A National Assessment of Racial and Ethnic Disparities in Cleft Lip Repair.

PURPOSE: This study examined the impact of patient race/ethnicity on the likelihood of experiencing delays to surgery, post-operative surgical complications, and prolonged hospital length of stay (LOS) following primary cleft lip (CL) repair. METHODS: Patients who underwent CL repair were identified in the 2006-2012 Kids' Inpatient Database. Primary outcomes were defined as treatment after 6-months-old, presence of any surgical complication, LOS >1 day, and total hospital charges. Multivariable analyses were performed to adjust for sociodemographic and clinical characteristics that might account for differences in outcomes. RESULTS: There were 5927 eligible patients with cleft lip: 3724 White, 279 Black, 1316 Hispanic, 277 Asian/Pacific-Islander, and 331 other race/ethnicity. Across all outcomes, there were significant unadjusted differences (p<0.001) by race/ethnicity, with White children having the lowest odds of delayed surgery, complications, and prolonged LOS, and the lowest charges. Multivariable analyses suggested that differences in baseline health status may account for much of this disparity in combination with factors such as income, insurance type, and location. Even after adjusting for co-variates, significantly increased odds of delayed surgery and higher charges remained for Hispanic and Asian/PI patients. CONCLUSION: There are significant differences in the odds of delays, complications, prolonged hospital stays, and total charges among CL patients of different race/ethnicity. Advocacy efforts to ameliorate disparity in early infant health may subsequently improve equity in cleft outcomes.

"The Effects of Gingivoperiosteoplasty and Cleft Palate Repair on Facial Growth."

PURPOSE: Gingivoperiosteoplasty (GPP) can avoid secondary alveolar bone graft in up to 60% of patients. The effects of GPP on maxillary growth are a concern. However, palatoplasty can also negatively impact facial growth. This study quantifies the isolated effects of GPP and cleft palate repair on maxillary growth at the age of mixed dentition. METHODS: A single institution, retrospective study of all patients undergoing primary reconstruction for unilateral cleft lip and alveolus (CLA) or cleft lip and palate (CLP) was performed. Study patients had lateral cephalograms at age of mixed dentition. Patients were stratified into four groups: CLA with GPP (CLA+GPP), CLA without GPP (CLA-GPP), CLP with GPP (CLP+GPP), and CLP without GPP (CLP-GPP). Cephalometric measurements included: sella-nasion-point A (SNA), sella-nasion-point B (SNB), and A point-nasion-B point (ANB). Landmarks were compared between patient groups and to Eurocleft Center D data. RESULTS: 110 patients met inclusion criteria: 7 CLA-GPP, 16 CLA+GPP, 24 CLP-GPP, and 63 CLP+GPP patients. There were no significant differences in SNA, SNB, and ANB between CLA+GPP and CLA-GPP, or between CLP+GPP and CLP-GPP groups. In patients who did not receive GPP, SNA was significantly lower in patients with a cleft palate compared to patients with an intact palate (p < 0.05). There were no significant differences in SNA or SNB of CLP-GPP or CLP+GPP groups when compared to Eurocleft data. CONCLUSION: When controlling for the effects of cleft palate repair, GPP does not appear to negatively affect midface growth at the age of mixed dentition.

Malignant Melanoma in Older Adults: Different Patient or Different Disease?

Objective In this study, we aimed to compare the clinical outcomes between older and younger patients with melanoma and to evaluate for differences in tumor genetic makeup that might explain differences in clinical behavior between older and younger cohorts. Materials and methods A consecutive sample of patients diagnosed with melanoma at a single institution from 1984 to 2019 was categorized by age into younger, middle, and older cohorts. Tumor characteristics, melanoma-specific survival, and recurrence-free survival were assessed while accounting for differential follow-up and death from other causes using Kaplan-Meier analysis with log-rank testing. Results A total of 4378 patients were included in the study. Older patients presented with a higher incidence of T3 and T4 tumors, and a lower incidence of T1 tumors (p<0.001). The same group of patients had a lower nodal positivity at any given Breslow thickness (p<0.01). Melanoma-specific survival was lower for older patients with T2 tumors (p=0.046). There was no difference in recurrence-free survival among all age groups and tumor thicknesses (p>0.05). For patients with a given genetic profile, the melanoma-specific survival and recurrence-free survival were equivalent across ages. BRAF was the most common driver in the younger group, while NRAS and other mutations increased in prevalence as age rose. Conclusions Older adults have decreased melanoma-specific survival for T2 tumors and lower nodal positivity, suggesting a different pattern of metastatic progression. The mutational drivers of cutaneous melanoma change with age and may play a role in the different metastatic progression as well as the differential melanoma-specific survival across all age cohorts.

Clinical Outcomes of Bilateral Cleft Lip and Palate Repair with Nasoalveolar Molding and Gingivoperiosteoplasty to Facial Maturity.

BACKGROUND: The long-term effects of nasoalveolar molding (NAM) on patients with bilateral cleft lip and palate (BCLP) are unknown. The authors report clinical outcomes of facially mature patients with complete BCLP who underwent NAM and gingivoperiosteoplasty (GPP). METHODS: A single-institution retrospective study of nonsyndromic patients with complete BCLP who underwent NAM between 1991 and 2000 was performed. All study patients were followed to skeletal maturity, at which time a lateral cephalogram was obtained. The total number of cleft operations and cephalometric measures was compared with a previously published external cohort of patients with complete and incomplete BCLP in which a minority (16.7%) underwent presurgical orthopedics before cleft lip repair without GPP. RESULTS: Twenty-four patients with BCLP comprised the study cohort. All patients underwent GPP, 13 (54.2%) underwent alveolar bone graft, and nine (37.5%) required speech surgery. The median number of operations per patient was five (interquartile range, two), compared with eight (interquartile range, three) in the external cohort ( P < 0.001). Average age at the time of lateral cephalogram was 18.64 years (1.92). There was no significant difference between our cohort and the external cohort with respect to sella-nasion-point A angle (SNA) [73 degrees (6 degrees) versus 75 degrees (11 degrees); P = 0.186] or sella-nasion-point B angle (SNA) [78 degrees (6 degrees) versus 74 degrees (9 degrees); P = 0.574]. Median ANB (SNA - SNB) was -3 degrees (5 degrees) compared with -1 degree (7 degrees; P = 0.024). Twenty patients (83.3%) underwent orthognathic surgery. CONCLUSION: Patients with BCLP who underwent NAM and GPP had significantly fewer total cleft operations and mixed midface growth outcomes at facial maturity compared with patients who did not undergo this treatment protocol. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Bone Tissue Engineering Strategies for Alveolar Cleft: Review of Preclinical Results and Guidelines for Future Studies.

The current standard of care for an alveolar cleft defect is an autogenous bone graft, typically from the iliac crest. Given the limitations of alveolar bone graft surgery, such as limited supply, donor site morbidity, graft failure, and need for secondary surgery, there has been growing interest in regenerative medicine strategies to supplement and replace traditional alveolar bone grafts. Though there have been preliminary clinical studies investigating bone tissue engineering methods in human subjects, lack of consistent results as well as limitations in study design make it difficult to determine the efficacy of these interventions. As the field of bone tissue engineering is rapidly advancing, reconstructive surgeons should be aware of the preclinical studies informing these regenerative strategies. We review preclinical studies investigating bone tissue engineering strategies in large animal maxillary or mandibular defects and provide an overview of scaffolds, stem cells, and osteogenic agents applicable to tissue engineering of the alveolar cleft. An electronic search conducted in the PubMed database up to December 2021 resulted in 35 studies for inclusion in our review. Most studies showed increased bone growth with a tissue engineering construct compared to negative control. However, heterogeneity in the length of follow up, method of bone growth analysis, and inconsistent use of positive control groups make comparisons across studies difficult. Future studies should incorporate a pediatric study model specific to alveolar cleft with long-term follow up to fully characterize volumetric defect filling, cellular ingrowth, bone strength, tooth movement, and implant support.

Perceived Age and Personality Profiling after Orthognathic Surgery.

BACKGROUND: Recent studies suggest that orthognathic surgery can improve facial age and personality profiling. The authors expand on these findings by assessing the role of patient facial profile and sociodemographics on perceived changes following surgery. METHODS: Preoperative and postoperative images of 65 patients operated on by a single surgeon were randomly assorted and rated by 30 respondents. Patient facial profiles were categorized as convex, concave, or straight. Paired and unpaired t tests were used to assess differences preoperatively and postoperatively. Multivariate regression and post hoc receiver operating characteristic curve analyses were used to quantify the influence of various patient factors. RESULTS: Significant decreases in perceived age were seen following orthognathic surgery overall (-1.31 years; p < 0.01) and in the straight (-1.10 years; p = 0.02) and convex (-1.80 years; p ≤ 0.01) subgroups. After controlling for patient sociodemographics, there were no significant differences in age change based on facial profile. Older age at the time of surgery was independently associated with greater perceived age changes ( p = 0.04); older patients (>26.5 years, determined by receiver operating characteristic curve) experienced greater net decreases in perceived age in comparison to younger patients (-2.0 years versus -1.2 years; p < 0.01). Improvements were seen in overall attractiveness ( p < 0.01) and in each tested personality characteristic following surgery ( p < 0.01). These differences were not significantly associated with different patient sociodemographics or facial profile. CONCLUSIONS: The authors' data add to the growing base of evidence that orthognathic surgery improves patient-perceived age and personality. Significant decreases in perceived age are more likely to be gained by patients undergoing surgery at an older age. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Perceived Age and Attractiveness Using Facial Recognition Software in Rhinoplasty Patients: A Proof-of-Concept Study.

ABSTRACT: Artificial intelligence (Al)-based analyses may serve as a more objective tool for measuring cosmetic improvements following aesthetic plastic surgery. This preliminary proof-of-concept study utilized a novel commercial facial recognition software to assess perceived changes in age and attractiveness among patients receiving rhinoplasty.This study was a retrospective evaluation of three-dimensional photographs of patients who underwent rhinoplasty by the senior author (DS). Both pre- and post-operative (> 12-month follow-up) Vectra three-dimensional images (Canfield Scientific, Parsippany, NJ) were assessed using Haystack AI Software (Haystack AI, New York, NY). Facial attractiveness (score 1-10) and apparent age were predicted. A retrospective chart review of demographic variables was additionally performed. Paired t tests were used to compare age and attractiveness scores before and after surgery. Multivariate linear regression was performed to identify factors associated with age and attractiveness scores.One hundred twenty-four patients receiving rhinoplasty met the study criteria (average age: 35.58). Overall, rhinoplasty was associated with increases in Al-rated attractiveness (+0.28, P = 0.03) and decreases in perceived age relative to the patient's true age (-1.03 years, P = 0.03). Greater decreases in postoperative perceived age were achieved in patients who appeared older than their actual age preoperatively ( P < 0.001).Facial recognition software was successfully used to evaluate improvements in perceived age and attractiveness in patients undergoing aesthetic rhinoplasty. Patients were perceived by the software as younger and more attractive following rhinoplasty. Age reversal was greatest among patients who appeared much older than their actual age at the time of surgery.Level of Evidence: IV.

A Preliminary Management Algorithm for Velopharyngeal Insufficiency in Cleft-Orthognathic Patients.

PURPOSE: Patients born with a cleft palate often suffer from velopharyngeal insufficiency (VPI) due to the soft palate musculature's abnormal structure. Surgical correction of the palate at a young age can hinder maxillary growth, requiring surgical correction of the maxillomandibular discrepancy at skeletal maturity. Orthognathic surgery can then cause or further exacerbate VPi in these patients. The purpose of this paper is to assess cleft-orthog-nathic patients under the lens of persistent or newly-developed VPi, to understand outcomes and generate a targeted management algorithm. METHODS: A retrospective study was performed inspecting cleft-orthognathic patients presenting to a single surgeon. Patients with sufficient follow-up were placed into predefined algorithmic cohorts by their VPi development pattern in relation to orthognathic surgery. They were further stratified into groups by level of adherence to our algorithm to evaluate VPi outcomes. Demographic factors, risk factors, and outcomes were compared between groups via Welch t test and Fisher exact test. RESULTS: Fifty-one patients were examined, including 16 with VPI. Velopharyngeal insufficiency fully resolved amongst all algorithmically adherent patients and remained in nonadherent patients ( P  < 0.001). CONCLUSIONS: Our targeted algorithm may improve symptoms and the management of VPI in cleft-orthognathic patients. Multi-centered studies with larger sample sizes and prospective studies are encouraged to validate our proposed treatment algorithm further.

Race-Based Differences in the Utilization and Timing of Secondary Cleft Procedures in the United States.

Primary CL/P repair, revisions, and secondary procedures-cleft rhinoplasty, speech surgery, and alveolar bone grafting (ABG)-performed from 2014-2018 were identified from the Pediatric National Surgical Quality Improvement Program (NSQIP) database. Utilization estimates were derived via univariable and multivariable logistic regression. A Kruskal-Wallis rank-sum test and multivariable linear regression were used to assess differences in timing for each procedure cohort.The primary outcome measures were the odds of a patient being a certain race/ethnicity, and the age at which patients of different race/ethnicity receive surgery.There were 23 780 procedures analyzed. After controlling for sex, diagnosis, and functional status, there were significant differences in utilization estimates across procedure groups. Primarily, utilization was lowest in patient who were Black for cleft rhinoplasty (OR = 0.70, P = .023), ABG (OR = 0.44, P < .001) and speech surgery (OR = 0.57, P = .012), and highest in patients who were Asian patients in all surgery cohorts (OR 2.05-4.43). Timing of surgery also varied by race, although differences were minimal. CONCLUSIONS: Estimates of utilization and timing of secondary cleft procedures varied by race, particularly among patients who were Black (poor utilization) or Asian (high utilization). Further studies should identify the causes and implications of underutilized and/or delayed cleft care.

Postoperative Edema Resolution Post-Orthognathic Triple Jaw Surgery: A Three-Dimensional Volumetric Analysis.

PURPOSE: The final result following orthognathic surgery may be hidden for months due to postoperative swelling. However, no substantial evidence supports this time estimate. Our study aims to three-dimensionally quantify volumetric changes in facial edema following triple-jaw surgery. MATERIALS AND METHODS: This was a retrospective, three-dimensional (3D) study of patients who underwent primary orthognathic triple jaw surgery (Le Fort I, Bilateral Sagittal Split Osteotomy (BSSO), and osseous genioplasty) by the senior author (DMS). Vectra 3D Software (Canfield, Fairfield, NJ) was used to assess and quantify volumetric changes between serial 3D photos. An inverse line of best-fit was plotted to assess reduction in postoperative facial edema. The effects of gender, age, body mass index, and tranexamic acid administration on swelling resolution were analyzed through mixed linear model analysis. RESULTS: A total of 46 patients (198 images) met the study criteria. The equation for the inverse function line of best fit was y = -13.14ln (x) + 39.54 (P < 0.01). On average, 60% of the swelling resolved in 1 month, 84% after 6 months, and nearly 93% after 12 months. There were no significant differences in the rate of swelling resolution when accounting for age, gender, body mass index, or tranexamic acid administration. CONCLUSIONS: Most facial edema resolved during the first month following triple jaw surgery, with significant reduction in swelling between 6 and 12 months postoperatively. After 1 year, approximately 10% of the initial edema remained.

Which Maturation Indicator is Most Accurate in Predicting Cessation of Facial Growth? A Systematic Review of the Literature.

PURPOSE: The determination of facial growth maturity is crucial before surgical intervention in pediatric patients. To the author's knowledge, there are several indicators of skeletal maturity, but there remains a lack of consensus regarding their application when determining surgical timing. The purpose of this study was to determine the most accurate skeletal maturity indicator in predicting facial growth maturation. MATERIALS AND METHODS: A systematic review was done to determine the most predictive indicator for facial growth maturity. We hypothesized that menses' onset was the most predictive of these maturity indicators. This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A systematic search of MEDLINE, Cochrane, Embase, Scopus databases, and Google Scholar, was done in October 2020 to identify citations related to maturity indicators assessing craniofacial growth. The quality of evidence was determined using the Joanna Briggs Institute Critical Appraisal Checklist for Cohort Studies. RESULTS: Of the 13,289 articles screened, 1 retrospective and 1 prospective study met inclusion criteria. No articles were identified that provided evidence for our hypothesis. Based on the 2 included studies, it was concluded that a handwrist x-ray was more predictive of facial growth cessation (compared to other skeletal maturity indicators). CONCLUSIONS: Based on the literature, handwrist radiography serves as the most predictive method in determining the facial growth maturity. The paucity of articles within this investigation highlights the need for greater research efforts to investigate the predictability of indicators to evaluate facial growth maturation. PROSPERO REGISTRATION NUMBER: CRD42020207388.

Utilizing Age of Menarche to Optimize Pediatric Rhinoplasty.

BACKGROUND/PURPOSE: Pediatric septorhinoplasty has sparked controversial debate amongst craniofacial surgeons, particularly due to its potential growth disturbances of the face and nose. The purpose of this study is (1) to conduct a systematic literature review that explores unique considerations and limitations associated with performing rhinoplasty in the pediatric population; (2) to discuss objective indicators for determining craniofacial skeleton maturation; (3) to perform a case series to further understand whether the age of menarche serves as a good proxy for estimating the time of facial growth maturation, and by extension, whether a post-menarchal patient is a suitable candidate for rhinoplasty. METHODS: Systematic literature review was performed in order to assess unique considerations and limitations of pediatric rhinoplasty. Retrospective chart review and anthropometric (9 linear, 3 angular, 6 indices) measurements were performed for ten pediatric female patients who underwent open septo-rhinoplasty. Follow-up times ranged from 66 to 103 weeks. Patients were separated into 2 cohorts according to age at the time of menarche. Cohort 1 consisted of patients who had undergone menses for longer than 2 years at the time of rhinoplasty, whereas Cohort 2 comprised of patients who either had menses within 2 years of rhinoplasty or did not have menses at the time of rhinoplasty. Data included demographic factors, procedural variables, revision surgeries, and complications. Measurements were conducted using VECTRA software (Canfield Scientific, Parsippany, NJ). Differences in measurements between the 2 postoperative timepoints were compared. RESULTS: Literature review yielded 17 articles, which had conflicting opinions regarding pediatric rhinoplasty and ultimately, highlighting the need for a more objective tool for guiding the decision to perform rhinoplasty.Patients in Cohort 1 had minimal deviations in measurements over time, within the exception of an increase in nasal tip projection and a decrease in nasolabial angle and facial width. Patients in Cohort 2 had decreases in facial height, upper facial height, nasal tip angle, and nasofrontal angle. Nasolabial angle decreased for both cohorts. Of the ten patients, 1 in Cohort 2 underwent revision rhinoplasty. CONCLUSIONS: Our case series suggests that anthropometric measurements remain relatively more stable for patients who have undergone menses for more than 2 years, compared to those who have not. Although this study has limitations, further investigation is warranted in order to determine whether age of menarche may serve as a useful tool for craniofacial surgeons in guiding the decision to perform rhinoplasty.

Major Complications and Associated Risk Factors for Osseous Genioplasty With Bimaxillary Orthognathic Surgery: An American College of Surgeons-National Surgical Quality Improvement Program Analysis.

PURPOSE: Patients with significant dentofacial deformities undergoing aesthetic and functional orthognathic surgery may often require genioplasty to advance the position of the pogonion relative to B point. No study to date has evaluated nationally registered data pertaining to addition of osseous genioplasty to bimaxillary orthognathic surgery and its associated clinical outcomes. METHODS: Data was extracted from the National Surgical Quality Improvement Program from 2010 to 2018 using current procedural terminology codes pertaining to Le Fort I osteotomy (LF), bilateral sagittal split osteotomy (BSSO), and osseous genioplasty (G) and divided into 2 cohorts: bimaxillary orthognathic surgery with and without osseous genioplasty. Thirty-day postoperative outcomes inherently recorded within National Surgical Quality Improvement Program were identified and recorded. Chi-squared analysis and unpaired 2-tail t tests were performed between the cohorts and their respective outcomes to determine significant relationships with significance set as P < 0.05. RESULTS: There were 373 patients double- or triple-jaw patients identified from the years 2010 to 2018. The most common recorded indication for LF/BSSO was maxillary hypoplasia (27.3%) and mandibular hypoplasia (6.8%). The most common indications for LF/BSSO/G were maxillary hypoplasia (16.1%) and maxillary asymmetry (16.1%). In comparison to LF/BBSO only, LF/BSSO/GP was not associated with any differences in the rate of surgical (0.0% versus 0.31%, P = 0.72) or medical complications (0.0% versus 0.63%, P = 0.60), in addition to unplanned readmissions (0.0% versus 1.56% versus P = 0.41) or reoperations (0.0% versus 1.25%, P = 0.46). However, osseous genioplasty addition was associated with increased overall operating time (271.77 versus 231.75 minutes, P = 0.04). CONCLUSIONS: Osseous genioplasty does not alter short-term, 30-day complication rate when performed with bimaxillary orthognathic surgery. As reoperation rates remained relatively unchanged, it can be inferred that immediate adverse events or patient dissatisfaction were not apparent within 30 days. Although mean operating time is slightly longer, cardiopulmonary resuscitation without medical comorbidity was achieved at the conclusion of the procedure.

The Opportunity Cost of Resident Involvement in Adult Craniofacial Surgery: An Analysis of Relative Value Units.

PURPOSE: Within the academic surgical setting resident involvement may confer longer operative times. The increasing pressures to maximize clinical productivity and decreasing reimbursement rates, however, may conflict with these principles. This study calculates the opportunity cost of resident involvement in craniofacial surgery. METHODS: Retrospective analysis was conducted with patients who underwent craniofacial procedures from the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2012. Patients were selected based on relevant Current Procedural Terminology codes for craniofacial pathologies (ie, trauma, head and neck reconstruction, orthognathic surgery, and facial reanimation). Variables included patient demographics, operative time, and presence or absence of resident trainee. Average relative value units were calculated to determine the opportunity cost of resident involvement for each craniofacial procedure. RESULTS: In total, 2096 patients were identified through the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2012. Resident involvement was associated with a statistically significant higher operative time (P < 0.001) for facial reanimation, facial trauma, orthognathic surgery, and head and neck reconstruction. The opportunity costs per case associated with resident involvement were the highest for head and neck reconstruction ($1468.04), followed by orthognathic surgery ($1247.03), facial trauma ($533.03), and facial reanimation ($358.32). Resident involvement was associated with higher rate of complications for head and neck reconstruction (P < 0.043). CONCLUSIONS: Resident involvement is associated with longer operative times, higher complications, and higher re-operations, compared to attending exclusive surgical care. Future studies may consider how reimbursements should align incentives to promote resident education and training.

Aesthetic Repair of Unilateral Cleft Lip using the Modified Inferior Triangle and Adjunctive Techniques.

SUMMARY: Surgical management of unilateral cleft lip is challenging. Correction requires a comprehensive approach to ensure optimal aesthetic outcomes. Various techniques have been proposed for the repair of cleft lip. This article and video vignette highlight the senior author's (D.S.) preferred method for repair of a unilateral cleft lip using a modified inferior triangle technique, a Noordhoff triangular flap for vermillion augmentation, orbicularis oris chemodenervation to reduce tension at the repair site, and autologous fat grafting for lip sculpting.

The Geographic Availability of Certified Cleft Care in the United States: A National Geospatial Analysis of 1-Hour Access to Care.

PURPOSE: Children with cleft lip and/or palate (CLP) require longitudinal multidisciplinary care. Travel distance to comprehensive cleft centers may be a barrier for some families. This study evaluated the geospatial availability of certified cleft teams across the United States. MATERIALS AND METHODS: A geographic catchment area within a 1-hour travel radius of each American Cleft Palate-Craniofacial Association-certified cleft center was mapped using TravelTime distance matrix programming. The proportion of children located within each catchment area was calculated using county-level data from the National Kids Count Data Center, with aggregate estimates of patients with CLP based on state-level data from the Centers for Disease Control and Prevention. One-hour access was compared across regions and based on urbanization data collected from the US Census. RESULTS: There were 182 American Cleft Palate-Craniofacial Association-certified centers identified. As per study estimates, 28,331 (27.3%) children with CLP did not live within 1-hour travel distance to any center. One-hour access was highest in the Northeast (84.2% of children, P < .001) and lowest in the South (65.7%) and higher in states with the greatest urbanization in comparison with more rural states (85.1 vs 37.4%, P < .001). Similar patterns were seen for access to 2 or more cleft centers. The number of CLP children-per-center was highest in the West (775) and lowest in the Northeast (452). CONCLUSIONS: Travel distances of more than 1 hour may affect more than 25,000 (1 of 4) CLP children in the US, with significant variation across geographic regions. Future studies should seek to understand the impact of and provide strategies for overcoming geographic barriers.