Faculty Bibliography

PURPOSE: There is no more important decision an academic Plastic Surgery Department or Division can make than naming a chair or chief. Externally recruited leadership brings fresh perspectives and connections. Critics, however, argue that they lack the in-depth knowledge of the institution's culture and history that may be needed to succeed. The ability and skill of an internal candidate is already known and can increase the odds of that person's success in the leadership position. Finally, external recruitment can be a more costly process. Ultimately, the decision is really a litmus test for a Plastic Surgery program. The authors aim to evaluate factors influencing ascent in Plastic Surgery leadership, including training history, internal promotion, and external recruiting. METHODS: All Plastic Surgery residency programs accredited by the Accreditation Council for Graduate Medical Education were noted (n = 71). Academic departmental chairs or divisional chiefs of these residency programs were identified at the time of study design (October 1, 2011). For each chair or chief, gender, training history, and faculty appointment immediately prior to the current leadership position was recorded. RESULTS: There were 71 academic chairs or chiefs of Plastic Surgery residency programs at the time of data collection. The majority (62%) had done fellowship training following Plastic Surgery residency. Fellowships included hand (43%), craniofacial (29%), microsurgery (18%), and other types (10%). The majority (73%) of leaders were internal hires (P < 0.01), having faculty appointments at their institutions prior to promotion. However, only a fraction (22%) of these internal hires had done Plastic Surgery residency or fellowship training at that institution (P < 0.01). External recruits consisted of 27% of all 71 academic hires (P < 0.01). CONCLUSIONS: Many factors influence the decision to recruit leadership from internally or to hire an external candidate. These include the time to fill the position, program culture, candidate experience, and cost. These results support that the insider/outsider hire decision is ultimately one of duality. That dichotomy is achieved with an emphasis on internal promotion, but always with an eye towards the advantages of bringing in external talent as a valuable contribution to increase organizational success.

BACKGROUND: : Tumors of the mandible are complex, often requiring replacement of bone, soft tissue, and teeth. The fibula flap has become a routine procedure in large tumors of the jaw, providing bone and soft tissue at the time of the resection. In current practice, dental reconstruction is delayed for 3 to 6 months, leaving the patient without teeth in the interim. This can be disfiguring and anxiety provoking for the patient. METHODS: : In this article, the authors present three patients with benign tumors of the mandible who underwent virtually guided resection, fibula reconstruction, and insertion of an implant-retained dental prosthesis in one operation. In addition, the authors report their early experience using this technique in the maxilla. RESULTS: : The authors present a case series of three patients with benign mandibular tumors and one patient with a benign maxillary tumor who underwent total reconstruction using computer-aided design and computer-aided manufacturing technology in a single stage. CONCLUSIONS: : In the right situation, total mandibular reconstruction is possible in a single stage. This is demonstrated by the successful outcomes of these patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: : Therapeutic, V.

BACKGROUND: Access to the frontal sinus remains a challenging problem for the craniofacial surgeon. A wide array of techniques including minimally invasive endoscopic approaches have been described. Here we present our technique using medical modeling to gain fast and safe access for multiple indications. METHODS: Computer-aided surgery involves several distinct phases: planning, modeling, surgery, and evaluation. Computer-aided, precise cutting guides are designed preoperatively and allowed to perfectly outline and then cut the anterior table of the frontal sinus at its junction to the surrounding frontal bone. The outcomes are evaluated by postoperative three-dimensional computed tomography scan. RESULTS: Eight patients sustaining frontal sinus fractures were treated with the aid of medical modeling. Three patients (37.5%) had isolated anterior table fractures, and 4 (50%) had combined anterior and posterior table fractures, whereas 1 patient (12.5%) sustained isolated posterior table fractures. Operative times were significantly shorter using the cutting guides, and fracture reduction was more precise. There was no statistically significant difference in complication rates or overall patient satisfaction. CONCLUSIONS: The surgical approach to the frontal sinus can be made more efficient, safe, and precise when using computer-aided medical modeling to create customized cutting guides.

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 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: : 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.

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: : Free tissue transfer to improve bulk and contour in facial deformities has been proven useful, yet refinements that turn an acceptable result into an excellent result are essential to reconstruction. The authors reviewed their experience and described these refinements. METHODS: : The charts of 371 free tissue transfer cases (1989 to 2010) performed by the senior author (J.W.S.) were reviewed. Free tissue transfer of a circumflex scapular variant flap or superficial inferior epigastric was performed to treat deformities arising from hemifacial atrophy (n = 126), hemifacial microsomia (n = 89), radiation therapy (n = 40), bilateral malformations including lupus and polymyositis (n = 50), other congenital anomalies (n = 25), facial palsy (n = 17), and burns and trauma (n = 24). RESULTS: : Revision surgery planning began at initial flap operation where the flap was stretched maximally and interdigitated with recipient tissue. More tissue was required in the malar region. Revision refinement was indicated in all cases (after 6 months). Flap revision involved liposuction, debulking, reelevation, and release of tethering, followed by tissue rearrangement by means of advancement, rotation, transposition, and/or turnover flaps of subcutaneous tissues from the previous free flap. The jawline frequently required more debulking. Periorbital reconstruction was combined with lower lid support with or without canthal repositioning. Conventional face-lift techniques with the flap as superficial musculoaponeurotic system augmented the result. Autologous fat injection to the alar rim, medial canthus, upper eyelid, and lip was a useful adjunct. Severe lip deficiencies were addressed with local flaps. CONCLUSION: : The keys to improving results were continual critical reassessment, open-mindedness to new approaches, and maintaining high expectations. CLINICAL QUESTION/LEVEL OF EVIDENCE: : Therapeutic, V.

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.