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This study aims to determine the utility of 3D photography for evaluating the severity of metopic craniosynostosis (MCS) using a validated, supervised machine learning (ML) algorithm. This single-center retrospective cohort study included patients who were evaluated at our tertiary care center for MCS from 2016 to 2020 and underwent both head CT and 3D photography within a 2-month period. The analysis method builds on our previously established ML algorithm for evaluating MCS severity using skull shape from CT scans. In this study, we regress the model to analyze 3D photographs and correlate the severity scores from both imaging modalities. 14 patients met inclusion criteria, 64.3% male (n = 9). The mean age in years at 3D photography and CT imaging was 0.97 and 0.94, respectively. Ten patient images were obtained preoperatively, and 4 patients did not require surgery. The severity prediction of the ML algorithm correlates closely when comparing the 3D photographs to CT bone data (Spearman correlation coefficient [SCC] r = 0.75; Pearson correlation coefficient [PCC] r = 0.82). The results of this study show that 3D photography is a valid alternative to CT for evaluation of head shape in MCS. Its use will provide an objective, quantifiable means of assessing outcomes in a rigorous manner while decreasing radiation exposure in this patient population.

Background: Pierre Robin sequence (PRS), characterized by the triad of retrognathia, glossoptosis, and airway obstruction, remains challenging to treat and no standard treatment protocols exist. Inadequate treatment may lead to obstructive sleep apnea and necessitate more invasive airway interventions. The purpose of this study is to present the results of a single center’s treatment protocol and the postoperative effect on airway status. Methods: A retrospective cohort study of consecutive patients with PRS treated with MDO from 2010 to 2020 was identified. Descriptive statistics and student’s t-tests were analyzed, and a P

Background and Purpose: The study of nasal changes in cleft lip and palate (CLP) orthognathics is limited. This study aimed to determine differences in 3-dimensional (3D) nasal changes for unilateral cleft lip and palate (UCLP) and bilateral cleft lip and palate (BCLP) patients after Le Fort I advancement. Methods: This study was a retrospective cohort evaluation of 18 subjects (9 male, 9 female) treated at a single institution over a 5-year period who had class III skeletal and dentoalveolar malocclusion related to non-syndromic cleft lip and/or palate and underwent surgical correction via Le Fort I osteotomy. Patients underwent pre- and postoperative cephalometric measurements and 3D volumetric assessment for comparison to analyze nasal changes. Statistical analysis was performed to determine changes in nasal parameters using student’s t-test and multivariate analysis. Differences were considered significant for P-values ≤.05. Results: All nasal parameters except for nasolabial angle and nasal length changed significantly postoperatively in the entire cohort. Alar base and flare width both increased significantly (2.1 mm, P = .0002, 1.4 mm, P = .0005), while both relative and total tip projection decreased (−3.4 mm, P = .000004, −2.2 mm, P = .0008). An advancement of the entire nasal complex was seen postoperatively (1.0 mm, P = .0005). UCLP patients had a significantly larger decrease in total nasal tip projection following surgery relative to BCLP patients (−3.5 ± 1.2 mm, −0.8 ± 2.1 mm, P = .008). BCLP morphology increases the degree of 3D nasal surface area advancement relative to UCLP (1.2 mm ± 0.3, 0.8 mm ± 0.6, P = .028). Alar cinch stitch decreases nasolabial angle ( P = .024) but increases nasal length ( P = .004). Conclusion: Discrepancies exist in nasal changes after Le Fort I advancement between UCLP and BCLP patients. Increased understanding of outcomes for cleft patients undergoing Le Fort I can help improve the predictability of nasal esthetic changes in this patient population.

BACKGROUND The submucous cleft palate can be overt or occult and may require surgical repair. The double-opposing Z-plasty (Furlow repair) is the authors' center's preferred approach. This study evaluated complication rates, differences in outcome between overt and occult types, and patient factors associated with surgical failure. METHODS This retrospective study reviewed documentation on all patients who underwent Furlow Z-plasty for submucous cleft palate at a single center between 2004 and 2018. Speech pathology was quantified using the Pittsburgh Weighted Speech Score. RESULTS A total of 351 patients were included (125 overt and 226 occult cases). Furlow Z-plasty was successful (postoperative Pittsburgh Weighted Speech Score

There have been few longitudinal studies assessing the effect of preoperative phenotypic severity on long-term esthetic outcomes in metopic craniosynostosis. This study evaluates the relationship between metopic severity and long-term esthetic outcomes using interfrontal angle (IFA) and CranioRate, a novel metopic synostosis severity measure.Patients with metopic craniosynostosis who underwent bifrontal orbital advancement and remodeling between 2012 and 2017 were reviewed. Preoperative computed tomography head scans were analyzed for IFA and CranioRate, a machine learning algorithm which generates quantitative severity ratings including metopic severity score (MSS) and cranial morphology deviation (CMD). Long-term esthetic outcomes were assessed by craniofacial surgeons using blinded 3-rater esthetic grading of clinical photos. Raters assessed Whitaker score and the presence of temporal hollowing, lateral orbital retrusion, frontal bone irregularities and/or "any visible irregularities."Preoperative scans were performed at a mean age of 7.7±3.4 months, with average MSS of 6/10, CMD of 200/300, and IFA of 116.8±13.8 degrees. Patients underwent bifrontal orbital advancement and remodeling at mean 9.9±3.1 months. The average time from operation to esthetic assessment was 5.4±1.0 years. Pearson correlation revealed a significant negative correlation between MSS and age at computed tomography (r=-0.451, P=0.004) and IFA (r=-0.371, P=0.034) and between IFA and age at surgery (r=-0.383, P=0.018). In multinomial logistic regression, preoperative MSS was the only independent predictor of visible irregularities (odds ratio=2.18, B=0.780, P=0.024) and preoperative IFA alone significantly predicted Whitaker score, with more acute IFA predicting worse Whitaker score (odds ratio=0.928, B=-0.074, P=0.928).More severe preoperative phenotypes of metopic craniosynostosis were associated with worse esthetic dysmorphology. Objective measures of preoperative metopic severity predicted long-term esthetic outcomes.

A subset of patients with metopic craniosynostosis are noted to have elevated intracranial pressure (ICP). However, it is not known if the propensity for elevated ICP is influenced by the severity of metopic cranial dysmorphology.Children with nonsyndromic single-suture metopic synostosis were prospectively enrolled and underwent optical coherence tomography to measure optic nerve head morphology. Preoperative head computed tomography scans were assessed for endocranial bifrontal angle as well as scaled metopic synostosis severity score (MSS) and cranial morphology deviation score determined by CranioRate, an automated severity classifier.Forty-seven subjects were enrolled between 2014 and 2019, at an average age of 8.5 months at preoperative computed tomography and 11.8 months at index procedure. Fourteen patients (29.7%) had elevated optical coherence tomography parameters suggestive of elevated ICP at the time of surgery. Ten patients (21.3%) had been diagnosed with developmental delay, eight of whom demonstrated elevated ICP. There were no significant associations between measures of metopic severity and ICP. Metopic synostosis severity score and endocranial bifrontal angle were inversely correlated, as expected ( r =-0.545, P0.001). A negative correlation was noted between MSS and formally diagnosed developmental delay ( r =-0.387, P =0.008). Likewise, negative correlations between age at procedure and both MSS and cranial morphology deviation was observed ( r =-0.573, P0.001 and r =-0.312, P =0.025, respectively).Increased metopic severity was not associated with elevated ICP at the time of surgery. Patients who underwent later surgical correction showed milder phenotypic dysmorphology with an increased incidence of developmental delay.

Background After completion of training, a physician's training institution has a lasting and meaningful impact on career trajectory. Training program influence on first job placement and academic promotions remain uncertain in academic plastic surgery. The aim of this study was to determine the impact of training and internal bias in academic plastic surgery employment and promotion. Methods Academic plastic surgery faculty were identified through an internet search of all Accreditation Council for Graduate Medical Education-accredited residency training programs. Faculty demographics, training background, employment, and leadership status were gathered. The analysis examined the impact of internal recruitment bias on first job employment, the impact of training history on institutional leadership promotion (chair/chief, residency director, or fellowship director), and the impact of alumni effect on academic employment. Results A significant proportion of recent graduates (38.6%) are practicing at the same institution as where they received residency or fellowship training. Of the 229 institutional leaders, 31.5% of chairs/chiefs, 39.6% of residency directors, and 37.5% of fellowship directors were internal hires. Overall, 34% of plastic surgery faculty in the United States share a common training program with at least 1 colleague. The top 5 programs that have the most faculty who trained at their hiring institution are Harvard (30 faculty), University of Southern California (15 faculty), University of California Los Angeles (12 faculty), University of Michigan (12 faculty), and Albert Einstein (12 faculty). Overall, 54% of plastic surgery departments employ 2 or more faculty who share a common external training program. The top 5 programs that have the most faculty who share an external training program are (1) Methodist Houston, 8 faculty who trained at Baylor; (2) Hofstra, 7 faculty who trained at New York University; (3) Stanford, 6 faculty who trained at University of California, Los Angeles; (4) Wisconsin, 5 faculty who trained at University of Pittsburgh Medical Center; and (5) University of Southern California, 4 faculty who trained at New York University. Conclusions The study highlights that an internal bias exists in the recruitment for first jobs and leadership promotions. However, a clear bias of internal hiring exists at several institutions. In addition, an alumni effect was identified, where some programs have a bias of hiring faculty who trained at the same external institution.

Background: Thoracic intramedullary neurosarcoidosis is an uncommon but serious manifestation of spinal cord disease. Its concomitant occurrence with thoracic disc herniation can mislead the physician into attributing neurologic and radiographic findings in the spinal cord to disc pathology rather than inflammatory disorder. Here, we present such a rare case of concomitant thoracic disc and spinal neurosarcoidosis. Case Description: A 37-year-old male presented with progressive right lower extremity weakness and numbness. Magnetic resonance imaging (MRI) of the thoracic spinal cord revealed a T6-T7 paracentral disc eccentric to the right with T2 signal change extending from T2 to T10 level. This prompted acquiring a contrasted MRI that also depicted intramedullary enhancement around the T6-T7 disc bulge. Computed tomography scan of the chest showed mediastinal lymphadenopathy concerning for sarcoidosis. Lymph node biopsy confirmed the diagnosis of sarcoidosis, and high-dose steroid treatment was initiated. The patient had significant symptomatic improvement with steroids with full neurological recovery and improvement of his symptoms. Conclusion: While stenosis from thoracic disc disease could potentially suggest a mechanical etiology for the patient’s symptoms, attention must be paid to the imaging findings as well as the degree and extent of cord signal change and intramedullary contrast enhancement. Appropriate and timely diagnosis is essential to avoid unnecessary invasive procedures.

Non-cultured, autologous cell-spray grafting is an alternative to mesh grafting for larger partial- and deep partial-thickness burn wounds. The treatment uses a suspension of isolated cells, from a patient's donor site skin tissue, and cell-spray deposition onto the wound that facilitates re-epithelialization. Existing protocols for therapeutic autologous skin cell isolation and cell-spray grafting have defined the donor site area to treatment area ratio of 1:80, substantially exceeding the coverage of conventional mesh grafting. However, ratios of 1:100 are possible by maximizing the wound treatment area with harvested cells from a given donor site skin tissue according to a given burn area. Although cell isolation methods are very well described in the literature, a rational approach addressing critical aspects of these techniques are of interest in planning clinical study protocols. We considered in an experimental study the cell yield as a function of the donor site skin tissue, the cell density for spray grafting, the liquid spray volume, the sprayed distribution area, and the percentage of surface coverage. The experimental data was then used for the development of constants and mathematical equations to give a rationale for the cell isolation and cell-spray grafting processes and in planning for clinical studies.