Publications by authors named "Mark S Granick"

100 Publications

Management of Pediatric Nasoorbitoethmoid Complex Fractures at a Level 1 Trauma Center.

Am Surg 2021 Feb 24:3134821998682. Epub 2021 Feb 24.

Division of Plastic Surgery, 12286Rutgers New Jersey Medical School, Newark, NJ, USA.

Purpose: A universally accepted treatment algorithm for rare pediatric nasoorbitoethmoid (NOE) fractures has yet to be established. In this study, the authors examine how severity of pediatric NOE fractures interplays with patient characteristics, management choices, and complications from injury and surgical intervention at our institution.

Methods: A retrospective chart review was performed for all cases of pediatric NOE fracture at a level 1 trauma center (University Hospital in Newark, New Jersey) between 2002 and 2014.

Results: Fifteen of 1922 patients met our inclusion criteria. Ten (66.7%) demonstrated Markowitz type I injuries, 2 (13.3%) had type II NOEs, and 3 (20%) sustained type III fractures. Five (33.3%) of our patients were only monitored. Six (40.0%) were treated with plate fixation. One patient (6.7%) required enucleation alone, while 1 (6.7%) warranted enucleation with medial canthoplasty and plate fixation. Transnasal canthopexy was performed for 1 patient (6.7%). Zero patients managed without surgery had complications at 1-year follow-up. Surgical intervention was associated with complications in 4 of 15 patients. Both nonoperative treatment and plate fixation were associated with a higher rate of complications from initial injury or subsequent therapy when than other mentioned forms of treatment ( = .004).

Conclusion: Nonoperative management for nondisplaced fractures is associated with zero complications at 1-year follow-up in our data; plate fixation and watchful waiting yield significantly fewer postoperative complications and injury sequelae than surgical intervention for medial canthal tendon and globe injuries.
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http://dx.doi.org/10.1177/0003134821998682DOI Listing
February 2021

Pediatric Palate Fractures: An Assessment of Patterns and Management at a Level 1 Trauma Center.

Craniomaxillofac Trauma Reconstr 2021 Mar 7;14(1):23-28. Epub 2020 Jul 7.

Division of Plastic and Reconstructive Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.

Study Design: Literature discussing palate fractures in the pediatric population is limited. We performed a retrospective review of pediatric palatal fractures at our institution to better understand the impact of this fracture pattern in the pediatric patient.

Objectives: The goal of our study is to analyze our institutional experience with pediatric palate fractures, focusing on epidemiology, concomitant injuries, and fracture management.

Methods: Records were collected for all palatal fractures in pediatric patients diagnosed between 2000 and 2016 at an urban Level I trauma center. Patient imaging was reviewed. Demographic characteristics and inpatient clinical data were recorded.

Results: Nine pediatric patients were diagnosed with fracture of the bony palate. Average age was twelve with male predominance (66%). Pedestrian struck injuries (33%) and motor vehicle accidents (33%) were the most common etiologies. Five patients sustained skull fractures. Three patients were found to have intracranial hemorrhage, two required emergent bolt placement. Two patients sustained cervical spine injury. One patient had severe facial hemorrhage requiring embolization. According to the Hendrickson classification, there were three type I fractures, two type II fractures, one type III fracture, one type IV fracture, and one type V fracture. Lefort I and/or alveolar fracture was present in every patient. Four patients underwent surgical treatment with open reduction and restoration of facial height with maxillomandibular fixation. Three patients underwent concomitant mandible fracture repair.

Conclusions: Pediatric palatal fractures are rare and are usually accompanied by devastating concomitant injuries. Surgical repair of the palate in the pediatric patient is often necessary to restore facial height.
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http://dx.doi.org/10.1177/1943387520935013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7868506PMC
March 2021

A prospective, randomized, controlled, crossover study comparing three multilayered foam dressings for the management of chronic wounds.

J Comp Eff Res 2021 Apr 19;10(6):481-493. Epub 2021 Feb 19.

Serena Group Research Foundation, Cambridge, MA 02140, USA.

Compare foam dressings - Mepilex Border Flex (MxBF), Allevyn Life (AL) and Optifoam Gentle EX (OGEX) - in treatment of chronic wounds. Prospective, randomized, controlled trial (crossover design). Subjects received one dressing for 2 weeks, then comparator dressing for following 2 weeks. Wound/periwound characteristics evaluated weekly at dressing change. Primary end point: dressing durability (incidence of exudate strikethrough). Higher incidence of intact dressings (no strikethrough) at Day 7 (Week 1) with MxBF (6/17; 35.3%) compared with AL (1/18; 5.6%), and with MxBF (7/16; 43.8%) compared with OGEX (2/16; 12.5%; p < 0.05). No significant differences between groups regarding wound size reduction. MxBF had statistically greater durability than AL/OGEX during first critical week of treatment.
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http://dx.doi.org/10.2217/cer-2020-0268DOI Listing
April 2021

Facial Fractures and Mixed Dentition - What Are the Implications of Dentition Status in Pediatric Facial Fracture Management?

J Craniofac Surg 2021 Jan 7;Publish Ahead of Print. Epub 2021 Jan 7.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ Division of Plastic and Reconstructive Surgery, Department of Surgery, The University of Mississippi Medical Center, Jackson, MS.

Introduction: The stage of maturation of the pediatric facial skeleton at the time of injury has a significant impact on both facial fracture patterns and management strategies. For instance, the relative prominence of the pediatric cranium during the early years of life affords protection to the structures of the midface, whereas delayed aeration of the frontal sinuses may predispose younger patients to frontal bone fractures. The dentition status of a pediatric patient may have similar implications in the setting of facial fracture. In this study, the authors examine the effect of dentition status on facial fracture patterns and management strategies at an urban, level 1 trauma center.

Methods: A retrospective chart review was performed for all cases of facial fracture occurring in the pediatric patient population at a level 1 trauma center (University Hospital in Newark, NJ) between 2002 and 2014. A database including patient demographics, facial fracture, and concomitant injury patterns, and operative management data was constructed and analyzed.

Results: A total of 72 patients with mixed dentition met inclusion criteria for our study and were compared against patients with primary (n = 35) and permanent (n = 349) dentition. The mean age at presentation was 9.2 years, with a male predominance of 68%. The most common fracture etiology was pedestrian struck accident (n = 23), fall (n = 21), motor vehicle collision (n = 12), and assault (n = 9). The most frequently identified facial fractures were that of the orbit (n = 31), mandible (n = 21), nasal bone (n = 19), and frontal sinus (n = 14). Additionally, 8 Le Fort and 4 nasoorbitoethmoid fractures were identified. Twenty-one patients (29%) required operative management for 1 or more facial fractures. Operative intervention was required in 38% of mandibular fractures, with 6 patients requiring only maxillomandibular fixation and 2 requiring open reduction and internal fixation with titanium plating. Nine cases of orbital fracture (29%) were managed operatively - 4 with absorbable plates, 3 with Medpor implants, and 8 with titanium plating. Management of all nasal fractures requiring operative intervention was accomplished through closed reduction. Concomitant injuries included traumatic brain injury (TBI) (n = 35), skull fracture (n = 24), intracranial hemorrhage (ICH) (n = 20), and long bone fracture (n = 12). Seventeen patients required admission to the intensive care unit. Patients with mixed dentition were significantly more likely to sustain frontal sinus and Le Fort fractures (P < 0.01), as well as skull fracture, ICH, and TBI (P < 0.01) as compared to those with permanent dentition.

Conclusions: The dentition status of a pediatric patient may have significant implications in both patterns of injury and operative management strategies in the setting of acute facial trauma. Our study finds that Le Fort and frontal sinus fractures were significantly more common in patients with mixed dentition. Severe concomitant injuries such as ICH and TBI were also significantly more likely in this cohort. A patient's dentition status may also play a role in the decision for ridged fixation of mandibular and orbital fractures, as well as the method of maxillomandibular fixation in maxillary and mandibular alveolar fracture.
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http://dx.doi.org/10.1097/SCS.0000000000007424DOI Listing
January 2021

Rigid External Distractors in Midface Fractures: A Review of Relevant and Related Literature.

Eplasty 2020 19;20:e11. Epub 2020 Oct 19.

Division of Plastic and Reconstructive Surgery, Rutgers New Jersey Medical School, Newark, NJ.

Introduction: Literature discussing the use of rigid external distraction devices in midfacial trauma is limited. Rigid external distraction devices have been described for use in craniofacial surgery, allowing for distraction and stabilization of bony segments. In complex facial trauma, bony fragments are often comminuted and unstable, making traditional approaches with internal fixation difficult. Moreover, these approaches require subperiosteal dissection, limiting blood supply that is important for bone healing.

Objective: The goal of this study was to evaluate the role of rigid external distraction devices for the treatment of complex facial trauma.

Methods: We performed a literature review of rigid external distraction devices, as relevant both for facial trauma and for other craniofacial indications, to better elucidate their use and efficacy in complex facial fractures.

Results: The review revealed only 2 articles explicitly describing rigid external distraction devices for facial trauma, while 6 other articles describing its use for other craniofacial cases. An important benefit associated with the use of rigid external distraction devices is their ability to provide controlled traction of bony segments while also allowing for movement as needed for fracture reduction. Various articles describe performing internal fixation following rigid external distraction device usage, while others emphasize that internal fixation is not necessarily indicated if the rigid external distraction device is left intact long enough to ensure bony healing. One potential setback described is unfamiliarity with using the rigid external distraction device, which can preclude its use by many surgeons. In addition, the literature review did not provide any uniform guidelines or recommendations about how long rigid external distraction devices should remain intact.

Conclusion: Based on relevant literature, rigid external distraction devices have been shown to be useful in the stabilization and treatment of complex facial fractures. Further studies should be conducted to better elucidate the specific indications for rigid external distraction devices in complex facial trauma.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7656155PMC
October 2020

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

Motor Vehicle Collision Injuries: An Analysis of Facial Fractures in the Urban Pediatric Population.

J Craniofac Surg 2020 Oct;31(7):1910-1913

Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ.

Purpose: Motor vehicle collisions (MVC) are a leading cause of unintentional death and injury in the US pediatric population. Compliance with prevention measures such as seatbelts and child safety seats varies considerably with patient demographics. In this study, the authors examine facial fracture secondary to MVC in an urban pediatric population.

Methods: A retrospective chart review was performed of all facial fractures as a result of MVC in the pediatric population in a level 1 trauma center in an urban environment (University Hospital in Newark, NJ). Patient demographics were collected, as well as location of fractures, concomitant injuries, and surgical management strategies.

Results: Seventy-five patients met inclusion criteria for the authors' study. Mean age was 14 years old. Common fracture sites included orbital, mandible, nasal bone, and frontal sinus. Patients were more likely to incur fracture of the zygoma, orbit, nasal bone, frontal sinus, and nasoorbitoethmoid (NOE) if involved in an MVC compared to all other etiologies. Common concomitant injuries included traumatic brain injury, intracranial hemorrhage, and skull and long bone fractures. Open reduction and internal fixation with titanium plates was the most common surgical procedure indicated.

Conclusion: Motor vehicle collisions related injury has significant health implications in the urban pediatric population. Orbital, zygoma, and nasal facial fractures and TBI are injuries commonly associated with MVC. The facial fractures are likely due to lack of proper utilization of safety equipment and airbags. Development of effective prevention techniques relies heavily on analysis of injury patterns and management strategies.
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http://dx.doi.org/10.1097/SCS.0000000000006671DOI Listing
October 2020

Mentorship Through Research: A Novel Approach to Increasing Resident and Medical Student Research Competency Through an Institutional Database.

J Surg Educ 2020 Nov - Dec;77(6):1331-1333. Epub 2020 Jun 3.

Rutgers - New Jersey Medical School, Division of Plastic and Reconstructive Surgery, Newark, New Jersey. Electronic address:

Background: We describe a novel research database development project to increase resident and medical student scholarly ability and mentorship skills. We collected data on 3147 facial fractures treated at our institution over a 12-year period. This data was used to publish novel research on multiple types of facial fractures and outcomes.

Methods: We learned about key database aspects that led to its high level of research quality and output volume through over 6 years of database development and expanded research output. A retrospective review was completed to compile the total research produced during this time period.

Results: Research resulted in 20 manuscripts, 17 podium presentations, and 11 posters. 16 medical students, 5 residents and 3 faculty members were authors on at least one project. The average number of published manuscripts was 5.17 overall and 2.9, 7.0, and 14.0 for medical students, residents, and faculty, respectively. Four residents matched into fellowship, 7 medical students matched into residency, and one faculty member was promoted academically.

Conclusions: A database focused on a common and under-researched pathology can result in a high volume of novel research output. Additional program benefits include increased scholarly and mentorship ability in engaged residents and medical students.
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http://dx.doi.org/10.1016/j.jsurg.2020.04.010DOI Listing
June 2020

Latest Advances in Wound Debridement Techniques.

Surg Technol Int 2020 May;36:37-40

Wound Care Center University Hospital, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ.

The surgical surgical debridement of wounds has evolved over the past 250 years. At that time, the amputation of extremities was recognized as a life-saving procedure to treat major wounds suffered in combat. This continued until after World War I. As the survival of patients with diabetes and other chronic conditions improved, and as advanced therapies were developed to meet the needs of an increasing number of patients with chronic wounds, debridement became a focal point of surgical wound care. It is now well-established that debridement enhances wound-healing and improves the efficacy of advanced therapies and surgical closure. Up until the last two decades, sharp excision with "cold steel" was the only option for debridement. In the early 2000's, a high-power waterjet was introduced, and provided a more precise debridement of wound surfaces. As our understanding of biofilms increased, so came the realization that biofilms are stratified within the wound, with anaerobic species preferentially developing deeper within the wound. The latest surgical instrument for wound debridement, the direct contact low frequency ultrasound device (DCLFU), has recently been introduced. A vacuum sheath was added to the active tip to contain spray dispersion. The device is capable of removing all of the wound tissue including biofilm down to a healthy base. This allows for optimal preparation of the wound prior to deployment of an advanced therapy, graft, or flap. This instrumentation is designed specifically for use in the operating room. However, the manufacturer has recently introduced a less powerful, but still effective, version for use in the outpatient clinic. These advances in surgical debridement technology have paved the way for more effective subsequent interventions for treating chronic wounds.
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May 2020

Assessment of Panfacial Fractures in the Pediatric Population.

J Oral Maxillofac Surg 2020 Jul 8;78(7):1156-1161. Epub 2020 Mar 8.

Professor of Plastic Surgery, Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ.

Purpose: Management of panfacial fractures is critical and often difficult in adults; however, there is little to no literature regarding these fractures in the pediatric population. In this study, we present our experience to provide insight and further investigation regarding prevention and management strategies within the pediatric population.

Patients And Methods: We performed a retrospective chart review of all panfacial fractures in the pediatric population between 2002 and 2014 treated at an urban, level 1 trauma center (University Hospital, Newark, NJ). Data including patient demographic characteristics, mechanisms of injury, locations of fractures, concomitant injuries, and surgical management strategies were collected.

Results: We identified 82 patients aged 18 years or younger who had sustained a panfacial fracture. The mean age at the time of injury was 12.9 years, with a male predominance of 64.9%. A total of 335 fractures were identified on radiologic imaging. The most common etiologies were motor vehicle accidents and pedestrians being struck. Orbital, frontal sinus, nasal, and zygoma fractures were the most common fractures. The mean score on the Glasgow Coma Scale on arrival was 12.0. A total of 29 patients were intubated on arrival-or before arrival-at the trauma bay. A surgical airway was required in 9 patients. The most common concomitant injuries were traumatic brain injury, intracranial hemorrhage, and skull fracture. Surgical repair was required in 38 patients. The cephalic-to-caudal approach was used most, followed by caudal to cephalic, medial to lateral, and lateral to medial. Within a year of the initial surgical procedure, 4 patients underwent reoperations for complications. Four patients died.

Conclusions: Pediatric panfacial fractures are rare occurrences; however, the impact of these injuries can be devastating, with concomitant life-threatening injuries and complications. Given the lack of literature, as well as the preventable nature of these injuries, we hope this study can address primary prevention strategies and provide insight toward the management and characteristics of these fractures.
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http://dx.doi.org/10.1016/j.joms.2020.03.001DOI Listing
July 2020

Human-derived Acellular Dermal Matrix Grafts for Treatment of Diabetic Foot Ulcers: A Systematic Review and Meta-analysis.

Wounds 2020 Feb;32(2):57-65

Rutgers New Jersey Medical School, Division of Plastic Surgery, Newark, NJ.

Background: Treating diabetic foot ulcers (DFUs) requires thorough understanding of available surgical tools.

Objective: This meta-analysis compares human-derived acellular dermal matrices (H-ADMs) with standard of care (SOC) to evaluate the number of healed ulcers at 12 and 16 weeks and number of days to complete healing. As a secondary outcome, the efficacy of 3 H-ADM subtypes are studied.

Methods: Two researchers searched PubMed, EMBASE, and The Cochrane Central Register of Controlled Trials for relevant titles from inception through July 2018. Inclusion criteria indicated articles be randomized controlled trials investigating the effects on neuropathic, nonischemic DFUs.

Results: Data from 312 DFUs in total were included in the meta-analysis. The results show H-ADMs are more effective in healing patients within a 12-week (3.14; range, 2.04-4.83) and 16-week period (2.35; range, 1.25-4.43) in comparison with SOC. Further, the mean time to complete healing was shorter in the H-ADM group (-2.31 days; range, -2.67 to -1.95 days) in comparison with SOC. Within the subgroups, 2 H-ADMs were associated with a higher likelihood of complete healing within 12 weeks when compared with SOC. The third H-ADM had a point estimate, which suggested superiority over SOC.

Conclusions: This study shows H-ADMs are associated with a higher likelihood of complete healing and fewer days to complete healing within a 12-week and 16-week periods when compared with SOC. Also, the commercial products performed similarly.
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February 2020

Pediatric Pedestrian Facial Fracture Patterns and Management Following Motor Vehicle Collisions.

J Craniofac Surg 2020 Jan/Feb;31(1):265-268

Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ.

Purpose: Pedestrian trauma due to motor vehicle crashes can be especially destructive to the pediatric population as the facial skeleton is immature and developing. Almost half of crashes resulting in pedestrian death involved alcohol consumption, and children are often victims of irresponsible driving. The objective of this study was to examine the prevalence of facial fractures in this patient population in order to analyze management strategies that optimize functional recovery.

Methods: A retrospective chart review was performed for all facial fractures resulting from motor vehicle collisions with pedestrians in the pediatric population at a level 1 trauma center in an urban environment (University Hospital in Newark, NJ). Patient demographics were collected, as well as location of fractures, concomitant injuries, and surgical management strategies.

Results: During the time period examined, 55 patients were identified as 18 years of age or younger and having sustained a facial fracture as the result of being struck by a motor vehicle. The mean age was 11.3 (range 1-18) years, with a male predominance of 69.0%. There were a total of 125 fractures identified on radiologic imaging via CT or X-ray. The most common fractures were those of the orbit (20.0%), mandible (19.2%), and nasal bone (10.4%). The mean Glasgow Coma Scale on arrival was 12.1 (range 4-15). Fifteen patients were intubated on, or prior to, arrival to the trauma bay. The most common concomitant injuries were intracranial hemorrhage, long bone fractures, and cervical spine fractures. The mean operative time was 216.9 (range 63-515) minutes. Surgery was required in 36 patients, with most undergoing open reduction and internal fixation with titanium plates and screws. Two patients required resorbable plates, and one required Medpor implants. The mean hospital length of stay was 9.9 (range 1-59) days. Two patients expired.

Conclusions: There is currently a dearth of literature regarding the management and patterns of injury for pediatric pedestrian injuries due to motor vehicle collisions. The impact of these injuries can be devastating with concomitant life-threatening complications, and may influence the future development of the facial skeleton after healing of the bone and soft tissue. The authors hope this study can provide insight and further investigation regarding prevention and management.
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http://dx.doi.org/10.1097/SCS.0000000000006034DOI Listing
March 2020

Sports-Related Pediatric Facial Trauma: Analysis of Facial Fracture Pattern and Concomitant Injuries.

Surg J (N Y) 2019 Oct 9;5(4):e146-e149. Epub 2019 Oct 9.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey.

 Sports-related injuries, such as facial fractures, are potentially debilitating and may lead to long-term functional and aesthetic deficits in a pediatric patient. In this study, we analyze sports-related facial fractures in the urban pediatric population in an effort to characterize patterns of injury and improve management strategies and outcomes.  Retrospective chart review was performed for all facial fractures resulting from sports injuries in the pediatric population at a level-1 trauma center (University Hospital, Newark, NJ).  Seventeen pediatric patients were identified as having sustained a fracture of the facial skeleton due to sports injury. Mean age was 13.9 years old. A total of 29 fractures were identified. Most common fracture sites included the orbit (  = 12), mandible (  = 5), nasal bone (  = 5), and zygomaticomaxillary complex (  = 3). The most common concomitant injuries included skull fracture (  = 3), intracranial hemorrhage (  = 4), and traumatic brain injury (  = 4). One patient was intubated upon arrival to the emergency department. Hospital admission was required in 13 patients, 4 of which were admitted to an intensive care setting. Nine patients required operative intervention. Mean length of hospital stay was 2.4 days. No patients were expired.  Sports-related facial fractures are potentially debilitating injuries in the pediatric population. Analysis of fracture pattern and concomitant injuries is imperative to develop effective management strategies and prevention techniques.
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http://dx.doi.org/10.1055/s-0039-1697627DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6785318PMC
October 2019

Patterns of Nasoorbitalethmoid Fractures in the Pediatric Population.

Am Surg 2019 Jul;85(7):730-732

There is an absence of literature regarding nasoorbitoethmoid (NOE) facial fractures. Although NOE fractures are uncommon, there are a significant number in the pediatric population. These fractures also often occur in conjunction with other facial fractures because the NOE region adjoins the nose, orbit, maxilla, and cranium. They can also be a harbinger for more serious concerns such as traumatic brain injury and intracranial hemorrhage. For this reason, NOE fractures can be highly complicated and a challenge to manage. We aim to define the etiologies and patterns of NOE fractures to guide hospital and surgical management strategies. From 2001 to 2014, 15 pediatric patients were identified as having sustained an NOE fracture. Four (26.7%) of the patients were female and 11 (68.8%) were male. Average age was 11.40. The most common etiologies recorded were motor vehicle accident (n = 8), pedestrian struck (n = 3), and assault (n = 2). Orbital fracture (n = 13), nasal fracture (n = 13), and frontal sinus fracture (n = 10) were the most commonly associated facial fractures sustained alongside NOE fracture. Several patients sustained traumatic brain injury (n = 11) and loss of consciousness (n = 13). The mean Glasgow Coma Score was 10.5. In addition, eight required intubation and five required a surgical airway. Thirteen of the patients were admitted to the ICU and eight required surgical management for their fractures. Titanium plates were most commonly used (n = 4) for surgical management. Alternatively, resorbable implants were used for two patients. The remaining two were treated with closed reduction.
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July 2019

Management of Frontal Bone Fractures.

J Craniofac Surg 2019 Oct;30(7):2026-2029

Division of Plastic and Reconstructive Surgery, Department of Surgery.

Background: The purpose of this study was to examine a level 1 trauma center's 12-year experience treating frontal sinus fractures with regards to patient demographics, management strategies, and treatment outcomes.

Methods: An institutional review board-approved retrospective review of all facial fractures at a level 1 trauma center was performed for the years 2000 to 2012. Patient demographics, location of fractures, concomitant injuries, use of antibiotics, surgical management strategies and outcomes were collected for all frontal sinus fractures. A significance value of 5% was used.

Results: There were 291 frontal sinus fractures treated at our institution. The mean age of patients was 34.4 years with a male predominance (90%). The most common mechanisms of injury were assault in 82 (28.2%) and motor vehicle accidents in 80 (27.5%). Anterior table fractures were seen in 261 patients (89.7%) and posterior table fractures were seen in 181 (62.2%). Treatment included ORIF with sinus preservation in 18 (6.2%), ORIF with sinus obliteration in 20 (6.9%), and cranialization in 18 (6.2%). Antibiotics were started on admission in 152 patients (52.2%). Fatality occurred in 9.3% of patients and complications included meningitis (1%), frontal sinusitis (1%), early wound infection (0.3%), and mucopyelocele (0.3%).

Conclusions: Frontal sinus fractures in our center are most often caused by interpersonal violence. Anterior table fractures were more common than posterior table fractures and ORIF with sinus obliteration was the most common surgical intervention. Most frontal sinus fractures at our institution (82%) were treated conservatively with no surgical intervention and we observed a low rate of long term complications.
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http://dx.doi.org/10.1097/SCS.0000000000005720DOI Listing
October 2019

In vivo expansion and regeneration of full-thickness functional skin with an autologous homologous skin construct: Clinical proof of concept for chronic wound healing.

Int Wound J 2019 Jun 13;16(3):841-846. Epub 2019 Mar 13.

Department of Research and Development, PolarityTE, Inc., Salt Lake City, Utah.

A new cell-tissue technology uses a patient's skin to create an in vivo expanding and self-organising full-thickness skin autograft derived from potent cutaneous appendages. This autologous homologous skin construct (AHSC) is manufactured from a small full-thickness skin harvest obtained from an uninjured area of the patient. All the harvested tissue is incorporated into the AHSC including the endogenous regenerative cellular populations responsible for skin maintenance and repair, which are activated during the manufacturing process. Without any exogenous supplementation or culturing, the AHSC is swiftly returned to the patient's wound bed, where it expands and closes the defect from the inside out with full-thickness fully functional skin. AHSC was applied to a greater than two-year old large (200 cm ) chronic wound refractory to multiple failed split-thickness skin grafts. Complete epithelial coverage was achieved in 8 weeks, and complete wound coverage with full-thickness functional skin occurred in 12 weeks. At 6-month follow-up, the wound remained covered with full-thickness skin, grossly equivalent to surrounding native skin qualitatively and quantitatively equivalent across multiple functions and characteristics, including sensation, hair follicle morphology, bio-impedance and composition, pigment regeneration, and gland production.
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http://dx.doi.org/10.1111/iwj.13109DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6850009PMC
June 2019

Implications of Facial Fracture in Airway Management of the Adult Population: What Is the Most Effective Management Strategy?

Ann Plast Surg 2019 04;82(4S Suppl 3):S179-S184

Division of Craniofacial and Reconstructive Surgery, Department of Surgery, University of Mississippi Medical Center, Jackson, MS.

Purpose: Facial fractures are a harbinger when it comes to airway management. Facial fractures can cause airway obstruction or preclude the use of intubation. We aim to examine the etiologies, types of facial fractures, and the risk factors that may lead to requirement of an advance airway.

Methods: A retrospective chart review was performed of all facial fractures in the adult population in a level 1 trauma center in an urban environment (University Hospital in Newark, NJ). Patient demographics were collected, as well as location of fractures, concomitant injuries, and course of hospital stay.

Results: During the period examined, 2626 patients were identified as 18 years or older and with facial fracture. Among these patients, 443 received airway management. Mean age was 34.21 years (range, 18-95 years), with a male predominance of 91.9%. One hundred nineteen patients were intubated on, or before, arrival to the trauma bay. One hundred three patients required surgical airways on arrival to the trauma bay, and 91 of these patients were also reported to have been intubated before arrival. There were a total of 741 fractures identified on radiologic imaging. The most common fractures observed were orbital fractures, frontal sinus fractures, and nasal fractures. Mean Glasgow Coma Scale score on arrival was 9.45 (range, 3-15). Gunshot wound was also the most common etiology among those who were intubated and those who received a surgical airway. The most common concomitant injuries were traumatic brain injury, intracranial hemorrhage, and skull fracture. Forty-one patients died, most of which were intubated during their hospital course.

Conclusions: There is a dearth of literature detailing standardization of airway management for patients who present with facial fractures. The difference between intubation and surgical airway is often a subjective judgment call, but the authors believe that a more streamlined process can be elucidated after analyzing previous trends as well as variabilities in patient survival and prognosis.
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http://dx.doi.org/10.1097/SAP.0000000000001883DOI Listing
April 2019

Facial Fractures as a Result of Falls in the Elderly: Concomitant Injuries and Management Strategies.

Craniomaxillofac Trauma Reconstr 2019 Mar 17;12(1):45-53. Epub 2018 May 17.

Department of Plastic Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey.

Mechanical falls are a common cause of facial trauma in the elderly population. It has been shown that the likelihood of sustaining a facial fracture due to a fall or activities of daily life significantly increases with age. Craniomaxillofacial fractures are most common during the first three decades of life; however, elderly patients more frequently require lengthy hospital stays and surgical intervention, and have shown increased complication rates compared with younger patients. The objective of this study was to examine the prevalence of facial fractures secondary to mechanical falls in the elderly population to analyze mechanism of injury, comorbidities, and fracture management. A retrospective review of all facial fractures as a result of falls in the elderly population in a level 1 trauma center in an urban environment was performed for the years 2002 to 2012. Patient demographics were collected, as well as location of fractures, concomitant injuries, and surgical management strategies. During the time period examined, 139 patients were identified as greater than 60 years of age and having sustained a fracture of the facial skeleton as the result of a fall. The average age was 75.7 (range, 60-103) years, with no gender predominance of 50.4% female and 49.6% male. There were a total of 205 fractures recorded. The most common fractures were those of the orbit (42.0%), nasal bone (23.4%), zygoma (13.2%), and zygomaticomaxillary complex (7.32%). The average Glasgow Coma Scale on arrival was 12.8 (range, 3-15). Uncontrolled hemorrhage was noted on presentation to the trauma bay in five patients. Twenty-one patients were intubated on, or prior to, arrival to the trauma bay, and 44 required a surgical airway. The most common concomitant injury was a long bone fracture (23.5%), followed by cervical spine fracture (18.5%), skull fracture (17.3%), intracerebral hemorrhage (17.3%), rib fracture (17.3%), ophthalmologic injuries (6.2%), short bone fracture (4.9%), pelvic fracture (2.9%), thoracic spine fracture (1.2%), and lumbar spine fracture (1.2%). Of the 114 patients admitted to the hospital, 53 were admitted to an intensive care setting. The average hospital length of stay was 8.97 days (range, 0-125). Sixteen patients expired. Surgical management of fractures in the operating room was required in 47 of the 139 patients. Of the patients treated, 36.2% required an open reduction and internal fixation procedure. Facial fractures as a result of falls in the geriatric population represent an increasing number of cases in clinical practice as life expectancy steadily rises. These patients require a specific standard of treatment since they are more susceptible to nosocomial infections, as well as have higher complication rates and longer recovery time. Concomitant injuries such as cervical spine and pelvic fractures can greatly increase risk of mortality. Surgical and soft tissue management must be approached with caution to optimize function and aesthetics while preventing secondary infection. The authors hope that this study can provide some insight and further investigation as there is a dearth of literature to the management of facial fractures in falls in elderly patients.
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http://dx.doi.org/10.1055/s-0038-1642034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6391279PMC
March 2019

Traumatic Falls in the Pediatric Population: Facial Fracture Patterns Observed in a Leading Cause of Childhood Injury.

Ann Plast Surg 2019 04;82(4S Suppl 3):S195-S198

University of Mississippi Medical Center, Jackson, MS.

Purpose: Falls are a leading cause of nonfatal injury in the pediatric population, resulting in numerous hospitalizations. Children may not have fully developed reflexive and balancing abilities, rendering them more susceptible to traumatic falls. Here the authors present their findings regarding patterns of facial fracture and concomitant injury seen in the pediatric population secondary to falls.

Methods: A retrospective chart review was performed of all facial fractures as a result of falls in the pediatric population in a level 1 trauma center in an urban environment (University Hospital in Newark, NJ). Patient demographics were collected, as well as location of fractures, concomitant injuries, and surgical management strategies.

Results: Fifty-five patients were identified as 18 years or younger and having sustained a facial fracture as the result of a fall. This cohort was compared with 418 pediatric patients with facial fractures due to nonfall etiologies. The mean age was 9.6 years (range, 0-18 years), with a male predominance of 67.3%. There were a total of 70 fractures identified on radiological imaging. The most frequently fractured bones were the orbit (n = 27), nasal bone (n = 15), and mandible (n = 11). Orbital and frontal sinus fractures each occurred more frequently due to falls compared with all other causes of injury. Patients with orbital fractures were significantly more likely to present with an additional facial fracture compared with those without (P < 0.01). The most common concomitant injuries were traumatic brain injury, skull fracture, and intracranial hemorrhage. Patients who suffered a facial fracture due to a fall were significantly more likely to sustain a concomitant skull fracture (P < 0.05) and intra-abdominal injury (P < 0.05) compared with all other etiologies. Fourteen patients required surgical intervention. One patient died.

Conclusions: Pediatric facial fractures are a unique entity. The general plasticity of the pediatric anatomy can predispose patients to significant injury without obvious external signs. A high level of clinical suspicion is required to avoid misdiagnosis and delay of treatment. The authors hope this study can address a preventable issue in child safety, educate caregivers, and provide insight towards fracture management that fosters functional and aesthetic recovery.
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http://dx.doi.org/10.1097/SAP.0000000000001861DOI Listing
April 2019

Indocyanine Green Laser Angiography in the Setting of Tumescence.

Eplasty 2019 7;19:e1. Epub 2019 Jan 7.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark.

Indocyanine green laser angiography utilizes fluorescent dye to assess tissue perfusion in real time. While various studies have recommended against the concurrent use of indocyanine green angiography with vasoconstrictors, few studies have described the intraoperative effect of tumescent wetting solutions on indocyanine green angiography and its subsequent impact on scan interpretation and clinical decision-making. A retrospective medical record review was performed for cases in which indocyanine green angiography was utilized to assess an area where epinephrine-based tumescent solution had been used. The authors report 2 cases that utilized epinephrine-based tumescent solution along with intraoperative indocyanine green angiography assessment of the region. The first case was a bilateral reduction mammoplasty, whereas the second case was a nipple-sparing mastectomy with immediate tissue expander reconstruction. In both cases, intraoperative angiography predicted poor tissue perfusion while clinical examination showed good perfusion. Clinical examination was followed in both cases, with no additional tissue being removed. Neither case resulted in tissue necrosis despite angiography results. While indocyanine green angiography is a powerful tool in tissue perfusion assessment, there are some situations in which clinical examination must be used to determine tissue viability.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6337689PMC
January 2019

Reconstruction of Simple Incomplete Syndactyly of the Foot.

Eplasty 2018 3;18:ic24. Epub 2018 Dec 3.

Rutgers-New Jersey Medical School, Newark.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6322353PMC
December 2018

Extracellular polymeric substance (EPS)-degrading enzymes reduce staphylococcal surface attachment and biocide resistance on pig skin in vivo.

PLoS One 2018 10;13(10):e0205526. Epub 2018 Oct 10.

Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, United States of America.

Staphylococcal extracellular polymeric substances (EPS) such as extracellular DNA (eDNA) and poly-N-acetylglucosamine surface polysaccharide (PNAG) mediate numerous virulence traits including host colonization and antimicrobial resistance. Previous studies showed that EPS-degrading enzymes increase staphylococcal biocide susceptibility in vitro and in vivo, and decrease virulence in animal models. In the present study we tested the effect of EPS-degrading enzymes on staphylococcal skin colonization and povidone iodine susceptibility using a novel in vivo pig model that enabled us to colonize and treat 96 isolated areas of skin on a single animal in vivo. To quantitate skin colonization, punch biopsies of colonized areas were homogenized, diluted, and plated on agar for colony forming unit enumeration. Skin was colonized with either Staphylococcus epidermidis or Staphylococcus aureus. Two EPS-degrading enzymes, DNase I and the PNAG-degrading enzyme dispersin B, were employed. Enzymes were tested for their ability to inhibit skin colonization and detach preattached bacteria. The effect of enzymes on the susceptibility of preattached S. aureus to killing by povidone iodine was also measured. We found that dispersin B significantly inhibited skin colonization by S. epidermidis and detached preattached S. epidermidis cells from skin. A cocktail of dispersin B and DNase I detached preattached S. aureus cells from skin and increased their susceptibility to killing by povidone iodine. These findings suggest that staphylococcal EPS components such as eDNA and PNAG contribute to skin colonization and biocide resistance in vivo. EPS-degrading enzymes may be a useful adjunct to conventional skin antisepsis procedures in order to further reduce skin bioburden.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0205526PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6179274PMC
March 2019

Amniotic Membrane Adjuncts and Clinical Applications in Wound Healing: A Review of the Literature.

Wounds 2018 Jun;30(6):168-173

Rutgers New Jersey Medical School, Newark, NJ.

Introduction: Recent advances in the preservation and processing of amnion/chorion tissue have dramatically increased the bioavailability of these wound healing factors as well as the shelf life of their related tissue products, allowing for a surge in clinical use. Many studies, including basic science, clinical trials, and randomized controlled trials, have emerged examining the biologic properties of amnion/chorion membrane products and their efficacy in wound healing.

Objective: A literature review was conducted regarding the safety and efficacy of amniotic membrane adjuncts.

Methods: The PubMed and MEDLINE databases were queried and sorted based on clinical trials with publication dates ranging from 2013 to 2017. Only studies pertaining to human subjects were included for review.

Results: Amnion/chorion membranes have been studied in the treatment of burns, diabetic foot ulcers, fistulas, ocular defects, and venous leg ulcers, among other wounds. Amnion/chorion allografts were found to be beneficial in the setting of difficult-to-heal fistulas and were effective in treating diabetic and venous ulcers when combined with standard therapy.

Conclusions: Overall, clinical trials have demonstrated that patients treated with amniotic membrane products have increased rates of wound healing compared with the standard of care. Additional trials are needed to examine more amnion/chorion membrane products.
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June 2018

A Single-Center Review of Facial Fractures as the Result of High-Speed Projectile Injuries.

Eplasty 2018 9;18:e16. Epub 2018 Apr 9.

Division of Plastic Surgery, Department of Surgery, New Jersey Medical School, Rutgers Biomedical Health Sciences, Newark.

Gunshot injuries to the face that result in fractures of the underlying skeleton present a challenge in management. The goal of this study was to evaluate patterns of facial fractures as a result of gunshot injuries and strategies for management. A retrospective review of facial fractures resulting from gunshot injuries in a level 1 trauma center was performed for the years 2000 to 2012. Data were collected for patient demographics, fracture distribution, concomitant injuries, and surgical management strategies. A total of 190 patients sustained facial fractures from a gunshot injury. The average age was 29.9 years, and 90% were male. Sixteen injuries were self-inflicted. The most common fractures were of the mandible and the orbit. Uncontrolled hemorrhage was noted on presentation in 68 patients; 100 patients were intubated on arrival. The average Glasgow Coma Scale score on arrival was 11.9. Concomitant injuries included skull fracture, intracranial hemorrhage, and intrathoracic injury. Surgical management was required in 89 patients. Nine patients required soft-tissue coverage. Thirty patients expired. Gunshot injuries to the face resulting in fractures of the underlying skeleton have high instances of morbidity and mortality. Life-threatening concomitant injuries can complicate management of facial fractures in this population.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5896170PMC
April 2018

Pediatric Facial Fractures: An Assessment of Airway Management.

J Craniofac Surg 2017 Nov;28(8):2004-2006

Rutgers New Jersey Medical School, Newark, NJ.

Pediatric facial fractures present unique and challenging management considerations, especially with regards to airway management. Anatomical differences in children increase both airway resistance and the difficulty of intubation. A surgical airway may be required if intubation is unable to be performed. The purpose of this study was to examine a single center's experience with pediatric facial fractures to determine the frequency of advanced airway use, as well as the risk factors that may predispose a patient to requiring an advanced airway. A retrospective review of all facial fractures at a level 1 trauma center was performed from 2000 to 2012. Patients age 18 years and younger were included. Patient demographics were collected, as well as location of fractures, concomitant injuries, services consulted, and surgical management strategies. Information was collected regarding the need for an advanced airway, including intubation and the need for a surgical airway. A total of 285 patients met inclusion criteria. Of these, 57 patients (20%) required emergency intubation and 5 (1.8%) required a surgical airway. Intubation was significantly related to fractures of the midface, frontal sinuses, spine, skull, and pelvis, as well as depressed Glasgow coma scores and traumatic brain injury. The need for a surgical airway is extremely uncommon (1.8%), and tracheostomy was only needed in the setting of penetrating head trauma. Both emergent intubation and tracheostomy are associated with complications, but these complications must be weighed against the potentially life-saving measure of securing an airway.
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http://dx.doi.org/10.1097/SCS.0000000000004036DOI Listing
November 2017

An Analysis of Malpractice Litigation and Expert Witnesses in Plastic Surgery.

Eplasty 2017 28;17:e30. Epub 2017 Sep 28.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark.

Expert witness testimony is crucial for juror decision making. The goals of this study were to examine the trends in malpractice litigation in plastic surgery and to examine the characteristics of expert witnesses in litigation. The Westlaw legal database was queried for jury verdict and settlement reports related to plastic surgery cases from 2009 to 2015. Cases were examined for expert witness testimony, procedure performed, alleged injury, cause of action, verdict, and indemnity payments. Ninety-three relevant cases were examined. Mean plaintiff award was $1,036,469, whereas mean settlement was $633,960. The most commonly litigated procedures involved breast surgery (34.4%), liposuction (18.3%), and body contouring (14.0%). Cases involving body contouring (risk ratio [RR] = 1.48; 95% CI, 1.04-2.10) were more likely to result in favor of the defendant, whereas cases involving breast surgery (RR = 0.27; 95% CI, 0.13-0.57) were more likely to result in favor of the plaintiff ( < .05). Cases in which there was claimed pain (RR = 1.22; 95% CI, 1.01-1.48) or emotional distress (RR = 1.38; 95% CI, 1.11-1.70) were more likely to result in favor of the plaintiff ( < .05). The party of a lawsuit was more likely to win the case if its expert witness was a plastic surgeon ( < .05). Plastic surgery litigation tends to favor defendants. Most litigation involves breast surgery, liposuction, and body contouring. The type of procedure and alleged claim affect case success. Parties with a plastic surgeon as an expert witness tend to be more successful in litigation.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5638964PMC
September 2017