Scientific Abstract Presentations: Craniomaxillofacial 9 Sunday, October 29 Sun, Oct 29 10:30 a.m.-12:30 p.m. CDT

PURPOSE: Few studies reported on the surgical treatment outcomes of early-onset Facioscapulohumeral Muscular Dystrophy (FSHD). There is no unified diagnostic approach for these patients prior to undergoing facial reanimation surgery. This study aims to standardize the workup protocol for congenital facial weakness and discuss the possible limitations of current standard surgical approaches to facial reanimation in this pediatric population. METHODS: We conducted a literature review on current surgical techniques for facial reanimation in pediatric patients with FSHD. RESULTS: The recommended diagnostic approach for congenital facial paralysis includes a genetic workup, MRI, and EMG, all reviewed by a multidisciplinary treatment team of a pediatrician, pediatric craniofacial surgeon, neurologist with expertise in neuromuscular disorders, geneticist, and ophthalmologist. The three current standard techniques for facial reanimation are gracilis muscle transfer, temporalis myoplasty (Labbé procedure), and tensor fascia lata (TFL) sling. Although the gracilis muscle transfer is considered the gold standard, recent FSHD cohort studies have noted fatty infiltrate in the gracilis muscle, which could make the gracilis muscle an unfavorable flap candidate. Patient presentation of bilateral temporalis muscle atrophy could also indicate that a temporalis myoplasty may have unfavorable results if used, including possible trismus and occlusal changes. Static procedures like TFL slings may be the most appropriate technique in patients with FSHD-related facial paralysis. CONCLUSION: Early-onset FSHD is a pediatric progressive disease that does not have a delineated protocol for diagnostics and pre-surgical treatment for reanimation surgery. We suggest a multidisciplinary approach to have the patient be properly evaluated by a neurologist, pulmonologist, and a craniofacial surgeon. The most promising surgical reanimation for early-onset FSHD patients may be the TFL sling due to the decreased secondary complications post-operation. Surgeons who treat patients with facial paralysis need to be aware of FSHD as a possible etiology, provide a thorough work-up, and consider potential long-term complications based on the type of tissue transfer for facial reanimation.

BACKGROUND: Multidisciplinary team-based care provides comprehensive, long-term treatment for children with craniofacial differences. American Cleft Palate and Craniofacial Association (ACPA)-certified "Craniofacial Teams" meet stringent standards to gain and maintain ACPA approval. Despite the existence of American Cleft Palate and Craniofacial Association-approved Craniofacial Teams, access to care remains challenging for patients from rural areas, leading to disparities in care. We investigated the geospatial relationship between US counties and ACPA-approved craniofacial centers.

METHODS: The geographic location of all ACPA-approved craniofacial centers in the U.S. was identified. Distance between individual US counties (n=3,142) and their closest ACPA-approved craniofacial team was determined. Counties were mapped based on distance to nearest craniofacial team. Distance calculations were combined with demographic data from the Small Area Income and Poverty Estimates to model the number of children served by each team and economic characteristics of families served. These relationships were analyzed using independent t-tests and ANOVA.

RESULTS: Over 40% of counties did not have access to one of the ACPA-approved craniofacial teams within a 100-mile radius (n=1,366). 89% of these counties had a population <75,000 (n=1,213) and 47% had a child poverty rate greater than national average (n=640; P<.001). Counties with the highest birth rate and >100 miles to travel to an ACPA team are in the Mountain West, with Primary Children's Hospital in Salt Lake City, Utah, serving the greatest number of children traveling >100 miles.

CONCLUSIONS: Craniofacial teams serving many rural patients face challenges associated with prolonged travel distance, magnified by limited available financial resources. Given the the time sensive nature of operative intervention the lack of equitable distribution in craniofacial teams is concerning. Centers may better serve families from distant areas by establishing sallelite clinics, nonprofit partnerships, telehealth visits, and training local primary care providers in referral.

Purpose: The most widely accepted treatment for alveolar bone grafting (ABG) is with an autologous iliac crest bone graft (ICBG). However, autologous bone grafting may be less than ideal in those undergoing early ABG concurrently with palate repair. Our institution uses a combination of demineralized bone matrix (DBX), bone morphogenic protein (rfBMP-2), and freeze-dried bone chips (FDBC) in early concurrent ABG as well as secondary ABG. Given the paucity of literature examining the efficacy of early concurrent ABG and the optimal combination of existing allografts, we sought to investigate the feasibility of DBX, rhBMP-2, and FDBC on ABG at a single institution.

Methods: Consecutive patients undergoing early concurrent and secondary ABG utilizing DBX, rhBMP-2, and FDBC were identified from August 2018- June 2022. Postoperative CT images were reviewed and scored by two independent reviewers with discrepancies settled by a third reviewer. Alveolar graft height (GH) and graft thickness (GT) were recorded. A standardized scoring system was developed with a score of 0 representing no graft take and 3 representing best possible graft take. Descriptive statistics were obtained and cohorts were stratified by early concurrent versus secondary ABG, and initial versus salvaged ABG. One way ANOVA were used to determine statistical significance.

Results: Seventy-two clefts (54 patients) were identified as having undergone ABG. Of these, 59.5% underwent early concurrent ABG, 37.5% underwent secondary ABG. 26.4% underwent salvage procedures after failed ICBG. Median age was 5 years old. The mean follow-up time to CT after ABG was 13.3 months. Only 1 patient (1.8%) required salvage after placement of DBX, rhBMP-2, and FDBC. The mean GH and GT recorded for all clefts was 2.4 and 2.0, respectively. When comparing early concurrent versus secondary grafting, mean GH was 2.3 vs 2.6 (p=0.14) and mean GT was 2.1 vs 2.0 (p=0.08). When stratified by age groups, no statistically significant differences were identified in regard to GH (p=0.27) and GH (p=0.63) between those in 0-3, 4-6, 7-9 age groups who underwent early concurrent ABG. When comparing those who received a first-time graft to those who required salvage after a failed ICBG, the salvage cohort had a higher graft height (2.6) when compared to first time grafts (2.4; p=0.82) and both groups had a graft thickness of 2.0 (p=0.45). Conclusion: Our early results evaluating the efficacy of primary ABG using DBX, rhBMP-2, and FDBC suggest feasibility in regard to graft height and thickness. Those who underwent early ABG with concurrent hard palate repair demonstrated acceptable graft take in regard to height and thickness from ages 0-9. Additionally, those who underwent secondary ABG after hard palate repair demonstrated equally favorable in outcomes in regard to graft take, suggesting that DBX, rhBMP-2, FDBC may act as an acceptable substitute to autologous bone grafting. Further study is needed to determine long-term outcomes in regard to graft resorption and effects of early repair on maxillary growth.

Introduction

Craniosynostosis is a medical condition in which one or more of the sutures of an infant's skull close prematurely, leading to problems in normal brain and skull growth in infants. Early intervention of the disease is crucial for better clinical outcomes, and the development of an objective algorithm using artificial intelligence (AI) can potentially enhance the accuracy and efficiency of diagnosing craniosynostosis through automated analysis of medical images, such as CT scans and MRIs. This systematic review aims to analyze different approaches to utilizing AI, such as deep learning and convolutional neural networks, and the use of 2D and 3D imaging techniques.

Methods Two independent reviewers systematically reviewed PubMed/MEDLINE, Scopus, OVID, and Web of Science databases using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). One hundred thirty-one studies evaluating the role of artificial intelligence and machine learning in diagnosing and treating craniosynostosis were screened, and 11 studies met the inclusion criteria. Data on study design, modality of artificial intelligence, level of accuracy, and outcomes were collected.

Results Deep learning, a branch of AI, can analyze and categorize craniosynostosis without human assistance. Of the AI studies, 36.4% used convolutional neural networks (CNN), a type of artificial neural network widely used for image/object recognition and classification, vs. 63.6% used machine learning to automatically identify and classify craniosynostosis cases based on various features and measurements. While 63.6% of studies were based on 3D photographs, 36.4% relied on 2D imaging. Only two studies focused on the use of AI in non-syndromic craniosynostosis. The results of these studies show that the CNN and machine learning models performed with promising accuracy of ≥90.6% and≥93.3% in detecting and classifying craniosynostosis, respectively. 3D photogrammetric scans are a promising alternative to computed tomography scans in cases of single suture or non-syndromic synostosis for diagnostic imaging. However, the diagnosis is often not automated and relies on additional cephalometric measurements and the surgeon's experience. Nevertheless, recent studies have shown that AI-based facial analysis can match the diagnostic capabilities of expert clinicians in syndrome identification with an accuracy of 99.98%. These systems use 2D images and analyze texture and color, making them unsuitable for medical imaging modalities such as ultrasound, MRI, or CT.

Conclusion Overall, the integration of AI technology in the diagnosis and treatment of craniosynostosis has the potential to improve outcomes for patients with this condition by enabling earlier and more accurate diagnosis, personalized treatment planning, and more comprehensive monitoring of long-term development. Our review highlights that further research is warranted to develop novel AI technologies and confirm their diagnostic potential in craniosynostosis. Once validated, the goal is to apply the AI models in the clinical environment.

Introduction: Bilateral sagittal split osteotomy (BSSO) for mandibular repositioning is performed in close proximity to the inferior alveolar nerve (IAN). Transient lower jaw paresthesia post-operatively is common, however direct nerve injuries can result in persistent sensory deficits. Pre-operative imaging can provide valuable information on IAN location to minimize the risk of nerve injury. We hypothesized that proximity of the nerve to the mandibular cortex at certain locations was associated with increased risk of persistent post-operative numbness.

Methods: All patients undergoing a Lefort I and BSSO advancement with a single surgeon between 12/1/2020 and 10/7/2022 were included. Pre-operative surgical planning was performed using PROPLAN CMF ™ Online, DePuy Synthes. Pre-operative IAN location was obtained from CT imaging bilaterally at the 1st, 1st-2nd, and 2nd molar. Patients with less than 60 days of follow-up were excluded. Patient characteristics and outcomes measures were collected. Statistical analysis using chi-squared, Schapiro-Wilk, and Wilcoxon-Mann-Whitney tests compared sensate versus insensate patients at their last follow-up visit.

Results: N=61 patients were included. Mean (SD) age at the time of procedure was 26.4 years (10.07) and mean length of time (days) from procedure to longest follow-up was 216 days (147.17). 56% patients reported ongoing numbness at 187 days (4.7). In general, all pre-operative measurements from nerve to mandibular cortex were smaller among patients who reported persistent numbness compared to sensate patients. The distances between the nerve and lateral cortex at the left and right 1st molar and right 2nd molar were significantly smaller among patients who reported persistent numbness compared to sensate patients (p=0.02, p=0.017, p=0.032, respectively).

Conclusion: Lateral location of the IAN at the molars is a predictable risk factor for higher rates of persistent post-operative numbness among patients undergoing BSSO advancement.

Introduction: Three-dimensional (3D) printing is widely used in craniofacial surgery to enhance pre-operative planning, surgical precision, and patient outcomes. However, this technology comes with high costs and lengthy turnaround times that hinder its broad application in acute craniofacial trauma cases. Industry-printed orbital floor implants cost $8,000 on average and require several days of production time. We previously innovated a novel approach using in-house 3D printers to create contour models to generate patient-specific orbital floor implants. This method enables trauma centers to create patient-specific anatomical implants in a few hours and we hypothesized that this could be done a fraction of the cost of industry-produced implants.

Methods: A retrospective cohort study was performed for 14 patients who have undergone orbital floor reconstruction using either in-house or industry-printed 3D models at our institution from 2019 to 2022. Demographic information (age, sex, comorbidities, type of trauma, and BMI), perioperative data (operative length, blood loss, and length of hospital stay), and postoperative results (complications, functional outcomes, and subjective aesthetic outcomes) were collected. In-house orbital floor 3D stamps were designed using mirrored patient CT scans and printing costs were retrieved from our in-house 3D printing lab.

Results: In-house 3D-printed stamps were used as contour models to press absorbable plates (Sonicweld®, KLS Martin) into patient-specific implants, and associated costs were compared to those for industry-created custom implants. Implants created with the help of in-house 3D printing costed 85% less than industry 3D printing ($998 and $6,701, respectively). In-house 3D printing averaged a turnaround time of 3.5 hours and was quicker than the industry average of several days. There were no significant differences found in complication rates and no patients in either group required re-operation.

Conclusions: This new method of in-house 3D printing to treat orbital floor fractures is rapid, low-cost, and as clinically effective as industry 3D-printed implants. Due to its quick turnaround time, this approach contributes unique value in acute trauma settings where patients may require urgent operation. With greater adoption of this technology, we hope that trauma centers can offer more patients access to custom orbital floor implants, shaped to their own individual anatomy.

Objective: Each learner will be able to identify a novel, cost-effective, and rapid approach in utilizing in-house 3D printers to repair acute orbital floor trauma.

Background: Nasoorbitoethmoid (NOE) fractures are among the least common pediatric craniofacial fractures, accounting for between 1% and 8% of all pediatric facial fractures. While pediatric anatomy lends to lower frequency of NOE fractures in children than in their adult counterparts, these anatomic differences also necessitate a close examination of the impact of NOE fractures on growth of the craniofacial skeleton, as well as their association with other sites of injury. This study describes characteristics, management, and outcomes of pediatric NOE fractures seen at a single institution.

Methods: A retrospective review of patients under 18 years of age who presented to our institution from 2006 to 2021 with facial fractures was conducted; patients with NOE fractures were included. Patients were subdivided into three age groups: younger than 6 years, 6 to 12 years, and 13 to 18 years. These age groups were selected primarily on differences in dental maturity, though additional characteristics are reflected by this division. Data collected included demographics, injury details, associated fractures, mechanism of injury, management, and outcomes. NOE fractures were divided into type I, type II, and type III fractures in accordance with the Markowitz and Manson classification system, and were evaluated using CT scans and operative notes.

Results: 58 patients met inclusion criteria and mean age at presentation was 12.48 +/- 0.96 years. A majority (77.6%) of patients presented with Type I fractures; 17.2% presented with Type II fractures, and 5.2% presented with Type III fractures. The most common causes of injury were motor vehicle accidents (MVAs, 39.7%) and sports (31%). Glasgow Coma Score (GCS) and injury mechanism were not predictive of injury severity in the pediatric population (p=0.353, p=0.493). Secondary orbital fractures were the most common associated fractures across all NOE fracture subtypes (n=55, 94.8%). Concomitant parietal bone fractures were more likely in Type III fractures (p=0.047), while LeFort III fractures were more likely in type II fractures (p=0.011). Soft tissue and neurological injuries were the most common associated injuries regardless of NOE fracture type (81% and 58.6%, respectively). Most patients (40 patients, 69.0 percent) required operative management, while 31.0 percent of patients underwent non-operative management. A multivariate regression revealed that after correcting for confounders (e.g., GCS, age), only type III fractures were predictive of operative intervention (C-statistic = 0.80; p = 0.0003). Type III fractures were predictive of longer length of stay (p = 0.0021); however, there was no significant difference in the rates of adverse outcomes between types of NOE fracture (p>0.05).

Conclusions: These findings suggest that pediatric NOE fractures, though rare, present differently from adult NOE fractures and that revisiting predictive heuristics and treatment strategies is warranted in this population.

Purpose: Patients with cleft lip and/or palate (CLP) often experience many medical and psychosocial challenges due to their condition. The medicolegal implications of this diagnosis are not well documented. The purpose of this study was to explore the frequency and types of litigation that children and adults with CLP are involved in within a modern timeframe.

Methods: A retrospective review of the Westlaw Campus Research legal database for cases involving individuals with a CLP between January 2015 and October 2022 was performed. Cases were excluded if there were not any specific individuals with CLP or if there was limited documentation. The reason for litigation as well as gender, age, and vital status (alive or deceased) of the individual with CLP was determined. The state where the case took place and case outcomes were also collected. Descriptive statistics were calculated.

Results: A total of 81 cases were included. 50.6% (N=41) of the individuals were male and 79% (N=64) of the cases involved children with CLP. 66.7% (N=54) of the individuals involved had a cleft palate, 9.9% (N=8) had a cleft lip, and 23.5% (N=19) had both cleft lip and palate. Only one case involved a medical malpractice claim for wrongful birth. This case arose based on a prenatal care provider's failure to timely inform the patient that her child would be born with congenital anomalies, including a cleft lip. The majority of the cases were parent custody cases that involved children or a parent with a diagnosis of CLP (N=43, 55.1%). Other reasons for litigation included supplemental security (N=16, 20.5%) and product liability (N=3, 3.8%). All of the supplemental security cases were either awarded in favor of the defendant, instead of the individual with the cleft lip and/or palate, or remanded.

Conclusions: The risk of being involved in medical malpractice litigation initiated by patients with CLP is very low. The majority of litigation focuses on child custody issues, in which CLP may factor in as a variable indicating a chronic condition for the involved child or parent. Healthcare providers can aid individuals with CLP as well as parents of children with CLP by providing proper referrals to social supports and collaborating with medical-legal partnerships.

Background Patient reported outcome measures (PROM) in oncologic head and neck reconstruction have yet to be thoroughly evaluated and incorporated into patient care. Tumor involvement of the posterior mandible often necessitates resection of the condyle and associated soft tissue elements, thereby increasing complexity of the ensuing reconstruction and rehabilitation. While previous studies have focused on clinical assessments of postoperative morbidity and functional status1, this study compares FACE-Q scores of patients whose condyles were sacrificed versus those whose condyles were preserved prior to free flap reconstruction of lateral mandibulectomy defects.

Methods Patients who underwent lateral mandibulectomy and free flap reconstruction between 2000-2021 and completed at least one postoperative FACE-Q were retrospectively reviewed. Cohorts were divided based on whether the mandibular condyle was included in the resection. Baseline patient and treatment characteristics were compared. FACE-Q responses were divided into appearance, functional, and stress domains scored from 0-100, where higher scores represent better outcomes.

Results A total of 117 patients underwent free flap reconstruction of a lateral mandibulectomy defect and subsequently completed a FACE-Q survey; of these, 51 patients had condyle resection, and 66 patients had condyle preservation. Patients within the condyle preserved group were more likely to have received a bony free flap, and those in the condyle resected group were more likely to have received a soft tissue flap (p=0.001). Condyle preserved patients reported significantly greater satisfaction with their overall appearance score (p=0.017), swallowing (p=0.018), and eating and drinking (p=0.015) function. Condyle preserved patients also reported significantly greater satisfaction with their appearance distress (p=0.022) and eating and drinking distress (p=0.016). Condyle resected patients reported significantly better cancer worry distress (p=0.002).

Conclusion A preliminary analysis of FACE-Q outcomes for lateral mandibulectomy with and without condyle resection found that patients who had their condyles preserved reported greater post-reconstructive satisfaction in multiple domains. As expected, surgical involvement of the temporomandibular joint is associated with decreased satisfaction in more PROM domains. Studies with larger cohorts and longer follow-up interval could provide valuable information for surgeons when counseling patients on expected outcomes after mandible resection.

References 1. Wang L, Liu K, Shao Z, Shang ZJ. Management of the condyle following the resection of tumours of the mandible. Int J Oral Maxillofac Surg. 2017 Oct;46(10):1252-1256. doi: 10.1016/j.ijom.2017.04.029. Epub 2017 Jul 5. PMID: 28688540.

Purpose: Cleft lip and/or palate (CL/P) is a common congenital anomaly, and maternal infectious disease (ID) status during pregnancy has been suggested to be a risk factor for CL/P [1]. However, there is a dearth of evidence establishing the association between various types of ID and CL/P status. Previous studies have reported an association between maternal influenza and herpes simplex virus [2] , but evidence for other common types of infectious diseases, particularly sexually transmitted diseases (STD), have been limited. To address gaps in research, we examine the association between various IDs and CL/P in the United States.

Methods: This is a population-based retrospective cohort study using data from the Centers for Disease Control and Prevention (CDC) natality data from 2016 to 2021 [3]. We examined the prevalence of (1) cleft lip with or without palate and (2) cleft palate-only and their associations with maternal gonorrhea, syphilis, chlamydia, Hepatitis B Virus (HBV), and Hepatitis C Virus (HCV) present and/or treated during pregnancy. We further adjust for a range of maternal demographic and health conditions previously reported to be associated with CL/P (e.g., age, smoking, obesity, pregestational diabetes) in multivariate modeling. Logistic regression models were used to estimate the odds ratios and 95% confidence intervals from the analysis. Significance was set at <.05.

Results: Of 22,669,736 births included in our study, 11,341 had cleft lip with or without cleft palate and 5,145 had cleft palate only. In both univariate modeling and models accounting for maternal demographic variables, the following associations emerged as significantly associated with cleft lip with or without palate (adjusted values presented): (1) Chlamydia, Odds Ratio (OR) = 1.255 (1.114,1.414); (2) HCV, OR = 1.390 (1.124,1.721); (3) Any maternal infection, OR = 1.200 (1.118, 1.276); the following emerged as significantly associated with cleft palate-only: (1) HCV, OR = 2.907 (2.351,3.596); (2) Any maternal infection, OR = 1.307 (1.204,1.396). After controlling for maternal demographics and health conditions, Syphilis was found to be associated with cleft lip with or without palate, OR = 13.188 (1.828,95.127).

Conclusions: Our results demonstrate that maternal chlamydia and HCV are associated with orofacial clefts and other maternal health conditions examined in our study. Our findings also revealed an interesting suppression effect of syphilis where it was found to be significantly associated with cleft lip with or without palate only after controlling for maternal demographic and health condition variables. The strongest univariate effect size was observed between HCV and risk of cleft palate-only. The mechanisms by which maternal infectious diseases may increase the risk of CL/P are not well understood. Suggested explanations include inflammation and immune dysregulation which interferes with normal fetal development, but further research is needed to elucidate these findings and to better understand the underlying mechanisms. To our knowledge, our study is the first in the literature to document these important findings.

References:

1. Barrera, C., & Mezarobba, N. (2016). Maternal risk factors associated with cleft lip with or without cleft palate: a review. International Journal of Odontostomatology, 10(2), 359-368.
2. Zhang X, Zheng Y, Zhu J, Yan J, Wei Z, Yang X, et al. Maternal infection during pregnancy and risk of fetal congenital anomalies: a systematic review and meta-analysis of cohort studies. Journal of Maternal-Fetal & Neonatal Medicine. 2018;31(17):2252-63.
3. Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Natality on CDC WONDER Online Database. Data are from the Natality Records 2016-2021, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at http://wonder.cdc.gov/natality-expanded-current.html.

Purpose The Pediatric Health Information System (PHIS) database collects admissions, diagnostic, and treatment data from 44 children's hospitals across the U.S. Gunshot wounds (GSW) are a significant mechanism of pediatric injury, accounting for an estimated 13,000 injuries each year. Of the total cases of recorded GSW, 13% required plastic surgery involvement. Despite their increasing prevalence and the significant morbidity and mortality associated with this mechanism of injury, a paucity of literature underlines the national surgical burden of these injuries. The purpose of this study is to characterize the geographical distribution of non-accidental GSW in the US and identify socioeconomic risk factors that impact patient length of stay (LOS); in particular, this analysis focuses on the relationship between length of stay and the Child Opportunity Index (COI), a composite measure of neighborhood resources that aid in healthy child development and for which higher COI indices correspond to more severe deprivation and unfavorable socioeconomic conditions.

Methods A retrospective review was performed after querying the PHIS database for ICD codes pertaining to pediatric firearm injuries. Patient demographics, clinical data, and Child Opportunity Index were analyzed. Univariate analysis, two-sample t-tests, and multinomial logistic regressions were performed using R statistical software (Version 1.3.1093).

Results 16,543 patients were pulled from PHIS and met inclusion criteria. Among these patients, 14,467 (87.5%) were male and 11,447 (69.2%) were Caucasian. Mean age at presentation was 13.03± 0.029 years (range 0-18 years). Each mile increase in distance from the hospital was associated with a 43-minute increase in patient LOS (p< 0.0001). Additionally, each 1% increase in childhood opportunity index (COI) was associated with an additional nine hours spent in the hospital (p< 0.0001). Non-white patients had a significantly higher LOS compared to white patients (p<0.0001) and hailing from a rural town with a significant proportion of commuters to a nearby area was associated with a two-day increase in the average LOS (p<0.01).

Conclusions This study provides a detailed characterization of pediatric patients admitted to U.S. hospitals for management of GSW related injuries. Higher distances from the hospital, higher COI, and non-white race were associated with increased LOS in this patient cohort.

Introduction: Free tissue transfer is the gold standard for reconstruction of complex head and neck defects following major resection. Data regarding risk factors for post-operative complications such as reoperation and readmission rates have been elucidated, but socioeconomic considerations remain poorly investigated. The purpose of this study was to determine the impact of patient demographic factors and socioeconomic status (SES) on patient outcomes following fibula free flap repair.

Methods: A retrospective study of patients who had a fibula free flap repair following head and neck cancer resection at a single institution was performed from 2016-2022. Patient demographics including sex, race, median household income (MHI), insurance type, and patient history including pre-operative radiation treatment were collected. Primary outcome variables included 30-day, 90-day-and 180-day surgical complications, 30-day re-admission rates, and number of operative revisions following the initial procedure. Bivariate analyses using Chi-square tests and linear regression were performed for outcome measures and p-value of < 0.05 was considered significant.

Results: Sixty-three patients (39 male, 29 female) were included in this study. Most patients (76.2%) underwent fibula free flap repair for oncologic reconstruction. Thirty-two patients (50.8%) underwent radiation treatment to the surgical site pre-operatively. Patients who underwent radiation treatment pre-operatively were at an increased risk of developing surgical complications 30- and 180-days following surgery (p=0.021, p=0.036). The most common surgical complications in our patient cohort included recipient surgical site infection and dehiscence. Furthermore, patients with a lower MHI (below first quartile range of $55,000 per year) were more likely to be re-admitted 30 days post-operatively (p=0.045) and have a higher number of operative revisions following the index procedure (median: 2; IQR: 2; p=0.011). Sex and insurance type did not significantly impact the primary outcome variables investigated.

Conclusion: Pre-operative radiation treatment and lower MHI were associated with worse outcomes following fibula free flap repair. This finding suggests that socioeconomic status may exert a similar impact on patient outcomes as pre-operative radiation treatment. Therefore, identification of these risk factors is critical, as it can inform preoperative counseling and postoperative management to improve outcomes for patients undergoing head and neck reconstruction. Efforts to address socioeconomic disparities in access to care and treatment should be made to optimize patient outcomes.

Introduction Cranial vault reconstruction (CVR) with and without frontal orbital advancement (FOA) for craniosynostosis is a complex procedure. Virtual surgical planning (VSP) for pre-operative planning has been increasing in use and has been shown to optimize workflow. However, little is known regarding the impact on the peri-operative course with conflicting reports on the impact on blood loss. In this study, we aimed to evaluate the impact of VSP on operative time and peri-operative transfusions in patients with craniosynostosis undergoing CVR.

Methods A retrospective chart review from 2014 to 2023 was conducted of patients with craniosynostosis who underwent open cranial vault remodeling. Patient demographics, peri-operative variables, use of virtual surgical planning, and complications were obtained. Peri-operative variables collected include operative time, length of stay, intraoperative transfusions, and post-operative transfusions. An independent t-test was used to compare variables from patients who had surgery with VSP and patients who did not have surgery with VSP.

Results There were 126 infants with craniosynostosis who underwent open cranial vault remodeling, 79 (62.7%) of which used VSP. There was no difference in average age at surgery (9.26 ± 5.67 months vs 13.22 ± 31.09 months, p=0.39). Compared to those who did not use VSP, surgeries with VSP had on average a shorter operative time (3.68 ± 1.07 hours vs 5.03 ± 1.05 hours, p<0.001) and shorter length of stay (3.91 ± 1.27 days vs 4.60 ± 1.69 days, p=0.01). There was a lower volume per weight of intraoperative transfusion for surgeries that utilized VSP (29.16 ± 12.45 mL/kg vs 50.17 ± 27.59 mL/kg, p<0.0001). Post-operatively, patients who did not use VSP required more transfusions (59.5% vs 19.0%, p<0.001). These trends were similar in patients who underwent FOA. Among those who underwent FOA (44 with VSP, 27 without VSP), surgeries with VSP had a shorter operative time (3.88 ± 1.08 hours vs 5.57 ± 1.00 hours, p<0.001), lower intraoperative transfusion volume per weight used (30.83 ± 12.98 mL/kg vs 53.32 ± 32.79 mL/kg, p<0.001) and required fewer post-operative transfusions (18.2% vs 55.6%, p<0.001). There was no difference in complications rates of dehiscence, infection, return to the operating room and 30-day readmission.

Conclusions In addition to decreasing operative time for open cranial vault remodeling and CVR with frontal orbital advancements, VSP was found to decrease the volume transfused during surgery and the need for post-operative transfusions. These findings suggest that VSP is effective in reducing anesthetic exposure in infants and decreasing estimated blood loss.

INTRODUCTION:

Social determinants of health may be associated with non-syndromic cleft lip with or without palate (CL/P) and cleft palate (CP). Exposing these effects can help target resources and bring awareness to vulnerable populations within the US.

METHODS:

CL/P and CP incidence rates from 2016 - 2020 were extracted from the Centers for Disease Control and Prevention (CDC) Vital Statistics Database and combined with CDC Social Vulnerability Index (SVI) by county. SVI domains, reported as percentile rank, include socioeconomic status (SES), minority status and language (MSL), household composition/disability, and housing type/transportation. Multiple linear regressions evaluated the incidence of CL/P and CP as a function of individual and composite SVI domains.

RESULTS:

There were 1,292 CL/P births per 2,876,892 live births (incidence of 0.45/1000 births) and 181 CP births per 690,662 live births (incidence of 0.26/1000 births). For CL/P, the SVI composite index coefficient estimate (CE) was -0.35 (p-value = 0.029), SES CE was -0.24 (p-value = 0.096), MSL CE was -0.43 (p-value = 0.015), and housing type and transportation CE was -0.67 (p-value = 0.003). For CP, the SVI composite index CE was -1.95 (p-value = 0.005), SES CE was -1.39 (p-value = 0.034), and MSL CE was -3.67 (p-value < 0.001), and housing type and transportation CE was -0.98 (p-value = 0.297). Household composition/disability CE were not significant.

CONCLUSION:

Social vulnerability was significantly correlated with increased incidences of non-syndromic CL/P and CP. These indexes can be utilized to direct state and national resources to target these areas of need.

References:

https://journals.lww.com/plasreconsurg/Abstract/2022/01000/PovertyandRiskofCleftLipandPalate_An.28.aspx

Introduction: Mandible fractures account for a large percentage of craniofacial trauma. In complex orthognathic and mandibular cases, virtual surgical planning (VSP) and patient-specific models are frequently used to reduce operative times and improve accuracy of reconstruction. These models often include occlusal splints, which can stabilize the occlusion and aid with osteotomies. However, occlusal splints often require supplemental intraoral scans and several days of production time. This study explores the feasibility of rapid in-house design of occlusal splints using only CT imaging, without the supplementation of high-resolution intraoral scanners.

Methods: For two patients with acute occlusal trauma, DICOM files were obtained from CT scans and imported into Materialise Mimics for bone thresholding. The maxilla, mandible, and damaged fragments were individually segmented and subsequently exported to Geomagic for virtual surgical reduction. If occlusal interference was present, fine adjustments were made with the aim of optimizing molar occlusion and incisal relationship. 3D occlusal splints were created and printed in UMA 90 resin using a Carbon M1 printer at our in-house 3D printing lab. Intraoperatively, the 3D printed occlusal splint was soaked in betadine and placed intraorally prior to wiring.

Results: The average material cost for printing a resin occlusal splint was $20.43, with a total printing cost of $329.10 including labor. Turnaround time averaged 6.5 hours (3 hours of design and 3.5 hours of printing). Intraoperatively, the 3D printed occlusal splint set flawlessly in the patient's teeth, aligning the mandibular fragments and allowing for plating of the mandible fractures with ease.

Conclusions: With the seamless intraoperative application of a 3D printed occlusal splint, this study suggests that designing occlusal splints from solely CT imaging may be viable. This method would contribute unique value in an acute trauma setting where time is limited and only CT imaging is available. Additionally, in traumatic cases with multiple mandible fractures, creating an occlusal splint would aid in stabilizing mandible fragments and allow for accurate plating. Further application of this technique will allow for refinement and outcomes analyses.

Objective: Each learner will be able to recognize the feasibility of CT-based 3D-printed occlusal splints for repair of acute occlusal trauma.

Introduction:

Few studies exist that evaluate quality of life (QoL) in pediatric patients with diverse craniofacial conditions (CFCs), especially in a global setting.1 One qualitative study noted the increased public harassment experienced by patients with CFCs in Mexico.2 This study explores the differences in parent and patient-reported quality of life outcomes for patients living in the U.S. versus Mexico when matching for common cofounders such as age, sex, and diagnosis.

Methods:

In total, 144 parents (n=92) and patients (n=52) completed the Craniofacial Conditions Quality of Life scale (CFC-QoL), which measures 6 domains: bullying, peer problems, psychological impact, family support, appearance satisfaction, and desire for appearance change. Patients included were ages 1-22 years old with a variety of craniofacial diagnoses (cleft lip/palate, craniosynostosis, microtia, microsomia, and dermatologic conditions). Participants who reported Mexico as their country of residence were matched with participants from the United States based on age range, sex, and diagnosis. QoL outcomes were scored for each subscale and those with higher means indicated worse outcomes. An independent samples t-test was run to determine if there were any significant differences between patients living in the U.S. versus Mexico for each subscale.

Results:

Patients who reside in Mexico reported significantly worse outcomes in psychological impact (p=0.008) and desire for change in appearance (p=0.009) compared to those who reside in the U.S. when matched for age, sex, and diagnosis. Parents who reside in Mexico reported significantly higher desire for change in their child's appearance (p=0.043) compared to U.S.-based families.

Conclusions:

Although most subscales of parent and patient-reported QoL outcomes are similar between the matched cohort in the U.S and Mexico, we can conclude that participants in Mexico report worse outcomes in 2 domains: psychological impact and desire for appearance change. Factors that might be influencing these outcomes include limited access to care and increased public harassment in Mexico.2 However, further study and a larger sample size is needed to determine the modifiable factors that are causing worse QoL outcomes in Mexico-based patients with CFCs. Additionally, the discrepancy in QoL outcomes demonstrates the need to include CFC patients from outside of the U.S. to determine the global need for future interventions.

References:

1) Tapia VJ, Epstein S, Tolmach OS, Hassan AS, Chung NN, Gosman AA. Health-related quality-of-life instruments for pediatric patients with diverse facial deformities. Plastic and Reconstructive Surgery. 2016;138(1):175-187. doi:10.1097/prs.0000000000002285
2) Tapia VJ, Drizin JH, Dalle Ore C, et al. Qualitative methods in the development of a bilingual and bicultural quality of life outcomes measure for pediatric patients with Craniofacial Conditions. Annals of Plastic Surgery. 2017;78(5). doi:10.1097/sap.0000000000001027

Background Mandibular fractures account for up to 48.8% of pediatric facial fractures, making them one of the most common pediatric facial fractures. While a wide range of treatment modalities are available for these injuries, conservative treatment options, including jaw rest or chewing gum, are most frequently indicated. Despite the ubiquitous availability of conservative treatment regimens, pediatric mandibular fracture patients are often transferred, leading to costly and time-consuming "potentially avoidable" transfers for patients, families, and hospital systems. This study evaluates factors influencing "potentially avoidable" transfer, defined as a patient receiving conservative treatment post-transfer to a children's hospital.

Methods A retrospective review was performed of patients under 18 years of age who were evaluated for mandibular fractures at a pediatric level I trauma center between 2006 and 2021. Variables studied included demographics, etiology, medical history, associated injuries, treatments, and outcomes. Chi-squared, linear regression, Welch's t-test and ANOVA tests were conducted using Stata SE Software (College Station, TX).

Results A total of 480 pediatric patients (121 female and 359 male) met inclusion criteria. More than half of the patients (n=281, 58.5%) were transferred from an outside hospital and of those, 177 (63.0%) were deemed "potentially avoidable." Subsequent treatment (conservative vs. surgical intervention) did not differ significantly between the transfer and non-transfer groups (p=0.415). Insurance status (uninsured, p=0.023) and presence of a soft tissue injury (p=0.022) were significantly associated with likelihood of transfer. Trauma level, cause of incidence, gender, and presence of another fracture, musculoskeletal or brain injury did not significantly influence rate of transfer.

Conclusions "Potentially avoidable" patient transfers are a significant logistical and economic burden to patients and hospital systems. Uninsured pediatric mandibular fracture patients were more likely to be transferred than similar peers regardless of presenting trauma level, yet they were no more likely to receive subsequent surgical care post-transfer than similar non-transferred peers. Concurrent soft-tissue injuries were a significant factor influencing "potentially avoidable" transfers. These findings support additional research and innovation in remote plastic surgery consultations for pediatric patients who may not benefit from urgent transfer.