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Background: Midvault reconstruction is an essential element of functional rhinoplasty. An improved understanding of airflow patterns after spreader graft (SG) or spreader flap (SF) techniques can inform surgical techniques based on individual anatomy. Objectives: The objective of this study was to compare the physiologic changes related to nasal function after midvault reconstruction with SF and SG. Methods: Soft tissue elevation (STE), SG, and SF were performed in sequence on 5 cadaveric specimens. Computational modeling was used to simulate airflow, heat transfer, and humidity in three-dimensional nasal airway reconstructions of each specimen. Results: Median bilateral airflow-rates (L/min) were similar for STE (29.4), SF (27.6), and SG (28.9), and were not statistically significant (STE vs SF: P = 1.0, power = 5%; STE vs SG: P = .31, power = 16%; SF vs SG: P = .42, power = 14%). Both SF and SG had increased unilateral airflow volume (L/min) through the more obstructed nasal passage (median: STE 10.3, SF 12.2, SG 12.7), but these differences were not significant (STE vs SF: P = .19, power = 24%; STE vs SG P = .19, power = 30%). Furthermore, SF and SG had decreased unilateral nasal resistance (Pa s/mL) on the more obstructed side (median: STE 0.085, SF 0.072, SG 0.062) (STE vs SF: P = .13, power = 23%; STE vs SG P = .13, power = 24%). For all 3 models, heat flux distribution was greater in the anterior portion of the nasal passage than the posterior portions. Conclusions: Differences in nasal airflow and resistance after SF and SG were not statistically significant, but both procedures resulted in higher airflow rates and decreased nasal resistance through the more obstructed nasal passage.

After studying this article, the participant should be able to: (1) understand the functional significance of nasal anatomy as it relates to rhinoplasty and perform a comprehensive functional nasal assessment. (2) Identify the anatomical level of obstruction based on the authors' algorithmic approach and understand the current evidence supporting operative techniques for correcting nasal airway obstruction from septal deformity, inferior turbinate hypertrophy, internal nasal valve collapse, external nasal valve collapse. (3) Understand the current evidence supporting operative techniques for correcting nasal airway obstruction from septal deformity, inferior turbinate hypertrophy, internal nasal valve collapse, and external nasal valve collapse. (4) Appreciate the objective assessment tools for functional nasal surgery from a clinical and research perspective.The intent of functional rhinoplasty is to improve nasal airflow (and the perception thereof) by surgically correcting the anatomical sources of obstruction in the nasal airway. Cosmetic and functional rhinoplasty are not mutually exclusive entities, and the techniques that address one area, inevitably may affect the another. The rate of functional problems after cosmetic rhinoplasty range from 15 to 68 percent with nasal airway obstruction found to be the most common indication for secondary surgery. The objective of this CME article is to provide readers with an understanding of the (1) functional components of nasal anatomy, (2) clinical functional assessment, and (3) the current evidence supporting corrective maneuvers for each component.

Dorsal hump reduction is one of the most common techniques used in modern rhinoplasty, yet it carries a high propensity for untoward aesthetic and functional sequelae, as evidenced by a nontrivial revision rate. Component dorsal hump reduction with stepwise deconstruction and manipulation of component parts allows for an adaptable and precise approach to variances in anatomy and in desired aesthetic result. Secondary changes must be anticipated and addressed at the index operation to avoid negative results and prevent the need for revision. Adequate reconstruction of the midvault is paramount to achieving optimal aesthetic and functional outcomes.

PURPOSE: Individuals with unilateral cleft lip nasal deformity (uCLND) often require rhinoplasty in adolescence to correct nasal obstruction. The intent of this study is to identify sites of greatest nasal obstruction and evaluate the effects of isolated and combinations of simulated surgical procedures on these sites using computational fluid dynamics (CFD). METHODS: Computed tomography imaging of an adolescent subject with uCLND was converted to an anatomically accurate three-dimensional nasal airway model. Initial analysis was performed to identify anatomic sites of obstruction based on CFD computed resistance values. Virtual surgery procedures corresponding to common uCLND surgical interventions were simulated. Resulting airspace models were then analyzed after conducting airflow and heat transfer simulations. RESULTS: The preoperative model had 21 obstructed sites with a nasal resistance of 0.075 Pa s/mL. Following simulated surgical procedures with functional interventions alone and in combinations, the three virtual surgery models with most improved nasal airflow were inferior turbinate reduction (ITR) with posterior septoplasty (resistance = 0.054 Pa s/ml, reduction in 14 of 21 obstructed sites), ITR with anterior septoplasty (resistance = 0.058 Pa s/ml, reduction in 8 of 21 obstructed sites), and ITR with both anterior and posterior septoplasty (resistance = 0.052 Pa s/ml, reduction in 17 of 21 obstructed sites). CONCLUSION: This study introduces a new technique for analysis of the impact of different simulated surgical interventions on uCLND-induced nasal obstruction. In this subject, simulated septoplasty with ITR on the non-cleft side provided maximal relief of nasal obstruction. The proposed technique can be further studied for possible utility in analyzing potential surgical interventions for optimal relief of nasal obstruction in patients with uCLND.

BACKGROUND Given the competition in the integrated plastic surgery Match, away rotations are ubiquitous among plastic surgery applicants to differentiate their applications. This study aimed to characterize how performing an away rotation affects rank order and Match outcomes for integrated plastic surgery programs. METHODS An online survey was designed and distributed to the top 25 integrated plastic surgery programs in the United States as determined by Doximity. Programs were polled about away rotation structure, position of rotators on their 2018 to 2019 rank list, and composition of current resident classes. RESULTS Twenty-five programs completed the survey (response rate, 100 percent). On average, programs interviewed 34.9 applicants (range, 22 to 50 applicants) and ranked 32.8 applicants (range, 10 to 50 applicants). Most "ranked-to-match" positions were occupied by home students or away rotators (60.9 percent). Rank order of home students, away rotators, and nonrotators varied significantly (p < 0.001), with median rank order of home students [5 (interquartile range, 1 to 9)] and rotators [14 (interquartile range, 6 to 27)] higher than nonrotators [17 (interquartile range, 10 to 29)]. Rank orders of away rotators tended to follow a bimodal distribution. Furthermore, 64.4 percent of integrated residents were either a home student or away rotator at their matched integrated program, with 20 percent of residency programs composed of greater than 70 percent of away rotators/home students across postgraduate years 1 through 6 classes. CONCLUSIONS For integrated plastic surgery programs, the majority of ranked-to-match students on rank lists and current residents were either home students or away rotators at their respective program. Performing well on an away rotation appears to confer significant benefit to the applicant applying in the integrated plastic surgery Match.

Background: Unilateral cleft lip nasal deformity (uCLND) creates multiple sites of nasal airway obstruction, impacting patients’ quality of life. Surgical restoration of function remains technically challenging and complex. Objectives: This is a single patient case report to determine consistency of patient’s subjective perception of nasal outcomes after septorhinoplasty with objective assessments, and effectiveness of standard surgical techniques in targeting sites of greatest nasal anatomical obstruction. Method: Patient-reported quality of life (QOL) measures were collected. Pre- and post-surgery radiographic images of a patient with uCLND were obtained for computational fluid dynamics (CFD) modeling of patient-specific nasal function. Objective assessments were obtained using rhinomanometry and CFD. CFD-derived localized resistance at multiple cross-sectional segments were determined and used to identify greatest nasal obstructive sites. Results: Patient-reported QOL scores improved by 20 to 73 points. CFD-calculated bilateral resistance decreased from 0.155 to 0.061 Pa.s/ml, cleft-side resistance from 0.407 to 0.091 Pa.s/ml, and non-cleft-side from 0.228 to 0.120 Pa.s/ml. Rhinomanometry showed similar decreases in resistance. On the cleft side, 25 identified sites of greatest obstruction decreased to 15 sites post-surgery; on the non-cleft side, 23 sites of greatest obstruction decreased to 16 sites post-surgery. Conclusion: Results suggest improvement in nasal patency after septorhinoplasty. Additional greatest obstructive sites in the post-surgical airway were mostly around the superior airway.

This issue of Clinics explores the concept of "preservation" rhinoplasty. At present, this topic is gaining considerable attention. As proponents of preservation suggest, a great number of problems we encounter in rhinoplasty are problems that were not present before the surgery; therefore, they can often be attributable to the deconstruction and reconstruction that took place. Preservation rhinoplasty should be viewed generally as a mindset to limit deconstructive steps in rhinoplasty when possible, understanding that these steps and those to later reconstruct provide the potential to create new problems that did not previously exist.

Limited visibility characteristic of cleft palate repair presents both ergonomic and educational challenges to cleft surgeons. Despite widespread recognition and reporting, posture-related spine disorders continue to represent a significant and potentially career-limiting problem for cleft/craniofacial surgeons. In addition, education and participation during palate repairs is difficult because of visual field constraints. At the authors' institution, a novel videoscope system was designed and implemented to (1) provide visualization for all surgical team members during palate operations, (2) facilitate active resident education, and (3) improve surgeon ergonomics. The authors' prior report demonstrated proof of concept for this method, which is now used in all cleft palate operations at their center. The purpose of this report is to share the detailed methodology to facilitate implementation by others and a retrospective review of the authors' experience before and after implementation. Video demonstration of the videoscope setup and a representative, recorded case are provided. The use of the videoscope was feasible in palatoplasties regardless of palatal phenotype and repair technique and did not have an effect on operative time. Subjectively, the authors report reduced procedure time in cervical flexion and subjectively improved musculoskeletal strain associated with videoscope use. Importantly, use of this system also provided complete visualization for all operating room team members and enabled enhanced resident autonomy during palate operations. Finally, it has facilitated the creation and archive of high-definition educational videos with unparalleled perspective. The equipment required to implement the system is likely already available in many medical centers. Adoption of this system may provide an opportunity to improve posture and teaching capabilities for cleft surgeons. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, III.

Background Dorsal hump reduction during open rhinoplasty disrupts the continuity between the upper lateral cartilages and the dorsal septum. Options to reconstitute the midvault include primary closure of the upper lateral cartilages to the dorsal aspect of the septum, placement of spreader grafts, and creation of spreader flaps. The authors sought to clarify from highly experienced rhinoplasty surgeons their decision-making rationale for midvault reconstruction, distilling down the group consensus into algorithmic guidelines. Methods A panel of internationally recognized rhinoplasty surgeons participated in a two-part organized communication method. An introductory summit consisted of open discussions on various topics in midvault reconstruction. The summit transcription was analyzed by thematic content analysis to develop a survey encompassing clinical scenarios for primary rhinoplasty, which was then individually administered to each panelist. Data gathered from both parts were used to generate technical guidelines and a decision-making algorithm. Results The panelists identified the following anatomical features as pertinent to their selection of midvault reconstruction method: size of the dorsal hump reduction, width of the midvault relative to the upper vault, presence of dorsal angulation, and presence of nasal obstructive symptoms. Individual panelist preference was gathered from the 24-scenario survey divided into either cosmetic or functional rhinoplasty cases. Conclusions Management of the midvault after dorsal hump reduction is important to establish proper aesthetic relationships and to provide functional integrity of the internal valve. Our authors present an algorithmic approach to decision-making based on the systematic analysis practiced by senior rhinoplasty surgeons.

Background Adverse events after rhinoplasty vary in etiology and severity, a fact that is reflected in the current American Society of Plastic Surgeons rhinoplasty consent form. However, there is currently no literature providing a comprehensive summation of evidence-based quantifiable risk of adverse events after rhinoplasty. Given this limitation, patients considering rhinoplasty are unable to fully ascertain preoperative risk, and the ability of physicians to obtain true informed consent is similarly flawed. This systematic review provides the first rigorous, comprehensive, and quantitative reporting of adverse events after rhinoplasty. Methods This review was registered on the International Prospective Register of Systematic Reviews (PROSPERO) database (registration no. CRD42018081826) in April of 2018. Eligible articles were published in peer-reviewed journals with available abstracts and full-text articles. Interventions included primary functional, aesthetic, and combined functional/aesthetic rhinoplasty. The following data were extracted: study size, population characteristics, indication, surgical approach, concomitant procedures, and incidence of adverse events. Results A search yielded 3215 publications for title and abstract screening. Three hundred twenty-two were eligible for full-text review. Thirty-six met final inclusion criteria. A total of 13 adverse events were reported among these studies and included need for revision (0 to 10.9 percent), infection (0 to 4 percent), dehiscence (0 to 5 percent), bleeding (0 to 4.1 percent), septal perforation (0 to 2.6 percent), nasal airway obstruction requiring revision (0 to 3 percent), and hypertrophic scarring (0 to 1.5 percent). Conclusions This systematic review presents the first comprehensive and quantitative reporting of adverse event frequency after rhinoplasty. This is a crucial tool for preoperative patient counseling and an essential adjunct in the acquisition of informed consent. Future investigations will benefit from transparency and standardization of reporting to further quantify adverse event rates.

The nasal deformity that accompanies cleft conditions is often acknowledged as the most difficult obstacle to restoring facial balance in affected children. Despite considerable progress in the treatment of cleft lip and palate, the outcomes of cleft septorhinoplasty have proven variable and difficult to predict, possibly because of incomplete understanding of the underlying anatomical deformities. The authors sought to characterize unilateral cleft septal and dorsal deformities through a detailed morphologic model based on photogrammetric, qualitative, and quantitative computerized tomographic image analysis.Twenty-five consecutive patients with a unilateral cleft nasal deformity without prior septorhinoplasty were included.Dorsal angulation, as measured by the nasal dorsal angle, consistently deviated away from the cleft side at a mean angle of 8.9 degrees. In a majority of patients, the septal deformity was complex and consistent in the anterior and middle regions of the airspace, but variable in the posterior region. Finally, discrete sites of potential nasal obstruction were noted in the anterior, middle, and posterior regions along the acoustic axis. Considerable variation was seen in the anterior and posterior regions, with potential obstructions variably on both the cleft and noncleft sides.The authors' results underscore the importance of subject-specific analysis in cleft septorhinoplasty to address multiple potential sites of nasal obstruction.

Objective:Children with orofacial clefts (OFCs) may experience poor reading proficiency, learning disabilities, and academic underachievement. We examined the association between nonsyndromic (NS) OFCs and end-of-grade (EOG) performance in reading and math from third through eighth grade in a sample subgroup.Participants:We identified a cohort of 559 children with NS-OFCs and 6822 children without birth defects, classifying cleft type by cleft lip alone, with or without cleft alveolar ridge (CL); cleft lip with cleft palate (CL+P); and cleft palate only (CP).Main Outcome Measures:Using logistic regression, we estimated the odds of not meeting grade-level standards among children with NS-OFCs compared to unaffected peers. Using longitudinal analyses, we estimated the odds of not meeting grade-level standards and average change in test scores through eighth grade.Results:Children with NS-OFCs were 1.22 (95% CI: 0.96, 1.83) times as likely not to meet grade-level standards in reading compared to unaffected peers. The effect was similar for math (OR: 1.17; 95% CI: 0.92, 1.48). Children with CL+P were 1.33 (95% CI: 0.86, 1.83) and 1.74 (95% CI: 1.19, 2.56) times as likely not to meet grade-level standard in reading and in both subjects, respectively, compared to unaffected peers. The average rate of change in both scores was similar for children with and without OFCs.Conclusions:Poor academic performance appears greatest for children with CL+P, a finding compatible with previous observations and hypothesized mechanisms associating orofacial clefts with subtle abnormalities in brain development. Academic performance monitoring and referral for academic assistance is warranted.

This study evaluated the impact of unilateral cleft lip nasal deformity (uCLND) on the ability of the nasal passages to warm and humidify inspired environmental air using computational fluid dynamics (CFD) modeling. Nasal air conditioning was simulated at resting inspiration in ten individuals with uCLND and seven individuals with normal anatomy. The overall heat and water transfer through nasal mucosa was significantly greater (p = 0.02 for both heat and moisture fluxes) on the non-cleft side than on the cleft side. Unilateral median and interquartile range (IQR) for heat flux (W/m2) was 190.3 (IQR 59.9) on the non-cleft side, 160.9 (IQR 105.0) on the cleft side, and 170.7 (IQR 87.8) for normal subjects. For moisture flux (mg/(s·m2), they were 357.4 (IQR 112.9), 298.7 (IQR 200.3) and 320.8 (IQR 173.0), respectively. Significant differences of SAHF50 between cleft side of uCLND and normal existed except for anterior region. Nevertheless, air conditioning ability in subjects with uCLND was generally comparable to that of normal subjects.

Summary. Small-to-medium cutaneous defects of the distal nose pose a significant challenge to reconstructive surgeons, and commonly described reconstructive techniques have their limitations. As the skin of this region is characteristically rigid and sebaceous, care must be taken to avoid introducing unfavorable tension vectors that can result in functional or anatomic distortion of the nasal free margins. With this in mind, the authors discuss 3 alternative reconstructive options, the East-West, nasalis sling, and trilobed flaps, which have wide utility in the repair of distal nasal cutaneous defects and can result in excellent cosmesis. The indications, surgical technique, and limitations of each are discussed in detail, and are compared with several of the more commonly described options in the context of distal nasal reconstruction.

Summary. The paramedian forehead flap is a historic cornerstone of plastic surgery and a mainstay of complex nasal reconstruction. Although initially described as a 2-stage procedure, several procedural advancements and modifications have been proposed, with the most notable being the addition of a third, intermediate stage. Proponents of this 3-stage approach argue that the addition of an intermediate stage improves flap perfusion, expands lining and structural support options, and provides superior aesthetic outcomes. Although this technique has grown in popularity, studies comparing the 2- versus 3-stage approach are relatively scarce in the literature. Existing comparative studies seem to suggest that the 3-stage paramedian forehead flap may have advantages in large, complex nasal defects and patients at high risk for vascular compromise. Additionally, comparative analyses with respect to aesthetic outcome were found to be largely equivocal, suggesting that surgeon comfort and preference should guide flap selection.

Objectives: To evaluate the magnitude of olfactory recess opacity in patients with unilateral cleft lip nasal deformity (uCLND). Design: Subject-specific 3-dimensional reconstruction of the nasal airway anatomy was created from computed tomography images in 11 (4 males and 7 females) subjects with uCLND and 7 (3 males, and 4 females) normal subjects. The volume and surface area of each subject’s unilateral and bilateral olfactory airspace was quantified to assess the impact of opacification. Qualitatively speaking, patients with 75% to 100% olfactory recess opacification were classified as extreme, 50% to 75% as severe, 25% to 50% as moderate, and 0% to 25% as mild. Results: Of the 11 subjects with uCLND, 5 (45%) were classified as having extreme olfactory recess opacification, 3 (27%) subjects had severe opacification, and 3 (27%) subjects had moderate opacification. Mean (±SD) bilateral olfactory recess volume was significantly greater in normal subjects than in subjects with uCLND (0.9668 cm3 ± 0.4061 cm3 vs 0.3426 cm3 ± 0.1316 cm3; P < .001). Furthermore, unilateral olfactory airspace volumes for the cleft and non-cleft sides in subjects with uCLND were considerably less than unilateral olfactory volume in subjects with normal anatomy (uCLND cleft side = 0.1623 cm3 ± 0.0933 cm3; uCLND non-cleft side = 0.1803 cm3 ± 0.0938 cm3; normal = 0.4834 cm3 ± 0.2328 cm3; P < .001). Conclusions: Our findings indicate a high prevalence of olfactory recess opacification among subjects with uCLND when compared to subjects with normal anatomy. The majority of subjects with uCLND had extreme olfactory recess opacity, which will likely influence their sense of smell.

This issue of Clinics explores the concept of "preservation" rhinoplasty. At present, this topic is gaining considerable attention. As proponents of preservation suggest, a great number of problems we encounter in rhinoplasty are problems that were not present before the surgery; therefore, they can often be attributable to the deconstruction and reconstruction that took place. Preservation rhinoplasty should be viewed generally as a mindset to limit deconstructive steps in rhinoplasty when possible, understanding that these steps and those to later reconstruct provide the potential to create new problems that did not previously exist.

Premature fusion of the cranial sutures can lead to significant neurocognitive, developmental, and esthetic consequences, especially if not corrected within the first year of life. This study aimed to identify the drivers of delayed cranial vault reconstruction (CVR) and its impact on complication and 30-day readmission rates among craniosynostosis patients.The medical records of all children who underwent CVR for craniosynostosis between 2005 and 2017 at an academic institution were retrospectively reviewed. A delay in operation was defined by surgery performed12 months of age. Patient demographics, comorbidities, perioperative complication rates, and 30-day readmission rates were collected.A total of 96 patients underwent primary CVR, with 79 (82.3%) patients undergoing nondelayed surgery and 17 (17.7%) patients undergoing surgery12 months of age. Children undergoing delayed surgery were significantly more likely to be non-White (P 0.0001), have Medicaid insurance (P = 0.023), and have a non-English primary language (P 0.005). There was increased incidence of developmental disability identified at first consult (no-delay: 3.9% vs delay: 41.2%, P 0.0001) and increased intracranial pressure (no-delay: 6.3% vs delay: 29.4%, P 0.005) among children undergoing delayed surgery. The delayed cohort had a significantly higher unplanned 30-day readmission rate (no-delay: 0.0% vs delay: 5.9%, P = 0.03).Our study suggests that craniosynostosis patients who are non-White, have a non-English primary language, and have Medicaid insurance are at risk for delayed primary surgery, which may lead to increased 30-day readmission. Interventions are necessary to reduce craniosynostosis patients' barriers to care to minimize the sequelae associated with delayed surgery.

Objective: Our objective is to describe the process of adapting a conceptual framework into a practical toolkit for one cleft team. Design: This is a single-arm implementation study in a single institution. Setting: Implementation took place at a mid-sized multidisciplinary clinic for patients with cleft lip and/or palate (CL/P) from urban/suburban and rural areas across North Carolina and neighboring states. Participants: Eligible participants were patients with CL/P from English-speaking families. Sixty patients entered and finished the study. Interventions: The implementation of a prospective data collection system based on the International Consortium for Health Outcomes Measurement (ICHOM) standard set of outcome measures for CL/P was accomplished in multiple stages. Patient- and clinician-reported forms and protocols for gathering data were created. Team members were trained and the system was tested; finally, the system was deployed. Main outcome measures: Success was appraised using the RE-AIM framework to assess reach, effectiveness, adoption, implementation, and maintenance. Results: Ninety-eight percent of patients and all team members agreed to participate. Ninety-four percent of required data were captured. Adaptations to friction points were made; specifically, visible reminders were affixed to charts, primary clinicians were required to assume data entry responsibility, and e-mail reminders were instituted. Development cost was US$7707; average time cost per clinician was 21 min/wk. Conclusions: Conceptual frameworks for outcomes studies must be tailored to their environments; otherwise, they cannot be practically implemented and sustained. We present this process for a cleft team using the ICHOM standard set. The process may help other teams implement the standard set or other conceptual frameworks.

Objective: Oronasal fistula is an important complication of cleft palate repair that is frequently used to evaluate surgical quality, yet reliability of fistula classification has never been examined. The objective of this study was to determine the reliability of oronasal fistula classification both within individual surgeons and between multiple surgeons. Design: Using intraoral photographs of children with repaired cleft palate, surgeons rated the location of palatal fistulae using the Pittsburgh Fistula Classification System. Intrarater and interrater reliability scores were calculated for each region of the palate. Participants: Eight cleft surgeons rated photographs obtained from 29 children. Results: Within individual surgeons reliability for each region of the Pittsburgh classification ranged from moderate to almost perfect (κ = .60-.96). By contrast, reliability between surgeons was lower, ranging from fair to substantial (κ = .23-.70). Between-surgeon reliability was lowest for the junction of the soft and hard palates (κ = .23). Within-surgeon and between-surgeon reliability were almost perfect for the more general classification of fistula in the secondary palate (κ = .95 and κ = .83, respectively). Conclusions: This is the first reliability study of fistula classification. We show that the Pittsburgh Fistula Classification System is reliable when used by an individual surgeon, but less reliable when used among multiple surgeons. Comparisons of fistula occurrence among surgeons may be subject to less bias if they use the more general classification of “presence or absence of fistula of the secondary palate” rather than the Pittsburgh Fistula Classification System.

The management of frontal sinus fractures has evolved in the endoscopic era. The development of functional endoscopic sinus surgery (FESS) has been incorporated into management algorithms proposed by otolaryngologists, but the extent of its influence on plastic surgeons and oral and maxillofacial surgeons is heretofore unknown. A cross-sectional survey was performed to assess the practice pattern variations in frontal sinus fracture management across multiple surgical disciplines. A total of 298 surveys were reviewed. 33.5% were facial plastic surgeons with otolaryngology training, 25.8% general otolaryngologists, 25.5% plastic surgeons, and 15.1% oral and maxillofacial surgeons. 74.8% of respondents practiced in an academic setting. 61.7% felt endoscopic sinus surgery changed their management of frontal sinus fractures. 91.8% of respondents favored observation for uncomplicated, nondisplaced frontal sinus outflow tract fractures. 36.4% favored observation and 35.9% favored endoscopic sinus surgery for uncomplicated, displaced frontal sinus outflow tract fractures. For complicated, displaced frontal sinus outflow tract fractures, obliteration was more frequently favored by plastic surgeons and oral and maxillofacial surgeons than those with otolaryngology training. The utility of FESS in managing frontal sinus fractures appears to be recognized across multiple surgical disciplines.

Cleft lip and/or palate (CL/P) is phenotypically diverse, making classification difficult. This article explores the evolution of ideas regarding CL/P classification and includes the schemes described by Davis and Ritchie (1922) , Brophy (1923) , Veau (1931) , Fogh-Andersen (1943), Kernahan and Stark (1958) , Harkins et al. (1962) , Broadbent et al. (1968), Spina (1973) , and others. Based on these systems, a longhand structured form is proposed for describing CL/P in a way that is clear, comprehensive, and consistent. A complementary shorthand notation is also described to improve the utility and convenience of this structured form.

On October 1,2015, the United States required use of the Clinical Modification of the International Classification of Diseases, 10th Revision (ICD-10-CM) for diagnostic coding. This primer was written to assist the cleft care community with understanding and use of ICD-10-CM for diagnostic coding related to cleft lip and/or palate (CL/P).

The advent of inexpensive, clinical exome sequencing (ES) has led to the accumulation of genetic data from thousands of samples from individuals affected with a wide range of diseases, but for whom the underlying genetic and molecular etiology of their clinical phenotype remains unknown. In many cases, detailed phenotypes are unavailable or poorly recorded and there is little family history to guide study. To accelerate discovery, we integrated ES data from 18,696 individuals referred for suspected Mendelian disease, together with relatives, in an Apache Hadoop data lake (Hadoop Architecture Lake of Exomes [HARLEE]) and implemented a genocentric analysis that rapidly identified 154 genes harboring variants suspected to cause Mendelian disorders. The approach did not rely on case-specific phenotypic classifications but was driven by optimization of gene- and variant-level filter parameters utilizing historical Mendelian disease-gene association discovery data. Variants in 19 of the 154 candidate genes were subsequently reported as causative of a Mendelian trait and additional data support the association of all other candidate genes with disease endpoints.

Background:. Nasal airway obstruction (NAO) due to nasal anatomic deformities is known to be more common among cleft patients than the general population, yet information is lacking regarding severity and variability of cleft-associated nasal obstruction relative to other conditions causing NAO. This preliminary study compares differences in NAO experienced by unilateral cleft lip nasal deformity (uCLND) subjects with noncleft subjects experiencing NAO. Methods:. Computational modeling techniques based on patient-specific computed tomography images were used to quantify the nasal airway anatomy and airflow dynamics in 21 subjects: 5 healthy normal subjects; 8 noncleft NAO subjects; and 8 uCLND subjects. Outcomes reported include Nasal Obstruction Symptom Evaluation (NOSE) scores, cross-sectional area, and nasal resistance. Results:. uCLND subjects had significantly larger cross-sectional area differences between the left and right nasal cavities at multiple cross sections compared with normal and NAO subjects. Median and interquartile range (IQR) NOSE scores between NAO and uCLND were 75 (IQR = 22.5) and 67.5 (IQR = 30), respectively. Airflow partition difference between both cavities were: median = 9.4%, IQR = 10.9% (normal); median = 31.9%, IQR = 25.0% (NAO); and median = 29.9%, IQR = 44.1% (uCLND). Median nasal resistance difference between left and right nasal cavities were 0.01 pa.s/ml (IQR = 0.03 pa.s/ml) for normal, 0.09 pa.s/ml (IQR = 0.16 pa.s/ml) for NAO and 0.08 pa.s/ml (IQR = 0.25 pa.s/ml) for uCLND subjects. Conclusions:. uCLND subjects demonstrated significant asymmetry between both sides of the nasal cavity. Furthermore, there exists substantial disproportionality in flow partition difference and resistance difference between cleft and noncleft sides among uCLND subjects, suggesting that both sides may be dysfunctional.

Supplemental Digital Content is available in the text., Background: Tissue expansion is a versatile reconstructive technique providing well-vascularized local tissue. The current literature focuses largely on tissue expansion for breast reconstruction and in the context of burn and pediatric skin/soft tissue replacement; however, less traditional applications are also prevalent. The aim of this study was to systematically review the utilization of tissue expansion in such less well-characterized circumstances. Methods: The authors conducted a systematic review of all publications describing non-breast applications of tissue expansion. Variables regarding expander specifications, expansion process, and complications were collected and further analyzed. Results: A total of 565 publications were identified. Of these, 166 publications described tissue expansion for “less traditional” indications, which fell into 5 categories: ear reconstruction, cranioplasty, abdominal wall reconstruction, orthopedic procedures, and genital (penile/scrotal and vaginal/vulva) reconstruction. While lower extremity expansion is known to have high complication rates, tissue expander failure, infection, and exposure rates were in fact highest for penile/scrotal (failure: 18.5%; infection: 15.5%; exposure: 12.5%) and vaginal/vulva (failure: 20.6%; infection: 10.3%; exposure: 6.9%) reconstruction. Conclusions: Tissue expansion enables index operations by providing additional skin before definitive reconstruction. Tissue expanders are a valuable option along the reconstructive ladder because they obviate the need for free tissue transfer. Although tissue expansion comes with inherent risk, aggregate outcome failures of the final reconstruction are similar to published rates of complications without pre-expansion. Thus, although tissue expansion requires a staged approach, it remains a valuable option in facilitating a variety of reconstructive procedures.

Background On October 1, 2015, the United States required use of the Clinical Modification of the International Classification of Diseases, 10th Revision (ICD-10-CM) for diagnostic coding. The ICD-10-CM code set is limited to gross categories for cleft lip and/or cleft palate (using only four of a possible seven characters). Methods Herein, a clinically useful expansion of the ICD-10-CM code set is proposed to improve the diagnostic accuracy necessary for individual clinical, research, and statistical projects that require it. (This is similar to how the Centers for Disease Control and Prevention/British Paediatric Association Code served to extend the ICD-9 code base.) Results Our proposed expansion does not replace the required use of ICD-10-CM for clinical, administrative, or financial transactions. Rather, it is offered as an optional set of cleft codes that could be used in parallel to document true classification-level data with phenotypic accuracy. Conclusion The expanded set is “collapsible” into the official ICD-10-CM codes; this improves compatibility of the expanded codes that would be contained in research and epidemiologic databases with the standard codes from hospital electronic medical record systems and administrative billing data. Birth Defects Research (Part A) 106:905–914, 2016. © 2016 Wiley Periodicals, Inc.

The purpose of this study was to evaluate the utility of a previously validated interfrontal angle for classification of severity of metopic synostosis and as an aid to operative decision-making.An expert panel was asked to study 30 cases ranging from minor to severe metopic synostosis. Based on computed tomographic images of the skull and clinical photographs, they classified the severity of trigonocephaly (1 = normal, 2 = mild, 3 = moderate, and 4 = severe) and management (0 = nonoperative and 1 = operative). The severity scores and management reported by experts were then pooled and matched with the interfrontal angle computed from each respective computed tomographic scan. A threshold was identified at which most experts agree on operative management.Expert severity scores were higher for more acute interfrontal angles. There was a high concordance at the extremes of classifications, severe (4) and normal (1) (p0.0001); however, between interfrontal angles of 114.3 and 136.1 degrees, there exists a "gray zone," with severe discordance in expert rankings. An operative threshold of 118.2 degrees was identified, with the interfrontal angle able to predict the expert panel's decision to proceed with surgery 87.6 percent of the time.The interfrontal angle has been previously validated as a simple, accurate, and reproducible means for diagnosing trigonocephaly, but must be obtained from computed tomographic data. In this article, the authors demonstrate that the interfrontal angle can be used to further characterize the severity of trigonocephaly. It also correlated with expert decision-making for operative versus nonoperative management. This tool may be used as an adjunct to clinical decision-making when the decision to proceed with surgery may not be straightforward.Diagnostic, V.

Cranial fasciitis is a rare, rapidly growing, but benign fibroblastic tumor of the skull that generally presents in childhood. Local resection or curettage of the affected bone is generally curative and the tumor is thought not to recur. Cranial fasciitis is distinguished by positive cytoplasmic and nuclear beta-catenin staining. Fibromatosis is a clonal myofibroblastic nonmalignant proliferation that generally demonstrates positive nuclear beta-catenin staining. In this report, the authors present a patient with fibromatosis with cranial fasciitis characteristics in a 2.5-month-old boy who has had 7 recurrences (total 8 resections) of this fibroblastic neoplasm over 6 years of follow-up.

BACKGROUND Children with nonsyndromic orofacial clefts (NS OFCs) may require exceptional children's (EC) services for academic delays. We examined EC service use of children with and without NS OFCs in NC in elementary school. METHODS We included 559 children with NS OFCs and 6,822 children without birth defects who had NC educational records. We estimated prevalence ratios, trends in enrollment, and characteristics of eligibility classification using descriptive statistics and logistic regression by cleft subtype and race/ethnicity. We estimated the odds of third grade retention by EC enrollment using logistic regression with inverse probability of treatment weights. RESULTS Children with NS OFCs were 3.02 (95% CI: 2.50, 3.64) times as likely to receive third grade special education (SE) services compared to unaffected peers. The prevalence odds was highest among children with CL+P (OR: 4.61, 95% CI: 3.49, 6.09) declining by 54% by fifth grade. The prevalence odds of SE for white children was approximately 1.50 times that for African American children in fourth and fifth grades. Approximately 33% of children with NS OFCs within each racial/ethnic group received SE in third grade. African American children were twice as likely to receive services under specific learning disability. Children with NS OFCs receiving EC services were 44% (OR: 0.56; 95% CI: 0.13, 2.38) less likely to be retained in third grade compared to children with NS OFCs who were not receiving services. CONCLUSIONS Children with NS OFCs are more likely to receive SE services in elementary school compared to their unaffected peers. The eligibility category differed by racial/ethnic group.

BACKGROUND Cranial vault reconstruction (CVR) is the gold standard in the operative treatment of craniosynostosis. Full thickness osseous defects (FTOD) of the calvaria have been observed in 5% to 15% patients after CVR, with higher rates cited in the fronto-orbital advancement (FOA) subset. Particulate bone graft (PBG) harvested manually has been shown to decrease FTOD after FOA from 24% to 5.5%. The authors used a modified technique using a powered craniotome, with the hypothesis that the technique would also improve outcomes. METHODS A retrospective review was performed of patients who underwent CVR for craniosynostosis between 2004 and 2014. Patient demographics, diagnosis, age, operative details, and postoperative care were reviewed in detail. Categorical, nonparametric variables were compared by Fisher exact tests. RESULTS A total of 135 patients met inclusion criteria. The most common diagnoses were metopic (n = 41), sagittal (n = 33), and unilateral coronal craniosynostosis (n = 31); 65% (n = 88) underwent FOA, 29% (n = 39) underwent single-stage total vault reconstruction, and 6% (n = 8) had a posterior vault reconstruction. CVR was performed without PBG in 95 patients and with PBG in 40 patients. Without PBG, FTOD were discovered on clinical examination in 18% of patients (n=17): 11 presented with subcentimeter defects, while 6 had larger defects requiring revision cranioplasty (6% operative revision rate). Among those receiving PBG, 1 patient presented a subcentimeter FTOD (2.5% FTOD incidence and 0% operative revision rate). CONCLUSION Particulate bone graft harvested with a powered device decreases the rate of FTOD and reoperation rate after CVR for craniosynostosis.