Scientific Abstract Presentations: Craniomaxillofacial Session 3 Thursday, September 26 Thu, Sep 26 3:00-4:00 p.m. PDT

Background & Purpose: The zygomaxillary complex (ZMC) is one of the most commonly fractured areas of the midface.1 Integral to the architectural stability of this area is the zygoma's intimate relationship with the orbital floor. Hence, ZMC fractures always have an orbital floor component to the injury. Previous studies have focused on the surgical outcomes and complications associated with zygomatic fractures, but few have extensively explored clinical and radiographic indications for orbital floor exploration and implant placement following open reduction of the zygoma.2,3 This study sought to evaluate whether displacement at different sites of injury could be predictive of the need for orbital floor reconstruction.

Methods: Institutional Review Board approval was obtained for a retrospective review of all patients with zygoma fractures who underwent operative intervention by the plastic surgery service over an 8-year period. All patients during the study period underwent exploration of the orbital floor at the time of ZMC reconstruction. When deemed necessary, an implant was placed for reconstruction of the defect. Computed Tomography (CT) imaging was correlated with data from the Electronic Medical Record to assess for the presence of co-occurring facial fractures. CT data was used to assess the following: zygomaxillary impaction at the infraorbital rim; maximum zygoma displacement at the zygomaticomaxillary buttress, zygomaticofrontal suture, and zygomaticotemporal suture; and orbital floor displacement in the anterior-posterior, inferior-superior, and transverse directions. All displacement measurements were recorded to the nearest tenth of a millimeter. Logistic regression models were fit to assess the adjusted effects of age and gender on implant placement. Results were considered significant at p < 0.05.

Results: Counting bilateral fractures as separate entities, we identified 123 cases spread among 100 patients. The cohort was 73% male and 27% female. Average patient age was 40.1 years old. The youngest patient was 16 years old and the oldest was 75 years old. Fifty-five cases (44.7%) received an implant following orbital floor exploration. In addition to a zygomatic fracture, 79 cases (64.2%) had a concurrent nasoorbitoethmoid fracture; 38 (30.9%) had a concurrent frontal bone fracture; and 64 (52.0%) had a concurrent LeFort I, II, or III fracture. With every 1mm increase in zygomatic displacement in the anterior-posterior direction, patients had 1.14 times higher odds of receiving an orbital implant (OR 1.14, CI (1.01-1.32), p = 0.046). Rectus rounding and orbital floor displacement in the inferior-superior, anterior-posterior, and transverse directions were all similarly significantly associated with implant placement (p < 0.001).

Conclusion: A regression model evaluating zygoma fractures shows that rectus rounding, zygomatic impaction, and orbital floor defect volume were among the strongest indications for orbital floor implant placement.

  References 1. Krasadakis C, Igoumenakis D, Schoinohoriti O, Mourouzis C, Rallis G. The significance of orbital floor exploration during open reduction of zygomaticomaxillary complex fractures. JRPMS. 2017;01(02):45-49. doi:10.22540/JRPMS-01-045 2. Farber SJ, Nguyen DC, Skolnick GB, Woo AS, Patel KB. Current Management of Zygomaticomaxillary Complex Fractures: A Multidisciplinary Survey and Literature Review. Craniomaxillofac Trauma Reconstr. 2016;9(4):313-322. doi:10.1055/s-0036-1592093 3. Flynn J, Lu GN, Kriet JD, Humphrey CD. Trends in Concurrent Orbital Floor Repair During Zygomaticomaxillary Complex Fracture Repair. JAMA Facial Plast Surg. 2019;21(4):341-343. doi:10.1001/jamafacial.2019.0201

PURPOSE: The wide spectrum of malformation in orofacial clefts is associated with various surgical approaches, including single-staged repair, staged repair, or concurrent tip rhinoplasty and/or septoplasty.[1] Previous literature reports 31% of patients undergoing primary cleft lip repair with rhinoplasty and 47% undergoing pre-operative naso-alveolar molding (NAM).[2,3] This study comprehensively examines the national prevalence of cleft lip repair techniques compared to current literature and highlights changes in NAM billing practices over two decades.   METHODS: This retrospective study utilized TriNetX, a national deidentified aggregate database, to evaluate patients under 12 months who underwent unilateral (CPT-40700) or bilateral cleft lip repair (CPT-40701, CPT-40702) from 1/1/2000-11/3/2023. Patients with subsequent cleft lip revisions (CPT-40720) were categorized by initial repair year. Data on NAM use (CPT-21079, CPT-21080, D-5931, D-5932, D-5936) and concurrent tip rhinoplasty/septoplasty (CPT-30460, CPT-30462) were collected through identified dental and procedural billing codes. Patient demographics were analyzed using TriNetX, and logarithmic interpolation analysis was performed with PRISM software.   RESULTS: Among the 5,642 patients who underwent cleft lip repair, 4,405 patients (78%) had a unilateral cleft lip repair and 1,237 (22%) had a bilateral cleft lip repair. Of those patients, 2,699 (48%) had a same-day tip rhinoplasty or septoplasty. Among the bilateral cleft lip repair patients, 1,136 (91%) were billed with a single staged procedure. The database showed 551 (9.7%) patients had a cleft lip revision, and 128 (2.3%) underwent pre-operative NAM devices.   Over the study period, the prevalence of concomitant tip rhinoplasty and/or septoplasty increased from 14% in 2000 to 59% in 2023 (R^2=0.86, P<0.001). The prevalence of cleft lip revisions peaked in 2006 at 33% and declined to 9.8% in 2023 (R^2=0.93, P<0.001).The prevalence of staged operations increased from 0% in 2000 to 17% (n=12) in 2023 (R^2=0.75, P<0.001). The prevalence of NAM was zero in the first 12 years (2000-2011) and increased from 0.1% in 2012 to 2.2% by 2023 (R^2=0.996, P<0.001).   CONCLUSION: More patients are undergoing cleft lip repair with concomitant tip rhinoplasty and/or septoplasty, and fewer patients have required cleft lip revisions, possibly due to improved surgical techniques. The majority of bilateral cleft lip repairs remain single-staged, which may be supported by the increased availability of NAM. Billing inconsistencies may explain why only 2.3% of our patients reported NAM use, despite literature reporting 47%.[2]   [1] Shkoukani MA, Chen M, Vong A. Cleft lip–a comprehensive review. Frontiers in pediatrics 2013: 1: 53. [2] Jazayeri HE, Lopez J, Pourtaheri N, et al. Clinical practice trends and postoperative outcomes in primary cleft rhinoplasty. The Cleft Palate-Craniofacial Journal 2022: 59: 1079-85. [3] Sischo L, Chan JW, Stein M, et al. Nasoalveolar molding: prevalence of cleft centers offering NAM and who seeks it. The Cleft palate-craniofacial journal 2012: 49: 270-75.

Purpose

Both the Pi procedure and posterior vault reconstruction (PVR) are surgical procedures that address sagittal craniosynostosis and aim to increase intracranial volume by differing methods. This study seeks to compare the volumetric differences between the two methods.

Methods

A 3-dimensional analysis was performed of pre and post-operative head computed tomography (CT) scans from patients who underwent PVR and the Pi procedure for treatment of sagittal craniosynostosis at a single institution from 2018 to 2023. Pre and post operative CTs of 18 patients with nonsyndromic single-suture sagittal craniosynostosis were separated by operative technique performed. Both pre and post operative scans were compared to age-sex matched controls. PVR patients were further stratified by those requiring a subsequent bifrontal orbital advancement reconstruction (BFOAR). Cranial index (CI) and intracranial compartment volumes were analyzed utilizing SyngoVia. Paired and unpaired t-tests examined differences between groups.

Results

Ten patients underwent a Pi procedure and 8 patients underwent a PVR. Postoperatively, the Pi procedure demonstrated an increase of mean CI from 70.2 to 77.0 (p = 0.01). However, CI continued to be statistically significantly decreased compared to controls post-operatively (p = 0.007). Mean CI increase amongst PVR patients between surgeries was not significant and this trend continued in those receiving a subsequent BFOAR. When compared to controls post-operatively the PVR mean CI was significantly decreased (p = 0.002). Preoperatively, both Pi and PVR patients had a significantly larger total intracranial volume compared to controls (p = 0.043, p = 0.042, respectively). Postoperatively, the Pi cohort's total intracranial volume remained statistically significantly larger than controls (p = 0.002) but those undergoing PVR alone as well as those undergoing a PVR and a subsequent BFOAR total intracranial volume did not differ significantly compared to controls.

Conclusions

The preliminary results of this study demonstrate that neither procedure corrected cranial index post-operatively. The PVR procedure did not increase intracranial volume significantly compared to controls, thus effectively normalizing it (due to increased intracranial volume preoperatively). The Pi procedure significantly increased the total cranial volume when compared to controls. The distribution of the volume changes between the two techniques is different and warrants continued investigation.

BACKGROUND: We examined differences in long-term morphometric outcomes of spring-assisted expansion for various forms of isolated nonsyndromic sagittal craniosynostosis.

METHODS: A retrospective review was performed of children who underwent spring-assisted expansion from 2011 to 2020 at the Children's Hospital of Philadelphia. Cephalic indices (CI), Whitaker grades, parietal bone thickness, degree of suture fusion were assessed. Frontal bossing and vertex-nasion-opisthocranion (VNO) angles were compared to a normal control group.

RESULTS: Fifty-four subjects underwent surgery at age 3.6±1.0 months with follow-up of 6.3±1.8 years. Mean CI was 75.2±4.1 at 5.9±2.0 years postoperatively. Mean CI were 75.8±4.1 (n=32), 76.4±4.0 (n=22), and 77.1±4.8 (n=11) at 5, 7, and 9+ years postoperatively, respectively. Fifty-one (94.4%) were Whitaker Grade I. On physical examination, 12 (22.2%) demonstrated craniofacial abnormalities. At long-term follow-up, there were no differences in frontal bossing angle (102.7±5.2 degrees versus 100.7±5.6 degrees, p=.052) and VNO angle (44.9±3.3 degrees versus 43.9±2.2 degrees, p=.063) between study and control groups. Younger age at surgery predicted a lower Whitaker grade, more normalized VNO angle, and greater change in CI during active expansion. Increased percentage fused of the posterior sagittal suture predicted a higher Whitaker grade, while decreased anterior fusion was associated with frontal bossing and temporal hollowing. Three (5.6%) required reoperation for persistent scaphocephalic cranial deformity.

CONCLUSIONS: Overall, children undergoing spring-mediated expansion for sagittal craniosynostosis demonstrated maintenance of CI, favorable cosmetic outcomes, and a low reoperation rate at mid-term follow-up. Early intervention is associated with improved aesthetic outcomes, and regional fusion patterns may influence long-term craniofacial dysmorphology.

Introduction Advances in surgical techniques in recent decades have allowed for the development of minimally invasive approaches. The popularity of minimally invasive surgical repair for treatment of craniosynostosis is increasing, yet data regarding morbidity from these procedures compared to traditional open repair techniques is sparse. This study compares the surgical outcomes, as well as blood transfusion and opioid requirements of open versus minimally invasive single suture craniosynostosis procedures.

Methods We conducted a retrospective chart review of patients at our institution with a diagnosis of craniosynostosis who underwent surgical repair from 2007-2023. Patients with multi-suture synostosis were excluded from the study. Those meeting inclusion criteria were assessed for the following: 1) type of synostosis, 2) surgical repair characteristics (repair technique, operative time), 3) intraoperative/postoperative complications, blood transfusions, and opioid administration, and 4) length of stay. Demographic information was also recorded. Pearson's chi squared test was used to test for differences in complications between repair methods, and independent t-tests used to assess for differences in blood transfusion volumes and opioid administration.

Results A total 317 patients were included in our analysis. Sagittal suture synostosis was the most frequently encountered (66.9%), followed by metopic (17%), coronal (14.5%), and lambdoid (1.6%). Only 32.2% of patients underwent repair with minimally invasive techniques (endoscopic or limited incision), with 52.9% of these occurring from 2017-2023. The average age of patients undergoing minimally invasive repair was 3.6 months, whereas those who underwent open repair averaged 9.7 months (p < 0.01). Operative time was significantly shorter for minimally invasive repairs (186 minutes) than for open repair (309 minutes) (p < 0.01). The most common complication observed among all patients was incidental dural laceration (n = 25). Patients who underwent minimally invasive repair were significantly less likely to suffer from a cerebrospinal fluid leak postoperatively compared to patients who underwent open repair (p < 0.05). No statistically significant differences in the rate of hematoma, postoperative bleeding, infection, wound dehiscence, or increased intracranial pressure were observed. Total blood transfusion volume per kilogram of body weight was significantly higher for patients treated with open repair (20 mL/kg) than minimally invasive (7 mL/kg) (p < 0.05). Postoperative opioid administration within two days postoperatively averaged 10.8 mg of oral morphine equivalent (OME) for patients who underwent open repair and 4.6 mg OME for patients treated with minimally invasive techniques (p < 0.05). When corrected for body weight, patients who underwent open repair were administered nearly 70% more opioids per kilogram postoperatively (p < 0.01). Length of stay was also longer for patients who were treated with open repair (3.5 days) than patients who underwent minimally invasive correction (1.9 days) (p < 0.01).

Conclusion This study demonstrates that the use of minimally invasive repair procedures in patients with single-suture craniosynostosis may result in less morbidity and fewer complications than traditional open repair techniques. As the frequency of early screening and diagnosis of craniofacial abnormalities rises, physicians have increasing opportunities to intervene with a less morbid surgical technique.

Background: Utilizing biological scaffolds for cartilage tissue engineering is a promising tool for improving auricular reconstruction. Decellularized auricular scaffolds provide a means of regenerating cartilage in vitro for in vivo implantation, but the identification of the ideal regenerative mix remains a challenge. The purpose of this study was to identify the best regenerative mix for inducing chondrogenesis by evaluating decellularized human auricular cartilage seeded with auricular chondrocytes in the presence of adipose-derived stem cells with and without platelet-rich plasma.

Methods: Human cadaver auricular cartilage was decellularized. Biopsy punches of this tissue were recellularized with either auricular chondrocytes alone, auricular chondrocytes with adipose-derived stem cells, or both cells with platelet-rich plasma. Confirmation of decellularization and recellularization was done by hematoxylin and eosin staining. Extracellular matrix preservation and production were determined by Masson's Trichrome, Alcian blue, and Verhoeff-van Gieson staining. Collagen II assessments were made using immunohistochemistry. All sections were mounted and imaged at a magnification level of 4×. Five images per section were obtained to make collagen II quantifications using ImageJ. Unpaired, two-tailed t-tests were performed to evaluate statistical differences between groups.

Results: Decellularization of cadaver auricular cartilage was successful by the absence of cells, reduction in glycosaminoglycans, and the preservation of collagen and elastin. Recellularization was more efficient when chondrocytes were seeded with adipose-derived stem cells, and this was further enhanced with the addition of platelet-rich plasma. The co-culture with platelet-rich plasma yielded better collagen and glycosaminoglycan induction. Moreover, when platelet-rich plasma was added, collagen II induction was significantly increased (p<0.05).

Conclusion: We identified a regenerative mix that included auricular chondrocytes, adipose-derived stem cells, and platelet-rich plasma, which stimulated chondrogenesis on decellularized auricular cartilage. This finding provides a model that can be further explored in vivo to assess the formation of cartilage. The scaffold and regenerative mix hold the potential for developing novel auricular reconstruction techniques.

Purpose: The debate continues among craniofacial surgeons regarding the effectiveness of strip craniectomy (SC) compared with cranial vault remodeling (CVR) in achieving functional and aesthetic outcomes in patients with single-suture craniosynostosis. This study aimed to compare long-term patient-reported outcomes (PROs) between SC and CVR/FOA (fronto-orbital advancement) procedures at a single institution using the validated FACE-Q Craniofacial Module.

Methods: Patients ages ≥8 years of age and parents of patients <8 years of age who underwent SC or CVR/FOA for single-suture craniosynostosis were eligible. Patients with <2 years of follow up, lambdoid synostosis, and syndromes were excluded. Primary endpoints were PROs as measured by the FACE-Q, with higher scores indicating increased health-related quality of life. Linear regression was used to control for covariates.

Results: Sixty-two participants completed the module (response rate 33.3%). SC was performed in 29 patients (46.8%) and CVR/FOA in 33 patients (53.2%). On bivariate analysis, SC patients had higher Eye (p=0.03) and Forehead (p=0.05) scores. On regression analysis, there was no significant difference in PROs between operation type. Both metopic and sagittal synostosis were associated with higher Eye (metopic: 17.61, p=0.049; sagittal: 41.44, p<0.001) and Head scores (metopic 48.12, p=0.001; sagittal 49.35, p<0.001) compared with unicoronal, and sagittal synostosis was associated with higher FACE (38.16, p<0.001), Forehead (55.93, p<0.001), and Nose scores (19.28, p=0.003).

Conclusions: From patients' and parents' perspectives at a single institution, SC and CVR/FOA were equivalent regarding aesthetics and health-related quality of life.

Background: The management of advanced head and neck cancers has undergone a partial paradigm shift with the emerging role of neoadjuvant chemotherapy. The aim of this study was to evaluate the surgical outcomes of microsurgical reconstruction in head and neck cancer patients who underwent neoadjuvant chemotherapy. Methods: This retrospective cohort study reviewed patients who underwent head and neck microsurgical reconstruction from January 2014 to August 2022. Patients with prior history of chemotherapy were included and categorized into two groups: preoperative neoadjuvant chemotherapy (A group) and postoperative adjuvant chemotherapy (B group). A 1:1 propensity score-matched analysis was performed to evaluate flap survival, microsurgical revision rates, and complications. Results: The study cohort included 53 patients in the A group and 265 patients in the B group. After propensity score matching, the A group had significantly higher rates of flap loss (Odds ratio, [OR] 3.98; 95%CI, 1.08-15.18; p=0.031), wound-related complications (OR 4.30; 95%CI, 1.31-8.02; p=0.036), and microsurgical revision rates (OR 4.73; 95%CI, 2.10-10.64; p=0.02). Conclusion: Preoperative neoadjuvant chemotherapy for advanced head and neck cancers can have deleterious effects on wound healing and flap outcome during subsequent microsurgical reconstruction. Surgeons should exercise caution in patient selection for this approach.

Purpose: Craniosynostosis extends beyond aesthetic concerns, significantly influencing neurocognitive development. Children affected by this condition often face difficulties in several areas including academic achievement, motor skills, language development, and social interactions. Presently, there is a lack of universally employed standardized methodology for evaluating neurocognitive outcomes in these children. This research intends to explore the various neurocognitive assessment tools employed in the study of craniosynostosis, with the goal of identifying, comparing, and synthesizing these instruments to enhance understanding and evaluation of neurocognitive impacts.

Methods: A comprehensive systematic review was carried out, examining research related to neurocognitive assessments within the context of craniosynostosis. This review encompassed studies involving individuals of any age group and included all variations of the condition-whether syndromic or non-syndromic, and regardless of the affected suture(s), covering both single and multi-suture craniosynostosis cases. Data pertaining to a range of neurocognitive developmental indicators were collected using a standardized template. Data was then evaluated by a trained neuropsychologist, who classified them and analyzed the most effective practices for their use.

Results: Our review encompassed 134 studies, published from 1981 to 2023. The age range of patients evaluated spanned from as young as one month to as old as 50 years at the time of their assessment. Across these studies, 117 distinct tests were referenced for the neurocognitive evaluation of patients with craniosynostosis, with 73 of these assessments mentioned only in a single publication. The Bayley Scales of Infant Development (BSID) emerged as the most frequently used test, appearing in 40 (33.9%) of the studies. The BSID was administered to patients ranging from 1.5 to 43 months in age. Following the BSID in prevalence was the Wechsler Intelligence Scale for Children (WISC), which targeted an older demographic, being applied to patients aged 6 to 16 years and referenced in 37 (31.4%) of the papers.

Our analysis revealed six critical domains of neurocognitive development pertinent to the evaluation of craniosynostosis patients: Development/Intelligence, ADHD/Attention, Social-Emotional/Behavioral, Adaptive Functioning, Autism Spectrum Disorders, and Academic Achievement. Out of the 117 tests referenced across the studies we reviewed, 56 were classified under these six categories. For each domain, we identified the "gold standard" tests, distinguishing between those that are screening scales and comprehensive assessments, which require more time and expertise. Furthermore, we also highlight additional questionnaires that, although not encountered in our literature review, are recognized as gold standard instruments within the neuropsychological community for these specific areas.

Conclusion: The critical role of integrating neurocognitive evaluations into craniosynostosis management cannot be emphasized enough. Our responsibility extends beyond achieving aesthetic corrections to encompassing a holistic view of the patient's functional outcomes. Choosing the right neurocognitive assessment tools is crucial, as these instruments play a significant role in screening patients, monitoring progress, and determining the success of treatments. This systematic review lays the groundwork for developing a standardized and efficient strategy for assessing and addressing the neurocognitive impacts of craniosynostosis. By doing so, we aim to improve patient care and optimize treatment results.

BACKGROUND: Orofacial clefts (OFC) are a spectrum of congenital facial differences including clefts of the lip and palate, which impact 1 in 700 infants. It is widely accepted that OFC is the result of interplay between genetic and environmental factors; however, little is known about the specific environmental contaminants that contribute to their development. The aim of this review is to create a catalog of known contaminants that are associated with OFC to better understand which contaminants lead to OFC.

METHODS: Preferred Reporting Item for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to conduct a systematic review. A search was conducted of the following databases from database inception to January 3, 2024: PubMed, Embase.com (Elsevier), Web of Science Core Collection (Clarivate) multi-file search of Science Citation Index-Expanded and Emerging Sources Citation Index, and Agricultural & Environmental Science Collection (Proquest) multi-file search of Environmental Science Index, TOXLINE, Environmental Science Database, AGRICOLA, and Agriculture Science Database. Select study and demographic characteristics were extracted and analyzed.

RESULTS: Literature search yielded 2,450 results, of which 70 were included for analysis. Included studies were published between 1982 and 2023. Case-control studies accounted for 54% of studies followed by retrospective designs at 17%, cross sectional studies at 10% and the remaining 19% a combination of ecological, prospective, and other. Included studies represent 20 different countries including China, Japan, Taiwan, Indonesia, India, France, Italy, Sweden, Denmark, Germany, Norway, Iran, South Africa, Mexico, Mongolia, Australia, Netherlands, the UK, Finland and the USA. When applied, race/ethnicity stratification was predominantly by Non-Hispanic white, Non-Hispanic Black, Hispanic and other or Han and Non-Han ethnicity. The majority of mothers fell between 20 to 34 years of age. Nearly all studies chose 1 month preconception through the first trimester as the study timeframe. Approximately 50% of studies evaluated and noted associations with multiple defects in addition to OFC including neural tube defects and cardiac anomalies. Risk of OFC was described with odds ratios (OR) in 80% of included studies.

Over 115 environmental contaminants associated with OFC were identified. Major water contaminants related to OFC include trihalomethanes and haloacetic acids from water disinfection byproducts, elements and metals, such as lead, and nitrates. Key air pollutants leading to OFC are particulate matter (PM) less than 10 um and PM2.5 um, nitrogen dioxide, carbon monoxide, and sulfur dioxide. Exposure to glycol ethers and organic solvents in an occupational setting also demonstrate increased risk of OFC. Additionally, heavy metals and elements such as arsenic, lead, mercury, rubidium, strontium, and Molybdenum have also been implicated in OFC development. Some contaminants may inhibit Hedgehog (Hh) signaling, a critical mediator of growth and differentiation during embryogenesis. Furthermore, contaminants such as dioxins are hypothesized to impact growth factor expression and interact with retinoic acid and glucocorticoid pathways leading to OFC.

CONCLUSION: Environmental contaminants associated with OFC are diverse, present globally, and utilize several modes of transmission. This systematic review provides a comprehensive list of contaminants that can be utilized for future research efforts, including understanding mechanisms leading to OFC.