Scientific Abstract Presentations: Craniomaxillofacial Session 3 Thursday, October 15 Thu, Oct 15 5:00-6:00 p.m. CDT

Background: Deformational plagiocephaly is a common condition in infancy, with management strategies ranging from conservative interventions such as repositioning, physiotherapy, and massage therapy to cranial remolding orthosis (helmet therapy) in selected patients. Several studies have reported an association between plagiocephaly and developmental delay; however, it remains unclear whether different management approaches are associated with meaningful differences in neurodevelopmental outcomes. Data comparing developmental risk between helmet therapy and conservative management are limited and derived largely from small, single-center studies. To address this gap in evidence, we performed a population-level, multicenter analysis evaluating incident developmental delay among infants with plagiocephaly treated with helmet therapy versus those managed without helmet therapy.

Methods: We conducted a retrospective cohort study using the TriNetX database comprising data from 64 healthcare organizations. Infants aged ≤1 year with a diagnosis of plagiocephaly were identified, reflecting the period during which cranial growth is most rapid, and helmet therapy is considered most effective. Patients with a diagnosis of craniosynostosis were excluded. Two cohorts were defined: (1) infants who received cranial remolding orthosis therapy and (2) infants managed without helmet therapy. Cohorts were balanced using propensity score matching on demographic characteristics. The index date was defined as the initial diagnosis of plagiocephaly for non-helmeted infants and the first helmet therapy encounter for helmeted infants, with outcomes assessed at any time after the index date. The primary outcome was incident developmental delay, defined by ICD-10 codes for delayed milestones and developmental disorders. Patients with documented developmental delay prior to the outcome time window were excluded. Risk-based, time-to-event, and frequency-of-diagnosis analyses were performed.

Results: A total of 35,483 patients with a diagnosis of plagiocephaly were identified (175 helmeted vs 35,30 non-helmeted). After exclusion of patients with prior history of developmental delay and propensity matching, there were 145 patients in the helmeted cohort and 150 in the non-helmeted cohort. Incident developmental delay occurred in 11 helmeted patients (7.6%) and 20 non-helmeted patients (13.3%), with no significant difference in risk between the two cohorts (p=0.11, 95% CI: -12.7 - 1.2%). Kaplan-Meier analysis demonstrated no significant difference in time to first developmental delay diagnosis (log-rank p=0.80; HR: 0.90, 95% CI: 0.42–1.94). Among patients who developed developmental delay, the mean number of recorded developmental delay diagnoses did not differ significantly between groups (2.09 helmeted vs 3.20 non-helmeted; p=0.55).

Conclusions: In this multicenter analysis of infants with plagiocephaly, no statistically significant differences in incident developmental delay were observed between helmeted and non-helmeted patients. These findings suggest that helmet therapy does not provide a developmental benefit compared with conservative management and highlight the importance of cautious interpretation of observational data in this population. When considered alongside existing literature demonstrating equivalent courses in skull shape, as well as the side-effect profile and costs of helmet therapy, these findings suggest that the routine role of helmeting in plagiocephaly management warrants continued evaluation and individualized consideration.

Background: Autologous cranioplasty using a cryopreserved bone flap remains a common reconstructive strategy after decompressive craniectomy because it restores cranial contour with biologic tissue and avoids immediate implant cost. However, long-term durability is limited by complications such as bone flap resorption and infection, which may ultimately require flap removal and secondary alloplastic reconstruction.[1,2] Although postoperative complications after cranioplasty are well described, fewer studies have quantified long-term bone flap survival and the cumulative risk of requiring secondary cranioplasty in a standardized cohort over time. We therefore evaluated the incidence, timing, and clinical predictors of secondary alloplastic cranioplasty after delayed autologous cranioplasty with frozen bone flap replacement.

Methods: After institutional review board approval, we performed a retrospective cohort study of patients who underwent delayed autologous cranioplasty using banked frozen bone at a single institution (2012–2025). Patients with craniectomy performed for craniotomy-related complications (e.g., postoperative abscess) were excluded to maintain a uniform population. The primary outcome was bone flap failure requiring secondary cranioplasty, defined as either clinically significant resorption (functional and/or aesthetic compromise determined by a neurosurgeon or craniofacial surgeon) or flap removal due to postoperative complications. Demographic, clinical, operative, and follow-up data were abstracted from the medical record. Craniectomy defect size was estimated using the validated AC method. Risk factors for resorption-related and infection-related failure were assessed with Cox proportional hazards models; spline modeling was used to evaluate defect size. Kaplan–Meier methods were used to estimate cumulative incidence of secondary cranioplasty over time.

Results: A total of 367 patients were included (mean age 39.2 ± 19.7 years; range 0.3–84.4), with mean follow-up of 2.2 ± 3.2 years after cranioplasty. Secondary cranioplasty was required in 50 patients (13.6%). The leading causes of failure were bone flap resorption (52%) and infection (42%), with resorption typically identified later than infection (mean 822 vs 204 days after index cranioplasty). Patients who failed autologous reconstruction had larger defects on average than those who did not (137.4 ± 30.6 cm² vs 121.4 ± 39.5 cm²). In adjusted analyses, traumatic etiology (HR 2.37, 95% CI 1.07–5.26; p = 0.03) and age <18 years (HR 2.99, 95% CI 1.35–6.62; p = 0.01) were independently associated with resorption-related secondary cranioplasty. Defect size was also associated with increased resorption risk, with risk becoming significant at approximately 95 cm² (HR 2.54, 95% CI 1.04–6.20; p = 0.04). No variable was significantly associated with infection-related secondary cranioplasty. Kaplan–Meier analysis estimated the cumulative incidence of secondary cranioplasty at 37% by 10 years after autologous reconstruction.

Conclusion: Delayed autologous cranioplasty with frozen bone flap replacement was successful in most patients, but a substantial subset ultimately required secondary alloplastic reconstruction, particularly over longer follow-up. Pediatric age, traumatic indication, and larger defect size were associated with increased risk of resorption-related failure. These findings support risk-stratified counselling and suggest that primary alloplastic reconstruction may merit stronger consideration in selected high-risk patients, especially younger individuals and those with traumatic, large calvarial defects.

Citations:

1. Morton RP, Abecassis IJ, Hanson JF, et al. Timing of cranioplasty: a 10.75-year single-center analysis of 754 patients. J Neurosurg. Jun 2018;128(6):1648-1652. doi:10.3171/2016.11.Jns161917

2. Brommeland T, Rydning PN, Pripp AH, Helseth E. Cranioplasty complications and risk factors associated with bone flap resorption. Scand J Trauma Resusc Emerg Med. Oct 6 2015;23:75. doi:10.1186/s13049-015-0155-6

Background. Children with syndromic presentations of cleft palate have demonstrated a significantly increased risk of revision surgery compared to nonsyndromic counterparts.1,2 Previous studies have shown patients with velocardiofacial syndrome (VCFS) to be at greater risk for requiring revisionary surgical management for velopharyngeal insufficiency.1 The purpose of this study was to evaluate the relative risk for all indications of revision surgery among patients with cleft palate and VCFS compared to those with nonsyndromic presentations.

Methods. The TriNetX database was utilized to identify patients who previously underwent palatoplasty for cleft palate (CPT 42200) within the last 20 years across 100 healthcare organizations. Patients were stratified by diagnosis of VCFS (ICD10 Q93.81) and matched by age, race, gender, and presence of cleft lip and palate vs palate alone. Primary outcome was defined as revision surgery inclusive of secondary palatoplasty, palate lengthening, or pharyngoplasty. Kaplan-Meier survival analysis was conducted to assess time to revision following primary palatoplasty.

Results. After propensity score matching, 230 matched patients were identified within both groups and included within this study. Of patients with VCFS, 20.0% required revision surgery compared to 8.3% among those without. On Kaplan-Meier analysis, patients without VCFS demonstrated 19.5% greater freedom from revision surgery compared to those with VCFS (HR 2.086, 95% CI 1.222-3.562, p = 0.006).

Conclusions. At any given age, a patient with VCFS is about twice as likely to need revisionary speech surgery relative to a patient with cleft palate without VCFS. These findings suggest that recognition of heightened risk may benefit surgeons and multidisciplinary cleft teams in longitudinal planning and balancing patient/family expectations for patients with VCFS.

References 1. Jolibois MI, Pekcan A, Tanner A, et al. A Comparison of Speech Outcomes Among Patients With Syndromic Cleft Palate: A 20-year Review. Journal of Craniofacial Surgery. 2025;37(1/2):69-74. doi: 10.1097/SCS.0000000000011591 2. Chernov ES, Taniguchi AN, Nguyen SA, et al. Surgical outcomes and revision rates for velopharyngeal insufficiency (VPI) in syndromic and non-syndromic children: A systematic review and meta-analysis. American Journal of Otolaryngology. 2024;45(4):104341. doi: 10.1016/j.amjoto.2024.104341

Introduction Cleft lip with or without cleft palate (CL/P) requires longitudinal multidisciplinary care and is associated with significant psychosocial and functional challenges for patients and families.1 While prior qualitative studies have characterized caregiver experiences through interviews and surveys,2 less is known about how patients and caregivers use online forums to process cleft care across the lifespan. We aimed to characterize thematic patterns in patient- and caregiver-generated discussions and contextualize these findings with caregiver interviews to inform multidisciplinary cleft care.

Methods Following IRB approval, we conducted a grounded theory–based thematic analysis of posts from r/cleftlip, a publicly accessible Reddit forum dedicated to CL/P. Using the Reddit API, we collected the 500 highest net-voted English-language posts between January 2020 and November 2025. Open coding saturation was achieved after analysis of 122 posts authored by 94 unique users. Posts were analyzed using iterative open, axial, and selective coding. Author type, tone (positive, neutral, negative), and post characteristics were recorded. To contextualize findings, six semi-structured interviews were conducted with caregivers of children receiving care at our multidisciplinary cleft clinic and analyzed descriptively.

Results Six selective themes emerged: (1) Surgical Outcomes and Recovery, (2) Long-Term Outcomes and Secondary Care, (3) Community Support and Advice, (4) Emotional and Psychological Coping, (5) Self-Image and Identity, and (6) External Perception and Relationships.

Posts were predominantly authored by patients (70%). Patient-authored posts focused on long-term management, secondary procedures, psychosocial adjustment, identity development, and social experiences extending into adulthood. Caregiver posts (30%) centered around diagnosis and early surgical milestones, emphasizing perioperative preparation, nasoalveolar molding, wound care, and early recovery.

Post tone varied by theme. Community Support posts were largely positive (73%), while Emotional Coping posts demonstrated a mixed distribution (52% positive, 38% neutral, 10% negative). External Perception and Relationships contained the highest proportion of negative tone (16%), reflecting ongoing social scrutiny and stigma. Self-Image posts were predominantly positive (60%) and illustrated shifts from self-criticism toward acceptance and pride.

In-person caregiver interviews mirrored online findings. Parents reported using social media most heavily at diagnosis and during early surgical repair for emotional support and experiential guidance, while relying on healthcare teams for clinical decision-making. Engagement decreased after early surgical milestones.

Conclusions Online forums reflect evolving informational and psychosocial needs across the cleft care continuum. Caregiver engagement concentrates around diagnosis and early repair, while patient engagement centers on long-term management, identity formation, and social experience. These findings highlight the importance of longitudinal, multidisciplinary cleft care extending beyond perioperative milestones to address identity, stigma, and psychosocial development across the lifespan. Proactive guidance toward reputable online communities may complement standardized clinical education and enhance patient-centered care.

References 1. Lethaus B, Grau E, Kloss-Brandstätter A, Brauer L, Zimmerer R, Bartella AK, Hahnel S, Sander AK. Clinical Follow-Up in Orofacial Clefts-Why Multidisciplinary Care Is the Key. Journal of Clinical Medicine. 2021; 10(4):842. https://doi.org/10.3390/jcm10040842 2. Nelson P, Glenny AM, Kirk S, Caress AL. Parents' experiences of caring for a child with a cleft lip and/or palate: a review of the literature. Child Care Health Dev. 2012;38(1):6-20. doi:10.1111/j.1365-2214.2011.01244.x

Purpose: Mandible fractures are among the most common craniomaxillofacial injuries requiring surgical intervention, and perioperative antibiotic prophylaxis is standard of care. Current guidelines discourage extended pre- or postoperative prophylaxis, yet it remains commonly used in clinical practice. Prior studies have been limited by small sample sizes and a failure to evaluate drug-specific effects. This study leverages a large national administrative cohort to examine the association between prophylactic antibiotic use, timing, drug class, and postoperative adverse events following open reduction and internal fixation (ORIF) of closed mandible fractures.

Methods: Patients undergoing ORIF for closed mandible fractures were identified from a national administrative database and stratified by antibiotic exposure: extended preoperative prophylaxis, extended postoperative prophylaxis, or no documented extended antibiotics beyond standard perioperative prophylaxis. Drug-specific subgroup analyses were performed for cephalosporins, penicillin, clindamycin, ciprofloxacin/metronidazole, and amoxicillin/clavulanate. Primary outcomes included skin and soft tissue infection, osteomyelitis, face abscess, nonunion, debridement, hardware removal, and overall complications. Multivariable logistic regression was performed to control for patient demographics and comorbidities.

Results: A total of 16,110 patients were included; 64.4% received no extended pre- or postoperative antibiotic prophylaxis, 26.2% received extended postoperative prophylaxis, and 9.4% received extended preoperative prophylaxis. In combined analyses, extended postoperative antibiotics were not associated with reduced infectious complications but were associated with increased hardware removal (OR 1.2 [1.1–1.4]; p=0.03). Drug-specific analyses revealed that extended postoperative clindamycin was associated with significantly increased odds of infection (OR 1.8 [1.5–2.2]; p<0.001), osteomyelitis (OR 2.0 [1.6–2.5]; p<0.001), face abscess (OR 2.1 [1.6–2.8]; p<0.001), nonunion (OR 1.6 [1.2–2.2]; p=0.007), and hardware removal (OR 1.3 [1.1–1.6]; p=0.001). Extended postoperative penicillin was similarly associated with higher odds of hardware removal (OR 2.8 [2.0–3.9]; p<0.001) and overall complications (OR 1.9 [1.4–2.6]; p=0.001). In contrast, extended postoperative amoxicillin/clavulanate was associated with reduced infection rates (OR 0.68 [0.53–0.86]; p=0.03).

Conclusions: Extended antibiotic prophylaxis following ORIF of closed mandible fractures was not associated with uniform improvement in postoperative outcomes, with substantial drug-specific variability across antibiotic classes. Postoperative clindamycin and penicillin were associated with worse infectious and healing-related outcomes, while amoxicillin/clavulanate demonstrated protective associations. These findings reinforce current guidelines discouraging routine extended prophylaxis and underscore the importance of antibiotic selection when extended postoperative coverage is clinically indicated.

Introduction

Cleft lip and palate are the most common craniofacial anomalies. After primary repair, patients may consider elective revision procedures to address residual asymmetries. The choice to undergo cleft-related revision procedures is preference sensitive, meaning that proceeding with surgery is based on patient values and goals. To facilitate shared decision-making, a decision aid was previously developed with input from patients and experts. In this study, the decision aid underwent alpha testing as part of the rigorous, evidence-based process for decision aid development.

Methods

After IRB approval, 4 craniofacial surgeons, 7 parents of infants with cleft lip, and 2 children with isolated cleft palate, none of whom were currently facing the decision to undergo a cleft-related revision procedure, were recruited for alpha testing. "Think aloud" interviews were conducted via Microsoft Teams as patients navigated the decision aid website, and content was transcribed for qualitative analysis. All participants completed the Single Item Literacy Screener (SILS), the Decision Aid Acceptability Scale (DAAS), and the System Usability Scale (SUS). Quantitative data was analyzed via descriptive statistics calculated in Microsoft Excel.

Results

During analysis of qualitative data from think aloud interviews, three themes emerged: use affirming and neutral language, improve visual appeal and usability, and clarify realistic expectations. Mean SUS was 85.2 (out of 100, SD 11.0), corresponding with an excellent level of usability. DAAS indicated that 100% of participants found the decision aid useful in decision making. The majority (77%) of participants indicated that the amount of information in the decision aid was appropriate. While 15% felt it skewed toward surgery, 85% indicated that the aid was balanced. Results from the SILS showed most participants selected "Never" (38%) or "Rarely" (31%) needing help reading health materials, while 31% indicated "Often" needing help.

Conclusions

This is the first decision aid developed to assist children with making informed choices about cleft-related revision surgery. In alpha testing, participants overwhelmingly found the tool acceptable and usable. Qualitative feedback from alpha testing will guide revisions, with additional focus on avoiding stigmatizing language, maximizing visual appeal, and clearly communicating what surgery can achieve. These results support the readiness of the decision aid for beta testing and eventual integration into clinical practice as a resource that enhances shared decision-making.

Purpose: Nearly 73,000 people in the United States were diagnosed with head and neck cancer (HNC) in 2025, of which an estimated 17,000 died from this dreadful disease. Radiation therapy is a mainstay of HNC treatment. Although effective at controlling disease, radiation exerts detrimental collateral effects on bone tissue through damage to osteocytes and surrounding vascularity. Patients are then predisposed to debilitating impacts of late pathologic fractures and non-unions, which only heal 20% of the time, limiting further reconstructive options. To mitigate the deleterious effects of radiation on bone, our laboratory has developed an implantable conjugate, Ferroximend, containing hyaluronic acid (HA) and deferoxamine (DFO). DFO promotes neovascularization through iron chelation and activation of the HIF-1α pathway, however, its short half-life limits its therapeutic utility. As such, we coupled DFO to an HA scaffold, a compound with intrinsic osteogenic capacity. This project evaluated the ability of Ferroximend to promote osteogenesis following radiation-induced injury. Our work introduces a translational therapeutic approach with the potential to substantially improve outcomes in clinical non-unions.

Methods and Materials: Experimental groups included 1) a non-irradiated group (Control, n=5), 2) irradiation alone (XRT, n=6), and 3) irradiation + Ferroximend (Ferroximend, n=6). All rats underwent a left mandibular 2.1-mm osteotomy stabilized by external fixation. The non-Control groups received fractionated, 35-Gy human equivalent radiation therapy 2 weeks before surgery, and Ferroximend was injected intraoperatively in the fracture site in the treatment group. After a 40-day recovery period, all mandibles were harvested and subjected to high-resolution µCT imaging. Mineralization metrics were analyzed in Dragonfly 3D to obtain bone mineral density (BMD), callus bone volume fraction (BVF), tissue mineral content (TMC), and bony union rate.

Results: Bony union rates differed significantly among groups (p<0.01): Control - 5/6 (83%); XRT - 0/6 (0%); Ferroximend - 5/5 (100%). For both callus BVF and TMC, the Ferroximend and Control groups were significantly higher compared to the XRT group (p<0.01 and p=0.02, respectively) but not from each other (p=0.1 and p=0.07, respectively). Callus BVF values were 28.8% (Ferroximend), 23.0% (Control), and 12.6 (XRT). TMC (mg) values were 13.8 (Ferroximend), 9.8 (Control), and 5.2 (XRT). The BMD (mg/cc Calcium Hydroxylapatite) of the Ferroximend (633.2) and XRT (602) groups compared to the positive control (501.2) were also significantly increased (p<0.05 and p<0.01, respectively).

Conclusion: Administration of Ferroximend significantly improved irradiated mandibular fracture repair in our murine model, demonstrating 100% bony union compared to 0% in the irradiated, non-treated group. Quantitative µCT analysis revealed that Ferroximend restored bone mineralization metrics to levels statistically indistinguishable from non-irradiated controls, while both parameters were significantly reduced in the XRT group. The improvements in mineralized callus formation and union rate underscore the therapeutic efficacy of Ferroximend. These findings support Ferroximend as a clinically translatable strategy to restore bone repair after XRT injury, addressing a critical unmet need in patients with limited reconstructive options.

Purpose: This study aimed to compare risk factors, complication rates, and perioperative outcomes among pediatric patients undergoing LeFort I osteotomy, mandibular osteotomy, bimaxillary osteotomy (LeFort I + mandibular osteotomy), or LeFort I with distraction osteogenesis.

Methods & Materials: We conducted a retrospective review of the National Surgical Quality Improvement Program Pediatrics (NSQIP-P) database from 2018 to 2023, including patients age 5 years and older who underwent one of the four orthognathic procedures. The primary outcome was the occurrence of complications, defined as at least one unplanned readmission or reoperation. Multivariable logistic regression was used to evaluate the odds of complications by procedure type. Secondary outcomes-total hospital length of stay and operative time-were assessed using multivariable linear regression.

Results: A total of 1,203 patients met inclusion criteria: LeFort I (n=651), bimaxillary osteotomy (n=294), mandibular osteotomy (n=190), and LeFort I with distraction (n=68). Bimaxillary osteotomy was associated with a significantly higher risk of complications compared to both LeFort I (OR=4.84, p<0.01) and mandibular osteotomy (OR=2.10, p=0.03). An ASA classification of 3 or higher was independently linked to increased hospital length of stay (β=6.3, p<0.01) and longer operative times (β=4.3, p<0.01). Additionally, bimaxillary osteotomy was associated with a longer hospital stay compared to LeFort I alone (β=2.2, p=0.03).

Conclusions: Bimaxillary osteotomy was associated with the highest risk of postoperative complications and the longest hospital length of stay amongst pediatric orthognathic procedures. Additionally, higher ASA classification independently predicted longer hospital stays and operative times. These results emphasize the need for careful patient selection, risk stratification, and multidisciplinary planning-especially in patients with complex medical histories or those requiring bimaxillary intervention-to improve safety and optimize outcomes in pediatric orthognathic surgery.

Purpose: Rare craniofacial clefts (Tessier 0–14) present severe soft-tissue deficiency, skeletal hypoplasia, and disruption of facial aesthetic units, often resulting in visible scars and growth-incompatible reconstruction with traditional techniques (1,4). Subperiosteal tissue expansion generates autologous, like-for-like tissue while preserving neurovascular structures and respecting aesthetic-unit boundaries. We present outcomes of four complex pediatric patients demonstrating the safety and versatility of staged subperiosteal expansion.

Methods: A retrospective case series was conducted of four patients aged 15 months to 11 years who underwent staged subperiosteal tissue expansion between January 2017 and December 2024 at a tertiary craniofacial center. Expanders (27–50 cc) were placed subperiosteally through intraoral, retroauricular, or scalp incisions with remote port positioning. Serial outpatient expansions (20–50 mL per session) were performed over 4–24 weeks. Definitive reconstruction utilized expanded local flaps designed along aesthetic-unit junctions. Primary outcomes included adequacy of soft-tissue coverage, scar quality and position, and complications. Secondary outcomes included need for revision and long-term aesthetic stability. Follow-up ranged from 12 months to 6 years.

Results: Mean expansion duration was 12.5 weeks (range, 4–24), with mean expansion volume of 38.5 cc (range, 27–50). No cases of expander exposure, infection, flap necrosis, or neurovascular injury occurred. All patients achieved adequate soft-tissue coverage allowing definitive reconstruction without distant or free-tissue transfer.

A 7-year-old male with bilateral Tessier 4 clefts achieved stable closure and aesthetic contour at 6-year follow-up. A 4-year-old male with right Tessier 4 oro-ocular cleft obtained restoration of eyelid continuity, alar base position, and vermilion alignment without complications. A 5-year-old female with complex Tessier 2-3-11-12 clefts and severe neurologic comorbidities underwent coordinated neurosurgical and craniofacial management with stable soft-tissue reconstruction. An 11-year-old female with Tessier 0-14 cleft and craniofrontonasal dysplasia achieved functional nasal reconstruction with improved projection and airway patency following frontal expansion and structural cartilage grafting. Revisions were limited to planned growth-related refinements. No patient required tissue-patch grafts.

Conclusions: Subperiosteal tissue expansion provides growth-compatible, autologous tissue for rare craniofacial cleft reconstruction while protecting neurovascular structures and maintaining aesthetic-unit integrity (2,3). This technique permits tension-free local flap reconstruction with inconspicuous scars and avoids reliance on distant or free-tissue transfer in pediatric patients. In Tessier 0–14 clefts, where conventional approaches frequently yield suboptimal results, subperiosteal expansion offers durable outcomes with low complication rates and long-term stability.

Van Slyke AC, Burge J, Bos R, Parker G, Chong DK. The anatomical subunit approach to managing Tessier numbers 3 and 4 craniofacial clefts. Plast Reconstr Surg Glob Open. 2022;10(9):e4553.

Ueda K, Shigemura Y, Nuri T, Iwanaga H, Seno T. A case of complex facial clefts treated with staged tissue expansion. Plast Reconstr Surg Glob Open. 2014;2(12):e264.

Menard RM, Moore MH, David DJ. Tissue expansion in the reconstruction of Tessier craniofacial clefts: a series of 17 patients. Plast Reconstr Surg. 1999;103(3):779-786.

Kawamoto HK Jr. The kaleidoscopic world of rare craniofacial clefts: order out of chaos (Tessier classification). Clin Plast Surg. 1976;3(4):529-572.

Moore MH. Rare craniofacial clefts. J Craniofac Surg. 1996;7(6):408-411.

Background Frailty has emerged as an important predictor of postoperative outcomes, particularly in complex head and neck (H&N) reconstruction. The modified frailty index (mFI-5) is a surgical risk stratification tool validated across multiple specialties. The purpose of this study was to examine association between frailty and surgical complexity on postoperative outcomes in patients undergoing head and neck reconstruction.

Methods A retrospective review was conducted for all patients who underwent H&N free flap reconstruction at a single institution from 2016-2024. Each patient's frailty was assessed using the mFI-5 and categorized as not frail (mFI-5 = 0), moderate frailty (mFI-5 = 1), or frail (mFI-5 ≥ 2). Surgical complexity was stratified as soft tissue only, bone only, or both, and by flap type (e.g., fibula free flap, scapular flap). Postoperative outcomes included complication rates (30 days, total, major, minor), RTOR, total hospital and ICU length of stay (LOS). Kruskal-Wallis tests with post-hoc analyses were performed to assess associations.

Results Of the 138 patients included, 47 (34%) were not frail, 47 (34%) were moderate frailty, and 44 (32%) were frail. The majority of patients underwent reconstruction for oncologic indications (61.6%) and received fibula free flaps (43.6%). Flap/recipient site was the most common complication (62.6%). While total LOS trended higher in frail patients (mean = 15.86 days; p = 0.222), ICU LOS significantly increased with frailty (p = 0.021), with means of 4.79, 5.3, and 6.59 days for not frail, moderate, and frail groups, respectively. An increase in average complication burden was observed as frailty increased, though it was not statistically significant. Patients undergoing more complex surgery had longer hospital LOS (p<0.001) and higher complications <30 days (p=0.046). Total hospital LOS was significantly shorter for radial forearm flaps than both anterolateral thigh and scapular flaps (p=0.004; median 8 vs 13.5 and 12 days, respectively). Although ICU LOS differed by flap type on global testing (p=0.04), no pairwise comparisons remained significant following Bonferroni correction.

Conclusion Although frailty was not significantly associated with complication incidence in this cohort, it was associated with increased postoperative resource utilization, as demonstrated by longer ICU LOS. Greater surgical complexity was independently associated with longer hospitalization and increased short-term morbidity. Differences in total LOS across flap types suggest reconstructive choice may also influence peri- and postoperative course. These findings support the use of the mFI-5 as a practical preoperative risk stratification tool and highlight the importance of integrating frailty and operative complexity into surgical planning and patient counseling in H&N reconstruction.