Faculty Bibliography

Chest masculinization is the most common gender-affirming operation performed. With increased access to care and improved insurance coverage, there has been a marked increase in the number of procedures performed. A video is presented with narration focused on the surgical technique of a "double-incision" mastectomy for gender-affirming chest masculinization. The Fisher grading scale used in technique selection of double-incision versus periareolar mastectomy, based on patient-specific anatomical parameters, is reviewed. Technical pearls for refinement of the double-incision top surgery technique for gender affirmation are then demonstrated.

Due to the high complication rate of panniculectomies, preoperative risk stratification is imperative. This study aimed to assess the predictive value of the 5-item modified frailty index (mFI-5) for postoperative complications in the elderly following panniculectomy.

Whether G protein-coupled receptors signal from endosomes to control important pathophysiological processes and are therapeutic targets is uncertain. We report that opioids from the inflamed colon activate δ-opioid receptors (DOPr) in endosomes of nociceptors. Biopsy samples of inflamed colonic mucosa from patients and mice with colitis released opioids that activated DOPr on nociceptors to cause a sustained decrease in excitability. DOPr agonists inhibited mechanically sensitive colonic nociceptors. DOPr endocytosis and endosomal signaling by protein kinase C (PKC) and extracellular signal-regulated kinase (ERK) pathways mediated the sustained inhibitory actions of endogenous opioids and DOPr agonists. DOPr agonists stimulated the recruitment of Gα_i/o and β-arrestin1/2 to endosomes. Analysis of compartmentalized signaling revealed a requirement of DOPr endocytosis for activation of PKC at the plasma membrane and in the cytosol and ERK in the nucleus. We explored a nanoparticle delivery strategy to evaluate whether endosomal DOPr might be a therapeutic target for pain. The DOPr agonist DADLE was coupled to a liposome shell for targeting DOPr-positive nociceptors and incorporated into a mesoporous silica core for release in the acidic and reducing endosomal environment. Nanoparticles activated DOPr at the plasma membrane, were preferentially endocytosed by DOPr-expressing cells, and were delivered to DOPr-positive early endosomes. Nanoparticles caused a long-lasting activation of DOPr in endosomes, which provided sustained inhibition of nociceptor excitability and relief from inflammatory pain. Conversely, nanoparticles containing a DOPr antagonist abolished the sustained inhibitory effects of DADLE. Thus, DOPr in endosomes is an endogenous mechanism and a therapeutic target for relief from chronic inflammatory pain.

INTRODUCTION/BACKGROUND:Abdominoplasty is currently one of the most widely requested cosmetic procedures in the United States. There is limited literature describing the corrective measures following skin loss from a flap necrosis due to an abdominoplasty complication. METHODS:A 53-year-old female presented with a large split thickness skin graft due to skin loss as a necrotic complication from an abdominoplasty performed at our center. The patient suffered from emotional stress related to the abdominal deformity, which included a lack of an umbilicus. RESULTS:Patient recovered well post-operatively. She required two procedures - the initial procedure involved excision of the skin graft and closure with the patient's own full-thickness skin and tissue. The second procedure, which occurred six months later, involved the creation of an umbilical stalk from a small cuff of skin. CONCLUSION/CONCLUSIONS:Abdominoplasty, although sought for cosmetic purposes, is indeed a major procedure and can result in complications especially from aggressive liposculpture. When complications do occur, revisions are indeed possible with aesthetically pleasing results.

Systemic and structural barriers limit dental health for individuals with special healthcare needs (SHCN), who have poorer dental hygiene, higher rates of dental disorders, and less access to oral care. We aimed to understand these barriers directly from the patient and caregiver population as well as review the literature on oral health of individuals with SHCN. We reviewed the literature on individuals and caregivers of those with SHCN to identify barriers to dental healthcare faced by these individuals. We focused on clinical and educational interventions to support clinicians treating this population. For the literature review, PubMed, Google, and Google Scholar were searched. We also relied upon the knowledge gained during the course of routine clinical care and patient advocacy activities. Published manuscripts were searched for the following Medical Subject Heading (MeSH) term: "Dental Care for Disabled" and the following subheading: pharmacology, adverse effects, ethics, methods, standards, and therapy. Relatively few dentists have formal training on caring for those with SHCN. Barriers faced by these individuals include accessibility, comorbidities, communication challenges, and barriers to home oral hygiene. Strong care coordination and communication between dentists, caregivers, and other providers is essential for positive outcomes. Our current dental healthcare system has failed to meet the needs of those with SHCN. The comfort and dignity of the patient are of paramount importance.

OBJECTIVE/UNASSIGNED:This systematic review aims to evaluate nasoalveolar molding (NAM) in the context of burden of care defined as physical, psychosocial, or financial burden on caregivers. SEARCH METHODS/UNASSIGNED:Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, 5 databases were searched from inception through December 24, 2019, for keywords and subject headings pertaining to cleft lip and/or palate and NAM. ELIGIBILITY CRITERIA/UNASSIGNED:Clinical studies on NAM with reference to physical (access to care, number of visits, distance traveled), psychosocial (caregiver perceptions, family interactions, breast milk feeding), and financial (direct and indirect costs) burden were included. DATA COLLECTION AND ANALYSIS/UNASSIGNED:Study selection was performed by 2 independent reviewers. RESULTS/UNASSIGNED:The search identified 1107 articles and 114 articles remained for qualitative synthesis. Burden of care domains were discussed but not measured in 43% of articles and only 25% assessed burden of care through a primary outcome. Of these, 20 articles reported on physical, 8 articles on psychosocial, and 12 articles on financial burden. Quality of evidence is limited by study design and risk of bias. CONCLUSION/UNASSIGNED:Nasoalveolar molding has been indiscriminately associated with burden of care in the literature. Although NAM may not be the ideal treatment option for all patients and families, the physical considerations are limited when accounting for the observed psychosocial advantages. Financial burden appears to be offset, but further research is required. Teams should directly assess the impact of this early intervention on the well-being of caregivers and advance strategies that improve access to care.

Migraine is commonly reported among patients with temporomandibular disorders (TMDs), especially myogenic TMD. The pathophysiologic mechanisms related to the comorbidity of the two conditions remain elusive. In the present study, we combined masseter muscle tendon ligation (MMTL)-produced myogenic TMD with systemic injection of nitroglycerin (NTG)-induced migraine-like hypersensitivity in mice. Facial mechanical allodynia, functional allodynia, and light-aversive behavior were evaluated. Sumatriptan, an FDA-approved medication for migraine, was used to validate migraine-like hypersensitivity. Additionally, we examined the protein level of calcitonin gene-related peptide (CGRP) in the spinal trigeminal nucleus caudalis using immunohistochemistry. We observed that mice with MMTL pretreatment have a prolonged NTG-induced migraine-like hypersensitivity, and MMTL also enabled a non-sensitizing dose of NTG to trigger migraine-like hypersensitivity. Systemic injection of sumatriptan inhibited the MMTL-enhanced migraine-like hypersensitivity. MMTL pretreatment significantly upregulated the protein level of CGRP in the spinal trigeminal nucleus caudalis after NTG injection. Our results indicate that a pre-existing myogenic TMD can upregulate NTG-induced trigeminal CGRP and enhance migraine-like hypersensitivity.

Introduction: Oral cancer remains prevalent, despite being largely preventable. The widespread use of technology at chairside, combined with advances in electronic health record (EHR) capabilities, present opportunities to improve oral cancer screening by dentists, especially for disadvantaged patients with severe health needs. Design and methods: Using a mixed-methods approach, we will evaluate the feasibility and acceptability of integrating a telementoring component into the identification of oral lesions using the following 3 methods: 1) administering provider surveys that consist of a checklist of 10 key components of the intervention based on process, and asking the dental provider subjects if each one was covered; 2) conducting semi-structured interviews informed by the Consolidated Framework for Implementation Research and the Implementation Outcomes Framework with dental resident subjects to assess specific barriers to sustaining the intervention and strategies for addressing these barriers to facilitate integration of the intervention into the routine workflow of the dental clinics; and 3) administering brief exit interviews with patient subjects regarding the acceptability of the intervention to assess satisfaction with the use of intra-oral cameras at chairside to screen for and refer patients with oral lesions and identification of these oral lesions via EHR and secure e-mail tele-mentoring with an oral pathology expert. Expected impact of the study for public health: If successful, then later clinical trials will maximize the external validity of the intervention and facilitate the widespread implementation and dissemination of the model for the teaching of dentists and residents, with the ultimate goal of improving patient care.

BACKGROUND:The authors present an institutional experience treating congenital and acquired temporomandibular joint (TMJ) ankylosis, detailing outcomes and potential risk factors of recurrence. METHODS:Retrospective chart review identified patients with TMJ ankylosis (1976-2019). Clinical records, operative reports, and imaging studies were reviewed for demographics, surgical operations, and ankylosis including maximal interincisal opening (MIO) and re-ankylosis. RESULTS:Forty-four TMJs with bony ankylosis were identified in 28 patients (mean age at any initial mandibular surgery: 3.7; range:0-14 years). Follow-up was 13.7 ± 5.9 years. Sixteen (57.1%) patients had bilateral ankylosis; 27(96.4%) had syndromes. Nine patients had congenital ankylosis, 16 had iatrogenic ankylosis (4.5 ± 3.7 years from initial distraction osteogenesis or autologous mandibular reconstruction) referred from outside institutions in 6 instances, and 3 had post-infectious ankylosis. Patients having their first mandibular operation at a younger age had more frequent reoperations for recurrent TMJ ankylosis, although this did not reach statistical significance. Mean improvement in MIO was 21.4 ± 7.3 mm. Ankylosis recurred in 21 (75%) patients. Five patients with congenital TMJ ankylosis required gastrostomy and remained at least partially dependent. Five patients had tracheostomy at the time of TMJ ankylosis surgery: 2 were eventually decannulated and 3 required repeat tracheostomy after ankylosis recurrence and remained tracheostomy-dependent. CONCLUSION/CONCLUSIONS:The clinical course of TMJ ankylosis in children affected by craniofacial differences is complex and typically involves a high rate of recurrence and multiple reoperations despite initial improvement in postoperative MIO. Younger age at initial mandibular surgery and number of operations require further investigation as potential predictors of recurrent TMJ ankylosis as well as tracheostomy and gastrostomy dependence.