Background: Adolescents and young adults who undergo gender-affirming care require special consideration in the postoperative period. This study evaluated pain management and perioperative details during our clinic’s transition to outpatient gender-affirming mastectomy (GAM). Methods: This was a retrospective review of demographic and perioperative data for individuals who underwent GAM at a single institution from 2019 to 2022. Patients were grouped by the timing of surgery: before (“preprotocol,” n = 25) or after (“postprotocol,” n = 45) implementation of the outpatient protocol. Multivariate linear and logistic regression and independent t tests were used. Results: There were 70 patients with a mean age of 19.3 years (SD = 1.75 y). Patients who received an erector spinae plane nerve block before the procedure received fewer morphine milligram equivalents postoperatively compared with those who received a postincision erector spinae plane nerve block ( P = 0.006). There was a trend in association such that patients who had liposuction received fewer morphine milligram equivalents ( P = 0.09). The average hospital stay for the postprotocol group was shorter compared with the preprotocol group ( P < 0.001). At discharge, 28% of preprotocol patients were prescribed opioids compared with 9% of postprotocol patients. There was no difference in minor complications between the cohorts. One patient experienced a major complication, which was treated nonoperatively. Conclusions: Our findings highlight the successful implementation of outpatient GAM for young adults at a children’s hospital. The new protocol yielded a shorter duration of hospital stay and less frequent postoperative opioid prescriptions without impacting the incidence of complications.

Only 20% of the current plastic surgery workforce is female, but since 2022 most matched applicants in integrated plastic surgery programs have been women. The aim of this study was to examine current practice models among female plastic surgeons, including those outside of academia, as the field continues to evolve. In this study we surveyed female plastic surgeons in different practice models to elicit perspectives, career path advice, characterize and project trends, and provide recommendations for success. A 37-question survey focusing on demographics, practice models, career paths, desire for practice changes, and advice for women trainees was emailed to 1342 members of the American Society of Plastic Surgeons and The Aesthetic Society. Chi square analyses compared practice type characteristics (academia, employed roles, private practice), at a significance level of .05. Response rate was 53%. Most respondents were age 35-45, in solo practice, trained in traditional pathways, without fellowships, and lacked female mentors. Private practice surgeons were very satisfied in their career, employed surgeons were moderately satisfied, and academic surgeons were mildly satisfied. Academic surgeons reported a higher number of working hours (>60) and cases per month (20-30) than employed or private practice surgeons. Recommendations for success included seeking female mentorship and enhancing business skills and building a social media platform during training. Results highlight the importance of female mentorship and acquiring business skills, and indicate private practice leads to greater career satisfaction. Training programs should consider accounting for these factors to better promote women's success and improve equity in academic practice.

Background: Burn injuries are a global public health problem and continue to be one of the leading causes of unintentional death and injury. Electrical injuries, a relatively rare cause of burns, are increasingly being reported with higher rates of mortality in low and middle-income countries due to rapid industrialization in the absence of safety regulations. Electrical burn injuries can result in death, various organ system dysfunctions, or limb amputations. Methods: A 5-year retrospective, cross-sectional study was conducted to assess the rate of amputation and associated risk factors in electrical burn injuries among burn patients at AaBET Hospital in Addis Ababa, Ethiopia. Results: The rate of amputation among the 150 patients admitted with electrical burn in the study period was 33.3% (n = 50). A majority (62%; n = 31) of the patients were men (M:F 1.6:1) in the age range of 18-65 years. A fallen electrical wire coming in contact with the patients was the cause of the electrical burns in 50% of the cases. 65.3% of the patients had upper limb amputations, whereas 34.7% had lower limb amputations. Major amputations were more likely to occur when the entry site was the hand, whereas minor amputations were more likely to occur when the entry site was the scalp (P = 0.005). Conclusions: Younger male patients were identified as the main victims of electrical burns that resulted in amputations. Electrical burns showed substantial morbidity and mortality of patients. Total body surface area and entry site being the hand significantly affected the level and site of amputation.

Abstract Goals/Purpose The status of women in medicine has been rapidly evolving. Recent data shows that women now make up the majority of current medical students in the United States. Women now constitute 40.5% of integrated plastic surgery residents and make up 20% of the current plastic surgery workforce. The evolving face of the plastic surgery workforce warrants a deeper look at where we stand today. There has been literature published in recent years looking at women plastic surgeons in academia but little attention has been paid to the greater female plastic surgery workforce to include those in other practice settings. The purpose of this study is to look at current practices for female plastic surgeons, paths taken to get there, and advice for young female surgeons and surgical trainees. We aim to characterize and project future trends of the status of women in plastic surgery. We further outline recommendations on how to be successful as a female entering the field. Methods/Technique A survey was created using Survey Monkey with a series of 37 questions. These questions focused on demographics, what practices currently look like, paths taken to get there, individual desires for practice changes, and advice for female plastic surgeons early in their career. Email addresses were obtained through a web-based search using both the American Society of Plastic Surgeons and American Society of Aesthetic Plastic Surgeons listed board-certified female plastic surgeon members in the United States. A total of 748 surveys were emailed and survey responses were collected. Results/Complications There was a total response rate of 33%. Most respondents trained in an integrated pathway program (54%) and did not complete a fellowship (37.7%). The majority practice in a large city (44.6%), work 40-60 hours per week (63.4%) and perform 20-30 cases per month (34.05%). Most respondents work in a solo practice (32.05%). For those that previously worked in a different practice setting, the most common prior settings were small group practice (36.89%) and academia (32.04%). Fifty six percent of women did not have a female mentor. The majority of respondents are very satisfied in their current career (54.63%). The factors that ranked highest for helping women achieve success were persistence (81.14%), patient care (76.75%), patient rapport/communication (77.19%) and grit (74.89%). The highest ranked barrier to success included discrimination as a female (17.18%), lack of mentorship (16.81%), and personal/family demands (16.74%). Recommendations for women pursuing a career in private practice included starting to learn to run a business in residency/fellowship and get additional business education, finding a mentor, and to start growing your social media platform during training. Conclusion The plastic surgery workforce for women continues to evolve. Most practicing female plastic surgeons recommend for trainees to start learning how to run a business during their training and acquire additional business education. In addition, they stress the importance of mentorship throughout this process. As more women continue to enter the field of plastic surgery, mentorship and support for childcare to help with family demands will be paramount to their success. Residency programs should consider incorporating more business training into their curriculum given the majority of trainees will go on to work in a private practice setting.

OBJECTIVE The Craniofacial Condition Quality of Life Scale (CFC-QoL) was used to evaluate the relationship between surgical burden and quality of life (QoL). DESIGN Patient-parent dyads completed the CFC-QoL which queries the following QoL domains: Bullying, Peer Problems, Psychological Impact, Family Support, Appearance Satisfaction, and Desire for Appearance Change. Stepwise multivariate linear regressions were performed for each QoL domain. SETTING Urban tertiary care center. PATIENTS, PARTICIPANTS Pediatric patients with facial differences, and their parents. INTERVENTION Survey study. MAIN OUTCOME MEASURE(S) Demographic, diagnostic, and surgical characteristics were collected. Surgical burden was calculated as the standard deviation from the mean number of surgeries per diagnostic cohort. RESULT Patients (N  =  168) were majority female (57.1%) and Hispanic (64.3%). Diagnoses were cleft lip and/or palate (CLP,n  =  99) or other craniofacial conditions (CFC,n  =  69). Average patient age was 2.3  ±  5.6 years at first reconstructive surgery and 12.3  ±  3.4 years at study enrollment. Patients received an average of 4.3  ±  4.1 reconstructive surgeries.Worse Bullying was associated with higher surgical burden. Worse Peer Problems was associated with higher surgical burden, but only for children with non-CLP CFCs. Worse Family Support was associated with CFC diagnosis, female sex, and higher surgical burden. Worse Psychological Impact was associated with higher surgical burden. Worse Appearance Satisfaction was associated with younger age and with lower surgical burden. Greater Desire for Appearance Change was associated with older age, higher surgical burden, CLP diagnosis, female sex, and non-Hispanic ethnicity. Socioeconomic status did not predict QoL per patient self- or parent-proxy report. CONCLUSIONS Higher surgical burden was associated with worse QoL outcomes in multiple domains.

Abstract Introduction For adolescents, affiliative parenting behaviors (e.g., warm) are generally associated with better sleep and non-affiliative parenting behaviors (e.g., hostile) are associated with deficient sleep. However, specificity of interpersonal behaviors is unknown. We applied an interpersonal theoretical framework and conducted a meta-analysis to test and operationalize the theory that safety and security are necessary for good sleep. Methods Included in the meta-analysis were 41 studies on adolescent (10-19 years) sleep health and parenting behaviors. Studies included a total of 57,549, primarily female (52%), participants (Mage = 14.92, SDage = 2.00). Race/ethnicity was 76.7% White, 5.9% Black, 6.5% Hispanic, 1.5% Asian, and 9.4% Other. Structural analysis of social behavior (SASB) was applied to define and operationalize optimal (e.g., affiliative and autonomy granting/taking) and sub-optimal (e.g., non-affiliative and autonomy granting/taking) parenting behaviors (independent variable). Dependent variables were sleep regularity, duration, efficiency, latency, timing, quality, alertness/sleepiness, and disturbance. The final effect size of interest for analysis was a correlation efficient r. Results Optimal parenting behaviors were associated with longer sleep duration (r = 0.11, p = .02), decreased latency (r = -0.16, p < .001), less daytime sleepiness (r = -0.28, p < .001), and less sleep disturbances (r = -0.22, p < .001). Suboptimal parenting behaviors were associated with decreased sleep duration (r = -0.04, p = .05), increased latency (r = 0.12, p < .01), and more sleep disturbances (r = 0.38, p < .001). Conclusion This study applied interpersonal theory to define and operationalize parenting behaviors and their association with adolescent sleep. Findings support anthropological theory that parental interpersonal warmth is important for adolescent sleep and further indicate that security likely includes appropriate use of structure and autonomy granting behaviors. SASB analysis additionally revealed significant methodological issues that hamper understanding of the role of parental control (versus autonomy-granting) as separate from parental affiliation (versus hostility). This topic points the way to a crucial next step in developing an empirically grounded and comprehensive interpersonal model of sleep. Support (if any)

Background: Innovation is an essential aspect of plastic and reconstructive surgery (PRS), whether it involves improving current processes or implementing radical change that disrupts the status quo. Collaborating and sharing innovations help advance the field of PRS as a whole. Methods: An anonymous survey was administered to members of the American Association of Plastic Surgeons on their opinions of the top five innovations in PRS of the last 100 years. Results: A list of 69 unique innovations were compiled; the top five innovations overall were microsurgery, myocutaneous flaps, craniofacial surgery, negative pressure wound therapy, and organ transplantation. This list was reviewed by the American Association of Plastic Surgeons Technology Committee, and expanded to 100 unique innovations. Conclusions: We discuss why the above innovations were essential to the development of PRS, as well as the unique factors that can make a new product or procedure into something that remodels the field of PRS.

BACKGROUND:Concomitant carpal injuries with dislocations and fracture-dislocations of the carpometacarpal joints (CMCD/FD) are often hard to see on plain radiographs, making advanced imaging a useful diagnostic adjunct. We aim to: (1) characterize bony injury patterns with CMCD/FD; and (2) determine the frequency that preoperative computed tomography (CT) scans change surgical management. METHODS:A retrospective review was performed of patients who underwent operative fixation of CMCD/FD from 2006 to 2021. X-ray and CT scan diagnoses were reviewed and correlated to intraoperative findings and procedures performed. Statistical analyses were performed to evaluate the frequency in which CT scans changed management and the frequency of new intraoperative diagnoses. RESULTS:Seventy-five patients were identified. All patients had a preoperative x-ray, and 27 patients (36%) additionally had a CT scan. Patients who sustained high-velocity trauma were significantly more likely to obtain a CT scan than patients with low-velocity trauma (P = .019); however, the number of additional diagnoses was not significantly associated with trauma velocity (P = .35). Computed tomography scans significantly increased the number of diagnoses (P < .001) and changed operative management in 58% of cases. Six of the 48 patients (12.5%) that did not receive a CT scan had new intraoperative diagnoses, which changed the procedure for five of these patients. New intraoperative diagnoses were identified significantly more when patients did not have a CT scan (P = .04). CONCLUSIONS:Obtaining a CT scan in CMCD/FD patients changed the patient's diagnosis at a significant rate and changed operative management roughly half of the time. The authors recommend routine CT scans be obtained in patients with CMCD/FD.

Background: Acute flaccid myelitis (AFM) is a childhood illness characterized by sudden-onset weakness impairing function. The primary goal was to compare the motor recovery patterns of patients with AFM who were discharged home or to inpatient rehabilitation. Secondary analyses focused on recovery of respiratory status, nutritional status, and neurogenic bowel and bladder in both cohorts.Methods: Eleven tertiary care centers in the United States performed a retrospective chart review of children with AFM between January 1, 2014, and October 1, 2019. Data included demographics, treat-ments, and outcomes on admission, discharge, and follow-up visits.Results: Medical records of 109 children met inclusion criteria; 67 children required inpatient rehabili-tation, whereas 42 children were discharged directly home. The median age was 5 years (range 4 months to 17 years), and the median time observed was 417 days (interquartile range = 645 days). Distal upper extremities recovered better than the proximal upper extremities. At acute presentation, children who needed inpatient rehabilitation had significantly higher rates of respiratory support (P < 0.001), nutri-tional support (P < 0.001), and neurogenic bowel (P = 0.004) and bladder (P = 0.002). At follow-up, those who attended inpatient rehabilitation continued to have higher rates of respiratory support (28% vs 12%, P = 0.043); however, the nutritional status and bowel/bladder function were no longer statistically different.Conclusions: All children made improvements in strength. Proximal muscles remained weaker than distal muscles in the upper extremities. Children who qualified for inpatient rehabilitation had ongoing respiratory needs at follow-up; however, recovery of nutritional status and bowel/bladder were similar.& COPY; 2023 Elsevier Inc. All rights reserved.

Burn injuries are common in low- and middle-income countries (LMICs) and their associated disability is tragic. This study is the first to explore burn scars in rural communities in Mozambique. This work also validated an innovate burn assessment tool, the Morphological African Scar Contractures Classification (MASCC), used to determine surgical need. Using a stratified, population-weighted survey, the team interviewed randomly selected households from September 2012 to June 2013. Three rural districts (Chókwè, Nhamatanda, and Ribáuè) were selected to represent the southern, central and northern regions of the country. Injuries were recorded, documented with photographs, and approach to care was gathered. A panel of residents and surgeons reviewed the burn scar images using both the Vancouver Scar Scale and the MASCC, a validated visual scale that categorizes patients into four categories corresponding to levels of surgical intervention. Of the 6104 survey participants, 6% (n = 370) reported one or more burn injuries. Burn injuries were more common in females (57%) and most often occurred on the extremities. Individuals less than 25 years old had a significantly higher odds of reporting a burn scar compared to people older than 45 years. Based on the MASCC, 12% (n = 42) would benefit from surgery to treat contractures. Untreated burn injuries are prevalent in rural Mozambique. Our study reveals a lack of access to surgical care in rural communities and demonstrates how the MASCC scale can be used to extend the reach of surgical assessment beyond the hospital through community health workers.

BACKGROUND:Tissue expander-assisted component separation can be used to increase the amount of skin, muscle, and fascial components available for repair of congenital abdominal wall defects via a staged approach without the need for flap reconstruction. We present the largest case series to date using a tissue expander-assisted component separation technique for treatment of congenital abdominal wall defects in a pediatric patient population.METHODS:A retrospective chart review of 9 patients with large congenital abdominal wall defects not initially amenable to primary repair between 2009 and 2020 was performed. Patients first underwent placement of tissue expanders, followed by removal once they had reached a sufficient expander volume. Component separation, with and without mesh placement, was performed to achieve abdominal wall closure.RESULTS:The average age of patients at primary repair was 3.2 years (SD ±1.7 years). Eight patients (88.8%) had congenital omphalocele, and 1 patient (11.1%) had gastroschisis; none were amenable to primary repair. The average size of the defects before closure was 87.6 cm2 (SD = 33.6 cm2). Eighteen tissue expanders were placed in 9 patients, 72.2% of which were placed in the plane between the external and internal oblique muscles. Patients were seen in clinic an average of 6.8 times (SD, ±3.3 visits) for volume expansion into the tissue expander, receiving an average of 32.0 mL in each per visit. An average of 4.3 months (SD, ±1.8 months) elapsed between placement and removal of the expanders. At the time of tissue expander removal and abdominal wall closure, the defects ranged from 30 to 132 cm2 (mean, 54 cm2). All defects were successfully repaired using a component separation and bilateral fasciocutaneous flap advancement. Two patients (18.2%) experienced infection of the surgical site and seroma, both of which required debridement. One patient (9.1%) experienced partial thickness skin necrosis that was managed nonsurgically. The overall complication rate was 36.4%.CONCLUSIONS:Omphalocele and gastroschisis can produce abdominal wall defects that are not amenable to primary repair. Staged reconstruction using tissue expander-assisted component separation is a safe and effective method of obtaining adequate local soft tissue to achieve primary closure.

Background: There is a paucity of data on normal intracranial volumes for healthy children during the first few years of life, when cranial growth velocity is greatest. The aim of this study was to generate a normative predictive model of intracranial volumes based on brain magnetic resonance imaging from a large sample of healthy children to serve as a reference tool for future studies on craniosynostosis. Methods: Structural magnetic resonance imaging data for healthy children up to 3 years of age was acquired from the National Institutes of Health Pediatric MRI Data Repository. Intracranial volumes were calculated using T1-weighted scans with FreeSurfer (version 6.0.0). Mean intracranial volumes were calculated and best-fit logarithmic curves were generated. Results were compared to previously published intracranial volume curves. Results: Two-hundred seventy magnetic resonance imaging scans were available: 118 were collected in the first year of life, 97 were collected between years 1 and 2, and 55 were collected between years 2 and 3. A best-fit logarithmic growth curve was generated for male and female patients. The authors’ regression models showed that male patients had significantly greater intracranial volumes than female patients after 1 month of age. Predicted intracranial volumes were also greater in male and female patients in the first 6 months of life as compared to previously published intracranial volume curves. Conclusions: To the authors’ knowledge, this is the largest series of demographically representative magnetic resonance imaging–based intracranial volumes for children aged 3 years and younger. The model generated in this study can be used by investigators as a reference for evaluating craniosynostosis patients.

PURPOSE: The Craniofacial Condition Health-Related Quality of Life Scale (CFC-HRQoL) was used to evaluate the impact of the number of reconstructive surgeries on quality of life (QoL) in an English and Spanish-speaking population of pediatric patients with craniofacial conditions. METHODS: 196 patient-parent dyads completed the CFC-HRQoL. A multivariate linear regression was run to isolate factors that predicted QoL. Number of surgeries was calculated from deviation from the average number of surgeries per diagnostic cohort (cleft lip and/or palate, other congenital CFC, traumatic CFC). RESULTS: Patient cohort was average 12.5 years old, 61% Hispanic, and 55% female. Diagnosis did not significantly predict QoL. Female sex and more surgeries predicted increased desire to change appearance, while older patient age predicted decreased satisfaction with appearance. Parents reported older age and fewer surgeries predicted more teasing by peers. Parents reported more surgeries predicted worse peer relationships and worse psychological impact on patients. Parents reported female sex, more surgeries, and younger age at first surgery predicted less patient satisfaction with appearance. CONCLUSION: In our cohort, patient sex, age, number of surgeries, and age at first surgery predicted QoL.

Background: Alveolar bone grafting is utilized to manage alveolar clefts in patients with cleft lip and palate. However, the timing of bone grafting is variable with conflicting evidence supporting the use of primary alveolar bone grafting (PABG) in clinical practice. Primary Aim: To provide a qualitative systematic review analysis of long-term outcomes after PABG. Materials and Methods: A qualitative systematic review was performed following the Cochrane Handbook and reported using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Summative findings were evaluated using Confidence in the Evidence from Reviews of Qualitative research to assess the quality of evidence supporting the findings. Results: After removing duplication, 2182 publications were identified, and 2131 were excluded after screening through titles and abstracts. Inclusion criteria for this study included patients who underwent PABG at 24 months of age or younger and a minimum of 5 year follow-up. Thirty-two publications met the inclusion criteria and were included for qualitative analysis. Primary outcome measures included cephalometric analysis, bone graft survival, occlusal analysis, hypomineralization, tooth eruption, radiograph analysis, and arch relationships. Four assessment themes were characterized from the systematic review: (1) bone graft survival, (2) craniofacial skeletal relationships, (3) occlusion and arch forms, and (4) recommendations for utilizing PABG in practice. Conclusion: The reported systematic review provides evidence that performing PABG leads to poor long-term outcomes related to bone graft survival and maxillary growth restriction despite some reported positive outcomes.

Background Although multi-center research is needed in pediatric urology, collaboration is impeded by differences in physician documentation and research resources. Electronic health record (EHR) tools offer a promising avenue to overcome these barriers. Objective To assess the accuracy, completeness, and utilization of structured data elements across multiple practices. Study design A standardized template was developed and implemented at five academic pediatric urology practices to document clinic visits for patients with congenital hydronephrosis and/or vesicoureteral reflux. Data from standardized elements in the template and from pre-existing EHR fields were extracted into a secure database. A 20% random sample of infants with data from structured elements from 1/1/2020 and 4/30/2021 were identified and compared to manual chart review at sites with >100 charts; all other sites reviewed at least 20 charts. Manual chart review was standardized across sites and included: clinic and operative notes, orders linked to the clinic encounter, radiology results, and active medications. Accuracy of data extraction was evaluated by computing the kappa statistic and percentage agreement. For sites that had adopted the templates prior to 6/1/2019 (early adopters), a list of eligible patients with an initial clinic visit from 1/1/2020-7/27/ 2020 was generated using standardized reporting techniques and confirmed by manual chart review. Physician utilization of the template was then calculated by comparing patients with data obtained from the note template to the generated list of eligible patients. Results 230 patient records met study criteria. Agreement between manual chart review and data extracted from the EHR was high (>85%). Race, ethnicity and insurance data were misclassified in about 10-15% of cases; this was due to sitespecific differences in how these fields were coded. Renal ultrasound was misclassified 12% of the time; this was primarily due to outside images documented in radiology results but not included in the clinical note. All other data elements had >90% agreement (Figure). Template utilization for early adopters was >75% (75.5-87.5%). Discussion This is the first study in urology to demonstrate that use of structured data elements can support multi-center research. Limitations include: inclusion of only academic sites with the Epic EHR and lack of data on utilization and sustainability at sites without a prior history of structured template use. Conclusions Multi-center research collaboration using EHR-based data collection tools is feasible with generally high accuracy compared to manual chart review. Additionally, sites with a long history of template adoption have high levels of provider utilization. [GRAPHICS] .

Background: Unilateral coronal craniosynostosis (UCS) is the third most prevalent form of craniosynostosis. Traditional treatment of UCS has been achieved with fronto-orbital advancement and cranial vault remodeling (FOAR), but utilization of cranial distraction osteogenesis (DO) techniques has increased. This study aims to compare perioperative complications and reoperation trends in FOAR versus DO techniques at a single institution. Methods: An Institutional Review Board-approved retrospective review was performed from January 1999 to November 2018 at a single institution. Patients were those that have undergone FOAR or DO with an anterior rotational flap technique as previously described. Indications for secondary procedures included: contour deformities, relapse, surgical site infection, and persistent cranial defects. Results: Eighty-one patients with UCS were identified, 64 patients underwent FOAR and 17 patients underwent DO. When perioperative characteristics were compared, patients who underwent DO were younger in age, however, there was no significant difference in transfusion requirement or length of stay between patient cohorts. Surgery time was increased in DO patients. When perioperative complications were compared, more intraoperative dural tears were observed in the FOAR cohort. When unplanned reoperation rates were compared, patients who had undergone FOAR had a statistically significant higher reoperation rates at 5 years of follow up. When including routine distractor removal as a reoperation, reoperative rate was increased in the DO cohort. No difference in reoperation rates was noted at 5 years following index operation. Conclusions: The safety profile of DO is similar to that of traditional FOAR techniques for treatment of UCS. Longer-term follow-up studies are needed to elucidate whether outcomes are durable, but the unplanned reoperation rate in DO is less than that of FOAR at 5 years and presents several advantages that warrants its use in patients with UCS.

Background/Purpose: Pain control is important after penile surgery, and opioid use should be minimized as able. We sought to describe our experience performing complex penile surgeries with vs without post-operative opioids.Methods: A retrospective review of penile surgeries, including 3998 between 2009 and 2019. We iden-tified patients < 8 years who underwent outpatient penile surgery requiring either penile degloving or hypospadias repair. Patients who were or were not prescribed opioids were matched 1:1 by age and type of penile surgery. Primary outcomes of interest were pain-related encounters, delayed opioid prescription, and predictors of pain.Results: 200 children were identified, 100 per group, with mean age 1.3 +/- 0.8 years. 48% were penile degloving procedures, 31% hypospadias repairs with catheters, and the remaining 21% hypospadias repairs without catheters. Perioperative features were comparable between groups(p > 0.05). 59% of patients without opioids had an impromptu post-operative encounter vs 41%, and 20% had an associated pain complaint vs 9%( p = 0.026). Two patients in both groups received delayed opioid prescription(p = 1.00). The presence of a catheter (OR 2.9) and no opioid prescription (OR 2.6) were independent predictors for pain complaint.Conclusions: Patients discharged without an opioid were more likely to contact a provider postoperatively and were more likely to endorse pain complaint (number needed to treat: 9).(c) 2021 Elsevier Inc. All rights reserved.

OBJECTIVE:To determine whether graft survival for patients with congenital anomalies of the kidney and urinary tract (CAKUT) is impaired compared to non-CAKUT counterparts. METHODS:The United States Renal Data System (USRDS) is a national data system that has collected information about end stage renal disease (ESRD) and renal transplantation since 1995. We identified 10,635 first-time renal transplant patients with ESRD attributed to a CAKUT diagnosis transplanted between 1995 and 2018, with follow-up of 7.9 ± 5.8 years. We matched 1:1 with non-CAKUT transplant recipients, using age at transplant, sex, race, year of transplant, and donor-type. We compared renal transplant death-censored graft survival between CAKUT vs non-CAKUT controls, with further stratification for age at transplant and lower urinary tract malformations (LUTM) vs upper urinary tract malformations (UUTM). RESULTS:Graft survival was better in CAKUT patients with a 5-year survival of 83.3% vs 79.3% (P< .001), and CAKUT status infers a hazard ratio of 0.878 for graft failure on multivariable analysis with Cox regression. Favorability of CAKUT status persisted when stratifying for both pediatric (80.3 vs 77.6% P< .001) and adult (84.5 vs 81.4% P< .001) age groups. Looking within the CAKUT population: comparison of LUTM to UUTM yielded no difference, implying that LUTM is not a risk factor for graft failure. Examining pediatric LUTM alone, graft survival was not better than matched non-CAKUT counterparts with 5-year graft survival of 69%-75% for LUTM adolescents. CONCLUSION:Renal transplant graft survival is better overall in CAKUT patients as opposed to non-CAKUT counterparts. Pediatric LUTM patients have similar graft survival to controls.

Introduction The primary outcome metric in patients with craniosynostosis are changes in intracranial volumes (ICVs). In patients who undergo distraction osteogenesis (DO) to treat craniosynostosis, changes are also dependent on the length of distraction. Virtual surgical planning (VSP) has been used to predict anticipated changes in ICV during cranial vault reconstruction. The purpose of this study is to analyze the actual versus predicted ICV changes using VSP in patients who undergo DO for craniosynostosis management. Methods All patients with craniosynostosis treated with DO at a single institution, Rady Children's Hospital, between December 2013 and May 2019 were identified. Inclusion criteria are as follows: VSP planning with predicted postoperative ICV values and preoperative and postdistraction CT scans to quantify ICV. Postoperative ICV and VSP-estimated ICV were adjusted for age-related ICV growth. The primary outcome measure calculated was age-adjusted percent volume change per millimeter distraction (PVCPD), and results were analyzed using paired Wilcoxon signed rank tests. Results Twenty-seven patients underwent DO for cranial vault remodeling. Nineteen patients were nonsyndromic, and 8 patients were syndromic. The median postoperative PVCPD was 0.30%/mm, and the median VSP-estimated PVCPD was 0.36% per millimeter (P < 0.001). A subanalysis of nonsyndromic patients showed a median postoperative PVCPD of 0.29%/mm in nonsyndromic patients that differed significantly from the VSP estimate of 0.34%/mm (P = 0.003). There was also a significant difference in syndromic patients' observed PVCPD of 0.41%/mm versus VSP estimate of 0.79%/mm (P = 0.012). Conclusions Virtual surgical planning overestimates the change in ICV attributable to DO in both syndromic and nonsyndromic patients.

Introduction: The craniofacial asymmetry seen in unilateral lambdoid craniosynostosis may not be effectively treated by posterior cranial vault remodeling, endoscopic suturectomy, and helmet therapy, or suturectomy and distraction osteogenesis alone due to limitations in soft-tissue envelope expansion and relapse of the deformity. The authors report a series of unilateral lambdoid craniosynostosis patients treated with a posterior rotational cranial-flap technique using internal distraction osteogenesis. Methods: Posterior cranial vault reconstruction combined with internal distraction was used, aided by preoperative virtual surgical planning. An in situ posterior rotational flap osteotomy was utilized to maximize dural preservation. Primary outcome measures included age-adjusted volume change and age-adjusted percent volume change per mm distraction. Distraction characteristics and perioperative characteristics were also assessed. Results: A total of 5 patients were identified. Mean predistraction intracranial volume was 1087.5 cc (SD = 202.3 cc) and mean postdistraction included intracranial volume was 1266.1cc (SD = 131.8cc). Mean age-adjusted percent included intracranial volume change was 14.1% (SD = 9.6%), and mean percent intracranial volume change per mm distraction was 0.43%/mm distraction (SD = 0.37%/mm distraction). One patient developed a distractor site infection postoperatively that was treated successfully with oral antibiotics. All patients had a Whitaker score of 1 at one year follow up. Conclusions: Posterior cranial vault remodeling using osteogenesis and a rotational cranial flap technique with dural preservation can be effectively used to maximize bone flap viability and limit postoperative relapse in patients with unilateral lambdoid craniosynostosis. Long term analysis as well as comparison to open techniques will need to be interrogated.