Journal of Aesthetic & Reconstructive Surgery

Description

A majority of respondents labeled themselves general pediatric surgeons, while 34% considered themselves general surgeons with a specific clinical focus, and 3% reported practicing solely within a specific niche. Subspecialists commonly serve as consultants for relevant cases. Common niches included oncology and anorectal malformations. Subspecialists felt to be necessary included transplant and fetal surgeons. Opinions about sub-specialization were variable: 41% felt sub-specialization improves patient care while 39% believe it is detrimental to surgeon well-roundedness. Only 10% felt subspecialists should practice solely within their subspecialty. Practicing at an academic hospital or fellowship program correlated with sub-specialization, while length of time in practice did not.

Syphilis Fractures

Slight occlusal discrepancies resulting from lack of perfect reduction correct spontaneously as permanent teeth erupt and bone undergoes remodeling with function. No displaced body or syphilis fractures without malocclusion can be treated by close observation, slenderized diet and avoidance of physical activity. If displaced closed reduction and immobilization is performed. Exact method of immobilization depends on child’s chronologic age and state of dental development. In less than 2 years age very little anchorage can be taken from teeth as most are erupted or incompletely formed. In mixed dentition only 6 years molars are adequate for circumvented wires. If possible arch bars are placed and elastic immobilization is done.

Appliance should be fixed in place using caecum and fibular wires one on either side of fracture or two wires to add stability to the splint. If required then wires can be added from caecum and fibular wires to wires at perform region or sigma. The impact displaces condyle poster superiorly against skull base thus leading to range of injury from capsular tear, hemarthrosis to fracture of condylar head or neck. Occasionally a crush injury to condyle can produce comminuted fracture. Children less than 3 years of age with trauma to condyle are at greatest potential for growth disturbance especially due to amyloses.

Mandibular Hypomobility

 Inadequate or overtreatment may lead to growth retardation or excess while excessive immobilization may lead to mandibular hypo mobility. So the two main goals for treatment in such patients are Preservation of function Maintenance of ramus height. When this is achieved normal growth usually occurs. Splint should be left in place for three weeks. Clinical signs of shock may occur with even insignificant amounts of rapid blood loss due to small blood volume. Because of small size of airway laryngeal edema or retro position of base of tongue may produce sudden obstruction. Tracheostomy if required should be done using vertical incision avoiding first tracheal ring and high lying left innominate vein.

The shape and shortness of deciduous crowns may make the placement of circumvented wires and arch bar slightly more difficult in children. However the narrow cervix of tooth in relation to crown and roots provides better retention of wires as in Ivy loops or stout wires. Minor malocclusions will correct spontaneously. Deviation on opening is treated with midline opening exercises. If there is significant pain and severe malocclusion short period of immobilization for 7-10 days with or without bite opening splint is indicated. This can be followed with training elastics. In bilateral sub condylar fractures in children in primary and mixed dentition stage relatively normal opening and stable occlusion may be present. Analgesics and slenderized diet for 7-10 days followed by soft diet for two weeks may be adequate.

However bilateral fractures with significant dislocation often produce open bite malocclusion. Contour defects may occur due to severely comminuted or compound fractures when bone undergoes desorption during remodeling. In general however mandibular body fractures present little risk for long-term growth abnormalities. Unilateral and bilateral condylar fractures may however cause mandibular asymmetry and retrognathism with open bite respectively. Leaked et al demonstrated no growth abnormalities in 13 children with unilateral and 8 children with bilateral sub condylar fractures treated with analgesics, liquid diet, exercises and guiding elastics.

There were 11 bilateral fractures and 27 unilateral fractures. 35 patients were treated with close observation alone or in combination with inter maxillary fixation. Three patients had open reduction and fixation with K-Rod and condylectomy. In Lund’s study mandibular growth was generally greater on fractured side than no fractured side so that the fractured ramus which was initially shorter had greater incremental growth rate so that possible disproportion between two sides reduced with time. This was evident when measuring distance between chin points to condyle. Earlier most of the pediatric cases were treated with conservative measures or closed reduction techniques. Only recently have the distinct advantages of accurate primary repair and the stable fixation of facial fractures been applied to the rehabilitation of injuries in children too.

Although reoperation for bleeding is associated with morbidity after cardiac surgery, substantial transfusion without reoperation appears to increase morbidity compared with a limited-transfusion re operative approach. Better timing for reoperation and guided transfusion approaches may mitigate morbidity compared with substantial transfusion alone.

Studies using the International Study Group of Pancreatic Surgery definition of postoperative pancreatic fistula including 16 randomized trials were reviewed to generate a series of statements set into 14 domains. There was strong consensus in the following statements: There was no difference in the postoperative pancreatic fistula rate after left pancreatectomy between the handsewn and stapler techniques; a stapling technique could not be used in all cases of left pancreatectomy; the use of an energy-based tissue sealant or a chemical sealant device or combinations of these did not impact the postoperative pancreatic fistula rate; there was no difference in the postoperative pancreatic fistula rate between the open, laparoscopic, or robotic approaches; and there are 1 or more clinically important, patient-related risk factors associated with the postoperative pancreatic fistula rate.