Scientific Abstract Presentations: Craniomaxillofacial Session 8 Saturday, October 17 Sat, Oct 17 10:30 a.m.-12:30 p.m. CDT

Background Postoperative oral feeding practices following head and neck mucosal free-flap reconstruction vary widely, largely due to concerns regarding wound integrity and fistula formation. Although delayed oral intake of 6-12 days has traditionally been favoured, emerging evidence spearheaded by Enhanced Recovery After Surgery programmes suggests that earlier feeding may optimise physiological function, reduce stress response and facilitate recovery and healing. Nevertheless, the ideal timing for oral nutrition is uncertain and its effects on post-operative complications and hospital length-of-stay (LOS) remains contentious.

Methods A systematic review and meta-analysis was performed following PRISMA guidelines. Medline, EMBASE, Cochrane Central, and Scopus were searched for studies comparing early (≤5 postoperative days) and delayed (>5 days) oral feeding after head and neck mucosal free-flap reconstruction. Random- and fixed-effects models were used where appropriate. Primary outcomes included fistula formation, with secondary outcomes comprising pneumonia, flap failure, wound complications, and length of hospital stay (LOS).

Results Thirteen studies met inclusion criteria, representing 1,657 patients. Early oral feeding was associated with a significantly lower incidence of fistula formation compared with delayed feeding (3.66% vs 11.35%; RR 0.37, 95% CI 0.22-0.64; p = 0.0004). Rates of postoperative pneumonia were also reduced in the early feeding group (6.31% vs 12.38%; RR 0.53, 95% CI 0.33-0.87; p = 0.011). Mean LOS was significantly shorter among patients who commenced oral intake early (9.85 vs 13.11 days; MD −4.10 days, 95% CI −7.07 to −1.14; p = 0.0067). No statistically significant differences were observed between groups for flap failure, haematoma, or wound dehiscence. Available data did not demonstrate an increased risk of fistula formation associated with early feeding in patients who had received preoperative radiotherapy.

Conclusion Early initiation of oral feeding following head and neck mucosal free-flap reconstruction is not associated with increased reconstructive complications and is linked to lower rates of fistula formation, reduced pneumonia, and shorter hospital stays. These findings support consideration of earlier oral intake in appropriately selected patients and highlight the need for evidence-based postoperative feeding pathways.

Purpose: Metopic synostosis (MS) is commonly corrected using multi-segment fronto-orbital advancement (FOA), including the frontal bone and supraorbital bandeau. Although this technique reliably expands the anterior vault, it is associated with contour irregularities and bandeau step-offs. The single-segment FOA, utilizing a unified parietal bone flap, was developed to restore a seamless frontal contour. This study compares morphologic outcomes between single-segment and multi-segment FOA in MS.

Methods: A retrospective review was conducted of patients with MS who underwent single-segment or multi-segment FOA. Pre- and post-operative three-dimensional photogrammetry and computed tomography were analyzed to assess intracranial volumes and craniofacial morphology at 2 weeks, 1 year, and 2 years postoperatively. Craniometric variables included cranial index, interfrontal angle, intercanthal distance, and outer canthal distance. Craniofacial composites were created. Control patients were included for comparison.

Results: Twenty patients were included (10 single-segment, 10 multi-segment). Single-segment FOA demonstrated significantly shorter operative time (p=0.003), reduced blood loss (p=0.008), and shorter ICU and hospital stays. Both groups achieved comparable increases in total (13–15%) and anterior cranial volume (23–28%) postoperatively. Craniometric analysis revealed equivalent improvement in cranial index and orbital morphology. The interfrontal angle normalized to control levels in the single-segment group but remained significantly different in the multi-segment cohort through two years.

Conclusions: Single-segment FOA provides cranial and orbital morphologic correction equivalent to multi-segment FOA while reducing perioperative burden and maintaining seamless frontal contour. This technique offers an efficient and reliable alternative for appropriately selected patients with MS.

Background: Endoscopic suturectomy is a minimally invasive option for treating nonsyndromic craniosynostosis. While conferring lower morbidity than traditional techniques, recurrence of suture synostosis is of particular concern given the more conservative correction and reliance on early timing and postoperative molding. While previous studies report variable recurrence rates ranging from 2% to over 10%, the specific incidence following endoscopic techniques and factors predictive of recurrence remain underexplored. Methods: We performed a retrospective review of nonsyndromic patients with isolated single-suture craniosynostosis who underwent endoscopic suturectomy between January 2012 and July 2025. Re-synostosis was defined as radiographic or clinical evidence of pathologic refusion of the released suture. Patient demographics, suture involvement, timing of diagnosis, and reoperation details were collected. Results: A total of 238 patients with nonsyndromic single-suture craniosynostosis underwent endoscopic suturectomy. The average age at surgery was 0.28 years (range: 0.14–0.53), with a male predominance (174 male, 64 female). The most common suture involved was sagittal (n=154), followed by metopic (n=62), coronal (n=19), and lambdoid (n=3). Ten patients (4.2%) developed recurrence. The average age at initial surgery for patients with recurrence was significantly younger than those without recurrence (0.23 vs. 0.28 years, p = 0.003). While sagittal cases made up the majority of the overall cohort and recurrence group, the recurrence rate was not significantly different from other suture types (p = 1.0). In contrast, recurrence was significantly more common in patients with coronal synostosis (p = 0.036), and no recurrences were observed in metopic or lamdoid cases. There was a significant association with female sex (7 female vs 3 male, p = 0.005). Re-synostosis was suspected or diagnosed at a mean of 1.67 years postoperatively (range: 0.61–4.44) on average, and reoperation occurred at a mean age of 1.81 years (range: 1–4.94). Conclusion: In this large single-institution cohort, the re-synostosis rate following endoscopic suturectomy for nonsyndromic single-suture craniosynostosis was 4.2%. Our findings suggest that female sex, younger age at the time of endoscopic suturectomy, and coronal suture involvement are associated with increased risk of recurrence. The association with younger surgical age may be due to faster bone remodeling and suture healing in early infancy, potentially predisposing to premature re-fusion. Additionally, coronal synostosis may be inherently more prone to recurrence due to its complex anatomical location and technical challenges with achieving a complete release. These findings underscore the need for tailored surveillance strategies in higher-risk subgroups and appropriate family counseling.

Background: Facial trauma represents a significant source of morbidity requiring complex, multidisciplinary management. While most outcomes data are derived from Level I trauma centers, Level II centers are disproportionately more numerous across the United States and collectively manage a substantial portion of the national facial fracture burden. Care protocols for operative timing, specialty consultation, and postoperative follow-up are largely extrapolated from higher-acuity settings, and relatively little is known about how management patterns and outcomes differ at the Level II center level. The role of individual surgical specialties in leading versus consulting on facial trauma cases may also vary across center types, with implications for care coordination and outcomes. The present study describes the epidemiology, management patterns, and clinical outcomes of facial trauma at a community, academic-affiliated Level II trauma center. Methods: A retrospective cohort study was conducted at a single Level II trauma center (2020–2024). An initial query of the institutional trauma registry and electronic health record identified 964 encounters; after excluding minor trauma and applying predefined criteria, a final cohort of 260 patients with significant facial fractures was identified. Variables include demographics, injury mechanism, fracture distribution, polytrauma status, primary managing service, subspecialty consultation patterns, operative management, time from ED to the operating room, and clinical outcomes including complications, ICU admission, length of stay, 30-day ED return, readmission, and mortality. Descriptive statistics and multivariable logistic regression identified independent predictors of operative intervention. Results: Findings demonstrate a mean age of 62.9 years with a male predominance (63%). Falls were the leading mechanism (64%), followed by motor vehicle collision (22%) and assault (13%), with blunt mechanism accounting for 96% of cases. Polytrauma was present in 73% of patients. The most frequently involved facial regions were orbital (56%), maxillary (45%), nasal (34%), zygomatic (19%), and mandibular (7%). Trauma Surgery served as the primary managing service in the majority of encounters. Plastic Surgery was the most frequently consulted specialty (50%), followed by OMFS (29%) and Ophthalmology (24%). Notably, among patients with mandibular fractures, Plastic Surgery was consulted in 70% of cases compared to OMFS in 20%, and Ophthalmology was consulted in only 37% of patients with orbital fractures. Operative management was undertaken in 16%; mean time from ED to the operating room was 50.9 hours (median 30.0 hours). ICU admission was required in 26%, with a mean length of stay of 4.7 days. Overall complication rates were low and mortality was 5.0%. On multivariable logistic regression, mandibular fracture was the strongest independent predictor of operative intervention (OR 5.70, 95% CI 2.26–12.35, p<0.001). Plastic Surgery consultation was independently associated with operative management (OR 2.33, 95% CI 1.02–5.36, p=0.042). Conclusion: Facial trauma managed at a Level II trauma center carries a meaningful operative burden, with mandibular fracture emerging as the strongest independent predictor of surgical intervention. Plastic Surgery consultation is independently associated with operative management, suggesting a clinically relevant and previously undercharacterized role for the specialty in this setting. These data provide an evidence base for formalizing Plastic Surgery involvement in Level II facial trauma protocols.

Background: Mandibular distraction osteogenesis (MDO) is widely used to treat airway obstruction in infants and young children with micrognathia and Pierre Robin sequence. Large multicenter data evaluating outcomes stratified by syndromic status remain limited. Methods: A retrospective cohort study was performed using the Epic Cosmos national electronic health record network. Children younger than 2 years old who underwent MDO between 2014 and 2024 were identified. Patients with pre-existing tracheostomy were excluded. Syndromic status was defined using ICD-10-CM codes for craniofacial and chromosomal syndromes. Postoperative outcomes included feeding difficulty, failure to thrive (FTT), gastrostomy tube placement, respiratory failure, respiratory-related readmission, new tracheostomy, and repeat distraction. Unadjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Results: A total of 1,162 patients met inclusion criteria, including 291 syndromic and 871 non-syndromic patients. Syndromic patients demonstrated significantly higher postoperative morbidity across all measured outcomes. Compared with non-syndromic patients, syndromic patients had increased odds of new tracheostomy (6.2% vs 1.3%; OR 5.14, 95% CI 2.36–11.20), repeat distraction (11.3% vs 3.1%; OR 4.00, 95% CI 2.32–6.89), and respiratory-related readmission (12.0% vs 3.1%; OR 4.28, 95% CI 2.50–7.34). Feeding-related morbidity was also significantly higher, including feeding difficulty (79.0% vs 49.5%; OR 3.83, 95% CI 2.78–5.28), gastrostomy tube placement (22.3% vs 8.6%; OR 3.04, 95% CI 2.10–4.39), and failure to thrive (35.1% vs 20.1%; OR 2.15, 95% CI 1.59–2.90). Postoperative respiratory failure was more common among syndromic patients (23.0% vs 11.4%; OR 2.33, 95% CI 1.63–3.33). Conclusions: In this large multi-center cohort, syndromic diagnosis was associated with substantially increased airway re-intervention and feeding morbidity following MDO. These findings support incorporating syndromic status into preoperative counseling, perioperative planning, and anticipatory guidance regarding potential re-intervention and feeding support needs.

Purpose: To evaluate the differential cost burden associated with custom versus standard (non-custom) mandibular and maxillary fixation plates in pediatric jaw reconstruction.

Background: Jaw reconstruction frequently requires surgical hardware to restore structural stability, re-establish native anatomy, and support oral function. Traditionally, reconstruction is performed using standard titanium plates contoured intraoperatively to approximate patient anatomy. Advances in computer-aided design and manufacturing and virtual surgical planning have enabled the development of patient-specific, custom endoprostheses designed preoperatively for optimized fit and anticipated reconstructive outcomes. While custom hardware is widely understood to carry higher upfront costs, there is limited literature quantifying the true cost differential, particularly in pediatric head and neck reconstruction.

Methods: A retrospective review was conducted of pediatric patients undergoing maxillary and/or mandibular reconstruction at a single tertiary children's hospital between 2014 and 2025. Patients were included if custom endoprostheses or standard reconstruction plates were used and manufacturer invoice data were available. To minimize pricing variability, cases were limited to a single manufacturer. Data collected included total hardware invoice cost, hospital reimbursement for non-hardware costs, demographics, reconstructive indication and type, operative time, and length of stay. Hardware costs and financial outcomes were compared using parametric and nonparametric testing as appropriate. Multivariable linear regression was performed to control for reconstruction type, anatomic location, age, operative time, insurance status, and length of stay.

Results: Twenty-eight operations met inclusion criteria. The cohort was predominantly male (57.1%), Hispanic (60.7%), and publicly insured (85.7%). Most reconstructions were performed for mass resection (96.4%). Twenty-two cases (78.6%) involved mandibular reconstruction and six (21.4%) involved maxillary reconstruction. Thirteen operations (46.4%) utilized custom plates and 15 (53.6%) utilized non-custom plates. Mean hardware cost for custom reconstruction was $66,718.64 ± 13,666.55 compared to $13,455.59 ± 19,742.57 for non-custom reconstruction (mean difference $53,263.06; p < 0.001). On multivariable regression, non-custom plates were independently associated with a $27,945.68 lower hardware bill compared to custom plates (p = 0.001). Operative time was longer in custom cases on unadjusted analysis (p = 0.002); however, custom plate use was not independently associated with operative time after controlling for reconstruction type and location (p = 0.865). There was no significant difference in reimbursement percentage between groups on unadjusted analysis. However, multivariable regression demonstrated that non-custom plates were associated with a 15.1% higher reimbursement rate (p = 0.017) while public insurance was associated with a 21.9% lower reimbursement rate (p = 0.004).

Conclusions: Custom pediatric jaw reconstruction hardware is associated with substantially higher upfront costs compared to standard plates. Although custom implants may offer technical and reconstructive advantages in select cases, their financial impact is significant. Surgeons and institutions should carefully weigh cost considerations alongside clinical benefit when selecting implant type. Further investigation into patient-centered outcomes and long-term cost-effectiveness is warranted to better define the value of custom hardware in pediatric jaw reconstruction.

Purpose: Mature cleft rhinoplasty is commonly performed after completion of facial growth. Among tools to achieve nasal tip symmetry, the Potter technique aims to recruit the displaced lower lateral cartilage by a complete vestibular release and V to Y nasal mucosal closure. This study evaluates anthropometric outcomes of the Potter technique for mature unilateral cleft rhinoplasty across a ten-year period.

Methods: A retrospective, single-surgeon review was conducted of all facially mature patients with unilateral cleft lip who underwent mature cleft rhinoplasty with the Potter technique from January 2015 to December 2024. Data collection included patient demographics, surgical history, and anthropometric measurements of standardized pre- and post-operative photographs at a minimum of one-year follow-up. Ten anthropometric parameters were measured using the Dolphin Imaging Software. These included: alar cant, vertical alar height, alar height angle, columellar angle, nostril width ratio, nostril height ratio, nostril height-to-width ratio, alar base width ratio, nasofacial angle, and nasolabial angle. Paired t-tests were used to compare pre- and postoperative measurements. Statistical significance was defined as p < 0.05.

Results: A total of 12 patients met the inclusion criteria, 33.3% of which were male. The mean age of patients at the time of mature cleft rhinoplasty was 23.3 ± 7.7 years. Orthognathic surgery was performed in 50.0% of patients prior to mature cleft rhinoplasty, and secondary alveolar bone grafting in 66.7%. Post-operative photographs were taken at a mean follow-up of 2.3± 1.3 years. There were statistically significant improvements in alar height angle (p < 0.001), vertical alar height ratio (p = 0.01), columellar angle (p = 0.002), nostril width ratio (p = 0.04), nostril height ratio (p = 0.03), nostril height-to-width ratio (p = 0.005), and nasofacial angle (p = 0.01). There were no statistically significant differences in alar cant, alar base width ratio, or nasolabial angle.

Conclusions: The Potter technique for mature cleft rhinoplasty in patients with unilateral cleft lip can improve anthropometric dimensions. It should be considered in patients with symmetric alar base width who would benefit from advancement of the lower lateral cartilage to improve nostril and nasal tip symmetry.

Purpose: Midface hypoplasia (MFH) is a known sequela of cleft lip and palate (CLP), but whether it reflects inherent growth disturbance or restriction from surgical repair remains unclear. This study aims to define the prevalence and severity of MFH in unoperated CLP and characterize natural midfacial growth patterns across cleft phenotypes.

Methods: This cross-sectional descriptive study includes patients aged 4 and older presenting with an untreated cleft lip and palate to Operation Smile surgical programs. Patients undergo clinical assessment, performed by a cleft surgeon, evaluating Angle's classification of malocclusion, visual assessment of the maxillary-mandibular relationship, and measurement of the degree of discrepancy between the maxilla and mandible. Patient demographics, cleft phenotype, palate severity, alveolar involvement, and barriers to surgical access which resulted in the patient's late presentation are also collected. All eligible patients meeting inclusion criteria are being continuously enrolled across multiple global sites.

Results: Preliminary data include 10 untreated CLP patients from Pakistan, Colombia, Honduras, and Madagascar. Palatal severity among patients with cleft palate was classified as severe in two patients, moderate in two, and mild in five, with one additional patient presenting with cleft lip phenotype alone. Occlusal classification demonstrated Class I malocclusion in five patients, Class II in one, and Class III in four. Maxillary-mandibular discrepancy measured <1 mm in one patient, 1–5 mm in eight, and 6–10 mm in one. No revisions were recommended. Delayed presentation was most commonly associated with financial barriers and limited access to surgical services, with additional contributions from geographical constraints, comorbid conditions limiting surgical clearance, cultural factors inhibiting access to care, and malnutrition.

Conclusions: These early findings, based on our small initial cohort, suggest that characteristics of MFH can be identified prior to surgical intervention in patients with late presenting, unoperated clefts. As data collection expands across multiple sites this upcoming year, larger cohorts will enable a more complete understanding of the natural history, severity, and variation of midface growth patterns in unoperated CLP.

Purpose: Children born outside formal health systems miss a critical entry point to established referral pathways for receiving cleft care. In this study, we examine the impact of home versus hospital birth on the timeliness of primary cleft repair in a multinational cohort of low-income country patients.

Methods: A retrospective review of Operation Smile program data was performed from 2022–2025. CLP patients with documented place of birth and ages of both primary lip and palate surgery were included. Outcomes were age at surgery and timeliness of lip and palate repair (lip ≤12 months; palate ≤18 months). Analyses used descriptive statistics, chi-square tests, and calculation of risk differences (RD) and risk ratios (RR).

Results: Of a total of 1,586 patients, the mean age at lip repair was significantly later among children born at home compared to those born in hospitals 20.7 ± 35.4 months vs. 12.0 ± 27.0 months (p=0.0007), and the mean age at palate repair was also delayed for home births 44.3 ± 60.6 months vs. 28.3 ± 47.0 months (p = 0.0009). For primary lip surgery, 72% of home births achieved repair by 12 months compared to 85% of hospital births (p < 0.001). For primary palate surgery, 46% of home births achieved palate repair by 18 months compared to 56% of hospital births (p = 0.019).

Conclusion: Hospital delivery was associated with significantly earlier access to CLP repair. Bridging the gap between obstetric and surgical systems is therefore of utmost importance to improving equity in cleft care access. Understanding the impact of hospital delivery on surgical timeliness equips providers and programs to prioritize early engagement and referral pathways, which can increase rates of timely cleft repair and improve long-term speech and growth outcomes.

Background Biodegradable Temporizing Matrix (BTM) is increasingly utilized for reconstruction of complex cutaneous defects following oncological resection (1). However, the impact of radiotherapy on BTM integration and wound healing remains poorly characterized. This study evaluates the resilience of BTM to radiotherapy, focusing on healing outcomes, breakdown rates, and reconstruction success.

Methods A retrospective analysis of 295 patients who underwent BTM reconstruction between September 2020 to February 2026 was performed. Of these, 252 were for reconstruction following cutaneous malignancy excision, with 143 in the head and neck region. 22 patients, all of whom had cutaneous malignancies in the head and neck region, received radiotherapy following BTM reconstruction (8.7% of all malignancies, 15.4% of head and neck cases). Primary outcomes included BTM breakdown, time to healing, and graft take rates. Secondary reconstruction methods included split-thickness skin graft (SSG), full-thickness skin graft (FTSG), and secondary intention healing.

Results Data pertaining to 22 patients were collected with a median follow-up of 23 months (range 8-57). 18 patients had adjuvant radiotherapy, 4 had prior radiotherapy to the area operated upon. Median age was 76 years (range 32-91). The majority of tumors were stage 3-4 (95%) with invasion to bone (64%). 4 patients had Mohs micrographic surgery, the remainder had conventional excision. Overall graft take rate (SSG/FTSG) was 94.4% (17/18). Mean time to secondary reconstruction with skin graft was 55.4 days. In cases where secondary healing was allowed to occur, mean time to healing was 89 days. Overall BTM integration success was 81.8% (18/22). Breakdown occurred in 4 patients (18.2%), with one case (4.5%) attributable to tumor recurrence. As such, BTM breakdown due to radiotherapy could be considered to have occurred in 3 cases (13.7%). In these three cases, breakdown was noted to have occurred in 2, 25 and 28 months following radiotherapy. All non-recurrence breakdowns occurred on burred calvarium and were successfully managed with local interventions.

Conclusions This study represents the largest and only series worldwide examining adjuvant radiotherapy following BTM reconstruction. Our findings demonstrate that BTM exhibits acceptable resilience to radiotherapy, with an overall integration success rate of 81.8% and graft take rate of 94.4%. Prior radiotherapy does not appear to impair BTM integration. Clinicians should be aware that breakdown of BTM can occur up to 2 years following radiotherapy. These novel data provide important guidance for the management of patients requiring both BTM reconstruction and adjuvant radiotherapy for advanced cutaneous malignancies.

References Conway L, Snashall E, Gill P, Harper-Machin A. The Use of Novosorb Biodegradable Temporizing Matrix for Reconstruction in Head and Neck Cancer: A Simple Answer to a Complex Problem. Plast Reconstr Surg Glob Open. 2025;13(4):e6702.

Introduction: Patients with Treacher Collins syndrome (TCS) undergo multiple reconstructive procedures throughout childhood and into adulthood. Lateral canthopexy is a common surgical technique utilized to address lower eyelid appearance in this cohort of patients. However, long-term outcomes and surgical techniques remain poorly defined. This study evaluated the longitudinal stability of changes in MRD2, scleral show, and canthal tilt when using three different techniques for malar augmentation with lateral canthopexy. Methods: We conducted a retrospective analysis of 14 patients with TCS who underwent lateral canthopexy. The malar augmentation techniques considered included: malar implant (n=3), bone graft (n=4), fat graft (n=5), and no malar augmentation (n=2). Linear mixed effects models were used to evaluate changes in marginal reflex distance 2 (MRD2), scleral show, and canthal tilt over time, with preoperative severity scale included as a covariate. Estimated marginal means were computed for each augmentation and surgical technique at each time point. Pairwise comparisons contrasted each post-operative timepoint against preoperative baseline to assess for significance. Results: The results of lateral canthopexy in this cohort are mixed. Patients who received soft tissue canthopexy showed sustained significant improvements at multiple timepoints (0-6mo: p=0.012; 1-3yr: p=0.002; 3+yr: p=0.016). Conversely, patients who received the bone anchoring technique demonstrated worsening (1-3yr: p=0.024). Patients who received bone grafting showed better improvement in MRD2, compared to patients who received fat grafting and had better canthal tilt. Patients who received implant-based reconstruction demonstrated the most robust early improvement with significant reduction in MRD2 (p=0.003) and scleral show (p=0.035) at 0–6 months (p=0.029). However, long-term data is unavailable for this subgroup. Patients who received fat grafting demonstrated significant improvement in canthal tilt at 0-6 months that remained after 3 years (p=0.024). Patients without malar augmentation did not demonstrate significant changes at any time point. Conclusion: Lateral canthopexy alone provides limited sustained benefit for Treacher Collins patients. Soft tissue techniques unexpectedly outperformed bone anchoring, challenging conventional surgical assumptions. Patients who received malar implants demonstrate a significant immediate improvement. However, fat grafting confers durability in maintaining correction of canthal tilt long term. These findings support a differentiated approach to malar augmentation selection based on desired outcomes. Long-term evaluation is required to assess durability of implant based reconstruction.

PURPOSE: Sleep-disordered breathing (SDB), and obstructive sleep apnea (OSA) in particular, are common conditions with significant implications for perioperative and anesthesia risk, neurocognitive development, cardiovascular health, and long-term quality of life. To provide customized and excellent care to the SDB patient, a craniofacial surgeon should be fluent in sleep medicine terminology, diagnostic and treatment options, and perioperative management strategies. The purpose of this project was to construct a proposed clinical workflow algorithm for the craniofacial surgeon, based on sleep-medicine principles and institutional experience.

MATERIALS AND METHODS: Definitions and terminologies were extracted from sleep-medicine literature. Indications and limitations of routine objective testing modalities were reviewed. Interpretations of their results were stratified by risk. Additionally, specific craniofacial conditions were analyzed for key differentiating factors in surgical decision making, such as airway mechanics and collapsibility, structural issues, and central versus obstructive events.

RESULTS: Key definitions identified included apnea, hypopnea, apnea-hypopnea index (AHI), obstructive apnea index (OAI), oxygen desaturation index (ODI), and arousal index. Objective testing modalities included polysomnography, cardiorespiratory polygraphy, overnight oximetry (ONO), and drug-induced sleep endoscopy (DISE). High-risk features identified included severe OSA, obesity in older children/adults, severe facial skeletal dysplasia, significant cardiopulmonary comorbidities, as well as micrognathia, midface hypoplasia, syndromic diagnoses, feeding difficulty, failure to thrive, witnessed apneas, and significant desaturation on telemetry. Using previously published sleep medicine principles and key perioperative considerations, as well as our institutional experience, a standardized clinical workflow for use by craniofacial surgeons was developed.

DISCUSSION: Craniofacial surgeons play a pivotal role in recognizing, diagnosing, and managing SDB across a patient's lifespan. Mastery of sleep terminology, age-specific diagnostic criteria, and testing limitations is necessary to make appropriate perioperative and long-term management decisions. Our proposed clinic-ready algorithm informs a more standardized approach to the management of patients in need of craniofacial surgery, focusing on the pertinent polysomnographic parameters that guide management. The developed workflow provides key standardized steps for craniofacial surgeons to consider, including initial screening, risk stratification, testing selection, perioperative planning, and post-treatment protocols. Future assessments should utilize standardized evidence-based protocols tailored to craniofacial and pediatric OSA patients to reduce practice variability and adverse events.

Background

Primary cutaneous squamous cell carcinoma (cSCC) of the head and neck with close or involved deep excision margins carries high risk of recurrence, necessitating adjuvant radiotherapy or bone burring and subsequent reconstruction. Minimal work has been published examining the efficacy of burring. We describe a cohort of such patients and assess their recurrence rate.

Methods

Retrospective chart review to obtain patient demographics and tumour characteristics. Patients with primary disease only with either close (<1mm) or involved deep excision margin at their initial operation were included. Patients had been managed with burring, radiotherapy or observation alone. Logistic regression was used to examine the association between burring and recurrence, reported as odds ratio (OR) with 95% confidence intervals (95% CI).

Results

Data for 200 patients were collected. 167 were male (83.5%), mean age of cohort 81 years (SD 8.51). Burring was done in 112 patients (56%), of which 12 had radiotherapy. Radiotherapy was the sole modality in 39 patients (19.5%) and observation alone in 49 (24.5%). In burred patients, 9 developed local recurrence or new nodal disease (8%). This is lower than rates demonstrated in other case series (11.8-50%). In patients that received radiotherapy alone, incidence of recurrence was seen in 6 cases (11.8%) and in patients that had no intervention, recurrence was observed in 8 cases (16.3%).

In logistic regression models, burring is strongly inversely associated with local disease recurrence (OR 0.24, 95% CI 0.06-0.90). This was statistically significant (p=0.03), following multivariate adjustment for age, sex, radiotherapy, tumour characteristics, perineural invasion and staging.

Conclusion

Our results demonstrate that outer table bone burring appears to be strongly protective against local SCC disease recurrence in the head and neck, with a significant inverse association. As such it should be considered as a primary treatment modality in patients with close/involved deep margins, offering robust local disease control and deep margin management. Our approach appears to have lower recurrence rates than other reported series, perhaps due to our extensive use of burring, however prior series have been limited in their scope.

Introduction Precise assessment of facial paralysis outcomes remains challenging due to the subjective nature of clinical measurements. Current facial movement evaluation methods are examiner-dependent and lack reproducibility. To this end, we developed an automated tool, numeriFACE suite, to quantify facial movement from images and videos, eliminating the need for manual landmark placement.

Methods Preoperative and postoperative images of 100 patients who underwent free muscle flap facial reanimation were analyzed using numeriFace. Static-Commissure-Displacement (SCD) was calculated as the change in commissure position between pre and postoperative images at repose. Commissure-Excursion (CE) measured how far the commissure traveled from repose to smile. Static-Upper-Lip-Displacement (SULD) was calculated as the vertical displacement of the Cupid's bow–to–commissure midpoint from preoperative to postoperative repose positions. Commissure-Excursion (CE) and Upper-Lip-Dental-Show (ULD) measured how far the commissure and upper lip, respectively, moved from repose to smile. Values were reported as mean (min,max), where negative SCD/CE and SULD/ULD values correspond to medial and caudal directions, respectively. Moreover, symmetry ratio (SR) was calculated as the ratio of the smaller CE to the larger CE.

Results Across 100 facial reanimation patients, the affected side SCD increased on average by 6.1 mm (min: 0.7 mm, max: 18.4 mm) laterally, accompanied by gains in CE at 4.6 mm (0.1,13.8), SULD at 4.8 mm (-1.9,17.8), and ∆ULD at 2.3 mm (0.0,7.8). Corresponding contralateral values were -3.9 mm (-9.9,-0.7), 3.8 mm (0.0-14.2), -3.5 mm (-10.0, 9.6), and 2.2 mm (0.0-8.8), respectively. Symmetry ratio improved from 0.62 to 0.79 on average postoperatively.

Conclusion numeriFACE is a novel, reliable, standardized, and patient-specific clinical tool that can quantify, monitor and assess facial function and recovery in facial paralysis patients.

Introduction The use of venous coupler devices for venous anastomosis in head and neck free flap reconstruction is increasingly more common as compared to hand-sewn anastomoses. Few studies have analyzed the effect of venous coupler size on venous complications. Those that have, only included patients who required a revision of the anastomosis and did not include venous congestion or use of leeches as complications. We aimed to analyze the impact of venous coupler size on venous complications stratified by the type of flap performed for head and neck reconstruction.

Methods An IRB-approved retrospective study was performed for all patients who underwent head and neck free flap reconstruction at a single academic institution from 2016 to 2024. Patients underwent maxilla, mandible, tongue, or floor of mouth reconstruction. Data collected included flap type, number of veins used for anastomosis, venous coupler size, and venous complications such as venous congestion, flap takeback for redo venous anastomosis, or flap loss. Statistical analysis included a two-sample t-test with p-value < 0.05 indicating statistical significance.

Results Of the 124 patients were included, 63 (50.8%) underwent free fibula flap, 31 (25%) free radial forearm flap, 18 (14.5%) free anterolateral thigh flap (ALT), and 12 (9.7%) free scapula flap. There were a total of 8 (6.5%) patients with venous complications. 74.6% of fibula flaps used two or more veins compared to 19.4% of radial forearm flaps, 27.8% of ALT, and 25% of scapula. The average coupler size in fibula flaps without venous complications was 3.62 +/- 0.58 vs 3.63 +/- 0.48 with complications (p = 0.97). The average coupler size in radial forearm flaps without venous complications was 3.45 +/- 0.75 vs 3.5 in the one patient with complications. The average coupler size in ALT flaps without complications was 3.68 +/- 0.48 vs 4.0 in the one patient with complications. The average coupler size in scapula flaps without complications was 3.85 +/- 0.23 vs 3.0 +/- 0 with complications (p = 0.005).

Conclusion Overall, venous coupler size was not associated with venous complications across most flap types, suggesting that coupler size alone should not drive intraoperative decision-making. Microsurgeons should continue to select coupler size based on vessel quality, match, and clinical experience rather than attempting to maximize size. However, in free scapula flaps, venous complications were significantly associated with a smaller coupler size. This finding may reflect the greater anatomic heterogeneity of the subscapular system, as well as the frequent use of scapula flaps as chimeric flaps with larger tissue volume and more complex venous drainage patterns indicating outflow dynamics may be more sensitive to coupler diameter.

Background Successful cleft palate repair requires reconstruction of the velar musculature, tension-free closure, and sufficient soft-palate lengthening to establish velopharyngeal competence. This study introduces a novel hybrid approach that integrates elements of established repairs to optimize muscular reconstruction and palatal lengthening. Prospective intraoperative morphometric changes and preliminary postoperative outcomes are reported.

Methods The proposed Hybrid Approach Palatoplasty incorporates three major components: 1) a radical intravelar veloplasty to release and reconstruct the levator veli palatini sling with mirrored posteriorly based oral myomucosal flaps, 2) a midline closure of the nasal lining; and 3) effective soft palate lengthening with a buccal myomucosal flap (BMF) to offload tension and facilitate retropositioning of the muscular sling. Prospectively followed, consecutive patients undergoing Hybrid Approach Palatoplasty were evaluated. For comparison, patients who underwent Furlow palatoplasty without BMF were included. Demographics, cleft phenotype, flap utilization, intraoperative measurements, and postoperative outcomes were collected. Morphometric outcomes included intraoperative changes in palatal length (Base of Uvula to Hard Palate-Soft Palate Junction; BU–HPSP) and resting AP dimension of the velar port (Posterior Pharyngeal Wall to Base of Uvula; PPW–BU). Associations between cleft severity and palatal morphometric changes were assessed using Spearman correlation.

Results A total of 41 pediatric patients met inclusion criteria. Of these, 33 patients underwent the Hybrid Approach Palatoplasty; eight patients underwent Furlow palatoplasty without BMF. The median age at surgery was 14.0 months (interquartile range [IQR] 12.0-18.5). The majority of patients were male (56.1%), Hispanic (75.6%) and publicly insured (67.5%).

Both the Hybrid Approach and control groups demonstrated significant increase in postoperative palatal length (BU-HPSP) (p<0.001 for both) and postoperative pharyngeal wall advancement (PPW-BU) (p<0.001 for both). Direct comparison demonstrated that the Hybrid Approach group achieved significantly greater palatal lengthening than the control group (median 13 [IQR 10.5–15.5] vs. 6 [5–8.5] mm, p<0.001). Posterior pharyngeal wall approximation was significantly greater in the Hybrid Approach cohort (12 [9–14] vs. 6.5 [5.25–9.25] mm, p<0.001). Spearman's rank correlation analysis demonstrated a positive association between increasing cleft severity and magnitude of palatal lengthening (ρ=0.641, p<0.001) and velar advancement to the PPW (ρ=0.651, p<0.001). There was no difference in operative time (p=0.428) and estimated blood loss (p=0.972) between the two groups.

One patient in the Hybrid Approach cohort developed postoperative respiratory distress requiring intubation. No postoperative fistula, bleeding, or wound dehiscence occurred in both cohorts.

Conclusions Hybrid Approach Palatoplasty represents an integrated approach for cleft palate repair. Preliminary outcomes demonstrate significant improvements in palatal length and velar port dimension across cleft severities and compared to palatal changes generated by the traditional Furlow, with no observed early complications or fistulas. This approach can be applied to all cleft types and, in the setting of Veau II clefts, does not require hard palate mucosal elevation. Further prospective evaluation to assess long-term speech and velopharyngeal outcomes is necessary

Background

Deep neck contouring procedures involving near-total anterior digastric excision, subhyoid fasciotomy, and submandibular gland reduction are increasingly utilized to achieve refined cervicomental definition. However, concerns persist regarding potential long-term functional compromise, particularly in swallowing, articulation, and lower lip competence. Prior aesthetic surgical series and anatomic analyses have demonstrated low rates of persistent dysphagia or oral incompetence following anterior digastric modification and submandibular gland contouring, supporting functional preservation when meticulous technique is employed.¹–⁵

Methods

A retrospective cohort study was conducted including 186 patients who underwent advanced deep neck surgery incorporating near-total anterior digastric excision, subhyoid fascial release, and selective submandibular gland reduction. All patients had a minimum follow-up of 14 months. Functional outcomes including swallowing, articulation, oral competence, and lower lip motor function were evaluated clinically during early and long-term follow-up.

Results

Approximately one-third of patients experienced transient early swallowing difficulty lasting 1–3 days postoperatively. Temporary articulation or voice changes resolved within 5–7 days. One patient with more pronounced early dysfunction received intraoperative submandibular botulinum toxin injection and demonstrated full recovery by 14 months.

Transient lower lip weakness was observed in approximately one-third of patients in the early postoperative period, decreasing to one-seventh at long-term follow-up. Notably, 45% of patients had undergone previous lower face or neck procedures.

Twelve patients required revision surgery for residual digastric laxity between 8–12 months postoperatively; no functional compromise was observed following revision.

Conclusion

Advanced deep neck contouring incorporating near-total digastric excision and gland reduction demonstrates preserved long-term swallowing, articulation, and oral competence. Early functional changes are transient and self-limiting. These findings are consistent with prior aesthetic and anatomical literature demonstrating functional redundancy within the suprahyoid complex and low rates of persistent dysfunction following digastric modification and submandibular gland contouring.¹–⁵ With refined technique and appropriate patient selection, the procedure appears functionally safe at mid-term follow-up.

References (Sequential Order)

1. Marten TJ, Feldman JJ, Connell BF. Treatment of the full obtuse neck. Aesthetic Surgery Journal. 2005;25(4):387–396. https://academic.oup.com/asj/article/25/4/387/190221

2. McCleary SP, Moghadam S, Le C. Volumetric assessment of the anterior digastric muscles: a deeper understanding of the volumetric changes with aging. Aesthetic Surgery Journal. 2023;43(1):1–10. https://academic.oup.com/asj/article-abstract/43/1/1/6678813

3. Ch'ng S, Bravo FG. In vivo anatomy of the facial nerve: implications for partial parotidectomy in neck lift surgery. Aesthetic Surgery Journal. 2025. https://academic.oup.com/asj/advance-article/doi/10.1093/asj/sjaf126/8173647

4. Rauso R, De Cicco D. Surgical anatomy of the face and neck. In: Stepwise Atlas of Aesthetic Medicine and Surgery. Springer; 2025. https://link.springer.com/chapter/10.1007/978-3-031-95036-0_1

5. Bitar G, Giampapa V. Algorithm for neck rejuvenation. In: Simplified Facial Rejuvenation. Springer; 2008. https://link.springer.com/chapter/10.1007/978-3-540-71097-4_79

Background The free fibula osteocutaneous flap is widely used for head and neck reconstruction due to its reliability and versatility. Despite low donor-site morbidity, postoperative weakness of great toe dorsiflexion remains a recognized complication, most commonly attributed to injury to the nerve supplying the extensor hallucis longus (EHL) muscle. The anatomical course of this nerve is variable and places it at risk during proximal fibular dissection. This study evaluates anatomical variations of the nerve to the EHL and assesses the impact of deliberate nerve identification and preservation on postoperative functional outcomes. Methods A prospective study was conducted between January 2024 and June 2025, including 62 patients undergoing free fibula flap harvest for mandibular or maxillary reconstruction (Group A). Intraoperative identification of the deep peroneal nerve and its branches to the EHL was performed using nerve stimulation, and detailed anatomical measurements were recorded. Postoperative assessment of great toe dorsiflexion was performed on day one and at 6-month follow-up. Outcomes were compared with a retrospective cohort of 580 patients who underwent fibula flap harvest without targeted nerve identification between 2016 and 2023 (Group B). Statistical analysis was performed using Fisher's exact test. Results Significant anatomical variability in the nerve to the EHL was observed. The first nerve branch was most commonly located on the tibial side (48.3%), followed by the anterior (38.7%) and fibular sides (12%). Similar distribution was noted for the second branch. The mean distance of the nerve from the anterior border of the fibula was 0.25 cm, highlighting its vulnerability during proximal osteotomy. In Group A, isolated postoperative EHL weakness occurred in 1 patient (1.6%), with complete recovery by 6 months. In Group B, 12 patients (2.06%) developed EHL weakness, of whom 7 (1.2%) had persistent deficits. The difference between groups was not statistically significant (p=0.11). Conclusions The nerve to the extensor hallucis longus demonstrates considerable anatomical variability and lies in close proximity to the fibula, placing it at risk during flap harvest. Systematic intraoperative identification and preservation of this nerve is associated with a low incidence of postoperative great toe weakness and may reduce persistent deficits. Understanding nerve anatomy and adopting meticulous dissection techniques are critical for minimizing donor-site morbidity following free fibula flap reconstruction.

(Panel Submission, all authors as panelists) Success in porous polyethylene (PP) ear reconstruction requires precise surgical technique, patient selection, and postoperative care. To achieve reproducible and consistent results, surgeons must master foundational techniques, anticipate complications, and develop strategies for salvage and long-term management. These challenges can lead many surgeons to abandon the technique or become burdened by recurring negative outcomes. This panel discussion aims to provide a guide for both early-career and experienced plastic surgeons who wish to successfully implement and refine PP ear reconstruction in their practice.

This session will address the following key aspects of PP ear reconstruction: 1. Technical Mastery: Provide resources on harvesting and elevating the temporal parietal fascia flap and occipital fascia flap, emphasizing anatomical landmarks, flap design, and maximal preservation of the vascular networks to ensure robust coverage of alloplastic frameworks. 2. Patient Selection: Strategies for distinguishing straightforward cases from complex ones, with guidance on selecting appropriate patients for early-career surgeons to build confidence and competence while minimizing risks. 3. Postoperative Management: Best practices for postoperative care, including surgical dressings, wound care, monitoring for vascular compromise, and patient education to optimize healing and aesthetic outcomes. 4. Practice Evolution: Insights into adapting techniques over time, incorporating new technologies, and adjusting approaches based on patient outcomes and evolving standards of care. 5. Complication Identification: Techniques for early recognition of impending complications, such as implant exposure, infection, or flap necrosis, with emphasis on clinical signs and diagnostic tools. 6. Salvage and Revision Strategies: Discussion of flap options for salvage (e.g., secondary local or regional flaps) and optimal timing for revision surgeries to preserve aesthetic and functional outcomes. 7. Hearing Assistance Devices: Management of hearing restoration in conjunction with reconstruction, including coordination with implantation of bone-anchored hearing aids or other devices. 8. Bilateral Cases: Unique challenges in bilateral alloplastic ear reconstruction, including symmetry, staging of procedures, and patient counseling for realistic expectations. The panel will feature experienced and early career plastic surgeons, with a breadth of perspectives regarding the challenges of PP ear reconstruction. The session will combine didactic presentations, case-based discussions, and resources for continued education. Interactive Q&A segments will allow attendees to engage with panelists on real-world challenges and solutions. Emphasis will be placed on evidence-based practices and lessons learned from complications and revisions. Attendees will leave with a structured approach to PP ear reconstruction, from patient selection to complication management. The session will equip surgeons with the tools to confidently incorporate this procedure into their practice, adapt to challenges, and achieve consistent, high-quality outcomes.

Purpose: Safe elevation of the temporoparietal fascia (TPF) flap is essential for successful auricular reconstruction. However, vascular anatomy of the TPF in patients with microtia-particularly venous patterns-remains incompletely characterized. This study aimed to define arterial and venous anatomy of the TPF using computed tomographic angiography (CTA) and to evaluate clinically relevant artery–vein (A–V) relationships affecting flap design.

Methods: Preoperative CTA images of 172 patients with microtia were retrospectively analyzed. Arterial and venous origins supplying the TPF, branching patterns, and main pedicle configurations were identified. A standardized TPF flap (approximately 13 × 10 cm) was simulated, and A–V distances were measured at the zygomatic arch, frontozygomatic suture, and distal flap margin. Associations between hemifacial microsomia (HFM), mandibular dysplasia severity (OMENS classification), and vascular patterns were evaluated.

Results: A total of 179 affected sides were analyzed, including 72 cases with HFM. The most common vascular configuration was the superficial temporal artery–superficial temporal vein (STA–STV) combination (60.3%), followed by postauricular artery–postauricular vein (PAA–PAV) (17.9%). (figure 1) PAA and PAV involvement occurred exclusively in patients with HFM and increased significantly with mandibular dysplasia severity (p < 0.001). All PAA cases demonstrated a postauricular artery–originated superficial temporal artery variation with an anteriorly displaced course beneath the auricular vestige. (figure 2) The STV frequently followed an independent course rather than accompanying the STA and was most commonly a single parietal branch. In contrast, the STA typically exhibited bifurcation. A–V distances increased distally in STA–STV configurations (p < 0.001). Configurations involving the PAV demonstrated significantly larger A–V distances at the distal flap margin compared with STV-based patterns (p < 0.05), indicating the need for wider flap designs. (Figure 3)

Conclusions: Marked arterial and venous variations exist in the TPF of patients with microtia, particularly in those with HFM. The STV often functions as an independent venous pedicle rather than a true accompanying vein. Preoperative identification of artery–vein relationships is critical for determining flap width, minimizing venous injury, and ensuring reliable TPF flap elevation.

References 1. Park C, Lew DH, Yoo WM. An analysis of 123 temporoparietal fascial flaps: anatomic and clinical considerations in total auricular reconstruction. Plast Reconstr Surg. 1999;104:1295-1306. 2. Nakajima H, Imanishi N, Minabe T. The arterial anatomy of the temporal region and the vascular basis of various temporal flaps. Br J Plast Surg. 1995;48:439-450. 3. Lopez R, Benouaich V, Chaput B, et al. Description and variability of temporal venous vascularization. Surg Radiol Anat. 2013;35:831-836. 4. Kim YS. Temporoparietal fascia flaps in children under 15 years of age. Plast Reconstr Surg Glob Open. 2021;9:e3573. 5. Vento AR, LaBrie RA, Mulliken JB. The O.M.E.N.S. classification of hemifacial microsomia. Cleft Palate Craniofac J. 1991;28:68-76.