FACE

Munabi, Naikhoba C.O.; Obinero, Chioma G.; Valenti, Alyssa B.; Greives, Matthew R; Imahiyerobo, Thomas A.

doi: 10.1177/27325016241292522pmid: N/A

Purpose: The timing of cleft palate (CP) repair has been refined based on decades of study to optimize feeding, speech, and quality of life outcomes. However, sociodemographic disparities may impact accessibility of cleft care, surgical timing, and outcomes. This study reviews published data on sociodemographic disparities impacting primary CP repair access, timing, and outcomes in the United States. Methods: A systematic review was performed following PRISMA guidelines in the Pubmed, Embase, and Medline/OVID databases. Included studies focused on sociodemographic disparities in access to, timing, and outcomes after CP surgery. Studies performed outside the United States or published before 2000 were excluded. Results: Twenty-three studies were included in the review focusing on access to care (n = 8), financial cost (n = 1), surgical timing (n = 12), and surgical outcomes (n = 9). Access is most challenging for non-White patients and those with public insurance. Financial disparities are poorly studied and understood. Non-White, particularly Asian patients, those with public insurance, or geographically remote patients receive delayed care. The same populations struggle with obtaining quality outcomes. Government health policies or the provision of a cleft navigator can resolve disparities in surgical timing and potentially outcomes. Conclusions: Disparities in CP repair access and outcomes affect minority, particularly Asian, publicly insured, and geographically remote patients. The presence of a cleft navigator to help guide patients through the healthcare system can be effective. Future studies should aim to further investigate financial disparities and design initiatives that improve coordination of care for CP surgery in underserved populations.

Hush, Stefanie E.; Williams, Joseph K.; Brady, Colin M.; Soldanska, Magdalena; D. Tashima, Alexis

doi: 10.1177/27325016241302404pmid: N/A

For patients born with cleft lip and/or cleft palate, surgical reconstruction(s) during early childhood serve as the foundation for attaining more normal anatomy and function of the involved areas. As a longstanding cleft and craniofacial institution, we have experienced significant changes in perioperative care regimens. Most notably, the evolution of enhanced recovery protocols has transformed how we care for our patients in the perioperative period. Part I of this publication provides an overview of our institution’s peri-operative protocols, for various cleft-related surgeries, including cleft lip repair, cleft palate repair, speech pharyngoplasty, and alveolar bone grafting. Part II will focus on orthognathic surgery and cleft lip/nasal revisions. This comprehensive review may serve as a prototypical guide for other institutions.

Kim, Michelle H.; Martin, Hannah L.; Avashia, Yash J.; Sicard, Ryan M.; Chiang, Harry; Woodard, Charles R.; Marcus, Jeffrey R.; Frank-Ito, Dennis O.

doi: 10.1177/27325016241310616pmid: N/A

Background: This study compared the impact of spreader grafts (SG) and spreader flaps (SF) on the transport of intranasal drug delivery to target the posterolateral nasal wall. Method: SG and SF were each performed in sequence on two cadaveric specimens after soft tissue elevation technique. Computed tomography scans were acquired following each procedure to generate anatomic models for computational fluid dynamics simulation of intranasal sprays under the following conditions: inhalation rate (15 and 30 L/min), spray velocity (1, 5, and 10 m/s), spray released location (center, lateral, medial, top, and bottom), head position (upright, tilted-forward, tilted-backward, and supine), and particle diameter (1-100 µm). Percentage of particles deposited on the posterolateral nasal wall were calculated. Results: For Specimen 1, highest posterolateral wall depositions were Pre-Op: left = 74%, right = 74%; SF: left = 53%, right = 22%; SG: left = 60%, right = 61%. For Specimen 2, highest posterolateral wall depositions were Pre-Op: left = 25%, right = 83%; SF: left = 29%, right = 76%; SG: left = 14%, right = 72%. In general, posterolateral wall deposition was higher at 30 L/min inhalation rate and at 1 m/s spray velocity. Conclusions: Drug delivery targeting the posterolateral nasal wall appears to be dependent on many factors. However, midvault nasal reconstruction does not increase drug delivery to the posterolateral nasal wall.

Chapman, Leah; Runyan, Christopher; Couture, Daniel; Thibodaux, Lia; Wright, Avery; David, Lisa

doi: 10.1177/27325016241299005pmid: N/A

Objectives:The neurocognitive profile of patients who have undergone spring-assisted surgery (SAS) for craniosynostosis is not well understood, and a variety of different cognitive measures have been used across various studies. Although neuropsychological evaluations can document cognitive strengths and weaknesses across a number of cognitive areas, they can be time consuming. This study aimed to: (1) describe the neurocognitive profile of patients who underwent SAS using both a common intelligence measure and iPad assisted testing measuring several cognitive areas, as well as parent ratings; (2) better understand the feasibility and utility of using iPad assisted assessments in this population.Methods:Thirty-six patients between the ages of 6 and 18 with sagittal synostosis who underwent SAS participated in a brief battery of assessments including a measure of abbreviated IQ, National Institutes of Health Toolbox Cognition Battery (NIH Toolbox), and caregiver ratings on the Behavior Rating Inventory of Executive Function – Second Edition (BRIEF-2). Statistical analyses assessed performance within the group and between measures.Results:Positive correlations were found between all 3 NIH Toolbox Composite scores and abbreviated IQ. Five of 7 subtests were positively correlated with Full Scale IQ, while 4 of 7 were positively correlated with both verbal and visual reasoning indices. Negative correlations between the Crystallized Composite score and BRIEF-2 were found for 8 of 9 BRIEF-2 subscales. Three of 9 BRIEF-2 subscales were negatively correlated with Fluid Composite and Total Composite scores.Conclusions:Cognitive data were generally aligned with the normal distribution curve. Although caregiver ratings yielded several executive functioning concerns, significant correlations were found with composite scores and a few specific subtests. Use of the NIH Toolbox was feasible in this population and shows promise as a tool for measuring a range of different cognitive domains.

Palmer, Skyler K.; Gomez, Diego A.; Elkhill, Connor; French, Brooke; Wilkinson, Charles; Porras, Antonio R.; Nguyen, Phuong D.

doi: 10.1177/27325016241308140pmid: 41426652

Introduction: Treatment of multi-sutural craniosynostosis presents unique challenges and requires a patient specific approach. Patients with contralateral multi-suture craniosynostosis are particularly challenging as the surgical technique utilized must induce opposing forces of expansion. When patients present early in life, early dynamic expansion may be preferable to open approaches. Herein we report a 2-stage technique to treat contralateral right unicoronal and left lambdoid synostosis with simultaneous distraction osteogenesis and spring-mediated cranioplasty. Methods: A 3-month-old male presented to our clinic for concern for head asymmetry. A CT scan confirmed right coronal and left lambdoid craniosynostosis. Preoperative and postoperative head CT and 3D photogrammetry were used to compute the Head Shape Anomaly index (HSA) and difference in head volume from a personalized normative reference for shape and volume. Results: The surgery lasted 163 minutes, and the patient received a 168 mL blood transfusion. The patient was discharged after 3 days. Two springs were placed following a 1 cm strip craniectomy of the lambdoid suture, and a 40 mm uniplane cranial distractor was placed after a right fronto-orbital osteotomy. Devices were removed following activation and consolidation phases. There were no major complications. Postoperative 3D head CT showed correction of left lambdoid and right coronal craniosynostosis with improved plagiocephaly. The patient’s postoperative HSA Index improved from 4.39 pre-operatively to 2.85 at 145 days post-operatively. In addition, the difference in intracranial volume from the personalized normative reference improved from -87.35 mL pre-operatively to 1.65 mL post-operatively. Conclusion: This early dynamic expansion technique provided improved safety outcomes including decreased operative time, transfusion requirement, and hospital stay when compared to other techniques for multi-suture correction such as cranial vault reconstruction. This technique also produced desired results in shape correction and correction of volumetric anomalies. This illustrates the importance of innovation to develop patient specific surgical designs that maximize safety and morphologic outcomes.

Amm, Christian El; Bowen, Ira; Gernsback, Joanna; Gross, Naina

doi: 10.1177/27325016241299009pmid: N/A

Background: Blood loss is a major concern in craniofacial surgery due to extensive skeletal remodeling. Various strategies and technologies have been employed to mitigate blood loss, but the impact of Extended Reality (XR) visualization has not been extensively studied. This study investigates the effect of XR visualization on blood loss in craniofacial surgery. Materials and Methods: This retrospective cohort study included patients undergoing major craniofacial procedures at a tertiary academic medical center from January 2018 to February 2022. An internally developed XR system displaying Virtual Surgical Planning (VSP) data overlaid on patient anatomy was introduced in 2019. The study compared blood loss between patients who had XR-assisted surgeries (n = 17) and those who did not (n = 62). Primary outcome measured was calculated blood loss (ERCV%), and secondary outcomes included the incidence of sinus proximity bleeding, dural injuries, surgery duration, and transfusion volumes. Results: The XR-assisted group had significantly lower blood loss (43.7% vs 61.9%, P < .05). Sinus proximity bleeding during craniotomy was also significantly reduced in the XR group. More patients in the XR-assisted group avoided transfusion altogether (35% vs 24%) and tended to have fewer donor-units exposure (0.88 vs 1.34), but those trends did not reach statistical significance in our small study sample. Conclusion: In this pilot study, XR visualization in craniofacial surgery is associated with reduced blood loss and sinus proximity bleeding during craniotomy. While the study suggests XR can enhance surgical safety, larger, well-designed investigations are needed to confirm these results and fully understand the implications of XR technology in craniofacial surgery.

Saha, Ayush; Law, Huay-Zong; Barceló, Carlos Raul

doi: 10.1177/27325016241290457pmid: N/A

Introduction:This investigation aims to evaluate outcomes of LeFort I distraction osteogenesis (DO) using external distraction (ED) versus internal distraction (ID), focusing on acute complication rates and relapse/malocclusion necessitating a secondary LeFort I osteotomy. Factors associated with a higher likelihood of complication and secondary surgery are also described.Methods:A retrospective review of 467 electronic medical records was conducted for patients who underwent at least one maxillary or mandibular orthognathic procedure between 2003 and 2023.Results:Among these patients, 17% (79/467) underwent LeFort I with maxillary distraction and had at least 30 days of follow-up for acute complications. Eleven percent (50/467) underwent LeFort I with maxillary distraction and had at least 2 years of follow-up for the likelihood of a secondary LeFort I procedure. A statistically significant difference was seen in the number of acute complications for patients who used ED versus ID devices after LeFort I osteotomy with distraction. The need for secondary LeFort I osteotomy was not significantly different between patients using ED and ID devices.Conclusion:The complication and reoperation rates reported here may help counsel patients and families about potential outcomes and expectations for LeFort I advancement using ED and ID devices, as well as provide a point of comparison for future investigations.

Sivakanthan, Thiviya; Steinbacher, Derek M.

doi: 10.1177/27325016241297151pmid: N/A

Background:Patients with unilateral condylar hyperplasia (UCH) may present with TMJ symptoms, rather than concerns or recognition of asymmetry. Localization of TMJ pain may be on the affected (long) side, unaffected side, or both. Flattening, severe erosion and internal derangement on the opposite side can be appreciated radiologically. This can be a red herring, shielding the true diagnosis of UCH from the contralateral side. We hypothesize that excessive growth of the ipsilateral condylar neck and head on the side of UCH results in an upward and backward force on the opposite side TMJ, with resultant symptoms and findings (condylar flattening, anterior disk displacement, eminence changes). The purpose of this paper is to highlight the bilateral TMJ findings in UCH, and address potential treatment strategies.Methods:This is a retrospective study involving radiologic and biographical data from subjects with TMJ UCH, as well as controls. Patient details and high quality Cone beam CT (CBCT) scans (1 mm slices or less) were analyzed. CT scans were digitized and morphometric points were placed using Planmeca software (Hoffman Estates, Illinois). Linear and volumetric measures were taken in reference to the eminence, TMJ space, condylar position, and neck lengths. Volumetric analysis of the condylar head and neck was done using Analyze 14.0 software (Overland Park, KS, USA). Results were assessed using univariate analysis (T-Wilcoxon test).Results:Forty patients were included (29 with UCH, 11 controls). The condylar head was flatter and erosive appearing on the contralateral UCH side compared to both ipsilateral side in the same subject, and compared to controls. Analysis between the affected and unaffected sides in patients with UCH showed a significant difference in condylar head and neck length (P = .0019) and volume (P = .0030); anterior glenoid space (P = .035) and vertical height of condylar eminence (P = .00044). The difference in ramus length was not significant (P = .6533). Between the controls and the UCH patients, there was a significant difference in the variance in condylar head and neck length (P = 1.98e-07) and volume between the 2 sides (P = 1.94e-08) but not ramus length (P = 1). The vertical height of the condylar eminence was smaller on the affected side than in the controls (P = .0018) and the anterior glenoid space was significantly smaller on the unaffected side compared to the controls (P = .0053).Conclusion:This study highlights TMJ morphological differences in patients with UCH. These differences in condylar and glenoid morphology are consistent and should be used to aid and underpin the diagnosis and direct treatment. Importantly, patients who present with TMJ pain and erosion on one side, should be assessed for opposite side UCH, as the underlying culprit.