Scientific Abstract Presentations: Craniomaxillofacial Session 7 Saturday, October 17 Sat, Oct 17 8:00-9:30 a.m. CDT

Purpose: Facial fractures accounted for an estimated $10.8 billion in U.S. expenditures between 2021 and 2022[1]. Chronic substance use disorder (SUD) and alcohol-related mechanisms of injury (MOI) are highly prevalent in craniofacial trauma[2]. While chronic SUD drives resource utilization in general trauma populations[3], its impact on cost following operative craniofacial fracture repair remains unclear. This study evaluated the independent effects of chronic SUD and alcohol-related MOI on hospital cost in facial trauma.

Methods: A retrospective study included adults who underwent operative repair of craniofacial fractures (excluding nasal bone fractures) from 2019-2025 across four high-volume urban trauma centers. Behavioral variables included alcohol use disorder (AUD), chronic SUD (excluding AUD), alcohol-related MOI, and smoking status. Total hospital cost was estimated using standardized unit costs for length of stay (LOS), operating room time, emergency department visits, and surgical adjuncts (plates, screws, bone grafts), then log-transformed. Multivariable regression adjusted for age, sex, fracture location, and open vs. closed injury. A secondary model adjusted for hardware utilization and operative time. Statistical significance was set at p<0.05.

Results: A total of 414 patients were included. 76.8% were male; median age was 36.1 years (IQR 27.7-49.7). Median estimated total hospital cost was $12,486 (IQR $8,802–$18,572). AUD was present in 13.0% of patients, chronic SUD in 7.0%, and alcohol-related MOI in 20.5%.

In multivariable models, chronic SUD was associated with a 53% increase in total cost (β = 0.43, 95% CI 0.16–0.69, p = 0.002), and AUD with a 24% increase (β = 0.22, 95% CI 0.00–0.43, p = 0.048). Alcohol-related MOI (β = −0.02, p = 0.80) and smoking (β = 0.07, p = 0.31) were not significantly associated with cost. After further adjustment for hardware utilization and operative time, chronic SUD remained associated with increased cost (β = 0.34, 95% CI 0.09–0.58, p = 0.007), suggesting the effect was not due to surgical complexity, whereas the AUD association was attenuated (β = 0.19, p = 0.050). Cost decomposition showed that SUD and AUD were associated with increased LOS (SUD: β = 0.66, 95% CI 0.21–1.11, p = 0.004; AUD: β = 0.38, 95% CI 0.02–0.74, p = 0.040), with no differences in operative time or hardware costs.

Conclusion: Chronic SUD, rather than alcohol-related MOI, is independently associated with increased hospital cost in craniofacial trauma repair. Increased costs are mediated by prolonged LOS rather than surgical complexity. These findings highlight chronic SUD as a key driver of inpatient resource utilization and support targeted perioperative strategies to reduce LOS and hospital cost.

References: 1. Han MD, Vogel S, et al. Epidemiology of Facial Fractures Encountered in the Emergency Department Setting in the United States: An Update of Nationwide Estimates. J Oral Maxillofac Surg. January 22, 2026. doi:10.1016/j.joms.2026.01.015 2. Derakhshan A, Archibald H, et al. Premorbid Incidence of Mental Health and Substance Abuse Disorders in Facial Trauma Patients. Craniomaxillofac Trauma Reconstr. 2024;17(4):NP257-NP262. doi:10.1177/19433875241280780 3. Ng C, Fleury M, et al. The impact of alcohol use and withdrawal on trauma outcomes: A case control study. Am J Surg. 2021;222(2):438-445. doi:10.1016/j.amjsurg.2020.12.026

Background: Children with craniofacial conditions are at an increased risk for psychosocial burden, presenting as anxiety, depression, low self-esteem and social difficulties. Due to these risks, mental health screening has proven essential to monitor psychosocial functioning in this population. This is the largest known study to characterize the psychosocial health and emotional wellbeing of children with craniofacial differences through standardized mental health screening instruments and explore associations with demographics and medical history.

Methods: A retrospective chart review was conducted on pediatric patients (< 18 years old) who were seen at a pediatric academic medical center cleft-craniofacial team and were administered various mental health instruments including the PSC (a screening tool for emotional, behavioral, and psychosocial problems), the GAD-7 (a screening tool for anxiety), and the PHQ-9 Teen Version (a screening tool for depression), from November 2022 to July 2025. Patients were organized in a database, and their completed surveys were analyzed. Pertinent data was extracted from patient charts, including demographic characteristics, surgical history, psychosocial status, and social needs.

Results: Of the patient records screened, 567 patients met inclusion criteria and had a mean age of 11.78 years (SD: 3.16). The majority of patients were male (n=334, 58.91%) and White (n=506, 89.24%). Males had significantly higher PSC scores than their female peers (mean±SD: 12.31±11.50 vs. 10.13±9.77, p=0.020). Patients without insurance coverage or on Medicaid had higher PSC scores on average than those with private insurance (mean±SD: 20.83±16.01 and 16.68±12.65 vs. 9.32±9.18, p<0.001) and syndromic patients had higher GAD-7 scores than non-syndromic patients (mean±SD: 4.65±1.12 vs. 2.80±3.56, p=0.043). Patients undergoing more craniofacial-related surgeries correlated with lower PSC scores (r=-0.09, p=0.042), and patients with a psychological diagnosis underwent less craniofacial-related surgeries on average (mean±SD: 2.00±0.14 vs. 2.43±0.10, p=0.011). Patients with higher scores on the PSC, GAD-7, and PHQ-9T were enrolled in psychiatric care (p<0.001), highlighting the success of these standardized mental health screening tools at identifying patients with psychosocial needs. Social determinants of health played a factor in psychosocial concerns, as patients with documented social needs were associated with having psychological diagnoses (p=0.004) and receiving psychiatric treatment (p<0.001).

Conclusions: Patients with craniofacial differences face psychosocial burden, but the routine use of standardized mental health screening instruments proves to be essential in identifying these concerns and facilitating proper treatment. Unexpectedly, a higher surgical burden was protective of psychological concerns, suggesting that timely surgical management may contribute to improved wellbeing. Social determinants of health need to be addressed in this population to ensure equitable mental health support.

Purpose: Over the past century, numerous techniques for unilateral cleft lip repair have been named, described, and modified. While these techniques are widely cited in surgical education and training, the specific anatomic rationale underlying iterative modifications to these techniques is often incompletely discussed in the literature. Understanding how operative technique evolves in response to observed functional and aesthetic outcomes, as well as experience, mentorship, and international collaboration, is essential to advancing cleft surgical education. This work characterizes the evolution of the senior author's unilateral cleft lip repair by outlining the current operative approach with detailed anatomic references and contextualizing technical modifications within their intended functional and aesthetic objectives to facilitate reproducibility and outcome-oriented surgical education.

Methods: A retrospective qualitative review was performed. The senior author was interviewed to identify key technical modifications implemented over time. Preoperative and postoperative outcomes data including lip symmetry analysis, complication profiles, and revision patterns from the surgeon's career from 2007 to 2025 were reviewed to contextualize these modifications in relation to their intended reconstructive objectives. The current operative approach was then documented stepwise, with reference to relevant anatomic landmarks and practice-informed technical refinements.

Results: The current approach represents a modified rotation advancement repair with elements of Mohler and Fisher techniques adapted over time. Long-term follow-up revealed inconsistencies in commissure-to-peak symmetry, philtral height, vermilion contour, and nasal symmetry, prompting modification. Adjustments in lip marking, including medialization of Noordhoff's point and incorporation of a dual triangular advancement to restore vertical lip height, were implemented to improve the cupid's bow definition without lip shortening. Transition to a lateral dry vermilion triangle improved visible vermilion contour, with resultant wet vermilion deficiency subsequently addressed through mucosal borrowing via frenulectomy to restore vertical sulcal height. Recognition of the lip and nose as a single reconstructive unit prompted incorporation of primary nasal correction, requiring broader release from the piriform aperture and anterior nasal spine to facilitate layered nasal floor reconstruction. Selective thinning of the lateral alar soft tissue and nasal fat pad was subsequently added to improve nostril contour and reduce alar bulk. In the neonatal repair setting, increased sensitivity of outcomes to millimeter-level variation in operative design prompted more precise rotation and tapering of triangular advancement flaps to improve philtral height, lip length, and nasal symmetry across diverse cleft lip severities.

Conclusion: Longitudinal assessment and reflective analysis of cleft surgical outcomes is essential for surgeon development and informs the evolution of repair techniques over time, underscoring the importance of long-term outcome evaluation, iterative refinement, and core anatomic principles in trainee education globally.

Purpose: Postoperative follow up is essential to comprehensive cleft care, allowing for identification of complications and evaluation of surgical outcomes. However, global rates of postoperative follow up among patients remain poorly characterized, particularly in low- and middle-income countries (LMICs). Loss to follow up in these settings may result in delayed recognition of complications and unmet need for revision surgery, impacting long term aesthetic and functional outcomes. Understanding factors associated with failure to return for postoperative follow up is critical to improving continuity of care globally.

Methods: A retrospective review of patients undergoing primary cleft lip and or cleft palate repair through an international surgical NGO between 2022 and 2025 was conducted. Demographic, household, and patient clinical characteristics including age at primary surgery, insurance status, parental literacy and education, family history of cleft, travel time to surgical site, prior surgical care, cleft phenotype, and reported barriers to care were analyzed. The primary outcome was failure to return from postoperative follow up. Chi square and t-tests were used to compare follow up status; significant variables were included in multivariable logistic regression to identify predictors of loss to follow up.

Results: a total of 2,737 patients undergoing primary cleft repair were included; mean age at surgery was 56.0 months (SD±89.9). Patients who did not return for postoperative follow up were significantly younger at the time of surgery (p<0.001) and significantly more likely to have undergone cleft palate repair (p<0.001). Patients treated in MENA countries were less likely to return to follow up (p<0.001), as were patients with health insurance (p<0.001). Parental literacy, parental education, family history of cleft, travel time to care, and cleft phenotype were not associated with follow up status. Among patients reporting barriers to care, lack of awareness was more frequently reported among those who did not return (p<0.001). On multivariate regression, younger age at surgery (OR=0.97, p=0.002), cleft palate repair (OR=1.36, p=0.001), treatment in MENA countries (OR=1.47, p=0.002), health insurance (OR=1.29, p=0.010), and reported barriers to care (OR=1.58, p=0.010) were independently associated with failure to return for postoperative follow up. Among patients presenting for follow up, postoperative complications occurred in 9.2% of whom 46.2% required revision surgery; 91.5% presented within 14 days postoperatively, and no patients returned beyond 30 days.

Conclusion: Failure to return for postoperative follow up after primary cleft repair remains common in global cleft populations, with younger age at surgery, cleft palate repair, access to health insurance, treatment in MENA countries, and reported barriers to independently associated with loss to follow up. Notably, no patients returned for long term follow up care beyond 30 days following their primary repair. Targeted strategies to address barriers to longitudinal care access are needed to improve continuity of cleft care and identify patients requiring secondary intervention.

Background: Staged alveolar bone grafting (ABG) is often employed in patients with complex cleft phenotypes or suboptimal soft tissue conditions. However, whether staging influences perioperative outcomes compared with non-staged ABG remains unclear. This study aims to evaluate patient characteristics and early postoperative outcomes between staged and non-staged ABG.

Methods: A retrospective cohort study was conducted of consecutive alveolar bone grafting (ABG) cases performed between 2017 and 2025 at a tertiary children's hospital by a single surgeon. Baseline demographics, cleft phenotype, dental stage at the time of surgery, operative metrics, and postoperative outcomes were compared between staged and non-staged groups. Categorical variables were analyzed using chi-square or Fisher's exact tests, and continuous variables were analyzed using Mann–Whitney U tests.

Results: A total of 72 patients were included, consisting of 35 non-staged and 37 staged patients. Bilateral clefts were more common in the staged cohort (35.14%) compared with the non-staged cohort (17.14%) (p=0.0162). Chronologic age and dental stage at the time of ABG did not differ significantly between staged and non-staged groups (10.28 vs 9.13 years; p=0.0526).

Operative duration and length of stay were similar between groups. Rates of any complication (5.41% vs 14.29%, p=0.2543), facial swelling (0% vs 8.57%, p=0.1097), dehiscence (5.41% vs 5.71%, p=1.0000), ICU transfer (0% vs 2.86%, p=0.4861), regraft requirement (8.11% vs 11.43%, p=0.7066), and additional regrafts (5.41% vs 8.57%, p=0.6088) were also comparable between groups. No surgical site infections, unplanned 30-day readmissions, or unplanned 30-day reoperations occurred in either cohort.

Conclusion: Staged ABG was more frequently performed in patients with bilateral clefts but demonstrated perioperative outcomes comparable to non-staged procedures. Despite greater surgical complexity, staging did not increase operative time, hospital stay, or complication rates. These findings support phenotype-driven surgical selection without added short-term morbidity.

Background Enhanced Recovery After Surgery (ERAS) protocols are evidence-based, multimodal perioperative pathways designed to optimize surgical outcomes by minimizing physiologic stress and accelerating recovery. Despite these documented benefits, ERAS implementation in alveolar bone grafting (ABG) remains inconsistent. This study aims to evaluate the implementation and outcomes of the ERAS protocol for pediatric patients undergoing alveolar bone graft (ABG) at a single institution.

Methods This retrospective cohort study reviewed all pediatric patients who underwent ABG at a tertiary children's hospital between 2022 and 2025. Patients receiving synthetic bone grafts were excluded. Patients were divided into two groups: those managed under an institutional ERAS protocol (ERAS cohort) and those managed with standard perioperative care prior to ERAS implementation (non-ERAS cohort). The ERAS protocol consisted of preoperative closure of type IV/V fistulas, preoperative chlorhexidine mouthwash, intraoperative suprazygomatic maxillary nerve block, and reinforcement of the nasal lining with external oblique fascia or periosteal graft oversewn in a watertight fashion, followed by double-layered closure. Postoperative management included an OnQ continuous local anesthetic pump at the donor site, scheduled ketorolac and ibuprofen, full liquids for two days, and a soft diet for two weeks. Patient demographics, clinical characteristics, narcotic utilization, pain scores, hospital length of stay, and post-operative complications were compared between cohorts. Statistical analyses were performed using IBM SPSS.

Results
Forty-six patients were included, with 23 patients in the ERAS cohort (50%) and 23 patients in the non-ERAS cohort. The cohort was predominantly male (26/46, 56.5%), Hispanic (26/46, 56.5%), and publicly insured (29/46, 63%), with a median age of 10.5 years (IQR 9–12). Most patients underwent unilateral alveolar grafting (36/46, 78.3%) and required repair of nasolabial and alveolar fistulas prior to surgery (36/46, 78.3%). Graft type included corticocancellous block (14/46, 30.4%), cancellous only (29/46, 63.0%), and combined (3/46, 6.5%). External oblique fascia or periosteal graft reinforcement of the nasal lining was performed in 52.2% of patients overall. The ERAS cohort was significantly associated with same day discharge compared to the non-ERAS cohort (p = 0.007). No statistically significant differences were observed in inpatient opioid utilization (p = 0.126) or PACU pain scores (p = 0.591). In the non-ERAS group, one patient developed postoperative bone exposure with a type VI fistula requiring subsequent repair, and two patients had inadequate graft take per orthodontist assessment (6.5%). No complications occurred in the ERAS group, and there were no significant between-group differences in graft take or overall complication rates.

Conclusion
Implementation of an ERAS protocol for ABG surgery was feasible and safe, achieving higher rates of same-day discharge without increasing postoperative complications or pain. Though the study was underpowered based on a priori analysis, these preliminary findings support the safety and feasibility of the ERAS protocol in pediatric cleft care and suggest potential benefits in resource utilization and patient recovery.

Background: National, fracture-specific benchmarks for short-term morbidity after operative facial fracture repair are limited. Simultaneously, trauma systems have experienced measurable increases in patient acuity and operative complexity. Whether postoperative risk has escalated in parallel-or remained resilient-has not been defined at scale.

Methods: We performed a 15-year retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS–NSQIP) (2007–2022), capturing 4,805 adults undergoing operative repair of mandibular, zygomaticomaxillary complex (ZMC), orbital, LeFort, or multifocal fractures by plastic or otolaryngologic surgeons. Thirty-day outcomes included superficial, deep, and organ-space surgical site infection (SSI), wound dehiscence, unplanned return to the operating room, and medical complications. Multivariable logistic regression identified independent predictors and evaluated temporal trends in risk-adjusted morbidity.

Results: Across this nationally representative cohort, the overall 30-day complication rate was 6.7%. Morbidity demonstrated marked fracture specificity, with mandibular injuries exhibiting the highest complication rate (13.1%), compared with ZMC (2.7%), orbital (3.4%), LeFort (4.8%), and multifocal fractures (2.7%) (p<0.001). Independent predictors of postoperative morbidity included active smoking (aOR 1.43), increasing ASA class (ASA II–IV: aOR 1.94–3.67), prolonged operative time (aOR 1.20 per 10-minute increment), and escalating wound contamination (dirty/infected: aOR 3.48). Plastic surgery–led repairs were associated with lower adjusted odds of complications compared with otolaryngology (aOR 0.74). Importantly, over the 15-year study period, patient acuity and operative complexity increased significantly-reflected by higher ASA class distribution, greater wound contamination, and longer operative duration. Despite this progressive escalation in case severity, the risk-adjusted annual probability of postoperative complications remained stable at approximately 6–7%, with no significant temporal trend.

Conclusions: In this large, national, longitudinal analysis of operative facial fracture repair, early morbidity has remained stable despite increasing clinical complexity. Complications are fracture-specific, concentrated in mandibular injuries, and strongly associated with modifiable risk factors. These findings establish contemporary, risk-adjusted national benchmarks and demonstrate the capacity of modern trauma systems to maintain outcome stability amid rising acuity. Targeted perioperative strategies-including smoking cessation, contamination mitigation, and operative efficiency-remain essential to sustaining performance as case complexity continues to evolve.

Purpose: Complex cranioplasties involving the frontal sinus, orbit, and skull base remain at heightened risk for infection and implant-related complications. While polyetheretherketone (PEEK) offers advantages in contouring and customization, concerns persist regarding its performance in high-risk, anatomically complex reconstructions, and comparative data against titanium in these settings are limited. We sought to evaluate postoperative outcomes of PEEK versus titanium implants in complex cranioplasties, with particular attention to infection, reoperation, and implant replacement rates across high-risk anatomical subsites.

Methods and Materials: We conducted a retrospective review of alloplastic cranioplasties performed by a single surgeon from January 2011 to January 2025. Data collection included anatomical site and complexity including defect size, involvement of the frontal sinus or orbital involvement. We collected postoperative outcomes including infection rate, reoperation, explantation, and implant replacement rates. Statistical analysis utilized Fisher's exact test for categorical variable comparisons between PEEK and titanium cohorts. Experience: Our analysis included 101 cases (60 PEEK and 41 titanium cranioplasties). Subgroup analysis included 15 cases involving the frontal sinus (9 PEEK, 6 titanium), with additional stratification by anatomical regions including the orbit.

Results: Overall, infection rates were 8.0% for PEEK versus 17.0% for titanium (p = 0.35), and reoperation rates were 20.37% for PEEK versus 28.21% for titanium, while implant replacement rates were 12.96% and 12.82%, respectively (all p > 0.05). In cranioplasties involving the frontal sinus, PEEK had a 33.33% infection rate (3 of 9 cases) compared to 0.0% (0 of 6) for titanium, though this difference did not reach statistical significance (p = 0.26). Cases with concurrent orbital and frontal sinus reconstruction demonstrated 20.0% infection for PEEK versus 0.0% for titanium (p > 0.05). Anatomical subsite analysis revealed comparable infection, reoperation, and replacement rates across isolated zygoma (1 of 6 PEEK versus 0 of 8 titanium), sphenoid (0 of 5 PEEK versus 0 of 8 titanium), and orbital defects (1 of 12 PEEK versus 0 of 14 titanium) between materials (all p > 0.05).

Conclusions: In this series, PEEK demonstrated complication profiles comparable to titanium in complex cranioplasties, including high-risk reconstructions involving the frontal sinus, orbit, and skull base. These findings support PEEK as a viable alternative to titanium in complex craniofacial reconstruction, without clear evidence of increased infection, reoperation, or implant replacement rates in this cohort. While the retrospective, single-surgeon design may limit broader generalizability, the data contribute to the growing body of evidence supporting material selection based on reconstructive needs rather than presumed differences in complication risk. Larger prospective, multicenter studies are warranted to further validate these findings and evaluate additional alloplastic materials.

Division of Plastic and Reconstructive Surgery University of Tennessee Health Science Center St. Jude Children's Research Hospital, Memphis, TN

Background

Pediatric facial palsy presents unique reconstructive challenges in children with oncologic disease. Etiologies include direct tumor invasion, surgical injury, treatment-related neuropathy, and radiation-induced damage. Despite the complexity of these cases, no widely accepted algorithm guides surgical intervention for tumor-related facial nerve palsy in children. We present a structured, reproducible algorithm for facial reanimation informed by duration of denervation, electromyographic (EMG) recovery, trigeminal nerve (CN V) integrity, and patient age.

Methods

A retrospective review was performed of all pediatric patients evaluated for facial nerve palsy at a tertiary pediatric oncology center. Data collected included primary tumor diagnosis, oncologic treatment history (surgery, chemotherapy, radiation), facial nerve status using House–Brackmann (HB) and Sunnybrook grading scales, timing and type of surgical intervention, adjunctive therapies, complications, and functional outcomes. Patients were stratified by etiology (tumor-related, treatment-induced, other) and chronicity: subacute (<12 months), late subacute (12–18 months), and chronic (>18 months). A treatment algorithm was developed incorporating four decision points: denervation duration, EMG recovery trajectory, CN V motor integrity, and patient age.

Results

Ninety-one pediatric patients were included. The most common diagnoses were medulloblastoma (n=18, 19.8%), diffuse intrinsic pontine glioma (n=11, 12.1%), and ependymoma (n=9, 9.9%). Radiation exposure was documented in 42 patients (46.2%). Mean HB grade at presentation was IV with a mean Sunnybrook score of 26. Surgical reanimation was required in 7 patients (7.7%), most commonly cross-facial nerve grafting with or without staged free muscle transfer (n=5). Additional procedures included cranial nerve transfer (n=1) and interposition nerve grafting with neurorrhaphy and regional muscle flap (n=1). The algorithm (Figure 1) stratifies patients by chronicity.

Conclusions

Tumor-related pediatric facial nerve palsy can be effectively managed using a structured, time-dependent algorithm incorporating EMG recovery, CN V integrity, patient age, and denervation duration. Most patients were managed nonoperatively, with dynamic reanimation reserved for persistent deficits. Surgical intervention did not interfere with oncologic management. This algorithm provides a systematic framework applicable across pediatric oncology centers to standardize the treatment of facial nerve palsy in this complex population.

Background: Cervical lymph node dissection (CLND) remains a cornerstone in the treatment of head and neck malignancies, but it carries a significant risk of lymphedema. The role of autoimmune and metabolic comorbidities in modulating this risk is not well established. Methods: We conducted a longitudinal analysis of all patients who underwent CLND for head and neck cancer at a tertiary cancer center between 2013 and 2025. Demographic, oncologic, metabolic, and autoimmune variables were analyzed. A multivariable logistic regression model was developed to identify independent predictors of lymphedema and support the construction of a clinical risk prediction tool. Results: Among 4,925 patients, 752 (15.3%) developed lymphedema. Independent predictors of increased risk included radiation therapy (OR = 6.88; 95% CI: 5.66–8.39; p<0.0001), chemotherapy (OR = 1.98; 95% CI: 1.63–2.40; p<0.0001), older age (OR = 1.008 per year; 95% CI: 1.002–1.015; p=0.0096), Hispanic ethnicity (OR = 0.69; 95% CI: 0.49–0.96; p=0.0291), Hashimoto's thyroiditis (OR = 1.71; 95% CI: 1.00–2.85; p=0.0437), and scleroderma (OR = 4.61; 95% CI: 1.14–16.31; p=0.0221). The model demonstrated strong predictive performance, with an area under the ROC curve (AUC) of 0.803 (95% CI: 0.786–0.820; p<0.0001). Conclusion: This is the first large-scale study to model lymphedema risk following CLND using autoimmune and treatment-related predictors. The resulting model, with strong discriminative ability, may serve as a clinically useful tool to guide surveillance and early intervention strategies in high-risk patients, taking into account autoimmune conditions in addition to known risk factors.

Introduction: Financial toxicity (FT), defined as material and psychological medical expenses, is increasingly recognized in surgical care but remains poorly characterized in craniofacial populations. Craniofacial conditions often require staged interventions beginning in infancy, multidisciplinary coordination, prolonged follow-up, generating cumulative financial strain across diverse health systems. We performed a systematic review to evaluate the magnitude, risk factors, and consequences of FT in craniofacial surgery.

Methods: In accordance with PRISMA guidelines, PubMed, Embase, Scopus, Web of Science, and Global Health were searched through December 2025 for studies reporting patient-level financial outcomes in craniofacial surgery. Two reviewers independently conducted screening and extraction.

Results: Of 2,885 records identified, 18 studies met inclusion criteria (61.1% US-based; 27.8% from Low Middle-Income Countries (LMICs); N=18,224). Most studies evaluated pediatric populations (88.9%), predominantly cleft lip and/or palate. Travel and indirect cost estimation was the most common outcome domain (55.6%), followed by out-of-pocket (OOP) cost quantification and insurance barrier assessment (44.4% each). No study employed a validated FT-specific instrument. Mean cumulative OOP costs reached $45,140 per family, with 47% reporting reductions in essential household spending. Caregiver employment disruption was common: 53% missed more than 3 weeks of work and 39.6% ceased employment. Travel costs varied dramatically, with 860% higher costs for Lefort 1 distraction versus advancement. Risk factors included lower income, rural residence, and government-funded insurance. Only 32% of surveyed orthodontists accepted Medicaid for cleft care.

Conclusion: Financial toxicity imposes cumulative burden on craniofacial surgery families through direct costs, travel, caregiver employment disruption, and treatment delays. The absence of validated FT-specific measurement across all studies limits true prevalence estimation. Integrating financial screening into multidisciplinary care, strengthening insurance reform, and price transparency are critical in mitigating financial harm in this population.

Purpose: Unilateral lambdoid synostosis (ULS) is characterized by posterior plagiocephaly with a complex cranial and facial asymmetry. The occipital switch (OS) technique is commonly used to correct the posterior vault deformity, while the occipital neo-bandeau (ON) has been proposed as an adjunct to improve cranial vault proportions. The purpose of this study was to compare post-operative differences in craniofacial morphology between OS and OS+ON in ULS.

Methods: A retrospective review of patients with ULS who underwent OS or OS+ON was performed. Three-dimensional images were obtained pre-operatively and at 1 year post-operatively. Craniometric measurements included anterior, posterior, and height asymmetry ratios; cranial and turricephaly indices; orbital, midface, and ear asymmetry; and nasal and chin deviation.

Results: Twenty-four patients were identified, 13 treated with OS, and 11 treated with OS+ON. Both cohorts demonstrated significant post-operative improvements in anterior, posterior, and height asymmetry, as well as nasal and chin deviation (p < 0.05). No significant changes were observed in orbital, midface, or ear asymmetry in either group. The OS+ON cohort demonstrated a significant postoperative increase in the turricephaly index (p = 0.039), which was also significantly greater than in the OS-alone group in the intergroup comparison (p = 0.037).

Conclusions: OS with or without ON results in significant improvements in the posterior cranial vault and facial symmetry in patients with ULS. The addition of ON resulted in a significantly greater increase in cranial height, suggesting a role in patients with vertical deficiency.

Background Comprehensive cleft lip and palate (CLP) care relies on a multidisciplinary surgical workforce, primarily composed of plastic surgeons (PS), otolaryngologists (ENT), and oral maxillofacial surgeons (OMFS). While prior studies have examined cleft outcomes and access to care, limited data exist characterizing the current distribution, training background, and age structure of the CLP surgical workforce in North America. Understanding workforce aging and anticipated retirements is essential for future workforce planning and equitable access to cleft care.

Methods A cross-sectional analysis of surgeons actively involved in CLP care in the United States, Canada, and Puerto Rico was conducted. Surgeons were identified using the American Cleft Palate–Craniofacial Association (ACPA) Team Directory. Specialty, degree type, credentials, residency training institution, year of residency completion, and current practice location were verified using publicly available sources. Residency graduation years were stratified into four cohorts: 1973–1994, 1995–2004, 2005–2014, and 2015–2025. Surgeons who completed training prior to 2005 were considered at highest risk for retirement within the next decade. To estimate the new workforce entering the field, we calculated the average annual number of new surgeons based on observed entries from 2021–2025 and applied this mean forward to project future workforce entry.

Results A total of 623 CLP surgeons were identified. Graduation year data were available for 586 physicians. Of these, 346 were plastic surgeons (59%), 137 (23%) ENT, and 103 (17%) OMFS. Graduation cohort analysis demonstrated that 94 surgeons (16%) completed training between 1973–1994 and represent those most likely to retire within the next five years. An additional 116 surgeons (20%) graduated between 1995–2004, indicating that 36% of the CLP workforce is approaching late-career status and may retire within the next decade. By 2030, the CLP surgeon workforce is projected to have a net loss of 18 CLP surgeons, driven by a decrease of 94 surgeons that is only partially offset by 76 new entrants; by 2035, this shortfall is expected to widen to a net loss of 58 CLP surgeons, reflecting a total decrease of 210 surgeons despite the addition of 152 new surgeons. Regionally, the highest proportions of surgeons nearing retirement were observed in the Great Lakes (40%) and New England (39%), followed by the Southwest (37%), Southeast (31%), South (32%), Midwest (29%), and Northwest (29%). Among CLP plastic surgeons, residency and fellowship training were highly concentrated, with the University of Pennsylvania training the greatest number of surgeons at the residency level (n=17) and the Hospital for Sick Children's Toronto training the most at the fellowship level (n=23).

Conclusion The North American CLP surgical workforce demonstrates substantial geographic concentration and a significant proportion of late-career surgeons nearing retirement. Anticipated workforce attrition over the next five years may disproportionately affect regions with limited provider availability. These findings underscore the need for proactive workforce planning, targeted cleft-focused training pathways, and strategic recruitment efforts to ensure sustainable and equitable access to CLP surgical care.

Purpose: Midface hypoplasia (MFH) is a long-term sequela of cleft lip and palate (CL/P), though the extent to which this outcome reflects intrinsic growth disturbance versus growth restriction following surgical repair remains unclear. In high income country settings, early cleft repair limits the ability to characterize long-term midface growth prior to intervention. Preoperative evaluation through global cleft care programs provides an opportunity to assess MFH across developmental timepoints prior to primary repair. This retrospective study aims to define the presence of MFH and characterize its distribution across cleft phenotypes and severity in an internationally representative cohort of patients with unoperated CLP.

Methods: A retrospective review was conducted among patients undergoing cleft evaluation through an international non-governmental organization across 25 countries between 2022 and 2025. Patients with midface measurements recorded at surgical screening were included. MFH status was determined by clinical assessment. MFH prevalence was evaluated across developmental age groups, cleft diagnoses, lip completeness, and palate phenotype using Chi square tests. Continuous cleft severity measurements including unilateral and bilateral cleft lip width and palatal gap width, were categorized as severe if greater than 10 mm and compared between patients with MFH and normal facial projection measurements using Chi square tests.

Results: A total of 3,903 patients undergoing cleft evaluation were included, of whom 449 (11.5%) demonstrated MFH. MFH prevalence differed significantly across age groups, occurring in 14.1% of patients aged <4 years, 6.6% aged 4-8 years, 7.4% aged 8-12 years, 5.1% aged 12-16 years, and 4.9% aged ≥16 years (p<0.001). MFH prevalence also differed significantly across cleft lip diagnoses (p<0.001), with the highest prevalence observed in patients with UCLP (22.45) and BCLP (20.8%) compared to UCL (4.8%) and ICP (5.6%). Among patients with CL completeness recorded, MFH was more prevalent in those with complete lip deformities compared to incomplete lip deformities (p<0.001). MFH prevalence also differed significantly across CP phenotypes (p<0.001), occurring in 21.7% of patients with complete palate, 4.8% with soft+hard palate, 2.4% with soft palate only, 5.2% with submucous cleft, and 25% with alveolar ridge involvement. Among patients with unilateral CL measurements available, cleft widths greater than 10mm were associated with increased MFH prevalence (p<0.01). Among patients with bilateral CL measurements available, CP greater than 10mm were associated with increased MFH prevalence compared to CP <10mm in size (p<0.05).

Conclusion: MFH can be identified at preoperative screening among patients with unoperated CLP and is more prevalent among those with cleft palate, complete clefts, and greater cleft severity measurements. Ongoing prospective data collection will further characterize midface growth development across global populations to better define the natural history of growth trajectories in unoperated CLP patients.