Multidisciplinary surgical considerations for en bloc resection of sacral chordoma: review of recent advances and a contemporary single-center series

OBJECTIVE

Contemporary management of sacral chordomas requires maximizing the potential for recurrence-free and overall survival while minimizing treatment morbidity. En bloc resection can be performed at various levels of the sacrum, with tumor location and volume ultimately dictating the necessary extent of resection and subsequent tissue reconstruction. Because tumor resection involving the upper sacrum may be quite destabilizing, other pertinent considerations relate to instrumentation and subsequent tissue reconstruction. The primary aim of this study was to survey the surgical approaches used for managing primary sacral chordoma according to location of lumbosacral spine involvement, including a narrative review of the literature and examination of the authors' institutional case series.

METHODS

The authors performed a narrative review of pertinent literature regarding reconstruction and complication avoidance techniques following en bloc resection of primary sacral tumors, supplemented by a contemporary series of 11 cases from their cohort. Relevant surgical anatomy, advances in instrumentation and reconstruction techniques, intraoperative imaging and navigation, soft-tissue reconstruction, and wound complication avoidance are also discussed.

RESULTS

The review of the literature identified several surgical approaches used for management of primary sacral chordoma localized to low sacral levels (mid-S2 and below), high sacral levels (involving upper S2 and above), and high sacral levels with lumbar involvement. In the contemporary case series, the majority of cases (8/11) presented as low sacral tumors that did not require instrumentation. A minority required more extensive instrumentation and reconstruction, with 2 tumors involving upper S2 and/or S1 levels and 1 tumor extending into the lower lumbar spine. En bloc resection was successfully achieved in 10 of 11 cases, with a colostomy required in 2 cases due to rectal involvement. All 11 cases underwent musculocutaneous flap wound closure by plastic surgery, with none experiencing wound complications requiring revision.

CONCLUSIONS

The modern management of sacral chordoma involves a multidisciplinary team of surgeons and intraoperative technologies to minimize surgical morbidity while optimizing oncological outcomes through en bloc resection. Most cases present with lower sacral tumors not requiring instrumentation, but stabilizing instrumentation and lumbosacral reconstruction are often required in upper sacral and lumbosacral cases. Among efforts to minimize wound-related complications, musculocutaneous flap closure stands out as an evidence-based measure that may mitigate risk.

Assessing the Reliability of Facial Feminization Content on Social Media and Its Impact on the Dissemination of Misinformation

BACKGROUND

The surge in social media usage has transformed the dissemination and consumption of healthcare information, notably impacting plastic surgery and cosmetic specialties. This study focuses on the influence of social media, particularly Instagram and TikTok, in shaping perceptions of individuals seeking facial feminization (FF) procedures.

METHODS

Using the validated DISCERN scale, we assessed the reliability and accuracy of FF content on TikTok and Instagram. The study also analyzed the relationship between content reliability on engagement metrics (likes, comments, views) and the type of content shared (educational, testimonial, promotional).

RESULTS

The analysis encompassed 225 TikTok videos and 75 Instagram posts. TikTok content showed 9.33% as "very poor," 66.2% as "poor," 22.6% as "fair," and only 1.33% as "excellent." Similarly, Instagram content demonstrated 14.67% as "very poor" and 69.33% as "poor," with no content rated as "good" or "excellent." Educational content received higher reliability scores on both platforms. TikTok engagement metrics showed lower reliability ratings correlating with more views, comments, and likes.

CONCLUSION

The study underscores the critical role of social media in shaping patient perspectives on FF procedures. The prevalence of inaccurate information necessitates a focus on responsible engagement by healthcare professionals, aiming to provide accurate, educational content that aligns with patients' informational needs and ultimately enhances surgical outcomes.

Systematic Review of Prophylactic Plastic Surgery Closure to Prevent Postoperative Wound Complications Following Spine Surgery

Spinal surgeries are increasingly performed in the United States, but complication rates can be unacceptably high at up to 26%. Consequently, plastic surgeons (PS) are sometimes recruited by spine surgeons (SS) for intraoperative assistance with soft tissue closures. An electronic multidatabase literature search was systematically conducted to determine whether spinal wound closure performed by PS minimizes postoperative wound healing complications when compared to closure by SS (neurosurgical or orthopedic), with the hypothesis that closures by PS minimizes incidence of complications. All published studies involving patients who underwent posterior spinal surgery with closure by PS or SS at index spine surgery were identified. Filtering by exclusion criteria identified 10 studies, 4 of which were comparative in nature and included both closures by PS and SS. Of these 4, none reported significant differences in postoperative outcomes between the groups. Across all studies, PS were involved in cases with higher baseline risk for wound complications and greater comorbidity burden. Closures by PS were significantly more likely to have had prior chemotherapy in 2 of the 4 (50%) studies (P = 0.014, P < 0.001) and radiation in 3 of the 4 (75%) studies (P < 0.001, P < 0.01, P < 0.001). In conclusion, closures by PS are frequently performed in higher risk cases, and use of PS in these closures may normalize the risk of wound complications to that of the normal risk cohort, though the overall level of evidence of the published literature is low.

Single Surgeon Comparison of Midline Versus Overlapping Locoregional Flap Closure Following Spinal Instrumentation

BACKGROUND

Two techniques for paraspinous muscle flap closure of spine surgeries have been described: one with tension-free mobilization of the muscle flaps approximated at the midline and one with perforators more aggressively dissected to allow for overlapping of the flaps. We seek to compare the surgical outcomes in patients who underwent either type of complex spinal closure as no investigation has yet evaluated a superior technique.

METHODS

An institutional review board (IRB)-approved retrospective analysis was conducted on all patients who underwent spine surgery followed by locoregional muscle flap complex closure performed by a single plastic surgeon between January 2016 and July 2021. Patients were divided into 2 groups based on which closure method was employed. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed by multivariable logistic regression with Firth's correction.

RESULTS

One hundred and 10 patients with similar baseline demographics were included. There were significantly more smokers (15% vs. 0%, P = 0.02) and a significantly greater rate of postoperative radiation (40% vs. 17%, P = 0.009) in the overlapping group. After controlling for smoking and postoperative radiation, the incidence of surgical site infection, skin necrosis, dehiscence, hematoma, and seroma did not differ between the groups. The procedure length per centimeter of closure was shorter in the midline approximation group, although this data fell just short of significance (3.2 vs. 3.8 minutes/cm, P = 0.08).

CONCLUSIONS

The present study demonstrates that both the overlapping and midline approximation of muscle flaps are equally safe and effective strategies for locoregional closure of spinal wounds.

Mandible Fractures Undergoing Transfer Rarely Require Acute Intervention

Study Design

A retrospective review was conducted of all patients with mandibular fractures who were evaluated by plastic surgery at a Level I trauma center between January 1, 2017 and May 1, 2020. Data including demographic characteristics, mechanism of injury, type of presentation (e.g., primary or transfer), treatment plan, and time to intervention were recorded.

Objective

Mandibular fractures are common traumatic injuries. Because these injuries are managed by surgical specialists, these patients are often emergently transferred to tertiary care hospitals. This study aims to assess the benefits of emergent transfer in this patient group.

Methods

Variables were summarized using descriptive statistics. The relationship with initial disposition was assessed via tests of association, including Student's t-test, Fisher's exact test, or chi-square tests. Significance was set to p values less than 0.05. Multivariate regression analysis was conducted to determine predictors of presentation to outside hospital followed by transfer to our institution.

Results

Records from 406 patients with isolated mandibular fractures were evaluated. 145 (36%) were transferred from an outside hospital specifically for specialty evaluation. One patient required intervention in the Emergency Department (ED). Of the 145 patients that were transferred to our facility, eight (5.5%) were admitted for operative management. Patients with open injuries and pediatric patients showed benefit from transfer.

Conclusions

Patients are frequently transferred to tertiary care facilities for specialty service evaluation and treatment. However, when isolated mandible fractures were evaluated, only one patient required intervention in the ED. Patients with grossly open fractures and pediatric patients were more frequently admitted specifically for operative management. This practice of acute interfacility transfer represents an unnecessary cost to our health system as isolated mandible fractures can be managed on an outpatient basis. We suggest that pediatric patients and patients with open fractures be transferred for urgent evaluation and management, whereas most patients would be appropriate for outpatient evaluation.

The Impact of a Centralized Plastic Surgery Research Infrastructure on Scholarly Productivity and Output

Although research and innovation is a key within the field of plastic and reconstructive surgery, the impact of team structure, interpersonal dynamics, and/or standardized infrastructure on scholarly output has been infrequently studied. In this work, we present the formation and implementation of a novel plastic surgery research program that aims to unite previously disparate clinical and translational research efforts at our institution to facilitate critical inquiry. From July 2022 to June 2023, our department launched a pilot research program based on three pillars: (1) formalization of a research curriculum (monthly research meetings for agenda setting and discussion for project honing, formal research leadership for meeting facilitation and workflow regulation), (2) development of a centralized database to compile ongoing research (Google Drive repository to house all ongoing research documents, facilitate real-time editing, and provide resources/templates for assisting in the research process), and (3) bolstering of a core research identity built on mentorship and collaboration (more frequent interactions to shift previously siloed faculty-student mentorship into a robust milieu of intercollaboration). During the first year, we saw an increased number of publications and presentations, as well as robust participation and contribution from faculty, residents, and medical students. Future directions will focus on addressing resource limitation, such as project idea availability and funding, to sustain the success and growth of this novel research infrastructure.

A Brief Clinical Study: Consecutive Occurences of Frontal Sinus Pneumocele

Sinus pneumocele is a rare condition marked by pathologic expansion of a paranasal sinus with concomitant bone loss. Here, we describe the case of a 24-year-old male who first presented with a 2×3 cm bony projection of his right medial forehead. Exam and history were notably absent for any skin tethering, prior trauma, inflammation, or neurological symptoms. A computed tomography scan confirmed the prominence was secondary to an enlarged right frontal sinus. The pneumocele was successfully corrected through surgery, but the patient notably developed a similar presentation on the left frontal sinus nearly 1 year later. Clinical findings support a hypothesis of air trapping through mucosal thickening. This second pneumocele was managed similarly.

Spontaneous Reossification Following Craniectomy in a Pediatric Patient

Spontaneous reossification following a cranial defect is described by only a few case reports. A 6-month-old male with epidural hematoma underwent decompressive craniotomy, subsequently complicated by scalp abscess requiring removal of the bone flap. On serial outpatient follow-up, the patient demonstrated near-complete resolution of cranial defect over the course of 18 months, thus deferring the need for future cranioplasty. Prior articles have identified this occurrence in children and young adults; however, the present case is the first to report of this phenomenon in an infant less than 1 year of age. A brief review of the literature is provided with the proposed physiologic underpinning for the spontaneous reossification observed. While prior studies propose that recranialization is mediated by contact with the dura mater and pericranium, new investigations suggest that calvarial bone repair is also mediated by stem cells from the suture mesenchyme.

Early Outcomes of Muscle Flap Closures in Posterior Thoracolumbar Fusions: A Propensity-Matched Cohort Analysis

BACKGROUND

Plastic surgery closure with muscle flaps after complex spinal reconstruction has become increasingly common. Existing evidence for this practice consists of small, uncontrolled, single-center cohort studies. We aimed to compare 30-day postoperative wound-related complication rates between flap closure and traditional closure after posterior thoracolumbar fusions (PTLFs) for non-infectious, non-oncologic pathologies using a national database.

METHODS

We performed a propensity-matched analysis using the 2012-2020 National Surgical Quality Improvement Program dataset to compare 30-day outcomes between PTLFs with flap closure versus traditional closure.

RESULTS

A total of 100,799 PTLFs met our inclusion criteria. The use of flap closure with PTLF remained low but more than doubled from 2012 to 2020 (0.38% vs. 0.97%; P = 0.002). A higher proportion of flap closures had higher American Society of Anesthesiologists classifications and higher number of operated spine levels (all P < 0.001). We included 1907 PTLFs (630 for flap closure; 1257 for traditional closure) in the propensity-matched cohort. Unadjusted 30-day wound complication rates were 1.7% for flap and 2.1% for traditional closure (P = 0.76). After adjusting for operative time, wound complication, readmission, reoperation, mortality, and non-wound complication were not associated flap use (all P > 0.05).

CONCLUSIONS

Plastic surgery closure was performed in patients with a higher comorbidity burden, suggesting consultation in sicker patients. Although higher rates of wound and non-wound complications were expected for the flap cohort, our propensity-matched cohort analysis of flap closure in PTLFs resulted in non-inferior odds of wound complications compared to traditional closure. Further study is needed to assess long-term complications in prophylactic flap closure in complex spine surgeries.

The Life Cycle of Orofacial Cleft Operations

Patients with cleft lip and palate must undergo various surgical interventions at appropriate times to achieve optimal outcomes. While guidelines for the timing of these operations are well known, it has not yet been described if national surgical practice reflects these recommendations. This study evaluates whether orofacial operations are performed in time frames that align with advised timing. Time-to-event analyses were performed using the 2012-2020 Pediatric National Surgical Quality Improvement Program database on the ages at time of orofacial operations. Outliers with an absolute Z-score of 3.29 or greater were excluded. Cleft lip (N=9374) and palate (N=13,735) repairs occurred earliest at mean ages of 200.99±251.12 and 655.08±694.43 days, respectively. Both operations clustered along the later end of recommended timing. 69.0% of lip versus 65.1% of palate repairs were completed within the advised age periods. Cleft lip (N=2850) and palate (N=1641) revisions occurred at a mean age of 7.73±5.02 and 7.00±4.63 years, respectively. Velopharyngeal insufficiency operations (N=3026), not including palate revision, were performed at a delayed mean age of 7.58±3.98 years, with only 27.7% of operations occurring within the recommended time frame. Finally, 75.8% of alveolar bone grafting cases (N=5481) were found to happen within the advised time period, with a mean age of 10.23±2.63 years. This study suggests that, with the exception of VPI procedures, orofacial operations reliably cluster near their recommended age periods. Nevertheless, primary lip repair, palatoplasty, and velopharyngeal insufficiency procedures had a mean age that was delayed based on advised timing.

Plastic Surgery Closure of Complex Spinal Wounds

Wound breakdown and infection are common complications after complex spine surgery and may occur in up to 40% of high-risk patients. These are challenging scenarios which can result in a prolonged hospital stay, revision surgery, and elevated costs. Reconstructive specialists can do prophylactic closures for high-risk groups to potentially reduce the risk of developing a wound complication. These plastic surgery techniques often involve multilayered closure, with the addition of local muscle and/or fasciocutaneous flaps. The goal of this study was to review the literature for risks associated with wound complications, identification of high-risk patients, and the advantages of using plastic surgery techniques. In addition, we elaborate on the multilayered and flap closure technique for complex spine surgery which is done at our institution.

A Cost-effective, 3D Printed Simulation Model Facilitates Learning of Bilobed and Banner Flaps for Mohs Nasal Reconstruction: A Pilot Study

SUMMARY

Flap design for Mohs reconstruction is a complex 3-dimensional decision-making process. Simulation offers trainees the chance to practice techniques safely, prior to opportunities in the operating room. To aide in teaching, we developed a high-fidelity, cost-effective model of the face using three-dimensional (3D) printing to simulate flap reconstruction following Mohs surgery. We describe the design of this model and its impact on the comfort and proficiency of trainees.

Craniofacial Trauma from Electronic Scooter Use

BACKGROUND

In 2018, the City of Providence introduced a program in which electronic scooters were deployed for public use. We aim to characterize the burden of craniofacial injuries associated with these scooters.

METHODS

A retrospective review was conducted of all patients consulted to the plastic surgery service for evaluation of craniofacial injury between September 2018 and October 2022. Data pertaining to patient sociodemographics, site and time of injury, and craniofacial trauma were recorded.

RESULTS

Twenty-five patients sustaining craniofacial trauma were identified over a four-year period. Most patients required soft tissue repair (64%) and bony fractures were sustained by approximately half of all patients (52%). Admission to ICU was uncommon (16%), and there were no fatalities.

CONCLUSIONS

The incidence of craniofacial injury from electronic scooter use is low. However, these injuries may involve extensive surgical reconstruction and ICU admission. We advise the City of Providence to optimize best safety practices and monitoring to minimize risk.

Lateral Canthotomy Revisited: A Refined Surgical Approach for Orbital Access

The transconjunctival incision is a common and effective approach for establishing surgical exposure to the orbital floor. When access to the lateral orbit is also required, this incision may be extended by an accompanying lateral canthotomy, which releases the tarsal plates from the conjunctiva. Although this approach broadens surgical access through a simple extension, it is often remarked for unpredictable healing patterns and negative aesthetic sequelae, such as rounding of the lateral canthal angle. Traditionally, lateral canthotomy is performed by a transverse incision through a natural skin crease of the lateral palpebral fissure. Herein, we discuss our experience with a less common approach to lateral canthotomy, in which only the inferior crus of the lateral canthal tendon is divided. This approach limits manipulation of delicate orbital anatomy and aims to minimize unsightly scarring while still affording excellent visualization of the lateral orbit and orbital floor.

Re-evaluating the Timing of Surgery after Isolated Orbital Floor Fracture

Orbital floor fractures are among the most common facial injuries. Although urgent surgical repair may be indicated, most patients require interval follow-up to assess for symptom onset and need for definitive operative intervention. This study aimed to evaluate the time to operative indication after these injuries.

Methods

A retrospective review was conducted of all patients with isolated orbital floor fractures at a tertiary academic medical center from June 2015 to April 2019. Patient demographic and clinical data were recorded from the medical record. Time until operative indication was evaluated by the Kaplan-Meier product limit method.

Results

Of 307 patients meeting inclusion criteria, 9.8% (30/307) developed indications for repair. Among these, 60% (18/30) were recommended surgery on the day of initial evaluation. Of 137 follow-up patients, 8.8% (12/137) developed operative indications based on clinical evaluation. The median period to decision for surgery was 5 days (range, 1-9). No patients developed symptoms suggesting the need for surgery beyond 9 days after trauma.

Conclusions

Our investigation demonstrates that only about 10% of patients presenting with isolated orbital floor fracture develop an indication for surgery. For patients undergoing interval clinical follow-up, we found that patients demonstrated symptoms within 9 days of trauma. No patients demonstrated need for surgery beyond 2 weeks of injury. We believe these findings will assist to establish standards of care and inform clinicians on the appropriate length of follow-up for these injuries.

The Role of Antibiotics in Nasal Fractures after Closed Reduction

Nasal fractures represent the most common fracture in facial trauma. The role of prophylactic antibiotics in these injuries is debated, given low infection rates and demonstrated risks of antibiotics. We studied the isolated effect of prophylactic antibiotics on infection rate in patients with nasal fracture after closed reduction.

Methods

Retrospective cohort study of a prospectively maintained facial trauma database was conducted. Demographics, comorbidities, fracture classifications, and management of patients who received antibiotics at the time of closed nasal reduction were compared against those who did not receive antibiotics. Infection rates between groups were analyzed. Multivariate analysis was conducted to control for confounding variables. Qualitative analysis was performed for patients who experienced infection following nasal fracture.

Results

A total of 282 patients met inclusion criteria (n = 144, antibiotic; n = 138, nonantibiotic). Six patients experienced infection. There was no difference in infection rate between antibiotic and nonantibiotic groups (2.0% versus 2.2%; P = 0.90). On multivariate regression, antibiotics did not significantly decrease odds of infection (OR 1.7 [0.17-13.6]; P = 0.64). Moreover, patients with open nasal fractures did not have significantly higher odds of infection (OR 1.9 [0.08-20.8]; P = 0.64). Similarly, increasing severity of injury based on Rohrich classification did not significantly impact odds of infection (OR 0.68 [0.23-1.9]; P = 0.46). All six infections were managed at the bedside, with zero infections following operating room management (P = 0.32).

Conclusions

Prophylactic antibiotics do not decrease infection rates following nasal fractures managed by closed reduction. Bedside management may be a risk factor for the development of infection; however, this finding requires further evaluation.

Update on ladder plates for mandibular angle fractures

PURPOSE OF REVIEW

Fractures of the mandibular angle are surgically challenging with high rates of postoperative complications. Among established fixation techniques for these injuries, Champy's tension band approach with miniplate fixation has held prominence. Rigid fixation, using two plates, also remains commonly used. More recently, geometric ladder plates, which confer greater three-dimensional stability have been developed to overcome the shortcomings of conventional fixation approaches. Herein, we aim to summarize the recent evidence surrounding the use of ladder plates and offer our own opinion for optimal treatment of these fractures.

RECENT FINDINGS

In high-powered studies, the rates of hardware failure, malocclusion, and malunion are lower among cohorts managed with ladder plates relative to miniplate groups. Rates of infection and paresthesia remain similar. Ladder plates have also been shown to decrease operative time in preliminary study.

SUMMARY

Ladder plates show superiority to miniplate approaches across several outcomes. However, the relatively larger strut plate constructs may not be necessary for minor, uncomplicated fractures. It is our belief that reasonable outcomes may be achieved with either approach depending on surgeon experience and comfort with the given fixation technique.

Medical Malpractice Litigations Involving Infant Craniosynostosis and Deformational Plagiocephaly in the United States

OBJECTIVE

To identify characteristics of malpractice litigations involving skull deformity in infants (craniosynostosis and deformational plagiocephaly).

DESIGN

Retrospective review of all lawsuits with jury verdicts or settlements involving infant skull deformity as the primary diagnosis using the Westlaw Legal Database.

SETTING

United States.

PATIENTS, PARTICIPANTS

Plaintiffs with skull deformity as the primary diagnosis.

MAIN OUTCOME MEASURES

Litigation outcome and indemnity payment amount.

RESULTS

From 1990 to 2019, 9 cases involving infant skull deformity met our inclusion/exclusion criteria. Among these cases, 8 (88.9%) cases resulted in indemnity payments to plaintiffs, totaling $30,430,000. Failure to diagnose (n = 4, 44.4%) and surgical negligence (n = 3, 33.3%) were the most common reasons for litigations.

CONCLUSIONS

There were a small number of malpractice lawsuits involving infant skull deformity over three decades. When cases go to court, physicians and hospitals have a high likelihood of judgment against them, frequently resulting in high indemnity payments.

Superficial temporal artery injury and delayed post-cranioplasty infection

OBJECTIVE

Complications after cranioplasty after decompressive craniectomy (DC) have been reported to be as high as 40%. The superficial temporal artery (STA) is at substantial risk for injury in standard reverse question-mark incisions that are typically used for unilateral DC. The authors hypothesize that STA injury during craniectomy predisposes patients to post-cranioplasty surgical site infection (SSI) and/or wound complication.

METHODS

A retrospective study of all patients at a single institution who underwent cranioplasty after decompressive craniectomy and who underwent imaging of the head (computed tomography angiogram, magnetic resonance imaging with intravenous contrast, or diagnostic cerebral angiography) for any indication between the two procedures was undertaken. The degree of STA injury was classified and univariate statistics were used to compare groups.

RESULTS

Fifty-four patients met inclusion criteria. Thirty-three patients (61%) had evidence of complete or partial STA injury on pre-cranioplasty imaging. Nine patients (16.7%) developed either an SSI or wound complication after cranioplasty and, among these, four (7.4%) experienced delayed (>2 weeks from cranioplasty) complications. Seven of 9 patients required surgical debridement and cranioplasty explant. There was a stepwise but non-significant increase in post-cranioplasty SSI (STA present: 10%, STA partial injury: 17%, STA complete injury: 24%, P=0.53) and delayed post-cranioplasty SSI (STA present: 0%, STA partial injury: 8%, STA complete injury: 14%, P=0.26).

CONCLUSIONS

There is a notable but statistically non-significant trend toward increased rates of SSI in patients with complete or partial STA injury during craniectomy.

Craniosynostosis: Are Online Resources Readable?

OBJECTIVE

This study aims to analyze the readability of online craniosynostosis materials from the perspective of a caregiver, and to assess if readability levels conform to recommendations by the American Medical Association (AMA) and National Institutes of Health (NIH).

DESIGN

This is a cross-sectional investigation in which an internet search was conducted simulating the search terms of a caregiver of a patient with craniosynostosis. The first three pages of resulting records were calculated for comprehension ease using validated readability indices. Records were also classified by author type, including hospital system, national health organization, academic journal, and other.

MAIN OUTCOME MEASURES

Flesch-Kincaid Reading Grade Level, Gunning fog Index, SMOG Index, and Coleman Liau Index.

RESULTS

Thirty records were identified for which the mean readability level was 12.8 ± 2.6 grade levels (range, 7.6-15.9). There were no significant differences in mean readability across readability indices or author type. None of the thirty records met levels recommended by the AMA or NIH and were 6.8 grade levels above these guidelines on average.

CONCLUSIONS

Online material pertaining to craniosynostosis is written, on average, at the reading level of a first-year undergraduate student. The AMA and NIH recommend that articles be written at approximately a sixth-grade reading level to promote comprehension. Therefore, there is significant room for improvement of current online materials. Authors should consider consulting publicly available guides in preparing future resources.

Operative technique for a combined transcaruncular-transconjunctival approach to double-walled orbital fractures

Double-walled orbital fractures involving the floor and medial wall are commonly encountered in instances of significant midface trauma. Operative intervention is indicated in the presence of persistent diplopia, significant enophthalmos, or muscle entrapment. Surgical repair of these injuries may be challenging due to large fracture sizes or loss of bony supports. The transconjunctival and transcaruncular approaches have been popularized to reconstruct isolated floor and medial wall fractures, respectively. However, surgical approaches for fractures involving both these walls have not been well described in the literature. In this technical note, we detail a combined transcaruncular-transconjunctival approach that is safe, effective, and aesthetically sensitive.

Post-traumatic hydrocephalus may be associated with autologous cranioplasty failure, independent of ventriculoperitoneal shunt placement: a retrospective analysis

PURPOSE

Decompressive craniectomy (DC) is a common procedure used for the treatment of intracranial hypertension. Once brain swelling has subsided, a cranioplasty is performed to restore cosmesis and protection to the brain. While using the patient's autologous bone flap is often the first choice in cranioplasty, this procedure is frequently complicated by bone flap resorption and infection. This study seeks to identify predictors of autologous cranioplasty failure.

METHODS

A retrospective analysis was conducted on patients who underwent decompressive craniectomy and autologous cranioplasty. Patient demographics and factors related to both surgeries and failure rates were recorded from patient records. Logistic regressions were conducted to determine which factors were implicated in autologous cranioplasty failure.

RESULTS

In our cohort, 127 patients underwent autologous cranioplasty. Overall, 18 (14.2%) patients experienced autologous cranioplasty failure. Regression analysis identified development of post-traumatic hydrocephalus (PTH) following DC (OR: 3.26, p = 0.043), presence of neurological deficits following DC (OR: 4.88, p = 0.025), and reoperation prior to CP (OR 3.0, p = 0.049) as significant predictors of autologous cranioplasty failure. Of the 16 patients who developed PTH following DC, 9 received a VP shunt. The rate of flap failure was similar across the 9 PTH patients who received a shunt and the 7 PTH patients who did not receive a shunt (33% vs. 57% failure rate, respectively, p = 0.341).

CONCLUSION

Autologous cranioplasty is a reasonably successful procedure with a flap failure rate of 14.2%. We identified PTH, persistent neurological deficits, and reoperation prior to cranioplasty as significant predictors of autologous cranioplasty failure. Interestingly, the presence of VP shunt did not impact the odds of flap failure.

Evidence of linear bone flap resorption in patients undergoing autologous cranioplasty following decompressive craniectomy: A 3D Slicer segmented analysis of serial CT images

OBJECTIVES

Autologous cranioplasty (CP) following decompressive craniectomy (DC) carries risk of bone flap resorption (BFR). The current literature offers limited information regarding the natural progression of BFR, and the rate at which it occurs. We aim to characterize the progression of BFR over time and elucidate risk factors for accelerated BFR.

METHODS

A retrospective analysis was conducted on patients who underwent DC and autologous CP. Serial computed tomography (CT) images were used to quantify degree of BFR over time. Risk factors included age, diabetes, smoking status, flap fragmentation, defect size, and DC-CP time interval. Chi-square analyses and Student's t-tests were performed to examine differences between patients who experienced BFR and those who did not.

RESULTS

Overall, 82% of patients demonstrated evidence of clinically relevant resorption on CT. On average, the bone flap decreased in volume by 36.7% within the first year, with a linear loss in volume after multiple years of follow-up. Individuals who developed greater BFR were significantly younger (43 ± 17 vs. 56 ± 12, p=0.022), had a lower incidence of diabetes (5.9% vs. 43%, p=0.037), and had more bone flap fragments (1.4 ± 0.67 vs. 1.00 ± 0, p <0.001) than those who did not.

CONCLUSION

Resorption following CP with cryopreserved bone appears to progress in a fairly linear and continuous fashion over time. Using serial CT images, we found a resorption rate of 82% at our institution. We identified several possible risk factors for resorption, including flap fragmentation, younger age, and absence of diabetes.

Evaluating the Inaccuracy of the National Surgical Quality Improvement Project Surgical Risk Calculator in Plastic Surgery: A Meta-analysis of Short-Term Predicted Complications

BACKGROUND

Preoperative surgical risk assessment is a major component of clinical decision making. The ability to provide accurate, individualized risk estimates has become critical because of growing emphasis on quality metrics benchmarks. The American College of Surgeons National Surgical Quality Improvement Project (NSQIP) Surgical Risk Calculator (SRC) was designed to quantify patient-specific risk across various surgeries. Its applicability to plastic surgery is unclear, however, with multiple studies reporting inaccuracies among certain patient populations. This study uses meta-analysis to evaluate the NSQIP SRC's ability to predict complications among patients having plastic surgery.

METHODS

OVID MEDLINE and PubMed were searched for all studies evaluating the predictive accuracy of the NSQIP SRC in plastic surgery, including oncologic reconstruction, ventral hernia repair, and body contouring. Only studies directly comparing SCR predicted to observed complication rates were included. The primary measure of SRC prediction accuracy, area under the curve (AUC), was assessed for each complication via DerSimonian and Laird random-effects analytic model. The I2 statistic, indicating heterogeneity, was judged low (I2 < 50%) or borderline/unacceptably high (I2 > 50%). All analyses were conducted in StataSE 16.1 (StataCorp LP, College Station, Tex).

RESULTS

Ten of the 296 studies screened met criteria for inclusion (2416 patients). Studies were classified as follows: (head and neck: n = 5, breast: n = 1, extremity: n = 1), open ventral hernia repair (n = 2), and panniculectomy (n = 1). Predictive accuracy was poor for medical and surgical complications (medical: pulmonary AUC = 0.67 [0.48-0.87], cardiac AUC = 0.66 [0.20-0.99], venous thromboembolism AUC = 0.55 [0.47-0.63]), (surgical: surgical site infection AUC = 0.55 [0.46-0.63], reoperation AUC = 0.54 [0.49-0.58], serious complication AUC = 0.58 [0.43-0.73], and any complication AUC = 0.60 [0.57-0.64]). Although mortality was accurately predicted in 2 studies (AUC = 0.87 [0.54-0.99]), heterogeneity was high with I2 = 68%. Otherwise, heterogeneity was minimal (I2 = 0%) or acceptably low (I2 < 50%) for all other outcomes.

CONCLUSIONS

The NSQIP Universal SRC, aimed at offering individualized quantifiable risk estimates for surgical complications, consistently demonstrated poor risk discrimination in this plastic surgery-focused meta-analysis. The limitations of the SRC are perhaps most pronounced where complex, multidisciplinary reconstructions are needed. Future efforts should identify targets for improving SRC reliability to better counsel patients in the perioperative setting and guide appropriate healthcare resource allocation.

Re-evaluating the need for orthopantomography in the management of mandibular trauma: is computed tomography enough?

BACKGROUND

Mandibular fractures are frequent indications for computed tomography (CT) and orthopantomography (OPG) scans in emergency rooms. Numerous studies found CT to have higher sensitivity and enhanced accuracy compared to OPG in diagnosing mandible fractures. Controversy exists regarding additional need for OPG when evaluating dental trauma. This study investigates whether OPG adds diagnostic value to CT in mandibular trauma and whether additional OPG significantly alters management.

METHODS

A retrospective chart review identified 100 patients ≥ 18 years of age with known mandibular trauma who received CT and OPG in the emergency department between May 2015 and January 2020. All patients demonstrated a fracture in at least one study. CT and OPG studies were anonymized and randomized. A single attending surgeon evaluated mandible fracture and dental trauma characteristics and subsequently compared findings.

RESULTS

One hundred patient CT and OPG scans were reviewed. CT detected mandible fractures in all patients and OPG detected fractures in 93% (p = 0.01). Twenty-eight patients had different findings between scans. CT demonstrated 1 or more additional fracture(s) than OPG in 20 patients and dental trauma not seen on OPG in 4. OPG detected 1 fracture and no dental trauma that was not seen on CT. CT drove treatment-determining differences in 17 cases and OPG in 0 cases.

CONCLUSIONS

CT appears efficacious in detecting clinically significant mandible fractures and dental trauma with little additional benefit from OPG in emergency settings. Helical CT may be the only imaging necessary in evaluating patients with such trauma.

Comparing diagnosis of midfacial fractures by radiologists and plastic surgeons

BACKGROUND

Clinicians who manage facial fractures often rely on radiologist interpretations to help with assessment and management. Among treating physicians, facial fractures are categorized into clinically relevant patterns of injury. On the other hand, while radiologists are unsurpassed at identifying individual breaks in the bone, larger fracture patterns are not always conveyed in radiology reports.

PURPOSE

This study aims to assess the frequency with which the terminology describing midfacial fracture patterns is concordant among radiologists and treating clinicians.

METHODS

The authors identified patients with different patterns of midfacial injury including Le Fort I, Le Fort II, Le Fort III, naso-orbito-ethmoid (NOE), and zygomaticomaxillary complex (ZMC) fractures. Plastic surgery consult notes and radiological imaging reports were reviewed for concordance in documentation of injury patterns. Identification of individual fractures consistent with the diagnosed fracture pattern was also recorded.

RESULTS

Radiologists were noted to be highly successful in describing individual fractures of the facial bones, identifying at least two defining components of a fracture pattern in 96% of Le Fort, 88% of NOE, and 94% of ZMC injuries. However, when injury patterns were considered, only 32% of Le Fort, 28% of ZMC, and 6% of NOE fractures were explicitly identified in radiology reports.

CONCLUSIONS

Radiologists are highly skilled in discerning individual fractures in facial trauma cases. However, less reliability was seen in the identification of fracture patterns in midfacial injury, with particular weaknesses in descriptions of NOE and ZMC fractures. This data suggests that greater focus on patterns of midfacial injury would improve the clinical applicability of radiological reports.

Subgaleal drains may be associated with decreased infection following autologous cranioplasty: a retrospective analysis

BACKGROUND

Autologous bone is often the first choice in cranioplasty following a decompressive craniectomy. However, infection is a common complication, with reported rates up to 25%. While the incidence and management of infection are well documented, the risk factors associated with infection remain less clear. The current study aims to identify predictors of infection risk following autologous cranioplasty.

METHODS

A retrospective analysis was conducted on patients who underwent decompressive craniectomy and cranioplasty using cryopreserved autologous bone flaps between 2010 and 2020. Patient demographics and factors related to both surgeries and infection rates were recorded from patient records. Logistic regressions were conducted to determine which factors were implicated in the development of infection.

RESULTS

In our cohort, 126 patients underwent autologous cranioplasty. A total of 10 patients (7.9%) developed an infection following reconstruction, with half resulting in implant failure. We did not identify any significant risk factors for infection. Regression analysis identified placement of subgaleal drain following cranioplasty as a protective factor against the development of infection (OR: 0.16, p = 0.007). On average, drains remained in for 3 days, with no difference between the length of drains for those with infection vs. those without (p = 0.757).

CONCLUSIONS

The current study demonstrates an infection rate of 7.9% in patients who receive an autologous cranioplasty following decompressive craniectomy, which is consistent with previous data. Half (4%) of patients who experienced an infection ultimately required removal of the implant. While it is common practice for neurosurgeons to use drains to prevent hematomas and fluid collections, we found that subgaleal drain placement following cranioplasty was associated with decreased infection, thus demonstrating another benefit of a commonly used tool.

Refining Indications for Orbital Floor Fracture Reconstruction: A Risk-Stratification Tool Predicting Symptom Development and Need for Surgery

BACKGROUND

Challenges in orbital floor fracture management include delayed symptom onset and controversial surgical indications based on radiographic findings. This study assessed which imaging characteristics most reliably predict symptomatology to generate a tool quantifying individual need for surgery on initial presentation.

METHODS

The clinical course for all patients with isolated orbital fractures at a single institution from 2015 to 2017 were reviewed. Trauma mechanism, computed tomographic scan findings, and symptoms necessitating surgery (diplopia, enophthalmos) were noted. Univariable and multivariable regression modeling was used to generate a predictive risk model for operative fractures.

RESULTS

One hundred twenty-one patients with isolated orbital fractures were identified. Mechanism of injury included falls (41 percent), assault (37 percent), and vehicular trauma (17 percent). Patient follow-up averaged 4.4 ± 4.8 months. Average orbital floor fracture area was 2.4 cm2 (range, 0.36 to 6.18 cm2), and orbital volume herniation averaged 0.70 cm3 (range, 0.01 to 4.23 cm3). Twenty-one patients (17.3 percent) required surgical intervention for symptomatic fractures. The strongest predictors of symptoms were orbital volume increase greater than 1.3 cm3 (OR, 10.5; p = 0.001) and inferior rectus displacement within/below the fracture line (OR, 3.7; p = 0.049). Mechanical fall was risk-reducing (OR, 0.08; p = 0.005). Symptom risk was stratified from low (3.6 percent) to high risk (71 percent) (C-statistic = 0.90). The volume of herniated orbital contents was significantly more predictive of symptoms than fracture area (C-statistic = 0.81 versus C-statistic = 0.66; p = 0.02).

CONCLUSIONS

The proposed risk tool allows highly accurate, early prediction of symptomatic orbital floor fractures. Findings suggest that orbital volume change, not fracture area, more reliably informs operative indications, along with inferior rectus muscle caudal malposition. A simplified stepwise decision algorithm demonstrates the potential utility of this risk-assessment tool.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Changes in Academic Plastic Surgery Programs During the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic has presented unprecedented challenges for surgical teaching programs, as operating rooms closed and resources were redirected for patient care. As a result, both educational challenges and opportunities emerged. The objective of this study was to assess the changes used by plastic surgery programs as a result of the pandemic.

METHODS

A 34-question American Council of Academic Plastic Surgeons-approved survey was distributed on April 29, 2020, to attendings in academic plastic surgery programs in the United States. Variables were controlled whenever multiple attending responses were submitted from the same program.

RESULTS

A total of 113 attendings, including 30 (27.8%) program directors, responded to the survey. Most respondents were located in the northeast (41.4%). The average percentage of elective case volume was 23% of pre-COVID states. Those who reported a decrease in emergent surgical case volume (55.2%) estimated it to be at an average of 45% of the normal. Almost all the respondents (95.6%) agreed that they were working fewer hours than usual, and 40.9% of those reported a decrease of more than 20 hours per week of work. Most attendings (82.1%) also reported a decrease in their monthly salary. The percentage projected current salary compared with normal was 85%.

CONCLUSIONS

Our survey data suggest that academic plastic surgery programs have had impactful changes to their operative and educational schedules, teaching, revenue, and patient care. The data described in this study could be used as a baseline for future pandemics affecting plastic surgery programs to help strategize their operational and educational structures.

A modern multidisciplinary approach to a large cervicothoracic chordoma using staged en bloc resection with intraoperative image-guided navigation and 3D-printed modeling: illustrative case

BACKGROUND

Cervicothoracic junction chordomas are uncommon primary spinal tumors optimally treated with en bloc resection. Although en bloc resection is the gold standard for treatment of mobile spinal chordoma, tumor location, size, and extent of involvement frequently complicate the achievement of negative margins. In particular, chordoma involving the thoracic region can require a challenging anterior access, and en bloc resection can lead to a highly destabilized spine.

OBSERVATIONS

Modern technological advances make en bloc resection more technically feasible than ever before. In this case, the successful en bloc resection of a particularly complex cervicothoracic junction chordoma was facilitated by a multidisciplinary surgical approach that maximized the use of intraoperative computed tomography–guided spinal navigation and patient-specific three-dimensional–printed modeling.

LESSONS

The authors review the surgical planning and specific techniques that facilitated the successful en bloc resection of this right-sided chordoma via image-guided parasagittal osteotomy across 2 stages. The integration of emerging visualization technologies into complex spinal column tumor management may help to provide optimal oncological care for patients with challenging primary tumors of the mobile spine.

A 3-Dimensional-Printed Hand Model for Home-Based Acquisition of Fracture Fixation Skills Without Fluoroscopy

OBJECTIVE

To design a low cost ($40), realistic and fluoroscopy-free percutaneous Kirschner wire hand fracture fixation training instrument kit for home-based skill acquisition during the COVID-19 pandemic.

DESIGN

A 3D-printed hand was designed from a computed tomography scan of a healthy hand. These data were used to create replaceable hand and wrist bones and reusable silicone molds for a replica of the soft tissue envelope. The model is currently being integrated into the simulation curriculum at 2 integrated plastic surgery residency programs for training in percutaneous wire fixation of hand fractures.

SETTING

Brown University, Warren Alpert Medical School of Brown University. Department of Surgery, Division of Plastic and Reconstructive Surgery. Large academic quaternary referral institution. Yale University, Yale School of Medicine. Department of Surgery, Division of Plastic and Reconstructive Surgery. Large academic quaternary referral institution.

PARTICIPANTS

PGY 1-4 plastic surgery residents preparing to meet ACGME Accreditation for Graduate Medical Education hand surgery specific milestones.

RESULTS

A realistic and durable 3D model with interchangeable bones allows trainees to practice the key motor skills necessary for successful fixation of hand and wrist fractures with K-wires in a home-based setting.

CONCLUSIONS

A low cost, realistic and durable 3D hand model with interchangeable bones allows easy integration into any home-based hand surgery curriculum. With 3D printers and programming becoming more prevalent and affordable, such models offer a means of low-cost and safe instruction of residents in fracture fixation with no harm to patients.

Comparison of 2 Sagittal Craniosynostosis Repair Techniques: Spring-Assisted Surgery Versus Endoscope-Assisted Craniectomy With Helmet Molding Therapy

INTRODUCTION

This study compares anthropometric outcomes of 2 sagittal synostosis repair techniques: spring-assisted surgery and endoscope-assisted craniectomy with molding helmet therapy.

METHODS

Patients undergoing spring-assisted surgery (n = 27) or endoscope-assisted craniectomy with helmet therapy (n = 40) at separate institutions were retrospectively reviewed. Pre- and 1-year postoperative computed tomography (CT) or laser scans were analyzed for traditional cranial index (CI), adjusted cranial index (aCI), and cranial vault volume (CVV). Nine patient-matched scans were analyzed for measurement consistency.

RESULTS

The spring-assisted group was older at both time points (P < .050) and spring-assisted group CVV was larger preoperatively and postoperatively (P < .01). However, the change in CVV did not differ between the groups (P = .210). There was no difference in preoperative CI (helmet vs spring: 70.1 vs 71.2, P = .368) between the groups. Postoperatively, helmet group CI (77.0 vs 74.3, P = .008) was greater. The helmet group also demonstrated a greater increase in CI (6.9 vs 3.1, P < .001). The proportion of patients achieving CI of 75 or greater was not significantly different between the groups (helmet vs spring: CI, 65% vs 52%, P = .370). There was no detectable bias in CI between matched CT and laser scans. Differences were identified between scan types in aCI and CVV measurements; subsequent analyses used corrected CVV and aCI measures for laser scan measures.

CONCLUSIONS

Both techniques had equivalent proportions of patients achieving normal CI, comparable effects on cranial volume, and similar operative characteristics. The study suggests that there may be greater improvement in CI in the helmet group. However, further research should be performed.

Three-Dimensional Printed Anatomic Modeling for Surgical Planning and Real-Time Operative Guidance in Complex Primary Spinal Column Tumors: Single-Center Experience and Case Series

OBJECTIVE

Three-dimensional (3D) printing has emerged as a visualization tool for clinicians and patients. We sought to use patient-specific 3D-printed anatomic modeling for preoperative planning and live intraoperative guidance in a series of complex primary spine tumors.

METHODS

Over 9 months, patients referred to a single neurosurgical provider for complex primary spinal column tumors were included. Most recent spinal magnetic resonance and computed tomography (CT) imaging were semiautomatically segmented for relevant anatomy and models were printed using polyjet multicolor printing technology. Models were available to surgical teams before and during the operative procedure. Patients also viewed the models preoperatively during surgeon explanation of disease and surgical plan to aid in their understanding.

RESULTS

Tumor models were prepared for 9 patients, including 4 with chordomas, 2 with schwannomas, 1 with osteosarcoma, 1 with chondrosarcoma, and 1 with Ewing-like sarcoma. Mean age was 50.7 years (range, 15-82 years), including 6 males and 3 females. Mean tumor volume was 129.6 cm³ (range, 3.3-250.0 cm³). Lesions were located at cervical, thoracic, and sacral levels and were treated by various surgical approaches. Models were intraoperatively used as patient-specific anatomic references throughout 7 cases and were found to be technically useful by the surgical teams.

CONCLUSIONS

We present the largest case series of 3D-printed spine tumor models reported to date. 3D-printed models are broadly useful for operative planning and intraoperative guidance in spinal oncology surgery.

Revisiting the Resolution of Chiari Malformation in Nonsyndromic Craniosynostosis: A Case of Posterior Cranial Vault Reconstruction in Secondary Pan-Suture Synostosis

BACKGROUND

While commonly seen in syndromic craniosynostosis, the incidence of Chiari malformation (CM) in nonsyndromic craniosynostosis has been reported at 5% and there is a lack of understanding of the pathophysiology and management of CM in this patient population.

CASE DESCRIPTION

We present a 5-year-old male patient who underwent a sagittal craniosynostosis repair at the age of 5 months and returned at the age of 5 years with daily headaches associated with behavioral changes. He was found to have pan-synostoses and radiographic evidence of increased intracranial pressure, including a Chiari malformation. Neurologic and genetic workup was unremarkable. A cranial vault reconstruction was performed, and subsequent imaging demonstrated resolution of previously noted Chiari malformation.

CONCLUSIONS

In our case, we provided a unique window into the underlying pathophysiology for CM in patients with concurrent nonsyndromic craniosynostosis that we hope will add to the current foundation of literature supporting the intricate relation between cranial vault compliance and Chiari malformation or hindbrain herniation. Furthermore, we provide insight into the management of acquired CM and support isolated cranial vault reconstruction in those who do not appear to have symptomatic suboccipital compression.

A 3D printed suturing trainer for medical students

BACKGROUND

Medical students must be able to suture competently upon graduation. To learn suturing technique, students must have access to practice materials. The purpose of this pilot study was to develop a novel suturing trainer and to evaluate its ability to provide realistic and accessible suturing practice. A cohort of senior students at one institution compared the device with standard suture-training media (porcine feet and sponges).

METHODS

Using 3D printing and silicone casting, a novel suturing trainer was developed and a cohort of senior medical students trialed the device in a standardised suturing workshop. Participants evaluated the novel suturing trainer, porcine feet and sponges for simulating human tissue with regard to: (i) tissue layers; (ii) tissue texture; (iii) ability to perform interrupted suturing; (iv) running subcuticular suturing; and (v) knot tying.

RESULTS

Compared with porcine feet and sponges, the suturing trainer had significantly higher mean scores (p < 0.001) for the simulation of human tissue layers and texture, as well as for the ability to facilitate the practice of interrupted suturing, running suturing and knot tying. All (n = 32) participants identified the silicone trainer as the best tool upon which to practice suturing, and 92% (n = 23) responded that their suturing skills would improve if the silicone trainer replaced porcine feet and sponges.

DISCUSSION

The silicone suturing device provides a more realistic and accessible suture learning experience than porcine feet and sponges. Further validation is required to assess its long-term effectiveness in medical education.

Underdiagnosis of Nasoorbitoethmoid Fractures in Patients with Zygoma Injury

BACKGROUND

Nasoorbitoethmoid fractures commonly accompany midface fractures and may be underdiagnosed, resulting in incomplete reconstruction or inadequate treatment following facial trauma. To better understand the nasoorbitoethmoid fracture diagnosis and treatment tendencies, the authors analyzed concomitant nasoorbitoethmoid injuries in the setting of zygoma fractures.

METHODS

The facial trauma database at a level I trauma center was evaluated. All patients with diagnosed zygoma fractures from June of 2011 to March of 2016 were assessed for a concomitant nasoorbitoethmoid injury. Documentation of these fractures in radiology, plastic surgery, and operative notes was recorded, as was the rate of nasoorbitoethmoid fracture surgical repair.

RESULTS

The authors identified 339 eligible patients and completed retrospective analysis of computed tomographic images for their 356 zygoma fractures. The incidence of concomitant nasoorbitoethmoid fractures was 30.6 percent (109 of 356). Documentation rates of nasoorbitoethmoid fractures were 0 percent, 3.7 percent, and 8.3 percent in radiology, plastic surgery, and operative notes, respectively. The rate of surgical correction of nasoorbitoethmoid injuries was 22.9 percent (25 of 109). Of those fractures identified, 44.9 percent (49 of 109) were minimally displaced or nondisplaced. Subset analysis of only significantly displaced fractures yielded an incidence of 16.8 percent (60 of 356). Of significantly displaced fractures, documentation rates were 0 percent, 6.7 percent, and 16.8 percent in radiology, plastic surgery, and operative notes, respectively. The surgical repair rate of significantly displaced fractures was 31.7 percent (19 of 60).

CONCLUSIONS

These findings suggest a high concomitance rate of nasoorbitoethmoid fractures with zygoma fractures and identify a tendency to underdocument and undertreat this injury pattern. Clinicians managing patients with midface trauma should have a high suspicion for nasoorbitoethmoid trauma. Plastic surgeons and radiologists should be better trained in identifying the nasoorbitoethmoid fracture pattern.

Complex wound closure by plastic surgery following resection of spinal neoplasms minimizes postoperative wound complications in high-risk patients

OBJECTIVE

Wound breakdown and infection are common postoperative complications following resection of spinal neoplasms. Accordingly, it has become common practice at some centers for plastic surgeons to assist with closure of large posterior defects after spine tumor resection. In this study, the authors tested the hypothesis that plastic surgery closure of complex spinal defects improves wound outcomes following resection of spinal neoplastic disease.

METHODS

Electronic medical records of consecutive patients who underwent resection of a spinal neoplasm between June 2015 and January 2019 were retrospectively reviewed. Patients were separated into two subpopulations based on whether the surgical wound was closed by plastic surgery or neurosurgery. Patient demographics, preoperative risk factors, surgical details, and postoperative outcomes were collected in a central database and summarized using descriptive statistics. Outcomes of interest included rates of wound complication, reoperation, and mortality. Known preoperative risk factors for wound complication in spinal oncology were identified based on literature review and grouped categorically. The presence of each category of risk factors was then compared between groups. Univariate and multivariate linear regressions were applied to define associations between individual risk factors and wound complications.

RESULTS

One hundred six patients met inclusion criteria, including 60 wounds primarily closed by plastic surgery and 46 by neurosurgery. The plastic surgery population included more patients with systemic metastases (58% vs 37%, p = 0.029), prior radiation (53% vs 17%, p < 0.001), prior chemotherapy (37% vs 15%, p = 0.014), and sacral region tumors (25% vs 7%, p = 0.012), and more patients who underwent procedures requiring larger incisions (7.2 ± 3.6 vs 4.5 ± 2.6 levels, p < 0.001), prolonged operative time (413 ± 161 vs 301 ± 181 minutes, p = 0.001), and greater blood loss (906 ± 1106 vs 283 ± 373 ml, p < 0.001). The average number of risk factor categories present was significantly greater in the plastic surgery group (2.57 vs 1.74, p < 0.001). Despite the higher relative risk, the plastic surgery group did not experience a significantly higher rate of wound complication (28% vs 17%, p = 0.145), reoperation (17% vs 9%, p = 0.234), or all-cause mortality (30% vs 13%, p = 0.076). One patient died from wound-related complications in each group (p = 0.851). Regression analyses identified diabetes, multilevel instrumentation, and BMI as the factors associated with the greatest wound complications.

CONCLUSIONS

Involving plastic surgery in the closure of spinal wounds after resection of neoplasms may ameliorate expected increases in wound complications among higher-risk patients.

Partial Suture Fusion in Nonsyndromic Single-Suture Craniosynostosis

INTRODUCTION

Partial synostosis of cranial sutures has been shown to have clinical and diagnostic significance. However, there is limited published information about how suture fusion progresses over time. In this study, we evaluate patients with nonsyndromic single-suture synostosis. We aim to define the incidence of partial versus complete suture fusion and whether a correlation exists between the degree of suture fusion and age.

METHODS

Two hundred fifty-four patients with nonsyndromic single-suture synostosis were evaluated. Preoperative computed tomography (CT) scans were rendered in 3-dimensions, all sutures were visualized and assessed for patency or fusion, and length of fusion was measured. Findings were grouped according to suture type (sagittal, coronal, metopic, or lambdoid), the degree of fusion (full, >50%, or <50%), and patient age at time of CT scan (0-90, 91-180, 181-360, or >360 days). Data were analyzed to correlate patient age versus the degree of suture fusion.

RESULTS

For all patients, 72% had complete and 28% had partial synostosis. Ratios of full to partial fusion for each suture type were as follows: sagittal 97:36, coronal 35:22, metopic 46:4, and lambdoid 4:10. The sagittal, coronal, and metopic groups demonstrated greater probabilities of complete suture fusion as patient age increases (P = .021, P < .001, P = .001, respectively). This trend was also noted when all sutures were considered together by age-group (P < .001).

CONCLUSION

We note a partial suture fusion rate of 28.3%. Our analysis shows a correlation between the extent of suture synostosis and patient age. Finally, we demonstrate that different sutures display different patterns of partial and complete fusion.

Introduction of Medical Three-Dimensional Printing in Rhode Island

Since the early 2000s, three-dimensional (3D) printing has become a well-rounded, evolving technology which has begun to revolutionize healthcare. 3D printing enables rapid creation and manufacture of individual patient models from original designs or medical imaging data. These models can be used for surgical planning, procedural training for residents and medical students, and the design and manufacture of surgical instruments, implants and prostheses. Current availability of this advanced technology at the Lifespan 3D Printing Lab permits Rhode Island physicians to utilize 3D printing in multiple, diverse settings to help improve their medical practice and optimize healthcare outcomes. This article describes three case-based examples to demonstrate varies used of 3D printing in Medicine.

Incidence of Palatal Fistula at Time of Secondary Alveolar Cleft Reconstruction

OBJECTIVE

We aim to establish consistent time points for evaluating palatal fistula incidence to standardize reporting practices and clarify prospective literature.

DESIGN

An institutional retrospective chart review was conducted on 76 patients with unilateral or bilateral complete cleft lip and palate who underwent secondary alveolar bone grafting between 2006 and 2015.

MAIN OUTCOME MEASURES

Early fistula incidence rates were reported prior to maxillary expansion, and late fistula rates were reported at the time of alveolar bone grafting. Fistula recurrence rates after primary repair were also measured.

RESULTS

We found an early fistula incidence rate of 20% (n = 15) and a late fistula rate of 55% (n = 42) at the time of secondary ABG. Fistulae recurred after initial repair in 43% of cases. Fistulae were classified using the Pittsburgh Classification System as type III (33%), type IV (60%), or type V (7%). The presence of a bilateral cleft ( P = 0.01) and history of early fistula repair ( P < 0.01) were associated with late fistula incidence in a univariate analysis. In a logistic regression model, only early fistula repair was associated with late fistula incidence (OR = 17.17) and overall likelihood of recurrence (OR = 70.89).

CONCLUSIONS

Early fistulae should be reported prior to orthodontic expansion of the maxillary arch. Late fistulae should be reported at the time of ABG, following palatal expansion. Patients who develop an early fistula after palatoplasty are likely to experience recurrent fistula formation.

Gnathodiaphyseal dysplasia: Severe atypical presentation with novel heterozygous mutation of the anoctamin gene (ANO5)

Gnathodiaphyseal dysplasia (GDD; OMIM #166260) is an ultra-rare autosomal dominant disorder caused by heterozygous mutation in the anoctamin 5 (ANO5) gene and features fibro-osseous lesions of the jawbones, bone fragility with recurrent fractures, and bowing/sclerosis of tubular bones. The physiologic role of ANO5 is unknown. We report a 5-year-old boy with a seemingly atypical and especially severe presentation of GDD and unique ANO5 mutation. Severe osteopenia was associated with prenatal femoral fractures, recurrent postnatal fractures, and progressive bilateral enlargement of his maxilla and mandible beginning at ~2months-of-age that interfered with feeding and speech and required four debulking operations. Histopathological analysis revealed benign fibro-osseous lesions resembling cemento-ossifying fibromas of the jaw without psammomatoid bodies. A novel, de novo, heterozygous, missense mutation was identified in exon 15 of ANO5 (c.1553G>A; p.Gly518Glu). Our findings broaden the phenotypic and molecular spectra of GDD. Fractures early in life with progressive facial swelling are key features. We assessed his response to a total of 7 pamidronate infusions commencing at age 15months. Additional reports must further elucidate the phenotype, explore any genotype-phenotype correlation, and evaluate treatments.

Predicting Adverse Perioperative Events in Patients Undergoing Primary Cleft Palate Repair

Objective:

This study aimed to identify risk factors for adverse perioperative events (APEs) after cleft palatoplasty to develop an individualized risk assessment tool.

Design:

Retrospective cohort.

Setting:

Tertiary institutional.

Patients:

Patients younger than 2 years with cleft palate. Interventions: Primary Furlow palatoplasty between 2008 and 2011.

Main Outcome Measure(s):

Adverse perioperative event, defined as laryngo- or bronchospasm, accidental extubation, reintubation, obstruction, hypoxia, or unplanned intensive care unit admission.

Results:

Three hundred patients averaging 12.3 months old were included. Cleft distribution included submucous, 1%; Veau 1, 17.3%; Veau 2, 38.3%; Veau 3, 30.3%; and Veau 4, 13.0%. Pierre Robin (n = 43) was the most prevalent syndrome/anomaly. Eighty-three percent of patients received reversal of neuromuscular blockade, and total morphine equivalent narcotic dose averaged 0.19 mg/kg. Sixty-nine patients (23.0%) had an APE, most commonly hypoventilation (10%) and airway obstruction (8%). Other APEs included reintubation (4.7%) and laryngobronchospasm (3.3%). APE was associated with multiple intubation attempts (odds ratio [OR] = 6.6, P = .001), structural or functional airway anomaly (OR = 4.5, P < .001), operation >160 minutes (OR = 2.2, P = .04), narcotic dose >0.3 mg/kg (OR = 2.3, P = .03), inexperienced provider (OR = 2.1, P = .02), and no paralytic reversal administration (OR = 2.0, P = .049); weight between 9 and 13 kg was protective (OR = 0.5, P = .04). Patients were risk-stratified according to individual profiles as low, average, high, or extreme risk (APE 2.5%-91.7%) with excellent risk discrimination (C-statistic = 0.79).

Conclusions:

APE incidence was 23.0% after palatoplasty, with a 37-fold higher incidence in extreme-risk patients. Individualized risk assessment tools may enhance perioperative clinical decision making to mitigate complications.

The Temporal Region in Unilateral Coronal Craniosynostosis: Fronto-orbital Advancement Versus Endoscopy-Assisted Strip Craniectomy

OBJECTIVE

To compare postoperative temporal expansion in patients treated with fronto-orbital advancement or endoscopy-assisted craniectomy with cranial orthotic therapy.

DESIGN

This is a retrospective, multicenter cohort study of patients with unilateral coronal craniosynostosis (UCS).

SETTING

Computed tomographic (CT) scans were drawn from UCS patients treated at Boston Children's Hospital or St Louis Children's Hospital.

PATIENTS

The study included 56 patients with UCS after fronto-orbital advancement (n = 32) or endoscopic repair (n = 24) and 10 age-matched controls.

INTERVENTION

Fronto-orbital advancement entails a craniotomy of the frontal bone and superior orbital rim followed by reshaping and forward advancement. Endoscopic repair is the release of the synostotic suture and guidance of further growth of the cranium using a molding orthotic.

MAIN OUTCOME MEASURES

Measures included posterior temporal width, anterior temporal width, orbital width, and anterior cranial fossa area taken preoperatively and 1 year postoperatively. Linear regression was performed to assess 1 year postoperative improvement in symmetry; covariates included preoperative symmetry and type of surgery.

RESULTS

Both treatments showed improvement in orbital width and anterior cranial fossa area symmetry 1 year postoperatively ( P < .001), but no significant improvement in posterior or anterior temporal width symmetry. Linear regression revealed no difference between the 2 procedures in any of the 4 measurements (.096 ≤ P ≤ .898).

CONCLUSIONS

Fronto-orbital advancement and endoscopic repair show equivalent outcomes 1 year postoperatively in all 3 width measurements and anterior cranial fossa area. Neither procedure produced significant improvement in temporal width.