by implementing the 3D stereophotogrammetry technique. METHODS: Healthy Taiwanese elementary school children (n = 652) aged 6-12 years with no known craniofacial anomaly were recruited. After the 3dMD scanning procedure, 32 landmarks were manually placed on the 3D cranial images. Thin plate spline algorithm based on landmarks and closest point matching was applied to deform a symmetric 3D template into the scale of each scanned images. Skull asymmetry and facial asymmetry were calculated using 3dMD vultus and MATLAB. Average head shape models were also presented. RESULTS: Overall, the mean head transverse width, height, anteroposterior length, and circumferences were 163.02, 220.79, 179.07, and 526.55 mm, respectively. On average, the skull asymmetry and facial asymmetry were 2.47 ± 1.26 mm and 0.96 ± 0.53 mm, respectively, with no significant (all p > 0.05) differences found when comparing males and females. In the average head shape model, certain craniofacial areas on the right side were found to be more protruded than those on the left side. CONCLUSIONS: This study shows that the baseline craniofacial form of the Taiwanese elementary school children is asymmetric with a tendency of more protrusion of the head on the right side.

Early Pediatric Nasal Reconstruction Utilizing the Tagliacozzi Flap.

The Tagliacozzi cross arm flap has been historically described for repair of large nasal defects. The authors report what we believe is the youngest case in modern literature of nasal reconstruction with a Tagliacozzi flap, in a 6-year-old girl. Due to her poor face and scalp skin quality, the more modern reconstructive options of a forehead flap or free tissue transfer were not deemed suitable. Two delay procedures and a complex splint were required to position the medial arm fasciocutaneous flap over the nasal construct. The arm was immobilized for 3 weeks to allow for vascularization of the recipient bed. The child successfully tolerated the splint. She has improved breathing and nasal contour.

Molding Helmet Therapy for Deformational Brachycephaly.

BACKGROUND: Molding helmet therapy is used for the treatment of infants with deformational brachycephaly (DB). There is a lack of rigorous outcome measures of helmet therapy in patients with DB using 3-dimensional (3D) imaging, with most reports rely on either subjective or 2-dimensional analyses. Furthermore, the longitudinal assessment of head shape improvement over the course of helmet therapy has not been documented. Our goal was to assess the outcome of molding helmet therapy using 3D surface imaging, and to document the pace of improvement during treatment. METHODS: The head shape of 18 infants with DB who underwent orthotic molding helmet therapy was assessed. The 3D scans were obtained before treatment, during treatment, and at the end of treatment. First, we applied shape analysis techniques based on template deformation to obtain average (composite) heads of the 18 patients at the 3 time points of treatment (pretreatment, during, and posttreatment). In addition, we used 3D curvature analysis to quantify the degree of flatness at the same time points. RESULTS: Molding helmet therapy started at 6.7 ±â€Š0.9 months of age and lasted for 4.3 ±â€Š0.8 months. The overall difference in the occipital contour between pretreatment and end of treatment was 6.3 ±â€Š1.7 mm. Curvature analysis revealed that 15% of the back of the head had prehelmet marked flatness (mean curvature <5/m), which decreased to 9% at 2.5 months into treatment and 7% at the end of treatment. CONCLUSION: Over 65% of the head shape improvement occurred during the 2.5 months of molding helmet therapy.