Faculty Bibliography

INTRODUCTION/BACKGROUND:Treacher Collins syndrome is a rare congenital disease characterized by the multiple craniofacial malformations. Although the deformities affecting patients with Treacher Collins syndrome have been well characterized, the effects of these malformations to clinical severity of the syndrome are not well understood. OBJECTIVE:To determine the association of specific Treacher Collins mandibular malformations with clinical severity. DESIGN/METHODS: SETTING/METHODS:Study conducted at a single institution, a quaternary craniofacial care center. PATIENTS/METHODS:54 patients with Treacher Collins syndrome. INTERVENTIONS/METHODS:Computed tomography (CT), clinical photographs and medical history were included in this analysis. Mandibles were isolated from CT data and reconstructed in three dimensions using Mimics software. Cephalometric measurements were performed on CT data. Clinical severity was determined by Teber and Vincent scores. Association of craniofacial dysmorphology to clinical severity was determined by Spearman rank coefficient. MAIN OUTCOME MEASURES/METHODS:The main results obtained were the measurements of the mandibles and the quantification of the malformations of the evaluated patients. RESULTS:Among the most frequent findings in the sample are hypoplasia of the zygomatic complex, descending palpebral cleft and mandibular hypoplasia. Patients with a lower ramus/corpus ratio had a higher (more severe) Teber and Vincent classification. CONCLUSION/CONCLUSIONS:Patients with the most compromised mandible are also the patients with the highest number of malformations, thus, the most severe patients.

To compare lower lip changes after Le Fort I advancement surgery in patients with a cleft. Single institution, retrospective review. Academic tertiary referral hospital. Skeletally mature patients with a cleft who underwent one-piece Le Fort I advancement surgery who had a lateral cephalogram or cone-beam computed tomography (CBCT) scan preoperatively and at least 6 months postoperatively. Patients who underwent concomitant mandibular surgery or genioplasty were excluded. 64 patients were included: 45 male and 19 female, 25 with BCLP and 39 with UCLP. The mean age at surgery was 18.4 years. Single jaw one-piece Le Fort I advancement surgery. Standard lateral cephalometric landmarks of the bony skeleton and soft tissue were compared before and after Le Fort I advancement. Pearson correlation coefficients (r) were calculated to measure the correlation between lower lip position and other soft and hard tissue changes. After comparable maxillary advancements [BCLP: 7.2 mm (95% CI: 6.2-8.3 mm), UCLP: 6.4 mm (95% CI: 5.7-7.0 mm)] the horizontal upper-to-lower lip discrepancy significantly improved in both groups. The lower lip became thinner and more posteriorly positioned. Changes in lower lip position correlated strongly with mandibular bony landmarks and moderately with upper lip position, but poorly with maxillary landmarks. Le Fort I advancement results in posterior displacement of the lower lip and better lip competence, thereby improving facial harmony. This lower lip change is not predictable by degree of maxillary advancement, and does not differ in patients with BCLP vs. UCLP.

Oral cancer patients suffer pain at the site of the cancer. Calcitonin gene related polypeptide (CGRP), a neuropeptide expressed by a subset of primary afferent neurons, promotes oral cancer growth. CGRP also mediates trigeminal pain (migraine) and neurogenic inflammation. The contribution of CGRP to oral cancer pain is investigated in the present study. The findings demonstrate that CGRP-immunoreactive (-ir) neurons and neurites innervate orthotopic oral cancer xenograft tumors in mice. Cancer increases anterograde transport of CGRP in axons innervating the tumor, supporting neurogenic secretion as the source of CGRP in the oral cancer microenvironment. CGRP antagonism reverses oral cancer nociception in preclinical oral cancer pain models. Single-cell RNA-sequencing is used to identify cell types in the cancer microenvironment expressing the CGRP receptor components, receptor activity modifying protein 1 Ramp1 and calcitonin receptor like receptor (CLR, encoded by Calcrl). Ramp1 and Calcrl transcripts are detected in cells expressing marker genes for Schwann cells, endothelial cells, fibroblasts and immune cells. Ramp1 and Calcrl transcripts are more frequently detected in cells expressing fibroblast and immune cell markers. This work identifies CGRP as mediator of oral cancer pain and suggests the antagonism of CGRP to alleviate oral cancer pain.

Background: Prophylactic nipple-sparing mastectomies (NSM) have become increasingly common, although there is little long-Term data on its efficacy in prevention of breast cancer. The objective of this study was to assess the incidence of breast cancer in a cohort of patients undergoing prophylactic NSM with a median follow-up of 10 years. Methods: Patients receiving prophylactic NSM at a single institution from 2006 to 2019 were included in a retrospective nature. Patient demographics, genetic mutations, operative details, and specimen pathology were recorded, and all postoperative patient visits and documentation were screened for cancer occurrence. Descriptive statics were performed where appropriate. Results: Two hundred eighty-four prophylactic NSMs were performed on 228 patients with a median follow-up of 120.5 ± 15.7 months. Roughly, a third of patients had a known genetic mutation, with 21% BRCA1 and 12% BRCA2. The majority (73%) of prophylactic specimens had no abnormal pathology. The most commonly observed pathologies were atypical lobular hyperplasia (10%) and ductal carcinoma in situ (7%). Cancer was identified in 10% of specimens, with only one case of lymphovascular invasion. Thus far, there have been no incidences of locoregional breast cancer occurrence in this cohort. Conclusions: The long-Term breast cancer occurrence rate in this cohort of prophylactic NSM patients at the time of this study is negligible. Despite this, continued surveillance of these patients is necessary until lifetime risk of occurrence following NSM has been established.

BACKGROUND:Nipple-sparing mastectomy is associated with a higher risk of mastectomy skin-flap necrosis than conventional skin-sparing mastectomy. There are limited prospective data examining modifiable intraoperative factors that contribute to skin-flap necrosis after nipple-sparing mastectomy. METHODS:Data on consecutive patients undergoing nipple-sparing mastectomy between April 2018 and December 2020 were recorded prospectively. Relevant intraoperative variables were documented by both breast and plastic surgeons at the time of surgery. The presence and extent of nipple and/or skin-flap necrosis was documented at the first postoperative visit. Necrosis treatment and outcome was documented at 8-10 weeks after surgery. The association of clinical and intraoperative variables with nipple and skin-flap necrosis was analysed, and significant variables were included in a multivariable logistic regression analysis with backward selection. RESULTS:Some 299 patients underwent 515 nipple-sparing mastectomies (54.8 per cent (282 of 515) prophylactic, 45.2 per cent therapeutic). Overall, 23.3 per cent of breasts (120 of 515) developed nipple or skin-flap necrosis; 45.8 per cent of these (55 of 120) had nipple necrosis only. Among 120 breasts with necrosis, 22.5 per cent had superficial, 60.8 per cent had partial, and 16.7 per cent had full-thickness necrosis. On multivariable logistic regression analysis, significant modifiable intraoperative predictors of necrosis included sacrificing the second intercostal perforator (P = 0.006), greater tissue expander fill volume (P < 0.001), and non-lateral inframammary fold incision placement (P = 0.003). CONCLUSION:Modifiable intraoperative factors that may decrease the likelihood of necrosis after nipple-sparing mastectomy include incision placement in the lateral inframammary fold, preserving the second intercostal perforating vessel, and minimizing tissue expander fill volume.

The benefits of tissue expansion go unrealized if flap design and coverage concepts do not exist in pre-operative thinking. Without proper analysis, the surgeon will likely burden the patient with more expanders than necessary. Tissue coverage needs can be simplified in forms of triangles and rectangles to determine expanded tissue advancement. Single or double back cuts allow usage of all the expanded tissue. Furthermore, early subtotal excisions, especially in children less than four months old, can reduce the number of expanders required. With methods presented herein, the face can be resurfaced with better color and less distortion. Eyebrows should be maintained and positioned by keeping the lower frontalis muscles intact. Cheeks can be covered with a large "Schrudde" design and color can be improved by using upper neck skin preferentially over lower neck harvest. Laser hair removal allows larger swaths of forehead to be covered by hair-bearing scalp tissue. Prior incisional delay can expedite success with no tissue loss. The results speak for themselves when surfaces are covered with large, expanded flaps which are expeditiously harvested.

BACKGROUND:Implant-based reconstruction remains the most common form of postmastectomy breast reconstruction. With ever-evolving device characteristics, including the advent of high-profile, cohesive, fifth-generation implants, the incidence of anterior-posterior flipping of implants is presenting a new challenge. Patient and device characteristics associated with this phenomenon have yet to be fully elucidated. METHODS:Patients who underwent nipple- or skin-sparing mastectomy with subsequent 2-stage or direct-to-implant reconstruction with smooth implants between 2015 and 2021 were retrospectively identified and stratified by incidence of implant flipping. Patient, procedural, and device characteristics were evaluated. RESULTS:Within 165 patients (255 reconstructed breasts), 14 cases of implant flipping were identified (flip rate 5.5%). All flips occurred in patients with cohesive implants (odds ratio [OR], 87.0; P = 0.002). On univariate analysis, extra full implant profile (OR, 11.2; P < 0.001) and use of a smooth tissue expander for 2-stage reconstruction (OR, 4.1; P = 0.03) were associated with flipping. Implants that flipped were larger than those that did not (652.5 ± 117.8 vs 540.1 ± 171.0 mL, P = 0.0004). Prepectoral implant placement (OR, 2.7; P = 0.08) and direct-to-implant method (OR, 3.17; P = 0.07) trended toward association, but this effect was not significant. Patient BMI, weight fluctuation during the reconstructive course, mastectomy weight, AlloDerm use, and history of seroma or periprosthetic infection were not associated with flipping. CONCLUSION:Patients who receive a highly cohesive, high profile, larger implant are at increased risk for implant flipping. In addition, patients who receive a smooth tissue expander are more likely to experience flipping of their subsequent implant, compared with those who had textured tissue expanders. These characteristics warrant consideration during device selection to minimize discomfort, aesthetic deformity, and the need for reoperation.

BACKGROUND:Racial disparities in American healthcare contribute to worse outcomes among minority patients. Minority patients undergoing breast reconstruction are more likely to report dissatisfaction with their reconstruction process as compared with White patients, yet there is limited research exploring contributory factors. This study investigates which process-of-care, clinical, and surgical variables are most strongly correlated with Black and Hispanic patients' reported satisfaction. METHODS:A retrospective review of all patients who underwent postmastectomy breast reconstruction at a single academic center from 2015 to 2021 was performed. Patients were included for analysis if they identified as Black or Hispanic and completed preoperative, less than 1-year postoperative, and 1- to 3-year postoperative BREAST-Q surveys. At both postoperative time points, the association between satisfaction with outcome and surgeon and selected independent variables was determined using regression analysis. RESULTS:One hundred eighteen Black and Hispanic patients were included for analysis, with average age 49.59 ± 9.51 years and body mass index 30.11 ± 5.00 kg/m2. In the multivariate model for predicting satisfaction with outcome, only satisfaction with preoperative information (P < 0.001) was a statistically significant predictor during early and late postoperative evaluations. For predicting satisfaction with surgeon, satisfaction with information (P < 0.001) remained a significant predictor in the early and late postoperative evaluations, with lower body mass index as an additionally significant predictor during the late postoperative period. CONCLUSIONS:Patient satisfaction with preoperative information received is the single most significant factor associated with Black and Hispanic patient satisfaction with outcome and plastic surgeon. This finding encourages further research on effective and culturally inclusive information delivery so as to both improve patient satisfaction and reduce healthcare disparities.