Predicting Reduction Mammaplasty Total Resection Weight With Machine Learning.

BACKGROUND: Machine learning (ML) is a form of artificial intelligence that has been used to create better predictive models in medicine. Using ML algorithms, we sought to create a predictive model for breast resection weight based on anthropometric measurements. METHODS: We analyzed 237 patients (474 individual breasts) who underwent reduction mammoplasty at our institution. Anthropometric variables included body surface area (BSA), body mass index, sternal notch-to-nipple (SN-N), and nipple-to-inframammary fold values. Four different ML algorithms (linear regression, ridge regression, support vector regression, and random forest regression) either including or excluding the Schnur Scale prediction for the same data were trained and tested on their ability to recognize the relationship between the anthropometric variables and total resection weights. Resection weight prediction accuracy for each model and the Schnur scale alone were evaluated based on using mean absolute error (MAE). RESULTS: In our cohort, mean age was 40.36 years. Most patients (71.61%) were African American. Mean BSA was 2.0 m2, mean body mass index was 33.045 kg/m2, mean SN-N was 35.0 cm, and mean nipple-to-inframammary fold was 16.0 cm. Mean SN-N was found to have the greatest variable importance. All 4 models made resection weight predictions with MAE lower than that of the Schnur Scale alone in both the training and testing datasets. Overall, the random forest regression model without Schnur scale weight had the lowest MAE at 186.20. CONCLUSION: Our ML resection weight prediction model represents an accurate and promising alternative to the Schnur Scale in the setting of reduction mammaplasty consultations.

TMJ Ankylosis Following Mandibular Distraction Osteogenesis: Management With Simultaneous Midface External Distraction and Bilateral Temporomandibular Joint Replacement.

Early mandibular distraction osteogenesis (MDO) can decrease upper airway and feeding complications in pediatric patients with micrognathia; however, temporomandibular joint (TMJ) complications like TMJ ankylosis (TMJA) may occur. TMJA can disturb pediatric patients' function and craniofacial growth, resulting in significant physical and psychosocial consequences. Additional surgical procedures may also be required, increasing the burden of care on patients and their families. CMF surgeons must discuss the potential complications of early MDO surgery with families as well as potential solutions should these problems occur. This report presents the case of a 17-year-old male with a severe craniofacial anomaly with features of Treacher-Collins syndrome (TCS) and a surgical history of tracheostomy, cleft palate repair, mandibular reconstruction with harvested costochondral grafts, and MDO with resultant bilateral TMJA and limited mouth opening. The patient Was treated with bilateral custom alloplastic TMJ replacements and simultaneous maxillary DO using a Rigid External Distraction (RED) device.

Dorsal Augmentation With the Dorsal Extension Spreader Graft.

Spreader grafts traditionally are used to improve airflow through opening the internal nasal valve, as well as enhance the cosmetic appearance of the nose. The graft's versatility proves useful in surgical correction of several nasal profiles by enhancing dorsal aesthetic lines and by maintenance of the nasal pyramid at midline. The authors describe a modified spreader graft that adds an additional benefit of dorsal augmentation in patients with underprojected or saddle noses. This technique utilizes harvested septal cartilage and fixation of the graft that extends beyond the septal and upper lateral cartilage dorsal border to improve nasal dorsum height. Patients who received this operative technique by the senior author were identified and their operative courses and surgical outcomes were analyzed. Case examples are provided to illustrate indications and outcomes. This grafting technique allows for improved functionality, defined dorsal aesthetic lines, changes in nasal width, and a more balanced profile in patients with underprojected noses.

Extent of Extranodal Extension in Oral Cavity Squamous Cell Carcinoma is Not Independently Associated With Overall or Disease-Free Survival at a 2.0-mm Threshold.

PURPOSE: The presence of extranodal extension (ENE) conveys a poor prognosis in oral cavity squamous cell carcinoma (OSCC); however, there is no consensus regarding whether the histopathologic extent of ENE (e-ENE) may be a more discriminating prognostic indicator. The purpose of this study was to assess the impact of minor ENE (<2.0 mm) versus major ENE (≥ 2.0 mm) on overall survival (OS) and disease-free survival (DFS) in OSCC. MATERIALS AND METHODS: A single-institution, retrospective cohort study was designed using an electronic medical record review. Inclusion criteria included patients with OSCC and cervical node metastasis. All subjects were treated between the years 2009 and 2017 in the Michigan Medicine Department of Oral and Maxillofacial Surgery (Ann Arbor, Michigan). The primary predictor variable was e-ENE, measured as the maximum distance of tumor invasion into extranodal tissue from the outer aspect of the nodal capsule. Primary outcome variables were OS and DFS. Other covariates included demographic data, tumor staging, and histopathologic data. Descriptive statistics were performed. Kaplan-Meier survival plots for OS and DFS were performed. The data were mined for an alternative threshold at which e-ENE may impact survival using Cox proportional hazards models. RESULTS: One hundred sixty eight subjects were included (91 ENE-negative, 48 minor ENE, and 29 major ENE). Most subjects were male (62%) and the mean age was 62.9 years. Mean follow-up time was 2.97 +/- 2.76 years. There was no statistically significant difference in OS or DFS between minor and major ENE. Five-year OS for minor ENE was 30.4% versus 20.7% for major ENE (P = .28). Five-year DFS for minor ENE was 26.7% versus 18.1% for major ENE (P = .30). Five-year OS and DFS was worse for subjects with ENE-positive disease versus ENE-negative disease (OS: 26.9% vs 63.1%, hazard ratio [HR]: 2.70, 95% confidence interval [CI]: [1.77, 4.10], P < .001; DFS: 23.7% vs 59.7%, HR = 2.55, 95% CI [1.71, 3.79], P < .001). At an alternative threshold of 0.9 mm e-ENE, there was greater DFS in subjects with e-ENE 0.1-0.9 mm versus e-ENE > 0.9 (40.6% vs 18.9%, respectively) (HR = 0.49, 95% CI [0.24, 0.99], P = .047). CONCLUSION: There was no independent association between survival and e-ENE at a 2.0-mm threshold.

Major Complications and Associated Risk Factors for Osseous Genioplasty With Bimaxillary Orthognathic Surgery: An American College of Surgeons-National Surgical Quality Improvement Program Analysis.

PURPOSE: Patients with significant dentofacial deformities undergoing aesthetic and functional orthognathic surgery may often require genioplasty to advance the position of the pogonion relative to B point. No study to date has evaluated nationally registered data pertaining to addition of osseous genioplasty to bimaxillary orthognathic surgery and its associated clinical outcomes. METHODS: Data was extracted from the National Surgical Quality Improvement Program from 2010 to 2018 using current procedural terminology codes pertaining to Le Fort I osteotomy (LF), bilateral sagittal split osteotomy (BSSO), and osseous genioplasty (G) and divided into 2 cohorts: bimaxillary orthognathic surgery with and without osseous genioplasty. Thirty-day postoperative outcomes inherently recorded within National Surgical Quality Improvement Program were identified and recorded. Chi-squared analysis and unpaired 2-tail t tests were performed between the cohorts and their respective outcomes to determine significant relationships with significance set as P < 0.05. RESULTS: There were 373 patients double- or triple-jaw patients identified from the years 2010 to 2018. The most common recorded indication for LF/BSSO was maxillary hypoplasia (27.3%) and mandibular hypoplasia (6.8%). The most common indications for LF/BSSO/G were maxillary hypoplasia (16.1%) and maxillary asymmetry (16.1%). In comparison to LF/BBSO only, LF/BSSO/GP was not associated with any differences in the rate of surgical (0.0% versus 0.31%, P = 0.72) or medical complications (0.0% versus 0.63%, P = 0.60), in addition to unplanned readmissions (0.0% versus 1.56% versus P = 0.41) or reoperations (0.0% versus 1.25%, P = 0.46). However, osseous genioplasty addition was associated with increased overall operating time (271.77 versus 231.75 minutes, P = 0.04). CONCLUSIONS: Osseous genioplasty does not alter short-term, 30-day complication rate when performed with bimaxillary orthognathic surgery. As reoperation rates remained relatively unchanged, it can be inferred that immediate adverse events or patient dissatisfaction were not apparent within 30 days. Although mean operating time is slightly longer, cardiopulmonary resuscitation without medical comorbidity was achieved at the conclusion of the procedure.

Outcomes in Pediatric Maxillofacial Reconstruction With Vascularized Fibular Flaps: A Systematic Review.

BACKGROUND: The purpose of this study was to examine the complications and outcomes after maxillofacial reconstruction using the free fibular flap in the pediatric population. METHODS: A systematic review and descriptive analysis were conducted using data variables, including study characteristics; patient characteristics; postoperative complications (major and minor); surgical revision; and dental rehabilitation. RESULTS: The systematic review resulted in 1622 articles, 55 of which met inclusion criteria for this study. The 55 articles consisted of 17 case series and 38 case reports with level III/IV and level V of evidence, respectively. Of the 155 identified pediatric patients, the rate of major complications was 13.5% and minor complications was 24.5%. The most common complication was mild growth distortion (n = 7) at the recipient site. Complications at the donor site were less common. During follow-up, 29 patients (18.7%) underwent or awaited surgical revision, and 43 patients (27.7%) underwent or awaited dental rehabilitation. CONCLUSIONS: Our study suggests that the free fibular flap for pediatric maxillofacial reconstruction is safe and reliable. Additionally, surgical revision to correct the functional impairments resulting from primary reconstruction using the free fibular flap is relatively common.

Clinical Practice Trends and Postoperative Outcomes in Primary Cleft Rhinoplasty.

PURPOSE: Optimal correction of the cleft nasal deformity remains challenging. The purpose of this study was to examine the practice patterns and postoperative course of patients undergoing cleft lip repair with rhinoplasty compared to those who have primary lip repair without rhinoplasty. METHODS AND MATERIALS: A retrospective cohort study was conducted based on the Kids' Inpatient Database. Data were collected from January 2000 to December 2011 and included infants aged 12 months and younger who underwent cleft lip repair. The predictor variable was the addition of rhinoplasty at primary cleft lip repair. Primary outcome variables included hospital setting, year, and admission cost, while secondary outcome variables included length of stay and postoperative complication rate. Independent t-tests and chi-squared tests were performed. Continuous variables were analyzed by multiple linear regression models. RESULTS: The study sample included 4559 infants with 1422 (31.2%) who underwent primary cleft rhinoplasty. Over time, there was a significant increase in the proportion of cleft lip repairs accompanied by a rhinoplasty (p < .01). A greater proportion of patients with unilateral cleft lips received simultaneous rhinoplasty with their lip repairs (33.8 vs 26.0%, p < .01). This cohort had a significantly shorter length of stay (1.6 vs 2.8 days, p < .01) when compared to children that underwent cleft lip repair alone. CONCLUSIONS: Performing primary cleft rhinoplasty is becoming more common among cleft surgeons. Considering comparable costs and complication rates, a rhinoplasty should be considered during the surgical treatment planning of patients with cleft nasal deformities.

Comparing Load-Sharing Miniplate and Load-Bearing Plate Fixation in Atrophic Edentulous Mandibular Fractures: A Systematic Review and Meta-Analysis.

PURPOSE: To critically examine reported data to compare patient outcomes between load-sharing and load-bearing plate fixation for edentulous mandibular fractures. MATERIALS AND METHODS: A systematic review and meta-analysis were designed to test the null hypothesis of no difference in postoperative outcomes between load-sharing and load-bearing plate fixation in atrophic, edentulous mandibular fractures. The PubMed, EMBASE, Cochrane Library, Elsevier text mining tool database, and clinicaltrials.gov trial registries were queried up until July 2016. The quality of evidence was determined using the Grading of Recommendations Assessment, Development, and Evaluation method. RESULTS: A total of 1212 studies were screened for inclusion of which we included 1 high-quality Cochrane review, 6 narrative reviews, and 21 publications of case reports and case series. Overall, the quality of evidence was low. No difference was found between load-bearing and load-sharing fixation in functional recovery, nonunion, or infection. An uncontrolled case series portrayed complete functional and morphological restoration in 96.9% of patients (83.2-99.5; 95% confidence interval) in load-bearing osteosynthesis while another demonstrated the same outcome in only 40.0% of patients (17.5-65.0; 95% confidence interval). CONCLUSIONS: The authors did not find a statistically significant difference between load-bearing and load-sharing plate fixation in edentulous atrophic mandibular fracture patients; although this finding may be influenced by type 2 statistical error. Surgeons should continue to use their best clinical judgment in deciding on treatment approach for these challenging fractures. Future studies with higher level evidence are necessary to guide optimal fracture management.

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

PURPOSE: The purpose of this study was to determine whether the timing of mandibular fracture repair within the academic year affects the complication rate using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. MATERIALS AND METHODS: The ACS-NSQIP database was accessed and queried from 2008 to 2017 for all Current Procedural Terminology codes pertaining to open treatment of mandibular fractures. The cases were stratified into 2 groups based on academic quarter: the quarter 1 (Q1) group (July-September) and the remaining-quarters group. The inclusion criteria encompassed all Current Procedural Terminology codes in the ACS-NSQIP registry that defined mandibular fractures and age greater than 18 years. Demographic characteristics, as well as medical and surgical complications, were compared between the 2 cohorts. Descriptive statistics were calculated to characterize and compare patient cohorts, and Fisher exact test and χ2 analyses were performed to compare complication rates between groups. RESULTS: The Q1 group included 614 cases, and the remaining-quarters group included 1,454. The most common individual complications included wound dehiscence (1.6% overall; 2.1% in Q1 group vs 1.4% in remaining-quarters group, P = .22), combined superficial and deep-space infection (4.9% overall; 4.4% in Q1 group vs 3.3% in remaining-quarters group; P = .91 and P = .21, respectively), and reoperation (3.9% overall; 4.6% in Q1 group vs 3.6% in remaining-quarters group, P = .29). Medical complications including acute kidney injury, venous thromboembolism, urinary tract infection, and sepsis or septic shock were rare (<1%). Complication rates did not significantly differ between the third quarter and the remainder of the year on bivariate analysis. CONCLUSIONS: Our results do not support the idea of a "July effect" regarding postoperative outcomes after mandibular fracture repair. Further studies are needed to elucidate this phenomenon within all procedures under the wide umbrella of the specialty.

Standing on the Shoulders of Giants: Dental Students Seek Academically Productive Mentors.

PURPOSE: The purpose of this study was to determine whether a strong statistical correlation exists between the involvement of trainee groups and the academic productivity of the senior author. MATERIALS AND METHODS: A retrospective cohort study of publications in the Journal of Oral and Maxillofacial Surgery from 2002 to 2016 was designed and implemented. The primary predictor variables were the presence of a trainee (dental student or oral and maxillofacial surgery [OMS] resident), year of publication, and study design and topic. The outcome variable was the Hirsch index (h-index) of the senior author. Author affiliations were queried using ScienceDirect, and the Scopus database was used to identify the h-index of the senior author from each publication spanning the previous 15 years. Descriptive statistics and t tests were performed to determine significance. RESULTS: Of the 6,398 articles published in the Journal of Oral and Maxillofacial Surgery from January 2002 to December 2016, 1,341 (21.0%) met the inclusion criteria. The mean h-index of senior authors of articles with trainees or OMS residents was not significantly different from the mean h-index of senior authors without trainees (P = .50) or OMS residents (P = .37), whereas the mean h-index of senior authors working with dental students was significantly greater than the h-index of those not working with dental students (P < .01). Dental student mentors had a mean h-index that was below the sample mean from 2002 to 2007 but rose above the sample mean from 2010 to 2016. Trainees were more likely to work with academically productive mentors in orthognathic surgery (P < .01), temporomandibular joint (P < .05), retrospective cohort (P < .05), and innovative technique (P < .05) studies but less likely in randomized controlled trials (P < .05). CONCLUSIONS: Dental students seek more academically productive mentors to a greater degree. More studies should be conducted to elucidate the attributes of the ideal mentor in academic OMS and to determine whether differences in mentorship exist between domestic and foreign OMS programs.

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

PURPOSE: The purpose of this study was to determine if there is an increased postoperative complication rate in orthognathic surgery during the first academic quarter (Q1) (July to September). MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was accessed to identify cases with Current Procedural Terminology codes pertaining to orthognathic procedures from 2008 to 2017. Procedures were separated into 2 groups based on time in the academic year: Q1 (July to September) versus remaining quarters (RQ). The inclusion criteria were Current Procedural Terminology codes representing operations resulting in movement of the dentate portion of the jaws and age of 18 years or older. Patient demographic characteristics and perioperative complications were compared between the groups. Descriptive statistics, Fisher exact tests, and χ2 tests were executed. RESULTS: The Q1 cohort included 877 cases, and the RQ cohort included 2,062 cases. The average age of patients was 47.0 ± 19.5 years in Q1 versus 47.2 ± 19.4 years in RQ. The most frequent complications were blood transfusion (11.97% in Q1 vs 12.57% in RQ, P = .64), reoperation (8.67% in Q1 vs 8.84% in RQ, P = .87), and combined superficial and deep-space infection (5.02% in Q1 vs 5.76% in RQ, P = .51). Medical complications involving other organ systems were rare (<1%). Analyses showed no significance between complication rate and time of year. CONCLUSIONS: The results of this study indicate that there is no association between time of year and complication rates after orthognathic surgery. Additional investigations could be useful in shining light on this topic as it pertains to the training of future surgeons.

Are Industry Payments Associated With the Level of Evidence in Oral and Maxillofacial Surgery?

PURPOSE: The purpose of the present study was to determine whether the industry payments in oral and maxillofacial surgery (OMS) are associated with a study's level of evidence (LOE). MATERIALS AND METHODS: A retrospective cohort study was designed and implemented to query the Journal of Oral and Maxillofacial Surgery from 2002 to 2016. The primary predictor variables were the presence of a self-reported conflict of interest (COI) and the type of COI. The outcome variable was the LOE. The secondary outcome variables investigated were the topic of the study and the inclusion of trainees. The inclusion criteria entailed contributions from domestic academic OMS training programs. Disclosure of the COIs and type of COI, the LOE, topic of the study, and inclusion of trainees were recorded for every report from January 2002 until December 2016. Descriptive statistics were calculated, and χ2 tests were performed to determine a significant relationship primarily between the COIs and LOE. RESULTS: The sample included 1455 reports, and 4.2% of the sample size had disclosed a COI. The studies that disclosed industry payments demonstrated a significant positive correlation with the LOE (P < .01), especially for cohort studies. Also, the type of COI was significantly associated with the LOE (P < .05). Industry payments were not shown to be significantly related statistically to topic of the study (P = .16); however, the stock-related payments were associated with the topic (P < .05). No association was found between COI disclosure and trainee contribution. CONCLUSIONS: The results have indicated that industry payments are associated with the LOE in the OMS literature. Further studies are needed to elucidate both the accuracy of the financial disclosures by comparing them with publicly available open payment databases and the perceptions of the OMSs, their trainees, and their patients regarding the influence of industry payments on the specialty's academic interests.

Characterizing Craniomaxillofacial Injuries in American Professional Sports Leagues.

PURPOSE: The purpose of this study was to characterize the types of craniomaxillofacial (CMF) injuries that occur in professional sports leagues and the associated recovery times. MATERIALS AND METHODS: A retrospective cohort study was designed and implemented using the Pro Sports Transaction Archive. The database was queried for all registered CMF injuries in the 4 main men's major professional sports leagues in the United States from 2013 to 2018. The sport, injury location, and season were the predictor variables, and the frequency and length of time on the injured list were the outcome variables. Descriptive statistics were computed, and Fisher's exact tests were used to determine the association between the predictor and outcome variables. Analysis of variance was used to compare the injury frequency and duration. RESULTS: Of the 198 injuries that met the inclusion criteria, 60 were from Major League Baseball (MLB) (30%), 49 from the National Basketball Association (25%), 8 from the National Football League (4%), and 81 from the National Hockey League (NHL) (41%). Injuries to the midface were most common (mean, 25.2 ± 3.6 injuries per season; P < .001) compared with the upper face (mean, 6.0 ± 2.0 injuries per season) and lower face (mean, 8.4 ± 2.3 injuries per season). The mean time on the injured list after CMF trauma was 8.4 ± 10.4 days, with MLB injuries requiring the shortest duration (mean, 3.9 ± 6.6 days; P = .001). A significant association was found between the injury location and sport (P < .001). However, no statistically significant difference was found in the number of injuries per season from 2013 to 2018 for each league (P = .818). CONCLUSIONS: Midface trauma was significantly more common than upper or lower face trauma in professional sports leagues during the past 5 seasons. The NHL had the greatest injury rate, even after adjustment for games played.

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

PURPOSE: To date, no clear evidence-based guidelines exist pertaining to the ideal timing to perform surgical treatment of orbital fractures. The purpose of this study was to determine if early treatment of orbital fractures resulted in better patient outcomes. MATERIALS AND METHODS: We designed and implemented a systematic review and meta-analysis to test the null hypothesis of no difference in outcomes between different time intervals between orbital injury and surgical intervention. PubMed, Embase, the Cochrane Library, the Elsevier text mining tool database, and clinicaltrials.gov trial registry were queried. The quality of evidence was based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The predictor variable was the timing of operative repair (early vs late). The outcome variable was complete recovery. Other variables of interest were diplopia, enophthalmos, and preoperative motility restriction. Meta-analyses were performed when definitions of active and control interventions and patient outcomes were deemed similar. In addition, χ2 tests were performed to determine differences in clinical outcomes between early and late operative repair. RESULTS: Of the 1,160 articles reviewed, 20 met the inclusion criteria. Surgery performed less than 2 weeks after injury was significantly associated with greater odds of complete recovery of symptoms (odds ratio [OR], 6.9 [95% confidence interval (CI), 1.35-35.06]), as well as a lower incidence of postoperative diplopia (OR, 0.3 [95% CI, 0.1-0.9]) and enophthalmos (OR, 0.2 [95% CI, 0.1-0.9]). Repair performed less than 30 days after injury was associated complete resolution of preoperative motility restriction (OR, 24.6 [95% CI, 1.30-462.34]) as well as diplopia. CONCLUSIONS: Differences in the timing of surgery and definition of patient outcomes, as well as variations in methods of evaluating postoperative outcomes, potentiate the risk of bias and warrant downgrading of the quality of evidence in a study. The timing of repair varied among 2, 4, and 8 weeks after injury. However, a short time to surgical intervention was significantly associated with resolution of vertical dystopia, postoperative enophthalmos, and motility restriction.

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

BACKGROUND: Current Procedural Terminology (CPT) codes are an important part of surgical documentation and billing for services provided within the United States. This limited coding language presents a challenge in the heterogenous and rapidly evolving field of craniofacial surgery. The authors aimed to survey members of the American Society of Maxillofacial Surgery (ASMS) to characterize the variability in coding practices in the surgical management of craniofacial trauma. METHODS: A cross-sectional of 500 members of the ASMS survey was carried out. Descriptive statistics were calculated. The effect of various practice characteristics on coding practices was evaluated using Chi-squared tests and Fisher's exact tests. RESULTS: In total, 79 participants responded including 77 plastic surgeons. About 75% worked in academic centers and 38% reported being in practice over 20 years. Coding practices were not significantly associated with training background or years in practice. Unilateral mandibular and unilateral nasoorbitoethmoid fractures demonstrated the greatest agreement with 99% and 88% of respondents agree upon a single coding strategy, respectively. Midface fractures, bilateral nasoorbitoethmoid fractures, and more complex mandibular demonstrated considerable variability in coding. CONCLUSION: There is a wide variability among members of the ASMS in CPT coding practices for the operative management of craniofacial trauma. To more accurately convey the complexity of craniofacial trauma reconstruction to billers and insurance companies, the authors must develop a more descriptive coding language that captures the heterogeneity of patient presentation and surgical procedures.

Online Patient Education Materials for Orthognathic Surgery Fail to Meet Readability and Quality Standards.

PURPOSE: The purpose of this study was to evaluate the readability and quality of online patient educational materials (PEMs) for orthognathic surgery. MATERIALS AND METHODS: Two internet searches were performed using the search terms orthognathic surgery and jaw surgery. The presence of content related to the risks, benefits, procedure, and postoperative care was recorded. Readability was measured using 4 validated scales: Flesch-Kincaid grade level, Gunning Fog index, Coleman-Liau index, and Simple Measure of Gobbledygook index. Materials were readable if they were written at or below an eighth-grade reading level as recommended by the American Medical Association (AMA) and the National Institutes of Health (NIH). Quality was assessed using 2 metrics: the DISCERN instrument and the Journal of the American Medical Association benchmark criteria. A DISCERN score of 50 was set as the lower limit of acceptable quality. Mann-Whitney U and Fisher exact tests were used to compare the readability, quality, and presence of content between private practice and non-private practice PEMs. RESULTS: Fifty websites were included in the study after removing duplicates and applying exclusion criteria. On average, PEMs were written at a 13.4-grade level (range, 7.8 to 17.3). Nearly every website (n = 49; 98%) mentioned the benefits of surgery; however, very few websites discussed the surgical procedure (n = 12; 24%), postoperative care (n = 10; 20%), and risks or complications (n = 6; 12%). The mean DISCERN score was 25.5 of 80 (range, 18 to 63), and only 2 websites achieved DISCERN scores of acceptable quality. Private practice websites reported less content related to the surgical procedure (P = .03) and had lower DISCERN scores (P = .02). CONCLUSIONS: As a whole, online PEMs for orthognathic surgery failed to meet AMA and NIH readability recommendations and yielded poor quality scores. Increasing the presence of content related to treatment risks and postoperative care will help improve the quality of PEMs.

Industry Payments in Oral and Maxillofacial Surgery: A Review of 112,448 Payments From a National Disclosure Program.

PURPOSE: The purpose of this study was to characterize the sources, amounts, and nature of general industry payments to oral and maxillofacial surgeons (OMSs). MATERIALS AND METHODS: The Open Payments database was searched from August 2013 to December 2017 for all general payments made to OMSs. For each payment, data were recorded regarding the date, value, paying organization, and nature of the payment. Analyses of variance were performed to compare payment amount per surgeon, number of payments per surgeon, and amount per payment across payment years. RESULTS: Overall, there were 112,448 payments totaling $28,644,063.20. Although, on average each year, 69% of OMSs received at least 1 payment, the top 10% of earners accounted for 89% ($25,607,781) of all payments. Each OMS received a median total of $93.75 (interquartile range, $33 to $263) and an average of $1,109.68 (SD, $14,297; range, $2-$2,250,345) per year. The mean payment value was $254.73 (SD, $2,727; range, $0.01-$548,126) compared with a median of $28.90 (interquartile range, $15-$82). Most payments were in the form of food and beverage (72%); however, the most dollars were spent on consulting fees ($5,594,087; 20%). From 2014 to 2016, significant decreases occurred in the payment amounts (P < .01) and number of payments (P < .01) per surgeon, as well as the value of each payment (P < .01). CONCLUSIONS: Although OMSs receive a substantial amount of industry payments, the overall figure is driven by a small percentage of top earners. Most individual payments were of nominal value, and their effect on clinical practice remains to be seen.

Trainee Contribution Is Not Associated With Citation Frequency: A Retrospective Study.

PURPOSE: Publication citation frequency is a measure of scientific influence. The purpose of this study was to measure the association between trainee involvement in publications and citation frequency. MATERIALS AND METHODS: A retrospective cohort study of the Journal of Oral and Maxillofacial Surgery from January to December 2010 was conducted. For each included publication, the study topic and design were recorded. The primary predictor variable was trainee involvement (yes or no). For the purpose of our study, the term "trainee" encompassed dental students, graduate (non-dental) students, oral and maxillofacial surgery residents, and non-oral and maxillofacial surgery residents, as indicated by author affiliations listed in each article. The outcome variable was the number of citations accumulated between 2010 and 2017. Descriptive statistics were computed. Analyses of variance were performed to compare citation distribution among study types and designs. Student t tests and χ2 tests were performed. RESULTS: The sample consisted of 111 publications, of which 85 (76.6%) had at least 1 trainee author. Among all publications, the mean number of citations was significantly different across study designs (P = .03), with case reports earning the lowest number of citations on average (mean, 14.9 citations). Trainee publications had significantly different distributions of study topics (P = .02) and designs (P < .01). Among publications with a trainee author, the most common topic was pathology (37%) and the most common study design was a case report (45%). Despite the higher proportion of case reports, the mean number of citations between trainee (mean, 30.4 citations) and non-trainee (mean, 30.5 citations) publications was not significantly different (P = .99). CONCLUSIONS: Including trainees does not alter the citation frequency of the articles published in the Journal of Oral and Maxillofacial Surgery. This finding is encouraging to both academic surgeons and their trainees, as a higher volume of students and residents can be engaged in research while preserving the influence of the published works.

A 15-Year Review of Trainee Contributions to the Journal of Oral and Maxillofacial Surgery.

PURPOSE: The purpose of this study was to quantify trainee contributions to the Journal of Oral and Maxillofacial Surgery (JOMS). MATERIALS AND METHODS: This was retrospective cohort study of research articles published in the JOMS from 2002 to 2016. Predictor variables were the presence and type of trainee author. Outcomes were study topic and design. Comparisons were performed using χ2 tests. To quantify trainee contributions, the 1) number and 2) proportion of articles with a trainee author and 3) the proportion of trainee authors per publication were calculated. The association between time and the number and proportion of trainee articles was determined using simple correlations. The association between time and percentage of trainee authors per publication was determined using analysis of variance. RESULTS: Of the 1,455 articles included in this study, 72.0% had at least 1 trainee author and trainees composed 27.6% of all authorships. The number and proportion of trainee articles slowly increased with time, and there was a strong correlation between percentage of trainee articles and publication year (r = 0.86; P < .01). Compared with articles without a trainee, a larger proportion of trainee articles were on orthognathic procedures (P < .01). Trainee articles also had a larger proportion of case reports and series (P = .03) and retrospective cohort studies (P < .01) and a smaller proportion of prospective cohort studies (P = .02), literature reviews and meta-analysis (P < .01), and randomized controlled trials (P = .02). CONCLUSIONS: Trainee authors contributed to most JOMS articles, and an increasing percentage of articles included trainee authors. Efforts should be made to include trainees in studies with higher levels of evidence.

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

PURPOSE: Controversy remains regarding the optimal degree of anatomic exposure, reduction, and fixation required during open reduction and internal fixation of zygomaticomaxillary complex (ZMC) fractures. We critically examined the reported data to compare the patient outcomes after various degrees of ZMC reduction and internal fixation. MATERIALS AND METHODS: A systematic review and meta-analysis were designed to test the null hypothesis of no difference in outcomes between different degrees of fixation of ZMC fractures. The PubMed, EMBASE, Cochrane Library, Elsevier text mining tool database, and clinicaltrials.gov trial registries were queried. The quality of evidence was determined using the Grading of Recommendations Assessment, Development, and Evaluation method. RESULTS: Of 1213 screened studies, 13 met the inclusion criteria. Fracture instability at 3 months was greater with 2-point fixation (61.1%) than with 3-point fixation (10.6%; relative risk, 2.5, 95% confidence interval [CI], 1.4 to 3.3). Less vertical orbital dystopia was seen with 3-point fixation than with 2-point fixation (mean difference, 0.9 mm; 95% CI, 0.6 to 1.3 mm). The incidence of infection and malar asymmetry did not differ between the groups. The quality of evidence was very low to low. CONCLUSIONS: The reported data were limited by low quality, retrospective studies. However, the meta-analysis of randomized control trial data suggested a superiority of 3 points of exposure and fixation regarding fracture stability. When 2 points appear to provide stable fixation, the potential benefits of a third point should be weighed against the cost, operative time, and exposure/periosteal stripping on a case-by-case basis.