Faculty Bibliography

Despite a growing consensus that seclusion or restraint should never be used with children or adolescents, there are a few patients who are resistant to treatment, and are persistently violent. The purpose of this study was to measure the efficacy of installing a padded seclusion room to decrease the use of mechanical restraints, a potentially more emotionally traumatic and dangerous intervention than seclusion. After padded room installation, the number of monthly mechanical restraint events per 1000 patient days decreased by 93.7%, from 21.2 to 1.3. A padded seclusion room may offer a safer, albeit a less than desirable alternative to mechanical restraint.

BACKGROUND: Frontal sinus fracture treatment strategies lack statistical power. The authors propose statistically valid treatment protocols for frontal sinus fracture based on injury pattern, nasofrontal outflow tract injury, and complication(s). METHODS: An institutional review board-approved retrospective review was conducted on frontal sinus fracture patients from 1979 to 2005. Fractures were categorized by location, displacement, comminution, and nasofrontal outflow tract injury. Demographic data, treatment, and complications were compiled. RESULTS: One thousand ninety-seven frontal sinus fracture patients were identified; 87 died and 153 were excluded because of insufficient data, leaving a cohort of 857 patients. The most common injury was simultaneous displaced anteroposterior walls (38.4 percent). Nasofrontal outflow tract injury constituted the majority (70.7 percent), with 67 percent having a diagnosis of obstruction. Of the 857 patients, 504 (58.8 percent) underwent surgery, with a 10.4 percent complication rate; and 353 were observed, with a 3.1 percent complication rate. All complications except one involved nasofrontal outflow tract injury (98.5 percent). Nasofrontal outflow tract injuries with obstruction were best managed by obliteration or cranialization (complication rates: 9 and 10 percent, respectively). Fat obliteration and osteoneogenesis had the highest complication rates (22 and 42.9 percent, respectively). The authors' treatment algorithm provides a receiver operating characteristic area under the curve of 0.8621. CONCLUSIONS: A frontal sinus fracture treatment algorithm is proposed and statistically validated. Nasofrontal outflow tract involvement with obstruction is best managed by obliteration or cranialization. Osteoneogenesis and fat obliteration are associated with unacceptable complication rates. Observation is safe when the nasofrontal outflow tract is intact.

Horizontal maxillary osteotomy with an interpositional fibula flap for maxillary deficiency offers several advantages over conventional techniques for maxillary reconstruction. Maxillary deficiencies in all 3 planes, vertical, anterior-posterior, and transverse, can be corrected with a long-term stable construct while simultaneously restoring bony and soft tissue deficiencies. We conducted a retrospective review of patients with maxillary hypoplasia who underwent Horizontal maxillary osteotomy with interpositional osteoseptocutaneous fibula flaps. Compared with nonvascularized bone grafts, vascularized bone flaps undergo less resorption and can be used in poorly vascularized, mechanically unstable, irradiated, or scarred wound beds.

BACKGROUND: Microsurgical reconstructive algorithms for craniofacial defects have focused on soft-tissue flaps with or without conventional bone grafts. However, volumetric loss from muscle atrophy, bone resorption, and soft-tissue contraction limits long-term preservation of facial contour. Applying craniofacial principles of skeletal buttress support, the authors used composite vascularized bone flaps to reconstruct the soft tissue and the vertical and horizontal buttresses of the face. In this manner, facial proportions and aesthetics are maintained in composite tissue defects resulting from high-energy trauma or oncologic extirpation. METHODS: The authors conducted a retrospective review of 31 patients with craniofacial defects treated by a single surgeon with composite bone flaps at the R Adams Cowley Shock Trauma Center and The Johns Hopkins Hospital from 2001 to 2006. Charts were reviewed and data were collected on age, sex, mechanism of injury, type of defect, type of reconstructive procedure, and outcome. RESULTS: Thirty-one patients with composite tissue loss, primarily men (n = 21) with an average age of 37.4 years, underwent reconstruction with vascularized bone flaps (25 fibula flaps and six iliac crest flaps). There were three cranial defects, eight periorbital defects, 17 maxillary defects, and three maxillary and periorbital defects. The flap survival rate was 93.5 percent, with an average follow-up of 13.5 months. CONCLUSIONS: Restoration of facial height, width, and projection through skeletal buttress replacement is essential for achieving facial harmony. Since 2001, the authors' unit has pursued a paradigm shift with regard to treatment of composite oncologic or traumatic defects, advocating vascularized bone flaps to achieve excellent long-term functional and aesthetic outcomes.