Scientific Abstract Presentations: Craniomaxillofacial Session 4 Friday, October 10 Fri, Oct 10 10:30 a.m.-12:30 p.m. CDT

Purpose: Despite advances in surgical techniques, the impact of craniosynostosis on neurodevelopmental outcomes in pediatric patients remains a significant concern, particularly in those with coexisting neuropsychiatric diagnoses (Peck 2022). This study aims to explore the neuropsychiatric outcomes and potential risk factors in pediatric patients diagnosed with craniosynostosis.

Methods: We retrospectively reviewed patients with craniosynostosis at UPMC Children's Hospital (March 2003 to September 2023), examining demographics, clinical presentation, neurocognitive diagnoses, surgeries, and patient outcomes. Descriptive statistics, chi-square tests, t-tests, and logistic regressions were performed using STATA, with significance set at p<0.05.

Results: An analysis was conducted on a cohort of 719 pediatric patients with craniosynostosis with an average duration of follow-up of 5.68 ± 3.99 years. Among our patients, 64.3% were male and 83.0% were Caucasian, with a mean age at diagnosis of 36.77 ± 43.61 months. Furthermore, 132 patients were eventually diagnosed with neurocognitive and psychiatric disorders. These patients had a mean Pediatrics Symptom Checklist score of 17.68±9.24, General Anxiety Disorder-7 score of 6.78±8.11, and Patient Health Questionnaire-9 score of 5.32±6.10.

Patients who developed neurocognitive and psychiatric outcomes were diagnosed with craniosynostosis at a later age ([57.62 ± 44.56] vs. [30.10 ± 41.21]; p<0.001), were older at their initial PRS visit ([48.63 ± 40.75] vs. [29.15 ± 41.21]; p<0.001), and had a longer follow-up duration in PRS ([81.70 ± 54.71] vs. [57.73 ± 47.58]; p=0.002) compared to those without such outcomes. Patients with squamosal and lambdoid craniosynostosis were significantly more likely to develop developmental delay (p=0.013), and patients with squamosal craniosynostosis were significantly more likely to develop autism spectrum disorder (ASD) (p=0.042). In addition, patients with sagittal craniosynostosis had significantly higher Autism Diagnostic Observation Schedule (ADOS) Comparison Scores compared to other types of craniosynostosis. Each additional month of age at the time of diagnosis significantly raised the odds of having ASD by approximately 1.08% (p=0.002), ADHD by approximately 1.42% (p<0.001), learning disorders by approximately 1.97% (p<0.001), and developmental delay by approximately 1.26% (p<0.001). Similar analysis looking at the age at surgical intervention did not yield significant results.

Conclusions: This study underscores the critical importance of early diagnosis and characterization of craniosynostosis, as delayed detection was associated with increased rates of ASD, ADHD, developmental delay, and learning disorders. These associations highlight the intricate and interconnected relationship between craniosynostosis and the subsequent development of comorbid psychiatric and neurocognitive conditions in pediatric patients. Given the significant impact of age at diagnosis on neurodevelopmental outcomes, early screening and intervention may help mitigate long-term cognitive and behavioral challenges. Future research should explore the underlying mechanisms driving these associations and evaluate targeted interventions to improve patient outcomes.

References: 1. Peck CJ, Junn A, Park KE, et al. Longitudinal Outpatient and School-Based Service Use among Children with Nonsyndromic Craniosynostosis. Plastic & Reconstructive Surgery. Published online September 20, 2022. doi:https://doi.org/10.1097/prs.0000000000009678

Purpose: Microvascular free tissue transfer represents the most advanced reconstructive modality for extensive scalp defects. In pediatric patients, this approach presents unique technical challenges, including limited donor site availability due to a high skull-to-body ratio, concerns regarding donor site morbidity and long-term effects on growth, and a smaller vessel caliber with increased risk of vasospasm. This study systematically reviews the literature on free tissue transfer for scalp reconstruction in pediatric patients to assess safety, compare outcomes across different flap types, and determine optimal donor site selection.

Methods: A systematic review of the available literature was conducted following PRISMA guidelines. Studies reporting on pediatric (0–17 years of age) free flap scalp reconstruction were included. Scalp replantations and pedicled flaps were excluded. Extracted variables included patient demographics, surgical characteristics, and postoperative outcomes. Statistical analyses were performed to evaluate complication rates and flap-specific performance.

Results: A total of 34 studies comprising 105 pediatric patients (107 free flaps) met inclusion criteria. Mean patient age was 8.5 ± 4.58 years (male, 66.3%; female, 33.7%; not reported, 6.7%). Trauma and burns accounted for most scalp defects (73.3%), followed by malignancy (14.3%), infection (7.6%), and congenital anomalies (4.8%). The mean defect size was 246 ± 164 cm². The most frequently utilized donor sites were the anterolateral thigh (ALT, 43.8%) and latissimus dorsi (LD, 36.2%), followed by the scalp (4.8%) and groin (3.8%). Younger children (0-6) were more likely to receive ALT flaps (68.4%), while 7–12-year-olds were more likely to receive LD flaps (70%; p<0.001).

Overall, 19% of patients experienced at least one complication (22 total complications), of which 63.6% were minor and 36.4% were major. Flap-related complications comprised 81.8% of all complications. Neither patient age nor defect etiology was associated with increased complication risk. Compared to other flap types (excluding LD), ALT flaps had a significantly lower complication rate (OR 0.093; CI 0.0183–0.365; p<0.001). However, in cases where complications occurred, ALT flaps were associated with a higher proportion of flap-related complications compared to LD flaps (100% vs. 70%; p<0.001). Muscle-sparing flaps exhibited a 64% higher, albeit statistically insignificant, odds of complication compared to muscle-containing flaps.

Conclusions: Microvascular free tissue transfer is a safe and effective reconstructive approach for pediatric scalp defects across all age groups, demonstrating high flap survival despite anatomical and technical challenges. The ALT and LD flaps remain the preferred options, with the LD flap demonstrating a lower rate of flap-related complications. Flaps other than ALT and LD were associated with a significantly higher complication rate, underscoring the importance of individualized flap selection to optimize reconstructive outcomes in pediatric patients.

Introduction: Advancements in three-dimensional (3D) reconstruction have significantly contributed to our understanding of mandibular growth and development. While previous research has primarily focused on congenital deformities and orthodontic applications, the normal developmental trajectory of the mandible in early infancy remains underexplored. The present study addresses this gap by analyzing mandibular development patterns in pediatric patients from birth to 12 months using 3D cephalometric measurements.

Methods: A retrospective chart review of patients undergoing computed tomography (CT) facial bone, spine, or neck from 2000 to 2023 was conducted. The inclusion criteria included patients between 0-12 months and CT scans with complete visibility of the mandible. The population excluded patients undergoing CT imaging for a known or suspected mandibular abnormality (developmental or post-traumatic) as well as patients with reported syndromic diagnosis at the time of imaging. Three-dimensional mandibular models were reconstructed using the open-source software 3D Slicer 5.6.1 (https://slicer.org/) and marked with 24 cephalometric landmarks to calculate 12 bilateral and 4 trans-mandibular measurements, including gonial angle, mandibular body length, ramus length, mandibular notch width, notch angle, condylar surface area, alveolar ridge surface area, bicondylar width, mandibular basal width bigonial, mandibular basal width bi-antegonial, and coronoid process and condylar height, width, and length. Statistical t-tests assessed associations, with statistical significance set at p<0.05.

Results: Of 77 patients analyzed, nine (12%) were neonates (0-28 days), fourteen (18%) were 1-3 months old, twenty (26%) were 3-6 months old, twenty (26%) were 6-9 months old, and fourteen (18%) were 9-12 months old. The largest growth was observed in condylar surface area with 91.7% increase from 0.284±0.06 cm² in neonates to 0.543±0.11 cm² in the 9-12-month cohort, followed by condyle length with an 84.8% increase from 7.29±0.66 mm to 13.5±1.86 mm, ramus length at 54.4% increase from 21.16±2.05 mm to 33.52±2.94 mm, and coronoid process length (42.8% increase from 6.68±0.55 mm to 9.54±0.87 mm). All growth changes stated were statistically significant with p<0.001. Alveolar ridge surface area increased substantially, from 3.50±0.43 cm² in neonates to 4.80±0.43 cm² in those aged 9-12 months. Additionally, the mental angle was significantly smaller (p=0.02) in the 9-12 month population (80.98±4.99 degrees) than neonates (88.25±7.31 degrees). Curves between the 6-9 month and 9-12 month populations were flat, suggesting the infant phase of mandibular growth is complete by 9 months.

Conclusion: The present study demonstrates significant growth patterns in healthy pediatric patients with most notable increases in the condylar surface area, condylar length, ramus length, and alveolar ridge development. These findings highlight the dynamic nature of mandibular maturation during infancy, emphasizing the role of the condyle and ramus in early mandibular elongation. The results provide valuable baseline data for understanding normal growth patterns, which may aid in the early detection of developmental anomalies and contribute to clinical applications in pediatric craniofacial care.

Purpose Prior research has found that delayed referral to a specialist is linked to worsened surgical and long-term neurologic outcomes in patients with craniosynostosis (1, 2). Therefore, the present study aimed to investigate the interplay between neighborhood-level factors, age at initial clinic presentation, and age at surgical repair in patients undergoing craniosynostosis.

Methods A retrospective chart review of patients with craniosynostosis who underwent surgical repair at our institution from 2007-2023 was conducted. Patient race, ethnicity, primary language, insurance status, operative time, length of stay, complications, suture type, and repair type were collected. Patient geographic information was extracted to perform geospatial analyses involving neighborhood disadvantage.

Specifically, three metrics of neighborhood disadvantage were used: Area Deprivation Index (ADI), Social Vulnerability Index (SVI), and Child Opportunity Index (COI). Tertiles based on these metrics were established to compare age at initial clinic presentation, age at repair, and delays in clinic presentation/repair (over 9 and 12 months, respectively) with tertile 1 indicating the least disadvantaged for ADI/SVI but the most disadvantaged for COI. Bivariate analyses and multivariate logistic regression models were used for comparisons.

Results Overall, 388 patients were included. Across tertiles, there were significant differences in distribution of race, ethnicity, and insurance status along with differences in postoperative infection rates (p<0.05). Compared to the most disadvantaged tertiles across the three indices (ADI, SVI, COI), the least disadvantaged tertile had significantly earlier age at surgical repair and age at clinic representation (p<0.05). There was a stepwise increased frequency of delayed repair and clinic presentation across tertiles in all indices (p<0.05). On multivariate analysis, ADI tertile 3 (OR: 2.90, p=0.043) was associated with higher odds of delayed surgical repair whereas COI tertile 3 (OR: 0.37, p=0.032) was associated with lower odds. In addition, private insurance was shown to independently decrease the odds of both delayed initial presentation to clinic and delayed surgical repair (p<0.05).

Conclusions Overall, our study found that neighborhood level disadvantage was significantly associated with later timing of both initial clinic visit and surgical repair in craniosynostosis patients. Therefore, efforts should be made to facilitate timely referrals for patients and address systemic barriers to care that disproportionately affect patients from disadvantaged areas.

References 1. Bruce WJ, Chang V, Joyce CJ, Cobb AN, Maduekwe UI, Patel PA. Age at Time of Craniosynostosis Repair Predicts Increased Complication Rate. Cleft Palate Craniofac J. 2018;55(5):649-654. doi:10.1177/1055665617725215

2. Patel A, Yang JF, Hashim PW, et al. The impact of age at surgery on long-term neuropsychological outcomes in sagittal craniosynostosis. Plast Reconstr Surg. 2014;134(4):608e-617e. doi:10.1097/PRS.0000000000000511

Background Early cleft lip repair (ECLR) leverages the natural plasticity of neonates from maternal estrogen to reshape the cleft and nose. Our institution has demonstrated short-term aesthetic and functional success in 300 patients, but long-term results remain unexplored. This study evaluates the long-term outcomes of ECLR.

Methods A retrospective review was conducted of nonsyndromic patients with unilateral cleft lip±palate (UCL/P) undergoing lip repair before three months of age from 2015 to 2024. Patients were excluded if they had less than five years of follow-up. Demographic, preoperative, and postoperative data were collected, along with anthropometric measurements from frontal and basal images.

Results Of the 133 patients who met inclusion criteria, 57 had suitable images for analysis. The mean gestational age at surgery was 37±18.4 days, and mean follow-up time was 7.3±1.3 years. Comparing preoperative to postoperative ratios, ECLR demonstrated significant improvements in commissure length (p<0.001), nostril breadth (p<0.001), and nostril width (p<0.001). Compared to traditional lip repair with nasoalveolar molding (TLR+NAM), the ECLR cohort had a similar cleft width ratio (0.49 vs. 0.42; p=0.41), while showing equivalent improvements in medial lip height (p=0.79), lateral lip height (p=0.21), and lateral lip length (p=0.74).

Conclusion Early cleft lip repair (ECLR) enhances aesthetic outcomes while maintaining similar cleft width ratios compared to traditional repair (TLR+NAM). These results underscore the long-term benefits of ECLR as a superior approach for managing unilateral cleft lip±palate.

Purpose While the stability of LeFort I osteotomies has long been demonstrated, there is less well documented data evaluating the long-term outcomes of custom 3D-printed titanium fixation plates. With the increasing adoption of virtual surgical planning (VSP) and CAD/CAM technology, patient-specific implants are becoming more prevalent in orthognathic surgery. This study investigates the long-term stability of patient-specific 3D-printed titanium plates in LeFort I orthognathic surgery.

Methods A retrospective review was conducted of all patients who underwent LeFort I osteotomy using patient-specific 3D-printed titanium fixation plates at our institution between July 2015 and August 2023. Patients were included if they had available preoperative, immediate postoperative (<30 days post-op), and long-term postoperative (>360 days post-op) CT scans or lateral cephalograms. Patients who underwent additional surgical interventions between imaging time points were excluded. Cephalometric analysis was performed using Dolphin Imaging Software (Version 12.0.63).

Results A total of 58 patients met the inclusion criteria, with a mean age of 18.8 years at surgery. Nineteen patients (32.8%) had a cleft-related diagnosis. Preoperative occlusion included 38 (65.6%) Class III cases, 15 (25.9%) Class II cases, and 5 (8.6%) Class I cases with an associated cant, crossbite, or vertical maxillary hyperplasia. Nineteen patients (32.8%) had a congenital syndrome. Average interval between operation and long-term imaging was 602 days (SD 424 days). The mean preoperative SNA was 79.1 degrees, increasing to 86.3 degrees immediately postoperatively and measuring 84.9 degrees at long-term follow-up, with statistically significant differences between all three time points (p<0.0001). This resulted in the mean increase in SNA being 7.2 degrees (SD 3.8), with an average long-term relapse rate of 22.2% (SD 17.2%). Despite this relapse, 86.2% (n=50 of 58) of patients remained in Class I occlusion at long-term follow up. Magnitude of relapse was positively correlated with magnitude of immediate post-operative change in SNA (r: 0.295, p=0.014). When controlling for age at surgery, sex, magnitude of immediate post-operative change in SNA, and post-operative day of long-term imaging, there were no differences in amount of long-term relapse among patients with a history of cleft palate (p=0.527), congenital syndrome (p=0.464), or prior surgery to the maxilla (p=0.152), though this may reflect a lack of statistical power.

Conclusions This study represents the largest cohort to date evaluating long-term relapse rates in LeFort I osteotomies using patient-specific 3D-printed titanium fixation plates. Although a small degree of long-term relapse can be expected beyond one year, the clinical impact of this low-magnitude relapse appears minimal, with most patients maintaining Class I occlusion. Encouragingly, patients with syndromic diagnoses, cleft palate, or prior surgery of the maxilla did not experience greater degrees of long-term relapse, suggesting the ability of patient-specific plates to provide similar stability across a wide range of patient phenotypes.

Purpose

Among craniofacial anomalies, microtia-a congenital deformity characterized by an underdeveloped or absent external ear-can profoundly affect the psychosocial well-being of those impacted. While surgical interventions have improved aesthetic outcomes, the mental health implications of living with a visible facial defect remain underexplored.

The Patient-Reported Outcomes Measurement Information System (PROMIS) is a validated tool that provides insights into the emotional health of children with craniofacial conditions. This study leverages PROMIS instruments to understand the mental health landscape for individuals with microtia, aiming to inform holistic, patient-centered care that addresses both physical and psychological needs.

Methods

Patients diagnosed with microtia (ICD-10 code Q17.2) who underwent or were evaluated for surgical treatment at a tertiary children's hospital completed PROMIS assessments to evaluate psychosocial outcomes, including family and peer relationships, anger, anxiety, depression, and stress using a Likert-scale format. The control group consisted of pediatric patients from well-child visits at the same institution with no craniofacial abnormalities. Data were collected directly from patients and guardians and supplemented by a retrospective electronic medical record review recorded in the REDCap program. A t-test analysis compared psychosocial outcomes between patients with microtia, control groups, and those with other craniofacial anomalies.

Results

A total of 704 individuals were included in the dataset, 82 of whom had a diagnosis of microtia (39 male, 42 female). Compared to controls, patients with microtia showed no significant differences in family and peer relationships or anger. However, patients with microtia reported significantly higher levels of anxiety, depression, and stress (M = 1.94, SD = 0.70 vs. M = 2.21, SD = 0.89, p = 0.047; M = 1.62, SD = 0.69 vs. M = 1.96, SD = 0.89, p = 0.017; M = 1.91, SD = 0.75 vs. M = 2.14, SD = 0.89, p = 0.033, respectively). Additionally, lower family relationship ratings approached significance in patients with microtia compared to those with other craniofacial anomalies (M = 4.12, SD = 0.88 vs. M = 4.38, SD = 0.61, p = 0.058). No significant differences in anger, anxiety, depression, or stress were found between patients with microtia and other craniofacial anomaly groups. Analyzing gender differences revealed that males reported significantly higher peer relationship scores compared to females (M = 4.04, SD = 0.83 vs. M = 3.47, SD = 1.05), while no significant sex differences were observed in other psychosocial outcome measures, although males generally reported slightly lower scores than females.

Conclusions

This study highlights the psychosocial challenges faced by individuals with microtia, such as elevated depression and weaker family and peer relationships compared to those with other craniofacial anomalies. It also emphasizes gender-specific psychosocial differences that patients experience. The findings underscore the need for holistic care that addresses both physical and emotional needs. Insights from PROMIS assessments can guide integrated care, combining psychological support with surgical treatment to improve overall well-being in patients with microtia.

Introduction: Traditionally, the assessment of skull fractures in pediatric patients has relied heavily on conventional CT scans, which come with concerns regarding ionizing radiation exposure, especially in children. We present an approach to assess the dynamic healing progression of pediatric skull fractures using motion-corrected pseudo-CT images derived from MRI scans. Our innovative technique seeks to address these concerns while offering a deeper understanding of the healing process.

Methods: Our methodology involved enrolling a single 5-week-old patient diagnosed with a parietal skull fracture. Following conventional CT, biweekly non-sedated MRI scans were conducted until the fracture was no longer visible. These scans employed a cutting-edge 5-minute golden-angle stack-of-stars radial VIBE MR sequence. A self-navigated motion correction technique was utilized to minimize motion artifacts in the MR images. A pre-trained 3D ResUNet network was then applied to generate pseudo-CT images from the MRI data, enabling the visualization of fracture healing progress across four imaging time points.

Results: The results feature the standard-of-care CT plus pseudo-CT imaging from four scans which depict the progression of a mildly depressed fracture of the parietal bone healing across nine weeks. Pseudo-CT images demonstrated some evidence of healing in the skull fractures three weeks post-trauma. Importantly, it was observed that the fracture in this infant had not completely healed until approximately seven to nine weeks post-trauma.

Conclusion: Our study sheds light on the timeline for healing skull fractures and introduces an innovative method for assessing pediatric skull fractures using pseudo-CT images generated from MRI scans. This understanding is crucial for guiding medical assessments in cases of such fractures. Furthermore, our findings highlight the utilization of automated motion correction and machine learning-generated pseudo-CT images for pediatric cranial imaging. This research contributes to both the clinical management of pediatric skull fractures and the broader utilization of advanced safe imaging techniques in pediatric healthcare.

Introduction and Purpose: Myelomeningocele (MMC), the most severe form of neural tube defect (NTD), requires surgical intervention within the first few days of life. Despite advances in surgical repair techniques, MMC patients remain at high risk for postoperative complications, including wound dehiscence, cerebrospinal fluid leaks, and infection (1). Neonatal wound healing presents unique challenges due to immature skin barrier function, increased susceptibility to infection, limited subcutaneous tissue, and potential nutritional deficits exacerbated by prematurity and associated comorbidities (2). Nutrition plays a critical role in tissue regeneration, collagen synthesis, and immune function, yet postoperative nutritional optimization in this population remains poorly characterized in the literature (3). We aimed to evaluate the relationship between weight-for-age z-scores (WAZ) and wound healing outcomes following primary MMC repair and hypothesized that infants with lower z-scores would have an increased incidence of wound healing complications.

Methods: A retrospective chart review was conducted on patients who underwent primary MMC repair between 2017-2024. Data collected included demographics, gestational age, birth weight, nutritional support, and WAZ recorded throughout the first 30 days of life. Postoperative wound healing complications including superficial dehiscence, full dehiscence, CSF leaks, infection, and tissue necrosis, were documented. Patients were divided into two cohorts: those with no dehiscence and those with any dehiscence (superficial or full). Z-scores at different postoperative time points were compared between groups.

Results: A total of 29 patients met inclusion criteria, with 10 (34%) experiencing no dehiscence, 11 (38%) having superficial dehiscence, and 8 (28%) having full dehiscence. Patients with wound dehiscence consistently had lower WAZ at all time points compared to those without dehiscence, though differences did not reach statistical significance. The largest difference in WAZ was observed at weeks 3 and 4 (Week 3: -0.93 vs. -1.50, p=0.199; Week 4: -0.91 vs. -1.53, p=0.178).

Conclusions: Preliminary findings suggest that lower WAZ may be associated with increased wound dehiscence following primary MMC repair, supporting the role of nutritional status in postoperative wound healing. The greatest differences in WAZ were observed during weeks 3 and 4, coinciding with the expected timing of suture dissolution and early tissue remodeling, a period when insufficient healing may contribute to dehiscence. However, the current sample size is underpowered to reach statistical significance. Further data collection is ongoing, with plans to expand the cohort to improve statistical power and validate these findings. Optimizing early postoperative nutrition may serve as a modifiable factor to improve surgical outcomes in this high-risk population.

References: 1. Cherian J, Staggers KA, Pan IW, Lopresti M, Jea A, Lam S. Thirty-day outcomes after postnatal myelomeningocele repair: a National Surgical Quality Improvement Program Pediatric database analysis. J Neurosurg Pediatr. 2016;18(4):416-422. doi:10.3171/2016.1.PEDS15674 2. Riddle S, Karpen H. Special Populations-Surgical Infants. Clin Perinatol. 2023;50(3):715-728. doi:10.1016/j.clp.2023.04.008 3. Li K, Li X, Si W, et al. Preoperative and operation-related risk factors for postoperative nosocomial infections in pediatric patients: A retrospective cohort study. PLoS One. 2019;14(12):e0225607. Published 2019 Dec 23. doi:10.1371/journal.pone.0225607

Background: Spring-assisted cranioplasty (SAC) has been shown to decrease operative time, intraoperative blood loss, and postoperative hospital stay when compared to open procedures. Also, endoscopic strip craniectomy with helmeting has been shown to be less costly overall than open procedures. However, it is unknown if this is also true with SAC, which requires a second surgery for spring removal. The goal of this study is to provide a financial comparison between spring-assisted cranioplasty and other open surgical procedures for the treatment of single-suture craniosynostosis.

Methods: Following Institutional Board Review approval, a retrospective review was conducted on all patients diagnosed with single-suture craniosynostosis between 2012-2024. Charges for the operating room (OR), anesthesia, intensive care unit (ICU) stay, non-ICU stay, and total overall costs, along with other surgical data, were analyzed. Costs were adjusted for inflation utilizing Consumer Price Index codes provided by the US Bureau of Labor. Expenses for patients with single-suture craniosynostosis who underwent SAC (n=36) were compared to those who underwent open cranial vault remodeling procedures (n=103) such as fronto-orbital advancement (n=57), posterior vault distraction osteogenesis ( n=2), posterior cranial vault remodeling (n=19), pi-plasty (n=21), or total cranial vault remodeling (n=4). Independent t-tests were utilized with the significance value of 0.05.

Results: The total overall cost of treatment for patients undergoing SAC was over $13,500 less than those undergoing open procedures (p=0.05). Patients undergoing SAC also had shorter total hospital length of stay (2.97 days versus 5.09 days, p<0.01) and ICU length of stay (25.44 hours vs 30.65, p<0.02). There was no significant difference in the hospital stay costs between groups, likely due to the additional post-anesthesia care unit expenses for spring removal, which was added to the hospital stay average. Although the time spent in the ICU was shortened between the subgroups, the difference was not reflected in the cost analysis as ICU stays are charged per diem. Individual procedure lengths were also lower in patients undergoing SAC (1.90 hours vs 3.35 hours, p<0.01), along with blood loss and blood replacement (108.44 mL and 117.94 vs 237.91 mL and 281.57 mL, respectively, p<0.01).

Conclusion: This study shows that when compared to open procedures for single-suture craniosynostosis, SAC can decrease overall costs of care, hospital and ICU length of stay, procedure length, and blood loss.

Background: Cleft lip with or without palate (CL/P) and cleft palate (CP) are common birth defects in the U.S. CLP and CP are associated with a genetic anomaly or classified as an isolated, non-syndromic orofacial cleft (NSOFC), with NSOFC making up 70-75% of occurrences (1). The underlying mechanism is thought to be multifactorial, having both genetic and environmental interactions (2). Based on a meta-analysis, there is a large body of evidence regarding the teratogenicity of pesticides including 18 relevant studies. Pesticide associated birth defects included neural tube defects, including two times increased risk for spina bifida, cryptorchidism, and gastroschisis (3). Given there is a lack of data looking specifically at NSOFC and pesticide exposure has been linked with other midline defects, our aim is to explore the correlation between county pesticide levels and the incidence of NSOFC.

Methods: A retrospective chart review of patients who had a consultation for NSOFC at a single institution was performed. Data was collected on patient demographics, geographic data, and prenatal and/or maternal information, such as substance use, that was included in their chart. Patient data was combined with pesticide data exported from California's Pesticide Use Reporting database by zip code. CL/P and CP were analyzed separately. Incidence of NSOFCs were calculated using live birth rate by county from the California Health and Human Services open data portal. Multiple poisson regressions for the top ten most frequently reported pesticides for CL/P and CP respectively were performed to evaluate the association between unique pesticides and CL/P and CP.

Results: Of the patients included, n= 146 for CL/P and n= 68 for CP. Pesticides significantly associated with increased risk of CL/P are spinosad (Estimate [E]=0.4135, p=0.010) and spinetoram (E=0.6053, p=0.0227). Pesticides significantly associated with increased risk of CP are abamectin (E=1.0244, p=0.0495) and potassium bicarbonate (E=0.8426, p=0.0056). All other positive pesticide association estimates were not statistically significant.

Conclusion: Presence of certain pesticides are associated with increased incidence of CL/P and CP at a zip code level of geographic granularity, even when established confounding factors are controlled for. The significant associations of spinetoram, spinosad, and abamectin are particularly pertinent due to the breadth of their uses ranging from agricultural and urban pest control to household applications. Spinosad and abamectin both help control various insects in farms, gardens, and urban environments. Spinetoram helps control pests in stored grain and on domestic cats (4). More research is needed to determine causality.

References: 1. Evans K, Hing AV, Cunningham M. Chapter 95-Craniofacial Malformations. In: Gleason CA, Devaskar SU, eds. Avery's Diseases of the Newborn (Ninth Edition). Philadelpia: W.B. Saunders; 2012:1331-1350. 2. Khan MI, Cs P, Srinath NM. Genetic Factors in Nonsyndromic Orofacial Clefts. Glob Med Genet. 2020;7(4):101-108. 3. Mostafalou S, Abdollahi M. Pesticides: an update of human exposure and toxicity. Archives of Toxicology. 2017;91(2):549-599. 4. Environmental Protection Agency. (n.d.-b). Spinetoram, Spinosad, Abamectin. EPA. https://comptox.epa.gov/dashboard/

Introduction: Fistula recurrence remains a significant challenge in cleft surgery, often necessitating revision procedures. Understanding the factors associated with revision surgery can inform strategies to improve surgical outcomes. This study evaluates fistula repair trends in Latin America and Caribbean (LAC) region from 2022 to 2024, analyzing revision rates by country, surgical technique, and fistula size to identify key predictors of revision surgery.

Methods: A retrospective review of patients who underwent fistula repair in surgical programs in Latin America and the Caribbean (LAC) between 2022 and 2024 was conducted. Patient demographics, surgical details, and revision rates were extracted from program records. Descriptive statistics were used to summarize revision rates by country, technique, and fistula size. A logistic regression model assessed predictors of revision surgery. Cases with missing or blank data for key variables were excluded from the analysis.

Results: Of the 3,656 patients screened, 173 (4.7%) underwent fistula repair. Among these, 12 (6%) were primary repairs, 100 (51%) were classified as first revision surgeries, 28 (14%) as second revision surgeries, and 11 (5.6%) as third or higher revision surgeries. Revision rates varied by country, with the highest observed in Panama (16.4%), Honduras (6.3%), and Guatemala (5.0%), while Ecuador (2.5%) and Bolivia (2.5%) had the lowest rates. Among surgical techniques, turn-over flaps (81.4%) had the highest revision rates. Fistula size influenced revision likelihood, with larger fistulas (>1 cm) showing an 87.3% revision rate, while smaller fistulas (<0.5 cm) had an 86.2% revision rate. Logistic regression identified FAMM flap (OR: 0.046, p=0.039) as a significant predictor of lower revision likelihood. No significant association was found between revision status and country.

Conclusion: The rate of fistula repair in the LAC region is comparable to that in high-resource settings, despite delays in presentation. Revision rates in the LAC region remain high, with variability across countries and surgical techniques. Larger fistulas and turn-over flaps were associated with higher revision rates.

Background: Mandibular distraction osteogenesis (MDO) is an effective technique for improving respiratory and feeding function in patients with Robin Sequence (RS). While many patients with RS have comorbid conditions, there is limited data regarding their impact on feeding outcomes after MDO. We aim to examine the relationship between comorbidities and feeding outcomes in patients with RS who underwent MDO.

Methods: A retrospective review of patients with RS who underwent MDO at a tertiary children's hospital between 2004 and 2022 was conducted. Patients with preoperative tracheostomy or less than one year of follow up were excluded. Data on respiratory, cardiac, gastrointestinal and neuromuscular comorbidities were collected. Primary outcome measures included gastrostomy tube (G-tube) placement and time from surgery to full per-os (PO) intake. Statistical analyses were conducted using chi-squared tests and Mann-Whitney U tests.

Results: A total of 73 patients met inclusion criteria. Patients had a median corrected gestational age at MDO of 4.3 weeks (IQR: 2.4-7.4 weeks) and were distracted to a median distance of 30.0 mm (IQR: 25-30 mm). Twenty seven patients (37.0%) had respiratory comorbidities, including central sleep apnea (40.7%), laryngomalacia (22.2%), and subglottic stenosis (11.1%). Twenty one patients (28.8%) had cardiac comorbidities, including atrial septal defect (42.9%), patent ductus arteriosus (23.8%), and ventricular septal defect (14.3%). Additionally, 28 patients (38.4%) had gastroesophageal reflux disease and 22 patients (30.1%) had hypotonia. Postoperative G-tube placement rates were 5.0% for patients with one comorbidity, 21.4% for those with two comorbidities, 33.3% for those with three comorbidities, and 58.3% for patients with three or more comorbidities (p = 0.011). The risk of postoperative G-tube placement was 10.5 times higher in patients with three comorbidities compared to those with no comorbidities (p = 0.001). Hypotonia was associated with the highest rate of G-tube placement (45.5%) and the lowest rate of full PO intake (68.2%). Only 73% of patients with one or more comorbidities reached full PO intake, while 100% of patients with no comorbidities achieved full PO intake (p = 0.03). The time required to achieve full PO intake did not significantly vary between those with and without comorbidities.

Conclusion: The prevalence of comorbid conditions in patients with RS was associated with higher rates of postoperative G-tube placement and a lower likelihood of achieving full PO intake. For patients with three or more comorbidities, considering G-tube placement at the time of MDO surgery may be beneficial due to the significantly higher rates of postoperative G-tube placement observed in this group. G-tube placement can provide essential nutritional support, which is critical for recovery and healing during the postoperative catabolic state.

Introduction Cranioplasty with autologous cryopreserved bone is associated with up to 52% failure rates, in part due to bone resorption from impaired revascularization. The aim of this study was to delineate the process of calvarial bone healing and determine the effect of Nanotransfection technology on calvarial bone healing in mice. Methods Two groups of C56BL/6 mice underwent hemicraniectomy and cranioplasty with either non-cryopreserved (nCCBG) or cryopreserved (CCBG) bone grafts. Each group had six cohorts (≥8 mice) euthanized at 1, 2, 3, 4, 8, and 10 weeks post-cranioplasty. For nanotransfection, experimental mice received brdU-labeled EFF-nanotransfected cells with Matrigel, while the sham group received sham-transfected cells. Healing was evaluated using immunohistochemistry and Micro-CT. Results Different regions were evaluated: 1) central bone graft, 2) bone graft and 3) rim of native bone to evaluate the healing process at different regions after cranioplasty. DAPI intensity and nuclei counts indicated a significantly higher cell density in the bone grafts (p <0.001) of nCCBG group only from weeks 3 to 4, compared to the CCBG group. There was no difference in cell densities of nCCBG compared to CCBG at week 1 and 2 (p >0.05). Vascular intensity via lectin staining was similar across groups and timepoints. Micro-CT analysis showed that at week 1 through 8 post-cranioplasty, the rim of bone graft had significantly more new bone added than central bone graft (p <0.05) in both CCBG and nCCBG, however, no difference was found between the rim of the bone graft and the and rim of native bone in the amount new bone added in both CCBG and nCCBG groups (p <0.05). Further, the rim of bone graft had significantly lower TMD than central bone graft and rim of native bone in both CCBG and nCCBG groups (p <0.05) over the same period. The quality of bone at the rim of the bone graft was more heterogeneous than every other regions, as indicated by their wide standard deviation in gray level. Finally, EFF-nanotransfected cells were assessed for their impact on cranioplasty healing. BrdU-labelled cells were identified at the cranioplasty site as early as week 1 post-cranioplasty. Defect site in EFF and sham mice had higher lectin vascular intensity than native bone in EFF (P=0.0044) and sham mice (P=0.0009) respectively. Conclusion These studies demonstrate that EFF-nanotransfected cells are viable at the cranioplasty site. Further studies are ongoing to determine the effect on rates of autologous calvarial bone healing.

Introduction Cranioplasty with autologous cryopreserved bone is associated with up to 52% failure rates, in part due to bone resorption from impaired revascularization. The aim of this study was to delineate the process of calvarial bone healing and determine the effect of Nanotransfection technology on calvarial bone healing in mice. Methods Two groups of C56BL/6 mice underwent hemicraniectomy and cranioplasty with either non-cryopreserved (nCCBG) or cryopreserved (CCBG) bone grafts. Each group had six cohorts (≥8 mice) euthanized at 1, 2, 3, 4, 8, and 10 weeks post-cranioplasty. For nanotransfection, experimental mice received brdU-labeled EFF-nanotransfected cells with Matrigel, while the sham group received sham-transfected cells. Healing was evaluated using immunohistochemistry and Micro-CT. Results Different regions were evaluated: 1) central bone graft, 2) bone graft and 3) rim of native bone to evaluate the healing process at different regions after cranioplasty. DAPI intensity and nuclei counts indicated a significantly higher cell density in the bone grafts (p <0.001) of nCCBG group only from weeks 3 to 4, compared to the CCBG group. There was no difference in cell densities of nCCBG compared to CCBG at week 1 and 2 (p >0.05). Vascular intensity via lectin staining was similar across groups and timepoints. Micro-CT analysis showed that at week 1 through 8 post-cranioplasty, the rim of bone graft had significantly more new bone added than central bone graft (p <0.05) in both CCBG and nCCBG, however, no difference was found between the rim of the bone graft and the and rim of native bone in the amount new bone added in both CCBG and nCCBG groups (p <0.05). Further, the rim of bone graft had significantly lower TMD than central bone graft and rim of native bone in both CCBG and nCCBG groups (p <0.05) over the same period. The quality of bone at the rim of the bone graft was more heterogeneous than every other regions, as indicated by their wide standard deviation in gray level. Finally, EFF-nanotransfected cells were assessed for their impact on cranioplasty healing. BrdU-labelled cells were identified at the cranioplasty site as early as week 1 post-cranioplasty. Defect site in EFF and sham mice had higher lectin vascular intensity than native bone in EFF (P=0.0044) and sham mice (P=0.0009) respectively. Conclusion These studies demonstrate that EFF-nanotransfected cells are viable at the cranioplasty site. Further studies are ongoing to determine the effect on rates of autologous calvarial bone healing.

Introduction Cranioplasty with autologous cryopreserved bone is associated with up to 52% failure rates, in part due to bone resorption from impaired revascularization. The aim of this study was to delineate the process of calvarial bone healing and determine the effect of Nanotransfection technology on calvarial bone healing in mice. Methods Two groups of C56BL/6 mice underwent hemicraniectomy and cranioplasty with either non-cryopreserved (nCCBG) or cryopreserved (CCBG) bone grafts. Each group had six cohorts (≥8 mice) euthanized at 1, 2, 3, 4, 8, and 10 weeks post-cranioplasty. For nanotransfection, experimental mice received brdU-labeled EFF-nanotransfected cells with Matrigel, while the sham group received sham-transfected cells. Healing was evaluated using immunohistochemistry and Micro-CT. Results Different regions were evaluated: 1) central bone graft, 2) bone graft and 3) rim of native bone to evaluate the healing process at different regions after cranioplasty. DAPI intensity and nuclei counts indicated a significantly higher cell density in the bone grafts (p <0.001) of nCCBG group only from weeks 3 to 4, compared to the CCBG group. There was no difference in cell densities of nCCBG compared to CCBG at week 1 and 2 (p >0.05). Vascular intensity via lectin staining was similar across groups and timepoints. Micro-CT analysis showed that at week 1 through 8 post-cranioplasty, the rim of bone graft had significantly more new bone added than central bone graft (p <0.05) in both CCBG and nCCBG, however, no difference was found between the rim of the bone graft and the and rim of native bone in the amount new bone added in both CCBG and nCCBG groups (p <0.05). Further, the rim of bone graft had significantly lower TMD than central bone graft and rim of native bone in both CCBG and nCCBG groups (p <0.05) over the same period. The quality of bone at the rim of the bone graft was more heterogeneous than every other regions, as indicated by their wide standard deviation in gray level. Finally, EFF-nanotransfected cells were assessed for their impact on cranioplasty healing. BrdU-labelled cells were identified at the cranioplasty site as early as week 1 post-cranioplasty. Defect site in EFF and sham mice had higher lectin vascular intensity than native bone in EFF (P=0.0044) and sham mice (P=0.0009) respectively. Conclusion These studies demonstrate that EFF-nanotransfected cells are viable at the cranioplasty site. Further studies are ongoing to determine the effect on rates of autologous calvarial bone healing.

ABSTRACT Background: Pediatric opioid prescribing following surgery has received increased attention due to concerns regarding misuse, prolonged use, and associated risks. While opioid stewardship has been widely studied in general pediatric surgery, prescribing patterns in cleft and craniofacial surgery remain unclear. This study analyzes opioid prescription trends at discharge for craniofacial procedures, identifying demographic, procedural, and perioperative factors associated with opioid use. Methods: A retrospective analysis of the 2023 Pediatric National Surgical Quality Improvement Program (PNSQIP) database was conducted, identifying all patients who underwent cleft and craniofacial procedures. Patients were stratified based on whether they received an opioid prescription at discharge. Demographic variables (age, sex, race, ASA classification), hospital status (inpatient vs. outpatient), and perioperative characteristics (operative time, anesthesia time, and length of stay) were compared. Opioid prescribing rates were analyzed across individual CPT codes to identify procedures most and least associated with opioid use. Statistical comparisons were performed using t-tests and chi-square analyses. Results: Among 16,806 patients, 7,260 (43.2%) were discharged with an opioid prescription. Oxycodone (73.36%) was the most commonly prescribed opioid, followed by hydrocodone (19.97%). Patients who received opioids were older (7.00 ± 6.36 vs. 5.36 ± 5.63 years, p < 0.001), less often male (58.15% vs. 61.29%, p < 0.001), and more likely to have inpatient status (39.16% vs. 34.95%, p < 0.001). Opioid prescribing rates varied significantly across craniofacial procedures. The highest opioid prescription rates were observed in major craniofacial osteotomies, including 21147 (81.82%), 21146 (78.95%), and 21141 (75.18%). In contrast, the lowest opioid prescription rates were observed for CPT codes 42810 (excision of a branchial cleft cyst or vestige limited to skin and subcutaneous tissues, 5.42%), 42815 (excision of a branchial cleft cyst, vestige, or fistula extending beneath the subcutaneous tissue and/or into the pharynx, 10.04%), and 69300 (otoplasty, 25%). Among cleft-related procedures, primary cleft lip repair (40700: 43.61%, 40701: 45%) had moderate opioid prescribing rates, whereas palatoplasty (42210: 66.13%) was associated with higher opioid prescriptions. Perioperative characteristics also differed between opioid and non-opioid groups, with longer operative times (144.45 ± 88.88 min vs. 120.79 ± 83.11 min, p < 0.001), longer total anesthesia times (209.10 ± 103.17 min vs. 180.60 ± 100.77 min, p < 0.001), and shorter hospital stays in opioid recipients (1.11 ± 1.73 vs. 1.32 ± 4.30 days, p < 0.001). Conclusions: Postoperative opioid prescribing patterns vary widely across cleft and craniofacial procedures, with osteotomies and palatoplasty associated with higher opioid use compared to primary cleft lip repair and otolaryngologic procedures. The findings suggest that procedure-specific factors, rather than standardized guidelines, drive opioid prescribing practices. Given the known risks of opioid exposure in pediatric populations, these results underscore the need for specialty-specific opioid stewardship programs and evidence-based prescribing guidelines in craniofacial surgery. Future research should assess longitudinal opioid use and whether variability in prescribing practices affects long-term outcomes.

Purpose: Neonates with cleft lip and/or palate (CL/P) on occasion require neonatal intensive care unit (NICU) admission and care. However, the specific NICU clinical interventions and outcomes of this population remain poorly characterized in large-scale studies. This study aims to describe the clinical course, interventions, and outcomes of neonates with CL/P admitted to the NICU, providing data to improve neonatal care strategies, optimize resource allocation, and enhance family education.

Methods: A retrospective cohort study was conducted using the Pediatric Health Information System (PHIS), a national database aggregating data from over 49 children's hospitals. NICU admissions for neonates <31 days old with CL/P between January 2016 and December 2023 were identified. Subjects were stratified into three groups: cleft palate only (CP), cleft lip only (CL), and both cleft lip and palate (CLP). Data extraction included demographics, birth characteristics, length of stay, procedural interventions, respiratory support, feeding therapy, medication use, and imaging studies. Statistical analyses included descriptive statistics, odds ratios, and regression modeling to evaluate differences between cleft subtypes.

Results: A total of 923 neonates met inclusion criteria (CL: 9.6%, CP: 36.6%, CLP: 53.7%). Birth characteristics varied significantly among groups, with neonates with CL exhibiting the highest rates of prematurity (65.7%) and lowest gestational age (36.0 weeks, IQR: 34.0-38.0). Median NICU length of stay differed significantly (p<0.001), with CP having the longest duration (12.0 days, IQR: 5.0-23.0), followed by CLP (9.0 days, IQR: 5.0-18.0) and CL (5.0 days, IQR: 3.0-17.0). Feeding interventions were among the most common NICU procedures, reflecting significant feeding challenges in this population. Swallowing evaluations were performed in 75.1% of CLP, 71.5% of CP, and 40.7% of CL neonates. Feeding therapy was initiated in 71.2% (CLP), 66.4% (CP), and 39.6% (CL), with a high reliance on feeding tubes and specialized feeding equipment. Respiratory support was frequently required, with non-invasive ventilation used in 35.8% of cases. Airway management strategies, including CPAP and supplemental oxygen, were particularly necessary in neonates with Pierre Robin sequence. Medication use was also significant, with anti-infective agents administered to 71.4% (CL), 58.3% (CP), and 53.8% (CLP), highlighting increased infection risk in this population. Gastrointestinal agents were used in over 85% of cases, supporting enteral feeding challenges, while pain management and sedation were commonly required for procedural interventions.

Conclusions: NICU admission for neonates with CL/P is associated with substantial healthcare utilization, with feeding and respiratory complications being primary drivers of prolonged hospitalization. Infants with CP and CLP exhibited the highest burden of interventions, emphasizing the need for structured feeding protocols, early lactation support, and standardized airway management strategies. These findings underscore the importance of multidisciplinary coordination and targeted parental education to optimize neonatal outcomes and reduce hospital length of stay. Future research should explore strategies for standardizing NICU protocols to enhance care consistency and improve long-term health outcomes for neonates with CL/P.

Background Gender-affirming surgery (GAS) includes reconstructive procedures designed to align a patient's physical characteristics with their gender identity. Facial feminization surgery (FFS) is essential in reducing gender dysphoria, with modifications to the forehead, mandible, and other facial structures enhancing feminine facial aesthetics and improving quality of life in transgender patients. However, limited quantitative assessments exist regarding cephalometric changes following FFS and their correlation with patient-reported outcomes using a validated, transgender-specific instrument. This study investigates the relationship between cephalometric changes and GENDER-Q outcomes in FFS patients.

Methods Patients who underwent FFS procedures-including frontal sinus setback, suprabrow contouring, genioplasty, and gonial angle reduction-at a single academic institution were identified. Preoperative and postoperative CT scans were analyzed using validated methods to isolate regions of interest. Surface area, volume, and region-specific morphometric values were calculated.

The GENDER-Q is a validated patient-reported outcome measure (PROM) designed for transgender and gender-diverse (TGD) individuals. This study included gender dysphoria and social well-being scales from the health-related quality of life domain, the surgery information scale from the experience of care domain, and facial appearance scales.

Preoperative and six-month postoperative GENDER-Q scores were compared using paired two-tailed Student's t-tests. Pearson correlation assessed relationships between GENDER-Q scores and cephalometric changes, with univariate linear regression performed for significant correlations.

Results A total of 24 patients were included, with a mean age of 34.5 ± 8.7 years. The average time between surgery and postoperative GENDER-Q assessment was 7.0 ± 3.4 months. Case distribution was as follows: 21 forehead contouring/frontal sinus setbacks, 21 genioplasties, and 10 mandibular angle reductions.

A significant correlation was observed between the change in frontonasal angle (FNA) and overall facial satisfaction. For every 1% decrease in FNA, facial satisfaction increased by 1.01 (p = 0.04). Additionally, for each 1% reduction in chin volume, the magnitude of improvement in facial satisfaction increased by 0.27 (p = 0.04). A statistically significant correlation was also found between the change in gonial surface area and improvement in facial satisfaction; for every 1 mm² decrease in surface area, improvement in satisfaction increased by 0.011 (p = 0.0166).

Conclusion This study demonstrates that FFS significantly enhances patient-reported outcomes. To our knowledge, it is the first to establish correlations between specific cephalometric changes and improvements in facial satisfaction and reductions in gender dysphoria. These findings underscore the critical role of FFS in improving quality of life for transgender patients and highlight the need for further research with larger patient cohorts. With the availability of a validated PROM tool for transgender patients, future research can focus on refining surgical planning to optimize aesthetic and functional outcomes, ultimately enhancing patient satisfaction and well-being.

Background: Robin Sequence (RS) is a triad of micrognathia, glossoptosis, and upper airway obstruction, often causing breathing, feeding, and speech problems. Up to 90% of patients with RS have a cleft palate (CP), and about 41% are diagnosed with velopharyngeal insufficiency (VPI). These patients require multiple surgeries throughout their lives. The impact of early mandibular distraction osteogenesis (MDO) on VPI outcomes remains unknown. This study aims to evaluate the impact of surgical timing on VPI correcting surgery following MDO.

Methods: A retrospective review of RS patients who underwent MDO at a major children's hospital between 2004 and 2023 was conducted. A sensitivity analysis was performed to determine the age at which MDO surgery was associated with the lowest incidence of VPI surgery. Length of follow-up, surgical technique, and subsequent interventions including CP repair, VPI surgery, and tracheostomy were recorded. MDO failure was defined as tracheostomy after MDO. Primary outcomes included VPI surgery and postoperative palatal fistulas. Statistical analyses were performed using Pearson's chi-squared test, Student's t-test, and Mann-Whitney U test.

Results: A total of 115 PRS patients underwent MDO, of which 16 (14%) patients were diagnosed with VPI after CP repair. Overall MDO success was 97.4%. Mean follow-up time was 6.5 ± 5.2 years. Sensitivity analysis identified a threshold age of six weeks, after which VPI correcting surgery rates were significantly higher (p<0.05). Both cohorts had similar rates of VPI diagnosis on speech evaluation (6.1% vs 16.0% p=0.087). Fifty patients who underwent MDO surgery after six weeks of age also had higher rates of postoperative fistulas (p<0.05). All VPI patients received speech therapy. The late cohort was 4.7 times more likely to have VPI surgery than the early cohort. There was no significant difference in time between MDO to CP repair, to VPI surgery, or MDO failure between cohorts.

Conclusion: Our study demonstrates that patients who underwent MDO before six weeks of birth were less likely to undergo VPI surgery. After CP repair, the younger cohort also experienced fewer postoperative fistulas. MDO may benefit speech by improving airway patency and overall health. The findings of this study suggest that early MDO could further reduce the need for speech-correcting surgery and postoperative fistula repair.

Introduction: Options for reconstructive surgery of head and neck defects following oncologic resection, trauma, or burns include skin grafting, locoregional flaps, staged tissue expansion, and vascularized tissue transfer. Skin substitutes, such as Integra dermal regeneration template, have emerged as a potential alternative, particularly for patients in whom autologous tissue is unavailable or contraindicated. Despite Integra's growing clinical use, the literature on its application to head and neck defects is limited primarily to case reports and studies focused on specific anatomical regions. This systematic review addresses knowledge gaps in our understanding of Integra's role in head and neck reconstruction by comprehensively examining patient factors, surgical techniques, and postoperative outcomes.

Methods: A systematic literature search was conducted following PRISMA guidelines across PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases. Studies were included if they involved adult patients with head and neck defects reconstructed using Integra. Case reports and small case series, among other publications, were excluded. Extracted data included patient demographics, comorbidities, defect characteristics, intraoperative details, complications, and postoperative outcomes. Due to heterogeneity in study design and outcome measures, a meta-analysis was not performed.

Results: A total of 3,828 articles were screened, of which 44 met inclusion criteria. These studies included 1,431 patients (mean age 69±14 years). The majority of articles (34, or 1199 patients) reported only post-oncologic reconstruction. Only 3 articles (28 patients) focused on using Integra in burn reconstruction and 2 articles (21 patients) in trauma reconstruction. Five articles (183 patients) reported a mix of oncologic, burn, and trauma reconstruction. Amongst studies reporting comorbidities, hypertension (52% of patients), diabetes (20%), and peripheral arterial disease (15%) were the most common. In studies focused on post-oncologic reconstruction, the most common diagnoses were squamous cell carcinoma (39% of patients), basal cell carcinoma (29%), and melanoma (24%), with a mean defect size of 43±37 cm². The majority of post-oncologic defects were on the scalp (70% of patients) and nose (16%). For trauma studies, the mean defect size was 101±33 cm²; the burn-focused studies did not report defect size. Amongst all studies, 14 reported 1-stage reconstruction with Integra, 21 reported 2-stage reconstruction, and 9 reported a mix of 1- and 2-stage reconstruction. Infection was the most common complication, found in 10% of patients in studies in which it was reported, followed by Integra failure (2%) and partial or total loss of skin graft (2%). The average follow-up period was 17.7±9.5 months.

Conclusion: This systematic review summarizes published patient characteristics, surgical techniques, and postoperative outcomes for Integra-based reconstruction of head and neck defects resulting from burns, trauma, or oncologic surgery. The evidence supports the feasibility of Integra for such defects, however, most of the literature is focused on oncological defects, with limited data on traumatic and burn-related applications. Standardized reporting of relevant preoperative, intraoperative, and postoperative factors will help further characterize Integra's role in head and neck reconstruction and facilitate comparison with reconstruction techniques involving autologous tissue and other skin substitutes.

Background: Maxillofacial giant cell lesions (GCLs) are often aggressive, disfiguring tumors in children. The functional deficits and psychosocial impact necessitate urgent treatment; however, a consensus on management is lacking given the rarity and the variable presentation in children. The purpose of this study is to evaluate the treatment and outcomes of unifocal and multifocal pediatric maxillofacial GCLs and to elucidate an optimal approach to management.

Methods: A retrospective review of patients with histologically confirmed maxillofacial GCLs at a tertiary children's hospital from February 2003 to December 2024 was performed, excluding those with incomplete documentation and less than six months of followup. Tumors were classified as aggressive or nonaggressive using Chuong et al.'s criteria, modified by Kaban et al (1,2). Outcomes included local recurrence and final disease status (remission, progressive, or non-progressive). Univariate and bivariate statistics were used to compare treatment characteristics and outcomes between syndromic and non-syndromic cohorts, with statistical significance determined by p-values < 0.05.

Results: Twenty-eight patients met inclusion criteria, 16 non-syndromic with unifocal lesions and 12 syndromic, of which 11 had multifocal lesions. Mean age at presentation was 10.7 ± 4.8 years and the mean follow-up time was 5.4 ± 4.2 years. Overall, 96.4% of lesions were aggressive, with 89.3% exhibiting rapid growth, 100% dental displacement, and 44.0% cortical perforation. Non-syndromic subjects were more frequently treated with adjuvant pharmacologic therapy compared to syndromic subjects (75.0% vs. 25.0%, p=0.020). Recurrence occurred in one non-syndromic subject (6.2%) and 50% of syndromic subjects (p=0.008). Remission was achieved in 100% of the non-syndromic cohort and only 8.3% of the syndromic cohort (p<0.001).

Conclusion: Maxillofacial GCLs are highly morbid, resulting in significant facial disfigurement and mass effect. Our results showed that syndromic and multifocal cases exhibited the highest recurrence and lowest remission rates, warranting a more aggressive treatment approach and consideration of a targeted approach with neoadjuvant or adjuvant denosumab. We present our institution's management algorithm to guide optimal management of pediatric maxillofacial GCLs.

References:

1. Chuong R, Kaban LB, Kozakewich H, Perez-Atayde A. Central giant cell lesions of the jaws: a clinicopathologic study. J Oral Maxillofac Surg. 1986;44(9):708-713. doi:10.1016/0278-2391(86)90040-6

2. Kaban LB, Troulis MJ, Wilkinson MS, Ebb D, Dodson TB. Adjuvant antiangiogenic therapy for giant cell tumors of the jaws [published correction appears in J Oral Maxillofac Surg. 2007 Nov;65(11):2390. Wilkinson, Michael J [corrected to Wilkinson, Michael S]]. J Oral Maxillofac Surg. 2007;65(10):2018-2024. doi:10.1016/j.joms.2007.03.030