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Elwell Z, Candelo E, Srinivasan T, Nuss S, Zalaquett N, Tuyishimire G, Ncogoza I, Jean‐Gilles PM, Legbo JN, Tollefson T, Shaye D. The State of Craniomaxillofacial Trauma Care in Low- and Middle-Income Countries: A Scoping Review. OTO Open 2024; 8:e70000. [PMID: 39211787 PMCID: PMC11358761 DOI: 10.1002/oto2.70000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 07/19/2024] [Accepted: 07/30/2024] [Indexed: 09/04/2024] Open
Abstract
Objective This scoping review aims to contribute a descriptive analysis of the craniomaxillofacial trauma (CMF trauma) literature in low- and middle-income countries (LMICs) to identify knowledge gaps, direct future research, and inform policy. Data Sources PubMed/MEDLINE, Cochrane Review, EMBASE, ClinicalTrials.gov, and Google Scholar from January 1, 2012 to December 10, 2023. Review Methods The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guided reporting, and the PRISMA flowchart documented database searches. Specific, predefined search terms and inclusion criteria were used for screening, and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist was used for quality assessment. The search yielded 54 articles, with 13 meeting the inclusion criteria. Key findings were summarized and divided into 7 categories. Results There were 10,420 patients (7739 [74.3%] male, 2681 [25.7%] female) with a male-to-female ratio of 2.9:1. The mean peak age of incidence of CMF trauma was 30.8 years, ranging from 20 to 40 years. Road traffic accidents were the leading cause (60.4%), followed by assault (27.2%) and falls (12.2%). The most common injuries were soft tissue injury (31.7%), isolated mandibular fracture (22.8%), and isolated middle-third of mandible fracture (18.1%). The most common treatments were closed reduction and immobilization (29.5%), conservative management (27.6%), and open reduction and internal fixation (19.6%). Most patients (77.8%) experienced a treatment delay due to a lack of fixation materials (54.8%) or surgeon unavailability (35.7%). Conclusion CMF trauma remains a significant cause of global morbidity, yet there remains a lack of high-quality, CMF trauma-specific data in LMICs. Country-specific investigations are required to enhance knowledge and inform novel interventions. Implementing policy change must be community-specific and account for unique cultural barriers, attitudes, and behaviors to maximize patient care outcomes.
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Affiliation(s)
- Zachary Elwell
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Arizona College of Medicine—TucsonTucsonArizonaUSA
| | - Estephania Candelo
- Department of Otolaryngology–Head and Neck SurgeryMayo Clinic JacksonvilleJacksonvilleFloridaUSA
| | - Tarika Srinivasan
- Department of Otolaryngology–Head and Neck SurgeryMassachusetts Eye and Ear, Harvard Medical SchoolBostonMassachusettsUSA
| | - Sarah Nuss
- Department of Otolaryngology–Head and Neck SurgeryWarren Alpert Medical School at Brown UniversityProvidenceRhode IslandUSA
| | - Nader Zalaquett
- Department of Otolaryngology–Head and Neck SurgeryAmerican University of Beirut Medical CenterBeirutLebanon
| | - Gratien Tuyishimire
- Department of Otolaryngology–Head and Neck SurgeryMedical Business Company HospitalKigaliRwanda
| | - Isaie Ncogoza
- Department of Otolaryngology–Head and Neck SurgeryUniversity Teaching Hospital of KigaliKigaliRwanda
| | - Patrick Marc Jean‐Gilles
- Department of Otolaryngology–Head and Neck SurgeryUniversity Hospital of Port‐au‐PrincePort‐au‐PrinceHaiti
| | - Jacob Ndas Legbo
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck SurgeryUsmanu Danfodiyo University/Teaching HospitalSokotoNigeria
| | - Travis Tollefson
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck SurgeryUniversity of California, DavisSacramentoCaliforniaUSA
| | - David Shaye
- Department of Otolaryngology–Head and Neck SurgeryMassachusetts Eye and Ear, Harvard Medical SchoolBostonMassachusettsUSA
- Department of Otolaryngology–Head and Neck SurgeryUniversity Teaching Hospital of KigaliKigaliRwanda
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck SurgeryMassachusetts Eye and Ear, Harvard Medical SchoolBostonMassachusettsUSA
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Wichlas F, Necchi M, Gruber T, Hofmann V, Deininger S, Deininger SHM, Deluca A, Steidle-Kloc E, Pruszak J, Wittig J, Deininger C. Off-Label Use of an External Hand Fixator for Craniomaxillofacial Fractures-An Anatomical Feasibility Study. Bioengineering (Basel) 2024; 11:279. [PMID: 38534553 DOI: 10.3390/bioengineering11030279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 02/25/2024] [Accepted: 03/11/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND The lack of resources limits the treatment of craniomaxillofacial fractures (CMF) in low-income countries (LIC). Therefore, Barton bandages and/or interdental wiring are considered in these regions. Fracture reduction is maintained by permanent occlusion for 6 weeks, which often leads to limited compliance and dissatisfying results. The aim of this cadaver-based study is to evaluate the feasibility of the use of an external face fixator (EFF) for the treatment of CMF, its biomechanical values and to define the optimal pin insertion points and angles. MATERIALS AND METHODS An AO hand fixator was used. CMF of types Le Fort 1-3 with split fractures of the hard palate were treated with EFF on 13 anatomical specimens. Fractures were created using a chisel, and pins were placed in specific anatomical regions. The maximal pull-out force [N] of pins was analysed by a tensile force gauge, and Fmax of the mandibular pins was evaluated. Computer tomography scans were performed on the healthy, fractured and EFF-treated skulls. RESULTS The pull-out forces for the single pins were mandibular pins (n = 15, median 488.0 N), supraorbital pins (n = 15, median 455.0 N), zygomatic pins (n = 14, median 269.1 N), medial hard palate pins (n = 12, median 208.4 N) and lateral hard palate pins (n = 8, median 49.6 N). CONCLUSIONS The results indicate that the operation technique is feasible, and the stability of the EFF is sufficient for maintaining the reduction. The required pins can safely be inserted into the described areas with good reduction results. Using EFF offers a feasible alternative to the non-surgical treatment of CMF in LIC.
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Affiliation(s)
- Florian Wichlas
- Department of Orthopedics and Traumatology, University Hospital Salzburg, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria
- No Limit Surgery, Ernest-Thun-Strasse 6, 5020 Salzburg, Austria
| | - Marco Necchi
- No Limit Surgery, Ernest-Thun-Strasse 6, 5020 Salzburg, Austria
- Department of Surgery and Orthopaedics, Hospital Sterzing, Margarethenstraße 24, 39049 Sterzing, Italy
| | - Teresa Gruber
- Department of Orthopedics and Traumatology, University Hospital Salzburg, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria
| | - Valeska Hofmann
- No Limit Surgery, Ernest-Thun-Strasse 6, 5020 Salzburg, Austria
- BG Trauma Centre, Department of Trauma and Reconstructive Surgery, University of Tübingen, 72076 Tübingen, Germany
| | - Susanne Deininger
- No Limit Surgery, Ernest-Thun-Strasse 6, 5020 Salzburg, Austria
- Department of Urology and Andrology, University Hospital Salzburg, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria
| | | | - Amelie Deluca
- Institute of Tendon and Bone Regeneration, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Eva Steidle-Kloc
- Institute of Anatomy and Cell Biology|Salzburg, Paracelsus Medical University, 5020 Salzburg, Austria
- Center of Anatomy and Cell Biology, Salzburg and Nuremberg, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Jan Pruszak
- Institute of Anatomy and Cell Biology|Salzburg, Paracelsus Medical University, 5020 Salzburg, Austria
- Center of Anatomy and Cell Biology, Salzburg and Nuremberg, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Jörn Wittig
- Department of Oral and Maxillofacial Surgery, University Hospital Salzburg, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria
| | - Christian Deininger
- Department of Orthopedics and Traumatology, University Hospital Salzburg, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria
- No Limit Surgery, Ernest-Thun-Strasse 6, 5020 Salzburg, Austria
- Institute of Tendon and Bone Regeneration, Paracelsus Medical University, 5020 Salzburg, Austria
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Gadkaree SK, Derakhshan A, Nyabenda V, Ncogoza I, Tuyishimire G, Shaye DA. Wire Osteosynthesis in the Treatment of Mandible Fractures in Low Resource Settings: A Force Study. Craniomaxillofac Trauma Reconstr 2024; 17:13-17. [PMID: 38371214 PMCID: PMC10874206 DOI: 10.1177/19433875221143605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024] Open
Abstract
Study Design Cadaveric investigation. Objective Rigid internal fixation (RIF) using plates and screws is often not feasible in low and middle-income countries due to limited resources. Interosseous wiring to achieve semi-rigid fixation is often used, but lacks biomechanical force data. Herein we aim to quantitatively compare interosseous wiring to RIF. Methods Cadaveric mandibles were fractured at the parasymphysis and angle. Fixation was achieved using interosseous wiring in both single wire loop and figure-of-eight formations, as well as plate and screw fixation (n = 5 for each fixation type at each fracture site). A force gauge was used to measure the number of Newtons (N) required to achieve diastasis and complete failure at the fixation site. Results For angle fractures, the mean force required for initial diastasis was 4.1, 5.9, and 10.9 N for single wire, figure-of-eight wiring, and plating respectively (P < .001). Complete failure was achieved with 152.9, 168.9, and 237.6 N of force for the three methods, respectively (P < .001). Complete failure was achieved for parasymphyseal fractures with 197.7, 263.0, and 262.8 N of force for single wire, figure-of-eight wiring, and plating respectively (P = .002). Forces to achieve initial diastasis for parasymphyseal fractures were not statistically significant among the three fixation methods (P = .29). Conclusions Figure-of-eight interosseous wiring resists comparable forces across mandibular fractures compared to the gold standard of plating. In resource-limited settings when plates and screws are not available, this technique can be considered to achieve semi-rigid fixation of mandibular fractures.
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Affiliation(s)
- Shekhar K. Gadkaree
- Department of Otolaryngology Head and Neck Surgery, Harvard Medical School, Boston, MA, USA
- Department of Otolaryngology Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, Harvard Medical School, Massachusetts Eye and Ear, Boston, MA, USA
| | - Adeeb Derakhshan
- Department of Otolaryngology Head and Neck Surgery, Harvard Medical School, Boston, MA, USA
- Department of Otolaryngology Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, Harvard Medical School, Massachusetts Eye and Ear, Boston, MA, USA
| | - Victor Nyabenda
- Department of Otolaryngology – Head & Neck Surgery, University Teaching Hospital of Kigali, Rwanda
| | - Isaie Ncogoza
- Department of Otolaryngology – Head & Neck Surgery, University Teaching Hospital of Kigali, Rwanda
| | - Gratien Tuyishimire
- Department of Otolaryngology – Head & Neck Surgery, University Teaching Hospital of Kigali, Rwanda
| | - David A. Shaye
- Department of Otolaryngology Head and Neck Surgery, Harvard Medical School, Boston, MA, USA
- Department of Otolaryngology Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, Harvard Medical School, Massachusetts Eye and Ear, Boston, MA, USA
- Department of Otolaryngology – Head & Neck Surgery, University Teaching Hospital of Kigali, Rwanda
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Mao J, Li X, Cao K, Xue J, Wang M, Yan D, Zhou Z. Epidemiology of maxillofacial fractures in northwest China: an 11-year retrospective study of 2240 patients. BMC Oral Health 2023; 23:313. [PMID: 37221520 DOI: 10.1186/s12903-023-03006-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 05/02/2023] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND The aim of this study was to determine the epidemiological pattern of maxillofacial fractures in northwestern China by retrospectively analysing the demographics, aetiologies, concomitant injuries, fracture sites, and management. METHODS A 10-year retrospective analysis of 2240 patients with maxillofacial fractures admitted to the General Hospital of Ningxia Medical University was conducted. The extracted data included sex, age, aetiology, fracture site, concomitant injuries, time of treatment, therapeutic approaches and complications. Statistical analyses were performed, including descriptive analysis and the chi-square test. Logistic regression was used to determine the impact factors of maxillofacial fractures and concomitant injuries. P values < 0.05 were considered statistically significant. RESULTS The age of the included patients ranged from 1 to 85 years, and the mean age was 35.88 ± 15.69 years. The male-to-female ratio was 3.9:1. The most frequent aetiology of maxillofacial fractures was road traffic accidents (RTAs) (56.3%), and the most common fracture sites were the anterior wall of the maxillary sinus, arcus zygomaticus and mandibular body. A total of 1147 patients (51.2%) were affected by concomitant injuries, with craniocerebral injury being the most common. Logistic regression analyses revealed increased risks of mid-facial fractures in elderly individuals (odds ratio (OR) = 1.029, P < 0.001) and females (OR = 0.719, P = 0.005). Younger patients had a higher risk of mandibular fractures (OR = 0.973, P < 0.001). RTAs increased the risk for mid-facial fractures and high falls increased the risk for mandibular fractures. CONCLUSIONS The maxillofacial fracture pattern is correlated with sex, age and aetiology. Patients were mainly young and middle-aged males, and the main cause of injury was RTAs, mostly causing compound fractures. Medical staff must be systematically educated to comprehensively examine patients with injuries resulting from RTAs. The management of patients with fractures requires thorough consideration of the patient's age, aetiology, fracture site, and concomitant injuries.
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Affiliation(s)
- Jingjing Mao
- Ningxia Medical University, No. 1160, Sheng Li South Road, Yinchuan, 750004, Ningxia, P.R. China
| | - Xiaojie Li
- Department of Dental and Endodontic Diseases, General Hospital of Ningxia Medical University, No. 804, Sheng Li South Road, Yinchuan, 750004, Ningxia, P.R. China
| | - Kun Cao
- Department of Oral and Maxillofacial Surgery, General Hospital of Ningxia Medical University, No. 804, Sheng Li South Road, Yinchuan, 750004, Ningxia, P.R. China
| | - Jiawen Xue
- Ningxia Medical University, No. 1160, Sheng Li South Road, Yinchuan, 750004, Ningxia, P.R. China
| | - Min Wang
- Department of Stomatology, The Eighth People's Hospital of Jinan, No. 68, Xin Xing Road, Jinan, 271100, Shandong, P.R. China
| | - Di Yan
- Institute of Medical Sciences, General Hospital of Ningxia Medical University, No. 804, Sheng Li South Road, Yinchuan, 750004, Ningxia, P.R. China
| | - Zhongwei Zhou
- Department of Oral and Maxillofacial Surgery, General Hospital of Ningxia Medical University, No. 804, Sheng Li South Road, Yinchuan, 750004, Ningxia, P.R. China.
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Pitak-Arnnop P, Tangmanee C, Muangchan C, Meningaud JP, Neff A. Asymptomatic or mildly symptomatic COVID-19 patients with craniomaxillofacial injuries have an increase risk of surgical site infection. Br J Oral Maxillofac Surg 2022; 60:1118-1124. [PMID: 35927146 PMCID: PMC9155182 DOI: 10.1016/j.bjoms.2022.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 04/19/2022] [Accepted: 05/17/2022] [Indexed: 02/09/2023]
Abstract
The aim of this paper was to evaluate the association between ‘asymptomatic or mildly symptomatic’ severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (AS/MS-COVID) and surgical site infection (SSI) after repair of craniomaxillofacial injury (CMFI). Using a case-control study design with a match ratio of 1:4, we enrolled a cohort of AS/MS-COVID cases with immediately treated CMFI during a one-year period. The main predictor variable was SARS-CoV-2 infection (yes/no), and the outcome of interest was SSI (yes/no). The other variables were demographic, clinical, and operative. Appropriate statistics were computed, and p<0.05 was considered statistically significant. The study group comprised 257 cases (28.8% female; 13.2% aged ≥ 60 years; 10.5% with fractures; 39.7% with involvement of nasal/oral/orbital tissue [viral reservoir organs, VROs]; 81.3% with blunt trauma; 19.1% developed an SSI [vs 6.8% in the control group]) with a mean (SD) age of 39.8 (16.6) years (range 19–87). There was a significant relation between SARS-CoV-2 infection and SSI events (p<0.0001; odds ratio 3.22; 95% confidence interval 2.17 to 4.78). On subgroup analysis, SSIs significantly increased with age ≥ 60 years, presence and treatment of fracture, contact with VROs, and prolonged antibiotic use (PAU). However, multivariate logistic regression analysis confirmed a positive effect only from old age, contact with VROs, and PAU (relative risk = 1.56, 2.52, and 2.03, respectively; r = 0.49; p = 0.0001). There was a significant 2.8-fold increase in SSIs among AS/MS-COVID cases, especially in those aged ≥ 60 years, or those with injuries to VROs, or both, who therefore required PAU.
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Stanford-Moore GB, Niyigaba G, Tuyishimire G, Yau J, Kulkrani A, Nyabyenda V, Ncogoza I, Shaye DA. Effect of Delay of Care for Patients with Craniomaxillofacial Trauma in Rwanda. OTO Open 2022; 6:2473974X221096032. [PMID: 35480144 PMCID: PMC9036345 DOI: 10.1177/2473974x221096032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/22/2022] [Indexed: 11/16/2022] Open
Abstract
Objectives Craniomaxillofacial (CMF) trauma represents a significant proportion of global surgical disease burden, disproportionally affecting low- and middle-income countries where care is often delayed. We investigated risk factors for delays to care for patients with CMF trauma presenting to the highest-volume trauma hospital in Rwanda and the impact on complication rates. Study Design This prospective cohort study comprised all patients with CMF trauma presenting to the University Teaching Hospital of Kigali, Rwanda, between June 1 and October 1, 2020. Setting Urban referral center in resource-limited setting. Methods Epidemiologic data were collected, and logistic regression analysis was undertaken to explore risk factors for delays in care and complications. Results Fifty-four patients (94.4% men) met criteria for inclusion. The mean age was 30 years. A majority of patients presented from a rural setting (n = 34, 63%); the most common cause of trauma was motor vehicle accident (n = 18, 33%); and the most common injury was mandibular fracture (n = 28, 35%). An overall 78% of patients had delayed treatment of the fracture after arrival to the hospital, and 81% of these patients experienced a complication (n = 34, P = .03). Delay in treatment was associated with 4-times greater likelihood of complication (odds ratio, 4.25 [95% CI, 1.08-16.70]; P = .038). Conclusion Delay in treatment of CMF traumatic injuries correlates with higher rates of complications. Delays most commonly resulted from a lack of surgeon and/or operating room availability or were related to transfers from rural districts. Expansion of the CMF trauma surgical workforce, increased operative capacity, and coordinated transfer care efforts may improve trauma care.
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Affiliation(s)
- Gaelen B. Stanford-Moore
- Department of Otolaryngology–Head and Neck Surgery, University of California–San Francisco, San Francisco, California, USA
| | - Gilbert Niyigaba
- Department of ENT, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Gratien Tuyishimire
- Department of Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Jenny Yau
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye & Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Amol Kulkrani
- Department of Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Victor Nyabyenda
- Department of Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Isaie Ncogoza
- Department of ENT, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- Department of Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - David A. Shaye
- Department of Surgery, University Teaching Hospital of Kigali, Kigali, Rwanda
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye & Ear, Harvard Medical School, Boston, Massachusetts, USA
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Wu CA, Dutta R, Virk S, Roy N, Ranganathan K. The need for craniofacial trauma and oncologic reconstruction in global surgery. J Oral Biol Craniofac Res 2021; 11:563-567. [PMID: 34430193 DOI: 10.1016/j.jobcr.2021.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 07/22/2021] [Indexed: 10/20/2022] Open
Abstract
The global burden of surgical disease is concentrated in low- and middle-income countries and primarily consists of injuries and malignancies. While global reconstructive surgery has a long and well-established history, efforts thus far have been focused on addressing congenital anomalies. Craniofacial trauma and oncologic reconstruction are comparatively neglected despite their higher prevalence. This review explores the burden, management, and treatment gaps of craniofacial trauma and head and neck cancer reconstruction in low-resource settings. We also highlight successful alternative treatments used in low-resource settings and pearls that can be learned from these areas.
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Affiliation(s)
| | - Rohini Dutta
- WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, BARC Hospital (Government of India), Mumbai, India.,Christian Medical College and Hospital, Ludhiana, Punjab, India
| | - Sargun Virk
- Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, Punjab, India
| | - Nobhojit Roy
- WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, BARC Hospital (Government of India), Mumbai, India
| | - Kavitha Ranganathan
- Harvard Medical School, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
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