BMP-6 promotes type 2 immune response during enhancement of rat mandibular bone defect healing.

Introduction: Bone morphogenetic proteins (BMPs) are used as key therapeutic agents for the treatment of difficult fractures. While their effects on osteoprogenitors are known, little is known about their effects on the immune system. Methods: We used permutations of BMP-6 (B), vascular endothelial growth factor (V), and Hedgehog signaling pathway activator smoothened agonist (S), to treat a rat mandibular defect and investigated healing outcomes at week 8, in correlation with the cellular landscape of the immune cells in the fracture callus at week 2. Results: Maximum recruitment of immune cells to the fracture callus is known to occur at week 2. While the control, S, V, and VS groups remained as nonunions at week 8; all BMP-6 containing groups - B, BV, BS and BVS, showed near-complete to complete healing. This healing pattern was strongly associated with significantly higher ratios of CD4 T (CD45+CD3+CD4+) to putative CD8 T cells (CD45+CD3+CD4-), in groups treated with any permutation of BMP-6. Although, the numbers of putative M1 macrophages (CD45+CD3-CD11b/c+CD38high) were significantly lower in BMP-6 containing groups in comparison with S and VS groups, percentages of putative - Th1 cells or M1 macrophages (CD45+CD4+IFN-γ+) and putative - NK, NKT or cytotoxic CD8T cells (CD45+CD4-IFN-γ+) were similar in control and all treatment groups. Further interrogation revealed that the BMP-6 treatment promoted type 2 immune response by significantly increasing the numbers of CD45+CD3-CD11b/c+CD38low putative M2 macrophages, putative - Th2 cells or M2 macrophages (CD45+CD4+IL-4+) cells and putative - mast cells, eosinophils or basophils (CD45+CD4-IL-4+ cells). CD45- non-haematopoietic fractions of cells which encompass all known osteoprogenitor stem cells populations, were similar in control and treatment groups. Discussion: This study uncovers previously unidentified regulatory functions of BMP-6 and shows that BMP-6 enhances fracture healing by not only acting on osteoprogenitor stem cells but also by promoting type 2 immune response.

Correlating the Bony Facial Trauma Score with Clinical Outcomes.

Background: In 2017, the Bony Facial Trauma Score (BFTS) was developed to quantify and describe bony trauma of the face. Objective: To compare BFTSs for the need of hospital admission, intensive care unit (ICU) admission, surgery, tracheostomy tube placement, cervical spine (c-spine) injury, and mortality. Methods: A retrospective review of patients sustaining bony facial trauma from January 1, 2017 to November 30, 2019 was done. Logistic regression modeling measured the association between BFTS and admission status, need for operative repair, tracheostomy, mortality, ICU admission, and c-spine injury. Results: Three hundred six patients were included for this analysis. Median BFTS was 3.5 (interquartile range, 5), while the average age was 45.0 years (standard deviation, 22.3). The most common mechanisms of injury were motor vehicle accident (44.8%) and ground-level fall (32.5%). BFTS was found to correlate with the following (p < 0.05): admission (odds ratio [OR] 1.06, 95% confidence interval [CI] 1.01-1.13), mortality (OR 1.05, 1.00-1.10), tracheostomy (OR 1.11, 1.07-1.17), operative management (OR 1.16, 1.11-1.22), ICU (OR 1.07, 1.03-1.11), and c-spine injury (OR 1.05, 95% CI 1.03-1.11). Conclusion: A significant correlation was found between BFTS and all the outcomes investigated.

Do Postoperative Antibiotics Affect Outcomes in Mohs Reconstructive Surgery?

OBJECTIVES/HYPOTHESIS: The prescribing of postoperative antibiotics for patients undergoing Mohs reconstructive surgery has increased in the last decade, while antibiotic resistance has been increasing. We hypothesized that routine prescribing of postoperative antibiotics after Mohs reconstruction does not decrease the risk of surgical site infection. STUDY DESIGN: Retrospective, single-institution cohort study. METHODS: This study assessed patients who underwent Mohs reconstructive surgery from January 1, 2012, to January 29, 2019. The main outcomes assessed included postoperative surgical site infections, partial or full flap/graft necrosis, hematoma, and dehiscence. RESULTS: A total of 900 defects in 800 patients (mean age [range] = 65.3 [21-96], 54.60% female) were identified over the 7-year period. Patient-specific variables reviewed included comorbidities, age, and smoking status. Surgery-specific variables analyzed included defect characteristics, time interval between Mohs micrographic surgery and reconstruction, reconstructive modalities, and use of postoperative antibiotics. All patients received peri-incisional antibiotics. On regression analysis, use of cartilage grafts (odds ratio [OR]: 6.53; 95% CI: 2.1-20.6; P = .001), current smoking status (OR: 6.67; 95% CI: 2.09-21.30; P = .001), full-thickness defects (OR: 1.2; 95% CI: 1.0-3.4; P = .045), and interpolated flap reconstruction (OR: 3.4; 95% CI: 1.0-11.5; P = .049) were associated with an increased risk of postoperative infections. Smoking and cartilage grafting remained significant on bivariable regression modeling. Use of perioperative antibiotics was not associated with a decreased risk of infection (OR: 1.82; 95% CI: 0.23-14.21; P = .568). CONCLUSIONS: We found no association between postoperative infections after Mohs reconstructive surgery and the use of postoperative antibiotics. These data support a more targeted approach to antibiotic prescribing in Mohs reconstructive surgery. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E434-E439, 2021.

Development of a Patient-Reported Outcome Measure for Mohs Reconstruction.

Objective: There are currently no validated patient-reported outcome measures (PROMs) to specifically evaluate quality-of-life (QOL) outcomes for patients undergoing Mohs micrographic surgery (MMS) reconstruction. Therefore, the objective of this report was to develop a short PROM that can be used to evaluate the outcome after MMS reconstruction from the patient's perspective. Methods: Following established guidelines for PROM development, a comprehensive literature review, concept elicitation interviews (n = 25), and cognitive debriefing interviews (n = 5) were performed. These data were used to develop a preliminary survey to measure patient QOL throughout the MMS reconstruction process. Results: Participants identified many items from existing validated QOL instruments as being irrelevant to their situation, indicating that the sensitivity of existing instruments may be relatively low for patients undergoing MMS. There was significant overlap between what patients frequently identified and what expert physicians believed would be important in terms of factors that affect patient QOL throughout this process. Cognitive debriefing interviews indicated that the survey can be quickly and easily administered. Conclusions: Following accepted standards, we have created a 12-item disease- and treatment-specific QOL PROM for individuals undergoing the MMS reconstruction process. Given the prevalence of MMS, this PROM could be an important tool for clinicians to assess outcomes in future interventional studies aimed at minimizing morbidity and maximizing QOL for these skin cancer patients. Psychometric testing and validation of this newly developed PROM are currently underway.

Nasal Reconstruction: Defects that Cross Anatomical Subunits.

The nose plays a crucial role in the human experience, both aesthetically and functionally. The biomechanics of covering flaps, the importance of a firm framework, and the anatomical basis for aesthetic subunits are imperative concepts as one proceeds through the algorithm of reparative options. The subunits consist of three paired units-the ala, soft tissue facets (also known as soft tissue triangles), and sidewall, as well as three unpaired units-the dorsum, tip, and columella. Because many defects cross aesthetic subunits, it is critical to understand when to adapt the subunit principle and how or when to use a combination of techniques. It can be more challenging to apply the subunit principle to small grafts and local flaps of the nose. Convex subunits, such as the nasal tip and alar lobule, more frequently follow the subunit principle. In our practice, we adhere to a teaching of producing "straight lines and sharp corners." This applies to local flaps and grafts and focuses on keeping scar lines inconspicuous. In this article, we discuss approaches we follow for various defects along with technical pearls for performing these reconstructions. The subunit principle is more of a practice of thinking of resultant scars within a background of existing lines, reflections, and contour inflections.

Comparison of Outcomes of Early vs Delayed Graft Reconstruction of Mohs Micrographic Surgery Defects.

IMPORTANCE: Reconstructing Mohs defects often requires grafting in the form of full-thickness skin grafts (FTSGs) and composite grafts. These grafts can be complicated by a variable and often indeterminable survival rate. Other researchers have found that delaying FTSG reconstruction improves graft outcomes, but the optimal interval between excision and reconstruction remains unclear, and no study has examined the association between delaying composite graft reconstruction and graft survival. OBJECTIVE: To review the outcomes of Mohs micrographic surgery defect reconstruction using FTSG and composite grafts with respect to patient- and surgery-specific variables, particularly early vs delayed reconstruction. DESIGN, SETTING, AND PARTICIPANTS: This retrospective, single-institution cohort study assessed patients who underwent Mohs reconstructive surgery from January 1, 2012, to January 1, 2018. No patients had to be excluded for inadequate follow-up or incomplete medical records. Delayed reconstruction was defined as greater than 6 days after Mohs excision, the third quartile of the interval to reconstruction among our cohort. MAIN OUTCOMES AND MEASURES: Primary outcome was postoperative complications, including hematoma, infection, dehiscence, epidermolysis, and partial or full graft loss. RESULTS: A total of 320 defects were reconstructed with FTSG or composite grafts in 310 patients (median [range] age, 68 [21-96] years; 167 female [53.9%]) during the 6-year study period. The mean interval between the ablative and reconstructive operations was 4.73 days (range, 0-35 days). Univariate logistic regression was used to determine the significant indicators among patient and defect characteristics analyzed. A multivariate logistic regression model found delayed reconstruction to have a protective association (odds ratio, 0.52; 95% CI, 0.27-0.97; P = .046) and male sex to have a harmful association (odds ratio, 2.51; 95% CI, 1.52-4.20; P < .001) with postoperative complications. CONCLUSIONS AND RELEVANCE: This study found that delaying reconstruction in FTSGs and composite grafts was associated with decreased rates of postoperative complications, and male sex was associated with an increased risk of postoperative complications. The findings suggest that this strategy can be considered in patients at increased risk for developing postoperative complications, such as current smokers, patients with large defects, and patients who require use of composite grafts. LEVEL OF EVIDENCE: 3.

Assessment of Hedgehog Signaling Pathway Activation for Craniofacial Bone Regeneration in a Critical-Sized Rat Mandibular Defect.

IMPORTANCE: Osseous craniofacial defects are currently reconstructed with bone grafting, rigid fixation, free tissue transfer, and/or recombinant human bone morphogenetic protein 2. Although these treatment options often have good outcomes, they are associated with substantial morbidity, and many patients are not candidates for free tissue transfer. OBJECTIVE: To assess whether polysaccharide-based scaffold (PS) constructs that are cross-linked with smoothened agonist (SAG), vascular endothelial growth factor (VEGF), and bone morphogenetic protein 6 (BMP-6) would substantially increase bone regeneration. DESIGN, SETTING, AND PARTICIPANTS: This animal model study was conducted at the University of Virginia School of Medicine Cui Laboratory from March 1, 2017, to June 30, 2017. Thirty-three 10-week-old female Lewis rats were acquired for the study. Bilateral nonsegmental critical-sized defects were created in the angle of rat mandibles. The defects were either left untreated or filled with 1 of the 9 PSs. The rats were killed after 8 weeks, and bone regeneration was evaluated using microcomputed tomographic imaging and mechanical testing. Analysis of variance testing was used to compare the treatment groups. MAIN OUTCOMES AND MEASURES: Blinded analysis and computer analysis of the microcomputed tomographic images were used to assess bone regeneration. RESULTS: In the 33 female Lewis rats, minimal healing was observed in the untreated mandibles. Addition of SAG was associated with increases in bone regeneration and bone density in all treatment groups, and maximum bone healing was seen in the group with BMP-6, VEGF, and SAG cross-linked to PS. For each of the 5 no scaffold group vs BMP-6, VEGF, and SAG cross-linked to PS group comparisons, mean defect bone regeneration was 4.14% (95% CI, 0.94%-7.33%) vs 66.19% (95% CI, 54.47%-77.90%); mean bone volume, 14.52 mm3 (95% CI, 13.07-15.97 mm3) vs 20.87 mm3 (95% CI, 14.73- 27.01 mm3); mean bone surface, 68.97 mm2 (95% CI, 60.08-77.85 mm2) vs 96.77 mm2 (95% CI, 76.11-117.43 mm2); mean ratio of bone volume to total volume, 0.11 (95% CI, 0.10-0.11) vs 0.15 (95% CI, 0.10-0.19); and mean connectivity density 0.03 (95% CI, 0.02-0.05) vs 0.32 (95% CI, 0.25-0.38). On mechanical testing, mandibles with untreated defects broke with less force than control mandibles in which no defect was made, although this force did not reach statistical significance. No significant difference in force to fracture was observed among the treatment groups. CONCLUSIONS AND RELEVANCE: In this rat model study, activation of the hedgehog signaling pathway using smoothened agonist was associated with increased craniofacial bone regeneration compared with growth factors alone, including US Food and Drug Administration-approved recombinant human bone morphogenetic protein 2. Pharmaceuticals that target this pathway may offer a new reconstructive option for bony craniofacial defects as well as nonunion and delayed healing fractures. LEVEL OF EVIDENCE: NA.

Dog bite injuries to the face: Is there risk with breed ownership? A systematic review with meta-analysis.

INTRODUCTION: Dog bite injuries to the face are a serious, yet modifiable public health concern. This study explores the relationship between dog breed and the risk of biting and injury. The objective of this study is to determine the relative risk and severity of dog bite injuries to the face by breed. METHODS: Retrospective chart review of facial dog bite injuries presenting to the University of Virginia Health System and Nationwide Children's Hospital. Additionally, descriptive data was collected from 240 patients over the last 15 years. Bite risk by breed was assessed by a literature search from 1970 to current. A composite measure was used to determine the severity of injury, and characterize each patient into an ordinal scale of bite severity. An average of each breed bite rate within each study was calculated and combined to create an empiric bite risk by breed. Dog breeds were also further characterized morphologically. RESULTS: Bite risk by breed from the literature review and bite severity by breed from our case series were combined to create a total bite risk plot. Injuries from Pitbull's and mixed breed dogs were both more frequent and more severe. This data is well-suited for a bubble plot showing bite risk on the x-axis, bite severity on the y-axis, and size of the bubble by number of cases. This creates a "risk to own" graphic for potential dog owners. CONCLUSIONS: Breeds vary in both rates of biting and severity. The highest risk breeds had both a high rate of biting and caused significant tissue injury. Physical characteristics can also help determine risk for unknown or mixed dog breeds. Potential dog owners can utilize this data when assessing which breed to own.

A Facial Trauma Simulation Course for Evaluation and Treatment of Facial Fractures.

IMPORTANCE: Traditional facial trauma laboratories are used for teaching basic concepts of fracture reduction and hardware manipulation. Facial trauma simulation laboratories allow training physicians the opportunity to develop unique treatment plans as they would in real patient encounters. OBJECTIVE: To assess the value of a novel facial trauma simulation course requiring residents to practice advanced decision making. DESIGN, SETTING, AND PARTICIPANTS: Data were prospectively collected July 23 and August 23 and 24, 2016, in a survey study during a resident physician trauma simulation course. Fresh frozen cadaver heads were fractured using an impactor that applied a measurable amount of force. Each head was scanned with high-resolution computed tomography. Residents were paired and tasked with evaluating their specimen's imaging findings and developing a treatment plan. MAIN OUTCOMES AND MEASURES: Before the course, residents were asked their postgraduate year level, number of facial fractures treated as a resident surgeon, and their comfort level based on the Otolaryngology Milestone for Facial Trauma (OMFT; ratings range from 0-5, with 5 indicating equivalent to fellow-level experience). After the course, residents were asked to assess the course's value relative to a theoretical number of actual operative cases, and a posttraining OMFT assessment was obtained. RESULTS: Thirty resident physicians completed the course at 2 institutions. Residents represented an equivalent distribution of postgraduate year levels. The residents stated that the course was worth a mean (SD) of 6.4 (2.8) operative cases of facial trauma in terms of surgical learning. The mean change in self-reported OMFT rating after the course was 0.87 (95% CI, 0.67-1.07; P < .001, paired t test). On the basis of this change in self-perceived OMFT rating, the course was deemed to be worth 1.5 years of residency training in the management of facial fractures. CONCLUSION AND RELEVANCE: Conducting a facial trauma simulation course increases resident experience with advanced surgical decision making. LEVEL OF EVIDENCE: NA.

Classifying and Standardizing Panfacial Trauma With a New Bony Facial Trauma Score.

IMPORTANCE: The practice of facial trauma surgery would benefit from a useful quantitative scale that measures the extent of injury. OBJECTIVE: To develop a facial trauma scale that incorporates only reducible fractures and is able to be reliably communicated to health care professionals. DESIGN AND SETTING: A cadaveric tissue study was conducted from October 1 to 3, 2014. Ten cadaveric heads were subjected to various degrees of facial trauma by dropping a fixed mass onto each head. The heads were then imaged with fine-cut computed tomography. A Bony Facial Trauma Scale (BFTS) for grading facial trauma was developed based only on clinically relevant (reducible) fractures. The traumatized cadaveric heads were then scored using this scale as well as 3 existing scoring systems. Regression analysis was used to determine correlation between degree of incursion of the fixed mass on the cadaveric heads and trauma severity as rated by the scoring systems. Statistical analysis was performed to determine correlation of the scores obtained using the BFTS with those of the 3 existing scoring systems. Scores obtained using the BFTS were not correlated with dentition (95% CI, -0.087 to 1.053; P = .08; measured as absolute number of teeth) or age of the cadaveric donor (95% CI, -0.068 to 0.944; P = .08). MAIN OUTCOME MEASURES: Facial trauma scores. RESULTS: Among all 10 cadaveric specimens (9 male donors and 1 female donor; age range, 41-87 years; mean age, 57.2 years), the facial trauma scores obtained using the BFTS correlated with depth of penetration of the mass into the face (odds ratio, 4.071; 95% CI, 1.676-6.448) P = .007) when controlling for presence of dentition and age. The BFTS scores also correlated with scores obtained using 3 existing facial trauma models (Facial Fracture Severity Scale, rs = 0.920; Craniofacial Disruption Score, rs = 0.945; and ZS Score, rs = 0.902; P < .001 for all 3 models). In addition, the BFTS was found to have excellent interrater reliability (0.908; P = .001), which was similar to the interrater reliability of the other 3 tested trauma scales. Scores obtained using the BFTS were not correlated with dentition (odds ratio, .482; 95% CI, -0.087 to 1.053; P = .08; measured as absolute number of teeth) or age of the cadaveric donor (odds ratio, .436; 95% CI, -0.068 to 0.944; P = .08). CONCLUSIONS AND RELEVANCE: Facial trauma severity as measured by the BFTS correlated with depth of penetration of the fixed mass into the face. In this study, the BFTS was clinically relevant, had high fidelity in communicating the fractures sustained in facial trauma, and correlated well with previously validated models. LEVEL OF EVIDENCE: NA.

Regenerative Medicine in Facial Plastic and Reconstructive Surgery: A Review.

The field of regenerative medicine aims at enhancing tissue healing and regeneration through the exogenous addition of therapeutic growth factors and cells, often in combination with tissue-compatible scaffolds. Perhaps the biggest advances in facial plastic and reconstructive surgery (FPRS) in the coming years will be the result of regenerative medicine techniques. While many articles on regenerative medicine have been published in the FPRS literature, to our knowledge there are no reviews that describe both soft-tissue and bony regeneration strategies, including scaffolds, stem cells, growth factors, and platelet-rich plasma. In reviewing the literature, we found that these strategies have produced very promising results and that regenerative medicine has the potential to augment conventional treatment options in the FPRS subspecialty. In the near future, these novel approaches may begin to replace autologous grafting and free tissue transfer in FPRS, the current standards of care. In this review we look at where our subspecialty is today with regard to regenerative medicine and suggest ways for future study and growth.

Poly(lactic-co-glycolide) polymer constructs cross-linked with human BMP-6 and VEGF protein significantly enhance rat mandible defect repair.

We have previously shown that the combined delivery of mesenchymal stem cells (MSCs), vascular endothelial growth factor (VEGF) and bone morphogenetic protein 6 (BMP-6) induces significantly more bone formation than that induced by the delivery of any single factor or a combination of any two factors. We now determine whether the exogenous addition of VEGF and BMP-6 is sufficient for bone healing when MSCs are not provided. Poly(lactic-co-glycolic acid) (PLAGA) microsphere-based three-dimensional scaffolds (P) were fabricated by thermal sintering of PLAGA microspheres. The scaffolds were chemically cross-linked with 200 ng recombinant human VEGF (P(VEGF)) or BMP-6 (P(BMP-6)) or both (P(VEGF+BMP-6)) by the EDC-NHS-MES method. Release of the proteins from the scaffolds was detected for 21 days in vitro which confirmed their comparable potential to supply the proteins in vivo. The scaffolds were delivered to a critical-sized mandibular defect created in 32 Sprague Dawley rats. Significant bone regeneration was observed only in rats with P(VEGF+BMP-6) scaffolds at weeks 2, 8 and 12 as revealed by micro-computer tomography. Vascular ingrowth was higher in the P(VEGF+BMP-6) group as seen by microfil imaging than in other groups. Trichrome staining revealed that a soft callus formed in P(VEGF), P(BMP-6) and P(VEGF+BMP-6) but not in P. MSCs isolated from rat femurs displayed expression of the bone-specific marker osteocalcin when cultured with P(VEGF), P(BMP-6), or P(VEGF+BMP-6) but not with P. Robust mineralization and increased alkaline phosphatase gene expression were seen in rat MSCs when cultured on P(VEGF+BMP-6) but not on P, P(VEGF), or P(BMP-6). Thus, unlike the delivery of VEGF or BMP-6 alone, the combined delivery of VEGF and BMP-6 to the bone defect significantly enhanced bone repair through the enhancement of angiogenesis and the differentiation of endogenously recruited MSCs into the bone repair site.

Early Practice Focus: Evidence-Based Practice in Facial Plastic Surgery.

The practice of evidence-based medicine combines physician experience, knowledge of current literature, and patient preferences. Different grading systems are used to evaluate current levels of evidence and recommendations. A variety of common instruments are used to measure outcomes in facial plastic surgery. These instruments are used for expert data collection, including assessment of pathology and response to treatment, or for patient-reported outcome measures, including quality of life, disability, and daily function. Integration of data collection requires storage and protection of health information. We provide an outline to what is involved in understanding evidence-based medicine and incorporating it into daily practice.

Update in disease-specific quality-of-life studies in facial plastic surgery.

PURPOSE OF REVIEW: Improvements in the quality of life (QOL) of patients undergoing facial plastic and reconstructive surgery are readily apparent to any practitioner performing these procedures and interacting with these patients. However, proving these benefits objectively has become ever more important in the current practice environment and there has been a body of literature reported to address this need. RECENT FINDINGS: As techniques for facial reanimation, revision cleft surgery and other procedures are further developed and the tailored treatments of these ailments are honed, the body of literature for QOL improvements is growing. A better understanding of the nature of these disorders and the elements that are more impactful to patients has led to procedures that more specifically address these objectives and improve functional and psychological outcomes. SUMMARY: Interest in QOL data to support the interventions performed by facial plastic and reconstructive surgeons has and will continue to expand. The addition of QOL surveys to everyday practice, reporting of objective data in the literature and most importantly the focus of the practitioner on improving the patient's overall health and welfare are testaments to the tailoring of practice to not only address the functional and cosmetic goals but also the overall wellbeing.

Histopathologic margin distance in survival in resection of cutaneous melanoma of the head and neck.

OBJECTIVES/HYPOTHESIS: Treatment of cutaneous melanoma involves surgical excision with wide clinical margins. No guidelines regarding safe histopathologic margin distance exist. This study examines the impact of histopathologic margin, measured from closest cut edge of the specimen, on overall survival in resection of cutaneous melanoma of the head and neck. We hypothesize that close histopathologic margins (<2 mm) are associated with decreased survival. STUDY DESIGN: Retrospective chart review. METHODS: A total of 637 patients were treated for cutaneous melanoma of the head and neck between 2001 and 2011. Demographics, tumor characteristics, histopathologic margin distance (from a pathology database), and survival data from state health registries and health system clinical data repositories were used to create a dataset. Cox regression models and Kaplan-Meier curves were used to analyze data, adjusting for age, tumor location, ulceration, and depth of invasion (DOI). RESULTS: When analyzing for overall survival, Cox multivariate regression analysis showed age (hazard ratio [HR] = 1.0-1.1), DOI (HR = 1.2-1.5), ulceration (HR = 1.3-3.8), and subsite (ear, HR = 1.0-3.9) were significant predictors of survival. Histopathologic margin distance was not significant for predicting survival. Three percent of histopathologic margins were <1 mm. CONCLUSIONS: In a large dataset of head and neck cutaneous melanoma, known factors associated with overall survival (age, DOI, ulceration, subsite) proved significant, validating the dataset. Examining the effect of histopathologic margin distance on survival, while controlling for these factors, we failed to reject the null hypothesis. Margin distance as measured by histopathology does not affect survival. LEVEL OF EVIDENCE: 4.

Cost-based decision analysis of postreduction imaging in the management of mandibular fractures.

IMPORTANCE: Immediate postreduction imaging is a standard practice in the management of mandibular fractures at many hospitals. However, the literature suggests that postreduction imaging in maxillofacial fractures fails to influence clinical decision making significantly. OBJECTIVES: To determine the cost-effectiveness of different clinical decision pathways regarding postreduction imaging as it relates to the experience of the surgeon, and to demonstrate that baseline postreduction imaging has utility based on the complication rate of the surgeon. DESIGN, SETTING, AND PARTICIPANTS: We developed a decision tree model using commercially available software. The model accounted for cost of imaging modalities, adequacy of reduction, complication rate, cost of initial operating room time, and, if applicable, operative charges for revision surgery in the event of a complication. A review of the University of Virginia clinical data repository of 100 patients with recent mandible fractures was used to estimate the cost associated with running an operating suite for mandibular fracture repair. The University of Virginia billing system also provided costs associated with a single computed tomogram, panoramic radiography, and intraoperative 3-dimensional computed tomography. A sensitivity analysis determined how variation in complication rate affects the cost of the decision pathways. INTERVENTION: Intraoperative imaging, postreduction imaging, or no imaging. MAIN OUTCOMES AND MEASURES: Sensitivity of the decision tree model to variation in complication rate. RESULTS: Using current hospital charges, the model is sensitive to variability in the complication rate with a breakpoint of 17.7%. It is most cost-effective to obtain a post-reduction panorex if the surgeon's complication rate is above 17.7% and most cost-effective not to obtain any postreduction imaging if the complication rate is below 17.7%. Intraoperative computed tomography is not cost-effective at any complication rate. Two-way sensitivity analysis allowed the model to be generalizable to varied institutional costs and surgical complication rates. CONCLUSIONS AND RELEVANCE: The utility of postreduction imaging from the standpoint of cost analysis depends on the complication rate of the facial traumatologist and institutional charge data. Based on this model, the facial traumatologist at our institution should obtain postreduction panorex imaging for patients with mandible fractures until their complication rate drops below 17.7%. The 2-way sensitivity analysis in this study allows the facial traumatologist to apply his or her complication rate and institutional cost data to determine whether routine postreduction imaging is necessary. LEVEL OF EVIDENCE: NA.

Surgical perspectives in craniofacial trauma.

Knowledge of relevant anatomy and underlying mechanisms of traumatic injury is essential for understanding the radiologic findings in craniofacial trauma and their clinical importance. Craniofacial anatomy is diverse, and as a result of this anatomic diversity, physicians from numerous different specialties scrutinize similar imaging sets, looking for different pathologic abnormalities within the same anatomic regions. Radiologists familiar with the chief concerns of this anatomically diverse region can help expedite the decision-making process by keeping those concerns in mind when they report their findings. This review provides an overview of situations wherein surgical management may be indicated.