Scientific Abstract Presentations: Craniomaxillofacial Session 6 Friday, September 27 Fri, Sep 27 10:30 a.m.-12:30 p.m. PDT

Background Fibrin sealants have been increasingly applied to various reconstructive procedures. In this article, we review cases where fibrin sealant was used to stabilize microvascular pedicles and compared them with those performed without fibrin sealant. Materials and methods Between 2018 and 2021, 711 consecutive patients underwent free tissue transfer for head and neck reconstruction. Following microvascular anastomosis，the microvascular pedicles were placed in the optimal position and fibrin sealant was used in 488 cases to fix and stabilize them. The other group with 223 free flaps without fibrin sealant usage were analyzed. For those with fibrin sealant usage also performed fat grafts in 111 cases for vascular protection. The complications including infection, hematoma, and vascular exploration, were compared. Results Both groups showed an excellent success rate of around 98%. Among those 488 cases with fibrin sealant usage groups, 65 complications were noted which involved 27 hematomas (5.5%), 27 tissue infections (5.5%), and 12(2.5%) vascular compromises. Analysis of the other 223 free flaps without fibrin sealant usage revealed 21 hematomas (9.4%), 19 infections (8.5%), and 18 (8.1%) vascular compromised. The usage of fibrin sealant showed a statistically significant reduction in both vascular compromise and infection rate (Infection: OR 0.465, p<0.05; Vascular compromised: OR:0.34, both p<0.05), while hematoma showed no statistical significance. Conclusion The usage of fibrin sealant in head and neck reconstruction showed a significant reduction of complications including vascular compromise and infection. It can be used to prevent vascular kinking but also in stabilizing the position of the microvascular pedicles.

INTRODUCTION Radiographs (XRs), computed tomography (CT) scans, and cone-beam CT scans (CBCT) are utilized for postoperative assessment of secondary alveolar bone graft (SABG) in patients with cleft lip and palate (CLP). However, the optimal choice for imaging modality remains unclear. This study compares the image fidelity and safety profile for XR, CT, and CBCT in the assessment of patients with CLP who have undergone SABG.

METHODS This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles from MEDLINE and Elsevier Embase were screened and reviewed. Observational or interventional studies that involved use of XR, CT, or CBCT for postoperative graft assessment after SABG were included. The primary outcome was graft success rate. Secondary outcomes were percent-by-volume of graft maintained and patient safety, defined by radiation exposure. A random effects model was used to calculate the pooled outcomes for each imaging modality. Chi-squared analysis was used to compare pooled outcomes between different imaging modalities.

RESULTS Of the 149 articles identified initially, 14 met the inclusion criteria, including 7 cohort studies, 6 case series, and 1 case-control study. There were 2225 total participants included in the meta-analysis, of which 199 patients underwent XR, 988 patients underwent CT, and 1038 patients underwent CBCT for assessment of SABG outcomes. CT demonstrated the lowest graft success rate (62.0%) compared to both XR (72.6%, p <0.01) and CBCT (69.8%, p <0.01). Compared to the other 2 imaging modalities, CBCT had the lowest reported mean percent-by-volume of graft maintained (32.1%). Lastly, CT had a higher mean radiation dosage (39.7 milligray; mGy) than what has been reported for both XR (intraoral: 0.65 to 3.6 mGy; panorex: 3.3 to 4.2 mGy) and CBCT (9.9 to 25.2 mGy).

CONCLUSION CT demonstrated lower graft success rates than both XR and CBCT, possibly indicating a higher image fidelity for postoperative assessment of SABG. However, compared to CBCT, CT may have a higher radiation exposure. Randomized trials and longitudinal studies are necessary to perform a direct comparison between CT and CBCT and to correlate the image fidelity of these modalities with important clinical outcomes, such as long-term orthodontic outcomes and total radiation exposure.

BACKGROUND: Cleft lip and palate (CLP) management requires longitudinal care from several coordinated providers. Many CLP teams offer multidisciplinary services, but patients with less economic, social, and cultural capital face barriers accessing these resources and may experience poorer longitudinal outcomes.

PURPOSE: This study describes the geospatial distribution of cleft care across the United States, assesses disparities in social determinants of health between families with and without access to CLP care, and recommends interventions for improving access.

MATERIALS AND METHODS: We identified American Cleft Palate Craniofacial Association-approved CLP teams in the United States and calculated a one-hour driving radius around each clinic. We defined counties within each radius as having access to care and those outside of each radius as being without access. Using data from the National Vital Statistics Survey, American Community Survey, and Behavioral Risk Factor Surveillance System, we compared counties with and without access across risk factors for developing cleft (i.e., incidence risk factors) and obstacles to care (i.e., access risk factors).

RESULTS: We identified 187 CLP teams in 45 states and the District of Columbia. Most were in the South (n = 60, 32.0%), followed by the West (n = 45, 24.1%), Midwest (n = 42, 22.5%), and Northeast (n = 40, 21.4%). The proportion of children with CLP team access was greatest in New York, New Jersey, and Pennsylvania (89.6%) and least in Alabama, Mississippi, Tennessee, and Kentucky (45.4%). Nationally, children without access to CLP teams were 38% more likely to have prenatal tobacco exposure, 7% more likely to have prenatal obesity exposure, and 28% less likely to have health insurance (p < 0.01). Although insurance disparities were most pronounced in the Middle Atlantic and Midwest, children in Texas, Oklahoma, Arkansas, and Louisiana were the most likely to be uninsured, regardless of CLP team access. Children without CLP team access in the South were 29% more likely to have a birth weight < 2,500 grams and 46% more likely to be living below the federal poverty line (p < 0.01). Southern children were also less likely to have married parents and more likely to live with single mothers or grandparents (p < 0.01). Children with access to CLP teams were more likely to have mothers and fathers ≥ 40-years-old (33% and 22%, respectively), and significantly more likely to have married parents (p < 0.01). Children with access were also 2.2-times more likely to live in families that migrated to the United States and 7-times more likely to speak English as a second language.

CONCLUSIONS: There are pronounced disparities affecting patients with and without access to CLP care. To ease access for patients > 1 hour from a CLP team, immediate interventions must address transportation and care costs since these patients typically have fewer financial resources and suboptimal insurance; Long-term interventions must address systemic contributors, such as tobacco use and obesity. For patients near a CLP team, interventions should anticipate cultural diversity and ensure clinic offerings and materials are appropriate for a multicultural and multilingual patient population.

Introduction Skeletal facial structure deficiency can be observed as a result of congenital malar hypoplasia, micrognathia, and microtia or from traumatic injury. While technological advancements have enriched the development of customized implants, concerns persist regarding alloplastic implants, which are prone to infection, irregularities, and extrusions (1). Augmentation with autologous or allogeneic cartilage, produced with custom-designed blades, may be an alternative. We present the design and testing of customizable blades for production of anatomical subunits for facial augmentation.

Methods Blades for the zygoma, chin, and retroauricular ear block (to gain projection during stage 2 microtia repair) were designed using Computer-Aided Design software. Proof-of-concept blades were 3D-printed in resin with a Stratasys-J55-Prime Polyjet 3D printer. Next, stainless-steel versions of chin and ear blades were created via Direct Metal Laser Sintering. Medical students (n=13) were recruited to test each blade. Students initially hand-carved constructs from carrots-an experimental cartilage-like substrate-using a 10-blade. Next, each student used the experimental blades to generate blade-cut constructs with potential additional hand-carving if needed. For each construction method, time to construct production was measured and students were asked for agreeance on ease of production, achievement of intended shape, and preference for hand-carving versus blade-cutting, using a Likert scale of 1-5 (1=strongly disagree, 5=strongly agree). Constructs underwent blind rating by a surgeon and surgical resident who scored constructs compared to reference models using 4 criteria: length (±2mm), width (±2mm), thickness (±2mm), and contour/shape. Scores were given on a scale of 1-5 (1=0/4 criteria met, 5=4/4 criteria met).

Results Overall zygoma, chin, and retroauricular ear block production times by blade-cutting (zygoma: 132 sec, chin: 66 sec, ear: 73 sec), were lower than hand-carving (zygoma: 188 sec, chin: 132 sec, ear: 116 sec; p<0.05). Blade-cutting with zygoma and retroauricular ear block blades allowed for greater ease of production. All blades achieved higher anatomical accuracy of the intended construct shape. Blade-cutting was the preferred method over traditional hand-carving (p<0.05). Blind rater scores demonstrated increased construct cosmesis in blade-cut zygoma constructs compared to hand-carved (p<0.05), but there was no significant difference in blind ratings for blade-cut versus hand-carved chin and retroauricular ear block constructs.

Conclusion Implementation of customizable blades to shape cartilage may prove useful in producing cartilaginous implants with lower potential to carry risk compared to alloplastic implants. Utilization of these blades may allow for user-friendly, reproducible, and precise production of cartilaginous units while reducing operative time compared to manual carving.

References 1. Keyhan SO, Ramezanzade S, Yazdi RG, et al. Prevalence of complications associated with polymer-based alloplastic materials in nasal dorsal augmentation: a systematic review and meta-analysis. Maxillofac Plast Reconstr Surg. Apr 22 2022;44(1):17. doi:10.1186/s40902-022-00344-8

Background: Hemangiomas are one of the most common head and neck masses encountered in the pediatric population and can be broadly classified into infantile and congenital hemangiomas. Accurate diagnosis and classification are essential for selecting the appropriate treatment approach, including observation, medical therapy, or surgery. The aim of this study is to review our clinical experience and early outcomes with evaluation and management of infants less than one year of age with hemangiomas in the head and neck region.

Methods: A retrospective review of all infants with hemangiomas in the head and neck region managed by our team over a 3-year period were included. Clinical characteristics, such as location, depth, symptoms, imaging, biopsy, and treatment modality, were tabulated. Hemangiomas were classified into infantile hemangioma (IH), rapidly involuting congenital hemangioma (RICH), and non-involuting congenital hemangioma (NICH). Physician assessment at around one year of age of whether of patients needed further treatment was obtained from review of patient chart and clinical photographs.

Results: A total of 164 patients with 262 hemangiomas met inclusion criteria. Of the vascular lesions identified, 160 patients had IH, 2 had RICH, and 2 had NICH. The most common locations were the scalp (n=55, 21.0%), eyelid/periorbital region (n=28, 10.3%), and the neck (n=25, 9.5%). The average number of hemangiomas per patient was 1.6 ± 0.1. The average age of initial evaluation was 6.6 ± 1.7 months. 18 (11.1%) patients reported symptoms related to the hemangioma including ulceration, bleeding, and visual obstruction. Most did not require imaging for diagnosis (n=134, 81.2%), although some underwent ultrasound (n=18, 10.9%), MRI (n=7, 4.2%), or both (n=5, 3.0%), to aid in diagnosis or to exclude visceral involvement if suspected (e.g. liver ultrasound). One patient met diagnostic criteria for PHACE. Only one patient underwent biopsy of their hemangioma. Most patients underwent medical treatment for their hemangiomas (n=139, 84.2%), with only one (0.6%) undergoing surgical excision, and 22 (13.3%) opting for observation alone. Two patients (1.2%) underwent both medical and surgical treatment in the first year of life. Systemic propranolol was the most common initial medical therapy (n=107, 77.5%), followed by topical timolol (n=29, 21.0%) and oral atenolol (n=2, 1.5%). The average length of follow-up was 11.1 ± 1.8 months. Of the patients treated with propranolol, only 14 (13.1%) experienced complications, mostly minor complications such as cold hands and feet (n=9, 8.4%) and sleep disturbances (n=4, 3.7%). No patients were required to stop treatment due to complications. At the most recent follow-up, a majority of the patients were deemed to unlikely need any additional treatment (74.55%).

Conclusion: Most head and neck hemangiomas can be diagnosed based on history and physical exam alone. Beta blocker therapy is the mainstay of treatment in infancy for head and neck IH that require treatment, with an excellent safety profile. Surgical management may be indicated for select cases of IH for diagnostic or treatment indications. Congenital hemangiomas present with unique features and require a different treatment approach, with surgical resection usually indicated in cases of NICH.

Introduction: Outcomes in alveolar bone grafting (ABG) in cleft lip and palate care are influenced by several factors, such as age at grafting, diagnosis severity, and dental/orthodontic care. Few studies to date have emphasized the importance of the surgical approach taken for bone grafting, including the degree of alveolar dissection and pocket creation for graft deposition. The current study aims to describe and objectively evaluate an "extensive dissection technique" for bone grafting, and, in doing so, describes a new scale for evaluation of graft quality.

Methods: Unilateral cleft lip and palate patients who underwent the "extensive dissection technique" for ABG were retrospectively compared to patients who underwent the traditional technique. Patients who received allograft were excluded from analysis. Outcomes compared included post-operative complications and regraft rates. Bone graft quality following ABG was assessed by two blinded orthodontists using the standardized way to assess grafts (SWAG) scale. When the 6-point SWAG scale was determined to be insufficiently sensitive to detect postoperative changes in graft quality, the authors devised a new Pittsburgh Clinical Correlate Score (PCCS) for assessment of the blinded post-op radiographs. The PCCS is a four-point scale where 1 means a regraft is requested, 2 means that there is orthodontic movement with informed consent of some bony deficiency, 3 means that the results are clinically acceptable, with no reservations in orthodontic movement, and 4 means that the orthodontists have determined that they should allow for dental eruption and re-assessment. Univariate comparisons of several clinical variables (e.g., left or right complete on incomplete cleft lip and palate, syndromic status, and use of acellular dermal matrix, etc.) across patient cohorts were conducted using Welch's t-test, and interrater reliability of each orthodontist's rating of bone graft quality was assessed using Pearson's correlation coefficient). The difference in PCCS between the old and new method cohorts was determined by the Wilcoxon rank sums test.

Results: One hundred seventy-three (60% male) who underwent ABG were evaluated in clinic during the study period. Of these patients, 85 underwent the traditional ABG method (75.2%, 61% male), and 88 (24.8%, 57% male) underwent the extensive dissection technique. None of the patients who underwent the new method needed a revision bone graft, whereas 20 (23.5%) of patients undergoing the old method did (p-value <0.0001). Clinical correlate scores of bone graft quality for patients who underwent the new, extensive dissection technique were significantly lower (and therefore, improved) relative to those who underwent the traditional ABG method (p-value = 0.04).

Conclusion: This study objectively demonstrates that the extended dissection technique reduces regraft rates for alveolar reconstruction in patients with orofacial clefts. While this technique does result in a larger dissection pocket and a need for a greater amount of bone graft, our experiences suggests that this disadvantage is outweighed by the reduced complications of this technique.

Purpose: Accurate coding is critical to proper reimbursement in the US fee-for-service system. Ambiguity and undervaluation of current procedure terminology (CPT) in craniofacial surgery may create variation in billing practices of common procedures like primary palatoplasty (CPT: 42200). This study aims to identify unbundling trends in primary palatoplasty and discuss its appropriateness based on current coding guidelines.

Methods and Materials: Retrospective data from the Pediatric National Surgical Quality Improvement Program (PNSQIP) database reviewed patients from 2016 to 2021 with the primary CPT code 42200 (palatoplasty for cleft palate, soft and/or hard palate only). Patients in the 'unbundled' cohort had an additional CPT code 42235 (repair of anterior palate, including vomer flap), while 42200 was billed alone in the 'bundled' cohort. Operative time, surgical specialty, length of stay (LOS), and other perioperative variables were compared.

Results: There were 9,827 patients with CPT 42200. Of these, 9,156 patients (93.2%) were bundled, and 671 (6.8%) were unbundled. Operative time was significantly longer in the unbundled cohort (157.08 min vs 133.16 min; p<0.001). LOS was shorter in the unbundled group (1.42 days vs 1.58 days; p=0.026). Plastic surgeons were less likely to unbundle (6.2% vs otolaryngology, 9.12%; p=<.001).

Conclusion: Significant variations in primary palatoplasty billing practices exist. Longer operative times in unbundled cases may indicate a more involved procedure. A critical review of current coding guidelines is needed, including an examination of undervalued and ambiguous CPT codes in cleft surgery.

Background & Purpose: Enhanced Recovery After Surgery (ERAS®) protocols have become more prevalent in clinical practice and in the primary literature given their reliable demonstration of improved surgical outcomes. In the process of seeking to develop our own ERAS pathway for craniosynostosis, the authors sought to assess the quality and breadth of the existing ERAS® literature in craniofacial surgery.

Methods and Materials: A systematic review was performed using PubMed and Embase, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). Two independent reviewers screened 89 abstracts and 34 full texts using Covidence systematic review manager. Ultimately, fifteen clinical studies reporting on ERAS® protocols in craniofacial surgery were included. Data on adherence to ERAS® guidelines as well as study design, patient demographics, components of the ERAS® perioperative pathway, and outcomes following pathway implementation were collected. Descriptive statistics were used to summarize findings.

Results: Most published ERAS® pathways in craniofacial surgery are designed for cleft lip and/or palate (CLP) repair (46.7%), followed by orthognathic surgery (33.3%), speech surgery (6.7%), fronto-orbital advancement (6.7%), and alveolar bone grafting (6.7%). Eighty percent of studies were conducted in the United States, with representation from China, Japan, and Brazil. The average number of participants per study is 104 (range 19-359), and most studies (73.3%) contained a historical control group as well as the intervention group post-ERAS® implementation. The most common outcome evaluated was postoperative pain control/narcotic minimization (66.6%), followed by oral intake (26.7%), length of stay (26.7%), readmissions/ED visits (20%), the impact of a standardized surgical technique (20%), blood loss/minimizing transfusion requirements (13.3%), and minimizing postoperative nausea and vomiting (13.3%). One hundred percent of studies that compared pre- and post-ERAS® cohorts found improved outcomes in one or more domain in the ERAS® group. The studies themselves were imperfectly designed as zero studies reported endorsement from ERAS® society leadership, only two followed ERAS® society methods, four used the proper ERAS® formatting and diagram, eight were developed by individuals from different health settings and different professions with consideration for patient involvement, nine were multidisciplinary and created with a plan for audit and evaluation, 11 addressed all phases of operative care, and only one failed to report on multiple patient outcomes.

Conclusion: Existing ERAS® literature in craniofacial surgery is primarily in cleft lip and palate and orthognathic surgery with a paucity of published craniosynostosis ERAS® pathways. Existing pathways consistently demonstrate improvement in surgical outcomes but fall short in their ability to adhere to ERAS® guidelines and holistically address perioperative care.

Purpose:
For patients with craniosynostosis, early diagnosis and intervention are imperative to optimize treatment options and long-term outcomes. The impact of sociodemographic factors and diagnostic timing is unclear. This study aims to investigate this relationship and identify healthcare disparities and barriers to timely intervention in the authors' home state using Social Vulnerability Index (SVI), a tool developed by CDC/ATSDR to assess community-level vulnerability.

Methods Retrospective chart review was conducted for patients diagnosed with craniosynostosis before age 2 years who were treated at the authors' institution between 2012-2023. Patients were stratified into quartiles based on the SVI of their home county and age at the time of diagnosis was recorded. Statistical analysis was conducted utilizing one-way ANOVA with Tukey's multiple comparisons tests.

Results 136 patients were identified for sociodemographic analysis. A one-way ANOVA comparing age at diagnosis revealed a main effect of SVI quartile (p < 0.002). The most socially vulnerable quartile (quartile 4) was significantly older at the time of diagnosis compared to all other quartiles (p < 0.001). In contrast, no difference was found between quartiles 1, 2, and 3.

Conclusions Relative to their peers, the most socially vulnerable patients are more likely to experience delayed diagnosis of craniosynostosis. These delays may contribute to delayed treatment, thereby limiting treatment options and impacting surgical outcomes. These findings highlight the need for targeted interventions to improve equity in craniosynostosis care for vulnerable populations.

Background

Patients with unilateral condylar hyperplasia (UCH) may present with TMJ symptoms, rather than concerns or recognition of asymmetry. Localization of TMJ pain may be on the affected (long) side, unaffected side, or both. Flattening, severe erosion and internal derangement on the opposite side can be appreciated radiologically. This can be a red herring, shielding the true diagnosis of UCH from the contralateral side. We hypothesize that excessive growth of the ipsilateral condylar neck and head on the side of UCH results in an upward and backward force on the opposite side TMJ, with resultant symptoms and findings (condylar flattening, anterior disc displacement, eminence changes). The purpose of this paper is to highlight the bilateral TMJ findings in UCH, and address potential treatment strategies.

Methods

This is a retrospective study involving radiologic and biographical data from subjects with TMJ UCH, as well as controls. Patient details and high quality Cone beam CT (CBCT) scans (1mm slices or less) were analyzed. CT scans were digitized and morphometric points were placed using Planmeca software (Hoffman Estates, Illinois). Linear and volumetric measures were taken in reference to the eminence, TMJ space, condylar position, and neck lengths. Volumetric analysis of the condylar head and neck was done using Analyze 14.0 software (Overland Park, KS, USA). Results were assessed using univariate analysis (T-Wilcoxon test).

Results

40 patients were included (29 with UCH, 11 controls). The condylar head was flatter and erosive appearing on the contralateral UCH side compared to both ipsilateral side in the same subject, and compared to controls. Analysis between the affected and unaffected sides in patients with UCH showed a significant difference in condylar head and neck length (p=0.0019) and volume (p=0.0030); anterior glenoid space (p=0.035) and vertical height of condylar eminence (p=0.00044). The difference in ramus length was not significant (p=0.6533). Between the controls and the UCH patients, there was a significant difference in the variance in condylar head and neck length (p=1.98e-07) and volume between the two sides (p=1.94e-08) but not ramus length (p=1). The vertical height of the condylar eminence was smaller on the affected side than in the controls (p=0.0018) and the anterior glenoid space was significantly smaller on the unaffected side compared to the controls (p=0.0053).

Conclusion This study highlights TMJ morphological differences in patients with UCH. These differences in condylar and glenoid morphology are consistent and should be used to aid and underpin the diagnosis. Importantly, patients who present with TMJ pain and erosion on one side, should be assessed for opposite side UCH, as the underlying culprit.

Background: Anatomical abnormalities in the nasal airway associated with unilateral cleft lift nasal deformity (uCLND) often create multiple sites of nasal airway obstruction (NAO), and little is understood regarding the extent or severity of NAO induced by uCLND compared to those experienced by non-uCLND patients with NAO. Most studies investigating NAO in patients with cleft lip and/or palate have focused on comparisons with a control group exhibiting normal nasal anatomy or among different cleft morphologies.

Objective: The aim of this study is to employ computational techniques to quantify the patent nasal airways in individuals with uCLND, comparing them with non-uCLND subjects experiencing NAO and a healthy control group. Additionally, differences in the patent nasal airway were evaluated based on sex and population group.

Methods: Anatomically accurate three-dimensional patient-specific nasal airways were reconstructed from computed tomography images in 30 subjects: 10 subjects with uCLND, 10 non-uCLND subjects with NAO, and 10 healthy controls. Unilateral nasal airways surface area (SA) and volume (V) were calculated for each subject with uCLND for both cleft (CS) and noncleft (NCS) sides, and more obstructed (MOS) and less obstructed (LOS) sides for non-uCLND subjects with NAO, as well as for healthy controls.

Results: Median nasal airspace SA was smaller on the impacted side for subjects with uCLND and non-uCLND subjects with NAO when both sexes were combined, as well as when isolated by sex. For subjects with uCLND - mean SA for both sexes was CS=64.68cm² (IQR=9.72cm²) versus NCS=75.68 cm² (IQR=5.90cm²). Mean SA for all non-uCLND subjects with NAO was LOS=91.97cm² (IQR=18.47cm²) versus MOS=97.66 cm² (IQR=16.79cm²). Males consistently displayed higher median (IQR) SA than females across all categories. When including both male and female subjects, the difference in SA between the CS and NCS for subjects with uCLND is statistically significant (p=0.006). However, the difference in volume for both sexes between the CS and NCS was not statistically significant. Furthermore, nasal volume had higher variability when comparing males and females: IQR of the NCS was 3.19cm3 vs 1.54cm3, 2.42 cm3 vs 0.29cm3 for the MOS, and 2.62cm3 vs 0.56cm3 for the LOS, respectively. The MOS among non-uCLND subjects with NAO had the highest SAV ratio a median of 21.28cm-1 (IQR=14.51cm-1) for both sexes, 25.13cm-1 (IQR=19.98cm-1) for males, and 20.66cm-1 (IQR=0.38cm-1) for females.

Conclusion: SA was consistently smaller on the impacted side compared to the non-impacted side across all three groups: both sexes, males, and females. Males had increased SA (IQR) compared to females across all classifications. Nasal volume results paralleled SA findings; however, males subjects with uCLND on the NCS and with NAO on both sides were found to have smaller nasal volumes their female counterparts. Notably, there was a higher variability of volumes for males than females. Lastly, surface area to volume (SAV) ratios indicated that more affected sides had a larger SAV ratio, suggesting potential nasal obstruction, while normal subjects generally had the smallest SAV ratio.

Background: Most pediatric head and neck cancers are aggressive sarcomatous neoplasms. Treatment often involves neoadjuvant and adjuvant therapies in addition to surgical intervention. However, extensive surgical dissection in this region can present challenges to craniofacial surgeons who aim to achieve negative margins while minimizing associated morbidity and mortality. The purpose of this study is to identify the prognostic factors associated with surgical intervention in pediatric patients with head and neck sarcomas.

Methods: Pediatric patients who underwent surgical resection of head and neck sarcomas at a tertiary children's hospital between 2006 and 2023 were retrospectively reviewed. Patient demographics, pathological diagnosis, treatment modality (i.e., surgery, chemotherapy, and radiation), surgical margins, and survival were abstracted. The primary outcome was the 5-year survival rate following surgical intervention by plastic and maxillofacial surgery services. Kaplan-Meier analysis using the log-rank test was used to compare the predicted survival rates between various risk factors while adjusting for metastatic disease.

Results: Of 310 pediatric patients with craniofacial tumors, 229 were classified as non-odontogenic tumors. Of these, 60 tumors were sarcomatous- most commonly rhabdomyosarcoma (50.0%), followed by osteosarcoma (8.3%) and Ewing sarcoma (6.7%). The mean follow-up time was 6.3±5.2 years. The 5-year survival rate of all patients with sarcomatous tumors was 76.7%. Compared to patients who underwent surgical resection with R1/2 margins, those who achieved R0 margins had a significantly higher 5-year survival rate (100.0% vs. 73.6%; p=0.024). Patients treated with early surgical intervention rather than neoadjuvant chemoradiation had improved 5-year survival rates (90.9% vs. 60.0%, p=0.040).

Conclusion: Radical primary surgical intervention resulted in significantly higher 5-year survival rates in pediatric patients with head and neck sarcomas. When possible, achieving R0 margins during surgical resection might improve survival among this population. Future investigations are encouraged to provide patients and families with a more comprehensive understanding of various treatment options to better guide informed decision-making.

Background: The rapid development of the craniofacial skeleton from infancy to adulthood represents a unique obstacle in the clinical management of pediatric orbital fractures. Historically, treatment of orbital fractures in children has been approached similarly to that of adult patients. Distinct structural differences in boney composition and skull proportions however warrant the investigation of consequent adverse outcomes in pediatric orbital fractures and potential solutions to mitigate them. In adults, the orbital index, a measurement first suggested by Davidson et al., acts as a validated tool to stratify risk of delayed enophthalmos. The present study aims to demonstrate the utility of the orbital index, a composite measure of fracture location, size, and inferior rectus distortion, in the prediction of enophthalmos and surgical intervention in pediatric patients.

Methods: A retrospective review was performed for all patients under 18 years of age who presented to Children's Hospital of Pittsburgh, a pediatric level I trauma center. Demographic information, trauma mechanism, adverse outcomes, and craniomaxillofacial unenhanced high-resolution computed tomography (CT) scans were collected. Each scan was assessed for the following three parameters: total area of the fracture (cm2), primary location (anterolateral, anteromedial, posterolateral, or posteromedial), and shape of the inferior rectus muscle. Logistic regression analysis was utilized to generate a predictive model of management-type and adverse outcomes. Two-sample Student's t-tests were applied for comparison of orbital index across patient groups.

Results: A total of 3,334 patients were diagnosed with facial fractures between 2006 and 2021. Of 275 patients that presented with isolated orbital floor fractures (8.2%), 63 patients were excluded based on unextractable or missing data, poor CT image quality, or non-isolated fractures. The final analytic sample consisted of 212 patients with an average age of 11.6 (SD: 4.5) and range of 1.0 to 17.9 years. Average time of follow-up for each patient was 17 days (SD: 4.3). High-velocity injuries were the most common cause of fracture, specifically sports-related injuries (31.1%) and motor vehicle accidents (25.0%). Anteromedial fractures were the most common fracture type (34.0%). Thirteen patients developed enophthalmos (6.1%) and 52 (25.0%) received surgical intervention. Larger orbital index scores contributed to a 73% increase in the odds of developing enophthalmos (p=0.005). A larger score was also associated with a 69% increase in the odds of surgery (p<0.001).

Conclusions: The management of pediatric orbital floor fractures is complex though can be further clarified with the utilization of CT to analyze fracture characteristics and assign a composite orbital index. In scenarios where typical surgical indications (e.g., enophthalmos, inferior rectus entrapment) are not apparent, the orbital index is effective in predicting management-type and the development of feared adverse outcomes.

Background: Enhanced Recovery After Surgery (ERAS) protocols implement perioperative interventions to improve patient outcomes by limiting the surgical stress response, optimizing physiological function, and facilitating recovery. They have demonstrated success in adult surgical populations. We predict these benefits extend to the pediatric craniofacial population and can be particularly effective for orthognathic surgery. This study investigates current attitudes and use of ERAS protocols in orthognathic surgery.

Methods: An electronic survey was distributed to 102 craniofacial (CF) and oral and maxillofacial (OMF) surgeons in the United States. Responses were collected from April to July 2023. Surveys queried surgeons' knowledge, use, and attitudes regarding specific ERAS elements in pediatric (patients under age 25) orthognathic surgery. Surgeons were specifically asked about their preoperative, intraoperative, and postoperative practices and beliefs. Survey responses were collated and analyzed.

Results: 41 (40.2%) of 102 surgeons completed the survey. 7 of 14 surveyed elements are employed by a majority of surgeons for all patients: hypothermia prevention (61.0%), standardized protocol for maintaining normovolemia (61.0%), bolus of intraoperative tranexamic acid (51.2%), multimodal approach to postoperative nausea (61.0%), minimized use of opioids for postoperative pain control (51.2%), postoperative antiemetics in the first 48 to 72 hours (53.7%), and postoperative bite stabilization (58.5%). Additionally, 21 (51.2%) of surgeons reported using short acting anesthetic agents, like Precedex, intraoperatively for all or most patients, but only 11 (26.9%) surgeons reported use for all or most patients postoperatively. With regards to bite stabilization, 29 surgeons (70.7%) reported using just elastics. Liposomal bupivacaine was not commonly used: 37 surgeons (90.2%) reported never using this modality. Infusion dosing of intraoperative tranexamic acid was used for no or some patients by 24 surgeons (58.5%). Surveyed surgeons were least familiar with preoperative nutritional screenings or consultations (17.1%) and postoperative goal directed or zero fluid balance models (29.3%). Surgeons reported the most familiarity with bite stabilization (65.9%), minimizing use of opioids for postoperative pain control (48.8%), and administering a bolus of intraoperative tranexamic acid (43.9%).

Conclusions: Surveyed surgeons endorse and report using ERAS-type perioperative elements in pediatric orthognathic surgery. Most surgeons reported, at minimum, being somewhat knowledgeable about most surveyed ERAS elements. Further evidence and multidisciplinary cooperation is necessary to implement a formalized ERAS protocol for pediatric orthognathic surgery.

Introduction Branches of the internal and external carotid arteries that supply the scalp and face are susceptible to injury by blunt trauma while crossing bony structures or direct damage from penetrating injuries (1). Blunt trauma can have effects ranging from vessel dissection to pseudoaneurysm to complete transection with free extravasation (2). Unless avulsion with hemorrhage is present, the vascular injury patterns can present days to months after the trauma (3). Further complicating the matter is that additional injuries are rarely found (4). Unlike for blunt cerebro-vascular injury (5), there is no grading algorithm for blunt cephalo-vascular injury to guide proper diagnosis of these injuries.

Methods A systematic review of the literature as of January 2024 was performed to collect all reports describing blunt injury to branches of the internal and external carotid arteries supplying the cutaneous regions of the face and scalp. The preference was directed toward specific the vascular injury encountered and the treatment regimen. Patient demographics and ancillary injuries were also identified. A novel grading algorithm for these injuries was proposed.

Results 99 abstracts were collected, and 74 articles were included in the systematic review after inclusion criteria were met (Figure 2). 64 (86.5%) were case reports while the others included sample sizes ranging from to 2-13 patients. In this analysis, we included a 77-year-old female with no significant past medical history who presented immediately after colliding with her door with a grade 3 injury which was repaired by surgical ligation (Figure 3).

111 patients were included in total. 91 (81.9%) were male, and average patient age at the time of presentation was 39.3 ± 25.9 years. The most commonly injured vessel was the superficial temporal artery (89, 80.2%). This was identified by computed tomography angiography (CTA) in 65 (58.6%) cases. 16 (14.4%) patients presented with concomitant facial fractures, and 9 (8.0%) patients reported anticoagulation use. The most common type of vessel injury was pseudoaneurysm (101, 91.0%), followed by arteriovenous fistula (3, 2.7%), and transection (7, 6.3%). The characteristics and timing of symptom presentation after the injury varied depending on the injury pattern. The most common treatments included surgical ligation with or without aneurysm resection (79, 71.2%), endovascular embolization (16, 14.4%), or anticoagulation (9, 8.1%). 107 (96.4%) patients saw complete resolution of symptoms after their given treatment.

Conclusions Blunt cephalovascular trauma is an uncommon injury and often missed in the acute setting due to paucity of symptoms unless complete transection is present. The literature surrounding this topic involves low sample sizes. There must be a high index of suspicion to obtain a CTA to identify facial and scalp vasculature injuries. Treatment of arteriovenous fistula, pseudoaneurysm, or vessel avulsion most often involves surgical ligation or endovascular embolization which provides strong outcomes with complete resolution. Plastic surgeons must be equipped to handle such injuries should they present as a facial trauma consult.

References 1. H. Conner WC, Rohrich RJ, Pollock RA. Traumatic Aneurysms of the Face and Temple: A Patient Report and Literature Review, 1644 to 1998. Ann Plast Surg. 1998;41(3):321-326. doi:10.1097/00000637-199809000-00019 2. Davis JW, Holbrook TL, Hoyt DB, Mackersie RC, Field TO, Shackford SR. Blunt carotid artery dissection: incidence, associated injuries, screening, and treatment. J Trauma. 1990;30(12):1514-1517. 3. Rodallec MH, Marteau V, Gerber S, Desmottes L, Zins M. Craniocervical Arterial Dissection: Spectrum of Imaging Findings and Differential Diagnosis. RadioGraphics. 2008;28(6):1711-1728. doi:10.1148/rg.286085512 4. McNutt MK, Kale AC, Kitagawa RS, et al. Management of blunt cerebrovascular injury (BCVI) in the multisystem injury patient with contraindications to immediate anti-thrombotic therapy. Injury. 2018;49(1):67-74. doi:10.1016/j.injury.2017.07.036 5. Biffl WL, Moore EE, Offner PJ, Brega KE, Franciose RJ, Burch JM. Blunt Carotid Arterial Injuries: Implications of a New Grading Scale: J Trauma Inj Infect Crit Care. 1999;47(5):845. doi:10.1097/00005373-199911000-00004

Jansen metaphyseal chondrodysplasia (JMC) is an ultra-rare skeletal dysplasia caused by constitutive activation of the parathyroid hormone type 1 receptor (PTH1R). Patients usually present in childhood with characteristic metaphyseal flaring, short limbed-short stature, and bowed legs, ultimately requiring multiple surgeries for fractures and deformities. There are only 30 patients estimated to have the disease globally. Literature describing the craniofacial characteristics is sparse despite the striking craniofacial phenotype. This study investigates the prevalent craniofacial manifestations and functional implications of a cohort of patients with JMC.

Six patients (4 males, 67%) with genetically confirmed JMC underwent comprehensive craniofacial phenotyping consisting of CT and 18F-NaF PET/CT scans in addition to ophthalmologic, otolaryngologic, audiometric, and dental evaluations. Median age at the time of evaluation was 27.5 [IQR: 29] years. Sagittal suture craniosynostosis was seen in 5 of the 6 patients; one patient underwent cranial reconstruction for severe craniosynostosis in infancy. Patients also had characteristic pronounced supraorbital ridges, widely spaced eyes (hypertelorism), high arched palate, abnormal-shaped teeth, and relative mandibular retrognathia due to maxillary prognathism. Obstructive sleep apnea requiring continuous positive airway pressure (CPAP) was noted in 2 patients and, though the remaining patients had no clinical symptoms, airway analysis showed tracheal narrowing in 5 of the 6 patients on head CT. On CT skull, all patients showed bilateral, relatively symmetrical expansile, mixed lytic and sclerotic bone lesions throughout the skull. Neural crest cell (NCC)-derived bones of the viscerocranium (face), sagittal suture with adjacent parietal bones, and skull base showed greater involvement than mesoderm-derived bones (occipital and parietal), resulting in what can be considered a typical radiographic appearance. Sphenoid bone expansion was associated with optic canal narrowing in all patients when compared to age-matched controls. Additional findings include progressive optic nerve atrophy, conductive or mixed hearing impairment, facial nerve palsy, and malocclusion requiring orthodontic treatment.

To conclude, patients with JMC have a prominent craniofacial phenotype with a distinct facial and radiographic appearance, hearing and vision impairment, sleep apnea and dental anomalies. Sagittal craniosynostosis is common and surgical intervention may be warranted depending on the severity of craniosynostosis. Given the prominence of airway narrowing, airway management should be considered during surgical procedures requiring anesthesia. Additional reconstructive surgical procedures of affected facial structures are yet to be described due to the rarity of this condition. These findings begin to explore the consideration for craniofacial interventions in patients with JMC. Prominent involvement of neural crest cell-derived structures and its association with neurocristopathies that result in well-known congenital craniofacial anomalies implicates a role for NCCs in the development of JMC.

Background: Complications following mandibular fracture repair (MFR) may carry significant morbidity to patients. The purpose of our study is to determine the risk factors for postoperative complications following MFR. Methods: We conducted a retrospective cohort study of trauma patients who underwent MFR in 2018 and 2019. Excluded were patients <18 years old and those with postoperative follow-up <2 weeks. The primary outcome was the incidence of major and minor postoperative complications following MFR. Demographics, mandibular fracture characteristics, and postoperative complications were reported. The mandibular injury severity score (MISS) of each patient was calculated. Bivariate analysis and multivariate logistic regression were performed. Results: Of n=275 patients included, mean (SD) age was 35 (14) years and median (IQR) follow up was 49 (26-117) days. Most patients (n=208 [76%]) underwent both maxillomandibular/intermaxillary fixation (MMF/IMF) and open reduction and internal fixation (ORIF). The incidence of major postoperative complications was 19% (n=51) including malunion (n=8 [2.9%]), malocclusion (n=21 [7.6%]), and reoperation (n=26 [9.5%]). The incidence of minor postoperative complications was 61% (n=167) including jaw pain (n=108 [39.3%]), mental nerve paresthesia (n=85 [30.9%]), infection (n=31 [11.3%]), TMJ complications (n=29 [10.6%]), restricted maximal intercisal opening (n=15 [5.5%]), hardware loosening or exposure (n=15 [5.5%]) and wound dehiscence (n=14 [5.1%]). Alcohol use at the time of surgery and greater MISS score were associated with greater odds of major complications (adjusted odds ratio [aOR] 95% confidence interval [95% CI] 3.4 [1.2-9.0], 1.09 [1.02-1.16], respectively. Smoking at the time of surgery and moderate-to-severe fracture displacement (>2 mm) were associated with greater odds of minor complications (aOR [95% CI] 2.1 [1.04-4.2], 2.7 [1.2-6.4], respectively). Conclusion: Alcohol use, smoking, greater MISS score, and displaced fractures >2 mm were significant risk factors for postoperative complications following MFR. Our findings can help guide informed decision making and surgical planning in patients with mandibular fractures.

BACKGROUND: Gradual onset facial nerve dysfunction due to benign tumors presents diagnostic and surgical challenges due to the often-multiyear progression of intermittent episodes of facial weakening and partial recoveries. This study aims to share our experience with this unique population and review the literature.

METHODS: Adult patients with slowly progressive facial weakness or hemifacial spasm due to facial nerve involvement of a single benign tumor across a 13-year period were analyzed for demographics, facial palsy history, tumor characteristics, tumor treatments, reanimation treatments, and outcomes.

RESULTS: 14 met the inclusion criteria, with a mean age of symptom onset of 49 years and mean age of first visit of 54 years. 64% of patients were initially misdiagnosed. All patients presented with incomplete facial palsy, and 50% with synkinesis. The most common benign tumor type was facial nerve schwannoma (50%), followed by facial nerve hemangioma (21%), acoustic neuroma (14%), paraganglioma, and cavernous hemangioma (both 7%). 36% underwent complete tumor extirpation, 36% radiation, 14% mastoid decompression, and the remaining 14% are under observation. The facial nerve was sacrificed in 60% of patients who underwent extirpation. 43% of patients underwent dynamic facial reanimation, which, when feasible, was performed prophylactically, prior to potential future extirpation.

CONCLUSIONS: Identification and consideration of the prolonged course of facial nerve dysfunction, often with synkinesis, is necessary, as is evaluation of retained mimetic muscle tone given the uncertainty of denervation time. In suitable patients, prophylactic reanimation surgery should be proposed to avoid periods of complete flaccid facial paralysis and corneal exposure.

Introduction: Cryopreserved autogenous cranioplasty (AC) is often performed by plastic surgeons and neurosurgeons following a decompressive craniectomy. Previously removed calvarial bone is widely considered the gold standard for cranioplasty given its low rejection rate and low cost (1). However, AC is associated with many complications including bone flap resorption (BFR) which can necessitate surgical revision. Clinically relevant BFR can occur in as many as 34% of all cranioplasty patients (2). Prior meta-analyses have attempted to investigate various factors contributing to BFR. However, these studies are limited by varying definitions of BFR and varying methods of bone flap preservation across the literature (3). The goal of this meta-anaylsis was to examine factors associated with severe bone flap resorption in cryopreserved autogenous cranioplasty patients.

Methods: A literature search was performed across 4 databases (PubMed, Scopus, Web of Science, EMBASE). A total of 1085 papers were screened according to PRISMA guidelines. Studies which examined factors related to bone flap resorption were examined. Studies with the same definition of BFR (resorption requiring reoperation) and the same calvarial bone storage method (cryopreservation) were included for final analysis.

Results: Of the 1085 studies were screened, 7 were found to meet inclusion criteria for analysis. These 7 studies include a total of 1650 patients. Patients with resorption were significantly younger (WMD = -8.38, p = <0.001). Calvarial bone flap fragmentation also caused significant increases in BFR (OR = 4.88, p = <0.001). Interval between craniectomy and cranioplasty did not significantly impact resorption rates (WMD = 1.37, p = 0.82) neither did patient sex (OR = 0.88, p = 0.36) or bone flap size (WMD = 0.17, p = 0.94). Finally, presence of a ventriculoperitoneal (VP) shunt was not associated with an increased risk of resorption (OR = 1.09, p=0.80).

Conclusion: The risks of performing cranioplasty on younger patients has been well established, as has the risk of performing cranioplasty with fragmented calvarial bone. Interestingly, the presence of a VP shunt and size of the bone flap were not found to significantly affect resorption rates, which contradicts pervious findings (2)(4). We hope the results of this focused meta-analysis lead to a reevaluation of the factors associated with severe BFR in future autogenous cranioplasty patients.

Citations: 1) Rashidi A, Sandalcioglu IE, Luchtmann M. Aseptic bone-flap resorption after cranioplasty - incidence and risk factors. PLoS One. 2020;15(1):e0228009. Published 2020 Jan 30. doi:10.1371/journal.pone.0228009 2) Kim JH, Kim JH, Kwon TH, Chong K, Hwang SY, Yoon WK. Aseptic Bone Flap Resorption after Cranioplasty with Autologous Bone: Incidence, Risk Factors, and Clinical Implications. World Neurosurg. 2018;115:e111-e118. doi:10.1016/j.wneu.2018.03.197 3) Yang J, Guan J, Ma L. Predisposing factors of bone flap resorption after autologous bone cranioplasty: questions unanswered. Neurosurg Rev. 2023;46(1):43. Published 2023 Jan 28. doi:10.1007/s10143-023-01946-0 4) Mustroph CM, Malcolm JG, Rindler RS, Chu JK, Grossberg JA, Pradilla G, Ahmad FU. Cranioplasty Infection and Resorption Are Associated with the Presence of a Ventriculoperitoneal Shunt: A Systematic Review and Meta-Analysis. World Neurosurg. 2017 Jul;103:686-693.

Purpose: Chiari I malformation (CM) is typically the result of either caudal traction or craniocerebral disproportion. Craniosynostosis (CS), the premature fusion of cranial sutures, can result in craniocerebral disproportion and thus has been associated with CM. Although there are studies with small sample sizes evaluating the association between CM and CS, a comprehensive meta-analysis of the cumulative data has not been reported. Moreover, most patients with CS who develop CM are diagnosed incidentally and have asymptomatic presentations [1]. For this reason, knowing the distribution of CM among different phenotypic presentations of CS will help in clinical evaluation. We aim to highlight the prevalence of CM amongst diverse phenotypic presentations of CS. Materials and Methods: A meta-analysis via PRISMA guidelines was conducted with keywords for Chiari malformation OR terms related to Chiari malformation AND craniosynostosis OR multi-sutural craniosynostosis OR single-suture craniosynostosis OR related terms. These terms were applied to databases OVID (Medline), Cumulated Index to Nursing and Allied Health Literature (CINAHL), Scopus, and the register Cochrane Trials on 1/11/24, with the yield of 688 articles with 264 duplicates. Records were further screened by three independent reviewers with perusal of individual abstracts, with the inclusion criteria of specific discussion of craniosynostosis (single suture, multi-suture, or syndromic) and CM as diagnosed by cerebellar tonsillar herniation at or below 5 mm. Logistic regression analyses were performed for suture types and syndromes independently. The coronal suture and Saethre-Chotzen syndrome served as the reference categories for regression analysis, respectively. Results: Based on the inclusion criteria, 23 reports were sought for retrieval. Based on the cumulative data in all reports, 30.2% of single-suture CS was associated with CM. Specifically, 43.9% of lambdoid, 6.7% of coronal, 6.5% of sagittal, 0.8% of metopic, and 20.5% of multi-sutural CS were associated with CM. Additionally, 22.2% of all syndromic cases presented with CM. By specific syndrome, 73.0% of Pfeiffer, 43.0% of Crouzon, 30.6% of Crouzon-Pfeiffer, 17.2% of Apert, 7.7% of Muenke, and 1.2% of Saethre-Chotzen presented with CM. The results highlight a significant positive association between CM and lambdoid CS (β = 2.38, p < 0.001) and multi-suture CS (β = 1.28, p = 0.001). Conversely, metopic suture involvement demonstrated a negative association with CM (β = -2.20, p = 0.038), while sagittal CS showed no significant association (β = -0.034, p = 0.932). There was a significantly greater association of CM with the syndromes Apert (β = 2.81, p = 0.00579), Crouzon (β = 4.10, p < 0.0001), Crouzon-Pfeiffer (β = 3.56, p = 0.000495), and Pfeiffer (β = 5.38, p < 0.000001). Conclusions: Based on this meta-analysis, the rates of CM are significantly associated with lambdoid CS and with multisutural CS. Additionally, there is a significant association between CM and the syndromes Apert, Crouzon, Pfeiffer, and Crouzon-Pfeiffer. These data emphasize the importance of careful evaluation of at-risk phenotypes of CS for CM. References: 1. Valentini LG, Saletti V, Erbetta A, Chiapparini L, Furlanetto M. Chiari 1 malformation and untreated sagittal synostosis: a new subset of complex Chiari?. Childs Nerv Syst. 2019;35(10):1741-1753.