Prevalence and Severity of Burn Scars in Rural Mozambique.

BACKGROUND: Burn injuries are common in low- and middle-income countries (LMICs) and their associated disability is tragic. This study is the first to explore burn scars in rural communities in Mozambique. This work also validated an innovate burn assessment tool, the Morphological African Scar Contractures Classification (MASCC), used to determine surgical need. METHODS: Using a stratified, population-weighted survey, the team interviewed randomly selected households from September 2012 to June 2013. Three rural districts (Chókwè, Nhamatanda, and Ribáuè) were selected to represent the southern, central and northern regions of the country. Injuries were recorded, documented with photographs, and approach to care was gathered. A panel of residents and surgeons reviewed the burn scar images using both the Vancouver Scar Scale and the MASCC, a validated visual scale that categorizes patients into four categories corresponding to levels of surgical intervention. RESULTS: Of the 6104 survey participants, 6% (n = 370) reported one or more burn injuries. Burn injuries were more common in females (57%) and most often occurred on the extremities. Individuals less than 25 years old had a significantly higher odds of reporting a burn scar compared to people older than 45 years. Based on the MASCC, 12% (n = 42) would benefit from surgery to treat contractures. CONCLUSION: Untreated burn injuries are prevalent in rural Mozambique. Our study reveals a lack of access to surgical care in rural communities and demonstrates how the MASCC scale can be used to extend the reach of surgical assessment beyond the hospital through community health workers.

Analysis of Readmission and Complications After Repair of Orbital Fractures Using California's Office of Statewide Health Planning and Development Database.

BACKGROUND: Orbital fractures represent one of the most common trauma-related facial fractures and may present with a variety of concomitant injuries. Many factors including age, associated diagnoses, and fracture complications are important in determining surgical candidacy. We used a statewide database to determine the prevalence of orbital fractures, rates of surgical repair during initial admission, and early patient outcomes. METHODS: A longitudinal analysis of patients with orbital fracture was performed using California's Office of Statewide Health Planning and Development patient discharge database for admissions occurring between January 2015 and December 2018.Patients were identified using International Classification of Diseases, Tenth Revision codes. The primary risk factor was surgical management of orbital fractures. The primary outcomes of interest were readmission requiring surgical management and complications of the fracture. Survival models were developed to evaluate the risk of a repair at readmission adjusting for relevant covariates. RESULTS: Of the 67,408 facial fractures included in our study, 8.7% (n = 5872) were diagnosed with orbital fractures. Among this population, 18.4% (n = 1082) underwent surgical repair during their initial admission. Patients were primarily male (71.1%; n = 4,173) and presented in a nonurgent fashion (93.7%; n = 5501). Less than half (42.8%) of patients with an urgent presentation and 16.8% of patients with a nonurgent presentation underwent repair. Centers of Medicaid & Medicare Services guidelines dictated presentation classification. Repair was associated with a significantly higher survival outcome. Orbital fractures were more frequently repaired in the setting of concomitant zygomatic, nasal, and LeFort I-III fractures. Increased risk in complications was observed in all concomitant fracture groups, and there existed a decreased risk of postsurgical complications in these same cohorts. CONCLUSIONS: Although most orbital fractures were managed nonoperatively, our analysis found that rates of repair for orbital floor, maxillary, and zygomatic fractures were greater than for other facial fractures. Concomitant fractures were associated with an increased hazard ratio for complications. Although low in prevalence overall, the most often observed postoperative complications in this population were diplopia, glaucoma, and blindness/low vision.

Using the Disruptive Score to Identify Publications That Changed Plastic Surgery Practice.

PURPOSE: The impact of academic publications is often characterized by the total number of future citations. However, this metric does not adequately characterize the true impact in terms of changing practices or paradigms. A new metric called the "disruption score" (DS) has been developed and validated in nonsurgical publications. This study aims to use the DS to identify the most disruptive publications in plastic surgery.The DS, a ratio of 2 numbers, varies between -1 and +1. Scores closer to -1 are developing papers that summarize the known literature while papers closer to +1 are disruptive-they result in a paradigm shift in the field of study. METHODS: A search was performed for all articles from 1954 to 2014 in the following journals: Plastic and Reconstructive Surgery; Aesthetic Surgery Journal; Journal of Plastic, Reconstructive, and Aesthetic Surgery; Annals of Plastic Surgery; Aesthetic Plastic Surgery; Clinics in Plastic Surgery; and Plastic Surgery. The disruptive score was calculated for each article.The top 100 papers ranked by DS were examined and any editorials/viewpoints, publications with less than 26 citations, or less than 3 references were excluded because of their subjective nature and smaller academic contribution. The remaining 64 publications were analyzed for topic, study type, and citation count. RESULTS: A total of 32,622 articles were found with a DS range from 0.385 to 0.923. The mean score of the top 64 articles was 0.539 with an average citation count of 195 and 9 references. Plastic and Reconstructive Surgery had the most disruptive papers with 50. There were no randomized controlled trials with a majority of the studies being technical descriptions or case series. CONCLUSIONS: There are many ways to measure academic success, but there are fewer ways to measure the impact of academic contributions. The DS is a novel measurement that can demonstrate when an article results in a paradigm shift as opposed to just total citation count. When applied to the plastic surgery literature, the DS demonstrates that technical innovation and creativity are the most academically impactful. Future evaluations of academic success should include the DS to measure the quality of academic contributions.

Analysis of Pediatric Facial Fracture Repair Rates and Complications Using California's Office of Statewide Health Planning and Development Database.

BACKGROUND: There exists a paucity of data on which pediatric facial fractures should be surgically repaired and when. In this study, the authors used a California state-wide database to determine the prevalence of facial fractures in the pediatric population and examine, which fractures are repaired. in addition to the timing of the repair, complications and resource utilization of the healthcare system were analyzed. METHODS: Pediatric patients under the age of 18 were identified using the California Office of Statewide Health Planning and Development patient discharge database for admissions occurring between January 2015 and December 2018. International Classification of Diseases, Version 10 diagnosis codes were used to classify facial fractures. The associated diagnoses, complications, and number of subsequent repairs patients underwent were analyzed to determine the typical course of pediatric facial fractures. RESULTS: Of the 3058 patients diagnosed with facial fracture, 32% underwent surgical repair (N = 982). The 4 most repaired fractures were mandible (40%), nasal (16.2%), and orbital (15.1%). Surgical intervention steadily increased with age, with a peak in the 12 to 15-year-old cohort. CONCLUSIONS: Our analysis found that most fractures were managed nonoperatively, but those that did receive an operation did so during their index admission. In addition, the most repaired fractures were mandibular, nasal, and orbital fractures. The present study represents 1 of the largest pediatric samples to have assessed facial fractures, repair rates, and their sequelae.

The new face of war: Craniofacial injuries from Operation Inherent Resolve.

BACKGROUND: During the last 20 years of conflict in the Middle East, improvements in body armor and the use of improvised explosive devices have resulted in an increased incidence of complex craniofacial trauma (CFT). Currently, CFT comprises up to 40% of all casualties. We present new data from the recent conflict in Iraq and Syria during Operation Inherent Resolve. METHODS: Data were collected for patients treated at role 1, role 2, and role 3 facilities in Iraq and Syria over a 1-year period. During this time, a specialized head & neck surgical augmentation team was deployed and colocated with the central role 3 facility. Data included for this cross-sectional study are as follows: injury type and mechanism, triage category, initial managing facility and subsequent levels of care, and procedures performed. RESULTS: Ninety-six patients sustained CFT over the study period. The most common injuries were soft tissue (57%), followed by cranial (44%) and orbital/facial (31%). Associated truncal and/or extremity injuries were seen in 46 patients (48%). There were marked differences in incidence and pattern of injuries between mechanisms (all p < 0.05). While improvised explosive devices had the highest rate of cranial and truncal injuries, gunshot wounds and blunt mechanisms had higher incidences of orbital/facial and neck injuries. Overall, 45% required operative interventions including complex facial reconstruction, craniotomy, and open globe repair. Mortality was 6% with 83% due to associated severe brain injury. Most patients were local nationals (70%) who required discharge or transfer to the local health care system. CONCLUSION: Complex craniofacial trauma is increasingly seen by deployed surgeons, regardless of subspecialty training or location. Deployment of a centrally located head and neck team greatly enhances the capabilities for forward deployed management of CFT, with excellent outcomes for both US and local national patients. LEVEL OF EVIDENCE: Therapeutic/care management; Level V.

Contemporary management of flail chest.

Thoracic injury is currently the second leading cause of trauma-related death and rib fractures are the most common of these injuries. Flail chest, as defined by fracture of three or more ribs in two or more places, continues to be a clinically challenging problem. The underlying pulmonary contusion with subsequent inflammatory reaction and right-to-left shunting leading to hypoxia continues to result in high mortality for these patients. Surgical stabilization of the fractured ribs remains controversial. We review the history of management for flail chest alone and when combined with pulmonary contusion. Finally, we propose an algorithm for nonoperative and surgical management.