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Background: Recipients of Vascularized Composite Allotransplants require effective immunosuppressive therapy to prevent graft rejection. This systematic review summarizes the current body of literature on immunosuppressive regimens used in face and hand transplants while summarizing their outcome in terms of rejection, renal failure, and infections. Methods: A systematic search of electronic databases was conducted to identify relevant studies from 1998 until July 1st, 2023. We included all studies that discussed immunosuppressive strategies in face and hand transplant recipients according to PRISMA. Results: The standard triple maintenance therapy was mostly adjusted due to nephrotoxicity or high incidence of rejection. The most common alternative treatments utilized were sirolimus (25/91; 27.5%) or everolimus (9/91; 9.9%) following hand- and photophoresis (7/45; 15.6%), sirolimus (5/45; 11.1%) or belatacept (1/45; 2.2%) following face transplantation. Episodes of rejection were reported in 60 (65.9%) of hand- and 33 (73%) of face transplant patients respectively. Graft loss of 12 (13.2%) hand and 4 (8.9%) face transplants was reported. Clinical CMV infection was observed in 6 (6.6%) hand and 7 (15.5%) face transplant recipients. Conclusions: Based on the herein presented data, facial grafts exhibited a heightened incidence of rejection episodes and CMV infections. Facial mucosa adds complexity to the immunological graft composition highlighting the need of individualized immunosuppressive regimens and further research.
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Facial feminization surgery (FFS) is a type of gender-affirming surgery aimed at bringing masculine facial features more in line with typically feminine characteristics. Specifically, mandibular contouring can create a softer jawline and help create a more round, feminine face. As the popularity of FFS continues to increase, improving surgical techniques and patient satisfaction is imperative. However, no quantitative measurement system currently exists to measure these changes. In this study, the authors describe the use of a novel segmentation technique using computerized tomography imaging to quantify the bony changes that occur during gonial angle reduction. Further, authors utilize this technique to describe changes in a cohort of 13 patients, and how these changes correlate with patient satisfaction. The authors found that gonial angle volume and surface area significantly decreased, as well as the intergonial:interzygomatic ratio, with a smaller ratio associated with more feminine features. In addition, patient satisfaction significantly increased post-operatively both specifically regarding jawline appearance (P = 0.0014) and regarding overall social and psychological function (P = 0.0021 and P = 0.0032, respectively), as captured by the FACE-Q and World Health Organization Quality of Life (WHOQOL) surveys. Patients with greater changes in surface area reported greater improvements in WHOQOL psychological scores (P = 0.0086), and patients with greater changes in the intergonial:interzygomatic ratio reported greater improvements in WHOQOL social scores (P = 0.0299). Overall, our novel technique captures significant changes in gonial angle shape and can be applied to a wide range of future studies to improve the quality and accessibility of FFS.
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IMPORTANCE: Social media platforms are increasingly utilized to distribute medical information. Our study emphasizes the need for accuracy in pelvic health education on social media and the involvement of female pelvic floor (FPF) specialists in content creation. AIMS: In this cross-sectional study, we assessed the FPF TikTok videos with the highest engagement for quality of information and misinformation and investigated the relationship between misinformation and user engagement. METHODS: We collected all TikTok videos on the US app with hashtags related to FPF conditions, including 76 on pelvic organ prolapse, 323 on urinary tract infection, 84 on overactive bladder, and 972 on incontinence. The top 20 videos for each FPF condition were selected based on highest engagement, and 74 videos total met inclusion criteria. TikTok videos were scored with the validated DISCERN instrument for quality of consumer health information and a 5-point Likert scale for misinformation. The correlation between misinformation and user engagement was assessed. RESULTS: Our analysis revealed positive correlations among higher average misinformation scores and shares (r = 0.37, p < 0.001), likes (r = 0.23, p = 0.004), and overall engagement (r = 0.25, p = 0.002) in FPF TikTok videos as a group, likely driven by the #UTI category. Most TikTok videos (96%) had poor quality of information (DISCERN score < 3), and 18% of TikTok videos contained misinformation. CONCLUSION: The poor quality and prevalence of misinformation in FPF-related TikTok videos with the highest engagement raise concerns about the propagation of nonevidence-based health information.
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BACKGROUND: The loss of an upper extremity is a severely disabling condition made medically challenging by the limited window for replantation. This study aims to investigate the burden of traumatic major upper extremity amputations in the United States and uncover possibilities for improvements in treatment. METHODS: The Healthcare Cost and Utilization Project's National Inpatient Sample was screened for International Classification of Diseases-9/10 diagnosis/procedure codes for traumatic and nontraumatic major upper extremity amputations and replantations within the years 2008 to 2017. The resulting pool of cases was analyzed for multiple variables, including level of injury, patient demographics, hospital type and location, length of stay, costs, comorbidities, and complications. RESULTS: A total of 15 155 major upper extremity amputations were recorded, of which 15.20% (n = 2305) were traumatic amputations-almost half of them related to the upper arm (49.6%; P = .0002). The great majority of replantations, however, was conducted at the lower arm level (87.4%; P < .0001), with an overall replantation rate of 22.3%. Nontraumatic amputations were overall associated with significantly higher burden of comorbidities relative to traumatic amputations except for long-term alcohol use (P < .0001). Both, amputations and replantations, were predominantly treated in large urban teaching hospitals, and were significantly more likely to occur in white men. The Southern region of the United States was handling the highest proportion of amputations in the United States, but had the lowest likelihood of replantation. CONCLUSION: This study provides an overview of the national trends in major traumatic upper extremity amputations and replantations, revealing potential health care shortcomings.
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BACKGROUND: Children with metopic synostosis have been found to have more neurocognitive and behavioral difficulties. The variables that may affect future neurodevelopmental outcomes, including presenting morphologic severity, have not been fully studied. In the largest study to date, we aimed to assess what portends worse neurocognitive and behavioral outcomes at school age. METHODS: Children 6-18 years old with surgically corrected metopic nonsyndromic craniosynostosis underwent neurocognitive testing. Parents completed behavior rating surveys about their child: Conners-3 (ADHD), Social Responsiveness Scale-2 (autism spectrum disorder), Behavior Rating Inventory of Executive Function-2 (BRIEF-2: executive function), and Child's Behavior Checklist (overall behavior). The endocranial bifrontal angle (EBA), adjusted EBA (aEBA), frontal angle (FA), and AI-derived metopic severity score (MSS) were determined on pre-operative CT images. Multivariate linear regressions were used to evaluate the association of age at surgery and severity. RESULTS: There were 87 children who underwent neurocognitive testing (average age 10.9 ± 3.3 years) of whom 67 also completed behavioral assessments. Greater phenotypical severity of metopic synostosis (lower FA, aEBA, and EBA) was associated with worse scores on the subscales of the BRIEF-2 (executive function) and executive subscale of the Conners-3. Increasing age at surgery was associated with worse executive function subscale scores of the Conners-3 when controlling for each severity measurement and sociodemographic risk. CONCLUSION: Children with greater phenotypic severity of metopic synostosis have worse executive function at school age. The majority of children with metopic synostosis have signs of ADHD. Later surgeries (greater than 12 months) may impact executive functioning, regardless of the degree of severity. Future research should aim at identifying the direct structural changes to the brain.
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BACKGROUND: The surge in social media usage has transformed the dissemination and consumption of healthcare information, notably impacting plastic surgery and cosmetic specialties. This study focuses on the influence of social media, particularly Instagram and TikTok, in shaping perceptions of individuals seeking facial feminization (FF) procedures. METHODS: Using the validated DISCERN scale, we assessed the reliability and accuracy of FF content on TikTok and Instagram. The study also analyzed the relationship between content reliability on engagement metrics (likes, comments, views) and the type of content shared (educational, testimonial, promotional). RESULTS: The analysis encompassed 225 TikTok videos and 75 Instagram posts. TikTok content showed 9.33% as "very poor," 66.2% as "poor," 22.6% as "fair," and only 1.33% as "excellent." Similarly, Instagram content demonstrated 14.67% as "very poor" and 69.33% as "poor," with no content rated as "good" or "excellent." Educational content received higher reliability scores on both platforms. TikTok engagement metrics showed lower reliability ratings correlating with more views, comments, and likes. CONCLUSION: The study underscores the critical role of social media in shaping patient perspectives on FF procedures. The prevalence of inaccurate information necessitates a focus on responsible engagement by healthcare professionals, aiming to provide accurate, educational content that aligns with patients' informational needs and ultimately enhances surgical outcomes.
Subject(s)
Social Media , Humans , Female , Reproducibility of Results , Information Dissemination/methods , Communication , Feminization , Face , MaleABSTRACT
BACKGROUND: This study evaluates the racial distribution in Plastic and Reconstructive Surgery (PRS) publication authorship and illustrates the impact underrepresented in medicine (URiM) mentorship has on increasing diverse trainee contributions to the PRS peer-reviewed literature. METHODS: Articles published in the seven highest-impact PRS peer-reviewed journals within the last 10 years (2012-2022) were reviewed and analyzed for first and senior authors' race and ethnicity, publication year, and citation count. RESULTS: A total of 23,549 publications were identified of which 8250 were from the US-based institutions. A random sampling of 778 publications (â¼10 â%) were scrutinized for first and senior author race and ethnicity. Across all journals, 64.5 â% of senior authors were White, 29.9 â% Asian, 4.6 â% Hispanic, and 1.0 â% Black. First authors were 59.5 â% White, 32.8 â% Asian, 5.2 â% Hispanic, and 2.6 â% Black (p=<0.0001). The presence of a URiM senior author increased the likelihood of a URiM first author 7-fold (p=<0.0001); 95 â% CI [3.5-14.0]). There was no statistically significant difference in the total citation count relative to author race or ethnicity. The Aesthetic Surgery Journal had the greatest proportion of White senior authors (73.6 â%), while Microsurgery had the highest percentage of URiM senior authors (8.7 â%). CONCLUSIONS: URiM authorship of PRS publications is limited and mentorship is essential to improve underrepresented perspectives in the PRS peer-reviewed literature.
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Burn management has significantly advanced in the past 75 years, resulting in improved mortality rates. However, there are still over one million burn victims in the United States each year, with over 3,000 burn-related deaths annually. The impacts of individual patient, hospital, and regional demographics on length of stay (LOS) and total cost have yet to be fully explored in a large nationally representative cohort. Thus, this study aimed to examine various hospital and patient characteristics using a sample of over 20,000 patients. Inpatient data from the National Inpatient Sample from 2008 to 2015 were analyzed, and only patients with an ICD-9 code for second- or third-degree burns were included. In addition, a major operating room procedure must have been indicated on the discharge summary for patients to be included in the final dataset, ensuring that only severe burns requiring complex care were analyzed. Analysis of covariance models was used to evaluate the impact of various patient, hospital, and regional variables on both LOS and cost. The study found that skin grafts and fasciotomy significantly increased the cost of hospitalization. Having burns on the face, neck, and trunk significantly increased costs for patients with second-degree burns, while burns on the trunk resulted in the longest LOS for patients with third-degree burns. Infections in the hospital and additional procedures, such as flaps and skin grafts, also led to longer stays. The study also found that the prevalence of postoperative complications, such as electrolyte imbalance, was high among patients with burn surgery.
Subject(s)
Burns , Humans , United States/epidemiology , Length of Stay , Burns/surgery , Hospitalization , Fasciotomy , Retrospective StudiesABSTRACT
OBJECTIVE: To elucidate trends in publication productivity over the past 50 years and how they correlate with the stage of training as well as the competitiveness of residency and fellowship programs. The authors hypothesize that research qualifications play an important role in obtaining a competitively ranked craniofacial surgery fellowship and that over the past 50 years, there has been an upward shift in the research qualifications held by applicants at the time of application. DESIGN: A cross-sectional study was performed involving all 121 academic craniofacial surgeons in the United States for whom sex, years since fellowship, current institution rank, current academic position, and years since graduation were available. MAIN OUTCOME MEASURES: The relationship between research qualifications, as determined by the overall number of publications, number of first authorship publications, H-index scores, and years since fellowship completion, was examined. The study also analyzed the placement of surgeons at programs ranked in the top 25 versus the lower 25. RESULTS: As the number of decades since beginning craniofacial fellowship decreased, the average number of first authorship publications and average H-index increased. Those who attended higher-ranking residency and fellowship programs had a higher average number of publications, number of first authorship publications, and H-index. CONCLUSIONS: Over the past 5 decades, research productivity at all stages of medical training has surged, potentially fueled by the trend toward pass/fail grading in medical school evaluations and standardized exams and the need to differentiate oneself in an increasingly competitive field.
Subject(s)
Internship and Residency , Surgeons , Humans , United States , Cross-Sectional Studies , Efficiency , Fellowships and ScholarshipsABSTRACT
BACKGROUND: Face transplantation has emerged as a viable solution for reconstructing the most complex facial injuries. Prior work has demonstrated that surgical revisions are necessary to optimize outcomes. The authors' group has updated the previous report of revisions in their cohort, quantified and described which revisions were performed for functional, aesthetic, or mixed indications, and described the rationale, safety, and long-term outcomes of these revisions. METHODS: A retrospective analysis of the authors' ten face transplants was performed from April 2009 to February 2023. The patients' medical records, preoperative facial defects, and operative reports (index and secondary revisions) were reviewed. RESULTS: Nine patients were included. One patient underwent irreversible acute on chronic allograft rejection and received a second face transplant. The average number of revisions was 5.2 per patient (range, 2 to 11 procedures). The median time interval from transplantation to first revision was 4 months (range, 1 to 21 months). Median follow-up was 106 months (range 39 to 142 months). Most interventions consisted of debulking the allograft or revising the periorbital tissues. CONCLUSIONS: In the current study, we report longer term data on revision surgeries needed in face transplant recipients. Patients should expect to undergo revisions for both functional and aesthetic considerations. Although the majority of revisions are performed within two years following transplantation, revisions can be safely performed at any time point. Shared decision-making between the patient and provider team is essential in deciding which revisions are performed and when.
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Microtia can have deleterious impacts on the functional, psychological, and aesthetic outcomes of affected young children. Reconstructive procedures can alleviate these negative outcomes and significantly improve the quality of life for patients; however, the cost and length of hospital stay (LOS) for such procedures and the factors that impact them have not been well-characterized. This study seeks to understand the hospital-level (institution type, size, and geographic region) and patient-level factors (race, age, and insurance status) that impact cost and LOS in patients who undergo microtia reconstructive surgery. A retrospective data analysis was conducted utilizing the National Inpatient Sample (NIS) database for the years 2008 to 2015. Inclusion criteria included patients who had an International Classification of Diseases, Ninth Revision (ICD-9) diagnostic code for microtia (744.23) as well as a procedure for microtia correction (186×/187×). A total of 714 microtia repair cases met the inclusion criteria and were sampled from the NIS database. Microtia repair cost was significantly increased on the West Coast compared with the Northeast ($34,947 versus $29,222, P =0.020), increased with patient age ($614/y, P =0.012), and gradually increased from 2008 to 2015 ($25,897-$48,985, P <0.001). Microtia LOS was significantly increased with government-controlled hospitals compared with private hospitals (1.93 versus 1.39 d, P =0.005), increased with patients on Medicaid compared with private insurance (2.33 versus 2.00 d, P =0.036), and overall decreased with patient age (-0.07 d/y, P =0.001). The results not only identify the multifactorial impacts that drive cost and LOS in microtia repair but provide insights into the financial and medical considerations patients and their families must navigate.
Subject(s)
Congenital Microtia , Child , United States , Humans , Child, Preschool , Length of Stay , Retrospective Studies , Congenital Microtia/surgery , Quality of Life , Esthetics, Dental , HospitalsABSTRACT
BACKGROUND: Radiographic severity of metopic synostosis has been suggested as a predictor of long-term neurocognitive outcomes, and artificial intelligence (AI) has recently been used to quantify severity. Age at surgery is predictive of long-term neurocognition in sagittal synostosis but has not been adequately explored in metopic synostosis. METHODS: Children ages 6 to 18 years old with corrected metopic synostosis underwent testing of intelligence quotient (IQ), academic achievement, and visuomotor integration (VMI). Various manual measurements and AI-derived severity scores were determined. Scans were categorized as moderate or severe for head-to-head comparisons and multivariable linear regressions were used to assess the relationship of age at surgery and severity with neurocognitive outcomes. RESULTS: 41 patients with average age at testing of 10.8 ± 3.4 years were included. 18 patients were in the severe group while 23 patients were in the moderate group with average ages at surgery 6.6 ± 2.7 and 10.6 ± 8.4 months, respectively (p = 0.062). Greater AI-derived severity was significantly associated with lower reading comprehension (p = 0.040 and 0.018) and reading composite scores (p = 0.024 and p = 0.008). Older age at surgery was significantly associated with lower VMI scores (p-values ranging from 0.017 to 0.045) and reading composite scores (p = 0.047 and 0.019). CONCLUSIONS: This study suggests an association between greater AI-derived radiographic severity and lower reading ability in corrected metopic synostosis. Older age at surgery was independently associated with lower reading ability and visuomotor integration. Surgical correction may mitigate neurodevelopmental differences based on severity that have been observed pre-operatively.
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Pediatric facial burns pose significant challenges in terms of physical, psychological, and social impacts on children. Understanding the causes of these burns is crucial for prevention and appropriate care. This study aims to provide a comprehensive analysis of causes and preventive measures related to pediatric facial burns caused by consumer products. Using data from the National Electronic Injury Surveillance System (NEISS) from 2012 to 2021, we analyzed 130,461 cases of pediatric facial burns. Common causes included household items such as cleaning supplies, hot water, kitchen appliances, and health and beauty products. Differences in burn causes were observed between genders, with boys more prone to burns from welding equipment, gasoline, and grills, while girls were more susceptible to burns from hair curling equipment, candles, and health and beauty products. The mean age of children burned by different items varied, highlighting the need for age-appropriate preventive measures. The authors discuss the importance of caregiver education, safe storage practices, supervision, and clear communication in preventing pediatric facial burns. By raising awareness of potential burn sources and implementing preventive strategies, the incidence of pediatric facial burns can be significantly reduced.
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PURPOSE: Craniosynostosis, which describes premature fusion of one or more cranial sutures, has been associated with a variety of neurocognitive deficits. We sought to explore the cognitive profiles of the various types of single-suture, non-syndromic craniosynostosis (NSC). METHODS: A retrospective review of children 6-18 years old with surgically corrected NSC who underwent neurocognitive testing (Weschler Abbreviated Scale of Intelligence, Beery-Buktenica Developmental Test of Visuomotor Integration) from the years 2014-2022 was conducted. RESULTS: 204 patients completed neurocognitive testing (139 sagittal, 39 metopic, 22 unicoronal, 4 lambdoid suture). 110 (54%) of the cohort was male, and 150 (74%) were White. Mean IQ was 106.10±14.01 and mean age at surgery and testing were 9.0±12.2 months and 10.9±4.0 years, respectively. Sagittal synostosis was associated with higher scores than metopic synostosis, with significant differences in verbal IQ (109.42±15.76 vs 101.37±10.41), full-scale IQ (108.32±14.44 vs 100.05±11.76), visuomotor integration (101.62±13.64 vs 92.44±12.07), visual perception (103.81±12.42 vs 95.87±11.23), and motor coordination (90.45±15.60 vs 84.21±15.44). Sagittal synostosis was associated with significantly higher scores for visuomotor integration (101.62±13.64 vs 94.95±10.24) and visual perception (103.81±12.42 vs 94.82±12.75) than unicoronal synostosis. CONCLUSIONS: Compared to patients with sagittal synostosis, patients with metopic synostosis exhibited lower scores in verbal IQ, full-scale IQ, visuomotor integration, visual perception, and motor control after surgical correction. Despite surgical correction for premature metopic suture fusion, the effect on the adjacent frontal lobe and white matter connections to other regions of the brain may have a lasting functional impact. Patients with unicoronal synostosis exhibited lower visuomotor integration and visual perception scores.
Subject(s)
Craniosynostoses , Child , Humans , Male , Infant , Adolescent , Craniosynostoses/complications , Craniosynostoses/surgery , Cranial Sutures/surgery , Brain/surgery , Craniotomy , SuturesABSTRACT
BACKGROUND: Helmet therapy for deformational plagiocephaly has an ideal window for treatment, and timely access to care is vital to achieving optimal benefit. The authors evaluated the hypothesis that patients insured through Medicaid experience decreased access to helmet therapy. METHODS: This was a retrospective analysis of referrals for helmet therapy to Cranial Technologies, Inc. between 2014 and 2020 across 21 states. Outcome measures were likelihood of receiving a helmet, receiving a second helmet, receiving delayed treatment, and having delayed presentation. RESULTS: From 2014 to 2020, a total of 219,869 patients were referred and 141,513 of these received a helmet. Patients with Medicaid were less likely to receive treatment (OR, 0.63; P < 0.001) and more likely to present late (OR, 1.55; P < 0.001) or receive delayed treatment (OR, 3.24; P < 0.001) compared with the commercially insured. Patients with Medicaid were less likely to receive helmet therapy in nine states, with the strongest association in Texas (OR, 0.32; P < 0.001), and more likely to receive helmet therapy in five states, with the strongest association in Colorado (OR, 1.89; P < 0.001). Medicaid was associated with late presentation and delayed treatment in all states. CONCLUSIONS: Patients with Medicaid presented later and were less likely to receive helmet therapy. Findings reflected state-specific Medicaid policies, with patients in some states more likely to receive a helmet with Medicaid than with commercial insurance. However, late presentation and delays in treatment with Medicaid were observed across all states. State-specific Medicaid restrictions are likely a driving factor in determining access to helmet therapy.
Subject(s)
Insurance , Plagiocephaly, Nonsynostotic , Humans , Plagiocephaly, Nonsynostotic/therapy , Retrospective Studies , Treatment Outcome , Head Protective DevicesABSTRACT
Sex diversity among plastic surgery and its subspecialties faculties lags behind many medical specialties. Despite the significant evidence in favor of diversity in leadership, female presence in high-ranking positions in medicine is lacking across multiple specialties. In this study, we aim to evaluate sex disparity among faculty across craniofacial fellowship programs by comparing the disparities among total number of faculty, program directors, years in practice, and academic rank. Our sample included 354 individuals including 193 craniofacial surgery journal editorial board members, 130 craniofacial surgery academic faculty members, and 31 craniofacial surgery association board members. A significant difference (P-value <0.0001) was seen among male and female craniofacial surgery faculty with 84.6% males. Faculty members were further subdivided by academic rank. A significant difference was found between the number of male and female faculty members at all academic positions (P-value =0.043). Of 41 full professors, 2.4% were female. There were 42 associate professors queried with 14.3% female. Similarly, 43 assistant professors were identified with 32.0% female. Years in practice after completing terminal training were analyzed across the academic faculty. There was a significant difference in the number of male and female faculty members across all experience levels (P-value =0.0037). Among the faculty with <10 years since completion of terminal training, 32.4 % were female. For faculty with 10 to 20 years after post-terminal training, 19.6% were female. For those with 20 to 30 years of experience, 0% were female. Finally, for the faculty with over 30 years since graduation, 5.9% were female. Board membership in 2 craniofacial surgery organizations was analyzed: the American Cleft Palate-Craniofacial Association and the American Society of Maxillofacial Surgeons. Among the 17 board members of the American Cleft Palate-Craniofacial Association, 8 (47.1%) were female. For the American Society of Maxillofacial Surgeons, 5 (35.7%) were female. Data were collected for 193 editorial board members from 2 craniofacial surgery journals. There was a significant difference between the number of male and female members across both journals (χ2 value: 33.3570; P-value <0.0001). Among 56 editorial board members from Cleft Palate-Craniofacial Journal, 26 (46.4%) members were female. In comparison, Journal of Craniofacial Surgery has 24.8% female editorial board members. Sex diversity among faculty members is really important and should be brought into light to highlight and improve areas of particular importance and of tremendous potential impact. Given our results, surgical residencies and fellowship programs should begin to show concrete commitment and increase their efforts to recruit and retain a diverse faculty not only for the educational benefit but more importantly to achieve a higher level of care for all.
Subject(s)
Cleft Palate , Internship and Residency , Surgery, Plastic , Humans , Male , United States , Female , Faculty, Medical , Fellowships and ScholarshipsABSTRACT
OBJECTIVE: Deformational Plagiocephaly (DP) is commonly treated with cranial orthosis, or helmet therapy. A large, national study on the impact of insurance status on helmet outcomes is lacking. We assessed treatment outcomes for helmet therapy based on insurance status. DESIGN: This was a retrospective data analysis of patients referred to Cranial Technologies, Inc for helmet therapy between 2014-2020 across 21 states. PATIENTS, PARTICIPANTS: There were a total of 211,417 patients referred for helmeting, of whom 141,513 received helmet therapy. MAIN OUTCOMES MEASURES: Multivariate regression was used to assess the relationship of insurance status with post-treatment residual flattening, measured by cephalic index (CI) and cranial vault asymmetry index (CVAI), and treating provider rating of success. RESULTS: Patients with Medicaid were more likely to complete treatment with residual flattening measured by CI and CVAI when compared to patients with private insurance (OR: 1.58, CI: 1.51-1.65, p < 0.001 and OR: 1.21, CI: 1.15-1.28, p < 0.001, respectively). Providers of patients with Medicaid were more likely to give a low rating of success following treatment (OR: 3.25, CI: 2.70-3.92, p < 0.001). CONCLUSIONS: Our study investigating the impact of insurance status on helmet therapy across 21 states found that patients with Medicaid were more likely to experience residual flattening and have lower provider-rated outcomes compared to those with commercial insurance. Given significant caregiver burden posed by helmet therapy, which requires frequent visits and consistent helmet use, caregivers of patients with Medicaid may require greater support to reduce outcome disparities observed here.