Faculty Bibliography

BACKGROUND: The central face high-energy avulsive injury has been frequently encountered and predictably managed at the R Adams Cowley Shock Trauma Center. However, despite significant surgical advances and multiple surgical procedures, the ultimate outcome continues to reveal an inanimate, insensate, and suboptimal aesthetic result. METHODS: To effectively address this challenging deformity, a comprehensive multidisciplinary approach was devised. The strategy involved the foundation of a basic science laboratory, the cultivation of a supportive institutional clinical environment, the innovative application of technologies, cadaveric simulations, a real-time clinical rehearsal, and an informed and willing recipient who had the characteristic deformity. RESULTS: After institutional review board and organ procurement organization approval, a total face, double jaw, and tongue transplantation was performed on a 37-year-old man with a central face high-energy avulsive ballistic injury. CONCLUSIONS: This facial transplant represents the most comprehensive transplant performed to date. Through a systematic approach and clinical adherence to fundamental principles of aesthetic surgery, craniofacial surgery, and microsurgery and the innovative application of technologies, restoration of human appearance and function for individuals with a devastating composite disfigurement is now a reality. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Frontal sinus mucoceles may present many years after traumatic injuries or surgical procedures involving the frontal bone, but have been rarely reported after fronto-orbital advancement. We describe a case of frontal sinus mucocele development in a 43-year-old patient with Apert syndrome who underwent fronto-orbital advancement as a child. This was treated with resection and free fibula osteomuscular flap reconstruction. Computer-aided design and manufacturing techniques were used to virtually plan the procedure and guide the osteotomies intraoperatively. Follow-up at 1 year postoperatively revealed no evidence of recurrence.

BACKGROUND: Treatment of facial fractures in the setting of open-globe injuries poses a management dilemma because of the often disparate treatment priorities of multidisciplinary trauma teams and the lack of prognostic data regarding visual outcomes. METHODS: Patients in the University of Maryland Shock Trauma Registry sustaining facial fractures with concomitant open-globe injuries from January of 1998 to August of 2010 were identified. Odds ratios were calculated to identify demographic and clinical variables associated with blindness, and multivariate regression analysis was performed. RESULTS: A total of 99 patients were identified with 105 open-globe injuries. Seventy-nine percent of injuries were blinding, whereas 4.8 percent of globes achieved a final visual acuity greater than or equal to 20/400. Blindness was associated with penetrating injury, increasing number of facial fractures, zygomaticomaxillary complex fracture, admission Glasgow Coma Scale score less than or equal to 8, and globe injury spanning all three eye zones. Fracture repair was performed more frequently (62.5 percent) and more quickly (average time to fracture repair, 4.5 days) in cases of primary globe enucleation/evisceration when compared with complete (21.2 percent; 8 days; p=0.35) or incomplete (42.9 percent; 11 days; p=0.058) primary globe repair. CONCLUSIONS: Penetrating injury mechanism and zone of eye injury appear to be better indicators of visual prognosis than facial fracture patterns. Given the high rates of blindness, secondary enucleation, and delay of fracture repair in patients that were not primarily enucleated, the authors recommend that orbital fracture repair not be delayed in the hopes of eventual visual recovery in cases of high-velocity projectile trauma. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

BACKGROUND: The purpose of this study was to investigate whether a delay in operative management of frontal sinus fractures is associated with increased risk of serious infections. METHODS: Retrospective chart review was performed of 242 consecutive patients with surgically managed frontal sinus fractures who presented to the R Adams Cowley Shock Trauma Center between 1996 and 2011. Collected patient characteristics included demographics, surgical management, hospital course, and complications. All computed tomographic imaging was reviewed to evaluate involvement of the posterior table and nasofrontal outflow tract. Serious infections included meningitis, encephalitis, brain abscess, frontal sinus abscess, and osteomyelitis. Delayed operative interventions were defined as procedures performed more than 48 hours after admission. Adjusted relative risk estimates were obtained using multivariable regression. RESULTS: There were 14 serious infections (5.8 percent). All patients with serious infections had both involvement of the posterior table and nasofrontal outflow tract injury. The cumulative incidence of serious infection in these patients was 10.8 percent. After adjustments for confounding, multivariable regression showed that operative delay beyond 48 hours was independently associated with a 4.03-fold (p < 0.05) increased risk for serious infection; external cerebrospinal fluid drainage catheter use and local soft-tissue infection conferred a 4.09-fold (p < 0.05) and 5.10-fold (p < 0.001) increased risk, respectively. Antibiotic use beyond 48 hours postoperatively was not associated with fewer infections. CONCLUSIONS: Delay in operative management of frontal sinus fractures in patients requiring operative intervention is associated with an increased risk for serious infections. Continued antibiotic prophylaxis beyond the perioperative period provides little benefit in preventing serious infections. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

PURPOSE: To investigate whether complex midface fractures have a greater association with death and intracranial injury than simple midface fractures. MATERIALS AND METHODS: A retrospective chart review was performed for patients with blunt-mechanism midface fractures who had presented to an urban trauma center from 1998 to 2010. The survival and intracranial injury status was evaluated for patients with simple and complex midface fractures, including Le Fort, naso-orbitoethmoid, and/or zygomaticomaxillary fractures. Intracranial injury included hemorrhage and brainstem injury. Patients with upper face fractures were excluded to minimize confounding. Adjusted relative risk estimates were obtained using multivariate regression analysis. RESULTS: Of 3,291 patients with midface fractures, 213 (6.3%) died and 693 (21.3%) had an intracranial injury. The cumulative mortality reached 11.6% in patients with complex midface fractures and 5.1% in those with simple midface fractures (P < .001). Patients with complex midface fractures were 57% more likely to die (relative risk = 1.57; P < .005). Specifically, Le Fort II fractures independently conferred a 94% increased risk of death (relative risk = 1.94; P < .01), but Le Fort I and III fractures were not significantly associated with death. Among patients presenting without neurologic impairment, those with Le Fort II and III fractures remained 2.88-fold (P < .01) and 2.54-fold (P < .001) more likely to have an underlying intracranial injury, respectively. CONCLUSIONS: Le Fort II fractures are associated with increased mortality. Furthermore, Le Fort II and III fractures are associated with serious intracranial injury, even in the absence of alterations in consciousness. These patients should be monitored with heightened vigilance and followed up closely during hospitalization, regardless of the presenting clinical findings.

BACKGROUND: Chronic rejection of vascularized composite allografts (VCA) is an emerging phenomenon that may decrease long-term allograft survival and impair allograft function. Although intimal hyperplasia has been reported in human hand transplants, chronic changes in VCAs remain poorly described. METHODS: We developed a nonhuman primate model of face transplantation to evaluate the effect of various immunosuppressive regimens on allograft survival that we have previously reported. Nineteen grafts were successfully transplanted and serially biopsied to assess for rejection. Five VCA grafts with long-term survival (>200 days) were weaned off immunosuppression. We performed additional histologic and immunohistochemical studies on previously collected samples. RESULTS: All five grafts developed features consistent with chronic rejection, including neointimal proliferation, transplant vasculopathy, vessel wall fibrosis, progressive luminal occlusion, and tertiary lymphoid follicles. Review of 186 serial allograft skin and subcutaneous tissue biopsies revealed that tertiary follicles and vascular changes developed in the absence of acute skin rejection. No relationship was found between alloantibody production and these changes. CONCLUSIONS: Recognition of these characteristics of VCA chronic rejection is important for diagnosis in clinical hand and face transplantation. Studies directed towards minimizing VCA chronic rejection responses may be required to improve long-term outcomes.

PURPOSE: Blunt internal carotid artery injuries (BCAIs) can result from craniofacial trauma, yet the association between craniofacial fractures and BCAIs is poorly understood. MATERIALS AND METHODS: A retrospective cohort study of patients with blunt-mechanism facial fracture(s) presenting to a large trauma center was undertaken to identify facial fracture patterns predictive of BCAIs. Predictor variables included specific facial fracture patterns. Additional variables included demographic, injury mechanism, and associated injury classifications. Outcome variables included the presence or absence of BCAIs. All radiographic fracture patterns were confirmed by author review of computed tomographic imaging. BCAIs were confirmed and graded using the Biffl system. Differences in fracture patterns and demographic parameters in patients who presented with versus without concomitant BCAIs were compared, and relative risks for BCAI were calculated. Existing Eastern Association for the Surgery of Trauma Level III Blunt Cerebrovascular Injury (BCVI) screening criteria then were applied to the dataset to determine if additional fracture patterns would be useful in BCAI screening as determined by alterations in screening sensitivity and specificity. RESULTS: Seventy BCAIs were identified in 54 of 4,398 patients with facial fractures (1.2%). Bilateral fractures in each facial third, complex midface, Le Fort, and subcondylar fractures, fractures in association with the cervical spine, and basilar skull fractures were high risk for concomitant BCAI. Twenty percent of BCAIs would not have been captured by existing Eastern Association for the Surgery of Trauma Level III BCVI screening criteria. When patients meeting these screening criteria were removed from the study population, Le Fort I and subcondylar fractures were the only fracture patterns conferring increased risk for BCAI. Addition of these criteria to existing criteria improved the screening negative predictive value. CONCLUSION: Specific facial fracture patterns, including bilateral fractures in any facial third and complex midface, Le Fort I, and subcondylar fractures, confer increased risk of BCAI, especially in association with basilar skull fractures. Suspicion for BCAI in these patients may improve diagnosis and enable prompt therapeutic intervention. Addition of Le Fort I fractures to existing BCAI screening criteria improves sensitivity and may be of clinical utility in ruling out BCAIs.

The translation of tissue engineering approaches to the clinic has been hampered by the inability to find suitable multipotent cell sources requiring minimal in vitro expansion. Enhanced bone marrow (eBM), which is obtained by reaming long bone medullary canals and isolating the solid marrow putty, has large quantities of stem cells and demonstrates significant potential to regenerate bone tissues. eBM, however, cannot impart immediate load-bearing mechanical integrity or maintain the gross anatomical structure to guide bone healing. Yet, its putty-like consistency creates a challenge for obtaining the uniform seeding necessary to effectively combine it with porous scaffolds. In this study, we examined the potential for combining eBM with mechanically strong, osteoinductive trabecular bone scaffolds for bone regeneration by creating channels into scaffolds for seeding the eBM. eBM was extracted from the femurs of adult Yorkshire pigs using a Synthes reamer-irrigator-aspirator device, analyzed histologically, and digested to extract cells and characterize their differentiation potential. To evaluate bone tissue formation, eBM was seeded into the channels in collagen-coated or noncoated scaffolds, cultured in osteogenic conditions for 4 weeks, harvested and assessed for tissue distribution and bone formation. Our data demonstrates that eBM is a heterogenous tissue containing multipotent cell populations. Furthermore, coating scaffolds with a collagen hydrogel significantly enhanced cellular migration, promoted uniform tissue development and increased bone mineral deposition. These findings suggest the potential for generating customized autologous bone grafts for treating critical-sized bone defects by combining a readily available eBM cell source with decellularized trabecular bone scaffolds. (c) 2013 S. Karger AG, Basel.

PURPOSE: The aim of this article was to assess how regional facial fracture patterns predict mortality and occult intracranial injury after blunt trauma. METHODS: Retrospective chart review was performed for blunt-mechanism craniofacial fracture patients who presented to an urban trauma center from 1998 to 2010. Fractures were confirmed by author review of computed tomographic imaging and then grouped into 1 of 5 patterns of regional involvement representing all possible permutations of facial-third injury. Mortality and the presence of occult intracranial injury, defined as those occurring in patients at low risk at presentation for head injury by Canadian CT Head Rule criteria, were evaluated. Relative risk estimates were obtained using multivariable regression. RESULTS: Of 4540 patients identified, 338 (7.4%) died, and 171 (8.1%) had intracranial injury despite normal Glasgow Coma Scale at presentation. Cumulative mortality reached 18.8% for isolated upper face fractures, compared with 6.9% and 4.0% for middle and lower face fractures (P < 0.001), respectively. Upper face fractures were independently associated with 4.06-, 3.46-, and 3.59-fold increased risk of death for the following fracture patterns: isolated upper, combined upper, panfacial, respectively (P < 0.001). Patients who were at low risk for head injury remained 4 to 6 times more likely to suffer an occult intracranial injury if they had involvement of the upper face. CONCLUSIONS: The association between facial fractures, intracranial injury, and death varies by regional involvement, with increasing insult in those with upper face fractures. Cognizance of the increased risk for intracranial injury in patients with upper face fractures may supplement existing triage tools and should increase suspicion for underlying or impending neuropathology, regardless of clinical picture at presentation.

Maxillary mucoceles are a relatively rare entity especially following surgical procedures involving osteotomies of the maxilla. The etiology of maxillary mucoceles has been ascribed to facial trauma (fractures), sinus surgery, and chronic inflammatory diseases or infections. Mucoceles can follow injury to the sinus mucosa and/or sinus outflow tract with a resulting expansile cystic mass. The clinical presentation ranges from swelling, pain, a palpable mass, proptosis, enophthalmos, and diplopia. The treatment involves either open or endoscopic incision and drainage of the cyst, mucosal resection, and an antrostomy for drainage.We report the case of a patient with Pfeiffer syndrome who underwent Le Fort III distraction osteogenesis and developed a symptomatic mucocele 15 years postoperatively.