The Editorial Board of FACE is pleased to publish the craniofacial abstracts from the 67th annual meeting of the Ohio Valley Society of Plastic Surgeons (OVSPS) in Pittsburgh, PA. This is the 5th year that the Journal FACE has published abstracts from this annual meeting. All of the abstracts have been peer-reviewed and are published as they appeared for the Pittsburgh meeting.
The OVSPS meeting is an extremely strong regional gathering of clinicians from academic institutions along the course of the Ohio River. I fondly remember presenting at the OVSPS meeting when I was a resident and fellow at Indiana University in the early 2000s, and later as a faculty member at Cincinnati Children’s Hospital.
I have met many colleagues in Craniofacial Surgery at these meetings and have maintained contact with them as friends.
John van Aalst
Predictors Of Syndrome Of The Trephined Severity Using Patient Related Parameters
Abdulaziz Elemosho MD, Taborah Zaramo BS, Jude Kluemper BS, Kerry-Ann Mitchell MD-PhD
Ohio State University
Syndrome of the trephined is an important complication following decompressive craniectomy, and it could manifest with motor, cognitive or behavioral deficits. The critical size craniectomy defect for the development of SoT remains unknown. It is important to delineate, if any, the relationship between multiple patient's parameters and the eventual development and resolution of SoT. Methods: Data was collected on patients who had an assessment with the Activity Measure for Post Acute Care AM-PAC system, before and after cranioplasty between 2014 and 2022. SoT was diagnosed based on a difference of atleast a score of 2 in pre-craniectomy and post-craniectomy AM-PAC score in any of the domains. Patients who had SoT were further subclassified according to severity. Results: Of the 160 patients who underwent decompressive craniectomy, 43 patients were assessed using the AM-PAC system. 28 patients had SoT based on our inclusion criteria. 14 patients had severe SoT. Patients in the SoT group had a significantly higher mean cranial defect size 155.86 ± 76.7 (p=0.0087). Similarly, patients in the severe SoT group had a significantly higher mean cranial defect size (197.33 ± 65.76) (p=0.013). There was no difference in age, smoking status, comorbidities, types of primary brain injury between SoT group and the non-SoT group. Conclusion: Patients undergoing craniectomy should receive a neurologic assessment at multiple timepoints while on admission. This will increase the index of detection of SoT. SoT should be anticipated in patients who are undergoing large sized craniectomy.
Early Outcomes in Buccal Myomucosal Flaps Versus Buccal Fat Pad Flaps as Adjunctive Techniques in Primary Palatoplasty
Rommy Obeid, BS, Fuad Abbas, BS, Marisa Pavia, MA, CCC-SLP, Mychajlo Kosyk, MD, MPH, Riley Marlar, DO, Antonio Rampazzo, MD, PHD, Bahar Bassiri Gharb, MD, PHD
Cleveland Clinic Foundation
Background: Traditionally, adjunctive flaps have been used to repair oronasal fistulas and lengthen the palate as a secondary intervention. In this study, we report our experience in primary palate repair using a combination of buccal myomucosal propeller, buccal myomucosal peninsular, and buccal fat pad flaps in conjunction with straight line and Furlow Z-plasty techniques. Methods: An IRB-approved retrospective review was performed of all cleft palate patients who underwent palatoplasty from 2015-2023. Patients were excluded if follow-up was less than 30 days. Age, comorbidities, cleft characteristics, palatoplasty technique, and post-operative outcomes were recorded. Results: 59 sequential cleft palate repairs were operated on in that time frame. 39 repairs utilized the buccal myomucosal flap (BMMF) and 20 utilized the buccal fat pad flap (BFF). 1 (2.6%) BMMF patient had oronasal fistula formation and 1 (5.0%) BFF flap patient had oronasal fistula formation (p=.567). Both fistulas required surgical intervention. Wound dehiscence resulted in 4 (10.3%) BMMF patients and 1 (5%) BFF patient (p=.444). There was 1 (2.5%) incidence of partial flap loss in the BMMF group and zero in the BFF group (p=.661). There were no incidences of infection, total flap loss, hematoma, seroma, or acute reoperation. Additionally, surgery for lengthening of the palate was required in just 2 BFF patients and 0 BMMF patients. Conclusion: Balancing sufficient palatal length while limiting oronasal fistula incidence can be achieved equally by using either BMMF or BFF adjunctive techniques in primary palatoplasty and have reasonable complication rates as compared to the literature.
Radiologic findings in children with absent/fused cranial sutures. Analysis of prevalence of incidental sagittal craniosynostosis: is it more common than we expect?
Mallory Wampler, MD Meghan Brown, MD Niyant Patel, MD
Summa Health
Introduction: Postnatal development of craniosynostosis can lead to either normal or subtly pathologic phenotypes. This study aims to determine the incidence, demographics, radiologic findings, and morphologic changes associated with fused cranial sutures. Methods: Children undergoing head CT in our emergency department in 2019 were included, excluding those previously diagnosed with craniosynostosis, VP shunts, and age > 21. CT scans were assessed for sutural appearance, inner table changes, tonsillar herniation, sella, ventricle size, optic nerve diameter, and sulcal effacement. The primary outcome was radiographically absent suture excluding the metopic (RASEM). Results: Among 678 patients (286F, 391M), 146 (21.5%) were black, and 500 (73.8%) were white. Mean age of non-fused suture (NFS) group was 7.7 years and RASEM group was 10.9 years. RASEM was found in 7.8%, with 5.4% having isolated sagittal suture absence. RASEM correlated with male sex (43M vs. 10F, p < 0.001). Optic average was higher in RASEM (5.4 vs. 4.9). Neurological complaints (10.5% vs. 5.7%, p = 0.022), inner table changes (25.4% vs. 5.8% for change = 1 vs. change = 0, p < 0.001) were associated with RASEM. Multivariate analysis identified positive associations with RASEM for males, African American race, increased optic nerve thickness, severe inner table changes, and neurological chief complaints (p < 0.001). Conclusion: This study reveals a 7.8% incidence of RASEM in children under 21 years. Significant associations with RASEM include male sex, African American race, neurological chief complaints, inner table changes, and increased optic nerve thickness.
A systematic review of surgical techniques for wide alveolar cleft repair
Isaac Mordukhovich, Fiona Fragomen, Abigail Meyers MD, Antonio Rampazzo MD PhD
Cleveland Clinic Department of Plastic Surgery
Objective: This study is a comprehensive analysis of surgical techniques and outcomes for wide (≥ 8 mm) alveolar cleft repair. Methods: A PRISMA-adherent systematic review was conducted. Study inclusion criteria required surgical technique descriptions and wide alveolar cleft repair outcomes. Review articles and redundant patient data across articles were excluded. Complications were defined as events necessitating surgical revision. Results: Twenty-one retrospective cohort studies and 30 case studies/series published 1987-2022 met inclusion criteria, representing 501 patients aged 4 to 66 years (mean 15.43 plus/minus 5.21 years). Distraction osteogenesis was the most common technique (57.59% of patients; mean age 13.30 plus/minus 3.44 years), predominantly by incremental distraction (mean distraction rate 0.80 plus/minus 0.22 mm/day). 98.37% of orthognathic surgery patients (26.94% of cases; mean age 14.41 plus/minus 1.01 years) had undergone prior cleft repair surgeries. Only free flaps (4.99% of cases; mean age 23.14 plus/minus 13.74 years) and local flaps (10.80% of cases; mean age 17.16 plus/minus 8.63 years) were used in papers with mean ages over 35 years, although no significant differences in mean reported patient ages were found between techniques (F = 0.95, one-way ANOVA). Local flaps had lower soft tissue closure frequencies than other treatments (p < 0.00096, Tukey HSD test), but did not differ in osseous closure rates (p = 0.12, Kruskal-Wallis) and complication rates (p = 0.28, Kruskal-Wallis). Conclusion: Every wide alveolar cleft repair technique evaluated in this review poses its own merits, offering surgeons a breadth of options for customizing treatment plans to the individual patient.
Fat Transposition to Decrease Orbital Rim Hardware Palpability
Ashley Leberfinger, MD, Michael Subichin, MD
Summa Health
Background: Zygomaticomaxillary complex (ZMC) fractures are the most common midface fracture, accounting for 15-23.5% of fractures. Adequate reduction is important for both aesthetic and functional reasons. Hardware may become palpable, visible, or cause cold sensitivity requiring removal. Incidence of plate removal from the infraorbital rim (IOR) has been reported as high as 30%. We sought a technique to minimize the risk of palpable or visible IOR plates. Methods: We performed a retrospective review of patients with ZMC fractures and IOR plates seen by a single surgeon from 2020-2023. To decrease palpable or visible hardware, we utilized a technique commonly used in cosmetic lower eyelid surgery: fat transposition. The lower lid medial and middle fat pads were transposed over the IOR plate. Results: The fat transposition technique was used in five patients. Four males and one female. Patient ages ranged from 20-40. There were no complications and operative time was similar. Minimum follow-up time was three months. The lower lid incisions healed well. No patients developed palpable or visible hardware during the follow-up period. Comparatively, patients without this technique had a hollow lower eyelid, palpable hardware, and hardware extrusion. Conclusion: Similar to facial aging, fat atrophy is seen after trauma. Lower lid fat transposition of the medial and middle fat pads reduces IOR hardware palpability and visibility after ZMC fracture fixation. This decreases the need for plate removal. There is minimal increased risk and operative time added to the procedure. Further studies will include a larger sample size with longer follow-up.
Establishing the Pediatric Head Circumference Growth Curve for Patients with Sagittal Craniosynostosis
Justin Beiriger, Casey Zhang, Nicolas M. Kass, Angel Dixon, Joseph Mocharnuk, Jeffrey Chen, Megan Pencek, Joseph Losee, Jesse Goldstein
UPMC Children\'s Hospital of Pittsburgh
Introduction: Head circumference is an integral measurement of pediatric care and helps to diagnose conditions that result in increased intracranial pressure or growth restriction, among others. However, no comparable growth curve exists for patients with sagittal synostosis. Our study aims to generate standardized, validated growth curves for patients diagnosed with isolated sagittal craniosynostosis. Methods: Patients diagnosed with isolated sagittal craniosynostosis between 2004-2022 were analyzed. Smoothed, LOESS non-parametric curves of head circumference were generated preoperatively and postoperatively. They were further stratified into three groups by treatment approach: Group 1 (no surgery), Group 2 (minimally invasive surgery), and Group 3 (open vault surgery). Results: 241 patients were included, 76.8% male. 39.8% of patients were managed non-surgically, 35.3% with minimally invasive endoscopic surgery, and 24.9% with open cranial vault reconstruction. Average age at surgery was 0.5 and 2.8 years for Group 2 and Group 3, respectively. Growth curves extended to 7 years of age for Group 1, 5.75 years for Group 2, and 3.5 years for Group 3. In non-operative patients, the 50th percentile at 0.5 years of age was equivalent to between the 3rd and 5th percentile according to the CDC's growth curves for healthy infants. At 1.0 year of age, the 50th percentile circumference was equivalent to between the 50th and 75th percentiles for healthy infants. Conclusion: Our study establishes a head circumference growth curve for patients with isolated sagittal craniosynostosis and will generate future studies to leverage head circumference as an important clinical metric in the care of these patients.
Over the Ridge: Discerning Metopic Ridge vs. Metopic Craniosynostosis Using an Image-Based, Deep-Phenotyping Toolset
Cristian Gonzalez, Joseph Mocharnuk, Anne Glenney, Nicole H. Goldschmidt, Angel Dixon, Nicolas M. Kass, Alexander Comerci, Carlos E. Barrero, Lauren Salinero, Wenzheng Tao, Erin Anstadt, Lucas A. Dvoracek, Megan Pencek, Ross Whitaker, Lisa R. David, Jesse Goldstein
UPMC Children\’s Hospital of Pittsburgh
Background: This study highlights the challenge in distinguishing metopic craniosynostosis, emphasizing the need for standardization. We compare CranioRate's tool to subjective measurements with surgeons\' visual assessments to demonstrate its utility in objectively evaluating metopic ridge (MR) vs. metopic craniosynostosis (MC). Methods: A mixed qualitative/quantitative survey comprised of demographic questions and 20 anonymized, randomized-order CT scan clinical vignettes (10 each of MR and MC) was distributed to the professional Listserv of the American Society of Craniofacial Surgery over six months beginning in March 2023. Respondent information (e.g., age, gender, training background) was collected. Using descriptive statistics, univariate analysis, and regression analysis, data was analyzed in R Studio (V 1.3.1093). Results: 27 complete responses were received. On average, the correct identification rate of clinical vignettes was 66.8% (SD: 28%). There was a significantly higher correct identification rate of MR CT scans than of MC CT scans (p-value =.02). Additionally, there was a statistically significant association between metopic severity score (MSS), one of CranioRate's two standardized measures for phenotypic severity, and the correct identification of an image as either MR or MC (p-value = 0.03). Among the MC scans only, decreasing MSS (i.e., milder phenotypes) were associated with a significant increase in image identification error by craniofacial surgeons (p-value = 0.023). Conclusions: Our study reveals variable accuracy among craniofacial surgeons in visually distinguishing MR and MC, especially in mild cases. It underscores the clinical need for an objective measurement tool to aid accurate classification, potentially preventing unnecessary surgery for patients with MR.
Racial Disparities Within Non-syndromic Craniosynostosis Diagnosis and Management
Christopher Fedor, Angel Dixon, Casey Zhang, Joseph Mocharnuk, Megan Pencek, MD, Nicolas M. Kass, Jesse Goldstein, MD
University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, UPMC Department of Plastic Surgery
Patients with craniosynostosis require timely and coordinated care from primary care providers and specialized multidisciplinary teams to mitigate unfavorable consequences like elevated intracranial pressure and cognitive deficits. However, achieving equitable access to such intervention, particularly addressing disparities between Black and White patients, remains a global concern. This study aims to investigate potential discrepancies in diagnosis and management of non-syndromic craniosynostosis among racial groups in our patient population. We conducted a single-center retrospective analysis of 275 patients diagnosed with non-syndromic craniosynostosis at UPMC's Cleft-Craniofacial Clinic between 2017 and 2021. Demographics, referral status, age of diagnosis, radiological assessments, and surgical interventions were specifically evaluated and compared among White (n=238), Black (n=25), and Asian (n=3) identifying patients. No significant differences were found in the age of diagnosis, rates of CT imaging, or rates of surgical intervention among these demographic groups. For White, Black, and Asian patients, respectively, the median ages at first CT were 6.1, 13.9, and 5.3 months (p=0.07), and the median ages at surgical intervention were 9.6, 15.6, and 32.3 months (p=0.17). The average time between the first CT and surgery was 5.9, 11.4, and 15.2 months (p=0.25) for White, Black, and Asian patients, respectively. No other predictive associations between race and outcome measures were observed (logistic regression, p=0.62). While these data suggest that the multidisciplinary teams at our institution are delivering impartial care to craniosynostosis patients, further exploration of observed trends is warranted to address potential disparities, particularly as we narrow our studies to the neighborhood level.
Understanding Syndrome of the Trephined: Development of a Novel Mouse Model
Jude Kluemper, BS Bilan Yakoub, BS Sabrina Almashni, BS Abdulaziz Elemosho, MD Taborah Z Zaramo, BS Kerry-Ann S Mitchell, MD PhD
The Ohio State University College of Medicine
Introduction: Syndrome of the Trephined (SoT) is a disorder characterized by neurological deterioration after a segment of the skull is removed. SoT lacks well-defined diagnostic criteria, with the main feature being neurologic improvement after the skull is repaired in a cranioplasty surgery. The aim of this study is to elucidate the underlying pathophysiology of SoT by evaluating neurologic dysfunction in a novel mouse model of decompressive craniectomy and cranioplasty after traumatic brain injury (TBI). Methods: This study utilized a controlled cortical impact model of TBI. Cohorts of adult C57/BL6 mice underwent right-sided craniectomy with or without a TBI. In certain groups, the removed calvarial bone was cryopreserved and replaced in a cranioplasty surgery several weeks later. Behavioral analysis, including balance beam and open field testing, was performed at weekly timepoints after craniectomy and cranioplasty to evaluate neurological function. Results: Preliminary results indicate that there were significant improvements in neurologic function following cranioplasty. On open field analysis, the number of inner zone entries, total inner zone distance, and total distance travelled all decreased significantly (p=0.03, p=0.006, and p=0.049 respectively). Also, after cranioplasty, there was no longer a significant difference in neurologic function between the TBI mice and control mice (p = 0.08). Conclusion: These preliminary results indicate that mice may experience neurologic improvement following replacement of their calvarial bone which coincides with the current understanding of SoT. To our knowledge, this is the first report of an animal model of SoT following a neurologic insult.
The Spectrum of Severity in Metopic Craniosynostosis: An Updated Analysis of the Largest Cohort to Date Using Craniorate Machine Learning Algorithm
Angel Dixon, Nicolas Kass, Annie Glenney, Joseph Morcharnuk, Erin Anstadt, Lucas Dvoracek, Megan Pencek, Wenzheng Tao, Ross Whitaker, Lisa David, Christopher Runyan, Michael Golinko, Michael Alperovich, Jesse Taylor, Jordan Swanson, Jesse Goldstein
UPMC Children's Hospital of Pittsburgh
Purpose: CranioRateTM is a machine learning tool designed to assess craniosynostosis severity by analyzing cranial morphology. This study examines the largest metopic craniosynostosis patient group to date, aiming to understand metopic severity and identify affected skull regions. Methods: CranioRateTM provides two objective, holistic metrics for quantifying severity in metopic craniosynostosis: Metopic Severity Score (MSS) and Cranial Morphology Deviation (CMD). De-identified CTs from normal and metopic patients from multiple U.S. institutions were compiled and analyzed using descriptive statistics, demographic associations, and regression analyses. Results: A total of 656 CT scans (92 normal patients, 564 metopic patients) from the CranioRateTM portal, including five U.S. institutions, were analyzed. Average age at CT was 0.75 ± 0.51 years, and 74.0% of patients were male. Among normal controls, average MSS was 0.00 ± 1.04, and average CMD was 85.23 ± 19.32. Among metopic patients, mean MSS was 5.31 ± 2.59, and mean CMD was 196.66 ± 46.96. Both MSS and CMD were significantly different between control and metopic patients (p<0.0001); no severity differences were noted between centers (p>0.05). There was a positive correlation between severity and earlier age at CT (MSS: r2 = .03, p=0.045). Regression analysis identified the central frontal bone, lateral orbit, and supraorbital rim as regions most associated with severity differences (p<0.05). Conclusions: Our novel results objectively identify cranial regions associated with metopic craniosynostosis severity and establish a temporal relationship between severity and presentation. Future work with CranioRateTM aims to encompass the entire metopic spectrum through additional institutional collaborations.
The Business of Plastic Surgery: A Machine Learning Model for wRVU Prediction and Salary Benchmarking of Pediatric Plastic Surgeons
Joseph W. Mocharnuk, B.A. Elizabeth A Moroni, M.D. Joseph E. Losee, M.D.
University of Pittsburgh School of Medicine
Background: Craniofacial and pediatric plastic surgeons contribute significant value to their institutions. The goal of this survey study was to evaluate billing, collection, and compensation patterns in academic pediatric plastic surgery using machine learning-based predictive models for work RVU and salary benchmarks. Methods: A survey was created and distributed via Qualtrics to 36 pediatric plastic surgery divisions in the United States. Requested information included faculty salaries, compensation models, RVUs sources of funding support, as well as individual attending surgeon demographics, training backgrounds, and distribution of professional responsibilities. Data was collected over six months, anonymized, and classified by AAMC region (i.e., West, Midwest, Northeast, and South), and subsequently analyzed using R Studio (Version 1.3.1093). Results and Discussion: Of the 36 national pediatric plastic surgery divisions surveyed, 27 programs responded with complete data. Responses were almost evenly distributed across most AAMC regions. Across institutions, the average estimated starting wRVU benchmark for a full-time (1.0 FTE) clinical faculty member was 5,551 (SD: 1707, Range: 2,250-8,272). The average starting salary for a fellowship-trained pediatric plastic surgeon was 385,476 (SD: $74,915, Range: $175,000-$500,000). Two variables were found to be highly statistically significant predictors of salary, namely the portion of practice comprised of craniofacial surgery (p-value = 0.005), a positive predictor, and the portion of practice in the outpatient clinic (p-value <0.001), a negative predictor. These and covariates were used to create an interactive salary and wRVU predictive calculator. Conclusion: Our study provides baseline measures and standards for compensation and wRVUs in academic pediatric plastic surgery.
Autologous Fasciae for Dura Reconstruction: Systematic Review
Abdulaziz Elemosho MD, Emily Pfahl BS, Jude Kluemper BS, Kerry-Ann Mitchell MD-PhD
The Ohio State University
Introduction: Patients undergoing cranioplasty reconstruction with alloplastic cranial implants for acquired skull defects may encounter complications such as cerebrospinal fluid (CSF) leaks, durotomies, and infections. Duraplasty using xenografts, a common practice, is associated with increased infection risk and additional costs for patients. This study focuses on the established method of using autologous fascia for dural reconstruction, sourced from various donor sites like tensor fascia lata (TFL), galea-pericranium, rectus abdominis fascia, and cervical fasciae. This approach aims to mitigate complications observed with xenograft reconstruction, particularly in settings where cost-effective alternatives are crucial. Methods: A systematic literature review was conducted across major databases, resulting in 461 patients from 10 relevant articles (case series and cohort studies) meeting the inclusion criteria. Results: Among the patients, 185 (40.1%) underwent duraplasty with galea-pericranium, while 52 (11.3%) had TFL duraplasty without recorded postoperative complications. Notably, 26 patients (5.6%) with a prior xenograft infection underwent reoperation with TFL replacement. Duraplasty using cervical fascia was performed in 218 patients (47.3%) after posterior fossa tumor resection, and 6 patients (1.3%) used anterior rectus fascia (ARF) for large skull defects. No postoperative CSF leaks or infections were reported. Conclusion: Autologous fascia emerges as a cost-effective option for dural closure in neurosurgical procedures, outperforming xenografts or synthetic dura due to its lower infection risk and preserved vascular supply. This method presents a valuable opportunity, particularly in resource-limited settings where affordable alternatives are imperative.
Combining Virtual Surgical Planning and Mixed-Reality for Verification of Bony Alignment in Orthognathic Surgery
Nicolas M Kass, Anjali Raghuram, Angel Dixon, Megan Pencek, Nikhil Sharma, Stephen Canton, Edward Andrews, Jesse Goldstein
UPMC
Introduction: Virtual surgical planning (VSP) gives a surgeon a roadmap of the operation prior to the start of the case and Mixed Reality (MR) allows for superimposed visualization and manipulation of patient imaging intraoperatively. We evaluated a workflow for incorporating VSP and MR to better understand complex patient anatomy in orthognathic surgery and compare intraoperative results with an idealized version. Methods: VSP was done in mimics for Le Fort I osteotomy, BSSO, and genioplasty in a pediatric patient. Medivis SurgicalAR and Microsoft Hololens2 were used to visualize preoperative patient CT imaging during the start of the case and VSP to verify bony alignment. Deviation from real patient anatomy was assessed in multiple methods of registration and ease of workflow was assessed. Results: Virtual surgical planning was carried out multiple weeks preoperatively. Initial registration on bilateral medial and lateral canthi lasted 8 minutes and 43 seconds and was significantly different than patient anatomy. Second registration with a fifth point over the frontal bone lasted 4 minutes and 47 seconds. Registration with a sixth point over the naision lasted 1 minute 30 seconds and was most accurate. The hologram was highly sensitive to manipulation of tracking fiducial array. Discussion: We found that increasing the number of virtual fiducials in multiple axes increased registration accuracy and that superimposing VSP imaging is a viable method of verification of intraoperative efficacy. Although workflow was efficient, more work needs to be devoted to ensuring image registration is correctly aligned throughout the case.
Feeding and Swallowing Outcomes in Pierre-Robin Sequence: a 10-Year Cohort Study
Nicolas M Kass, Angel Dixon, Alexander J. Comerci, Anne Glenney, Casey Zhang, Pooja Humar, Megan Pencek, Matthew Ford, Jesse A. Goldstein
UPMC
Background: Although surgical intervention is performed in patients with Pierre-Robin Sequence (PRS) to maintain airway patency, feeding and swallowing dysfunction remain a significant contributor to patient morbidity. We conducted a retrospective cohort study of feeding/swallowing outcomes in PRS patients following surgical intervention or conservative management. Methods: PRS patients who underwent mandibular distraction osteogenesis (MDO) or conservative management between 2010 and 2021 were included. Feeding outcomes were evaluated from clinical/radiographic evaluations, modified barium swallow studies (MDS) and polysomnography data. Results: Ninety-three patients were included. Fifty-eight (62.4%) were male. Almost all required a prolonged stay in the NICU (79/93, 84.9%), for a mean of 38.8 (SD 15.7) days. The majority of surgical patients received an MDO (47/63, 74.6%) while a small number received a supraglottoplasty (11/63, 17.5%) or combined procedure (5/63, 0.1%). Surgery significantly improved the Apnea-Hypopnea Index (AHI) (median 17.3 vs 4.35, p<<0.001) and MBS t (Z= 2.479, p=.01). The majority of patients were able to feed exclusively by mouth (48/84, 57.1%), 23/84 (27.3%) were "safe for PO", but required gastrostomy tube, and 13/84 (15.5%) continued requiring gastrostomy tube due to inability to safely feed by mouth. Conclusions: We found surgical intervention to be highly successful in improving both airway and feeding outcomes, although small cohort of patients remained unsafe for oral feeding and dependent on gastrostomy-tube feeds. Our results can be used to discuss expectations with patient families and inform clinical decision making.
Understanding Syndrome of the Trephined: Development of a Novel Mouse Model
Jude Kluemper, BS Bilan Yakoub, BS Sabrina Almashni, BS Abdulaziz Elemosho, MD Taborah Z Zaramo, BS Kerry-Ann S Mitchell, MD PhD
The Ohio State University College of Medicine
Introduction: Syndrome of the Trephined (SoT) is a disorder characterized by neurological deterioration after a segment of the skull is removed. SoT lacks well-defined diagnostic criteria, with the main feature being neurologic improvement after the skull is repaired in a cranioplasty surgery. The aim of this study is to elucidate the underlying pathophysiology of SoT by evaluating neurologic dysfunction in a novel mouse model of decompressive craniectomy and cranioplasty after traumatic brain injury (TBI). Methods: This study utilized a controlled cortical impact model of TBI. Cohorts of adult C57/BL6 mice underwent right-sided craniectomy with or without a TBI. In certain groups, the removed calvarial bone was cryopreserved and replaced in a cranioplasty surgery several weeks later. Behavioral testing was performed at various timepoints after craniectomy and cranioplasty to evaluate neurological function. Results: Preliminary results indicate that prior to cranioplasty, mice who received a TBI had significantly more neurologic dysfunction compared to the control mice (p=0.004). After cranioplasty was performed, there was a trend toward improvement in neurologic functioning, although this was not significant. Notably, after cranioplasty, there was no longer a significant difference in neurologic function between the TBI mice and control mice (p = 0.08). Conclusion: To our knowledge, this is the first report of an animal model of SoT following a neurologic insult. It is anticipated that these studies will lead to an increased understanding of the pathophysiology underlying SoT.
Cryopreserved Autogenous Cranioplasty: A Systematic Review and Meta-Analysis of Factors Associated with Severe Bone Resorption
Jude Kluemper, BS Emily Pfahl, BS Abdulaziz Elemosho, MD Kerry-Ann S. Mitchell, MD PhD
The Ohio State University College of Medicine
Introduction: Cryopreserved autogenous cranioplasty (AC) is often performed by plastic surgeons and neurosurgeons following a decompressive craniectomy. AC is associated with many complications including bone flap resorption (BFR). Previous meta-analyses have attempted to investigate various factors that contribute to BFR. However, these analyses are limited by varying definitions of BFR and varying methods of bone flap preservation across different studies. Methods: A literature search was performed across 4 databases (PubMed, Scopus, Web of Science, Embase). A total of 1085 papers were screened. Studies with the same definition of BFR (resorption requiring reoperation) and the same calvarial bone storage method (cryopreservation) were included. Results: Of the 1085 studies screened, 7 have met inclusion criteria for preliminary analysis which includes a total of 1650 patients. Preliminary results indicate patients with resorption were significantly younger (WMD = -8.38, p = <0.001). Calvarial bone flap fragmentation also caused significant increases in BFR (logOR = 1.57, p = <0.001). Patient sex did not significantly impact resorption (logOR -0.13, p = 0.36). Interval between craniectomy and cranioplasty also did not significantly impact resorption rates (WMD = 1.37, p = 0.82). Finally, presence of a ventriculoperitoneal (VP) shunt wasn't associated with an increased risk of resorption (logOR = 0.08, p=0.80). Conclusion: These results demonstrate certain factors such as age and bone flap fragmentation may impact incidence of calvarial bone resorption and need for re-operation. The results of this focused meta-analysis should provide new insight into factors affecting severe calvarial bone resorption and lead to improved patient outcomes.
Complex Scalp and Calvarial Reconstruction in Burn Patients- The Neuroplastic Surgery Approach
Jude Kluemper, BS Abdulaziz Elemosho, MD Emily Pfahl, BS Kerry-Ann Mitchell, MD PhD
The Ohio State University College of Medicine
Introduction: Management of head and neck burns is challenging for a variety of reasons, including the multiple critical structures and specialized tissue types in this region. Here we present a novel algorithm for scalp and skull reconstruction in the burn patient based on the growing field of Neuroplastic Surgery. We performed a systematic literature review and utilize cases performed at our institution to highlight relevant principles. Cases: The first patient was a 38 y.o. female involved in a house fire who sustained <5% total body surface area burns to her upper extremities, torso and approximately 50% of her scalp including the pericranium. The scalp and outer table of the calvaria were debrided. A synthetic dermal matrix was then overlayed to generate neodermis upon which a full thickness skin graft was placed. The second patient was a 31 y.o. male who sustained an electrocution burn to the scalp. The wound was debrided and reconstruction was attempted in previous surgeries. He presented ~1 year after initial injury with a non-healing wound and a large scalp/calvarial defect. The scalp and skull were debrided via craniectomy. A rotational flap was used to provide coverage. Cranioplasty using an alloplastic implant was performed in a staged procedure after adequate healing. Discussion: Reconstruction varies based on the extent of the scalp/calvarial injury. Full-thickness scalp burns require debridement of the outer table of the calvaria whereas full-thickness scalp and skull burns necessitate a craniectomy and alloplastic reconstruction. The unique characteristics of scalp tissue also limit reconstructive options.
Technique and Outcomes in Tissue Augmenting Palatoplasty for Cleft Palate Repair: a Single Institution Analysis
Nicolas M. Kass; Pooja Reddy; Vivian Wang; Anne Glenney; Angel Dixon; Shirley X. Liu; Lucille Cheng; Anjali Raghuram; Megan Pencek; Lucas A. Dvoracek; Noel Jabbour; Joseph E. Losee; Jesse A. Goldstein
UPMC
Background: Tissue augmenting palatoplasty (TAP) is a novel technique to address velopharyngeal insufficiency (VPI) risk following pharyngoplasty. We discuss our center's technique using various TAP modalities, including buccal myomucosal flaps (BMMF), buccal fat flaps (BFF), and their effect on sleep, speech, and surgical outcomes. Methods: A retrospective cohort study comparing non-syndromic primary TAP patients, syndromic primary TAP patients, and non-TAP Furlow palatoplasty control patients who presented to a single tertiary care center between 2017 and 2021. Demographic, speech, sleep, and surgical outcomes were summarized and compared between groups. Results: 157 records were analyzed, including 62 non-syndromic primary TAP, 51 syndromic primary TAP, and 43 control patients. Veau classification was similar between patients receiving TAP (Fischer's exact test p=.139), but Veau II cleft were associated with receiving TAP compared to non-TAP Furlow palatoplasty (Fischer's exact test p=.01). Overall complication rates were similar between patients who received TAP and non-TAP Furlow palatoplasty (χ2=.48, p=.49). However, TAP displayed decreased odds of developing a post-operative fistula (OR .16, χ2=11.35, p=.003). Of patients who had pre- and postoperative PWSS, two patients (one TAP, one non-TAP) had postoperative documentation of VPI (PWSS ≥7). Both TAP and non-TAP Furlow palatoplasty were associated with adequate post-operative PWSS scores (median 15 vs 4, p=.002). Conclusions: Tissue augmenting palatoplasty is effective at treating cleft palate, specifically reducing VPI without notable change in complication rate. Although flap selection and overall technique can be nuanced, TAP is an important tool for cleft palate repair.
An Initial Demonstration of Mixed Reality-Guided Percutaneous Screw Placement in Mandible Angle Fractures
Nicolas M. Kass, Kelly Daniels, Anthony Tang, Sumaarg Pandya, Malke Asaad, Stephen Canton, Nikhil Sharma, Edward Andrews, Jesse Goldstein, Mario Solari
University of Pittsburgh Medical Center
Background: Mandibular angle fractures have high rates of complications due, in part, to impaired visibility. Mixed Reality (MR) allows surgeons to display holographic renderings of patient CT scans and plan drilling trajectories directly on top of a patient. We demonstrate a method of planning trajectories and guiding screw placement by using MR to visualize the entire skull, including the mandible, prior to an incision. Methods: Two metal targets were fixed to the mandible of a cadaver and a CT was obtained. The CT was uploaded and projected using the Medivis SurgicalAR system and Microsoft HoloLens 2. Virtual target and entry points were placed on the hologram, creating two trajectory lines perpendicular to the mandible. Drilling was performed according to feedback on depth and angulation of the drill from the MR system. Results: Time to plot trajectories, place fiducials, and match the hologram to the cadaver was 4 minutes 53 seconds. Time to locate correct trajectories and drill screw guide holes was 5 minutes and 13 seconds. On assessment of the drilling accuracy, eight guide holes were drilled with mean deviation from intended location of 1.67mm and angle deviation of 2.8 ± 2.7. Discussion: We found that MR guided trajectory planning led to a high level of precision in percutaneous screw placement with minimal potential increase in operating time. This technology can reduce complication rates and reduce operating time in mandible angle fractures. Immediate future directions include a comparison with standard of care on more cadavers.
Infant Mandibular Condyle Fractures: Literature Review and Case Series
Ashley Leberfinger, MD, Alexa Mier, BS, and Ashish Francis, MD
Summa Health
Background: Mandible fractures are rare in infants. There's a paucity of data regarding infant condylar fractures. The condyle is the primary growth center of the mandible and surgical treatment can lead to growth disturbances. Methods: We performed a literature review of infant condylar fractures and reviewed our institutional experience. Results: A PubMed search produced 7 articles describing 7 infants with condyle fractures. Most patients (57%) had condylar in addition to symphyseal fractures. Two patients had unilateral and one bilateral condylar fractures. Fractures were more common in males (57%). The most common mechanism was falls (57%). Non-accidental trauma (NAT) was not identified. Treatment was conservative in 43%, which were all isolated condylar fractures. Surgical treatment was performed to address symphyseal fractures in all multi-segment cases, but condylar fractures were treated in a closed manner. Average follow up was 10 months & all were reported to have normal growth. Our institutional experience revealed 5 patients with condylar fractures, two of which were bilateral. 60% were male and all presented after a fall. NAT was identified in one case. Conservative treatment was performed in all cases. Follow up was on average 1.4 weeks, but all symptoms had resolved. Conclusion: Normal condylar growth is important for facial growth. Although non or minimally displaced condylar fractures in infants demonstrate remarkable remodeling and can be treated conservatively, it is important they are followed closely. Additionally, they should be screened for NAT, as infant facial proportions render the mandible relatively protected. Further investigation is needed to elucidate long-term sequelae.
Provider Characteristics and Pre-Transfer Costs of Potentially Avoidable Transfers for Pediatric Facial Fracture Patients In a Single Institution
Shirley X. Liu, MS; Lucille G. Cheng, BA; Nicholas M. Kass, BA; Angel Dixon, BS; Anne E. Glenney, BA; Jesse A. Goldstein, MD
University of Pittsburgh School of Medicine
Purpose: Among some types of common pediatric facial fractures, conservative treatment is the most typical and readily available treatment method. However, patients may still be transferred, leading to costly and potentially "avoidable" transfers (PAT). This study identifies provider characteristics and initial presenting facility type associated with PAT, and the resulting financial burden borne by the patients. Methods: Records of patients who presented to a pediatric level I trauma center after inter-hospital system transfer of a facial fracture were retrospectively reviewed. Variables studied included demographics, provider credentials, pre-transfer facility, and transportation modality. PAT was defined as a patient with a stay less than one day, and no admission, surgery, or emergent procedure post-transfer. Results: Of 75 patients, 37 met PAT criteria. Provider credentials (p = 0.013) and initial presenting facility type (p = 0.024) were significantly associated with PAT. Patients initially seen by APPs had increased odds of PAT compared to those initially presented to MD/DOs (OR = 3.17, 95% CI [1.17, 8.54]). Additionally, there is a significant difference in the likelihood of PAT when initially presenting to trauma center EDs compared to non-trauma center EDs (p = 0.024). The estimated PAT cost per patient was $6,332.11, with imaging at $5,844.66 (92.3% of total cost) and transportation at $487.45 (7.7%). Conclusions: Emergent transfer in pediatric facial fracture patients is often unnecessary. Our findings highlight the significance of provider and facility characteristics associated with PATs, offering avenues to reduce PATs through provider and facility training.
3D Volumetric Analysis of Alveolar Clefts Using Cone-Beam Computed Tomography
Trent James, BS Kiersten Woodyard De Brito, MPH Nathan Lawera, MD, MS Sydni Meunier, MD Joseph Easton, MD Brian Pan, MD, FACS Scott Rapp, MD, FACS
University of Cincinnati
Presenter: Nathan Lawera Purpose: Alveolar bone grafting (ABG) is standard management for alveolar defects in cleft lip and palate patients. In this study, we examine the potential use of Cone-Beam Computed Tomography (CBCT) and 3-Dimensional segmentation for volumetric quantification of alveolar clefts. Methods: A retrospective chart review was performed for patients who underwent ABG from 2018-2022. ITK-Snap neuroimaging software was used in 3-Dimensional segmentation of CBCT imaging, obtaining measurements of volume and widths of alveolar clefts pre- and post-operatively. Anatomic landmarks for 3D segmentation were agreed upon by craniofacial orthodontists and surgeons. Results: 11 post-operative and 15 pre-operative CBCT studies for patients who underwent ABG were available for 3D segmentation. 10 pre-operative studies were conducted for primary ABG and 5 for revision planning. For post-operative segmentations of successful ABG, original cleft width averaged 5.35mm, cleft residual volume averaged 559.1mm3, and bony bridging height averaged 6.06mm. Original cleft width in patients who required revision was significantly higher compared to those who did not (7.89mm vs. 5.35mm, p=0.025). However, there was not a statistically significant difference between the residual volume of clefts which required revision and those that did not (945.9mm3 vs. 559.1 mm3, p=0.11). Conclusions: 3D segmentation has potential in pre-operative planning of alveolar bone grafting, utilizing images often already obtained by craniofacial orthodontists. Preliminary results from 3D analysis of CBCT indicate width of cleft may be more influential in ABG success compared to overall cleft volume. Continued investigation will include regression analysis of cleft width and volume corresponding to ABG outcomes.
Assessment of Long-Term Speech Outcomes in Children with Pierre Robin Sequence
Casey Zhang, BA; Nicholas M. Kass, BA; Joseph W. Mocharnuk, BA; Justin Beiriger BSE; Angel Dixon, BA; John Smetona, MD; Matthew Ford, MS; Joseph E. Losee, MD; Jesse A. Goldstein, MD
University of Pittsburgh Medical Center
Introduction: The purpose of this study was to evaluate long-term Pittsburgh Weighted Speech Scores (PWSS) and the need for secondary speech surgery for velopharyngeal insufficiency (VPI) in patients with Pierre Robin Sequence (PRS) after primary palatoplasty compared to patients without PRS. Methods: A retrospective cohort study was performed of patients diagnosed with PRS who underwent primary cleft palate repair at a tertiary care children's hospital between 2001-2019. The control group included patients matched on presence Veau Class I or II cleft palate. Outcomes included PWSS and secondary operation for VPI. Results: 106 patients with PRS and 94 control patients met inclusion criteria. Patients with PRS underwent primary palatoplasty at a median age of 1.2 ± 0.8 compared to 1.1 ± 1.1 years in patients without PRS (p=0.11). Patients with PRS underwent most recent speech evaluation at a mean age of 8.7 ± 3.9 years compared to 7.0 ± 2.6 years in the control group (p<.001). Median PWSS among patients with PRS was 4.0 ± 3.4 compared to that of control patients, 4.0 ± 1.9 (p=.58). 37.1 % of patients with PRS had additional secondary palate surgery compared to 19.1% of control patients (p=.005). Similar numbers of patients with and without PRS had VPI (PWSS >7) at most recent evaluation (10.9% vs 4.2%, p=.11). Conclusion: Long-term speech outcomes are similar among patients with and without PRS. However, patients with PRS required higher rates of secondary palate surgery for persistent VPI, with only 8.4% achieving complete velopharyngeal competence.
Does Intraoperative Systemic Anticoagulation After Anastomosis Revision Improve Outcomes in Head and Neck Free Flap Reconstruction?
Mohsina Subair, Fuat Baris Bengur, Preetha Velu, Mark Kubik, Chaud Sridharan, Mario G Solari
Department of Plastic Surgery, UPMC, Pittsburgh
Purpose: Heparin drip is often started intraoperatively when there is concern for postoperative thrombosis, especially, in setting of an anastomotic revision (AR). We aimed to determine the outcomes following intraoperative systemic anticoagulation in head and neck free flaps requiring AR to help guide future use. Methods: This was a single centre retrospective review of all patients who underwent head and neck free flap reconstruction from 2012 to 2022. Data including anastomosis revision, flap loss, and return to the operating room was extracted from our Head and Neck free flap database. Results: Among 1174 patients included, 77(6.5%) had AR.Flap-loss was 2% overall and 20%(16/77) in AR group. Intraoperative heparin-drip was administered in 35 patients, 22 at index &13 at take-back surgery. Among AR patients, heparin group had significantly higher bleeding rates(23%vs7%;OR=3.65,p=0.027) with similar flap failure rates(20%vs 22%,p=0.804).In patients with AR at index surgery(52/77), heparin drip resulted in a higher rate of bleeding(11%vs6%,p=0.51) with lesser flap loss rates(6%vs 9%;p=0.67). In patients with an identifiable thrombus(45%), use of heparin-drip significantly reduced flap failure (25% vs 81%p=0.002) with similar bleeding (29% vs 27%p=0.98) when compared with patients who did not receive heparin-drip. In patients without identifiable thrombus (54%), use of heparin-drip had relatively higher bleeding rates (14%vs3%, p=0.24) with similar flap failure rate(0 vs 3%,p=0.79) Conclusion: In patients needing AR, intraoperative systemic anticoagulation was associated with better flap outcomes when a thrombus was identified. In the absence of an identifiable thrombus, there was a significantly higher rate of bleeding with comparable flap survival rates.
