Scientific Abstract Presentations: Craniomaxillofacial Session 6 Friday, October 10 Fri, Oct 10 5:00-6:00 p.m. CDT

Background: Congenital encephaloceles are associated with high morbidity and mortality, which vary with defect location, size, and perinatal factors. Their rarity and variable presentations contribute to an incomplete understanding, necessitating further research on clinical outcomes and management.

Methods: A retrospective review of congenital encephaloceles managed from 2012-2024 at a single institution was conducted. Data collected included demographics, perinatal history, comorbidities, radiological findings, defect characteristics, and therapeutic interventions. Descriptive statistical analyses were used to discern associations and trends.

Results: There were 17 total patients, with 12 (70.6%) females and 5 (29.4%) males; 12 (70.6%) Black/African American, 4 (23.5%) White, and 1 (5.9%) Hispanic/Latino. Seven patients (41.2%) are deceased. Posterior defects (n=15; 88.2%) were more common than anterior defects (n=2; 11.8%). The most frequent subtype of posterior encephalocele was occipital (n=11; 91.7%). All patients had neural tissue herniation, while 3 (23.1%) had ventricular herniation and 5 (38.5%) had major vascular involvement. Surgical closure was performed in 12 patients (70.6%). Among deceased patients, 3 (42.9%) had surgery, while 9 (90%) living patients underwent surgery. Birth weight was significantly different between living and deceased patients (p<0.05), but gestational age and head circumference were not.

Conclusions: Limited knowledge exists on factors influencing outcomes in patients with congenital encephalocele. This study characterizes the clinical profile and outcomes of congenital encephaloceles at our institution, enhancing our understanding of current management standards.

Background: Unicoronal craniosynostosis (UCS) leads to altered craniofacial growth which requires a surgical correction to optimize both aesthetics and neurological development. While past literature has focused on preoperative morphological characteristics influencing UCS surgical outcomes, insight into specific predictors of revision and reoperation remain limited. Additionally, prior studies demonstrated that overcorrection during initial surgery significantly reduced complications, such temporal hollowing, and led to better aesthetic results. This study aims to investigate patient and surgical factors associated with unplanned reoperation, with the goal of refining preoperative planning to improve long-term surgical outcomes in UCS.

Methods: We retrospectively analyzed 108 patients treated for UCS at a single institution between 2001-2024, with a median follow up of 5.30 ± 4.85 years. Demographic data, initial surgical approach, and reoperation details were collected. Chi squared was utilized to compare unplanned reoperation rates by gender and by approach and t-test were utilized to compare average age at initial surgery in no unplanned reoperations and unplanned reoperation cohorts.

Results: Our analyzed cohort predominantly included female (73.1%) and had a mean age of 10.45 ± 8.7 months at their first surgery. Front-orbital advancement (FOA) without distractors was the most common procedure (n=71, 65.7%), followed by fronto-orbital distraction osteogenesis (FODO, n=27, 25.0%), and by endoscopic suturectomy with helmeting (ENDO, n=10, 9.3%). All patients who underwent FODO had a planned reoperation to remove the cranial distractor devices. When looking at long-term unplanned reoperations, 50.7% of FOA patients required an unplanned reoperation at a mean of 4.8 ± 3.4 years postoperatively, 51% of FODO patients required an unplanned reoperation at a mean of 1.1 ± 0.2 years postoperatively, and 20% of ENDO patients required an unplanned reoperation at a mean of 4.93 ± 0.02 years postoperatively. Of the unplanned reoperations, the leading reason was due to cranial defect / relapse of deformity (35%), followed by aesthetic concerns (33%),17% due to infection, and finally the combined indication of both persistent aesthetic and cranial defects (15%). Unplanned reoperations included infectious debridement (17.3%), soft tissue augmentation (9.6%), onlay cranioplasty (42.3%), inlay cranioplasty (9.6%), and total revision FOA (21.2%). 15.5% of FOA patients required a secondary FOA, with 2 of those FOA patients requiring two secondary FOA procedures, while no FODO patients or ENDO patients required additional FOA. Statistical analysis showed that the average age at initial surgery did not differ significantly between patients who did and did not undergo an unplanned reoperation (p = 0.7045, t-test). Additionally, the rates of unplanned reoperation were not statistically different between the FOA and FODO surgical approaches (p = 0.9193, chi-squared test). Similarly, no significant difference was found in unplanned reoperation rates based on gender (p = 0.39366, chi-squared test).

Conclusions: These findings emphasize the critical role of further morphological assessment and preoperative planning to improve long-term craniofacial outcomes and minimize reoperations.

PURPOSE – Syndrome of the Trephined (SoT) involves neurological decline following segmental skull removal, that improves following cranioplasty. Decompressive craniectomy (DC) after TBI is frequently associated with SoT in patients. Cranioplasty repairs skull defects, protects the brain, improves aesthetics, and improves neurological function in SoT. This study uses a mouse model of decompressive craniectomy to examine SoT's neurological impact and the role of cranioplasty timing after traumatic brain injury (TBI).

METHODS - Adult C57BL/6 mice underwent craniectomy, with the calvarial bone cryopreserved and replaced in an early cranioplasty (ECP) at 2 weeks or delayed cranioplasty (DCP) at 10 weeks. Groups included: 1) ECP, 2) DCP, 3) TBI+ECP, and 4) TBI+ DCP. This study utilized a controlled cortical impact model of TBI, with an impact depth of 2mm. Balance and fine motor coordination were evaluated through balance beam testing at baseline and at weekly time points from 1 to 16 weeks after their craniectomy surgery.

RESULTS – As expected, all groups exhibited motor deficits in the early post-operative period. By week 4, the ECP group had nearly returned to baseline performance, while the DCP group continued to decline, experiencing significantly more foot slips from weeks 4 to 10 (p < 0.02). Between weeks 2 and 10, there was no significant difference in foot slips between the DCP and TBI+DCP groups, indicating that the lack of calvarial bone replacement leads to neurological dysfunction in balance and fine motor coordination, regardless of the presence of traumatic brain injury (TBI). However, following delayed cranioplasty at week 10, the DCP group showed marked improvement compared to the ECP group, highlighting the benefits of cranioplasty. Overall, the TBI groups performed worse than the non-TBI groups, regardless of cranioplasty. Interestingly, TBI+ECP mice had significantly more foot slips than TBI+DCP mice for 10 out of 16 weeks, peaking at week 8 (p = 0.0086).

CONCLUSION – A key feature of the Syndrome of the Trephined is the improvement of neurological symptoms, such as balance and motor coordination, following cranioplasty. In this study, we demonstrate using a novel mouse model that cranioplasty can resolve these deficits even in the absence of traumatic brain injury (TBI), at both early and delayed time points. However, in cases of TBI, mice that underwent early cranioplasty performed worse, suggesting that premature bone replacement may hinder neurological recovery if brain swelling has not fully resolved. Ongoing studies aim to determine the optimal timing for cranioplasty after TBI, with the goal of maximizing recovery from TBI while alleviating symptoms associated with the Syndrome of the Trephined.

PURPOSE – Syndrome of the Trephined (SoT) involves neurological decline following segmental skull removal, that improves following cranioplasty. Decompressive craniectomy (DC) after TBI is frequently associated with SoT in patients. Cranioplasty repairs skull defects, protects the brain, improves aesthetics, and improves neurological function in SoT. This study uses a mouse model of decompressive craniectomy to examine SoT's neurological impact and the role of cranioplasty timing after traumatic brain injury (TBI).

METHODS - Adult C57BL/6 mice underwent craniectomy, with the calvarial bone cryopreserved and replaced in an early cranioplasty (ECP) at 2 weeks or delayed cranioplasty (DCP) at 10 weeks. Groups included: 1) ECP, 2) DCP, 3) TBI+ECP, and 4) TBI+ DCP. This study utilized a controlled cortical impact model of TBI, with an impact depth of 2mm. Balance and fine motor coordination were evaluated through balance beam testing at baseline and at weekly time points from 1 to 16 weeks after their craniectomy surgery.

RESULTS – As expected, all groups exhibited motor deficits in the early post-operative period. By week 4, the ECP group had nearly returned to baseline performance, while the DCP group continued to decline, experiencing significantly more foot slips from weeks 4 to 10 (p < 0.02). Between weeks 2 and 10, there was no significant difference in foot slips between the DCP and TBI+DCP groups, indicating that the lack of calvarial bone replacement leads to neurological dysfunction in balance and fine motor coordination, regardless of the presence of traumatic brain injury (TBI). However, following delayed cranioplasty at week 10, the DCP group showed marked improvement compared to the ECP group, highlighting the benefits of cranioplasty. Overall, the TBI groups performed worse than the non-TBI groups, regardless of cranioplasty. Interestingly, TBI+ECP mice had significantly more foot slips than TBI+DCP mice for 10 out of 16 weeks, peaking at week 8 (p = 0.0086).

CONCLUSION – A key feature of the Syndrome of the Trephined is the improvement of neurological symptoms, such as balance and motor coordination, following cranioplasty. In this study, we demonstrate using a novel mouse model that cranioplasty can resolve these deficits even in the absence of traumatic brain injury (TBI), at both early and delayed time points. However, in cases of TBI, mice that underwent early cranioplasty performed worse, suggesting that premature bone replacement may hinder neurological recovery if brain swelling has not fully resolved. Ongoing studies aim to determine the optimal timing for cranioplasty after TBI, with the goal of maximizing recovery from TBI while alleviating symptoms associated with the Syndrome of the Trephined.

Purpose: Cranioplasty is commonly performed after craniectomies to provide structural protection of the cerebrum and restore cosmesis. Complications after cranioplasty are not insignificant and cause prolonged recovery and return to the operating room. While the procedure may be performed solely by neurosurgeons, plastic/reconstructive surgeons (PRS) are occasionally consulted in cranioplasties for implant placement and wound closure. The impact of PRS involvement on postoperative cranioplasty outcomes remains poorly researched. Similarly, the role of PRS in primary versus secondary cranioplasties is also underexplored.

Methods: A retrospective chart review was conducted examining all cranioplasties performed at a single institution between 2015 to 2024. No cranioplasty materials were excluded. PRS involvement as determined by operative notes, cranioplasty number (primary versus secondary), and postoperative complications requiring further imaging or workup were noted for each procedure. Logistic regression analyses were performed in RStudio (v.2023, Posit PBC) with statistical significance at p<0.05.

Results: A total of 364 cranioplasties were evaluated, with 154 (42.3%) involving PRS. Of the 364 cranioplasties, 304 (83.5%) were primary and 60 (16.5%) were revision cranioplasties. For all cranioplasties when adjusting for obesity, PRS involvement had a significantly lower rate of extra-axial fluid collection (OR 0.42, 95% CI 0.19-0.86, p=0.022). When examining only primary cranioplasties, PRS involvement also had significantly decreased rates of extra-axial fluid (OR 0.27, CI 0.09-0.67, p=0.009). While not significant, PRS involvement in primary cranioplasties had lower rates compared to no PRS involvement for overall any complication at 35.2% vs. 37.8% (OR 0.87, CI 0.52-1.41, p=0.566), pseudomeningocele/CSF leak at 5.6% vs. 7.7% (OR 0.66, CI 0.23-1.70, p=0.414), implant exposure/abscess at 5.6% vs. 6.1% (OR 0.84, CI 0.28-2.26, p=0.743), hydrocephalus at 5.6% vs. 6.1% (OR 0.98, CI 0.33-2.62, p=0.965), and overall any infection at 11.1% vs. 12.2% (OR 0.92, CI 0.42-1.90, p=0.825).

For secondary cranioplasties, PRS involvement had significantly lower odds of overall any complication (OR 0.19, CI 0.03-0.90, p=0.049), pseudomeningocele/CSF leak (OR 0.12, CI 0.01-0.67, p=0.022), and unplanned reoperation (OR 0.14, CI 0.02-0.68, p=0.022). PRS involvement in secondary cranioplasties had near significance for lower rates of implant exposure/abscess at 12.5% vs. 36.4% (OR 0.25, CI 0.05-1.29, p=0.093), hydrocephalus at 6.3% vs. 27.3% (OR 0.16, CI 0.02-1.15, p=0.073), overall any infection at 18.8% vs. 45.5% (OR 0.27, CI 0.06-1.21, p=0.085), and surgical site/tissue/wound infection at 18.8% vs. 45.5% (OR 0.27, CI 0.06-1.21, p=0.085). While not significant, PRS involvement in secondary cranioplasties also had lower rates compared to no PRS involvement for extra-axial fluid at 12.5% vs. 18.2% (OR 0.63, CI 0.10-5.09, p=0.623) and implant failure at 28.1% vs. 54.5% (OR 0.31, CI 0.07-1.30, p=0.112).

Conclusion: Cranioplasties can be associated with high postoperative morbidity, and thus exploring ways to minimize complications is critical. At this institution, PRS involvement was found to significantly improve postoperative outcomes for overall, primary, and secondary cranioplasties particularly in reducing development of extra-axial fluid collections, CSF leak, and unplanned reoperation. Further investigation is warranted to explore the benefits and potential of PRS involvement in cranioplasties.

Introduction: Obesity is a known risk factor for postoperative complications across surgical fields (1,2). However, its impact on mandibular reconstruction using the fibula free flap (FFF) remains underexplored. This study investigates the association between BMI and postoperative morbidity in patients undergoing mandibular reconstruction with FFF, focusing on complications and donor site ambulatory function.

Methods: This retrospective cohort study included patients who underwent mandibular reconstruction with FFF from 2000 to 2024. Patients aged 18 years or older were eligible. The primary outcome was the incidence of donor and recipient site complications. Secondary outcomes included physical therapy data such as gait distance, training duration, pain levels, session count, and follow-up. Patients were categorized by BMI: underweight (<18.5 kg/m²), normal weight (18.5–24.9 kg/m²), overweight (25–29.9 kg/m²), and obese (≥30 kg/m²). Statistical analyses included chi-square tests and multivariate regression to identify independent predictors of morbidity. Multivariate models adjusted for age, gender, smoking status, Charlson co-morbidity score, and timing of chemotherapy.

Results: Among 434 patients (median BMI: 24.4, IQR 20.7–27.4), 12.2% were underweight, 43.5% normal weight, 30.9% overweight, and 13.4% obese. Gender distribution varied by BMI, with a higher proportion of females in the underweight group (58%) and a male predominance in the normal weight, overweight, and obese groups (58%, 74%, and 67%, respectively; p < 0.001). Variables capturing the extent of the resection, such as number of fibula segments, flap area, and donor site closure (primary vs. skin graft), did not differ across BMI cohorts (p = 0.9, 0.6, 0.3). Donor site complications occurred in 29% of patients, with delayed wound healing being the most common. Donor site complication rates differed significantly across BMI cohorts. The underweight group had a significantly lower complication rate (11%) compared to the normal weight group (33%, p = 0.02). In contrast, complication rates in the overweight (27%, p = 1.00) and obese (41%, p = 0.358) groups did not differ significantly from the normal weight group. Recipient site complications and 90-day readmission, reoperation, and mortality did not differ across BMI categories. All physical therapy outcomes were similar. Multivariate analysis found that being underweight was protective against donor site morbidity (OR = 0.25, 95% CI 0.09–0.61, p = 0.004), while being overweight or obese were not significant predictors.

Conclusion: Underweight patients were found to have significantly lower rates of donor site complications compared to normal weight patients, which remained true in multivariate analyses. However, BMI did not predict recipient site morbidity or affect physical therapy outcomes, suggesting functional recovery may be independent of weight status. These findings highlight the nuanced role of BMI in FFF morbidity and underscore the need for further research to optimize patient selection and perioperative care.

REFERENCES:
(1) Pierpont YN, Dinh TP, Salas RE, et al. Obesity and Surgical Wound Healing: A Current Review. ISRN Obes. 2014;2014:638936. doi:10.1155/2014/638936 (2) Goltsman D, Warrier S, Mak C, Spillane A, Ascherman JA. Association between body mass index and adverse surgical outcomes of implant-based breast reconstruction: a prospective cohort study of 5,545 breast reconstructions. Ann Breast Surg. 2022;6(0). doi:10.21037/abs-21-2

Purpose: This study characterizes and compares syndromic craniosynostosis treatment approaches of the Children's Hospital of Philadelphia (CHOP) and Children's Hospital Los Angeles (CHLA).

Methods: ​A retrospective review was performed of patients with Apert, Crouzon, Pfeiffer, Muenke, or Saethre-Chotzen syndromes treated at CHOP or CHLA. Study inclusion required treatment according to each institution's respective management algorithms. Primary outcomes were type, timing, and number of craniofacial surgeries.

Results: Sixty-one patients were included. All CHOP patients (100.0%) underwent posterior vault distraction osteogenesis (PVDO) at age 10.2±7.5 months. In the CHLA cohort, 11 (36.7%) underwent early PVDO at 3.9±0.9 months of age, and all (100%) underwent fronto-orbital advancement (FOA) at age 9.6±3.3 months. For patients aged 10 or older (n=28), the number of major craniofacial procedures in the first 10 years of life was greater in the CHOP cohort (2.3±0.6 versus 1.8±0.6, p=.023), but the number of frontofacial procedures was fewer (1.2±0.7 versus 1.7±0.5, p=.044) in comparison to the CHLA cohort. Among those with Apert, Crouzon, and Pfeiffer syndromes, CHOP patients were more likely to undergo midface surgery at a younger age (6.0±1.2 years versus 7.5±1.5 years, p=.003) via a transcranial approach (61.9% versus 20.8%, p=.005). All midface distractions were performed using external devices at CHOP and internal devices at CHLA.

Conclusions: CHOP patients underwent more major craniofacial procedures but fewer frontofacial interventions compared with CHLA patients. Patients with Apert, Crouzon, or Pfeiffer syndromes were more likely to undergo an earlier midface procedure via a transcranial approach in the CHOP cohort versus the CHLA cohort. Further investigation is necessary to evaluate the impact of each protocol on patient outcomes.

Introduction Sarcomas of the head and neck are relatively rare in the pediatric population. They are a heterogeneous group of malignancies, posing both diagnostic and therapeutic challenges. Prognostic indicators for long term outcomes including local recurrence and metastasis have yet to be established in this patient population. In this study, we describe long-term outcomes in children with head and neck sarcoma (HNS).

Methods A retrospective review was conducted of patients with HNS treated at a tertiary children's hospital from 2006 to 2024. Patients who had a follow-up time of less than one year were excluded. Demographic data, tumor characteristics, and treatment modality were collected. Primary outcome measures included secondary surgical resection, incidence of local recurrence, occurrence of metastasis, and associated morbidity. Statistical analyses were performed using Pearson's chi-squared test, independent samples t-test, and Wilcoxon-sign rank test. Multivariable logistic regression was also performed to assess the predictive value of individual determinants on primary outcome measures.

Results A total of 61 children with HNS met inclusion criteria. Of them, 35 patients (57.3%) had rhabdomyosarcoma, 10 patients (16.4%) had fibrosarcoma, and 7 patients (11.5%) had osteosarcoma. The remaining 9 patients had Ewing sarcoma (6.6%), epithelioid sarcoma (4.9%), or synovial sarcoma (1.6%). The median age at diagnosis was 7.4 years [3.1-14.8] and the average follow-up time was 6.6 years. Mortality during the study period was 26.2%. Patients with rhabdomyosarcoma were 2 times less likely to require surgical re-resection compared to all other HNS types (p=0.03). Other protective factors against surgical re-resection were R0 margins at initial surgery (p<0.001) and adjuvant chemotherapy (p=0.019). In terms of recurrence rates, patients with histologic grade G1 tumors were 9 times less likely to have local recurrence compared to higher grade tumors (p=0.015). Additionally, patients without lymph node invasion were 2 times less likely to have local recurrence (p=0.03). Tumor size was not correlated with local recurrence (p=0.136). In terms of metastasis, tumor size less than 2 cm was 4 times less likely to be associated with metastatic disease (p<0.001). Finally, patients with osteosarcoma and high histologic grade G3-G4 tumors were more likely to develop metastases (p=0.011 and p=0.014, respectively). Finally, morbidity rates were significantly lower in patients with no metastatic disease (p=0.006) and who were surgically resected (p=0.001).

Conclusion In this study, we identified critical factors influencing local and distant recurrence in pediatric patients with HNS. Adjuvant chemotherapy and small tumor size were both associated with a lower likelihood of surgical re-resection and distant metastasis, respectively. High histologic grade and lymph node involvement were significant predictors of local recurrence. These findings highlight the importance of early diagnosis and tailored therapeutic strategies to enhance long-term survivability in this vulnerable population.

Background: Patients undergoing cleft palate (CP) repair may require additional procedures for palatal fistulas, velopharyngeal insufficiency (VPI), and midface hypoplasia. This study examines trends in these outcomes and evaluates risk factors for secondary procedures at a single institution.

Methods: We retrospectively reviewed patients who underwent CP repair between 1994 and 2019 at a tertiary institution, excluding those with less than five years of follow-up. Outcomes included rates of post-CP-repair palatal fistulas, VPI surgeries, and orthognathic surgeries or recommendations for orthognathic surgery.

Results: Of the 812 patients who met inclusion criteria, 630 were non-syndromic. The median age at CP repair was 12.1 months, with a median follow-up of 11.8 years. Over time, rates of palatal fistulas (β = -0.808, p<0.001), VPI surgeries (β = -0.395, p<0.001), and orthognathic surgeries (β = -4.612, p<0.001) significantly decreased despite a rising trend in CP repairs (β = 1.476, p<0.001). In multivariate analysis, bilateral CP and older age at CP repair increased odds of postoperative palatal fistulas, while straight-line repair (SLR) palatoplasty was protective. Bilateral CP and palatal fistulas increased the risk of VPI surgery rate, while surgeon experience and SLR were protective. Bilateral CP, palatal fistulas, and palatal expansion increased the risk of orthognathic surgery, while SLR was protective

Conclusion: In high-volume institutions, factors like cleft type, repair timing, repair technique, and surgeon experience significantly influence outcomes, suggesting that targeted interventions may optimize long-term results.

Purpose: Sexual dimorphism in craniofacial skeletal structures has been thoroughly described. While differences in facial soft tissue structure have also been recognized, they have historically been appraised through qualitative or superficial anthropometric analyses. Consequently, procedural guidelines for soft tissue intervention may lack the precision or dimensionality applied in osseous reconstruction. Modern imaging tools have improved quantification of subsurface soft tissue parameters, including depth, yet these data are seldom directly implemented in aesthetic practice. This systematic review investigates facial soft tissue thickness (FSTT) variability across sex, ethnicity, body mass index (BMI), and age, integrating findings with facial fat pad anatomy to predict fat pad contributions to FSTT and propose a guide informing fat grafting.

Methods: A systematic review and meta-analysis were performed following PRISMA guidelines. PubMed and Web of Science were searched for in vivo imaging-based studies in adult males and females with specified ethnicities. Data were extracted for mean FSTT (±SD) at 31 craniofacial landmarks, stratified by age and BMI where available. Landmarks were grouped into nine surface regions and aligned with 14 established fat compartments (11 superficial, 3 deep). Statistical analyses included multiple linear regression models and unpaired parametric t-tests with Welch corrections.

Results: 33 studies comprising 6,530 individuals (3,303 Male, 3,227 Female) across various ethnic categories-including South Asian (31.5%), Caucasian (25.2%), and East Asian (23.7%) individuals-met inclusion criteria. Males exhibited greater FSTT at most facial regions, with particularly higher magnitude at midline regions such as the perioral area (M=11.9±2.5mm, F=10.7±2.4mm, p<0.001), while females had thicker paramedian FSTT in only zygomatic (F=9.3±2.5mm, M=8.6±2.4mm, p<0.001) and infraorbital (F=9.9±2.8, M=9.3±2.7mm, p<0.001) regions. Increasing age and BMI reduced the magnitude of sexual FSTT dimorphism, and comparisons of ethnic groups revealed differential dimorphism that varied across landmarks. FSTT mapping to fat compartments suggested that female-dominant thickness occurs only in regions containing both deep and superficial fat pads. In pooled multiethnic analyses, deep fat pad regions were significantly thicker in females (F=13.1±3.4mm, M=12.6±3.3mm, p<0.001), while superficial fat pad regions were thicker in males (F=8.8±2.6mm, M=9.3±2.5mm, p<0.001). Age-stratified linear regression models for individuals with normal BMI (20-25) revealed significant FSTT variation in deep fat pad-aligned landmarks in females (R²=0.94, F=50.6, p<0.01) but not males (R²=0.24, F=0.93, p<0.01). No significant trends were found in non-fat pad regions or superficial-only compartments for either sex.

Conclusion: This study established the largest in vivo FSTT database, with several ethnicity, age, and BMI trends identified upon preliminary analyses, and alignment with fat pad anatomy for data-driven, personalized facial fat grafting. While sexual dimorphism at lateral or paramedian landmarks may be primarily due to fat pad differences, that seen for midline landmarks unaligned with fat compartments may be a function of general subcutaneous thickness. The findings here further suggest sex-dependent aging patterns in fat compartments. Deep fat pad regions may undergo grafting for more dramatic facial reshaping, while superficial regions may be more appropriate for subtle recontouring. Further research may seek to refine clinical applications and directly validate fat pad dynamics.

Introduction Craniosynostosis, characterized by the early closure of cranial sutures, can disrupt normal skull growth and potentially hinder brain development, resulting in developmental delays. This study evaluates developmental outcomes in patients with single-suture sagittal, metopic, or coronal craniosynostosis, comparing two surgical approaches: open cranial vault remodeling and endoscopic strip craniectomy.

Methods A retrospective cohort analysis was performed at a tertiary pediatric surgery center, reviewing cases of single-suture craniosynostosis managed between 2013 and 2024. Patients diagnosed with sagittal, metopic, or coronal craniosynostosis were grouped based on their surgical treatment: open cranial vault remodeling or endoscopic strip craniectomy. Collected data encompassed patient demographics, intraoperative parameters, and postoperative outcomes. Developmental progress across behavior, cognition, social function as well as gross and fine motor was tracked using postoperative progress notes, with preexisting developmental delays serving as an exclusion criterion.

Results A total of 69 patients with isolated sagittal (28 endoscopic vs. 17 open), metopic (6 endoscopic vs. 6 open), and coronal (5 endoscopic vs. 7 open) craniosynostosis were analyzed. Those treated endoscopically were younger (3.23 months (SD=0.65) & 6.36 kg (SD=1.69) vs. 9.98 months (SD=5.30) & 9.18 kg (SD=1.93), p<0.001), experienced less blood loss (63 mL (SD=37) vs. 126 mL (SD=79), p<0.001), fewer drains (0% vs. 63%, p<0.001), shorter procedure durations (97 minutes (SD=24) vs. 242 minutes (SD=86), p<0.001), shorter stays (2.66 days (SD=0.82) vs. 3.73 days (SD=0.98), p<0.001), and fewer opioids at discharge (41% vs. 77%, p=0.004) compared to those treated openly.

Within the first year postoperatively, those treated endoscopically for isolated sagittal craniosynostosis experienced lower rates of social delay (0% vs. 19%, p=0.049) compared to those treated openly and experienced lower rates of cognitive delay (4% vs. 31%, p<0.001) within the first three years postoperatively. Within the first three years postoperatively, those treated endoscopically for isolated coronal craniosynostosis experienced greater rates of cognitive delay (60% vs. 0%, p=0.045) compared to those treated openly. Overall, no significant differences in general developmental outcomes were observed between the two surgical approaches across all suture types within 12 months, between 12 and 36 months, or up to 36 months postoperatively.

Conclusion Endoscopic strip craniectomy demonstrates improved intraoperative metrics, reduced postoperative recovery times, and shorter hospital stays compared to open cranial vault remodeling. While sample size limits long-term developmental outcomes conclusions, the findings suggest a potential advantage for endoscopic treatment in select cases.