INTEGRATED APPROACH TO OCULOFACIAL TRAUMA: INTERSECTIONS BETWEEN OPHTHALMOLOGY, PLASTIC SURGERY AND OTORHINOLARYNGOLOGY

Continuous positive airway pressure (CPAP) intolerance remains a persistent problem for many obstructive sleep apnea patients. Clinicians and researchers continue to search for other effective treatment modalities given the well-documented sequelae associated with untreated obstructive sleep apnea. A multidisciplinary "Alternatives to CPAP program" (ALT) can facilitate systematic evaluation of non-CPAP therapies appropriate for an individual patient. We review successful strategies and barriers encountered during implementation of an ALT at our institution. Creation of similar programs in private practice and academic settings can help medical, dental, and surgical sleep medicine specialists coordinate evaluation and treatment of CPAP-intolerant patients.

This new book, ‘Combination Facial Reconstruction after Mohs Surgery’, is a very valuable read for dermatologic surgeons and any surgeon involved in facial plastic reconstruction. It is an intelligent reconstructive facial surgery atlas and offers a wide array of more than 60 complex modalities of wound closure, including many for multi-subunit facial defects after Mohs surgery. The book provides useful advice for difficult repair surgery after facial skin cancer removal. The authors are experts in the field—Stanislav N. Tolkachjov is the director of Mohs Micrographic & Reconstructive Surgery Epiphany Dermatology Dallas-Fort Worth Metroplex, in Texas, USA. His coauthor, Felipe B. Cerci, works at Mohs Curitiba-Clínica Cepelle, Hospital Universitário evangélico Mackenzie, in Curitiba, Brazil. Both authors have a broad year-long experience in facial reconstruction, which they nicely share with the reader. The love and passion for their work emanates in all 184 pages filled with meticulous surgical photographs and compact additional information mostly in the form of tables for fast assessment. The structure of the book makes it especially convenient as a quick guide in the operation room, as it divides the surgical procedures according to location, and ideas for difficult closures can be promptly found. Skin closure interventions can easily be reproduced step by step by observing the more than 600 self-explaining excellent surgical photographs. In addition, the authors also offer alternative repair options—even secondary intention healing when adequate, with long-term clinical follow-up. The book provides useful advice in the concise bullet ‘Learning Points’; for neuralgic locations, pros and cons are given, and potential complications are discussed. This makes the work also very helpful for a rapid explanation of complex procedures to patients, thus improving patient satisfaction. The book is a valuable addition to any library on basic dermatologic surgery, especially for physicians with prior knowledge in the field. With the advanced wound closure options, one is fully equipped to close even difficult facial defects. Overall, this outstanding book is a must-have for dermatologic surgeons, ideally to be stored within reach in the operation room as a quick guide for complex cases; I already use it with satisfaction in my surgical practice.

To review the clinical features, treatments, complications, and outcomes of horses with traumatic orbital fractures. Retrospective study. Eighteen horses with confirmed orbital fractures. Medical records of horses presenting with orbital fractures between 2006 and 2013 were reviewed. Signalment, etiology of fracture, clinical signs, fracture descriptions, diagnostic imaging, treatments, complications, and outcomes were evaluated. Eighteen horses presented with orbital fractures resulting from rearing in a confined space (n = 5), being kicked (4), colliding with a stationary object (3), and unknown trauma (6). Radiography and computed tomography were effective at classifying fractures and evaluating sinus/nasal involvement. Epistaxis/sinusitis were associated with fractures of the zygomatic process of the temporal bone (n = 3) and comminuted fractures of multiple bones (5). Seventeen fractures required treatment, with fifteen receiving a combination of medical and surgical therapy. Surgery included reduction of large bony fragments (n = 8), removal of small fragments (12), stabilization with a wire implant (1), and sinus trephination and lavage (5). Factors contributing to a favorable outcome included: globe retention (n = 16), vision (14), comfort (15), cosmesis (9), and return to previous function (13). Horses sustaining orbital fractures treated promptly with medical and surgical therapy have a favorable prognosis for return to function and cosmesis. Fractures affecting the zygomatic process of the frontal bone are unlikely to involve the sinus/nasal cavities. Epistaxis and sinusitis warrant more aggressive therapy and decrease functional and cosmetic outcome.

Collective Wisdom and Multidisciplinary Tumor Boards

Bronchiectasis and pulmonary nontuberculous mycobacteria (NTM) infections are chronic diseases that can cause debilitating respiratory symptoms, exacerbations, and even lead to respiratory failure. Clinical care has historically been provided by individual specialists, but multidisciplinary care teams have recently emerged to improve evaluation of underlying etiology and interventions that disrupt the trajectory of disease progression. Does a multidisciplinary care program reduce bronchiectasis exacerbations or improve sputum conversion rates in pulmonary NTM infections? This is a retrospective study of INTEGRATE, a multidisciplinary bronchiectasis and NTM care program launched in 2019 and shaped by the principles of a patient-centered and integrated care (PC-IC) model. Those who consistently submitted microbiologic samples and received prescriptions through the program were included in outcome models. Interrupted time series analysis and segmented Poisson regression were used to compare bronchiectasis exacerbation rates prior to and following INTEGRATE consultation. Sputum culture conversion of NTM was analyzed by Cox hazard regression to estimate the hazard ratio. The analysis included 453 individuals cared for at INTEGRATE, evaluated for demographic characteristics, encounter frequency, and clinical characteristics. INTEGRATE was associated with a 36% reduction in quarterly exacerbations in the year following consultation compared with the pre-consultation trend (rate ratio, 0.64; 95% CI, 0.55-0.74; P = .0004). Among individuals with NTM lung infection, those followed up at INTEGRATE had shorter time to culture conversion compared with general care (hazard ratio, 0.68; 95% CI, 0.47-0.97; P = .0311), indicating a higher rate of conversion over time. Furthermore, an established multidisciplinary conference improved provider comfort and perceived practice safety. The INTEGRATE multidisciplinary program for bronchiectasis and pulmonary NTM disease has been well received, with PC-IC argued as the ideal model. Further studies are needed to identify specific measures and timing to inform quality improvement and broader implementation.

The evolving role of neurosurgery for central nervous system metastases in the era of personalized cancer therapy

Facial defect coverage is a common subject in the field of reconstructive surgery. There are many methods for facial defect reconstruction, and reconstructive surgeons should choose the most appropriate method on a case-by-case basis to achieve both functional and aesthetic improvement. Among various options for facial reconstruction, the local flap technique is considered the best reconstructive modality to provide good tissue matches of color and texture, which is consistent with the ideal goal of reconstruction (replacement of like-with-like). Keystone design perforator island flap (KDPIF), devised by Behan in 2003, has been applied to various fields of reconstructive surgery in the past decade due to its design simplicity, robust vascular supply, and reproducibility. Several studies have reported KDPIF reconstruction of facial defects, such as large parotid defects, small-to-moderate nasal defects, and eyelid defects. However, KDPIF has been used relatively less in facial defects than in other body regions, such as the trunk and extremities. The purpose of this review is to provide an organized overview of facial KDPIF reconstruction including the classification of KDPIF, modifications, physiology, mechanism of flap movement, consideration of facial relaxed skin tension lines and aesthetics, surgical techniques, clinical applications, and precautions for successful execution of KDPIF reconstruction.

Botulinum toxin is a neurotoxin that has been utilized to induce chemo-denervation of muscles. Cutaneous wounds represent a special situation in which the tensile forces applied by these muscles on wound edges might have deleterious effects on the healing process. The aim of this review was to investigate such an effect and to review other mechanisms this toxin might have on the healing process. We also reviewed the role of botulinum toxin in the management of hypertrophic scars and cleft lip repair.

Transposition movement of V–Y flaps for facial reconstruction

Morbidity and mortality rates in patients with perforated peptic ulcer (PPU) remain substantial. The aim of the present study was to evaluate the effect of a multimodal and multidisciplinary perioperative care protocol on mortality in patients with PPU. This was an externally controlled multicentre trial set in seven gastrointestinal departments in Denmark. Consecutive patients who underwent surgery for gastric or duodenal PPU between 1 January 2008 and 31 December 2009 were treated according to a multimodal and multidisciplinary evidence-based perioperative care protocol. The 30-day mortality rate in this group was compared with rates in historical and concurrent national controls. The 30-day mortality rate following PPU was 17·1 per cent in the intervention group, compared with 27·0 per cent in the three control groups (P = 0·005). This corresponded to a relative risk of 0·63 (95 per cent confidence interval 0·41 to 0·97), a relative risk reduction of 37 (5 to 58) per cent and a number needed to treat of 10 (6 to 38). The 30-day mortality rate in patients with PPU was reduced by more than one-third after the implementation of a multimodal and multidisciplinary perioperative care protocol, compared with conventional treatment. NCT00624169 (http://www.clinicaltrials.gov).

This study aimed to evaluate the safety of a modified pre-aricular approach in the treatment of orbital zygomatic maxillary complex fractures. This was a retrospective study of clinical data from 108 adults who were diagnosed with orbital zygomatic maxillary complex fractures and undergo open reduction and internal fixation through a modified pre-auricular approach. Exophthalmometry and limitation of extraocular muscle movement were determined using a Hertel exophthalmometer or synoptophore examination respectively. Primary complications were recorded, and postoperative facial nerve injury was tested by electrophysiologic analysis. All patients received satisfied functional and cosmetic results at least 6 moths postoperatively. There were 2 cases (1.85%) involving complete or incomplete facial nerve injury confirmed by electrophysiologic analysis. The incidence of other postoperative complications including a hematoma rate of 1.85% patients and permanent hypesthesia or paresthesia in 2.78% of patients, and no cases of clinically significant temporal hollowing, alopecia, infection, or unacceptable scars encountered during a mean follow-up period of 2 years. A modified pre-auricular approach with dissection deep to the temporalis fascia offers a safe and reliable surgical technique for accessing the malar arch in orbital zygomatic maxillary complex fractures.

Fabric monofilament polyethylene mesh is an implant primarily used in the repair of abdominal and chest walls. However, there have been isolated reports of using this implant in facial reconstruction. The authors describe a patient who underwent prior orbital floor fracture repair with polyethylene mesh and subsequently developed a recurrent orbital abscess 12 years later. Despite incorporation of the fabric monofilament polyethylene mesh within healed bone, an orbitocutaneous fistula developed after a secondary injury, causing hyperglobus and cicatricial lower eyelid retraction.

The optimal surgical pathway for the remediation of orbital floor fractures persists as a topic of considerable deliberation among ophthalmic and maxillofacial surgeons. The primary surgical modalities—transconjunctival, subciliary, and endoscopic techniques—each present a unique profile of advantages and inherent limitations with respect to surgical exposure, aesthetic outcomes, and the incidence of postoperative complications. This meta-analysis was undertaken to conduct a comparative evaluation of the clinical outcomes and complication rates associated with these three principal surgical approaches employed in the repair of orbital floor fractures. A meticulous and systematic search of prominent medical databases, including PubMed, Embase, and the Cochrane Library, was performed to identify relevant comparative studies published between January 2014 and December 2024. These studies were required to evaluate transconjunctival, subciliary, and/or endoscopic techniques for the repair of orbital floor fractures. Data from seven heterogeneous comparative studies were ultimately synthesized for this analysis. The primary outcome measures assessed were the incidence of postoperative persistent diplopia and the occurrence of significant enophthalmos, defined as globe retrodisplacement of 2 mm or greater. Secondary outcomes encompassed a range of complication rates, specifically including infraorbital nerve (ION) hypoesthesia, lower eyelid malpositions such as ectropion and entropion, and postoperative surgical site infections. Pooled odds ratios (ORs) or risk ratios (RRs) with their corresponding 95% confidence intervals (CIs) were calculated, employing a random-effects model to account for inter-study variability. The analysis incorporated seven studies, comprising a total of 850 patients who underwent surgical correction for orbital floor fractures. The distribution of patients across the surgical modalities was as follows: 300 patients were managed via a transconjunctival approach, 350 patients via a subciliary approach, and 200 patients via an endoscopic approach. The findings indicated that the transconjunctival approach was associated with a statistically significant lower rate of postoperative ectropion (OR 0.25, 95% CI 0.10-0.65) when compared to the subciliary approach. No statistically significant differences were observed in the rates of persistent diplopia (Transconjunctival vs. Subciliary: OR 0.90, 95% CI 0.55-1.48; Transconjunctival vs. Endoscopic: OR 1.10, 95% CI 0.60-2.01) or significant enophthalmos among the three surgical groups. Endoscopic approaches demonstrated a trend towards lower rates of new or worsened ION hypoesthesia (OR 0.60, 95% CI 0.30-1.19 vs. combined transcutaneous approaches), although this did not achieve statistical significance. In conclusion, this meta-analysis suggests that the transconjunctival approach may offer a superior lower eyelid cosmetic outcome by substantially reducing the risk of ectropion relative to the subciliary approach. All three evaluated techniques demonstrated comparable efficacy in addressing the primary functional objectives of resolving diplopia and correcting enophthalmos. The selection of an appropriate surgical approach should, therefore, be an individualized decision, meticulously considering surgeon experience and expertise, the specific characteristics and complexity of the fracture, and pertinent patient-related factors and preferences. There remains a compelling need for further high-quality, large-scale randomized controlled trials to definitively establish the potential superiority of one approach over the others across a broader range of outcomes.

UNSTRUCTURED Importance Men’s health, particularly in the field of urology, is characterized by significant challenges due to delayed engagement in care, limited access to specialists, and rising healthcare costs. Men often avoid screenings and interventions until conditions become severe. This is compounded by 62% of U.S. counties lacking a practicing urologist with only one new urologist entering the field for every ten retiring. Historically underserved populations like African American or Latino men face disproportionate rates of prostate cancer, mortality, and accessibility barriers. These factors result in advanced-stage diagnoses and significant health inequities. This review explores the role of telehealth and integrated care as potential solutions to these pressing issues in men’s urological healthcare. Observations Telehealth and AI-enabled integrated care offers promising solutions to gaps in access, quality, and cost efficiency in urological care.These modern technologies enable virtual consultations, point-of-care diagnostics, remote monitoring, and continuous patient engagement, particularly in areas with a shortage of urologists. Integrated care models, which connect providers and services for comprehensive, patient-centered care, reduce hospital admissions, readmissions, and the need for advanced-stage interventions. These models have successfully lowered costs, improved patient satisfaction, and increased male engagement in healthcare, while the AI-enabled care model further enhances efficiency, improves outcomes and reduces provider burnout. Conclusions and Relevance Telehealth and integrated care models have the potential to transform men’s urological healthcare by making it more accessible, efficient, and equitable. These models present a viable pathway for addressing major gaps in care, though no large-scale integrated telehealth practices for urology currently exist. Digital health solutions enable healthcare providers to ensure timely diagnosis and improve outcomes for men. Telehealth models have provided equivalent or superior care to in-person models while significantly reducing logistical barriers and costs. Addressing these challenges through innovations in telehealth and integrated care is critical for improving men’s clinical outcomes in the future.

Purpose Intraorbital encephalocele (OMEC) is a rare entity in adults, usually secondary to an orbital pathology or prior trauma, in particular orbital roof fractures. Treatment of the OMEC is warranted to alleviate the pulsating exophthalmos and prevent potential visual decline. OMEC and orbital roof fractures have been predominantly treated via a craniotomy with a reconstruction of the orbital roof using various implants. With the advances in the endoscopic techniques, neuroendoscopy found its application in the treatment of orbital pathologies. We report a minimally invasive alternative: endoscopic transorbital repair of OMEC. Material and methods The repair technique is described with illustrations and clinical images. Narrated operative video demonstrating the procedure is provided. Results Illustrative case: 50-year-old female presented with progressive right eye proptosis over 6 months. Computed tomography (CT) demonstrated bony erosion in the lateral orbital roof, and magnetic resonance imaging (MRI) showed a small hyperintense T2-weighted and T1-weighted contrast enhancing lesion in the orbit, in the area of the bony erosion. Intraoperatively, the lesion was found to be an orbital encephalocele. The orbital defect was successfully repaired by employing the ‘sandwich’ technique, in which a dural substitute reinforced with tissue glue were deployed without repair of the osseous orbital roof. The patient tolerated the procedure well with ultimate resolution of proptosis. The cosmetic outcome was excellent. Conclusion The transorbital neuroendoscopic approach (TONES) presents a feasible, minimally invasive alternative treatment option for circumscribed intraorbital encephaloceles with minimal side effects, well tolerated by patients.