Implant Texture and Capsular Contracture: A Review of Cellular and Molecular Pathways.

Background: Capsular contracture (CC) is a leading cause of morbidity in implant-based breast surgery. Implant surface texture has been implicated in CC development, yet its etiopathogenesis remains unclear. We conducted a systematic review to determine the influence of implant surface texture on cellular and molecular mechanisms involved in the etiopathogenesis of CC. Methods: A systematic review of the MEDLINE, Embase, Web of Science, and Scopus databases was completed to examine the influence of implant texture on cellular and molecular pathways leading to CC. Excluded articles were reviews and those examining solely the clinical presentation of CC. Results: Development of CC includes prolonged inflammation, increased myofibroblast density, parallel arrangement of collagen fibers, and biofilm formation. When compared with textured implants, smooth implants are associated with reduction in parallel collagen, capsule thickness, and sheer frictional force. Microtextured implants trigger a reduced macrophage response and decreased fibroblast activation as compared with smooth and macrotextured surfaces. Bacterial counts on microtextured and smooth surfaces are significantly lower than that of macrotextured surfaces. Both micro- and macrotextured implants have increased matrix metalloproteinases and activation of tumor necrosis factor α pathway, with increased activation of the transforming growth factor ß1 pathway relative to smooth implants. Conclusions: Implant surface texture alters the cellular and molecular mechanisms in the chronic inflammatory process leading to CC. Given the complex biological system of cellular and molecular events in CC, a mathematical model integrating these influences may be optimal to deduce the etiopathogenesis.

Machine Learning to Predict the Need for Postmastectomy Radiotherapy after Immediate Breast Reconstruction.

Background: Post mastectomy radiotherapy (PMRT) is an independent predictor of reconstructive complications. PMRT may alter the timing and type of reconstruction recommended. This study aimed to create a machine learning model to predict the probability of requiring PMRT after immediate breast reconstruction (IBR). Methods: In this retrospective study, breast cancer patients who underwent IBR from January 2017 to December 2020 were reviewed and data were collected on 81 preoperative characteristics. Primary outcome was recommendation for PMRT. Four algorithms were compared to maximize performance and clinical utility: logistic regression, elastic net (EN), logistic lasso, and random forest (RF). The cohort was split into a development dataset (75% of cohort for training-validation) and 25% used for the test set. Model performance was evaluated using area under the receiver operating characteristic curve (AUC), precision-recall curves, and calibration plots. Results: In a total of 800 patients, 325 (40.6%) patients were recommended to undergo PMRT. With the training-validation dataset (n = 600), model performance was logistic regression 0.73 AUC [95% confidence interval (CI) 0.65-0.80]; RF 0.77 AUC (95% CI, 0.74-0.81); EN 0.77 AUC (95% CI, 0.73-0.81); logistic lasso 0.76 AUC (95% CI, 0.72-0.80). Without significantly sacrificing performance, 81 predictive factors were reduced to 12 for prediction with the EN method. With the test dataset (n = 200), performance of the EN prediction model was confirmed [0.794 AUC (95% CI, 0.730-0.858)]. Conclusion: A parsimonious accurate machine learning model for predicting PMRT after IBR was developed, tested, and translated into a clinically applicable online calculator for providers and patients.

Models for Implant-Induced Capsular Contracture Post Breast Cancer Surgery.

Capsular contracture is a painful deformation of scar-tissue that may form around an implant in post-breast cancer reconstruction or cosmetic surgery. Inflammation due to surgical trauma or contamination in the tissue around the implant could account for recruitment of immune cells, and transdifferentiation of resident fibroblasts into cells that deposit abnormally thick collagen. Here we examine this hypothesis using a mathematical model for interacting macrophages, fibroblasts, myofibroblasts, and collagen. Our model demonstrates that cellular response can, together with inflammatory cell recruitment, account for prognoses.

Implications of the COVID-19 Pandemic on Immediate Breast Reconstruction Access.

AIMS: As a result of COVID-19, there have been restrictions on surgical interventions across Canada. Immediate breast reconstruction (IBR), while an essential component of cancer care, is classified as elective surgery and therefore has been restricted in access over the course of the pandemic. The purpose of this study was to compare wait times for breast cancer patients undergoing surgical intervention for IBR before and since the COVID-19 pandemic. METHODS: This was a retrospective cross-sectional study of consecutive patients who underwent IBR between July 2018 and October 2021 by 5 plastic surgeons at a single Canadian health center. Wait times to consultation and surgical intervention between pre- and post-COVID cohorts were analyzed. RESULTS: A total of 161 patients met inclusion criteria. For ablative surgery, there was no difference in wait times to surgical oncology consultation (14.0 ± 12.3 vs 14.0 ± 11.0 days, P = 0.991) and surgical intervention with IBR (41.0 ± 49.8 vs 35.0 ± 58.0 days, P = 0.621) between the pre- and post-COVID cohorts. For breast reconstruction, while time to consultation with plastic surgery (12.5 ± 14.8 vs 11.0 ± 12.8 days, P = 0.775) remained unchanged, usage of autologous techniques was reduced [n = 13 (16%) vs n = 2 (2%), P = 0.006], and time to second-stage alloplastic reconstruction increased (230 ± 102 vs 325 ± 224 days, P = 0.044) post-COVID. CONCLUSIONS: Swift adoption of evidence driven protocols has resulted in comparable wait times for breast cancer ablative procedures. However, utilization of autologous techniques and wait times to second-stage reconstructions have increased.

Methods of Recruitment for Surgical and Perioperative Randomized Controlled Trials: A Rapid Review.

Due to the complex nature of surgical randomized controlled trials (RCTs), reaching target recruitment can be challenging. The primary objective was to report on characteristics of successful pilot surgical and perioperative RCTs and the methodological strategies implemented to optimize recruitment. The secondary objective was to provide recommendations for successful recruitment strategies for future surgical RCTs. Ovid MEDLINE, Ovid EMBASE, and Web of Science (via Ovid) databases were searched from 2012 to 2022. This review included surgical and perioperative pilot studies that met their recruitment targets. Study and recruitment characteristics were summarized, and potential relationships between study design and recruitment rate were assessed. Optimized recruitment strategies were extracted when reported. Of 4156 total articles identified, 255 underwent full-text screening, and 52 articles were included. Of the included pilot studies, 21% (n = 11) did not indicate a target sample size or recruitment rate. Recruitment methods were minimally reported in pilot studies for perioperative or surgical RCTs. Strategies to optimize recruitment included internal iterative evaluations of the recorded recruitment appointments and staged introduction of the study. Recruitment rate was not associated with invasiveness of intervention or burden of participation. Patient involvement is absent from current reports on methodological design and offers valuable opportunity to optimize recruitment. Recruitment strategies in perioperative and surgical RCTs can be optimized with iterative qualitative evaluation of the recruitment methods with input from the interdisciplinary research team.

Breast-Conserving Therapy is Associated with Improved Survival Without an Increased Risk of Locoregional Recurrence Compared with Mastectomy in Both Clinically Node-Positive and Node-Negative Breast Cancer Patients.

INTRODUCTION: Randomized trials demonstrated equivalent survival between breast-conserving surgery combined with radiotherapy (BCT) and mastectomy alone. Contemporary retrospective studies using pathological stage have reported improved survival with BCT. However, pathological information is unknown before surgery. To mimic real-world surgical decision-making, this study assesses oncological outcomes by using clinical nodal status. METHODS: Female patients aged 18-69 years who were treated with upfront BCT or mastectomy between 2006 and 2016 for T1-3N0-3 breast cancer were identified by using prospective, provincial database. The patients were divided into clinically node-positive (cN+) and node-negative (cN0) strata. Multivariable logistic regression was used to assess the effect of local treatment type on overall survival (OS), breast cancer-specific survival (BCSS), and locoregional recurrence (LRR). RESULTS: Of 13,914 patients, 8228 had BCT and 5686 had mastectomy. Mastectomy patients had higher-risk clinicopathological factors: pathologically positive axillary staging was 21% in BCT and 38% in mastectomy groups. Most patients received adjuvant systemic therapy. For cN0 patients, 7743 had BCT and 4794 had mastectomy. On multivariable analysis, BCT was associated with improved OS (hazard ratio [HR] 1.37, p < 0.001) and BCSS (HR 1.32, p < 0.001), whereas LRR was not different between the groups (HR 0.84, p = 0.1). For cN+ patients, 485 had BCT and 892 had mastectomy. On multivariable analysis, BCT was associated with improved OS (HR 1.46, p = 0.002) and BCSS (HR 1.44, p = 0.008), whereas LRR was not different between the groups (HR 0.89, p = 0.7). CONCLUSIONS: In the era of contemporary systemic therapy, BCT was associated with better survival than mastectomy, without an increased risk of locoregional recurrence for both cN0 and cN+ presentations.

Chronic pain in breast cancer patients post mastectomy with alloplastic reconstruction: A scoping review.

INTRODUCTION: Women diagnosed with breast cancer are receiving mastectomy with implant-based reconstruction at an increasing rate. Chronic post-surgical pain can be a major concern for these patients. This review sought to address the knowledge gap on the prevalence, severity and characteristics of chronic pain in this population. METHODS: A scoping review was conducted using the Arksey and O'Malley framework. Five databases were searched using keywords. Two independent reviewers performed selection and data extraction of studies that met inclusion criteria. RESULTS: Seventeen studies were included in this review. Ten studies reported prevalence of chronic pain which ranged from 7.3%-90.9% with pooled prevalence of 26.3%. Nine studies reported severity of chronic pain using various scales and methodology; most patients' pain was not severe. Risk factors for chronic pain included axillary dissection, lack of perioperative local anaesthetic, younger age and use of a tissue expander. No studies reported on possible correlation between ethnicity and pain. Eleven different assessment tools were used to measure pain. CONCLUSION: Chronic pain following post-mastectomy implant-based breast reconstruction is prevalent, associated with specific risk factors and poorly characterised. There is a need to investigate and evaluate chronic pain in this population using validated breast cancer specific pain assessment tools.

Automated medical chart review for breast cancer outcomes research: a novel natural language processing extraction system.

BACKGROUND: Manually extracted data points from health records are collated on an institutional, provincial, and national level to facilitate clinical research. However, the labour-intensive clinical chart review process puts an increasing burden on healthcare system budgets. Therefore, an automated information extraction system is needed to ensure the timeliness and scalability of research data. METHODS: We used a dataset of 100 synoptic operative and 100 pathology reports, evenly split into 50 reports in training and test sets for each report type. The training set guided our development of a Natural Language Processing (NLP) extraction pipeline system, which accepts scanned images of operative and pathology reports. The system uses a combination of rule-based and transfer learning methods to extract numeric encodings from text. We also developed visualization tools to compare the manual and automated extractions. The code for this paper was made available on GitHub. RESULTS: A test set of 50 operative and 50 pathology reports were used to evaluate the extraction accuracies of the NLP pipeline. Gold standard, defined as manual extraction by expert reviewers, yielded accuracies of 90.5% for operative reports and 96.0% for pathology reports, while the NLP system achieved overall 91.9% (operative) and 95.4% (pathology) accuracy. The pipeline successfully extracted outcomes data pertinent to breast cancer tumor characteristics (e.g. presence of invasive carcinoma, size, histologic type), prognostic factors (e.g. number of lymph nodes with micro-metastases and macro-metastases, pathologic stage), and treatment-related variables (e.g. margins, neo-adjuvant treatment, surgical indication) with high accuracy. Out of the 48 variables across operative and pathology codebooks, NLP yielded 43 variables with F-scores of at least 0.90; in comparison, a trained human annotator yielded 44 variables with F-scores of at least 0.90. CONCLUSIONS: The NLP system achieves near-human-level accuracy in both operative and pathology reports using a minimal curated dataset. This system uniquely provides a robust solution for transparent, adaptable, and scalable automation of data extraction from patient health records. It may serve to advance breast cancer clinical research by facilitating collection of vast amounts of valuable health data at a population level.

Canadian Expert Opinion on Breast Reconstruction Access: Strategies to Optimize Care during COVID-19.

BACKGROUND: Breast reconstructive services are medically necessary, time-sensitive procedures with meaningful health-related quality of life benefits for breast cancer survivors. The COVID-19 global pandemic has resulted in unprecedented restrictions in surgical access, including access to breast reconstructive services. A national approach is needed to guide the strategic use of resources during times of fluctuating restrictions on surgical access due to COVID-19 demands on hospital capacity. METHODS: A national team of experts were convened for critical review of healthcare needs and development of recommendations and strategies for patients seeking breast reconstruction during the pandemic. Following critical review of literature, expert discussion by teleconference meetings, and evidenced-based consensus, best practice recommendations were developed to guide national provision of breast reconstructive services. RESULTS: Recommendations include strategic use of multidisciplinary teams for patient selection and triage with centralized coordinated use of alternate treatment plans during times of resource restrictions. With shared decision-making, patient-centered shifting and consolidation of resources facilitate efficient allocation. Targeted application of perioperative management strategies and surgical treatment plans maximize the provision of breast reconstructive services. CONCLUSIONS: A unified national approach to strategically reorganize healthcare delivery is feasible to uphold standards of patient-centered care for patients interested in breast reconstruction.

Truncal-based perforator flaps for autologous breast reconstruction: A review of 975 flaps and their clinical application.

BACKGROUND: When autologous breast reconstruction is desired and deep inferior epigastric artery perforator (DIEP) flap is inadequate or unavailable, other perforator flaps in the truncal region should not be disregarded. This study aimed to review all truncal-based perforator flaps used for autologous breast reconstruction to identify clinical indications and outcomes of alternate perforator flaps. METHODS: From 2013 to 2018, patients undergoing truncal-based perforator flap breast reconstruction were reviewed and data recorded for; indications, pre-operative and intra-operative treatment decisions, flap failures, take-backs, and revisions. Compared to the gold standard of the DIEP flap, alternate truncal-based flaps were evaluated for their reconstructive merit and application. RESULTS: A total of 975 perforator flaps were harvested circumferentially around the lower trunk. As an alternative or adjunct to the DIEP flap (n = 633, 65%), perforator flaps were harvested based on the superficial inferior epigastric, the deep and superficial circumflex iliac arteries, the intercostal, and lumbar arteries (n = 342, 35%). Overlapping vascular territories facilitate the safe harvest of these alternate flaps with 0.8% of flaps requiring take back (n = 8) and 0.2% flap failure rate (n = 2). There was no difference in peri-operative outcomes between anterior abdominal and alternate truncal-based flaps (p > .05). CONCLUSIONS: Circumferential harvest of alternate truncal flaps is an appropriate option for autologous reconstruction with comparable peri-operative and long-term outcomes as compared to flaps from the anterior abdomen.

The Best of Chest Wall Reconstruction: Principles and Clinical Application for Complex Oncologic and Sternal Defects.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Appraise and evaluate risk factors for respiratory compromise following oncologic resection. 2. Outline and apply an algorithmic approach to reconstruction of the chest wall based on defect composition, size, and characteristics of surrounding tissue. 3. Recognize and evaluate indications for and types of skeletal stabilization of the chest wall. 4. Critically consider, compare, and select pedicled and free flaps for chest wall reconstruction that do not impair residual respiratory function or skeletal stability. SUMMARY: Chest wall reconstruction restores respiratory function, provides protection for underlying viscera, and supports the shoulder girdle. Common indications for chest wall reconstruction include neoplasms, trauma, infectious processes, and congenital defects. Loss of chest wall integrity can result in respiratory and cardiac compromise and upper extremity instability. Advances in reconstructive techniques have expanded the resectability of large complex oncologic tumors by safely and reliably restoring chest wall integrity in an immediate fashion with minimal or no secondary deficits. The purpose of this article is to provide the reader with current evidenced-based knowledge to optimize care of patients requiring chest wall reconstruction. This article discusses the evaluation and management of oncologic chest wall defects, reviews controversial considerations in chest wall reconstruction, and provides an algorithm for the reconstruction of complex chest wall defects. Respiratory preservation, semirigid stabilization, and longevity are key when reconstructing chest wall defects.

A call to bridge the divide in breast reconstruction research: A systematic review.

PURPOSE: Breast reconstruction is an important component of comprehensive breast cancer care. Although reconstructive plans require multidisciplinary clinical-decision making, research in cross-discipline collaborations is often limited. This study aims to evaluate multidisciplinary involvement in breast reconstruction outcomes research. METHODS: A systematic review of breast reconstruction literature published from 2000 to 2019 using Ovid MEDLINE, Ovid EMBASE, and PubMed databases was conducted. English language articles published in North America or Europe with n ≥ 12 nonpediatric patients were included. Articles concerning procedures not performed in the context of breast cancer care or articles that did not evaluate at least one outcome, diagnostic test, or risk factor were excluded. Authors' affiliations were used to define multidisciplinary involvement. Quality of research was evaluated using the level of evidence,  journal impact factor (IF), and altmetrics. RESULTS: Of the 1679 articles screened, 784 met the stated eligibility criteria. Only half (50.6%) of these articles involved an author outside the discipline of plastic surgery. Compared to nonmultidisciplinary studies, multidisciplinary studies were more likely to be designated with a higher level of evidence (I or II) (p<0.001), published in journals with higher IF (p<0.05), have higher usage (p = 0.03), and mentions (p = 0.02). There was no difference in citations, captures, and social media posts (p>0.05). CONCLUSION: Breast reconstruction outcomes research often fails to offer author collaborations from nonplastic surgery disciplines. Multidisciplinary involvement in breast cancer care research is strongly recommended to improve the quality and impact of clinical studies in breast reconstruction.

The Impact of the COVID-19 Pandemic on Breast Reconstruction: A Canadian Perspective.

BACKGROUND: The COVID-19 pandemic has led to unprecedented challenges and restrictions in surgical access across Canada, including for breast reconstructive services which are an integral component of comprehensive breast cancer care. We sought to determine how breast reconstructive services are being restricted, and what strategies may be employed to optimize the provision of breast reconstruction through a pan-Canadian evaluation from the providers' perspective. METHODS: This was a cross-sectional survey of Canadian plastic and reconstructive surgeons who perform breast reconstruction. The 33-item web-based questionnaire was developed by a pan-Canadian working group of breast reconstruction experts and disseminated via email to members of the Canadian Society of Plastic Surgery. The questionnaire queried respondents on the impact of the COVID-19 pandemic and associated restrictions on surgeons' breast reconstruction practice patterns and opinions on strategies for resource utilization. RESULTS: Responses were received from 49 surgeons, who reported practicing in 8 of 10 Canadian provinces. Restrictions on the provision of breast reconstructive procedures were most limited during the First Wave of the COVID-19 pandemic, where all respondents reported at least some reduction in capacity and more than a quarter reporting complete cessation. Average reported reduction in capacity ranged from 31% to 78% across all 3 waves. Autologous, delayed, and prophylactic reconstructions were most commonly restricted. CONCLUSION: This study provides a pan-Canadian impact assessment on breast reconstructive services during the COVID-19 pandemic from the providers' perspective. To uphold the standards of patient-centred care, a unified approach to strategically reorganize health care delivery now and in the future is needed.

HISTORIQUE: La pandémie de COVID-19 a donné lieu à des défis et des restrictions sans précédent en matière d'accès aux interventions chirurgicales au Canada, y compris les services de reconstruction mammaire qui font partie intégrante des soins complets du cancer du sein. Les chercheurs ont voulu déterminer le mode de restriction des services de reconstruction mammaire et les stratégies possibles pour en optimiser la prestation grâce à une évaluation pancanadienne du point de vue des chirurgiens. MÉTHODOLOGIE: La présente étude transversale a été effectuée auprès de chirurgiens plasticiens et reconstructeurs canadiens qui font de la reconstruction mammaire. Un groupe de travail pancanadien d'experts de la reconstruction mammaire a préparé le questionnaire en ligne en 33 points, lequel a été transmis par courriel aux membres de la Société canadienne de chirurgiens-plasticiens. Le questionnaire portait sur les répercussions de la pandémie de COVID-19 et les restrictions connexes sur les modes de pratique de reconstruction mammaire des chirurgiens, de même que sur leurs avis et stratégies à l'égard de l'utilisation des ressources. RÉSULTATS: Un total de 49 chirurgiens, qui ont déclaré exercer dans huit des dix provinces canadiennes, ont répondu au sondage. Les restrictions imposées aux interventions de reconstruction mammaire ont été plus limitées pendant la première vague de la pandémie COVID-19, puisque tous les répondants ont rendu compte d'au moins une certaine restriction de la capacité et que plus du quart ont fait état de leur arrêt complet. La diminution moyenne de la capacité a varié de 31 % à 78 % dans l'ensemble des trois vagues. Ce sont les reconstructions autologues, tardives et prophylactiques qui ont surtout été touchées. CONCLUSION: La présente étude fournit une évaluation pancanadienne des incidences de la pandémie de COVID-19 sur les services de reconstruction mammaire du point de vue des chirurgiens. Pour maintenir les normes des soins axés sur les patients, il faudra procéder à une réorganisation stratégique unifiée de la prestation des soins, tant maintenant qu'à l'avenir.

Management of patients requiring reconstructive breast surgery during the COVID-19 pandemic: recommendations from the BC Regional Breast Reconstruction Network.

Summary: The COVID-19 pandemic has caused unprecedented challenges in health care, threatening access and delivery of medical services across all sectors. Patients with breast cancer desiring breast reconstruction require timely interdisciplinary care; resource limitations threaten access to this elective reconstructive element of cancer care. An expert panel was convened to identify challenges, recommend preliminary solutions, and identify important future directions in anticipation of prolonged restrictions. This paper presents consensus recommendations for care of breast cancer reconstruction patients during the pandemic based on expert opinion from the BC Breast Reconstruction Network.

Beware the Alar Base Optical Illusion in Assessment of Unilateral Cleft Lip Nasal Deformity.

BACKGROUND: After repair of unilateral cleft lip, lateral drift of the alar base is expected and may require revision. Although the alar base appears wider than on the noncleft side, by measurement it could be symmetric or narrow. Is this an optical illusion? METHODS: This is a retrospective photographic evaluation of children who underwent repair of unilateral complete cleft lip and palate. On submental standardized photographs, raters judged whether the alar base position was wider, equal to, or narrower than on the noncleft side. The true alar base position was measured by photogrammetry and the frequency of alar base misjudgment was assessed. On control photographs, the cleft side alar base was wider than the noncleft side. On test photographs, the cleft side alar base was narrower than the noncleft side. Possible association between misjudgment and nasal features was also evaluated. Data were analyzed using the Fisher's exact test. RESULTS: Three raters assessed 61 patients aged 6 to 9 years and treated between 1995 and 2015. In 77 percent of control photographs, raters correctly judged the cleft side alar base as wider. In 65 percent of test photographs, raters incorrectly judged the alar base position as wider on the cleft side. Asymmetry of nostril outline and a transverse nostril axis were associated with misjudged photographs (p < 0.05). CONCLUSIONS: Alar base assessment can be altered by an optical illusion. Simple anthropometry counters this misperception. Measurement should be repeated after correction of the deviated anterocaudal septum and elevation of the lower lateral cartilage. Thereafter, a decision is made on altering the alar base position. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

Nonsyndromic Unilateral Coronal Synostosis: A Comparison of Fronto-Orbital Advancement and Endoscopic Suturectomy.

BACKGROUND: Comparative effectiveness research is needed to optimize treatment of unilateral coronal synostosis. This study compares perioperative morbidity, ophthalmic, and aesthetic outcomes of patients with nonsyndromic unilateral coronal synostosis treated by endoscopic suturectomy or fronto-orbital advancement. METHODS: From 2004 to 2015, patients with unilateral coronal synostosis were reviewed and data recorded for operative details, reoperations, and aesthetic results using the Whitaker classification, severity of strabismus, and need for surgical correction. Categorical data were analyzed using the Fisher's exact test and continuous data were analyzed using the Wilcoxon rank sum test. RESULTS: Ninety-four patients were treated with endoscopic suturectomy (n = 60) or fronto-orbital advancement (n = 34). Median age at follow-up was 3.5 years (range, 1 to 9 years) for endoscopic suturectomy and 5.0 years (range, 2 to 11 years) for fronto-orbital advancement (p = 0.06). The endoscopic suturectomy group had a lower operative time (42 minutes versus 216 minutes), length of stay (1 day versus 4 days), blood loss (25 cc versus 260 cc), and transfusion rate (0 percent versus 88 percent). Two patients treated with fronto-orbital advancement required secondary intervention for intracranial pressure. Thirty-one percent (16 of 52) of the endoscopic suturectomy group and 65 percent (19 of 29) of the fronto-orbital advancement group developed clinically significant strabismus requiring surgical repair (p = 0.002). In the endoscopic suturectomy group, 88 percent (50 of 57) were Whitaker class I and 5 percent were class II. In the fronto-orbital advancement group, 41 percent (14 of 34) were class I and 44 percent class II. Need for bony revision (two of 57 versus three of 34) and need for secondary cranial procedure (two of 57 versus two of 34) were similar following endoscopic suturectomy and fronto-orbital advancement. CONCLUSIONS: For treatment of unilateral coronal synostosis, endoscopic suturectomy is associated with lower morbidity and comparable aesthetics. Patients treated with endoscopic suturectomy are half as likely to require strabismus surgery compared with those treated with fronto-orbital advancement. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Development of the Submental Nasal Appearance Scale for the Assessment of Repaired Unilateral Complete Cleft Lip: A Pilot Study.

OBJECTIVE: To develop the "Submental Nasal Appearance Scale" (SNAS), which is an easy-to-use objectified tool to represent a cleft surgeon's standard for assessment of the nasal appearance from the submental perspective. DESIGN: Eighty-five photographs of patients with unilateral complete cleft lip and palate were selected and cropped, displaying the submental view. Sixty-one photographs were used to develop 5 sets of reference photographs. Three cleft surgeons graded 24 photographs with these sets and subjectively graded the overall nasal appearance as well. Internal agreement for both methods was calculated, as well as correlation between them. The SNAS was created, by only using the combination of sets that showed the highest reliability and correlation. SETTING: Boston Children's Hospital, Boston, Massachusetts. PATIENTS: Six- to 9-year-old patients with unilateral complete cleft lip and palate. RESULTS: The intrarater and interrater reliability was 0.84 and 0.79, respectively, for the SNAS and 0.76 and 0.62, respectively, for the overall appearance assessment. The correlation was 0.74 between the methods. CONCLUSIONS: The SNAS is a reliable tool that reflects a cleft surgeon's standard and could be used independently or in combination with existing rating scales using the frontal and/or lateral view, for assessment after cleft lip repair.

Modification of the Melbourne Method for Total Calvarial Vault Remodeling.

BACKGROUND: Sagittal synostosis is the most common form of single suture synostosis. It often results in characteristic calvarial deformities, including a long, narrow head, frontal bossing, a bullet-shaped occiput, and an anteriorly placed vertex. Several methods for correcting the phenotypic deformities have been described, each with their own advantages and challenges. In this study, we describe a modification of the Melbourne method of total calvarial remodeling for correcting scaphocephaly. METHODS: We conducted a retrospective review of all consecutive patients who underwent total calvarial remodeling using a modified version of the Melbourne technique from 2011 to 2015. We evaluated clinical photographs, computed tomographic imaging, and cephalic indices both pre- and postoperatively to determine morphologic changes after operation. RESULTS: A total of 9 patients underwent the modified Melbourne technique for calvarial vault remodeling during the study period. Intraoperative blood loss was 260 mL (range, 80-400 mL), and mean intraoperative transfusion was 232 mL (range, 0-360 mL). The average length of stay in the hospital was 3.9 days. The mean cephalic indices increased from 0.66 to 0.74 postoperatively (P < 0.01). CONCLUSIONS: A modified Melbourne method for calvarial vault reconstruction addresses the phenotypic aspects of severe scaphocephaly associated with isolated sagittal synostosis and maintains a homeotopic relationship across the calvaria. It is associated with shorter operative times, lower blood loss, and lower transfusion requirements.

Analysis of clinical outcomes for treatment of sagittal craniosynostosis: a comparison of endoscopic suturectomy and cranial vault remodeling.

The authors compared the effectiveness of two main surgical techniques used for treating sagittal craniosynostosis (SC): endoscopic suturectomy (ES) and cranial vault remodeling (CVR). The safety, head growth, and aesthetic results following ES and CVR were compared by reviewing the charts of more than 200 patients. By comparing the effectiveness of these two treatments, this study will help guide selection of the optimal surgical treatment for patients with SC.