Scientific Abstract Presentations: Craniomaxillofacial 6 Saturday, October 28 Sat, Oct 28 2:00-3:30 p.m. CDT

Background: Although complication rates after primary cleft procedures are low, the potential for life-threatening risks still exists. We sought to understand how predictive risk factors for complications differ between cleft palate patients and cleft lip patients. We hypothesize that longer operative and anesthesia time and presence of comorbidities will increase the risk for postoperative complications in both groups of patients. Methods: The 2016-2021 ACS NSQIP® Pediatric database was utilized to identify all patients between 0-2 years of age with a postoperative diagnosis of cleft palate or cleft lip. Risk factors studied included demographics, presence of comorbidities, and anesthesia/operative times. Outcome variables included reintubation, wound complications, unplanned readmission, and reoperation. Multivariable logistic regression assessed risk factors associated with postoperative complications, controlling for multiple variables. Results: A total of 8,283 patients were included, of which 61% were cleft palate patients. Among cleft palate patients, 85.7% underwent palatoplasty, 46% had at least one comorbidity, and mean age was 1 year. Longer anesthesia time was significantly associated with increased risk for wound complications (OR 1.007, p=.003), reintubation (OR 1.008, p=.003), and reoperation (OR 1.007, p=.01). Preoperative ASA Class 3 classification was significantly associated with unplanned readmissions (OR 2.34, p=.02), and Native Hawaiian or Pacific Islander ancestry was significantly associated with reoperation (OR 11.477, p=.002). Among cleft lip patients, 81.5% underwent repair of cleft lip, 24.8% had at least one comorbidity, and mean age was 5.5 months. Presence of comorbidities was associated with increased risk of readmissions (OR 2.228, p=.016), and older age was associated with increased risk of reoperation (OR 4.26, p=.003). There were no risk factors predictive for wound complications or adverse airway events in cleft lip patients. Conclusion: Among these subgroups of cleft patients, differing risk factors are predictive for postoperative complications. Longer anesthesia time leads to increased postoperative complications in cleft palate patients while presence of comorbidities and older age leads to increased postoperative complications in cleft lip patients. Minimizing anesthesia time and optimizing the patient's surgical status may improve safety and outcomes for cleft palate and cleft lip patients.

Purpose: Alloplastic cranioplasty is a common procedure in cranial reconstruction, yet factors related to success and failure have been incompletely characterized [1,2]. Further, few robust studies exist specifically for alloplastic cranioplasty, and literature is scant regarding aesthetic outcomes [3-5]. The purpose of this study is to describe factors related to both functional and aesthetic outcomes in alloplastic cranioplasty.

Methods: The authors conducted a large-scale retrospective review of patients who underwent alloplastic cranioplasty between 2014 and 2021 at a single institution. Information was collected regarding demographics, wound healing comorbidities, indications for surgery, and outcomes. A multivariable regression analysis was used to determine variables associated with operative complications, implant explantation, and contour defects.

Results: One hundred and one patients underwent alloplastic cranioplasty. Fifty-seven percent of patients had at least one wound healing comorbidity. The most frequent indications for surgery were trauma (44%), cerebrovascular accident (18%), and cancer (18%). The operative complication rate was 24%. Thirty-six percent of patients had a postoperative contour deformity, and 16% underwent additional surgeries related to cosmesis. At a median follow-up of 1.5 years, 99% of patients maintained either a primary (84%) or secondarily placed (15%) implant. On multivariable analysis, level four ASA classification (OR 5.9, 95% CI [1.03, 33.1], p = 0.05) and heavy alcohol use (OR 6.2, 95% CI [1.5, 25.5], p = 0.01) were significantly associated with complications. Cerebrovascular accident (CVA) was associated with contour defects (OR 6.1, 95% CI [1.2, 30.7], p = 0.03). The only factor associated with explantation was heavy alcohol use (p = 0.05).

Conclusion: This study reviews predictive factors for complications, implant explantation, and poor contour outcomes after alloplastic cranioplasty in a large cohort. Results indicate that alloplastic cranioplasty can have a high success rate with reasonable aesthetic outcomes.

Bibliography: 1. Zanotti B, Zingaretti N, Verlicchi A, Robiony M, Alfieri A, Parodi PC. Cranioplasty: Review of Materials. J Craniofac Surg. 2016;27(8):2061-2072. doi:10.1097/SCS.0000000000003025 2. Johnston DT, Lohmeier SJ, Langdell HC, et al. Current Concepts in Cranial Reconstruction: Review of Alloplastic Materials. Plast Reconstr Surg Glob Open. 2022;10(8). 3. Satapathy D, Nadeem M, Shukla DP, Prabhuraj AR, Devi BI. Cosmetic Outcome of Cranioplasty After Decompressive Craniectomy-An Overlooked Aspect. World Neurosurg. 2019;129:e81-e86. doi:10.1016/j.wneu.2019.05.027 4. Bader ER, Kobets AJ, Ammar A, Goodrich JT. Factors predicting complications following cranioplasty. J Cranio-Maxillofac Surg. 2022;50(2):134-139. doi:10.1016/j.jcms.2021.08.001 5. Reddy S, Khalifian S, Flores JM, et al. Clinical Outcomes in Cranioplasty: Risk Factors and Choice of Reconstructive Material. Plast Reconstr Surg. 2014;133(4):864. doi:10.1097/PRS.0000000000000013

Purpose The subplatysmal structures, such as the submandibular gland (SMG) and paired anterior digastric muscles (ADM), play an essential role in submandibular fullness with aging. Subsequently, this has resulted in various targeted procedures to enhance and rejuvenate the aging neck. However, the current understanding of the volumetric changes is limited, with findings isolated to individual structures. Therefore, this study aimed to expand the current knowledge of the age-associated changes to the SMG and ADM by comprehensively examining the changes in the surrounding anatomy while longitudinally incorporating patient-related factors to improve the aesthetic surgeon's understanding, foster shared decision-making and optimize outcomes.

Methods This retrospective, longitudinal study utilized MRI segmentation (Vitrea) to calculate the SMG's total and inframandibular volume, along with the ADM and mandibular volume. Additionally, various morphological measurements were obtained and analyzed along with patient demographics to track their longitudinal effects on the SMG and ADM comprehensively. Subjects with at least two prior MRIs of the head and neck separated by a minimum of four years were used for analysis. Those with pathology or artifact compromising the anatomy of interest were excluded.

Results The study included 75 subjects (Females n=41; Males n=34) with a mean age of 51.9 (range 7-81) and 59.3 (range 16-89) at time point one and two, respectively (mean difference 7.4; range 4-15). Mean total SMG and inframandibular SMG volume increased from 8.34 ml and 7.01 ml to 9.03 ml (p < 0.001) and 7.81 ml (p < 0.001), respectively. The inframandibular SMG volume had a mean rate of change of 0.12 ml/year, with the majority of growth occurring before 60 years. The total and inframandibular height of the gland increased from 33.93 mm and 26.21 mm to 34.82 mm and 27.91 mm (p < 0.0001). The mean ADM volume increased from 2.41 ml to 2.43 ml, while the length of the ADM (digastric fossa to hyoid bone) increased from 37.12 mm to 39.42 mm (p = 0.0072). The mean vertical distance between the inferior border of the mandible and the hyoid bone increased from 22.80 mm to 24.44 mm (p = 0.83). Male gender and overweight or obese BMI class were associated with significantly higher SMG and ADM volumes.

Conclusion Our findings suggest that the SMG increases in volume, with most growth occurring before age 60 and greater than 70% of the gland below the mandible in subjects 50 years and older. Further, while the volume of the ADMs did not increase with age, the length of the ADM and the distance between the mandible and hyoid bone did, which may contribute to the perceived bulkiness of the muscle belly. Rejuvenating the aging neck has been and will continue to be a timeless pursuit sought out by many. As we deepen the current understanding of the age-related changes to the deep subplatysmal structures, the plastic surgeon may approach each patient with increased insight to develop a patient-centered operative plan, ideally targeting their less-than-ideal anatomy and optimizing outcomes following cervical rejuvenation.

Purpose:
Cleft lip and palate (CLP) are typically continuous, extending from the lip through the primary and secondary palate. Concurrent clefts, which we define here as a cleft lip and incomplete cleft of the hard and soft palate, are a distinct and uncommon pattern of orofacial clefts.

Methods and Materials:
An IRB approved retrospective review of all patients with orofacial clefts at a single institution between October 2015 to June 2022 was completed. Patients with CL and an incomplete cleft of the soft and hard palate were included. Children with complete CLP were excluded. Data collected comprised demographics, descriptive cleft information, and events of pregnancy.

A systematic review of the literature by PRISMA guidelines was completed from 2015-2022 using PubMed.

Summary of Results: Of 421 children managed, thirty-three (7.8%) had concurrent clefts; 25(76%) male, 23(70%) non-Hispanic, and all conceived naturally. Three had a family history of clefting, three diagnosed with associated syndrome, and four had maternal drug or medication exposure. Twenty-seven (82%) children were conceived in Oregon spanning 14 counties with the highest commonality being Marion County (n=7, 22%). Concurrent clefts were classified as: Unilateral or Bilateral, complete, or incomplete CL with: Type I: Submucous cleft Type II: Soft palate cleft Type III: Incomplete cleft of the soft and hard palate Within our study, 30.3% (n=10) were Type I, 33.3% (n=11) were Type 2, and 36.4% (n=12) were Type 3.

Upon review of 356 articles, three were identified with data regarding concurrent clefting. Two articles investigated potential genetic links in this population, without incidence rate reported. One article analyzed velopharyngeal function in submucous cleft patients, reporting 28.99% with associated CL, fitting our description of Type I.1

Conclusions: Concurrent clefts are a rare presentation whose existence is increasingly being recognized. Larger studies are needed to further understand this entity of orofacial clefts and potential etiology.

References: 1. Heng Y, Chunli G, Bing S, Yang L, Jingtao L. Hua Xi Kou Qiang Yi Xue Za Zhi. 2016;34(5):488-492. doi:10.7518/hxkq.2016.05.011

INTRODUCTION:The soft tissue, cartilage and bone structures are affected as a whole in secondary rhinoplasty of cleft lip and palate patients, which is final step of rehabilitation in this group. The aim of this study is to evaluate the postoperative anthropometric changes of nose in patients with cleft lip and palate undergoing secondary rhinoplasty. MATERIAL AND METHODS: The study included patients with unilateral cleft lip and palate who were older than 18 years and underwent secondary rhinoplasty between 2020 and 2022. Patients with bilateral cleft lip and palate and patients with surgeries affecting nasal morphology, such as distraction osteogenesis, were excluded from the study. Nasofrontal angle was measured by the Goode method, and projection, nasal root length with alar width values, and columella length were measured from cephalometric points using the ImageJ program on preoperative and postoperative photographs. Data analysis was performed with the SPSS v22.0. Paired-t test was used to analyze and a value of p<0.05 was considered statistically significant. RESULTS:Totally 21 patients(7 males, 14 females) enrolled in study were found to have left unilateral cleft lip in 12 and right in 9. Mean age of patients was 21.81±2.48 years and mean postoperative follow-up time was 14.33±8.08 months. Mean preoperative and postoperative nasofrontal angles were 140.43±1.48, and 132.14±1.64 degrees. Mean preoperative nasal projection percentages were 58.10±1.63% whereas postoperative were 67.00±2.18%. Preoperative and postoperative ratios of nasal root and nasal alar width distances were 53.71±1.34% and 46.48±1.28%, respectively. Preoperative and postoperative means of columella lengths were 9.62±0.34 mm and 13.00±0.38 mm, respectively and there was a statistically significant difference for all preoperative and postoperative mean values in between each two groups. DISCUSSION:All patients were operated on by a single surgeon using standard open rhinoplasty technique. It was observed that mean value of nasofrontal angles decreased from 140 degrees to 132 degrees, approaching normal values, but results did not reach the range of 115-130 degrees, which is considered as normal mean value in the literature. Reduction in the ratio of distance of nasal root and width of nasal base indicates that a narrower and symmetrical nasal structure is achieved in postoperative period when dorsal aesthetic lines are taken into account. With the effect of medialization and narrowing of nostrils which are more lateralized and wider especially on cleft side, columella distances increased postoperatively and nostril asymmetry was eliminated. According to measurements with Goode method, better nasal projection was obtained with an increase of approximately 10% in the postoperative period(1). CONCLUSION:Secondary rhinoplasty surgery in young adult patients with cleft lip and palate is a very important step in a long treatment process that lasts for years for these patients, as it allows elimination of external deformities of the nose, ensuring nasal harmony and achieving a more symmetrical and natural appearance of nose, as well as eliminating breathing problems. 1-Huempfner-Hierl H, Hemprich A, Hierl T. Results of a prospective anthropometric and functional study about aesthetics and nasal respiration after secondary rhinoplasty in cleft lip and palate patients. J Craniofac Surg. 2009;20 Suppl 2:1863-1875

Pediatric craniofacial fractures associated with dental injuries present a complex challenge to the surgical provider. This study sought to perform a thorough epidemiologic review of pediatric craniofacial fractures associated with dental injuries in order to outline their most common clinical presentation, stratify their risk factors and analyse their outcomes.

Following a review of 4,451 pediatric patients with craniofacial fractures who received their care at a single institution between 2005 to 2021, 377 patients (8.4 % of patients overall) were identified to suffer from concomitant dental injuries. Demographic indicators, clinical details, imaging results, and outcomes data were reviewed and compared to those of patients without dental injuries. P-values <0.05 were considered statistically significant.

In summary, patients were 10.8 years old on average at the time of presentation, with a statistically significant change in the age distribution due to an equal representation of children aged 6 to 12 years and 12 to 18 years (40.3 % respectively). Neither the distribution of sex (65.2 % male) nor that of race (81.2 % Caucasian, 16.2 % African-American) significantly differed from that of patients without associated dental injuries. The most common mechanisms of injury were distinct from the group of comparison, with an overrepresentation of motor vehicle accidents and non-motorized vehicle accidents (21.8 % and 19.4 %, respectively). 10.3% of patients were diagnosed with a concussion during their stay. The most commonly obtained imaging was CT (20.7%). As anticipated, the most common locations of craniofacial fractures associated with dental injuries were the mandible (49.3%) and maxilla (43.2 %), followed by the orbit (14.1%) and skull (9.5%). A significantly larger number of children had discernible soft tissue injuries (69.2%). Most dental injuries were maxillary (59.1%), with only 1.9% of patients being diagnosed with combined maxillary and mandibular dental injuries. The most common dental injuries were root fractures (26.5%) and crown fractures (24.9%). Of interest, a significantly larger proportion of patients with facial fractures and concomitant dental injuries were transferred to our trauma centre from an outside hospital (41.4 %) and admitted (58.6 %). The number of children requiring an ICU admission however was not influenced (5.8 %). A smaller percentage of the patients affected by concomitant dental injuries received surgical intervention for their fractures (31.6% vs. 48.4%).

In summary, pediatric patients with craniofacial fractures and associated dental injuries proved to be distinct in both epidemiology and management. Our study was able to highlight a feature of dentition-related fracture locations that we believe may impact the classification of compound fracture patterns (specifically Le Fort fractures) in the future. Despite their relative infrequency, our study highlights the requirement for continued review of the triaging and management of craniofacial fractures associated with dental injuries in the future.

Background:

Microvascular free tissue transfer is a common tool for the reconstruction of oncologic head and neck defects. Adequate pre-operative assessment can aid in appropriate risk stratification for post-operative complications. The modified five-item frailty index (mFI-5) is a validated for risk-assessment scale, however, its utility in head and neck free flap reconstruction is unknown when compared to other common risk factors.

Methods:

A retrospective, single institution chart review (2017-2020) was performed. Patient demographics, defect and repair characteristics, pre- and peri-operative factors, and flap outcomes were recorded. A "high" modified five-item frailty index score was defined as greater than 2. The total score, as well as other patient factors, were correlated to post-operative flap complications.

Results:

A total of 214 subjects were deemed appropriate for conclusion. The mean age was 64.5 ± There were an even number of males (52.8%) and females (47.2%). A fifth of subjects (20.8%) underwent pre-operative radiotherapy. There were 21 cases (9.8%) of complete flap loss. A total of 34 patients (29.4%) experienced any post-operative complication related to flap outcomes. An elevated mFI-5 was significantly associated with a higher overall rate of postoperative complications (39.7 vs. 29.4%, p< 0.019) and total flap loss (16.7% vs. 6.6%, p<0.033). Preoperative radiation was found to be associated with an increased complication rate. (p<0.003).

Conclusion:

The mFI-5 may be a potentially significant tool in the risk stratification of patients undergoing head and neck free flap reconstruction as opposed to commonly utilized risk factors. Appropriate pre-operative assessment may help tailor patient care pre-operatively.

Purpose: The success of alveolar bone grafting (ABG) can be attributed to many factors, such as graft type, preoperative cleft size, cleft phenotype, and timing of repair. We aim to identify the best predictor for successful bony bridge formation in ABG. ​​ Materials and Methods: A retrospective review evaluated patients undergoing ABG from 2009-2022. Patients with genetic syndromes, bilateral clefts, and missing postoperative cone beam computed tomography (CBCT) were excluded. Cleft width and 3-dimensional volumetric defect sizes were calculated using preoperative CBCT scans. Alveolar cleft volume was calculated based on a trapezoidal pyramid model. The area under the curve (AUC) using receiver-operating characteristic analysis was used to determine the strongest predictor of graft success among age at ABG, preoperative cleft width, and volumetric size. AUC>0.700 was the marker of adequate sensitivity and specificity.

Results: Of the 517 patients screened, 70 met inclusion criteria and underwent ABG with ICBG (n=32) or rhBMP-2/DBM (n=38). There was no significant difference in failure of bony bridge formation between graft types (ICBG: 25.0%, rhBMP-2/DBM: 39.5%; p=0.768). Across both cohorts, preoperative volumetric cleft size had a significantly larger AUC (0.843) compared to preoperative cleft width (0.695; p=0.007) and age (0.649; p=0.024). Individually, volumetric cleft size strongly predicted graft failure among both ICBG (AUC: 0.953) and rhBMP-2/DBM (AUC: 0.780) cohorts. The average follow-up time after ABG among all patients was 26.9±15.9 months.

Conclusion: Our findings identified preoperative volumetric cleft size as the strongest predictor for successful bony bridge formation in ABG. Clinicians can prioritize volumetric analysis via CBCT to better predict graft failure among clefts of varying sizes.

Introduction: The prone position is a postural adjunctive therapy, which improves ventilation in patients with ARDS and is widely used to treat severe COVID-19. However, its prolonged use generates a sustained mechanical load on bone structures, causing the origin of facial ulcers, multiple factors are involved in this mediate complication. Goals: Describe the prevalence and the most important risk factors for developing facial pressure ulcers in prone patients with severe COVID-19. Methods: An observational, cross-sectional, retrospective and descriptive study was carried out in patients who were treated with the prone position as an adjuvant for severe COVID-19, in the Plastic and Reconstructive Surgery service of the ISSEMYM Toluca Medical Center, in a period of 2 years. Results: 54 patients included. The most affected site was the malar eminence 52%. The associated factors were diabetes, smoking and obesity. A positive linear correlation was observed between ulcer grade and C-reactive protein, D-dimer and norepinephrine dose (p<0.001). The use of norepinephrine was significantly associated with the development of ulcers 95.7% vs 14.3% in those who did not use it (p<0.001); OR 6.7. Conclution: Multiple risk factors contributed to the development of facial ulcers. It is necessary to perform clinical guidelines for prevention and early treatment, recommending the application of pressure redistributing devices and prophylactic dressings to protect these patients in an early and timely manner. As well as the adequate dosage of the metabolic and pharmacological requirements.

Background: Treatment of pediatric maxillary and mandibular tumors can cause significant morbidity due to post-resection disfiguration and masticatory dysfunction. The need to balance restoration of form and function without compromising growth at both the recipient and donor sites poses a particular reconstructive challenge. This study evaluates reconstructive outcomes of custom endoprosthesis (CE) compared to stock reconstructions and introduces an algorithm using CE to optimize available free tissue transfer.

Methods: An IRB-approved retrospective review of all patients undergoing maxillary or mandibular reconstruction at a tertiary care pediatric hospital between 2016 and 2022 was performed. The following variables including demographics (ie. age at surgery, gender, race), pathologic diagnosis, reconstructive details (ie. volume of resection, reconstruction type) and postoperative outcomes (ie. hardware exposure, hardware failure, major complications, revisions) were collected. Patients undergoing mandibular reconstruction were analyzed separately from maxillary reconstruction. Patients were compared based on reconstruction type.

Results: During the study period, 51 patients (37 mandible, 14 maxilla) underwent CE/stock reconstruction combined with osteocutaneous, fasciocutaneous, and axial patterned local flaps. 37.2% (n=19) of patients received CE. Overall, the rates of hardware failure and exposure were 25.5% (n=13) and 27.5% (n=14), respectively. Of patients undergoing mandibular reconstruction there were significantly lower rates of hardware exposure (14.3% vs. 47.8%, p=0.018), failure (7.1% vs. 43.5%, p=0.048), major complications (28.6% vs 78.2%, p=0.008), and revisions (11.1% vs 50.0% , p=0.002) in the CE cohort compared to the stock reconstruction cohort. The rates of hardware failure, hardware exposure, major complications and revisions did not significantly differ based on reconstruction type in the maxilla cohort. However, CEs reconstructed significantly larger defects (179.5 cm3 vs 74.6 cm3, p = 0.020) than stock reconstructions. The average follow up time was 1.90 ± 1.80 years.

Conclusion: Pediatric maxillary and mandibular masses present a reconstructive challenge that could benefit from CE with free tissue transfer, optimizing the reconstructive ladder. Deviating from stock reconstructions, we propose an algorithm based on surgical practice patterns considering anatomical location, extent of resection, and patient age for free tissue selection. This algorithm yielded improved mandibular reconstructive outcomes and insignificant differences in maxillary reconstruction despite larger resection defects. Overall, incorporating CE into pediatric maxillary and mandibular reconstruction may facilitate improved form and function following pediatric maxilla and mandible tumor ablation.

Background:

The method of epidermal closure during cleft lip repair is important to consider, as it may affect both cosmetic outcomes as well as patient comfort. Historically, this has most commonly been performed with permanent suture that requires subsequent removal, which is not well tolerated in infants. Previous studies have demonstrated comparable scar outcomes with the use of 2-octyl cyanoacrylate topical skin adhesive (Dermabond) in lieu of permanent suture.1,2 Tissue glue provides the benefit of avoiding patient discomfort during suture removal. This study investigated the use of an alternative product, 2-octyl cyanoacrylate liquid with a self-adhesive polyester mesh (Dermabond Prineo). To our knowledge, no previous study has investigated the outcomes of Dermabond Prineo for cleft lip repair closures. The purpose of this study is to compare the aesthetic outcomes and the complication rate between Dermabond Prineo and typical suture techniques.

Methods:

In nine consecutive cleft lip repairs, the epidermal closure was performed with permanent suture, and in the subsequent nine consecutive cleft lip repairs, the epidermal closure was performed with Dermabond Prineo. Rates of complications, including incisional dehiscence, scar hypertrophy, and scar widening, were compared between the two groups. Aesthetic scar outcomes were investigated via photographic analysis. All post-operative photographs were taken as part of the patients' routine post-operative care. Photographs were graded by a panel of plastic surgeons utilizing the Manchester scar scale, a validated scar scoring system that has previously been used to assess the appearance of cleft lip repair scars. Fischer Exact Tests were performed to determine significance for rates of complications between the two groups. Wilcoxon Rank-Sum tests were performed to determine significance for the photographic analysis.

Results:

Three patients in the permanent suture group had documented scar-related complications, including one instance of incisional dehiscence, two instances of scar hypertrophy, and one instance of scar widening. One patient in the Dermabond Prineo group had documented scar-related complications, including incisional dehiscence and scar hypertrophy. No statistically significant difference was found in complication rates between the two groups. Average post-operative photographs that underwent review were taken 3.1 years after the cleft lip repair. One patient in the permanent suture group was lost to follow up and did not have post-operative photographs available for review. No statistically significant difference was found in aesthetic scar scores between the two groups.

Conclusion:

Overall, the use of Dermabond Prineo offers a comparable outcome to the use of permanent suture in epidermal closure of cleft lip repairs. The results of lip closure were found to be equivalent for both scar-related complication rates as well as for aesthetic outcomes.

References:

1. Magee WP, Ajkay N, Githae B, Rosenblum RS. Use of octyl-2-cyanoacrylate in cleft lip repair. Ann Plast Surg. 2003;50:1–5.

2. Spauwen, PH, de Laat WA, Hartman, EH. Octyl-2-cyanoacrylate tissue glue (Dermabond) versus Monocryl 6 x 0 Sutures in lip closure. The Cleft palate-craniofacial journal: official publication of the American Cleft Palate-Craniofacial Association; 43(5): 625-627.

Background: The reasons for hardware removal from the craniofacial skeleton continue to evolve alongside advancements in surgical technique and hardware technology. The University of Michigan experience delineating the reasons for removal of rigid internal fixation devices from the craniofacial skeleton were originally published in a highly referenced article 25 years ago. The purpose of this study is to compare past (1989-1995) and present (2000-2020) reasons for unplanned hardware removal from the craniofacial skeleton among patients treated by the University of Michigan Section of Plastic Surgery.

Methods: A retrospective review study was designed and approved by the University of Michigan Institutional Review Board. Patients who underwent craniofacial hardware removal by the University of Michigan Section of Plastic Surgery between 2000-2020 were included. Patients who underwent planned craniofacial hardware removal (i.e. arch bars) were excluded. Patient demographics, indication for hardware placement and removal, and length of hardware time in situ were documented. Data from the original paper was obtained1. A descriptive statistical analysis was performed using Microsoft Excel.

Results: One hundred fifty-five patients were included in this study. The gender profile remained similar between time periods (51.6% male from 1989-1995 compared to 52.7% from 2000-2020). The average age at hardware placement reduced from 32.3 + 17.3 years (1989-1995) to 28.0 + 19.9 years (2000-2020). Importantly, the length of time with hardware in situ increased from 12.6 + 17.1 months (1989-1995) to 25.1 + 54.2 months (2000-2020). The most common reasons for hardware placement from 1989 to 1995 were motor vehicle accidents (50.9%) and congenital deformity (20.0%), compared to congenital deformity (31.5%) and motor vehicle accident (28.2%) from 2000 to 2020. Moreover, the most common reasons for hardware removal shifted from palpable/prominent hardware (34.5%) and pain/paresthesia (29.1%) in the original patient series to exposure (33.7%) and palpable/prominent hardware (27.2%) in the recent patient series.

Conclusions: Reasons for craniofacial hardware removal substantially changed over the last 10 – 15 years. Patients who underwent open reduction and internal fixation of the craniofacial skeleton between 2000 and 2020 also retained hardware for two times longer than patients who underwent open reduction and internal fixation between 1989 and 1995. Potential contributors to the increased length of hardware time in situ and the differing reasons for hardware removal over time include improved surgical technique, increased emphasis on irrigation, decreased size of plates and screws, advent of self-tapping and self-drilling screws, and increased surgeon experience. Further studies are warranted to correlate preoperative risk factors and subsequent reasons for hardware removal.

1. Orringer JS, Barcelona V, Buchman SR. Reasons for removal of rigid internal fixation in craniofacial surgery. J Craniofac Surg. 1998;9:40-44

BACKGROUND: Binaural hearing restoration after external ear reconstruction in patients with microtia continues to be sought by patients and families. The optimal surgical method for hearing restoration using either bone anchored hearing aids (BAHA) or canaloplasty with middle ear ossicular reconstruction (MEOR) remains understudied.

METHODS: A retrospective metanalysis evaluating hearing outcomes after BAHA implantation or MEOR was performed using PUBMED, EMBASE and MEDLINE following PRISMA guidelines (79 studies). Primary predictor variables were auricular reconstruction method (alloplastic vs. autologous) and type/timing of hearing intervention. Primary outcomes were hearing outcomes, and postoperative complications. Hearing success was defined as postintervention pure tone average (PTA), air-bone gap (ABG) <30 dB, hearing gain >30 dB. Standard statistical analysis was performed with SPSS27 software.

RESULTS: Twelve studies (n=847 hearing procedures) with a mean MINORS score of 12.67 (10-16) met inclusion criteria. BAHA implantation was associated with two times greater odds of obtaining a successful hearing outcome than canaloplasty (OR 2.07, 95% CI, 1.69-2.53). Of the 60 cases with comparable complication outcome data, the median number of complications was 1 for canaloplasty cases (n=17) vs. 0 for BAHA cases (n=43) (p=0.001). In subset analysis, mean hearing gain after BAHA implantation (n=17) was 37.4 dB (95% CI, 32.9- 41.9) vs. 24.9 dB (95% CI, 18.3- 31.5) for canaloplasty cases (n=17) (p=.002).

CONCLUSION: BAHA implantation after microtia reconstruction was associated with superior hearing outcomes and lower complications than canaloplasty in a large retrospective meta-analysis cohort study. Subset analysis also identified superior hearing improvement and overall improved hearing using BAHA