Publications by authors named "Christian J Vercler"

60 Publications

Computed Tomography in Patients With Craniosynostosis: A Survey to Ascertain Practice Patterns Among Craniofacial Surgeons.

Ann Plast Surg 2021 Feb 12. Epub 2021 Feb 12.

From the Section of Plastic Surgery, Department of Surgery Department of Neurosurgery, University of Michigan, Ann Arbor, MI.

Background: In patients with craniosynostosis, imaging remains up to the discretion of the plastic surgeon or neurosurgeon. To inform best practice guidelines, we sought to obtain data surrounding the frequency at which craniofacial surgeons order computed tomography (CT), as well as indications. We hypothesized that we would identify considerable variation in both imaging and associated indications.

Methods: We surveyed members of the American Society of Maxillofacial Surgeons and the American Society of Craniofacial Surgeons to measure the frequency of preoperative and postoperative head CTs, as well as indications. Initial items were piloted with 2 craniofacial surgeons and 1 neurosurgeon, using interviews to ensure content validity. χ2 Tests were used to measure associations between operative volume, years in practice, and imaging.

Results: Eighty-five craniofacial surgeons responded (13.8% response rate), with the majority (63.5%) having performed a craniosynostosis operation in the last month. Only 9.4% of surgeons never order preoperative CTs. Of those who do, the most common indications included diagnosis confirmation (31.2%) and preoperative planning (27.3%). About 25% of surgeons always obtain postoperative head CTs, usually to evaluate surgical outcomes (46.7%). Only 13.3% of respondents order 2 or more postoperative scans. Higher operative volume was associated with a lower likelihood of ordering preoperative head CTs (P = 0.008).

Conclusions: The majority of surgeons obtain preoperative head CTs, whereas only 25% obtain CTs postoperatively, often to evaluate outcomes. Because outcomes may be evaluated clinically, this is a poor use of resources and exposes children to radiation. Consensus guidelines are needed to create best practices and limit unnecessary studies.
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http://dx.doi.org/10.1097/SAP.0000000000002751DOI Listing
February 2021

Time for a Consensus? Considerations of Ethical Social Media Use by Pediatric Plastic Surgeons.

Plast Reconstr Surg 2020 12;146(6):841e-842e

Department of Plastic Surgery, University of Michigan Hospital and Health Systems, University of Michigan, Ann Arbor, Mich.

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http://dx.doi.org/10.1097/PRS.0000000000007389DOI Listing
December 2020

Complications and the Need for Long-Term Follow-Up after Secondary Speech Surgery: A National and Longitudinal Claims Analysis.

Plast Reconstr Surg 2020 12;146(6):1340-1346

From the Section of Plastic Surgery, Department of Surgery, University of Michigan.

Background: Although most patients attain normal speech after cleft palate repair, up to 20 percent require secondary speech surgery. Despite the frequency of these procedures, complications and rates of subsequent revisions of secondary speech surgery after all procedure types have never been reviewed using national, longitudinal data.

Methods: The authors examined insurance claims from Clinformatics Data Mart between 2001 and 2017. Cases were categorized as palatalprocedures (i.e., palatoplasty, revision palatoplasty, secondary lengthening, palatal island flap) or pharyngeal procedures (i.e., pharyngeal flap, dynamic sphincter pharyngoplasty) (n = 846). Continuous enrollment from 180 days before to 30 days after surgery was required. Patients were excluded if they underwent palatoplasty, or any surgery at less than 3 years of age, without a speech diagnosis. Outcomes included 30-day complications and rates of subsequent revision secondary speech surgery. Multivariable logistic regression was used to evaluate the relationship between procedure type and complications.

Results: In this cohort, 52.5 percent underwent pharyngeal procedures, and 47.5 percent underwent palatal procedures. Complications occurred in 10.9 percent of patients and included respiratory complications (4.0 percent), bleeding (1.2 percent), dehiscence (3.6 percent), and critical care episodes (3.0 percent). There was no difference in complications between procedure types (OR, 0.87; 95 percent CI, 0.56 to 1.37; p = 0.56). The subsequent revision rate was 12.7 percent, but was 21.7 percent in patients with 3 years of postoperative enrollment.

Conclusions: Although complication rates were comparable to those in recent literature, rates of subsequent revisions of secondary speech procedures were high in patients with longer postoperative enrollment. Thus, these patients merit prolonged follow-up, as velopharyngeal dysfunction may recur over time.

Clinical Question/level Of Evidence: Therapeutic, III.
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http://dx.doi.org/10.1097/PRS.0000000000007339DOI Listing
December 2020

Decision Making in Pediatric Plastic Surgery: Autonomy and Shared Approaches.

J Craniofac Surg 2020 Nov/Dec;31(8):2139-2143

Department of Surgery, Section of Plastic Surgery, University of Michigan Health System, Ann Arbor, MI.

Background: Although shared decision-making is essential to patient-centered healthcare, its role in pediatric plastic surgery remains unclear. The objective of this study was to define the preferred level of involvement in surgical decision-making among children, caregivers, and surgeons.

Methods: The authors surveyed pediatric plastic surgery patients (n = 100) and their caregivers regarding their preferences on child involvement during surgical decision-making. Fleiss' kappa was used to assess agreement between groups. Bivariate Chi-square tests and multinomial logistic regression were used to assess the relationship between decision-making preferences and select demographic factors.

Results: Only 34% of children and their caregivers agreed upon their decision-making preferences (k = 0.04). The majority of children (40%) and caregivers (67%) favored shared decision-making between the patient, caregiver, and surgeon. Only 16% of children preferred physician-driven decisions, while 20% of children desired complete autonomy. Children's preferences were significantly associated with their age; the relative risk of children deferring to caregivers or surgeons over a shared approach was lower for adolescents and teens compared to children under 10 years old (relative risk = 0.20; 95% confidence interval: 0.054-0.751; P = 0.02). Caregiver's preferences did not change based on the child's age, but rather were related to the child's gender. Caregivers were more likely to choose the option that gave the child more autonomy when the child was male.

Conclusions: While most caregivers preferred a shared approach to decision-making, children desired greater autonomy, particularly with increasing age. Since there was limited agreement between caregivers and children, surgeons must be cognizant of differing preferences when discussing treatment plans to optimize both patient and parent satisfaction.
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http://dx.doi.org/10.1097/SCS.0000000000006738DOI Listing
March 2021

Hospital Visitation Policies During the SARS-CoV-2 Pandemic.

Am J Infect Control 2021 04 28;49(4):516-520. Epub 2020 Sep 28.

University of Michigan Medical School; Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School; Department of Otolaryngology-Head & Neck Surgery, University of Michigan Medical School. Electronic address:

A significant change for patients and families during SARs-CoV-2 has been the restriction of visitors for hospitalized patients. We analyzed SARs-CoV-2 hospital visitation policies and found widespread variation in both development and content. This variation has the potential to engender inequity in access. We propose guidance for hospital visitation policies for this pandemic to protect, respect, and support patients, visitors, clinicians, and communities.
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http://dx.doi.org/10.1016/j.ajic.2020.09.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7521399PMC
April 2021

Endovascular Treatment of Arteriovenous Malformations of the Head and Neck: Focus on the Yakes Classification and Outcomes.

J Vasc Interv Radiol 2020 Nov 18;31(11):1810-1816. Epub 2020 Sep 18.

Department of Radiology, University of Michigan, Ann Arbor, Michigan; Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan. Electronic address:

Purpose: To evaluate endovascular treatment of head and neck arteriovenous malformations (AVMs) based on the Yakes AVM classification and correlate treatment approach with clinical and angiographic outcomes.

Materials And Methods: A retrospective single-center study was performed in patients who underwent endovascular treatment of head and neck AVMs between January 2005 and December 2017. Clinical and operative records, imaging, and postoperative courses of patients were reviewed. Clinical stage was determined according to the Schobinger classification. AVM architecture and treatment approaches were determined according to the Yakes classification. Primary outcomes were clinical and angiographic treatment success rates and complication rates, with analysis according to the Yakes classification.

Results: A total of 29 patients (15 females) were identified, with a mean age of 30.6 years. Downgrading of the Schobinger clinical classification was achieved in all patients. Lesions included 8 Yakes type IIa, 5 type IIb, 1 type IIIa and IIIb, and 14 type IV. Lesions were treated using an intra-arterial, nidal, or transvenous approach, using ethanol and liquid embolic agents. Arteriovenous shunt eradication of >90% was achieved in 22 of 28 patients (79%), including 9 of 13 (69%) of Yakes type IV lesions and 13 of 15 (87%) of the other types. There were 5 significant complications in 79 procedures (6%), including 4 of 50 (8%) in Yakes type IV lesions.

Conclusions: Schobinger stage was downgraded in all patients. Arteriovenous shunt eradication of >90% was achieved in most patients. Yakes type IV lesions required more sessions, and shunt eradication was higher in the Yakes II and III groups.
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http://dx.doi.org/10.1016/j.jvir.2020.01.036DOI Listing
November 2020

Achieving the Optimal Aesthetic Benefit While Correcting Midface Deficiency: Utilizing A High Winged Le Fort I in Cleft and Craniofacial Patients.

J Craniofac Surg 2021 Jan-Feb 01;32(1):46-50

Department of Surgery, Section of Plastic and Reconstructive Surgery.

Abstract: Craniofacial anomalies are congenital disorders that affect the cranium and facial bones, with cleft lip and palate being the most common. These anomalies are often associated with abnormal development of pharyngeal arches and can result in the development of class III malocclusion and severe maxillary retrusion. Current treatment includes orthodontic decompensation and Le Fort I osteotomy to correct the maxillomandibular relationship. However, the traditional Le Fort I (LFI) advancement does not fully address the lack of skeletal volume in the midface. The high winged Le Fort I osteotomy (HWLFI) is an excellent surgical option for simultaneous correction of the midface deficiency and malocclusion while restoring optimal esthetic convexity. A retrospective chart review was conducted to include all cleft and craniofacial patients who underwent HWLFI advancement from 2002 to 2018. Patients had a minimum of 12 months of follow-up. Patient data and complications were reviewed. Standardized facial photographs were analyzed for esthetic improvement, occlusion, and beneficial salutary effects on the midface. Forty-three patients met the inclusion criteria. The mean age at surgery was 18.9 years. The mean follow-up was 32 months. Early complications included infection (9.3%) and temporary nerve paresthesia (2.3%). Late complications included infection (6.5%), wound dehiscence (4.3%), and painful hardware (2.3%). One patient (2.3 percent) had clinically significant relapse that required surgery. Postoperatively, patients demonstrated excellent midface projection and correction of the skeletal malocclusion. The HWLFI advancement significantly improves both the malocclusion and esthetic concerns of cleft and craniofacial patients by reestablishing maximal midfacial support. Important advantages of the HWLFI are avoidance of alloplastic implant use and extensive and potentially unstable surgical procedures that increase orbital volume.
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http://dx.doi.org/10.1097/SCS.0000000000006871DOI Listing
August 2020

Institutionalized Youth and the Anatomy Lab in Twentieth Century Michigan.

Pediatrics 2020 08 3;146(2). Epub 2020 Jul 3.

Departments of Internal Medicine and History, Medical School, University of Michigan, Ann Arbor, Michigan

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http://dx.doi.org/10.1542/peds.2019-2748DOI Listing
August 2020

Responding to the COVID-19 Crisis: If Not Now, Then When?

Plast Reconstr Surg 2020 09;146(3):711-712

From the Section of Plastic Surgery, Department of Surgery, University of Michigan; and the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center.

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http://dx.doi.org/10.1097/PRS.0000000000007144DOI Listing
September 2020

Saving Face: Patient Strategies to Reduce Stigma and Barriers to Effective Decision-Making Among Children With Cleft Lip.

J Craniofac Surg 2020 Sep;31(6):1608-1612

Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI.

Facial differences associated with cleft lips are often stigmatizing and can negatively impact psychosocial development and quality of life. However, little is known regarding patients' responses to societal expectations of appearance, or how these responses may impact utilization of revision surgery. Thus, patients with cleft lips at least 8 years of age (n = 31) were purposively sampled for semi-structured interviews. After verbatim transcription, first cycle coding proceeded with a semantic approach, which revealed patterns that warranted second cycle coding. The authors utilized an eclectic coding design to capture deeper meanings in thematic analysis. Additionally, survey data from a separate study were examined to evaluate participants' interest in improving appearance. Three major themes emerged, all of which reflected a desire to "save face" when interacting with society: (1) Cultural Mantras, which included societal mottos that minimized the importance of appearance; (2) Toughening Up, wherein the participants downplayed the difficulty of having a cleft; and (3) Deflection, wherein the participants took pride in facial features unrelated to their clefts. Despite these efforts to "save face," 78% of participants expressed interest in improving their appearance in the separate survey data.In conclusion, children with cleft lips try to "save face" when interacting with society by depreciating appearance, making light of clefts, and focusing on non-cleft related features. Paradoxically, many desired improvements of their appearance in an earlier survey. Awareness of these coping strategies is critical, as they may negatively impact surgeon-patient communication and inhibit patients from expressing interest in revision surgery.
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http://dx.doi.org/10.1097/SCS.0000000000006520DOI Listing
September 2020

A Simplified Approach to Myelomeningocele Defect Repair.

Ann Plast Surg 2021 01;86(1):58-61

From the Section of Plastic Surgery.

Background: Repair of the soft tissue defect in myelomeningoceles remains challenging. The literature currently lacks a systematic approach, reporting high rates of complications. We present outcomes from the largest series to date and describe a simplified approach that minimizes morbidity and streamlines decision making.

Methods: Patients 1 year or younger who underwent myelomeningocele repair between 2008 and 2018 were reviewed. Flap types were categorized by tissue composition. Complications were dichotomized into early and late (<30 days and >30 days postoperative, respectively). Logistic regression was used to measure the impact of flap tissue composition and skin closure technique on odds of postoperative complications.

Results: Ninety-seven patients met inclusion criteria. Reoperation was required in only 3 (3.0%) patients-1 for wound dehiscence and 2 for surgical site infections. Zero cases of tethered cord or cerebrospinal fluid leak occurred. The most common minor complications were early wound complications (n = 18, 18.6%) and early infection (n = 5, 5.2%). Fascia-only flaps and muscle + other tissue flaps were not associated with higher odds of complications compared with muscle-only flaps (odds ratio [OR], 2.13; 95% confidence interval [CI], 0.53-8.50, P = 0.29; OR = 2.87, 95% CI 0.66-12.51, P = 0.16, respectively). Rhomboid flaps for skin closure were associated with higher odds of complications (OR, 4.47; 95% CI, 1.00-19.97; P = 0.05).

Conclusions: Our approach to myelomeningocele repair demonstrated no cases of secondary tethered cord or cerebrospinal fluid leak, and reoperative rates were extremely low. Because complications were unrelated to flap type, we recommend a simplified approach using any tissue type for dural coverage and 2-layer primary closure of the skin.
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http://dx.doi.org/10.1097/SAP.0000000000002374DOI Listing
January 2021

Ethical Use of Public Networks and Social Media in Surgical Innovation.

J Laparoendosc Adv Surg Tech A 2020 Apr 17. Epub 2020 Apr 17.

Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA.

The use of social media among surgeons is increasing in the professional domain as a result of the benefits of rapid communication for advertising, professional development, advocacy, and innovation. Social media allows for collaboration and consultation on cases that may be difficult or uncommon, drawing on collective wisdom but also bypassing traditional privacy protections and other regulatory firewalls. The expanded access that comes with social media produces challenges, including the management of information dissemination and ensuing perceptions, the risk of biased patient/research participant recruitment, the potential for overlap between personal and professional lives, and the precarious nature of self-interest in professional social media use. The ethics of surgical innovation in the context of social media has not been extensively discussed. The nature of social media favors attention grabbing, sensationalized content. Innovation is inherently sensational and demands attention. The alignment of these intrinsic characteristics forms a basis for its appeal and contagion on social media. Despite strict regulatory clinical research environment, many surgical innovations and subsequent evolution in practice arise from a longitudinal surgical culture of trial and error that happens every day. The difficulty in distinguishing innovation from research and the precarious nature of interactions found on social media create a unique ethical dilemma to be addressed for the innovative surgeon. Therefore, the use of social media in surgical innovation thus requires a more robust ethical analysis.
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http://dx.doi.org/10.1089/lap.2019.0758DOI Listing
April 2020

HEC-C: From Halsted's Perspective.

Am J Bioeth 2020 03;20(3):35-37

University of Michigan Medical School.

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http://dx.doi.org/10.1080/15265161.2020.1714797DOI Listing
March 2020

The changing paradigm of ethics in uterus transplantation: a systematic review.

Transpl Int 2020 Mar 6;33(3):260-269. Epub 2020 Jan 6.

Division of Plastic Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA.

The first uterus transplantation was performed in 2000. As key milestones are reached (long-lasting graft survival in 2011, and first birth from a transplanted womb in 2014), the ethical debate around uterus transplant evolves. We performed a systematic review of articles on uterus transplantation. Ethical themes were extracted and categorized according to four bioethical principles. Papers were divided into time periods separated by key events in uterus transplant history: Phase I (first technical achievement, 2002-2011), Phase II (clinical achievement, 2012-2014), and Phase III (after the first childbirth, 2015-2018). Eighty-one articles were included. The majority of ethics papers were published in Phase III (65%, P < 0.0001), that is after the first birth. Eighty percent of papers discussed nonmaleficence making it the most discussed principle. The first birth acted as a pivotal point: nonmaleficence was discussed by a lower proportion of articles (P = 0.0073), as was beneficence (P = 0.0309). However, discussion of justice increased to become the most discussed principle of the time period (P = 0.0085). The ethical debate surrounding uterus transplantation has evolved around landmark events that signify scientific progress. As safety and efficacy become evident, the focus of ethical debate shifts from clinical equipoise to socioeconomic challenges and equitable access to uterus transplantation.
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http://dx.doi.org/10.1111/tri.13548DOI Listing
March 2020

How Should a Physician Respond to a Patient's Pain When New Opioid Prescribing Laws Limit Shared Decision Making?

AMA J Ethics 2019 10 1;21(10):E838-843. Epub 2019 Oct 1.

An associate professor of surgery and the co-chief of the Clinical Ethics Service of the Center for Bioethics and Social Sciences in Medicine at the University of Michigan in Ann Arbor.

This commentary responds to a case and examines pragmatic concerns about operating a busy outpatient practice in compliance with new laws that regulate opioid prescribing. Specifically, the article considers how regulating opioid prescribing can influence the therapeutic alliance in patient-physician relationships and how innovations in decision science can facilitate shared decision making given time constraints.
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http://dx.doi.org/10.1001/amajethics.2019.838DOI Listing
October 2019

Variation in the Utilization of Postoperative Computed Tomography for Patients With Nonsyndromic Craniosynostosis: A National Claims Analysis.

Cleft Palate Craniofac J 2020 03 24;57(3):288-295. Epub 2019 Oct 24.

Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA.

Objective: Routine postoperative computed tomography (CT) imaging in nonsyndromic craniosynostosis remains controversial due to the hazards of radiation exposure. The extent to which postoperative head CTs are performed remains unknown. Therefore, we sought to measure the use of postoperative CTs in this population.

Design: The authors reviewed insurance claims from OptumInsight, using Current Procedural Terminology codes to identify procedures and postoperative imaging. Multilevel logistic regression was used to describe the odds of undergoing postoperative CTs, adjusting for patient and provider covariates.

Participants: Craniosynostosis patients who underwent reconstruction between 2001 and 2017 were reviewed. Patients older than 5 years at surgery, postoperative lengths of stay >15 days, syndromic diagnoses, operative complications within 30 days of surgery, and cranial bone grafting merited exclusion.

Main Outcome Measure: Odds of postoperative head CTs after cranial vault reconstruction.

Results: In this cohort (n = 1150), 326 (28.4%) patients underwent postoperative head CTs. The number of CTs ranged from 0 to 14. Older age at surgery (odds ratio [OR]: 1.32, = .002), increasing years of follow-up (OR: 1.12, < .001), and increasing comorbidities (OR: 1.21, = .017) were associated with postoperative CTs. After adjusting for patient factors, provider factors accounted for 31.3% of variation in imaging.

Conclusions: Over a quarter of patients underwent head CTs following reconstruction, and provider factors accounted for a large percentage of the variation. Given the risks of radiation, neurosurgeons and craniofacial surgeons face a critical need to establish postoperative imaging protocols to reduce unnecessary imaging in these vulnerable patients.
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http://dx.doi.org/10.1177/1055665619882568DOI Listing
March 2020

The Impact of Ethnicity on Craniosynostosis in the United States.

J Craniofac Surg 2019 Nov-Dec;30(8):2526-2529

Division of Plastic and Reconstructive Surgery, Washington University, St. Louis Children's Hospital, St. Louis, MO.

While many studies have examined potential risk factors for nonsyndromic craniosynostosis, there have been no publications to date investigating the role of ethnicity in the United States. The current study was undertaken as the first multi-center investigation to examine the relationship between ethnicity and nonsyndromic craniosynostosis, looking at both overall prevalence as well as potential correlation between ethnicity and pattern of affected suture site. A chart review of patients diagnosed with nonsyndromic craniosynostosis treated at four major children's hospitals was performed to obtain ethnicity data. Analysis was preformed based on ethnic group as well as suture site affected. To account for potentialOne regional selection bias, the KID database (1997-2012) was utilized to identify all cases of craniosynostosis on a national level. This data was analyzed against birth rates by ethnicity obtained from CDC WONDER natality database.Amongst the 2112 cases of nonsyndromic craniosynostosis at all institutions, Caucasians and African Americans were consistently the predominant ethnic groups. There was a statistically significant difference in the distribution of affected suture type with African Americans more likely to present with unicoronal synostosis and Caucasians more likely to present with metopic synostosis (P = 0.005). The national data revealed that there were more cases of craniosynostosis in Caucasians and fewer in African Americans than expected when compared to population birth rates. Our findings demonstrate that the Caucasian race is associated with increased rates of synostosis.
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http://dx.doi.org/10.1097/SCS.0000000000006009DOI Listing
January 2020

Age at Craniosynostosis Surgery and Its Impact on Ophthalmologic Diagnoses: A Single-Center Retrospective Review.

Plast Reconstr Surg 2019 09;144(3):696-701

From the Section of Plastic Surgery, Department of Surgery, the Department of Ophthalmology, and the Section of Plastic Surgery, University of Michigan; and the University of Toledo College of Medicine and Life Sciences.

Background: Ocular abnormalities in craniosynostosis are a persistent concern for patients and providers, and some surgeons feel that early surgical intervention for synostosis alleviates the progression of ophthalmologic abnormalities. In contradistinction, the authors hypothesize that operating early will have no bearing on postoperative ophthalmologic outcomes.

Methods: Single-suture craniosynostosis patients who underwent surgical correction between 1989 and 2015 were reviewed. Patients with multisuture craniosynostosis, syndromic diagnoses, no preoperative ophthalmology evaluation, and less than 2 years of follow-up were excluded. Logistic regression was used to determine odds of preoperative and postoperative ophthalmologic abnormalities by age, while controlling for patient-level covariates.

Results: One hundred seventy-two patients met inclusion criteria. The median age at surgery was 10 months (interquartile range, 7 to 12.9 months). Increasing age at the time of surgery was associated with increased odds of preoperative ophthalmologic diagnoses (OR, 1.06; p = 0.037) but not postoperative diagnoses (OR, 1.00; p = 0.91). Increasing age at surgery was also not associated with increased odds of ophthalmologic diagnoses, regardless of timing (OR, 1.04; p = 0.08). Patients with coronal synostosis (OR, 3.94; p = 0.036) had significantly higher odds of preoperative ophthalmologic diagnoses. Patients with metopic (OR, 5.60; p < 0.001) and coronal (OR, 7.13; p < 0.001) synostosis had significantly higher odds of postoperative ophthalmologic diagnoses.

Conclusions: After reviewing an expansive cohort, associations of both overall and postoperative ophthalmologic diagnoses with age at surgery were not found. The authors' findings thus run counter to the theory that early surgical intervention lessens the likelihood of postoperative ophthalmologic diagnoses and improves ophthalmologic outcomes.

Clinical Question/level Of Evidence: Risk, III.
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http://dx.doi.org/10.1097/PRS.0000000000005915DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6729144PMC
September 2019

Decision-Making in Cleft-Related Surgery: A Qualitative Analysis of Patients and Caregivers.

Cleft Palate Craniofac J 2020 02 5;57(2):161-168. Epub 2019 Aug 5.

Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA.

Objective: Preference-sensitive surgical decisions merit shared decision-making, as decision engagement can reduce decisional conflict and regret. Elective cleft-related procedures are often preference sensitive, and therefore, we sought to better understand decision-making in this population.

Design: Semistructured interviews were conducted to elicit qualitative data. A hierarchical codebook was developed through an iterative process in preparation for thematic analysis. Thematic analysis was performed to examine differences between patients and caregivers.

Setting: Multidisciplinary cleft clinic at a tertiary care center.

Participants: Patients with cleft lip aged 8 and older (n = 31) and their caregivers (n = 31) were purposively sampled. Inability to converse in English, intellectual disability, or syndromic diagnoses resulted in exclusion.

Main Outcome Measures: Preferences surrounding surgical decision-making identified during thematic analysis.

Results: Mean patient age was 12.7 (standard deviation: 3.1). Most had unilateral cleft lip and palate (43.8%). Three themes emerged: Insufficient Understanding of Facial Difference and Treatment, Diversity of Surgical Indications, and Barriers to Patient Autonomy. Almost half of caregivers believed their children understood their clefts, but most of these children failed to provide information about their cleft. Although many patients and caregivers acknowledged that surgery addressed function and/or appearance, patients and caregivers exhibited differences regarding the necessity of surgery. Furthermore, a large proportion of patients believed their opinions mattered in decisions, but less than half of caregivers agreed.

Conclusions: Patients with clefts desire to participate in surgical decisions but have limited understanding of their facial difference and surgical indications. Cleft surgeons must educate patients and facilitate shared decision-making.
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http://dx.doi.org/10.1177/1055665619866552DOI Listing
February 2020

Variation in the Desire for Cleft Revision Surgery among Children, Caregivers, and Surgeons.

Plast Reconstr Surg 2019 07;144(1):171-178

From the Section of Plastic Surgery, Department of Surgery, and the Department of Physical Medicine and Rehabilitation, Michigan Medicine; and the University of Michigan Medical School.

Background: Although revision surgery is part of the reconstructive process for children with cleft lip and/or cleft palate, the indications for revision vary, and the extent to which surgeons and families agree on appearance is unclear. The authors sought to understand the extent to which children with cleft lip and/or cleft palate, surgeons, caregivers, and control observers agree on satisfaction with appearance and the desire for revision.

Methods: Children with cleft lip and/or cleft palate (n = 100) and their caregivers (n = 100) were surveyed regarding satisfaction with appearance using the Cleft Evaluation Profile. Surgeons (n = 10) and control observers (n = 10) rated photographs of these children using questions analogous to the Cleft Evaluation Profile. General linear model repeated measures analysis of variance were used to detect significant differences between raters, with an alpha of 0.05.

Results: The children reported greater satisfaction with appearance across all domains compared with surgeons (nose, 7.77 versus 5.51, p < 0.001; lip, 7.94 versus 5.90, p < 0.001; maxilla, 8.16 versus 6.56, p < 0.001) and general observers (nose, 7.78 versus 6.00, p < 0.001; lip, 7.80 versus 6.12, p < 0.001; maxilla, 8.16 versus 7.40, p < 0.001). Children and caregivers expressed similar degrees of satisfaction with appearance of the lip (5.48 ± 1.69 versus 5.6 ± 1.49, p > 0.5) and maxilla (6.08 ± 1.1 versus 5.8 ± 1.2, p = 0.07). There was no significant relationship between children and surgeons in terms of the desire for revision surgery (p = 0.44).

Conclusions: All groups expressed differing levels of satisfaction with cleft-specific aspects of appearance. Importantly, children were more satisfied than all other groups. Care must be taken to evaluate perceptions of all stakeholders before moving forward with cleft revision surgery.
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http://dx.doi.org/10.1097/PRS.0000000000005722DOI Listing
July 2019

Short- and Long-Term Outcomes by Procedure Type for Nonsagittal Single-Suture Craniosynostosis.

J Craniofac Surg 2019 Mar/Apr;30(2):458-464

Section of Plastic Surgery, University of Michigan, Ann Arbor, MI.

Background: Minimally invasive approaches for the treatment of single-suture craniosynostosis are sometimes touted as equivalent to cranial vault reconstruction. While techniques for sagittal synostosis have been reviewed previously, evidence regarding open and less invasive surgical techniques for metopic, coronal, and lambdoid synostosis has yet to be reviewed.

Methods: Systematic searches were performed using Embase.com and PubMed. Included studies reported short- or long-term outcomes, compared at least 2 standard techniques, discussed single-suture coronal, metopic, or lambdoid craniosynostosis, and enrolled at least 20 study participants. Two authors screened titles and abstracts, and also performed full text review and data extraction. Given heterogeneous outcomes, qualitative synthesis was performed after data extraction.

Results: The search strategy yielded 2348 articles. Of these, 313 were removed as duplicates, and 1935 were excluded during title/abstract review. After full text review of 100 articles, 19 were selected for data extraction. The heterogeneity of outcomes precluded meta-analysis and required qualitative synthesis. While short-term outcomes indicated decreased morbidity of minimally invasive techniques, only 2 articles presented long-term reoperation rates. One study reported higher reoperation rates in the less invasive technique, and the second reported no reoperations in the median follow-up period of 33 months.

Conclusion: Studies comparing long-term outcomes between different surgical techniques for single-suture craniosynostosis remain deficient. The development of standardized outcome measures is essential, and prospective, multicenter studies are necessary to assess the long-term efficacy of these procedures.
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http://dx.doi.org/10.1097/SCS.0000000000005129DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6541498PMC
August 2019

Debunking a Surgical Myth: Do Not Touch the Temporalis.

J Craniofac Surg 2019 Mar/Apr;30(2):429-432

Section of Plastic Surgery, University of Michigan.

Background: A longstanding dictum exists to avoid surgical manipulation of the temporalis muscle out of concern for an exceedingly high rate of muscle atrophy and recurrent temporal hollowing. The authors challenge this surgical myth, considering such advice to be erroneous. The authors hypothesize that elevation of the temporalis muscle, if performed using standard muscle flap principles, will demonstrate excellent results.

Methods: To assess temporalis response to surgical manipulation, the authors reviewed patients who underwent calvarial vault remodeling by the senior author for craniosynostosis between 1988 and 2011. Nonsyndromic patients with single-suture synostosis and 5 years of follow-up were eligible for inclusion. The medical record was used to measure rates of reoperation, recurrent temporal hollowing, and persistent temporalis overcorrection.

Results: Of the cohort reviewed, 196 patients met inclusion criteria. Ten patients (5.1%) exhibited recurrent bitemporal constriction. One patient (0.5%) underwent a revision temporalis turnover flap, and 2 patients (1.0%) underwent soft tissue augmentation. The overall reoperation rate was 1.5%. Temporalis overcorrection, in an attempt to prophylactically rectify the expected atrophy after temporalis manipulation, persisted in 11 patients (5.6%). Three of these patients required treatment with steroid injections, Botox injections, or operative muscle debulking. The overall reoperation rate for temporalis overcorrection was 1.5%.

Conclusions: The authors' low reoperation rates for recurrent deformity, in combination with persistent temporalis overcorrection in 5.6% of patients, should dispel the myth that manipulation of the temporalis invariably results in atrophy. The muscle may be surgically manipulated, as long as plastic surgery principles are followed.
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http://dx.doi.org/10.1097/SCS.0000000000005106DOI Listing
August 2019

Caregiver-Reported Outcomes and Barriers to Care among Patients with Cleft Lip and Palate.

Plast Reconstr Surg 2018 12;142(6):884e-891e

From the Section of Plastic Surgery, Department of Surgery, University of Michigan.

Background: For children with cleft lip and/or palate, access to care is vital for optimizing speech, appearance, and psychosocial outcomes. The authors posited that inadequate access to care negatively impacts outcomes in this population.

Methods: Sixty caregivers of children with cleft lip and palate were surveyed to assess perceived barriers using the validated Barriers to Care questionnaire. The questionnaire includes 39 items divided into five subscales, with higher scores indicating fewer barriers. Caregiver-reported outcomes were assessed using the Cleft Evaluation Profile, which captures cleft-specific appearance- and speech-related outcomes. Higher scores correspond to less satisfactory outcomes. Desire for revision surgery was assessed as a binary outcome among caregivers. Multivariable regression was used to evaluate the relationship of barriers to care, caregiver-reported outcomes, and desire for revision, adjusting for clinical and demographic covariates.

Results: Sixty percent of caregivers perceived barriers to care, and caregivers who reported poorer access to care described poorer cleft-related outcomes (r = 0.19, p = 0.024). Caregivers with poorer skills (r = 0.17, p = 0.037), expectations (r = 0.17, p = 0.045), and pragmatics (r = 0.18, p = 0.026) subscale scores were associated with worse Cleft Evaluation Profile scores. Barriers were also negatively associated with aesthetic item scores (r = 0.11, p = 0.025). Finally, caregivers reporting fewer barriers were 21.2 percent less likely to express interest in revision surgery.

Conclusions: Barriers to care were associated with poorer appearance-related outcomes and increased interest in revision among caregivers of cleft patients. Enhancing access to care is critical in order to effectively meet goals of care for these families.
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http://dx.doi.org/10.1097/PRS.0000000000004987DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6282168PMC
December 2018

The Ethical and Professional Use of Social Media in Surgery: A Systematic Review of the Literature.

Plast Reconstr Surg 2018 09;142(3):388e-398e

From the Section of Plastic Surgery, Department of Surgery, and the Taubman Health Sciences Library, University of Michigan; the Division of Plastic Surgery, Department of Surgery, Columbia University; and the Division of Medical Ethics, Department of Medicine, Weill Medical College of Cornell University.

Although certain medical societies have released guidelines on the use of social media, plastic surgery, with its inherent visual nature and potential for sensationalism, could benefit from increasing direction regarding the ethical use of social media. The authors hypothesized that although general platitudes for use exist in the literature, guidelines articulating the boundaries of professional use are nonspecific. Systematic searches of MEDLINE, Embase.com, and Cochrane Central Register of Controlled Trials were completed on January 18, 2017. Searches consisted of a combination of Medical Subject Headings terms and title and abstract keywords for social media and professionalism concepts. In addition, the authors manually searched the three highest impact plastic surgery journals (ending in October of 2017). Two authors screened all titles and abstracts. Studies related to clinical medicine, patient care, and the physician-patient relationship were included for full-text review. Articles related to surgery merited final inclusion. The initial search strategy yielded 954 articles, with 28 selected for inclusion after final review. The authors' manual search yielded nine articles. Of the articles from the search strategy, 10 were published in the urology literature, eight were published in general surgery, six were published in plastic surgery, three were published in orthopedic surgery, and one was published in vascular surgery. Key ethical themes emerged across specialties, although practical recommendations for professional social media behavior were notably absent. In conclusion, social media continue to be a domain with potential professional pitfalls. Appropriate use of social media must extend beyond obtaining consent, and plastic surgeons must adhere to a standard of professionalism far surpassing that of today's media culture.
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http://dx.doi.org/10.1097/PRS.0000000000004692DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6112181PMC
September 2018

Persistent Opioid Use Among Children, Adolescents, and Young Adults After Common Cleft Operations.

J Craniofac Surg 2018 Oct;29(7):1697-1701

Section of Plastic Surgery.

Background: Surgical care represents an important source of opioid prescribing and chronic use, but rates of prolonged opioid use following pediatric procedures remain unclear. The authors describe the rates and risk factors for new persistent opioid use in patients after common cleft operations.

Methods: The authors examined claims from the Truven Marketscan databases from January 1, 2010 to December 31, 2014. The authors included opioid-naive patients ages 8 to 25, who underwent 1 of 10 cleft-related procedures. Patients were considered opioid-naïve if they had no opioid prescription fills in the 11 months prior to the perioperative period. The authors obtained a random sample of age-matched, nonsurgical patients from the same dataset to be used as a control group. Included cleft patients had no procedural codes in the 6 months following surgery. All included patients filled an opioid prescription during the perioperative period, defined as 30 days before and 14 days after surgery. The primary outcome was new persistent opioid use, which is defined as continued opioid prescription fills between 90 and 180 days after the procedure.

Results: This cohort included 2039 cleft patients and 2100 control patients. The incidence of new persistent opioid use following surgery was 4.4% and 0.1% in the control group. Higher odds of opioid use 3 months beyond surgery were associated with distractor placement (OR 5.34, CI 2.00-14.24, P = 0.001). Increasing age (OR 1.11, CI 1.04-1.17, P = 0.001) and presence of a gastrointestinal comorbidity (OR 7.37, CI 1.49-36.54, P = 0.014) were also associated with new persistent use.

Conclusions: New persistent opioid use occurs after cleft-related procedures and could lead to chronic use in children, adolescents, and young adults.
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http://dx.doi.org/10.1097/SCS.0000000000004762DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6173989PMC
October 2018

Guidelines for the Ethical Publication of Facial Photographs and Review of the Literature.

Cleft Palate Craniofac J 2019 01 1;56(1):7-14. Epub 2018 May 1.

1 Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA.

Facial photography presents a unique ethical dilemma, as faces are difficult to deidentify for publication. We performed a review of the literature to examine current guidelines for the publication of facial photographs. We also reviewed societies' websites, journal requirements, and ethical and legal aspects of confidentiality. Most articles emphasized the importance of consent for photography and publication. Masking is not appropriate, but some journals continue to allow masking. Most legislation allows patients to restrict the uses of photographs. In the end, it is imperative to protect patient privacy by obtaining consent for photograph publication after full disclosure of risks, and specific recommendations are provided regarding a comprehensive consent process.
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http://dx.doi.org/10.1177/1055665618774026DOI Listing
January 2019

What Should Be the Surgeon's Role in Defining "Normal" Genital Appearance?

AMA J Ethics 2018 Apr 1;20(4):384-391. Epub 2018 Apr 1.

A clinical assistant professor in the Division of Craniofacial Surgery in the Section of Plastic and Reconstructive Surgery at the University of Michigan in Ann Arbor, where he is also co-chief of the Clinical Ethics Service of the Center for Bioethics and Social Sciences in Medicine.

The recent rise in women seeking cosmetic surgery of their genitalia (labiaplasty) coincides with the increasing number of surgeons posting videos of these operations on social media accounts and websites. Sociocultural influences significantly contribute to our ideas of what constitutes healthy and pathologic, and surgeons have historically played a role in defining "normal" and "abnormal" anatomy. In the nineteenth century, Saartjie Baartman-a woman with a large posterior and unusually long labia minora-was used by physicians to "educate" the public about these differences. We examine the parallels with the twenty-first century practice of surgeons using social media to educate patients about the operations they perform and discuss ethical and professional hazards associated with this practice.
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http://dx.doi.org/10.1001/journalofethics.2018.20.4.msoc4-1804DOI Listing
April 2018

When Is Posting about Patients on Social Media Unethical "Medutainment"?

AMA J Ethics 2018 Apr 1;20(4):328-335. Epub 2018 Apr 1.

A clinical assistant professor in the Division of Craniofacial Surgery in the Section of Plastic and Reconstructive Surgery at the University of Michigan in Ann Arbor, where he is also co-chief of the Clinical Ethics Service of the Center for Bioethics and Social Sciences in Medicine.

Social media is characterized by online spaces for rapid communication, advertising, professional development, and advocacy, and these platforms have revolutionized the way we interact with people and our culture. In plastic surgery, platforms like Facebook, Snapchat, and Instagram are especially attractive for practice promotion and instantaneous connection with potential patients. However, considerable risks and ethical dilemmas lie in wait for the plastic surgeon who attempts to use patient photographs and videos for advertising. It is critical for plastic surgeons who use patient images for this purpose to facilitate fully informed consent, consider both context of use and the patient-physician power differential, and put patients' interests ahead of their own.
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http://dx.doi.org/10.1001/journalofethics.2018.20.4.ecas1-1804DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6020156PMC
April 2018