Scientific Abstract Presentations: Craniomaxillofacial Session 11 Sunday, October 18 Sun, Oct 18 8:00-9:30 a.m. CDT

PURPOSE: Enhanced Recovery After Surgery (ERAS) protocols have reduced morbidity, narcotic use, and length of stay across surgical disciplines, yet their application in pediatric open cranial vault remodeling (CVR) remains limited. There are currently no ERAS Society guidelines for pediatric cranial surgery. At our ACPA-accredited craniofacial center, rapid surgical volume growth, from 14 cranial vault cases in 2023 to 29 in 2025, necessitated standardization of perioperative care. We report the development and outcomes of an advanced practice provider (APP)-led ERAS protocol for children undergoing fronto-orbital advancement (FOA) and total cranial vault remodeling (TCVR) for craniosynostosis.

METHODS: A retrospective cohort study compared outcomes in patients undergoing open CVR before (pre-ERAS, 2023) and after (ERAS, 2025) protocol implementation at Le Bonheur Children's Hospital. The protocol was developed and coordinated by a dedicated pediatric nurse practitioner in collaboration with plastic surgery, neurosurgery, pediatric anesthesiology, and the PICU team. Inclusion criteria were patients ≥6 months of age undergoing open cranial vault procedures (FOA or TCVR) for syndromic and non-syndromic craniosynostosis. Endoscopic suturectomies, Pi procedures, and cranial vault distractions were excluded. Key protocol elements included: tranexamic acid (10 mg/kg bolus followed by 5–10 mg/kg/hr infusion); colloid-first resuscitation, PICU admission POD 0, arterial line and Foley monitoring; scheduled IV acetaminophen, IV ketorolac, and IV ondansetron; diazepam as first-line breakthrough analgesia with dexmedetomidine or morphine as second-line; regular diet and bowel regimen; early mobilization; transfer to floor on POD 1; and discharge criteria of at least one eye open with no oral narcotics. Primary outcomes were hospital length of stay (LOS) and narcotic medication doses.

RESULTS: Forty patients were included (12 pre-ERAS, 28 ERAS). In the pre-ERAS cohort (2023), 11 FOA and 1 TCVR were performed with a mean LOS of 4.5 days, mean IV pain medication doses of 3.7, and mean oral pain medication doses of 2.0. Following ERAS implementation in 2025, 18 FOA and 10 TCVR were performed (1 FOA was excluded from the pathway). FOA patients demonstrated a 31% reduction in LOS (3.1 vs. 4.5 days), a 57% reduction in IV narcotic medication doses (1.6 vs. 3.7), and a 78% reduction in oral narcotic medication doses (0.44 vs. 2.0). TCVR patients achieved a mean LOS of 2.4 days with a mean of 2.7 IV and 0.6 oral narcotic pain medication doses. During this period, total craniofacial surgical volume doubled from 33 to 60 craniosynostosis cases per year, underscoring the scalability of the APP-led model.

CONCLUSIONS: An APP-led ERAS protocol for open cranial vault remodeling is safe and effective, yielding meaningful reductions in hospital length of stay and narcotic use. The APP-driven model provides continuity across the perioperative period and facilitates protocol compliance during rapid program growth. This framework is reproducible and may serve as a template for other craniofacial centers seeking to standardize and optimize cranial vault perioperative care.

Background and Objectives: Frontal bone osteomas are benign osseous tumors characterized by abnormal bone proliferation. Though typically asymptomatic, these masses often produce visible deformity of the facial morphology and may cause localized discomfort and headaches. When surgical management is indicated, the optimal approach is determined by osteoma size, location, and surgeon expertise. Endoscopic resection has emerged as an ideal technique for appropriately selected frontal osteomas because it enables complete excision while minimizing visible scarring and risk of neurovascular injury. This study reviews the senior author's patient outcomes and complications using a scalp-based, endoscopic-assisted surgical approach for frontal bone osteoma excision.

Materials and Methods: A review was conducted of all patients (n=22) who underwent endoscopic-assisted frontal bone osteoma excision performed by a single surgeon between February 2019 and December 2025. All procedures involved endoscopic-assisted visualization through remote scalp incisions, osteoma excision, and frontal bone contouring. Specimens were sent for histopathologic confirmation after dissection. Patient demographics, presenting symptoms, CT imaging findings, operative details, histopathology results, and postoperative outcomes were recorded.

Results: 22 patients (21 females, 1 male) underwent endoscopic-assisted excision of frontal bone osteomas performed by the senior author (NT). The primary concern prompting surgical intervention was aesthetic deformity, with localized pain reported in some cases. For all patients, CT imaging was obtained preoperatively to evaluate lesion size and anatomical relationships to nearby facial structures. Histopathology confirmed cortical bone consistent with osteoma in all cases. Postoperative swelling and ecchymosis were common in the first week but resolved spontaneously. No contour irregularities, fluid collections, residual bone, or sensory deficits were observed. Some alopecia was noted in the first three patients, prompting the senior author to modify the technique. All patients healed with small, flat, well-concealed scars adjacent to the hairline.

Conclusions: This single-surgeon experience demonstrates that endoscopic-assisted excision of frontal bone osteomas is a safe and effective technique that permits complete excision with excellent aesthetic outcomes and minimal morbidity. The operative framework presented in this study, which outlines surgical planning, technique steps, and postoperative management, supports endoscopic resection as an ideal alternative to traditional direct approaches for frontal bone osteomas.

Background: Sagittal craniosynostosis exhibits phenotypic heterogeneity that influences surgical decision-making and outcomes. While machine learning-derived severity metrics including Cranial Morphology Deviation (CMD) and Sagittal Severity Scale (SSS) provide objective assessments, regional severity variations within the sagittal suture remain understudied. This study characterizes phenotypic subtypes based on regional severity patterns and examines associations with overall morphological severity and clinical management in infants with isolated sagittal craniosynostosis.

Methods: A retrospective analysis was conducted on patients <1 year with isolated sagittal craniosynostosis at a single academic center. Regional severity scores for frontal, middle, posterior, and bandeau sagittal segments were analyzed with CMD and SSS. Unsupervised clustering identified phenotypic subtypes from regional severity patterns. Statistical analysis evaluated associations between subtypes, overall severity, operative decisions, and symptoms including intracranial pressure and sleep apnea. Regional severity assessment was conducted as part of CranioRate™.

Results: 123 patients met inclusion criteria with a median age of 119.5 days (range: 1–322). All were planned for primary operative intervention. Regional analysis revealed anterior–posterior gradients with frontal (2.073 ± 0.613) and middle (1.977 ± 0.608) regions showing greater severity than posterior (0.989 ± 0.303) and bandeau (0.569 ± 0.239) (p<0.001). Three phenotypic subtypes emerged: frontal-predominant, diffuse, and posterior-sparing. Regional scores correlated with overall metrics (frontal-SSS: r=0.92; posterior-CMD: r=0.72).

Conclusion: Regional severity analysis reveals distinct phenotypic subtypes in isolated sagittal craniosynostosis that correlate with overall morphological severity and clinical management. Regional severity assessment provides objective criteria for phenotypic classification and may guide surgical decision-making in infant craniosynostosis care.

Background: The optimal timing of cleft palatoplasty after mandibular distraction osteogenesis (MDO) in Pierre Robin Sequence (PRS) remains understudied. While early palatoplasty may improve speech outcomes, airway considerations in PRS may justify delayed repair to reduce perioperative complications and hospitalizations. This study used a national claims database to evaluate palatoplasty timing after MDO and its association with short-term outcomes and healthcare expenditures.

Methods: Using the PearlDiver Mariner database (2010–2023), patients with PRS and cleft palate were identified and stratified by MDO status. A 2-year continuous enrollment requirement was applied. Among MDO patients undergoing palatoplasty, timing relative to the MDO index date was categorized as early (≤6 months) versus standard (6–24 months), with a secondary sensitivity analysis using <12 versus ≥12 months between MDO and palatoplasty.

The primary outcome was all-cause readmission within 1 year after palatoplasty. Multivariable logistic regression evaluated predictors of readmission adjusting for age, sex, and Elixhauser Comorbidity Index (ECI). Total reimbursed healthcare expenditures within 90 days and 1 year following palatoplasty were compared using patient-level Wilcoxon rank-sum tests.

Separately, to evaluate absolute chronological age at cleft palate repair independent of MDO, first palatoplasty per patient was indexed using the MIN function. Age distributions between MDO and non-MDO cohorts were compared using Mann–Whitney–Wilcoxon testing.

Results: Of 2,650 PRS patients (MDO: n=267; non-MDO: n=2,383), 838 underwent palatoplasty (MDO: n=155; non-MDO: n=683).

Among MDO patients, 20 (13%) underwent palatoplasty within 6 months of MDO. Early timing was not independently associated with 1-year readmission compared to later timing (OR 4.26, 95% CI 0.78–21.83, p=0.078). ECI independently predicted readmission (OR 1.54 per point, 95% CI 1.12–2.14, p=0.0067). Early repairs had higher median expenditures at 90 days ($3,972 vs $2,395) and 1 year ($10,332 vs $5,068), though differences were not statistically significant (p=0.241 and 0.063).

Using the 12-month timing cutoff, no association with 1-year readmission was observed (OR 0.60, 95% CI 0.16–2.53, p=0.448), and ECI remained the only significant predictor (OR 1.44 per point, 95% CI 1.06–1.96, p=0.016). No significant cost differences were observed at 90 days (p=0.708) or 1 year (p=0.635). Expenditures also did not differ between MDO and non-MDO cohorts (90-day p=0.895; 1-year p=0.498).

When indexing to first palatoplasty to assess absolute age at repair, 91.6% of MDO patients underwent repair before 1 year of age compared to 74.7% of non-MDO patients (p=3.17×10⁻⁶), with a broader age distribution extending into later childhood in the non-MDO cohort.

Conclusion: Timing of palatoplasty after MDO was not independently associated with 1-year readmission or short-term healthcare expenditures. Readmission risk was driven primarily by comorbidity burden, suggesting postoperative utilization reflects underlying medical complexity rather than timing of repair. Notably, MDO patients were more likely to undergo palatoplasty before 1 year of age, an unexpected finding that may indicate that early airway stabilization facilitates earlier cleft palate repair without exacerbating prior airway difficulties. These findings support individualized palatoplasty timing based on patient-specific airway and developmental considerations.

Purpose The complexity and lack of objective characterization of the three-dimensional bilateral cleft lip nasal deformity (bCLND) pose significant obstacles to appropriate primary correction. While prior work has focused on unilateral deformity, less is known about the skeletal, septal, and surface morphology of bCLND. The purpose of this cross-sectional study is to develop an objective, three-dimensional characterization of bCLND using combined skeletal and surface anatomy and to assess morphological differences relative to controls.

Methods and Materials Previously obtained computed tomographic (CT) scans of children with unrepaired bilateral cleft lip ± cleft palate prior to primary repair were analyzed. Patients with binder-type presentations or syndromic conditions were excluded. All patients underwent presurgical nasoalveolar molding. CT scans of age-matched subjects without craniofacial anomalies served as controls. Skeletal and soft tissue landmarks were identified, and the osseocartilaginous nasal septum was manually segmented. Deviations in landmark position between bCLND and control cohorts were assessed using t-tests, with significance defined as p < 0.05. Transformation from the mean control septal segment to the mean cleft septal segment was calculated using a deformable registration method from the ANTsR toolbox.

Results Nine patients (six males and three females) were identified as suitable for inclusion. The median age was six weeks, with ages ranging from eight days to four months. Three-dimensional models of bCLND were generated for both skeletal and surface anatomy. Relative to controls, the rhinion was inferiorly displaced, and the piriform apices were deviated posterolaterally. Anteroposterior distances between the anterior nasal spine and piriform apices, and between subnasale and subalare landmarks, were approximately twofold greater in bCLND compared with controls (8.3 vs 4.1 mm and 5.9 vs 2.7 mm, respectively; p < 0.05). On surface analysis, subalare landmarks were displaced laterally, and alar curvature landmarks were displaced inferolaterally. Septal analysis showed that the bCLND septum was shorter in height and slightly shorter in anteroposterior distance but otherwise comparable to controls. Finally, unlike the unilateral cleft lip nasal deformity (uCLND), the bCLND septum appeared symmetric.

Conclusion This study provides an objective, three-dimensional characterization of bilateral cleft lip nasal deformity using combined skeletal and surface analysis. The findings suggest that posterolateral displacement of the piriform apices may be the primary osseous deformity contributing to bCLND morphology. These data-driven models offer a framework for improved understanding of bCLND anatomy and may support more precisely defined treatment goals aimed at improving aesthetic outcomes.

Introduction: While primary treatments for syndromic craniosynostosis entail the correction of skeletal deformities, residual irregularities may require additional revisions or soft tissue interventions throughout a patient's life. The purpose of this study was to conduct a systematic review to evaluate for subsequent soft tissue surgeries within the long-term management of patients with syndromic craniosynostosis.

Methods: PubMed, Embase, and Web of Science were the search engines for this PRIMA-compliant systematic review. Inclusion criteria were studies that examined patients with syndromic craniosynostosis, provided a description of long-term surgical management, and had a follow-up of at least 5 years. Collected variables included study design, location, sample size, syndrome diagnosis, surgical treatment, treatment indication, and treatment age.

Results: The initial search identified 4586 articles, with 13 full text articles included after screening. Among 367 patients, common syndromes included Crouzon (8 articles), Apert (7 articles), Saethre-Chotzen (7 articles), and Pfeiffer (6 articles). Six articles reported on onlay cranioplasty (62 patients, 16.9%) after patients underwent frontal-orbital advancement. Four articles described frontotemporal or malar fat grafting (31 patients, 8.4%) after cranial vault, forehead, or midface skeletal surgery. Periorbital surgeries included lateral and medial canthopexy (48 patients, 13.1%), ptosis reconstruction (20 patients, 5.4%), and strabismus surgery (15 patients, 4.1%). Other common soft tissue surgeries included scalp reconstruction (28 patients, 7.6%) and rhinoplasty (20 patients, 5.4%).

Conclusion: While soft tissue operations are valuable in correcting residual irregularities for patients with syndromic craniosynostosis, they are underreported in the literature. This systematic review highlights the relationship between skeletal and soft tissue surgeries, exploring the incidence of interventions that may aid in patient and family education.

Purpose: People experiencing homelessness sustain traumatic injuries at higher rates than housed populations, with head and neck injuries particularly common (1,2). Despite this, disparities in outcomes after operative facial fracture repair remain poorly characterized. This study evaluated differences in postoperative complications, hospital length of stay (LOS) and follow-up among unhoused versus housed patients undergoing operative facial fracture repair.

Methods: A retrospective study was performed of adult facial fracture patients (≥18 years) presenting to the emergency department and undergoing operative repair between January 2019 and July 2024 across four trauma centers. Median follow-up was 27.0 days (IQR 0.0-67.0). Patients were stratified into two groups by housing status at presentation: housed group or unhoused group. Primary outcomes included postoperative complications, hospital readmission, and reoperation. Secondary outcomes included LOS, operative time, and outpatient follow-up. Baseline differences were analyzed using Mann-Whitney U tests for continuous and Fisher's exact or chi-square for categorical variables. Multivariable logistic regression adjusted for age, sex, body mass index, ASA class, insurance status, smoking, and alcohol use. Significance was set at p<0.05.

Results: Among 337 patients, 47 (13.9%) were in the unhoused group and 290 (86.1%) were in the housed group. Patients in the unhoused group were more likely to have Medicaid insurance (66.0% vs 34.8%; p<0.001), higher comorbidity burden as reflected by ASA class ≥3 (44.6% vs 15.8%; p<0.001), and alcohol use disorder (54.5% vs 9.0%; p<0.001). Both groups had similar rates of alcohol use at the time of injury (p=0.246).

On adjusted analysis, patients in the unhoused group experienced significantly longer hospitalizations (β=2.15, 95% CI 1.52–3.97; p<0.001). However, patients in the unhoused group did not demonstrate higher clinical complexity as measured by hardware burden (p=0.150) or operative time (p=0.614). Among patients in the unhoused group, AUD was the only factor independently associated with increased LOS (β=3.58 days, 95% CI 0.39–6.76; p=0.029).

The incidence of complications, readmission and reoperation did not differ between groups, though interpretation may be limited by loss to follow-up. Patients in the unhoused group trended toward lower odds of follow-up (aOR 0.58, 95% CI 0.26–1.31; p=0.191) and shorter follow-up duration (β=−14.64 days, 95% CI −36.38–7.11; p=0.186), without statistical significance.

Conclusion: Unhoused patients undergoing operative facial fracture repair experience prolonged hospitalization despite similar complication rates, operative time, and hardware burden compared with housed patients. This suggests prolonged hospitalization reflects social and discharge barriers rather than surgical complexity. AUD was the strongest predictor of increased LOS in this population, independent of acute intoxication at presentation. Persistent inequities in perioperative outcomes underscore the need for targeted postoperative support for unhoused patients, including substance use intervention and structured discharge planning (3).

References: 1. Beaulieu-Jones BR, Smith SM, Kobzeva-Herzog AJ, et al. Association of houselessness and outcomes after traumatic injury. Injury. 2025;56(5):112214. 2. Silver CM, Thomas AC, Reddy S, et al. Injury patterns and hospital admission after trauma among people experiencing homelessness. JAMA Netw Open. 2023;6(6):e2320862. 3. Park S, Kim S, Kim HK, et al. Unhoused and injured: injury characteristics and outcomes in unhoused trauma patients. J Surg Res. 2024;301:365-370.

Background: Revision surgery following primary cleft palate repair, often performed to address velopharyngeal insufficiency (VPI) and speech impairment, remains a significant clinical concern.(1) Although many recommend earlier repair to optimize speech outcomes, ideal timing remains debated. The exact effect of age on development of VPI and need for revision surgery is undetermined.(2,3) The purpose of this study was to evaluate if age at primary repair influences the risk of subsequent palate revision surgery.

Methods: The TriNetX database was queried to identify patients who underwent palatoplasty for cleft palate (CPT 42200) within the last 20 years across 100 healthcare organizations. Patients were divided into two cohorts: patients repaired <2 years and ≥2 years. Cohorts were balanced using propensity score matching to control for demographics (race, sex), cleft phenotype, syndromic diagnoses, and chromosomal abnormalities. Primary outcome was defined as subsequent palate revision surgery, which was defined using CPT codes for secondary palatoplasty, pharyngoplasty, and palatal lengthening procedures. Kaplan-Meier survival analysis was performed to assess time to revision following index palatoplasty.

Results: After matching, each group included 2,306 patients. Revision surgery occurred in 363 patients (15.7%) repaired before age 2 and 411 patients (17.8%) in the group repaired at ≥2 years. Kaplan-Meier survival analysis demonstrated statistically significant freedom from secondary surgery in patients repaired before age 2 (HR 0.81, 95% CI 0.70–0.93, p = 0.003).

Conclusion: Palate repair at ≥2 years is associated with an increased risk of subsequent revision surgery. These findings suggest that earlier palate repair may reduce the need for secondary procedures and may inform surgical timing and family counseling.

References Xepoleas MD, Naidu P, Nagengast E, et al. Systematic Review of Postoperative Velopharyngeal Insufficiency: Incidence and Association With Palatoplasty Timing and Technique. J Craniofac Surg. 2023;34(6):1644-1649. doi:10.1097/SCS.0000000000009555 Stanton EW, Rochlin D, Lorenz HP, Sheckter CC. Early Cleft Palate Repair is Associated With Lower Incidence of Velopharyngeal Insufficiency Surgery. J Craniofac Surg. 2025;36(3):781-785. doi:10.1097/SCS.0000000000010540 Schaar Johansson M, Becker M, Eriksson M, Stiernman M, Klintö K. Surgical treatment of velopharyngeal dysfunction: Incidence and associated factors in the Swedish cleft palate population. J Plast Reconstr Aesthet Surg. 2024;90:240-248. doi:10.1016/j.bjps.2024.01.034

Purpose: Operative delay in craniofacial trauma is common and often related to transfer logistics and resource limitations. Nearly half of patients requiring operative facial fracture repair undergo interfacility transfer prior to definitive management (1). Although delays beyond 24 hours have been associated with complications (2), timing guidelines remain inconsistent, and the independent contributions of transfer and operative delay to postoperative outcomes remain unclear (3). The present study sought to: 1) evaluate whether interfacility transfer is associated with prolonged time to intervention (TTI), and 2) examine the independent associations of interfacility transfer and delayed TTI with postoperative outcomes following craniofacial fracture repair.

Methods: A retrospective review was conducted of adults (≥18 years) presenting with facial fractures to four urban trauma centers from 2019–2025. Inclusion was limited to patients undergoing operative repair within 7 days of presentation to exclude delayed outpatient management. Demographics, comorbidities, fracture location, interfacility transfer status, and TTI were collected. TTI was analyzed as both a binary (<24 vs ≥24 hours) and log-transformed continuous variable. Primary outcomes were postoperative complications, 30-day readmission, and unplanned reoperation. Secondary outcomes included inpatient hospital length of stay (LOS) and operative time. Multivariable regression adjusted for age, sex, diabetes, alcohol use, smoking, and fracture location. Statistical significance was defined as p<0.05.

Results: Among 235 patients, 42.1% underwent interfacility transfer. Median TTI was 39.8 hours (IQR 22.8–72.6), and transferred patients experienced longer TTI (46.5 vs 34.1 hours, p=0.0029). On multivariable analysis, interfacility transfer remained independently associated with prolonged TTI (β=0.31, 95% CI 0.11–0.52, p=0.003), corresponding to a 37% longer time to surgery. Delayed TTI was not associated with LOS, reoperation, readmission, or complications. In contrast, interfacility transfer was independently associated with increased odds of postoperative complications (OR 4.59, 95% CI 1.04–20.25, p=0.04). Smoking (OR 7.39, 95% CI 1.41-39.1, p=0.02) and increasing age (OR 1.08, 95% CI 1.02-1.14, p=0.01) were also associated with complications. Neither interfacility transfer nor TTI predicted readmission or reoperation.

Conclusion: Interfacility transfer is associated with prolonged TTI and increased odds of postoperative complications after craniofacial repair. However, surgical delay itself was not independently associated with adverse outcomes. These findings suggest that system-level factors related to interfacility transfer, rather than timing alone, may drive the risk of complications.

References: 1. Wasicek PJ, Kantar RS, Gebran S, et al. Less Operating and More Overtriage: National Trends in Interfacility Transfer of Facial Fracture Patients. Plast Reconstr Surg. 2022;149(5):943e-953e. doi:10.1097/PRS.0000000000009039 2. Sharma RK, Vivek N, Yang SF, Stephan SJ, Patel PN. Time-to-operation delays and in-hospital complications in operative facial trauma: A national analysis. Am J Otolaryngol. 2024;45(2):104148. doi:10.1016/j.amjoto.2023.104148 3. Rothweiler R, Bayer J, Zwingmann J, et al. Outcome and complications after treatment of facial fractures at different times in polytrauma patients. J Craniomaxillofac Surg. 2018;46(2):283-287. doi:10.1016/j.jcms.2017.11.027

Background: Posterior vault distraction osteogenesis (PVDO) aims to increase intracranial volume in patients with craniosynostosis to prevent intracranial hypertension and improve head shape. However, limited access to healthcare can complicate treatment. The average complication rate reported in the literature is 30%, with cerebrospinal fluid leak and wound infection being most common. The purpose of this study is to describe a single institution's experience treating patients undergoing PVDO who face barriers to accessing healthcare.

Methods: A retrospective analysis of patients undergoing PVDO at our institution from 2014-2023 was conducted. Data collection included demographics, social vulnerability index (SVI), cranial sutures involved, intraoperative details, and complications. Descriptive statistical analyses along with Chi-squared and Mann-Whitney U tests were used to compare variables of interest.

Results: Twenty-three patients (13 females, 10 males) were included, with a mean U.S. SVI of 0.73. Patients with a syndromic diagnosis comprised 48% of the patient population (n=11). The median age at surgery was 8.5 months (range: 3 months-6 years). Patients with multi-suture craniosynostosis represented 74% of the cohort (n=17), with the coronal suture most frequently involved (n=14; 61%). Nine patients (39%) developed postoperative infections and 1 of those patients required a return to the operating room for washout. Ten patients (43%) underwent multiple cranial vault surgeries. There were no significant differences in complication rates or hospital length of stay between SVI quartiles.

Conclusions: This study highlights clinical outcomes in a vulnerable patient population undergoing PVDO. The average SVI highlights limited access to healthcare, and potentially a higher risk for non-compliance and adverse outcomes. Despite facing socioeconomic barriers, the studied patients had similar complication rates to those reported in the literature.

Background: Social determinants of health are acknowledged to impact access to surgical care and postoperative outcomes (1), yet institutional-level studies in craniomaxillofacial surgery suggest not all socioeconomic factors are predictive of surgical outcomes (2,3). Area Deprivation Index (ADI) is a frequently used measure of disparity that has begun to be explored as a predictor for loss to follow-up in this population (4). The present study sought to evaluate whether ADI is associated with time to intervention, postoperative complications, and access to postoperative care for craniomaxillofacial fracture repair.

Methods: An institutional retrospective review was conducted of patients who had presented with craniomaxillofacial fractures between November 2017 and July 2024. Patients were included if they resided in neighboring states (New York, New Jersey, Connecticut). Data were collected on patient demographics, injury location (nasal, mandible, zygomaticomaxillary complex, orbital blowout, frontal, complex/multiple/LeFort), surgical service (oral and maxillofacial surgery, plastic and reconstructive surgery, otolaryngology, other), insurance type (Medicare, Medicaid, private, self-pay, other/unknown), time to intervention, follow-up appointment within 30 days (yes/no), and postoperative complications (infection, hematoma, fistula, wound dehiscence, fat necrosis). State-level decile ADI, a measurement of economic disadvantage relative to other neighborhoods in the state, was assigned using the Neighborhood Atlas® (University of Wisconsin School of Medicine and Public Health). Descriptive statistics on ADI and each outcome of interest were performed. Skewness was evaluated. Linear and binary logistic regression models were constructed using ADI as the independent variable of interest to evaluate the outcomes of time to intervention, follow-up appointment, and postoperative complications. Models were adjusted for insurance type, injury location, and surgical service. Statistical significance was defined as p < 0.05.

Results: Of 522 patients identified for review, 504 met inclusion criteria. The mean state-decile ADI was 3.0 ± 1.9. The mean time to intervention was 5.8 ± 12.2 days and was log-transformed for analysis due to skewness. Overall, 74.0% of patients attended follow-up within 30 days. Of patients presenting for follow-up or readmission, 8.6% experienced complications. In the three models adjusting for covariates, ADI was not associated with log-transformed time to intervention (ADI β = -0.025, p = 0.50; n = 502), follow-up (ADI β = -0.025, p = 0.67; n = 494), or postoperative complications (ADI β = -0.15, p = 0.21; n = 382).

Conclusion: At a high-volume urban institution, state-level decile ADI was not independently associated with time to intervention, post-operative complication rate, or follow-up in patients undergoing traumatic craniomaxillofacial surgery. This may suggest institutional success in promoting equity among patient outcomes. Alternatively, state-level ADI alone may not be sufficient as a proxy for this population's social determinants of health. Future studies are warranted to identify if institutional practices mitigate socioeconomic inequities or if state-level ADI is insufficient to detect surgical outcome disparities in patients with craniomaxillofacial trauma.

References (1) Paro, A., Hyer, J. M., Diaz, A., Tsilimigras, D. I., & Pawlik, T. M. (2021). Profiles in social vulnerability: The association of social determinants of health with postoperative surgical outcomes. Surgery, 170(6), 1777–1784. https://doi.org/https://doi.org/10.1016/j.surg.2021.06.001

(2) Bhethanabotla, R. M., Patel, N., Behnam, R., Boscardin, W. J., Xu, M. J., Heaton, C., Wai, K. C., Park, A. M., & Knott, P. D. (2025). Social Determinants of Health in Patients Undergoing Osteocutaneous Free Flap Reconstruction for Malignant Disease of the Mandible. Head & Neck, 47(11), 2982–2989. https://doi.org/https://doi.org/10.1002/hed.28218

(3) Manasyan, A., Pekcan, A., Bakovic, M., Mejia, V., Patel, R., Turk, M., Naidu, P., Urata, M., & Hammoudeh, J. (2025). The Impact of Neighborhood Socioeconomic Deprivation on Pediatric Head and Neck Free Flap Reconstruction. Plastic and Reconstructive Surgery – Global Open, 13(S5), 12–13.

(4) Cui, A. Z., Goyal, S. S., Okigbo, A. A., Govani, V. N., Gillman, G. S., Sridharan, S. S., Spector, M. E., Wang, E. W., Contrera, K. J., & Yver, C. M. Predictors of Loss to Follow-Up After Operative Facial Trauma. The Laryngoscope, n/a(n/a). https://doi.org/https://doi.org/10.1002/lary.70330

Background Head and neck necrotizing soft tissue infections (NSTIs) are rare but life-threatening, with reported mortality rates of 10–15%, increasing to as high as 40% in cases with mediastinal involvement (1, 2). Proximity to critical structures complicate care, emphasizing early identification and aggressive debridement. This study examines multidisciplinary management strategies, reconstructive approaches, and clinical outcomes in patients with head and neck NSTIs

Methods A retrospective review was conducted of patients with head and neck NSTIs treated at two academic institutions between 2015 and 2025. Patients were identified using the Research Patient Data Registry. Demographics, comorbidities, infectious details, clinical course, medical and surgical treatments, surgical services involved, reconstruction during index admission, and 6-month outcomes were studied.

Results Thirty-five patients (mean age 52 ± 15 years) were included in the study. Odontogenic sources (n=15) were most commonly associated with the Streptococcus milleri group (53% alone; 13% with anaerobes), cutaneous infections (n=13) were predominantly caused by Group A Streptococcus (54%), and pharyngeal/parapharyngeal infections (n=7) most frequently demonstrated mixed aerobic and anaerobic flora (43%). The neck was most frequently involved (75%). Mediastinitis occurred in 14% of cases. Sixty-three percent underwent debridement on the day of presentation, with a mean of 4.2 ± 3.2 debridements. Oral and Maxillofacial Surgery and Acute Surgical Care were most frequently involved. Mean ICU stay was 13 ± 8.5 days. The six-month mortality rate was 8.6%, all expiring within 13 days. Diabetic ketoacidosis and dementia-related complications were contributing factors in two fatal cases. Advanced age was significantly associated with mortality. Reconstruction during the index admission was performed in 13 patients, most commonly with skin grafting (38%) and pedicled flaps (8.6%). Among these patients, complications included wound dehiscence (15%) and infection (15%). There were no instances of skin graft or flap loss.

Conclusions Head and neck NSTIs are morbid infections, but early surgical intervention and coordinated multidisciplinary care were associated with lower mortality than historically reported, despite critical illness. Reconstruction during index admission was feasible and associated with few complications.

Citations 1. Gunaratne DA, Tseros EA, Hasan Z, et al. Cervical necrotizing fasciitis: Systematic review and analysis of 1235 reported cases from the literature. Head Neck. 2018;40(9):2094-2102. doi:10.1002/hed.25184 2. Ahmadzada S, Rao A, Ghazavi H. Necrotizing fasciitis of the face: current concepts in cause, diagnosis and management. Curr Opin Otolaryngol Head Neck Surg. 2022;30(4):270-275. doi:10.1097/MOO.0000000000000820

Purpose Each operative design for unilateral cleft lip repair has unique lip-nose trade-offs. Mulliken's "cut-as-you-go" modification of the rotation-advancement repair prioritizes aesthetic subunits and consistently favors the nose. Despite widespread adoption of his bilateral nasolabial repair, results of his unilateral repair remain under-reported. The anatomic subunit repair is an increasingly popular geometric approach that adopts several of Mulliken's principles. This study evaluates anthropometric outcomes of Mulliken's approach to unilateral nasolabial repair and compares its use of triangular cutaneous augmentation with that of the anatomic subunit repair.

Methods
Infants who underwent primary unilateral nasolabial repair at an academic children's hospital from April 2016 to August 2025 were included. One author performed all repairs using Mulliken's technique while the other used the anatomic subunit approach. Patient demographics and clinical characteristics were collected. The height of the inferior philtral triangle was compared. For the Mulliken repair, direct perioperative anthropometry was recorded at initial repair and at suture removal. Statistical analyses were performed using IBM SPSS.

Results A total of 146 primary unilateral cleft lip repairs were included, with 119 undergoing Mulliken repair (81.5%) and 27 on anatomic subunit approach (18.5%). Most patients were male (62.3%) with complete (63%) left-sided cleft lip (60%). Mean birth weight was 3.3 kg and age at surgery was 6.18 months. Within the cohort of Mulliken's repair, 42.6% of children completed preoperative nasoalveolar molding (NAM). Primary rhinoplasty was performed using either semi-open marginal rim incision (46.8%) or no rim incision (53.2%).

Among those who underwent Mulliken's repair, nasal tip projection (sn-prn) increased significantly by an average of 3.8 mm (p<0.001). When examining changes to hemi-columellar length, the mean cleft side sn-c increased from 3.4 to 7.1 mm (p<0.001) while non-cleft side mean sn-c increased from 4.8 to 6.6 mm; cleft-side cphs-c increased from 2.4 to 6.5 mm while non-cleft cphs-c increased from 4.0 to 5.9 mm. There was significantly greater lengthening and overcorrection of the deficient cleft-sided hemi-columella (sn-c 3.5 vs. 1.7 mm; cphs-c 4.2 vs. 1.9 mm, both p<0.001).

Mulliken repair resulted in significant correction of preoperative asymmetry of labial height (sn-cphi, 3.9 to 0.7 mm, p<0.001), heminasal width (sn-ala, 7.0 to 0.6 mm, p<0.001), and shortening of nasal width (ala-ala, 34.8 to 29.2 mm, p<0.001). The height of the inferior philtral cutaneous triangle was clinically similar between the Mulliken modification and the anatomic subunit approach (median [range] 2.6 [2.25-3.0] vs. 2.2 mm [1.5-2.5]).

Conclusion
Mulliken's modification of the unilateral rotation-advancement repair respects the philtral anatomic subunit. Direct anthropometry demonstrates that this "cut-as-you-go" approach achieves nasal symmetry (with overcorrection of cleft-sided hemi-columellar height) while also achieving symmetry of labial height. The height of the inferior philtral cutaneous triangle is similar to that used in the pre-determined "geometric" design of the anatomic subunit approach.

Background

Palatal flap dehiscence represents a clinically significant yet underreported complication following primary palatoplasty. Unlike general wound dehiscence, which can occur anywhere in the palate, palatal flap dehiscence refers specifically to the partial or complete anatomic separation of the previously approximated mucoperiosteal flaps in the midline, beginning at the uvula and extending anteriorly along the soft and/or hard palate. Despite its clinical implications, such as significant oronasal regurgitation of liquids/food and velopharyngeal insufficiency due to extensive defects, this condition is often underreported within the literature. The absence of a standardized definition, classification system, and management algorithm has contributed to inconsistent reporting and variable treatment approaches. This study aims to define palatal flap dehiscence as a distinct clinical entity, validate a structured classification system based on anatomic extent, and propose a reproducible surgical treatment algorithm for its management.

Methods

A retrospective cohort study was conducted at CLAPP Hospital, a high-volume cleft center in Lahore, Pakistan, from January 2015 to December 2024. Patients presenting with palatal flap dehiscence following primary palatoplasty were included. Flap dehiscence was categorized using a structured classification system (D1-D4) based on the extent of separation from the uvula to the anterior hard palate, with additional subcategories for dehiscence extending to one side [unilateral or bilateral mucoperiosteal flap necrosis (D3-R/L/B + D4-R/L/B). Surgical management was guided by a predefined algorithm emphasizing multilayered closure, levator reconstruction, and selective use of regional flaps depending on the category. Outcomes included recurrence of flap dehiscence and fistula formation. Univariate and multivariate logistic regression analyses were performed to identify predictors of postoperative complications.

Results

A total of 398 patients were included (49.7% male; mean age 7.52 ± 6.56 years). The most common presentation was D2 (43.5%), followed by D3 (30.6%). Complex defects involving unilateral or bilateral mucoperiosteal flap loss (D3-R/L/B + D4-R/L/B) accounted for 17.3% of cases. Overall postoperative recurrence rates were 6.5% for flap dehiscence and 7.0% for fistula formation. On multivariate analysis, defect extent was the strongest independent predictor of complications. Compared with D2 defects, D3 defects were associated with significantly increased risk (adjusted odds ratio [aOR] 4.23; p = 0.003), while D3-R/L/B + D4-R/L/B defects demonstrated the highest risk (aOR 7.90; p = 0.001). In subgroup analyses, D3-R/L/B + D4-R/L/B defects remained independently associated with both fistula formation (aOR 15.95; p = 0.004) and recurrent flap dehiscence (aOR 5.09; p = 0.04). Age, sex, and surgical technique were not independently associated with postoperative complications after adjustment.

Conclusion

Palatal flap dehiscence is a distinct and significant complication following primary palatoplasty that warrants equal consideration alongside palatal fistulae. A structured classification system based on anatomic extent reliably stratifies this condition and guides surgical management. Defects involving mucoperiosteal flap loss carry substantially higher complication rates and warrant advanced reconstructive strategies. Adoption of such an algorithmic treatment approach will ultimately help optimize surgical management of this challenging condition.

Introduction: Auricular framework carving remains one of the most technically demanding steps in microtia reconstruction and continues to rely on antiquated two-dimensional (2D) methods, including tracing the contralateral ear onto transparent projection film. While commonly used, these 2D templates fail to capture the three-dimensional (3D) relationships between auricular subunits and their relative planes, often resulting in poor anatomic fidelity and suboptimal framework geometry. Even with accurate 2D tracings, the lack of depth, subunit contour, and inter-subunit spatial relationships contributes to inconsistent outcomes. We present the development of a 3D, auricular subunit–specific, interlocking template system designed to address these limitations and improve reproducibility of framework construction.

Methods: Three-dimensional auricular framework templates were designed using computer-aided design (CAD) software and fabricated in autoclavable resin using a Stratasys J55 Prime PolyJet 3D printer (patent pending). Individual subunit templates incorporated a tongue-in-groove interlocking mechanism to facilitate assembly and provide inherent structural stability. Two antihelical templates with open and closed crural configurations were created to accommodate variability in available costal cartilage surface area. Perforations within each template permitted placement of 25-gauge needles for temporary fixation to the cartilage block during template tracing.

Results: A complete 3D template set was generated, consisting of four base components, two antihelical variants, a tragal unit, and a helical unit. Three base components interlocked to form the foundation, while a fourth served as a platform for the tragus and helical root. The tragal and antihelical components interlocked and overlaid the base framework, whereas the helical template overlaid the base independently. This modular system preserved three-dimensional subunit relationships during framework design, enabling early visualization of cartilage allocation and subunit spacing prior to carving. The dual antihelical variants allowed preselection of crural configuration based on available cartilage.

Conclusion: By replacing antiquated 2D projection-based tracing methods with a modular 3D interlocking template system, this approach directly addresses a key technical limitation in auricular framework carving: the inability to reliably reproduce anatomic subunit relationships and spatial planes. These templates may improve geometric accuracy, structural stability, and reproducibility of auricular frameworks, particularly for trainees or surgeons early in their learning curve, and they warrant further evaluation in operative and simulation-based settings.