Faculty Bibliography

BACKGROUND:: The vascular anatomy of the supraclavicular artery island (SAI) flap has been investigated using both cadaveric anatomic dissections and angiographic studies. Accurate preoperative evaluation and localization of its vascular pedicle confirms its location, course, anatomic variation, and improves flap success. The objective of this report is to demonstrate the utility of multislice computed tomography (CT) angiography for confirming the presence of the vascular pedicle of the SAI flap when planning head and neck reconstruction. METHODS:: Patients were studied using 64-multislice CT angiography to localize the supraclavicular artery, including its origin and destination. Axial images, multiplanar reconstructions, and 3D volume-rendered images were analyzed on a Philips workstation. Radiologic image findings and clinical experience will be described. RESULTS:: SAI CT angiography was successfully performed in 15 patients (30 shoulders) ranging from ages 22 to 81 years. Accurate identification of the main vascular pedicle was achieved in 14/15 patients. Location, course, pedicle length, and anatomic variations were reported for 23 of 30 arteries. Mean vessel diameter was found to be 1.49 mm (range, 0.8-2.0 mm) on the right and 1.51 mm (range, 1.0-2.1 mm) on the left. The mean length of the artery was 38.3 mm on the right (range, 26.6-59.6 mm) and 38.4 mm on the left (range, 24.3-67.0 mm). In all patients, the supraclavicular artery originated off the transverse cervical artery-a branch of the thyrocervical trunk. Positioning of the patient's upper extremities at the side was helpful in the identification of the supraclavicular artery and its distribution. Contrast injection site should be contralateral to the side needed for the flap if sidedness is of importance, secondary to contrast bolus artifact. CONCLUSIONS:: Preoperative evaluation of the SAI flap with multislice computed tomography angiography is feasible in patients. A radiologic study protocol has been developed which improves ability to detect this vessel. This technique provides a noninvasive approach to the identification of the vascular anatomy and is easily standardized/reproducible. The identification of the vascular pedicle and its anatomy can be a benefit to the surgical team during preoperative design of the SAI flap; however, clinical experience confirming these radiologic findings will be needed to optimize surgical outcome.

Statement of Problem: Reconstruction of maxillectomy defects is challenging due to the complex 3-dimensional anatomy of the region. It is diverse with multiple effective techniques that appear to functionally aid patients in speech and mastication. Defects can be secondary to benign or malignant pathology, craniofacial or post-traumatic deformities, and infection. Interocclusal and orthognathic relationships are tantamount to successful reconstruction. Rehabilitation must provide adequate upper lip support and maintain symmetrical alar bases as well as create an adequate seal from the oral cavity to nasal cavity to prevent regurgitation of fluids. Many different classification schemes have been discussed at length within the literature.¹ At our institution we utilize the maxillectomy classification system set forth by Brown et al.² The classification of the vertical component is as follows: Class 1, maxillectomy without an oro-antral fistula; Class 2, low maxillectomy not including orbital floor or contents; Class 3, high maxillectomy involving orbital contents; and Class 4, radical maxillectomy includes orbital exenteration. The horizontal component is classified as follows: a, unilateral alveolar maxillectomy; b, bilateral alveolar maxillectomy; and c, total alveolar maxillary resection. Methods: A retrospective review was performed of case records at Bellevue Hospital Center/New York University Langone Medical Center during a 6-year period from June 2006 to February 2012. In addition to patient demographics the charts were reviewed for Brown classification, tumor pathology, type of reconstruction, timing of feeding by mouth, and patient satisfaction. Methods of Data Analysis: This was a retrospective chart review from June 2006 to February 2012. Descriptive statistics were used to analyze the data. Results: Fifty patients were identified, the average age was 49. The lowest Brown classification was 1A; there were no orbital exenterations thus our highest Brown class was 3C. The pathology was reviewed; 40% of the lesions were malignant and 60% of lesions were benign. 24% of patients were treated with microvascular free tissue transfer: 38% osteocutaneous and 62% myofasciocutaneous. 18% were treated with obturators, 16% were treated with local flaps, 16% were treated with nonvascularized bone grafts, 14% were treated zygomatic implants, and 12% were treated using a combination of local flaps, obturators, zygomatic implants, and free tissue transfer. 34% of patients fell into Brown class one, 48% of patients were Brown class two, and 18% of patients were Brown class three. Postoperatively patients were fed immediately unless treated with free tissue transfer. Subjectively, all but one patient was satisfied with their maxillary reconstruction. This patient had an obturator placed after resection of squamous cell carcinoma of the maxilla, and was unable to tolerate the obturator. She was later reconstructed using a microvascular radial forearm free flap and is now able to function, phonate, and is content with her current status. Conclusion: All methods described above are viable surgical options and decisions for reconstruction must be on a patient specific basis. However, one can extrapolate that the higher the Brown class the larger the defect and thus the need for microvascular free tissue transfer increases. An algorithm for our reconstruction protocol will be presented

INTRODUCTION: Beginning in 2004, we modified our surgical technique for a cranial vault remodeling in sagittal and lambdoid synostosis. Beginning in the early 1990s, we started using a calvarial vault remodeling technique in sagittal and lambdoid synostosis that involves removing the posterior two thirds of the skull, extending from the coronal suture to below the lambdoid suture to within 1-1.5 cm of the foramen magnum. Up until 2004, the bone fixation evolved from wire fixation, then micro-metallic fixation plates and resorbable sutures. DISCUSSION: Over the last 9 years, we have used a novel technique of absorbable fixation plates and a polydioxanone suture trellis or lattice network, which has reduced operating times significantly and continued to give excellent results. Additional advantages include the absence of a need for molding or protective helmets, the absence of bony defects at the completion of the procedure, the absence of age limitation, and the ability to correct the tightly constricted occiput. CONCLUSION: To date, we have had no significant complications, no return to operating room, and the aesthetics have held up well since its introduction.

PURPOSE: Failures of implant-abutment connections have been observed clinically, especially in single-tooth replacements. This study sought to evaluate the reliability and failure modes of implant-supported anterior crowns restored with different implant systems. MATERIALS AND METHODS: Forty-two Ti-6Al-4V dental implants (~4 mm diameter) were used for single anterior crown replacement and divided into two groups according to tested system: (NB) Replace Select system, Nobel Biocare (n = 21); and (IL) Internal connection system, Intra-Lock International (n = 21). Proprietary abutments were screwed to the implants and anatomically correct maxillary central incisor metal crowns were cemented and subjected to step-stress-accelerated life testing in water. Use-level probability Weibull curves and reliability for a mission of 50,000 cycles at 200 N (95% 2-sided confidence intervals) were calculated. Polarized-light and scanning electron microscopes were used for failure analyses. RESULTS: The Beta values for NB and IL (2.09 and 2.05, respectively) indicated that fatigue accelerated the failure of both groups. The calculated reliability for the NB system (0.81) was lower than for the IL system (0.96), but no significant difference was observed between groups. Screw and abutment fracture was the chief failure mode in group NB, while screw fracture was most representative in specimens of group IL. CONCLUSIONS: Reliability of implant-supported maxillary central incisor crowns was not significantly different between NB and IL abutments. Failure modes differed between implant systems

BACKGROUND: Face transplantation allows the reconstruction of the previously nonreconstructible injury. Anthropometric landmarks are fixated to corresponding cephalometric landmarks to restore function and appearance, with emphasis on phonation, mastication, and functional upper airway. Currently, only a few face transplantations have been performed worldwide. A portion of these reconstructions involves combinations of hard and soft tissues of the midface. METHODS: Craniofacial and orthognathic considerations should be emphasized for functional effect in the planning and execution of face transplants that include both bone and soft tissue elements. These steps are taken to restore normal anatomy by fixating the midface into proper relationship with the skull base. Traditional orthognathic planning, using cephalometric parameters, often involves a line through sella and nasion as a reference for the skull base. Intraoperatively though, without a cephalograph, the sella-nasion plane is not accessible as a reference point. RESULTS: Postoperative analysis of our first face transplant recipient revealed that the Frankfort horizontal plane can alternatively serve as an accessible skull base reference point to guide the positioning of the midface. We have developed a technique to ensure fixation of the midface donor allograft in a proper functional relationship with the skull base, within 1 SD of Bolton normative data. CONCLUSIONS: "Reverse craniofacial planning" allows for precise fixation of the hard tissue components of the face transplant in relation to the skull base, as opposed to a "best fit" approach. We believe that this relationship results in the most anatomical restoration of occlusion, speech, and airway function.

BACKGROUND: Larger thoracic defects require stable yet flexible reconstruction to prevent flail chest and debilitating respiratory impairment. We present the use of locking rib-spanning plates as a chest salvage procedure. METHODS: A 30-year-old male presented with a massive desmoid tumor in the posterolateral aspect of the chest wall. The mass measured 22 by 14 by 6 cm and involved the posterior third through seventh ribs. The patient underwent wide excision and reconstruction in layers with a porcine dermal substitute for the pleura, locking rib-spanning plates for structural support, and coverage with ipsilateral latissimus dorsi. RESULTS: The patient tolerated the procedure without complication. He was extubated on postoperative day zero and has had an uneventful course. CONCLUSION: Chest wall reconstruction with rib-spanning plates is an alternative method of reconstruction for large chest wall defects. This method limits the foreign body burden while providing rigid structural support. This technique also makes chest wall reconstruction possible in situations that might previously have been treated with pneumonectomy.

One of the enduring lessons of cities is the essential relationship between grey infrastructure (e.g., streets and buildings) and green infrastructure (e.g., parks and open spaces). The design and management of natural resources to enhance human health and well-being may be traced back thousands of years to the earliest urban civilizations. From the irrigation projects of the Indus Valley and the aqueducts of the Roman Empire to integrated systems of landscaped urban parks and street trees in contemporary times, humans have sought to harness the capacity of nature to advance city life. This article presents a systems science framework that delineates critical relationships between grey and green elements of cities and human health and well-being by modeling the complex, dynamic problem of asthma in socioeconomically disadvantaged city neighborhoods. By understanding the underlying structure of urban spaces and the importance of social interactions, urban planners, public health officials, and community members may capitalize on opportunities to leverage resources to improve the health and well-being of urban populations and promote social justice and health equity