Faculty Bibliography

BACKGROUND: The free fibula flap is the standard of care in mandibular reconstruction; however, procedural nuances continue to optimize results. More accurate and efficient osteotomies for graft insetting can be envisioned, which address the difficulty in obtaining a perfect match between the cut ends of the fibula and the mandible and the subsequent giving up of maximal bone contact. We propose a method of complementary offset osteotomies. The angled cuts were virtually planned using three-dimensional computed tomographic images. Optimal offset cuts maximized surface area contact and facilitated intraoperative repositioning in the setting of additional native bone margin requirement. METHODS: Using previously described protocols, three-dimensional virtual reconstructions of the facial skeleton and the fibula (average, series of five) were used to simulate osteotomies at 25, 30, 45, 60, 75, and 90 degrees to the long axis of the fibula. Complementary osteotomies were then simulated at the mandibular body just distal to the first molar in simulated free fibula reconstructions. Total area of apposing surfaces was calculated using computer-aided design. The results from the 25-, 30-, 45-, 60-, and 75-degree cuts were compared with the conventional 90-degree cut. Resin-based mandibular osteotomy guides and a complementary fibula jig were manufactured using computer-aided design. Two representative clinical cases were presented to illustrate proof of principle and benefits. RESULTS: The total surface area of apposing fibula and mandible surfaces in a conventional 90-degree cut was 103.8 +/- 2.05 mm. Decreasing this angle to 75, 60, 45, 30, and 25 degrees yielded increased surface areas of 0.86%, 10.3%, 35.3%, 136.7%, and 194.3%, respectively. Cuts of 25 degrees also allowed for adequate bony contact in the setting of additional margin requirements up to 2.77 cm. Complementary 45-degree cuts provided excellent bone-to-bone contact in a free fibula reconstruction using resin guides and a jig. This angle also facilitated access of the saw to the distal mandible. CONCLUSIONS: Virtual surgical planning is an increasingly recognized technology for optimizing surgical outcomes and minimizing operative time. We present a technique that takes advantage of the precision complementary osteotomies that this technology affords. By creating offset cuts, we can maximize bony contact and ensure adequate contact should additional margins or intraoperative adjustments be required. This flexibility maximizes the precision of premanufactured cutting guides, mitigates the constraints of sometimes unpredictable intraoperative environments, and maximizes bony contact.

BACKGROUND: Moderate to severe soft tissue deficits can exist with craniofacial microsomia or progressive hemifacial atrophy. The authors reviewed the surgical correction of these defects, including serial autologous fat grafting and parascapular free tissue transfer. METHODS: Recently treated patients at the Institute of Reconstructive Plastic Surgery at NYU Medical Center were identified. Patients with microvascular free flap underwent reconstruction with parascapular flaps. These flaps have been modified from previously reported inframammary extended circumflex scapular flaps. Demographic information, operative interventions, complications, and outcomes were reviewed and analyzed. The clinical outcomes of these patients were compared with previously reported patients who underwent serial autologous fat grafting. RESULTS: Five patients were recently treated with 7 parascapular flaps. The mean age of the patients at the time of parascapular flap reconstruction was 13.1 years. These were compared to those previously reported who have undergone serial autologous fat grafting. The mean number of procedures was less for the free tissue transfer cohort. There were no microvascular complications because all free flaps survived. One patient had wound dehiscence of the donor site managed with local wound care and healing by secondary intention. CONCLUSIONS: For patients undergoing multiple-stage reconstruction of craniofacial microsomia, serial fat grafting is a useful tool for soft tissue reconstruction. Alternatively, in those patients with isolated soft tissue hypoplasia, such as progressive hemifacial atrophy, microvascular free tissue transfer is a safe and efficient option.

BACKGROUND: Breast reconstruction rates continue to slowly rise in large part because of patients and physicians becoming more knowledgeable about postmastectomy options. Overall satisfaction with breast reconstruction after mastectomy has traditionally been high, only adding to the popularity of this choice. Prior research has demonstrated that race, age, and socioeconomic status are important determinants in whether a patient undergoes breast reconstruction; specifically, indigent women have a lower rate of breast reconstruction when compared to the national average. METHODS: All records of patients who received mastectomies between January 2001 and December 2009 were examined. The PubMed database was used to search for reference articles. RESULTS: Between January 2001 and December 2009, 309 patients underwent mastectomy, and 134 (43.4%) elected reconstruction. Patients in age ranges 20 to 39 and 40 to 59 were both significantly more likely to undergo reconstruction than patients older than 60 years. Disease stage was not significantly related to rates of breast reconstruction. Reconstruction rates by race and ethnicity were analyzed and demonstrated a significantly lower rate of breast reconstruction in Asian women (34%) compared with Hispanic women (48%), despite the same access to available services. CONCLUSIONS: Our data demonstrate breast reconstruction rates significantly higher than prior studies for women in this public hospital demographic, rivaling the reported numbers from dedicated cancer centers where breast reconstruction is expected to be at the highest range. Types of reconstruction were based mainly on patient choice after full discussion regarding individual options. These data suggest that patients considered to be financially indigent are more likely to have breast reconstruction when their care is delivered at a university-based public hospital where immediate and consistent patient education is practiced in a multidisciplinary setting.

OBJECTIVE: This study aims to use the evidenced-based approach to better understand the surgical management and treatment of pressure ulcers. SUMMARY OF BACKGROUND DATA: Pressure sores are a cause of significant morbidity in the medical community. Although there are a multitude of preventative and treatment options, there remains some degree of uncertainty in the literature in defining the best way to treat and manage pressure sores. METHODS: An exhaustive literature search was performed using several electronic databases. The search revealed several identified modalities for treatment of pressure ulcers. We then assessed each modality individually for the level of evidence that exists in the most current literature, with preference given to more recent studies (2005-present). RESULTS: Here, we reviewed the most relevant, high-level evidence that exists for the following modalities for managing pressure ulcers from a surgical perspective: wound cleansers, repositioning, negative pressure therapy, enteral and parenteral feeding, vitamin and mineral supplementation, specialized mattresses, ultrasound therapy, honey, cellular therapy, debridement, ostectomy, and musculocutaneous and fasciocutaneous flap closure. CONCLUSIONS: Although many of the previously mentioned modalities are used, we encourage clinicians and health care providers to consider the evidence-based data when deciding how to most appropriately manage their patient's pressure sores.

Statement of Problem: Reconstruction of maxillectomy defects is challenging due to the complex 3-dimensional anatomy of the region. It is diverse with multiple effective techniques that appear to functionally aid patients in speech and mastication. Defects can be secondary to benign or malignant pathology, craniofacial or post-traumatic deformities, and infection. Interocclusal and orthognathic relationships are tantamount to successful reconstruction. Rehabilitation must provide adequate upper lip support and maintain symmetrical alar bases as well as create an adequate seal from the oral cavity to nasal cavity to prevent regurgitation of fluids. Many different classification schemes have been discussed at length within the literature.¹ At our institution we utilize the maxillectomy classification system set forth by Brown et al.² The classification of the vertical component is as follows: Class 1, maxillectomy without an oro-antral fistula; Class 2, low maxillectomy not including orbital floor or contents; Class 3, high maxillectomy involving orbital contents; and Class 4, radical maxillectomy includes orbital exenteration. The horizontal component is classified as follows: a, unilateral alveolar maxillectomy; b, bilateral alveolar maxillectomy; and c, total alveolar maxillary resection. Methods: A retrospective review was performed of case records at Bellevue Hospital Center/New York University Langone Medical Center during a 6-year period from June 2006 to February 2012. In addition to patient demographics the charts were reviewed for Brown classification, tumor pathology, type of reconstruction, timing of feeding by mouth, and patient satisfaction. Methods of Data Analysis: This was a retrospective chart review from June 2006 to February 2012. Descriptive statistics were used to analyze the data. Results: Fifty patients were identified, the average age was 49. The lowest Brown classification was 1A; there were no orbital exenterations thus our highest Brown class was 3C. The pathology was reviewed; 40% of the lesions were malignant and 60% of lesions were benign. 24% of patients were treated with microvascular free tissue transfer: 38% osteocutaneous and 62% myofasciocutaneous. 18% were treated with obturators, 16% were treated with local flaps, 16% were treated with nonvascularized bone grafts, 14% were treated zygomatic implants, and 12% were treated using a combination of local flaps, obturators, zygomatic implants, and free tissue transfer. 34% of patients fell into Brown class one, 48% of patients were Brown class two, and 18% of patients were Brown class three. Postoperatively patients were fed immediately unless treated with free tissue transfer. Subjectively, all but one patient was satisfied with their maxillary reconstruction. This patient had an obturator placed after resection of squamous cell carcinoma of the maxilla, and was unable to tolerate the obturator. She was later reconstructed using a microvascular radial forearm free flap and is now able to function, phonate, and is content with her current status. Conclusion: All methods described above are viable surgical options and decisions for reconstruction must be on a patient specific basis. However, one can extrapolate that the higher the Brown class the larger the defect and thus the need for microvascular free tissue transfer increases. An algorithm for our reconstruction protocol will be presented

Statement of Problem: The microvascular free fibula flap is widely used to reconstruct complex craniomaxillofacial defects following ablative surgery. Since its popularization for mandibular bony reconstruction in 1989, many permutations of the fibula flap have been applied to composite head and neck defects. Several authors describe endosseous implantation of the fibula post operatively or at the time of surgery to aid in dental reconstruction, but this can leave a patient partially edentulous for up to 1 year after initial surgery. Many patients are lost to follow up and do not go on to complete dental rehabilitation. This may contribute to suboptimal nutritional status, poor cosmetic outcomes, and decreased patient satisfaction. We will discuss how these problems can be circumvented by single stage surgery that incorporates dental implants and a prosthesis to allow for complete jaw reconstruction. Methods: A retrospective chart review at NYU Langone Medical Center and Bellevue Hospital Center was completed to identify patients undergoing extirpative surgery of the maxilla or mandible with immediate reconstruction with a free fibula flap, dental implants, and dental prosthesis from 2011-2012. A total of 5 patients were treated for ameloblastoma (n=3), intraosseus hemangioma (n=1), and odontogenic myxoma (n=1) of the maxilla (n=1) and mandible (n=4). Virtual surgical planning was implemented in all cases. During the computer assisted design phase, a virtual dental construct of an implant supported prosthesis was applied to the planned resection site and the fibula flap was designed to support the desired prosthesis. The cutting jigs for the jaw and fibula were manufactured according to plan as well as the implant borne dental prosthesis. In addition to osteotomy cutting slots, the fibular jig had implant drill guides to aid in correct placement. The prosthesis was secured to the fibular implants with custom abutments and then placed into temporary maxillomandibular fixation with the native dentition prior to plate osteosynthesis of the fibula. Post operative physical examination and computed tomography was used to evaluate occlusion and flap position. Results: All patients were reconstructed successfully with this method without any flap or implant failures. Longest follow up time was 12 months with a mean of 6 months. A total of 23 implants were planned and placed with no implant failures. 1 implant was not used due to suboptimal position in relation to the prosthesis. All patients required post operative guiding elastics with all patients achieving a reproducible desired occlusion by 2 (Figure psented) weeks. All patients tolerated a soft diet by postoperative week 3 without the need for supplemental enteral or parenteral feeding. All patients reported satisfaction in their reconstruction. The mean operative time was 8 hours. One patient needed revision surgery for a mobile locking screw in the plate hardware. Conclusion: The fibula flap continues to be the workhorse of jaw reconstruction, and with proper patient selection and pre-operative planning, it can be used to successfully reconstruct complex maxillofacial defects from bone to teeth in a single operation. In our experience, computer assisted design and virtual planning is essential in achieving the above described results while maintaining appropriate operative times

A serious consequence of diabetes mellitus is impaired wound healing, which largely resists treatment. We previously reported that topical application of calreticulin (CRT), an endoplasmic reticulum chaperone protein, markedly enhanced the rate and quality of wound healing in an experimental porcine model of cutaneous repair. Consistent with these in vivo effects, in vitro CRT induced the migration and proliferation of normal human cells critical to the wound healing process. These functions are particularly deficient in poor healing diabetic wounds. Using a genetically engineered diabetic mouse (db/db) in a full-thickness excisional wound healing model, we now show that topical application of CRT induces a statistically significant decrease in the time to complete wound closure compared with untreated wounds by 5.6 days (17.6 vs. 23.2). Quantitative analysis of the wounds shows that CRT increases the rate of reepithelialization at days 7 and 10 and increases the amount of granulation tissue at day 7 persisting to day 14. Furthermore, CRT treatment induces the regrowth of pigmented hair follicles observed on day 28. In vitro, fibroblasts isolated from diabetic compared with wild-type mouse skin and human fibroblasts cultured under hyperglycemic compared with normal glucose conditions proliferate and strongly migrate in response to CRT compared with untreated controls. The in vitro effects of CRT on these functions are consistent with CRT's potent effects on wound healing in the diabetic mouse. These studies implicate CRT as a potential powerful topical therapeutic agent for the treatment of diabetic and other chronic wounds.

BACKGROUND: : Acellular dermal matrix is commonly used in implant-based breast reconstruction to allow for quicker tissue expansion with better coverage and definition of the lower pole of the breast. This study was performed to analyze complications associated with its use in immediate two-stage, implant-based breast reconstruction and to subsequently develop guidelines for its use. METHODS: : A retrospective analysis of 628 consecutive immediate two-stage tissue expander breast reconstructions at a single institution over a 3-year period was conducted. The reconstructions were divided into two groups: reconstruction with acellular dermal matrix and reconstruction without it. Demographic information, patient characteristics, surface area of acellular dermal matrix, and complications were analyzed and compared. RESULTS: : A total of 407 patients underwent 628 immediate two-stage, implant-based breast reconstructions; 442 reconstructions (70.3 percent) used acellular dermal matrix and 186 (29.6 percent) did not. The groups had similar patient characteristics; however, major complications were significantly increased in the acellular dermal matrix group (15.3 versus 5.4 percent; p = 0.001). These complications included infection requiring intravenous antibiotics (8.6 versus 2.7 percent; p = 0.001), flap necrosis requiring excision (6.7 versus 2.7 percent; p = 0.015), and explantation of the tissue expander (7.7 versus 2.7 percent; p = 0.004). CONCLUSIONS: : Use of acellular dermal matrix in immediate two-stage, implant-based breast cancer reconstruction is associated with a significant increase in major complications. Therefore, it should only be used in specific patients and in minimal amounts. Indications for its use include single-stage permanent implant reconstruction and inadequate local muscle coverage of the tissue expander. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, III.