Faculty Bibliography

BACKGROUND: Acellular dermal matrix is a commonly used adjunct in implant-based breast reconstruction. Several investigations have shown increased complications associated with its use. Therefore, the authors' institution placed strict limitations on its use and transitioned to sterile "ready-to-use" acellular dermal matrix. The purpose of this investigation was to compare the infectious complications associated with aseptic versus sterile acellular dermal matrix. METHODS: A prospective study of all patients undergoing immediate implant-based breast reconstruction at a single academic medical center between November of 2010 and October of 2012 was conducted. AlloDerm (Life Cell Corporation, Branchburg, N.J.) was used as the source of acellular dermal matrix. Breasts were divided into three cohorts: total submuscular coverage, aseptic acellular dermal matrix, and sterile, ready-to-use acellular dermal matrix. Breasts were then compared based on demographic information, cancer qualities, and complications. RESULTS: A total of 546 reconstructed breasts met inclusion criteria: 64.3 percent (n = 351) with no acellular dermal matrix, 16.5 percent (n = 90) with aseptic matrix, and 19.2 percent (n = 105) with ready-to-use matrix. When comparing reconstructions with ready-to-use versus aseptic acellular dermal matrix, patients had a decrease in overall infection (8.5 percent versus 20.0 percent; p = 0.0088), major infection (4.7 percent versus 12.2 percent; p = 0.069), and need for explantation (1.9 percent versus 6.6 percent; p = 0.1470). When comparing patients undergoing reconstruction with ready-to-use matrix to total submuscular coverage, patients had similar overall infectious complications (8.5 percent versus 5.7 percent; p = 0.3602). Diabetes mellitus, seroma, mastectomy skin flap necrosis, and aseptic acellular dermal matrix were independent predictors of infectious complications. CONCLUSIONS: Ready-to-use acellular dermal matrix in immediate implant-based breast reconstruction provides a useful adjunct. In addition, it mitigates the risks of infectious complications when compared with aseptic acellular dermal matrix. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

BACKGROUND: The purpose of this study was to characterize soft-tissue profile changes following Le Fort III (midface) distraction in growing patients with syndromic craniosynostosis. METHODS: The cohort consisted of 20 syndromic patients who underwent Le Fort III osteotomy with midface advancement using a rigid external distraction device. The mean age at surgery was 5.7 years (range, 3 to 12.5 years). Lateral cephalograms were obtained preoperatively (time 1), after distraction device removal (time 2), and 1 year after distraction (time 3). Ten skeletal hard-tissue and 11 soft-tissue profile landmarks were identified and digitized at time points 1, 2, and 3. The x and y displacement of each landmark was studied to determine the ratios for soft- to hard-tissue change. RESULTS: The horizontal ratio of soft- to hard-tissue change for nasal dorsum to orbitale was 0.73:1 and the soft-tissue tip of nose to the anterior nasal spine was 0.86:1. The horizontal ratio of soft-tissue A point to hard-tissue A point was 0.88:1. The horizontal ratio of the upper lip position to the labial surface of maxillary incisor was 0.88:1. The ratio for nasal tip elevation to the anterior nasal spine advancement was 0.27:1. CONCLUSIONS: The result of this study supported the hypothesis that there exists a linear relationship between soft- and hard-tissue changes in the horizontal direction for the midface landmarks following Le Fort III distraction. However, there was a nonlinear relationship between soft- and hard-tissue changes in the vertical direction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

BACKGROUND: The classic Le Fort III procedure was recommended in syndromic craniosynostotic children to reduce exorbitism, improve airway function, and decrease dysmorphism. This study reports on a cohort of syndromic craniosynostosis patients who have undergone early primary subcranial (classic Tessier) Le Fort III advancement and who have been followed longitudinally through skeletal maturity and beyond. METHODS: In this study, the Le Fort III advancements all occurred between the ages of 3 to 5 years, with a mean age of 4.6 years. Subsequently, these early Le Fort III patients were followed throughout development with longitudinal dental, medical, radiographic, and photographic evaluations conducted through skeletal maturity and beyond. For study inclusion, the patients had to have preoperative medical photographs and cephalometric studies at 6 months and 1, 5, and 10 years postoperatively after the primary Le Fort III advancement as well as cephalometric documentation 6 months and 1 year after the secondary midface advancement after skeletal maturity. RESULTS: After early or primary Le Fort III advancement, there was no evidence of relapse and only minimal anterior or horizontal postoperative growth of the midface. However, there was also a return of occlusal disharmony from "anticipated" mandibular growth, approaching a maximum at skeletal maturity. The dysmorphic concave facial profile and malocclusion, and airway and ocular considerations, provided the impetus for secondary midface surgery after skeletal maturity was attained. CONCLUSION: The data demonstrate that early Le Fort III advancement performed before the age of mixed dentition does not obviate the need for a secondary advancement after skeletal maturity is reached. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The objective of this study was to characterize the chemical and physical properties of bioactive ceramics prepared from an aqueous paste containing hydroxyapatite (HA) and beta tri-calcium phosphate (beta-TCP). Prior to formulating the paste, HA and beta-TCP were calcined at 800 degrees C and 975 degrees C (11 h), milled, and blended into 15%/85% HA/beta-TCP volume-mixed paste. Fabricated cylindrical rods were subsequently sintered to 900 degrees C, 1100 degrees C or 1250 degrees C. The sintered specimens were characterized by helium pycnometry, X-ray diffraction (XRD), Fourier transform-infrared (FT-IR), and inductively coupled plasma (ICP) spectroscopy for evaluation of porosity, crystalline phase, functional-groups, and Ca:P ratio, respectively. Mechanical properties were assessed via 3-point bending and diametral compression. Qualitative microstructural evaluation using scanning electron microscopy (SEM) showed larger pores and a broader pore size distribution (PSD) for materials sintered at 900 degrees C and 1100 degrees C,whereas the 1250 degrees C samples showed more uniform PSD. Porosity quantification showed significantly higher porosity for materials sintered to 900 degrees C and 1250 degrees C (p < 0.05). XRD indicated substantial deviations from the 15%/85% HA/beta-TCP formulation following sintering where lower amounts of HA were observed when sintering temperature was increased. Mechanical testing demonstrated significant differences between calcination temperatures and different sintering regimes (p < 0.05). Variation in chemical composition and mechanical properties of bioactive ceramics were direct consequences of calcination and sintering.