Faculty Bibliography

OBJECTIVE: To report the associations of oro-nasal fistulae on the patient-centered outcomes oral health-related quality of life and self-reported speech outcomes in school aged-children. DESIGN: Prospective, nonrandomized multicenter design. SETTING: Six ACPA-accredited cleft centers. PARTICIPANTS: Patients with cleft palate at the age of mixed dentition. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Prevalence of fistula and location of fistula (Pittsburgh Classification System). Patients were placed into one of three groups based on the following criteria: alveolar cleft present, no previous repair (Group 1); alveolar cleft present, previously repaired (Group 2); no congenital alveolar cleft (Group 3). Presence of fistula and subgroup classification were correlated to oral health-related quality of life (Child Oral Health Impact Profile [COHIP]) and perceived speech outcomes. RESULTS: The fistula rate was 5.52% (62 of 1198 patients). There was a significant difference in fistula rate between the three groups: Group 1 (11.15%), Group 2 (4.44%), Group 3 (1.90%). Patients with fistula had significantly lower COHIP scores (F1,1188 = 4.79; P = .03) and worse self-reported speech scores (F1,1197 = 4.27; P = .04). Group 1 patients with fistula had the lowest COHIP scores (F5,1188 = 4.78, P =.02) and the lowest speech scores (F5,1188 = 3.41, P = .003). CONCLUSIONS: Presence of palatal fistulas was associated with lower oral health-related quality of life and perceived speech among youth with cleft. The poorest outcomes were reported among those with the highest fistula rates, including an unrepaired alveolar cleft.

BACKGROUND: Autologous breast reconstruction has been shown to have fewer complications and superior outcomes. In the elderly patient population, a paucity of literature on the subject may render the surgeon reluctant to recommend or perform such a procedure. The objective of this study was to compare complications and satisfaction after abdominally based breast reconstruction in patients older than versus younger than 65 years. METHODS: A retrospective study was performed with data from 5 North American centers from 2002 to 2012. Patients who underwent autologous reconstruction were identified retrospectively, and chart review was performed. The BREAST-Q questionnaire was sent to these patients via mail. Patient variables, operative outcomes and BREASTQ results were analyzed. The Pearson chi and analysis of variance tests were used. Given the number of analyses, a more conservative alpha of 0.01 was used for each comparison. RESULTS: A total of 1809 patients were included with 1751 patients younger than 65 years and 58 patients aged 65 years or older. Analysis of postoperative complications showed no significant differences between the age groups, though there was a trend toward higher seroma development (17.2% vs 8.1%; P = 0.013) and infection (19.0% vs 10.0%; P = 0.028) in the older group with statistical significance set at P less than 0.01 to account for multiple comparisons. A total of 1809 BREAST-Q surveys were sent with a response rate of 52.5%. Patient satisfaction results were equally high between the 2 age groups. CONCLUSIONS: This is the largest study to compare patients undergoing autologous breast reconstruction older than and younger than 65 years within the same cohort. Women older than 65 years represent a minority and constituted only 3% of patients in this multicenter 10-year review. We have shown that with careful patient selection, abdominally based autologous reconstruction should be considered in the elderly patient population because it is well tolerated and achieves high patient satisfaction.

INTRODUCTION: Keloids represent a challenging problem for plastic surgeons and patients. Surgical excision remains the definitive treatment for immediate lesion debulking. However, post-excisional recurrence rates are reported to be 45% - 100%. We present a series of 5 patients undergoing excision of keloids and a staged reconstructive approach using a dermal regeneration substrate and epidermal grafting to minimize recurrence and donor site morbidity. METHODS: Keloids were completely excised down to normal subcutaneous tissue or perichondrium. A bilaminar dermal regeneration matrix (Integra, Integra Lifesciences Corp.) was approximated to the entire wound, with the silicone lamina oriented superficially. Reconstruction was delayed for at least 21 days to allow for neo-dermal ingrowth. The silicone lamina was then removed, and an epidermal skin graft was harvested from the thigh using an epidermal graft harvesting system (CelluTome, KCI Inc.) and secured to the neo-dermis with non-occlusive dressing (Tegaderm, 3M). Dressings were removed after 7-14 days. Reconstructed defects and donor sites were assessed for recurrence of keloids and scar appearance. RESULTS: 5 patients underwent treatment. Two patients had keloids involving the superior helix of the ear with average area of 2.6 cm. Two patients had keloids involving the chest with average area of 28 cm. One patient had a keloid in the pubic region with an area of 10 cm. All had failed at least one previous treatment with direct excision and steroid injections. Mean follow up was 48.8 weeks [38-60 weeks]. Patients required an average of 5.5 weeks for complete wound epithelialization. There were no instances of infection or cellulitis. All reconstructed defects were aesthetically acceptable and remained flat without significant widening. There were no long-term complaints of pruritis or pain, and no evidence of scarring at donor sites. CONCLUSION: Epidermal graft harvesting devices are a new weapon in the armamentarium of reconstructive surgeons. Epidermal grafting provides significant advantages when used in conjunction with a dermal regeneration matrix. This approach obviates reliance on skin creep and flap undermining to achieve primary closure. Exclusion of dermis and significant extracellular matrix components limits contracture exerted by the graft, further facilitating tension-free wound healing. Scarring response within the donor site and graft are also minimized because the dermis is not violated.

Background Surgical management of head and neck cancer is resource intensive and physiologically demanding. In patients with incurable disease, although the indications for surgery are not well defined, palliative benefit can be significant. The goal of this investigation was to compare outcomes of patients who underwent resection and reconstruction of head and neck cancer with curative intent with those who underwent similar procedures with palliative intent. Methods A retrospective review of patients who underwent reconstruction for head and neck cancer between 2008 and 2014 was conducted. Patients were divided into curative and palliative groups. Outcomes assessed included postoperative complications and survival. Results A total of 147 patients who underwent 156 operations met inclusion criteria (27 palliative and 129 curative). In both cohorts, the most common histology was squamous cell carcinoma (SCC) and the most common primary tumor site was the oral cavity. There was no significant difference between the cohorts in the rates of systemic and reconstructive complications, postoperative hospital length of stay, 30-day mortality, and flap survival. Overall survival in palliative patients was significantly shorter compared with curative patients (median OS, 6.2 months vs. 56.1 months, respectively; p < 0.0001). Among patients undergoing palliative surgery, patients without carotid involvement and those with non-SCC were significantly more likely to have longer survival. Conclusion Surgical resection with reconstruction is possible in head and neck oncologic patients undergoing palliative treatment. Palliative patients have similar short-term outcomes when compared with patients undergoing resection for curative intent. Quality-of-life and economic implications of these approaches deserve closer scrutiny.

Moderate-to-severe fatigue occurs in up to 94% of oncology patients undergoing active treatment. Current interventions for fatigue are not efficacious. A major impediment to the development of effective treatments is a lack of understanding of the fundamental mechanisms underlying fatigue. In the current study, differences in phenotypic characteristics and gene expression profiles were evaluated in a sample of breast cancer patients undergoing chemotherapy (CTX) who reported low (n = 19) and high (n = 25) levels of evening fatigue. Compared to the low group, patients in the high evening fatigue group reported lower functional status scores, higher comorbidity scores, and fewer prior cancer treatments. One gene was identified as upregulated and 11 as downregulated in the high evening fatigue group. Gene set analysis found 24 downregulated and 94 simultaneously up- and downregulated pathways between the two fatigue groups. Transcript origin analysis found that differential expression (DE) originated primarily from monocytes and dendritic cell types. Query of public data sources found 18 gene expression experiments with similar DE profiles. Our analyses revealed that inflammation, neurotransmitter regulation, and energy metabolism are likely mechanisms associated with evening fatigue severity; that CTX may contribute to fatigue seen in oncology patients; and that the patterns of gene expression may be shared with other models of fatigue (e.g., physical exercise and pathogen-induced sickness behavior). These results suggest that the mechanisms that underlie fatigue in oncology patients are multifactorial.

BACKGROUND: Autologous fat grafting is an increasingly popular procedure used for facial rejuvenation and body contouring. The purpose of this article is to perform an evidence-based review to determine fact from fiction for the hot topics in autologous fat grafting. METHODS: A comprehensive literature search was performed. The following key words were then searched: "fat grafting," "autologous fat grafting," "autologous fat transfer," "lipotransfer," "liposculping," and "lipofilling." The authors then assessed each modality individually for the level of evidence that exists and whether the majority of evidence supports or refutes it. RESULTS: A review of the literature demonstrated that there is no standard test for determining fat viability or volume augmentation after grafting. Furthermore, there is no difference in cell viability seen between syringe aspiration and liposuction pump aspiration harvest techniques (Level II). The decision to wash or centrifuge the fat plays very little role in fat graft survival (Level III). There is no difference between cell viability as a function of harvest location (Level IV). Nearly all studies show no significant effect of local anesthesia on adipocyte cells (Level IV). There are excellent data that support the fact that low-shear devices maintain fat structural integrity (Level IV). There is quality evidence that supports longevity of fat grafted to the breast (Level III). Two studies support large-volume fat grafting longevity but fail to prove their results using objective measures or with sufficiently large sample sizes (Level IV). External preexpansion devices improve total graft survival rate (Level IV). There is quality evidence to support that fat should be injected soon after harvesting, as properties of fat begin to change after processing (Level IV). Microneedling (preconditioning) before fat grafting has been demonstrated to improve fat survival (Level III). CONCLUSIONS: Currently, the highest levels of evidence derive from human studies of clinical trials and animal studies using human fat. The evidence presented here helps to address the need for accurate and quantitative viability assays. These assays would facilitate a systematic evaluation of each procedural step during fat graft harvest, processing, and grafting to improve the overall viability and predictability of fat grafts.

BACKGROUND: Approximately 20 percent of women select autologous tissue for postmastectomy breast reconstruction, and most commonly choose the abdomen as the donor site. An increasing proportion of women are seeking muscle-sparing procedures, but the benefit remains controversial. It is therefore important to determine whether better outcomes are associated with these techniques, thereby justifying longer operative times and increased costs. METHODS: Patients from five North American centers were eligible if they underwent reconstruction by means of the deep inferior epigastric artery perforator (DIEP) flap, muscle-sparing free transverse abdominis myocutaneous (TRAM) flap, free TRAM flap, or the pedicled TRAM flap. Patients were sent the BREAST-Q. Demographics and complications were collected. RESULTS: The authors analyzed 1790 charts representing 670 DIEP, 293 muscle-sparing free TRAM, 683 pedicled TRAM, and 144 free TRAM patients with an average follow-up of 5.5 years. Flap loss did not differ by flap type. Partial flap loss was higher in pedicled TRAM compared with DIEP (p = 0.002). Fat necrosis was higher in pedicled TRAM compared with DIEP and muscle-sparing free TRAM (p < 0.001). Hernia/bulge was highest in pedicled TRAM (p < 0.001). Physical well-being (abdomen) scores were higher in DIEP compared with pedicled TRAM controlling for confounders. CONCLUSIONS: Complications and patient-reported outcomes differ when comparing abdominally based breast reconstruction techniques. The results of this study show that the DIEP flap was associated with the highest abdominal well-being and the lowest abdominal morbidity compared with the pedicled TRAM flap, but did not differ from muscle-sparing free TRAM and free TRAM flaps. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The objective of this split-mouth clinical study was to compare a combination of in-office and at-home dental bleaching with at-home bleaching alone. Two applications of in-office bleaching were performed, with one appointment per week, using 38% hydrogen peroxide. At-home bleaching was performed with or without in-office bleaching using 10% carbamide peroxide in a custom-made tray every night for 2 weeks. The factor studied was the bleaching technique on two levels: Technique 1 (in-office bleaching combined with home bleaching) and Technique 2 (home bleaching only). The response variables were color change, dental sensitivity, morphology, and surface roughness. The maxillary right and left hemiarches of the participants were submitted to in-office placebo treatment and in-office bleaching, respectively (Phase 1), and at-home bleaching (Phase 2) treatment was performed on both hemiarches, characterizing a split-mouth design. Enamel surface changes and roughness were analyzed with scanning electron microscopy and optical interferometry using epoxy replicas. No statistically significant differences were observed between the bleaching techniques for either the visual or the digital analyses. There was a significant difference in dental sensitivity when both dental bleaching techniques were used, with in-office bleaching producing the highest levels of dental sensitivity after the baseline. Microscopic analysis of the morphology and roughness of the enamel surface showed no significant changes between the bleaching techniques. The two techniques produced similar results in color change, and the combination technique produced the highest levels of sensitivity. Neither technique promoted changes in morphology or surface roughness of enamel.

OBJECTIVE: To analyze indications and outcomes for primary premaxillary setback. DESIGN: Retrospective. SETTING: Academic children's hospital. PATIENTS: All children with bilateral complete cleft lip age