Implementation of an Enhanced Recovery After Surgery Protocol for Cranial Vault Remodeling Procedures.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols have been implemented across surgical disciplines, including cranial vault remodeling for craniosynostosis. The authors aim to describe the implementation of an ERAS protocol for cranial vault remodeling procedures performed for patients with craniosynostosis at a tertiary care hospital. DESCRIPTION: Institutional review board approval was received. All patients undergoing a cranial remodeling procedure for craniosynostosis at the authors' institution over a 10-year period were collected (n = 168). Patient and craniosynostosis demographics were collected as well as operative details. Primary outcome measures were intensive care unit length of stay (ICU LOS) and narcotic usage. Chi squared and independent t-tests were employed to determine significance. A significance value of 0.05 was utilized. RESULTS: During the time examined, there were 168 primary cranial vault remodeling procedures performed at the authors' institution - all of which were included in the analysis. Use of the ERAS protocol was associated with decreased initial 24-hour morphine equivalent usage (p < 0.01) and decreased total morphine equivalent usage (p < 0.01). Patients using the ERAS protocol experienced a shorter ICU LOS (p < 0.01), but the total hospital length of stay was unchanged. CONCLUSION: This study reiterates the benefit of developing and implementing an ERAS protocol for patients undergoing cranial vault remodeling procedures. The protocol resulted in an overall decreased ICU LOS and a decrease in narcotic use. This has implications for ways to maximize hospital reimbursement for these procedures, as well as potentially improve outcomes.

The Fisher Subunit Anatomical Approach for Cleft Lip Revisions: An Evolution and Case Series.

ABSTRACT: Many techniques exist to reapproximate a cleft lip but can leave unsatisfactory results with nonanatomic scars and a short upper lip, creating a need for revision. Many revisions focus on adjacent tissue transfers and realignment of landmarks, but in the senior authors' experience, recreating the defect and utilizing the Fisher repair for revision have led to aesthetically pleasing results and less noticeable scars. A database was collected that included all cleft lip revisions performed at a large, comprehensive children's hospital from October 2018 to July 2021. Inclusion criteria included any cleft patient with a cleft lip revision performed by two craniofacial surgeons. Data collected included sex, characteristics of the cleft lip, age at initial and index repair, type of initial repair, previous revisions, type of revision with any additional tissue rearrangement, and any nose repair. Sixty-five patients were included in the study for analysis. The type of initial repair was known in sixty-four cases (98%), and fifty-four were Millard repairs (83%). Twenty-two patients (33%) had a previous revision prior to their index revision. Sixty patients (92%) underwent the Fisher repair technique for their index revision and forty-six patients (70%) underwent nasal revision. In follow-up, all patients demonstrated an improvement in lip aesthetics. This study demonstrates a large subset of patients that have undergone cleft lip revision using the Fisher technique. In the senior surgeons' experience, the Fisher repair technique in the setting of cleft lip revision is an ideal way to address the shortcomings of historical repair techniques.

Plastic Surgery Outreach Clinics Expand Access to Cleft and Craniofacial Care in Mississippi.

ABSTRACT: Accessing treatment at ACPA (American Cleft Palate-Craniofacial Association)-approved centers is challenging for individuals in rural communities. This study aims to assess how pediatric plastic surgery outreach clinics impact access for patients with orofacial cleft and craniosynostosis in Mississippi. An isochrone map was used to determine mean travel times from Mississippi counties to the sole pediatric hospital and the only ACPA-approved team in the state. This analysis was done before and after the establishment of two outreach clinics to assess differences in travel times and cost of travel to specialized plastic surgery care. Two sample t-tests were used for analysis.The addition of outreach clinics in North and South Mississippi led to a significant reduction in mean travel times for patients with cleft and craniofacial diagnoses across the state's counties (1.81 hours vs 1.46 hours, P < 0.001). Noteworthy travel cost savings were observed after the introduction of outreach clinics when considering both the pandemic gas prices ($15.27 vs $9.80, P < 0.001) and post-pandemic prices ($36.52 vs $23.43, P < 0.001).The addition of outreach clinics in Mississippi has expanded access to specialized healthcare for patients with cleft and craniofacial differences resulting in reduced travel time and cost savings for these patients. Establishing specialty outreach clinics in other rural states across the United States may contribute significantly to reducing burden of care for patients with clefts and craniofacial differences. Future studies can further investigate whether the inclusion of outreach clinics improves follow-up rates and surgical outcomes for these patients.

Implementation of an Enhanced Recovery After Surgery Protocol for Cleft Palate Repair.

OBJECTIVE: This study examines an Enhanced Recovery After Surgery (ERAS) protocol for patients with cleft palate and hypothesizes that patients who followed the protocol would have decreased hospital length of stay and decreased narcotic usage than those who did not. DESIGN: Retrospective cohort study. SETTING: The study takes place at a single tertiary children's hospital. PATIENTS: All patients who underwent cleft palate repair during a 10-year period (n = 242). INTERVENTIONS: All patients underwent cleft palate repair with the most recent cohort following a new ERAS protocol. MAIN OUTCOME MEASURES: Primary outcomes included hospital length of stay and narcotic usage in the first 24 hours after surgery. RESULTS: Use of local bupivacaine during surgery was associated with decreased initial 24-hour morphine equivalent usage: 2.25 vs 3.38 mg morphine equivalent (MME) (P < 0.01), and a decreased hospital length of stay: 1.71 days vs 2.27 days (P < 0.01). The highest 24-hour morphine equivalent a patient consumed prior to the ERAS protocol implementation was 24.53 MME, compared with 6.3 MME after implementation. Utilization of the ERAS protocol was found to be associated with a decreased hospital length of stay: 1.67 vs 2.18 days (P < 0.01). CONCLUSIONS: Use of the proposed ERAS protocol may lead to lower narcotic usage and decreased length of stay.

Longitudinal Speech and Fistula Outcomes Following Primary Cleft Palate Repair at a Single Institution.

INTRODUCTION: Fistula formation and velopharyngeal insufficiency (VPI) are complications of cleft palate repair that often require surgical correction. The goal of the present study was to examine a single institution's experience with cleft palate repair with respect to fistula formation and need for surgery to correct velopharyngeal dysfunction. METHODS: Institutional review board approval was obtained. Patient demographics and operative details over a 10-year period were collected. Primary outcomes measured were development of fistula and need for surgery to correct VPI. Chi-square tests and independent t tests were utilized to determine significance (0.05). RESULTS: Following exclusion of patients without enough information for analysis, 242 patients were included in the study. Fistulas were reported in 21.5% of patients, and surgery to correct velopharyngeal dysfunction was needed in 10.7% of patients. Two-stage palate repair was associated with need for surgery to correct VPI (P = 0.014). Furlow palatoplasty was associated with decreased rate of fistula formation (P = 0.002) and decreased need for surgery to correct VPI (P = 0.014). CONCLUSION: This study reiterates much of the literature regarding differing cleft palate repair techniques. A 2-stage palate repair is often touted as having less growth restriction, but the present study suggests this may yield an increased need for surgery to correct VPI. Prior studies of Furlow palatoplasty have demonstrated an association with higher rates of fistula formation. The present study demonstrated a decreased rate of fistula formation with the Furlow technique, which may be due to the use of the Children's Hospital of Philadelphia modification. This study suggests clinically superior outcomes of the Furlow palatoplasty over other techniques.

Patients Requiring Multiple Surgeries for Velopharyngeal Insufficiency: Findings From a 10-Year Retrospective Review.

This study analyzed patients undergoing multiple surgeries for velopharyngeal insufficiency (VPI) and reviewed their preoperative evaluations and techniques selected for subsequent surgeries. A retrospective chart review was performed including patients having undergone multiple surgeries for VPI at the authors' institution between 2012 and 2022. All patients were evaluated and managed at the author's institution under the direction of 4 senior surgeons. The objective of this study was to provide insight into preoperative evaluation, surgical technique selection, and other factors that may contribute to patients who require multiple VPI surgeries. Of 71 patients having undergone surgery for VPI, 8 required at least 1 additional operation for persistent VPI following the initial intervention. Six patients who initially underwent a superiorly based posterior pharyngeal flap (PPF) required additional surgery, and for those patients' subsequent operations, 5 different techniques were used throughout their treatment. Of the remaining 2 patients who had multiple VPI surgeries, 1 initially received autologous fat transfer and 1 initially underwent a furlow palatoplasty. Finally, 0 patients that initially underwent buccal flaps or collagen injection required further unplanned surgical intervention. This study demonstrates the importance of selecting an appropriate surgical approach when operating on patients following a failed VPI surgery. The algorithm developed from these findings emphasizes the importance of properly identifying the anatomical deficiency resulting from the failed intervention. A review of the advantages of nasopharyngoscopy as a preoperative evaluative technique of velopharyngeal form and function when compared to lateral barium video fluoroscopy was also included.

Mandibular Distraction in Patients With Pierre Robin Sequence: A Multisurgeon Experience.

OBJECTIVE: Mandibular distraction osteogenesis (MDO) is rapidly becoming a standard of care for management of patients with severe Pierre Robin sequence. The tongue is brought forward to alleviate airway obstruction. This study will look at an institutional, multisurgeon experience with MDO over 10 years. DESIGN: A retrospective chart review was conducted. SETTING: All patients who underwent MDO at the authors' institution from 2012 to 2022 were included. Three craniofacial surgeons performed all interventions. PATIENTS: Demographics, preoperative and postoperative respiratory and feeding status, and distraction data were collected for 27 patients meeting inclusion criteria. MAIN OUTCOME MEASURES: Primary outcomes were avoidance of a gastrostomy tube, avoidance of a tracheostomy, discharge from hospital on room air, and complications. A significance value of 0.05 was utilized. RESULTS: The average age at MDO was 135 days, mean activation phase was 13.6 days, mean distraction length was 14.9 mm, and mean consolidation phase was 64.2 days. A longer activation phase was associated with discharge with a gastrostomy tube and a shorter activation phase was associated with discharge on full oral feeds. The ability to discharge on room air was associated with a shorter latency phase, shorter activation phase, and decreased distance of distraction. CONCLUSIONS: The goal of MDO is to achieve full oral feeds with no respiratory support. Several different latency periods were used in this study, and a short latency period was demonstrated to be safe.

Posterior Vault Distraction in the Acute Setting.

ABSTRACT: Posterior vault distraction osteogenesis (PVDO) has been shown to resolve acute intracranial hypertension (AIH) while carrying an acceptable perioperative morbidity profile. PVDO has been associated with symptomatic improvement and fewer surgeries in those requiring ventriculoperitoneal shunts. The authors' experience using PVDO as an acute intervention is presented, demonstrating its safety and efficacy for management of AIH. Four cases of children with craniosynostosis that underwent PVDO in the acute setting are outlined. All patients presented with papilledema and symptoms of AIH. One patient with slit ventricle syndrome (SVS) presented with a nonfunctioning shunt following multiple shunt revisions. No intraoperative complications during distractor placement or removal were reported. Distraction protocol for all patients began on postoperative day 1 at 1-2 mm per day, resulting in an average total distraction of 30.25 mm. For the 3 cases with no shunt, the average length of stay was 7 days. As part of the planned treatment course, the patient with SVS required externalization of the shunt during distraction followed by early distractor removal and planned shunt replacement. One case of surgical site infection (in an immunocompromised patient) required premature distractor removal during the consolidation period. Computed tomography (CT) in all patients indicated increased intracranial volume following distraction, and symptomatic improvement was reported. Six-month follow-up showed resolution of papilledema in all patients. The authors' experience using PVDO in the acute setting is reported, alongside a review of current literature, in order to provide supporting evidence for the efficacy of PVDO as a tool for resolving AIH.

"Travel Burden to ACPA Approved Cleft and Craniofacial Teams: A Geospatial Analysis".

BACKGROUND: Despite the existence of American Cleft Palate and Craniofacial Association (ACPA)-approved Cleft and Craniofacial Teams, access to multidisciplinary team-based care remains challenging for patients from rural areas, leading to disparities in care. We investigated the geospatial relationship between U.S. counties and ACPA-approved centers. METHODS: The geographic location of all ACPA-approved cleft and craniofacial centers in the U.S. was identified. Distance between individual U.S. counties (n=3,142) and their closest ACPA-approved team was determined. Counties were mapped based on distance to nearest cleft or craniofacial team. Distance calculations were combined with U.S Census data to model the number of children served by each team and economic characteristics of families served. These relationships were analyzed using independent t-tests and ANOVA. RESULTS: Over 40% of U.S. counties did not have access to an ACPA-approved craniofacial team within a 100-mile radius (n=1,267) versus 29% for cleft teams (n=909). Over 90% of counties greater than 100 miles to a craniofacial team had a population <7,500 (n=1,150). Of the counties >100 miles from a cleft team, 64% had a child poverty rate greater than national average (n=579). Counties with the highest birth rate and >100 miles to travel to an ACPA team are in the Mountain West. CONCLUSIONS: Given the time-sensitive nature of operative intervention and access to multidisciplinary care, the lack of equitable distribution in certified cleft and craniofacial teams is concerning. Centers may better serve families from distant areas by establishing satellite clinics, telehealth visits, and training local primary care providers in referral practices.

Dr. ChatGPT: Utilizing Artificial Intelligence in Surgical Education.

OBJECTIVE: This study sought to explore the unexamined capabilities of ChatGPT in describing the surgical steps of a specialized operation, the Fisher cleft lip repair. DESIGN: A chat log within ChatGPT was created to generate the procedural steps of a cleft lip repair utilizing the Fisher technique. A board certified craniomaxillofacial (CMF) surgeon then wrote the Fisher repair in his own words blinded to the ChatGPT response. Using both responses, a voluntary survey questionnaire was distributed to residents of plastic and reconstructive surgery (PRS), general surgery (GS), internal medicine (IM), and medical students at our institution in a blinded study. SETTING: Authors collected information from residents (PRS, GS, IM) and medical students at one institution. MAIN OUTCOME MEASURES: Primary outcome measures included understanding, preference, and author identification of the procedural prompts. RESULTS: Results show PRS residents were able to detect more inaccuracies of the ChatGPT response as well as prefer the CMF surgeon's prompt in performing the surgery. Residents with less expertise in the procedure not only failed to detect who wrote what procedure, but preferred the ChatGPT response in explaining the concept and chose it to perform the surgery. CONCLUSIONS: In applications to surgical education, ChatGPT was found to be effective in generating easy to understand procedural steps that can be followed by medical personnel of all specialties. However, it does not have expert capabilities to provide the minute detail of measurements and specific anatomy required to perform medical procedures.

A Review on Lumps, Bumps, and Birthmarks: When and Why to Refer.

Skin lesions of the face, trunk, and extremities are commonly seen in the pediatric population. Although most of these lesions are benign, they can be locally destructive or interfere with normal development. Recognition and diagnosis of these lesions allow for timely workup and referral; treatment, if needed; and facilitation of parental discussions. The purpose of this article is to review common pediatric skin and soft-tissue lesions-or "lumps, bumps, and birthmarks"-to assist with diagnosis, workup, and guidelines for referral to pediatric plastic surgery. [Pediatr Ann. 2023;52(1):e23-e30.].

Utilization of the Labial Flap in Anterior Palatal Fistula Repair.

Background: Palatal fistulas are the most common postoperative complications in primary cleft palate surgery, with incidence rates ranging from 10% to 30%. Functional indications for repair include food regurgitating from the nose, food impaction resulting in malodor, and hypernasality with speech. Anterior palatal fistulas (APFs), in particular, present difficult reconstructive cases due to lack of available local tissue. Here, we describe a case series of 3 patients who underwent APF repair with a random pattern labial flap. Methods: The 3 patients included in this report underwent surgical repair of APF. The size of defects measured 2 × 1cm, 2.5 × 1.5cm, and 3 × 2cm. In each case, the labial flap was elevated on the free border of the superior lip mucosa and advanced through the alveolar cleft to cover the oral layer of the fistula. After 3 weeks, the proximal part of the pedicled flap was incised and inset to the alveolar ridge. Results: From 2020 through 2021, 2 lip flaps were successful in providing full coverage to the oral fistula. In one patient, a 3-year-old who did not cooperate with postoperative care, one of the flaps dehisced before division. Conclusions: APFs are common postoperative complications in patients with primary palate repairs and present difficult reconstructions due to lack of local tissue flaps. Here, we describe a 2-stage method in which a random pattern labial flap is used to provide oral fistula coverage. We recommend this procedure when multiple prior traditional attempts at closure have been unsuccessful and the patient can comply with postoperative care.

Management of pediatric sternal wounds following congenital heart surgery: The role of the plastic surgeon in debridement and closure.

BACKGROUND: Management of sternal wound infections (SWIs) in pediatric patients following congenital heart surgery can be extremely difficult. Patients with congenital cardiac conditions are at risk for complications such as sternal dehiscence, infection, and cardiopulmonary compromise. In this study, we report a single-institution experience with pediatric SWIs. METHODS: Fourteen pediatric patients requiring plastic surgery consultation for complex sternal wound closure were included. A retrospective chart review was performed with the following variables of interest: demographic data, congenital cardiac condition, respective surgical palliations, development of mediastinitis, causative organism, number of debridements, presence of sternal wires, and choice of flap coverage. Primary endpoints included achieved chest wall closure and overall survival. RESULTS: Of the 14 patients, 8 (57%) were diagnosed with culture-positive mediastinitis. The sternum remained wired at the time of final flap closure in eight (57%) patients. All patients were reconstructed with pectoralis major flaps, except one (7%) who also received an omental flap and two (14%) who received superior rectus abdominis flaps. One patient (7%) was treated definitively with negative pressure wound therapy, and one (7%) was too unstable for closure. Six patients developed complications, including one (7%) with persistent mediastinitis, two (14%) with hematoma formation, one (7%) with abscess, and one (7%) with skin necrosis requiring subsequent surgical debridement. There were three (21%) mortalities. CONCLUSIONS: The management of SWI in congenital cardiac patients is challenging. The standard tenets for management of SWI in adults are loosely applicable, but additional considerations must be addressed in this unique subset population.

Inferiorly Based Alar Groove Flap for Correction of Alar Base Malposition and Nasal Stenosis.

When the external nasal valve (ENV) is excessively narrow or lacks support, nasal obstruction can develop causing decreased airflow. Although cartilage grafts may support a collapsed nasal ala, addressing severe nasal stenosis requires further intervention. Techniques to move flared ala inward are well-known; however, repositioning a medially displaced alar base is less commonly described. Our surgical team developed an inferiorly based alar groove flap to achieve lateral movement of a malpositioned alar base, with goals of widening the ENV and improving nasal symmetry and cosmesis. A retrospective chart review was performed on a series of five patients over a two-year period. Charts were reviewed for demographic data, medical and surgical history, functional airway complaints, and subjective aesthetic concerns. All patients presented with unilateral ENV collapse, alar base malposition, and nostril asymmetry. Our operative method consisted of repositioning the affected alar base laterally and inferiorly to alleviate nostril stenosis and using an alar rim graft to support the ENV. Postoperatively, all patients demonstrated immediate alleviation of subjective nasal obstruction and improvement in size of ENV aperture, nostril symmetry, and overall cosmesis. Four patients showed lasting postoperative results. One patient experienced restenosis by 4 months and required revision. Our inferiorly based alar groove flap provides a reproducible solution for repositioning a medially displaced alar base. This technique reliably corrects ENV stenosis, relieves airway obstruction, and improves nasal symmetry and cosmesis.

The Simultaneous Use of Spring-Mediated Cranioplasty and Distraction Osteogenesis as a Safe Modality for Multi-Suture Craniosynostosis.

ABSTRACT: Craniosynostosis caused by premature fusion of the cranial sutures most commonly involves a single suture. Less commonly, multiple sutures may fuse prematurely resulting in complex craniosynostosis. The authors present 1 case of a patient with unilateral sagittal and unilateral lambdoid craniosynostosis treated safely simultaneous with spring-mediated cranioplasty and distraction osteogenesis.

A Cohort Study of Strabismus Rates Following Correction of the Unicoronal Craniosynostosis Deformity: Conventional Bilateral Fronto-Orbital Advancement Versus Fronto-Orbital Distraction Osteogenesis.

BACKGROUND: The purpose of this prospective study is to compare perioperative morbidity and strabismus rates between traditional fronto-orbital advancement reconstruction (FOAR) and fronto-orbital distraction osteogenesis (FODO) in unicoronal craniosynostosis (UCS). METHOD: A consecutive group of 15 patients undergoing FODO for isolated UCS were compared to a contemporaneous group of 15 patients undergoing traditional FOAR for UCS. Patient age, operative time, blood loss, blood replacement, technical details of the surgery, length of stay, complications, and strabismus rates were documented and compared statistically using chi-square and Student t test with a significance value of 0.05. RESULTS: The 15 patients undergoing FODO were younger (6.3 and 9.8 months, P < 0.05), experienced less operative time for the initial procedure (111 versus 190 minutes, P < 0.01), less blood loss (26% versus 50% of total blood volume, P < 0.01), and less blood replacement (40% versus 60% of total blood volume, P < 0.05). One patient in the FODO group experienced a new-onset strabismus postoperatively compared with 5 in the FOAR group (P < 0.05). There were no complications requiring a return to the operating room in either group. CONCLUSIONS: Fronto-orbital distraction osteogenesis for the treatment of isolated UCS is associated with a favorable perioperative morbidity profile and a decreased incidence of postoperative strabismus compared with traditional FOAR. These positive factors are tempered by the need for an additional procedure for removal of the device and lack of long-term outcomes data on the technique.

How to Treat a Tongue-tie: An Evidence-based Algorithm of Care.

Ankyloglossia, or tongue-tie, is characterized by a short or thickened lingual frenulum; this can be associated with impaired breastfeeding, speech, and dentofacial growth. The indications for performing frenotomy, frenuloplasty, or other operative interventions are unclear. METHODS: A meta-analysis was performed to identify the extent of the benefit from frenotomy in breastfeeding measures, degree of tongue-tie, and maternal pain during feeding in randomized controlled trials. A structured literature review analyzed the optimal type and timing of repair. An algorithm was developed to incorporate this evidence into a management pathway. RESULTS: Among 424 studies reviewed, 5 randomized controlled trials met inclusion criteria for meta-analysis. Frenotomy significantly improved the degree of tongue-tie, with a 4.5-point decrease in Hazelbaker Assessment Tool for Lingual Frenulum Function score compared with a decrease of 0 in those who did not undergo frenotomy (P < 0.00001). This was associated with improved self-reported breastfeeding (relative risk [RR] = 3.48, P < 0.00001) and decreased pain (Short-Form McGill Pain Questionnaire, P < 0.00001); however, Breastfeeding Self-Efficacy-Short Form and Latch, Audible Swallowing, Type of Nipple, Comfort, Hold scores did not significantly improve. Multiple studies demonstrated significant improvements following frenuloplasty when compared with frenotomy but demonstrated mixed results as to the effect of timing of tongue-tie division. CONCLUSIONS: Frenotomy is associated with breastfeeding improvements that vary individually but trend toward significance collectively during a critical time in infant development. Among patients with a severe Hazelbaker Assessment Tool for Lingual Frenulum Function score or difficulty breastfeeding, we conclude that simple frenotomy without anesthetic is generally indicated in infancy and frenuloplasty under general anesthesia for older children.

Facial Fractures and Mixed Dentition - What Are the Implications of Dentition Status in Pediatric Facial Fracture Management?

INTRODUCTION: The stage of maturation of the pediatric facial skeleton at the time of injury has a significant impact on both facial fracture patterns and management strategies. For instance, the relative prominence of the pediatric cranium during the early years of life affords protection to the structures of the midface, whereas delayed aeration of the frontal sinuses may predispose younger patients to frontal bone fractures. The dentition status of a pediatric patient may have similar implications in the setting of facial fracture. In this study, the authors examine the effect of dentition status on facial fracture patterns and management strategies at an urban, level 1 trauma center. METHODS: A retrospective chart review was performed for all cases of facial fracture occurring in the pediatric patient population at a level 1 trauma center (University Hospital in Newark, NJ) between 2002 and 2014. A database including patient demographics, facial fracture, and concomitant injury patterns, and operative management data was constructed and analyzed. RESULTS: A total of 72 patients with mixed dentition met inclusion criteria for our study and were compared against patients with primary (n = 35) and permanent (n = 349) dentition. The mean age at presentation was 9.2 years, with a male predominance of 68%. The most common fracture etiology was pedestrian struck accident (n = 23), fall (n = 21), motor vehicle collision (n = 12), and assault (n = 9). The most frequently identified facial fractures were that of the orbit (n = 31), mandible (n = 21), nasal bone (n = 19), and frontal sinus (n = 14). Additionally, 8 Le Fort and 4 nasoorbitoethmoid fractures were identified. Twenty-one patients (29%) required operative management for 1 or more facial fractures. Operative intervention was required in 38% of mandibular fractures, with 6 patients requiring only maxillomandibular fixation and 2 requiring open reduction and internal fixation with titanium plating. Nine cases of orbital fracture (29%) were managed operatively - 4 with absorbable plates, 3 with Medpor implants, and 8 with titanium plating. Management of all nasal fractures requiring operative intervention was accomplished through closed reduction. Concomitant injuries included traumatic brain injury (TBI) (n = 35), skull fracture (n = 24), intracranial hemorrhage (ICH) (n = 20), and long bone fracture (n = 12). Seventeen patients required admission to the intensive care unit. Patients with mixed dentition were significantly more likely to sustain frontal sinus and Le Fort fractures (P < 0.01), as well as skull fracture, ICH, and TBI (P < 0.01) as compared to those with permanent dentition. CONCLUSIONS: The dentition status of a pediatric patient may have significant implications in both patterns of injury and operative management strategies in the setting of acute facial trauma. Our study finds that Le Fort and frontal sinus fractures were significantly more common in patients with mixed dentition. Severe concomitant injuries such as ICH and TBI were also significantly more likely in this cohort. A patient's dentition status may also play a role in the decision for ridged fixation of mandibular and orbital fractures, as well as the method of maxillomandibular fixation in maxillary and mandibular alveolar fracture.

Motor Vehicle Collision Injuries: An Analysis of Facial Fractures in the Urban Pediatric Population.

PURPOSE: Motor vehicle collisions (MVC) are a leading cause of unintentional death and injury in the US pediatric population. Compliance with prevention measures such as seatbelts and child safety seats varies considerably with patient demographics. In this study, the authors examine facial fracture secondary to MVC in an urban pediatric population. METHODS: A retrospective chart review was performed of all facial fractures as a result of MVC in the pediatric population in a level 1 trauma center in an urban environment (University Hospital in Newark, NJ). Patient demographics were collected, as well as location of fractures, concomitant injuries, and surgical management strategies. RESULTS: Seventy-five patients met inclusion criteria for the authors' study. Mean age was 14 years old. Common fracture sites included orbital, mandible, nasal bone, and frontal sinus. Patients were more likely to incur fracture of the zygoma, orbit, nasal bone, frontal sinus, and nasoorbitoethmoid (NOE) if involved in an MVC compared to all other etiologies. Common concomitant injuries included traumatic brain injury, intracranial hemorrhage, and skull and long bone fractures. Open reduction and internal fixation with titanium plates was the most common surgical procedure indicated. CONCLUSION: Motor vehicle collisions related injury has significant health implications in the urban pediatric population. Orbital, zygoma, and nasal facial fractures and TBI are injuries commonly associated with MVC. The facial fractures are likely due to lack of proper utilization of safety equipment and airbags. Development of effective prevention techniques relies heavily on analysis of injury patterns and management strategies.