Reduction cranioplasty for hydrocephalic macrocephaly: a systematic review of surgical outcomes.

OBJECTIVE: Hydrocephalic macrocephaly can result in poor psychosocial development, positioning difficulties, skin breakdown, and poor cosmesis. Although reduction cranioplasty can address these sequelae, the postoperative outcomes, complications, and mortality risk of reduction cranioplasty are not well understood given the rarity of hydrocephalic macrocephaly. Therefore, the primary objective of this systematic review was to evaluate the surgical outcomes of reduction cranioplasty for the treatment of hydrocephalic macrocephaly. METHODS: A systematic review was performed using the PubMed, Scopus, and Web of Science databases while following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two independent reviewers screened 350 studies; 27 studies reporting surgical outcomes on reduction cranioplasty for hydrocephalic macrocephaly met inclusion criteria. Data on study design, patient demographics, operative details, and surgical outcomes were collected. RESULTS: There were 65 reduction cranioplasties among the 27 included studies. Eighteen (66.7%) studies presented level V evidence, 7 (25.9%) presented level IV evidence, and 2 (7.4%) presented level III evidence. Following reduction cranioplasty, there was improvement in postoperative head positioning in 23 (85.2%) studies, improvement in postoperative cosmesis in 22 (81.5%) studies, and improvement in global postoperative neurological functioning in 20 (74.1%) studies. The median estimated blood loss was 633 mL (range 20-2600 mL). Shunt revisions were the most common complication, reported in 9 (47.4%) of the 19 studies assessing complications. Of the 65 patients, there was a mortality rate of 6.2% (n = 4). CONCLUSIONS: The majority of the included studies reported improvement in head size, head positioning, cranial cosmesis, and global neurological functioning following reduction cranioplasty for hydrocephalic macrocephaly. However, the prevalence of lower-level evidence, risk of blood loss, complications, and mortality indicates the need for a serious discussion of surgical indication, an experienced team, and thorough perioperative planning to perform these complex surgeries.

Eyeing Risks: A Critical Analysis of the Use of Periorbital Steroids in Fronto-orbital Advancement.

OBJECTIVE: To evaluate the outcomes associated with two techniques of periorbital steroid administration in bilateral fronto-orbital advancement (FOA). DESIGN: Multi-institutional retrospective chart review. SETTING: Two high volume, tertiary US craniofacial centers. PATIENTS, PARTICIPANTS: Patients who underwent FOA between 2012 and 2021. INTERVENTIONS: Patients were divided into three cohorts based on method of steroid administration. Groups GEL and INJ represent those who received steroids in the form of triamcinolone soaked gelfoam or direct injection of dilute triamcinolone to the frontal/periorbital region, respectively. Group NON did not receive any periorbital steroids. MAIN OUTCOME MEASURE(S): Peri-operative outcomes including hospital length of stay and complications were evaluated based on method of periorbital steroid administration. Variables predictive of infectious complications were assessed using stepwise logistic regression. RESULTS: Four hundred and twelve patients were included in our sample (INJ:249, GEL:87, NON:76). Patients in the INJ group had a higher ASA class (P < .001) while patients in the NON group were significantly more likely to be syndromic (P < .001) and have multisuture craniosynostosis (P < .001). Rate of infectious complications for each cohort were NON: 2.6%, INJ: 4.4%, and GEL: 10.3%. There was no significant difference between groups in hospital length of stay (P = .654) or rate of post-operative infectious complications (P = .061). Increased ASA class (P = .021), increased length of stay (P = .016), and increased intraoperative narcotics (P = .011) were independent predictors of infectious complications. CONCLUSIONS: We identified a dose-dependent relationship between periorbital steroids and rate of postoperative infections, with key contributions from ASA class, hospital length of stay, and dose of intraoperative narcotics.

Patient outcomes and complications following various maxillomandibular fixation techniques: A systematic review and meta-analysis.

PURPOSE: Currently, there are several methods of achieving maxillomandibular fixation (MMF), each with its unique operative considerations and subsequent patient outcomes and complications. In this study, we reviewed the literature to evaluate and compare all MMF methods. METHODS: A systematic review of all MMF types was conducted and post-operative outcome data were analyzed and compared among the different types. Conventional Erich arch bars were compared to hybrid arch bars, MMF screws, and eyelet interdental wiring. A random-effects meta-analysis was used to determine the mean differences, and 95% confidence intervals (CIs) with a statistical significance of P < 0.05. RESULTS: Among the 4234 articles identified, 24 were included, and 17 were meta-analyzed. Time to achieve MMF (-43.38 min; 95% CI, -58.20 to -28.56; P < 0.001), total operative time (-30.33 min; 95% CI, -61.05 to 0.39; P = 0.05), incidence of wire puncture injuries and glove perforations (0.11; 95% CI, 0.04 to 0.30; P < 0.001), and incidence of poor oral hygiene (0.08; 95% CI, 0.02 to 0.28; P < 0.001) were lower for alternative MMF interventions compared to those of the conventional Erich arch bars. CONCLUSIONS: Alternative MMF methods required shorter operative time to achieve MMF and demonstrated other increased efficiencies of practice such as shorter total operative time and decreased glove perforations, when compared to conventional Erich arch bars. If a patient is a candidate for MMF, the presented alternative MMF techniques should be considered depending on the clinical context and availability of institutional resources.

Craniofacial Soft-Tissue Anthropomorphic Database with Magnetic Resonance Imaging and Unbiased Diffeomorphic Registration.

BACKGROUND: Objective assessment of craniofacial surgery outcomes in a pediatric population is challenging because of the complexity of patient presentations, diversity of procedures performed, and rapid craniofacial growth. There is a paucity of robust methods to quantify anatomical measurements by age and objectively compare craniofacial dysmorphology and postoperative outcomes. Here, the authors present data in developing a racially and ethnically sensitive anthropomorphic database, providing plastic and craniofacial surgeons with "normal" three-dimensional anatomical parameters with which to appraise and optimize aesthetic and reconstructive outcomes. METHODS: Patients with normal craniofacial anatomy undergoing head magnetic resonance imaging (MRI) scans from 2008 to 2021 were included in this retrospective study. Images were used to construct composite (template) images with diffeomorphic image registration method using the Advanced Normalization Tools package. Composites were thresholded to generate binary three-dimensional segmentations used for anatomical measurements in Materalise Mimics. RESULTS: High-resolution MRI scans from 130 patients generated 12 composites from an average of 10 MRI sequences each: four 3-year-olds, four 4-year-olds, and four 5-year-olds (two male, two female, two Black, and two White). The average head circumference of 3-, 4-, and 5-year-old composites was 50.3, 51.5, and 51.7 cm, respectively, comparable to normative data published by the World Health Organization. CONCLUSIONS: Application of diffeomorphic registration-based image template algorithm to MRI is effective in creating composite templates to represent "normal" three-dimensional craniofacial and soft-tissue anatomy. Future research will focus on development of automated computational tools to characterize anatomical normality, generation of indices to grade preoperative severity, and quantification of postoperative results to reduce subjectivity bias.

Autologous Cranioplasty Using a Dental SafeScraper Device.

SUMMARY: Conventional methods to reconstruct cortical bone defects introduced by pediatric cranial vault remodeling (CVR) procedures have shortcomings. Use of bone burr shavings as graft material leads to variable ossification, and harvesting split-thickness cortical grafts is time-intensive and often not possible in thin infant calvaria. Since 2013, the authors' team has used the SafeScraper, originally developed as a dental instrument, to harvest cortical and cancellous bone grafts during CVR. The authors assessed the effectiveness of this technique by analyzing postoperative ossification using computed tomography scans of 52 patients, comparing cohorts treated with the SafeScraper versus those who received conventional methods of cranioplasty during fronto-orbital advancement. The SafeScraper cohort had a greater reduction in total surface area of all defects (-83.1% ± 14.9 versus -68.9% ± 29.8; P = 0.034), demonstrating a greater and more consistent degree of cranial defect ossification compared with conventional methods of cranioplasty, suggesting potential adaptability of this tool. This is the first study that describes the technique and efficacy of the SafeScraper in reducing cranial defects in CVR. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

LeFort III Versus Monobloc Frontofacial Advancement: A Comparative Analysis of Soft Tissue Changes.

INTRODUCTION: The LeFort III and monobloc are commonly used midface advancement procedures for patients with syndromic craniosynostosis with well characterized postoperative skeletal changes. However, the differential effects of these procedures on facial soft tissues are less understood. The purpose of this study was to critically analyze and compare the effects of these 2 procedures on the overlying soft tissues of the face. METHODS: Frontal and lateral preoperative and postoperative photographs of patients undergoing monobloc or LeFort III were retrospectively analyzed using ImageJ to measure soft tissue landmarks. Measurements included height of facial thirds, nasal length and width, intercanthal distance, and palpebral fissure height and width. Facial convexity was quantified by calculating the angle between sellion (radix), subnasale, and pogonion on lateral photographs. RESULTS: Twenty-five patients with an average age of 6.7 years (range 4.8-14.5) undergoing monobloc (n=12) and LeFort III (n=13) were identified retrospectively and analyzed preoperatively and 6.4±3.6 months postoperatively. Patients undergoing LeFort III had a greater average postoperative increase in facial convexity angle acuity (28.2°) than patients undergoing monobloc (17.8°, P =0.021). Patients in both groups experience postoperative increases in nasal width ( P <0.001) and decreases in palpebral fissure height ( P <0.001). CONCLUSIONS: Both subcranial LeFort III advancements and monobloc frontofacial advancements resulted in significant changes in the soft tissues. Patients undergoing LeFort III procedures achieved greater acuity of the facial convexity angle, likely because the nasion is not advanced with the LeFort III segment.

Visual Attention Toward Patients with Hemifacial Microsomia Reconstruction: A Prospective Eye-Tracking Study.

BACKGROUND: Facial areas attracting the most visual attention in Hemifacial Microsomia (HFM) are poorly understood. Further, it is not clear if and how visual attention changes from pre- to post-operatively. This study characterized layperson visual attention to pre- and post-reconstruction hemifacial microsomia (HFM) using eye-tracking technology. METHODS: Visual fixations (Tobii Pro Nano) were recorded in four areas of interest from sixty participants completing two consecutive trials of 68 total images in each hemi-face of 17 patients with HFM pre- and post- orthognathic jaw reconstruction. Linear mixed effect models evaluated if visual fixations were affected by surgical reconstruction. RESULTS: 47,354 visual fixations were captured over 120 trials within defined AOIs. Linear mixed effect models revealed significantly decreased postoperative visual fixations in the mandible and chin region [716 (54.8%) pre-reconstruction, 591 (45.2%) post reconstruction; ß = -0.198, SE = 0.056, z = -3.550, p < 0.001]. Analysis also revealed significantly increased postoperative visual fixations in the forehead and orbit region [11350 (48.6%) pre-reconstruction, 12000 (51.4%) post-reconstruction; ß = 0.086, SE = 0.015, z = 5.664, p < 0.00001]. CONCLUSIONS: Following corrective jaw surgery for HFM, laypersons demonstrated significantly less visual attention to the mandible and chin and increased visual attention to the forehead and orbit. These findings suggest postoperative improvement towards aesthetic normalcy may reduce visual attention to previously anomalous anatomy.

The Use of Resorbable Fixation for Posterior Cranial Vault Distraction Osteogenesis.

SUMMARY: Posterior vault distraction osteogenesis (PVDO) traditionally relies on the use of cranial distractors affixed with titanium screws to the posterior cranial vault transport segment to allow for expansion of intracranial volume. We describe a novel technique using the Synthes RAPIDSORB IPS resorbable fixation system for stable fixation of the distraction hardware for PVDO. In a retrospective review of our experience with the IPS system, there was no instance of hardware or fixation failure. This off-label use of the IPS system results in a significant reduction in operative time for hardware removal while allowing for a more limited dissection, which can help reduce devascularization of the bony regenerate, bony relapse, and other complications.

Sociodemographic Disparities in Craniosynostosis: A Systematic Review.

OBJECTIVE: Given the consequences of delayed treatment and diagnosis of craniosynostosis, this study reviews the literature on sociodemographic risk factors and disparities associated with delayed craniosynostosis treatment. DESIGN: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A literature search of PubMed/Medline and Embase was performed by two independent reviewers. Included studies discussed craniosynostosis health disparities. Demographic characteristics and outcomes were analyzed. SETTING: Not applicable. PATIENTS: Patients with craniosynostosis. INTERVENTIONS: Standard surgical intervention for craniosynostosis. RESULTS: Our literature search yielded 273 studies, of which 18 were included for analysis. Included studies represented data from 31 256 U.S. patients with craniosynostosis. Sixty percent of patients (n = 16 510) were White, 13.8% were Hispanic/Latino, 6.2% were Black/African American, 1.3% were Asian, 0.3% were American Indian or Alaska Native, and 0.1% were Native Hawaiian or Pacific Islander. Average age at surgery was 6.36 months for White patients, 10.63 months for Black patients, and 9.18 months for Hispanic patients. Minority racial and/or ethnic status was a risk factor for delayed presentation, and increased incidence of open surgery, complication rates, hospital charges, operative time, anesthesia duration, and hospital length of stay. Government-funded health insurance was associated with delayed intervention and increased complications. CONCLUSIONS: Minority craniosynostosis patients experience delays in intervention and increased complication rates. Our findings highlight the importance of expedited and equitable referrals, screenings, and treatment, and the need for a standardized approach to investigating longitudinal demographic and outcomes data in this population.

Real Face Analysis of Masculinity-Femininity, Facial Ratios, and Attractiveness.

BACKGROUND: Previous studies have evaluated the influence of facial features in determining male and female sex using prototypical renderings or artificially altered faces in relatively small sample sizes. Using a large set of human photographs and raters, this study hypothesized that certain anatomic facial ratios are associated with perceptions of masculinity/femininity, can interact to predict sex, and are associated with ratings of attractiveness differently in males and females. METHODS: Ratings of masculinity-femininity and binary self-identification (male or female) were compared with facial anatomic ratios from 827 frontal facial photographs. Ratios were used to characterize facial feature relativity, where higher ratio scores indicated relatively more facial feature representation. RESULTS: Femininity was associated with prominent middle third ratio, nose length, lip vermillion height, eye height, and eye width ratios; masculinity was associated with prominence of the upper and lower facial thirds, nose width, chin height, and philtrum height ratios (all P < 0.01). Subgroup analysis demonstrated many of these relationships persisted when evaluating masculinity in females and femininity in males. Misgendering in males was associated with greater middle third ratio and upper lip ratio, whereas misgendering in females was associated with increased nose width ratio. CONCLUSIONS: This study demonstrates associations of femininity with increased horizontal middle third representation, and masculinity was associated with increased upper and lower horizontal representation. These facial ratios interact to predict male and female sex, which could have implications for optimizing facial feminization/masculinization outcomes and building algorithms for artificial intelligence analysis of faces.

Disability Caused by Cleft Lip and Palate: A Systematic Review and Critical Valuation Appraisal.

OBJECTIVE: Measuring disability as a concept of impaired global function enables beneficiaries of treatment, the impact of treatment, and targets of health system investment to be rigorously assessed. Measures of disability are not well established for cleft lip and palate. This study aims to systematically review disability weight (DW) studies pertaining to orofacial clefts (OFCs) and identify methodological strengths and shortcomings of each approach. DESIGN: Systematic literature review of studies that met the following criteria: (1) peer-reviewed publication, (2) focus on disability valuation, (3) mention orofacial clefts, and (4) publication January 2001-December 2021. SETTING: None. PATIENTS/PARTICIPANTS: None. INTERVENTIONS: None. MAIN OUTCOME MEASURE(S): Disability weight method of valuation and the value itself. RESULTS: The final search strategy yielded 1,067 studies. Seven manuscripts were ultimately included for data extraction. The disability weights used in our studies, including those newly generated or taken from the Global Burden of Disease Studies (GBD), ranged widely for isolated cleft lip (0.0-0.100) and cleft palate with or without cleft lip (0.0-0.269). The GBD studies limited their consideration of cleft sequelae informing disability weights to impact on appearance and speech-related concerns, while other studies accounted for comorbidities such as pain and social stigma. CONCLUSIONS: Current measures of cleft disability are sparse, inadequately reflect the comprehensive impact of an OFC on function and socialization, and are limited in detail or supporting evidence. Use of a comprehensive health state description in evaluating disability weights offers a realistic means of accurately representing the diverse sequelae of an OFC.

Integration of the Cleft-Q Patient Reported Outcome Tool into a Multidisciplinary Cleft and Craniofacial Clinic: A Proof of Concept.

SUMMARY: Implementation of patient reported outcome (PRO) tools has increased internationally in a variety of clinical settings, with emerging evidence suggesting benefits for patient satisfaction, improved patient-provider communication, and management of chronic conditions. However, integrating PROs into clinical workflow remains a barrier to implementation, with common challenges including patient completion, provider review of results, and future accessibility of data. Cleft lip and/or palate (CL/P) presents with a variety of aesthetic, functional, and psychosocial sequelae optimally managed by a multidisciplinary team, and Cleft-Q is a validated twelve-module PRO that captures patient perception in these domains. Given the emerging proven benefits of using PROs in a clinical setting, the authors integrated the Cleft-Q PRO at a multidisciplinary cleft and craniofacial clinic at a large, urban, tertiary care center. We collaborated with our institution's EHR Clinical Informatics Team to automatically identify eligible CL/P patients and generate the Cleft-Q PRO prior to weekly multidisciplinary cleft and craniofacial clinic days. Patient results were automatically scored, compared to age-based normative data, and populated into the EHR patient note. Cleft-Q results were viewed by clinicians during patient visits to initiate module-specific discussion in relation to patient age-based normative results. Patient-specific Cleft-Q data were also discussed during multidisciplinary cleft and craniofacial team discussions to aid in clinical decision making. This experience may have applicability to other PRO tools in plastic surgery and other medical specialties where integrating PROs may yield superior patient experience and outcomes.

Correlation between degree of sagittal suture fusion and surrogates of elevated intracranial pressure in sagittal craniosynostosis.

OBJECTIVE: Sagittal craniosynostosis constricts transverse skull growth, with possible neurocognitive sequelae. While the degree of sagittal suture fusion has been shown to influence the degree of dysmorphology, it is unknown if it impacts functional findings, including elevated intracranial pressure (ICP). The purpose of this study was to determine associations between the degree of sagittal suture fusion and optical coherence tomography (OCT) surrogates suggestive of increased ICP in patients with nonsyndromic sagittal craniosynostosis. METHODS: Three-dimensional CT head images of patients with sagittal craniosynostosis were analyzed in Materialise Mimics and parietal bones were manually isolated to determine the percentage fusion of the sagittal suture. Retinal OCT was performed prior to the cranial vault procedure with analysis for thresholds that correlate with elevated ICP. The degree of sagittal suture fusion was compared with OCT retinal parameter measurements using Mann-Whitney U-tests, Spearman's correlations, and multivariate logistic regression models controlled for age. RESULTS: Forty patients (31 males) with nonsyndromic sagittal craniosynostosis at a mean (± SD) age of 3.4 ± 0.4 months were included in this study. OCT surrogates of elevated ICP (maximal retinal nerve fiber layer [RNFL] thickness and maximal anterior projection [MAP]) were not associated with total sagittal suture fusion (p > 0.05). Maximal RNFL thickness was positively associated with increased percentage of posterior one-half (rho = 0.410, p = 0.022) and posterior one-third (rho = 0.417, p = 0.020) sagittal suture fusion. MAP was also positively associated with increased percentage of posterior one-half (rho = 0.596, p < 0.001) and posterior one-third (rho = 0.599, p < 0.001) sagittal suture fusion. Multivariate logistic regression models revealed increased percentage of posterior one-half (p = 0.048) and posterior one-third (p = 0.039) sagittal suture fusion predicted ICP > 20 mm Hg. CONCLUSIONS: Increased percentage fusion of the posterior sagittal suture, but not total suture, was positively associated with retinal changes indicative of increased ICP. These findings suggest suture fusion leading to increased ICP may be region specific.

The Natural History of Fibrous Dysplasia of the Orbit.

BACKGROUND: Orbital fibrous dysplasia (FD) is a disease of disordered fibro-osseous proliferation secondary to altered osteogenesis, with potential sequelae including compressive neuropathy and irreversible vision loss. The purpose of this study was to evaluate the natural history and longitudinal outcomes of 37 patients with orbital FD who underwent stratified surgical management. METHODS: All patients treated for FD from 2015-2021 were identified, yielding 185 patients, 39 with orbital involvement. Impressions from head CTs were analyzed by a craniofacial radiologist to evaluate location and timing of tumor growth. Operative records were reviewed to determine surgical approach (partial excision/contouring, complete excision, or partial excision with optic nerve decompression). RESULTS: Average age at diagnosis was 10.7±4.5 years, with average follow up of 5.2±4.7 years. Of the 37 patients with orbital involvement, 28 (75.7%) had optic canal involvement. Of those with optic canal involvement, 13 (46.4%) required partial excision with optic nerve decompression while 15 (53.6%) did not. Of those without optic canal involvement, two patients (22.2%) underwent partial excision/contouring of the anterior orbit to correct dystopia and/or proptosis and four patients (44.4%) underwent complete excision of the orbital component and reconstruction with bone graft or mesh. Younger age at diagnosis was associated with an increased number of surgical interventions (p=.011), younger age at first optic canal decompression (p=.003) and worse visual outcomes (p=.009). CONCLUSIONS: In our cohort, patients diagnosed at a younger age required more surgeries, underwent decompression earlier, and had worse visual outcomes.

Visual Attention, Bias, and Social Dispositions Toward People With Facial Anomalies: A Prospective Study With Eye-Tracking Technology.

BACKGROUND: Facial attractiveness influences our perceptions of others, with beautiful faces reaping societal rewards and anomalous faces encountering penalties. The purpose of this study was to determine associations of visual attention with bias and social dispositions toward people with facial anomalies. METHODS: Sixty subjects completed tests evaluating implicit bias, explicit bias, and social dispositions before viewing publicly available images of preoperative and postoperative patients with hemifacial microsomia. Eye-tracking was used to register visual fixations. RESULTS: Participants with higher implicit bias scores fixated significantly less on the cheek and ear region preoperatively (P = 0.004). Participants with higher scores in empathic concern and perspective taking fixated more on the forehead and orbit preoperatively (P = 0.045) and nose and lips (P = 0.027) preoperativel. CONCLUSIONS: Participants with higher levels of implicit bias spent less visual attention on anomalous facial anatomy, whereas participants with higher levels of empathic concern and perspective taking spent more visual attention on normal facial anatomy. Levels of bias and social dispositions such as empathy may predict layperson gaze patterns toward those with facial anomalies and provide insights to neural mechanisms underlying the "anomalous is bad" paradigm.

Long-term aesthetic and photogrammetric outcomes in non-syndromic unicoronal synostosis: comparison of fronto-orbital distraction osteogenesis and fronto-orbital advancement and remodeling.

BACKGROUND: Fronto-orbital advancement and remodeling (FOAR) is among the most common surgical approaches for unicoronal craniosynostosis (UCS), although some data demonstrate failure to achieve long-term aesthetic normalcy, leading some to seek alternative treatment paradigms such as fronto-orbital distraction osteogenesis (FODO). This study compares long-term aesthetic outcomes of patients with UCS treated with FOAR and FODO. METHODS: Twenty patients (four males) with non-syndromic UCS presenting to our institution and undergoing distraction were compared to a matched cohort of 20 patients (six males) undergoing FOAR. Clinical photographs and ImageJ were used to quantify periorbital anatomy including palpebral fissures, pupil-to-brow distance (PTB), and margin-reflex distance (MRD1) in pixels. Whitaker classification was blindly assigned by craniofacial surgeons. RESULTS: Photogrammetric analysis and Mann-Whitney U tests demonstrated significantly improved postoperative symmetry in distraction patients for palpebral width (p = 0.020), MRD1 (p = 0.045), and canthal tilt (p = 0.010). Average Whitaker classification scores between FOAR (1.94) and distraction (1.79) cohorts were similar (p = 0.374). CONCLUSIONS: UCS patients demonstrated significant postoperative improvements in periorbital symmetry, with distraction patients demonstrating superior results in palpebral width and canthal tilt. FOAR and FODO patients achieved similar Whitaker classification scores. These cohorts will be followed until craniofacial maturity prior to making any definitive conclusions.

Spinal pseudomeningocele closure: capsulofascial interposition technique.

INTRODUCTION: The development of a spinal pseudomeningocele is a complication of dural repair or reconstruction that carries significant morbidity for pediatric patients. In addition to cerebrospinal fluid (CSF) hypotension and positional headaches, CSF leaking into the extradural space increases the risk for incisional breakdown, meningitis, and cosmetic deformity. Spinal pseudomeningocele management is challenging, and reported techniques range from local wound revisions/exploration to shunt placement for permanent CSF diversion. METHODS: At our institution, we have recently implemented a multidisciplinary approach of capsulofascial interposition for the surgical repair of the symptomatic spinal pseudomeningocele with a combined neurosurgery-plastic surgery team. To our knowledge, this technique has not previously been characterized, and we describe the technical aspects of this surgery here. RESULTS: Among 10 patients treated with this technique, none required reoperation or developed infections following pseudomeningocele closure; 2 patients received postoperative transfusions; and 2 patients underwent CSF diversion procedures. CONCLUSION: We propose that this capsulofascial interposition technique should be employed in the surgical treatment of symptomatic spinal pseudomeningoceles.

Geospatial and Socioeconomic Factors Interact to Predict Management and Outcomes in Cleft Lip and Palate Surgery: A Single Institution Study of 740 Patients.

OBJECTIVE: Determine interactions between geospatial and socioeconomic factors influencing cleft lip and/or cleft palate (CL/P) management and outcomes. DESIGN: Retrospective review and outcomes analysis (n = 740). SETTING: Urban academic tertiary care center. PATIENTS: 740 patients undergoing primary (CL/P) surgery from 2009 to 2019. MAIN OUTCOMES MEASURES: Prenatal evaluation by plastic surgery, nasoalveolar molding, cleft lip adhesion, and age at CL/P surgery. RESULTS: Prenatal evaluation by plastic surgery was predicted by the interaction between higher patient median block group income and shorter patient distance from the care center (OR = 1.07, p = 0.022). Nasoalveolar molding was also predicted by the interaction between higher patient median block group income and shorter distance from the care center (OR = 1.28, p = 0.016), whereas cleft lip adhesion was predicted by higher patient median block group income alone (OR = 0.41, p < 0.001). Lower patient median block group income predicted later age at cleft lip (ß = -67.25, p = 0.011) and cleft palate (ß = -46.35, p = 0.050) repair surgery. CONCLUSIONS: Distance from the care center and lower median income by block group interacted to significantly predict prenatal evaluation by plastic surgery and nasoalveolar molding for patients with CL/P at a large, urban, tertiary care center. Patients living farthest from the care center who received prenatal evaluation by plastic surgery or who underwent nasoalveolar molding had higher median block group income. Future work will determine mechanisms perpetuating these barriers to care.

Crowdsourcing in Plastic and Reconstructive Surgery: A Systematic Review with Reporting Recommendations.

BACKGROUND: Crowdsourcing uses online platforms to collect large data from laypersons and has been increasingly used over the past 5 years to answer questions about aesthetic and functional outcomes following plastic and reconstructive surgery. This systematic review evaluates crowdsourcing articles in plastic and reconstructive surgery based on study topic, participants, and effect size in the hopes of describing best practices. METHODS: A systematic search strategy was developed with a licensed librarian and attending plastic surgeon to query all articles using crowdsourcing in plastic and reconstructive surgery. Covidence systematic review manager was used by two independent reviewers to import articles, screen abstracts, evaluate full texts, and extract data. RESULTS: A search run on October 8, 2021, yielded 168 studies, of which 45 were ultimately included. Craniofacial surgery and aesthetic surgery collectively constituted over half of studies. Participants in plastic surgery crowdsourcing studies are more commonly from the United States, female, straight, 25 to 35 years old; have completed college; and earn $20,000 to $50,000 per year. Studies typically assessed aesthetic perceptions, cost approximately $350, ran a median of 9 days, included approximately 60 unique survey items, and included approximately 40 unique human images. CONCLUSIONS: Crowdsourcing is a relatively new, low-cost method of garnering high-volume data from laypersons that may further our understanding of public perception in plastic and reconstructive surgery. As with other nascent fields, there is significant variability in number of subjects used, subject compensation, and methodology, indicating an opportunity for quality improvement.