Faculty Bibliography

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.

PURPOSE: The National Residency Matching Program Match is a very unique process in which applicants and programs are coupled to each other based on a ranking system. Although several studies have assessed features plastic surgery programs look for in applicants, no study in the present plastic surgery literature identifies which residency characteristics are most important to plastic surgery applicants. Therefore, we sought to perform a multi-institutional assessment as to which factors plastic surgery residency applicants consider most important when applying for residency. METHODS: A validated and anonymous questionnaire containing 37 items regarding various program characteristics was e-mailed to 226 applicants to New York University, Albany, University of Michigan, and University of Southern California plastic surgery residency programs. Applicants were asked to rate each feature on a scale from 1 to 10, with 10 being the most important. The 37 variables were ranked by the sum of the responses. The median rating and interquartile range as well as the mean for each factor was then calculated. A Wilcoxon signed rank test was used to compare medians in rank order. RESULTS: A total of 137 completed questionnaires were returned, yielding a 61% response rate. The characteristics candidates considered most important were impressions during the interview, experiences during away rotations, importance placed on resident training/support/mentoring by faculty, personal experiences with residents, and the amount of time spent in general surgery. The characteristics candidates considered least important were second-look experiences, compensation/benefits, program reputation from Internet forums, accessibility of program coordinator, opportunity for laboratory research, and fellowship positions available at the program. CONCLUSIONS: Applicants value personal contact and time spent in general surgery when selecting residency programs. As the number of integrated programs continues to grow, programs will benefit from learning what factors their applicants value most.

BACKGROUND: The Accreditation Council for Graduate Medical Education requires accredited fellowship programs to exhibit proficiency in six broadly defined domains; however, core competencies specifically mandated for hand surgery training have yet to be established. Several studies have demonstrated significant disparities in exposure to essential skills and knowledge between orthopedic surgery- and plastic surgery-based hand surgery fellowship programs. To determine whether significant discrepancies also exist after fellowship between hand surgeons trained in orthopedic surgery and those trained in plastic surgery, clinical practice patterns were evaluated. METHODS: A 20-question survey was created and distributed electronically to American Society for Surgery of the Hand and American Association for Hand Surgery members. Responses were compared using descriptive statistics. RESULTS: Nine hundred eighty-two hand surgeons (76 percent orthopedic and 24 percent plastic) responded, representing a 39 percent response rate. Most plastic surgery hand practices were academic-based (41 percent), whereas orthopedic practices were private (67 percent). More orthopedic hand surgeons worked in multipractitioner practices than plastic surgeons (54 percent versus 30 percent; p < 0.0001). Orthopedic hand surgeons performed a higher percentage of hand cases in their practice facilities (86 percent versus 71 percent; p < 0.0001). Plastic surgeons performed more congenital hand (56 percent versus 35 percent; p < 0.05) and digital replantation cases (53 percent versus 22 percent; p < 0.05) but treated significantly fewer open reduction and internal fixation distal radius fractures. CONCLUSIONS: Orthopedic and plastic surgery hand surgeons differ significantly in their clinical practice patterns. Differences in clinical exposure during training are reflected in practice and persist over time. Referral patterns and practice situations are also contributors to ultimate practice patterns.

BACKGROUND: Fingertip injuries are extremely common in children, and severe trauma with pulp loss requires soft-tissue reconstruction to restore length, bulk, and sensibility. The thenar flap is a well-described technique but there are few reports of its use in pediatric patients. METHODS: Pediatric thenar flap reconstructions were retrospectively identified from October 2000 to October 2010 at a single institution. RESULTS: Sixteen pediatric patients (eleven male, five female) underwent thenar flap procedures. The average age was 10.8years (1.1-17.8years). The average defect size was 1.5cmx1.5cm (1cm(2)-2cm(2)). Division and inset occurred on average 16days later (12-24days). Average follow-up was 6.8months (4.1-9.6months). The average total active range of motion (TAM) in flexion was 248 degrees (235 degrees -260 degrees ) [normal maximum: 260 degrees ]. All patients had 85 degrees metacarpophalangeal joint (MCPJ) range of motion (ROM) [normal maximum: 85 degrees ]. The average proximal interphalangeal joint (PIPJ) ROM was 103 degrees (95 degrees -110 degrees ) [normal maximum: 110 degrees ] in flexion, and an average 60 degrees distal interphalangeal (DIPJ) ROM (55 degrees -65 degrees ) [normal maximum: 65 degrees ] in flexion. Objective sensibility in the flap was ascertained as an average static two-point discrimination of 7mm (6mm-10mm) in 10 compliant patients and was grossly intact in all other patients. There were no complications. CONCLUSIONS: The thenar flap is a safe and effective option for pediatric fingertip amputation injuries requiring soft-tissue reconstruction.

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.

BACKGROUND: Clinical results of fat grafting have been unpredictable. In this article, the authors hypothesize that centrifugation creates "graded densities" of fat with varying characteristics that influence lipoaspirate persistence and quality. METHODS: Aliquots of human female lipoaspirate (10 cc) were centrifuged for 3 minutes at 1200 g. The bloody and oil fractions were discarded. Subsequently, 1.0 cc of the highest density and lowest density fat was separated for lipoinfiltration or analysis. Highest density or lowest density fat grafted into adult FVB mice was harvested at 2 and 10 weeks to quantify short- and long-term persistence, respectively. Progenitor cell number and expression of vascular endothelial growth factor, stromal cell-derived factor-1alpha, platelet-derived growth factor, and adiponectin were analyzed by flow cytometry and enzyme-linked immunosorbent assay, respectively. RESULTS: Greater percentages of highest density fat grafts remain at 2 and 10 weeks after injection compared with lowest density fat grafts (85.4 +/- 1.9 percent versus 62.3 +/- 0.1 percent, p = 0.05; and 60.8 +/- 4.9 versus 42.2 +/- 3.9, p < 0.05, respectively). Highest density fractions contain more progenitor cells per gram than lowest density fractions (2.0 +/- 0.2-fold increase, p < 0.01). Furthermore, concentrations of vascular endothelial growth factor, stromal vascular fraction, platelet-derived growth factor, and adiponectin are all elevated in highest density compared with lowest density fractions (34.4 percent, p < 0.01; 34.6 percent, p < 0.05; 52.2 percent, p < 0.01; and 45.7 percent, p < 0.05, respectively). CONCLUSIONS: Greater percentages of highest density fractions of lipoaspirate persist over time compared with lowest density fractions. A vasculogenic mechanism appears to contribute significantly, as highest density fractions contain more progenitor cells and increased concentrations of several vasculogenic mediators than lowest density fractions.

BACKGROUND: Autogenous fat grafting has been observed to alleviate the sequelae of chronic radiodermatitis. To date, no study has replicated this finding in an animal model. METHODS: The dorsa of adult wild-type FVB mice were shaved and depilitated. The dorsal skin was then distracted away from the body and radiated (45Gy) using a Varian 2300 Linear Accelerator. Four weeks following radiation, 1.5cc fat or sham grafts were placed in the dorsal subcutaneous space. Gross results were analyzed photometrically. The animals were sacrificed at 4 and 8 weeks following fat or sham grafting and their dorsal skin was processed for histologic analysis. Inflammation was assessed by epidermal thickness measurements on H&E stained sections. Vascular density was assessed using CD31 staining. Fibrosis was assessed using Smad-3 and Picrosirius Red staining. RESULTS: Hyperpigmentation and ulceration were grossly improved in fat-grafted mice compared to sham-grafted controls. Epidermal thickness measurements demonstrated decreased thickness in fat-grafted animals at both timepoints (20.6+/-1.5mum vs 55.2+/-5.6mum, p=0.004; 17.6+/-1.1mum vs 36.3+/-6.1mum, p=0.039). Vascular density was decreased in fat-grafted mice compared to sham-grafted at both timepoints (17.5+/-1.3 vessels/hpf vs 29+/-3.5, p=0.055; 13.25+/-1.4 vs 17.0+/-1.6, p=0.003). Intensity of Smad3 staining was significantly decreased in fat-grafted animals at both timepoints (2.77+/-0.3% vs 4.98+/-0.9%, p=0.004; 3.05+/-0.2% vs 5.81+/-0.3%, p=0.011). Picrosirius red staining demonstrated a diminished scar-index in fat-treated animals at both timepoints (.54+/-0.05 vs .74+/-0.07, p=0.034; .55+/-0.06 vs .93+/-.07, p=0.001). CONCLUSIONS: Fat grafting attenuates inflammation in acute radiodermatitis and slows the progression of fibrosis in chronic radiodermatitis

BACKGROUND: : Radiation therapy is a cornerstone of oncologic treatment. Skin tolerance is often the limiting factor in radiotherapy. To study these issues and create modalities for intervention, the authors developed a novel murine model of cutaneous radiation injury. METHODS: : The dorsal skin was isolated using a low-pressure clamp and irradiated. Mice were followed for 8 weeks with serial photography and laser Doppler analysis. Sequential skin biopsy specimens were taken and examined histologically. Tensiometry was performed and Young's modulus calculated. RESULTS: : High-dose radiation isolated to dorsal skin causes progressive changes in skin perfusion, resulting in dermal thickening, fibrosis, persistent alopecia, and sometimes ulceration. There is increased dermal Smad3 expression, and decreased elasticity and bursting strength. CONCLUSIONS: : This model of cutaneous radiation injury delivers reproducible localized effects, mimicking the injury pattern seen in human subjects. This technique can be used to study radiation-induced injury to evaluate preventative and therapeutic strategies for these clinical issues

The inflammatory response to ionizing radiation (IR) includes a proangiogenic effect that could be counterproductive in cancer but can be exploited for treating impaired wound healing. We demonstrate for the first time that IR stimulates hypoxia-inducible factor-1alpha (HIF-1alpha) up-regulation in endothelial cells (ECs), a HIF-1alpha-independent up-regulation of stromal cell-derived factor-1 (SDF-1), as well as endothelial migration, all of which are essential for angiogenesis. 5 Gray IR-induced EC HIF-1alpha and SDF-1 expression was greater when combined with hypoxia suggesting an additive effect. While small interfering RNA silencing of HIF-1alpha mRNA and abolition of HIF-1alpha protein induction down-regulated SDF-1 induction by hypoxia alone, it had little effect on SDF-1 induction by IR, demonstrating an independent pathway. SDF-1-mediated EC migration in hypoxic and/or radiation-treated media showed IR induced strong SDF-1-dependent migration of ECs, augmented by hypoxia. IR activates a novel pathway stimulating EC migration directly through the expression of SDF-1 independent of HIF-1alpha induction. These observations might be exploited for stimulation of wound healing or controlling tumor angiogenesis