Faculty Bibliography

The aim of this study was to evaluate the in vivo performance of two different deproteinized bovine bone (DBB) grafting materials: DBBB (Bio-Oss®) and DBBL (Laddec®), for the regeneration of critically sized (8 mm) defects in rabbit's calvaria. Three round-shaped defects were surgically created in the calvaria of 13 New Zealand White rabbits proximal to the coronal suture in the parietal bone. Two of the defects were filled with one of the grafting materials while a third was left empty to serve as a negative control. Bone regeneration properties were evaluated at 4- and 8-weeks after implantation by means of histological and histomorphometrical analyses. Statistical analyses were performed through a mixed model analysis with fixed factors of time and material. Histological evaluation of the control group evidenced a lack of bridging bone formation across the defect sites at both evaluation time points. For the experimental groups, new bone formation was observed around the defect periphery and to progress radially inwards to the center of the defect site, regardless of the grafting material. Histomorphometric analyses at 4 weeks demonstrated higher amount of bone formation through the defect for DBBB group. However, at 8 weeks, DBBL and DBBB demonstrated osteoconductivity and low resorption rates with evidence of statistically similar bone regeneration through the complete boney defect. Finally, DBBB presented lower soft tissue migration within the defect when compared to DBBL at both evaluation time points. DBBB and DBBL presented similar bone regeneration performance and slow resorption rates. Although both materials promoted bone regeneration through the complete defect, DBBB presented lower soft tissue migration within the defects at 4- and 8-weeks.

Nonthumb metacarpal (NTMC) fractures are common in the incarcerated and the underinsured civilian populations. However, certain social challenges contribute to high rates of follow-up noncompliance and complications in these unique populations. We conducted a retrospective review of the treatments, outcomes, and complications in the incarcerated and civilian patient population who were treated at a tertiary public hospital for NTMC fractures. Even though incarcerated patients were more likely than their civilian counterparts to undergo operative interventions, both populations showed similar complication profiles as well as low rates of treatment compliance and follow-up. This article affirms that incarcerated individuals do not receive inferior care compared with civilians, and both the incarcerated and underinsured civilians would benefit from careful consideration of treatment algorithms and additional access to hand therapy.

Increased access to care and insurance coverage has led to an increase in gender-affirming surgeries performed in the United States. Gender-affirming phalloplasty has a variety of donor sites and surgical techniques including both pedicled and free flaps. Although surgical techniques and patient outcomes are well-described, no reports in the literature specifically discuss postoperative management, which plays a crucial role in the success of these operations. Here, we present a postoperative protocol based on our institution's experience with gender-affirming phalloplasty with the hope it will serve as a standardized, reproducible reference for centers looking to offer these procedures.

SUMMARY:The surgical treatment of gender incongruence with gender-affirming surgery requires a sophisticated understanding of the substantial diversity in patient expectations and desired outcomes. There are patients with gender incongruence who desire surgical intervention to achieve the conventional bodily configuration typical for cisgender men and women and those who desire surgery without the goal of typical cisgender presentation. Proper communication regarding diverse expectations poses a challenge to those unfamiliar with the nuances of this heterogeneous population; such difficulties have led to mistakes during patient care. Based on the lessons learned from these experiences, the authors provide conceptual recommendations with specific examples to account for cultural context and conceptions of gender within surgical practice and scientific research.

OBJECTIVE:To provide a critical overview of current radiation modalities for keloid management. BACKGROUND:Despite multimodal therapies, keloids that can develop following injury are poorly controlled. A number of studies have suggested that post-excisional radiation therapy can reduce rates of keloid recurrence. However, existing reports span multiple radiation modalities, including brachytherapy, electron beam radiation, and photon radiation. In this review, we describe the advantages and disadvantages of commonly used radiation techniques and highlight their efficacy in keloid management. RESULTS:Electron beam radiation and high-dose rate brachytherapy are the two most commonly used modalities for adjuvant radiotherapeutic management of keloids and can provide effective keloid control but may be suited for different kinds of keloid growth patterns. Increasing biologically equivalent dose (BED) likely improves rates of control, though the clinical significance of this finding remains to be elucidated. Though radiation treatments are associated with acute and chronic side effects, the risk of developing a secondary malignancy is minimal. CONCLUSIONS:While radiation therapy is a promising modality for treating keloids, more studies of a prospective, randomized nature are needed to standardize its utility.

Currently, there is an increasing trend in women seeking aesthetic flat closure after mastectomy. To date, there is no plastic surgery literature on specific techniques to achieve an aesthetic flat closure after mastectomy. As plastic surgeons, we need to continue to innovate and to iterate new surgical techniques in our reconstructive armamentarium to address the desires of and to optimize the outcomes for our reconstructive breast surgery patients. Herein, we seek to delineate key considerations and employed techniques for reconstructive plastic surgeons performing aesthetic flat closure after mastectomy. Namely, it is crucial to listen to the patient, and to fully understand the patient's concerns, wishes, and particular aesthetic desired. From a technical perspective, the key surgical pearls include completely obliterating the inframammary fold, ensuring the same size and flap thickness bilaterally, appropriately de-fatting medially on the chest wall to allow for a smooth contour, obviating any presence of dog ears medially or laterally with precise tissue excision, and confirming that the incisions are entirely symmetric bilaterally. Intraoperatively, it is important to sit these patients up to assess soft tissue re-draping, and to confirm that there are no dog ears nor any excess tissue that could compromise the perfectly flat aesthetic chest closure. With the increasing demand for flat closures after mastectomy, plastic surgeons need to be keen on employing modified surgical techniques to best optimize the desired aesthetic flat closure reconstructions for these patients, as these reconstructions are not simply linear closures.

OBJECTIVE:The aim of this investigation is to determine if the nasal form of patients with unilateral cleft lip and palate (UCLP) treated with pre-surgical nasoalveolar molding (NAM) therapy, primary lip-nose surgery, and post-surgical Nostril Retainer (PSNR) is different from patients treated with pre-surgical NAM and primary lip and nose surgery alone. DESIGN/METHODS:A cross-sectional, retrospective review of 50 consecutive non-syndromic patients with UCLP: 24 treated with NAM and primary lip-nose surgery followed by PSNR (Group I) compared to 26 patients treated with NAM and primary lip-nose surgery without PSNR (Group II). Polyvinyl siloxane nasal impressions were performed at the average age of 12 months and 6 days. Bilateral measurements of alar width at maximum convexity, total alar base width, nasal tip projection, columella length, and nostril aperture width and height were recorded. Statistical comparison of cleft versus non-cleft side nasal measurements were performed within Group I and Group II, as well as comparison of the difference between the two groups. RESULTS:Cleft side nasal dimension was statistically significantly better in Group I than Group II across all measures except nasal projection (P<0.05). Group I showed less difference between the cleft and non-cleft side in all six measurements than Group II (p<0.05). CONCLUSION/CONCLUSIONS:There is a significant difference in the nasal shape of patients who underwent PSNR compared to those that did not. The patients who used PSNR showed better nasal shape at the average age of 12 months than the control group.

BACKGROUND:Hematomas are reported to be the most common immediate complication in patients undergoing gender-affirming mastectomy, with rates substantially higher than those associated with other types of breast surgery. This study sought to examine the breadth of current literature and provide evidence-based explanations regarding the development of hematomas in chest masculinizing surgery and technical considerations for reducing their incidence. METHODS:A systematic review was conducted to identify all articles related to gender-affirming mastectomy published through September 2021. Literature search yielded 2,661 articles for screening, of which 20 met inclusion criteria. Themes from the selected articles were compiled to generate consensus statements qualified by associated level of evidence (LOE). RESULTS:The rate of hematoma following gender-affirming mastectomy is reported in the literature ranging from 0% to 31.2%. The use of more limited, nipple-sparing incisions is associated with a higher hematoma rate than mastectomy with free nipple grafting (Level III). There is no conclusive evidence indicating any relationship between the use of masculinizing hormones and the incidence of hematoma (Level IV). Factors such as body mass index (Level III) and breast size (Level III) were not found to influence hematoma risk, though nicotine use (Level IV) was significantly associated with the incidence of hematoma. CONCLUSIONS:Hematoma is a known complication following gender-affirming mastectomy. The use of limited incision approaches has the strongest association with an increased risk of hematoma. There is no evidence indicating an association between hormone use (i.e., testosterone) and hematoma incidence. Future studies are needed to better define factors, interventions, and protocols to reduce the rate of hematoma. LEVEL OF EVIDENCE/METHODS:III.

BACKGROUND:Recipient selection is an important determinant of surgical outcomes in facial transplantation (FT). Appropriately, each FT program develops their own guidelines for recipient selection criteria. Currently, there is no resource to simultaneously assess and identify similarities and differences between these guidelines. Such information could be useful in distinguishing areas of FT that are well understood from those that could benefit from further exploration. METHODS:We performed a systematic review of the scientific literature from inception to June 18, 2021, using Pubmed, Embase, Cochrane Library, and Scopus to identify articles pertaining to recipient selection criteria. Clinical trials were identified through the Clinicaltrials.gov registry. United States and international program websites were reviewed for patient-facing information. RESULTS:Our systematic review yielded 90 suitable articles, 8 clinical trials, and 7 program websites containing the recipient selection criteria of 24 different FT programs. The most reported on recipient criteria were age, positive human immunodeficiency viral status (HIV+), positive hepatitis C viral status, psychosocial stability, and medical compliance. Other criteria were rarely addressed, such as blindness and recipient immune status. CONCLUSIONS:Guidelines among different face transplant programs are changing over time. We found consensus on certain recipient selection criteria, but the majority remain program or surgeon dependent, emphasizing that FT is still an evolving procedure. Although most programs reported on their recipient selection criteria, the rationale was often missing. Further discussion about recipient selection criteria and the reasoning behind employing or changing them will help advance the field.