Scientific Abstract Presentations: Craniomaxillofacial 3 Friday, October 27 Fri, Oct 27 10:30 a.m.-12:30 p.m. CDT

Background: Using posterior vault distraction osteogenesis (PVDO) in cases of slit ventricle syndrome (SVS) and idiopathic intracranial hypertension (IIH) has been shown to resolve acutely increased intracranial pressure (ICP) while carrying an acceptable complication and risk profile. PVDO in such cases has been associated with symptomatic improvement postoperatively and decreased need for additional shunt related surgeries in those patients requiring ventriculoperitoneal shunt placement. We present our experience with PVDO performed as an acute intervention as evidence for the safety and efficacy for management of acutely increased intracranial pressure (ICP).

Methods: We report four cases of PVDO in patients with acutely increased ICP of varying etiologies.

Results: Four children with craniosynostosis underwent PVDO to address acutely increased ICP, all at less than 5 years of age. The four patients all presented with papilledema and symptoms of increased ICP. One patient presented with SVS and multiple shunt revisions, now with a non-functioning shunt. There were no reported intraoperative complications during distractor placement or removal. Distraction protocol was similar in all patients with distraction beginning on post-operative day one and proceeding at 1-2 mm per day for an average total distraction of 28 mm. For the 3 cases not requiring shunt placement, the average length of stay was 7 days following distractor placement. The patient with SVS required externalization of the shunt during distraction followed by early distractor removal and replacement of shunt. Computed tomography in all patients indicated increased intracranial volume following distraction and improved symptoms. One case of surgical site infection (in an immunocompromised patient) required premature distractor removal during the consolidation period.

Conclusions: Our experience with PVDO in the acute setting is reported, alongside a review of current literature, in order to provide supporting evidence for the efficacy of posterior vault distraction as a tool for resolving acutely increased ICP.

Purpose: Mandibular fractures are one of the most common facial bone fractures seen in the Emergency Department and primarily result from motor vehicle accidents and physical altercations.1 Open reduction and internal fixation (ORIF) with plate and screws is the definitive management for mandibular fractures. The procedure is not without risks and potential complications due to the location near the airway and need for proper alignment to prevent malocclusion. We aim to understand the risk factors for unplanned readmission and reoperation following treatment of isolated mandibular fractures to better risk-stratify patients based on their initial presentation and demographics.

Methods and Materials: Retrospective review was performed using the National Surgical Quality Improvement Program (NSQIP) database to analyze all patients from January 2015 to December 2019 who presented with mandibular fractures. Multivariate logistic regression analysis was conducted to examine potential risk factors for reoperation and readmission. Variables with p value less than 0.2 in univariate analysis were included in the multivariate logistic regression model. Stepwise model selection was used to select the best set of predictors. Statistical analyses were performed in SAS software version 9.4 (SAS Institute Inc., Cary, NC). P values less than 0.05 were considered statistically significant.

Results: Overall, 1090 cases of mandibular fracture were reported in the NSQIP database from January 2015 to December 2019. Of these cases, 83.6% (911/1090) were male and 16.4% (179/1090) were female. Inpatient status [OR 2.41 (1.15,5.05), p 0.020], ASA classification of 3 or 4 [OR 2.65 (1.28,5.49), p 0.009], and longer hospital stay from operation to discharge [OR 1.06 (1.00,1.12), p 0.049] were significantly associated with reoperation following isolated mandibular fracture repair. Inpatient status [OR 2.43 (1.05,5.63), p 0.039], open fractures [OR 3.91 (1.07,14.26), p 0.039], and ASA classification of 3 or 4 [OR 2.80 (1.22,6.45), p 0.015] were significantly associated with readmission following isolated mandibular fracture repair. Patient demographics and comorbidities on admission including gender, age, smoking status within one year of operation, body mass index (BMI), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hypertension requiring medication, diabetes, and sepsis were not significant predictors of reoperation nor readmission.

Conclusions: Mandibular fractures are one of the most common facial bone fractures that plastic surgeons are entrusted with managing. Patient demographics and comorbidities on admission including diabetes, BMI and smoking status are not associated with risk of reoperation and readmission for mandibular fractures. Inpatient status, ASA classification of 3 or 4, longer postoperative hospital stay, and open wound (open fracture) were significantly associated with reoperation or readmission for isolated mandibular fractures. Patients with open mandibular fractures and higher ASA classification on admission should be monitored carefully and receive close follow-up.

References: 1Braasch DC, Abubaker AO. Management of mandibular angle fracture. Oral Maxillofac Surg Clin North Am. 2013;25(4):591-600. doi:10.1016/j.coms.2013.07.007

Background Maxillofacial fractures are common sequalae of various traumatic injuries to the face.1 Previous studies have established epidemiology of facial fractures in the US, however these studies typically evaluate patients in urban settings. Our study aims to assess etiology and patterns of facial fractures in the largely rural patient population at the University of Vermont Medical Center (UVMMC) over a seven-year period to determine if trends are consistent with urban or international populations. Additionally, this study aims to compare facial fracture patterns and mechanism of injury between patients from rural and urban counties presenting to UVMMC. Methods Medical records for adults with a diagnosis of facial fracture presenting to UVMMC between January 2014 and December 2021 were reviewed. The search returned 458 patients meeting inclusion criteria the study. Patient demographics, fracture patterns, and etiology of injury were evaluated. Patients with zip were classified as "urban" or "rural" based on county of their home zip code. Data was analyzed using traditional statistical techniques, t-testing and chi-squared analyses. Results The injury mechanism accounting for the greatest number of facial fractures was ground level fall (24.7%), followed by motor vehicle accident (MVA) (19.7%), fall from height (17.9%), and blunt trauma (14.0%), assault (11.4%), bicycle fall (4.1%), motorcycle accident (3.7%), auto vs pedestrian (3.1%), gunshot wound (0.7%), and stabbing (0.2%). The most common facial fracture was of the maxilla/maxillary sinus (41.7%), followed by nasal bone/septum (41.2%), orbital (excluding the floor) (34.5%), orbital floor (33.6%), zygoma (25.2%), mandible (19.2%), frontal sinus (11.8%), LeFort I (6.6%), LeFort II (6.6%), LeFort III (4.1%) and NOE (2.4%). A total of 427 patients were categorized as "rural" or "urban." Comparing injury mechanism between these groups revealed a higher rate of facial fractures from assault in the urban cohort (15.2%, 6.9%, p= 0.007) and a higher rate from fall from height (21.2%, 13.4%, p=0.033) and MVA (23.6%, 16.1%, p=0.049) in the rural cohort. There were no statistically significant differences in rates of facial fracture patterns between the two groups. Conclusion Fall was the most frequent cause of facial fracture at UVMMC and globally, whereas at several US urban centers assault was most common.2,3 Patients presenting to UVMMC were most likely to have a fracture of the maxilla/maxillary sinus. This contrasts findings in the US and globally, where nasal bone fractures and mandible fractures were the most common, respectively.4,5 Additionally, residence in a rural or urban setting was found to impact mechanism of injury but did not impact facial fracture patterns.

References 1. Erdmann D, Follmar KE, DeBruijn M, et al. A retrospective analysis of facial fracture etiologies. Annals of Plastic Surgery. 2008;60(4):398-403. doi:10.1097/sap.0b013e318133a87b 2. Lalloo R, Lucchesi LR, Bisignano C, et al. Epidemiology of facial fractures: incidence, prevalence and years lived with disability estimates from the Global Burden of Disease 2017 study. Injury Prevention 2020;26:i27-i35. 3. Allareddy V, Allareddy V, Nalliah RP. Epidemiology of facial fracture injuries. Journal of Oral and Maxillofacial Surgery. 2011;69(10):2613-2618. doi:10.1016/j.joms.2011.02.057 4. Lee K. Global trends in maxillofacial fractures. Craniomaxillofacial Trauma & Reconstruction. 2012;5(4):213-222. doi:10.1055/s-0032-1322535

Background: The prevalence of cannabis use has increased with the legalization of cannabis in the United States. Despite this, there is a scarcity of research investigating its effects on pain management following facial trauma. The purpose of this study was to study patterns of postoperative opioid demand in patients with a history of cannabis use undergoing open surgical treatment of traumatic mandibular fractures.

Materials and Methods: PearldiverTM, a commercially available healthcare database, was queried to identify all patients who underwent open reduction and internal fixation (ORIF) of traumatic mandibular fractures between 2010 and 2020. Patients were subdivided into those with a history of cannabis use (case) and those without (control) based on ICD-9 and ICD-10 coding. The two groups were propensity score matched by age, gender, region in the United States, Elixhauser Comorbidity Index (ECI), and various psychiatric diagnoses to control for confounding variables. Welch two-sample T-test was used to compare average morphine milligram equivalents (MME) and days per prescription between the case and control group within the 30-day postoperative period.

Results: A total of 1,996 patients who underwent surgical repair of mandibular fractures were included in the study after patients were propensity score matched by a 1:3 ratio - 499 patients with an active diagnosis of cannabis use and 1,497 patients without. The case population filled a significantly decreased amount of MME in their first prescription compared to the control population (212.78 MME vs. 291.59 MME per prescription, p = 0.003). In patients who filled a second opioid prescription, there was no significant difference in the amount of MME per prescription between the case and the control (291.59 MME vs. 380.33 MME per prescription, p = 0.22). The average number of days per prescription provided ranged between 6 to 7 days and was comparable between the two groups (p = 0.19).

Conclusion: This study found a significant reduction of opioid volume filled, measured as MME per prescription, in patients with an active diagnosis of cannabis compared to those without following ORIF of traumatic mandibular fractures. Due to the increased mortality and morbidity burden of opioids, surgeons should take into consideration a patient's history of cannabis use to prevent the overprescription of opioids and further reduce the risk of misuse.

Background: Orbital fractures constitute up to 25% of facial trauma injuries in adults.¹ Baltimore, a city with one of the highest per-capita violent crime rates in the US, experiences a considerable volume of high-intensity trauma.² Although surveillance data is collected by Baltimore city, the characteristics of patients presenting with orbital fractures remain poorly understood.

Objective: Our study is the first multicenter analysis of the etiologies, fracture patterns, and management of patients treated for orbital fractures at two Level I trauma centers in Baltimore.

Methods: We conducted a retrospective review of trauma patients who underwent orbital fracture repair at the R. Adams Cowley Shock Trauma Center and the Johns Hopkins Hospital from January 2015 to December 2019. Primary outcomes were fracture etiology, severity, and location. Secondary outcomes were length of total hospital stay, operating time, surgical service, and incidence of any postoperative ocular complication following repair. Descriptive statistics were calculated. Secondary outcomes were compared between the two institutions using bivariate analysis and multivariate regression.

Results: Of n=374 patients, n=179 (47.9%) had orbital fractures due to violent trauma, n=252 (67.4%) had moderately severe to severe orbital fractures, and n=338 (90.4%) had concomitant neurological symptoms/signs. Patients who presented to Shock Trauma (n=208), compared to those who presented to Hopkins (n=166), were more likely to have had assault (n=97/208 [46.6%], n=72/166 [43.4%]; P <0.001), concomitant intracranial hemorrhage (n=23/208 [12.3%], n=5/166 [4.4%]; P=0.024), intracranial injury (n=28/208 [15.0%], n=7/166 [6.2%]; P=0.025), and loss of consciousness (n=80/208 [42.8%], n=24/166 [21.2%]; P <0.001). After controlling for factors pertaining to injury severity, there was no significant difference in patient throughput or incidence of any postoperative ocular complication following repair between the two centers.

Conclusion: Most patients treated for orbital fractures at our institutions presented after violent trauma and had concomitant neurological symptoms/signs. Despite the different management systems of orbital fracture at our two centers, patient throughput and outcomes were similar.

References: 1. Roth FS, Koshy JC, Goldberg JS, Soparkar CN. Pearls of orbital trauma management. Semin Plast Surg. 2010 Nov;24(4):398-410. doi: 10.1055/s-0030-1269769. 2. Etra JW, Canner JK, Aslam U, Nasr IW. Penetrating Trauma in Baltimore: An Analysis of the Effect of a Rise in Localized Violence by Age Group. J Surg Res. 2021 Jun;262:38-46. doi: 10.1016/j.jss.2020.11.083.

Background: 22q11.2 deletion syndrome (22q) has a heterogeneous phenotypic spectrum with many named syndromes under a single genetic mutation. Children with anomalies such as congenital heart defects are diagnosed at an early age, while those with less severe phenotypes often go undiagnosed until later in life. Velopharyngeal dysfunction (VPD) is a common sequela of 22q, therefore work-up of non-cleft VPD may identify children with previously undiagnosed 22q. Moreover, there may be a unique relationship between VPD and feeding in the 22q population. To those ends, this study identifies patients for whom multidisciplinary VPD clinic evaluation led to a new diagnosis of 22q and comprehensively reports speech, feeding, and medical characteristics of children with 22q evaluated in a multidisciplinary VPD program.

Methods: This retrospective cohort study included children with genetically confirmed 22q evaluated at a single multidisciplinary VPD program between February 2007 and February 2023. Pathways to 22q diagnosis, mechanisms of VPD in 22q including velopharyngeal mislearning and neuromuscular hypotonia, speech characteristics, medical comorbidities, surgical management, and referral patterns to our VPD program were systematically extracted from the medical record.

Results: 71 children were evaluated during the 16-year period. Median age at intake was 5.1 years (IQR 2.9 years) with median length of follow-up 21.5 months(IQR 50.6 months). Children were referred by otolaryngology (36.6%), cleft clinic (19.7%) and plastic surgery (4.2%)%, genetics (12.6%), primary-care pediatrics (7.0%), and speech and language clinic (5.6%). 23 referrals (32.9%) were made by providers involved in the VPD program.

Six children received new diagnoses of 22q after evaluation in our multidisciplinary VPD program. An additional three children were diagnosed by VPD providers in cleft or otolaryngology clinic, with subsequent referral to the VPD program for comprehensive evaluation. For collectively these nine cases, non-cleft VPI combined with craniofacial differences (n=6), polydactyly (n=2), aberrant internal carotid (n=3), history of congenital heart defect (n=1), and complex medical history concerning for syndromic cause (n=1) prompted further genetic investigation.

Speech concerns were the primary reason for referral (87.3%), with significant subsets presenting with question of submucous cleft (26.7%) and feeding concerns(19.7%). While secondary to speech concerns, nasal regurgitation and reflux were reported by 52.1% of children(n=37), with 18.3%(n=13) reporting history of nasogastric or gastrostomy tube placement for enteral feeds. Of these children, three presented for VPD evaluation primarily for feeding concerns and were ultimately recommended non-operative management.

40 children underwent superiorly based pharyngeal flaps, five Furlow palatoplasty, and three sphincter pharyngoplasty at our institution. Five children had undergone prior speech surgery and were referred for further management. 18 children were managed non-operatively, with one child deemed not a surgical candidate given cardiac comorbidities. Postoperative perceptual speech evaluations showed compensatory articulation errors in 21.3% of assessments(n=10/47), with seven cases of persistent VPI due to articulation errors.

Conclusions: Multidisciplinary VPD care effectively identified children with previously undiagnosed 22q, further elucidating the heterogeneous phenotypic presentation that involves non-cleft VPD, speech, and feeding concerns. A high index of suspicion for an overarching diagnosis is warranted in children with complex, multisystem diagnoses presenting for VPD evaluation.

Background Teens with repaired cleft palate commonly present with class III skeletal malocclusion secondary to post-surgical scar tethering. When not correctable with orthodontics alone, the malocclusion is treated surgically. Ideally, we could reduce patients' surgical burden by optimizing maxillary growth during infancy.

We posit that the addition of vascularized tissue during cleft palatoplasty diminishes palatal scarring, thereby enhancing maxillary growth. The pedicled buccal fat pad flap (BFPF) is an excellent source of vascularized tissue given its proximity to the operative field and low morbidity associated with flap harvest. We expect that patients that have had a BFPF as part of their palatoplasty during infancy are at a lower risk for developing class III skeletal malocclusion and corrective operations than those that underwent palatoplasty without BFPF.

Methods A retrospective chart review was conducted for patients with cleft lip and/or cleft palate that were eligible to undergo orthognathic surgery (OGS) between 2010-2022. Data collected included sex, age at jaw surgery, operative details (fixation vs. rigid external distraction/RED), and complications. Details of prior palatoplasty, including Veau classification and BFPF use, were documented. Cleft severity scores were calculated based on Veau classification and the number of patients with each type.

Results The charts of 131 patients with a cleft diagnosis that were eligible for OGS between 2010-2022 were reviewed. Of these, 60 had BFPF as part of their palatoplasty in infancy. Three patients in the BFPF group (5.0%) underwent OGS versus 20 patients in the non-BFPF group (28.2%).

All 3 BFPF patients had early RED as their only corrective jaw surgery. Five of the non-BFPF patients (25.0%) underwent RED and 15 patients (75.0%) underwent traditional OGS with plate fixation. Nine of these 15 traditional OGS patients underwent a concomitant mandibular surgery. The average age for jaw surgery was 13.2 years for the BFPF group and 18.2 years for the non-BFPF group.

When comparing age-matched groups, BFPF patients had an overall decreased incidence of OGS compared to the non-BFPF group. This was evident in the early RED group (3.8% for BFPF vs. 10.0% for non-BFPF, RR 0.4) and in the skeletally mature patients (14.3% vs. 31.1%, RR 0.5). Cleft severity scores were 3.67 for the BFPF group (more Veau III and IV) and 2.70 for the non-BFPF group.

After OGS, the BFPF group had no post-operative complications. The non-BFPF patients had 4 complications, which included infection, dehiscence, velopharyngeal insufficiency and RED device shift. In each, a secondary procedure was required.

Conclusion The group of patients with cleft lip and/or cleft palate that had BFPF as part of their palatoplasty during infancy had up to 2.6 times decreased incidence of OGS than those that did not, even despite having an overall higher cleft severity score than the non-BFPF group. Our study findings show that incorporating a BFPF during infants' cleft palatoplasty can enhance maxillary growth, reduce the incidence of skeletal class III malocclusion treated surgically and improve OGS surgical complication profiles, ultimately decreasing surgical burden in the cleft population.

Introduction: Gunshot wounds (GSW) to the face present unique challenges regarding effective management and limiting morbidity. This is largely attributed to complex fracture patterns, extensive soft tissue injury and high rates of contamination.(1,2) This project aims to document changes in demographics, presentation, treatment, and clinical outcomes of GSW to the face over the past decade. Furthermore, it identifies trends and helps delineate the current standard of care for management of GSW to the face.

Methods: A retrospective chart review of GSW to the face from a Level 1 metropolitan trauma center registry was conducted for patients from January 1, 2009, to December 31, 2020. Patients were included if they sustained a GSW to the face, survived for more than 48 hours, and received care at that institution. Data collected included demographic information, injury details, specifics of antibiotic therapy, surgical management, and infections, as well as airway management techniques. The Microsoft Excel Statistical Package and Jamovi statistical software were used to generate graphs and create univariate linear regression models for the parameters studied.

Results: From 2009-2020, a total of 432 patients met the inclusion criteria, with an average of 36 per year [range: 19-72]. The average age at presentation was 31.0 (SD 14.8) and the majority of patients were males (83.8%). These demographic variables remained relatively constant throughout the study period. While the total annual trauma volume increased by 56.3% over the study period (6,029 to 9,426), incidence of GSW to the face tripled, representing a 91.9% increase in the proportion of the total trauma volume. Over the study period, patients requiring facial surgery decreased by 19.4% (1.8% per year, p<0.001) and the average length of hospitalization decreased by 4.2 days (0.48 days per year, p=0.044). There were no identifiable trends in operative techniques. However, among patients who underwent facial surgery, 109 (34.4%) required open reduction internal fixation (ORIF), 36 (11.4%) required external fixation, and 29 (9.1%) required a flap. The percentage of patients receiving antibiotics during their hospitalization remained relatively constant, but the average duration of antibiotic coverage per patient decreased by 24.6% over the study period (2.0% per year, p=0.004). Despite this, the incidence of head and neck infections decreased by 13.9% (1.0% per year, p=0.067).

Conclusion: Although GSW to the face are relatively uncommon, the incidence of these injuries is increasing. While the demographic profile of patients sustaining GSW to the face remains constant, there is evidence of reduced operative intervention, decreased infection rates, and better antibiotic stewardship. There is also a potential reduction in hospital costs as evidenced by shorter lengths of stay.

References: 1. Jose A, Arya S, Nagori S. High-velocity ballistic injuries inflicted to the maxillofacial region. J Craniofac Surg. 2019;30(6). doi:10.1097/scs.0000000000005418 2. Fagin AP, Dierks EJ, Bell RB, Cheng AC, Patel AA, Amundson MS. Infection prevalence and patterns in self-inflicted gunshot wounds to the face. Oral Surg Oral Med Oral Pathol Oral Radiol. 2019;128(1):9-13. doi:10.1016/j.oooo.2019.02.022

Purpose:
The incidence of airway compromise following palatoplasty is reported to be as high as 38%, with an even higher incidence in syndromic children.1 The tongue stitch (TS) is often used by cleft surgeons as a protective airway maneuver to anteriorly displace the tongue from the oropharynx. Although no evidence-based protocol for its use yet exists, many institutions retain the stitch until postoperative day one.2 This study describes a protocol for early tongue stitch removal following palatoplasty and evaluates the impact of this approach on safety, time to feed, narcotic use, and length of stay.

Methods and Materials:
Our protocol outlines TS removal in the PACU if the following criteria is met: no use of the tongue stitch to clear the airway for 20 minutes after arrival in PACU, no physical signs of increased work of breathing or retractions, no supplemental oxygen use >2L/min, no fresh blood or clots in pharynx, and the patient is able to protect airway when asleep in supine position.

A retrospective chart review was performed on all patients with cleft palate who received care at a single academic institution from September 2019 to September 2022. Patients who underwent primary palate repair prior to 24 months of age with TS placement postoperatively were included in the study.

Experience:
Seventy-eight patients with cleft palate were included in this study in an ACPA certified Cleft Center.

Summary of Results: Of the 78 patients included, 85.9% had their tongue stitch removed in the PACU, with the remaining 11 patients retaining the stitch until postoperative day one. Duration of anesthesia and duration of operation were not statistically different between the two groups (p=0.23, p=0.95). Six patients (9.0%) who underwent tongue stitch removal in PACU had documented desaturations of less than 90% oxygen saturation that resolved spontaneously or by short term blow-by oxygen. No patients required reintubation. Mean time to feed of these patients was 9.1 hours compared to 15.4 hours for patients who retained their tongue stitch after transfer from the PACU (p=0.01). Mean morphine equivalent was 3.4 mg versus 6 mg (p=0.051) for those who had the stitch removed in PACU versus after transfer. Average length of stay for patients with the stitch removed in PACU was 1.6 days versus 2.0 days for those with the tongue stitch removed later.

Conclusions: The outcomes of our study support the airway safety profile of our postoperative tongue stitch protocol status following palatoplasty in patients less than 24 months of age. Patients with stitch removal in PACU fed earlier on average, required less narcotics, and were discharged earlier.

References 1. Jackson O, Basta M, Sonnad S, Stricker P, Larossa D, Fiadjoe J. Perioperative risk factors for adverse airway events in patients undergoing cleft palate repair. Cleft Palate Craniofac J. 2013;50(3):330-336. doi:10.1597/12-134 2. Dorfman DW, Ciminello FS, Wong GB. Tongue suture placement after cleft palate repair. J Craniofac Surg. 2010;21(5):1601-1603. doi:10.1097/SCS.0b013e3181ebccb1

Purpose Craniosynostosis, the premature fusion of cranial sutures, requires early surgical treatment to minimize the risk of developmental and cognitive deficits. Recent literature showed that caregivers prefer three-dimensional (3D) tools for learning about craniosynostosis. Nevertheless, few 3D tools exist to help caregivers comprehend craniosynostosis anatomy and surgical options. This study aims to assess the efficacy of 3D animated videos for enhancing craniosynostosis education in caregivers and laypersons.

Methods We created 3D animated videos describing anatomy and surgical options (e.g., fronto-orbital advancement, posterior vault reconstruction) for three craniosynostosis diagnoses: bicoronal, metopic, and sagittal. A cross-sectional survey was distributed to caregivers through Facebook support groups and to laypersons through Amazon Mechanical Turk. Respondents rated their understanding of craniosynostosis on 10-point Likert-scales, labelled anatomic sutures, and answered true/false general (e.g., "The sutures have fused too early") and diagnosis-specific (e.g., "The distractors are not removed after surgery") questions on craniosynostosis. Caregivers were shown the video that best corresponded to their patient's diagnosis while laypersons were randomized to a diagnosis video. After the video, respondents were asked the same set of questions asked before the video.

Results
A total of 69 craniosynostosis caregivers (mean age 35 years, 73% Caucasian, 64% female) and 111 laypersons (mean age 37 years, 100% Caucasian, 41% female) completed the survey. After watching the video, caregivers scored significantly higher on the knowledge questions (mean score difference: 1.27, p<0.01). Laypersons did not score significantly higher on the knowledge questions (mean score difference: 0.32, p=0.08). Both caregivers (mean value pre-video: 38.87, mean value post-video: 41.49, p<0.01) and laypersons (mean value pre-video: 45.29, mean value post-video: 52.84, p<0.01) self-rated their understanding of craniosynostosis as higher after watching the video. Thirty-nine percent of caregivers correctly labeled all four skull sutures before the video while 48% of caregivers correctly labeled all four skull sutures after the video.

Conclusions Our 3D animated videos significantly improved caregiver craniosynostosis understanding and knowledge. Caregiver knowledge after watching animations objectively and subjectively improved. Thus, these animations provide an accurate instrument to improve caregiver spatial and anatomical understanding of craniosynostosis. In addition, these videos are an accessible tool that can be easily incorporated into a surgeon's discussion with caregivers about craniosynostosis diagnosis and surgical treatment. Future work includes creating 3D animated videos from patient-specific CT scans that can provide a more comprehensive tool for the caregivers as well as encompass more diverse patient diagnoses and treatment options.

Introduction: The Le Fort I osteotomy is used to reposition the maxilla to correct numerous maxillofacial and occlusal deformities. This procedure can be performed with one segment or with multiple, depending on surgeon preference and patient need. Patients may also need bone grafting. Though the theoretical risk of multiple segments and bone grafting is well established, no study has assessed the perioperative risk of multiple part Le Fort I osteotomy and the use of bone grafting in comparison to single piece Le Fort I osteotomies without bone grafting. Thus, the aim of this study was to delineate perioperative complication rates associated with Le Fort I osteotomy and determine if the number of maxillary segments or bone grafting yielded increased complication rates.

Methods Patients undergoing Le Fort I osteotomy from 2012-2019 were identified from the multi-institution National Surgical Quality Improvement Program (NSQIP) database using Current Procedure Terminology (CPT) codes. The predictor variables of interest included maxillary segmentation defined as one, two, or three pieces and the presence of absence of bone graft. Perioperative complications were collected as the primary outcome variable, including superficial and deep space infections, wound dehiscence, airway complication, peripheral nerve injury, and hemorrhage. The secondary outcome variables included readmission and reoperation rate within the 30-day postoperative period. Complication rates were compared using multivariate analysis across groups stratified by number of maxillary segments and inclusion of bone grafting.

Results: A total of 532 patients were identified that met the inclusion criteria of undergoing a variant of a Le Fort I osteotomy procedure. Of the total cohort, 333 patients (62.6%) received one-piece, while 114 patients received two-piece (21.4%), and 85 three-piece (16%) Le Fort I osteotomies. When comparing all complication types, there was no significant effect of the number of maxillary segments or addition of a bone. Similarly, the reoperation and readmission rates within 30 days for patients undergoing a single piece Le Fort I were equivalent regardless of number of pieces. The use of bone grafting also did not have a significant effect on the observed reoperation or readmission rates. This analysis held when patients with complex congenital syndromes were analyzed as a subgroup.

Conclusion: Large database sets suggest that the Le Fort I Osteotomy is a safe surgical procedure with low complication rates in the immediate postoperative period irrespective of number of maxillary segments or implementation of bone graft.

Background: The volume of facial feminization surgery (FFS) performed in the United States has increased tremendously over the last decade as new gender affirmation programs have formed and insurance coverage has improved over time. Advancements in surgical planning and treatment protocols have resulted in complex, multiprocedural FFS operations. 1,2,3 The World Professional Association of Transgender Health Standards of Care 8 recommends that these procedures be done by expert multidisciplinary teams with proper training in transgender health. However, all new programs take time to evolve and mature. This study sought to examine the changes in characteristics, outcomes, and safety of a large-scale FFS program over a 5-year lifespan.

Methods: A retrospective analysis was performed of all patients who underwent FFS in a single high-volume integrated healthcare system from program initiation in 2018-2019 (early cohort) to maturation in 2021-2022 (late cohort). Patient charts were reviewed for length of stay, operative details, surgery duration, complications, post-operative Emergency Department or Urgent Care (ED/UC) visits, revisions, readmissions, and demographic factors. Patient characteristics and major outcomes including complications, readmissions, revisions, and ED/UC visits were analyzed and compared between early and late cohorts.

Results: A total of 191 patient charts were included in the analysis, including 109 in the early cohort and 82 in the late cohort. Patient demographics were similar in the two groups with the exception of mean age (40.3 years in the early group, 36.3 years in the late group, p=0.03). Mean follow up time was over 90 days in both groups. Patients in the late cohort on average had longer operations (5.40 hours versus 6.16 hours, p=0.008) with a greater percentage of patients having genioplasty, rhinoplasty, fat grafting, or lip lift in addition to hairline advancement and frontal bone modification. Despite this, fewer patients in the late cohort were admitted post-operatively (62.4% versus 13.4%, p<0.001). There were no significant differences in total complications, minor complication rates, revisions, ED/UC visits, or readmissions between the two groups. However, major complications (infections, abscesses, or hematomas requiring IV antibiotics, readmission, or surgical drainage) were significantly more common in the early program group (4.6% vs. 0.0%, p=0.05).

Conclusion: As a nascent facial gender affirmation program gains experience and optimizes its processes, case complexity and operative length tend to rise. Despite this, post-operative admission rates decreased to the point where most cases were outpatient procedures. Patient demographics may also change over time as an initial cohort of patients with gender dysphoria who have been awaiting therapy for much of their lives gives way to younger, newly-identified patients. The greatest benefits to increasing institutional experience are seen in the prevention of major complications. Overall safety and positive outcomes were maintained throughout the program history as total complications, ED/UC visits, readmission, and revision rates remained low in both early and late cohorts. These results can help guide developing programs and serve as a standard of care for large-scale healthcare systems.

References 1. Chaya, B. F., Berman, Z. P., Boczar, D., Siringo, N., Rodriguez Colon, R., Trilles, J., Diep, G. K., & Rodriguez, E. D. (2021). Current Trends in Facial Feminization Surgery: An Assessment of Safety and Style. The Journal of Craniofacial Surgery, 32(7), 2366–2369. https://doi.org/10.1097/SCS.0000000000007785 2. Rodman, R. (2022). Developments in facial feminization surgery. Current Opinion in Otolaryngology & Head and Neck Surgery, 30(4), 249–253. https://doi.org/10.1097/MOO.0000000000000811 3. Tirrell, A. R., Abu El Hawa, A. A., Bekeny, J. C., Chang, B. L., & Del Corral, G. (2022). Facial Feminization Surgery: A Systematic Review of Perioperative Surgical Planning and Outcomes. Plastic and Reconstructive Surgery. Global Open, 10(3), e4210. https://doi.org/10.1097/GOX.0000000000004210

Background: Minimally invasive surgery is preferred to open repair in correction of craniosynostosis due to lower risk of postoperative complications.1 Previous studies identified Hispanic and non-White patients were diagnosed later in life, had higher rates of open repair, and experienced more complications.2 This study analyzed recent trends and identified predictors of postoperative outcomes following craniosynostosis surgery. Methods: Retrospective review of Pediatric NSQIP 2019 to 2021 identified all craniosynostosis patients (ICD-10 Q75.0) who underwent surgical repair. Patients who underwent a combination of minimally invasive and open repair were excluded. Covariates included demographics and comorbidities. Outcomes studied include transfusions, postoperative complications (i.e. superficial incisional surgical site infection, wound infection, dehiscence, pneumonia, unplanned intubation, seizure, cardiac arrest, length of stay, reoperations, and readmissions. Multivariable regression assessed predictors for postoperative complications. Results: 4,711 patients were included. 469 (9.96%) underwent minimally invasive repair, 4,242 (90.04%) open repair. Median age at time of surgery was significantly lower in minimally invasive repair (3.4 months, IQR = 2.8, 4.2) compared with open repair (9.2 months, IQR = 5.0, 15.2, p<0.001). Race distribution was significantly different (p<0.001): White patients made up a greater proportion of minimally invasive cohort (72.9%) compared with open repair cohort (62.1%), while Black patients made up a greater proportion of open repair cohort (9.5%) compared with minimally invasive cohort (3.0%). Minimally invasive surgery was associated with shorter operative time (80 minutes, IQR = 61, 104), anesthesia time (171 minutes, IQR = 143, 219), and length of stay (1 day, IQR = 1, 2) compared with open repair (179 minutes, IQR = 104, 254, p<0.001; 290 minutes, IQR = 214, 375, p<0.001; 3 days, IQR = 2, 4, p<0.001). In minimally invasive surgery, significant predictors of blood transfusions were American Indian or Native Alaskan race (OR = 7.7, p=0.031), longer anesthesia time (OR = 1.02, p<0.001), while a significant predictor of other postoperative complications was increasing age (OR = 1.028, p=0.016). In open repair, significant predictors of blood transfusions included younger age (OR = 1.014, p<0.001), Hispanic ethnicity (OR = 1.226, p<0.029), prolonged anesthesia (OR = 1.005, p<0.001) and operative times (OR = 1.003, p<0.001), while signficiant predictors of other postoperative complications were Asian race (OR = 2.827, p=0.009) and presence of preexisting comorbidities (OR = 1.883, p=0.004). Conclusions: Disparities continue to exist in craniosynostosis care. White and younger aged children are more likely to undergo minimally invasive repair, associated with improved postoperative outcomes. Increased efforts in early craniosynostosis diagnosis in non-White children allowing for minimally invasive surgery is necessary to improve outcomes for all craniosynostosis patients.

1. Marupudi NI, Reisen B, Rozzelle A, Sood S. Endoscopy in Craniosynostosis Surgery: Evolution and Current Trends. J Pediatr Neurosci. 2022 Sep;17(Suppl 1):S44-S53. doi: 10.4103/jpn.JPN4722. Epub 2022 Sep 19. PMID: 36388003; PMCID: PMC9648654.
2. Badiee, Ryan K. BA, BS; Maru, Johsias BA; Yang, Stephen C. DDS†; Alcon, Andre MD; Rosenbluth, Glenn MD‡,§; Pomerantz, Jason H. MD,§. Racial and Socioeconomic Disparities in Prompt Craniosynostosis Workup and Treatment. The Journal of Craniofacial Surgery 33(8):p 2422-2426, November/December 2022. | DOI: 10.1097/SCS.0000000000008815

Background: The use of adjunctive techniques in conjunction with primary palatoplasty is imperative when faced with tension at the defect site and inadequate local tissue coverage. This review aimed to summarize and compare outcomes across various adjuncts employed in primary palatoplasty.

Methods: A literature search was conducted of MEDLINE, EMBASE, and Cochrane Library from inception to December 2022 using keywords cleft palate, palatoplasty, primary repair, primary reconstruction, surgical flaps, allografts, autografts, and adjunctive techniques. Adjunctive techniques were defined as methods that obtain non-palatal tissue for additional coverage of the local defect. Data extracted included demographics, cleft severity (Veau classification), primary and adjunctive techniques, outcomes, and follow-up periods. Logistic regression models and Chi-squared tests were performed to investigate associations among variables.

Results: Forty-seven articles were included, comprising a total of 2,234 patients aged 3 months to 32 years. Follow-up periods ranged from 1 month to 25 years. Submucous cleft was described in 24 (1%) patients, whereas Veau I/II and Veau III/IV in 681 (30.5%) and 1451 (65%) patients, respectively. Furlow (56%) and intravelar veloplasty (9.5%) were the most reported techniques for soft palate repair, while Bardach (21.9%) and V-Y Pushback (11.2%) for the hard palate. Buccal myomucosal flap (BMMF) was utilized in most cases (52%), followed by buccal fat pad flap/graft (BFP) in 32.1%, and acellular dermal matrix (ADM) in 10.3%. Postoperative complications were identified in 3.9% of patients, including bleeding, infection, flap loss, necrosis, delayed healing, re-operation, and dehiscence. Oronasal fistula was present in 4.4% of patients, and velopharyngeal insufficiency (VPI) in 6.5%. Greater cleft severity (Veau III/IV) was most frequently repaired with BMMF compared to ADM/BFP (p<.0001). No significance was found between cleft severity and VPI (p=0.2) or fistula (p=0.6). ADM was associated with a higher incidence of postoperative complications compared to BFP (p=0.0003). Within the Veau III/IV subgroup, fistula was associated with ADM when compared to BFP (p=0.01).

Conclusion: Primary palatoplasty adjuncts mitigate the risks of unfavorable outcomes associated with high cleft severity, with BMMF being considered superior given its inherent tissue properties in contrast to BFP and ADM. BFP is effective in reducing the incidence of fistula formation.

Objective: Delayed diagnosis and treatment of craniosynostosis leads to craniofacial deformity and threatens elevated intracranial pressure with long term neurocognitive deficits and psychosocial implications. We conducted a systematic review of the literature to evaluate risk factors for delayed craniosynostosis treatment and consistency of reporting practices.

Methods: PubMed, Embase, and Scopus were searched. Two independent reviewers screened articles by title and abstract followed by full text. Any disagreements were discussed between reviewers and resolved. Pooled means and proportions were calculated to estimate the mean age at presentation and racial/ethnic composition of the patients represented in the literature.

Results: Of 273 resultant articles, 19 were included, representing data from 31,568 patients. All 19 papers were retrospective reviews in the craniofacial (74%), neurosurgical (21%), or oromaxillofacial (5%) literature. There were no publications on the topic of disparity in craniosynostosis treatment prior to 2014, and 42% of publications have been published since 2020. Pooled mean age at presentation was calculated for 14 of the 19 studies and was found to be 9.38 months with a pooled variance of 5.08 months. Pooled proportions revealed a racial/ethnic distribution of 56% White patients (n=17 studies), 12% Hispanic patients (n=11 studies), 6% Black/African American patients (n=15 studies), <2% Asian patients (n=8 studies), <1% American Indian/Alaska Native (n=5 studies) and <1% Native Hawaiian/Pacific Islander patients (n=3 studies). One study by Lin et al. 2015 collapsed Black and Hispanic patients into one group comprising 17% of their sample. Minority racial/ethnic status was found to be a risk factor for delayed presentation (n=8 studies), increased incidence of open rather than minimally invasive surgery (n=4 studies), higher hospital admission costs (n=3 studies), higher complication rates (n=3 studies), increased length of hospital stay (n=2 studies), increased duration of anesthesia/length of surgery (n=2 studies), and increased transfusion requirement (n=1 studies). The pooled mean delay in initial presentation for non-White patients was 5.7 months (range 4.0 – 9.3 months) compared to White patients, with pooled average delay-to-surgery of 3.0 months (range 2.7-10.1 months). Similar patterns were seen based on insurance status, with government-funded patients at increased risk of requiring open surgery (n=5), delayed intervention (n=3), complications (n=2), and transfusion requirements (n=1). Eighty-nine percent of studies reported any racial composition, with only 3 of 19 (16%) consistently reporting all U.S. Census racial and ethnic categories.

Conclusions: Disparity in craniosynostosis is a topic that has garnered more interest over the past decade as the differences in referral patterns, treatment, and outcomes have come to light. In addition to the delay in presentation, what's more concerning is the delay to surgery even after being seen by a specialist. Moving forward, it is essential to collect demographic data consistently and systematically in this population so we may investigate how these observations trend over time and, thus, identify key areas of intervention that may address pressing disparities.

Background: Velopharyngeal insufficiency (VPI) and resonance disorders may occur following primary cleft palate repair and affect speech. Speech sounds may differ based on primary language. The contributory role of language to VPI is unknown. This study seeks to determine the incidence of VPI in Spanish- versus English-speaking patients after cleft palate repair, as well as to evaluate how primary language affects patient-reported speech outcomes.

Methods: Patients from the Texas Cleft-Craniofacial Team at UTHealth who had primary cleft palate repair from 2004 to 2019 were identified. Surgical and demographic data were collected. Patients were divided into two groups based on primary language defined by patient report: English (EN) or Spanish (SP). A retrospective analysis of VPI incidence and a prospective patient-reported survey of speech outcomes were conducted. VPI was defined as receiving VPI surgery, recommendation for VPI surgery, or a Universal Parameters hypernasality score of at least 2 on most recent follow-up. CLEFT-Q Speech Function and Speech Distress surveys were administered to patients ages 7-18 years and parents of patients 4-18 years. Surveys were scored 0-100 with higher scores indicating better function and less distress.

Results: Of the 228 patients included in the study, 46 (20%) were SP and 182 (80%) were EN. There was no statistical difference in the Veau class or type of primary palate repair performed in SP and EN patients. There was a greater incidence of VPI in SP patients compared to EN patients (52% vs. 38%, p=0.04). For patient-reported speech outcomes, 40 cleft palate patients and their parents were surveyed. The median age of surveyed patients was 13 (IQR 8,15.25) years for both groups. There were 30% SP (n=12) and 70% EN (n=28) patients. SP patients had worse CLEFT-Q patient reported Speech Function scores than EN patients (58 ± 18.19 vs. 68 ± 20.61, p=0.17). SP patients also felt more Speech Distress than EN patients (64 ± 17.30 vs. 70 ± 18.16, p=0.43). Parent reported Speech Function scores were worse for SP patients compared to EN patients (61 ± 25.47 vs. 66 ± 24.55, p=0.59).

Conclusions: In this single institution study, there was a statistically significant greater incidence of VPI in Spanish-speaking patients compared to English-speaking patients. Furthermore, Spanish-speaking patients trended towards worse patient- and parent-reported speech outcomes. It is unclear if these findings are caused by primary language differences. Further research is needed to investigate contributing factors such as socio-demographics with the goal of achieving equitable outcomes in these groups.

Purpose: Fistula formation is a dreaded complication of cleft palate repair and can result in decreased patient quality of life and additional surgeries. Likewise, the development of velopharyngeal insufficiency recalcitrant to speech therapy following cleft palate repair often results in patient distress and necessitates surgical correction. The goal of the present study was to further add to the literature regarding cleft palate repair by providing the authors institution's experience. Specifically, the authors aim to examine different repair techniques with regards to primary endpoints.

Method: Institutional review board approval was received. All patients undergoing repair of a cleft palate at the authors' institution over a 10-year period were collected (n=242). Patient and cleft demographics were collected as well as operative details. Primary outcomes measured were development of a fistula and the need for speech surgery. Further details regarding fistula management and speech surgery were collected. Chi square tests and independent t-tests were utilized to determine significance. A significance value of 0.05 was utilized.

Results: During the time period examined, there were 290 cleft palate repairs performed at the authors' institution, 242 patients had enough data for analysis. The most common cleft palate encountered was a Veau II (37%). A two-stage palate repair was performed in 17% of patients. A Furlow palatoplasty was performed on 57% of patients. Fistulas were reported in 22% of patients and speech surgery was needed in 11% of patients. A two-stage palate repair was associated with the eventual need for speech surgery (p < 0.001). Furlow palatoplasty was associated with a decreased rate of fistula formation (p < 0.01) and a decreased need for eventual speech surgery (p < 0.001).

Conclusion: This study reiterates much of the existing literature regarding differing cleft palate repairs. A two-stage palate repair is often touted as having a lesser degree of growth restriction, but the present study demonstrates that this comes at the cost of an increased need for speech surgery. Furlow palatoplasty has proven in prior studies to demonstrate an improved speech outcome, which is corroborated in the present study, but is often associated with a higher rate of fistula formation. The present study demonstrated a decreased rate of fistula formation with the Furlow technique, which may be a result of the adoption of the Children's Hospital of Philadelphia modification of the technique. This study further solidifies the clinically superior outcomes of the Furlow palatoplasty over other techniques.

Purpose: Sphincter pharyngoplasty has been an established treatment method for velopharyngeal insufficiency after cleft palate repair. Existing studies have generally reported isolated outcomes, in which speech and revision surgery outcomes are separated from airway obstruction complications, a known postoperative risk. Furthermore, studies that have evaluated postoperative airway complications have not distinguished between transient and persistent symptomatology. The purpose of this study is to evaluate the long-term outcomes of sphincter pharyngoplasties, including speech outcomes, revision surgeries, and postoperative incidence of obstructive sleep apnea.

Methods: A retrospective matched cohort study was conducted across two institutions. Patients with cleft lip/palate (CLP) or isolated cleft palate (iCP) who underwent sphincter pharyngoplasty between 1992 to 2022 were identified. Patients who had sphincter pharyngoplasty surgery at > 21 years of age and patients with less than 6 months of postoperative follow-up were excluded. An age- and diagnosis- matched control group of patients with no history of velopharyngeal insufficiency was also identified. Postoperative speech outcomes, revision surgeries, and incidence of obstructive sleep apnea were evaluated. To evaluate whether sphincter pharyngoplasty was associated with obstructive sleep apnea, we first performed univariable analyses to identify all potential predictors of obstructive sleep apnea. Multivariable regression was then used to evaluate independent predictors of obstructive sleep apnea.

Results: A total of 233 patients (mean age 19.0 ± 2.6 years) with CLP/iCP were reviewed: 166 patients underwent sphincter pharyngoplasty and 67 patients with no history of velopharyngeal insufficiency comprised the control group. Among the pharyngoplasty cohort, 63.9% demonstrated improved and sustained speech outcomes after a single pharyngoplasty, with a median postoperative follow-up of 8.8 years (interquartile range [IQR], 3.6-12.0 years). One-third of pharyngoplasty patients required a revision surgery, with a median time to primary revision of 3.9 (IQR 1.9-7.0) years. Obstructive sleep apnea rates increased significantly among the pharyngoplasty cohort, from 3% preoperatively to 14.5% postoperatively (p < 0.001). The average time from sphincter pharyngoplasty to obstructive sleep apnea diagnosis was 4.4 ± 2.4 years. On multivariable analysis, sphincter pharyngoplasty surgery was independently associated with a fourfold increase in obstructive sleep apnea (OR 4.24, p = 0.03). Furthermore, patients who had histories of both sphincter pharyngoplasty and secondary Furlow surgery for velopharyngeal insufficiency were eight times more likely to exhibit obstructive sleep apnea compared to controls (OR 8.17, p = 0.01).

Conclusions: While sphincter pharyngoplasty remains successful in improving speech outcomes over long-term periods for the majority of patients, persistent obstructive sleep apnea is a complication that should be monitored for beyond the immediate postoperative period. This work underscores the importance of long-term follow-up of patients who undergo sphincter pharyngoplasty to monitor for velopharyngeal insufficiency reoccurrence, need for revision surgery, and persistent obstructive sleep apnea.

Background: Traumatic brain injury (TBI) associated with facial fractures is a significant public health concern worldwide. TBI has been reported to be as high as 86% in patients presenting with facial fractures. Our study is the first to evaluate the prevalence and risk factors of TBI in patients with frontal sinus fracture(s).

Methods: We retrospectively reviewed patients who presented with traumatic frontal sinus fractures in 2019. Excluded were patients with no documentation of neurologic symptoms/signs on presentation. Our primary outcomes were prevalence of concomitant TBI on presentation and at >2 weeks after trauma. TBI on presentation was defined as having GCS<15 or any neurologic symptom/sign and categorized into mild (GCS=14-15), moderate (GCS=9-13), and severe (GCS<8). Persistent/incident post-traumatic neurologic symptoms were assessed at >2 weeks after injury. Bivariate analysis and logistic regression were performed.

Results: Of n=62 patients, n=57 (91.9%) had concomitant TBI on presentation. Compared to patients with no concomitant TBI, patients with severe TBI were more likely to have had combined anterior and posterior table fractures (n=0 [0.0%], n=12 [85.7%]; P=.002), displaced fractures (n=1 [20.0%], n=12 [85.7%]; P=.036), and comminuted fractures of the frontal sinus (n=0 [0.0%], n=13 [92.9%]; P<.001). Of n=51 patients who were followed up for a median (interquartile range [IQR]) of 162 [23-970] days, n=41 (80.4%) had neurologic symptoms at >2 weeks following trauma. Combined anterior and posterior table fractures of the frontal sinus was associated with 7 times the odds [crude odds ratio (cOR) (95% confidence interval [CI]) 7.0 (1.3-38.6)] of having neurologic symptoms at >2 weeks after trauma compared to isolated anterior table fracture. This was not significantly associated with mechanism of injury, fracture displacement, or surgical repair.

Conclusion: Emergency physicians should maintain a high degree of suspicion of TBI, even when their primary concern is facial trauma with frontal sinus fracture. Head CT at presentation and close neurologic follow-up are recommended for frontal sinus fracture patients with combined anterior and posterior table fractures.