Faculty Bibliography

Autologous fat grafting is an exciting part of plastic and reconstructive surgery. Fat serves as a filler and its role in tissue regeneration will likely play a more important role in our specialty. As we learn more about the basic science of fat grafting and the standardized techniques and instruments used for fat grafting, this procedure alone or in conjunction with invasive procedures may be able to replace many operations that we perform currently. Its minimally invasive nature will benefit greatly our cosmetic and reconstructive patients, and may even achieve better clinical outcomes.

The Asher-McDade system is a 5-point ordinal scale frequently used to rate the components of nasolabial appearance, including nasal form and nasal symmetry, in unilateral cleft lip and palate. Although reference photographs illustrating this scale have been identified for the frontal and right profile view, no reference photographs exist for the basal view. The aim of this study was to identify reference photographs for nasal form and nasal symmetry from the basal view to illustrate this scale and facilitate its use. Four raters assessed nasolabial appearance (form and symmetry) on basal view photographs of 50 children (average age 8 years) with a repaired cleft lip. Intraclass correlation coefficients show fair to moderate inter-rater reliability. Cronbach alpha indicated strong agreement between raters (0.77 nasal form; 0.78 nasal symmetry; 0.80 overall), along with low duplicate measurement error and strong internal consistency between the measures. The photographs with the highest agreement among raters were selected to illustrate each point on the 5-point scale for nasal form and for nasal symmetry, resulting in the selection of 10 reference photographs. The basal view reference photograph set developed from this study may complement existing reference photograph sets for other views and facilitate rating tasks.

This paper uses a collaborative, interdisciplinary systems science inquiry to explore implications of Medicaid expansion on achieving oral health equity for older adults. Through an iterative modeling process oriented toward the experiences of both patients and oral health care providers, complex feedback mechanisms for promoting oral health equity are articulated that acknowledge the potential for stigma as well as disparities in oral health care accessibility. Multiple factors mediate the impact of Medicaid expansion on oral health equity.

Background & Purpose: The aim of this study was to compare 3D symmetry of the nose in patients with UCLP, subsequent to rotation advancement (Millard) without primary nasal repair and the NAM/Cutting primary nasal repair. Methods & Description: Nasal casts were made for 12 consecutively appearing patients with UCLP, in each of two groups. Group 1 patients had a Millard repair without primary nasal repair (Bardach) while Group 2 patients had NAM and primary nasal repair. Patients were 6 to 18 years of age (mean=12.04). Surgery was performed at the mean age of 3.8 months. None of patients in Group 1 had primary nasal surgery as it was believed at the time by the surgeon that nasal growth might be inhibited. A two flap palatoplasty was performed at 12-24 months (mean age 19.75). All operations were performed by one surgeon in Group 1 and another surgeon in Group 2. Nasal casts were scanned using the 3Shape e scanner. All noses were scaled to the same size prior to evaluation. Procrustes analysis of 3D nasal symmetry was performed using 3dMD Vultus software. The Procrustes technique, determines nasal symmetry by performing a superimposition of its surface with its mirror image (ref Maull 1999). 4 linear measurements including columellar height, nasal dome height, alar base and nasal projections were performed on cleft and non-cleft side in both groups (ref Cutting 1984). For 3D analysis, student's t-test was used to determine the difference between the mean asymmetry index for each group. If symmetry is perfect the asymmetry index is zero. For linear analysis, student's T test was utilized to compare the differences. SPSS was used to perform a descriptive analysis of the groups. Results: The mean asymmetry index in the Millard rotation advancement repair was 4.41 and the NAM plus primary nasal repair was 2.45. The difference was statistically significant (P=0.006). In linear measurements, columellar length and alar base were significantly different when cleft side was compared to non-cleft side in Millard group (P=0.04 and 0.005). There was no significant difference in columellar length, nasal dome height, alar base and nasal projection in cleft versus non-cleft side in NAM group. Inter-group analysis showed that alar base in cleft and non-cleft side is significantly different in Millard versus NAM group (P=0.02). Conclusions: To our knowledge this is the first long-term, quantitative 3D study to analyze the asymmetry of the nose in the Millard rotation advancement versus NAM plus primary nasal repair in patients with complete UCLP. This study shows that the NAM plus primary nasal repair results in significantly less asymmetry of the nose compared to the Millard rotation advancement without nasal correction

Background & Purpose: We have produced a freely available, web-based, multimedia surgical simulator in partnership with Smile Train which demonstrates the cardinal procedures in primary cleft surgery. This tool is intended to help surgeons in developing countries care for their local cleft populations. Limitations of Internet access and local technology may hinder use in the developing world. We report on the international utilization of the world's first internet-based cleft simulator. Methods & Description: The Smile Train Virtual Surgery Simulator contains an internal tracking system which records the unique Internet Protocol (IP) addresses all users. Using these IP addresses, each country accessing the Simulator was identified over a one year period. All users accessing the Simulator for less than 5 minutes were eliminated. The countries were analyzed based upon economic factors such as Gross Domestic Product (GDP) and per capita income (PCI) as well as health metrics such as health expenditures and underweight children. Results: There were 849 novel users of the Simulator from 78 countries were recorded over the one-year study period. Those countries represent 6.28 billion persons or 88.5% of the global population. Of the countries utilizing the simulator 54 were classified as developing economies, representing 5.3 billion people. The developing countries average GDP was $467.4 +/- 147 billion and PCI was $8,281 +/- 815. The poorest developing countries accessing the Simulator in terms of PCI were Congo ($400), Ethiopia ($1,200), and Nepal ($1,300). In terms of percent population living below the poverty line, the poorest countries accessing the simulator were Haiti (80%) Congo (71%) and Nigeria (70%). In developing countries, the health expenditures as a percentage of GDP averaged 6.1%. The nations with the lowest healthcare expenditures as a percentage of GDP were Myanmar 2%, Pakistan 2.2%, and Indonesia 2.6%. Penetration into advanced economies was also extensive including 24 countries representing 979 million people and an aggregate GDP of $40.98 Trillion. In the United States the simulator was used in 40 states from both academic and community Internet service providers. Surprisingly, the simulator was used in 21 countries with active armed conflicts and 28 where the US State Department advises against travel including Ukraine, Egypt, Yemen, Iraq and Nigeria. Conclusions: The presented internet-based surgical simulator is accessible globally and has quickly gained use in 78 countries representing 88% of the global population including 5.3 billion of the worlds developing population. Over 2/3rds of the countries accessing the simulator are developing nations and include regions experiencing severe poverty. Projects directed towards international education of cleft care in the developing world should strongly consider the use of web-based digital technology as a means to immediately access and educate caregivers, particularly in countries with significant economic and political constraints. Disclosure: Receipt of Intellectual Property Rights/Patent Holder-Aaron Oilker holds the intellectual property rights for the biodigital surgery simulator

OBJECTIVES: To define the effect of APP treatments on the mechanical properties of enamel and on its ability to promote sealant bonding to unetched enamel. METHODS: Human molar teeth were sectioned exposing flat enamel regions at the buccal and lingual surfaces. The specimens were divided into two substrate groups (etched and unetched) and distributed over three surface treatments (i) 5 slm Argon APP treatment, NaOH surface treatment, and (iii) compressed air application (control). The Enamel surfaces were characterized by SEM, IFM, and Goniometer instruments. For the mechanical tests nanoindentation and microshear bond strength were employed. Initial data evaluation comprised normality verification (SPS S software) and variance checking and the appropriated statistical analysis model employed. For all statistical inferences, significance was set at 0.05. RESULTS: SE was significantly higher for the etched and unetched group treated with Plasma relative to the NaOH and control groups. Nanoindentation testing determined that Rank hardness was significantly higher in the control and Plasma group relative to NaOH for the etched group. Rank Elastic Modulus was significantly higher on Control groups relative to NaOH and Plasma groups for the etched substrate. No difference was detected between treatments for the unetched group. For the microSBS test, we observed that APP treatment on etched and unetched enamel increased bonds significantly (p < 0.001). CONCLUSIONS: This study demonstrated that APP increased SE, surface wettability and bond strength between enamel and sealants potentially serving as a substitute for conventional acid etching procedures or as an adjuvant for self-etch sealants. (c) 2014 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 2014.

BACKGROUND: Patients with unilateral cleft lip and palate (CLP) deformities commonly develop nasal airway obstruction, necessitating septoplasty at the time of definitive rhinoplasty. We assessed the contribution of the bony septum to airway obstruction using computed tomography (CT) and cone beam CT (CBCT). METHODS: A 2-year retrospective review of all subjects with unilateral CLP who underwent CBCT imaging (n = 22) and age-matched controls (n = 9) who underwent CT imaging was conducted. Control CT scans were used to determine the segment of nasal septum comprised almost entirely of bone. The CBCT of the nasal airway was assessed using Dolphin software to determine the contribution of the bony septum to septal deviation and airway obstruction. RESULTS: The nasal septum posterior to the midpoint between anterior and posterior nasal spine is comprised of 96% bone. The nasal airway associated with this posterior bony segment was 43.1% (P < 0.001) larger by volume on the non-cleft side in patients with unilateral CLP. The average septal deviation within the posterior bony segment was 5.4 mm, accounting for 74.4% of the maximal deviation within the nasal airway. The average airway stenosis within the posterior bony nasal airway was 0.45 mm (0-2.2 mm). CONCLUSIONS: In patients with unilateral CLP, the bony nasal septum can demonstrate significant deviation and airway stenosis. Surgeons should consider a bony septoplasty in their treatment algorithm in unilateral CLP patients who have reached skeletal maturity.

Patients with multisutural craniosynostosis can develop anomalous venous connections between the intracranial sinuses and cutaneous venous system through enlarged emissary veins. Cranial vault remodeling in this subset of patients carries the risk of massive intraoperative blood loss and/or occlusion of collateral draining veins leading to intracranial venous hypertension and raised intracranial pressure, increasing the morbidity of cranial expansion. The authors report the use of spring-mediated expansion as a technique for cranial reconstruction in which the collateral intracranial venous drainage system can be preserved. A patient with bilateral lambdoid, sagittal, and unicoronal synostosis presented for cranial reconstruction. A tracheostomy and ventriculoperitoneal shunt were placed prior to intervention. At the time of reconstruction, a Luckenschadel skull abnormality and Chiari malformation Type I were present. A preoperative CT venogram demonstrated large collateral superficial occipital veins, small bilateral internal jugular veins, and hypoplastic jugular foramina. Collateral flow from the transverse and sigmoid sinuses through large occipital emissary veins was seen. Spring-mediated cranial vault expansion was performed with care to preserve the large collateral veins at the occipital midline. Four springs were placed at each lambdoid and the posterior and anterior sagittal sutures following 1-cm strip suturectomies. Removal of the springs was performed 2 months postoperatively. Cranial vault expansion was performed without disturbing the aberrant intracranial/extracranial venous collateral system. Estimated blood loss was 150 ml. A CT scan obtained 3 months postoperatively showed resolution of the Luckenschadel deformity and a 40% volumetric increase in the skull compared with the preoperative CT. Patients with anomalous venous drainage patterns and multisutural synostosis can undergo spring-mediated cranial vault expansion while preserving the major emissary veins draining the intracranial sinuses. Risks of blood loss, intracranial venous hypertension, and increased intracranial pressure may be decreased compared with traditional techniques of repair.