Faculty Bibliography

Surgical reconstruction of an earlobe requires adequate support without sacrificing the delicacy necessary for an attractive result. A two-stage ear lobule reconstruction using a mastoid skin pocket and cartilage from the nasal septum was performed in six patients. The earlobe aesthetics were acceptable and allowed ear piercing. There were no major complications, including no loss of flap, graft extrusion, septal perforation, or infection. Range of follow-up was 1 to 6 years, with an average of 3 years. No revisions have been performed. A two-stage technique for ear lobule reconstruction is described using septal cartilage to preserve shape and definition that has the additional advantage of minimal morbidity.

OBJECTIVE: : To use an evidenced-based approach to better understand the management and treatment of pressure ulcers. BACKGROUND: : Pressure sores are a cause of significant morbidity in the medical community. Although there are a multitude of preventative and treatment options, there remains some degree of uncertainty in the literature in defining the best way to treat and manage pressure sores. METHODS: : An exhaustive literature search was performed using several electronic databases. The search revealed several identified modalities for treatment and/or prevention of pressure ulcers. We then assessed each modality individually for the level of evidence that exists in the most current literature, with preference given to more recent studies (2005 to present). RESULTS: : We reviewed the most relevant, high-level evidence that exists for the following modalities for understanding, preventing, and treating pressure ulcers: wound cleansers, repositioning, negative pressure therapy, debridement, enteral and parenteral feeding, vitamin and mineral supplementation, specialized mattresses, ultrasound therapy, honey, cellular therapy, musculocutaneous and fasciocutaneous flap closure, and other miscellaneous therapies. CONCLUSIONS: : Although many of these modalities are used, we encourage clinicians and health care providers to consider the evidence-based data when deciding how to most appropriately manage their patients' pressure sores.

BACKGROUND: Microtia reconstruction remains one of the most challenging procedures encountered by the reconstructive surgeon. A national report on the current management of microtia has never been presented before. The purpose of this project was to survey members of the American Society of Plastic Surgeons (ASPS) to identify their preferences and practices and report their opinions regarding issues related to microtia reconstruction. METHODS: An anonymous web-based survey consisting of 19 questions was distributed to the members of the ASPS. Questions focused on the management of microtia. The study design was descriptive, using categorical data analysis. RESULTS: Thirty-eight percent of all respondents perform microtia reconstruction; 91 % learned the autogenous cartilage-based reconstruction technique, while only 16 % were exposed to alloplastic reconstruction. Seventy percent of all respondents learned autogenous cartilage-based ear reconstruction exclusively. Fifty percent of respondents who perform microtia reconstruction reported a steep learning curve. In the pediatric patient population, 49 % of microtia surgeons prefer performing the surgery when the patient is between 7 and 10 years of age, while 40 % of microtia surgeons prefer the patient to be 4-6 years of age. Fifty-nine percent of all respondents believe that in 15 years tissue engineering will represent the gold standard of microtia reconstruction. CONCLUSION: Staged microtia repair using autogenous cartilage remains the heavily favored method of microtia reconstruction among plastic surgeons. Moreover, there is a deficiency in training the newer surgical techniques, such as alloplastic and osseointegrated options. This study also highlights the continuing need to elucidate the optimal timing for microtia repair in the pediatric patient to mitigate the potential psychosocial morbidity well described in the literature. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

BACKGROUND: Many health organizations sponsor overseas surgical outreach initiatives, yet none has published a standardized protocol to prevent and manage unforeseen emergencies. Surgeons, anesthesiologists, nurses, and administrators-working together on a brief overseas humanitarian initiative-benefit from education and training to maximize their collective emergency responsiveness. This article outlines the emergency response protocol instituted by the Global Smile Foundation, a 501(c)(3) nonprofit global outreach organization providing comprehensive cleft care for the past 25 years. METHODS: The Global Smile Foundation emergency response protocol was constructed to provide all team members resources and training needed to emulate the high emergency response standards of developed nations. In this article, the authors share their education/training strategy, emergency "crash" cart inventory, site-specific safety checklist, and team member roles and responsibilities during various emergencies. RESULTS: The authors' protocol emphasizes equipment portability, location-specific adaptability, clear workflow/communication, and standardized team roles. On-site training is likewise portable, standardized, reproducible, efficient, and adaptive to each setting. These characteristics make the authors' protocol widely adoptable. CONCLUSIONS: Most morbidity and mortality during overseas surgical outreach initiatives result from unfamiliarity with the host hospital and other team members during operative (e.g., airway, bleeding, circulatory, anesthetic) or location-based (e.g., power outage, fire, oxygen shortage) emergencies. These complications are prevented and managed with aggressive team education and training. The Global Smile Foundation protocol adapts to the uncertainties of providing medical care in underresourced settings and reflects experience accumulated over the past quarter century. It is the authors' hope that other humanitarian outreach groups will adopt, customize, and build on these basic tenets.

PURPOSE: Osteonecrosis of the jaw (ONJ) has been reported to be associated with patients receiving bisphosphonate (BP) therapy. There are many reports that suggest that the time of exposure to BPs is a significant risk factor for ONJ and that the greatest risk occurs after dentoalveolar surgery. The aim of this study was to retrospectively investigate the duration of BP therapy and related events before the onset of ONJ based on an intravenous (IV) or oral route of administration. MATERIALS AND METHODS: We conducted a retrospective cohort study of patients referred to our institution to identify the onset of ONJ based on the exposure to BP therapy and associated triggers (ie, dentoalveolar surgery or spontaneous occurrence) based on the route of BP administration. Demographic data (ie, age, gender, and race), medical diagnosis related to BP therapy, and information as to whether the BP therapy was continued at the time of ONJ diagnosis were also collected. RESULTS: We reviewed the records for 114 patients with a history of ONJ. We divided patient cohorts by route of BP administration, with 76 patients having a history of IV BP therapy and 38 patients having a history of oral BP therapy. The overall onset of ONJ was earlier in the IV BP group (median, 3 years) compared with the oral BP group (median, 5 years). There was no statistical difference in the duration to occurrence of ONJ associated with dental extraction compared with spontaneous occurrence for both the IV and oral BP groups. CONCLUSIONS: The median onset of ONJ for patients undergoing IV BP therapy occurs earlier than the median onset for patients undergoing oral BP therapy, and there was no difference in onset occurring spontaneously and after dental extraction. The significance of these findings suggests that patients who receive IV BP therapy should be closely evaluated after the initiation of BP therapy. The lack of evidence suggesting greater onset after dental extraction may provide clinical support for dentoalveolar surgery that is indicated for patients with a history of BP therapy. Research focusing on the clinical circumstances and physiologic events during early antiresorptive therapy may provide insight as to the critical risk factors.

BACKGROUND: Composite facial allografts have become increasingly popular in the reconstruction of complex facial defects. Good to excellent aesthetic results can be achieved, particularly when a foundation of donor skeleton has been transferred. The authors propose using a conventional craniofacial technique (monobloc osteotomy) to transfer a thin monocortical foundation of bone, even in lieu of a skeletal defect, to improve the recipient periorbital and malar aesthetics. METHODS: The monobloc osteotomy approach was used to obtain a full facial allograft and modified ex vivo to a thin monocortical layer and transferred to an anatomical facial skeleton. The authors have named this the "masque" flap because of the resemblance of the outline of the foundation of bone to a costume worn in masquerade balls. RESULTS: The masque flap was performed on two fresh-frozen cadavers. The total time to harvest and thin the osteomyocutaneous flap was 155 minutes (30 minutes to modify it ex vivo). The average total surface area was 1060 cm. Periorbital and malar ligaments were maintained, as was the integrity of the canthal tendons. CONCLUSION: The modified monobloc composite facial allograft technique allows transfer of a full facial allograft and maintains malar projection and excellent shape of the palpebral aperture.

OBJECTIVES: To evaluate the effect of framework design modification and veneering techniques in fatigue reliability and failure modes of veneered Yttria-Stabilized Tetragonal Zirconia Polycrystals (Y-TZP) crowns. METHODS: A CAD-based mandibular molar crown preparation served as a master die. Y-TZP crown cores (VITA-In-Ceram-YZ, Vita-Zahnfabrik, Bad Sackingen, Germany) in conventional (0.5mm uniform thickness) or anatomically designed fashion (cusp support) were porcelain veneered with either hand-layer (VM9) or pressed (PM9) techniques. Crowns (n=84) were cemented on 30 days aged dentin-like composite dies with resin cement. Crowns were subjected to single load to fracture (n=3 each group) and mouth-motion step-stress fatigue (n=18) by sliding a WC indenter (r=3.18mm) 0.7mm buccally on the inner incline surface of the mesio-lingual cusp. Stress-level curves (use level probability lognormal) and reliability (with 2-sided 90% confidence bounds, CB) for completion of a mission of 50.000 cycles at 200N load were calculated. Fractographic analyses were performed under light-polarized and scanning electron microscopes. RESULTS: Higher reliability for hand-layer veneered conventional core (0.99, CB 0.98-1) was found compared to its counterpart press-veneered (0.50 CB 0.33-65). Framework design modification significantly increased reliability for both veneering techniques (PM9 [0.98 CB 0.87-0.99], VM9 [1.00 CB 0.99-1]) and resulted in reduced veneer porcelain fracture sizes. Main fracture mode observed was veneer porcelain chipping, regardless of framework design and veneering technique. SIGNIFICANCE: Hand-layer porcelain veneered on conventional core designs presented higher reliability than press-veneered with similar core designs. Anatomic core design modification significantly increased the reliability and resulted in reduced chip size of either veneering techniques.

BACKGROUND: The greater omentum is easily harvested for coverage of sternal wounds without muscle sacrifice. Its major disadvantage is a laparotomy incision with potential bowel injury, adhesions, or hernia. Over the past 20 years, the authors' technique has evolved to use a transdiaphragmatic opening for omental harvest when possible. METHODS: The authors performed a retrospective cohort analysis of 140 consecutive patients undergoing omental flap harvest for treatment of sternal wounds following median sternotomy. Patients were divided into two groups by access incision: laparotomy incision (n = 80) versus a transdiaphragmatic opening (n = 60). RESULTS: The authors found that both techniques provided reliable closure of sternal wounds, but the transdiaphragmatic approach was faster, with less blood loss. There was no significant difference in rates of ventral hernias. We had only one bowel injury (laparotomy group) and no postoperative abdominal bleeding or small bowel obstruction. CONCLUSION: Transdiaphragmatic omental harvest provides safe and efficient coverage of deep sternal wounds without a laparotomy incision.