Faculty Bibliography

PURPOSE: This study evaluated the effect of the platform-switching phenomenon, the use of a smaller diameter abutment on a larger diameter implant platform. Clinical and histological outcomes of the periimplant mucosa around titanium abutments in a nonsubmerged implant were evaluated. MATERIALS AND METHODS: Ten healthy adult patients, ranging from 27 to 65 years, participated in the study. A minimum of 2 endosseous implants with immediate abutment connection was placed per patient, 1 conventional and 1 platform-switched abutment. All sites for implant placement had an adequate zone of keratinized mucosa before surgical intervention. RESULTS: No clinical signs of inflammation were observed in the periimplant soft tissue mucosa, and healing was uneventful throughout the study period. Histological findings showed abnormally thick stratified squamous epithelium for both groups with few inflammatory cells in the connective tissue and none on the surface of the epithelium. CONCLUSION: Histological findings for both conventional and platform-switched implant-abutment configurations showed a similar composition of the soft tissue. These findings were in direct agreement with previous studies.

BACKGROUND: The Accreditation Council for Graduate Medical Education requires accredited fellowship programs to exhibit proficiency in six broadly defined domains; however, core competencies specifically mandated for hand surgery training have yet to be established. Several studies have demonstrated significant disparities in exposure to essential skills and knowledge between orthopedic surgery- and plastic surgery-based hand surgery fellowship programs. To determine whether significant discrepancies also exist after fellowship between hand surgeons trained in orthopedic surgery and those trained in plastic surgery, clinical practice patterns were evaluated. METHODS: A 20-question survey was created and distributed electronically to American Society for Surgery of the Hand and American Association for Hand Surgery members. Responses were compared using descriptive statistics. RESULTS: Nine hundred eighty-two hand surgeons (76 percent orthopedic and 24 percent plastic) responded, representing a 39 percent response rate. Most plastic surgery hand practices were academic-based (41 percent), whereas orthopedic practices were private (67 percent). More orthopedic hand surgeons worked in multipractitioner practices than plastic surgeons (54 percent versus 30 percent; p < 0.0001). Orthopedic hand surgeons performed a higher percentage of hand cases in their practice facilities (86 percent versus 71 percent; p < 0.0001). Plastic surgeons performed more congenital hand (56 percent versus 35 percent; p < 0.05) and digital replantation cases (53 percent versus 22 percent; p < 0.05) but treated significantly fewer open reduction and internal fixation distal radius fractures. CONCLUSIONS: Orthopedic and plastic surgery hand surgeons differ significantly in their clinical practice patterns. Differences in clinical exposure during training are reflected in practice and persist over time. Referral patterns and practice situations are also contributors to ultimate practice patterns.

BACKGROUND: Despite inclusion of periorbital structures in facial transplants, critical assessment of posttransplantation short- and long-term periorbital function has not been reported. The purpose of this article is to report recovery of ocular and periorbital function, with critical appraisal of posttransplant blink in the setting of revision surgery. METHODS: Prospective ocular and periorbital functional assessments were completed at multiple time points in a patient undergoing facial transplantation and subsequent revision operations. Function was evaluated using clinical ocular examinations, visual acuity assessments, photography, and video at various intervals from preoperative baseline to 13.5 months after transplantation. During this period, revision operations involving periorbital structures were performed at 6 and 9 months after transplantation. RESULTS: Before transplantation, volitional blink was 100 percent in both eyes. Involuntary blink was 40 percent in the right eye and 90 percent in the left eye, with occasional full closure. Following face transplantation, voluntary blink was preserved, partial skin sensation was present, and involuntary blink improved to 70 percent in the right eye and 100 percent in the left eye. Following revision surgery, visual acuity and voluntary and involuntary blink were impaired. By 7.5 months after revision, improvement comparable to the pretransplantation assessment was observed. CONCLUSIONS: Adherence to principles of blink preservation is critical in periorbital transplantation. Involuntary blink is essential for preserving vision, and can be improved after transplantation. Revision surgery may temporarily impair advances made with initial allotransplantation. A comprehensive understanding of ocular biomechanics and function is invaluable to the reconstructive surgeon performing facial transplantation involving periorbital structures and posttransplant revision operations. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

True arterial aneurysms of the upper extremity are rare. The case described is that of a 48-year-old man presenting with median neuropathy and distal vascular compromise 4 years after ligation of a brachiocephalic arteriovenous fistula. We describe our approach and present a review of the relevant literature.

OBJECTIVE: To investigate the presence of non-infiltrated, partially demineralized dentin (PDD) beneath the hybrid layer for self-etch adhesive systems, and its effect on micromechanical behavior of dentin-adhesive interfaces (DAIs). This in-vitro laboratory and computer simulation study hypothesized that the presence of non-infiltrated PDD beneath the hybrid layer does not influence the mechanical behavior of the DAI of self-etch adhesive systems. METHODS: Fifteen sound third molars were restored with composite resin using three adhesive systems: Scotchbond Multipurpose (SBMP), Clearfil SE Bond (CSEB) and Adper Promp L-Pop (APLP). The thickness and length of all DAIs were assessed using scanning electron microscopy, and used to generate three-dimensional finite element models. Elastic moduli of the hybrid layer, adhesive layer, intertubular dentin, peritubular dentin and resin tags were acquired using a nano-indenter. Finite element software was used to determine the maximum principal stress. Mixed models analysis of variance was used to verify statistical differences (P<0.05). RESULTS: Elastic moduli and morphology were found to differ between the adhesive systems, as well as the presence and extension of PDD. SIGNIFICANCE: Both self-etch adhesive systems (APLP and CSEB) had PDD. The DAI stress levels were higher for the one-step self-etch adhesive system (APLP) compared with the etch-and-rinse adhesive system (SBMP) and the self-etch primer system (CSEB).

OBJECTIVES: To evaluate the influence of implant-abutment interface (IAI) placement depth on bone remodeling around implants with two different types of tapered internal IAI: screwed-in (SI) and tapped-in (TI) connections in dogs. MATERIALS AND METHODS: Eight weeks post mandibular tooth extraction in six beagle dogs, two SI implants (OsseoSpeed , Astra Tech, DENTSPLY) and two TI implants (Integra-CP , Bicon LLC) were placed in one side of the mandible. The four experimental groups were as follows: (i) SI-placed equicrestally (SIC); (ii) TI-placed equicrestally (TIC); (iii) SI-placed 1.5 mm subcrestally (SIS); and (iv) TI-placed 1.5 mm subcrestally (TIS). Healing abutments were connected 12 weeks after implant placement. Sixteen weeks later, the dogs were sacrificed and histomorphometric analysis was performed. Histometrical outcomes were evaluated using a nonparametric Brunner-Langer model. RESULTS: Mean distance from the IAI to first bone-implant contact (IAI-fBIC) was 0.88 mm (median: 0.77; SD: 0.54) for SIC group, 1.23 mm (median: 1.22; SD: 0.66) for TIC group, 0.41 mm (median: 0.31; SD: 0.36) for SIS group, and 0.41 mm (median: 0.26; SD: 0.45) for TIS group. Subcrestal groups showed lower IAI-fBIC compared with equicrestal groups (P < 0.001). Connective tissue presented similar measurements regardless of the IAI placement depth and IAI type (P > 0.05), but the epithelium length and peri-implant soft tissue length in subcrestal groups were significant larger than that in the equicrestal groups (P < 0.001 and P = 0.004, respectively). CONCLUSION: Subcrestal implant placement with tapered internal IAI is beneficial for bone contact with the implant neck, and concurrently, it may not increase the soft tissue inflammation around IAI.

Diabetic patients exhibit dysfunction of the normal wound healing process, leading to local ischemia by vascular occlusive disease as well as sustained increases in the proinflammatory cytokines and overproduction of reactive oxygen species (ROS). Of the many sources of ROS, the enzyme xanthine oxidase (XO) has been linked to overproduction of ROS in diabetic environment and studies have demonstrated that treatment with XO inhibitors decreases XO overactivity and XO-generated ROS. This study evaluates the role of XO in the diabetic wound and the impact of specifically inhibiting its activity on wound healing. Treatment of diabetic wounds with siXDH (xanthine dehydrogenase siRNA) decreased XDH mRNA expression by 51.6%, XO activity by 35.9%, ROS levels by 78.1%, and pathologic wound burden by 31.5%, and accelerated wound healing by 7 days (23.3%). PCR analysis demonstrated that increased XO activity in wild type wound may be due to XDH to XO conversion and/or XO phosphorylation, but not to gene transcription, whereas increased XO activity in diabetic wounds may also be from gene transcription. These results suggest that XO may be responsible for large proportion of elevated oxidative stress in the diabetic wound environment and that normalizing the metabolic activity of XO using targeted delivery of siXDH may decrease overproduction of ROS and accelerate wound healing in diabetic patients.

BACKGROUND: To decrease the rate of infectious complications, surgeons have begun to use Biopatch (Ethicon, Somerville, N.J.) disks at drain exit sites. The authors investigated whether use of a Biopatch disk could convey a reduction in perioperative infections in patients undergoing immediate tissue expander breast reconstruction. METHODS: A retrospective review was conducted of all patients undergoing tissue expander/implant breast reconstruction from November of 2010 to November of 2012 at a single institution. Breasts were divided into two cohorts: controls with traditional adhesive dressings and those with Biopatch disks at drain sites. Breasts were compared based on demographics, complications, drain duration, and antibiotic type. RESULTS: A total of 1211 breasts met inclusion criteria. The control group (November of 2010 to October of 2011) included 606 breasts. The Biopatch cohort (November of 2011 to October of 2012) included 605 breasts. When comparing breasts with disks to controls, there were no statistical differences in overall infection (6.2 versus 7.4 percent; p = 0.4235), major infection (4.0 versus 4.3 percent; p = 0.8853), need for explantation (2.2 versus 1.8 percent; p = 0.5372), and mastectomy skin flap necrosis (12.6 versus 14.6 percent; p = 0.3148). However, age greater than 50 years, diabetes mellitus, hypertension, hypercholesterolemia, obesity, history of prior breast irradiation, and mastectomy skin flap necrosis were independent predictors of infectious complications. CONCLUSIONS: Biopatch disks do not reduce the rate infectious complications in patients undergoing immediate tissue expander breast reconstruction. Other conventional risks, including medical comorbidities, obesity, and mastectomy skin flap necrosis, remain significantly associated with infectious complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

BACKGROUND: Practitioners who are not board-certified by the American Board of Plastic Surgery are practicing cosmetic surgery. The extent of this issue across the United States has yet to be examined in detail. METHODS: A systematic search using Google was performed to evaluate the qualifications of clinicians marketing themselves as plastic surgeons. For every U.S. state, the following searches were performed: [state] plastic surgery, [state] cosmetic surgery, and [state] aesthetic surgery. The first 50 Web sites returned for each search were visited and scrutinized using the American Society of Plastic Surgeons and American Board of Plastic Surgery Web sites. RESULTS: In total, 7500 Web sites were visited, yielding 2396 board-certified plastic surgeons (77.9 percent of all practitioners). There were 284 board-certified ear, nose, and throat surgeons, 61 (21.5 percent) of whom practice outside their scope; 106 board-certified general surgeons, 100 (94.3 percent) of whom practice outside their scope; 104 board-certified oral and maxillofacial surgery surgeons, 68 (65.4 percent) of whom practice outside their scope; 70 board-certified ophthalmologists/oculoplastic surgeons, 49 (70 percent) of whom practice outside their scope; and 74 board-certified dermatologists, 36 (48.6 percent) of whom practice outside their scope. There were also 16 internal medicine doctors, 13 obstetrics and gynecology physicians, six emergency medicine physicians, three pediatricians, two urologists, two anesthesiologists, and finally one phlebotomist; all of these practitioners practice outside their scope as defined by Accreditation Council for Graduate Medical Education core competencies. CONCLUSIONS: Many clinicians performing cosmetic surgery are not board-certified. This finding has important implications for patient safety.

INTRODUCTION: To evaluate the influence of storage time on the elastic modulus, micromorphology, nanoleakage, and micromechanical behavior of the dentin-adhesive interfaces of five adhesive systems (Scotchbond Multi-Purpose, Clearfil SE Bond, One Up Bond F, Adper Easy One, and Filtek LS Adhesive) after 24h (T0) and 12 months (T1). METHODS: Fifty teeth were restored and distributed according to each adhesive system (n=10). At least four specimens were obtained from each tooth. One specimen was evaluated under SEM to obtain the micromorphology of dentin-adhesive interface (DAI). Two specimens were used to assess nanoleakage, one tested in T0 and the other in T1. The last specimen was used for nanoindentation, in T0 and T1, to obtain the initial and final mechanical properties of DAI structures. Two non-restored teeth were evaluated under SEM to obtain the dentin morphology. Laboratorial data were used to build 15 finite element models to assess the maximum principal stress in each time of analysis. RESULTS: Storage resulted in hydrolysis of the dentin-adhesive interfaces for all groups. Silver impregnation increased for all groups after 1 year storage (p<.05), except for Clearfil SE Bond. In general, a decrease in elastic modulus values was observed for all groups from T0 to T1 (p<.05), mainly at the hybrid layer. The FEAs showed higher stress levels at T1 than T0 simulations for all adhesives. CONCLUSION: At T1, degradation occurred at the dentin-adhesive interface formed by all adhesives, and the intensity of degradation differed depending on the type of adhesive system used. The interface formed by the self-etching primer containing the 10-MDP functional monomer showed the highest stability among the adhesive systems after 12 months of storage.