Faculty Bibliography

OBJECTIVES/OBJECTIVE:To determine the relationships between the number and class of xerogenic medications on whole stimulated salivary flow rates and oral health-related quality of life (OH-QOL) measures in patients who received high-dose external beam radiation therapy (RT) for head and neck cancer (HNC). STUDY DESIGN/METHODS:Complete medication lists were generated using patient electronic health records from every attended study visit for 146 HNC patients. Whole stimulated salivary flow was measured before RT, and 6 and 18-months after RT. Ten single-item questions and two composite scales of swallowing problems and senses problems (taste and smell) were assessed at baseline and at 6-month intervals up to 24 months after RT. Linear mixed-effects models examined associations between the total number and class of medications and stimulated salivary flow and OH-QOL. RESULTS:There was no detected association between the total number of medications and stimulated salivary flow (p-value = .18). Only antidepressant usage was significantly associated with stimulated salivary flow (P = .006). Number of medications, narcotic analgesic, and antidepressant usage were significantly associated with a clinically meaningful decrease in OH-QOL. CONCLUSION/CONCLUSIONS:Antidepressants were associated with reduced stimulated salivary flow, but no cumulative negative effect on whole stimulated salivary flow was identified. Polypharmacy was associated with worse OH-QOL.

BACKGROUND:The gracilis flap is a versatile muscle flap that can be utilized as a muscle only or myocutaneous flap for soft tissue coverage, as well as for reconstruction of facial animation or extremity function. Few studies have compared donor site complications of free and pedicled gracilis flaps, including the effect of skin paddle harvest on donor site morbidity. METHODS:We performed a retrospective review of patients who underwent a free or pedicled gracilis flap at our institution from 2013-2023. Gracilis flaps were categorized as: pedicled gracilis muscle flaps used for vaginectomy in gender reaffirming surgery, free gracilis muscle flaps, and free gracilis myocutaneous flaps. Outcome variables were duration of drain placement and complications including seroma, hematoma, infection, dehiscence, and persistent numbness. RESULTS:We identified 128 gracilis flaps including 19 free myocutaneous flaps, 35 free muscle flaps, and 74 pedicled muscle flaps. Free myocutaneous flaps required longer drain placement as compared to free muscle flaps or pedicled flaps (13.6 vs 8.4 vs 7.4 days, respectively, p=0.002). Free myocutaneous flaps displayed a higher complication rate (36.8%) as compared to pedicled muscle flaps (10.8%), or free muscle flaps (11.4%, p=0.020). After adjusting for age, BMI, and ASA status, free myocutaneous flaps demonstrated higher odds of major donor site complication as compared to pedicled muscle flaps (OR 1.23, p<0.001), while free muscle flaps were not associated with increased odds of major complication (OR 1.08, p=0.117). Of the documented complications, the most common were surgical site infection (36.8%), hematoma (21.1%) and seroma (21.1%). CONCLUSION/CONCLUSIONS:The inclusion of a skin paddle during gracilis flap harvest is associated with increased duration of drain placement and donor site complications including surgical site infection, hematoma, and seroma. These factors should be carefully considered in the context of patients' reconstructive needs and other risk factors.

Presurgical lip, alveolus, and nose approximation (PLANA) is a novel form of presurgical infant orthopedics (PSIO) designed without an intraoral molding plate. While early studies on PLANA have demonstrated improvements in nasolabial morphology, its impact on infant feeding and weight gain has not been assessed. A single-institution, retrospective review of all patients with cleft lip and palate (CL±P) treated with PLANA over a 1-year period was therefore performed. Weight values at baseline and at surgery were compared with World Health Organization (WHO) Child Growth Standards, and weight-for-age z-scores (WAZ) as well as changes in weight-for-age z-scores (WAZ) were obtained. A cohort of patients who underwent PSIO with NasoAlveolar Molding (NAM) was evaluated as a reference group. The PLANA (n=19) and NAM (n=25) groups were comparable in age (15.63 versus 21.16 d, P=0.2), weight (3.38 versus 3.50 kg, P=0.2), and WAZ (-0.80 versus -0.94, P=0.8) at baseline, and in age (103.11 versus 113.04 d, P=0.06), weight (5.82 versus 5.68 kg, P=0.3), and WAZ (-0.92 versus -1.47, P=0.2) at surgery. Both groups had similar weight gain (2.44 versus 2.18 kg, P=0.1) and WAZ (-0.12 versus -0.53, P=0.2). The PLANA group exhibited statistically significant greater daily weight gain (0.028 versus 0.024 kg/d, P=0.04). None of the patients experienced surgical delays due to insufficient weight gain. PLANA did not interfere with presurgical weight gain in infants with CL±P.

Orthognathic surgery requires precise manipulation of skeletal structures in close proximity to highly sensitive nerve, vascular, and airway anatomy. Rare iatrogenic injuries including hemorrhage and neurovascular compromise are reported and can have devastating sequelae including stroke, blindness, and death. Established technologies have primarily focused on positional accuracy rather than enhancing patient safety. This review investigates the adoption of intraoperative navigation in orthognathic surgery to reduce the risk of iatrogenic complications. Following PRISMA guidelines, a systematic search of PubMed, Embase, Web of Science, and Cochrane Library was conducted to identify original studies reporting on the application and outcomes of intraoperative navigation in orthognathic surgery. Data were extracted on indications, surgical procedures, navigation technologies, primary purpose for use, and outcomes. Thirty studies met inclusion criteria, and most were published after 2015 (63.3%). The majority (96.7%) used navigation to enhance accuracy of skeletal segment positioning; only 6.7% of studies reported use of intraoperative navigation to identify and avoid critical anatomic structures. BrainLab systems were most frequently used (40.0%), followed by Stryker (13.3%) and Aurora/Northern Digital Inc. (10.0%). Extensive evidence across multiple surgical specialties validates the efficacy of intraoperative navigation in reducing injury to critical structures and in limiting blood loss, operative time, and reoperation rates. Current literature supports intraoperative navigation as a highly accurate modality for orthognathic surgery but rarely addresses its potential to mitigate severe iatrogenic complications. Evidence from other surgical disciplines substantiates its role in enhancing safety, underscoring the need for high-level studies focused on complication prevention in orthognathic surgery.

Several biologic and synthetic adjuncts have been employed to reduce ptosis and improve cosmesis in breast surgery. Poly-4-hydroxybutyrate (P4HB), a fully absorbable polymer, continues to increase in use. This study sought to identify uses of P4HB in both reconstructive and aesthetic breast surgery and synthesize the available data on its outcomes and efficacy. A literature search was performed from inception to May 2024 following PRISMA in PubMed (MEDLINE), EMBASE, and Cochrane databases. Two independent reviewers screened the studies for eligibility. Bibliographies and citing references from selected articles from Scopus (Elsevier) were also reviewed. The search identified 372 studies, with 16 articles included. All prospective and retrospective case series utilizing P4HB reported high rates of patient satisfaction and scaffold incorporation as well as low complication rates including recurrent ptosis, implant malposition, and capsular contracture. One retrospective cohort study reported significantly higher rates of capsular contracture with use of P4HB sling in dual-plane, two-stage breast reconstruction. No other studies reported significantly higher rates of capsular contracture with P4HB and no other significant differences in complication rates were noted. Two animal studies exploring the use of P4HB in nipple reconstruction reported that P4HB promoted the growth of fibrovascular tissue with higher rates of nipple projection with respect to control. This study supports P4HB as a safe and efficacious adjunct in a variety of indications. Large-scale, randomized trials between P4HB and other types of soft-tissue support are needed to further delineate the above trends.

OBJECTIVE:To describes our institutional experience of a case series using a novel multi-segment, chimeric free ileal flap for posterior urethral reconstruction, focusing on surgical technique, perioperative management, and functional outcomes. Complex posterior urethral defects, particularly those resulting from radiation pose a significant reconstructive challenge that is not easily approachable with standard reconstructive techniques. In this case series, we present a novel approach for this complex problem. METHODS:We retrospectively reviewed consecutive patients who underwent posterior urethral reconstruction with a chimeric free ileal flap at our institution. Data were collected via chart review. RESULTS:Six male patients (median age: 61 years range: 59-77) with radiation-associated posterior urethral stenosis and bladder neck pathology underwent reconstruction. One was an active smoker; three had prior failed reconstructions. A 20-cm ileal segment was harvested and designed into a chimeric construct in all cases. The left deep inferior epigastric vessels were used for flap anastomosis. Median operative time was 717 minutes, and median hospital stay was 9 days. Two patients experienced early postoperative complications; none had flap loss. At median follow-up of 204 days, four patients had successful functional outcomes. One had persistent leak, and one required cystectomy for newly diagnosed squamous cell carcinoma found at the bladder neck on final pathology. CONCLUSIONS:Chimeric free ileal flap reconstruction is a novel management option for radiation-associated posterior urethral defects, offering well-vascularized, versatile tissue in patients unsuitable for traditional approaches. However, this approach is complex that requires multidisciplinary collaboration and extensive surgical planning.

Although many internalized G protein-coupled receptors (GPCRs) continue to signal, the mechanisms and outcomes of intracellular GPCR signaling are uncertain due to the challenges of measuring organelle-specific signals and of selectively antagonizing receptors in intracellular compartments. Herein, genetically encoded biosensors targeted to the plasma membrane and early endosomes were used to analyze compartmentalized signaling of protease-activated receptor 2 (PAR₂); the propensity of nanoparticles (NPs) to accumulate in endosomes was leveraged to preferentially antagonize intracellular PAR₂ signaling of pain. PAR₂ agonists evoked sustained activation of PAR₂, Gαq, and β-arrestin-1 in early endosomes and activated extracellular signal regulated kinase (ERK) in the cytosol and nucleus, measured with targeted biosensors. Fluorescent dendrimer and core-shell polymeric NPs accumulated in endosomes of HEK293T cells, colonic epithelial cells, and nociceptors, detected by confocal microscopy. NPs efficiently encapsulated and slowly released AZ3451, a negative allosteric PAR₂ modulator. NP-encapsulated AZ3451, but not unencapsulated AZ3451, rapidly and completely reversed PAR₂, Gαq, and β-arrestin-1 activation in early endosomes and ERK activation in the cytosol and nucleus. When administered into the mouse colon lumen, fluorescent dendrimer NPs accumulated in endosomes of colonocytes and polymeric NPs accumulated in neurons, sites of PAR₂ expression. Both NP formulations of AZ3451, but not unencapsulated AZ3451, caused long-lasting analgesia and normalized aberrant behavior in preclinical models of inflammatory bowel disease. These results provide evidence that PAR₂ endosomal signaling mediates pain and that nanomedicines that antagonize PAR₂ in endosomes effectively relieve pain. NP-mediated delivery may improve the efficacy of other GPCR antagonists for treatment of diverse diseases.

Simultaneous rhytidectomy and laser resurfacing has become a common single-stage facial rejuvenation technique. However, concerns remain, particularly with photothermal injury to undermined tissue. This is the first methodologically robust systematic review and meta-analysis to evaluate the safety, satisfaction, and predictors of outcomes for this dual-modality procedure. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines, a systematic review was conducted through April 2025. Data extracted included patient satisfaction, postoperative complications, and covariates for meta-regression. Seventeen studies comprising 1,361 patients were included. The pooled patient satisfaction rate was 98.1%. Complications were rare: full-thickness flap necrosis (0.01%), skin slough (0.21%), secondary superficial infections (0.74%), hypertrophic scarring (0.51%), hematoma (0.35%), ectropion (0.12%), nontransient dyspigmentation (0.35%), contour irregularity (0.04%), and delayed reepithelialization (0.03%). Meta-regression demonstrated that lasering in areas undermined in the facelift dissection at the same energy density as non-dissected regions of the face was significantly associated with higher skin slough rates. Superficial musculoaponeurotic system manipulation and biplanar rhytidectomy techniques were more likely to result in nontransient dyspigmentation compared to endoscopic subperiosteal techniques. Additionally, lasering undermined flaps with multiple different techniques was associated with higher rates of nontransient dyspigmentation. Procedures performed by plastic surgeons were also associated with lower rates of hypertrophic scarring compared to dermatologists. Concomitant rhytidectomy and laser resurfacing appears safe with high patient satisfaction when laser and surgical technique are optimized. Identification of modifiable risk factors provides guidance to reduce complications and improve outcomes.

Osseointegration is critical for the long-term success of endosteal implants, as it is influenced by factors such as implant design, material selection, and site of implantation. Considering the structural and vascular properties of trabecular bone, it is reasonable to hypothesize that osseointegration could be enhanced in this region. However, emerging evidence indicates that cortical bone frequently offers a more favorable environment for osseointegration. The objective was to conduct a systematic review of preclinical translational studies comparing osseointegration outcomes around implants placed in cortical and trabecular bone. Preclinical studies comparing bone-to-implant contact (BIC) and bone area fraction occupied (BAFO) between cortical and trabecular regions in animals with solid endosteal implants were retrieved from the PubMed, EMBASE, and Cochrane databases. We included randomized and nonrandomized preclinical translational trials published in English between 2014 and 2024 that reported at least one outcome of interest. Exclusion criteria comprised in vitro or ex vivo experiments, research involving human subjects, studies using powder, liquid, or plasma implants, abstracts, technical descriptions, and narrative or systematic reviews. The systematic review comprised 15 studies, which included a total of 298 animals and 877 implants. The mean follow-up period ranged between 4 and 17 weeks. In 13 studies, the cortical bone region demonstrated higher BIC values, with differences in BIC between cortical and trabecular bone ranging from 5.55% to 49.55% during the first 4 weeks, 1.80% to 51.30% between 4 and 8 weeks, and 9.65% to 35.41% following the 8-week healing period. Regarding BAFO values, data were reported in three studies, all of which indicated elevated values in cortical bone. The mean difference in the first 4 weeks ranged from 15.83% to 29.92%, and from 26.33% to 60.11% after 4 weeks of healing. These findings suggest that cortical regions exhibit enhanced short- and long-term osseointegration outcomes compared to trabecular bone regions. Impact Statement The specific site of implantation significantly influences the degree and rate of osseointegration. Trabecular bone, characterized by its high porosity and larger surface area relative to volume, facilitates the diffusion of nutrients and oxygen from the surrounding marrow and blood vessels. Nevertheless, emerging evidence indicates that cortical bone, due to its greater density and superior mechanical properties, often provides a more stable environment for osseointegration compared to trabecular bone. This systematic review of preclinical studies represents the first comprehensive effort to evaluate and compare osseointegration in cortical versus trabecular bone.