Primary Unilateral Cleft Lip Rhinoplasty Technique: The Melbourne Technique.

Addressing the primary nasal deformity associated with congenital cleft lip is a complex problem that ranges in severity. There are both esthetic and functional ramifications that develop over time. This paper serves to describe the novel Melbourne technique in addressing the primary cleft nasal deformity through repositioning the septal cartilage to the facial midline, reconstructing the nasal floor, and an upper lateral suture to suspend and overcorrect the lower lateral cartilage by modifying the McComb technique. The definitive aim is long-term symmetry in the correction of the cleft lip nasal deformity and these techniques have demonstrated improved nasal symmetry in our unilateral cleft patients.

The First Hybrid International Educational Comprehensive Cleft Care Workshop.

OBJECTIVE: Describe the first hybrid global simulation-based comprehensive cleft care workshop, evaluate impact on participants, and compare experiences based on in-person versus virtual attendance. DESIGN: Cross-sectional survey-based evaluation. SETTING: International comprehensive cleft care workshop. PARTICIPANTS: Total of 489 participants. INTERVENTIONS: Three-day simulation-based hybrid comprehensive cleft care workshop. MAIN OUTCOME MEASURES: Participant demographic data, perceived barriers and interventions needed for global comprehensive cleft care delivery, participant workshop satisfaction, and perceived short-term impact on practice stratified by in-person versus virtual attendance. RESULTS: The workshop included 489 participants from 5 continents. The response rate was 39.9%. Participants perceived financial factors (30.3%) the most significant barrier and improvement in training (39.8%) as the most important intervention to overcome barriers facing cleft care delivery in low to middle-income countries. All participants reported a high level of satisfaction with the workshop and a strong positive perceived short-term impact on their practice. Importantly, while this was true for both in-person and virtual attendees, in-person attendees reported a significantly higher satisfaction with the workshop (28.63 ± 3.08 vs 27.63 ± 3.93; P = .04) and perceived impact on their clinical practice (22.37 ± 3.42 vs 21.02 ± 3.45 P = .01). CONCLUSION: Hybrid simulation-based educational comprehensive cleft care workshops are overall well received by participants and have a positive perceived impact on their clinical practices. In-person attendance is associated with significantly higher satisfaction and perceived impact on practice. Considering that financial and health constraints may limit live meeting attendance, future efforts will focus on making in-person and virtual attendance more comparable.

The Anatomical Subunit Approach to Managing Tessier Numbers 3 and 4 Craniofacial Clefts.

Patients with atypical facial clefts are rare, and there is a paucity of literature outlining the surgical approach to managing these patients. The anatomical subunit approach to the surgical correction of the cleft lip has revolutionized cleft care. Here, we outline our approach and operative technique to treating Tessier clefts 3 and 4 using a novel technique based on the anatomical subunit approach. Methods: All cases of Tessier facial clefts 3 and 4 between 2019 and 2021 from the senior author's practice were reviewed retrospectively. Patient demographics, clinical presentation, procedure details, and complications are reported. The senior author's technique is described in detail. Results: Five patients underwent treatment by the senior author during the study period. One patient had bilateral Tessier 4 clefts, one patient had bilateral Tessier 3 clefts, two patients had a unilateral Tessier 4 cleft, and one patient had a unilateral Tessier 3 cleft. Two of the patients had their clefts treated as secondary procedures. The surgical complication profile was a lost nasal stent in one patient. Treatment principles of the senior author's technique are presented. Conclusions: The anatomical subunit approach to managing atypical facial clefts provides a structured approach to a complex problem for the cleft and craniofacial surgeon. The technique of repair presented here can assist surgeons attempting to treat patients with Tessier 3 and 4 clefts.

Cleft Palate Repair: A History of Techniques and Variations.

Orofacial clefting is a common reconstructive surgical condition that often involves the palate. Cleft palate repair has evolved over three centuries from merely achieving anatomical closure to prioritizing speech development and avoiding midface hypoplasia. Despite centuries of advancements, there is still substantial controversy and variable consensus on technique, timing, and sequence of cleft palate repair procedures. Furthermore, evaluating the success of various techniques is hindered by a lack of universal outcome metrics and difficulty maintaining long-term follow-up. This article presents the current controversies of cleft palate repair and details how the history of cleft palate repair has influenced current techniques commonly used worldwide. Our review highlights the need for a global consortium on cleft care to gather expert opinions on current practices and outcomes and to standardize technique classifications. An understanding of global protocols is crucial in an attempt to standardize technique and timing to achieve anatomical closure with optimal velopharyngeal competence, while also minimizing the occurrence of maxillary hypoplasia and palatal fistulae.

The Melbourne Classification of the Complete Unilateral Cleft Lip Based on Hypoplasia.

BACKGROUND: The hypoplastic lateral lip element within the cleft lip presentation is a recognized entity that has been recently shown to be more common on the right side. The spectrum of such change is yet to be defined. The authors propose the Melbourne classification system of cleft lip hypoplasia and see it as an important step towards discerning the relevance of these anatomical observations to the management of cleft lip/palate patients. METHODS: This is a retrospective observational study of patients with complete unilateral cleft lips treated by the senior author (DKC) at the Royal Children's Hospital, Melbourne. Patient charts were retrospectively reviewed and patients were classified into different degrees of hypoplasia based on preoperative, intraoperative, and postoperative photography. Data was reported using descriptive statistics. RESULTS: Fifty-nine patients with complete unilateral cleft lip deformity were grouped according to lateral lip element hypoplasticity. Twenty patients had right-sided clefts and 39 patients had cleft lips on the left side. Of those with right-sided clefts, 18 patients had evidence of hypoplasia (90%). Three patients had Type 1 deformities, 3 patients were Type 2, and 12 patients were Type 3. Patients with left-sided clefts were found to have hypoplasia less frequently with 15 patients showing evidence (38.5%). CONCLUSIONS: The authors report a classification system of hypoplasia involving the lateral lip element in complete unilateral cleft lip. The authors propose this classification system as a new measure of cleft severity that will have implications for patient expectations, surgical planning, and future outcome studies.

Comparison of Presurgical Anthropometric Measures of Right and Left Complete Unilateral Cleft Lip and/or Palate.

BACKGROUND: Left clefts occur twice as frequently as right ones. The sidedness has been suggested to influence certain outcomes. Some surgeons consider a right cleft more challenging to repair. This is often attributed to their reduced prevalence. The authors question whether this may be caused by morphologic differences. The authors' hypothesis is that there are anthropometric differences between left and right complete cleft lips. METHODS: Patients with complete unilateral cleft lip, with or without cleft palate, operated on at the age of 3 to 6 months, between 2000 and 2018, by a single surgeon, were included. Eight standardized anthropometric measurements of the cleft lip, collected just before cleft lip repair, compare lip and vermillion dimensions and ratios between left and right clefts. RESULTS: One hundred thirty-nine left and 80 right unilateral cleft lips were compared. A significant difference was found between left and right clefts for cleft-side to non-cleft-side ratios comparing the lateral lip element vertical heights and vermillion heights. CONCLUSIONS: Patients with right cleft lips have a greater degree of lateral lip element hypoplasia, demonstrating greater deficiencies of lateral lip element vertical height and vermillion height when compared to patients with left clefts. This has clinical implications for preoperative assessment, choice of surgical technique, and postoperative and long-term outcomes.

A Guide to Bilateral Cleft Lip Markings: An Anthropometric Study of the Normal Cupid's Bow.

OBJECTIVE: The aim of this study was to define the ratio of the heights of the vermilion between the peaks and trough of the Cupid's bow and hence assist in defining the point of closure on the lateral lip element to achieve a balanced Cupid's bow in bilateral lip repair based on our findings. DESIGN: This study is a retrospective observational study of the anthropometrics of the upper lip's Cupid's bow. Three-dimensional (3D) images of toddlers between 2009 and 2016 were extracted from a normative 3D image database of toddlers at the Royal Children's Hospital, Melbourne. PATIENTS: Participants from the normative 3D image database at the age of 1 year were studied. This excluded any patients with prior trauma or surgical intervention of the nasolabial region. INTERVENTION: Landmarks measured were right and left crista philtri (cphR and cphL), labial superius (ls), stomion (sto), right and left chelion, and labial fissure (lf). OUTCOME: Vermilion height of the right peak, trough, and left peak of the Cupid's bow was calculated by analyzing the vertical linear distance between cphR-lf, ls-sto, and cphL-lf. The ratio between the median and paramedian heights were recorded. RESULTS: The paramedian height of the upper lip vermilion is consistently greater than the midline height. There was no significant sexual dysmorphism between ratio of paramedian to midline height on the right (P = .538) and left (P = .410). CONCLUSION: We describe an anthropometric observation of the vermilion relationship at the Cupid's bow and define a specific lateral lip marking for bilateral cleft lip repair based on our anthropometric findings.

Accessory Nostril Associated With Choanal Atresia.

ABSTRACT: Accessory nostril or supernumerary nostril is one of the rare congenital deformities of the nose. The first case was reported by Lindsay B (1906),1 since then 42 cases have been reported in the literature. There is no uniform surgical approach to treat this anomaly. The authors present a child with left side accessory nostril with bilateral choanal atresia and describe our surgical approach.

The Evolution of Unilateral Cleft Lip Repair.

ABSTRACT: The understanding of cleft lip etiology and approaches for surgical repair have evolved over time, allowing for improved ability to restore form and function. The variability of cleft lip presentations has necessitated a nuanced surgical approach with multidisciplinary cleft care. The earliest documentation of unilateral cleft lip repair predates the 19th century, with crude outcomes observed before the advent of curved incisions and advancement flaps. In the 20th century, straight line, quadrilateral flap, and triangular flap repairs were introduced to mitigate post-repair surgical scarring, increase lip length, and restore the symmetry of the Cupid's bow. Towards the latter part of the century, the development of rotation-advancement principles allowed for improved functional and aesthetic outcomes. Future technical improvements will continue to address the goals of lip and nasal symmetry, muscular continuity, precise scar concealment, and improved patient satisfaction in an increasing range of cleft phenotypes and during subsequent years of growth.

Reducing the Cleft Nose Deformity in Bilateral Cleft Lip Repair.

Repair of a bilateral cleft lip and nose deformity remains a challenge. The nose remains the main persisting stigma for patients, deserving an equal amount of attention as the lip during the repair. We share 3 technical principles to help achieve the optimal nasolabial result and minimize cleft nose deformity after bilateral cleft lip repair. Firstly, cephalad rotation of C-flaps from the prolabium is used to define the nasolabial angle. Secondly, the nasal base and contour is set before the lip repair, as the vectors and tension of nasal repair differ from the vector and tension of the orbicularis oris muscle closure. Thirdly, different suspension and shaping stitches are used to define alar shape and position after lower lateral cartilage release, avoiding additional scars.

The Essential Anatomical Subunit Approximation Unilateral Cleft Lip Repair.

The anatomical subunit approximation cleft lip repair advantageously achieves a balanced lip contour, with the line of repair hidden along seams of aesthetic subunits. Dr. David Fisher's original description of the repair reflects the considerable thought that went into the evolution of his design. As his technique has gained acceptance in the intervening 10 years, the authors note several key principles embodied in it that represent a shift in the cleft lip repair paradigm. The authors believe understanding these principles is important to mastery of the anatomical subunit technique, and facilitate its teaching. First, design a plan that adheres to anatomical subunits and perform measurements precisely. Second, identify and adequately release each cleft tissue layer from the lip and nose to enable restoration of balance. Third, drive surgical approximation through inset of the lateral muscle into the superiorly backcut medial orbicularis muscle, followed by skin closure with inferior triangle interposition above the white roll. In this article, the authors present essential components of the technique, and identify several principles that enable its successful execution.

Three patterns of fronto-orbital remodeling for metopic synostosis: comparison of cranial growth outcomes.

BACKGROUND: The authors compared cranial growth across three patterns of fronto-orbital remodeling for metopic synostosis. METHODS: The authors reviewed all patients who underwent fronto-orbital remodeling for isolated metopic synostosis between 2006 and 2009. Inclusion criteria consisted of patients with preoperative, short-term postoperative (4 to 12 months), and long-term postoperative (>36 months) three-dimensional photographs. Patients were categorized by fronto-orbital remodeling pattern: group 1, retrocoronal; group 2, partial coronal; and group 3, precoronal. Head circumference, minimum frontal breadth (ft-ft), and maximum cranial length were measured by three-dimensional photographs, converted to standard Z scores, and compared. RESULTS: Thirty-one patients met inclusion criteria (group 1, n=12; group 2, n=10; and group 3, n=9). Group 1 presented with the greatest phenotypic severity. From preoperative to short-term postoperative assessment, head circumference Z scores rose for group 1 but dropped for groups 2 and 3, and the three groups demonstrated equivalent increases in minimum frontal breadth Z scores. From short-term to long-term postoperatively, the three groups demonstrated similar stability in head circumference Z scores but decreased minimum frontal breadth Z scores. From preoperatively to long-term postoperatively, head circumference Z scores rose for group 1 but fell for groups 2 and 3 (change in Z score, 0.5, -0.5, and -0.7, respectively; p=0.06) and the three groups demonstrated equivalent drops in minimum frontal breadth Z scores. Across preoperative to short-term postoperative and preoperative to long-term postoperative assessment, group 1 displayed the least drop in maximum cranial length Z scores. CONCLUSIONS: Retrocoronal patterns of fronto-orbital remodeling provide long-term gains in head circumference percentile and the least growth impairment in cranial length. Irrespective of osteotomy design, expansion in frontal breadth relapses significantly over time. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Computed tomography-based morphometric analysis of extended strip craniectomy for sagittal synostosis.

BACKGROUND: The purpose of this study is 2-fold: (1) to identify computed tomography (CT)-based morphometric parameters that differentiate the normal skull from one with sagittal synostosis and (2) to evaluate correction of sagittal synostosis with extended strip craniectomy and postoperative helmeting based on morphometric parameters. METHODS: An institutional review board-approved, retrospective review was carried out at the Hospital for Sick Children for all patients who underwent an extended strip craniectomy and postoperative helmeting for sagittal synostosis from 1999 to 2005. Inclusion criteria consisted of patients who underwent a routine craniofacial CT preoperatively and 12 months postoperatively. Craniofacial CT scans of age-matched control subjects were used for preoperative and postoperative comparison. RESULTS: Thirty-nine patients with sagittal synostosis met inclusion criteria. Median age at preoperative CT was 3.0 months. Nine control subjects were identified, with a median age at CT scan of 5.0 months. Patients with sagittal synostosis preoperatively had a significantly longer maximum cranial length, smaller maximum cranial breadth, more acute frontal takeoff and occipital incline angles, lower cephalic index, and an anteriorly positioned vertex. Postoperative CT scans (median, 17.0 months) were compared with 10 control subjects (median, 19.0 months). Patients with sagittal synostosis postoperatively had equivalent maximum cranial breadth, frontal takeoff, and occipital incline angles as compared with controls. Sagittal synostosis patients remained with a significantly longer maximum cranial length, lower cephalic index, and anteriorly positioned vertex. CONCLUSIONS: Twelve months following extended strip craniectomy and helmeting for sagittal synostosis, CT-based morphometric analysis demonstrated correction of cranial breadth, frontal bossing, and occipital bulleting. Skull length and vertex position did not fully correct.

Total cranial vault remodeling for isolated sagittal synostosis: part I. Postoperative cranial suture patency.

BACKGROUND: Total vault reconstruction addresses all phenotypic aspects of scaphocephaly. The clinical implications of remodeling across open cranial sutures, however, remain unclear. The purpose of this study was to assess patency of unaffected sutures following total vault remodeling for isolated sagittal synostosis. METHODS: The authors reviewed routine postoperative computed tomographic scans of patients who underwent total vault remodeling for isolated sagittal synostosis between 2004 and 2008. Sutural patency was scored by a single reviewer as follows: 0 = closed, 1 = partial, and 2 = open. Individual suture scores were tallied for a total sutural patency score. Computed tomographic scans were stratified by postoperative time and craniofacial surgeon. RESULTS: Forty-two patients met the inclusion criteria. Individual sutural closure rates were 42.6, 38.3, 74.5, and 74.5 percent for right coronal, left coronal, right lambdoidal, and left lambdoidal sutures, respectively. Lambdoidal sutures had a significantly higher rate of closure than coronal sutures (OR(Closure), 4.3; 95 percent CI, 2.3 to 8.0; p < 0.001); lambdoidal patency significantly changed over time (χ2 = 9.9, p = 0.04). Across craniofacial surgeons, coronal and lambdoidal patency were equivalent. The total sutural patency score did not significantly correlate with postoperative time, surgical age, preoperative cephalic index, or craniofacial surgeon. CONCLUSIONS: Total vault remodeling for isolated sagittal synostosis results in a high degree of secondary craniosynostosis. Lambdoidal sutures are especially prone to closure, with their patency diminishing over time. At this time, radiographic fusion of adjacent sutures following surgery has not been related to any difference in head shape. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Longitudinal study of the neurodevelopmental characteristics of treated and untreated nonsyndromic craniosynostosis in infancy.

PURPOSE: Nonsyndromic craniosynostosis (NSC) are a group of congenital disorders sharing premature fusion of one or more of the cranial sutures that restricts and distorts growth of the skull and underlying brain. This study examined the neurodevelopmental sequelae of NSC both prior to and following reconstructive cranial surgery. METHODS: Sixty-four consecutive referrals with mixed forms of untreated NSC aged 4 to 16 months (M = 8.9, SD = 2.9) comprised the pre-operative cohort. Forty-four of these patients aged 6 to 32 months (M = 21.2, SD = 4.5) underwent post-operative developmental evaluation. Neurodevelopmental function was assessed with the mental (Mental Development Index) and motor (Psychomotor Development Index) scales of the Bayley Scales of Infant Development-2nd edition. RESULTS: Children with untreated NSC displayed significantly lower mental (M = 97.5) and motor (M = 87.7) scores than normative expectations, with the distribution of scores also differing significantly from the normative distribution. Post-operatively, children continued to display significantly lower mental (M = 89.5) and motor (M = 88.0) abilities, with mental abilities falling significantly lower than pre-operative levels. An increased prevalence of severe motor delay was found, and no child displayed accelerated development. Subgroup comparisons revealed no differences in mental or motor skills between the primary diagnostic subtypes (sagittal and metopic synostosis) both prior to and following corrective surgery. CONCLUSIONS: NSC is associated with an increased incidence of developmental delay in both treated and untreated conditions. Timing of surgery appears unrelated to developmental outcome.

Delayed sagittal sinus tear: a complication of spring cranioplasty for sagittal craniosynostosis.

Spring cranioplasty is now a well-established surgical technique in the treatment of sagittal craniosynostosis. It is widely regarded as a less invasive modality compared with operations such as cranial vault remodeling. Indeed, very few complications have been described in the literature in association with spring cranioplasty. We present a case of delayed sagittal sinus tear with hemorrhage following spring cranioplasty in a 4-month-old patient with sagittal craniosynostosis. Likely causes of the injury are discussed highlighting sagittal sinus injury as a potential risk of spring cranioplasty.

Analysis of morbidity and mortality in surgical management of craniosynostosis.

Multidisciplinary care involving plastic surgery and neurosurgery is generally accepted as optimal to manage craniosynostosis to avoid complications and to identify patients at risk. We conducted a retrospective 30-year review of craniosynostosis surgery at a single major craniofacial institute to establish the rate and predictors of complications. Medical records of 796 consecutive patients who underwent primary surgery for craniosynostosis from 1981 to 2010 at our institute were analyzed for complications. Complications were defined as intraoperative and postoperative adverse events requiring changed management. Reoperation was defined as a repeat transcranial procedure. Multivariate logistic regression was used to identify predictors for complications or revision. Across the years, the procedures evolved from technically simple to complex, which increased complications but better outcomes. Complications occurred in 111 patients (14%), and 33 (5.4%) needed major revision. Multivariate analysis identified multisuture and syndromic craniosynostosis, more recent surgeries, younger age (<9 months), spring-assisted cranioplasty, longer surgery, and greater transfusion as predictors of complications. Patients with syndromic and multisutural craniosynostosis and those operated on younger than 9 months had increased risk of major revision surgery for regression to phenotype. Our experience over 30 years indicates that pediatric transcranial craniosynostosis surgery can be safely carried out in our tertiary referral center. There were no deaths from primary surgery, and complication and reoperation rates mirror those of other published studies. Syndromic and complex craniosynostosis predicted both complications and need for major revision. Spring cranioplasty was associated with higher complications. Overall results support a recommended age for craniosynostosis surgery between 9 and 12 months.

Changing epidemiology of nonsyndromic craniosynostosis and revisiting the risk factors.

Recent studies in Europe and the United States report increased incidence of metopic synostosis. Whether a similar trend had occurred in Australia remains unknown. This research aimed to determine changes in incidence and subtypes of craniosynostosis in Victoria and to identify perinatal risk factors. A retrospective audit of patients (n = 522) presenting to the Royal Children's Hospital in Melbourne with nonsyndromic craniosynostosis from 1982 to 2008 was undertaken. Perinatal data were sourced from the Victorian Perinatal Data Collection. The changes in incidence of craniosynostosis subtypes were calculated based on Poisson regression, and risk factors for craniosynostosis and subtypes were analyzed by univariate logistic regression analysis. The prevalence of nonsyndromic craniosynostosis was 3.1 in 10,000 live births in Victoria. On average, the incidence of nonsyndromic craniosynostosis increased by 2.5% per year among Victorian live births. Over 25 years, metopic synostosis incidence significantly increased by 7.1% per year in the population of Victoria, outpacing other subtypes. The risk factors for metopic synostosis include being male, multiple births (ie, twins), preterm gestation, low birth weight, high maternal age, and emergency cesarean birth. This study revealed a true increase in incidence of metopic synostosis in Victoria, which could be a result of increased frequency of multiple births, preterm gestation, low birth weight, and high maternal age in the Victorian population from 1982 to 2008. The incidence of other nonsyndromic craniosynostoses, which include sagittal, unicoronal, and multisutural craniosynostoses, however, has remained unchanged.

Neurodevelopmental functioning of infants with untreated single-suture craniosynostosis during early infancy.

PURPOSE: Single-suture craniosynostosis (SSC) is a congenital craniofacial disorder, in which premature fusion of one of the skull sutures restricts and distorts growth of the cranium and underlying brain. This disorder of prenatal onset occurs during a critical phase of rapid growth and development of the immature brain. Craniosynostosis carries a known risk of developmental impairment. The neurodevelopmental sequelae of SSC prior to treatment remains however incompletely understood. This study sought to determine the neurodevelopmental sequelae of untreated single-suture craniosynostosis during early infancy. METHODS: Fifty-six consecutive patients with unoperated SSC (sagittal, metopic and unicoronal) comprised the sample cohort. Patients were aged between 4 and 16 months (M = 8.9 months, SD = 2.9 months). Neurodevelopmental functioning was assessed with the mental (Mental Development Index) and motor (Psychomotor Development Index) scales of the Bayley Scales of Infant Development, second edition. RESULTS: Children with SSC displayed significantly lower mean mental (M = 97.7, SD = 6.7, p < 0.05) and motor (M = 87.7, SD = 13.0, p < 0.001) scores than normative population averages. The distribution of these scores also differed significantly from the normative distribution; an increased rate of significant motor developmental delay was found, and none of the children displayed accelerated development. Subgroup comparisons between the primary diagnostic subtypes in this sample revealed no significant differences in mental or motor skill functioning. CONCLUSIONS: Untreated SSC is associated with an increased incidence of developmental delay during early infancy, with motor skills appearing the most vulnerable to impairment during this developmental phase.

Measuring cranial vault volume with three-dimensional photography: a method of measurement comparable to the gold standard.

The gold standard for measuring cranial vault volume is a computed tomography (CT) scan. Computed tomography scans in the pediatric population carry the significant risk of inducing a malignancy later in life. In a novel study, we show that a three-dimensional (3D) photograph can be used to measure and track cranial vault volume changes in craniosynostosis patients. In a study of adequate power as determined by pre hoc analysis, we demonstrate a greater than 0.91 correlation coefficient between volume as measured by CT and 3D photograph in more than 70 patients presenting to a tertiary craniofacial center (P < 0.001). Volume above a plane running through the lateral canthus (ex) and tragus (t) sag-ex-t on the digital 3D photograph differs from CT by a mean percentage difference of 31.9% (SD, 14.0%; 95% confidence interval, P < 0.0001). A linear regression model was used to determine the equation describing the relationship between volume as measured by 3D photograph and CT; with this equation, the absolute volume of the cranial vault is easily determined using only the 3D image. Interrater reliability is high (>0.99, ICC). The ability to measure cranial vault volume from the 3D photograph adds an important dimension to the complete and objective analysis of skull growth and postoperative change.