To what extent do oral and maxillofacial surgery residents suffer from imposter syndrome?

OBJECTIVE: This study aims to evaluate the frequency and severity of imposter syndrome (IS) in oral and maxillofacial surgery (OMS) residents and identify factors associated with higher Clance Imposter Phenomenon Survey (CIPS) scores. STUDY DESIGN: A cross-sectional study was performed with a survey including CIPS, demographic, and training program structure questions distributed to all OMS training programs and residents in the United States. The primary predictor variable was gender, and the main outcome variable was the CIPS score. Statistical analyses were performed using linear regression in R v4.3.1; statistical significance was set to P value < .05. RESULTS: A total of 175 OMS residents responded. The average CIPS score was 59.8 (IQR 52, 70). Statistically significant differences were found between average male and female resident scores (56.5 vs 66.9; P < .001) and male and female single-degree residents (54.3 vs 73.1; P < .001), but not for dual-degree residents (58.8 vs 63.9; P = .35). CONCLUSIONS: The average male resident experiences moderate IS, whereas the average female resident experiences frequent IS. Loss of significance between male and female dual-degree resident scores may be due to the completion of a doctoral degree, an internship, and/or dental board exams upon entering medical school, leading to more favorable accomplishment comparisons among medical school peers.

A retrospective study of orthognathic surgery reimbursement and volume changes at an American academic medical center over a 13-year period.

OBJECTIVE: This study aimed to measure the association between orthognathic surgeon reimbursement and surgical volume over time. STUDY DESIGN: A retrospective cohort study of patients who underwent orthognathic surgery from January 1, 2010, to December 23, 2022, at an academic medical center was performed. Five patients per year were randomly selected and evaluated for insurance type and associated costs to create representative averages. Pearson correlation analysis was performed to test associations over 13 years with 2-tailed significance reported and statistical significance set at P < .05. RESULTS: A total of 618 patients who underwent 942 procedures were included. The average procedure charge was $6,153.76, and the average total surgeon collection was $1,535.75 per procedure. When monetary values were adjusted to reflect 2010 purchasing power, there was a negative correlation between the average charge per procedure and the year (r[11] = -0.59, P = .04). The year was not significantly correlated with the average amount collected (r[11] = -0.09, P = .78) or average insurance reimbursement (r[11] = -0.52, P = .07). CONCLUSIONS: Collections by surgeons did not change significantly over 13 years and were not correlated with the volume of procedures performed. Increased collections were correlated with increased patient costs. The stagnation of surgeon collection is concerning in the face of increased monetary inflation during this period. Increased volume of surgeries per year was correlated with decreases in patient cost and total collections.

The Role of Procalcitonin in Predicting Failure of Non-operative Management in Bowel Obstructions.

Procalcitonin has been investigated as a marker for bowel ischemia. This study examined the role of procalcitonin in predicting failure of non-operative management (NOM) in bowel obstructions. Patients with bowel obstructions at a single center from August 2022 to January 2023 were prospectively enrolled (n = 79). Lactic acid (LA) and procalcitonin were collected after surgical consultation. The primary outcome was success or failure of NOM. Univariate analysis, multivariable logistic regression, and performance measures of procalcitonin and LA in predicting bowel ischemia was performed. Of 79 patients included, 48 (61%) required operative intervention during index admission. There were no significant differences in demographics, comorbidities, procalcitonin, nor LA between groups. Time from last bowel movement was associated with failure of NOM (OR 1.03 [95% CI 1.01-1.06]; P = .008), though initial procalcitonin or LA was not. Procalcitonin >.3 ng/mL had acceptable sensitivity in screening for bowel ischemia.

Contralateral prophylactic mastectomy in a rural population: A single-institution experience.

Background: The incidence of contralateral prophylactic mastectomy (CPM) for unilateral breast cancer (UBC) has continued to increase, despite an absent survival benefit except in populations at highest risk for developing contralateral breast cancer (CBC). CPM rates may be higher in rural populations but causes remain unclear. A study performed at our institution previously found that 21.8 % of patients with UBC underwent CPM from 2000 to 2009. This study aimed to evaluate the CPM trend at a single institution serving a rural population and identify the CPM rate in average-risk patients. Methods: Retrospective review of patients who underwent mastectomies for UBC at our institution from 2017 to 2021 was performed. Analysis utilized frequencies and percentages, descriptive statistics, chi-square, and independent sample t-tests. Results: A total of 438 patients were included, of whom 64.4 % underwent bilateral mastectomy for UBC (CPM). Patients who underwent CPM were significantly younger, underwent genetic testing, had germline pathogenic variants, had a family history of breast cancer, had smaller tumors, underwent reconstruction, and had more wound infections. Of CPM patients, 50.4 % had no identifiable factors for increased risk of developing CBC. Conclusions: The rate of CPM in a rural population at a single institution increased from 21.8 % to 64.4 % over two decades, with an average-risk CPM rate of 50.4 %. Those that undergo CPM are more likely to undergo reconstruction and have more wound infections. Identifying characteristics of patients undergoing CPM in a rural population and the increased associated risks allows for a better understanding of this trend to guide conversations with patients. Key message: This study demonstrates that the rate of contralateral prophylactic mastectomy for unilateral breast cancers performed at a single institution serving a largely rural population has nearly tripled over the last two decades, with half of these patients having no factors that increase the risk for developing contralateral breast cancers. Contralateral prophylactic mastectomy was significantly associated with smaller tumors, younger age, genetic testing, germline pathogenic variants, family history of breast cancer, breast reconstruction, and increased wound infections.

The Use and Outcomes of 3D Printing in Pediatric Craniofacial Surgery: A Systematic Review.

Three-dimensional (3D) printing has demonstrated efficacy in multiple surgical specialties. As accessibility improves, its use in specific fields deserves further attention. We conducted a systematic review of the implementation and outcomes of 3D printing in pediatric craniofacial surgery, as none has been performed. A systematic review was conducted according to Cochrane and PRISMA guidelines. PubMed, Embase, Cochrane library, and Clinicaltrials.gov were queried with combinations of the terms: "3D printing," "craniofacial," "surgery," and "pediatric." Original human studies containing patients <18 years old implementing 3D printing to aid in craniofacial surgery were included. Study selection, grading, and data extraction were performed independently by multiple authors. After screening 120 articles, 7 (3 case series and 4 case reports) were included, published from 2017 to 2022. All studies addressed patients with different disease processes including craniosynostosis, cleft lip/palate, and mandibular hypoplasia. 3D printing was used to create mock surgical models in 2 studies, intraoperative cutting guides/molds (CGs) in 6 studies, and cranioplasty implants in 2 studies. Two case series determined the accuracy of the CGs was acceptable within historical comparison, while 4 articles included subjective statements on improved accuracy. Five studies noted reduced operating time, 2 noted reduced intraoperative blood loss, and 1 felt the use of 3D printed materials was responsible for shorter hospitalization duration. No adverse events were reported. Despite the limitations of the current literature, all studies concluded that the use of 3D printing in pediatric craniofacial surgery was beneficial. Definitive conclusions cannot be made until further controlled research is performed.

Risk Factors for Pediatric Facial Trauma in an Appalachian Region: An Epidemiological Review at a Single Institution.

BACKGROUND: Rural and low-income pediatric populations are at higher risk for trauma. Craniomaxillofacial (CMF) trauma in this population has not been studied. PURPOSE: This study's purpose was to determine if rural populations or low-income populations are at higher risk for pediatric CMF trauma than urban or high-income populations, respectively, and to determine differences in mechanism of injury (MOI). STUDY DESIGN, SETTING, SAMPLE: A retrospective cohort study of CMF trauma patients younger than 17 years-old, living in the region served by one institution in Tennessee, and requiring oral and maxillofacial surgery consultation between January 2011 and December 2022 was performed. Exclusion criteria were incomplete medical records. PREDICTOR VARIABLE: The primary predictor variable was geographic residence of the patient grouped into two categories: rural or urban defined by the state of Tennessee. Secondary variables were postal code (PC) average median household income (MHI) and PC population density. MAIN OUTCOME VARIABLE(S): The main outcome variable was pediatric CMF injury rate per 100,000 people. MOI is a secondary outcome variable. COVARIATE(S): Covariates included sex, age, and race. ANALYSES: Frequencies and percentages, Fisher's exact test, and Poisson regression models were utilized. Statistical significance was assumed at P-value <.05. RESULTS: Rural or urban county designation was not associated with differing trauma rates (incident risk ratio (IRR) = 0.91; 95% confidence interval (CI) 0.78 to 1.05; P = .18) by itself. One standard deviation increase in MHI decreased CMF trauma rates in rural designation counties by 24% (IRR: 0.76, 95% CI: 0.66, 0.88) and 6% in urban designation counties (IRR: 0.94, 95% CI: 0.87, 1.02). Lower rates of CMF trauma were associated with residence in higher income PCs (IRR = 0.91; 95% (CI) 0.86 to 0.97; P = .004), and higher population density (IRR = 0.87; 95% CI 0.79 to 0.94; P < .001). Dog bites and falls were more common in infancy and early childhood. Interpersonal violence was more common in older patients. CONCLUSIONS AND RELEVANCE: Patients in PCs with lower population density or incomes were at highest risk for CMF injuries. MOI differences by age were similar to findings in other studies. Tennessee's urban/rural county designation has complex interactions with MHI and pediatric CMF trauma rates.

Mandible Reconstruction in a Rural Population: Comparison of Radial Forearm and Free Fibula Flap Outcomes.

Comparison of microsurgical reconstructive options after mandible resection is limited in the literature. Fibula free flaps (FFFs) can be costly and have timing limitations, but dental restoration can be performed, with varied reported rates of completion. The radial forearm free flap (RFFF) with mandible plating may be an alternative in select populations. The purpose of this study was to determine if the RFFF has similar outcomes to the FFF for mandible reconstruction in a rural population. A retrospective review of patients who underwent mandibulectomy from 2017 to 2021 at a single tertiary-care academic institution was performed. Those with FFF or RFFF reconstruction were included. Mandible defects were classified using the Jewer-Boyd H-C-L system. Sixty-eight patients were included with 53 undergoing FFF and 15 undergoing RFFF. Immediate reconstruction was significantly more common with RFFF than FFF (100% versus 64.2%; P =0.01). Lateral mandible defects were most common among both groups (52.9% FFF versus 73.3% RFFF; P =0.04). Osseous defect length was similar (9.5 cm FFF versus 7.7 cm RFFF; P =0.07), but soft tissue defect size was significantly larger in the RFFF group (28.6 cm 2 versus 15.3 cm 2 ; P =0.01). Complication rates (47.1% FFF versus 46.7% RFFF; P =0.98) and disease-free status at last follow-up (96.2% FFF versus 80.0% RFFF; P =0.06) were similar. Dental restoration occurred in 21.3% of patients undergoing FFF. Patients undergoing RFFF or FFF reconstruction after mandibulectomy had similar surgical and disease outcomes, with a low rate of completed dental restoration after FFF. Our findings suggest RFFF is a reasonable alternative to FFF for mandible reconstruction in select patients.

Ambulatory Status before Diabetic Foot Ulcer Development as a Predictor of Amputation and 1-Year Outcomes: A Retrospective Analysis.

Background: Up to 25% of people with diabetes develop a diabetic foot ulcer (DFU) during their lifetime, which precedes approximately 85% of nontraumatic lower limb amputations. Diabetic limb salvage has been at the forefront of recent research, as major amputation is associated with 5-year mortality rates of 52%-80%. We sought to determine if ambulatory status before DFU diagnosis is predictive of amputations and outcomes within 1 year, as no studies have directly examined this relationship. Methods: A retrospective review of patients diagnosed with DFUs from January 2011 to December 2021 was performed. Patients aged 18 years or more with type II diabetes were included. Ambulatory status was defined as the primary form of mobility reported by the patient before development of DFU, and was categorized as independent ambulation, ambulatory with assisting device (AWAD), or nonambulatory (NA). Statistical analyses included χ2, multinomial, and multivariable logistic regressions. Results: After review, 506 patients were included. NA (OR = 5.10; P = 0.002) and AWAD status (OR = 2.77; P = 0.01) before DFU development were predictive of major (below or above-knee) amputation during hospitalization, emergency department visits within 30-days (NA: OR = 4.19; P = 0.01, AWAD: OR = 3.09; P = 0.02), and mortality within one-year (NA: OR = 4.19; P = 0.01, AWAD: OR = 3.09; P = 0.02). AWAD status was also associated with increased risk of hospital readmission (OR = 2.89; P < 0.001) within 30-days and any amputation (OR = 1.73; P = 0.01) within 1 year. Conclusions: In patients with DFUs, NA and AWAD status were predictive of major amputation during hospitalization and are associated with poorer 1-year outcomes, including mortality. Ambulatory status assessment may be used to inform DFU treatment approaches.

Preoperative Nutritional Laboratory Values, Demographics, and Wound Healing Following Facial Trauma Surgery: Which Variables Predict Postoperative Complications?

In individuals who have sustained maxillofacial trauma, inadequate nutrition is often a sequela and may lead to complications. The purpose of this study was to investigate the association between preoperative laboratory values and postoperative complications in patients with maxillofacial trauma requiring surgical intervention. A retrospective cohort study of patients with maxillofacial trauma requiring surgical repair from 2014 to 2020 was performed at a single academic Level I Trauma Center. The primary predictor variables were preoperative laboratory values including serum albumin, white blood cell count, absolute neutrophil count, and lymphocyte count. Complications related to surgical reconstruction of facial injuries represented the primary outcome variable. The patient cohort included 152 patients, of whom 50 (32.9%) were female. When controlling for all other variables, female gender (odds ratio=2.08, 95% confidence interval, 1.02-4.21; P =0.04) and number of procedures performed ( P =0.02) were the only statistically significant predictors of postoperative complications. There were no significant differences between the complication groups for age ( P =0.89), injury severity score ( P =0.59), hospital length of stay ( P =0.30), serum albumin ( P =0.86), hemoglobin ( P =0.06), white blood cell count ( P =0.20), absolute neutrophil count ( P =0.95), lymphocyte count ( P =0.23), or absolute neutrophil/lymphocyte count ratio ( P =0.09). In this study, it was found that only gender and the number of procedures performed significantly predicted postoperative complications, while preoperative nutritional laboratory values did not. Further study with a larger cohort of patients is likely required.

The Impact of Prior Breast Augmentation on Breast Reconstruction after Mastectomy.

The risk of women developing breast cancer after augmentation mammaplasty may be lower than the general population, with minimal current literature on breast reconstruction in this population. We sought to evaluate the impact of previous augmentation on postmastectomy breast reconstruction. Methods: Retrospective review of patients who underwent mastectomies from 2017 to 2021 at our institution was performed. Analysis included frequencies and percentages, descriptive statistics, chi-square analysis, and Fisher exact test. Results: Four hundred seventy patients were included, with average body mass index of 29.1 kg/m2, 96% identifying as White, and an average age at diagnosis of 59.3 years. Twenty (4.2%) patients had a prior breast augmentation. Reconstruction was performed in 80% of the previously augmented patients compared to 49.9% of nonaugmented patients (P = 0.01). Reconstruction was alloplastic in 100% of augmented and 88.7% of nonaugmented patients (P = 0.15). All reconstructed augmented patients underwent immediate reconstruction compared with 90.5% of nonaugmented patients (P = 0.37), and two-stage reconstruction was most common (75.0% versus 63.5%; P = 0.42). Of the previously augmented patients, 87.5% increased implant volume, 75% underwent same implant plane reconstruction, and 68.75% underwent same implant-type reconstruction as their augmentation. Conclusions: Previously augmented patients were more likely to undergo reconstruction after mastectomy at our institution. All reconstructed augmented patients underwent alloplastic reconstruction, with most performed immediately in staged fashion. Most patients favored silicone implants and maintained the same implant type and plane of reconstruction, with increased implant volume. Larger studies are required to further investigate these trends.

The Development of Breast Cancer-Related Lymphedema After Mastectomy in a Rural Population.

Breast cancer-related lymphedema (BCRL) is a lifelong condition that can impact the quality of life, affecting approximately 20% of breast cancer patients. Risk factors for the development of BCRL after mastectomy in rural populations have not been studied.Retrospective review of mastectomy patients from 2017 to 2021 was performed at a single institution. Statistical analysis included logistic and linear regression models.475 patients were included, and 40 (8.4%) patients were diagnosed with BCRL. Increased odds of developing BCRL were significantly associated with tumor-involved lymph nodes, radiation therapy, axillary lymphadenectomy, adjuvant chemotherapy, and endocrine therapy. Postmastectomy reconstruction significantly reduced the odds of developing BCRL. There was no significant association in our population with age, body mass index, diabetes, tobacco use, cancer type, or complications.This study demonstrates that individuals underrepresented in the literature, such as patients in largely rural communities, have some differences in risk factors for developing BCRL when compared to national studies.

The Impact of Travel Distance and Income on Breast Reconstruction after Mastectomy in a Rural Population.

Factors that influence breast reconstruction after mastectomy have been previously examined in national databases. The purpose of this study was to determine the impact of patient travel distance and income on breast reconstruction after mastectomy in a rural population. Methods: Retrospective review of mastectomy patients from 2017 to 2021 was performed from our prospectively enrolled tumor registry. Analysis included frequencies and percentages, descriptive statistics, χ 2 analysis, independent sample t tests, and multivariable analysis. Results: In total, 462 patients were included. Median BMI was 27.6 kg/m2, 96.1% of patients were White, and median age at diagnosis was 60.0 years. Reconstruction rate was 52.6%, and median length of follow-up was 24.6 months. No significant difference was found in the distance traveled by patients who underwent reconstruction (16.6 versus 16.7 miles; P = 0.94). Rates of reconstruction in patients who traveled 0-10 miles, 11-30 miles, and over 30 miles did not differ significantly (P = 0.16). Median household income was significantly different in reconstructed and nonreconstructed patients ($55,316.00 versus $51,629.00; P = 0.047). Rates of reconstruction were significantly higher in patients with median household income greater than $65,000 (P = 0.024). This difference was not significant on multivariable analysis. Conclusions: Travel distance did not significantly impact reconstruction rates after mastectomy, while household income did on univariable analysis. Studies at an institutional or regional level remain valuable, especially in populations that may not be accurately represented in larger database studies. Our findings highlight the importance of patient education, resource allocation, and multidisciplinary approach to breast cancer care, especially in the rural setting.

Utilization of Intravascular Ultrasound and Aptus Heli-Fx EndoAnchors for a Complex Type Ia Endoleak Repair.

Type Ia endoleaks are a complication of endovascular aneurysm repair that require intervention due to the increased risk of aneurysmal rupture. Many techniques have been studied in order to minimize the occurrence of these complications, as well as to aid in their repair. We introduce the utilization of intravascular ultrasound in conjunction with the endovascular EndoAnchor systems for the repair of a complex type Ia endoleak in an infrarenal aortic stent graft. This technique allowed us to have real-time feedback of EndoAnchor placement and aortic wall to stent graft apposition with a reduction in radiation exposure and contrast dye load.

Fall-Related Facial Trauma: A Retrospective Review of Fracture Patterns and Medical Comorbidity.

PURPOSE: Medical comorbidities may contribute to falls and thus require identification for education and prevention. We hypothesized that the epidemiology and injuries seen will be similar to the literature, with most falls that result in injury occurring in the elderly, to prominent facial structures, and are associated with specific comorbidities. METHODS: A retrospective review was performed of patients evaluated by the Trauma and Oral and Maxillofacial Surgery services after sustaining traumatic facial injury from July 2015 to June 2016 as a result of a fall. Associations between injury patterns, previous falls, and medical comorbidities were analyzed, and descriptive and bivariate statistics were reported. RESULTS: Of 152 patients included, 53.3% were females with a mean age of 61.2 years. Soft tissue laceration was seen in 59.9% of patients. The 3 most common fracture patterns seen were nasal fracture in 30.9%, orbital fracture in 30.3%, and zygoma fracture in 20.4%. Cardiovascular disease (53.3%) was the most common comorbidity. No major comorbidity was seen in 32.9% of patients. There was a significant association between orbital fracture and neurologic disease (P = .04). Patients with neurologic disease had a significantly longer length of stay (P < .001), and those without any major comorbidities had a significantly shorter length of stay (P = .02). Patients with previous emergency department visits for falls were significantly older (P = .03), had more comorbidities (P = .005), and were more likely to have cardiovascular disease and associated comorbidities (P = .001). CONCLUSIONS: The results are consistent with the literature, with the most fall-related trauma occurring in the elderly with injury to prominent facial structures. The most common comorbidity was cardiovascular disease, which was associated with previous falls. There is a significant association between neurologic disease and orbital fractures. Future studies should focus on recurrent falls after receiving appropriate education to reduce risk based on their specific comorbidities.

Two-stage Reconstruction of the Scalp with Facial AV Loop.

We present the case of a 65-year-old woman with extensive osteoradionecrosis of the scalp and calvaria after external beam radiation therapy for follicular lymphoma. Due to the compromise of her adjacent vasculature including the superficial temporal vessels, she underwent two-stage reconstruction with the creation of an AVL (arteriovenous loop) graft utilizing her great saphenous vein. This was anastomosed to her right facial artery and vein, which was then matured. She underwent resection of the necrotic portions of calvaria and soft tissue of approximately 180 cm2, and a vascularized free latissimus dorsi muscle flap was harvested and anastomosed to her new conduit. This free muscle flap was then covered with a split-thickness skin graft harvested from her thigh. She achieved satisfactory functional and cosmetic results with minimal morbidity and without complication despite her age, multiple co-morbidities, and extensive and complex disease process.

The Effects of Timing of Soft Tissue Coverage on Outcomes After Reconstruction of Type IIIB Open Tibia Fractures.

High-energy open fractures of the tibia are frequently associated with tissue loss, wound contamination, and compromised vascularity that often result in amputation. The management of these severe injuries remains a challenge for orthopedic reconstructive surgeons. Studies have compared the timing of soft tissue coverage of Gustilo type IIIB open tibia fractures with associated outcomes such as rate of deep infection, primary union, length of hospitalization, flap failure, and eventual secondary amputation. These studies often highlight better outcomes with specific time domains that are not always attainable at a large tertiary hospital with multi-system trauma patients. Many studies do not account for delayed patient transfers after initial open fracture management elsewhere. This retrospective analysis of the limb salvage outcomes included 140 consecutive patients with Gustilo type IIIB open tibia fractures who presented to the authors' level I trauma center between 2001 and 2014. The authors included patients who required delayed coverage or who were transferred from outside institutions. The majority (77%) were male, and the mean age was 39.4 years. Motor vehicle accidents were the most common cause of injury, and 83% of patients obtained full weight-bearing status with successful limb salvage. Twenty patients had a secondary amputation, with the cause being refractory osteomyelitis in 52%. This study provides guidance on treating a heterogeneous patient population with severe open tibia fractures typically seen in a large tertiary hospital orthopedic trauma service. [Orthopedics. 2019; 42(5):260-266.].