Are There Differences in Opioid Prescriptions to Urban and Rural Patients by Oral and Maxillofacial Surgeons in Massachusetts From 2011 to 2021?

PURPOSE: Oral-maxillofacial surgeons (OMSs) are frequent prescribers of opioid analgesics. It remains unclear if prescription patterns differ for urban versus rural patients, given potential differences in access to and delivery of care. This study aimed to characterize urban-rural differences in opioid analgesic prescriptions to patients in Massachusetts by OMSs from 2011 to 2021. METHODS: This retrospective cohort study used the Massachusetts Prescription Monitoring Program database to identify Schedule II and III opioid prescriptions by providers with specialty of oral and maxillofacial surgery from 2011 to 2021. The primary predictor variable was patient geography (urban/rural) and secondary predictor was year (2011-2021). The primary outcome variable was milligram morphine equivalent (MME) per prescription. Secondary outcome variables were days' supply per prescription and number of prescriptions received per patient. Descriptive and linear regression statistics were performed to analyze differences in prescriptions to urban and rural patients each year and throughout the study period. RESULTS: The study data, which includes OMS opioid prescriptions (n = 1,057,412) in Massachusetts from 2011 to 2021, ranged annually between 63,678 and 116,000 prescriptions to between 58,000 and 100,000 unique patients. The cohorts each year ranged between 48 and 56% female with mean ages between 37 and 44 years. There were no differences in the mean number of patients per provider in urban and rural populations in any year. The study sample had a large majority of urban patients (>98%). MME per prescription, days' supply per prescription, and prescriptions received per patient were all generally similar between urban and rural patients each year, with the largest MME per prescription difference in 2019 (87.3 for rural to 73.9 for urban patients, P < .01). From 2011 to 2021, all patients had a steady decrease in MME per prescription (ß = -6.64, 95% confidence interval: -6.81, -6.48; R2 = 0.39) and day's supply per prescription (ß = -0.1, 95% confidence interval: -0.1, -0.09; R2 = 0.37). CONCLUSION: In Massachusetts, there were similar opioid prescribing patterns by oral and maxillofacial surgeons to urban and rural patients from 2011 to 2021. There has also been a steady decrease in the duration and total dosage of opioid prescriptions to all patients. These results are consistent with multiple statewide policies over the last several years aimed at curbing opioid overprescribing.

What explains very poor Yelp reviews of oral and maxillofacial surgeons in private practice?

OBJECTIVE: Websites that maintain online physician ratings, such as Yelp.com, have been growing in popularity throughout the United States. The purpose of this study was to determine which factors increase the risk for very poor reviews (1 out of 5 stars) on Yelp.com for oral and maxillofacial surgeons (OMSs) in private practice. STUDY DESIGN: A retrospective cohort study was conducted using data on OMSs from Yelp.com. Predictor variables included clinician characteristics, practice characteristics, and review characteristics. The primary outcome variable was a very poor review. Logistic regression was used to determine risk factors for a very poor review. RESULTS: The final sample consisted of 3802 reviews. Relative to male clinicians, female clinicians were 2.7 times (P < .01) more likely to receive a very poor review. Clinicians who completed residency during the 1970s were over 4.5 times (P < .01) more likely to receive a very poor review relative to clinicians who completed residency during the 2010s. Relative to clinical reviews, nonclinical reviews were more likely (odds ratio = 2.6, P < .01) to be very poor and clinical and nonclinical reviews were less likely (odds ration = 0.5, P < .01) to be very poor. CONCLUSIONS: Nonclinical reviews were more likely to be very poor relative to clinical reviews. Several clinician factors, including female sex and completing OMS residency during the 1970s, were risk factors for receiving a very poor review.

Development of Competencies in Oral and Maxillofacial Surgery Training.

The goal of graduate surgical education is to ensure that the graduate is competent to practice in his or her chosen specialty. Traditionally, surgical learning has been based on an apprenticeship model; that is, the long-term observation and assessment of the trainee over a prolonged period of time. Patient expectations, work hour restrictions, and expectations of increased faculty oversight have led to decreased resident autonomy and independence. Graduates completing surgical training with less surgical autonomy may have lower clinical competence, which may affect patient safety, patient outcomes, and career satisfaction. This will require the modification of current assessment and training methods.

What are the Risk Factors for Mortality Among Patients Who Suffer Le Fort III Fractures?

PURPOSE: Le Fort III fractures are the most severe subtype of the Le Fort fractures and are associated with adverse clinical outcomes. The purpose of this study was to identify risk factors for mortality among patients who suffer Le Fort III fractures. MATERIALS AND METHODS: A retrospective cohort study was completed using the 2016-2018 National Inpatient Sample. Patients with isolated Le Fort III fractures were selected. Patients who incurred bone fractures or organ injuries outside the head and neck were excluded. There were multiple, heterogenous predictor variables. The primary outcome variable was mortality. Relative risk was used to determine independent risk factors of mortality. Statistical significance was deemed for P values less than .05. RESULTS: The final sample consisted of 559 patients (mean age, 45.9 years) who suffered a Le Fort III fracture, of whom 15 patients (2.68%) died. Most patients were male (82.7%) middle-aged adults (42.9%) of White race (66.5%) within the lowest income quartile (31.7%) that lived in large metro areas (54.9%). Relative to males, females were nearly 62 times more likely to die (P < .01). Relative to privately insured subjects, uninsured subjects were 23 times (P < .05) more likely to die. Relative to weekday admissions, weekend admissions increased the risk of mortality by 8 times (P < .05). Cranial vault fractures (odds ratio, 7.24; P < .05) and upper cervical fractures (odds ratio, 63.27; P < .05) were risk factors for mortality. Relative to males, females were at an increased risk for mortality (relative risk [RR] 7.14, 95% confidence interval [CI] 2.60, 19.61). Skull base fracture (RR 2.99, 95 CI 1.04, 8.63), cranial vault fracture (RR 3.04, 95 CI 1.07, 8.65), subdural hemorrhage (RR 2.98, 95 CI 1.10, 8.05), subarachnoid hemorrhage (RR 6.73, 95 CI 2.34, 19.35), and injury of blood vessels at neck level (RR 13.24, 95 CI 2.46, 71.16) were each risk factors for mortality. CONCLUSIONS: Intracranial injury was not a risk factor for mortality. Instead, cranial vault fractures and skull base fractures increased the risk for mortality. In addition, uninsured patients and female patients were each at an increased risk for mortality.

Evaluation of Accessibility and Content of Oral and Maxillofacial Surgery Fellowship Program Websites.

PURPOSE: Opportunities for graduating oral and maxillofacial surgery residents to pursue fellowship training are expanding. However, there is a paucity of information in the literature for prospective applicants in our specialty. The purpose of this study was to evaluate the accessibility and content of oral and maxillofacial surgery fellowship program websites (FPWs). METHODS: The authors designed a cross-sectional study including oral and maxillofacial surgery fellowship programs in North America listed on 4 major websites: 1) The American Association of Oral and Maxillofacial Surgeons, 2) The American Academy of Craniomaxillofacial Surgeons Match, 3) The American Dental Association, and 4) The American Academy of Cosmetic Surgery. The existence and accessibility of stand-alone FPWs from these listings were assessed. Content scores were generated based on the presence or absence of 23 content variables related to program characteristics, fellow recruitment, and fellow education on listings and available webpages. Descriptive and bivariate statistics were used to evaluate the relationship between predictor variables and content scores. RESULTS: A total of 44 fellowship programs were included. Of these fellowships, 26 (59.1%) had a stand-alone FPW. The mean content score was 10.8 ± 4.82 out of a maximum of 23. Content scores were significantly greater for head and neck oncology fellowships (P ≤ .001), programs with a stand-alone FPW (P ≤ .001), and Commission on Dental Accreditation-accredited programs (P = .046). Programs with a stand-alone FPW had content scores 1.87 times greater than those without and was the predictor variable with the greatest mean difference between groups. There was no significant difference in content scores with respect to geographic region. CONCLUSIONS: Oral and maxillofacial surgery FPWs demonstrate deficiencies in content areas relevant to prospective applicants. Optimizing the content of FPWs may represent an opportunity to better inform and recruit graduating residents into fellowship programs.

Do Patterns of Opioid Prescriptions to Medicare Beneficiaries Differ Between Oral and Maxillofacial Surgeons Practicing in Urban and Rural Settings?

PURPOSE: This study compared opioid prescription patterns among oral and maxillofacial surgeons (OMSs) treating Medicare beneficiaries in urban and rural settings, in an effort to identify avenues to further promote responsible opioid prescribing in a patient demographic vulnerable to opioid diversion. MATERIALS AND METHODS: This study used Medicare Provider Utilization and Payment Data from 2014 to 2018, focusing on providers labeled as an OMS. Rural-urban commuting area codes were used to categorize each OMS as urban or rural. The demographic variables included total number of OMSs, provider gender, beneficiaries per provider, beneficiaries' age, and beneficiary hierarchal condition category (proxy for clinical complexity). The outcome variables included opioid prescribing rate, opioid claims per provider, opioid claims per beneficiary, and number of days' supply of opioids per claim. Descriptive statistics, χ2 tests, 2-tailed t tests, and Wilcoxon rank-sum tests were used as appropriate. RESULTS: Across all years, the data consisted of mostly urban and male OMSs. The mean number of Medicare beneficiaries prescribed opioids per OMS varied widely, and the mean age of beneficiaries was 70.4 ± 4.4 and 69.9 ± 4.1 years for urban and rural OMSs, respectively. Mean opioid claims per provider were higher among rural OMSs, with large standard deviations among both rural and urban OMSs. However, there were no significant differences in the opioid prescribing rate or in the mean opioid claims per beneficiary in all 5 years included in the study. There were also no clinically significant differences between urban and rural OMSs in the number of days' supply per claim (between 3 and 4 days in all periods). However, in each year, there was a significantly higher proportion of urban OMSs who prescribed more than 7 days' supply per claim. CONCLUSIONS: Opioid prescription practices were generally similar between rural and urban OMSs treating Medicare beneficiaries. The small subset of longer-term opioid prescribers, which were more prevalent in urban areas, warrants further investigation.

Algorithmic Approach to Antibiotic Prophylaxis for Traumatic Craniomaxillofacial Injuries.

ABSTRACT: Prophylactic antibiotics are commonly used in the management of traumatic injuries to the maxillofacial complex, yet there are no set guidelines for when and when not to prescribe. The purpose of this review is to present the evidence for antibiotic prophylaxis in different clinical scenarios and to propose algorithms to facilitate the decision making process with the ultimate goal of improving antibiotic prescribing practices. A number of databases were searched using a wide range of keywords to ensure the topic was fully encapsulated. The review is divided into 3 sections: soft tissue trauma, maxillofacial fractures, and ballistic injuries. The algorithms were constructed using the current evidence as well as pathophysiologic principles, especially when there were insufficient studies. This review found the literature on antibiotic prophylaxis to be highly varied and not standardized. Creating an algorithm for providers to follow will help to set a standard of care and decrease the misuse of antibiotics.

Is Outpatient Management of Mandibular Fractures Associated With Inflammatory Complications? An ACS-NSQIP Study.

PURPOSE: Timing of mandibular fracture repair has long been debated. The purpose of the present study was to assess the incidence of postoperative inflammatory complications (POICs) following open repair of mandibular fractures managed non-urgently in the outpatient setting versus urgently in the inpatient setting. METHODS: The authors utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to enroll a sample of patients with mandibular fractures who underwent open repair. The primary independent variable was treatment protocol: outpatient (elective) versus inpatient (urgent/non-elective). The primary dependent variable was POIC (yes/no). Descriptive, bivariate, and multiple logistic regression statistics were utilized to evaluate the relationship between treatment protocol and POICs. RESULTS: The study cohort was comprised of 1,848 subjects with 1,134 outpatients and 714 inpatients. The incidence of POICs was 6.53% for the outpatient group compared to 8.96% for the inpatient group, with no significant difference between groups (P= .052). However, subjects treated as inpatients were 1.51 times more likely to experience any complication (P = .008) due to an increase in non-POICs (P = .028), in particular urinary tract infections (P = .035). After adjusting for age, hypertension requiring medical treatment, and smoking, classification as ASA II (P = .046, OR = 2.21, 95% CI 1.01 to 4.83), ASA III (P = .020, OR = 2.88, 95% CI 1.18 to 7.02), diabetes (P = 0.004, OR = 3.11, 95% CI 1.43 to 6.74), and preoperative hematocrit (P = 0.010, OR = 0.950, 95% CI 0.913 to 0.988) were independent predictors of POICs. Length of stay was 0.83 ± 2.61 days compared to 2.36 ± 3.63 days for the outpatient and inpatient groups, respectively (P ≤ .001). CONCLUSIONS: There was no significant difference in POICs between patients treated as outpatients versus inpatients, though outpatients had fewer non-POICs and a shorter length of hospital stay.

How Do Oral and Maxillofacial Surgery Residency Program Directors Feel About Their Graduating Residents' Level of Competence?

PURPOSE: The purpose of this study was to assess program directors' impressions of how competent graduating residents are in practicing the full scope of the specialty. The investigators hypothesized that program directors' impressions of their graduating residents' ability to practice the full scope of oral and maxillofacial surgery would fall within Laskin's suggested levels. MATERIALS AND METHODS: The investigators implemented a cross-sectional study. A questionnaire was designed and a link to a Partners REDCap (Nashville, TN) survey was e-mailed to 101 oral-maxillofacial surgery program directors. The questionnaire included demographics, and program director's perceived level of preparedness, level of proficiency, comfort, and experience of their graduating residents (July 2018). RESULTS: The response rate was 34.7%. Analyses included univariate statistics and a Wilcoxon signed-rank test. Significance was set at P < .05. There was no significant difference between orthognathic surgery and each discipline in the area of expertise category, and in some cases, a significantly higher perception of training in orthognathic surgery (P < .05). There was a significantly lower perception of training in oral medicine than each discipline in area of expertise (P < .05), suggesting a deficit in oral medicine training. CONCLUSIONS: Using our analyses, program directors believed that the chief residents training in orthognathic surgery was at the level of expertise. Furthermore, 97% of respondents considered orthognathic surgery an area of expertise, suggesting that training at that level is necessary. Our results show that program directors' impressions of their graduates' competence fall within the levels suggested by Laskin.

What Factors Are Associated With Open Treatment of Pediatric Mandibular Fractures?

PURPOSE: There is a paucity of data with respect to management of pediatric facial fractures. The purpose of this study was to describe the population of pediatric patients with mandibular fractures at our institution and to assess predictors of fractures requiring open reduction and internal fixation (ORIF). PATIENTS AND METHODS: This was a retrospective cohort study of patients aged ≤17 years presenting with mandibular fractures. The primary predictor variable was age ≥13 years and <13 years. The primary outcome variable was ORIF (yes or no). Epidemiologic factors and complications were also assessed. Descriptive, bivariate, and multiple logistic regression statistics were computed to measure the association between predictor variables and ORIF. RESULTS: The study sample was composed of 84 subjects with 61 subjects aged ≥13 years and 23 subjects aged <13 years. ORIF was used for 21.4% of subjects. Increased age was associated with ORIF (P = .009). After adjusting for the effects of concurrent variables, age (P = .047, OR = 2.30, 95% CI = 1.01 to 5.24), fracture displacement between 2 and 4 mm (P = .032, OR = 18.1, 95% CI = 1.29 to 254), fracture displacement >4 mm (P = .019, OR = 16.9, 95% CI = 1.60 to 179), and the presence of 3 fractures (P = .027, OR = 30.8, 95% CI = 0.001 to 0.641) were positive independent predictors of ORIF. Concomitant facial, skull, or skull base fractures (P = .039, OR = 0.027, 95% CI = 0.001 to 0.641) were a negative independent predictor of ORIF. Secondarily, both mechanism of injury and fracture location varied significantly by age and gender. Complication rate was 6.33%. CONCLUSIONS: Most pediatric mandibular fractures were managed nonoperatively. Increased age, fracture displacement, presence of 3 fractures, and concomitant craniofacial injuries were independent predictors of ORIF. Complication rates were low regardless of treatment modality.

Do Graduating Oral-Maxillofacial Surgery Residents Feel Confident in Practicing the Full Scope of the Specialty?

PURPOSE: Laskin (2008) suggested that the core of oral and maxillofacial surgery could be divided into 3 levels: 1) areas of expertise, such as oral pathology, oral medicine, dentoalveolar surgery, preprosthetic surgery, and maxillofacial traumatology; 2) areas of competence, including orthognathic surgery, temporomandibular joint surgery, and local reconstructive surgery; and 3) areas of familiarity that include cleft lip and palate surgery, craniofacial surgery, regional reconstructive surgery, oncologic surgery, and cosmetic surgery. The purpose of this study is to assess residents' confidence in practicing the full scope of oral-maxillofacial surgery and their perception of gaps existing in their training. The investigators hypothesized that graduating residents' confidence in practicing the full scope of oral-maxillofacial surgery falls within the suggested levels by Laskin. METHODS: The investigators implemented a cross-sectional study. A questionnaire was designed, and a link to a Partners REDCap (Nashville, TN) survey was electronically mailed to 252 chief residents in the final month (July 2018) of their program. The questionnaire included resident demographic characteristics, program demographic characteristics, and residents' perceived preparedness, level of proficiency, comfort, and experience for each area. RESULTS: The sample was composed of 78 graduating residents, with a response rate of 31%. Analyses included univariate statistics and a Wilcoxon signed rank test. Significance was set at P < .05. There was no significant difference between orthognathic surgery and each area in the expertise category, and in some cases, a significantly higher perception of ability in orthognathic surgery (P < .05). There was a significantly lower perception of training in oral medicine than each area in the expertise category (P < .05), suggesting a deficit in oral medicine training. CONCLUSIONS: Residents perceived that their training in orthognathic surgery was at the level of expertise, higher than expected. They also perceived a training deficit in oral medicine. Training proficiency in dentoalveolar surgery was found to be at a level higher than any other area.

Masks or N95 Respirators During COVID-19 Pandemic-Which One Should I Wear?

PURPOSE: Coronavirus Disease 2019 (COVID-19) has caused suffering and death around the world. Careful selection of facial protection is paramount for preventing virus spread among healthcare workers and preserving mask and N95 respirator supplies. METHODS: This paper is a comprehensive review of literature written in English and available on Pubmed comparing the risk of viral respiratory infections when wearing masks and N95 respirators. Current international oral and maxillofacial surgery guidelines for mask and N95 respirator use, patient COVID-19 disease status, aerosol producing procedures were also collected and incorporated into a workflow for selecting appropriate facial protection for oral and maxillofacial surgery procedures during the current pandemic. RESULTS: Most studies suggest N95 respirators and masks are equally protective against respiratory viruses. Some evidence favors N95 respirators, which are preferred for high-risk procedures when aerosol production is likely or when the COVID-19 status of a patient is positive or unknown. N95 respirators may also be used for multiple patients or reused depending on the type of procedure and condition of the respirator after each patient encounter. CONCLUSION: N95 respirators are preferred over masks against viral respiratory pathogens, especially during aerosol-generating procedures or when a patient's COVID-19 status is positive or unknown.

Can Patients With Isolated Mandibular Fractures Be Treated as Outpatients?

PURPOSE: Treating mandibular fractures urgently is controversial. The purpose of this study was to estimate and compare the rates of postoperative inflammatory complications (POICs) in patients with isolated mandibular fractures treated in a nonurgent manner by an outpatient protocol versus a traditional, urgent inpatient protocol. PATIENTS AND METHODS: We implemented a retrospective cohort study and enrolled a sample of patients with isolated mandibular fractures treated with open reduction-internal fixation (ORIF). The primary predictor variable was the treatment protocol: outpatient (elective) or inpatient (urgent). The outpatient group was treated with closed reduction and intermaxillary fixation, discharged, and scheduled for definitive treatment as outpatients. The inpatient group was admitted to the hospital, and the fracture was treated with ORIF as soon as possible. The primary outcome variable was POIC (present or absent). Descriptive, bivariate, and multiple logistic regression statistics were computed to measure the association between the treatment protocol and POICs, with statistical significance set at P < .05. RESULTS: The study sample was composed of 193 patients, with 82 in the outpatient group and 111 in the inpatient group. The frequency of POICs was 17.1% and 18.9% in the outpatient and inpatient groups, respectively (P = .13; relative risk, 0.80; 95% confidence interval [CI], 0.62 to 1.0). The time to ORIF was not significantly associated with POICs (P = .71). After adjustment for treatment group, fracture location, and time to fracture stabilization, smoking (P = .04, odds ratio, 2.3; 95% CI, 1.0 to 5.1) and intraoral incision with a transbuccal trocar (P = .02, odds ratio, 3.4; 95% CI, 1.2 to 9.8) were associated with an increased risk of POICs. Length of stay was 0.6 ± 0.8 days in the outpatient group compared with 2.7 ± 2.0 days in the inpatient group (P < .0001). CONCLUSIONS: An outpatient model to treat isolated mandibular fractures was not associated with an increased risk of POICs. This outpatient care model reduced the hospital length of stay without increasing the risk of POICs.

Mandibular Intraosseous Angiofibroma-A Rare Clinical Entity.

Angiofibromas located in the maxillofacial region are rare and almost exclusively occur in adolescent males. These benign tumors are highly vascular, locally invasive, and commonly found in the nasopharyngeal space. In the present report, we describe a very rare case of an intraosseous mandibular angiofibroma in a 23-year-old male patient with histomorphologic and molecular confirmation. This type of tumor occurring in the mandible has been reported previously only once, to the best of our knowledge.

Are Industry Payments Associated With the Level of Evidence in Oral and Maxillofacial Surgery?

PURPOSE: The purpose of the present study was to determine whether the industry payments in oral and maxillofacial surgery (OMS) are associated with a study's level of evidence (LOE). MATERIALS AND METHODS: A retrospective cohort study was designed and implemented to query the Journal of Oral and Maxillofacial Surgery from 2002 to 2016. The primary predictor variables were the presence of a self-reported conflict of interest (COI) and the type of COI. The outcome variable was the LOE. The secondary outcome variables investigated were the topic of the study and the inclusion of trainees. The inclusion criteria entailed contributions from domestic academic OMS training programs. Disclosure of the COIs and type of COI, the LOE, topic of the study, and inclusion of trainees were recorded for every report from January 2002 until December 2016. Descriptive statistics were calculated, and χ2 tests were performed to determine a significant relationship primarily between the COIs and LOE. RESULTS: The sample included 1455 reports, and 4.2% of the sample size had disclosed a COI. The studies that disclosed industry payments demonstrated a significant positive correlation with the LOE (P < .01), especially for cohort studies. Also, the type of COI was significantly associated with the LOE (P < .05). Industry payments were not shown to be significantly related statistically to topic of the study (P = .16); however, the stock-related payments were associated with the topic (P < .05). No association was found between COI disclosure and trainee contribution. CONCLUSIONS: The results have indicated that industry payments are associated with the LOE in the OMS literature. Further studies are needed to elucidate both the accuracy of the financial disclosures by comparing them with publicly available open payment databases and the perceptions of the OMSs, their trainees, and their patients regarding the influence of industry payments on the specialty's academic interests.

Does Early Repair of Orbital Fractures Result in Superior Patient Outcomes? A Systematic Review and Meta-Analysis.

PURPOSE: To date, no clear evidence-based guidelines exist pertaining to the ideal timing to perform surgical treatment of orbital fractures. The purpose of this study was to determine if early treatment of orbital fractures resulted in better patient outcomes. MATERIALS AND METHODS: We designed and implemented a systematic review and meta-analysis to test the null hypothesis of no difference in outcomes between different time intervals between orbital injury and surgical intervention. PubMed, Embase, the Cochrane Library, the Elsevier text mining tool database, and clinicaltrials.gov trial registry were queried. The quality of evidence was based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The predictor variable was the timing of operative repair (early vs late). The outcome variable was complete recovery. Other variables of interest were diplopia, enophthalmos, and preoperative motility restriction. Meta-analyses were performed when definitions of active and control interventions and patient outcomes were deemed similar. In addition, χ2 tests were performed to determine differences in clinical outcomes between early and late operative repair. RESULTS: Of the 1,160 articles reviewed, 20 met the inclusion criteria. Surgery performed less than 2 weeks after injury was significantly associated with greater odds of complete recovery of symptoms (odds ratio [OR], 6.9 [95% confidence interval (CI), 1.35-35.06]), as well as a lower incidence of postoperative diplopia (OR, 0.3 [95% CI, 0.1-0.9]) and enophthalmos (OR, 0.2 [95% CI, 0.1-0.9]). Repair performed less than 30 days after injury was associated complete resolution of preoperative motility restriction (OR, 24.6 [95% CI, 1.30-462.34]) as well as diplopia. CONCLUSIONS: Differences in the timing of surgery and definition of patient outcomes, as well as variations in methods of evaluating postoperative outcomes, potentiate the risk of bias and warrant downgrading of the quality of evidence in a study. The timing of repair varied among 2, 4, and 8 weeks after injury. However, a short time to surgical intervention was significantly associated with resolution of vertical dystopia, postoperative enophthalmos, and motility restriction.