Scientific Abstract Presentations: Craniomaxillofacial Session 9 Saturday, September 28 Sat, Sep 28 8:00-9:30 a.m. PDT

Purpose: The mandible is the second most fractured facial bone. While closed reduction via mandibulomaxillary fixation (MMF) is therapeutically beneficial, open reduction internal fixation (ORIF) has become the standard of care for the treatment of mandibular fractures. Timing of ORIF has evolved through time and has been a subject of debate for decades. Existing research investigating the association between timing of ORIF and postoperative complications is characterized by small sample sizes and yields conflicting recommendations regarding early vs delayed surgical intervention (Reference 1). Our study aimed to investigate the association between timing of ORIF and the incidence of postoperative complications. Methods: We conducted a retrospective cohort study of trauma patients who underwent mandibular fracture repair in 2018 and 2019. Excluded were patients <18 years old, those who underwent MMF only, and those with postoperative follow-up <2 weeks. The primary outcome was the incidence of postoperative complications following ORIF. The duration between injury and ORIF was categorized into: 1-3, 4-7, 8-14, and >14 days. The association between surgical timing categories and the incidence of postoperative complications was assessed using bivariate analyses and multivariate logistic regression. Results: Of n=226 patients included, median (IQR) age was 32 (25-42) years, and median (IQR) follow up was 49 (25-118) days. The majority of patients (n=207 [92%]) underwent both ORIF and MMF. Most patients had early ORIF within 3 days of injury (n=168 [74%]). Figure 1 shows the distribution of ORIF procedures by days from injury to surgery. Major postoperative complications included unplanned reoperation (n=25 [11.1%]), malocclusion (n=20 [8.8%]), and malunion (n=7 [3.1%]). Minor postoperative complications included jaw pain (n=91 [40.3%]), mental nerve paresthesia (n=79 [35%]), infection (n=30 [13.3%]), temporomandibular joint complications (n=17 [7.5%]), and wound dehiscence (n=14 [6.2%]). After controlling for potential confounders of the association between timing of ORIF and postoperative complications e.g., mechanism of injury, past medical history, and mandibular fracture site, delayed ORIF beyond 2 weeks of injury was associated with significantly greater odds of malunion (aOR [95% CI] 17.9 [1.9->100], P=0.012) and unplanned reoperation (aOR [95% CI] 5.8 [1.3-26], P=0.023). Delayed ORIF 8-14 days after injury was associated with significantly greater odds of malocclusion (aOR [95% CI] 14.5 [1.8->100], P=0.012). Conclusion: The timing of ORIF following mandibular fracture is a critical factor in postoperative outcomes. Delayed ORIF beyond 1 week of injury was significantly associated with greater odds of postoperative complications. Our findings underscore the importance of timely ORIF in the management of mandibular fractures to minimize the risk of postoperative complications.

Reference: 1. Stone N, Corneman A, Sandre AR, Farrokhyar F, Thoma A, Cooper MJ. Treatment Delay Impact on Open Reduction Internal Fixation of Mandibular Fractures: A Systematic Review. Plast Reconstr Surg Glob Open. 2018 Jun 18;6(6):e1829. doi: 10.1097/GOX.0000000000001829.

Purpose The cleft lip and palate patient (CLCP) requires multiple interventions to address structural and functional deficits. Alveolar bone grafting (ABG) during mixed dentition is performed to stabilize the maxillary arch and to facilitate closure of oronasal fistulas. Some patients will also undergo revision palatoplasty during this time period to treat velopharyngeal insufficiency (VPI). In the following study, we evaluate the safety and efficacy of performing revision palatoplasty at the time of ABG.

Methods A retrospective single institution review was conducted of pediatric patients with CLCP who underwent ABG at a large urban academic children's hospital from 2017 to 2023. Patient records were reviewed for age at surgery, cleft repair type (unilateral or bilateral), grafting method, performance of concurrent procedures, surgery duration, and length of hospital stay. The primary outcome, bone graft success, was confirmed by imaging at least 6 months postoperatively. Patients who underwent revision rhinoplasty, cheiloplasty, and myringotomy tube placement at the time of secondary ABG were excluded. Statistical analyses were performed using R studio (Posit, PBC) to examine differences between patients who underwent concurrent revision palatoplasty with ABG (ABG+VPI) and ABG alone (ABG Only).

Results Of the 156 ABGs performed, 102 (65.4%) met our inclusion criteria. Thirteen patients (12.7%) underwent ABG+VPI and eighty-nine patients (87.3%) underwent ABG Only. The median age at the time of surgery was 9 years (IQR:8-10) and 61.8% of patients had a unilateral cleft palate. There were no significant differences in age, cleft laterality, or grafting method between the groups. The median operative time for the ABG Only patients was 75 minutes (IQR:63-97), compared to 134 minutes (IQR:108-162) for the ABG+VPI group (p <0.001). Patients in the ABG+VPI group had planned admissions, with a median length of stay of 20 hours (IQR:19-24). Whereas those in the ABG Only group were discharged a median of 2 hours (IQR:1-2) after arrival in PACU (p < 0.001). There were no complications for either group. Post-operative imaging confirmed bone graft success in 57.1% of ABG Only and 61.5% of ABG+VPI patients (p > 0.9).

Conclusion While we do not want to delay VPI surgeries, some CLCP patients do not have an indication for surgery until later in life. Our study demonstrates that revision palatoplasty can be performed safely at the same time as ABG without affecting graft survival. This is an important consideration for this complex patient population to potentially minimize the overall number of surgeries.

Purpose: Historical management of complex lesions with calvarial extension involves staged resection and reconstruction, which requires multiple operations and is complicated by scalp flap contracture and scarring of surgical planes with subsequent distortion of anatomic landmarks. Advances in virtual surgical planning (VSP) and intraoperative guided navigation have enabled new possibilities for complex, multi-disciplinary, single-stage resection-reconstruction. Multiple prior studies have demonstrated the safety and utility of custom PEEK (polyetheretherketone) implants for calvarial defect reconstruction, however, a paucity of articles with limited sample size have been reported regarding VSP-guided one-stage extirpation and reconstruction. We describe our technique and report outcomes for the largest cohort to date of single-stage, VSP-guided oncologic resection and custom fabricated PEEK implant reconstruction.

Methods A retrospective review was performed from September 2019 to February 2024. Patients were included if they underwent preoperative VSP and design of intraoperative cutting guides and custom PEEK implants for simultaneous neoplastic/dysplastic lesion excision and PEEK reconstruction. Data including demographics, defect location and characteristics, length of surgery, length of hospital stay, estimated blood loss (EBL), length of follow up and postoperative complications were recorded. A brief description of planning and operative technique is provided.

Our technique involves a joint preoperative VSP session with the neurosurgical and plastic surgery teams for design of the cutting guides and PEEK implant. Cutting guides are designed based on available imaging with a margin as determined by the extirpative surgeon. Contour, boundaries, and location of planned fixation of the PEEK implant are then designed by the plastic surgeon. Intraoperatively, the overlay of the cutting guide and tumor are confirmed by linked intraoperative guided navigation. Precise extirpation enables high fidelity fit of preoperatively custom fabricated PEEK implants.

Results: During the study period, 10 patients (6 female, average age 55 years) underwent single-stage VSP-guided extirpation and immediate PEEK implant reconstruction. Defect etiologies included meningioma (n=3), fibrous dysplasia (n=2), metastatic tumor (n=2), glioma (n=1), hemangioma, and invasive recurrent dermoid cyst (n=1). The majority of defect locations predominantly involved the frontal bone and various additional regions of the fronto-orbital-temporal-skull base (6/10) or occupied the occipital/parietal regions (4/10). Average defect diameter was 10cm. Mean case duration was 363 +/- 173 minutes with a mean EBL of 281 +/-130 cubic centimeters. Median (IQR) hospital length of stay was 3 days (4.25). Median (IQR) follow up was 36.5 (71.75) days. One patient developed a postoperative cerebrospinal fluid leak requiring diversion complicated by ventriculitis and intracranial abscess requiring washout and PEEK implant removal. Otherwise, no complications were noted. One patient noted mild contour irregularities of the temporal region, otherwise, patients were satisfied with the aesthetic outcomes of reconstruction

Conclusions: VSP-guided single-stage resection and PEEK implant reconstruction as performed by a multidisciplinary plastic surgery and neurosurgical team is feasible with low complication rates and good cosmetic outcomes. Future interventions comparing overall cost, hospital length of stay, number of operations and complications between staged vs simultaneous resection/reconstruction are needed to better characterize the potential benefits of this emerging technique.

Purpose: Ear molding is a non-invasive, effective treatment modality for congenital auricular deformities. However, limited literature to date addressed disparities in access to ear molding. We hypothesized that patients who underwent ear molding therapy tended to come from more socioeconomically advantaged backgrounds.

Methods: We retrospectively reviewed all patients with a primary diagnosis of congenital auricular deformity who underwent ear molding between April 2015 and October 2023 at a single institution. Descriptive statistics were performed to characterize the cohort's demographic, socioeconomic, and clinical characteristics. The national percentile and state decile for the Area Deprivation Index (ADI) score corresponding to each patient's block group based on home address were extracted from the Neighborhood Atlas website (Center for Health Disparities Research, University of Wisconsin School of Medicine and Public Health, Madison, WI). The empirical cumulative distribution functions for the cohort's ADI national percentiles and state deciles were plotted and compared with the null cumulative percentile and decile distribution functions, respectively; two-sample one-sided Kolmogorov-Smirnov tests were used to evaluate the statistical significance of differences in the distributions. Alpha levels were set a priori at 0.05.

Results: 140 patients underwent ear molding therapy during the study period. Mean age at treatment initiation was 15.4 days (standard deviation = 8.6 days). Male infants accounted for 56% of the cohort (N = 78). Most of the patients were White/Caucasian (N = 108; 77%) and non-Hispanic/Latino (N = 116; 83%). English was the primary household language in 135 patients (96.4%). Private insurance paid for the treatment in the majority of patients (N = 95; 68%), followed by Medicaid/Child Health Plus (N = 40; 29%), self-pay (N = 3; 2%), and other types of government insurances (N = 2; 1%). The empirical cumulative distribution function (eCDF) for the cohort's ADI national percentiles was significantly greater than the null cumulative percentile distribution function (D+ = 0.21; p = 0.012), indicating that our cohort of patients undergoing ear molding therapy tended to be more socioeconomically disadvantaged on a national scale. Similarly, the eCDF for the cohort's ADI state deciles also showed dominance over the respective null distribution, suggesting higher deprivation in the ear molding cohort on a state level, although this relationship was not statistically significant (D+ = 0.50; p = 0.084).

Conclusions: Contrary to our initial belief that patients who have access to ear molding therapy tend to be more socioeconomically advantaged, evidence from our cohort demonstrated that those who received this treatment might come from less privileged or at least similar socioeconomic backgrounds compared to the general population. This finding may suggest successful pipelines from the early diagnosis of auricle deformities by pediatricians to timely referral to pediatric plastic surgeons and favorable insurance coverage patterns for this condition, although further investigations are warranted to elucidate other factors that influence this relationship.

Introduction Several studies suggest high rates of relapse with larger orthognathic maxillary advancements in patients with cleft lip and palate (CLP), yet this is common practice in many craniofacial centers. We have employed LeFort 1 osteotomy and maxillary distraction osteogenesis (MaxDO) in a range of patients with substantial negative overjet, either as a bridge to orthognathic surgery or with the aim to avoid it. We studied patterns and outcomes of maxillary distraction, with a primary endpoint of malocclusion requiring secondary orthognathic surgery. Methods We retrospectively reviewed all patients with a diagnosis of CLP who underwent MaxDO from 2007 to 2022. Using patient factors, age at skeletal maturity, cephalometric analysis, and surgical history, we determined predictors for long-term occlusal normalization and risk factors for relapse and additional orthognathic surgery. Chi-square tests were used for binomial variables and a multivariate logistic regression was performed. Results Twenty-six patients with CLP who underwent MaxDO for midface hypoplasia and Angle Class III malocclusion between ages 9.0-19.2 years were included. There were 11 female and 15 male patients. Seventeen patients (65.4%) had bilateral clefts and six patients (23.1%) were syndromic. These patients had an average of 12.5 ± 2.5mm negative overjet preoperatively, had an average ANB angle of -7.6 ± 2.7 degrees, and they were distracted an average of 13.9 ± 3.1 mm. Nine patients (34.6%) underwent additional orthognathic surgery for definitive skeletal correction. Patients with genetic syndromes (66.7% versus 30.0%), age younger than 14 (46.2% versus 30.8%), and bilateral clefts (47.1% versus 22.2%) had higher rates of secondary orthognathic surgery. In females, MaxDO achieved stable occlusion without additional surgical intervention in 83.3% of those who underwent surgery after the age of 13.5 years, compared to 0% under 13.5 years (Figure 1, p=0.006). In males, MaxDO achieved stable occlusion without additional surgical intervention in 50.0% after the age of 17 years, compared to 0% below 17 years (Figure 1, p=0.018). On multivariate logistic analysis, older age at time of MaxDO was associated with long-term normalization of occlusion (p=0.045). Conclusion Le Fort I distraction osteogenesis effectively achieves maxillary advancements of greater than 12mm in patients with cleft lip and palate. In young children, maxillary advancement with distraction osteogenesis may normalize severe malocclusion through secondary school ages as a bridge to definitive orthognathic surgery. For some patients, surgical overcorrection into a skeletal Class II relation can avoid future orthognathic surgery while they are orthodontically treated into a final occlusion. In most females over 13.5 years of age and half of males over 17 years of age, strategically planned maxillary distraction osteogenesis achieves stable normalization of occlusion without need for further orthognathic surgery.

Background: Perioperative pain control in cranial vault remodeling (CVR) poses significant challenges. Pain medication administration may conceal signs of neurologic compromise related to intracranial surgery. Additionally, increased narcotic use in CVR has been associated with increased length of hospital stay, hypoxic respiratory events and increased episodes of emesis prolonging recovery.[1] The purpose of this study was to identify modifiable factors associated with increased narcotic use in an effort to optimize pain management and postoperative recovery.

Methods: A retrospective review was performed on 237 patients with craniosynostosis who presented to a tertiary pediatric hospital between 2012 and 2020 for open CVR. Outcomes of interest included total morphine equivalents for hospitalization.

Results: Patients who received postoperative NSAIDs required significantly lower total morphine equivalents (ME) for hospitalization (ME = 0.43±0.48 cc/kg) compared to children who did not receive NSAIDs (ME = 1.12±1.17 cc/kg, p<0.005). The relationship between total volume transfused intraoperatively (mL/kg) and total ME for the hospitalization (cc/kg) had a moderately significant positive relationship (r = 0.25, p<0.001). There was a weak positive relationship between operative time and total hospitalization ME (cc/kg) (r =0.18, p0.006). Subjects who underwent placement of a drain received significantly higher total hospitalization ME when compared to those who did not (ME=1.39±1.25 cc/kg) versus (ME= 0.46±0.49 cc/kg, p<0.001).

Conclusions: Postoperative NSAID use is associated with decreased narcotic requirements during the immediate postoperative period whereas increased fluid requirements intraoperatively, longer operative durations, and drain placement are associated with higher narcotic use. Modifying these intraoperative factors when clinically appropriate may reduce postoperative narcotic requirements and expedite postoperative recovery.

1. Smith, K.J., et al., Pediatric Outcomes following Cranial Vault Remodeling with Restricted Use of Postoperative Narcotics: A Retrospective Review. Plast Reconstr Surg, 2022. 150(6): p. 1293e-1299e.

Purpose: Tranexamic acid (TXA) has become an increasingly common adjunct to assist with the mitigation of blood loss in both elective and traumatic surgery. Through its mechanism of action of inhibiting the activation of plasmin and therefore inhibiting the breakdown of clotting, it is thought to assist in limiting intraoperative blood loss. This study examines a single institution's use of TXA in cranial vault remodeling surgery and how it correlates with improved recovery following cranial vault remodeling surgery.

Methods: A retrospective chart analysis of 168 patients who underwent craniosynostosis surgery between 2012 and 2023 at the authors' institution was performed. 149 patients received a loading and maintenance dose of TXA during surgery. Outcomes recorded included TXA loading and running dose, estimated blood loss, blood replaced, length of hospital stay and morphine equivalents needed.

Results: While the dose was not consistent in all patients, all patients receiving TXA within the study received a loading and maintenance dose. For the TXA cohort, there was a trend towards a decrease (R = 0.3) in overall blood loss, blood replacement and percent loss of circulating blood volume; however this was not statistically significant. Even though the average weight of patients in the TXA cohort was lower, indicating a lower blood volume, the patients who received TXA on average lost 6% less of their total blood volume. Also, the average blood loss in these cases decreased from 280 cc to 199 cc, but this as well as the percent loss was not statistically significant. Additionally, there was a trend (p = 0.087) in patients that received TXA and decreased ICU stay and a significantly (p = 0.043) decreased amount of morphine equivalents required postoperatively.

Conclusion: In evaluation of this subset of patients, while there was not a statistically significant decrease, there was a trend toward less surgical blood loss and the amount of resuscitative blood products needed in the patients that received TXA in cranial vault remodeling surgery. This may have contributed to the enhanced recovery of these patients which was noted by the trend towards a decreased ICU stay and a significant decreased need for morphine products in the postoperative period.

Background : Early detection of rare genetic diseases, including velocardiofacial syndrome (VCFS), is essential for patient well-being. However, their rarity and limited clinical experience of physicians make diagnosis challenging. Deep learning algorithms have emerged as promising tools for efficient and accurate diagnosis [1]. This study investigates the use of a deep learning algorithm to develop a face recognition model for diagnosing VCFS. Methods: The study employed publicly available labeled face datasets to train the multitask cascaded convolutional neural networks (MTCNN) model [2]. Subsequently, we examined the binary classification performance for diagnosing VCFS using the most efficient face recognition model. A total of 98 VCFS patients (920 facial photographs) and 91 non-VCFS controls (463 facial photographs) were randomly divided into training and test sets. Additionally, we analyzed whether the classification results matched the known facial phenotype of VCFS [3]. Results: The face recognition model demonstrated high accuracy, ranging from 94.03% to 99.78%, depending on the training dataset. The accuracy of the binary classification diagnostic model varied from 80.82% to 88.02% when evaluating with photographs taken at various angles, but reached 95.00% evaluating with frontal photographs only. Gradient-weighted class activation mapping heatmap revealed the high importance level of perinasal and periorbital areas, exhibiting consistency with the conventional facial phenotypes of VCFS. Conclusion: This study shows the feasibility and effectiveness of MTCNN-based model for detecting VCFS solely from facial photographs. The high accuracy underscores the potential of deep learning in aiding early diagnosis of rare genetic diseases, facilitating timely interventions for patient care.

References 1. Porras AR, Rosenbaum K, Tor-Diez C, Summar M, Linguraru MG. Development and evaluation of a machine learning-based point-of-care screening tool for genetic syndromes in children: A multinational retrospective study. Lancet Digit Health. 2021;3:e635-e643. 2. Zhang K, Zhang Z, Li Z, Qiao Y. Joint face detection and alignment using multitask cascaded convolutional networks. IEEE Signal Process Lett. 2016;23:1499-1503. 3. Gurovich Y, Hanani Y, Bar O, et al. Identifying facial phenotypes of genetic disorders using deep learning. Nat Med. 2019;25:60-64.

Background: Although craniosynostosis has been linked to developmental delays, current studies often fail to account for additional patient characteristics that may independently impact rates of cognitive and speech delays in these cohorts. This study sought then to assess predictors of developmental delays in children undergoing surgical management of craniosynostosis. Methods: Retrospective chart review was performed on patients with craniosynostosis who underwent surgical correction at a single institution between 2016-2023. Logistic regression identified predictors of developmental and speech delays. Variables included age, gender, insurance status, syndromic presentation, sutural involvement, surgical approach, revision surgery, and neurodevelopmental comorbidities. Delay comorbidities were defined as coexistent patient conditions impacting long-term speech and cognition apart from their synostosis. Results: A total of 300 patients underwent either endoscopic (53%) or open (47%) surgical correction. Median age at surgery was 4.2 months [IQR 2.6-10.3 months]. Revision surgery was performed in 2.7% of patients. Syndromic presentations were observed in 6.0%. Of the total cohort, 9.0% were diagnosed with developmental delay and 13.7% had speech delays. The most prevalent neurodevelopmental comorbidities included autism (4.0%), hearing loss (3.7%), hydrocephalus (3.3%), and epilepsy (1.7%). Delay comorbidities [OR = 1.33; 95% CI 1.20-1.47; p < 0.01] and need for revision surgery [OR = 1.45; 95% CI 1.19-1.76; p < 0.01] increased odds of a concurrent developmental delay diagnosis. Odds of speech delay were also increased by delay comorbidities [OR = 1.45; 95% CI 1.28-1.64; p < 0.01] and revision surgery [OR = 1.38; 95% CI 1.09-1.76; p < 0.01]. Factors associated with longitudinal rehabilitation resource utilization at latest follow-up were delay comorbidities [OR = 1.50; 95% CI 1.28-1.76; p < 0.01], age at surgery > 6 months [OR = 1.24; 95% CI 1.06-1.44; p < 0.01], and use of early intervention/school programs [OR = 1.57; 95% CI 1.20-2.06; p < 0.01]. Conclusions: In the general population, there is a 17% rate of developmental delay in children and a 2-19% rate of speech delay. As demonstrated in this study, the rates of developmental delays in patients undergoing surgical correction of craniosynostosis mirror those of the general population. Consistent predictors of developmental delays in craniosynostosis patients include need for revision surgery and co-existent developmental comorbidities. Notably, surgical approach, sutural involvement, and age at surgery > 6 months were not independent predictors of developmental or speech delays. Future studies linking synostosis to developmental delays and assessing neuropsychological outcomes after surgery should control for these factors.

PURPOSE: Whole-eye transplantation has emerged as a potential intervention for cases of irreversible blindness due to facial and ocular trauma. Central to the success of this procedure is reconnection of the optic nerve, which has historically been considered incapable of regeneration due to the central nervous system's inherent inhibitory environment. Stem cells have the ability to differentiate and promote tissue repair and have been proposed as a potential method to enhance optic nerve regeneration and function. Due to the paucity of literature on this topic, we sought to perform a systematic review analyzing the current methodologies, outcomes, and challenges surrounding the use of stem cells as an approach to promote 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 utilizing stem cells to investigate optic nerve regeneration in the setting of injury or trauma in warm-blooded animal models. Data extraction included animal model and stem cells used, techniques for optic nerve injury and application of stem cells, and outcome measurements. RESULTS: We included 29 studies, of which 93% utilized rodent models and 72% induced injury though optic nerve crush. Regarding stem cells, 72% utilized mesenchymal cells while 24% chose neural cells. Most studies injected stem cells intravitreally following optic nerve crush (59%), while others injected them at the site of the lesion (17%) or in the sub-tenon space (10%). All studies included at least one outcome measure of optic nerve regeneration, including the number of regenerated axons distal to the lesion site, relative expression of growth-associated protein 43, or density of retinal ganglion cells. Of these, 11 studies demonstrated a 9-fold increase in regenerating nerve axons 825 micrometers from the site of optic nerve lesion after 54 days, on average. Additionally, 7 studies reported an average 4-fold increase in relative expression of growth-associated protein 43 over 18 days. Several studies (38%) also reported functional outcome measurements, including those from electroretinograms or flash visual evoked potentials. Two studies reported improved flash visual evoked potential outcomes based on the decrease in the latency of the P1 wave. Additionally, 6 studies demonstrated improved electroretinogram results following stem cell transplantation indicated by an augmented a-wave amplitude or an increased amplitude of the scotopic threshold response. Notably, there was no evidence of full-length optic nerve regeneration nor complete restoration of retinal function following stem cell transplantation. CONCLUSION: Stem cells appear to be a viable option to enhance optic nerve regeneration following injury due to trauma. Many studies demonstrated positive preliminary results, including enhanced optic nerve regrowth and even functional improvement in certain models. Identifying the most efficacious stem cell type, perfecting delivery mechanisms, and ensuring long-term cell survival are challenges that should be explored. Furthermore, understanding the integration of regenerated nerve fibers within the intricate visual pathway is crucial. Given the findings of our review, additional research is warranted to assess long-term optic nerve regeneration after whole-eye transplantation with stem cells.

Introduction: Blood transfusion is common in cranial vault surgery, and protocolized efforts to minimize transfusion have been reported in recent years. This study assesses the long-term, prospective outcomes of a pediatric blood management protocol for the cranial vault reconstruction (CVR) population.

Methods: A protocol for preoperative hematologic optimization of patients undergoing CVR was developed. In brief, patients were screened with standard hematologic laboratory assessment. Based on patient hemoglobin (Hgb), preoperative interventions were recommended: if Hgb >13 g/dL, no further intervention was required, those between 10 and 13 g/dL were given oral vitamin C, oral iron, and erythropoietin alfa/darbepoetin alfa, and those <10 g/dL received additional intravenous iron supplementation. Patients found with abnormal coagulation studies underwent formal hematology consultation. Preoperatively, patients received tranexamic acid (TXA) and/or aminocaproic acid. Intraoperatively, cell-saver technology and blood sparing operative techniques were employed. Postoperatively, iron or erythropoietin alfa supplementation was prescribed. Prospective data was collected for all CVR patients from January 2016 - October 2023. A retrospective control cohort of patients undergoing CVR without the described protocol from January 2015 - December 2015 was also reviewed. For statistical analysis, p<0.05 was deemed significant.

Results: A total of 194 successive patients (20 control, 174 treatment) underwent CVR from January 2015 - October 2023. Age, sex, and weight were not significantly different between control and treatment groups (Age: 11.1 vs 13.0 months; Sex (Male): 65.5% vs 67.8%; Weight (kg): 8.6 vs 9.4). Mean postoperative Hgb was significantly higher in the control group (10.9 vs 9.4 g/dL, p<0.01). No difference was observed in Hgb at time of discharge between control and treatment groups (9.6 vs 9.4 g/dL, p>0.05). Mean estimated blood loss (217.4 vs 125.2 ml, p<0.01) and volume of intraoperative packed red blood cells (223.8 vs 47.8 ml, p<0.001) were significantly higher in the control group compared to the treatment group. The rate of packed red blood cell transfusion (80.0% vs 31.6%, p<0.001) and mean total transfusion volume during hospitalization (226.9 vs 56.5 ml, p<0.001) were higher for the control group compared to treatment. Mean length of stay did not differ between groups (3.6 vs 3.4 days).

Conclusion: Multi-disciplinary and multi-approach efforts to optimize blood management in the CVR population are critical. This prospective study represents a robust and reproducible protocol for pediatric blood management with significant reductions in transfusion requirements.

Background: The Lamina Papyracea ('Paper-Thin') orbital bone often fractures in orbital blow-out injuries while the globe remains intact. Repair of the orbital floor or medial wall has been successfully accomplished with multiple constructs (cranial bone, titanium, resorbable plate) as long as the pyramidal anatomy of the orbit is recreated. However, 'repeat offenders' who suffer serial orbital trauma after repair may be at risk for globe injury. We reviewed treated orbital floor fractures to see if globe injury was more likely with certain repairs.

Methods: We culled through 18 years of trauma data and studied isolated orbital floor fractures (no other facial fractures) (n=589); the recurrent isolated orbital floor fractures were studied in detail. Type of initial procedure and subsequent globe injury were documented.

Results: There were 9% or 53 recurrent isolated orbital injuries following initial orbital floor fracture. The mechanism of injury in these repeat orbital injuries was mostly from an assault (96%). Of the recurrent isolated orbital injuries, 11% (6/53) had a significant globe injury (globe rupture). The breakdown including globe injury to repeat orbital injury was: 5 out of 6=Titanium plate, 1 out of 14=split cranial bone graft, 0 out of 31=resorbable plate, 0 out of 2=gelfilm. Only 1 of 6 with globe injury regained (marginal) sight in that respective eye.

Conclusions: Although patients not at risk of recurrent orbital trauma may be treated successfully with different orbital floor materials, those known to be repeat trauma offenders (like boxers, or known gang members) are at risk for globe rupture unless a less rigid material like a resorbable plate is used to repair the orbital floor or medial wall.

Background:: A previous retrospective analysis demonstrated elevated levels of narcotic use amongst craniofacial trauma patients admitted to our institution. No studies to date have investigated enhanced recovery pathways in craniofacial trauma. An Enhanced Recovery After Surgery (ERAS) protocol was subsequently developed and implemented for this patient population. This study's aim was to investigate the ERAS protocol's efficacy in reducing opioid use post-operatively.

Methods:: This single-institution, prospective cohort included 41 patients recruited from February 2020 to June 2023. The control group included 31 patients retrospectively reviewed from October 2015 to September 2018. Opioid use was quantified in morphine milliequivalents (MME). Total MME use at 24 hours post-operatively and during inpatient stay was gathered. A Wilcoxon rank sum test was conducted to compare medians between both groups. Multivariable linear regression analysis was also conducted to control for age, gender, length of stay (LOS), and facial fracture type.

Results:: There was a significant decrease in MME requirement in the ERAS group at 24 hours post-operatively (30 vs 71.5, P<0.001) and during entire LOS (92 vs 844, P<0.001). LOS was similar between both groups (Median= 48-96hrs, P>0.05). These results were consistent when controlling for age, gender, LOS and fracture type between both groups.

Conclusion:: Implementation of an ERAS protocol for patients undergoing surgery for isolated craniofacial trauma was found to be associated with decreased opioid use in the first 24 hours after surgery and throughout admission. These results highlight the potential efficacy of an ERAS protocol for pain control in this patient population.

Purpose: Microsurgeons often start a heparin-drip intraoperatively when concerned about thrombosis in the setting of an anastomotic revision(AR) based on anecdotal evidence. There is a paucity of studies analysing antithrombotic effect in flaps requiring AR(1). We aimed to determine outcomes following intraoperative anticoagulation in head and neck free flaps requiring AR to guide future use. Methods: This was a single-centre retrospective review of all patients who underwent head neck and free flap reconstruction from January2012 to October2022. Data including intraoperative findings comprising severity score for the vascular issue, flap loss, return to operating room for bleeding/vascular compromise was extracted from department REDCap database. Results: Among 1173 patients, 71 patients with72 flaps(6%) had AR;(48 at index surgery; 24at take-back).Flap-loss was 2% overall and 23%(17/72) in the AR group. Intraoperative heparin-drip was administered in 32 patients, 18 at index &14 at take-back surgery. Among 71 patients with AR, flap-loss in patients who received heparin-drip were comparable to those who did not(22% vs 25%). In the 41patients with an identifiable thrombus, flap-loss rate was significantly lower(26%vs 65%; OR=5.14;CI:1.27-20.67) in heparin group. Within the thrombus group, heparin use had a significantly lesser flap-loss in patients requiring revision of only single vessel (9% vs 85%; p=0.003), and those with AR for isolated arterial issue (18% vs 100%, p=0.038); the flap outcomes were not affected in cases requiring revision of both vessels. There was no association found between heparin and flap loss in the no-thrombus group(p=0.79). There was no significant difference in flap loss rates in subgroups with AR at index(heparin vs no heparin :5% vs 17%,p=0.38) or take-back surgery( heparin vs no heparin: 35% vs 58%,p=0.125) . There was no significant difference in the bleeding rates between heparin and no-heparin groups in the overall cohort(25%vs15%;p=0.29),thrombus(22%vs21%;p=0.95) and no-thrombus(40%(2/5)vs 12%(3/26);p=0.138) subgroups. There was no significant association found between heparin and bleeding in subgroups of patients based on number of vessels revised or severity scoring. Intraoperative tPA use was not found to impact flap outcomes, however, there was a significant increase in bleeding rates in the overall cohort (43%vs 13%,p=0.022) and in thrombus subgroup(46% vs 10%;p=0.023) both in univariate and multivariate analysis. Conclusion:. In patients with AR and thrombus, heparin-drip use demonstrated significant reduction in flap loss with similar bleeding rates. In patients with AR without a thrombus, the difference in flap outcomes or bleeding rates did not achieve statistical significance. In patients with thrombus, heparin was particularly beneficial in patients who required revision of single vessel (vein or artery) and those with primarily arterial issues without an increase in bleeding. Use of tPA was associated with higher rates of bleeding without an increase in flap salvage in the setting of a thrombus. Although restrictive use is recommended, there is a potential benefit from precise use of heparin in the AR patients with an identified thrombus and lesser surgical complexity of vascular compromise. References 1. Bishop et al. Effect of Perioperative Antithrombotics on Head and Neck Microvascular Free Flap Survival After Anastomotic Revision. Otolaryngol-Head Neck Surg 2023;168:1353-61.