Faculty Bibliography

BACKGROUND: In 1964, faced with the challenge of traumatic amputation, a team of surgeons at Clinica Guayaquil was convinced that the transplantation of a hand could significantly improve function and quality of life for the recipient. With a current but basic understanding of immunosuppression, the surgeons identified a recipient and waited for the correct donor. A human hand transplant had never been performed to date. METHODS: The surgeons' criteria for the recipient included a young healthy individual who had sustained a traumatic amputation at the distal forearm level with full motion of the proximal joints. Communication with receiving hospitals and military facilities identified what they perceived to be a feasible donor for an allograft transplantation. Consent was obtained from the family in conjunction with the local military medical authorities and the clergy. Iced saline solution and Heparin irrigation were to be used to prepare the donor extremity. The immunosuppression regimen, limited at the time, consisted only of intravenous cortisone, Imuran, and a single dose of radiation. RESULTS: A member of the Ecuadorian marine sustained a limited blast injury that amputated his dominant hand but spared the forearm. He was transferred to the emergency department of Clinica Guayaquil. A donor who had recently died in a nearby hospital was identified not long after. A successful technical surgical transplantation was achieved. Consultants from major hospitals around the world (including Peter Bent Brigham Hospital) convened at the patient's bedside to observe the results. Despite all efforts, the patient suffered an irreversible rejection at 21 days post-transplant. CONCLUSION/CONCLUSIONS: This was the first allograft transplantation of a hand. The surgeons embarked on an intervention never tried before, firmly believing that better function and quality of life would result. The bravery of this surgical team was commendable. This early surgical endeavor opened the way for future successes in transplant surgery today.

INTRODUCTION:Patients with burn wounds of the lower extremities are at increased risk of developing cellulitis. The probability of developing burn-associated cellulitis is presumed to be correlated with a medical history of diabetes, the etiology of the burn, delay in hospitalization of the patient during their initial presentation, and depth of the burn itself. This study aims to identify factors that place patients at increased risk for developing lower extremity burn wound cellulitis. MATERIALS AND METHODS:A retrospective chart review was performed of all Nassau University Medical Center Burn Center admissions from January 2010 to January 2016. All patients admitted with burns of any etiology isolated to the lower extremity were included in this study. Patients who were evaluated and followed as an outpatient were not included in this study. Pediatric patients less than or equal to 12 years of age were excluded from this study. RESULTS:Of the 218 admissions for lower extremity burns during the 6-year study period, 34% of patients developed cellulitis. Risk factors for developing lower extremity burn wound cellulitis included being male, greater depth of burn, and burn-to-admission delay. This was true in both univariate and multivariate analysis. total body surface area was a risk factor on univariate analysis but was not found to be an independent risk factor on multivariate analysis. No difference was observed in the development of cellulitis in patients discharged on oral antibiotics compared with those not given antibiotics. CONCLUSIONS:Burn wound cellulitis is the second most common complication observed in burns. Identification of patients at risk for developing cellulitis is important. Admitting these patients at increased risk and excising and grafting the burned area is a reasonable solution in preventing this costly complication.

LEARNING OBJECTIVES/OBJECTIVE:After reviewing this article, the participant should be able to: 1. Understand the most modern indications and technique for neurotization, including masseter-to-facial nerve transfer (fifth-to-seventh cranial nerve transfer). 2. Contrast the advantages and limitations associated with contiguous muscle transfers and free-muscle transfers for facial reanimation. 3. Understand the indications for a two-stage and one-stage free gracilis muscle transfer for facial reanimation. 4. Apply nonsurgical adjuvant treatments for acute facial nerve paralysis. SUMMARY/CONCLUSIONS:Facial expression is a complex neuromotor and psychomotor process that is disrupted in patients with facial paralysis breaking the link between emotion and physical expression. Contemporary reconstructive options are being implemented in patients with facial paralysis. While static procedures provide facial symmetry at rest, true 'facial reanimation' requires restoration of facial movement. Contemporary treatment options include neurotization procedures (a new motor nerve is used to restore innervation to a viable muscle), contiguous regional muscle transfer (most commonly temporalis muscle transfer), microsurgical free muscle transfer, and nonsurgical adjuvants used to balance facial symmetry. Each approach has advantages and disadvantages along with ongoing controversies and should be individualized for each patient. Treatments for patients with facial paralysis continue to evolve in order to restore the complex psychomotor process of facial expression.

Simultaneous Mie scattering and laser-induced fluorescence (LIF) signals are obtained from individual polystyrene latex microspheres dispersed in an air flow. Microspheres less than 1 μm mean diameter were doped with two organic fluorescent dyes, Rhodamine B (RhB) and dichlorofluorescein (DCF), intended either to provide improved particle-based flow velocimetry in the vicinity of surfaces or to provide scalar flow information (e.g., marking one of two fluid streams). Both dyes exhibit measureable fluorescence signals that are on the order of 10(-3) to 10(-4) times weaker than the simultaneously measured Mie signals. It is determined that at the conditions measured, 95.5% of RhB LIF signals and 32.2% of DCF signals provide valid laser-Doppler velocimetry measurements compared with the Mie scattering validation rate with 6.5 W of 532 nm excitation, while RhB excited with 1.0 W incident laser power still exhibits 95.4% valid velocimetry signals from the LIF channel. The results suggest that the method is applicable to wind tunnel measurements near walls where laser flare can be a limiting factor and monodisperse particles are essential.

Many burn patients experience more intense pain from the split thickness skin donor site than in the grafted burn wound in their postoperative period. Often, split thickness autografts are harvested from the lateral thigh area, which is innervated by the lateral femoral cutaneous nerve (LFCN). Sonographic nerve localization has been an increasingly popular technique to provide regional nerve blocks and we explore its role in improving pain control during skin harvesting. The LFCN was identified and blocked using ultrasound in 16 patients with a variety of wounds. The donor site was tested and marked after the injection. General anesthesia or sedation was administered after markings were completed. A postoperative survey was performed to assess the return of sensation at the donor site. All blocks were successful with adequate visualization of LFCN using ultrasound. Full anesthesia at the donor site, defined as absence of pain in response to a sharp object prick, was tested at 15 min and confirmed at 20 min after the block. The size of the anesthetized field ranged from 119 to 630 cm(2), with a mean surface area of 268.5 cm(2). Donor site sensation returned within 5-16 h with a mean time of 9.1h. Ultrasound guided LFCN block provides a simple and safe choice of anesthesia for harvesting skin from the lateral thigh.

BACKGROUND:Patient reported outcome studies are extremely valuable. We hypothesize that breast reduction surgery has a high satisfaction rate, and that body mass index (BMI), and the amount of breast tissue removed would not alter this outcome. The purpose of this study was to determine if there is an improvement in the quality of life in patients undergoing breast reduction surgery, and whether breast volume or patient size influences this outcome. METHODS:A retrospective chart review was performed on 600 consecutive patients at a single institution from 2000 to 2010. Patients were mailed The Breast Q questionnaire to complete. Demographic, surgical, and clinical data were collected and entered into a database. Descriptive statistical analyses were conducted using SAS Software version 9.1.3 with statistical significance determined at P<0.05. RESULTS:A total of 178 surveys were returned and included in our study (a response rate of 29.6%). Patient data included a mean BMI of 28.3 (4.6) kg/m, and mean total amount of breast tissue removed of 1220.9 (665.4) g. The primary indications for patients having breast surgery were for symptomatic macromastia (85%), asymmetry (5.6%), and for cosmesis (2.5%). The Breast Q questionnaire demonstrated patients overwhelmingly agreed that they were satisfied with their breast surgery. The mean response was 2.8 with a standard deviation (SD) of 0.47 (where 1, disagree; 2, somewhat agree; and 3, definitely agree). Patient BMI and total amount of breast tissue removed had a statistically significant positive correlation (0.479; P<0.0001). There was no statistically significant difference between the amount of total breast tissue removed and patient response (P=0.57). CONCLUSIONS:The study supports a positive outcome after breast reduction surgery. Over 95% of the patients surveyed were satisfied and would do it again. It demonstrates the improvement of the patient's quality of life regardless of the amount of breast tissue removed. Furthermore, it suggests that the size and weight of the patient has no impact on this outcome. As we face new government and insurance restrictions for surgeries that have both cosmetic and reconstructive value, patient reported outcome studies may have an influence on future third-party payer.

OBJECTIVE: To review our experience with tissue expanders for resurfacing the penis in selected cases of complex hypospadias repairs. MATERIALS AND METHODS: We reviewed the medical records of 6 hypospadias male patients who underwent tissue expansion for phallic skin resurfacing. The patients ranged in age from 14-29 years of age at the time of placement of the tissue expander. All 6 patients had 5-8 failed surgeries and were "hypospadias cripples." In each case, the injection port was placed in the suprapubic area, whereas the tissue expander was placed under the skin on the dorsum of the penis. The tissue expanders were inflated slightly in the operating room and then subsequently at 2-week intervals over 12-16 weeks. At the point of maximum tissue expansion, the patients underwent reconstructive surgery and removal of the tissue expanders. RESULTS: Successful tissue expansion occurred in all 6 patients. The patients then underwent penile skin flap reconstruction of their penises. Two patients developed minor complications (1 urethrocutaneous fistula, 1 meatal stenosis), which were successfully corrected. Long-term follow-up ranged from 1-22 years. Successful phallus resurfacing with penile skin was achieved in all 6 patients. CONCLUSION: Patients who have undergone multiple attempted hypospadias repairs may lack a sufficient amount of healthy, unscarred penile skin for a successful outcome. These patients are therefore candidates for tissue expansion of the relatively normal skin usually found on the dorsum of the penis. In our experience, tissue expanders are a safe and effective method of acquiring genital skin for resurfacing in selected cases of hypospadias cripples and therefore should have a place in the surgical armamentarium of complex and redo-hypospadias repairs.

We report a case of a child with isolated unilateral ulnar polydactyly with fusion of the affected digit to the fifth metacarpal and development at an angle retrograde to the axis of the hand.

BACKGROUND:Diabetic nephropathy has become the single most important cause of end-stage renal disease (ESRD) worldwide. Strategies to slow the rate of loss of renal function in these patients have been developed. We examined the risk factors that predict loss of kidney function (doubling of serum creatinine) or ESRD (dialysis or transplantation) in patients with type 2 diabetes in whom blood pressure was controlled. METHODS:We evaluated risk factors for doubling of serum creatinine or the development of ESRD in the Reduction of End Points in NIDDM with the Angiotensin II Receptor Antagonist Losartan (RENAAL) study, which included 1513 patients with type 2 diabetes and nephropathy. RESULTS:Univariate analyses demonstrated a group of 23 risk factors that significantly predicted doubling of serum creatinine or ESRD. From these univariate analyses, a multivariate model was developed that demonstrated four independent risk factors: proteinuria, serum creatinine, serum albumin, and hemoglobin level. Proteinuria was the strongest and most consistent risk factor. The multivariate risk model was derived from only the placebo group and was similar to that derived for the total population, suggesting that the risk predictors for progression of kidney disease were independent of therapy. CONCLUSION/CONCLUSIONS:After control of blood pressure in type 2 diabetic patients with nephropathy, proteinuria, degree of renal failure, serum albumin, and hemoglobin level are independent risk factors that predict renal outcomes. The level of proteinuria proved to be the most important risk for progressive kidney injury in these diabetic patients.