Publications by authors named "Paul N Manson"

93 Publications

Concomitant Pediatric Burns and Craniomaxillofacial Trauma.

J Craniofac Surg 2021 Jul 12. Epub 2021 Jul 12.

Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL Division of Plastic Surgery, Yale-New Haven Hospital, New Haven, CT.

Abstract: This study is the first to investigate pediatric craniomaxillofacial (CMF) trauma patients that present with concomitant burns. The authors aim to identify differing etiologies, presentations, facial fracture patterns, interventions, and outcomes between pediatric CMF trauma patients with versus without concomitant burns. In this retrospective cohort study of a tertiary care center between the years 1990 and 2010, concomitant burns were identified among pediatric patients presenting with CMF fractures. Patient charts were reviewed for demographics, presentation, burn characteristics (total body surface area %, location, and degree), imaging, interventions, involvement of child protective services, and long-term outcomes. Data were analyzed using two-tailed Student t tests and chi-square analysis. Of the identified 2966 pediatric CMF trauma patients (64.0% boys; age 7 ± 4.7 years), 10 (0.34%) patients presented with concomitant burns. Concomitant burn and CMF traumas were more likely to be due to penetrating injuries (P < 0.0001) and had longer hospital lengths of stay (13 ± 18.6 versus 4 ± 6.2 days, P < 0.0001). 40% were due to child abuse, 40% due to motor vehicle collisions, and 20% due to house fires. All four child abuse patients presented in a delayed fashion; operative burn care was prioritized and 70% of the CMF fractures were managed nonoperatively. Concomitant burn and CMF trauma is a rare injury pattern in pediatrics and warrants skeletal surveys with suspicious injury patterns. Future research is necessary to develop practice guidelines.
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http://dx.doi.org/10.1097/SCS.0000000000007839DOI Listing
July 2021

Neuroma of The Supraorbital Nerve Following Forehead Flap Reconstruction - Presentation and Surgical Management.

J Craniofac Surg 2021 Jun;32(4):1515-1516

Department of Plastic and Reconstructive Surgery.

Abstract: Localized pain or headache from neuroma formation is a rare and challenging complication of forehead flap surgery. Here the authors present a patient who developed local pain and dysesthesia following iatrogenic injury to the left supraorbital nerve during forehead flap elevation. Following a diagnostic nerve block in clinic, surgical excision of the neuroma was performed through an upper blepharoplasty approach. The patient had immediate postoperative pain relief and remains pain free at fifteen-month follow-up. The authors describe etiology, workup, and surgical management of sensory nerve injury during forehead flap reconstruction.
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http://dx.doi.org/10.1097/SCS.0000000000007566DOI Listing
June 2021

Combined Symphyseal and Condylar Fractures: Considerations for Treatment in Growing Pediatric Patients.

Plast Reconstr Surg 2021 Jul;148(1):51e-62e

From the Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital; the Department of Plastic and Oral Surgery, Boston Children's Hospital; and the Division of Plastic and Reconstructive Surgery, Rush Medical College of Rush University.

Background: Combined symphyseal-condylar mandible fractures are relatively common but difficult to manage in children. This study investigated the cause and management of symphyseal-condylar fractures in pediatric patients.

Methods: This study presents a retrospective review and expert opinion of pediatric symphyseal-condylar mandibular fracture management at the authors' institution between 1990 and 2019. National data from the Healthcare Cost and Utilization Project Kids' Inpatient Database (2000 to 2016) were used to determine whether institutional data had national applicability.

Results: Twenty-one patients at the authors' institution met inclusion criteria. Of these patients, 26.7 percent of deciduous dentition patients underwent open reduction and internal fixation, 40 percent underwent closed treatment (maxillomandibular fixation), and 33.3 percent received a soft diet. All mixed dentition patients underwent open reduction and internal fixation or closed treatment; all permanent dentition patients underwent open reduction and internal fixation. The national database (n = 1708) demonstrated similar treatment patterns: most permanent dentition patients (88.7 percent) underwent open reduction and internal fixation, most mixed dentition patients (79.2 percent) underwent closed treatment, and among deciduous dentition patients, 53.5 percent patients received a soft diet; 38 percent received closed treatment. In this study, the overall posttreatment complication rate was 62.5 percent among open reduction and internal fixation patients, 14.3 percent among closed treatment patients, and 16.7 percent among patients treated with a soft diet.

Conclusions: Symphyseal-condylar mandibular fractures were associated with substantial morbidity in children. The authors created a treatment algorithm to maximize outcomes in children who suffer from this challenging fracture pattern.

Clinical Question/level Of Evidence: Therapeutic, III.
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http://dx.doi.org/10.1097/PRS.0000000000008055DOI Listing
July 2021

Discussion: Fifteen-Year Review of the American Board of Plastic Surgery Maintenance of Certification Tracer Data: Clinical Practice Patterns and Evidence-Based Medicine in Zygomatico-Orbital Fractures.

Authors:
Paul N Manson

Plast Reconstr Surg 2021 Jun;147(6):976e-977e

From the Johns Hopkins School of Medicine, University of Maryland Shock Trauma Unit, and the University of Maryland School of Medicine.

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http://dx.doi.org/10.1097/PRS.0000000000008005DOI Listing
June 2021

The Association of Zygomaticomaxillary Complex Fractures with Naso-Orbitoethmoid Fractures in Pediatric Populations.

Plast Reconstr Surg 2021 May;147(5):777e-786e

From the Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital; the Department of Biostatistics, Boston University School of Public Health; and the Division of Plastic and Reconstructive Surgery, Department of Surgery, Rush Medical College.

Background: Naso-orbitoethmoid fractures associated with ipsilateral zygomaticomaxillary complex fractures are more challenging injuries than zygomaticomaxillary complex fractures alone. However, there is a paucity of information on this complex fracture pattern in the pediatric population. This study investigated the cause, treatment, and outcomes of combined zygomaticomaxillary complex and naso-orbitoethmoid fractures versus isolated zygomaticomaxillary complex fractures in pediatric patients.

Methods: This was a 25-year retrospective cohort study of pediatric patients who presented to a single institution with zygomaticomaxillary complex fractures. Baseline patient demographics and clinical information, and concomitant injuries, treatment/operative management, and postoperative complications/deformities were recorded and compared between patients with combined zygomaticomaxillary complex and naso-orbitoethmoid fractures and patients with isolated zygomaticomaxillary complex fractures.

Results: Forty-nine patients were identified to have had zygomaticomaxillary complex fractures in the authors' 25-year study period, of whom 46 had adequate clinical documentation and follow-up. Seventeen patients had combined zygomaticomaxillary complex-naso-orbitoethmoid fractures, of whom six had panfacial fractures. Both patient groups (zygomaticomaxillary complex only and combined zygomaticomaxillary complex-naso-orbitoethmoid fractures) were similar in terms of demographics. However, a significantly greater proportion of combined fracture patients experienced postoperative complications compared to isolated zygomaticomaxillary complex fracture patients, even after excluding those with panfacial fractures (87.5 percent versus 35.3 percent; p < 0.001). Enophthalmos (37.5 percent) and midface growth restriction (37.5 percent) were the two most common complications/deformities in all combined fracture patients.

Conclusions: High-impact trauma can lead to zygomaticomaxillary complex fractures with associated naso-orbitoethmoid fractures in children. This injury pattern was found to cause significantly greater postoperative morbidity than isolated zygomaticomaxillary complex fractures alone. Thus, pediatric patients presenting with this complex facial fracture pattern should be closely monitored.

Clinical Question/level Of Evidence: Risk, II.
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http://dx.doi.org/10.1097/PRS.0000000000007836DOI Listing
May 2021

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

Plast Reconstr Surg 2021 02;147(2):443-452

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

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

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

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

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

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

Resolution of Vertical Gaze Following a Delayed Presentation of Orbital Floor Fracture With Inferior Rectus Entrapment: The Contributions of Charles E. Iliff and Joseph S. Gruss in Orbital Surgery.

Craniomaxillofac Trauma Reconstr 2020 Dec 18;13(4):253-259. Epub 2020 Nov 18.

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

Introduction: Orbital floor fractures occur commonly as a result of blunt trauma to the face and periorbital region. Orbital floor fractures with a "trapdoor" component allow both herniation and incarceration of contents through a bone defect into the maxillary sinus as the bone rebounds faster than the soft tissue, trapping muscle, fat, and fascia in the fracture site. In children, the fractured floor, which is often hinged on one side, tends to return toward its original anatomical position due to the incomplete nature of the fracture and elasticity of the bone. The entrapment of the inferior rectus muscle itself is considered a true surgical emergency-prolonged entrapment frequently leads to muscle ischemia and necrosis leading to permanent limitation of extraocular motility and difficult to correct diplopia. For this reason, prompt surgical intervention is recommended by most surgeons. In adults, true entrapment of the muscle itself is not as common because the orbital floor is not as elastic and fractures are more complete.

Methods: We present an adult patient with an isolated orbital floor fracture with clinical and radiologic evidence of true entrapment of the inferior rectus muscle itself.

Results: Despite the delayed surgical repair (4 days after the injury), the patient's inferior rectus muscle function returned to near normal with mild upward gaze diplopia.

Conclusions: Inferior rectus entrapment in adults may more likely be associated with immobilization of the muscle without total vascular compression/incarceration significant enough to lead to complete ischemic necrosis.
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http://dx.doi.org/10.1177/1943387520965804DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7797985PMC
December 2020

"JOE" (JOSEPH S. GRUSS, MD).

Authors:
Paul N Manson

Craniomaxillofac Trauma Reconstr 2020 Dec 18;13(4):245. Epub 2020 Nov 18.

Distinguished Service Professor, Johns Hopkins School of Medicine.

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http://dx.doi.org/10.1177/1943387520965805DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7797977PMC
December 2020

Surgical Treatment and Visual Outcomes of Adult Orbital Roof Fractures.

Plast Reconstr Surg 2021 01;147(1):82e-93e

From the Division of Plastic, Reconstructive, and Maxillofacial Surgery, R Adams Cowley Shock Trauma Center; the Department of Plastic and Reconstructive Surgery, Johns Hopkins University; and the Division of Plastic and Reconstructive Surgery, University of Maryland School of Medicine.

Background: Fractures of the orbital roof require high-energy trauma and have been linked to high rates of neurologic and ocular complications. However, there is a paucity of literature exploring the association between injury, management, and visual prognosis.

Methods: The authors performed a 3-year retrospective review of orbital roof fracture admissions to a Level I trauma center. Fracture displacement, comminution, and frontobasal type were ascertained from computed tomographic images. Pretreatment characteristics of operative orbital roof fractures were compared to those of nonoperative fractures. Risk factors for ophthalmologic complications were assessed using univariable/multivariable regression analyses.

Results: In total, 225 patients fulfilled the inclusion criteria. Fractures were most commonly nondisplaced [n = 118 (52.4 percent)] and/or of type II frontobasal pattern (linear vault involving) [n = 100 (48.5 percent)]. Eight patients underwent open reduction and internal fixation of their orbital roof fractures (14.0 percent of displaced fractures). All repairs took place within 10 days from injury. Traumatic optic neuropathy [n = 19 (12.3 percent)] and retrobulbar hematoma [n = 11 (7.1 percent)] were the most common ophthalmologic complications, and led to long-term visual impairment in 51.6 percent of cases.

Conclusions: Most orbital roof fractures can be managed conservatively, with no patients in this cohort incurring long-term fracture-related complications or returning for secondary treatment. Early fracture treatment is safe and may be beneficial in patients with vertical dysmotility, globe malposition, and/or a defect surface area larger than 4 cm2. Ophthalmologic prognosis is generally favorable; however, traumatic optic neuropathy is major cause of worse visual outcome in this population.

Clinical Question/level Of Evidence: Risk, III.
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http://dx.doi.org/10.1097/PRS.0000000000007436DOI Listing
January 2021

Open Reduction, Internal Fixation, or Maxillo-Mandibular Fixation for Isolated, Unilateral, Tooth-Bearing, Mandibular Body Fractures in Children.

J Craniofac Surg 2021 Jan-Feb 01;32(1):73-77

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

Background: Mandibular body fractures can cause severe and long-term morbidity in the pediatric population. Nonetheless, there is insufficient data on the treatment and management of this specific fracture type in children. This study aimed to investigate the etiology, treatment, and outcomes of pediatric mandibular body fractures by analyzing our institution's experience managing these uncommon injuries.

Methods: This was a 30-year retrospective, longitudinal cohort study of pediatric patients presenting to a single institution with isolated, unilateral, mandibular body fractures. Patient data was extracted from electronic medical records, while subgroup analysis was completed by dentition stage.

Results: A total of 14 patients met inclusion criteria, of whom 8 (57.1%) had deciduous, 3 (21.4%) had mixed, and 3 (21.4%) had permanent dentition. Deciduous dentition patients with displaced, mobile or comminuted fractures underwent open reduction and internal fixation (ORIF), while those with nondisplaced and/or nonmobile fractures received soft diet or closed treatment with maxillomandibular fixation. For the mixed dentition cohort, all patients (100%) received closed treatment with maxillomandibular fixation. Among permanent dentition patients, most patients (66.6%) underwent ORIF regardless of fracture severity. The post-ORIF complication rate was 20% (dental maleruption).

Conclusions: Isolated, unilateral mandible body fractures are relatively uncommon in the pediatric population, and management differs by dentition stage and injury pattern. While isolated body fractures had considerable associated morbidity, this fracture pattern did not result in major growth restrictions or malformations.
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http://dx.doi.org/10.1097/SCS.0000000000006990DOI Listing
June 2021

Open Reduction, Internal Fixation of Isolated Mandible Angle Fractures in Growing Children.

J Craniofac Surg 2020 Oct;31(7):1946-1950

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

Background: Mandible angle fractures can result in significant, long-term morbidity in children. However, management of this particular mandibular fracture type is not well-characterized in the pediatric population. This study investigated isolated mandibular angle fractures in the pediatric patients.

Methods: This was a 30-year retrospective, longitudinal cohort study of pediatric patients presenting to a single institution with mandibular angle fractures. Patient data were abstracted from electronic medical records. Subgroup analyses were completed by dentition stage.

Results: Seventeen patients met inclusion criteria, of whom 6 (35.3%) had deciduous, 4 (23.5%) had mixed, and 7 (41.2%) had permanent dentition. Deciduous/mixed dentition patients with mobile, displaced fractures underwent ORIF, whereas those with nondisplaced fractures underwent treatment with soft diet. Among permanent dentition patients, most patients (71.4%) underwent ORIF regardless of fracture severity. The post-ORIF complication rate was 55.6%; no complications were reported after soft diet or closed treatment (Fischer exact: P = 0.05). The most common post-ORIF complication was alveolar nerve paresthesia (17.6%) and post-ORIF complication rates did not vary by age (deciduous: 16.7%, mixed: 25.0%, permanent: 42.9%, Fischer exact: P = 0.80). ORIF patients who received a single upper border miniplate had a lower complication rate (42.9%) than other plating methods (upper and lower miniplates-100%). Fracture severity was predictive of post-ORIF complications (odds ratio: 2.23, 95% confidence interval: 2.22-2.24, P < 0.0001).

Conclusions: Isolated mandible angle fractures were relatively rare in children, and treatment requirements varied by injury severity and dentition stage. Although isolated angle fractures had substantial associated morbidity, this fracture pattern did not result in notable growth limitations/deformity.
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http://dx.doi.org/10.1097/SCS.0000000000006892DOI Listing
October 2020

Managing Isolated Symphyseal and Parasymphyseal Fractures in Pediatric Patients.

J Craniofac Surg 2020 Jul-Aug;31(5):1291-1296

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

Background: Isolated symphyseal or parasymphyseal mandibular fractures can confer significant morbidity in children. However, this mandibular injury pattern has not been well-characterized in children. This study investigated isolated symphyseal/parasymphyseal mandibular fractures in pediatric patients.

Methods: This was a 29-year retrospective, longitudinal cohort study of pediatric patients who presented to a single institution with isolated symphyseal/parasymphyseal mandibular fractures. Patient data were abstracted from medical records and compared between patients of varying dentition stages.

Results: Fourteen patients met inclusion criteria during the study period, of whom 2 (14.3%) had deciduous dentition, 7 (50.0%) had mixed dentition, and 5 (35.7%) had permanent dentition. Patients with deciduous dentition were significantly more likely to receive soft diet or closed treatment with mandibulomaxillary fixation than open reduction and internal fixation when compared to patients with mixed or permanent dentition (p = 0.04). The post-treatment complication rate was 40% among all patients treated with open reduction and internal fixation, 16.7% among patients who underwent closed treatment with mandibulomaxillary fixation, and 75% amongst patients treated with soft diet (though 2 patients who received soft diet had permanent dentition and thus were inappropriately managed). The most common complication overall was malocclusion (20%). A treatment algorithm was proposed based on study data; adherence to the algorithm significantly decreased odds of complications (odds ratio: 0.03, 95% confidence interval:0.001-0.6).

Conclusions: The etiology, management, and outcomes of children with isolated symphyseal or parasymphyseal mandibular fractures at our institution varied by dentition stage. The authors proposed a treatment algorithm in order to optimize outcomes of symphyseal/parasymphyseal mandibular fractures in this patient population.
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http://dx.doi.org/10.1097/SCS.0000000000006573DOI Listing
November 2020

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Discussion: Underdiagnosis of Nasoorbitoethmoid Fractures in Patients with Zygoma Injury.

Plast Reconstr Surg 2020 04;145(4):1009-1010

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

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http://dx.doi.org/10.1097/PRS.0000000000006733DOI Listing
April 2020

Absorbable Fixation Devices for Pediatric Craniomaxillofacial Trauma: A Systematic Review of the Literature.

Plast Reconstr Surg 2019 09;144(3):685-692

From the Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital.

Background: The purpose of this study was to investigate surgical outcomes with the use of resorbable plating systems for the repair of craniomaxillofacial trauma in the pediatric population.

Methods: A systematic review of the literature was performed. A descriptive analysis, operative technical data, outcomes, and postoperative complications with the use of absorbable plating systems for craniomaxillofacial trauma were included.

Results: The systematic literature review identified 1264 abstracts, of which only 19 met inclusion criteria. From these 19 studies, 312 clinical cases with 443 facial fractures that were treated with absorbable fixation systems were extracted for analysis. The review identified only level III/IV (n = 17) and level V (n = 2) studies. Minor and major complications were rare, occurring in 5.45 percent (n = 17) and 3.21 percent (n = 10) of cases, respectively. The most common complications were surgical-site infections (n = 4) and plate extrusion (n = 4).

Conclusions: This report is, to the authors' knowledge, one of the first comprehensive reports on the use of absorbable plating systems for pediatric craniomaxillofacial trauma. Their analysis suggests that the use of absorbable fixation devices for pediatric craniomaxillofacial trauma is relatively safe, with a low-risk profile. Outcome studies with longer follow-up periods specifically investigating facial growth, reoperation rates, standardized surgical outcome metrics, and cost are necessary to effectively compare these fixation devices to titanium alternatives for craniomaxillofacial trauma.
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http://dx.doi.org/10.1097/PRS.0000000000005932DOI Listing
September 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.
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http://dx.doi.org/10.1055/s-0038-1668500DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6697470PMC
September 2019

Editor's Commentary: Blood Collection within the Maxillary Sinus following Fracture Repair: The Impact of Mesh Implants and Drains.

Authors:
Paul N Manson

Craniomaxillofac Trauma Reconstr 2019 Sep 1;12(3):174. Epub 2019 Jul 1.

Johns Hopkins School of Medicine, Baltimore, Maryland.

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http://dx.doi.org/10.1055/s-0039-1692657DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6697475PMC
September 2019

Frequency of Cervical Spine Injuries in Pediatric Craniomaxillofacial Trauma.

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

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

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

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

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

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

Milton Edgerton and Johns Hopkins, 1941-1970: Building the Foundations of Modern Plastic Surgery.

J Craniofac Surg 2019 Mar/Apr;30(2):282-283

Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.

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http://dx.doi.org/10.1097/SCS.0000000000005311DOI Listing
January 2019

Pediatric Nasoorbitoethmoid Fractures: Cause, Classification, and Management.

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

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

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

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

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

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

Full-Thickness Skin Grafting for Local Defect Coverage Following Scalp Adjacent Tissue Transfer in the Setting of Cranioplasty.

J Craniofac Surg 2019 Jan;30(1):115-119

Neuroplastic and Reconstructive Surgery, Department of Plastic and Reconstructive Surgery.

Introduction: Numerous techniques have been described to overcome scalp deficiency and high-tension closure at time of cranioplasty. However, there is an existing controversy, over when and if a free flap is needed during complex skull reconstruction (ie, cranioplasty). As such the authors present here our experience using full-thickness skin grafts (FTSGs) to cover local defects following scalp adjacent tissue transfer in the setting of cranioplasty.

Methods: By way of an institutional review board-approved database, the authors identified patients treated over a 3-year period spanning January 2015 to December 2017, who underwent scalp reconstruction using the technique presented here. Patient demographics, clinical characteristics, technical details, outcomes, and long-term follow up were statistically analyzed for the purpose of this study.

Results: Thirty-three patients, who underwent combined cranioplasty and scalp reconstruction using an FTSG for local donor site coverage, were identified. Twenty-five (75%) patients were considered to have "high complexity" scalp defects prior to reconstruction. Of them, 12 patients (36%) were large-sized and 20 (60%) medium-sized; 21 (64%) grafts were inset over vascularized muscle or pericranium while the remaining grafts were placed over bare calvarial bone. In total, the authors found 94% (31/33) success for all FTSGs in this cohort. Two of the skin grafts failed due to unsuccessful take. Owing to the high rate of success in this series, none of the patient's risk factors were found to correlate with graft failure. In addition, the success rate did not differ whether the graft was placed over bone verses over vascularized muscle/pericranium.

Conclusion: In contrary to previous studies that have reported inconsistent success with full-thickness skin grafting in this setting, the authors present a simple technique with consistent results-as compared to other more complex reconstructive methods-even in the setting of highly complex scalp reconstruction and simultaneous cranioplasty.
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http://dx.doi.org/10.1097/SCS.0000000000004872DOI Listing
January 2019

Commentary on: The Role of Postoperative Imaging after Orbital Floor Repair.

Authors:
Paul N Manson

Craniomaxillofac Trauma Reconstr 2018 Jun 15;11(2):102-103. Epub 2018 May 15.

Johns Hopkins School of Medicine, Baltimore, Maryland.

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http://dx.doi.org/10.1055/s-0038-1645864DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5993657PMC
June 2018

Pediatric Zygomaticomaxillary Complex Fracture Repair: Location and Number of Fixation Sites in Growing Children.

Plast Reconstr Surg 2018 07;142(1):51e-60e

From the Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine; and the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center.

Background: Relatively few reports have been published investigating the operative management of pediatric zygomaticomaxillary complex fractures. The purpose of this study was to assess pediatric zygomaticomaxillary complex fracture management and associated complications, and potentially describe a standard treatment paradigm for these cases.

Methods: A retrospective cohort review was performed of all patients younger than 15 years presenting to a single institution with zygomaticomaxillary complex fractures from 1990 to 2010. Patient demographics, concomitant injuries, management details, and complications were recorded. Complications were compared among patients by dentition stage, number of fixation points, and identity of fixation sites.

Results: A total of 36 patients with 44 unique zygomaticomaxillary complex fractures met the authors' inclusion criteria. Thirty-two fractures exhibited at least 2.0 mm of diastasis along at least one buttress (73 percent), and all but one of these were managed operatively. Among operatively managed patients with deciduous dentition, two-point fixation was associated with a lower overall complication rate compared with one- and three-point fixation (0 percent versus 75 percent and 75 percent; p = 0.01). Furthermore, rigid plate-and-screw fixation at the zygomaticomaxillary buttress was not associated with an increased complication rate in operatively managed patients with deciduous dentition (40 percent versus 50 percent; p = 0.76).

Conclusions: The authors' results suggest that two-point fixation is an effective management strategy for repair of displaced zygomaticomaxillary complex fractures in children. In addition, rigid plate-and-screw fixation at the zygomaticomaxillary buttress in children with deciduous dentition appears to be safe and effective when performed.

Clinical Question/level Of Evidence: Therapeutic, III.
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http://dx.doi.org/10.1097/PRS.0000000000004487DOI Listing
July 2018

Contemporary Management of Mandibular Fracture Nonunion-A Retrospective Review and Treatment Algorithm.

J Oral Maxillofac Surg 2018 Jul 6;76(7):1479-1493. Epub 2018 Feb 6.

Associate Professor, Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD. Electronic address:

Purpose: Nonunion is an uncommon complication after mandibular fractures. The purpose of this investigation was to compare outcomes of patients with mandibular fracture nonunion who were treated with a 1- versus 2-stage approach and propose a pragmatic treatment algorithm for surgical management based on preoperative characteristics.

Materials And Methods: The authors conducted a retrospective study consisting of patients who presented to 2 level 1 trauma centers for the management of mandibular fracture nonunion over a 10-year period. The primary predictor variable was 1- versus 2-stage treatment. Outcomes were examined to propose a treatment algorithm.

Results: Eighteen patients were included in the study. The sample's mean age was 44.0 ± 19.3 years and most were men (88.9%). Mandibular angle and body accounted for 77.8% of cases. A single-stage approach was used in 13 patients (72.2%). Bone grafts or vascularized bone flaps were required in 13 patients (72.2%). Patients who required 2-stage treatments had intraoral soft tissue defects. Mean length of follow-up was 13.3 ± 20.4 months. All patients achieved bony union, with complications occurring in 5 patients (27.8%). The authors' 10-year experience was used to formulate a treatment algorithm based on bony defect size and soft tissue status, which can be used to inform optimal surgical management.

Conclusions: Nonunion of mandibular fractures is an infrequent and complex condition requiring careful and deliberate surgical management. A single-stage approach is appropriate in most cases and does not negatively affect outcomes. Bony defect size and soft tissue status are essential parameters for determining the approach and timing of reconstruction.
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http://dx.doi.org/10.1016/j.joms.2018.01.027DOI Listing
July 2018

Controversies in the Principles for Management of Orbital Fractures in the Pediatric Population.

Plast Reconstr Surg 2017 03;139(3):804e-805e

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

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http://dx.doi.org/10.1097/PRS.0000000000003122DOI Listing
March 2017

The Ever-Evolving State of the Art: A Look Back at the AONA Facial Reconstruction and Transplantation Meetings.

Craniomaxillofac Trauma Reconstr 2016 Sep 15;9(3):211-8. Epub 2016 Apr 15.

Hansjorg Wyss Department of Plastic Surgery, NYU Langone Medical Center, New York City, New York.

Historically, periodic academic meetings held by surgical societies have set the stage for discussion and exchange of ideas, which in turn have led to advancement of clinical practices. Since 2007, the AONA State of the Art: Facial Reconstruction and Transplantation Meeting (FRTM) has been organized to provide a forum for specialists around the world to engage in open conversation about the approaches currently at the forefront of facial reconstruction. Review of registration data of FRTM iterations from 2007 to 2015 was performed. The total number of participants, along with their level of medical training, location of practice, and medical specialty, was recorded. Additionally, academic programs and 2015 participant feedback were evaluated. From 2007 to 2011, there was a decrease in the overall number of participants, with a slight increase in the number of clinical specialties present. In 2013, a sharp increase in total participants, international attendance, and represented clinical specialties was observed. This trend continued in 2015. Adjustments to academic programs have included reorganization of lectures and optimization of content. FRTM is a unique forum for multidisciplinary professionals to discuss the evolving field of facial reconstruction and join forces to accelerate progress and improve patient care.
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http://dx.doi.org/10.1055/s-0036-1582461DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4980144PMC
September 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.
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http://dx.doi.org/10.1097/PRS.0000000000002152DOI Listing
June 2016

Modified Transconjunctival Approach to the Lower Eyelid: Technical Details for Predictable Results.

Craniomaxillofac Trauma Reconstr 2016 Mar 22;9(1):29-34. Epub 2015 Jun 22.

Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

The transconjunctival approach to the lower orbit is well described in the literature and has been used for both cosmetic and reconstructive purposes. When properly performed, it allows access to the orbital floor and inferior orbital rim with minimal lower lid morbidity and an inconspicuous scar. Many variations of this approach have been described and these can lead to confusion and uncertainty regarding the surgical technique including when and how to best utilize this approach in the traumatized eyelid. Residents and less experienced attendings employing this approach often fail to fully understand the technical and anatomic details that can make this a very fast and simple way to gain complete access to the inferior, medial, and lateral orbit while minimizing complications such as postoperative lid malposition and canthal deformities. We describe our method for transconjunctival access to the inferior orbital rim and orbital floor with specific attention to several precise surgical aspects that make this a fast and reliable technique with low morbidity and predictable architecture of closure.
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http://dx.doi.org/10.1055/s-0035-1556051DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4755724PMC
March 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.
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http://dx.doi.org/10.1097/PRS.0000000000001907DOI Listing
January 2016
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