Scientific Abstract Presentations: Craniomaxillofacial Session 10 Saturday, September 28 Sat, Sep 28 10:30 a.m.-12:30 p.m. PDT

Purpose: Nasoalveolar molding (NAM) has historically improved nasal cartilage shape before cleft lip repair. Similar to NAM's mechanism, early cleft lip repair (ECLR) leverages neonatal plasticity from residual maternal estrogen to reshape the nose and approximate the cleft segments before surgical repair. This study compared nasal anthropometrics to assess the nasal symmetry of patients who underwent ECLR versus traditional lip repair (TLR) with NAM (TLR+NAM).

Methods: Non-syndromic patients with complete unilateral cleft lip and palate (UCL±P) who underwent primary lip repair between 2005 and 2023 at a tertiary pediatric hospital were reviewed retrospectively. Cohorts included patients who underwent repair before three months of age (ECLR, n=231) and those who underwent TLR+NAM (n=86). Preoperative and postoperative (within one year) anthropometrics were measured from frontal and basal images, including nasal width, nostril width, and nostril breadth. The cleft severity was quantified based on the cleft width ratio (CWR). Pre- and post-operative cleft and non-cleft ratios were compared. Smaller ratios were considered more symmetric, with zero indicating an ideal symmetry.

Results: Sixty-one patients were included (36 with ECLR and 25 with TLR+NAM). ECLR and TLR+NAM had comparable CWR (0.51±0.09 vs. 0.50±0.09, p=0.620). All patients' mean follow-up time was 3.6±3.5 years (TLR + NAM: 7.3±5.2, ECLR: 2.7±2.0). Pre- to postoperative nasal symmetry significantly improved with ECLR (Nasal width: 1.69±0.76 vs. 0.11±0.11; p<0.001; Nostril width: 2.20±1.72 vs. 0.19±0.20, p<0.001; Nostril breadth: 1.40±0.52 vs. 0.09±0.10; p<0.001) and TLR+NAM (Nasal width: 1.94±1.25 vs. 0.14±0.12 p<0.001; Nostril width: 2.00±1.06 vs. 0.19±0.16, p<0.001; Nostril breadth: 1.35±0.61 vs. 0.09±0.09, p<0.001). ECLR and TLR+NAM achieved comparable postoperative improvement in all anthropometric nasal symmetry measurements (nasal width: 8.6% vs. 9.7%, p=0.678; nostril width: 14.3% vs. 10.4%, p=0.293; nostril breadth: 8.5% vs. 13.9%, p=0.292).

Conclusion: ECLR and TLR + NAM effectively corrected cleft nasal deformity and achieved comparable nasal symmetry after UCL±P repair. Since both approaches achieve a similar nasal appearance, families can make more informed treatment decisions based on timing preferences, financial circumstances, and patient needs.

Background/Purpose: Premaxillary osteotomy may be needed during primary lip repair to normalize labial topography. There is a paucity of guidelines and long term data regarding premaxillary setback at primary lip repair. This study analyzes indications and outcomes for premaxillary osteotomy (PO) and presents an algorithm for its use in the management of patients with bilateral cleft lip (BCL).

Methods: A retrospective review was conducted evaluating patients undergoing lip repair at our institution from 2003-2023. Cohorts included patients with BCL ± cleft palate who underwent lip repair with simultaneous PO(BCL+PO) or without PO(BCL-PO). Indications, timing of surgery, complications, and the need for orthognathic surgery to correct midface hypoplasia were assessed.

Results: 1,090 patients who underwent cleft lip repair were identified, of which 266 patients with BCL/P met inclusion criteria. Of these, 51 patients required premaxillary setback. Based on these results, a management algorithm was developed. One hundred forty nine patients with complete BCL/P were recommended NAM. For patients with a protruding premaxilla who failed treatment (n=12) or not deemed candidates of NAM (n=31), premaxillary setback was recommended (6.056±4.682 months). Patients with a protruding premaxilla who presented to our institution late were also recommended premaxillary setback (n=8, 12.977± 8.196 months). Across all patients, complications included wound dehiscence (n=3) and abscess formation (n=2). Notably, there were no instances of avascular necrosis of the premaxilla. Compared to BCL-PS, BCL+PS had comparable rates of wound dehiscence (2.7%vs. 7.7%; p=0.932), lip revisions (10.0% vs. 11.3%; p=0.976), and orthognathic surgery rates ( 50.0% vs. 56.3%; p>0.999).

Conclusion: Premaxillary osteotomy is a safe procedure with comparable outcomes to traditional bilateral cleft lip. Thus, we advocate for premaxillary setback at primary lip repair for protuberant premaxillas preventing tension-free closure. This algorithm provides safe experiential based guidance for the management of the premaxillary segment.

Background: Primary treatment of craniosynostosis typically involves cranial vault remodeling (CVR) with or without fronto-orbital advancement (FOA). Though a single corrective surgery is often necessary, patients with syndromic craniosynostosis might require additional revisional procedures. Relapse-manifesting as fronto-orbital or midface retrusion-is a common sequela necessitating additional surgical intervention. This study investigates the impact of craniofacial syndrome status on long-term reoperation rates following primary CVR±FOA for coronal synostosis.

Methods: A retrospective chart review evaluated patients with syndromic-craniosynostosis who underwent primary CVR±FOA at our institution from 2004-2023. Patients with unicoronal or bicoronal synostosis with at least three years of follow-up were included. Revisional surgeries included repeat FOA, LeFort III, or monobloc advancement/distractions after index operation. Multivariate regression with interaction analysis was performed, adjusting for age at surgery, suture-type craniofacial-syndromic diagnosis, posterior vault distraction osteogenesis (PVDO), and post-operative helmetting.

Results: Upon review, 266 patients with coronal synostosis who underwent CVR±FOA were identified with a mean follow-up time of 4.8±4.3 years. Sixty-six (24.8%) patients had a craniofacial syndromic diagnosis (23 Apert, 17 Crouzon, 10 Pfieffer, 9 Saethre-Chotzen, 6 Muenke, and 1 Carpenter). The syndromic cohort had a significantly higher revision rate than the non-syndromic cohort (33.3% vs. 2.0%; p<0.001). The average time until revision surgery was 7.2±2.9 years postoperatively. Upon multivariate regression, patients with a syndromic diagnosis had a 17-fold increased risk of reoperation following their index operation (Odds Ratio [OR]: 16.8; p<0.001). Further regression analysis revealed that PVDO reduced the risk of revision surgery for the syndromic cohort by 98% (OR: 0.02; p-interaction=0.025).

Conclusion: The diagnosis of an associated craniofacial syndrome was a significant predictor of relapse after initial surgical intervention for coronal synostosis. However, implementing PVDO as the initial surgical approach for these patients could mitigate the need for revisional surgery, thereby decreasing the need for subsequent surgical interventions.

Morphea, also called localized scleroderma (LoS), is a rare disease of unknown etiology without satisfactory treatment for skin sclerosis and soft tissue atrophy. To provide clinical, histologic, and transcriptome evidence of the anti-sclerotic and regenerative effects of sequential fat grafting with fresh fat and cryopreserved stromal vascular fraction-gel (SVF-gel) for LoS. We conducted this single-center, non-randomized controlled trial between January 2022 and March 2023. This study was conducted in the Department of Plastic and Reconstructive Surgery of Nanfang Hospital, Southern Medical University. Adult participants with young or old-onset LoS, and presented with varying degrees of skin sclerosis and soft tissue defect. Group A received sequential grafting of fresh fat and cryopreserved SVF-gel (at 1 and 2 months post-operation). Group B received single autologous fat grafting. All patients were included in a 12-month follow-up. The primary outcome included changes in the modified Localized Scleroderma Skin Severity Index (mLoSSI) and Localized Scleroderma Skin Damage Index (LoSDI) scores evaluated by two independent blinded dermatologists. The histologic and transcriptome changes of LoS skin lesions were also evaluated. Of 44 patients (median [IQR] age, 26 [23-33] years) enrolled, 24 were assigned to Group A and 20 to Group B. No serious adverse events were noted. The mean mLoSSI scores at 12 months showed a 1.6 (SD [standard deviation], 1.50) decrease in Group A and 0.9 (SD, 1.46) in Group B (p=.134), whereas the mean LoSDI scores at 12 months showed a 4.3 (SD, 1.34) decrease in Group A and 2.1 (SD, 1.07) in Group B (p<.001), indicating that Group A had a more significant effect in reversing LoS skin damage but not disease activity compared with Group B. Histologic analysis showed improved skin regeneration and reduced skin sclerosis in Group A, whereas skin biopsies of Group B patients did not show significant change. Transcriptome analysis of skin biopsies from Group A patients suggested "TNFα signaling via NF-κB" might be at central play in the immunosuppressive and anti-fibrotic effect of sequential fat grafting. 15 hub genes were captured, among which many associated with scleroderma pathogenesis were down-regulated and validated by immunohistochemistry, such as EDN1, PAI-1, and CTGF. Sequential fat grafting with fresh fat and cryopreserved SVF-gel was safe and its therapeutic effect is superior to that of single autologous fat transplantation with improved mLoSSI and LoSDI scores. Histological and transcriptomic changes further support the effective changes after treatment.

PURPOSE: Although several open techniques have been described for surgical correction of lambdoid synostosis, no consensus exists on the optimal technique. This study describes a new osteotomy design for surgical correction of isolated lambdoid synostosis followed by postoperative helmet therapy (PHT) and reviews postoperative outcomes.

METHODS: A single-institution retrospective cohort study evaluated patients who underwent open posterior vault remodeling (PVR) for correction of isolated lambdoid synostosis between 2014–2023. Patients with significant deformational plagiocephaly and multisuture craniosynostosis were excluded. Variables included patient history, perioperative data, estimated blood loss (EBL), length of hospital stay (LOS), and postoperative outcomes. Anthropometric measurements, including cranial index (CI) and cranial vault asymmetry index (CVAI) at initiation and termination of PHT, were collected using a proprietary machine learning application (Cranial Technologies). Fisher's exact, Wilcoxon rank-sum and Wilcoxon signed-rank tests were performed.

Osteotomy Design: A single oval-shaped bone flap was elevated, encompassing both the contralateral compensatory occipital-mastoid bossing and the ipsilateral occipital synostotic flattening above the torcula. The calvarial bone flap was then recontoured. Radial osteotomies were performed on the side contralateral to the synostotic suture. A rongeur was used to out-fracture and flare these osteotomies, reducing the convexity of the bone. On the ipsilateral side, several radial wedge osteotomies were performed to increase the curvature of the contour of bony underprojection. The bone flap was then rotated 180 degrees and tucked underneath the edge of the native bone. Barrel staves were used to out- or in-fracture the native bone as needed. After discharge, patients were seen approximately 2 weeks postoperatively. PHT was performed for 3–12 months.

RESULTS: Forty-eight patients underwent open surgical correction of lambdoid synostosis, with 19 patients meeting inclusion criteria (new technique [n=6], old technique [n=13]). PVR occurred at a mean age of 9.9±3.0 months. The median time from surgery to initiating helmet therapy after fittings and swelling reduction was 1.9±1.6 months (range 0.4–4.6). The mean duration of PHT was 4.1±2.8 months (range 1.3–11.5). Patients undergoing the new technique had a median operative time of 3.1 hours, EBL of 160 mL, and LOS of 3 days. The perioperative profile of the new technique was comparable to that of the old technique (p>0.05). The new technique had improved CI after surgery (preoperative: 89.8 vs. pre-PHT: 89.0, p=0.031) and following PHT (preoperative: 89.8 vs. post-PHT: 87.9, p=0.188). The new technique demonstrated improvement in CVAI after surgery (preoperative: 7.8 vs. pre-PHT: 3.4, p=0.031) and after PHT (preoperative: 7.8 vs. post-PHT: 2.8, p=0.031). Relative to preoperative baselines, the new and old techniques demonstrated 4.6% vs. 3.3% improvements in CI (p=0.623) and 66% vs. 59% improvements in CVAI (p=0.624), respectively.

CONCLUSIONS: This novel surgical technique, in conjunction with PHT, can result in improved symmetry after open PVR for unilateral lambdoidal synostosis. This technique serves as an alternative for surgical correction of lambdoid synostosis.

Introduction: While radiotherapy plays an important role in Head and Neck Cancer treatment, its side effects can be devastating. Osteoradionecrosis (ORN) remains a challenging disease from the definition, incidence, and pathogenesis to treatment modalities. Objective: To investigate the predictors of ORN of the transferred fibula bone in head and neck cancer patients who undergoing segmental mandibulectomy followed by free fibula flap (FFF) reconstruction. Methods: A retrospective analysis of 329 patients at Chang Gung Memorial Hospital between January 2014 and December 2019 who underwent free fibula flap reconstruction was conducted. A variety of clinicopathological postoperative parameters were identified and assessed. The data was statistically analyzed with univariate and multivariate logistic regression and the probability of ORN rate was plotted as Kaplan-Meier survival curve. Results: A total of 66 (20%) patients with symptomatic ORN was identified. Tumor status, overall tumor staging, postoperative chemotherapy, re-exploration and postoperative wound infection have been identified as risk factors for the ORN occurrence. In multivariate logistic analyses, re-exploration (OR, 3.02 [95% CI, 1.06-8.94], p = 0.04) and postoperative wound infection (OR, 6.36 [95% CI, 3.23-13.49], p < 0.001) indicated higher risks for ORN. Few ORN cases were found 3 years after the index surgery. Conclusions and Relevance: Our study highlighted re-exploration and postoperative wound infection are independent risk factors for ORN. We also found the rate of ORN is underestimated in the current literature. If dental osteointegration is to be performed at a later stage, it should be considered at least 3 years after postoperative radiotherapy bearing in mind the increased risk of ORN.

Abstract Objective: The authors presented a new method of vermilion tubercle reconstruction in cleft lip secondary repair.

Methods: Thirty-nine patients with secondary repair of cleft lip underwent the operation of vermilion tubercle reconstruction with a vermilion flap transferred vertically. The reconstruction procedure mainly included three processes, restoring the vermilion tubercle tissue in the cleft area, heightening the vermilion with the vermilion flap, and augmenting the volume of the tubercle with the subcutaneous, scar and muscle tissue underlying that vermilion flap. Pre- and post-surgical measurements were obtained from three-dimensional photographs using the VECTRA-XT system, and then the data from both groups were analyzed with paired-samples t test. A patient satisfaction survey was performed postoperatively to evaluate the effect of the reconstruction.

Results: The reconstructions of vermilion tubercle were successful in all patients and no complications occurred. Most of vermilion tubercles appeared pronounced bulges post-operation. Follow-up had been completed in twenty-eight patients and the average follow-up period was 9.71±5.02 months. The effective vermilion height increase was from 5.32mm±0.91mm、3.98mm±0.89mm、4.30mm±0.86mm pre-operation to 6.35mm±0.87mm、7.75mm±1.03mm、7.48mm±0.97mm post-operation in the midline of lip, the peak of cleft side and the midline of short arm respectively. The postoperative height of vermilion in the cleft side was heightened significantly. the projection of the tubercle was increased significantly from 0.38mm±0.46mm to 0.83mm±0.51mm. Three-dimensional analysis showed a significant increase in the volume of vermilion tubercle. 96.4% (27) patients achieved satisfied results of vermilion tubercle reconstruction with operation.

Conclusion: Vertical transfer of the vermilion flap has been found to be an effective method of vermilion tubercle reconstruction in secondary repair of cleft lip.

Background Concerns over the aesthetic appearance of the lower face, particularly the chin and neck, are common due to excess submental fat (SMF), weakened muscles, and loose skin, which may alter the facial contour, leading to a heavier look under the chin and along the jawline. These issues are exacerbated by tissue degeneration, resulting in reduced definition in the submental area and apparent aging signs, negatively impacting self-esteem. This study assesses the effectiveness and safety of combining Synchronized radiofrequency+ (Sync RF+) and High-Intensity Facial muscle stimulation (HIFES™ technology) for non-surgical submental enhancement. Methods In this multicenter, single-arm, open-label, interventional study, thirty-seven (n=37, 36 females and 1 male, aged 42.2 ± 12.4 years, BMI 28.2 ± 7.2 kg/m2, skin type II-V) subjects received four (4) treatment sessions targeting the submentum, spaced 5-10 days apart, using a non-invasive, self-adhesive device that delivers both HIFES & Sync RF+ energy. The effectiveness in reducing subcutaneous fat and overall submental volume was assessed via Magnetic Resonance Imaging (MRI) and 3D photography. Patient satisfaction, comfort, and safety were also evaluated, with follow-ups at one and three months post-treatment. Results Initial findings indicate a significant reduction in subcutaneous fat volume (-25%) and total submental volume (-31%) one month after treatment, with further reductions (-35% for both) observed at three months. 3D photographic analysis showed a -5.78 ml reduction in submental volume at one month. High satisfaction rates were reported by 93.6% of participants, with 87% finding the treatment comfortable. Conclusion The integration of Sync RF+ and HIFES™ technologies for submental enhancement appears safe and effective, offering insights into its mechanism, including the role of Digastric muscle stimulation, in improving aesthetic outcomes and patient satisfaction.

Background: Similar to nasoalveolar molding (NAM), early cleft lip repair (ECLR) takes advantage of the high degree of plasticity within neonatal tissues to shape the nasal cartilage and maxilla. This study assesses the efficacy and outcomes of ECLR in our institution's first 200 patients.

Methods: This retrospective cohort study included 200 non-syndromic patients with unilateral cleft lip±palate (UCL/P) undergoing lip repair before three months of age from 2015-2023. Demographic, preoperative, perioperative, and postoperative data were collected. Anthropometric measurements were obtained from frontal and basal images, which included medial lip height, lateral lip height, commissure length, and nasal width. Cleft severity was quantified by cleft width ratio (CWR). Ratios between the cleft and non-cleft sides were calculated pre- and post-operatively. Ideal symmetry was defined as a cleft to non-cleft ratio of 1. The difference from ideal symmetry was calculated postoperatively between the cleft and non-cleft sides, with values closer to zero indicating a favorable outcome. The number of presurgical appointments and revision rates were compared between the ECLR cohort and patients who underwent traditional lip repair with NAM (n=86, TLR+NAM).

Results: Corrected gestational age of the cohort was 1.1±0.5 months at surgery with a mean follow-up of 2.9±2.5 years. ECLR operative and anesthetic times were 118±33 and 187±35 minutes, respectively. No intraoperative complications occurred. Six patients (3.0%) had postoperative complications, most commonly nasal stent dislodgement (n=4). Compared to TLR+NAM, ECLR patients had significantly fewer presurgical appointments (1.3±0.2 vs 13.6±3.5, p <0.001) and fewer lip revisions (9.0% vs 37.2%; p<0.001). Comparing preoperative to postoperative symmetric ratios, ECLR demonstrated significant improvements in medial lip height (p<0.001), lateral lip height (p<0.001), commissure length (p<0.001), and nasal width (p<0.001). Compared to TLR+NAM, the ECLR cohort had similar CWR (0.512 vs. 0.498; p=0.571), while demonstrating equivalent postoperative improvements in symmetry in medial lip height (p=0.082), lateral lip height (p=0.292), commissure length (p=0.823), and nasal width (p=0.449).

Conclusion: This study demonstrates that ECLR continues to be a safe and effective alternative to TLR+NAM for UCL/P with potentially improved aesthetics and reduced burden of care on patients and families.

Introduction Free tissue transfer for reconstruction of complex head and neck defects is the standard of care throughout the world. These procedures are not without morbidity and infection is a leading cause of post operative complication. Recent data suggests that current Australian antibiotic prophylaxis guidelines may not fully consider the complexity of these procedures and are inappropriate for effectively mitigating infection. The Australian guidelines recommend cephazolin monotherapy or a cephazolin-metronidazole combination as the first-line prophylaxis options, with clindamycin recommended in penicillin-allergic patients, for a period of no longer than 24 hours. Methods A retrospective cohort study was done over a 5 year period at Westmead hospital (Sydney, Australia) reviewing data from consecutive 100 free flaps for head and neck reconstruction. Univariate and multivariate analyses have been employed to elucidate statistically significant associations, examining potential risk factors for post operative infection including duration and type of antibiotic. Results A surgical site infection developed in 32.0% of cases, with an average onset of 11.3 days post-operation. Preoperative anemia (OR: 3.259) and a prophylactic antibiotic duration of ≤24 hours (OR: 3.010) were found to be independently significant risk factors for infection. Furthermore, surgical site infection was found to significantly increase unplanned returns to theatre (P = <0.001), complete flap failure (P = 0.005), and length of stay (P = 0.026). The results also suggest that a 48-hour prophylaxis duration may be optimal, with no significant difference in infection rate at this cut-off point. Conclusion This single tertiary center study has found that pre-operative anemia in the head and neck patient is an independent risk factor for post operative infection and indicates that current Australian guidelines for antibiotic prophylaxis may not be adequate in reducing the risk of infection in our population.

Reference: Therapeutic Guidelines [Internet]. Melbourne: Therapeutic Guidelines Limited. Surgical antibiotic prophylaxis for specific procedures; [amended 2023 Jun; cited 2023 Jul 21]. Available from: https://tgldcdp-tg-org-au.ezproxy.library.sydney.edu.au/viewTopic?etgAccess=true&guidelinePage=Antibiotic&topicfile=surgical-antibiotic-prophylaxis procedures&guidelinename=Antibiotic&sectionId=tocd1e2024#tocd1e2024

Background:
Orbital floor fractures are a leading cause of eye trauma hospitalizations in the US. Clinical criteria (e.g. persistent diplopia, enophthalmos) are clear indications for surgery. Nevertheless, these signs are frequently masked by initial post-traumatic swelling. A variety of radiographic parameters continue to be recommended to guide treatment strategies (e.g. fracture size, orbital volume, rounding of IRM (inferior rectus muscle), and IRM displacement. The evidence behind these criteria is unclear. This systematic review aims to identify the most reliable radiographic indications for orbital floor reconstruction. Methods: A PubMed search (years: 2000 to 2021) was conducted to identify original, peer-reviewed, human studies analyzing radiographic indications for orbital floor reconstruction in patients aged 16 years and older. Specifically, we included only studies where the surgical decision was based exclusively on clinical grounds and radiographic correlation only established retrospectively. Two reviewers independently screened the studies for inclusion based on a protocol developed according to PRISMA guidelines. Eligible studies were analyzed to extract radiographic indications for surgical reconstruction and their correlation with patient outcomes. Results: Out of 572 articles, eight met the inclusion criteria. Predictors for surgical repair encompassed a variety of clinical and CT-scan parameters. Persistent diplopia and symptomatic IRM entrapment were widely agreed upon clinical indications. Among radiographic criteria, fracture size was an unreliable predictor for reconstruction. Orbital volume measurements displayed wide variability in methodology. Their predictive value was controversial among studies. The degree of IRM displacement was significantly correlated with the need for surgery in two studies. Conclusion: Clinical criteria continue to be the most reliable indications for orbital floor reconstruction. Displacement of more than ½ of the IRM below the level of the orbital floor seems to be the most predictive radiographic parameter for surgery. Nevertheless, more quality research with prospective design and larger cohorts is needed to confirm its predictive value. Until there is a gold standard for calculating orbital volume change, a specific volume alteration cannot be reliably employed to guide treatment strategy. Fracture size (% surface area of orbital floor) alone is not a reliable indication for surgery.

Introduction: Osteoradionecrosis (ORN) is an insidious and extremely difficult pathology to manage. The pathology can develop anytime following radiotherapy. Complication rates for treating ORN of the mandible with free tissue transfer are over 30% in the literature with high rates of disease recurrence. This study aims to assess the performance of different reconstructive options following resection of ORN of the mandible and free osseocutaneous tissue reconstruction. A further focus of this systematic review was to produce evidence from the literature surrounding complications and their rates from the treatment. Outcomes and complications across reconstructive options were assessed. Methods: A systematic review of published literature was conducted with no restriction on year of publication. The search was limited to the English language. The study followed PRISMA guidelines for systematic review. Inclusion and exclusion criteria were generated by the two authors and all articles were assessed by two authors for inclusion in the study. Results: A total of 23 relevant articles fit the inclusion and exclusion criteria as seen in figure 1 of the PRISMA flow diagram. There were 23 retrospective reviews producing 776 patients who underwent a total of 815 free flap reconstructions. An overall free flap failure rate of 5.15% and a complication rate of 42.7% for all treatments. 22 out of these 23 studies sub-categorized the reconstructive methods with the free fibula flap being the best performing option. It has a statistically significant lower failure rate when analysed through a Random-Effects Model with a log odds ratio of -0.99 (C.I. -1.80 - -0.17) p=0.017 (Figure 2-3). Flap associated complications were the highest frequency and occurred at a rate of 16.8% - this included exposure of hardware, partial flap loss, fistula formation, and non-union. Infection was the second most frequent complication recorded at 10.1%. Across the 776 patients there were 35 instances of recurrence for an average follow up time of 20 months across 15 papers that included follow up time in their studies. Discussion: This review shows statistically significant evidence that the fibula flap had the lowest flap failure rates in managing mandibular ORN. It also produces evidence for overall high complication rates as well as specific potential complications. The data is useful for surgeons in discussions and throughout the consent process with patients, which is essential to manage patients' expectations and allow them to make a more informed decision in their journey.

Introduction: Elevated intracranial pressure (ICP) has been implicated as a causative factor for neurocognitive impairment in patients with craniosynostosis.1 Despite being invasive, direct measurements remain the gold standard to measure ICP in patients with craniosynostosis. However, due to risks of direct measurement, there has been persistent effort to develop non-invasive modalities to measure ICP. Previous studies have examined the efficacy of non-invasive methods of ICP monitoring, but these were not limited to the craniosynostosis population.2,3 Here, we performed a systematic review of the current state of non-invasive ICP measurement techniques specific to the craniosynostosis population.

Methods: A systematic review was conducted using PubMed, Cochrane and Web of Science databases to identify studies describing the use of non-invasive ICP measurements in patients with craniosynostosis. Studies were included if they assessed a non-invasive method of ICP monitoring against a direct/invasive ICP monitoring technique in patients with craniosynostosis. Non-English and non-human studies were excluded.

Results: A total of 735 studies were screened, of which 52 were included in the study. Nine methods of non-invasive ICP measurement were identified, with varying sensitivities and specificities in detecting elevated ICP. In general, clinical signs and symptoms, radiologic evaluations, visual evoked potentials, and transcranial doppler demonstrated inadequate ability to detect elevated ICP. Optical coherence tomography had the most robust evidence supporting its use to detect elevated ICP in patients with craniosynostosis (90% sensitivity, 81.3% specificity).4 Using ultrasound to measure optic nerve sheath diameter also showed promise in small series, but has not been rigorously evaluated.5

Conclusion: Developing a technique to measure ICP non-invasively would overcome a major hurdle in efforts to advance our understanding on the effects of suture fusion on the developing brain. The ideal measurement modality would be highly sensitive and specific for elevations in ICP, be easy to perform in children at any age, and would be reproducible. From the current literature, OCT has demonstrated promise in larger sampled studies in being able to accurately predict elevations in ICP non-invasively. Another promising modality involves the use of ocular ultrasonography to measure the optic nerve sheath diameter. Fundoscopic examination although specific, has not been shown to be sensitive enough to be used as a screening tool in children. However, until further validation and investigation is performed, invasive measures remain the gold-standard for ICP measurements in patients with craniosynostosis.

1. Thiele-Nygaard AE, Foss-Skiftesvik J, Juhler M. Intracranial pressure, brain morphology and cognitive outcome in children with sagittal craniosynostosis. Childs Nerv Syst. 2020;36(4):689-695. doi:10.1007/s00381-020-04502-z
2. Khan M, Shallwani H, Khan M, Shamim M. Noninvasive monitoring intracranial pressure – A review of available modalities. Surg Neurol Int. 2017;8(1):51. doi:10.4103/sni.sni40316
3. Dong J, Li Q, Wang X, Fan Y. A Review of the Methods of Non-Invasive Assessment of Intracranial Pressure through Ocular Measurement. Bioengineering. 2022;9(7):304. doi:10.3390/bioengineering9070304
4. Kalmar CL, Humphries LS, McGeehan B, et al. Elevated Intracranial Pressure in Patients with Craniosynostosis by Optical Coherence Tomography. Plast Reconstr Surg. 2022;149(3):677-690. doi:10.1097/PRS.0000000000008821
5. Padayachy LC, Padayachy V, Galal U, Gray R, Fieggen AG. The relationship between transorbital ultrasound measurement of the optic nerve sheath diameter (ONSD) and invasively measured ICP in children: Part I: repeatability, observer variability and general analysis. Childs Nerv Syst. 2016;32(10):1769-1778. doi:10.1007/s00381-016-3067-5

Purpose Understanding the significant impact of socio-economic and geographic factors on healthcare access is crucial in the comprehensive care of cleft palate (CP) patients.1,2 While existing research acknowledges the influence of socio-economic factors on healthcare outcomes, the specific contributions of ADI and geographic location, especially in relation to adoption status and access to healthcare facilities, remain underexplored. This study aims to clarify how these variables interact to affect healthcare availability and quality for CP patients.

Methods We conducted a propensity score-matched analysis on a cohort of 183 cleft palate patients to evaluate the impacts of Area Deprivation Index (ADI), adoption status, and geographic distance to a care center with healthcare access. Healthcare utilization, specifically the requirement for speech therapy, was compared among patient groups with variable ADI scores, adoption statuses, and distances to healthcare facilities. Bivariate analyses and univariate and multivariable logistic regressions assessed healthcare utilization differences. The study applied propensity score matching to align syndromic and non-syndromic patient groups, adjusting for confounders such as gender, migrant status, race, and age to elucidate the effects of socioeconomic and geographic factors on access to care.

Results Significant differences in ADI and speech therapy outcomes emerged in the propensity-matched cohorts. Patients from higher ADI quartiles demonstrated a lower probability of timely speech therapy (OR = 2.45, 95% CI [1.05, 5.70], p = 0.038). Adopted patients exhibited a higher need for speech therapy (78.1% vs. 51.0%, OR = 3.43, 95% CI [1.47-9.04], p = 0.005). Additionally, adopted patients faced delays in receiving care (OR for delayed first consultation = 13.27, p<0.001; OR for delayed first surgery = 41.65, p<0.001). Specifically, patients from areas with higher ADI scores exhibited a greater need for speech therapy, with speech therapy needs being notably higher in patients from the most deprived quartiles (OR = 3.05, 95% CI [1.22, 8.71], p = 0.0235 for syndromic patients). There was a significant relationship between higher ADI and increased average travel distance to the care center (p = 0.047). Patients living farther from the care center were less likely to access necessary treatments on time (mean distance = 120.5 miles for lower utilization vs. 30.2 miles for higher utilization, p = 0.045). Additionally, a substantial portion of the cohort was uninsured (47.5%).

Conclusion Area deprivation, adoption status, and healthcare facility proximity significantly influence healthcare access for cleft palate patients. The data suggest that these factors should be integral considerations in healthcare planning and policy development to improve access and outcomes for this patient group. Further research is warranted to explore targeted strategies that address these determinants to enhance healthcare equity for cleft palate patients.

References:

1. Upadhyaya, D., Reddy, G., Mishra, R., & Singh, A. (2017). Impact of educational and socioeconomic status of parents on healthcare access in cleft patients. Journal of Cleft Lip Palate and Craniofacial Anomalies, 4, 109 - 113. https://doi.org/10.4103/JCLPCA.JCLPCA3917.
2. Villavisanis, D., Wagner, C., Morales, C., Smith, T., Blum, J., Cho, D., Bartlett, S., Taylor, J., & Swanson, J. (2023). Geospatial and Socioeconomic Factors Interact to Predict Management and Outcomes in Cleft Lip and Palate Surgery: A Single Institution Study of 740 Patients.. The Cleft palate-craniofacial journal: official publication of the American Cleft Palate-Craniofacial Association, 10556656221150291. https://doi.org/10.1177/10556656221150291.

Background/Purpose: Alloplastic cranioplasty is a safe and durable alternative to autologous reconstruction in pediatric patients that allows for reconstruction of large calvarial defects without concerns for bony resorption or when autologous bone is unavailable (Fu et al. 2016). Custom computer-aided design and manufacture (CAD/CAM) implants have gained popularity in alloplastic cranioplasty due to their ease of use, decreased operative times, and highly predictable results (Maniskas et al. 2021, Nguyen et al 2018). While a traditional inlay design is thought to improve contour and minimize overlying soft tissue requirements, the inset requires substantial epidural dissection that confers additional surgical risks. In recent years, we have transitioned to utilization of a custom polyetheretherketone (PEEK) CAD/CAM implant with an onlay design in pediatric cranioplasty, allowing minimization of epidural dissection. To our knowledge, no study to date has compared outcomes between inlay and onlay CAD/CAM implant design in pediatric cranioplasty.

Methods: This retrospective cohort study included all patients < 18 years of age who underwent alloplastic cranioplasty with a custom PEEK implant over a two-year period with a consistent craniofacial and neurosurgical team at a single tertiary pediatric hospital. Patients were divided into inlay or onlay group based on implant design. Patient demographics and clinical data were collected via chart review. Outcomes of interest included operative time, estimated blood loss, presence of a dural tear (Y/N), location of dural tear, need for implant revision (Y/N), hospital length of stay (LOS), and 30-day complications. Continuous variables were compared via Mann-Whitney U tests, and categorical variables were examined with Fisher's exact tests.

Results: Over the study period, 20 patients underwent alloplastic cranial reconstruction utilizing either inlay or onlay implants. Four patients were >18 years of age at the time of reconstruction and were excluded. Among the 16 study subjects, 8 underwent reconstruction with inlay implants and 8 underwent reconstruction with onlay implants. There were no significant group differences in age, gender, defect etiology, or defect size (p > 0.06). Three subjects in the inlay group had durotomies along the bone margin; no durotomies occurred in the onlay group (p = 0.06). Operative time was significantly decreased in the onlay group (90 + 23 minutes versus 163 + 45 minutes, p < 0.01) with less overall estimated blood loss (72 + 23 mL versus 250 + 312 mL, p = 0.04) when compared to the inlay group. Three subjects in the inlay group required implant modification at the time of the operation to ensure passive fit, while none required revision in the onlay group (p = 0.06). There were no significant differences in 30-day complications or hospital LOS (p > 0.13).

Conclusions: Onlay cranioplasty for reconstruction of fronto-temporo-parietal craniectomy defects in children is associated with shorter operative time and less blood loss compared to inlay cranial implant design, without an associated increase in 30-day complications, including wound healing. Future research may seek to characterize the long-term safety and efficacy of the onlay technique in pediatric alloplastic cranioplasty.

References:

1. Fu, K. J., Barr, R. M., Kerr, M. L., Shah, M. N., Fletcher, S. A., Sandberg, D. I., Teichgraeber, J. F., & Greives, M. R. (2016). An Outcomes Comparison Between Autologous and Alloplastic Cranioplasty in the Pediatric Population. The Journal of Craniofacial Surgery, 27(3), 593–597. https://doi.org/10.1097/SCS.0000000000002491

2. Maniskas, Seija M.S.; Pourtaheri, Navid M.D., Ph.D.; Chandler, Ludmila B.S.; Lu, Xiaona M.D., Ph.D.; Bruckman, Karl C. M.D., D.M.D.; Steinbacher, Derek M. M.D., D.M.D.. Conformity of the Virtual Surgical Plan to the Actual Result Comparing Five Craniofacial Procedure Types. Plastic and Reconstructive Surgery 147(4):p 915-924, April 2021. | DOI: 10.1097/PRS.0000000000007776

3. Nguyen, P. D., Khechoyan, D. Y., Phillips, J. H., & Forrest, C. R. (2018). Custom CAD/CAM implants for complex craniofacial reconstruction in children: Our experience based on 136 cases. Journal of Plastic, Reconstructive & Aesthetic Surgery, 71(11), 1609–1617. https://doi.org/10.1016/j.bjps.2018.07.016

Introduction: Cleft lip and palate is the most frequent congenital craniofacial deformity.1 A recent multicenter study estimated the incidence of cleft lip with or without cleft palate to be 1 in 2,000 live-births in the United States.2 While cleft lip and palate repair traditionally falls into the domain of plastic surgery, several related specialties perform these surgeries in this country. In this study, the authors attempt to determine which specialty performs cleft lip and palate repairs in North America by American Cleft Palate Craniofacial Association (ACPA) certified teams.

Methods: The ACPA website was used to identify cleft team leaders. The website for each team was then examined to determine the surgical specialty of the team leader. The assumption was made that the specialty of the cleft team leader indicates the specialty performing the highest volume of cleft lip/palate repairs at that institution. For teams that had a leader listed that is not a surgeon or for teams that had multiple team leaders listed on the ACPA website, further examination of the team's website was performed to determine which specialty is likely performing the majority of cleft cases based on the wording of cleft surgery explanations or scheduling instructions for cleft patients. If this information was not available, the team was omitted from the study. To validate these findings, the PEDS-NSQIP database from 2016 – 2021 was queried for all palatoplasties performed and primary surgical specialty was recorded.

Results: Of the 199 ACPA-approved cleft teams, 5 teams were omitted from the study due to the inability to determine the team leader or the specialty performing cleft cases. Of the remaining 194 ACPA-approved teams, plastic surgeons are the predominant cleft specialists at 157 (80.9%) institutions, oral surgeons at 16 (8.2%) institutions, and otolaryngologists at 15 (7.7%) institutions. At another 6 institutions, cleft palate repairs appear to be performed more evenly between plastics and oral surgery (3), plastics and otolaryngology (2) or oral surgery and otolaryngology (1). Upon querying the PEDS-NSQIP database 9,827 cleft palate repairs were recorded, with plastic surgery performing 81.1% and otolaryngology performing 18.1% of procedures. Oral surgery was not listed in the database.

Conclusion: In North America, it appears that plastic surgeons perform the highest proportion of cleft lip and palate repairs in comparison to other surgical specialties. The data collected from the ACPA website correlates with the PEDS-NSQIP database.

Introduction Cranial distraction osteogenesis in treatment of craniosynostosis has many demonstrated benefits, however, questions remain on how to optimize outcomes. Protocols for latency, distraction, and consolidation periods vary in the literature and are guided by clinical observations rather than prospective studies. Our goal is to identify the effect of patient factors and postoperative protocols on consolidation formed in children undergoing distraction osteogenesis for craniosynostosis.

Methods We performed a retrospective review of patients with craniosynostosis who underwent distraction osteogenesis at Rady Children's Hospital between September 2015 and May 2023. Patients with pre-operative and post-operative CT scans from which measurements could be obtained were included. Mimics software was used to create 3-D reconstructions of pre- and post-operative CTs. Geomagic software was used to measure the surface areas of the distraction gap and residual bony defects, the difference between the measurements representing the amount of consolidation formed on postoperative CT. The surface area of consolidation was measured as a proportion of the total surface area of the gap. Linear regression models were used to analyze which patient variables independently predicted consolidate formation. These included gender, race, ethnicity, age at surgery, suture involved, early reintervention, and length of latency, distraction, and consolidation. Age as a dichotomized variable was substituted for age at first surgery in a secondary model to examine potential differences between patients younger and older than 1 year.

Results Seventy-two patients were identified and 48 met inclusion criteria. 31 patients were female and 17 were male. Most patients identified as white (n=29) and Hispanic (n=26). Median age at surgery was 286 days, with 33 patients undergoing surgery prior to 1 year old. Suture involvement included 19 unicoronal, 9 unilateral lambdoid, and 20 multisuture, 9 of which were bicoronal. Seventeen patients had syndromic diagnoses. Latency period was most often 72 hours and distraction period was 35.7 + 10.3 days. Consolidation period measured between start of consolidation and postoperative CT was 72.8 + 40.7 days. Six patients required early distractor removal for infection. When controlling for other factors, only the length of the consolidation period significantly predicted higher proportion of bony consolidate within the distraction gap (B = .39, p = .01), such that for every additional day of consolidation, there was .39 increase in the value of the proportion of consolidate. The second age model mirrored these findings, and being younger or older than 1 year did not significantly predict proportion of consolidate formed.

Conclusions Our findings demonstrate that longer distraction periods have quantifiable benefit. Further investigation into differences in consolidation period length and the impact of early removal of distractors is indicated. The finding of dichotomized age as a non-significant predictor of consolidate formation is interesting due to the loss of dural osteogenic potential as patients near 1 year old. This may indicate the effect of membranous ossification at the osteotomy in consolidate formation. Our nonsignificant findings are reassuring in that current practice patterns are not detrimental to patient outcomes, however we acknowledge the need for further analysis in larger, prospective cohorts.

Background & Purpose – This study examines the use of periorbital infiltration of epinephrine and steroids along the anticipated surgical incision as well as within the periorbital soft tissue and its association with postoperative infection risk. Additionally, this study looks at the benefits that are associated with the use of intraoperative steroids such as decreased need for pain medication and stay in the ICU.

Method/Description – All patients undergoing cranial vault remodeling surgery over a 10 year period at the senior authors institution were analyzed. Variables collected included the use of periorbitally infiltrated steroids, documented concern for infection, readmission for intravenous antibiotics, a need for reoperation, surgical blood loss, length of intensive care stay, and amount of narcotic pain medication administered.

Results – During this time period 168 patients met inclusion criteria and 68 patients received periorbital steroids infiltrated along the proposed incision line as well as around the superior and lateral orbital rim. When comparing the patients that received the steroid infiltration to those that did not, there was no increased infectious risk in the postoperative period. In contrast, there was a significant decrease in the amount of morphine required both in the immediate postoperative period and during the course of their hospitalization. There was also a trend toward decreased length of stay in the ICU but this was not significant.

Conclusions – At the authors' institution, patients that received periorbital steroid infiltrations were not shown to be at an increased risk of developing a postoperative infection. Additionally, we noted that the use of steroids decreased the need for postoperative morphine and decreased their stay in the ICU. This may be attributed to the decrease in postoperative swelling secondary to the steroids. Because of the postoperative benefits and the limited risk of increasing postoperative infection risk, the authors' institution continues to use periorbital steroid infiltration for cranial vault remodeling surgery involving the periorbital region.

Main Objectives of Presentation – This presentation describes the authors' recommendation of using periorbital steroid infiltration in craniofacial surgery as it has well defined benefits while not increasing the risk of postoperative infection.

Background: Optimal treatment of cleft lip with or without cleft palate requires early evaluation by a cleft team, detailed surgical planning, and close follow-up to allow a timely operative repair. Furthermore, in complete clefts, the use of nasoalveolar molding (NAM) or lip adhesion surgery (LAS) may be employed, which introduces further logistical challenges. Due to the complexity of care, sociodemographic barriers may cause delays in the treatment of cleft lip patients. This study aims to identify the sociodemographic factors that may limit access to a timely cleft lip care.

Methods: This was an IRB-approved retrospective analysis of patients who were treated for cleft lip at a tertiary academic center between 2015 and 2023. Unilateral and bilateral cleft lips with or without cleft palates were included. Study endpoint was definitive cleft lip repair. The study outcomes analyzed for a timely cleft lip care included the time of initial evaluation, use of NAM vs LAS, age at cleft lip repair, and number of missed appointments. These were compared across different sociodemographic factors including race/ethnicity, family income, insurance status, distance from the hospital, and primary language spoken to identify barriers to cleft lip care.

Results: A total of 244 patients (88 white, 75 Hispanic, 21 black, and 60 other) were included in the study. Eighty-four patients had an isolated cleft lip, while the remaining 160 had a cleft lip and palate. Of the clefts, 41 were bilateral and 27 were part of a syndromic presentation. Median age at first cleft evaluation was 2.9 weeks (IQR 1.7-5.7). A family income of <$75,000/year was associated with a delay in initial evaluation (3.1 [1.9-7.5] vs 2.3 [1.1-4.0] weeks, p=0.003). In the 83 patients who underwent an intervention prior to surgery, NAM was used in 79.5% (n=66) and LAS in 20.5% (n=17). Medicaid insurance was associated with a lower rate of NAM utilization than private insurance (72.7% vs 92.8%, p=0.03). The median time to cleft lip repair was 4.5 months (IQR 3.8 to 5.7 months). Delays in surgery were associated with a family income of <$75,000/year (4.5 [3.8 - 6.0] vs 4.3 [3.7 - 5.0] months, p=0.04) and Medicaid insurance (4.7 [4.0 - 6.1] vs 4.0 [3.5 - 4.7] months, p<0.001). During cleft lip treatment, 48.1% of patients had at least one missed appointment. A >50-mile commute to the hospital was associated with a higher rate of missed appointments (66.7% vs 45.8%, p=0.04). Race/ethnicity and a primary language other than English were not associated with an inferior outcome in the healthcare access indicators analyzed.

Conclusion: Patients with cleft lip with and without cleft palate continue to be impacted by various healthcare disparities. In the current study, low family income, longer commute to the hospital, and Medicaid insurance were identified as impediments to optimal cleft lip care. State-level and institutional programs targeting these factors may help decrease the barriers to cleft care access.

Utilization of fat grafting to address irregularities, facial defects, and body contouring has become increasingly prevalent in reconstructive surgery. The advantages of adipose tissue are diverse: it can be harvested with minimal morbidity at the donor site, it is autologous, and its malleability allows for seamless integration with native architecture. However, a notable drawback lies in its relatively low retention rates, typically ranging from 40-50% after one year. Various factors, harvesting, processing, and infiltration techniques, significantly influence the viability of fat grafts. The substantial absorption of the graft often necessitates subsequent surgical interventions, leading to heightened costs and inherent procedural risks for the patient.

The purpose of this study was to standardize the type of cannula that produces less distortion and trauma on the architecture of the adipocyte. This will enable us to achieve optimal long-term results in this procedure, as well as improvement in volume retention in fat transfer.

This was a descriptive, observational, comparative, and cross-sectional study. The main variable evaluated was the architecture of the fat graft according to the use of different liposuction cannulas.

The abdomen was divided into 4 quadrants, and infiltration was performed using modified Klein solution, which consisted of 1000cc of 0.9% saline solution plus 1 vial of 1mg adrenaline. Fat aspiration was obtained using 2 cannulas of 3mm and 2 cannulas of 5mm with fenestrations of A: 1 mm2 diameter and B: 2.5mm2 diameter. Evaluation included the area of the adipocyte in mm2, the oily fraction (cell lysis), presence of cellular debris, morphological alteration of the adipocyte, and alteration in its septa.

A total of 40 samples were included in the study. Cannula D showed adipocytes with a larger area, with a median of 6.62mm2. However, no statistically significant differences were observed between the groups (p=0.49).

Additionally, it was observed that cannula D presented a higher proportion of adipose phase with a median of 12.5mL.

On the other hand, the highest oily phase was obtained with cannula C with a median of 2.44mL, indicating greater adipocyte lysis. In the analysis of alterations in adipocytes and septal alterations, it was found that cannula A has a higher tendency towards severe changes in the architecture of the adipocyte and its septa.

In our analysis, we found an association between the type of cannula and the presence of cellular debris (p=0.03). The values that contributed the most to the difference between groups were those of the cannula in group B.

Based on the obtained results, we can conclude that the diameter of the distal fenestrations in the liposuction cannula impacts the architecture of the fat graft, leading to greater disruption of septa and increased cellular debris fragmentation when the area is 1mm2. Regarding the oily fraction, indicative of adipose cell lysis, it was found to be higher with the 3mm diameter cannula regardless of the fenestration area.

Findings align with those reported in the literature, larger caliber cannulas with wider fenestrations result in less damage to the adipocyte architecture, reduced lysis or oily fraction.