Mandible Fractures Undergoing Transfer Rarely Require Acute Intervention.

Study Design: A retrospective review was conducted of all patients with mandibular fractures who were evaluated by plastic surgery at a Level I trauma center between January 1, 2017 and May 1, 2020. Data including demographic characteristics, mechanism of injury, type of presentation (e.g., primary or transfer), treatment plan, and time to intervention were recorded. Objective: Mandibular fractures are common traumatic injuries. Because these injuries are managed by surgical specialists, these patients are often emergently transferred to tertiary care hospitals. This study aims to assess the benefits of emergent transfer in this patient group. Methods: Variables were summarized using descriptive statistics. The relationship with initial disposition was assessed via tests of association, including Student's t-test, Fisher's exact test, or chi-square tests. Significance was set to p values less than 0.05. Multivariate regression analysis was conducted to determine predictors of presentation to outside hospital followed by transfer to our institution. Results: Records from 406 patients with isolated mandibular fractures were evaluated. 145 (36%) were transferred from an outside hospital specifically for specialty evaluation. One patient required intervention in the Emergency Department (ED). Of the 145 patients that were transferred to our facility, eight (5.5%) were admitted for operative management. Patients with open injuries and pediatric patients showed benefit from transfer. Conclusions: Patients are frequently transferred to tertiary care facilities for specialty service evaluation and treatment. However, when isolated mandible fractures were evaluated, only one patient required intervention in the ED. Patients with grossly open fractures and pediatric patients were more frequently admitted specifically for operative management. This practice of acute interfacility transfer represents an unnecessary cost to our health system as isolated mandible fractures can be managed on an outpatient basis. We suggest that pediatric patients and patients with open fractures be transferred for urgent evaluation and management, whereas most patients would be appropriate for outpatient evaluation.

Intramedullary Fixation of Hand Fractures and Arthrodeses.

Intramedullary fixation has long been popular for fracture fixation in the upper extremity from the shoulder through the carpus. Recently, intramedullary fixation in the hand has gained increasing interest, specifically in the metacarpals and phalanges, corresponding with the development of improved cannulated headless screw technology. Along with the advantages of increased operative speed and less surgical dissection, which can promote rapid healing, many benefits exist, supporting their use despite some drawbacks. This article reviews the background and biomechanics of intramedullary fixation with a specific focus on cannulated headless screws, describes the application and techniques of intramedullary screw fixation in the hand, and details the associated outcomes and costs for metacarpal fractures, phalangeal fractures, and interphalangeal joint arthrodesis.

Quantifying the Effective Lift of Skin-Only, SMAS Plication, and Extended SMAS Face-Lift Techniques in a Cadaveric Study.

BACKGROUND: Rhytidectomies are performed to rejuvenate the aging face. Various techniques exist to achieve soft-tissue elevation and skin tightening. This study analyzes three common face-lift techniques: skin-only, superficial musculoaponeurotic system (SMAS) plication, and extended SMAS lifts. The authors characterize effective facial changes with each procedure in a cadaver model. METHODS: The authors performed face-lift procedures on 18 cadaver hemifaces. Each face was measured along horizontal and vertical vectors. The primary outcome was change along these vectors. Skin-only, SMAS plication, and extended SMAS lifts were performed sequentially on each hemiface. SMAS plication was used to approximate a lateral SMASectomy procedure. Parameter measurements were compared. RESULTS: All three procedures exhibited a significant tightening along horizontal vectors. SMAS procedures provided a significant lift along all vertical vectors, whereas the skin-only lift failed to demonstrate significant vertical elevation. SMAS procedures achieved significantly greater composite horizontal and vertical lifts compared to the skin-only operation. There was only an incremental increase in lift between the SMAS plication and extended SMAS procedures in the upper and midface regions. The extended SMAS led to the greatest lift in the lower face. CONCLUSIONS: SMAS procedures provided a greater lift along both horizontal and vertical vectors than the skin lift alone. The increased dissection in the extended SMAS technique resulted in only a modest increase in lift compared to SMAS plication. The extended SMAS approach appears to offer the most benefit at the lower face and may be the best choice for targeting this region.

Taming the Tongue: The Surgical Approach to Macroglossia.

While traditionally in the realm of otorhinolaryngology or oral maxillofacial surgery, conditions involving the tongue may also be managed by plastic surgeons. The authors present an unusual case of acquired macroglossia resulting from angiotensin-converting enzyme inhibitor-induced angioedema and review the literature to discuss its surgical management from a plastic surgery perspective. A 62-year-old female suffered severe airway obstruction, respiratory arrest, and anoxic brain injury from angioedema-associated macroglossia. After tracheostomy, the patient was managed nonsurgically, with bite wound care and medications to minimize angioedema to marginal effect. Ultimately, a partial glossectomy was planned. The edematous distal tongue was amputated and closed primarily. On postoperative day 2, she was successfully weaned off mechanical ventilation and no longer suffers trauma from tongue biting. The simple anterior tongue resection described in this paper was an appropriate approach for our patient. More research is needed to guide plastic surgeons in an optimal approach for clinical scenarios.

Using 3D Printing and Mirror Image Modeling in Orbital Floor Reconstruction.

ABSTRACT: Three-dimensional (3D) modeling and printing technologies are increasingly utilized as tools to assist in complex craniofacial reconstructions. Herein, the authors report the intraoperative use of sterilized 3D models printed in-house to mold a custom resorbable implant in the case of a pediatric patient with a unilateral complex orbital fracture. The imaging was processed with open-source software. Two patient-specific orbital models were 3D-printed (Fig. 2): a life-size print of the patient's preoperative CT scan and a left orbit reconstructed to resemble its uninjured state using mirrored-imaging of the uninjured side. This construct ultimately served as a sterilized template to mold a resorbable implant intraoperatively. Post-operatively, the patient experienced no complications. At the 18-month follow-up, the patient had done well without diplopia, headaches or visual problems. The authors report a case of a successful orbit reconstruction assisted by mirrored-image computer modeling and patient-specific 3D printing.

Cleft Lip and Palate Surgery Crowdfunding and Access to Care.

ABSTRACT: A total of 169 ACPA approved teams treat cleft deformities in the United States. These centers are unevenly distributed, and families may disproportionally pay extra travel costs to consult a multidisciplinary cleft team. Families experiencing hardships are able to create campaigns on GoFundMe to advertise their fundraiser publicly. The authors sought to establish whether a correlation exists between patients asking for support for cleft treatment and their geographic location in the US.A total of 635 crowdfunding campaigns for cleft lip and/or palate were reviewed from GoFundMe. Google searches for cleft lip and palate were evaluated utilizing Google Trends, with values reported as Relative Search Volumes (RSV). Driving distances and travel time to the nearest approved ACPA center were calculated using Google Maps data.There was a statistically significant difference in average driving distance and travel duration between the different subregions of the US (P  =  0.0059 and 0.026, respectively). The South subregion had the highest proportion of campaigns (n = 259, 40.9%), mean driving distance (105.75 km) and mean driving duration (1 hour 8 minutes). The number of approved teams per state was negatively correlated to both RSV scores (r = -0.38, P  =  0.048) and the number of campaigns (r = -0.34, P  =  0.014).There is an uneven distribution of ACPA centers among the US subregions. The South seems to have the highest need for care, as identified by proportionate number of campaigns, adjusted driving distances and travel time. This data suggests that underserved areas for cleft care are correlated with greater numbers of hardship campaigns and more internet searches regarding cleft lip and palate.

Underdiagnosis of Nasoorbitoethmoid Fractures in Patients with Zygoma Injury.

BACKGROUND: Nasoorbitoethmoid fractures commonly accompany midface fractures and may be underdiagnosed, resulting in incomplete reconstruction or inadequate treatment following facial trauma. To better understand the nasoorbitoethmoid fracture diagnosis and treatment tendencies, the authors analyzed concomitant nasoorbitoethmoid injuries in the setting of zygoma fractures. METHODS: The facial trauma database at a level I trauma center was evaluated. All patients with diagnosed zygoma fractures from June of 2011 to March of 2016 were assessed for a concomitant nasoorbitoethmoid injury. Documentation of these fractures in radiology, plastic surgery, and operative notes was recorded, as was the rate of nasoorbitoethmoid fracture surgical repair. RESULTS: The authors identified 339 eligible patients and completed retrospective analysis of computed tomographic images for their 356 zygoma fractures. The incidence of concomitant nasoorbitoethmoid fractures was 30.6 percent (109 of 356). Documentation rates of nasoorbitoethmoid fractures were 0 percent, 3.7 percent, and 8.3 percent in radiology, plastic surgery, and operative notes, respectively. The rate of surgical correction of nasoorbitoethmoid injuries was 22.9 percent (25 of 109). Of those fractures identified, 44.9 percent (49 of 109) were minimally displaced or nondisplaced. Subset analysis of only significantly displaced fractures yielded an incidence of 16.8 percent (60 of 356). Of significantly displaced fractures, documentation rates were 0 percent, 6.7 percent, and 16.8 percent in radiology, plastic surgery, and operative notes, respectively. The surgical repair rate of significantly displaced fractures was 31.7 percent (19 of 60). CONCLUSIONS: These findings suggest a high concomitance rate of nasoorbitoethmoid fractures with zygoma fractures and identify a tendency to underdocument and undertreat this injury pattern. Clinicians managing patients with midface trauma should have a high suspicion for nasoorbitoethmoid trauma. Plastic surgeons and radiologists should be better trained in identifying the nasoorbitoethmoid fracture pattern.

The Economic Impact of Flexor Tendon Lacerations of the Hand in the United States.

PURPOSE: Flexor tendon lacerations are a common and debilitating injury for thousands of Americans annually. Despite this, no study has attempted to estimate the economic impact of these injuries. The objective of this study was to estimate the economic impact of flexor tendon lacerations in America. METHODS: The cost of flexor tendon lacerations to society was estimated using a validated prevalence-based cost of illness model. The primary cohort was defined as all patients in the United States presenting with complete flexor tendon lacerations who underwent surgical repair. The secondary cohort was defined by all patients who required reoperation within 1 year of their initial operation. For these groups, both direct and indirect costs (lost income, missed workdays, and disability payments) were measured. RESULTS: Flexor tendon lacerations incur an estimated cost of between US $240.8 and US $409.1 million annually to the American medical system. The total direct cost per injury is estimated to be US $13,725, whereas estimates to the indirect costs range from US $60,786 to US $112,888. CONCLUSIONS: Flexor tendon lacerations represent an important economic burden to our health care system, even when compared with other common hand conditions. Specifically, indirect costs, such as missed workdays, are the major contributor toward the total cost these injuries incur on society, accounting for upward of 89% of the total cost. This suggests that we should focus our efforts to improve treatments and rehabilitation protocols which decrease these indirect costs.

Improved Diagnostic Accuracy of Periprosthetic Breast Infection: Novel Application of the Alpha Defensin-1 Biomarker.

Prompt, accurate diagnosis of breast implant infection is critical to minimizing patient morbidity. Bacterial culture false negative rate approaches 25%-30%, and better costeffective testing modalities are needed. Alpha defensin-1 (AD-1) is a neutrophil-mediated biomarker for microbial infection. With sensitivity/specificity of 97% and 96%, it has replaced culture as the preferred diagnostic modality for orthopedic periprosthetic infection, but has yet to be investigated in breast reconstruction. This pilot study compares the diagnostic performance of AD-1 to bacterial culture in suspected periprosthetic breast infection. METHODS: Patients with prosthetic breast reconstruction and suspected periprosthetic infection were prospectively studied. Implant pocket fluid was analyzed with gram stain and culture, AD-1 assay, and adjunctive markers. Demographics, operative history, prosthetic characteristics, and antibiotic exposure were collected, and diagnostic performance of each test was compared. RESULTS: Fifteen breasts with suspected periprosthetic breast infection were included, 10 (66.7%) of which were acutely infected. Gram stain correctly identified only 1 of 10 infections, whereas culture failed to identify 1 infection and reported equivocal/false-positives in 2 noninfected samples. AD-1, however, correctly classified all 15 samples. AD-1 exhibited 100% sensitivity and specificity, comparing favorably to culture (sensitivity: 90%, specificity: 60%), although this did not reach significance (P=0.22). Infected breasts also demonstrated significantly higher adjunctive marker levels compared to noninfected breasts. CONCLUSIONS: This study demonstrates the utility of AD-1 in diagnosing periprosthetic breast infection. Combining AD-1 with adjunctive inflammatory markers may allow more accurate, prompt detection of implant infection which may reduce morbidity and reconstructive failures.

Gangrenous cholecystitis: A silent but potential fatal disease in patients with diabetic neuropathy. A case report.

Gangrenous cholecystitis (GC) is a severe and potentially deadly complication of acute cholecystitis. We present a 83-year-old gentleman with a past medical history of type 2 diabetes mellitus with significant associated neuropathy, presenting to a community hospital in a major metropolitan area with 10 days nausea and vomiting and a benign abdominal exam. While the patient was admitted for hyperglycemia, he was subsequently found to have severe GC requiring urgent surgical intervention.

The Use of a Magnetic Port Finder in the Retrieval of Air Rifle BBs to the Upper Extremity.

Air-powered rifles shoot ball bearings with enough kinetic energy to penetrate skin and fracture underlying bones. In addition, there are reports of these ball bearings embolizing within the vascular network, causing serious injuries such as ischemic stroke with resultant blindness. The severity of these complications warrants occasional removal of these foreign bodies; however, they can be difficult to localize. In this case report, we describe the use of a magnetic port finder, a sterilizable tool used in breast reconstruction, to localize the foreign body in situ. We believe that this tool is effective at locating ferrous foreign bodies precisely, allowing for surgical retrieval while minimizing damage to surrounding tissue.

The use of Synthes MatrixWAVE bone anchored arch bars for closed treatment of multiple concurrent mandibular fractures.

BACKGROUND: Maxillomandibular fixation (MMF) is an important tool in the treatment of facial fractures and bone-anchored arch bar systems have emerged as treatment options. This study illustrates our experience with the Synthes MatrixWAVE MMF system and the novel application in closed treatment of patients with multiple concurrent mandibular fractures. METHODS: We enrolled eight patients with concurrent mandibular fractures and treated them with the MatrixWAVE MMF system. The malleable arch bars were fitted and then secured using 6-8 mm screws. The arch bar was and either stretched or compressed to ensure optimal positioning. 24-gauge interdental fixation wiring was placed using the fish loop technique on either side of the fracture to achieve stabilization of the mandible fractures. RESULTS: All eight patients were retained in MMF until stable occlusion was achieved with clinical evidence of healing, approximately 4-6 weeks. Post-operative Panorex scans did not reveal any evidence of damage to tooth roots. None of the screws became overly embedded in the mucosa secondary to overgrowth; the arch bars were successfully removed in an outpatient setting without local anesthesia. CONCLUSIONS: The Synthes MatrixWAVE MMF system has unique features such as prominent screw anchor heads and horizontal malleability unique from other bone anchored arch bars. These features allow for completely closed treatment of patients with multiple concurrent mandible fractures.

The rapidly increasing trend of cannabis use in burn injury.

The use of cannabis is currently increasing according to U.S. Department of Health and Human Services (HHS). Surprisingly, cannabis use among burn patients is poorly reported in literature. In this study, rates of cannabis use in burn patients are compared with general population. Data from the National Burn Repository (NBR) were used to investigate incidence, demographics, and outcomes in relation to use of cannabis as evidenced by urine drug screen (UDS). Thousands of patients from the NBR from 2002 to 2011 were included in this retrospective study. Inclusion criteria were patients older than 12 years of age who received a drug screen. Data points analyzed were patients' age, sex, UDS status, mechanism of burn injury, total body surface area, length of stay, ICU days, and insurance characteristics. Incidence of cannabis use in burn patients from the NBR was compared against national general population rates (gathered by Health and Human Services) using chi-square tests. Additionally, the burn patient population was analyzed using bivariate analysis and t-tests to find differences in the characteristics of these patients as well as differences in outcomes. Seventeen thousand eighty out of over 112,000 patients from NBR had information available for UDS. The incidence of cannabis use is increasing among the general population, but the rate is increasing more quickly among patients in the burn patient population (P = .0022). In 2002, 6.0% of patients in burn units had cannabis+ UDS, which was comparable with national incidence of 6.2%. By 2011, 27.0% of burn patients tested cannabis+ while national incidence of cannabis use was 7.0%. Patients who test cannabis+ are generally men (80.1%, P < .0001) and are younger on average (35 years old vs 42, P < .0001). The most common mechanisms of injury among patients who test cannabis+ or cannabis- are similar. Flame injury makes up >60% of injuries, followed by scalds that are >15%. In comparing cannabis+/- patients, cannabis+ patients are more likely to be uninsured (25.2% vs 17.26%, P < .0001). Finally, patients who test cannabis+ have larger burns (TBSA% of 12.94 vs 10.98, P < .0001), have a longer length of stay (13.31 days vs 12.6, P = .16), spend more days in the ICU (7.84 vs 6.39, P = .0006), and have more operations (2.78 vs 2.05, P < .0001). The rate patients testing positive for cannabis in burn units is growing quickly. These patients are younger and are less likely to be insured. These patients also have larger burns, spend more time in ICUs, and have a greater number of operations. The increasing use of cannabis, as expected from legalization of cannabis in multiple states, among burn patient population may lead to increased burden on already tenuous health care resources.