Publications by authors named "Amir H Dorafshar"

159 Publications

Noninvasive Management of Pediatric Isolated, Condylar Fractures: Less Is More?

Plast Reconstr Surg 2021 Feb;147(2):443-452

From the Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine; the Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale School of Medicine; and Rush Medical College of Rush University.

Background: The purpose of this study was to examine injury patterns in pediatric mandibular condylar fractures and to propose and evaluate the validity of an institutional treatment algorithm for such fractures.

Methods: A retrospective chart review was conducted on pediatric patients who presented to the authors' institution with isolated mandibular condylar fractures between 1990 and 2016. Patients were categorized by dentition, and information regarding demographics, injury characteristics, management, and complications was compiled.

Results: Forty-three patients with 50 mandibular condylar fractures were identified. Twelve patients (27.9 percent) had deciduous dentition, 15 (34.9 percent) had mixed dentition, and 16 (37.2 percent) had permanent dentition. The most common fracture pattern in all groups was diacapitular [n = 30 (60 percent)]; however, older groups showed higher rates of condylar base fractures and bilateral fractures (p = 0.029 and p = 0.011, respectively). Thirty-one patients (72.1 percent) were treated with nonoperative management, 10 (23.2 percent) with closed treatment and mandibulomaxillary fixation, and two (4.7 percent) with open treatment and mandibulomaxillary fixation; nonoperative treatment was more common in younger patients (p = 0.008). Management for 10 patients (23.2 percent) was nonadherent to the treatment algorithm. Eight patients had complications (18.6 percent). Common complications included temporomandibular joint ankylosis (n = 2) and malocclusion (n = 2). Although complications were seen in all groups, adherence to the algorithm was associated with an 81.8 percent reduction in odds of complications (p = 0.032).

Conclusions: Nonoperative management has a low complication rate in deciduous children. Children with permanent/mixed dentition may undergo closed treatment and mandibulomaxillary fixation if they have malocclusion/contralateral open bite, significant condylar dislocation, and ramus height loss greater than 2 mm.

Clinical Question/level Of Evidence: Therapeutic, III.
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http://dx.doi.org/10.1097/PRS.0000000000007527DOI Listing
February 2021

The Affordable Care Act and Its Impact on Plastic and Gender-Affirmation Surgery.

Plast Reconstr Surg 2021 Jan;147(1):135e-153e

From the Department of Surgery, Division of Plastic and Reconstructive Surgery, Rush University Medical Center; Law Office of Ezra Young; the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health; Loyola University Chicago Stritch School of Medicine; the University of Illinois at Chicago; and the Center for Gender Confirmation Surgery, Weiss Memorial Hospital.

Summary: The Affordable Care Act's provisions have affected and will continue to affect plastic surgeons and their patients, and an understanding of its influence on the current American health care system is essential. The law's impact on pediatric plastic surgery, craniofacial surgery, and breast reconstruction is well documented. In addition, gender-affirmation surgery has seen exponential growth, largely because of expanded insurance coverage through the protections afforded to transgender individuals by the Affordable Care Act. As gender-affirming surgery continues to grow, plastic surgeons have the opportunity to adapt and diversify their practices.
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http://dx.doi.org/10.1097/PRS.0000000000007499DOI Listing
January 2021

Medical device related pressure ulcer of the lip in a patient with COVID-19: Case report and review of the literature.

J Stomatol Oral Maxillofac Surg 2020 Oct 8. Epub 2020 Oct 8.

Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL 60607, USA. Electronic address:

Pressure ulcers of the lip constitute a rare entity faced by plastic surgeons and there is a relatively paucity of data regarding optimal management. In this study we present one case of upper lip pressure ulcer related to prone intubation for respiratory distress due to SARS-CoV-2 infection, treated with surgical excision and reconstruction. We also performed a review of the literature to identify other studies on pressure lip ulcers. Six studies were considered relevant. Conservative management constitutes the most common method of treatment; however, little is known about the aesthetic, and functional morbidity related to either surgical or non-surgical treatments.
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http://dx.doi.org/10.1016/j.jormas.2020.09.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7543895PMC
October 2020

Patient Race and Insurance Status Do Not Impact the Treatment of Simple Mandibular Fractures.

Craniomaxillofac Trauma Reconstr 2020 Mar 4;13(1):15-22. Epub 2020 Mar 4.

Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA.

Introduction: Health-care disparities have been reported throughout medical literature for decades. While blatant explicit bias is not prevalent, a substantial body of research has been published suggesting that systemic biases related to sex, race, income, and insurance status likely exist. To our knowledge, no study has assessed the impact of patient race and insurance status on clinical decision-making in facial fracture repair in the United States. Thus, the objective of this project was to assess if race and insurance status impacted whether patients obtained open or closed treatment of simple mandibular fractures.

Methods: Patients who had either open or closed treatment of mandibular fractures were extracted from the 2012 and 2013 National Inpatient Sample and analyzed. Patients who had a length of stay longer than 3 days or died during their inpatient stay were excluded. These exclusion criteria were used to control for patients with polytrauma as well as complicated fractures. Univariate analysis was undertaken to elucidate different variable associations with the type of reduction performed. All covariates were then entered into a multivariable logistic regression model to test the variables simultaneously.

Results: Patients with simple condylar, alveolar border, and closed mandibular fractures were more likely to undergo closed reduction (CR) on univariate analysis, as were patients with female gender and a fall mechanism ( value < .05). African Americans, Hispanics, and patients without insurance were more likely to undergo open reduction on univariate analysis ( value < .05). Multivariate analysis demonstrated that patients with simple condylar, subcondylar, alveolar border, or closed mandibular fractures were more likely to undergo a CR, as were patients with female gender and a firearm or fall mechanism ( < .05). However, neither race nor insurance status demonstrated a statistically significant association with closed or open reduction.

Conclusion: Anatomic location and mechanism of injury were the variables found to be significantly associated with patients undergoing open reduction versus CR of simple mandibular fractures-not race or insurance status.
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http://dx.doi.org/10.1177/1943387520905399DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7311844PMC
March 2020

Global Contributions and Trends in Research within the Top-ranked Plastic Surgery Journal.

Plast Reconstr Surg Glob Open 2020 Apr 30;8(4):e2712. Epub 2020 Apr 30.

Department of Surgery, Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, Ill.

Background: We aimed to longitudinally study the relative research contributions of US and international plastic surgeons by evaluating publications within the premier plastic surgery journal over the last 2 decades. We hypothesized that even with an increased pressure to publish in this journal, the relative research contributions from American plastic surgeons will continue to be the largest overall and in all subspecialties.

Methods: Data for the surgical subspecialty, corresponding author's country of origin, and region were extracted from all original articles in 2 randomly selected monthly issues of () from the last 2 decades to evaluate longitudinal trends. Data were also extracted from all of the original articles published in for the last 3 years to analyze the recent distribution of research output.

Results: During the last 2 decades, the relative proportion of total original articles written by US authors has increased. They have published proportionally more articles in the Reconstructive and Breast field while publishing relatively less in the hand/peripheral nerve field. From the first decade of analysis, US authors wrote relatively fewer articles in the hand/peripheral nerve field, whereas in the second decade, the US authors wrote relatively fewer articles in the Experimental field. In the last 3 years, US authors published relatively fewer articles in the Experimental and Cosmetic fields.

Conclusions: Each country's scientific productivity in is related to funding, interest, patients' demand, and healthcare market pressure. In this study, we see that these factors influence trends within research publications over the last 2 decades.
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http://dx.doi.org/10.1097/GOX.0000000000002712DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7209831PMC
April 2020

Pediatric Skull Fracture Characteristics Associated with the Development of Leptomeningeal Cysts in Young Children after Trauma: A Single Institution's Experience.

Plast Reconstr Surg 2020 05;145(5):953e-962e

From the Department of Plastic and Reconstructive Surgery and the Department of Neurological Surgery, Division of Pediatric Neurosurgery, The Johns Hopkins Hospital; and the Division of Plastic and Reconstructive Surgery, Rush University Medical Center.

Background: Currently, the pathogenesis of leptomeningeal cysts, also known as growing skull fractures, is still debated. The purpose of this study was to examine the specific skull fracture characteristics that are associated with the development of growing skull fractures and describe the authors' institutional experience managing this rare entity.

Methods: A retrospective cohort study was performed that included all patients younger than 5 years presenting to a single institution with skull fractures from 2003 to 2017. Patient demographics, cause of injury, skull fracture characteristics (e.g., amount of diastasis, linear versus comminuted fracture), concomitant neurologic injuries, and management outcomes were recorded. Potential factors contributing to the development of a growing skull fracture and neurologic injuries associated with growing skull fractures were evaluated using univariate logistic regression.

Results: A total of 905 patients met the authors' inclusion criteria. Of these, six (0.66 percent) were diagnosed with a growing skull fracture. Growing skull fractures were more likely to be comminuted (83.3 percent versus 40.7 percent; p = 0.082) and to present with diastasis on imaging (100 percent versus 26.1 percent; p < 0.001; mean amount of diastasis, 7.1 mm versus 3.1 mm; p < 0.001). Univariate logistic regression analysis confirmed the role of a comminuted fracture pattern (OR, 7.572) and the degree of diastasis (OR, 2.081 per mm diastasis) as significant risk factors for the development of growing skull fractures.

Conclusions: The authors' analysis revealed that fracture comminution and diastasis width are associated with the development of growing skull fractures. The authors recommend dural integrity assessment, close follow-up, and early management in young children who present with these skull fracture characteristics.

Clinical Question/level Of Evidence: Risk, III.
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http://dx.doi.org/10.1097/PRS.0000000000006745DOI Listing
May 2020

Does Early Repair of Orbital Fractures Result in Superior Patient Outcomes? A Systematic Review and Meta-Analysis.

J Oral Maxillofac Surg 2020 04;78(4):e15-e16

Professor and Chief, Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL. Electronic address:

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http://dx.doi.org/10.1016/j.joms.2019.12.016DOI Listing
April 2020

Pediatric Frontal Bone and Sinus Fractures: Cause, Characteristics, and a Treatment Algorithm.

Plast Reconstr Surg 2020 04;145(4):1012-1023

From the Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital; the Rush Medical College of Rush University; and the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center.

Background: The purpose of this study was to assess the incidence, cause, characteristics, presentation, and management of pediatric frontal bone fractures.

Methods: A retrospective cohort review was performed on all patients younger than 15 years with frontal fractures that presented to a single institution from 1998 to 2010. Charts and computed tomographic images were reviewed, and frontal bone fractures were classified into three types based on anatomical fracture characteristics. Fracture cause, patient demographics, management, concomitant injuries, and complications were recorded. Primary outcomes were defined by fracture type and predictors of operative management and length of stay.

Results: A total of 174 patients with frontal bone fractures met the authors' inclusion criteria. The mean age of the patient sample was 7.19 ± 4.27 years. Among these patients, 52, 47, and 75 patients were classified as having type I, II, and III fractures, respectively. A total of 14, 9, and 24 patients with type I, II, and III fractures underwent operative management, respectively. All children with evidence of nasofrontal outflow tract involvement and obstruction underwent cranialization (n = 11).

Conclusions: The authors recommend that type I fractures be managed according to the usual neurosurgical guidelines. Type II fractures can be managed operatively according to the usual pediatric orbital roof and frontal sinus fracture indications (e.g., significantly displaced posterior table fractures with associated neurologic indications). Lastly, type III fractures can be managed operatively as for type I and II indications and for evidence of nasofrontal outflow tract involvement. The authors recommend cranialization in children with nasofrontal outflow tract involvement.

Clinical Question/level Of Evidence: Risk, II.
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http://dx.doi.org/10.1097/PRS.0000000000006645DOI Listing
April 2020

Variability in Current Procedural Terminology Codes for Craniomaxillofacial Trauma Reconstruction: A National Survey.

J Craniofac Surg 2020 Jun;31(4):996-999

Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL.

Background: Current Procedural Terminology (CPT) codes are an important part of surgical documentation and billing for services provided within the United States. This limited coding language presents a challenge in the heterogenous and rapidly evolving field of craniofacial surgery. The authors aimed to survey members of the American Society of Maxillofacial Surgery (ASMS) to characterize the variability in coding practices in the surgical management of craniofacial trauma.

Methods: A cross-sectional of 500 members of the ASMS survey was carried out. Descriptive statistics were calculated. The effect of various practice characteristics on coding practices was evaluated using Chi-squared tests and Fisher's exact tests.

Results: In total, 79 participants responded including 77 plastic surgeons. About 75% worked in academic centers and 38% reported being in practice over 20 years. Coding practices were not significantly associated with training background or years in practice. Unilateral mandibular and unilateral nasoorbitoethmoid fractures demonstrated the greatest agreement with 99% and 88% of respondents agree upon a single coding strategy, respectively. Midface fractures, bilateral nasoorbitoethmoid fractures, and more complex mandibular demonstrated considerable variability in coding.

Conclusion: There is a wide variability among members of the ASMS in CPT coding practices for the operative management of craniofacial trauma. To more accurately convey the complexity of craniofacial trauma reconstruction to billers and insurance companies, the authors must develop a more descriptive coding language that captures the heterogeneity of patient presentation and surgical procedures.
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http://dx.doi.org/10.1097/SCS.0000000000006362DOI Listing
June 2020

Characterizing Craniomaxillofacial Injuries in American Professional Sports Leagues.

J Oral Maxillofac Surg 2020 Apr 3;78(4):588-593. Epub 2019 Dec 3.

Assistant Professor, Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital and Harvard School of Dental Medicine, Boston, MA. Electronic address:

Purpose: The purpose of this study was to characterize the types of craniomaxillofacial (CMF) injuries that occur in professional sports leagues and the associated recovery times.

Materials And Methods: A retrospective cohort study was designed and implemented using the Pro Sports Transaction Archive. The database was queried for all registered CMF injuries in the 4 main men's major professional sports leagues in the United States from 2013 to 2018. The sport, injury location, and season were the predictor variables, and the frequency and length of time on the injured list were the outcome variables. Descriptive statistics were computed, and Fisher's exact tests were used to determine the association between the predictor and outcome variables. Analysis of variance was used to compare the injury frequency and duration.

Results: Of the 198 injuries that met the inclusion criteria, 60 were from Major League Baseball (MLB) (30%), 49 from the National Basketball Association (25%), 8 from the National Football League (4%), and 81 from the National Hockey League (NHL) (41%). Injuries to the midface were most common (mean, 25.2 ± 3.6 injuries per season; P < .001) compared with the upper face (mean, 6.0 ± 2.0 injuries per season) and lower face (mean, 8.4 ± 2.3 injuries per season). The mean time on the injured list after CMF trauma was 8.4 ± 10.4 days, with MLB injuries requiring the shortest duration (mean, 3.9 ± 6.6 days; P = .001). A significant association was found between the injury location and sport (P < .001). However, no statistically significant difference was found in the number of injuries per season from 2013 to 2018 for each league (P = .818).

Conclusions: Midface trauma was significantly more common than upper or lower face trauma in professional sports leagues during the past 5 seasons. The NHL had the greatest injury rate, even after adjustment for games played.
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http://dx.doi.org/10.1016/j.joms.2019.11.031DOI Listing
April 2020

Management of Teeth in the Line of Mandibular Angle Fractures Treated with Open Reduction and Internal Fixation: A Systematic Review and Meta-Analysis.

Plast Reconstr Surg 2019 12;144(6):1393-1402

From the Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital; the Department of Oral and Maxillofacial Surgery, University of Pennsylvania Health System; the Division of Plastic Surgery, Rush University Medical Center; Quality Assurance, Evidence-Based Medicine Center, Elsevier; and the Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital and Harvard School of Dental Medicine.

Background: Mandibular angle fractures are common and frequently involve a tooth in the fracture line. Despite trends toward more conservative indications for tooth extraction during open repair, the literature remains heterogeneous. This review aims to ascertain the effect of tooth extraction/retention on patient outcomes following mandible open reduction and internal fixation and to evaluate the evidence surrounding indications for extraction.

Methods: PubMed, EMBASE, the Cochrane Library, Elsevier text mining tool database, and clinicaltrials.gov were queried through March of 2018 for English language publication on adults with traumatic mandibular fractures. The review protocol was not registered online. Quality of evidence was assigned using the Grading of Recommendations Assessment, Development and Evaluation methodology. Meta-analyses were performed when definitions of outcomes were deemed similar.

Results: Overall, 26 of 1212 identified studies met inclusion criteria. Indications for tooth extraction and rates of extraction varied considerably across studies. The quality of evidence was low or very low for all outcomes. Tooth retention was associated with lower overall complications (OR, 0.54; 95 percent CI, 0.37 to 0.79), major complications requiring readmission or reoperation (OR, 0.47; 95 percent CI, 0.24 to 0.92), and malocclusion (OR, 0.56; 95 percent CI, 0.32 to 0.97); there was no difference in wound issues or nonunion. Removal of asymptomatic teeth was associated with inferior alveolar nerve injury (39.4 percent versus 16.1 percent).

Conclusions: The literature is limited by retrospective study deign and poor follow-up; however, when indicated, tooth extraction is not associated with an increased risk of infection or nonunion. Removal of asymptomatic teeth was associated with a risk of inferior alveolar nerve injury. Additional high-quality studies are needed to evaluate potentially expanded indications for tooth extraction.
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http://dx.doi.org/10.1097/PRS.0000000000006255DOI Listing
December 2019

Does Early Repair of Orbital Fractures Result in Superior Patient Outcomes? A Systematic Review and Meta-Analysis.

J Oral Maxillofac Surg 2020 Apr 10;78(4):568-577. Epub 2019 Oct 10.

Professor and Chief, Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL. Electronic address:

Purpose: To date, no clear evidence-based guidelines exist pertaining to the ideal timing to perform surgical treatment of orbital fractures. The purpose of this study was to determine if early treatment of orbital fractures resulted in better patient outcomes.

Materials And Methods: We designed and implemented a systematic review and meta-analysis to test the null hypothesis of no difference in outcomes between different time intervals between orbital injury and surgical intervention. PubMed, Embase, the Cochrane Library, the Elsevier text mining tool database, and clinicaltrials.gov trial registry were queried. The quality of evidence was based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The predictor variable was the timing of operative repair (early vs late). The outcome variable was complete recovery. Other variables of interest were diplopia, enophthalmos, and preoperative motility restriction. Meta-analyses were performed when definitions of active and control interventions and patient outcomes were deemed similar. In addition, χ tests were performed to determine differences in clinical outcomes between early and late operative repair.

Results: Of the 1,160 articles reviewed, 20 met the inclusion criteria. Surgery performed less than 2 weeks after injury was significantly associated with greater odds of complete recovery of symptoms (odds ratio [OR], 6.9 [95% confidence interval (CI), 1.35-35.06]), as well as a lower incidence of postoperative diplopia (OR, 0.3 [95% CI, 0.1-0.9]) and enophthalmos (OR, 0.2 [95% CI, 0.1-0.9]). Repair performed less than 30 days after injury was associated complete resolution of preoperative motility restriction (OR, 24.6 [95% CI, 1.30-462.34]) as well as diplopia.

Conclusions: Differences in the timing of surgery and definition of patient outcomes, as well as variations in methods of evaluating postoperative outcomes, potentiate the risk of bias and warrant downgrading of the quality of evidence in a study. The timing of repair varied among 2, 4, and 8 weeks after injury. However, a short time to surgical intervention was significantly associated with resolution of vertical dystopia, postoperative enophthalmos, and motility restriction.
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http://dx.doi.org/10.1016/j.joms.2019.09.025DOI Listing
April 2020

Evaluating the July Effect in Oral and Maxillofacial Surgery: Part II-Orthognathic Surgery.

J Oral Maxillofac Surg 2020 Feb 4;78(2):261-266. Epub 2019 Sep 4.

Assistant Professor, Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital and Harvard School of Dental Medicine, Boston, MA. Electronic address:

Purpose: The purpose of this study was to determine if there is an increased postoperative complication rate in orthognathic surgery during the first academic quarter (Q1) (July to September).

Materials And Methods: The American College of Surgeons National Surgical Quality Improvement Program database was accessed to identify cases with Current Procedural Terminology codes pertaining to orthognathic procedures from 2008 to 2017. Procedures were separated into 2 groups based on time in the academic year: Q1 (July to September) versus remaining quarters (RQ). The inclusion criteria were Current Procedural Terminology codes representing operations resulting in movement of the dentate portion of the jaws and age of 18 years or older. Patient demographic characteristics and perioperative complications were compared between the groups. Descriptive statistics, Fisher exact tests, and χ tests were executed.

Results: The Q1 cohort included 877 cases, and the RQ cohort included 2,062 cases. The average age of patients was 47.0 ± 19.5 years in Q1 versus 47.2 ± 19.4 years in RQ. The most frequent complications were blood transfusion (11.97% in Q1 vs 12.57% in RQ, P = .64), reoperation (8.67% in Q1 vs 8.84% in RQ, P = .87), and combined superficial and deep-space infection (5.02% in Q1 vs 5.76% in RQ, P = .51). Medical complications involving other organ systems were rare (<1%). Analyses showed no significance between complication rate and time of year.

Conclusions: The results of this study indicate that there is no association between time of year and complication rates after orthognathic surgery. Additional investigations could be useful in shining light on this topic as it pertains to the training of future surgeons.
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http://dx.doi.org/10.1016/j.joms.2019.08.020DOI Listing
February 2020

Evaluating the July Effect in Oral and Maxillofacial Surgery: Part I-Mandibular Fractures.

J Oral Maxillofac Surg 2020 Feb 9;78(2):248-253. Epub 2019 Aug 9.

Assistant Professor, Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital and Harvard School of Dental Medicine, Boston, MA. Electronic address:

Purpose: The purpose of this study was to determine whether the timing of mandibular fracture repair within the academic year affects the complication rate using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

Materials And Methods: The ACS-NSQIP database was accessed and queried from 2008 to 2017 for all Current Procedural Terminology codes pertaining to open treatment of mandibular fractures. The cases were stratified into 2 groups based on academic quarter: the quarter 1 (Q1) group (July-September) and the remaining-quarters group. The inclusion criteria encompassed all Current Procedural Terminology codes in the ACS-NSQIP registry that defined mandibular fractures and age greater than 18 years. Demographic characteristics, as well as medical and surgical complications, were compared between the 2 cohorts. Descriptive statistics were calculated to characterize and compare patient cohorts, and Fisher exact test and χ analyses were performed to compare complication rates between groups.

Results: The Q1 group included 614 cases, and the remaining-quarters group included 1,454. The most common individual complications included wound dehiscence (1.6% overall; 2.1% in Q1 group vs 1.4% in remaining-quarters group, P = .22), combined superficial and deep-space infection (4.9% overall; 4.4% in Q1 group vs 3.3% in remaining-quarters group; P = .91 and P = .21, respectively), and reoperation (3.9% overall; 4.6% in Q1 group vs 3.6% in remaining-quarters group, P = .29). Medical complications including acute kidney injury, venous thromboembolism, urinary tract infection, and sepsis or septic shock were rare (<1%). Complication rates did not significantly differ between the third quarter and the remainder of the year on bivariate analysis.

Conclusions: Our results do not support the idea of a "July effect" regarding postoperative outcomes after mandibular fracture repair. Further studies are needed to elucidate this phenomenon within all procedures under the wide umbrella of the specialty.
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http://dx.doi.org/10.1016/j.joms.2019.07.019DOI Listing
February 2020

Does Fracture Pattern Influence Functional Outcomes in the Management of Bilateral Mandibular Condylar Injuries?

Craniomaxillofac Trauma Reconstr 2019 Sep 21;12(3):211-220. Epub 2018 Sep 21.

Division of Plastic and Reconstructive Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland.

The purpose of this study was to compare the functional outcomes of different types of bilateral mandibular condylar fractures. This was a retrospective study of patients with bilateral mandibular condylar fractures at a level-1 trauma center over a 15-year period. The primary predictor variable was fracture pattern, classified as type I (bilateral condylar), type II (condylar-subcondylar), or type III (bilateral subcondylar). Secondary predictor variables were demographic, injury-related, and treatment factors. Bivariate associations between the predictors and complication rates were computed; a multiple logistic regression model was utilized to adjust for confounders and effect modifiers. Thirty-eight subjects with bilateral condylar injuries met the inclusion criteria. The sample's mean age was 37.6 + 18.2 years, and 16% were female. The most common mechanisms of injury were motor vehicle collisions (53%) and falls (29%). Seventy-four percent had associated noncondylar mandibular fractures, and 32% of cases had concomitant midface fractures. Fifty-three percent of cases were classified as type I, 21% as type II, and 26% as type III. Ten subjects (26%) were managed with open reduction and internal fixation. The average length of follow-up was 4.5 + 6.3 months. After adjusting for confounders and effect modifiers, the type of fracture was a significant predictor of functional complications with type II injuries having the highest likelihood of a poor functional outcome (odds ratio: 7.77, 95% confidence interval: 1.45-41.53,  = 0.02). Asymmetric bilateral mandibular condylar fractures may be associated with an increased risk of poor functional outcomes.
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http://dx.doi.org/10.1055/s-0038-1668500DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6697470PMC
September 2019

Computer-Assisted Design and Manufacturing Assists Less Experienced Surgeons in Achieving Equivalent Outcomes in Cranial Vault Reconstruction.

J Craniofac Surg 2019 Oct;30(7):2034-2038

Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD.

Purpose: The purpose of this study was to assess whether long-term outcomes were equivalent between computer-assisted design and manufacturing (CAD/CAM) -assisted cranial vault reconstruction performed by an inexperienced surgeon, with fewer years of surgical experience, and traditional reconstruction performed by senior surgeons with many decades of experience.

Methods: An Institutional Review Board-approved retrospective cohort study was performed for all patients with nonsyndromic craniosynostosis between the ages of 1 month to 18 years who received primary, open calvarial vault reconstruction at the Johns Hopkins Hospital between 1990 and 2017. The primary outcome variable was the Whitaker category (I-IV) for level of required revision at the 2-year follow-up visit. Secondary outcomes included estimated blood loss, length of stay, operative time, and postoperative complications. CAD/CAM-assisted surgery was considered noninferior if the proportion of cases requiring any revision (Whitaker II, III, or IV) was no more than 10% greater than the proportion in the traditional surgery group with multivariate logistic regression analysis. t tests and fisher exact tests were used for secondary outcomes.

Results: A total of 335 patients were included, with 35 CAD/CAM-assisted reconstructions. CAD/CAM-assisted reconstruction was noninferior to traditional after accounting for patient demographics, type of surgery, and experience level of the plastic surgeon. The traditional group required revision more frequently at 29.0% compared to CAD/CAM at 14.3%. Secondary outcomes were not significantly different between groups, but CAD/CAM had significantly longer average operative times (5.7 hours for CAD/CAM, 4.3 hours for traditional, P < 0.01).

Conclusion: CAD/CAM technology may lower the learning curve and assist less experienced plastic surgeons in achieving equivalent long-term outcomes in craniofacial reconstruction.
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http://dx.doi.org/10.1097/SCS.0000000000005748DOI Listing
October 2019

Infectious Complications After Open Cranial Vault Remodeling for Craniosynostosis.

J Craniofac Surg 2020 Jan/Feb;31(1):32-36

Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD.

Background: Surgical site infection (SSI) after open cranial vault reconstruction (CVR), while relatively uncommon, has received little attention in the literature to date. Here, the authors report our institution's experience with the perioperative management of infectious complications following CVR for craniosynostosis and present the first systematic review of the literature on this topic.

Methods: The authors performed a retrospective chart review for patients with syndromic and nonsyndromic craniosynostosis who underwent open CVR between 1990 and 2015 at a single institution to determine predictors of SSIs and a systematic review of studies that evaluated for SSI after CVR to ascertain the pooled incidence of SSI, common infectious organisms, and prophylactic antibiotic protocols.

Results: Out of 548 primary and 163 secondary CVR cases at our institution, 6 primary reconstruction patients (1.09%) and 9 secondary reconstruction patients (5.52%) developed an SSI requiring extended hospital stay or readmission (P <0.001); overall infection rate was 2.11%. Streptococcus and Staphylococcus species were the most common organisms isolated. On multivariate analysis, syndromic status conferred more than 7 times greater odds of SSI (OR 7.7, P = 0.023). Pooled analysis of the literature yielded an overall SSI rate of 1.05% to 2.01%. In contrast to our institutional findings, the most common organisms reported were Candida species and Pseudomonas aeruginosa. The most common prophylactic antibiotic protocol was a first-generation cephalosporin for 24 to 72 hours post-operatively.

Conclusions: Patients undergoing secondary reconstruction have higher infection rates after CVR, and syndromic status is an important predictor of infection when controlling for other patient factors. Our literature review reveals nosocomial organisms to be the most commonly reported source of infection, though this is contrary to our institutional findings of skin flora being most common. Antibiotic prophylaxis varies institutionally.
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http://dx.doi.org/10.1097/SCS.0000000000005695DOI Listing
April 2020

Fixation Points in the Treatment of Traumatic Zygomaticomaxillary Complex Fractures: A Systematic Review and Meta-Analysis.

J Oral Maxillofac Surg 2019 Oct 30;77(10):2064-2073. Epub 2019 Apr 30.

Professor and Chief, Division of Plastic Surgery, Rush University Medical Center, Chicago, IL. Electronic address:

Purpose: Controversy remains regarding the optimal degree of anatomic exposure, reduction, and fixation required during open reduction and internal fixation of zygomaticomaxillary complex (ZMC) fractures. We critically examined the reported data to compare the patient outcomes after various degrees of ZMC reduction and internal fixation.

Materials And Methods: A systematic review and meta-analysis were designed to test the null hypothesis of no difference in outcomes between different degrees of fixation of ZMC fractures. The PubMed, EMBASE, Cochrane Library, Elsevier text mining tool database, and clinicaltrials.gov trial registries were queried. The quality of evidence was determined using the Grading of Recommendations Assessment, Development, and Evaluation method.

Results: Of 1213 screened studies, 13 met the inclusion criteria. Fracture instability at 3 months was greater with 2-point fixation (61.1%) than with 3-point fixation (10.6%; relative risk, 2.5, 95% confidence interval [CI], 1.4 to 3.3). Less vertical orbital dystopia was seen with 3-point fixation than with 2-point fixation (mean difference, 0.9 mm; 95% CI, 0.6 to 1.3 mm). The incidence of infection and malar asymmetry did not differ between the groups. The quality of evidence was very low to low.

Conclusions: The reported data were limited by low quality, retrospective studies. However, the meta-analysis of randomized control trial data suggested a superiority of 3 points of exposure and fixation regarding fracture stability. When 2 points appear to provide stable fixation, the potential benefits of a third point should be weighed against the cost, operative time, and exposure/periosteal stripping on a case-by-case basis.
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http://dx.doi.org/10.1016/j.joms.2019.04.025DOI Listing
October 2019

Heparin-Conjugated Decellularized Bone Particles Promote Enhanced Osteogenic Signaling of PDGF-BB to Adipose-Derived Stem Cells in Tissue Engineered Bone Grafts.

Adv Healthc Mater 2019 05 3;8(10):e1801565. Epub 2019 Apr 3.

Translational Tissue Engineering Center, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA.

Adipose-derived stem cells (ASCs) are a promising cell source for regenerating critical-sized craniofacial bone defects, but their clinical use is limited due to the supraphysiological levels of bone morphogenetic protein-2 required to induce bone formation in large grafts. It has been recently reported that platelet-derived growth factor-BB (PDGF) directly enhances the osteogenesis of ASCs when applied at physiological concentrations. In this study, a biomimetic delivery system that tethers PDGF to decellularized bone matrix (DCB) is developed to enhance osteogenic signaling in bone grafts by colocalizing PDGF-extracellular matrix cues. Heparin is conjugated to DCB particles (HC-DCB) to promote sustained binding of PDGF via electrostatic interactions. HC-DCB particles bind to PDGF with >99% efficiency and release significantly less PDGF over 21 days compared to nonconjugated DCB particles (1.1% vs 22.8%). HC-DCB-PDGF signaling in polycaprolactone (PCL)-fibrin grafts promotes >40 µg Ca µg DNA deposition by ASCs during in vitro osteogenic culture compared to grafts without HC-DCB or PDGF. Furthermore, more bone formation is observed in grafts with HC-DCB-PDGF at 12 weeks following implantation of grafts into murine critical-sized calvarial defects. Collectively, these results demonstrate that HC-DCB enhances the osteogenic signaling of PDGF to ASCs and may be applied to promote ASC-mediated bone regeneration in critical-sized defects.
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http://dx.doi.org/10.1002/adhm.201801565DOI Listing
May 2019

Frequency of Cervical Spine Injuries in Pediatric Craniomaxillofacial Trauma.

J Oral Maxillofac Surg 2019 Jul 27;77(7):1423-1432. Epub 2019 Feb 27.

Adjunct Professor, Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD; Professor, Department of General Surgery, Division of Plastic Surgery, Rush Medical Center, Chicago, IL. Electronic address:

Purpose: In pediatric patients with craniomaxillofacial (CMF) trauma, evaluation for cervical spine injury (CSI) is critical, but there are no studies investigating CSI in this unique population. The aim of this study was to measure the frequency of CSI in the pediatric CMF fracture population.

Materials And Methods: A retrospective cohort study of all pediatric patients who presented to the Johns Hopkins Hospital Emergency Department (Baltimore, MD) with CMF fractures were examined for concurrent CSIs. Patient charts were reviewed for mechanism of injury, type and level of CSI, type and location of CMF fracture patterns, and overall outcome. Data were analyzed for correlation and statistical relevance.

Results: A total of 2,966 pediatric patients (1,897 boys [64.0%]; age range, 0 to 15 yr; average age, 7 ± 4.73 yr) were identified from 1990 to 2010 to have CMF fractures. Of these patients, only 5 children were found to have concomitant CSIs (frequency, 0.169%). The frequency of CSI in patients with CMF fracture and deciduous, mixed, and permanent dentition was 0, 0.307, and 0.441%, respectively. Of the 5 identified cases, 4 had concomitant middle-third facial skeletal fracture, 4 had concomitant upper-third cranial skeletal fracture, and 2 had concomitant lower-third cranial skeletal fracture.

Conclusion: CSIs in pediatric patients with CMF fracture are rare (frequency, 0.169%); this is considerably lower than the reported ranges in adults (3.69 to 24%). No child with deciduous dentition was found to have a CSI. The lack of CSI in deciduous patients with CMF fracture could be explained by the anatomic differences between pediatric and adult cervical spines and supports conservative imaging for children in this age group (level of evidence, III).
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http://dx.doi.org/10.1016/j.joms.2019.02.034DOI Listing
July 2019

An Interdisciplinary Approach to Treatment of Adult Facial Arteriovenous Malformations: A Review of the Literature and A Single Institution's Experience With "Late" Surgical Resection and Aesthetic Reconstruction.

J Craniofac Surg 2019 Sep;30(6):1635-1639

Department of Plastic and Reconstructive Surgery.

Background: Arteriovenous malformations (AVMs) are high flow vascular anomalies that are difficult to manage given their high recurrence rate. At this time, the optimal treatment of AVMs involves embolization and surgical resection. However, few studies have examined patient outcomes after a delayed surgical resection approach.

Methods: A retrospective chart review of all patients presenting to a single institution with vascular malformations from 2000 to 2016 was performed. Patients with facial AVMs that underwent operative management were included. Records were reviewed for patient characteristics, lesion natural history, operative timing after embolization (<72 vs >72 hours), and outcomes.

Results: 11 patients fulfilled the inclusion/exclusion criteria. Nine patients were female, with an average age at resection of 29.1 years. Three patients had hemi/mid-facial AVMs, 1 patient had a nasal AVM, 3 patients had labial AVMs, 1 patient had an AVM on the chin, and 1 had a periorbital AVM. Average time between embolization and primary resection was 8.6 days (range 1-24). No complications requiring reoperation occurred in any patient. Average follow-up was 32.6 months, with 2 recurrences at a mean of 47.6 months. Timing of resection, Schobinger stage, and resection completeness did not significantly affect recurrence (P >0.05). Lesion size >6 cm in any dimension was significantly associated with recurrence (P = 0.018).

Conclusion: Compared to early resection, delayed (>72 h) surgical resection after embolization of facial AVMs is a viable treatment option and results in non-inferior recurrence rates (25 vs 14% respectively over a 40-month period).
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http://dx.doi.org/10.1097/SCS.0000000000005423DOI Listing
September 2019

What Do Plastic Surgery Patients Think of Financial Conflicts of Interest and the Sunshine Act?

Ann Plast Surg 2019 06;82(6):597-603

Division of Plastic & Reconstructive Surgery, Massachusetts General Hospital, Boston, MA.

Background: The purpose of this study was to evaluate patients' views of conflicts of interest (COI) and their comprehension of recent legislation known as the Physician Payments Sunshine Act. This report constitutes the first evaluation of plastic surgery patients' views on COI and the government-mandated Sunshine Act.

Methods: This cross-sectional study invited patients at an academic, general plastic surgery outpatient clinic to complete an anonymous survey. The survey contained 25 questions that assessed respondents' perceptions of physician COI and awareness of the Sunshine Act. Analyses were performed to examine whether perspectives on COI and the Sunshine Act varied by level of education or age.

Results: A total of 361 individuals completed the survey (90% response rate). More than half of respondents with an opinion believed that COI would affect their physician's clinical decision-making (n = 152, 52.9%). Although almost three fourths (n = 196, 71.2%) believed that COI should be regulated and COI information reported to a government agency, the majority were not aware of the Sunshine Act before this survey (n = 277, 81.2%) and had never accessed the database (n = 327, 95.9%). More than half of patients (n = 161, 59.2%) stated that they would access a publicly available database with physicians' COI information. A larger proportion of older and educated patients believed that regulation of physicians' COI was important (P < 0.001).

Conclusions: Awareness of and access to plastic surgeon COI information is low among plastic surgery patients. Older and more educated patients believed that transparency regarding COI is important with regard to their clinical care.
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http://dx.doi.org/10.1097/SAP.0000000000001756DOI Listing
June 2019

Incorporating Oral and Maxillofacial Surgeons on Facial Allotransplantation Teams.

J Oral Maxillofac Surg 2019 Jun 11;77(6):1103-1104. Epub 2018 Dec 11.

Assistant Professor, Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Boston, MA.

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http://dx.doi.org/10.1016/j.joms.2018.11.031DOI Listing
June 2019

Pediatric Nasoorbitoethmoid Fractures: Cause, Classification, and Management.

Plast Reconstr Surg 2019 01;143(1):211-222

From the Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital; Rush Medical College of Rush University; the Division of Plastic Surgery, University of Washington Medical Center; the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center; the Department of Biostatistics, Boston University School of Public Health; and the Division of Pediatric Plastic Surgery, University Hospital Rainbow Babies and Children's Hospital.

Background: Currently, there is a paucity of information on the presentation and proper management of pediatric nasoorbitoethmoid fractures. The purpose of this study was to examine the incidence, cause, associated injuries, and management of these fractures. Furthermore, the authors sought to assess outcomes after transnasal wiring or suture canthopexy for type III nasoorbitoethmoid fractures.

Methods: A retrospective cohort review was performed of all patients with nasoorbitoethmoid fractures who presented to a Level I trauma center from 1990 to 2010. Charts and computed tomographic imaging were reviewed, and nasoorbitoethmoid fractures were labeled based on the Markowitz-Manson classification system. Patient fracture patterns, demographics, characteristics, and outcomes were recorded. Univariate and multivariate methods were used to compare groups.

Results: A total of 63 pediatric patients were identified in the study period. The sample's mean age was 8.78 ± 4.08 years, and 28.6 percent were girls. The sample included 18 type I injuries, 28 type II injuries, and 17 type III injuries. No significant demographic differences were found between patients with type I, II, and III fractures (p > 0.05). Operative intervention was pursued in 16.7, 46.4, and 82.4 percent of type I, II, and III nasoorbitoethmoid fractures, respectively. In patients with type III nasoorbitoethmoid fractures, no patients with transnasal wiring developed telecanthus.

Conclusions: Pediatric nasoorbitoethmoid fractures are uncommon injuries. Type I fracture can often be treated with close observation. However, type II and III injury patterns should be evaluated for operative intervention. Transnasal wiring is an effective method to prevent traumatic telecanthus deformity in type III fracture patterns.
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http://dx.doi.org/10.1097/PRS.0000000000005106DOI Listing
January 2019

Surgical "Safe Zone": Rapid Anatomical Identification of the Lesser Occipital Nerve.

J Reconstr Microsurg 2019 Jun 18;35(5):341-345. Epub 2018 Dec 18.

Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, Illinois.

Background:  Surgical intervention has established a vital role in the management of chronic headaches. The lesser occipital nerve (LON) is a common target in patients suffering from occipital neuralgia and is often resected as a first-line option. We endeavored to define the relationships of the LON in the posterolateral neck to facilitate its safe and rapid intraoperative identification.

Methods:  Seven fresh cadavers (14 nerves) were dissected, and their relationships to the mastoid prominence and nearby spinal accessory nerve (SAN) and greater auricular nerve were noted.

Results:  The distance from the mastoid to the emergence of the LON along the posterior sternocleidomastoid ranged from 36 to 51 mm (mean: 45.2 mm), with relative symmetry between the two nerves in the same cadaver. The SAN emerged an average of 54 mm from the mastoid prominence.

Conclusion:  Exploration for the LON should begin at a point 40 mm from the mastoid prominence along the posterior border of the sternocleidomastoid muscle. If the point of exit of the LON is not identified within 10 mm of this exposure, our dissection continues cranially along the posterior border of the sternocleidomastoid, anterior to the trapezius. In rare cases the nerve may pierce the fibers of the muscle and ascend directly on top of the muscle belly. By limiting the caudal extend of the dissection, we can avoid exposure of the SAN and minimize the risk of iatrogenic nerve injury.
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http://dx.doi.org/10.1055/s-0038-1676601DOI Listing
June 2019

International Medical Graduates in the US Plastic Surgery Residency: Characteristics of Successful Applicants.

Eplasty 2018 27;18:e33. Epub 2018 Nov 27.

Department of Plastic and Reconstructive Surgery, The Johns Hopkins Hospital, Johns Hopkins School of Medicine, Baltimore, Md.

Within the United States, plastic surgery is a difficult field to match into for both US and international medical graduates. While the number of available residency positions has grown in recent years, this has not been mirrored by an equal increase in the number of international medical graduates who match. Furthermore, there are few reliable resources to guide international medical graduates who are interested in matching into US-based programs, so the process is often even more difficult and unpredictable than for US applicants. An anonymous survey was distributed electronically to international medical graduates who successfully matched into independent and integrated US plastic surgery residency programs. The survey assessed qualities such as medical school performance, test scores, research experience, and other relevant applicant information, and χ analysis was done to compare the survey results for integrated and independent track international medical graduates. International medical graduates who successfully match tend to rank high and score well in their medical school classes, score between 230 and 250 on USMLE step 1 and 2CK tests, and have a mean of 2 years of research experience before applying to the match. International medical graduates in the independent track tend to have higher step 1 scores, whereas international medical graduates in the integrated track tend to have more research experience and additional nonmedical degrees. This is a survey-based overview that describes the characteristics of successfully matched international medical graduates. Limitations of this study include the inability to identify and survey the unsuccessful applicants as well as poor response rate of the successful candidates in the independent pathway who successfully matched.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6263251PMC
November 2018

Using Computer-Aided Design/Computer-Aided Manufacturing for Autogenous, Split Calvarial Bone Graft-based Cranioplasty: Optimizing Reconstruction of Large, Complex Skull Defects.

J Craniofac Surg 2019 Mar/Apr;30(2):347-351

Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD.

Background: While autologous split calvarial bone is an ideal graft material in cranioplasty, selection of a donor site can be challenging and limited in the reconstruction of complicated cranial defects. Computer-aided design and manufacturing (CAD/CAM) may improve donor-site harvest and contouring and mitigate operative complications in split calvarial bone graft-based cranioplasty for complex patients, but has not previously been studied in this unique setting.

Methods: In this study, a retrospective review of patients who presented to the institution and underwent split-calvarial bone graft-based cranioplasty using CAD/CAM to optimize reconstruction of full-thickness cranial defects ≥30 cm was performed. Patient demographics, complications from past operations, intraoperative variables, and immediate and long-term postoperative outcomes were recorded. The CAD/CAM predicted and actual postoperative graft measurements were compared.

Results: Five patients were identified who fulfilled inclusion criteria. Mean age at operation was 43 years and mean size of cranial defect was 69 cm. Mean operative time was 443 minutes and mean estimated blood loss was 450 mL. There were no dural tears, sagittal sinus bleeds, or other intraoperative complications. There were no immediate postoperative complications requiring extended hospital stay or reoperation. The postoperative graft surface areas were on average within 2.1% of the planned graft and this difference was not statistically significant (P = 0.28). All patients expressed satisfaction with cranial contour postoperatively.

Conclusion: Based on the early experience, the use of CAD/CAM enhances calvarial graft selection and improves contour accuracy in the reconstruction of complex skull defects with minimal complications.
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http://dx.doi.org/10.1097/SCS.0000000000005010DOI Listing
August 2019

A Road Map for Important Centers of Growth in the Pediatric Skeleton to Consider During Radiation Therapy and Associated Clinical Correlates of Radiation-Induced Growth Toxicity.

Int J Radiat Oncol Biol Phys 2019 03 7;103(3):669-679. Epub 2018 Nov 7.

Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland. Electronic address:

With the increasing use of advanced radiation techniques such as intensity modulated radiation therapy, stereotactic radiation therapy, and proton therapy, radiation oncologists now have the tools to mitigate radiation-associated toxicities. This is of utmost importance in the treatment of a pediatric patient. To best use these advanced techniques to mitigate radiation-induced growth abnormalities, the radiation oncologist should be equipped with a nuanced understanding of the anatomy of centers of growth. This article aims to enable the radiation oncologist to better understand, predict, and minimize radiation-mediated toxicities on growth. We review the process of bone development and radiation-induced growth abnormalities and provide an atlas for contouring important growth plates to guide radiation treatment planning. A more detailed recognition of important centers of growth may improve future treatment outcomes in children receiving radiation therapy.
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http://dx.doi.org/10.1016/j.ijrobp.2018.10.026DOI Listing
March 2019

The Use of Virtual Surgical Planning in Total Facial Skeletal Reconstruction of Treacher Collins Syndrome: A Case Report.

Craniomaxillofac Trauma Reconstr 2018 Sep 21;11(3):230-237. Epub 2017 Jul 21.

Department of Plastic and Reconstructive Surgery, JHMI, Baltimore, Maryland.

Facial skeletal reconstruction of patients with severe Treacher Collins syndrome (TCS) requires correction of both midface and mandibular deficiencies. Implementing virtual surgical planning can provide an accurate three-dimensional analysis of craniofacial abnormalities, creating calvarial donors that match the anatomy of the desired malar augmentation and facilitating bimaxillary movements, positioning, and fixation in orthognathic surgery. We present a case of an 18-year-old patient with TCS, who underwent staged zygomaticomaxillary reconstruction and double-jaw osteotomy with sliding genioplasty, using computer-assisted surgical planning. Following these operations, the patient achieved not only improved facial harmony but also class I occlusion.
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http://dx.doi.org/10.1055/s-0037-1604424DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6078706PMC
September 2018