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Rubber bullets have long been known to cause, on rare occasions, traumatic brain injury (TBI). However, neurosurgical literature on this occurrence is limited, and no focused review of this injury pattern has been conducted. The authors present the case of a 28-year-old male struck by a rubber bullet in the left periorbital region, causing TBI in addition to complete left visual loss and complex facial fractures. After developing a cerebrospinal fluid (CSF) leak, the patient was taken to the operating room for combined neurosurgical-craniofacial intervention. Utilizing frameless intraoperative computation tomography navigation assistance, a successful repair was made of both the patient's CSF leak and complex craniofacial injuries. TBI due to a rubber bullet is a rare but severe occurrence. Unfortunately, much of the limited literature on this topic is bereft of demographic, clinical course, injury pattern, and imaging data. Presented here is the first operative case report of TBI due to a rubber bullet. Volume rendered imaging is provided to demonstrate the extent of trauma incurred. Additionally, a methodology for frameless intraoperative computation tomography navigation assistance is shared for consideration, as it served as a helpful adjunct for a combined intracranial-craniofacial surgical repair. The experience of treating the patient's traumatic CSF leak in the context of severe craniofacial and ophthalmologic injuries highlights the need for a multidisciplinary surgical approach that may arise when treating patients with TBI due to a rubber bullet.

Sagittal craniosynostosis results in scaphocephaly from abnormal fusion of the sagittal suture. Traditionally, craniosynostosis presents at birth and is diagnosed within the first year of life. The authors report a patient with development of sagittal craniosynostosis after birth, which we term postnatal sagittal craniosynostosis. This is a rare occurrence in which management considerations are critical but are not well discussed. A 3-year-old boy presented with concerns of a metopic ridge. Workup revealed metopic ridging and an open sagittal suture. The patient later developed signs of increased intracranial pressure and repeat computed tomography scan 14 months later identified a newly fused sagittal suture. The patient underwent open posterior cranial vault expansion, resulting in resolution of symptoms. Postnatal sagittal craniosynostosis is a rare condition and should be considered in otherwise unexplained increases in increased intracranial pressure among pediatric patients. Open posterior cranial vault expansion represents a safe and effective method to treat this condition.

Background While commonly seen in syndromic craniosynostosis, the incidence of Chiari malformation (CM) in nonsyndromic craniosynostosis has been reported at 5% and there is a lack of understanding of the pathophysiology and management of CM in this patient population. Case Description We present a 5-year-old male patient who underwent a sagittal craniosynostosis repair at the age of 5 months and returned at the age of 5 years with daily headaches associated with behavioral changes. He was found to have pan-synostoses and radiographic evidence of increased intracranial pressure, including a Chiari malformation. Neurologic and genetic workup was unremarkable. A cranial vault reconstruction was performed, and subsequent imaging demonstrated resolution of previously noted Chiari malformation. Conclusions In our case, we provided a unique window into the underlying pathophysiology for CM in patients with concurrent nonsyndromic craniosynostosis that we hope will add to the current foundation of literature supporting the intricate relation between cranial vault compliance and Chiari malformation or hindbrain herniation. Furthermore, we provide insight into the management of acquired CM and support isolated cranial vault reconstruction in those who do not appear to have symptomatic suboccipital compression.

Introduction: This study compares anthropometric outcomes of 2 sagittal synostosis repair techniques: spring-assisted surgery and endoscope-assisted craniectomy with molding helmet therapy. Methods: Patients undergoing spring-assisted surgery (n = 27) or endoscope-assisted craniectomy with helmet therapy (n = 40) at separate institutions were retrospectively reviewed. Pre- and 1-year postoperative computed tomography (CT) or laser scans were analyzed for traditional cranial index (CI), adjusted cranial index (aCI), and cranial vault volume (CVV). Nine patient-matched scans were analyzed for measurement consistency. Results: The spring-assisted group was older at both time points ( P < .050) and spring-assisted group CVV was larger preoperatively and postoperatively ( P < .01). However, the change in CVV did not differ between the groups ( P = .210). There was no difference in preoperative CI (helmet vs spring: 70.1 vs 71.2, P = .368) between the groups. Postoperatively, helmet group CI (77.0 vs 74.3, P = .008) was greater. The helmet group also demonstrated a greater increase in CI (6.9 vs 3.1, P < .001). The proportion of patients achieving CI of 75 or greater was not significantly different between the groups (helmet vs spring: CI, 65% vs 52%, P = .370). There was no detectable bias in CI between matched CT and laser scans. Differences were identified between scan types in aCI and CVV measurements; subsequent analyses used corrected CVV and aCI measures for laser scan measures. Conclusions: Both techniques had equivalent proportions of patients achieving normal CI, comparable effects on cranial volume, and similar operative characteristics. The study suggests that there may be greater improvement in CI in the helmet group. However, further research should be performed.

OBJECTIVEWound breakdown and infection are common postoperative complications following resection of spinal neoplasms. Accordingly, it has become common practice at some centers for plastic surgeons to assist with closure of large posterior defects after spine tumor resection. In this study, the authors tested the hypothesis that plastic surgery closure of complex spinal defects improves wound outcomes following resection of spinal neoplastic disease.METHODSElectronic medical records of consecutive patients who underwent resection of a spinal neoplasm between June 2015 and January 2019 were retrospectively reviewed. Patients were separated into two subpopulations based on whether the surgical wound was closed by plastic surgery or neurosurgery. Patient demographics, preoperative risk factors, surgical details, and postoperative outcomes were collected in a central database and summarized using descriptive statistics. Outcomes of interest included rates of wound complication, reoperation, and mortality. Known preoperative risk factors for wound complication in spinal oncology were identified based on literature review and grouped categorically. The presence of each category of risk factors was then compared between groups. Univariate and multivariate linear regressions were applied to define associations between individual risk factors and wound complications.RESULTSOne hundred six patients met inclusion criteria, including 60 wounds primarily closed by plastic surgery and 46 by neurosurgery. The plastic surgery population included more patients with systemic metastases (58% vs 37%, p = 0.029), prior radiation (53% vs 17%, p < 0.001), prior chemotherapy (37% vs 15%, p = 0.014), and sacral region tumors (25% vs 7%, p = 0.012), and more patients who underwent procedures requiring larger incisions (7.2 ± 3.6 vs 4.5 ± 2.6 levels, p < 0.001), prolonged operative time (413 ± 161 vs 301 ± 181 minutes, p = 0.001), and greater blood loss (906 ± 1106 vs 283 ± 373 ml, p < 0.001). The average number of risk factor categories present was significantly greater in the plastic surgery group (2.57 vs 1.74, p < 0.001). Despite the higher relative risk, the plastic surgery group did not experience a significantly higher rate of wound complication (28% vs 17%, p = 0.145), reoperation (17% vs 9%, p = 0.234), or all-cause mortality (30% vs 13%, p = 0.076). One patient died from wound-related complications in each group (p = 0.851). Regression analyses identified diabetes, multilevel instrumentation, and BMI as the factors associated with the greatest wound complications.CONCLUSIONSInvolving plastic surgery in the closure of spinal wounds after resection of neoplasms may ameliorate expected increases in wound complications among higher-risk patients.

BACKGROUND Medical students must be able to suture competently upon graduation. To learn suturing technique, students must have access to practice materials. The purpose of this pilot study was to develop a novel suturing trainer and to evaluate its ability to provide realistic and accessible suturing practice. A cohort of senior students at one institution compared the device with standard suture-training media (porcine feet and sponges). METHODS Using 3D printing and silicone casting, a novel suturing trainer was developed and a cohort of senior medical students trialed the device in a standardised suturing workshop. Participants evaluated the novel suturing trainer, porcine feet and sponges for simulating human tissue with regard to: (i) tissue layers; (ii) tissue texture; (iii) ability to perform interrupted suturing; (iv) running subcuticular suturing; and (v) knot tying. RESULTS Compared with porcine feet and sponges, the suturing trainer had significantly higher mean scores (p

Introduction: Partial synostosis of cranial sutures has been shown to have clinical and diagnostic significance. However, there is limited published information about how suture fusion progresses over time. In this study, we evaluate patients with nonsyndromic single-suture synostosis. We aim to define the incidence of partial versus complete suture fusion and whether a correlation exists between the degree of suture fusion and age. Methods: Two hundred fifty-four patients with nonsyndromic single-suture synostosis were evaluated. Preoperative computed tomography (CT) scans were rendered in 3-dimensions, all sutures were visualized and assessed for patency or fusion, and length of fusion was measured. Findings were grouped according to suture type (sagittal, coronal, metopic, or lambdoid), the degree of fusion (full, >50%, or 360 days). Data were analyzed to correlate patient age versus the degree of suture fusion. Results: For all patients, 72% had complete and 28% had partial synostosis. Ratios of full to partial fusion for each suture type were as follows: sagittal 97:36, coronal 35:22, metopic 46:4, and lambdoid 4:10. The sagittal, coronal, and metopic groups demonstrated greater probabilities of complete suture fusion as patient age increases ( P = .021, P < .001, P = .001, respectively). This trend was also noted when all sutures were considered together by age-group ( P < .001). Conclusion: We note a partial suture fusion rate of 28.3%. Our analysis shows a correlation between the extent of suture synostosis and patient age. Finally, we demonstrate that different sutures display different patterns of partial and complete fusion.

BACKGROUND Autologous bone is often the first choice in cranioplasty following a decompressive craniectomy. However, infection is a common complication, with reported rates up to 25%. While the incidence and management of infection are well documented, the risk factors associated with infection remain less clear. The current study aims to identify predictors of infection risk following autologous cranioplasty. METHODS A retrospective analysis was conducted on patients who underwent decompressive craniectomy and cranioplasty using cryopreserved autologous bone flaps between 2010 and 2020. Patient demographics and factors related to both surgeries and infection rates were recorded from patient records. Logistic regressions were conducted to determine which factors were implicated in the development of infection. RESULTS In our cohort, 126 patients underwent autologous cranioplasty. A total of 10 patients (7.9%) developed an infection following reconstruction, with half resulting in implant failure. We did not identify any significant risk factors for infection. Regression analysis identified placement of subgaleal drain following cranioplasty as a protective factor against the development of infection (OR: 0.16, p = 0.007). On average, drains remained in for 3 days, with no difference between the length of drains for those with infection vs. those without (p = 0.757). CONCLUSIONS The current study demonstrates an infection rate of 7.9% in patients who receive an autologous cranioplasty following decompressive craniectomy, which is consistent with previous data. Half (4%) of patients who experienced an infection ultimately required removal of the implant. While it is common practice for neurosurgeons to use drains to prevent hematomas and fluid collections, we found that subgaleal drain placement following cranioplasty was associated with decreased infection, thus demonstrating another benefit of a commonly used tool.

Three-dimensional (3D) modeling and printing technologies are increasingly utilized as tools to assist in complex craniofacial reconstructions. Herein, the authors report the intraoperative use of sterilized 3D models printed in-house to mold a custom resorbable implant in the case of a pediatric patient with a unilateral complex orbital fracture. The imaging was processed with open-source software. Two patient-specific orbital models were 3D-printed (Fig. 2): a life-size print of the patient's preoperative CT scan and a left orbit reconstructed to resemble its uninjured state using mirrored-imaging of the uninjured side. This construct ultimately served as a sterilized template to mold a resorbable implant intraoperatively. Post-operatively, the patient experienced no complications. At the 18-month follow-up, the patient had done well without diplopia, headaches or visual problems. The authors report a case of a successful orbit reconstruction assisted by mirrored-image computer modeling and patient-specific 3D printing.

Background Challenges in orbital floor fracture management include delayed symptom onset and controversial surgical indications based on radiographic findings. This study assessed which imaging characteristics most reliably predict symptomatology to generate a tool quantifying individual need for surgery on initial presentation. Methods The clinical course for all patients with isolated orbital fractures at a single institution from 2015 to 2017 were reviewed. Trauma mechanism, computed tomographic scan findings, and symptoms necessitating surgery (diplopia, enophthalmos) were noted. Univariable and multivariable regression modeling was used to generate a predictive risk model for operative fractures. Results One hundred twenty-one patients with isolated orbital fractures were identified. Mechanism of injury included falls (41 percent), assault (37 percent), and vehicular trauma (17 percent). Patient follow-up averaged 4.4 ± 4.8 months. Average orbital floor fracture area was 2.4 cm2 (range, 0.36 to 6.18 cm2), and orbital volume herniation averaged 0.70 cm3 (range, 0.01 to 4.23 cm3). Twenty-one patients (17.3 percent) required surgical intervention for symptomatic fractures. The strongest predictors of symptoms were orbital volume increase greater than 1.3 cm3 (OR, 10.5; p = 0.001) and inferior rectus displacement within/below the fracture line (OR, 3.7; p = 0.049). Mechanical fall was risk-reducing (OR, 0.08; p = 0.005). Symptom risk was stratified from low (3.6 percent) to high risk (71 percent) (C-statistic = 0.90). The volume of herniated orbital contents was significantly more predictive of symptoms than fracture area (C-statistic = 0.81 versus C-statistic = 0.66; p = 0.02). Conclusions The proposed risk tool allows highly accurate, early prediction of symptomatic orbital floor fractures. Findings suggest that orbital volume change, not fracture area, more reliably informs operative indications, along with inferior rectus muscle caudal malposition. A simplified stepwise decision algorithm demonstrates the potential utility of this risk-assessment tool. Clinical question/level of evidence Risk, III.

Hypertrophic scarring is a significant complication of severe face and neck burns. Burn masks offer an effective treatment. However, the conventional method of making these masks has notable shortcomings. Most notably, the use of alginate to form an impression is a laborious and uncomfortable process, especially for younger patients. To optimize this practice, the authors present a novel method of burn mask production that utilizes a 3-dimensional-printed positive mold to avoid the direct placement of alginate onto burned patient skin.

A total of 169 ACPA approved teams treat cleft deformities in the United States. These centers are unevenly distributed, and families may disproportionally pay extra travel costs to consult a multidisciplinary cleft team. Families experiencing hardships are able to create campaigns on GoFundMe to advertise their fundraiser publicly. The authors sought to establish whether a correlation exists between patients asking for support for cleft treatment and their geographic location in the US.A total of 635 crowdfunding campaigns for cleft lip and/or palate were reviewed from GoFundMe. Google searches for cleft lip and palate were evaluated utilizing Google Trends, with values reported as Relative Search Volumes (RSV). Driving distances and travel time to the nearest approved ACPA center were calculated using Google Maps data.There was a statistically significant difference in average driving distance and travel duration between the different subregions of the US (P = 0.0059 and 0.026, respectively). The South subregion had the highest proportion of campaigns (n = 259, 40.9%), mean driving distance (105.75 km) and mean driving duration (1 hour 8 minutes). The number of approved teams per state was negatively correlated to both RSV scores (r = -0.38, P = 0.048) and the number of campaigns (r = -0.34, P = 0.014).There is an uneven distribution of ACPA centers among the US subregions. The South seems to have the highest need for care, as identified by proportionate number of campaigns, adjusted driving distances and travel time. This data suggests that underserved areas for cleft care are correlated with greater numbers of hardship campaigns and more internet searches regarding cleft lip and palate.

BACKGROUND The need for surgical correction of frontal bossing in patients with sagittal synostosis is currently debated. The authors retrospectively analyzed frontal bossing in patients with isolated, nonsyndromic sagittal synostosis who underwent calvarial remodeling with and without frontal craniotomy and compared with control subjects. METHODS The authors analyzed computed tomography (CT) scans of patients with sagittal synostosis

INTRODUCTION: Craniosynostosis is typically corrected surgically within the first year of life through cranial vault reconstruction. These procedures often leaves open calvarial defects at the time of surgery, which are anticipated to close over time in a large proportion of cases. However, residual calvarial defects may result as long-term sequelae from cranial vault remodeling. When larger defects are present, they may necessitate further reconstruction for closure. Better understanding of the calvarial osseous healing process may help to identify which defects will resolve or shrink to acceptable size and which will require further surgery. Our study aims to assess the long-term changes in defect size after cranial vault reconstruction for craniosynostosis. METHODS: One year post-operative and long-term computed tomography scans were retrieved from the craniofacial anomalies archive. Analysis used custom software. All defects above the size of 1 cm(2) were analyzed and tracked for calvarial location, surface area, and circularity. Monte Carlo simulation was performed to model the effect of initial defect size on the rate of defect closure. RESULTS: We analyzed a total of 74 defects. The average initial defect surface area was 3.27 ± 3.40 cm(2). The average final defect surface area was 1.71 ± 2.54 cm(2). The average percent decrease was 55.06 ± 28.99 %. There was a significant difference in the percentage decrease of defects in the parietal and fronto-parietal locations: 68.4% and 43.7%, respectively (p = 0.001). Monte Carlo simulation results suggest that less than 10% of defects above the size of 9 cm(2) will close to the size of 2.5 cm(2) or less. CONCLUSIONS: We describe and make available a novel, validated method of measuring cranial defects. We find that the large majority of initial defects greater than 9cm(2) remain at least one square inch in size (2.5cm(2)) one year post-operatively. Additionally, there appear to be regional differences in closure rates across the cranium, with front-parietal defects closing more slowly than those in the parietal region. This information will aid surgeons in the decision-making process regarding cranioplasty after craniosynostosis correction.

Pierre Robin sequence consists of clinical triad of micrognathia, glossoptosis, and airway compromise with variable inclusion of cleft palate. Evaluation of airway obstruction includes physical examination, polysomnography for obstruction events, and a combination of nasoendoscopy and bronchoscopy to search for synchronous obstructive lesions. A multidisciplinary approach is required given the high rate of syndromic disease. Management of airway obstruction and feeding starts with nonsurgical maneuvers, such as prone and lateral positioning, nasopharyngeal stenting, and continuous positive airway pressure. Surgical management includes mandibular distraction and tongue-lip adhesion. Subglottic obstruction and central sleep apnea may best be treated with tracheostomy.

Orbital asymmetry in unicoronal synostosis impacts craniofacial appearance and can potentiate functional visual disturbances, such as strabismus. Surgical treatment aims to normalize overall cranial morphology, including that of the orbits. The purpose of this study was to compare postoperative changes in orbital asymmetry following 2 common procedures.Preoperative and 1-year postoperative computed tomography scans for patients with isolated, nonsyndromic unicoronal synostosis treated from 2007 to 2012, at 2 academic institutions were analyzed. Only patients treated by endoscopic suturectomy and postoperative helmeting or bilateral fronto-orbital advancement were included. Orbital index, depth, and volume asymmetry were determined for each patient both pre- and 1-year postoperatively. Student's t-tests were used to compare pre- and postoperative asymmetries within each treatment group. Regression analyses were used to examine postoperative change in asymmetry between treatment groups.Scans from 12 patients treated by fronto-orbital advancement and 23 treated by endoscopic suturectomy were analyzed. Differences between synostotic and nonsynostotic orbital index, depth, and volume were statistically significant both pre- and postoperatively. Statistically significant postoperative improvements in asymmetry were observed for orbital index, depth, and volume following suturectomy. Regression analysis indicated that the amount of pre- to postoperative change in all measures of asymmetry did not depend on surgical technique. Residual asymmetry following both procedures was apparent at 1 year postoperatively.Orbital asymmetry is improved, but not resolved following both fronto-orbital advancement and endoscopic suturectomy. Degree of improvement in symmetry is independent of surgical technique used.

BACKGROUND: The COVID-19 pandemic has presented unprecedented challenges for surgical teaching programs, as operating rooms closed and resources were redirected for patient care. As a result, both educational challenges and opportunities emerged. The objective of this study was to assess the changes used by plastic surgery programs as a result of the pandemic. METHODS: A 34-question American Council of Academic Plastic Surgeons-approved survey was distributed on April 29, 2020, to attendings in academic plastic surgery programs in the United States. Variables were controlled whenever multiple attending responses were submitted from the same program. RESULTS: A total of 113 attendings, including 30 (27.8%) program directors, responded to the survey. Most respondents were located in the northeast (41.4%). The average percentage of elective case volume was 23% of pre-COVID states. Those who reported a decrease in emergent surgical case volume (55.2%) estimated it to be at an average of 45% of the normal. Almost all the respondents (95.6%) agreed that they were working fewer hours than usual, and 40.9% of those reported a decrease of more than 20 hours per week of work. Most attendings (82.1%) also reported a decrease in their monthly salary. The percentage projected current salary compared with normal was 85%. CONCLUSIONS: Our survey data suggest that academic plastic surgery programs have had impactful changes to their operative and educational schedules, teaching, revenue, and patient care. The data described in this study could be used as a baseline for future pandemics affecting plastic surgery programs to help strategize their operational and educational structures.

Nasal deviations pose a 2-fold task for plastic surgeons, as the correction must often address both functional and aesthetic challenges. Regardless of the etiology of the nasal deviation, the principles of treatment have been previously extensively described. The authors present an extreme case of congenital nasal deviation in an 18-year-old male acquired as a result of abnormal in-utero positioning during a multigestational pregnancy. Through this case, the authors demonstrate effective use of previously described surgical principles in treating a severe congenital nasal deviation and reinforce the importance of postoperative nasal manipulation to maintain the desired outcome.

BACKGROUNDCervicothoracic junction chordomas are uncommon primary spinal tumors optimally treated with en bloc resection. Although en bloc resection is the gold standard for treatment of mobile spinal chordoma, tumor location, size, and extent of involvement frequently complicate the achievement of negative margins. In particular, chordoma involving the thoracic region can require a challenging anterior access, and en bloc resection can lead to a highly destabilized spine.OBSERVATIONSModern technological advances make en bloc resection more technically feasible than ever before. In this case, the successful en bloc resection of a particularly complex cervicothoracic junction chordoma was facilitated by a multidisciplinary surgical approach that maximized the use of intraoperative computed tomography–guided spinal navigation and patient-specific three-dimensional–printed modeling.LESSONSThe authors review the surgical planning and specific techniques that facilitated the successful en bloc resection of this right-sided chordoma via image-guided parasagittal osteotomy across 2 stages. The integration of emerging visualization technologies into complex spinal column tumor management may help to provide optimal oncological care for patients with challenging primary tumors of the mobile spine.

The 3-stage paramedian forehead flap is the gold standard for subtotal and complete nasal defects, but significant surgeon artistry and experience are required to achieve good, consistent results. The authors describe the use of virtual surgical planning and three-dimensional printing to create a patient-specific soft tissue cutting guide for the design of a forehead flap in the reconstruction of a hemirhinectomy defect. Application of this technology to these challenging reconstructive scenarios promises to improve accessibility and consistency of results.

Background:. Stay-at-Home (SAH) orders implemented in the United States to combat COVID-19 had a significant impact on health care delivery for patients with all conditions. In this study, we examined the effect SAH orders had on the Emergency Department (ED) consultation volume, injury patterns, and treatment of patients managed by our plastic surgery service. Methods:. In Rhode Island, SAH orders were instituted from March 28, 2020, to June 30, 2020. A retrospective chart review of patients presenting to our Level-1 academic medical center was performed. Patient demographics, types of injuries, and need for treatment in the ED or operating room (OR) were collected. Tests of significance were conducted using a comparison group spanning the same time period, in 2019. Results:. There was a 36% decrease in ED consultations to plastic surgery during SAH orders when compared with those in 2019. No observed differences were noted in patient demographics between time periods. There were significant increases in the proportions of hand injuries secondary to power tools and facial injuries secondary to falls. No observed differences were identified in injury severity and need for either operating-room interventions or ED interventions for patients seen in consultation during SAH orders. Conclusions:. SAH orders resulted in a decreased volume of plastic surgery consults in the ED but did not alter patient demographics, injury severity, or need for procedural interventions. There was a 2.9% positivity rate for COVID-19 for asymptomatic patients presenting in the ED with primary hand and facial injuries.

Objective To design a low cost ($40), realistic and fluoroscopy-free percutaneous Kirschner wire hand fracture fixation training instrument kit for home-based skill acquisition during the COVID-19 pandemic. Design A 3D-printed hand was designed from a computed tomography scan of a healthy hand. These data were used to create replaceable hand and wrist bones and reusable silicone molds for a replica of the soft tissue envelope. The model is currently being integrated into the simulation curriculum at 2 integrated plastic surgery residency programs for training in percutaneous wire fixation of hand fractures. Setting Brown University, Warren Alpert Medical School of Brown University. Department of Surgery, Division of Plastic and Reconstructive Surgery. Large academic quaternary referral institution. Yale University, Yale School of Medicine. Department of Surgery, Division of Plastic and Reconstructive Surgery. Large academic quaternary referral institution. Participants PGY 1-4 plastic surgery residents preparing to meet ACGME Accreditation for Graduate Medical Education hand surgery specific milestones. Results A realistic and durable 3D model with interchangeable bones allows trainees to practice the key motor skills necessary for successful fixation of hand and wrist fractures with K-wires in a home-based setting. Conclusions A low cost, realistic and durable 3D hand model with interchangeable bones allows easy integration into any home-based hand surgery curriculum. With 3D printers and programming becoming more prevalent and affordable, such models offer a means of low-cost and safe instruction of residents in fracture fixation with no harm to patients.

Objective Three-dimensional (3D) printing has emerged as a visualization tool for clinicians and patients. We sought to use patient-specific 3D-printed anatomic modeling for preoperative planning and live intraoperative guidance in a series of complex primary spine tumors. Methods Over 9 months, patients referred to a single neurosurgical provider for complex primary spinal column tumors were included. Most recent spinal magnetic resonance and computed tomography (CT) imaging were semiautomatically segmented for relevant anatomy and models were printed using polyjet multicolor printing technology. Models were available to surgical teams before and during the operative procedure. Patients also viewed the models preoperatively during surgeon explanation of disease and surgical plan to aid in their understanding. Results Tumor models were prepared for 9 patients, including 4 with chordomas, 2 with schwannomas, 1 with osteosarcoma, 1 with chondrosarcoma, and 1 with Ewing-like sarcoma. Mean age was 50.7 years (range, 15–82 years), including 6 males and 3 females. Mean tumor volume was 129.6 cm3 (range, 3.3–250.0 cm3). Lesions were located at cervical, thoracic, and sacral levels and were treated by various surgical approaches. Models were intraoperatively used as patient-specific anatomic references throughout 7 cases and were found to be technically useful by the surgical teams. Conclusions We present the largest case series of 3D-printed spine tumor models reported to date. 3D-printed models are broadly useful for operative planning and intraoperative guidance in spinal oncology surgery.

OBJECTIVE Facial prosthetic rehabilitation using additive manufacturing technology relies on data acquisition from computed tomography or magnetic resonance imaging. Three-dimensional (3D) photography has become widespread in craniofacial and plastic surgery due to its ability to provide more comprehensive topographical data than radiographic techniques. Despite the rising popularity of 3D photography in preoperative planning, reports on the use of this technology for facial prosthetic rehabilitation are lacking. The present clinical report demonstrates the indirect fabrication of a nasal prosthesis using 3D surface-imaging by the VECTRA-M5 360 Head System. DESIGN A 61-year-old woman presented with a nasal defect due to a partial rhinectomy secondary to multiple resections of recurrent basal cell carcinoma. After opting out of any further surgical intervention, the patient expressed a preference for prosthetic rehabilitation. Prosthesis fabrication using CAD/CAM technology typically relies on patient data from computed tomography or magnetic resonance imaging scans for the 3D printing of the replica of the nasal defect. In this case, facial data was acquired by a 3D surface-imaging system using a 3D photograph captured by the VECTRA-M5 360 Head System. CONCLUSIONS Acquisition of facial data using 3D surface-imaging systems may be recommended for patients with external facial deformities to decrease subsequent radiation exposure. The integration of 3D photography and 3D printing provides a promising method for prosthetic rehabilitation that decreases total production time while minimizing radiation exposure.

Background Nasoorbitoethmoid fractures commonly accompany midface fractures and may be underdiagnosed, resulting in incomplete reconstruction or inadequate treatment following facial trauma. To better understand the nasoorbitoethmoid fracture diagnosis and treatment tendencies, the authors analyzed concomitant nasoorbitoethmoid injuries in the setting of zygoma fractures. Methods The facial trauma database at a level I trauma center was evaluated. All patients with diagnosed zygoma fractures from June of 2011 to March of 2016 were assessed for a concomitant nasoorbitoethmoid injury. Documentation of these fractures in radiology, plastic surgery, and operative notes was recorded, as was the rate of nasoorbitoethmoid fracture surgical repair. Results The authors identified 339 eligible patients and completed retrospective analysis of computed tomographic images for their 356 zygoma fractures. The incidence of concomitant nasoorbitoethmoid fractures was 30.6 percent (109 of 356). Documentation rates of nasoorbitoethmoid fractures were 0 percent, 3.7 percent, and 8.3 percent in radiology, plastic surgery, and operative notes, respectively. The rate of surgical correction of nasoorbitoethmoid injuries was 22.9 percent (25 of 109). Of those fractures identified, 44.9 percent (49 of 109) were minimally displaced or nondisplaced. Subset analysis of only significantly displaced fractures yielded an incidence of 16.8 percent (60 of 356). Of significantly displaced fractures, documentation rates were 0 percent, 6.7 percent, and 16.8 percent in radiology, plastic surgery, and operative notes, respectively. The surgical repair rate of significantly displaced fractures was 31.7 percent (19 of 60). Conclusions These findings suggest a high concomitance rate of nasoorbitoethmoid fractures with zygoma fractures and identify a tendency to underdocument and undertreat this injury pattern. Clinicians managing patients with midface trauma should have a high suspicion for nasoorbitoethmoid trauma. Plastic surgeons and radiologists should be better trained in identifying the nasoorbitoethmoid fracture pattern.

Gnathodiaphyseal dysplasia (GDD; OMIM #166260) is an ultra-rare autosomal dominant disorder caused by heterozygous mutation in the anoctamin 5 (ANO5) gene and features fibro-osseous lesions of the jawbones, bone fragility with recurrent fractures, and bowing/sclerosis of tubular bones. The physiologic role of ANO5 is unknown. We report a 5-year-old boy with a seemingly atypical and especially severe presentation of GDD and unique ANO5 mutation. Severe osteopenia was associated with prenatal femoral fractures, recurrent postnatal fractures, and progressive bilateral enlargement of his maxilla and mandible beginning at ~ 2 months-of-age that interfered with feeding and speech and required four debulking operations. Histopathological analysis revealed benign fibro-osseous lesions resembling cemento-ossifying fibromas of the jaw without psammomatoid bodies. A novel, de novo, heterozygous, missense mutation was identified in exon 15 of ANO5 (c.1553G>A; p.Gly518Glu). Our findings broaden the phenotypic and molecular spectra of GDD. Fractures early in life with progressive facial swelling are key features. We assessed his response to a total of 7 pamidronate infusions commencing at age 15 months. Additional reports must further elucidate the phenotype, explore any genotype-phenotype correlation, and evaluate treatments.

Objective: This study aimed to identify risk factors for adverse perioperative events (APEs) after cleft palatoplasty to develop an individualized risk assessment tool. Design: Retrospective cohort. Setting: Tertiary institutional. Patients: Patients younger than 2 years with cleft palate. Interventions: Primary Furlow palatoplasty between 2008 and 2011. Main Outcome Measure(s): Adverse perioperative event, defined as laryngo- or bronchospasm, accidental extubation, reintubation, obstruction, hypoxia, or unplanned intensive care unit admission. Results: Three hundred patients averaging 12.3 months old were included. Cleft distribution included submucous, 1%; Veau 1, 17.3%; Veau 2, 38.3%; Veau 3, 30.3%; and Veau 4, 13.0%. Pierre Robin (n = 43) was the most prevalent syndrome/anomaly. Eighty-three percent of patients received reversal of neuromuscular blockade, and total morphine equivalent narcotic dose averaged 0.19 mg/kg. Sixty-nine patients (23.0%) had an APE, most commonly hypoventilation (10%) and airway obstruction (8%). Other APEs included reintubation (4.7%) and laryngobronchospasm (3.3%). APE was associated with multiple intubation attempts (odds ratio [OR] = 6.6, P = .001), structural or functional airway anomaly (OR = 4.5, P < .001), operation >160 minutes (OR = 2.2, P = .04), narcotic dose >0.3 mg/kg (OR = 2.3, P = .03), inexperienced provider (OR = 2.1, P = .02), and no paralytic reversal administration (OR = 2.0, P = .049); weight between 9 and 13 kg was protective (OR = 0.5, P = .04). Patients were risk-stratified according to individual profiles as low, average, high, or extreme risk (APE 2.5%-91.7%) with excellent risk discrimination (C-statistic = 0.79). Conclusions: APE incidence was 23.0% after palatoplasty, with a 37-fold higher incidence in extreme-risk patients. Individualized risk assessment tools may enhance perioperative clinical decision making to mitigate complications.

OBJECTIVEEndoscope-assisted repair of sagittal craniosynostosis was adopted at St. Louis Children’s Hospital in 2006. This study examines the first 100 cases and reviews the outcomes and evolution of patient care protocols at our institution.METHODSThe authors performed a retrospective chart review of the first 100 consecutive endoscopic repairs of sagittal craniosynostosis between 2006 and 2014. The data associated with length of hospital stay, blood loss, transfusion rates, operative times, cephalic indices (CIs), complications, and cranial remolding orthosis were reviewed. Measurements were taken from available preoperative and 1-year postoperative 3D reconstructed CT scans.RESULTSThe patients’ mean age at surgery was 3.3 ± 1.1 months. Of the 100 patients, 30 were female and 70 were male. The following perioperative data were noted. The mean operative time (± SD) was 77.1 ± 22.2 minutes, the mean estimated blood loss was 34.0 ± 34.8 ml, and the mean length of stay was 1.1 ± 0.4 days; 9% of patients required transfusions; and the mean pre- and postoperative CI values were 69.1 ± 3.8 and 77.7 ± 4.2, respectively. Conversion to open technique was required in 1 case due to presence of a large emissary vein that was difficult to control endoscopically. The mean duration of helmet therapy was 8.0 ± 2.9 months. Parietal osteotomies were eventually excluded from the procedure.CONCLUSIONSThe clinical outcomes and improvements in CI seen in our population are similar to those seen at other high-volume centers. Since the inception of endoscope-assisted repair at our institution, the patient care protocol has undergone several significant changes. We have been able to remove less cranium using our “narrow-vertex” suturectomy technique without affecting patient safety or outcome. Patient compliance with helmet therapy and collaborative care with the orthotists remain the most essential aspects of a successful outcome.

Distraction osteogenesis with a rigid external distractor is a widely accepted treatment for midfacial hypoplasia. In this study, the authors introduce the utilization of alar pinning with the external halo distractor for maxillary advancement, in place of an oral splint.A retrospective chart review was conducted of 7 patients who successfully underwent distraction osteogenesis using the alar pinning technique. Midfacial hypoplasia was secondary to Crouzon syndrome (n = 4), Apert syndrome (n = 1), Pfeiffer syndrome (n = 1), or bacterial meningitis (n = 1). Three patients were managed with monobloc osteotomies, 2 with Le Fort III osteotomies, 1 with Le Fort III osteotomy and frontoorbital advancement, and 1 with Le Fort I osteotomy alone. Patient charts were analyzed for postoperative course and complications relating to the alar pins.Two patients had minor complications specifically related to the alar pins. One patient had concern for a mild skin infection at a pin site that resolved with oral antibiotics. The other patient had loosening of an alar pin, which did not require operative management. Retrospective chart review indicated that all patients were pleased with their results from the distraction, and no patients opted for further advancement.Utilization of alar pin sites for external distraction is a feasible and reasonable option for treatment of midfacial hypoplasia involving a Le Fort osteotomy or monobloc procedure. Fixation sites within the alar crease minimize the visibility of pin site scars and eliminate the need for a custom-made oral splint, which prevents usage of the upper dentition and frequently requires consulting a dentist or orthodontist for fabrication.Alar pinning with an external halo distraction system for management of midfacial hypoplasia has minimal complications and is an alternative to using a custom-made oral splint.

In 1989, the Cleft Palate-Craniofacial Journal published the first randomized prospective cleft surgery study, comparing the Kriens intravelar veloplasty (IVV) with a non-IVV 2-flap repair. Results in that and follow-up publications yielded no difference between the 2 groups for need for secondary velopharyngeal management. The subjects have now reached adulthood. This study was designed to ask: Is there any difference between the groups in the outcomes that multidisciplinary team care addresses: speech intelligibility, facial growth, breathing while awake and asleep, attainment of education, and long-term socioeconomic status?Enrollees from the original published study were invited to participate in a survey. Subjects responded to questions about speech therapy and speech satisfaction, additional surgery, breathing patterns, sleep quality/sleep disorder, and dental occlusion. Demographic information, information on education level, profession, and socio-economic status were queried. Student t test and Fisher exact test were used to compare results.Forty-two of the original 200 patients (20 Kriens IVV and 19 non-IVV) chose to participate. Average age at survey was 25 ± 3 years. Analysis yielded no difference between the 2 respondent groups for need for secondary velopharyngeal management. There were no differences in speech outcome and satisfaction (8 questions, 0.30P 0.97), sleep concerns (3 questions, 0.16P 0.39), and dental occlusion (P = 0.69). Equivalent proportions of the 2 groups had been in speech therapy (P = 0.22). There was no difference in education attainment of the 2 groups (P = 0.26).The original randomized prospective trial suggested that there was no difference between the 2 surgery types in need for secondary velopharyngeal management. This long-term survey study on the same group of patients suggests that in young adulthood, the 2 groups have similar outcomes in terms of education, career choice, speech satisfaction, dental occlusion, and sleep disorder.

Reconstruction of the levator musculature during cleft palate repair has been suggested to be important in long-term speech outcomes. In this study, we compare the need for postoperative speech therapy between 2 intravelar veloplasty techniques.Chart review was performed for patients with nonsyndromic cleft palate who underwent either primary Kriens or overlapping intravelar veloplasty before 18 months of age. All subjects completed a follow-up visit at approximately 3 years of age. Data obtained included documentation of ongoing or recommended speech therapy at age 3 years and reasons for speech therapy, which were categorized as cleft-related and non-cleft-related by a speech-language pathologist.One surgeon performed all Kriens procedures (n = 81), and the senior author performed all overlapping procedures (n = 25). Mean age at surgery (Kriens = 13.5 ± 1.4 months; overlapping = 13.1 ± 1.5 months; P = 0.188) and age at 3-year follow-up (Kriens = 3.0 ± 0.5 years; overlapping = 2.8 ± 0.5 years; P = 0.148) were equivalent in both groups. Cleft severity by Veau classification (P = 0.626), prepalatoplasty pure tone averages, (P = 0.237), pure tone averages at 3-year follow-up (P = 0.636), and incidence of prematurity (P = 0.190) were also similar between the 2 groups. At 3 years of age, significantly fewer overlapping intravelar veloplasty patients required cleft-related speech therapy (Kriens = 47%; overlapping = 20%; P = 0.015). The proportions of patients requiring non-cleft-related speech therapy were equivalent (P = 0.906).At 3 years of age, patients who received overlapping intravelar veloplasty were significantly less likely to need cleft-related speech therapy compared with patients who received Kriens intravelar veloplasty. Cleft severity, hearing loss, and prematurity at birth did not appear to explain the difference found in need for speech therapy.

Background Nasal fractures are the most common facial fracture. Improper reduction is a common occurrence, resulting in a residual deformity that requires secondary surgery. A treatment protocol for nasal fracture management is presented with the aim of reducing secondary deformities requiring corrective surgery. Methods After institutional review board approval, a retrospective review of all closed nasal reductions performed by a single surgeon between 2006 and 2015 was conducted. Patient age, sex, presence of secondary deformity, and need for a correctional operation were recorded. Clinical records were analyzed for evidence of postoperative deformity and need for subsequent manipulation or surgery. Results A total of 90 patients with nasal bone fractures who underwent closed nasal reduction were identified. The mean age of patients was 24.9 years. The male-to-female ratio was 2.2:1. Postoperative deformity was reported in 14 patients (15.6 percent). Four of the 90 patients (4.4 percent) were found to have avulsion of their upper lateral cartilage from the nasal bone. Nine of the 14 subjects (64.3 percent) presenting with secondary deformity were managed with external manipulation, avoiding a secondary operation. Five patients (5.5 percent) from the original cohort of 90 underwent revision surgery. Conclusions By using the described protocol to treat nasal fractures, we have seen a low rate of postreduction deformity and a small percentage of need for secondary operation. The overall success rate of closed nasal reduction with postoperative manipulation (when necessary) was identified to be 94.5 percent. Using this protocol, surgeons may see a decrease in secondary deformities following closed nasal reduction procedures. Clinical question/level of evidence Therapeutic, IV.

INTRODUCTION Several bioresorbable plating systems have become standard in pediatric craniosynostosis reconstruction. A comparison of these systems is needed to aid surgeons in the preoperative planning process. The authors aim to evaluate 1 institution's experience using Resorb-X by KLS Martin and Delta Resorbable Fixation System by Stryker (Stryker Craniomaxillofacial, Kalamazoo, MI). METHODS A sample of patients with single-suture nonsyndromic craniosynostosis treated at St Louis Children's Hospital between 2007 and 2014 using either Resorb-X or Delta bioresorbable plating systems were reviewed. Only patients with preoperative, immediate, and long-term 3-dimensional photographic images or computed tomography scans were included. A comparison of plating system outcomes was performed to determine the need for clinic and emergency room visits, imaging obtained, and incidence of subsequent surgical procedures due to complications. RESULTS Forty-six patients (24 Resorb-X and 22 Delta) underwent open repair with bioabsorbable plating for single suture craniosynostosis. The mean age at each imaging time point was similar between the 2 plating systems (P > 0.717). Deformity-specific measures for sagittal (cranial index), metopic (interfrontotemporale), and unicoronal (frontal asymmetry) synostosis were equivalent between the systems at all time points (0.05

OBJECTIVE Endoscope-assisted methods for treatment of craniosynostosis have reported benefits over open calvarial vault reconstruction. In this paper, the authors evaluated 2 methods for endoscope-assisted correction of sagittal synostosis: wide vertex suturectomy and barrel stave osteotomies (WVS+BSO) and narrow vertex suturectomy (NVS). METHODS The authors evaluated patients with nonsyndromic sagittal synostosis treated with either wide vertex suturectomy (4–6 cm) and barrel stave osteotomies (WVS+BSO) or narrow vertex suturectomy (NVS) (approximately 2 cm) between October 2006 and July 2013. Prospectively collected data included patient age, sex, operative time, estimated blood loss (EBL), postoperative hemoglobin level, number of transfusions, complications, and cephalic index. Fourteen patients in the NVS group were age matched to 14 patients in the WVS+BSO group. Descriptive statistics were calculated, and Student t-tests were used to compare prospectively obtained data from the WVS+BSO group with the NVS group in a series of univariate analyses. RESULTS The mean age at surgery was 3.9 months for WVS+BSO and 3.8 months for NVS. The mean operative time for patients undergoing NVS was 59.0 minutes, significantly less than the 83.4-minute operative time for patients undergoing WVS+BSO (p < 0.05). The differences in mean EBL (NVS: 25.4 ml; WVS+BSO: 27.5 ml), mean postoperative hemoglobin level (NVS: 8.6 g/dl; WVS+BSO: 8.0 g/dl), mean preoperative cephalic index (NVS: 69.9; WVS+BSO: 68.2), and mean cephalic index at 1 year of age (NVS: 78.1; WVS+BSO: 77.2) were not statistically significant. CONCLUSIONS The NVS and WVS+BSO produced nearly identical clinical results, as cephalic index at 1 year of age was similar between the 2 approaches. However, the NVS required fewer procedural steps and significantly less operative time than the WVS+BSO. The NVS group obtained the final cephalic index in a similar amount of time postoperatively as the WVS+BSO group. Complications, transfusion rates, and EBL were not different between the 2 techniques.

Background The infraorbital nerve (ION) is at risk for iatrogenic injury during orbital floor repair. The authors aim to anatomically characterize the intraosseous course of the ION between the inferior orbital fissure and infraorbital foramen. Methods Ten cadaver heads (20 orbits) were dissected, with exposure of the orbital floor. The ION was identified from the infraorbital fissure to inferior orbital foramen. The presence and caliber of an osseous roof was noted. Distances measured were infraorbital foramen to infraorbital margin; length of the inferior orbital groove; length of the inferior orbital canal; length from the inferior orbital fissure to the infraorbital margin. Results Three variations of the osseous anatomy around the ION were identified. Four cadavers had no identifiable groove (Type 1, 40%) and the ION was completely roofed throughout its course. Five specimens exhibited a thin, transparent osseous roof over the nerve before forming the true canal, which we describe as a "pseudocanal" (Type 2, 50%). A true groove was seen in both orbits from a single cadaver (Type 3, 10%). Each cadaver had an ION course of the same type on both sides. Mean ± SD intraorbital foramen to infraorbital margin distance was 7.1 ± 1.4 mm. Distance from the infraorbital fissure to the infraorbital margin was 28.5 ± 2.3 mm. Conclusions The course of the infraorbital nerve can be described as Type 1 (true canal), Type 2 (pseudocanal), and Type 3 (groove and canal). The authors propose that this novel classification system will raise awareness of variations in orbital floor anatomy.

OBJECT The authors present a retrospective cohort study examining complications in patients undergoing surgery for craniosynostosis using both minimally invasive endoscopic and open approaches. METHODS Over the past 10 years, 295 nonsyndromic patients (140 undergoing endoscopic procedures and 155 undergoing open procedures) and 33 syndromic patients (endoscopic procedures in 10 and open procedures in 23) met the authors’ criteria. Variables analyzed included age at surgery, presence of a preexisting CSF shunt, skin incision method, estimated blood loss, transfusions of packed red blood cells, use of intravenous steroids or tranexamic acid, intraoperative durotomies, procedure length, and length of hospital stay. Complications were classified as either surgically or medically related. RESULTS In the nonsyndromic endoscopic group, the authors experienced 3 (2.1%) surgical and 5 (3.6%) medical complications. In the nonsyndromic open group, there were 2 (1.3%) surgical and 7 (4.5%) medical complications. Intraoperative durotomies occurred in 5 (3.6%) endoscopic and 12 (7.8%) open cases, were repaired primarily, and did not result in reoperations for CSF leakage. Similar complication rates were seen in syndromic cases. There was no death or permanent morbidity. Additionally, endoscopic procedures were associated with significantly decreased estimated blood loss, transfusions, procedure length, and length of hospital stay compared with open procedures. CONCLUSIONS Rates of intraoperative durotomies and surgical and medical complications were comparable between endoscopic and open techniques. This is the largest direct comparison to date between endoscopic and open interventions for synostosis, and the results are in agreement with previous series that endoscopic surgery confers distinct advantages over open surgery in appropriate patient populations.

We evaluate the safety and efficacy of the transcaruncular approach for reconstruction of medial orbital wall fractures and the combined transcaruncular-transconjunctival approach for reconstruction of large orbital defects involving the medial wall and floor. A retrospective review of the clinical and radiographic data of patients who underwent either a transcaruncular or a combined transcaruncular-transconjunctival approach by a single surgeon for orbital fractures between June 2007 and June 2013 was undertaken. Seven patients with isolated medial wall fractures underwent a transcaruncular approach, and nine patients with combined medial wall and floor fractures underwent a transcaruncular-transconjunctival approach with a lateral canthotomy. Reconstruction was performed using a porous polyethylene implant. All patients with isolated medial wall fractures presented with enophthalmos. In the combined medial wall and floor group, five out of eight patients had enophthalmos with two also demonstrating hypoglobus. The size of the medial wall defect on preoperative computed tomography (CT) scan ranged from 2.6 to 4.6 cm2; the defect size of combined medial wall and floor fractures was 4.5 to 12.7 cm2. Of the 11 patients in whom postoperative CT scans were obtained, all were noted to have acceptable placement of the implant. All patients had correction of enophthalmos and hypoglobus. One complication was noted, with a retrobulbar hematoma having developed 2 days postoperatively. The transcaruncular approach is a safe and effective method for reconstruction of medial orbital floor fractures. Even large fractures involving the orbital medial wall and floor can be adequately exposed and reconstructed with a combined transcaruncular-transconjunctival-lateral canthotomy approach. The level of evidence of this study is IV (case series with pre/posttest).

Objective: To compare postoperative temporal expansion in patients treated with fronto-orbital advancement or endoscopy-assisted craniectomy with cranial orthotic therapy. Design: This is a retrospective, multicenter cohort study of patients with unilateral coronal craniosynostosis (UCS). Setting: Computed tomographic (CT) scans were drawn from UCS patients treated at Boston Children’s Hospital or St Louis Children’s Hospital. Patients: The study included 56 patients with UCS after fronto-orbital advancement (n = 32) or endoscopic repair (n = 24) and 10 age-matched controls. Intervention: Fronto-orbital advancement entails a craniotomy of the frontal bone and superior orbital rim followed by reshaping and forward advancement. Endoscopic repair is the release of the synostotic suture and guidance of further growth of the cranium using a molding orthotic. Main Outcome Measures: Measures included posterior temporal width, anterior temporal width, orbital width, and anterior cranial fossa area taken preoperatively and 1 year postoperatively. Linear regression was performed to assess 1 year postoperative improvement in symmetry; covariates included preoperative symmetry and type of surgery. Results: Both treatments showed improvement in orbital width and anterior cranial fossa area symmetry 1 year postoperatively ( P < .001), but no significant improvement in posterior or anterior temporal width symmetry. Linear regression revealed no difference between the 2 procedures in any of the 4 measurements (.096 ≤ P ≤ .898). Conclusions: Fronto-orbital advancement and endoscopic repair show equivalent outcomes 1 year postoperatively in all 3 width measurements and anterior cranial fossa area. Neither procedure produced significant improvement in temporal width.

To improve the rotation of Cupid's bow and achieve sufficient vertical lip height, several variations of the Millard rotation-advancement have incorporated a small laterally based triangular flap above the cutaneous roll. This study uses three-dimensional photogrammetry to evaluate the outcomes of unilateral cleft lip repairs performed with and without pennant flaps.Three-dimensional photographs were analyzed to assess postoperative lip height asymmetry in 90 unilateral cleft lip patients (58 complete and 32 incomplete) treated between 2001 and 2012. Cleft lip repairs were performed by three pediatric cleft surgeons using different techniques. Thirty-nine of 90 procedures (43 percent) used an inferiorly placed triangular flap. All patients were photographed at least 9 months postoperatively (mean, 4.2 years). Lip height asymmetry was based on the vertical distances from the subnasale to the peaks of Cupid's bow.Regression analysis revealed that the use of a pennant flap was a significant predictor of postoperative lip height asymmetry (β = 4.2 percent, p = 0.015). The surgeon performing the repair was also a significant factor in patients with complete cleft lips (β = 3.6 percent, p = 0.005). All three surgeons achieved greater lip height symmetry when a pennant flap was performed.The results of unilateral cleft lip repairs are affected by both the surgeon and the surgical technique. Procedures that used a pennant flap showed better philtral height symmetry than nonpennant repairs.Therapeutic, III.

Objective To determine a correlation between the width of the cleft palate measured at the time of lip adhesion, definitive lip repair, and palatoplasty and the subsequent occlusal classification of patients born with unilateral cleft lip and palate. Design Retrospective, observational study. Setting Referral, urban, children's hospital Participants Dental models and records of 270 patients were analyzed. Interventions None. Main Outcome Measure Angle occlusion classification. Results The mean age at which occlusal classification was determined was 11 ± 0.3 years. Of the children studies, 84 were diagnosed with Class I or II occlusion, 67 were diagnosed with Class III occlusion, and 119 were lost to follow up or transferred care. Mean cleft widths were significantly larger in subjects with Class III occlusion for all measures at time of lip adhesion and definitive lip repair ( P < .02). At time of palatoplasty, cleft widths were significantly greater at the alveolus ( P = .025) but not at the midportion of the hard palate ( P = .35) or posterior hard palate ( P =. 10). Conclusion Cleft widths from the lip through to the posterior hard palate are generally greater in children who are diagnosed with Class III occlusion later in life. Notably, the alveolar cleft width is significantly greater at each time point for patients who went on to develop Class III occlusion. There were no significant differences in cleft widths between patients diagnosed later with Class I and Class II occlusions.

Background Previous studies have shown that open cranial vault remodeling does not fully address the endocranial deformity. This study aims to compare endoscopic-assisted suturectomy with postoperative molding helmet therapy to traditional open reconstruction by quantifying changes in cranial base morphology and posterior cranial vault asymmetry. Methods Anthropometric measurements were made on pre- and 1-year postoperative three-dimensionally reconstructed computed tomography scans of 12 patients with unilateral lambdoid synostosis (8 open and 4 endoscopic-assisted). Cranial base asymmetry was analyzed using: posterior fossa deflection angle (PFA), petrous ridge angle (PRA), mastoid cant angle (MCA), and vertical and anterior-posterior (A-P) displacement of external acoustic meatus (EAM). Posterior cranial vault asymmetry was quantified by volumetric analysis. Results Preoperatively, patients in the open and endoscopic groups were statistically equivalent in PFA, PRA, MCA, and A-P EAM displacement. At 1 year postoperatively, open and endoscopic patients were statistically equivalent in all measures. Mean postoperative PFA for the open and endoscopic groups was 6.6 and 6.4 degrees, PRA asymmetry was 6.4 and 7.6%, MCA was 4.0 and 3.2 degrees, vertical EAM displacement was -2.3 and -2.3 millimeters, and A-P EAM displacement was 6.8 and 7.8 millimeters, respectively. Mean volume asymmetry was significantly improved in both open and endoscopic groups, with no difference in postoperative asymmetry between the 2 groups (P = 0.934). Conclusions Patients treated with both open and endoscopic repair of lambdoid synostosis show persistent cranial base and posterior cranial vault asymmetry. The results of endoscopic-assisted suturectomy with postoperative molding helmet therapy are similar to those of open calvarial vault reconstruction.

Deformational plagiocephaly and/or brachycephaly (DPB) is a misshapen head presenting at birth or shortly thereafter, caused by extrinsic forces on an infant’s malleable cranium. There are two treatment methods available for DPB: helmeting and repositioning. Little is known about the long-term outcomes of these two treatment options. The purpose of this study was to examine children who received helmeting or repositioning therapy for DPB as infants and compare the long-term head shape outcomes of the two groups. A longitudinal cohort study design was used to evaluate change in head shape of the two groups. One hundred children (50 helmeted, 50 repositioned) were initially evaluated at 6 months or younger for DPB. Anthropometric skull measurements taken as infants before treatment were compared with measurements taken for this study. Inclusion criteria included initial clinic visit at age 6 months or younger, evaluation by the same practitioner, and current age 2–10 years. Cephalic index and cranial vault asymmetry were calculated based on caliper measurements. Data from 100 children were evaluated for this study. Significant differences between the treatment groups in the mean change in cephalic index (p = 0.003) and cranial vault asymmetry (p

The thickness of the calvarium and presence of the diploic space in children can aid surgical planning for split-thickness calvarial bone grafting when needed in calvarial reconstruction. However, the normal anatomical characteristics of calvarial thickness and the diploic space in children are poorly defined. Computed tomography scans of pediatric heads over a 2-year period were culled from a large, urban pediatric referral hospital. Subjects with a craniofacial/developmental abnormality or history of surgery were excluded. 104 scans met inclusion criteria. Each skull was marked at 40 locations over the frontal, parietal, and occipital bones. At each location, thickness measurements of the calvarium and the diploe were taken. The left posterior parietal region was thicker than the right in both skull and diploic thickness. Over 90 % of subjects had diploe demonstrable on CT in the frontal and posterior parietal regions by age 3–5. In all ages, the diploe was thickest in the frontal bone and in posterolateral parts of the parietal bones. The skull and the diploe are bilaterally symmetric except in the posterior parietal region, where the left is thicker than the right. The presence of a diploe in surgically important regions can be reliably demonstrated using CT by age 3–5. Level IV, diagnostic study.