Plastic and Reconstructive Surgery Highlights: Pediatric/Craniofacial

Last year brought an abundance of high-quality pediatric plastic and craniofacial surgical research. Highlights included studies describing technologic innovations, long-term results, and comparative outcomes of different procedures. This Editorial summarizes and reflects on 7 of our most innovative or impactful articles published in 2024, addressing topics such as patient/parent perspectives, advanced technology, and surgical treatment. These articles were chosen for novelty, strength of methodology, or potential patient care benefit, yet represent only a fraction of the excellent research published last year. Notes on other work strongly considered (and worth reading!) are included in the full bibliography. (See Appendix, Supplemental Digital Content 1, which shows the annotated bibliography, https://links.lww.com/PRS/I7.) PATIENT AND PARENT PERSPECTIVES Social Media Use in Pediatric Plastic Surgery Social media platforms are vital for adult plastic surgery, but they present ethical challenges in pediatrics. Parental consent and child assent are crucial. Huffman et al.1 surveyed parents about social media use by pediatric craniofacial surgeons, focusing on consent, assent, and perception of exploitation. Most respondents (88% to 91%) thought written consent for use of photographs was necessary, regardless of a child's age. The average age felt necessary for child assent was 9.7 years. Disturbingly, 40% felt children in craniofacial social media posts were being exploited. Although the inherently identifiable nature of craniofacial posts and the educated, internet-savvy respondent demographic likely influence the results, this study raises important ethical questions. Should parents consent when posts will be forever online? Can children assent with limited personal social media experience? How will children feel about having personal medical information public when they become adults? Pontell and Taylor's thoughtful discussion expands to question the purpose of these posts: are they for education or self-promotion?2 Children with craniofacial differences are already vulnerable to bullying and depression. This article critically explores the ethics of sharing their photographs on social media, and should prompt careful consideration by pediatric plastic surgeons. Using Patient-Reported Outcome Metrics to Improve Care Patient-reported outcome metrics (PROMs) capture an individual's experiences of their disease, treatment outcomes, and quality of life. Although often used in research, their impact on clinical practice is less clear. In pediatric plastic surgery, the CLEFT-Q PROM is collected at many cleft centers. Salinero et al.3 explored how using the CLEFT-Q during 70 team visits influenced care. In 36% of visits, they found discordance between patients' and parents' verbalized concerns and CLEFT-Q results in at least 1 domain. This led to further clinical action in 44% of cases (eg, referrals for psychiatric services or surgical interventions). This study showed that discussing CLEFT-Q results can reveal concerns families might be hesitant to raise and demonstrates how PROMs can effect positive change during visits. It also highlights the gap between patient-provider communication and actual feelings, showcasing the value of PROMs for capturing patient perspectives. My own experiences with the CLEFT-Q and other PROMs have been similar to those of the authors.4 Armed with these data, plastic surgeons should feel encouraged to not just collect PROMs but actively discuss their results during clinic visits. ADVANCED TECHNOLOGY Velopharyngeal Magnetic Resonance Imaging Although once limited to research, magnetic resonance imaging (MRI) is emerging as a clinically valuable method for evaluating velopharyngeal insufficiency (VPI). Sitzman et al.5 used MRI and nasopharyngoscopy to compare children with cleft-related and noncleft VPI (median age, 8.5 years) to matched healthy controls, finding substantial agreement between the diagnostic modalities on closure patterns (κ = 0.64). Compared with controls, the palates of children in all VPI groups were short in absolute length and relative to pharyngeal depth. MRI revealed interesting findings about levator veli palatini discontinuity, absent in healthy controls but present in 53% of cleft-affected individuals with VPI (Fig. 1). This suggests that half of those with cleft-related VPI might benefit from velar rerepair. Discontinuity was also found in 40% of patients with persistent VPI after pharyngeal flap and 40% with noncleft VPI, despite no identifiable submucous cleft palate. This MRI evidence of frequent levator veli palatini discontinuity could change treatment plans compared with using nasopharyngoscopy alone.Fig. 1.: MRI evidence of levator veli palatini discontinuity. (Republished with permission from Sitzman TJ, Williams JL, Singh DJ, Temkit M, Snodgrass TD, Perry JL. Magnetic resonance imaging of the velopharynx: clinical findings in patients with velopharyngeal insufficiency. Plast Reconstr Surg. 2024;153:1155e–1168e.)Notably, the study population is older than many children undergoing workup for VPI, and the only MRI failures (4%) were in children aged 2 to 5 years. Although MRI offers nuanced visualization, its feasibility for a typically-aged population with VPI (often 4 to 7 years in our center) remains a concern. Despite this, MRI represents the first major diagnostic advance for VPI in decades, and is poised to refine surgical intervention. Machine-Learning Evaluation of Craniosynostosis The metopic suture is the sole major cranial suture to fuse during infancy. Beyond a few months of age, its absence on imaging is not pathognomonic for synostosis, resulting in unique diagnostic ambiguity. Fusion timing creates a range of shapes from a metopic ridge to frank trigonocephaly. Although 2-dimensional computed tomographic measures, such as interfrontal angle, have been suggested to define synostosis, they oversimplify its complex 3-dimensional nature. Beiriger et al.6 piloted a machine-learning algorithm ("CranioRate"7,8) to identify metopic synostosis on computed tomography using both a phenotype-specific measure to quantify "metopicness" and a nonspecific measure to quantify deviation from normal shape (cranial morphology deviation). The pretreatment metopicness and cranial morphology deviation distribution of children with metopic synostosis barely overlapped with normal controls, validating the algorithm's accuracy in distinguishing normal from pathologic shape. They also demonstrate resolution of trigonocephaly after surgery, but failure to fully normalize shape (Fig. 2). This is attributed to overcorrection, but may also be related to operations that do not address all differences, such as compensatory occipitoparietal widening.Fig. 2.: Scatterplot of metopicness and cranial morphology deviation. (Republished with permission from Beiriger JW, Tao W, Bruce MK, et al. CranioRate: an image-based, deep-phenotyping analysis toolset and online clinician interface for metopic craniosynostosis. Plast Reconstr Surg. 2024;15:112e–119e.)Validation of CranioRate's ability to appraise head shape and surgical outcome is a beautiful illustration of how machine-learning can be applied to plastic surgery. This has implications for deciding who warrants correction of metopic synostosis in an objective, 3-dimensional fashion. Machine learning is also being developed in areas such as velopharyngeal dysfunction,9,10 orthognathic surgery,11 and more, and will soon enhance clinical diagnosis and craniofacial surgical treatment across the resource spectrum. CLEFT AND CRANIOFACIAL SURGICAL TREATMENT Impact of Modern Gingivoperiosteoplasty on Maxillofacial Growth Historically, gingivoperiosteoplasty (GPP) used large flaps to close sizable alveolar gaps. Facial growth was impaired, making the technique controversial. Modern GPP requires less dissection, thanks to alveolar approximation with presurgical infant orthopedics. Despite this technical evolution and benefits such as preventing nasal regurgitation and sometimes eliminating need for alveolar bone grafting, controversy around GPP continues. Park et al.12 investigated whether modern minimal-dissection GPP affects maxillary growth. They compare cephalometric data during mixed dentition (age 6 to 13 years) of 110 children treated by the same surgeon. GPP was performed if the alveolar gap was less than or equal to 2 mm. Data were stratified into 4 groups: unilateral cleft lip and alveolus with or without GPP and unilateral cleft lip and palate with or without GPP. Multiple linear regression tested whether GPP, cleft palate, nasoalveolar molding, age, and sex predicted maxillary projection (sella-nasion–A point) and maxillomandibular relationship (point A–nasion–point B). The authors found cleft palate significantly predicted maxillary retrusion but GPP, nasoalveolar molding, age, and sex did not. When only children without cleft palate were compared, there was no difference in maxillary projection, whether GPP was performed or not. These findings suggest impaired anterior maxillary growth is more related to cleft palate, or its surgical repair, than to GPP. Limitations included a small sample size in some groups and a wide age range. Considerable maxillary growth occurs from ages 6 to 13 years, and although median age did not differ between groups, ability to detect differences is constrained by sample size. Furthermore, impaired maxillary growth is likely underestimated in this skeletally immature population. From a practical standpoint, it should also be acknowledged that the impressively small alveolar gaps achieved by the New York University orthodontics team are not universally achieved. The dissection needed to perform GPP in many centers is larger; thus, applicability of the results is potentially limited. Despite this, for surgeons who perform GPP, such as myself, these results support its continued application. Predicting Success and Failure of Alveolar Cleft Bone Graft An alveolar cleft is most often reconstructed with a bone graft at approximately 7 to 10 years of age. Padwa et al.13 reviewed posterior iliac crest bone graft outcomes in 722 patients with 900 alveolar clefts to identify factors predictive of graft success and failure. The overall rate of radiographic success was 94.6%. Numerous demographic, phenotypic, and treatment-related factors were analyzed. In multivariable analysis, presence of an erupted canine, large bony gap, and premaxillary osteotomy at the time of bone graft were significant predictors of failure, whereas the presence of a bony palatal bridge was protective against failure. The success rate achieved in this very large series is higher than that for most surgeons, but factors associated with failure and success are broadly applicable, with 2 worthy of further mention. The single predictor of success was a bony palatal bridge. This bone likely formed along the periosteal surface of a prior vomerine flap; the current data indicate an undescribed benefit of vomerine flap use. A predictor of failure was a descended canine, occurring when the graft is performed late. This emphasizes how crucial regular and timely follow-up is for children with clefts, especially for underrepresented minorities, who may experience gaps in care and delayed bone grafting.14 Microvascular Reconstruction for Hemifacial Atrophy Although medical treatments, such as steroids and methotrexate, can slow progression of hemifacial atrophy in Parry-Romberg syndrome, surgery remains a mainstay of treatment. Depending on disease extent, procedures can include fat grafting, skeletal implants, orthognathic surgery, microvascular surgery, and more. Zhao et al.15 assessed long-term outcome in 42 patients with moderate to severe hemifacial atrophy treated with the anterolateral thigh adipofascial flap by a single surgeon. Patients were surveyed about satisfaction and the extent to which facial function and appearance still affects their quality of life. Preoperative and postoperative photographs (Fig. 3) were rated by 3 clinicians and 3 laypersons.Fig. 3.: Patient is shown before and 10 years after use of an anterolateral thigh flap to treat hemifacial atrophy. (Republished with permission from Zhao J, Guo X, Lai C, Song G, Zong X, Jin X. Successful treatment and long-term follow-up of Parry-Romberg syndrome with anterolateral thigh adipofascial flap. Plast Reconstr Surg. 2024;154:326e–334e.)Patients reported high satisfaction with free flap outcome and the decision to pursue surgery, and all would do it again and recommend it to others. However, scores pertaining to appearance, social interactions, emotional well-being, and physical symptoms revealed that patients continue to experience moderate distress, even after surgery. Clinician and layperson assessments were generally concordant and revealed long-term improvement in facial symmetry, skin condition and texture, and skin color. Two aspects of this study are impressive. First is the very long-term follow-up, ranging from 5 to 21 years. Second, although the outcome metrics are simplistic, combining patient, clinician, and layperson evaluations provides a uniquely wholistic perspective of the long-term outcome of using the anterolateral thigh free flap for hemifacial atrophy. This sheds light on the fact that, although all parties recognized improvements with surgery, patients continue to experience disease-related distress years later that warrants further consideration. DISCLOSURE The author has no financial interest in any of the products, devices, or drugs mentioned in this article. PATIENT CONSENT The patient shown in Figure 3 provided written informed consent for the use of her images.