Faculty Bibliography

Background & Purpose: Traditional neurosurgical access to tumors or vascular anomalies of the anterior cranial fossa and/or ethmoid sinus requires coronal incision and extensive frontal dissection. Here we detail a limited supra-brow approach, focusing on operative technique, anatomic exposure, and clinical considerations. Methods & Description: Operative Technique: After epineph-rine infiltration, a supra-brow incision is made. Intermuscular dissection separates preorbital orbicularis oculi from inferior frontalis. Frontal periosteum is identified and supraperiosteal exposure is obtained from glabella medially to deep temporalis fascia laterally. The periosteum surrounding the supraorbital nerve is incised and the nerve is reflected inferiorly with periorbita (making an osteotomy for true foramina). Next, a medially based pericranial flap is raised, exposing frontal bone for mini-craniotomy; this flap is kept protected beneath the medial frontalis muscle. After neurosurgical intervention and dural repair, cranial bone is rigidly restored. Overlying soft tissue is closed in layers. Anatomic Exposure: Before craniotomy, various maneuvers provide additional exposure. Subperiosteal dissection within the supero-medial orbit permits supraorbital craniotomy and access to the ethmoid sinus. Elevating anterior temporalis permits more lateral craniotomy and access to neurosurgical targets within the lateral anterior cranial fossa. Clinical Considerations: To prevent injury to the fronto-temporal branch of the facial nerve, dissection over the frontal bone is supraperiosteal and dissection over temporalis is just above deep muscle fascia. When the craniotomy includes lateral frontal sinus, mucosa is burred off the removed bone and in situ sinus; the nasofrontal outflow tract is obliterated with the pericranial flap and sealed with fibrin glue. The preserved pericranial flap can also be used to restore dural integrity. When bone is deficient, the removed cranium can be split for additional graft. Results: We used the supra-brow approach in 14 patients to provide sufficient access for definitive neurosurgical management of an anterior clinoid meningioma, three lateral frontal lobe meningioma, nine aneurysms of the anterior communicating artery, and an intra-ethmoidal arterio-venous malformation. Blood loss during exposure was minimal in all cases. There was no injury to the ophthalmic division of trigeminal nerve or frontal branch of facial nerve. Split calvarial grafts were used in nine of fourteen patients. At one year follow-up, all patients had excellent frontal contour, bony union, and an aesthetic scar. Conclusions: A supra-brow approach limits extensive dissection and permits sufficient neurosurgical exposure to tumors and vascular anomalies of the entire anterior cranial fossa and ethmoid sinus

Background & Purpose: The aim of this study was to compare 3D symmetry of the nose in patients with UCLP, subsequent to rotation advancement (Millard) without primary nasal repair and the NAM/Cutting primary nasal repair. Methods & Description: Nasal casts were made for 12 consecutively appearing patients with UCLP, in each of two groups. Group 1 patients had a Millard repair without primary nasal repair (Bardach) while Group 2 patients had NAM and primary nasal repair. Patients were 6 to 18 years of age (mean=12.04). Surgery was performed at the mean age of 3.8 months. None of patients in Group 1 had primary nasal surgery as it was believed at the time by the surgeon that nasal growth might be inhibited. A two flap palatoplasty was performed at 12-24 months (mean age 19.75). All operations were performed by one surgeon in Group 1 and another surgeon in Group 2. Nasal casts were scanned using the 3Shape e scanner. All noses were scaled to the same size prior to evaluation. Procrustes analysis of 3D nasal symmetry was performed using 3dMD Vultus software. The Procrustes technique, determines nasal symmetry by performing a superimposition of its surface with its mirror image (ref Maull 1999). 4 linear measurements including columellar height, nasal dome height, alar base and nasal projections were performed on cleft and non-cleft side in both groups (ref Cutting 1984). For 3D analysis, student's t-test was used to determine the difference between the mean asymmetry index for each group. If symmetry is perfect the asymmetry index is zero. For linear analysis, student's T test was utilized to compare the differences. SPSS was used to perform a descriptive analysis of the groups. Results: The mean asymmetry index in the Millard rotation advancement repair was 4.41 and the NAM plus primary nasal repair was 2.45. The difference was statistically significant (P=0.006). In linear measurements, columellar length and alar base were significantly different when cleft side was compared to non-cleft side in Millard group (P=0.04 and 0.005). There was no significant difference in columellar length, nasal dome height, alar base and nasal projection in cleft versus non-cleft side in NAM group. Inter-group analysis showed that alar base in cleft and non-cleft side is significantly different in Millard versus NAM group (P=0.02). Conclusions: To our knowledge this is the first long-term, quantitative 3D study to analyze the asymmetry of the nose in the Millard rotation advancement versus NAM plus primary nasal repair in patients with complete UCLP. This study shows that the NAM plus primary nasal repair results in significantly less asymmetry of the nose compared to the Millard rotation advancement without nasal correction

Sutures elicit an inflammatory response, which may impede the healing process and result in wound complications. We recently reported a novel family of biocompatible, biodegradable polymers, amino acid-based poly(ester amide)s (AA-PEA), which we have shown to significantly attenuate the foreign body inflammatory response in vitro. Two types of AA-PEA (Phe-PEA and Arg-Phe-PEA) were used to coat silk or plain-gut sutures, which were implanted in the gluteus muscle of C57BL/6 mice, while the uncoated control sutures were implanted in the contralateral side. After 3, 7, 14, and 28 days the mean area of inflammation surrounding the sutures was compared. Phe-PEA coating of silk sutures significantly decreased inflammation compared with noncoated controls (67.8 +/- 17.4% after 3d [p = 0.0014], 51.6 +/- 7.2% after 7d [p < 0.001], and 37.3 +/- 8.3% after 28d [p = 0.0001]) when assessed via analysis of photomicrographs using digital image software. Phe-PEA coated plain-gut sutures were similarly assessed and demonstrated a significant decrease in the mean area of inflammation across all time points (54.1 +/- 8.3% after 3 d, 41.4 +/- 3.9% after 7 d, 71.5 +/- 8.1% after 14 d, 78.4 +/- 8.5%, and after 28 d [all p < 0.0001]). Arg-Phe-PEA coated silk demonstrated significantly less inflammation compared to noncoated controls (61.3 +/- 9.4% after 3 d, 44.7 +/- 4.7% after 7 d, 19.6 +/- 8%, and 38.3 +/- 6.8% after 28 d [all p < 0.0001]), as did coated plain-gut (37.4 +/- 8.3% after 3 d [p = 0.0004], 55.0 +/- 7.8% after 7 d [p < 0.0001], 46.0 +/- 4.6% after 14 d [p < 0.0001], and 59.0 +/- 7.9% after 28 d [p < 0.0001]). Both Phe-PEA and Arg-Phe-PEA coatings significantly decrease the inflammatory response to sutures in vivo for up to 28 days.

INTRODUCTION: Despite a recent rise in popularity of endovascular techniques, open bypass surgery is still required for treating many lower extremity vascular lesions. Greater saphenous vein (GSV) of adequate length and caliber for successful infrainguinal lower extremity bypass is unavailable in 15% to 45% of patients. To overcome limitations imposed by absent vein due to prior use, short vessel length, or sclerotic segments, both alternate (ie, basilic and cephalic) and GSV conduits may be "spliced" together in series via venovenostomy. Although vascular surgeons typically perform a hand-sewn venovenostomy, device-based venous coupling has been performed by plastic surgeons for many years. We therefore sought to review our experience with venous coupling for segmental lower extremity bypass graft assembly. METHODS: A retrospective review was performed in all patients who underwent lower extremity revascularization using autogenous vein grafts spliced together with the Synovis (Birmingham, Alabama) anastomotic coupler at a single institution over a 5-year period. RESULTS: The anastomotic coupler device was used on 5 patients for 7 venovenostomies. The mean age of patients was 66 years, and the mean follow-up period was 751 days. Two patients were lost to follow-up, while 2 other patients died of causes unrelated to their lower extremity bypass. The average time to perform venovenostomy was 3 minutes. Three patients developed stenosis of their composite graft at a site other than the venovenostomy, who were successfully treated with either angioplasty or bypass revision. One-year primary and primary-assisted patency rates were 50% and 75%, respectively. CONCLUSIONS: Given the known benefits of the anastomotic coupling device when used for venous anastomoses in microsurgical reconstruction, transition of this device to the vascular surgery realm represents a logical progression. Although small, our series demonstrates that the anastomotic coupler can successfully be used for the formation of spliced autogenous grafts for lower extremity revascularization in the absence of adequate GSV.

Numerous studies have demonstrated that Schwann cells (SCs) play a role in nerve regeneration; however, their role in innervating a bioceramic scaffold for potential application in bone regeneration is still unknown. Here we report the cell growth and functional behavior of SCs on beta-tricalcium phosphate (beta-TCP) scaffolds arranged in 3D printed-lattice (P-beta-TCP) and randomly-porous, template-casted (N-beta-TCP) structures. Our results indicate that SCs proliferated well and expressed the phenotypic markers p75LNGFR and the S100-beta subunit of SCs as well as displayed growth morphology on both scaffolds, but SCs showed spindle-shaped morphology with a significant degree of SCs alignment on the P-beta-TCP scaffolds, seen to a lesser degree in the N-beta-TCP scaffold. The gene expressions of nerve growth factor (beta-ngf), neutrophin-3 (nt-3), platelet-derived growth factor (pdgf-bb), and vascular endothelial growth factor (vegf-a) were higher at day 7 than at day 14. While no significant differences in protein secretion were measured between these last two time points, the scaffolds promoted the protein secretion at day 3 compared to that on the cell culture plates. These results together imply that the beta-TCP scaffolds can support SC cell growth and that the 3D-printed scaffold appeared to significantly promote the alignment of SCs along the struts. Further studies are needed to investigate the early and late stage relationship between gene expression and protein secretion of SCs on the scaffolds with refined characteristics, thus better exploring the potential of SCs to support vascularization and innervation in synthetic bone grafts.

Alopecia-neurological defects-endocrinopathy (ANE) syndrome is a rare inherited hair disorder, which was shown to result from decreased expression of the RNA-binding motif protein 28 (RBM28). In this study, we attempted to delineate the role of RBM28 in hair biology. First, we sought to obtain evidence for the direct involvement of RBM28 in hair growth. When RBM28 was downregulated in human hair follicle (HF) organ cultures, we observed catagen induction and HF growth arrest, indicating that RBM28 is necessary for normal hair growth. We also aimed at identifying molecular targets of RBM28. Given that an RBM28 homologue was recently found to regulate miRNA biogenesis in C. elegans and given the known pivotal importance of miRNAs for proper hair follicle development, we studied global miRNA expression profile in cells knocked down for RBM28. This analysis revealed that RBM28 controls the expression of miR-203. miR-203 was found to regulate in turn TP63, encoding the transcription factor p63, which is critical for hair morphogenesis. In conclusion, RBM28 contributes to HF growth regulation through modulation of miR-203 and p63 activity.

PURPOSE: We present our use of magnetic resonance (MR) measurement to determine the amount of residual breast tissue (RBT) following total mastectomy with reconstruction. METHODS: Breast MR images of 45 women who underwent surgery between January and November 2011 were reviewed. The cohort included therapeutic and prophylactic mastectomies. RBT was evaluated at four points with a digital caliper assessing T2-weighted and T1-weighted images. RESULTS: Patients undergoing mastectomy for carcinoma tended to have less RBT than in prophylactic surgery. Greater age and recent surgery both correlated with larger RBT. CONCLUSIONS: Variable thickness of RBT is demonstrable following mastectomy and implant reconstruction using MR imaging.

INTRODUCTION: In the USA, 450,000 thermal burns receive medical treatment annually. Burn scars are commonly excised and covered with skin grafts. Long-term, these treatments commonly leave patients with discomfort, reduced total lung capacity and forced vital capacity, and restriction of thoracic expansion and shoulder joint mobility. In this article, we present our experience with using scar release and immediate flap reconstruction to treat thoracic restriction due to burn sequelae. METHODS: From 1998 to 2014, we enrolled 16 patients with anterior thoracic burn sequelae that had previously been treated conservatively or with skin grafts that eventually recidivated. Preoperatively, we measured thoracic circumference in expiration and inspiration, %FVC, %FEV1, and shoulder mobility. All patients underwent anterior thoracic scar release and immediate flap resurfacing. RESULTS: At 2 weeks to 3 months postoperatively (mean, 2.6 months), mean thoracic circumference upon inspiration increased from 83.6 cm+/-5.7 to 86.5 cm+/-5.8 (p<0.0000000001). Mean %FVC improved from 76.0%+/-2.64% to 88.2%+/-4.69% (p<0.0000001). Mean %FEV1 improved from 79.2%+/-3.85 to 87.8%+/-2.98 (p<0.000001). All 14 patients who had restricted shoulder mobility preoperatively no longer had restricted shoulder mobility postoperatively. The mean patient-reported satisfaction was 4.6/5 (range, 3-5). At a mean follow up of 2.5 years, none of the contractures recidivated. Complications included 2 cases of tissue necrosis of the distal end of the flap. In one case, the flap was restored; in the other case, the patient eventually had to receive a new flap. Additional complications included two local infections that were successfully treated with oral and local antibiotics and two hematomas that were drained and eventually healed without tissue loss. CONCLUSIONS: Scar releases and flaps provide a safe and effective method for the correction of restricted thoracic expansion, respiratory restriction, decreased range of shoulder motion, and discomfort from thoracic burn sequelae.