Scientific Abstract Presentations: Craniomaxillofacial Session 5 Friday, September 27 Fri, Sep 27 8:00-9:30 a.m. PDT

Background Medpor ear reconstruction is championed for its ability to create an aesthetic, long-term reconstruction, but challenged for its risk of implant exposure or infection (1-3) . Technique refinements continue to lower these risks, and while several papers demonstrate successful secondary flap coverage after implant exposure, a paucity of literature exists on the management of the implant itself, namely whether the implant should be debrided, removed, or exchanged entirely in instances of exposure and infection. This study borrows established techniques for breast implant salvage (4-5), details an adjuvant technique to secondary flap coverage– that of concomitant implant exchange–, and describes its application in five successful Medpor ear reconstruction salvages.

Methods This study is a retrospective case series identifying five patients who underwent Medpor ear reconstruction for congenital microtia with salvage procedures performed between January 2018 to December 2023. Three of these patients had their initial reconstruction at an outside facility. Patients' ages ranged from 5 to 10 years old. All patients had a diagnosis of congenital microtia, one patient had Goldenhaar syndrome with bilateral microtia, and another patient had Treacher-Collins syndrome. Patients underwent operative debridement, cultures, implant exchange, and simultaneous flap reconstruction. Oral antibiotics were continued for one to two weeks and were tailored to culture results. Patients were followed for a minimum of 8 months post-operatively.

Results Each patient experienced successful implant salvage without further exposure or infection. Prophylactic antibiotics of Cefazolin or Cephalexin IV were given intraoperatively. Intraoperative cultures were positive in five patients, with the most common bacterial species being Staph aur. and MRSA. Patients had an average recovery time of 14.2 days. The negative outcome in all patients was a decreased ear projection over time.

Conclusion A paucity of literature exists demonstrating Medpor ear implant exchange in the setting of chronic exposure or infection. The infrequency of implant exposure makes the subject more challenging to study. This case series demonstrates a technique that may optimize the success rate for Medpor salvage in microtia reconstruction while eliminating the period without a reconstructed ear.

Citations: 1. Dougherty WR, Wellisz T. The natural history of alloplastic implants in orbital floor reconstruction: an animal model. J Craniofac Surg. 1994 Feb;5(1):26-32; discussion 33. doi: 10.1097/00001665-199402000-00007. PMID: 8031975. 2. Fialkov JA, Holy C, Forrest CR, Philips JH, Antonyshyn OM. Postoperative infections in craniofacial reconstructive procedures. J Craniofacial Surg 2001;12:362-8. 3. Mok D, Lessard L, Cordoba C, Harris PG, Nikolis A. A review of materials currently used in orbital floor reconstruction. Can J Plast Surg. 2004 Fall;12(3):134-40. doi: 10.1177/229255030401200302. PMID: 24115885; PMCID: PMC3792801. 4. Prince MD, Suber JS, Aya-ay ML, Cone Jr JD, Greene JN, Smith Jr DS, Smith PS. Prosthesis salvage in breast reconstruction patients with periprosthetic infection and exposure. Plast Reconstr Surg. 2012 Jan; 129(1):42-48. Doi: 10.1097/PRS.0b013e3182361fbd. PMID: 22186499 5. Xue AS, Kania KE, Brown RH, Bullocks JM, Hollier LH Jr, Izaddoost SA. Salvage of Infected Prosthetic Breast Reconstructions. Semin Plast Surg. 2016 May;30(2):55-9. doi: 10.1055/s- 0036-1580729. PMID: 27152096; PMCID: PMC4856532.

Background:

Complex, multi-fracture craniofacial trauma can be challenging, given limited exposure, fracture morphology, and preservation of vital facial structures. The use of virtual surgical planning (VSP) with operative deliverables (guides/plates) has become an integral tool in the practice of elective craniomaxillofacial surgery, such as orthognathic surgery, improving surgical accuracy and efficiency. However, in the setting of craniofacial trauma, it has proven difficult to incorporate due to inadequate time to design, transportation, burden of cost, and potential inaccuracy of printed models. Our institution sought to address the question of practical utility of technology for acute craniofacial trauma.

Objective:

To review experience with use of virtual planning and intraoperative deliverables (VSPD) in performing open reduction internal fixation (ORIF) of various fractures within the craniofacial skeleton.

Methods:

A retrospective review was performed for patients who underwent ORIF of acute craniofacial fractures using a VSPD protocol at our institution between January 1, 2020 and December 31, 2023. Patient demographics, medical history, primary injuries, surgical treatments, complications, and reoperation information were collected.

Upon admission, the patient's CT was sent for planning. During VSP (typically within 48hrs) fracture fragments were reduced with mirror imaging, creating a reduction/perfection image. Validity of reduction was checked by assessing occlusion, symmetry, and overall appearance of the craniofacial skeleton. Virtually planned reduction/perfection models were created with marked fracture lines. For occlusal fractures (LeFort-type and mandible), occlusal splints were also generated from CT data. Intraoperatively, standard plates were contoured and applied to the reduction/perfection model with fracture sites etched on the plate; generating real-time 3D custom plates to guide fracture reduction/fixation. Postoperative CT scans were compared with the generated virtual plan to assess the accuracy of the predictive virtual plan. Specific craniofacial regions were studied for applicability of this technique.

Results:

Within the specified time frame, we identified 45 patients who met inclusion criteria. The majority of patients had multiple and comminuted facial fractures, most commonly including orbital floor (n=21) and zygomaticomaxillary complex (n=23). VSP planning was typically performed within 48hrs of admission, with model turnaround times 2-3 days. The VSPD protocol was successfully applied in all patients studied. All craniofacial regions where VSPD protocol was utilized had improved operative efficiency/postoperative accuracy. This was especially noted in treatment of frontal sinus, restoration of proper orbital size, combined dental/bone reduction in occlusal fractures, and restoring height of condylar/subcondylar fractures. Delay in treatment of open mandible fractures did not lead to increased rate of postoperative infection. There was a good correlation of the predicted VSP plan and the actual postoperative scan.

Conclusion:

The use of technology in the form of a VSPD protocol for treatment of complex craniofacial fractures was successfully applied to treat patients in a timely fashion. Reduction/perfection models marked with fracture sites were useful to create real time custom 3D plates with occlusal splints useful to transfer the virtual plan surgically, thus improving accuracy and efficiency in ORIF procedures in all regions of the craniofacial skeleton studied. Postoperative CT scans compared to the virtual plan showed a high degree of accuracy.

Introduction

A primary advantage of autologous auricular reconstruction in microtia repair is preservation of sensation. However, given the complexity of the reconstruction and unique anatomy of patients affected by microtia, little has been done to characterize how sensation is affected after receiving microtia reconstruction using the gold standard technique, Nagata Technique. The purpose of this study is to understand how different types of sensation are affected among patients who received autologous reconstruction.

Methods

Seven patients underwent first stage autologous reconstruction by the senior author using the Nagata Technique. Each patient was tested with different sensory tests in clinic preoperatively, at the 3-month post op visit, and 6-month post op visit. Each test was conducted at 9 different areas on the affected ear and results were averaged together for each test. The sensory exams conducted assessed tactile perception, locational accuracy, discrimination between sharp and dull pressures, thermal differentiation (hot vs cold), and sensitivity to fine touch using microfilaments of 5 different sizes.

Results

All seven patients completed the preoperative and 3-month post operative tests, and four patients completed an additional set of tests at the 6-month visit. At the 3-month post op visit, tactile perception was fully preserved in three patients across the 9 tested points on the ear, while four patients experienced a decrease in sensation at one or two points. Of these four patients, half regained full sensation in all 9 points by 6 months. Regarding locational accuracy, at the 3-month post op visit, four patients fully preserved sensation across the 9 points on the ear, while three patients had a loss in sensation at one or two points. Of these three patients, one regained full sensation by 6 months. Regarding discrimination between sharp and dull pressures, at the 3-month post op visit, four patients preserved sensation across the 9 distinct points on their ear, while three had reduced discrimination at up to four points with one of these fully recovering sensation at 6 months. Regarding thermal differentiation at 3 months, three patients fully preserved discriminatory ability while four had reduced discrimination at up to four points. Two of these patients regained full discriminatory ability by 6 months. Regarding sensitivity to fine touch, only one patient maintained preoperative levels at all points with the other six demonstrating reduced sensitivity to the same size microfilament tested preoperatively. By 6 months, two of these patients had improved sensitivity to the smaller microfilaments.

Conclusion

While some sensory functions are regained quickly, others may take up to 6 months or longer. This preliminary study highlights the degree of sensory preservation in patients after the first stage of microtia reconstruction using the Nagata Technique. This data will arm microtia surgeons and aid families in making more informed decisions about their choice for microtia reconstruction.

Introduction: Microtia is a congenital anomaly characterized by malformation of the external ear. In the early 2000s, the Complex Chronic Conditions (CCC) classification system was developed to identify children with serious, long-standing health problems based on various body systems and disease types. Microtia as a diagnosis itself does not meet the definition of a CCC, but having the condition may elevate the incidence of CCC occurrence given its association with other complex organ anomalies. Here, we utilized the Pediatric Health Information System (PHIS) database to investigate the epidemiology of Microtia and its association with CCC and other conditions. Understanding common diagnoses associated with microtia can help guide screening protocols.

Methods: A retrospective review of the PHIS database was conducted between 2015 and 2023. Patients were identified with an initial encounter at a PHIS-registered hospital having an associated ICD-10 diagnosis of Microtia. The database included data from patients across 26 states, their demographics, associated organ system flags, and any CCC.

Results: A total of 22,075 patients were identified as having an initial ICD-10 diagnosis of Microtia. Of these patients, 12,187 cases were male (55.2%), with a significant proportion of cases identified as non-Hispanic white (n=8,775, 39.8%) or Hispanic (n=7,135, 32.3%). Nearly 40% of the population was found to have at least one CCC (n=8,496), with half of these patients noted to have two or more CCCs. Cardiovascular issues were the most common associated organ flag (16.8%), followed by gastrointestinal and neurologic conditions (15.4% and 12.0% respectively).

Conclusions: This study highlights a significant correlation between microtia and complex chronic conditions (CCCs). With 40% of patients diagnosed with microtia also presenting with at least one CCC, the research underscores the need for comprehensive medical assessment and care strategies for this patient population. This study further supports the finding that cardiac conditions appear to affect this population more than other conditions, necessitating a re-evaluation of first-line screening modalities for conditions associated with microtia.

Purpose: Patients with cleft lip and palate (CLAP) often have substantial nasal deformity. These patients require a primary rhinoplasty a few months after birth. This can be completed using either an open or closed approach as there is no consensus in the literature regarding which approach is more effective. Despite initial rhinoplasty, many patients with CLAP undergo intermediate and/or definitive rhinoplasty in early adolescence, demonstrating a need for improved primary rhinoplasty outcomes. The goal of this project is to compare nostril asymmetry in patients with CLAP that underwent closed or open primary rhinoplasty at our institution.

Methods: We conducted prospective enrollment of patients with unilateral complete CLAP at our single institution. Inclusion criteria consisted of patients less than 17 years of age, no intermediate or secondary rhinoplasty, and with unilateral complete CLAP. Each patient that qualified and consented for the study had photos of their nostrils taken. Maximum nostril height and width were measured using ImageJ. All measures were expressed as ratios with respect to the unaffected nostril. A ratio of 1 represents perfect symmetry in that nostril measurement. Chart review was performed to obtain demographic information and past surgical history. Open rhinoplasty approach was characterized as utilizing a rim incision and placement of interdomal sutures.

Results: 11 patients satisfied the inclusion criteria, 6 in the open rhinoplasty and 5 in the closed rhinoplasty group. Mean age of the entire cohort was 7.1 years. Group comparison analysis was conducted via two-sided unpaired t-test. Both groups had an average nostril height ratio less than 1 and an average nostril width ratio greater than 1. There was no significant difference in nostril height ratio for open vs. closed technique (0.82 vs. 0.69, p=.15). There was no significant difference in nostril width ratio for open vs. closed technique (1.10 vs. 1.13, p=.77). We calculated that a cohort of 36 subjects would be needed to provide 80% power to detect differences in nostril height between the two groups.

Conclusion: Reduction of cleft nasal deformity can be performed using both open and closed techniques. Patients with open techniques had clinically increased nostril symmetry in height, but not statistically significant. Both techniques had residual cleft nasal deformity, characterized by increased width and decreased height in ipsilateral nostril. We are continuing to prospectively enroll patients in this study to increase our sample size.

Purpose: Reconstruction with osteocutaneous fibula free flaps (FFF) is a common procedure following resection for head and neck cancer. FFF has drastically improved the functional and aesthetic outcomes of patients, particularly in regard to oral function. The purpose of this study was to evaluate the clinical outcomes and timing of dental implant placement in patients following head and neck reconstruction with FFF.

Methods: A retrospective analysis of 60 patients who underwent FFF reconstruction for head and neck cancer and had dental implants placed from 2012-2023 was performed. Patient demographics and characteristics including sex, race, insurance type, history of radiation therapy, and medical comorbidities were assessed. Primary outcome measures evaluated included surgical complications, operative time, number of implants placed, follow-up, time of radiotherapy initiation, and dental implant success. Bivariate analyses using Chi-square tests and linear regression were performed for outcome measures and p-value of < 0.05 was considered significant.

Results: There were a total of 234 implants done for 60 patients (24F, 36M). The majority were white (n=48, 80%) and had a median household income of $55,000 to $100,000 (n=40, 66.7%). The most common primary resection surgery was mandibulectomy (n=29, 48.3%), and 39 patients received neoadjuvant radiation treatment. The most common surgical complications in our patient cohort were nonunion or delayed union and recipient dehiscence. The median time to implant placement was 547 days and median number of implants was 4 (range = 1-8). A history of preoperative radiotherapy was significantly associated with a longer time to implant placement following FFF reconstruction (p=0.046). Patients with osteoradionecrosis were associated with a longer time to dental implant placement (p=0.03). Post-operative FFF complication rates were not associated with dental implant survival.

Conclusion: Both neoadjuvant radiation therapy and a history of osteoradionecrosis have an impact on timing of dental implant placement. These factors should be considered when assessing the timing of dental implant placement following FFF reconstruction.

Purpose: While many studies discuss the changes in pharyngeal airway dimension and function following maxillary advancement surgery, less is known about the long-term consequences of sphincter pharyngoplasty surgery on maxillary growth. The current body of literature that reports on maxillary and mandibular growth outcomes after pharyngoplasty is either limited by small cohort sizes or short follow-up duration after surgery. This study aims to report on maxillary and mandibular growth effects as a long-term outcome of sphincter pharyngoplasty.

Methods: All patients with cleft lip and palate (CLP) or isolated cleft (iCP) who underwent sphincter pharyngoplasty at a single institution from 1992 to 2023 were retrospectively reviewed. An age- and diagnosis-matched control group with CLP/iCP who did not undergo sphincter pharyngoplasty was also identified. Exclusion criteria were patients with less than 15 years of age at the last office visit, follow-up duration less than 1 year after pharyngoplasty, Lefort surgery prior to pharyngoplasty, and any pre-existing conditions that could significantly affect craniofacial growth (e.g. hemifacial microsomia, velocardiofacial syndrome, craniosynostosis, etc.). Postoperative outcomes include clinical diagnoses of maxillary and mandibular hypoplasia, indication for Lefort surgery, as well as sella-nasion-A point (SNA) and sella-nasion-B point (SNB) angles obtained from lateral cephalograms. Chi square tests and independent samples t-tests were performed to compare outcome differences between pharyngoplasty and control groups. Multivariable logistic regression was also performed to evaluate independent predictors of maxillary hypoplasia.

Results: Among the pharyngoplasty cohort (n=114), the average age at time of surgery was 12.0±4.5 years (mean±SD) and average follow-up duration was 8.4±5.1 years after pharyngoplasty. Average age at the last office visit in the pharyngoplasty cohort was 20.4±3.0 years compared to 19.5±3.4 years (p=0.06) in the control cohort (n=86). Diagnosis of maxillary hypoplasia was significantly more frequent in the pharyngoplasty cohort than controls (60.5% vs. 33.7%, respectively, p<0.001). Compared to control patients, pharyngoplasty patients had greater indication for Lefort surgery (25.6% vs. 54.4%, respectively, p<0.001) and significantly smaller SNA angles (78.2±5.4 degrees vs. 75.4±4.5 degrees, respectively, p=0.03). There were no significant differences in diagnosis of mandibular hypoplasia (9.6% pharyngoplasty vs. 9.3% control, p=0.93) or SNB angles (76.9±6.0 degrees pharyngoplasty vs. 78.2±5.0 degrees control, p=0.40). Multivariable analysis results indicated that pharyngoplasty was independently associated with a three-fold increase in later diagnosis of maxillary hypoplasia (OR=3.4, 95%CI 1.7-6.9, p<0.001).

Conclusion: Although it is well known that maxillary surgery may subsequently compromise pharyngeal air space, pharyngoplasty surgery may conversely be associated with a higher likelihood of long-term maxillary hypoplasia and indication for future Lefort surgeries.

Purpose: Delays in the presentation of craniosynostosis impede timely surgical intervention and can be detrimental to patient outcomes. Disparities in accessing care may influence referral time and hinder access to providers who can provide swift and accurate diagnoses. Furthermore, an initial evaluation by a provider unfamiliar with the diagnosis might prolong referral to a neurosurgeon or craniofacial surgeon. This study aimed to explore referral patterns associated with surgical consultation for craniosynostosis.

Methods: A retrospective review of California-based craniosynostosis patients at a tertiary children's hospital between 2014 and 2024 was performed. The demographic variables collected included patient sex, age, race/ethnicity, median household income, and patient zip code. Patient zip codes were used to calculate state-specific Area Deprivation Index (ADI), a measure of socioeconomic disadvantage in deciles from least (1) to most (10) disadvantaged based on income, education, employment, and housing quality. ADI scores of (5) and greater were considered to have higher disadvantages. Referral-related information was abstracted, including the type of provider, zip code of the referring institution, and the referral date. Patient age at presentation and craniosynostosis surgery were also recorded. Descriptive statistics, chi-squared tests, and independent t-tests were used for the statistical analysis.

Results: In total, 278 patients with craniosynostosis were evaluated. There were 126 (43.9%) Hispanic/Latinx, 76 (26.5%) White, 10 (3.5%) Asian, three (1.0%) Black/African American, and 56 (19.5%) other unknown patients. More than half (57.5%) of the patients had public insurance, and a median household income of $81,559 ± $29,293. The mean ADI was 5.48 ± 2.25. The mean age at referral was 4.38 ± 4.56 months, and the mean age at presentation for surgical consultation was 5.49 ± 4.54 months. The mean time from referral to presentation was 43.10 ± 79.50 days. Across racial groups, significant differences were observed in the age at presentation (p<0.001). The majority of referrals were from pediatricians (n=222, 74.4%), followed by outside craniofacial/neurosurgeons (n=26, 8.6%), self-referrals (n=12, 4.0%), neonatologists (n=10, 3.4%), and unknown (n=2, 0.1%). Patients referred from mid-level providers had the oldest age at referral (6.73 ± 6.47 months), followed by patients referred from outside hospital craniofacial/neurosurgeons (6.34 ±5.18 months), pediatricians (4.14 ±4.21 months), self-referrals (4.15 ±5.91 months) and neonatologists (​​0.82 ±1.20 months), p = 0.0147.

Conclusion: This study highlights significant differences in the age of referral for patients with craniosynostosis depending on provider type and patient race. Education and awareness of craniosynostosis at the community and provider levels may affect referral timing. Initiatives should be taken to address these disparities, promote equitable access to all craniosynostosis surgical options, and improve patient outcomes.

Introduction: Serial measurement of head circumference is an integral part of pediatric care and is important for diagnosing conditions that result in head shape abnormalities, such as sagittal craniosynostosis, which is the most common form of craniosynostosis. The importance of monitoring head circumference growth curves in healthy patients is widely known; however, there exists no comparable metric for patients with sagittal synostosis. Our study aims to generate standardized, validated growth curves for patients diagnosed with isolated sagittal craniosynostosis. Secondarily, we aim to stratify growth by different treatment approaches.

Methods: A total of 241 patients diagnosed and treated for isolated sagittal craniosynostosis at a single institution between 2004-2022 were analyzed. Smoothed, LOESS non-parametric curves were estimated preoperatively and postoperatively to compare patient age to head circumference. The postoperative growth curves were further stratified into three groups by treatment approach: Group 1 (no surgery), Group 2 (minimally invasive surgery), and Group 3 (open vault surgery). Analysis was conducted using RStudio (Version 1.3).

Results: Among the patients who met inclusion criteria, 76.8% were male. The majority of patients were Caucasian (79.7%). 39.8% of patients were managed non-surgically, 35.3% with minimally invasive endoscopic surgery, and 24.9% with open cranial vault reconstruction. Average age at surgery for 5.5 months and 2.8 years for Group 2 and Group 3, respectively. Optimal curve smoothing required restricting the age ranges for growth tracking to attenuate the effect of outlier patients: 0-7 years for Group 1, 0-5.75 years for Group 2, and 0-3.5 years for Group 3. In patients with sagittal craniosynostosis who did not undergo surgery, the 50th percentile measurement at 6.5 months of age was equivalent to between the 3rd and 5th percentile according to the CDC's growth curves for healthy infants. At 12.5 months of age, the 50th percentile circumference was equivalent to between the 50th and 75th percentiles of the national CDC growth curve for healthy infants.

Conclusion: Our study represents the first attempt to create a "well-child" growth curve to aid pediatric care providers in the long-term management of infants diagnosed with isolated sagittal craniosynostosis in order to monitor for abnormal development and neurologic sequelae. Our efforts yielded comprehensive curves illustrating growth trends over time and across treatment approaches, indicating reasonable benchmarks for head circumference growth based on the 10th, 50th, and 90th percentiles.

Purpose

Poor oral feeding outcomes in Pierre Robin Sequence (PRS) patients are a cause of significant morbidity and can lead to caregiver distress. PRS is often divided into syndromic and non-syndromic, but the effect of medical complexity remains unexplored. Minimal literature exists to guide surgeon-patient family conversations on development of oral feeding ability. In this study, we aimed to assess the utility of a three-part classification, determine time until being safe to feed orally, and the effect of surgical management in PRS.

Methods

A retrospective cohort study was performed on all patients with PRS between 2010 and 2021. Patients were divided into isolated, syndromic, and complex based on genetic status and existence of 2 or more significant medical comorbidities. Imaging data from modified barium swallow was reviewed and used in predictive models. Differences in time until being safe to feed orally based on was plotted on Kaplan Meier curves were used to identify differences between variables of interest and cox regression to determine predictive ability of relevant covariables.

Results

Of the 122 PRS patients included in this study, 37 were isolated, 56 syndromic, and 29 complex. Isolated patients were more likely than syndromic or complex patients to be safe to feed at birth (16 vs 11 vs 3, c2=9.28, p=.01). Kaplan Meier plot demonstrated significant differences across time points for each diagnosis (medians 1.14 IQR[0-8.5] vs 8.35 IQR[3.61-52.18] vs 12.71 IQR[2.57-84.29], p=.0001). A similar pattern was seen after stratifying further based on conservative management or MDO (medians 0.0 IQR[0-0] vs 8.35 IQR[3.61-52.18] vs 12.71 IQR[2.57-84.29], p<.0001). Cox regression demonstrated differences between conservative management and MDO for isolated (p=.01) and syndromic (p=.007), which disappeared upon controlling for pre-operative AHI (p=.26) and (p=.12). Cox regression demonstrated syndromic patients were 46.3% less likely to be safe to feed at a given time (HR .463, 95% CI [.293, .734], p=.001) and complex patients were 32.6% less likely to be safe to feed at a given time (HR .326, 95% CI [.194, .569], p=.0005) compared to isolated patients. Additionally, the presence of laryngomalacia was not associated with a statistically significant change in the likelihood of being safe to feed by mouth at any level (HR 1.08, 95% CI [0.71 to 1.65], p=0.71).

Conclusions

Our study demonstrated highly significant and impactful differences in feeding outcomes between isolated, syndromic, and medically complex PRS. In doing so, we confirmed the utility of expanding stratification of PRS from two to three categories. Finally, we were unable to confirm surgical intervention as a factor that shortens time until a patient is safe to feed orally. These findings will impact strategies for future research into PRS and can be used during difficult conversations between surgeons and patient families.

Purpose: Craniosynostosis is a primarily surgically managed congenital condition with functional and aesthetic sequela. Based on the complexity of the pathology and patient comorbid conditions, there are several well-described post-surgical complications in surgical management of craniosynostosis, including surgical site infection and neurologic implications (e.g. dural injury and CSF leaks). While outcomes have been reported from single institutional studies, fewer have evaluated complication rates for patients from a national cohort. The purpose of the present study was to report the outcomes, utilization, and procedural costs of patients admitted for craniosynostosis from a large, national database.

Methods: A database retrospective cohort study was conducted using the 2018, 2019, and 2020 National Inpatient Sample (NIS). Discharge information was obtained for patients who fulfilled both a primary diagnosis with ICD-10 classification for craniosynostosis (ICD-10: Q75.0) as well as ICD-10 PCS classification for related surgical management (i.e., opening of cranial suture, linear / strip craniectomy, formation of / repair with cranial bone flap, other cranial osteoplasty) in the same admission. To assess inpatient safety, data were collected for demographics, hospital characteristics, inpatient mortality, inpatient medical complications (IMC), and inpatient surgical complications (ISC).

Results: Between January 1, 2018, and December 31, 2020, there were a total of 2,135 patients who received surgical management for a primary diagnosis of craniosynostosis after admission. Within this cohort, 1,470 (68.9%) of patients were male and 1,475 (69.1%) were under 1 year of age. Postoperative inpatient surgical complication rates were relatively low, totaling 120 (5.6%) patients which included 15 (0.7%) hemorrhages, 5 (0.2%) infections, and 100 (4.7%) neurologic complications. There were no inpatient mortalities or thromboembolic events reported in the database. There were 70 (3.3%) patients with postoperative inpatient medical complications including 5 (0.2%) cardiovascular, 60 (2.8%) pulmonary, and 5 (0.2%) renal / urinary complications. Procedures were performed on 2110 (98.8%) patients in urban teaching hospitals and 1825 (85.5%) patients in private not-for-profit hospitals.

Conclusion: By leveraging a large, national database, the present study underscores the relative safety and efficacy of surgical interventions for craniosynostosis, with manageable complication rates. In particular, there were no thromboembolic events in this population. These insights into specific complication rates of craniosynostosis surgeries provide valuable benchmarks for surgeons aiming to optimize patient outcomes. However, the predominance of surgeries in urban teaching and private not-for-profit hospitals highlights a potential accessibility and resource distribution issue that warrants further investigation. Future research should investigate the risk profiles, cost, and utilization for each of the included heterogeneous surgical procedures, ensuring the continuous improvement of care for this vulnerable population.