Bone-Anchored Maxillary Protraction for Adolescents with Cleft Palate and Class III Malocclusion: A Case Series.

To describe the long-term treatment course of bone-anchored maxillary protraction (BAMP) and evaluate orthognathic surgical indications after BAMP.Retrospective case series.Craniofacial/Cleft Palate Program at the Orthopaedic Institute for Children in Los Angeles, CA.Twelve male patients with cleft palate (CP), unilateral cleft lip and palate (UCLP), or bilateral cleft lip and palate (BCLP) and Class III malocclusion treated with BAMP (mean age: 11.4 ± 2.6 years) were included.BAMP treatment was performed by placement of bone-anchored maxillary and mandibular plates connected with intraoral Class III dental elastics or maxillary plates connected to a facemask.We retrospectively assessed BAMP treatment variables, including age at surgery, revision surgeries, and treatment duration. The primary goal was correction to class I occlusion.Twelve patients underwent BAMP treatment for an average of 4.4 ± 2.4 years. Two patients were corrected to class I occlusion at the time of this report. Le Fort I advancement was no longer required in two patients (16.7%), it was required for nine patients (75.0%) and was completed for one patient following BAMP treatment (8.3%).This preliminary report demonstrated that BAMP treatment may be associated with a minimal reduction in the requirement for Le Fort I advancement at skeletal maturity. Future studies with larger sample sizes are necessary to confirm this association.

Revisiting the Pericranial Flap for Scalp Reconstruction.

ABSTRACT: Soft tissue deficits of the scalp due to trauma, infection, or tumor resection present a unique challenge to the reconstructive surgeon whose goal is to achieve excellent cosmesis in a hair bearing area without compromising coverage. While extensive undermining for large rotation flaps or free tissue transfer can provide necessary coverage, the pericranial flap is an excellent alternative for less ideal surgical candidates who cannot tolerate more extensive interventions or for patients who require long-term cancer surveillance. Elevation of the pericranial flap limits the need for back cuts through the skin and uses blunt dissection to preserve overlying hair follicles. Here we present a review of the anatomy and historical use of the pericranial flap for scalp coverage and we present 4 cases to demonstrate its current utility.

Rolling With the Punches: A National Electronic Injury Surveillance System Database Study of Craniofacial Injuries in Boxing.

INTRODUCTION: Boxing is a popular combat sport in which competitors may sustain high impact blows to the face. For this reason, they are at high risk for craniofacial injuries; however, data on facial injuries specific to boxing remains sparse. Studies on safety measures, such as headgear, to prevent such injuries in boxing have been inconclusive. Boxing is popular with a wide audience. However, there is no consensus on safety measures across different populations involved in boxing due to lack of data. The objective of this study is to characterize the demography and incidence of injury types of patients presenting to emergency departments with boxing-related craniofacial injuries on a national scale in order to facilitate the establishment of evidence-based safety guidelines for prevention of boxing-related injuries. METHODS: The National Electronic Injury Surveillance System database was searched for boxing-related craniofacial injuries from the last 10 years (2010-2019). Injuries involving boxing were isolated and organized into 5-year age groups. Information on demographics and injury type was extracted from the National Electronic Injury Surveillance System database. Statistical analysis was performed between different age and gender groups. RESULTS: A total of 749 boxing-related craniofacial injuries treated in US emergency departments between 2010 and 2019 were recorded. The 19 to 34-year-old age group had the highest number of cases (54%), followed by the 12 to 18-year-old age group (31%). The most common injury types within both of these age groups were concussions and lacerations. This difference was found to be significant when compared to other craniofacial injury types (P < 0.05). The majority of athletes in these age groups were male (93% and 91%, respectively). Analysis of sex differences demonstrated concussions were more common in females compared to other injury types, whereas lacerations in males were more common compared to other injury types; these differences were found to be significant (P < 0.05). CONCLUSIONS: The high incidence of boxing-related craniofacial injuries such as concussions and lacerations incurred in young adults (19-34 years) and adolescents (12-18 years) indicate that protective measures such as community-based safety interventions and revised guidelines for protective equipment may be indicated in these groups to protect against craniofacial injuries such as lacerations and concussions. Further studies are required to develop algorithms for management of boxing-related craniofacial injuries and to evaluate the safety and efficacy of protective equipment such as boxing headgear on concussions.

The Oculocardiac Reflex: Its Evolution and Management.

INTRODUCTION: The oculocardiac reflex is initiated by a pressure stimulus to the orbit or periorbital structures causing in bradycardia transmitted via the trigeminal-vagus nerve reflex arc. While this most frequently occurs with ophthalmologic surgeries, trauma to the orbit and periorbital structures can result in bradycardia and even in some cases, asystole. The aim of this case report and review of the literature is to identify and examine recent studies of the oculocardiac reflex related to facial trauma and to identify associated patient age, symptoms, and fracture patterns. METHODS: A literature search was performed using the database within PubMed.gov using the term "oculocardiac." Results were reviewed for case reports or series related to facial trauma from the year 2000 to 2019. Studies were then evaluated for fracture pattern, presence of entrapment, patient symptoms, and age. RESULTS: The initial search resulted in 109 articles. A total of 22 articles were case reports or series of trauma patients. Twenty articles met inclusion criteria. Median age was 22 years. Eleven patients sustained orbital floor fractures. Four patients sustained medial wall fractures. Three patients had concomitant orbital floor and zygomatic fractures, and 4 with concomitant orbital floor and medial wall fractures. The most common extracardiac symptom experienced was nausea and vomiting (15/23) followed by diplopia (10/23). Status of entrapment was available in 20 patients of which entrapment was reported in fourteen (14/20). CLINICAL REPORT: A 26-year old male presents after blunt trauma to the face resulting in a left orbital floor, rim, and maxillary fractures. Extraocular movements were initially intact and the patient had no diplopia. He developed bradycardia to 30 to 40 bpm just prior to induction of anesthesia. He was found to have developed entrapment of the inferior rectus muscle. The orbital floor and rim were repaired with complete resolution of bradycardia. CONCLUSION: Patients who sustain maxillofacial trauma involving the orbit are at risk of developing the oculocardiac reflex. Patients tend to be younger. The orbital floor is more commonly the site of traumatic injury. Nausea and vomiting are common encountered symptoms. The oculocardiac reflex, clinicians must recognize, is not static but may evolve over a patient's clinical course as seen in our patient.

Primary selection of a pedicled rectus femoris flap for protection of aortic graft.

The rectus femoris pedicled muscle flap is a widely used option for coverage of infected vascular grafts in groin reconstruction as well as in reconstruction of abdominal wall defects. Here we present the case of primary placement of a pedicled rectus femoris flap to provide well-vascularized tissue interposed between an aortic Dacron interposition graft and bowel. This previously undescribed use of the rectus femoris proves to be an indispensable method when the more common alternatives, such as omental and rectus abdominis flaps, are not available.

Education on the Business of Plastic Surgery During Training: A Survey of Plastic Surgery Residents.

BACKGROUND: Entrepreneurial skills are important for physicians, especially plastic surgeons. Nevertheless, these skills are not typically emphasized during residency training. OBJECTIVE: Evaluate the extent of business training at plastic surgery residency programs as well as means of enhancing business training. METHODS: A 6-question online survey was sent to plastic surgery program directors for distribution to plastic surgery residents. Responses from residents at the PGY2 level and above were included for analysis. Tables were prepared to present survey results. RESULTS: Hundred and sixty-six residents including 147 PGY2 and above residents responded to our survey. Only 43.5% reported inclusion of business training in their plastic surgery residency. A majority of residents reported they do not expect on graduation to be prepared for the business aspects of plastic surgery. Additionally, a majority of residents feel establishment of a formal lecture series on the business of plastic surgery would be beneficial. CONCLUSIONS: Results from our survey indicate limited training at plastic surgery programs in necessary business skills. Plastic surgery residency programs should consider incorporating or enhancing elements of business training in their curriculum. LEVEL OF EVIDENCE V: 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Surgical Mission Trips as an Educational Opportunity for Medical Students.

Although much debate remains regarding the ethical obligations of surgeons who conduct mission trips in foreign countries, it seems certain from our experience that medical students who participate on such trips have invaluable educational opportunities. From patient care to resource allocation, medical students gain first-hand experience in relatively short periods. They develop skills of patient management along with an enhanced cultural sensitivity and sense of fiscal responsibility. With appropriate guidance and teaching, medical students gain experience that can positively influence their careers and shape their development into competent physicians.

Brachial plexus injury: treatment options and outcomes.

The brachial plexus is a series of nerves formed by roots of cervical segments 5 to 8 (C5-C8) as well as the first thoracic nerve (T1). It functions to provide sensation and motor innervation to the skin and muscles of the chest and upper limb. It does so through different segments: roots, trunks, divisions, and cords. Injuries to the brachial plexus occur relatively frequently and are due mainly to traumatic accidents that lead to traction or compression of the nerve roots. When considering the etiology and treatment of such injuries, it is important to make a distinction between adult versus obstetric brachial plexus injury. Although several surgical treatment options are described and used for patients with brachial plexus injury, no perfect remedy currently exists. Prevention and safety should be the focus. At the same time, high-quality studies and new technology and techniques are needed to determine more effective treatments for this group.

The current format and ongoing advances of medical education in the United States.

The objective of this study was to examine the current system of medical education along with the advances that are being made to support the demands of a changing health care system. American medical education must reform to anticipate the future needs of a changing health care system. Since the dramatic transformations to medical education that followed the publication of the Flexner report in 1910, medical education in the United States has largely remained unaltered. Today, the education of future physicians is undergoing modifications at all levels: premedical education, medical school, and residency training. Advances are being made with respect to curriculum design and content, standardized testing, and accreditation milestones. Fields such as plastic surgery are taking strides toward improving resident training as the next accreditation system is established. To promote more efficacious medical education, the American Medical Association has provided grants for innovations in education. Likewise, the Accreditation Council for Graduate Medical Education outlined 6 core competencies to standardize the educational goals of residency training. Such efforts are likely to improve the education of future physicians so that they are able to meet the future needs of American health care.

Congenital hand anomalies: etiology, classification, and treatment.

Congenital hand anomalies have a wide range of presentations and functional consequences. Understanding and treatment of these deformities require an understanding of embryology of upper-extremity development. In this report, common anomalies of the hand and upper extremity have been reviewed according to the International Federation for Societies for Surgery of the Hand classification system. We examine the epidemiology, etiology, functional consequences, and current treatments available for each anomaly.