Long-term Aesthetic Results Research Articles

Long-Term Aesthetic Cicatrization Analysis of Lower Eyelid Incision for Orbital Floor Fracture Approach.

Orbital fractures are among the most frequent facial injuries. Of the 3 most widely described approaches in the literature, the lower eyelid approach is the authors' preference. This study retrospectively analyzed the patients treated at the Trauma Center of the Umberto I Hospital, Sapienza University of Rome from January 2010 to December 2020. Inclusion criteria were as follows: diagnosis of pure/impure orbital bone fracture, complete clinical and radiological documentation, and a minimum of 12 months follow-up. Sex, age, etiology, treatment, and associated complications were analyzed using IBM SPSS Statistics. Two internationally validated scales were used for the functional and esthetic long-term evaluation: the Patient and Observer Scar Assessment Scale (POSAS) and the Vancouver one. The scales were compiled by the patient himself and by 3 independent expert observers. Of the 543 patients who underwent surgery in the specified period, 208 fully met the inclusion criteria. One hundred forty-two (68.2%) were males and 66 (31.8%) were females, with a mean age of 40.68 years. The main cause was represented by assaults (33.1%). One hundred seventy-nine patients had a pure orbital fracture (83.8%) and 29 an impure one (16.2%). The most frequent symptoms at the time of diagnosis were diplopia (31.2%), followed by anesthesia of the second trigeminal branch (24.3%). Open reduction with internal fixation was the preferred treatment and proved to be effective in reducing the main signs and symptoms of the fracture in a statistically significant way ( P < 0.05). Long-term esthetic results of the lower eyelid, using the Vancouver and POSASs, were respectively as follows: Vancouver Scar Scale mean total score was 2.41 (range: 0-8), observer POSAS mean total score was 1.83 (range: 1.2-3.9), observer general opinion mean score was 1.66, patient POSAS mean total score was 2.23 (range: 1.33-3.7), and patient general opinion mean score was 2.87. The lower eyelid approach has proven to be reproducible, with a fast-learning curve and a low complication rate. The analysis conducted highlighted an excellent long-term esthetic-functional result. Further studies will be needed to statistically compare the results obtained with other orbital floor surgical approaches.

Ear Molding Therapy of Congenital Ear Anomalies: Long-Term Aesthetic Outcomes and Caretaker Satisfaction.

Ear molding is a safe, non-surgical approach to treat newborns with congenital ear anomalies. In this study, we aimed to investigate long-term aesthetic outcomes and caretaker satisfaction from ear molding therapy. A retrospective chart review from 2018 to 2020 was conducted for infants who underwent ear molding treatment at our institution. Patient demographics and treatment related variables were collected. Caretakers were surveyed regarding their experience, expectations, and aesthetic outcome at 1year (short-term) and 3years (long-term) from treatment. Independent physicians evaluated treatment efficacy. Responses were converted to a Likert scale (1-5), with 5 representing most desirable. Overall, 38 of 42 patients participated in our long-term study (90%) for a total of 62 ears. Average follow-up was 3.31 ± 0.50years after completion of treatment. Mean age at treatment was 23.2 ± 19.7days with a mean treatment duration of 21.7 ± 7.7days. Caretakers' satisfaction regarding auricular appearance remained high (short-term: 4.18 vs. long-term: 4.17, p = 0.54) and anticipated social distress decreased over time. Physician aesthetic evaluations were favorable between "somewhat effective" and "very effective" and remained consistent over time (short term: 3.46 vs. long-term: 3.31, p = 0.31). Furthermore, physician evaluations were higher for deformations than malformations (p = 0.04) and in children who began treatment by 30days old (p = 0.04). Caretaker satisfaction from ear molding therapy remained high after long-term follow up, and social distress from the perception of their child's ears decreased with time. Physician aesthetic ratings confirmed efficacy, with better outcomes seen in deformations than in malformations. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Comparing definitive unilateral cleft rhinoplasty with and without diced-cartilage alar-base augmentation: A retrospective cohort study

This retrospective cohort study aimed to compare the long-term aesthetic outcomes and satisfaction of patients who underwent two techniques of definitive unilateral cleft rhinoplasty. The two cohorts, comprising patients with mature unilateral cleft deformity, were managed with definitive rhinoplasty, either with or without diced-cartilage alar-base and peri-alar augmentation (ABPA). Thirty patients were included in each cohort. Anthropometric measurements, complications, patient satisfaction scores, and third-party surgeon assessment scores were reviewed. In both cohorts, anthropometric parameters improved. Rhinoplasty with ABPA was the superior cohort in terms of columellar length (10.3 ± 1.0 in the cohort with ABPA, compared with 7.9 ± 0.6 in the cohort without ABPA; p < 0.001), alar-base angle (0.2 ± 0.2, compared with 4.3 ± 0.3; p < 0.001), and columellar deviation (2.5 ± 1.4, compared with 10.3 ± 2.1; p < 0.001). This cohort also had more symmetry in nostril height and nostril width (p < 0.001), a lower recurrence rate (one case compared with 22 cases; p < 0.001), a higher patient satisfaction score (p = 0.002), and a higher surgeon assessment score (p < 0.001, Cronbach’s alpha = 0.706, Kendall’s coefficient of concordance = 0.787). Within the limitations of this study, it appears that the described technique for augmenting the alar-base and peri-alar maxillary area is manageable, and yields consistent long-term results.

Spatial Fidelity of Microvascular Perforating Vessels as Perceived by Augmented Reality Virtual Projections.

Autologous breast reconstruction yields improved long-term aesthetic results but requires increased resources of practitioners and hospital systems. Innovations in radiographic imaging have been increasingly used to improve the efficiency and success of free flap harvest. Augmented reality affords the opportunity to superimpose relevant imaging on a surgeon's native field of view, potentially facilitating dissection of anatomically variable structures. To validate the spatial fidelity of augmented reality projections of deep inferior epigastric perforator flap-relevant anatomy, comparisons of three-dimensional (3D) models and their virtual renderings were performed by four independent observers. Measured discrepancies between the real and holographic models were evaluated. The 3D-printed models of deep inferior epigastric perforator flap-relevant anatomy were fabricated from computed tomographic angiography data from 19 de-identified patients. The corresponding computed tomographic angiography data were similarly formatted for the Microsoft HoloLens to generate corresponding projections. Anatomic points were initially measured on 3D models, after which the corresponding points were measured on the HoloLens projections from two separate vantage points (V1 and V2). Statistical analyses, including generalized linear modeling, were performed to characterize spatial fidelity regarding translation, rotation, and scale of holographic projections. Among all participants, the median translational displacement at corresponding points was 9.0 mm between the real-3D model and V1, 12.1 mm between the 3D model and V2, and 13.5 mm between V1 and V2. Corresponding points, including topography of perforating vessels, for the purposes of breast reconstruction can be identified within millimeters, but there remain multiple independent contributors of error, most notably the participant and location at which the projection is perceived.

Volume changes in the reconstructed breast over two years after free abdominal tissue transfer: Comparison of unipedicled versus bipedicled flaps

Volume changes in reconstructed flaps, particularly regarding symmetry, are an important consideration to improve long-term esthetic results in patients who undergo breast reconstruction. Asian patients with thin abdominal tissues tend to require bipedicled flaps, which provide a greater volume of abdominal tissue. We investigated volume changes in free abdominal flaps and the factors that may affect flap volume, particularly the number of pedicles. The study included all consecutive patients who underwent immediate unilateral breast reconstruction using free abdominal flaps between January 2016 and December 2018. The initial flap volume was calculated intraoperatively, and the postoperative flap volume was calculated using computed tomography or magnetic resonance imaging based on the Cavalieri principle. The study included 131 of 249 patients. Compared with the initial inset volume, the mean flap volumes at 1 and 2 years postoperatively decreased to 80.11% and 73.80%, respectively. The multivariable analysis of factors that affect flap volume showed a significant association with the flap inset ratio, radiation (P=.019,.040, respectively). Stratification based on the number of pedicles showed that the flap inset ratio was significantly negatively correlated with the postoperative flap volume change in unipedicled (P<.05) but not in bipedicled flaps. The flap volume decreased over time, and its change had a negative correlation with the flap inset ratio in the unipedicled group. Therefore, prediction of postoperative volume changes in various clinical situations is important before breast reconstruction.

Sagittal synostosis: does choice of intervention and its timing affect the long-term aesthetic and neurodevelopmental outcome? A single-institution study of 167 children.

Sagittal craniosynostosis (SC) is the most commonly encountered form of craniosynostosis. Despite its relative frequency, there remains significant heterogeneity in both operative management and follow-up between centers and a relative paucity of long-term outcome data in the literature. At the authors' institution, families of children presenting with SC are offered the following options: 1) conservative management with ophthalmic surveillance, 2) minimally invasive surgery at < 6 months of age (spring-assisted cranioplasty [SAC]) or 3) calvarial vault remodeling at any age (CVR). The authors reviewed outcomes for all children presenting with SC during a 5-year period, regardless of the treatment received. Consecutive children born between January 1, 2008, and December 31, 2012, presenting with SC were identified, and detailed chart reviews were undertaken. Demographic, surgical, perioperative, head shape, scar, and neurodevelopmental (behavioral, education, speech, and language) data were analyzed. The cohort was divided by type of surgery (none, SAC, or CVR) and by age at surgery (early, defined as ≤ 6 months; or late, defined as > 6 months) for comparison purposes. A total of 167 children were identified, 129 boys and 38 girls, with a median age at presentation of 5.0 (range 0.4-135) months. Three families opted for conservative management. Of the 164 children who underwent surgery, 83 underwent SAC, 76 underwent CVR, and 5 underwent a "hybrid" procedure (CVR with springs). At a median age of 7.0 (range 0.5-12.3) years, there was no significant difference in concerns regarding head shape, scar, or neurodevelopmental outcomes between the early and late intervention groups over all procedures performed, or between the early or late SAC and CVR cohorts. There were more head shape concerns in the SAC group than in the CVR group overall (25.7% vs 11.8%, respectively; p = 0.026), although most of these concerns were minor and did not require revision. In this cohort, regardless of operative intervention and timing of intervention, infants achieved similar neurodevelopmental outcomes. Minimally invasive surgery (SAC) appears to result in less complete correction of head shape than CVR, but this may be balanced by advantages in reduced operative time, hospitalization, and blood loss. SAC was equal to CVR in neuropsychological outcomes.

Long-Term Esthetic Outcome of Different Treatment Modalities for Nontuberculous Mycobacterial Cervicofacial Lymphadenitis

BackgroundNontuberculous mycobacterial (NTM) cervicofacial lymphadenitis is a rare infection which almost exclusively occurs in children, most commonly children 0–5 years old. It can leave scars in highly visible areas. The present study aimed to evaluate the long-term esthetic outcome of different treatment modalities for NTM cervicofacial lymphadenitis. MethodsThis retrospective cohort study included 92 participants with a history of bacteriologically proven NTM cervicofacial lymphadenitis. All patients were diagnosed at least 10 years prior and were aged >12 years upon enrollment. Based on standardized photographs, the scars were assessed by subjects with the Patient Scar Assessment Scale, and by five independent observers with the revised and weighted Observer Scar Assessment Scale. ResultsThe mean age at initial presentation was 3,9 years and the mean follow-up time was 15.24 years. Initial treatments included surgical treatment (n = 53), antibiotic treatment (n = 29) and watchful waiting (n = 10). Subsequent surgery was performed in two patients, due to a recurrence after initial surgical treatment, and in 10 patients initially treated with antibiotic treatment or watchful waiting. Esthetic outcomes were statistically significantly better with initial surgery, compared to initial non-surgical treatment, based on patient scores of scar thickness, and based on observer scores of scar thickness, surface appearance, general appearance and the revised and weighted sum score of all assessment items. ConclusionsThe long-term esthetic outcome of surgical treatment was superior to non-surgical treatment. These findings could facilitate the process of shared decision making. Level of EvidenceLevel III

Expanding Usage of Superior Pedicled Techniques with Reducing Resistance in the Pedicle by Lipoaspiration.

Despite the advantages of the superior pedicles in breast reduction, there are some limitations with this technique. The mobility of the pedicle may be augmented by liposuction in the pedicle area which may relieve tissue resistance and decrease pedicle compression in order to overcome circulation problems. In fact, the indications of breast reduction using superior pedicles may be expanded by liposuction in the pedicle area. The patients who underwent breast reduction with superior pedicle techniques between March 2014 and November 2020 and whose pedicle resistances were decreased by liposuction were included in this study. Internal breast morphology was classified into three groups based on the morphology of the periareolar tissues. Group 1 breasts were lipomatous, Group 2 breasts were lipo-glandular and Group 3 breasts were fibroglandular. During the short-term follow-up, the circulation of the nipple-areola complex (NAC) was evaluated both clinically and with an hand held Doppler device. The long-term aesthetic results were evaluated at the postoperative twelfth month with a visual analogue scale. One hundred eighty-nine patients with either Group 1 or Group 2 breasts were included in this study. The mean age of the patients was 38.3 years. The mean follow-up period was 31.7 months. Neither partial nor total NAC loss was observed and none of the patients had bottoming-out deformity. Liposuction to the pedicle area is an effective and reliable method that both reduces the resistance in the pedicle and overcomes the circulation problems in certain patient groups (groups 1 and 2), increases the mobilization of the pedicle, reduces the breast to the desired size and prevents bottoming-out in the long term and increases the use of superior pedicle techniques. According to our clinical results, it was demonstrated that pedicle vascular mapping with preoperative Doppler sonography was not necessary in these patients. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Outcomes, Concepts, Technical Refinements, and Challenges in the Microvascular Repair of Full-Thickness Nasal Defects.

Repair of full-thickness nasal defects may require distant tissue, when local or regional donors are inadequate or unavailable. The authors' microvascular designs, technical details, and complications using a radial forearm flap to restore nasal lining have been described in past publications. In this article, the authors review stages 2 through 5, using a forehead flap and rib grafts to resurface the nose and build a support framework. The authors examine their complications, long-term aesthetic and functional outcomes, clinical refinements, and continuing reconstructive challenges. Thirty-eight full-thickness nasal defects were repaired between 2001 and 2018. Records review identified the type and frequency of complications and their management. Patients were surveyed to determine their overall satisfaction, quality of life, restoration to a normal appearance, donor scars, the value of a late revision, airway function, and need for nasal stents. Postoperative results were classified by independent evaluators as very good, good, fair, and poor. Repair was completed in 35 of 38 patients. Fifty percent of patients returned an anonymous survey; 85% were very satisfied; 75% declared excellent, very good, or good breathing; 75% used stents never/rarely; 95% appeared normal; and 95% would recommend to other patients. An independent review classified the aesthetic results as 94% very good to good, 3% fair, and 3% poor. A folded radial forearm lining flap, a three-stage full-thickness forehead flap for cover, and a late revision can repair difficult nasal defects, as shown in a large series of patients with long-term follow-up. Therapeutic, IV.

Lower Eyelid Transcutaneous Blepharoplasty, Minimizing Complications and Correction of Lower Eyelid Malposition.

The periocular area is one of the first and most noticeable areas affected by ageing. Common signs of lower lid ageing include rhytids, prominent eye bags caused by prolapse of orbital fat pads, increased lid laxity leading to lid malpositioning, and deepening of tear troughs, all of which give a sunken aged appearance. Lower lid transcutaneous blepharoplasty can correct most of these problems providing excellent long-term aesthetic outcomes with minimal downtime for the patient. However, lower eyelid anatomy is complex, and a thorough understanding of its structure and function is needed to avoid serious complications such as lid malpositioning and blindness. In this review, we present the anatomy of the lower lid and useful surgical techniques to circumvent and avoid such complications.

Analyzing Patient Questions before and after Injectable Facial Aesthetic Procedures Using Machine Learning.

Injectable facial aesthetic procedures such as botulinum toxin chemodenervation and soft-tissue dermal fillers are generally associated with mild and limited adverse effects and high patient satisfaction rates.1 A variety of different factors may affect a patient’s satisfaction, including patient expectations, short-term and long-term aesthetic outcomes, and postoperative complications. Information regarding aesthetic surgical procedures on the Internet has increased rapidly as patients often turn to online resources before consultation with a physician.2 In this study, we analyzed the top viewed preoperative and postoperative patient questions on realself.com regarding injectable facial aesthetic procedures in an effort to better understand the patient concerns expressed on social media. The most viewed questions posted to realself.com about injectable facial aesthetic procedures including botulinum toxin and dermal fillers were collected automatically using a web crawler. Each question was categorized as preoperative or postoperative and then subcategorized based on the topic focus. A machine-learning workflow described by Tseng et al.3 was applied to analyze the questions further. Question text was preprocessed and then grouped via K-means clustering. The most representative questions in each cluster were then determined to produce the most common preoperative and postoperative questions. A total of 2000 questions were collected, including 1500 dermal filler and 500 botulinum toxin questions because of the greater representation of dermal fillers on the site. The overall number and frequency of questions with their primary categories are described in Table 1. There were 1012 preoperative questions (50.6%) and 988 postoperative questions (49.4%). The most common preoperative categories were eligibility for injectables (25.1%) and specific appearance desired (19.8%). The most common postoperative queries concerned appearance (60.6%) and behavior allowed or disallowed (14.6%). (See Appendix, Supplemental Digital Content 1, which shows the most common preoperative and postoperative questions determined by machine-learning analysis, https://links.lww.com/PRS/F604.) Table 1. - Frequency of Primary Question Categories Category No. of Questions Proportion of Questions Preoperative (n = 1012) Alternatives to injectables 23 2.27 Behavior allowed or disallowed 8 0.79 Best product for patient 138 13.64 Cost 39 3.85 Dosage 79 7.81 Duration of results 29 2.87 Eligibility for injectables 254 25.10 Injectables with other procedures or products 30 2.96 Injection location 43 4.25 Miscellaneous 25 2.47 Potential adverse effects 91 8.99 Specific appearance desired 200 19.76 Surgeon recommendation 21 2.08 Technical aspects of procedure 12 1.19 Who can perform injections 20 1.98 Postoperative (n = 988) Appearance 599 60.63 Behavior allowed or disallowed 144 14.57 Miscellaneous 8 0.81 Recovery duration 64 6.48 Reversing results 17 1.72 Symptoms after surgery 156 15.79 The most common preoperative question category was eligibility for injectable procedures, indicating the importance of a thorough individualized discussion based on the patient’s personal factors during the initial consultation.4 The next most common category was obtaining a specific appearance. Before surgery, physicians can increase patient satisfaction rates by encouraging patients to express their aesthetic goals and establishing realistic expectations for specific products.5 The most common postoperative question category concerned patients’ postprocedure appearance, underscoring the significance of thoroughly discussing with patients their anticipated appearance during preoperative planning. The next most common postoperative question category was behavior allowed or disallowed, demonstrating the importance of explaining to patients what behaviors should be done or not done, as well as the duration of time before patients can return to normal activities, to optimize results and improve patient satisfaction. These results were largely reflected by the most common preoperative and postoperative questions determined by machine learning. Our analysis using crowdsourced data from realself.com can provide insight into patient concerns regarding injectable facial aesthetic procedures. Our study revealed several common categories of questions patients have during their preoperative and postoperative course regarding injectable facial aesthetic procedures. The educational handout we developed can be applied to assist physicians in better addressing patient questions and improving patient satisfaction. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

Craniotomy Burr Hole Covers: A Comparative Study of Biomechanical, Radiological, and Aesthetic Outcomes Using 3 Different Plug Materials.

Burr holes in the cranial vault are usually made during trephination for craniotomy or drainage of chronic subdural hematomas. The resulting cranial defect might bring to unsatisfactory esthetic outcome. In the current study the authors report clinical data regarding a cohort of patients who were treated with 3 different types of burr hole covers; autologous bone dust from skull trephination, and 2 different types of cylindric plug made out of porous hydroxyapatite in order to evaluate medium and long-term esthetic and radiological outcomes. Twenty patients were consecutively enrolled in the study and in each patient all 3 types of materials were used to cover different holes. Clinical and radiological outcomes at 6 and 12 months, were analyzed for all 3 types of plugs in terms of thickness of the graft coaptation of margins, remodeling, fractures, mobilization, and contour irregularities. In all craniotomy holes filled with autologous bone dust the authors have observed partial or complete bone reabsorption at 1 year and in 60% of the cases a visible and palpable cranial vault contour irregularity was reported. Both types of bone substitutes gave satisfactory results, comparable to autologous bone dust at 6 months and superior at 12 months, especially in terms of thickness and esthetic appearance. Hydroxyapatite plugs have shown better esthetic and biomechanical results and higher patients' satisfaction compared to autologous bone dust while not giving any additional complications.

Aesthetic Outcome of Propranolol vs Atenolol Treatment of Children with Infantile Haemangioma.

Infantile haemangiomas are common benign tumours of infancy, which can be treated effectively with beta-blockers such as propranolol and atenolol. Different types of beta-blockers may result in different long-term aesthetic outcomes. This study evaluated the difference in long-term aesthetic outcomes between infantile haemangiomas treated with either propranolol or atenolol, including the perspective of physicians, parents, and children. Children, aged ≥6 years, treated with propranolol or atenolol for infantile haemangioma during infancy, participated in this 2-centre cross-sectional study. The primary endpoint was change in appearance of the infantile haemangioma from pre-treatment to follow-up, using a physician-rated visual analogue scale (VAS). Secondary outcomes were the Patient Observer Scar Assessment Scale (physician- and parent-rated) and a VAS (child-rated), assessing the residual lesion. In total, 103 children (35 treated with propranolol, 68 with atenolol) were analysed. No differences were found between children treated with propranolol and children treated with atenolol on physician-rated VAS (p = 0.10) or any secondary outcomes. Physicians indicated a large aesthetic improve-ment from pre- treatment to follow-up. Physicians, parents and children were positive about the current state of the residual lesion. Minor sequelae were common (86%). These results, in combination with the favourable safety profile of atenolol, should be considered when choosing beta-blocker treatment for infantile haemangioma.

Smile makeover treatments.

The demand for aesthetic smile makeover treatments is increasing, especially with the rise in social media use. Historically, healthy tooth structure was sacrificed in order to achieve rapid results but this would invariably lead to compromise of the occlusion and a less-than-ideal result.Multi-disciplinary treatment planning, including the use of orthodontic treatment, is now routinely used in order to achieve optimal results. This paper aims to highlight the importance of a combined orthodontic-restorative planning process to allow a long-term aesthetic and functional result for our patients.

Assessment and aesthetic impact of a long-term vertical discrepancy between the single anterior maxillary implant-supported crown and adjacent teeth: A retrospective cross-sectional study.

ObjectivesTo assess the vertical discrepancy between implant‐supported crowns and adjacent teeth in the maxillary anterior region at least 8 years after implant placement and to evaluate the influence of this discrepancy on the level of aesthetic awareness of patients.Material and MethodsThe sample consisted of 23 adult individuals evaluated at least 8 years after placement of an implant‐supported central or lateral single tooth‐fixed partial denture. Patients had their crowns delivered at a mean age of 47.8 years (range: 18.9–65.8). The vertical discrepancy was measured by comparing initial and follow‐up periapical radiographs using the implant as a stable structure. The patients' satisfaction with their anterior teeth condition and awareness of the possible vertical problem were evaluated using a questionnaire. The aesthetic outcome and patient awareness were related to the objective measurement of the vertical discrepancy.ResultsThe implant showed a mean infraocclusion of 0.62 mm (range: 0.15–1.63 mm). The vertical discrepancy was not associated with the patient's gender, age at implant placement, and duration between initial and recall radiograph. Patients were generally satisfied with the long‐term aesthetic outcome of their smile (mean: 3.9 on a 1–5 scale, 1 unsatisfied, and 5 completely satisfied). Out of 23 patients, 8 noticed the implant infraocclusion and 4 of them found the problem severe enough to be willing to improve the situation. The amount of vertical discrepancy was not associated with the patient's perception of the discrepancy and the pink aesthetic score.ConclusionImplant‐supported crowns in the anterior region may suffer infraocclusion over the long term. The amount of vertical discrepancy was not dependent on the gender and age of the patient. Patients were generally satisfied with the aesthetic result of the restoration. The amount of vertical discrepancy, at least in the range we have measured, was not perceived by the patients as a complication.

Machine Learning in Metopic Craniosynostosis: Does Phenotypic Severity Predict Long-Term Esthetic Outcome?

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

Inferiorly Directed Posterior Cranial Vault Distraction for Treatment of Chiari Malformations.

The authors present a case series of patients with Chiari I malformations treated with distraction osteogenesis of the posterior cranial vault, utilizing a vertical distraction vector for appropriate cranial vault expansion while mitigating the risks of scaphocephaly and cerebellar ptosis. Patients with syndromic and nonsyndromic Chiari I malformations treated with vertical-vector distraction osteogenesis of the posterior cranial vault were identified from 2008 to 2014. Demographics, preoperative and postoperative clinical symptoms, and perioperative details were assessed. Long-term esthetic outcomes, complications, and symptomatic improvement were evaluated in conjunction with neurosurgery. Nine patients were identified. Five had known syndromes, 2 likely had unidentified syndromes, and 2 were nonsyndromic. Seven had prior Chiari-related surgeries. Most presented with hydrocephalus, motor symptoms, and developmental delay. Operatively, 2 to 3 internal distraction fixators were applied such that the vector of distraction was along a cephalad-caudad axis. Devices were activated on postoperative day 5 and distracted 1mm per day. Three postoperative complications were found within the first 3 months which included a dislodged distraction arm, a device extrusion, and a local cellulitis. No complications affected the clinical outcome. Radiographic follow-up showed good bone formation, decompression of the posterior fossa, improved cerebrospinal fluid flow, and no cerebellar ptosis. Neurological surveillance showed improvement in intracranial pressure, hydrocephalus, motor symptoms, and behavioral problems. The authors have presented 9 patients with Chiari I malformations treated with distraction osteogenesis, along with a novel technique to safely and effectively expand the posterior fossa while minimizing the risk of cerebellar ptosis. Level II (prognostic/risk studies).

18. Machine Learning in Metopic Craniosynostosis: Does Phenotypic Severity Predict Long-term Aesthetic Outcome?

18. Machine Learning in Metopic Craniosynostosis: Does Phenotypic Severity Predict Long-term Aesthetic Outcome?

Endoscopic strip craniectomy with orthotic helmeting for safe improvement of head growth in children with Apert syndrome.

Bilateral coronal craniosynostosis in Apert syndrome is traditionally managed with open cranial vault remodeling procedures like fronto-orbital advancement (FOA). However, as minimally invasive procedures gain popularity, limited data exist to determine their efficacy in this syndromic population. This study examines whether endoscopic strip craniectomy (ESC) is inferior to FOA in correcting head growth in patients with Apert syndrome. The authors conducted a retrospective review of children with Apert syndrome over a 23-year period. Postoperative head circumferences until 24 months of age were compared for patients treated with ESC versus FOA by using normative growth curves. Intraoperative and postoperative morbidity was compared between groups. The median postoperative follow-up for the FOA (n = 14) and ESC (n = 16) groups was 40 and 28.5 months, the median age at operation was 12.8 and 2.7 months, and the median operative time was 285 and 65 minutes, respectively (p < 0.001). The FOA group had significantly higher rates of blood transfusion, ICU admission, and longer hospital length of stay (p < 0.01). There were no statistically significant differences in premature reossification rates, complications, need for further procedures, or complaints of asymmetry. Compared to normative growth curves, all patients in both groups had head circumferences comparable to or above the 85th percentile at last follow-up. Children with Apert syndrome and bilateral coronal craniosynostosis treated with ESC experience early normalization of head growth and cephalic index that is not inferior to those treated with FOA. Longer-term assessments are needed to determine long-term aesthetic results and the correlation between head growth and neurocognitive development in this population.

Primary Teeth Supported Fixed Prosthesis-A Predictable Treatment Alternative.

Background: Individuals with tooth agenesis often present a significant clinical challenge for dental practitioners. This retrospective study evaluated clinical and radiological long-term functional and esthetic outcomes following restoration using primary teeth to support fixed all-ceramic prosthesis in patients with teeth agenesis. Methods: Patients with teeth agenesis and at least one year follow-up were included. Examinations included panoramic X-ray, clinical examination and family history records. Only primary teeth without permanent teeth underneath were chosen. All ceramic fixed restorations were used. All data were collected from patient files. Outcome parameters included: restoration parameters (restoration survival, restoration fractures, restoration detachment, restoration replacement, and secondary caries), plaque index, and gingival index. Results: The study included 58 porcelain restorations inserted in 25 individuals; mean age 12 ± 2.1 years (range 10–19 years); mean number of missing teeth 12.3 ± 9 (range 6–12). Mean follow-up 48 ± 6 months (range 12–60 months). All restorations survived up to last follow-up, rendering a survival rate of 100%. Restorations outcome—porcelain chipping (9%), detachment (2%), no restoration replacement nor secondary caries, mean gingival index—0.7 ± 0.5 and mean plaque index—0.9 ± 0.3. Conclusions: In tooth agenesis, restoration using primary teeth to support fixed all-ceramic prosthesis is a viable treatment alternative.