Guidance for Circumflex Scapular Artery Flap Utilization in Pediatric Reconstruction.

BACKGROUND: The circumflex scapular artery (CSA) flap system, consisting of scapular, parascapular, and chimeric flaps, is useful for pediatric reconstruction in many anatomical locations. The objectives of this case series are to offer insights into our decision-making process for selecting the CSA flap in particular pediatric reconstructive cases and to establish a framework for choosing a scapular or parascapular skin paddle. We also aim to emphasize important technical considerations of CSA flap utilization in pediatric patients. METHODS: Pediatric reconstruction with CSA flaps performed at our institution between 2006-2022 was retrospectively reviewed. Patient demographics, indications, flap characteristics, complications, and operative data were abstracted. Functional donor site morbidity was assessed through postoperative physical examinations. Unpaired t test analyzed scapular versus parascapular flap size. RESULTS: Eleven CSA flaps were successfully performed in 10 patients (6 scapular and 5 parascapular flaps). Patient ages ranged from 2 to 17 years. Scapular fasciocutaneous free flaps (n = 4) were performed in patients' ages 2-5 years for hand and forearm scar contractures. Two pedicled scapular flaps were performed for a single patient for bilateral axillary hidradenitis suppurativa. The 5 parascapular flaps were performed in patients' ages 2-14 years for calcaneus and forearm avulsion wounds and reconstruction after resection of hidradenitis suppurativa, nevus sebaceous, and Ewing sarcoma. In the sarcoma resection case, a chimeric flap with latissimus dorsi was employed. Average flap size was 101.6 ± 87.3 cm2 (range: 18-300 cm2). Parascapular flaps were significantly larger than scapular flaps (156.60 ± 105.84 cm2 vs 55.83 ± 26.97 cm2, P = 0.0495). Overall, 3 complications occurred (27.3% of cases) including venous congestion (n = 2) and wound dehiscence (n = 1). There were no reported cases of compromised shoulder function at 1.9 ± 2.5-year follow-up. The successful reconstruction rate for scapular, parascapular, and chimeric flaps was 100%. CONCLUSIONS: The CSA flap treated a wide variety of indications demonstrating the flap's attributes: large vessel caliber, wide arc of rotation, reliable vascular anatomy, minimal donor site morbidity, and ability to incorporate bone and muscle. Our cases also highlight important pediatric considerations such as vascular mismatch and limited scapular bone stock. We recommend selection of the parascapular over the scapular flap with reconstruction of larger, complex defects given its ability to be harvested with a large skin paddle.

Skeletal and Soft Tissue Surgeries in the Long-term Management of Patients With Syndromic Craniosynostosis: A 20-Year Review.

BACKGROUND: Soft tissue procedures are often crucial for normalizing the long-term facial appearance in patients with syndromic craniosynostosis, yet they are underrepresented in the literature and existing treatment algorithms. This study evaluated secondary soft tissue surgeries in relation to skeletal operations in patients with syndromic craniosynostosis. METHODS: A retrospective review evaluated patients with syndromic craniosynostosis treated at a tertiary children's hospital from 2003 to 2023. Craniofacial skeletal and soft tissue procedures were assessed for timing and frequency. Skeletal surgeries included redo fronto-orbital advancements, monobloc advancement/distraction ± facial bipartition, and LeFort III or III/I advancement/distraction. Soft tissue surgeries encompassed oculoplastic procedures, scalp reconstruction, fat grafting, and septorhinoplasty. RESULTS: Of 106 patients with syndromic craniosynostosis, 57 (57.8%) underwent ≥1 secondary skeletal operation, and 101 (95.3%) underwent ≥1 soft tissue procedures, averaging 3.7 ± 3.3 soft tissue procedures per patient. Patients who underwent secondary forehead advancement had significantly higher rates of subsequent lateral canthopexy (71.4% vs 25.6, P < 0.001), ptosis reconstruction (17.9% vs 7.7%, P = 0.025), and frontotemporal fat grafting (50.0% vs 15.4%, P < 0.001) than those who did not. Patients who underwent midface advancement surgery had significantly higher rates of subsequent lateral canthopexy (65.4% vs 11.1%, P < 0.001), medial canthopexy (7.7% vs 0.0%, P = 0.038), scalp reconstruction (36.5% vs 16.7%, P = 0.020), frontotemporal fat grafting (34.6% vs 14.8%, P = 0.018), malar fat grafting (11.5% vs 0.0%, P = 0.010), and septorhinoplasty (26.9% vs 1.9%, P < 0.001) than those who did not. Specifically, LeFort III or III/I advancement/distractions were significantly associated with higher rates of subsequent septorhinoplasties (33.3% vs 1.6%, P < 0.001). The mean follow-up was 10.2 ± 7.0 years. CONCLUSIONS: This study revealed an intricate interplay between skeletal and soft tissue surgery in patients with syndromic craniosynostosis. Exploring techniques to reduce the need for further corrective surgery and anticipating necessary secondary interventions may improve patient counseling and outcomes.

Feminization of the Forehead: A Scoping Literature Review and Cohort Study of Transfeminine Patients.

BACKGROUND: Facial feminization may be performed to alleviate gender dysphoria among transfeminine patients. The upper third of the face has several characteristics, including hairline shape and position, brow position, and forehead protrusion, that may confer feminine identity. The purpose of this study is to conduct a scoping literature review of techniques performed for forehead feminization and to additionally study clinical outcomes within an institutional cohort. METHODS: A systematic literature review was conducted to review articles that discussed techniques and clinical outcomes associated with procedures performed for feminization of the upper third of the face. A retrospective review of patients undergoing such procedures by the senior author was then conducted. Variables collected included demographic factors, operative details, and postoperative outcomes such as complications, revisions, and re-operations. RESULTS: Initial review yielded sixty-seven articles. Title and abstract review followed by standardized application of inclusion and exclusion criteria resulted in a total of twenty-two studies for analysis. Priorities of forehead feminization entail frontal bossing reduction, frontonasal angle widening, orbital contouring, brow lifting, and hairline advancement. Eighty-five patients were included for analysis. The majority were of Caucasian race (56%) and had type 3 forehead classification (92%). The average planned setback of the anterior table was 4.12 mm. CONCLUSIONS: The core tenets of the feminization of the forehead lie in the overall creation of a harmonic curvature of the forehead with other facial features. Our multi-pronged analysis presents an updated review of these principles, which may help plastic surgeons in performing procedures to feminize the upper third of the face. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266.

Lessons Learned from a Single Institution's Eight Years of Experience with Early Cleft Lip Repair.

Background and Objectives: The traditional approach in managing wide cleft lip deformities involves presurgical nasoalveolar molding (NAM) therapy followed by surgical cleft lip repair between three and six months of age. This institution has implemented an early cleft lip repair (ECLR) protocol where infants undergo primary cleft lip repair between two and five weeks of age without NAM. This study aims to present this institution's ECLR repair protocol over the past eight years from 188 consecutive patients with unilateral or bilateral CL/P deformity. Materials and Methods: Retrospective review was conducted at Children's Hospital Los Angeles evaluating patients who underwent ECLR before three months of age and were classified as American Society of Anesthesiologists (ASA) class I or II from 2015-2022. Anthropometric analysis was performed, and pre- and postoperative photographs were evaluated to assess nasal and lip symmetry. Results: The average age at cleft lip repair after correcting for gestational age was 1.0 ± 0.5 months. Mean operative and anesthetic times were 120.3 ± 33.0 min and 189.4 ± 35.4, respectively. Only 2.1% (4/188) of patients had postoperative complications. Lip revision rates were 11.4% (20/175) and 15.4% (2/13) for unilateral and bilateral repairs, respectively, most of which were minor in severity (16/22, 72.7%). Postoperative anthropometric measurements demonstrated significant improvements in nasal and lip symmetry (p < 0.001). Conclusions: This analysis demonstrates the safety and efficacy of ECLR in correcting all unilateral cleft lip and nasal deformities of patients who were ASA classes I or II. At this institution, ECLR has minimized the need for NAM, which is now reserved for patients with bilateral cleft lip, late presentation, or comorbidities that preclude them from early repair. ECLR serves as a valuable option for patients with a wide range of cleft severity while reducing the burden of care.

"A Simplified Approach for Surgical Correction of Vertical Orbital Dystopia: A 45-year Retrospective Cohort Study."

INTRODUCTION: Vertical Orbital Dystopia (VOD) results in significant facial asymmetry, psychological distress, and poor quality of life in affected patients. The traditional approach (TA) for surgical correction has entailed a standard frontal craniotomy along with circumferential orbital osteotomy, vertical translocation of the orbit, and bone grafting to the lower maxilla. Caution has been expressed regarding its invasive transcranial nature. In this report, we describe the limited approach (LA) for simplified surgical correction of VOD, which obviates the need for a standard frontal craniotomy. METHODS: A 45-year retrospective review was conducted of all patients that underwent surgical correction of VOD, as performed by a single surgeon. Demographic details, procedural characteristics, and complications were compared between patients who were corrected by the TA and those who were corrected by the LA. Complications were defined as CSF leak, infection of the frontal bone, permanent diplopia, permanent ptosis, sudden-onset vision loss, persistent asymmetry, and surgical revision. RESULTS: Forty patients met inclusion criteria for correction of true VOD, of which 18 underwent the TA and 22 underwent the LA. Mean length of hospital stay was 5.3±2.3 days and 4.0±1.5 days for the TA and LA cohorts, respectively. Mean follow-up time was 4.9±7.5 years for the TA and 2.6±3.3 years for the LA. The only reported complications were persistent asymmetry in 2 patients in the TA cohort with one patient requiring surgical revision due to undercorrection, while the LA cohort exhibited no postoperative asymmetry or need for surgical revision. CONCLUSIONS: Both the TA and LA are effective for surgical correction of VOD. The limited craniotomy of the LA reduces exposure of intracranial structures and adequately achieves postoperative symmetry.

De novo variants implicate chromatin modification, transcriptional regulation, and retinoic acid signaling in syndromic craniosynostosis.

Craniosynostosis (CS) is the most common congenital cranial anomaly. Several Mendelian forms of syndromic CS are well described, but a genetic etiology remains elusive in a substantial fraction of probands. Analysis of exome sequence data from 526 proband-parent trios with syndromic CS identified a marked excess (observed 98, expected 33, p = 4.83 × 10-20) of damaging de novo variants (DNVs) in genes highly intolerant to loss-of-function variation (probability of LoF intolerance > 0.9). 30 probands harbored damaging DNVs in 21 genes that were not previously implicated in CS but are involved in chromatin modification and remodeling (4.7-fold enrichment, p = 1.1 × 10-11). 17 genes had multiple damaging DNVs, and 13 genes (CDK13, NFIX, ADNP, KMT5B, SON, ARID1B, CASK, CHD7, MED13L, PSMD12, POLR2A, CHD3, and SETBP1) surpassed thresholds for genome-wide significance. A recurrent gain-of-function DNV in the retinoic acid receptor alpha (RARA; c.865G>A [p.Gly289Arg]) was identified in two probands with similar CS phenotypes. CS risk genes overlap with those identified for autism and other neurodevelopmental disorders, are highly expressed in cranial neural crest cells, and converge in networks that regulate chromatin modification, gene transcription, and osteoblast differentiation. Our results identify several CS loci and have major implications for genetic testing and counseling.

An Oncoplastic Approach to Primary Pediatric Pterygomaxillary Osteosarcoma.

Osteosarcomas arising within the pterygomaxillary/infratemporal fossa region are rare among the pediatric population. Survival rates are most influenced by tumor resection with negative margins, which can be dependent on surgical accessibility of the tumor site. The pterygomaxillary/infratemporal fossa location poses several challenges to safe and adequate tumor resection, including proximity of the facial nerve and great vessels and scarring associated with traditional transfacial approaches. In this article, we present the case of a 6-year-old boy with an osteosarcoma of the left pterygomaxillary/infratemporal fossa region successfully managed with an "oncoplastic" approach, incorporating the use of CAD/CAM and mixed reality technologies.

Comparison of Collagen and Human Amniotic Membrane Nerve Wraps and Conduits for Peripheral Nerve Repair in Preclinical Models: A Systematic Review of the Literature.

BACKGROUND: Collagen and human amniotic membrane (hAM) are Food and Drug Administration (FDA)-approved biomaterials that can be used as nerve wraps or conduits for repair of peripheral nerve injuries. Both biomaterials have been shown to reduce scarring and fibrosis of injured peripheral nerves. However, comparative advantages and disadvantages have not been definitively shown in the literature. The purpose of this systematic review is to comprehensively evaluate the literature regarding the roles of hAM and collagen nerve wraps and conduits on peripheral nerve regeneration in preclinical models. METHODS: The MEDLINE database was queried using the PubMed search engine on July 7, 2019, with the following search strategy: ("amniotic membrane" OR "amnion") OR ("collagen conduit" OR "nerve wrap")] AND "nerve." All resulting articles were screened by two independent reviewers. Nerve type, lesion type/injury model, repair type, treatment, and outcomes were assessed. RESULTS: Two hundred and fifty-eight articles were identified, and 44 studies remained after application of inclusion and exclusion criteria. Seventeen studies utilized hAM, whereas 27 studies utilized collagen wraps or conduits. Twenty-three (85%) of the collagen studies utilized conduits, and four (15%) utilized wraps. Six (35%) of the hAM studies utilized conduits and 11 (65%) utilized wraps. Two (9%) collagen studies involving a conduit and one (25%) involving a wrap demonstrated at least one significant improvement in outcomes compared with a control. While none of the hAM conduit studies showed significant improvements, eight (73%) of the studies investigating hAM wraps showed at least one significant improvement in outcomes. CONCLUSION: The majority of studies reported positive outcomes, indicating that collagen and hAM nerve wraps and conduits both have the potential to enhance peripheral nerve regeneration. However, relatively few studies reported significant findings, except for studies evaluating hAM wraps. Preclinical models may help guide clinical practice regarding applications of these biomaterials in peripheral nerve repair.

A characterization of home maintenance equipment-related hand and lower arm injuries.

Background: Thousands of Americans sustain injuries from various household appliances each year, though injury patterns have not been well characterized. We thus sought to determine the incidence, characteristics, and trends of household appliance-related hand injuries over the past decade. Methods: The National Electronic Injury Surveillance System database (NEISS) was queried from 2010 through 2019. Our analysis grouped patients into 10-year age groups. We defined types of appliances and injuries Chi-square tests were used to compare the most common injury mechanisms by age group. Results: Between 2010 and 2019, 30,336 total cases of home workshop equipment-related upper extremity injuries were recorded; 2,574 (8.48%) of these affected females, compared to 27,762 (91.52%) of the cases affecting males. Across all age groups, males were between 6 and 13 more times likely to be injured than females (p < 0.001). Between 2010 and 2019, we recorded a decline in total injuries from 168,795 to 147,584, with a Pearson correlation coefficient of -0.68 (p = 0.031). The appliances most likely to injure those in their 10s through 40s were mechanical tools such as screwdrivers. Meanwhile, those in their 50s through 70s were most likely to be injured by saws. Both amputations and avulsions were found to significantly increase with age (p = 0.038, p = 0.027, respectively). Most injuries result from manual tools and saws. Discussion: Males are significantly more likely to incur injuries than females from maintenance equipment, and risk of avulsions and amputations increase significantly with age. This aligns with previous research which also suggested that older saws were most likely to injure older individuals; namely, following new regulations on saws, older adults were more likely to be affected. This is especially worrisome in light of recent research showing that older adults with amputations are less likely to be offered replantations. Overall, these results can continue to guide and optimize community interventions on an epidemiological basis.

Objective Comparison of Donor-Site Morbidity following Full and Thoracodorsal Nerve-Preserving Split Latissimus Dorsi Flaps.

BACKGROUND: The latissimus dorsi flap is a workhorse for reconstruction. However, flap harvest has been variably reported to result in donor-site morbidity. The aim of this study was to compare donor-site morbidity following harvest of a split latissimus dorsi flap, preserving the anterior branch of the thoracodorsal nerve, and a traditional nerve-sacrificing full latissimus dorsi flap. METHODS: Patients who underwent split or full latissimus dorsi flaps between July of 2017 and August of 2020 at a single center were recalled for assessment. Donor-site morbidity in the shoulder was evaluated through the Disabilities of the Arm, Shoulder and Hand questionnaire; the Shoulder Pain and Disability Index; and the American Shoulder and Elbow Surgeons questionnaire. Medical Research Council strength grading was also performed. RESULTS: A total of 22 patients in the split latissimus dorsi cohort and 22 patients in the full latissimus dorsi cohort were recalled. Patient-reported outcomes as assessed through the Disabilities of the Arm, Shoulder and Hand questionnaire; Shoulder Pain and Disability Index; and American Shoulder and Elbow Surgeons questionnaire scores revealed statistically greater (p < 0.05) donor-site morbidity associated with the traditional compared to split latissimus dorsi flap. Seven patients in the full latissimus dorsi cohort had less than Medical Research Council grade 5 power at the shoulder, whereas all patients in the split latissimus dorsi cohort demonstrated full power at the shoulder. CONCLUSIONS: Traditional full latissimus dorsi flaps were found to result in greater donor-site morbidity compared to thoracodorsal nerve-preserving split latissimus dorsi flaps. Split latissimus dorsi flaps may be beneficial in preserving donor-site function and strength. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Two Cases Surviving Macro Fat Emboli Complications Following Gluteal Fat Grafting.

Media attention has in recent years created an increased patient demand for gluteal contouring and augmentation. Gluteal augmentation and contouring with autologous fat transfer, colloquially referred to as the "Brazilian butt lift" (BBL), can be performed safely and effectively, with an overall complication rate ranging from 1.5% to 6.8%. However, there have been an alarming number of lethal events from intravenous passage of injected fat and fatal pulmonary embolism due to macro-fat emboli (MAFE). MAFE (fat emboli >1 cm in diameter), distinct from micro-fat emboli, can quickly result in catastrophic cardiopulmonary compromise and death. Accurate mortality estimates are limited by difficulties in determining accurate values for the total number of BBL procedures performed because most of these cases are performed at budget clinics. Accurate morbidity estimates are limited by a lack of published outcomes and a low level of evidence in published studies. The first case of survival of MAFE secondary to BBL was reported in 2019 by Peña et al. Few highly morbid complications secondary to MAFE have been reported because such events are almost universally lethal. We present 2 recent cases of survival after MAFE in the setting of gluteal fat transfer following expedient transfer to a tertiary care setting, allowing for timely and successful intervention. We illustrate examples of how MAFE is a highly lethal complication of gluteal fat grafting. Early recognition and immediate aggressive vital support to stabilize the patient are key for survival.

Comparison of human amniotic membrane and collagen nerve wraps around sciatic nerve reverse autografts in a rat model.

Human amniotic membrane (hAM) and collagen nerve wraps are biomaterials that have been investigated as therapies for improving outcomes of peripheral nerve regeneration; however, their efficacy has not been compared. The purpose of this study is to compare the efficacy of collagen and human amniotic membrane nerve wraps in a rodent sciatic nerve reverse autograft model. Lewis rats (n = 29) underwent sciatic nerve injury and repair in which a 10-mm gap was bridged with reverse autograft combined with either no nerve wrap (control), collagen nerve wrap or hAM nerve wrap. Behavioral analyses were performed at baseline and 4, 8 and 12 weeks. Electrophysiological studies were conducted at 8, 10 and 12 weeks. Additional outcomes assessed included gastrocnemius muscle weights, nerve adhesions, axonal regeneration and scarring at 12 weeks. Application of both collagen and hAM nerve wraps resulted in improvement of functional and histologic outcomes when compared with controls, with a greater magnitude of improvement for the experimental group treated with hAM nerve wraps. hAM-treated animals had significantly higher numbers of axons compared to control animals (p < 0.05) and significantly less perineural fibrosis than both control and collagen treated nerves (p < 0.05). The ratio of experimental to control gastrocnemius weights was significantly greater in hAM compared to control samples (p < 0.05). We conclude that hAM nerve wraps are a promising biomaterial that is effective for improving outcomes of peripheral nerve regeneration, resulting in superior nerve regeneration and functional recovery compared to collagen nerve wraps and controls.

Gingivosupraperiosteoplasty following Presurgical Maxillary Orthopedics Is Associated with Normal Midface Growth in Complete Unilateral and Bilateral Cleft Patients at Mixed Dentition.

BACKGROUND: Passive orthodontic appliances and gingivosupraperiosteoplasty are adjuncts that can be used by surgeons at the time of primary cleft lip repair. These treatments, along with the surgical technique of cleft lip and palate repair, may impact midface growth. The objective of this study was to describe the authors' protocol for unilateral and bilateral cleft lip repair and to evaluate midfacial growth in a cohort of patients at mixed dentition who had undergone presurgical passive orthodontic appliance therapy and gingivosupraperiosteoplasty at the time of unilateral and bilateral cleft lip repair. METHODS: Fifteen complete unilateral and 15 complete bilateral cleft lip and palate patients underwent passive orthodontic appliance treatment and primary lip repair with gingivosupraperiosteoplasty. Lateral cephalograms were analyzed by three blinded reviewers. Mean cephalometric measurements at mixed dentition were compared to cephalometric values for noncleft patients, unilateral cleft lip and palate patients who did not undergo gingivoperiosteoplasty or presurgical treatment, and unilateral cleft lip and palate patients who underwent gingivoperiosteoplasty/nasoalveolar molding with independent samples t tests. RESULTS: Mean cephalometric values were within age-specific normal values for sella-nasion-A point, sella-nasion-B point, A point-nasion-B point, and facial axis. Eighty-seven (13/15) percent of unilateral cleft lip and palate patients and 93 percent (14/15) of bilateral cleft lip and palate patients did not exhibit skeletal class III malocclusion. There was no significant difference between cephalometric values for our patients and patients who did not receive gingivosupraperiosteoplasty or presurgical treatment or who underwent the gingivoperiosteoplasty/nasoalveolar molding protocol. CONCLUSIONS: Presurgical passive orthodontic appliances, combined with gingivosupraperiosteoplasty at the time of lip repair, leads to normal maxillary development in most patients at mixed dentition. Assessment of midface growth at skeletal maturity is required. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Use of Commercially Produced Medical Education Videos in a Cardiovascular Curriculum: Multiple Cohort Study.

BACKGROUND: Short instructional videos can make learning more efficient through the application of multimedia principles, and video animations can illustrate the complex concepts and dynamic processes that are common in health sciences education. Commercially produced videos are commonly used by medical students but are rarely integrated into curricula. OBJECTIVE: Our goal was to examine student engagement with medical education videos incorporated into a preclinical Cardiovascular Systems course. METHODS: Students who took the first-year 8-week Cardiovascular Systems course in 2019 and 2020 were included in the study. Videos from Osmosis were recommended to be watched before live sessions throughout the course. Video use was monitored through dashboards, and course credit was given for watching videos. All students were emailed electronic surveys after the final exam asking about the course's blended learning experience and use of videos. Osmosis usage data for number of video views, multiple choice questions, and flashcards were extracted from Osmosis dashboards. RESULTS: Overall, 232/359 (64.6%) students completed surveys, with rates by class of 81/154 (52.6%) for MD Class of 2022, 39/50 (78%) for MD/MPH Class of 2022, and 112/155 (72.3%) for MD Class of 2023. Osmosis dashboard data were available for all 359 students. All students received the full credit offered for Osmosis engagement, and learning analytics demonstrated regular usage of videos and other digital platform features. Survey responses indicated that most students found Osmosis videos to be helpful for learning (204/232, 87.9%; P=.001) and preferred Osmosis videos to the traditional lecture format (134/232, 57.8%; P<.001). CONCLUSIONS: Commercial medical education videos may enhance curriculum with low faculty effort and improve students' learning experiences. Findings from our experience at one medical school can guide the effective use of supplemental digital resources for learning, and related evaluation and research.

Operational and Financial Impact of COVID-19: A Survey of Plastic Surgeons in Miami.

BACKGROUND: In response to the COVID-19 pandemic, new guidelines were issued cautioning against performing elective procedures. We aimed to assess the impact of the COVID-19 pandemic on operational and financial aspects of plastic surgery in Miami. METHODS: A multiple-choice and short-answer survey regarding practice changes and financial impact was sent to all 67 members of the Miami Society of Plastic Surgeons. RESULTS: A 41.8% (n = 28) response rate was obtained, five responses did not meet the inclusion criteria, and statistical analysis was performed on 34.3% (n = 23) of responses. Of the plastic surgeons who responded, 21.74% operate in an academic setting, 60.87% are in a single practitioner private practice, and 17.39% are in a multi-practitioner private practice. An estimated 60% of academic plastic surgeons had 75% or more of their previously scheduled cases canceled, compared with 57.14% in single practitioner private practice and 100% in multi-practitioner private practice. In total, 64.29% of single practitioner private practices and 50% of multi-practitioner private practices have had to obtain a small business loan. Single practitioner private practice plastic surgeons reported having an average of 6.5 months until having to file for bankruptcy or permanently close their practices, and multi-practitioner private practice plastic surgeons reported an average of 6 months. CONCLUSIONS: Guidelines to support small business must be implemented in order to allow private practice surgeons to recover from the substantial economic impact caused by the pandemic because it is necessary to reestablish patient access and provide proper care to our patients.

Is Digital Animation Superior to Text Resources for Facial Transplantation Education? A Randomized Controlled Trial.

BACKGROUND: Facial transplantation is a complex surgical procedure that requires education of medical professionals, patients, and the general public. The objective of this randomized controlled trial was to compare the educational efficacy of facial transplantation digital animation versus text resources for teaching medical students a complex surgical procedure and its applicable anatomical and surgical principles. METHODS: Medical student volunteers were recruited and prospectively randomized to an animation or a text group. Students completed preintervention and postintervention assessments of confidence and knowledge of head and neck anatomy and facial transplantation. Student Evaluations of Educational Quality survey assessed student satisfaction with both tools following study crossover. Knowledge assessment was developed using National Board of Medical Examiners guidelines and content validated by four experts. The Cohen d statistic was used to measure the effect size of each intervention. RESULTS: Thirty-six students were assigned randomly to the animation group (n = 19) or the text (n = 17) group. Postintervention analysis demonstrated significantly higher performance scores in the animation group compared to the text group (p = 0.029). The animation group had a larger effect size (Cohen d = 1.96 versus 1.27). Only students in the animation group reported significantly improved confidence in head and neck anatomy after the intervention (p = 0.002). Both groups demonstrated significantly increased postintervention confidence in knowledge of facial transplantation (p < 0.001). Satisfaction scores revealed that students significantly favored the animation resource (p < 0.001). CONCLUSIONS: Animation can be an effective tool for facial transplantation education and results in improved student knowledge, confidence, and satisfaction compared to text resources. Facial transplantation can also be used as an educational framework for teaching medical students anatomical and surgical principles.

Craniofacial Injuries in Lacrosse: A Novel Algorithm for Injury Assessment.

INTRODUCTION: Lacrosse is played widely across the United States, as evidenced by growing participation in the sport. The rapid increase in participation suggests that many of the new players are inexperienced. Many coaches might be ill-equipped to deal with player trauma. There are several crucial differences in the way the sports are played between males and females, altering the experience of the game and the injury profiles that may arise. METHODS: A query of the National Electronic Injury Surveillance System database was performed to study the types of craniofacial injuries incurred from lacrosse. RESULTS: Concussions were the most common injury type, and players between 10 and 14 years old were found to be at greater risk of contusions relative to older players. Players between 15 and 19 years old were at a greater risk of sustaining lacerations. In terms of gender, females were more likely to experience concussions than males, and were at increased risk of head injuries relative to face injuries. DISCUSSION: The finding that females are at increased risk of concussion might be subsequent to a lack of adequate training by coaches. Female athletes tend to experience worse outcomes following concussions incurred secondary to playing sports. Recent work has suggested that this may be a consequence of female anatomy; women tend to have shorter neck dimensions, which predisposes them to more deleterious head-neck accelerations, and thus concussions. These results may inform a layperson-friendly algorithm for the workup of craniofacial injuries sustained from lacrosse.

Heads Up Play: Acute Assessment and Management of Basketball-Related Craniofacial Injuries by On-Court Personnel.

INTRODUCTION: With a following of over 825 million people, basketball currently ranks amongst the world's most popular sports. Despite a number of concussion awareness and player safety protocols that have been implemented at the professional level of organized play, a standardized, layperson-friendly algorithm for the acute management of basketball-related craniofacial injuries does not appear to presently exist. METHODS: This 10-year retrospective cohort study was conducted using the National Electronic Injury Surveillance System database to examine basketball-related craniofacial injuries from 2010 to 2019. Within the National Electronic Injury Surveillance System dataset, factors including patient age, gender, diagnosis, injury type, and injury location were included in our analysis. RESULTS: Overall, 22,529 basketball-related craniofacial injuries occurred between 2010 and 2019 in players ages 5 to 49 years old. Adolescent (12-18-year-old) and young adult (19-34-year-old) age groups had the highest incidence of craniofacial injuries. The adolescent cohort experienced a significantly greater proportion of concussions and lower proportion of both facial lacerations and fractures compared with the within group null hypothesis of equal proportions (P < 0.05). The young adult cohort experienced a significantly greater proportion of facial lacerations and fractures and lower proportion of concussions, contusions/abrasions, hematomas, and internal injuries compared to this cohort's null hypothesis (P < 0.05). Males experienced a significantly greater proportion of fractures, lacerations, and dental injuries and lower proportion of concussions, contusions/abrasions, and internal injuries compared to the hypothesized equality of proportions (P < 0.05). Females experienced a significantly greater proportion of concussions, contusions/abrasions, and internal injuries and lower proportion of fractures, lacerations, and dental injuries compared to the hypothesized equality of proportions (P < 0.05). CONCLUSIONS: Although several steps have already been taken at the professional level to try to promote player safety, particularly with concussion protocols and prevention of lower extremity injuries, there remains a paucity of resources to guide management of other types of acute craniofacial injury. The role of layperson-friendly educational interventions remains intriguing as a potential means of improving outcomes regardless of socioeconomic status or health literacy. Additional studies still need to be completed to determine efficacy and best future direction.