Journal of Aesthetic & Reconstructive Surgery

Description

In the setting of the current novel coronavirus pandemic, this document has been generated to provide guiding statements for the adult cardiac surgeon to consider in a rapidly evolving national landscape. Acknowledging the risk for a potentially prolonged need for cardiac surgery procedure deferral, we have created this proposed template for physicians and interdisciplinary teams to consider in protecting their patients, institution, and their highly specialized cardiac surgery team. In addition, recommendations on the transition from traditional inperson patient assessments and outpatient follow-up are provided. Lastly, we advocate that cardiac surgeons must continue to serve as leaders, experts, and relevant members of our medical community, shifting our role as necessary in this time of need.

Mandibular Fixation

The case in which the splint was cemented showed delayed healing due to continuous dislodgement of the splint, which occurred because of dissolution of the cement. According to peterson with the exception of mandibular condyle fractures judicious use of ORIF is preferable to the closed reduction and immobilization techniques with splints when treating fractures in the deciduous and mixed dentition. Extended periods of maxilla mandibular fixation can lead to alkalosis in children and should be avoided.

In cases of condylar fractures, non-operative management is overwhelmingly popular, because minimal complications occur and the outcomes are good in both adults and children. Moreover, in older children, the bone has less capacity to adapt and remodel, and the ramus height may not be regained. Previous research has shown the use of arch-bar fixation restricts normal dietary intake in children, resulting in significant weight and protein loss. Here in the present case series, maxilla mandibular fixation was performed using light-training elastics so that an active exercise program could be started as soon as the child could cooperate.

Dependence on hospital infrastructure to manage the outbreak is variable and difficult to predict. Mandatory quarantines are present in many states, and the centers for disease control and prevention has stated that certain individuals are at higher risk in the setting of the pandemic and should avoid close contact with others. This specifically includes patients aged older than 65 years and those with lung or heart conditions, diabetes, and obesity. This obviously represents most of the population that requires cardiac surgery.

The intent of this document is to provide guidance to the adult cardiac surgery perioperative community regarding management of patients considered or scheduled for surgical procedures in the context of the current pandemic. Specifically, contained within is a proposed template for physicians and interdisciplinary teams to consider and adapt to the unique aspects of each patient in the specific context of the prevalence of COVID-19 at the medical center where they are being treated.

Cardiac Surgical Procedure

There is obviously a balance of risk, as patients with significant cardiovascular disease have their definitive treatment delayed increasing the likelihood of acquiring a nosocomial COVID-19 infection and its consequences. The factors resulting in delaying a cardiac surgical procedure are multifold. Blood products are in short supply because volunteer donation rates are substantially reduced under the advisory of avoiding close contact. Each cardiac surgical procedure will necessarily consume increasingly scarce resources that might delay or prevent treatment of a patient suffering from the sequela of a COVID-19 infection. Lastly, there is an increasing awareness of the importance of preventing infections of the health care team by patients who may be asymptomatic carriers. Screening of asymptomatic patients should be determined based on institutional practice.

The arch bar was extended to the last tooth on both sides in the oral cavity. The hooks were positioned symmetrically in the upper and lower jaws to achieve calculable tension forces on both the bars for functional training with elastics. Once the wire was secured to the awl, it was withdrawn until the tip of the awl reached the lower border of the mandible and then the wire was carefully passed on to the buckle sulcus along the body of the mandible, with care taken to prevent soft-tissue injury. One wire was passed on each side, taking precaution to avoid injury to the mental neurovascular bundle.

To fix the arch bar in place, a ligature in the premolar region was prepared on each side. The arch bar was positioned and fixed using the wire twister. It is more difficult to make use of the teeth in children for fixation, because deciduous teeth may be either insufficient in number or their roots may be resorbed and permanent teeth may be incompletely erupted. The wire was cut with a cutter, and the ends were turned away from the gingiva to prevent damage. Maxilla mandibular fixation was performed with elastics for intraoperative management of the occlusion Management of mandibular fractures in children differs somewhat from that in adults because of several considerations, including anatomic variation, rapidity of healing, degree of patient cooperation, and the potential for changes in mandibular growth. Ankylosis of the temporomandibular joint causing impairment of function is more common in children and damage to the condylar growth center can result in facial deformity.

Elasticity of the bone in children, the relatively small size of the face, and the growth process in the young bone is also among the factors that influence the pattern of fracture and its management and also depends on the postoperative period of fixation. This invagination induces cellular proliferation in the ectomesenchyme, which subsequently forms the dental papilla. These developing ectomesenchymal cells are contained in a sac known as the dental follicle. Eventually, the overlying dental lamina forms the ameloblasts (which produce the outer tooth enamel), the dental papilla forms the dental pulp and the odontoblasts (which produce dentin), and the follicle forms the cementum as well as the periodontal ligament (which anchors the tooth to the underlying alveolar bone). Simplified, the overlying ectoderm, or dental lamina, invigilates into the underlying ectomesenchyme. Minimally displaced fractures can be treated by soft diet, analgesic use and antibiotic prophylaxis. However, in very young children, healing might be prolonged because of insufficient cooperation in following postoperative instructions. In such cases, fabrication of a splint and cementing onto the arch can be used to overcome these hindrances.