Faculty Bibliography

The effect of diabetes on postoperative outcomes following surgical management of pressure ulcers is poorly defined despite evidence showing that patients with diabetes are at increased risk for developing pressure ulcers, as well as postoperative wound complications including delayed healing and infection. This study aimed to examine the impact of diabetes on postoperative outcomes following surgical management of pressure ulcers using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. In this retrospective analysis all CPT codes with ICD-9 diagnoses of pressure ulcers were reviewed. A total of 3,274 patients who underwent surgical management of pressure ulcers were identified, of which 1,040 (31.8%) had diabetes. Overall primary outcomes showed rates of superficial and deep incisional SSI were 2.0% and 4.2%, respectively, while the rate of wound dehiscence was 2.1%. Univariate analysis of primary outcomes stratified by diabetes status showed that patients with diabetes had significantly higher rates of superficial incisional SSI (3.9% vs. 2.3%; p=0.01), deep incisional SSI (7.0% vs. 4.3%; p=0.001), wound dehiscence (5.2% vs. 2.7%; p<0.001), as well as significantly higher rates of readmission (12.8% vs. 8.9%; p=0.001). Multivariate analysis for significant outcomes between groups on univariate analysis demonstrated that diabetes was an independent risk factor for superficial incisional SSI (OR = 2.7; 95% CI: 1.59 - 4.62; p<0.001), deep incisional SSI (OR = 1.85; 95% CI: 1.26 - 2.70; p=0.002), wound dehiscence (OR = 4.09; 95% CI: 2.49 - 6.74; p<0.001), and readmission within 30 days (OR = 1.38; 95% CI: 1.05 - 1.82; p=0.02). These findings emphasize the importance of preoperative prevention, and vigilant postoperative wound care and monitoring in patients with diabetes to minimize morbidity and optimize outcomes. Future prospective studies are needed to establish causality between diabetes and these outcomes.

Chronic inflammation of the salivary glands from pathologic conditions such as Sjögren's syndrome can result in glandular destruction and hyposalivation. To understand which molecular factors may play a role in clinical cases of salivary gland hypofunction, we developed an aquaporin 5 (AQP5) Cre mouse line to produce genetic recombination predominantly within the acinar cells of the glands. We then bred these mice with the TNF-αglo transgenic line to develop a mouse model with salivary gland-specific overexpression of TNF-α; which replicates conditions seen in sialadenitis, an inflammation of the salivary glands resulting from infection or autoimmune disorders such as Sjögren's syndrome. The resulting AQP5-Cre/TNF-αglo mice display severe inflammation in the salivary glands with acinar cell atrophy, fibrosis, and dilation of the ducts. AQP5 expression was reduced in the salivary glands, while tight junction integrity appeared to be disrupted. The immune dysregulation in the salivary gland of these mice led to hyposalivation and masticatory dysfunction.

CASE/METHODS:A 32-year-old right-handed surgeon presented with a history of intermittent pain at the right medial epicondyle, a mild Tinel's sign, and dysesthesia in the ulnar nerve distribution. Dynamic ultrasound demonstrated a hypertrophic anconeus epitrochlearis bilaterally, and chronic irritation of the ulnar nerve. Anterior release with myectomy of the accessory muscle was performed. No compressive symptoms were present at 1-year follow-up. CONCLUSIONS:The anconeus epitrochlearis is an often-underappreciated cause of ulnar nerve compression that can lead to significant functional impairment. Dynamic ultrasound is an excellent diagnostic modality, and anterior release with myectomy provides durable relief with minimal downtime.

Background/Purpose: Identify components needed to create a sustainable model. Methods/Description: Global Smile Foundation (GSF) is a not-forprofit foundation whose volunteers have been providing outreach cleft care in Guayaquil, Ecuador, for over 3 decades. Building on GSF's efforts to provide comprehensive and multidisciplinary cleft care yearround, an advanced training program in NasoAlveolar Molding (NAM) therapy was started in 2012 as part of GSF's empowerment and sustainability initiative. Components needed in host country were (1) establishing infrastructure, (2) cleft team (including cleft surgeon, speech pathologist, dental and psychosocial health-care professionals), (3) training of qualified local cleft health-care providers to ensure continued treatment and follow up, (4) academic collaboration: provide qualified trainers for NAM (didactic, clinical, laboratory), (5) local ownership and leadership, (6) local empowerment and sustainability programs, (7) yearly Follow-up.
Result(s): Year 1 (2012): 3 months training of 2 NAM providers (prosthodontist, orthodontist) prior to yearly surgical mission. Twenty patients treated w/NAM, NAM center continued year round, new patients followed by local cleft surgeon. Year 2 (2013): Existing providers train additional new provider (orthodontist) under supervision of visiting trainers. Fifty-seven patients treated w/NAM for the cleft team. Year 3 (2014): under same model, 2 new NAM providers trained (pediatric dentists). Year 4 (2015): Both providers remain at center, one becomes cleft team coordinator. Official cleft team established. Year 5 (2016): 2 international providers (pediatric dentist, orthodontist) selected for training to integrate NAM into their comprehensive cleft care model. NAM training expanded to cover educational components needed to set up comprehensive cleft team and NAM clinic in home settings. Training timed during surgical mission to rotate in all specialties and expanded to include online modules. Year 6 (2017): 2 new providers trained (periodontist, dentist) to remain at cleft center year round. Year 7 (2018): 3 International GSF providers (dentist, orthodontists) trained to provide NAM treatment at their centers. Total of 175 patients treated w/NAM. 2012-2018: Twelve dental providers trained in presurgical NAM and comprehensive cleft care in an outreach setting (7 from Ecuador, 2 from Peru, 1 from Salvador, 1 from Nicaragua, 1 from Egypt). 2012 Fundacion Global Smile-Ecuador was founded to ensure sustainability of ongoing and expanding cleft care programs. 2015 Comprehensive Cleft Center officially established at Leon Becerra Hospital in Guayaquil, Ecuador. In addition to their support of GSF's surgical missions, the local governorship started funding a presurgical NAM position to deliver presurgical and dental care year-round. By 2018, 175 patients had received NAM therapy.
Conclusion(s): Over the 7 years, our experience has shown, in addition to academic training and follow-up, local empowerment is key for long-term sustainability of the model

Background/Purpose: To develop a database that documents the oral health of patients with cleft lip/palate (CL/P). This will be used to assess outcomes of outreach cleft programs by Global Smile Foundation (GSF) in developing countries. Methods/Description: GSF, is a registered nonprofit organization, whose volunteers have been involved with outreach cleft programs for over 3 decades in Latin America, Africa, Middle East, and Indian subcontinent. GSF conducts 6 annual missions. At each site, 75 to 365 patients are screened and 35 to 127 surgical procedures are performed along with 20 to 80 speech therapy and psychosocial consultations and 150 to 1600 dental procedures. GSF has developed a surgical database and safety guidelines to provide and ensure long-term follow-up of patients. In 2017, GSF created its own electronic medical record system (EMR). GSF now proposes a parallel dental database to follow-up the oral health of its patients. Following the 13th International Cleft Congress in Chennai, India in 2017, the "Cleft without Caries" Task force group reconfirmed the need for a standardized platform to capture and compare this information, across all countries and centers represented. A Literature review of accepted guidelines and data collection references for CL/P (ICHOM, CRANE, CLEFTSiS, etc) was carried out to identify key factors being used to capture: condition, treatment approach, timing of data collection, phenotype, demographics, and oral health of the patient.
Result(s): A dental database template is being developed for long-term follow-up on oral health of patients in outreach settings with standardized recording times. This should include: (1) Collecting data: radiographs, dental casts, facial appearance (extraoral photos), intraoral photos. (2) Treatment: dental (procedures), presurgical (nasoalveolar molding/NAM), orthodontic (interceptive/phase II,) prosthodontic treatment needed. (3) Clinical examination: occlusion (overjet, overbite, crossbite), dental caries (DMFT/ICDAS index), gingival/periodontal health (near the cleft/outside the cleft region), disturbances in dental development and dental anomalies. (4) Overall dental health: COHIP OSS (Child Oral Health Impact Profile- Oral symptoms scale) and DMFT/ICDAS score. We are currently reviewing online platforms and existing dental software for standardization and data capture.
Conclusion(s): GSF's goal is to create an all-inclusive dental database platform. Recording these parameters would allow the measuring of differences between various geographic sites, taking into account several relevant factors (eg, presurgical treatment, dental anomalies, caries risk). Once a standardized dental database platform is created, this model will be shared with other organizations and centers. These results will allow comparable measurements for long-term followup on the oral health of patients with CL/P across different cultures and countries. This will eventually lead to improved delivery of care and oral health of our patients in outreach settings

Background/Purpose: Previous in vivo and in vitro animal studies demonstrate that the adenosine A2A receptor (A2AR) agonist dipyridamole (DIPY) stimulates robust osteogenic differentiation and proliferation without adverse effects on craniofacial suture development. However, no studies to date have been performed on human tissue. This study compares the effects of DIPY, BMP-2, and standard osteogenic media on osteogenic differentiation by human mesenchymal stem cells to lay the foundation for translating this bone tissue engineering approach to pediatric craniofacial reconstruction. Methods/Description: Pediatric mesenchymal stem cells were isolated from surplus bone taken from consented patients undergoing craniofacial surgery. Cells were cultured at early passage for 3 weeks in 1 of 7 experimental conditions: control media; osteogenic media (control + 100 muM beta-glycerophosphate, 0.1 muM dexamethasone and 100 mg/ mL L-ascorbic acid); osteogenic media + 200 ng/mL BMP-2; osteogenic media + 10, 100, 1000, or 10 000 muM DIPY. All experiments were performed in biological triplicates. Samples were analyzed using Alkaline phosphatase (ALP) assay at 6 hours, 24 hours, 48 hours, and 7 days as a marker of early osteogenic differentiation. At the end of the 3-week differentiation period, cells underwent immunocytochemistry to verify phalloidin, osteocalcin, and collagen I expression. Alizarin red staining was used to detect mineralization. Statistical analysis used 1-way ANOVA with Tukeys post hoc correction and multiple t test comparison of means.
Result(s): In all osteogenic conditions, relative peak ALP activity occurred at 48 hours. One thousand micrometer DIPY showed significantly increased peak ALP activity compared to BMP-2 (3.6 +/- 0.1 fold increase vs 3.1 +/- 0.1; P = .006). There was no significant difference between 1000 muM DIPY and osteogenic media (4.1 +/- 0.1; P = .36). At 3 weeks, immunocytochemistry revealed differentiation in all osteogenic conditions compared to control. One thousand micrometer DIPY cells showed greater evidence of mature osteogenic differentiation including cuboidal cell morphology and deposition of collagen I in an extracellular fibrillar network pattern compared to both control osteogenic media and BMP-2. Alizarin red quantification demonstrated significantly increased extracellular matrix mineralization at 100 muM(2.4+/-0.4; P = .002), 1000 muM (4.3+/-0.6; P = .001), and 10 000 muM (5.1 +/- 0.2; P < .0001) DIPY compared to nonosteogenic control medium (1.0 +/- 0.1). Matrix mineralization was not significantly different between BMP-2 (2.4 +/- 0.2) and 1000 muM DIPY (P = .08). ImageJ analysis revealed increased proportion of osteocalcin expressing cells (40.0% +/- 2.8%) in stem cells treated with 1000 muM of dipyridamole compared to control (1.0% +/- 0.6%), osteogenic (5.8% +/- 1.0%), and BMP-2 (16.9% +/- 2.2%; P < .0001).
Conclusion(s): Dipyridamole promotes early osteogenic differentiation and maturation of human bone-derived mesenchymal stem cells. These data suggest that dipyridamole may be an effective tissue engineering strategy for pediatric craniofacial reconstruction

Background/Purpose: Knowledge of cleft lip (CL) surgical markings is essential prior to performing the repair. Work hours restrictions, increased patient care documentation time, and requests by patients not to have trainees involved in their care are limiting the acquisition of this skill in the operating room. Textbooks provide 2-dimensional illustrations of CL markings; while the cost of 3-dimensional (3D) printed CL models prohibit their widespread utilization for this purpose. We propose 3D stone models as simple and affordable tools to teach surgical trainees unilateral CL markings. Methods/Description: Polyvinyl siloxane (PVS) impression material was used to create a negative of a patient with unilateral CL. Snapstone mixed with water was poured into the PVS impression to create unilateral CL stone models. Eleven plastic surgery residents were prospectively recruited in the study. They were provided with a textbook chapter and online module detailing surgical markings for unilateral CL repair, and were given 15 minutes of study time, before providing them with a unilateral CL stone model for performing the CL markings within 10 minutes. The participants were then provided with a standardized patient photograph for the same purpose. Learner satisfaction with the stone model and patient photograph as educational tools for learning surgical markings were evaluated using a modified survey based on the Student Evaluation of Educational Quality (SEEQ) survey, a validated tool for measuring higher education student satisfaction. Learner satisfactions with each tool were compared using a Mann-Whitney U test.
Result(s): The total production time of one stone model, including the PVS impression, was 10 minutes. The cost of one PVS impression and one stone model were 64 and 83 cents respectively, for a total of $1.47. Participants reported that when compared to the standardized patient photograph, the stone model was more stimulating (4.72 +/- 0.47 vs 3.82+/-0.87; U = 25.5; P = .01), increased their interest in the subject (4.63 +/- 0.50 vs 3.45 +/- 1.29; U = 26.5; P = .02), allowed better learning of the subject matter (4.54 +/- 0.52 vs 2.91 +/- 0.83; U = 5.0; P < .001), had greater clarity (4.64 +/- 0.50 vs 3.00 +/- 0.89; U = 6.0; P < .001), and was a more effective means of teaching CL markings (4.73 +/- 0.47 vs 2.91 +/- 1.04; U = 6.0; P < .001). Participants were also more likely to recommend the stone model (4.82+/-0.40) over the standardized patient photograph (3.00 +/- 1.10; U = 5.0; P < .001).
Conclusion(s): 3D stone models of the unilateral cleft lip deformity are affordable and simple to produce. Plastic surgery residents report that these models are superior training tools to learn cleft lip markings compared to patient photographs. These educational tools have the potential to overcome significant financial, logistic, and time constraints in teaching cleft lip surgery markings

Background/Purpose: Our goal is to present to mental health professionals and craniofacial center providers a 2-part workshop series called "Social Stories." Social Stories are a creative and effective tool for helping children with craniofacial conditions cope with feelings that arise in new and/or stressful situations: such as surgery, doctor visits, and school transitions. This presentation will teach psychosocial teams at other craniofacial centers how to develop workshops using Social Stories as a platform for helping school-age children and their parents cope with stressful and/or novel situations. The first workshop of the 2-part series was developed for parents of children with craniofacial conditions. Parents learned about the concept of Social Stories and identified situations that their child was struggling with. Parents were asked to provide detailed information for these situations and help collect images and photos to be used in their child's Social Story Workbooks. The second workshop was developed for children ages 8 to 12 years old with craniofacial conditions. In this workshop, the children created their Social Story Workbooks, utilizing a combination of ideas, images, and photographs from home (provided by parents) and collected by the psychosocial team. Parent participants completed a psychological screening questionnaire to help us assess how this intervention impacted their child's level of coping with stressful and novel situations. Methods/Description: The concept of Social Stories, initially developed for children and adolescents with autism, was created and trademarked by Carol Gray in 1991. Our team modified this modality for children with craniofacial conditions to help improve their ability to cope with distressing or novel situations. Social Stories can include specific information about expectations, emotions, and feelings and why they occur, and empower children to gain mastery and resilience