Faculty Bibliography

Introduction: The profunda artery perforator (PAP) flap is a new addition to our reconstructive armamentarium. In effort to better understand patient candidacy for the PAP flap we characterized the profunda artery perforators on preoperative imaging. Methods: A retrospective review was completed of 40 preoperative posterior thigh computed tomography angiographies and magnetic resonance angiographies by four plastic surgeons. The positioning of the patient, type of study, number of perforators, and size of perforators were documented. The location was documented on an x-y-axis. Perforator course and surrounding musculature was documented. Results: In 98.8% of posterior thighs suitable profunda artery perforators were identified. The average number and size of perforators was 3.3 and 1.9 mm. The most common perforator was medial (present in 85.6% of thighs); found near the adductor magnus at 3.8 cm from midline and 5.0 cm below the gluteal fold. The second most common perforator was lateral (present in 65.4% of thighs); found near the biceps femoris and vastus lateralis at 12.0 cm from midline and 5.0 cm below the gluteal fold. Nearly 48.3% were purely septocutaneous. And 51.7% had an intramuscular course (average length 5.7 cm). Preoperative imaging corresponded to suitable perforators at the time of dissection of all PAP flaps. Thirty five PAP flaps (18 patients) were performed with 100% flap survival. Conclusion: Analysis of preoperative posterior thigh imaging confirms our intraoperative findings that a considerable number of suitable posterior thigh profunda perforators are present, emerge from the fascia in a common pattern, and are of sufficient caliber to provide adequate flap perfusion and recipient vessel size match. (c) 2012 Wiley Periodicals, Inc. Microsurgery, 2012.

BACKGROUND: Isolated nonsyndromic bicoronal synostosis is a relatively rare entity that produces a characteristic turribrachycephalic skull shape. The purpose of this study was to evaluate the long-term outcomes of the isolated nonsyndromic bicoronal synostosis patients treated at the authors' institution. METHODS: A retrospective chart review of all patients who underwent cranial vault remodeling for nonsyndromic bicoronal synostosis was performed at the Children's Hospital of Philadelphia from 1991 to 2011. Fifteen patients were identified for this study, and information regarding their demographic, perioperative, and postoperative details were analyzed. RESULTS: Four boys and 11 girls were identified for inclusion in this study. The average age at the time of the initial surgery was 9 months, with an average follow-up of 13.4 years. There were no reported complications. Six patients with at least a 10-year follow-up (six of 10 patients) underwent revision for contour improvement in the forehead and temporal regions, and two patients required a repeated fronto-orbital advancement. Four patients underwent subsequent strabismus surgery. No patients were documented to have midface hypoplasia requiring orthognathic surgery. One patient with an associated diagnosis of autism was noted to have significant developmental delay. CONCLUSIONS: Isolated nonsyndromic bicoronal synostosis confers a high rate of revisions for contour deformities but is associated with a low risk of complications. Overall, nonsyndromic patients require less secondary fronto-orbital advancement when compared with syndromic patients. In contrast to the syndromic population, there were no instances of midface hypoplasia necessitating surgery. There did not appear to be significant correlation between bicoronal synostosis and developmental abnormalities or delays.

Posterior tongue defects present a unique reconstructive challenge. The various reconstructive options available for treating the defect created by a posterior hemiglossectomy frequently result in a distorted tongue and functional impairment. This paper describes a novel sliding anterior hemitongue flap to allow reconstruction of moderate resection defects (i.e. for T1-T2 tongue squamous cell carcinomas) of the posterior tongue. By mobilizing the anterior tongue, near normal mobility and tongue length are maintained. This surgical technique may be performed alone intraorally or in combination with a neck dissection.

BACKGROUND: Transplantation of a facial vascularized composite allograft is a highly complex procedure that requires meticulous planning and affords little room for error. Although cadaveric dissections are an essential preparatory exercise, they cannot simulate the true clinical experience of facial vascularized composite allograft recovery. METHODS: After obtaining institutional review board approval to perform a facial vascularized composite allograft research procurement, a 66-year-old, brain-dead donor was identified. The family graciously consented to donation of a total face, double jaw, and tongue allograft and multiple solid organs. RESULTS: A craniofacial computed tomographic angiogram was obtained preoperatively to define the vascular anatomy and facilitate virtual computerized surgical planning. The allograft was procured in 10 hours, with an additional 2 hours required for an open tracheostomy and silicone facial impression. The donor was coagulopathic throughout the recovery, resulting in an estimated blood loss of 1500 ml. Fluorescence angiography confirmed adequate perfusion of the entire allograft based on lingual and facial arterial and external jugular and thyrolinguofacial venous pedicles. The solid organ transplant team initiated abdominal organ isolation while the facial allograft procurement was in progress. After completion of allograft recovery, the kidneys and liver were recovered without complication. CONCLUSIONS: Before conducting a clinical face transplant, adequate preparation is critical to maximize vascularized composite allotransplantation outcomes and preserve solid organ allograft function. As more centers begin to perform facial transplantation, research procurement of a facial vascularized composite allograft offers a unique educational opportunity for the surgical and anesthesia teams, the organ procurement organization, and the institution.

BACKGROUND: With the transplantation of more extensive facial vascularized composite allografts, fundamental craniofacial and aesthetic principles become increasingly important. In addition, computer-assisted planning and intraoperative navigation may improve precision and efficiency in these complex procedures. METHODS: Ten mock face transplants were performed in 20 cadavers. The vascularized composite allograft consisted of all facial skin, mimetic muscles, the tongue, the midface by means of a Le Fort III osteotomy, and the mandible by means of sagittal split osteotomies. Craniofacial computed tomographic scans were obtained before and after the mock transplants. Surgical planning software was used to virtually plan the osteotomies, and a surgical navigation system guided the osteotomies intraoperatively. Cephalometric analyses were compared between the virtually planned transplants and the actual postoperative results. RESULTS: The combination of preoperative computerized planning and intraoperative guidance consistently produced a vascularized composite allograft that could be easily fixated to the prepared recipient, with only minimal burring of osteotomy sites necessary. Satisfactory occlusion was maintained, and postoperative computed tomography confirmed accurate skeletal fixation. Insignificant differences with regard to cephalometric analyses were noted when predicted and actual postoperative data were compared. CONCLUSIONS: The authors' experience treating severe craniofacial injury allowed consistent transfer of facial vascularized composite allografts, maintaining proper occlusion. Preoperative computer planning and intraoperative navigation ensured precise osteotomies and a good donor-recipient skeletal match, which greatly reduced the need for intraoperative adjustments and manipulation. This total facial vascularized composite allograft represents one of the most extensive described and is intended to represent a typical central facial demolition pattern.

BACKGROUND: Abdominal fascia plication using a simple continuous suture can sometimes cause tears in the fascia. This problem can be circumvented when the continuous horizontal mattress suture is used. No data exist from comparing the two suturing techniques. The aim of this study was to examine which technique can potentially cause greater tissue damage. The time required to perform each type of suture was also recorded. METHODS: Wound closure pads were plicated using the simple continuous and continuous horizontal mattress techniques performed by a single operator using Ethilon 2-0 nylon sutures. To verify their resilience, plastic bags were inflated beneath the pads to 30, 60, and 120 mmHg and tears were recorded. The time needed to perform the procedures was recorded using a stopwatch. RESULTS: Mean time for the continuous vertical mattress suture was 87 s and for the simple continuous suture 116 s. Tears in the pad that was plicated with the simple continuous pattern were significantly longer than those in the pad plicated with the continuous horizontal mattress pattern (fissure mean length +/- SD = 3.958 +/- 0.157 vs. 2.736 +/- 0.157, respectively, p < 0.001). This finding was true for each of the three measured pressures (fissure mean length for 30 mmHg was 3.40 +/- 1.807 vs. 2.12 +/- 1.709 cm; for 60 mmHg, 3.94 +/- 2.90 vs. 2.90 +/- 1.893 cm; and for 120 mmHg, 4.54 +/- 1.924 vs. 3.19 +/- 2.110 cm; p < 0.001). CONCLUSIONS: Continuous horizontal mattress pattern sutures were found to be superior to simple continuous pattern sutures in the suggested model, in terms of suturing time and damage to the pad. Further research in human subjects is still required. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article.

BACKGROUND:Impaired wound healing remains a major clinical problem with many etiologies. Altering gene expression to enhance healing is an innovative therapeutic approach. In recent years, we have developed a means to topically silence genes at the post-transcriptional level to locally alter wounds and improve the healing process. THE PROBLEM/OBJECTIVE:Many types of chronic wounds have been associated with alterations in the expression of genes that mediate healing. Targeting the expression of these genes in a way that can improve healing while limiting systemic side effects has been very challenging. BASIC/CLINICAL SCIENCE ADVANCES/UNASSIGNED:Our laboratory's recent work has focused on the use of topically applied small interfering ribonucleic acid (siRNA) to inhibit messenger RNA expression of certain mediators involved in healing in two different types of cutaneous injury-radiation-induced cutaneous injury and the diabetic excisional wound. By successfully inhibiting specific gene mediators with topical siRNA, we reversed downstream signaling pathways, which led to expedited wound healing in diabetic wounds and restoration to a more normal phenotype in radiation-induced skin injuries. CLINICAL CARE RELEVANCE/UNASSIGNED:The signaling pathways and gene mediators that we targeted and inhibited in murine models are present in humans. Applying parallel treatment strategies in humans may provide novel means of treating these burdensome and costly conditions. CONCLUSION/CONCLUSIONS:Our novel method for local gene silencing is effective in treating various types of cutaneous murine wounds. Topical gene silencing with siRNA obviates the side effects of systemic medication and has the potential to be effective in healing or preventing a wide array of cutaneous human conditions.