Faculty Bibliography

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:Feminizing Facial Gender-Affirming Surgery (FFGAS) is gaining popularity among the diverse population of patients impacted by gender incongruence. However, most studies examining facial femininity are based on Caucasians. Thus, it is unclear if ethnic differences exist in anthropometric measures relevant to FFGAS procedures. This study aims to analyze ethnic anthropometric variations in the cisgender female face to identify differences that are potentially relevant to FFGAS. METHODS:A systematic review and meta-analysis of the PubMed, EMBASE, and Cochrane databases was performed following PRISMA guidelines on June 25, 2021. Original studies reporting facial anthropometry in cisgender women were included. Anthropometric measures of interest included mandibular and zygomatic width, facial and forehead height, and nasolabial angle. A meta-analysis was performed using a linear mixed-effects model for each anthropometric measure. RESULTS:A total of 1246 abstracts were screened, yielding 21 articles that met the inclusion criteria. Facial anthropometric data of 4792 cisgender females of 16 different ethnicities were analyzed. This meta-analysis demonstrated that compared with Caucasian cisgender women, Japanese, Chinese, and Korean cisgender women had a wider mandible (Japanese +20.13 mm [SE 4.43, P<0.001, P value adjusted for multiple comparisons (p-adj)=0.002], Chinese +16.22 mm [SE 4.39, P=0.002, p-adj=0.013]; and Korean +14.46 mm [SE 3.97, P=0.002, p-adj=0.014]). Further, when compared with Caucasian cisgender women, Chinese cisgender women demonstrated a larger zygomatic width, African American cisgender women tended to have smaller nasolabial angles, and Indian and Japanese cisgender women tended to have a smaller and larger facial height, respectively. However, following P value adjustment for multiple comparisons, these differences were not found to be statistically significant. CONCLUSIONS:We found that mandibular width tends to be greater for Japanese and Chinese cisgender women relative to Caucasian cisgender women. This data may be useful in counseling patients during preoperative evaluations ahead of mandibular reduction. No other anthropometric features were found to be significantly different among the ethnic groups studied. This portends that current approaches to FFGAS, which emphasize patient-specific needs and maintenance of a harmonious appearance, may require minimal or no adjustment to account for ethnic facial anthropometric differences.

BACKGROUND:Successful osseointegration of endosteal dental implants has been attributed to implant design, including the macro-, micro- and nano- geometric properties. Based on current literature pertaining to implant design, the resultant cellular and bone healing response is unknown when the thread thickness of the implants is increased, resulting in an increased contact area in implants designed with healing chambers. The aim of this study was to evaluate the effect of two implant designs with different thread profiles on the osseointegration parameters and implant stability at 3- and 6-weeks in vivo using a well-established preclinical dog model. MATERIAL AND METHODS/METHODS:A total of 48 type V Ti alloy implants were divided in two groups according to their thread design (D1= +0.1x/mm and D2= +0.15x/mm) and placed in an interpolated fashion into the radii of six beagles. Insertion torque was measured at time of placement, radii were extracted for histological processing following 3- and 6-week healing intervals. Histologic and histomorphometric analyses were performed in terms of bone to implant contact (%BIC) and bone area fraction occupancy within implant threads (%BAFO). Statistical analyses were performed through a linear mixed model with fixed factors of time and implant thread design. RESULTS:Surface roughness analysis demonstrated no significant differences in Sa and Sq between D1 and D2 implant designs, which confirmed that both implant designs were homogenous except for their respective thread profiles. For insertion torque, statistically significant lower values were recorded for D1 in comparison to D2 (59.6 ± 11.1 and 78.9 ± 10.1 N⋅cm, respectively). Furthermore, there were no significant differences with respect to histological analysis and histomorphometric parameters, between D1 and D2 at both time points. CONCLUSIONS:Both thread profiles presented equivalent potential to successfully osseointegrate in the osteotomies, with D2 yielding higher mechanical retention upon placement without detrimental bone resorption.

Sphenoorbital meningiomas are a challenge to access and reconstruct. Although there is much neurosurgical literature on resection of such tumors, there is little discussion on the best methods for the reconstruction of consequent defects, which are often extensive due to large areas of hyperostosis requiring resection. We performed a retrospective analysis of patients who underwent resection and reconstruction of a sphenoorbital meningioma by the senior authors (C.S. and D.A.S.) between 2010 and 2020. Surgical access in all cases included an orbitozygomatic osteotomy. The study cohort consisted of 23 patients (20 female, 3 male) with an average age of 50 (range: 37-72) years at the time of surgery. Most patients had progressive proptosis before the ablative operation. Orbital reconstruction was with a combined titanium-Medpor implant in 18 patients, split calvarial bone graft in 3 patients, and a Medpor implant in 2 patients. Calvarial reconstruction was performed with titanium mesh in 21 patients, split calvarial bone graft and titanium mesh in 1 patient, and craniotomy bone and titanium plate in 1 patient. Reoperation was required in 7 patients due to hypoglobus or enophthalmos (N=2), orbital implant malposition (N=1), abscess (N=1), pain (N=1), intracranial fat graft modification (N=1), and soft tissue deformities (N=2). Our experience demonstrates that sphenoorbital meningiomas can require broad areas of resection of the skull base and calvarium and necessitate comprehensive reconstruction of the anterior cranial fossa, orbital walls, and cranium. Collaboration between craniofacial surgeons and neurosurgeons can achieve optimal results.

PURPOSE/OBJECTIVE:To evaluate the effect of short curing time using a high-radiant emittance light on polymerization shrinkage vectors in different consistency bulk-fill composites (BFRCs) using micro-computed tomography. METHODS AND MATERIALS/METHODS:Radiopaque zirconia fillers were homogeneously incorporated and functioned as radiopaque tracers into two regular-paste: TBFill (Tetric EvoCeram Bulk Fill) and TPFill (Tetric PowerFill), and two flowable (n=6): TBFlow (Tetric EvoFlow Bulk Fill) and TPFlow (Tetric PowerFlow) resin composites. Class I cavities (4 mm depth × 4 mm length × 4 mm width) were 3D-printed and filled in a single increment: TBFill and TBFlow were light-activated using a Bluephase Style 20i (10 seconds in high-mode); TPFill and TPFlow were light-activated using a Bluephase PowerCure (three seconds). The same adhesive system (Adhese Universal) was used for all groups. Microcomputed tomography scans were obtained before and after light-activation. Filler particle movement was identified by polymerization shrinkage vectors at five depths (from 0-4 mm): top, top-middle, middle, middle-bottom and bottom. RESULTS:TPFlow showed the lowest total vector displacement, followed by TBFlow, TBFill and TPFill, significantly different among each other (p<0.05). Generally, BFRCs showed decreased vector displacement with increased depth, and higher displacement at the top-surface (p<0.05). Qualitative analysis showed a similar pattern of vector magnitude and displacement for groups TBFill and TPFill, with displacement vectors on occlusal (top) surfaces toward the center of the restoration from the top to middle areas, and relatively limited displacement at the bottom. TBFlow and TPFlow showed more displacement on the occlusal (top). CONCLUSIONS:Short curing time with high-radiant emittance on fast-curing BFRCs was shown to be a feasible option in terms of vector displacement. Flowable BFRCs presented lower vector displacement than their regular-viscosity versions.

Youth-onset type two diabetes mellitus is associated with a more rapid decline in beta cells, and earlier onset of medical complications compared to adult-onset diabetes. However, its impact on surgical wounds remains less clear. Therefore, this study aimed to determine whether Youth-onset Diabetes is a risk factor for wound healing complications in the 30-day postoperative period. To do so, the National Surgical Quality Improvement Program Database years 2012-2019 was analyzed. Patients aged 18-24 with non-insulin-dependent diabetes were included. Outcomes assessed included wound infections, wound dehiscence, readmissions, and re-operation. Univariate analysis identified differences between the diabetic and non-diabetic cohorts after which, multivariate logistic regression was employed to control for potential confounding. Analysis included 1,589 diabetic and 196,902 non-diabetic patients ages 18-24. The diabetic cohort exhibited a higher proportion of female (83.8% vs. 55.2%, p <0.001), non-white (22.7% vs. 19.5%, p = 0.001), and Hispanic patients (16.2% vs. 13.6%, p = 0.002). Diabetic patients were less likely to have dirty or contaminated wounds (16.2% vs 25.2% p<0.001) however, had increased odds of developing superficial surgical site infections (2.0% vs 0.8%, p<0.001) and requiring readmission (4.0% vs 3.0%, p=0.026). After, regression, diabetes remained a significant positive predictor of superficial surgical site infection (Odds ratio: 1.546, p=0.022), however it no longer significantly predicted 30-day readmission. Overall, this analysis of a large multi-center surgical outcomes database found that when compared to non-diabetics, youth-onset diabetic patients exhibited a higher proportion of superficial surgical site infections in the 30-day postoperative period. These infections were found, despite the diabetic cohort exhibiting lower rates of wound contamination. After controlling for confounding variables, diabetes remained a significant predictor of superficial surgical site infection. Clinically, prevention and treatment of diabetes along with judicious wound care is recommended. This article is protected by copyright. All rights reserved.

BACKGROUND:Gender-affirming mastectomy, or "top surgery," has become one of the most frequently performed procedures for transgender and nonbinary patients. However, management of perioperative testosterone therapy remains controversial. Despite a lack of supporting evidence, many surgeons require cessation of testosterone prior to top surgery. This represents the first study to compare complication rates in patients undergoing gender-affirming mastectomy with and without discontinuation of perioperative testosterone. METHODS:Retrospective review identified patients undergoing top surgery by the senior author between 2017 and 2020. Reflecting a change in the senior author's practice, prior to May 2019, all patients were required to discontinue testosterone prior to surgery, while all patients treated after this point continued their testosterone regimens throughout the perioperative period. Patients were stratified according to testosterone regimen and perioperative hormone management, with demographics and postoperative outcomes compared between groups. RESULTS:490 patients undergoing gender-affirming mastectomy during the study period were included. Testosterone was held perioperatively in 175 patients and continued in 211 patients, while 104 patients never received testosterone therapy. Demographics were similar between groups, and there was no difference in rates of hematoma (2.9% vs. 2.8% vs 2.9% respectively, p=0.99), seroma (1.1% vs. 0% vs 1%, p=0.31), venous thromboembolism (0% vs. 0.5% vs 0%, p=0.99), or overall complications (6.9% vs. 4.3% vs 5.8%, p=0.54). CONCLUSIONS:Our results demonstrate no difference in postoperative complication rates between groups. While further investigation is warranted, our data suggest that routine cessation of testosterone in the perioperative period is not necessary for patients undergoing gender-affirming mastectomy.

Chronic pain involves sensitization of nociceptors and synaptic transmission of painful signals in nociceptive circuits in the dorsal horn of the spinal cord. We investigated the contribution of clathrin-dependent endocytosis to sensitization of nociceptors by G protein-coupled receptors (GPCRs) and to synaptic transmission in spinal nociceptive circuits. We determined whether therapeutic targeting of endocytosis could ameliorate pain. mRNA encoding dynamin (Dnm) 1-3 and adaptor-associated protein kinase 1 (AAK1), which mediate clathrin-dependent endocytosis, were localized to primary sensory neurons of dorsal root ganglia of mouse and human and to spinal neurons in the dorsal horn of the mouse spinal cord by RNAScope®. When injected intrathecally to mice, Dnm and AAK1 siRNA or shRNA knocked-down Dnm and AAK1 mRNA in dorsal root ganglia neurons, reversed mechanical and thermal allodynia and hyperalgesia, and normalized non-evoked behavior in preclinical models of inflammatory and neuropathic pain. Intrathecally administered inhibiters of clathrin, Dnm and AAK1 also reversed allodynia and hyperalgesia. Disruption of clathrin, Dnm and AAK1 did not affect normal motor functions of behaviors. Patch clamp recordings of dorsal horn neurons revealed that Dnm1 and AAK1 disruption inhibited synaptic transmission between primary sensory neurons and neurons in lamina I/II of the spinal cord dorsal horn by suppressing release of synaptic vesicles from presynaptic primary afferent neurons. Patch clamp recordings from dorsal root ganglion nociceptors indicated that Dnm siRNA prevented sustained GPCR-mediated sensitization of nociceptors. By disrupting synaptic transmission in the spinal cord and blunting sensitization of nociceptors, endocytosis inhibitors offer a therapeutic approach for pain treatment.

BACKGROUND:The bulk metallic glass (BMG), Pd79Ag3.5P6Si9.5Ge2, has a high fracture toughness and has been found to accommodate post-yield stress, unlike most other BMG. Moreover, due to its greater noble gas composition it has a intrinsic corrosion resistance, ideal for dental and orthopedic implants. OBJECTIVE:This present study aimed to evaluate the in vivo application of Pd79Ag3.5P6Si9.5Ge2 in a large translational sheep model to assess its efficacy to be utilized as an endosteal device. METHODS:Twelve implants in the form of cylindrical rods (3 mm in diameter) were produced through rapid quenching. Each sheep (n = 12) received one osteotomy in the mandibular region using rotary instrumentation, which was subsequently filled with Pd79Ag3.5P6Si9.5Ge2. After 6- and 24-weeks the animals were euthanized, and samples collected en bloc to conduct histomorphometric analysis. The level/degrees of osseointegration were assessed through bone-to-implant contact (BIC). RESULTS:Favorable BIC was observed with fibrous connective tissue layers at both 6- and 24-weeks. Bone along with interfacial remodeling was observed in proximity with the metallic glass surface at 6 weeks with higher degrees of bone organization being observed at the later healing time, 24 weeks. CONCLUSIONS:The introduced BMG revealed potential to serve as an alternative biomaterial to commonly used Ti alloys given its unique combination of toughness and strength.