Faculty Bibliography

BACKGROUND: Use of the tumescent mastectomy technique has been reported to facilitate development of a hydrodissection plane, reduce blood loss, and provide adjunct analgesia. Previous studies suggest that tumescent dissection may contribute to adverse outcomes after immediate implant reconstruction; however, its effect on autologous microsurgical reconstruction has not been established. METHODS: A retrospective review was conducted of all immediate microsurgical breast reconstruction procedures at a single academic center between January 2004 and December 2013. Records were queried for age, body mass index, mastectomy weight, diabetes, hypertension, smoking, preoperative radiation, reconstruction flap type, and autologous flap weight. Outcomes of interest were mastectomy skin necrosis, complete and partial flap loss, return to the operating room, breast hematoma, seroma, and infection. RESULTS: There were 730 immediate autologous breast reconstructions performed during the study period; 46% with the tumescent dissection technique. Groups were similar with respect to baseline patient and procedural characteristics. Univariate analysis revealed no significant difference in the incidence of mastectomy skin necrosis, complete or partial flap loss, return to the operating room, operative time, estimated blood loss, recurrence, breast hematoma, seroma, or infection in patients undergoing tumescent mastectomy. Multivariate analysis also demonstrated no significant association between the use of tumescent technique and postoperative breast mastectomy skin necrosis (P = 0.980), hematoma (P = 0.759), or seroma (P = 0.340). CONCLUSIONS: Use of the tumescent dissection technique during mastectomy is not significantly associated with adverse outcomes after microsurgical breast reconstruction. Despite concern for its impact on implant reconstruction, our findings suggest that this method can be used safely preceding autologous procedures.

BACKGROUND: Fractures of the mandibular condyle are common following blunt facial trauma and carry an increased risk for concomitant blunt carotid artery injuries (BCAI), a potentially life-threatening complication. Further elucidation of the relationship between specific condylar fracture patterns and BCAI may improve vascular injury screening and management. METHODS: A retrospective cohort study was performed for all craniofacial trauma patients sustaining condylar fractures that presented to a large trauma center from 2000 to 2012. Condylar fracture locations were classified according to the Strasbourg Osteosynthesis Research Group (SORG) system (SORG 1: condylar head, SORG 2: condylar neck, SORG 3: extracapsular condylar base). BCAI severity was based on the Biffl scale. Severe BCAI was defined as a Biffl score greater than I. RESULTS: We identified 605 patients with mandibular condyle fractures consisting of 21.0% (n=127) SORG 1, 26.8% (n=162) SORG 2, and 52.2% (n=316) SORG 3. Overall incidence of BCAI in this population was 5.5%(n=33), of which 75.8 % (n=25) were severe. Severe BCAIs occurred in 1.6% (n=2) of SORG 1, 2.5% (n=4) of SORG 2, and 6.0% (n=19) of SORG 3 fractures (p<0.05). SORG 3 fractures were independently associated with a 2.94-fold increased risk of a severe BCAI compared to other condyle fractures on multivariable analysis (p-value <0.05). CONCLUSIONS: The presence of extracapsular subcondylar fractures should heighten suspicion for concomitant BCAI. Our data additionally support a force transmission mechanism of injury in addition to direct vascular injuries from bony fragments.

Abstract The aim of this study was to evaluate the physico-chemical properties and the in vivo host response of a surface sandblasted with particles of titanium oxide (TiO2) followed by acid etching as an alternative to aluminium oxide. Thirty titanium disks manufactured in the same conditions as the implants and 24 conventional cylindrical implants were used., Half of the implants had a machined surface (Gcon) while in the other half the surface was treated by with particles of TiO2 followed by acid etching (Gexp). Surface characterization was assessed by Scanning Electron Microscope (SEM), Energy Dispersive X-ray Spectrometry (EDS), profilometry, and wettability. For the in vivo test, 12 implants of each group were implanted in the tibia of 6 rabbits, and were reverse torque tested after periods of 30 or 60 days after implantation. Following torque, SEM was utilized to assess residual bone-implant contact. The surface characterization by SEM showed a very homogeneous surface with uniform irregularities for Gexp and a small amount of residues of the blasting procedure, while Gcon presented a surface with minimal irregularities from the machining tools. Wettability test showed decreased contact angle for the Gcon relative to the Gexp. The Gexp removal torque at 30 and 60 days was 28.7%, and 33.2% higher relative to the Gcon, respectively. Blasting the surface with particles of TiO2 represents an adequate option for the surface treatment of dental implants, with minimal risk of contamination by the residual debris from the blasting procedure.

INTRODUCTION: During preoperative discussions with breast reconstruction patients, questions often arise about what to expect during the recovery period. However, there is a paucity of data elucidating post-breast reconstruction pain, fatigue, and physical morbidity. This information is important to patient and physician understanding of reconstructive choices and the postoperative recovery process. We sought to evaluate how recovery may vary for patients based on the timing and type of reconstruction. MATERIALS AND METHODS: Patients were recruited as part of the Mastectomy Reconstruction Outcomes Consortium (MROC) study, which is a prospective, multicentered National Institute of Health (NIH)-funded study (1RO1CA152192). Here, patients completed the Numerical Pain Rating Scale (NPRS), McGill Pain Questionnaire, and Breast-Q preoperatively, at 1 week, and 3 months postoperatively. Pain, fatigue, and upper body morbidity were evaluated by the type and timing of reconstruction. RESULTS: A total of 2013 MROC study participants had completed a 3-month follow-up, and therefore they were included for the analysis. A total of 1583 (78.6%) and 1517 patients (75.3%) completed surveys at 1 week and 3 months, respectively, post reconstruction. Across all procedure groups, fatigue and physical well-being scores did not return to preoperative levels by 3 months. At 3 months, pain measured by the NPRS differed across procedure types (P = 0.01), with tissue expander/implant (TE/I) having more pain than direct to implant (P < 0.01). Similarly, at 3 months, chest and upper body physical morbidity, as measured by BREAST-Q, differed by procedure types (P < 0.001), with generally less morbidity for autologous reconstruction as compared with TE/Is. CONCLUSIONS: For all reconstructive procedure groups, patients did not fully recover at 3 months post surgery. In addition, postoperative pain and upper body physical morbidity vary significantly by reconstructive procedure with patients undergoing TE/I reporting the most distress.

BACKGROUND: Interest in and acceptance of autologous fat grafting for use in contour abnormalities, breast reconstruction, and cosmetic procedures have increased. However, there are many procedural variations that alter the effectiveness of the procedure and may account for the unpredictable resorption rates observed. METHODS: The authors highlighted studies investigating the effects of harvesting procedures, processing techniques, and reinjection methods on the survival of fat grafts. This review focused on the impact different techniques have on outcomes observed in the following: in vitro analyses, in vivo animal experiments, and human studies. RESULTS: This systemic review revealed the current state of the literature. There was no significant difference in the outcomes of grafted fat obtained from different donor sites, different donor-site preparations, harvest technique, fat harvesting cannula size, or centrifugation speed, when tumescent solution was used. Gauze rolling was found to enhance the volume of grafted fat, and no significant difference in retention was observed following centrifugation, filtration, or sedimentation in animal experiments. In contrast, clinical studies in patients found more favorable outcomes with fat processed by centrifugation compared with sedimentation. In addition, higher retention was observed with slower reinjection speed and when introduced into less mobile areas. CONCLUSIONS: There has been a substantial increase in research interest to identify methodologies for optimizing fat graft survival. Despite some differences in harvest and implantation technique in the laboratory, these findings have not translated into a universal protocol for fat grafting. Therefore, additional human studies are necessary to aid in the development of a universal protocol for clinical practice.

OBJECTIVE: The treatment of head and neck cancer has varying impact on postoperative recovery and return of swallowing function. The authors aim to establish screening tools to assist in preoperatively determining the need for gastrostomy tube placement. METHODS: The authors prospectively assessed all patients undergoing complex head and neck reconstructive surgery during a 1-year study period. Only patients tolerating an oral diet, without preoperative gastrostomies, were enrolled for study. Eight parameters were assessed including: body mass index (BMI), prealbumin, albumin, smoking history, comorbidities [including coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), and diabetes mellitus (DM)], age, use of microvascular reconstruction, and type of defect. Two specific screening tools were assessed. In the first, a multivariate logistic regression model was employed to determine factor(s) that predict postoperative gastrostomy tube. In a second screening tool, the 8 parameters were scored between 0 to 1 points. The total score obtained for each patient was correlated with postoperative gastrostomy placement. RESULTS: Out of the 60 study patients enrolled in the study, 24 patients (40%) received a postoperative gastrostomy. In the logistic regression model, albumin level was the only factor that was significantly associated with need for postoperative gastrostomy (P < 0.0023). A score of 4 or greater was determined to have a sensitivity of 83% and specificity of 61% for postoperative gastrostomy. CONCLUSIONS: Patients with a score of 4 or more with this screening scoring system or those patients with an albumin level <3.5 g/dL were at high risk for postoperative feeding tube placement.