Scientific Abstract Presentations: Craniomaxillofacial Session 2 Thursday, September 26 Thu, Sep 26 1:00-2:30 p.m. PDT

Goals/Purpose: Juvenile localized scleroderma (JLS) is a rare connective tissue disease associated with craniofacial deformities. Surgical intervention seeks to restore facial symmetry through the reconstruction of affected hard and soft tissues. This retrospective study features a case series of JLS patients treated with diverse surgical techniques, providing a comprehensive analysis of outcomes.

Methods/Technique: A retrospective analysis encompassed 21 patients diagnosed with craniofacial scleroderma who underwent reconstructive procedures at a tertiary pediatric hospital between January 2012 and October 2023. Data, comprising patient characteristics, disease progression, medical interventions, primary and adjuvant procedures, complications, and follow-up status were collected.

Results/Complications: Parry-Romberg syndrome (PRS) was the predominant diagnosis (n=14), followed by linear scleroderma (en coup de sabre [ECDS]) (n=2), and localized morphea in (n=2). Patients exhibited an average age of 14.5 ± 5.2 years, a disease duration of 7.4 ± 7.8 years, and a remission period of 4.8 ± 4.9 years prior to their initial surgery. A third of patients (n=7) were taking disease-modifying medication at the time of surgery. The majority underwent multiple procedures (n=15), averaging 2.4 surgeries. Primary interventions included fat transfer (n=20), implants (n=2), free flaps (n=1), facial reanimation via functional muscle transfer (n=1), biomaterial filler (n=1), and dermal grafting (n=1). Adjuvant procedures involved rhinoplasty (n=2) and orthognathic surgery (n=1). In the fat transfer group, the mean number of sessions was 2.3 with a volume of 20.3 cc. Fat grafting complications occurred in four patients, such as extensive fat absorption (n=3), recipient site hyperpigmentation (n=1), and donor site hypertrophic scarring (n=1). In those who underwent flap-based reconstruction, one patient experienced hypertrophic scarring of the donor site and one patient had a surgical site infection which required reoperation. Following malar reconstruction with a customized implant, one patient suffered periorbital cellulitis and recurrent cheek swelling, requiring long-term antibiotics and implant removal. Mild graft contraction was observed in the dermal-graft patient. No significant difference in complication rates existed between patients on active disease-modifying medication versus those not (OR 2.0, 95% CI [0.382, 10.482], p=0.412). There was no distinction in complication rates between patients with disease quiescent intervals below and above one year (OR 1.8, 93% CI [0.259, 12.502], p=0.552). The average follow-up duration was 18.7 ± 19.0 months.

Conclusion: Pediatric JLS patients frequently undergo multiple procedures, with fat transfer the primary surgical intervention, offering favorable aesthetics and minimal risk. Contrary to literary norms, the use of disease-modifying medications and remission duration does not seem to influence surgical outcomes.

Introduction
The timing of procedures for cleft lip and palate patients is constantly evolving and heavily debated. Conventionally, institutions utilizing a two-stage palatoplasty approach perform the soft palate closure at 3 months, hard palate repair at 1 year, and alveolar cleft repair at 6-8 years. Most hard palates are closed without bony reconstitution; however, the lack of support can lead to a collapsed maxillary arch, dental crowding, and posterior cross-bite, particularly in patients with complete clefts. For the past six years, patients at our institution with a complete cleft lip and palate have been treated with a two-staged palatoplasty. Patients undergo cleft lip repair at 3 months, soft palate repair at 10-12 months, followed by concomitant repair of the hard palate and alveolar cleft at 2-3 years of age. A custom hard palate prosthesis is placed during the lip repair and replaced at the time of soft palate repair. Hard palate and alveolar cleft repairs are done with bone grafting, using demineralized bone matrix and bone morphogenic protein. The evolution of our hard palate prosthesis allowed for better alignment of the palate shelves, enabling simultaneous bone grafting of the alveolus and hard palate at the time of hard palate surgery. We aimed to showcase that our unique approach to cleft care has potential advantages over traditional cleft care.

Methods A retrospective analysis of syndromic and non-syndromic patients with a complete unilateral or bilateral cleft lip and palate (Veau 3 & 4 classification) was conducted from 2015 to 2023 at our institution. All patients who underwent a two-staged palatoplasty with alveolar cleft repair at the time of hard palate repair were included. Postoperative outcomes of interest included palatal fistula occurrence and location, bone graft take, and velopharyngeal insufficiency necessitating surgical intervention.

Results A cohort of 45 patients completed the protocol, with 28 veau 3 patients and 17 veau 4 patients. The mean age at hard palate and alveolar cleft repair was 2.5 years, with a mean follow-up time of 3 years. The mean total number of major procedures was 3.5. 46.7% (3/45) of patients, all veau 4, had a subsequent palatal fistula develop. 17.8% (8/45) of patients required an additional bone grafting procedure. There were no significant differences between veau 3 and veau 4 patients. The remaining patients had good consolidation, confirmed by a 6 month post-operative CT scan. Out of the 21 patients with a minimum age of 5 years, 9.5% (2/21) underwent surgical intervention for velopharyngeal insufficiency recalcitrant to speech therapy.

Discussion Our two-staged palatoplasty protocol with early bone grafting has led to the ability to complete the bulk of cleft surgeries by the age of 3, restoring near-normal anatomy of the palate and the piriform aperture at an early age. Our protocol demonstrates complication rates comparable to national single-stage palatoplasty data. Current mid-growth data supports the safety and efficacy of our protocol, and continued growth analysis will follow as this cohort reaches facial maturity.

Purpose: Infants with cleft palate experience early feeding difficulties resulting in increased hospital utilization from prolonged birth encounters and re-admissions for poor nutritional status. Sociodemographic factors influence cleft palate outcomes, but their impact on early nutritional outcomes is not yet described. This study investigates the association of social vulnerability, race, and urbanicity on birth encounter metrics, and failure to thrive (FTT) rates in patients diagnosed with cleft palate.

Methods and Materials: Retrospective data from 2013 to 2023 was queried from Cosmos, a national deidentified database from the Epic electronic health record. Primary outcomes compared birth encounter metrics and prevalence of FTT across sociodemographic cohorts based on 1) social vulnerability index (SVI) quartiles (Q), 2) race, and 3) USDA Rural-Urban Commuting Area codes. SVI, derived from US census data, quantifies community susceptibility to adverse health events. A higher SVI quartile indicates greater social vulnerability. Statistical analysis compared birth weight, birth length of stay (LOS), discharge weight, FTT diagnosis and re-admissions, and utilization of the provider communication platform MyChart.

Results: There were 92,437 patients diagnosed with cleft palate. Birth weight was lower in socially vulnerable and Black patients (SVI Q75: 101.50 ± 1.569oz; SVI Q25: 106.40 ± 1.85oz; Black: 95.3 ± 2.63oz; White: 104.90 ± 1.02oz; Other: 104.80 ± 2.09oz), as was longer length of stay (SVI Q75: 21 ± 2.39 days; SVI Q25: 15 ± 2.18d; Black: 22 ± 4d). The diagnosis of FTT increased consistently at each SVI level from 5.1% in the lower quartile to 7.8% in the upper quartile (Q25: 5.1%, Q25-50: 6.1%, Q50-70: 6.5%, Q75%: 7.8%) p<0.001. As did FTT re-admissions, which increased from 0.19% in the lower quartile to 0.47% in the upper quartile (p<0.001). An opposite trend was observed for MyChart activation rates (p<.001). FTT was significantly higher in Black patients (10.6%) compared to other race categories (range 4.6%-7.1%; p<0.001), as was FTT re-admissions (p<.001). MyChart engagement was highest among White patients (60.3%) and lowest in Black (54.4%) and Other Race groups (52.1%; p<0.001).

Conclusions: Sociodemographic factors affect early outcomes in cleft palate, as evidenced by a large nationwide analysis. Socially vulnerable and Black patients are more susceptible to unfavorable nutritional outcomes including lower birth weights and higher incidence of FTT. Attention toward targeted interventions is needed to reduce disparities in cleft care related to social identities, geography, and community. Access disparities, such as utilization of the MyChart Messaging Platform, may contribute to this phenomenon.

PURPOSE: Single-stage bilateral cleft lip repair is frequently espoused as the gold standard for bilateral cleft lip repair procedures. Two-stage bilateral cleft lip repair is an alternative method that, while not as universally accepted, may result in acceptable functional and aesthetic long-term outcomes. We propose and provide long-term follow-up for a different approach to bilateral cleft lip repair following the principles used for the unilateral cleft deformity. Although the downside of this surgical technique is that it involves an additional operation, in the long-term it may be an acceptable alternative to one-stage repairs.

METHODS: This is a 16-year retrospective review of all patients that underwent two-stage repair for complete bilateral cleft lip deformity, performed by a single surgeon (S.A.W). Patients meeting inclusion criteria were in mixed dentition and were treated with the following protocol: (1) Pre-surgical naso-alveolar molding and approximation of alveolar segments, (2) Staged rotation advancements with gingivosupraperiosteoplasty and closure of alveolar defect extending back to closure of the anterior palate, (3) McComb nasal correction, (4) Rotation advancement lip repair just as is done in a unilateral cleft, (5) Repetition of the procedure on the contralateral side after 3 months, (6) Closure of the remaining hard palate and soft palate with levator muscle retroposition at 18 months. Cephalometric and anthropometric evaluation at mixed dentition was conducted to evaluate midface growth. Mean Farkas anthropometric measurements for patients in our cohort were compared to mean values for non-cleft patients (nasolabial angle, cutaneous/total upper lip height and nasal tip protrusion/nose height). Mean cephalometric values (SNA, SNB, ANB) for our cohort were compared to values for non-cleft patients.

RESULTS: Thirty-two patients were identified via retrospective review who met inclusion criteria. There was no significant difference between anthropometric values for normal versus cleft lip and palate patients for nasolabial angle, cutaneous/total upper lip height, and nasal tip protrusion/nose height (p > 0.05). Anthropometric measurements fell within 1-2 standard deviations of the norm. Cephalometric films were evaluated for 15 patients. Mean SNA was 78.9±4.3, SNB was 74.1±3.8, and ANB was 5.0±3.4, with no significant difference between SNA (80.0±3.7), SNB (74.0±3.4) and ANB (4.0±1.4) for non-cleft patients (p > 0.05).

CONCLUSION: Using the staged method, noses are normal with a normal nasolabial angle and a normal columella. Lips are full and pouting. There is no ventroflexion of the premaxilla. The results that can be obtained with the use of the staged rotation advancement procedure justify continuing its use. The long-term follow-up of this patient population has proven to have results that resemble the dimensions and ratios of the lip and nose of unaffected children.

PURPOSE: Whole-eye transplantation is being investigated as a potential solution for individuals suffering from permanent blindness resulting from facial and ocular injuries. The pivotal challenge in achieving success with this surgery lies in restoring the optic nerve's connectivity, which is challenging due to the inhibitory nature of the central nervous system. Peripheral nerves, unlike their central counterparts, have a demonstrated capacity for regeneration. By leveraging this regenerative potential, scientists and clinicians hypothesize that grafting segments of peripheral nerve tissue could serve as scaffolds or conduits to guide and promote optic nerve regrowth following injury. Given the limited literature on this subject, our aim was to conduct a systematic review that examines the current techniques, outcomes, and challenges related to utilizing peripheral nerve grafts to facilitate optic nerve regeneration. METHODS: Following PRISMA 2020 guidelines, we conducted a systematic review of PubMed, MEDLINE, Cochrane, and Web of Science from inception through June 26, 2023. We included original research studies that employed peripheral nerve grafts to explore optic nerve regeneration following injury or trauma in warm-blooded animal models. Extracted data covered the type and source of the graft, techniques of inducing optic nerve injury, graft implantation methodology, the use of neurotrophins, and observed regenerative outcomes. RESULTS: We included 36 studies, all of which were conducted on rodents. Techniques for inducing optic nerve injuries varied, with transections being the most common method (78%). The sciatic nerve was used for grafting in 75% of the studies. Additionally, 31% of the studies supplemented the peripheral nerve grafts with neurotrophins, including ciliary neurotrophic factor and brain-derived neurotrophic factor. Most studies grafted the peripheral nerve segments to the site of the lesion (67%), while others implanted the graft intravitreally (33%). All studies included at least one outcome measure of optic nerve regeneration, including the count of regenerating retinal ganglion cells, number of regenerated axons distal to the lesion site, or length of regenerating retinal ganglion cell axons. In studies reporting the count of retinal ganglion cells (47%), there was a significant increase in cell regeneration in models utilizing peripheral nerve grafts compared to controls. Seven studies demonstrated a 15-fold increase in regenerating nerve axons 1.8 millimeters from the site of optic nerve lesion after 46 days, on average. In addition, several studies reported an average 2-fold increase in the mean length of axon growth distal to the site of lesion. Notably, there was no evidence of full-length optic nerve regeneration following peripheral nerve graft transplantation. CONCLUSION: This systematic review underscores the potential of peripheral nerve grafts in facilitating retinal ganglion cell regeneration and axonal regrowth, with a significant number of studies reporting positive outcomes. However, there remain consistent challenges, such as graft integration, long-term viability, and translating observed regrowth into tangible functional vision improvements. Additionally, the variability in grafting techniques and methodologies across different studies highlights the need for standardization and optimization. Future research is warranted to assess the effect of peripheral nerve grafts in promoting optic nerve regeneration following whole-eye transplantation.

Purpose: There is a backlog of 4,000,000 patients with unrepaired cleft lip and palate (CLP) in low- and middle-income countries (LMICs) (1). Somaliland is the world's fourth poorest nation and has no practicing plastic surgeons. Since 2011, an American plastic surgeon has conducted 40 surgical camps for CLP patients in Hargeisa, Somaliland and trained the nation's first surgeon capable of repairing cleft lips. Patient age is a surrogate marker for evaluating CLP backlog (2). The purpose of this study was to evaluate the impact of these surgical camps and training program on the backlog of CLP patients.

Methods: A retrospective chart review was conducted on all patients who received CLP repair at Edna Adan University Hospital in Hargeisa, Somaliland between 2011-2024. In the last two years of the study, surgical duties were shared between the visiting surgeon and the locally trained surgeon. Information regarding patient age, cleft etiology and surgical management were retrieved. Chi-squared analysis and t-tests were conducted to compare the first years of surgical camps (2011-12) to the last (2023-24).

Results: Authors identified 787 surgical procedures, 722 of which were primary repairs (229 palates, 18.0 primary repairs per camp). The average age of treatment decreased from 93.3 months in 2011-12 to 51.9-m in 2023-24 (p<0.001). The percentage of patients with primary cleft lip repaired by 6-m increased from 6.8 to 8.8% (p=0.660). The number of patients who were repaired after the age of 6 years decreased from 59.1 to 20.6% (p=0.006). The percentage of patients with primary cleft palate repaired by 18-m decreased from 25.0 to 20.0% (p=0.780). The percentage of patients with primary cleft palate repaired after the age of 6-y decreased from 62.5 to 0.0% (p=0.003). The presence of a locally trained surgeon increased operative capacity by 32.4%.

Conclusions: Despite regular surgical camps and the presence of a local surgeon capable of performing cleft lip repairs, rates of timely CLP treatment in Somaliland remain low. However, the significant decreases in the number of children over the age of 6-y receiving primary CLP repair suggests that surgical camps and training partnerships are efficacious in decreasing the backlog of unrepaired CLP in Somaliland. These findings validate calls for increasing global plastic surgery partnerships in neglected LMICs (3).

1. Borrelli MR, King's College London, WC2R 2LS. What Is the Role of Plastic Surgery in Global Health? A Review. wjps. 2018;7(3):275-282. doi:10.29252/wjps.7.3.275
2. Poenaru D. Getting the job done: analysis of the impact and effectiveness of the SmileTrain program in alleviating the global burden of cleft disease. World journal of surgery. 2013;37:1562-1570.
3. Chung KY. Plastic and Reconstructive Surgery in Global Health: Let's Reconstruct Global Surgery. Plast Reconstr Surg Glob Open. 2017;5(4):e1273. doi:10.1097/GOX.0000000000001273

Introduction Cleft lip and/or palate (CL/P) has one of the highest incidences of any congenital defect, with around 1 in every 700 people born being afflicted with this condition. Because of the prevalence of CL/P, physicians have established a number of techniques even before surgery to improve the outcomes of CL/P repair. For approximately 6 months after birth, neonates have elevated levels of maternal estrogen which allows physicians to readily manipulate the defect prior to a surgical repair. With this in mind, Dr. Barry Grayson initially introduced active nasoalveolar molding (ANAM) and revolutionized CL/P treatment by reducing the alveolar and palatal defects through the traction applied by the device. This treatment can lead to improved surgical results because the defect was reduced. However, this method is quite labor intensive, expensive, and requires weekly visits for adjustments. There have been a number of modifications inspired by the original ANAM technique including passive nasoalveolar molding (PNAM). These techniques require fewer follow up appointments and do not require external taping for support thus making it cheaper, less labor intensive, and have a lower frequency of visits for adjustments. However, the common issue with PNAM methods is that they are not nearly as efficacious as ANAM methods. The goal of this study is to measure the proficiency of a novel PNAM technique in comparison to the commonly implemented Grayson ANAM technique. Methods A retrospective study was conducted on CL/P patients undergoing ANAM and PNAM. Each patient's CL/P was imaged with a three dimensional camera prior to the study and at the end. Using the captured images, the interalveolar width, maxillary width, and the canine positions of each patient was measured prior to initiation of treatment and after cessation of treatment. The change in interalveolar width, maxillary width, and canine positions were then calculated. Two tailed independent t tests were then used to compare the changes in maxillary width, interalveolar width, and canine positions of the two techniques. The PNAM technique n = 16 and the ANAM n = 11. Results The mean for the change in interalveolar segment distance for the PNAM and ANAM techniques were 10.19 mm and 8.32 mm, but there was no significant difference. The mean for the change in canine distance for the PNAM and ANAM techniques were 2.89 mm and 1.74 mm, but there was no significant difference. The mean for the change in maxillary width for the PNAM and ANAM techniques were 1.36 mm and 0.79 mm, but there was no significant difference. Conclusion There is no significant difference in the final results of these two techniques. However, the PNAM technique is less costly, less labor intensive, and requires fewer follow up adjustment visits in comparison to the ANAM technique. Further in depth analysis is needed, however, reducing the costs and barriers to this care will promote improved patient outcomes.

Purpose: In order to optimize speech outcomes, the lead surgeon on this study performs a modified straight-line repair (SLR) palatoplasty with a single layer closure of oral mucosa only at the hard-soft junction. The purpose of this study is to assess fistula and speech correcting surgery outcomes of this modified SLR technique. Methods: A retrospective chart review evaluated patients without a craniofacial syndrome with Veau III or IV CP ± cleft lip who underwent a SLR palatoplasty at our institution from 1993-2023. Patients who underwent the modified SLR by the lead author were compared to those undergoing traditional SLR. The modified SLR technique involves cutting the nasal mucosa with the aberrant insertion of the levator muscle off of the hard palate along the medial pterygoid plate just to the edge of the eustachian tube. This allows for full release of the levator muscle for which maximum length can be achieved. The criticism for this maneuver has always been the single layer closure at the hard-soft palate junction. Primary outcomes included postoperative palatal fistula, fistula location based on the Pittsburgh Fistula Classification System (PFCS), need for fistula repair, and VPI correcting surgery. Multivariate logistic regression was performed adjusting for sex, race, age at palatoplasty, and Veau classification. Results: A total of 1,857 patients underwent palatoplasty, of which 343 met inclusion criteria (160 modified SLR, 183 traditional SLR). Average length of follow-up from palatoplasty was 6.4±5.3 years. Upon multivariate regression, significantly fewer fistulas were observed with the modified SLR versus traditional SLR technique (3.1% vs 15.3%, Odds Ratio [OR]: 0.19; p=0.001). According to the PFCS, modified SLR had Type V (80%, n=4) and Type IV (20%, n=1) fistula locations compared to traditional SLR with Type V (57%, n=16), Type VI (18%, n=5), Type III (14%, n=4), and Type II (11%, n=3) fistula locations. The modified SLR technique compared to traditional SLR was associated with lower rates of fistula repair surgery (0.6% vs 13.1%, OR: 0.26; p=0.022) and VPI correcting surgery (1.0% vs 16.8%, OR: 0.051; p=0.004). Conclusion: The modified SLR technique resulted in fewer fistulas and lower rates of fistula repair surgery and VPI surgery compared to traditional SLR. Release of the nasal mucosa off the hard palate facilitates more posterior positioning of the levator muscle. This may result in improved speech and allow for more medial mobilization of the oral mucosa leading to less tension on repairs at the hard-soft junction accounting for fewer fistulas. A more in depth discussion about the technique to achieve this success is warranted.

Background: Around 85% of patients with Beckwith-Wiedemann syndrome (BWS) have macroglossia, and symptomatic patients often undergo tongue reduction surgery. While many surgical techniques are used, little is known about the relative benefits of different approaches. This study leverages a large cohort of patients with BWS who have had tongue reduction surgery to evaluate the risks and benefits of various surgical techniques.

Methods: Medical records of patients with BWS seen between December 2004 and February 2024 were reviewed for molecular variant, surgical history, pre- and postoperative polysomnography findings, tongue reduction technique, and perioperative complications.

Results: Three hundred and thirty-five patients with BWS and macroglossia were retrospectively reviewed, with 102 undergoing a total of 111 tongue reduction procedures. Six surgical techniques were used: anterior wedge (1, 0.9%), anterior wedge with keyhole (6, 5.4%), peripheral (21, 19.0%), peripheral with keyhole (29, 26.1%), W-plasty (10, 9.1%), and W-plasty with keyhole (35, 31.5%). Obstructive apnea-hypoxia index decreased by 13.1 (3.8-21.0) events/minute after surgery and oxygen saturation nadir increased by 5.5 (-0.5-17.0) % after surgery, with similar improvements across techniques. There were no differences in tongue mass or volume resected using different surgical approaches. The W-plasty technique had the longest operative time (median: 40.0 minutes (interquartile range: 27.0-45.0, p<0.05) and resulted in the most blood loss (12.5 (0-28.8) mL, p<0.001), but incidence of complications, re-operation rates, hospital admission time, and intensive care unit stay were similar across techniques. The peripheral resection had the shortest operative time (24.0 (22.8-31.0), p<0.05) and least blood loss (0 mL; p<0.05). Prior to 2019, our team primarily used the W-plasty with/without keyhole approach (82.5% of total), but since 2019, most surgeries are performed using the peripheral with/without keyhole approach (74.2%, p<0.001).

Conclusion: The peripheral resection is faster and results in less blood loss than the W-plasty surgical technique for treating symptomatic macroglossia in Beckwith-Wiedemann syndrome. This study documents our institutions transition towards increasingly adopting the peripheral resection approach.

Background: Bilateral cleft lip and palate presents a multitude of challenges that significantly impact a child's speech, hearing, language, and psychosocial development. Current management strategies follow a protocol that often does not adjust to patient/family factors or anatomy. This can often necessitate multiple secondary procedures and result in suboptimal outcomes. This retrospective study, conducted at a tertiary care center from 2011 to 2023, aims to investigate the efficacy of a foundation-based approach for patients with bilateral cleft lip and palate. Foundation based approach requires the premaxilla to be in line with the lateral alveolar segments prior to lip and nose repair. Premaxilla is managed using presurgical orthopedics (passive molding and lip taping) and lip/nose repair at 5-6 months of age, or a premaxillary setback at around 10 months of age during palatoplasty, followed by lip and nose repair 3 months later. This study seeks to establish a patient-centered approach and contribute valuable insights into optimizing treatment strategies, potentially reducing the need for additional procedures, and improving overall quality of life.

Methods: This retrospective study included 27 patients who underwent bilateral cleft lip repair. Comprehensive demographic and clinical data were collected, including pre- and postoperative assessments of nose, lip, and palate repair, as well as patient-reported outcomes, along with comorbidities and syndromic status where applicable. Descriptive and comparative statistical analyses were performed using SPSS to evaluate the success of the premaxillary setback, and multivariate analyses were conducted to identify predictors of favorable outcomes.

Results: The cohort predominantly comprised males (63%), with an average age of 12 weeks (range: 1 - 59 weeks) at the onset of initial presentation. Among these patients, 8 (30%) required a surgical setback to correctly position the premaxilla, whereas 19 (70%) attained the desired alignment solely through passive molding. Post-initial repair, 5 patients underwent a total of 7 revision surgeries, which included 6 palate revisions (1 fistula repair and 5 VPD repair), 1 lip revision (wedge excision along free margin with VPD procedure).

Conclusion: Our study presents a foundation-based approach to patients with bilateral cleft lip and palate. Our treatment protocol has evolved over the past 12 years to ensure the premaxilla (foundation) is set before performing lip and nose repair. If required, the palate repair and setback is done before lip repair, which marks a significant departure from traditional methods and addresses the challenge of protrusive premaxilla early in the treatment process. Benefits of the approach include: 1) Appropriate lip and nose aesthetic outcomes, 2) Closure of the junction between primary and secondary palate during palatoplasty, 3) closure of the alveolar ridge and nasolabial fistula during palatoplasty for boneless bone grafting. To avoid secondary VPD related procedures, our current protocol now also includes the use of buccal adipose, with and without buccal myomucosal flaps, at time of primary palatoplasty to manage tissue deficiency during primary palatoplasty.

Background & Purpose: Special consideration is often given to patient age when planning craniofacial procedures. In pediatric patients, the craniofacial skeleton is still maturing and undergoing a rapid period of expansion during the first few years of postnatal life.1 The timing of surgical interventions thus lies in a critical balance: intervening too early or late may lead to suboptimal outcomes or necessitate additional procedures. This is particularly true regarding endoscopic-assisted and open cranial vault reconstructions in craniosynostosis patients.2,3 However, there is conflicting data and a lack of strong consensus regarding the optimal timing for these procedures. While examining a cohort of matched controls for a craniosynostosis study, we hypothesized that weight and sex may impact skull thickness in addition to age.

Methods: Institutional Review Board (IRB) approval was obtained and maintained throughout the study period. A retrospective review of an institution-wide imaging database was performed to identify 40 pediatric patients who received computed tomography (CT) head scans for non-traumatic indications over a 9-year period. Each skull was segmented in 3D Slicer along suture lines into frontal (right and left), parietal (right and left), and occipital segments. Average calvarial thickness per bone segment and overall thickness per skull were then obtained for each subject using vector arrays. Gamma regression models were created to determine the adjusted effects of age, weight, and sex on skull thickness. Results were considered significant at p < 0.05.

Results: We found that for the bilateral frontal bones, left parietal bone, and occipital bone, weight was a more significant predictor of calvarial thickness than age or sex alone (p < 0.001). Age was a marginally more significant predictor of right parietal bone thickness (p = 0.010), although weight itself remained a significant predictor (p = 0.017). The interaction of age and weight was also a significant predictor of left parietal bone thickness (p = 0.009). Further subanalysis showed that among children 1-5 months old, each additional kilogram of body weight resulted in a 1.05-fold increase in left parietal bone thickness (p < 0.001); among children 6-11 months old, left parietal thickness increased 1.06-fold (p = 0.012); and for children 12-17 months old, left parietal thickness increased 1.09-fold (p = 0.036). Overall, weight was a significant predictor of calvarial thickness in all five bone segments and overall per individual skull.

Conclusions: Given these results, we propose that weight be included when considering surgical timing rather than age alone. The lack of consensus and wide range in individual variation in skull thickness by age underscore the need for a more individualized approach to surgical planning in pediatric cranial reconstruction.

  References

1. Huelke DF. An Overview of Anatomical Considerations of Infants and Children in the Adult World of Automobile Safety Design. Annu Proc Assoc Adv Automot Med. 1998;42:93-113.
2. Nguyen DC, Farber SJ, Skolnick GB, et al. One hundred consecutive endoscopic repairs of sagittal craniosynostosis: an evolution in care. J Neurosurg Pediatr. 2017;20(5):410-418. doi:10.3171/2017.5.PEDS16674
3. Pagnoni M, Fadda MT, Spalice A, et al. Surgical timing of craniosynostosis: What to do and when. Journal of Cranio-Maxillofacial Surgery. 2014;42(5):513-519. doi:10.1016/j.jcms.2013.07.018

Background: In this study, we compared the perioperative characteristics and photogrammetric outcomes of patients who underwent endoscopic-assisted fronto-orbital distraction osteogenesis (FODO) versus open FODO via a traditional coronal incision. Methods: We retrospectively reviewed patients treated for unicoronal synostosis (UCS) from 2013 to 2023. Perioperative characteristics were compared between patients who underwent endoscopic-assisted FODO ("endo-FODO") and open FODO. Photogrammetric outcomes at one to three years postoperatively were compared between a sub-cohort of patients who underwent endo-FODO and a contemporaneous sub-cohort of age- and sex-matched controls who underwent open FODO. The formula symmetry ratio=-[ |(1-(s/n)|×100] was used to compare linear periorbital dimensions of the synostosed and nonsynostosed sides, with zero indicating perfect symmetry and a more negative value indicating greater asymmetry. Canthal tilt symmetry was represented by Δ canthal tilt=|(s-n)|. Differences between pre- and postoperative periorbital symmetry ratios, canthal tilt symmetry, orbital dystopia angle (ODA), and frontal bossing angle were calculated, with positive differences representing improvement postoperatively. Results: A total of 34 patients (14 endo-FODO, 20 open FODO) were included. Patients underwent surgery at a similar mean age in the endo-FODO and open FODO groups (6.0±1.7 vs. 6.5±3.4 months, p=0.916). Duration of anesthesia was shorter in the endo-FODO compared to open FODO group (211.0±30.3 vs. 243.4±30.2 minutes, p=0.004), as was estimated blood loss (12.1±6.3 vs. 21.0±8.2 mL/kg, p<0.001) and blood transfusion requirements (15.5±9.3 vs. 68.0±21.9, p<0.001). Twenty patients (10 endo-FODO, 10 open FODO) were included in our photogrammetric analysis, with photographs taken at similar postoperative timepoints in the endo-FODO and open FODO groups (1.6±0.9 and 1.3±0.9, p=0.597). Patients who underwent endo-FODO demonstrated significant improvements in margin-reflex distance 1 (MRD1) symmetry ratio (-65.0±86.1 to -12.7±15.1, p=0.004), palpebral height symmetry ratio (-11.9±6.4 to -5.8±5.7, p=0.004), canthal tilt symmetry (5.1°±3.2° to 1.2°±1.2°, p=0.020), and ODA (81.7°±2.1° to 86.1°±1.9°, p=0.009). Patients who underwent open FODO demonstrated significant improvements in MRD1 symmetry ratio (-36.0±28.9 to -6.6±6.9, p=0.004), palpebral height symmetry ratio (-19.8°±15.4° vs. -5.3°±4.1°, p=0.033), and ODA (82.6°±1.7° to 86.4°±1.7°, p=0.004). All postoperative measurements as well as degrees of improvement were similar between the endo- and open FODO groups (p>0.05). Conclusions: Both endo-FODO and open FODO achieved significant improvements in periorbital symmetry and orbital dystopia at 1.5 years postoperatively. Endo-FODO may achieve comparable aesthetic outcomes to open FODO while demonstrating significantly reduced perioperative morbidity and scar burden.

Purpose: In this study, we compared the long-term photogrammetric and subjective aesthetic outcomes of patients who underwent fronto-orbital distraction osteogenesis (FODO) versus traditional fronto-orbital advancement and remodeling (FOAR). Methods: We retrospectively reviewed patients treated for nonsyndromic unicoronal synostosis (UCS) from 2009 to 2023. Aesthetic outcomes at five years postoperatively were compared between patients who underwent FODO and a contemporaneous cohort of age- and sex-matched controls who underwent FOAR. The formula symmetry ratio=-[ |(1-(s/n)|×100] was used to compare linear periorbital dimensions of the synostosed and nonsynostosed sides, with zero indicating perfect symmetry and a more negative value indicating greater asymmetry. Canthal tilt symmetry was represented by Δ canthal tilt=|(s-n)|. Differences between pre- and postoperative periorbital symmetry ratios, canthal tilt symmetry, orbital dystopia angle (ODA), and frontal bossing angle were calculated, with positive differences representing improvement postoperatively. The presence of several characteristic dysmorphological features were assessed. Results: A total of 28 patients (14 FOAR, 14 FODO) underwent surgery at a mean age of 7.4±2.1 months. At an average of 6.7±1.8 years postoperatively, the FODO cohort achieved superior margin-to-reflex distance 1 symmetry ratios (-6.7±6.4 vs. -20.1±17.7, p=0.010), ODA correction (5.7°±3.2° vs. 3.5°±1.8°, p=0.027) and improvements in canthal tilt symmetry (3.2°±4.2° vs. -0.6°±2.8°, p=0.004) compared to the FOAR cohort. Fewer patients in the FODO cohort exhibited temporal hollowing (14% vs. 79%, p<0.001), supraorbital retrusion (14% vs. 79%, p=0.018), and forehead irregularities (21% vs. 71%, p=0.008) compared to the FOAR cohort. Conclusions: Compared to FOAR, FODO was associated with greater improvements in periorbital symmetry, orbital dystopia, and fronto-temporal retrusion at seven years postoperatively. It will be important to follow these cohorts to cranial maturity to ensure durability of soft tissue changes and to adequately compare results.

PURPOSE: With the advancement of microsurgical techniques, free tissue reconstruction has emerged as an effective treatment for larger and more complex scalp defects. Previous reports on free tissue transfer for scalp reconstruction have either lacked sufficient patient numbers or provided limited follow-up data. We aim to assess flap selection, procedure staging, and long-term complications at our institution in order to provide valuable insights for surgeons in choosing the optimal reconstructive options for patients with complex scalp defects.

METHODS: A retrospective review was conducted of a consecutive set of scalp reconstruction cases that required free tissue transfer between 01/01/2015 and 04/01/2023. Comorbidities, surgical details, and post-operative complications up to 90 days after surgery were noted. Surgical details of interest included pre-surgical scalp defect size, flap selection, whether the procedure was staged, subsequent debulking surgeries, and incidence of concomitant cranioplasty. Postoperative complications identified up to 90 days after surgery included infection, hematoma, wound dehiscence, implant exposure, flap failure, vessel compromise, or death. Descriptive analysis was performed through Microsoft Excel.

RESULTS: There were 33 free flaps performed for scalp reconstruction for 28 patients. Reconstruction for oncologic reasons was done in 75% of cases, and 27% of free flap cases had a concurrent cranioplasty. Common comorbidities included smoking (n=18; 64%) and history of radiation (n=17; 61%).

The most common flaps used for scalp reconstruction were latissimus dorsi muscle flap (LD; n=14; 42%) and anterolateral thigh flap (ALT; n=11; 33%). For LD flaps, hematoma (n=5; 36%) was the most common 30-day postoperative complication. For ALT flaps, wound dehiscence (n=3; 27%) and hematoma requiring return to OR (n=2; 18%) were the most common 30-day postoperative complications. At the end of the 90-day period, partial flap failure occurred in four (29%) LD flaps and two (19%) ALT flaps. Complete flap failure occurred in four (14%) LD flaps and zero (0%) ALT flaps. The 90-day complete flap failure rate for all types of free flap scalp reconstructions was 9% (n=3).

CONCLUSION: Free flap reconstruction can be an effective method for the treatment of complex soft tissue scalp defects, though it is not without its associated morbidities. Understanding the risks and benefits of such procedures is crucial for both surgeons and patients alike.