Protecting the gains of health care reform.
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Health Care Reform↗
Biomedical subjects
B Markowitz
Publications and source records attributed to B Markowitz.
Cost and outcome of osteocutaneous free-tissue transfer versus pedicled soft-tissue reconstruction for composite mandibular defects.
Thirty-nine patients underwent reconstruction of composite mandibular defects following resection for squamous cell carcinoma. Thirty-four underwent immediate reconstruction, while 5 were reconstructed secondarily. Twenty-one received soft-tissue reconstruction only with a pectoralis major myocutaneous flap, 14 underwent osteocutaneous free-tissue transfer, and 4 received a reconstruction plate with free-tissue transfer for soft-tissue coverage. The mandibular defects in the pectoralis major myocutaneous flap group tended to be posterolateral, while free-tissue transfer defects were more severe, usually involving the anterior mandible. Length of surgery and duration of intensive care unit care were significantly longer for free-tissue transfer patients, while flap complications were more common in the pectoralis major myocutaneous flap patients. Facial appearance scores were higher for the free-tissue transfer group by both patient and physician assessment. Social function, speech, and oral function did not differ significantly. Patients reconstructed secondarily with free-tissue transfer reported significant improvement in appearance, oral continence, and social function, with little change in speech intelligibility, deglutition, or diet tolerance. The cost of the main hospitalization was significantly higher in the free-tissue transfer group than in the pectoralis major myocutaneous flap group, although when the costs of subsequent hospitalizations are included, the difference in total cost narrows. Despite more adverse defects, free-tissue transfer provided more predictable aesthetic results and expeditious return to normal social function than did pectoralis major myocutaneous flap reconstruction. The fiscal impact of these complex reconstructions is, however, significant. Cost-containment issues are presented and recommendations are made.
Aged↗
Achieving mandibular continuity with vascular bone flaps: a comparison of primary and secondary reconstruction.
This retrospective study was performed to compare the functional and aesthetic results achieved in two distinct groups of patients undergoing composite reconstruction of complex head and neck defects using vascularized bone flaps. Fourteen consecutive patients undergoing reconstruction over a 30-month period (January 1988 through June 1991), nine primary and five secondary, were analyzed. The two groups were similar with respect to age, physical status, tumor type and stage, exposure to radiation, and previous history of cigarette smoking and alcohol consumption. The bone defect was similar between the two groups, but the soft tissue deficit was greater in the group of patients reconstructed secondarily. Surgery time and blood loss tended to be less in the patients reconstructed secondarily, but length of hospitalization was similar. Flap survival was 100%, although the complication rate approached 60%. Restoration of mandibular continuity and orofacial soft tissue defects with vascularized composite free flaps had a favorable impact on function and aesthetics in the group of patients reconstructed primarily. In those reconstructed secondarily the benefit was primarily cosmetic. Continued emphasis on primary reconstruction of the composite defect with composite free tissue transfers is advised.
Aged↗
Blindness after blepharoplasty.
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Animals↗
Toward CT-based facial fracture treatment.
Facial fractures have formerly been classified solely by anatomic location. CT scans now identify the exact fracture pattern in a specific area. Fracture patterns are classified as low, middle, or high energy, defined solely by the pattern of segmentation and displacement in the CT scan. Exposure and fixation relate directly to the fracture pattern for each anatomic area of the face, including frontal bone, frontal sinus, zygoma, nose, nasoethmoidal-orbital region, midface, and mandible. Fractures with little comminution and displacement were accompanied by subtle symptoms and required simple treatment; middle-energy injuries were treated by standard surgical approaches and rigid fixation. Highly comminuted fractures were accompanied by dramatic instability and marked alterations in facial architecture; only multiple surgical approaches to fully visualize the "buttress" system provided alignment and fixation. Classification of facial fractures by (1) anatomic location and (2) pattern of comminution and displacement define refined guidelines for exposure and fixation.
Facial Bones↗
Complex fractures of the clivus: diagnosis with CT and clinical outcome in 11 patients.
During a 20-month period, fractures of the clivus occurring after craniocerebral trauma were diagnosed with computed tomography (CT) in 11 patients. Five patients had longitudinally oriented fractures; these were fatal in four patients due to either vertebral-basilar artery occlusion, brain stem trauma, or both. Six other patients had transversely oriented fractures that extended through the carotid canal and petrous temporal bone. While less frequently contributing directly to mortality, transverse fractures were also associated with cerebrospinal fluid leaks (two patients) and a cavernous sinus-carotid fistula (one patient). They were not as frequently associated with Horner syndrome or cranial nerve deficits as suggested in the current literature. This retrospective evaluation reveals two distinct injury patterns that demonstrate a difference in related morbidity and mortality.
Adolescent↗