To identify skull-base growth patterns in Crouzon syndrome, we hypothesized premature minor suture fusion restricts occipital bone development, secondarily limiting foramen magnum expansion. Skull-base suture closure degree and cephalometric measurements were retrospectively studied using preoperative computed tomography (CT) scans and multiple linear regression analysis. Evaluation of multi-institutional CT images and 3D reconstructions from Wake Forest’s Craniofacial Imaging Database (WFCID). Sixty preoperative patients with Crouzon syndrome under 12 years-old were selected from WFCID. The control group included 60 age- and sex-matched patients without craniosynostosis or prior craniofacial surgery. None 2D and 3D cephalometric measurements. 3D volumetric evaluation of the basioccipital, exo-occipital, and supraoccipital bones revealed decreased growth in Crouzon syndrome, attributed solely to premature minor suture fusion. Spheno-occipital (β = −398.75; P < .05) and petrous-occipital (β = −727.5; P < .001) suture fusion reduced growth of the basioccipital bone; lambdoid suture (β = −14 723.1; P < .001) and occipitomastoid synchondrosis (β = −16 419.3; P < .001) fusion reduced growth of the supraoccipital bone; and petrous-occipital suture (β = −673.3; P < .001), anterior intraoccipital synchondrosis (β = −368.47; P < .05), and posterior intraoccipital synchondrosis (β = −6261.42; P < .01) fusion reduced growth of the exo-occipital bone. Foramen magnum morphology is restricted in Crouzon syndrome but not directly caused by early suture fusion. Premature minor suture fusion restricts the volume of developing occipital bones providing a plausible mechanism for observed foramen magnum anomalies.

Background: Frontal bossing is a prominent forehead feature common in sagittal craniosynostosis (SC). Assessment of severity of frontal bossing is limited by the use of serial CT imaging or complex computer programing. Three-dimensional measurements of cranial surface morphology provide a radiation-free alternative for assessing cranial shape. This study describes the creation of a frontal bossing index (FBI), a novel tool using surface morphology to assess the frontal severity in patients with SC. Methods: Surface imaging from CT scans or 3D photographs of 359 individuals with sagittal craniosynostosis and 224 normocephalic individuals were compared to identify differences in frontal morphology. Cartesian grids were created on each individual’s surface mesh using equidistant axial and sagittal planes yielding 33 unique points of intersection on the forehead. Area under the curve (AUC) analyses were performed to identify frontal points with the greatest discrepancy between groups. Results: All points in the SC population had significantly greater protrusion than corresponding points in the control group. The largest differences were located in the superior lateral regions. Combining the superior- and lateral-most points gave the maximal AUC (0.9707) and was therefore selected to generate the frontal bossing index (FBI). The FBI distinguished between the 2 groups with a sensitivity of 93.5% and specificity of 92.9%. Conclusions: The frontal bossing index is a useful tool for evaluating the severity of the frontal region in patients with SC, comparing outcomes of differing surgical techniques, and tracking frontal changes in individuals over time, without the need for radiation.

Introduction: Residency programs and applicants were forced to hold virtual interviews during the 2020–2021 application cycle. Inability to evaluate a program and/or applicant in person has intangible drawbacks. However, there are obvious advantages: cost, convenience, and comfort. Do the advantages outweigh the disadvantages? How have applicant behaviors changed to learn about programs in a virtual-only interview process? Methods: A survey was distributed to 302 applicants to a single plastic surgery residency program during the 2020 application cycle. Demographics, social media presence and utilization, and experience with the virtual application and interview process were analyzed. A 2018 survey from our institution was compared with a subset of questions for longitudinal analysis. Results: Seventy-six respondents (25.2%) completed the survey. Most applicants (88.2%) spent less than $1000 during the interview and application cycle. Over half (56.6%) did not receive letters of recommendation from outside their home program. A significant minority (27.6%) of applicants attended more than one interview in a single day. Compared to 2018, applicants in 2021 were significantly more likely to access alternative digital resources (forums/discussion boards, social media, and podcasts) when learning about programs. Average number of interviews remains in the range of pre-COVID studies, but the percentage of interviews attended increased. Conclusions: Applicants spent substantially less money on interviews and relied on alternative digital sources to learn about residency programs. This study objectively quantifies the advantages of virtual interviews. Disadvantages include inability to assess “fit” and lack of nonverbal communication.

remature fusion of the sagittal suture results in inhibited perpendicular biparietal expansion and parallel anterior and posterior compensatory elongation. 1 The resulting head shape is described by a classic dysmorphology: scaphocephaly. 2 Attempts to measure this abnormality globally have led to the widespread adoption of the cephalic index and its derivatives. 3,4 The cephalic index is limited by its 2-dimensionality and an inability to regionalize dysmorphology. [4][5][6][7][8][9] For example, 2 patients with sagittal craniosynostosis (SC) and identical cephalic indices, as depicted in Figure 1, may have vastly different shape abnormalities (eg, either predominance of frontal bossing or an occipital bullet), each potentially necessitating different surgical approaches. The recently described frontal bossing index (FBI; Fig. 2, above) and occipital Background: The recently described frontal bossing index (FBI) and occipital bullet index (OBI) allow for quantification of scaphocephaly. A similar index examining biparietal narrowing has not been described. Addition of such an index measuring width would allow for direct evaluation of the primary growth restriction in sagittal craniosynostosis and the formation of an optimized global width/length measure. Methods: Computed tomography scans and three-dimensional photographs were used to recreate scalp surface anatomy. Equidistant axial, sagittal, and coronal planes were overlaid, creating a Cartesian grid. Points of intersection were analyzed for population trends in biparietal width. Using the most descriptive point coupled with the sellion protrusion to control for head size, the vertex narrowing index is formed. By combining this index with the FBI and OBI, the scaphocephalic index (SCI) is created as a tailored width/length measure. Results: Using 221 controls and 360 individuals with sagittal craniosynostosis, the greatest difference occurred superiorly and posteriorly at a point 70% of the head's height and 60% of the head's length. This point had an area under the curve of 0.97 and sensitivity and specificity of 91.2% and 92.2%, respectively. The SCI has an area under the curve of 0.9997, sensitivity and specificity greater than 99%, and interrater reliability of 0.995. The correlation coefficient between computed tomography imaging and three-dimensional photography was 0.96. Conclusions: The vertex narrowing index, FBI, and OBI evaluate regional severity, while the SCI is able to describe global morphology in patients with sagittal craniosynostosis. These measures allow for superior diagnosis, surgical planning, and outcome assessment, independent of radiation. (Plast.