Background: The purpose of this study was to investigate the financial implications of demographic and socioeconomic factors upon the cost of surgical procedures for craniosynostosis. Methods: A retrospective cohort study was conducted of admissions for craniosynostosis surgery in the United States from 2015 through 2020 using the Pediatric Health Information System. Patient demographics, case volume, and surgical approach were analyzed in context of hospital charges. Results: During the study interval, 3869 patients were admitted for surgery for craniosynostosis. In multivariate regression accounting for demographic and socioeconomic factors, hospital admission charges were significantly higher in patients with longer hospital length of stay (P < 0.001), longer ICU length of stay (P < 0.001), living in an underserved area (P = 0.046), preoperative risk factors (P = 0.016), and those undergoing open procedures (P < 0.001); hospital admission charges were significantly lower in patients with White race (P = 0.020) and those treated at high-volume centers (P < 0.001). In multivariate regression, ICU length of stay was significantly higher in patients with preoperative risk factors (P < 0.001), undergoing open procedures (P < 0.001), government insurance (P = 0.018), and not treated at high-volume centers (P = 0.005). There were significant differences in admission charges (P < 0.001), charge-to-cost ratios (P < 0.001), and likelihood of being treated at high-volume craniofacial centers (P < 0.001) across geographic regions of the country. Conclusions: In the United States, there is significant sociodemographic variability in charges for craniosynostosis care, with increased hospital charges independently associated with non-White race, preoperative risk factors, and living in an underserved area.

OBJECTIVE Children with multiple prematurely fused cranial sutures and those undergoing surgical correction later in life appear to experience worse neurocognitive outcomes, but it is unclear whether higher intracranial pressure (ICP) is implicated in this process. The purpose of this study was to elucidate the effect of age at intervention and number of involved cranial sutures on ICP, as well as to assess which cranial suture closure may be more associated with elevated ICP. METHODS The prospective craniofacial database at the authors’ institution was queried for patients undergoing initial corrective surgery for craniosynostosis in whom intraoperative measurement of ICP was obtained prior to craniectomy. Age, involved sutures, and syndromic status were analyzed in the context of measured ICP by using multiple linear regression. RESULTS Fifty patients met the inclusion criteria. Age at procedure (p = 0.028, β = +0.060 mm Hg/month) and multiple-suture involvement (p = 0.010, β = +4.175 mm Hg if multisuture) were both significantly implicated in elevated ICP. The actual number of major sutures involved was significantly correlated to ICP (p = 0.001; β = +1.687 mm Hg/suture). Among patients with single-suture involvement, there was an overall significant difference of median ICP across the suture types (p = 0.008), with metopic having the lowest (12.5 mm Hg) and sagittal having the highest (16.0 mm Hg). Patients with multiple-suture involvement had significantly higher ICP (p = 0.003; 18.5 mm Hg). Patients with craniofacial syndromes were 79.3 times more likely to have multiple-suture involvement (p < 0.001). Corrective surgery for craniosynostosis demonstrated significant intraoperative reduction of elevated ICP (all p < 0.050). CONCLUSIONS Syndromic status, older age at intervention for craniosynostosis, and multiple premature fusion of cranial sutures were associated with significantly higher ICP.

cantholysis can be performed to reduce intraorbital pressure and to minimize the risk of vision loss. It is then characterized as a medical emergency, because it can lead to blindness or other life-threatening complications if not treated promptly. [21][22][23] Therefore, the clinical presentation of our patient demanded an early surgical intervention.It is not clear whether SARS-CoV-2 itself is a contributing factor to the pathogenesis in these cases. However, the time of onset and the absence of previous symptoms of chronic sinus disease raises the possibility that congestion of the upper secondary airway by COVID-19 contributed to impaired mucociliary clearance, sinus obstruction, and secondary orbital bacterial infection. Health professionals involved in the care of COVID 19 cases should be aware of this unusual presentation.

The purpose of this study was to review our institution's experience using helmet molding therapy in children with isolated non-syndromic sagittal craniosynostosis before placement of cranial springs and provide objective measurements of craniometric changes to help determine its role in treatment.Patients who underwent preoperative helmet molding therapy for sagittal craniosynostosis were retrospectively reviewed. Three-dimensional surface tomography scans were used to measure head circumference, cranial width, cranial length, cranial index (CI), and cranial vault asymmetry.Seventeen patients underwent orthotic helmeting therapy before spring mediated cranial vault expansion. Patients spent a median of 48 days (interquartile range [IQR] 32, 57) in preoperative orthotic helmeting therapy. There were increases in both cranial width and length post-helmeting (median: 107.5 mm [IQR 104.8, 110.4] versus 115.6 mm [IQR 114.5, 119.3]; P < 0.001) (median: 152.8 mm [IQR 149.2, 154.9] versus 156.8 mm [IQR 155.0, 161.5]; P < 0.001), respectively. There was a greater increase in cranial width (P ¼ 0.015). Consequently, patients' CI improved after preoperative helmeting (median: 0.702 [IQR 0.693, 0.717] versus 0.739 [0.711, 0.752]; P < 0.001). There was no evidence of growth restriction from helmeting (pre-helmeting Head circumference [HC]: median 96.8 percentile [IQR 90.6, 99.9] versus post-helmeting HC: 98.7 percentile [IQR 94.7, 99.8]; P ¼ 0.109).Preoperative helmeting in patients with non-syndromic isolated sagittal craniosynostosis can be used to improve CI before surgical correction. Significant benefits can be achieved in shorter preoperative helmeting durations than previously reported with no evidence of cranial growth restriction, which supports its feasibility and utility in children undergoing spring mediated cranial vault expansion.

Objective The purpose of this study was to utilize a multicenter dataset to elucidate whether socioeconomic factors were associated with access to cleft lip surgery, treatment by higher-volume providers, and family choice for higher-volume centers. Design Retrospective cohort study. Setting Hospitals participating in the Pediatric Health Information System. Patients Primary cleft lip repair performed in the United States between 2010 and 2020. Outcomes Travel distance, hospital volume, hospital choice. Results During the study interval, 8954 patients underwent unilateral (78.4%, n  =  7021) or bilateral (21.6%, n  =  1933) primary cleft lip repair. Patients with unilateral cleft lip were repaired significantly earlier if they were White ( P < .001) and significantly later if they lived in an urban community ( P  =  .043). Similarly, patients with bilateral cleft lip were repaired significantly earlier if they were White ( P < .001). Patients from above-median income households ( P  =  .011) and living in urban communities ( P < .001) were significantly more likely to be treated at high-volume hospitals, whereas those living in underserved communities ( P < .001) were significantly less likely to be treated at high-volume hospitals. White patients were significantly more likely to be treated by high-volume surgeons ( P < .001). Patients with White race were significantly more likely to choose a higher-volume hospital than the one most locally available ( P < .001). Conclusions Patients with White race are more likely to travel farther and be treated by high-volume surgeons although at smaller hospitals. Patients from underserved areas travel significantly farther for cleft care and are treated at lower-volume hospitals. Patients in urban communities have shorter travel distances and are treated at higher-volume hospitals.

Background: Facial proportionality and symmetry are positively associated with perceived levels of facial attractiveness. Objective: The aims of this study were to confirm and extend the association of proportionality with perceived levels of attractiveness and character traits and determine differences in attractiveness and character ratings between "anomalous" and "typical" faces using a large dataset. Methods: Ratings of 597 unique individuals from the Chicago Face Database were used. A formula was developed as a proxy of relative horizontal proportionality, where a proportionality score of "0" indicated perfect proportionality and more negative scores indicated less proportionality. Faces were categorized as "anomalous" or "typical" by 2 independent reviewers based on physical features. Results: Across the ratings for all faces, Spearman correlations revealed greater proportionality was associated with attractiveness (ρ = 0.292, P < 0.001) and trustworthiness (ρ = 0.193, P < 0.001), while lesser proportionality was associated with impressions of anger (ρ = 0.132, P = 0.001), dominance (ρ = 0.259, P < 0.001), and threateningness (ρ = 0.234, P < 0.001). Mann-Whitney U tests revealed the typical cohort had significantly higher levels of proportionality (-13.98 versus -15.14, P = 0.030) and ratings of attractiveness (3.39 versus 2.99, P < 0.001) and trustworthiness (3.48 versus 3.35, P < 0.001). Conclusions: This study demonstrated that facial proportionality is not only significantly associated with higher ratings of attractiveness, but also associated with judgements of trustworthiness.Proportionality plays a role in evoking negative attributions of personality characteristics to people with facial anomalies.

Purpose: Mandibular distraction osteogenesis (MDO) effectively treats tongue-based airway obstruction (TBAO) in micrognathic patients with Robin Sequence. Mandibular distraction osteogenesis may also address TBAO in certain nonmicrognathic patients who have severe obstructive apnea, although there is no current literature to guide MDO use in these atypical patients. This study describes outcomes of MDO in a series of patients with TBAO without micrognathia. Methods: Patients who underwent MDO for TBAO from 2013-20 were reviewed, and patients with micrognathia were excluded. Study subjects received baseline/ follow up polysomnography. Polysomnography variables, including Obstructive Apnea Hypopnea Index, oxyhemoglobin saturation nadir (SpO 2 nadir), percent sleep time end tidal CO 2 greater than 50 mm Hg (%ETCO 2 > 50), and respiratoryrelated arousals were compared before and after MDO. Demographics, syndromic/cleft palate status, airway anomalies, respiratory support, and feeding outcomes were collected. Results: One hundred and twenty-four patients underwent MDO during this study period; 5 were nonmicrognathic and included in analysis. Sixty percent (n = 3) of the cohort was syndromic: 1 patient each had Trisomy 9, Beckwith Wiedemann syndrome, and duplicated pituitary gland plus syndrome. Forty percent (n = 2) of patients had a cleft palate, 60% (n = 3) had laryngomalacia, and 40% had tracheomalacia. Median (range) age at MDO was 53 days (47-167 days), and median length of distraction was 16 mm (14-20 mm). After MDO, median Obstructive Apnea Hypopnea Index decreased from x̃= 60.7/h (11.6-109.4) to x̃= 5.3/h (3.5-19.3) (P = 0.034). SpO 2 nadir increased (69% [58][59][60][61][62][63][64][65][66][67][68][69][70][71][72][73][74] to 85% [80-88], P = 0.011), and median %ETCO 2 > 50 mm Hg decreased (5.8% [5.2-30.1] to 0.0% [0.0-1.3], P ≤ 0.043). Continuous positive airway pressure was used by all patients immediately after MDO, and at 6 months postoperatively, 1 patient remained on continuous positive airway pressure and 1 patient required supplemental oxygen. At last follow up, no patients had significant residual airway obstruction or required a tracheostomy. Conclusions: Mandibular distraction osteogenesis can effectively treat severe TBAO in some patients without micrognathia that would otherwise be candidates for tracheostomy. When used in select patients, MDO significantly improves obstructive sleep apnea and reduces need for ventilatory support, although feeding support is still needed in most patients at 6 months. Further study in a larger cohort will help identify appropriate candidates for MDO and characterize outcomes of unique patient populations.

Objective: Ideal timing of palatoplasty continues to be debated given that early repair is thought to improve speech and hearing, whereas delayed repair is associated with less midface growth disruption. The purpose of this study is to elucidate optimal timing of palatoplasty in patients with comorbidities to mitigate perioperative complications. Design: Retrospective cohort study. Setting: Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program Pediatric. Patients: Palatoplasty performed for children younger than the age of 2 years with comorbidities. Outcomes: Medical/surgical complications, reoperations, readmissions within 30 days postoperatively. Results: Patients with comorbidities having Veau I or II cleft palate were associated with significantly decreased risk of adverse events when performing palatoplasty after 125 days of age ( P < .001). Patients with comorbidities having Veau III cleft palate were associated with significantly decreased risk of adverse events when performing palatoplasty after 225 days of age ( P = .010). Patients with comorbidities having Veau IV cleft palate were associated with significantly decreased risk of adverse events when performing palatoplasty after 250 days of age ( P = .045). Conclusions: Infants with comorbidities having progressively increasing Veau classification demonstrate unique age-dependent perioperative thresholds, such that more extensive phenotypes are associated with better perioperative outcomes with older age at time of cleft palate repair.