Scientific Abstract Presentations: Craniomaxillofacial Session 4 Thursday, September 26 Thu, Sep 26 5:00-6:00 p.m. PDT

Background & Purpose: Anterior palatal reconstruction using vomer flaps has been described at the time of primary cleft lip repair. In this procedure, the mucoperiosteal tissue of the vomer is elevated to reconstruct the nasal mucosa overlying the cleft of the hard palate. Here we evaluate the efficacy of a technique in which a superiorly-based vomer flap is sutured to the lateral nasal mucosa. We assess vomer flap dehiscence rates and compare the likelihood of fistula development in this cohort to patients who underwent palatoplasty without vomer flap reconstruction.

Methods: A retrospective chart review was conducted of all palatoplasties performed by the senior author at an academic institution during a seven-year period. Medical records were reviewed for demographic variables, operative characteristics, and postoperative complications up to one year following surgery. Logistic regression analysis was conducted to assess the effects of vomer flap reconstruction on fistula formation, adjusting for age and sex.

Results: Fifty-eight (N=58) patients met inclusion criteria. Of these, 38 patients (control group) underwent cleft palate reconstruction without previous vomer flap placement. The remaining 20 patients underwent either unilateral or bilateral cleft lip repair with vomer flap reconstruction prior to palatoplasty (vomer flap group). When bilateral cases were counted independently, 25 vomer flap reconstructions were performed in total. Seventeen of these 25 vomer flap reconstructions (68%) completely dehisced by the time of cleft palate repair.

In the vomer flap group, three of the 20 patients (15%) developed fistulas in the anterior hard palate following the subsequent palatoplasty procedure. In the control group, only one of the 38 patients (2.6%) developed a fistula in the anterior hard palate. There was no significant association between cohorts and the development of anterior hard palate fistulas [OR = 10.88, 95% CI (0.99–297.77) p = 0.07], although analysis was limited by low statistical power due to small sample size.

Conclusions: In our patient population, anterior palatal reconstruction using a superiorly-based vomer flap technique was associated with complete dehiscence in 68% of cases. Fistula formation in the anterior hard palate was also proportionately higher following initial vomer flap reconstruction (15% vs 2.6%). These results prompted the senior author to adjust his surgical technique to one in which the vomer flap is overlapped with the oral mucosa. While follow-up from these adjusted vomer flap reconstruction cases remains ongoing, early evidence suggests a reduced requirement for surgical revision following implementation of the modified technique.

Introduction: The long-term effects of the modified-Furlow palatoplasty on patients with bilateral cleft lip and palate (BCLP) are unknown. We aim to report the clinical outcomes of skeletally mature patients with BCLP who underwent a modifed Furlow palatoplasty in infancy.

Methods: We retrospectively reviewed all patients with BCLP who underwent modified Furlow palatoplasty between 2000 and 2006 who were followed to skeletal maturity and had a lateral cephalogram. The total burden of cleft surgeries and cephalometric measurements were compared to external cohorts who underwent straight-line palatoplasty with intravelar-veloplasty.

Results: Twenty-four patients with BCLP were included with an average follow-up of 18.8 ± 2.0 years. Six patients (20.7%) underwent presurgical orthopedics, 16 patients (55.1%) underwent a single-stage lip repair (mean ± standard deviation, 4.0 ± 1.5 months), all patients underwent modified-Furlow palatoplasty (10.7 ± 0.9 months), and all patients underwent alveolar bone grafting (7.5 ± 1.0 years). Three patients (10.3%) required speech surgery and thirteen patients (54.2%) underwent orthognathic surgery. On lateral cephalograms taken at mean age 15.3 ± 2.1 years, we found greater midfacial growth compared to an external cohort at sella-nasion-A-point angle (SNA) (78 ± 5 degrees versus 73 ± 5 degrees, p=0.009). There was no difference at sella-nasion-B-point angle (SNB) (79 ± 7 degrees versus 76 ± 5 degrees, p = 0.254) or ANB angle (SNA − SNB) was (-1 ± 5 degrees versus -3 ± 4 degrees, p = 0.101).

Conclusion: Patients with BCLP who underwent modified Furlow palatoplasty had improved midfacial growth outcomes at skeletal maturity compared with an external cohort of patients who underwent straight-line palatoplasty in infancy.

PURPOSE Facial transplantation serves as a "life-giving" reconstructive option for patients impacted by the most severe facial traumas. Despite the procedure's capacity for dramatically improving facial form and function, patients experience significant degrees of facial ptosis post-operatively that can impede facial functionality, necessitating multiple secondary revision surgeries. Especially as a significant majority of the face transplant cohort ages into their second decade of life post-transplantation, the extent of this facial ptosis and its evolution over time has not been described. In this study we seek to not only provide a quantitative assessment of facial ptosis following face transplantation but also provide a characterization of the facial regions most egregiously impacted.

METHODS Several anthropometric facial landmarks both novel and previously reported in the literature were utilized to create angular and ratio-based metrics to evaluate facial ptosis prone regions.¹ ² These measurements were executed utilizing ImageJ, an open-source Java-based processing program. A total of nine face transplant patients- the largest single-center cohort in the world- were included for analysis utilizing 2D headshot photos at two time points: approximately one year post-transplant and most recent follow-up photo available. Changes in facial ptosis metrics were evaluated with Wilcoxon Signed-Rank Test.

RESULTS Patient post-operative time points between facial ptosis measurements ranged from 3-11 years. The following metrics all demonstrated statistically significant changes between the most recent follow-up time point and approximately one-year post-transplant: left lateral canthus-oral-nasal angle (median difference -1.234°, p=0.0391), right lateral canthus-oral-nasal angle (-6.323°, p=0.0391), bigonial-bizygomatic ratio (+0.01814, p=0.0391), and ergotrid length-upper lip inferior border ratio (+0.05427, p=0.0117). Additionally, eyebrow peak angle demonstrated trending decreases (left= -4.064°, right= -3.302°).

CONCLUSIONS: This study provides the first quantification of facial ptosis metrics for facial transplantation patients. The noted decreases in bilateral canthus-oral-nasal angle between the two timepoints highlights the ptosis of the oral commissures in the facial allograft while the increasing bigonial-bizygomatic ratio and ergotrid length-upper lip inferior border ratios demonstrates increased lower cheek/jowl ptosis and ergotrid lengthening. Collectively these results highlight that ptosis in the lower parts of the face surrounding the oral commissure may predominate in this patient population providing surgical insight into the facial regional anatomy that should be closely monitored and targeted for revision operations.

1. Leem S, Gu KN, Kim Y, Jeong E, Lim JM, Kang NG. Two newly developed indices evaluating facial skin aging. J Cosmet Dermatol. Oct 2022;21(10):5203-5207. doi:10.1111/jocd.15034

2. Tsai LC, Lin ET, Chang CC, et al. Quantitative and objective measurements of facial aging process with anatomical landmarks. J Cosmet Dermatol. Mar 2022;21(3):1317-1320. doi:10.1111/jocd.14221

Background: Recent studies have investigated the growing trend of electric scooter (e-scooter) related injuries [1,2]. The current literature describes primary injuries from single or regional institutions [3,4], with similar reports from national databases [5]. Given that e-scooter trauma patients often suffer multiple injuries, we assessed the prevalence and risk factors for combinatorial injury patterns following e-scooter traumas. We sought to provide evidence for local government and e-scooter companies to improve safety policies.

Methods: The data for this study was obtained from the National Electronic Injury Surveillance System (NEISS), which provides national estimates of injuries presented to emergency departments across the United States. In 2019, the NEISS had its first major update to include new variables, including multiple body parts, multiple injury types, alcohol use, and drug use. We queried the NEISS for year 2019 (most recent data available) using product code 5042 ("Scooter/skateboards, powered") and subsequently used key search terms for the exclusion of non-electric scooter injuries. National estimates were created using weights provided by the NEISS. Patient demographics, body part, diagnosis, and disposition were reported. Multivariable logistic regression was performed to identify independent predictors of concomitant injuries. SAS/STAT software was used for data analysis with significance threshold set at an alpha value of 0.05.

Results: In 2019, there were an estimated 31,193 (n=840, unweighted) patients with e-scooter injuries in the United States. Of these, 48.2% (n=405) presented with secondary body part involvement. The most common injured, primary body part was the head (16.8%), with the face (17.8%) reported as the most common secondary site of injury. Fracture (27.5%) was the most common primary diagnosis while contusions/abrasions (33.8%) was the most common secondary diagnosis. Among patients with concomitant body part injuries, the most prevalent primary/secondary injury patterns included head/face (7.9%), head/head (4.9%), face/face (3.95%), face/knee (1.98%), and face/mouth (1.98%). Alcohol use (AOR 0.372; 95% CI 0.210-0.661; p=0.0007) and other race (AOR 0.214; 95% CI 0.059-0.772; p=0.0153) were protective for injury to multiple body parts. Male sex was protective for both primary fracture (AOR 0.651; 95% CI 0.465-0.912; p=0.0125) and upper extremity injury (AOR 0.614; 95% CI 0.445-0.847; p=0.003) but was not predictive for head and neck injury. Patient age was not predictive for primary fracture, head/neck injury, and upper or lower extremity injuries. Overall, 11.1% of all patients were admitted/hospitalized.

Conclusions: We have shown that e-scooter trauma patients most commonly experience injury of the head or face, regardless of sex and age differences. This suggests that all e-scooter riders may benefit from mandated helmet use. Further, these results will serve as a baseline for guiding clinical suspicion for the treatment of e-scooter patients. Our work assumes the need for accurate inpatient coding of e-scooter injuries to assess surgical treatment algorithms and outcomes within this population.

References

1 Namiri,N.K.etal.Electric Scooter Injuries and Hospital Admissions in the United States,2014-2018.JAMA Surg155,357-359(2020). https://doi.org:10.1001/jamasurg.2019.5423 2 Cohen,L.L.,Geller,J.S.,Yang,B.W.,Allegra,P.R.&Dodds,S.D.Pediatric injuriesrelatedtoelectricscooteruse:a nationaldatabasereview.JPediatrOrthopB31,e241-e245(2022). https://doi.org:10.1097/bpb.0000000000000879 3 Kobayashi,L.M.et al.Thee-merginge-pidemicofe-scooters.TraumaSurgAcuteCareOpen4,e000337(2019). https://doi.org:10.1136/tsaco-2019-000337 4 Osti,N.et al.E-scooterandE-bikeinjurypatternprofileinaninner-citytraumacenterinupper Manhattan.Injury54,1392-1395(2023). https://doi.org:10.1016/j.injury.2023.02.054 5 LaGreca,M.,Didzbalis,C.J.,Oleck,N.C.,Weisberger,J.S.& Ayyala,H.S.IncreasingIncidenceofHandandDistal UpperExtremityInjuriesAssociatedWithElectricScooterUse.JHandSurgAm47,478.e471-478.e477(2022). https://doi.org:10.1016/j.jhsa.2021.05.021

Background and purpose: The literature exploring diversity, equity, and inclusion (DEI) within craniofacial surgery collectively illuminates the historical challenges faced by women and underrepresented minorities. Across numerous studies, gender disparities persist as a prominent and recurrent theme, with women consistently underrepresented in the number of craniofacial surgeons, faculty positions, leadership roles, and representation at conferences.1-3 This is despite substantial progress in female representation within plastic surgery and the broader medical landscape. Academic productivity, often measured through publication records, emerges as a critical determinant influencing career advancement. Multiple studies have highlighted that female plastic surgeons tend to have fewer publications compared to their male counterparts4 with the same theme seen in burn surgery, aesthetic surgery, and hand surgery. Furthermore, analyses of craniofacial fellowship programs reveal disparities in gender and ethnic composition, although younger cohorts show a more equitable distribution of leadership roles among genders signifying some progress in DEI within craniofacial surgery.5 This study benchmarks the academic productivity of craniofacial surgeons in 2022 and surveys their perspectives regarding diversity, equity, and inclusion (DEI). Methods: Total, first author, and senior author PubMed publications in 2022 were recorded for 193 craniofacial attendings and fellows. Craniofacial surgeons were also surveyed regarding academic experience, leadership roles, and DEI perceptions. Results: For analysis of the academic craniofacial cohort in 2022, women comprised 27% (n=53). Males led total publications (81% vs 19%, p<0.001), senior-author publications (84% vs 16%, p<0.001), average total publications (6.6 vs 4.0, p=0.043), and average senior-author publications (3.1 vs 1.5, p=0.02). Sub-analysis of craniofacial fellows showed a higher proportion of women (65%) with no statistical difference in total or average publication counts. Survey responses (n=26) included a perceived lack of female representation in academic and leadership roles. Barriers included inadequate support from current leadership, systemic issues, and biases. Recommendations for improvement included mentorship programs, targeted recruitment, and equitable conference speaker selection. Conclusion: The landscape of DEI within craniofacial surgery is characterized by multifaceted challenges and evolving dynamics. This study revealed that while gender disparities still exist, they are accompanied by signs of progress, with younger craniofacial surgeons exhibiting more balanced publication records and leadership positions. Further studies are needed to examine these cohorts more comprehensively and longitudinally. DEI remains an ongoing journey, and tangible steps that can be implemented include mentorship programs tailored to women and underrepresented minorities, increased recruitment efforts, enhanced DEI education, and equitable representation of women in conference speakers. This study highlights both challenges and promising developments, paving the way for a more inclusive craniofacial surgery community.

References: 1. Rivera JC, Haus SC, Juan HY, et al. Assessment of Sex Diversity Among Craniofacial Academic Faculty. The Journal of craniofacial surgery. 2023;34(1):202-205. doi:10.1097/SCS.0000000000009109 2. Blum JD, Cho DY, Villavisanis, DF, et al. Update: Diversity and Practice Patterns of International Craniomaxillofacial Surgeons. The Journal of craniofacial surgery. 2022;33(6):1659-1663. doi:10.1097/SCS.00000000000084866. 3. Reghunathan M, Parmeshwar N, Gallus KM, Gosman AA. Diversity in Plastic Surgery: Trends in Female Representation at Plastic Surgery Meetings. Ann Plast Surg. 2020;84. doi:10.1097/SAP.0000000000002209 4. Silvestre J, Wu L, Lin I, Serletti J. Gender Authorship Trends of Plastic Surgery Research in the United States. Plastic and reconstructive surgery (1963). 2016;138(1):136e-142e. doi:10.1097/PRS.0000000000002308 5. Lala BM, Salvador TM, Wang F, Shah J, Ricci JA. Gender Disparities Among Craniofacial Surgeons. The Cleft palate-craniofacial journal. 2023;60(8): 1002-1009. doi:10.1177/10556656221089828

Introduction Parents of children with rare conditions may use social media to better understand and care for their children (1). Thus, a comprehensive understanding of the shared online experiences of parents and patients with conditions like craniosynostosis is warranted. Analysis of these shared media posts may provide insights into care outcomes and satisfaction (2). This study intends to investigate patient and caregiver experiences with craniosynostosis via social media.

Methods Instagram and TikTok posts featuring "#craniosynostosis" were systematically analyzed. Data were extracted from 350 Instagram and 350 TikTok posts directly sharing insights into the patient journey with craniosynostosis. Three reviewers subsequently examined, classified, and verified these contributions according to the predominant themes reflecting the lived experiences of those affected by craniosynostosis.

Results The most commonly identified themes included "Raising Awareness" (556, 79%), "Spreading Positivity" (470, 67%), "Trauma/Resilience" (430, 61%), "Hopes/Anniversaries" (367, 52%), "Quality of Life" (352, 50%), "Family Dynamics" (284, 41%), "Anxiety/Fear" (280, 40%), "Impact on Parental Mental Health" (263, 38%), "Early Detection/Diagnosis" (230, 33%), and "Decision-Making" (224, 32%). Other notable themes included "Developmental Milestones" (183, 26%), "Appearance Concerns" (164, 23%), "Transitioning Home After Hospitalization" (116, 17%), and "Scientific Explanations" (93, 13%).

TikTok videos encompassed more themes (p=0.047) than Instagram posts. TikTok posts more likely (p<0.001) regarded raising awareness, spreading positivity, trauma/resiliency, hopes/anniversaries, quality of life, family dynamics, anxiety/fear, impact on parental mental health, early detection/diagnosis, and decision-making. Instagram posts more likely surrounded developmental milestones (p<0.001), multidisciplinary care teams (p=0.038), emotional support (p<0.001), stigma (p=0.038), education/advocacy (p<0.001), and hydrocephalus/ICP concern (p<0.001).

Generally, both male and patient accounts were limited. However, females more likely (p<0.001) posted compared to males, and caregivers more likely (p<0.001) posted than patients. Male patients more likely (p<0.001) posted than female patients, while female caregivers more likely (p<0.001) posted than male caregivers. Patients more likely (p<0.001) used TikTok, while caregivers more likely (p<0.001) used Instagram. Patients more likely posted regarding spreading positivity (p=0.026), quality of life (p=0.021), appearance concerns (p<0.001), quality staff (p=0.043), stigma (p=0.008), peer relationships/social integration (p<0.001), psychological impact/support services (p=0.008), using humor (p<0.001), etiology/causes (p<0.001), and transitioning to adulthood (p<0.001). Caregivers more likely posted regarding impacts on parental mental health (p=0.029).

Conclusion Online content analysis revealed that social media may serve as an avenue to seek support, share experiences, and celebrate milestones like "cranioversaries." Coping and concerns about appearance or development were common. Male caregiver perspectives were underrepresented, and TikTok may emerge as a platform to hear experiences directly from patients. Social media generally may serve physicians to gain insights into experiences with craniosynostosis, disseminate accurate information, and connect with patients.

References 1. Nicholl H, Tracey C, Begley T, King C, Lynch AM. Internet Use by Parents of Children With Rare Conditions: Findings From a Study on Parents' Web Information Needs. J Med Internet Res. 2017;19(2):e51. Published 2017 Feb 28. doi:10.2196/jmir.5834

2. Timberlake AT, Wu RT, Cabrejo R, Gabrick K, Persing JA. Harnessing Social Media to Advance Research in Plastic Surgery. Plast Reconstr Surg. 2018;142(4):1094-1100. doi:10.1097/PRS.0000000000004811

Purpose: Previous studies have characterized individual sociodemographic factors affecting care adherence and operative rates; however, there is limited data on how neighborhood-level disadvantage may affect surgical outcomes in patients with cleft palate. The area deprivation index (ADI) and the childhood opportunity index (COI) are novel measures of disadvantage, incorporating several US census indicators of poverty, education, housing, and income. Our study aims to elucidate whether neighborhood disadvantage, measured via ADI and COI, is associated with intervention outcomes and follow-up adherence in patients with cleft palates.

Methods: Pediatric patients with cleft palate who received repair, revision, and fistula repair procedures between 2013-2023 were included. Patients with a traumatic cleft, previously adopted, and 18 years of age or older were excluded. State ADI and COI scores, represented as quintiles, were determined based on zip codes or addresses. We collected basic demographic and clinical variables including opioid and antibiotic prescriptions at discharge, complications, ED return, PICU, and hospital readmissions within 30 days of discharge. Furthermore, postoperative follow-up adherence variables include no-shows, cancellations (patients and administrative), significant delay in follow-up (more than 2-year delay) and lost to follow-up. Univariable logistic regressions were used to assess the association of ADI and COI with binary variables and Spearman-ranked correlations were utilized to assess continuous variables.

Results: A total of 244 patients (138 Male) were included and had Veau classification breakdown of 25 Veau I, 73 II, 67 III, 38 IV, and 41 submucous. Our results reveal significant delays in follow-up in both high disadvantaged ADI (OR1.265, 95%CI [1.052–1.523]; p=0.013) and COI (OR1.263, 95%CI [1.017–1.567]; p=0.034) groups. In palate repair procedures, higher disadvantaged ADI quintiles revealed significant associations with greater total number of no-shows (rs(162)=0.200 [95%CI 0.043–0.348]; p=0.011), patient cancellations at 30 days post-op (OR1.400, 95%CI [1.056–1.858]; p=0.020), total number of patient cancellations (rs(162)=0.157 [95%CI -0.002–0.308]; p=0.047), and total number of overall cancellations (rs(162)=0.171 [95%CI 0.012–0.321]; p=0.030). Meanwhile, higher disadvantaged COI quintiles revealed significant associations with greater rates of no-shows at 60 days post-op (OR1.952, 95%CI [1.130–3.372]; p=0.016), and total number of no-shows (rs(162)=0.159 95%CI [0.001–0.310]; p=0.043). In palate revision surgeries, higher disadvantaged ADI quintiles were significantly associated with higher post-op complication rates (OR1.875, 95%CI [1.200–2.931]; p=0.006) and post-operative fistula rates (OR1.900, 95%CI [1.055–3.424] p=0.033), while higher disadvantaged COI quintiles were significantly associated with higher rates of hospital readmission (OR5.297, 95%CI [1.417 – 19.796]; p=0.013) and greater administrative cancellations at 30 days post-op (OR1.602, 95%CI [1.005–2.554]; p=0.048). In oronasal fistula repair procedures, higher disadvantaged COI quintiles showed significant negative associations with opioid prescriptions at discharge (OR0.524, 95%CI [0.276–0.994] p=0.048).

Conclusions: Our results showcased that neighborhood deprivation, as indexed by ADI and COI, had many significant associations to measured outcomes and follow-up adherence rates in cleft palate procedures. Understanding how neighborhood disadvantage impacts cleft repair outcomes is crucial to clinical care, policy making, and tackling health disparities for our patients. Future analyses will explore how ADI and COI intersects with demographic characteristics such as race, sex, age, insurance and their impact on management outcomes and follow-up adherence.

PURPOSE: Pediatric facial fractures place significant physical, psychological, and financial burdens on both the patients and their families. These injuries require prompt and specialized care, often prompting transfers from local facilities to tertiary centers or a children's hospital ED staffed with pediatric providers. Literature reports that approximately 40% of children moved to specialized pediatric hospitals were either immediately released post-transfer or admitted for less than a day, indicating a set of transfers that might have been unnecessary or avoidable [1]. These potentially avoidable transfers (PAT) to alternative facilities may exacerbate the treatment process, leading to prolonged and expensive care [2][3]. There remains a gap in the literature regarding the predictors linked to a higher likelihood of PAT. Our study aims to elucidate the provider and facility characteristics associated with PAT and estimate the subsequent costs borne by the patients.

METHODS: We conducted a retrospective chart review for pediatric patients who presented to a University of Pittsburgh Medical Center-affiliated (UPMC) ED with facial fractures and were subsequently transferred to the Children's Hospital of Pittsburgh (CHP) ED between 2006 and 2021. The primary outcome examined was a PAT, defined as a patient with a length of stay less than one day, with no admission, surgery, or emergent procedure performed post-transfer. Provider credentials, pediatric training, and pre-transfer facility type were assessed by multivariate logistic regression and odds ratio analyses. Pre-transfer costs, including ED imaging and transportation costs, were estimated based on the UPMC Charge Description Master file and Department of Human Services Pennsylvania ambulance fees published in 2023.

RESULTS: Of the 175 identified patients who met the inclusion criteria, 73 had accessible electronic medical records available and 37 were PAT. Characteristics significantly associated with PATs include provider credentials (p = 0.013) and the initial presenting facility type (p = 0.024). An increased odds of initiating a PAT is observed in patients who initially presented to Advanced Practice Providers (APPs), including Nurse Practitioners and Physician Assistants, compared to those who presented to MD/DOs (OR = 3.17, 95% CI [1.17, 8.54]). Additionally, there is a significant difference in the likelihood of PAT when initially presenting to trauma center EDs compared to non-trauma center EDs (p = 0.024). The total estimated cost per PAT patient, which included expenses for imaging and transportation, amounted to $6,332.11, where imaging expenses accounted for $5,844.66 (92.3% of total cost) and transportation costs amounted to $487.45 (7.7%).

CONCLUSIONS: Facial fractures in pediatric patients necessitate prompt and specialized medical care; however, emergent transfer is often avoidable. Our findings highlight the significance of provider and facility characteristics associated with PATs, offering potential avenues for reducing unnecessary transfers. We found that PATs are associated with initial presentation to APPs, as well as to non-trauma center hospital EDs. These insights provide valuable guidance on possible strategies to reduce PAT, such as additional provider training and targeted site interventions, to minimize patient expenses and avoid unnecessary utilization of specialized hospital resources.

REFERENCES: 1. Mohr, N. M., Harland, K. K., Shane, D. M., Miller, S. L., & Torner, J. C. (2016). Potentially Avoidable Pediatric Interfacility Transfer Is a Costly Burden for Rural Families: A Cohort Study. Acad Emerg Med, 23(8), 885-894. doi:10.1111/acem.12972 2. Gattu, R. K., De Fee, A. S., Lichenstein, R., & Teshome, G. (2017). Consideration of Cost of Care in Pediatric Emergency Transfer-An Opportunity for Improvement. Pediatr Emerg Care, 33(5), 334-338. doi:10.1097/pec.0000000000000805 3. Drolet, B. C., Tandon, V. J., Ha, A. Y., Guo, Y., Phillips, B. Z., Akelman, E., & Schmidt, S. T. (2016). Unnecessary Emergency Transfers for Evaluation by a Plastic Surgeon: A Burden to Patients and the Health Care System. Plast Reconstr Surg, 137(6), 1927-1933. doi:10.1097/PRS.0000000000002147

Purpose Cleft palate (CP) is among the most common congenital anomalies in the United States and may be non-syndromic or syndromic. Patients with CP may undergo several surgeries from birth to adulthood. Unfortunately, a myriad of factors may contribute to care delays, which may be predisposing to intra- and post-operative complications or worse long-term outcomes (e.g., revisionary surgeries). Therefore, we aimed to compare the timing of CP care and characterize the long-term outcomes for syndromic and non-syndromic CP patients.

Methods
We retrospectively reviewed patients at our institution receiving CP care between January 2003 and September 2023. Patients who received initial CP repair elsewhere or were diagnosed with Pierre Robin sequence were excluded. Data extracted included patient demographics, syndromes, prenatal diagnosis, ages at first visit and initial repair, and long-term outcomes, including surgical complications, velopharyngeal insufficiency, and speech therapy. Bivariate analysis and univariate/multivariable logistic regression were performed. Propensity score matching was performed to match syndromic and non-syndromic patients based on their gender, migrant status, adopted status, race, and category of age.

Results
A total of 183 patients were included in the study, out of which 14.2% (n=26) were diagnosed with a syndrome, while 86.0% (n=157) were non-syndromic. Stickler syndrome (n=14/26, 54%) was the most common syndrome. Syndromic patients were more likely to receive a prenatal diagnosis (24.0% vs. 5.3%, p<0.001) and showed a trend towards earlier initial consultations and repairs than non-syndromic patients, although not statistically significant (first consultation: 228 vs. 413 days, p=0.07; first repair: 542 vs. 639 days, p=0.36). Syndromic patients required more speech therapy (76.9% vs. 52.2%, p=0.019), with no significant differences in surgical complications (p=0.601) or velopharyngeal insufficiency (p=0.532). Propensity score analysis revealed syndromic patients had higher odds for speech therapy (OR = 3.05, 95% CI [1.22, 8.71], p = 0.024) and growth delays (OR = 6.7, 95% CI [1.18, 38.12], p = 0.025). The odds ratio for OSA was notably higher in syndromic patients (OR = 7.99, 95% CI [3.26-20.09], p < 0.001). There was a significant difference in the mean distance to healthcare facilities, with syndromic patients traveling further to receive care (113.6 miles vs. 32.04 miles, p = 0.047).

Conclusion
Syndromic CP patients are more likely to be diagnosed prenatally and commence treatment earlier compared to their non-syndromic counterparts. However, this expedited care pathway does not necessarily translate to reduced long-term healthcare needs, as evidenced by the higher demand for speech therapy.

Background: Patients with syndromic craniosynostosis often require secondary soft tissue procedures to normalize facial appearance. This study evaluated the soft tissue procedures required for patients with different syndromic craniosynostoses.

Methods: This retrospective chart review evaluated patients with syndromic craniosynostosis who received care at a tertiary children's hospital between 2004 and 2023. Soft tissue procedures of interest included medial canthopexy, lateral canthopexy, facial fat grafting, scalp scar revision, scalp reconstruction, ptosis repair, and septorhinoplasty. Descriptive statistics, chi-squared tests, and independent t-tests were used to analyze the differences in soft tissue procedures across craniofacial syndromes.

Results: A total of 103 patients with syndromic craniosynostosis were included, with a mean follow-up of 7.7±5.7 years. Syndromes included Apert (n=39, 37.9%), Crouzon (n=32, 31.1%), Pfieffer (n=16, 15.5%), Saethre-Chotzen (n=10, 9.7%), Muenke (n=5, 4.9%), and Carpenter (n=1, 1.0%). Ninety-three patients (90.3%) underwent at least one soft tissue procedure, averaging 3.6±3.3 procedures per patient. A significantly higher percentage of patients with Apert syndrome (48.7%) underwent lateral canthopexies than Crouzon (25.0%, p=0.041), Saethre-Chotzen (20.0%, p=0.102), and Pfeiffer syndrome (12.5%, p=0.012) patients. Brow elevations were more common among patients with Saethre-Chotzen syndrome (63.6%) compared to Pfeiffer (33.3%, p=0.036) and Crouzon syndromes (28.1%, p=0.009). Scalp reconstructions were more common among patients with Pfeiffer syndrome (50.0%) compared to all other syndromes (Apert: 32.5%, p=0.039; Crouzon: 22.6%, p=0.007; Saethre-Chotzen: 9.1%, p=0.098; Muenke: 0.0 %, p=0.015). A higher percentage of patients with Crouzon syndrome (21.9%) underwent septorhinoplasty than those with Apert syndrome (5.1%; p=0.035). There were no significant differences in the proportion of patients who underwent fat grafting or scar revisions between syndromes.

Conclusion: Our findings indicate that soft tissue procedures are a common adjunct to bony reconstruction in patients with syndromic craniosynostosis, with significant differences in procedures required for treating craniofacial irregularities in each syndrome. Despite excellent initial bony correction, patients often underwent several soft tissue procedures from infancy to adulthood. The underlying genetic mutations that characterize these syndromes may contribute to abnormalities in soft tissue elasticity, wound healing, and overall integrity. Awareness of these soft tissue differences and the procedures for their correction may better prepare syndromic craniosynostosis patients, families, and care teams for the treatment ahead.