Posterior Vault Distraction Osteogenesis: Rates of Ossification in Bone Gaps After Consolidation.

ABSTRACT: The authors observe significant bone gaps upon distractor removal in posterior vault distraction osteogenesis (PVDO). The purpose of this study was to quantify bone gaps upon distractor removal, determine whether they close over time, determine if they predispose to relapse, and investigate whether age affects rate and degree of re-ossification. The authors performed a retrospective review of PVDO patients and included those with computed tomography (CT) scans at 2 timepoints: 1 at completion of consolidation and another at least 4 months later. Using Mimics software, bone gaps were traced to calculate total surface area. A paired t test and linear regression were used to compare size of bone gaps, presence of relapse, and rates of re-ossification. Sixty-nine patients were identified, with 7 meeting inclusion criteria. Three were under 1 year. Consolidation began 28.3 ± 6.0 days after surgery and continued for 64.9 ± 14.5 days. Length of time between CT scans was 7.5 ± 2.7 months. A significant decrease in bone gaps occurred between scans (33.4 ± 14.6 cm2 versus 19.2 ± 17.2 cm2, P = 0.005). After consolidation, ossification occurred at a rate of 2.4 cm2/month (P = 0.046). The rate of bony regeneration in patients under and over 1 year was 4.3 cm3/month (P = 0.025) and 1.5 cm3/month (P = 0.552), respectively. Despite differential bony regeneration rates, no patient demonstrated relapse. From this study, the authors conclude the following. Calvarial bone gaps are present after PVDO consolidation. These gaps undergo re-ossification at a rate that appears to be faster in infants. Overall, they decrease in size over time. The presence of bone gaps does not correlate with relapse of cranial expansion.

A Quantification of Scalp Thickness before and after Posterior Vault Distraction Osteogenesis.

SUMMARY: Previous literature has documented craniometric changes of the bony calvaria, increases in intracranial volume, and resolution of Chiari malformations following posterior vault distraction osteogenesis. No studies have analyzed changes to the soft-tissue envelope after posterior vault distraction osteogenesis. In this study, the authors aimed to provide objective measurements of scalp thickness in patients undergoing posterior vault distraction osteogenesis, utilizing facial soft-tissue thickness as a proxy to control for growth. The authors hypothesized that the soft tissues of the scalp are not made thinner by the distraction process, either in the region of distraction or in neighboring areas. Subjects who underwent posterior vault distraction osteogenesis for a craniosynostosis diagnosis who had high-resolution predistraction and post-distractor removal computed tomographic scans within 100 days of each operation were included. The scans were analyzed on Materialise Mimics version 21 software (Materialise, Ghent, Belgium). Six key craniometric landmarks (glabella, pogonion, zygion, vertex, euryon, and opisthocranium) were identified on the three-dimensional bone masks in the Frankfort horizontal plane. The points were overlaid onto soft-tissue thickness masks and thicknesses were recorded. Percent change in postoperative facial soft-tissue thickness was used to control for growth of the craniofacial soft-tissue envelope during the study interval. The preoperative and postoperative posterior vault distraction osteogenesis cohorts did not differ significantly at the glabella, pogonion, opisthocranium, vertex, and zygion. The corrected median thickness at the euryon was significantly increased in the post-posterior vault distraction osteogenesis cohort [2.67 mm (IQR, 2.49 mm to 4.02 mm) versus 5.26 mm (IQR, 3.83 mm to 7.82 mm), p = 0.002]. This is the first study to quantify changes in soft-tissue thicknesses preoperatively and postoperatively in patients undergoing posterior vault distraction osteogenesis, demonstrating maintenance of scalp thickness. . CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Forces Exerted in Craniofacial Distraction Osteogenesis.

BACKGROUND: The purpose of this study was to develop a methodology for quantifying linear forces of distraction osteogenesis, and thereafter apply this methodology to measure and compare distraction force magnitudes between cranial vault distraction osteogenesis (CVDO) and mandibular distraction osteogenesis (MDO). METHODS: Patients undergoing CVDO or MDO as inpatients had distraction forces acquired with a digital torque-measuring screwdriver. Torque measurements were then converted into linear distraction force values, which were then compared across distraction types and protocols with appropriate statistics. RESULTS: CVDO was performed on 7 patients (41.2%), and MDO was performed on 10 patients (58.8%). Across the entire cohort, the average maximum force per activation was 27.0 N, and the average elastic force was 10.7 N. Maximum force (CVDO: 52.9 N versus MDO: 12.9 N; P < 0.001) and elastic force (CVDO: 22.0 N versus MDO: 4.5 N; P < 0.001) were significantly higher in patients undergoing CVDO than MDO. Multivariate regression demonstrated that maximum activation force was significantly associated with sequential days of distraction (B= + 1.1 N/day; P < 0.001), distraction rate (B= + 8.9 N/mm/day; P = 0.016), distractor hardware failure (B= + 10.3 N if failure; P = 0.004), and distraction type (B= + 41.4 N if CVDO; P < 0.001). CONCLUSIONS: Cranial vault distraction requires significantly more linear distraction force than mandibular distraction. Maximum forces increase with each day of distraction, as well as with increased distraction rates. Linear distraction force methodology from this study may provide the foundation for future development of optimized procedure-specific or patient-specific distraction protocols.

Long Term Speech Outcomes Following Midface Advancement in Syndromic Craniosynostosis.

Midface advancement by distraction osteogenesis (DO) is commonly performed in patients with craniosynostosis for indications including midface hypoplasia, exorbitism, obstructive sleep apnea, class III malocclusion, and overall aesthetic facial deficiency. There is evidence to suggest that maxillary LeFort I advancement increases the risk of velopharyngeal dysfunction in the cleft palate population, yet few studies have investigated changes in speech following LeFort III or monobloc midface advancement in patients with syndromic craniosynostosis. The purpose of this study was to examine the effect of midface DO on speech as indicated by the Pittsburgh Weighted Speech Score in patients with Apert, Crouzon, and Pfeiffer Syndrome. Among 73 midface advancement cases performed during the study period, 19 cases met inclusion criteria. Overall, the highest post-advancement Pittsburgh Weighted Speech Score (PWSS) was significantly higher than the pre-advancement PWSS (0.52 versus 2.42, P = 0.01), indicating an acute worsening of VPI post-advancement. Specifically, the PWSS components nasal emission and nasality were significantly higher post-advancement than pre-advancement (nasal emission: 1.16 versus 0.21, P = 0.02) (nasality: 0.68 versus 0.05, P = 0.04). However, there was no significant difference between pre-advancement PWSS and the latest post-advancement PWSS (P = 0.31). Midface distraction is associated with an acute worsening of VPI post-operatively that is followed by improvement, and often resolution over time. Future work with additional patient accrual is needed to determine the effect of different advancement procedures and syndromes on VPI rates and profundity.

Strabismus in Unicoronal Craniosynostosis: Effect of Orbital Dysmorphology and Fronto-Orbital Advancement and Remodeling.

BACKGROUND: The purpose of this study was to determine what craniometric changes occur to both orbits of unicoronal craniosynostosis patients undergoing fronto-orbital advancement and remodeling, and which of these changes are associated with new onset of postoperative strabismus. METHODS: A retrospective analysis was performed of the preoperative and postoperative orbits of 24 unicoronal craniosynostosis patients and the orbits of 24 control subjects, totaling 144 orbits. Eight parameters were evaluated using multivariate logistic regression analysis. One of the parameters was modified orbital index, an indicator of severity of harlequin deformity. RESULTS: Significant differences in orbital dimensions and angles were present bilaterally in unicoronal craniosynostosis orbits when compared to controls. Fronto-orbital advancement and remodeling increased the ipsilateral unicoronal craniosynostosis orbital volume from 13,184 ± 2003 mm to 16,220 ± 2323 mm (p < 0.001). Ipsilateral horizontal cone angles were increased from 48 ± 5 degrees to 54 ± 7 degrees (p = 0.004). Ipsilateral vertical cone angles were decreased from 73 ± 8 degrees to 66 ± 10 degrees (p = 0.003). Ipsilateral modified orbital index improved from 0.83 ± 0.06 to 0.88 ± 0.06 (p = 0.003). Three of the 19 unicoronal craniosynostosis patients developed transient postoperative strabismus. Logistic regression analysis displayed a strong significant association between new-onset strabismus and a change in modified orbital index with a coefficient of 30.84 ± 14.51 (p < 0.05). CONCLUSIONS: The orbital dysmorphology in unicoronal craniosynostosis is bilateral in nature, and it is not wholly treated with conventional fronto-orbital advancement and remodeling. The severity of ipsilateral orbital dysmorphology is correlated with the incidence of postoperative strabismus following conventional fronto-orbital advancement and remodeling. Future research is needed to develop strategies to mitigate the risk of development of strabismus in this group of patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

A Craniometric Analysis of the Posterior Cranial Base After Posterior Vault Distraction.

BACKGROUND: Posterior vault distraction osteogenesis (PVDO) has been demonstrated to effectively increase intracranial volume, treat increased intracranial pressure, and improve head shape in syndromic patients. The purpose of this study is to compare changes along the posterior cranial base before and after distraction. METHODS: A retrospective review was completed of subjects who underwent PVDO with computed tomography scans at 2 time-points: within 3 months preoperatively and 1 to 6 months postoperatively. Using Mimics software, craniometric landmarks were identified and surface area of the foramen magnum was calculated. A comparison of pre- to postoperative measurements was completed using Wilcoxon matched-paired signed rank tests and linear regression. RESULTS: A total of 65 PVDO subjects were identified, 12 subjects met inclusion criteria. Mean operative age was 3.0 ±â€Š4.0 years. The cranial vault was distracted on average 25.0 ±â€Š6.0 mm, with those < 12 months of age distracted 29.5 ±â€Š4.9 mm and >12 months of age distracted 22.0 ±â€Š4.9 mm (P = 0.0543). There was a significant increase in pre- to postoperative foramen magnum surface area (52.1 ±â€Š63.2 mm, P = 0.002), length (0.9 ±â€Š1.4 mm, P = 0.050), and width (0.6 ±â€Š1.0 mm, P = 0.050). Similarly, linear distances between nasion and posterior cranial base landmarks such as foramen magnum (3.4 ±â€Š4.2 mm, P = 0.010), and occipital protuberance (9.1 ±â€Š9.6 mm, P = 0.003) were increased. Subjects under 12 months had a greater percentage increases in posterior vault length than those over 12 months. CONCLUSION: Posterior vault distraction osteogenesis is associated with an increase in size of the foramen magnum, and lengthening of the posterior cranial base, both of which may be beneficial in patients with turribrachycephaly.

Evaluation of parental and surgeon stressors and perceptions of distraction osteogenesis in pediatric craniofacial patients: a cross-sectional survey study.

PURPOSE: There is a paucity of literature on how limitations of distraction osteogenesis (DO) are perceived by physicians and parents of pediatric patients. Specifically understanding which features of DO are most concerning to these two groups may better inform parent education, as well as direct improvements in distraction protocols and devices. METHOD: Parents/guardians of patients (between January 2016 and October 2017) being treated with craniofacial distraction were recruited to complete a survey regarding level of stress (1 = not stressful, 9 = maximally stressful) associated with eight features of DO. Craniofacial surgeons completed a survey asking them to report (1) their personal level of stress and (2) their perceptions of parental stress regarding these same eight features of DO. RESULTS: Thirty-five parents and 15 craniofacial surgeons completed the survey. The risk of the device getting infected was perceived as most stressful by parents (5.5 ± 2.3) followed by the device sticking through the skin (4.9 ± 2.6) and the second operation for removal (4.7 ± 2.3). These same three features also elicited the highest level of stress among surgeons. Surgeon-perceived parental stress regarding turning of the distractor (5.8 ± 1.5) was significantly higher than parent self-reported stress (4.2 ± 2.8, p = 0.042). CONCLUSIONS: Both parents and surgeons perceive risk of device-associated infection, the protrusion of the device through the skin, and the requirement of a second operation for removal as the most stressful drawbacks of distraction. Infection reduction protocols, less obtrusive devices, and devices that do not require removal are potential targets for stress reduction.

Comparative Effectiveness of Retromuscular and Intraperitoneal Repair: What Is the Value of Posterior Sheath Reconstruction?

BACKGROUND: The authors hypothesize that posterior sheath reconstruction to achieve retromuscular mesh placement provides outcomes comparable to traditional retromuscular mesh placement and superior to intraperitoneal repair. METHODS: Patients were divided into three groups: (1) retromuscular mesh placement with repaired posterior sheath defects, (2) retromuscular repair with an intact posterior sheath, and (3) intraperitoneal repair. Primary outcomes included recurrence, surgical-site occurrences, and cost. RESULTS: Overall, 179 patients were included. Posterior sheath defects were repaired primarily with absorbable suture or biological mesh. Recurrence rates differed significantly between standard retromuscular repair and intraperitoneal repair groups (p < 0.009), trended toward significance between repaired posterior sheath and intraperitoneal repair groups (p < 0.058), and showed no difference between repaired posterior sheath and standard retromuscular repair (p < 0.608). Retromuscular repair was clinically protective and cost-effective. CONCLUSIONS: This analysis of posterior sheath reconstruction suggests outcomes comparable to traditional retromuscular repair and a trend toward superiority compared with intraperitoneal repair. Achieving retromuscular closure appears to demonstrate clinical and cost efficacy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

5000 Free Flaps and Counting: A 10-Year Review of a Single Academic Institution's Microsurgical Development and Outcomes.

BACKGROUND: The establishment of an effective clinical and academic culture within an institution is a multifactorial process. This process is cultivated by dynamic elements such as recruitment of an accomplished and diverse faculty, patient geographic outreach, clinical outcomes research, and fundamental support from all levels of an institution. This study reviews the academic evolution of a single academic plastic surgery practice, and summarizes a 10-year experience of microsurgical development, clinical outcomes, and academic productivity. METHODS: A 10-year retrospective institutional review was performed from fiscal years 2006 to 2016. Microsurgical flap type and operative volume were measured across all microsurgery faculty and participating hospitals. Microvascular compromise and flap salvage rates were noted for the six highest volume surgeons. Univariate and multivariable predictors of flap salvage were determined. RESULTS: The 5000th flap was performed in December of 2015 within this institutional study period. Looking at the six highest volume surgeons, free flaps were examined for microvascular compromise, with an institutional mean take-back rate of 1.53 percent and flap loss rate of 0.55 percent across all participating hospitals. Overall, 74.4 percent of cases were breast flaps, and the remaining cases were extremity and head and neck flaps. CONCLUSIONS: Focused faculty and trainee recruitment has resulted in an academically and clinically productive practice. Collaboration among faculty, staff, and residents contributes to continual learning, innovation, and quality patient care. This established framework, constructed based on experience, offers a workable and reproducible model for other academic plastic surgery institutions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Incidence of Cranial Base Suture Fusion in Infants with Craniosynostosis.

BACKGROUND: Cranial base sutures are important drivers of both facial and cranial growth. The purpose of this study was to compare the incidence and location of cranial base suture fusion among three groups: nonaffected controls, patients with nonsyndromic craniosynostosis, and patients with syndromic craniosynostosis. METHODS: Patients and computed tomographic scans were accrued from the authors' prospective craniofacial database. Computed tomographic scans were graded on the frequency of cranial vault and cranial base suture/synchondrosis fusion (0, open; 1, partially/completely fused) by an attending craniofacial surgeon and neuroradiologist. Statistical comparisons were conducted on location and rates of fusion, age, and diagnosis. RESULTS: One hundred forty patients met inclusion criteria: 55 syndromic, 64 nonsyndromic, and 21 controls. Average age at computed tomography of syndromic patients (3.6 ± 3.1 months) was younger than that of nonsyndromic patients (5.4 ± 3.1 months; p = 0.001) and control subjects (5.1 ± 3.2 months; p = 0.058). Syndromic craniosynostotic patients had over three times as many cranial base minor sutures fused (2.2 ± 2.5) as nonsyndromic craniosynostosis patients (0.7 ± 1.2; p < 0.001) and controls (0.4 ± 0.8; p = 0.002), whose rates of fusion were statistically equivalent (p = 0.342). Syndromic craniosynostosis patients had a greater frequency of cranial base suture fusion in the coronal branches, squamosal arch, and posterior intraoccipital synchondrosis (p < 0.05). CONCLUSIONS: Patients with syndromic craniosynostosis have higher rates of cranial base suture fusion in infancy, especially in the coronal arches, and this may have significant implications for both cranial and facial growth. In contrast, patients with nonsyndromic craniosynostosis have similar rates and sites of cranial base suture fusion as controls. Interestingly, there is a low, "normal," rate of cranial base suture/synchondrosis closure in infancy, the implications of which are unknown. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Quality of Life in Adults with Nonsyndromic Craniosynostosis.

BACKGROUND: Although studies have analyzed quality of life in children with nonsyndromic craniosynostosis, to date nobody has investigated long-term quality of life in adults with nonsyndromic craniosynostosis. The purpose of this study was to compare quality of life in adult nonsyndromic craniosynostosis patients with a cohort of unaffected controls. METHODS: The authors queried their institution's prospectively maintained craniofacial registry for nonsyndromic craniosynostosis patients aged 18 years and older, and administered the validated World Health Organization Quality of Life Biomedical Research and Education Foundation questionnaire. Responses were compared, using a two-sample t test, to an age-matched U.S. normative database provided by the World Health Organization. RESULTS: One hundred fifty-one adults met inclusion criteria: 52 were successfully contacted and 32 completed the questionnaire. Average age of respondents was 23.0 ± 6.1 years (range, 18.1 to 42.1 years). Nonsyndromic craniosynostosis patients had a superior quality of life compared with comparative norms in all domains: physical health (17.8 ± 2.7 versus 15.5 ± 3.2; p < 0.001), psychological (16.3 ± 2.9 versus 13.8 ± 3.2; p < 0.001), social (16.9 ± 2.6 versus 13.2 ± 3.6; p < 0.001), and environmental (17.2 ± 2.5 versus 11.7 ± 2.7; p < 0.001). Comparison between single-suture subtypes revealed no difference in any quality-of-life domain (p > 0.05). CONCLUSIONS: Adult patients previously treated for nonsyndromic craniosynostosis perceive their quality of life to be high, superior to that of a normative U.S. SAMPLE: Future work will seek to analyze additional patients and better understand the reasons behind these findings.

Craniometric Analysis of Frontal Cranial Morphology Following Posterior Vault Distraction.

BACKGROUND: Posterior vault distraction osteogenesis (PVDO) is believed to improve frontal contour in infants with syndromic craniosynostosis and turribrachycephaly. This study provides an objective craniometric analysis to determine how PVDO affects anterior cranial morphology. METHODS: A retrospective chart review of patients who underwent PVDO was performed. Inclusion criteria included pre- and postoperative computed tomography (CT) scans within 3 months before surgery and another 1 to 6 months after device removal. Volumetric and craniometric data were derived using Mimics software and compared using paired t-test and Wilcoxon rank-sum test. RESULTS: About 65 patients underwent PVDO, and 13 patients met inclusion criteria. Mean age at intervention was 3.4 ±â€Š4.2 years. Total cranial volume increased 249 ±â€Š159 cm in all patients (P = 0.0001) and 380 ±â€Š128 cm in patients younger than 1 year of age (n = 6, P =0 .0008). Supraorbital retrusion decreased from 5.44 ±â€Š3.89 to 4.54 ±â€Š3.91 mm postoperatively (P = 0.0004), decreasing significantly in patients without previous frontal surgery and not in those with previous frontal surgery (P = 0.2115; comparison P = 0.0047). Basofrontal angle decreased by 2.92 ±â€Š2.16 degrees (P = 0.0004) with a greater decrease of 3.33±2.68 degrees in those younger than 12 months (P = 0.0289) and 2.58±1.74 degrees in those older (P = 0.0079). No change was found in anterior cranial height and anterofrontal angle (P > 0.05). CONCLUSION: PVDO improves frontal contour by decreasing supraorbital retrusion and reducing frontal bossing in syndromic craniosynostosis patients with turribrachycephaly. When combined with its demonstrated efficacy for cranial expansion, these frontal changes likely reinforce PVDO's ability to influence the timing of, and to a degree, the need for frontal surgery in this group.

Posterior Vault Distraction Osteogenesis in Nonsyndromic Patients: An Evaluation of Indications and Safety.

PURPOSE: The purpose of this study was to evaluate the indications, safety, and short-term outcomes of posterior vault distraction osteogenesis (PVDO) in patients with no identified acrocephalosyndactyly syndrome (study) and to compare those to a syndromic cohort (controls). METHODS: Demographic and perioperative data were recorded and compared across the study and control groups for those who underwent PVDO between January 2009 and December 2016. Univariate analysis was conducted using χ and Fisher exact tests for categorical variables, and Mann-Whitney U test for continuous variables. RESULTS: Sixty-three subjects were included: 19 in the nonsyndromic cohort, 44 in the syndromic cohort. The cohorts had similar proportion of subjects exhibiting pansynostosis (42.1% of nonsyndromic versus 36.4% of syndromic, P = 0.667). The nonsyndromic cohort was significantly older (4.04 ±â€Š3.66 years versus 2.55 ±â€Š3.34 years, P = 0.046) and had higher rate of signs of raised intracranial pressure (68.4% versus 25.0%, P = 0.001) than the syndromic cohort. There was no significant difference in perioperative variables or rate of complications (P > 0.05). The mean total advancement distance achieved was similar, 27 ±â€Š6 mm in the nonsyndromic versus 28 ±â€Š8 mm in the syndromic cohort (P = 0.964). All nonsyndromic subjects with signs of raised intracranial pressure demonstrated improvement at an average follow-up of 22 months. CONCLUSION: As in the syndromic patient, PVDO is a safe and, in the short-term, effective modality for cranial vault expansion in the nonsyndromic patient. The benefits and favorable perioperative profile of PVDO may therefore be extended to patient populations other than those with syndromic craniosynostosis.

Spring-Mediated Cranioplasty in Sagittal Synostosis: Does Age at Placement Affect Expansion?

PURPOSE: The aim of this study is to evaluate the effect of timing of surgery and spring characteristics on correction of scaphocephalic deformity in patients undergoing spring-mediated cranioplasty (SMC) for sagittal craniosynostosis. METHODS: The authors conducted a review of patients with sagittal craniosynostosis who underwent SMC at a tertiary referral center between July 2011 and March 2017, with a primary outcome measure of head shape, both preoperatively and postoperatively, determined by cephalic index (CI). Patient demographics and operative details including timing of surgery and spring characteristics were collected. Differences in CI preoperation and postoperation were compared using Wilcoxon signed-rank test. Ordinary least-squares linear regression was used to assess the impact of timing, number of springs, maximum single spring force, and total spring force on postoperative change in CI. RESULTS: Thirty-six subjects (12 males and 24 females) were included in the study. Mean age at spring placement was 3.9 months (range: 1.9-9.2) with a mean follow-up of 1.4 years (range: 0.3-5.2). The mean number of springs used was 3 (range: 2-4). The mean maximum single spring force was 9.9 Newtons (N) (range: 6.9-13.0) and the mean total spring force was 24.6 N (range: 12.7-37.0). Mean CI increased from 70 ±â€Š0.9 preoperatively to 77 ±â€Š1.0 postoperatively (P < 0.001). Age at spring placement was significantly associated with change in CI: for every month increase in age, the change in CI decreased by 1.3 (P = 0.03). The number of springs used, greatest single spring force, and total spring force did not correlate with changes in CI (P = 0.85, P = 0.42, and P = 0.84, respectively). CONCLUSION: In SMC, earlier age at time of surgery appears to correlate with greater improvement in CI, at least in the short-term. While spring characteristics did not appear to affect head shape, it is possible that the authors were underpowered to detect a difference, and spring-related variables likely deserve additional study.

Cleft-Palate Repair: Does Hospital Case-Volume Impact Outcomes or Cost?

BACKGROUND: How hospital case-volume affects operative outcomes and cost continues to grow in importance. The purpose of this study was to examine the relationship of case volume with operative outcomes and cost in cleft palate repair. METHODS: Subjects undergoing cleft palate repair between 2004 and 2015 were identified in the Pediatric Health Information System. Outcomes were compared between two groups: those undergoing treatment at a high-volume institution, and those undergoing treatment at a low-volume institution. Primary outcomes were as follows: any complication, prolonged length of stay, and increased total cost. RESULTS: Over 20,000 patients (n = 20,320) from 49 institutions met inclusion criteria. On univariate analysis, those subjects who underwent treatment at a high-volume institution had a lower rate of overall complications (3.4 percent versus 5.1 percent; p < 0.001), and lower rates of prolonged length of stay (4.5 percent versus 5.8 percent; p < 0.001) and increased total cost (48.6 percent versus 50.9 percent; p = 0.002). In multivariate regression analyses, subjects treated in high-volume centers were less likely to experience any complication (OR, 0.678; p < 0.001) and were less likely to have an extended length of stay (OR, 0.82; p = 0.005). Subjects undergoing palate repair at a high-volume institution were no less likely to incur increased total cost (OR, 1.01; p = 0.805). CONCLUSION: In institutions performing a high volume of cleft palate repairs, subjects had significantly decreased odds of experiencing a complication or prolonged length of stay. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

More Than Meets the Eye: The Effect of Intercanthal Distance on Perception of Beauty and Personality.

In judging normalcy, surgeons rely on established facial anthropometric measures and proportions. However, there exists a range of "normal," and a degree of disproportion may be considered more attractive. The authors set out to determine how changes in only intercanthal distance affect the layperson's perception of beauty and personality traits of a face. The authors used Amazon.com's Mechanical Turk (MTurk), a crowdsourcing tool, to determine how changes in intercanthal distance affect overall perception of beauty and personality. MTurk respondents provided demographic information and were asked to survey 16 female subjects, each digitally edited to be hypoteloric or hyperteloric. Data were collected from 490 MTurk crowd raters. Paired t test analysis found that respondents perceived subjects to be more submissive, friendly, and attractive with increased intercanthal distance (P < 0.05). Women respondents were less likely to perceive change in regards to how unthreatening and how intelligent the subject appeared upon intercanthal widening (P < 0.05). Compared with Caucasian respondents, minorities (Asian- and African-American) were more likely to perceive difference in submissiveness, threat, intelligence, and attractiveness with increased intercanthal distance (P < 0.05). All respondents >46 years of age were less likely to perceive a change in any of the 7 traits upon intercanthal widening, compared with respondents between 18 and 25 years of age (P < 0.05). The layperson perceives significant increases in a female subject's submissivness, friendliness, and attractiveness with an intercanthal distance increase of 10% from normal. Surgeons should be aware of this when correcting hypertelorism, given the potential positive impact of a slightly increased intercanthal distance on perceived beauty and personality.

A Sustainable Model for Patient follow-up following an International Cleft Mission: A Proof of Concept.

PURPOSE: Patient follow-up after cleft missions is imperative if we are to critically assess the quality of care provided in these settings. The adoption of mobile telephones among disadvantaged families abroad may enable such an undertaking in a cost-effective manner. This project aimed to assess the efficacy of cellular phone-based follow-up in a developing country following a cleft mission to Thailand. METHODS: Changing Children's Lives Inc. performed a cleft surgical mission to Udon Thani, Thailand, in January 2013. Telephone numbers collected at that time were used to survey the patients or their parents 1.5 years postoperatively. RESULTS: Of the 56 patients who underwent cleft lip and/or palate surgery during the mission, more than 50% ( n = 30, 54%) were reachable by telephone; all chose to participate in the study. The cost for families was U.S. $124.92 (56.15); 26 families (87%) believed their money was well spent. Follow-up care was received by 22 (73%) patients, and all but one family ( n = 29, 97%) felt that their child received all of the medical care and support required. All families ( N = 30) would recommend similar cleft care to a friend. Of the patients younger than 18 years of age ( n = 24, 80%), 20 (80%) families found their child more comfortable interacting with peers, more comfortable interacting with adults, and more confident postoperatively. CONCLUSION: In one month, a survey response rate of more than 50% was obtained by leveraging the increased adoption of mobile phones in rural settings. Nearly all patients/families treated during the cleft mission were satisfied with the care that they received.

Orthognathic Surgery Has a Significant Effect on Perceived Personality Traits and Emotional Expressions.

BACKGROUND: The effects of orthognathic surgery go beyond objective cephalometric correction of facial and dental disproportion and malocclusion, respectively. The authors hypothesized that there is tangible improvement following surgery that alters publicly perceived personality traits and emotions. METHODS: The authors used Amazon.com's Mechanical Turk (MTurk), a crowdsourcing tool, to determine how preoperative and postoperative images of orthognathic surgery patients were perceived on six personality traits and six emotional expressions based on posteroanterior and lateral photographs. Blinded respondents provided demographic information and were randomly assigned to one of two sets of 20 photographs (10 subjects before and after surgery). RESULTS: Data on 20 orthognathic surgery patients were collected from 476 individuals. The majority of participants were female (52.6 percent), 18 to 39 years old (67.9 percent), Caucasian (76.6 percent), had some college or technical training or graduated college (72.7 percent), and had an annual income between $20,000 and $99,999 (74.6 percent). A paired t test analysis found that subjects were perceived significantly more favorably after orthognathic surgery in 12 countenance categories: more dominant, trustworthy, friendly, intelligent, attractive, and happy; and also less threatening, angry, surprised, sad, afraid, and disgusted (p < 0.05). Raters with the highest annual income perceived a greater magnitude of dominance after surgery than those earning less (p < 0.001). CONCLUSIONS: There is significant improvement in the countenance of patients after orthognathic surgery, with both perceived personality traits and emotions deemed more favorable. Additional work is needed to better understand the physiologic underpinnings of such findings. Crowdsourcing technology offers a unique opportunity for surgeons to gather data regarding laypeople's perceptions of surgical outcomes in areas such as orthognathic surgery.

Craniosynostosis Surgery: Does Hospital Case Volume Impact Outcomes or Cost?

BACKGROUND: The relationships between hospital/surgeon characteristics and operative outcomes and cost are being scrutinized increasingly. In patients with craniosynostosis specifically, the relationship between hospital volume and outcomes has yet to be characterized. METHODS: Subjects undergoing craniosynostosis surgery between 2004 and 2015 were identified in the Pediatric Health Information System. Outcomes were compared between two exposure groups, those undergoing treatment at a high-volume institution (>40 cases per year), and those undergoing treatment at a low-volume institution (40 cases per year). Primary outcomes were any complication, prolonged length of stay, and increased total cost. RESULTS: Over 13,000 patients (n = 13,112) from 49 institutions met inclusion criteria. In multivariate regression analyses, subjects treated in high-volume centers were less likely to experience any complication (OR, 0.764; p < 0.001), were less likely to have an extended length of stay (OR, 0.624; p < 0.001), and were less likely to have increased total cost (OR, 0.596; p < 0.001). Subjects undergoing strip craniectomy in high-volume centers were also less likely to have any complication (OR, 0.708; p = 0.018) or increased total cost (OR, 0.51; p < 0.001). Subjects undergoing midvault reconstruction in high-volume centers were less likely to experience any complications (OR, 0.696; p = 0.002), have an extended length of stay (OR, 0.542; p < 0.001), or have increased total cost (OR, 0.495; p < 0.001). CONCLUSION: In hospitals performing a high volume of craniosynostosis surgery, subjects had significantly decreased odds of experiencing a complication, prolonged length of stay, or increased total cost compared with those undergoing treatment in low-volume institutions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A Volumetric and Craniometric Analysis of Cranial Base Differences in Unicoronal Craniosynostosis.

BACKGROUND: The authors hypothesized that patients with unicoronal craniosynostosis (UCS) have deviation of the vault, cranial base, and face resulting in significant differences in skull base morphology and segmental cranial vault volume relative to nonaffected controls. METHODS: Unicoronal craniosynostosis patients were collected from the authors' IRB-approved, prospective, craniofacial registry; controls were from a trauma registry. Mimics software was used to compare those with UCS to controls for a series of standardized craniometric angles and distances. A segmented volumetric analysis of anterior, middle, and posterior cranial fossae was performed, as well. RESULTS: The study included 18 patients with UCS and 19 controls. Nearly all angles measured were statistically different in UCS versus controls. Overall cranial vault volume did not differ between UCS and controls (P = 0.250). Three volumetric ratios comparing the synostosed side to the contralateral were significantly less than controls: anterior (0.44 ±â€Š0.03 versus 0.5 ±â€Š0.01, P < 0.001), middle (0.45 ±â€Š0.02 versus 0.5 ±â€Š0.02, P < 0.001), posterior (0.46 ±â€Š0.02 versus 0.50 ±â€Š0.02, P < 0.001). The ratio of total middle volume to total cranial volume was larger in UCS patients versus controls, but the posterior ratio was smaller: anterior (0.13 ±â€Š0.02 versus 0.12 ±â€Š0.02, P = 0.545), middle (0.50 ±â€Š0.05 versus 0.42 ±â€Š0.04, P = 0.001), posterior (0.37 ±â€Š0.05 versus 0.45 ±â€Š0.03, P = 0.001). CONCLUSIONS: This study provides quantitative evidence of the degree of angulation and torsion of the cranial base in UCS and its profound effect on volumetric differences in the cranial vault, with significant restriction on the synostosed side and compensatory expansion on the nonsynostosed side. Future work will focus on the effects of volumetric differences on cerebral architecture and postoperative volumetric changes.