Volleyball-related Adult Maxillofacial Trauma Injuries: A NEISS Database Study.

INTRODUCTION: Craniofacial trauma among athletes of various sports has been well detailed and described. Despite this research, there is a dearth of literature describing the nature of facial trauma secondary to volleyball, despite its global popularity. METHODS: A cross-sectional analysis of volleyball-related facial trauma was conducted using the National Electronic Injury Surveillance System (NEISS) database from 2009 to 2018. Patient demographics (age, sex, and race), medical injury information (injury type and location), and disposition (observed and discharged, admitted, deceased) were collected and analyzed. χ2 testing was performed to compare categorical variables. RESULTS: A total of 235 volleyball-related facial traumas were recorded with an estimated 10,424 visits occurring nationally. The majority of injuries were among young adults aged 20 to 29 years (52.3%) and was evenly distributed for men and women. Lacerations were the most frequent injury type (37.9%), whereas the face was the most common site of injury (41.7%). The majority of fractures involved the nose (71.4%) and among individuals aged 20 through 49 (90.5%). Males had significantly more lacerations than females (75.3% vs 24.7%), whereas females had significantly more contusions/abrasions (64.5% vs 35.5%) and concussions (72.9% vs 27.1%). CONCLUSIONS: Volleyball-related craniofacial injuries can vary depending on patient demographics. This information can help with the development of safety and preventative measures for individuals participating in the sport.

Single-Point Fixation for Noncomminuted Zygomaticomaxillary Complex Fractures-A 20-Year Experience.

PURPOSE: Zygomaticomaxillary complex (ZMC) fractures occur often. However, no clinical consensus has been reached regarding the number of fixation points required when performing open reduction and internal fixation (ORIF). The objective of the present study was to explore the utility of single-point fixation in the management of noncomminuted ZMC fractures. PATIENTS AND METHODS: We analyzed the data from a retrospective case series of 211 patients treated during a 20-year period. RESULTS: The mean length of follow-up was 3.4 months. Of the 211 patients, 162 with noncomminuted ZMC fractures had been treated with single-point fixation of the zygomaticomaxillary buttress. During the follow-up period, 1 patient experienced tooth loss because of a root present in the fracture line, 7 experienced intraoral plate exposure, with 2 subsequently undergoing plate exchange, and 8 developed a wound infection. No patients required orthognathic surgery or cheek implants for malar asymmetry. No patient developed hypoglobus or enophthalmos, and none required revision ORIF of their ZMC fracture. CONCLUSIONS: To the best of our knowledge, the present study represents the largest series in the literature reporting the surgical results and outcomes of patients with noncomminuted ZMC fractures treated with single-point fixation. In experienced hands, we believe this is a viable surgical option if appropriate surgical considerations are made.

Surgical Techniques to Improve the Soft Tissue Triangle in Rhinoplasty: A Systematic Review.

In this systematic review we aim to (1) describe the anatomy and function of the soft tissue triangle, (2) identify the existing rhinoplasty literature that discusses the role of the soft tissue triangle, (3) provide a summary of the outcome measures for soft tissue triangle techniques in rhinoplasty, and (4) demonstrate the need for further research reviewing soft tissue triangle techniques in rhinoplasty. A systematic literature review was conducted from 2002 to 2019 utilizing MEDLINE/PubMed, Embase, Ovid, and Cochrane databases with the keywords, "rhinoplasty" and "soft tissue triangle" or "facet" to identify articles that describe the anatomical significance, clinical applicability, and rhinoplasty outcomes involving the soft tissue triangle. A total of 26 studies were identified as appropriate for inclusion. The vast majority describe the relationship of structure and function of the soft tissue triangle with particular focus on notching and retraction. The soft tissue triangle is an important area of the nose often neglected in rhinoplasty. This area is a common source of patient dissatisfaction and the need for revision rhinoplasty. Due to this fact, a formal evaluation of the role of the soft tissue triangle in nasal airway patency is needed. Specific validated outcome measures such as the NOSE (Nasal Obstruction and Septoplasty Effectiveness) score or the SCHNOS (Standardized Cosmesis and Health Nasal Outcomes Survey) should be employed in the evaluation of surgical intervention to the soft tissue triangle.

The Paramedian Forehead Flap for Nasal Reconstruction: From Antiquity to Present.

Nasal reconstruction is considered the historic foundation of facial plastic surgery, and the forehead flap remains the workhorse of repair. To recreate both the aesthetic contour and function of the nose, all anatomic layers must be addressed-covering, lining, and structural support. This article reviews the noteworthy history underlying the development of the paramedian forehead flap as the primary tool in reconstruction of large nasal defects while highlighting its implications on modern nasal repair. Current developments in the use of 2-staged paramedian forehead flap reconstruction are examined and a modern technique is presented.

Management of Complex Mandible Fractures.

Mandible fractures represent a common sequela of craniomaxillofacial trauma encountered by reconstructive surgeons. Management of complex mandibular fractures, and reestablishment of the occlusal relationship, represents a challenging reconstructive endeavor for even the most skilled surgeon. In this article, the authors review the treatment options for particularly complex presentations of this injury pattern.

Dental Injuries and Management.

Traumatic dental injuries affect 1 to 3% of the population, and disproportionately affect children and adolescents. The management of these injuries incorporates the age of patients, as children between 6 and 13 years of age have a mixed dentition. This helps to preserve the vitality of teeth that may be salvaged after a traumatic event. The clinical examination of these cases involves a thorough examination of the maxilla and mandible for associated fractures and any lodged debris and dislodged teeth or tooth fragments. The objective is to rule out any accidental aspiration or displacement into the nose, sinuses, or soft tissue. After ruling out any complications, the focus is on determining the type of injury to the tooth or teeth involved. These include clinical examination for any color change in the teeth, mobility testing, and testing for pulp vitality. Radiographic evaluation using periapical, occlusal, panoramic radiographs, and cone beam computed tomography is performed to view the effect of trauma on the tooth, root, periodontal ligament, and adjoining bone. The most commonly used classification system for dental trauma is Andreasen's classification and is applied to both deciduous and permanent teeth. Managing dental trauma is based on the type of injury, such as hard tissue and pulp injuries, injuries to periodontal tissue, injuries of the supporting bone, and injuries of the gingiva and oral mucosa. Hard-tissue injuries without the involvement of the pulp typically require restoration only. Any pulp involvement may require endodontic treatment. Fractures involving the alveolar bone or luxation of the tooth require stabilization which is typically achieved with flexible splints. The most common procedures employed in managing dental injuries include root canal/endodontics, surgical tooth repositioning, and flexible splinting. Recognition and treatment of these injuries are necessary to facilitate proper healing and salvage of a patient's natural dentition, reducing future complications to patients.

Management of Orbital Floor Fractures.

Fractures of the orbital floor represent a common yet difficult to manage sequelae of craniomaxillofacial trauma. Repair of these injuries should be carried out with the goal of restoring normal orbital volume, facial contour, and ocular motility. Precise surgical repair is imperative to reduce the risk of long-term debilitating morbidity. This article aims to review concepts on the management of orbital floor fractures in the hope of further elucidating perioperative evaluation and decision-making regarding operative intervention.

Surgical Management of Panfacial Fractures.

The evaluation and management of a patient with panfacial fractures are multifaceted. Herein, we describe basic facial skeletal anatomy, considerations for airway securing, and common concurrent injuries. Finally, we discuss primary and secondary reconstructions of facial trauma including sequencing of repair, available landmarks, and the utility of intraoperative computed tomography imaging and virtual surgical planning with custom implants.

Facial Gunshot Wounds.

Craniomaxillofacial gunshot injuries, resulting from assault, suicide attempts, and accidental trauma, represent a major public health dilemma in the United States. Due to the extent of injury and resulting osseous and soft tissue loss, facial gunshot wounds pose a unique challenge to the reconstructive surgeon. Initial management should use advanced trauma life support principles with the goal of patient stabilization. Acute operative management should center around wound decontamination, debridement, and temporary closure. Historically, definitive surgical management focused on delayed reconstruction secondary to high rates of wound infections, necrosis, and ischemia. With improvements in imaging modalities, the advent of virtual surgical planning, and the popularization of microvascular free flaps, contemporary methods have shifted toward earlier more definitive reconstruction. Autologous free tissue transfer has resulted in a decrease in hospital stay and the number of overall surgeries. Importantly, due to the variability in injury pattern and complexity in reconstruction, a systematic approach toward intervention is needed to mitigate complications and optimize overall functional and aesthetic outcomes.

The Role of External Fixation in Trauma and Reconstruction of the Mandible in the Age of Rigid Fixation.

Internal rigid fixation is the gold-standard treatment for facial fractures, but there are some specific cases that are more amenable to external fixation (ex-fix) application. Herein, we discuss advantages and disadvantages to ex-fix in the modern treatment of comminuted mandible fractures, infected mandible fractures, fractures of the condylar region, oncologic mandibular resection, pediatric mandible fractures, and fractures in the edentulous patient.

Secondary Management of Mandible Fractures.

Mandibular fractures are the most common facial fractures that need surgical intervention. If untreated, these fractures affect a patient's occlusion, degree of mouth opening, and facial symmetry, and could cause infection with significant pain. The goal of any surgical intervention is to restore the preinjury occlusion, even if the preinjury occlusion is abnormal. Initial therapies, whether surgical or conservative, are not always successful, however, and revision or delayed surgical intervention can be challenging. Herein, we review common causes of failure of primary surgical management of mandibular fractures and provide tips to successful secondary intervention.

Management of Skull Fractures and Calvarial Defects.

Scalp and calvarial defects can result from a myriad of causes including but not limited to trauma, infection, congenital malformations, neoplasm, and surgical management of tumors or other pathologies. While some small, nondisplaced fractures with minimal overlying skin injury can be managed conservatively, more extensive wounds will need surgical repair and closure. There are many autologous and alloplastic materials to aid in dural and calvarial reconstruction, but no ideal reconstructive method has yet emerged. Different reconstructive materials and methods are associated with different advantages, disadvantages, and complications that reconstructive surgeons should be aware of. Herein, we discuss different methods and materials for the surgical reconstruction of calvarial defects.

Patterns of facial trauma before and after legalization of marijuana in Denver, Colorado: A joint study between two Denver hospitals.

INTRODUCTION: The effect of marijuana on human health has been studied extensively. Marijuana intoxication has been shown to affect performance, attention span, and reaction time. The public health relationship between trauma and cannabis use has also been studied, with mixed conclusions. In this report, the effect of marijuana legalization on many aspects of facial trauma at two hospitals in Denver, Colorado is examined. METHODS: A retrospective review of the electronic medical records was undertaken. Mann-Whitney U tests were used to compare age of patients before and after legalization, and chi squared analyses were used to compare mechanism of injury, and fracture types before and after recreational marijuana legalization in Denver, Colorado. Geographical location of patients was also considered. RESULTS: No significant increase was found in race before and after marijuana legalization (p=0.19). A significant increase in age was found before (M=39.54,SD=16.37), and after (M=41.38,SD=16.66) legalization (p<0.01). Maxillary and skull base fracture proportions significantly increased following legalization (p<0.001 and p<0.001respectively). No significant differences were seen in the proportion of patients who lived in urban and rural counties before and after legalization (p>0.05). CONCLUSION: Public health efforts should be directed towards educating residents and visitors of Colorado on the effects and toxicology of marijuana. More epidemiologic studies are needed for further assessment of the long-term effects of the legalization of marijuana on the population.

Effect of allergic rhinitis on nasal obstruction outcomes after functional open septorhinoplasty.

OBJECTIVE: To evaluate whether a diagnosis of allergic rhinitis affects surgical outcomes of open septorhinoplasty (OSR) and to examine whether OSR provides the same level of improvement in quality of life to patients with and without allergic rhinitis. STUDY DESIGN, SETTING, SUBJECTS AND METHODS: We performed a retrospective evaluation of 646 patients who underwent open septorhinoplasty in a tertiary otolaryngology practice between 2008 and 2015. Preoperative and postoperative quality of life (QoL) measurement using the validated Nasal Obstruction Symptom Evaluation (NOSE) Scale was performed on 307 patients meeting inclusion criteria. These patients were then divided into two groups based on a diagnosis of allergic rhinitis (non-AR vs AR). Comparisons were then made based on quality of life improvements by the NOSE score. RESULTS: There were 213 patients in the non-AR group vs. 94 patients in the AR group. After OSR, patients in both groups experienced significant improvement in nasal airway obstruction. Pre-op NOSE score averages were similar for the non-AR and AR groups (69.9 vs 73.4 p = 0.087). Average improvement in NOSE score for the non-AR and AR groups at 30 days was 48.6 vs 45.9 (p = 0.41); and at 90 day of 48.1 vs 51.5 (p = 0.402). CONCLUSION: Patients with and without allergic rhinitis experience similar OSR outcomes as measured by the NOSE score. Open septorhinoplasty addresses multiple components contributing to nasal airway obstruction, and may offset the effects of allergic rhinitis. When indicated, it should be offered to patients with allergic rhinitis after complete medical management.

Preoperative radiation and complication rates after double free flap reconstruction of head and neck cancer.

INTRODUCTION: In this study, we explore whether preoperative external beam radiation affects complication rates in patients that have undergone double simultaneous free tissue transfer for head and neck defects. STUDY DESIGN, SETTING, SUBJECTS AND METHODS: Approval was obtained from the JPS Institutional Review Board. We performed a retrospective analysis of patients who underwent double free flap reconstruction of head and neck defects between August 1997 and April 2017. Minimum follow up was 6 months. Patients were grouped according to preoperative radiation status (XRT vs non-XRT). The chi-squared test was used for all comparisons. P-values and 95% confidence intervals (CI) were reported as (P, 95% CI). RESULTS: 90 flaps were performed on 45 patients. The most common flap combination utilized was fibula plus radial forearm free flap (RFF) in 17 out of 45 patients. There were no statistically significant differences in frequency of flap failure (0.35, -15.9-20.1), wound infection (0.75, -22.1-19.3), hematoma (0.16, -5.3-36.7), or fistula formation (0.69, -22.5-24.6). There were also no statistically significant differences in cardiac complications (0.57, -10.3-28.2) and DVT (0.22, -12.4-25.3). CONCLUSION: Our findings suggest that double free flap patients who had preoperative radiation are not more likely to have complications compared to non- radiated patients. Simultaneous double free flaps should be reserved for the most complex cases. Extensive discussion should be had with the patient about possible morbidity and mortality.

Total mandibulectomy defect in the setting of chronic bisphosphonate use.

Bisphosphonates are among several drugs known in modern medicine to have a potentially deleterious effect on the mandible with chronic use. While purportedly causing a necrotic reaction in the bone, the complete mechanism is not fully elucidated yet as cases are quite rare in the general public. Despite the esoteric nature of this entity, patients suffering from bisphosphonate induced necrosis have a complicated and prolonged course often involving varying degrees of mandibular debridement with severe cases requiring reconstruction. In this report, we present the unique case of a patient with a progressive mandibular osteonecrosis requiring complete mandibulectomy and fibula flap reconstruction.

Expression of immunoglobulin D is increased in chronic rhinosinusitis.

BACKGROUND: Immunoglobulin (Ig) D is largely localized to the upper airway and reacts with colonizing respiratory pathogens. OBJECTIVE: To determine whether chronic rhinosinusitis (CRS) is associated with increased IgD expression. METHODS: We performed immunofluorescent staining for cytoplasmic IgD, IgA, IgM, and surface plasma cell marker CD138 (syndecan-1) in sinus tissue of patients with CRS with and without nasal polyps (CRSwNP and CRSsNP, respectively) and control subjects without CRS (n = 6 each). Sinonasal mucus antibody levels of patients with CRSwNP or CRSsNP and control subjects were measured by enzyme-linked immunosorbent assay (n = 13, 11, and 9 subjects, respectively). Cells per square millimeter and antibody levels were compared by analysis of variance. Histopathology was performed with sinus tissue from subjects in the 3 groups (n = 6, 8, and 13 subjects respectively). RESULTS: Cells expressing cytoplasmic IgD exceeded those with cytoplasmic IgA and IgM and represented most CD138+ plasma cells in the lamina propria. The frequencies of IgD+ plasma cells were significantly higher in patients with CRSsNP and CRSwNP compared with control subjects (P < .01). Only patients with CRSwNP showed increased frequencies of IgM and IgA plasma cells (P < .01). In contrast to high plasma cell frequencies in tissues, the levels of secreted IgD were lower than those of IgA, IgM, and IgG but were highest in the CRSwNP group compared with the other groups (P < .05). CONCLUSION: IgD plasma cells are prominent in sinus tissues and are increased in CRS. That IgD protein also shows the lowest concentration of antibodies in secretions suggests that its activity might be targeted to the tissue rather than secretions.

Causes and Prevention of Secondary Obstruction.

Secondary nasal obstruction occurs when surgery fails to improve a patient's nasal obstruction symptoms. This may occur from failure to recognize a problem preoperatively or failure to address mucocutaneous medical ailments. Secondary obstruction may even occur despite perfect execution of the operative plan. In this article, we discuss the etiology, intraoperative pitfalls, and surgical correction of secondary obstruction after primary rhinoplasty. When managing postrhinoplasty secondary obstruction, care must be taken to correct the cause of obstruction without creating new problems.