The Top 100 Most-Cited Publications in Clinical Craniofacial Research.

INTRODUCTION: Craniosynostosis is a birth defect defined as premature closure of sutures leading to possible neurological deficits and cosmetic deformities. Most of the current literature to date focuses on craniosynostosis etiology by analyzing genetics. This paper is a bibliometric analysis of the most influential works related to the clinical management of craniosynostosis to help guide clinicians in their decision-making. METHODS AND MATERIALS: Clarivate Web of Science database was used to identify the top 100 most-cited articles addressing the clinical management of craniosynostosis. A bibliometric review was performed to analyze publication metrics and track research trends. RESULTS: The 100 most-cited publications pertaining to craniosynostosis management were cited a cumulative 12,779 times. The highest cited article was Shillito and colleagues' "Craniosynostosis: A Review Of 519 Surgical Patients" with 352 citations. The oldest clinical craniosynostosis article dates back to 1948, and the most recent was published in 2016. The year with the most clinical-focused publications was 2011. The most prolific author was Renier, D. The United States produced 56 of the 100 articles. Most articles (n=52) were level 3 evidence. DISCUSSION: This bibliometric evaluation of craniosynostosis provides insight into the most impactful literature on this topic. The highest cited articles retrospectively analyze large sample sizes, outline proper evaluation, discuss intervention timelines, and highlight specific treatment plans for this birth defect. By filtering through existing literature, this analysis can guide clinicians on the management of craniosynostosis to maximize patient outcomes.

Management of Maxillofacial Trauma in Pregnant Women.

INTRODUCTION: Trauma during pregnancy deserves special attention as management must be directed towards both the mother and the fetus. Management of maxillofacial fractures in pregnancy can adversely affect the well-being of the fetus by impinging on normal functions such as respiration, mastication, and nutrition. Pregnancy complicates the management of facial injury due to the maintenance of the patent airway, anesthesia considerations, and imaging restraints. The purpose of this study is to use three illustrative from our own institution to further elucidate education on the management of mandible fracture in pregnancy with a focus on multidisciplinary treatment and outcomes. METHODS: A retrospective chart review was performed for all cases of facial fractures admitted to Ryder Trauma Center from 2012 to 2022. During this time, 4,910 patients presented with facial fractures 1319 patients were female. Three of the patients were pregnant at the time of admission. Demographics, mechanism of injury, associated injuries, and management information were collected. RESULTS: Patient 1 was a 20-year-old female presented to Ryder Trauma Center following a motor vehicle collision. She was 17 weeks pregnant at the time of admission and was found to have a left mandibular angle fracture. Patient 2 was a 14-year-old female who presented to Ryder Trauma Center status post gunshot wound to the mandible after she and her brother were unknowingly playing with a loaded gun. She was 18 weeks pregnant at the time of admission, with a past medical history of domestic violence, suicidal ideation, and major depressive disorder. Patient 3 was a 20-year-old female 36 weeks pregnant at the time of admission. She presented with a right paraymphyseal fracture and left mandibular angle fracture as a result of falling on the stairs. Patients all underwent surgical repair of fractures.

Outcomes of Immediate versus Delayed Autologous Reconstruction in the Setting of Post-Mastectomy Radiation Therapy: A Meta-analysis.

INTRODUCTION: Post-mastectomy autologous breast reconstruction can be immediate (IBR) or delayed (DBR). The safety of performing IBR and the impact of radiation on the newly reconstructed breast is not yet validated. METHODS: A Pubmed, EMBASE, and Google scholar search was conducted from inception to September 17th 2023. We included comparative studies that assessed complications or aesthetic outcomes of IBR versus DBR in the setting of post-mastectomy radiotherapy (PMRT). RESULTS: The search identified 2693 articles. Thirteen were eligible for inclusion. A total of 565 patients underwent IBR followed by radiotherapy while 699 had DBR. Mean follow-up time and age for both groups were comparable (p > 0.1). None of revision surgery, infection, total flap failure, seroma, hematoma, dehiscence, or delayed wound healing was significantly different across groups (p > 0.1). IBR was found to have a higher risk of flap fibrosis (OR 28.18 [5.15 - 154.12]; p = 0.0001, I 2 of 44%) and skin flap necrosis (OR 6.12 [2.71 - 13.82]; p < 0.0001, I 2 of 27%) but a lower risk of partial flap failure (OR 0.18 [0.06 - 0.58]; p 0.004, I 2 of 0%) when compared to DBR. Results of fat necrosis should be interpreted with caution. Patient-reported as well as objective aesthetic outcomes were mostly comparable between groups. CONCLUSION: IBR in the setting of PMRT is increasingly being performed and poses a specific set of challenges that surgeons usually consider. The choice between IBR or DBR in the setting of PMRT should be an individualized decision based on patient risk factors and desires. LEVEL OF EVIDENCE: III.

Pain and Functional Outcomes following Targeted Muscle Reinnervation: A Systematic Review.

BACKGROUND: It is estimated that by 2050, a total of 3.6 million patients will be living with an amputation in the United States. The objective of this systematic review is to evaluate the effect of targeted muscle reinnervation (TMR) on pain and physical functioning in amputees. METHODS: A literature search was performed on PubMed, Embase, and MEDLINE up to November 28, 2021. Clinical studies assessing the outcomes of TMR (pain, prosthesis control, life quality, limb function, and disability) were included. RESULTS: Thirty-nine articles were included. The total number of patients who underwent TMR was 449, and 716 were controls. Mean follow-up was 25 months. A total of 309 (66%) lower-limb and 159 (34%) upper-limb amputations took place in the TMR group, the most common being below-knee amputations (39%). The control group included a total of 557 (84%) lower-limb and 108 (16%) upper-limb amputations; the greatest proportion being below-knee amputations in this group as well (54%). Trauma was the most common indication for amputation. Phantom limb pain scores were lower by 10.2 points for intensity ( P = 0.01), 4.67 points for behavior ( P = 0.01), and 8.9 points for interference ( P = 0.09). Similarly, residual limb pain measures were lower for cases for intensity, behavior, and interference, but they failed to reach significance. Neuroma symptoms occurred less frequently, and functional and prosthesis control outcomes improved following TMR. CONCLUSION: The literature evidence suggests that TMR is a promising therapy for improving pain, prosthesis use, and functional outcomes after limb amputation.

Unraveling the Enigma: A Rare Case of Recurrent Idiopathic Gynecomastia in an Adolescent.

Gynecomastia presents as abnormal hypertrophy of mammary tissue in males that is typically asymptomatic and usually does not require intervention. Gynecomastia responds well to medical and surgical treatment, when necessary, with low recurrence rates. The authors report an atypical case of recurrent idiopathic unilateral gynecomastia first presenting in an adolescent male. Physical examination, hormonal, and oncologic evaluations were normal. After subcutaneous mastectomy with liposuction and treatment with Tamoxifen at 19 years old, his unilateral gynecomastia recurred over the course of 3 years, requiring a second surgery. Furthermore, we review the literature for recurrent gynecomastia after surgical management to examine prevalence and risk factors.

The Impact of Florida Law HB21 on Opioid Prescribing Patterns After Outpatient Hand Surgery.

BACKGROUND: The purpose of this study is to evaluate the effects of Florida lae House Bill 21 (HB21) on opioid prescribing patterns by a single orthopedic hand surgeon after outpatient hand and upper extremity surgery. METHODS: The following variables were evaluated with retrospective chart review before and after implementation of HB21: type of opioid, number of pills, morphine milligram equivalents (MMEs), emergency department visits, and readmissions. In addition, the Florida Prescription Drug Monitoring Program (E-FORCSE [Electronic-Florida Online Reporting of Controlled Substance Evaluation]) was queried to determine the number of pills and MMEs prescribed and sold for the latter cohort. Student t tests, Fisher exact tests, and binary logistic regression were used for statistical analysis. P < .05 was considered significant. RESULTS: We reviewed 231 consecutive patients who underwent hand or upper extremity surgery from July 2017 to July 2018 and 207 consecutive patients from January 2020 to January 2021. The average age was significantly different between the cohorts (48.41 vs 44.98 years, P = .025); however, there were no significant differences across other demographic variables. After controlling for age, the average number of pills prescribed per patient decreased significantly after HB21 (25.11 vs 21.6 pills, P < .001). The number of MMEs prescribed per patient decreased as well, but the decrease was not statistically significant (167.8 vs 154.1 MMEs, P = .054). There was an association between preoperative opioid prescriptions filled and prolonged opioid use (odds ratio 6.438, P = .003). CONCLUSION: Florida law HB21 resulted in significantly fewer pills prescribed per patient, suggesting that legislation likely changed prescriber behavior and/or patient demand regarding postoperative opioid prescriptions after outpatient hand and upper extremity surgery.

Correlation Between Altmetric Scores and Citation Count in 4 High-Impact Plastic Surgery Journals.

BACKGROUND: The Altmetric Attention Score (AAS) aims to determine the impact of research articles throughout the internet and social media outlets. The AAS is a weighted average of the interaction on platforms including Twitter, Facebook, Reddit, and more. OBJECTIVES: The aim of this study was to investigate the relationship between the AAS and traditional bibliometrics across plastic surgery journals. METHODS: Articles, number of citations (NOC), and H-index information in Annals of Plastic Surgery (APS), Plastic and Reconstructive Surgery (PRS), Plastic and Reconstructive Surgery Global Open (PRS GO), and Aesthetic Surgery Journal (ASJ) from 2017, 2018, and 2019 were queried with the Scopus Online Tool. AAS metrics were collected with the Altmetric Score Calculator Bookmarklet. Descriptive statistics, Spearman rank-correlation analyses, and analyses of variance were performed to measure associations between NOC and AAS. RESULTS: A total of 3612 articles were analyzed. NOC was weakly correlated with AAS in APS, PRS GO, and ASJ, and moderately correlated with AAS in PRS. NOC was weakly correlated with Twitter mentions in APS, PRS GO, and ASJ, and moderately correlated in PRS. NOC was weakly correlated with news outlet reporting. The H-index of the first author showed more significant correlations with the AAS than the H-index of the last author. CONCLUSIONS: NOC and H-index of the first author correlated with AAS in the plastic surgery literature, suggesting AAS may be a useful adjunct to traditional bibliometrics when evaluating the impact and reach of peer-reviewed articles.

Diagnosis and Management of Craniofacial Osteomas.

IMPORTANCE: Osteoid osteomas are benign bony overgrowths that can occur in any region of the body. However, they have a predilection to occur in the craniofacial region. Because of the rarity of this entity, there is a lack of literature detailing the management and prognosis of craniofacial osteoid osteomas. OBSERVATIONS: Craniofacial osteomas have a predilection to involve the paranasal sinuses, but can also be found within the jaw, skull base, and facial bones. Because of their slow-growing nature, craniofacial osteomas are often incidentally discovered on routine imaging or after they compress nearby structures or distort nearby anatomy. Osteoid osteomas of the face can be treated with resection via various approaches. Recent advancements describe minimally invasive endoscopic techniques and adjuvant therapy with radiofrequency ablation guided by cone biopsy computed tomography. Osteoid osteomas have an excellent prognosis with complete resection. They demonstrate a low incidence of recurrence when compared with other osteoblastic lesions of the craniofacial structures. CONCLUSIONS AND RELEVANCE: Craniofacial osteoid osteomas remain a developing topic within the field of craniofacial surgery. Their removal may be trending toward minimally invasive techniques. However, all treatment modalities appear to result in improved cosmetic outcomes and low recurrence rates.

Do Plastic Surgery Residents Get Sued? An Analysis of Malpractice Lawsuits.

Trainees may be implicated in malpractice lawsuits. Our study examines malpractice cases involving plastic surgery trainees. Methods: Using the LexisNexis database, verdicts and settlements from appellate state and federal cases between February 1988 and 2020 were queried. A nonrepresentative sample of 300 cases was compiled. Results: During a 32-year period, 21 lawsuits involving plastic surgery trainees were identified. Of these, 14 (66.67%) involved claims when a trainee was directly named as a defendant. Eighteen (85.7%) cases were due to procedural-related adverse outcomes, while three (14.3%) cases were associated with clinical or diagnostic-related adverse outcomes. Of the procedure-related cases, five (27.8%) occurred when the trainee was the lead surgeon. Allegations included lack of informed consent of procedure complications (11, 52.4%), procedural error (11, 52.4%), failure to supervise trainee (11, 52.4%), inexperience of trainee (eight, 38.1%), incorrect diagnosis or treatment (five, 23.8%), delay in evaluation (three, 14.3%), lack of awareness of resident involvement (three, 14.3%), lack of follow-up (three, 14.3%), and prolonged operative time (one, 4.8%). Median time from injury to lawsuit resolution was 3.8 years [interquartile range (IQR), 3-5 years]. Verdicts were ruled in favor of the defense in eight (38.1%) cases and for plaintiff in six (28.6%) cases. A settlement was made in seven (33.3%) cases. Median payout for plaintiff-won cases was $5,100,000 (IQR, $1,530,000-$17,500,000); the median settlement was $2,500,000 (IQR, $262,500-$4,410,000). Conclusions: Procedural error, improper informed consent, improper trainee supervision, and resident inexperience were the most common allegations. These factors can lead to financial and psychological burdens early in a physician's career.

Trends in Female Representation at Plastic Surgery Meetings: A Move Toward Gender Equity at the Podium.

Anecdotally, female plastic surgeons are disproportionately underrepresented as speakers, moderators, and panelists at national and regional plastic surgery meetings. No studies have attempted to quantify female representation at Plastic Surgery The Meeting (PSTM). The objective of our study is to examine trends in female participation at PSTM. Names of participating plastic surgeons and their conference positions were obtained from PSTM meeting programs between 2015-2020. Conference positions included instructor, lead, lecturer, moderator, panelist, or other. Presentations were grouped as the following: conference/symposium; general session; instructional course; and lab. An automated gender assignment tool (gender-api.com) was used to determine the gender of participants. Descriptive statistics and trend analyses using Cochran-Armitage trend tests were performed. Between 2015-2020, 3,382 individuals (602 females, 17.8%) presented at PSTM in one of the instructional or moderating roles. Female presenters at PSTM increased from 60 (12.4%) in 2015, to 155 (26.5%) by 2020. The results for the proportion of females presenting in the general session and the instructional courses were statistically significant (p < .0001; p =.029), demonstrating a positive linear trend in the female proportions over the years. From 2015 to 2020, the proportions of females holding positions as moderators, panelists, and "other" increased significantly (p = .011; p = .011; p < .0001). Although female participation at PSTM has shown substantial growth over the last five years, there still exists a considerable gender imbalance. Notably, females were less likely to hold prominent positions, such as instructors, leads, or lecturers.

Facial Feminization Surgery: Part 1 of the Plastic Surgeon's Perspective of Gender-Affirming Surgery.

The perceived feminine face is distinctly unique from the perceived masculine face. Facial feminization surgery (FFS) includes a range of surgical procedures designed to change characteristically masculine facial features into feminine ones. FFS encompasses a set of bone and soft-tissue reconstructive procedures including, but not limited to, forehead contouring with or without frontal sinus setback, hairline adjustment, brow lift, rhinoplasty, lip lift, mandibular shaping, genioplasty, and "tracheal" shave, and fat grafting. Some patients choose to undergo one, all, or groupings of the procedures. The surgical decision is tailored to the individual and based on clinical opinion, patient desire, and insurance status or means to pay. FFS improves patient quality of life, has good general aesthetic outcomes, and improves feminine gender appearance (Morrison et al., 2020).

Plastic Surgery Training During Coronavirus Disease 2019 Pandemic: A Quantitative Study on Trainees' Wellness and Education.

PURPOSE: Coronavirus disease 2019 (COVID-19) pandemic has had far reaching impacts on all aspects of the healthcare system, including plastic surgery training. Due to reduction in the number of elective surgery cases and need for social distancing, plastic surgery education has shifted from the operating room to the virtual learning environment. Although these changes have been qualitatively described, the authors present a quantitative analysis of plastic surgery training changes due to the COVID-19 pandemic. Our study has identified residents' greatest impediments and inquired about suggestions for further improvements. Our goal is to help residency programs through the COVID-19 pandemic era and contribute to future guidelines when residency education encounters additional unexpected changes. METHODS: An institutional review board approved anonymous survey using Qualtrics was forwarded on April 23, 2020 to US plastic surgery program directors to be distributed to plastic surgery residents and fellows. Questions centered on the impact of COVID-19 on residents' well-being, education and career plans results were collected for data analysis. Residents were given the option to be in a raffle to win a $50 amazon gift card. Completion of the survey was both anonymous and voluntary. RESULTS: A total of 69 trainees responded (52 integrated residents and 17 independent fellows) from 18 states. Fifty-one percent were male and 49% were female. Fifty-six percent of trainees plan to complete a fellowship program after graduation, 31% will join private practice. Nine percent of trainees reported changes in their postgraduation plans due to the pandemic, 67% were senior trainees. Of those whose goals were affected by COVID-19 pandemic, 56% opted to pursue additional fellowship training. They described reduced operative exposure and cancelations of elective surgeries (50%), the limited availability of private practice jobs (37.5%), and financial reasons (12.5%) for their decision. Twelve percent reported being concerned about not meeting the necessary requirements to finish their residency and graduate on time. Seventy-six percent of trainees expressed concerns about the health and safety of themselves, family and loved ones. Forty-nine percent of trainees reported increased levels of stress since the onset of the pandemic. Ninety-seven percent of trainees reported having reduction in their operative time during the COVID-19 pandemic. They utilized their nonoperative time for online education modules (84%), educational readings (82%), and research (80%). Plastic surgery trainees learned about national webinars through emails from professional society (83%), co-resident/fellow (77%), program director emails (74%), and social media (22%). Webinars attended were mostly through virtual platform modalities, among which Zoom and Webex were the most preferred. Less interactions with colleagues and faculty was the biggest barrier to adopting virtual conferences. Despite this, 72% agreed that having grand rounds, didactics and journal clubs online increased attendance. Additionally, 88% of respondents expressed interests in attending professional society sponsored virtual grand rounds in the future. CONCLUSIONS: Results from our survey demonstrated that the overwhelming majority of plastic surgery residents have had reductions in operative times and widespread curriculum changes during the COVID-19 pandemic. These recent changes have increased residents' stress levels and adversity affected their future career plans. Additionally, COVID-19 has heralded an increase in virtual conferences and learning modules. Plastic surgery trainees expressed a preference for virtual educational platforms and interest in continuing virtual didactics in the future. This may irreversibly change the landscape of future plastic surgery training.

Reflecting on Plastic Surgery Training During Early COVID-19 Pandemic: Resident Exposure and Telemedicine.

PURPOSE: Coronavirus disease 2019 (COVID-19) pandemic has been an unprecedented public health crisis. As hospitals took measures to increase their capacity to manage COVID-19 patients, plastic surgeons have also had to modify their routine to continue serving their vital role within the hospital environment. In an effort to reduce exposure to COVID-19 and conserve hospital resources, many plastic surgery programs drastically modified call schedules, restructured inpatient teams, triaged operative cases, and expanded telemedicine encounters. Plastic surgery programs focused on craniofacial procedures were impacted by precautionary preventative protocol and shifts in case load made to protect both the healthcare teams and the patients. At academic centers, plastic surgery trainees of all domains felt the impact of these changes. Recognizing the implications on future craniofacial surgical practice, the pandemic has made, the goal of the authors' study is to measure initial impacts of COVID-19 on plastic surgery trainees using a nationwide survey. The authors' results present the first quantitative analysis of plastic surgery trainees' exposure to COVID-19, deployment to other medical specialties, usage of personal protective equipment, and implementation of telemedicine during the pandemic. While healthcare systems have greatly adapted to pandemic complications and can anticipate vaccination, resurgence of COVID-19 cases linked to the delta variant heightens the authors' urgency in understanding the early pandemic, and its lasting impacts on healthcare. In the months following pandemic onset, telemedicine has become a mainstay in healthcare, trainees have adapted and become integrated in patient care in novel ways, and visits unable to transition to telemedical settings received substantial attention to ensure patient and provider safety. METHODS: An institutional review board-approved anonymous, multiple-choice and short-answer, Qualtrics survey regarding plastic surgery resident experiences with COVID-19 exposure. It was sent to all US plastic surgery program directors and program coordinators on April 23, 2020 with the request to distribute the survey to their residents. Residents were given the option to participate in a raffle for a $50 gift card. Outcomes measured included demographics, exposure to COVID-19, availability of resources, and adjustments to residency training practices. RESULTS: Sixty-nine plastic surgery residents throughout all years of training from 18 states responded. Gender, year of training, and location did not significantly impact these reports.Sixteen percent of residents reported covering a COVID-19 team. Twelve percent reported covering a shift not within their scope of practice. From these reports, residents mostly worked in the intensive care unit (50%) and the emergency department (29%).Half of the residents believe they were exposed to high-risk patients. This was reported in a variety of settings: the emergency department for plastic surgery consults (34%), caring for plastic surgery inpatients (16%), performing trauma reconstruction surgery (16%), cancer reconstruction surgery (12%), elective surgery (6%), and intraoperative consults (6%).Seventy-two percent of residents reported adequate access to personal protective equipment. Equipment type varied by patient exposure. When attending to a non-COVID-19 inpatient, most residents used a standard mask (62%) rather than an N95 mask (21%). N95 masks were generally used in patients with unknown COVID-19 status. Residents reported using eye and face shields when attending to non-COVID-19 ICU patients (17%), patients with unknown COVID-19 status (27%), and in the operating room (34%).Forty percent of residents implemented telemedicine to see patients for new consults, follow-up visits, postop checks, and wound checks. Eighty-five percent of residents report that they would continue to incorporate telemedicine in the future. Most significant reported barrier to using telemedicine is the limited ability to perform a physical examination (33%) followed by limited patient access to telemedicine (21%). Other challenges included poor ease of use for patients or providers, billing questions, and lack of interpersonal connection with patients. CONCLUSION: This study, to the best of the authors' knowledge, is the first to quantitatively investigate how plastic surgery residents have been affected by the widespread impacts of the COVID-19 pandemic. It reports resident exposure to COVID-19 and their associated concerns, resident access to and perceived adequacy of personal protective equipment, as well as changes to clinical practice.

Correlation Between Altmetric Attention Scores and Citations for Articles Published in High-Impact Factor Ophthalmology Journals From 2018 to 2019.

Importance: The Altmetric attention score (AAS) provides new information to gauge the impact of a research article not found through typical metrics, such as impact factor or citation counts. Objective: To explore the association between AAS and common impact markers among high-impact ophthalmology journals from 2018 to 2019. Design, Setting, and Participants: All articles published in the American Journal of Ophthalmology (AJO), JAMA Ophthalmology (JAMAO), and Ophthalmology (OPH) from January 1, 2018, to December 31, 2019, were collected for this cross-sectional study. Excluded articles were those missing Altmetric data at the time of data collection. The AAS and associated social media impact for each article were collected with the AAS calculator bookmarklet. Spearman rank correlation analyses and analysis of variance tests were conducted to assess differences in various metrics between AJO, JAMAO, and OPH. The study included articles published of all document types (article, conference paper, editorial, erratum, letter, note, retracted, review, and short survey) and access status (open access and not open access). Main Outcomes and Measures: The correlation between citation counts and Altmetric variables including AAS. Results: A total of 2467 articles were published in the study period. There were 351 articles excluded owing to missing Altmetric data. Of the 2116 articles included in the analysis, 1039 (49.1%) were published in 2018, and 1077 (50.9%) were published in 2019; the mean number of citations was 8.8 (95% CI, 7.9-9.6) for AJO, 6.2 (95% CI, 5.3-7.1) for JAMAO, and 15.1 (95% CI, 13.3-17.0) for OPH. The mean AAS was 4.5 (95% CI, 3.3-5.6) for AJO (723 publications), 27.4 (95% CI, 22.1-32.8) for JAMAO (758 publications), and 15.1 (95% CI, 10.9-19.3) for OPH (635 publications). Citation rate was moderately correlated with AAS across the 3 journals (AJO, ρ = 0.39; P < .001; JAMAO, ρ = 0.41; P < .001; OPH, ρ = 0.40; P < .001), as well as minimally or moderately correlated with engagement or mention by Facebook posts (AJO, ρ = 0.38; P < .001; JAMAO, ρ = 0.24; P < .001; OPH, ρ = 0.20; P < .001), news outlet reporting (AJO, ρ = 0.12; P < .001; JAMAO, ρ = 0.38; P < .001; OPH, ρ = 0.19; P < .001), and Twitter posts (AJO, ρ = 0.40; P < .001; JAMAO, ρ = 0.38; P < .001; OPH, ρ = 0.42; P < .001). Conclusions and Relevance: Results of this cross-sectional study suggest that citation rate has a moderate positive correlation with online and social media sharing of research in ophthalmology literature. Peer-reviewed journals may increase their reach and impact by sharing their literature through social media and online platforms.

Traumatic Lower Extremity Vascular Injuries and Limb Salvage in a Civilian Urban Trauma Center.

BACKGROUND: Data on management of traumatic lower extreity arterial injuries comes largely from military experience and involves few civilian centers. This study reports on the experience of an urban trauma center and factors associated with limb loss. METHODS: A retrospective review of lower extremity arterial injuries between 2013 and 2020 at an academic urban level 1 trauma center was completed. Patients with lower extremity revascularization were included in the final data analysis. Demographics, clinical variables, operative details, type of revascularization, as well as 30-day morbidity and postoperative outcomes were analyzed. The primary outcome of interest was 30-day limb loss. Secondary outcomes included postoperative complications and functional outcomes. RESULTS: Seventy-five patients were included in our analysis. Sixty-nine were male (92%), mean age 33 ± 15 years, 50 patients had penetrating trauma (67%), mean injury severity score was 15 ± 9. Thirty-day limb loss was reported in 8 (11%). Factors associated with limb loss included female sex (P = 0.001), high body mass index (P = 0.001), blunt injury (P = 0.001), associated fractures (P = 0.005), significant soft tissue injury (P = 0.007), delayed repair after shunt placement (P = 0.003), bypass revascularization (P = 0.001), initial revascularization failure (P = 0.019), and wound complications (P < 0.001). Fifty-five patients had at least one return to the operating room (ROR), including 24 patients (32%) for complications related to their revascularization. These included delayed compartment syndrome (n = 7), revascularization failure (n = 9), bleeding (n = 3), and vascular surgical wound complications (n = 5). Mean length of hospital stay (LOS) for the cohort was 24 ± 20 days with 3 ± 3 ROR, in contrast patients who ultimately required amputation had LOS of 57 ± 21 days with 8 ± 4 ROR. Fifty-seven patients (76%) followed in clinic for a median 36 [14-110] days, with only 32 (43%) at >30 days. Twenty-three reported ambulation without assistance, 9 neuromotor deficit including 1 patient that had delayed amputation. CONCLUSION: Patients with blunt trauma and associated fracture and/or extensive soft tissue injury are at risk of limb loss. These injuries are often associated with postoperative wound complications, requiring aggressive soft tissue care that substantially increases ROR and LOS; Expectations for limb salvage in these patients should be tempered when the other associated factors with limb loss mentioned above are also present. When limb salvage is achieved, regaining full limb function remains a challenge.

Healing Adjuncts in Craniofacial Surgery: Review of Dietary Vitamins and Supplements.

BACKGROUND: In the United States, the use of herbal supplements on a regular basis ranges from 32% to 97%. Prevalence of supplement use is particularly elevated after facial surgery. It has been reported as high as 50%. Unfortunately, there is a paucity of literature on the dietary use of supplements. They are not regulated by the FDA. Often, they are not reported by patients. This study examines the role of dietary supplements as adjuncts to healing in craniofacial and facial aesthetic surgeries. METHODS: A comprehensive literature review was conducted using MEDLINE, PubMed, and EMBASE. Databases were screened for papers describing the use of supplements in craniofacial procedures in adult patients using relevant search terms. Data on criteria, outcomes, and patient satisfaction were collected. RESULTS: A total of 19 articles were selected from the 806 identified. Fifteen different supplements or combinations of supplements have been studied for use in facial surgeries. Of these 15 supplements, the following demonstrated potential healing benefits: dry ivy leaf extract, Nazalzem ointment (vitamin A and dexpanthenol), combination nasal sprays (phospholipids, fatty acids, vitamin A, and vitamin E), Saireito pills, topical olive oil, yunnan baiyao, melilotus extract, arnica, and combination arnica and ledum. Arnica is the most commonly studied supplement in a variety of facial operations. CONCLUSIONS: There is ample evidence to support a role for the use of certain dietary supplements to optimize wound healing in craniofacial and facial aesthetic surgery. Controlled diet and use of appropriate supplements may have a synergistic beneficial effect on wound healing following craniofacial surgery. However, there is a need for additional reporting to allow for the creation of stronger guidelines and increased patient screening, reporting, and compliance.

Acute upper limb ischemia as the first manifestation in a patient with COVID-19.

Coronavirus disease-19 (COVID-19) first emerged in December 2019 in China and rapidly spread worldwide. Although various studies have reported that COVID-19 is associated with a hypercoagulable state and thrombotic complications in critically ill patients, there are few case reports on thrombotic events as one of the presenting symptoms. We report a case of acute upper extremity ischemia as the initial clinical presentation of a patient with COVID-19.

Transaxillary decompression of thoracic outlet syndrome patients presenting with cervical ribs.

OBJECTIVE: The transaxillary approach to thoracic outlet decompression in the presence of cervical ribs offers the advantage of less manipulation of the brachial plexus and associated nerves. This may result in reduced incidence of perioperative complications, such as nerve injuries. Our objective was to report contemporary data for a series of patients with thoracic outlet syndrome (TOS) and cervical ribs managed through a transaxillary approach. METHODS: We reviewed a prospectively maintained database for all consecutive patients who underwent surgery for TOS and who had a cervical rib. Symptoms, preoperative evaluation, surgical details, complications, and postoperative outcomes form the basis of this report. RESULTS: Between 1997 and 2016, there were 818 patients who underwent 1154 procedures for TOS, including 873 rib resections. Of these, 56 patients underwent 70 resections for first and cervical ribs. Cervical ribs were classified according to the Society for Vascular Surgery reporting standards: 25 class 1, 17 class 2, 5 class 3, and 23 class 4. Presentations included neurogenic TOS in 49 patients and arterial TOS in 7. Operative time averaged 141 minutes, blood loss was 47 mL, and hospital stay averaged 2 days. No injuries to the brachial plexus, long thoracic, or thoracodorsal nerves were identified. One patient had partial phrenic nerve dysfunction that resolved. No hematomas, lymph leak, or early rehospitalizations occurred. Average follow-up was 591 days. Complete resolution or minimal symptoms were noted in 52 (92.8%) patients postoperatively. Significant residual symptoms requiring ongoing evaluation or pain management were noted in four (7.1%) at last follow-up. Somatic pain scores were reduced from 6.9 (preoperatively) to 1.3 (at last visit). Standardized evaluation using shortened Disabilities of the Arm, Shoulder, and Hand scores indicated improvement from 60.4 (preoperatively) to 31.3 (at last visit). CONCLUSIONS: This series of transaxillary cervical and first rib resections demonstrates excellent clinical outcomes with minimal morbidity. The presence of cervical ribs, a positive response to scalene muscle block, and abnormalities on electrodiagnostic testing are reliable indicators for surgery. A cervical rib in a patient with TOS suggests that there is excellent potential for improvement after first and cervical rib excision.