Publications by authors named "Gerhard S Mundinger"

86 Publications

Autologous Homologous Skin Constructs Allow Safe Closure of Wounds: A Retrospective, Noncontrolled, Multicentered Case Series.

Plast Reconstr Surg Glob Open 2020 May 18;8(5):e2840. Epub 2020 May 18.

Division of Plastic Surgery, Department of Surgery, Rutgers University of School of Medicine, Newark, N.J.

An autologous homologous skin construct (AHSC) has been developed for the repair and replacement of skin. It is created from a small, full-thickness harvest of healthy skin, which contains endogenous regenerative populations involved in native skin repair. A multicenter retrospective review of 15 wounds in 15 patients treated with AHSC was performed to evaluate the hypothesis that a single application could result in wound closure in a variety of wound types and that the resulting tissue would resemble native skin. Patients and wounds were selected and managed per provider's discretion with no predefined inclusion, exclusion, or follow-up criteria. Dressings were changed weekly. Graft take and wound closure were documented during follow-up visits and imaged with a digital camera. Wound etiologies included 5 acute and chronic burn, 4 acute traumatic, and 6 chronic wounds. All wounds were closed with a single application of AHSC manufactured from a single tissue harvest. Median wound, harvest, and defect-to-harvest size ratio were 120 cm (range, 27-4800 cm), 14 cm (range, 3-20 cm), and 11:1 (range, 2:1-343:1), respectively. No adverse reactions with the full-thickness harvest site or the AHSC treatment site were reported. Average follow-up was 4 ± 3 months. An AHSC-treated area was biopsied, and a micrograph of the area was developed using immunofluorescent confocal microscopy, which demonstrated mature, full-thickness skin with nascent hair follicles and glands. This early clinical experience with ASHC suggests that it can close different wound types; however, additional studies are needed to verify this statement.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/GOX.0000000000002840DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7571939PMC
May 2020

Experimental Model of Zygomatic and Mandibular Defects to Support the Development of Custom Three-Dimensional--Printed Bone Scaffolds.

J Craniofac Surg 2020 Jul-Aug;31(5):1488-1491

Division of Plastic and Reconstructive Surgery, Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, LA.

Introduction: Autologous reconstruction of segmental craniomaxillofacial bone defects is limited by insufficient graft material, donor site morbidity, and need for microsurgery. Reconstruction is challenging due to the complex three-dimensional (3D) structure of craniofacial skeleton. Customized 3D-printed patient-specific biologic scaffolds hold promise for reconstruction of the craniofacial skeleton without donor site morbidity. The authors report a porcine craniofacial defect model suitable for further evaluation of custom 3D-printed engineered bone scaffolds.

Methods: The authors created a 6 cm critical load-bearing defect in the left mandibular angle and a 1.5 cm noncritical, nonload bearing defect in the contralateral right zygomatic arch in 4 Yucatan minipigs. Defects were plated with patient-specific titanium hardware based on preoperative CT scans. Serial CT imaging was done immediately postoperatively, and at 3 and 6 months. Animals were clinically assessed for masticatory function, ambulation, and growth. At the 6-month study endpoint, animals were euthanized, and bony regeneration was evaluated through histological staining and micro-CT scanning compared to contralateral controls.

Results: All 4 animals reached study endpoint. Two mandibular plates fractured, but did not preclude study completion due to loss of masticatory function. One zygoma plate loosened while the site of another underwent heterotopic ossification. Gross examination of site defects revealed heterotopic ossification, confirmed by histological and micro-CT evaluation. Biomechanical testing was unavailable due to insufficient bony repair.

Conclusions: The presented porcine zygoma and mandibular defect models are incapable of repair in the absence of bone scaffolds. Based on the authors' results, this model is appropriate for further study of custom 3D-printed engineered bone scaffolds.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SCS.0000000000006647DOI Listing
November 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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SCS.0000000000006362DOI Listing
June 2020

Regeneration and expansion of autologous full-thickness skin through a self-propagating autologous skin graft technology.

Clin Case Rep 2019 Dec 6;7(12):2449-2455. Epub 2019 Nov 6.

Division of Plastic and Reconstructive Surgery Department of Surgery Louisiana State University Health Sciences Center New Orleans Louisiana.

New autologous skin regeneration technology yielded full-thickness skin as evidenced by clinical observation and skin biopsy 5 months after surgery, providing relief for debilitating split-thickness skin graft contracture in a pediatric burn case.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ccr3.2533DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6935643PMC
December 2019

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0038-1668500DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6697470PMC
September 2019

Rigid External Le Fort I Distraction Followed by Secondary Bone Grafting for Maxillary Advancements in Patients With Cleft Lip and Palate.

J Craniofac Surg 2019 Oct;30(7):1974-1978

Department of Surgery, Division of Plastic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK.

Introduction: Maxillary hypoplasia after cleft lip and palate (CLP) repair can result in significant functional and aesthetic impairments. Le Fort I osteotomy & advancement and Le Fort I distraction osteogenesis are standard treatment options for individuals with CLP-associated midface retrusion. However, both of these modalities continue to be associated with a high relapse rate. This study describes surgical outcomes of a 2-stage technique utilizing distraction osteogenesis combined with bone grafting and rigid fixation, which may optimize skeletal stability by reducing relapse.

Methods: A retrospective review of CLP patients with severe maxillary hypoplasia evaluated by a single surgeon from 2003 to 2014 was performed. Twenty-one subjects were identified that underwent maxillary advancement via a 2-stage technique: (1) Le Fort I external rigid distraction using a HALO device, followed by (2) autologous iliac crest bone graft application and plate-fixation. Post-operative cephalograms were taken on average 1-year following surgery.

Results: Twelve subjects met the inclusion/exclusion criteria. A distraction rate of 1 mm/day was achieved with an average of 14 mm of maxillary advancement. Average increase in SNA was +9.03°, with an increase from 71.84° to 80.88° (normal = 82.0°, P value <0.0001), with no significant change in SNB, and a +9.63° change in ANB from -7.76° to 1.88° (normal = 1.6°, P value <0.0001).

Conclusions: The described 2-step procedure had similar cephalometric improvements as compared to distraction osteogenesis alone. However, successive bone grafting and rigid fixation as a second procedure may help ameliorate relapse risk and optimize the correction of maxillary hypoplasia in susceptible populations.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SCS.0000000000005620DOI Listing
October 2019

American Society of Plastic Surgeons Member Post-Operative Opioid Prescribing Patterns.

Plast Reconstr Surg Glob Open 2019 Mar 13;7(3):e2125. Epub 2019 Mar 13.

Elite Plastic Surgery, Phoenix, Ariz.

Introduction: Despite the widespread use of opioids in pain management, there are currently no evidence-based guidelines for the treatment of postoperative pain with opioids. Although other surgical specialties have begun researching their pain prescribing patterns, there has yet to be an investigation to unravel opioid prescribing patterns among plastic surgeons.

Methods: Survey Monkey was used to sample the American Society of Plastic Surgeons (ASPS) members regarding their opioid prescribing practice patterns. The survey was sent randomly to 50% of ASPS members. Respondents were randomized to 1 of 3 different common elective procedures in plastic surgery: breast augmentation, breast reduction, and abdominoplasty.

Results: Of the 5,770 overall active ASPS members, 298 responses (12% response rate) were received with the following procedure randomization results: 106 for breast augmentation, 99 for breast reduction, and 95 for abdominoplasty. Overall, 80% (N = 240) of respondents used nonnarcotic adjuncts to manage postoperative pain, with 75.4% (N = 181) using nonnarcotics adjuncts >75% of the time. The most commonly prescribed narcotics were Hydrocodone with Acetaminophen (Lortab, Norco) and Oxycodone with Acetaminophen (Percocet, Oxycocet) at 42.5% (N = 116) and 38.1% (N = 104), respectively. The most common dosage was 5 mg (80.4%; N = 176), with 48.9% (N = 107) mostly dispensing 20-30 tablets, and the majority did not give refills (94.5%; N = 207).

Conclusions: Overall, plastic surgeons seem to be in compliance with proposed American College of Surgeon's opioid prescription guidelines. However, there remains a lack of evidence regarding appropriate opioid prescribing patterns for plastic surgeons.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/GOX.0000000000002125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6467612PMC
March 2019

Facial Fracture Patterns Associated with Traumatic Optic Neuropathy.

Craniomaxillofac Trauma Reconstr 2019 Mar 30;12(1):39-44. Epub 2018 Mar 30.

Department of Plastic Surgery, New York University Langone Medical Center, New York.

Traumatic optic neuropathy (TON) is rare. The heterogeneity of injury patterns and patient condition on presentation makes diagnosis difficult. Fracture patterns associated with TON have never been evaluated. Retrospective review of 42 patients diagnosed with TON at the R. Adams Cowley Shock Trauma Center from May 1998 to August 2010 was performed. Thirty-three patients met criteria for study inclusion of fracture patterns. Additional variables measured included patient demographics and mechanism. Cluster analysis was used to form homogenous groups of patients based on different fracture patterns. Fracture frequency was analyzed by group and study population. Visual depiction of fracture patterns was created for each group. Cluster analysis of fracture patterns yielded five common "groups" or fracture patterns among the study population. Group 1 (  = 3, 9%) revealed contralateral lateral orbital wall (100%), zygoma (67%), and nasal bone (67%) fractures. Group 2 (  = 7, 21%) demonstrated fractures of the frontal bone (86%), nasal bones (71%), and ipsilateral orbital roof (57%). Group 3 (  = 14, 43%) involved fractures of the ipsilateral zygoma (100%), lateral orbital wall (29%), as well as frontal and nasal bones (21% each). Group 4 (  = 5, 15%) consisted of mid- and upper-face fractures; 100% fractured the ipsilateral orbital floor, medial and lateral walls, maxilla, and zygoma; 80% fractured the orbital roof and bilateral zygoma. Group 5 (  = 4, 12%) was characterized by fractures of the ipsilateral orbital floor, medial and lateral orbital walls (75% each), and orbital roof (50%). A notably high 15 of 33 patients (45%) sustained penetrating trauma. Our study demonstrates five fracture pattern groups associated with TON. Zygomatic, frontal, nasal, and orbital fractures were the most common. Fractures with a combination of frontal, nasal, and orbital fractures are particularly concerning and warrant close attention to the eye.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0038-1641172DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6391254PMC
March 2019

Single Versus Simultaneous Double Free Flaps for Head and Neck Reconstruction: Comparison of Flap Outcomes and Donor-Site Morbidity.

Ann Plast Surg 2019 02;82(2):184-189

Department of Otolaryngology, Tulane University School of Medicine, New Orleans, LA.

Introduction: Ablative procedures of the head and neck often result in substantial defects that require large-volume tissue transfer for restoration of form and function. Multiple simultaneous free flaps may be required for complex defects, but these procedures are often avoided because of the perception of an increase in associated surgical complications and morbidity. We present our experience with the use of simultaneous multiple free flaps as compared with single free flaps (SFFs) for head and neck reconstruction.

Methods: Thirty-seven patients with a history of head and neck malignancy underwent SFF reconstruction, and 21 patients underwent double free flap (DFF) reconstruction. Statistical analysis was conducted comparing demographics, comorbidities, etiology of disease, and surgical outcomes between the 2 patient groups.

Results: Operative time and length of hospital stay were both significantly longer in the DFF group versus the SFF group. Despite significantly higher rates of preoperative radiation, osteoradionecrosis, and operation for secondary malignancy in DFF group, no significant differences in flap survival, partial flap loss, recipient site complications, or donor site complications were found. Overall flap-related reoperation rates were low, as were total flap losses. There were 10 complications (24%) that required reoperation in the DFF group, and 1 total flap loss (2.4%), on per-flap basis. There were 10 complications (27%) that required reoperation in the SFF group and 3 total flap losses (8.1%). Per-flap incidence of donor site morbidity in the DFF group was significantly lower than that in the SFF group (23.8% vs 56.8%, respectively, P = 0.011).

Conclusions: The use of multiple free flaps for reconstruction of major head and neck tissue defects is sometimes necessary to achieve adequate reconstructive results. These procedures have no significant associated increase in overall flap-related complications. Our findings suggest that donor site morbidity can be minimized in double-flap reconstructions by thoughtful flap selection.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SAP.0000000000001713DOI Listing
February 2019

Novel De Novo EFTUD2 Mutations in 2 Cases With MFDM, Initially Suspected to Have Alternative Craniofacial Diagnoses.

Cleft Palate Craniofac J 2019 05 21;56(5):674-678. Epub 2018 Oct 21.

3 Craniofacial Team, Children's Hospital, New Orleans, LA, USA.

We report 2 cases of mandibulofacial dysostosis with microcephaly (MFDM) with different and novel de novo mutations in the elongation factor Tu GTP binding domain containing 2 gene. Both cases were initially thought to have alternative disorders but were later correctly diagnosed through whole-exome sequencing. These cases expand upon our knowledge of the phenotypic spectrum in patients with MFDM, which will aid in defining the full phenotype of this disorder and increase awareness of this condition.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1055665618806379DOI Listing
May 2019

Phentermine: A Systematic Review for Plastic and Reconstructive Surgeons.

Ann Plast Surg 2018 10;81(4):503-507

Department of Plastic Surgery, Louisiana State University Health Sciences Center, New Orleans, LA.

Purpose: Phentermine is the most prescribed antiobesity drug in America, with 2.43 million prescriptions written in 2011. Case reports suggest there are anesthetic risks, such as refractory hypotension, involved with its perioperative use. Despite these risks and the frequency of phentermine use among plastic surgery patients, there are no published guidelines for the perioperative management of phentermine use in the plastic surgery literature. To address this patient safety issue, we performed a systematic review and provide management recommendations.

Methods: A systematic review of the pharmacology of phentermine and the anesthetic risks involved with its perioperative use was undertaken using the search engines PubMed/MEDLINE, EMBASE, and Scopus.

Results: A total of 251 citations were reviewed, yielding 4 articles that discussed perioperative phentermine use and complications with anesthesia. One was a review article, 2 were case reports, and 1 was a letter. Complications included hypotension, hypertension, hypoglycemia, hyperthermia, bradycardia, cardiac depression, and acute pulmonary edema.

Conclusions: The relationship between phentermine and anesthesia, if any, is unclear. Hypotension on induction of general anesthesia is the most reported complication of perioperative phentermine use. Specifically, phentermine-induced hypotension may be unresponsive to vasopressors that rely on catecholamine release, such as ephedrine. Therefore, the decision to perform surgery, especially elective surgery, in a patient taking phentermine should be made with caution. Because of the half-life of phentermine, we recommend discontinuing phentermine for at least 4 days prior to surgery. This differs from the classic 2-week discontinuation period recommended for "fen-phen." The patient should be made aware of the increased risk of surgery, and a skilled anesthesiologist should monitor intraoperative blood pressure and body temperature for signs of autonomic derailment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SAP.0000000000001478DOI Listing
October 2018

Cosmetic Surgeon Representation: Ensuring Board Certification Transparency and Patient Awareness.

Ann Plast Surg 2018 06;80(6S Suppl 6):S431-S436

Department of Surgery, Division of Plastic Surgery and Otolaryngology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.

Background: Previous studies revealed that patients preferred plastic surgeons over cosmetic surgeons for surgical procedures, but few knew that any physician with a medical degree was legally qualified to perform cosmetic surgery. Results also indicated that a primary consideration for patients in selecting a surgeon was board certification. Although patient preferences concerning aesthetic surgery have previously been surveyed, no study examined a consumer's ability delineate between specialties based on Web sites. The purpose of this study was to investigate the responses of medical students to questions regarding a cosmetic and plastic surgeon's board certification.

Methods: A total of 4 cosmetic and 5 plastic surgeon Web sites were selected, in a single large city, from a Google search for the following procedures: liposuction, breast augmentation, blepharoplasty, rhytidectomy, and abdominoplasty. Screenshots of the Google search link, the page after clicking on the link, and the about the doctor page were collected to simulate an actual patient search experience. Four randomized surveys were created using screenshots and scenarios through Survey Monkey. Surveys were distributed and collected anonymously. Data analysis was accomplished using a chi-square test of independence (P < 0.05).

Results: A total of 474 medical students responded, and the difference between cosmetic and plastic surgeon variables was significant (P < 0.001). Upon comparison of different procedures, the cosmetic and plastic groups were found to be statistically different (P < 0.05), with some exceptions. On average, when presented with a plastic surgeon, 95.3% thought this was a board-certified plastic surgeon. When presented with a cosmetic surgeon, 54.3% also thought this was a board-certified plastic surgeon. The decline in responses regarding board certification, for the first and second cosmetic surgeons presented, was found to be statistically different (P < 0.0001).

Conclusions: Over 50% of medical students had difficulty distinguishing between a cosmetic and plastic surgeon based on Web site advertisements; therefore, patients may have a more difficult experience. Results of this study prove the need for a universal definition, and patient education, relating to board certifications.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SAP.0000000000001430DOI Listing
June 2018

Virtual Surgical Planning for Correction of Delayed Presentation Scaphocephaly Using a Modified Melbourne Technique.

J Craniofac Surg 2018 Jun;29(4):914-919

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

Background: Late treatment of scaphocephaly presents challenges including need for more complex surgery to achieve desired head shape. Virtual surgical planning for total vault reconstruction may mitigate some of these challenges, but has not been studied in this unique and complex clinical setting.

Methods: A retrospective chart review was conducted for patients with scaphocephaly who presented to our institution between 2000 and 2014. Patients presenting aged 12 months or older who underwent virtual surgical planning-assisted cranial vault reconstruction were included. Patient demographic, intraoperative data, and postoperative outcomes were recorded. Pre- and postoperative anthropometric measurements were obtained to document the fronto-occipital (FO) and biparietal (BP) distance and calculate cephalic index (CI). Virtual surgical planning predicted, and actual postoperative anthropometric measurements were compared.

Results: Five patients were identified who fulfilled inclusion criteria. The mean age was 50.6 months. One patient demonstrated signs of elevated intracranial pressure preoperatively. Postoperatively, all but one needed no revisional surgery (Whitaker score of 1). No patient demonstrated postoperative evidence of bony defects, bossing, or suture restenosis. The mean preoperative, simulated, and actual postoperative FO length was 190.3, 182, and 184.3 mm, respectively. The mean preoperative, simulated, and actual postoperative BP length was 129, 130.7, and 131 mm, respectively. The mean preoperative, simulated, and actual postoperative CI was 66, 72, and 71.3, respectively.

Conclusions: Based on our early experience, virtual surgical planning using a modified Melbourne technique for total vault remodeling achieves good results in the management of late presenting scaphocephaly.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SCS.0000000000004290DOI Listing
June 2018

Microsurgical Engineering: Bilateral Deep Inferior Epigastric Artery Perforator Flap with Flow-Through Intraflap Anastomosis.

Plast Reconstr Surg Glob Open 2018 Jan 16;6(1):e1554. Epub 2018 Jan 16.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Louisiana State University Health Sciences Center, New Orleans, La.; Department of Surgery, Division of Plastic and Reconstructive Surgery, Children's Hospital of New Orleans, New Orleans, La.

Squamous cell carcinoma (SCC) of the head and neck affects a significant number of people around the world every year. Treatment generally entails surgical resection, radiotherapy, chemotherapy, or some combination of the three. Following resection, microsurgical reconstruction can provide definitive coverage, replace many tissue types simultaneously, and bring healthy tissue to irradiated wound beds. Microsurgical engineering, the manipulation and reorganization of native vascular tissue, can further augment the adaptability of free tissue transfer to complex, compromised wound beds. We present one such case. The patient described in the following report was treated for a recurrent SCC of the left face, which required extensive resection resulting in a complex, composite tissue defect with compromised vascular supply. Using the principals of microsurgical engineering, definitive coverage of the defect, with accept- able aesthetic result, was achieved via bipedicle, DIEP flap with flow-through intraflap anastomosis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/GOX.0000000000001554DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5811279PMC
January 2018

Effects of unilateral vertical mandibular distraction osteogenesis on airway anatomy in children with hemifacial microsomia.

J Craniomaxillofac Surg 2017 Dec 13;45(12):2041-2045. Epub 2017 Oct 13.

Department of Plastic and Reconstructive Surgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA. Electronic address:

Purpose: To assess the two- and three-dimensional airway changes following unilateral vertical mandibular distraction osteogenesis (vMDO) in patients with hemifacial microsomia (HFM).

Methods: A retrospective evaluation was performed for consecutive patients over an 18-month period with HFM and with Kaban-Pruzansky Type-II mandibular deformities who underwent unilateral vMDO for correction of vertical mandibular asymmetry. Patients with complete records and a minimum of 12 months of clinical follow-up post-consolidation were included. Pre-operative airway dimensions (diameters, cross-sectional areas, and volumes) were measured for the oropharynx and nasopharynx. Pre-operative airway dimensions were compared to post-distraction measurements taken from 3D-CT data obtained at a minimum of 3 months post-consolidation.

Results: Five patients met inclusion criteria. Median age was 12.6 years, 3 were female, and median distraction length was 21.3 mm. Median final follow-up CT was performed 5 months after completion of distraction. There were no major or minor complications. Median total airway volume change was +33.7%, corresponding to median volume changes of 80.5% and 10.5% for the oropharyngeal and nasopharyngeal airways, respectively.

Conclusion: Unilateral vMDO expands the minimum diameter and volume of the oropharyngeal to a greater extent than the nasopharyngeal airway in HFM patients with Kaban-Pruzansky Type-II mandibular deformities.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jcms.2017.10.008DOI Listing
December 2017

Subcranial and orthognathic surgery for obstructive sleep apnea in achondroplasia.

J Craniomaxillofac Surg 2017 Dec 5;45(12):2028-2034. Epub 2017 Oct 5.

Craniofacial Center, Division of Plastic and Craniofacial Surgery (Head of Division: Richard A. Hopper), Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA. Electronic address:

Purpose: Obstructive sleep apnea (OSA) is a common problem in patients with achondroplasia. The purpose of this study was to assess changes in airway volumes following various degrees of facial skeletal advancement.

Methods: This was a retrospective evaluation of patients with achondroplasia who underwent facial skeletal advancement for obstructive sleep apnea. Patients were treated with either an isolated Le Fort III distraction (LF3) or Le Fort II distraction with or without subsequent Le Fort I and bilateral sagittal split osteotomies (LF2 ± LF1/BSSO). Demographic, cephalometric, volumetric, and polysomnographic variables were recorded pre- and postoperatively.

Results: Six patients with achondroplasia underwent midface advancement for treatment of OSA (2 LF2 + LF1/BSSO, 2 LF2, 2 LF3). Patients undergoing LF2 + LF1/BSSO had consistent volumetric improvements at the nasopharyngeal and oropharyngeal levels (Δ ≥ +347% and ≥+253%, respectively). Patients undergoing LF2 alone had consistent improvement in the nasopharyngeal airway alone (Δ ≥ +214%). Patients undergoing LF3 alone had consistent, but less dramatic, changes in nasopharyngeal volume (Δ ≥ +97.1%). All patients undergoing LF2 distraction (with or without LF1/BSSO) had a ≥50% reduction in the apnea-hypopnea index (AHI) postoperatively; there was no improvement in AHI with LF3 alone.

Conclusion: In patients with achondroplasia-associated OSA there are variable improvements in airway volume. This preliminary report suggests that LF2 distraction, with or without subsequent LF1/BSSO, may provide consistent reductions in AHI relative to LF3 distraction.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jcms.2017.09.028DOI Listing
December 2017

Defining and Correcting Asymmetry in Isolated Unilateral Frontosphenoidal Synostosis: Differences in Orbital Shape, Facial Scoliosis, and Skullbase Twist Compared to Unilateral Coronal Synostosis.

J Craniofac Surg 2018 Jan;29(1):29-35

The Craniofacial Center, Seattle Children's Hospital, Seattle, WA.

Introduction: Isolated frontosphenoidal synostosis (FS) is a rare cause of fronto-orbital plagiocephaly that can be challenging to distinguish from isolated unicoronal synostosis (UC). The purpose of this paper is to analyze differences in fronto-orbital dysmorphology between the 2 conditions, to describe approaches for surgical correction, and to report surgical outcomes between FS and UC patients in a casecontrol fashion.

Methods: Patients treated for craniosynostosis over a 12-year period at our institution were retrospectively evaluated under institutional review board approval. Frontosphenoidal synostosis patients who underwent bilateral fronto-orbital correction of anterior plagiocephaly with minimum 2-year follow-up, adequate pre-, and minimum 2-year postoperative computed tomography scans were included in the case-control portion of the study. These patients were randomly age-matched to UC patients meeting the same inclusion criteria. Preoperative and postoperative orbital shape and volumetric analysis was performed using Mimics software.

Results: Twelve FS patients were treated during the study period. Seven of these patients met casecontrol inclusion criteria with average follow-up of 47.5 months. The characteristic FS orbit was a relatively wide, short, and shallow trapezoid, while the characteristic UC orbit was a relatively narrow, tall, and deep parallelogram. Frontosphenoidal synostosis orbits were significantly wider, shorter, shallower, and smaller than UC orbits. Surgical correction tailored to the differential dysmorphologies resulted in statistical equalization of these differences between affected and contralateral control orbits at follow-up, with the exception of UC orbital width, which remained significantly narrower than unaffected contralateral control. One patient in each group required cranioplasty for skull defects at follow-up, while no patient underwent surgical readvancement.

Conclusions: Frontosphenoidal synostosis and UC orbital shape differ significantly, and can be normalized using fronto-orbital advancement tailored to the distinct orbital dysmorphologies of these 2 groups.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SCS.0000000000004052DOI Listing
January 2018

Lymphatic Reconstitution and Regeneration After Face Transplantation.

Ann Plast Surg 2017 Nov;79(5):505-508

From the *Hansjörg Wyss Department of Plastic Surgery, NYU Langone Medical Center, New York, NY; †Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center School of Medicine, New Orleans, LA; and ‡Department of Pathology, University of Maryland Medical Center, Baltimore, MD.

Background: The purpose of this study was to investigate whether lymphatic reconstitution and regeneration occurs after clinical facial transplantation using indocyanine green lymphography and immunohistochemical markers.

Methods: Allograft skin biopsies at multiple posttransplant time points were stained with Lyve1 lymphatic antibody and other endothelial antibodies. Staining intensity was interpreted on a scale of none, mild, moderate, and strong by 2 investigators and consolidated by a third party for final interpretation. Standardized real-time lymphography was performed at various posttransplant time points to evaluate lymphatic reconstitution and regeneration.

Results: Forty-two biopsies were evaluated at 15 different time points from posttransplant days 7 to 420. Strong Lyve1 staining was observed in 52.4%, moderate staining in 14.3%, and weak staining in 33.3% of biopsies. Strong staining was present on days 7, 10, 44, 79, 269, 402, and 420. Three lymphographic studies were conducted at 8.5, 30, and 35 months posttransplant. Initial drainage via distinct lymphatic channels with abrupt dermal splash and lymphostasis was observed at 8.5-month posttransplant. At 30- and 35-month posttransplant, communication of multiple lymphatic channels between donor tissue and recipient tissue was evident with distinct drainage into native recipient cervical lymph nodes. This correlated with ongoing clinical resolution of facial edema and was unaffected by 3 episodes of acute rejection.

Conclusions: These findings support ongoing lymphatic reconstitution between the donor facial allograft and recipient native tissue. Donor lymphatic regeneration begins after facial transplantation and continues long term. This mechanism may be responsible for the temporal and spatial process of lymphatic reconstitution with recipient lymphatic channels.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SAP.0000000000001222DOI Listing
November 2017

Posterior Auricular Mass.

Eplasty 2017 22;17:ic16. Epub 2017 Jun 22.

Division of Plastic and Reconstructive Surgery, Louisiana State University, New Orleans, La.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5489652PMC
June 2017

Evidence-Based Medicine: Evaluation and Treatment of Zygoma Fractures.

Plast Reconstr Surg 2017 Jan;139(1):168e-180e

Seattle, Wash.

Learning Objectives: After studying this article, the participant should be able to: 1. Diagnose zygomaticomaxillary complex fractures from physical examination and radiographic findings. 2. Plan the necessary surgical approaches for operative treatment of zygomaticomaxillary complex fractures depending on severity. 3. Understand the three-dimensional anatomy of the orbit and zygomaticomaxillary complex and the importance of the zygomaticosphenoid suture along the lateral orbital sidewall. 4. Be aware of pitfalls and associated fractures that can complicate anatomical reduction of zygomaticomaxillary complex fractures.

Summary: Fractures of the zygoma are some of the most commonly treated facial fractures, yet reconstruction of the three-dimensional structure of the zygomaticomaxillary complex can be challenging, and malunions are common. This article presents an evidence-based, systemic approach to the assessment and treatment of zygoma fractures from the simple to the complex. Anatomy, approaches, techniques, and pitfalls are described in an effort to improve the treatment of these common facial fractures.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PRS.0000000000002852DOI Listing
January 2017

Gastrostomy Placement Rates in Infants with Pierre Robin Sequence: A Comparison of Tongue-Lip Adhesion and Mandibular Distraction Osteogenesis.

Plast Reconstr Surg 2017 Jan;139(1):149-154

Baltimore, Md.

Background: This study was conducted to compare the gastrostomy rates in infants with Pierre Robin sequence treated with tongue-lip adhesion or mandibular distraction osteogenesis.

Methods: This was a retrospective study of symptomatic plastic and reconstructive surgery patients treated over an 8-year period. The primary predictor variable was surgical intervention (tongue-lip adhesion or distraction osteogenesis). Secondary predictor variables were categorized as demographic and clinical factors. The primary outcome was the need for gastrostomy tube placement. Secondary outcomes were complication rates, costs, and length of stay.

Results: Thirty-one tongue-lip adhesion and 30 distraction osteogenesis patients were included in the study. The groups were statistically comparable with regard to demographic and clinical factors (p > 0.18). Gastrostomy rates were higher in patients who underwent tongue-lip adhesion (48 percent) versus those who underwent distraction osteogenesis (16.7 percent; p = 0.008). In an adjusted model, subjects undergoing tongue-lip adhesion were more likely to require gastrostomy tube for nutritional support (OR, 6.5; 95 percent CI, 1.7 to 25.2; p = 0.007). There were two major complications in the tongue-lip adhesion group and none in the distraction osteogenesis group. There were three minor complications in the tongue-lip adhesion group and five in the distraction osteogenesis group. Total operating room costs were higher for distraction osteogenesis (p = 0.05), and total hospital costs and length of stay were higher for tongue-lip adhesion (p < 0.05).

Conclusions: Among infants with symptomatic Pierre Robin sequence, treatment by distraction osteogenesis is associated with a lower risk for gastrostomy placement for nutritional support. Hospital costs are higher for tongue-lip adhesion.

Clinical Question/level Of Evidence: Therapeutic, III.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PRS.0000000000002865DOI Listing
January 2017

Nasal Unit Transplantation: A Cadaveric Anatomical Feasibility Study.

J Reconstr Microsurg 2017 May 26;33(4):244-251. Epub 2016 Dec 26.

Division of Plastic Surgery, Saint Joseph Hospital, Chicago, Illinois.

 The science and technical acumen in the field of vascularized composite allotransplantation has progressed rapidly over the past 15 years, and transplantation of specialized units of the face, such as the nose, appears possible. No study to date has evaluated the technical feasibility of isolated nasal unit transplantation (NUT). In this study, we explore the anatomy and technical specifics of NUT.  In this study, four fresh cadaver heads were studied. Bilateral vascular pedicle dissections were performed in each cadaver. The facial artery was cannulated and injected with food dye under physiologic pressure in two cadavers, and with lead oxide mixture in two cadavers to evaluate perfusion territories supplied by each vascular pedicle.  The facial artery and vein were found to be adequate pedicles for NUT. Divergent courses of the vein and artery were consistently identified, which made for a bulky pedicle with necessary inclusion of large amounts of subcutaneous tissue. In all cases, the artery remained superficial, while the vein coursed in a deeper plane, and demonstrated consistent anastomoses with the superior transverse orbital arcade. While zinc oxide injection of the facial artery demonstrated filling of the nasal vasculature across the midline, dye perfusion studies suggested that unilateral arterial inflow may be insufficient to perfuse contralateral NUT components. Discrepancies in these two studies underscore the limitations of nondynamic assessment of nutritive perfusion.  NUT based on the facial artery and facial vein is technically feasible. Angiosome evaluation suggests that bilateral pedicle anastomoses may be required to ensure optimal perfusion.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0036-1597693DOI Listing
May 2017

Management of the Repeatedly Failed Cranioplasty Following Large Postdecompressive Craniectomy: Establishing the Efficacy of Staged Free Latissimus Dorsi Transfer/Tissue Expansion/Custom Polyetheretherketone Implant Reconstruction.

J Craniofac Surg 2016 Nov;27(8):1971-1977

*Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, WA†Walter Reed National Military Medical Center, Bethesda, MD‡Department of Neurosurgery, University of Washington, Seattle, WA.

Background: Postdecompressive craniotomy defect management following failed prior cranioplastyis challenging. The authors describe a staged technique utilizing free muscle transfer, tissue expansion, and custom polyetheretherketone (PEEK) implants for the management of previously failed cranioplasty sites in patients with complicating local factors.

Methods: Consecutive patients with previously failed cranioplasties following large decompressive craniectomies underwent reconstruction of skull and soft tissue defects with staged free latissimus muscle transfer, tissue expansion, and placement of custom computer-aided design and modeling PEEK implants with a 'temporalis-plus' modification to minimize temporal hollowing. Implants were placed in a vascularized pocket at the third stage by elevating a plane between the previously transferred latissimus superficial fascia (left on the skin) and muscle (left on the dura/bone). Patients were evaluated postoperatively for cranioplasty durability, aesthetic outcome, and complications.

Results: Six patients with an average of 1.6 previously failed cranioplasties underwent this staged technique. Average age was 33 years. Average defect size was 139 cm. Average time to procedure series completion was 14.9 months. There were no flap failures. One patient had early postoperative incisional dehiscence following PEEK implant placement that was managed by immediate scalp flap readvancement. At 21.9 month average follow-up, there were no cranioplasty failures. Three patients (50%) underwent 4 subsequent refining outpatient procedures. All patients achieved complete coverage of their craniectomy defect site with hear-bearing skin, acceptable head shape, and normalized head contour.

Conclusions: The described technique resulted in aesthetic, durable craniectomy defect reconstruction with retention of native hear-bearing scalp skin in a challenging patient population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SCS.0000000000003043DOI Listing
November 2016

Timing of cranial vault remodeling in nonsyndromic craniosynostosis: a single-institution 30-year experience.

J Neurosurg Pediatr 2016 Nov 9;18(5):629-634. Epub 2016 Aug 9.

Departments of 1 Plastic and Reconstructive Surgery and.

OBJECTIVE Due to the changing properties of the infant skull, there is still no clear consensus on the ideal time to surgically intervene in cases of nonsyndromic craniosynostosis (NSC). This study aims to shed light on how patient age at the time of surgery may affect surgical outcomes and the subsequent need for reoperation. METHODS A retrospective cohort review was conducted for patients with NSC who underwent primary cranial vault remodeling between 1990 and 2013. Patients' demographic and clinical characteristics and surgical interventions were recorded. Postoperative outcomes were assessed by assigning each procedure to a Whitaker category. Multivariate logistic regression analysis was performed to determine the relationship between age at surgery and need for minor (Whitaker I or II) versus major (Whitaker III or IV) reoperation. Odds ratios (ORs) for Whitaker category by age at surgery were assigned. RESULTS A total of 413 unique patients underwent cranial vault remodeling procedures for NSC during the study period. Multivariate logistic regression demonstrated increased odds of requiring major surgical revisions (Whitaker III or IV) in patients younger than 6 months of age (OR 2.49, 95% CI 1.05-5.93), and increased odds of requiring minimal surgical revisions (Whitaker I or II) in patients older than 6 months of age (OR 2.72, 95% CI 1.16-6.41). CONCLUSIONS Timing, as a proxy for the changing properties of the infant skull, is an important factor to consider when planning vault reconstruction in NSC. The data presented in this study demonstrate that patients operated on before 6 months of age had increased odds of requiring major surgical revisions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2016.5.PEDS1663DOI Listing
November 2016

Distraction Osteogenesis for Surgical Treatment of Craniosynostosis: A Systematic Review.

Plast Reconstr Surg 2016 Sep;138(3):657-669

Baltimore, Md.

Background: Distraction osteogenesis has been proposed as an alternative to cranial remodeling surgery for craniosynostosis, but technique descriptions and outcome analyses are limited to small case series. This review summarizes operative characteristics and outcomes of distraction osteogenesis and presents data comparing distraction osteogenesis to cranial remodeling surgery.

Methods: A systematic review of the literature was undertaken. Descriptive analysis, operative technical data, outcomes, or postoperative complications of distraction osteogenesis for craniosynostosis were included.

Results: A total of 1325 citations were reviewed, yielding 53 articles and 880 children who underwent distraction osteogenesis for craniosynostosis. Distraction plates were used in 754 patients (86 percent), whereas springs were used for the remaining 126 patients (14 percent). Standard and spring distraction osteogenesis was reported to successfully treat the primary condition 98 percent of the time. Suboptimal results were reported in 11 patients (1.3 percent), and minor complications were reported in 19.5 percent of cases (n = 172).Major complications were rare, occurring in 3.5 percent of cases (n = 31), and included two reported deaths. Absolute operative times and blood loss were marginally greater for cranial remodeling surgery cases, but the differences were not statistically significant.

Conclusions: Distraction osteogenesis is an effective cranial vault remodeling technique for treating craniosynostosis. No statistical differences were found with respect to operative time, blood loss, need for transfusion, or intensive care unit resources compared with cranial remodeling surgery. Outcome studies with longer follow-up periods specifically investigating cost, relapse, and reoperation rates are necessary to effectively compare this treatment modality as an alternative to cranial remodeling surgery.

Clinical Question/level Of Evidence: Therapeutic, IV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PRS.0000000000002475DOI Listing
September 2016

Principles for Management of Orbital Fractures in the Pediatric Population: A Cohort Study of 150 Patients.

Plast Reconstr Surg 2016 Apr;137(4):1234-1240

Baltimore, Md.

Background: Pediatric orbital fractures represent a challenging and sometimes controversial clinical problem. Patients may present with clear indications for surgery, but most require balancing benefits against intraoperative and late complications. The authors assessed these fractures at a state-designated ophthalmology referral center to develop criteria for surgery.

Methods: Institutional review board approval was obtained to retrospectively analyze pediatric trauma registry patients with orbital fracture diagnoses at the Wilmer Eye Institute over 10 years. Patients were excluded if they did not undergo a full ophthalmologic examination, never followed up after their injury, or had significant facial fractures outside of the orbit.

Results: One hundred fifty patients met selection criteria; 116 patients (77 percent) completed all follow-up (average, 309 days). Two patients had 20/40 vision or worse at the end of follow-up. One hundred ten patients (71 percent) underwent surgery; 96 underwent acute repair (<3 weeks) and 11 underwent delayed repair (median, 49 days). Three patients required reoperation, two for plate infection and one for hyperglobus, with an overall complication rate of 4.7 percent.

Conclusions: The authors analyzed the largest series of operative pediatric orbital fractures to propose criteria for surgical intervention. There are four potential indications: (1) rectus muscle entrapment; (2) early enophthalmos; (3) central-gaze diplopia or extraocular movement restriction after the resolution of swelling; and (4) loss of orbital support likely to produce secondary changes in globe position and/or binocular stereo vision. In our series, application of these principles offered excellent long-term aesthetic and ophthalmic outcomes with an acceptably low complication profile.

Clinical Question/level Of Evidence: Therapeutic, III.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PRS.0000000000002006DOI Listing
April 2016

Optimizing Reconstruction with Periorbital Transplantation: Clinical Indications and Anatomic Considerations.

Plast Reconstr Surg Glob Open 2016 Feb 26;4(2):e628. Epub 2016 Feb 26.

Hansjörg Wyss Department of Plastic Surgery, New York University Langone Medical Center, Institute of Reconstructive Plastic Surgery, New York, N.Y.; Division of Plastic, Reconstructive and Maxillofacial Surgery, R Adams Cowley Shock Trauma, Center, University of Maryland Medical Center, Baltimore, Md.; Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, Md.; Department of Ophthalmology, Johns Hopkins Bellevue Medical Center, Baltimore, Md.

Unlabelled: Complex periorbital subunit reconstruction is challenging because the goals of effective reconstruction vary from one individual to another. The purpose of this article is to explore the indications and anatomic feasibility of periorbital transplantation by reviewing our institutional repository of facial injury.

Methods: Institutional review board approval was obtained at the R Adams Cowley Shock Trauma Center for a retrospective chart review conducted on patients with periorbital defects. Patient history, facial defects, visual acuity, and periorbital function were critically reviewed to identify indications for periorbital or total face (incorporating the periorbital subunit) vascularized composite allotransplantation. Cadaveric allograft harvest was then designed and performed for specific patient defects to determine anatomic feasibility. Disease conditions not captured by our patient population warranting consideration were reviewed.

Results: A total of 7 facial or periorbital transplant candidates representing 6 different etiologies were selected as suitable indications for periorbital transplantation. Etiologies included trauma, burn, animal attack, and tumor, whereas proposed transplants included isolated periorbital and total face transplants. Allograft recovery was successfully completed in 4 periorbital subunits and 1 full face. Dual vascular supply was achieved in 5 of 6 periorbital subunits (superficial temporal and facial vessels).

Conclusions: Transplantation of isolated periorbital structures or full face transplantation including periorbital structures is technically feasible. The goal of periorbital transplantation is to re-establish protective mechanisms of the eye, to prevent deterioration of visual acuity, and to optimize aesthetic outcomes. Criteria necessary for candidate selection and allograft design are identified by periorbital defect, periorbital function, ophthalmologic evaluation, and defect etiology.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/GOX.0000000000000545DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4778899PMC
February 2016

Which Factors Are Associated with Open Reduction of Adult Mandibular Condylar Injuries?

Plast Reconstr Surg 2016 Jun;137(6):1813-1821

Baltimore, Md.; and New York, N.Y.

Background: The purpose of this study was to identify factors associated with the decision to perform open reduction and internal fixation of mandibular condylar fractures.

Methods: This was a retrospective cohort study of patients with mandibular condylar fractures managed by the plastic and reconstructive surgery, oral and maxillofacial surgery, and otorhinolaryngology services over a 15-year period. Bivariate associations and a multiple logistic regression model were computed for injury characteristics that were associated with open reduction and internal fixation. For all analyses, a value of p ≤ 0.05 was considered significant.

Results: Six hundred fifty-four condylar injuries were identified in 547 patients. The sample's mean age was 36.0 ± 16.5 years, 20.5 percent were women, and 63 percent were Caucasian. The most common mechanisms of injury were motor vehicle collisions (49 percent), 53.4 percent involved the subcondylar region and 20 percent were bilateral injuries. Associated noncondylar mandibular fractures were present in 60 percent of cases; 20.7 percent were managed with open reduction and internal fixation. The overall complication rate was 21.6 percent. In a multiple logistic regression model, factors associated with an increased likelihood of open reduction and internal fixation were the presence of extracondylar mandibular injuries, condylar neck or subcondylar region injuries, increasing dislocation, and treatment by plastic and reconstructive surgery/oral and maxillofacial surgery (p ≤ 0.04).

Conclusions: Increasing severity of mandibular injury, lower level of fracture, joint dislocation, and treatment by plastic and reconstructive surgery/oral and maxillofacial surgery are associated with open reduction and internal fixation of mandibular condylar injuries.

Clinical Question/level Of Evidence: Risk, III.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PRS.0000000000002152DOI Listing
June 2016

Defining Population-Specific Craniofacial Fracture Patterns and Resource Use in Geriatric Patients: A Comparative Study of Blunt Craniofacial Fractures in Geriatric versus Nongeriatric Adult Patients.

Plast Reconstr Surg 2016 Feb;137(2):386e-393e

Baltimore, Md. From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center.

Background: This study investigates the hypothesis that mechanisms of injury, fracture patterns, and burden to the health care system differ between geriatric and nongeriatric populations sustaining blunt-force craniofacial trauma.

Methods: A 5-year retrospective chart review of patient records and computed tomographic imaging was performed. Demographic and outcome data were extracted for equally numbered samples of blunt-mechanism facial fracture patients aged 60 years or older (geriatric), and adult patients aged 18 to 59 years (adult nongeriatric). Comparisons were made between these two populations using t tests and multivariable logistic regression.

Results: One thousand eighty-seven geriatric and 1087 nongeriatric patients were included. Geriatric patients were significantly more likely to be Caucasian, female, and have sustained fractures as the result of falling. They also had significantly longer hospital stays, were more likely to die, and were more likely to be discharged to home with services. Mandible fractures and panfacial fractures were significantly more common in the nongeriatric population. Geriatric age was associated with doubled length of hospitalization for patients with midface fractures. Logistic regression revealed that significantly higher incidences of orbital floor, maxillary, and condylar fractures in geriatric patients were dependent on geriatric age status, rather than mechanism of injury alone.

Conclusions: Resource allocation for geriatric patients with craniofacial trauma should differ from that of their nongeriatric adult counterparts, with more resources allocated to supportive care during hospitalization and assistive care after discharge. The authors' data indicate that structural and biological changes in the craniofacial skeleton contribute to differences in fracture location independent of mechanism of injury.

Clinical Question/level Of Evidence: Risk, II.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/01.prs.0000475800.15221.cdDOI Listing
February 2016

Treatment Outcomes following Traumatic Optic Neuropathy.

Plast Reconstr Surg 2016 Jan;137(1):231-238

Baltimore, Md.; New York, N.Y.; and Washington, D.C. From the Division of Plastic, Reconstructive and Maxillofacial Surgery, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center; the Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital; the Department of Plastic Surgery, New York University Langone Medical Center; and the George Washington University School of Medicine and Health Sciences.

Background: Traumatic optic neuropathy is characterized by sudden loss of vision following facial trauma leading to variable visual deficits. The purpose of this study was to evaluate recent institutional trends in the treatment of traumatic optic neuropathy, evaluate the outcomes of different treatment strategies, and identify factors associated with improved vision.

Methods: Institutional review board approval was obtained to retrospectively review patients diagnosed with traumatic optic neuropathy at a high-volume trauma center from 2004 to 2012. Pretreatment and posttreatment visual acuity was compared using quantitative analysis of standard ophthalmologic conversion.

Results: A total of 109 patients met inclusion criteria (74.3 percent male patients), with a mean age of 38.0 ± 17.5 years (range, 8 to 82 years). Management of traumatic optic neuropathy involved intravenous corticosteroids alone in 8.3 percent of patients (n = 9), 56.9 percent (n = 62) underwent observation, 28.4 percent (n = 31) had surgical intervention, and 6.4 percent (n = 7) underwent surgery and corticosteroid administration. Only 19.3 percent of patients returned for follow-up. Vision improved in 47.6 percent of patients, with a mean follow-up of 12.9 weeks. Patients younger than 50 years had a trend toward higher rates of visual improvement, 60 percent versus 16.7 percent (p = 0.15).

Conclusions: The majority of traumatic optic neuropathy patients are unlikely to return for a follow-up examination. Optic nerve decompression has fallen out of favor in the authors' institution, and observation is the most common management strategy. Outcomes following corticosteroid administration and observation are comparable.

Clinical Question/level Of Evidence: Therapeutic, IV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/PRS.0000000000001907DOI Listing
January 2016