Reply

Abstract

Sir:FigureThank you for giving us the opportunity to respond to Dr. Dediol's insightful comments regarding our published article on the differences in diagnostic accuracy of two-dimensional and three-dimensional tomographic images in the hands (and eyes) of various specialists with different degrees of experience. A few of Dr. Dediol's statements deserve particular attention. Although our results do corroborate several published reports on this topic, we disagree with the notion that our results are “predictable.” There were several notable findings that, as physicians who are regularly involved in the triage, diagnosis, and surgical management of craniofacial trauma patients at two busy trauma referral centers, we found to be somewhat surprising. For example, the fact that residents who reviewed three-dimensional computed tomographic scans were able to diagnose fractures and identify indications for surgical management as accurately as attending physicians is not necessarily intuitive and was an unexpected observation. We anticipated that experienced practitioners would have a diagnostic edge and greater insight into operable fractures, regardless of imaging modality, but in this case technology seemed to trump experience. Although this finding may be “logical,” it is novel and not necessarily banal. Nor is it readily apparent that neuroradiologists would have a higher false-positive read rate than surgeons; practitioners who heavily rely on their radiologist's interpretation in planning patient management might find this particular observation of great interest. We respect and share Dr. Dediol's opinion regarding the importance of two-dimensional multiplanar tomography, but we would argue that dismissing the value of three-dimensional reconstruction as merely a “convenient adjunct … for quick and rough orientation” is somewhat shortsighted. In our experience, the three-dimensional image is a valuable tool for patient education and preoperative counseling, as patients and their families tend to appreciate and comprehend these types of images better than axial, coronal, or sagittal cuts. In addition, more than just a “useful upgrade,” we use three-dimensional renderings for presurgical planning and in the operating room to assist in surgical execution, particularly in complex pattern panfacial fractures or severely comminuted zygomaticomaxillary complex fractures. This helps us not only as surgeons but also as educators of residents and fellows, as we receive regular positive feedback on the value of three-dimensional imaging as a useful educational tool. It seems that this is not just an example of technology in search of a new home but also a representation of data that complement the two-dimensional images. We agree wholeheartedly that differences among surgical subspecialties charged with the management of facial fractures are related to geography, but not only based on “scope of work,” as Dr. Dediol states. Factors that contribute to predominant referral patterns include, but are not solely limited to, exposure to and experience with facial trauma management during residency training, the interest of individual practitioners in developing their facial trauma practice, the dynamics among various divisions and departments within a given institution, the presence or absence of “dominant” facial trauma surgeons or facilities within a given region, financial considerations (e.g., surgeon and institution reimbursement rates), and the organization of the local trauma triage infrastructure that delivers facial trauma patients into the health care delivery system. There is an ongoing discussion in the United States regarding definitions of scope of practice among the different groups of surgical subspecialists that operate above the clavicles. Recent legislative focus has been on facial cosmetic procedures. A similarly impassioned discourse regarding who should or should not be performing maxillofacial trauma reconstruction is lacking, possibly because the scale of reimbursement for these cases relative to aesthetic surgery is drastically lower. We therefore believe that our study offers valuable insights and novel perspectives that are universally applicable and not just relevant to practice in the United States only, as Dr. Dediol suggests. For example, oral surgeons in our study had a significantly lower ability to diagnose orbital fractures, regardless of imaging modality. We surmise that this is attributable to limited experience with orbital surgery during oral surgery residency training. One rather simplistic way of looking at it is this: would you want an oral surgeon with limited experience in orbital surgery responsible for diagnosing your orbital floor fracture and then repairing it with a cranial bone graft? Would your answer be the same in Los Angeles as it would be in Zagreb? We would suggest that unless training patterns in Croatia—or any other country for that matter—among subspecialist groups are so uniform that levels of experience with diagnosis and treatment of various forms of head and neck abnormalities are accurately and reliably predictable, studies such as ours provide useful information to physicians, patients, administrators, researchers, and third-party payers alike. Reza Jarrahy, M.D. James P. Bradley, M.D. Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, Los Angeles, Calif.