Faculty Bibliography

Background The authors describe our current practice of computer-aided virtual planned and pre-executed surgeries using microvascular free tissue transfer with immediate placement of implants and dental prosthetics.Methods All patients with ameloblastomas treated at New York University (NYU) Medical Center during a 10-year period from September 2001 to December 2011 were identified. Of the 38 (36 mandible/2 maxilla) patients that were treated in this time period, 20 were identified with advanced disease (giant ameloblastoma) requiring aggressive resection. Reconstruction of the resultant defects utilized microvascular free tissue transfer with an osseocutaneous fibular flap in all 20 of these patients.Results Of the patients reconstructed with free vascularized tissue transfer, 35% (7/20) developed complications. There were two complete flap failures with consequent contralateral fibula flap placement. Sixteen patients to date have undergone placement of endosteal implants for complete dental rehabilitation, nine of which received immediate placement of the implants at the time of the free flap reconstruction. The three most recent patients received immediate placement of dental implants at the time of microvascular free tissue transfer as well as concurrent placement of dental prosthesis.Conclusions To our knowledge, this patient cohort represents the largest series of comprehensive computer aided free-flap reconstruction with dental restoration for giant type ameloblastoma.

OBJECTIVE: : To use an evidenced-based approach to better understand the management and treatment of pressure ulcers. BACKGROUND: : 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 and/or prevention 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 to present). RESULTS: : We reviewed the most relevant, high-level evidence that exists for the following modalities for understanding, preventing, and treating pressure ulcers: wound cleansers, repositioning, negative pressure therapy, debridement, enteral and parenteral feeding, vitamin and mineral supplementation, specialized mattresses, ultrasound therapy, honey, cellular therapy, musculocutaneous and fasciocutaneous flap closure, and other miscellaneous therapies. CONCLUSIONS: : Although many of these modalities are used, we encourage clinicians and health care providers to consider the evidence-based data when deciding how to most appropriately manage their patients' pressure sores.

BACKGROUND: : Nipple-sparing mastectomy warrants thorough preoperative evaluation to effectively achieve risk reduction, high patient satisfaction, and improved aesthetic outcome. To the authors' knowledge, this review represents the largest series of microsurgical breast reconstructions following nipple-sparing mastectomies. METHODS: : All patients undergoing nipple-sparing mastectomy with microsurgical immediate breast reconstruction treated at New York University Medical Center (2007-2011) were identified. Patient demographics, breast cancer history, intraoperative details, complications, and revision operations were examined. Descriptive statistical analysis, including t test or regression analysis, was performed. RESULTS: : In 51 patients, 85 free flap breast reconstructions (n = 85) were performed. The majority of flaps were performed for prophylactic indications [n = 55 (64.7 percent)], mostly through vertical incisions [n = 40 (47.0 percent)]. Donor sites included abdominally based [n = 66 (77.6 percent)], profunda artery perforator [n = 12 (14.1 percent)], transverse upper gracilis [n = 6 (7.0 percent)], and superior gluteal artery perforator [n = 1 (1.2 percent)] flaps. The most common complications were mastectomy skin flap necrosis [n = 11 (12.7 percent)] and nipple necrosis [n = 11 (12.7 percent)]. There was no correlation between mastectomy skin flap or nipple necrosis and choice of incision, mastectomy specimen weight, body mass index, or age (p > 0.05). However, smoking history was associated with nipple necrosis (p < 0.01). CONCLUSIONS: : This series represents a high-volume experience with nipple-sparing mastectomy followed by immediate microsurgical reconstruction. When appropriately executed, it can deliver low complication rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: : Therapeutic, IV.

Craniofacial vascularized composite allotransplantation is especially challenging when bony components are required. Matching the complex three-dimensional anatomy of the donor and recipient craniofacial skeletons to optimize bony contact and dental occlusion is a time-consuming step in the operating room. Currently, few tools exist to facilitate this process. The authors describe the development of a virtual planning protocol and patient-specific device design to efficiently match the donor and recipient skeletal elements in craniofacial vascularized composite allotransplantation. The protocol was validated in a cadaveric transplant. This innovative planning method allows a "snap-fit" reconstruction using custom surgical guides while maintaining facial height and width and functional occlusion. Postoperative overlay technology in the virtual environment provides an objective outcome analysis.

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: 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.

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