Lower Third Soft Tissue Changes After Orthognathic Surgery.

BACKGROUND: Triple jaw surgery, inclusive of a LeFort osteotomy, bilateral sagittal split osteotomy, and genioplasty, is used to maximize functional and esthetic outcomes for patients. This is achieved through the procedure's measurable effects on the craniofacial skeleton but is also influenced by the soft tissue changes that occur as a result of the procedure. This study aims to characterize the three-dimensional (3D) soft tissue changes of triple jaw surgery. METHODS: Patient demographics were collected along with pre and postoperative 3D images (3D VECTRA photosystem, Canfield, Fairfield, NJ). Orolabial anthropometric measurements were performed using Mirror (Canfield Scientific Inc., Fairfield, NJ). RESULTS: Forty-eight 3D data sets were included. The male/female ratio was 0.6, with a mean age of 23.4 years. Significant postoperative decreases (P<0.001) were seen in the mean absolute distance from the lower lip to S-line and distance from lower lip to H-line. In female patients, upper vermilion fullness, lower lip height, lower vermilion fullness, distance from lower lip to S-line, and absolute distance from lower lip to H-line were found to fall within ideal norms postoperatively. In male patients, lower lip height, lower vermilion fullness, distance from lower lip to S-line, and absolute distance from lower lip to H-line were found to fall within ideal norms postoperatively. CONCLUSIONS: Triple jaw surgery has a significant soft tissue impact and can transform some orolabial measurements to conform to ideal norms.

A Systematic Review of Idiopathic Secondary Stenosis Following Index Surgery for Craniosynostosis.

BACKGROUND: Primary craniosynostosis is a congenital craniofacial disorder in which cranial sutures prematurely close. Iatrogenic secondary stenosis is abnormal cranial suture closure caused by surgical manipulation of the suture. In contrast, idiopathic secondary stenosis develops in a suture that did not undergo surgical manipulation. The objective of this systematic review was to consolidate and characterize the incidence, classification, and management of idiopathic secondary stenosis in the literature. METHODS: Literature from PubMed, Web Of Science, and EMBASE from 1970 to March 2022 was reviewed. The following information was extracted for individual patients: incidence of idiopathic secondary stenosis, index primary craniosynostosis, primary surgical correction, presenting signs of secondary stenosis, management, and further complications. RESULTS: Seventeen articles detailing 1181 patients were included. Ninety-one developed idiopathic secondary stenosis (7.7%). Only 3 of these patients were syndromic. The most common index craniosynostosis was sagittal synostosis (83.5%). The most common suture undergoing idiopathic secondary stenosis was the coronal suture (91.2%). Patients presented at a median age of 24 months. The most common presenting sign was a radiologic finding (85.7%), although some patients presented with headache or head deformity. Only 2 patients, both syndromic, had complications following surgical correction of secondary stenosis. CONCLUSIONS: Idiopathic secondary stenosis is a rare, long-term complication following index surgical repair of craniosynostosis. It can occur following any surgical technique. It most commonly affects the coronal suture but can affect any of the sutures, including pansynostosis. Surgical correction is curative in nonsyndromic patients.

Comparative Benefits of Open versus Closed Reduction of Condylar Fractures: A Systematic Review and Meta-Analysis.

BACKGROUND: Many fractures of the mandibular condylar neck are amenable to both open reduction and internal fixation (ORIF) and closed treatment. Clinical outcomes following these two modalities remains a topic of debate. This systematic review critically appraises the literature to compare them following these treatment options. METHODS: A systematic review and meta-analysis was performed to test the null hypothesis of no difference in clinical outcomes in ORIF versus closed treatment of mandibular condyle fractures. The PubMed, Embase, Cochrane Library, Elsevier text mining tool database, and clinicaltrials.gov trial registries were queried from 1946 to 2020. The quality of evidence was determined using Grading of Recommendations Assessment, Development, and Evaluation methodology. RESULTS: Of 1507 screened articles, 14 met inclusion criteria. ORIF was favored significantly when evaluating temporomandibular joint pain [relative risk (RR), 0.3; 95% CI, 0.1 to 0.7] (number needed to treat to prevent an outcome in one patient, 3; 95% CI, 2 to 6), laterotrusive movements of the mandible (mean difference, 2.3; 95% CI, 1.7 to 3.0) (standardized mean difference, 0.9; 95% CI, 0.4 to 1.3), and malocclusion (RR, 0.5; 95% CI, 0.4 to 0.7) (number needed to treat to prevent an outcome in one patient, 19; 95% CI, 10 to 200). However, ORIF yielded a higher incidence of postoperative infection (RR, 3.6; 95% CI, 0.9 to 13.8) and must be weighed against the understood risk of facial nerve injury. CONCLUSIONS: Meta-analysis of high-level evidence in randomized controlled trial suggests that ORIF significantly improves functional outcomes, decreases pain, and restores occlusion and jaw symmetry. These long-term benefits must be weighed against the increased risk of postoperative infection and exposure of the facial nerve to potential injury.

Disparities in Access to Cranial Remodeling Orthosis for Deformational Plagiocephaly.

OBJECTIVE: Moderate to severe cases of deformational plagiocephaly (DP) may be treated with cranial remolding orthoses (CRO). This study investigated the socioeconomic disparities in access to care for CRO for DP correction. DESIGN: This was a retrospective review of medical records from a single CRO company in Connecticut from 2014 to 2020. METHODS: Demographic variables were collected from all patients. Univariable logistic regressions were used to identify differences for presenting age at consultation, whether CRO was pursued, and length of CRO treatment by insurance payor and household income quartile. RESULTS: Of the 5620 patients identified, 4100 (73.0%) received CRO, with 674 (12.0%) receiving a second helmet. Of those receiving CRO, 1536 (37.5%) had Medicaid insurance while 2558 (62.4%) were commercially insured. Patients on Medicaid were 1.30 times more likely to have delayed presentation (P = .017), while patients from the lowest income quartile were 1.26 1.50 (P < .001) and 1.58 (P < .001) times more likely to have a delayed presentation relative to those in the highest and second-highest income quartiles, respectively. Patients in the highest and second-highest income quartiles were also 1.55 (P < .001) and 1.45 (P < .001) more likely, respectively, to receive CRO after consultation than those from the lowest income quartile. CONCLUSIONS: Lower income and Medicaid-insured patients had delayed presentation for CRO consultation. Those from the lowest income quartile were more likely to never receive CRO than those from wealthier backgrounds. Low socioeconomic status and Medicaid insurance, which can have more restrictive coverage policies for CRO, may result in the delayed treatment of DP.

Determining Morbidity of Adding Genioplasty to Bimaxillary Orthognathic Surgery.

BACKGROUND: Patients with dentofacial anomalies may undergo orthognathic surgery to address functional and aesthetic concerns. Past works have evaluated determinants affecting length of stay (LOS) in patients undergoing upper and/or lower jaw surgery alone. No studies have assessed the addition of genioplasty to double-jaw (Lefort I, bilateral sagittal split osteotomy (BSSO))) surgery and its effect on LOS and other outcomes. This study investigates whether the addition of genioplasty incurs additional morbidity to patients undergoing complex orthognathic surgery. METHODS: This was a retrospective cohort study of patients undergoing orthognathic surgery at Yale-New Haven Hospital. Clinical and demographic information were compared across the "double"- and "triple"-jaw cohorts with t tests and Chi-squared analyses. Multivariable linear and logistic regression analyses were utilized to assess the impact of genioplasty when controlling for baseline patient differences. RESULTS: A total of 27 patients received Lefort I and BSSO (double-jaw), and 224 received Lefort I, BSSO, and genioplasty (triple-jaw). Six (22.2%) double-jaw patients were segmental and fifty-eight (25.9%) triple-jaw patients were segmental (p > 0.05), during the study period. Triple-jaw surgery was associated with increased operative time (+ 41.1 min, p < 0.01). There was no increase in LOS, postoperative nausea and vomiting, opioid use, hematoma, or infection (p > 0.05). CONCLUSIONS: This study attempted to determine if triple-jaw surgery could influence patients' LOS and other surgical outcomes compared to double-jaw surgery. Only the operative time was significantly affected. This indicates that incorporation of a genioplasty can provide aesthetic benefit without incurring significant additional morbidity to the patient. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Dorsal Augmentation With the Dorsal Extension Spreader Graft.

Spreader grafts traditionally are used to improve airflow through opening the internal nasal valve, as well as enhance the cosmetic appearance of the nose. The graft's versatility proves useful in surgical correction of several nasal profiles by enhancing dorsal aesthetic lines and by maintenance of the nasal pyramid at midline. The authors describe a modified spreader graft that adds an additional benefit of dorsal augmentation in patients with underprojected or saddle noses. This technique utilizes harvested septal cartilage and fixation of the graft that extends beyond the septal and upper lateral cartilage dorsal border to improve nasal dorsum height. Patients who received this operative technique by the senior author were identified and their operative courses and surgical outcomes were analyzed. Case examples are provided to illustrate indications and outcomes. This grafting technique allows for improved functionality, defined dorsal aesthetic lines, changes in nasal width, and a more balanced profile in patients with underprojected noses.

A Preliminary Management Algorithm for Velopharyngeal Insufficiency in Cleft-Orthognathic Patients.

PURPOSE: Patients born with a cleft palate often suffer from velopharyngeal insufficiency (VPI) due to the soft palate musculature's abnormal structure. Surgical correction of the palate at a young age can hinder maxillary growth, requiring surgical correction of the maxillomandibular discrepancy at skeletal maturity. Orthognathic surgery can then cause or further exacerbate VPi in these patients. The purpose of this paper is to assess cleft-orthog-nathic patients under the lens of persistent or newly-developed VPi, to understand outcomes and generate a targeted management algorithm. METHODS: A retrospective study was performed inspecting cleft-orthognathic patients presenting to a single surgeon. Patients with sufficient follow-up were placed into predefined algorithmic cohorts by their VPi development pattern in relation to orthognathic surgery. They were further stratified into groups by level of adherence to our algorithm to evaluate VPi outcomes. Demographic factors, risk factors, and outcomes were compared between groups via Welch t test and Fisher exact test. RESULTS: Fifty-one patients were examined, including 16 with VPI. Velopharyngeal insufficiency fully resolved amongst all algorithmically adherent patients and remained in nonadherent patients ( P  < 0.001). CONCLUSIONS: Our targeted algorithm may improve symptoms and the management of VPI in cleft-orthognathic patients. Multi-centered studies with larger sample sizes and prospective studies are encouraged to validate our proposed treatment algorithm further.

The Superficial Inferior Epigastric Artery Interpolated Flap for Closure of Large Anterolateral Thigh Flap Donor Site Defects.

ABSTRACT: The Anterolateral Thigh (ALT) flap has a critical role in head, neck, and extremity reconstruction. Unfortunately, when the ALT flap is dimensionally large, it leaves an open donor site that may not respond optimally to primary or secondary closure. Traditionally, skin grafting has been used to close large ALT flap donor site defects. However, skin grafting offers less than desirable aesthetic and functional results. The purpose of this article is to present the first reported case of a 70-year-old woman with a large ATL donor site defect, not responsive to direct primary closure, which was successfully reconstructed using a superficial inferior epigastric artery (SIEA) interpolated flap. After 3 weeks, the SIEA interpolated flap was divided, with the patient reporting good outcomes after a 3-month follow-up. The authors suggest that a SIEA interpolated flap as a novel potential approach to optimally repair large ALT donor site defects.

Postoperative Edema Resolution Post-Orthognathic Triple Jaw Surgery: A Three-Dimensional Volumetric Analysis.

PURPOSE: The final result following orthognathic surgery may be hidden for months due to postoperative swelling. However, no substantial evidence supports this time estimate. Our study aims to three-dimensionally quantify volumetric changes in facial edema following triple-jaw surgery. MATERIALS AND METHODS: This was a retrospective, three-dimensional (3D) study of patients who underwent primary orthognathic triple jaw surgery (Le Fort I, Bilateral Sagittal Split Osteotomy (BSSO), and osseous genioplasty) by the senior author (DMS). Vectra 3D Software (Canfield, Fairfield, NJ) was used to assess and quantify volumetric changes between serial 3D photos. An inverse line of best-fit was plotted to assess reduction in postoperative facial edema. The effects of gender, age, body mass index, and tranexamic acid administration on swelling resolution were analyzed through mixed linear model analysis. RESULTS: A total of 46 patients (198 images) met the study criteria. The equation for the inverse function line of best fit was y = -13.14ln (x) + 39.54 (P < 0.01). On average, 60% of the swelling resolved in 1 month, 84% after 6 months, and nearly 93% after 12 months. There were no significant differences in the rate of swelling resolution when accounting for age, gender, body mass index, or tranexamic acid administration. CONCLUSIONS: Most facial edema resolved during the first month following triple jaw surgery, with significant reduction in swelling between 6 and 12 months postoperatively. After 1 year, approximately 10% of the initial edema remained.

Non-Surgical Correction of Congenital Ear Anomalies: A Critical Assessment of Caretaker Burdens and Aesthetic Outcomes.

INTRODUCTION: Congenital ear anomalies result from cartilage and skin compression in utero. They can be corrected in infancy before the cartilage hardens and loses its malleability. Caretaker burden of ear molding and its impact on esthetic outcomes has not been studied. METHODS: Demographic and procedural variables were retrospectively collected for infants who underwent ear molding. Parents were surveyed regarding their experience, caretaker burden, and esthetic outcome. Outside physicians were provided with pre- and post-treatment photographs and asked to rate outcomes. A Likert scale was developed for responses and converted to a numeric score from 1 to 5 with 5 as the most desirable. RESULTS: Seventy-four patients comprising 121 ears were included. Mean age at treatment was 20.1 ± 21.4 days with treatment duration of 21.1 ± 7.7 days. Parental participation in the survey was 70.1%. Questions that queried parents' experiences revealed a "very positive" experience with minor burden related to bathing and cleaning (Mean Likert Score 4.1, Range 1-5). Favorable parent-reported outcomes were obtained regarding anticipated social distress (4.28, 1-5), satisfaction with results (4.27, 1-5), and perception of final appearance (4.18, 1-5). Physician assessments of esthetic outcomes were slightly lower, but favorable between "somewhat effective" and "very effective" (3.46, 1-5). Earlier treatment trended favorably, but did not reach significance. Ear malformations had higher parent-reported satisfaction than ear deformations (4.75 ± 0.46 vs 4.21 ± 1.25, p = 0.025). CONCLUSION: Despite the additional obligation for new parents, infant ear molding is rated low in terms of caretaker burden. Esthetic outcomes are excellent as assessed by parents and physicians. However, caretakers reported higher esthetic outcomes than physician evaluations. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Which Maturation Indicator is Most Accurate in Predicting Cessation of Facial Growth? A Systematic Review of the Literature.

PURPOSE: The determination of facial growth maturity is crucial before surgical intervention in pediatric patients. To the author's knowledge, there are several indicators of skeletal maturity, but there remains a lack of consensus regarding their application when determining surgical timing. The purpose of this study was to determine the most accurate skeletal maturity indicator in predicting facial growth maturation. MATERIALS AND METHODS: A systematic review was done to determine the most predictive indicator for facial growth maturity. We hypothesized that menses' onset was the most predictive of these maturity indicators. This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A systematic search of MEDLINE, Cochrane, Embase, Scopus databases, and Google Scholar, was done in October 2020 to identify citations related to maturity indicators assessing craniofacial growth. The quality of evidence was determined using the Joanna Briggs Institute Critical Appraisal Checklist for Cohort Studies. RESULTS: Of the 13,289 articles screened, 1 retrospective and 1 prospective study met inclusion criteria. No articles were identified that provided evidence for our hypothesis. Based on the 2 included studies, it was concluded that a handwrist x-ray was more predictive of facial growth cessation (compared to other skeletal maturity indicators). CONCLUSIONS: Based on the literature, handwrist radiography serves as the most predictive method in determining the facial growth maturity. The paucity of articles within this investigation highlights the need for greater research efforts to investigate the predictability of indicators to evaluate facial growth maturation. PROSPERO REGISTRATION NUMBER: CRD42020207388.

Single-Sided Segmental Maxillary Osteotomies for Alveolar Cleft Deformities.

ABSTRACT: Although the use of a one-sided segmental maxillary osteotomy has been described for repairing alveolar clefts, there remains little consensus regarding the indications and outcomes of such approaches. This brief clinical note aims to summarize previous studies of one-sided segmental maxillary osteotomies for alveolar cleft (AC) repair. A literature search yielded only 2 articles that described the use of a single-sided segmental maxillary osteotomies (SMO) for AC repair. The overall outcomes for the implementation of SMO in correcting AC were positive without major or minor complications. Although the available studies show promising results for the single-sided SMO technique, further validation is warranted to assess the indications and outcomes for this technique.

Decreasing Inpatient Opioid Use Following Orthognathic Surgery.

PURPOSE: Strategies to decrease postoperative opioid use are important for mitigating the immediate and long-term risks associated with their use. We aimed to investigate the impact of perioperative various factors on inpatient opioid needs for patients undergoing orthognathic surgery. METHODS: This was a retrospective cohort study of all patients who underwent orthognathic surgery performed by the senior author from 2012 to 2018. Patients were grouped into intravenous (IV) acetaminophen and no-IV acetaminophen cohorts. Opioid medications received by patients during hospital stay were converted to mean morphine equivalents (MME) for comparison. Additional factors that influenced opioid consumption, such as transexamic acid (TXA) and postoperative nausea and vomiting (PONV), were identified using univariate analysis. Factors found to have statistical significance were added to a multivariate linear regression model. RESULTS: 319 patients were included. Those who received IV acetaminophen had lower rates of total opioid use (57.3 versus 74.8 MME; P = 0.002) and postoperative opioid use (24.0 versus 37.7 MME; P < 0.001). Perioperative prothrombotic agents, such as TXA, were associated with lower total and postoperative MME (P = 0.005, P = 0.002). Multivariate regression analysis showed that increased PONV resulted in increased postoperative opioid use, whereas perioperative acetaminophen lowered total and postoperative quantities. CONCLUSIONS: Perioperative IV acetaminophen is an effective method for decreasing inpatient opioid analgesia after orthognathic surgery. Intravenous TXA and PONV control may provide additional benefit to decreasing inpatient opioid consumption. More research as to the mechanisms and ideal clinical applications for both IV acetaminophen and TXA are warranted.

Comparing Load-Sharing Miniplate and Load-Bearing Plate Fixation in Atrophic Edentulous Mandibular Fractures: A Systematic Review and Meta-Analysis.

PURPOSE: To critically examine reported data to compare patient outcomes between load-sharing and load-bearing plate fixation for edentulous mandibular fractures. MATERIALS AND METHODS: A systematic review and meta-analysis were designed to test the null hypothesis of no difference in postoperative outcomes between load-sharing and load-bearing plate fixation in atrophic, edentulous mandibular fractures. The PubMed, EMBASE, Cochrane Library, Elsevier text mining tool database, and clinicaltrials.gov trial registries were queried up until July 2016. The quality of evidence was determined using the Grading of Recommendations Assessment, Development, and Evaluation method. RESULTS: A total of 1212 studies were screened for inclusion of which we included 1 high-quality Cochrane review, 6 narrative reviews, and 21 publications of case reports and case series. Overall, the quality of evidence was low. No difference was found between load-bearing and load-sharing fixation in functional recovery, nonunion, or infection. An uncontrolled case series portrayed complete functional and morphological restoration in 96.9% of patients (83.2-99.5; 95% confidence interval) in load-bearing osteosynthesis while another demonstrated the same outcome in only 40.0% of patients (17.5-65.0; 95% confidence interval). CONCLUSIONS: The authors did not find a statistically significant difference between load-bearing and load-sharing plate fixation in edentulous atrophic mandibular fracture patients; although this finding may be influenced by type 2 statistical error. Surgeons should continue to use their best clinical judgment in deciding on treatment approach for these challenging fractures. Future studies with higher level evidence are necessary to guide optimal fracture management.

Racial Disparities in the Surgical Management of Benign Craniomaxillofacial Bone Lesions.

PURPOSE: Racial disparities can influence surgical care in the United States. The purpose of this study was to determine if race and ethnicity were independent risk factors for adverse 30-day outcomes after surgical management of benign craniomaxillofacial bone tumors. METHODS: This was a retrospective cohort study from 2012 to 2018 National Surgical Quality Improvement Program databases. Patients undergoing surgical removal of craniomaxillofacial benign lesions based on Current Procedural Terminology and International Classification of Diseases codes were included. Patients who had unrelated concurrent surgeries, or malignant, skull-based or soft tissue lesions were excluded. Primary outcomes were surgical complications and hospital length of stay (LOS). Univariate analyses were used with race as the independent variable to identify predictors of primary outcomes. Statistically significant factors were added to a multivariable logistic regression model. RESULTS: This study included 372 patients. Postoperative complications were highest among Black patients, who had a 4-fold increase in minor complications (P = 0.023) and over a 6-fold increase in major complications (P = 0.008) compared to White patients. Black patients also had a mean increase of 2.3 days in LOS compared to White patients (P < 0.001). The multivariate regression model showed higher rates of major complications and longer LOS for Black patients (P = 0.003, P = 0.006, respectively). CONCLUSIONS: Even when controlling for other variables, Black race was an independent risk factor for major complications and increased LOS. Further research should seek to identify the root cause of these findings in order to ensure safe and equitable surgery for all patients, regardless of race or ethnicity.