Scientific Abstract Presentations: Craniomaxillofacial Session 4 Friday, October 16 Fri, Oct 16 8:00-9:30 a.m. CDT

Background: Obstructive sleep apnea (OSA) is a common disorder of the upper airway associated with poor sleep quality and significant cardiovascular comorbidities. The anatomy of the oral cavity and dental arches can influence airway patency, and there are concerns within the orthognathic community that extracting premolars for orthodontic treatment may reduce airway size and increase OSA risk. The objective of this study was to compare both oropharyngeal size and Apnea-hypopnea index (AHI) scores by premolar extraction status in OSA patients being evaluated for double jaw surgery. We hypothesized that patients with prior premolar extractions would have smaller airways and thus higher AHI scores, which may have important implications for OSA screening and surgical planning.

Methods: A retrospective cohort study was conducted of patients undergoing orthognathic surgery evaluation with available cone-beam computed tomography (CBCT) and polysomnography. Patients were grouped by premolar extraction history (no extractions, n=52; extractions, n=52). Preoperative airway volume and minimum cross-sectional area (minCSA) were measured on CBCT. AHI scores and prevalence of moderate-to-severe OSA (AHI ≥15) were compared between groups. Multivariable linear regression assessed whether extraction history independently predicted AHI after adjustment for age, body mass index (BMI), and sex.

Results: Patients with a history of premolar extractions demonstrated a significantly smaller mean oropharyngeal airway volume when compared to those without extractions (14.24 ± 6.56 cm3 vs 16.81 ± 6.29 cm3, p= 0.047). While the minCSA followed a similar trend with a smaller mean area in the extractions group compared to the group without extractions, this difference was not statistically significant (140.91 ± 82.99 mm2 vs 152.54 ± 72.33 mm2, p= 0.452). Patients with premolar extractions were older (40.8 ± 11.89 vs 35.9 ± 11.25 years, p=.03) and more often female (69.2% vs 48.1%, p= 0.029), while BMI did not differ significantly between groups. The mean AHI was 20.1 ± 15.5 in patients without premolar extractions and 24.2 ± 15.7 in patients with premolar extractions (p= 0.178). Moderate-to-severe OSA was more common in the extraction group (73.1% vs 55.8%), though this did not reach statistical significance (p= 0.065). In adjusted regression models, premolar extraction history was not an independent predictor of AHI (beta= 3.61, 95% CI -2.48-9.70, p= 0.24), while BMI (beta=.66, 95% CI 0.12-1.19, p= 0.016) and age (beta=.27, 95% CI .01-0.53, p= 0.04) were significant predictors.

Conclusions: In this cohort of orthognathic surgery candidates, premolar extraction history was associated with a trend toward higher OSA severity but did not predict AHI after adjustment for patient factors. These findings suggest that OSA severity in this population is more strongly explained by established clinical predictors such as BMI and age than by premolar extraction history alone. Oropharyngeal airway volume was significantly smaller in the premolar extraction group, suggesting that prior premolar extractions may result in clinically meaningful airway narrowing and should be carefully considered within the craniofacial surgical evaluation. The use of three-dimensional CBCT airway analysis in orthognathic surgery candidates provides objective anatomic data to inform the ongoing clinical discussion about premolar extractions and OSA.

Purpose: To highlight the persistent racial and ethnic disparities in the timing of alveolar bone grafting and to emphasize the need for more equitable surgical planning across diverse patient populations.

Background: The timing of alveolar bone grafting (ABG) remains a debated aspect of cleft care. While it is standard to perform these procedures in the late mixed dentition stage of oral development (around 6-12 years of age), ABG is often performed across a broader age range. Recent literature has shown that racial and ethnic disparities exist in the timing of ABG. This study aims to evaluate how racial and ethnic predictors of ABG timing have evolved over time as a means of assessing the persistence, progression, or regression of these disparities.

Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) pediatric databases for 2012 through 2023 were queried for patients who underwent alveolar bone grafting as defined by common procedural terminology (CPT) code 42210. Age at the time of surgery was used to define ABG timing cohorts as follows: Primary (<2 years), Early Secondary (2-5 years), Late Secondary (6-12 years), and Tertiary (>12 years). Chi-square, Fisher exact test, and 2-tailed t-tests were used to analyze appropriate demographic and perioperative variables. Ordinal logistic regression was used to examine associations between race/ethnicity and ABG timing, and whether these associations changed over time.

Results: 8,923 patients were included in our analysis over the 12-year course of this study. Patients were majority White (5088, 57.0%) and Non-Hispanic (6500, 72.8%). A majority of patients underwent grafting during the Late Secondary stage (7151, 80.1%) followed by the Tertiary stage (1367, 15.3%). Overall, Black/African American (87, 19.6%) and Hispanic (291, 18.2%) children underwent Tertiary alveolar bone grafting at significantly higher frequency than the other racial and ethnic groups. There was no statistically significant change in the relationship between race and surgical timing (p = 0.3362) nor between ethnicity and surgical timing across the years of this study (p = 0.7752).

Conclusions: Black/African American race and Hispanic ethnicity were associated with significantly higher frequency of Tertiary ABG, which has been associated with increased rates of surgical complications when compared to younger cohorts. The disparity in surgical timing between racial and ethnic groups has persisted over the past 12 years. This stable relationship calls into question whether similar patterns exist across hospital systems nationwide and underscores the need for further discussion about implementing timely and equitable cleft care across racial and ethnic groups.

Purpose: The timeliness of cleft surgery often depends on the agency of families in navigating complex health systems. This study examines how key indicators of household empowerment influence global patterns of surgical access.

Methods: A retrospective analysis of Operation Smile program data was performed from 2015 to 2023. Parental literacy and employment were measured in relation to age at primary cleft repair using t-tests and ANOVA.

Results: A total of 19,042 patients across 25 countries were included. Overall, 81.8% of patient households consisted of two illiterate parents, and 92.6% of two unemployed parents. Among these measures of household empowerment, parental literacy was the only consistent predictor of delayed surgery. Illiteracy was associated with delayed lip repair in Colombia, Madagascar, South Africa, Paraguay, and Peru (p<0.05), and with later palate repair in Honduras, Guatemala, and Morocco (p < 0.05). Parental employment status was not predictive of delayed repair, though this likely reflects sample homogeneity.

Conclusion: These findings suggest that informational barriers, rather than purely financial barriers, drive delays in access to cleft repair in this global context. Health system strengthening efforts that prioritize accessible, literacy appropriate community outreach is critical to improving early access and improved surgical outcomes among at risk families.

Background: Craniofacial fractures encompass a spectrum of injuries that vary in location, complexity, and operative management. While mechanism of injury (MOI) anecdotally influences fracture pattern, the quantitative relationship between MOI, fracture location, and surgical resource utilization has not been well characterized. Understanding these associations could improve pre-operative planning, resource allocation, and systematic approaches to craniofacial trauma care. The present study sought to examine whether MOI is independently associated with fracture pattern and whether MOI or fracture pattern predicts surgical resource utilization.

Methods: Patients with craniofacial fractures presenting to a multi-hospital urban trauma system between 2018 and 2024 were retrospectively reviewed. MOI was classified as one of: assault, fall, vehicle/bicycle collision, sports-related, or other/unknown. Fracture location was categorized as one of: mandible, nasal bone, zygomaticomaxillary complex (ZMC), orbital, frontal, or complex/LeFort. Surgical resource utilization was assessed by four outcomes: operative time (minutes), implant use (binary), screw count, and plate count. Two models were constructed: Model 1 used multinomial logistic regression to evaluate the association between MOI and fracture location, with the most common fracture (mandible; n=254) and MOI (assault; n=249) patterns set as reference categories. Model 2 used multivariable regression (linear for operative time, logistic for implant use, negative binomial for hardware counts) to assess MOI and fracture location as predictors of surgical resource utilization. Statistical significance was set at p<0.05.

Results: A total of 508 patients met inclusion criteria for Model 1 and 476 with complete covariate data were included in Model 2. The most common MOI was assault (n=249), and the most prevalent fracture location was mandible (n=254). These were followed by falls (n=101) and ZMC fractures (n=92).

In Model 1, MOI was independently associated with fracture pattern after adjusting for age and sex. Compared to assault, sports-related injuries were strongly associated with both nasal bone fractures (OR 32.4, p<0.001) and complex/LeFort fractures (OR 7.1, p=0.003). Vehicle/bicycle collisions were associated with higher odds of ZMC and complex/LeFort fractures (both p=0.001), while falls were associated with higher odds of nasal bone fractures (p=0.002). Older age independently predicted both orbital (p=0.015) and complex/LeFort (p=0.001) fractures.

In Model 2, fracture location, not MOI, was the dominant predictor of surgical resource utilization after adjusting for age, sex, ASA class, hospital, and surgical service. Compared to mandible fractures, nasal fractures required significantly shorter operative times (57% shorter, p<0.001) and less implant/hardware utilization (all p<0.001), whereas complex/LeFort fractures required greater plate utilization (IRR 1.53, p<0.001). MOI did not independently predict operative time or implant use after adjustment.

Conclusions: MOI is significantly associated with certain craniofacial fracture patterns, with sports injuries demonstrating the highest odds of nasal and complex/LeFort fractures, and vehicle/bicycle collisions with ZMC and complex/LeFort fractures. However, surgical resource utilization is primarily determined by fracture pattern rather than MOI. These findings suggest that while the mechanism of injury helps predict fracture patterns, surgical resource burden is largely driven by the resulting fracture anatomy, with important implications for operative planning and resource allocation within this injury cohort.

Introduction: Posterior pharyngeal flap (PPF) surgery is a standard option for velopharyngeal insufficiency (VPI), yet revisions may lead to adverse outcomes (e.g., hypernasality, hyponasality, apnea/OSA, wound complications). Evidence on the post-revision outcome profile and how these outcomes are managed is fragmented. This study aimed to determine the frequency of poor outcomes after PPF revision and to quantify the frequency and types of subsequent management strategies (e.g., flap takedown or other surgical/non-surgical interventions).

Methods: This is a PRISMA-guided systematic review. A comprehensive search of PubMed, Embase, Scopus, and the Cochrane Library (inception through August 2025) was performed using terms for revision/reoperation, VPI/palatopharyngeal incompetence, and surgical flaps. Reference lists of eligible reviews, meta-analyses, and textbooks were hand-searched. Eligibility (participants, interventions, outcomes, study design) required: secondary PPF (post-cleft palate repair); inclusion of revision or postoperative management for PPF-related complications. Exclusions included non-original articles, mixed procedures without isolated PPF data, lack of post-intervention outcomes, unspecified primary/secondary status, and non-English language. Titles/abstracts and full texts are screened in duplicate in Covidence. Data extracted included study characteristics, patient demographics, operative details, and outcomes. Random-effects meta-analyses were used to calculate pooled revision rates. Sensitivity analyses assessed the influence of heterogeneity, and meta-regression evaluated sources of between-study variability.

Results: A total of 18 studies comprising 2,056 patients with PPF procedures were included. The pooled revision rate was 19.2% (95% CI: 9.4%-35.3%) using a random-effects model. Across reported PPF cases, the most common complication was postoperative obstruction/hyponasality (190 cases; 8.8%), followed by hypernasality (84 cases; 3.9%), dehiscence (19 cases; 0.9%), and bleeding (9 cases; 0.4%). The most frequently performed revision procedures were flap takedown (135 cases, 38.4%), port enlargement (64 cases, 18.2%), and port tightening (11 cases, 3.1%). Meta-regression demonstrated that a higher proportion of patients with any cleft was significantly associated with lower revision rates (β=-1.21, SE=0.55, p=0.029) while higher rates of postoperative obstruction were significantly associated with increased revision rates (β=0.13, SE=0.06, p=0.0315)

Conclusions: PPF patients most commonly undergo revision surgery for symptoms of postoperative obstruction and are managed with flap take down or port enlargement. Patients with clefts were associated with lower revision rates while patients with postoperative obstruction had higher rates.

Purpose Hypertelorism frequently presents with syndromic craniofacial deformities requiring not only orbital medialization but also anterior projection of the midface. Bilateral orbital box osteotomy circumferentially mobilizes the orbital segments as independent units, theoretically enabling multivector repositioning. However, the extent of anterior advancement achievable with box osteotomy has not been quantified.

Methods A retrospective review was performed of patients undergoing bilateral box osteotomy between 2009 and 2025 at a tertiary pediatric center. Three-dimensional reconstructions were generated using Mimics and 3-matic software (Materialise, Ghent, Belgium), and anterior movement of the lateral orbital and infraorbital rims was measured relative to a sella-based coronal reference plane. Postoperative positions were growth-adjusted using proportional change in nasion-to-sella distance. For contextual comparison, facial bipartition cases during the same period were analyzed. Multivariable linear regression was adjusted for age, sex, and prior fronto-orbital advancement in order to compare the anterior movements in both cohorts.

Results Twenty-eight procedures were included (11 box osteotomy, 17 facial bipartition). Box osteotomy achieved significantly greater anterior advancement of the lateral orbital rims (11.1–12.5 mm vs. 1.0–1.8 mm, p≤0.01) and infraorbital rims (6.5–7.7 mm vs. 2.1–2.4 mm, p≤0.036). After adjustment, box osteotomy remained independently associated with greater anterior movement at the lateral orbital and right infraorbital rims (p=0.017).

Conclusions Bilateral orbital box osteotomy enables anterior advancement of the orbital segments in addition to transverse narrowing. Our analysis supports its role as a projection-capable procedure that expands the range of orbital repositioning.

PURPOSE: While it is generally accepted that major cranial sutures fuse through intramembranous ossification, there is little human data to support this claim. This study aims to compare the histology of patent and prematurely fused cranial sutures to elucidate the ossification mechanisms in each.

METHODS: Patent (sagittal n=2, coronal n=4, lambdoid n=2) and prematurely fused (sagittal n=4) cranial sutures were harvested from human infants aged 3-11 months. Samples were sectioned and stained with H&E, Alizarin Red, Safranin O, Pentachrome as well as CD31 and Aggrecan immunofluorescence to assess ossification, vascularization and proteoglycan localization. Bone maturity was assessed using polarized trichome.

RESULTS: Patent sutures displayed osteogenic fronts separated by a dense mesenchymal zone with active intramembranous ossification in the absence of cartilage. Vascular endothelial and Aggrecan+ cells lined the osteogenic fronts with distinct zonality, and bone trabeculation was consistent with patient age. Craniosynostotic sutures displayed disorganized suture mesenchyme with overt chondrocytes and cartilage. Vascular endothelial and Aggrecan+ cells lost their zonality and were present throughout the suture in a disordered fashion. Bone trabeculation was consistent with advanced ossification.

CONCLUSIONS: The results of this study suggest that cells with chondrocyte differentiation potential line the osteogenic fronts of patent human cranial sutures. Dysregulation in sutural vasculature, zonality of osteogenic fronts, and the emergence of chondrocytes suggest a conversion from intramembranous to endochondral ossification not previously described in humans. Furthermore, advanced trabeculation in adjacent bone suggests that craniosynostosis is not simply a disease of the suture but also of the bone itself.

Objectives To evaluate reimbursement variability of craniofacial procedures at locations of major craniofacial centers to uncover underlying patterns in healthcare costs.

Methods A cross sectional analysis of reimbursement variability for five craniofacial CPT codes (40700 - unilateral cleft lip repair, 40701 - bilateral cleft lip repair, 61550 - strip craniectomy, 61559 - open calvarial vault remodeling, and 21182 - fronto-orbital advancement) using the FAIR Health database was performed. Payment data of the 80th percentile of CPT associated procedure cost was queried between 2/1/2026 and 2/20/2026. The zip codes corresponding to hospitals associated with accredited craniofacial surgery fellowships in the United States were queried in respect to each procedure. Price correction (PC) was performed using regional price parity associated with the metropolitan areas. Intraregional procedural reimbursement disparity was calculated as the reimbursement difference between the highest and lowest cost region for a procedure as a percentage of the highest cost region. The institutions were divided into four regions based on the US census database.

Results In total, N = 30 institutions were included in the study. Without PC, all procedures without in network insurance (OON) had the highest average reimbursement in the northeast institutions ($1372 per procedure greater than the 2nd on average). Without PC and with in network insurance(IN), 40700, 61559, and 21182 had on average the highest reimbursement in West region institutions and 40701 and 61550 in the Midwest institutions. With PC and OON, 40700, 61550, and 61559 had on average the highest reimbursement in the Northeast with 40701 and 21182 in the Midwest. With PC and IN, 40700, 40701, and 61550 had on average the highest reimbursement in the Midwest with 61559 and 21182 in the West. Disparity between in network reimbursement versus out of network reimbursement was largest in the South with reimbursement decreased by 46% among the 5 procedures compared to the lowest reimbursement reduction of 26% in the West. Highest intraregion variability was in the Northeast with one institution's costs being almost 2.5x higher compared to the next highest institution in the region when OON. Highest intraregional disparity in procedural reimbursement was 61550, strip craniectomy, with 38.8% for OON and 21182, fronto-orbital advancement for IN, 36.4%.

Conclusion Our analysis revealed significant variability in US craniofacial related procedure reimbursement across different institutions and regions. Key findings included interregional reimbursement disparities with and without price correction, disparities in insurance coverage of costs interregionally, and intraregional reimbursement disparity. These findings underwrite a greater need for standardization of insurance coverage of care and transparency in healthcare reimbursement to ensure the equity of the management of craniofacial patients in the United States. Further research should explore the causes and implications of these inequitable variations for health policy.

Purpose A significant number of head and neck cancer patients present for microvascular reconstruction while taking selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). These have been shown to potentially increase platelet dysfunction, bleeding, and downstream wound complications, though evidence in plastic surgery is limited. Given the microvascular complexity of head and neck free-flap reconstruction, we used a large, multi-institutional electronic health record network to quantify the association between preoperative SSRI/SNRI exposure and early postoperative complications after head and neck reconstruction.

Methods We conducted a retrospective cohort study using the TriNetX Research Network, including adults who underwent head and neck free-flap reconstruction. To ensure anatomic specificity, index cases were required to have same-day head/neck ablative codes and were additionally anchored with head/neck malignancy diagnoses. Preoperative SSRI/SNRI exposure was defined as a record within 90 days of the index procedure; comparators had no SSRI/SNRI record within 6 months. We used 1:1 nearest-neighbor propensity-score matching (logistic regression within TriNetX) with a prespecified balance threshold of standardized mean difference (SMD) <0.1 across covariates: age, race/ethnicity, procedure type, cancer site and treatment, obesity, diabetes, hypertension, tobacco and alcohol use, anemia, coagulopathy, obstructive sleep apnea, chronic kidney disease, and liver disease. Outcomes were analyzed on the TriNetX platform with risk ratios (RRs) and 95% confidence intervals; significance was set at p <0.05. The primary endpoint was a bleeding/hematoma composite (postprocedural hemorrhage/hematoma, hematoma evacuation, or transfusion) assessed at 7, 15, and 30 days. Secondary endpoints were flap complications, surgical-site infection, and wound dehiscence at the same time points.

Results Across 58 health systems, 35,309 patients met inclusion criteria; 4,898 had preoperative SSRI/SNRI exposure and 30,411 served as comparators. After matching, 4,726 exposed and 4,726 unexposed patients achieved covariate balance. At 7 days, exposed patients had higher risk of bleeding/hematoma (15.85% vs 14.35%; RR 1.1; p<0.05) There was also an increased risk of infection (10.67% vs 7.97%; RR 1.34; p<0.0001) and wound dehiscence (7.4% vs 5.45%; RR 1.36; p<0.0002), with no significant difference in flap complications. At 15 days, there was an increased risk of all postoperative complications: bleeding/hematoma (17.9% vs 15.79%; RR 1.13; p<0.006), infection (15.17% vs 13.2%; RR 1.15; p<0.006), wound dehiscence (10.31% vs 8.46%; RR 1.22; p<0.002), and flap complications (4.02% vs 3.24%; RR 1.24; p<0.04). Similarly, by 30 days, the risks were significantly higher for the exposed cohort: bleeding/hematoma (19.3% vs 17.14%; RR 1.12; p<0.008), infection (20.48% vs 18.18%; RR 1.13; p<0.005), wound dehiscence (13.58% vs 11.79%; RR 1.15; p<0.008), and flap complications (5.18% vs 4.3%; RR 1.21; p<0.04).

Conclusions Across a multi-institutional cohort of head and neck free-flap reconstructions, recent SSRI/SNRI exposure was associated with a higher early postoperative complication burden, driven primarily by bleeding-related and wound-healing events. Although absolute risks remained modest, the relative increase has practical implications for preoperative counseling and postoperative monitoring in microsurgical head and neck reconstruction. Prospective studies are warranted to refine risk stratification and evaluate standardized perioperative protocols for patients on serotonergic antidepressants.

Background: Double jaw advancement surgery can be performed to improve airway patency in selected patients. While airway enlargement is expected following advancement, the magnitude, durability, and determinants of postoperative remodeling are poorly defined in current literature. This study evaluated the time course of airway expansion and the effect of skeletal advancement on both acute and durable airway change.

Methods: A retrospective review of 99 patients undergoing double jaw surgery with available preoperative, 1-week postoperative, and later follow-up CBCT were included. Oropharyngeal airway volume and minimum cross-sectional area (minCSA) were measured at each timepoint. Changes were calculated between preoperative and 1-week postoperative measurements and between preoperative and latest follow-up. Linear regression was performed to evaluate the relationship between millimeters of jaw advancement and airway change. Multivariable models assessed predictors of durable airway change.

Results: Airway volume increased from 15.52 ± 6.53 cm3 preoperatively to 21.50 ± 8.73 cm3 at 1 week and remained elevated at 20.26 ± 7.94 cm3 at latest follow-up. Minimum cross-sectional area increased from 146.43 ± 77.68 mm2 preoperatively to 278.98 ± 123.62 mm2 at 1 week and remined elevated at 272.89 ± 122.11 mm2 at follow-up. Increases from preoperative measurements were statistically significant, with no significant change between the 1 week and latest postoperative measurements. Mandibular advancement demonstrated a positive correlation with 1-week airway volume change (r= 0.28, p= 0.01) and 1-week minCSA (r= 0.22, p= 0.03). In adjusted regression models, each 1 mm of mandibular advancement was associated with a 0.55 cm3 increase in airway volume at 1 week (95% CI 0.12-0.97, p= 0.01). For minCSA, each 1 mm of advancement was associated with a 6.54 mm2 increase, though this did not reach statistical significance (p= 0.07). In a regression model assessing durable airway change (preoperative measurements vs latest follow-up), baseline airway volume (r = -0.45, p= 0.001) and female sex (r= -4.33, p= 0.01) were significant predictors of volume increase. Mandibular advancement demonstrated a positive but nonsignificant association with durable volume change (r= 0.24, p= 0.27).

Conclusions: Double jaw advancement surgery results in substantial three-dimensional airway expansion. Most structural change is evident by 1 week postoperatively and remains stable at later follow-up, supporting the durability of surgical airway enlargement. Acute airway gain demonstrates a measurable dose-response relationship with mandibular advancement, whereas longer-term remodeling appears to be more influenced by baseline airway anatomy and patient characteristics than by millimeters advanced alone. These findings provide objective quantification of both the immediate effects of mandibular advancement and the factors that shape further airway changes over time.

Background: Perioperative antibiotic use for cleft lip and palate surgery remains highly variable, with no universally accepted standard beyond limited guidance from the American Cleft Palate Association recommending a single preoperative dose of ampicillin/sulbactam [1]. Common antimicrobials include first-generation cephalosporins, ampicillin/sulbactam, and clindamycin, with their use being highly arbitrary [2,3]. Rising concern for surgical site infection has led to continued prophylactic use to prevent complications including infection, fistula formation and wound dehiscence leading to substantial morbidities postoperatively [4,5]. The objective of this study was to nationally evaluate antibiotic prescribing patterns following cleft palate repair and assess their association with postoperative complications.

Methods: A retrospective cohort study was conducted using the global TriNetX database to identify patients who had undergone primary cleft lip repair, primary palatoplasty, secondary revisions, and associated nasal procedures. Patients were stratified by same-day perioperative antibiotic class, including first-generation cephalosporins (n=8,031), ampicillin-sulbactam (n=1,711), and clindamycin (n=1,383). Antibiotic exposure was limited to administration on the day of surgery. Complications were assessed within 1-90 days. Pairwise comparisons were performed between antibiotic classes for aggregate and individual complication outcomes.

Results: Comparison of overall complication rates across antibiotic classes demonstrated no statistically significant difference between first-generation cephalosporins and ampicillin-sulbactam (p=0.2546), first-generation cephalosporins and clindamycin (p= 0.0839), ampicillin-sulbactam and clindamycin (p= 0.5534). Analyses of wound disruption and acquired lesions or deformities similarly demonstrated no significant differences across antibiotic classes. Other complication subsets were underpowered for statistical comparison.

Discussions/Conclusions: Same-day perioperative administration of first-generation cephalosporins, ampicillin-sulbactam, or clindamycin did not show significant differences within 90-day postoperative complication rates following cleft surgery. These findings suggest that antibiotic class selection may not meaningfully influence short-term complication rates. Prospective studies with standardized antibiotic timing and duration are needed to further refine prophylactic guidelines.

References 1. Sunouchi, T., Fujishiro, J., Oba, K. et al. Impact of prophylactic antibiotic duration on surgical site infection rate in neonatal surgery: a multicenter retrospective observational study. J Perinatol 45, 1443–1449 (2025). https://doi.org/10.1038/s41372-025-02400-3 2. Ebrahimi, P., Parsa, H., Tavassoli, A. et al. Incidence of Surgical-Site Infections Following Oral and Maxillofacial Surgery: A Systematic Review and Meta-Analysis. J. Maxillofac. Oral Surg. (2025). https://doi.org/10.1007/s12663-025-02682-2 3. Piccillo EM, Farsar CJ, Holmes DM. Prophylactic Antibiotics After Cleft Lip and Palate Reconstruction: A Review From a Global Health Perspective. Cureus. 2023 Mar 19;15(3):e36371. doi: 10.7759/cureus.36371. PMID: 37090369; PMCID: PMC10113116. 4. Narayan, Nitisha, et al. "Antibiotic prophylaxis for the prevention of fistulae in cleft palate repair: A quality improvement study." JPRAS open 43 (2025): 377-383. 5. Davies A, Davies A, Main B, Wren Y, Deacon S, Cobb A, McLean N, David D, Chummun S. Association of Perioperative Antibiotics with the Prevention of Postoperative Fistula after Cleft Palate Repair. Plast Reconstr Surg Glob Open. 2024 Feb 6;12(2):e5589. doi: 10.1097/GOX.0000000000005589.

Introduction: Extearna®, identified as costal cartilage allograft specifically designed for total ear reconstruction, has emerged as a promising alternative to traditional autologous microtia reconstruction [1]. Characterization of the biomechanical and histologic properties of Extearna® versus pediatric and adolescent costal cartilage is important for translational integration. This study aims to identify the biomechanical and histological properties of Extearna® and compare them with those of autologous costal cartilage.

Methods: Twelve Extearna® and six pediatric/adolescent autologous costal cartilage (ACC) samples were obtained from patients undergoing microtia reconstruction. Samples were fixed for histology analysis and preserved for biomechanical testing. The tissues were subjected to immunohistochemistry (IHC) for collagen 2 (COL2) evaluation and stained with Safranin O (SO) and Masson's Trichrome (MT). Standardized imaging protocols were used, and images were quantified and analyzed using ImageJ. A Student's t-test was used to evaluate differences between Extearna® and ACC. Additionally, qualitative analyses were conducted to evaluate overall collagen, glycosoaminoglycan, and proteoglycan content in both Extearna® and ACC. Seven Extearna® samples underwent biomechanical testing. Mechanical property assessments included tensile values (Young's modulus, ultimate tensile strength, strain at failure, resilience, toughness) and compressive values (ultimate compressive strength). These parameters were compared with published normative biomechanical values of matched ACC.

Results: Histologically, the overall collagen fiber intensity was significantly lower in the Extearna® group (2.38 vs. 3.83, p<0.01). The proteoglycan content of the extracellular matrix showed reduced staining intensity in the Extearna® group (2.45 vs. 2.94, p<0.05). The ultimate tensile strength of Extearna® was 4.94 ± 3.16 MPa, comparable to the published normative values of 5.03 MPa [2]. Similarly, Young's modulus of Extearna® was measured at 13.54 ± 9.89 MPa, compared to the literature value of 11.1 ± 5.6 MPa [3]. Strain at failure was 0.72 ± 0.33 mm/mm. Strain-derived resilience and toughness were 1.19 ± 1.05 and 2.10 +/- 1.56 MJ m^-3, respectively. The ultimate compressive strength of Extearna® was 9.14 ± 5.28 MPa, comparable to the published normative values of 8.3 ± 1.0 MPa [4].

Discussion/Conclusion: Our study suggests that Extearna® shows reduced collagen fiber and ECM component levels compared to ACC. However, COL2 levels were similar across the tissues. The reduction in overall collagen fiber is likely a consequence of the tissue preparation process. Despite these differences, Extearna® maintains histologic similarity to ACC with respect to structural markers. Additionally, Extearna® demonstrates biomechanical performance similar to that of ACC in tensile and compressive strength prior to implantation. Future efforts include understanding the long-term clinical outcomes of Extearna® in ear reconstruction.

References: 1. https://www.mtfbiologics.org/our-products/detail/extearna-costal-cartilage-allograft 2. Alkan Z, Yigit O, Acioglu E, Bekem A, Azizli E, Kocak I, Unal A, Buyuk Y. Tensile characteristics of costal and septal cartilages used as graft materials. Arch Facial Plast Surg. 2011 Sep-Oct;13(5):322-6. doi: 10.1001/archfacial.2011.54. PMID: 21931086. 3. Weber M, Rothschild MA, Niehoff A. Anisotropic and age-dependent elastic material behavior of the human costal cartilage. Sci Rep. 2021 Jun 30;11(1):13618. doi: 10.1038/s41598-021-93176-x. PMID: 34193931; PMCID: PMC8245550. 4. Feng J, Hu T, Liu W, Zhang S, Tang Y, Chen R, Jiang X, Wei F. The biomechanical, morphologic, and histochemical properties of the costal cartilages in children with pectus excavatum. J Pediatr Surg. 2001 Dec;36(12):1770-6. doi: 10.1053/jpsu.2001.28820. PMID: 11733904.

Goals/Purpose: Craniofacial surgery has evolved significantly, with modern craniomaxillofacial (CMF) fellowship training increasingly spanning pediatric, adult reconstructive, trauma, orthognathic, gender-affirming, and aesthetic domains. Despite this broadened scope, the job market is commonly perceived as constrained, driven by concern for a mismatch between fellowship training and "pure" pediatric craniofacial academic positions. This study is the largest longitudinal analysis to date of craniofacial-aligned plastic surgery job postings and benchmarks trends against national fellowship match capacity and program director–reported competency domains.

Methods/Technique: (American Council of Educators in Plastic Surgery) ACEPS and (American Society of Plastic Surgeons) ASPS job postings (2007–2024) were extracted, screened to exclude duplicates, non-surgical roles, research fellowships, and non–plastic surgery positions and classified into three tiers: Tier 1 (pediatric/transcranial cleft–craniofacial), Tier 2 (adult or mixed craniofacial reconstruction and related domains), or Tier 3 (all other plastic surgery). Temporal trends were quantified using linear regression, and independent predictors of Tier 1 classification were tested through multivariable logistic regression using practice setting and institutional affiliation variables. Fellowship capacity was summarized using SF Match annual reports (2007–2024). All 35 U.S. craniofacial fellowship program directors completed a binary survey across 13 ASCFS clinical domains and reported training settings.

Results: Among 4,566 unique postings, 170 (3.7%) were Tier 1 and 317 (6.9%) were Tier 2 (combined Tier 1+2: 10.7%); 4,079 (89.3%) were Tier 3. Overall postings increased substantially, driven primarily by Tier 3 growth (33.08 postings/year, p0.001) versus modest Tier 1 growth (1.51 postings/year, p0.001). Critically, craniofacial-aligned opportunities nearly tripled when including Tier 2 roles (487 vs. 170 postings), reframing the market beyond "pure" pediatric positions. Tier 1 postings were strongly associated with children's hospital affiliation (OR 74.33; 95% CI 48.03–115.05; p0.001) and academic setting (OR 2.57; p0.01) and inversely associated with level I trauma centers (OR 0.41; p0.001). Nineteen states had zero Tier 1 postings across the study period. SF Match reported 500 positions offered, 372 filled, and 128 unfilled (median 21 filled/year), indicating stable training output comparable in magnitude to annual craniofacial-aligned postings. All 35 program directors responded, 91.4% reported graduate competency in all three ASCFS core domains, with variable adult/aesthetic endorsement: adult CMF trauma 54.3%, adult cranioplasty 54.3%, facial aesthetics 45.7%. All programs trained in children's hospitals; 57.1% included adult hospital rotations.

Conclusions: The market for pure pediatric/transcranial craniofacial positions is objectively small (3.7% of postings) and geographically concentrated within children's hospital–based academic centers, validating long-standing perceptions of scarcity. However, this narrow focus obscures a broader reality: craniofacial-aligned opportunities nearly triple when Tier 2 hybrid roles are included, and both tiers have expanded over two decades. Fellowship training capacity has remained stable while craniofacial-aligned postings have grown, suggesting improved alignment for graduates prepared to enter hybrid practice. These data support that the craniofacial job market is not as constrained as perceived, but opportunities increasingly favor "prenatal-to-pension" practice models combining pediatric craniofacial care with adult reconstruction, trauma, and aesthetics. Fellowship programs should align training priorities and transparency with this market reality.

Purpose: Consensus guidelines for the surgical treatment of patients with Robin Sequence recommend preoperative respiratory and anatomic assessment to better inform surgical indications. Experts recommend that patients undergoing mandibular distraction osteogenesis (MDO) undergo preoperative evaluation including computed tomography (CT) imaging, airway endoscopy, and polysomnography (PSG). Meanwhile, consensus guidelines recommend that patients undergoing tongue-lip adhesion (TLA) or tracheostomy also receive an airway endoscopy and PSG prior to surgery. However, implementation of these recommendations has not been comprehensively assessed at a populational level. This study examines contemporary practices among surgically managed patients with Robin Sequence in the United States and assesses concordance with expert recommendations.

Methods: The Epic Cosmos dataset was queried to identify all patients diagnosed with Robin Sequence during the first year of life between January 2015 and December 2024. To assess whether surgically treated patients received the appropriate diagnostic studies prior to definitive airway surgery, the first recorded airway surgery (MDO, TLA, or tracheostomy) for each patient was identified, and rates of each diagnostic evaluation (CT, airway endoscopy, and PSG) were calculated for each cohort.

Results: A total of 838 patients with Robin Sequence who underwent airway surgery were identified within the study period, including MDO (639), TLA (223), and tracheostomy (101). The rates of all diagnostic airway evaluations among surgically managed patients did not reflect concordance with expert treatment recommendations. Across patients who underwent MDO, 473 (74.0%) had a preoperative CT. Endoscopic airway evaluation was pursued in less than half of all patients (316; 49.5%), including flexible laryngoscopy (219; 34.3%), rigid laryngoscopy (110, 17.2%), bronchoscopy (126, 19.7%), drug-induced sleep endoscopy (15; 2.3%), and nasopharyngoscopy (8; 1.3%). The rates of preoperative sleep evaluation were similarly low (294; 46.0%), including complete PSG (284; 44.4%) and unattended sleep study (12; 1.9%). Among patients who underwent TLA, 130 (58.3%) had a preoperative airway endoscopy, including flexible laryngoscopy (75; 33.6%), rigid laryngoscopy (65; 29.1%), bronchoscopy (66, 29.6%), drug-induced sleep endoscopy (2; 0.9%), and nasopharyngoscopy (2; 0.9%). In this cohort, a sleep evaluation was documented in only 104 (46.6%) patients, including PSG (103; 46.2%) and unattended sleep study (4; 1.8%). Finally, less than two thirds of all patients who underwent tracheostomy had a preoperative airway endoscopy (63; 62.4%), including flexible laryngoscopy (39; 38.6%), rigid laryngoscopy (37; 36.6%), bronchoscopy (35; 34.7%), drug-induced sleep endoscopy (4; 4.0%), and nasopharyngoscopy (2; 0.0%). In this cohort, 377 (43.7%) had a preoperative sleep study, including complete PSG (354; 42.2%) and unattended sleep study (17; 2.0%).

Conclusions: Contemporary practices in the surgical treatment of Robin Sequence in the United States reflect nonadherence with consensus guidelines. Diagnostic airway evaluation modalities are significantly underutilized, and surgical intervention is frequently pursued without prior comprehensive airway assessment.