Scientific Abstract Presentations: Craniomaxillofacial Session 9 Saturday, October 11 Sat, Oct 11 2:00-3:30 p.m. CDT

Background Patients with cleft lip and/or palate (CL/P) frequently present with maxillofacial skeletal deficiencies that can predispose them to upper airway obstruction and an increased risk of obstructive sleep apnea (OSA). While orthognathic surgery is often performed to improve facial aesthetics and function in these patients, the prevalence of OSA at the time of surgery remains poorly characterized. This study aims to evaluate the rates of OSA in patients with CL/P undergoing orthognathic surgery. Methods A retrospective chart review was conducted on 819 patients who underwent orthognathic surgery between 2012 and 2024. A total of 202 patients met the inclusion criteria of undergoing surgery in the setting of non-syndromic CL/P. Data collected included demographic information, cleft laterality, and pre-operative sleep study data were collected. Patients with clinical concern for OSA were identified, and apnea-hypopnea index (AHI) scores from sleep studies were analyzed. Patients were categorized as OSA-positive or OSA-negative based on sleep study results, and AHI values were compared between groups. Statistical analyses included chi-square testing for categorical variables and independent t-tests for continuous variables, with significance set at p < 0.05. Results Of the 202 included patients, 92 (46%) were male and 110 (54%) were female, with the majority identifying as White (74%), followed by Black (10%), Asian (7%), and Other (10%). Clinical concern for OSA prompted 55 patients (54%) to undergo a pre-operative sleep study. Among these, 24 patients (43.6%) met diagnostic criteria for OSA, while the remaining 31 (56.4%) did not. The mean AHI for OSA-positive patients was 16.25 events/hour, significantly higher than the mean AHI of 5.85 events/hour in OSA-negative patients (p < 0.01). Notably, cleft phenotype appeared to be associated with OSA diagnosis. Of the 24 patients diagnosed with OSA, 18 (75%) had bilateral CL/P, while only 6 (25%) had unilateral involvement. In contrast, among the 31 patients who underwent a sleep study but did not receive an OSA diagnosis, the majority (28/31, 90.3%) had unilateral CL/P, with only 3 (9.7%) presenting with bilateral clefts (p < 0.01). These findings suggest that patients with bilateral clefts may have a higher predisposition for OSA compared to those with unilateral clefts. Conclusion This study demonstrates a high prevalence of OSA in patients with CL/P undergoing orthognathic surgery, with 43.6% of patients who underwent a sleep study meeting diagnostic criteria for OSA. The significant difference in AHI scores between OSA-positive and OSA-negative patients suggests that undiagnosed OSA may be underrecognized in this population. Furthermore, the strong association between bilateral CL/P and OSA diagnosis highlights a potential anatomical predisposition to airway obstruction in these patients.

Background: The paramedian forehead flap is a well-established and robust option for reconstruction of complex nasal defects. Conventionally, forehead flaps are utilized to reconstruct large composite defects affecting multiple aesthetic subunits of the nose as they can support both structural and internal lining grafts. However, when defects involve the alar-facial groove or extend to the adjacent cheek, forehead flaps alone are unable to provide sufficient tissue coverage and recreate the natural contours of affected areas. Here, we present our experience with combined cheek and nasal defects treated with a staged reconstruction approach involving an initial cheek advancement flap followed by a staged forehead flap. The various nuances and guiding principles of this approach relating to staging, defect and template preparation, and flap design, elevation, and inset are discussed. Methods: This is a retrospective cohort study of all patients who underwent combined cheek advancement and paramedian forehead flaps from 1994-2024. Suture technique, contralateral templating, and stacked cartilage grafts were modified to improve function and aesthetics and will be demonstrated. Results: A total of 38 patients underwent combined cheek advancement flap with staged forehead flap for complex defects involving the cheek and nose from 1994 to 2024. Patients were more often female (n=26, 68.4%). Average age at surgery was 66.3±15.2 years and patients underwent prior Mohs excision (n=34, 89.5%) or wide local excision (n=4, 10.5%). Patients were treated for basal cell carcinoma (n=25, 65.8%), melanoma (n=8, 21.1%), and squamous cell carcinoma (n=6, 15.8%). Average defect size was 18.6±19.2cm2. A cheek advancement flap was performed at time of first stage forehead flap in the majority of patients (n=27, 71.1%) or a preliminary separate stage in large or deep defects (mean 10.7±8.8 vs 31.5±25.4 cm2, p=0.019) to prevent drift. Forehead flap was most often performed in 2 stages (n=22, 57.9%) and were more commonly ipsilateral to the defect (n=21, 55.3%). Most patients required cartilage grafting (n=30, 78.9%) while few required tissue expansion (n=3, 7.9%). Nasal stents or xeroform stents were used to ensure patency in all patients. At mean follow-up of 17.5±30.7 years, 4 (10.5%) patients had minor soft tissue infections, 2 (5.3%) required revision, 1 (2.6%) had partial flap necrosis, and 1 (2.6%) had disease recurrence. Conclusions: The cheek advancement flap creates a stable platform on which further reconstruction can be built upon, and when combined with a forehead flap, offers a durable treatment option that allows the functional and aesthetic resurfacing of complex multi-unit defects of the cheek and nose.

Purpose: Craniosynostosis is associated with a range of neurological and psychological challenges. This study aimed to investigate the epidemiology of associated neurophysiological disorders in patients with craniosynostosis, stratified by suture involvement and syndromic diagnosis.

Methods: Using TriNetX, a de-identified global health research network, 12,870 patients diagnosed with craniosynostosis were identified. Patients were categorized based on craniosynostosis subtype (sagittal, coronal, metopic, lambdoid, multi-suture) and syndromic diagnosis. Neuropsychological outcomes were assessed using diagnostic codes for attention-deficit hyperactivity disorder (ADHD), conduct disorder, anxiety disorder, intellectual disability, autism, and speech, motor, and scholastic developmental disorders. Statistical analysis was performed to compare the prevalence of these conditions across subgroups.

Results: The cohort included 4,685 sagittal, 4,570 coronal, 2,896 metopic, 265 lambdoid, and 454 multi-suture patients. The overall rates of neuropsychological disorders were ADHD (4.71%), conduct disorder (1.83%), anxiety disorder (2.98%), intellectual disability (2.00%), autism (4.27%), and speech (16.81%), motor (7.44%), and scholastic (2.76%) developmental disorders. Speech developmental disorder was the most common diagnosis in all suture subtypes. Multi-suture involvement had significantly higher rates than single-suture in ADHD (8.15% vs. 4.58%, p<0.001), conduct disorder (3.52% vs. 1.76%, p=0.01), anxiety disorder (9.03% vs. 2.75%, p<0.001), intellectual disability (7.05% vs. 1.81%, p<0.001), autism (6.61% vs. 4.18%, p=0.017), speech disorder (27.75% vs. 16.41%, p<0.001), motor disorder (11.67% vs. 7.28%, p<0.001), and scholastic disorder (5.73% vs. 2.65%, p<0.001). Among single-suture patients, those with metopic craniosynostosis had the highest rate of conduct disorder (2.87%), anxiety disorder (3.35%), intellectual disability (2.76%), autism (5.70%), and speech (21.51%), and motor (9.01%) developmental disorders. Syndromic patients (n=314) had a significantly higher prevalence of anxiety disorder (6.37% vs. 2.89%, p<0.001), intellectual disability (5.41% vs. 1.89%, p<0.001), as well as speech (32.80% vs. 16.27%, p<0.001), motor (15.92% vs. 7.17%, p<0.001), and scholastic (6.69% vs. 2.56%, p<0.001) developmental disorders.

Conclusions: This study highlights the significant burden of neuropsychological conditions among patients with craniosynostosis, particularly those with multi-suture and syndromic presentations. Multi-suture involvement had a significantly higher rate of all evaluated disorders compared to single-suture involvement. Those with syndromic diagnosis had a significantly higher rate of anxiety disorder, intellectual disability, and speech, motor, and scholastic development. Speech developmental disorder was the most associated condition in all suture types. These findings underscore the need for multidisciplinary care models to address these associated neuropsychological disorders.

Purpose: Craniosynostosis is associated with a range of neurological and psychological challenges. This study aimed to investigate the epidemiology of associated neurophysiological disorders in patients with craniosynostosis, stratified by suture involvement and syndromic diagnosis.

Methods: Using TriNetX, a de-identified global health research network, 12,870 patients diagnosed with craniosynostosis were identified. Patients were categorized based on craniosynostosis subtype (sagittal, coronal, metopic, lambdoid, multi-suture) and syndromic diagnosis. Neuropsychological outcomes were assessed using diagnostic codes for attention-deficit hyperactivity disorder (ADHD), conduct disorder, anxiety disorder, intellectual disability, autism, and speech, motor, and scholastic developmental disorders. Statistical analysis was performed to compare the prevalence of these conditions across subgroups.

Results: The cohort included 4,685 sagittal, 4,570 coronal, 2,896 metopic, 265 lambdoid, and 454 multi-suture patients. The overall rates of neuropsychological disorders were ADHD (4.71%), conduct disorder (1.83%), anxiety disorder (2.98%), intellectual disability (2.00%), autism (4.27%), and speech (16.81%), motor (7.44%), and scholastic (2.76%) developmental disorders. Speech developmental disorder was the most common diagnosis in all suture subtypes. Multi-suture involvement had significantly higher rates than single-suture in ADHD (8.15% vs. 4.58%, p<0.001), conduct disorder (3.52% vs. 1.76%, p=0.01), anxiety disorder (9.03% vs. 2.75%, p<0.001), intellectual disability (7.05% vs. 1.81%, p<0.001), autism (6.61% vs. 4.18%, p=0.017), speech disorder (27.75% vs. 16.41%, p<0.001), motor disorder (11.67% vs. 7.28%, p<0.001), and scholastic disorder (5.73% vs. 2.65%, p<0.001). Among single-suture patients, those with metopic craniosynostosis had the highest rate of conduct disorder (2.87%), anxiety disorder (3.35%), intellectual disability (2.76%), autism (5.70%), and speech (21.51%), and motor (9.01%) developmental disorders. Syndromic patients (n=314) had a significantly higher prevalence of anxiety disorder (6.37% vs. 2.89%, p<0.001), intellectual disability (5.41% vs. 1.89%, p<0.001), as well as speech (32.80% vs. 16.27%, p<0.001), motor (15.92% vs. 7.17%, p<0.001), and scholastic (6.69% vs. 2.56%, p<0.001) developmental disorders.

Conclusions: This study highlights the significant burden of neuropsychological conditions among patients with craniosynostosis, particularly those with multi-suture and syndromic presentations. Multi-suture involvement had a significantly higher rate of all evaluated disorders compared to single-suture involvement. Those with syndromic diagnosis had a significantly higher rate of anxiety disorder, intellectual disability, and speech, motor, and scholastic development. Speech developmental disorder was the most associated condition in all suture types. These findings underscore the need for multidisciplinary care models to address these associated neuropsychological disorders.

Purpose: Craniosynostosis is associated with a range of neurological and psychological challenges. This study aimed to investigate the epidemiology of associated neurophysiological disorders in patients with craniosynostosis, stratified by suture involvement and syndromic diagnosis.

Methods: Using TriNetX, a de-identified global health research network, 12,870 patients diagnosed with craniosynostosis were identified. Patients were categorized based on craniosynostosis subtype (sagittal, coronal, metopic, lambdoid, multi-suture) and syndromic diagnosis. Neuropsychological outcomes were assessed using diagnostic codes for attention-deficit hyperactivity disorder (ADHD), conduct disorder, anxiety disorder, intellectual disability, autism, and speech, motor, and scholastic developmental disorders. Statistical analysis was performed to compare the prevalence of these conditions across subgroups.

Results: The cohort included 4,685 sagittal, 4,570 coronal, 2,896 metopic, 265 lambdoid, and 454 multi-suture patients. The overall rates of neuropsychological disorders were ADHD (4.71%), conduct disorder (1.83%), anxiety disorder (2.98%), intellectual disability (2.00%), autism (4.27%), and speech (16.81%), motor (7.44%), and scholastic (2.76%) developmental disorders. Speech developmental disorder was the most common diagnosis in all suture subtypes. Multi-suture involvement had significantly higher rates than single-suture in ADHD (8.15% vs. 4.58%, p<0.001), conduct disorder (3.52% vs. 1.76%, p=0.01), anxiety disorder (9.03% vs. 2.75%, p<0.001), intellectual disability (7.05% vs. 1.81%, p<0.001), autism (6.61% vs. 4.18%, p=0.017), speech disorder (27.75% vs. 16.41%, p<0.001), motor disorder (11.67% vs. 7.28%, p<0.001), and scholastic disorder (5.73% vs. 2.65%, p<0.001). Among single-suture patients, those with metopic craniosynostosis had the highest rate of conduct disorder (2.87%), anxiety disorder (3.35%), intellectual disability (2.76%), autism (5.70%), and speech (21.51%), and motor (9.01%) developmental disorders. Syndromic patients (n=314) had a significantly higher prevalence of anxiety disorder (6.37% vs. 2.89%, p<0.001), intellectual disability (5.41% vs. 1.89%, p<0.001), as well as speech (32.80% vs. 16.27%, p<0.001), motor (15.92% vs. 7.17%, p<0.001), and scholastic (6.69% vs. 2.56%, p<0.001) developmental disorders.

Conclusions: This study highlights the significant burden of neuropsychological conditions among patients with craniosynostosis, particularly those with multi-suture and syndromic presentations. Multi-suture involvement had a significantly higher rate of all evaluated disorders compared to single-suture involvement. Those with syndromic diagnosis had a significantly higher rate of anxiety disorder, intellectual disability, and speech, motor, and scholastic development. Speech developmental disorder was the most associated condition in all suture types. These findings underscore the need for multidisciplinary care models to address these associated neuropsychological disorders.

Introduction Lymph node status is an important prognostic factor in cutaneous head and neck melanomas, with sentinel lymph node biopsies (SLNBs) used to determine occult disease. While traditional techniques use dual modality based on radiocolloid lymphoscintigraphy in combination with blue dye, or more recently near-infrared imaging with indocyanine green (ICG) dye, no studies to date have examined the technique of using ICG as a single modality. This study examined the feasibility of ICG as a single modality for detecting sentinel nodes in cutaneous head and neck melanomas.

Methods A prospective study was performed of all consecutive cutaneous head and neck melanomas patients between August 2023 and October 2024 undergoing SLNB at a single supraregional skin cancer centre in the U.K. Three cohorts were formed: group A (ICG-only); group B (ICG and radiocolloid); and group C (radiocolloid and blue dye). ICG technique involved intraoperative injection of ICG dye at the melanoma site and real time tracking of lymph drainage to the sentinel node(s) to guide surgical dissection. Statistical analyses were performed using Fisher's exact test.

Results 182 nodes were obtained from 67 patients: 29 patients (71 nodes) in group A, 22 patients (61 nodes) in group B, and 16 patients (49 nodes) in group C. Where each technique was utilised, 100% of nodes were detected by ICG; 84.5% by radiocolloid; and 79.6% by blue dye. There was a failure to detect any sentinel nodes by radiocolloid in three patients and by blue dye in four patients. In group B, ICG detected significantly more nodes than radiocolloid (P=0.0001); in group C, there was no difference between radiocolloid and blue dye (P=0.1471). Twelve sentinel nodes were positive for melanoma: 100% were ICG positive, 88.9% were radiocolloid positive and 50% were blue dye positive.

Conclusion Single modality ICG is a feasible technique for detecting sentinel nodes in cutaneous head and neck melanomas, with nodal detection and metastases detection rates superior to radiocolloid and blue dye. As an intraoperative surgeon-led technique, ICG-alone negates the need for preoperative lymphoscintigraphy with its associated radiation risk and nuclear medicine resource requirements. This feasibility study provides the evidence base for future randomised controlled trials to investigate the role of single modality ICG as a gold standard technique.

Purpose: A common approach for improving vermilion on the cleft side of the lip is to advance the vermilion triangular augmentation flap from the lateral lip between the wet-dry border of the vermillion of the medial lip. The tip of the triangular augmentation flap on the lateral lip is typically advanced to the midline of the medial lip, stopping at Cupid's bow. However, this can lead to under projection of the central vermilion and lack of a central lip tubercle. The objective of this study was to analyze the central vermilion projection with a new technique aimed to improve the augmentation of the central vermillion.

Method: A retrospective cohort study was performed on all patients with history of unilateral cleft lip who underwent primary unilateral cleft lip repair from October 2020-September 2024 by a single surgeon. Primary unilateral cleft lip repair procedures included complete, incomplete, and microform cleft lip repairs. Cases prior to January 2024 implemented the standard vermilion triangle augmentation technique, where the advancement was brought to midline at the level of Cupid's bow. Cases after January 2024 implemented the new technique to enhance the central vermilion. In these cases, the vermilion triangle augmentation flap from the lateral lip was carried across midline and inset between the wet-dry border of the vermilion at the level of the peak of Cupid's bow on the non-cleft side. Quantitative image analysis was used to examine the projection of the central vermilion before and after implementation of the technique for central vermilion augmentation.

Results: There were 47 patients included in the database who underwent unilateral cleft lip repair, 35 underwent the standard technique for vermilion augmentation and 12 underwent the new technique to improve central vermilion fullness. Quantitative image analysis demonstrated an improvement in central vermilion projection after implementation of the new central vermilion augmentation technique.

Conclusions: The implementation of the technique used to augment the central vermilion is an effective method of improving the projection and height of the central vermilion to create a central lip tubercle at the time of primary unilateral cleft lip repair.

Introduction Field sterility is a practice used frequently in ambulatory skin and minor hand surgeries. The concept challenges the notion that a fully sterile environment is necessary in every instance to prevent superficial site infection. The benefits are a reduction in medical waste and an improvement in cost-efficiency. A prior literature review found no increase in infection rate in ambulatory procedures using field sterility compared to those performed in the main operating room. The present study is the first to apply field sterility in cleft-related procedures.

Methods A prospective cohort study was conducted on patients undergoing specific cleft procedures between January 2022 and June 2024. The procedures included lip repair, primary or secondary palate repair and pharyngoplasty. It omitted alveolar bone grafting and cleft-related orthognathic surgery. The operative field was maintained with sterile blue towels, sterile gloves, and sterile instruments without the use of full drape packs or surgical gowns. Patient demographics, surgical procedure, and postoperative outcomes were collected. Descriptive statistics were used for analysis.

Results A total of 74 unique patients were identified for cleft repairs. Of which, 20 patients underwent unilateral cleft lip repair had a mean age of 7.1 months (range: 2.5 – 8.2 months), while 8 patients underwent bilateral cleft lip repair with mean age of with a mean age of 4.5 months (range: 3.1 – 8.0 months). Additionally, 10 patients underwent secondary lip repair with mean age of 8.3 years (range: 3.6 – 21.0 years). For cleft palate repairs, 24 patients with mean age of 14.9 months (range: 10.0 – 26.4 months) were included in addition to 6 secondary cleft palate repair patients with mean age of 2.1 years (range: 1.0 – 4.5 years). 6 patients underwent pharyngoplasty at a mean age 21.9 years (range: 6.7 – 47.8 years). There was no evidence of superficial surgical infection across all cohorts. There were no complications reported in the unilateral, bilateral or secondary cleft lip repairs. One complication of a palatal fistula occurred in the cleft palate cohort and no complications in the secondary palate repairs or pharyngoplasty groups.

Conclusion The present study showed limited draping and gowning is a safe alternative to standard operating room sterility for several cleft-related procedures. Despite the presence of high microbial flora in the oral cavity, complication rates in cleft lip and palate repairs remain low, consistent with that reported in the literature. By reducing operative waste and medical cost, the use of field sterility in cleft procedures has significant potential to improve efficiency.

PURPOSE: Pierre Robin Sequence (PRS) is a craniofacial anomaly characterized by micrognathia, glossoptosis, and airway obstruction, often associated with syndromic conditions. While traditionally categorized as isolated or syndromic, this classification remains debated due to overlapping phenotypic and genetic features. This study aims to characterize the clinical presentation, comorbidities, and surgical interventions of these patients and connect them with genetic evaluation patterns and genetic findings in PRS patients over a 21-year period. METHODS: A retrospective review of 292 patients diagnosed with PRS from 2002 to 2023 was conducted. Data included demographics, medical and surgical history, genetic testing results, and clinical outcomes. Variants of unknown significance were classified using ClinGen, gnomAD, GTEx, OMIM, and Orphanet. Statistical analyses included t-tests for continuous variables, χ² tests for categorical variables, and logistic regression to identify predictors of pathogenic genetic findings. RESULTS: Nearly half of the patients (43.13%) were delivered via C-section, with 34.42% experiencing birth complications, including emergent C-sections (5.21%) and nuchal cord (4.72%). The majority (85.65%) required NICU admission, with an average stay of 45.54 days, and 27.00% required intubation at birth. Inpatient consultation was found to be the most common form of presentation, occuring in 54.58% of cases, at an average age of 8.12 days. Genetic evaluation was conducted in 66.90% of patients, with 77.08% of that cohort undergoing genetic testing. Of those tested, 34.68% had a pathogenic variant, 20.72% had a variant of uncertain significance (VUS), and 51.35% had normal results. COL2A1 (32.14%), CHD7 (5.36%), COL11A1 (3.57%), SECISBP2 (3.57%), and SF3B4 (3.57%) were the most frequently implicated genes. Patients with pathogenic variants exhibited higher rates of concomitant comorbidities such as developmental delay (61.04% vs. 37.24%, p=0.001) and congenital heart defects, including patent ductus arteriosus (23.38% vs. 11.03%, p=0.019). Overall, surgical interventions were common, with 87.97% undergoing myringotomy and tube placement, 37.33% requiring palatoplasty, and 36.21% undergoing mandibular distraction osteogenesis. Common long-term outcomes included speech/language delay (63.41%), developmental delay (39.66%), gastroesophageal reflux disease (39.04%), and obstructive sleep apnea (37.33%). CONCLUSION: A significant proportion of PRS patients harbor pathogenic genetic variants, reinforcing the need for routine genetic evaluation. The high prevalence of associated anomalies supports a spectrum-based classification rather than a strict isolated diagnostic dichotomy. Genetic findings have the potential to enhance personalized treatment strategies, guiding airway management, feeding interventions, educational support and surgical planning, and should be a strong focus point in future research.

Introduction: Frontoorbital advancement (FOA) surgery aims to normalize cranial vault parameters affected in metopic craniosynostosis. While FOA can improve cranial shape and alleviate brain growth restriction, hypotelorism, characterized by a narrowed interdacryon distance, is typically not addressed with standard surgical techniques. This study aims to examine the changes in interdacryon distance, and other key parameters, following traditional open FOA/CVR.

Methods: After IRB approval, this single institution study evaluated 20 patients with metopic synostosis undergoing FOA. Preoperative and postoperative CT scans were evaluated by institutional radiologists who measured four key parameters: Interdacryon distance, endocranial bifrontal angle, inter-zygomaticofrontal (inter-ZF) suture distance, and orbital rim angles. These measurements were compared before and after surgery for each patient, as well as against age matched controls with normal cranial morphology. Patients were stratified into two groups based on the time between the repair and post operative imaging: 0-13 months (one-year group) and 13-24 months (two-year group). Student's t-test was used to assess differences between the patient groups and their respective matched controls.

Results: The average age at the time of surgery was 212 days (7 months). Both groups exhibited a persistent undercorrection of interdacryon distance despite cranial vault repair (one-year group p = <0.001; two year group p= 0.0005). Post operatively, the one-year group exhibited an average interdacryon distance that was 4mm smaller than that of age matched controls, while the two-year group demonstrated an average reduction of 3.6mm. When compared to preoperative images, inter-ZF suture distance and right orbital rim angle were found to significantly increase following repair. Increases in endocranial bifrontal angle and left orbital rim angle after repair did not approach significance.

Conclusions: Open FOA/CVR, involving remodeling of the supraorbital bandeau and frontal bones, results in improvement but not complete correction of hypotelorism when re-evaluated at one and two years postoperatively. This may suggest that intrinsic developmental factors may be contributing beyond premature suture fusion, though more research is needed to better characterize this phenomenon. The present study challenges the assumption that hypotelorism may spontaneously improve with growth after repair. These insights play a crucial role in informing clinical decisions and optimizing surgical plans to prevent the need for additional procedures to correct this persistent deformity.

Background: Nasal deformities in cleft lip patients are highly stigmatizing, often causing asymmetry, deviation, and reduced projection. Secondary rhinoplasty in these patients is particularly challenging due to severe anatomical deviations, pre-existing scars, and the need for both structural correction and aesthetic refinement. While most studies on secondary cleft rhinoplasty outcomes focus on surgeons' perspectives, research on patient satisfaction remains limited.(1) This study aims to bridge that gap by evaluating patient perceptions of secondary cleft rhinoplasty outcomes. Methods: This prospective, self-controlled clinical trial was conducted at Suez Canal University Hospital between October 2021 and October 2024. Patient satisfaction following secondary cleft rhinoplasty was evaluated using the validated Arabic version of the Rhinoplasty Outcome Evaluation (ROE) questionnaire.(2,3) A total of 36 patients (21 females, 15 males), aged 15 to 40 years, were selected through convenience sampling. They completed the questionnaire preoperatively and again at six months and two years postoperatively. Results: Patient satisfaction significantly improved, with the mean total ROE score increasing from 30.21% preoperatively to 71.18% at 6 months and 80.90% at 2 years (p < 0.001). The most significant improvements were observed in nasal appearance (p < 0.001) and breathing function (p < 0.001), while the need for revision surgery decreased substantially. Improvements in social confidence and professional interactions highlight the broader impact of rhinoplasty beyond aesthetics. Satisfaction remained high over time, with a slight but significant increase between 6 months and 2 years postoperatively (p = 0.013), indicating sustained and progressive benefits. Patients in whom septal cartilage grafts were used reported significantly higher satisfaction compared to those with conchal or rib grafts (p = 0.047). Additionally, satisfaction was highest among patients with normal occlusion, whereas those with class III malocclusion reported the lowest satisfaction (p = 0.002). Literacy level also significantly influenced postoperative satisfaction (p = 0.031), while gender, age, marital status, cleft type, cleft palate presence, and lip revision surgery showed no significant impact. Patients with the lowest preoperative satisfaction experienced the most significant postoperative improvement, while those with moderate dissatisfaction had more varied outcomes. Conclusion: Secondary cleft rhinoplasty significantly improves patient satisfaction, particularly in nasal appearance, breathing function, and overall quality of life. Beyond aesthetics, the procedure enhances social confidence and professional interactions. These findings highlight the functional and psychosocial benefits of cleft rhinoplasty, reinforcing its importance in comprehensive cleft care. References: 1. Hens G, Picavet VA, Poorten V Vander, Schoenaers J, Jorissen M, Hellings PW. High patient satisfaction after secondary rhinoplasty in cleft lip patients. Int Forum Allergy Rhinol. 2011;1(3):167-172. doi:10.1002/alr.20023 2. Alsarraf R. Outcomes research in facial plastic surgery: A review and new directions. Aesthetic Plast Surg. 2000;24(3):192-197. doi:10.1007/s002660010031 3. Mulafikh DS, Alharethy SE, Alqabbani AA, Mesallam TA. Validation and clinical application of the Arabic rhinoplasty outcomes evaluation questionnaire. Saudi Med J. 2021;42(6):655-659. doi:10.15537/smj.2021.42.6.20210038

Background: Pediatric cranioplasties pose a unique set of reconstructive challenges due to considerations for skull growth (1,2). Autologous reconstruction has been regarded as the gold standard for repair, but is complicated by bone resorption, donor morbidity, and need for revision (3,4). Several reconstructive materials exist for alloplastic cranioplasty, however, insufficient data exists to support its use in the pediatric population (5). Objective: The purpose of this study was to assess outcomes of pediatric alloplastic cranioplasties and compare them to documented complications in published literature. Methods: This was a single-institution, retrospective, cohort study of all patients less than 18 who underwent cranioplasty with an alloplastic material between July 1996 and July 2024. Patients were excluded due to lack of appropriate documentation or failure to follow-up post-operatively. Patients were identified by their CPT code. Data collected included: demographic information, defect etiology, defect size, defect location, implant material, follow-up duration, interval between original surgery and reconstruction, and age at original surgery and definitive reconstruction. Outcomes included infection, implant exposure, revision rate, implant removal, indication for removal, and growth restriction. Results: During this 28-year period, 69 pediatric patients were identified. The average age was 8.29 years at the time of cranioplasty. The most common alloplastic materials used for reconstruction included porous polyethylene/titanium (n=12), porous polyethylene (n=11), methyl methacrylate (n=10) and titanium mesh with methyl methacrylate overlay (n=10). Mean follow-up duration was 3.6 years. We found an exposure rate of 4.3% (n=3) and an infection rate of 5.8% (n=4). A total of 8 patients (11.5%) underwent implant removal with indications including infection, fluid collection, hardware malfunction, and implant exposure. Eleven patients required additional revisions (15.9%) including additional cranioplasty, fluid collection drainage and hardware manipulation. Thirty patients had adequate charting to evaluate growth restriction with no evidence of growth restriction identified on head circumference measurements. Conclusions: Our data demonstrates low rates of infection, implant exposure, and growth restriction in pediatric patients undergoing alloplastic reconstruction with a variety of synthetic materials. Existing literature demonstrates pediatric cranioplasty infection rates of 9-10% with bone resorption rates of 10-50% in autologous reconstructions, necessitating revision. Our revision rate of 15.9% and explant rate of 11.5% falls within the lower range of this spectrum. Our data suggests that pediatric alloplastic cranioplasty demonstrates acceptable outcomes. Future research should aim to identify the ideal alloplastic implant for this population.

References 1. Frassanito P et al. Problems of reconstructive cranioplasty after traumatic brain injury in children. Childs Nerv Syst. 2017 Oct;33(10):1759-1768. doi: 10.1007/s00381-017-3541-8. 2. Rocque BG et al. Complications following pediatric cranioplasty after decompressive craniectomy: a multicenter retrospective study. J Neurosurg Pediatr. 2018 Sep;22(3):225-232. doi: 10.3171/2018.3.PEDS17234. 3. Hersh DS et al. Bone flap resorption in pediatric patients following autologous cranioplasty. Oper Neurosurg (Hagerstown). 2021 Apr 15;20(5):436-443. doi: 10.1093/ons/opaa452. 4. Klieverik VM et al. Cranioplasties following craniectomies in children-a multicenter, retrospective cohort study. Childs Nerv Syst. 2019 Sep;35(9):1473-1480. doi: 10.1007/s00381-018-4024-2. 5. Lam S, et al. Cranioplasty for large-sized calvarial defects in the pediatric population: a review. Craniomaxillofac Trauma Reconstr. 2015 Jun;8(2):159-70. doi: 10.1055/s-0034-1395880.

Purpose: Distraction osteogenesis (DO) is an important tool for addressing the severely hypoplastic mandible and/or midface, allowing advancement of the craniofacial skeleton and its overlying soft tissues without adjunctive bone grafting. There is an expected period of relapse after DO, followed by altered growth of the facial skeleton (1). Many patients will have continued craniofacial discrepancies following completion of skeletal growth that require subsequent orthognathic surgery. Here we describe the characteristics and outcomes of patients with a history of DO undergoing orthognathic surgery at skeletal maturity.

Methods: This retrospective study included all patients with a history of maxillofacial DO who underwent orthognathic surgery at skeletal maturity. Variables of interest included age, sex, type of distraction, primary diagnoses, severity of the current deformity, magnitude of correction, use of bone grafts, osteotomy designs, ICU admission, hospital length of stay (LOS), and 30-day complications.

Results: Eighteen patients met the inclusion criteria. Of these, 8 underwent prior midface distraction, 8 underwent mandibular distraction, and 2 underwent simultaneous midface and mandibular distraction.

Among patients with prior mandibular distraction (n=10), 100% had a diagnosis of obstructive sleep apnea (OSA), 50% had an underlying syndromic diagnosis, and 40% had a diagnosis of Robin Sequence. Pre-operative SNA and SNB angles were 76.1 +/- 5.9 and 71.1 +/- 7.9, respectively. Ninety percent underwent bimaxillary surgery, and all underwent concurrent genioplasty. Thirty-three percent required segmental maxillary osteotomies, 90% required mandibular bone grafting and 30% required maxillary bone grafting. Most patients (80%) presented with atypical ramus morphology (no medullary space within ramus above the lingula) or an abnormal course of the inferior alveolar nerve (<5 mm from buccal plate or inferior border in molar region) on at least one side necessitating revision of the osteotomy design. Eighty percent required ICU admission post-operatively, but with a relatively short hospital LOS (1.6 +/- 0.7 days). There were no complications within 30 days for this group.

Among patients with prior midface distraction (n=10), 50% had a diagnosis of OSA and 80% had an underlying syndromic diagnosis. The SNA and SNB angles pre-operatively were 74.2 +/- 7.3 and 78.8 +/- 7.3, respectively. Sixty percent underwent bimaxillary surgery and 60% underwent concurrent genioplasty. Thirty percent required segmental maxillary osteotomies, 80% required maxillary bone grafting, and 30% required mandibular bone grafting. Fifty percent required ICU admission post-operatively, with a similarly short hospital LOS (1.5 +/- 0.7 days). One subject experienced early hardware displacement necessitating revision within 30 days of surgery and one subject experienced a surgical site infection, which was treated with antibiotics.

Conclusions: Prior craniofacial distraction poses unique challenges, with most patients requiring bimaxillary surgery at skeletal maturity with bone grafting to the previously distracted region and revision of the standard osteotomy designs. Despite these challenges, orthognathic surgery can be safely performed in this population with relatively short hospital LOS and favorable complication profile.

References: 1. Peacock ZS, Salcines A, Troulis MJ, Kaban LB. Long-Term Effects of Distraction Osteogenesis of the Mandible. J Oral Maxillofac Surg. 2018;76(7):1512-1523.

Introduction: Mandible fractures are common facial injuries in the U.S., often caused by assaults, motor vehicle crashes, and falls. Individuals with a history of incarceration may face unique challenges, including delayed care, increased exposure to violence, and higher rates of medical comorbidities. This study explores fracture patterns, treatment disparities, and the impact of incarceration on outcomes. Methods: A single-center retrospective review of mandible fracture patients from 2017 to 2024 compared incarcerated and non-incarcerated groups. Patients evaluated at our institution were included, excluding minors and those initially assessed elsewhere with no intervention here. Data on demographics, injury characteristics, management factors, and outcomes were collected, and group comparisons were made using Fisher's exact and T-tests (p < 0.05). Descriptive statistics and regression analyses were conducted in RStudio. Results: Of 349 patients, 291 met inclusion criteria, of which 48 (19.75%) had a history of incarceration. Incarcerated patients were more likely to have assault-related injury (OR = 3.34, p = 0.0002) and less likely to have non-assault trauma injuries (OR = 0.30, p = 0.0002). Regarding management, similar proportions of incarcerated and non-incarcerated patients were recommended for surgery (80.2% vs 88.7%, p = 0.172). Of those recommended for surgery, significantly fewer incarcerated (87.2%) than non-incarcerated patients (95.3%) actually received surgery (Z = -2.05, p = 0.0408). Overall, regardless of management recommendations, non-incarcerated patients were 2.94 times more likely to receive surgery than incarcerated patients, while incarcerated patients were 66% less likely to receive surgery (OR = 0.34, p = 0.0516), though this was not statistically significant. Incarcerated patients were also nearly twice as likely to be lost to follow-up (OR = 1.89, p = 0.04236). Between incarcerated and non-incarcerated groups, there were no significant differences in time from presentation to surgery (β = -3.06, p = 0.472), time from injury to surgery (p = 0.6567), or likelihood of unfavorable outcomes (nonunion (p = 0.728), malunion (p = 0.374), persistent pain (p = 0.947), re-operation (p = 0.374), and infection (p = 0.337)). Conclusion: This study highlights disparities between incarcerated and non-incarcerated adults with mandible fractures, including lower surgery rates, higher rates of loss to follow up, substance abuse, and a greater likelihood of assault-related injuries. However, incarceration status did not significantly impact time to surgery or postoperative outcomes. These findings underscore the need for further research into the factors driving these treatment differences. Data collection on functional outcomes is ongoing.

Background Optimal treatment of the unilateral cleft lip nasal deformity (uCLND) continues to be a challenge, and an incomplete understanding of the complex three-dimensional nasal deformity hampers clinical progress. Our group recently examined the uCLND present in infants prior to cleft lip and palate repair by developing a three-dimensional data driven model of the primary unrepaired osseocartilaginous skeleton of the nasomaxillary complex. This demonstrated the presence of a collapsing twist of the cleft side aperture and medialization of the bony margin of the nasal airway with deviation of the nasal bone complex toward the non-cleft side 1, contradicting many previously published descriptions. We hypothesize that the uCLND continues to evolve secondary to growth and in response to surgical intervention. The purpose of the current study is to develop a data-driven model of the osseocartilaginous skeleton in uCLND in early mixed dentition, focusing on the septum and bony nasal vault.

Methods Computed tomographic (CT) scans of 49 unilateral patients with a history of repaired unilateral cleft lip and/or palate in early mixed dentition were identified from the institutional Craniofacial database. A retrospective chart review was then performed for demographics, clinical, and operative variables. For comparison, CT scans of 49 control patients with no craniofacial anomalies were identified. CT scans were analyzed using 3D Slicer2 and soft tissue and osseous landmarks were manually plotted in both the control and study cohort. Osseous landmark deviation in subjects with clefts was compared to controls. Segmentation of the osseocartilaginous septum was also manually performed, and deformational differences were calculated between cleft and non-cleft cohorts.

Results Forty-nine patients with a unilateral cleft lip and palate deformity were identified. The average age at time of CT scan was 7 years (median 7 years, range 5-12 years). The majority of the patients had a history of a complete cleft lip and palate deformity (n=38). All patients had undergone repair of the cleft lip and/or palate in infancy. Four patients had a history of intermediate rhinoplasty, and five patients had a history of alveolar bone grafting. A three-dimensional data driven model of the osseocartilaginous skeleton of the nasomaxillary complex was generated. Notably, there was divergence of the skeletal piriform margins away from the midline. Segmentation of the septum revealed anterior deviation towards the non-cleft side.

Conclusions Herein, we developed an objective three-dimensional data driven model of the uCLND in early mixed dentition. These analyses will allow us to better define goals of treatment and to optimize our surgical approach to the uCLND to optimize functional respiration and aesthetic outcomes. Further analysis will be performed to determine if cleft severity or history of septorhinoplasty influence the anatomical morphology of the uCLND in early mixed dentition.

Reference:

1. Linkugel, A.D., et al. "The Septum and Nasomaxillary Vault Associated with Unrepaired Unilateral Cleft Lip and Palate: A Data-Driven 3D Model". Plast Reconstr Surg (2024).
2. Fedorov, A., et al. 3D Slicer as an image computing platform for the Quantitative Imaging Network. Magn Reson Imaging 30, 1323-1341 (2012).

Background: Patients with cleft lip and cleft palate (CLCP) require multiple interventions to address structural and functional deficits. Patients may undergo revision palatoplasty during childhood to treat velopharyngeal insufficiency (VPI). Some patients may also require alveolar bone grafting (ABG) during mixed dentition to stabilize the maxillary arch and to facilitate closure of oronasal fistulas. This study evaluates the safety and efficacy of combining revision palatoplasty with ABG.

Methods: A retrospective review of pediatric patients with CLCP who underwent ABG and/or revision palatoplasty at a large academic children's hospital (January 2017 to January 2024) was conducted. Records were reviewed for age at surgery, Veau classification, revision indications, grafting method, concurrent procedures, surgery duration, and length of hospital stay. Patients were divided into three groups based on the procedure(s) performed: ABG alone (ABG), revision palatoplasty alone (Palate), and revision palatoplasty with concurrent ABG (ABG + Palate). Bone graft success was confirmed by imaging ≥ 6 months postoperatively, and revision success (VPI improvement or fistula closure) was assessed via speech-language pathology evaluation.

Results: A total of 180 patients met our inclusion criteria: 100 (55.6%) in the ABG group, 66 (36.7%) in the Palate group, and 14 (7.8%) in the ABG + Palate group. Grafting methods and graft success rates were similar between the ABG (63.0%) and ABG + Palate groups (78.6%; p=0.21). Although the age at VPI diagnosis was significantly higher in the ABG + Palate group (8 years [IQR: 7-9]) compared to the Palate group (5 years [IQR: 3-9]) (p=0.02), there was no difference in the time from diagnosis to revision (4 months). Both the Palate and ABG + Palate groups showed similar rates of VPI success (83.7% vs 88.9%, respectively) and fistula closure (92.3% vs 100%), as well as improved speech scores (improvement from moderate to mild hypernasality in both groups).

Conclusion: While we aim to avoid delaying VPI surgeries, patients who present with VPI at a later stage may benefit from concurrent procedures. Our study demonstrates that revision palatoplasty can be safely combined with ABG without compromising graft survival or speech outcomes, providing an opportunity to potentially minimize surgeries in this complex patient population.