Faculty Bibliography

BACKGROUND:Florida enacted legislation limiting opioid prescriptions and affecting the management of acute pain in the postoperative patient. Patients in a reconstructive surgery practice were receiving prescriptions for opioids as their primary method of pain management. Clinic providers identified a need to limit opioid prescriptions. AIM/OBJECTIVE:The aim of this quality improvement initiative was to decrease the number of opioids prescribed while effectively managing pain in women undergoing mastectomy and breast tissue expander placement. DESIGN/METHODS:This is a quality improvement project. METHODS:The Model for Improvement was used as a framework for this project. An evidence-based pain management plan was developed after a review of the breast reconstruction surgery literature. The plan incorporated preoperative patient and family education and the standard use of preemptive analgesia, intraoperative nerve blocks, and postoperative multimodal analgesia in all patients undergoing mastectomy with breast tissue expander placement. Patient and family education and perioperative pain management were provided to patients, and the number of opioid tablets prescribed was tracked. RESULTS:Between January 2018 and August 2019, the average number of opioid tablets prescribed per patient decreased from 84.7 to 8.4. CONCLUSIONS:Opioid prescriptions can be decreased in women undergoing breast reconstruction with the use of patient education and multimodal analgesia.

Anesthetic considerations are integral to the success of facial transplantation (FT), yet limited evidence exists to guide quality improvement. This study presents an institutional anesthesia protocol, defines reported anesthetic considerations, and provides a comprehensive update to inform future directions of the field.

The aim of facial transplantation (FT) was to enhance quality of life (QoL) for individuals living with severe facial disfigurement. Yet QoL has proved challenging to assess, as the field lacks a unified approach for incorporating FT recipients' perspectives into meaningful QoL measures. In this study, we review FT recipients' self-reported QoL through a qualitative analysis of publicly available posttransplant interviews to identify the aspects of QoL they report as meaningful.

OBJECTIVES/OBJECTIVE:To evaluate the clinical outcomes, histological parameters, and bone nanomechanical properties around implants retrieved from healthy and metabolic syndrome (MS) patients. METHODS:Twenty-four patients with edentulous mandibles (12/condition), received four implants between the mental foramina. An additional implant prototype was placed for retrieval histology. The following clinical outcomes were evaluated: insertion torque (IT), implant stability quotient (ISQ) values at baseline and after 60 days of healing, and implant survival. The prototype was retrieved after the healing and histologically processed for bone morphometric evaluation of bone-to-implant contact (%BIC) and bone area fraction occupancy (%BAFO), and bone nanoindentation to determine the elastic modulus (Em) and hardness (H). Descriptive statistical procedures and survival tests were used to analyze the data. RESULTS:The final study population was comprised of 10 women and 11 men (∼64 years). A total of 105 implants were placed, 21 retrieved for histology. Implant survival rates were similar between groups (>99 %). Similarly, IT and ISQ analyses showed no significant association with systemic condition (p > 0.216). Histological micrographs depicted similar bone morphology, woven bone, for both conditions. While MS (33 ± 5.3 %) and healthy (39 ± 6.5 %) individuals showed no significant difference for %BIC (p = 0.116), significantly higher %BAFO was observed for healthy (45 ± 4.6 %) relative to MS (30 ± 3.8 %) (p < 0.001). No significant differences on bone nanomechanical properties was observed (p > 0.804). CONCLUSIONS:Although no significant influence on clinical parameters and bone nanomechanical properties was observed, MS significantly reduced bone formation in the peri-implant area in the short-term. CLINICAL SIGNIFICANCE/CONCLUSIONS:A lower amount of bone formation in the peri-implant area was observed in comparison to healthy patients, although the other short-term clinical outcomes were not significantly different. Considering the escalating prevalence of MS patients in need for implant treatment, it becomes crucial to understand bone-to-implant response to determine the ideal loading time in this population.

OBJECTIVE/UNASSIGNED:Evaluate simulation-based comprehensive cleft care workshops as a reproducible model for education with sustained impact. DESIGN/UNASSIGNED:Cross-sectional survey-based evaluation. SETTING/UNASSIGNED:Simulation-based comprehensive cleft care workshop. PARTICIPANTS/UNASSIGNED:Total of 180 participants. INTERVENTIONS/UNASSIGNED:Three-day simulation-based comprehensive cleft care workshop. MAIN OUTCOME MEASURES/UNASSIGNED:Number of workshop participants stratified by specialty, satisfaction with the workshop, satisfaction with simulation-based workshops as educational tools, impact on cleft surgery procedural confidence, short-term impact on clinical practice, medium-term impact on clinical practice. RESULTS/UNASSIGNED:< .001) surgery procedural confidence following the simulation sessions. Participants also reported a positive short-term and medium-term impact on their clinical practices. CONCLUSION/UNASSIGNED:Simulation-based comprehensive cleft care workshops are well received by participants, lead to improved cleft surgery procedural confidence, and have a sustained positive impact on participants' clinical practices. Future efforts should focus on evaluating and quantifying this perceived positive impact, as well reproducing these efforts in other areas of need.

Biomaterial scaffolds have served as the foundation of tissue engineering and regenerative medicine. However, scaffold systems are often difficult to scale in size or shape in order to fit defect-specific dimensions, and thus provide only limited spatiotemporal control of therapeutic delivery and host tissue responses. Here, a lithography-based 3D printing strategy is used to fabricate a novel miniaturized modular microcage scaffold system, which can be assembled and scaled manually with ease. Scalability is based on an intuitive concept of stacking modules, like conventional toy interlocking plastic blocks, allowing for literally thousands of potential geometric configurations, and without the need for specialized equipment. Moreover, the modular hollow-microcage design allows each unit to be loaded with biologic cargo of different compositions, thus enabling controllable and easy patterning of therapeutics within the material in 3D. In summary, the concept of miniaturized microcage designs with such straight-forward assembly and scalability, as well as controllable loading properties, is a flexible platform that can be extended to a wide range of materials for improved biological performance.

Inflammatory orbital lesions include a broad list of diagnoses, many of them with overlapping clinical and radiographic features. They often present a diagnostic conundrum, even to the most experienced orbital specialist, thus placing considerable weight on surgical biopsy and histopathological analysis. However, histopathological diagnosis is also inherently challenging due to the rarity of these lesions and the overlaps in histologic appearance among distinct disease entities. We herein present the case of an adolescent male with a subacutely progressive orbital mass that generated a significant diagnostic dilemma. Early orbital biopsy was consistent with a benign fibro-inflammatory lesion, but corticosteroid therapy was ineffective in halting disease progression. After an initial substantial surgical debulking, histopathological analysis revealed several key features consistent with IgG4-related disease (IgG4-RD), a systemic fibro-inflammatory process typically accompanied by multifocal tumor-like lesions. Surprisingly, within months, there was clear evidence of clinical and radiographic disease progression despite second-line rituximab treatment, prompting a second surgical debulking. This final specimen displayed distinctive features of Rosai-Dorfman disease (RDD), a systemic inflammatory disease characterized by uncontrolled histiocytic proliferation. Interestingly, certain features of this re-excision specimen were still reminiscent of IgG4-RD, which not only reflects the difficulty in differentiating RDD from IgG4-RD in select cases, but also illustrates that these diagnoses may exist along a spectrum that likely reflects a common underlying pathogenetic mechanism. This case emphasizes the importance of surgical biopsy or resection and histopathological analysis in diagnosing-and, ultimately, treating-rare, systemic inflammatory diseases involving the orbit, and, furthermore, highlights the shared histopathological features between RDD and IgG4-RD.