Cervical Necrotizing Fasciitis: A Severe Sequela of Open Mandibular Fracture and Delay in Treatment.

Cervical necrotizing fasciitis (CNF) is a rare condition in the United States, with very few cases reported as a sequela of mandibular fracture. The authors describe the case of a 40-year-old man with poor oral health and no significant past medical history who developed CNF following delayed treatment of an open mandibular fracture, leading to life-threatening septic shock, thrombophlebitis of the internal jugular vein, and septic emboli to the lungs. Successful management of this patient was accomplished by serial surgical debridement, the administration of broad-spectrum antibiotics, and hemodynamic support. Eventual reconstruction was performed with external fixation of the mandible fracture and split-thickness skin grafting for the left neck and chest wound. The authors recommend early treatment of open mandibular fractures for immunocompromised patients or patients with poor oral hygiene to avoid the rare but potentially fatal complication of CNF and highlight external fixation as a useful technique in select cases of complex mandibular fractures.

Assessing the representativeness of cluster randomized trials: Evidence from two large pragmatic trials in United States nursing homes.

BACKGROUND/AIMS: When the randomized clusters in a cluster randomized trial are selected based on characteristics that influence treatment effectiveness, results from the trial may not be directly applicable to the target population. We used data from two large nursing home-based pragmatic cluster randomized trials to compare nursing home and resident characteristics in randomized facilities to eligible non-randomized and ineligible facilities. METHODS: We linked data from the high-dose influenza vaccine trial and the Music & Memory Pragmatic TRIal for Nursing Home Residents with ALzheimer's Disease (METRICaL) to nursing home assessments and Medicare fee-for-service claims. The target population for the high-dose trial comprised Medicare-certified nursing homes; the target population for the METRICaL trial comprised nursing homes in one of four US-based nursing home chains. We used standardized mean differences to compare facility and individual characteristics across the three groups and logistic regression to model the probability of nursing home trial participation. RESULTS: In the high-dose trial, 4476 (29%) of the 15,502 nursing homes in the target population were eligible for the trial, of which 818 (18%) were randomized. Of the 1,361,122 residents, 91,179 (6.7%) were residents of randomized facilities, 463,703 (34.0%) of eligible non-randomized facilities, and 806,205 (59.3%) of ineligible facilities. In the METRICaL trial, 160 (59%) of the 270 nursing homes in the target population were eligible for the trial, of which 80 (50%) were randomized. Of the 20,262 residents, 973 (34.4%) were residents of randomized facilities, 7431 (36.7%) of eligible non-randomized facilities, and 5858 (28.9%) of ineligible facilities. In the high-dose trial, randomized facilities differed from eligible non-randomized and ineligible facilities by the number of beds (132.5 vs 145.9 and 91.9, respectively), for-profit status (91.8% vs 66.8% and 68.8%), belonging to a nursing home chain (85.8% vs 49.9% and 54.7%), and presence of a special care unit (19.8% vs 25.9% and 14.4%). In the METRICaL trial randomized facilities differed from eligible non-randomized and ineligible facilities by the number of beds (103.7 vs 110.5 and 67.0), resource-poor status (4.6% vs 10.0% and 18.8%), and presence of a special care unit (26.3% vs 33.8% and 10.9%). In both trials, the characteristics of residents in randomized facilities were similar across the three groups. CONCLUSION: In both trials, facility-level characteristics of randomized nursing homes differed considerably from those of eligible non-randomized and ineligible facilities, while there was little difference in resident-level characteristics across the three groups. Investigators should assess the characteristics of clusters that participate in cluster randomized trials, not just the individuals within the clusters, when examining the applicability of trial results beyond participating clusters.

Does Facial Fracture Management Require Opioids? A Pilot Trial of a Narcotic-Minimizing Analgesia Protocol for Operative Facial Trauma.

Opioid minimization in the acute postoperative phase is timely in the era of the opioid epidemic. The authors hypothesize that patients with facial trauma receiving multimodal, narcotic-minimizing pain management in the perioperative period will consume fewer morphine milligram equivalents (MMEs) while maintaining adequate pain control compared with a traditional analgesia protocol. An IRB-approved pilot study evaluating isolated facial trauma patients compared 10 consecutive prospective patients of a narcotic-minimizing pain protocol beginning in August 2020 with a retrospective, chart-reviewed cohort of 10 consecutive patients before protocol implementation. The protocol was comprised of multimodal nonopioid pharmacotherapy given preoperatively (acetaminophen, celecoxib, and pregabalin). Postoperatively, patients received intravenous (IV) ketorolac, scheduled acetaminophen, ibuprofen, and gabapentin. Oxycodone was reserved for severe uncontrolled pain. The control group had no standardized protocol, though opioids were ad libitum. Consumed MMEs and verbal Numeric Rating Scale (vNRS) pain scores (0-10) were prospectively tracked and compared with retrospective data. Descriptive and inferential statistics were run. At all recorded postoperative intervals, narcotic-minimizing subjects consumed significantly fewer MMEs than controls [0-8 h, 21.5 versus 63.5 ( P = 0.002); 8-16 h, 4.9 versus 20.6 ( P = 0.02); 16-24 h, 3.3 versus 13.9 ( P = 0.03); total 29.5 versus 98.0 ( P = 0.003)]. At all recorded postoperative intervals, narcotic-minimizing subjects reported less pain (vNRS) than controls (0-8 h, 7.7 versus 8.1; 8-16 h, 4.4 versus 8.0; 16-24 h 4.3 versus 6.9); significance was achieved at the 8 to 16-hour time point ( P = 0.006). A multimodal, opioid-sparing analgesia protocol significantly reduces opioid use in perioperative facial trauma management without sacrificing satisfactory pain control for patients.

Should Degree of Third Molar Eruption Influence Operative Management of Mandibular Angle Fractures? A Systematic Review.

Study Design: Systematic review. Objective: There is a growing trend toward evidence-based management of third molars in the fracture line of mandibular angle fractures (MAFs). This study aimed to differentiate MAF fixation complications by degree of third molar eruption and by extraction strategy in patients undergoing Champy fixation. Methods: PubMed, EMBASE, OVID, SCOPUS, the Cochrane Library, and clinicaltrials.gov were queried through May 2020 for English-language publications for MAFs with third molar involvement for this systematic review. Bias was assessed using author-defined criteria. Relative risk (RR) of post-operative complications associated with extracted unerupted and retained partially erupted third molars (Group I) was calculated against controls of retained unerupted and extracted partially erupted third molars (Group II). Results: Ten studies reported complications by eruption or extraction; however, only one study stratified complications by both eruption and extraction to meet inclusion criteria. The risk of bias was medium as only cases meeting defined follow-up were included. 73 cases (N) were included: 34 qualified for Group I and 39 for Group II. Quantitative synthesis of individual case data demonstrated significantly higher complication rate in Group I compared to Group II (23.5% vs 5.1%) (RR 4.6, 95% CI 1.04-20.1). No significant differences were observed between groups for infectious complications, mechanical complications, nonunion, or dehiscence. Reoperation was required significantly more often for Group I (P = .043). Conclusions: For MAFs involving the third molar, concomitant extraction of unerupted as well as retention of partially erupted third molars increases risk of complications with Champy fixation technique. For these patients, alternative strategies for fixation should be considered.

A Demographic Analysis of Craniomaxillofacial Trauma in the Era of COVID-19.

Study Design: Retrospective cohort study. Objective: The challenges of COVID-19 could magnify socioeconomic vulnerability for craniomaxillofacial (CMF) trauma. This study compares subjects who presented with CMF fractures to a regional healthcare system during the pandemic with those in 2019. We hypothesized societal circumstances of 2020 would correlate with disproportionately more CMF fractures in vulnerable patients compared to pre-pandemic trends. Methods: An IRB approved retrospective study of CMF fracture presentations in 2019 and 2020 was performed. Demographics, injury details, and management details were collected. A residence-based poverty index was calculated for each subject utilizing census data. Pre-pandemic and pandemic cases were compared to identify differences between cohorts. Results: A large decrease in presentations was noted between pre-pandemic and pandemic cohorts. There was significantly greater poverty the pre-pandemic cohort as compared to the pandemic cohort (P = .026). Overall, there was a significant correlation between higher poverty and violent MOI (P < .001). This association was maintained pre-pandemic, (P = .001) but was insignificant in the pandemic cohort (P = .108). Difference between cohorts with respect to violent injury was non-significant (P = .559) with non-significant difference in demographics including age (P = .390), place of injury (P = .136), employment status (P = .905), insurance status (P = .580), marital status (P = .711), ethnicity (P = .068), and gender (P = .656). Management was not significantly different between cohorts including percent hospital admission (P = .396), surgical intervention (P = .120), and time to operation (P = .109). Conclusions: Contrary to our hypothesis, this analysis indicates that the societal changes brought on by the COVID-19 pandemic did not magnify vulnerable populations. Some changes were noted including in volume of presentation, demographic distribution, and injury detail.

Amniotic Membrane Scaffolds Support Organized Muscle Regeneration in A Murine Volumetric Muscle Defect Model.

Current treatment for volumetric muscle loss is limited to muscle transfer or acellular collagen scaffold (ACS) therapies that are associated with donor site morbidity and nonfunctional fibrosis, respectively. The aim of this study is to assess the utility of amniotic membrane scaffold (AMS) for volumetric muscle loss treatment. Methods: Murine quadriceps defects were created and randomized to three groups (n = 5/group): untreated controls, ACS, and AMS. In vivo muscle regeneration volume was quantified by MRI and microcomputed tomography. Muscle explants were analyzed using standard histology and whole-mount immunofluorescence at 8 weeks. Results: The cross-sectional muscle regeneration ratio was 0.64 ± 0.3 for AMS, 0.48 ± 0.07 for ACS, and 0.4 0 ± 0.03 for controls as assessed by MRI (P = 0.09) and 0.61 ± 0.28 for AMS, 0.50 ± 0.06 for ACS, and 0.43 ± 0.04 for controls as assessed by microcomputed tomography (P = 0.2). Histologically, AMS demonstrated significantly higher cellular density (900 ± 2 70 nuclei/high powered field) than ACS (210 ± 36) and control (130 ± 4) groups (P = 0.05). Immunofluorescence for laminin (AMS 623 ± 11 versus ACS 339 ± 3 versus control 115 ± 7; P < 0.01) and myosin heavy chain (AMS 509 ± 7 versus ACS 288 ± 5 versus control 84 ± 5; P = 0.03) indicated greater organized muscle fiber formation with AMS. Conclusion: AMS mediated muscle healing was characterized by increased cellular infiltration and organized muscle formation when compared with controls and ACS.

Orbital Index: A Novel Comprehensive Quantitative Tool for Prediction of Delayed Enophthalmos in Orbital Floor Fracture Management.

SUMMARY: Early identification of surgical indication is critical to optimizing outcomes in orbital floor fracture management. However, identifying those at risk for delayed enophthalmos and requiring subsequent repair has remained a challenge. This study aimed to validate the Orbital Index, a prediction tool using computed tomography to stratify risk for delayed enophthalmos and establish a threshold for repair. The Orbital Index stratifies fractures by size, location, and inferior rectus rounding (a surrogate for fascioligamentous sling disruption) on a scale 0 to 6. A 22-year (1998 to 2020) multi-institution analysis of unilateral isolated orbital floor fractures was performed. Index scores were assigned to each scan, unoperated patients invited for blinded Hertel exophthalmometry assessment, and enophthalmos measurements correlated with Index scores. Interobserver scoring reproducibility was assessed with weighted Cohen kappa. Preintervention and postintervention Likert scale surveys were administered to determine whether this tool improved understanding and communication. The Orbital Index demonstrated high fidelity and interobserver reproducibility and identified a score of four or greater as a surgical threshold. Of 1769 computed tomography scans, 395 met criteria and were included for analysis. Eighty of 395 were managed operatively (operative rate, 20.3 percent). Of 315 patients managed nonoperatively, 41 (13.0 percent) agreed to follow-up evaluation and 28 (68.3 percent) were found to have enophthalmos. Unoperated patients with an Orbital Index score of 4 or higher were more likely to have enophthalmos than those with a score of 3 or less ( p = 0.001). The mean weighted Cohen kappa was 0.73, corroborating reproducibility. Communication ( p = 0.0003) and ability to correctly identify surgical need ( p = 0.01) were improved with use of this tool. The Orbital Index is a reproducible tool to stratify risk for enophthalmos in orbital floor fracture management.

Corneal Neurotization: A Meta-analysis of Outcomes and Patient Selection Factors.

BACKGROUND: Corneal neurotization describes reinnervation of the anesthetic or severely hypoesthetic cornea with a healthy local nerve or graft. Preliminary evidence has shown corneal neurotization to improve corneal sensation, visual acuity, and ocular surface health. Factors that improve patient selection and lead to better neurotization outcomes have yet to be elucidated, limiting ability to optimize perioperative decision-making guidelines. METHODS: A systematic review with meta-analysis was performed of the MEDLINE and Embase databases using variations of "corneal," "nerve transfer," "neurotization," and "neurotization." The primary outcomes of interest were corrected visual acuity, NK Mackie stage, and central corneal sensation. Regression analyses were performed to identify the effects of surgical technique, duration of denervation, patient age, and etiology of corneal pathology on neurotization outcomes. RESULTS: Seventeen studies were included. Corneal neurotization resulted in significant improvement in NK Mackie stage (0.84 vs 2.46, P < 0.001), visual acuity (logarithm of minimum angle of resolution scale: 0.98 vs 1.36, P < 0.001), and corneal sensation (44.5 vs 0.7, P < 0.001). Nerve grafting was associated with greater corneal sensation improvement than nerve transfer (47.7 ± 16.0 vs 35.4 ± 18.76, P = 0.03). Denervation duration was predictive of preneurotization visual acuity (logarithm of minimum angle of resolution scale; R2 = 0.25, P = 0.001), and older age (ß = 0.30, P = 0.03) and acquired etiology (ß = 0.30, P = 0.03) were predictive of improved visual acuity. CONCLUSIONS: Corneal neurotization provides significant clinical improvement in visual acuity, NK Mackie staging, and corneal sensation in patients who experience NK. Both nerve grafting and nerve transfer are likely to yield similar levels of benefit and ideally should be performed early to limit denervation time.

An age-related algorithm for management of micro-orbitism from anophthalmia: a systematic review with supplemental case reports.

Management of pediatric anophthalmia and resultant micro-orbitism is challenging. The efficacy and safety of treatment methods vary with age as bony changes grow recalcitrant to implants in those at skeletal maturity and osteotomies become technically challenging following frontal sinus pneumatization. This study aims to review methods for managing micro-orbitism and develop an age-based treatment approach. A systematic literature review was conducted. Data were screened and extracted by two investigators and relevant English-language primary-literature was analyzed. Information on sample-size, number of orbits, intervention, age, complications, and prosthetic retention was obtained. Representative case reports are presented, in addition. Nineteen studies met inclusion: 294 orbits in 266 patients were treated. Two studies reported distraction-osteogenesis. Two studies utilized bone grafting. Osteotomies were performed in 41 patients from three studies. Use of solid implants was detailed in two studies. Three studies described osmotic implant. Four studies described inflatable implants. Other techniques were described by three of the included studies, two of which utilized dermis-fat grafting. All but one study were observational case reports or case series. Across all studies regardless of surgical technique, risk of bias and heterogeneity was high due to attrition bias and selective outcomes-reporting. Selection of therapy should be tailored to skeletal-age to optimize outcomes; those 0-4 yrs are managed with dermis-fat grafts, 5-7 yrs managed with implants, and 8+ yrs managed with osteotomies. For those 8+ yrs with aerated frontal sinuses or insufficient bone stock, we propose onlay camouflage prosthetics which improve projection, increase orbital volume, and avoid risk for frontal sinus injury.

Orthoptic Vision Therapy: Establishing a Protocol for Management of Diplopia Following Orbital Fracture Repair.

INTRODUCTION: Persistent diplopia following orbital fracture is a well-recognized problem. While observation is the standard-of-care, symptoms may be protracted. Orthoptic vision therapy is a form of ocular physical therapy that achieves functional rehabilitation through targeted exercises. This study presents a protocol for post-traumatic orthoptics and describes preliminary results. MATERIALS AND METHODS: Protocols for home-therapy/office-assessment were developed using commercial software and exercises targeting motility and fusion. Office-assessment also included validated questionnaire chronicling symptomatology. Healthy-volunteers (n = 10) trailed the protocol three times (n = 30) and normative data was compiled. Comparative measurements were made in chronic (>1year; n = 8) and acute (<2 weeks; n = 4) fracture cohorts. Time-of-therapy was recorded, monetary cost-analysis performed, and side-effects assessed. RESULTS: Severe/moderate motility limitation was found in 3 of 4 acute fracture patients but not in chronic or healthy cohorts. The acute cohort had worse fusion when comparing convergence (mean break/recovery of 8.0/6.5 prism diopters (pd) versus 31.87/21.23pd; P = 0.001/0.015) and divergence (3.00/1.50pd versus 18.37/12.83pd; P = 0.000/0.001) to the healthy cohort. Those with chronic fracture had lower convergence (15.71/5.00pd; P = 0.01/0.001) and divergence (12.29/4.71pd; P = 0.04/0.002) when compared with healthy subjects, but better function than acute patients. Acute fracture patients reported greater symptomatology than chronic (mean score 18.8 versus 4.6; P = 0.003) or healthy (5.0; P = 0.02) groups, but there was no difference between chronic and healthy groups (P = 0.87). Assessment took <10 minutes. Per patient software cost was <$70. Mild eyestrain related to therapy was self-resolving in all cases. CONCLUSIONS: Orthoptic therapy may improve fusion and motility following orbital fracture. This protocol serves as basis for prospective work.

National Disparities in Insurance Coverage of Comprehensive Craniomaxillofacial Trauma Care.

Comprehensive craniomaxillofacial trauma care includes correcting functional deficits, addressing acquired deformities and appearance, and providing psychosocial support. The aim of this study was to characterize insurance coverage of surgical, medical, and psychosocial services indicated for longitudinal facial trauma care and highlight national discrepancies in policy. METHODS: A cross-sectional analysis of insurance coverage was performed for treatment of common functional, appearance, and psychosocial facial trauma sequelae. Policies were scored for coverage (3), case-by-case coverage (2), no mention (1), and exclusion (0). The sum of points determined coverage scores for functional sequelae, acquired-appearance sequelae, and psychosocial sequelae, the sum of which generated a Comprehensive Coverage Score. RESULTS: Medicaid earned lower comprehensive coverage scores and lower coverage scores for psychosocial sequelae than did private insurance (P = 0.02, P = 0.02). Medicaid CCSs were lowest in Oklahoma, Arkansas, and Missouri. Private insurance CCSs and psychosocial sequelae were highest in Colorado and Delaware, and lowest in Wisconsin. Coverage scores for functional sequelae and for acquired-appearance sequelae were similar for Medicaid and private policies. Medicaid coverage scores were higher in states that opted into Medicaid expansion (P = 0.04), states with Democrat governors (P = 0.02), states with mandated paid leave (P = 0.01), and states with >40% total population living >400% above federal poverty (P = 0.03). Medicaid comprehensive coverage scores and coverage scores for psychosocial sequelae were lower in southeastern states. Private insurance coverage scores for functional sequelae and for ASCSs were lower in the Midwest. CONCLUSIONS: Insurance disparities in comprehensive craniomaxillofacial care coverage exist, particularly for psychosocial services. The disparities correlate with current state-level geopolitics. There is a uniform need to address national and state-specific differences in coverage from both Medicaid and private insurance policies.

Standardized Schematics for Facial Trauma Planning: A Clinical Education Tool.

INTRODUCTION: Learning facial fracture management principles can be challenging for surgical trainees. Residents must assimilate nuances of fixation techniques, skeletal biomechanics, and hardware use while managing acute work-flow limitations. This study aims to design a standardized-schematic for teaching facial fracture management and evaluate its performance improving resident operative planning. METHODS: Printable schematics of the facial skeleton with soft-tissue overlay were developed. Instructions on depicting fracture pattern, incisions, plating sequence, loadbearing/sharing plates, locking/nonlocking screws, and mono/bicortical screws were given. Senior residents (n=5) evaluated computed tomography of 3 mandibular fractures and submitted 3 operative plans per case: first without guidance, then with written instruction, and finally using the schematic (n=45). Performance was graded on content and conceptual correctness. Data on time to completion was obtained. Likert-scale surveys assessing understanding, communication, and operative planning were given RESULTS:: Schematic use improved operative plan content and facilitated communication of resident operative schemes. Of 7 content domains spanning approach, plating strategy, and screw selection, a mean of 2.3, 3.7, and 6.5 were included with no guidance, written instruction, and schematic use respectively. Information on approach (P=0.001), plating type (P=0.02), screw location (P<0.000), screw depth (P=0.000), and screw locking status (P=0.000) were improved when comparing pre- and postintervention plans. Mean time to completion was 8 minutes and 54 seconds. All subjects "agreed" (n=2) or "strongly agreed" (n=3) that schematic use aided planning and communication. CONCLUSIONS: Simple, guided interventions can enhance surgical training by identifying knowledge gaps, improving visuospatial conceptualization, and facilitating targeted discussions with attendings.

Defining the Zygomaticosphenoidal Angle as a Guide to Anatomic Zygomaticomaxillary Complex Fracture Reduction.

BACKGROUND: Alignment of the zygomaticosphenoid suture is fundamental to reduction of zygomaticomaxillary complex fractures. To prevent a rotational deformity, the correct angle of the zygoma relative to the cranial base must be restored. Clinically, this can be a challenge, especially when there is comminution of the zygomaticosphenoid suture. Defining a zygomaticosphenoidal angle would provide a reference for use with stereotactic navigation to achieve anatomic reduction. METHODS: A single-center retrospective analysis of 100 patients was designed to determine normative zygomaticosphenoidal angle values. An angle subtended by the midline and a best-fit line through the zygomaticosphenoid suture on axial computed tomography was measured bilaterally in patients with isolated mandibular or nasal fractures. The mean of this measurement for 3 vertically adjacent cuts was calculated with position of central cut determined by the equator of the globe and trigone of the sphenoid. Multivariate regression was completed to identify changes in zygomaticosphenoidal angle with age, sex, and race. RESULTS: The mean zygomaticosphenoidal angle was 47° (range 39°-55°). 97% of angles were within 2 standard deviations (8°) of mean. Regression analysis demonstrated no significant change in angle with age (P = 0.74) or sex (P = 0.89). For each angle, the variation across the 3 sample cuts was ≤4.5°. Patients demonstrated high fidelity in zygomaticosphenoidal angle bilaterally with mean difference of 3°. CONCLUSION: The zygomaticosphenoidal angle is a useful reference, in conjunction with stereotactic navigation, for reduction of zygomaticomaxillary complex fractures. Contralaterally obtained patient-specific data may be used to guide unilateral repair. Normative values may serve as reference in bilateral injury.

Correction of Complex Neurofibromatosis Orbital and Globe Malposition Using the Orbital Box Segmentation Osteotomy With Patient-Specific Internal Orbit Reconstruction.

INTRODUCTION: Correction of severe orbital and globe malposition from neurofibromatosis remains a significant clinical challenge. Current techniques including zygoma osteotomy, bone grafting, or placement of orbital implants do not adequately address aberrant anatomy, under-correct the deformity, and are prone to relapse. The authors have developed the orbital box segmentation osteotomy to reduce vertical orbital height and translocate the orbit and use patient-specific custom internal orbital titanium implants to close the cranio-orbital communication-reestablishing both the external orbital shape and internal orbital volume. METHODS: Virtual surgical planning with contralateral mirror imaging was used to design symmetrical repositioning of the external orbit and to determine segmentation required to reduce the vertical excess and inferior rim malposition as well as for manufacturing patient-specific titanium implants. Orbital volume was measured from preoperative, virtual surgical simulation, and postoperative imaging using stereotactic software. Globe position was assessed using pre- and postoperative 3-dimensional photography software (Canfield). RESULTS: All patients (n = 3, mean age 12 years) demonstrated improved globe position and orbital contour with resolution of globe pulsatility. Virtual surgical planning predicted postoperative volumes within 0.8 cm ±â€Š0.5. Mean volume orbital change was 4.5 cm, change in conformation and distribution of orbital volume was present in all patients. Vertical globe position improved from 11.5 mm preoperatively to within 1 mm of the unaffected side postoperatively. One patient had surgical site infection, there is no evidence of relapse at mean 24-months follow-up. CONCLUSION: Segmental box osteotomy with internal orbital reconstruction redistributes orbital volume safely and accurately addresses globe malposition from neurofibromatosis.

Establishing a Protocol for Closed Treatment of Mandibular Condyle Fractures with Dynamic Elastic Therapy.

Treatment of mandibular condyle fractures is controversial. Open treatment achieves anatomic reduction with occlusal stability and faster functional recovery but risks facial nerve injury and jeopardizes joint capsule circulation which can lead to bone resorption. Traditional closed treatment avoids these issues but requires prolonged fixation and risks subsequent facial asymmetry, occlusal disturbance, and ankylosis. Rather than wires, closed treatment with elastics allows for customizable management of a healing fracture with ability to alter vector and degree of traction to restore vertical height and occlusion with less discomfort and decreased risk for ankylosis. In this protocol, unilateral condylar fractures were treated with class II elastics ipsilateral to injury and class I contralaterally. Class III elastics were used contralaterally if additional traction was required and Class II elastics were placed bilaterally for bilateral fractures. Patients were sequentially advanced from fixating to guiding to supportive elastics by titrating elastic vector to any dental midline incongruency or chin deviation. Six patients were treated with this protocol with six-month follow-up. Fracture patterns included displaced and dislocated fractures as well as intracapsular and extracapsular condylar fractures. All patients at completion of the protocol had objective centric occlusion with no subjective malocclusion, chin deviation, facial asymmetry, or temporomandibular joint pain. These early data demonstrate a safe and efficacious innovative protocol for closed treatment of mandibular condylar fractures with dynamic elastic therapy.

International Medical Graduates in the US Plastic Surgery Residency: Characteristics of Successful Applicants.

Objectives: Within the United States, plastic surgery is a difficult field to match into for both US and international medical graduates. While the number of available residency positions has grown in recent years, this has not been mirrored by an equal increase in the number of international medical graduates who match. Furthermore, there are few reliable resources to guide international medical graduates who are interested in matching into US-based programs, so the process is often even more difficult and unpredictable than for US applicants. Methods: An anonymous survey was distributed electronically to international medical graduates who successfully matched into independent and integrated US plastic surgery residency programs. The survey assessed qualities such as medical school performance, test scores, research experience, and other relevant applicant information, and χ2 analysis was done to compare the survey results for integrated and independent track international medical graduates. Results: International medical graduates who successfully match tend to rank high and score well in their medical school classes, score between 230 and 250 on USMLE step 1 and 2CK tests, and have a mean of 2 years of research experience before applying to the match. International medical graduates in the independent track tend to have higher step 1 scores, whereas international medical graduates in the integrated track tend to have more research experience and additional nonmedical degrees. Conclusions: This is a survey-based overview that describes the characteristics of successfully matched international medical graduates. Limitations of this study include the inability to identify and survey the unsuccessful applicants as well as poor response rate of the successful candidates in the independent pathway who successfully matched.