Scientific Abstract Presentations: Craniomaxillofacial Session 3 Thursday, October 9 Thu, Oct 9 5:00-6:00 p.m. CDT

PURPOSE: Endoscopically assisted surgery for craniosynostosis has emerged as a sophisticated alternative to open cranial vault remodeling, offering significant advantages particularly with respect to reduced blood loss and overall perioperative morbidity. However, intraoperative blood loss remains a significant concern even with minimally invasive repair. Herein we describe our experience with the novel technique of performing the endoscopic strip craniectomy using a diamond burr drill bit, which provides continuous hemostasis to the bone edges during cutting. Outcomes with the diamond burr (DB) are compared with those of procedures where the strip craniectomy was performed with traditional instrumentation (scissors, rongeurs, and/or non-diamond burr drill bit).

METHODS: A retrospective chart review was conducted of patients who underwent endoscopic strip craniectomy with two pediatric neurosurgeons at a single institution between 2012 and 2024 for the treatment of single-suture craniosynostosis. Instrumentation used to complete the craniectomy was documented alongside operative duration, incidence of durotomy, intraoperative blood loss, and intraoperative transfusion requirements. Postoperative transfusion requirements and postoperative complications were also noted.

Multivariable linear regression was conducted to compare DB procedures with traditional endoscopic procedures (control group) for outcomes of intraoperative blood loss, length of stay (LOS), operative time, and intraoperative volume transfused, while controlling for age, weight, and craniosynostosis type. Additionally, binary logistic regression, using the same covariates, was employed to compare DB procedures with traditional endoscopic procedures in assessing the likelihood of intraoperative transfusion, postoperative transfusion, durotomy, and persistent calvarial defect after one year.

RESULTS: A total of 83 patients met inclusion criteria, with the DB group comprising 68 patients and the control group comprising 15. The mean intraoperative blood loss for the DB group was 26.6 mL compared to 74.0 mL in the control group. Operative time in the DB group was 143.0 minutes versus 114.9 minutes in the control group. The incidence of intraoperative blood transfusion was 16.2% in the DB group and 53.3% in the control group.

In multivariable analysis, use of DB was associated with significantly less intraoperative blood loss (β=-48.5 mL, 95% CI -73.2 – -23.8 mL, p=0.0002) and a significantly lower odds of intraoperative blood transfusion (OR 0.142, 95% CI 0.037–0.509, p=0.0032). Use of DB was not significantly associated with odds of durotomy (p=0.648), postoperative blood transfusion (p=0.952), or persistent calvarial defect (p=0.252), nor was it associated with a shorter LOS (p=0.677). Intraoperative transfusion volumes were slightly lower in the DB group, although this did not reach statistical significance (β=-60.7 mL, 95% CI -128.8–7.5 mL, p=0.076). Use of DB was associated with a slightly longer operative time (β=26.8 min, 95% CI 0.3–53.3 min, p=0.048). Two patients in the DB group experienced a wound breakdown requiring operative washout and antibiotics.

CONCLUSIONS: Performing strip craniectomy using a diamond burr results in significantly less intraoperative blood loss and significantly lower odds of requiring an intraoperative blood transfusion when compared to traditional endoscopic instrumentation. This technique is relatively easily implemented and stands to further enhance the known effect of endoscopic craniosynostosis repair on perioperative outcomes relative to open cranial vault remodeling.

Background Otoplasty is a surgical procedure that corrects protruding ears, enhancing both functionality and aesthetics. Beyond physical appearance, this intervention may influence societal perceptions of a patient's attractiveness, personality traits, and interpersonal characteristics. This study examines social perceptions of pediatric patients following otoplasty.

Methods Using Amazon Mechanical Turk, a RedCap survey was distributed to assess social perceptions of pre- and postoperative photographs of two patients who underwent otoplasty. Respondents rated patient images using a seven-point Likert scale across categories, including personality traits, expressed emotions, interpersonal attributes, and expected life experiences. Pre- and postoperative results were averaged for each patient, and paired t-tests (p < 0.05, 95% CI) determined significance.

Results Among 998 responses, postoperative images were perceived more negatively. Patients appeared more submissive (p < 0.000), untrustworthy (p < 0.009), unattractive (p < 0.041, p < 0.027), surprised (p < 0.008), less happy (p < 0.039), and less fun (p < 0.010). They were also associated with loneliness (p < 0.026), anxiety (p < 0.045), and academic struggles (p < 0.006). Socioeconomic status perceptions were inconclusive, with one patient seen as having higher SES (p < 0.027) and the other lower SES (p < 0.027). Patient 1 was perceived as more successful postoperatively (p < 0.000), while Patient 2 appeared more dominant (p < 0.009).

Conclusion This study highlights the psychosocial implications of otoplasty, emphasizing the need for preoperative education and expectation management for patients and families.

Introduction and Purpose: Velopharyngeal dysfunction (VPD), commonly associated with cleft palate, results in hypernasal speech that affects intelligibility and can lead to social stigmatization. Accurate diagnosis and classification of VPD are critical for determining whether a patient requires surgical intervention or would benefit from speech therapy alone. The gold standard for VPD assessment is perceptual speech evaluation by trained speech-language pathologists (SLPs) using the CAPS-A-AM (1). However, access to these specialists is limited in many centers. Recent efforts to incorporate machine learning (ML) into VPD diagnosis have relied on samples limited to isolated phonemes, internet speech samples, and crowd-sourced data (2). These models have not been trained on prospectively accrued and reproducibly rated speech samples. Our project aims to develop a clinically viable ML algorithm for VPD diagnosis based on CAPS-A-AM-rated, standardized speech samples, advancing beyond the approaches previously attempted.

Methods: This prospective, single-center study enrolled pediatric participants (ages 2–17) with and without VPD. Participants provided standardized speech samples recorded by an SLP following CAPS-A-AM protocols. Speech samples were independently rated by blinded and unblinded CAPS-A-AM-trained SLPs, with inter- and intra-rater reliability assessed. Mel spectrogram images of sustained vowels (/a/, /i/, /u/) were generated using Audacity, and acoustic features (jitter, shimmer, formant frequencies) were extracted using Praat. To enhance model performance, a pairwise comparison technique was applied to the Mel spectrogram images, increasing class separability. ML models were trained to differentiate hypernasal from normal speech using /i/ and /u/ spectrograms, as these vowels are the most sensitive to hypernasality detection. Performance was assessed using standard metrics, including accuracy and F1-score. Additionally, a large language model (ChatGPT-4.0) was tested as a classification tool for comparison.

Results: A total of 36 speech samples have been collected and processed (VPD: n=24, Control: n=12), with a median age of 8.1 years (range: 5.1–17.9) and an equal male-to-female distribution (18:18). All participants completed standardized speech tasks without exclusions. CAPS-A-AM ratings classified VPD participants as borderline (29%), mild (25%), moderate (21%), and severe (25%) hypernasality. No control participants had hypernasality scores above zero. ML models, trained on /i/ and /u/ Mel spectrogram images, achieved an F1-score of 0.97, significantly outperforming ChatGPT-4.0 (F1 = 0.44).

Conclusions: This study establishes a reproducible pipeline for standardized speech sample collection and demonstrates the feasibility of AI/ML for binary hypernasality classification. Future work will expand datasets through multi-center collaboration, integrate longer speech samples with richer acoustic features, and transition toward severity grading models to enhance clinical utility.

References: 1. Ruda JM, MD, Krakovitz P, MD, Rose AS, MD. A Review of the Evaluation and Management of Velopharyngeal Insufficiency in Children. Otolaryngologic clinics of North America. 2012;45(3):653-669. doi:10.1016/j.otc.2012.03.005W.-K. Chen, Linear Networks and Systems (Book style). Belmont, CA: Wadsworth, 1993, pp. 123–135. 2. Zhang A, Pyon RE, Chen K, Lin AY. Speech Analysis of Patients with Cleft Palate Using Artificial Intelligence Techniques: A Systematic Review. FACE. 2023;4(3):327-337. doi:10.1177/27325016231187985

PURPOSE: This study evaluates how incision type (intraoral vs retromandibular) and patient characteristics influence postoperative complications following open reduction and internal fixation (ORIF) of mandibular angle fractures.

BACKGROUND: Mandibular angle fractures account for approximately 30% of mandibular fractures and pose unique challenges due to their anatomical location and high risk of complications such as infection, malocclusion, and hardware failure. (1) The optimal surgical approach remains debated; intraoral incisions minimize scarring and facilitate third molar extraction, whereas retromandibular approaches may offer shorter operative times. (2,3) However, comparative data on complication rates remain limited.

METHODS AND MATERIALS: A retrospective review of 116 patients with mandibular angle fractures treated with ORIF from January 2018 to April 2023 was conducted. Multivariate logistic regression assessed the impact of surgical approach while controlling for patient factors (age, BMI, smoking status, caries presence, number of fractures, and third molars). Postoperative complications served as the primary outcome stratified into infection, return to the operating room (RTOR), and postoperative third molar extractions.

RESULTS: The median age was 31.7 years (Interquartile Range [IQR] = 23.4–46.3), and BMI was 24.4 kg/m² (IQR = 21.9–27.8). Retromandibular incisions increased complication risk 11.2-fold versus intraoral (P = 0.022, 95% CI = 1.4–86.7), while combined approaches increased risk 3.6-fold (P = 0.030, 95% CI = 1.1–12.2). Among retromandibular subtypes, trocar use significantly increased complications (Odds Ratio [OR] = 5.11, P = 0.014, 95% CI = 1.9–14.0), whereas transparotid and retroparotid approaches were not significantly different from intraoral. Isolated angle fractures were protective (OR = 0.17, P = 0.023, 95% CI = 0.04–0.79). Age, BMI, smoking, and third molar extraction were not significant predictors. No significant predictors emerged for infection or RTOR, though older age and avoiding intraoperative third molar extraction trended toward increased infection risk (P = 0.053) and decreased RTOR rates (P = 0.078).

CONCLUSIONS: Surgical approach significantly impacts complication rates in mandibular angle fracture repair. Retromandibular and combined incisions pose higher risks than intraoral approaches, with trocar use carrying the greatest risk. Patient factors appear to play a lesser role in outcomes than previously assumed. These findings underscore the importance of refining incision selection to optimize patient outcomes and reduce morbidity.

REFERENCES: (1) Singh S, Fry RR, Joshi A, Sharma G, Singh S. Fractures of angle of mandible - A retrospective study. J Oral Biol Craniofac Res. 2012;2(3):154-158. doi:10.1016/j.jobcr.2012.10.001 (2) Ellis E III, Schubert W. Transoral approach to the angle. AO Surgery Reference. Published 2024. Accessed February 27, 2025 (3) Nam SM, Kim YB, Lee SJ, et al. A comparative study of intraoral versus retromandibular approach in the management of subcondylar fracture. BMC Surg. 2019;19:28. doi:10.1186/s12893-019-0487-7

BACKGROUND - Traumatic brain injury (TBI) and strokes account for over 1 million hospitalizations annually in the US. Decompressive craniectomy (DC) is a life-saving surgical procedure in which a segment of the skull is removed to alleviate elevated intracranial pressure in severe cases. However, this intervention can lead to a condition known as the Syndrome of the Trephined (SoT) or "Sinking Flap Syndrome", which is characterized by marked neurological dysfunction due to the large size skull defect. A defining feature of SoT is neurologic improvement following cranioplasty (CP). Optimal timing for cranioplasty remains uncertain in this patient population.

OBJECTIVE – To determine whether the timing of CP, early (≤3 months) versus delayed (>3 months), can influence neurological outcomes in patients with Syndrome of the Trephined (SoT).

METHODS - Following PRISMA guidelines, we conducted electronic searches across PubMed, Embase, Cochrane, Web of Science, and PsycINFO to identify studies evaluating neurologic outcomes in SoT patients based on CP timing. All study types, including case reports and case studies, were included. Eligible studies reported on patients of all ages diagnosed with SoT or demonstrating neurologic improvement following CP, with documented timing of symptom resolution. Non-English articles, non-human studies, cases involving external CP, and duplicate articles were excluded.

RESULTS - Among 514 articles reviewed, 85 met inclusion criteria, with 201 patients undergoing early and 347 delayed CP. Early CP was primarily performed for hemorrhage (51.2%), trauma (33.8%), and stroke (16.4%), while delayed CP was most often indicated for trauma (59.1%), stroke (16.4%), and hemorrhage (13.3%). Patients in the early group most commonly presented with altered consciousness (60.5%), motor deficits (14.9%), and cognitive deficits (10.7%), whereas the delayed group primarily exhibited motor deficits (36.1%), cognitive deficits (17.1%), and altered consciousness (10%). Interestingly, early CP led to significantly higher rates of symptom improvement, with altered consciousness (100% vs. 71.7%), motor deficits (95.2% vs. 75.4%), and cognitive deficits (100% vs. 81%) showing enhanced recovery rates compared to delayed CP (p<0.001, p<0.001, p<0.02, respectively). Overall improvement rates of these symptoms were significantly higher in the early group (98.9%) than in the delayed group (82.1%, p<0.05).

CONCLUSION – Our findings indicate that early cranioplasty is associated with significantly higher symptom improvement rates in SoT patients compared to delayed cranioplasty. However, the retrospective nature of the included studies introduces variability, and differences in surgical indications-such as the higher prevalence of TBI in delayed cranioplasty cases-may confound the results. Further randomized controlled trials are needed to validate these findings and establish the optimal timing for cranioplasty.

BACKGROUND - Traumatic brain injury (TBI) and strokes account for over 1 million hospitalizations annually in the US. Decompressive craniectomy (DC) is a life-saving surgical procedure in which a segment of the skull is removed to alleviate elevated intracranial pressure in severe cases. However, this intervention can lead to a condition known as the Syndrome of the Trephined (SoT) or "Sinking Flap Syndrome", which is characterized by marked neurological dysfunction due to the large size skull defect. A defining feature of SoT is neurologic improvement following cranioplasty (CP). Optimal timing for cranioplasty remains uncertain in this patient population.

OBJECTIVE – To determine whether the timing of CP, early (≤3 months) versus delayed (>3 months), can influence neurological outcomes in patients with Syndrome of the Trephined (SoT).

METHODS - Following PRISMA guidelines, we conducted electronic searches across PubMed, Embase, Cochrane, Web of Science, and PsycINFO to identify studies evaluating neurologic outcomes in SoT patients based on CP timing. All study types, including case reports and case studies, were included. Eligible studies reported on patients of all ages diagnosed with SoT or demonstrating neurologic improvement following CP, with documented timing of symptom resolution. Non-English articles, non-human studies, cases involving external CP, and duplicate articles were excluded.

RESULTS - Among 514 articles reviewed, 85 met inclusion criteria, with 201 patients undergoing early and 347 delayed CP. Early CP was primarily performed for hemorrhage (51.2%), trauma (33.8%), and stroke (16.4%), while delayed CP was most often indicated for trauma (59.1%), stroke (16.4%), and hemorrhage (13.3%). Patients in the early group most commonly presented with altered consciousness (60.5%), motor deficits (14.9%), and cognitive deficits (10.7%), whereas the delayed group primarily exhibited motor deficits (36.1%), cognitive deficits (17.1%), and altered consciousness (10%). Interestingly, early CP led to significantly higher rates of symptom improvement, with altered consciousness (100% vs. 71.7%), motor deficits (95.2% vs. 75.4%), and cognitive deficits (100% vs. 81%) showing enhanced recovery rates compared to delayed CP (p<0.001, p<0.001, p<0.02, respectively). Overall improvement rates of these symptoms were significantly higher in the early group (98.9%) than in the delayed group (82.1%, p<0.05).

CONCLUSION – Our findings indicate that early cranioplasty is associated with significantly higher symptom improvement rates in SoT patients compared to delayed cranioplasty. However, the retrospective nature of the included studies introduces variability, and differences in surgical indications-such as the higher prevalence of TBI in delayed cranioplasty cases-may confound the results. Further randomized controlled trials are needed to validate these findings and establish the optimal timing for cranioplasty.

Background: Current findings show that medication-related osteonecrosis of the jaw (MRONJ) and osteoradionecrosis (ORN) have higher postoperative complication rates than benign lesions following reconstruction. Although malignant cancer reconstruction surgeries also carry risks, MRONJ and ORN often result in more severe, chronic complications. This study examines complication rates following head and neck (H&N) reconstruction across these disease processes.

Methods: A retrospective review identified patients who underwent H&N reconstruction at a single institution from 2016 to 2024. Patients were categorized by disease type: Cancer, Benign Lesion, ORN, MRONJ, or other. Demographic data, including race, age, and social vulnerability index (SVI) quartile, were collected. Mean complication rates were analyzed for total, within 30 days post-op, and beyond 30 days post-op. ANOVA and post-hoc tests were used to assess significance (p<0.05).

Results: Among 121 patients, disease cohorts included: cancer (60.33%, n=73), benign lesions (20.66%, n=25), ORN (3.30%, n=4), MRONJ (5.79%, n=7), and Other (9.92%, n=12). Complication rates beyond 30 days post-op were SVI 1 (39%), SVI 2 (36%), SVI 3 (18%), and SVI 4 (59%) (p=0.014). Significant differences were found between SVI 3 and SVI 4 (p=0.007).

Conclusion: There were no significant differences in complication rates between disease types. SVI 4 patients may experience more complications due to poorer living conditions and healthcare access, while SVI 3 patients might have lower complication rates due to loss to follow-up. These findings highlight the importance of considering patient population factors post-operatively to optimize outcomes.

Background: Facial nerve palsy in children leads to significant functional impairment and facial asymmetry. While free gracilis muscle transfer (FGMT) is a cornerstone technique for smile reanimation in both pediatric and adult patients, its evaluation has mainly focused on the single metric of commissure excursion. This study uses machine learning-based image analysis for a comprehensive assessment of FGMT's effectiveness in restoring dynamic smiles in children with facial palsy.

Methods: A retrospective review was conducted in children who underwent FGMT for facial palsy at a major children's hospital between 2007 and 2020. Data collection included pre- and post-operative chart reviews and image analysis. Anthropometric measurements were obtained by a single reviewer using an artificial intelligence-based smile analysis software. Primary outcomes included commissure excursion, commissure angle, dental show, and smile symmetry. Statistical analysis was performed using Wilcoxon sign-rank test.

Results: A total of 31 patients with an average age of 10 years underwent FGMT for smile reanimation during the study period. The most common diagnosis was Moebius Syndrome (48%). Donor nerves for gracilis neurotization included 18 ipsilateral trigeminal nerves (58.1%) and 12 contralateral facial nerves via cross-face sural nerve grafts (38.7%). Overall, 84% of patients demonstrated active gracilis contraction within a mean of 2.5 years postoperative follow up. Commissure excursion increased by 9.7 mm at one year (p<0.05) and symmetry significantly improved for commissure height, commissure excursion, upper lip height and smile angle. There were no significant improvements in dental show, commissure angle, and symmetry of dental show and lower lip height. Furthermore, only 16% of patients demonstrated symmetric smiles within the follow up period.

Conclusion: While FGMT effectively restores commissure excursion in pediatric patients with facial palsy, achieving multidimensional smile reanimation remains a challenge. New techniques in multi-vector free tissue transfer and a better understanding of postoperative smile rehabilitation may help optimize FGMT outcomes in pediatric patients.

Introduction: Temporal hollowing and muscle atrophy are common sequelae following decompressive hemicraniectomy (DHC), which typically involves intraoperative transection of the temporalis muscle to achieve access. These changes may compromise craniofacial aesthetics and necessitate subsequent reconstruction. This study quantifies volume and morphological changes of the temporalis muscle using postoperative CT imaging. These measurements are essential for surgical planning and improving patient education regarding expected outcomes. Methods: We conducted a retrospective study on adult patients at our institution who underwent DHC and had preoperative and at least six-month postoperative CT imaging between January 2005 to December 2019. Temporalis muscle dimensions (volume, surface area, length, and height) were measured and compared between operative and nonoperative sides using 3D Slicer. Flatness and elongation, denoting muscle flattening and stretching, respectively, were included for clinical relevance. Statistical analyses were performed and adjusted for confounders including age, sex, smoking status, and medical comorbidities. Results: One hundred patients met inclusion criteria. The cohort consisted of 44 females and 56 males. Smoking history varied among participants, with 18% identified as current smokers, 34% as former smokers, and 48% as never having smoked. Hypertension was present in 46% of patients, while 11% had diabetes. Twenty-two percent of patients had associated facial fractures, and 23% had skull fractures. The mean age at DHC was 45.8 ± 16.5 years. The most common indication for DHC was cerebrovascular events (52%), followed by trauma (44%), and infection (4%). Patients were categorized into two primary groups based on DHC indication: cerebrovascular etiology (ischemic stroke, hemorrhagic stroke) and trauma (blunt and penetrating head injuries). Due to limited sample size, patients with infection-related DHC were excluded from sub-analyses. Notably, 100% of patients exhibited temporal hollowing on follow-up imaging. The mean decrease in temporalis muscle volume was 13.01 cm³ (SD = 8.36 cm³). The average time between DHC and cranioplasty was 141 ± 630 days, while the average time between cranioplasty and CT imaging was 435 ± 618 days. Additionally, 71% of patients required reoperation for plastic surgery indication (23%). Significant changes were observed on the operative side compared to the nonoperative control. Muscle volume decreased by 36.6% (p < 0.001), surface area by 39.0% (p < 0.001), and flatness by 16.6% (p < 0.001). Elongation decreased by 5.03% (p < 0.05), length by 26.9% (p < 0.001), and height by 29.5% (p < 0.001). Height above the zygomatic process, a marker of temporal hollowing, was reduced by 42.7% (p < 0.001). Additionally, we examined the relationship between temporalis muscle atrophy and surgical factors. There was no significant difference in mean atrophy severity between patients with and without complications (p=0.133). Similarly, no significant association was found between indication for DHC and degree of muscle atrophy (p=0.413). Conclusion: Our findings reveal profound morphometric changes in the temporalis muscle following DHC which significantly impact facial symmetry. Given that all patients exhibited temporal hollowing postoperatively, this study underscores the need for improved patient education regarding aesthetic and functional outcomes. Further research should explore surgical modifications to improve post-DHC craniofacial aesthetics.

Purpose: Patients who have undergone traumatic injury are at increased risk for readmission or re-presentation to emergency departments. Additionally, documented follow up rates are low after traumatic injury (1). To address possible socioeconomic and systemic barriers a comprehensive social services program – the Violence Recovery Program (VRP) was implemented at a level 1 trauma center. Program specialists are trained to provide social support, case management, and psychological services. In this study, we aim to investigate the impact of this program on no-show rate after facial trauma.

Methods: A retrospective review of facial trauma patients consulted to plastic surgery at a level 1 trauma center was performed. Two cohorts were identified: 1) A 2018 low-VRP cohort (May 2018 to October 2018) ) and 2) A 2024 high-VRP cohort (January 2024 to June 2024). The low-VRP cohort was defined as the first 6 months the level 1 trauma center was established, when the VRP program was initiated in a limited capacity. The high-VRP cohort consists of the most recent months, when the VRP program was operating at full capacity. Data collected included VRP intervention and patient demographics including insurance status and injury mechanism. Univariate analysis was performed to assess differences between the 2018 and 2024 cohorts in demographics, VRP involvement, and no-show rate. Additionally, univariate analysis was performed on the combined cohort to determine associations between VRP involvement and no-show rate. Logistic regression analysis was conducted on the combined cohort.

Results: Overall, 204 patients were included in the 2024 cohort and 139 in the 2018 cohort. There was a significantly higher rate of no-show in the 2018 cohort (n=42, 30.2%) compared to the 2024 cohort (n=32, 15.7%) (OR: 2.32, p=0.001). There was also significantly higher VRP intervention in the 2024 cohort (n=82, 40.2%) than the 2018 cohort (n=4, 2.9%) (OR: 22.73, p<0.001). Patient demographics were similar between cohorts with no significant differences in race (p=0.057), age (p=0.157), gender (p=0.317), or proportion of violent (assault, ballistic) injury (p=0.483). However, there was a significant difference in insurance providers between cohorts (p<0.001) as well as significant association between no-show rate and gender (p=0.009) within the 2024 cohort. All other patient information was not significantly associated with no-show rate in either cohort. When pooling the 2024 and 2018 cohorts, VRP intervention was significantly associated with clinic attendance (OR: 1.96, p=0.047). Logistic regression using the combined cohort identified VRP intervention as an independent predictor of higher clinic attendance (OR: 2.50, p=0.015). Insurance status and gender were not significant after regression analysis.

Conclusions: The integration of a comprehensive social services program is associated with decreased no-show rates after facial trauma. Our data shows that VRP involvement remained a predictor of increased plastic surgery clinic attendance, highlighting the potential impact of social support services on patient engagement. Future studies should explore the specific mechanisms by which this multifaceted program influences patient adherence.

Reference: 1. Shilati FM, Silver CM, Baskaran A, et al. Transitional care programs for trauma patients: A scoping review. Surgery. 2023;174(4):1001-1007. doi:10.1016/j.surg.2023.06.038

Background: Midline cleft lip (MCL) is an extremely rare congenital anomaly, with an estimated incidence of less than 1% of all patients with cleft lip and palate. Although its precise origin is unknown, it is thought to occur as a result of incomplete merging of the medial nasal prominences. There are very few reported cases characterizing MCL in the literature. Our study seeks to offer further information on MCL and its associated anomalies, as well as various techniques for effective surgical repair.

Methods: A retrospective review was conducted of all patients evaluated by the Plastic and Reconstructive Surgery department at a tertiary children's hospital for repair of MCL from 2005-2023. Data collected included cleft phenotype, associated comorbidities, operative metrics, and perioperative outcomes.

Results: Our review identified 20 patients, 70% female and 30% male. Of this cohort, 20% were born prematurely. and 20% were diagnosed with a craniofacial syndrome, these being oro-facial-digital syndrome in three patients and craniofrontonasal dysplasia in one patient. 40% had isolated cleft lip while 60% had cleft lip and palate. In terms of associated anomalies, central nervous system anomalies were the most prevalent. Half of the cohort had agenesis or dysgenesis of the corpus callosum, 30% had holoprosencephaly, and 15% had encephalocele. Only three patients had no associated comorbidities. One patient expired prior to surgery. The median age at repair was 6.4 months (IQR: 3.5-15 months). Mean follow-up time after repair was 10.4±5.5 years. Surgical techniques employed involved wedge excision of redundant midline tissue with straight line approximation of cleft margins±incorporation of triangular flaps, release of aberrant oribicularis oris attachments from bilateral maxilla, and gingivobuccal sulcus release with supraperiosteal dissectio for mobilization. There were no intraoperative complications. Postoperatively, two patients developed infections and one patient developed hemangioma. 25% of patients required revision surgery; indications included: scar revision, vermillion asymmetry, constricted nasal orifices, and wound debridement.

Conclusion: This study highlights the rarity of MCL and its frequent association with significant comorbidities, particularly central nervous system disorders. The favorable safety profile of the surgical techniques used is notable; however, the 25% revision rate suggests a need for continued evaluation and refinement of postoperative outcomes. Future research should focus on establishing standardized care protocols for these patients.