Scientific Abstract Presentations: Craniomaxillofacial 7 Saturday, October 28 Sat, Oct 28 5:00-6:00 p.m. CDT

Background: Granulomatosis with polyangitis (Wegener's) is known to cause progressive nasal collapse related to the dissolution of septal and other nasal cartilage resulting in nasal obstruction and severe central face deformity. It is not known whether structural reconstruction with cadaveric cartilage is comparable to traditional rib cartilage grafting. To investigate this we compared the 2 reconstructive groups for long term stability.

Methods: Patients suffering from Granulomatosis with polyangitis (Wegener's) were divided into 2 groups: 1) Costocartilaginous and 2) Cadaveric cartilage (MTF) based on reconstructive grafts ("L-strut', alar rim, spreaders, tip grafts) used for structural reconstruction (n=55) performed consecutively over an 18-year period. Outcome assessment was based on perioperative complications, long term stability (1-year), need for revisions, and patient-reported functional and aesthetic outcomes using the SCHNOS validated questionnaire (Student's T-test used).

Results: Perioperative complications (infection, exposed cartilage, need for take-back) was similar in the 2 groups (9% and 7%) and related to preoperative severity (increased SCHNOS score); all with scores more than 40)-likely related to soft tissue contraction. With patient reported outcomes, cadaveric cartilage was slightly superior (lower scores) to costocartilaginous with postoperative scores: (11.1+2 vs 19.2+4) and improvement (greater difference between preoperative to postoperative scores (36.3+9 vs 29.9+7). Donor site morbidity was a concern postoperative pain after costocartilaginous grafts. Cost matrix analysis showed costocartilaginous cases were 9% more costly due to increased operative time, despite the additional cadaveric cost.

Conclusions: Cadaveric cartilage structural reconstruction was comparable to traditional rib cartilage for Polyangiitis Granulomatosis nasal reconstruction and provided patients with major functional and cosmetic improvement.

Background: Patients with complex facial trauma often require surgical intervention to restore facial height, width, and occlusion. There is some uncertainty regarding safety of nasotracheal intubation in this patient population. This investigation compares complications and surgical outcomes in complex facial trauma patients across prevalent intubation methods.

Methods: A retrospective chart review was conducted for patients who were surgically treated for LeFort I-III fractures between 2018-2022. Data collection included age, fracture pattern, intubation method, performing surgical service, and any complications. Data on cribriform plate fractures and CSF leaks were also collected. Complications specific to intubation method were examined between fracture type and intubation method. Statistical analysis included equivalence testing with one-sided t-tests, F-distribution tests, and Chi-squared analysis. Binomial multivariate regression was performed to investigate relationships of patient variables in relation to patient outcomes, including having at least one complication, and having to return to the OR. Model selection was performed using Akaike Information Criterion with a backward selection method. P-values less than 0.05 were considered statistically significant.

Results: 60 patients were identified who were surgically treated for LeFort I-III from 2018-2022. Intubation-related complications included bleeding from airway site, malocclusion, and need for hardware removal. There were 21 complications total, with 11 complications related to intubation method utilized on individual patients. 14 patients had cribriform plate fractures, suggesting skull base instability, and 12 patients had a CSF leak at some point in their treatment course. 68% of patients who received tracheostomy had evidence of either cribriform plate fracture or CSF, while the remaining 32% had evidence of neither sign of skull base instability. The pooled complication rate in patients who had tracheostomy and nasotracheal intubation were proved to be statistically similar (p-value =0.019), a trend maintained when examining only patients with LeFort II or III fractures (p-value=0.040). There was no difference between overall complications and surgical service. However, the likelihood of a complication requiring a return to OR was significantly higher in tracheostomy compared to other intubation methods (p=0.043). Further, results of the binomial multivariate regression demonstrated that tracheostomy was a significant predictor for a complication requiring return to the OR (p=0.0250) when accounting for age, Le Fort fracture pattern, number of fractures, CSF leak, and cribriform plate fracture.

Conclusion: Nasotracheal intubation had statistically equivalent complication rates to tracheostomy, demonstrating safe use in patients with complex facial trauma. Tracheostomy has an associated cosmetic scar burden, and complications more frequently required an OR return. Nasotracheal intubation could present an equally safe alternative, with lower morbidity than tracheostomy.

PURPOSE: Buccal artery myomucosal (BAMM) flap has been well-described for cleft palate (CP) reconstruction. However, anatomic investigation and application of an islanded propeller flap have not been reported in the literature.

METHODS: Anatomical study was performed using Indocyanine green, red and blue latex injected directly into the buccal pedicle of 22 fresh hemifacial cadavers. Then, clinical analysis of the senior authors' (BBG, AR) experience with 25 consecutive primary cleft palate reconstructions utilizing a propeller islanded BAMM flap was conducted to assess palatal healing and flap outcomes.

RESULTS: Mean buccal artery diameter was 0.95±0.29mm. Neurovascular pedicle entered the flap 11.38±2.87mm anterior to the pterygomandibular raphe. Buccal artery advanced inside the flap as much as 66.8%±6.0% of the total flap length. All reconstructions were performed using Furlow palatoplasty. 36 flaps were utilized in 25 patients (mean age 478d). The mean maximum cleft width was 11.7 mm. Mean BAMM flap width was 1.2 cm and 11 cases utilized bilateral flaps. The flap always reached the contralateral pillar and the buccal nerve was always preserved. Mean follow-up was 400 days. There were 2/36 flap loss. In both flap losses, pedicles were aggressively dissected. 4/36 flaps underwent revision surgery for flap debulking.

CONCLUSIONS: This study shows that the buccal pedicle is the main blood supply to the flap and this modification allows preservation of the sensory innervation. The contralateral pillar could always be reached improving the traditional advancement and inset. Traditional extensive propeller flap dissection should be avoided in these neonates to avoid vascular compromise.

INTRODUCTION: Bilateral cleft lip is the most severe manifestation of orofacial clefts. Due to its complexity, it is a surgical challenge to obtain good aesthetic and functional results. Dr. Mario Mendoza surgical technique was described by Pérez and Arámburo in 2018. [1-4] This technique was adopted by our institution as a standard of surgical care in bilateral cleft lip repair. Prolabium mucose flap for enhancing volume is obtained by the dissection of the remaining of mucosa from the prolabium and premaxilla. It combines remaining tissue that previously was trimmed off and now we use it to project a more aesthetic lip.

MATERIALS AND METHODS: Our group reviewed 50 cases of bilateral cleft lip repair with our Institution surgical technique from 2018 to 2023 at the Plastic and Reconstructive Surgery Department at Dr. Manuel Gea González Hospital in Mexico City. Medical records and patients preop and postop photographies were reviewed retrospectively. We divided our results in a subjective manner as "Fair", "Good" and "Excellent" results. Evaluation of results were measure by a plastic surgeon and cleft lip surgical expert.

RESULTS: 50 patients were analyzed 33 male (66%) and 17 women (33%). We did not experience any complication during surgical intervention. 45 patients out of the 50 (90%) were evaluated as "Excellent result", 3 (6%) as "Good" result and 2 (4%) as "Fair" result.

CONCLUSION: This addition to previously described "Mendoza" surgical repair for bilateral cleft lip by Pérez and Arámburo is an example on how a good surgical tecnique can be improven for a better aesthetic and functional outcome. Using prolabium mucose flap can add volume, better projection for the lip and lenghtens buccal sulcus in bilateral cleft lip repair.

References

Pérez González A, Arámburo-García R. Anatomical Reconstruction in Bilateral Cleft Lip With Mendoza Technique. J Craniofac Surg. 2018 Sep;29(6):1452-1456.

Zhang JX, Arneja JS. Evidence-based medicine: the bilateral cleft lip repair. Plast Reconstr Surg 2017;140:152e–165e

Germec-Cakan D, et al. Interdisciplinary treatment of a patient with bilateral cleft lip and palate and congenitally missing and transposed teeth. Am J Orthod Dentofacial Orthop 2014;145:381–392

Queiroz SB, et al. Bilateral incomplete cleft lip. J Craniofac Surg 2016;27:e288–e289

Purpose: Characteristics of successful craniofacial surgery fellowship candidates is limited amongst the literature. This study aims to highlight the criteria that successful applicants met and the characteristics that influenced their craniofacial surgery fellowship match.

Methods and Materials: An anonymous 24-question survey was distributed in 2021 to ACGME-accredited craniofacial surgery fellowship match applicants who successfully secured a position. The electronic survey was prepared using the online Qualtrics survey platform. The questionnaire elucidated factors that influenced the application process including, demographics, any previously completed fellowships, society memberships, degrees held, academic productivity, interview numbers, rank order, COVID-19's influence, debt accrued, any offers of employment, and future career plans.

Results: A total of 18 out of 30 responses were received from craniofacial surgery fellowship applicants for a response rate of 60%. Respondents were mostly male (67%), non-Hispanic Caucasian (39%), and from integrated residency programs (67%). The large proportion of respondents did not complete a previous fellowship (67%), belonged to multiple national societies, and held no additional degrees (61%). With respect to academic productivity, the median (IQR) manuscripts published at the time of application were 25 (5-35), conference publications at time of application 10 (4-45), and h-index at time of application 9 (9-10). Five (28%) respondents completed a research year during their time in residency. A total of 6 (33%) applicants completed an away rotation, with 28% completing one or two away rotations. COVID-19 impacted the ability to visit in 61% of cases and reduced clinical exposure to elective cleft and craniofacial surgery for 50% of applicants. Craniofacial surgery fellowship applicants applied to a total of 5-10 programs in 8 (28%) cases with the same proportion applying to 15+ programs (28%). Applicants applying identified a desire for an academic career (10, 56%) and hybrid career (8, 44%). With regard to employment offers after graduation, 7 (39%) had received offers. Financial debt was as high at $400,000 in 2 (11%) cases and between $50,000-400,000 in 8 (44%) cases.

Conclusions: This study provides characteristics of successful craniofacial surgery fellowship applicants. We highlight some of the criteria important to programs when it comes to selecting qualified applicants. Given the limited data available, we hope that applicants, fellowship directors, and residency programs find this information useful as they prepare for the craniofacial surgery match.

Background: In cranial defect reconstruction, the goals are to re-establish mechanical protection of the brain, restore normal appearance, and in some cases, normalize intracranial pressure. The choice of material used to remodel the cranium (cranioplasty) has changed throughout the years. The use of autologous bone was thought to result in less complications and risk for infection than alloplastic materials; however, recent studies have reported difficulty with shaping, limited donor site availability, donor site morbidity, and higher infection and bone resorption rates when compared to alloplastic materials. As a result, the use of alloplastic materials (such as polyetheretherketone (PEEK)) has risen in popularity. Computer-designed PEEK implants are patient specific implants designed to precisely match the skull defect, have thermal conductivity, chemical resistance, are light weight, stiff, durable, do not intervene with radiographic imaging, and require minimal to no intraoperative shaping. While there have been several studies comparing and analyzing PEEK implants to other techniques, long-term outcomes remain to be studied. The aim of this study was to report six-year long-term clinical outcomes after PEEK implant cranioplasty.

Methods: A retrospective chart review of patients undergoing PEEK cranioplasty was performed. Inclusion criteria included patients of at least 18 years of age, follow-up time of at least 24 months, and cranioplasty with a PEEK implant between January 2007 and January 2023.

Results: Twenty-three patients who underwent PEEK cranioplasty between June 2008 and March 2023 by a single surgeon were included in this study. Mean postoperative follow-up was 75 months (range 29.60-173.87). Indications for PEEK cranioplasty included loss of an infected autologous bone flap (12), infected methyl methacrylate (2), infected titanium mesh (1), secondary reconstruction (3), and primary reconstruction (5). The average time between latest cranial procedure and PEEK cranioplasty was 10.5 months. Mean surgical time was 152 minutes. Additional intraoperative shaping of the PEEK implant was necessary in three cases, but there was no difference in time from CT model creation to PEEK cranioplasty between patients who required intraoperative shaping and patients that did not (70 days vs. 89 days; p = 0.69). The mean postoperative hospital stay was 4 days. One patient developed an open wound secondary to direct trauma to the scalp with subsequent implant infection one month post-operatively. This patient underwent a second PEEK implant 12 months later with no complications to this date. A second patient underwent two PEEK implant insertions- both complicated by development of subdural hematomas (mean of 2.5 days post-operatively) and implant infection (mean of 7.5 months post-operatively). A third patient presented with a delayed infection four years post-operatively. Three patients who preoperatively presented with syndrome of the trephined improved in neurological function after PEEK cranioplasty.

Conclusions: In this study, most complications occurred within a year of PEEK implant placement. At a mean follow-up of 6 years, PEEK implants continued to provide durable and stable protection while maintaining aesthetics.

INTRODUCTION Debates surrounding scope of practice are ongoing in numerous medical disciplines, and are especially controversial regarding fields where such scope of practice overlaps between those of different certifications. While in recent years these discussions have largely centered on the process and integrity of board certification regarding cosmetic procedures, there is ongoing controversy in other specialties, namely reconstructive surgery. There are no agreed upon "ideal" qualifications for those who perform orthognathic surgery, and debates surrounding the issue remain intense–something evidenced by the strong opposition of the American Society of Plastic Surgeons (ASPS) to efforts by the American Board of Oral and Maxillofacial Surgery (ABOMS) to join the American Board of Medical Specialties (ABMS), the largest physician-led specialty certification organization in the United States. Some argue that those who are trained in oral surgery, or are "double boarded", possess greater qualifications to perform orthognathic procedures than plastic surgeons who are not formally trained in oral surgery; even though their scope of practice and training overlaps significantly with their aforementioned counterparts. The purpose of this study was to gather opinions regarding overall competency in orthognathic procedures from a population of surgeons practicing in this field with diverse training backgrounds.

METHODS A voluntary online survey, without offer of incentives, was sent out to active members of the ASMS. This 26 question survey, of which, gathered demographic information including level of experience, credentials, training (dental, oral, and/or surgery), etc., was intended to address ASMS member opinions on whether qualification to perform orthognathic surgery differs depending upon if an individual trained in plastic surgery or oromaxillofacial surgery. Results were obtained using a 5 degree scale (strongly agree, agree, somewhat agree, somewhat disagree, strongly disagree) and analyzed for statistical significance.

RESULTS Survey responses were collected from 77 (23.3%) of the 330 active members of the ASMS, however, three responses were missing from the questions pertaining to orthognathic surgery qualification opinions. Subdivided by degree, 1 respondent (1.3%) obtained a degree of dental surgery (DDS), 21 respondents (27.3%) obtained both a DDS and medical degree (MD), and 55 respondents (71.4%) obtained a MD. While 100% of DDS holding surgeons and 77.4% of MD/DDS surgeons agree, to at least some extent, that single-boarded surgeons do not understand teeth and how they are to be optimally positioned in orthognathic surgery, only 30.8% of MD surgeons at least somewhat agree. Additionally, 0% of DDS surgeons, and 9.62% of MD surgeons believed that it is impossible for single-board plastic surgeons to achieve consistently good orthognathic surgery results, as opposed to 57.1% of MD/DDS surgeons. Finally, 0% of DDS surgeons, 15.4% of MD surgeons, and 52.4% of MD/DDS surgeons believe patients who see a single-board plastic surgeon should obtain a second opinion from a double-boarded or oral surgeon.

CONCLUSIONS Given the survey data, the large majority of respondents believe that oral surgery training or plastic surgery training does not give an individual greater qualification to perform, or succeed in, orthognathic surgery. However, there is a discrepancy in opinions between double-boarded degree holders and single-boarded degree holders. These results provide insight into the opinions of ASMS members on qualifications for orthognathic surgery and suggest that quality is the most important aspect of training. Future studies can look to redress ASMS members in hopes of improving survey response rate, keeping opinions up to date, and include a larger number of double boarded and DDS surgeons.

Purpose: Children with metopic craniosynostosis have distinct orbital morphologies that include perceived hypotelorism and a symmetric, elliptical orbital aperture canted toward the synostosed suture. Though less commonly seen than in unicoronal craniosynostosis, this can result in strabismus and other ocular imbalances.1 The purpose of this study is to quantify the anthropometric changes in the orbits of children with metopic craniosynostosis after endoscopic strip craniectomy (ESC).

Methods: A retrospective, cohort study was performed at a single center over a three-year (2020 – 2023) period. Using Slicer (slicer.org) software, a three-dimensional craniometric analysis was performed on preoperative and one-year postoperative CT images of children with metopic craniosynostosis. All participants were treated with ESC and orthotic helmet therapy. All patients had post-operative CT scans documenting complete suturectomy. Eleven craniometric parameters were obtained. The modified orbital index (MOI),2, 3 a measure of severity of the Harlequin deformity in unicoronal synostosis, is used to quantify changes in the minor and major axes of the symmetric ellipse-shaped orbital apertures in metopic synostosis.

Results: Nine children (5 males, 4 females) were included in the study. The mean age at pre-operative CT scan was 69.3 days (± 9.5 days). The mean age at post-operative CT scan was 14.8 months (± 0.5 months), for a mean follow-up of 11.4 months after ESC. 36 orbits were analyzed. MOI improved from 0.83 (± 0.01) pre-operatively to 0.93 (±0.01; p<0.0001) post-operatively. Over the study period, the greater axis of the orbital aperture increased in length by 8.50%; the lesser axis increased by 24.1% (p < 0.0001). There were no significant differences in the vertical orbital cone, horizontal orbital cone, or zygomaticofrontal angles. Intercanthal (dacryon-dacryon) distance increased from 13.39 mm (± 0.71 mm) to 17.34 mm (±0.75 mm; p=0.0002), orbital volume increased from 11910 mm3 (± 515 mm3) to 18490 mm3 (± 526 mm3; p<0.0001). These latter parameters follow a normal trajectory when compared to historical data.4 No patients in our series had pre- or post-operative strabismus.

Conclusions: Endoscopic strip craniectomy allows for differential growth of the orbits, favoring the lesser axis of the ellipse, such that the two axes approximate the same length. This creates a more symmetric, square-shaped orbital aperture at one year post-operatively. Further study is required to compare to age- and sex-matched controls and to better understand the impact of ESC on intercanthal distance as well ocular muscle imbalances in this patient population.

References 1. Nguyen, T.B., Shock, L.A., Missoi, T.G., Muzaffar, A.R. (2016). Incidence of amblyopia and its risk factors in children with isolated metopic craniosynostosis. Cleft Palate-Craniofacial J., 53(1), e14-e17. 2. Beckett, J. S., Persing, J. A., & Steinbacher, D. M. (2013). Bilateral orbital dysmorphology in unicoronal synostosis. Plast Reconstr Surg, 131(1), 125-130. 3. Showalter, B. M., David, L. R., Argenta, L. C., & Thompson, J. T. (2012). Influence of frontosphenoidal suture synostosis on skull dysmorphology in unicoronal suture synostosis. J Craniofac Surg, 23(6), 1709-1712. 4. Hoyte, D.A. (1997). Growth of the orbit. In Dixon, A.D., Hoyte D.A. & Ronning O. Fundamentals of craniofacial growth. CRC Press.

PURPOSE: To evaluate the impact of body mass index (BMI) on pulmonary embolism (PE) rates within 30 days of surgery in patients undergoing head and neck reconstruction with free tissue transfer and receiving prophylactic enoxaparin.

METHODS: This retrospective cohort study included patients who underwent head and neck reconstruction with free tissue transfer and received enoxaparin 30 mg twice daily prophylaxis. Patients with renal insufficiency were excluded. The cohort was divided into patients with BMI less than 25 (group A) and patients with BMI more than 25 (group B). PE within 30 days of surgery was retrospectively recorded. Statistical analysis was performed using chi-square and binary logistic regression, accounting for Caprini score.

RESULTS: 676 patients were included, with a mean BMI of 26.69 ± 8.35. PE rates among all patients were 2.7%. PE rates in group A (n=319) were significantly lower than in group B (n=357) (1.3% vs. 3.9%, p=0.031). After accounting for Caprini score, BMI more than 25 was independently associated with nearly three times increased PE risk (OR, 3.12; 95% CI, 1.004-9.697).

CONCLUSIONS: BMI more than 25 is associated with an increased risk of PE within 30 days of head and neck reconstruction with free tissue transfer, even after adjusting for Caprini score. This may indicate insufficient anticoagulation in this group. Limitations of the retrospective study design and potential biases should be considered.