Faculty Bibliography

Breast augmentation remains one of the most commonly performed aesthetic procedures in the United States and worldwide. Throughout the last few decades, the implants used for this procedure have undergone significant advancements, which has allowed surgeons to provide safer and more aesthetically pleasing outcomes. This article discusses the history of breast implants since their invention in 1962. Particular emphasis is given to the evolution of silicone implants with its many challenges, which has resulted in the development of the currently used fourth- and fifth-generation devices. Knowledge of these advances will allow physicians to more critically evaluate their results, and also will encourage them to provide more up-to-date scientific data on these devices to further improve the clinical outcomes of their patients.

BACKGROUND:Based on an established classification system of Apert syndrome subtypes, detailed regional morphology and volume analysis may be useful to provide additional clarification to individual Apert cranial structure characteristics, and treatment planning. METHODS:Computed tomography scans of 32 unoperated Apert syndrome and 50 controls were included and subgrouped as: type I, bilateral coronal synostosis; type II, pansynostosis; type III, perpendicular combination synostosis. Three-dimensional analysis of craniometric points was used to define structural components using Materialise Mimics and 3-Matics software. RESULTS:Occipitofrontal circumference of all subtypes of Apert syndrome patients is normal. Intracranial volumes of types I and II were normal, but type III was 20% greater than controls. Middle cranial fossa volume was increased in all 3 types, with the greatest increase in type II (86%). Type II developed a 69% increase in anterior cranial fossa volume, whereas type III had 39% greater posterior cranial fossa volume. Increased cranial fossa depth contributed most to above increased volume. The anteroposterior lengths of middle and posterior cranial fossae were reduced in type I (15% and 17%, respectively). However, only the anterior cranial fossa was significantly shortened in type III. CONCLUSIONS:Occipitofrontal circumference and overall intracranial volume is not always consistent in individual subunits of Apert syndrome. Detailed and segmental anterior, middle, and posterior cranial fossae volumes and morphology should be analyzed to see what impact this may have related to surgical planning.

PURPOSE/OBJECTIVE:To describe the revenue from a collaboration between a dedicated wound care center and an interventional radiology (IR) practice for venous leg ulcer (VLU) management at a tertiary care center. MATERIALS AND METHODS/METHODS:This retrospective study included 36 patients with VLU referred from a wound care center to an IR division during the 10-month active study period (April 2017 to January 2018) with a 6-month surveillance period (January 2018 to June 2018). A total of 15 patients underwent endovascular therapy (intervention group), whereas 21 patients did not (nonintervention group). Work relative value units (wRVUs) and dollar revenue were calculated using the Centers for Medicare and Medicaid Services Physician Fee Schedule. RESULTS:Three sources of revenue were identified: evaluation and management (E&M), diagnostic imaging, and procedures. The pathway generated 518.15 wRVUs, translating to $37,522. Procedures contributed the most revenue (342.27 wRVUs, $18,042), followed by E&M (124.23 wRVUs, $8,881), and diagnostic imaging (51.65 wRVUs, $10,599). Intervention patients accounted for 86.7% of wRVUs (449.48) and 80.0% of the revenue ($30,010). An average of 33 minutes (38.3 hours total) and 2.06 hours (36.8 hours total) were spent on E&M visits and procedures, respectively. CONCLUSIONS:In this collaboration between the wound center and IR undertaken to treat VLU, IR and E&M visits generated revenue and enabled procedural and downstream imaging revenue.

Pain is rated by oral cancer patients as the worst symptom and significantly impairs a patient's ability to eat, talk, and drink. Mediators, secreted from oral cancer microenvironment, excite primary afferent neurons, which in turn generate pain. Oral cancer cells release TNFalpha which induces acute inflammation and nociception in mice. We hypothesize that TNFalpha activates Schwann cells to amplify pain signals. First, we confirmed the involvement of TNFalpha in oral cancer pain in patients and animal models. We found that oral cancer tissues collected from patients have higher TNFalpha concentration compared to anatomically matched normal tissues. Differences in TNFalpha concentration between the tumor and anatomically matched normal tissues correlate positively with total pain scores. In a Nitroquinoline 1-oxide (4NQO) mouse oral cancer model we demonstrated reduced mechanical hypersensitivity (P<0.05, N=8) with the dolognawmeter gnawing assay when TNFalpha was neutralized with C-87. Using a non-contact co-culture model, we found that HSC-3 cells induced a more activated human primary Schwann cells phenotype with increased proliferation (P<0.05) and migration (P<0.05); introduction of C-87 in the co-culture reduced Schwann cell proliferation (P<0.05) and migration (P<0.05) induced by HSC-3 cells. After removal of the co-cultured cancer cells, cancer-activated Schwann cells secrete greater amounts of TNFalpha and nerve growth factor (NGF), another known nociceptive mediator in the oral cancer microenvironment, compared to Schwann cells initially co-cultured with DOK (P<0.05) or naive Schwann cells (P<0.05). To determine whether activated Schwann cells mediate oral cancer pain, we cultured Schwann cells in hypoxic conditions - a known cancer stimulus that induces robust Schwann cell activation. Schwann cell supernatant was then collected and injected into the mouse cheek. Supernatant from hypoxia-activated Schwann cells induced greater facial allodynia (measured with von Frey filaments) in mice (P<0.05, N=7), compared to supernatant from Schwann cells cultured in normoxic conditions (N=5). C-87 significantly reduced facial allodynia caused by hypoxiaactivated Schwann cells (P<0.05, N=5). We infer from our results that TNFalpha plays a role in the activation of Schwann cells and that cancer-activated Schwann cells are a source of nociceptive mediators in the cancer microenvironment. Inhibition of Schwann cell activation might be clinically useful for alleviating oral cancer pain

Primary sternal osteomyelitis (PSO) remains a rare but morbid and challenging condition. Due to the limited reports of PSO in the literature, management of this disease continues to lack consensus. We present a case report highlighting how PSO remained, in our experience, refractory to medical management, and how operative intervention provided resolution, and a review of the literature.

Despite promising short- and long-term results to date in vascularized composite allotransplantation (VCA), acute rejection remains the most common major complication in recipients. Currently, diagnosis of acute rejection relies on clinical inspection correlated with histopathological analysis. However, disagreement exists regarding the value of full-thickness skin and mucosal biopsies and histopathology remains semiquantitative, subject to sampling bias, and prone to intra- and inter-observer variabilities. Additionally, biopsies may cause infection, scarring, and/or potentially incite rejection through immune activation after injury. Noninvasive methods to diagnose rejection represent a critical unmet need for the emerging field of VCA. Here, we propose a novel technique utilizing skin stripping of the epidermis and subsequent molecular analysis to detect known markers of acute rejection. Using a small animal VCA model, we sought to validate our epidermal sampling technique as a noninvasive diagnostic test for acute rejection.

Face transplant (FT) candidates present with unique anatomic and functional defects unsuitable for autologous reconstruction, making the accurate design and transplantation of patient-specific allografts particularly challenging. In this case series, we present our computerized surgical planning (CSP) protocol for FT.

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.

OBJECTIVE/UNASSIGNED:To assess the timing, type, and associated adjunct procedures for secondary cleft rhinoplasty nationally. DESIGN/UNASSIGNED:Data were extracted from a national database of all secondary cleft rhinoplasty procedures (Current Procedural Terminology [CPT] codes 30460 and 30462). Frequency statistics were utilized to analyze demographics, comorbidities, surgical procedures, and timing. Chi-squared analysis and Fisher exact test were used for analysis. SETTING/UNASSIGNED:National Surgical Quality Improvement Program-Pediatric Database. PARTICIPANTS/UNASSIGNED:A total of 1720 patients met inclusion criteria for secondary cleft rhinoplasty repair. INTERVENTIONS/UNASSIGNED:No relevant intervention. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Age, demographics, comorbidities, and associated procedures. RESULTS/UNASSIGNED:< .001). CONCLUSIONS/UNASSIGNED:This study reveals that a large proportion of cleft rhinoplasties are performed in skeletally immature patients. Although patients undergoing rib grafting, nasal osteotomies, and a major septal component were older, these procedures are still performed in a large proportion of patients who are younger than expected.