Comparing the Management of Eye Injuries by Coalition Military Surgeons during the Iraq and Afghanistan Conflicts.

PURPOSE: To compare incidences, ocular injury types, and treatment performed on United States and United Kingdom military service members and host nation civilians within the Iraq and Afghanistan conflicts to inform future military surgical training requirements and military medical planning. The United States routinely deployed ophthalmologists, whereas the United Kingdom did not. DESIGN: Retrospective cohort study of the United States and United Kingdom military Joint Theatre Trauma Registries. PARTICIPANTS: All patients with eye injuries treated at a deployed Military Treatment Facility between March 2003 and October 2011. METHODS: An adjusted multiple logistic regression model was performed using enucleation or evisceration and primary open-globe repair as dependent variables and casualty nationality, location, and the presence of an ophthalmic surgeon as independent variables. MAIN OUTCOME MEASURES: Incidence of eye removal (enucleation or evisceration) or primary repair for open globe injury. RESULTS: Five thousand seven hundred nineteen of 67 586 (8%) survivors or those who died of wounds were recorded to have sustained eye injuries. The most common eye injuries were open-globe injury without intraocular foreign body (3201/5719 [56%]). Adnexal injuries (eyelid lacerations and damage to lacrimal apparatus) were recorded in 1265 of 5719 patients (22%). The odds of undergoing evisceration or enucleation for open-globe injury was highest in host nation civilians (odds ratio [OR], 9.23; P < 0.001), but there was no evidence of a difference between United States and United Kingdom military service member casualties (P = 0.38). The presence of an ophthalmic surgeon (OR, 16.3; P < 0.001) significantly affected the odds of eye removal. CONCLUSIONS: Eye injuries were more likely to have been treated definitively in United States Medical Treatment Facilities (MTFs), reflecting the absence of ophthalmologists in most deployed United Kingdom MTFs. The Iraq and Afghan conflicts were notable for coalition air dominance; the shape of future conflicts may mandate delays in evacuation, which may affect visual outcomes negatively, particularly if primary repair of patients with open-globe injuries is delayed. This study provides evidence to support the maintenance of specialist ophthalmic surgical competencies in deployed coalition MTFs for future conflicts.

Affinity and cross-reactivity engineering of CTLA4-Ig to modulate T cell costimulation.

CTLA4-Ig is an Fc fusion protein containing the extracellular domain of CTLA-4, a receptor known to deliver a negative signal to T cells. CTLA4-Ig modulates T cell costimulatory signals by blocking the CD80 and CD86 ligands from binding to CD28, which delivers a positive T cell costimulatory signal. To engineer CTLA4-Ig variants with altered binding affinity to CD80 and CD86, we employed a high-throughput protein engineering method to map the ligand binding surface of CTLA-4. The resulting mutagenesis map identified positions critical for the recognition of each ligand on the three CDR-like loops of CTLA-4, consistent with the published site-directed mutagenesis and x-ray crystal structures of the CTLA-4/CD80 and CTLA-4/CD86 complexes. A number of single amino acid substitutions were identified that equally affected the binding affinity of CTLA4-Ig for both ligands as well as those that differentially affected binding. All of the high-affinity variants showed improved off-rates, with the best one being a 17.5-fold improved off-rate over parental CTLA4-Ig binding to CD86. Allostimulation of human CD4(+) T cells showed that improvement of CD80 and CD86 binding activity augmented inhibition of naive and primed T cell activation. In general, increased affinity for CD86 resulted in more potent inhibition of T cell response than did increased affinity for CD80. Optimization of the affinity balance to CD80 and CD86 to particular disease settings may lead to development of a CTLA4-Ig molecule with improved efficacy and safety profiles.

Synovial chondromatosis: a case series and review of the literature.

This case series reviews 2 patients worked up and treated for unilateral synovial chondromatosis of the temporomandibular joint (TMJ). The first was a 58-year-old female evaluated and treated for synovial chondromatosis of the left TMJ using an arthrotomy of the joint to remove the cartilaginous and osteocartilaginous nodules. The second is a 63-year-old male who was evaluated and treated for synovial chondromatosis of the right TMJ with the removal of extracapsular masses and an arthrotomy with intra-joint removal of nodules. Six-year radiographic follow-up demonstrated no recurrence of the pathology in his case. The cases are reviewed in this article, along with a current review of the literature.

Soft Tissue Trauma: Critical Recognition and Timing of Intervention in Emergency Presentations.

The facial trauma surgeon will see a variety of facial injuries. Recognition of emergency cases and proper intervention is and this article aims to highlight those cases and the respective proper interventions.

Closed reduction of nasoseptal fractures: key concepts for predictable results.

Nasal complex injuries are the most common facial fracture encountered in the trauma population. Multiple surgical techniques for treatment of these fractures have been described with varying results. The goal of this study was to review the efficacy of closed reduction of nasal and septal fractures using a technique based upon several key concepts. We reviewed the records of patients who had undergone isolated nasal and/or septal fractures with closed reduction at our institution between January 2013 and November 2021. Inclusion criteria consisted of preoperative CT imaging, surgical treatment within fourteen days of initial injury, and follow up of at least one year. All patients were treated under general or deep sedation. The same surgical technique was applied with closed reduction of the septum and nasal bones with internal and external postoperative splints. Of the 232 records initially reviewed, 103 met inclusion criteria. Four patients had undergone revision septorhinoplasty (3.9%). Mean (range) follow up was 2.7 (1-8.2) years. Three patients had undergone revision nasal repair due to persistent airflow obstruction with complete resolution of symptoms after revision. The other patient received multiple revisions at another institution as a result of their dissatisfaction with cosmesis without improvement. Closed reduction of nasal and septal fractures can be a highly successful procedure and yield predictable results, limiting the need for post-traumatic open septorhinoplastic surgery. Five critical concepts of nasal fracture repair can help surgeons achieve predictable functional and cosmetic results: selection, timing, anaesthesia, reduction, and support.

Vascularized Fibula TMJ Reconstruction: A Report of Five Cases featuring Computerized Patient-specific Surgical Planning.

Background: Mandibular defects involving the condyle represent a complex reconstructive challenge for restoring proper function of the temporomandibular joint because it requires precise bone graft alignment, or alloplastic materials, for complete restoration of joint function. The use of computerized patient-specific surgical planning (CPSSP) technology can aid in the anatomic reconstruction of mandibular condyle defects with a vascularized free fibula flap without the need for additional adjuncts. The purpose of this study was to analyze clinical and functional outcomes after reconstruction of mandibular condyle defects using only a free fibula graft with the assistance of virtual surgery techniques. Methods: A retrospective review was performed to identify all patients who underwent mandibular reconstruction utilizing CPSSP with only a free fibula flap without any temporomandibular joint adjuncts after a hemimandibulectomy with total condylectomy. Results: From 2018 to 2021, five patients underwent reconstruction of mandibular defects involving the condyle with CPSSP technology and preservation of the native temporomandibular articulating disk. The average age was 62 years (range, 44-73 years). The average follow-up period was 29.2 months (range, 9-46 months). Flap survival was 100% (N = 5). The maximal interincisal opening range for all patients was 22-45 mm with no lateral deviation or subjective joint pain. No patients experienced progressive joint hypomobility or condylar migration. Conclusion: The use of CPSSP technology can aid in the anatomic reconstruction of mandibular condyle defects with a vascularized free fibula flap through precise planning and intraoperative manipulation with optimal functional outcomes.

Current Concepts in Cranial Reconstruction: Review of Alloplastic Materials.

Cranioplasty for acquired cranial defects can be complex and challenging. Benefits include improved cosmesis, protection of intracranial structures, and restoration of neurocognitive function. These defects can be reconstructed with preserved craniectomy bone flaps, split autografts, or alloplastic materials. When alloplastic cranioplasty is planned, the material should be carefully selected. There is confusion on which material should be used in certain scenarios, particularly in composite defects. Methods: The PubMed database was used to conduct a nonsystematic review of literature related to these materials and the following factors: time required in preoperative planning and fabrication, intraoperative time, feasibility of intraoperative modification, fixation method (direct or indirect), implant cost, overall complication rate, and surgical revision rates. Results: Surgical revision rates for alloplastic materials range from 10% to 23%. Retention of titanium mesh at 4 years is 85% in composite reconstruction with free fasciocutaneous and free myocutaneous flaps. In composite reconstruction with locoregional and free muscle flaps, the retention of titanium mesh at 4 years is 47%. The retention of nontitanium and nonpreserved autogenous reconstruction is 72% and 82%, respectively. Conclusions: Alloplastic materials should be considered for reconstruction of large (>100 cm2) cranial defects, especially for adult patients younger than 30 years, and all patients with bone flaps that are fragmented or have been cryopreserved for an extended period. Preformed titanium mesh provides a favorable primary reconstructive option when a staged reconstruction is not possible or indicated but should be avoided in composite defects reconstructed with locoregional scalp and free muscle flaps.

Clinical Competency Committees in Plastic Surgery Residency.

BACKGROUND: Clinical competency committees (CCCs) are now an Accreditation Council on Graduate Medical Education (ACGME) requirement for plastic surgery training programs. They serve to monitor resident progress and make formal recommendations to program directors on promotion, remediation, and dismissal, based on resident progress toward the curricular milestones. METHODS: Here, we present an overview on building, conducting, and improving a CCC, reviewing the literature available regarding best practices regarding this novel assessment system, with attention to the particular requirements for plastic surgery training. RESULTS: We present the results of the Duke University CAQCC as a case study in the efficacy of a well-executed group in terms of improved resident outcomes, particularly regarding In-service Examination scores as an objective measure. CONCLUSIONS: Rather than simply serving as a necessary ACGME dictum, the CCC has the opportunity to demonstrably improve resident education. This article is valuable for department leaders, program directors, faculty, and residents toward understanding the purpose and design of their CCC.

A review of the surgical treatment options for the obstructive sleep apnea/hypopnea syndrome patient.

Obstructive sleep apnea/hypopnea syndrome (OSAHS) is a medical condition that has received significant attention within the medical community and mainstream media due to its potentially serious physiological consequences and relatively frequent occurrence within the general population. From the military perspective, the impact on individual readiness for deployment, and the potential degradation of performance in critically important military duties, often results in tremendous expenditures of training resources, time, and expertise to replace the military member with a suitable substitute or release of the individual from active duty. This article reviews common surgical techniques for clinical management of OSAHS patients in a presentation format for primary care and sleep medicine specialists, as well as surgeons interested in the philosophies of surgical management of sleep disordered breathing. Presentation of risks and benefits of surgical treatment are discussed in a manner to facilitate communication between patient and health care provider.

Maxillary Prosthetics, Speech Impairment, and Presidential Politics: How Grover Cleveland Was Able to Speak Normally after His "Secret" Operation.

In the summer of 1893, President Grover Cleveland discovered a mass on the roof of his mouth. Two physicians examined it, determined that it was a neoplasm, and recommended resection. In an effort to avoid revealing the illness to the public, the President and his doctors boarded a yacht on July 1 1893, where the surgeons resected the affected portion of his maxilla and several teeth under an ether anesthetic. Afterward, Kasson C. Gibson, a New York dentist, created a rubber obturator, which was placed in the surgical defect in the maxilla and restored the President's facial contour and speech. Due to the precise reconstruction with the rubber appliance crafted by Gibson, the President lived the rest of his public life without facial or speech abnormality. This article will review the details of the work of Kasson Gibson and the President's maxillary prosthesis.

The Impact of COVID-19 on the Treatment of Craniomaxillofacial Trauma and Head and Neck Infections.

There is no shortage of news, information, and guidelines with regards to novel coronavirus (COVID-19). However, there is none yet that is specific to the treatment of patients who have sustained trauma or active head and neck infections-frequently encountered from oropharyngeal sources such as peritonsillar abscess or odontogenic infections. The COVID outbreak has not diminished the incidence of these conditions, and in fact has exacerbated access to care by the closing of urgent care treatment centers as well as private dental offices. The purpose of this article is to outline a protocol to protect health care providers in the provision of this care for at-risk patient populations.

Outcomes following penetrating neck injury during the Iraq and Afghanistan conflicts: A comparison of treatment at US and United Kingdom medical treatment facilities.

INTRODUCTION: The United States and United Kingdom (UK) had differing approaches to the surgical skill mix within deployed medical treatment facilities (MTFs) in support of the military campaigns in Iraq and Afghanistan. METHODS: The US and UK combat trauma registries were scrutinized for patients with penetrating neck injury (PNI) at deployed coalition MTF between March 2003 and October 2011. A multivariate mixed effects logistic regression model (threshold, p < 0.05) was used stratified by MTF location and year of injury. The dependent variable was fatality on leaving Role 3, and the independent variables were ISS on arrival, nationality, MTF nationality, and presence of head and neck surgeon. RESULTS: A total of 3,357 (4.9%) of 67,586 patients who arrived alive at deployed military MTF were recorded to have sustained neck injuries; of which 2,186 (83%) were PNIs and the remainder were blunt injuries. When service members killed in action were included, the incidence of neck injury rose from 4.9% to 10%. Seven hundred nine (32%) of 2,186 patients with PNI underwent neck exploration; 555 patients were recorded to have sustained cervical vascular injury, 230 (41%) of 555 underwent vascular ligation or repair. Where it was recorded, PNI directly contributed to death in 64 (28%) of 228 of patients. Fatality status was positively associated with ISS on arrival (odds ratio, 1.05; 95% confidence interval, 1.04-1.06; p < 0.001) and the casualty being a local national (odds ratio, 1.74; 95% confidence interval, 1.28-2.38; p < 0.001). CONCLUSION: Significant differences in the treatment and survival of casualties with PNI were identified between nations in this study; this may reflect differing cervical protection, management protocols, and surgical capability and is worthy of further study. In an era of increasing specialization within surgery, neck exploration remains a skill that must be retained by military surgeons deploying to Role 2 and Role 3 MTF. LEVEL OF EVIDENCE: Retrospective cohort study, level III.

Epitope and Fc-Mediated Cross-linking, but Not High Affinity, Are Critical for Antitumor Activity of CD137 Agonist Antibody with Reduced Liver Toxicity.

CD137 (TNFRSF9, 4-1BB) agonist antibodies (mAb) have demonstrated potent antitumor activity with memory response while causing hepatotoxicity in mouse models. In clinical trials, the degrees of liver toxicity of anti-CD137 vary from grade 4 transaminitis (urelumab) to nonexistent (utomilumab). To exploit the antitumor potential of CD137 signaling, we identified a new class of CD137 agonist mAbs with strong antitumor potency without significant transaminitis in vivo compared with CD137 agonists previously reported. These mAbs are cross-reactive to mouse and cynomolgus monkey and showed cross-linking-dependent T-cell costimulation activity in vitro Antitumor efficacy was maintained in Fc gamma receptor (FcγR) III-deficient mice but diminished in FcγRIIB-deficient mice, suggesting the critical role for FcγRIIB to provide cross-linking in vivo Interestingly, a single dose of an affinity-reduced variant was sufficient to control tumor growth, but a higher affinity variant did not improve efficacy. These observations suggest that binding epitope and FcγR interaction, but not necessarily high affinity, are important for antitumor efficacy and reduced liver toxicity of CD137 mAb. Our study suggests the possibility of CD137 agonist therapy with improved safety profile in humans.

Concomitant cranial and ocular combat injuries during Operation Iraqi Freedom.

BACKGROUND: Concomitant cranial and ocular injuries were frequently seen in combat casualties during Operation Iraqi Freedom. The incidence of these injuries is reported along with an interventional case series. METHODS: A retrospective review was conducted of all surgical patients treated by U.S. Army neurosurgeons and ophthalmologists in Iraq from December 2005 to April 2006. RESULTS: Out of 104 patients with cranial trauma and 158 patients with ocular trauma, 34 had both cranial and ocular injuries (32.7 and 21.5% of patients with cranial and ocular injuries, respectively). Neurosurgical procedures included exploratory craniotomy, decompressive craniectomy, and frontal sinus surgery. Ophthalmologic surgical procedures included globe exploration, open globe repair, primary enucleation, orbital fracture repair, lateral canthotomy and cantholysis, and repair of lid and periocular lacerations. Patients with cranial trauma had a higher incidence of orbital fracture, orbital compartment syndrome, and multiple ocular injuries compared with patients without cranial trauma (odds ratio 6.4, 3.9, and 3.3, respectively). CONCLUSION: A strong association exists between cranial and ocular trauma in combat casualties treated during Operation Iraqi Freedom. Combat health support personnel should maintain a high level of suspicion for one of these injuries when the other is present. Co-locating neurosurgeons and ophthalmologists in support of combat operations facilitates the optimal treatment of patients with these combined injuries.

Facial injury management undertaken at US and UK medical treatment facilities during the Iraq and Afghanistan conflicts: a retrospective cohort study.

OBJECTIVES: To perform the first direct comparison of the facial injuries sustained and treatment performed at USA and UK deployed medical treatment facilities (MTFs) in support of the military campaigns in Iraq and Afghanistan. SETTING: The US and UK Joint Theatre Trauma Registries were scrutinised for all patients with facial injuries presenting alive to a UK or US deployed MTF between 1 March 2003 and 31 October 2011. PARTICIPANTS: US and UK military personnel, local police, local military and civilians. PRIMARY AND SECONDARY OUTCOME MEASURES: An adjusted multiple logistic regression model was performed using tracheostomy as the primary dependent outcome variable and treatment in a US MTF, US or UK military, mandible fracture and treatment of mandible fracture as independent secondary variables. RESULTS: Facial injuries were identified in 16 944 casualties, with the most common being those to skin/muscle (64%), bone fractures (36%), inner/middle ear (28%) and intraoral damage (11%). Facial injuries were equally likely to undergo surgery in US MTF as UK MTF (OR: 1.06, 95% CI 0.4603 to 1.142, p=0.6656); however, variations were seen in injury type treated. In US MTF, 692/1452 (48%) of mandible fractures were treated by either open or closed reduction compared with 0/167 (0%) in UK MTF (χ2: 113.6; p≤0.0001). US military casualties who had treatment of their mandible fracture (open reduction and internal fixation or mandibulo-maxillary fixation) were less likely to have had a tracheostomy than those who did not undergo stabilisation of the fractured mandible (OR: 0.61, 95% CI 0.44 to 0.86; p=0.0066). CONCLUSIONS: The capability to surgically treat mandible fractures by open or closed reduction should be considered as an integral component of deployed coalition surgical care in the future.

Oral and maxillofacial surgery careers in the military and department of veterans affairs.

Within the Federal Services, a myriad of career opportunities exist for the oral and maxillofacial surgeon. The Department of Veterans Affairs and the Department of Defense, consisting of the Army, Navy, and Air Force, have the greatest number of positions available. Federal Services careers are also for those oral and maxillofacial surgeons with a calling to serve their country. The personal fulfillment, patient appreciation, and inter- and cross-specialty relationships are unique to this practice setting because it is free of many of the impediments, to these relationships, that exist in private practice. The highlights of a career in each of these Federal Services are described in this article.

A Novel Approach for the Management and Prevention of Self-Induced Masticatory Lingual Trauma in the Neurologically Injured Patient.

Self-induced masticatory trauma is an unfortunate complication of a variety of neurologic disorders, including epileptic seizures, cerebral palsy, mental retardation, psychiatric disease, and brain trauma, in addition to other described etiologies. While single or occasional occurrences of tongue biting are relatively benign, recurrent self-injury can pose major issues and predispose a patient to chronic, severe complications. To prevent the complications associated with ongoing trauma to the tongue, steps must be taken to protect individuals from chronic self-injurious behavior. Often, these interventions cause significant morbidity to the patient, such as elective removal of the dentition or complications in gaining access to the oral cavity/airway associated with maxillomandibular fixation. In the neurologically impaired patient, immobilization of the jaws is frequently associated with higher rates of agitation, aspiration, or development of complicating infections of the gingival tissues. We report a case of self-induced masticatory trauma managed with the fabrication of a custom-fabricated oral appliance. This treatment modality successfully prevents the recurrence or incidence of self-induced masticatory trauma to the tongue. The benefits of this modality are that it allows access to the oral cavity, prevents immobilization of the jaws, has minimal to no morbidity, and is completely reversible.