Scientific Abstract Presentations: Craniomaxillofacial Session 9 Saturday, October 17 Sat, Oct 17 2:00-3:30 p.m. CDT

INTRODUCTION: Pterygomaxillary junction (PMJ) osteotomy is a common maneuver used for midface reconstruction, involving the separation of the maxilla and pterygoid plates. Due to soft tissue anatomy, this technique is often carried out in a blind fashion, leading to variations in final osteotomy patterns. The purpose of this study was to determine PMJ dysjunction techniques and common practices through an international survey, as well as a single-center retrospective radiologic review of LeFort osteotomies to better quantify variation of location of PMJ osteotomy and associated outcomes.

MATERIAL AND METHODS: A thirteen-question survey was distributed to members of the International Society of Craniofacial Surgery. Data was collected and analyzed based on three categories: demographics, technique, and confidence. A retrospective review was conducted of patients who underwent LeFort osteotomies at University of Chicago from 2010 to 2024. Data extracted included demographics, presenting symptoms, medical and surgical history, as well as intraoperative details and postoperative outcomes. Postoperative maxillofacial computed tomography scans were independently reviewed by two radiologists to identify specific PMJ osteotomy details (level of axial osteotomy [maxillary sinus, greater palatine foramen, posterior to the greater palatine foramen, or pterygoid plate], location of pterygoid plate fracture [medial, lateral or both], and coronal plane of fractures [above, at, below PMJ]). Descriptive statistics were used for all demographic, clinical, surgical, and post-op outcome variables.

RESULTS: Of 127 respondents (7.5% response rate), 70% were plastic surgery trained, with 35% having >20 years of experience. Seventy-five percent perform >50 craniofacial procedures (e.g., cranium, facial bone, or cleft reconstruction) yearly. Intraoperatively, 58% use both a bicoronal and intraoral approach, whereas 33% and 9% reported using only intraoral or bicoronal approaches, respectively. Though seventy-four percent reported complete confidence identifying the PMJ intraoperatively, only 44% felt completely confident that the osteotomy was performed accurately 100% of the time. Of 124 patients retrospectively reviewed, mean age was 23.5 years, and 32.5% had any comorbidity. The most common preoperative diagnoses were dentofacial anomaly/malocclusion (68%), craniofacial syndrome (14%), and cleft lip/palate (12%). Nearly 77% of patients had a preoperative class III occlusion. Of 236 radiology-reviewed osteotomies, 230 (97.5%) were considered impure. The most common location of PMJ osteotomy was the greater palatine foramen (55.6%), followed by the pterygoid plates (51.3%). Of the pterygoid plate-type fractures, 94.9% included the lateral pterygoid plate, and 47.5% included the medial pterygoid plate. Postoperative complications occurred in 53.7% of patients, most commonly sensation loss (22.8%). Only 29.3% of patients underwent revision surgery, and 27.6% underwent hardware removal.

CONCLUSIONS: Among international craniofacial surgeons, there remains wide variation in technique, confidence, and outcomes with regards to PMJ dysjunction. This single-center review demonstrated greater prevalence for greater palatine foramen fractures than true pterygoid plate fractures, with multivariate logistic regression analysis echoing previously known risk factors. Limitations include mixed age and osteotomy type (Lefort I, II, or III). The data reinforces the need for development of training tools and novel techniques for more accurate PMJ osteotomies.

Purpose: Mercedes Benz craniosynostosis is a rare multi-sutural pattern characterized by posterior vault constriction due to fusion of sagittal and bilateral lambdoid sutures. Middle-Posterior cranial vault remodeling (MPCVR) and posterior cranial vault distraction osteogenesis (PCVDO) are commonly used to address posterior vault deficiency, but comparative data in this population remain limited. This study evaluates perioperative, volumetric, and craniometric outcomes following MPCVR and PCVDO in Mercedes Benz craniosynostosis.

Methods: A retrospective review was performed of patients with Mercedes Benz craniosynostosis who underwent MPCVR or PCVDO. Demographics, operative characteristics, and computed tomographic imaging were analyzed before and 1 year after surgery.

Results: Eighteen patients were included; 50% underwent MPCVR, 27.8% PCVDO, and 22.2% strip craniectomy. PCVDO had a significantly shorter operative time than MPCVR (p = 0.008) and showed a trend toward lower blood loss. MPCVR produced a 50.8% increase in total intracranial volume, with the greatest expansion in the posterior vault (60.6%). PCVDO resulted in a 28.6% total volume increase, with posterior expansion (21.5%). Craniometric outcomes showed MPCVR achieved larger gains in width (20.4%), middle height (19.3%), and posterior height (14.7%), whereas PCVDO produced greater increases in circumference (11.22%), cranial length (15.28%), and vertex angle (18.99%). Both procedures improved skull base angles, with larger reductions observed in the PCVDO group.

Conclusions: MPCVR and PCVDO exhibit distinct expansion patterns in Mercedes Benz craniosynostosis. MPCVR offers broad volumetric remodeling, while PCVDO provides greater longitudinal expansion. These findings support individualized selection of posterior vault techniques for this rare craniosynostosis subtype.

Introduction: Facial aging involves changes in skin, soft tissues, and bone structures, leading to wrinkles, skin laxity, and psychological effects such as social anxiety. Traditional facelifting techniques reposition soft tissues to achieve a youthful appearance, but they do not fully address skin aging signs such as fine wrinkles and photoaging. This study introduces the biplanar facelift, a novel technique combining facelifting with subdermal radiofrequency (RF) technology to enhance skin outcomes and reduce aging signs.

Methods: A retrospective cohort study was conducted on 256 patients who underwent facelifting combined with subdermal RF from 2018 to 2024. Patients with significant comorbidities or smoking habits were excluded. Data on medical history, surgical procedures, and satisfaction were analyzed, along with changes in five key skin aging signs: laxity, spots, nodules, telangiectasias, and scars. The study utilized descriptive statistics and student's t-test for significance testing.

Results: Biplanar facelift demonstrated a significant reduction in skin aging signs, with skin laxity reduced in 96.49% of cases and hyperpigmentation in 98.7%. The average additional surgical time for RF was 10–15 minutes. Minor complications, such as hematomas and dyschromia, occurred in 7.42% of patients, all resolving postoperatively. Patient satisfaction was high, with an increase in Face-Q scores from 11.6 to 92.7 out of 100.

Discussion: This technique effectively combines traditional facelifting benefits with the skin-tightening effects of RF, yielding superior results in facial rejuvenation. The biplanar facelift represents an innovative approach for treating both structural and skin-related aspects of facial aging.

Background:

Large palatal fistulae represent one of the most challenging complications following cleft palate repair, often resulting in oronasal regurgitation, nasal air emission, and diminished quality of life. While small defects have been traditionally managed using local tissue rearrangement, extensive fistulae, particularly those exceeding 2 cm, are frequently considered indications for free tissue transfer. Free flap reconstruction, including radial forearm and fascia lata free flaps, has demonstrated high success rates. However, these procedures are resource-intensive, require advanced microsurgical expertise, and significantly prolong operative time. In low- and middle-income countries (LMICs), limited infrastructure and microsurgical capacity render free flap reconstruction impractical in many settings. This study evaluates the outcomes of large palatal fistulae (>2 cm) managed exclusively with local and regional flaps, challenging the prevailing paradigm favoring free tissue transfer for extensive defects.

Methods:

A retrospective cohort study was conducted at CLAPP Hospital, Lahore, Pakistan, between January 2022 and December 2024. Patients presenting with large palatal fistulae (>20 mm in the largest dimension) who underwent repair exclusively using local or regional flaps were included. Patients with syndromic diagnoses were excluded. Fistulae were classified pre- and post-operatively using the Pakistan Comprehensive Fistula Classification (PCFC). Surgical techniques included, but were not limited to, Bardach redo-palatoplasty, buccinator myomucosal flaps, and tongue flaps, and were selected based on defect location and tissue availability. Standardized perioperative hemostatic protocols were employed. Patients were followed for a minimum of three months, and recurrence was assessed clinically. Univariate and multivariate logistic regression analyses were performed to identify factors associated with recurrence.

Results:

A total of 129 patients were included (53.5% male), with a mean age of 10.04 ± 7.85 years (range, 1.6-36 years). The most common preoperative defects were subtotal right (42.6%), subtotal bilateral (34.1%), and subtotal left (23.2%). The Bardach redo-palatoplasty was the most frequently utilized technique (53.5%), followed by buccinator myomucosal flaps (22.5%) and tongue flaps (12.4%). Overall, postoperative recurrence occurred in 20 patients (15.5%). The most common sites of recurrence were the hard-soft junction (4.6%) and posterior hard palate (2.3%). Age, gender, and fistula laterality were not independently associated with recurrence. Procedure type demonstrated a significant association, with local flap approaches (tongue flap ± buccal flap) being independently protective against recurrence in multivariate analysis (aOR 0.20; p = 0.04). Additionally, younger patients demonstrated higher recurrence rates descriptively, but this did not reach statistical significance.

Conclusion:

Local and regional flap techniques can achieve acceptable outcomes in the management of large palatal fistulae (>2 cm), with recurrence rates comparable to those reported for free tissue transfer. In resource-constrained settings where microsurgical reconstruction is not feasible, local flaps offer a practical and cost-effective alternative without the added burden of donor site morbidity or prolonged operative time. These findings challenge the prevailing preference for free flap reconstruction in extensive palatal defects and support a resource-aware, adaptable approach to complex fistula repair. Prospective comparative studies are warranted to further define the role of local flaps relative to free tissue transfer in large defect reconstruction.

Purpose Nasal ala reconstruction aims to preserve function while maintaining cosmesis, but the complex shape, delicate underlying cartilage, and lack of surrounding tissue mobility make this challenging. Reconstruction is often complicated by scarring, notching, retraction, asymmetry, overall unsatisfactory aesthetic result, and sometimes impaired function of the alar rim. Bilobed flaps alone, though frequently used to overcome local tissue mobilization, do not provide structural support to recreate the natural alar contour. Failure to recreate the appropriate structural support can further lead to functional complications such as lateral wall collapse. We hypothesized bilobed flaps with nasal septal cartilage reconstruction would yield superior results. Nasal septal cartilage is ideal given its natural thickness and lack of curvature, offering superior support and improving final contour. The purpose of this study was to investigate clinical outcomes of bilobed flaps with septal cartilage grafting in alar rim reconstruction.

Methods All patients undergoing alar rim reconstruction via bilobed flap with septal cartilage rim graft at our single academic tertiary care hospital from October 2020 to October 2023 were identified. Demographic, clinical (etiology, medical comorbidities), and surgical data (defect size and location, complications) was collected. Primary outcomes included functional and aesthetic results. A novel 6-question aesthetic outcomes grading scale comparing postoperative to pre-defect patient photos was created and evaluated by two uninvolved attending surgeons. Questions were aimed at identifying common aesthetic complications in alar rim reconstruction: alar notching or retraction, caudal septal deviation, nasal tip rotation or malposition. Additional objective measurements were performed to investigate changes in alar position/contour and overall nasal shape/symmetry during healing.

Results Twelve patients (five male and seven female) 54-78 years old underwent laterally-based bilobed flap with septal cartilage graft alar rim reconstruction. Average follow-up time was 22.2 months (range 20.4 to 25.8 months). All patients underwent Mohs resection of a single basal cell carcinoma lesion. Defect size ranged from 5 to 18 mm (average = 10 mm). The defect was located in the posterior ⅓ of the alar rim in two patients, anterior ⅓ in three patients, and middle ⅓ in most patients (7 out of 12). There were no intraoperative complications. Two patients experienced numbness to the lateral nose postoperatively which improved over time, and one patient developed a suture abscess which was drained uneventfully in the clinic. No patient required revision or additional procedures. There were no functional deficits or valve collapse in our cohort. Attending surgeon survey respondents on our outcomes grading scale agreed or strongly agreed that nasal tip position and overall nasal shape was maintained and alar retraction avoided in all patients.

Conclusion Laterally based bilobed flap with nasal septal cartilage rim graft is an effective reconstruction technique for defects of the alar rim. This method provides structure and support to the nasal ala while avoiding common complications like alar retraction and lateral wall insufficiency, ultimately addressing the functional and cosmetic goals of reconstruction.

Background Systemic corticosteroids are sometimes administered peri-operatively in facial nerve grafting and facial reanimation procedures, but their association with postoperative wound complications and longer-term functional outcomes remains unclear.

Methods A retrospective cohort study was conducted using the TriNetX Global Collaborative Network (168 healthcare organizations). Adults undergoing facial nerve grafting/facial paralysis grafting procedures (CPT 64885, 64886, 15840–15842, 15845) were identified. Patients receiving systemic corticosteroids within ±7 days of the index procedure (prednisone/prednisolone, dexamethasone, methylprednisolone, hydrocortisone, or triamcinolone) comprised the corticosteroid (CS) cohort; those without corticosteroid exposure in the same window comprised the no-CS cohort. Outcomes were assessed from postoperative day 1 through 365. Propensity-score matching (1:1) balanced 15 covariates, yielding 954 patients in each cohort.

Results After matching, CS exposure was not associated with higher risk of surgical site infection (2.4% vs 2.6%; RR 0.923, 95% CI 0.528–1.614; p=0.778) or wound dehiscence (4.2% vs 5.2%; RR 0.821, 95% CI 0.542–1.242; p=0.350). Nonetheless, the CS cohort demonstrated a higher risk of abnormal involuntary movement–related diagnoses (5.9% vs 3.8%; RR 1.546, 95% CI 0.997–2.397; p=0.049). Rates of chemodenervation treatment proxy (CPT 64612) were numerically higher with CS exposure but did not reach statistical significance (2.8% vs 1.9%; RR 1.481, 95% CI 0.818–2.682; p=0.192). Return to the operating room (OR) for nerve revision occurred more frequently in the CS cohort (4.5% vs 1.8%; RR 2.529, 95% CI 1.453–4.403; p=0.001). Emergency department visits did not significantly differ (8.4% vs 6.4%; RR 1.305, 95% CI 0.910–1.871; p=0.147).

Conclusions In this propensity-matched comparative analysis of facial nerve grafting/facial reanimation procedures, peri-operative systemic corticosteroid exposure was not associated with increased 1-year SSI or wound dehiscence, but was associated with higher rates of abnormal involuntary movement–related diagnoses and return to OR for nerve revision. Further studies with more granular clinical data are needed to clarify whether these associations reflect treatment effects versus residual confounding by indication and procedure heterogeneity.

INTRODUCTION: The treatment of disfiguring, nodular rhinophyma has experience a renaissance as new technologies have emerged. Published techniques recently support laser, cryotherapy, and sanding ablation despite the decreased efficiency and increased expense associated. A review of the traditional, simplified surgical approach and wound management merits review.

METHODS: Patients with nodular rhinophyma who were referred for treatment underwent simple surgical excision, and a simplified wound care program. Light sedation administered by anesthesia allowed for a generous infiltration of the nose with 10 to 15 cc of 0.5% lidocaine and epinephrine (1/200,000). The solution was injected across the nasal tip, dorsum, glabella, and intranasally along the anterior septum. A #10 scalpel (flat blade) affixed to a standard handle was used to directly excise the tissue starting with normal epithelium above the nodular tissue. A simple, downward back-n-forth scalpel motion was used. Sharp excision proceeded distally towards the nasal tip to carefully preserve a thin layer of dermis. Scalpel blades were exchanged frequently. When excising over the lateral cartilage and alae, determining the depth of the excision was assisted by an index finger inserted into the nostrils. A thin layer of dermis was maintained over the perichondrium. Careful refinement of the surface irregularities with the scalpel was required to produce a smooth surface. Pin-point electrocautery was used to occlude the bleeding vessels when encountered. Supplemental lidocaine-epinephrine solution (approximately 5 cc) was injected deep to the cartilage into the mucosa below once the excision was complete. Antibiotic ointment was applied across the open wound, and a 3-inch square petroleum gauze was cut to cover the open nasal wound. No external dressing other than the thin gauze layer was placed. Patients were instructed to keep the gauze moist by applying a thin layer of antibiotic ointment daily. Weekly office visits allowed the gauze to be trimmed as it lifted from the underlying healed epithelium.

RESULTS: Six male patients tolerated the rhinophyma surgery under light sedation and local anesthesia. Operative time was less than one-hour. Bleeding was minimal and the few persistent oozing sites were easily occluded with electrocautery. The depth of the free-hand scalpel excision was easy to judge, and no large areas of perichondrium were exposed. The gauze quickly adhered to the wound by the tissue fluid and fibrin from the injured dermal surface. Epithelium developed from the dermis and covered the entire nasal surface within 2-3 weeks, including the small sites of exposed perichondrium. Discomfort was minimal and controlled with oral medication. All patients healed without further therapy (Figures 1,2,&3). Patients were advised to return to their referring dermatologist to prevent a recurrence with a possible addition of topical therapy.

DISCUSSION: Nodular rhinophyma resulting from a chronic inflammatory process of the nasal skin can be reliably addressed with this direct approach. The surgeon has many options to effectively treat the condition. Direct scalpel excision of nodular rhinophyma remains the easiest, most efficient, and arguably the most prudent option for restoring a normal nasal appearance.

Purpose: To identify sociodemographic and clinical factors associated with missed outpatient plastic surgery appointments among children with cleft lip and palate (CLP).

Methods: A retrospective chart review was performed on all patients with CLP who received cleft lip repair at a single urban tertiary children's hospital between January 2015 and August 2025. Exclusion criteria included <5 total outpatient visits during the study period or out-of-state primary residence. Collected data included outpatient appointment attendance with plastic surgery providers, demographics (sex, race/ethnicity, language, religion, siblings, area deprivation index, number of addresses), and clinical variables (timing of operations and follow-up, interventions, comorbidities). Outcomes included (1) occurrence of ≥1 missed outpatient appointment and (2) No-show rate (%) among patients with any missed visit. Analyses included a four-block hierarchical linear and logistic regression where applicable.

Results: The cohort (n=308) was predominantly Hispanic/Latino (55.2%), with high prevalence of public insurance (61.0%), siblings (71.4%), and household instability (40.6%). Patients attended a mean of 12.0 appointments over 5.2 years of follow-up, with 46.1% missing at least one visit. Among those with ≥1 missed appointment, the mean no-show rate was 8.4%. Hierarchical logistic regression identified Black race (OR 9.25, p = 0.012), household instability (OR 4.01, p = 0.002), siblings (OR 2.52, p = 0.003), and pulmonology care (OR 3.45, p = 0.013) as being associated with appointment no-show. In hierarchical linear regression among patients with ≥1 missed visit, older age at follow-up (β -0.005, p < 0.001) and greater operative burden (β -0.007, p = 0.022) were associated with slightly lower no-show rates, with limited contribution from sociodemographic or care coordination factors.

Conclusions: Disparities in appointment attendance exist among CLP patients. Social context including race and household-level factors appear to increase the odds of initial no-show, but repeat behavior is less influenced by clinical or socioeconomic variables. Targeted support such as automated appointment reminders may help reduce missed outpatient plastic surgery visits.

Background The most critical outcome following cleft palate repair is velopharyngeal function, which can change over time. Rates of velopharyngeal insufficiency vary significantly across the literature, with surgical technique being a key factor. Recent advances in palatoplasty indicate that vascularized tissue augmentation during primary repair may improve outcomes. We report a single surgeon's outcomes across a 20-year period and evaluate the efficacy of incorporating vascularized tissue augmentation during primary modified Furlow palatoplasty.

Methods This retrospective cohort study examined 285 patients who underwent primary palatoplasty by a single surgeon over 20 years (2004-2024). The study period was divided into two phases based on whether a patient received a Furlow palatoplasty with or without vascularized tissue augmentation – tissue augmentation palatoplasty (TAP). Outcomes included rates of velopharyngeal insufficiency (VPI) requiring surgery, speech performance scores, and presence of clinically significant functional fistulas.

Results Over the entire study period, 37 patients (13.0%) underwent secondary speech surgery at median age of 6.2 years, with higher rates in complete clefts (p=.03). Fistula rate was 4.2% (n=12), exclusively in Veau III/IV defects (p=.027). Twelve patients (5.5%) in phase 1 experienced fistulas and zero patients (0.0%) experienced fistulas in phase 2 (p=.11). Secondary speech surgery was performed in 37 patients in phase 1 (16.8%) and 0 patients in phase 2 (0.0%) (p=.004).

Conclusions Tissue augmentation palatoplasty significantly reduced the need for secondary speech surgery and eliminated fistula formation in this longitudinal single-surgeon experience. These findings support incorporating vascularized tissue during primary palatoplasty to optimize functional outcomes.

Introduction: Avulsion lip trauma resulting from a dog bite is a devastating injury that requires careful planning and operative and post-operative management to achieve an optimal outcome. In select cases, skin substitutes used during the primary repair can facilitate healing and may obviate the need for subsequent autologous skin grafting or complex reconstruction. Here we describe cases of single-stage application of a dermal regeneration template to treat avulsion lip defects caused by dog bites.

Methods: A retrospective review of the electronic medical record was carried out on all patients 18 years and older with avulsion lip defects resulting from a dog bite who underwent reconstruction with a dermal regeneration template by the senior surgeon between January 2024 and November 2025. Patient demographics, wound characteristics, complications, and post-procedure course were analyzed. A successful outcome was defined as >95% re-epithelialization and reasonable function and cosmesis after single-stage wound matrix application without the need for additional coverage procedures. Primary outcomes of interest included time to wound closure, reoperation rate, and the use of skin grafting, local tissue rearrangement, flap, laser therapy, or filler.

Results: We identified 5 patients (all female, mean age: 39.8 years, SD: 7.6) who underwent avulsion lip reconstruction using a dermal regeneration template. The mean wound area treated was 3.4 cm2 (SD: 0.37). One patient underwent intraoperative application in the days following injury, one underwent application in the clinic, and three underwent application in the emergency room at the time of injury. All were treated with preventative antibiotics. No patients underwent subsequent autologous skin graft or a locoregional flap due to incomplete re-epithelialization. In all patients, lip reconstruction after single-stage wound matrix application achieved reasonable functional and aesthetic outcomes without complication and with patient satisfaction.

Discussion: A dermal regeneration template can be safely and reliably used for single-stage reconstruction of select avulsion lip defects resulting from dog bites. Larger and comparative studies are needed to further investigate dermal matrix selection, and specific patient and lip wound characteristics, for optimal outcomes.

Purpose

The aim of this study was to compare the efficacy of nitinol staples (NS) versus titanium plates (TP) for repair of parasymphyseal mandibular fractures in a cadaveric model. The investigators hypothesized differences in maximum tolerable forces and deflection with each technique but proposed that NS used for parasymphyseal mandibular fractures would withstand typical mastication forces.

Methods

Specimens were fresh, dentate cadaver mandibles fractured and fixated with TP or NS. Mandibles were potted into bone cement and secured under a hydraulic press simulating the direction of mastication forces - applying pressure at the angle of the mandible. The primary outcome was maximum load before fixation failure measured in Newtons (N).

Results

Four mandibles were grouped by fixation modality, TP (n=1) and NS (n=3). For the fracture repaired with TP, maximum load tolerated was 481 N at 25.7 mm of deflection with failure at 446 N and 31.42 mm of displacement. NS tolerated overall greater displacement before cessation of experimentation, averaging 39.62 mm. However, max load averaged 149.44 N at 16.60 mm of displacement and major failure force averaged 145.30 N and 20.28 mm of deflection.

Conclusions

NS demonstrated flexibility and displacement tolerance despite enduring less maximal load capacity than TP. Based on the pilot data in this cadaveric model in a laboratory setting, NS may provide sufficient fixation strength for mastication forces required for the typical minced and moist (4.6-7.7N) and soft/bite-sized diets (14.3-20.1N) in the post-operative period immediately after fixation. NS offer promise given their overall smaller hardware size with less risk of palpability and increased elasticity – allowing for greater contact compression forces, conformability, and ease of application with less exposure necessary for fixation. Additionally, NS can be associated with reduced cost, resource utilization, and operative times, which can be extremely helpful in patients considered higher risk surgical candidates.

Objectives

Atypical fibroxanthoma (AFX) is a rare low-grade sarcoma that usually presents on the head and neck, for which surgical excision is typically curative. While 1 cm margins have historically been recommended as the standard of care, our unit advocates 6 mm excision margins. We aimed to describe our cohort of AFX patients, evaluate surgical management and recurrence rates, and assess whether a 6 mm margin is adequate to ensure complete excision and/or avoid further operations.

Methods

A retrospective review of patients treated for AFX between October 2014 and December 2024 was performed. Demographics, tumour characteristics and location, operative margins, histological clearance, reconstruction, recurrence, and re-operation rates were recorded. The association between operative margin and recurrence or second operation was assessed using chi-squared testing.

Results

A total of 106 patients with AFX were identified during the study period. The mean age of the cohort was 77.4 years (SD 8.8, range 36-96) and 91.5% of the patients were male (n=97). Most lesions excised were located on the scalp (n=78, 73.5%). Mean follow-up was 30.5 months (SD 31.8), ranging from 0-21 months.

Operative excision margins ranged from 1–20 mm; the most frequently used margin was 6 mm (n = 37, 39%), followed by 10 mm (n=28, 35%).

Recurrence occurred in 3 patients (2.8%).

There was no significant association between margins less than 5 mm or 6 mm and recurrence (p=0.355 and p=0.198 respectively). A significant relationship was shown between a narrow histological peripheral margin (<1mm) and use of an operative margin less than 5mm (p = 0.05). Data also demonstrated that a 6 mm margin was not associated with an increased need for re-excision or second operation. Margins >6 mm were significantly associated with a requirement for graft or flap reconstruction (p=0.04).

In the three patients where recurrence was observed, initial operative margins were 6mm in one case and 20mm in another. In the third case, a 6mm margin was used initially, with adequate excision margins (peripheral 1mm, deep 1.5mm); however further excision of an additional 6mm was performed.

Conclusion

AFX is a rare tumour with limited published data regarding its behaviour. Within this cohort, recurrence was fortunately low. Statistical analysis demonstrated that a 6mm excision margin was safe and not associated with recurrence, an increased requirement for re-excision or second operation in this cohort. Margins >6 mm were significantly associated with increased need for graft or flap reconstruction (p=0.04). We acknowledge that recurrence occurred in one patient treated with a 6mm excision margin, but was also observed in two patients with much greater excision margins. Larger prospective studies may be beneficial to assess the safety of different surgical margins.

Purpose: Orthognathic surgery corrects dentofacial deformities affecting occlusion, facial balance, airway function, and quality of life. Patient-specific implants (PSIs) have gained popularity for optimizing fixation and enhancing osseous positioning; however, their increased bulk relative to conventional titanium stock plates may pose challenges during intraoperative positioning. This study evaluates plan-to-postoperative discrepancies in three-dimensional skeletal positioning between stock plates and PSIs in patients undergoing orthognathic surgery.

Methods: An IRB-approved retrospective review was conducted of patients who underwent bimaxillary osteotomy performed by two surgeons at a single institution between 2020 and 2025. Patients with incomplete records, age < 15 years, or an open bite on pre- or postoperative CT scans were excluded. Data collected included sex, age, type of surgery, fixation method, operative time, malocclusion class, postoperative complications, and Arnett's soft tissue cephalometric measurements. Patients were categorized into stock plate and PSI groups. The PSI protocol included fabrication of patient-specific drilling/cutting guides with 2 plates used for each bilateral sagittal split osteotomy and 4 plates for maxilla osteotomy (medial and lateral buttresses). Planned skeletal positions were determined using virtual surgical planning. Directional (transverse, vertical, sagittal) and linear discrepancies between planned and postoperative positions were calculated based on CT scan analysis. Wilcoxon signed-rank, paired and independent t-tests, Mann–Whitney U, and Fisher's exact tests were performed to evaluate outcomes between the 2 groups.

Results: 30 patients (16 PSI, 14 stock plates) with a mean age of 25.8±9.58 years were included. Mean follow-up was 12±10.23 months. Twelve patients had Class II malocclusion and 18 had Class III. All patients underwent bimaxillary osteotomy, with adjunctive genioplasty performed in 6 PSI patients and 3 stock plate patients. Operative time was 1.18 hours shorter in the PSI group (5.74±1.46 hours) compared to the stock plate group (6.92±1.29 hours, p=0.03). The majority of plan-to-postoperative discrepancies were similar between the 2 groups, including ANS (all planes), A point (all planes), B point (all planes), maxillary/mandibular incisor midpoint (all planes), maxillary right molar (vertical), maxillary left molar (all planes), mandibular right/left molar (all planes), maxillary left/right canine (all planes), pogonion (all planes), SNA/SNB, and occlusal plane pitch (all planes). A significant difference was noted in maxillary right molar transverse discrepancy (PSI: 0.53±0.5 mm, stock plate: 0.86±0.6 mm, p=0.03) and sagittal discrepancy (PSI: 0.86±1.06 mm, stock plate: 1.35±0.86 mm, p=0.04). Postoperative complication rates were similar between groups (PSI: 13%, stock plate: 29%, p=0.4), including 1 intraoral abscess and 1 hardware extrusion in the PSI group, and 3 hardware irritation/extrusion and 1 hardware infection in the stock plate group.

Conclusions: Patient-specific implants in orthognathic surgery demonstrate a significant reduction in operative time. Both patient-specific implants and stock plates achieve good accuracy and similar complication rates.