Faculty Bibliography

BACKGROUND:The social determinants of health (SDOH) are the conditions in which people are born, grow, work, live, and age. Lack of SDOH training of dental providers on SDOH may result in suboptimal care provided to pediatric dental patients and their families. The purpose of this pilot study is to report the feasibility and acceptability of SDOH screening and referral by pediatric dentistry residents and faculty in the dental clinics of Family Health Centers at NYU Langone (FHC), a Federally Qualified Health Center (FQHC) network in Brooklyn, NY, USA. METHODS:Guided by the Implementation Outcomes Framework, 15 pediatric dentists and 40 pediatric dental patient-parent/guardian dyads who visited FHC in 2020-2021 for recall or treatment appointments participated in this study. The a priori feasibility and acceptability criteria for these outcomes were that after completing the Parent Adversity Scale (a validated SDOH screening tool), ≥ 80% of the participating parents/guardians would feel comfortable completing SDOH screening and referral at the dental clinic (acceptable), and ≥ 80% of the participating parents/guardians who endorsed SDOH needs would be successfully referred to an assigned counselor at the Family Support Center (feasible). RESULTS:The most prevalent SDOH needs endorsed were worried within the past year that food would run out before had money to buy more (45.0%) and would like classes to learn English, read better, or obtain a high school degree (45.0%). Post-intervention, 83.9% of the participating parents/guardians who expressed an SDOH need were successfully referred to an assigned counselor at the Family Support Center for follow-up, and 95.0% of the participating parents/guardians felt comfortable completing the questionnaire at the dental clinic, surpassing the a priori feasibility and acceptability criteria, respectively. Furthermore, while most (80.0%) of the participating dental providers reported being trained in SDOH, only one-third (33.3%) usually or always assess SDOH for their pediatric dental patients, and most (53.8%) felt minimally comfortable discussing challenges faced by pediatric dental patient families and referring patients to resources in the community. CONCLUSIONS:This study provides novel evidence of the feasibility and acceptability of SDOH screening and referral by dentists in the pediatric dental clinics of an FQHC network.

BACKGROUND:In July of 2019, the Food and Drug Administration (FDA) recalled the Allergan Natrelle® 410 Highly Cohesive Anatomically Shaped Silicone-Filled Textured Breast Implants (Allergan, Santa Barbara, CA) because of a heightened risk of developing breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). The objective of this study was to describe patient decision-making in management of preexisting 410 textured implants. METHODS:A single-institution retrospective chart review was conducted to determine all patients who received 410 anatomic implants from two surgeons. Patients who received these implants were contacted in July-September of 2019 regarding the FDA recall and requested to schedule a consultation to discuss explant/exchange versus surveillance. Outcomes analyzed included decision of surveillance versus explanation and subsequent reconstructive operations. RESULTS:89 patients had received 410 implants from 2013-2017. Of the 147 breasts that were reconstructed, 58.5% were oncologic mastectomies and 41.5% were prophylactic. The majority of patients (71.9%) cited BIA-ALCL as the predominant influencing factor in their decision for management. Others factors included cosmesis, implant concerns unrelated to BIA-ALCL, and other medical conditions. 20 (22.5%) patients underwent explantation of the Style 410 implants. The remaining 77.5% of patients have elected for monitored surveillance. There was a significant association between a history of breast cancer and explantation of the Style 410 implants (p=0.0335). CONCLUSIONS:The majority of patients with Style 410 textured implants elected to undergo surveillance for BIA-ALCL. When deciding to explant or exchange the Style 410 implants, plastic surgeons should work in conjunction with their patients to carefully outline management options.

BACKGROUND:Reduction mammaplasty is a safe, effective procedure to alleviate symptoms of adolescent macromastia. However, there remains limited data on surgical complications associated with reduction mammaplasty in adolescents, which may not be concordant with those cited for adults seeking reduction mammaplasty. METHODS:A retrospective review was conducted of all consecutively performed reduction mammaplasty cases for symptomatic macromastia in patients aged 20 years old and younger over a seven-year period from 2014 to 2021. RESULTS:One hundred sixty total breasts were analyzed in 80 patients. Mean age was 18.3±1.4 years with an age range from 15 to 20 years old. Mean BMI was 27.17±5.49. Mean reduction weight was 584.79±261.19 grams. A medial pedicle was used in 91%, and inferior pedicle in 9%. For skin incision, Wise pattern was used in 60%, and short-scar in 40%. There was a 16.3% rate of any surgical complication, which included wound healing by secondary intention treated with local wound care. There were no significant risk factors for a surgical complication in reduction mammaplasty, and no differences in surgical complications related to skin incision type, pedicle use, or breast reduction weight. Performance of a ROC curve for age at surgery and complication demonstrated that there was no age cut-off where the risk of surgical complication was appreciably increased or decreased. CONCLUSION/CONCLUSIONS:Age was not identified as a risk factor for surgical complications in adolescent reduction mammaplasty. Overall, complication rates are very low and minor in nature for adolescent reduction mammaplasty with no significant risk factors identified.

The transpalpebral "eyelid" approach is an innovative alternative to the traditional incisions for exposure of the anterior cranial fossa for neurosurgery. Yet, there is a paucity of data on such a surgical technique in the plastic surgery literature for accessing the anterior cranial fossa. A retrospective review was performed of patients who underwent supraorbital frontal craniotomy using an anterior skull base approach with transpalpebral exposure over eight years by a single plastic surgeon (D.A.S.). Surgical techniques, medical co-morbidities, intra-operative complications, and long-term complications were assessed. Twenty patients (mean age 52±12 years, 55% male, 45% female) underwent supraorbital frontal craniotomy using an anterior skull base approach with upper transpalpebral exposure. Operative indications included: 75% had anterior communicating aneurysms with a mean aneurysm size of 5.36±1.91 mm, 10% had meningiomas, 10% had dural fistulas, and 5% had an orbital hemangioma. Notably, 60% had a smoking history. No intra-operative complications were encountered, and no cases required conversion to a traditional open approach. Mean length of hospital stay was 3.2±1.5 days. Post-operative imaging revealed no residual or recurrent pathology. Mean follow up time was 62.2±30.6 months. No long-term neurological or ophthalmologic complications or infections occurred. No forehead paresthesias, and no brow ptosis or brow paralysis were noted. The transpalpebral technique is an excellent, minimally invasive alternative to approach lesions of the anterior cranial fossa. Successful application may require appropriate management of the frontal sinus and supraorbital nerve. As described, this approach does not limit neurosurgical access or results, and led to no neurosurgical complications.

BACKGROUND:Relative value units (RVUs) are broadly used for billing and physician compensation; however, the accuracy of RVU assignments has not been scientifically evaluated for craniofacial surgery. The authors hypothesize that unbalanced RVU allocation creates inappropriate disparities in value among procedures performed by cleft and craniofacial surgeons. METHODS:The National Surgical Quality Improvement Program Pediatric database was queried to identify all cleft and craniofacial surgery cases performed by plastic surgeons from 2012 to 2019 based on CPT code. Microsurgical cases and CPT codes with a case count of fewer than 10 were excluded. Efficiency was defined as total RVUs divided by total operative time (ie, RVUs/hour). Mean efficiency per CPT code was ranked and compared by quartile using t tests. RESULTS:The sample consisted of 69 CPT codes with 50,450 cases. In the top quartile, most CPT codes were craniofacial procedures including frontofacial procedures (23.53%) and craniectomies for craniosynostosis or bony lesions (35.29%) (mean, 15.65 ± 4.22 RVUs/hour). The lowest quartile was composed mainly of CPT codes for cleft procedures including operations for velopharyngeal insufficiency (17.65%), cleft palate repair (23.53%), and cleft septoplasty (5.88%) (mean, 7.39 ± 0.98 RVUs/hour; P < 0.001). It was 2.5 times more efficient for a cleft and craniofacial surgeon to perform a local skin flap (15.18 RVUs/hour) than a secondary palatal lengthening for cleft palate (6.09 RVUs/hour). CONCLUSIONS:The current RVU allocation to cleft and craniofacial procedures creates arbitrary disparities in physician efficiency, with cleft procedures disproportionately negatively affected. RVU assignments should be reevaluated to avoid disincentivizing cleft surgical care.

Background: Cephalic index (CI) is an objective measure of head shape used by craniofacial surgeons to support a diagnosis of head shape abnormality. However, the consensus on what values correspond to a normal head shape are changing following the Back to Sleep campaign. Recent work has shown an increase in mean CI from 74 to 84. Following this shift, no study has been undertaken to evaluate whether the perception of normal head shape has changed as well. Methods: About 1020 subjects, 18 or older, were recruited through Amazon Turk crowdsourcing platform. Subjects were asked to select the head shapes they considered most normal in a series of questions identifying ideal head shape in children 6 months or younger. Demographic information was recorded for study participants to identify differing ethnic perceptions of head shape. Results: The mean cephalic index preferred by a crowdsourced population was 81.84 (SD 2.48). There was a difference in mean preferred CI between people who identified as black (CI = 82.875) and people who identified as white (CI = 81.500; P =.00062). There was no difference in mean preferred CI between males and females. Education level, age healthcare occupation status, medical literacy, and work involving children did not affect preference. Conclusions: The typical head shape has changed following the Back to Sleep campaign and the current perception of head shape aligns with the newly described norm as opposed to the historic population data. Criteria for intervention and outcome goals should be adjusted accordingly.