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OBJECTIVE Outcomes research on unilateral coronal synostosis is mostly limited to the early postoperative period. This study examines facial asymmetry, desire for revision, and patient-reported outcomes at school age in children who received either endoscopic strip craniectomy with helmet therapy or fronto-orbital advancement (open repair). METHODS Patients with repaired unilateral coronal synostosis born between 2000 and 2017, with 3D photographs taken when they were between 3.5 and 8 years of age, were eligible for study inclusion. Three pairs of bilateral linear measurements and two angular measurements were taken. Parent- and physician-reported desire for revision and patient-reported outcomes (Patient-Reported Outcomes Measurement Information System cognitive function and Quality of Life in Neurological Disorders stigma scores) were collected from patient charts. RESULTS Thirty-five patients qualified, including 25 with open repair and 10 with endoscopic repair. The median patient ages at repair were 3 months and 8 months in the endoscopic and open groups, respectively. The average ages at final 3D photography were 5.8 years and 5.5 years in the endoscopic and open groups, respectively. Digital anthropometry revealed no significant differences in measures of facial asymmetry between the repair groups (p ≥ 0.211). Midface depth (tragion to subnasale) was significantly less symmetric at school age than other linear measures (F(2,102) = 9.14, p < 0.001). Forehead asymmetry was significantly associated with parent- and physician-reported desire for revision (p ≤ 0.006). No significant associations were found between physical asymmetry and patient-reported stigma or cognitive function (p > 0.046, Holm-Bonferroni correction). CONCLUSIONS Children who underwent open or endoscopic repair for unilateral coronal synostosis have comparable facial symmetry at school age, but midface depth remains highly asymmetrical in both groups. Forehead asymmetry at school age correlates with parent- and physician-reported desire for revision.

Objective To examine the frequency of autologous and alloplastic ear reconstructions for patients with microtia in the United States, and describe post-index procedure rates associated with each method. Design Retrospective cohort study. Setting Claims data from 500 + hospitals from IBM® MarketScan® Commercial and Multi-State Medicaid databases. Patients/Participants A total of 649 patients aged 1 to 17 years with International Classification of Diseases, ninth/tenth revision (ICD-9/10) diagnoses for microtia, congenital absence of the ear, or hemifacial microsomia. Interventions Alloplastic or autologous ear reconstruction between 2006 and 2018. Main Outcome Measure Post-index procedures performed within 1 year following the index repair, analyzed across the study period and separately for each half of the study period (2006-2012, 2012-2018). Results A total of 486 (75%) qualifying patients received autologous and 163 (25%) received alloplastic reconstruction. Secondary procedure rates were significantly higher in the autologous group at 90 days ( P = .034), 180 days ( P < .001), and at 365 days ( P < .001). Alloplastic reconstruction accounted for 23.2% of reconstructions in the first half of the study period compared with 26.7% in the second half ( P = .319). One-year secondary procedure rates in the autologous group were not significantly different between both halves of the study period (69.7% vs 67.1%, P = .558), but were significantly lower in the second half for the alloplastic group (44.9% vs 20.2%, P = .001). Conclusions In these databases, autologous reconstruction is more common than alloplastic reconstruction. Autologous reconstruction is staged, with most undergoing a secondary procedure between 3 months and 1 year postoperatively. Secondary procedure rates decreased over time in patients undergoing alloplastic reconstruction.

ver the past 40 years, the incidence of vestibular schwannoma (VS) has been increasing, according to epidemiologic studies in Denmark as well as a population-based study in Olmsted County, Minnesota. [1][2][3] This change is likely explained by increased access to health care and advances in diagnostic technology. Once discovered, these tumors require careful decision-making about treatment options given the slow rate of tumor growth and morbidity associated with treatment. The decision to pursue surgical management instead of radiotherapy or active surveillance is multifactorial and largely depends on features including age, comorbidity, initial tumor size, rate of growth, hearing status, and patient preference. The mortality rate in patients sur-gically managed is very low and affords the opportunity to shift focus to other relevant clinical outcomes, such as recurrencefree survival, growth-free survival, surgical complications, facial nerve functioning, hearing preservation, and quality of life. [4][5][6] Patient symptom presentation is a fundamental characteristic of the patient with VS and likely relates to the pathophysiologic characteristics of the tumor. Symptoms at presentation include cardinal symptoms, such as hearing loss, vestibular dysfunction, facial numbness, tinnitus, and headaches. Despite their clinical relevance, symptoms at presentation have not been thoroughly investigated in the context of clinical outcomes. Earlier investigations have described the IMPORTANCE Vestibular schwannomas have long been treated as a homogeneous entity. Clinical symptoms at presentation may help elucidate the underlaying pathophysiologic characteristics of tumor subtypes. Describing the heterogeneity of these benign tumors may assist in predicting clinical outcomes associated with their treatment.OBJECTIVE To create a tumor staging system that incorporates symptoms at presentation and tumor size to predict severe surgical complications. DESIGN, SETTING, AND PARTICIPANTSA retrospective cohort of patients at a single-center tertiary referral center from January 1, 1998, to October 13, 2020, was studied. Patients diagnosed with sporadic vestibular schwannoma surgically treated at Washington University in St Louis, Missouri, were included. MAIN OUTCOMES AND MEASURESSevere surgical complications within 30 days of surgery as determined by the Clavien-Dindo classification system. Patients experiencing a complication of grade 3 or above were determined to have a severe complication. RESULTSOf 185 patients evaluated, 40 (22%) had severe postoperative complications. Twenty of the 40 patients (50%) were women; mean (SD) age was 46 (13) years. Patients with severe complications were more likely to have large tumors (>2.5 cm in largest diameter), vestibular symptoms, and recent hearing loss at presentation. Using conjunctive consolidation, a 4-stage clinical severity staging system that incorporates clinical symptoms and tumor size at presentation was created to predict severe complications. The clinical severity staging syste...

BACKGROUND: Successful intraoperative microvascular anastomoses are essential for deep inferior epigastric perforator (DIEP) flap survival. This study identifies factors associated with anastomotic failure during DIEP flap reconstruction and analyzes the impact of these anastomotic failures on post-operative patient outcomes and surgical costs. METHODS: A retrospective cohort study was conducted of patients undergoing DIEP flap reconstruction at two high-volume tertiary care centers from January 2017 to December 2020. Patient demographics, intraoperative management, anastomotic technique, and post-operative outcomes were collected. Data were analyzed using Student’s t-tests, chi-square analysis, and multivariate logistic regression. RESULTS: Of the 270 patients included in our study (mean age 52, majority Caucasian [74.5%]), intraoperative anastomotic failure occurred in 26 (9.6%) patients. Increased number of circulating nurses increased risk of anastomotic failure (Odds Ratio (OR) 1.02, 95% Confidence Interval (CI) 1.00-1.03, P<0.05). Presence of a junior resident also increased risk of anastomotic failure (OR 2.42, 95% CI 1.01-6.34, P<0.05). Increased surgeon years in practice was associated with decreased failures (OR 0.12, CI 0.02-0.60, P<0.05). Intraoperative anastomotic failure increased the odds of post-operative hematoma (OR 8.85, CI 1.35-59.1, P<0.05) and was associated with longer operating room times (bilateral DIEP: 2.25 hours longer, P<0.05), longer hospital stays (2.2 days longer, P<0.05), and higher total operating room cost ($28,529.50 versus $37,272.80, P<0.05). CONCLUSION: Intraoperative anastomotic failures during DIEP flap reconstruction are associated with longer, more expensive cases and increased rates of post-operative complications. Presence of increased numbers of circulators and junior residents was associated with increased risk of anastomotic failure. Future research is necessary to develop practice guidelines for optimizing patient and surgical factors for intraoperative anastomotic success.