Scientific Abstract Presentations: Craniomaxillofacial Session 2 Thursday, October 9 Thu, Oct 9 3:30-4:30 p.m. CDT

Background:

Palatal fistulas represent the most challenging complication after cleft palate repair, with recurrence rates ranging from 2.4% to 35%. The lack of a standardized difficulty index complicates surgical decision-making, specifically in the management of complex defects. The Palatal Fistula Difficulty Index (PFDI) was formulated as a quantitative tool to stratify fistula complexity based on anatomical and functional factors. With numerical scores assigned across six categories - location, size, configuration, number of fistulae, velopharyngeal function, and recurrence - the index ensures patients with complex defects receive timely referrals to tertiary institutes, optimizing postoperative outcomes. This study aimed to develop and validate the Palatal Fistula Difficulty Index by assessing its reliability and accuracy in identifying high-risk cases necessitating specialized intervention.

Methods:

A prospective study was conducted at CLAPP Hospital, Lahore, Pakistan, over three months from November 2024 to January 2025. A total of 30 patients with palatal fistulas were selected and assessed using the six-category index, which assigned scores for: (1) Fistula Location (Midline, Lateral, Subtotal); (2) Size (<1 cm, 1–3 cm, >3 cm); (3) Configuration (Longitudinal, Transverse, Irregular); (4) Number of Fistulae (Single, Two, >Two); (5) Palate Function (Both Adequate, Function Adequate but Length Inadequate, Neither Adequate); and (6) Recurrence (Primary, Operated Once, Operated More Than Once). Selected cases were distributed to 20 experienced cleft surgeons across different institutions. Each surgeon independently evaluated the cases and assigned a score, which they sent back for analysis. Inter-rater reliability was assessed using the intraclass correlation coefficient (ICC). Postoperative outcomes were analyzed, focusing on fistula recurrence, operative time, and functional outcomes. Statistical analyses were conducted using R Statistical Software (Version 4.3.2; R Core Team 2024).

Results:

The inter-rater reliability of the PFDI was excellent (ICC = 0.91, 95% CI: 0.87–0.94), indicating high agreement among evaluators. The index score correlated significantly with operative time (r = 0.82, p < 0.001), confirming its predictive value for surgical complexity. Logistic regression analysis demonstrated that each 1-point increase in the score was associated with a 2.95-fold increased risk of recurrence (OR = 2.95, 95% CI: 2.11–4.27, p < 0.001). The recurrence rate increased significantly with complexity, with low complexity cases (6–9 points) showing a 5% recurrence rate, moderate cases (10–14 points) an 18% recurrence rate, and high complexity cases (15–18 points) a 42% recurrence rate (p < 0.001, χ² test). Operative time also varied significantly between groups (low complexity: 43 ± 11 min; moderate: 74 ± 19 min; high: 112 ± 24 min, p < 0.001, ANOVA). 72% of high-complexity cases treated at non-specialized centers ultimately required referral to the tertiary cleft center due to failed closure.

Conclusion:

The Palatal Fistula Difficulty Index is a reliable and predictive tool for classifying palatal fistula complexity and guiding referral decisions. Higher scores were strongly associated with longer operative times, increased recurrence risk, and the need for specialized surgical intervention, making the scorecard a valuable triage system for identifying cases that should be referred to tertiary cleft centers.

Introduction and Purpose: Velopharyngeal dysfunction (VPD) disrupts speech by impairing velopharyngeal closure, leading to nasal air escape. Accurate anatomical assessment is essential for selecting appropriate surgical interventions. Speech MRI provides detailed visualization of the levator veli palatini (LVP) and velopharyngeal closure patterns, surpassing traditional diagnostic tools (1). Patients with syndromic VPD have an increased risk (49-60%) of carotid artery medialization (2), necessitating preoperative vascular imaging, as intraoperative assessment using carotid pulsations poorly correlates with actual artery position (3). While 22q11.2 Deletion Syndrome has the highest association, other syndromes also present with vascular variability, highlighting the need for vascular assessment (4). Traditionally, speech MRI and carotid MRA are performed separately, with MRA requiring anesthesia. To improve efficiency and reduce patient burden, we developed a novel dual-imaging protocol combining speech MRI and carotid MRA into a single, nonsedated imaging session. We describe our protocol parameters to facilitate replication at other centers.

Methods: Our dual protocol was applied to high-risk VPD patients, including those with syndromic diagnoses or incomplete genetic workups. Imaging consisted of: 1. Speech MRI – Nonsedated acquisition guided by a speech-language pathologist, capturing sustained phonation of "EEE," "SSS," and "SHH" in sagittal and oblique coronal views. The MRI assessed LVP orientation, velopharyngeal closure patterns, and VP gap size. 2. Carotid MRA – Nonsedated 2D and 3D time-of-flight sequences from the skull base to the neck. The protocol was truncated to exclude the aortic arch and circle of Willis, optimizing imaging time while maintaining surgical relevance.

Results: Eight patients have completed the dual-protocol. Speech MRI consistently provided information for surgical planning including LVP integrity, VP gap size, and closure patterns. Carotid MRA successfully mapped vascular anatomy, with image quality comparable to traditional sedated MRA protocols. One case demonstrated carotid medialization. In all patients, the dual-protocol directly influenced surgical decision-making by simultaneously providing comprehensive anatomical and vascular data. Average total imaging time ranged from 15-20 minutes.

Conclusions: This dual-imaging protocol is a novel, efficient approach to preoperative VPD evaluation, offering comprehensive anatomical and vascular data in a single session. It streamlines diagnostics, eliminates unnecessary anesthesia, improves surgical planning, and reduces patient burden. Future studies will assess larger cohorts, evaluate cost-effectiveness, and further refine implementation strategies.

References: 1. Zwa 5. Perry JL, Snodgrass TD, Gilbert IR, et al. Establishing a clinical protocol for velopharyngeal MRI and interpreting imaging findings. Cleft Palate Craniofac J. 2024;61(5):748–758. doi:10.1177/10556656221141188 2. Oppenheimer AG, Fulmer S, Shifteh K, et al. Cervical vascular and upper airway asymmetry in velo-cardio-facial syndrome: correlation of nasopharyngoscopy with MRA. Int J Pediatr Otorhinolaryngol. 2010;74(6):619–625. doi:10.1016/j.ijporl.2010.03.006
3. Mitnick RJ, Bello JA, Golding-Kushner KJ, Argamaso RV, Shprintzen RJ. The use of magnetic resonance angiography prior to pharyngeal flap Surgery in patients with velocardiofacial syndrome. Plast Reconstr Surg. 1996;97(5):908–919. doi:10.1097/00006534-199604001-00005 4. Raol N, Caruso P, Hartnick CJ. Use of imaging to evaluate course of the carotid artery in surgery for velopharyngeal insufficiency. Ann Otol Rhinol Laryngol. 2015;124(4):261–265. doi:10.1177/0003489414554943

Introduction: Sagittal craniosynostosis (SCS) manifests with complex phenotypes and requires precise assessments to guide management and lower the risk of developmental complications. CranioRate™ is an advanced supervised machine learning algorithm initially developed to characterize and quantify metopic craniosynostosis (MCS) severity, validated by expert craniofacial surgeon ratings. (1) Here we describe the process of developing the CranioRate™ sagittal severity score (SSS) using our validated supervised machine learning (ML) techniques and describe the spectrum of severity among a large population of patients with SCS.

Methods: A survey with an internet-based rating portal was administered to expert craniofacial surgeons. Respondents evaluated the severity of a series of SCS and normal control images. These ratings validated a principal-component-analysis ML tool to produce the SSS. A leave-one-out-cross-validation (LOOCV) analysis evaluated SSS against the prior gold standard, cephalic index (CI). We assessed its performance in comparison with the cranial morphology deviation (CMD) score which is based on unsupervised ML and applied the SSS to a large population of patients with SCS.

Results: The survey was completed by 54 craniofacial surgeons, each rating a random set of 20 patients (75% SC:25% control), resulting in 1080 rating records. After applying AUC-based screening, 50 surgeons were retained for analysis. The SSS achieved a significantly higher accuracy in predicting expert responses than CI in LOOCV (p<0.01). Consensus ratings were superior to diagnostic labels in quantifying within-group variations, and skin descriptors were shown to be equivalent in terms of predictive power as skull descriptors. The CMD score showed a strong correlation with the SSS (Pearson coefficient of 0.92, Spearman coefficient of 0.90, p< 0.01). We present the frequency distribution of SSS in 195 patients with SCS as well a population of 170 normal and 221 patients with metopic craniosynostosis.

Conclusions: We introduce the SSS as a novel metric to quantify severity in SCS and describe the distribution of phenotypic severity in a large cohort of patients (Figures 1 and 2). The findings underscore the potential of machine learning models for comprehensive severity quantification in SCS. These methods pave the way for more objective, precise, and consistent evaluations, marking a significant step forward in the collaborative study and management of SCS.

1. Beiriger JW, Tao W, Bruce MK, et al. CranioRate: An Image-Based, Deep-Phenotyping Analysis Toolset and Online Clinician Interface for Metopic Craniosynostosis. Plast Reconstr Surg. 2024;153(1):112e-119e. doi:10.1097/PRS.0000000000010452

Background: Injuries caused by craniofacial trauma (CFT) require specialized surgical care. This represents a challenge in low- and middle-income countries (LMICs) where the burden of injury is high and specialized plastic surgical capacity is low. This study aimed to characterize the epidemiology, injury patterns, and demographic distribution of CFT cases in Mexico, to understand CFT trends which could lead to more effective prevention strategies, improved treatment capacity, and improved patient outcomes. Methods: This retrospective study analyzed trauma cases from a national public hospital registry in Mexico from January through December 2022. CFT cases were identified using ICD-10 diagnostic codes, while surgical interventions were classified using ICD-9 procedure codes. Demographic data, injury mechanisms, fracture patterns, surgical interventions, infection rates, length of stay (LOS), and mortality rates were analyzed. Geographic trends were evaluated by correlating case distributions with patients' home state and healthcare center characteristics. Results: Of 462,103 trauma cases, 33,935 (7.3%) involved CFT, with 6,733 cases (19.8%) requiring surgical intervention. The median age of patients was 28 years (IQR 20), with young adults (18–40 years) comprising 56.7% of cases, followed by adults over 40 years (24.9%) and children under 18 years (18.4%). Males accounted for 79.7% (n=5,366) of operative cases. Nationally, the leading causes of injury were road traffic events (25.8%, n=1,736), interpersonal violence (24.2%, n=1,631), and falls (22.6%, n=1,522). Regional variability was observed: states with larger urban centers, such as Ciudad de México, Puebla, and Guanajuato, reported the highest caseloads (n=2,385). Road traffic events dominated in Puebla (26.3%, n=190), while interpersonal violence was more common in Guanajuato (18.3%, n=89). Among older adults, falls accounted for 52.4% (n=246) of cases. Mandibular fractures (17.9%, n=1,207) were the most common, followed by maxillary and zygomatic fractures (10.1%, n=678) and nasal bone fractures (7.0%, n=471). Interpersonal violence was associated with mandibular fractures, while falls correlated with nasal fractures. Median LOS was 2 days (IQR 7). Mortality occurred in 3.39 per 1,000 cases. Postoperative infection rates were 1.2%, with higher rates reported in second-level care centers in resource-limited areas. Conclusions: Craniofacial trauma in Mexico disproportionately affects young adult males, primarily resulting from road traffic events, interpersonal violence, and falls, with distinct patterns by age and mechanism. Variations in outcomes of CFT across Mexico are associated with regional resource availability. While infection and mortality rates were relatively low, mortality was higher in Mexico than in CFT cases in the United States.(1) Prolonged LOS in resource-limited regions demonstrates a need for strengthening surgical capacity. Addressing regional inequities in healthcare access, expanding emergency response capabilities, and increasing the plastic surgery workforce can improve patient outcomes and equity in trauma care. References 1. Sethi RK, Kozin ED, Fagenholz PJ, Lee DJ, Shrime MG, Gray ST. Epidemiological survey of head and neck injuries and trauma in the United States. Otolaryngol Head Neck Surg. 2014 Nov;151(5):776-84. doi: 10.1177/0194599814546112. Epub 2014 Aug 19. PMID: 25139950; PMCID: PMC4481864.

Background Restoring facial symmetry in patients with Tessier 7 clefts may present challenges in achieving functional and aesthetic outcomes. While oral commissure reconstruction has been performed with varying degrees of success, there remains a need for comprehensive facial analysis to evaluate the symmetry of outcomes. Similarly, the rarity of this condition has resulted in limited data regarding the efficacy of current treatment paradigms. This study analyzes facial anthropometrics to compare postsurgical symmetry after commissuroplasty in children with Tessier 7 cleft over 18 years.

Methods A retrospective review of children who underwent commissuroplasty at a major children's hospital between 2005 and 2023 was conducted. Cohorts included preoperative and postoperative measurements within 6 months. Anthropometric measurements from frontal images (repose position) included stomion-to-chelion (Sto-Ch), chelion-to-contralateral ala (Ch-Ala), chelion-to-lateral canthus line (Ch-LC), chelion-to-menton (Ch-Men) and chelion angle deviation (Ang-Dev) (Figure 1). Symmetry ratios between the operative and non-operative sides were calculated using a range of [0.0-1.0], with 1.0 signifying ideal symmetry. For patients with bilateral Tessier 7 clefts, symmetry ratios were calculated from both sides of the face. Major revisions were defined as repeat commissuroplasty for facial asymmetry or excision of contracted scarring. Statistical analysis was performed using Student T-tests.

Results A total of 32 patients underwent commissuroplasty for Tessier 7 of which 25 met inclusion criteria. Six patients had bilateral Tessier 7 clefts and 19 patients had unilateral Tessier 7 clefts (Right-sided: 76% vs Left-sided: 24%). All patients' clefts were repaired with a myomucosal advancement flap commissuroplasty technique. Mean age at surgery was 13.3 ± 3.0 months. Of all patients, 48% were female, 32% had an additional Tessier cleft, and 20% were syndromic. Overall, 25% of patients required major revisional procedures. Compared to the preoperative cohort, postoperative patients demonstrated increased symmetry in four anthropometric measurements (Sto-Ch: 0.73 vs 0.89, p<0.001; Ch-Ala: 0.84 vs 0.92, p<0.001; Ch-LC: 0.88 vs 0.94, p=0.002; Ch-Men: 0.86 vs 0.94 (p<0.001). No significant difference was found between pre- and postoperative chelion angle deviation symmetry ratios (Ang-Dev: 0.51 vs 0.61, p=0.139). Percent improvement was recorded across each measurement (Table 1). Mean follow-up time was 3.74 ± 6.5 years for 7 patients. Symmetry ratios from follow-up anthropometric measurements did not vary significantly from postoperative asymmetry ratios.

Conclusion Overall, oral commissure reconstruction demonstrated improved facial symmetry in the following measurements: Sto-Ch, Ch-Ala, Ch-LC, and Ch-Men with the myomucosal advancement flap technique. However, there was no significant improvement in chelion angulation symmetry after the surgery. Postoperative symmetry did not change significantly over follow-up time. More studies are required to evaluate the most effective means of repairing these clefts to optimize long-term symmetrizing outcomes.

Background: Orbital fractures are among the most common craniofacial injuries in children, varying significantly from adult cases in their patterns and presentations. This study analyzes the mechanisms and management of pediatric orbital fractures over a two-decade period.

Methods: A retrospective review was conducted of patients with CT-confirmed orbital fractures at a major children's hospital from 2004 to 2024. Health records were reviewed for fracture type, injury mechanism, associated injuries, and surgical history. Statistical analyses used Pearson's chi-squared and ANOVA.

Results: A total of 188 patients with orbital fractures were included. Of them, 39.4% underwent surgical correction at an average of 16.3 days after presentation. The mean age at injury was 11.6 years. Fractures most commonly occurred in males (72.5%) and were most commonly due to sports-related injuries (20.7%). Orbital floor fractures (47.2%) and zygomaticomaxillary complex (ZMC) fractures (17.6%) were the most common subtypes overall. Naso-orbital ethmoid fractures were the most common subtype requiring surgical correction (71.4%). Entrapment was observed in 7.3% of patients and was most common in orbital floor fractures (71.4%). Orbital roof fractures had the highest rate of pneumocephalus (50%) while orbital rim fractures had the highest rate of vertebral fracture (16.7%). ZMC fractures had higher rates of infraorbital nerve hypoesthesia (25%), with improvement after surgery in 70% of cases.

Conclusion: Pediatric orbital fractures exhibit distinct patterns and associations, emphasizing the need for targeted approaches in diagnosis and management that differ from adult paradigms.

Purpose Craniofacial masses, including jaw cysts, benign tumors, and malignant lesions of the maxilla, mandible, and oral vestibule, require tailored surgical management to balance oncologic control with functional and aesthetic outcomes. While some lesions are amenable to simple excision, others demand extensive resection, increasing the risk of complications. Despite advances in surgical techniques, postoperative morbidity remains a concern, influenced by patient factors such as comorbidities and frailty. Frailty, a state of reduced physiological reserve, is a known predictor of poor surgical outcomes but remains underexplored in craniofacial mass resections. This study evaluates the impact of frailty on postoperative outcomes in craniofacial mass resections by stratifying patients into low-risk (5-mFI<2) and high-risk (5-mFI≥2) cohorts. By analyzing morbidity, hospital length of stay, and readmission rates, we aim to determine whether integrating frailty assessment into preoperative planning can improve risk stratification and optimize patient care.

Methods A retrospective analysis was conducted using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2011 to 2021. Patients undergoing craniofacial mass excisions were identified through CPT codes, and frailty was assessed using the 5-mFI, comprising hypertension, diabetes, respiratory disease, congestive heart failure, and functional dependence. Patients were stratified into 5-mFI<2 and 5-mFI≥2 cohorts. Demographics, comorbidities, operative characteristics, and postoperative outcomes were compared between groups.

Results A total of 6,858 patients were analyzed, with 4,372 (63.8%) in the 5-mFI<2 cohort and 2,486 (36.2%) in the 5-mFI≥2 cohort. Patients in the 5-mFI≥2 group were significantly older (mean age: 63.15 vs. 44.12 years, p<0.001) and had higher BMI (29.08 vs. 26.71, p<0.001). Functional independence was significantly lower in the 5-mFI≥2 cohort (95.62% vs. 99.27%, p<0.001).

Postoperatively, the 5-mFI≥2 cohort exhibited higher rates of all-cause complications (38.29% vs. 20.11%, p<0.001) and severe systemic complications (4.10% vs. 0.73%, p<0.001). Specific complications such as postoperative bleeding (9.53% vs. 3.59%, p<0.001), wound dehiscence (2.17% vs. 1.30%, p=0.006), and unplanned intubation (1.53% vs. 0.32%, p<0.001) were significantly more frequent in the 5-mFI≥2 group. The length of hospital stay was significantly longer for patients in the 5-mFI≥2 cohort (3.63 vs. 2.55 days, p<0.001), and prolonged hospitalization (>30 days) was more prevalent (1.21% vs. 0.41%, p<0.001). Readmission rates were also higher in the 5-mFI≥2 cohort (5.79% vs. 3.61%, p<0.001). Multivariable analysis demonstrated that patients with 5-mFI≥2 had increased odds of all-cause complications (p=0.031) and severe systemic complications (p=0.023), even after adjusting for confounders. Operative time was significantly longer in the 5-mFI≥2 group (213.84 vs. 166.51 minutes, p<0.01).

Conclusion Patients with 5-mFI≥2 undergoing craniofacial mass resections experience significantly higher rates of postoperative complications, including systemic and wound-related complications, along with longer hospital stays. Frailty assessment using the 5-mFI provides valuable risk stratification for surgical candidates, enabling better perioperative planning and patient counseling. Integrating frailty metrics into routine preoperative evaluations may optimize clinical outcomes and inform targeted interventions for high-risk patients. Further prospective studies are warranted to refine risk prediction models and enhance perioperative management strategies in craniofacial surgery.

Background Microtia and anotia are traditionally reconstructed using costal or auricular cartilage. However, recent advancements in alloplastic techniques challenge autologous reconstruction as the gold standard. While alloplastic implants enable earlier intervention and potentially enhance aesthetic outcomes, they carry potentially higher risks of early complications. Differences in long-term outcomes are unexplored. This study compares short-term (30-day) and long-term (≥3-year) outcomes of autologous and alloplastic microtia/anotia reconstruction.

Methods/Techniques We used TriNetX, a global research platform, to analyze patient-level data from multiple healthcare organizations. Patients who underwent autologous or alloplastic microtia/anotia repair were identified by CPT and ICD-10 codes. Propensity-score matching controlled for demographics and comorbidities to establish comparable autologous/alloplastic cohorts. Short-term outcomes captured surgical wound dehiscence; surgical site infection; any postoperative infection; graft- or prosthetic-related complications; and debridement procedures occurring within 30 days after surgery. Long-term outcomes assessed graft/prosthetic complications and additional ear surgeries documented at least three years after surgery. The aggregate risk of any of these outcomes is termed all-cause complications. Multivariate and Kaplan-Meier analyses assessed differences in risk over time. Cox proportional hazards models further measured the impact of select variables on outcome risk.

Results Before matching, the autologous reconstruction group had 352 patients, and the alloplastic reconstruction group had 187 patients. Mean age at surgery was not significantly different (8.2­­­­­±10.5 vs 6.44±10.3 years, p=0.0643). After matching, each cohort had 182 patients. Follow-up was longer in the autologous group than in the alloplastic group (median: 3,824 vs. 3,369.5 days). In the 30-day post-operative period, alloplastic repairs had significantly higher risk of wound disruption (RD: 5.5%, 95% CI: 2.184%–8.805%, p = 0.0013); all-cause complications were similar.

At three years after surgery or later, the autologous cohort experienced significantly more additional external ear operations (Risk Difference: 9.49%, 95% CI: 0.967%–18.017%, p = 0.0322), and they were 32.8% more likely than the alloplastic group to have any additional surgeries (RR=1.328, 95% CI: 1.023-1.724) in that timeframe. However, autologous repairs had significantly less long-term graft/prosthetic complications (HR = 0.586, p = 0.0156).

The Cox model reaffirmed that alloplastic repairs carry higher rates of short-term complications, but timing within the thirty-day window did not significantly differ between groups (HR=1.747, p=0.4055). Musculoskeletal and connective tissue diseases imparted the highest risk of experiencing a complication in 30 days (HR=7.229, p=0.0061). At three years after surgery or later, the long-term Cox model similarly found that alloplastic repairs were more likely to have complications than autologous repairs (HR=0.557, p=0.0028). Age at surgery was not significant in the long-term model.

Conclusions Autologous microtia repair may offer greater long-term durability but is likely to need adjustments, while alloplastic repair has higher risk of complications in short- and long-term settings, requiring postoperative monitoring. It is important to note that longer follow-up times in the autologous group may have led to more surgeries observed. When selecting a reconstructive approach for microtia, surgeons should weigh the importance of durability vs. need for adjustment alongside the patient's priorities and surgical expectations.

Introduction The use of myomucosal buccal flaps during the repair of the cleft palate may decrease the rate of complications such as dehiscence and perforation, decreasing tension during closure and lengthening the nasal layer. However, some surgeons have concerns for unilateral harvest of buccal flaps, which can result in subsequent facial asymmetry. This study aims to investigate if the use of unilateral buccal flaps in primary palatoplasty results in perceived facial asymmetry for a patient. Methods Photographs of patients with cleft palate who have undergone primary palatoplasty at our institution were included in a de-identified survey to obtain crowdsourced data within medical students and physicians at our institution. Patients were grouped by unilateral or no buccal flaps used with their palatoplasty. The photographs were obtained from the medical records and de-identified by censor bars across the eyes and thinly around the nose in a T-shape so that only the cheeks and mouth area and administered as a survey where respondents were asked to rate the degree of asymmetry of the face (symmetry score) and which side appeared larger (cheek laterality score). Statistical analysis was performed to describe the differences between perceived facial asymmetry of patients between groups with an intraclass correlation coefficient (ICC) to report inter-rater reliability. Results The cohort included 14 patients, divided into two treatment groups: 7 patients with unilateral buccal flaps and 7 patients with no buccal flaps. Of these patients, 8 (57%) are male, and 6 (43%) are female. The vast majority of patients (11 (79%)) had Veau III cleft palate; 2 (14%) had Veau IV, and 1 (7%) had Veau I. The mean age at surgery was 12.9 ± 2.4 months and age at time of survey was 6.2 ± 0.8 years. The groups were similar with no difference in age at surgery, age at survey, cleft type, race, and gender. A total of 35 completed survey responses were received. The mean symmetry score (with 10 being most symmetric) was 6.7 ± 0.7: 6.7 ± 0.8 for unilateral buccal flaps, and 6.8 ± 0.7 for none (p = 0.7). The mean cheek laterality score (1 being bigger on the left and 5 being bigger on the right) was 2.8 ± 0.5: 2.7 ± 0.5 for unilateral buccal flaps, and 2.9 ± 0.4 for none (p = 0.4). Overall, the inter-rater reliability was good (0.8), using the interclass correlation coefficient. Discussion There was no significant difference between perceived asymmetry of patients status post primary cleft palate repair. Future directions include surveying lay people to assess broader perspectives of facial asymmetry and long-term follow-up of outcomes in patients with and without buccal flaps. This suggests that patients can safely undergo palatoplasty with unilateral buccal flaps without the concern for aesthetic impacts on future facial symmetry.

Background: Maxillofacial fractures in adults carry a risk for cervical spine injuries (CSI), yet this risk remains understudied in pediatric patients. This study examines injury mechanisms, treatment approaches, and CSI associations in pediatric maxillofacial fractures over two decades.

Methods: A retrospective review of patients under 18 with computed tomography-confirmed maxillofacial fractures from 2002 to 2024 was conducted. Inclusion criteria were nonsyndromic patients with fractures due to blunt trauma. Data on demographics, fracture types, injury mechanisms, CSI occurrence, and treatment were analyzed using chi-squared and T-tests.

Results: Of 2,401 patients, 395 met the inclusion criteria; 35.2% required surgery. The mean age was 11.6 years, with a male-to-female ratio of 3:1. Orbital fractures were most common (47.6%), followed by maxillary fractures (25.1%). Falls (27.8%) and assault (17.7%) were the leading causes. Patients with orbital fractures had a significantly higher CSI rate (3.2%) than those with other fracture types (0.57%, p<0.05). Orbital fractures also correlated with higher surgical intervention rates (39.9% vs. 28.9%, p<0.05).

Conclusions: Children with orbital fractures are at a notably higher risk for CSI than those with other maxillofacial fractures. This risk may result from unique pediatric biomechanics, specifically a higher upper-to-lower face ratio, potentially facilitating force transmission from the face to the cervical spine. Given the frequency of high-energy trauma in orbital fractures, careful cervical spine evaluation in these patients is essential to ensure comprehensive care and avoid missed injuries.