Jonathan P. Massie

Nasal Septal Anatomy in Skeletally Mature Patients With Cleft Lip and Palate.

IMPORTANCE Septal deviation commonly occurs in patients with cleft lip and palate (CLP); however, the contribution of the cartilaginous and bony septum to airway obstruction in skeletally mature patients is poorly understood. OBJECTIVES To describe the internal nasal airway anatomy of skeletally mature patients with CLP and to determine the contributors to airway obstruction. DESIGN, SETTING, AND PARTICIPANTS This single-center retrospective review included patients undergoing cone-beam computed tomography (CBCT) from November 1, 2011, to July 6, 2015, at the cleft lip and palate division of a major academic tertiary referral center. Patients met inclusion criteria for the study if they were at least 15 years old at the time of CBCT, and images were used only if they were obtained before Le Fort I osteotomy and/or formal septorhinoplasty. Twenty-four skeletally mature patients with CLP and 16 age-matched control individuals were identified for the study. MAIN OUTCOMES AND MEASURES Septal deviation and airway stenosis were measured in the following 3 coronal sections: at the cartilaginous septum (anterior nasal spine), bony septum (posterior nasal spine), and midpoint between the anterior and posterior nasal spine. The perpendicular plate of the ethmoid bone and vomer displacement were measured as angles from the vertical plane at the coronal section of maximal septal deviation. The site of maximal septal deviation was identified. RESULTS Among the 40 study participants, 26 were male. The mean (SD) age was 21 (5) and 23 (6) years for patients with CLP and controls, respectively. Septal deviation in patients with CLP was significantly worse than that of controls at the anterior nasal spine (2.1 [0.5] vs 0.8 [0.2] mm; P < .05) and posterior nasal spine (2.9 [0.5] vs 1.0 [0.3] mm; P < .01) and most severe at the midpoint (mean [SD], 4.4 [0.6] vs 2.1 [0.3] mm; P < .01). The point of maximal septal deviation occurred in the bony posterior half of the nasal airway in 27 of 40 patients (68%). The CLP bony angular deviation from the vertical plane was significant in the CLP group compared with the control group (perpendicular plate of the ethmoid bone, 14° [2°] vs 8° [1°]; vomer, 34° [5°] vs 13° [2°]; P < .05 for both), and vomer deviation was significantly associated with anterior nasal airway stenosis (r = -0.61; P < .01). CONCLUSIONS AND RELEVANCE Skeletally mature patients with CLP have significant septal deviation involving bone and cartilage. Resection of the bony and cartilaginous septum should be considered at the time of definitive cleft rhinoplasty. LEVEL OF EVIDENCE NA.

Ethnic Considerations for Rhinoplasty in Facial Feminization

Ethnic Considerations for Rhinoplasty in Facial Feminization To the Editor The recent publication by Bellinga and colleagues1 highlights a case series of feminization rhinoplasties to identify important factors to achieve superior long-term results and to improve patient satisfaction. This work contributes to a small but growing collection of research in facial feminization, which has become an area of interest in facial plastic surgery. The authors highlight the importance of sufficient long-term support and stability through manipulation of the osteocartilaginous skeleton of the nose and cartilage grafting as well as lip-lift and nasofrontal transition modification for improved aesthetic outcomes. The authors identify 3 objectives in planning a rhinoplasty in the context of facial feminization surgery, including feminization of the nose, creating harmony between the feminized nose and other modified facial structures, and achieving aesthetic results that transcend gender differences. In the Invited Commentary for that article, Spiegel2 notes that in facial feminization, it is important to create an unambiguously feminine form of the nose because the transgender womanmustovercomeaconstellationofphysicaltraitsthatsend male gender cues. The female nose is described as having a straight narrow bridge, well-defined projecting tip, refined alae, and a nasolabial angle of approximately 95° to 100°.3 However, as with most aesthetic ideals, these characteristics are the ideal for white women and may not result in a successful and racially congruent aesthetic result in all patients. Many studies have been published describing differences in the nasal aesthetics of different ethnicities; in their comprehensive review, Rohrich and Bolden3 described the multiple anatomic variants of nasal aesthetics even within each ethnic group, which highlights the importance of ethnic rhinoplasty techniques. Facial feminization surgery can significantly enhance the quality of life and reduce the psychosocial sequelae faced by transgender women, who are often marginalized and discriminated against in health care and society.4,5 When planning for rhinoplasty in facial feminization, it is imperative that the surgeon does not rely solely on the aesthetic standards used for white rhinoplasty patients or classic rhinoplasty techniques in transgender women of other ethnicities. The surgeon should determine each individual patient’s aesthetic goals during the preoperative consultation and develop a surgical plan that is informed by the patient’s anatomy, ethnicity, and desires to achieve a result that is feminine, aesthetically pleasing, and harmonious in the context of the entire feminized face.

Microenvironmental cues enhance mesenchymal stem cell-mediated immunomodulation and regulatory T-cell expansion

Mesenchymal stem cells (MSCs) are known to both have powerful immunosuppressive properties and promote allograft tolerance. Determining the environmental oxygen tension and inflammatory conditions under which MSCs are optimally primed for this immunosuppressive function is essential to their utilization in promoting graft tolerance. Of particular interest is the mechanisms governing the interaction between MSCs and regulatory T cells (Tregs), which is relatively unknown. We performed our experiments utilizing rat bone marrow derived MSCs. We observed that priming MSCs in hypoxia promotes maintenance of stem-like characteristics, with greater expression of typical MSC cell-surface markers, increased proliferation, and maintenance of differentiation potential. Addition of autologous MSCs to CD4+/allogeneic endothelial cell (EC) co-culture increases regulatory T cell (Treg) proliferation, which is further enhanced when MSCs are primed in hypoxia. Furthermore, MSC-mediated Treg expansion does not require direct cell-cell contact. The expression of indolamine 2,3-dioxygenase, a mediator of MSC immunomodulation, increases when MSCs are primed in hypoxia, and inhibition of IDO significantly decreases the expansion of Tregs. Priming with inflammatory cytokines IFNγ and TNFα increases also expression of markers associated with MSC immunomodulatory function, but decreases MSC proliferation. The expression of IDO also increases when MSCs are primed with inflammatory cytokines. However, there is no increase in Treg expansion when MSCs are primed with IFNγ, suggesting an alternate mechanism for inflammatory-stimulated MSC immunomodulation. Overall, these results suggest that MSCs primed in hypoxia or inflammatory conditions are optimally primed for immunosuppressive function. These results provide a clearer picture of how to enhance MSC immunomodulation for clinical use.

Beyond Phonosurgery: Considerations for Patient-Reported Outcomes and Speech Therapy in Transgender Vocal Feminization.

Providing appropriate care for transgender women is essential as more seek gender confirmation treatment for gender dysphoria. A variety of nonsurgical and surgical interventions are available. In terms of voice, pitch elevation in transgender women can have a significant effect on gender confirmation. Both surgical and nonsurgical options for pitch elevation exist. Phonosurgery can be an effective treatment; however, it is not without risk, and alternative nonsurgical interventions like voice therapy should be considered. A recent meta-analysis by Song and Jiang confirmed that transgender phonosurgery can result in significantly increased fundamental frequency (F0). However, lacking from this study was a mention of speech therapy’s role and effectiveness. Primary literature suggests F0 can be increased after speech therapy in transgender women, but no review of these data has been compiled. With a minimal risk profile, speech therapy has an important role in vocal feminization. Cost of surgery and limited availability of surgical specialists may be other reasons to consider speech therapy. Patient centeredness is paramount in treatment decision making, as it is the patients’ perspective and happiness with their voice that is the ultimate arbiter of success, not solely the ability to raise F0 with either voice therapy or surgery. We argue that the primary outcome for pitch elevation interventions should be patient centered. Interventions to change physiologic aspects of the voice should be judged based on whether the patient achieves improved quality of life and sense of self. Ultimately, it is the patient’s goals and perceptions that are most important. Successful outcomes in gender-confirming surgery are largely defined based on patients’ ability to live and be perceived as their true gender in all aspects of life. To date, little data exist on patient-reported outcomes after gender-confirming surgery, and when evaluated, the data are often nonstandardized and analyzed unreliably. Song and Jiang acknowledge this limitation in outcome assessment in primary literature. A standardized and reliable assessment of patient-reported outcomes after pitch elevation could add substantially to our understanding of the outcomes of pitch elevation. Transgender patients are often discriminated against and marginalized in the health care field. As the benefits of gender-confirming therapies are becoming more established, it is imperative that our surgical research be rigorous, standardized, and balanced, recognizing that nonsurgical interventions like voice therapy should also be strongly considered and studied. While we strive to deliver improved surgical interventions to better the quality-oflife outcomes to our transgender patients, we must not overlook effective nonsurgical options.

Outpatient Alveolar Bone Grafting.

Purpose:Alveolar bone graft (ABG) has traditionally been performed with a postoperative inpatient stay secondary to donor site pain. Upon transitioning from an open iliac bone harvesting technique to an Acumed trephine, the authors observed that donor site pain was reduced eliminating an inpatient stay. This study examines the cost savings associated with outpatient ABG surgery. Methods:A retrospective single-institution review was conducted on all patients who had an ABG performed from 2012 to 2015. Patients were categorized based upon hospital stay: inpatient, observation (23-hour), or outpatient. Cost data reported included: total direct cost, total variable direct cost, fixed direct cost, and the sum of total direct costs for both medical/surgical supplies and operating room costs. T tests were used to determine differences in various cost categories between groups of patients. Results:Sixty-two procedures were performed: 7 procedures were inpatient, 16 observation, and 39 outpatient. The total direct costs averaged

Abstract 103: primed mesenchymal stem cells prevent endothelial activation and improve allograft perfusion following transplantation.

4536 for inpatients,

The Effect of Nasoalveolar Molding on Nasal Airway Anatomy: A 9-Year Follow-up of Patients With Unilateral Cleft Lip and Palate

3222 for the observation group, and

Ex vivo allotransplantation engineering: Delivery of mesenchymal stem cells prolongs rejection-free allograft survival

3340 for the outpatient group. Inpatient and outpatient costs were significantly different (P <0.01). Total variable direct costs (P <0.05) and fixed direct costs (P <0.01) were significantly lower in the outpatient/observation group. All costs for the observation group were significantly lower than inpatient costs, but were not significantly different than outpatient costs. There were no readmissions reported. Conclusions:Cost of an inpatient stay is significantly higher than outpatient or 23-hour observation for ABG procedures. The Acumed trephine technique allows for same-day discharge. In the face of declining reimbursement, safe and cost-efficient treatments are an appealing option.

Variations in Databases Used to Assess Academic Output and Citation Impact

PurPose: Endothelial activation following ischemia-reperfusion injury (IRI) in transplantation triggers the inflammatory cascade, compromising allograft perfusion. Additionally, IRI is a critical factor that contributes to the incidence and severity of both acute and chronic rejection. We have previously demonstrated that mesenchymal stem cells (MSCs) can be seeded into allografts ex vivo where they take up residence in the perivascular space. While conventional expansion of MSCs produces an innate immunomodulatory phenotype, conditions that enhance this phenotype may be utilized to attenuate endothelial failure following ischemic insult during transplantation. We hypothesized that expansion under hypoxic conditions or with inflammatory cytokines primes the immunosuppressive functions of MSCs and improves allograft perfusion subsequent to ex vivo delivery.

The Drivers of Academic Success in Cleft and Craniofacial Centers: A 10-year Analysis of over 2000 Publications

Objective: To determine the effects of nasoalveolar molding (NAM) on nasal airway architecture. Design: Retrospective case-control study of patients with unilateral cleft lip treated with NAM vs without NAM. Setting: Tertiary referral center specializing in cleft and craniofacial care. Patients, Participants, and Interventions: Thirty-six patients with complete unilateral cleft lip and alveolus: 19 with NAM therapy and 17 without NAM therapy. Main Outcome Measures: Cone beam computed tomography (CBCT) scans were compared in multiple coronal sections and were evaluated for linear and angular septal deviation, inferior turbinate hypertrophy, and linear and 2-dimensional airway area. Results: There were no significant differences in linear or angular septal deviation, inferior turbinate area, linear stenosis, or airway area between NAM- and non-NAM-treated patients. Conclusions: NAM effectively molds the external nasal cartilage and structures but may have limited effects on internal nasal structures.