Pre-Operative Characteristics Helping to Avoid Gastrostomy Tube After Mandibular Distraction in Neonates With Pierre-Robin Sequence: A Institutional Case-Series and Review of the Literature.

OBJECTIVE: to investigate the ability of mandibular distraction osteogenesis (MDO) to avoid gastrostomy tube (G-tube). DATA SOURCES: PubMed, EBSCOhost, Cochrane, and Embase. REVIEW METHODS: We retrospectively reviewed the number of MDO cases performed at our institution for patients with Robin Sequence (RS) over the past 10 years. In our institutional review, patients were excluded if they had a G-tube already placed at the time of surgery. We also performed a systematic review of the literature. Articles were excluded if they did not detail feeding outcomes after MDO, or if MDO was performed on patients that did not have RS. RESULTS: In our systematic review, 12 articles were included that comprised a total of 209 neonates with RS that underwent MDO. A total of 174 (83.3%) patients avoided a G-tube once MDO was performed. A total of 14 patients met the inclusion criteria at our institution. Of the 14 RS patients, 9 (64%) avoided having a G-tube placed and all (14/14) avoided tracheostomy. The average birth weight of patients avoiding a G-tube was 3.11 kg compared to 2.25 kg (P = .045) in the group requiring a G-tube. In the group avoiding a G-tube, the average weight at time of operation was 3.46 kg compared to 2.83 kg (P = .037) in the group requiring a G-tube. CONCLUSION: MDO may be considered as a surgical option to prevent G-tube placement for neonates with non-syndromic RS who have difficulty with PO feeding but whose airway obstruction is not severe enough to require respiratory support. Based on our institutional experience, a minimum weight of 3.00 kg correlated with higher success rates of PO intake and avoiding a G-tube.

Machine Learning for Automatic Detection of Velopharyngeal Dysfunction: A Preliminary Report.

BACKGROUND: Even after palatoplasty, the incidence of velopharyngeal dysfunction (VPD) can reach 30%; however, these estimates arise from high-income countries (HICs) where speech-language pathologists (SLP) are part of standardized cleft teams. The VPD burden in low- and middle-income countries (LMICs) is unknown. This study aims to develop a machine-learning model that can detect the presence of VPD using audio samples alone. METHODS: Case and control audio samples were obtained from institutional and publicly available sources. A machine-learning model was built using Python software. RESULTS: The initial 110 audio samples used to test and train the model were retested after format conversion and file deidentification. Each sample was tested 5 times yielding a precision of 100%. Sensitivity was 92.73% (95% CI: 82.41%-97.98%) and specificity was 98.18% (95% CI: 90.28%-99.95%). One hundred thirteen prospective samples, which had not yet interacted with the model, were then tested. Precision was again 100% with a sensitivity of 88.89% (95% CI: 78.44%-95.41%) and a specificity of 66% (95% CI: 51.23%-78.79%). DISCUSSION: VPD affects nearly 100% of patients with unrepaired overt soft palatal clefts and up to 30% of patients who have undergone palatoplasty. VPD can render patients unintelligible, thereby accruing significant psychosocial morbidity. The true burden of VPD in LMICs is unknown, and likely exceeds estimates from HICs. The ability to access a phone-based screening machine-learning model could expand access to diagnostic, and potentially therapeutic modalities for an innumerable amount of patients worldwide who suffer from VPD.

What to do with an incidental finding of a fused sagittal suture: a modified Delphi study.

OBJECTIVE: As many as 5% of normocephalic children may have a prematurely fused sagittal suture, yet the clinical significance and best course of management of this finding remain unclear. Providers in the Synostosis Research Group were surveyed to create a multicenter consensus on an optimal treatment and monitoring algorithm for this condition. METHODS: A four-round modified Delphi method was utilized. The first two rounds consisted of anonymous surveys distributed to 10 neurosurgeons and 9 plastic surgeons with expertise in craniosynostosis across 9 institutions, and presented 3 patients (aged 3 years, 2 years, and 2 months) with incidentally discovered fused sagittal sutures, normal cephalic indices, and no parietal dysmorphology. Surgeons were queried about their preferred term for this entity and how best to manage these patients. Results were synthesized to create a treatment algorithm. The third and fourth feedback rounds consisted of open discussion of the algorithm until no further concerns arose. RESULTS: Most surgeons preferred the term "premature fusion of the sagittal suture" (93%). At the conclusion of the final round, all surgeons agreed to not operate on the 3- and 2-year-old patients unless symptoms of intracranial hypertension or papilledema were present. In contrast, 50% preferred to operate on the 2-month-old. However, all agreed to utilize shared decision-making, taking into account any concerns about future head shape and neurodevelopment. Panelists agreed that patients over 18 months of age without signs or symptoms suggesting elevated intracranial pressure (ICP) should not undergo surgical treatment. CONCLUSIONS: Through the Delphi method, a consensus regarding management of premature fusion of the sagittal suture was obtained from a panel of North American craniofacial surgeons. Without signs or symptoms of ICP elevation, surgery is not recommended in patients over 18 months of age. However, for children younger than 18 months, surgery should be discussed with caregivers using a shared decision-making process.

ImageAssist: A Novel Smartphone Application for Standardized Clinical Photography That Implements and Automates American Society of Plastic Surgery/Plastic Surgery Foundation Photographic Guidelines With Background Deletion.

STATEMENT OF THE PROBLEM: Standardized medical photography of the face is a vital part of patient documentation, clinical evaluation, and scholarly dissemination. Because digital photography is a mainstay in clinical care, there is a critical need for an easy-to-use mobile device application that could assist users in taking a standardized clinical photograph. ImageAssist was developed to answer this need. The mobile application is integrated into the electronic medical record (EMR); it implements and automates American Society of Plastic Surgery/Plastic Surgery Research Foundation photographic guidelines with background deletion. INITIAL PRODUCT DEVELOPMENT: A team consisting of a craniofacial plastic surgeon and the Health Information Technology product group developed and implemented the pilot application of ImageAssist. The application launches directly from patients' chart in the mobile version of the EMR, EPIC Haiku (Verona, Wisconsin). Standard views of the face (90-degree, oblique left and right, front and basal view) were built into digital templates and are user selected. Red digital frames overlay the patients' face on the screen and turn green once standardized alignment is achieved, prompting the user to capture. The background is then digitally subtracted to a standard blue, and the photograph is not stored on the user's phone. EARLY USER EXPERIENCE: ImageAssist initial beta user group was limited to 13 providers across dermatology, ENT, and plastic surgery. A mix of physicians, advanced practice providers, and nurses was included to pilot the application in the outpatient clinic setting using Image Assist on their smart phone. After using the app, an internal survey was used to gain feedback on the user experience. In the first 2 years of use, 31 users have taken more than 3400 photographs in more than 800 clinical encounters. Since initial release, automated background deletion also has been functional for any anatomic area. CONCLUSIONS: ImageAssist is a novel smartphone application that standardizes clinical photography and integrated into the EMR, which could save both time and expense for clinicians seeking to take consistent clinical images. Future steps include continued refinement of current image capture functionality and development of a stand-alone mobile device application.

Surgical Complexity and Physician Workload in Craniofacial Surgery: Do RVUs Need to be Adjusted?

RVU valuations need to be revisited regularly as procedure complexity and patient care pathways continue to evolve. The NSQIP-P database was queried for craniofacial procedures performed in North America between 2012 and 2019. Multivariate regression was performed to determine correlation coefficients of perioperative variables deemed to reflect procedure severity, including procedure duration, blood transfusion, length of stay, serious adverse events, related readmission, and related reoperation. CPT 21159 Le Fort III with forehead advancement remains the craniofacial procedure with the highest RVUs using our model at 33.93 units. The most underestimated procedure is CPT 42235 Repair of anterior palate, including vomer flap, with a suggested change of +8.27 units, which is a 194% increase from current compensation. Adjusted RVUs based on quantitative and nationally representative perioperative variables that reflect procedure severity might be a better alternative for procedure valuation over current survey methods to determine appropriate insurance compensation.

Complete Extensive Heterotopic Ossification of the Entire Free Fibula Flap Vascular Pedicle in Maxillary Reconstruction.

INTRODUCTION: Heterotopic ossification is a pathologic extra-skeletal bone formation as a form of aberrant repair process with acquired or genetic etiologies. In plastic surgery, it has been well-described in the burn and trauma patients. Rarely, it can happen along the vascular pedicle of free tissue transfer, and when it happens, it is most commonly in head and neck reconstruction. CASE PRESENTATION: Here we present a case of complete extensive heterotopic ossification of the entire vascular pedicle from the anastomosis to the bone in an osteocutaneous free fibula flap (FFF). The fibula was used as a 2-segment reconstruction for a maxillary defect resulting from a self-inflicted gunshot wound. The skin paddle was used to reconstruct the anterior palatal defect. DISCUSSION: Heterotopic ossification of the FFF vascular pedicle is most reported in the head and neck reconstruction cases. It is rare, but when it happens, it occurs earlier, more commonly, and more extensively in cases of maxillary reconstruction than in cases of mandibular reconstruction. Flap loss due to this sequela has not been reported, and surgical debridement is indicated only when symptomatic. CONCLUSION: Heterotopic ossification of an FFF vascular pedicle is a rare but well-described entity. The periosteal bone formation capacity preservation after revascularization of the flap is thought to be one of the major etiologies of this phenomenon. Hence, some have suggested a modification in the harvesting technique of the FFF that could mitigate return to the operating room, especially when it is for maxillary reconstruction in the trauma patient. Keywords: Keywords: free fibula flap, heterotopic ossification, maxillary reconstruction, mandibular reconstruction.

Easing the Burden on Caregivers- Applications of Artificial Intelligence for Physicians and Caregivers of Children with Cleft Lip and Palate.

OBJECTIVE: Many caregivers of children with cleft lip and palate experience a high level of anxiety throughout their child's medical and surgical care. We aim to evaluate artificial intelligence (AI) as a tool to mitigate these feelings and can aid clinicians in the development of robust pediatric educational materials for caregivers and families. DESIGN: Thirteen of the most common postoperative questions following cleft lip and/or palate repair were developed by an expert panel of senior Pediatric Plastic Surgeons and were posed to ChatGPT. Professional answers from the expert panel were provided and compared to responses from ChatGPT. A literature review was also conducted to generate a new support model for caregivers with children undergoing a surgical procedure. SETTING: Department of Pediatric Plastic Surgery at a metropolitan Children's Hospital. PARTICIPANTS: Senior Pediatric Plastic Surgeons at a metropolitan Children's Hospital. INTERVENTIONS: None. MAIN OUTCOME MEASURE: The primary outcome was to determine the ability of ChatGPT to respond to common postoperative questions and to develop a model for AI assistance in family-centered perioperative care. RESULTS: ChatGPT had a postoperative question response accuracy rate of 69% when compared with subject matter expert responses, with its greatest errors being information errors. An extensive literature search revealed that AI can assist in multiple traditional perioperative strategies to reduce caregivers and patient anxiety. CONCLUSIONS: Artificial Intelligence can help to reduce the burden of generating patient education materials as well as support caregivers in multiple aspects and perioperative care.

Improved Confidence and Clinical Application: The Effects of a Longitudinal Suture Curriculum for Medical Students.

OBJECTIVE: The ability to competently suture is an expected skill for graduating medical students, but many graduates report feeling unprepared to perform this skill. This study aimed to improve student confidence and clinical readiness for third-year clerkships by implementing a novel, mandatory 7.5-hour longitudinal suturing skills curriculum across the first 3 years of medical school. METHODS: The required suturing skills curriculum was implemented for all medical students throughout the first 3 years of medical school at a large academic health center in the mid-South United States. Precurriculum (n = 167) and postcourse (n = 148) surveys were administered to first-year students in the first year of the curriculum (2017-2018), and a parallel follow-up survey was administered to this cohort in 2020 after students completed their clinical clerkship year (n = 82). Aggregate changes in students' survey responses were analyzed for proper instrument position, simple interrupted sutures, and instrument ties using independent groups Mann-Whitney U tests and Rosenthal correlation coefficients for effect sizes. RESULTS: Statistically significant improvement from pre to post was observed in student comfort in performing three basic skills: proper instrument position (P < 0.001), simple interrupted suture (P < 0.001), and instrument ties (P < 0.001). These pre-post gains were sustained at 2-year follow-up (P < 0.001). Also, the majority of students (66%) reported they were very or completely prepared to suture wounds during their clerkships. Most (83%) also reported they had successfully sutured patient wounds during third-year clerkships without needing significant direction or guidance. CONCLUSIONS: We found that a longitudinal suture curriculum with dedicated faculty involvement can improve student confidence in suturing and overall preparedness for third-year clerkships. Although the study is limited to ratings of student comfort and self-reported performance as well as some attrition of responses at postcourse survey and postclerkship survey, the findings highlight the importance of a focused curriculum dedicated to teaching basic suturing skills. Our findings also contribute to the limited body of work examining longitudinal surgical skills development for medical students.

Frontal sinus hypoplasia in unoperated older patients with craniosynostosis: a pilot study.

PURPOSE: The purpose of this study is to determine whether patients with unoperated craniosynostosis have different frontal sinus pneumatization than unaffected controls. METHODS: Retrospective review was performed between 2009 and 2020 of previously unoperated patients with craniosynostosis older than 5 years old at first presentation to our institution. Total frontal sinus volume (FSV) was calculated using 3D volume rendering tool in Sectra IDS7 PACS system. Age-matched normative FSV data was collected from 100 normal CT scans for the control group. The two groups were statistically compared using Fisher's exact test and T-test. RESULTS: Study group included nine patients, 5-39 years old, median age 7 years. Frontal sinus pneumatization was absent in 12% of the normal 7-year-old controls, while frontal sinus pneumatization was absent in 89% of the studied craniosynostosis patients (p < .001). Mean FSV of the study group (113 ± 340 mm3) was significantly different from that of age matched control mean FSV (2016 ± 2529 mm3) (p = .027). CONCLUSIONS: Frontal sinus pneumatization is suppressed in unreleased craniosynostosis and may be an intracranial space conservation phenomenon. This absent frontal sinus can have implications in future frontal region trauma and frontal osteotomies.

An Enhanced Audiologic Protocol for Early Identification of Conductive Hearing Loss in Patients with Cleft Palate.

OBJECTIVE: To characterize the onset and prevalence of conductive hearing loss (CHL) in pediatric patients with cleft palate (CP) prior to palatoplasty with an enhanced audiologic protocol. DESIGN: Retrospective cohort study. SETTING: Multidisciplinary cleft and craniofacial clinic at a tertiary care center. PATIENTS: Patients with CP who received audiologic workup pre-operatively. Patients with bilateral permanent hearing loss, expiration prior to palatoplasty, or no pre-operative data were excluded. INTERVENTIONS: Patients with CP born February 2019 to November 2019 who passed newborn hearing screening (NBHS) received audiologic testing at 9 months of age (standard protocol). Patients born December 2019 to September 2020 underwent testing prior to 9 months of age (enhanced protocol). MAIN OUTCOME MEASURES: Age of identification of CHL in patients after implementation of the enhanced audiologic protocol. RESULTS: The number of patients who passed their NBHS in the standard protocol (n = 14, 54%) and the enhanced protocol (n = 25, 66%) did not differ. Infants who passed their NBHS, but demonstrated hearing loss on subsequent audiologic testing did not differ between enhanced (n = 25, 66%) and standard cohort (n = 14, 54%). Of patients who passed NBHS in the enhanced protocol, 48% (n = 12) had CHL identified by 3 months, and 20% (n = 5) by 6 months of age. With the enhanced protocol, patients who did not undergo additional testing post NBHS significantly dropped from 44.9% (n = 22) to 4.2% (n = 2) (P < .0001). CONCLUSION: Even with passed NBHS, CHL is still present for infants with CP pre-operatively. Earlier and more frequent testing for this population is recommended.

National Trends in Orthognathic Surgery: A Multi-Institutional Analysis of 6640 Patients.

BACKGROUND: LeFort I osteotomy (LF1) and bilateral sagittal split osteotomy (BSSO) have unique operative challenges and inherent anatomic considerations that predispose to certain adverse outcomes, yet their respective complication profiles continue to be debated given conflicting results from single-center investigations. The purpose of this study is to perform a multi-institutional analysis of complications, socioeconomic trends, and financial charges associated with orthognathic surgery. METHODS: A retrospective cohort study was conducted of orthognathic procedures performed in the United States from 2010 through 2020 using the Pediatric Health Information System. Patients younger than 12 years of age were excluded. Medical complications, surgical complications, and admission costs were compared across procedures. Socioeconomic determinants and trends across regions of the country were also analyzed. RESULTS: During the study interval, 6640 patients underwent orthognathic surgery, including LF1 (59.2%, n=3928), BSSO (14.4%, n=959), and double-jaw surgery (26.4%, n = 1753). Patients undergoing LF1 were more likely to experience overall complications ( P <0.001), infections ( P <0.001), and blood transfusions ( P <0.001) than those undergoing BSSO. High-volume hospitals were more likely to perform double-jaw procedures than other hospitals ( P <0.001), yet high-volume hospitals were less likely to have surgical complications ( P =0.014). Patient admission charges related to orthognathic operations at high-volume hospitals were less than other hospitals ( P <0.001). Household income was higher for orthognathic procedures performed at high-volume hospitals ( P <0.001). White patients were 1.5 times more likely to choose a farther, higher volume hospital for orthognathic surgery than the one locally available ( P =0.041). CONCLUSIONS: LeFort I osteotomy procedures had higher infection and transfusion rates than BSSO procedures. High-volume hospitals were more likely to perform double-jaw procedures, yet high-volume hospitals had fewer complications and decreased admission charges. Future study will be needed to further elucidate case-mix index details and socioeconomic determinants of health contributing to these disparities.

Resorbable Versus Titanium Rigid Fixation for Pediatric Mandibular Fractures: A Systematic Review, Institutional Experience and Comparative Analysis.

Study Design: Pediatric mandible fractures mandate special consideration because of unerupted teeth, mixed dentition, facial growth and the inability to tolerate maxillomandibular fixation. No consensus exists as to whether resorbable or titanium plating systems are superior with regards to clinical outcomes. Objective: This study aims to systematically review and compare the outcomes of both material types in the treatment of pediatric mandible fractures. Methods: After PROSPERO registration, studies from 1990-2020 publishing on outcomes of ORIF of pediatric mandible fractures were systematically reviewed according to PRISMA guidelines. An additional retrospective review was conducted at a pediatric level 1 trauma center. Results: 1,144 patients met inclusion criteria (30.5% resorbable vs. 69.5% titanium). Total complication rate was 13%, and 10% required a second, unplanned operation. Complication rates in the titanium and resorbable groups were not significantly different (14% vs. 10%; P = 0.07), and titanium hardware was more frequently removed on an elective basis (P < 0.001). Condylar/sub-condylar fractures were more often treated with resorbable hardware (P = 0.01); whereas angle fractures were more often treated with titanium hardware (P < 0.001). Within both cohorts, fracture type did not increase the risk of complications, and comparison between groups by anatomic level did not demonstrate any significant difference in complications. Conclusions: Pediatric mandible fractures requiring ORIF are rare, and hardware-specific outcomes data is scarce. This study suggests that titanium and resorbable plating systems are equally safe, but titanium hardware often requires surgical removal. Surgical approach should be tailored by fracture anatomy, age-related concerns and surgeon preference.

A multi-institutional survey on calvarial vault remodeling techniques for sagittal synostosis and outcomes analysis for patients treated at 12 months and older.

OBJECTIVE: Surgical treatment of sagittal craniosynostosis is challenging in older patients. This study aimed to assess the effect of increasing age on open surgical technique selection and patient outcomes using the multi-institutional Synostosis Research Group (SynRG) collaboration. METHODS: Surgeons in SynRG were surveyed for key influences on their preferred open calvarial vault remodeling techniques at various patient ages: < 6, 6-12, and > 12 months. The SynRG database was then queried for open repairs of nonsyndromic sagittal craniosynostosis performed for patients older than 12 months of age. Perioperative measures, complications, and preoperative and postoperative cephalic indices were reviewed. RESULTS: All surgeons preferred to treat patients at an earlier age, and most (89%) believed that less-optimal outcomes were achieved at ages older than 12 months. The modified pi procedure was the dominant technique in those younger than 12 months, while more involved open surgical techniques were performed for older patients, with a wide variety of open calvarial vault remodeling techniques used. Forty-four patients met inclusion criteria, with a mean (± SD) age at surgery of 29 ± 16 months. Eleven patients underwent parietal reshaping, 10 parietal-occipital switch, 9 clamshell craniotomy, 7 geometric parietal expansion, 6 modified pi procedure, and 1 parietal distraction. There were no readmissions, complications, or mortality within 30 days postoperatively. Patients' cephalic indices improved a mean of 6.4% ± 4.0%, with a mean postoperative cephalic index of 74.2% ± 4.9%. Differences in postoperative cephalic index (p < 0.04) and hospital length of stay (p = 0.01) were significant between technique cohorts. Post hoc Tukey-Kramer analysis identified the parietal reshaping technique as being significantly associated with a reduced hospital length of stay. CONCLUSIONS: Patient age is an important driver in technique selection, with surgeons selecting a more involved calvarial vault remodeling technique in older children. A variety of surgical techniques were analyzed, with the parietal reshaping technique being significantly associated with reduced length of stay; however, multiple perioperative factors may be contributory and require further analysis. When performed at high-volume centers by experienced pediatric neurosurgeons and craniofacial surgeons, open calvarial vault techniques can be a safe method for treating sagittal craniosynostosis in older children.

Interfacility Transfer Guidelines for Isolated Facial Trauma: A Multidisciplinary Expert Consensus.

BACKGROUND: The objective of this study was to develop guidelines for the transfer of patients with isolated craniomaxillofacial trauma. METHODS: A national, multidisciplinary expert panel was assembled from leadership in national organizations and contributors to published literature on facial reconstruction. The final panel consisted of five plastic surgeons, four otolaryngologist-head and neck surgeons, and four oral and maxillofacial surgeons. The expert panelists' opinions on transfer guidelines were collected using the modified Delphi process. Consensus was predefined as 90 percent or greater agreement per statement. RESULTS: After four Delphi consensus building rounds, 13 transfer guidelines were established, including statements on fractures of the frontal sinus, orbit, midface, and mandible, as well as soft-tissue injuries. Twelve guidelines reached consensus. CONCLUSIONS: The decision to transfer a patient with craniomaxillofacial trauma to another facility is complex and multifactorial. While a percentage of overtriage is acceptable to promote safe disposition of trauma patients, unnecessarily high rates of secondary overtriage divert emergency medical services, increase costs, delay care, overload tertiary trauma centers, and result in tertiary hospital staff providing primary emergency coverage for referring hospitals. These craniomaxillofacial transfer guidelines were designed to serve as a tool to improve and streamline the care of facial trauma patients. Such efforts may decrease the additional health care expenditures associated with secondary overtriage while decompressing emergency medical systems and tertiary emergency departments.