Faculty Bibliography

Reconstruction of large maxillary and mandibular defects following ablative surgery has posed a challenge to the head and neck surgeon due to the high functional and esthetic demands requiring precise three-dimensional reconstruction. Previous issues with maxillofacial reconstruction have included poor facial contour, unfavorable orthognathic relationships, and inability to provide adequate dental rehabilitation. The advent of the fibula flap along with (3D) facial analysis and virtual surgical simulation has revolutionized surgical interventions of the head and neck. Recent reports on the long-term success of dental implants in fibula reconstructions have made dental rehabilitation a reality. However, the loading and restoration of these implants are usually delayed prior to final prosthodontic rehabilitation leading to adverse functional, esthetic and psychological effects. Rohner et al. has documented the success of a two-stage surgery of fibula harvest and dental implant placement (Stage 1) followed by ablative surgery, inset and immediate loading with a dental prosthesis (Stage 2)⁽²⁾; this procedure is a two stage process that involves a 10-week delay between each surgery and will leave the patient edentulous. At our institution, computer-aided surgery and CAD/CAM technologies have enabled us to virtually plan complex surgery and have afforded our group the opportunity of providing a "Jaw in a Day '¹ This technique is a one-stage complete surgery including ablation, free flap, implant, and prosthetic reconstruction. A retrospective chart review was conducted for all patients who received immediate dental implants with a dental prosthesis in a fibular free flap following mandibular resection due to benign tumors. "Jaw in a Day 'procedures were completed at two of our affiliated hospitals (Bellevue Hospital Center and NYU Langone Medical Center) from January 2011 to January 2015. We looked at success rate of flaps, implants, and prostheses. We also looked at primary and long-term complications. Of the 8 patients who underwent the above procedure, a total of 35 immediate implants were placed along with a fixed prosthesis. Patients received maxillary/mandibular resection, fibula free flap reconstruction with immediate implant and dental prosthesis placement. All patients treated were diagnosed with benign mandibular (7) and maxillary (1) tumors, including ameloblastoma (6), odontogenic myxoma (1), and AV malformation (1). Of the 35 implants placed, 1 implant failed and was removed. The cumulative survival of fibular-free flaps was 100%. The cumulative implant success rate was 97%. Complications included soft tissue perimplantitis (2), plate exposure (2), and (1) prosthesis that did not adequately fit. The followup of the 8 patients was from January 2011 to January 2015. Single-stage maxillofacial reconstruction with virtual surgical planning has greatly impacted the field of maxillofacial reconstruction allowing for precision and accuracy while improving patient's function and quality of life. The above study shows its feasibility and low complication rates. Immediate implant and dental prosthesis placement has helped reduce the time for dental prosthetic rehabilitation and avoid the traditional 3- to 6-month delay period. Reconstruction with a MVFFF and immediate dental rehabilitation has revolutionized the treatment of benign tumor following ablative surgery

BACKGROUND: Patients undergoing autologous breast reconstruction have higher long-term satisfaction rates compared with those undergoing prosthetic reconstruction. Regardless, most patients still undergo prosthetic reconstruction. The authors compared outcomes of microsurgical reconstruction to those of prosthetic reconstruction in thin patients and evaluated the effect of reconstructive type on quality of life. METHODS: After institutional review board approval was obtained, the authors reviewed all patients undergoing breast reconstruction at a single institution from November of 2007 to May of 2012. Thin patients (body mass index <22 kg/m) were included for analysis and divided into two cohorts: microsurgical reconstruction and tissue expander/implant reconstruction. Once identified, patients were mailed a BREAST-Q survey for response; a retrospective chart review was also conducted. RESULTS: A total of 273 patients met inclusion criteria: 81.7 percent (n = 223) underwent tissue expander/implant reconstruction and 18.3 percent (n = 50) underwent microsurgical reconstruction. Of the patients undergoing microsurgical reconstruction, 50 percent (n = 25) responded to the BREAST-Q survey, whereas 48.4 percent of patients (n = 108) with implant reconstruction were responders. Microsurgical patients required more secondary revision [48 percent (n = 12) versus 25.9 percent (n = 28)] and autologous fat grafting [32 percent (n = 8) versus 16.9 percent (n = 19)] and a greater volume of fat per injection (147.85 ml versus 63.9 ml; p < 0.001). Furthermore, BREAST-Q responses showed that these patients were more satisfied with their breasts (71.1 percent versus 64.9 percent; p = 0.004), but had similar overall satisfaction with reconstruction (73.0 percent versus 74.8 percent; p = 0.54). CONCLUSIONS: Microsurgical breast reconstruction is efficacious in patients with a body mass index less than 22 kg/m and, when compared with prosthetic reconstruction, results in higher satisfaction with breasts. However, it requires more secondary revision surgery and the use of autologous fat grafting as an adjunct. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Background Prolonged operative time has been associated with increased postoperative complications and higher costs. Many academic centers have a designated day for didactics that cause cases to start 1 hour later. The purpose of this study is to analyze the late-start effect of microvascular breast reconstructions on operative duration. Methods A retrospective review was performed on all patients who underwent abdomina-based free flap breast reconstruction from 2007 to 2011 and analyzed by those who had surgery on late-start versus normal-start days. Patient demographics, average operative time, postoperative complications, and individual surgeon effects were analyzed. A Student t-test was used to compare operative times with statistical significance set at p < 0.05. A multivariate regression analysis was performed to control for potential confounders. Results A total of 272 patients underwent 461 free flap breast reconstructions. Twenty-one cases were performed on late-start days and 251 cases were performed on normal-start days. Patient demographics and complications were not statistically different between the groups. The average operative time for all reconstructions was 434.3 minutes. The average operative times were significantly longer for late-start days, 517.6 versus 427.3 minutes (p = 0.002). This was true for both unilateral and bilateral reconstructions (432.8 vs. 350.9 minutes, p = 0.05; 551.5 vs. 461.2 minutes, p = 0.007). There were no differences in perioperative complications and multivariate regression showed no statistically significant relationship of confounders to duration of surgery. Conclusion Starting cases 1 hour later can increase operative times. Although outcomes were not affected, we recommend avoiding lengthy procedures on late-start days.

PURPOSE: Image-guided surgical navigation, or computed tomography (CT)-guided surgery, is a technology used by many specialties to reduce complications and improve surgical outcomes. Its use has become widespread in neurosurgical intracranial and otolaryngological skull base procedures. The authors hypothesize that CT image-guided surgical navigation has a wide scope of utility in complex craniomaxillofacial procedures. With time and experience, its use will further advance the safety and efficacy of craniomaxillofacial surgery. METHODS: A multicenter retrospective study at the University of California-Los Angeles, New York University, University of Pittsburgh, and the University of Kansas Medical Center was conducted. All craniomaxillofacial procedures using CT image-guided surgical navigation were reviewed. RESULTS: Twenty subjects were identified who underwent a total of 26 CT-guided navigation procedures (6 cases were bilateral). Subunits reconstructed included: the upper face (n = 5), middle face (n = 7), and lower face (n = 6). Two additional patients used CT navigation to reconstruct multiple facial subunits. In all 20 subjects, the image-guided system correctly identified the surgical anatomy to less than 2 mm. There were no perioperative complications. Long-term follow-up demonstrated no revisionary procedures were required to date. CONCLUSIONS: Computed tomography-guided navigation is a safe and effective tool with multiple applications in craniomaxillofacial surgery. Indications for its use in complex craniomaxillofacial procedures continue to broaden. Further experience with this technology will continue to expand its clinical utility in craniomaxillofacial surgery.

Large cell neuroendocrine carcinoma of the breast (NECB) is an extremely rare type of breast cancer; little is known about effective chemotherapies, and data on pathologic response to treatment are unavailable. We report the case of a 34-years-old woman with large cell NECB with initial clinical and pathologic evidence of treatment response to anthracycline-containing neo-adjuvant therapy. Histologic reassessment early during anthracycline chemotherapy revealed cell death with necrosis of 50% of the tumor cells seen in the biopsy specimen. After completing neo-adjuvant chemotherapy, the patient underwent breast-conserving surgery. Pathologic evaluation of the surgical specimen showed a partial response but margins were positive for residual carcinoma. Despite repeated neo-adjuvant chemotherapy, radiotherapy, and surgical resection, the tumor grew rapidly between surgeries and recurred systemically. Therefore, we review the literature on large cell NECB and its treatment options.

Background The purpose of this investigation was to examine patients with low body mass index (BMI) regarding the feasibility to perform autologous breast reconstruction in such patients, as well as to determine optimal donor sites and evaluate outcomes accordingly. Patients and Methods All patients undergoing microsurgical breast reconstruction were divided into three cohorts based on BMI. Group 1 included patients with BMI greater than or equal to 22 kg/m2 and was defined "low-normal BMI." Patients with BMI 22 to 25 kg/m2 were placed in Group 2, labeled as "high-normal BMI." Group 3, defined as "overweight," included patients with BMI greater than 25 kg/m2, but less than 30 kg/m2. Patients were then analyzed based on demographics, breast cancer history, intraoperative details, complications, and revisionary surgeries. F-tests, chi-square goodness-of-fit tests, and Freeman-Halton extension of the Fisher exact tests were used for statistical analysis. Results During the study period, a total of 259 reconstructions were performed. Group 1 included 30 patients (n = 49 flaps), Group 2 included 58 patients (n = 98 flaps), and Group 3 included 69 patients (n = 112 flaps). Patients undergoing nipple-areolar sparing mastectomy were more likely to be in Groups 1 (39% [n = 19]) and 2 (37% [n = 37]) as compared with Group 3 (14.2% [n = 16]) (p < 0.001) as compared with the overweight cohort. Patients with increasing BMI were more likely to undergo abdominally based free flaps as compared with alternative donor sites (Group 1 = 2.26, Group 2 = 7.9, Group 3 = 27 [p < 0.001]). Conclusions Abdominally based free flaps are possible in the majority of patients, however alternative harvest sites have to be used more frequently in low BMI patients.

BACKGROUND: The free fibula osteocutaneous flap has become the criterion standard for reconstruction of complex mandibular defects. The authors present their institutional experience with optimization of flap contouring and inset using virtual planning and prefabricated cutting jigs. METHODS: All free fibula-based mandible reconstructions performed at the authors' institution using virtual planning technology between 2009 and 2012 were retrospectively analyzed. The authors evaluated a variety of patient and procedural variables and outcomes. A series of cases performed before virtual planning was reviewed for comparison purposes. RESULTS: Fifty-four reconstructions were performed in 52 patients. Patients were divided evenly between a private university-affiliated medical center and a large county hospital. The most common indications were malignancy (43 percent), ameloblastoma (26 percent), and osteonecrosis/osteomyelitis (23 percent). Thirty percent of patients had irradiation of the recipient site and 38 percent had previous surgery. Sixty-three percent of patients received dental implants, with 47 percent achieving functional dentition. Twenty-five percent of patients had immediate dental implant placement, and 9 percent had immediate dental restoration. Postoperative imaging demonstrated excellent precision and accuracy of flap positioning. Comparison with cases performed before virtual planning demonstrated increased complexity of flap design along with reduced operative time in the virtually planned group. CONCLUSIONS: Preoperative virtual planning along with use of prefabricated cutting jigs allows for precise contouring and positioning of microvascular fibula free flaps in mandibular reconstruction. Using this technique, the authors have achieved unprecedented rates of dental rehabilitation along with reduced operative times. The authors believe that virtual planning technologies are an emerging criterion standard in mandible reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

BACKGROUND: Reconstruction in the setting of prior breast irradiation is conventionally considered a higher-risk procedure. Limited data exist regarding nipple-sparing mastectomy in irradiated breasts, a higher-risk procedure in higher-risk patients. METHODS: The authors identified and reviewed the records of 501 nipple-sparing mastectomy breasts at their institution from 2006 to 2013. RESULTS: Of 501 nipple-sparing mastectomy breasts, 26 were irradiated. The average time between radiation and mastectomy was 12 years. Reconstruction methods in the 26 breasts included tissue expander (n = 14), microvascular free flap (n = 8), direct implant (n = 2), latissimus dorsi flap with implant (n = 1), and rotational perforator flap (n = 1). Rate of return to the operating room for mastectomy flap necrosis was 11.5 percent (three of 26). Nipple-areola complex complications included one complete necrosis (3.8 percent) and one partial necrosis (3.8 percent). Complications were compared between this subset of previously irradiated patients and the larger nipple-sparing mastectomy cohort. There was no significant difference in body mass index, but the irradiated group was significantly older (51 years versus 47.2 years; p = 0.05). There was no statistically significant difference with regard to mastectomy flap necrosis (p = 0.46), partial nipple-areola complex necrosis (p = 1.00), complete nipple-areola complex necrosis (p = 0.47), implant explantation (p = 0.06), hematoma (p = 1.00), seroma (p = 1.00), or capsular contracture (p = 1.00). CONCLUSION: In the largest study to date of nipple-sparing mastectomy in irradiated breasts, the authors demonstrate that implant-based and autologous reconstruction can be performed with complications comparable to those of the rest of their nipple-sparing mastectomy patients.