Scientific Abstract Presentations: Craniomaxillofacial Session 5 Friday, October 10 Fri, Oct 10 2:00-3:30 p.m. CDT

Purpose Septal cartilage is a common source of graft material used for mature cleft rhinoplasty. However, some surgeons advocate for rib cartilage due to concerns for the ability of septal cartilage to achieve stable changes to nasal morphology. The purpose of this study is to evaluate long term nasal morphological outcomes of mature cleft rhinoplasty when septal cartilage is utilized as the exclusive graft source. Methods A single-institution retrospective review was performed on all patients with non-syndromic unilateral cleft lip who underwent mature cleft rhinoplasty from May 2015 to December 2023, using septal cartilage as the exclusive graft source. Facial maturity was defined at fifteen years of age. Patient demographics including age, sex, and diagnosis, were recorded. Preoperative and postoperative (minimum six-month follow-up) photographs were analyzed to identify the quantitative effects of surgery on nasal morphology. Nasal symmetry was assessed using both frontal and worm's-eye view photographs. Frontal view photographs were used to measure alar cant, alar height angle, nasal tip deviation, and vertical alar height, while worm's-eye view photographs were analyzed to calculate the columellar angle and nostril height. Sagittal view photographs were used to calculate the nasofacial angle and nasolabial angle. Vertical alar height and nostril height were calculated as ratios of the affected to the unaffected side, while all other parameters were calculated as angles. For each study parameter, a preoperative and postoperative populational mean was calculated. A Student's t-test was performed to compare the means before and after surgery, with statistical significance defined as p < 0.05. Results Seventy-five patients were included in the study analysis. The average age of patients was 20.9 years (ranging from 15 to 51 years of age). Forty-five patients had available preoperative and postoperative photographs. The mean changes following mature cleft rhinoplasty were: alar cant 1.84 to 0.98 (p < 0.0001), alar height angle 1.81 to 1.18 (p = 0.0006), nasal tip deviation 2.87 to 2.10 (p = 0.0004), vertical alar height ratio 0.95 to 0.96 (p = 0.3), nasofacial angle 28.10 to 30.42 (p = 0.002), nasolabial angle 81.90 to 87.82 (p = 0.0004), columellar angle 7.90 to 2.90 (p < 0.0001), and nostril height ratio 0.80 to 0.87 (p < 0.0001). Conclusions This study supports the usage of septal cartilage as a stable graft source for mature cleft rhinoplasty. Surgeons may utilize their clinical judgement when choosing their graft source depending on the severity and characteristics of the nasal deformity unique to the patient. Septal cartilage can be a reliable option to minimize donor site morbidity in mature cleft rhinoplasty procedures while achieving a restoration of nasal symmetry, nasal tip projection, and upward nasal tip rotation.

Background Mandibular bilateral sagittal split osteotomy (BSSO) is a common procedure used in orthognathic surgery. The greatest risk of BSSO is damage to the inferior alveolar nerve (IAN), resulting in facial numbness and poor quality of life. A lack of surgical experience is associated with a higher risk of complications, and as a result, BSSO surgical training is critical. Existing training tools, like cadavers and anatomical models, may be expensive, limit options for repeated training, and are not patient-specific. This study aimed to create a low-cost, biomechanically accurate mandibular model for surgical training to prevent such complications.

Methods A virtual 3D model of a human mandible was segmented from computed tomography scans and printed using 9 different resin mixtures. Two residents and two attending surgeons performed user testing to determine which resin mixture had the most realistic haptic feedback. Tensile testing was performed to determine biomechanical properties, like tensile strength, yield strength, and Young's modulus, of each resin mixture. After the best resin mixture was selected, testing in mock-operative conditions was performed to determine the amount of force required to cut through the model, a human cadaveric mandible, and commercially available model.

Results A mix of 45% Anycubic Colored UV Resin and 55% Siraya Tech Tenacious was found to best mimic human bone. Surgeons reported feeling an accurate proprioceptive transition between cancellous and cortical bone layers of the 3D printed mandible. The osteotomy force profiles were similar across our 3D printed (2.8 +/- 1.7 N), cadaveric (2.6+/- 1.6 N), and commercial (2.9 +/- 1.8 N) mandibles. On maximal force testing, our model (5.6 N) closely resembled the cadaveric mandible (5.3 N) compared to the commercially available model (6.3 N). The total cost per 3D printed mandible was $2.48.

Discussion A low-cost 3D printed mandible was developed and validated for surgical simulation in BSSO. Future applications include resident education and pre-operative planning to prevent operative complications.

Purpose: Microtia reconstruction remains a complex procedure requiring precision in both the positioning of the reconstructed ear and the harvesting of rib cartilage. Current surgical techniques for autologous reconstruction employ projection paper or transparent templates for ear placement, lacking accuracy and relying on manual measurements. Furthermore, manual palpation for rib harvesting can be challenging, particularly in patients with higher body mass index (BMI). This study explores the integration of 3D printing technologies and Augmented Reality (AR) to enhance preoperative planning and intraoperative execution, providing improved precision and reducing operative time and morbidity in microtia reconstruction.

Methods: Two technological innovations were recently integrated into our microtia practice: (1) patient-specific 3D-printed positioning masks (hEARo masks) to optimize ear framework placement during cartilage repair (n=9) and (2) augmented reality (AR)-assisted costal cartilage incision planning for rib harvest, utilizing the Microsoft HoloLens to project 3D-CT data onto the surgical field in a selected patient (n=1). HEARo masks were designed from 3D facial imaging using 3dMD technology following cephalometric analysis and customized to mirror the unaffected ear, ensuring accurate ear placement and symmetry. In one obese patient, rib harvest was performed by overlaying 3D rib data on the patient's chest using AR, facilitating precise incision planning.

Results: The integration of 3D printing and AR aims to improve the precision of auricular framework positioning and rib cartilage harvest in selected cases. The hEARo mask consistently demonstrates high accuracy in replicating the contralateral ear's position, ensuring symmetric ear placement. Remote preoperative planning was also feasible for one patient, facilitated by 3D printing of patient-specific models, allowing for accurate surgical planning and alignment of auricular constructs during an inter-institutional collaboration. In patients with higher BMI, AR-guided incision placement may facilitate cartilage harvest and possibly result in reduced operative time by guiding intraoperative decisions.

Conclusions: The use of 3D printed positioning guides (hEARo masks) and AR in microtia reconstruction has the potential to improve auricular framework positioning and incision placement for rib cartilage harvesting in especially challenging cases secondary to obesity. Enhancements in pre-operative planning techniques aim to streamline the surgical process and enhance patient outcomes. Future studies will focus on long-term outcomes, objective measurements of ear symmetry, and further refinement of these techniques.

Purpose: The COVID-19 pandemic and its associated challenges, including increased unemployment, rising inflation, and increased barriers to pre-existing public health resources, have significantly impacted community health and well-being. In Oregon, these pressures coincided with the implementation of Measure 110 in early 2021, which decriminalized the possession of small amounts of certain controlled substances. This study examines incidence of facial trauma in an urban academic Level 1 Trauma Center in Oregon before and after the pandemic, as well as its relationship to socio-economic stressors.

Methods and materials: We conducted a retrospective analysis comparing two time periods: Pre-COVID (11/15/2016-3/15/2020) and Post-COVID (1/1/2021-4/30/2024), a period also aligning with the enactment of Measure 110. We utilized chi-square, Mann-Whitney U tests, student t-test, and OLS regression to analyze data from patient encounters involving facial trauma.

Results/Complications: Our findings indicate a statistically significant increase in the overall incidence of both operative and non-operative facial trauma in the post-COVID period (p<0.0001) (Fig 1). A regression analysis revealed a significant relationship between substance use and facial trauma (OR=2.96, p<0.0001), with roughly 1/3rd of the monthly facial trauma patients having a concurrent and active substance use diagnosis as of July 2024. Overall, a greater percentage of patients with facial trauma had a concurrent substance use diagnosis in the post-COVID period (p<0.0001). Moreover, patients using substances and individuals experiencing houselessness showed a disproportionately higher increase in facial trauma incidence compared to the general population in the post-COVID era (p<0.001).

Conclusion: This study underscores the complex interplay between socio-economic factors and health outcomes, namely facial trauma in our investigation. Our results demonstrate a significant increase in the incidence of facial trauma coinciding with the COVID-19 pandemic and the subsequent rise in unemployment, inflation, and utilization of SNAP benefits, as well as the enactment of Measure 110 in Oregon. The overlapping timelines of these events pose challenges in distinguishing their individual impacts on the incidence of facial trauma. The complexity of this landscape highlights the need for further research to distinguish these influences with greater clarity.

Background: Curvilinear mandibular distraction osteogenesis (MDO) allows for mandibular lengthening in both the sagittal and vertical planes. However, the stability of these movements is less well known. This study aims to examine the stability of the occlusal plane changes seen in patients who have undergone curvilinear mandibular distraction, with and without peri-operative orthodontics at extended follow-up.

Methods: A retrospective review of demographic, perioperative, and distraction data was performed on all patients who underwent isolated curvilinear MDO at our institution from January 2011 - December 2023. Cephalometric analysis was conducted on pre-operative, immediate post-operative, and extended post-operative lateral cephalograms, lateral radiographs, or computed tomography scans with special attention paid to Sella-nasion-B point angle (SNB), SN-mandibular plane angle (MPA), and SN-occlusal plane angle (OPA). Paired t-tests, student's t-tests, and repeated measures ANOVA were used to compare pre-operative, immediate post-operative, and extended post-operative cephalometrics.

Results: 25 patients underwent curvilinear MDO in mixed dentition and had requisite pre-op and immediate post-op imaging, of which 15 had adequate extended post-operative imaging for analysis. Average age at surgery was 8±5 years, with an average follow-up of 4±3 years. The most common diagnoses in the cohort were Treacher Collins (24.0%, n=6), followed by Hemifacial Microsomia (12.0%, n=3), Goldenhar Syndrome (12.0%, n=3), and Pierre Robin Sequence (12%, n=3). 32% (n=8) of patients were tracheostomy dependent pre-operatively, with 50.0% (n=4) decannulated post-operatively. Average distraction distance was 30±8 millimeters. 56% (n=14) underwent post-operative orthodontic treatment. The average SNB angle improved from 69±6º pre-op to 75±7º postop (p<0.001) and maintained at 73±7º at 4-year follow-up (p<0.001). MPA improved from 57±12º pre-op to 48±11º postop (p<0.001) and 53±12º at 4-year follow up (p=0.003). Preop OPA changed from 30±11º pre-op to 23±6º postop (p<0.001) and 26±6º at 4-year post-operative evaluation (p=0.005). When comparing patients with HFM and Treacher Collins, patients with Treacher Collins tended to have greater relapse than patients with HFM at extended follow-up (1.9±4.4 vs. 1.2±6.2, p=0.8), though this failed to reach significance. OPA relapse was similar between patients who did and did not undergo post-operative orthodontics (p>0.05).

Conclusions: Curvilinear MDO results in significant cephalometric improvements in SNB, MPA, and OPA. While there is some expected relapse in these measurements at extended follow-up, these improvements remain significantly improved at 4-year follow-up. Further investigation into relapse differences of long-term results is needed to understand the optimal patient selection.

Background
Microtia reconstruction traditionally relies on autologous costal cartilage, yet challenges remain in achieving optimal biomechanical properties and minimizing donor site morbidity. Tissue engineering utilizing patient-derived chondrocytes presents a solution to overcome these limitations. However, the ideal source of chondrocytes needs to be defined. Auricular chondrocytes from microtia patients may possess unique chondrogenic properties compared to costal chondrocytes while using a decellularized cadaveric scaffold presents a promising approach for structural support and cellular incorporation (1-3). This study compared the chondrogenic potential of microtia-derived auricular chondrocytes (MCs) and costal chondrocytes (CCs) in four settings. This research will provide insight into novel strategies for improving microtia reconstruction.

Methods
The chondrogenic properties of CCs and MCs were assessed in: 1) native tissue, 2) 2D-in vitro culture, 3) pellet culture, and 4) on a decellularized scaffold. CCs and MCs were isolated from costal and microtia cartilage of pediatric donors undergoing autologous microtia reconstruction by digesting the tissue in type II collagenase. The chondrogenic properties of the cells were assessed via immunohistochemistry (IHC), immunofluorescence (IF), and cell proliferation assays using the Cell Counting Kit-8 (CCK-8). Auricular cadaver tissue was decellularized and combined with MCs and CCs, then cultured for 3 weeks. The tissue was fixed and processed to detect collagen by Masson's Trichrome, glycosaminoglycans (GAGs) by Alcian blue or collagen type II expression by immunohistochemistry. Assays were quantified using ImageJ, and descriptive and inferential statistical analyses were conducted using SPSS.

Results The cellular yield averaged 3.30x10^6 cells/gram from microtia cartilage and 9.79x10^5 cells/gram from costal cartilage. Adding MCs or CCs to decellularized auricular tissue induced comparable levels of collagen, GAG formation and the expression of collagen type II. Also, there was no significant difference in collagen type II expression in IHC (p=0.80) or IF assays (0.59). The pellet culture suggested that MCs hold greater collagen type II expression. There was no significant difference in the proliferative capacity of MCs and CCs at 3hr, 24hr, 48hr and 72 hr timepoints.

Conclusion This study demonstrates that MCs and CCs exhibit comparable chondrogenic potential across all tested conditions, including native tissue, in vitro culture, and pellet culture. When integrated into a decellularized auricular scaffold, both MCs and CCs contributed similarly to collagen and glycosaminoglycan formation and collagen type II expression. These findings suggest that CCs, as a more readily available source, may be a viable alternative to MCs for microtia reconstruction, particularly in tissue-engineering approaches utilizing decellularized scaffolds. Further research is warranted to explore long-term viability and functional outcomes in vivo.

References: 1. He A, Ye A, Song N, et al. Phenotypic redifferentiation of dedifferentiated microtia chondrocytes through a three-dimensional chondrogenic culture system. Am J Transl Res. 2020;12(6):2903-2915. Published 2020 Jun 15. 2. Baluch N, Nagata S, Park C, et al. Auricular reconstruction for microtia: A review of available methods. Plast Surg (Oakv). 2014;22(1):39-43.

Background: While Nasoalveolar Molding (NAM) is considered the standard of care in many cleft centers, it has been associated with an increased burden of care due to access, cost, and frequent follow-up appointments. As of 2012, just over one-third of cleft centers offered NAM to patients with cleft deformities. This study aims to depict the socioeconomic stratification of patients who received NAM compared to those who did not based on Social Vulnerability Index (SVI), race, and urbanicity.  

Methods: A retrospective analysis was performed using Epic Cosmos, a national deidentified database from Epic electronic health record. Patients under 6 months with cleft lip or cleft lip and palate from 2016-2023 were included in the study. The rate of NAM was compared across sociodemographic cohorts based on SVI quartiles, race, and urbanicity. Statistical analyses were performed using chi-square.  

Results: 14,212 patients were included in the study. A total of 446 (3.14%) patients were identified as having been treated with NAM versus a total of 13,766 (96.86%) without NAM. The implementation of NAM was significantly associated with the highest SVI quartile, White race, and metropolitan populations (p < 0.05).  

Conclusion: Sociodemographic factors influence treatment options for cleft care. In a nationwide database analysis, very few patients were treated with NAM. However, its usage was significantly associated with the highest social vulnerability, white race, and metropolitan populations. These results indicate that access to NAM is limited to urban areas where the largest craniofacial/cleft centers are located. Expanding access to NAM for all patients is crucial to increasing its utilization across the United States. 

Background: Facial paralysis (FP) affects both function and aesthetics, leading to asymmetry, altered muscle activation, and soft tissue imbalance. Strain analysis provides a quantitative measure of soft tissue deformation, capturing regional stretch and compression patterns that define facial motion. Three-dimensional motion tracking was employed to quantify the displacement of individual surface landmarks and evaluate their dynamic spatial relationships with adjacent points. By analyzing strain distribution in 3D dynamic images, we can better understand how FP impacts facial dynamics, particularly in key regions such as the nasolabial fold, cheek, and orbit.

Purpose: This study applies strain tensor analysis to 4D images to objectively evaluate facial movement asymmetry in patients with FP.

Methods: Dynamic facial expressions, from rest to maximum smile, were captured using a 4D imaging system in pediatric patients with FP (n=9) and age- and sex-matched controls (n=9). Facial surfaces were tracked using a standardized mesh template in Tempus software (3dMD), ensuring full-face correspondence across frames. Strain analysis was performed on 4D video sequences from neutral to maximum smile for each vertex. Strain tensor fields were derived from local mesh deformations to capture directional changes in facial structure. Strain magnitudes were quantified using the Frobenius norm, which provides a single scalar measure of overall deformation by incorporating both stretching and shear effects. The resulting strain distribution was visualized as a color-coded heatmap to assess spatial deformation patterns. Additionally, mesh displacement analysis and nasolabial fold curves were extracted from each 3D hemiface to quantify excursion and asymmetry between affected and unaffected sides in patients with FP and controls.

Results: Strain and displacement analysis revealed distinct differences in mechanical deformation between individuals with FP and those with normal facial function. In patients with FP, strain distribution was highly asymmetric with greater deformation localized to one side of the nasolabial fold and perioral region. Similarly, the malar region exhibited heterogeneous strain propagation between the affected and unaffected sides, indicative of impaired muscle activation and distinct patterns of soft tissue displacement. In contrast, control subjects demonstrated a symmetric strain pattern, with high-strain regions evenly distributed around the lips and oral commissures. Strain remained balanced across the nasolabial folds with minimal asymmetry in deformation intensity or spread. High-strain zones coincided with muscle insertion sites, underscoring the mechanical role of these areas in facial movement.

Conclusions: We present a novel mathematical model using patient-specific 3D meshes to quantify dynamic facial movements in patients with FP. Strain analysis revealed both the unaffected and affected sides of the face exhibit abnormal strain in patients with FP. It remains to be determined if the increased strain on the unaffected side of the face in patients with FP is due to a lack of motion on the affected side or due to overcompensation on the unaffected side. Providers may choose to address both sides of the face during treatment, as the unaffected side also undergoes significant changes.

Background/Purpose: Face transplantation (FT) is a groundbreaking procedure that offers transformative benefits to patients with severe facial disfigurements. As of 2024, 50 FT procedures, including two re-transplants, were documented globally. Despite numerous publications, total patient and graft survival rates are unknown. In contrast, outcomes of solid organ transplants are routinely evaluated as such. Despite numerous publications, patient and graft survival rates remain relatively unstudied. This systematic review aims to describe patient and graft survival among FT recipients worldwide. These are compared with US (United States) national data for renal transplants. In addition, graft loss, rejection, major complications, and mortality are analyzed.

Methods: Adhering to PRISMA guidelines, a systematic review of FT cases sourced from PubMed, Medline, Google Scholar, and Google search was conducted. Data on patient and graft survival, graft loss, rejection, complications, and mortality were extracted. Kaplan-Meier estimates were used to determine patient and graft survival. Further data were described as percentages. Data for US national cadaveric kidney transplant outcomes were derived from the United Network of Organ Sharing.

Results: The search yielded 346 reports, of which 76 were included. Fifty transplants were performed in 48 patients. Patient survival was 96% at 1 year, 93.9% at 3 years, and 89.6% at 5 and 10 years. Graft survival was 94% at one, 3, and 5 years, and 82.5% at 10 years. In contrast, US cadaveric kidney transplant patient/graft survival rates are 96.3%/93.2% at 1 year, 91.3%/85.1% at 3 years, and 83.6%/74.4% at 5 years. Graft loss (7 patients, 14%) was managed with free flap reconstruction (4 patients) or re-transplantation (2 patients), while one patient died from sepsis. Acute and chronic rejections were identified in 37 (74%) and 6 (12%) transplants respectively. Major complications requiring prolonged hospitalizations (29 patients - 60.4%) were mostly secondary to infectious complications, followed by immunosuppressant side effects and malignancies. Mortality occurred in ten patients (20.8%) due to infectious complications (4 patients, 8.3%), malignancies (3 patients, 6.3%), non-compliance with immunosuppression (1 patient, 2%), and suicide (1 patient, 2%).

Conclusion: Long-term (10-year) patient and graft survival following FT is 89.6% and 82.5%, respectively, and compares favorably with US cadaveric renal transplant outcomes. Graft loss (seven patients, 14%) was managed with free flap reconstruction in 4 patients and re-transplantation of 2 recipients. Infectious complications remain the major cause of morbidity and mortality.

Background: Microtia reconstruction using the Nagata technique which utilizes autologous rib cartilage remains the gold standard. However, rib cartilage harvest is associated with significant post-operative pain, leading to increased opioid requirements and longer hospital stays. Despite advances in analgesia, including local infiltration, nerve blocks, and systemic pain control, optimal pain management remains challenging. Cryoablation, successfully used for pain control in pectus excavatum repair, offers a potential solution by temporarily disrupting nerve transmission through extreme cold application. Our case series presents the novel use of cryoablation during rib cartilage harvest in microtia reconstruction and investigates its impact on pain management.

Methods: Three patients, aged 10–15 years, undergoing microtia reconstruction with autologous rib cartilage harvest were included. Under ultrasound guidance, cryoablation was performed at the donor site targeting the intercostal nerves beneath the 6th–9th ribs. A freeze cycle of ten minutes followed by a five-minute thawing process was applied, with real-time ultrasound monitoring to prevent thermal injury. Post-operative pain scores, opioid consumption, and time to resumed ambulation were collected.

Results: • Case 1: A 15-year-old female required 2.4 mg IV hydromorphone via patient-controlled analgesia (PCA), which was discontinued on post-operative day (POD) 1. She received a total of 10 mg oral oxycodone and transitioned to non-opioid analgesia by POD 2. She was discharged on POD 3, reporting 1/10 pain with resumed ambulation. • Case 2: A 12-year-old male had 2.8 mg IV hydromorphone PCA discontinued on POD 2, with a total of 90 mg IV Toradol and 3.8 mg oral oxycodone administered. By POD 3, he reported 0/10 pain and was discharged with resumed ambulation. • Case 3: A 10-year-old male was given 1.1 mg IV hydromorphone PCA, discontinued on POD. He received a total of 90 mg IV Toradol. He reported 3/10 pain at the donor site on POD 1 and was discharged on POD 2 with resumed ambulation.

All patients demonstrated early time to ambulation (average: 2 ±1 days), short length of stay (2.7±0.6 days), and reduced opioid requirements (2.1± 0.9 mg IV hydromorphone, 4.6±4.3 mg oral oxycodone, 90mg IV Toradol). Patients typically experience moderate to severe pain at the donor site for several weeks post-operatively; however, those undergoing cryoablation achieved pain-free ambulation as early as POD 1. While this study is limited by a small sample size, the results suggest that cryoablation may enhance pain control without additional surgical risk or prolonged operative time.

Conclusion: We highlight the first application of intercostal nerve cryoablation for rib cartilage harvest in microtia reconstruction. The observed reduction in post-operative pain and opioid consumption suggests a potential paradigm shift in pain management for these patients. Future studies will compare pain scores, opioid use, and length of stay between cryoablation and traditional pain management to further validate its clinical efficacy. Cryoablation may represent a significant advancement in optimizing patient recovery following microtia reconstruction.

Purpose Surgical treatment of craniosynostosis can be performed via an endoscopic or open approach, with endoscopic surgery generally available to patients presenting before 5 months of age. A growing body of evidence points to superior outcomes with endoscopic surgery, but the limited window of eligibility and requirement for additional postoperative interventions can pose access challenges. This study assesses the relationship between surgical approach, age at presentation, age at surgery, and the wait time between presentation and surgery and relative neighborhood-level socioeconomic deprivation, as assessed by the Area Deprivation Index (ADI).

Methods A retrospective chart review of patients with nonsyndromic craniosynostosis at American Family Children's Hospital between 2010 and 2023 was performed. Patient addresses were used to calculate a state-based ADI quintile using the University of Wisconsin's Neighborhood Atlas. Sex, ethnicity, race, age at the time of presentation, age at primary reconstructive surgery, operative technique, and wait time between presentation and surgery were abstracted from charts. Patients lost to follow-up, those with unavailable medical records, or those who resided outside of WI were excluded. Descriptive statistics and univariate analyses were used for binary variables and ANOVA and Spearman-ranked correlation were used to analyze continuous variables (p<0.05).

Results Our cohort included 126 patients. Patients with the least relative disadvantage represented 26% of patients, while patients with the most disadvantage represented 11% of patients. A higher ADI quintile, indicating greater socioeconomic disadvantage, was associated with an increased likelihood of undergoing open rather than endoscopic surgery (OR 1.615, 95% CI 1.191 – 2.191, p=0.002). Age at time of presentation (95% CI -0.082 – 0.265, p=0.306, Spearman's ρ=0.092) and age at time of primary surgery (95% CI -0.006 – 0.333, p=0.066, Spearman's ρ=0.164) were not significantly associated with ADI quintile. A higher ADI quintile was associated with an increased wait time between presentation and primary reconstructive surgery (95% CI 0.013 – 0.351, p=0.041, Spearman's ρ=0.182).

Conclusions Greater socioeconomic disadvantage was associated with a higher likelihood of receiving open surgery and an increased wait time between presentation and surgery, but not with age at initial surgery. This suggests that factors beyond age at presentation contribute to the choice of surgical approach in patients from more disadvantaged areas. Additionally, such patients may experience barriers in receiving prompt surgical treatment following their initial presentation. Open techniques are associated with inferior perioperative outcomes and less aesthetically favorable results, with emerging evidence suggesting it may be associated with inferior neurocognitive outcomes and increased reoperation rates. However, a relative benefit of open surgery over endoscopic surgery is that it does not require additional postoperative interventions including regular appointments for helmet therapy or a second surgery for spring removal, which can be burdensome. Further outreach and advocacy efforts to improve equitable access to endoscopic surgery and the interventions that make its outcomes most optimal are likely to help alleviate socioeconomic disparities in perioperative and long-term outcomes for patients with craniosynostosis.

Chronic scalp wounds with exposed bone in patients with prior radiation therapy present a significant reconstructive challenge. These wounds can be treated conservatively with excellent results when the wound has not been previously radiated; however, conservative treatment of chronic scalp wounds with exposed bone and prior radiation therapy is not well established and demonstrates varying levels of success in the limited literature (1-3). The purpose of this study is to examine the safety and efficacy of treating these complex wounds conservatively. Patients with radiated chronic scalp wounds with exposed bone that persist despite reconstructive efforts with local flaps, split-thickness skin grafts, skin substitutes, or free flaps must often rely on conservative management and secondary intention healing (4). We retrospectively reviewed 10 patients with previously radiated chronic scalp wounds with exposed bone treated conservatively from December 2014 to December 2024. Our cohort had either exhausted reconstructive options or elected to decline further surgical intervention. They received structured wound care instruction, a regimen of regular application of Silvadene and Aquaphor, and followed closely. The duration of treatment varied with a range of 1-73 months (mean=29.4 months). The area of exposed bone in 7 individuals decreased (70%), with 3 (30%) achieving complete wound resolution with reepithelialization. Conversely, the area of exposed bone increased in 3 patients (30%). At the time of data collection, 8 patients remained stable, while 2 had passed away from unknown causes. To our knowledge, no patients experienced any major complications or significant bleeding with this approach. Our results demonstrate the relative safety of conservative management of radiated chronic scalp wounds with exposed bone when all prior reconstructive interventions have failed or when patients are not candidates for further surgery.

1. Patel P, Young J, McRae M, et al. (June 21, 2020) A Retrospective Cohort and Systematic Review of Non-Operative Management of Exposed Calvaria Post-Radiotherapy. Cureus 12(6): e8751. doi:10.7759/cureus.8751
2. Wong N, Zloty D. Secondary Intention Healing Over Exposed Bone on the Scalp, Forehead, and Temple Following Mohs Micrographic Surgery. Journal of Cutaneous Medicine and Surgery. 2022;26(3):274-279. doi:10.1177/12034754221077903
3. BECKER, G. D., ADAMS, L. A., & LEVIN, B. C. (1999). Secondary intention healing of exposed scalp and forehead bone after Mohs surgery. Otolaryngology-Head and Neck Surgery, 121(6), 751–754. https://doi.org/10.1053/hn.1999.v121.a98216
4. Leedy, J. E., Janis, J. E., & Rohrich, R. J. (2005). Reconstruction of acquired scalp defects: an algorithmic approach. Plastic and reconstructive surgery, 116(4), 54e–72e. https://doi.org/10.1097/01.prs.0000179188.25019.6c

Purpose: Accurate reimbursement under the U.S. fee-for-service model necessitates precise coding for healthcare procedures. Inadequate educational resources have contributed to unclear definitions of current procedure terminology (CPT) which may lead to inconsistencies in billing routines for procedures such as craniotomy and craniectomy in patients with craniosynostosis. As such, the present study sought to analyze the impact of unbundling and bundling trends in craniosynostosis treatment and outcomes to assess the need for educational interventions in billing practices.

Methods:
The Pediatric National Surgical Quality Improvement Program (NSQIP) database was queried to identify cases recorded between 2013 to 2020. Bundled CPT code 21175 and the individual craniosynostosis-specific CPT codes 61550, 61552, 61556, 61557, 61558, and 61559 were utilized. The unbundled cohort was categorized by any number of the individual craniosynostosis-specific CPT codes and the bundled cohort by CPT code 21175. Length of stay (LOS), operative time, and surgical specialty were analyzed.

Results:
A total of 8,817 patients were identified of which 5.9% patients were bundled, and 94.1% were unbundled. Operative time was significantly shorter in the unbundled cohort (177.6 ± 108.1 min) compared to the bundled cohort (249.1 ± 89.0 min, p<0.001). LOS was shorter in the unbundled group (3.05 ± 9.0 days) compared to the bundled group (3.60 ± 7.9 days, p = 0.18). Plastic surgeons were significantly more likely to bundle (11.6%) compared to neurosurgeons (1.3%, p<0.001).

Discussion:
The majority of craniosynostosis treatment procedures were unbundled, which was associated with significantly shorter operative times compared to bundled cases. LOS was also shorter in the unbundled group, and plastic surgeons were significantly more likely to bundle procedures than other specialties. The findings suggest a need for a critical review of current coding guidelines and educational interventions to eliminate ambiguity in the treatment of craniosynostosis.