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Background: Children who sustain injuries resulting in facial fractures are at risk for concomitant concussion. Prompt diagnosis and appropriate management of concussions are crucial in preventing neurocognitive impairment. The goal of this study is to examine the relationships between distinct craniofacial fracture patterns, injury mechanism, and concussion in pediatric patients. Methods: A retrospective review of 3334 patients Results: Two hundred twenty-seven patients met inclusion criteria (67.9% male), mean age at injury was 12.3 ± 4.3 years. Overall, concussions were more common in children >12 years old (54.2%), with sports as the most common cause of injury (32.5%). In patients Conclusions: Nearly 7% of pediatric patients with facial fractures in this retrospective series were diagnosed with a concomitant concussion. The results suggest that a higher index of suspicion for concussions should be maintained for patients with midface fractures and those with a previous history of concussions.

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.

Velopharyngeal insufficiency (VPI), a stigmatizing hallmark of palatal dysfunction, occurs in a wide spectrum of pediatric craniofacial conditions. The mainstays for surgical correction include palate repair and/or pharyngeal surgery. However, primary pharyngoplasty has a failure rate of 15% to 20%. Although revision pharyngoplasty may be necessary in those with persistent VPI, little is known regarding the indications for and outcomes after such procedures. The purpose of this study is to describe the authors' experience with indications for and outcomes after revision pharyngoplasty.A single-center retrospective review was performed of all patients undergoing revision pharyngoplasty between 2002 and 2019. Demographic data and Pittsburgh Weighted Speech Scores, diagnoses, comorbidities, and complications were tabulated. Two-tailed Student t test was used, and a P value of 0.05 or less was considered statistically significant.Thirty-two patients (65.6% male) met inclusion criteria for this study. The most common diagnoses included cleft palate (68.8%), submucous cleft palate (SMCP, 18.8%), and congenital VPI (6.3%, likely occult SMCP). Most patients (84.4%) underwent palatoplasty before their initial pharyngoplasty. The primary indication for initial pharyngoplasty was VPI (mean age 7.1 ± 4.6 years). The most common indication for revision pharyngoplasty (mean age 11.2 ± 5.1 years) included persistent VPI (n = 22), followed by obstructive sleep apnea (OSA) (n = 11). Persistent VPI (n = 8) and OSA (n = 6) were the most common complications after secondary pharyngoplasty. Thirteen patients (40.6%) within the revision pharyngoplasty cohort required additional surgical intervention: 4 underwent tertiary pharyngoplasty, 4 underwent takedown for OSA (n = 3) or persistent VPI (n = 1), 3 underwent takedown and conversion Furlow for persistent VPI (n = 2), OSA (n = 2) and/or flap dehiscence (n = 1), and 2 underwent palatal lengthening with buccal myomucosal flaps for persistent VPI. Of the 4 patients who required a tertiary pharyngoplasty, the mean age at repair was 6.6 ± 1.1 years and their speech scores improved from 13.5 to 2.3 after tertiary pharyngoplasty (P = 0.11). The overall speech score after completion of all procedures improved significantly from 19 to 3.3.Patients who fail primary pharyngoplasty represent a challenging population. Of patients who underwent secondary pharyngoplasty, nearly half required a tertiary procedure to achieve acceptable speech scores or resolve complications.

Chest masculinization surgeries are one of the most common gender-affirming procedures performed. There is a need for better understanding of the risk of breast cancer and postsurgical screening in female to male (FtM) individuals. This study aimed to evaluate the incidence of high-risk pathologic findings in FtM transgender patients undergoing gender-affirming chest reconstructive surgery.Medical records were reviewed from all FtM patients undergoing gender-affirming chest reconstructive surgery from January 2010 to February 2021 by 3 plastic surgeons at the University of Pittsburgh Medical Center. Relative risk of malignant progression was used to stratify pathologic data. Subsequent management of atypical, in situ, and invasive pathology were recorded.A total of 318 patients were included in this study; the average age at surgery was 24.6 ± 8.1 years. Eighty-six patients (27%) had a family history of breast and/or ovarian cancer. Overall, 21 patients (6.6%) had some increased risk of breast cancer: 17 (5.3%) had proliferative lesions, mean age 38.2 ± 12.4 years; 2 had atypical ductal hyperplasia, ages 33.4 and 38.3 years; and 2 had invasive ductal carcinoma, ages 35.4 and 40.6 years.In this study, we found that 6.6% of FtM transgender patients undergoing top surgery had an elevated risk of breast cancer, with 1.2% of patients having a greater than 2 times risk of breast cancer. These results highlight the importance of appropriate preoperative screening as well as pathological analysis of surgical specimens to help guide clinical care. The authors advocate for a thorough breast cancer risk assessment before surgery for all patients, as well as using pathologic findings to guide postoperative cancer screening and follow-up.

Introduction The concept of “overcorrection” for trigonocephaly has been reported to achieve both anterior cranial fossa expansion and normalization of craniofacial form. The purpose of this study is to describe in detail a standardized technique to fronto-orbital advancement utilizing the concept of “overcorrection” and objectively evaluate intermediate results. Methods This retrospective study included patients with isolated metopic synostosis who underwent surgery via the proposed surgical technique and age and sex-matched unaffected controls. Craniofacial morphometric analysis was performed on pre-, immediate post-, and intermediate postoperative (>2 years) three-dimensional (3D)-rendered computed tomographic (CT) scans and photographs. Key CT-based measurements included interzygomaticofrontal suture distance (IZFS), endocranial bifrontal angle (ECA), and temporal expansion. 3D photogrammetry was performed using established measurements and associated Z-scores converted. A Paired t-test and analysis of variance were performed when appropriate. Results Forty-one patients were included. A comparison of pre- and immediate postoperative CT scans demonstrated statistically significant increases in all measurements. Subset analysis of 12 patients with intermediate follow-up (age: 39.6 ± 3.6 months) demonstrated significant differences from preoperative values except for IZFS, which decreased from immediate postoperative values and was smaller than age- and sex-matched controls. 3D photogrammetry demonstrated a mean Z-score above the norm for frontal breath. 3D photogrammetry is also positively correlated with CT-based measurements. Conclusions This standardized “overcorrection” approach for trigonocephaly can provide the appropriate changes to maintain a normal ECA despite a reduction in bifrontal width over time. 3D photogrammetry positively correlated with CT-based measurements and may provide useful information when following patients clinically. Long-term follow-up assessment to determine the necessary degree of overcorrection at skeletal mature is needed.

Background Pierre Robin Sequence (PRS) is characterized by micrognathia, glossoptosis, and upper airway obstruction. Early recognition and appropriate perinatal management is crucial for optimizing outcomes. This study aimed to evaluate 20-week fetal ultrasounds to determine if specific mandibular measurements could predict PRS diagnosis and disease severity. Methods A retrospective case-control study of 48 patients with PRS and gender-matched controls was performed. Medical records were reviewed for respiratory and surgical interventions. Three parameters to assess micrognathia were measured on mid-sagittal profile ultrasound images: frontal nasal-mental angle (FNMA), facial-maxillary angle (FMA), and alveolar overjet. Student's t-test and univariate logistic regression was performed. P ≤ 0.05 was considered statistically significant. Results Patients with PRS demonstrated a significantly smaller mean FNMA compared to the control group, 129.3 ± 8.6° and 137.4 ± 3.2°, respectively (p Conclusions Mandibular features on the 20-week ultrasound can be measured to predict diagnosis and severity of PRS. This is an important first step to prepare for potential respiratory intervention at delivery to minimize perinatal hypoxia. Alveolar overjet, previously not described in prenatal ultrasound literature, is measurable and has utility in prenatal screening for PRS, as do FMA and FNMA.

Objective Several severity metrics have been developed for metopic craniosynostosis, including a recent machine learning-derived algorithm. This study assessed the diagnostic concordance between machine learning and previously published severity indices. Design Preoperative computed tomography (CT) scans of patients who underwent surgical correction of metopic craniosynostosis were quantitatively analyzed for severity. Each scan was manually measured to derive manual severity scores and also received a scaled metopic severity score (MSS) assigned by the machine learning algorithm. Regression analysis was used to correlate manually captured measurements to MSS. ROC analysis was performed for each severity metric and were compared to how accurately they distinguished cases of metopic synostosis from controls. Results In total, 194 CT scans were analyzed, 167 with metopic synostosis and 27 controls. The mean scaled MSS for the patients with metopic was 6.18 ± 2.53 compared to 0.60 ± 1.25 for controls. Multivariable regression analyses yielded an R-square of 0.66, with significant manual measurements of endocranial bifrontal angle (EBA) (P = 0.023), posterior angle of the anterior cranial fossa (p Conclusions The machine learning algorithm offers an objective assessment of morphologic severity that provides a reliable composite impression of severity. The generated score is comparable to other severity indices in ability to distinguish cases of metopic synostosis from controls.

Purpose Persistent velopharyngeal insufficiency (VPI) following primary palatoplasty remains a difficult problem to treat. This study evaluates speech outcomes following revision palatoplasty with tissue augmentation using buccal myomucosal flaps (BMF) as an alternative to pharyngoplasty for patients with VPI. Methods A retrospective single-center review of revision palatoplasty with tissue augmentation at a tertiary pediatric hospital Cleft-Craniofacial Center between January 2017 and March 2021 was conducted. Patients with a history of previous palatoplasty, a diagnosis of persistent or recurrent VPI, and comprehensive pre- and postoperative speech evaluations who underwent revision palatoplasty with BMF were included. Results Twenty patients met inclusion criteria (35% female, 20% syndromic). Mean age at the time of revision palatoplasty with BMF was 9.7 years. Preoperatively, all patients had stigmatizing speech and received the recommendation for speech surgery; the mean Pittsburgh Weighted Speech Score (PWSS) was 14.3 ± 4.9. The mean postoperative PWSS at the most recent assessment was 4.2 ± 2.3, representing a statistically significant improvement from preoperative scores ( P Conclusion In patients with VPI following primary palatoplasty, revision palatoplasty with tissue augmentation offers an alternative to pharyngoplasty. This approach preserves dynamic velopharyngeal function, improves speech outcomes, and should be considered an option when treating patients with post-primary palatoplasty VPI.

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.

Maxillo-mandibular fixation (MMF) is common technique used in mandibular fractures to stabilize the fragments and maintain the patient in normal dental occlusion during the healing process. Arch bars with elastics are one of the most frequently used methods of MMF and are temporary, and designed to be removed after the healing process is completed. There is controversy as to what impact the hardware has on dental hygiene and oral health. No reports of long-term retention of the hardware exist. This report details the case of arch bars retained for 14 years. The patient underwent MMF and internal fixation at age 16 for a complex mandibular fracture and failed to follow-up for timely removal of the arch bars due to loss of insurance. He presented at age 30 with dental pain and returned to the treating center for removal. He was in normal occlusion, but general indices of dental and periodontal health were extremely poor with multiple non-restorable teeth despite reporting good oral hygiene in the intervening period. A decline in overall dental health was evident at 1 year following removal of arch bars. Due to the presence of smooth surface dental caries, it was concluded that the presence of the arch-bars had exacerbated already poor oral hygiene and contributed to the extensive dental pathology seen. This case highlights the need for timely follow-up and hardware removal. Understanding each patient’s individual social and financial circumstances is essential to this process and a formalized office recall process may have prevented this complication.

Objectives: Pediatric mandibular distraction osteogenesis (MDO) is an increasingly common surgical procedure used to lengthen the mandible. Little is known about the long-term effects of MDO on dental development. This retrospective study sought to identify dental abnormalities at mixed dentition and early permanent dentition stages in patients who had undergone MDO. Methods: All pediatric patients who underwent MDO with imaging and clinical exams at mixed dentition and early permanent dentition stages were evaluated identify pathology. Data included demographic information, medical and surgical history, complications, and dental exam information. Descriptive statistics were reported. Results: Twenty-two hemimandibles at mixed dentition stage and 24 at early permanent stage were included. Mean age at initial MDO was 7.95 years with a mean follow-up time of 15.1 years. Nine patients required more than 1 distraction. At the mixed dentition stage, all patients showed abnormalities. The most common abnormalities were absent, dysplastic, or ectopic molars. At early permanent dentition stage, 87.5% of patients had dental abnormalities. The most common abnormality was missing molars (third, second, and first), but dysplastic, impacted, and ectopic teeth were also noted. At both mixed and early permanent dentition stages, some patients were noted to have abnormal V-shaped sigmoid notching of the mandibular ramus of undetermined clinical significance. Buccal mucosal scarring that interfered with orthodontic treatment was observed in a subset of patients. Conclusions: This study provides long-term dental analyses of patients undergoing MDO for mandibular hypoplasia. Dental abnormalities were seen at both mixed and early permanent dentition stages. Molars were the most commonly affected with absence the most commonly seen abnormality. Dysplastic, ectopic, and impacted teeth were also seen in posterior and anterior dentition, and abnormalities in buccal soft tissue and the mandibular ramus were also seen. MDO remains a crucial tool for functional and aesthetic improvement in children with hypoplastic mandibles. Dental abnormalities as a consequence of MDO should be considered as part of surgical planning process.

The role of computed tomography (CT) for diagnosis and surgical planning for craniosynostosis (CS) is well-established. The aim of this study was to quantify the cumulative medical radiation exposure from CT in patients with CS at a tertiary care children’s hospital. Medical records of patients who presented at 6 months, 5.3 ± 1.9 versus 4.3 ± 1.4 mSv, respectively (p = 0.001). Patients with nonsyndromic CS undergo 2 CT scans on average related to their diagnosis, with a mean total ERD of 9.1 mSv; this is equivalent to 1.5 years of the average annual background radiation dose a person living in the USA will encounter from environmental radiation, medical exposures, and consumer products. A CT obtained at

IntroductionThe squamosal suture (SQS) joins the temporal to the parietal bones bilaterally and is a poorly described site of craniosynostosis. SQS fusion is thought to occur as late as the fourth decade of life and beyond; however, we have incidentally noted its presence among our pediatric patients and hypothesize that it may occur earlier in life and more frequently than previously believed.MethodsA retrospective review of imaging performed on pediatric patients was completed to identify patients with SQS synostosis. This included a review of clinical notes as well as computed tomography (CT) images obtained by our craniofacial clinic. Relevant patient data and imaging were reviewed.ResultsForty-seven patients were identified with SQS synostosis, 21 were female (45%). Age at the time of radiographic diagnosis was 10.1 ± 8.4 years (range 17 days to 27 years). A majority of patients had bilateral SQS synostosis (57%), with a relatively even distribution of unilateral right (23%) versus left (19%). SQS was an isolated finding (no other suture involvement) in 15 patients (32%), all of whom were normocephalic and did not require surgical intervention. Thirty-two patients (68%) had concomitant craniosynostosis of other sutures, most commonly sagittal and coronal. Nine patients (19%) underwent surgery to correct cranial malformations—all these patients had multi-suture synostosis ( P = 0.012). Twenty-seven patients (57%) had SQS synostosis diagnosed incidentally compared to 20 (43%) who were imaged with suspicion for synostosis. In those who were symptomatic, common findings included developmental delay, elevated intracranial pressure, hydrocephalus, seizures, and visual/hearing impairments. Ten patients (21%) were syndromic, the most frequent of which was Crouzon syndrome. No single pattern of calvarial malformation could be definitively described for SQS synostosis.ConclusionGiven that most isolated SQS synostosis cases were normocephalic, asymptomatic, and discovered incidentally, it is likely that there are many cases of unidentified SQS synostosis. The significance of SQS synostosis is currently unclear, and warrants further investigation into this phenomenon, its natural course, and its potential presence in the spectrum of normal development.

The diagnosis of late-presentation sagittal suture craniosynostosis (SCS) can be challenging, especially in the setting of subtle physical exam findings. The clinical significance of clinocephaly—a retro-coronal concavity along the midvault—in this context remains unknown. The aim of this study is to evaluate the predictive value of clinocephaly in identifying late-presentation SCS. A retrospective chart review of all patients >1 year old presenting to the craniofacial clinic with a concern for SCS was performed. The presence or absence of SCS in the setting of clinocephaly was recorded following diagnostic imaging. Student's t test, Chi Square test, and multivariate logistic regression analysis were performed to determine predictors for SCS. 75 patients met inclusion criteria. 32 patients (42.7%, 6% female) were diagnosed with SCS. No difference in age between patients with and without SCS was detected. Stratification of patients by age (1–2, 2–4, and >4 years) revealed a higher rate of SCS in younger patients (P = 0.04). The cephalic index (C.I.) of those with sagittal synostosis was significantly smaller but within the normal range, indicating a more scaphocephalic shape (P = 0.003). Logistic regression analysis revealed that C.I. was a strong predictor for SCS (P = 0.003). Of those with SCS, a mix of complete and partial fusion of the sagittal suture was appreciated. This study found that 42.7% of patients with clinocephaly had SCS. C.I. was the only predictor for SCS and unique suture fusion patterns were identified in those with SCS. This study suggests that clinocephaly should be considered a core component of the exam and work-up for SCS. Future studies aimed at evaluating the positive predictive value of this exam finding and identifying risk factors associated with late-presentation SCS are underway.

Head and neck injury as a consequence of in utero pressure and birth trauma is a rare event. We report a case of a patient who was born full-term via vaginal delivery and presented soon after birth with skin changes over the nasal tip consistent with a pressure-related injury that progressed to a stable eschar. Conservative management with close clinical monitoring resulted in a well-healed wound over the nasal tip. A detailed discussion regarding the diagnosis and management of head and neck lesions after birth is provided.

Optimizing operating room (OR) utilization is a critical component of health care system efficiency. The purpose of our study was to analyze the extent of OR cancellation and its effect on raw utilization of OR block time allotted to surgeons in the pediatric plastic surgery department.The authors retrospectively reviewed the cases of 4 plastic surgeons at a tertiary pediatric hospital between 2018 and 2019. Data collected included patient demographics, type of surgery, time of cancellation, reason for cancellation, length of surgery, and minutes of block time allotted to each surgeon per year. Percent of cases canceled, scheduled times lost, and block times lost were calculated.Surgeons A, B, C, and D scheduled 170, 416, 305, and 474 cases, respectively. Overall, 7% of cases were canceled, 9.1% of scheduled time was lost, and a total of 5.1% of block time was lost due to cancellation. Patients of surgeon A and D were more likely to cancel due to reasons classified as ''other,'' including causes such as failure of nil per os or a family's last-minute decision to forego elective surgery (33.3% and 37.2%, respectively), whereas patients of surgeon B and C were more likely to cancel due to illness (67.9% and 36.4%, respectively).Cancellations negatively impact raw utilization times; if fewer cases are performed, allotted block times are redistributed. Communication with patients in the week prior to surgery may allow for earlier identification of likely cancellations. Future directions include exploring whether particular surgeon characteristics are linked to rate of cancellations.

Nipple discharge is a rare but possible occurrence after nipple-sparing mastectomy (NSM). This study presents the first case of galactorrhea in a female patient after NSM. Although milky discharge due to physiologic lactation related to pregnancy is more common, galactorrhea is still possible and should be worked up appropriately to ensure that all breast tissue has been removed and that there are no other more worrisome causes.

Purpose: Pierre-Robin Sequence (PRS) is characterized by micrognathia and glossoptosis and can result in upper airway obstruction. Prenatal diagnosis of PRS facilitates delivery team preparation for an airway emergency. Routine 20-week ultrasounds screen facial features and can characterize mandibular morphology and the maxillomandibular relationship. This study aimed to evaluate 20-week fetal ultrasounds to determine if specific facial measurements could predict PRS diagnosis and disease severity. Methods: A retrospective case control study of 40 patients with PRS and 40 gender-matched controls (24 male, 16 female in each cohort) between January 2014 and May 2019 was performed. Respiratory and surgical interventions were recorded and scored for severity. Mid-sagittal profile images of the ultrasounds were reviewed and measured for 3 parameters to assess micrognathia: facial nasomental angle (FNMA), facial-maxillary angle (FMA), and alveolar overjet. FMA

The role of computed tomography (CT) for diagnosis and surgical planning for craniosynostosis (CS) is well-established. The aim of this study was to quantify the cumulative medical radiation exposure from CT in patients with CS at a tertiary care children's hospital.Medical records of patients who presented at 2 years of age and underwent surgical intervention for CS were examined for demographic information. Effective radiation dose (ERD) in mSv was calculated for each head CT. Descriptive statistics and ANOVA were performed. Mean ± SD is reported; p 0.05 was considered significant.Two hundred seventy-two patients met inclusion criteria: 241 nonsyndromic and 31 with syndromic diagnoses. For nonsyndromic patients, mean age at first head CT was 6.0 ± 4.9 months, mean number of CT scans obtained was 2.1 ± 1.1, and the mean total combined ERD was 9.1 ± 4.8 mSv. CT scans obtained at 6 months of age had a significantly greater ERD than those obtained at 6 months, 5.3 ± 1.9 versus 4.3 ± 1.4 mSv, respectively (p = 0.001).Patients with nonsyndromic CS undergo 2 CT scans on average related to their diagnosis, with a mean total ERD of 9.1 mSv; this is equivalent to 1.5 years of the average annual background radiation dose a person living in the USA will encounter from environmental radiation, medical exposures, and consumer products. A CT obtained at 6 months is associated with a higher ERD; thus, we recommend delaying imaging from the initial presentation to the time of pre-operative planning when possible.

Bilateral lambdoid and sagittal synostosis, or Mercedes Benz Syndrome, is a rare complex craniosynostosis resulting in frontal bossing, a tapered posterior fossa, and an anteriorly displaced cranial vertex. Its ideal surgical correction must result in posterior expansion, skull elongation, and caudal repositioning of the vertex. We present a craniometric analysis of skull changes with posterior-superior distraction and introduce a novel craniometric measure: vertex position. In this study, a retrospective review was performed to analyze outcomes of posterior cranial vault distraction osteogenesis (PVDO) using a posterior-superior distraction vector from 2016 to 2019. Cranial vertex position was measured as a fraction of the occipitofrontal diameter from rostral to caudal (0-1.0). Four patients underwent PVDO at mean age 10.61 ± 3.16 months utilizing a posterior-superior distraction vector. Linear distraction distance averaged 30.30 ± 0.90 mm with a mean consolidation period of 3.98 ± 0.72 months. Mean corrected change in intra-cranial volume was 236.30 ± 3.71 mL, at an average rate of 7.81 ± 2.00 mL/mm of distraction. Increases in anterior cranial height (7.83 ± 2.51 mm), middle cranial height (8.43 ± 4.21 mm), posterior cranial height (13.15 ± 7.45 mm), and posterior cranial fossa height (21.99 ± 8.55 mm) were observed. Cranial vertex demonstrated a mean posterior movement of 0.18 ± 0.13. PVDO utilizing a posterior-superior distraction vector for management of nonsyndromic bilateral lambdoid and sagittal synostosis effectively increases intracranial volume and height and provides an esthetic outcome with posterior movement of the cranial vertex.

Background: The COVID-19 pandemic had multiple effects on the provision of health care, including the suspension of elective and nonessential surgeries. The objective of this study was to determine the early effect of the COVID-19 pandemic on the surgical care of patients with cleft lip and/or palate at a high-volume cleft center. Methods: A retrospective comparative cohort study of patients with cleft lip and/or palate undergoing lip adhesion, cleft lip and nose repair, and palatoplasty before and during the pandemic was conducted. There were 50 patients in the prepandemic cohort and 53 in the pandemic cohort. Results: Mean age at lip adhesion was 3.1 +/- 1.1 months prepandemic (n = 8) and 3.5 +/- 2.5 months in the pandemic cohort (n = 8) (P = 0.75). One lip adhesion was delayed by 1.6 months. Mean age at cleft lip and nose repair was 6.6 +/- 1.9 months prepandemic (n = 23) and 8.0 +/- 2.1 months in the pandemic cohort (n = 23) (P = 0.03). Six pandemic cleft lip and nose repairs were delayed;the mean delay was 2.6 +/- 1.8 months. The mean age at palatoplasty was 13.9 +/- 2.2 months prepandemic (n = 26) and 14.1 +/- 2.9 months in the pandemic cohort (n = 26) (P = 0.79). Seven pandemic palatoplasties were delayed;the mean delay was 3.3 +/- 1.4 months. Conclusions: The COVID-19 pandemic caused delays at each stage of repair for cleft lip and/or palate-related procedures;however, only cleft lip and nose repair were significantly affected. This study emphasizes the importance of remaining vigilant regarding the care of this vulnerable population during this challenging time.