Faculty Bibliography

The authors present a new and unique pattern of sutural fusion "peace sign synostosis" (PSS) characterized by synostosis of the metopic, bicoronal, and sagittal sutures and associated with abnormalities of the TWIST1 gene known to be associated with Saethre-Chotzen syndrome (SCS). To do so, we performed a retrospective review of patients with bicoronal, metopic, and at least partial anterior sagittal synostoses at the Children's Hospital of Philadelphia and Seattle Children's Hospital. Patients' demographics, genetic analysis, perioperative and clinic notes were reviewed. Five patients were identified with PSS and abnormalities of TWIST1 consistent with SCS. One patient, with the longest follow-up of 7 years, underwent 5 intracranial procedures and required a ventriculoperitoneal (VP) shunt. The remaining 4 patients underwent posterior cranial vault distraction as the initial procedure, followed by anterior cranial vault remodeling. Two patients required a VP shunt. To conclude, synostosis of the metopic, bicoronal, and sagittal sutures (PSS) appears to be associated with SCS and produces a characteristic skull morphology that can be readily identified on physical examination. Early data suggest a high rate of reoperation, increased necessity for a VP shunt, and potential complications. Of note, this novel phenotype had not been previously observed at our respective institutions, reported in the literature, or observed in association with TWIST1 abnormalities as described in association with SCS.

OBJECTIVES: Individuals with nerve transection face unpredictable outcomes, and microsurgical interventions have variable success. The facial nerve in particular is prone to traumatic transection and leads to debilitating sequelae. Surgeons have used multiple modalities of enhancing nerve regeneration and restoring premorbid functionality. The success of nerve regeneration is predicated on multiple physiologic factors. This article sought to collate the literature on factors influencing nerve damage and repair, using the facial nerve as a paradigm. As such, facial reanimation will also be briefly discussed as it relates to the central theme. DESIGN: A PubMed search was conducted to find articles published on nerve physiology and anatomy, as well as repair. Articles from 1947 to 2013 were studied; however, the preponderance of articles in the study was from the past 15 years to include recent advances. RESULTS: The type and severity of nerve injury, as well as timing of intervention, influence the anatomical and functional outcomes of nerve repair. As there is no uniform solution for all reconstructive challenges, multiple factors must be considered when planning an intervention. Future advances suggest a potential role for engineered nerve conduits in providing a tool for nerve regrowth. CONCLUSION: Our review has detailed mechanisms of nerve injury, physiology, interventions in nerve repair, and future direction of this expanding field. This review provides a guide for the microsurgeon in factors involved in restorative success.

BACKGROUND: The general public may not fully appreciate the role that plastic surgeons play in patient care. The authors sought to identify public perceptions of plastic surgery in a major US urban setting. METHODS: A short, anonymous, survey was distributed to the public in all of the major boroughs of New York City. Respondents were asked to choose the surgeon they believed were experts in 12 specific clinical issues representative of required competencies by both the Plastic Surgery Residency Review Committee and the American Board of Plastic Surgery. RESULTS: A total of 1000 surveys were collected. Respondent demographics were similar by sex (53% women) and age (6% ages<21 years, 31% ages 21-24 years, 46% ages 25-40 years, 10% ages 41-54 years, and 8% ages >/=55 years). The majority also completed high school (96%). The percent of respondents who chose plastic surgeons as experts in the following procedures included rhinoplasty (61%), mandible fracture (12%), blepharoplasty (71%), cleft lip and palate surgery (46%), thumb replantation (32%), hand/finger fracture (18%), rhytidectomy (85%), breast reconstruction (87%), breast augmentation (96%), open leg wound (15%), open wound on the face (40%), and Botox (47%). Plastic surgeons were the most commonly selected experts in only 8 of these 12 domains (67%). These included rhinoplasty, blepharoplasty, rhytidectomy, Botox injections, breast augmentation, breast reconstruction, cleft lip and palate surgery, and treatment of open wound of the face. CONCLUSIONS: Unfortunately, many conditions at the core of plastic surgery remain outside the realm of plastic surgery in the opinion of the surveyed public.

The present study aims to determine the risk of early secondary nasal revisions in patients with complete unilateral and bilateral cleft lip and palate (U/BCLP) treated with and without nasoalveolar molding (NAM) and examine the associated costs of care. A retrospective cohort study from 1990 to 1999 was performed comparing the risk of early secondary nasal revision surgery in patients with a CLP treated with NAM and surgery (cleft lip repair and primary surgical nasal reconstruction) versus surgery alone in a private practice and tertiary level clinic. The NAM treatment group consisted of 172 patients with UCLP and 71 patients with BCLP, whereas the non-NAM-prepared group consisted of 28 patients with UCLP and 5 with BCLP. The risk of secondary nasal revision for patients with UCLP was 3% in the NAM group and 21% in the non-NAM group. The risk of secondary nasal revision for patients with BCLP was 7% in the NAM group compared with 40% in the non-NAM group. Using multicenter averages, the non-NAM revision rates were calculated at 37.8% and 48.5% for U/BCLP, respectively. Applying these risks of revision, NAM treatment led to an estimated savings of between $491 and $4893 depending on the type of cleft. In conclusion, NAM can reduce the number of early secondary nasal revision surgeries and, therefore, reduce the overall cost of care.

This study assessed the osseointegrative effects of atmospheric pressure plasma (APP) surface treatment for implants in a canine model. Control surfaces were untreated textured titanium (Ti) and calcium phosphate (CaP). Experimental surfaces were their 80-second air-based APP-treated counterparts. Physicochemical characterization was performed to assess topography, surface energy, and chemical composition. One implant from each control and experimental group (four in total) was placed in one radius of each of the seven male beagles for three weeks, and one implant from each group was placed in the contralateral radius for six weeks. After sacrifice, bone-to-implant contact (BIC) and bone area fraction occupancy (BAFO) were assessed. X-ray photoelectron spectroscopy showed decreased surface levels of carbon and increased Ti and oxygen, and calcium and oxygen, posttreatment for Ti and CaP surfaces, respectively. There was a significant (P < 0.001) increase in BIC for APP-treated textured Ti surfaces at six weeks but not at three weeks or for CaP surfaces. There were no significant (P = 0.57) differences for BAFO between treated and untreated surfaces for either material at either time point. This suggests that air-based APP surface treatment may improve osseointegration of textured Ti surfaces but not CaP surfaces. Studies optimizing APP parameters and applications are warranted.

OBJECTIVES: To evaluate the probability of survival and failure modes of implant-supported resin nanoceramic relative to metal-ceramic crowns. METHODS: Resin nanoceramic molar crowns (LU) (Lava Ultimate, 3M ESPE, USA) were milled and metal-ceramic (MC) (Co-Cr alloy, Wirobond C+, Bego, USA) with identical anatomy were fabricated (n=21). The metal coping and a burnout-resin veneer were created by CAD/CAM, using an abutment (Stealth-abutment, Bicon LLC, USA) and a milled crown from the LU group as models for porcelain hot-pressing (GC-Initial IQ-Press, GC, USA). Crowns were cemented, the implants (n=42, Bicon) embedded in acrylic-resin for mechanical testing, and subjected to single-load to fracture (SLF, n=3 each) for determination of step-stress profiles for accelerated-life testing in water (n=18 each). Weibull curves (50,000 cycles at 200N, 90% CI) were plotted. Weibull modulus (m) and characteristic strength (eta) were calculated and a contour plot used (m versus eta) for determining differences between groups. Fractography was performed in SEM and polarized-light microscopy. RESULTS: SLF mean values were 1871N (+/-54.03) for MC and 1748N (+/-50.71) for LU. Beta values were 0.11 for MC and 0.49 for LU. Weibull modulus was 9.56 and eta=1038.8N for LU, and m=4.57 and eta=945.42N for MC (p>0.10). Probability of survival (50,000 and 100,000 cycles at 200 and 300N) was 100% for LU and 99% for MC. Failures were cohesive within LU. In MC crowns, porcelain veneer fractures frequently extended to the supporting metal coping. CONCLUSION: Probability of survival was not different between crown materials, but failure modes differed. SIGNIFICANCE: In load bearing regions, similar reliability should be expected for metal ceramics, known as the gold standard, and resin nanoceramic crowns over implants. Failure modes involving porcelain veneer fracture and delamination in MC crowns are less likely to be successfully repaired compared to cohesive failures in resin nanoceramic material.

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.

PURPOSE: Melanoma, the skin cancer with the lowest incidence, causes the majority of all skin cancer-related deaths. Early detection has led to the discovery of melanoma at less advanced stages, thus shifting the reconstructive paradigm from sole survivorship to the improvement of function and cosmesis while still maintaining an overall adequate outcome. Reconstructive approaches rely on two main factors: location of the lesion and size of the lesion. Due to the complexity of the hand, reconstructive options are quite heterogeneous. The purpose of this study is to explore the clinical data and reconstructive strategies of hand and digital cutaneous melanoma and subungual melanoma, review the current reconstructive options presented in the medical literature, and offer a reconstructive algorithm to surgically approach primary melanoma of the hand. METHODS: A retrospective chart review was conducted for all patients undergoing oncologic resection of primary melanoma of the hand at New York University Langone Medical Center (NYULMC) between April 2003 and October 2011. Variables collected included age, race, gender, type of melanoma, Breslow depth, stage, oncologic resection, reconstructive surgery, and outcomes. RESULTS: A total of 35 patients with primary melanoma of the hand comprised the study cohort. The mean age of presentation was 56 years with a total of 24 women and 11 men. The average Breslow depth of the cohort was 1.58 mm. There were 13 cases of melanoma in situ (MIS). All MIS cases were treated with wide local excision, yet the subungual group needed more extensive reconstruction including paronychial advancement flaps and full-thickness skin grafts (FTSG). Twenty-two cases presented as malignant melanoma. The majority of the patients with cutaneous melanoma underwent wide local excision with primary closure or FTSG. In the subungual group, all patients underwent amputation at the most distal interphalangeal joint or wide local excision. The reconstruction consisted of local advancement flaps, FTSG, or primary closure. CONCLUSION: Reconstructive options for primary melanoma of the hand are quite varied without strong guidelines as to which technique is superior. Location, size, and type of lesion (cutaneous or subungual) help shape which reconstructive strategies are optimal. With more conservative oncologic approaches and advanced reconstructive techniques, patients are able to maintain function with a satisfactory degree of cosmesis.

Tracheostoma wounds are complex defects that commonly occur in patients with vessel-depleted necks after cervical lymphadenectomy, who have multiple medical comorbidities, and a history of radiation therapy. The authors report reconstruction of 5 tracheostoma wounds using a pedicled, supraclavicular artery island flap as a reconstructive alternative. There were no flap losses, fistulas or leaks, revisions, or other complications. The supraclavicular artery island flap is a versatile, reliable, and effective option for tracheostoma reconstruction.

BACKGROUND: Acellular dermal matrix (ADM) is widely used for structural or dermal replacement purposes. Given its innate biocompatibility and its potential to vascularize, we explored the possibility of ADM to function as a small interfering RNA (siRNA) delivery system. Specifically, we sought to improve ADM vascularization by siRNA-mediated inhibition of prolyl hydroxylase domain-2 (PHD2), a cytoplasmic protein that regulates hypoxia inducible factor-1alpha, and improve neovascularization. MATERIALS AND METHODS: Fluorescently labeled siRNA was used to rehydrate thin implantable ADM. Pharmacokinetic release of siRNA was determined. Twelve millimeter sections of ADM reconstituted with PHD2 siRNA (nonsense siRNA as control) and applied to dorsal wounds of 40 FVB mice. Grafts were sewn in, bolstered, and covered with occlusive dressings. Photographs were taken at 0, 7, and 14 d. Wounds were harvested at 7 and 14 d and analyzed (messenger RNA, protein, histology, and immunohistochemistry). RESULTS: Release kinetics was first-order with 80% release by 12 h. By day 14, PHD2-containing ADM appeared viable and adherent, whereas controls appeared nonviable and nonadherent. Real-time reverse transcription-polymerase chain reaction demonstrated near-complete knockdown of PHD2, whereas vascular endothelial growth factor and FGF-2 were increased 2.3- and 4.7-fold. On enzyme-linked immunosorbent assay, vascular endothelial growth factor was increased more than fourfold and stromal cell-derived factor doubled. Histology demonstrated improved graft incorporation in treated groups. Immunohistochemical demonstrated increased vascularity measured by CD31 staining and increased new cell proliferation by denser proliferating cell nuclear antigen staining in treated versus controls. CONCLUSIONS: We concluded that ADM is an effective matrix for local delivery of siRNA. Strategies to improve the matrix and/or genetically alter the local tissue environment can be envisioned.