Scientific Abstract Presentations: Craniomaxillofacial Session 12 Saturday, September 28 Sat, Sep 28 5:00-6:00 p.m. PDT

Purpose: The Melbourne technique for total cranial vault remodeling aims to address all aspects of the scaphocephaly head shape in patients with sagittal craniosynostosis. These features include excessive cephalic length, anterior vertex position, frontal bossing, vertex narrowing, and occipital bulleting. This study aimed to determine the progressive cranial changes that occur over time following the Melbourne technique for total cranial vault remodeling in sagittal craniosynostosis. Methods: A retrospective review of 3D images of 25 patients with sagittal craniosynostosis treated with the Melbourne technique for cranial vault remodeling was performed. Images were collected pre-operatively, three weeks, three months, one year, and two years post-operatively. Head circumference, cephalic index, frontal bossing index, occipital bulleting index vertex narrowing index, and vertex-nasion-opisthocranion angle (a measure of vertex positioning) were evaluated. 3D composite cranial heat maps were created. Results: Head circumference significantly increased post-operatively (p<0.001), followed by progressive growth across time points. The cephalic index also significantly increased post-operatively (p=0.04) with a subsequent relapse at three months followed by progressively increased growth. The frontal bossing index significantly decreased post-operatively (p=0.02) with a progressive decrease over time. The frontal bossing improved from the 97th percentile to the 75th percentile at two years of age. The occipital bullet index had a relative decrease post-operatively with relapse at three months, followed by a progressive decrease across remaining time points. The occipital bulleting improved from the 84th percentile to the 70th percentile at two years of age. The vertex narrowing index significantly decreased post-operatively (p<0.001), followed by a plateau and slight relapse over time. The vertex narrowing improved from the 98th percentile to the 86th percentile for vertex narrowing at two years of age. The vertex-nasion-opisthocranion angle showed a relative decrease over time with a significant decrease by one year of age (p=0.002).
Conclusions: The Melbourne technique for correction of scaphocephaly demonstrated improvement in the cephalic index, frontal bossing, vertex narrowing, occipital bulleting, and vertex positioning at two years of age. Cephalic index and occipital bulleting showed slight relapse at three months, followed by progressive improvement over time.

Introduction LeFort I advancement with rigid internal fixation at the time of facial maturity is the traditional method used to treat maxillary hypoplasia in children with cleft lip and palate. Early LeFort I advancement prior to the time of facial maturity is controversial due to the risk of "outgrowing" the initial advancement and the need for a second advancement surgery when the child is done growing. However, there is very little in the literature that looks at long-term outcomes of early LeFort I advancement in children with cleft lip and palate. Early LeFort I advancement with Rigid External Distractor (RED) Halo, has been used at our institution for the past two decades in children with cleft lip and palate with significant maxillary hypoplasia between the ages of 9 and 14 with good success. We aim to show this is a safe and effective treatment to address significant maxillary hypoplasia in the cleft population prior to the time of facial maturity.

Method A retrospective analysis of all syndromic and non-syndromic cleft lip and palate patients who underwent a Lefort procedure was conducted from 2011 to 2023 at our institution. All patients who are currently at least 15 years old, and who underwent Lefort advancement with RED Halo before the age of 15 were included. The primary outcome of interest was the number of revision Lefort procedures performed.

Results A total of 145 patients had a Lefort advancement with RED Halo placed while they were still growing; before facial maturity was reached at the age of 15. This cohort had an average follow-up of 9 years. The mean age at the initial surgery was 11, with a range of 6.3-14.9. 9.7% of these patients (14/ 145) subsequently had a repeat Lefort surgery. These 14 patients had their initial surgery at a mean age of 10 (range of 7.6-13.9), and their second revision surgery at a mean age of 15.6 (range of 9.1-19.7).

Conclusion Lefort I advancement with RED Halo prior to the time of facial maturity, with overcorrection to account for additional mandibular growth, is a safe and effective way to correct significant maxillary hypoplasia in children with cleft lip and palate. To maintain the lowest risk for revision, surgical intervention should be performed after 11 years of age.

Background: Facial fractures are responsible for approximately 407,000 emergency department visits per year in the United States. The evaluation of bony facial trauma is frequently supplemented with imaging, and maxillofacial computed tomography (CT) is considered to be the gold standard. However, facial trauma patients often incur concomitant injuries that necessitate additional evaluations by a multi-disciplinary team. For example, traumatologists often utilize CT angiography (CTA) to screen for cerebrovascular injury. The decision to order CTA is typically based on the Denver Criteria. While the Denver Criteria was described over twenty years ago, a study in 2022 demonstrated that 16% of patients with blunt cerebrovascular trauma had none of the risk factors described in the Denver Criteria and advocated for CTA screening in any patient undergoing CT of the cervical spine. The purpose of this study was to investigate if CTA is sufficient to evaluate bony facial trauma without maxillofacial CT to reduce patient exposure to radiation, improve resource management, and decrease unnecessary costs.

Materials & Methods: This was a retrospective study at a single academic institution with level one adult and pediatric trauma centers. Patients who received both CTA and maxillofacial CT between October 2018 and October 2023 were included. The radiology reports for each scan were evaluated. Patients were excluded if the attending radiologist did not complete a dedicated evaluation for osseous facial trauma on either CTA or maxillofacial CT. Facial fractures from each scan were abstracted. The accuracy of CTA was compared against maxillofacial CT, and we calculated the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of CTA. McNemar's test was used to evaluate if there was a diagnostic difference between CTA and maxillofacial CT. Wilson 95% confidence intervals (CI) were calculated and an alpha of 0.05 was used to determine statistical significance.

Results: 113 patients were reviewed, and 30 patients were included, corresponding to 1,350 bones which were evaluated for fractures. The mean patient age was 48.8 (standard deviation = 18.9) years old. The accuracy of CTA was 96.9% (CI 95.8-97.7%) (n = 1,308/1,350). The sensitivity was 53.1% (CI 41.1-64.8%) and specificity was 99.0% (CI 98.4-99.5%). Simultaneously the NPV was 97.7% (CI 96.7-98.4%) and the PPV was 73.9% (CI 59.7-84.4%). Comparing the diagnostic differences between CTA and maxillofacial CT with McNemar's test demonstrated a p-value of 0.008. The most common fractures that CTA missed were nasal bone fractures (n = 4, 13.3%). No missed fracture required operative repair.

Conclusion: Our results confirm that maxillofacial CT is superior to CTA in correctly identifying facial fractures, as demonstrated by McNemar's test. However, our study suggests that CTA may mitigate the need for dedicated maxillofacial CT in patients who have already undergone CTA. While the sensitivity of CTA compared to maxillofacial CT was 53.1% (CI 41.1-64.8%), the fractures that were most commonly missed were nasal bone fractures and none of the missed fractures required operative intervention. Therefore, it appears as though CTA is sufficient to detect clinically significant facial fractures.

Background:: The free fibula osteomyocutaneous flap has historically been the workhorse flap for mandibular defects. The tenuous reliability of the skin paddle supplied by the septocutaneous perforators in addition to a limited arc of rotation are well-documented. Previous studies note the possibility of a second skin paddle based on soleus musculocutaneous perforators (lateral sural artery perforator, LSAP flaps) in cases of skin paddle compromise or those without peroneal perforators. In our experience, these LSAP vessels provide a reliable option for multiple skin paddles in cases of extensive soft tissue resection. We present our cohort of patients receiving chimeric flaps for extensive head and neck defect reconstruction based on both traditional peroneal septocutaenous and lateral sural artery perforators. Systematic review of the anatomy was performed.

Methods:: Retrospective review was performed on patients receiving chimeric fibula osteocutaneous and LSAP fasciocutaneous flaps. Musculocutaneous perforator prevalence and location were documented. The main pedicle for perforators was documented. Systematic review was performed in accordance with PRISMA guidelines.

Results:: Nineteen cases were assessed. Each case employed 2 skin paddles with an average of 2.2 perforators for each LSAP flap. In 15 cases, the lateral sural vessel emerged from the peroneal artery (78.9%). Four cases had aberrant anatomy with the lateral sural vessel emerging from the common tibioperoneal trunk requiring a second microanastamosis. Two fibula flaps were lost but there were no major nor minor complications with the LSAP skin paddles.

Conclusion:: In extensive soft tissue resection, the septocutaneous peroneal paddle is used to reconstruct the alveolar ridge and the improved arc of rotation with the LSAP paddle is used for larger defects extending beyond this ridge. Most often, this second skin paddle/soft tissue can be recruited from the lateral soleus artery branching from the peroneal vessel supplying the fibula flap. When these perforators have an aberrant origin, a second microanastamosis will need to be performed.

Background: Prenatal 3D and 4D ultrasound provide impressive anatomic detail which aid in craniofacial diagnosis. When micrognathia is detected in utero (suggestive of Pierre Robin Sequence) opportunities of prenatal counseling may provide important information for families. However, the psychosocial implications have not been well studied.

Methods: Perinatal newborns diagnosed with Pierre Robin Sequence were grouped into 1) those diagnosed prenatally via ultrasound screening and had extensive multidisciplinary counseling: and 2) those not diagnosed prenatally ('birthday- surprise') (n=34). The two groups were also subdivided into isolated Pierre Robin Sequence (PRS), PRS-Plus (additional anomalies), or PRS syndromic. PROMIS (Patient-Reported Outcomes Measurement Information System) surveys given at 6 weeks after birth were used to compare psychosocial scores from families of these 2 groups.

Results: PRS families diagnosed prenatally were counseled in critical airway protocols, PRS treatment algorithm work-ups, feeding, and surgical options; and compared to families with no prenatal diagnosis and no prenatal counseling. The prenatal diagnosed families who received counseling had less anxiety (32%±3 to 72%±5), less depression (34%±4 to 71%±5), and less feelings of social isolation (20%±2 to 69%±4). When the groups were subdivided and compared, this difference in prenatally diagnosed and diagnosed at birth was more profound with PRS-Plus and PRS syndromic families: less anxiety (27%±3 to 89%±5), less depression (36%±4 to 90%±5), and less feelings of social isolation (24%±2 to 87%±4).

Conclusions: Prenatal imaging diagnosis coupled with prenatal counseling offer improved psychosocial indicators for families of newborns with Pierre Robin Sequence.

Background: Spring-mediated cranioplasty (SMC) is widely used in treatment of sagittal synostosis, and there are numerous publications evaluating the various factors impacting clinical outcomes, but none describing the possible association of secondary synostosis. The aim of this study is to evaluate the early post operative course of patients who underwent SMC and determine incidence of secondary synostosis, specifically unicoronal synostosis (UCS). Methods: Patients undergoing SMC for non-syndromic sagittal synostosis between January 2021 and December 2023 were included. CT scans obtained preplacement of springs and pre-removal of springs were reviewed. Clinical photographs and measurements were reviewed. Results: A total of ten patients were included. Mean age at time of spring placement was 4± 1.3 months. The mean number of springs used was 2. The mean maximum single spring force was 8.7 Newtons and the mean total spring force was 18±5.4 Newtons. Mean cephalic index increased from 68.5 ± 3.4 preoperatively to 77.8 ± 3.8 postoperatively. Springs were removed at a mean interval of 4 months. Three of the ten patients (30%) were documented to have left unicoronal synostosis on pre-removal CT scan. Two of the three patients with UCS underwent suturectomy at time of spring removal. Conclusions: In our cohort of non-syndromic sagittal synostosis treated with SMC, 30% of patients was found to have UCS in the early postoperative period on CT imaging. This has not been previously described in the literature and deserves further evaluation to determine role of SMC as it relates to timing and location of spring placement and spring force.

Introduction: Children affected by Craniofacial Conditions (CFCs) or facial traumatic injuries are faced with a plethora of complex challenges that extend beyond the burden of care associated with their diagnosis. This is particularly applicable to patients' psychological and emotional wellbeing, specifically in relation to their social functioning amongst peers and family members. This study aims to analyze the differences between diagnoses on patient CFC-QOL subscale scores and additional psychosocial assessments.

Methods: Children (ages 8-21 years) with CFCs recruited by the craniofacial care team at a major urban children's hospital completed the Craniofacial Conditions Quality of Life Scale (CFC-QoL), including subscales assessing child physical functioning and psychological QoL. Subscales that were included as part of the analysis include: Bullying, Peer Problems, Psychological Impact, Appearance Satisfaction, Desire for Appearance Change, Family Support, and Physical Functioning (scale of 1-5, with higher score indicating worse QoL). Children also completed the Surgical Satisfaction Scale, a study team-developed tool with the following subscales: Satisfaction with Surgical Outcome, Surgical Recovery, Perception of Surgical Experience, Effects of Surgery on Others. Additional surveys included the Patient Health Questionnaire-4, PROMIS surveys on Peer Relationships, Stigma, and Meaning and Purpose, and the PedsQL Quality of Life Inventory. One-way ANOVAs and post-hoc Tukey tests assessed score differences for all assessments, including subscales, between the different diagnosis groups.

Results: A total of 105 patients completed the survey assessment. Patient language was primarily English (92.9%) with mean age of 13.8 (ranging from 8.1 to 21.1). The distribution of diagnoses across our patient population was as follow: 50 (47.6%) patients with Cleft lip or palate, 9 (8.6%) patients with craniosynostosis, 16 (15.2%) patients with FAV, 19 (18.1%) patients with facial trauma, and 11 (10.5%) patients with a dermatologic condition. On the CFC-QoL, patients had the worst mean scores on the Desire for Appearance Change subscale (M = 2.6, SD = 1.2) and the best mean scores on the Family Support subscale (M = 1.6, SD = 0.8). ANOVA analyses showed no significant differences between diagnosis groups on all assessments.

Discussion: Our results demonstrate that QoL, general functioning, and psychological symptoms were comparable across diagnoses. Findings suggest that different diagnostic groups share similar psychosocial experiences and burden of CFCs. These findings are encouraging for a psychosocial intervention that focuses on improving QoL in patients with CFCs.

Introduction: Inmates represent a vulnerable healthcare population within the United States, with inconsistent access to surgical specialty care [1,2]. Facial fractures are common among the incarcerated population, comprising approximately 14% of all traumatic injuries [3,4]. However, few studies have evaluated facial fracture outcomes in this population. The aim of this study is to identify disparities in mandible fracture outcomes in the incarcerated population.

Methods: A retrospective review of all traumatic mandible fractures at a single academic medical center from 2018 to 2023 was conducted. Mandible fractures were treated by either the plastic surgery, otolaryngology, or oral and maxillofacial surgery services. Outcome measures such as rates of persistent malocclusion, motor deficits, surgical site infection, reoperation, and readmission were compared between inmate and civilian subgroups.

Results: 205 patients (mean age 33.07, 81.46% male) who were treated for traumatic mandible fracture were included. 11.71% (n=24) were inmates, while 88.29% (n=181) were civilians. The mean time to operative intervention was 10.21 days in the incarcerated group and 4.35 days in the civilian group (p < 0.05). Persistent subjective malocclusion after surgery was noted in 20.83% (n=5) of incarcerated patients and 7.18% (n=13) of civilian patients (p < 0.05). There were no significant differences in rates of surgical site infection, reoperation, persistent motor deficits, or readmissions within 30 days.

Conclusion: Incarcerated patients with traumatic mandible fractures have increased time to operative intervention and increased rates of subjective malocclusion post-operatively. Increased time to operative intervention may reflect barriers in access to specialty surgical care, which could adversely affect patient outcomes.

References: 1. Scarlet S, Meyer AA, Dreesen EB. Lack of information on surgical care for incarcerated persons. JAMA Surg . 2018;153(6):503–504. 2. Busko A, Soe-Lin H, Barber C, Rattan R, King R, Zakrison TL. Postmortem incidence of acute surgical- and trauma-associated pathologic conditions in prison inmates in Miami Dade County, Florida. JAMA Surg . 2019;154(1):87–88. 3. Henning J, Frangos S, Simon R, Pachter HL, Bholat OS. Patterns of traumatic injury in New York City prisoners requiring hospital admission. J Correct Health Care. 2015;21(1):53-58. doi:10.1177/1078345814558046 4. Bryant MK, Tatebe LC, Siva NR, et al. Outcomes after emergency general surgery and trauma care in incarcerated individuals: An EAST multicenter study. J Trauma Acute Care Surg. 2022;93(1):75-83. doi:10.1097/TA.0000000000003614

Introduction Head and neck lymphedema (HNL), including external and internal types, could be a possible consequence for patients who have received neck dissection and radiotherapy for head and neck cancer. Initially, the common presentations are heaviness or tightness, followed by swelling in appearance, or difficulty speaking and swallowing in internal edema cases. Lymphovenous anastomosis (LVA) is an established approach to treat extremity lymphedema. We hereby present our preliminary experience in using LVA to treat HNL.

Patients and Methods Between March 2021 to January 2024, six patients with HNL were treated with LVA, which was performed via a preauricular or submandibular incision of the obstructed side. Lymphedema Symptom Intensity and Distress surveys – Head and Neck (LSIDS-H&N) were used for evaluation. In addition, for the external type, MD Anderson Cancer Center Head and Neck Lymphedema (MDACC HNL) rating scale was used for evaluation. For the internal type, Swallowing Quality of Life (SWAL-QOL) was used for evaluation.

Results With an average follow-up period of 15.4 ± 15.9 months, LSIDS-H&N improved from 1.11± 0.54 to 0.44 ± 0.66 (p = 0.02). For patients with external type, within an average follow-up period of 15 ± 16.1 months, the MDACC HNL rating scale improved from level 2 to 0 or 1a (p = 0.008). For patients with internal type, within an average follow-up period of 21 ± 17.3 months, SWAL-QOL improved from 130.5± 9.2 to 151± 19.8 (p = 0.5).

Conclusion Based on our preliminary results, LVA could be a potential solution to both external and internal HNL.

Background: Pediatric microtia is the most severe type of auricular malformation and presents as a spectrum of forms, all which pose a unique challenge for surgeons who are faced with choosing the optimal technique. Surgical techniques have evolved in the last 8 years to encompass both autologous and porous high-density polyethyene constructs. In this study, we examine our institution's early experience and evolution of technique with Medpor. We report our long-term outcomes of patients undergoing ear reconstruction with Medpor implant versus autologous rib cartilage.

Methods: A retrospective review was performed of all children who underwent ear reconstruction for congenital microtia from 2008 to 2023 at the Children's Hospital of Philadelphia. Auricles that were reconstructed with a Medpor implant were compared to those with autologous costal cartilage. Postoperative complications were graded using a modified Clavien-Dindo scale. Postoperative lateral and frontal photographs were assessed for ear definition, projection, size, and overall appearance in immediate (6 months to 1 year) and late (1 to 5 years) postoperative periods.

Results: One hundred patients were included, of whom 72 (72%) were male. Among the cohort, 105 ears were reconstructed, with 48 (45.7%) using a Medpor implant and 57 (54.3%) utilizing autologous costal cartilage. Mean age at surgery was 7.3 ± 2.3 years in the Medpor cohort and 9.2 ± 1.9 years in the autologous cohort (p<.001). Mean postoperative follow-up was 2.5 ± 1.9 and 4.0 ± 3.4 years, respectively. Twenty-four (50%) and 24 (42.1%) patients experienced any complication in the Medpor and autologous cohorts, respectively (p=.419). Medpor-reconstructed ears were more likely to experience a higher-grade complication (3.6 ± 0.8 versus 3.0 ± 1.2, p=.041). Long-term aesthetic outcome data are currently being tabulated.

Conclusion: Incorporating any novel innovation into practice is often accompanied by a learning curve followed by an evolution of technique. Our institution wished to report our early experience, lessons learned, and long-term follow up of our Medpor compared with autologous ear reconstructions after the first 7 years of adoption. Medpor facilitates an earlier reconstruction with minimal donor site morbidity in comparison to the autologous costal cartilage technique. While both techniques are associated with a high rate of complications, Medpor-reconstructed ears were more likely to be associated with higher-grade complications requiring surgical intervention. In our experience, the Medpor framework provides a more consistent aesthetic result with improved ear projection and definition, while autologous results vary depending on individual surgeon and level of experience. Additional data will provide insight on aesthetic outcomes of both modalities. The risk-benefit ratio of each surgical modality should be considered.