Scientific Abstract Presentations: Craniomaxillofacial Session 5 Friday, October 16 Fri, Oct 16 2:00-3:30 p.m. CDT

Purpose: Surgical repair of craniosynostosis favors earlier, less invasive interventions. However, in the era of increasingly capitated healthcare, a plastic surgery consultation often requires a referral from a primary care provider (PCP). This presents an additional barrier to time-sensitive craniosynostosis interventions. This project examines the impact of insurance type on age at initial surgery, and the clinical impact given the narrow treatment window.

Methods: A retrospective chart review was conducted on patients with nonsyndromic, single-suture craniosynostosis treated at a tertiary children's hospital between January 2009 and December 2024. Insurance types were categorized as PPO (preferred provider organization), HMO (health maintenance organization), TRICARE, and Medicaid. Age at which the patient was referred to Plastic and Reconstructive Surgery (PRS), age at initial surgery, and surgery type were collected. Continuous variables were compared using nonparametric tests. Categorical variables were analyzed using chi-square testing. Multivariable logistic regression assessed odds of open surgery and blood transfusion.

Results: 365 patients were included for analysis: 161 Medicaid, 87 PPO, 76 HMO, and 41 TRICARE. Children with TRICARE had the oldest median age when first referred to PRS at 184 days, compared to 138 days for Medicaid, 84 days for HMO, and 70 days for PPO (p < 0.001). Similarly, children with TRICARE had the oldest median age at initial surgery at 259 days, compared to 233 days for Medicaid, 198 days for HMO, and 166 days for PPO (p < 0.001). A priori comparison of HMO and PPO insurance plans revealed a significant difference between age when referred to PRS (p = 0.011), age at PRS consultation (p = 0.011), and age at initial surgery (p = 0.025). These referral patterns had treatment plan repercussions as only 29.3% of children with TRICARE underwent endoscopic repair, compared to 30.4% of Medicaid patients, 43.4% of HMO patients, and 51.7% of PPO patients; further analysis revealed a significantly higher proportion of Medicaid patients undergoing open procedures than PPO-holders (p < .001). With PPO-holders as a reference, odds of obtaining an open versus endoscopic procedure were 40% higher for HMO (p=.290), 145% higher for Medicaid (p=.001), and 159% higher for TRICARE (p=.019). Odds of the procedure necessitating a blood transfusion were 30% higher for TRICARE (p=.546), 76% higher for HMO (p=.127), and 122% higher for Medicaid (p=.012).

Conclusion: Patients with referral-based insurance providers experience significant delays in care for craniosynostosis compared to PPO-holders, which may result in increased likelihood of open repair and blood transfusion. Timely recognition and referral are essential for children to access appropriate surgical evaluation and intervention. In addition to mitigating inequities in healthcare accessibility, future efforts should target education for craniosynostosis screening by primary care providers to encourage earlier identification so that we can prevent delays, optimize outcomes, and reduce the long-term medical and developmental burdens associated with late diagnosis.

Purpose: Although fibula flaps remain the gold standard for mandibular defect reconstruction, reported complications and flap-failure rates vary widely, reflecting heterogeneity in patient demographics, oncologic burden, radiation exposure, and operative techniques. Existing literature combines data across all facial sites and both oncologic and non-oncologic indications, limiting the applicability of outcomes to mandibular reconstruction. Furthermore, advanced strategies such as computer-assisted planning (CAP) are increasingly adopted to improve precision and workflow efficiency, yet their true impact on complications and flap failure outcomes remains uncertain. To address these gaps, this study performs a systematic review and meta-regression to establish contemporary benchmarks for fibula flap reconstruction in oncologic mandibular defects, identify predictors of complications, and determine whether computer-assisted planning provides measurable clinical benefit.

Methods: PubMed, Embase, and Scopus were searched for studies published from 2015 to 2025 reporting fibula flap reconstruction for benign or malignant mandibular neoplasms. Two reviewers independently screened and extracted demographics, operative variables, quality-of-life outcomes, and flap outcomes. Statistical analysis was performed using a meta-analysis with a random-effects model. Meta-regression was performed for outcomes with high heterogeneity, with age, radiation, and malignancy as covariates.

Results: Sixty studies with 3,008 patients (mean age: 54; females: 36.6%) were included. Etiologies included squamous-cell carcinoma(61.4%), ameloblastoma(23.1%), and sarcoma(3.0%). Single-barrel and double-barrel flaps were used in 67.1% and 32.9% of cases, with 10.4% of patients receiving computer-assisted planning. Studies using the University of Washington QOL Questionnaire reported a mean score of 88.1/100. Compared with conventional techniques, CAP yielded no significant difference in overall complication rate (p>0.99) or flap failure rate (p=0.22). Pooled complication and flap-failure rates were 39.0% ([95% CI=0.29-0.50], I2=95%) and 1% ([0.01-0.03], I2=42%). Complications primarily included infection(4.4%), reoperations(4.4%), cancer recurrence(2.3%), and death(0.9%). Meta-regression showed each additional year of age yielded a 1% increase in complications, accounting for heterogeneity in the meta-analysis ([0.00-0.02], p=0.02, R²=8%). On the contrary, whether patients had a malignancy (p=0.69) or neoadjuvant radiation (p=0.45) was not associated with complication risk.

Conclusion: While free fibula flaps remain the cornerstone of mandibular reconstruction, complication rates remain substantial, underscoring the need to identify independent predictors of adverse outcomes. Notably, CAP did not reduce microvascular complications or flap loss, challenging assumptions that digital planning inherently improves clinical outcomes. Given the increased cost of CAP and prior reports of reductions in operative and ischemia times (1), CAP should be reserved for high-risk patients who would benefit from greater precision and reduced anesthesia time. Although malignancy and radiation have traditionally been linked to poorer outcomes, their lack of association shifts the focus toward frailty markers for complication reduction. As age independently predicted complications, greater emphasis on perioperative optimization and postoperative care is warranted in elderly patients undergoing microsurgical reconstruction. These findings establish benchmarks for fibula flap efficacy, identify predictors of adverse outcomes, and support a value-conscious approach to integrating CAP into reconstructive practice.

(1) Powcharoen W, Yang WF, Yan Li K, Zhu W, Su YX. Computer-Assisted versus Conventional Freehand Mandibular Reconstruction with Fibula Free Flap: A Systematic Review and Meta-Analysis. Plast Reconstr Surg. 2019;144(6):1417-1428. doi:10.1097/PRS.0000000000006261

Background: Managing facial nerve paralysis in patients with malignancy presents unique clinical reconstructive challenges. (1,2) While reanimation within 18 months is the gold standard, this window is often unattainable due to high complication rates (20-50%) and competing oncologic priorities. (3,4) These clinical and logistic burdens frequently delay eligibility for facial reanimation. This systematic review evaluates the literature on facial reanimation following malignancy related facial nerve injury, with a focus on timing, intervention selection, and functional recovery. Methods and Materials A systematic review of studies (2012–present) reporting facial reanimation following oncologic resection was performed, with study quality assessed using the Cochrane Collaboration risk of bias assessment tool and data extracted by two independent investigators. Inclusion required documentation of etiology, duration of paralysis, and postoperative follow-up. Studies were categorized as acute (<18 months) or chronic (≥18 months). (5) Exclusion criteria included review articles, animal/cadaveric studies, and non-English publications. Results: Forty-six studies (612 patients; mean age 47 ± 9.4 years) were analyzed, with 74% focusing on chronic palsy (mean denervation 283.9 ± 362.8 weeks). Primary etiologies included vestibular schwannoma (43.5%), parotid tumors (21.7%), meningiomas (15.2%) and a variety of head and neck cancers (19.6%). Time to functional recovery (16.4 vs. 28.5 weeks; p=0.125) and mean follow-up (96 vs.105 weeks; p=0.54) were comparable between acute and chronic cohorts. Interventions included nerve-based reinnervation (92% in acute cases, 53% in chronic cases) and muscle flaps (8% in acute cases,42% in chronic cases). Among studies reporting objective outcomes (n=55 patients), mean House-Brackmann scores improved significantly from 5.32 to 2.99 (p < 0.001) in chronic denervation patients. Conclusion:  This systematic review strongly suggests that robust facial recovery is attainable following malignancy-related nerve injury even when prolonged denervation is unavoidable due to essential oncologic management. Even in chronic cases, there may be a benefit to both nerve-based and flap-based reconstructions for meaningful functional improvement. Consequently, life-saving cancer treatment should be prioritized without the concern that necessary surgical delays will preclude successful facial reanimation. Citations
1.Freeman SRM, Kannan R, Nduka C. Prevention and rehabilitation of facial palsy in patients with vestibular schwannomas. Handb Clin Neurol. 2025;212:395-405. doi: 10.1016/B978-0-12-824534-7.00039-1. PMID: 41052862.
2.L. Huang, S. Liu, Q. Ye, W. Zhu, H. Lu, W. Yang, W. Xu, Management of facial nerve during parotid recurrent pleomorphic adenoma revision surgery,International Journal of Oral and Maxillofacial Surgery,2026, 3. Alicandri-Ciufelli M, Cantaffa C, Maccarrone F, Lo Manto A, Russo P, Gibertini M, Giordano FS, Amato N, Di Bartolomeo M, Anesi A, Mattioli F, Marchioni D, Presutti L, Molinari G. Influence of parotidectomy extent on complications after benign parotid surgery. J Craniomaxillofac Surg. 2025 Sep;53(9):1379-1384. doi: 10.1016/j.jcms.2025.05.013. Epub 2025 Jun 3. PMID: 40467361. 4.Mahboubi H, Ahmed OH, Yau AY, Ahmed YC, Djalilian HR. Complications of surgery for sporadic vestibular schwannoma. Otolaryngol Head Neck Surg. 2014 Feb;150(2):275-81. doi: 10.1177/0194599813512106. Epub 2013 Nov 7. PMID: 24201062. 5. Pinkiewicz M, Dorobisz K, Zatoński T. A Comprehensive Approach to Facial Reanimation: A Systematic Review. J Clin Med. 2022 May 20;11(10):2890. doi: 10.3390/jcm11102890. PMID: 35629016; PMCID: PMC9143601.

Background: Temporal fat grafting has emerged as an adjunctive technique after craniosynostosis surgery to address temporal hollowing, a common aesthetic deformity following cranial vault remodeling (1,2). Autologous fat is favored for its biocompatibility and ability to restore contour without introducing foreign material (3). This study aims to assess the prevalence of temporal fat grafting following craniosynostosis repair and evaluate outcomes.

Methods: A retrospective review of patients who underwent temporal fat grafting at a tertiary hospital between 2004 and 2024 was conducted. Aesthetic outcomes were scored by three independent reviewers: preoperative temporal hollowing on a 3 point scale (1 = mild, 2 = moderate, 3 = severe) and postoperative improvement on a 5 point scale (0 = none, 1 = mild, 2 = moderate, 3 = significant, 4 = complete). Continuous variables were compared using the t test; categorical variables with the chi square test.

Results: A total of 902 patients were identified to have craniosynostosis, 64 (7.1%) of whom underwent autologous fat grafting. The mean age at the time of fat grafting was 9.7±4.8 years, with males making up 57.8% (n=37) of the cohort. A total of 24 (37.5%) patients had syndromic diagnoses. Preoperative baseline hollowing severity was 2.1±0.8 (moderate). The majority of patients (n = 55, 85.9%) underwent bilateral fat grafting. The mean operative time was 1.7±0.8 hours. The peri-umbilical region was utilized as their donor site in the majority of patients (n=62, 96.9%), while the lateral thigh was used in two (3.2%) patients. The fat graft volumes injected were 10.1±4.7 mL on the left side and 10.1±4.5 mL on the right side. There were no cases of postoperative complications. The mean postoperative improvement was 2.9 ± 0.8. Notably, three patients required postoperative debulking due to excess fat graft. (moderate-to-significant).

Conclusion: Temporal fat grafting was performed in X% of craniosynostosis patients, resulting in clinically improved temporal contour and demonstrating a safe profile without reported complications. Prospective studies are needed to evaluate long-term outcomes and the durability of results into adulthood.

References: 1. Steinbacher DM, Wink J, Bartlett SP. Temporal hollowing following surgical correction of unicoronal synostosis. Plast Reconstr Surg. 2011;128(1):231-240. doi:10.1097/PRS.0b013e318218fcab 2. Masserano B, Woo AS, Skolnick GB, et al. The Temporal Region in Unilateral Coronal Craniosynostosis: Fronto-orbital Advancement Versus Endoscopy-Assisted Strip Craniectomy. Cleft Palate Craniofac J. 2018;55(3):423-429. doi:10.1177/1055665617739000 3. Wang Y, Hou L, Wang M, Xiang F, Zhao X, Qian M. Autologous Fat Grafting for Functional and Aesthetic Improvement in Patients with Head and Neck Cancer: A Systematic Review. Aesthetic Plast Surg. 2023;47(6):2800-2812. doi:10.1007/s00266-023-03331-0

Introduction: Pediatric desmoid tumors (also known as aggressive fibromatosis) of the mandible are rare, locally aggressive, and reconstructively challenging. Management often requires balancing oncologic control, growth considerations, and the morbidity of staged versus definitive reconstruction. We developed a mandible-focused, algorithm-based treatment framework (Pathways A-D) to guide multidisciplinary decision-making and reconstructive escalation based on soft tissue involvement, osseous disease burden, and clinical course.

Methods & Materials: A retrospective review was conducted at a tertiary pediatric craniofacial center. Pediatric head and neck desmoid tumor cases were reviewed and mapped to a mandibular reconstruction algorithm with four primary pathways: soft-tissue predominant disease (Pathway A), osseous involvement with limited bone stock (Pathway B), limited osseous involvement (Pathway C), and advanced osseous destruction requiring major reconstruction (Pathway D), with modifiers for preoperative systemic therapy and delayed reconstruction. Pathways C and D depend on the resection index (RI) threshold at our institution of 32%, which is measured as the tumor length divided by the total mandibular length. This was estimated in our patient cohort using the anatomic landmarks mentioned and preoperative imaging. Clinical course, pathway transitions, operative burden, hospitalization, age at surgery, and follow-up were analyzed descriptively.

Results: Nine pediatric patients with desmoid tumors of the head and neck were identified. One maxillary case was excluded from the mandible-focused algorithm cohort, leaving 8 mandibular/submandibular cases. Of these, 7 underwent surgery, and 1 recently completed systemic therapy and has yet to undergo resection. Initial pathway assignment was A (n=4), B (n=3), C (n=1), D (n=0). During treatment, 4/8 patients (50%) required pathway escalation/change, including A->C (n=1), B->C (n=1), B->D (n=1), and C->D (n=1). For the seven patients who underwent surgery, the median age at index reconstructive surgery was 5.1 years (range: 0.9–11.9 years). Mean cumulative hospitalization time was 25.1±21.8 days, and mean cumulative operative time was 18.4±12.7 hours. The number of operations needed for reconstruction ranged from 1 to 15 per patient (median = 3). For the four patients who required pathway escalation, the mean cumulative operative time was 26.5±10.6 hours, and the median number of operations per patient was 5.

Conclusions: A mandible-specific algorithm provides a practical framework for organizing treatment of pediatric desmoid-type fibromatosis across a spectrum of disease severity and reconstructive needs. In this series, half of the patients required pathway escalation, underscoring the dynamic nature of management and the importance of early multidisciplinary planning. This framework may help standardize decision-making, anticipate operative burden, and support the selection of definitive reconstruction in appropriately selected patients.

Purpose: Early cleft lip repair (ECLR), similar to nasoalveolar molding, exploits neonatal tissue plasticity to shape the nasal cartilage and maxilla. Prior research has demonstrated the safety and efficacy of this approach. This study examines long-term symmetry outcomes in an expanded institutional cohort of 106 ECLR patients.

Methods: This retrospective cohort study included 305 patients with unilateral cleft lip ± palate (UCL/P) undergoing lip repair before three months of age from 2015-2025. Anthropometric measurements were obtained from 2D frontal and basal images using ImageJ for 106 patients who had standardized photos at the following timepoints: preoperatively, within 1 year postoperatively, and within 3-6 years postoperatively. Measurements included medial lip height, lateral lip height, lateral lip length, commissure length, nasal and nostril width. Cleft severity was quantified by cleft width ratio (CWR). Cleft-to-non-cleft ratios were calculated pre- and post-operatively. Ideal symmetry was defined as a cleft to non-cleft ratio of 1. The difference from ideal symmetry was calculated postoperatively between the cleft and non-cleft sides, with values closer to zero indicating a favorable outcome.

Results: The mean CWR in our ECLR cohort was 0.38 (SD 0.20) and patients underwent primary cleft repair at 32.98 (SD 14.83) days of life when corrected for gestational age. On average, preoperative photos were taken 13.4 days prior to cleft lip repair, immediate postoperative photos were taken 6.4 months from the procedure, and long-term photographs were taken at 4.0 years from the operation. In a mixed-effects analysis, overall symmetry deviation scores were significantly lower in immediate and long-term postoperative photos when compared to preoperative photos (immediate postoperative: -0.072, 95% CI -0.127 to -0.017, p = 0.010; long-term postoperative: -0.073, 95% CI -0.128 to -0.019, p = 0.009). Similarly, when analyzing basal images, overall deviation scores were significantly lower in immediate (-0.575, 95% CI -0.647 to -0.503, p < 0.001) and long-term postoperative images (-0.570, 95% CI -0.642 to -0.498, p < 0.001) compared with preoperative photos. There were no significant differences between immediate and long-term postoperative symmetry deviation scores for either frontal (p = 0.965) or basal (p = 0.899) images. ECLR demonstrated significant symmetry improvements in all measurements when comparing pre and postoperative images, and these changes were maintained at long-term follow-up. In frontal images, commissure length and medial lip height deviation demonstrated the largest reductions (immediate postoperative: -0.775, 95% CI -0.884 to -0.665, p < 0.001; -0.416, 95% CI -0.442 to -0.390, p < 0.001, respectively). In basal images, nasal width deviation showed the largest reduction (immediate post-op: -0.955, 95% CI -1.062 to -0.847, p < 0.001).

Conclusion: This large-cohort study demonstrates that ECLR for UCL/P produces significant and durable improvements in facial symmetry, which are maintained over years following repair.

INTRODUCTION

CranioRate 1.0 has processed over 2,500 CT scans across 17 institutions for objective craniosynostosis severity assessment. However, the platform is limited by manual preprocessing requirements, a 10–15% scan failure rate from imaging artifacts, and difficulty processing complex cases. To address these limitations, we developed CranioRate 2.0, a deep learning pipeline designed to automate preprocessing, expand scan compatibility, and maintain score validity.

METHODS

CranioRate 2.0 employs a U-Net–based network consisting of four convolutional layers in the encoder and decoder paths for skull estimation and segmentation, replacing traditional Kittler-Illingworth thresholding. A deep convolutional autoencoder then removes artifacts from the segmented images, improving robustness for postoperative assessment. The pipeline subsequently places 2,048 homologous 3D correspondences via ShapeWorks and generates PCA-based shape descriptors capturing 95% of morphological variance in 8 principal components.

The networks were trained on the CranioRate 1.0 validated dataset. Validation employed head-to-head comparison of both pipelines on 1,392 CT scans from patients with nonsyndromic metopic (n=550), sagittal (n=412), and unicoronal (n=430) craniosynostosis. Outcome measures included processing success rates, previously failed scan recovery, score concordance via Pearson correlation, and processing time.

RESULTS

CranioRate 2.0 successfully processed 1,294 of 1,392 scans (93.0%) versus 1,184 of 1,392 (85.1%) with CranioRate 1.0. Of 208 scans that failed processing with CranioRate 1.0, 110 (52.9%) were recovered with the updated pipeline. The greatest improvement was observed among patients with sagittal craniosynostosis, where the success rate increased from 76.0% to 91.3%.

Score concordance between versions was high for both sagittal severity scores (r=0.95, p<0.001) and metopic severity scores (r=0.96, p<0.001). Score distributions on common scans demonstrated preservation of clinically meaningful patterns, including the characteristic bimodal distribution of metopic severity. Cranial morphology deviation distributions demonstrated clear separation between diagnostic groups. Mean processing time decreased from approximately 90 minutes to 20–30 minutes per scan.

CONCLUSIONS

CranioRate 2.0 integrates deep learning–based preprocessing and segmentation to improve processing success rates, recover previously failed scans, and reduce processing time while maintaining score validity. Enhanced automation and robustness to imaging artifacts remove barriers to institutional adoption and support standardized severity assessment in multi-center craniosynostosis research.

Background

Lower face procedures play a central role in facial feminization surgery (FFS) by reshaping mandibular width, chin projection, and soft-tissue contours that strongly influence gender perception. Common interventions, including mandibular angle reduction, genioplasty, and chondrolaryngoplasty, require extensive bony modification and soft-tissue dissection, which may predispose patients to a complication profile distinct from that of upper face surgery. However, complication data specific to lower FFS remain sparse and inconsistently reported, with prior studies limited by small sample sizes and variable outcome definitions. This study aims to characterize the early and late complications associated with lower FFS to support evidence-based perioperative decision-making.

Methods

A retrospective cohort study was conducted using the TriNetX database. Patients undergoing gender affirming care were identified using International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes. Lower FFS procedures included lip augmentation, genioplasty, mandibular osteotomy, submental liposuction, face/neck lift, and chondrolaryngoplasty. Primary outcomes included post-operative complications –including cellulitis, abscess, sepsis, swelling/edema, bleeding, and infection – stratified into early (<30 days) and late (>30 days) events. Complication rates were assessed using cohort-level analyses and Kaplan-Meier survival methods to estimate complication-free survival.

Results

A cohort of 1,217 patients undergoing gender-affirming surgery, of whom 60 (4.9%) underwent lip augmentation, 494 (40.6%) genioplasty, 706 (58.0%) mandibular osteotomy, 125 (10.3%) submental liposuction, 132 (10.8%) face/neck lift, and 29 (2.4%) chondrolaryngoplasty. Overall, complication rates were low, with consistently high Kaplan-Meier complication-free survival across all cohorts (>92% at the end of follow-up). No early or late complications were documented following lip augmentation, submental liposuction, or face/neck lift. Genioplasty demonstrated low early and late rates of swelling (3.54% and 3.24%, respectively) and infection (2.67% and 2.95%). Mandibular osteotomy showed low and late rates of swelling (2.03% and 2.36%) and infection (2.31% and 2.07%). Chondrolaryngoplasty was associated with a low early infection rate (1.57%) and no reported late complications.

Conclusion

Facial feminization of the lower face is associated with low rates of early and late postoperative complications, demonstrating the overall safety of these procedures in transgender and gender diverse individuals. These findings provide a reference framework for perioperative counseling and benchmarking, while underscoring the value of large-scale database analyses in characterizing complication profiles for procedures infrequently reported at the single-institution level. Future studies should focus on procedure-specific early versus late complications and evaluate the safety profiles of commonly performed adjunct procedures to better reflect real-world surgical practice.

Background:

Primary cleft palate repair reconstructs the velopharyngeal mechanism by repositioning the soft palate and levator sling, potentially altering upper airway morphology. Prior studies evaluating airway change after repair often report total airway volume without distinguishing nasopharyngeal and oropharyngeal compartments. This study evaluated regional airway volumetric changes following primary cleft palate repair using intraoperative MRI and three-dimensional segmentation.

Methods:

Pre-repair and post-repair craniofacial MRIs obtained intraoperatively during primary cleft palate repair were retrospectively analyzed. Three-dimensional airway segmentation was performed using the VisAR imaging platform. Standardized craniofacial landmarks were used to delineate nasopharyngeal and oropharyngeal compartments. Compartment volumes were calculated in cubic centimeters, and the combined regional volume was derived. Preoperative and postoperative measurements were compared using paired t tests.

Results:

Eight patients were included in this preliminary analysis. Patients were aged 2–5 years (mean 2.75 years); 62.5% were male. Mean nasopharyngeal volume decreased from 0.64 cm³ preoperatively to 0.34 cm³ postoperatively (mean change −0.30 cm³; 47% reduction; p = 0.13). Mean oropharyngeal volume decreased from 1.34 cm³ to 0.71 cm³ (mean change −0.63 cm³; 47% reduction; p ≈ 0.05). Combined regional airway volume decreased from 1.98 cm³ to 1.05 cm³ (mean change −0.93 cm³; 47% reduction), representing a statistically significant overall reduction (p = 0.024). Across patients, the magnitude of reduction was greater in the oropharyngeal compartment.

Conclusion:

Primary cleft palate repair is associated with a measurable decrease in regional upper airway volume immediately following reconstruction. The greater absolute reduction in the oropharyngeal compartment suggests airway remodeling occurs predominantly inferior to the velopharyngeal plane. Compartment-based airway segmentation may improve characterization of early postoperative airway remodeling following cleft palate repair.

Introduction

Sagittal craniosynostosis is the most common form of isolated craniosynostosis, yet operative decision making can be challenging especially in patients presenting after 1 year of age. Advances in machine learning have enabled automated quantification of cranial shape abnormalities through validated metrics such as preoperative Cranial Morphology Deviation (CMD) and Sagittal Severity Score (SSS). However, clinically validated thresholds for these metrics to guide surgical intervention are lacking. This study evaluates the association between CMD and SSS with operative management and proposes thresholds to aid surgical decision-making.

Methods

We retrospectively reviewed medical records of patients over 1 year of age with isolated sagittal synostosis treated at a single institution from January 1993 to December 2024. Data on operative status and demographics were extracted, and preoperative CT scans meeting CranioRate™ quality standards were analyzed to generate Cranial Morphology Deviation (CMD) and Sagittal Severity Score (SSS). Operative and non-operative groups were compared using the Wilcoxon rank-sum test. Multivariable logistic regression assessed the association of CMD and SSS with operative status, adjusting for age at imaging and sex. Model performance was evaluated using receiver operating characteristic (ROC) curves and area under the curve (AUC), and optimal thresholds were identified using the Youden index.

Results The final subgroup included 231 patients who presented after 1 year of age. Of these, 56 patients (24.2%) underwent operative treatment. The majority were male (73.6%), with a median age at CT imaging of 1183 days (IQR: 688–2103). CMD was significantly higher among operative patients (median: 176; IQR: 152–207) compared to non-operative patients (median: 139; IQR: 117–163; p < 0.001). Similarly, SSS was elevated in operative patients, with a median of 4.13 (IQR: 3.04–5.75) versus 2.29 (IQR: 0.99–3.25) in non-operative patients (p < 0.001).

In multivariable logistic regression models, both CMD and SSS were independently associated with operative status after adjusting for age at imaging and sex. For each unit increase in CMD, the odds of surgery increased by 2% (OR = 1.02, p < 0.001). For each unit increase in SSS, the odds increased by 50% (OR = 1.50, p < 0.001). Age and sex were not significant predictors in either model. Model discrimination was fair, with an AUC of 0.76 for CMD and 0.70 for SSS. The optimal predicted probability threshold for CMD was 0.192, corresponding to a CMD score of 138.96. For SSS, the optimal threshold was 0.204, corresponding to an SSS score of 2.69.

Conclusion

This study establishes evidence-based operative thresholds for machine learning derived cranial morphology metrics in sagittal craniosynostosis, providing objective criteria to guide surgical decision making for patients over 1 year with isolated sagittal craniosynostosis.

Purpose Restoring a symmetric, functional smile is the central goal of pediatric facial reanimation. Although multiple surgical strategies exist, the factors that drive meaningful postoperative improvement remain unclear. We sought to identify predictors of functional smile gain following pediatric facial reanimation using objective automated landmark analysis to quantify recovery. Methods We conducted a retrospective study of 32 pediatric patients who underwent facial reanimation between January 2015 and December 2023, with 107 standardized pre- and postoperative photographs available for analysis. Procedures included masseter nerve transfer, cross-face nerve graft, and dual-innervation techniques. Mean follow-up was 14.6 months (range 6–36 months). Commissure excursion (mm), smile angle (degrees), and symmetry index were quantified pre- and postoperatively using automated landmark analysis (Emotrics and MediaPipe Face Mesh). The primary outcome was change in commissure excursion. Clinically meaningful improvement was defined as ≥3 mm gain. Multivariable modeling evaluated predictors of excursion gain and the likelihood of achieving meaningful improvement. Results Clinically meaningful smile improvement (≥3 mm commissure gain) was achieved in 70% of patients following facial reanimation. Younger age at surgery was independently associated with higher odds of meaningful improvement (OR 2.3, 95% CI 1.1–4.8, p=0.03). Cross-face nerve graft procedures were also associated with greater likelihood of achieving ≥3 mm excursion gain compared with single-nerve techniques (OR 2.8, 95% CI 1.2–6.4, p=0.02). Longer postoperative follow-up remained independently associated with improved functional outcomes (OR 1.15 per additional month, 95% CI 1.03–1.27, p=0.01), consistent with continued neuromuscular adaptation over time. Across the cohort, commissure excursion improved by 4.0 ± 2.1 mm. Seventy-four percent of cross-face nerve graft patients achieved ≥3 mm improvement compared with 61% of single-nerve procedures. Conclusion Functional smile recovery after pediatric facial reanimation is influenced by age at intervention, surgical strategy, and duration of follow-up. Earlier treatment and cross-face nerve graft techniques were associated with greater objective improvement. Automated landmark analysis offers a reproducible method to quantify recovery and support longitudinal assessment in pediatric facial reanimation. References: Banks, C. A., Jowett, N., Iacolucci, C., Heiser, A., & Hadlock, T. A. (2019). Five-Year Experience with Fifth-to-Seventh Nerve Transfer for Smile. Plastic and reconstructive surgery, 143(5), 1060e–1071e. https://doi.org/10.1097/PRS.0000000000005591 Pham, T. B., & Greene, J. J. (2023). Reducing Risk in Facial Reanimation Surgery. Facial plastic surgery clinics of North America, 31(2), 297–305. https://doi.org/10.1016/j.fsc.2023.01.008 Hadford, S. P., Genther, D. J., & Byrne, P. J. (2024). Pediatric Facial Reanimation. Facial plastic surgery clinics of North America, 32(1), 169–180. https://doi.org/10.1016/j.fsc.2023.07.003

Purpose: Recombinant human bone morphogenetic protein (rhBMP)-2 with demineralized bone matrix (DBM) is a synthetic alternative with similar short term outcomes, but differences in bone quality and volume may affect long term functional and aesthetic results and require radiographic evaluation beyond revision rates (1,2). This study compares clinical and radiographic graft outcomes among patients undergoing ABG with rhBMP-2/DBM, ICBG alone, and ICBG augmented with rhBMP-2/DBM.

Methods and Materials: Patients with alveolar clefts undergoing secondary ABG between 2017 and 2023 were retrospectively queried. ABG performed using rhBMP-2/DBM, ICBG alone, or ICBG augmented with rhBMP-2. The main outcome measures were clinical graft success, defined as no indication for revision ABG, and radiographic graft success assessed by cone-beam computed tomography (CBCT), including bony bridge formation and alveolar bridge thickness. Mean follow-up was 17.8 ± 14.2 months.

Results: A total of 432 patients undergoing ABG were included, accounting for 527 primary grafting procedures between 2017 and 2023. Among these procedures, 284 (53.9%) utilized recombinant human bone morphogenetic protein-2 with demineralized bone matrix (rhBMP-2/DBM), 196 (37.2%) utilized iliac crest bone graft (ICBG) alone, and 47 (8.9%) utilized a combined approach of ICBG augmented with rhBMP-2. The clinical graft success rate across the 527 procedures was 95.9%, with comparable success rates across all three cohorts (rhBMP-2/DBM: 95.1% vs. ICBG: 95.4% vs. ICBG+rhBMP-2: 97.9%; p=0.692). However, based on CBCT imaging, 89.4% of the ICBG+rhBMP-2 cohort had demonstrated successful bony formation, which was significantly higher compared to ICBG (89.4% vs. 65.3%; p=0.001) and rhBMP-2/DBM (89.4% vs. 61.6%; p<0.001). The average bridge thickness was higher in the ICBG+rhBMP-2 cohort compared to ICBG (7.4±2.6mm vs.4.7±1.9mm; p<0.001) and rhBMP-2/DBM (7.4±2.6mm vs. 4.4±1.2mm; p<0.001).

Conclusion: Our preliminary findings demonstrate that the use of ICBG with rhBMP-2 appears to result in more bony bridge formation and greater bridge thickness. Future research should focus on long-term functional outcomes and how patient factors influence success when combining iliac crest bone grafting with BMP-2.

References: 1. Xiao WL, Jia KN, Yu G, Zhao N. Outcomes of bone morphogenetic protein-2 and iliac cancellous bone transplantation on alveolar cleft bone grafting: A meta-analysis. J Plast Reconstr Aesthet Surg. 2020;73(6):1135-1142. doi:10.1016/j.bjps.2020.01.011 2. Alawami EAA, Alomari F, Aloqaybi SA, et al. Efficacy of Recombinant Human Bone Morphogenetic Protein-2 in Alveolar Cleft Treatment for Children: Systematic Review and Meta-Analysis. Life (Basel). 2025;15(2):185. Published 2025 Jan 26. doi:10.3390/life15020185

Background: Bisphosphonates are widely prescribed for osteoporosis and metastatic bone disease due to their effects on bone remodeling. However, prolonged suppression of osteoclast-mediated bone resorption raises concern in the maxillary and mandibular bones, where high bone turnover accommodates micro-injuries associated with occlusion and mastication.1,2 Existing literature is limited to small case series primarily focused on osteonecrosis of the jaw, with minimal evaluation of broader postoperative outcomes.3,4 Methods: We retrospectively evaluated complications following orthognathic surgery in patients with prior bisphosphonate exposure using the TriNetX database. Adults (≥18 years) who underwent Le Fort I osteotomy, mandibular osteotomy, or genioplasty between January 2005 to January 2026 were stratified by bisphosphonate exposure within 10 years preceding surgery (n = 88) versus no exposure (n = 23,130). Postoperative complications included delayed fracture healing or nonunion, surgical site infection, hardware removal, medication-related osteonecrosis, inflammatory jaw conditions, jaw pain, and other jaw disorders. Results: After propensity score matching, complication rates were significantly higher among bisphosphonate users compared with non-users (34.1% vs. 15.9%), corresponding to a risk ratio of 2.14 (95% CI: 1.22–3.76). Kaplan–Meier analysis demonstrated significantly lower complication-free survival in the bisphosphonate cohort (60.6% vs. 78.9%; log-rank p = 0.02). After adjusting for age and sex in Cox proportional hazards regression, bisphosphonate exposure remained an independent predictor of postoperative complications (HR = 1.47; 95% CI: 1.01–2.11; p < 0.05). Conclusions: These findings highlight the need for judicious perioperative risk assessment and patient counseling when considering orthognathic surgery among bisphosphonate users.

Citations 1. Sharma D, Ivanovski S, Slevin M, et al. Bisphosphonate-related osteonecrosis of jaw (BRONJ): diagnostic criteria and possible pathogenic mechanisms of an unexpected anti-angiogenic side effect. Vasc Cell. 2013;5(1):1. doi:10.1186/2045-824X-5-1 2. Drake MT, Clarke BL, Khosla S. Bisphosphonates: mechanism of action and role in clinical practice. Mayo Clin Proc. 2008;83(9):1032-1045. doi:10.4065/83.9.1032 3. Zandi M, Dehghan A, Amini P, Rezaeian L, Doulati S. Evaluation of mandibular fracture healing in rats under zoledronate therapy: A histologic study. Injury. 2017;48(12):2683-2687. doi:10.1016/j.injury.2017.10.026 4. Gleizal A, Meon A, Asselborn M, Chauvel-Picard J. Orthognathic surgery in patients treated with bisphosphonates: A case series. J Cranio-Maxillo-fac Surg Off Publ Eur Assoc Cranio-Maxillo-fac Surg. 2023;51(9):521-527. doi:10.1016/j.jcms.2023.06.002

Background: Minimally invasive techniques for surgical correction of metopic craniosynostosis have grown in popularity. Minimally invasive techniques offer an improved safety profile and shorter operative duration while preserving cranial growth potential. Strip craniectomy with helmet therapy is associated with under correction and persistent supraorbital retrusion. Spring-mediated cranioplasty (SMC) is alternative technique, though data on outcomes remain limited. In this study, we present our institutional experience with SMC for metopic craniosynostosis. Methods: A retrospective chart review was performed of patients who underwent SMC for metopic craniosynostosis between January 2015 and October 2025. Pre and post-operative ICD were measured on CT scans and 2D photographs. Intercanthal distance (ICD) was classified based on age-matched normative values. Threshold analysis was performed to identify spring force parameters associated with overcorrection. Results: Twenty-three patients met inclusion criteria. One patient (4%) required a blood transfusion, and one patient (4%) required a revision for correction of head shape. Most (83%) patients received two springs, with a median total force of 18.6N and median force per spring of 9.3 N Transient hypertelorism occurred in 74% of patients, with 53% self-correcting at a median of 177 days. At final follow-up, 65% achieved normal ICD and 35% were hyperteloric. Threshold analysis revealed patients receiving >11N per spring had 12 times higher odds of persistent hypertelorism (p=0.033). Conclusion: SMC is a safe and effective minimally invasive treatment for metopic craniosynostosis with low complication and revision rates. Higher spring forces may increase risk of persistent overcorrection, and these findings offer preliminary parameters to guide surgical planning.