Faculty Bibliography

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: 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

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.

This study investigated the effects of osseodensification drilling on the stability and osseointegration of machine-cut and acid-etched endosteal implants in low-density bone. Twelve sheep received six implants inserted into the ilium, bilaterally (n = 36 acid-etched, and n = 36 as-machined). Individual animals received three implants of each surface, placed via different surgical techniques: (1) subtractive regular-drilling (R): 2.0 mm pilot, 3.2 and 3.8 mm twist drills); (2) osseodensification clockwise-drilling (CW): Densah Bur (Versah, Jackson, MI) 2.0 mm pilot, 2.8, and 3.8 mm multifluted tapered burs; and (3) osseodensification counterclockwise-drilling (CCW) Densah Bur 2.0 mm pilot, 2.8 mm, and 3.8 mm multifluted tapered burs. Insertion torque was higher in the CCW and CW-drilling compared to the R-drilling (p < 0.001). Bone-to-implant contact (BIC) was significantly higher for CW (p = 0.024) and CCW-drilling (p = 0.006) compared to the R-drilling technique. For CCW-osseodensification-drilling, no statistical difference between the acid-etched and machine-cut implants at both time points was observed for BIC and BAFO (bone-area-fraction-occupancy). Resorbed bone and bone forming precursors, preosteoblasts, were observed at 3-weeks. At 12-weeks, new bone formation was observed in all groups extending to the trabecular region. In low-density bone, endosteal implants inserted via osseodensification-drilling presented higher stability and no osseointegration impairments compared to subtractive regular-drilling technique, regardless of evaluation time or implant surface. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater 00B: 000-000, 2018.

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

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: Despite the increasing trend toward ambulatory surgery rate in general, for cleft lip repair, 72.1% of patients in the United States are still hospitalized. Multiple centers have been studying this and with the very recent publishing of 2 large volume studies published in Plastic and Reconstructive Surgery supporting the safety of outpatient cleft lip surgery, it has become a high-profile debatable topic in cleft management. Last year at ACPA in the plastic surgery breakout session there was a heated debate on the topic between surgeons. And just this summer, one of the authors articles was featured as the PRS Journal Club article of the month via Social media, where there were 68 comments, 11 shares, and 40 likes, which placed the article in the TOP 15 most viewed article in PRS Journal's website. So this is a topic that more and more surgeons and craniofacial teams are thinking about and considering changing practice management but that deserves being brought into the spotlight to discuss all the pros and cons. The goal of the presentation are to present a literature review up to date on inpatient versus outpatient cleft lip surgery and have members of the panel share their and data behind their approach to postoperative cleft lip management. We would like to focus on what has been studied and reported versus what people practice because "that is how they were trained" or that is how they "historically" have always done it. Methods/Description: We will start with an overview of the literature surrounding inpatient versus outpatient cleft lip surgery and epidemiology about the numbers of institutions that do inpatients versus outpatient. If possible, we would like to include an audience poll to get an idea of practice patterns in the room. Then based on the recent published studies, each panelist will share different protocols that have been successful for outpatient cleft lip management and how that could be implemented if a center wants to consider outpatient cleft lip surgery. This includes: preoperative education that can be done by the team or nurse managers, perioperative management before, during, and after the operation, and postoperative care after they go home. All are very key components to a successful outpatient cleft lip management. We will also discuss the barriers to doing outpatient cleft lip surgery as well as having a panelist who consistently does inpatient cleft lip surgery to present the rationale behind their practice management and also their barriers to outpatient cleft lip surgery. I have reached out to a few people and will be discussing with them at the upcoming ASPS meeting to see who may be interested in joining the panel to discuss that. We will discuss the economic impact overall of practice changes to a predominantly outpatient surgery and also potential insurance policy impact. We think this will be a very useful topic for any team member participating in the care of a cleft lip patient

BACKGROUND:Cleft deformities of the lip and palate affect nearly one in 500 to 700 births, and lead to increased morbidity and mortality if untreated. Nevertheless, significant global disparities in access to timely and appropriate care still exist. The relatively basic infrastructure required to surgically correct these deformities and large unmet disease burden have resulted in a significant number of foundation-based cleft care initiatives focused on developing countries. In this study, the authors evaluate the peer-reviewed literature generated by these foundations in an attempt to assess their clinical, scientific, educational, and economic impact. METHODS:A comprehensive review of the literature was performed using key search terms, and the level of evidence of identified articles was determined. Data were then analyzed to determine the different models of foundation-based cleft care in developing countries, and their clinical, scientific, educational, and economic impact. RESULTS:A total of 244 articles were identified through the authors' search and reviewed. Foundation-based cleft care initiatives in developing countries have significantly contributed to a better understanding of disease epidemiology, barriers to care, safety considerations, complications and outcomes, and international and local cleft surgery education. The cleft care center model is more cost-effective than the surgical mission model and provides more sustainable care. CONCLUSIONS:Foundation-based cleft care prevents significant morbidity in developing countries and has provided valuable resources for capacity building. The surgical mission model should be considered as a transitory conduit for establishing the more effective and sustainable cleft care center model of care.

Background/Purpose: Intraoral myomucosal flaps such as the facial artery myomucosal (FAMM) flap and the buccal flap can provide effective palatal lengthening for the management of velopharyngeal insufficiency (VPI). This surgical approach is not without limitations and can result in increased postoperative burden to the patient and caregiver and frequently involves a second anesthetic event for pedicle division and flap inset. We sought to analyze the postoperative speech and functional outcomes of patients undergoing such procedures at our institution. Methods/Description: A retrospective assessment of all patients undergoing intraoral myomucosal flaps by a single surgeon at a tertiary academic institution was conducted. Only patients undergoing bilateral FAMM or buccal flaps for VPI were included. Data included demographic characteristics, flap-related complications, and postoperative speech and oral function. Results were compared between 2 age groups (group 1: <13, group 2: >=13). Analysis was performed over 5 clinical time points: preoperatively (T0), and postoperatively at 1 to 4 weeks (T1), 3 to 6 months (T2), and 1 to 3 years (T3).
Result(s): Of 54 patients reviewed, 24 met inclusion criteria: fourteen (58.3%) underwent bilateral FAMM flaps and 10 (41.7%) buccal flaps. Group 1 included 15 (62.5%) patients (median age: 6; range: 4-12) and group 2 included 9 (37.5%; median age: 23; range: 13-52). Group 1 patients were more likely to undergo buccal (60%), whereas group 2 were more likely to undergo FAMM flaps (88.9%). No intraor postoperative donor site complications, bleeding, flap necrosis, or dehiscence were noted. Subsequent pedicle division was performed in 66.7% of patients in group 1 (median: 35 days, range: 18-174) and 55.6% in group 2 (median: 46 days, range: 35-980) for interference with mastication in 10 (41.7%) patients, timing with other elective procedures in 3 (12.5%), or molar eruption in 1 patient. Ten (41.7%) patients had longitudinal speech follow-up, 70% of which were from group 1. Structural hypernasality had completely resolved in 80% of patients at T1, and in the rest by T3. At T1, >50% displayed abnormal occlusion or tongue placement and weak articulatory contact, which subsequently resolved. Dysphagia, drooling, or reduced oral opening were noted at T1 in most patients but had largely resolved on follow-up.
Conclusion(s): FAMM and buccal flaps are effective palatal lengthening procedures with 100% resolution of structural hypernasality and minimal complications in our series. Patient age and timing of division of flap pedicles may have an effect on postoperative oral function. Our findings support the early division of FAMM and buccal flap pedicles