Faculty Bibliography

BACKGROUND:3D-printed bioceramic scaffolds composed of 100% beta(β)-tricalcium phosphate augmented with dipyridamole (3DPBC-DIPY) can regenerate bone across critically sized defects in skeletally mature and immature animal models. Prior to human application, safe and effective bone formation should be demonstrated in a large translational animal model. This study evaluated the ability of 3DPBC-DIPY scaffolds to restore critically sized calvarial defects in a skeletally immature, growing minipig. METHODS:Unilateral calvarial defects (~1.4cm) were created in six-week-old Göttingen minipigs (n=12). Four defects were filled with a 1000µ M 3DPBC-DIPY scaffold with a cap (a solid barrier on the ectocortical side of the scaffold to prevent soft tissue infiltration), four defects were filled with a 1000µM 3DPBC-DIPY scaffold without a cap, and four defects served as negative controls (no scaffold). Animals were euthanized 12-weeks post-operatively. Calvaria were subjected to micro-computed tomography, 3D-reconstruction with volumetric analysis, qualitative histologic analysis, and nanoindentation. RESULTS:Scaffold-induced bone growth was statistically greater than negative controls (p≤0.001) and the scaffolds with caps produced significantly more bone generation compared to the scaffolds without caps (p≤0.001). Histological analysis revealed woven and lamellar bone with the presence of haversian canals throughout the regenerated bone. Additionally, cranial sutures were observed to be patent and there was no evidence of ectopic bone formation or excess inflammatory response. Reduced elastic modulus (Er) and hardness (H) of scaffold-regenerated bone were found to be statistically equivalent to native bone (p = 0.148 for Er of scaffolds with and without caps, and p = 0.228 and p = 0.902, for H of scaffolds with and without caps, respectively). CONCLUSION/CONCLUSIONS:3DPBC-DIPY scaffolds have the capacity to regenerate bone across critically sized calvarial defects in a skeletally immature translational pig model.

INTRODUCTION:Radiation therapy is a promising modality for treating keloids after surgical excision. However, it is currently not standard practice among physicians because of concern surrounding the risk of radiation-induced secondary cancers, especially among pediatric patients. There is minimal research assessing the complications for radiation therapy in keloid management. AIM:The goal of this study was to determine radiation oncologists' perspectives about the utility and appropriateness of radiation therapy for keloid management in both adult and pediatric patients. This study also aimed to characterize radiation modality, dose, fractionation, and secondary complications observed by providers. METHODS:An electronic survey was delivered to 3102 members of the American Society for Radiation Oncology. The survey subjects were radiation oncologists who are currently practicing in the United States. Rates of responses were analyzed. RESULTS:A total of 114 responses from practicing radiation oncologists were received. Of these, 113 providers (99.1%) supported radiation therapy for keloid management in adults, whereas only 54.9% supported radiation therapy for pediatric patients. Of 101 providers that treated adults in the past year, the majority used external beam: electrons (84.2%), applied 3 fraction regimens (54.4%), and delivered radiation within 24 hours postexcision (45.5%). In pediatric patients, only 42 providers reported treating at least 1 patient. The majority used electron beam radiation (76.2%), applied 3 faction regimens (65%), and delivered radiation on the same day of keloid excision (50.0%) The main concern when treating pediatric patients were risk of secondary malignancy (92.1%). CONCLUSION:Although radiation therapy appears to be a widely accepted adjuvant treatment option for adults with keloids, the use of radiation therapy for pediatric patients is less widely accepted because of concerns regarding secondary malignancy. The findings suggest additional studies need to be carried out to assess the risk of those complications.

BACKGROUND:Previous work has identified an association between de novo and transmitted loss-of-function mutations in genes under high evolutionary constraint with neurodevelopmental delays in nonsyndromic craniosynostosis (NSC). The authors sought to quantify the neurocognitive effect of these genetic lesions. METHODS:In a prospective, double-blinded cohort study, demographic surveys and neurocognitive tests were administered to patients recruited from a national sample of children with sagittal NSC. Scores for academic achievement, Full-Scale Intelligence Quotient (FSIQ), and visuomotor skills were directly compared between patients with and without damaging mutations in genes with a high probability of loss of function intolerance using two-tailed t tests. Analysis of covariance was also used to compare test scores while controlling for surgery type, age at surgery, and sociodemographic risk. RESULTS:Fifty-six patients completed neurocognitive testing, 18 of whom had a mutation in a highly constrained gene. There was no significant difference between groups in any sociodemographic factors. After controlling for patient factors, patients with high-risk mutations had poorer performance compared with patients without high-risk mutations in every testing category, with significant differences in FSIQ (102.9 ± 11.4 versus 110.1 ± 11.3; P = 0.033) and visuomotor integration (100.0 ± 11.9 versus 105.2 ± 9.5; P = 0.003). There were no significant differences in neurocognitive outcome when stratifying groups based on type of surgery or age at time of surgery. CONCLUSIONS:Even after controlling for exogenous factors, the presence of mutations in high-risk genes led to poorer neurocognitive outcomes. High-risk genotypes may predispose individuals with NSC to deficits, particularly in FSIQ and visuomotor integration. CLINICAL QUESTION/LEVEL OF EVIDENCE:Risk, II.

Genital surgery for the treatment of gender dysphoria has undergone significant evolution since its inception in the first half of the 20th century. Robotic approaches to the pelvis allow for improved visualization and reduced abdominal wall morbidity, making the robotic surgical system a very useful tool in the gender affirming genital surgeon's armamentarium. In penile inversion vaginoplasty, robotically harvested peritoneal flaps can be used to augment the vaginal canal, thereby leading to improved vaginal depth, as well as improve operative efficiency by facilitating a two-surgeon approach. In transgender men, the robotic approach to vaginectomy assists with visualization to confirm complete obliteration of the vaginal canal. Robotic surgery will play a central role in the continued evolution of the field of gender affirming surgery.

OBJECTIVE:To identify the challenges encountered in obtaining the required support surfaces and products to meet pressure injury (PrI) prevention and treatment needs during COVID-19. METHODS:The authors used SurveyMonkey to gather data on healthcare perceptions and the challenges experienced regarding specific product categories deemed necessary for PrI prevention and treatment in US acute care settings during the pandemic. They created three anonymous surveys for the target populations of supply chain personnel and healthcare workers. The surveys addressed healthcare workers' perceptions, product requests, and the ability to fulfill product requests and meet facility protocols without substitution in the categories of support surfaces and skin and wound care supplies. RESULTS:Respondents answered one of the three surveys for a total sample of 174 respondents. Despite specific instructions, nurses responded to the surveys designed for supply chain personnel. Their responses and comments were interesting and capture their perspectives and insights. Three themes emerged from the responses and general comments: (1) expectations differed between supply chain staff and nurses for what was required for PrI prevention and treatment; (2) inappropriate substitution with or without proper staff education occurred; and (3) preparedness. CONCLUSIONS:It is important to identify experiences and challenges in the acquisition and availability of appropriate equipment and products for PrI prevention and treatment. To foster ideal PrI prevention and treatment outcomes, a proactive approach is required to face daily issues or the next crisis.

Use of body mass index (BMI) as a health care metric is controversial, especially in candidacy assessments for gender-affirming surgery. When considering experiences of fat trans individuals, it is important to advocate for equitable divisions of responsibility for and recognition of systemic fat phobia. This commentary on a case suggests strategies for increasing equitable access to safe surgery for all body types. If surgeons use BMI thresholds, simultaneous effort must be made to advocate for data collection so that surgical candidacy criteria are evidence-based and equitably applied.

OBJECTIVE:) ceramic structures fabricated using additive manufacturing (3D printing). METHODS:powder was combined with ammonium polyacrylate, hydroxypropyl methylcellulose, and polyelectrolyte to create a colloidal gel, which was then used for printing. A digital CAD model of a disc was designed, and the G-code transferred to a custom built DIW 3D printer. The control group samples were prepared using pre-crystallized ceramic blocks, which were cut to obtain discs with same dimensions as the AR group. Disc-shaped specimens from both groups were crystallized at 840 °C. Mechanical properties were evaluated using biaxial flexural strength test (BFS) and Vickers hardness test. Representative fractographic images of the specimens were acquired using scanning electron microscopy (SEM) to analyze the fracture origin and crack propagation. Energy-dispersive X-ray spectroscopy (EDS) and attenuated total reflection Fourier transform infrared spectroscopy (FTIR-ATR) were used for chemical analysis, and X-ray diffractometry (XRD) was performed to analyze the crystalline phases. RESULTS:) in the AM group. SEM micrographs showed a more porous microstructure associated with the 3D printed samples. SIGNIFICANCE/CONCLUSIONS:crystals and higher degrees of porosity.

OBJECTIVE:To evaluate the reliability, maximum principal stress, shear stress, and crack initiation of a computer-aided design/computer-aided manufacturing (CAD/CAM) resin composite (RC) incorporating surface pre-reacted glass (S-PRG) filler for primary molar teeth. METHODS:Mandibular primary molar crowns fabricated by experimental (EB) or commercially available CAD/CAM RCs (HC) were prepared and cemented to a resinous abutment tooth using an adhesive resin cement (Cem) or a conventional glass-ionomer cement (CX). These specimens were subjected to a single compressive test (n = 5/each) and the step-stress accelerated life testing (SSALT) (n = 12/each). Data was evaluated using Weibull analyses and reliability was calculated. Afterwards, the maximum principal stress and crack initiation point of each crown was analyzed by finite element analysis. To evaluate bonding of EB and HC to dentin, microtensile bond strength (μTBS) testing was conducted using primary molar teeth (n = 10/each). RESULTS:There was no significant difference between the fracture loads of EB and HC for either cement (p > 0.05). The fracture loads of EB-CX and HC-CX were significantly lower than EB-Cem and HC-Cem (p < 0.05). The reliability at 600 N for EB-Cem was greater than that for EB-CX, HC-Cem, and HC-CX. The maximum principal stress concentrated on EB was lower than that on HC. The shear stress concentrated in the cement layer for EB-CX was higher than that for HC-CX. There was no significant difference among the μTBSs of EB-Cem, EB-CX, HC-Cem, and HC-CX (p > 0.05). SIGNIFICANCE/CONCLUSIONS:The crowns fabricated with the experimental CAD/CAM RC incorporating S-PRG filler yielded greater fracture loads and reliability than the crowns manufactured with commercially available CAD/CAM RC regardless of the luting materials. These findings suggest that the experimental CAD/CAM RC crown may be clinically useful for the restoration of primary molars.

OBJECTIVE:1) To describe the authors' technique of anterolateral thigh (ALT) phalloplasty with staged skin graft urethroplasty and 2) to report the surgical outcomes and complications of this technique in a preliminary patient cohort. METHODS:Following IRB (Institutional Review Board) approval, retrospective chart review identified all patients undergoing primary three-stage ALT phalloplasty by the senior authors. Stage I involves single tube, pedicled ALT transfer. Stage II involves vaginectomy, pars fixa urethroplasty, scrotoplasty, and opening the ALT ventrally and construction of a urethral plate with split-thickness skin graft. Stage III involves tubularization of the urethral plate to create the penile urethra. Data collected included patient demographics, intraoperative details, postoperative courses, and complications. RESULTS:Twenty-four patients were identified. Twenty-two patients (91.7%) underwent ALT phalloplasty prior to vaginectomy. All patients underwent staged split-thickness skin grafting for the penile urethra reconstruction. Twenty-one patients (87.5%) achieved standing micturition at the time of data collection. Eleven patients (44.0%) experienced at least 1 urologic complication requiring additional operative intervention, most commonly urethrocutaneous fistulae (8 patients, 33.3%), and urethral strictures (5 patients, 20.8%). CONCLUSION/CONCLUSIONS:ALT phalloplasty with split-thickness skin grafting for urethral lengthening is an alternative technique to achieve standing micturition with an acceptable complication rate in gender-affirming phalloplasty.

Defects characterized as large osseous voids in bone, in certain circumstances, are difficult to treat, requiring extensive treatments which lead to an increased financial burden, pain, and prolonged hospital stays. Grafts exist to aid in bone tissue regeneration (BTR), among which ceramic-based grafts have become increasingly popular due to their biocompatibility and resorbability. BTR using bioceramic materials such as β-tricalcium phosphate has seen tremendous progress and has been extensively used in the fabrication of biomimetic scaffolds through the three-dimensional printing (3DP) workflow. 3DP has hence revolutionized BTR by offering unparalleled potential for the creation of complex, patient, and anatomic location-specific structures. More importantly, it has enabled the production of biomimetic scaffolds with porous structures that mimic the natural extracellular matrix while allowing for cell growth-a critical factor in determining the overall success of the BTR modality. While the concept of 3DP bioceramic bone tissue scaffolds for human applications is nascent, numerous studies have highlighted its potential in restoring both form and function of critically sized defects in a wide variety of translational models. In this review, we summarize these recent advancements and present a review of the engineering principles and methodologies that are vital for using 3DP technology for craniomaxillofacial reconstructive applications. Moreover, we highlight future advances in the field of dynamic 3D printed constructs via shape-memory effect, and comment on pharmacological manipulation and bioactive molecules required to treat a wider range of boney defects.