Scientific Abstract Presentations: Craniomaxillofacial Session 1 Thursday, October 15 Thu, Oct 15 1:30-3:00 p.m. CDT

Background Nasoalveolar molding (NAM) is the most widely used presurgical infant orthopedic (PSIO) modality implemented to facilitate primary lip and nose repair in patients with cleft lip and palate (1). However, NAM utilization is limited by frequent in-person visits, patient discomfort, and financial strain (1). Presurgical Lip, Alveolus, and Nose Approximation (PLANA) is an emerging PSIO alternative with a simplified protocol of lip taping and nasal stents, requiring just 4-5 visits over the course of 3 months (2). This study aims to objectively characterize changes in nasolabial and alveolar anatomy achieved through PLANA therapy.

Methods A prospective cohort study was performed on patients under 3 months of age with unilateral cleft lip ± palate (CL/P) who presented to a tertiary children's hospital for PSIO prior to primary cleft lip repair between March 2024 and January 2026. Patients progressed through a standardized protocol of lip taping and progressively larger PLANA nasal stents over 11 weeks. Pre- and post-treatment columellar angle, nostril width and height, alar base width, and cleft width ratio (CWR) were measured with Photoshop (version 26.8.1) based on clinic photos taken with a reference ruler. CWR was a surrogate marker of cleft lip severity and calculated by dividing labial commissure width by cleft width. Paired t-tests were used to assess pre- and post-treatment outcomes.

Results 13 patients with unilateral CL/P (6 complete, 7 incomplete cleft lip) were included with a median age of 16 days (IQR 13-31) at first PLANA nasal stent insertion. No patients experienced significant PLANA-related complications. PLANA achieved significant improvement in columellar angle from 55.63 ± 20.2° to 69.96 ± 7.03° (p = 0.005). PLANA also significantly increased nostril height ratio from 0.56 ± 0.30 to 1.03 ± 0.31 (p = 0.006), decreased nostril width ratio from 2.02 ± 0.73 to 1.55 ± 0.34 (p = 0.012), and normalized alar base ratio from 1.65 ± 0.42 to 1.30 ± 0.18 (p = 0.001). Furthermore, PLANA improved nasal symmetry with ratios of nostril height, width, and alar base approaching zero on a logarithmic scale, indicating greater symmetry (p = 0.008, 0.02, and <0.001, respectively). PLANA significantly improved CWR from 0.42 ± 0.13 mm to 0.30 ± 0.11 mm (p = 0.004). Lastly, in the 6 patients with complete clefts, alveolar cleft width decreased from 9.5 ± 4.85 mm to 1.92 ± 2.25 mm (p = 0.007) with PLANA.

Conclusion PLANA results in a 14% improvement in columellar angle, 80% alveolar gap reduction to a width of <2mm, and greater symmetry of cleft and non-cleft nasal morphology. These findings suggest that PLANA is effective in optimizing nasolabial and alveolar anatomy prior to cleft lip and nasal repair. With a simplified implementation protocol compared to NAM, PLANA may be a more effective PSIO technique to use prior to surgical repair in patients with CL/P.

References: 1. Alfonso AR, et al. Burden of care of nasoalveolar molding. Cleft Palate Craniofac J. 2020;57:1078-1092. 2. Shetye PR. Presurgical lip, alveolus, and nose approximation (PLANA) for infants with clefts. Craniofac Surg. 2024;35:e357-e359.

Purpose: To compare surgical outcomes and complications of Integra dermal regeneration template (DRT) versus biodegradable temporizing matrix (BTM) for periocular reconstruction following excision of cutaneous malignancy.

Methods: This is a retrospective review of adult patients who underwent periocular reconstruction with Integra DRT or BTM following Mohs micrographic surgery or surgical excision of cutaneous malignancy at a single, tertiary academic institution from January 2017 to October 2025. Demographics, defect characteristics, operative details, and postoperative complications were extracted from electronic medical records. Comparisons between groups were performed using Mann-Whitney U and Fisher's exact tests. Logistic regression was performed to identify independent predictors of complications, controlling for defect size, age, diabetes, radiation history, smoking, and BMI.

Results: One hundred and five patients were included: 65 Integra and 36 BTM. Mean age was 70.1 years and mean BMI was 26.8. Mean follow-up was 21.65 months. The most common cutaneous malignancy was basal cell carcinoma (45.7%), followed by squamous cell carcinoma (27.6%) and melanoma in situ (18.1%). The most frequently involved subunits were cheek (43.8%), sidewall (39.0%), and temple (35.2%). Integra defects were significantly larger than BTM defects (35.0 cm² vs. 15.6 cm², p < 0.001). Time to re-epithelialization was significantly shorter with Integra (33.5 ± 10.5 vs. 39.8 ± 15.3 days, p = 0.045), while time to definitive coverage was similar between groups (84.1 ± 33.2 vs. 72.9 ± 36.1 days, p = 0.165). Complications occurred in 45% of Integra versus 17% of BTM patients (p = 0.004). Ectropion was significantly more common in Integra patients (23% vs 6%, p = 0.027). Additional surgery was required more frequently in the Integra group (71% vs 17%, p<0.001). On logistic regression, Integra was associated with a trend toward increased odds of any complication (OR 3.00, 95% CI 0.98–9.13, p = 0.054) and any ocular complication (OR 2.74, 95% CI 0.84–8.93, p = 0.094) compared to BTM after controlling for defect size, age, diabetes, radiation history, smoking, and BMI.

Conclusions: Both Integra and BTM are effective options for periocular reconstruction following cutaneous malignancy excision. Integra was utilized for significantly larger defects and demonstrated faster re-epithelialization with comparable time to definitive coverage. Integra was associated with higher complication rates, particularly ectropion and need for additional surgery, with a trend toward increased odds of complications on multivariate analysis. These findings underscore the importance of patient selection and preoperative counseling regarding complication risk when choosing between reconstructive modalities.

Purpose: Allergic rhinitis (AR) is common among patients seeking rhinoplasty and may contribute to persistent mucosal inflammation that affects postoperative healing and symptom burden. This study aimed to evaluate the impact of preoperative AR on postoperative outcomes following primary rhinoplasty. We sought to determine whether patients with AR experience higher rates of complications, symptom-related encounters, and healthcare utilization compared with patients without AR.

Methods: A retrospective, propensity score–matched cohort study was conducted using the TriNetX federated research network. Patients who underwent primary rhinoplasty were identified and stratified by preoperative AR status. Cohorts were matched 1:1 based on demographic and clinical characteristics. Postoperative outcomes were assessed from day 1 through 365 days, with 30-day surgical site infection (SSI) analyzed separately. Outcomes of interest included persistent nasal congestion, additional nasal endoscopy, nasal valve collapse, epistaxis, hematoma/seroma, wound disruption/dehiscence, anosmia, and secondary rhinoplasty.

Results: After matching, 4,103 patients were included in each cohort. Compared with patients without AR, those with AR had significantly higher rates of persistent nasal congestion (14.8% vs 5.4%; RR 2.75) and additional nasal endoscopy (17.3% vs 7.0%; RR 2.47). AR was also associated with increased nasal valve collapse (11.1% vs 6.1%; RR 1.84) and epistaxis (3.3% vs 1.2%; RR 2.81). Thirty-day SSI occurred more frequently in the AR cohort (9.4% vs 5.9%; RR 1.59). Secondary rhinoplasty was less common among patients with AR (0.6% vs 1.3%; RR 0.43). Hematoma/seroma event counts were below reporting thresholds. Overall, AR was associated with greater postoperative symptom burden and increased healthcare utilization.

Conclusions: Preoperative allergic rhinitis is associated with higher rates of postoperative symptom-related complications and increased healthcare encounters following primary rhinoplasty, including an elevated risk of early SSI. These findings underscore the importance of optimizing AR management prior to surgery and incorporating AR status into preoperative counseling and risk stratification.

Purpose: Neurodevelopmental outcomes following surgery for nonsyndromic craniosynostosis remain a subject of debate. Prior studies are limited by small sample sizes and difficulty isolating the independent effect of surgical timing from sociodemographic and medical confounders. This study evaluated the association between age at surgery and long-term neurodevelopmental outcomes while adjusting for these factors using a large national cohort.

Methods: A retrospective cohort study including patients with single suture nonsyndromic craniosynostosis was performed using the Epic Cosmos database. Patients with multisuture, syndromic, genetic, or major neurologic comorbidities were excluded. Neurodevelopmental outcomes were identified using ICD-10 codes across eight domains. Surgical timing using cranial vault remodeling was categorized as 0–6 months, 6–12 months, and >12 months. Multivariable logistic regression adjusted for suture type, sex, pediatric comorbidity index (PCI), neighborhood-level social vulnerability index (SVI), and follow up duration.

Results: A total of 2,370 children met inclusion criteria. After adjustment, relative to 0-6 months, cranial vault remodeling surgery at 6–12 months was independently associated with increased odds of language (aOR 1.36), conduct (aOR 2.23), and scholastic disorders (aOR 5.69) (all p < 0.05). Surgery after 12 months was associated with higher odds of language (aOR 1.55), motor (aOR 1.56), conduct (aOR 2.13), autism spectrum (aOR 1.83), and scholastic disorders (aOR 4.07). Metopic synostosis independently predicted ADHD (aOR 1.86). Male sex, higher PCI, greater SVI, and longer follow-up were also associated with increased neurodevelopmental diagnoses.

Conclusions: Cranial vault remodeling surgery performed after six months was correlated with greater neurodevelopmental burden across multiple domains even after accounting for sociodemographic vulnerability and medical comorbidity.

Purpose Postoperative infection following rhinoplasty occurs in 0.19% to 3.63% of cases. Established risk factors include revision surgery, female sex, autologous costal cartilage use, and septal perforation repair (8.57% infection rate). However, the potential contribution of intraoperative mucosal violation has not been systematically evaluated. This study synthesizes existing evidence on mucosal integrity in rhinoplasty and proposes a mechanistic framework linking mucosal disruption to postoperative infection.

Methods/Experience A structured narrative review was performed integrating literature on rhinoplasty surgical techniques, reported rates and risk factors for postoperative infection, sinonasal microbiome biology, and mucosal barrier function. Evidence from otolaryngology, reconstructive surgery, and surgical infection research was examined to evaluate the biologic consequences of mucosal disruption. Findings were synthesized to develop a conceptual model describing potential pathways by which intraoperative mucosal violation may influence surgical site infection risk.

Results Four integrated mucosal barrier systems maintain host defense: structural epithelial integrity maintained by tight junction proteins (occludin, claudin, tricellulin); chemical defense (antimicrobial peptides, secretory IgA, and mucus glycoproteins); immune signaling mediated by pattern-recognition receptors (TLR2, TLR3, TLR7, TLR9); and microbiological stability via commensal homeostasis. We propose that mucosal disruption during rhinoplasty initiates multiple pathophysiologic processes that increase susceptibility to infection. (1) Barrier breach increases epithelial permeability, permitting bacterial translocation from the nasal lumen into submucosal tissue planes, particularly Staphylococcus aureus. (2) Tissue manipulation rapidly reduces antimicrobial peptide expression, facilitating bacterial overgrowth and systemic dissemination. (3) Translocated organisms may adhere to grafts or implants in devascularized planes, forming biofilms resistant to host immune responses and systemic antibiotics. (4) Surgical trauma impairs mucociliary clearance by disrupting ciliary function and mucus production, reducing mechanical pathogen elimination. Mucosal injury also triggers pro-inflammatory cytokine release (IL-1α, IL-1β, IL-6, GM-CSF) and slows local antimicrobial defense, producing an immunologically permissive environment. Tissue plane separation further creates poorly vascularized dead space that limits immune access and antibiotic penetration. Operative rhinoplasty techniques vary in the degree to which they disrupt mucosal integrity. Common maneuvers, including septoplasty and internal osteotomies, frequently violate the sinonasal mucosal barrier, whereas extramucosal approaches are specifically designed to preserve epithelial continuity. These differences place mucosal disruption along a procedural spectrum. Yet, no studies have stratified postoperative infection outcomes according to the degree of mucosal violation. Clinical observations at the higher end of this disruption spectrum provide indirect support for the proposed pathway. Procedures inherently involving extensive mucosal injury, such as septal perforation repair, demonstrate substantially higher infection rates (8.57%) compared with standard rhinoplasty (0.19-0.84%), consistent with the biological consequences of large-scale barrier disruption.

Conclusions Intraoperative mucosal violation represents a plausible but under-recognized technical variable influencing postoperative infection risk in rhinoplasty. Mechanisms include bacterial translocation, biofilm formation, impaired mucociliary clearance, immune dysregulation, and dead space formation. Preservation of mucosal barrier integrity may therefore represent a modifiable surgical risk factor. Prospective studies incorporating standardized assessment of mucosal injury are warranted to determine whether mucosal preservation strategies reduce infection risk and improve postoperative outcomes.

Purpose: Cranioplasty for very large calvarial defects in the pediatric population remains a significant reconstructive challenge. Limited autologous bone availability and ongoing cranial growth further complicate surgical decision-making. Although exchange cranioplasty and split calvarial bone grafting are established strategies, stable reconstruction may be difficult after prior graft failure or in the setting of scarred dura, where resorption risk is increased. Alloplastic implants such as polyetheretherketone (PEEK) restore contour but do not grow with the child and carry risks of infection, exposure, and revision. We describe a rescue cranioplasty technique utilizing a composite graft of demineralized bone matrix (DBX), bone morphogenetic protein (BMP), and bone chips stabilized with resorbable mesh in a pediatric patient with a recurrent cranial defect after multiple reconstructive failures.

Methods: A 7-year-old male with severe traumatic brain injury requiring decompressive left hemicraniectomy and ventriculoperitoneal shunt placement underwent multiple reconstructive attempts for a large left-sided cranial defect. Prior interventions included autologous bone flap cranioplasty, Medpor implants, and PEEK implantation, all complicated by infection or fixation failure. Subsequent total cranial vault reconstruction with split calvarial bone graft demonstrated significant resorption and recurrent defects on follow-up imaging. Rib grafting was limited by chest circumference (55 cm), and further calvarial harvest was not feasible. Given multiple prior failures, additional prosthetic reconstruction was also deemed nonviable. A salvage strategy was therefore elected using a composite DBX/BMP/bone chip graft, selected based on prior institutional success in alveolar cleft reconstruction. Defect margins were debrided to healthy bleeding bone, and the composite graft was applied to areas of residual defect and stabilized with a 0.25-mm resorbable mesh overlay.

Results: CT imaging on postoperative day two demonstrated complete coverage of the bony defect with graft material. The postoperative course was uncomplicated, with no evidence of infection, wound breakdown, or neurologic decline. At 6-month follow-up, CT imaging demonstrated substantial re-ossification with approximately 80% incorporation of the graft material. Although complete ossification was not achieved, there was significant improvement in defect coverage and restoration of calvarial contour. Clinical examination revealed no palpable soft tissue defect or bony instability. The patient reported no pain or functional complaints, and no new neurologic deficits were identified.

Conclusions: Composite grafting with DBX, BMP, and bone chips may represent a viable salvage strategy in complex pediatric cranioplasty when autologous options are limited and prior prosthetic reconstruction has failed. Despite the presence of scarred dura, substantial defect coverage and stable reconstruction were achieved without graft-related complications.

Background: Facio-auriculo-vertebral spectrum (FAV) is characterized by craniofacial malformations with variable extracranial involvement, including vertebral anomalies reported in 24-60% of patients.(1-3) Despite this prevalence, no standardized spinal imaging guidelines exist. For plastic surgeons managing longitudinal care, understanding the clinical impact of spinal imaging is essential. Methods: We retrospectively reviewed patients with FAV evaluated by a multidisciplinary Craniofacial or Genetics Dysmorphology clinic at a tertiary children's hospital between September 1999 and October 2025. Demographics, clinical findings, imaging history, and orthopedic interventions were collected. Vertebral anomaly detection rates were compared between screening and physical examination-driven imaging using chi-square analysis. Results: 202 patients met inclusion criteria. Median age at presentation was 209 days (IQR 68-729) with median follow-up of 6.7 years (IQR 1.9-12.0). 73 patients (36%) received spine imaging; detailed records were unavailable for 5 patients. Initial spine imaging occurred at a median age of 385 days (IQR 32-2269), most commonly with radiography (n=58), followed by MRI (n=5) and ultrasound (n=4). Indications included abnormal physical examination (n=36), screening after FAV diagnosis (n=18), incidental findings (n=11), and other clinical sequelae (n=3). Vertebral anomalies were identified in 36% of examination-driven studies versus 28% of screening studies (p=0.54). 11 anomalies were detected incidentally (10 chest radiographs, 1 CT facial bone). 35 patients (17%) had vertebral anomalies. Of these, 18 (51%) developed scoliosis; 3 required active intervention (2 surgery, 1 bracing) and 9 were observed. Among 17 patients without scoliosis, 3 had Klippel-Feil syndrome and were advised activity restrictions. Anomalies most frequently involved the thoracic (51%) and cervical (46%) regions, followed by cervicothoracic (11%), lumbar (6%), thoracolumbar (3%), and sacral (3%) (not mutually exclusive). Failures of segmentation were present in 71% (n=25) and failures of formation in 60% (n=21). Conclusions: Vertebral anomalies were present in 17% of this FAV cohort, with 36% detected on examination-driven imaging and 28% on screening imaging. Detection rates did not differ significantly, suggesting physical examination alone may miss clinically relevant anomalies. Although the prevalence of vertebral anomalies was lower in our cohort compared to published data, the relatively high prevalence in patients with a normal spine exam suggests screening all FAV patients for vertebral abnormalities may be warranted. Most vertebral anomalies did not require intervention, however their identification has important implications for scoliosis surveillance, activity counseling, and operative planning; patients should be referred to orthopedics if vertebral anomalies are identified. Further research is needed to inform evidence-based imaging guidelines in FAV that balance detection with clinical utility.

References: 1. Renkema RW, Caron CJJM, Wolvius EB, et al. Vertebral anomalies in craniofacial microsomia: a retrospective analysis of 991 patients. Int J Oral Maxillofac Surg. 2018;47(11):1365-1372. doi:10.1016/j.ijom.2018.05.016 2. Barisic I, Odak L, Loane M, et al. Prevalence, prenatal diagnosis and clinical features of oculo-auriculo-vertebral spectrum: a registry-based study in Europe. Eur J Hum Genet. 2014;22(8):1026-1033. doi:10.1038/ejhg.2013.287 3. Park J, Yang IH, Choi JY, et al. Distribution and Phenotype of Goldenhar Syndrome and Its Association With Other Anomalies. J Craniofac Surg. 2023 Oct 1;34(7):e664-e669. doi: 10.1097/SCS.0000000000009529. Epub 2023 Jul 7. PMID: 37417749.

Background: While acute alcohol intoxication is a well-established catalyst for traumatic injury, the influence of chronic alcohol use disorder (AUD) on operative outcomes in craniofacial trauma remains underexplored. The present study aimed to evaluate whether AUD independently affects surgical management, postoperative morbidity, and continuity of care following facial fracture repair.

Materials and Methods: A retrospective multicenter cohort study was conducted of patients undergoing operative repair of craniofacial fractures at four urban trauma centers between 2019 and 2025. Alcohol exposure was assessed in two contexts: 1) acute alcohol use, defined by documentation of acute intoxication or blood alcohol concentration (BAC) > 0.08% obtained during the index emergency department encounter; and 2) chronic alcohol use, defined by a documented diagnosis of alcohol use disorder (AUD). Demographics, comorbidities, mechanism of injury (MOI), fracture location and severity, and hospital course information were collected. Outcomes included length of stay (LOS), time to intervention (TTI), outpatient vs inpatient repair, postoperative complications, reoperations, and follow-up. Univariate comparisons were performed using chi-square and nonparametric tests (p < 0.05). Multivariable logistic regression was used to examine associations with binary outcomes, and generalized linear models with a gamma distribution and log link were used for continuous outcomes, adjusting for demographic and clinical covariates.

Results: AUD was present in 11.5% (n=59) of 515 patients who underwent operative repair of craniofacial fractures during the study period. AUD was associated with male sex (89.8% vs. 73.7%, p=0.025), Medicaid coverage (aOR 6.54 vs. private, p<0.001), and mandible fractures (aOR 2.98, p<0.001). Notably, nearly one-third of all patients (n=32) who developed postoperative complications had AUD, a greater proportion than any other comorbidity examined in this study. In multivariable models, AUD was independently associated with a 69.4% increase in LOS (p=0.004), as well as increased odds of any complication (aOR 4.31; p=0.002), infection (aOR 4.24; p=0.014), and reoperation (aOR 2.55; p=0.039). Patients with AUD were also less likely to undergo outpatient repair (aOR 0.26; p=0.003) and had significantly reduced odds of follow-up (aOR 0.33; p<0.001).

In contrast, acute alcohol use––also associated with male sex (86.0% vs. 73.5%, p=0.038), Medicaid coverage (aOR 1.60 vs private insurance, p=0.049), mandible fractures (aOR 2.33, p<0.001), as well as younger age (median: 36.5 vs. 40.5 years, p=0.033)––was not associated with differences in LOS, complications, or reoperation after adjustment for clinical and demographic covariates (all p>0.05). Similar to AUD, however, acute alcohol exposure was associated with 27.5% earlier TTI (p=0.035), decreased likelihood of outpatient repair (aOR 0.38, p=0.003), and shorter follow-up duration (adjusted mean 78 vs 132 days, p=0.002).

Conclusions: AUD is a clinically relevant chronic comorbidity in operative craniofacial trauma, independently associated with increased postoperative morbidity, prolonged hospitalization, and decreased continuity of care following facial fracture repair. These effects were not observed with acute alcohol intoxication, which influenced injury patterns and operative timing but did not independently worsen perioperative outcomes. AUD should therefore be considered a meaningful modifier of perioperative risk in craniofacial trauma, independent of the circumstances surrounding the index injury.

Background: Concurrent bimaxillary osteotomy with genioplasty (triple-jaw surgery) requires extensive facial skeletal manipulation to optimize both function and aesthetics. Historically, these procedures have been performed in the inpatient hospital setting with planned overnight admission. As surgical care increasingly shifts toward outpatient platforms, this study evaluates the safety, feasibility, and early postoperative outcomes of complex multi-jaw orthognathic surgery performed in a freestanding ambulatory surgery center (ASC) with same-day discharge.

Methods: A retrospective review was performed of all consecutive patients who underwent triple-jaw orthognathic surgery with at least two adjunctive procedures by a single surgeon at a freestanding ASC from November 2022 to October 2025. Patients were followed through routine postoperative visits to at least 60 days. A standardized perioperative protocol incorporating multimodal analgesia and selective use of liposomal bupivacaine was employed. Primary outcomes included intraoperative and immediate postoperative safety metrics: airway events, hemorrhage, need for hospital transfer, unplanned admission, or conversion to inpatient care. Secondary outcomes included postoperative nausea and vomiting (PONV), surgical site infection, hardware failure, emergency department (ED) utilization, and reoperation. Outcomes were compared with published inpatient reference cohorts.

Results: A total of 177 patients were included (mean age 29.5 years). Mean operative time was 200 minutes, and 82.7% of patients received liposomal bupivacaine. Mean post-anesthesia recovery time was 123 minutes. Common adjunctive procedures included autologous fat grafting, bone grafting, submental liposuction, dental extractions, and placement of bone implants. No patients required hospital transfer, unplanned admission, or conversion to inpatient care. There were no intraoperative airway complications or clinically significant hemorrhagic events. The rate of postoperative vomiting was 1.1%, compared with 28.4% in a published inpatient cohort. The surgical site infection rate was 1.1%, compared with 14.6% in prior inpatient series. There were no cases of hardware failure, airway compromise, return to the operating room, or mortality. ED utilization was low and did not result in readmission.

Conclusions: Complex multi-jaw orthognathic surgery with multiple adjunctive procedures can be performed safely and efficiently in a freestanding ASC with same-day discharge. Low complication rates, minimal PONV, and absence of unplanned admissions support the feasibility of outpatient management for appropriately selected patients. ASC orthognathic surgery offers a promising alternative to conventional inpatient hospital-based care.

Purpose: Presurgical infant orthopedics (PSIO) is utilized to reposition and approximate the cleft nasolabial structures in infants with cleft lip to facilitate surgical repair. NasoAlveolar Molding (NAM) is a widely used form of PSIO associated with favorable long-term outcomes, albeit with a significant burden of care. Presurgical Lip, Alveolus, and Nose Approximation (PLANA) is a novel form of PSIO that has exhibited early favorable morphologic outcomes with a lower burden of care. However, its efficacy has not been assessed from the perspective of the cleft surgeon. This study compared surgeon ratings of PSIO outcomes in infants with unilateral cleft lip treated with PLANA and NAM.

Methods: Ten consecutive patients with severe complete unilateral cleft lip treated with each form of PSIO at the study institution were selected. Two expert cleft surgeons uninvolved in any of the patients' care blindly rated outcomes for all patients using standardized pre- and post-PSIO photographs from a frontal and basilar view. The two surgeons independently evaluated improvement in lip approximation, lateral displacement of the subnasale from the midsagittal plane, nasal deviation, alar base width symmetry, alar base height symmetry, columellar angle, columellar length, nostril width symmetry, nostril height symmetry, nasal tip projection, and overall result. Outcomes were evaluated using a 4-point Likert scale, with 1 indicating a poor result, 2 a good result, 3 a very good result, and 4 an excellent result. A mean score for each parameter in each cohort was calculated (mean ± standard deviation), and independent samples t-tests were used, with statistical significance defined as p < 0.05.

Results: Patients in the PLANA group received significantly superior scores for overall result (3.65 ± 0.75 vs. 2.90 ± 1.17, p = 0.02), alar base width symmetry (3.45 ± 0.76 vs. 2.35 ± 0.99, p < 0.001), alar base height symmetry (3.40 ± 0.82 vs. 2.55 ± 1.23, p = 0.02), columellar angle (3.70 ± 0.47 vs. 3.10 ± 1.21, p = 0.05), and nostril width symmetry (3.65 ± 0.75 vs. 2.20 ± 1.11, p = 0.001). Scores were statistically similar for lip approximation (3.60 ± 0.68 vs. 3.15 ± 1.09, p = 0.13), lateral displacement of the subnasale (3.25 ± 0.97 vs. 3.10 ± 1.17, p = 0.66), nasal deviation (3.35 ± 0.81 vs. 3.15 ± 1.18, p = 0.54), columellar length (3.45 ± 0.76 vs. 2.95 ± 1.19, p = 0.12), nostril height symmetry (3.50 ± 0.69 vs. 3.00 ± 1.17, p = 0.11), and nasal tip projection (3.60 ± 0.68 vs. 3.10 ± 1.17, p = 0.11).

Conclusions: Surgeons rated improvement in nasolabial morphology among patients with a unilateral cleft lip treated with PLANA as similar or superior to the outcomes observed in patients treated with NAM. These findings can inform surgeons, orthodontists, and craniofacial care teams when selecting a form of PSIO in preparation for infant cleft lip repair.

Introduction: Frontal sinus fractures are complex injuries despite accounting for a small subset of facial trauma. Traditional management algorithms favored surgical intervention, especially for posterior table involvement. However, contemporary practice has shifted toward more conservative approaches. This study evaluated institutional adherence to current management algorithms for frontal sinus fractures and assessed the association between management strategy and clinical outcomes.

Methods: This was a retrospective review of patients ≥16 years who presented with frontal sinus fractures to a Level 1 trauma center from January 1, 2020, to January 1, 2025. Patients were identified from the trauma registry using ICD-9 diagnosis codes 801-804 and ICD-10 diagnosis codes SO2.1-SO2.8XX and confirmed by radiographic review. Demographics, injury characteristics, management strategy, hospital admission details, and follow-up data were collected. Concordance with a contemporary management algorithm was assessed, and predictors of major complications were evaluated using Firth penalized logistic regression.

Results: Among 257 patients who met the inclusion criteria, 229 (89.1%) underwent nonoperative management (NOP), and 28 (10.9%) underwent operative management (OP). Demographics were comparable between groups, with a median age at injury of 38.3 years (IQR 28.5-56.6). Combined anterior and posterior table fractures were the most common fracture pattern in both groups (57.0% in NOP vs 82.1% in OP, p=0.043), followed by isolated anterior table fractures (30.3% vs 14.3%). Nonoperative management was associated with shorter hospital stays (5.0 vs 11.0 days, p<0.001) and ICU stays (5.0 vs 8.0 days, p=0.019). Overall discordance from the current algorithm occurred in 63.5% of cases. Notably, 95.6% of deviations reflected fractures classified as operative that were managed nonoperatively, particularly posterior table fractures. Across the cohort, CSF leak was the most common major complication (2.9%), and there were no significant differences in complications (e.g., CSF leak, sinusitis) between groups. Most complications (53.1%) were managed nonoperatively, and 9 cases underwent reoperation for frontal sinus sequelae. On multivariable regression, NOP was not associated with increased odds of major complications compared to OP (OR 1.94; 95% CI 0.57–5.82; p=0.27 for OP vs NOP).

Conclusion: At our institution, management of frontal sinus fractures frequently deviates from established algorithms in favor of more conservative strategies. Nonoperative management was not associated with increased major complications, and more than half of the complications were successfully managed without surgery. Together, these findings support a continued shift toward selective, conservative management and may inform refinement of contemporary algorithms for frontal sinus fractures.

Introduction The Le Fort I osteotomy presents unique perioperative airway challenges due to procedure-induced anatomical alterations, significant mucosal edema, and hemorrhage. While Enhanced Recovery After Surgery (ERAS) pathways are increasingly ubiquitous, standardized anesthetic and emergence protocols tailored specifically to midface orthognathic surgery remain limited. This study evaluates the clinical impact of a novel, standardized anesthetic protocol and routine tranexamic acid (TXA) administration on perioperative outcomes in Le Fort I osteotomy.

Methods We conducted an IRB approved retrospective study of 177 patients who had undergone Lefort I osteotomy at a single tertiary center between February 2019 and June 2025. Collected variables included patient demographics and comorbidities; surgical and anesthesia duration; anesthetic factors such as perioperative analgesic use, tranexamic acid (TXA) administration, and emergence protocols; and intraoperative mean arterial pressure (MAP), heart rate (HR), and postoperative pain scores. Bivariate analyses were performed using Pearson's chi-square tests for categorical variables and independent Student's t-tests for continuous variables.

Results The standardized emergence protocol was implemented in 13% (n=22) of the cohort, while 83% (n=142) received intraoperative TXA. Patients managed with the standardized anesthetic protocol demonstrated significantly lower MAP on awakening (72.2±15.91 vs. 87.55±17.70; p<0.001), as well as reduced median pain scores (2.86±1.88 vs. 4.76±2.18; p<0.001). Independent of the anesthetic protocol, TXA administration was associated with a significantly lower MAP on awakening (83.61±17.87 vs. 94.38±17.39 mmHg; p<0.001), lower mean postoperative pain scores (4.29±2.23 vs. 5.28±2.06; p=0.015), and a significantly accelerated time to extubation (18.75±19.69 vs. 23.55±14.82 minutes; p=0.004).

Conclusion In this cohort, a procedure-specific anesthetic emergence protocol was associated with improved hemodynamic stability and reduced postoperative pain following Le Fort I osteotomy. Additionally, routine intraoperative TXA administration appeared to facilitate more rapid extubation. These preliminary findings suggest that targeted anesthetic strategies may help overcome the unique airway challenges of midface orthognathic surgery. Incorporating these protocols into existing ERAS pathways represents a promising approach to optimize early recovery, though broader prospective validation is required.

Introduction: Charitable surgical campaigns have expanded access to cleft lip and palate (CLP) repair in Peru. While the clinical outcomes of such programs are increasingly described, the lived experiences of caregivers remain less well understood. This study aims to characterize the emotional, social, and logistical impacts of cleft surgery from the caregiver perspective.

Methods: A cross-sectional survey of 100 caregivers was conducted in March to May 2025. In addition to quantitative items, the survey included open-ended questions on emotional responses, logistical challenges, and perceptions of surgical programs. Responses were analyzed thematically using inductive coding.

Results: Five major themes emerged. First, emotional distress at diagnosis was widely reported, including shock, sadness, stigma, and in some cases depressive symptoms. Second, fear of surgery and hospitalization was common, with anxiety about anesthesia, complications, and separation from the child. Third, feeding and early care challenges were described, including difficulty with bottle feeding, choking, and poor weight gain. Fourth, economic and logistical strain persisted despite free surgery, with long travel times, multiple appointments, and lost work contributing to stress. Finally, gratitude and perceived transformation dominated caregiver narratives, with many describing surgery as life-changing and programs as a source of hope and dignity.

Conclusion: Caregivers in Peru experience profound emotional and logistical impacts when navigating their child's cleft care. While surgical programs are viewed as transformative, these findings underscore the importance of psychosocial support, culturally sensitive communication, and decentralization to ensure sustainable, family-centered cleft services.