Faculty Bibliography

BACKGROUND: The integrated model of plastic surgery education, shortly to become the standard for all 6-year programs, has set minimal but no maximal exposure to plastic surgery. The authors hypothesized that the first 3 years of integrated training will show variability among residency programs. METHODS: Rotation schedules for all 42 integrated programs were analyzed for plastic surgery versus 18 nonplastic surgery rotations for postgraduate years 1, 2, and 3 as well as cumulatively for the first 3 years. Rotations "strongly suggested" by the Residency Review Committee on Plastic Surgery and American Board of Plastic Surgery were also examined. RESULTS: Postgraduate years 1 through 3 spent a wide range of 3 to 19 months (SD +/- 4.9 months) on plastic surgery (mean, 9.1 months). General surgery also varied dramatically, with 8 to 21 months (SD +/- 4.0 months) of exposure (mean, 16.3 months). Surgical subspecialty rotations ranged substantially from 1 to 6 months (SD +/- 1.0 months). Plastic surgery exposure was greater in programs based within plastic surgery departments than within divisions (13.8 versus 8.3 months, p < 0.005). Eighteen programs (42.9 percent) had dedicated hand surgery rotations, while seven (16.7 percent) had time dedicated for research. There was also wide variability in the inclusion of 18 nonplastic surgery rotations as well as specific "strongly suggested" rotations. CONCLUSIONS: The plastic surgery experience in the first 3 years of residency training varies by a greater than 6-fold difference among integrated programs. This was also found in the 2.5-fold and 6-fold differences in general surgery and subspecialty surgery experiences. Since standardized residency training is an expectation by both accrediting bodies and the public, this variability may warrant closer attention.

Bioglasses are considered osteoconductive and osteoproductive biomaterials and some types also exhibit angiogenic, bacteriostatic and anti-inflammatory properties. Despite these facts, bioglasses have only a few commercial applications, mainly because they do not exhibit as good mechanical properties as titanium. This study evaluated the biological performance of titanium implants coated with a highly bioactive glass. The experimental study was performed in vivo and in vitro. The in vitro study was conducted by evaluating the adhesion and cell viability on titanium disks treated with highly bioactive glass. For the in vivo study, implants were installed in the mandibles of dogs Beagles. A group of implants presented a surface with double acid-etched and the other group had a surface with double acid-etched + highly bioactive glass. The results confirmed that coating pattern tested in this study is non cytotoxic and does not adversely affect the new bone formation on the implant interface, showing performance comparable to that of physically modified surface with double acid-etched. The results of this research do not demonstrated a significant increase in bone formation after the incorporation of bioactive glass on titanium surfaces, but indicates the possibility of modifying titanium surfaces in a predicable and promisingway

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Perform preoperative assessment and patient selection for liposuction surgeries. 2. Explain the differences among the various types of anesthesia and wetting solutions used in liposuction. 3. Identify the available literature about skin-tightening procedures. 4. Convey to patients the complication profile for various modalities of liposuction. 5. Recall important ASPS consensus guidelines when discussing liposuction. SUMMARY: The article was prepared to feature recent evidence-based publications pertaining to liposuction. The authors placed special emphasis on the most clinically relevant data. In addition, they highlighted current data regarding liposuction-related fields, including autologous fat transfer and minimally invasive skin tightening.

AIM: To evaluate the relationship between intraoperative blood loss and juvenile nasopharyngeal angiofibroma (JNA) vascular supply and tumour stage in patients who underwent superselective external carotid artery (ECA) embolization. This series is unique in that all embolizations were performed by dedicated paediatric interventional radiologists at a tertiary referral paediatric centre. MATERIALS AND METHODS: Seventeen male patients treated from January 2002 to August 2009 underwent preoperative angiography and embolization using polyvinyl alcohol (PVA) particles. Tumours were graded using three different staging systems based on preoperative imaging and correlated to surgical blood loss. All patients underwent bilateral internal and external carotid angiography, with embolization of ECA tumour supply via microcatheter delivery of PVA particles. Particle size ranged from 150-500 mum with a mean size of 250-355 mum. Surgical resection was performed with either endoscopic or open techniques within 24 h and intraoperative blood loss was reported. RESULTS: Seven lesions were supplied strictly by the ECA circulation and had mean surgical blood loss of 336 ml. Twelve lesions had both ECA and internal carotid artery (ICA) supply and had mean surgical blood loss of 842 ml. The difference in blood loss in these two groups was statistically significant (p = 0.03). There was no case of inadvertent intracranial or ophthalmic embolization. There were statistically significant correlations between estimated surgical blood loss and the Andrews (p = 0.008), Radkowski (p = 0.015), and University of Pittsburgh Medical Center (UPMC; p = 0.015) preoperative tumour staging systems, respectively. CONCLUSION: Preoperative embolization of JNA tumours can be safely performed without neurological complications. The present study identified a statistically significant difference in intraoperative blood loss between those lesions with a purely ECA vascular supply and a combination of ECA and ICA vascular supply. Angiography is helpful in delineating ICA supply and can help guide surgical planning.

Behcet's disease (BD) is an autoimmune & autoinflammatory disease of unclear etiology characterized by recurrent oral & genital ulcers as well as other systemic manifestations. A key pathogenesis is excessive inflammatory wound healing response. While descriptions of the cutaneous manifestations of disease are limited to short-term consequences such as extensive pustule and papule formation in response to minor tissue injury, the long-term consequences are significant fibrosis and scarring of epithelial tissue. We describe the case of a patient with Behcet's disease who presented with unilateral facial atrophy secondary to minor trauma to the oral mucosa. She was treated with autologous fat grafting. Though a rare disease, plastic surgeons should be aware of the entity of Behcet's disease and its complications of tissue atrophy that may require reconstructive surgery.

BACKGROUND: T regulatory cells (Tregs) have been associated with prolonged allograft survival and tolerance across a wide variety of species and organ types. We used our nonhuman primate model of facial vascularized composite allotransplantation (VCA) to study the association of Tregs with graft outcomes. METHODS: We quantified Tregs in peripheral blood and allograft biopsies from nonhuman primates after heterotopic partial facial segment allotransplantation from major histocompatibility complex class I-mismatched donors using flow cytometry and immunohistochemistry. Immunosuppression consisted of tacrolimus and mycophenolate mofetil without induction or depletional therapies. Circulating and graft skin Treg values were compared with graft outcomes and with histologic grade from concurrent biopsies. RESULTS: Treg proportion in peripheral blood ranged from 0.156% to 9.00% with a mean of 3.34%+/-0.22%. FoxP3 staining was observed in 3 of 29 graft biopsies. Median circulating Treg value did not predict time to Banff grade II rejection (hazard ratio, 0.9; confidence interval, 0.4-2.2) or graft loss (hazard ratio, 0.5; confidence interval, 0.01-5.3). Animals that experienced rejection did not have significantly different peripheral blood or graft skin Treg values from those that did not. Biopsy specimens with grade I or II rejection were more likely to contain Tregs (25% vs. 0%; P=0.044) despite no difference in concurrent circulating Tregs (3.56% vs. 3.36%; P=0.704). CONCLUSIONS: These findings in a clinically relevant model suggest that Tregs may have limited prognostic value with standard immunosuppressive protocols used in VCA. Further studies are necessary to determine the specific role of Tregs in VCA and any role of Treg monitoring in clinical practice.

BACKGROUND: The central face high-energy avulsive injury has been frequently encountered and predictably managed at the R Adams Cowley Shock Trauma Center. However, despite significant surgical advances and multiple surgical procedures, the ultimate outcome continues to reveal an inanimate, insensate, and suboptimal aesthetic result. METHODS: To effectively address this challenging deformity, a comprehensive multidisciplinary approach was devised. The strategy involved the foundation of a basic science laboratory, the cultivation of a supportive institutional clinical environment, the innovative application of technologies, cadaveric simulations, a real-time clinical rehearsal, and an informed and willing recipient who had the characteristic deformity. RESULTS: After institutional review board and organ procurement organization approval, a total face, double jaw, and tongue transplantation was performed on a 37-year-old man with a central face high-energy avulsive ballistic injury. CONCLUSIONS: This facial transplant represents the most comprehensive transplant performed to date. Through a systematic approach and clinical adherence to fundamental principles of aesthetic surgery, craniofacial surgery, and microsurgery and the innovative application of technologies, restoration of human appearance and function for individuals with a devastating composite disfigurement is now a reality. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

BACKGROUND: Reconstructing periorbital defects is challenging because of the simultaneous need for ocular support, corneal protection, and restoration of aesthetic subtleties. In patients with extensive periorbital tissue loss, microvascular free tissue transfer is a reliable reconstructive option for composite defects. METHODS: The authors conducted a retrospective review of patients with periorbital craniofacial defects and identified those treated with microvascular reconstruction at the R Adams Cowley Shock Trauma Center and The Johns Hopkins Hospital from 2001 to 2010. RESULTS: Twenty-four patients underwent free flap reconstruction for periorbital defects secondary to trauma (n = 12), oncologic resection (n = 11), and congenital deformity (n = 1). The majority were men (n = 13), and the average age of the patients was 47 years (range, 19 to 80 years). Microvascular reconstructions included fibula (n = 9), anterolateral thigh (n = 6), ulnar forearm (n = 7), and groin flaps (n = 2). Flap survival rate was 100 percent, with an average follow-up of 26.5 months. CONCLUSIONS: Microvascular reconstruction of the periorbit can be accomplished successfully through careful analysis of tissue loss, eye or ocular prosthetic support, donor-site morbidity, and patient preference. Despite the multiple flap options that fulfill periorbital reconstructive needs, the authors find that the fibula, anterolateral thigh, ulnar forearm, and groin flaps can be used reliably to successfully reconstruct these defects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

PURPOSE: To investigate whether complex midface fractures have a greater association with death and intracranial injury than simple midface fractures. MATERIALS AND METHODS: A retrospective chart review was performed for patients with blunt-mechanism midface fractures who had presented to an urban trauma center from 1998 to 2010. The survival and intracranial injury status was evaluated for patients with simple and complex midface fractures, including Le Fort, naso-orbitoethmoid, and/or zygomaticomaxillary fractures. Intracranial injury included hemorrhage and brainstem injury. Patients with upper face fractures were excluded to minimize confounding. Adjusted relative risk estimates were obtained using multivariate regression analysis. RESULTS: Of 3,291 patients with midface fractures, 213 (6.3%) died and 693 (21.3%) had an intracranial injury. The cumulative mortality reached 11.6% in patients with complex midface fractures and 5.1% in those with simple midface fractures (P < .001). Patients with complex midface fractures were 57% more likely to die (relative risk = 1.57; P < .005). Specifically, Le Fort II fractures independently conferred a 94% increased risk of death (relative risk = 1.94; P < .01), but Le Fort I and III fractures were not significantly associated with death. Among patients presenting without neurologic impairment, those with Le Fort II and III fractures remained 2.88-fold (P < .01) and 2.54-fold (P < .001) more likely to have an underlying intracranial injury, respectively. CONCLUSIONS: Le Fort II fractures are associated with increased mortality. Furthermore, Le Fort II and III fractures are associated with serious intracranial injury, even in the absence of alterations in consciousness. These patients should be monitored with heightened vigilance and followed up closely during hospitalization, regardless of the presenting clinical findings.

BACKGROUND: The purpose of this study was to investigate whether a delay in operative management of frontal sinus fractures is associated with increased risk of serious infections. METHODS: Retrospective chart review was performed of 242 consecutive patients with surgically managed frontal sinus fractures who presented to the R Adams Cowley Shock Trauma Center between 1996 and 2011. Collected patient characteristics included demographics, surgical management, hospital course, and complications. All computed tomographic imaging was reviewed to evaluate involvement of the posterior table and nasofrontal outflow tract. Serious infections included meningitis, encephalitis, brain abscess, frontal sinus abscess, and osteomyelitis. Delayed operative interventions were defined as procedures performed more than 48 hours after admission. Adjusted relative risk estimates were obtained using multivariable regression. RESULTS: There were 14 serious infections (5.8 percent). All patients with serious infections had both involvement of the posterior table and nasofrontal outflow tract injury. The cumulative incidence of serious infection in these patients was 10.8 percent. After adjustments for confounding, multivariable regression showed that operative delay beyond 48 hours was independently associated with a 4.03-fold (p < 0.05) increased risk for serious infection; external cerebrospinal fluid drainage catheter use and local soft-tissue infection conferred a 4.09-fold (p < 0.05) and 5.10-fold (p < 0.001) increased risk, respectively. Antibiotic use beyond 48 hours postoperatively was not associated with fewer infections. CONCLUSIONS: Delay in operative management of frontal sinus fractures in patients requiring operative intervention is associated with an increased risk for serious infections. Continued antibiotic prophylaxis beyond the perioperative period provides little benefit in preventing serious infections. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.