Diffuse neurofibroma with hypertrichosis in a toddler.

Diffuse neurofibroma is a rare type of neurofibroma uncommonly reported in infancy. It is a slow growing tumor originating in the peripheral nerve sheath. We present the case of a 17-month-old boy with diffuse neurofibroma of the scalp associated with hypertrichosis. His genetic and clinical workup for neurofibromatosis was negative.

The Severity of Initial Unilateral Cleft Lip and Nasal Deformity Predicts Long-Term Postoperative Esthetic Outcome.

BACKGROUND: Infantile cleft lip and nasal severity influence the final esthetic result of the repair. Although various authors have described methods of cleft lip and nasal repair, there is a paucity of data that correlates cleft severity with esthetic outcomes. The aim of this study was to examine the correlation between presurgical severity of unilateral cleft deformity and long-term postoperative esthetic outcomes. METHODS: This retrospective study, based at a single institution, investigated patients with complete unilateral cleft lip, with or without cleft palate, who underwent repair by a single surgeon, had preoperative infantile facial casts, and had postoperative facial photographs at 6 to 11 years of age (N=31). Preoperative nostril width ratio and columellar angle measurements were taken from facial casts. Postoperative, long-term nasolabial appearance was rated by 5 blinded observers used a modified Kuijpers-Jagtman scale. Linear regression was used to determine the relationship between preoperative cleft severity and postoperative ratings. RESULTS: Preoperative nostril width ratio directly correlated with postoperative nasal form score (r=0.40; P=0.026); likewise, preoperative columellar angle predicted postoperative nasal form score (r=0.37; P=0.040). Preoperative cleft severity was not significantly correlated with vermillion border appearance. Cronbach α values of 0.91 (nasal form) and 0.79 (vermillion border) indicated good inter-rater reliability. Kappa values of 0.87 (nasal form) and 0.70 (vermillion border) indicated good intrarater reliability. CONCLUSIONS: Preoperative unilateral cleft nose severity directly correlates with long-term postoperative nasal appearance in childhood. Outcome studies should present and control for preoperative severity to allow more accurate assessment of repair techniques.

Successful application of the innovation process to a case of Floyd Type I tracheal agenesis.

Background: Innovation is broadly defined as the act of introducing a new product, idea, or process. The field of surgery is built upon innovation, revolutionizing technology, science, and tools to improve patient care. While most innovative solutions are aimed at problems with a significant patient population, the process can also be used on orphan pathologies without obvious solutions. We present a case of tracheal agenesis, a rare congenital anomaly with an overwhelming mortality and few good treatment options, that benefited from the innovation process and achieved survival with no ventilator dependence at three years of age. Methods: Utilizing the framework of the innovation process akin to the Stanford Biodesign Program, 1) the parameters of the clinical problem were identified, 2) previous solutions and existing technologies were analyzed, newly invented solutions were brainstormed, and value analysis of the possible solutions were carried out using crowd wisdom, and 3) the selected solution was prototyped and tested using 3D modeling, iterative testing on 3D prints of actual-sized patient parts, and eventual implementation in the patient after regulatory clearance. Results: A 3D-printed external bioresorbable splint was chosen as the solution. Our patient underwent airway reconstruction with "trachealization of the esophagus": esophageotracheal fistula resection, esophagotracheoplasty, and placement of a 3D-printed polycaprolactone (PCL) stent for external esophageal airway support at five months of age. Conclusions: The innovation process provided our team with the guidance and imperative steps necessary to develop an innovative device for the successful management of an infant survivor with Floyd Type I tracheal agenesis. Article summary: We present a case of tracheal agenesis, a rare congenital anomaly with an overwhelming mortality and few good treatment options, that benefited from the innovation process and achieved survival with no ventilator dependence at three years of age.The importance of this report is to reveal how the innovation process, which is typically used for problems with significant patient population, can also be used on orphan pathologies without obvious solutions.

A Descriptive Analysis of Integrated Plastic Surgery Residency Program Directors in the United States.

BACKGROUND: The role sex plays in surgical leadership positions is heavily discussed in the literature; however, there is an absence of research looking at plastic surgery program director (PD) demographics and the differences between male and female PDs. METHODS: A cross sectional study of publicly available online resources of all integrated plastic surgery residency programs was performed. Demographic and academic data of integrated plastic surgery PDs was analyzed focusing on the differences in PDs based on sex. RESULTS: Eighty-two integrated plastic surgery residencies were analyzed. Fifteen PDs (18.3%) were female. Fifty-six (68%) PDs completed general surgery residencies, whereas 24 (29%) completed an integrated plastics residency. All female PDs were fellowship trained, whereas only 46 (68%) male PDs pursued additional training after residency ( P = 0.02). Research output among male PDs was greater with 49.9 publications and a higher average H-index, at 13.3, compared with women with an average of 27.5 publications ( P = 0.008) and an H-index of 8.7 ( P = 0.02). When comparing male to female PDs, there was no difference between age at PD appointment ( P = 0.15), or in the amount of time between completion of plastic surgery training to PD appointment ( P = 0.29). Male PDs were older (52.2) compared with female PDs (46.5) ( P = 0.02). Male PDs served longer terms (4.98 years) than female PDs (2.87 years) ( P = 0.003). CONCLUSIONS: The majority of integrated plastic surgery PDs are men with a Doctor of Medicine degree who completed a general surgery residency and a plastic surgery fellowship. Most PDs also completed fellowship in a plastic subspecialty. Male PDs had higher research output, which may be attributed to their older age on average. Although women make up only 18.3% of plastic surgery PDs, this percentage is similar to the 17.2% of active female plastic surgeons in the United States. As more women train in plastic surgery, it is possible that the percentage of women serving academic leadership roles will increase. By gaining a better understanding of the demographics and diversity in plastic surgery residency program leadership, efforts can be made to increase the representation of minority groups in academic leadership roles.

Nodular fasciitis on the cheek of a child.

Nodular fasciitis is a benign proliferation of myofibroblastic cells affecting subcutaneous tissue, muscles, and fascia. This rare disorder is most commonly observed on the upper extremity of adults. We present a case of nodular fasciitis of the cheek of a 12-year-old girl.

Identifying the Misshapen Head: Craniosynostosis and Related Disorders.

Pediatric care providers, pediatricians, pediatric subspecialty physicians, and other health care providers should be able to recognize children with abnormal head shapes that occur as a result of both synostotic and deformational processes. The purpose of this clinical report is to review the characteristic head shape changes, as well as secondary craniofacial characteristics, that occur in the setting of the various primary craniosynostoses and deformations. As an introduction, the physiology and genetics of skull growth as well as the pathophysiology underlying craniosynostosis are reviewed. This is followed by a description of each type of primary craniosynostosis (metopic, unicoronal, bicoronal, sagittal, lambdoid, and frontosphenoidal) and their resultant head shape changes, with an emphasis on differentiating conditions that require surgical correction from those (bathrocephaly, deformational plagiocephaly/brachycephaly, and neonatal intensive care unit-associated skill deformation, known as NICUcephaly) that do not. The report ends with a brief discussion of microcephaly as it relates to craniosynostosis as well as fontanelle closure. The intent is to improve pediatric care providers' recognition and timely referral for craniosynostosis and their differentiation of synostotic from deformational and other nonoperative head shape changes.

Feasibility of Surgeon-Delivered Audit and Feedback Incorporating Peer Surgical Coaching to Reduce Fistula Incidence following Cleft Palate Repair: A Pilot Trial.

BACKGROUND: Improving surgeons' technical performance may reduce their frequency of postoperative complications. The authors conducted a pilot trial to evaluate the feasibility of a surgeon-delivered audit and feedback intervention incorporating peer surgical coaching on technical performance among surgeons performing cleft palate repair, in advance of a future effectiveness trial. METHODS: A nonrandomized, two-arm, unblinded pilot trial enrolled surgeons performing cleft palate repair. Participants completed a baseline audit of fistula incidence. Participants with a fistula incidence above the median were allocated to an intensive feedback intervention that included selecting a peer surgical coach, observing the coach perform palate repair, reviewing operative video of their own surgical technique with the coach, and proposing and implementing changes in their technique. All others were allocated to simple feedback (receiving audit results). Outcomes assessed were proportion of surgeons completing the baseline audit, disclosing their fistula incidence to peers, and completing the feedback intervention. RESULTS: Seven surgeons enrolled in the trial. All seven completed the baseline audit and disclosed their fistula incidence to other participants. The median baseline fistula incidence was 0.4 percent (range, 0 to 10.5 percent). Two surgeons were unable to receive the feedback intervention. Of the five remaining surgeons, two were allocated to intensive feedback and three to simple feedback. All surgeons completed their assigned feedback intervention. Among surgeons receiving intensive feedback, fistula incidence was 5.9 percent at baseline and 0.0 percent following feedback (adjusted OR, 0.98; 95 percent CI, 0.44 to 2.17). CONCLUSION: Surgeon-delivered audit and feedback incorporating peer coaching on technical performance was feasible for surgeons.

Patient-Centered Satisfaction After Secondary Correction of the Cleft Lip and Nasal Defect.

OBJECTIVE: To evaluate patient-reported aesthetic and psychosocial outcomes of secondary cleft lip and nose revision procedures. DESIGN: Single-center cohort study. SETTING: Tertiary care pediatric hospital. PATIENTS/PARTICIPANTS: Patients who underwent secondary revision procedures for cleft lip and nasal defect (N = 42). INTERVENTIONS: Patients were administered a survey during a routine postoperative clinic visit. MAIN OUTCOME MEASURE(S): Outcome measures were planned prior to data collection and included improvement in appearance seen in lip and nose, satisfaction with revision procedure, changes in self-confidence, likelihood to participate in social activities, and effect on teasing by peers. RESULTS: Patients agreed that an improvement was seen in the appearance of their lip (1.93) and nose (1.98) following surgery. Overall, patients felt satisfied with the results of their revision procedure (1.76). An improvement in confidence and decrease in feelings of self-consciousness was reported. Patients were teased less by their peers and more likely to participate in social activities. CONCLUSIONS: Secondary revision procedures of the cleft lip and nasal defect provide a patient-reported improvement in appearance and a positive psychosocial impact on patient's lives.

Current Trends in Unilateral Cleft Lip Care: A 10-Year Update on Practice Patterns.

BACKGROUND: The care of unilateral cleft lip (UCL) patients is extremely variable. Historical benchmarks for perioperative and intraoperative choices by cleft surgeons were produced by Sitzman et al (Plast Reconstr Surg. 2008;121:261e-270e) in 2005. However, emerging data and cleft lip repair methods around this period were not captured by this study. The aim of this study was to update the current practice patterns of cleft lip surgeons. METHODS: An electronic survey was distributed to surgeons in the American Cleft Palate Association. Demographic data about the surgeon were collected as well as their choices regarding perioperative and intraoperative cleft lip care. RESULTS: Eighty-six surgeons responded to the survey. Nearly 40% of surgeons have changed their technique for UCL repair with Fisher anatomical subunit repair gaining significant popularity. Nasoalveolar molding is also being used more frequently (41% vs 22%). At the time of the cleft lip repair, closure of the nasal floor is occurring in 83.1% of patients and primary cleft rhinoplasty is being performed routinely 57% of the time. CONCLUSIONS: Over the last 10 years, there has been an increase in the use of modified rotation advancement repairs and Fisher anatomic subunit approximation technique for treatment of UCL. There continues to be a lack of evidence regarding superiority of specific repair techniques or the benefits of adjunct procedures, which results in varying practice patterns. Educating all cleft surgeons on practices that are well supported is important to improve care to cleft patients.

Opioid Sparing in Cleft Palate Surgery.

OBJECTIVE: This study aimed to determine whether intraoperative acetaminophen was able to decrease opioid consumption, pain scores, and length of stay while increasing oral intake in cleft palate surgery. DESIGN/SETTING/PATIENTS: One hundred consecutive patients with cleft palate who underwent a von Langenbeck or 2-flap palatoplasty and intravelar veloplasty at a tertiary medical center by the 2 senior authors from 2010 to 2015 were reviewed. INTERVENTIONS: Three intraoperative treatment groups were analyzed: intravenous (IV) acetaminophen, per rectal (PR) acetaminophen, and no acetaminophen. All patients received long-acting local anesthesia infiltration before incision. Additionally, all patients were admitted overnight and given weight-based per oral (PO) acetaminophen and oxycodone and IV morphine as needed based on pain scores. OUTCOMES MEASURED: The study outcomes included pain scores, opioid requirement, length of stay, and oral intake. RESULTS: The treatment groups were comprised of 40 patients who received IV acetaminophen, 22 PR acetaminophen, and 35 none. Concerning demographic data, there was no statistical difference between treatment groups. There was no statistically significant difference for opioid intake, although both IV and PR acetaminophen groups had decreased pain scores ( P = .029). There was no difference in oral intake ( P = .13) or length of stay ( P = .31) between treatment groups. CONCLUSION: In this study, intraoperative administration of acetaminophen was associated with decreased pain scores, but no opioid-sparing effect. As other studies have shown an opioid-sparing effect with postoperative acetaminophen, we recommend withholding the intraoperative dose and beginning therapy in the immediate postoperative period.

The Americleft Project: Comparison of Ratings Using Two-Dimensional Versus Three-Dimensional Images for Evaluation of Nasolabial Appearance in Patients With Unilateral Cleft Lip and Palate.

This study was conducted to determine if nasolabial appearance is rated with comparable results and reliability on 3-dimensional stereophotogrammetric facial images versus standard clinical photographs (2-dimensional). Twenty-seven consecutively treated patients with repaired complete unilateral cleft lip and palate were selected. Six trained and calibrated raters assessed cropped 2- and 3-dimensional facial images. Nasolabial profile, nasolabial frontal, and vermillion border esthetics were rated with the 5-point scale described by Asher-McDade using the modified Q-sort method. Cropped 3-dimensional images were available for viewing by each rater, allowing for complete rotational control for viewing the images from all aspects. Two- and three-dimensional ratings were done separately and repeated the next day.Interrater reliability scores were good for 2-dimensional (κ = 0.607-0.710) and fair to good for 3-dimensional imaging (κ = 0.374-0.769). Intrarater reliability was good to very good for 2-dimensional (κ = 0.749-0.836) and moderate to good for 3-dimensional imaging (κ = 0.554-0.855). Bland-Altman analysis showed satisfactory agreement of 2- and 3-dimensional scores for nasolabial profile and nasolabial frontal, but more systematic error occurred in the assessment of vermillion border.Although 3-dimensional images may be perceived as more representative of a direct clinical facial evaluation, their use for subjective rating of nasolabial aesthetics was not more reliable than 2-dimensional images in this study. Conventional 2-dimensional images provide acceptable reliability while being readily accessible for most cleft palate centers.

Objective Assessment of the Unilateral Cleft Lip Nasal Deformity Using Three-Dimensional Stereophotogrammetry: Severity and Outcome.

BACKGROUND: Optimization of care to correct the unilateral cleft lip nasal deformity is hampered by lack of objective measures to quantify preoperative severity and outcome. The purpose of this study was to develop a consensus standard of nasal appearance using three-dimensional stereophotogrammetry; determine whether anthropometric measurements could be used to quantify severity and outcome; and determine whether preoperative severity predicts postoperative outcome. METHODS: The authors collected facial three-dimensional images of 100 subjects in three groups: 45 infants before cleft lip repair; the same 45 infants after cleft lip repair; and 45 children aged 8 to 10 years with previous repairs. Five additional age-matched unaffected control subjects were included in each group. Seven expert surgeons ranked images in each group according to nasal appearance. The rank sum score was used as consensus standard. Anthropometric analysis was performed on each image and compared to the rank sum score. Preoperative rank and anthropometric measurements were compared to postoperative rank. RESULTS: Interrater and intrarater reliability was excellent (intraclass correlation coefficient, >0.76; Pearson correlation, >0.75) on each of the three image sets. Columellar angle, nostril width ratio, and lateral lip height ratio were highly correlated with preoperative severity and moderately correlated with postoperative nasal appearance. Postoperative outcome was associated with preoperative severity (rank and anthropometric measurement). CONCLUSIONS: Consensus ranking of preoperative severity and postoperative outcome can be achieved on three-dimensional images. Preoperative severity predicts postoperative outcomes. Columellar angle, nostril width ratio, and lateral lip height ratio are objective measures that correlate with consensus ratings by surgeons at multiple ages.

Postoperative Pain and Analgesia in Children Undergoing Palatal Surgery: A Retrospective Chart Review.

PURPOSE: Pediatric patients undergoing palatal surgery may experience significant postoperative pain. Undertreatment of acute postoperative pain may impact postoperative bleeding and recovery. The primary objectives of this study were to evaluate the severity of acute postoperative pain scores, analgesia management, and discharge times after palatal surgery. DESIGN AND METHODS: A retrospective chart review was performed for all patients aged <18 years, born with cleft palate who underwent palatal surgery over a 1-year period. The primary outcome variable was the highest pain score recorded by the nursing staff at various time frames postoperatively. FINDINGS: Overall, the infant/toddler group demonstrated higher postoperative pain scores throughout the first 24 hours (1- to 6-hour period, P = .015). The duration of hospital stay was significantly greater in the infant/toddler age group (P < .001). CONCLUSION: The results of our study indicate that frequent pain monitoring, multimodal approach, and "round-the-clock" analgesics may be warranted in this vulnerable patient population.

Sparing a Craniotomy: The Role of Intraoperative Methylene Blue in Management of Midline Dermoid Cysts.

BACKGROUND: Midline nasal dermoid cysts are rare congenital anomalies that extend intracranially in approximately 10 percent of cases. Cysts with intracranial extension require a craniotomy to avoid long-term complications, including meningitis, abscesses, and cavernous sinus thrombosis. Current guidelines recommend preoperative imaging with either magnetic resonance imaging or computed tomography to determine appropriate management. METHODS: Patients who underwent excision of a midline nasal dermoid cyst between January 1995 and September 2016 were identified using Current Procedural Terminology codes. In cases with equivocal imaging findings or uncertain stalk extent during surgical dissection, methylene blue was used intraoperatively. Demographics, preoperative imaging findings, intraoperative dye findings, surgical approach, and complications were collected. RESULTS: A total of 66 midline dermoid cyst excisions were identified; 17 (25.8 percent) had intracranial extension requiring craniotomy. Preoperative imaging showed a subcutaneous cyst in 41 (62.1 percent), intraosseous tracking in three (4.5 percent), and intracranial extension in 15 (22.7 percent). Twelve patients (18.2 percent) had preoperative imaging that was inconsistent with intraoperative findings. Methylene blue was used in 17 cases and indigo carmine was used in one case. Intraoperative dye findings changed management in five cases, and in three cases a craniotomy was avoided without evidence of cyst recurrence. CONCLUSIONS: This report is the largest published series of midline dermoid cysts with intracranial extension. In almost 20 percent of cases, preoperative imaging was not consistent with intraoperative findings. Given disparate radiographic and intraoperative findings, methylene blue is a valuable tool that can facilitate appropriate, morbidity-sparing management of midline dermoid cysts. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Evolution of Fibroblastic Connective Tissue Nevus in an Infant.

Fibroblastic connective tissue nevus (FCTN) is a rare and recently described neoplasm of fibroblastic/myofibroblastic lineage. We report a case of a 1-month-old healthy male infant who presented with a dermal plaque on the upper chest since birth. A punch biopsy demonstrated a dermal spindle-cell neoplasm with variable smooth muscle actin positivity and negative staining for CD34, consistent with myofibroma. Over the course of the next year, the remaining lesional tissue exhibited clinical softening and a surgical excisional specimen revealed histologic findings distinct from the original biopsy. These included a poorly circumscribed proliferation of bland spindle cells arranged in short fascicles centered in the dermis and extending into the subcutis with positivity for CD34, and absence of staining with smooth muscle actin features diagnostic of FCTN. Our case allowed the opportunity to see this unusual neoplasm at different stages, and we hypothesize that FCTN may undergo an early cellular phase and that time is required for these lesions to "mature" and demonstrate the more characteristic features of FCTN.

Structural Fat Grafting to Improve Reconstructive Outcomes in Secondary Cleft Lip Deformity.

OBJECTIVE: To describe the technique and results of structural fat grafting in cleft lip revision, including patient satisfaction and aesthetic outcome. DESIGN: Retrospective case series. SETTING: Multidisciplinary cleft care center. PATIENTS: All patients who underwent structural fat grafting between June 2006 and September 2012 for cleft lip revision, with appropriate photographic follow-up included. Twenty-two cases were reviewed; 18 had sufficient data to be included. INTERVENTIONS: Patients underwent structural fat grafting for cleft lip revision, most commonly injecting fat under deficient philtral columns, the nostril base, and upper lip. MAIN OUTCOME MEASURES: Blinded observers rated outcomes using the Asher-McDade nasolabial appearance rating scale. Patients completed questionnaires assessing their satisfaction. A paired Student's t-test was used to test outcomes for significance (alpha = 0.05). RESULTS: Patients were an average of 16 years old (range: 6-43); average length of follow up was 11.7 months. Overall symmetry and aesthetics were improved based on the nasal form (P = 0.006) and vermillion border (P = 0.04) when rated using the Asher-McDade scale. No complications were recorded. Patients were significantly happier with their appearance after fat grafting (P < 0.001) and were uniformly positive when questioned about the ease of the surgery and rate of recovery. CONCLUSIONS: Structural fat grafting is a safe and effective way to improve symmetry and enhance facial proportions in patients with cleft lip. Given the high degree of patient satisfaction, few complications, and durable results, fat grafting offers many advantages in cleft lip revision.

Orbital Expansion for Congenital Anophthalmia May Be Achievable in Infancy But Not in Childhood.

BACKGROUND: Congenital anophthalmia is a rare anomaly that results in micro-orbitism and craniofacial microsomia. Treatment with static conformers is labor-intensive and provides minimal stimulation for orbital growth that requires eventual reconstruction with orbital osteotomies after skeletal maturity. METHODS: A protocol for the treatment of congenital anophthalmia is presented. Patients underwent a preoperative low-dose radiation computed tomography (CT) scan of the facial bones to assess orbital volume. An intraorbital expander was placed and was filled on a monthly basis. Quantitative changes in the affected and unaffected orbits were assessed by a repeat CT scan obtained 1 year postoperatively. RESULTS: Two patients with left unilateral congenital anophthalmia were prospectively followed. In a 4-month-old, the affected orbital width and height increased by 171.6% and 116.7% respectively compared with the unaffected orbit. In a 4-year-old, the affected orbital width increased by 36.1% but the height decreased by 35.3% compared with the unaffected orbit. At 18 months follow-up, no complications, ruptures, infections, or extrusions have been observed. CONCLUSIONS: Our results support that accelerated expansion can be achieved in a 4-month-old orbit reversing the effects of anophthalmia. However, in a 4-year-old, minimal growth was observed. The lack of accelerated growth in this study may be explained by synostosis of the orbital sutures. As such, expansion should be initiated at the earliest age possible. Further longitudinal study is ongoing to determine if sustained catch-up growth will obviate or reduce the complexity of a secondary correction.

Pedicled lower extremity fillet flap for coverage of massive pelvic wounds.

Fillet flaps are traditionally harvested from nonsalvagable extremities to reconstruct complex soft tissue defects. This method results in minimal donor site morbidity, and can be effective in reconstructing large pelvic wounds requiring significant soft tissue coverage. Here, we present their application in three young patients with extensive pelvic wounds secondary to trauma and its sequelae. In each case, neurologic injury limited limb function, and fillet flaps were used to fill soft tissue defects and pad bony prominences. The fillet flaps have been successful in providing wound coverage in all cases, and have all remained intact to date, with a mean follow up time of 29 months. These results demonstrate a role for fillet flaps in the management challenging pelvic wounds, as they can provide both satisfactory tissue coverage and improved functional outcomes.

A Multidisciplinary Evaluation of Prescribing Practices for Prophylactic Antibiotics in Operative and Nonoperative Facial Fractures.

BACKGROUND: Evidence supports short-term perioperative prophylaxis for facial fractures. It is unknown, however, whether there is any professional consensus on how to manage these injuries. No multidisciplinary evaluation of the prophylactic antibiotic prescribing patterns for neither operative nor nonoperative facial fractures has been performed. AIM: To evaluate the prophylactic antibiotic prescribing patterns of multiple specialties in operative and nonoperative facial fractures. METHODS: A 14 question anonymous online-based survey was distributed to members of the American Society of Maxillofacial Surgeons (ASMS) and the American Association of Facial Plastic Surgeons to evaluate current practices. RESULTS AND CONCLUSIONS: 205 respondents, including 89 plastic surgeons, 98 otolaryngologists, 12 oral and maxillofacial surgeons, and 7 with double board certification practicing throughout the United States with ranging experience from 11 to 30 years. As expected, preoperative, perioperative, or postoperative prophylactic antibiotics are either "always" or "sometimes" prescribed, 100% of the time with more varied practice upon further inspection. A total of 85.1% either "always" or "sometimes" use antibiotics while awaiting surgery. Dentate segment fractures are the most frequent type of facial fractures to receive prophylactic antibiotics for both operative (90.5%) and nonoperative (84.1%) fractures. Duration of antibiotic use is more varied with the majority providing 3 to 7 days despite current evidence. First generation cephalosporins alone are prescribed by 49% of respondents, which may not adequately cover oral flora. There is no multidisciplinary consensus for prophylactic antibiotics for specific operative fracture types or nonoperative facial fractures, an area with little published evidence.