Faculty Bibliography

BACKGROUND:Simulation is progressively being integrated into surgical training, yet its utility in plastic surgery has not been well described. We present a prospective, randomized, blinded trial comparing digital simulation to a surgical textbook for conceptualization of cleft-lip repair. METHODS:Thirty-five medical students were randomized to learning cleft repair using a simulator or textbook. Participants outlined markings for a standard cleft-lip repair before (pre-intervention) and after (post-intervention) 20 minutes of studying their respective resource. Two expert reviewers blindly graded markings according to a 10-point scale, on two separate occasions. Intra-rater and inter-rater reliability were calculated using intra-class correlation coefficients. Paired and independent t-tests were performed to compare scoring between study groups. A validated student satisfaction survey was administered to assess the two resources separately. RESULTS:Intra-rater grading reliability was excellent among both raters for pre-intervention and post-intervention grading (rater 1 ICC=0.94 and 0.95, respectively; rater 2 ICC=0.60 and 0.92, respectively; p<0.001). Mean pre-intervention performances for both groups were comparable (0.82±1.17 vs. 0.64±0.95; p=0.31). Significant improvement from pre-intervention to post-intervention performance was observed in the textbook (0.82±1.17 v. 3.50±1.62; p<0.001) and simulator (0.64±0.95 vs. 6.44±2.03; p<0.001) groups. However, the simulator group demonstrated a significantly greater improvement (5.81±2.01 vs. 2.68±1.49; p<0.001). Participants reported the simulator to be more effective (p<0.001) and a clearer tool (p<0.001), that allowed better learning (p<0.001) than textbooks. All participants would recommend the simulator to others. CONCLUSIONS:We present level I evidence supporting online digital simulation as a superior educational resource for novice learners, compared to traditional textbooks.

BACKGROUND:Despite early skepticism, the field of vascularized composite allotransplantation (VCA) has demonstrated feasibility. The ethics of VCA have moved past doubts about the morality of attempting such transplant to how to conduct them ethically. METHODS:Leaders of each program performing and/or evaluating VCA in the United States were invited to participate in a working group to assess the state and future of VCA ethics and policy. Four meetings were held over the course of 1 year to describe key challenges and potential solutions. RESULTS:Working group participants concluded that VCA holds great promise as treatment for patients with particular injuries or deficits, but the field faces unique challenges to adoption as standard of care, which can only be overcome by data sharing and standardization of evaluation and outcome metrics. CONCLUSIONS:Adequate attention must be given to concerns including managing the uniquely intense physician-patient relationship, ethical patient selection, ensuring patients have adequate representation, informing and earning the trust of the public for donation, standardizing metrics for success, and fostering an environment of data sharing. These steps are critical to transitioning VCA from research to standard of care, and to its insurance coverage inclusion.

BACKGROUND:Masculinizing top surgery (bilateral mastectomy with chest wall reconstruction) is an important gender-affirming procedure sought by many transmasculine and non-binary individuals. Current literature is primarily focused on details of surgical technique and complication rates, with limited data available on how top surgery affects subjective quality of life measures. METHODS:An anonymous online survey was distributed to 81 of the senior author's former top surgery patients. Survey response rate was 72% (58 respondents). Responses were analyzed to investigate quality of life, sexual confidence, mental health, satisfaction with top surgery, and patient attitudes toward top surgery's role in gender affirmation. RESULTS:Following top surgery, measures of quality of life and sexual confidence significantly improved (P < .001). Additionally, 86% reported improvement in gender dysphoria-related mental health conditions. All but 1 respondent reported that top surgery had an overall positive impact on their life. CONCLUSIONS:Top surgery had major positive effects on all mental health and quality of life metrics. Our findings contribute to a much-needed body of evidence that top surgery markedly improves the daily lives and functioning of transgender and non-binary individuals who choose to undergo it.

BACKGROUND:Widespread adoption of bariatric surgery in the treatment of obesity has led to greater numbers of patients seeking panniculectomy, including aged patients, who represent a rapidly growing proportion of the U.S population. Although the quality of life and functional benefits of abdominal panniculectomy have been established, its safety in patients 65 years and older has not been evaluated. METHODS:The American College of Surgeons National Surgical Quality Improvements (ACS-NSQIP) database was used to identify patients undergoing panniculectomy between 2010 and 2015. Age 65 years and older was the risk factor of interest, and primary outcomes included 30-day wound complications, overall complications, reoperation, readmission, and mortality. Multivariate regression was performed to control for confounders. RESULTS:Review of the database identified 7030 patients who underwent abdominal panniculectomy. When stratified by age, 6455 (91.8%) of patients were younger than 65, and 575 (8.2%) were 65 or older. Multivariate regression analysis demonstrated that age over 65 was a significant independent risk factor for wound complications (OR = 1.81; 95% CI 1.35-2.42; p < 0.001) and all complications (OR = 1.46; 95% CI 1.15-1.87; p = 0.002). BMI, smoking, diabetes, and partial or total dependence were also identified as significant independent risk factors for wound and all complications. CONCLUSION/CONCLUSIONS:Our analysis demonstrates that advanced age is an independent risk factor for wound and overall complications following abdominal panniculectomy. These results highlight the importance of preoperative evaluation and optimization of modifiable preoperative risk factors as well as close postoperative follow-up for safe outcomes in patients 65 and older.

The study evaluated the effects of a Supercritical CO₂ (scCO₂ ) on a commercially available decellularized/delipidized naturally derived porcine pericardium collagen membrane, Vitala®. The Vitala® and scCO₂ treated experimental membranes were evaluated for guided tissue regeneration (GTR) of periodontal tissue in class III furcation defects utilizing a dog model. Physical material characterization was performed by scanning electron microscopy (SEM), thermogravimetric analysis (TGA), and differential scanning calorimetry (DSC). The in vivo portion of the study was allocated to three-time points (6, 12, and 24-weeks) using standardized class III furcation defects created in the upper second and third premolars. The experimental defects (n = 5) were covered with either a collagen membrane (positive control), scCO₂ -treated collagen membrane (experimental) or no membrane (negative control). Following sacrifice, histologic serial sections were performed from cervical to apical for morphologic/morphometric evaluation. Morphometric evaluation was carried out by ranking the presence of collagen membrane, amount of bone formation within the defect site and inflammatory cell infiltrate content. SEM showed the experimental scCO₂ -treated membrane to have a similar gross fibrous appearance and chemical structure in comparison to the Vitala® Collagen membrane. A significant increase in membrane thickness was noted in the scCO₂ -treated membranes (366 ± 54 μm) vs non-treated membranes (265 ± 75 μm). TGA and DSC spectra indicated no significant qualitative differences between the two membranes. For the in vivo results, both membranes indicated significantly greater amounts of newly formed bone (scCO₂ : 2.85 ± 1.1; Vitala®: 2.80 ± 1.0) within the covered defects relative to uncovered controls (0.8 ± 0.27) at 24 weeks. Both membrane types gradually degraded as time elapsed in vivo from 6 to 12 weeks, and presented nearly complete resorption at 24 weeks. The inflammatory infiltrate at regions in proximity with the membranes was commensurate with healthy tissue levels from 6 weeks in vivo on, and periodontal ligament regeneration onset was detected at 12 weeks in vivo. The effect of the supplementary scCO₂ treatment step on the collagen membrane was demonstrated to be biocompatible, allowing for the infiltration of cells and degradation over time. The treated membranes presented similar performance in GTR to non-treated samples in Class III furcation lesions. Defects treated without membranes failed to achieve regeneration of the native periodontium. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res B Part B: Appl Biomater 00B: 000-000, 2018.

OBJECTIVES/HYPOTHESIS/OBJECTIVE:We describe the clinical features of granulomas of the membranous vocal fold secondary to endotracheal intubation, bronchoscopy or esophagogastroduodenoscopy. STUDY DESIGN/METHODS:Retrospective case series. METHODS:Review of cases at a single tertiary institution with evaluation of patient demographic characteristics, time to presentation, time to treatment, and clinical outcomes. RESULTS:Thirteen adult patients were identified with postintervention granuloma of the membranous vocal fold. All patients were female, with a mean age of 60 years (range, 28-81 years). None noted hoarseness prior to the intervention, and all noted significant hoarseness postoperatively. Conservative treatment with proton pump inhibitors and vocal rest was initially implemented in all patients. Four cases resolved without further intervention. Nine underwent surgical management because of airway symptoms, failure to improve, or patient request. One patient had injury to the contralateral vocal fold upon intubation. None experienced recurrence. Five had complete recovery of voice postoperatively, four did not. CONCLUSION/CONCLUSIONS:Iatrogenic granulomas of the membranous vocal fold after intubation or other upper airway instrumentation are rare complications presenting in the early postprocedure period with worsening hoarseness. Initial conservative treatment may be sufficient to yield resolution, and surgical treatment is effective for those failing medical management. Permanent voice damage may result from the original injury. LEVEL OF EVIDENCE/METHODS:4. Laryngoscope, 2018.

Masculinizing hormonal treatment in transgender men has the potential to increase the level of androgens at end organs, including the pilosebaceous unit. Androgen-induced sebocyte growth and differentiation, sebum production, and infundibular keratinization may underlie the development of acne vulgaris among patients receiving this therapy. Despite the incidence of treatment-related acne and the unique considerations in treating transgender men, studies addressing this topic among this patient population are limited. Generally, standard guidelines for the treatment of acne can be followed in treating these patients; however, several medical, social, and psychologic factors should be considered. The aim of this article is to familiarize dermatologists with the sensitivities and challenges of treating acne in transgender male individuals.

Background/UNASSIGNED:Recurrent platysma bands remain a common problem in neck rejuvenation. Objectives/UNASSIGNED:The goals of this cadaver study were to document the course of the cervical branches of the facial nerve and investigate the pattern of platysma muscle innervation before and after various platysmaplasty maneuvers. Methods/UNASSIGNED:A total of 8 fresh cadaver specimens were dissected for a total of 16 hemifaces/necks. After subcutaneous undermining and identification of the main trunk of the facial nerve, the cervical branch was dissected as distally/anteriorly as possible under loupe magnification. The following 4 platysmaplasty maneuvers were each performed on 4 hemifaces/necks: platysma window, extended SMAS with platysma flap, full width platysma transection, and lateral skin-platysma displacement (LSD). Upon completion of the techniques, the integrity of the cervical branches was evaluated. Results/UNASSIGNED:Contrary to some reports, all specimens in this study had only 1 main cervical branch. There were no branches detectable under 3.2× magnification until branches were given off to the platysma muscle at approximately the location of the facial vessels. The main cervical branch continued distally/anteriorly to the medial edge of the muscle below the thyroid cartilage. After performing the various platysma techniques, all cervical branches were in continuity in all specimens. Specifically, the main cervical branch was in continuity to the medial border of the muscle caudal to all platysmaplasty maneuvers. Conclusion/UNASSIGNED:Undermining the platysma muscle results in no injury to platysmal innervation unless continued beyond the facial vessels. Recurrent bands are likely related to persistent innervation of the medial platysma, which remains intact cranial and caudal to any described platysmal transection maneuvers.

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.