Faculty Bibliography

Mandibular distraction osteogenesis is an established technique used to treat infants with Pierre Robin sequence associated with severe airway obstruction. The authors present a 7-year retrospective review of all patients with Pierre Robin sequence treated with mandibular distraction osteogenesis. Recorded variables included improvements in apnea/hypopnea index and postintervention tracheostomy. Multiple preoperative variables were assessed for association with successful mandibular distraction osteogenesis or tracheostomy. Fifty patients were identified for this study. Four patients (8 percent) required tracheostomy after distraction. A Fisher's exact test demonstrated no statistical association of tracheostomy with prematurity, low birth weight, preoperative intubation, late intervention, genetic syndromes, cardiac abnormalities, pulmonary abnormalities, or gastrostomy tube. The absence of a cleft palate, gastroesophageal reflux disease, and need for Nissen fundoplication were associated with failure of distraction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

STUDY DESIGN: Multivariate analysis of prospectively collected registry data. OBJECTIVE: To determine the effect of payor status on complication rates after spine surgery. SUMMARY OF BACKGROUND DATA: Understanding the risk of perioperative complications is an essential aspect in improving patient outcomes. Previous studies have looked at complication rates after spine surgery and factors related to increased perioperative complications. In other areas of medicine, there has been a growing body of evidence gathered to evaluate the role of payor status on outcomes and complications. Several studies have found increased complication rates and inferior outcomes in the uninsured and Medicaid insured. METHODS: The Spine End Results Registry (2003-2004) is a collection of prospectively collected data on all patients who underwent spine surgery at our 2 institutions. Extensive demographic data, including payor status, and medical information were prospectively recorded as described previously by Mirza et al. Medical complications were defined in detail a priori and were prospectively recorded for at least 2 years after surgery. Using univariate and multivariate analysis, we determined risk of postoperative medical complications dependent on payor status. RESULTS: A total of 1591 patients underwent spine surgery in 2003 and 2004 that met our criteria and were included in our analysis. With the multivariate analysis and by controlling for age, patients whose insurer was Medicaid had a 1.68 odds ratio (95% confidence interval: 1.23-2.29; P = 0.001) of having any adverse event when compared with the privately insured. CONCLUSION: After univariate and multivariate analyses, Medicaid insurance status was found to be a risk factor for postoperative complications. This corresponds to an ever-growing body of medical literature that has shown similar trends and raises the concern of underinsurance.

The tips of mammalian digits can regenerate after amputation, like those of amphibians. It is unknown why this capacity is limited to the area associated with the nail. Here we show that nail stem cells (NSCs) reside in the proximal nail matrix and that the mechanisms governing NSC differentiation are coupled directly with their ability to orchestrate digit regeneration. Early nail progenitors undergo Wnt-dependent differentiation into the nail. After amputation, this Wnt activation is required for nail regeneration and also for attracting nerves that promote mesenchymal blastema growth, leading to the regeneration of the digit. Amputations proximal to the Wnt-active nail progenitors result in failure to regenerate the nail or digit. Nevertheless, beta-catenin stabilization in the NSC region induced their regeneration. These results establish a link between NSC differentiation and digit regeneration, and suggest that NSCs may have the potential to contribute to the development of novel treatments for amputees.

BACKGROUND: Autologous breast reconstruction offers higher rates of patient satisfaction, but not all patients are ideal candidates, often due to inadequate volume of donor sites. Although autologous fat grafting is frequently used to augment volume and contour abnormalities in implant-based breast reconstruction, its clear utility in microsurgical breast reconstruction has yet to be defined. Here, we examined patients undergoing autologous microsurgical breast reconstruction with and without the adjunct of autologous fat grafting to clearly define utility and indications for use. METHODS: A retrospective review of all patients undergoing autologous breast reconstruction with microvascular free flaps at a single institution between November 2007 and October 2011 was conducted. Patients were divided into 2 groups as follows: those requiring postoperative fat grafting and those not requiring fat grafting. Patient demographics, indications for surgery, history of radiation therapy, patient body mass index, mastectomy specimen weight, need for rib resection, flap weight, and complications were analyzed in comparison. RESULTS: Two hundred twenty-eight patients underwent 374 microvascular free flaps for breast reconstruction. One hundred (26.7%) reconstructed breasts underwent postoperative fat grafting, with an average of 1.12 operative sessions. Fat was most commonly injected in the medial and superior medial poles of the breast and the average volume injected was 147.8 mL per breast (22-564 mL). The average ratio of fat injected to initial flap weight was 0.59 (0.07-1.39). Patients undergoing fat grafting were more likely to have had deep inferior epigastric perforator and profunda artery perforator flaps as compared to muscle-sparing transverse rectus abdominis myocutaneous. Patients additionally were more likely to have a prophylactic indication 58% (n = 58) versus 42% (n = 117) (P = 0.0087), rib resection 68% (n = 68) versus 54% (n = 148) (P < 0.0153), and acute postoperative complications requiring operative intervention 7% (n = 7) versus 2.1% (n = 8) (P < 0.0480). Additionally, patients undergoing autologous fat grafting had smaller body mass index, mastectomy weight, and flap weight. CONCLUSIONS: Fat grafting is most commonly used in those breasts with rib harvest, deep inferior epigastric perforator flap reconstructions, and those with acute postoperative complications. It should be considered a powerful adjunct to improve aesthetic outcomes in volume-deficient autologous breast reconstructions and additionally optimize contour in volume-adequate breast reconstructions.

BACKGROUND: Le Fort III distraction advances the Apert midface but leaves the central concavity and vertical compression untreated. The authors propose that Le Fort II distraction and simultaneous zygomatic repositioning as a combined procedure can move the central midface and lateral orbits in independent vectors in order to improve the facial deformity. The purpose of this study was to determine whether this segmental movement results in more normal facial proportions than Le Fort III distraction. METHODS: Computed tomographic scan analyses were performed before and after distraction in patients undergoing Le Fort III distraction (n = 5) and Le Fort II distraction with simultaneous zygomatic repositioning (n = 4). The calculated axial facial ratios and vertical facial ratios relative to the skull base were compared to those of unoperated Crouzon (n = 5) and normal (n = 6) controls. RESULTS: With Le Fort III distraction, facial ratios did not change with surgery and remained lower (p < 0.01; paired t test comparison) than normal and Crouzon controls. Although the face was advanced, its shape remained abnormal. With the Le Fort II segmental movement procedure, the central face advanced and lengthened more than the lateral orbit. This differential movement changed the abnormal facial ratios that were present before surgery into ratios that were not significantly different from normal controls (p > 0.05). CONCLUSION: Compared with Le Fort III distraction, Le Fort II distraction with simultaneous zygomatic repositioning normalizes the position and the shape of the Apert face. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Apert syndrome carries a characteristic phenotype of midface hypoplasia, syndactyly, craniosynostosis, and developmental delay. These patients frequently require a large number of surgical procedures to produce a functional and aesthetically pleasing correction of their facial deformities. Although most of the focus for surgical planning is allocated to the cranial vault and the midface, controversy exists as to whether the mandible is intrinsically abnormal in this population.A retrospective chart review was performed to identify patients with Apert syndrome cared for at The Children's Hospital of Philadelphia. Patients with available craniofacial computed tomographic scans after skeletal maturity were examined using cephalometric and three-dimensional volumetric techniques. A comparison was made to age- and demographically matched controls, and statistical significance was determined using the Student t test (P < 0.05).Thirty-eight patients, in total, were identified, 9 of which had available three-dimensional computed tomographic scans. Most patients underwent frontal-orbital advancement in their infancy and at least 1 midface procedure later in life. Three-dimensional volumetric analysis identified a decreased maxillary volume (P = 0.03) in the population with Apert syndrome but found no difference in the mandibular volume (P = 0.59). Cephalometric analysis demonstrated that the patients with Apert syndrome have normal ramal height but a statistically significant decreased mandibular length.The mandible with Apert syndrome seems to be intrinsically normal on the basis of our three-dimensional analysis, and differences in appreciated mandibular length are likely related to the interrelationship with the maxilla. Patients can therefore be instructed that improving the midface position may likely also reduce the compensatory mandibular deformity.

During wound healing, stem cells provide functional mature cells to meet acute demands for tissue regeneration. Simultaneously, the tissue must maintain a pool of stem cells to sustain its future regeneration capability. However, how these requirements are balanced in response to injury is unknown. Here we demonstrate that after wounding or ultraviolet type B irradiation, melanocyte stem cells (McSCs) in the hair follicle exit the stem cell niche before their initial cell division, potentially depleting the pool of these cells. We also found that McSCs migrate to the epidermis in a melanocortin 1 receptor (Mc1r)-dependent manner and differentiate into functional epidermal melanocytes, providing a pigmented protective barrier against ultraviolet irradiation over the damaged skin. These findings provide an example in which stem cell differentiation due to injury takes precedence over stem cell maintenance and show the potential for developing therapies for skin pigmentation disorders by manipulating McSCs.

BACKGROUND: Although propranolol can be an effective primary medical therapy for infantile hemangiomas of the head and neck, the duration of treatment and time to discontinue propranolol is unclear. OBJECTIVE: The objective of this study is to determine the duration of treatment and age at which propranolol may be successfully discontinued in children with infantile hemangiomas of the head and neck. METHODS: A review of all patients presenting to a pediatric vascular anomalies clinic from January 2008 to December 2011 was performed. Those with head and neck infantile hemangiomas who completed propranolol therapy were included. Each patient's records were reviewed for demographics, clinical response to propranolol, age at discontinuation of propranolol, and adverse events. RESULTS: Forty-five patients were included for review (mean age at presentation, 3.5 months) with all demonstrating positive responses. The mean age at discontinuation of propranolol was 11.8 months of age (range, 8-15 months) with a mean treatment duration of 6.5 months (range, 3-11 months). No recurrences were noted over a mean follow-up period of 19.9 months (range, 10-28 months). CONCLUSION: Discontinuation of propranolol at approximately 12 months of age was found to be appropriate in our study population.

BACKGROUND: A number of historical texts published during the first half of the twentieth century played a pivotal role in shaping and defining modern plastic surgery in the United States. METHODS: Blair's Surgery and Diseases of the Mouth and Jaws (1912), John Staige Davis's Plastic Surgery: Its Principles and Practice (1919), Gillies's Plastic Surgery of the Face (1920), Fomon's Surgery of Injury and Plastic Repair (1939), Ivy's Manual of Standard Practice of Plastic and Maxillofacial Surgery, Military Surgery Manuals (1943), Padgett and Stephenson's Plastic and Reconstructive Surgery (1948), and Kazanjian and Converse's The Surgical Treatment of Facial Injuries (1949) were reviewed. RESULTS: These texts were published at a time when plastic surgery was developing as a distinct specialty. Each work represents a different point in this evolution. All were not inclusive of all of plastic surgery, but all had a lasting impact. Four texts were based on clinical experience from World War I; one included experience from World War II; and two included experience from both. CONCLUSIONS: One text became a military surgical handbook in World Wars I and II, playing an important role in care for the wounded. History has demonstrated that times of war spark medical/surgical advancements, and these wars had a dramatic impact on the development of reconstructive plastic surgery. Each of these texts documented surgical advancements and provided an intellectual platform that helped shape and create the independent discipline of plastic surgery during peacetime. For many future leaders of plastic surgery, these books served as their introduction to this new field.

BACKGROUND: The authors present a prospective, randomized, blinded trial comparing the educational efficacy of digital animation versus a textbook in teaching the Ivy loop technique to novice learners. METHODS: Medical student volunteers (n = 32) were anonymously videotaped as they fastened dental wire to the teeth of a skull model (preintervention analysis) and then were randomly assigned to one of two study groups. The animation and text groups (n = 16 each) were shown either a digital animation or textbook demonstrating the Ivy loop surgical technique. Volunteers were then videotaped as they performed the technique (postintervention analysis). Volunteers were then shown the educational material provided to the other study group and given a validated educational survey to compare the educational value of both materials. Preintervention and postintervention video recordings were graded using a validated surgical competency scale. Surgical performance grades, time to task completion, and educational survey scores were compared. RESULTS: Preintervention analysis performance scores did not significantly differ between the animation and text groups (10.7 [2.8] versus 11.1 [3.9]; p = 0.74), but postintervention analysis demonstrated significantly higher performance scores in the animation group (18.8 [2.9] versus 13.0 [3.5]; p < 0.001). Time to task completion was similar. The educational survey demonstrated significantly higher scores in the animation group. CONCLUSIONS: A prospective, randomized, blinded study comparing the educational efficacy of a surgical textbook to digital animation demonstrates that, in novice learners, digital animation is a more effective tool for learning the Ivy loop technique. Test takers found digital animation to be the superior educational medium.