Faculty Bibliography

OBJECTIVE:The objective of this study was to determine the outcomes of robotic peritoneal flap vaginoplasty. BACKGROUND:There is a lack of long-term outcomes data for gender-affirming vaginoplasty to inform patient decision-making. METHODS:A retrospective cohort of 500 consecutive patients undergoing robotic peritoneal flap vaginoplasty from 2017-2023 were reviewed. Complications requiring procedural intervention, self-reported vaginal dimensions, and orgasm were recorded at each follow up visit and analyzed as outcomes. RESULTS:487 (97%) of patients were followed to 3 months, and 425 (85%) to 1 year or greater. Twenty patients (4%) had a complication requiring procedural intervention, and 61(12%) had elective revision surgery. Median self-reported vaginal depth and width at 1 year was 14.5 cm (14.5-14.5) and 3.8 cm (3.8-3.8 cm). There were 12 patients (4%) no longer dilating using standard dilators at this pre-scheduled 1-year appointment, and at last follow-up ≥1 year, 8% were no longer dilating. Thirty-six (8%) of patients were considered anorgasmic at last follow up. Difficulty with orgasm prior to surgery was associated with lower rates of achieving orgasm after surgery and less consistent vaginal depth at 1 year, however 80% of these patients were able to orgasm after surgery. CONCLUSIONS:Clinician-observed and patient-reported outcomes for robotic gender-affirming peritoneal flap vaginoplasty were superior to those reported in the literature for penile inversion vaginoplasty. Patients who do not achieve orgasm prior to surgery are less likely to achieve orgasm and maintain vaginal depth afterwards, however the majority of these patients have improved sexual health after surgery.

LEARNING OBJECTIVES/OBJECTIVE:After studying this article, the participant should be able to (1) understand the nonsurgical and surgical techniques and advancements in the management of pediatric head and neck cancers, (2) describe the common management strategies used in pediatric head and neck cancers, and (3) Understand therapies to target head and neck cancers within pediatric patient populations. SUMMARY/CONCLUSIONS:Pediatric head and neck cancer management is complex and often requires a multidisciplinary approach. Management goals aim to deliver a multimodal treatment approach that integrates surgery with concurrent medical management through adjuvant and/or neoadjuvant chemotherapy and/or radiation therapy. Patients in remission should be monitored closely for recurrence or long-term treatment complications. Harmonizing a multidisciplinary approach between pediatric oncologists, hematologists, radiologists, pathologists, and surgeons is a priority. This review discusses advances in management strategies used for common pediatric head and neck malignancies, with a focus on surgical and medical techniques as well as treatment complications that can arise.

LEARNING OBJECTIVES/OBJECTIVE:After studying this article, the participant should be able to (1) understand how unique biological and developmental characteristics of children influence pediatric cancer treatment and how advancements in diagnostics and adjuvant therapy help tailor care, (2) describe treatment approaches to pediatric head and neck malignancies, and (3) understand how surgical resection integrates with multimodal systemic therapies. SUMMARY/CONCLUSIONS:Pediatric head and neck malignancies require a tailored, multidisciplinary management approach that considers the unique biological, developmental, and long-term implications in this vulnerable population. This comprehensive review provides a disease-specific overview of the most common pediatric head and neck cancers. Current evidence-based surgical and nonsurgical treatment strategies are summarized, and recent advancements in diagnostic imaging, minimally invasive techniques, and adjuvant therapies are discussed for each cancer type commonly incurred within the pediatric population. The integration of multi-agent chemotherapy, radiation therapy, and targeted therapeutic modalities with precise surgical intervention has reshaped treatment paradigms and led to improved survival outcomes while minimizing long-term patient morbidity. Emphasis is placed on the importance of early diagnosis, prompt initiation of treatment, and vigilant long-term follow-up to monitor patients for both recurrence and treatment-related complications. Ultimately, this review serves as a practical guide to clinicians, reinforcing the critical role of a coordinated, interdisciplinary team-including pediatric oncologists, surgeons, radiologists, pathologists, and allied specialists-in optimizing care and enhancing quality of life for children with head and neck malignancies.

Protease-activated receptor 2 (PAR₂) mediates oral cancer pain. Patients with metastatic (N + ) cancers report greater pain. PAR₂ is activated by N-terminal proteolytic cleavage. Here we show that proteases encoded by genes overexpressed in N+ cancers from patients with pain (matrix metallopeptidase 1, MMP1 and serine protease 23, PRSS23) elicit protease-specific receptor redistribution (trafficking) and signaling that differs from that promoted by proteases encoded by genes not differentially expressed (transmembrane serine protease matriptase, ST14 and cathepsin S, CTSS). Mixtures of the proteases prepared to model the oral cancer microenvironment revealed that ST14-mediated PAR₂ activation predominated at low protease concentrations. At high concentrations, MMP1 and PRSS23 prevailed over the greater potency of ST14. We propose that PAR₂ activation in oral N+ cancers from patients with pain is driven by high levels of MMP1 and PRSS23. Our study informs design of signaling and location-specific antagonists to provide more efficacious analgesia.

Critically sized bone defects are difficult to treat, necessitating tissue engineering strategies to restore form and function. However, translation of these approaches is often constrained by preclinical models that fail to replicate systemic comorbidities commonly seen in clinical practice, such as diabetes, prior irradiation, osteonecrosis, and osteoporosis, and instead favor healthy wound environments that may overestimate efficacy. This comprehensive review aimed to provide a detailed overview of in vivo bone regeneration strategies for critically sized defects specifically within compromised healing environments, summarizing how animal models are developed and how biomaterial, cellular, and drug delivery platforms are tailored to these disease states. Recent work has sought to address key pathological barriers including chronic inflammation, oxidative stress, poor vascularization, hypocellularity, and the limited efficacy of cell-seeding approaches through a range of bioengineered solutions. Strategies include nanoengineered drug delivery systems, bioactive ion-releasing scaffolds, immunomodulatory and antioxidant biomaterials, advanced cell provisioning, and extracellular vesicle-based therapies designed to restore redox balance, promote angiogenesis, and reestablish osteogenesis. Remaining challenges include heterogeneity and poor standardization of defect models, underrepresentation of multimorbidity and treatment-related injury, ethical and logistical barriers to large animal studies, and uncertainty in how best to bridge emerging platforms with regulatory expectations. Future directions will require coordinated refinement of disease-relevant models and development of multifunctional, context-responsive constructs to more reliably predict and improve clinical translation of bone tissue engineering therapies.

Infants with complete bilateral cleft lips and a significantly protruded premaxilla present considerable challenges for the surgeon during the primary lip and nasal reconstruction. Current presurgical infant orthopedics (PSIOs) methods to reduce cleft severity-such as lip adhesion surgery, the Latham appliance, and nasoalveolar molding-often increase the burden of care. Presurgical lip, nose alveolar approximation (PLANA) therapy offers an alternative that effectively reduces this burden. This case report describes the use of PLANA therapy in two infants with bilateral cleft lip and palate, one with mild and one with a significantly protruded premaxilla. PLANA utilizes medical adhesive lip taping and a prefabricated series of nasal silicone devices to retract the premaxilla while promoting nasal tip projection and gradual controlled columellar elongation. The combined action of hydrocolloid lip tapes and nasal devices supports early presurgical objectives and minimizes caregiver demands and prepares patients for primary reconstruction surgery. These two-case reports also address the variations in premaxillary retraction among infants with and without protruded premaxilla.

To evaluate the effect of graded glass infiltration on the fatigue behavior and mechanical reliability of translucent 4Y-PSZ zirconia before and after hydrothermal aging, disc-shaped specimens were fabricated by uniaxial pressing and divided into control and glass-graded groups (n = 36/group). Glass infiltration was performed on pre-sintered specimens followed by final sintering, and half of the specimens from each group underwent hydrothermal aging (134°C, 2.2 bar, 20 h). Microstructure and phase composition were assessed by scanning electron microscopy and x-ray diffraction. Mechanical performance was evaluated using step-stress accelerated life testing, with Weibull statistics, reliability analysis, and inverse power-law modeling. Glass-graded specimens demonstrated higher reliability and characteristic strength (≈330 MPa increase) with similar Weibull modulus compared to controls. The inverse power-law parameter α₀ was higher for the glass-graded group, indicating extended fatigue life, whereas comparable α₁ values suggested similar life-stress relationships. Hydrothermal aging did not significantly affect mechanical performance, although phase transformation occurred in the control group. Fractography revealed surface-initiated failures in controls and interface-related crack initiation in glass-graded specimens. Graded glass infiltration improved the fatigue reliability and characteristic strength without compromising hydrothermal stability of 4Y-PSZ. These results suggest that glass-graded 4Y-PSZ may expand the clinical applicability of translucent zirconia for long-span (≥4-unit) prosthetic reconstructions.

Pancreatic ductal adenocarcinoma (PDAC) with extensive peripancreatic vessel involvement is classified as locally advanced pancreatic cancer (LAPC). For this group of patients, the current standard of care does not include considering a potentially curative oncologic resection. However, recent advances in multiagent chemotherapy and surgical techniques are challenging this paradigm. Moreover, the current determination of anatomic resectability is vague and unreliable. Here we propose a definition of local resectability, based on pre- and intra-operative assessment. This anatomic definition of resectability assumes careful patient selection based on tumor biology and patient condition. The pre-operative evaluation of vascular anatomy and tumor involvement is conducted using 3D-rendering of pancreas-protocol computed tomography. Identifying a disease-free arterial or venous segment above and below the tumor involvement ("suitable target") is the single critical factor that determines anatomic resectability. Intraoperative isolation of these target vessels confirms the feasibility of vascular reconstruction before resection. This approach, which focuses on identifying target vessels rather than circumferential involvement, offers a more straightforward and clinically relevant method for assessing surgical eligibility in LAPC patients at centers of excellence. In summary, reconstructability-based on surgical expertise and guided by tumor biology-now defines the modern paradigm of resectability in LAPC.

BACKGROUND:Use of soft tissue support in postmastectomy, implant-based breast reconstruction (IBBR) has become increasingly common. Although soft tissue support (STS) offers benefits in terms of stability and contour, in some instances, its use has been associated with increased postoperative complications. This study assesses rates of postoperative complications following IBBR with and without soft tissue support in a large, nationwide database. METHODS:Using Epic Cosmos, a nationwide database of over 300 million patients, patients undergoing postmastectomy IBBR with implantation of a breast implant or tissue expander (CPT 19340) between 2015 and 2025 were identified. Patients were stratified by use of STS (CPT 15777). Primary outcomes included complications within 90 days of surgery: surgical site infection (SSI), seroma, hematoma, wound dehiscence, and implant loss. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for each complication, and P < 0.05 was considered statistically significant. RESULTS:Among 66,862 patients undergoing IBBR, 32,680 (48.9%) received STS and 34,182 (51.1%) did not. Average BMI was higher in patients with STS (26.9 ± 5.80 vs 26.5 ± 5.74 kg/m 2 , P < 0.05). STS was used less frequently among current smokers (3.7% vs 6.0%, P < 0.05). Adjusting for age, BMI, smoking status, and type 2 diabetes status, STS use was associated with increased odds of surgical site infection (adjusted odds ratio [aOR], 3.89; 95% confidence interval [CI], 3.13-4.90; P < 0.05), seroma (aOR, 2.38; 95% CI, 2.07-2.73; P < 0.05), hematoma (aOR, 1.69; 95% CI, 1.46-1.95; P < 0.05), wound dehiscence (aOR, 2.58; 95% CI, 2.31-2.89; P < 0.05), and implant loss (aOR, 3.40; 95% CI, 3.00-3.88; P < 0.05). CONCLUSIONS:In this nationwide cohort, use of soft tissue support in postmastectomy breast reconstruction was associated with a higher risk of select postoperative complications. These findings underscore the importance of patient selection and shared decision making when considering mesh in breast reconstruction, particularly in patients with modifiable comorbidities such as obesity or smoking.

LEARNING OBJECTIVES/OBJECTIVE:After studying this article, the participant should be able to (1) gather appropriate history and perform relevant physical exam maneuvers for head and neck complaints, (2) relate presenting complaints to differential diagnoses, (3) describe the appropriate workup for various head and neck complaints and presentations, and (4) perform clinical staging of head and neck tumors according to current guidelines. SUMMARY/CONCLUSIONS:Pediatric head and neck cancers are rare and complex, but plastic surgeons may play a crucial role in the multidisciplinary and multifaceted workup of a suspected malignancy. These cancers present unique diagnostic and therapeutic challenges given the unique anatomy, physiology, and developmental considerations in children compared to their adult counterparts. A comprehensive workup for pediatric head and neck malignancies is essential, starting with taking a thorough history and physical exam, followed by a well-considered and wide differential diagnosis. Appropriate imaging modalities and biopsy techniques are pivotal in obtaining an accurate diagnosis. Tumor and site-specific staging seek to provide essential information for guiding treatment planning. Plastic surgeons, therefore, must be informed and well versed in their evaluation and workup to best optimize patient outcomes.