Are Gender-Affirming Plastic Surgeons Adequately Compensated? An Analysis of Relative Value Units.

BACKGROUND: Gender-affirming surgery (GAS) has a complicated history within US health care. As GAS procedures and reimbursement availability continue to uptrend, the present study aims to investigate whether compensation is equitable between GAS procedures and general plastic surgery procedures. METHODS: The National Surgical Quality Improvement Program database was queried for all surgeries performed by plastic surgeons from 2016 to 2020. Cases were assigned to the GAS or non-GAS cohort using ICD-10 codes. Duplicate Current Procedural Terminology (CPT) codes were removed for analysis. Operative time, total wRVUs, wRVUs per hour (wRVU/h), reoperation/readmission rate, and number of concurrent procedures were compared between the cohorts. RESULTS: A total of 132,319 non-GAS and 3,583 GAS were identified. After duplicate CPT removal, 299 cases (21 unique CPTs) remained in the GAS cohort and 20,022 (37 unique CPTs) in the non-GAS cohort. Operative time was higher in the GAS cohort (262.9 vs 120.7 min, P < 0.001), as were total wRVUs (59.4 vs 21.6, P < 0.001). Reoperation/readmission rate (7.0% vs 6.0%) and wRVU/h (15.8 vs 15.1) were not significantly different (all P > 0.05). There was a positive correlation between total operative time and total wRVUs (P < 0.001) and a negative correlation between total operative time and wRVU/h (P < 0.001). CONCLUSIONS: Proportional wRVUs are allocated to gender affirming plastic procedures. However, the RVU scale does not allocate proportional wRVUs to longer operative times for both GAS and general plastic surgeries. Compensation for gender affirming plastic surgeries is higher than that of general plastic surgeries; however, there is no difference in wRVUs per hour on comparison.

Pediatric Plastic Surgery in the COVID-19 Era.

ABSTRACT: The COVID-19 pandemic has forced the healthcare system to adopt novel strategies to treat patients. Pediatric plastic surgeons are uniquely exposed to high rates of infections during examinations and surgeries via aerosol-generating procedures, in part because of the predilection of viral particles for the nasal cavities and pharynx. Telemedicine has emerged as a useful virtual medium for encouraging prolonged patient follow-up while maintaining physical distance. It has proven beneficial in mitigating infection risks while decreasing the financial burden on patients, their families, and healthcare teams. New trends driven by the pandemic added multiple elements to the patient-physician relationship and have left a lasting impact on the field of pediatric plastic surgery in clinical guidelines, surgical care, and patient outcomes. Lessons learned help inform pediatric plastic surgeons on how to reduce future viral infection risk and lead a more appropriately efficient surgical team depending on early triage.

Out-of-Pocket Costs and Payments in Autologous and Implant-Based Breast Reconstruction: A Nationwide Analysis.

BACKGROUND: Many factors influence a patient's decision to undergo autologous versus implant-based breast reconstruction, including medical, social, and financial considerations. This study aims to investigate differences in out-of-pocket and total spending for patients undergoing autologous and implant-based breast reconstruction. METHODS: The IBM MarketScan Commercial Databases were queried to extract all patients who underwent inpatient autologous or implant-based breast reconstruction from 2017 to 2021. Financial variables included gross payments to the provider (facility and/or physician) and out-of-pocket costs (total of coinsurance, deductible, and copayments). Univariate regressions assessed differences between autologous and implant-based reconstruction procedures. Mixed-effects linear regression was used to analyze parametric contributions to total gross and out-of-pocket costs. RESULTS: The sample identified 2079 autologous breast reconstruction and 1475 implant-based breast reconstruction episodes. Median out-of-pocket costs were significantly higher for autologous reconstruction than implant-based reconstruction ($597 vs $250, P < 0.001) as were total payments ($63,667 vs $31,472, P < 0.001). Type of insurance plan and region contributed to variable out-of-pocket costs (P < 0.001). Regression analysis revealed that autologous reconstruction contributes significantly to increasing out-of-pocket costs (B = $597, P = 0.025) and increasing total costs (B = $74,507, P = 0.006). CONCLUSION: The US national data demonstrate that autologous breast reconstruction has higher out-of-pocket costs and higher gross payments than implant-based reconstruction. More study is needed to determine the extent to which these financial differences affect patient decision-making.

Surgery or Not? A Systematic Review of Facial Congenital Melanocytic Nevi Treatment Patterns and Outcomes.

BACKGROUND: Treatment management for congenital melanocytic nevi (CMN) on the face (FCMN) is highly variable and requires a thorough assessment of multiple factors. To date, a systematic review of FCMN treatment is lacking. The purpose of the present study was to elucidate the frequency, variety, and outcomes of treatment modalities for FCMN with different levels of complexity. METHODS: A comprehensive review of Pubmed, Embase, and Google Scholar databases from 1950 to 2022 was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Articles reporting on FCMN treatment approaches, outcomes, and associated complications were screened and data were extracted according to inclusion criteria. Data were tabulated for thematic analysis of FCMN treatment types, anatomic locations, outcomes, and complications. RESULTS: Of the 561 studies retrieved, 34 met inclusion criteria including 19 surgical treatments, 14 nonsurgical treatments, and one combined surgical and nonsurgical treatment study, totaling 356 patients. The majority of treated FCMN were small-to-medium-sized (56%). Facial CMN treated conservatively were mostly located on the cheek (27%) and/or perinasal region (21%), whereas FCMN treated with surgery were primarily located in the periorbital region (44%) and/or the cheek (17%). Across all treatment cohorts, 22% of patients experienced at least one complication, with 12% of complications experienced by patients treated by surgery. CONCLUSIONS: There is a greater need for standardized FCMN nomenclature that encompasses nevi pattern, dimensions, anatomical coverage, and quantitative measurements of treatment outcome. Future studies should focus on identifying anatomic locations of FCMN that are more prone to complications and determine which treatment approach optimizes outcomes.

Nonsyndromic Craniosynostosis Correlation Between Ethnicity, Race, and Pattern of Affected Suture Type: Meta-Analysis.

BACKGROUND: Previous studies have sought to analyze risk factors associated with craniosynostosis and while syndromic craniosynostosis is often linked to genetic mutations, the factors impacting nonsyndromic cases are less investigated. The aim of current meta-analysis is to evaluate the relationship between ethnicity and suture type in nonsyndromic craniosynostosis patients. METHODS: The search term "craniosynostosis [Title/Abstract] AND (race [Title/Abstract] OR ethnicity [Title/Abstract])) NOT (syndrome [Title/Abstract])" was used to search the PubMed, Cochrane, and MEDLINE databases. Analyses were conducted separately for each racial and ethnic group for each suture type cohort. Odds ratios were conducted for each suture cohort and confounders were adjusted using linear mixed-effect models. Because of the homogeneity of the populations and categorical nature of the classification, binary logistic regression was run on aggregate data. RESULTS: The literature search yielded 165 articles. After reviewing titles, abstracts, and manuscript contents of these articles, 5 studies were ultimately included in a meta-analysis. Studies with missing data for a particular cohort or variable were excluded from the respective analysis. Hispanic children had higher odds of sagittal suture involvement (OR: 1.53, P<0.001), whereas Asian had coronal suture (OR: 2.47, P<0.001). Both Asian and African American children had significantly lower odds of sagittal suture involvement (OR: 0.50, P<0.001 and OR: 0.7, P=0.04, respectively). CONCLUSION: The relationship between ethnicity and craniosynostosis has been suggested as a risk factor, but without definitive conclusion. Present meta-analysis findings demonstrated association between ethnicity and suture type, however further research with larger scale and geographically varied data is warranted.

An Analysis of Medical Malpractice Litigation Involving Orbital Fractures.

BACKGROUND: Orbital fractures frequently require operative management by a plastic and reconstructive surgeon. Due to the proximity to the globe and complexity of the reconstruction, orbital fractures, and related procedures have the potential to be a source of medical litigation. The aim of the present study was to review orbital fracture malpractice litigation, including case outcomes and compensatory damages. METHODS: The Westlaw and Lexis Nexis databases were queried for jury verdicts and settlements related to orbital fracture malpractice lawsuits. The Boolean terms included "orbit! /10 fracture," "orbit! & fracture," and "ocular & fracture" for both databases. Cases were included if they were state or federal cases related to both orbital fracture and medical malpractice involving surgical or medical mismanagement or misdiagnosis of orbital fracture. RESULTS: A total of 49 cases from 1994 to 2018 met inclusion criteria between the databases. The most common legal complaint was the defendant's failure to make a diagnosis either by not ordering the proper radiological tests or by not interpreting radiological tests correctly, seen in 35% of cases. In 57% of the cases, the defendant was a surgeon, 46% of which involved a plastic surgeon specifically. Cases were resolved in favor of the defendant 49% of the time. Most cases (57%) resulted in a monetary outcome of $0. However, cases that were decided in favor of the plaintiff had significant compensatory damages with the majority being over $100,000, and 1 case as high as $8 million. CONCLUSION: Although almost half of the orbital fracture malpractice cases resulted in an outcome favoring the defendant, significant monetary consequences against the defendant were possible in cases when the plaintiff prevailed.

Orbital Foraminal Morphometrics in Nonsyndromic Unilateral Coronal Craniosynostosis.

ABSTRACT: Nonsyndromic unilateral coronal craniosynostosis (UCS) is a rare congenital disorder that results from premature fusion of either coronal suture. The result is growth restriction across the suture, between the ipsilateral frontal and parietal bones, leading to bony dysmorphogenesis affecting the calvarium, orbit, and skull base. Prior studies have reported associations between UCS and visual abnormalities. The present study utilizes a novel geometric morphometric analysis to compare dimensions of orbital foramina on synostotic versus nonsynostotic sides in patients with UCS. Computed tomography head scans of pediatric UCS patients were converted into 3-dimensional mesh models. Anatomical borders of left and right orbital structures were plotted by a single trained team member. Dimensions between synostotic and nonsynostotic sides were measured and compared. Medical records were examined to determine prevalence of visual abnormalities in this patient cohort. Visual abnormalities were reported in 22 of the 27 UCS patients (77.8%). Astigmatism (66.7%), anisometropic amblyopia (44.4%), and motor nerve palsies (33.3%) represented the 3 most prevalent ophthalmologic abnormalities. Orbits on synostotic sides were 11.3% narrower ( P < 0.001) with 21.2% less volume ( P = 0.028) than orbits on nonsynostotic sides. However, average widths, circumferences, and areas were similar between synostotic and nonsynostotic sides upon comparison of supraorbital foramina, infraorbital foramina, optic foramina, and foramina ovalia. Therefore, previously proposed compression or distortion of vital neurovascular structures within bony orbital foramina does not seem to be a likely etiology of visual abnormalities in UCS patients. Future studies will examine the role of ocular and/or neuro-ophthalmologic pathology in this disease process.

Maximizing the Virtual Surgical Planning Session for Orthognathic Surgery.

Virtual surgical planning (VSP) and computer-aided design/computer-aided manufacturing have become essential tools for planning orthognathic surgery. Despite widespread use, empirical gaps still exist in the literature regarding the logistics of the orthognathic planning session itself. More precisely, there is a need to explicate the VSP workflow on which specific parameters are needed for a translation into 3D software. Although each surgeon has his/her theoretical framework, none have been elucidated to properly communicate the necessary pieces of information needed to plan the correction of a variety of dentofacial deformities. The authors provide an outline for conducting a successful VSP planning session for orthognathic surgery.

Application of Field Sterility to Safely Reduce Cost and Waste in Cleft Surgery.

BACKGROUND: Healthcare spending in the United States remains a major concern, requiring reforms to control spending and curtail costs. Medical supply is one of the largest expenses for hospitals and strategies should be utilized to reduce nonbeneficial service delivery, which increases cost without concomitant increase in value. Introduction of field sterility is one of the potential strategies that has been applied in several surgical disciplines to improve cost-efficiency by reducing overuse of resources and decreasing enormous medical waste. Of course, this must be applied without a diminution in safety. METHODS: The PubMed, Medline, and Cochrane databases from 1980 to 2022 were used to review literature. Key words included "cleft surgery and field sterility," "sterile gloves and oral surgery," "oral surgery and field sterility," "sterile techniques and cleft palate surgery," "sterile versus nonsterile gloves," "sterile and non-sterile gloves and minor surgery," "skin laceration repair and sterile techniques," "sterile gloves and wound suture," "surgical site infection and field sterility," "operating room versus clinical setting," "operating rooms economics and hand surgery," and "main operating room versus ambulatory." RESULTS: The literature search yielded 827 articles. Following evaluation of titles, abstracts, and manuscript contents, 23 articles were ultimately included, of which 10 discussed field sterility and cost-efficiency for cutaneous procedures, 9 hand surgery, and 4 oral surgery. There was no study evaluating field sterility application in cleft surgery. In the reviewed studies, no statistical significance was observed in surgical site infection (SSI) with substantial cost savings and medical waste reduction when hand procedures were performed in ambulatory settings with field sterility compared to the main operating room (OR). Furthermore, no difference was observed for SSI in wound closure, excision of skin lesions, or Mohs micrographic surgery when nonsterile gloves were used. CONCLUSION: The incidence of infection following most cleft-related procedures remains low. As such, the application of field sterility may be ideal for this setting. The cost and waste associated with standard operating protocols are not warranted for many cleft procedures.

Trends in Craniofacial Fellowship Career Outcomes: A Call for Expanding Professional Opportunities in Craniofacial Surgery.

PURPOSE: Limited available pediatric plastic surgery positions fail to accommodate the increasing number of craniofacial fellows trained annually. However, many adult indications have increased the demand for craniofacial expertise. Given new opportunities available to craniofacial surgeons, the authors aim to evaluate career prospects for recent craniofacial graduates and explore additional career opportunities. METHODS: Upon approval from the American Society of Craniofacial Surgeons (ASCFS), an anonymous online survey invitation was sent to craniofacial fellows who graduated from 2016 to 2021. Respondents were queried regarding their craniofacial fellowship and subsequent career prospects. RESULTS: A total of 124 eligible participants were identified, of which 30 (24.2%) responded. Craniomaxillofacial case distribution at respondents' current practices varied, with 42.3% reporting a 50% to 75% craniofacial caseload and 38.5% reporting less than 25%. Craniofacial trauma reconstruction was performed most at current positions (92.3%), followed by general reconstruction (92.3%) and breast surgery (69.2%); the least commonly performed was facial feminization (23.1%). Most respondents desired an increased craniomaxillofacial caseload (65.4%). However, 26.9% were unable to secure their current position before fellowship completion, and 80.0% cited limited craniofacial job availability. Recommendations to improve fellowship comprehensiveness and increase candidate competitiveness included increased facial feminization, facial esthetic, and microsurgical experience. CONCLUSION: To adapt to trends in craniomaxillofacial surgery, ASCFS should encourage developing fellowships that increase exposure to gender-affirming, adult craniofacial reconstruction, orthognathic, and skeletal facial esthetic surgery. Expanding training beyond congenital deformities can provide additional employment opportunities while maintaining excellence and innovation in facial plastic surgery.

Clinical Practice Patterns and Evidence-Based Medicine in Rhinoplasty: A 10-Year Review of Continuous Certification Tracer Data from the American Board of Plastic Surgery.

BACKGROUND: The American Board of Plastic Surgery (ABPS) has collected data on cosmetic surgery from member surgeons since 2003. These data offer valuable information on national trends in clinical practice. OBJECTIVES: The present study was performed to analyze trends in rhinoplasty over the last decade. METHODS: Tracer data were compared between two cohorts 2012-2016 (early cohort "EC") and 2017-2021 (recent cohort "RC"). Data included patient demographics and surgical techniques. Results were considered in the context of current EBM-based guidance in the plastic surgery literature. RESULTS: Data from 730 rhinoplasties (270 EC and 460 RC) were analyzed. The median age was 30 years, and the most common patient concern was the nasal dorsum (79%). In the RC group, fewer patients voiced concerns about tip projection (58% vs 43%, p = 0.0002) and more complained of functional airway problems (38% vs 49%, p = 0.004). An open approach was most common (83%). Septoplasty (47% vs 52%, p = 0.005), caudal septum repositioning (14% vs 23%, p = 0.002), and tip rotation maneuvers (32% vs 49%, p < 0.0001) became more popular. There was also an increase in the use of spreader grafts (35% vs 45%, p = 0.01) and columellar strut grafts (42% vs 50%, p = 0.04), while there has been a decrease in alar base resection (17% vs 10%, p = 0.007) and non-cartilaginous dorsum/radix augmentation (9% vs 4%, p = 0.02). CONCLUSIONS: ABPS tracer data provide an excellent resource for the objective assessment of procedures in plastic surgery. The present study is the first to highlight evolving trends in rhinoplasty over the last 10 years. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Standardized Inclusive Numeric Academic Index: An Index to Measure Academic Productivity in Plastic Surgery.

PURPOSE: Academic productivity is a poorly defined metric that is commonly used to determine faculty career advancement. While various indices incorporate scholarly activity, no specific index assimilates the perceived importance of a variety of academic accomplishments a physician may make. Herein, the development and validation of an algorithm to generate an academic productivity score based on surveying physicians nationwide are described. METHODS: From 2016 to 2018, an online cross-sectional survey was distributed to faculty members at an academic institution and plastic surgeons from different academic levels nationwide. Respondents were presented with randomized, binary comparisons of 42 different achievements of an academic physician and asked to choose the more important achievement. Descriptive statistics of demographics and "win rates" of each achievement were reported and an algorithm for academic productivity scoring was designed. To validate the proposed index, 30 curricula vitae of academic surgeons were anonymized and ranked in order of increasing academic achievement by 6 volunteers. Interrater reliability was assessed by Krippendorff α (α ≥ 0.800). RESULTS: Survey respondents completed an average of 116 (SD, 97.6) comparisons each, generating a total of 14,736 ranked comparisons. Of the 42 variables, the highest win rates were attained by being the dean of a medical school (0.90) and editor of a medical journal (0.88). The lowest win rates were attained by industry spokesperson (0.1) and members of the local medical society (0.1). Initial validity evidence found the interrater reliability for the 6 rankers to have a Krippendorff α value of 0.843. The interrater reliability between the average rater ranking and the algorithm-generated ranking had a Krippendorff α value of 0.925. CONCLUSIONS: The present study demonstrates that the standardized inclusive numeric academic index may be used as a valid, comprehensive measure of academic productivity. Future studies should assess its application across different medical specialties.

Dorsal Fixation of Coronal Hamate and Fifth Metacarpal Base Fractures: An Anatomic Evaluation of the Ulnar Nerve.

PURPOSE: Traumatic drill overshoot during dorsal fixation of coronal hamate and fifth metacarpal base fractures risks iatrogenic ulnar nerve injury. This study describes the anatomic relationships between exiting volar drill tips and ulnar nerve branches. METHODS: Dorsal drilling of hamate bones and fifth metacarpal bases was performed on cadavers. Dorsal hamate bodies were subdivided into 4 quadrants: (1) distal-ulnar, (2) distal-radial, (3) proximal-ulnar, and (4) proximal-radial. Screws measuring 5 mm more than the dorsal-to-volar bone depths were placed in each quadrant to represent drill exit trajectories with consistent overshoot. A single screw was similarly placed 5 mm distal to the midline articular surface of the dorsal fifth metacarpal base. Distances between estimated drill tips and ulnar nerve branches were measured. RESULTS: Ten cadaver hands were examined. The fifth metacarpal base screw tips directly abutted the ulnar motor branch in 6 hands, and were within 1 mm in 4 hands (mean, 0.4 ± 0.5 mm). Distances from the tips to the ulnar motor and sensory branches were largest in the distal-radial quadrant (11.8 ± 0.8 mm and 9.2 ± 1.9 mm, respectively) and smallest in the proximal-ulnar quadrant (7.3 ± 1.5 mm and 4.3 ± 1.1 mm, respectively). Distances to the ulnar motor and sensory branches were similar between the proximal-ulnar and distal-ulnar quadrants, and between the proximal-radial and distal-radial quadrants. CONCLUSIONS: Dorsal drilling of coronal hamate fractures appears to be safe, as volar drill tips are well away from ulnar nerve motor and sensory branches. Distances to ulnar nerve branches are largest, and theoretically safest, with dorsal drilling in the distal-radial hamate. Dorsal drilling of fifth metacarpal base fractures appears to carry a high risk for potential ulnar motor nerve injury. CLINICAL RELEVANCE: These findings may help minimize potential risks for iatrogenic ulnar nerve injury with dorsal drilling of hamate and fifth metacarpal base fractures.

Enhanced healing outcomes in MRL/MpJ mouse tissues conserved in insertion site following surgical repair.

BACKGROUND: Surgical repair of supraspinatus tendons (SSTs) has a high failure rate at the insertion site. A significant hurdle to therapeutic development is that effective intrinsic healing mechanisms are unknown. The MRL/MpJ (MRL) mouse exhibits tissue-specific enhanced healing; however, these tissues exhibit disparate properties from the complex SST. The extent of SST healing in the complex environment of the rotator cuff is unknown. We hypothesized that MRL mice would exhibit enhanced restoration of the structurally complex insertion site, resulting in functional improvements. METHODS: B6 and MRL mice underwent SST detachment and immediate surgical repair. Mice were analyzed for gait assessment after either 2 or 6 weeks and were then killed humanely for immunohistologic analysis. RESULTS: MRL SSTs demonstrated enhanced recovery of zonal architecture and bone structure compared with B6 SSTs. MRL SSTs exhibited decreased levels of type III collagen at 2 weeks and increased levels of type I procollagen at 6 weeks compared with B6 SSTs. MRL mice experienced initial gait deficits at 2 weeks that had recovered by 6 weeks. DISCUSSION: The temporal balance of collagen in MRL mice suggests recovery toward naive composition. Initial gait deficits in MRL mice may provide a protective loading environment that is ultimately beneficial. The mechanisms of enhanced healing observed previously in MRL mice may be conserved in the complex SST, providing a platform to interrogate specific aspects of improved healing.

Combined Treatment of High-Flow Scalp Arteriovenous Malformations.

INTRODUCTION: Appropriate treatment of scalp arteriovenous malformations (SAVMs) remains largely unclear given the rarity of reported cases. This single-institution case series presents consecutive patients with extracranial SAVMs and long-term follow up.The primary aim of this study was to review treatment decisions, evaluate clinical outcomes, and compare our experience to available literature in order to better understand SAVMs and improve future outcomes. MATERIALS AND METHODS: A retrospective review of consecutive patients with extracranial SAVMs between January 2015 and December 2019 was performed. Treatment factors of interest included embolization method, embolic agents, and decision to proceed with surgical resection. Relevant clinical outcomes included recurrence rates, cure rates, and complications. RESULTS: Seven patients were included in the present series. Satisfactory outcomes were ultimately achieved for all 7 patients using embolization with or without combined surgical resection. Embolizations performed in combination with resection were curative in 4 of 4 cases (100%). Embolizations performed without resection were curative in 0 of 4 cases (0%), satisfactory in 2 of 4 cases (50%), and unsatisfactory in 2 of 4 cases (50%). DISCUSSION: All SAVM patients in this series were treated satisfactorily using embolization with or without operative resection. This study strongly suggests that embolization combined with surgical resection during the same admission yields the best treatment outcomes for SAVMs, specifically demonstrating lower rates of recurrence and embolization-related complications. Decisions on whether or not to proceed with resection should be made by the interventional radiologist, the plastic surgeon, and the patient together.

Can Frailty Indices Predict Surgical Risk in Open Reduction and Fixation of Facial Fractures?

PURPOSE: The present study sought to evaluate whether the mFI-5 and modified Charlson Comorbidity Index (mCCI) are stronger predictors of 30-day postoperative complications after open reduction of facial fractures compared with historic risk proxies. METHODS: A retrospective review of the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database was conducted to investigate patients who underwent open reduction facial fracture surgery between 2013 and 2018. Risk factors including age, smoking status, body mass index (BMI), comorbidities, and American Society of Anesthesiologists (ASA) class were extracted for each patient. The mFI-5 score and mCCI score were calculated based on this data. Univariate logistic regressions were performed (P<0.05). RESULTS: A total of 2667 cases were included. Of these, 2131 (80%) were male. The strongest predictors for overall 30-day complications and complication severity were ASA class ≥3 (Odds Ratio [OR]=3.34), comorbidities ≥2 (OR=2.78), mCCl score ≥2 (OR=2.19), and mFI-5 ≥1 (OR=1.96). Smoking status and BMI were not strong predictors of total complications or complication severity. Age was found to be a statically significant, but low-impact, predictor of complications, and severity (OR=1.02, P<0.001). The only significant predictors of surgical site infections (SSI) were smoking status (OR=1.56) and ASA class ≥3 (OR=2.40). mFI-5 ≥1 was a significant predictor of hospital readmission. BMI was not associated with any increased risk. CONCLUSIONS: The mCCI and mFI-5 are statistically significant predictors of total complications and complication severity in open reduction of facial fracture repair, and thus provide a tool to inform decision making and improve care. Smoking status may increase risk for SSIs following facial fracture repair.

"When to Nuss? patient age as a risk factor for complications of minimally invasive repair of pectus excavatum: a systematic review and meta-analysis".

PURPOSE: The optimal age for minimally invasive repair of pectus excavatum (MIRPE) is unclear; this study investigates the differences in complication rates among different age groups undergoing repair. METHODS: PubMed and Embase databases were searched from inception to October 2020. To assess age as a risk factor for complications, odds ratios from relevant studies were analyzed using the Mantel-Haenszel method with a random-effects model for younger vs older patients. Specific complication rates were compared between the two cohorts using a chi-squared test. RESULTS: Of the 4448 studies retrieved, 25 studies stratified complication data by age groups. From these studies, ten studies compared groups at ages < 18 and ≥ 18 and four studies compared ages < 20 and ≥ 20, and one study compared ages < 19 and ≥ 19. These fifteen studies reported on 5978 patients, with 1188 complications, for a complication rate of 19.87%. Older patients were more likely to have complications in a pooled analysis of studies comparing older vs younger patients (OR = 1.66, 95% CI = 1.28-2.14, heterogeneity I2 = 49%). Specifically, older patients were significantly more likely to experience pneumothorax, pleural effusion, wound infection, bar displacement, and reoperations. CONCLUSION: Increased age is a risk factor for complications of MIRPE. This supports repair of pectus excavatum prior to late adolescence.

Craniofacial Dysmorphology in Infants With Non-Syndromic Unilateral Coronal Craniosynostosis.

BACKGROUND: Unilateral coronal craniosynostosis (UCS) is a congenital disorder resulting from the premature suture fusion, leading to complex primary and compensatory morphologic changes in the shape of not only the calvarium and but also into the skull base. This deformity typically requires surgery to correct the shape of the skull and prevent neurologic sequelae, including increased intracranial pressure, sensory deficits, and cognitive impairment. METHODS: The present multicenter study sought to reverse-engineer the bone dysmorphogenesis seen in non-syndromic UCS using a geometric morphometric approach. Computed tomography scans for 26 non-syndromic UCS patients were converted to three-dimensional mesh models. Two hundred thirty-six unique anatomical landmarks and semi-landmarked curves were then plotted on each model, creating wireframe representations of the Patients' skulls. RESULTS: Generalized Procrustes superimposition, Principal Component Analysis, and heatmaps identified significant superior displacement of the ipsilateral orbit ("harlequin" eye deformity), anterior displacement of the ear ipsilateral to the fused coronal suture, acute deviation of midline skull base structures ipsilateral to the fused coronal suture and flattening of the parietal bone and associated failure to expand superiorly. CONCLUSIONS: The described technique illustrates the impact of premature coronal suture fusion on the development of the entire skull and proposes how bone dysmorphology contributes to the Patients' neurologic sequelae. By bridging novel basic science methodologies with clinical research, the present study quantitatively describes craniofacial development and bone dysmorphogenesis.

Appropriateness of Computed Tomography Scanning in the Diagnosis of Craniosynostosis.

INTRODUCTION: Although physicians from a variety of specialties encounter infants with possible craniosynostosis, judicious use of computed tomography (CT) imaging is important to avoid unnecessary radiation exposure and healthcare expense. The present study seeks to determine whether differences in specialty of ordering physician affects frequency of resulting diagnostic confirmations requiring operative intervention. METHODS: Radiology databases from 2 institutions were queried for CT reports or indications that included "craniosynostosis" or "plagiocephaly." Patient demographics, specialty of ordering physician, confirmed diagnosis, and operative interventions were recorded. Cost analysis was performed using the fixed unit cost for a head CT to calculate the expense before 1 study led to operative intervention. RESULTS: Three hundred eighty-two patients were included. 184 (48.2%) CT scans were ordered by craniofacial surgeons, 71 (18.6%) were ordered by neurosurgeons, and 127 (33.3%) were ordered by pediatricians. One hundred four (27.2%) patients received a diagnosis of craniosynostosis requiring operative intervention. Craniofacial surgeons and neurosurgeons were more likely than pediatricians to order CT scans that resulted in a diagnosis of craniosynostosis requiring operative intervention (P < 0.001), with no difference between craniofacial surgeons and neurosurgeons (P = 1.0). The estimated cost of obtaining an impact CT scan when ordered by neurosurgeons or craniofacial surgeons as compared to pediatricians was $2369.69 versus $13,493.75. CONCLUSIONS: Clinicians who more frequently encounter craniosynostosis (craniofacial and neurosurgeons) had a higher likelihood of ordering CT images that resulted in a diagnosis of craniosynostosis requiring operative intervention. This study should prompt multi-disciplinary interventions aimed at improving evaluation of pretest probability before CT imaging.

Choosing a Multidisciplinary Cleft and Craniofacial Team: Medical, Surgical, and Social Considerations.

Cleft and craniofacial conditions often present with a variety of functional and esthetic sequelae optimally treated by a multidisciplinary approach. Diagnosis of such conditions pre- or postnatally may evoke parental uncertainty and anxiety, and an important primary consideration is the selection of a cleft and craniofacial team. Identifying an optimal team may be particularly important for developing long-term relationships with clinicians who will ideally work intimately with the family from diagnosis to adulthood. While families, parents, and providers should consider several factors, a dearth of evidence-based suggestions preclude critical appraisal of cleft and craniofacial teams. In this article, the authors summarize medical, surgical, and social considerations for selecting a cleft and craniofacial team to optimize patient outcomes and the family/caregiver experience.