Scientific Abstract Presentations: Craniomaxillofacial 4 Friday, October 27 Fri, Oct 27 5:00-6:00 p.m. CDT

Background: Controversy persists regarding postoperative speech outcomes and complications of different "straight-line" repair techniques such as the Bardach Two-Flap (BTF) and von Langenbeck (VL) palatoplasties with or without Intravelar Veloplasty (IVVP).[1,2] We hypothesized that levator muscle repair in the BTF with IVVP demonstrates similar rates of postoperative oronasal fistula (ONF) with decreased rates of velopharyngeal insufficiency (VPI) and secondary VPI surgery as compared to VL palatoplasty.

Methods/Description: A retrospective cohort study was performed of non-syndromic subjects undergoing primary palatoplasty at a tertiary care pediatric hospital over a 20-year period. The VF procedure involved joining two mucoperiosteal flaps with minimal levator muscle dissection. The BTF procedure with IVVP incorporated a pushback technique with retropositioning of the levator musculature with an end-to-end repair while lengthening the soft palate. Subjects underwent palatoplasty by one of three fellowship-trained craniofacial surgeons prior to 20 months of age and had >2 years of postoperative speech evaluations. Speech evaluations were performed by a team of speech language pathologists using the Velopharyngeal Function Assessment Scale (VFAS) scoring system; a VFAS score >5 and subsequent need for secondary speech surgery indicated clinically significant VPI. Patient characteristics and postoperative outcomes related to ONF and speech surgery were collected. Predictors of postoperative complications were assessed, with p<0.05 denoting significance.

Results: In total, n=80 subjects underwent BTF with IVVP repair at mean age of 12.4 months and n=47 subjects underwent VL repair at mean age of 12.8 months (p<0.25). There was an increased proportion of Veau II clefts in the BTF cohort (8.5% VL v. 26.3% BTF, p<0.03). The mean length of follow-up was 10.5 years in BTF and 7.7 years in VL (p<0.001). Mean age at initial postoperative speech assessment was 3.1 and 3.7 years in the BTF and VL cohorts, respectively (p<0.03). VFAS scores at initial assessment were not significantly different between cohorts (4.4 BTF versus 5.6 VL, p<0.09). The rate of postoperative ONF was significantly greater in the VL cohort (22% BTF v. 66% VL, p<0.001). The rate of secondary VPI speech surgery was significantly greater in the VL cohort (33% v. 57%, p<0.01). Veau classification did not correlate with postoperative ONF or VPI. On multivariate regression, VL repair type correlated with the development of postoperative ONF complications and need for speech surgery (Odds Ratio 8.4, p<0.001).

Conclusion: When compared to von Langenbeck palatoplasty, Bardach Two-Flap Palatoplasty with Intravelar Veloplasty may be associated with decreased rates of speech surgery without increased rates of ONF. With either technique, degree of muscle overlap and tension potentially serve as confounding variables for the occurrence of ONF, VPI, and need for speech surgery. Future directions include comparing this cohort to subjects undergoing modified Furlow palatoplasty.

References 1. Sommerlad BC. A technique for cleft palate repair. Plast Reconstr Surg. 2003;112(6):1542-1548. 2. Agrawal K. Cleft palate repair and variations. Indian J Plast Surg. 2009;42 Suppl(Suppl):S102-S109.

Background: Facial feminization surgery (FFS) consists of a variety of procedures to treat gender dysphoria, including but not limited to hairline advancement and forehead contouring. Acute telogen effluvium, or "shock hair loss", is a known risk of major surgery, especially those involving the scalp region. 1 Hairline lowering procedures may be at particularly high risk due to high tension on the scalp tissue, reduced vascularization from galeal scoring techniques, or manipulation of the hair-bearing regions. 2 Post-operative hair loss in transfeminine patients may be exceptionally distressing for those who suffered from male-pattern hair loss prior to transitioning. Despite the known risk of telogen effluvium after FFS, there are very few studies in the literature describing its incidence, treatment, or outcomes. This is the first large-scale study examining the risks, outcomes, and treatments of shock hair loss after FFS.

Methods: All patients who underwent primary facial feminization surgery between 2018 and 2022 at a single integrated healthcare system were evaluated in a retrospective analysis. Patient charts were reviewed for operation type, length of stay, surgery duration, complications, postoperative course, post-operative Emergency Department or Urgent Care (ED/UC) visits, readmissions, and demographic factors. Primary outcomes included post-operative telogen effluvium, or diffuse hair loss outside of scar alopecia, and whether recovery of hair growth was observed. Chi square analyses and independent t tests were performed to compare groups and determine associations between outcomes.

Results: A total of 242 patients ages 18 to 80 were included for analysis. A total of 14 patients were found to have postoperative alopecia. Patients with alopecia were not found to have significant differences in age, body mass index, estimated blood loss, follow up duration (mean 140 days), or surgery time compared to patients with no reported hair loss. Of these patients, all 14 patients received forehead contouring procedures (p=0.16), 11 (79%) received hairline advancement procedures (p=0.69), 10 (71%) received brow lifts (p=0.30), and 9 patients (64%) had FFS of both the upper and lower face (p=0.88). Eleven patients (79%) had galeal scoring during hairline advancement. The risk of telogen effluvium across all FFS patients was 5.8%. The risk of telogen effluvium amongst those who had bicoronal incisions was 6.5%. Five patients (36%) received treatments including minoxidil (14%) or steroids (21%). Twelve out of 14 patients (86%) demonstrated documented recovery of hair growth. The remaining 2 patients were awaiting hair regrowth at the most recent follow up.

Conclusions: Acute telogen effluvium after FFS is a relatively common phenomenon, affecting approximately 5.8% of patients. All cases were associated with hairline advancement or frontal bone contouring procedures, with a risk of 6.5% amongst those patients. The overwhelming majority of patients suffering from shock hair loss demonstrated recovery of hair growth over time, regardless of whether medical interventions were used. Although hair loss after FFS may be concerning for transfeminine patients, they should be counseled on the risk of telogen effluvium preoperatively and reassured that the natural course is typically recovery of hair growth over time.

References: 1. Desai, S. P., & Roaf, E. R. (1984). Telogen Effluvium after Anesthesia and Surgery. Anesthesia & Analgesia, 63(1), 83. 2. Epstein, J., & Epstein, G. K. (2020). Hairline-Lowering Surgery. Facial Plastic Surgery Clinics of North America, 28(2), 197–203. https://doi.org/10.1016/j.fsc.2020.01.002

Background: Facial infections are common within the pediatric population and frequently occur due to trauma. There is a paucity of data investigating common microbiology, infection presentation, and treatment among pediatric patients with facial injury and concomitant infection. Extensive research exists regarding adult facial infections, however there are known differences in microbiologic flora and infection manifestations between adults and children. This can contribute to antibiotic misuse in the setting of pediatric facial infections. Objective: To evaluate common microbiology, presentation, and treatment options of pediatric patients admitted to a tertiary level care center with facial infection. Methods: A retrospective review of pediatric patients (<18yo) admitted to a tertiary care center with a diagnosis of a head or neck infection between 2012-2021 was performed. Plastic surgery was consulted on all patients. Patient factors evaluated included age, gender, comorbid conditions, diagnosis, mechanism of injury, time from onset of symptoms to presentation, prior evaluation at an outside center, prior antibiotic treatment for current condition, gram stain, culture results, and length of follow-up. Management factors evaluated included treatment type, empiric antibiotic administration by the emergency department (ED), inpatient duration, and discharge antibiotics. Results: Thirty-four children (mean: 6.6yo, 56% M) were admitted from the pediatric ED for management of facial infections. Most infections were caused by trauma (50%) with dog bites being most frequent, followed by falls. Infections after the development of acne vulgaris accounted for 41.1% of cases. The remainder were from unidentifiable causes. Over 70% of patients had failed oral antibiotic therapy prior to admission. On presentation, most patients were afebrile (85%), but nearly half of the patients had evidence of a leukocytosis. Imaging was completed in 48% of patients, with 24% receiving CT scan performed and 24% receiving ultrasound. The most common location of infection was the cheek/mandible (35%), followed by the nose, forehead/temple, lip, eye, chin, and ear. In the ED most patients were treated with IV clindamycin (44%) followed by Unasyn, Vancomycin, Zosyn and Zyvox. Almost all patients underwent incision and drainage in the ED, and two patients required formal operative intervention. Culture results varied by mechanism of injury with MRSA being the most common in the setting of acne vulgaris, and Pasteurella frequently associated with dog bites. Most cultures tested for gram stain were gram positive. Twenty-four percent of patients did not have cultures finalized by time of discharge. All patients were discharged on oral antibiotics with Clindamycin and Augmentin were most common. One patient required a PICC placement for IV antibiotics on discharge. Conclusions: Facial infections are common in the pediatric population. These infections can be safely managed with IV antibiotics and bedside drainage with subsequent local wound care. There are disparities in empiric antibiotic utilization for these patients. As such, standardized protocols to help guide clinicians' treatment approaches are needed for the pediatric population.

Introduction: Sagittal craniosynostosis is caused by premature fusion of the sagittal suture, which creates a scaphocephalic head shape and may lead to increased intracranial pressure.(1) Repair during the first year of life can help prevent social and neurodevelopmental complications. Common methods of repair are open cranial vault reconstruction (OCVR) and strip craniectomy with orthotic helmet therapy (SCOT).(2) However, although both SCOT and OCVR are considered to be efficacious for treatment of sagittal craniosynostosis, direct comparisons of cranial shape and appearance are lacking. The purpose of this study is to compare long-term cephalometric outcomes, and patient satisfaction between OCVR and SCOT.

Methods: Patients who were non-syndromic and underwent OCVR or SCOT before 12 months of age for isolated sagittal craniosynostosis at our institution were included in the study. A chart review was conducted to record demographics and assess intraoperative outcomes. Preoperative anthropometric measurements were made using computed tomography to include cranial index (CI), frontal bossing(3), occipital bulleting(3), vertex-nasion-opisthocranion (VNO) angle(4), vertical height, and intracranial volume. Patients were recruited for 3D photography, and anthropometric measurements were made using Vectra software to include CI, auricular height, VNO angle and circumference. Scaphocephaly is defined as having a CI <76%.(5) Recruited patients were asked to complete a satisfaction survey. Blinded Whittaker classification ratings were made on 3D photographs. Descriptive statistics, t-test, and Fisher's exact test were calculated.

Results: Forty-seven patients were included (18 SCOT and 29 OCVR), with a median age at the time of surgery of 3 months (2-4 months) and 7 months (6-8 months) in SCOT and OCVR patients, respectively. Follow-up at the time of recruitment was similar between groups (SCOT 6.7 +/-2.2 years, OCVR 7.0 +/-1.7 years). Patients who underwent SCOT had shorter operative times (p<0.001), less estimated blood loss (p<0.001), fewer blood transfusions (p=0.045), and shorter hospital stays (p=0.01). At baseline, the SCOT patients had more severe CI measurements (SCOT 67.29% vs. OCVR 73.1%; p=0.02) and occipital bulleting (SCOT 135.3° vs. OCVR 122.3°; p=0.01). There were no statistically significant differences in measurements on postoperative 3D photographs between OCVR and SCOT. More patients had a Whittaker classification rating of 1 in the OCVR group compared to SCOT with most patients receiving a score of 2 in both groups. OCVR and SCOT patients reported statistically similar satisfaction with the results of surgery (p=0.30) and appearance of the scar (p=0.42), and they were no more likely to report bullying (p=0.37)

Conclusions: Despite more severe CI and occipital bulleting measurements at baseline, SCOT patients had similar long-term morphological measurements to OCVR patients. Furthermore, patients reported similar satisfaction with their long-term healing, appearance, and appearance of the scar following SCOT compared with OCVR. However, Whittaker ratings indicate that OCVR may lead to lower scores compared to SCOT. These data suggest that neither SCOT nor OCVR has generalizable superiority in terms of perioperative and outcome metrics. The optimal approach should be decided on a case by case basis.

References: 1. Dempsey RF, Monson LA, Maricevich RS, et al. Nonsyndromic Craniosynostosis. Clinics in Plastic Surgery. 2019;46(2):123-139. doi:10.1016/j.cps.2018.11.001 2. Simpson A, Wong AL, Bezuhly M. Surgical Correction of Nonsyndromic Sagittal Craniosynostosis: Concepts and Controversies. Annals of Plastic Surgery. 2017;78(1):103-110. doi:10.1097/SAP.0000000000000713 3. Ou Yang O, Marucci DD, Gates RJ, et al. Analysis of the cephalometric changes in the first 3 months after spring-assisted cranioplasty for scaphocephaly. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2017;70(5):673-685. doi:10.1016/j.bjps.2016.12.004 4. Blum JD, Cho DY, Cheung L, et al. Making the Diagnosis in Sagittal Craniosynostosis-It's Height, Not Length, That Matters. Childs Nerv Syst. 2022;38(7):1331-1340. doi:10.1007/s00381-022-05518-3 5. Morritt DG, Yeh FJJ, Wall SA, Richards PG, Jayamohan J, Johnson D. Management of Isolated Sagittal Synostosis in the Absence of Scaphocephaly: A Series of Eight Cases: Plastic and Reconstructive Surgery. 2010;126(2):572-580. doi:10.1097/PRS.0b013e3181e09533

Introduction: Socioeconomic status (SES) is a known risk factor for delayed care of congenital birth defects. Current literature is sparse regarding the effect of race and socioeconomic status (SES) on the timing of cleft lip and/or palate (CL±P), craniosynostosis, and plagiocephaly presentation to clinic and possible repair. The goal of this study is to quantify differences in when socioeconomic and racial minorities with craniofacial defects present to a single-institution hospital for evaluation as compared to pediatric populations with higher resources.

Methods: A retrospective review of patients with CL±P and head shape conditions from Jan 2001 to Feb 2022 were included. Age at first plastic surgery clinic appointment, age at repair if applicable, gender, race, and zip code were collected. The Validated Child Opportunity Index (COI) scale was calculated based on zip code as a measure of SES. Kruskal-Wallis tests and Dunn's procedures were used for continuous variables and post hoc pairwise comparisons.

Results: 2733 patients with CL±P, 9974 with plagiocephaly/brachycephaly, and 59 patients with craniosynostosis were included. Among patients with CL±P, Black and Hispanic patients presented significantly later to both first plastic surgery clinic appointment and age at repair than White patients(p<.001). White patients and higher SES were associated with a significantly earlier date of initial presentation to plastic surgery clinic for head shape conditions(p<.001).

Conclusions: Race and SES may play an important role in the delay of first presentation to plastic surgery clinic and subsequent repair for these patient populations. Further educational efforts must be provided to ensure equitable care. This single institutional study may serve to encourage other academic centers to analyze the timing of care for our pediatric patients.

Background: Fresh Frozen cadaveric costal cartilage grafts have seen increased attention in the published literature. However, minimal efforts have been made to describe changes in histologic properties after implantation for reconstructive plastic surgery. In this study we assess cellularity of cadaveric costal cartilage samples before and after implantation for ear reconstruction.

Methods: Cadaveric costal cartilage samples were collected before and five months after implantation for ear reconstruction surgery along with post implantation autologous rib, auricular remnant, and branchial vestige cartilage. All samples were stained with hematoxylin & eosin to determine percent occupied lacunae. A one-way ANOVA with Hochberg's GT2 post hoc test was used to compare mean percent occupied lacunae across all five groups.

Results: Mean percent occupied lacune was not significantly different for cadaveric costal cartilage before (95% CI 16.82 – 34.70) and after (95% CI 21.59 – 36.18) implantation. Post implantation autologous costal cartilage had significantly higher lacunae occupancy (95%CI 52.81 – 62.16) compared to cadaveric cartilage (p < .001). The difference in mean was not significant between auricular remnant (95% CI 75.12 – 85.70) and the branchial vestige (95% CI 71.85 – 94.83) cartilage, although both had significantly higher occupancy than cadaveric cartilage (p <.001).

Conclusion: Cadaveric costal cartilage cellularity does not change five months after implantation for ear reconstruction, although it is overall lower than autologous and native cartilage. This suggests that the cartilage extracellular matrix effectively shields residual cells from the host immune system preventing further cartilage decellularization and inflammation.

Objective: Using cadaveric costal cartilage may allow preoperative automated auricular framework production for ear reconstruction. To evaluate the feasibility of this approach, we used automated milling to create auricular frameworks based on a handmade 3-dimensional (3D) model. Methods: A Firmin type I auricular framework model was manually carved en bloc out of soap and scanned using a dental lab 3D scanner. CAD/CAM software was used to process scans and create a tool path to guide an automated mill. Polyethylene, potato, and human cadaveric cartilage were used to attempt to produce acceptable frameworks. Time to mill a complete framework, and framework dimensions were compared across materials. Results: Type I en bloc frameworks were milled from polyethylene and potato. The tool path was modified to produce an en bloc type II framework due to the limited size of the available cadaveric cartilage block. Frameworks deviated less than 1mm in all dimensions from the model. Milling time was determined by the pre-made tool path and therefore did not vary between materials. Milling time was 35 minutes for a type I framework and 23 minutes for a type II framework with helix, antihelix, and antitragus definition matching the scanned model regardless of material. Conclusions: Framework milling can be done quickly and within a negligible margin of error. Cadaveric cartilage block size limits en block framework milling to type II/III frameworks; however, a tragus segment can also be milled and sutured in place intraoperatively.

Purpose: Macrocephaly occurs when a patient's head circumference is greater than 2 standard deviations above the population mean, and the most common etiology is hydrocephalus. Hydrocephalic macrocephaly results in significant morbidity that includes poor psychosocial development, positioning difficulties, skin breakdown, and poor cosmesis. Reduction cranioplasty (RC) is a surgical technique that has been applied to treat hydrocephalic macrocephaly. The primary objective of this systematic review is to report the surgical outcomes of RC for hydrocephalic macrocephaly, and secondarily, to synthesize the reported advantages and disadvantages of the various techniques for this procedure.

Methods and Materials: A systematic review was performed using PubMed, Scopus, and Web of Science, following modified Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). Two independent reviewers screened 350 studies and 25 studies reporting on RC for hydrocephalic macrocephaly were included. Data on study design, patient demographics, operative details, and surgical outcomes were collected. Levels of evidence were defined in accordance with the criteria set by the American Society of Plastic Surgeons.

Results: In the 25 included studies, there was a total of 64 reduction cranioplasties with a mean cohort size of 2.6 (SD 2.5) patients. Sixteen (64%) studies presented level V evidence, 7 (28%) presented level IV evidence, and 2 (8%) presented level III evidence. Single-stage reconstructions were employed in 64% of studies, while 32% of studies presented multi-stage reconstructions and one study (4%) presented both single and multi-stage techniques. Improved postoperative head positioning after RC was reported in 92% of studies, improved postoperative aesthetics was reported in 88% of studies, and improved postoperative neurologic functioning was reported in 76% of studies. All studies that examined pre- and post-operative differences in head circumference or intracranial volume reduction were successful in head size reduction. There was a mortality rate of 4.7% in the 64 RCs.

Conclusion: Most studies on RC report improvement in head size, head positioning, cosmesis, and neurologic functioning. However, these studies have small cohort sizes and low levels of evidence due to the rarity of hydrocephalic macrocephaly. These findings suggest that RC is a promising surgical technique for hydrocephalic macrocephaly that merits further investigation.

Background Previous work has identified an association between de novo and transmitted loss of function mutations in genes under high evolutionary constraint (high pLI) with neurodevelopmental delays in non-syndromic craniosynostosis (NSC). In this study, we investigated the behavioral outcomes of sagittal synostosis patients with genetic lesions (high pLI) compared to sagittal synostosis patients without genetic lesions (non-high pLI).

Methods Parents of children ages 6-18 years old with surgically corrected sagittal synostosis were recruited nationally to complete the Child's Behavioral Checklist (CBCL), Conners-3, Social Responsiveness Scale-2 (SRS-2), and Behavior Rating Inventory of Executive Function-2 (BRIEF-2). CBCL assesses behavioral and emotional function, Conners-3 assesses features of ADHD, SRS-2 assesses features of autism spectrum disorder (ASD), and BRIEF-2 assesses executive function. Multivariate linear regression was used to determine the association of high pLI with behavioral scores, while controlling for sociodemographic factors, age at surgery, surgery type, and IQ. Additional sub-analyses were completed to evaluate factors associated with each score within each group (non-high pLI group and high pLI group).

Results Parents of 45 patients completed the behavioral assessments. Sixteen patients had a mutation in a highly constrained gene (high pLI). There was no significant difference in average age at assessment (8.29±1.87 vs 8.74±2.55 years, p=0.31) between non-high and high pLI groups. There was a greater proportion of children with high pLI that reached at or above borderline clinical levels for aggression (18.8% vs 0.0%, p=0.05) and externalizing problems (31.3% vs 3.7%, p=0.02) as assessed by the CBCL. Multivariate linear regression further showed that high pLI was associated with rule breaking (p=0.05) and aggression (p=0.01). Upon sub-analysis of children with high pLI, sociodemographic factors, age at surgery, surgery type, and IQ were not associated with worse scores in any of the assessments. However, in children with non-high pLI, greater age at surgery was associated with worse scores in rule breaking, aggression and externalizing problems domains (p<0.05) and ASD-related social cognition, social communication, social motivation and restrictive interests and repetitive behaviors symptom domains (p<0.05).

Conclusion Children with sagittal synostosis and high pLI had worse problems in externalizing behaviors, including rule breaking and aggression. Among children with non-high pLI, greater age at surgery was associated with social difficulties and externalizing behaviors. High pLI may exacerbate externalizing behavioral problems, though when children do not have high pLI, other factors such as timing of surgery may become important.

Background: The Abbe flap is a useful approach in the reconstruction of a secondary cleft lip deformity. In brief, this approach utilizes a full-thickness, vermillion-pedicled flap that is rotated from the lower lip to the upper lip for secondary cleft lip repair and allows the surgeon to create philtrum divots and ridges that can be combined with other surgical approaches.

Methods: A literature review was established to review differing techniques, modifications, and combinations presented on the PubMed database. In total, about 88 papers resulted with 26 applicable after appropriate filters were applied. This was used to supplement a recent Abbe lip-switch flap conducted at Wake Forest Baptist Health for the indication of secondary cleft lip deformity. Of particular interest in this case is the presence of a concomitant nasolabial fistula repaired simultaneously at the initial Abbe surgery with a mucosal flap from the resected philtrum.

Results: From the literature, twenty-six studies published from 2002 to 2020 were included for a total of 456 patients. Ninety-seven percent of surveyed patients reported satisfactory results. The complication rate necessitating revision surgery was 32 patients, or 7.0%. Conclusions: The Abbe flap for secondary cleft lip reconstruction has a high rate of patient satisfaction and low rate of complication. This poses an argument for its utilization and practicality beyond its current scope. Leftover tissue from the philtral skin at the time for Abbe can be utilized with columellar elongation and nasolabial fistula repair, as noted in some of the selected texts.