Scientific Abstract Presentations: Craniomaxillofacial Session 11 Saturday, September 28 Sat, Sep 28 2:00-3:30 p.m. PDT

Historically, the cleft defect has been thought of as a gap in the tissue. Traditional primary repairs closed the gap with a combination of primary closure +/- secondary intention, rearranging muscle and mucosa, and the stretching of adjacent tissues to the maximum of elasticity. The Anatomic Cleft Restoration Philosophy (ACRP) is used to guide the "Buccal Flap Approach" where regional flaps address tissue deficiencies. The purpose of the study was to determine the similarities and differences, at maturity, between two groups; patients born with Veau 3&4 clefts and non-cleft controls. All repairs used "The Buccal Flap Approach" during primary palatoplasty. The question was how close to normal could the buccal flap group come to the non-cleft group?

Method: This was a prospective study of 119 patients from a single surgeon's practice, all of whom had Veau 3&4 clefts and were followed to maturity. The a priori power analysis required 14 subjects per group for statistically significant comparisons. The buccal flap (BF) group of 15 randomly selected patients (aged 18-31) received a Double Opposing Z - Plasty + Buccal Flaps (DOZP + BF) repair at primary palatoplasty and had no history of secondary speech or orthognathic surgery. The age and race matched control group (CG) had 15 adults with no history of cleft palate. All participants underwent MRI to visualize their anatomy. Ten standard anatomic measures were chosen for outcome analysis. Normative data studies were included in the analysis to corroborate the measured values.

Definition of selected measures: Velar Length; from back of hard palate to uvula tip. Pharyngeal Depth (PD); from back of hard palate to posterior pharyngeal wall. Effective Velar Length (EVL); from back of hard palate to levator veli palatini (levator) muscle bulge. Effective Velopharyngeal Ratio also called Effective VP Ratio (EVPR); is a calculation, EVL divided by PD. Maximal Velar Stretch (MVS); calculation in (mm), EVL in phonation minus EVL at rest.

Description of results: The velar length, velar thickness, pharyngeal depth, and levator muscle length were statistically the same for both groups and both groups matched normative values. This degree of similarity between patients with clefts and non-cleft groups is notably different than previously reported in the literature. The NSBa and SNB measures for the BF group matched the CG and normative data. Literature has reported smaller SNB angles between cleft palate group and control groups, indicating the mandible is relatively posterior in relation to cranial base. In the present study, the SNB angles for the BF group were statistically similar to both the CG and normative data. EVPR was significantly larger in the BF group, however, the EVPR for the BF and CG fell within the normative range for adults without clefts. The SNA in the BF group was statistically different than the CG. However, the BF measures fell within multiple normative data studies looking at "normal faces" and just out of standard deviation for two normative studies looking at "ideal faces." However, the CG fell outside of all the normative data studies. The MRI revealed the muscle and tissue mass of the buccal flap was at the junction between the hard palate and velum. And, in all of the subjects, the buccal flap was located anterior to the levator sling. The resulting EVL in the BF group was statistically longer than the CG and also fell outside of the values reported in a large-scale normative data study of non-patients. The MVS in the BF group did not match CG or normative studies.

Conclusions:

In this study 8 of 10 measures of the BF group matched controls or normative data. Results suggest that patients treated with buccal flap tissue replacement have a longer EVL due to the levator sling being placed more posteriorly in the mucosal envelope. This intentional outcome, allowed the levator muscle to be placed more favorably to achieve VP closure. The DOZP + BF repair adds flexible buccal flap tissue to the anterior soft palate which can now expand in response to growth. The buccal flap may also function as a "spacer," decreasing the migration of the levator muscle toward the posterior hard palate. The longer EVL may reflect a more advantageous muscle position, compensating for the decrease in velar stretch often seen in patients with cleft palate and observed in this study. The effective use of buccal flaps achieved a longer EVL, compensating for both the reduction in tissue mobility due to scar tissue, and the inherent deficiencies of malformed velar muscles.

The study demonstrates that when appropriate tissue replacement is possible, normal anatomy and function can be achieved. When appropriate tissue replacement is not possible, tissue augmentation can play an important role establishing successful compensations for irreplaceable tissues.

Introduction: Facio-auriculo-vertebral spectrum (FAV), also known as hemifacial microsomia or Goldenhar syndrome, refers to a congenital disorder of craniofacial malformations resulting from dysmorphogenesis of structures related to the first and second branchial arches. Clinical presentations of FAV range from mild to severe with significant variation in phenotypes. The etiology of FAV includes both genetic and environmental factors, and can either be sporadic or hereditary. The management of patients with FAV requires a multidisciplinary approach. This study presents our experience treating FAV patients over more than 20 years, reporting on patient demographic variables, phenotypes and the associated burden of care. Methods: A retrospective review of patients with FAV born between 1985 and 2021 who presented to Rady Children's hospital multidisciplinary Craniofacial group for care between November 2002 and May 2023 was conducted. Patient characteristics including demographic data, age at presentation, birth history, and medical comorbidities were collected. Clinical documentation of physical exams, radiographic imaging and photographs were used to classify the major manifestations of FAV using the OMENS scoring system. Additional information gathered included duration of follow up and number of surgical interventions. Statistical analysis included the use of Spearman rank correlations to examine relationships between OMENS component grades and burden of care. Results: 230 patients underwent initial chart review and 165 remained after application of exclusion criteria, including lack of documented diagnosis of FAV and insufficient clinical documentation. Our population was equally divided between male (n=82) and female (n=83), and most patients identified as white (n=75) and Hispanic (n=99). Median age at presentation was 203 days, with most patients presenting before 1 year old (n=102, 61%). Mean duration of follow up was 7.8 + 6.2 years. The most frequent manifestation of FAV in our patient population was microtia (n=125), followed by mandibular hypoplasia (n=93), soft tissue deficiency (n=58), facial nerve involvement (n=23), macrostomia (n=15), and orbital asymmetry (n=11). On average, patients underwent 2.0 + 2.8 craniofacial surgeries. Average length of follow up was 7.8 + 6.2 years and average age at last follow up was 10.3 + 6.7 years old. Almost half of patients (n=81) had medical comorbidities involving at least one other organ system. 72% of patients (n=118) were diagnosed with hearing loss, 54 patients with speech delay, and 16 with other developmental delays. Four patients had cleft lip/palate and 6 had cleft palate alone. A statistically significant correlation between severity of mandibular hypoplasia and increased surgical burden was noted (ρ=0.17, p=0.03), with additional trends identified in severity of orbital asymmetry (ρ=0.15, p=0.06) and cleft lip (ρ=0.14, p=0.07). Severity of mandibular hypoplasia (ρ=0.20, p=0.02), microtia (ρ=0.18, p=0.02), and soft tissue deficiency (ρ=0.17, p=0.03) were all significantly associated with increased length of follow up. Conclusions: We present one of the largest cohorts of patients with facio-auriculo-vertebral spectrum in recent literature. Our findings of increased surgical burden based on presence and severity of certain OMENS components and incidence of comorbidities and developmental delays can help guide conversations with patients and family about what to expect with a diagnosis of facio-auriculo-vertebral syndrome.

Purpose Pierre Robin Sequence (PRS) is characterized by a clinical triad of micrognathia, glossoptosis and upper airway obstruction, which increases risk for acute respiratory or airway deterioration. Surgical options to address this include tongue-lip adhesion (TLA), mandibular distraction osteogenesis (MDO) and tracheostomy. The majority of PRS patients will also require primary cleft palate repair due to the associated disruption of palatal shelf fusion during development. The purpose of our study is to investigate perioperative airway outcomes at the time of cleft palate repair in patients with PRS.

Methods IRB approval was obtained to perform a retrospective review of prospectively collected data through the Nationwide Children's Hospital electronic medical record. All patients undergoing primary cleft palate repair between March 1st, 2018 and December 31st, 2022 with a diagnosis of PRS were identified. The same time period was then sampled to include a similar number of non-PRS controls. Intraoperative data collected included difficult airway assessment, laryngoscopic view (1-4) and number of endotracheal tube (ETT) insertion attempts. Post-operative outcome data included 30 day readmission rate for airway/respiratory related complications, 30 day reintubation rate, and prolonged intubation beyond the end of surgery. Statistical analysis included students t-test and chi-square.

Results A total of 41 patients with a diagnosis of PRS ((+)PRS) undergoing primary cleft palate repair were identified over the study period; a similar number of controls without a PRS diagnosis ((-)PRS) (N=42) undergoing cleft palate repair were sampled. In the (+)PRS group, rates of prior management were conservative treatment (37%), TLA (24%), MDO (34%) and tracheostomy (4.9%). The (+)PRS group had higher rates of difficult airways during intubation (17.9% vs 0%, p = 0.004), were more likely to have a laryngoscopic view grade 2 or higher (41% vs 9.5%, p = 0.001) and on average had a greater mean average number of attempts at ETT placement (1.44 +/- 0.11 vs. 1.14 +/- 0.08; p = 0.030). When stratified by technique of prior PRS surgical intervention MDO was less likely to have a laryngoscopic view grade 2 or higher (7.7% vs. 57%, p = 0.0065; 7.7% vs. 50%, p = 0.022) and had fewer average number of attempts at ETT placement (1.14 +/- 0.097 vs. 1.6 +/- 0.19 p = 0.02; 1.14 +/- 0.097 vs. 1.88 +/- 0.23; p = 0.0013 ) compared to conservative management and TLA respectively. Post-operative outcomes including readmission within 30 days after surgery for airway/respiratory related complications, need for reintubation within 30 days after surgery, and prolonged intubation beyond the end of surgery did not differ between (+)PRS and (-)PRS.

Conclusion At the time of primary cleft palate repair, patients with a diagnosis of PRS are more likely to have a difficult airway, a worse laryngoscopic view and more attempts at ETT insertion during intubation. However, PRS patients with prior MDO have better laryngoscopic views and less attempts at ETT placement compared to those treated conservatively or with TLA.

Background: Cleft palate repair can be complex, often combining multiple individual surgical methods to both achieve anatomic closure of the cleft, while lengthening the palate and re-orienting the levator to improve speech outcomes. This elevates the learning curve required for palatal repair as familiarity with multiple techniques is required. Palatal repair techniques are often named after the surgeons who described them, but there have been multiple modifications over time. As the appetite for global education in cleft surgery increases, numerous modifications in techniques can complicate learning. This study aims to evaluate the number of original palatoplasty techniques and variations thereof and determine the number of studies in the literature that describe their technique in detail. Methods: A systematic review according to PRISMA guidelines was conducted. 1,899 articles were identified. Inclusion criteria included: primary articles objective was to describe a novel method of cleft palate repair either of the hard palate, soft palate, or both and provided details of intra-operative steps taken. Exclusion criteria were: absence of operative details, studies comparing techniques or surgical outcomes and revision rather than primary surgery technique reported. In total, 109 articles met criteria. Demographics gathered were year of publication, first author name and country of origin. Data were gathered on eight steps performed during a palate repair: Design of palatal incisions, islandization of greater palatine flaps, levator muscle management, anterior palate closure, soft palate closure, additional flaps/agents for either multi-layer closure or increasing length, and closure of lateral incisions. Results: Out of 109 articles 29 (26.6%) were cited by surgeon name. Furlow's technique was the most modified with 29 (26.6%) modifications, follow by von Langenbeck's with 18 (16.5%) modifications and Bardach's with 17 (15.6%) modifications. Palatal incision design was reported as straight in 66 (60.6%) articles, Z-plasty in 25 (22.9%) articles, combination of both in 6 (5.5%) and 12 (11%) reported other designs. Mucoperiosteal flaps were described for anterior palate closure in 98 89.9%) articles and elevation of such flaps was reported 86 (78.9%) articles. Further data were gathered on specific maneuvers for flap elevation and medialization including release of greater palatine artery in 38 (44.2%) articles, release of tensor tendon in 28 (32.6%) articles, dissection into the space of Ernst 11 (12.8%) and hamular fracture reported in 20 (23.3%) articles. Closure of the uvula 37 (33.9%) and final position of flaps for soft palatal closure 27 (24.8%) were both related to soft palatal closure and the least commonly reported intra-operative steps of the articles included. Of each of the named techniques, 26 original articles were retrieved of which 26 (100%) reported 2 or more of these principles of repair. NIneteen (17.4%) articles described all aspects of their technique in detail (all intraoperative steps). Conclusion: Combination and modification of palate repair techniques for different anatomical locations in the palate has resulted in widespread variation. Despite 109 techniques being reported, all techniques described at least one critical step, demonstrating that all techniques, regardless of name, rely on specific principles of palatoplasty. However, technique descriptions are incompletely defined in the literature, with only 19 (17.4%) describing the critical steps from from incision to closure. While design of flaps on the palate are noted, the details of extent of dissection, flap elevation, type of suture technique and method of multi-layer closure were palate surgery. This could be particularly challenging for plastic surgery trainees, particularly those without a mentor, who are looking to reproduce these techniques. Greater emphasis should be placed on providing specific details of all intra-operative steps taken to facilitate knowledge-sharing in the cleft surgical community.

Purpose: To evaluate how Medicaid reimbursements for cleft lip and palate repair compare with annual U.S. economic growth when adjusted for inflation.

Methods: Current Procedural Terminology (CPT) codes for cleft lip and palate repair were retrospectively reviewed between 2018-2023. Using Medicaid physician fee schedules for the top 5 U.S. states with the highest birth rates, and the study's home state, reimbursements were evaluated and adjusted for inflation to 2023 U.S. dollars. Annual total percentage changes in reimbursement, percent change in inflation-adjusted reimbursement, and reimbursement Compound Annual Growth Rate (CAGR) were evaluated and compared to annual changes in the U.S. Consumer Price Index (CPI).

Results: The U.S. CPI increased by 20.9% from 2018-2023. In comparison, the overall total percentage change in reimbursement rates for all cleft lip and palate procedures increased by 7.23%. Annual percent changes in cleft lip and palate reimbursements were significantly lower than annual changes in CPI for all procedures (CPT 40700 P-value = 0.006, CPT 40701 P-value = 0.046, CPT 40702 P-value = 0.038, CPT 42200 P-value = 0.038, CPT 42210 P-value =0.014). After adjusting for inflation, the overall percent change in reimbursements for all procedures decreased by -12.81%. The greatest mean decreases in inflation-adjusted reimbursement were observed for CPT code 40700, plastic repair of cleft lip/nasal deformity; primary, partial, or complete, unilateral (−14.94%), and CPT code 42210, palatoplasty for cleft palate, with closure of alveolar ridge ( -14.60%). For all procedures, the average CAGR was –2.66%.

Conclusion: In contrast to the overall economy, reimbursements for cleft lip and palate procedures in the U.S. are significantly declining each year when adjusted for inflation. To maintain the financial sustainability of cleft lip and palate care for providers and hospital systems, reimbursement trends relative to inflation and the overall economy need to be considered by federal lawmakers to ensure the ongoing financial sustainability of cleft lip and palate care.

Introduction: Aplasia Cutis Congenita (ACC) presents as a rare, yet challenging congenital anomaly characterized by the absence of skin in localized areas.(1) This condition poses significant clinical risks, including dehydration, meningitis, sinus thrombosis, and hemorrhage, with mortality rates reported between 20% and 55%.(2,3)The complexity of ACC necessitates a comprehensive and individualized management strategy tailored according to each case. Methods: Our retrospective analysis spans two decades (2000-2023), encompassing cases of ACC treated within the Plastic and Reconstructive Surgery Department at Soroka Medical Center. This study not only revisits the spectrum of clinical presentations and outcomes but also evaluates the effectiveness of a treatment algorithm developed by our team. (4)This classification system considers the size of the defect, the involvement of skin layers, vascular exposure, and other anomalies and provides a road map for immediate and subsequent treatment. It is designed to identify those who require surgical intervention versus those who can be managed conservatively. Results: The cohort includes 76 patients diagnosed with ACC, predominantly affecting the scalp (96.1%). Defect sizes varied, with a median of 2.5 cm² (IQR 15.0 cm²). A majority (47.4%) presented with isolated skin defects (Type I), while 25% exhibited underlying bone involvement (Type II), and 11.8% had large vein exposure (Type III). Notably, 19.7% of cases were accompanied by limb anomalies, with prevalence escalating in correlation with defect severity. Adams-Oliver Syndrome was identified in 9.2% of patients. Surgical intervention was pursued in 22.3% of cases, with a mortality rate of 3.95%, mainly by bleeding events. Our findings highlight the efficacy of Integra as a single-stage surgical option, facilitating re-epithelialization even in extensive defects, thereby obviating the need for traditional skin grafts. Conclusion: Over the last two decades, our classification-based treatment algorithm has demonstrated significant efficacy in guiding therapeutic decisions for ACC, leading to successful patient outcomes.

Reference: 1. Higgins C, Price A, Craig S. Aplasia cutis congenita. BMJ Case Rep. 2022;15(9). doi:10.1136/bcr-2022-251533 2. Humphrey SR, Hu X, Adamson K, Schaus A, Jensen JN, Drolet B. A practical approach to the evaluation and treatment of an infant with aplasia cutis congenita. Journal of Perinatology. 2018;38(2):110-117. doi:10.1038/jp.2017.142 3. Santos de Oliveira R, Barros Jucá CE, Lopes Lins-Neto A, Aparecida do Carmo Rego M, Farina J, Machado HR. Aplasia cutis congenita of the scalp: Is there a better treatment strategy? Child's Nervous System. 2006;22(9):1072-1079. doi:10.1007/s00381-006-0074-y 4. Silberstein E, Pagkalos VA, Landau D, et al. Aplasia cutis congenita: Clinical management and a new classification system. Plast Reconstr Surg. 2014;134(5):766e-774e. doi:10.1097/PRS.0000000000000638

Purpose: There is variation in recommendations for the timing of operative intervention following mandibular fractures. The National Trauma Data Bank (NTDB) is a validated, nationwide, multi-center trauma patient registry provided by the American College of Surgeons (ACS). This study aims to evaluate the effects of operative timing of mandibular fractures on outcomes and complications using the NTDB. Methods: A retrospective review of patients with mandibular fractures who underwent operative intervention from the ACS NTDB from 2019-2022 was completed. Patients were separated by timing of operative intervention into less than one day, from one day to two days, and greater than two days following mandible fracture. Demographics, fracture patterns, complications, and operative outcome data were collected. Univariate and multivariate analysis was performed to determine factors associated with complications after surgical repair of mandible fracture. Results: A total of 85,671 patients with 117,074 mandible fractures were identified. Of those, 36,380 (42.5%) patients underwent operative intervention. Most surgical patients were male (79.0%) and Caucasian (57.3%). The most common fracture pattern undergoing operative intervention was symphysis (21.2%), followed by angle (19.5%). Surgical and medical complication rates were significantly higher in patients who were operated on greater than two days following fracture (5.4%; 14.7%) compared to those who operated on less than one day following fracture (p<0.001; p<0.001). Additionally, rates of surgical site infection and unplanned return to the operating room were significantly higher (1.2%; 4.6%) compared to the rate in those who were operated on less than one day following fractures (p<0.001; p<0.001). When looking at patients > 18 years of age, the univariate analysis demonstrated that time to operation, preexisting conditions, GCS on arrival, and receiving antibiotics were associated with the presence of surgical complications. Multivariate analysis demonstrated that these all remained significant: total GCS (p<0.001), antibiotic therapy (p<0.001), total preexisting conditions (p<0.001), smoking (p<0.001), HTN (p=0.032), time to operation (p<0.001), and presence of ramus fracture (p<0.001). Conclusions: Among the 36,380 patients with operative mandibular fractures, those who underwent operative intervention in less than one day had the lowest rates of surgical and medical complications. The highest rates of complications were seen in those undergoing operative intervention greater than two days following a fracture. These findings suggest that an earlier timing of operative intervention may improve outcomes in patients requiring surgery.

INTRODUCTION In prior observational studies of children undergoing primary cleft palate (CP) repair, perioperative ketorolac combined with Enhanced Recovery After Surgery (ERAS) multimodal pain management has been shown to improve postoperative oral nutrition while reducing hospital length of stay (LOS) and narcotic use. However, these benefits have not been corroborated in a randomized interventional study. The purpose of this study is to assess, using a randomized trial, the impact of perioperative ketorolac combined with our institutional ERAS protocol on inpatient postoperative oral intake in patients receiving primary palatoplasty.

METHODS This is an interim analysis of an ongoing placebo-controlled, double-blinded randomized clinical trial with parallel treatment groups. Patients over 6 months old with CP with or without cleft lip were included in this study. Patients with syndromic CP, cardiac malformations, history of gastrointestinal complications, renal disorders, coagulopathy, and feeding tube dependency were excluded. After enrollment, patients were randomly assigned to the ketorolac (ERAS + ketorolac) or placebo group (ERAS + placebo). Randomization was stratified by cleft severity (incomplete or complete). Patients received ketorolac or placebo for 24 hours postoperatively in addition to our institutional ERAS protocol. The primary outcome was 24-hour postoperative oral intake. Secondary outcomes included LOS and total inpatient narcotic use in morphine milligram equivalents (MMEs). Univariate and multivariate analysis was performed.

RESULTS Twenty-seven patients were randomized with a median age of 12 months (IQR 12-13.8). Thirteen (48%) of the patients were female. Most were non-Hispanice white (14, 52%), with 9 (33%) and 2 (7.4%) identifying as Hispanic/Latino and non-Hispanic black, respectively. Twenty-three (85%) had complete CP, while 4 (15%) had incomplete CP. There were no statistically significant differences in demographic characteristics between the 2 treatment groups. When comparing the ketorolac and placebo groups using univariate analysis, there was no significant difference in 24-hour postoperative oral intake (360 vs 372 milliliters, p=0.4), LOS (26 vs 29 hours, p=0.5), or inpatient narcotic use (2.82 vs 2.96 MMEs, p=0.9). On multivariate analysis, ketorolac use was not a significant predictor of 24-hour postoperative oral intake (p=0.5), LOS (p=0.4), or total inpatient MMEs (p=0.8). Overall, there were no postoperative complications, though there was one readmission for fever in the placebo group.

CONCLUSION The addition of ketorolac to our institution's ERAS pain management protocol did not significantly impact postoperative oral intake, narcotic use, or hospital LOS after primary palatoplasty. However, by definition, this interim analysis is underpowered to detect any difference in the primary or secondary outcomes. It remains to be determined if any benefits of postoperative ketorolac on 24-hour postoperative oral intake will be identified with continued enrollment in this ongoing randomized trial.

Patients that undergo skin cancer excision in the head and neck region can present significant reconstructive challenges. These patients often have multiple comorbidities, complicating the use of general anesthetic procedures and complex reconstruction. High risk skin cancer excision in this area must also provide a reconstruction able to withstand the negative effects of radiotherapy, owing to the need for adjuvant treatment required in certain tumour pathologies.

Biogradable Temporising Matrix (BTM) is a polyurethane foam matrix that creates a scaffold for dermal regeneration. Although outcomes are well described for use in burns1 and other complex wounds2, there is limited data on its use in head and neck cancer reconstruction.

In addition to the scarcity of evidence regarding the use of BTM for skin cancer reconstruction in this region, there is also very limited evidence as to the effects of radiotherapy on BTM reconstructed wounds, with only a scattering of case reports in the literature.

In our unit, 53 patients underwent BTM reconstruction for head and neck skin cancer defects. In this study, we present a series of 9 patients from this group who had either received adjuvant radiotherapy following their reconstruction or had BTM reconstruction to resurface an excised radio-recurrent lesion.

Method

Retrospective analysis of all patients who underwent adjuvant radiotherapy to a BTM reconstructed skin cancer excision in the head and neck area or who were resurfaced with BTM for a radio-recurrent skin cancer at St Helens and Knowsley NHS Trust between May 2021 and April 2023.

Results

9 patients were identified with a mean age of 74, 2 of whom had BTM for radio-recurrent lesions. Tumour pathology was SCC in 7 patients (78%) and BCC in 2 patients (22%). Regions of the head and neck involved were scalp (34%), forehead (22%, orbit (22%) and cheek (22%). The wound base was bone in 7 patients (78%), muscle flap in 1 patient and post-parotidectomy in 1 patient. Second stage split skin graft (SSG) was performed in all primary tumour patients at a mean of 54 days post-BTM. Radiotherapy was completed within a mean of 4.4 months following second stage SSG in the primary tumour population. Breakdown following BTM application was not seen in any patient in either the primary tumour group or the radio-recurrent group with a mean follow-up of 17.5 months (range 5-35 months). 1 patient was excluded from follow-up due to early recurrence and has since died from disease.

Conclusion

Reconstruction with BTM appears to be robust even following insult with radiotherapy for this unique group of patients with skin cancer in the head and neck region.

1. Greenwood JE, Bradley J. Schmitt, Marcus J.D. Wagstaff. Experience with a synthetic bilayer Biodegradable Temporising Matrix in significant burn injury. Burns Open, Volume 2, Issue 1, 2018, Pages 17-34

2. Li H, Lim P, Stanley E, et al.. Experience with novosorb biodegradable temporising matrix in reconstruction of complex wounds. ANZ J Surg. 2021;91:1744–1750.

Background: Virtual Surgical Planning (VSP) and three-dimensional Printing (3DP) technologies have changed the landscape of complex craniofacial deformities from congenital, oncologic, and traumatic etiology. Across literature, this technology employed for its superiority in accuracy over the standard practice. Previously, our group has introduced an in-house, patient-centered management of facial fractures with the use of VSP back to normalized anatomy; EPPOCRATIS [1].

Methods: Out of more than 163 screened facial trauma patients, A retrospective review of 40 patients who underwent maxillofacial reconstructions after trauma from September 2014 to September 2023 was performed. We matched surgical cases that employed VSP (n=20) with those that did not (n=20). The cases were aligned based on the fracture patterns and complexity (including Naso-orbito-ethmoid [NOE] ± Frontal Sinus Involvement, Isolated Nasal Fractures, Orbital Fractures, Zygomaticomaxillary Complex [ZMC] fractures, Mandibular Fractures, and Pan-facial fractures) to ensure consistency and comparability of operative metrics. Data including age, BMI, comorbidities, fracture complexity, operative time, length of stay, follow-up period, and reported complications were collected. Differences between the groups were analyzed using t-tests and chi-square tests in RStudio (v.4.3). Lastly, we assessed the fracture reduction accuracy by segmenting the pre- and post-operative CT scans in Mimics 3D software (v25.0, Belgium). Seven cases from the VSP group were analyzed by comparing the pre- and the post-operative scans to the planned VSP. The findings were represented in a heatmap analysis to assess the accuracy of execution of the VSP.

Results: A total of 40 patients with a mean age of 41.5 years (SD=17.49) were included. Majority were male (80%). The motor-vehicle accidents were directly correlated with moderate to severe fracture pattern and the need of VSP. While the intra-operative time is less in the VSP group, this difference was not statistically significant (mean = 5.36 hours [SD: 2.67] with VSP, mean = 5.89 hours [SD = 2.67] without VSP, p-value = 0.802). Furthermore, the hospital stay duration was similar (average = 2.97 days for both groups; p-value = 0.665). The average follow-up period for each group was 221.6 days. Preoperatively, the heatmap analysis revealed regions with intense inward (red-hue) and outward (blue-hue) discrepancies, while post-operatively, the bones demonstrated closer alignment and neutralization of the colors towards the normal patient's anatomy. Some complex fractures showed a deviation of 1.2 mm to 3.8 mm from the plan. This deviation remained clinically acceptable, with no reported complications on this studied cohort.

Conclusion: Although operative time and lengths of hospital stay didn't show significant difference among the VSP and the control groups. This cohort demonstrated that VSP could effectively achieve precise fracture reduction in complicated facial fractures. The post-operative accuracy underscores the reliability of this technology. Further investigation with larger sample size is still required to comprehensively analyze the benefits of VSP on surgical outcomes and gather patient-reported outcome measures.

[1] Sharaf, B., et al., EPPOCRATIS: Expedited Preoperative Point-of-Care Reduction of Fractures to Normalized Anatomy and Three-Dimensional Printing to Improve Surgical Outcomes. Plastic and Reconstructive Surgery, 2022. 149(3): p. 695-699.

Purpose: Plastic surgeons assess facial expression and manipulate the facial neuromuscular system while employing neuromodulators, when performing facial rejuvenation surgeries, and in reconstructing patients after facial paralysis. Despite significant advances in imaging technologies, clinical changes in facial expression are still qualitatively assessed following surgical and non-surgical intervention. This is at least partly due to a paucity of data regarding normative metrics for the activity of facial muscles [1,2]. We aimed to quantitatively assess dynamic facial neuromuscular anatomy by cataloguing displacements, forces, and surface electromyography (sEMG) patterns associated with standard facial expressions in healthy participants. This pilot study focuses on parameters associated with zygomaticus major activity and lays the groundwork for developing a comprehensive database of facial movement.

Methods and Materials: Healthy volunteers were recruited via survey and cross-sectionally studied in a single in-person visit. Volunteers with self-reported disorders of facial movement were excluded. Baseline demographics were collected. Participants were seated with surface electrodes placed overlying their zygomaticus major muscles and wired to an sEMG sensor and processor. A custom platform containing a tension/compression load cell was used to measure forces produced by each participant. Camera phones were used to video-record participants from multiple angles as they performed "regular" and "maximal" volitional smiling, puckering, cheek blowing, and mouth opening exercises. sEMG signals, forces, and three-dimensional surface movements were assessed with each expression. These parameters were catalogued, correlated, and statistically analyzed.

Results: 32 participants were cross-sectionally studied (12 M, 20 F). Mean age of volunteers was 30.9 years (SD 10.1), and mean BMI was 24.3 (SD 3.9). As expected, sEMG signal was greatest overlying the zygomaticus major when participants initiated maximum volitional smiling. The sEMG signature for each volitional movement was distinct and could be statistically differentiated from every other expression (p<0.05). Force vector measurements correlated with sEMG signals and were also statistically different for each facial expression (p<0.05), with the greatest forces also produced during maximum volitional smiling (mean 0.93 N, SD 0.46N ). Mean maximum displacement of the oral commissure was 1.0 cm (SD 0.3 cm) with maximum volitional smiling.

Conclusions: A database which catalogues and correlates facial sEMG patterns, forces, and movements associated with various facial expressions has several applications. Algorithms can be derived from this data to quantitatively assess the effects of neuromodulators and complications from facial rejuvenation surgeries, monitor results of rehabilitation protocols after facial paralysis, and even to produce novel technologies in the space of facial roboto-prosthetics. Our protocol can be replicated for every facial muscle to create a comprehensive three-dimensional database of facial expression. Our study represents the first sizable contribution to this database.

[1] Kim KE, Oh SH, Lee SU, Chung SG. Application of isometric load on a facial muscle--the zygomaticus major. Clin Biomech (Bristol, Avon). 2009;24(8):606-612. [2] Schumann NP, Bongers K, Scholle HC, Guntinas-Lichius O. Atlas of voluntary facial muscle activation: Visualization of surface electromyographic activities of facial muscles during mimic exercises. PLoS One. 2021;16(7):e0254932. Published 2021 Jul 19.

Introduction There has been an increase in the use of buccal flaps during primary palatoplasty, however their efficacy in improving surgical outcomes is unknown. We aim to determine if use of buccal flap during primary Furlow palatoplasty in children with cleft lip/palate (CLP) decreases the likelihood of developing velopharyngeal insufficiency (VPI). Methods Retrospective cohort study of children with CLP who underwent primary palatoplasty between 1999 and 2022 at a single institution were reviewed. Patients < 2 years old at time of surgery, who underwent primary Furlow alone (FA) or Furlow with buccal flap (FB), and had speech-language pathologists (SLP) evaluation to determine presence of VPI were included. Bayesian multivariate logistic regression with a neutral prior was used to determine the posterior probability of VPI development after FB. Results Sixty patients were included in the study (64% FA vs 36% FB). Median age of patient at surgery was 12.6 months. Median age of SLP assessment was 4.6 years (range 3.8 – 6.1 years). There was no significant difference in baseline characteristics between those who did and did not develop VPI, except for Veau class (VPI higher with class 4, p = 0.045). Fistula rate was higher in patients who developed VPI (3 vs 1, p = 0.01). Ten percent of FB developed VPI versus 26% of FA (p = 0.125). After adjusting for Veau class, buccal flaps were found to have an OR of 0.42 (95% CI 0.12–1.36) in VPI development, with a 93% likelihood of decreasing the odds of VPI. Conclusion Performing buccal flap during primary Furlow palatoplasty for CLP patients has a 93% likelihood of decreasing the odds of VPI. Expansion of this database as new SLP evaluations become available is needed to further elucidate the beneficial therapeutic effects of buccal flap for preventing VPI in this heterogeneous patient population.

Even after palatoplasty, the incidence of velopharyngeal dysfunction (VPD) can reach 30%; however, these estimates arise from high-income countries (HICs) where speech-language pathologists (SLP) are part of standardized cleft teams. The VPD burden in low- and middle-income countries (LMICs) is unknown. This study aims to develop a machine learning model that can detect the presence of VPD using audio samples alone.

Case and control audio samples were obtained institutional and publicly available sources. A machine learning model was built using Python software.

The initial 110 audio samples used to test and train the model were re-tested after format conversion and file deidentification. Each sample was tested 5 times yielding a precision of 100%. Sensitivity was 92.73% (95% CI 82.41%-97.98%) and specificity was 98.18% (95% CI 90.28%-99.95%). One-hundred and thirteen prospective samples, which had not yet interacted with the model, were then tested. Precision was again 100% with a sensitivity of 88.89% (95% CI 78.44%-95.41%) and a specificity of 66% (95% CI 51.23%-78.79%).

VPD affects nearly 100% of patients with unrepaired overt soft palatal clefts and up to 30% of patients who have undergone palatoplasty. VPD can render patients unintelligible, thereby accruing significant psychosocial morbidity. The true burden of VPD in LMICs is unknown, and likely exceeds estimates from HICs. The ability to access a phone-based screening machine learning model could expand access to diagnostic, and potentially therapeutic modalities for an innumerable amount of patients world-wide who suffer from VPD.

Background: While current literature describes the utility of virtual surgical planning (VSP) in the treatment of open cranial vault reconstruction for craniosynostosis, there is a paucity of studies on its use in endoscopic repair. Well-known advantages to endoscopic repair over open cranial vault reconstruction include a shorter operative and anesthesia time, less blood loss, and shorter hospital stay. However, the endoscopic approach for unicoronal synostosis presents additional challenges including difficulty in identification of anatomic end points particularly distally at the skull base, a smooth cortical appearance of the skull as opposed to a frank ridge due to suture fusion, and the non-linear course of the craniectomy. Given that these factors can predispose to incomplete or inaccurate craniectomy when performing an endoscopic case, we devised a novel system to optimize neo-suture placement using VSP in this case series of patients with coronal craniosynostosis. Methods: 8 patients were retrospectively reviewed following endoscopic guided suturectomy for coronal craniosynostosis. For each of these patients a novel VSP system was used to create soft tissue and bone-registered guides which were then combined into a surface marking guide. This surface marking guide then facilitated pre-operative tattooing of the fused suture line along the periosteum using methylene blue. After obtaining access to the skull, the surgeon can follow the tattooing of the periosteum of the fused suture or "yellow brick road," and verify ideal craniectomy width and length. An additional intraoperative verification guide can then be used to validate complete craniectomy. Results: Of the 8 patients, 5 were female and 3 were male. 2 of the patients were syndromic cases. 4 of the patients had bilateral coronal craniosynostosis, while 4 had unilateral craniosynostosis. Average age at the time of operation was 2.4 +/- 1 months. Average operative time for the unilateral cases was 63 +/- 17 minutes and for the bilateral cases was 78 +/- 26 minutes. Average postoperative day at discharge was 1.5 +/- 1 days. Post-operative CTs were not obtained as there were no post-operative concerns and they are not part of the standardized postoperative pathway for these patients. During the cases, complete and accurate craniectomy was verified through utilization of the surface marking guide and by following the methylene blue tattoo markings of the periosteum along the fused sutured line. Conclusion: Successful suturectomy requires detailed knowledge of sutural anatomy and soft tissue interface with the skull base. With the use of VSP there is decreased reliance on intraoperative assessment in predicting both aesthetic and functional outcomes. In this case series of patients with coronal synostosis, we propose the use of a novel VSP system whose advantages include increased fidelity of neo-suture placement, idealized placement and decreased size of the access incision, restriction of neo-suture width to preserve non-fused bone, and minimized risk of collateral anatomic damage such as the sphenoid wing and lateral orbit.