Facial Soft Tissue Lesions in Children.

Facial soft tissue lesions in children are often classified based on their structure or cellular origin and can be benign or malignant. This review focuses on common facial soft tissue lesions in children, their clinical morphology, natural history, and medical and surgical management, with an emphasis on those considerations unique to soft tissue lesions present at this anatomic site.

Pediatric Cranial Vault Pathology.

A wide variety of diagnoses can be approached with a common framework for diagnosis, extirpation, and reconstruction of pediatric cranial vault pathologies. Durability of reconstruction is critical for the range of pediatric patients from infancy to adolescence. Rigid reconstruction, preferably with autologous tissue when possible, promotes brain protection and satisfactory aesthetic outcome. Careful planning can allow for immediate definitive reconstruction of defects without need for further surgical intervention.

Making a Statement: Positions of Professional Medical Organizations Towards Gender-Affirming Care.

OBJECTIVE: Despite politically charged media coverage and legislation surrounding gender affirming care (GAC), many organizations have released position statements to provide scientifically backed clinical practice standards, combat misinformation, and inform medicolegal policies. The purpose of this study is to objectively assess the availability and the content of the official position statements of relevant medical professional organizations regarding GAC. SUMMARY BACKGROUND DATA: A list of U.S. medical professional organizations with likely involvement in GAC based on medical or surgical specialties was compiled. METHODS: For included organizations, we evaluated the availability, content, and publication year of positions on GAC through October 2023. When available, formal positions were categorized as supportive or unsupportive. RESULTS: A total of 314 professional medical organizations were screened for our study based on specialty, relevance to GAC, and issuance of patient guidelines or position statements. Inclusion criteria were met by 55 organizations. Most organizations (35, 63.6%) had formal position statements on GAC. Support for GAC was described in 97.1% (n=34). Further, 94.2% (n=33) of available statements explicitly addressed GAC in individuals less than 18 years old and were largely supportive (96.9%, n=32). CONCLUSIONS: This cross-sectional analysis demonstrates that a majority of multidisciplinary professional medical organizations with relevance to GAC have issued formal position statements on the topic. Available positions were overwhelmingly supportive of individualized access to gender-affirming therapies in adult and adolescent populations. However, silence from some organizations continues to represent a modifiable disparity in the provision of GAC.

Gender-Affirming Facial Surgery: Lower Third of the Face.

This article is intended to give the reader an overview of facial gender-affirming procedures applicable to the lower face and neck. A review of facial analysis in the context of masculine versus feminine facial features and the contributions of both soft tissue and bone to this anatomy is provided. The use of systematic facial evaluation and patient-driven concerns as a guide for presurgical planning is reviewed. Detailed descriptions of the unique surgical interventions to feminize the soft tissues and the skeletal framework of the lower face and neck are provided.

Current Trends in Orthognathic Surgery.

Orthognathic surgery has evolved significantly over the past century. Osteotomies of the midface and mandible are contemporaneously used to perform independent or coordinated movements to address functional and aesthetic problems. Specific advances in the past twenty years include increasing fidelity with computer-assisted planning, the use of patient-specific fixation, expanding indications for management of upper airway obstruction, and shifts in orthodontic-surgical paradigms. This review article serves to highlight the contemporary practice of orthognathic surgery.

DOES THE LOW AND SHORT MEDIAL CUT AFFECT LINGUAL NERVE RECOVERY AFTER SAGITTAL SPLIT OSTEOTOMY?

PURPOSE: To evaluate the recovery of lingual nerve (LN) neurosensory function in patients undergoing sagittal split osteotomy (SSO) with a low and short medial horizontal cut. MATERIALS AND METHODS: This was a prospective study of patients with mandibular deformities undergoing SSO with a low and short medial horizontal cut over a 4-year period. The outcomes of interest were neurosensory recovery of the LN, as assessed objectively using functional sensory recovery (FSR) and subjectively by patient report. RESULTS: The sample included 123 SSOs in 62 subjects with a mean age of 19.3 ± 3.1 years. Thirty-seven (61.7%) subjects were female. Mandibular advancements were performed in 52 SSOs (42.3%); mandibular setbacks were performed in 71 SSOs (57.7%). One subject underwent revision BSSO. FSR was achieved at 122 LNs (99.1%) within 6-weeks post-operatively, with 120 sites (97.5%) having S4 sensation at 6-weeks. Decreased LN sensation was reported at 10 (8.3%) sites at 1-week post-operatively. At 6-weeks post-operatively, 118 sites (97.5%) had reported normal sensation. By 12-weeks post-operatively, all LN sites had S4 sensation and there were no subjective complaints. Revision sagittal split osteotomy was associated with prolonged (≥6 weeks) time to S4 sensation (p = 0.02) and subjective complaint of decreased sensation (p = 0.02). CONCLUSION: LN sensory recovery occurs rapidly following the low and short SSO, with 99% of sites achieving FSR and subjectively normal sensation within 6-weeks of surgery and all patients achieving FSR with S4 sensation by 12-weeks post-operatively. LN sensory recovery may be prolonged in patients undergoing revision SSO.

Adipose-Derived Stem Cells Enhance Graft Incorporation and Mineralization in a Murine Model of Irradiated Mandibular Nonvascularized Bone Grafting.

BACKGROUND: Nonvascularized bone grafting represents a practical method of mandibular reconstruction. However, the destructive effects of radiotherapy on native bone preclude the use of nonvascularized bone grafts in head and neck cancer patients. Adipose-derived stem cells have been shown to enhance bone healing and regeneration in numerous experimental models. The purpose of this study was to determine the impact of adipose-derived stem cells on nonvascularized bone graft incorporation in a murine model of irradiated mandibular reconstruction. METHODS: Thirty isogenic rats were randomly divided into 3 groups: nonvascularized bone graft (control), radiation with nonvascularized bone graft (XRT), and radiation with nonvascularized bone graft and adipose-derived stem cells (ASC). Excluding the control group, all rats received a human-equivalent dose of radiation. All groups underwent mandibular reconstruction of a critical-sized defect with a nonvascularized bone graft from the contralateral hemimandible. After a 60-day recovery period, graft incorporation and bone mineralization were compared between groups. RESULTS: Compared with the control group, the XRT group demonstrated significantly decreased graft incorporation (P = 0.011), bone mineral density (P = 0.005), and bone volume fraction (P = 0.001). Compared with the XRT group, the ASC group achieved a significantly increased graft incorporation (P = 0.006), bone mineral density (P = 0.005), and bone volume fraction (P = 0.013). No significant differences were identified between the control and ASC groups. CONCLUSIONS: Adipose-derived stem cells enhance nonvascularized bone graft incorporation in the setting of human-equivalent radiation.

Pediatric Panfacial Fractures.

Pediatric panfacial trauma is a rare occurrence with poorly understood implications for the growing child. Treatment algorithms largely mirror adult panfacial protocols with notable exceptions including augmented healing and remodeling capacities that favor nonoperative management, limited exposure to avoid disruption of osseous suture and synchondroses growth centers, and creative fracture fixation techniques in the setting of an immature craniomaxillofacial skeleton. The following article provides a review of our institutional philosophy in the management of these challenges injuries with important anatomic, epidemiologic, examination, sequencing, and postoperative considerations.

Gender-Affirming Surgery of the Mandible: Lower Jaw Feminization and Masculinization.

For patients with gender dysphoria, gender-affirming surgery of the face has been shown to vastly improve quality of life. The mandible is one area of the face that has distinct feminine and masculine presentations. This article will review gender-affirming surgery of the lower jaw, both for feminization and masculinization. Techniques for bony contouring and soft tissue manipulation will be discussed.

Management of the Inferior Alveolar Nerve in Large Sagittal Split Advancements: To Free or Not?

SUMMARY: The purpose of this study was to evaluate whether neurosensory recovery of the inferior alveolar nerve (IAN) is influenced by its location following sagittal split osteotomy (SSO) in patients undergoing large mandibular movements. This was a prospective, split-mouth study of skeletally mature patients undergoing bilateral SSO. Patients were included as study subjects if they underwent bilateral SSO for mandibular advancement greater than 10 mm and, following the splits, the IAN was freely entering the distal segment on one side and within the proximal segment on the other. Descriptive, bivariate, and Kaplan-Meier statistics were computed. The study sample included 13 subjects (eight female subjects; mean age, 18.7 ± 1.8 years) undergoing 26 SSOs. Eleven subjects underwent bimaxillary surgery; 10 had simultaneous genioplasty. The mean mandibular movement was 12.2 ± 1.4 mm and was not significantly different between sides ( P = 0.43). All subjects achieved functional sensory recovery (FSR) bilaterally within 1 year of surgery. There was no difference in the median times to FSR based on the location of the IAN (distal segment, 105 days, versus proximal segment, 126 days; P = 0.57). In SSO for mandibular advancement with movements greater than 10 mm, leaving the IAN within the proximal segment may not impact time to FSR. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

The Yin and Yang of Primary Unilateral Cleft Lip and Nose Repair: Balance through Opposing Cleft and Noncleft Side Changes.

BACKGROUND: Balance is achieved through opposing interactions. Objective three-dimensional assessment of changes during surgical treatment of the unilateral cleft lip and nasal deformity are limited, and false assumptions may prevent optimal management. METHODS: The authors performed anthropometric analysis on the immediate preoperative and postoperative images (captured under anesthetic) of patients undergoing primary repair ( n = 36). Changes in dimensions and measures of balance were assessed ( P < 0.05). RESULTS: Angles and ratios that reflect cleft to noncleft side balance normalized, although alterations occurred in opposing ways. Centralization of the columella narrowed the cleft nasal base and widened the noncleft nasal base. As the cleft columellar height elongated, the noncleft columellar height shortened. With these changes and correction of cleft alar base retrusion, the cleft alar dome was raised. The cleft and noncleft lateral lip heights and widths elongated. Meanwhile, the Cupid's bow broadened as the commissures were drawn closer together. Whereas the cleft philtral height lengthened, the noncleft philtral height shortened. Reduction in noncleft philtral height averaged 20% but varied with measures of preoperative severity including columellar angle ( R = 0.67), the difference in philtral heights ( R = 0.65), and lateral deviation of the subnasale ( R = 0.74). CONCLUSIONS: Tissue does not need to be added to "lengthen" the columella, the noncleft philtral height shortening can be estimated, and the contours of anatomic subunits change with surgery on both cleft and noncleft sides. It is inadequate to focus on correction of the cleft side alone without considering corresponding noncleft side changes. Achieving balance through opposing alterations should be the principal goal of treatment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Effect of COVID-19 Shelter-in-Place Orders on Pediatric Craniofacial Trauma.

Objectives: To investigate the impacts of the shelter-in-place orders on the injury patterns among children with craniofacial trauma. Materials and Methods: Pediatric (<18 years old) craniofacial trauma cases presenting to a regional level I trauma center 1 year before and after the initiation of Washington's shelter-in-place order were retrospectively reviewed. Demographic and injury-related variables were recorded, and bivariate and logistic regression analyses were computed. Results: One hundred nineteen children were evaluated over 2-year period (46 pre- and 73 post-shelter-in-place and were comparable in age, gender, and ethnicity (p ≥ 0.17)). The distribution of injury mechanisms between pre- and post-shelter-in-place were significantly different (p = 0.02), with the largest proportional increase in falls (10.5%) and had higher rates of associated brain injury (p ≤ 0.02). After adjusting for effect modifiers and confounders, children presenting during the post-shelter-in-place period were more likely to have associated brain injuries (odds ratio 3.4, 95% confidence interval: 1.11-10.6, p = 0.03). Conclusions: Among pediatric craniofacial injury cases, the shelter-in-place order was associated with a higher likelihood of brain injury and significant changes in injury mechanisms, with a higher proportion of falls.

Orthognathic Surgery in Patients with Syndromic Craniosynostosis.

Patients with syndromic and nonsyndromic synostosis may have end-stage skeletal discrepancies involving the lower midface and mandible, with associated malocclusion. While orthognathic surgical procedures in this population can be reliably executed, the surgeon must be aware of the unique morphologic characteristics that accompany the primary diagnoses as well as the technical challenges associated with performing Le Fort I osteotomies in patients who have undergone prior subcranial midface distraction.

Progressive-Tension Sutures in Reconstruction of Posterior Trunk Defects in Pediatric Patients: A Prospective Series.

SUMMARY: Following neurosurgical repair of spinal dysraphism defects, soft-tissue reconstruction is often required to obtain robust coverage of the dura. Layered closure utilizing local muscle and muscle fascia has proven reliable for this purpose, but it often results in significant dead space necessitating closed suction drainage. Progressive-tension sutures have been reported as an alternative to drains for prevention of fluid collection in several other procedures. In this study, the use of progressive-tension sutures for eliminating subcutaneous dead space and obtaining tension-free skin closure was prospectively evaluated in pediatric patients undergoing soft-tissue reconstruction for congenital spinal anomalies. Primary outcomes of interest included wound breakdown, seroma, hematoma, and cerebrospinal fluid leak. Patients were excluded if a lumbar, submuscular, or subcutaneous drain was placed during the index procedure. Over a 3-year period, 45 patients underwent muscle flap reconstruction for coverage of dural defects. The primary diagnoses were myelomeningocele (10 patients), lipomyelomeningocele (eight patients), myelocystocele (three patients), tethered cord release (15 patients), meningocele (three patients), spinal tumor (two patients), and hardware exposure following spinal instrumentation (three patients). During the follow-up period, three patients (6.7 percent) had postoperative wound complications. One patient had superficial dehiscence, one had cerebrospinal fluid leak requiring operative revision, and one had a surgical site infection necessitating operative drainage. No patients developed hematomas, seromas, cerebrospinal fluid fistulae, or wound breakdown requiring operative revision. The use of progressive-tension sutures is an effective method for eliminating subcutaneous dead space in pediatric soft-tissue reconstruction and eliminates the need for drain placement. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Defining the Safe Zone for the Low Medial Horizontal Cut in the Sagittal Split Osteotomy.

PURPOSE: A recent modification of the sagittal split osteotomy (SSO) utilizes a medial cut placed at the level of the mandibular occlusal plane (low) and terminating anterior to the retrolingular fossa (short). The purpose of this work was to evaluate the position of the inferior alveolar nerve (IAN) relative to the medial mandibular ramus cortex in patients undergoing SSO utilizing a low medial cut. METHODS: This was a retrospective, cross-sectional evaluation of patients evaluated at a tertiary-care center for facial skeletal deformities who were candidates for mandibular orthognathic surgery. Patients were included as study subjects if they had medical-grade computed tomography (CT) scans as part of preoperative planning. The measure of interest was the closest distance from the medial cortex to the IAN for a horizontal osteotomy placed at the level of the mandibular occlusal plane, as measured on CT scans using an automated process. Descriptive statistics were computed to identify the proximity of the IAN to the medial cortex as a function of the length of the medial horizontal osteotomy. RESULTS: Forty-seven patients (94 SSO sites) with a mean age of 18.7 ± 3.3 years were included as study subjects. Twenty-six subjects had a primary diagnosis of congenital craniofacial anomaly; 21 subjects had a primary dentofacial deformity. For medial ramus osteotomy lengths of 7.5 mm, 10 mm, 12.5 mm, 15 mm, and 20 mm, the closest distances to the IANs were 9.8 ± 2.5 mm, 8.3 ± 2.5 mm, 6.5 ± 2.4 mm, 4.8 ± 2.1 mm, and 2.9 ± 1.6 mm, respectively. CONCLUSION: When utilizing the low medial cut in the SSO, the IAN is reliably found ≥ 5 mm away from the medial cortex of the ramus when the osteotomy length is < 15 mm.

An Evaluation of Racial Diversity in Craniofacial Surgery Literature.

ABSTRACT: Implicit bias can lead to discrimination of certain populations within healthcare. Representation in medical literature is no exception and it is hypothesized that images with lighter skin tone are more prevalent than darker skin tones in craniofacial literature. Clinical photographs and figure graphics from 5 journals were examined for pre-defined years. Annals of Plastic Surgery, Aesthetic Surgery Journal, Journal of Craniofacial Surgery, Journal of Plastic, Reconstructive and Aesthetic Surgery, and Plastic and Reconstructive Surgery journals were reviewed. All craniofacial-focused articles containing at least one color image depicting human skin were included. 10,477 images and 627 graphics were evaluated using the Fitzpatrick scale as a guide. Most journals trended toward broader inclusion of nonwhite photographs and graphics over time. In 2016, 47% of articles published in Journal of Craniofacial Surgery included nonwhite images compared to Annals of Plastic Surgery (16%), Aesthetic Surgery Journal (40%), Journal of Plastic, Reconstructive and Aesthetic Surgery (25%), and Plastic and Reconstructive Surgery (7%). Comparison of domestic and international publications demonstrated that author's country of origin impacted the percentage of nonwhite clinical photographs for most journals. Comparisons of publications by country demonstrated increased diversity in Asia and the Middle East for clinical photographs but not graphics. The frequency of nonwhite figure graphics was staggeringly low, identified in only 18 articles across all journals and years. Craniofacial literature more commonly reflects white skin tones. The trend over time suggests increasing inclusion of racial diversity in clinical photographs; however, figure graphics remain less racially diverse. Time, country of origin, and publishing journal appear to play a role.

Accuracy and Reliability of 4D-CT and Flexible Laryngoscopy in Upper Airway Evaluation in Robin Sequence.

OBJECTIVES: To evaluate the performance of 4-dimensional computed tomography (4D-CT) in assessing upper airway obstruction (UAO) in patients with Robin sequence (RS) and compare the accuracy and reliability of 4D-CT and flexible fiber-optic laryngoscopy (FFL). STUDY DESIGN: Prospective survey of retrospective clinical data. SETTING: Single, tertiary care pediatric hospital. METHODS: At initial and 30-day time points, a multidisciplinary group of 11 clinicians who treat RS rated UAO severity in 32 sets of 4D-CT visualizations and FFL videos (dynamic modalities) and static CT images. Raters assessed UAO at the velopharynx and oropharynx (1 = none to 5 = complete) and noted confidence levels of each rating. Intraclass correlation and Krippendorff alpha were used to assess intra- and interrater reliability, respectively. Accuracy was assessed by comparing clinician ratings with quantitative percentage constriction (QPC) ratings, calculated based on 4D-CT airway cross-sectional area. Results were compared using Wilcoxon rank-sum and signed-rank tests. RESULTS: There was similar intrarater agreement (moderate to substantial) with 4D-CT and FFL, and both demonstrated fair interrater agreement. Both modalities underestimated UAO severity, although 4D-CT ratings were significantly more accurate, as determined by QPC similarity, than FFL (-1.06 and -1.46 vs QPC ratings, P = .004). Overall confidence levels were similar for 4D-CT and FFL, but other specialists were significantly less confident in FFL ratings than were otolaryngologists (2.25 and 3.92, P < .0001). CONCLUSION: Although 4D-CT may be more accurate in assessing the degree of UAO in patients with RS, 4D-CT and FFL assessments demonstrate similar reliability. Additionally, 4D-CT may be interpreted with greater confidence by nonotolaryngologists who care for these patients.