Faculty Bibliography

Introduction: Vascularized composite allotransplantation has redefined the frontiers of plastic and reconstructive surgery. The field has seen considerable advancement since its inception, with the first successful hand transplant in 1998 and the first partial face transplant in 2005. To date, over 40 bilateral hand transplants have been reported in the literature, along with 47 face transplants. Due to still limited available evidence and the heterogeneity of the sample population, little consensus exists on the anticipated timeline of functional recovery following vascularized composite allotransplantation. We hereby report on the early and accelerated functional recovery of a combined face and bilateral hand transplant recipient.
Method(s): A 21-year-old male was referred with sequelae of an 80% total body surface area burn sustained in a motor vehicle accident 1 year prior. The patient had extensive facial and bilateral upper extremity injuries. Serial debridement and split thickness skin grafting procedures left the patient with proximal digital syndactyly and distal digit amputations. Procurement and transplantation of the face and upper extremities was performed over a 23-h period in August of 2020. Postoperative functional assessment at predetermined time points included active range of motion, grip strength, sensory assessment, Carroll's Upper Extremity Function test, and the Disabilities of the Arm, Shoulder, and Hand questionnaire.
Result(s): Functional assessments were performed at 3 and 6 months post-transplant. Range of motion, grip strength, Carroll's test scores (left = 58 at 6 months post-transplant vs 13 pre-transplant, right = 61 at 6 months post-transplant vs 20 pre-transplant) and Disabilities of the Arm, Shoulder, and Hand evaluation (37 at 6 months post-transplant vs 90 pretransplant) showed substantial improvement. The patient remained rejection-free during the first 9 months post-transplant and has had steady and progressive functional improvement. He is highly motivated and consistently demonstrates functional independence in activities of daily living.
Conclusion(s): Combined face and bilateral hand transplant is a feasible, comprehensive reconstructive solution for composite face and bilateral hand injury in the appropriately selected recipient. Patient motivation, psychosocial support, intensive physical and occupational therapy, and vigilant clinical and immunologic surveillance are essential features of postoperative recovery

BACKGROUND/UNASSIGNED:The use of low-temperature plasma (LTP) is a novel approach to treating peri-implantitis. LTP disrupts the biofilm while conditioning the surrounding host environment for bone growth around the infected implant. The main objective of this study was to evaluate the antimicrobial properties of LTP on newly formed (24 h), intermediate (3 days), and mature (7 days) peri-implant-related biofilms formed on titanium surfaces. METHODS/UNASSIGNED: RESULTS/UNASSIGNED:≤ 0.016), and CLSM corroborated these results. CONCLUSION/UNASSIGNED:.

PURPOSE/OBJECTIVE:blasting + maleic + HCl) in a large translational animal model at 3 and 6 weeks in vivo. MATERIALS AND METHODS/METHODS:Nine female sheep were used, and 72 implants with trapezoidal threads and decompressing vertical chambers of 0.6 mm in diameter and 0.2 mm in depth were placed in the ilium crest. After 3 and 6 weeks, the animals were euthanized, and biomechanical and histomophometric analyses were performed. RESULTS:Survey histologic evaluation indicated intimate contact between the bone and the implants independent of surface treatment at both times in vivo. Bone formation at both time points depicted an intramembranous-type healing pattern between the implant threads. The mean removal torque values for all groups showed a relative increase in removal torque from 3 to 6 weeks. In terms of bone area fraction occupancy analysis, significant differences were found at 6 weeks between surface treatments (P = .046), where the experimental surface yielded higher degrees of bone area fraction occupancy. CONCLUSION/CONCLUSIONS:Conical implants with decompressing vertical chambers between threads presented similar osseointegration parameters regarding bone-toimplant contact and torque-out test values irrespective of surface treatment. However, shifting from a minimally rough to a moderately rough surface (experimental surface with supplemental acid-etching) resulted in significantly improved bone area fraction occupancy at 6 weeks.

Background/Purpose: Pediatric mandibular fractures remain a therapeutic challenge due to the presence of tooth buds, the need to preserve the growth centers of the jaw, and the high risk to ankylosis in patients with trauma to the condyles. More specifically, condylar fracture with lateral dislocation out of the temporomandibular joint (TMJ) can pose significant challenges due to the difficulty with application of maxillomandibular fixation (MMF) as well as rigid plate fixation. Furthermore, open reduction of the condyle poses long term risk to dysfunction. Herein, we present a novel transfacial pinning surgical technique for the management of pediatric bilateral condylar fractures with lateral dislocation and concomitant symphyseal fracture in a patient less than 5 years of age. Methods/Description: A healthy 3-year-old male patient, who sustained a complex facial fracture in a golf cart accident in which he was unrestrained. Physical exam was remarkable for panfacial edema with no soft tissue injuries and limited oral excursion. Craniofacial computed tomography (CT) revealed a tripartite mandibular fracture, including bilateral condylar fractures with lateral dislocation of the left condyle and a symphyseal fracture. There were no other facial fractures and the patient's cervical spine was cleared both clinically and radiographically. The deciduous teeth precluded the use of traditional MMF and the presence of tooth buds within the entirely of the mandibular body and symphysis made the use of rigid fixation not feasible. The operative plan entailed a staged lower jaw reconstruction with: closed reduction of the laterally dislocated condyle; transfacial pinning with a 2.8 mm threaded Steinman pin between the mandibular angles to secure the medial location mandibular ramus and angle; application of MMF using circummandibular wiring and intermaxillary fixation screws. Two weeks later, MMF was released and the patient started a soft diet and oral excursion exercises with the transfacial pin in place. Two months after the first surgery, the transfacial pin was removed.
Result(s): The patient tolerated all procedures well. Immediate postoperative CT taken after placement of the transfacial pin (first surgery) revealed appropriate reduction of the laterally displaced condyle. At the time of transfacial pin removal (8 weeks after the initial repair), the patient demonstrated full and pain free oral excursion and stable class I occlusion. Follow-up CT analysis after removal of the transfacial pin demonstrates a stable reduction of the dislocated condyle and bony union of all three fractures.
Conclusion(s): Transfacial pinning technique can be a safe and effective technique for treatment of pediatric mandible fractures with lateral dislocation of the condyle

Glass ceramics' fractures in zirconia fixed dental prosthesis (FDP) remains a clinical challenge since it has higher fracture rates than the gold standard, metal ceramic FDP. Nanoindentation has been shown a reliable tool to determine residual stress of ceramic systems, which can ultimately correlate to failure-proneness.

Background/Purpose: Nasoalveolar molding (NAM) in combination with primary gingivoperiosteoplasty (GPP) may obviate the need for a secondary alveolar bone graft. While the long-term facial growth following GPP has been well documented, no study has evaluated the transverse growth of the cleft-maxilla following NAM and GPP. Here we report the effects of NAM and GPP on the maxillary transverse dimension in patients with complete unilateral cleft lip and palate (UCLP). Methods/Description: A retrospective single-institution review of nonsyndromic patients with complete unilateral cleft lip and palate born between 2005 and 2010 was completed. Patients were divided into four groups based on their interventions: 1) NAM-GPP with adequate bone formation 2) NAM-GPP without adequate bone formation (requiring ABG) 3) NAM-no GPP (requiring ABG), and 4) No NAM-no GPP control (patients who received primary surgeries outside of our institution). Cone-beam computed tomographic scans (CBCTs) taken at the early-mixed dentition stage, prior to orthodontic intervention, were used to assess the anterior and posterior maxillary transverse dimensions. The transverse discrepancy at the affected and non-affected sides was measured at the level of the primary canines (anterior dimension) and the permanent first molars (posterior dimension) to the maxillary midline. Wilcoxon signed-rank tests were used to compare the transverse dimension of the affected versus non-affected sides within each group. Mann-Whitney U tests were used to compare each NAM group with the no NAM-no GPP control group.
Result(s): A total of 85 patients were included in this study (mean age = 8.7). Male patients (50.6%) and the left side (64.7%) were most affected. Of the 85 patients, 26 (30.6%) underwent NAM-GPP with adequate bone formation, 22 (25.9%) underwent NAM-GPP but required ABG, 16 (18.8%) underwent NAM without GPP, and 21 (24.7%) underwent no NAM-no GPP. Median values were significantly different in the anterior maxilla between the affected and nonaffected sides across all four groups (p = 0.001). The transverse dimension at the affected side also revealed a significant difference in both the NAM-GPP (with adequate bone formation) and the NAM-GPP (requiring ABG) groups compared to the no NAM-no GPP group (p= 0.022 and p= 0.001, respectively). There was no significant difference between the NAM-no GPP group compared to the control (p = 0.059). Distances to the molars of the affected and nonaffected sides were not statistically significant within or across any of the groups (p > 0.05).
Conclusion(s): In patients with UCLP, the maxillary primary canine transverse dimension on the affected side is significantly reduced in patients undergoing NAM and GPP compared to the control. However, the position of the maxillary first molars appear to be unaffected by NAM and GPP

Background/Purpose: The relative value unit (RVU) is a metric established by Medicare to quantify physician time and intensity required to furnish a surgical service, and is broadly used for the purposes of billing and physician compensation. Despite widespread use since the 1990s, the accuracy of RVU assignments has not been scientifically evaluated for cleft and craniofacial surgery. We hypothesize that unbalanced RVU allocation creates inappropriate disparities in value amongst procedures performed by cleft and craniofacial surgeons. Methods/Description: The American College of Surgeons Pediatric National Surgical Quality Improvement Program (NSQIP) database was queried to identify all cleft and craniofacial surgery cases performed by plastic surgeons from 2012-2019 based on Current Procedural Terminology (CPT) code. Microsurgical cases and CPT codes with a case count of fewer than 10 were excluded. Total RVUs per case were calculated based on the sum of work RVUs for the principal procedure, and any other procedure that was performed during the case. Efficiency was defined as total RVUs divided by total operative time (i.e. RVUs/hour), based on previously published methodology. Mean efficiency per CPT code was ranked and compared by quartile using Student's t-tests.
Result(s): The sample consisted of 69 CPT codes with a total of 50,450 cases. The most common procedure was cleft palate repair of the soft and/or hard palate (CPT 42200). The mean efficiency for the top quartile of CPT codes was 15.65+/-4.22 (range 12.05-26.56) RVUs/hour, compared to 7.39+/-0.98 (range 5.57-8.69) RVUs/hour for the bottom quartile (p<0.001). The mean operative time for the top quartile of CPT codes was 167.14+/-90.29 minutes, compared to 107.79 +/-55.17 minutes for the lowest quartile (p=0.029). In the top quartile, the majority of CPT codes were craniofacial procedures including frontofacial procedures (23.53%) and craniectomies for craniosynostosis or bony lesions (35.29%). The lowest quartile was comprised mainly of CPT codes for cleft procedures including surgeries for velopharyngeal insufficiency (17.65%), cleft palate repair (23.53%), and cleft septoplasty (5.88%). It was 2.5 times more efficient for a cleft and craniofacial surgeon to perform a local skin flap (15.18 RVUs/ hour, CPT 14040) than a secondary palatal lengthening for cleft palate (6.09 RVUs/hour, CPT 42200).
Conclusion(s): The current RVU allocation to cleft and craniofacial procedures creates arbitrary disparities in physician efficiency, with cleft procedures disproportionately negatively affected despite being among the most common procedures. RVU assignments should be reevaluated to avoid disincentivizing cleft surgical care

Background/Purpose: After LeFort I advancement surgery, soft tissue changes are unpredictable, especially in patients with orofacial clefts, as scar tissue from primary repair can alter soft tissue responses. Therefore, this study aimed to measure and evaluate soft tissue response following LeFort I advancement in skeletally matured patients with complete cleft lip and palate (CLP). Methods/Description: The cohort of 26 patients with non-syndromic CLP who underwent Le Fort I osteotomy between 2013 and 2019 and met the inclusion criteria. Patients were included if they had lateral cephalograms or CBCT at pre-operative (T1), immediately post-operative (T2), and one-year follow-up (T3). Patients who underwent nose/lip revision surgery before T3 were excluded. Four skeletal and dental hard-tissue (ANS, point A; A-point, upper incisor most labial; U1-most, upper incisor edge; U1-tip) and 5 softtissue (tip of nose or pronasale; Prn, subnasale; Sn, superior labial sulcus; SLS, upper lip anterior or labrale superius; LS, and stomion superius; SIMS) landmarks were digitized and measured. For the outcome analyses, 5 ratios of soft- to hard-tissue changes (Prn/ANS, Sn/A-point, SLS/A-point, LS/U1-most, and SIMS/ U1-tip) were calculated for each group, and associations between hard-and-soft tissue counterparts were assessed using Pearson correlation coefficient (r).
Result(s): Sixteen patients had UCLP, and 10 patients had BCLP. At one-year follow-up (T1-T3), the mean advancement in UCLP and BCLP groups at ANS were 4.4+/-3 and 4.7+/-3.9 mm, from point A were 6.6+/-2.5, 8.8+/- 2.6 mm, respectively. The mean horizontal changes of the corresponding soft tissue anatomy, Prn, were 2.7 +/-1.7, 4.6+/-3.5 mm, from Sn, were 3.9+/-1.9, 6.2+/-2.4. mm, and from SLS were 5.2+/-2.5, 7.4+/-2.8 mm. The mean advancement in at upper incisor most labial were 7.2+/-2.7 and 8.4+/-2.4 mm, and from the upper incisal edge were 7.5+/-2.9 and 8.4+/-2.7. mm. The mean horizontal changes of the soft tissue counterpart, LS, were 5.6+/-2.9, 7.9+/- 3.7 mm, and SIMS were 6.0+/-3.2, 7.3+/- 2.7 mm. All skeletal, dental, and soft tissue advancements from T1-T3 were significant (P< 0.01) except for Sn and LS in both groups and SIMS in UCLP group. For ratio and correlation analyses in UCLP and BCLP groups, Prn/AND were 0.48 (r=0.40) and (r=0.00), Sn/A-point were 0.58 (r=0.79) and 0.70 (r=0.77), SLS/A-point were 0.79 (r=0.82) and 0.85 (r=0.80), LS/U1-most were 0.74 (r=0.92) and 0.96 (r=0.74), and SIMS/U1-tip were 0.78 (r=0.75) and 0.82(r=0.67), respectively. All associations except for Prn/ANS were statistically significant (P< 0.01).
Conclusion(s): This study demonstrated a linear relationship between soft- and hard-tissue changes in the maxillary landmarks following LeFort I advancement in patients with complete cleft lip and palate (UCLP and BCLP)

Background/Purpose: Primary cheiloplasty for infants born with cleft lip and palate has long been preceded and facilitated by oral appliances intended to aid in feeding, narrow the cleft width, or mold the surrounding cartilages. Presurgical infant orthopedic (PSIO) therapy has evolved in both its popularity and focus of treatment since its advent. Nasoalveolar molding (NAM), nasal elevators, the Latham appliance, lip taping, and passive plates are the modern treatment options offered by cleft teams, and each varies in their associated protocols and treatment philosophies. The purpose of this study is to examine trends in the currently available modalities of PSIO care and PSNS for the management of patients with cleft lip and palate. Methods/Description: Methods: An electronic survey comprised of eight questions was distributed to the one hundred and sixty-seven cleft team coordinators listed by the American Cleft Palate Association. The survey reported on team setting, provider availability, PSIO treatment offerings, relative contraindications, and use of postsurgical nasal stenting. Descriptive statistics and analyses were performed using MS Excel (Microsoft, Redmond, WA) and SPSS (IBM, Chicago, IL).
Result(s): One hundred and two survey responses were received from the total one hundred, and sixty-seven sent, resulting in a response rate of 61%. The majority of settings were children's specialty hospitals (66%) or university hospitals (27%). PSIO was offered by 86% of cleft teams, and the majority of those (68%) provided NAM. Nasal elevators and lip taping are offered at 44% and 53% of centers, respectively. Latham and passive plates are both offered at 5.5% of centers. Teams with a dental specialist as the PSIO provider offered NAM significantly more than centers with surgeons as the provider of PSIO. Most centers (45%) had an orthodontist providing treatment. Patients are considered contraindicated for treatment at many centers for reasons such as mild cleft severity (46%), medically-compromised (42%), advanced age at first visit (29%), far commute (35%), and/or financial reasons (16%). The majority of centers use postsurgical nasal stenting (86%), and almost all insert the device immediately in the operating room (88%).
Conclusion(s): NAM is the most popular PSIO technique in North American cleft centers followed by the nasal elevator, suggesting that the nasal molding component of PSIO of critical influence on current treatment practices. With 86% of centers providing PSIO, access to care is improving with an increasing variety of treatment modalities. Postsurgical nasal stenting is also gaining popularity. The use of various PSIO techniques is ubiquitous, but the emphasis on nasal molding may continue to be the driving force for treatment in the future