A Scoping Review of Innervated Breast Reconstruction.

BACKGROUND: After breast surgery, patients experience significant alterations to breast sensation, which can diminish quality of life. Nerve coaptation technique, introduced in the 1990s, has gained traction in recent years. We performed a scoping review of the literature to determine the available outcomes in sensate breast reconstruction. METHODS: The review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews statement guidelines. EMBASE and PubMed databases were queried using standardized terminology. Studies were included if they reported original sensory outcomes following innervation techniques during breast reconstruction and were published from January 1, 1990, to April 18, 2022. Data extraction and analyses were performed on Microsoft Excel. RESULTS: From 602 screened articles, 27 studies met the inclusion criteria. Innervated autologous reconstructive procedures were described in 24, whereas the remaining 3 (all published after 2019) described direct reinnervation of the nipple-areola complex. Most (88.9%) of the studies comparing innervated versus noninnervated reconstruction reported improved sensory outcomes in at least 1 modality. Two studies investigated patient-reported outcomes using validated questionnaires, both of which reported improvement with innervated reconstruction. CONCLUSIONS: Sensate breast reconstruction has the potential to improve outcomes for patients. There is a recent progressive increase in studies involving direct nipple-areolar reinnervation. Larger, prospective studies are needed to better characterize the quality-of-life outcome using validated scales, as well as evaluate sensory and patient-reported outcomes with implant and autologous reconstruction.

Alterations in Sphenoid Anatomy in Craniosynostosis: Implications for Fronto-Orbital Advancement.

OBJECTIVE: Fronto-orbital advancement involves removal of the fronto-orbital bandeau. Visualization of the saw blade is lost as it passes through the fronto-orbital-sphenoid junction (FOSJ), placing the temporal lobe at risk of injury. We aim to provide a 3D analysis of the space surrounding this osteotomy to differentiate various types of craniosynostoses. DESIGN: Retrospective cohort. SETTING: Institutional. PATIENTS: Thirty patients with isolated unicoronal synostosis, nonsyndromic bicoronal synostosis, metopic synostosis, Apert syndrome, Crouzon syndrome, and Muenke syndrome. INTERVENTIONS: CT scans conducted between 2 months to 2 years of age were 3D reconstructed to compare craniometrics against normal controls. MAIN OUTCOME MEASURE(S): Craniometrics. RESULTS: The mean bone thickness of the FOSJ at the level of the supraorbital rim was significantly small for the Apert, unicoronal and bicoronal groups. The mean vertical height of the middle cranial fossa from the lesser sphenoid wing was significantly greater in the unicoronal group. The mean vertical height of the tip of the temporal lobe from the lateral sphenoid ridge was greater in the unicoronal, isolated bicoronal, and Apert groups. The mean corneal protrusion beyond the lateral orbital rim was significantly greater in the Apert and unicoronal groups. The mean horizontal depth of the orbit was smallest in the Apert group. The mean vertical distance between the dacryon and the foramen cecum, and the mean volume of temporal lobe beneath the sphenoid shelf were the largest in the Apert group. CONCLUSIONS: Patients with Apert syndrome have the most unfavorable morphology of the anterior and middle cranial fossae.

Comparison of methodologies for craniofacial soft-tissue cephalometrics: The value of virtual reality.

BACKGROUND: Myriad options are available for plastic surgeons to perform soft-tissue analysis, which is vital to perioperative evaluation and research. Our objective is to compare the accuracy, precision, and efficiency of the available cephalometric modalities for conducting facial soft-tissue measurements. METHODS: Twenty soft-tissue facial measurements were performed by 5 measurers with varying experiences on 5 adult subjects, using 6 methods-manual calipers, cone-beam CT, virtual reality (VR), 3D stereophotogrammetry, iPad-based 3D photogrammetry, and 2-dimensional photographs. Measurement sessions were timed and performed in triplicate, for a total of 9000 measurements. Intraclass correlation coefficient (ICC) was calculated for accuracy and one-way ANOVA was used for comparison. The coefficient of variation (CoV) was compared among groups to evaluate the precision of different methods by considering caliper measurements as the gold standard. RESULTS: ICC among raters was 0.932, indicating excellent reliability. VR was significantly faster than other methods (137 s vs. 217 s for caliper, p < 0.001). CoV was the highest for 2D photographs and the lowest for VR (11.0 vs. 6.4, p < 0.001). The CoV of the caliper was similar to that of other methods, except for 2D photography, which was significantly higher. Measurements with the greatest absolute difference from caliper measurements, across modalities, were those around the eyes (left to right exocanthion), tragion to antitragion, and tragion to exocanthion. CONCLUSION: 2D photography is not an accurate method for cephalometric measurements. VR had the lowest variation between measurements, and was the fastest and equivalent to caliper measurements in accuracy. For studies involving a large number of cephalometrics, VR measurements may be a good option to improve study throughput.

Virtual Reality Planning in Reconstructive Surgery for Orbital Prosthetic Rehabilitation Using ImmersiveTouch Platform: Preliminary Report.

BACKGROUND/PURPOSE: Virtual reality (VR) is emerging as an effective and intuitive surgical planning and 3D visualization tool. Digital surgical planning is the gold standard for planning the placement of implants in maxillofacial prosthetics, but the field lacks a platform exclusively designed to perform the task. Virtual reality planning (VRP) specific for maxillofacial prosthetics offers the clinician improved control of the presurgical planning and the potential to limit the need to adapt other advanced segmentation software. Furthermore, the virtual plan can be directly translated to the patient through custom 3D printed (3DP) surgical guides and visual aids. To the best of our knowledge, this article outlines the development of the world's first virtual reality planning platform and workflow for pre-operatory planning within a VR environment for clinical use specific to facial prosthetics and anaplastology. METHOD: The workflow was applied to managing 2 patients presenting with unilateral total exenteration and severe contracture enucleation, respectively (n=2). A cone-beam CT was acquired for each patient, and their data set was directly imported into the ImmersiveView Surgical Plan VR environment (ImmersiveTouch Inc, Chicago, IL). The clinicians virtually selected appropriately sized craniofacial implants and placed the implants in the desired orientation. Various measurement tools are available to aid in clinical decision-making. The ideal location of craniofacial implants was set according to an orbital and auricular prosthetic reconstruction. The resultant VR plan was exported for 3DP. The patients were evaluated preoperatively and postoperatively using the proposed VRP treatment. The workflow's data accuracy was validated postoperatively by comparing posterative CT data and the proposed VRP. Analysis was performed using Mimics software (Materialise, Leuven, Belgium). RESULT: It takes, on average, 10 minutes to place 4 implants in the virtual reality space. The 3DP files resulting from VRP take ~2 hours to print and are constructed with a biocompatible resin appropriate for clinical use as surgical guides. Our user-friendly VRP workflow allows for an accurate simulation of surgical and nonsurgical procedures with an average displacement in XYZ of 0.6 mm and an SD of 0.3 mm. In addition, VRP is an excellent tool to simulate the craniofacial placement procedure and improves unsupervised self-learning teaching. CONCLUSION: VRP is an exciting tool for training clinicians and students in complex surgical procedures. This study shows the promising applicability and efficiency of VR in clinical planning and management of facial rehabilitation. Patients allowed to interact with VR have been engaged, which would aid their treatment acceptance and patient education. A valuable advantage of surgical simulation is the reduced costs associated with renting instruments, buying implant dummies, and surgical hardware. The authors will explore VR to plan and treat surgical and nonsurgical reconstructive procedures and improve soft tissue manipulation. This study outlines the development of an original platform and workflow for segmentation, preoperative planning, and digital design within a VR environment and the clinical use in reconstructive surgery and anaplastology.

Craniometric and Aesthetic Outcomes in Craniosynostosis Surgery: A Systematic Review and Meta-Analysis.

OBJECTIVE: To systematically review the published comparative aesthetic outcomes, and its determinants, for craniosynostoses surgically treated by minimally-invasive cranial procedures and open cranial vault remodeling (CVR). DESIGN: PRISMA-compliant systematic review. SETTING: Not-applicable. PATIENTS/PARTICIPANTS: Articles were included if they compared spring cranioplasty, strip minimally-invasive craniectomy or CVR for outcomes related to aesthetics or head shape. Forty-two studies were included, comprising 2402 patients. INTERVENTIONS: None. MAIN OUTCOME MEASURE(S): The craniometric and PROM used to determine surgical outcomes. RESULTS: Twenty-five studies (59%) evaluated sagittal craniosynostosis, with metopic (7;17%) and unicoronal (4;10%) the next most prevalent. Thirty-eight studies (90%) included CVR, 24 (57%) included strip craniectomy with helmeting, 9 (22%) included strip craniectomy without helmeting, 11 (26%) included spring cranioplasty, and 3 (7%) included vault distraction. A majority of studies only used 1 (43%) or 2 (14%) craniometric measures to compare techniques. In sagittal synostosis, 13 (59%) studies showed no difference in craniometric outcomes, 5 (23%) showed better results with CVR, 3 (14%) with strip craniectomy, and 1 (5%) with springs. In studies describing other synostoses, 10/14 (71%) were equivocal. Subjective outcome measures followed similar trends. Meta-analysis shows no significant difference in cranial index (CI) outcomes between CVR and less invasive procedures in patients with sagittal synostosis. CONCLUSIONS: There is no difference in CI outcomes between CVR and less invasive procedures. The majority of literature comparing craniometric and aesthetic outcomes between CVR and less invasive procedures shows equivocal results for sagittal synostosis. However, the heterogeneity of data for other craniosynostoses did not allow meta-analysis.

Virtual Reality and Augmented Reality in Plastic and Craniomaxillofacial Surgery: A Scoping Review.

Virtual reality (VR) and augmented reality (AR) have evolved since their introduction to medicine in the 1990s. More powerful software, the miniaturization of hardware, and greater accessibility and affordability enabled novel applications of such virtual tools in surgical practice. This scoping review aims to conduct a comprehensive analysis of the literature by including all articles between 2018 and 2021 pertaining to VR and AR and their use by plastic and craniofacial surgeons in a clinician-as-user, patient-specific manner. From the initial 1637 articles, 10 were eligible for final review. These discussed a variety of clinical applications: perforator flaps reconstruction, mastectomy reconstruction, lymphovenous anastomosis, metopic craniosynostosis, dermal filler injection, auricular reconstruction, facial vascularized composite allotransplantation, and facial artery mapping. More than half (60%) involved VR/AR use intraoperatively with the remainder (40%) examining preoperative use. The hardware used predominantly comprised HoloLens (40%) and smartphones (40%). In total, 9/10 Studies utilized an AR platform. This review found consensus that VR/AR in plastic and craniomaxillofacial surgery has been used to enhance surgeons' knowledge of patient-specific anatomy and potentially facilitated decreased intraoperative time via preoperative planning. However, further outcome-focused research is required to better establish the usability of this technology in everyday practice.

Patient-specific Composite Anatomic Models: Improving the Foundation for Craniosynostosis Repair.

Preoperative surgical planning incorporating computer-aided design and manufacturing is increasingly being utilized today within the fields of craniomaxillofacial, orthopedic, and neurosurgery. Application of these techniques for craniosynostosis reconstruction can include patient-specific anatomic reference models, "normal" reference models or patient-specific cutting/marking guides based on the presurgical plan. The major challenge remains the lack of tangible means to transfer the preoperative plan to the operating table. We propose a simple solution to utilize a digitally designed, 3D-printed "composite model" as a structural template for cranial vault reconstruction. The composite model is generated by merging the abnormal patient cranial anatomy with the "dural surface topography" of an age-matched, sex-matched, and ethnicity-matched normative skull model. We illustrate the applicability of this approach in 2 divergent cases: 22-month-old African American male with sagittal synostosis and 5-month-old White male with metopic synostosis. The aim of this technical report is to describe our application of this computer-aided design and modeling workflow for the creation of practical 3D-printed skulls that can serve as intraoperative frameworks for the correction of craniosynostosis. With success in our first 2 cases, we believe this approach of a composite model is another step in reducing our reliance on subjective guesswork, and the fundamental aspect of the workflow has a wider application within the field of craniofacial surgery for both clinical patient care and education.

Cranial Shape Changes in Nonsyndromic Unilateral Lambdoid Synostosis after Open Posterior Vault Remodeling.

BACKGROUND: The purpose of this study was to quantify change in cranial morphology in patients with nonsyndromic unilateral lambdoid craniosynostosis (ULC) from presentation (t0), after open posterior switch-cranioplasty (t1), and at 2-year follow-up (t2). METHODS: Volumetric, linear, and angular analysis were performed on computed tomographic scans at the three time points and against normal control subjects. Significance was set at P < 0.05. RESULTS: Twenty-two patients were included. ULC cranial vault asymmetry index was higher than in control subjects before surgery (6.22 ± 3.55) but decreased after surgery (3.00 ± 2.53) to become comparable with the normal asymmetry range present in the controls. After surgery, both diagonals increased, but more on the fused side. In the 2 years after surgery, both diagonals in patients with ULC grew proportionately, but the fused diagonal remained slightly shorter than the patent side. Total cranial volume was higher in patients with ULC than in control subjects after surgery but became comparable at t2. Cranial base angulation improved by t2 but did not approach normal, and ear position remained unchanged. The facial twist was higher than in controls at t0 and t1 but was comparable at t2. Coronal asymmetry improved with surgery but remained undercorrected at t2, with the greatest residual asymmetry at opisthion. CONCLUSIONS: Open-switch cranioplasty normalizes cranial vault asymmetry index by increasing the fused cranial diagonal more than the patent side and is stable at 2 years. Skull base twist does not normalize, but facial twist approaches normal. Technique improvement should focus on residual coronal asymmetry present at opisthion. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Positional Plagiocephaly and Craniosynostosis.

Along with the decrease in sudden infant death syndrome due to the successful "Back to Sleep" Campaign, there was a reciprocal increase in cases of positional plagiocephaly (PP). The prevalence of PP significantly rose from approximately 5% to upward of 46% at age 7 months. Consequently, clinicians have seen a surge in the number of patients presenting with head shape abnormalities. Not only does this increase in patient volume pose a logistical problem to clinics, but it also poses a potential risk to patients with craniosynostosis, whose head shape anomalies are similar to a "needle in a haystack" of patients with more common PP. This review explores the causes, risk factors, and treatment options of PP and craniosynostosis, along with the differential of head shape anomalies based on phenotypic presentation. In doing so, we hope to provide pediatric care clinicians with the tools necessary to effectively evaluate and manage patients with head shape abnormalities. [Pediatr Ann. 2023;52(1):e10-e17.].

Primary Cleft Rhinoplasty: A Systematic Review of Results, Growth Restriction, and Avoiding Secondary Rhinoplasty.

BACKGROUND: Primary rhinoplasty during correction of unilateral cleft lip continues to be a topic of debate because of concerns that early nasal intervention may affect nasal and maxillary development over the long term. This study aims to determine the volume and quality of evidence for and against primary unilateral cleft rhinoplasty. METHODS: A systematic review was performed adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles were pulled from PubMed and EMBASE and screened by title and abstract. Studies with human participants undergoing rhinoplasty at the time of unilateral cleft lip repair and some evaluation of the nasal outcome were included. Studies with a large proportion of syndromic patients, case reports, editorials, letters, reviews, studies exclusive to bilateral clefts, and studies not available in English were excluded. Those that met criteria were then systematically reviewed. RESULTS: Twenty-five articles were included. Ten articles that assessed the results of primary rhinoplasty subjectively all supported cleft lip repair with primary rhinoplasty. Sixteen articles assessed the results of primary rhinoplasty objectively, with 15 supporting primary rhinoplasty during cleft lip repair. Eight of nine studies that evaluated nasal growth and development over time found no restriction in nasal development. Five studies with a follow-up period of at least 6 years found that the percentage of patients who avoided revision rhinoplasty ranged from 43% to 100%. There were significant risks of bias in the majority of studies. CONCLUSION: The majority of studies reviewed support that primary rhinoplasty during unilateral cleft lip repair results in good outcomes with limited or no effect on nasal growth.

Differences in Practice in Alveolar Bone Grafting Among American Cleft Palate-Craniofacial Association Members.

The purpose of this study is to determine areas of agreement and disagreement among American Cleft Palate-Craniofacial Association (ACPA)members in the clinical practice of alveolar bone grafting (ABG), to guide further research to optimize ABG practices.A cross-sectional survey was conducted.The respondents were in an academic, combination, or private practice.The respondents were either plastic or oral and maxillofacial surgeons (OMFS) from various countries.A de-identified 24-question online survey was distributed to ACPA surgeon members utilizing the Research Electronic Data Capture (REDCap) tool.Data collected included surgeon specialty, use of various alveolar bone graft surgical techniques, as well as protocols.There was more variability than consensus between specialties with regards to the preoperative workup, timing of surgery, materials used for bone graft, surgical techniques, perioperative management, and postoperative evaluation. There was consensus on grafting during mixed dentition, not staging soft and hard tissue closure, and using iliac crest for primary and secondary grafting. Disagreements involved factors used to time the procedure and type of imaging used to assess viability. Technical differences involved incision type, part of bone grafted, use of minimally invasive technique, and material used for revisions.Aside from areas of consensus among surgeons on ABG, several areas, including use of bone substitutes in revision grafting, incision and type of iliac crest graft used during initial grafting, and postoperative protocols, had no consensus. These areas should be targets of further research to determine if there truly is an optimal method to perform ABG.The study was approved by the University of Illinois at Chicago Institutional Review Board. A de-identified 24-question online survey was distributed to surgeon members of the ACPA utilizing the REDCap tool on August 7, 2020. The survey questions consisted of multiple choice and multiple selection questions including an option to select "other" and specify the information in a blank space. Data collected included surgeon specialty, use of various alveolar bone graft surgical techniques, as well as pre and postoperative protocols. The full survey is included in online Supplemental material. Data analysis was performed in SPSS Statistics 27 (IBM Corp.). Descriptive statistics were performed, and chi-square was used to test for significant differences in survey responses between groups.

A Systematic Review of Primary Rhinoplasty in Patients With Bilateral Cleft Lip.

BACKGROUND: Primary rhinoplasty (PR)at the time of cleft lip repair is controversial. We previously performed a systematic review that supported PR during unilateral cleft lip repair. We now aim to determine whether the same idea translates to care of patients with bilateral cleft lip. METHODS: A systematic review was conducted adhering to Preferred Reporting Items for Systematic Reviews and Meta-analysis statement guidelines. PubMed and Embase databases were searched for studies that met our inclusion criteria: (1) English language, (2) human subjects, (3) rhinoplasty at the time of bilateral cleft lip repair, and (4) evaluation of nasal outcome. Studies were excluded in case of: (1) inclusion of a large proportion of syndromic patients, (2) case reports, (3) editorials, (4) letters, (5) reviews, and (6) exclusive to unilateral clefts. Out of 281 studies that showed up on initial search, 12 were included in our review. Research quality and level of evidence rating were determined for each study. RESULTS: Of the 12 included studies, 9 supported PR at the time of bilateral cleft lip repair; 8 studies evaluated nasal growth and found no restriction over time; 4 studies followed 158 patients to an average of 15 years and showed 77% did not need secondary rhinoplasty. CONCLUSION: Although the available literature supports PR in patients with bilateral cleft lip with respect to subjective and objective outcomes, nasal growth, and reducing the need for secondary/revision rhinoplasty, there are significant limitations, necessitating large volume studies.

The Effect of Wearing a Mask on Facial Attractiveness.

Background: The COVID-19 pandemic necessitated masking in public spaces. Masks may impact the perceived attractiveness of individuals and hence, interpersonal relations. Objectives: To determine if facial coverings affect attractiveness. Methods: An online survey was conducted using 114 headshot images, 2 each-unmasked and masked-of 57 individuals. Two hundred and seven participants rated them on an ordinal scale from 1 (least attractive) to 10 (most attractive). Parametric and nonparametric tests were performed, as appropriate, for comparison. Results: For the first quartile, the average rating increased significantly when wearing a mask (5.89 ± 0.29 and 6.54 ± 0.67; P = 0.01). For control images ranked within the fourth quartile, the average rating decreased significantly when wearing a mask (7.60 ± 0.26 and 6.62 ± 0.55; P < 0.001). In the female subgroup (n = 34), there was a small increase in average rating when masked, whereas in the male subgroup (n = 23), there was a small decrease in average rating when masked, but the change was not statistically significant (P > 0.05). For unmasked female images ranked within the first quartile, the average rating increased significantly when wearing a mask (5.77 ± 0.27 and 6.76 ± 0.36; P = 0.001). For the female subgroup with mean ratings within the fourth quartile, the average decreased significantly when wearing a medical mask (7.53 ± 0.30 and 6.77 ± 0.53; P < 0.05). For unmasked male images ranked within the first quartile, the average rating increased when wearing a medical mask but the change was not statistically significant (P > 0.05), whereas for the control male images within the fourth quartile, the average rating decreased significantly when masked (7.72 ± 0.18 and 6.50 ± 0.54; P < 0.05). Conclusions: While wearing a facial covering significantly increased attractiveness for images less attractive at baseline, and decreased attractiveness for those that are more attractive at baseline; it did not cause a significant overall change in attractiveness in the study population.

A Novel Method of Fibula Flap In Situ Distraction Osteogenesis Prior to Flap Transfer.

BACKGROUND: The fibula flap is the workhorse for mandibular reconstruction, but fibula bone width is not ideal to match mandibular height. In this study, in situ widening of the fibula with distraction osteogenesis before transfer is evaluated as a solution. The authors present a proof of concept of this technique with a patient series, including one patient who has undergone subsequent orthognathic surgery of the reconstructed mandible. METHODS: A retrospective review of patients undergoing the authors' technique was performed. A longitudinal fibula osteotomy was made in situ and distraction was performed in the leg to widen the fibula. After distraction and consolidation periods, flaps were osteotomized and transferred to the mandible. RESULTS: This technique was applied to three patients (ages 9, 11, and 13 years) with Pruzansky III mandibular hypoplasia at the authors' institution over 15 years. In all cases, bony union was achieved. Mean surgical follow-up was 5 years. No significant morbidity occurred at the donor sites. Partial flap resorption was observed a number of years postoperatively in one patient. Temporomandibular joint ankylosis developed in one patient after closed treatment of an unrelated mandible fracture. A sinus tract developed in one patient, requiring débridement of a partial flap necrosis. One patient had orthognathic surgery, including osteotomy of the fibula. CONCLUSIONS: In situ fibula distraction osteogenesis is a novel technique to prelaminate a fibula flap before transfer to the mandible. This method allows for the reconstruction of challenging mandibular defects without compromising bone height, pedicle length, or the ability to perform orthognathic surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Lefort II distraction with zygomatic repositioning versus Lefort III distraction: A comparison of surgical outcomes and complications.

The aim of the study was to determine if the additional surgical complexity of Lefort II distraction with zygomatic repositioning (LF2ZR) results in increased complications compared to Lefort III distraction (LF3). A retrospective review was performed of all LF3 and LF2ZR advancements performed by the senior author over 15 years. Demographic, operative, postoperative, and cephalometric data were collected from initial procedure through greater than 1 year postoperatively. Univariate and multivariate analyses were performed to compare procedures. 19 LF2ZR and 39 LF3 in 53 patients met inclusion criteria. Diagnoses differed between procedures, with more Crouzon Syndrome in LF3 and more Apert Syndrome in LF2ZR. Complication rate was 7/19 for LF2ZR and 12/39 for LF3 with no severe morbidity or mortality, and no difference between procedures (p = 0.56). The types of complications encountered differed between procedures. LF2ZR had a significantly longer operative time (506 ± 18 vs. 358 ± 24 min, p<0.001). However, a greater number of LF2ZR patients underwent concomitant procedures (15/19 vs. 13/39, p<0.001). Multivariate analysis revealed that Apert Syndrome and reoperative midface advancement were the most significant predictors of increased blood loss. LF2ZR has an equivalent complication rate to LF3. Therefore, it is our treatment of choice for cases requiring differential sagittal and vertical distraction of the central midface.

Postoperative Quality of Life in Patients with Hidradenitis Suppurativa Utilizing the Hidradenitis Suppurativa Burden of Disease Tool.

Background Hidradenitis suppurativa (HS) severely impacts patients' quality of life (QoL). Surgery has shown potential in improving a patient's QoL in severe disease. Previous studies have evaluated QoL after surgery, but lack a disease-specific questionnaire to better evaluate the unique burden of disease that patients with HS experience. Objective To measure postoperative QoL in patients with HS using a modified version of the disease-specific questionnaire, the Hidradenitis Suppurativa Burden of Disease (HSBOD) Tool. Methods A retrospective study was conducted using 19 patients who underwent surgery for HS. A demographic form and a 19-item disease-specific questionnaire were emailed to patients who consented to complete the survey. Patient-reported outcomes were recorded on a 0-100 scale (100 representing the highest burden of disease). Results Of the 24 patients that received the survey, 19 completed it in its entirety. The mean±SD Burden of Disease (BoD) score for each of the five domains assessed by the survey were: symptoms and feelings (62±27), daily activities (65±30), leisure (57±31), work and school (48±32), and personal relationships (56±27). Pearson's correlation between the number of surgeries each patient underwent and their reported BoD scores were not significant. BoD scores were significantly higher in the symptoms and feelings domain for complex closure compared to both secondary intention and split-thickness skin grafting (STSG). Conclusion Despite having surgery, patients with hidradenitis still report impaired QoL. Further study is ongoing to determine how these measures compare to baseline preoperative values. This instrument provides a valuable tool to determine QoL in patients with hidradenitis.

Perioperative Management of Cleft Lip Repair: A Meta-Analysis and Clinical Practice Guideline.

OBJECTIVE: Few studies have focused on perioperative management of cleft lip repair. We sought to evaluate the available data on this topic to create evidence-based clinical guidelines. DESIGN: Systematic review, meta-analysis. METHODS: A PubMed search was performed focusing on perioperative management of cleft lip repair. Studies were included if they included comparative data. A systematic review and meta-analysis was performed according to preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. MAIN OUTCOME MEASURES: Systematic review of literature regarding wound closure, postoperative arm restraints, perioperative antibiotics, outpatient or ambulatory surgery, or feeding restrictions postoperatively. RESULTS: Twenty-three articles met inclusion criteria after initial screening of 3103 articles. This included 8 articles on wound closure, 2 on postoperative restraints, one on perioperative antibiotics, 6 on outpatient surgery, and 6 on postoperative feeding. Meta-analysis could be performed on dehiscence rates with postoperative feeding regimen and readmission rates after outpatient versus inpatient lip repair. There were few studies with low risk of bias. Outpatient cleft lip repair does not increase readmission (odds ratio [OR]: 0.92, 95% CI: 0.28-3.07). Allowing postoperative breastfeeding or bottle-feeding does not increase dehiscence (OR: 0.61, 95% CI: 0.19-1.95). There was no evidence of publication bias. CONCLUSION: Within the limitations of available data, there is no evidence of a clearly superior closure material. The evidence does not support use of postoperative arm restraints. The evidence does not support the use of preoperative nasal swabs for antibiotic guidance. With careful patient selection, outpatient cleft lip repair appears safe. The evidence supports immediate breastfeeding or bottle-feeding after cleft lip repair.

Magnitude of Horizontal Advancement is Associated With Apnea Hypopnea Index Improvement and Counter-Clockwise Maxillary Rotation After Subcranial Distraction for Syndromic Synostosis.

PURPOSE: Subcranial midface distraction is used to treat central midface deficiency in syndromic synostosis. Our aim was to determine which maxillary movements were associated with improvement in measures of obstructive sleep apnea. METHODS: This was a retrospective cohort study that reviewed patients with syndromic midface retrusion and documented sleep apnea who underwent subcranial midface distraction via either Le Fort 3 osteotomy or Le Fort 2 osteotomy with zygomatic repositioning. The predictor variables measured on cephalograms were the magnitude and direction of midface and mandibular movements. The primary outcome was the change in the apnea hypopnea index (AHI) from polysomnography before and after surgery. The secondary outcomes were volumes of upper airway containing bone spaces calculated from computed tomography scans. Data analysis included linear regression to estimate the effect of distraction vectors on bone space volumes and AHI changes. RESULTS: We included 18 patients primarily with Crouzon or Apert syndrome. The magnitude of distraction in a horizontal direction was the most significant factor for AHI improvement and primarily expanded the nasopharyngeal space, but with a smaller impact on the oral cavity space. Clockwise palate rotation was most influenced by a downward direction of distraction, with 24° below horizontal creating a neutral advancement. The greater the magnitude of advancement, the more likely a counterclockwise rotation was observed. CONCLUSIONS: Horizontal magnitude of advancement had the greatest impact on AHI improvement. Vertical lengthening and closure of anterior open bite deformities can be done without compromising airway results as long as total advancement is not compromised. Palate rotation is best controlled by a downward distraction vector, but counterclockwise rotation increases with greater advancement.

Evolution of Cranioorbital Shape in Nonsyndromic, Muenke, and Saethre-Chotzen Bilateral Coronal Synostosis: A Case-Control Study of 2-Year Outcomes.

BACKGROUND: The purpose of this study was to quantify change in cranioorbital morphology from presentation, after fronto-orbital advancement, and at 2-year follow-up. METHODS: Volumetric, linear, and angular analyses were performed on computed tomographic scans of consecutive bilateral coronal synostosis patients. Comparisons were made across three time points, between syndromic and nonsyndromic cases, and against normal controls. Significance was set at p < 0.05. RESULTS: Twenty-five patients were included: 11 were nonsyndromic, eight had Saethre-Chotzen syndrome, and six had Muenke syndrome. Total cranial volume was comparable to normal, age-matched control subjects before and 2 years after surgery despite an expansion during surgery. Axial and sagittal vector analyses showed advancement and widening of the lower forehead beyond control values with surgery and comparable anterior position, but increased width compared to controls at 2 years. Frontal bossing decreased with a drop in anterior cranial height and advanced lower forehead position. Middle vault height was not normalized and turricephaly persisted at follow-up. Posterior fossa volume remained lower at all three time points compared to control subjects. Supraorbital retrusion relative to anterior corneal position was overcorrected by surgery, with values comparable to those of control subjects at 2 years because of differential growth. There was no difference at 2 years between syndromic and nonsyndromic groups. CONCLUSIONS: Open fronto-orbital advancement successfully remodels the anterior forehead but requires overcorrection to be comparable to normal at 2 years. Although there are differences in syndromic cases at presentation, they do not result in significant morphometric differences on follow-up. Posterior fossa volume remains lower at all time points. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.