A Dedicated Multidisciplinary Growth and Feeding Clinic for Infants with Cleft Lip and/or Palate Demonstrates Need for Intervention.

OBJECTIVE: A Growth and Feeding Clinic (GFC) focused on early intervention around feeding routines in patients with cleft lip and/or palate (CL/P) was implemented. DESIGN: This study assessed the effect of preoperative feeding interventions provided by the GFC. SETTING: Tertiary academic center. METHODS: This study evaluated patients with CL/P who were cared for by the GFC and a control group of patients with CL/P. Weight-for-age (WFA) Z-score of less than -2.00 was used as a cutoff to classify patients who were underweight during the preoperative period. MAIN OUTCOME MEASURE: The number of underweight patients who were able to reach normal weight by the time of their cleft lip repair was used as the primary outcome measure. RESULTS: Within both the GFC and control groups, 25% of patients with CL/P were underweight as determined by WFA Z-score. GFC patients who were underweight received more clinic visits (P < .001) and GFC interventions (P < .001) compared to GFC patients who were normal weight. At the time of cleft lip surgery, 64.1% of GFC underweight patients were normal weight compared to 31.8% of control group underweight patients (P = .0187). CONCLUSION: This study showed that multidisciplinary care provided by the GFC was able to target preoperative nutritional interventions to the highest-risk patients, resulting in double the percentage of patients who were of normal weight at the time of their cleft lip repair. These results provide objective proof supporting the assertion that multidisciplinary team care of the infant with cleft leads to measurable improvement in outcomes.

Pediatric Facial Fracture Associated Craniofacial and Cervical Spine Injury.

Management of pediatric facial fractures depends on location and severity, age, and associated injuries. Accurate diagnosis of associated injuries is crucial for effective treatment. This study evaluates the incidence of associated injuries and seeks to determine the influencing factors to provide imaging guidance. A retrospective review of pediatric facial fractures from the American College of Surgeons National Trauma Data Bank from 2017 to 2021 was completed. Associated cervical spine (c-spine), skull fracture, traumatic brain injury (TBI), and intracranial bleeding were evaluated. Demographics, fracture patterns, mechanisms, protective devices, and the Glasgow Coma Scale (GCS) were reviewed. A total of 44,781 pediatric patients with 65,613 facial fractures were identified. Of the total, 5.47% had a c-spine injury, 21.86% had a skull fracture, 18.82% had TBI, and 5.76% had intracranial bleeding. Multiple fractures significantly increased the rate of all associated cranial and c-spine injuries. Single midface fractures had the highest c-spine, TBI, and intracranial bleeding rates. With increasing age, there was a significant increase in c-spine injury and TBI, while there was a decrease in skull fractures. Motor vehicle accidents and GCS <13 were associated with significantly increased rates of all injuries. Among pediatric patients with facial fractures, 5.47% had a c-spine injury, 21.86% had a skull fracture, 18.82% had TBI, and 5.76% had intracranial bleeding. The authors' findings recommend c-spine imaging in older age and cranial imaging in younger patients. Multiple facial fractures, fractures of the midface, decreased GCS, and motor vehicle accidents increase the need for both c-spine and cranial imaging.

Preoperative Velopharyngeal Closure Predicts Hypernasality Outcomes of Secondary Furlow Double-Opposing Z-Plasty.

OBJECTIVE: To determine if preoperative velopharyngeal closure percentage (VCP) is predictive of successful Furlow double opposing Z-plasty (DOZP) and subsequently determine the optimal velopharyngeal closure cutoff for successful DOZP. DESIGN: Retrospective study. SETTING: Tertiary academic center. PATIENTS: 110 patients with repaired cleft lip and palate having hypernasality treated with DOZP. INTERVENTIONS: Speech videofluoroscopy images were used to obtain the preoperative VCP and other measurements. MAIN OUTCOME MEASURES: Changes in hypernasality scores using the Cleft Audit Protocol for Speech-Augmented-Americleft Modification (CAPS-A-AM) rating system were used as the primary outcome measure. A successful DOZP was defined as a postoperative hypernasality score of ≤ 1 or an improvement of 2 or more scores from baseline. A receiver operating characteristic (ROC) curve was calculated to determine preoperative VCP cutoff. RESULTS: There were 110 patients who underwent DOZP for treatment of velopharyngeal insufficiency. Of these patients, 94 (85%) had successful surgery as determined by their postoperative CAPS-A-AM hypernasality score. Preoperative VCP was a statistically significant predictor of successful DOZP (P < .0001). The ROC curve with Youden index (J) determined a cutoff (c*) of 55% preoperative VCP or greater to optimize surgical success rate. Grouping by preoperative VCP showed that surgical success increases directly with preoperative VCP, and patients with low VCP had above a 50% success rate in reducing hypernasality scores. CONCLUSIONS: Preoperative VCP was significantly associated with improved hypernasality ratings postoperatively. A preoperative VCP of ≥55% may be used to help predict success of Furlow palatoplasty treatment. Patients with lower VCP can still benefit from secondary DOZP.

Multicenter comparison of head shape outcomes for three minimally invasive strip craniectomy techniques for sagittal craniosynostosis.

OBJECTIVE: A literature gap exists comparing whole head shape outcome following correction of sagittal craniosynostosis. The objective of this multicenter study was to provide an analysis of long-term results following three different endoscopic strip craniectomy techniques for correction of sagittal craniosynostosis: 1) spring-assisted strip craniectomy, 2) wide-strip craniectomy with biparietal and bitemporal barrel-stave wedge osteotomies plus helmet orthosis, and 3) narrow-strip craniectomy plus orthosis without barrel staves. METHODS: Pre- and postoperative 3D stereophotogrammetric images were collected from patients who underwent craniosynostosis surgery. Procedures were divided among institutions as follows: spring-assisted strip craniectomies were performed at Atrium Health Wake Forest Baptist Hospital; narrow-strip craniectomies were performed at St. Louis Children's Hospital by one craniofacial surgeon; and wide-vertex craniectomies were performed at St. Louis Children's Hospital prior to 2010, and then continued at Children's Medical Center Dallas. Pre- and postoperative 3D whole-head composite images were generated for each procedure to visually represent outcomes at final follow-up and compared with age-matched normal controls. RESULTS: Patients in the spring-assisted strip craniectomy group showed normalization of frontal bossing and skull height compared with age-matched controls, whereas patients undergoing wide-strip craniectomy showed greater correction of occipital protrusion. Patients in the narrow-strip craniectomy cohort had intermediate results between these outcomes. Nested aggregate head shapes showed good correction of head shapes from all techniques. CONCLUSIONS: This large, retrospective, multicenter study illustrated whole head shape outcomes from three different craniectomy procedures. Although each procedure showed some differences in loci of primary correction, all three surgical methods demonstrated good correction of primary scaphocephalic deformity.

Rating the Rater: A Technique for Minimizing Leniency Bias in Residency Applications.

Each program in the highly competitive match for a surgical residency needs a way to review applicants effectively. Often this task is undertaken by individual faculty members, reviewing an applicant's file and assigning a score. Despite being asked to rate on a standardized scale, our program found that ratings of the same applicants varied dramatically, with certain faculty consistently scoring higher or lower than others. This is termed leniency bias, or the Hawk-Dove effect, and can affect who is invited to interview depending on which faculty are assigned to review an applicant's file. Methods: A technique to minimize leniency bias was developed and applied to this year's 222 applicants for our plastic surgery residency. The effect of the technique was evaluated by comparing variance between ratings of the same applicants by different faculty before and after our technique. Results: The median variance of ratings of the same applicants reduced from 0.68 before correction to 0.18 after correction, demonstrating better agreement between raters of the applicants' scores after our technique had been applied. This year, applying our technique affected whether or not 16 applicants (36% of interviewees) were invited for interview, including one applicant who matched to our program but who otherwise would not have been offered an interview. Conclusions: We present a simple but effective technique to minimize the leniency bias between raters of residency applicants. Our experience with this technique is presented together with instructions and Excel formulae for other programs to use.

Open Versus Minimally Invasive Approach for Craniosynostosis: Analysis of the National Surgical Quality Improvement Program-Pediatric.

OBJECTIVE: This multicenter study aimed to compare demographic, operative, and short-term outcomes data between open and minimally invasive surgical approaches for craniosynostosis repair utilizing the American College of Surgeon's National Surgical Quality Improvement Program Pediatric (NSQIP-P) database and highlight surgical disparities among races and ethnicities. DESIGN: Retrospective review of large multicenter database. SETTING: Freestanding general acute care children's hospitals, children's hospitals within a larger hospital, specialty children's hospitals, or general acute care hospitals with a pediatric wing. PATIENTS AND PARTICIPANTS: A total of 4931 pediatric patients underwent craniosynostosis correction within the NSQIP-P database from 2013 to 2019. INTERVENTIONS: None. MAIN OUTCOME MEASURE(S): Demographic information included age at surgery, sex, race, and ethnicity. Operative and outcomes measures included operative time, anesthesia time, days until discharge, postoperative complications, blood transfusions, 30-day readmission, and 30-day unplanned return to operating room. RESULTS: Patients who underwent minimally invasive surgery had significantly shorter operative and anesthesia times (p < .001; p < .001), fewer days until discharge (p < .001), fewer postoperative complications (p < .05), and less blood transfusions (p < .001). The proportion of White patients was significantly higher in the minimally invasive surgery group (p < .01), whereas Black and Hispanic patients had a significantly higher proportion in the open surgery group (p < .001; p < .001). Additionally, the percentage of patients undergoing minimally invasive surgery increased from 3.8% in 2014 to over 13% in 2019. CONCLUSIONS: This study adds to a growing consensus that minimally invasive surgery has significantly decreased operative time, anesthesia time, transfusion rates, length of hospital stay, and postoperative complications compared to open surgery. Racial and ethnic surgical disparities showed larger proportions of Black and Hispanic populations undergoing open procedures.

Pediatric Tissue Expansion: Analysis of the National Surgical Quality Improvement Program-Pediatric.

INTRODUCTION: Tissue expansion (TE) in pediatric surgery provides vascularized tissue to attain functional and esthetic goals in a broad range of reconstructive procedures. Our study evaluates the demographic, operative, and short-term outcomes of TE in pediatric patients utilizing the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database and highlights factors associated with postoperative complications. MATERIALS AND METHODS: Retrospective review of a large multicenter database of 402 pediatric patients that underwent TE within the NSQIP-P database from 2013 to 2020 at freestanding general acute care children's hospitals, children's hospitals within a larger hospital, specialty children's hospitals, or general acute care hospitals with a pediatric wing. Patient demographics, clinical risk factors, operative information, and postoperative outcomes were collected with an odds ratio analysis of risk factors. RESULTS: Patients were majority female (55.5%), White (63.2%), and non-Hispanic (67.4%). The minority were born prematurely (11.9%) and had congenital malformations (16.7%). Complications occurred in 5.7%, unplanned readmission in 4.5%, and unplanned operation in 6.5% of patients. Complications lead to readmission in 2.5% and return to the operating room in 3.2% of patients. American Society of Anesthesiology (ASA) score III-IV, congenital malformations, >1-day hospital stay, and pulmonary, neurologic, and hematologic comorbidities were associated with the greatest increase in odds of complication. CONCLUSION: This study utilizes the NSQIP-P to provide a comprehensive multicenter view of pediatric patients undergoing TE. Increased understanding of risk factors for complications allows for guidance in patient selection and helps in achieving favorable surgical outcomes.

Three-Dimensional Motion Capture of a Smile in Repaired Unilateral Cleft Lip: What's Our Vector, Victor?

INTRODUCTION: Following surgical repair, patients with unilateral cleft lip (UCL) exhibit dynamic asymmetry during facial expressions compared to healthy individuals. Previous studies using Euclidean distances to describe this asymmetry fail to take the direction of the movement into account. The aim of this study is to compare differences in participants with UCL and controls using analysis of motion vectors during facial expressions. METHODS: In this cross-sectional study, twenty-six pediatric participants were recruited: 13 participants with repaired left UCL and 13 participants with no craniofacial diagnosis. Participants were recorded performing a maximal smile by a 4D stereophotogrammetric system. Phases of the smile were divided into closed lip and open lip smiles. Ten regions of interest were analyzed: subnasal area, upper lip, lower lip, oral commissure, and ala on both sides. The motion vectors were calculated and vector magnitude and direction for each region was compared. RESULTS: Between cleft and control groups, the differences in vector direction were greater than the magnitude differences. Significant differences in vector direction were identified at both oral commissures in the closed lip smile; and at the oral commissure, subnasal, upper lip, and lower lip regions during open lip smile. CONCLUSIONS: Vector analysis demonstrated significant movement asymmetry during facial animation in participants following UCL repair, not previously identified when analyzing magnitude of skin displacement.

Anterior "W" Tongue Reduction for Macroglossia in Beckwith-Wiedemann Syndrome.

INTRODUCTION: Macroglossia occurs in 80% to 99% of patients with Beckwith-Wiedemann syndrome (BWS) and a variety of surgical techniques for tongue reduction are offered by surgeons. The purpose of this study is to evaluate the postoperative outcomes of the anterior "W" tongue reduction technique in patients with BWS. METHODS: A retrospective review was conducted of all patients diagnosed with BWS that underwent an anterior "W" tongue reduction for macroglossia in the past 7 years, performed by 2 surgeons. Demographics, procedural characteristics, perioperative outcomes, and complications were assessed. RESULTS: A total of 19 patients met inclusion criteria consisting of 8 male and 11 female patients. The mean age at the time of surgery was 405 days, mean surgeon operating time was 1.06 h, and mean length of follow-up was 467 days. Postoperative oral competence was observed in 100% of patients. There was no reported history of sleep apnea or airway compromise. Speech delay was seen in 4 patients pre- and postoperatively. Feeding issues decreased from 7 patients preoperatively to 1 patient postoperatively. Preoperative prevalence of class III malocclusion (53%) and isolated anterior open bite (26%) decreased postoperatively to 37% and 16%, respectively. The only reported complications were superficial tip wound dehiscence in 3 patients treated with nystatin antifungal therapy. None of the patients required revisional surgery. CONCLUSION: Patients treated with the anterior "W" tongue reduction technique had low rates of perioperative complications and significant improvements in oral competence. Anterior "W" tongue reduction is safe and effective for the correction of macroglossia in patients with BWS.

Assessing outcomes of ear molding therapy by health care providers and convolutional neural network.

Ear molding therapy is a nonsurgical technique to correct certain congenital auricular deformities. While the advantages of nonsurgical treatments over otoplasty are well-described, few studies have assessed aesthetic outcomes. In this study, we compared assessments of outcomes of ear molding therapy for 283 ears by experienced healthcare providers and a previously developed deep learning CNN model. 2D photographs of ears were obtained as a standard of care in our onsite photography studio. Physician assistants (PAs) rated the photographs using a 5-point Likert scale ranging from 1(poor) to 5(excellent) and the CNN assessment was categorical, classifying each photo as either "normal" or "deformed". On average, the PAs classified 75.6% of photographs as good to excellent outcomes (scores 4 and 5). Similarly, the CNN classified 75.3% of the photographs as normal. The inter-rater agreement between the PAs ranged between 72 and 81%, while there was a 69.6% agreement between the machine model and the inter-rater majority agreement between at least two PAs (i.e., when at least two PAs gave a simultaneous score < 4 or ≥ 4). This study shows that noninvasive ear molding therapy has excellent outcomes in general. In addition, it indicates that with further training and validation, machine learning techniques, like CNN, have the capability to accurately mimic provider assessment while removing the subjectivity of human evaluation making it a robust tool for ear deformity identification and outcome evaluation.

Analysis of Facial Movement in Repaired Unilateral Cleft Lip Using Three-Dimensional Motion Capture.

ABSTRACT: Unilateral cleft lip (UCL) is one of the most common craniofacial deformities. Surgical intervention reconstructs lip and nose anatomy; however, some degree of asymmetry persists after repair. This demonstrates a need for a model for studying and improving outcomes for patients with orofacial clefts. This study's main question was whether there is a significant difference in dynamic facial asymmetry between participants with repaired UCLs and control participants during smiling. Ten pediatric subjects with repaired left UCLs and 12 with no craniofacial diagnoses were recorded performing maximum smiles using a markerless 4D video stereophotogrammetrical system. A facial mesh template containing 884 landmarks was conformed to each initial frame and tracked throughout. Kinetic analysis of smiles was performed by calculating landmark 3D Euclidean distance between frames. Patients with left repaired UCL showed increasing facial asymmetry throughout smiling. Oral commissures, upper, and lower lips demonstrated significantly greater movement on the right side (P < 0.05). Control patients showed facial asymmetry during the first half of smiling, with greater movement on the left side. Displacement difference between right and left was significantly greater at oral commissures and upper lips in patients with repaired ULC compared to control patients. This study provides a highly detailed, quantitative analysis of postoperative UCLs, and help improve outcomes of future repair surgeries.

Comparison of Head Shape Outcomes in Metopic Synostosis Using Limited Strip Craniectomy and Open Vault Reconstruction Techniques.

AIM: Metopic craniosynostosis (MCS), with its trigonocephalic head shape, is often treated with either limited incision strip craniectomy (LISC) followed by helmet orthotic treatment, or open cranial vault reconstruction techniques (OCVR). There is controversy regarding resultant shape outcomes among craniofacial surgeons. Those adverse to LISC claim normal head shape is never attained, while proponents believe there is gradual correction to an equivalent outcome. This study aims to quantitate, over time, the three-dimensional (3D) head shapes in patients who have undergone LISC or OCVR intervention for MCS. METHODS: Sixty-three 3D images of 26 patients with MCS were analyzed retrospectively. Head shape analyses were performed at: (1) preoperative, (2) 1-month postoperative, (3) 10 to 14 months postoperative (1 year), and (4) 2 years postoperative. Composite 3D head shapes of patients were compared at each time point. Two-dimensional (2D) standardized cross sections of the forehead were also compared. RESULTS: Composite head shapes for both groups were nested, to allow visual comparison as the child's forehead grows and expands. The difference between LISC and OCVR 2D cross sections was calculated; 108.26 mm preoperatively, 127.18 mm after 1-month postoperative, 51.05 mm after 10 to 14 months postoperative, and 27.03 mm after 2 years postoperative. CONCLUSIONS: This study found excellent head shape outcomes for both the LISC and OCVR techniques at 2 years of age. It also corroborates the slow and progressive improvement in head shape with the LISC technique. This study highlights the advantages of 3D photography for measurement of contour outcomes, utilizing both 2D vector and 3D whole head analytical techniques.

The Use of Eye Tracking to Discern the Threshold at Which Metopic Orbitofrontal Deformity Attracts Attention.

INTRODUCTION AND OBJECTIVES: Surgical treatment for trigonocephaly aims to eliminate a stigmatizing deformity, yet the severity that captures unwanted attention is unknown. Surgeons intervene at different points of severity, eliciting controversy. This study used eye tracking to investigate when deformity is perceived. MATERIAL AND METHODS: Three-dimensional photogrammetric images of a normal child and a child with trigonocephaly were mathematically deformed, in 10% increments, to create a spectrum of 11 images. These images were shown to participants using an eye tracker. Participants' gaze patterns were analyzed, and participants were asked if each image looked "normal" or "abnormal." RESULTS: Sixty-six graduate students were recruited. Average dwell time toward pathologic areas of interest (AOIs) increased proportionally, from 0.77 ± 0.33 seconds at 0% deformity to 1.08 ± 0.75 seconds at 100% deformity (P < .0001). A majority of participants did not agree an image looked "abnormal" until 90% deformity from any angle. CONCLUSION: Eye tracking can be used as a proxy for attention threshold toward orbitofrontal deformity. The amount of attention toward orbitofrontal AOIs increased proportionally with severity. Participants did not generally agree there was "abnormality" until deformity was severe. This study supports the assertion that surgical intervention may be best reserved for more severe deformity.

Kinematic Analysis of Smiles in the Healthy Pediatric Population Using 3-Dimensional Motion Capture.

INTRODUCTION: Facial normalcy, as measured with 2-dimensional or 3-dimensional photographs, has been documented in the healthy pediatric population. However, static images convey far from a complete representation of an individual's daily interactions with peers. Craniofacial surgery induces changes to soft or osseous tissues and thereby affects dynamic facial expression. To-date, there has not been rigorous, dynamic quantification of normal facial expression. In this study, we used 4-dimensional (4D) imaging to assess the facial expression of healthy children to provide a normative reference point for craniofacial surgeons. METHODS: A total of 36 healthy pediatric volunteers underwent 4D video recordings while performing a maximal voluntary smile. A face template containing 884 landmarks was registered and tracked throughout the videos using Dimensional Imaging software. Participants were divided into 2 smile groups: open-lip smile and closed-lip smile. Kinematic analysis of smiles was calculated for every landmark from its position in the resting frame to its terminal displacement. RESULTS: Composite smiles and Euclidean distance maps were generated displaying areas of greatest displacement near the oral commissures. There was significant difference between closed-lip and open-lip groups in regions of eyes and cheeks. In addition, the open-lip smile group demonstrated significantly greater displacement in the oral commissure on the left side compared to the right (P < .05); whereas, in the closed-lip group, the eyes and cheeks moved significantly more on the right side. CONCLUSION: This study presents an innovative method that can be used to evaluate facial expressions to help craniofacial surgeons restore functional movement in patients with facial anomalies.

Identifying Ear Abnormality from 2D Photographs Using Convolutional Neural Networks.

Quantifying ear deformity using linear measurements and mathematical modeling is difficult due to the ear's complex shape. Machine learning techniques, such as convolutional neural networks (CNNs), are well-suited for this role. CNNs are deep learning methods capable of finding complex patterns from medical images, automatically building solution models capable of machine diagnosis. In this study, we applied CNN to automatically identify ear deformity from 2D photographs. Institutional review board (IRB) approval was obtained for this retrospective study to train and test the CNNs. Photographs of patients with and without ear deformity were obtained as standard of care in our photography studio. Profile photographs were obtained for one or both ears. A total of 671 profile pictures were used in this study including: 457 photographs of patients with ear deformity and 214 photographs of patients with normal ears. Photographs were cropped to the ear boundary and randomly divided into training (60%), validation (20%), and testing (20%) datasets. We modified the softmax classifier in the last layer in GoogLeNet, a deep CNN, to generate an ear deformity detection model in Matlab. All images were deemed of high quality and usable for training and testing. It took about 2 hours to train the system and the training accuracy reached almost 100%. The test accuracy was about 94.1%. We demonstrate that deep learning has a great potential in identifying ear deformity. These machine learning techniques hold the promise in being used in the future to evaluate treatment outcomes.

Early Pediatric Nasal Reconstruction Utilizing the Tagliacozzi Flap.

The Tagliacozzi cross arm flap has been historically described for repair of large nasal defects. The authors report what we believe is the youngest case in modern literature of nasal reconstruction with a Tagliacozzi flap, in a 6-year-old girl. Due to her poor face and scalp skin quality, the more modern reconstructive options of a forehead flap or free tissue transfer were not deemed suitable. Two delay procedures and a complex splint were required to position the medial arm fasciocutaneous flap over the nasal construct. The arm was immobilized for 3 weeks to allow for vascularization of the recipient bed. The child successfully tolerated the splint. She has improved breathing and nasal contour.

Molding Helmet Therapy for Deformational Brachycephaly.

BACKGROUND: Molding helmet therapy is used for the treatment of infants with deformational brachycephaly (DB). There is a lack of rigorous outcome measures of helmet therapy in patients with DB using 3-dimensional (3D) imaging, with most reports rely on either subjective or 2-dimensional analyses. Furthermore, the longitudinal assessment of head shape improvement over the course of helmet therapy has not been documented. Our goal was to assess the outcome of molding helmet therapy using 3D surface imaging, and to document the pace of improvement during treatment. METHODS: The head shape of 18 infants with DB who underwent orthotic molding helmet therapy was assessed. The 3D scans were obtained before treatment, during treatment, and at the end of treatment. First, we applied shape analysis techniques based on template deformation to obtain average (composite) heads of the 18 patients at the 3 time points of treatment (pretreatment, during, and posttreatment). In addition, we used 3D curvature analysis to quantify the degree of flatness at the same time points. RESULTS: Molding helmet therapy started at 6.7 ±â€Š0.9 months of age and lasted for 4.3 ±â€Š0.8 months. The overall difference in the occipital contour between pretreatment and end of treatment was 6.3 ±â€Š1.7 mm. Curvature analysis revealed that 15% of the back of the head had prehelmet marked flatness (mean curvature <5/m), which decreased to 9% at 2.5 months into treatment and 7% at the end of treatment. CONCLUSION: Over 65% of the head shape improvement occurred during the 2.5 months of molding helmet therapy.

Digital Images in Academic Plastic Surgery: A Novel and Secure Methodology for Use in Clinical Practice and Research.

BACKGROUND: Digital photographs have become an integral part in plastic and reconstructive surgery. They are significant in clinical research and outcome evaluation. There is a need for effective and secure methods to store, search, and retrieve those photographs. We developed a Health Insurance Portability and Accountability Act compliant searchable database to archive and index clinical information for clinical and research purposes. METHODS: At our craniofacial clinic, digital media (2-D, 3-D, and 4-D photographs) are obtained on a regular basis to evaluate and document treatment outcomes. In addition, patients are asked to enroll in our institutional review board (IRB)-approved imaging database. Daily, we link all digital photographs to the patient encounter through EPIC's Media Manager. This allows us to automatically identify and extract new digital media, patient demographics, diagnosis codes, relevant providers, and the text of the clinic notes to our digital database. To search our extensive database, we employed the VIEW search engine. RESULTS: To date, our database contains more than 277 000 images of 11 000 patients where more than 1900 patients are enrolled in the IRB study. This search engine allows full-text search with query response time between 2 and 5 seconds. The search engine displays the returned through a web page interface, which includes image thumbnails and the relevant part of the clinic note. In addition, a patient-specific chart allows the user to examine all patient notes and photographs. CONCLUSION: Our solution allows providers and researchers to retrieve all digital media securely and efficiently.

Three-Dimensional Printing for Craniofacial Surgery: A Single Institution's 5-Year Experience.

BACKGROUND: As 3-dimensional (3D) printers and models become more widely available and increasingly affordable, surgeons may consider investing in a printer for their own cleft or craniofacial center. To inform surgeons considering adoption of this evolving technology, this study describes one multi-surgeon center's 5-year experience using a 3D printer. METHODS: This study included 3D models printed between October 2012 and October 2017. A 3D Systems ZPrinter 650 was used to create all models. Models were subclassified by type (craniofacial vs noncraniofacial) and diagnosis, and the cost of consumable materials was recorded. A survey was distributed to craniofacial team members who used the printed models. Likert scales and free texts were used for responses about lessons learned and the usefulness of the printer for different craniofacial indications. RESULTS: A total of 106 models were printed at this institution during the 5-year time period. Printing times were 7.4 ± 1.9 hours for complete skulls and 6.0 ± 1.7 hours for maxillofacial prints. The average cost for a complete skull was about US$60 in material cost alone. The 3D printer was most frequently used for complex craniosynostosis, hemifacial microsomia syndrome, and fibrous dysplasia cases. The surgeons found the printer to be most useful for planning complex facial orthognathic cases and least useful for routine single-suture synostosis. CONCLUSION: Three-dimensional printing was found to be helpful for all 4 craniofacial surgeons, who would all invest again in a 3D printer. For lower volume centers, commercially printed models may be a more cost-effective alternative.

Eye Tracking as a Proxy for Perceptual Evaluation of Repaired Cleft Lip.

Human interactions begin with near-instantaneous visual evaluation of the face, modifying emotional responses and social behavior toward the person. Eye-tracking technology can provide a potential window into how humans undertake this evaluation, and the threshold of whether a face containing a craniofacial difference is perceived as "normal." This study's main questions were whether gaze patterns differ from normal when evaluating children with craniofacial differences, and whether these gaze patterns vary with different levels of craniofacial deformity. Two experiments tested the feasibility of using eye tracking to study facial evaluation and whether there was a difference in the gaze pattern and characteristics, correlating with the Asher McDade Aesthetic Index. Fifty-three participants' eye movements were recorded as they gazed at photographs of children either with hemifacial microsomia or repaired cleft lip, with repaired cleft lip digitally corrected to symmetry, or with no craniofacial disorder. Recruitment and participation for this study occurred in a pediatric plastic surgery clinic and in a medical school student center. Participants gazed longer on the lip in the cleft-lip photographs compared with control photographs in the first experiment (207 ms; SD 75 versus 145 ms; SD 61, respectively; P = 0.04). This gaze bias was confirmed in the second experiment and found to correlate with severity (r = 0.042). Gaze patterns differ when individuals look at photographs with or without craniofacial differences. The degree to which these eye movement patterns differ correlates with the severity of craniofacial deformity.