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Recent studies suggest that orthognathic surgery can improve facial age and personality profiling. The authors expand on these findings by assessing the role of patient facial profile and sociodemographics on perceived changes following surgery.Preoperative and postoperative images of 65 patients operated on by a single surgeon were randomly assorted and rated by 30 respondents. Patient facial profiles were categorized as convex, concave, or straight. Paired and unpaired t tests were used to assess differences preoperatively and postoperatively. Multivariate regression and post hoc receiver operating characteristic curve analyses were used to quantify the influence of various patient factors.Significant decreases in perceived age were seen following orthognathic surgery overall (-1.31 years; p0.01) and in the straight (-1.10 years; p = 0.02) and convex (-1.80 years; p ≤ 0.01) subgroups. After controlling for patient sociodemographics, there were no significant differences in age change based on facial profile. Older age at the time of surgery was independently associated with greater perceived age changes ( p = 0.04); older patients (26.5 years, determined by receiver operating characteristic curve) experienced greater net decreases in perceived age in comparison to younger patients (-2.0 years versus -1.2 years; p0.01). Improvements were seen in overall attractiveness ( p0.01) and in each tested personality characteristic following surgery ( p0.01). These differences were not significantly associated with different patient sociodemographics or facial profile.The authors' data add to the growing base of evidence that orthognathic surgery improves patient-perceived age and personality. Significant decreases in perceived age are more likely to be gained by patients undergoing surgery at an older age.Risk, II.

PURPOSE The final result following orthognathic surgery may be hidden for months due to postoperative swelling. However, no substantial evidence supports this time estimate. Our study aims to three-dimensionally quantify volumetric changes in facial edema following triple-jaw surgery. MATERIALS AND METHODS This was a retrospective, three-dimensional (3D) study of patients who underwent primary orthognathic triple jaw surgery (Le Fort I, Bilateral Sagittal Split Osteotomy (BSSO), and osseous genioplasty) by the senior author (DMS). Vectra 3D Software (Canfield, Fairfield, NJ) was used to assess and quantify volumetric changes between serial 3D photos. An inverse line of best-fit was plotted to assess reduction in postoperative facial edema. The effects of gender, age, body mass index, and tranexamic acid administration on swelling resolution were analyzed through mixed linear model analysis. RESULTS A total of 46 patients (198 images) met the study criteria. The equation for the inverse function line of best fit was y = -13.14ln (x) + 39.54 (P

Older age cleft palate (CP) repair in international settings has been associated with increased surgical morbidity. This study assesses the prevalence and risks associated with late-age CP repair (age 5 years) in the United States.Primary CP repair patients less than the age of 18 years were identified in the National Surgical Quality Improvement pediatric database from 2012 to 2018. Total postoperative complications, readmissions, reoperations, duration of surgery, and length of stay were recorded. T-tests and χA total of 10,022 primary CP procedures were identified from 2012 to 2018, of which 868 (8.6%) received repair at age 5 years. Hispanic patients constituted a larger proportion of CP repair from ages 11 to 17 years than repair at other ages (P .001). In comparison with children treated from ages 0 to 5 years, children operated on between ages 6 and 10 or 11 and 17 years experienced no increases in unplanned readmissions, reoperations, or complication rates after surgery. Patients of ages 6-10 years and 11-17 years had decreased operating room time (P .001) compared with younger patients. Patients of ages 11-17 years also had decreased hospital length of stay (P = .04).Many children in the United States received primary CP repair after the age of 5 years likely due to late treatment of submucosal clefts or delayed care among international immigrants/adoptees. Old age procedures were not associated with increased short-term surgical morbidity in comparison with surgery at earlier time points. The causes and implications of older age primary surgery warrant further study.

Dorsal contour irregularities remain a potential undesirable sequela of rhinoplasty. Use of dorsal onlay grafts can camouflage such irregularities. In this article, a novel technique for dorsal onlay grafting utilizing crushed cartilage mixed with autologous fat is described. This study aims to assess long-term graft retention and aesthetic outcomes with this technique. Patients with >18-month follow-up who underwent primary open rhinoplasty with the described technique were reviewed. Three-dimensional photographs taken at multiple timepoints were overlaid with volumetric subtraction used to quantify graft retention. The Rhinoplasty module of the FACE-Q was completed by each patient, and the Rhinoplasty Assessment Scale Photographic (RASP) was completed by surgeon reviewers. Pre- and postoperative changes in dorsal height as well as RASP scores were compared with paired t-tests. Changes in BMI, dorsal volume, and dorsal height were compared with linear regression. P values

Background Rhinoplasty in older adults requires unique consideration of the aging nose. Objectives The purpose of this study was to systematically review the literature pertaining to rhinoplasty in the aging population, review the senior author’s experience, and describe techniques aimed at addressing age-related features. It was hypothesized that consistent age-related nasal dysmorphology is described in the literature and standard rhinoplasty techniques may effectively address these changes. Furthermore, it was hypothesized that rhinoplasty is more commonly performed for posttraumatic and functional indications than for aesthetic reasons. Methods A literature review including publications describing rhinoplasty in patients over 55 years old was conducted. Additionally, a retrospective review of the senior author’s cases was performed. Pre- and postoperative photographs were used to compare anthropometric changes. Demographic factors, surgical indications, and operative details were collected. Results Nine articles met the study criteria. Manifestations of the aging nose included soft tissue atrophy, bony fragility and resorption, tip ptosis, internal and external valve collapse, and worsening dorsal hump. Twenty-seven patients were included in this institutional review. Primary indication for rhinoplasty was posttraumatic deformity in 17 (63%) patients and nasal obstructive symptoms in 10 (37%) patients. Tip refinement and ptosis were addressed through tip grafts (70%), columellar struts (26%), and caudal septal extension grafts (67%). Nasal obstruction was relieved through septoplasty (96%), turbinate ablation (85%), and spreader grafts (70%). Conclusions This study presents a systematic review of rhinoplasty in the older adult as well as a retrospective review of the senior author’s patients. Unique considerations specific to this population should be integrated into treatment planning. Level of Evidence: 4

Black and Hispanic/Latino patients in the United States often experience poorer health outcomes in comparison to White patients. We aimed to assess the impact of race on complications, length of stay, and costs after orthognathic surgery.Pediatric and young adult orthognathic surgeries (age21) were isolated from the Kids Inpatient Database from 2000-2012. Procedures were grouped into cohorts based on the preoperative diagnosis: apnea, malocclusion, or congenital anomaly. T tests and χThere were 8,809 patients identified in the KID database (mean age of 16.3 years). Compared to White patients, complication rates were increased among Hispanic patients (2.1 vs 1.3%, P = .037) and other patients treated for apnea (8.7 vs 0.83%, P = .002). Hospital LOS was increased in both Black (3.3 vs 2.1 days, P .001) and Hispanic (2.9 days, P .001) patients. Costs were higher than Whites ($35,633.47) among Hispanic ($48,029.15, P .001), Black ($47,034.41, P .001), and Asian/Pacific-Islander ($44,192.49, P .001) patients. White patients comprised a larger proportion of the malocclusion group (77.8%) than apnea (66.9%, P .001) or congenital anomaly (59.1%, P .001), while the opposite was true for Black, Hispanic, and Asian/Pacific-Islander patients.There are significant differences in complications, LOS, and costs after orthognathic surgery among patients of different race/ethnicity. Further studies are needed to better understand the causes of disparity and their clinical manifestations.

Background Facial asymmetry from unilateral condylar hyperplasia (UCH) may be definitively treated in the presence of active disease (with high condylectomy and concurrent orthognathic surgery) or after waiting for disease inactivity (orthognathic surgery alone). There is currently no consensus on the standard of care. In this study, we sought to compare functional and esthetic outcomes, as well as treatment duration, between these 2 management options. Methods Patients who underwent treatment for UCH were identified through retrospective review. Pre- and postoperative 3-dimensional (3D) images were obtained. Short- and long-term operative outcomes of those treated during the active (group 1) were compared to those treated in the inactive phase (group 2). Total treatment time, operative time, and length of hospital stay were evaluated. Facial asymmetry was also assessed by laypersons using a Likert scale. Results Fifteen patients (mean 25.6 years, range 14-56) were included: 6 in group 1 and 9 in group 2. All surgical outcomes were statistically independent of procedure type. Treatment time was significantly longer in the group 2 (P = 0.03). Both groups demonstrated significant improvement in facial asymmetry scores postoperatively with no significant difference in pre- or postoperative asymmetry between groups (P = 0.64). Conclusions In patients with active UCH, high condylectomy and orthognathic surgery is a procedure that restores facial symmetry and improves jaw function while halting mandibular growth. Good esthetic and functional outcomes, as well as reduced treatment time and disease burden, support the use of this treatment option for this population.

Patients born with a cleft palate often suffer from velopharyngeal insufficiency (VPI) due to the soft palate musculature's abnormal structure. Surgical correction of the palate at a young age can hinder maxillary growth, requiring surgical correction of the maxillomandibular discrepancy at skeletal maturity. Orthognathic surgery can then cause or further exacerbate VPi in these patients. The purpose of this paper is to assess cleft-orthog-nathic patients under the lens of persistent or newly-developed VPi, to understand outcomes and generate a targeted management algorithm.A retrospective study was performed inspecting cleft-orthognathic patients presenting to a single surgeon. Patients with sufficient follow-up were placed into predefined algorithmic cohorts by their VPi development pattern in relation to orthognathic surgery. They were further stratified into groups by level of adherence to our algorithm to evaluate VPi outcomes. Demographic factors, risk factors, and outcomes were compared between groups via Welch t test and Fisher exact test.Fifty-one patients were examined, including 16 with VPI. Velopharyngeal insufficiency fully resolved amongst all algorithmically adherent patients and remained in nonadherent patients ( P 0.001).Our targeted algorithm may improve symptoms and the management of VPI in cleft-orthognathic patients. Multi-centered studies with larger sample sizes and prospective studies are encouraged to validate our proposed treatment algorithm further.

Surgical management of unilateral cleft lip is challenging. Correction requires a comprehensive approach to ensure optimal aesthetic outcomes. Various techniques have been proposed for the repair of cleft lip. This article and video vignette highlight the senior author's (D.S.) preferred method for repair of a unilateral cleft lip using a modified inferior triangle technique, a Noordhoff triangular flap for vermillion augmentation, orbicularis oris chemodenervation to reduce tension at the repair site, and autologous fat grafting for lip sculpting.

PURPOSE The determination of facial growth maturity is crucial before surgical intervention in pediatric patients. To the author's knowledge, there are several indicators of skeletal maturity, but there remains a lack of consensus regarding their application when determining surgical timing. The purpose of this study was to determine the most accurate skeletal maturity indicator in predicting facial growth maturation. MATERIALS AND METHODS A systematic review was done to determine the most predictive indicator for facial growth maturity. We hypothesized that menses' onset was the most predictive of these maturity indicators. This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A systematic search of MEDLINE, Cochrane, Embase, Scopus databases, and Google Scholar, was done in October 2020 to identify citations related to maturity indicators assessing craniofacial growth. The quality of evidence was determined using the Joanna Briggs Institute Critical Appraisal Checklist for Cohort Studies. RESULTS Of the 13,289 articles screened, 1 retrospective and 1 prospective study met inclusion criteria. No articles were identified that provided evidence for our hypothesis. Based on the 2 included studies, it was concluded that a handwrist x-ray was more predictive of facial growth cessation (compared to other skeletal maturity indicators). CONCLUSIONS Based on the literature, handwrist radiography serves as the most predictive method in determining the facial growth maturity. The paucity of articles within this investigation highlights the need for greater research efforts to investigate the predictability of indicators to evaluate facial growth maturation.PROSPERO registration number: CRD42020207388.

BACKGROUND/PURPOSE Pediatric septorhinoplasty has sparked controversial debate amongst craniofacial surgeons, particularly due to its potential growth disturbances of the face and nose. The purpose of this study is (1) to conduct a systematic literature review that explores unique considerations and limitations associated with performing rhinoplasty in the pediatric population; (2) to discuss objective indicators for determining craniofacial skeleton maturation; (3) to perform a case series to further understand whether the age of menarche serves as a good proxy for estimating the time of facial growth maturation, and by extension, whether a post-menarchal patient is a suitable candidate for rhinoplasty. METHODS Systematic literature review was performed in order to assess unique considerations and limitations of pediatric rhinoplasty. Retrospective chart review and anthropometric (9 linear, 3 angular, 6 indices) measurements were performed for ten pediatric female patients who underwent open septo-rhinoplasty. Follow-up times ranged from 66 to 103 weeks. Patients were separated into 2 cohorts according to age at the time of menarche. Cohort 1 consisted of patients who had undergone menses for longer than 2 years at the time of rhinoplasty, whereas Cohort 2 comprised of patients who either had menses within 2 years of rhinoplasty or did not have menses at the time of rhinoplasty. Data included demographic factors, procedural variables, revision surgeries, and complications. Measurements were conducted using VECTRA software (Canfield Scientific, Parsippany, NJ). Differences in measurements between the 2 postoperative timepoints were compared. RESULTS Literature review yielded 17 articles, which had conflicting opinions regarding pediatric rhinoplasty and ultimately, highlighting the need for a more objective tool for guiding the decision to perform rhinoplasty.Patients in Cohort 1 had minimal deviations in measurements over time, within the exception of an increase in nasal tip projection and a decrease in nasolabial angle and facial width. Patients in Cohort 2 had decreases in facial height, upper facial height, nasal tip angle, and nasofrontal angle. Nasolabial angle decreased for both cohorts. Of the ten patients, 1 in Cohort 2 underwent revision rhinoplasty. CONCLUSIONS Our case series suggests that anthropometric measurements remain relatively more stable for patients who have undergone menses for more than 2 years, compared to those who have not. Although this study has limitations, further investigation is warranted in order to determine whether age of menarche may serve as a useful tool for craniofacial surgeons in guiding the decision to perform rhinoplasty.

PURPOSE Within the academic surgical setting resident involvement may confer longer operative times. The increasing pressures to maximize clinical productivity and decreasing reimbursement rates, however, may conflict with these principles. This study calculates the opportunity cost of resident involvement in craniofacial surgery. METHODS Retrospective analysis was conducted with patients who underwent craniofacial procedures from the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2012. Patients were selected based on relevant Current Procedural Terminology codes for craniofacial pathologies (ie, trauma, head and neck reconstruction, orthognathic surgery, and facial reanimation). Variables included patient demographics, operative time, and presence or absence of resident trainee. Average relative value units were calculated to determine the opportunity cost of resident involvement for each craniofacial procedure. RESULTS In total, 2096 patients were identified through the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2012. Resident involvement was associated with a statistically significant higher operative time (P

Purpose: Facial recognition software may serve as a more objective tool for measuring aesthetic improvements following facial plastic surgery. This study utilized a novel facial recognition and artificial intelligence software in order to assess perceived changes in age and attractiveness amongst patients receiving rhinoplasty. Methods: This study was a retrospective evaluation of 3D photographs of patients who underwent aesthetic rhinoplasty alone by the senior author (DS). Both pre- and post-operative (>12-month follow-up) Vectra 3D images (Canfield Scientific, Parsippany, NJ) were assessed using Haystack Artificial Intelligence Software (Haystack AI, New York, NY). Facial attractiveness (score 1-10) and apparent age were predicted. Paired t-tests were used to compare age and attractiveness scores before and after surgery. Multivariate linear regression was performed to identify factors associated with age and attractiveness scores. Results: Forty patients receiving rhinoplasty met the study criteria (average age 48.3). Overall, rhinoplasty was associated with increases in AI-rated attractiveness (+0.58, p = 0.004) and decreases in perceived age relative to the patient’s true age (-1.62 years, p = 0.021). Greater decreases in post-operative perceived age were achieved in patients who appeared older than their actual age pre-operatively (p = 0.04). AI age predictions were also closer to true patient age post-operatively (+1.71 years) than they were pre-operatively (+3.33 years). Conclusion: Facial recognition software was successfully implemented to evaluate improvements in perceived age and attractiveness in patients undergoing aesthetic rhinoplasty. Using this technology, patients were found to appear more attractive and younger after rhinoplasty. Additionally, age reversal was greatest among patients who appeared older than their actual age at the time of surgery.

The current standard of care for an alveolar cleft defect is an autogenous bone graft, typically from the iliac crest. Given the limitations of alveolar bone graft surgery, such as limited supply, donor site morbidity, graft failure, and need for secondary surgery, there has been growing interest in regenerative medicine strategies to supplement and replace traditional alveolar bone grafts. Though there have been preliminary clinical studies investigating bone tissue engineering methods in human subjects, lack of consistent results as well as limitations in study design make it difficult to determine the efficacy of these interventions. As the field of bone tissue engineering is rapidly advancing, reconstructive surgeons should be aware of the preclinical studies informing these regenerative strategies. We review preclinical studies investigating bone tissue engineering strategies in large animal maxillary or mandibular defects and provide an overview of scaffolds, stem cells, and osteogenic agents applicable to tissue engineering of the alveolar cleft. An electronic search conducted in the PubMed database up to December 2021 resulted in 35 studies for inclusion in our review. Most studies showed increased bone growth with a tissue engineering construct compared to negative control. However, heterogeneity in the length of follow up, method of bone growth analysis, and inconsistent use of positive control groups make comparisons across studies difficult. Future studies should incorporate a pediatric study model specific to alveolar cleft with long-term follow up to fully characterize volumetric defect filling, cellular ingrowth, bone strength, tooth movement, and implant support.

Artificial intelligence (Al)-based analyses may serve as a more objective tool for measuring cosmetic improvements following aesthetic plastic surgery. This preliminary proof-of-concept study utilized a novel commercial facial recognition software to assess perceived changes in age and attractiveness among patients receiving rhinoplasty.This study was a retrospective evaluation of three-dimensional photographs of patients who underwent rhinoplasty by the senior author (DS). Both pre- and post-operative (12-month follow-up) Vectra three-dimensional images (Canfield Scientific, Parsippany, NJ) were assessed using Haystack AI Software (Haystack AI, New York, NY). Facial attractiveness (score 1-10) and apparent age were predicted. A retrospective chart review of demographic variables was additionally performed. Paired t tests were used to compare age and attractiveness scores before and after surgery. Multivariate linear regression was performed to identify factors associated with age and attractiveness scores.One hundred twenty-four patients receiving rhinoplasty met the study criteria (average age: 35.58). Overall, rhinoplasty was associated with increases in Al-rated attractiveness (+0.28, P = 0.03) and decreases in perceived age relative to the patient's true age (-1.03 years, P = 0.03). Greater decreases in postoperative perceived age were achieved in patients who appeared older than their actual age preoperatively ( P0.001).Facial recognition software was successfully used to evaluate improvements in perceived age and attractiveness in patients undergoing aesthetic rhinoplasty. Patients were perceived by the software as younger and more attractive following rhinoplasty. Age reversal was greatest among patients who appeared much older than their actual age at the time of surgery.Level of Evidence: IV.

Background Patients seek submental liposuction to remove excess fat and fullness under the jawline and achieve a more youthful appearance. However, few studies have examined the effect of neck liposuction on perceived age, health, attractiveness, and likeability. The purpose of this study was to quantify the changes in these perceived parameters following submental liposuction and to identify anthropometric changes that correlate with perceived ratings. Methods This study was a retrospective evaluation of 3D preoperative and postoperative photographs of patients who underwent submental liposuction alone or with other facial rejuvenation procedures by the senior author (DS) between 2014 and 2019. The preoperative and postoperative photographs of patients were split into 2 surveys. The pre- and postoperative images were randomized, and the same patient's images were not included in the same survey to avoid recall bias. A total of 148 survey responses were obtained from laypersons with each individual rating perceived age, health, attractiveness, and likeability. Photogrammetric assessment of patient images was completed using 3D VECTRA software (Canfield, Fairfield, NJ). Differences between pre- and postoperative labiomental angle, cervicomental angle, chin-throat distance, and facial angle were recorded. Paired T-tests were used to assess differences pre- and postoperatively. Multivariate regression was utilized to identify the influence of photogrammetric changes on perceived ratings. Results Twelve patients met the study criteria. All received submental liposuction, 67% received concurrent genioplasty, and 33% received simultaneous neck and facelift. After surgery, the cervicomental angle decreased by 7.3° (P = .0171), chin-throat distance increased by 3.9mm (P Conclusion Submental liposuction is effective in reducing perceived patient age. This effect is more pronounced when preformed with neck lift. Furthermore, decrease in labiomental and cervicomental angle are associated with decreased perceived age.

Background/purpose Virtual surgical planning (VSP) in orthognathic surgery has enabled reconstructive surgeons to achieve more predictive results when compared to conventional methods. Still, few studies have evaluated the accuracy of VSP in more complex cases, such as those requiring maxillary segmentation. The aim of this study was to examine the conformity of virtual surgical plans to postoperative results following segmental procedures performed by a single surgeon. Methods This was a retrospective study of patients who had undergone triple jaw (segmental Le Fort I, bilateral sagittal split osteotomy, and genioplasty by the senior author (DMS) between 2016 and 2020. The preoperative virtual surgical plan and postoperative cone beam computed tomographic scan were registered in 3-Matic software (Materialise, Leuven, Belgium) using cranial base landmarks. The conformity of the postoperative skull model to the virtual surgical plan was quantified using linear and angular measurements at various 3D bony landmarks. The average mean difference (AMD) in the x-, y-, and z-axes was calculated. Paired T-tests were used to compare postoperative measurements with those from the pre-operative STL. Multivariate linear regression was performed to analyze and modifying effects of age, gender, number of segments (2 vs. 3), and malocclusion class. Results Twenty-nine patients were included (mean age 24.5 years; 72.4% female). Three-dimensional analysis showed significant AMD between the virtual plan and postop CBCT for the following landmarks: U1 Midpoint (y, AMD: 1.65mm, P = .03), B point (y, AMD: 1.63mm, P = .005), pogonion (y, AMD: 2.38mm, P = .0005), menton (y, AMD: 2.22mm, P = .0003). There were no differences between the virtual plans and postop CBCT at any other points. Transversely, the overall AMD was 1.15mm, with under-expansion occurring in 79.3% (2.18mm) and over-expansion in 20.7% of patients (1.65mm). Angular measurements revealed statistical significance for SNB (AMD: 1.38, P = .02), but not for SNA and ANB values. Multivariate regression showed no association between age, gender, segmentation (2 vs. 3), or class of malocclusion and the extent of conformity for any measurements. Conclusion There is a high degree of conformity between the VSP and postoperative results following triple jaw orthognathic surgery with segmental maxillary osteotomies. The greatest nonconformity was found in the sagittal plane and was mostly limited to the mandible. Segmentation did not affect surgical accuracy of the maxillary movements.

Background/purpose Racial disparities in surgical care in the United States have been previously demonstrated. In cleft lip repair, however, an association between race and outcomes has not been established. This study aimed to identify the impact of race on timing, costs, and complications following cleft lip repair using the Kids’ Inpatient Database (KID). Methods Patients who underwent cleft lip repair were identified in the KID database from 2006 to 2012. Demographic data collected included race, diagnosis, insurance status, the mean income of patient Zip Code (as proxy for socioeconomic status), hospital costs, and comorbidities. ANOVA and Chi-squared analyses were used to assess differences in demographic variables across races. Bivariable linear and logistic regression models were used to identify gross differences in timing of surgery, cost of surgery, and hospital length of stay (LOS) for each race in comparison to white patients. Multivariable models were performed across the same parameters to adjust for other contributing variables. Results In total, 5927 patients were identified with cleft lip: 3724 white, 279 black, 1316 Hispanic, 277 Asian/Pacific-Islander, and 331 other races. Cleft diagnoses differed by race (P Conclusion Race was associated with significant differences in admission characteristics and outcomes in cleft lip repair. White patients generally underwent surgical repair earlier, incurred fewer hospital charges, and experienced shorter lengths of stay and fewer complications than their non-white counterparts. Disparities appear to be partially mediated by differences in socioeconomic status and underlying patient health, among other factors. Future efforts should aim to identify barriers to cleft care and minimize disparities for minority patients.

Dorsal contour irregularities remain a potential undesirable sequela of rhinoplasty. Use of dorsal onlay grafts can camouflage such irregularities. In this article, a novel technique for dorsal onlay grafting utilizing crushed cartilage mixed with autologous fat is described. This study aims to assess long-term graft retention and aesthetic outcomes with this technique.Patients with18-month follow-up who underwent primary open rhinoplasty with the described technique were reviewed. Three-dimensional photographs taken at multiple timepoints were overlaid with volumetric subtraction used to quantify graft retention. The Rhinoplasty module of the FACE-Q was completed by each patient, and the Rhinoplasty Assessment Scale Photographic (RASP) was completed by surgeon reviewers. Pre- and postoperative changes in dorsal height as well as RASP scores were compared with paired t-tests. Changes in BMI, dorsal volume, and dorsal height were compared with linear regression. P values0.05 were considered significant.Fourteen patients were included, mean age 32. Mean intermediate and final follow-up was 17.8 months and 28.9 months, respectively. There were no statistically significant dorsal height change (mean = 0.0 mm, p = 0.91) and minimal dorsal volume change (mean = 0.02 cmCrushed septal cartilage mixed with autologous fat is an effective option for dorsal nasal onlay in rhinoplasty and is associated with excellent graft retention, patient satisfaction, and nasal aesthetics.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.

Children with cleft lip and/or palate (CLP) require longitudinal multidisciplinary care. Travel distance to comprehensive cleft centers may be a barrier for some families. This study evaluated the geospatial availability of certified cleft teams across the United States.A geographic catchment area within a 1-hour travel radius of each American Cleft Palate-Craniofacial Association-certified cleft center was mapped using TravelTime distance matrix programming. The proportion of children located within each catchment area was calculated using county-level data from the National Kids Count Data Center, with aggregate estimates of patients with CLP based on state-level data from the Centers for Disease Control and Prevention. One-hour access was compared across regions and based on urbanization data collected from the US Census.There were 182 American Cleft Palate-Craniofacial Association-certified centers identified. As per study estimates, 28,331 (27.3%) children with CLP did not live within 1-hour travel distance to any center. One-hour access was highest in the Northeast (84.2% of children, P .001) and lowest in the South (65.7%) and higher in states with the greatest urbanization in comparison with more rural states (85.1 vs 37.4%, P .001). Similar patterns were seen for access to 2 or more cleft centers. The number of CLP children-per-center was highest in the West (775) and lowest in the Northeast (452).Travel distances of more than 1 hour may affect more than 25,000 (1 of 4) CLP children in the US, with significant variation across geographic regions. Future studies should seek to understand the impact of and provide strategies for overcoming geographic barriers.

BACKGROUND Facial asymmetry caused by unilateral condylar hyperplasia requires treatment to address facial and occlusal imbalances. There is no definitive evidence to suggest that a single intervention strategy (during either active condylar overgrowth or the burnt-out phase) results in better/more symmetric correction. This study sought to quantify preoperative and postoperative facial asymmetry in unilateral condylar hyperplasia patients comparing treatment for active versus burnt-out disease. METHODS Preoperative and postoperative three-dimensional photographs were obtained. Images were compared to those of unaffected controls as a standard for normal facial symmetry. Facial asymmetry was assessed using root-mean-square deviation. Paired t tests were performed to compare the root-mean-square deviations of preoperative and postoperative images between the unilateral condylar hyperplasia groups and against controls. RESULTS Forty patients were included (11 active, nine burnt-out, and 20 controls) and 60 three-dimensional images were evaluated. Preoperatively, patients in the burnt-out group had worse asymmetry than those with active unilateral condylar hyperplasia (p = 0.011). Both groups demonstrated significantly improved symmetry postoperatively (active, p = 0.0069; burnt-out, p = 1.74E-4). However, burnt-out patients remained with some residual asymmetry (p = 4.75E-4), whereas their active counterparts showed no significant difference compared to unaffected controls (p = 0.089). CONCLUSIONS Patients with end-stage unilateral condylar hyperplasia have more severe facial asymmetry that is more difficult to normalize compared to earlier intervention during active unilateral condylar hyperplasia. These findings suggest that, if possible, corrective intervention is preferable during active unilateral condylar hyperplasia. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.

Orthodontic treatment of patients with unilateral and bilateral cleft palate requires an extensive interdisciplinary approach to achieve optimal functional and esthetic rehabilitation. Intervention is divided into 3 main stages: early mixed, late mixed, and permanent dentition. Treatment modalities can vary according to developmental stage, severity of cleft, and presence of other dentofacial abnormalities. This article describes the use and efficacy of different orthodontic, orthopedic, and surgical approaches at each developmental stage of unilateral and bilateral clefts, whereby the orthodontist plays a pivotal role in the different phases of growth and development of the cleft lip and the patient.

Correction of facial asymmetry caused by active unilateral condylar hyperplasia (CH) requires proper diagnosis, arrested ongoing condylar growth, and ultimately orthognathic surgery. Traditionally, prior to performing orthognathic surgery, active CH is addressed either by: awaiting natural cessation of condylar overgrowth, or performing an interval high condylectomy (to stop growth). However, these strategies both add to the total treatment time, by either waiting and confirming no active growth, or performing a first stage growth-arresting procedure. In this report, the authors describe concurrent high condylectomy, and 3-jaw orthognathic surgery, to address the root of the problem and provide aesthetic correction in the same setting. This clinical series illustrates a detailed description of this approach, highlighting operative order, and an analysis of outcomes.

Summary: Mechanisms coordinating pancreatic β cell metabolism with insulin secretion are essential for glucose homeostasis. One key mechanism of β cell nutrient sensing uses the mitochondrial GTP (mtGTP) cycle. In this cycle, mtGTP synthesized by succinyl-CoA synthetase (SCS) is hydrolyzed via mitochondrial PEPCK (PEPCK-M) to make phosphoenolpyruvate, a high-energy metabolite that integrates TCA cycling and anaplerosis with glucose-stimulated insulin secretion (GSIS). Several strategies, including xenotopic overexpression of yeast mitochondrial GTP/GDP exchanger (GGC1) and human ATP and GTP-specific SCS isoforms, demonstrated the importance of the mtGTP cycle. These studies confirmed that mtGTP triggers and amplifies normal GSIS and rescues defects in GSIS both in vitro and in vivo. Increased mtGTP synthesis enhanced calcium oscillations during GSIS. mtGTP also augmented mitochondrial mass, increased insulin granule number, and membrane proximity without triggering de-differentiation or metabolic fragility. These data highlight the importance of the mtGTP signal in nutrient sensing, insulin secretion, mitochondrial maintenance, and β cell health. : Jesinkey et al. report that mitochondrial GTP (mtGTP) is an integrative nutrient sentinel regulating β cell function. Signaling from mtGTP raises calcium independent of oxidative phosphorylation to promote insulin secretion. Without overworking the β cell, mtGTP cycling potentiates insulin secretion, nutrient sensing, and mitochondrial expansion alongside promoting health and increasing insulin reserves. Keywords: mitochondrial GTP, PEPCK-M, insulin secretion, oxidative phosphorylation, phosphoenolpyruvate, anaplerosis, succinyl-CoA synthetase, stable isotope, metabolic flux, MIMOSA

PURPOSE Wider cleft palates are thought to be associated with increased complications and poorer outcomes following cleft palate repair. Objective cleft palate photographic measurement and assessment of complications have not been previously performed. The purpose of this study is to quantitatively characterize a series of cleft palate dimensions and to investigate possible correlations with Veau classification and intra-, peri-, and postoperative outcomes. METHODS The analytic sample included primary cleft palate repairs performed by the senior author over a 2-year period. Standard photographs of clefts taken at the time of repair were analyzed using Image-J software. Demographic, intraoperative, perioperative, and postoperative information were collected. Width measurements were correlated with Veau classification, intraoperative variables, perioperative variables, and adverse outcomes. Statistical tests performed included simple regression analyses and multiple regression analysis. RESULTS Out of 70 patients, 50 had adequate photographic documentation for inclusion in the study; 44% of patients were classified as Veau I with an average cleft width of 5.4 mm, 28% Veau II with an average of 8.9 mm, 16% Veau III with an average of 11.3 mm, and 12% Veau IV with an average of 10.0 mm. No patients exhibited postoperative bleeding, dehiscence, airway problems, infection, fistula formation, or return to the operating room. The authors found that increasing cleft width significantly predicts increasing Veau classification (P

BACKGROUND Secondary enophthalmos correction, especially in severe cases, represents a surgical challenge. The complex injury pattern involving the hard and soft tissue warrants individualized multimodality treatment strategies. Even with seemingly successfully surgical execution, relapse or incomplete correction of globe position can occur. In an attempt to improve ability for correction, we have implemented concurrent endo-orbital fat grafting and orbital framework reconstruction. The purpose of this study is to describe our treatment approach and objectively analyze the results. METHODS Preoperative and postoperative clinical examinations, Hertel measurements, and radiologic imaging were recorded. Orbitometric measurements were performed using a three-dimensional postprocessing software (SurgiCase; Materialise, Leuven, Belgium). A follow-up period of at least 6 months was taken for final evaluation. RESULTS Postoperatively, all patients showed a significant improvement of the globe's position. Neither visual impairment nor disability of globe motility was seen. Hertel and three-dimensional orbitometric measurements showed significant (P < 0.05) globe projection improvement representing a mean of 4.2 and 3.7 mm. Orbital volume (25.65 mL) significantly decreased after surgery (22.98 mL). CONCLUSIONS Alloplastic orbital floor reconstruction in combination with endo-orbital fat grafting represents an excellent method to achieve adequate globe support and positioning even in secondary enophthalmos correction.

Early childhood caries (ECC) is one of the most prevalent infectious diseases affecting children worldwide. ECC is an aggressive form of dental caries, which, left untreated, can result in rapid and extensive cavitation in teeth (rampant caries) that is painful and costly to treat. Furthermore, it affects mostly children from impoverished backgrounds, and so constitutes a major challenge in public health. The disease is a prime example of the consequences arising from complex, dynamic interactions between microorganisms, host, and diet, leading to the establishment of highly pathogenic (cariogenic) biofilms. To date, there are no effective methods to identify those at risk of developing ECC or to control the disease in affected children. Recent advances in deep-sequencing technologies, novel imaging methods, and (meta)proteomics-metabolomics approaches provide an unparalleled potential to reveal new insights to illuminate our current understanding about the etiology and pathogenesis of the disease. In this concise review, we provide a broader perspective about the etiology and pathogenesis of ECC based on previous and current knowledge on biofilm matrix, microbial diversity, and host-microbe interactions, which could have direct implications for developing new approaches for improved risk assessment and prevention of this devastating and costly childhood health condition.