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We aim to survey and compare integrated plastic surgery and plastic surgery subspecialty fellowship applicants on their experiences with virtual interviews and to determine if there are differences between them.An IRB-approved survey study was conducted using the Qualtrics platform.The study was conducted at the Johns Hopkins University and the R Adams Cowley Shock Trauma Center in Baltimore Maryland.Applicants that applied to 1) the Johns Hopkins/University of Maryland or the University of California San Diego integrated plastic surgery residency programs, 2) craniofacial surgery fellowship, and 3) microsurgery, hand surgery, or burn surgery fellowship at the Johns Hopkins University were selected to participate in the survey.A total of 94 surveys were completed by residency applicants and 55 by fellowship applicants. After the interview season, 80% of fellowship applicants recommended virtual interviews compared to 61.7% of residency applicants (p = 0.03). Fellowship applicants reported significantly less issues with self-advocacy and did not view the virtual interview process as significant of a detriment when meeting program residents/staff, viewing the hospital/surrounding area, and learning about the program (p0.05). A higher percentage of fellowship applicants interviewed at multiple programs during a single day compared to residency applicants (56.4% vs 27.7%; p0.001).A higher proportion of fellowship applicants prefer virtual interviews, which associated with key differences in perceptions, expectations, and priorities. Our data supports that fellowship programs may wish to continue virtual interviews even after COVID-related restrictions are lifted, because fellows are equally able to self-advocate in a virtual format while benefiting from cost and time savings; fellowship programs would also gain the cost and time savings from this model as well.

Over 35 million Americans have lymphedema. Nonetheless, lymphedema is underdiagnosed and undertreated worldwide. We investigated whether the rates of coverage for imaging and surgical procedures may contribute to the limited care provided for lymphedema.We performed a cross-sectional evaluation of 58 insurers, chosen based on state enrollment and market share. A web-based search or phone call determined whether a publicly available policy on lymphedema-specific imaging, physiological procedures, and excisional procedures was available. Coverage status and corresponding criteria were extracted.Of the two-thirds of insurers who included a policy on imaging, 4% (n = 2) provided coverage and 4% (n = 2) specified coverage only on a case-by-case basis. Forty-eight percent (n = 28) of insurers had a statement of coverage on lymphovenous bypass or vascularized lymph node transfer, in which reimbursement was almost universally denied (96%, n = 26; 93%, n = 26). Liposuction and debulking procedures were included in 25 (43%) and 13 (22%) policies, in which seven (28%) and four (31%) insurers would provide coverage, with over 75% having criteria. Coverage of liposuction was significantly more than for lymphovenous bypass (P .04).Nearly one-half of American insurers do not have a publicly available policy on most imaging, physiological, or excisional procedures, leaving coverage status ambiguous. Reimbursement was uncommon for imaging and physiological procedures, whereas the majority of insurers who did offer coverage for excisional procedures also had multiple criteria to be met. These elements may together be a limiting factor in receiving appropriate care for lymphedema.

Male-to-female (MtF) transgender individuals are at risk for prostate cancer, although guidelines for screening and management in this population are not well established. We describe a series of 9 MtF transgender patients who underwent prostate tissue sampling and highlight histopathologic features and challenges related to pathologic interpretation of prostate tissue in this patient population. Seven of 9 total patients were diagnosed with prostate cancer and all had elevated prostate-specific antigen at the time of diagnosis. Three of the 7 patients diagnosed with prostate cancer had received different types of hormone therapy for gender affirmation before the diagnosis of prostate cancer, and in all 3 of these patients, there was histologic evidence of hormone therapy effect in both benign prostate tissue and/or the adenocarcinoma. The 2 patients with benign prostate tissue underwent transurethral resection for lower urinary tract symptoms and were previously on hormone therapy for gender affirmation. Both of these specimens showed diffuse glandular atrophy and basal cell hyperplasia, indicative of hormone therapy effect on benign prostatic tissue. In the patients diagnosed with prostate cancer, a spectrum of grades was observed, ranging from Grade Group 1 to Grade Group 5. Four patients underwent radical prostatectomy, with 2 cases showing extraprostatic extension and Grade Group 5 prostatic adenocarcinoma, and 2 showing Grade Group 2 prostatic adenocarcinoma. Three of the 4 patients who underwent radical prostatectomy had received gender-affirming hormone therapy before surgery, and all 3 of these specimens showed hormone therapy effect in non-neoplastic prostate tissue and focal hormone therapy effect in prostatic adenocarcinoma. The presence of areas of viable carcinoma without hormone therapy effect enabled the assignment of a Gleason score and Grade Group in these 3 cases. Hormone therapy administered for gender identity affirmation induces histopathologic changes to both benign prostate tissue (nonkeratinizing squamous metaplasia, diffuse atrophy, basal cell hyperplasia, and stromal dominance with decreased numbers of glands) and prostatic adenocarcinoma (nuclear pyknosis, atrophy, cytoplasmic vacuolization, and architectural patterns that would qualify for Gleason 4 and 5 in the absence of hormone therapy effect) that have been traditionally seen in cis-male prostate cancer patients receiving hormone therapy. In the absence of hormone therapy, the morphology of prostatic adenocarcinoma in transgender patients shows classic morphologic features similar to those seen in cis-male patients not on hormone therapy. Prostate cancer with hormone therapy effect may not only be histologically quite subtle and may be overlooked if not suspected, but also should not be assigned a Gleason score because the Gleason score would substantially overstate its biologic potential. Therefore, similar to cis-male patients who have received androgen deprivation therapy for prostate cancer, transgender patients on hormone therapy for gender affirmation may be at risk for both underrecognition and over-grading of prostate cancer, particularly if the pathologist is not aware of the clinical history.

Although blunt cerebrovascular injury (BCVI) is recognized as a risk factor for trauma morbidity and mortality, little is described regarding similar cerebrovascular injury (CVI) in patients with penetrating wounds. The authors aim to characterize these injuries in the craniofacial self-inflicted gunshot wound (SIGSW) population.An institutional review board (IRB)-approved retrospective nstudy was conducted on patients presenting to the R Adams Cowley Shock Trauma Center with SIGSWs between 2007 and 2016. All CVIs were categorized by location, type, and associated neurologic deficits. Demographic data, patient characteristics, additional studies, and long-term outcomes were collected. A multivariate analysis determining independent predictors of CVI in the SIGSW population was performed.Of the 73 patients with SIGSWs, 5 (6.8%) had CVIs separate from the bullet/cavitation tract (distant CVIs) and 9 had CVIs along the bullet/cavitation tract (in-tract CVIs). A total of 55.6% of in-tract and 40% of distant injuries were missed on initial radiology read. One distant CVI patient suffered a stroke during admission. The anterior to posterior gunshot wound trajectory was positively associated with distant CVIs when compared with no CVIs ( P = 0.01). Vessel dissection was more prevalent in patients with distant CVIs, when compared against patients with in-tract CVIs ( P = 0.02).Nearly 20% of craniofacial SIGSW patients have CVIs and 6.8% have BCVI-like injuries, which is 2-to-6-fold times higher than traditional BCVIs. Craniofacial SIGSWs serve as an independent screening criterion with comparable screening yields; the authors recommend radiographic screening for these patients with particular scrutiny for CVIs as they are frequently missed on initial radiographic interpretations.

Background MicroRNAs (miRNAs) have been shown to be associated with osteoarthritis (OA) progression. This study aimed to explore the role of miR-520c-3p in OA progression. Methods Expression levels of miR-520c-3p and Growth arrest-specific 2 (GAS2) were detected using quantitative real-time PCR. The proliferation and apoptosis of cells were measured using cell counting kit 8 (CCK8) assay and flow cytometry. Furthermore, the protein levels of apoptosis-related markers, extracellular degradation markers, inflammatory response markers, and GAS2 were tested using quantitative real-time polymerase chain reaction (RT-PCR) and western blot (WB) analysis. In addition, the interaction between miR-520c-3p and GAS2 was examined using dual luciferase reporter assay. Results GAS2 was highly expressed, and miR-520c-3p was lowly expressed in OA cartilage tissues. miR-520c-3p could promote the proliferation and inhibit the apoptosis and inflammation of OA chondrocytes. miR-520c-3p could be sponged by GAS2, and its inhibitor could reverse the regulation of GAS2 on the biological functions of OA chondrocytes. GAS2 was a target of miR-520c-3p, which was identified by bioinformatic analysis and dual-luciferase reporter assay. Overexpression of GAS2 could inhibit the proliferation and promoted the apoptosis and inflammation of OA chondrocytes. Conclusion Our data showed that miR-520c-3p might regulate the GAS2 to inhibit the progression of OA.

Study Design Case series. Objective This retrospective review of frontal sinus fractures aims to describe our current experience managing these fractures at an urban level I trauma center. Methods An institutional database of 2081 patients who presented with maxillofacial fractures on computed tomography face/sinus in 2019 was queried for all patients with traumatic frontal sinus fractures. Demographics, trauma-related history, management approach, and follow-up data were collected and analyzed. Results Sixty-three (7.3%) patients had at least one fracture involving the frontal sinus. The most common etiologies were assaults, falls, and motor vehicle accidents. Surgical repair was performed in 26.8% of patients with frontal sinus fractures, and the other 73.2% were observed. Fractures that were displaced, comminuted, obstructive of the frontal sinus outflow tract, or associated with a dural tear or cerebrospinal fluid leak were more likely to be operative. Conclusions The majority of frontal sinus fractures in this study were treated with observation. Despite advances in transnasal endoscopic approaches, many surgeons still rely on open approaches to repair frontal sinus fractures.

BACKGROUND The purpose of this study was to characterize differences in facial fracture injury patterns among pediatric patients at highest risk of abusive head trauma/nonaccidental trauma (age ≤ 5 years). METHODS Using the National Trauma Databank from 2007 to 2015, patients (age ≤ 5 years) suffering facial fractures were included. Demographics and injury characteristics were compared between those sustaining accidental versus nonaccidental trauma (NAT). RESULTS Over 9 years 9741 patients were included with 193 patients (2.0%) suffering NAT. Nonaccidental trauma patients were younger (median [interquartile range]; 0 [0, 2] versus 3 [1, 4], P

The 2021 interview cycle for craniofacial fellowship applicants was the first to be held virtually due to the coronavirus disease 2019 pandemic. Here, we detail the craniofacial fellowship applicant perceptions and experience on the virtual interview process.An institutional review board-approved 35-question survey study on the perception of the virtual interview process among craniofacial fellowship applicants was conducted. Surveys were distributed to individuals who had applied through the match, overseen by the American Society of Craniofacial Surgeons (ASCFS).Ten surveys were fully completed with a corresponding response rate of 48%. The average number of interviews completed was 12.7±7.7 and 50% of applicants interviewed at1 program in a single day. Overall, 90% of respondents preferred in-person interviews before the interview season, however, only 10% preferred the in-person format afterwards. Preference for a virtual-only format increased from 10% to 70%. Applicants cited cost (100%), ease of scheduling (90%), and ability to participate in more interviews (70%) as the primary strengths of the virtual platform; none reported difficulties with self-advocacy. After the interview cycle, 90% stated they would recommend virtual interviews.The greatest strengths of virtual interviews were the ability to participate in more interviews, the ease of scheduling, and the cost benefits. Most applicants reported the same or increased ability for self-advocacy with virtual interviews. Following the index interview cycle for 2021, the majority of fellowship applicants now appear to prefer a virtual-only or hybrid format and would recommend virtual interviews in the future.

Bariatric surgery remains underutilized at a national scale, and insurance company reimbursement is an important determinant of access to these procedures. We examined the current state of coverage criteria for bariatric surgery set by private insurance companies. We surveyed medical policies of the 64 highest market share health insurance providers in the USA. ASMBS guidelines and the CMS criteria for pre-bariatric evaluation were used to collect private insurer coverage criteria, which included procedures covered, age, BMI, co-morbidities, medical weight management program (MWM), psychosocial evaluation, and a center of excellence designation. We derive a comprehensive checklist for pre-bariatric patient evaluation. Sixty-one companies (95%) had defined pre-authorization policies. All policies covered the RYGB, and 57 (93%) covered the LAGB or the SG. Procedures had coverage limited to center of excellence in 43% of policies (n = 26). A total of 92% required a BMI of 40 or above or of 35 or above with a co-morbidity; however, 43% (n = 23) of policies covering adolescents (n = 36) had a higher BMI requirement of 40 or above with a co-morbidity. Additional evaluation was required in the majority of policies (MWM 87%, psychosocial evaluation 75%). Revision procedures were covered in 79% (n = 48) of policies. Reimbursement of a second bariatric procedure for failure of weight loss was less frequently found (n = 41, 67%). A majority of private insurers still require a supervised medical weight management program prior to approval, and most will not cover adolescent bariatric surgery unless certain criteria, which are not supported by current evidence, are met.

The Coronavirus disease 2019 pandemic occurred during the interview period for numerous surgical fellowships, resulting in most programs transitioning to a virtual interview format during the 2020-2021 application cycle. This study investigated modifications adopted by fellowship programs and perceptions of the virtual interview format among hand surgery fellowship applicants.Voluntary, anonymous online surveys were emailed to all applicants to the Johns Hopkins hand surgery fellowship during the 2020-2021 interview cycle. The surveys were released after the rank order list certification deadline on May 6, 2021, and closed on May 18, 2021, before the match results were released. Descriptive statistics based on the overall cohort and primary outcome of an applicant's willingness to recommend virtual interviews in the future were conducted.Thirty-four of 112 (30.4%) applicants completed their surveys. Twenty-seven (79.4%) survey respondents recommended the virtual interview format in the future and 7 (20.6%) did not. Applicants who recommended virtual interviews were similar to those who did not on the basis of the number of interviews received and taken, information provided by programs, and self-rated competency with the virtual interview format. Those who recommended virtual interviews rated the effectiveness of self-advocacy higher compared with those who did not. All respondents agreed that cost savings and scheduling were more effective with virtual interviews. Perceived weaknesses differed between the 2 groups and included the lack of physical tour, difficulty with self-advocacy, and technical difficulties. The majority of survey respondents preferred in-person interviews before the interview cycle (n = 32, 94.1%), whereas nearly half of survey respondents preferred virtual interviews after the interview cycle (n = 16, 47.1%).Nearly 80% of survey respondents recommended virtual interviews in the future. Major benefits included effectiveness of scheduling and cost savings.Virtual interviews may be considered as an alternative or adjunct to in-person hand surgery fellowship interviews in the future.

Lymphedema affects1 in 1000 Americans, most often resulting from breast cancer surgery. Conservative treatment, such as compression garments, combined decongestive therapy (CDT), and pneumatic compression pumps, is the current standard of care. Despite the wide availability of these therapies, lymphedema has remained undertreated worldwide. We investigated whether third-party insurance coverage might be a barrier to obtaining conservative treatment in the United States.We conducted a cross-sectional analysis of publicly accessible insurance policies. A total of 58 insurers were included in accordance with their state enrollment data and market share. The analysis was conducted using a web-based search and individual telephone interviews. For those policies that extended coverage, the medical necessity criteria were abstracted.A total of 50 insurance companies (86%) had a policy in place addressing conservative management. Included in 37 policies (64%), compression garments were covered the least often (n = 33; 89%). Although CDT was included in only 22 policies (38%), it was universally covered. Noncalibrated pneumatic compression pumps were the most frequently addressed intervention (n = 46; 79%), significantly more often than CDT (P .01) and were universally covered, significantly more often than were compression garments (P .04). Criteria for reimbursement were present for more than one half of the policies that provided coverage.A large proportion of U.S. insurers provided coverage for conservative treatment of lymphedema. However, only 38% of the policies included a statement of coverage for CDT. Most of the policies that did provide coverage for these four therapies also had multiple criteria that were required to be met before considering reimbursement. These requirements could create barriers to the receipt of treatment.

INTRO Achieving anatomic reduction and re-establishing premorbid occlusion in patients with complex maxillomandibular fractures is challenging even for seasoned surgeons. Historically, surgeons have utilized occlusal splints to help establish occlusal relationships before fracture reduction and fixation. These acrylic splints are fabricated from dental impressions and require manual repositioning of tooth bearing segments along the fracture line to reapproximate premorbid occlusion. The process is laborious, requires a dental lab, and is less efficacious in edentulous patients or those with significantly comminuted fractures; as such it has largely fallen out of practice. Recently, with advances in virtual 3D modeling and printing, we demonstrate that occlusal splints can be designed from computed tomography scans, manipulated virtually, and printed without obtaining impressions from the patient. METHODS/RESULTS In our series of 3 patients with complex maxillomandibular fractures, occlusal splints were created by 1) obtaining maxillofacial computed tomography scans, 2) reducing the fractures virtually, and 3) using orthognathic virtual surgery software to create the splint. The time between planning and delivery of the splint was 4 to 7 days. These splints were successfully utilized to help establish premorbid occlusion in conjunction with maxillomandibular fixation and aided in expeditious intraoperative fracture reduction and fixation. CONCLUSIONS In the treatment of complex facial fractures, occlusal splints can be a useful adjunct in the operative reduction and fixation of fractures. With the advent of virtual preoperative surgical planning via 3D modeling and 3D printing, these occlusal splints can be created of a sufficient fidelity to avoid the strict need for dental impressions.

Contemporary description of facial fracture patterns and factors associated with early operative intervention at trauma centers is lacking. The purpose of this study was to characterize injuries and initial treatment patterns of patients suffering from facial fractures.Using the National Trauma Databank from 2007 to 2015, patients suffering from facial fractures were included. Demographics, injury characteristics, and outcomes including operative interventions were assessed.Over 9 years, 626,270 patients were included: 74.5% were male, 39.0% suffered traumatic brain injury (TBI), and 23.3% severe noncraniofacial injuries (chest, abdomen, and/or extremity Abbreviated Injury Score ≥3). A total of 537,594 (85.8%) patients were admitted and 184,206 (34.3%) underwent operations for their facial injuries during the index hospitalization. The frequency and patterns of fractures varied by age, sex, race, and mechanism of injury. Operative intervention rates were highest for mandible (63.2%) and lowest for orbit fractures (1.0%). Multiple regression revealed that multiple factors were independently associated with the odds of early fracture repair including: female versus male (odds ratio [95% confidence interval]: 0.96 [0.94-0.98]), age65 versus18 years (0.62 [0.59-0.64]), non-white race (0.95 [0.94-0.97]), uninsured versus Medicaid (0.88 [0.86-0.90]), hospital bed size (600 vs ≤200 beds, 1.67 [1.61-1.73]), TBI (0.70 [0.69-0.71]), and C-spine injury (0.93 [0.90-0.96]).Facial fractures are common among many demographic cohorts, and multiple patient and injury-specific factors influenced fracture patterns and management. Early operative intervention was highest for mandible fractures and lowest for orbit fractures. Multiple factors including age, sex, insurance status, hospital characteristics, and race/ethnicity were independently associated with early operative intervention, highlighting disparities in care.

BACKGROUND Presentation of pediatric facial fractures varies widely and many injuries are encountered infrequently by most practitioners. This study summarizes injury patterns in a large cohort of facial fractures and their subsequent surgical management. METHODS Demographic and clinical characteristics of patients 18 years of age or younger admitted between 2009 and 2015 to trauma centers participating in the National Trauma Data Bank were examined. Craniofacial fractures and reconstructive procedures performed at index admission were selected based on ICD-9 and AIS codes. A multivariable analysis was used to determine independent determinants of surgical repair. RESULTS Out of 60,094 pediatric patients evaluated in the US emergency departments, 48,821 patients were admitted and underwent open treatment (n = 8364; 17.1%) or closed treatment (n = 4244; 8.7%) of facial fractures. Falls were the most common mechanism of injury in infants and toddlers (

Background Fractures of the orbital roof require high-energy trauma and have been linked to high rates of neurologic and ocular complications. However, there is a paucity of literature exploring the association between injury, management, and visual prognosis. Methods The authors performed a 3-year retrospective review of orbital roof fracture admissions to a Level I trauma center. Fracture displacement, comminution, and frontobasal type were ascertained from computed tomographic images. Pretreatment characteristics of operative orbital roof fractures were compared to those of nonoperative fractures. Risk factors for ophthalmologic complications were assessed using univariable/multivariable regression analyses. Results In total, 225 patients fulfilled the inclusion criteria. Fractures were most commonly nondisplaced [n = 118 (52.4 percent)] and/or of type II frontobasal pattern (linear vault involving) [n = 100 (48.5 percent)]. Eight patients underwent open reduction and internal fixation of their orbital roof fractures (14.0 percent of displaced fractures). All repairs took place within 10 days from injury. Traumatic optic neuropathy [n = 19 (12.3 percent)] and retrobulbar hematoma [n = 11 (7.1 percent)] were the most common ophthalmologic complications, and led to long-term visual impairment in 51.6 percent of cases. Conclusions Most orbital roof fractures can be managed conservatively, with no patients in this cohort incurring long-term fracture-related complications or returning for secondary treatment. Early fracture treatment is safe and may be beneficial in patients with vertical dysmotility, globe malposition, and/or a defect surface area larger than 4 cm2. Ophthalmologic prognosis is generally favorable; however, traumatic optic neuropathy is major cause of worse visual outcome in this population. Clinical question/level of evidence Risk, III.

BACKGROUND Blood-borne pathogen infections (BPIs), caused by the human immunodeficiency virus, hepatitis C and hepatitis B viruses pose an occupational hazard to healthcare workers. Facial trauma reconstruction surgeons may be at elevated risk because of routine use of sharps, and a higher than average incidence of BPIs in the trauma patient population. METHODS The authors retrospectively reviewed health records of patients admitted to a level 1 trauma center with a facial fracture between January 2010 and December 2015. Patient demographics, medical history, mechanism of injury, type of fracture, and procedures performed were documented. The authors detemined the frequency of human immunodeficiency virus, hepatitis B, and hepatitis C diagnosis and utilized univariable/multivariable analyses to identify risk factors associated with infection in this population. RESULTS In total, 4608 consecutive patients were included. Infections were found in 4.8% (n = 219) of patients (human immunodeficiency virus 1.6%, hepatitis C 3.3%, hepatitis B 0.8%). 76.3% of BPI patients in this cohort were identified by medical history, while 23.7% were diagnosed by serology following initiation of care. 39.0% of all patients received surgical treatment during initial hospitalization, of whom 4.3% had a diagnosed BPI. History of intravenous drug use (odds ratio [OR] 6.79, P

In facial reanimation via microneurovascular muscle transfer, dual-nerve reinnervation of the muscle capitalizes on the synergistic effects of spontaneous motion from cross facial nerve grafting (CFNG) and increased excursion from masseteric nerve transfer. Two-stage approaches that delay masseteric nerve transfer until the time of the muscle flap increase spontaneity by maximizing muscle reinnervation from the CFNG. While this 2-stage, dual-nerve approach has been described in adults, we present a series of pediatric patients who underwent this reconstructive technique.We retrospectively reviewed all pediatric patients who underwent 2-stage, dual-nerve reconstruction with CFNG and ipsilateral masseteric nerve transfers. Procedures were performed between 2004 and 2016 by 2 surgeons at a single centre. Degree of facial paralysis before and after surgical intervention was measured using House-Brackmann scores.Nine patients with a mean age of 8.6 (range: 5-15 years) years at time of surgery underwent 2-stage, dual-nerve reconstruction. Average time between CFNG and transfer of the free gracilis with masseteric nerve transfer was 13.3 (SD 2.4) months. Mean follow-up was 27.3 months (SD 25.7). Patients demonstrated initiation of voluntary movement on paralyzed side by 3.6 months (SD 0.6) on average, with 3 patients demonstrating spontaneous movement at 3 months.The 2-stage, dual innervation technique using CFNG and delayed ipsilateral masseteric nerve transfer with a free gracilis is a promising reconstructive option to maximize spontaneous expression in pediatric patients. Validated, objective scoring systems for excursion are needed before meaningful comparisons can be made to other reconstructive strategies.Lors de la réanimation faciale par transfert du muscle microneurovasculaire, la réinnervation de deux nerfs du muscle tire profit des effets synergétiques du mouvement spontané à partir de la greffe de nerf transfacial (GNTF) et améliore l’excursion du transfert de nerf massétérin. Une intervention en deux étapes qui reporte le transfert du nerf massétérin jusqu’à ce que le lambeau musculaire améliore la spontanéité par une maximisation de la réinnervation musculaire à partir de la GNTF. Cette intervention sur deux nerfs en deux étapes a été décrite chez les adultes, mais les chercheurs présentent les résultats de cette technique chez une série de patients d’âge pédiatrique.Les chercheurs ont procédé à l’analyse rétrospective de tous les patients pédiatriques qui avaient subi une reconstruction de deux nerfs en deux étapes par transferts de la GNTF et du nerf massétérin ipsilatéral. Deux chirurgiens d’un même centre ont effectué les interventions entre 2004 et 2016. Les chercheurs ont mesuré le degré de paralysie faciale avant et après l’intervention chirurgicale au moyen des scores de House-Brackmann.Neuf patients, d’un âge moyen de 8,6 ans (plage de cinq à 15 ans) au moment de l’opération ont subi une reconstruction de deux nerfs en deux étapes. La période moyenne entre la GNTF et le transfert du muscle gracile libre avec le transfert du nerf massétérin était de 13,3 mois (ÉT 2,4). Le suivi moyen était d’une durée de 27,3 mois (ÉT 25,7). Les patients avaient commencé à faire des mouvements volontaires du côté paralysé au bout d’une moyenne de 3,6 mois (ÉT 0,6), et trois patients faisaient des mouvements spontanés au bout de trois mois.La technique d’innervation double en deux étapes à l’aide de la GNTF et du transfert tardif du nerf massétérin ipsilatéral avec le muscle gracile libre est une méthode de reconstruction prometteuse pour maximiser l’expression spontanée chez les patients d’âge pédiatrique. Il faudra établir des systèmes objectifs de scores d’excursion avant de faire des comparaisons significatives avec d’autres stratégies de reconstruction.

Computed tomographic scans are frequently obtained following craniomaxillofacial fracture reconstruction. The additive radiation from such scans is not trivial; cumulative radiation exposure poses stochastic health risks. In this article, the authors postulate that a low-dose computed tomography protocol provides adequate image quality for postoperative evaluation of reconstructed craniomaxillofacial fractures. This study included patients for whom a computed tomographic scan was indicated following craniomaxillofacial fracture repair at a Level I trauma center. Postoperative craniomaxillofacial computed tomography was performed using a low-dose protocol, rather than standard protocols. A craniomaxillofacial surgeon and a radiologist interpreted the images to determine whether they were of sufficient quality. It was decided a priori that any inadequate low-dose computed tomography would require repeated scanning using standard protocols. The primary endpoint was the need for repeated computed tomography. In addition, the clarity of clinically significant anatomical landmarks on the images was graded on a five-point Likert scale. Twenty patients were scanned postoperatively using the low-dose protocol. Mean radiation dose (total dose-length product) from the low-dose protocol was 71 mGy · cm versus 532 mGy · cm for the preoperative computed tomographic scans that were obtained using conventional protocols (p < 0.001). All 20 low-dose computed tomographic scans were determined to provide satisfactory image quality. No patients required repeated computed tomography secondary to poor image quality. Low-dose computed tomography received high image-quality scores. A low-dose computed tomography protocol that delivers approximately 7.5-fold less radiation than the standard protocols was found to be adequate for postoperative evaluation of craniomaxillofacial fractures. Larger prospective studies may be warranted. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

Craniofacial trauma can result in a wide variety of injuries that cause soft tissue injury of face. However, despite the enormous diversity in presentation of these injuries, they tend to follow certain patterns. Most facial injuries are either contusions, abrasions, lacerations, or avulsions. The extent of injury and approach to repair can be further assessed by the size, depth, and number of facial subunits involved. A plastic surgeon in the setting of acute craniofacial trauma, armed with certain principles of facial anatomy and primary repair methods, can drastically restore function and cosmesis to the face, while also mitigating the chance of future deformity and functional deficit. This review contains 3 figures and 26 references Keywords: facial trauma, craniofacial surgery, primary repair, facial soft tissue defects, soft tissue, facial injury, plastic surgery, facial lacerations, facial avulsions

Calvarial trauma in the pediatric population differs significantly from that seen in adults. Nonaccidental head trauma is the leading cause of death in infants less than 12 months of age, and must be ruled out during the initial patient evaluation. Unlike adults, most acute fractures can be managed nonoperatively, given the increased remodeling capacity of pediatric skulls. However, close follow-up is warranted in instances of conservative management; infants with linear skull fractures can develop a rare complication during early childhood as a result of accelerated calvarial expansion, known as growing skull fractures. While rare, this condition can result in severe and permanent neurological damage if diagnosis is delayed. Reconstructive options for calvarial defects need to take into account the growing skull, and need for long-term reliability and outcomes. As such, nonautologous techniques have a limited role in pediatric calvarial reconstruction, with most centers advocating for autologous techniques. Failure to appreciate the differences between children and adults when treating pediatric calvarial trauma will ultimately result in complications that can lead to severe morbidity or even death.

PURPOSE Self-inflicted facial gunshots (SIGSWs) typically result in a spectrum of severe injuries to facial structures, including the orbit and globe. Roughly three-quarters of those who arrive to the hospital will survive their injuries, and recidivism is typically low. Therefore, effective management is paramount to preserve vision, and long-term quality of life. The objective of this study is to characterize the common injuries to the orbit, globe, and periocular structures following SIGSWs, their management, and their eventual visual and reconstructive outcomes. METHODS Retrospective review of trauma registry records at a Level 1 trauma center for patients who presented alive following SIGSWs involving the globe and/or orbit from 2007 to 2016. RESULTS Of the 47 patients who presented with SIGSWs to the orbit, 33 (70%) were discharged alive from the hospital. Management strategies for these patients fell into 3 groups, based on the involved structures: i) Open globe injuries (Type I: n = 12, 34%) ii) Orbital fractures with preserved globe and optic nerve (Type II: n = 15, 43%), and iii) Optic nerve injuries with preserved globe (Type III: n = 8, 23%). Compared with Type II and III injuries, patients who had Type I injuries were more likely to die prior to hospital discharge (46% vs. 20% vs. 12%, p = 0.04), undergo ophthalmologic intervention (73% vs. 6% vs. 11%, p = 0.01), and more surgery (6 vs. 3 vs. 0.5 mean surgeries, p < 0.001). Type II injuries most frequently underwent debridement and reconstruction of the bony orbit. Type III and Type I injuries were associated with worse initial and final visual acuity, with the majority (100% and 75%, respectively) having No Light Perception (NLP) on initial exam, and no visual recovery during the follow-up period (median follow up= 25 months). CONCLUSIONS Management and visual outcomes of orbital injuries from SIGSWs is determined by whether the globe and optic nerve are preserved. Open globe injury by itself is associated with higher mortality and significant permanent vision loss.

Wide local excision is the gold standard and only potential curative therapy for recalcitrant hidradenitis suppurativa. However, high recurrence rates persist even post-surgery with little known on the influencing factors for remission. We evaluated the effect of patient, disease, and operative factors on local cure rate of moderate to severe hidradenitis following wide local excision. We performed a retrospective chart review for all patients who had undergone surgical excision of hidradenitis at a university hospital from 2012 to 2018. We identified 79 patients with a total of 220 operative sites. The majority were obese (mean body mass index [BMI] 32.5), female (71%), African-American (84%), and had a mean age of 31 years. A quarter of operative sites experienced a recurrence (n = 56). Patients who achieved remission had a significantly lower number of affected regions than those who experienced a recurrence (2.3 vs 3.6, P = .0023). Additionally, recurrence rate differed significantly between body locations (P = .0440). Smoking, BMI, Hurley grade, closure method, and excision size did not influence local cure rate. Surgical excision remains a worthy management option for hidradenitis patients with three quarters achieving remission after a single operation. Number of affected regions and location of hidradenitis may play a factor in recurrence.

Recent studies indicate that recombinant human bone morphogenetic protein-2 (rhBMP-2) in a demineralized bone matrix scaffold is a comparable alternative to iliac bone autograft in the setting of secondary alveolar cleft repair. Postreconstruction occlusal radiographs demonstrate improved bone stock when rhBMP-2/demineralized bone matrix (DBM) scaffold is used but lack the capacity to evaluate bone growth in three dimensions. This study uses cone beam computed tomography to provide the first clinical evaluation of volumetric and density comparisons between these two treatment modalities.A prospective study was conducted with 31 patients and 36 repairs of the alveolar cleft over a 2-year period. Twenty-one repairs used rhBMP-2/DBM scaffold and 14 repairs used iliac bone grafting. Postoperatively, occlusal radiographs were obtained at 3 months to evaluate bone fill; cone beam computed tomographic images were obtained at 6 to 9 months to compare volumetric and density data.At 3 months, postoperative occlusal radiographs demonstrated that 67 percent of patients receiving rhBMP-2/DBM scaffold had complete bone fill of the alveolus, versus 56 percent of patients in the autologous group. In contrast, cone beam computed tomographic data showed 31.6 percent (95 percent CI, 24.2 to 38.5 percent) fill in the rhBMP-2 group compared with 32.5 percent (95 percent CI, 22.1 to 42.9 percent) in the autologous population. Density analysis demonstrated identical average values between the groups (1.38 g/cc).These data demonstrate comparable bone regrowth and density values following secondary alveolar cleft repair using rhBMP-2/DBM scaffold versus autologous iliac bone graft. Cone beam computed tomography provides a more nuanced understanding of true bone regeneration within the alveolar cleft that may contribute to the information provided by occlusal radiographs alone.Therapeutic, II.

BACKGROUND Self-inflicted gunshot wounds involving the face are highly morbid. However, there is a paucity of objective estimates of mortality. This study aims to provide prognostic guidance to clinicians that encounter this uncommon injury. METHODS A retrospective review of patients presenting to R Adams Cowley Shock Trauma Center (a Level I trauma center) with self-inflicted gunshot wounds to the face from 2007 to 2016. Isolated gunshot wounds to the calvaria or neck were excluded. The data were analyzed to determine predictors of survival. RESULTS Of the 69 patients that met inclusion criteria, 90 percent were male and 80 percent were Caucasian, with an age range of 21 to 85 years. The most frequently seen injury patterns showed submental (57 percent), intraoral (22 percent), and temporal (12 percent) entry sites. Fewer than half (41 percent) of the cohort sustained penetrative brain injury. Overall, there were 18 deaths (overall mortality, 26 percent), 17 of which were secondary to brain injury. Independent predictors of death included penetrative brain injury (OR, 17; p < 0.0001) and age. Mortality was 17 percent among patients younger than 65 years, compared with 73 percent for those aged 65 years or older (p = 0.0001). Gastrostomy placement was independently associated with 25 percent reduction in length of hospitalization (p = 0.0003). CONCLUSIONS Despite tremendous morbidity, the overwhelming majority of patients who present with facial self-inflicted gunshot wounds will survive, especially if they are young and have no penetrative brain injury. These findings should help guide clinical decisions for this devastating injury. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.

Background A longstanding dictum exists to avoid surgical manipulation of the temporalis muscle out of concern for an exceedingly high rate of muscle atrophy and recurrent temporal hollowing. The authors challenge this surgical myth, considering such advice to be erroneous. The authors hypothesize that elevation of the temporalis muscle, if performed using standard muscle flap principles, will demonstrate excellent results. Methods To assess temporalis response to surgical manipulation, the authors reviewed patients who underwent calvarial vault remodeling by the senior author for craniosynostosis between 1988 and 2011. Nonsyndromic patients with single-suture synostosis and 5 years of follow-up were eligible for inclusion. The medical record was used to measure rates of reoperation, recurrent temporal hollowing, and persistent temporalis overcorrection. Results Of the cohort reviewed, 196 patients met inclusion criteria. Ten patients (5.1%) exhibited recurrent bitemporal constriction. One patient (0.5%) underwent a revision temporalis turnover flap, and 2 patients (1.0%) underwent soft tissue augmentation. The overall reoperation rate was 1.5%. Temporalis overcorrection, in an attempt to prophylactically rectify the expected atrophy after temporalis manipulation, persisted in 11 patients (5.6%). Three of these patients required treatment with steroid injections, Botox injections, or operative muscle debulking. The overall reoperation rate for temporalis overcorrection was 1.5%. Conclusions The authors' low reoperation rates for recurrent deformity, in combination with persistent temporalis overcorrection in 5.6% of patients, should dispel the myth that manipulation of the temporalis invariably results in atrophy. The muscle may be surgically manipulated, as long as plastic surgery principles are followed.

Background:. There is a paucity of patient-reported outcome measures for facial trauma reconstruction. To measure satisfaction and health-related quality of life (HRQOL), following repair of traumatic facial fractures, we used the FACE-Q, a set of patient-reported outcome instruments designed for aesthetic facial surgery. As a step toward validating the scales for facial trauma, we evaluated their reliability. Methods:. This is a prospective study of patients following primary repair of traumatic facial fractures at a level 1 trauma center from 2016 to 2018. Six FACE-Q scales with relevance to the facial trauma population were completed by patients at their 1-month postoperative visits. Predictors of satisfaction were examined using multiple linear regression models. Reliability of the scales in this population was evaluated using psychometric methods. Results:. One hundred eighty-five participants fulfilled inclusion criteria. Mean scores for the 6 scales ranged from 59 (SD = 15) for Recovery-Early Life Impact to 94 (SD = 13) for Satisfaction with Medical Team. Predictors of lower satisfaction and/or HRQOL include current tobacco smoking status, mandibulomaxillary fixation, and Le Fort pattern fractures. All scales were found to have good to excellent reliability (Cronbach’s alpha = 0.824–0.969). Conclusions:. Following repair of facial fractures, patient-reported outcomes can be reliably measured using FACE-Q scales. On average, patients report poor health-related quality of life in the early postoperative period. Predictors of low satisfaction and/or poor HRQOL include current smoking habit, mandibulomaxillary fixation, and Le Fort fractures.

Purpose To explore the possible surgical factors related with nonunion in femoral shaft fracture following intramedullary nailing. Methods We retrospectively analyzed totally 425 patients with femoral shaft fracture in level I urban trauma center, including 254 males and 171 females, with an average age of 37.6 (ranging from 21 to 56) years old. The inclusion criteria included: (1) traumatically closed fracture of femoral shaft, with preoperative films showing non-comminuted fracture, such as transverse fracture, oblique fracture or spiral fracture; (2) closed reduction and fixation with interlocking intramedullary nail at 3–7 days after trauma; (3) complete follow-up data available. The relationship between the following factors (fracture site, reduction degree, direction of nail insertion and nail size) and nonunion was studied. Results The incidence of femoral nonunion was 2.8% in patients with closed simple fracture undergoing interlocking intrameduallary nailing, including 11 cases of hypertrophic nonunion. Nonunion was related significantly to distal fracture, unsatisfactory reduction and unreamed nail (p 0.05). Conclusions Nonunion in femoral shaft facture following interlocking intramedullary nailing is related to fracture site, fracture reduction and nail diameter. The choice of reamed nails or unreamed nails depends on the fracture site and reduction degree.

BACKGROUND A lasting correction of trigonocephaly is difficult to achieve, as a durable correction requires significant expansion to overcome galeal restriction and soft tissue recoil of the scalp. High rates of relapse have been reported throughout the literature. The specific aim of this study was to determine if the senior author's method of "hypercorrection" decreases relapse and the need for subsequent revisional surgery. METHODS Patients who underwent operative correction of metopic craniosynostosis between 1988 and 2011 were reviewed. All patients underwent the "hypercorrection" technique performed by the senior author. Hypercorrection consisted of a fronto-orbital advancement of 2.5 to 3.5 cm and a concomitant hyperexpansion of bitemporal projection. Split cranial bone grafting ensured adequate coverage of the significantly expanded cranial vault. Only patients who had at least 5 years of follow-up were included for review of outcomes. Relapse was defined as recurrence of bitemporal constriction or lateral orbital retrusion, requiring surgical correction. RESULTS Fifty-eight patients met criteria. Mean age at the time of surgery was 11 months. Mean follow-up was 9.0 years. During this time, 2 patients exhibited relapse requiring camouflage procedures. Cranial bone defects were found in 4 patients (7%), 3 of whom underwent cranial bone grafting, while 1 underwent methylmethacrylate placement at an outside institution. One patient underwent fat grafting for areas of soft tissue irregularity. No patients exhibited persistent sequelae of hypercorrection significant enough to require repeat fronto-orbital advancement. CONCLUSION Surgical hypercorrection of trigonocephaly seems to minimize relapse and the need for revision in long-term follow-up and is therefore an important technique to consider.

Background Alveolar cleft reconstruction using iliac crest bone graft is considered standard of care for children with complete cleft lip and palate at the time of mixed dentition. Harvesting bone may result in donor-site morbidity and additional operating time and length of hospitalization. Recombinant human bone morphogenetic protein (rhBMP)-2 with a demineralized bone matrix is an alternative bone source for alveolar cleft reconstruction. The authors investigated the outcomes of rhBMP-2/demineralized bone matrix versus iliac crest bone graft for alveolar cleft reconstruction by reviewing postoperative surgical complications and cleft closure. Methods A retrospective chart review was conducted for 258 rhBMP-2/demineralized bone matrix procedures (mean follow-up, 2.9 years) and 243 iliac crest bone graft procedures (mean follow-up, 4.1 years) on 414 patients over a 12-year period. The authors compared complications, canine eruption, and alveolar cleft closure between the two groups. Results In the rhBMP-2/demineralized bone matrix group, one patient required prolonged intubation because of intraoperative airway swelling not thought to be caused by rhBMP-2, 36 reported facial swelling and one required outpatient steroids as treatment, and 12 had dehiscence; however, half of these complications resolved without intervention. Twenty-three of the 228 rhBMP-2/demineralized bone matrix patients and 28 of the 242 iliac crest bone graft patients required repeated surgery for alveolar cleft repair. Findings for canine tooth eruption into the cleft site through the graft were similar between the groups. Conclusions The rhBMP-2/demineralized bone matrix appears to be an acceptable alternative for alveolar cleft repair. The authors found no increase in serious adverse events with the use of this material. Local complications, such as swelling and minor wound dehiscence, predominantly improved without intervention. Clinical question/level of evidence Therapeutic, III.

Background: The optimal timing for cleft lip repair has yet to be established. Advances in neonatal anesthesia, along with a growing body of literature, suggesting benefits of earlier cleft lip and nasal repair, have set the stage for a reexamination of current practices. Methods: In this prospective study, cleft lip and nasal repair occurred on average at 34.8 days (13–69 days). Nasal correction was achieved primarily through molding the nasal cartilage without the placement of nasal sutures at the time of repair. A standardized anesthetic protocol aimed at limiting neurotoxicity was utilized in all cases. Anesthetic and postoperative complications were assessed. A 3-dimensional nasal analysis compared pre- and postoperative nasal symmetry for unilateral clefts. Surveys assessed familial response to repair. Results: Thirty-two patients were included (27 unilateral and 5 bilateral clefts). In this study, the overall complication rate was 3.1%. Anthropometric measurements taken from 3-dimensional-image models showed statistically significant improvement in ratios of nostril height (preoperative mean, 0.59; postoperative mean, 0.80), nasal base width (preoperative mean, 1.96; postoperative mean, 1.12), columella length (preoperative mean, 0.62; postoperative mean, 0.89; and columella angle (preoperative mean, 30.73; postoperative mean, 9.1). Survey data indicated that families uniformly preferred earlier repair. Conclusions: We present evidence that early cleft lip and nasal repair can be performed safely and is effective at improving nasal symmetry without the placement of any nasal sutures. Utilization of this protocol has the potential to be a paradigm shift in the treatment of cleft lip and nasal deformity.

The wide bandwidth and high amplitude feature of the beating heart motion makes surgeon hard to achieve the coronary artery bypass graph surgery on his or her own. The robot could help to cancel the relative motion between the end effecter of the robotic tool and certain point on the heart surface. Therefore a stationary operation screen could be used for the surgeon. The precise robot modeling is the prerequisite for tracking control algorithm. In the paper, we process the input and output data by using the nonlinear optimization method to obtain the system model. Next, we discuss the system identification related problems and modify the model. Finally, a good system model is achieved.