Faculty Bibliography

BACKGROUND: Gluteal augmentation is increasingly common. However, few studies have quantitatively reported postoperative gluteal projection. This study compared three different standardized instruments (i.e., radiographic, sonographic, and anthropometric) for quantifying gluteal projection after lumbar-hip dermal fat rotational flap to identify a simple, cost-efficient valid instrument. METHODS: A total of 10 women ages 35 to 68 years (mean, 47.3 years) with skin flaccidity and gluteal ptosis underwent bilateral lumbar-hip dermal fat rotation flap gluteal augmentation (20 procedures). Gluteal projection was measured 1 week preoperatively and 8 months postoperatively using computerized axial tomography (CAT) scan, ultrasound, and anthropometry. RESULTS: The CAT scan measured 1.40 cm of projection on the left (p < 0.001) and 1.43 cm on the right (p = 0.001). Ultrasound measured 2.16 cm of projection on the left (p < 0.001) and 1.88 cm on the right (p = 0.001). Anthropometry measured 1.75 cm of projection on the left (p < 0.01) and 1.35 cm on the right (p < 0.05). Repeated measures analysis of variance (ANOVA) comparing the CAT scan, ultrasound, and anthropometry demonstrated statistically similar results on the left (p = 0.43) and right (p = 0.62). CONCLUSIONS: All three instruments were sufficiently sensitive to measure a statistically significant increase in postoperative gluteal projection. Moreover, all three instruments were statistically similar in accuracy of measurement. Therefore, the authors conclude that ultrasound or anthropometry are satisfactory, inexpensive instruments for accurately quantifying postoperative gluteal projection

Although recent studies indicate that regional dura mater influences the fate of the overlying cranial suture, little is known about the assembly of extracellular matrix (ECM) molecules within the patent and fusing murine cranial suture complexes. Confocal laser scanning microscopy was used to study ECM assembly within patent and fusing cranial suture complexes. Coronal sections (20 microm thick) of patent sagittal (SAG) and fusing posterior frontal (PF) sutures from postnatal 8-, 14-, and 18-day-old Sprague-Dawley rats were scanned in 0.5-microm increments, and images were collected consecutively to create a z-series for three-dimensional reconstruction. Spatial and temporal collagen arrangements were compared between SAG and PF sutures by measuring interfiber distance, fiber thickness, and total collagen surface area at each time point.We demonstrate that on day 8 (before the onset of suture fusion), collagen bundles are randomly arranged in both the SAG and PF sutures. By day 14 (midfusion period), there was a statistically significant reduction in total collagen surface area (80.5% versus 67.4%; P < 0.05) as the collagen bundles were organized into orthogonal lattices along the anterior and endocranial margins of the PF suture. Furthermore, new bone matrix deposition was observed along the edges of these organized collagen bundles. In contrast, collagen within the SAG suture remained randomly arranged and unossified. By day 18 (late fusion period), the PF suture was completely fused except for the posterior-ectocranial portion. This patent section of the PF suture contained a highly organized mineralizing orthogonal collagen lattice. The total collagen surface area in the day-18 PF suture continued to decline compared with the day-8 PF suture (80.5% versus 55.6%; P < 0.05). In the day-18 SAG suture, the collagen bundles remained randomly arranged, and the total surface area did not change. The same analysis was performed in a human pathologic fusing and patent suture. Similar results were observed. The total collagen surface area significantly decreased in the pathologic fusing human suture compared with the patent suture (92.8% versus 60.6%; P < 0.05). Moreover, the pathologically fusing suture contained a highly organized mineralizing orthogonal collagen lattice. This is the first analysis of collagen patterns in patent and fusing cranial sutures

BACKGROUND: Distraction osteogenesis is a valuable clinical tool; however the molecular mechanisms governing successful distraction remain unknown. We have used a uniaxial in vitro strain device to simulate the uniaxial mechanical environment of the interfragmentary distraction gap. MATERIALS AND METHODS: Using the Flexcell system, normal human osteoblasts were subjected to different levels of cyclical uniaxial mechanical strain. Cellular morphology, proliferation, migration, and the expression of angiogenic (vascular endothelial growth factor [VEGF] and fibroblast growth factor-2 [FGF-2]) and osteogenic (osteonectin, osteopontin, and osteocalcin) proteins and extracellular matrix molecules (collagen IalphaII) were analyzed in response to uniaxial cyclic strain. RESULTS: Osteoblasts exposed to strain assumed a fusiform spindle-shaped morphology aligning parallel to the axis of uniaxial strain and osteoblasts exposed to strain or conditioned media had a 3-fold increase in proliferation. Osteoblast migration was maximal (5-fold) in response to 9% strain. Angiogenic cytokine, VEGF, and FGF-2, increased 32-fold and 2.6-fold (P < 0.05), respectively. Osteoblasts expressed greater amounts of osteonectin, osteopontin, and osteocalcin (2.1-fold, 1.8-fold, 1.5-fold respectively, P < 0.01) at lower levels of strain (3%). Bone morphogenic protein-2 production increased maximally at 9% strain (1.6-fold, P < 0.01). Collagen I expression increased 13-, 66-, and 153-fold in response to 3, 6, and 9% strain, respectively. CONCLUSIONS: Uniaxial cyclic strain using the Flexcell device under appropriate strain parameters provides a novel in vitro model that induces osteoblast cellular and molecular expression patterns that simulate patterns observed in the in vivo distraction gap

BACKGROUND: Silicone chin augmentation remains a popular treatment for microgenia because its placement appears deceptively simple. However, when extrusion, displacement, capsular contracture following implant removal, overaugmentation, or malposition occurs, a revision operation may be required. Secondary chin surgery is challenging because (1) implant removal alone may produce a disfigured chin; and (2) placement of a new implant in an oversized misshapen pocket demands precision, control, and reliability. METHODS: The textured implant may be placed by means of an intraoral or extraoral route. The extraoral route is usually chosen except when transoral procedures (e.g., mentalis suspension) are required. The superior 30 to 50 percent of a standard textured implant is always removed and then tapered anteriorly at a 45-degree angle to reduce its sharp front edge. The lateral wings are also reduced and tapered. Two pilot holes are drilled in each half of the implant and then it is divided in the midline. Each half is inserted and secured individually. The medial screw is placed first and nearly fully tightened. Then, holding the implant exactly along the inferior border of the mandible, the distal screw is placed and both screws are tightened completely. The lower border of the implant should be exactly along the lower border of the mandible. The soft tissues are closed in three layers over a drain. RESULTS: This technique has been used to treat more than 100 patients. Selected photographs illustrate this technique. CONCLUSION: This article explains how to place a textured implant efficiently and effectively under light premedication and local anesthesia

BACKGROUND: Although the condition is rare, some children are born with cervical clefts or masses that require repair during infancy. The scarring in the submental region can tether the developing mandible at the menton, producing a developmental microgenia or 'tethered chin.' METHODS: A retrospective review of the senior author's (B.M.Z.) patient records was performed; three cases of tethered chin were identified. In each case, a staged surgical approach was used. RESULTS: In two cases, previous unsuccessful surgery complicated the initial presentation. In all cases, the underlying soft-tissue anomalies were addressed and the microgenia was corrected. Satisfactory aesthetic and functional results were obtained. CONCLUSIONS: The tethered chin represents a rare entity. Correction of the tethered chin requires a comprehensive understanding of the underlying abnormality and an appreciation of the multiple factors that contribute to chin function and aesthetics

BACKGROUND: Correction of the long, nonprojecting chin requires both vertical reduction and sagittal augmentation. Wedge excision-based therapy reduces chin height and allows for advancement of the distal segment, but it is associated with at least a 10 percent incidence of mental nerve injury. The authors propose two innovative ways to correct the long, nonprojecting chin. METHODS: There are two approaches, intraoral and extraoral. With the intraoral approach, following a gingivobuccal incision, a single horizontally oblique osteotomy is made at least 6 mm beneath the mental nerve foramina. The vertically long genial segment is freed and the posterior edge is contoured with a side-cutting burr. The contoured jumping genial segment is secured to the mandible with countersunk screws and contoured in situ to preserve the lower 8 to 10 mm. With the extraoral approach, following a submental incision, the anterior and posterior surfaces of the symphysis are cleared (a double-armed suture is placed through the posterior musculature). A reciprocating saw is used to remove the lower border of the symphysis to reduce the vertical excess. The tagged musculature is resuspended, and a tapered, textured implant is secured to the new symphysis. RESULTS: Aesthetic outcomes using these two techniques were good and there were no complications. Representative patients, operated on by the senior author, illustrate these techniques. CONCLUSIONS: Both the intraoral one-cut in situ contoured jumping genioplasty and the extraoral vertical reduction/sagittal augmentation genioplasty reduce excess chin height, control sagittal advancement, provide pogonion projection, and avoid the risks of a standard wedge. Both techniques provide custom projection at the lower pole of the new symphysis

The ability to affect gene expression via topical therapy has profound therapeutic implications for conditions characterized by open wounds including cutaneous neoplasms, thermal injury, skin disorders and dysfunctional wound healing. Specifically targeting local gene expression avoids systemic toxicity and simplifies treatment. We have developed a new method of topical matrix-based short interfering RNA application to precisely and effectively silence local gene expression in nondelimited wounds

BACKGROUND: Treatment of macrogenia can be a challenging problem. In this article, the authors provide novel insights for treatment of a previously poorly treated problem. The authors have developed anatomical insights that facilitate the subtly difficult preoperative evaluation of the large chin and, when applied appropriately, will provide uniformly pleasing results. METHODS: A retrospective review of the senior author's (B.M.Z.) patient records was performed. More than 50 cases of macrogenia were identified. As previously described, almost all of the cases were performed under local anesthesia with oral premedication only. RESULTS: This article demonstrates why prior modalities such as intraoral burring and lower border setback failed to treat the variety of large chins properly. The nine critical factors the surgeon must consider in developing a successful surgical plan are outlined. The surgical plan is not primarily based on radiographs as much as on direct tactile and visual analysis of the sublabial structures both in repose and while smiling. Crucial aspects of the operative technique are highlighted. CONCLUSIONS: The large chin can be approached with confidence if nine parameters are appreciated. The authors have outlined these key variables that facilitate proper preoperative topographic analysis of the large chin. Once these variables are appreciated, an appropriate surgical plan can be formulated

BACKGROUND: Patients with craniofacial anomalies can have hard and soft tissue deficiencies. In some cases, distraction osteogenesis can restore the bony deficiencies, but the soft tissue contour defect remains problematic. For these patients, the union of distraction osteogenesis and microvascular free flaps (MVFF) can restore bone and soft tissue form and function. PATIENTS AND METHODS: A retrospective review of all patients treated with mandibular distraction osteogenesis between 1989 and 2005 was performed. A similar review of all patients treated with MVFFs was performed. These 2 cohorts were cross-referenced to identify all patients treated with both procedures. The indications, choices, safety, and efficacy of MVFF reconstruction of facial soft tissues following mandibular reconstruction are reviewed. RESULTS: Over a 16-year period, 141 patients underwent mandibular distraction osteogenesis; 8 patients treated with mandibular distraction osteogenesis subsequently underwent 12 MVFFs. Patient diagnoses included unilateral craniofacial microsomia (n = 2), bilateral craniofacial microsomia (n = 3), Goldenhar syndrome (n = 1), Nager syndrome (n = 1), and Treacher-Collins syndrome (n = 1). Free flap choices included 10 parascapular fasciocutaneous, 1 parascapular osteofasciocutaneous, and 1 fibular osteocutaneous flap. Four patients underwent staged bilateral free flaps. A single case of partial flap loss was the only complication. In all cases, facial contour was improved following MVFF transfer. CONCLUSIONS: In certain circumstances, facial rehabilitation may require the marriage of craniofacial and microsurgical techniques to restore both form and function. In these cases, mandibular distraction osteogenesis and MVFFs can be safely and effectively combined