Faculty Bibliography

BACKGROUND:Facial transplantation introduced a paradigm shift in the reconstruction of extensive facial defects. Although the feasibility of the procedure is well established, new challenges face the field in its second decade. METHODS:The authors' team has successfully treated patients with extensive thermal and ballistic facial injuries with allotransplantation. The authors further validate facial transplantation as a reconstructive solution for irreparable facial injuries. Following informed consent and institutional review board approval, a partial face and double jaw transplantation was performed in a 25-year-old man who sustained ballistic facial trauma. Extensive team preparations, thorough patient evaluation, preoperative diagnostic imaging, three-dimensional printing technology, intraoperative surgical navigation, and the use of dual induction immunosuppression contributed to the success of the procedure. RESULTS:The procedure was performed on January 5 and 6, 2018, and lasted nearly 25 hours. The patient underwent hyoid and genioglossus advancement for floor-of-mouth dehiscence, and palate wound dehiscence repair on postoperative day 11. Open reduction and internal fixation of left mandibular nonunion were performed on postoperative day 108. Nearly 1 year postoperatively, the patient demonstrates excellent aesthetic outcomes, intelligible speech, and is tolerating an oral diet. He remains free from acute rejection. CONCLUSIONS:The authors validate facial transplantation as the modern answer to the classic reconstructive challenge imposed by extensive facial defects resulting from ballistic injury. Relying on a multidisciplinary collaborative approach, coupled with innovative emerging technologies and immunosuppression protocols, can overcome significant challenges in facial transplantation and reinforce its position as the highest rung on the reconstructive ladder. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, V.

BACKGROUND:The numerous office visits required to complete expansion in implant-based breast reconstruction impact patient satisfaction, office resources, and time to complete reconstruction. This study aimed to determine whether prepectoral compared to subpectoral immediate implant-based breast reconstruction offers expedited tissue expansion without affecting complication rates. METHODS:Consecutive patients who underwent immediate implant-based breast reconstruction with tissue expanders from January of 2016 to July of 2017 by a single surgeon were grouped into subpectoral (partial submuscular/partial acellular dermal matrix) or prepectoral (complete acellular dermal matrix coverage), and reviewed. The primary outcomes were total days and number of visits to complete expansion. Groups were compared by univariate analysis with significance set at p < 0.05. RESULTS:In total, 101 patients (subpectoral, n = 69; prepectoral, n = 32) underwent 184 immediate implant-based breast reconstructions (subpectoral, n = 124; prepectoral, n = 60). There was no difference in age, body mass index, smoking, or diabetes between the groups (all p > 0.05). Follow-up was similar between groups (179.3 ± 98.2 days versus 218.3 ± 119.8 days; p = 0.115). Prepectoral patients took fewer days to complete expansion (40.4 ± 37.8 days versus 62.5 ± 50.2 days; p < 0.001) and fewer office visits to complete expansion (2.3 ± 1 .7 versus 3.9 ± 1.8; p < 0.001), and were expanded to greater final volumes than subpectoral patients (543.7 ± 122.9 ml versus 477.5 ± 159.6 ml; p = 0.017). Between prepectoral and subpectoral reconstructions, there were similar rates of minor complications (25 percent versus 18.5 percent; p = 0.311), readmissions (5 percent versus 2.4 percent; p = 0.393), seromas (8.3 percent versus 5.6 percent; p = 0.489), reoperations for hematoma (3.3 percent versus 1.6 percent; p = 0.597), and explantations (5 percent versus 2.4 percent; p = 0.393). CONCLUSION/CONCLUSIONS:This novel analysis demonstrates that prepectoral immediate implant-based breast reconstruction can facilitate expansion to higher total volumes in nearly half the office visits compared to subpectoral placement in similar populations without increasing complication rates. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, III.

The precise pathogenic mechanisms in the development, persistence and worsening of hidradenitis suppurativa (HS) remain ill-defined. This chronic inflammatory dermatosis displays a strong Th1 and Th17 inflammatory signature with elevated levels of TNF-α, IL-1β, IL-17 and IFNγ in lesional and perilesional tissue. HS significantly differs to other chronic inflammatory dermatoses due to the development of hypertrophic scarring and dermal tunnels. The development of scarring and tunnels suggests that fibroblastic stromal cells (including myofibroblasts, fibroblasts, pericytes etc) may be involved in the development and progression of disease. Heterogeneous populations of fibroblasts have been identified in other inflammatory disorders and malignancy which contribute to inflammation and present novel therapeutic targets for fibrotic disorders. Findings in HS are consistent with these fibroblast subpopulations and may contribute to tunnel formation, aggressive squamous cell carcinoma and the phenotypic presentation of familial HS variants. We describe the existing knowledge regarding these mechanistic pathways and methods to confirm their involvement in the pathogenesis of HS.

New resin-based restorative materials have been developed, such as computer-aided design/computer-aided manufacturing (CAD/CAM) and bulk-fill composites, as an alternative to traditional layering techniques. This study evaluated the biaxial flexural strength (BFS) before and after thermocycling of five different resin composites: one hybrid resin/ceramic CAD/CAM indirect material, Lava Ultimate CAD-CAM Restorative (LU, 3M Oral Care); a conventional composite, Filtek Z350 XT (Z350, 3M Oral Care); two bulk-fill composites, Tetric N-Ceram Bulk Fill (TBF, Ivoclar Vivadent) and Filtek Bulk Fill (FBF, 3M Oral Care); and one bulk-fill flow resin composite, Filtek Bulk Fill Flow (FBFF, 3M Oral Care). Three hundred disc-shaped specimens (6.5 mm in diameter and 0.5 mm thick) were fabricated and divided into five groups (n=30 for each composite and condition). The BFS test was performed in a universal testing machine at a crosshead speed of 0.5 mm/min immediately (i, 24 hours) and after thermocycling (a, 500 thermal cycles of 5°C to 55°C with a 30-second dwell time). The Weibull modulus (m) and characteristic stress (η) were calculated, and a contour plot was used (m vs η) to detect differences between groups (95% two-sided confidence intervals). Significantly higher characteristic stress was observed for LUi (286.6 MPa) and Z350i (248.8 MPa) compared to the bulk-fill groups (FBFi=187.9 MPa, FBFFi=175.9 MPa, TBFi=149.9 MPa), with no differences between LUi and Z350i. Thermocycling significantly decreased the characteristic stress of all groups with the highest values observed for LUa (186.7 MPa) and Z350a (188.9 MPa) and the lowest for FBFFa (90.3 MPa). Intermediate values were observed for FBFa (151.6 MPa) and TBFa (122.8 MPa). The Weibull modulus decreased only for FBFa compared to FBFi. Composition and thermocycling significantly influenced the biaxial flexural strength of resin composite materials.

Recombinant human bone morphogenetic protein-2 (rhBMP-2) is one of the most commonly used osteogenic agents in the craniofacial skeleton. This study reviews the safety and efficacy of rhBMP-2 as applied to craniofacial reconstruction and assesses the level of scientific evidence currently available.

AIM/OBJECTIVE:To evaluate the influence of brain-derived neurotrophic factor (BDNF) in combination with collagen sponges on periodontal tissue regeneration. METHODS:Unilateral, "box-type" (4x5mm), one-wall intrabony defects were surgically created at posterior mandibular teeth in 14 Beagle dogs. Animals received all experimental groups and the defects were randomly treated as follow: Emdogain® (positive control) [EMD]; HeliPlug®+BDNF [H/B]; RCP®+BDNF [R/B]; negative control [Control]; TeruPlug®+BDNF [Tp/B] and TeruPlug®+BDNF2 [Ts/B]. Periodontal wound healing was observed every 2 weeks by computed tomography. The animals were euthanized at 8 weeks post-surgery for microcomputed tomography and histomorphometric evaluation. RESULTS:All groups presented ∼1mm apical epithelial attachment relative to cementoenamel junction. Although linear measurements did not demonstrate significant differences between groups for cementum and periodontal ligament regeneration, semi-quantitative analysis depicted higher percentage of samples with mineralized cementum and functional PDL for Ts/B, R/B and H/B groups relative to EMD and Control (p<0.046). Irrespective of quantification method (2D or 3D), Ts/B, Control, Tp/B and H/B groups presented the highest mean percentage of new bone (not significantly different), followed by R/B and EMD groups. CONCLUSION/CONCLUSIONS:While no significant differences were detected in quantitative analyses, Ts/B combination results in significantly more samples with full periodontal tissue regeneration relative to control groups.

BACKGROUND:The Physician Payment Sunshine Act requires biomedical companies to disclose financial relationships between themselves and physicians. The authors compared the amount of money received by speakers at the American Society of Plastic Surgeons and the American Society for Aesthetic Plastic Surgery annual conferences with that received by the average plastic surgeon. METHODS:General payments data were gathered from the Open Payments database for physicians listed as a presenter, moderator, panelist, lecturer, or instructor at the 2017 annual American Society of Plastic Surgeons and American Society for Aesthetic Plastic Surgery conferences. Means and medians of payments to speakers were calculated for each conference. One-tail t tests were used to evaluate differences. RESULTS:The mean and median for general payments made to conference speakers at American Society for Aesthetic Plastic Surgery (n = 75) and American Society of Plastic Surgeons (n = 249) meeting were $75,577 and $861 and $27,562 and $1021, respectively. In comparison with the average general payment received by plastic surgeons (mean, $4788; median, $3209), these differences were significant (American Society for Aesthetic Plastic Surgery, p = 0.015; American Society of Plastic Surgeons, p = 0.0004). CONCLUSIONS:The significant difference in payments to speakers at conferences compared with the average plastic surgeon suggests that biomedical companies may have influence over some of the conference content. Speakers must make clear the full extent of industry relationships that could potentially bias their presentations.

INTRODUCTION/BACKGROUND:Online resources have become a major source of medical information for the general public. To date, there has not been an assessment of patient-oriented online resources for face and upper extremity transplantation candidates and patients. The goal of this study is to perform a comprehensive assessment of these resources. METHODS:Our analysis relied on 2 dimensions: comprehensiveness and readability. Comprehensiveness was evaluated using 14 predetermined variables. Readability was evaluated using 8 different readability scales through the Readability Studio Professional Edition Software (Oleander Software, Ltd, Vandalia, Ohio). Data were also collected from solid organ transplantation (SOT), specifically kidney and liver, programs for comparison. RESULTS:Face and upper extremity transplantation programs were significantly more likely to list exclusion criteria (73.9% vs 41.2%; P = 0.02), the need for life-long immunosuppression (87.0% vs 58.8%; P = 0.02), and benefits of transplantation (91.3% vs 61.8%; P = 0.01) compared with SOT programs. The average readability level of online resources by all face and upper extremity transplantation programs exceeded the sixth grade reading level recommended by the National Institutes of Health and the American Medical Association. The average reading grade level of online resources by these programs was also significantly higher than those of SOT with both exceeding the recommended reading level (13.95 ± 1.55 vs 12.60 ± 1.65; P = 0.003). CONCLUSIONS:Future efforts in face and upper extremity transplantation should be directed toward developing standardized, comprehensive, and intelligible resources with high-quality content and simple language.