Facial Trauma Surgeons Research Articles

Intermaxillary Fixation in the Primary and Mixed Dentition.

Anatomic differences of the primary dentition may hinder traditional methods of intermaxillary fixation. Furthermore, the presence of both the primary and permanent dentition can complicate establishing, and maintaining, the preinjury occlusion. The treating surgeon must be aware of these differences for optimal treatment outcomes. This article discusses and illustrates methods that facial trauma surgeons can use to establish intermaxillary fixation in children aged 12 years and younger.

Shared Decision-Making in Patients Seeking Surgery for Facial Trauma: The Role of Decisional Conflict and Perceived Discrimination.

Background: Shared decision-making (SDM) may facilitate challenging discussions between patients with facial trauma and reconstructive surgeons. Objective: To determine among patients seeking surgical evaluation for facial trauma, whether patient demographics, decisional conflict (DC), or experiences of discrimination in health care are associated with patient perceptions of SDM, as measured by scored responses on the CollaboRATE-10 questionnaire. Methods: English-speaking adults who presented to the offices of five facial trauma surgeons were contacted by telephone after their visit to complete a cross-sectional survey. Results: After screening 247 patients, 131 patients were recruited (53.0%). DC and history of discrimination were associated with lower perceived SDM (p < 0.001 and p = 0.048, respectively). After adjusting for age, sex, race, education, initial emergency department presentation, DC, and past discrimination, patients of older age (odds ratio [OR] 1.1, 95% confidence interval [CI] 1.02-1.09) and non-White race (OR 3.5, 95% CI 1.1-11.4) had higher perceptions of SDM; patients with DC (OR 0.52, 95% CI 0.01-0.20) reported less SDM. Conclusions: Patients who present to clinic for surgical evaluation after facial trauma feel that their physicians involve them less when deciding on a treatment plan if they have experienced discrimination in health care settings in the past, or if they have significant difficulty deciding between treatment options.

Craniofacial Growth and Development: A Primer for the Facial Trauma Surgeon.

Understanding craniofacial growth and development is important in the management of facial trauma in the growing pediatric patient. This manuscript is a review of craniofacial growth and development and clinical implications of pediatric facial fractures.

Does the Geographical Distribution of Facial Trauma Surgeons Correspond to Facial Trauma Burden? A Nationwide Population-Level Analysis.

It is unknown if craniofacial trauma services are inequitably distributed throughout the US. The authors aimed to describe the geographical distribution of craniofacial trauma, surgeons, and training positions nationwide. State-level data were obtained on craniofacial trauma admissions, surgeons, training positions, population, and income for 2016 to 2017. Normalized densities (per million population [PMP]) were ascertained. State/ regional-level densities were compared between highest/lowest. Risk-adjusted generalized linear models were used to determine independent associations. There were 790,415 craniofacial trauma admissions (x? = 2330.6 PMP), 28,004 surgeons (x? = 83.5 PMP), and 746 training positions (x? = 1.9 PMP) nationwide. There was significant state-level variation in the density PMP of trauma (median 1999.5 versus 2983.5, P < 0.01), surgeon (70.8 versus 98.8, P < 0.01), training positions (0 versus 3.4, P < 0.01) between lowest/highest quartiles. Surgeon distribution was positively associated with income and training positions density ( P < 0.01). Subanalysis revealed that there was an increase of 6.7 plastic and reconstructive surgeons/PMP for every increase of 1000 trauma admissions/PMP ( P < 0.01). There is an uneven state-level distribution of facial trauma surgeons across the US associated with income. Plastic surgeon distribution corresponded closer to craniofacial trauma care need than that of ENT and OMF surgeons. Further work to close the gap between workforce availability and clinical need is necessary.

Reply: Unnecessary Interfacility Transfers for Craniomaxillofacial Trauma

Sir: We appreciate the auhors’ review of our recent study.1 The question of whether a referring provider is able to diagnose a patient’s traumatic injuries is an important one. We did not address this because it was not the goal of this study. The goal of this study was to identify the problem of secondary overtriage of facial trauma patients. The second phase of our study has been designed to evaluate national perceptions of this problem and whether the craniomaxillofacial surgical community felt there was a need for transfer guidelines. Indeed, the results of this multidisciplinary survey demonstrated that roughly 50 percent of facial trauma surgeons agreed that most emergency transfers for isolated facial trauma at their institutions were unnecessary. Eighty-seven percent of respondents thought that transfer guidelines could help decrease unnecessary transfers, and data regarding which specific injury patterns should be transferred were also collected.2 With regard to the availability of on-call facial traumatologists, the data presented by the authors’ team appear to be regional. Unfortunately, studies have shown that a large percentage of referral centers implicated in secondary overtriage of facial trauma patients have full-time facial trauma coverage.3 This was also the case in our cohort. The long-term goal of our project is not to leave the diagnosis of facial injuries to the nontrauma practitioner; in fact, it is the opposite. Our goal is to educate those practitioners and provide them with tools to diagnose injuries of lesser acuity that may not require emergency systems activation. Education is essential in this effort. The first phase is to define the problem; the second, to quantify the need; and the third, to provide a solution. The third phase of our project, which is underway, uses an assembled panel of expert craniomaxillofacial traumatologists in the fields of ear, nose, and throat; oromaxillofacial; and plastic surgery. We aim to construct transfer guidelines similar to those put forth by the American Burn Association for referral to a regional burn center. The guidelines will be written for use by all providers, including those with little facial trauma experience. Using data collected from our second study2 and consensus collected in our third stage (using the modified Delphi method), our guidelines will define exactly which facial skeletal and soft-tissue injuries should be transferred. We agree that a patient with an unclear diagnosis should be transferred to a higher level of care. It is well documented that isolated facial trauma is implicated in secondary overtriage,2–6 and we, alongside facial trauma providers from different specialties across the nation, believe that there is room to improve the management of these patients. Our goal remains to refine the transfer process for facial trauma patients while minimizing the potential untoward consequence of secondary undertriage. Unfortunately, a small percentage of secondary undertriage is a necessary tradeoff for a reduction in substantial secondary overtriage, and a proper balance of undertriage and overtriage is paramount. Such a large percentage of unnecessary transfers carry far worse ramifications to the patient and the health care system than does the rare undertriage event. We thank the authors for their thoughtful commentary. DISCLOSURE The authors have no relevant financial disclosures related to the content of this communication.

Interfacility Transfers for Isolated Craniomaxillofacial Trauma: Perspectives of the Facial Trauma Surgeon

Interfacility Transfers for Isolated Craniomaxillofacial Trauma: Perspectives of the Facial Trauma Surgeon

Interfacility Transfers for Isolated Craniomaxillofacial Trauma: Perspectives of the Facial Trauma Surgeon.

Secondary overtriage is a burden to the medical system. Unnecessary transfers overload trauma centers, occupy emergency transfer resources, and delay definitive patient care. Craniomaxillofacial (CMF) trauma, especially in isolation, is a frequent culprit. The aim of this study is to assess the perspectives of facial trauma surgeons regarding the interfacility transfer of patients with isolated CMF trauma. A 31-item survey was developed using Likert-type scale and open-ended response systems. Internal consistency testing among facial trauma surgeons yielded a Cronbach's α calculation of .75. The survey was distributed anonymously to the American Society of Maxillofacial Surgeons, the North American Division of AO Craniomaxillofacial, and the American Academy of Facial Plastic and Reconstructive Surgery. Statistical significance in response plurality was determined by nonoverlapping 99.9% confidence intervals (P < .001). Sum totals were reported as means with standard deviations and z scores with P values of less than .05 considered significant. The survey yielded 196 responses. Seventy-seven percent of respondents did not believe that most isolated CMF transfers required emergency surgery and roughly half (49%) thought that most emergency transfers were unnecessary. Fifty-four percent of respondents agreed that most patients transferred could have been referred for outpatient management and 87% thought that transfer guidelines could help decrease unnecessary transfers. Twenty-seven percent of respondents had no pre-transfer communication with the referring facility. Perspectives on the transfer of specific fracture patterns and their presentations were also collected. Most facial trauma surgeons in this study believe that emergent transfer for isolated CMF trauma is frequently unnecessary. Such injuries rarely require emergent surgery and can frequently be managed in the outpatient setting without activating emergency transfer services. The fracture-specific data collected are a representation of the national, multidisciplinary opinion of facial trauma surgeons and correlate with previously published data on which specific types of facial fractures are most often transferred unnecessarily. The results of this study can serve as the foundation for interfacility transfer guidelines, which may provide a valuable resource in triaging transfers and decreasing associated health-care costs.

Medicolegal Aspects of Craniofacial Trauma.

Characterization of complications in facial trauma management is of special interest to practitioners of facial trauma surgery. It is important for facial trauma surgeons to not only understand the standard of care, but also the pitfalls that can expose them to litigation. Litigation within the realm of facial trauma surgery often manifests from issues with poor communication, inadequate informed consent processes, and poor surgical management. In this analysis, we comprehensively examine malpractice litigation in facial trauma surgery, and outline important factors for surgeons to consider in the care of this patient population. It is important for facial trauma surgeons to understand medicolegal issues within their scope of practice. These include principles of informed consent, state regulated statutes of limitation, and Emergency Medical Treatment and Active Labor Act laws. This analysis emphasizes the importance of exercising appropriate patient care, understanding the indications for surgery, and seeking counsel when necessary.

Management of Zygomatic Fractures: A National Survey.

Repair of zygomatic fractures can be classified into the early closed reduction or the more recent open reduction and rigid internal fixation (ORIF) methods. Surgical training and literature advocate ORIF, but the actual frequency of the different techniques in clinical practice is unknown. The purpose of this study was to determine the current trends in the management of zygomatic fractures among US surgeons and elucidate their influences. A 10-question survey was developed and distributed to over 16,000 practicing US facial trauma surgeons, including plastic surgeons (PS), oral and maxillofacial surgeons (OMFS), and otorhinolaryngologists (ENT). The survey queried training background, zygoma fracture treatment preferences, and rationale. Responses were tabulated and both univariate and bivariate statistical analyses completed. One thousand six hundred eleven (10%) total responses were received. Zygomatic fractures are treated most commonly by OMFS (61%), then PS (20%) and ENT (19%), with 71% of repairs being performed in private practice. Open reduction and rigid internal fixation is the most common treatment modality (81%), with most surgeons using 2 to 3 sites for exposure, reduction, and fixation with titanium miniplates (70%). Thirty-five percent of surgeons perform routine orbital floor exploration. Forty-three percent quoted training and 32% reported accuracy of repair as the primary reason for choosing ORIF. This is the largest reported survey on the repair of zygoma fractures. The response rate suggests dominance of OMFS in zygoma fracture care, an area pioneered by PS. Evolution of technique is also evident by predominance of ORIF with emphasis of multiple points of exposure, reduction, and fixation with rigid hardware.

Nasolacrimal System Fractures: A Description of Radiologic Findings and Associated Outcomes.

Fractures of the bony nasolacrimal system (NLS), including the lacrimal sac fossa and nasolacrimal canal, have not been comprehensively described in patients with facial trauma. Characterization of these injuries may help facial trauma surgeons better predict which patients will develop lacrimal outflow obstruction symptoms including epiphora and dacryocystitis and who may eventually need lacrimal surgery. CT images for all patients seen at the University of Wisconsin Hospital and Clinics for craniofacial trauma were reviewed from January 2001 to December 2005. Patients were included if they had a NLS fracture and at least 1 year of follow-up. Fracture patterns were described and correlated with clinical outcomes documented in the medical record. Outcomes, including the development of epiphora or dacryocystitis and the need for lacrimal surgery, were analyzed using Fisher exact test. We identified 104 patients with NLS fractures among 1980 patients with craniofacial trauma who had at least 1 year of follow-up. Eleven patients (10.6%) developed epiphora or dacryocystitis, and 2 patients (1.9%) required dacryocystorhinostomy (DCR). Ten radiographic injury patterns were characterized. Avulsion of the lacrimal crest, bone fragment in the lacrimal sac fossa or duct, duct compression greater than 50%, and nasomaxillary buttress displacement were significantly associated with the development of epiphora or dacryocystitis (P < 0.05). Nasomaxillary buttress displacement was significantly associated with the eventual need for DCR (P = 0.03). Patients with radiographic evidence of NLS fracture have an approximately 10% risk of developing epiphora or dacryocystitis. We describe 5 NLS fracture findings that are significantly associated with the development of lacrimal outflow obstruction. The presence of nasomaxillary buttress fracture and displacement suggests a significantly higher risk of eventually needing lacrimal surgery.

Posttraumatic Arteriovenous Malformation of the Face: A Case Report

BackgroundHead and neck arteriovenous malformations (AVMs) are reported to occur in 0.1% of the population. Extracranial AVMs account for only 8.1% of head and neck AVMs. Of these, traumatically acquired AVMs of the face are generally reported as quite rare. When secondary to trauma, the lesion is usually supplied by a single vessel, as compared to the multiple vessels often seen with congenital etiology. ObjectivesUnderstanding of regional anatomy is paramount when assessing and managing facial injuries. As an integral health care provider for the facial trauma patient, it is the responsibility of the emergency physician to recognize this rare pathologic lesion necessary to coordinate surgical management of the traumatic AVM. Case ReportWe present a case report of a patient who sustained a facial laceration complicated by the development of a vascular malformation. The facial laceration in this case report highlights the complexity of wound evaluation and management when treating patients in the emergency department. ConclusionTraumatic AVMs are quite rare in the head and neck and are mostly seen in the extremities. Although rare, they have been reported after typical facial trauma as well as elective surgical procedures. The management of such lesions may include selective embolization or surgical exploration with ligation. Emergency physicians and facial trauma surgeons are challenged with recognizing and treating these rare but very real vascular lesions. It is our hope that this case report provides an overview of posttraumatic AVMs in the head and neck.

Reply

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.

Pitfalls in Endoscopic Treatment of Mandibular Subcondylar Fractures

The facial trauma surgeon should be able to list indications for endoscopic treatment of mandibular condyle fractures and discuss the limitations and complications of the technique. The ideal treatment of mandibular subcondylar fractures continues to be debated. Acceptable results are often obtained with conservative measures such as mandibular maxillary fixation followed by elastics. On the other hand, an open approaches result in potential risk injury to the facial nerve. These 2 arguments have cautioned many surgeons from open treatment of condylar fractures. Recent advances in endoscopic techniques have made the mandibular condyle more accessible with less risk to the facial nerve. As with any new technique, endoscopic treatment of mandibular subcondylar fractures is not without its own limitations and complications. This was a retrospective case series. Three patients with mandibular subcondylar fractures with complications following endoscopic treatment were reviewed. There were a total of 4 condylar fractures (1 patient had bilateral fractures). There was 1 incidence of temporary facial nerve paresis, 1 failure of hardware positioning, 1 screw placement into the mandibular foramen, 2 condyles where adequate reduction of the fracture was impossible, and 1 failure to secure a screw into the proximal fracture segment. Endoscopic management of mandibular subcondylar fractures is a novel treatment with novel types of complications. Although promising, endoscopic treatment of mandibular subcondylar fractures should be approached prudently to avoid potential pitfalls.

Management of frontal sinus fractures.

This review summarizes the contemporary management of frontal sinus fractures. Recent additions to the armamentarium of the facial trauma surgeon include bioresorbable plates and screws, and attempts to use endoscopic techniques when feasible. The basic principles of frontal sinus fracture management remain the same. New approaches and new instruments help make repair easier, safer, and more cosmetically acceptable.

Surgical approaches in the management of facial trauma

Along with recent advances in rigid fixation, the adaptation and expansion of craniofacial surgical access technique has significantly improved the management of facial skeletal trauma. Four surgical approaches—coronal, transconjunctival, maxillary gingival buccal sulcus, and mandibular gingival buccal sulcus—provide access to the entire craniofacial skeleton while avoiding additional soft-tissue deformities or marring scars. Added modifications to these techniques widen exposure to adjacent subsites, thus enhancing the surgeon's ability to employ rigid fixation through concealed incisions. Recent applications of endoscopic technique to facial skeletal trauma provide an additional means of repair with minimal associated morbidities. These endoscopic approaches may become an important component of the facial trauma surgeon's armamentarium in the future. Along with recent advances in rigid fixation, the adaptation and expansion of craniofacial surgical access technique has significantly improved the management of facial skeletal trauma. Four surgical approaches—coronal, transconjunctival, maxillary gingival buccal sulcus, and mandibular gingival buccal sulcus—provide access to the entire craniofacial skeleton while avoiding additional soft-tissue deformities or marring scars. Added modifications to these techniques widen exposure to adjacent subsites, thus enhancing the surgeon's ability to employ rigid fixation through concealed incisions. Recent applications of endoscopic technique to facial skeletal trauma provide an additional means of repair with minimal associated morbidities. These endoscopic approaches may become an important component of the facial trauma surgeon's armamentarium in the future.

Surgical approaches in the management of facial trauma

Along with recent advances in rigid fixation, the adaptation and expansion of craniofacial surgical access technique has significantly improved the management of facial skeletal trauma. Four surgical approaches—coronal, transconjunctival, maxillary gingival buccal sulcus, and mandibular gingival buccal sulcus—provide access to the entire craniofacial skeleton while avoiding additional soft-tissue deformities or marring scars. Added modifications to these techniques widen exposure to adjacent subsites, thus enhancing the surgeon's ability to employ rigid fixation through concealed incisions. Recent applications of endoscopic technique to facial skeletal trauma provide an additional means of repair with minimal associated morbidities. These endoscopic approaches may become an important component of the facial trauma surgeon's armamentarium in the future. Along with recent advances in rigid fixation, the adaptation and expansion of craniofacial surgical access technique has significantly improved the management of facial skeletal trauma. Four surgical approaches—coronal, transconjunctival, maxillary gingival buccal sulcus, and mandibular gingival buccal sulcus—provide access to the entire craniofacial skeleton while avoiding additional soft-tissue deformities or marring scars. Added modifications to these techniques widen exposure to adjacent subsites, thus enhancing the surgeon's ability to employ rigid fixation through concealed incisions. Recent applications of endoscopic technique to facial skeletal trauma provide an additional means of repair with minimal associated morbidities. These endoscopic approaches may become an important component of the facial trauma surgeon's armamentarium in the future.

Warfare Facial Trauma: Who Will Treat?

Most of the facial trauma in the United States is treated in trauma centers in large urban or university medical centers, with limited trauma care taking place in our military medical treatment facilities. In many cases, active duty facial trauma surgeons may lack the current experience necessary for the optimal care of facial wounds of our inquired military personnel in the early stages of the conflict. Consequently, the skills of the reservist trauma surgeons who staff our civilian trauma centers and who care for facial trauma victims daily will be critical in caring for our wounded. These "trauma-current" reservists may act as a cadre of practiced surgeons to aid those with less experience. A plan for refresher training of active duty facial trauma surgeons is presented.

Results of intraoral cortical bone screw fixation technique for mandibular fractures

The intraoral cortical bone screw fixation technique carries many advantages over traditional methods of intermaxillary fixation. Simplicity of the technique, reduction of operative time, and reduction of risk of transmission of human immunodeficiency virus and hepatitis make this an important technique in the armamentarium of busy facial trauma surgeons. Since 1992, 45 mandibular fractures in 29 patients treated with the intraoral cortical bone screw technique for intermaxillary fixation were retrospectively analyzed. At our institution, this technique has become the workhorse method of repairing most mandiublar fractures and is associated with minimal complications. (OTOLARYNGOL HEAD NECK SURG 1995;113:248-52.)

Concepts of Soft-Tissue Trauma Repair

The proper evaluation and treatment of soft-tissue trauma to the face is extremely important because of the psychologic, cosmetic, and functional sequelae that can occur from these injuries. The facial trauma surgeon should have a wide armamentarium of techniques to manage soft-tissue facial trauma and should approach the repair in a meticulous and scientific fashion. Although the best possible repair of the acute trauma is the goal, it is usually necessary to perform later some camouflage or revision procedures on the scar because of the high likelihood of hypertrophic scarring or inappropriate healing in the trauma scar.

Nasoethmoid Complex Injuries

Blunt and penetrating trauma to the nasoethmoid complex can present a challenge to reconstruction by the facial trauma surgeon. Both functional and cosmetic problems exist with these injuries and both must be considered in the surgical plan. Adequate preoperative physical examination and roentgenologic evaluation, coupled with a thorough ophthalmologic consultation, are required for complete knowledge of the extent of the damage. The surgical repair of nasoethmoid fractures involving the medial canthal tendon and lacrimal drainage system should be repaired primarily. A medial blow-out fracture of the orbit is uncommon but should be considered in all cases of severe nasoethmoid complex fractures.