Faculty Bibliography

This clinical report describes the treatment of a partially dentate patient who presented with dental implants placed in a reconstructed fibula graft in the mandible. A complete mouth rehabilitation with a maxillary complete denture and a mandibular implant-supported fixed complete denture was fabricated with computer-aided design and computer-aided machining technology.

BACKGROUND: Fat grafting has become popular for repair of postsurgical/postradiation defects after head/neck cancers resection. Fat graft supplementation with adipose tissue-derived stromal/stem cells (ASCs) is proposed to improve graft viability/efficacy, although the impact of ASCs on head/neck cancer cells is unknown. OBJECTIVES: To determine whether ASCs affect growth, migration, and metastasis of human head/neck cancer. METHODS: Human Cal-27 and SCC-4 head/neck cancer cells were co-cultured human ASCs, or treated with ASC conditioned medium (CM), and cancer cell growth/migration was assessed by MTT, cell count, and scratch/wound healing assays in vitro. Co-injection of 3 x 10(6) Cal-27/green fluorescent protein (GFP) cells and ASCs into the flank of NUDE mice assessed ASC effect on tumor growth/morphology. Quantitation of human chromosome 17 DNA in mouse organs assessed ASC effects on micrometastasis. Primary tumors were evaluated for markers of epithelial-to-mesenchymal transition, matrix metalloproteinases, and angiogenesis by immunohistochemistry. RESULTS: Co-culture of Cal-27 or SCC-4 cells with ASCs from 2 different donors or ASC CM had no effect on cell growth in vitro. However, ASC CM stimulated Cal-27 and SCC-4 migration. Co-injection of ASCs from 2 different donors with Cal-27 cells did not affect tumor volume at 6 weeks, but increased Cal-27 micrometastasis to the brain. Evaluation of tumors sections from 1 ASC donor co-injection revealed that ASCs were viable and well integrated with Cal-27/GFP cells. These tumors exhibited increased MMP2, MMP9, IL-8, and microvessel density. CONCLUSIONS: Human ASCs did not alter growth of human head/neck cancer cells or tumor xenografts, but stimulated migration and early micrometastasis to mouse brain.

Unilateral breast reconstruction poses a special set of challenges to the reconstructive breast surgeon compared to bilateral reconstructions. No studies to date provide an objective comparison between autologous and implant based reconstructions in matching the contralateral breast. This study compares the quantitative postoperative results between unilateral implant and autologous flap reconstructions in matching the native breast in shape, size, and projection using three-dimensional (3D) imaging. Sixty-four patients who underwent unilateral mastectomy with tissue expander (TE)-implant (n = 34) or autologous microvascular free transverse rectus abdominus myocutaneous (TRAM; n = 18) or deep inferior epigastric artery perforator (DIEP; n = 12) flap (n = 30) reconstruction from 2007 to 2010 were analyzed. Key patient demographics and risk factors were collected. Using 3D scans of patients obtained during pre and postoperative visits including over 1 year follow-ups for both groups, 3D models were constructed and analyzed for total breast volume, anterior-posterior projection from the chest wall, and 3D comparison. No significant differences in mean age, body mass index, or total number of reconstructive surgeries were observed between the two groups (TE-implant: 52.2 +/- 10, 23.9 +/- 3.7, 3 +/- 0.9; autologous: 50.7 +/- 9.4, 25.4 +/- 3.9, 2.9 +/- 1.3; p > 0.05). The total volume difference between the reconstructed and contralateral breasts in the TE-implant group was insignificant: 27.1 +/- 22.2 cc, similar to the autologous group: 29.5 +/- 24.7 cc, as was the variance of breast volume from the mean. In both groups, the reconstructed breast had a larger volume. A-P projections were similar between the contralateral and the reconstructed breasts in the TE-implant group: 72.5 +/- 3.21 mm versus 71.7 +/- 3.5 mm (p > 0.05). The autologous reconstructed breast had statistically insignificant but less A-P projection compared to the contralateral breast (81.9 +/- 16.1 mm versus 61.5 +/- 9.5 mm; p > 0.05). Variance of A-P projection from the mean was additionally insignificant between the contralateral and reconstructed breasts. Both groups produced similar asymmetry scores based on global 3D comparison (TE-implant: 2.24 +/- 0.3 mm; autologous: 1.96 +/- 0.2 mm; p > 0.05). Lastly, when the autologous group was further subdivided into TRAM and DIEP cohorts, no significant differences in breast volume, A-P projection or symmetry existed. Using 3D imaging, we demonstrate that both TE-implant and autologous reconstruction can achieve symmetrical surgical results with the same number of operations. This study demonstrates that breast symmetry, while an important consideration in the breast reconstruction algorithm, should not be the sole consideration in a patient' decision to proceed with autologous versus TE-implant reconstruction.

BACKGROUND: Postoperative wound complications in patients undergoing complex spinal surgery can have devastating sequelae, including hardware exposure, meningitis, and unplanned reoperation. The literature shows that wound complication rates in this patient population approach 19 percent and, in very high-risk patients (i.e., prior spinal surgery, existing spinal wound infection, cerebrospinal fluid leak, malignancy, or history of radiation therapy), as high as 40 percent and with reoperation rates as high as 12 percent. The authors investigated whether prophylactic closure of spinal wounds with muscle flaps improves outcomes. METHODS: A retrospective review was performed of 102 reconstructions (in 96 patients) in which spinal wound closure was performed by means of paraspinous, trapezius, or latissimus muscle advancement flaps by a single plastic surgeon (J.A.S.) from 2006 to 2014. Data regarding presurgical diagnosis, patient demographics, and incidence of postoperative complications were recorded. RESULTS: One hundred two reconstructions were included, with follow-up ranging from 2 to 60 months. Eighty-eight reconstructions were classified as very high-risk for wound complications, defined as those having prior spinal surgery, existing spinal wound infection, cerebrospinal fluid leak, malignancy, or prior radiation therapy. Within the very high-risk group, there were six wound complications (6.8 percent), three of which (3.4 percent) required reoperation. CONCLUSIONS: In this study, there is a markedly lower rate (6.8 percent) of postoperative wound complications compared with historical controls after closure of spinal wounds with local muscle flaps in very high-risk patients. These data encourage safe and routine use of muscle flaps for closure in this cohort of patients undergoing spinal surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Importance: Limited data exist on performing major oral cavity resections and reconstructions without elective tracheotomy. Objectives: To describe a group of patients who successfully underwent major microvascular mandibular reconstruction without an elective tracheotomy and to perform a literature review to identify commonalities between our group and the available literature to identify potential common factors that might contribute to the success of this approach. Design, Setting, and Participants: Case series with retrospective medical chart review of 15 patients who underwent fibula microvascular free flap reconstruction of mandibular defects without tracheotomy between 2000 and 2014 (the most common indication was osteoradionecrosis) conducted at a tertiary referral hospital center. Exposures: Mandibular reconstruction with fibula free flap without elective tracheotomy. Main Outcomes and Measures: Perioperative morbidity and mortality with a focus on airway management and perioperative complications. Results: The median age of 15 patients (11 males and 4 females) at the time of reconstruction was 42 years (range, 10-64 years). The indication for surgery was nonmalignant pathologic abnormalities in 8 patients (53%), osteosarcoma in 4 patients (27%), and oral cavity squamous cell carcinoma in 3 patients (20%). All patients were intubated endonasally and, excepting 1 pediatric case, were extubated the day following surgery. The fibula spanned the parasymphysis and/or symphysis in 2 patients, and was limited to the mandibular body in others (mean length, 7.6 cm [range, 4.0-15.0 cm]). The flap design was osteocutaneous in 3 patients and osseous in the rest. No patient required reintubation or tracheotomy. No complications due to endonasal intubation occurred. The average hospital length of stay was 11 days. Conclusions and Relevance: Major oral cavity resection and reconstruction with microvascular free flaps can be performed safely without elective tracheotomy in a select group of patients. Limited data exist on patient selection criteria. Further studies are needed to identify favorable factors and develop protocols for safe patient selection.

BACKGROUND AND AIM: The increased media attention to shark attacks has led to a heightened fear and public awareness. Although few sharks are considered dangerous, attacks on humans can result in large soft tissue defects necessitating the intervention of reconstructive surgeons. This study aims to evaluate and describe the characteristics of shark-related injuries in order to improve treatment. METHODS: The Global Shark Accident File, maintained by the Shark Research Institute (Princeton, NJ, USA), is a compilation of all known worldwide shark attacks. Database records since the 1900s were reviewed to identify differences between fatal and nonfatal attacks, including: geography, injury pattern, shark species, and victim activity. RESULTS: Since the 1900s, there have been 5034 reported shark attacks, of which 1205 (22.7%) were fatal. Although the incidence of attacks per decade has increased, the percentage of fatalities has decreased. Characteristics of fatal attacks included swimming (p = 0.001), boating (p = 0.001), three or more bite sites (p = 0.03), limb loss (p = 0.001), or tiger shark attack (p = 0.002). The most common attacks were bites to the legs (41.8%) or arms (18.4%), with limb loss occurring in 7% of attacks. Geographically, the majority of attacks occurred in North America (36.7%) and Australia (26.5%). Most attacks in the USA occurred in Florida (49.1%) and California (13.6%). CONCLUSIONS: Although rare, shark attacks result in devastating injuries to patients. As these injuries often involve multiple sites and limb loss, this creates a significant challenge for reconstructive surgeons. Proper identification of the characteristics of the attack can aid in providing optimal care for those affected.