Safety Profile Comparison of 2 Smooth Tissue Expander Types: Artoura and CPX4.

INTRODUCTION: With the recent transition to smooth tissue expanders (TEs), functional differences between TE subtypes have not been fully elucidated. This study evaluated the differences in TE characteristics and complications between 2 commonly used Mentor smooth TE models, Artoura and CPX4. METHODS: A retrospective review of patients who received either smooth Mentor Artoura or CPX4 TE from 2012 to 2022 was conducted. Demographic data, perioperative information, pain scores, TE variables, cancer characteristics, and complications were collected. A multivariate analysis was used to evaluate the relationship between TE subtype and complications while controlling for demographic, TE characteristics, radiation, and chemotherapy exposure. RESULTS: During the study period, 62 smooth Artoura TEs and 79 smooth CPX4 TEs were used. Patients who received CPX4 smooth implants tended to be older (51.09 vs 46.18 years old, P = 0.02) and have a higher body mass index (28.66 vs 23.50 kg/m 2 , P < 0.001). There were no differences among patient comorbidities. CPX4 required on average a greater total fill volume (422.23 vs 348.07 mL, P = 0.01) and had a greater drain duration (16.91 vs 14.33 days, P = 0.05). There were no differences in TE plane placement between Artoura and CPX4. Additionally, there were no differences in complication rates, including infection, hematomas, seromas, wound breakdown, TE replacement, and capsular contracture. When controlling for body mass index, diabetes, TE plane placement, acellular dermal matrix use, radiation exposure, and chemotherapy, there was no association between TE subtype and any individual complication. DISCUSSION: Differences in total fill volume and drain duration were significantly different between Mentor Artoura and CPX4 implants, which may influence TE subtype selection. However, Artoura and CPX4 have excellent and equivalent safety profiles with similar complication rates, even when controlling for demographic and TE characteristics.

Quantification of Cephalometric Changes in Gonial Angle Morphology Following Facial Feminization Surgery.

Facial feminization surgery (FFS) is a type of gender-affirming surgery aimed at bringing masculine facial features more in line with typically feminine characteristics. Specifically, mandibular contouring can create a softer jawline and help create a more round, feminine face. As the popularity of FFS continues to increase, improving surgical techniques and patient satisfaction is imperative. However, no quantitative measurement system currently exists to measure these changes. In this study, the authors describe the use of a novel segmentation technique using computerized tomography imaging to quantify the bony changes that occur during gonial angle reduction. Further, authors utilize this technique to describe changes in a cohort of 13 patients, and how these changes correlate with patient satisfaction. The authors found that gonial angle volume and surface area significantly decreased, as well as the intergonial:interzygomatic ratio, with a smaller ratio associated with more feminine features. In addition, patient satisfaction significantly increased post-operatively both specifically regarding jawline appearance (P = 0.0014) and regarding overall social and psychological function (P = 0.0021 and P = 0.0032, respectively), as captured by the FACE-Q and World Health Organization Quality of Life (WHOQOL) surveys. Patients with greater changes in surface area reported greater improvements in WHOQOL psychological scores (P = 0.0086), and patients with greater changes in the intergonial:interzygomatic ratio reported greater improvements in WHOQOL social scores (P = 0.0299). Overall, our novel technique captures significant changes in gonial angle shape and can be applied to a wide range of future studies to improve the quality and accessibility of FFS.

Quantification of Changes in Chin Morphometric Parameters Following Feminization Genioplasty.

Genioplasty is frequently performed in facial feminization surgery, typically aiming to reduce chin height and projection for more feminine appearance. Quantification of the bony changes occurring during surgery have to date not been published. This study presents a method for segmentation of the chin using CT imaging to quantify changes to the chin after feminization genioplasty. CT scans of 21 patients before and after feminization genioplasty were segmented in Mimics to isolate the chin region. Surface area, volume, vertical chin projection, and horizontal chin projection were measured before and after surgery. Patient outcomes were evaluated using the FACE-Q and World Health Organization Quality of Life patient-reported outcome measures. Surface area, volume, and vertical chin projection demonstrated statistically significant decreases after surgery. The magnitude of changes in surface area and vertical chin projection were significantly associated with their presurgical values. In particular, patients with greater presurgical vertical projections experienced greater decreases in vertical projection after surgery, with some patients having increases in postsurgical vertical projection. Patient FACE-Q scores improved significantly on all scales, including chin, jawline, and neck satisfaction. This study demonstrates a method for evaluating bony changes on CT scan after feminization genioplasty. The measured changes cohere with the changes expected to create a more feminine chin. Furthermore, changes created by feminization genioplasty are in the context of the patient's overall facial harmony and are not uniform across all patients.

Quality and Readability of Accessible Facial Feminization Literature: Where Can We Improve?

BACKGROUND: Facial feminization surgery (FFS) consists of multiple, complex procedures. Well-informed patients have been shown to have better outcomes and expectations. However, there is limited data evaluating FFS patient-oriented material online. This study aims to evaluate the quality and readability of FFS literature online. METHODS: Facial feminization surgery-related terms were queried in Google with location, cookies, and user account information disabled. Websites were analyzed for readability using Flesch Reading Ease and Flesch-Kincaid Reading Grade Level, suitability using the suitability assessment of materials (SAM), and quality using the DISCERN scale. Unpaired t tests and χ2 tests were used to compare the websites of community-based and academic or public institutions. RESULTS: One hundred twenty websites met inclusion criteria (71 community-based and 49 academic). The average reading grade level was 11.68 ± 1.71. The average SAM score was 53.11 ± 11.75, denoting adequate readability. Only 16.67% of websites contained visual aids to assist in explaining procedures and benefits. Overall, 68.33% of websites' DISCERN score was rated very poor or poor, whereas only 8.33% were rated as good. The following DISCERN elements had the lowest scores across all graded websites: "clear source and date of information," "details of additional source of support," "refers to areas of uncertainty," and "describes risks of each treatment." Websites published by community-based institutions were significantly better in describing how FFS works and the benefits of each procedure. Academic sites overall were less biased (4.84 vs 4.62, P = 0.03) and provided additional sources of support (2.35 vs 1.32, P = <0.001). CONCLUSIONS: Online FFS patient resources should be written at a more inclusive reading level and should increase the use of pictorial aids to improve patient comprehension. Facial feminization surgery patient resources were significantly above the recommended sixth grade reading level for health literature. Academic and community-based institutions should include more information about procedural risks and limitations in surgical outcomes to ensure a broader scope of understanding.

Pediatric Facial Burns and Consumer Products: A Nationwide Analysis.

Pediatric facial burns pose significant challenges in terms of physical, psychological, and social impacts on children. Understanding the causes of these burns is crucial for prevention and appropriate care. This study aims to provide a comprehensive analysis of causes and preventive measures related to pediatric facial burns caused by consumer products. Using data from the National Electronic Injury Surveillance System (NEISS) from 2012 to 2021, we analyzed 130,461 cases of pediatric facial burns. Common causes included household items such as cleaning supplies, hot water, kitchen appliances, and health and beauty products. Differences in burn causes were observed between genders, with boys more prone to burns from welding equipment, gasoline, and grills, while girls were more susceptible to burns from hair curling equipment, candles, and health and beauty products. The mean age of children burned by different items varied, highlighting the need for age-appropriate preventive measures. The authors discuss the importance of caregiver education, safe storage practices, supervision, and clear communication in preventing pediatric facial burns. By raising awareness of potential burn sources and implementing preventive strategies, the incidence of pediatric facial burns can be significantly reduced.

Virtual Surgical Planning in Craniosynostosis Reduces Operative Time and Length of Stay for Cranial Vault Remodeling.

Cranial vault remodeling (CVR) with and without frontal orbital advancement remodels the skull in craniosynostosis. Virtual surgical planning (VSP) for preoperative planning has been previously shown to be effective in CVR. In this study, the authors aimed to evaluate the impact of VSP on operative and perioperative efficiency for craniosynostosis surgery. A retrospective chart review was conducted of patients with craniosynostosis who underwent CVR. Patient demographics, perioperative variables, use of VSP, and complications were obtained. Perioperative variables collected include operative time and length of stay. An independent t test was used to compare variables from patients who had surgery with VSP and patients who did not. Records were available for 126 patients with craniosynostosis who underwent CVR of whom 79 (62.7%) utilized VSP. There was no difference in average age at surgery (9.3±5.7 mo versus 13.2±31.1 mo, P =0.39). Surgeries planned using VSP demonstrated a decreased operative time of 1.3 hours (3.7±1.1 versus 5.0±1.1 h, P <0.001) and a shorter length of stay (3.9±1.3 versus 4.6±1.7 d, P =0.01). There were no differences in complication rates of dehiscence, infection, returns to the operating room, or 30-day readmission. These trends were similar among patients who underwent fronto-orbital advancement in addition to CVR. Virtual surgical planning was associated with decreased operative time and length of stay for patients with craniosynostosis and comparable complication rates. Virtual surgical planning is an effective tool for reducing anesthetic exposure time.

Assessment of Sex Diversity Among Craniofacial Academic Faculty.

Sex diversity among plastic surgery and its subspecialties faculties lags behind many medical specialties. Despite the significant evidence in favor of diversity in leadership, female presence in high-ranking positions in medicine is lacking across multiple specialties. In this study, we aim to evaluate sex disparity among faculty across craniofacial fellowship programs by comparing the disparities among total number of faculty, program directors, years in practice, and academic rank. Our sample included 354 individuals including 193 craniofacial surgery journal editorial board members, 130 craniofacial surgery academic faculty members, and 31 craniofacial surgery association board members. A significant difference (P-value <0.0001) was seen among male and female craniofacial surgery faculty with 84.6% males. Faculty members were further subdivided by academic rank. A significant difference was found between the number of male and female faculty members at all academic positions (P-value =0.043). Of 41 full professors, 2.4% were female. There were 42 associate professors queried with 14.3% female. Similarly, 43 assistant professors were identified with 32.0% female. Years in practice after completing terminal training were analyzed across the academic faculty. There was a significant difference in the number of male and female faculty members across all experience levels (P-value =0.0037). Among the faculty with <10 years since completion of terminal training, 32.4 % were female. For faculty with 10 to 20 years after post-terminal training, 19.6% were female. For those with 20 to 30 years of experience, 0% were female. Finally, for the faculty with over 30 years since graduation, 5.9% were female. Board membership in 2 craniofacial surgery organizations was analyzed: the American Cleft Palate-Craniofacial Association and the American Society of Maxillofacial Surgeons. Among the 17 board members of the American Cleft Palate-Craniofacial Association, 8 (47.1%) were female. For the American Society of Maxillofacial Surgeons, 5 (35.7%) were female. Data were collected for 193 editorial board members from 2 craniofacial surgery journals. There was a significant difference between the number of male and female members across both journals (χ2 value: 33.3570; P-value <0.0001). Among 56 editorial board members from Cleft Palate-Craniofacial Journal, 26 (46.4%) members were female. In comparison, Journal of Craniofacial Surgery has 24.8% female editorial board members. Sex diversity among faculty members is really important and should be brought into light to highlight and improve areas of particular importance and of tremendous potential impact. Given our results, surgical residencies and fellowship programs should begin to show concrete commitment and increase their efforts to recruit and retain a diverse faculty not only for the educational benefit but more importantly to achieve a higher level of care for all.

Technique for Cephalometric Analysis of the Craniofacial Skeleton Following Facial Feminization Surgery.

Facial feminization surgery (FFS) is characterized by a series of relatively diverse procedures aimed at aligning skeletal and soft tissue facial appearance with one's experienced feminine gender. Although there are several well-described outcomes from surgical techniques, there is no standardized methodology to provide reliable analyses of postoperative FFS outcomes. This paper describes the first reliable and reproducible technique to accurately and consistently measure post-FFS changes to guide surgical planning to optimize patient outcomes.

Tranexamic Acid in Facial Feminization Surgery: Quantifying a High-risk Setting With Exogenous Estrogen Supplementation.

Tranexamic acid (TXA) has been increasingly utilized in orthognathic surgery, aesthetic surgery, and craniofacial surgery. However, the risk of increasing venous thromboembolic events (VTE) must be carefully considered as TXA is a prothrombotic agent. Our study aimed to investigate the safety of TXA in the setting of facial feminization surgery. These patients are at an elevated risk for VTE at baseline given their uniform history of exogenous estrogen supplementation. A retrospective review of all patients that underwent facial feminization surgery at our medical center between December 2015 and September of 2022 was performed. Demographic information, procedure type, Caprini scores, hematoma rate, VTE rate, estimated blood loss, and operative time were all studied. Unpaired t tests were used to compare patients that received TXA and those who did not. In total, there were 79 surgeries performed during our study period. There were 33 surgeries (41.77%) that used TXA intraoperatively. Ten patients (12.65%) received anticoagulation postoperatively, 5 of whom received TXA intraoperatively. Of the 33 patients who received TXA, 30 patients remained on estrogen therapy. There was no statistically significant difference in VTE rates in patients who received TXA (n=33, 41.77%) and those who did not (n=46, 58.23%). Bleeding events, Caprini scores, estimated blood loss, and operative time were also not found to be significantly different between the 2 cohorts. The authors found no significant increase in VTE in facial feminization patients undergoing estrogen supplementation when intraoperative TXA was utilized. This is the first known report investigating the safety of TXA in this higher risk patient population.

Cost Comparison of Digital Nerve Repair Techniques.

PURPOSE: Direct cost comparison of nerve allograft with other techniques for repairing short digital nerve gaps are lacking. This study compares the costs of various techniques for digital nerve repair, anticipating significant cost increases for allograft implants. METHODS: The State Ambulatory Surgery and Services Database for Florida, New York, and Wisconsin from 2015-2020 was used. Patients with primary repair, short autograft, conduit, and allograft were compared along total, surgical supply, operating room (OR), and anesthesia charges. RESULTS: Among 5,009 patients were 2,967 primary nerve repairs (59.2%), 77 autografts (1.5%), 1,647 conduits (32.9%), and 318 allografts (6.3%). 2,886 patients were male (57.6%) with mean age 40.4 ± 16.3 years. Over the study period, primary repairs decreased (63.9% in 2015 to 56.3% in 2020) while allografts increased significantly (8.8% in 2018 to 12.6% in 2020).Median total charges significantly varied across procedures, with the most expensive being allograft ($35,295), followed by conduit ($25,717), autograft ($24,749), and primary repair ($18,767). On multivariable regression, allograft is significantly more expensive than autograft for total charges by $11,224 (95CI: $4,196-$18,252) and supply charges by $10,484 (95CI: $6,073-$14,896), but not for OR or anesthesia charges. Flexor tendon repair was associated with greater total, OR, and anesthesia charges but similar supply charges. CONCLUSIONS: Nerve allograft is the most expensive digital nerve repair technique most likely due to the cost of the implant. To minimize health care expenditure and ensure equitable patient access, surgeons should consider this cost along with clinical factors in choosing digital nerve repair techniques.

Facial Lacerations Related to Recreational Activities: A National 10-Year Evaluation From US Emergency Departments.

Study Design: This study serves as a nationally representative retrospective cohort of U.S emergency department visits related to facial lacerations caused by recreational activities. Objective: The aim of this work is to offer a representative sample of facial laceration and identify the recreational activities associated with the highest risk of such injuries. Methods: We conducted a retrospective study of patients reported to the National Electronic Injury Surveillance System (NEISS) which collects information on injuries related to consumer products. Patients were included in our dataset from the time period of 2012 to 2021 if they sustained a facial laceration that was caused by a recreational activity. Results: Our findings reveal 2,383,761 facial lacerations between the study period examined. Young male white adults were more likely to sustain a facial laceration related to recreational activities. Injuries related to exercise equipment were also more likely seen in male patients. The most common cause of facial lacerations was associated with bicycles and basketball. Conclusions: This study found that young white adults are notably prone to facial lacerations, with recreational activities such as bicycling and basketball accounting for the majority of cases. Understanding these statistics is pivotal for implementing targeted strategies to prevent these injuries and their associated consequences.

A Nationwide Analysis on Major Upper Extremity Amputations and Replantations.

BACKGROUND: The loss of an upper extremity is a severely disabling condition made medically challenging by the limited window for replantation. This study aims to investigate the burden of traumatic major upper extremity amputations in the United States and uncover possibilities for improvements in treatment. METHODS: The Healthcare Cost and Utilization Project's National Inpatient Sample was screened for International Classification of Diseases-9/10 diagnosis/procedure codes for traumatic and nontraumatic major upper extremity amputations and replantations within the years 2008 to 2017. The resulting pool of cases was analyzed for multiple variables, including level of injury, patient demographics, hospital type and location, length of stay, costs, comorbidities, and complications. RESULTS: A total of 15 155 major upper extremity amputations were recorded, of which 15.20% (n = 2305) were traumatic amputations-almost half of them related to the upper arm (49.6%; P = .0002). The great majority of replantations, however, was conducted at the lower arm level (87.4%; P < .0001), with an overall replantation rate of 22.3%. Nontraumatic amputations were overall associated with significantly higher burden of comorbidities relative to traumatic amputations except for long-term alcohol use (P < .0001). Both, amputations and replantations, were predominantly treated in large urban teaching hospitals, and were significantly more likely to occur in white men. The Southern region of the United States was handling the highest proportion of amputations in the United States, but had the lowest likelihood of replantation. CONCLUSION: This study provides an overview of the national trends in major traumatic upper extremity amputations and replantations, revealing potential health care shortcomings.

Understanding the Drivers of Cost and Length of Stay in a Cohort of 21,875 Patients with Severe Burn.

Burn management has significantly advanced in the past 75 years, resulting in improved mortality rates. However, there are still over one million burn victims in the United States each year, with over 3,000 burn-related deaths annually. The impacts of individual patient, hospital, and regional demographics on length of stay (LOS) and total cost have yet to be fully explored in a large nationally representative cohort. Thus, this study aimed to examine various hospital and patient characteristics using a sample of over 20,000 patients. Inpatient data from the National Inpatient Sample from 2008 to 2015 were analyzed, and only patients with an ICD-9 code for second- or third-degree burns were included. In addition, a major operating room procedure must have been indicated on the discharge summary for patients to be included in the final dataset, ensuring that only severe burns requiring complex care were analyzed. Analysis of covariance models was used to evaluate the impact of various patient, hospital, and regional variables on both LOS and cost. The study found that skin grafts and fasciotomy significantly increased the cost of hospitalization. Having burns on the face, neck, and trunk significantly increased costs for patients with second-degree burns, while burns on the trunk resulted in the longest LOS for patients with third-degree burns. Infections in the hospital and additional procedures, such as flaps and skin grafts, also led to longer stays. The study also found that the prevalence of postoperative complications, such as electrolyte imbalance, was high among patients with burn surgery.

FACE-Q Satisfaction Ratings Are Higher After Facial Feminization Surgery Than Hormone Replacement Therapy Alone.

Purpose: Facial feminization surgery (FFS) is associated with improved psychological outcomes in transgender patients. We aimed to evaluate the impact of FFS on patient satisfaction with facial appearance using validated, patient-reported outcome tools. Methods: Patients were recruited to complete a FACE-Q survey at least 6 months after their FFS. FACE-Q modules used included "Satisfaction with Facial Appearance Overall," "Facial Attributes" (forehead/eyebrows, nose, cheeks, cheekbone, chin, jawline, and neck), "Decision," "Outcomes," "Psychological Function," and "Social Function." "Satisfaction with Facial Appearance Overall" was compared to FACE-Q outcomes in transgender patients on hormone replacement therapy (HRT), alone. Results: Twenty-three patients completed the survey. Rhinoplasty was the most common procedure (82.6%). Insurance was rated as a major barrier in 50% of patients. "Satisfaction with Facial Appearance Overall" using the FACE-Q was 69.3, with "Psychological Function" rated at 73.7 and "Social Function" rated at 76.1. FFS was associated with a higher overall satisfaction in facial appearance compared to patients on HRT for 3 months (69.3 vs. 48.5, p<0.01) and 12 months, alone (69.3 vs. 54.4, p<0.001). Wait time for FFS of less than a year (ß=-20.4, p=0.04) and undergoing FFS at a younger age (ß=-1.4, p<0.001) were independently associated with higher satisfaction scores in overall facial appearance. Conclusions: FFS is associated with greater satisfaction with overall facial appearance, especially compared to transgender patients only on HRT. Insurance was the greatest barrier to receiving FFS. Improved access to surgery is needed to yield higher overall satisfaction with facial appearance.

Wide-Awake Carpal Tunnel Release in the United States: Trends in Volume and Reimbursement by Operative Setting.

BACKGROUND: Office-based surgery can increase logistical and financial efficiency for patients and surgeons. The current study compares wide-awake office-based carpal tunnel release to wide-awake surgeries performed in the operating room (OR) in terms of volume, financial burden, narcotic prescriptions, and adverse events. METHODS: Surgeries performed under local-only anesthesia from 2010 to 2020 were identified in a national administrative database (PearlDiver™). Patients were grouped by surgical setting and matched based on age, sex, comorbidity burden, and geographic region. Primary endpoints included total disbursement and physician reimbursement, as well as 30-day narcotics prescriptions, emergency department (ED) visits, and surgical site infections (SSI). RESULTS: Before matching, there were 303,741 OR surgeries and 5,463 office surgeries. From 2010 to 2020, the percent of surgeries in the office increased from 1.2% to 3.4%. Matched cohorts included 21,835 OR surgeries and 5,459 office surgeries. Office surgery was associated with lower total disbursement and physician reimbursement for patients with commercial insurance, Medicaid, and Medicare. Linear regression modeling indicated that office-based surgery was significantly associated with lower total disbursement and physician reimbursement. Fewer office patients filled narcotic prescriptions and visited the ED, and there was no difference in SSI. CONCLUSION: Compared to OR surgery, office surgery was associated with lower financial burden, fewer narcotics prescriptions and ED visits, and similar incidence of SSI. These findings, together with literature showing greater efficiency in the office, suggest that office-based surgeries are safe and cost-effective and should continue to grow.

Geriatric relationship with inpatient opioid consumption and hospital outcomes after open posterior spinal fusion for adult spine deformity.

OBJECTIVE: As the population ages, increasing attention has been placed on identifying risk factors for poor surgical outcomes in the elderly. The aim of this study was to assess the impact of geriatric status on inpatient narcotic consumption and healthcare resource utilization in patients undergoing spinal fusion for adult spinal deformity. METHODS: A retrospective study was performed using the Premier Healthcare Database (2016-2017). All adult patients who underwent thoracic/thoracolumbar fusion for spine deformity were identified using ICD-10-CM codes. Patients were categorized by age: 18-49 years-old (Young), 50-64 years-old (Older), and 65 + years-old (Geriatric). Patient demographics, comorbidities, hospital characteristics, intraoperative variables, adverse events (AEs), and healthcare resource utilization were assessed. Increased inpatient opioid use was categorized by MME (morphine milligram equivalents) admission consumption greater than the 75th percentile of the cohort. Multivariate logistic regression analysis was used to identify independent predictors of increased opioid usage, increased cost, and non-routine discharge (NRD). RESULTS: Of the 1831 patients identified, 199 (10.9 %) were in the Young cohort, 599 (32.7 %) were in the Older cohort, and 1033 (56.4 %) were in the Geriatric cohort. The Geriatric cohort had a greater proportion of patients who were Non-Hispanic White (p < 0.001) and government-insured (p < 0.001). Comorbidities [CCI (p < 0.001)] and frailty [mFI-5 (p < 0.001)] increased with age. AEs occurred at similar rates between cohorts. A greater proportion of Older patients consumed an increased amount of MMEs during their hospital stay (Young: 24.9 % vs. Older: 33.1 % vs. Geriatric: 20.2 %, p < 0.001). A greater proportion of Geriatric patients experienced high costs (p = 0.018), longer LOS (p = 0.011), and 30-day readmission (p = 0.004) compared to other cohorts. A significantly greater proportion of the Geriatric cohort experienced NRD (Young: 25.3 % vs. Older: 58.8 % vs. Geriatric: 83.0 %, p < 0.001) On multivariate analysis, Geriatric age was independently associated with NRD (OR: 11.59, p < 0.001), and inversely associated with increased MME use (OR: 0.66, p = 0.038). However, Older age was independently associated with increased MME use (OR: 1.58, p = 0.026) and NRD (OR: 4.27, p < 0.001), though not increased cost (OR: 1.49, p = 0.077). CONCLUSION: Our study demonstrates that geriatric patients may require fewer opioids than younger patients but require greater resource utilization on discharge. Additional studies investigating the impact of aging are necessary to improve patient risk stratification, healthcare delivery, and patient outcomes.

Risk of ADHD, Autism Spectrum Disorder, and Executive Function Impairment in Metopic Craniosynostosis.

INTRODUCTION: Favorable behavioral interactions are critical for academic and interpersonal success. An association between metopic synostosis and behavioral impairments has not been fully elucidated. Behavioral dysfunction in school age children with surgically corrected metopic synostosis was evaluated using targeted testing to detect the most common behavioral abnormalities in this population. METHODS: Parents of children 6-18 years old with metopic synostosis completed the Conners Short 3 rd edition (Conners-3: ADHD), Social Responsiveness Scale 2 nd edition (SRS-2: autism spectrum disorder), Behavior Rating Inventory of Executive Function 2 nd edition (BRIEF-2: executive functioning), and Child's Behavioral Checklist (CBCL: behavioral/emotional functioning). Children also completed neurocognitive testing. Multivariable regression was used to determine predictors of clinically significant behavioral impairments. RESULTS: 60 children were enrolled. Average age at surgery was 9.2 ± 7.9 months, with an average age at assessment of 10.3 ± 3.5 years. Nearly half of patients demonstrated symptoms associated with ADHD, demonstrated by reaching or exceeding borderline clinical levels for inattention and hyperactivity subscales of the Conners-3. Greater age at surgery was associated with worse executive function, measured by reaching or exceeding clinically significant levels of the executive function subscale of the Conners-3 (p=0.04) and subscales of the BRIEF-2 (behavioral regulator index [p=0.05], cognitive regulatory index [p=0.03], and global executive composite [p=0.04]). CONCLUSIONS: Nearly half of patients with surgically corrected metopic synostosis reached borderline clinical scores for inattention and hyperactivity. Greater age at surgery was associated with worse executive function. Prompt surgical correction of metopic synostosis may portend improved long-term emotional and behavioral function.

Quantifying Facial Feminization Surgery's Impact: Focus on Patient Facial Satisfaction.

Background: Facial feminization surgery (FFS) has been associated with improving gender dysphoria in transgender patients. This study aimed to quantify the impact of surgery on patient facial satisfaction, using the FACE-Q and a quality-of-life (QoL) survey. Methods: Transgender female patients were recruited to complete the FACE-Q and the World Health Organization's QoL Scale-Short Form (WHOQOL-BREF) if they were planning to or had undergone FFS at our institution. FACE-Q modules completed included "Satisfaction with Facial Appearance Overall," individual facial attributes (forehead/eyebrows, nose, cheeks, cheekbone, chin, jawline, and neck), and the WHOQOL-BREF, which assesses patient QoL through four domains (physical, psychological, social relations, and environment). Both matched and unmatched analyses of preoperative versus postoperative cohorts were performed. Results: Overall, 48 patients participated in our study and completed 31 FACE-Q surveys preoperatively and 37 postoperatively. On average, patients were 37.2 ± 12.5 years old. FACE-Q scores increased significantly for all facial attributes and for Satisfaction with Facial Appearance Overall between cohorts (P < 0.05). The facial attribute with the greatest increase in satisfaction was the jawline, followed by the nose. The WHOQOL-BREF's psychological and physical domains both improved significantly (P < 0.05). Wait time for surgery of less than 6 months (b = 22.42, P = 0.02) was associated with higher overall facial satisfaction, whereas age at surgery (b = -1.04, P < 0.01) was associated with lower overall facial satisfaction. Conclusions: Transgender female patients experienced significant improvements in facial satisfaction and QoL after FFS. Undergoing surgery at a younger age and shorter wait times for surgery were associated with increased overall facial satisfaction.