Background The COVID‐19 pandemic profoundly impacted breast cancer treatment in 2020. Guidelines initially halted elective procedures, subsequently encouraging less invasive surgeries and restricting breast reconstruction options. We examined the effects of COVID‐19 on oncologic breast surgery and reconstruction rates during the first year of the pandemic. Methods Using the National Surgical Quality Improvement Program, we performed an observational examination of female surgical breast cancer patients from 2017 to 2020. We analyzed annual rates of lumpectomy, mastectomy (unilateral/contralateral prophylactic/bilateral prophylactic), and breast reconstruction (alloplastic/autologous) and compared 2019 and 2020 reconstruction cohorts to evaluate the effect of COVID‐19. Results From 2017 to 2020, 175 949 patients underwent lumpectomy or mastectomy with or without reconstruction. From 2019 to 2020, patient volume declined by 10.7%, unilateral mastectomy rates increased (70.5% to 71.9%, p = 0.003), and contralateral prophylactic mastectomy rates decreased. While overall reconstruction rates were unchanged, tissue expander reconstruction increased (64.0% to 68.4%, p < 0.001) and direct‐to‐implant and autologous reconstruction decreased. Outpatient alloplastic reconstruction increased (65.7% to 73.8%, p < 0.0001), and length of hospital stay decreased for all reconstruction patients ( p < 0.0001). Conclusions In 2020, there was a nearly 11% decline in breast cancer surgeries, comparable mastectomy and reconstruction rates, increased use of outpatient alloplastic reconstruction, and significantly reduced in‐hospital time across all reconstruction types.

Background: Meniscal injuries are among the most common orthopaedic injuries, with a significant volume of published literature. Purpose: To perform a comprehensive bibliometric analysis that appropriately evaluates the 50 most cited articles in meniscal research. Study Design: Cross-sectional study. Methods: We performed a keyword search of the ISI Web of Knowledge database and then pared the results down to the 50 most cited articles using specific inclusion and exclusion criteria. Data extracted included title, first author, citation count, year of publication, topic, journal, article type, country of origin, and level of evidence. Correlation coefficients were calculated between publication date and citation density and between publication date and raw citation count. Results: The 50 most cited articles were published from 1975 to 2013. The mean number of citations was 258.24 (range, 163-926; median, 225). The majority of articles were published in The American Journal of Sports Medicine (19%), the Journal of Bone and Joint Surgery (12%), and Arthritis & Rheumatology (14%). Most articles focused on either the anatomy and biomechanics of meniscal injury or on prevention and physical rehabilitation (12 papers each). Conclusion: The most popular fields of meniscal research involved anatomy/biomechanics and prevention/rehabilitation, and both are areas that will likely increase the probability of an article’s being highly cited in the future. This study provided a quality selection of the most cited articles on meniscal injury and may provide a foundation for both beginner and senior clinician readers for further discussion and research.

Deformity and tissue loss involving the craniomaxillofacial region occurs frequently as a result of trauma, oncologic resection, or a congenital malformation. In order to maximize the patient's quality of life, reconstruction of the craniomaxillofacial skeleton must seek to restore aesthetics as well as function. Advances in diagnostic technology, surgical technique, instrumentation, and innovative biomaterials used have transformed the way reconstructive surgeons approach their patients’ needs. From the advent of alloplastic reconstruction, surgeons have sought the ideal material for use in craniomaxillofacial surgery. Substances such as metals, ceramics, glasses, and more recently resorbable polymers and bioactive materials have all been utilized. While autologous bone has remained widely-favored and the gold standard, synthetic alternatives remain a necessity when autologous reconstruction is not readily available. Today, alloplastic material, autografting via microvascular tissue transfer, hormone and growth factor-induced bone formation, and computer-aided design and manufacturing of biocompatible implants represent only a fraction of a wide range of options used in the reconstruction of the craniomaxillofacial skeleton. We present a brief review of the materials used in the repair of deformities of the craniomaxillofacial skeleton as well as a look into the potential future direction of the field.

bleeding profusely and probably contaminated, we recommend contacting emergency services. If a laceration is not suspected, the layperson should next move on to determining whether the injury is a concussion or contusion. If only bruising is seen, and the player exhibits no significant accompanying symptoms, then the player and layperson may decide together whether to continue playing. If there are more severe symptoms such as confusion, headache, lack of coordination, or blurry vision, concussion should be suspected. If a male player experiences 1 to 2 of these symptoms, they should be instructed to sit out for the remainder of the game. If they experience 3 or more symptoms, the layperson should consider seeking immediate medical help. This algorithm is largely the same for females, albeit with one important distinction: because females tend to suffer from more concussions than males, and because concussions in females are associated with worse prognoses, we suggest a more cautious approach to female players with suspected concussion. If one sign concerning for concussion is present, the player should be instructed to sit out, while 2 or more symptoms should prompt recruitment of emergency medical services. Prior studies have suggested that many players are aware of the symptoms of concussions, but often elect to continue playing after exhibiting these signs. 13 Proper application of this algorithm would prevent injuries from further progression during play, and would indicate proper care for a demographic at especially high risk of morbidity.This study carries several limitations which are primarily a consequence of usage of the NEISS database. Although NEISS provides a significant amount of information regarding injury mechanism and location, it cannot possibly encompass all of the factors that contribute to the injuries actually incurred. It would be impossible to realistically determine all of the underlying attributes that result in lacrosse-related injuries, and consequently, NEISS elects to view these through the lens of a select few. Furthermore, because the database does not provide results when estimates are below a certain value, it is possible that some results were close to but still underthe cutoff, prohibiting us from examining the corresponding data. Future studies should seek to characterize the injuries through other perspectives, and potentially use these to inform ways for the layperson to effectively intervene. Acquiring a thorough understanding of the events that promote trauma incurred from playing lacrosse would be among the most optimal ways to ensure safety for the players, and to avert injuries before they have a chance to occur.

Deep inferior epigastric perforator (DIEP) flap surgery commonly involves multiday hospitalization, although data suggest 95% of complications after unilateral DIEP flap breast reconstruction occur within the first 24 hours. The aim of this study was to decrease hospitalization time and optimize care of patients undergoing unilateral DIEP flap breast reconstruction. Our study followed Six Sigma's DMAIC (define, measure, analyze, improve, control) framework. First, we delineated the stakeholders involved in the process and defined workgroups based on temporal relation to the operation. We measured performance according to project SMART (specific, measurable, achievable, relevant, time bound) goals and subsequently conducted an analysis of inefficiencies. We then created new interventions for quality improvement. Control will entail ongoing monitoring to ensure progress is sustained after study completion. Our interventions lasted 6 months and included 70 patients. By actively striving to advance patients through postoperative milestones during their inpatient stay and creating an outpatient nursing roadmap including aspects of inpatient care, we decreased the median length of stay from 67.8 to 44.8 hours (p , .001). After receiving nursing instruction, 77% of patients agreed that they felt ready to be discharged. Our study suggests that the DMAIC framework can decrease hospitalization time after DIEP surgery and spare resources for additional patients.

dangers of aggression in the sport. When coupled with the widespread adoption of policies similar to those enforced by the NCAA, we would aim to see drastic decreases in fighting and a greater shift in hockey culture.Many teams who field an ''enforcer'' do so because they believe it will increase their chances of winning and competing. Contrary to this belief, violent player behavior is inversely associated with positive game outcomes. 23 There is concern that a change in public perceptions and entertainment expectations of hockey may result in a short-term decrease in public support and interest. It can be argued that the truth lies in the opposite. Limits on fighting can encourage teams to forgo enforcers who are often less skilled in lieu of players who are more agile and technical. 24 These changes have the potential benefit of leading to an increased pace of play, a higher chance of goal scoring, and a broadened popular appeal. Ultimately, we must prioritize the health and safety of hockey players to ensure that the sport continues to grow and thrive. CONCLUSIONSThe high incidence of hockey-related craniofacial injury among patients 12 to 18 years of age signals a need for continued interventions targeted towards this age group. Increased sideline personnel training and education while promoting stricter adherence to already established guidelines are an integral part of a greater strategy towards reducing injury incidence. As the sport continues to experience a historic rise in interest and participation, we should continue to work towards a common goal of harm reduction for the safety of its players.

Background: Telemedicine use has expanded rapidly since the COVID-19 pandemic in order to adhere to social distancing protocols and has been met with much enthusiasm. However, less is known about the use of telemedicine in sports and exercise medicine (teleSEM) and its utility to treat emergent craniofacial injuries. Given how common facial trauma is among athletes and its possible complications, incorporation of telemedicine in sports-related injuries may prove to be quintessential for athletes and coaches. Methods: A comprehensive literature search of the MEDLINE, PubMed, Google Scholar, EMBASE, and Cochrane Central Register of Controlled Trials was conducted for studies published through December 2020 with multiple search terms related to telemedicine in sports and trauma care. Results: Overall, teleSEM is appreciated by both patients and physicians alike. Studies show that the satisfaction rate among patients and physicians are high. Sports-related telemedicine visits can help improve resource utilization and total costs. Facial trauma studies also reveal that the level of concurrency of treatment options between telemedicine visits and in-person consultations is almost perfect. Further, there are many additional ways that teleSEM can be implemented in treating injured athletes, including possible collaboration between athletic coaches and physicians as well as mobile device applications. Telemedicine may be particularly useful in treating acute injuries in low-resourced areas with limited equipment and training. Conclusion: Telemedicine has been widely employed for sportsrelated injuries and in traumatic care. Patients and providers alike have noted its utility over other methods of communication with physicians. Our findings suggest that telemedicine has a significant potential in treating sports-related injuries and improving the efficiency of diagnoses and treatments. It may enhance outcomes for participants in athletic events. This may become a key aspect of determining whether a player can return to immediate competition.

Background: One option to optimize prepectoral tissue expander fill volume while minimizing stress on mastectomy skin flaps is to use air as an initial fill medium, with subsequent exchange to saline during postoperative expansion. The authors compared complications and early patient-reported outcomes (PROs) based on fill type in prepectoral breast reconstruction patients. Methods: Prepectoral breast reconstruction patients who underwent intraoperative tissue expansion with air or saline from 2018 to 2020 were reviewed to assess fill-type utilization. The primary endpoint was expander loss; secondary endpoints included seroma, hematoma, infection/cellulitis, full-thickness mastectomy skin flap necrosis requiring revision, expander exposure, and capsular contracture. PROs were assessed with the BREAST-Q Physical Well-Being of the Chest scale 2 weeks postoperatively. Propensity-matching was performed as a secondary analysis. Results: Of 560 patients (928 expanders) included in the analysis, 372 had devices initially filled with air (623 expanders), and 188 with saline (305 expanders). No differences were observed for overall rates of expander loss (4.7% versus 3.0%, P = 0.290) or overall complications (22.5% versus 17.7%, P = 0.103). No difference in BREAST-Q scores was observed (P = 0.142). Utilization of air-filled expanders decreased substantially over the last study year. After propensity matching, no differences in loss, other complications, or PROs were observed across cohorts. Conclusions: Tissue expanders initially filled with air seem to have no significant advantage over saline-filled expanders in maintaining mastectomy skin flap viability or PROs, including after propensity matching. These findings can help guide choice of initial tissue expander fill type. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.