Scientific Abstract Presentations: Craniomaxillofacial 5 Saturday, October 28 Sat, Oct 28 10:30 a.m.-12:30 p.m. CDT

INTRODUCTION Age-appropriate cleft lip repair (CLR) enhances speech and feeding performance, cosmetic appearance, and quality of life (QOL). However, there are differences in access to and experience with CLR, which can ultimately affect surgical outcomes. This study aims to review the current literature regarding sociodemographic disparities that impact access to CLR as well as surgical outcomes in the United States (US).

METHODS A systematic review was conducted using Pubmed, Embase, and Medline databases. Studies discussing sociodemographic disparities regarding access to and outcomes after CLR were included. Studies performed outside the US, those published before 2000, epidemiologic studies, case reports and case series were excluded. Studies were sorted according to the PRISMA guidelines for systematic reviews and assigned a level of evidence using the GRADE system.

RESULTS Out of the 3782 studies identified on our initial search, 31 met our inclusion criteria. Disparities discussed in these articles included access to care (n=10), missed appointments (n=3), use of preoperative nasoalveolar molding [NAM] (n=3), surgical timing (n=9), and surgical outcomes (n=10).

Four studies demonstrated that geographical location, particularly in rural areas and for American-Indian or Alaskan-Native populations, was associated with poor access to care. In addition, financial limitations, poor healthcare literacy, and logistical constraints, such as taking time off from work, also limited patients' access to care.

Predictors for missed appointments included low socioeconomic status (SES) as well as black race, public insurance, and unstable living conditions. Two studies found that decreased pursuit of NAM was associated with Asian race, long driving distance to care facilities, and multi-children households. Another study demonstrated that single parents and those with non-private insurance were more likely to have difficulty with NAM usage.

Factors associated with delayed CLR included non-white race, non-private insurance, non-English primary language, and non-urban setting. One study showed that Asian race and Child Protective Services involvement were also associated with delayed CLR. Surgical outcomes were assessed in many ways using various aesthetic, speech, and QOL measures. Factors linked to worse surgical outcomes included black, latin, or mixed race as well as non-private insurance. Furthermore, black race was associated with longer hospitalization after surgery, and medicaid insurance was linked to higher readmission rates.

CONCLUSION Patients who are non-white, publicly insured, have a lower SES, and those living in geographically remote regions are impacted by disparities in access to and outcomes after CLR. State-affiliated care centers and statewide facial surgery mandates can help address these disparities. Future research should focus on developing other strategies to promote equity in the management of patients with cleft lip.

Introduction In patients with advanced cancers involving hypopharynx, cervical esophagus, or thyroid gland, pharyngoesophageal reconstruction after extensive ablation of tumor is necessary but sometimes afflicted with a variety of complications. Anastomotic leakage between cervical neo-esophagus and thoracic esophagus is not uncommon, especially in patients receiving preoperative radiation therapy. Herein, we presented a novel method using pedicled colon flap anastomosed with the cervical neo-esophagus to manage the leakage.

Patients and Methods Between 2004 and 2022, a total of 18 patients had pharyngoesophageal reconstructions due to advanced cancers involving hypopharynx, cervical esophagus, or thyroid gland, and received pedicled colon transposition connecting to the reconstructed cervical neo-esophagus for anastomotic leakage management. One group of them including 14 patients had already received preoperative irradiation, extensive tumor ablation, and immediate pharyngoesophageal reconstruction, but suffered from repetitive leakage from the anastomosis between cervical neo-esophagus and thoracic esophagus. The pedicled colon transposition method was used to treat the anastomotic leakage. Another group of them including 4 patients had received preoperative radiotherapy to reduce tumor burden before tumor excision. After tumor ablation, the remaining stump of thoracic esophagus appeared fibrotic and ischemic. The pedicled colon transposition method was used to prevent the anastomotic leakage. The pedicled colon flap was harvested via open laparotomy and based on middle colic artery. The cephalic end of colon flap was connected to the cervical neo-esophagus, and the caudal end was connected to jejunum. Blood supply of the colon flap was supercharged with anastomosis of its pedicles with neck vessels.

Results The average duration of flap harvest was 7 hours. No anastomotic leakage between cervical neo-esophagus and thoracic esophagus was noted postoperatively in either group. All patients can resume oral intake. Regarding the intra-abdominal complications, only transient diarrhea was noted in 88% of patients for one month.

Conclusion For patients receiving pharyngoesophageal reconstructions and preoperative radiation therapy, a pedicled colon transposition method would be a feasible method to treat or prevent the anastomotic leakage between cervical neo-esophagus and thoracic esophagus.

Introduction: Osteoradionecrosis (ORN) of the mandible is an unfortunate possible sequela of radiotherapy for head and neck cancer. In advanced cases of ORN, mandibulectomy and free fibula flap reconstruction is required. We hypothesized that patients undergoing fibula free flap reconstruction of ORN mandibulectomy pose unique challenges and experience more complications than patients undergoing fibula free flaps after oncologic mandibulectomy.

Methods: After IRB approval, we reviewed a database of all free fibula flaps for mandible reconstruction from April 2005 through October 2019. Patient and surgical characteristics and post-operative outcomes were compared between reconstructions for mandibular ORN versus reconstructions for advanced stage malignancy involving the mandible (non-ORN). Propensity-matching was performed based on age, BMI, smoking status, preoperative chemotherapy and virtual surgery planning (VSP) use to control for bias. Multivariate logistic regression analysis was performed to define the relationship between patient and surgical factors and postoperative outcomes.

Results: 479 patients met inclusion criteria (168 ORN versus 311 non-ORN). Propensity-matching yielded 159 patients in each group. ORN patients received more double-skin-island fibula flaps compared to non-OR patients (20.8% vs. 5.7%, p<0.001). Recipient artery other than the facial artery was utilized more commonly in ORN patients (42.1% vs. 17.0%, p <0.001). In the unmatched cohort, ORN patients had higher rates of delayed wound healing (26.2% vs. 16.8%, p=0.01) and surgical site infections (21.4% vs. 13.2%, p=0.02). Rates of flap loss, return to operating room, hematoma, operative time, and length of stay were similar between the groups. Multivariate logistic regression analysis showed ORN to be an independent risk factor for delayed wound healing.

Conclusion: Our analysis supports our hypothesis that free fibula flap mandible reconstruction for ORN is more challenging than reconstruction for de novo malignancy, often requiring two skin islands for both intraoral and extraoral resurfacing and unconventional recipient vessels due to previous history of neck dissection and radiotherapy. ORN patients also experience more delayed wound healing compared to non-ORN patients.

Background: Non-syndromic cleft lip and palate (NSCL/P) is one of the most common craniofacial anomalies with multifactorial genetic and environmental etiologies. Senescence, as indicated by senescence-associated markers, including Alu methylation, AGE, RAGE and p16 expressions may be the pathogenesis of NSCL/P. However, link between those senescence-associated markers and the severity of NSCL/P has not been investigated. Thus, the present study aimed to explore the association of senescence-associated markers and the severity of NSCL/P.

Methods: Prospective cohort study was conducted from January 2022 to January 2023. The Alu methylation and aging marker, as indicated by AGE, RAGE and p16 expression, were examined in NSCL/P patients and their mothers. The NSCL/P white blood cells (WBCs)-Alu methylation were evaluated in three phases of patients, including 0-3 months old, 3-6 months old (cheiloplasty), and 9-12 months old (palatoplasty). WBCs-Alu methylation of mothers was examined only at the first visit. We also investigated for tissue specific Alu methylation, such as lip and palate from discarded tissues in cheiloplasty and palatoplasty.

Results: 39 NSCL/P patients (cleft lip only (CLO: n=6); cleft palate only (CPO: n=9); cleft lip with palate (CL/P: n=24) and their mothers were enrolled. 48.7% of patients were male. Our results showed that an increase in RAGE expression of WBCs-patients was positively correlated with severity of cleft subtypes (p<0.05). In mother, an increase in WBCs-Alu methylation was observed in CL/P group, compared with CPO group, whereas WBCs-Alu methylation was not different between CLO and CPO groups. However, mean WBCs-Alu methylation in patients were 64.3 +/- 2.9%, 66.0 +/- 1.8%, 61.8 +/- 6.0% for CLO, CPO, CLP, respectively (p >0.05). For tissue Alu methylation, mean Alu methylation were 62.2 +/- 4.1%, 66.1 +/- 5.3% for lip and palatal tissues, respectively, and there was not statistically significant between groups. We found no significant correlation between senescence-associated markers in tissues and cleft specific subtypes.

Conclusions: Our findings suggest a link between systemic aging-senescence-associated markers in patients, increased WBCs-Alu methylation in mothers, and the severity of NSCL/P. Therefore, NSCL/P pathogenesis may be influenced by the maternal aging process and senescence of the patients.

Several factors affect the outcome of the treatment of the Unilateral Cleft Lip, some of these, like the surgeon`s expertise, are hard to evaluate, some others can be better evaluated objectively, such as the cleft severity index and the surgical technique used. Materials and Methods: This study includes the patients, both private and from Operation Smile, treated by the MD participants, and it has two parts. The retrospective part studies the medical records of 298 patients with unilateral cleft lip treated from January 2015 to December 2017, it correlates the photographs, surgical technique, and evolution of the patients. In the prospective part, we applied the Algorithm proposed in this paper in 136 patients treated from January 2018 to December 2019. Results: In the retrospective part, all the cases were correlated with the case-technique analysis. Using this results we formulate the Four Line Algorithm. In the prospective part we applied the algorithm and, after the results analysis, we confirm its applicability and feasibility. Discussion: Even though the cleft severity in the Unilateral Cleft Lip is an important prognostic factor, the results of this study show that there are not universal surgical techniques. The Four Line Algorithm proposes to use a case specific surgical technique to achieve the best functional and esthetic result for our patients.

Introduction: Zygoma plays an important role in facial aesthetics by determining facial width and malar projection. Primary objective of Zygomatico -Maxillary Complex (ZMC) fracture management is to restore the facial contour by accurate reduction and fixation of ZMC. The accuracy of fracture reduction depends largely on the surgeon and can be potentially compromised by incomplete visualization of all ZMC articulations. 3 D surgical navigation is a tool which can be helpful in achieving accurate reduction of three-dimensional structure like ZMC. We evaluated the application of CT image-guided 3D navigation system in zygoma fractures
Materials & Methods: A prospective case control study was conducted among patients with unilateral zygoma fractures presenting in the acute setting to Level I trauma center. We divided the patients in study group, where fracture reduction was done under CT-image guided 3D navigation; and the control group, in whom, no navigation assistance was provided. HRCT scan of face with 3D reconstruction with 1 mm cuts was done preoperatively for Case and Control Group. However, virtual planning in BrainLAB iPLAN navigation software was done in the study group only This involved mirroring an individually defined 3D segment of the unaffected side into the affected side and defining a virtual correction, thus creating an ideal unilateral reconstruction. The points used for confirming accuracy were FMT (Most lateral point of the frontozygomatic suture), MP (Most anterior point of the zygoma) and ZTL (Most inferior point of the zygomatico-temporal suture). The accuracy of reduction was confirmed intraoperatively by using 3D navigation guide and only when path of navigation probe coincided with the fracture fragment edges in a desired position, reduction was considered to be accurate. In the control group, clinical judgement and experience were the only guides for accuracy of reduction intra-operatively. Study outcomes were assessed both radiologically and clinically. For radiological assessment, mean difference in the distance of selected points FMT, MP and ZTL on fractured side from normal side was calculated pre operatively and postoperatively in both the groups and analysed. For clinical assessment, standardised photographs were taken after 3-month post-operative period in both the groups. Scoring of photographs was done by trained blinded observer using Holmes and Mathews grading system of malar asymmetry and analysed. Results and Observations: 16 patients in study group and 15 patients in control group completed three monthly follow up. The mean surgical deviation of all the three points i.e., FMT, MP and ZTL in both the groups preoperatively were similar. Hence both the groups had comparable displacement of ZMC. After surgical correction, there was no statistically significant difference between the reduction accuracy between both groups at all the three points ( p-value 0.947,0.824 and 0.525 for FMT, MP and ZTL respectively). Similarly, no statistical difference (p- value 0.802) was found in photographic assessment of control and study group. Conclusions: In the present study, we did not find any additional advantage of using 3D navigation system in terms of accuracy of fracture reduction as confirmed by postoperative HRCT evaluation and photographic evaluation.

Background and Purpose:
Three-dimensional (3D) printing has demonstrated efficacy in areas such as surgical planning, intraoperative guide creation, and custom implant creation. As this technology becomes more accessible, its use in specific fields deserves further attention. We sought to perform a systematic review of the implementation of 3D printing in pediatric craniofacial surgery, as none had previously been performed, to determine how this technology is being used most often and if there are any demonstrable benefits to its use.

Methods:
A systematic review was conducted according to Cochrane and PRISMA guidelines. PubMed, Embase, Cochrane library and Clinicaltrials.gov were queried with combinations of the terms: 3D printing, craniofacial, surgery, pediatric. This returned 34 non-duplicate studies that underwent screening for inclusion. Inclusion criteria included all original human studies containing patients <18 years old implementing 3D printing to aid in craniofacial surgery. Of those screened, eight studies were deemed irrelevant to the topic and 19 studies were excluded for wrong study design, wrong patient population, and wrong intervention or outcomes. Seven studies were included in the final review. JBI Critical Appraisal Checklists were utilized for grading as only case reports and series had been published and met eligibility criteria during review, with risk of bias inheritably high. Study selection, data extraction, and grading were performed independently by two authors.

Results: A total of seven studies (three case series and four case reports) were included. All were published between January 2017 to December 2022. The total population included was 73 patients. Average age was 6.76 years, and 50.7% of patients were male. The average length of reported follow-up was 16.32 months.

All studies addressed patients with different disease processes including craniosynostosis, cleft lip/palate, and mandibular hypoplasia. 3D printing was used to create models for mock surgery in two studies, custom intraoperative cutting guides (CGs) or molds in six studies, and to print custom cranioplasty implants in two studies. Most studies reported the specific 3D printing technology used.

All studies concluded that the use of 3D printing was beneficial, with no reported adverse events related to its use. Two case series directly assessed the accuracy of the 3D printed CGs and determined it was acceptable and within historical comparison. Four other studies included statements on improved accuracy due to the guides used. Five studies noted reduced operating time due to the implementation of 3D printed materials. One report estimated this led to cost savings of 10,800 €. Two studies noted reduced intraoperative blood loss, and one felt that the use of 3D printed materials led to a shorter hospitalization compared to previous cases.

Conclusions: Despite the limitations of the current literature, all studies concluded that the use of 3D printing in pediatric craniofacial surgery was beneficial. The most common use in this population was for creating custom intraoperative guides. All studies included patients with different craniofacial diseases demonstrating a variety of applications. Definitive conclusions on the benefits of 3D printing in pediatric craniofacial surgery cannot be made until further controlled research is performed.

Traditionally the forehead bony lesion is approached through either forehead skin directly or coronal incision, both incisions may leave prominent scar. Endoscopic approach may provide a minimal invasive way to deal with this disease while having a concern of potential soft tissue injury from the high speed burr. We present a case of 35-year-old female with multiple frontal bone osteomas successfully removed via two small hairline incisions with the help of otorhinolaryngological system and an innovative mini-trocar. Significant improvement of forehead shape with minimal scars were observed at eighteen-month follow-up. This innovative and easily manipulating techniques may help surgeons to achieve better outcome when treating frontal bone osteoma endoscopically

(I am not able to upload Surgical Video which can show more clearly about the innovative procedure)

Introduction: Congenital orbital anomalies are challenging to characterize and manage due to the wide spectrum of pathology with variability in morphology, etiology, and severity. Multiple classification systems exist within the realm of craniofacial deformities and have been successful in helping organize the discussion pertaining to and treatment of these defects. A comprehensive classification system allows for more effective communication and helps direct treatment of congenital orbital anomalies. We propose a novel system for classification of congenital orbital anomalies.

Methods: A systematic review of the literature was performed to identify previously proposed congenital orbital anomaly classification systems. Studies were identified using a standardized search string on PubMed and then reviewed by two independent reviewers. Congenital orbital anomalies were categorized by deformities of orbital size, position, and shape.

Results: The initial literature review yielded 983 results published between 1966 and 2023. Thirteen results were identified for more detailed review based on title and abstract. References cited in these manuscripts provided three additional results for detailed review. Seven results were excluded given inability to access full manuscript, all of which were published in 1990 or earlier. Of the remaining results, none proposed a classification system for congenital orbital anomalies. A comprehensive classification system was then devised. Type 1 was defined as disorders of size: Macro-orbit e.g. neurofibromatosis type 1; or Micro-orbit e.g. craniofacial microsomia, anophthalmia. Type 2 was defined as disorders of position: Hypertelorism e.g. Apert syndrome or Tessier 0-14 cleft; Hypotelorism e.g. metopic craniosynostosis; Pseudohypertelorism e.g. nasal dermoid cyst, frontonasal encephalocele; Vertical Orbital Dystopia e.g. craniofacial microsomia; or Cyclopia e.g. holoprosencephaly. Type 3 was defined as disorders of shape: Exorbitism e.g. Apert and Crouzon syndromes; or Orbital Clefts.

Conclusions: Congenital deformities of the orbit are complex, variable and can include rare phenotypes. Surgical management requires an understanding of etiology and morphology to determine an approach that successfully corrects the specific anatomic differences. The proposed classification system is practical and comprehensive. It addresses distinct abnormalities in morphology as opposed to individual syndromes which more directly guides treatment.

Purpose: Craniosynostosis is a complex condition requiring interventions between three and nine months of age. Literature notes delays in craniosynostosis intervention in underserved communities, however the effect of these delays remain unclear(1,2 ). This study evaluates the impact of demographics on outcomes of calvarial vault remodeling (CVR).

Methods: All patients undergoing open surgical intervention for craniosynostosis from 2015-2022 at an urban academic institution were retrospectively reviewed. Patient demographics, age at presentation, age at surgery, intraoperative complications, and long-term outcomes were collected. Statistical analysis was performed in R studio 4.2.1.

Results: Upon review, 263 patients underwent surgical intervention for craniosynostosis. Patients with public insurance underwent CVR later than those with private insurance (9.46±6.00 vs. 7.64±4.34, p=0.051). Patients of Asian, Middle Eastern, Hispanic racial groups underwent CVR later than other races (p=0.015, Table 1). Delayed repair (>9 months) was correlated with higher blood loss (318.8cc vs. 262.7cc, p=0.024), less blood transfused (313.7cc vs 351.5cc, p=0.058), and higher rates of postoperative helmet therapy (48.6% vs. 23.1%, p=0.031) compared to repair before nine months.

Conclusions: Our results demonstrated delayed calvarial vault remodeling in patients of color and patients with public insurance. This delay in care was associated with increased intraoperative blood loss, trending lower subsequent transfusion volumes, and increased burden of postoperative care. In underserved populations, awareness and access to specialized reconstructive care may help mitigate negative intraoperative outcomes and additional postoperative interventions.

References: 1. Hauc SC, Junn A, Dinis J, Phillips S, Alperovich M. Disparities in Craniosynostosis Outcomes by Race and Insurance Status. J Craniofac Surg. 2022;33(1):121-124. doi:10.1097/SCS.0000000000008100 2. Badiee RK, Maru J, Yang SC, Alcon A, Rosenbluth G, Pomerantz JH. Racial and Socioeconomic Disparities in Prompt Craniosynostosis Workup and Treatment. J Craniofac Surg. 2022;33(8):2422-2426. doi:10.1097/SCS.0000000000008815

Background: The failure of cleft alveolar bone grafting (ABG) can lead to persistent alveolar fistula and inadequate bone stock to support the maxillary arch, causing difficulty in tooth eruption. The incidence of ABG failure has been reported to be as high as 18% in unilateral cleft lip and palate (UCLP) and 32% in bilateral cleft lip and palate (BCLP).1 Parents often desire an alternative to ABG with an autologous iliac crest graft, and cleft surgeons are utilizing an increased number of non-autologous materials.2 This study presents and assesses a novel approach that utilizes recombinant human bone morphogenic protein 2 (rhBMP-2) and allograft cellular bone matrix (CBM) for revision ABG.

Methods: Retrospective review of 14 UCLP and 4 BCLP patients who had failed secondary ABG with autologous iliac crest graft followed by revision rhBMP-2 and allograft CBM ABG. Cone beam CT (CBCT) was evaluated before and six months after the revision ABG. Cleft volume analysis was performed using CBCT manual segmentation of each slice of the cleft non-bone area from the pyriform aperture rim to the marginal gingiva of adjacent teeth.

Results: Revision surgery was at 11.45 ± 1.20 years in UCLP and 11.30 ± 1.82 years in BCLP. The revision surgery was found to have decreased operative times compared to the secondary ABG reconstruction in both UCLP and BCLP. The estimated blood loss was significantly lower in the UCLP group (p<0.001). Hospital length of stay was similar between secondary and revision ABG. No postoperative complications were found in either group. Repeat ABG surgery was required in one patient. Bergland score improved from 3.86 ± 0.53 to 1.21 ± 0.80 in the UCLP group and from 3.75 ± 0.50 to 1.00 ± 0.00 in the BCLP group. The cleft volume significantly decreased by 83.62 ± 9.78% (p<0.001) in UCLP and by 86.73 ± 13.65% (p<0.001) in the BCLP group.

Conclusions: Revision ABG with rhBMP-2 and allograft CBM have been shown to be a successful and reliable approach. This method decreased operative time, no postoperative complications, or increased hospital length of stay. All patients achieved clinically successful grafting with canine eruption, and no patients required further ABG operative intervention. Both UCLP and BCLP groups saw a significant decrease in cleft volume.

1. Goudy S, Lott D, Burton R, Wheeler J, Canady J. Secondary alveolar bone grafting: outcomes, revisions, and new applications. Cleft Palate Craniofac J. 2009;46(6):610-612
2. Qamar F, Cray Jr JJ, Halsey J, Rottgers SA. A survey of bone grafting practice patterns in north american cleft surgeons. Cleft Palate Craniofac J. 2022;Online ahead of print.

Background: Vascular malformations (VM) of the face and scalp can cause aesthetic and clinical concerns. While the majority of treatment is laser or medically based, there are opportunities for surgical intervention. We need to understand indications for surgical resection and reconstruction for pediatric facial VM.

Methods This is a retrospective review of pediatric patients with vascular malformations treated surgically at UTHealth Pediatric Plastic Surgery Department from 2015 to 2021. The CPT codes related to vascular resection and reconstruction were queried in our billing database and the records were reviewed for location of lesion, indication for surgery, any prior treatment, and outcomes.

Results 34 pediatric patients were included in this study as having surgery for a VM on the face or scalp. The average age at initial consultation at our department was 5.8, with a median age of 3. The major symptoms and reasons for surgical intervention at presentations were growth (53%), ulceration or bleeding (26%), residual erythema or scarring (11%), pain (5%), and difficulty speaking/oral incompetence (12%). Prior to surgery, 25 of 34 patients tried some form of medical therapy, including systemic and topical beta blockers, laser treatment, sclerotherapy, and topical steroids. 28 of 34 patients had a surgical resection of their vascular malformation. 13 of 34 patients underwent laser treatment. Of the 28 patients who had surgical resection, 5 needed primary closure, 16 needed local tissue rearrangement or complex closure, 1 needed a local flap, and 1 needed a graft. Complications were rare and consisted of skin necrosis, remaining vascularity, swelling, and numbness.

Conclusions VA's are relatively rare, and an understanding of the approach to the cosmetically and functionally sensitive area of the face is important, as medical management is not always successful. The questions remain: how do we maximize medical therapy, when do we intervene, and how do we do this in the least invasive manner with the best outcome? Creating a database, evaluating treatments and outcomes, and creating an algorithm for the facial subunits will help provide this insight and further education on treatment, clinical course, and outcomes.

ABSTRACT

Introduction: Craniomaxillofacial surgeries for pediatric patients with cleft lip and/or palate are usually tightly coordinated to include optimal timing during the child's development for more favorable outcomes. However, with the emergence of the COVID-19 pandemic, hospitals were forced to cancel or postpone elective cases to allocate resources for the predicted increase in patients with SARS-COV-2 viral infection. Due to its non-emergent status, the volume for cleft lip and/or palate repair was expected to decline after the start of the pandemic. The purpose of this study is to evaluate the financial impacts by measuring the magnitude of the potential decline in cleft lip and/or palate repair, comparing case volume and hospital changes experienced in a single tertiary academic medical center before and after the start of the COVID-19 pandemic.

Methods: Upon Institutional Review Board approval, using the Augusta University Medical Center's Financial Billing Data, 83 patients that underwent cleft lip and/or palate repair were queried. A time horizon of March 2019 to February 2021 was used to determine the caseload and incurred charges one year prior to the COVID pandemic (March 1st, 2019 to February 29th, 2020 as the pre-COVID cohort) compared to the two years following the start of the COVID pandemic (March 1st, 2020 to February 28th, 2022 as the post-COVID cohort). Statistical analysis to compare one year pre-COVID, one year post-COVID, and two years post-COVID was conducted using paired t-test and the Wilcoxon signed-rank test.

Results: From the year prior to the onset of COVID-19 (March 2019 to February 2020) to the year following the onset of the pandemic (March 2020 to February 2021), there was a decrease in the number of cleft lip and/or palate repairs performed per month (2.75 to 1.42 per month, p-value 0.021). Additionally, there was a decrease in the per-month charges from the AU Health system for cleft lip/palate repair for the same time period ($13,334.75 to $7,237.17 per month, p-value 0.036). However, when analysis of cases and charges is extended to encompass the two years post-COVID (March 2020 to February 2022), these differences lose statistical significance (p-value 0.25, p-value 0.34), suggesting a return to pre-COVID baseline.

Conclusion: There was a statistically significant decrease in craniomaxillofacial surgery for cleft lip and/or palate repair in the 12 months following the start of the COVID-19 pandemic. Both the caseload and total charges decreased after March 2020, with a subsequent return to baseline after two years, reflecting the short-term effects of the COVID-19 pandemic on pediatric craniomaxillofacial surgical volume. These findings highlight the potential impact of future pandemic events and its transient effects with expected return to pre-event volumes which can guide future hospital planning of resource allocation. Additionally this can allow for the detection of post-COVID surge in orofacial cleft and/or palate cases that are likely to occur due to maternal immune activation.

Closure of wide palatal defects poses an operative challenge. Many operative techniques have been described for both soft and hard palatal defects. The primary goal of palate repair is palatal lengthening and re-orientation of the palatal musculature to achieve velopharyngeal competence. While closure of soft palatal defects in wide clefts is typically achieved with utilization of lateral relaxing incisions, a multi-layered closure of anterior defects is more challenging. Oftentimes, palatal length must be sacrificed to allow for tension free closure of the repair, especially when the cleft is wide. This can result in poor velopharyngeal functioning and the need for additional speech surgeries. With the most common and dreaded complication following repair being development of fistula, water-tight and tension-free closure of both oral and nasal layers of the anterior palate is necessary. We present a novel bipedicled anterior palatal flap was utilized for complete and tension-free closure of the palatal defects. After closure of the soft palate utilizing the Furlow palatoplasty technique, attention is turned to the anterior palatal defect. A releasing incision is made along the lingual alveolar ridge and hard palatal oral mucosal flaps are elevated with 360 degree dissection of the greater palatine neurovascular bundles to achieve maximum central advancement. Instead of completing the anterior palatal repair at the level of the anterior aspect of the cleft, the anterior attachment of the palate is raised in a subperiosteal manner and dissected free and detached from the anterior palate at the incisive foramen. Dissection is carried posteriorly until the greater palatine neurovascular bundles are encountered bilaterally. The anterior palatal flap is then freely mobile and "U-shaped" receiving dual blood supply from bilateral greater palatine vessels. It is then sutured together in the midline as a bipedicled mucoperiosteal flap for a tension free closure of the oral mucosa. Complete palatal closure in patients with a wide U-shaped cleft palate is a challenge. It has been widely studied that incidence of fistula development after palatoplasty is higher in patients with wide cleft palates. This is often due to significant tension on the anterior palatal closure. Multiple techniques have been described to offload this tension in order to achieve adequate closure; however there is no general consensus or gold standard recommendation. Here, we present a novel technique where raising a bipedicled anterior palatal mucoperiosteal flap with complete detachment from the hard palate anteriorly allowed for water-tight and tension free closure of very wide hard palatal defects. To our knowledge, this technique has not yet been described in the literature. The complete release of the mucoperiosteal flap from the hard palate offloaded significant tension to allow for adequate medial apposition. Additionally, freeing of all other tissue attachments while leaving this flap bipedicled ensured dual arterial inflow for adequate perfusion. Another benefit of this technique is the ability to set back the anterior palatal closure to a more posterior location, preventing inadvertent shortening of the palate that can happen when attempting closure of the anterior palate, thereby hoping to limit negative speech outcomes. While allowing some posterior positioning of the soft palate, this primary closure technique is still limited in the amount of retroposition able to be achieved. This report is limited with regards to long term follow up and how this repair will affect both speech outcomes and maxillary growth. While any cleft surgeon aims to provide a functional palate repair in terms of speech and mastication while preserving maxillary growth potential, no surgical protocols have yet to completely circumvent the hypoplastic maxilla. The amount to which this specific surgical procedure will limit maxillary and premaxillary growth is unknown at present but is a consideration when proceeding with this method.

Purpose: Hypoglossal nerve stimulation (HNS) is a relatively new surgical treatment for obstructive sleep apnea (OSA) for patients that failed positive airway pressure therapy. It's a less invasive technique with less recovery time than orthognathic surgery. Although HNS has shown long-term reduction in apnea-hypopnea index (AHI) scores and improved subjective quality of sleep, 37% of patients do not respond to treatment. Optimized patient selection and pre-operative counseling is therefore needed. This study aimed to determine if cephalometric measurements were associated with objective and subjective improvement in OSA symptoms following HNS.

Materials and methods: A single-center retrospective cohort study of 24 adult patients who underwent HNS from 2019-2022. Standard cephalometric values were obtained using post-operative lateral neck x-rays. A combined validated and non-validated telephone survey regarding quality of life and sleep including the Epworth Sleepiness Scale (ESS) and Functional Outcomes of Sleep Questionnaire-10 (FOSQ-10) was conducted. Univariate analyses utilized Wilcoxon Signed-Rank Test and Spearman's Rho.

Summary of results: The median patient age was 58.6 [IQR:48.8-66.5] years with BMI of 28.9 [27.1-31.9]. The median baseline AHI score was 29 [21.3-39.2], with a titration score of 17.9 [8.7-30.4] and a significant change of -8.6 [-28.3-0.2] (P=0.0441). Baseline median ESS score was 11 [5.5-15.0] with a titration score of 4 [3.0-7.2] and a significant change of -6 [-9.8-2.0] (P=0.0010). Post-procedure survey participation was 70.8% with median follow-up of 377 [258-594] days. The median survey ESS was 7 [5.8-8.2] with a change of -4 [-8.8-2.0] compared to baseline (P=0.0141). The median survey FOSQ-10 score was 16.7 [14.1-17.2]. Patients reported high satisfaction with surgery and improved quality of sleep with median scores of 8 [8.0-9.2] and 8 [7.0-9.2] on Likert-10 scales. Increased sella-nasion-B-point (SNB) and decreased sella-nasion-mandibular-plane (SNM) angles (median 78.5 [76.8-81.0] & 36.5 [33.5-39.2)] degrees) were associated with improved FOSQ-10 (R=-0.9 and R=0.9, P=0.0379 for both). Greater mandibular length (median 13.8 [12.9-14.5] cm) was associated with lower ESS at baseline (R=-0.4, P=0.0398), and greater improvement at titration (R=-0.6, P=0.0142), and survey (R=-0.6, P=0.0172). No cephalometric values were significantly associated with AHI.

Conclusions: Patients who underwent HNS had an overall significant improvement in both objective and subjective OSA symptoms. However, those with smaller SNB angles and shorter mandibles did not have a significant change in AHI. Retrognathic patients may benefit more from orthognathic surgery for OSA treatment. To better counsel patients with OSA on treatment options, lateral cephalometric x-rays should be obtained as part of their initial work-up.

Purpose: The etiology of orofacial clefts is thought to be multifactorial, consisting of both genetic and environmental factors. Among the environmental elements, maternal ultraviolet (UV) exposure has not been shown to influence the risk of orofacial clefting in newborns. In this study, we investigated the associations between prenatal UV doses – during the first trimester and during the three months prior to conception – and the odds of cleft lip with/without cleft palate (CLP) and cleft palate only (CPO) in the U.S. after controlling for demographic and other risk factors.

Methods: The U.S. 2014 and 2015 Natality Data were utilized (n = 7,986,908). Births with missing data or simultaneous diagnoses of both CLP and CPO were excluded. Mean daily county-level population-weighted erythemally-weighted daily UV dose (EDD) was calculated over two specific periods for each live birth, namely the first trimester and the three months prior to conception. Multivariable logistic regression models were created to control for household demographics, prenatal care, maternal health, infant characteristics, and socioeconomic factors.

Results: Of 7,692,735 live births included, 3,895 (0.05%) had CLP and 1,483 (0.02%) had CPO. Higher mean daily UV dose during the first trimester was associated with statistically significantly lower odds of CPO (AOR = 0.99 [0.99, 0.99], p < 0.001); however, this effect was not significant for CLP (AOR = 0.99 [0.99, 1.00], p = 0.596). The odds of CPO (AOR = 0.99 [0.99, 1.00], p = 0.117) and CLP (AOR = 1.00 [0.99, 1.00], p = 0.357) were independent of the mean prenatal daily UV dose during the three-month pre-conception period. The models confirmed several known risk/protective factors for CLP, including higher maternal education level (protective, AOR = 0.75 [0.64, 0.87], p < 0.001 for holders of bachelors' degree or above compared to non-high school graduates), delayed prenatal care (risk, AOR = 1.40 [1.18, 1.65], p < 0.001 for initiation of care in the third trimester compared to the first trimester), and maternal obesity (risk, AOR = 1.25 [1.14, 1.38], p < 0.001). Likewise, several risk factors for CPO were re-demonstrated, such as presence of other congenital disorders (AOR = 21.2 [16.5, 27.1], p < 0.001) and maternal gestational diabetes (AOR = 1.26 [1.01, 1.58], p = 0.039).

Conclusions: Higher daily maternal dose of UV during the first trimester was associated with decreased odds of CPO, but not CLP, after controlling for a comprehensive list of known and potential risk factors for orofacial clefting. However, UV dose during the three months prior to conception did not appear to be significantly linked to the risk of orofacial clefting. Given that palatogenesis occurs in the first trimester, our study suggested that UV and UV-mediated metabolic processes may be implicated in the embryologic events that influence palatal development and integrity. Further studies are needed to confirm this association and elucidate its mechanism.

Purpose: Excess nasal air emission resulting from velopharyngeal insufficiency (VPI) impairs production of intelligible speech. Pharyngeal flap (PF) surgery is effective at improving velopharyngeal sufficiency but historical literature shows a concerning prevalence rate of obstructive sleep apnea (OSA), reported as high as 20%. The purpose of this study is to determine whether a protocol developed and implemented by our institution is successful in minimizing the risk of postoperative obstructive complications following PF surgery. We hypothesize that (1) pre-operative staged removal of significant adenotonsillar tissue along with (2) multiview videofluoroscopy to guide patient specific surgical approach via appropriately sized pharyngeal flaps can result in excellent speech outcomes while limiting occurrence of OSA. Methods: This was a retrospective chart review of all patients with VPI (ages 2-20) seen at the University of Rochester from 2015-2022 who underwent PF surgery to correct VPI. Nasopharyngoscopy was used for surgical planning and airway evaluation. All patients with tonsillar and adenoid hypertrophy underwent staged adenotonsillectomy at least 2 months before PF. Multiview videofluoroscopy was used to identify anatomic causes of VPI and to determine pharyngeal flap width. Patients underwent polysomnography and speech evaluation prior to and at least 6 months following PF surgery. Sleep studies were scored using the American Academy of Sleep Medicine Manual for Scoring Sleep guidelines. Speech evaluation was performed according to the Great Ormond Street Hospital Cleft Audit Protocol for Speech and Modified Pittsburgh Weighted Values for Speech Symptoms Associated with Velopharyngeal Incompetence score.
Results: 41 children aged 8.5±4.1 years (range 4 to 18 years) were identified who underwent posterior pharyngeal flap surgery for VPI. This included 10 patients with 22q11.2 deletion and 4 patients with Pierre Robin Sequence. 39 patients had both pre- and post-operative speech data and underwent both a pre- and post-operative sleep study. Polysomnography showed no significant difference in obstructive apnea hypopnea index (O-AHI) following posterior pharyngeal flap surgery (O-AHI pre-op 1.3±1.2 events/hour; post-op 1.7±2.1 events/hour; p=0.111). Significant improvements in speech outcome was seen in patients who underwent PF (modified Pittsburgh score pre-op 11.52±1.37; post-op 1.09±2.35; p<0.05).
Conclusions: Utilization of preoperative staged adenotonsillectomy as well as patient specific pharyngeal flap dimensions results in effective resolution of velopharyngeal insufficiency and a low risk of OSA.

Background: Fractures of the facial bones in women are less common than in men in the United States. However, little is known about the epidemiology and characteristics of women who sustain facial fractures. Our aim was to describe the patient population of women who seek emergency care for facial fractures in the United States as well as the type and cost of care received in this setting.

Methods: This is a retrospective cohort study using the 2019 National Emergency Department Sample. The inclusion criterion was a principal or secondary diagnosis of facial fracture. The primary outcome was the patient characteristics. The secondary outcomes were emergency department (ED) characteristics, discharge disposition, and total visit charges. Diagnoses and procedures were identified using the appropriate ICD10-CM codes. Outcomes were compared to men with adjustment for confounders using multivariate regression analysis.

Results: 180,407 women presented to the ED with facial fractures, comprising 37% of all facial fracture encounters. Facial fracture was the principal diagnosis in two thirds of encounters, 31% of which were on weekends. Facial fractures rarely occurred during pregnancy (0.3%), but 16% were due to physical assault. The most common facial fracture locations were the nasal bones (29%), mandible (11%), maxillary/malar/zygoma (9%), orbit (8%), and skull and facial bone combination (5%), similar to men (p=0.55). The mean age was 53 years, which was significantly older than men (42 years, adjusted mean difference (aMD): 11.6 (11.0-12.0), p<0.01). Most women had Medicare insurance (40%, Private 27%, Medicaid 19%, self-pay 10%, other 4%), whereas most men were privately insured (29%, Medicaid 23%, self-pay 20%, Medicare 18%, other 8%, p<0.01). Similar to men (p>0.05), most women were adults (93%), from the lowest income quartiles ($1–$45,999: 30%, $46,000– $58,999: 24%, $59,000–$78,999: 23%, $79,000 or more: 22%), Caucasian (71%, African American 13%, Hispanic 10%, Other 4%, Asian 2%), and presented to large metropolitan area (53%, small metropolitan 33%, micropolitan 8%, other 5%), teaching (67%), southern (40%, midwest 23%, northeast 19%, west 19%), non-trauma (45%, trauma Level 1 24%, trauma Level 2 18%, trauma Level 3 13%), private nonprofit emergency departments (51%). Mortality rate was 1% and similar to men (p=0.84), but women were more likely to be discharged home (71% versus 65%, p=0.02). The average total ED charges were $9,740, which were less than men (aMD: $650 ($865 - $434) p=<0.01). The overall ED healthcare cost was $1.6 billion for 2019.

Conclusions: 37% of all ED facial fractures were encountered in women. Both women and men were most likely adult, Caucasian, from the lowest median income quartile, sustained nasal bone fractures, and presented to a southern, metropolitan, private nonprofit, non-trauma EDs. Women were older, more likely insured by Medicare and less likely by private insurance, discharged home, and had lower total ED charges than their male counterparts. However, the financial burden of emergency care for facial fracture among women was $1.6 billion.

Background: Facial laceration repairs are one of the most common procedures performed in the emergency department (ED). The goal of this study was to describe the patient's characteristics and healthcare cost associated with ED encounters for facial lacerations using the largest nationally representative database in the United States.

Methods: This is a retrospective cohort study using the Nationwide Emergency Department Sample. The data was collected between January and December of 2019. Patients with either a primary or secondary diagnosis of facial laceration were included. The primary outcome was patient characteristics. The secondary outcomes were ED characteristics, number and type of procedures performed and total encounter charges. Diagnoses and procedures were identified using ICD-10 CM codes.

Results: There were 2,518,758 ED encounters for facial lacerations in the United States. Of those, laceration was the chief complaint in 75%. 81% of lacerations were unintentional, 8% were due to assaults, and 4% due to suicidal attempts. The most common laceration location was the scalp (42%) followed by the lip (22%) and eyelid (21%). The mean patient age was 38 years. Most patients were adults (69%), male (62%), Caucasian (64%, African American 14%, Hispanic 14%, Other 6%, Asian 2%), from low income levels ($1–$45,999: 29%, $46,000– $58,999: 24%, $59,000–$78,999: 24%, $79,000 or more: 23%), with private insurance (32%, Medicaid 25%, Medicare 24%, self-pay 12%, other 6%). Most encounters were during summer (June, July, August) at large metropolitan areas with at least 1 million residents (52%, small metropolitan: 31%, micropolitan: 10%, other: 6%) at teaching hospitals (65%) located in the southern region of the United States (37%, Midwest: 23%, west: 21%, northeast: 19%). Almost half of the encounters were at non-trauma-designated hospitals (48%, Level 1 trauma center: 21%, Level 2 trauma center: 17%, Level 3 trauma center: 13%). The number of procedures during each encounter was: none: 4%, one: 17%, two: 23%, three: 11%, four: 11, five or more: 34%. The most frequent laceration repair was a simple repair of superficial wounds of the face, ears, eyelids, nose, lips, and/or mucous membranes 2.5 cm or less, followed by simple repair of superficial wounds to the scalp, neck, axillae, external genitalia, trunk, and/or extremities 2.5 cm or less. Most emergency department visits were billed as a Level 3 encounter, followed by Level 2 then Level 4. CT scan of the head was the most common imaging modality. Of all patients, 8% were admitted to the hospital and 87% were discharged home. The average total emergency department charges were $5,730.

Conclusions: Facial laceration is a common complaint in the emergency department. It is costly, and disproportionately affects the impoverished. Most lacerations are classified as simple, less than 2.5 cm, involving the scalp, unintentional, with the discharge disposition being home. Thus, exploring pathways to treat facial lacerations outside of the ED can potentially reduce both healthcare cost and ED crowding.