Optimal Treatment Order With Fibula-Free Flap Reconstruction, Oncologic Treatment, and Dental Implants: A Systematic Review and Meta-Analysis.

Head and neck cancer (HNC) patients benefit from craniofacial reconstruction, but no clear guidance exists for rehabilitation timing. This meta-analysis aims to clarify the impact of oncologic treatment order on implant survival. An algorithm to guide placement sequence is also proposed in this paper. PubMed, Embase, and Web of Science were searched for studies on HNC patients with ablative and fibula-free flap (FFF) reconstruction surgeries and radiotherapy (RTX). Primary outcomes included treatment sequence, implant survival rates, and RTX dose. Of 661 studies, 20 studies (617 implants, 199 patients) were included. Pooled survival rates for implants receiving >60 Gy RTX were significantly lower than implants receiving < 60 Gy (82.8% versus 90.1%, P =0.035). Placement >1 year after RTX completion improved implant survival rates (96.8% versus 82.5%, P =0.001). Implants receiving pre-placement RTX had increased survival with RTX postablation versus before (91.2% versus 74.8%, P <0.001). One hundred seventy-seven implants were placed only in FFF with higher survival than implants placed in FFF or native bone (90.4% versus 83.5%, P =0.035). Radiotherapy is detrimental to implant survival rates when administered too soon, in high doses, and before tumor resection. A novel evidence-based clinical decision-making algorithm was presented for utilization when determining the optimal treatment order for HNC patients. The overall survival of dental prostheses is acceptable, reaffirming their role as a key component in rehabilitating HNC patients. Considerations must be made regarding RTX dosage, timing, and implant location to optimize survival rates and patient outcomes for improved functionality, aesthetics, and comfort.

Cervicofacial Pediatric Tissue Expansion: Aesthetic Unit-Based Algorithm.

BACKGROUND: Tissue expansion is a powerful tool for reconstruction of pediatric soft-tissue pathologies, but complication rates for children have been reported as high as 40%. Infection and implant extrusion lead to premature removal and delays in reconstruction. Expanding the head and neck is uniquely challenging because the confluence of facial aesthetic units must be respected. These challenges have prompted the senior author's creation of an aesthetic-unit based algorithm. METHODS: A retrospective study of pediatric patients who underwent cervicofacial tissue expander placement by the senior author (R.J.R) was performed over a 17-year period. Predictor variables included age, sex, race, indication, number of expanders placed at each operation, serial expansion, expander type, expander size, home versus clinic inflation, and prophylactic antibiotics. Univariate and multivariate analyses were performed to identify risk factors for complications. RESULTS: An aesthetic-unit based reconstructive algorithm is proposed. Forty-eight pediatric patients had 111 cervicofacial tissue expanders placed. Twenty expanders were associated with complications (18%) for surgical site-infection (12.6%), extrusion (4.5%), and expander deflation (6.3%). Expanders placed for congenital nevi (p=0.042) and use of textured expander (p=0.027) were significantly associated with decreased complications. When controlling for covariates, serial expansion of the same site was associated with increased rates of readmission (p=0.027) after having just one prior expander. Iatrogenic ectropion occurred in 13.5% of the study population; expanders with at least one complication during tissue expansion were significantly associated with incidence of iatrogenic ectropion (p=0.026). CONCLUSION: By using an aesthetic-unit based algorithm, reconstructive outcomes can be optimized for pediatric cervicofacial tissue expansion.

Orbital Fracture Characteristics and Outcomes in Baltimore.

Fracture characteristics and postoperative outcomes of patients presenting with orbital fractures in Baltimore remain poorly investigated. The purpose of our study was to determine the fracture patterns, etiologies, and postoperative outcomes of patients treated for orbital fractures at 2 level I trauma centers in Baltimore. A retrospective cohort study was conducted on patients who underwent orbital fracture repair at the R Adams Cowley Shock Trauma Center and the Johns Hopkins Hospital from January 2015 to December 2019. Of 374 patients, 179 (47.9%) had orbital fractures due to violent trauma, 252 (67.4%) had moderate to near-total orbital fractures, 345 (92.2%) had orbital floor involvement, and 338 (90.4%) had concomitant neurological symptoms/signs. Almost half of the patients had at least one postoperative ocular symptom/sign [n = 163/333 (48.9%)]. Patients who had orbital fractures due to violent trauma were more likely to develop postoperative ocular symptoms/signs compared with those who had orbital fractures due to nonviolent trauma [n = 88/154 (57.1%), n = 75/179 (41.9%); P = 0.006]. After controlling for factors pertaining to injury severity, there was no significant difference in patient throughput or incidence of any postoperative ocular symptom/sign after repair between the two centers. Timely management of patients with orbital fractures due to violent trauma is crucial to mitigate the risk of postoperative ocular symptoms/signs.

Penile Transplantation in Gender Affirmation Surgery: A Theoretical Feasibility Study.

BACKGROUND: It can be argued that individuals in the transgender and gender nonbinary (TGNB) community suffer from a similar impact on quality of life in the face of gender dysphoria, with psychosocial and physical consequences. Indications for penile allotransplantation for patients wishing to undergo gender affirmation surgery have yet to be elucidated, but technical lessons for feasibility can be gleaned from penis transplants that have already been performed on cisgender males to date. METHODS: This study investigates the theoretical feasibility for penile-to-clitoral transplantation, prior penile transplants, and current multidisciplinary gender affirmation health care modalities. RESULTS: Penile allotransplantation offers a potential solution for individuals in the TGNB community for a more aesthetic penis, improved erectile function without the need of a prosthesis, optimal somatic sensation, and improved urethral outcomes. CONCLUSION: Questions remain about ethics, patient eligibility, and immunosuppressive sequelae. Before these issues are addressed, feasibility of this procedure must be established.

Lower Extremity Pediatric Tissue Expansion: A Single Surgeon's 16-Year Experience.

BACKGROUND: Tissue expansion is a well-established approach to soft tissue reconstruction in the pediatric population for lower extremity pathologies. Unfortunately, complication rates range from 19% to 40% in literature, including infection and implant extrusion, leading to delays in reconstruction. These challenges have prompted investigation toward categorizing risk factors for lower extremity tissue expander placement. METHODS: A retrospective study of pediatric patients who underwent lower extremity tissue expander placement by the senior author (R.J.R.) was performed over a 16-year period. Patient charts were reviewed to categorize baseline and operative characteristics. Primary outcome variables were surgical-site infection, expander extrusion, and expander deflation. Univariate and multivariate logistic regressions were performed ( α < 0.05). RESULTS: There were 59 tissue expanders in our cohort. The overall complication rate was 27.1% with a 77.2% successful reconstruction rate. Greater number of expanders placed during 1 operation is associated with 2.5 increased odds of having any complication and is associated with 0.4 decreased odds of having a successful reconstruction. Incisions made in scar tissue for expander placement appear to be associated with a greater than 7 times increased odds of readmission. CONCLUSIONS: Reconstruction of soft tissue pathologies using lower extremity tissue expanders in the pediatric population is an effective yet challenging technique. This study identified that the number of expanders inserted during 1 operation, incisions made over scar tissue, and expanders placed in the anterior thigh were correlated with having a negative impact on reconstructive outcomes. Extra care should be taken with patients who require multiple expanders during 1 operation and with choosing the location and incision of expander placement.

Predictors of Postoperative Diplopia Following Orbital Fracture Repair in Adults.

PURPOSE: Postoperative diplopia is reported in up to 52% of orbital bone fracture (OBF) repair. Evidence on these risk factors is based on low-quality data, single-institution studies, and small sample sizes. Our study is the largest and first multi-center study to determine the predictors of postoperative diplopia following OBF repair. METHODS: We conducted a retrospective review of patients who underwent OBF repair at two centers from 2015 to 2019. Our primary outcome was the incidence or persistence of postoperative diplopia at least 2 weeks following OBF repair. Descriptive statistics were calculated. Multivariable logistic regression was performed to determine significant predictors of postoperative diplopia. RESULTS: Of 254 patients, the median (interquartile range [IQR]) age was 36.1 (27.8-50.7) years, and the median (IQR) follow-up was 79.5 (40.3-157.3) days. The most common postoperative ocular symptom was diplopia [n=51/254 (20.1%)]. Patients who had preoperative limited ocular motility or enophthalmos had adjusted odds ratio [aOR] (95% confidence interval [CI]) 2.33 (1.03-5.24) and 2.35 (1.06-5.24) the odds of developing postoperative diplopia, compared to patients who did not have these preoperative symptoms, respectively. Patients who had combined orbital floor and medial wall and moderate OBF (>2 cm2 defect or >3 mm displacement) on preoperative CT scan had aOR (95% CI) 2.16 (1.04-4.46) and 3.77 (1.44-9.83) the odds of developing postoperative diplopia, compared to patients without these preoperative CT findings, respectively. CONCLUSION: During primary assessment of the patient with OBF, preoperative ocular signs and symptoms, fracture severity, and location of OBF are key predictors of postoperative diplopia.

The impact of COVID-19 pandemic on free tissue transfer outcomes: A NSQIP analysis.

BACKGROUND: The COVID-19 pandemic significantly impacted hospital resources and patient care, although its effect on free tissue transfer procedures is poorly understood. We conducted the current study to investigate the potential impact of COVID-19 and its accompanying system shut-downs on the surgical outcomes of patients undergoing free flap procedures. METHODS: Patients undergoing free tissue transfer procedures were identified from the National Surgical Quality Improvement Program (NSQIP) database from 2016 to 2020. We used 2016-2019 as baseline (pre-pandemic) data to compare with 2020 (peri-pandemic). We divided the patients into the following 3 groups: all patients undergoing free tissue transfer, breast reconstruction free tissue transfer, and non-breast free tissue transfer cases. Outcomes of interest included patient morbidity/mortality, time to surgery, time to takeback, and length of hospital stay. We used Pearson's chi-square and Fisher's exact tests to assess categorical variables. Wilcoxon's ranked sign tests and ANOVA tests were used for non-parametric and parametric continuous variables, respectively. Significance was set at alpha < 0.05. RESULTS: When comparing peri-pandemic to pre-pandemic rates, patient morbidity and mortality and unplanned primary or secondary takeback operations were both significantly higher in all 3 groups peri-pandemic. Median time to primary or secondary takeback operation was also significantly greater peri-pandemic. CONCLUSION: Patients undergoing flap procedures peri-pandemic had an overall increase in median morbidity and mortality, unplanned primary or secondary takebacks, and median number of days to takebacks compared to the pre-pandemic period. This is concerning given that any future protocols instituted can have detrimental effects on patients who receive a free tissue transfer procedure.

Socioeconomic Status Diversity of Trainees and Faculty in Residency Programs: A Pilot Study in Plastic Surgery.

INTRODUCTION: The socioeconomic diversity of residents, fellows, and faculty members in any medical or surgical specialty is currently unknown making it difficult to understand socioeconomic status (SES) disparities and create programs to improve diversity. Additionally, the career trajectories of residents and faculty members who come from different SES backgrounds have not been explored. We have performed a survey-based research study to understand the SES composition and career trajectories of residents and faculty members within U.S. Plastic and Reconstructive Surgery (PRS) residency programs. METHODS: An anonymous online survey was administered to 754 recipients within plastic surgery residency programs in the United States. Self-reported SES information such as household income prior to age 18 and parental education level was collected. Data regarding career trajectories was obtained through questions about away rotations and research productivity. RESULTS: A total of 196 fellows, and faculty members participated in the study, with an estimated survey respondent rate of 25.9%. Only 9.9% (10 of 101) of residents and fellows reported a childhood (under age 18) family income less than $40,000. When analyzing parental education and occupation (EO-status), 42.6% (43 of 101) of residents and fellows had at least 1 parent in an executive, managerial, or professional position with a doctorate/professional degree. Low-income and low EO-status were associated with increased utilization of federal and state assistance programs (p = 0.0001) and approval for AAMC's Fee Assistance Program (FAP) (p = 0.0001). Residents and fellows who identified as White were not as likely to be from low EO-status households as those who identified as Asian (OR 0.3 and p = 0.015 vs. OR 2.9 and p = 0.038). Residents and fellows from low EO-status backgrounds were more likely to take a gap in education (87% vs. 65.4%, p = 0.047) compared to their high EO-status peers. Notably, more current residents and fellows performed away rotations and had first-author publications during or before medical school compared to full professors (p = 0.0001). CONCLUSION: Understanding the backgrounds and career trajectories of trainees and faculty in medicine is essential, yet it has not been performed at the resident or faculty level. This survey is the first to demonstrate the lack of socioeconomic diversity in a specialty (PRS) and identifies variation in career trajectories among those from different SES backgrounds. Large-scale research efforts are necessary to understand current SES diversity and barriers encountered by trainees and educators from low-SES backgrounds in all medical and surgical specialties.

Treatment Delays in Nonsyndromic Craniosynostosis: A 30-Year Retrospective Case-Control Analysis of the Impact of Socioeconomic and Family Status on Access to Care.

BACKGROUND: Patients with nonsyndromic craniosynostosis (NSC) generally undergo corrective surgery before 1 year of age to the mitigate morbidities and risks of delayed repair. The cohort of patients who receive primary corrective surgery after 1 year and factors associated with their gaps to care is poorly characterized in literature. METHODS: A nested case-control study was conducted for NSC patients who underwent primary corrective surgery at our institution and affiliates between 1992 and 2022. Patients whose surgery occurred after 1 year of age were identified and matched 1:1 by surgical date to standard-care control subjects. Chart review was conducted to gather patient data regarding care timeline and sociodemographic characteristics. RESULTS: Odds of surgery after 1 year of age were increased in Black patients (odds ratio, 3.94; P < 0.001) and those insured by Medicaid (2.57, P = 0.018), with single caregivers (4.96, P = 0.002), and from lower-income areas (+1% per $1000 income decrease, P = 0.001). Delays associated with socioeconomic status primarily impacted timely access to a craniofacial provider, whereas caregiver status was associated with subspecialty level delays. These disparities were exacerbated in patients with sagittal and metopic synostosis, respectively. Patients with multisuture synostosis were susceptible to significant delays related to familial strain (foster status, insurer, and English proficiency). CONCLUSIONS: Patients from socioeconomically strained households face systemic barriers to accessing optimal NSC care; disparities may be exacerbated by the diagnostic/treatment complexities of specific types of craniosynostosis. Interventions at primary care and craniofacial specialist levels can decrease health care gaps and optimize outcomes for vulnerable patients.

Do Racial and Ethnic Disparities Exist in Management of Pediatric Mandible Fractures? A 30-Year Outcome Analysis.

BACKGROUND: Mandibular fractures are the most common of pediatric facial fractures. The effect of race on management/outcomes in these injuries has not been previously studied. Given the significant association between race and healthcare outcomes in many other pediatric conditions, an in-depth study of race as related to mandibular fractures in the pediatric patient population is warranted. METHODS: This was a 30-year retrospective, longitudinal study of pediatric patients who presented to a single institution with mandibular fractures. Patient data were compared between patients of different races and ethnicities. Demographic variables, injury characteristics, and treatment variables were analyzed to find predictors of surgical treatment and posttreatment complications. RESULTS: One hundred ninety-six patients met inclusion criteria, of whom 49.5% were White, 43.9% were Black, 0.0% were Asian, and 6.6% were classified as "other." Black and "other" patients were more likely than their White counterparts to be injured as pedestrians (P = 0.0005). Black patients were also more likely than White patients or "other" patients to be injured by assault than by sports-related injuries or animal-related accidents (P = 0.0004 and P = 0.0018, respectively). Race or ethnicity were not found to be a predictor of receiving surgical treatment (ORIF) or of posttreatment complications. The posttreatment rates for all the complications observed were comparable among all race and ethnic groups. Higher mandible injury severity score (odds ratio [OR], 1.25), condyle fracture (OR, 2.58), and symphysis fracture (OR, 3.20) were positively correlated with receiving ORIF as treatment. Mandible body fracture (OR, 0.36), parasymphyseal fracture (OR, 0.34), bilateral mandible fracture (OR, 0.48), and multiple mandibular fractures (OR, 0.34) were negatively correlated with receiving ORIF as treatment. Only high mandible injury severity score (OR, 1.10) was identified as an independent predictor of posttreatment complications. Lastly, Maryland's transition to an all-payer model in 2014 also had no impact on treatment modality; treatment of fractures among race and ethnicity were not significantly different pre- and post-2014. CONCLUSIONS: There is no difference in how patients are treated (surgically vs nonsurgically) and no difference in outcomes for patients based on race at our institution. This could be due to institutional ideology, services provided by a tertiary care center, or simply the more diverse patient population at baseline.

Mentorship is Critical: An Analysis of the 2022 Plastic Surgery Match.

BACKGROUND: As the second cycle impacted by COVID-19, the 2022 Plastic and Reconstructive Surgery (PRS) Match maintained virtual interviews while offering a modest lift of subinternship restrictions. The residency application process continues to evolve, with changes such as pass/fail United States Medical Licensing Examination Step 1 reporting prompting programs to reconsider metrics of applicant success. It is critical to address the impact of board scores, mentorship, and resource availability on a diverse applicant population in the PRS Match. METHODS: A survey was electronically administered to students applying to a single institutional PRS residency program. The survey inquired about demographics, application statistics, mentorship experience, and match outcomes. Logistic regressions were modeled to assess for odds of matching into plastic surgery. RESULTS: In total, 151 responses were analyzed, a 49.7% response rate. Most participants were female (52.3%), White (68.9%), and not Hispanic/Latino (84.8%). The largest percentage of respondents had a faculty mentor only from their home institution (55.0%) and a resident mentor from only their home institution (32.3%). Participants with a faculty mentor from both a home and outside institution had 7.4 times the odds of matching into PRS ( P = 0.02) than students with no faculty mentorship. Students with dual-institution resident mentorship had 18.5 times higher the odds of matching compared with students with no resident mentorship ( P < 0.001). CONCLUSIONS: Subjective metrics, rather than objective scores, had the most influence on successfully matching into plastic surgery. As the PRS Match continues to become increasingly competitive, it behooves programs to provide equitable access to resources such as mentorship.

The Impact of Socioeconomic Factors on the 2022 Plastic Surgery Match.

BACKGROUND: In 2022, the plastic and reconstructive surgery (PRS) match faced unprecedented system-wide transitions that have redefined conventional measures of applicant success. This challenges the equitable assessment of student competitiveness and diversity in the field. METHODS: A survey of demography, application content, and 2022 match outcomes was distributed to applicants to a single PRS residency program. Comparative statistics and regression models were performed to assess the predictive value of factors in match success and quality. RESULTS: A total of 151 respondents (response rate 49.7%) were analyzed. Although step 1 and step 2 CK scores were significantly higher among matched applicants, neither examination predicted match success. Most respondents (52.3%) were women, although gender was also not significantly associated with match success. Underrepresented in medicine applicants made up 19.2% of responses and 16.7% of matches, and the plurality of respondents (22.5%) were raised with a household income ≥$300,000. Both Black race and household income ≤$100,000 were associated with lower odds of scoring above a 240 on either step 1 or step 2 CK (Black: OR, 0.03 and 0.06; P < 0.05 and P < 0.001; income: OR, 0.07-0.47 and 0.1 to 0.8, among income subgroups), receiving interview offers (OR, -9.4; P < 0.05; OR, -11.0 to -5.4), and matching into PRS (OR, 0.2; P < 0.05; OR, 0.2 to 0.5), compared with White and high-income applicants, respectively. CONCLUSIONS: Systemic inequities in the match process disadvantage underrepresented in medicine candidates and those from lower household incomes. As the residency match continues to evolve, programs must understand and mitigate the impacts of bias in various application components.

Insurance Coverage of Pediatric Bariatric Surgery: a Cross-Sectional Analysis of the USA.

PURPOSE: Pediatric bariatric surgery is increasingly recognized as a safe and effective option for the management of obesity and obesity-related conditions. However, insurance coverage is a key barrier to accessing these procedures. Criteria are variable and often not evidence-based. In an effort to characterize common patterns in insurance coverage, we report coverage criteria for adolescents relative to adults. MATERIALS AND METHODS: We surveyed medical policies of the 50 highest market share health insurance providers in the USA. Private insurer coverage criteria included age, Tanner staging, skeletal maturity, body mass index, procedures covered, medical weight management requirements, co-morbidities, and multidisciplinary team criteria. These were then compared to the American Society for Metabolic and Bariatric Surgery (ASMBS) guidelines. RESULTS: Two thirds (n = 33, 66%) of companies provided inclusion criteria for adolescents. All policies covered RYGB (n = 33), most covered sleeve gastrectomy (n = 32, 97.0%). Obstructive sleep apnea (OSA) (n = 32, 97%), hypertension (HTN) (n = 27, 81.8%), and gastroesophageal reflux disease (GERD) (n = 11, 33.3%) were the three most commonly cited co-morbidities used as inclusion criteria. Tanner staging or skeletal maturity were most commonly used (n = 10, 30.3%). Similarly, twenty (60.6%) insurers required medical weight management programs. Multi-disciplinary teams were required by 81.8% of adolescent policies (n = 27) as described by the ASMBS. Seventeen (51.5%) policies defined providers for these teams, and 10 (30.3%) provided other defined criteria. CONCLUSION: Contrary to ASMBS guidelines, companies commonly require Tanner staging and/or skeletal maturity criteria as well as participation in medical weight management programs. Also, multi-disciplinary team are frequently required but not well defined.