Scientific Abstract Presentations: Craniomaxillofacial Session 10 Saturday, October 11 Sat, Oct 11 5:00-6:00 p.m. CDT

Purpose: Anterior craniofacial changes in unilateral lambdoid craniosynostosis include forehead bossing, increased orbital heights, and asymmetry of the midface and mandible, creating a facial twist. The purpose of this study is to comprehensively analyze the post-operative anterior craniofacial changes in patients with unilateral lambdoid craniosynostosis following occipital switch cranioplasty. Methods: A retrospective two-center review of pre-operative and two-year post-operative three-dimensional images of eighteen patients with unilateral lambdoid craniosynostosis who underwent occipital switch cranioplasty. Results: Frontal and occipital asymmetry significantly improved post-operatively (p=0.029; p<0.001). Cranial height asymmetry and midface asymmetry did not significantly improve (p=0.240; p=0.586). The nasal deviation was, on average, 3.58 ± 1.69 degrees prior to surgery and significantly improved with a residual deviation of 2.18 ± 1.35 degrees (p=0.010). The chin deviation significantly improved post-operatively from an average of 2.21 ± 1.52 degrees to a residual deviation of 1.07 ± 1.12 degrees (p=0.040). Ear asymmetry, orbital width, and orbital height asymmetry did not significantly change with surgery. Conclusions: Two years after occipital switch cranioplasty, patients with unilateral lambdoid craniosynostosis had significantly improved frontal asymmetry, nasal deviation, and chin deviation. Residual asymmetry remained in nasal and chin deviation. Midface contralateral deficiency did not significantly change post-operatively. The release of the affected suture with occipital switch cranioplasty allowed for remodeling and growth to improve anterior craniofacial symmetry.

Purpose: Anterior craniofacial changes in unilateral lambdoid craniosynostosis include forehead bossing, increased orbital heights, and asymmetry of the midface and mandible, creating a facial twist. The purpose of this study is to comprehensively analyze the post-operative anterior craniofacial changes in patients with unilateral lambdoid craniosynostosis following occipital switch cranioplasty. Methods: A retrospective two-center review of pre-operative and two-year post-operative three-dimensional images of eighteen patients with unilateral lambdoid craniosynostosis who underwent occipital switch cranioplasty. Results: Frontal and occipital asymmetry significantly improved post-operatively (p=0.029; p<0.001). Cranial height asymmetry and midface asymmetry did not significantly improve (p=0.240; p=0.586). The nasal deviation was, on average, 3.58 ± 1.69 degrees prior to surgery and significantly improved with a residual deviation of 2.18 ± 1.35 degrees (p=0.010). The chin deviation significantly improved post-operatively from an average of 2.21 ± 1.52 degrees to a residual deviation of 1.07 ± 1.12 degrees (p=0.040). Ear asymmetry, orbital width, and orbital height asymmetry did not significantly change with surgery. Conclusions: Two years after occipital switch cranioplasty, patients with unilateral lambdoid craniosynostosis had significantly improved frontal asymmetry, nasal deviation, and chin deviation. Residual asymmetry remained in nasal and chin deviation. Midface contralateral deficiency did not significantly change post-operatively. The release of the affected suture with occipital switch cranioplasty allowed for remodeling and growth to improve anterior craniofacial symmetry.

Purpose: Anterior craniofacial changes in unilateral lambdoid craniosynostosis include forehead bossing, increased orbital heights, and asymmetry of the midface and mandible, creating a facial twist. The purpose of this study is to comprehensively analyze the post-operative anterior craniofacial changes in patients with unilateral lambdoid craniosynostosis following occipital switch cranioplasty. Methods: A retrospective two-center review of pre-operative and two-year post-operative three-dimensional images of eighteen patients with unilateral lambdoid craniosynostosis who underwent occipital switch cranioplasty. Results: Frontal and occipital asymmetry significantly improved post-operatively (p=0.029; p<0.001). Cranial height asymmetry and midface asymmetry did not significantly improve (p=0.240; p=0.586). The nasal deviation was, on average, 3.58 ± 1.69 degrees prior to surgery and significantly improved with a residual deviation of 2.18 ± 1.35 degrees (p=0.010). The chin deviation significantly improved post-operatively from an average of 2.21 ± 1.52 degrees to a residual deviation of 1.07 ± 1.12 degrees (p=0.040). Ear asymmetry, orbital width, and orbital height asymmetry did not significantly change with surgery. Conclusions: Two years after occipital switch cranioplasty, patients with unilateral lambdoid craniosynostosis had significantly improved frontal asymmetry, nasal deviation, and chin deviation. Residual asymmetry remained in nasal and chin deviation. Midface contralateral deficiency did not significantly change post-operatively. The release of the affected suture with occipital switch cranioplasty allowed for remodeling and growth to improve anterior craniofacial symmetry.

Purpose:
Fragility analyses have been utilized to evaluate the strength of randomized clinical trials (RCTs) and are interpreted in relative terms, given there is no universal cutoff (1-5). In heart failure and diabetes RCTs, median fragility indices (FI) are 26 [8.5, 39.3] and 16 [4, 29], respectively (1, 2). In contrast, the existing three reviews on plastic surgery RCTs report lower FI: 90 significant plastic surgery RCTs had a median FI of 1 [0, 4], landmark plastic surgery RCTs had 4 [2, 7.5], and acellular dermal matrix studies had 4 [3, 5] with a fragility quotient (FQ) of 0.04 [0.03, 0.07] (1-5).

This study conducts fragility analyses to examine the robustness of RCTs on antibiotic prophylaxis (AP) in craniofacial trauma.

Methods: RCTs with dichotomous outcomes were sourced from PubMed, Embase, Web of Science, SCOPUS, and Cochrane, using the PRISMA guidelines for systematic reviews. Fragility index (FI) and reverse fragility index (rFI) - number of events needed to alter outcome significance- and fragility quotient (FQ) - FI or rFI divided by sample size (standardized fragility across trials) - were calculated.

Results: Out of 1730 studies screened, four RCTs met the inclusion criteria. The RCTs evaluated fractures of the mandible, maxilla, orbital walls, and base of skull. The median sample size for the RCTs was 105 [IQR: 85.3, 121], with a median fragility index of 7.5 [IQR: 5.5, 8.3] and a median fragility quotient of 0.072 [IQR: 0.050, 0.12]. The two statistically significant RCTs showing decreases in infection with AP had a median sample size 129 [IQR: 115, 143], a median FI of 4.5 [IQR: 2.8, 6.3], and a median FQ of 0.043 [IQR: 0.025, 0.061]. The remaining two non-significant RCTs had a median sample size of 73.5 [IQR: 55.8, 91.2], median rFI of 8 [IQR: 7.5, 8.5], and a median rFQ of 0.15 [IQR: 0.11, 0.20].

Conclusions: The current RCTs on AP in craniofacial trauma are weak and susceptible to minor changes. We believe it is challenging to form blanket antibiotic prophylaxis protocols based on these data. Management of each individual patient and fracture should be undertaken on a case-by-case basis.

References:

1. Campbell RT, Jhund PS, Petrie MC, McMurray JJV. How robust are clinical trials in heart failure? Kieran F. Docherty1. Eur Heart J. 2017;38(5). doi:10.1093/eurheartj/ehw427

2. Chase Kruse B, Matt Vassar B. Unbreakable? An analysis of the fragility of randomized trials that support diabetes treatment guidelines. Diabetes Res Clin Pract. 2017;134. doi:10.1016/j.diabres.2017.10.007

3. Chin B, Copeland A, Gallo L, et al. The Fragility of Statistically Significant Randomized Controlled Trials in Plastic Surgery. Plast Reconstr Surg. 2019;144(5):1238-1245. doi:10.1097/PRS.0000000000006102

4. Ormseth BH, Elhawary H, Janis JE. The Fragility of Landmark Randomized Controlled Trials in the Plastic Surgery Literature. Plast Reconstr Surg Glob Open. 2024;12(1). doi:10.1097/GOX.0000000000005352

5. Wang A, Kwon D, Kim E, Oleru O, Seyidova N, Taub PJ. Statistical fragility of outcomes in acellular dermal matrix literature: A systematic review of randomized controlled trials. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2024;91:284-292. doi:10.1016/j.bjps.2024.02.047

Background: Conventional frontal-orbital advancement (FOA) effectively expands the cranial vault but is associated with long-term sequelae including temporal hollowing, bony contour irregularities, and supraorbital retrusion. To mitigate these challenges, an alternative single-segment neo-frontobandeau transposition has been employed at our center for five years. Previous studies have demonstrated comparable perioperative safety, volumetric expansion, and correction of metopic craniosynostosis-related cranial dysmorphology to conventional FOA. However, the most important question remains the longer-term aesthetic outcomes of neo-bandeau FOA in comparison to conventional FOA. In this study, we compare clinical and medium-term aesthetic outcomes between patients who underwent neo-bandeau FOA and conventional FOA for craniosynostosis with anterior dysmorphology. Methods: We retrospectively reviewed all children who underwent neo-frontobandeau FOA between 2013-2023 at our institution. Children 18 months of age or those with clinical signs of early relapse or irregularities were included. Patients were age- and sex-matched to patients who underwent traditional FOA for nonsyndromic isolated metopic craniosynostosis. Preoperative and immediate postoperative computed tomography (CT) scans were processed using CranioRate, a machine learning algorithm, to objectify the degree of cranial dysmorphology. A 5-point Likert scale (1 being the worst, 5 being the best) was developed through consensus refinement utilizing sentinel photographs and descriptions to exemplify scale thresholds. Blinded 2D photographs taken before revisions were reviewed by plastic surgeons for aesthetic outcomes (temporal hallowing, frontal bone irregularity/convexity, and supraorbital retrusion). Results: A total of 50 patients met inclusion criteria. All patients who underwent conventional FOA had metopic craniosynostosis (n=25, 100%), while patients who underwent neo-bandeau FOA had metopic (n=16, 64.0%), sagittal (n=6, 24.0%), bicoronal (n=2, 8.0%), or multi-suture synostosis (n=1, 4.0%). Preoperatively, there were no differences in cranial dysmorphology severity measures between cohorts (p>.05). Similarly, there were no significant differences in complication rates, perioperative outcomes, or surgical times (p>.05). Mean age at photo assessment was 3.9±1.5 years. On blinded Likert assessment, patients with NB (n=25) had improved temporal hallowing scores (4.2 ± 0.8 vs 3.5 ± 1.2, p<.001), frontal bone irregularity (4.5 ± 0.7 vs 3.6 ± 1.2, p<.001), sagittal frontal convexity (4.2 ± 0.9 vs 3.6 ± 1.2, p<.001), and supraorbital retrusion (3.9 ± 1.0 vs 3.5 ± 1.0, p=.010) compared to patients with FOA (n=25). In subgroup analysis with NB (n=17) or FOA (n=25) for metopic synostosis only, all of these findings held (p<.01). IRR was 88.8% overall, 89.7% for the temporal hallowing scale, 94.7% for frontal bone irregularity, 87.7% for frontal bone contour, and 83.3% for supraorbital retrusion. Conclusions: The neo-bandeau FOA technique for anterior cranial vault morphology shows similar clinical efficacy and complication rates to traditional FOA but may provide improved aesthetic outcomes and stability of result over time.

Background: Identifying the coronal suture endoscopically can be challenging yet few studies have evaluated using virtual surgical planning (VSP) guidance in assisting operative technique. We sought to compare operative outcomes following VSP-guided and non-VSP guided endoscopic suturectomy for patients with unicoronal and bicoronal craniosynostosis.

Methods: Patients who underwent endoscopic-assisted suturectomy for uni- or bicoronal craniosynostosis from 2020 to 2024 were retrospectively reviewed. In one cohort, a surface marking guide developed with VSP was used to facilitate identification of the coronal suture. Patient demographics, estimated blood loss, operative time, length of stay, and secondary fronto-orbital advancement were compared between VSP and non-VSP cohorts.

Results: 17 patients were included undergoing 12 unilateral and 5 bilateral suturectomies. Eight patients (4 unicoronal and 4 bicoronal) were in the VSP cohort and 9 patients (8 unicoronal and 1 bicoronal) were in the non-VSP cohort. Overall EBL for unilateral cases was 12.1 +/- 7.5 mL. Patients who underwent VSP had equivalent EBL to the non-VSP cohort (10.0 +/- 1.0 mL vs 13.1 +/- 19.2 mL, p = 0.53). For bilateral cases, EBL for the VSP cohort was 28.8 +/- 30.9 mL compared to 50 mL for the one bilateral non-VSP guided case. Patients who had VSP guidance had significantly reduced operative time for unilateral cases (63+/-17 minutes vs 81+/- 20 minutes, p < 0.01). For bilateral cases, VSP guidance was 78 +/- 26 minutes compared to 118 minutes for the one bilateral case with non-VSP guidance.

Conclusions: Using VSP to assist endoscopic coronal suturectomy reduces operative time. This outcome likely reflects a decreased reliance on intraoperative assessment, increased fidelity of neo-suture placement, idealized placement and decreased size of the access incision, and restriction of neo-suture width to preserve surrounding bone.

Background Surgical resection of pediatric mandibular tumors may result in significant facial disfigurement. While custom endoprosthesis (CE) and non-custom reconstruction (NCR) have been successfully used for microsurgical mandibular reconstruction, the comparative impact on facial symmetry between these techniques remains poorly characterized. The purpose of this study was to analyze facial anthropometrics to compare improvement in post-resection disfigurement among children undergoing CE and NCR following hemimandibulectomy.

Methods A retrospective review was conducted of children who underwent mandibular reconstruction at a major children's hospital from August 2009 to March 2022. Cohorts included patients receiving CE and NCR. Anthropometric measurements from frontal images taken one year postoperatively included gonion-to-menton (Go-Me), gonion-to-midline (Go-Mid), stomion-to-cheilion (Sto-Ch), intercanthal line (ICL) to gonion (ICL-Go) and ICL to cheilion (ICL-Ch). Symmetry ratios between the surgical and non-operative sides were calculated, with 1.0 signifying ideal symmetry. The percentage of absolute deviation from ideal symmetry was calculated, with lower values indicating favorable outcomes. Statistical analysis was performed using Fisher's exact and Mann-Whitney U tests.

Results A total of 25 patients undergoing mandibular reconstruction met inclusion criteria. Thirteen patients received CE and 12 underwent NCR. Of the resected tumors, 84% were benign and 16% were malignant. None of the patients received preoperative radiation therapy. Reconstructive methods included free tissue transfer (CE: 69.2% vs. NCR: 16.7%), bone grafting (23.1% vs. 66.7%), and local flaps (7.7% vs. 16.7%) (p=0.03). Overall flap survival was 100%. Hardware failure occurred in 7.7% of CE and 50.0% of NCR patients (p=0.03). Postoperatively, the CE cohort demonstrated decreased deviation from ideal symmetry compared to the NCR cohort in four anthropometric metrics (Go-Mid: 11.3% vs. 14.2% , p=0.42; Sto-Ch: 8.6% vs. 11.3%, p=0.39; ICL-Go: 4.6% vs. 7.0%, p=0.29; Go-Me: 7.1% vs. 9.9%, p=0.41). The CE cohort exhibited greater deviation from symmetry in only one metric (ICL-Ch: 2.7% vs. 1.3%, p=0.12).

Conclusion Overall, reconstruction with CE demonstrated a trend towards improved facial symmetry compared to NCR, as evidenced by reduced deviation from ideal symmetry in most anthropometric measurements. These findings may inform clinical decision-making and set more accurate preoperative expectations for pediatric mandibular reconstruction. Further studies with a larger patient population are necessary to more precisely determine the significance of differences in postoperative facial symmetry between CE and NCR in microsurgical mandibular reconstruction.

Purpose This study compares the aesthetic outcomes of two common surgical techniques for bilateral cleft lip revision: complete bilateral cleft lip revision and Abbe flap. Specifically, the study quantifies changes in upper lip anatomy, including scar width, philtrum width, lip height, and sagittal relationships between the upper and lower lip.

Methods A single-institution, 10-year, retrospective review was conducted on 39 patients with bilateral cleft lip who underwent either complete bilateral cleft lip revision (n=20) or Abbe flap (n=19) between 2014 and 2023. Preoperative and postoperative (at least six months follow-up) photographs were analyzed using Dolphin Imaging software. Frontal view measurements included left and right scar width, philtrum width, superior lip width, philtrum column height, total upper lip height, and vermillion tubercle height. Measurements were assessed as ratios of postoperative to preoperative values. Additionally, sagittal view measurements analyzed the angle formed between the radix, upper lip, and lower lip, as well as the labial angle relative to Frankfurt Horizontal. A paired t-test was performed to assess statistical significance (p < 0.05).

Results The study included 39 patients: 20 with complete bilateral cleft lip revision and 19 with Abbe flap. Key findings included: • Scar width: Significant reductions were observed in left (0.71, p<0.001) and right scar width (0.73, p<0.001) in the complete revision group, but no significant change in the Abbe flap group. • Philtrum width: The complete revision group demonstrated a significant reduction (0.62, p=0.001), while the Abbe flap group showed no change. • Total Upper Lip height: The complete revision group showed a slight increase in upper lip height (7%, p=0.04), while the Abbe flap group demonstrated a larger increase (22%, p<0.001). • Vermillion height: Both groups showed increases in superior vermillion height (13% in complete revision, p=0.005, and 21% in Abbe flap, p=0.0005). • Sagittal angles: The radix-upper lip-lower lip angle increased by 25 degrees (p=0.001) in the Abbe flap group, but did not change significantly in the complete revision group. Similarly, the labial angle from Frankfort Horizontal decreased significantly in the Abbe flap group (7 degrees, p=0.004), while only a slight change was observed in the complete revision group that was not significant.

Conclusions Both complete cleft lip revision and Abbe flap are effective in improving upper lip aesthetics, but they serve different purposes. Complete cleft lip revision is more effective at improving scar quality and narrowing the philtrum, while the Abbe flap is superior for elongating the philtrum, increasing total upper lip height, and correcting sagittal discrepancies. These findings can guide surgical decisions for patients with bilateral cleft lip, based on their specific anatomical needs. The study highlights the importance of considering both functional and aesthetic goals when selecting the appropriate surgical technique for bilateral cleft lip revision.

Purpose Various surgical techniques have been employed in the correction of maxillomandibular discrepancies. Distraction osteogenesis is a modality utilized when large bony deficiencies require reconstruction. In patients with severe mandibular transverse inadequacy, distraction osteogenesis can be utilized to correct the mandibular width (1, 2). Previous reports described external distractor appliances and bone-borne devices (3-5). Here, a novel technique in transverse mandibular expansion using a tooth-borne distraction appliance is described.

Methods Two patients with congenital anomalies that resulted in severe class II malocclusion, bilateral posterior crossbite, and mastication difficulties were treated for mandibular transverse correction. Preoperatively, a custom-designed tooth-borne mandibular distractor was fabricated by the orthodontic team for each patient. A midline mandibular osteotomy was made through a chin incision and the tooth-borne mandibular distractor was placed on the lower dental arch. Activation of the device was initiated on postoperative day three and was continued until imaging and clinical exam demonstrated acceptable mandibular width. Consolidation was carried out for 6 weeks prior to removal of the device. During this time, an additional stiff acrylic component was added to the device to prevent bony movement. Secondary mandibular ramus lengthening was performed in typical fashion several months later for both patients.

Results  Acceptable posterior overjet, mandibular form, and mandibular width were achieved for each patient. There were no identified complications with mandibular incisors health. These findings are suggestive of appropriate mandibular transverse correction.

Conclusion  These cases represent a novel technique for successful treatment of micrognathia in the transverse dimension while minimizing potential complications.

Refrences

1. Winters R, Tatum SA. Craniofacial distraction osteogenesis. Facial Plast Surg Clin North Am. Nov 2014;22(4):653-64. doi:10.1016/j.fsc.2014.08.003

2. 4. Efunkoya AA, Bamgbose BO, Adebola RA, Adeoye JB, Akpasa IO. Maxillomandibular distraction osteogenesis. J Craniofac Surg. Sep 2014;25(5):1787-92. doi:10.1097/scs.0000000000000907

3. Garreau É, Wojcik T, Rakotomalala H, Raoul G, Ferri J. Symphyseal distraction in the context of orthodontic treatment: a series of 35 cases. Int Orthod. Mar 2015;13(1):81-95. doi:10.1016/j.ortho.2014.12.003

4. Alkan A, Ozer M, Baş B, et al. Mandibular symphyseal distraction osteogenesis: review of three techniques. Int J Oral Maxillofac Surg. Feb 2007;36(2):111-7. doi:10.1016/j.ijom.2006.11.005

5. Starch-Jensen T, Kjellerup AD, Blæhr TL. Mandibular Midline Distraction Osteogenesis with a Bone-borne, Tooth-borne or Hybrid Distraction Appliance: a Systematic Review. J Oral Maxillofac Res. Jul-Sep 2018;9(3):e1. doi:10.5037/jomr.2018.9301

Background Virtual surgical planning (VSP) is an invaluable tool for craniofacial surgeons. In mandibular distraction osteotomy (MDO), routinely performed in severe cases of Robin sequence (RS), VSP allows surgeons to precisely place osteotomies and hardware, maximizing airway expansion while minimizing complications such as nerve or tooth bud injury (1). Longer distraction distances may predispose to condylar resorption, but current literature lacks consensus on regarding their effect other complications like facial nerve dysfunction (2,3). Nevertheless, increased distraction lengths may improve clinical outcomes such as postoperative Apnea-Hypopnea Index and oxygen requirements (4). Little evidence exists on whether VSP predictions match the eventual size of distraction. The authors conducted a review of MDO cases to determine whether VSP accurately predicts final distraction distance.

Methods Cases of MDO performed between 2019 and 2024 were retrospectively reviewed. Regardless of VSP prediction, patients were distracted until class III occlusion of 2-3 mm was achieved on clinical examination. Final distraction distance was assessed via computed tomography and direct measurement of distractors during explantation. These distances were compared to preoperative VSP from two independent surgical device companies. For each VSP, an ideal prediction (minimum distance to achieve desired class III occlusion) and maximum prediction (maximum distance simulated in the VSP) were recorded.

Results Thirty-four cases of MDO performed in RS were reviewed, representing n=65 osteotomies for which final distraction distance was measured. CT and direct measurement of final distraction demonstrated excellent agreement (mean difference 3.4%). For n=46 osteotomies, VSP predicted 5 to 10mm of distraction required to achieve class III occlusion. In these cases, VSP underestimated the final distraction by 9.0mm on average. N=16 predicted 11 to 15mm of ideal distraction, and n=5 predicted greater than 15mm, with mean underestimations of 7.2mm and 3.7mm, respectively. Overall, 96.4% of distractions exceeded the ideal distance predicted by VSP, with 60.0% of distractions exceeding the maximum prediction.

Discussion/Conclusions This study identifies significant discrepancies between distraction distances predicted by VSP and those needed to reach clinical endpoints. This study highlights both the importance of clinical assessment in determining distraction distance and a need for further research into the effects of long distraction lengths in RS.

References 1. Resnick CM. Virtual Surgical Planning for Mandibular Distraction in Infants with Robin Sequence. Plast Reconstr Surg Glob Open. 2017 Jun 16;5(6):e1379. 2. Shu KY, Liu W, Zhao JL, Zhang ZY, et al. Condylar resorption post mandibular distraction osteogenesis in craniofacial microsomia: A retrospective study. J Craniomaxillofac Surg. 2023 Nov;51(11):675-681. doi: 10.1016/j.jcms.2023.10.001. Epub 2023 Oct 6. PMID: 37852887. 3. Kapoor E, Mantilla-Rivas E, Rana MS, Oh AK, et al. Facial Nerve Dysfunction After Mandibular Distraction Osteogenesis in Patients with Robin Sequence: A Systematic Review and Meta-Analysis. Cleft Palate Craniofac J. 2023 Apr;60(4):395-404. 4. Stanton E, Kondra K, Jimenez C, Hammoudeh JA, et al. Increased Distraction Magnitude Leads to Greater Reduction in the Apnea-Hypopnea Index in Infants With Robin Sequence. J Oral Maxillofac Surg. 2022 Sep;80(9):1486-1492.

Introduction: As one of the most common congenital anomalies, cleft lip and palate (CLP) contribute significantly to the global surgical burden, particularly in low- and middle-income countries. Access to timely and safe surgical intervention is critical for improving patient outcomes, yet access to care remains limited. While prior research has explored barriers to surgical access and predictors of post-operative complications for patients with cleft lip and palate globally, few studies have investigated factors impacting preoperative surgical clearance. This study aims to identify patient characteristics associated with surgical clearance in pediatric patients treated by a cleft-focused NGO. Methods: A retrospective review was conducted of patients presenting for primary cleft repair within a major global cleft organization between 2022-2024. Patients were included if they were 5 years of age or below at time of assessment, had complete health records, and had a surgical indication of primary CLP repair. Patients with incomplete data or with surgical indication other than primary cleft repair were excluded. Health records were reviewed for patient demographics, country of origin income classification, nutritional status, and past medical history of all systems. Nutritional status was quantified using Z-Scores. The primary outcome of interest was clearance for surgery as determined by an examining pediatrician. Statistical analysis was performed using Chi-Square or T-tests as appropriate, significant variables were included in logistic regression models. Results: In total, 1,270 patients with CLP were included, of which 758 (58.1%) were male and 532 (41.9%) were females. The most common countries of origin were Honduras (n = 299, 23.5%), Paraguay (n = 160, 12.6%), Guatemala (n = 150, 11.8%), and Morocco (n = 143, 11.3%). The overall number of patients cleared for cleft surgery was 1,103 (86.9%). On multivariate regression patients from both low-income countries (OR = 0.35 [0.21, 0.58], p = 0.002) and low-middle incomes countries (OR = 0.54 [0.40, 0.73], p = 0.002) had decreased odds of surgical clearance than patients from upper-middle-income or high-income countries. Patients with greater Z-scores had increased odds of surgical clearance (OR = 1.26 [1.10, 1.43], p < 0.001). Additionally, patients with past medical history of any hematological (OR = 0.27 [0.14, 0.54], p = 0.002) or respiratory (OR = 0.09 [0.05, 0.17], p < 0.001) pathology had significantly decreased odds of surgical clearance. Conclusion: Preoperative clearance serves as a critical checkpoint ensuring safety before cleft surgery; however, it may also represent an additional barrier to surgical access for families who have already overcome significant challenges to reach care. Predictive factors associated with surgical non-clearance in pediatric patients seeking CLP repair highlight potential targets for preoperative education, medical optimization, and resource allocation to improve access for patients seeking safe and timely surgery. Further work aiming to understand the reason low-income and low-middle income status are predictive factors for surgical non-clearance is necessary, as these countries bear the greatest burden of untreated surgical disease. References: 1. Fletke KJ, Kaysin A, Jones S. Preoperative Evaluation in Children. Am Fam Physician. 2022;105(6):640-649. 2. Goldschneider KR, Cravero JP, Anderson C, et al. The Pediatrician's Role in the Evaluation and Preparation of Pediatric Patients Undergoing Anesthesia. Pediatrics. 2013; 134(3): 634-641. 10.1542/peds.2014-1840 3. Kantar RS, Hamdan US, Muller JN, et al. Global Prevalence and Burden of Orofacial Clefts: A Systematic Analysis for the Global Burden of Disease Study 2019. J Craniofac Surg. 2023; 34(7): 2012-2015. doi:10.1097/SCS.0000000000009591 4. Plonkowski AT, Naidu P, Davis GL, Etemad S, Otobo DD, Dwyer AM, Yao CA, Magee WP 3rd. Barriers to timely primary cleft surgery in patients treated by an international cleft-focused NGO across 18 countries. World J Surg. 2025 Feb 17. doi: 10.1002/wjs.12469. Epub ahead of print. PMID: 39961773. 5. Swanson MA, Auslander A, Morales T, et al. Predictors of Complication Following Cleft Lip and Palate Surgery in a Low-Resource Setting: A Prospective Outcomes Study in Nicaragua. Cleft Palate Craniofac J. 2022;59(12):1452-1460. doi:10.1177/10556656211046810

Background: Cleft palate repair aims to restore velopharyngeal function by repositioning the levator veli palatini (LVP) muscle and reconstructing the velar anatomy. While intraoperative assessment traditionally relies on surface level visualization, intraoperative magnetic resonance imaging (iMRI) provides real-time, high-resolution imaging of the deep anatomical structures to be manipulated during the operation. This study investigates the feasibility of iMRI use for surgical analysis and quantitative assessment of results. Methods: In this study, seven patients between the ages of 11 and 13 months undergoing primary palatoplasty were evaluated using iMRI. Pre- and postoperative measurements of LVP length, origin-to-origin, velar length, effective velar length, velopharyngeal depth, and angles of origin were compared to normative data. Paired sample t-tests and root mean square error (RMSE) analysis evaluated differences between preoperative, postoperative, and control measurements.
Results: Novel assessment of the preoperative cleft anatomy, including detailed analysis for the LVP size, position and anatomical variation were performed. Postoperatively, mean LVP length increased by 8.437 mm (p < 0.001), reducing RMSE calculated relative to normal anatomy from 15.421 preoperatively to 7.88 postoperatively. Post-surgically, mean reconstructed velar length was 27.97 ± 5.4, 7.723 mm longer than the control group (p < 0.01). After surgery, mean EVL increased by 3.323 mm (p < 0.05). Surgical repair established an intravelar segment length comparable to normal anatomy (17.0 ± 1.46 mm post-palatoplasty vs. 15.9 ± 2.06 mm in normative data). No significant differences were noted after data was normalized relative to weight, length and head size. Discussion: This study is the first compilation of a series of detailed anatomical analysis of the un-operated levator veli palatini muscles in infants at the time of surgical repair. Real-time quantitative assessment of cleft palate repair, intraoperative surgical planning and objective evaluation of outcomes was performed. Findings suggest that the un-operated levator sling has significant variability in shape, size and orientation. Postoperatively, the LVP length, IVL, and EVL may serve as markers of surgical success. The functional implications of differences in velar and velopharyngeal measurements are yet to be elucidated. Future studies with larger cohorts objectively analyzing the detailed preoperative and postoperative LVP anatomy are needed to further optimize surgical approaches aimed at reducing cleft palate repair complications.