Scientific Abstract Presentations: Craniomaxillofacial Session 8 Friday, September 27 Fri, Sep 27 5:00-6:00 p.m. PDT

Introduction: This study compares sensory outcomes in pediatric patients undergoing microtia reconstruction using alloplastic (Medpor, porous polyethylene) fascia-skin graft reconstruction and single and two-stage cutaneous flap-based reconstruction

Methods: In this IRB-approved, single-site, retrospective study, pediatric patients diagnosed with microtia (ICD-10 code Q17.2) or ear differences were included. Sensory recovery was assessed using the Semmes-Weinstein Monofilament Test (range: 0.07g to 4g monofilaments) before initial reconstruction and after single and two-stage reconstruction. Mann-Whitney U tests compared sensitivity between autologous cutaneous flap-based approaches versus alloplastic Medpor fascia-skin graft-based techniques. A Friedman test was carried out to compare sensitivity scores for the following regions: tragus, conchal bowl, lobule, and helix/antihelix followed by subsequent Dunn-Bonferroni post hoc tests.

Results: Seven Medpor patients (nine ears total) who underwent fascia-skin graft-based soft tissue coverage and 18 autologous cartilage patients who underwent single and two-stage cutaneous flap (Nagata technique; 18 ears total) were included. The total cohort included 20 grade III and 6 grade II microtic ears; one cauliflower ear that underwent Medpor-based reconstruction was included. The mean time from index procedure to sensory exam was 46 months in the Medpor group and 25 months in the cutaneous flap group. Overall, cutaneous flap-based reconstruction resulted in improved sensory outcomes when compared to Medpor reconstruction. There were significant differences in reported sensation between autologous and Medpor groups, including the tragus (0.07g vs. 4g; p<0.001), the conchal bowl (0.2g vs. 4g; p<0.001), and the helix/antihelix (0.2g vs. 4g; p<0.001), respectively. There were no significant differences in the lobule between either technical approach. Between the two groups, the most sensitive area was the lobule, while the least sensitive areas of the Medpor group were the tragus, bowl, and helix distributed equally (p=0.023). Meanwhile, only the helix/antihelix (p=0.009) showed reduced sensation in the autologous cutaneous flap-based approach but still demonstrated improved sensation in Medpor fascia-skin graft patients.

Conclusions: Cutaneous flap-based reconstruction results in improved sensation over Medpor fascia-skin graft-based reconstruction. These results add to the list of advantages and disadvantages of each approach and should be considered when treating patients with ear differences.

Background: An acute hematoma after implant reconstruction of hemispheric cranial defects can be significant. Despite high prevalence in 2% of head injuries and 15% of fatal head traumas, there is scant evidence of predictive factors risk of an acute hematoma post-operatively following alloplastic cranioplasty. An epidural hematoma can lead to compression of the brain with midline shift, and rapid neurologic decline, necessitating urgent reoperation (1). Previous reports describe associations with heavy alcohol use and level IV ASA classification (2). Herein, we describe a retrospective cohort study of patients who suffered an operative hematoma following alloplastic cranioplasty, assessing potential predictive factors.

Methods: A retrospective review was conducted for adult patients who underwent alloplastic cranioplasty, from January 2010 and October 2023, comparing patients who developed an operative post-operative hematoma vs. patients who did not. Operative hematoma was defined as epidural hematoma with neurologic exam change or epidural hematoma with midline brain shift on postoperative CT. Variables studied were demographic data (age, sex, and race), relevant medical history (diabetes, hypertension, smoking, and chronic alcohol use disorder), perioperative details (steroid usage, anticoagulant usage, and bleeding disorders), and blood pressure (BP) readings (pre-operative, intra-operative, and post-operative systolic and diastolic averages). Hypertension was determined when there were more than two blood pressure measurements greater than 140 mm Hg systolic and/or ≥80 mm Hg diastolic, respectively. Statistical analysis aimed to identify predictive factors for operative hematoma formation, employing a multivariable logistic regression model. All patients regardless of post-operative complications were followed up for a minimum of 6 months.

Results : There were 134 alloplastic cranioplasties included in our study during the studied time frame. Fourteen of the cases (10.4%) were operative hematomas. Patients with heavy alcohol use were associated with an increased risk of hematoma (p-value = 0.01). Patients with an elevated pre-operative systolic/diastolic BP reading had an increased risk of developing a hematoma as compared to the non-hematoma group, p-value 0.04 and 0.02 respectively. Patients with an elevated intra-operative systolic average BP also had an increased risk of hematoma formation after alloplastic cranioplasty (p-value 0.002). All other investigated variables-such as anticoagulants, bleeding disorders, and increased age-did not yield statistical significance in affecting the development of a hematoma.

Discussion: Hematoma after alloplastic cranioplasty necessitating reoperation can be a life-threatening complication. Despite its prevalence, there have been limited analyses of predictive risk factors leading to hematoma formation. In the 14/134 patients who developed an operative hematoma following alloplastic cranioplasty, we found an association of heavy alcohol use, increased preoperative systolic/diastolic BP, and increased intraoperative systolic BP. One limitation of our research is the limited sample size. Further study would include the implementation of a prospective protocol to control hemorrhage.

Sources: 1Rosenthal AA, Solomon RJ, Eyerly-Webb SA, Davare DL, Hranjec T, Carrillo EH. Traumatic Epidural Hematoma: Patient Characteristics and Management. Am Surg. 2017 Nov 1;83(11):e438-e440. PMID: 30401085.

2 Leathers KO, Bradshaw E, Holan C, Harshbarger R. Predictive factors for outcomes in alloplastic cranioplasty: A review of 101 cases. Plastic and Reconstructive Surgery - Global Open. 2023 Apr;11(4S):85–85. doi:10.1097/01.gox.0000934796.05113.9b

Introduction Individuals with microtia present with conductive hearing loss. They may also present with soft palate dysfunction, particularly velopharyngeal insufficiency (VPI), further affecting speech resonance and intelligibility (1). Current VPI evaluation methods include perceptual speech evaluation, intraoral examination, nasometry, nasopharyngoscopy, videofluoroscopy, and mirror fogging tests (2). Since a standardized speech evaluation for this population is not routinely available, these patients are not routinely screened. We propose a standardized resonance evaluation tool for patients with microtia to identify correctable speech errors early and provide appropriate therapy.

Methods A retrospective medical record review was conducted at a single, tertiary medical center from September 2022 to January 2024. Results of speech and resonance evaluation following our proposed algorithm were collected from charts of patients four to eighteen years of age with isolated or syndromic, unilateral and/or bilateral microtia. Data consisted of perceptual speech evaluation completed in both English- and Spanish-speaking patients by a bilingual speech-language pathologist (SLP) specialized in resonance disorders using the Cleft Audit Protocol for Speech-Augmented-Americleft Modification (CAPS-A-AM). Qualitative and quantitative VPI measures were gathered from nasometry, nasopharyngoscopy, and/or videofluoroscopy. Parent and patient questionnaire responses to the Velopharyngeal Insufficiency Effect on Life Outcomes (VELO) and Intelligibility in Context Scale (ICS) were collected to assess perception of speech and emotional impact on patients and caregivers.

Results Of sixty-six patients with microtia at our center, fourteen patients fitting inclusion criteria completed perceptual speech evaluation for VPI, with median age 10. All patients (n=14) displayed conductive hearing loss of affected ear(s). 36% of patients selected Spanish as their primary language (n=5). Microtia was present unilaterally in 86% of patients (n=12) and bilaterally in 14% (n=2). Signs of syndromic microtia were present in 29% (n=4). Hypernasality indicative of VPI was detected in 21% of patients (n=3) for which targeted speech therapy and follow-up assessment were recommended. Patient ICS scores were not significantly different between patients with or without VPI.

Conclusion Microtia patients can present with VPI, among other speech disorders. We propose a comprehensive screening algorithm for resonance disorders in patients with microtia through assessment of resonance, intelligibility, and oropharynx structure and function with appraisal of the emotional impact of VPI. Furthermore, assessment by a SLP certified in bilingual evaluation expands VPI detection to a larger population without inter-examiner variability. While the current sample size is limited, VPI evaluation has allowed for detection of hypernasality in patients with microtia, facilitating appropriate follow-up care. Implementation of a standardized evaluation may improve early identification and treatment.of VPI in patients with microtia.

References 1. van Hövell Tot Westerflier C, Bracamontes IC, Tahiri Y, Breugem C, Reinisch J. Soft Palate Dysfunction in Children With Microtia. J Craniofac Surg. Jan 2019;30(1):188-192. doi:10.1097/scs.0000000000004907 2. Kummer AW, Clark SL, Redle EE, Thomsen LL, Billmire DA. Current practice in assessing and reporting speech outcomes of cleft palate and velopharyngeal surgery: a survey of cleft palate/craniofacial professionals. Cleft Palate Craniofac J. Mar 2012;49(2):146-52. doi:10.1597/10-285

Background Large cranial defects in pediatric patients present unique challenges for craniofacial surgeons. Fresh autologous calvarial graft is the preferred reconstruction technique due to the growing pediatric cranium and the decreased infection risk. This study aims to evaluate the outcomes of autologous calvarial graft for reconstruction of large defects in pediatric patients. Methods A retrospective study on patients who underwent a cranioplasty with fresh autologous calvarial grafts at our institution between 2012-2022 was performed. Bone healing was assessed clinically on all the patients, and when available, a pre- and post-reconstruction three-dimensional computed tomography was used to quantify the defect size. Secondary outcomes included complications, readmissions, and reoperations. Results Twenty-seven patients with a median age of 9.8 years were included. The majority of defects were frontoparietal, with a median defect size of 175.4 (range 16.0-373.2) cm2. At a median of 11.8 months after surgery, only one patient (3.7%) exhibited an obvious, palpable cranial defect. There were no infections, cerebrospinal fluid leaks, readmissions, or reoperations reported. At a mean of 24 months after surgery, postoperative CT was available in thirteen (48.1%) patients. The median bone healing rate was 84.1%. Seven (53.8%) of the 13 patients showed a degree of incomplete bone healing. This sub-group of patients had an initial median defect size of 298 [IQR from 199-205] cm2 and, at an average of 24 months, showed a decreased but persistent median defect of 60 [IQR from 19.4-75.9] cm2. Incomplete bone healing correlated with larger initial defects and a higher number of previous craniofacial procedures (median of 2.0 [range between 2.0, 5.0], p-value=0.005). Conclusion Fresh autologous bone graft cranioplasty consistently remains a safe and effective procedure with a median bone healing rate of 84.1%. Patients with a higher number of previous cranial procedures and a larger initial defect size may be at higher risk of incomplete bone healing. Future prospective studies with larger sample sizes should be performed to further evaluate these risk factors.

There are almost unlimited anatomical variations of cleft defects. For the surgeon, this means an equivalent number of variables in planning treatment. Most surgeons tend to get comfortable with a single repair pattern and use it in most situations. However, as clefts become wider and more complex, most single patterns require more modifiers to reduce the tension to the central closure and this brings more secondary healing into play. The result of this traditional, single-pattern approach is that there are more speech failures with wider and more complex clefts. In the 2017 Plastic and Reconstructive Surgery Journal article, "The Double Opposing Z-Plasty Plus or Minus Buccal Flap Approach (DOZP+/-BFA), to Repair of the Cleft Palate: a review of 505 Consecutive Cases," Within the larger study the results for two groups of patients (pts) were compared; 1) Pts born with Veau 1 and narrow Veau 2 clefts, and 2) Pts with wider Veau 2, and Veau 3 and 4 clefts. There was no significant difference in nasal resonance scores. The present study expands the number of groups to ask the question: Across all cleft widths and classifications, is there a relationship that can be seen between the surgical replacement of missing tissue and eventual speech result?

Methods: This is a retrospective study that reviews outcomes for pts treated by one surgeon between 1985-2019. Multiple surgical patterns based of the DOZP+/-BFA were used, designed to replace missing tissue within the cleft defect as the defects progress from simple to complex. Every pt was treated with a Furlow type Z- Plasty. The only variable was the number of buccal flaps used for tissue replacement ( zero, one, or two). Pts were grouped by Veau classification & anatomically by width of the cleft as measured at the junction of hard and soft palate, establishing three width categories. 7 groups illustrate the increasing severity of the defect and the cleft widths. 1). V1. 2) Narrow and medium V2. 3). Wide V2. 4). Narrow V3. 5). Medium V3. 6). Wide V3. 7). V4. Two populations were evaluated. Population X was inclusive of all patients. And Population Z including only patients without syndromes or Pierre Robin sequence. Speech testing was done by multiple speech pathologists. Using a 1-4 nasal resonance scale. 1. non -nasal , 2. mild hyper nasal, 3. moderate hyper nasal, 4. severe hyper nasal. The Kruskal-Wallis test was used to compare resonance scores across populations and groups.

Results: Speech results were statistically similar across all groups and population categories. Population X, p-values 0.81 & 0.36, and population Z, p-value 0.85 & 0.27. Population X Group 1) 57 pts, Pts receiving Tissue replacement (TR) 8/ 57. Total Buccal flaps per group (BF) 10/57, median nasal resonance score (NRS) 1.26. 2) 57 pts, TR 20/57, BF 42/57, NRS 1.42. 3) 50pts, TR 42/50, BF 79/50, NRS 1.44. 4). 24 pts, TR 11/24, BF 16/24, NRS 1.33. 5) 93pts. TR 75/93, BF 128/93 NRS 1.28. 6). 73pts, TR 70/73, BF 132/73, NRS 1.26. 7). 85pts TR 83/85 BF 156/85, NRS 1.21. Population Z Group 1) 50 pts, TF 9/50, BF 10/50, NRS 1.28. 2) 21 pts, TR 10/21, BF 16/21, NRS 1.09. 3) 28 pts, TR 25/28, BF 48/28, NRS 1.39. 4) 20 pts, TR 9/20, BF 13/20, NRS 1.15. 5) 77 pts, TR 63/77, BF 109/77, NRS 1.16. 6) 64 pts, TR 63/64, BF 127/64, NRS 1.20. 7) 74 pts, TR 2/74, BF 135/74, NRS 1.13. The number of BF's increased from narrow to wide within V classes and increased when moving through from classes V1 through V4. Which demonstrates the number of BF per pt, as well as the NRS for each group and population.

Conclusion: The study shows the DOZP+/-BFA can achieve consistent excellent speech resonance results regardless of a pts V classification or cleft width. The higher resonance scores that were seen in population X group (2) & (3) is likely a reflection of the impact of an increased number pts with syndromes seen in these V2 cleft groups. For population Z the resonance scores demonstrated a remarkable consistency across all groups. The lower number of BF's used in V3 group 4, seems to be a product of the arch collapse that often accompanies this group. With experience the senior author better recognized how much the arch collapse was hiding the magnitude of the deficiency. Over the 34 years covered by this study, more and more BF's were added to the narrow V3 group to reduce future issues arch collapse can cause at maturity. Every pt born with a cleft is missing a specific amount of tissue relative to their unique cleft defect. It would appear that through the process of tissue replacement the DOZP+/-BFA establishes an equity of tissue across all V classes and cleft widths. When all cleft defects have essentially equal tissue to work with, surgeons more opportunity to achieve success for all patients. Future studies are necessary to better quantify the exact degrees of tissue deficiencies and to identify more tissue replacement options.

Purpose: Facial buttresses are supportive bony structures of the facial skeleton that form a thick, strong, and protective framework for the face. Surgical fixation may be required to restore morphology and function when damage to these buttresses occurs. We sought to determine if, similar to buttresses of the facial skeleton, buttresses of the internal orbit exist. Methods: We analyzed 10 human cadaver skulls imaged by microcomputed tomography (microCT). Image processing and thickness/heat mapping were performed using Avizo and ImageJ softwares. After identifying the orbital buttresses, we reviewed CT scans of patients who had orbital fractures across three years to determine the frequency of fracture of the orbital buttresses. Results: We identified 5 distinct orbital buttresses that consistently demonstrated increased thickness relative to adjacent orbital bones across skulls: supero-medial fronto-ethmoidal strut containing the deep orbital buttress, inferomedial strut containing the posterior ledge, inferior orbital fissure, sphenoid-frontal supero-lateral strut, and the sphenoid lip (Figure 1). These buttresses can be divided into 4 anterior-to-posterior horizontal buttresses (supero-medial fronto-ethmoidal strut, inferomedial strut, inferior orbital fissure, and sphenoid-frontal supero-lateral strut) and 3 posterior/deep buttresses (deep orbital buttress, posterior ledge, part of the sphenoid lip). To investigate the resilience and frequency of involvement of these buttresses after trauma, a total of 1186 orbits of 593 individuals with orbital fractures were analyzed. Orbital buttresses were spared in 770 (65%) orbits. The inferomedial strut with the posterior ledge was the most commonly fractured buttress in 14.4% of orbits (n=171), followed by the sphenoid strut and lip (66 [5.6%]), inferior orbital fissure (61 [5.1%]), and the supero-medial fronto-ethmoidal strut with the deep orbital buttress (42 [3.5%]). Fall and assault were the most common mechanisms of injury behind the involvement of orbital buttresses. Conclusion: To our knowledge, this is the first description of the buttresses of the internal orbit. Orbital reconstruction for fracture repair or oncologic purposes requires the support of orbital buttresses. Understanding the anatomy of orbital buttresses is crucial for successful surgical planning, proper implant positioning, and restoration of function and appearance.

Introduction Cranial defects necessitate reconstruction to ensure cerebral protection, neurological, and psychological well-being. The prevalent morbidity and infection rates associated with existing cranioplasty materials have sparked significant interest in the development of biomaterials that mimic tissue-specific extracellular matrix (ECM) properties, guiding osteoprogenitor cell differentiation. Nanoparticulate mineralized collagen glycosaminoglycan (MC-GAG) materials have been evaluated in our laboratory to induce osteogenic differentiation of primary osteoprogenitors in vitro and regeneration of rabbit skull defects in vivo without exogenous growth factors or cell seeding, an effect not observed in non-mineralized collagen glycosaminoglycan (Col-GAG) materials. Given that the critical difference between MC-GAG and Col-GAG is the mineral content, the temporal and spatial elution of inorganic ions may be critical to the osteogenic properties of MC-GAG. This is supported by prior research demonstrating the important role of calcium ions in bone homeostasis. To refine MC-GAG properties, understanding the downstream osteogenic signaling pathways activated by these biochemical cues and identifying potential targets for material optimization are imperative. Of particular interest is Orai1, a critical subunit of store-operated calcium release-activated calcium channel (CRAC), implicated in skeletal development. In this work, we evaluated the contribution of Orai1 to MC-GAG-mediated osteogenesis.

Methods To examine the role of extracellular calcium signaling through store-operated calcium entry (SOCE) on osteogenic differentiation of primary bone marrow-derived human mesenchymal stem cells (hMSCs), we treated 2D cell cultures with a small molecule inhibitor of store-operated calcium entry (SOCE), MRS1845, for 14 days. hMSCs were subsequently seeded on MC-GAG or Col-GAG materials for 7 days with or without MRS1845. Next, small interfering RNAs (siRNAs) targeting Orai1 and a scrambled control were used to specifically knockdown Orai1 expression in hMSCs cultured on Col-GAG and MC-GAG. Osteogenic gene and protein expression were measured using quantitative RT-PCR and western blot analysis, respectively. Mineralization was evaluated by Alizarin Red staining.

Results To understand whether store-operated calcium entry was essential to osteogenic differentiation of hMSCs and MC-GAG activity, cells in 2D and 3D cultures were treated with a small molecule inhibitor of SOCE, MRS1845. In 2D cultures, calcium depositions visualized with Alizarin Red staining were reduced with MRS1845 treatment compared to controls. In 3D cultures, MRS1845 decreased the gene expression of early and late osteogenic markers alkaline phosphatase (ALP) and osteocalcin, respectively, as well as protein expression of the osteogenic marker runt-related transcription factor-2 (Runx2) specifically in MC-GAG compared to control. As small molecule inhibitors lack channel specificity, siRNA was used to specifically knockdown Orai1 expression. Isolated Orai1 knockdown reduced Runx2 protein expression and gene expression of late osteogenic marker bone sialoprotein-2 (BSP2) specifically on MC-GAG compared to scrambled control siRNA. Mineralization significantly diminished on MC-GAG with Orai1 knockdown, whereas no effects were evident on Col-GAG as demonstrated by Alizarin Red staining.

Conclusions Orai1-mediated calcium ion signaling was required for MC-GAG-induced osteogenic differentiation. Further refinement of calcium levels on MC-GAG may facilitate its clinical application in the reconstruction of craniofacial defects.

Introduction Facial shape is significantly influenced by the contours of the underlying facial bony skeleton. Gender dimorphisms in facial skeletal anatomy are of particular interest to facial plastic surgeons for planning craniofacial and aesthetic surgery. While the orbits and upper face have been previously investigated, dimorphic differences in the mid-face skeleton are not well understood. Objectives This study aims to elucidate the morphological differences in the midface region, focusing on the maxilla and zygomatic bones in male and female subjects through the analysis of high-- resolution facial computed tomography (CT). Methods A retrospective review of facial CT scans in our institution's patient database was conducted. Data were extracted for 100 white patients aged between 20 and 79 years. Inclusion criteria were limited to scans with a resolution of 1 mm or finer. Scans indicating a history of facial trauma, tumors, orthognathic surgery, or orthodontic interventions were excluded. Segmentation and 3D volumetric reconstruction were performed using Materialise Mimics (version 25.0, Materialise NV, Belgium). Reformatted 3D CTs were transferred to 3-Matics software and manual measurements of the mid-facial skeleton, specifically the maxillary and zygomatic bones were performed. We took several measurements: the bizygomatic width (the horizontal distance between the most lateral part of the zygomatic bones), the distance between the frontozygomatic sutures, the orbitale distance (the horizontal distance between the lowest point of both orbit), the distance between the infraorbital foramina, the vertical distance from the nasal spine to the nasion, the depth from the nasal spine to the posterior boarder of the maxilla, the pyriform angle, and the maxillary angle (Figure 1). Relevant demographic information was summarized as mean and analyzed using unpaired Student t-tests, with a 95% confidence interval. Out of a total 100 patients, 46 were females and 52 were males. Patients were subdivided based on age into three groups: young (20-39 years), middle-aged (40-59 years) and elderly (60-79 years) with a mean age of 51 years in females and 50 years in males. Statistical analysis showed significant differences all the measured aspects of the mid-facial region between males and females, except for the maxillary angle, where the difference was not significant (P > 0.05). The average measurements where women differed from men included the bizygomatic width by -6.8 mm, the frontozygomatic sutures distance by -5.5 mm, the orbital distance by -3.3 mm, and the vertical distance from the nasal spine to the nasion by -4.2 mm, all with a P value of less than 0.01. The distance of the infraorbital foramen differed by -2.2 mm (P = 0.05), the facial depth by -1.7 mm (P = 0.015), and the pyriform angle by 3.01 mm (P = 0.045). Notably, when evaluating differences within subdivided age groups, the pyriform angle was the only measurement to show a statistically significant difference (P = 0.012). Conclusions Our analysis of mid-facial skeletal anatomy utilizing 3D imaging techniques has revealed significant sexual dimorphism. Measured parameters including zygion distance, frontozygomatic sutures distance, orbital distance, and vertical distance showed significant differences (P= 0.01).

Purpose: Orbital floor fractures account for most inpatient admissions and the highest emergency department costs among ophthalmologic traumas. Despite this, routine ophthalmology consultations for orbital fractures may not be an efficient use of resources, leading to unnecessary urgent transfers, increased wait times, and higher care costs. We sought to determine the risk factors associated with intervention following ophthalmologic consultation for patients with orbital fractures. Methods: This is a cross-sectional study of patients who were diagnosed with orbital fractures and had an ophthalmology consultation at the R Adams Cowley Shock Trauma Center emergency department or within 24 hours of admission between January 2015 and December 2020. Our primary outcomes were the frequency and predictors of interventions following ophthalmology consultation. Demographic information, ophthalmologic exam findings, and types of interventions were evaluated. Descriptive statistics, bivariate analysis, and multivariate logistic regression were conducted. Results: Of 815 patients included in our analysis, 20% (n=162) of patients required intervention following ophthalmology consultation. Patients who sustained gunshot wound injuries, medial wall fractures, or presented with a relative afferent pupillary defect, ocular muscle entrapment, gaze restriction, periorbital laceration, and subconjunctival hemorrhage, were significantly more likely to require intervention, compared with those who did not. On multivariate logistic regression, only reduced visual acuity (aOR [95% CI] 3.4 [1.95-5.98]) and periorbital laceration (aOR [95% CI] 4.6 [2.78-7.71]) were significant predictors of intervention following ophthalmology consultation. Topical antibiotics [51 (30.2%)], periorbital laceration repair [35 (20.7%)], and exploration/repair of globe rupture [28 (17.7%)] were the most common interventions. Conclusion: The fact that most patients with orbital fractures do not undergo intervention after an ophthalmology consultation raises questions about the initial need for such consultations. Our study offers crucial guidance for efficient patient triaging and identifying those in need of ophthalmology consultations, potentially leading to decreased morbidity from ocular trauma and improved resource utilization.

Introduction Teratomas are embryonal neoplasms composed of at least 2 of 3 germ layers. In neonates, the sacrococcygeal location is the most common location (60%) and head and neck involvement of is rarer (5%) with an incidence of 2.5-5:100,000 live births. (1) We present the case of a female neonate who had a rare, mature, skull-base teratoma identified on ultrasound during gestation. The management of this neoplasm involved fetal surgery, neurosurgery, ENT, and plastic surgery teams.

Methods Imaging of the teratoma revealed an anterior skull base teratoma with extension into and protruding from the nasopharynx resulting in gross enlargement of the right nostril and sinonasal cavity. Resection of the teratoma and reconstruction of the nostril involved 4 separate surgical procedures: an ex-utero intrapartum treatment (EXIT) procedure, teratoma resection, 2 stage nostril reconstruction. From the identification of the teratoma, plastic surgery was involved with preoperative planning due to the defect which required inevitable reconstruction. The EXIT procedure was performed to establish an airway before placental support was removed. Subsequently, neurosurgery and ENT performed an endonasal resection of the teratoma without intracranial involvement or cerebral spinal fluid leakage as previously described. (2) Although originally not part of the surgical plan, plastic surgery was available for consultation during the resection for optimization of post-resection anatomy. Plastic surgery was consulted when part of the nasal sill and cutaneous lip had to be resected due to teratoma adhesion. Plastic surgery performed an advancement flap to repair the defect caused by the adhesion as well as reduce the substantially sized ala. Histopathology of the mass specimen confirmed that it was a mature, cystic teratoma. After the resection, a 2-stage reconstruction was performed by the plastic and reconstructive surgeon. The first stage involved medial movement of the right ala and alar rim to reduce the size of the nostril and advance lateral tissue to compensate for the nasal cleft that existed after resection. The second stage involved harvesting cartilage from the concha to reinforce the alar rim, further reducing nostril size by V-Y advancement, achieving a more balanced nasal symmetry.

Results The child is now 3 years old and there is no evidence of recurrence of the tumor nor neurological defects. She has an optimal, symmetric cosmetic outcome of the nasolabial area that was involved.

Conclusion This rare case highlights the need for early diagnosis of these airway-obstructing masses to prepare for a safe delivery. Furthermore, a plastic surgery consult during the resection is indispensable to improved cosmetic outcomes and highlights the crucial communication that must exist within multidisciplinary team on complex cases.

1 - Kadlub N, Touma J, Leboulanger N, Garel C, Soupre V, L'Herminé AC, Vazquez MP, Picard A. Head and neck teratoma: from diagnosis to treatment. J Craniomaxillofac Surg. 2014 Dec 2 - Behbahani M, Rastatter JC, Eide J, Karras C, Walz P, Suresh K, Leonard JR, Alden TD. Pediatric Endoscopic Endonasal Skull Base Surgery: A Retrospective Review Over 11 Years. World Neurosurg. 2023 Feb