Faculty Bibliography

LEARNING OBJECTIVES/OBJECTIVE:After studying this article, the participant should be able to (1) understand the incidence and trends of pediatric head and neck cancer; (2) identify the common tumors that present in the head and neck region; (3) describe the risk factors and pathogenesis associated with these malignancies, to identify children at risk; and (4) describe and understand the common presentations of these tumors to gain confidence in diagnosing these patients early in practice. SUMMARY/CONCLUSIONS:Pediatric head and neck malignancies are rare; however, their incidence is rising rapidly, with an incidence of 3.29 diagnoses per 100,000 person-years. These malignancies often present with nonspecific symptoms distinct from adults, making early diagnosis more challenging. Recognizing early symptoms in children is essential to improve treatment and long-term outcomes. This review discusses the incidence, pathogenesis, classification, and presentation of the common pediatric head and neck malignancies, including lymphoma, soft tissue sarcoma, thyroid carcinoma, salivary gland malignancies, bone malignancies, nasopharyngeal carcinoma, and melanoma.

LEARNING OBJECTIVES/OBJECTIVE:After studying this article, the participant should be able to (1) gather appropriate history and perform relevant physical exam maneuvers for head and neck complaints, (2) relate presenting complaints to differential diagnoses, (3) describe the appropriate workup for various head and neck complaints and presentations, and (4) perform clinical staging of head and neck tumors according to current guidelines. SUMMARY/CONCLUSIONS:Pediatric head and neck cancers are rare and complex, but plastic surgeons may play a crucial role in the multidisciplinary and multifaceted workup of a suspected malignancy. These cancers present unique diagnostic and therapeutic challenges given the unique anatomy, physiology, and developmental considerations in children compared to their adult counterparts. A comprehensive workup for pediatric head and neck malignancies is essential, starting with taking a thorough history and physical exam, followed by a well-considered and wide differential diagnosis. Appropriate imaging modalities and biopsy techniques are pivotal in obtaining an accurate diagnosis. Tumor and site-specific staging seek to provide essential information for guiding treatment planning. Plastic surgeons, therefore, must be informed and well versed in their evaluation and workup to best optimize patient outcomes.

BACKGROUND:This study evaluates the Presurgical Lip, Alveolus, and Nose Approximation (PLANA) technique as a novel alternative to NasoAlveolar molding (NAM). The study hypothesizes that PLANA can achieve comparable Nasolabial outcomes to NAM while addressing its limitations, particularly by reducing the burden of care. METHODS:A retrospective review was conducted on 50 patients with non-syndromic unilateral or bilateral cleft lip and palate (CLP) treated with either NAM (n=28, including 2 treatment discontinuations) or PLANA (n=22). The overall physical burden of care was assessed in the full cohort. A subset of 25 patients with complete unilateral CLP (PLANA n=12; NAM n=13) was further analyzed to assess changes in nasolabial anthropometric ratios between cleft and non-cleft side using standardized 2D photographs taken pre-treatment (T1) and post-treatment (T2). RESULTS:The physical burden of care was significantly lower in the PLANA group, with 61.2 % fewer total office visits (5.2 vs. 13.4; p<0.001). The PLANA group also showed 72.19 % reduction in transient reversible side effects, such as oral, nasal, and cheek irritations (18.18% [n=4] vs. 65.38% [n=17]; p<0.001). PLANA achieved a significantly greater improvement in the columellar length ratio (0.53 vs. 0.37; p = 0.026), while NAM demonstrated a greater increase in the nostril height ratio (0.29 vs. 0.39; p = 0.04). No significant differences were observed in nostril width and alar base width ratios, or columellar deviation angle between the groups. CONCLUSION/CONCLUSIONS:These findings suggest that PLANA significantly reduces the burden of care for patients with cleft lip and palate and may offer comparable nasolabial outcomes to NAM.

BACKGROUND:The severity of unilateral cleft lip significantly influences surgical outcomes, yet no standardized system exists to classify cleft severity or assess the impact of presurgical infant orthopedics (PSIO). This study proposes an objective classification system integrating anthropometric measurements with expert evaluations. METHODS:Deidentified pre- and post-PSIO photographs of 50 infants with unilateral cleft lip from the Smile Train Express database were analyzed. Three anthropometric parameters-nostril width ratio (NWR), columellar angle (CA), and subnasale lateral displacement (SN)-were measured. An expert panel of orthodontists and surgeons independently rated cleft severity and PSIO outcomes in a structured three-stage process. Severity thresholds were established through consensus, and interrater agreement was analyzed using weighted kappa. RESULTS:Consensus-derived thresholds categorized NWR, CA, and SN into four severity levels. Interrater agreement for cleft severity improved across stages, reaching near-perfect levels in Stage 3 (weighted kappa = 0.91 pre-PSIO, 0.93 post-PSIO). While pre-PSIO agreement was similar between surgeons and orthodontists, post-PSIO assessments showed greater variability. PSIO had a disproportionate effect on nasal morphology (CA) compared to maxillary segments (NWR, SN), with severe NWR and SN frequently coexisting with mild CA. The proposed classification system demonstrated substantial reliability, aligning at least two parameters within the same severity subclassification. CONCLUSIONS:This study introduces a standardized classification system for cleft severity and PSIO outcomes, demonstrating strong interrater reliability. By integrating anthropometric data with expert assessments, it provides a reproducible framework for clinical and research applications. Further refinements, including intraoral measurements and 3D imaging, may enhance its precision and applicability.

BACKGROUND:Whole eye transplantation (WET) has long been looked to as a potential solution for the aesthetic and functional deficits caused by severe ocular pathology and trauma. Here, we describe the first successful combined face and whole eye transplantation (FT/WET), highlighting the logistical, ethical, and technical considerations that enabled this milestone. METHODS:A 46-year-old male with severe facial and ocular deficits underwent multidisciplinary evaluation and was deemed a candidate for FT/WET. Subsequently, a surgical algorithm was developed through rigorous preoperative planning and team based surgical simulations. This process focused on techniques that would allow for efficient graft procurement and inset, while simultaneously limiting trauma to the globe and its adnexa. RESULTS:Longitudinal monitoring demonstrated maintained graft viability throughout the postoperative period. Fluorescein angiography and ICG angiography confirmed robust retinal and choroidal perfusion. Diffusion-weighted MRI revealed structural preservation of the optic tracts, despite inner retinal atrophy. The patient has also experienced significant improvement in facial aesthetics and functionality with no episodes of graft rejection to date. CONCLUSIONS:This case demonstrates the feasibility of addressing deficits once deemed irreparable through advanced surgical techniques, preoperative planning, and multidisciplinary collaboration. Although functional vision recovery has not been observed, this innovation expands the reconstructive options available for patients with severe facial and ocular deficits, paving the way for future advancements in vascularized composite allotransplantation.

BACKGROUND:Congenital palatal fistula (CPF), most often associated with submucous cleft palate (SMCP), is a rare clinical entity. Surgical management is challenging owing to anatomical variation and risk of persistent velopharyngeal insufficiency (VPI). We reported outcomes from a case series of 27 patients with CPF associated with SMCP managed using a standardized institutional algorithm. METHODS:A retrospective review was conducted at CLAPP Hospital, Lahore, from 2015 to 2020. Patients with CPF associated with SMCP were included; acquired fistulae and syndromic cases were excluded. Fistulae were classified using the Pakistan Comprehensive Fistula Classification Scheme. SMCP was further stratified according to the CLAPP Classification and Treatment Algorithm, guiding surgical approach (midline incision, modified Langenbeck, or standard Langenbeck with/without adjunctive procedures). Outcomes included fistula recurrence and speech results. RESULTS:The cohort comprised 27 patients (mean age 9.9 years; range 1-23 years), and 52% were female. Two patients (7.4%) developed postoperative fistula recurrence. Preoperatively, 94% of patients had severe hypernasality (G3). Postoperatively, mean composite speech scores improved by 52.3% (14.9→7.1). Fourteen patients [14/17 (82.4%)] achieved G0/G1 (normal resonance). Younger patients (<12 years) showed greater improvement (90% to G0/G1) compared to older patients (71.4%). No middle-ear sequelae were observed. CONCLUSIONS:A tailored algorithmic approach for CPF associated with SMCP yielded low recurrence (7.4%) and substantial speech improvement. Younger patients demonstrated greater postoperative speech benefit, underscoring the importance of early diagnosis and repair.