Faculty Bibliography

Lymphangiogenic cytokines such as vascular endothelial growth factor-C (VEGF-C) are critically required for lymphatic regeneration; however, in some circumstances, lymphatic function is impaired despite normal or elevated levels of these cytokines. The recent identification of anti-lymphangiogenic molecules such as interferon-gamma (IFN-gamma), transforming growth factor-beta1, and endostatin has led us to hypothesize that impaired lymphatic function may represent a dysregulated balance in the expression of pro/anti-lymphangiogenic stimuli. We observed that nude mice have significantly improved lymphatic function compared with wild-type mice in a tail model of lymphedema. We show that gradients of lymphatic fluid stasis regulate the expression of lymphangiogenic cytokines (VEGF-A, VEGF-C, and hepatocyte growth factor) and that paradoxically the expression of these molecules is increased in wild-type mice. More importantly, we show that as a consequence of T-cell-mediated inflammation, these same gradients also regulate expression patterns of anti-lymphangiogenic molecules corresponding temporally and spatially with impaired lymphatic function in wild-type mice. We show that neutralization of IFN-gamma significantly increases inflammatory lymph node lymphangiogenesis independently of changes in VEGF-A or VEGF-C expression, suggesting that alterations in the balance of pro- and anti-lymphangiogenic cytokine expression can regulate lymphatic vessel formation. In conclusion, we show that gradients of lymphatic fluid stasis regulate not only the expression of pro-lymphangiogenic cytokines but also potent suppressors of lymphangiogenesis as a consequence of T-cell inflammation and that modulation of the balance between these stimuli can regulate lymphatic function.

BACKGROUND: : The use of perforator flaps has allowed for the transfer of large amounts of soft tissue with decreased morbidity. For breast reconstruction, the deep inferior epigastric perforator flap, the superior and inferior gluteal artery perforator flaps, and the transverse upper gracilis flap are all options. The authors present an alternative source using posterior thigh soft tissue based on profunda artery perforators, termed the profunda artery perforator flap. METHODS: : Preoperative imaging helps identify posterior thigh perforators from the profunda femoris artery. These are marked, and an elliptical skin paddle, approximately 27 x 7 cm, is designed 1 cm inferior to the gluteal crease. Dissection proceeds in a suprafascial plane until nearing the perforator, at which point subfascial dissection is performed. The flap has a long pedicle (approximately 7 to 13 cm), which allows more options when performing anastomosis at the recipient site. The long elliptical shape of the flap allows coning of the tissue to form a more natural breast shape. RESULTS: : All profunda artery perforator flaps have been successful. The donor site is well tolerated and scars have been hidden within the gluteal crease. Long-term follow-up is needed to evaluate for possible fat necrosis of the transferred tissue. CONCLUSIONS: : The authors present a new technique for breast reconstruction with a series of 27 flaps. This is an excellent option when the abdomen is not available because of the long pedicle, muscle preservation, ability to cone the tissue, and hidden scar. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V

BACKGROUND:Controversy persists regarding the optimal procedure to rejuvenate the aging neck. More invasive procedures carry increased risks of complications, whereas less invasive approaches may deliver marginal results. The challenge is selecting the appropriate procedure for delivering consistent, durable results meeting both the patient's and surgeon's expectations. OBJECTIVES/OBJECTIVE:The authors describe their trampoline platysmaplasty (TPP) approach, a percutaneous suture suspension necklift that constitutes a less invasive approach for neck rejuvenation. METHODS:A retrospective study was conducted of 105 consecutive patients who underwent TPP. Age, sex, procedure(s) performed, complications, and patient satisfaction were recorded. Cadaver studies were conducted to compare the tensile strength of the ligaments that anchor the TPP to the tensile strength of the sutures placed to approximate the medial platysma borders. In addition, the accuracy of light transillumination to determine depth of travel of the light-emitting diode (LED) lighted rod was evaluated. RESULTS:Patients underwent either TPP alone (18 women, 24 men) or TPP with a facelift (35 women, 28 men) between October 2007 and June 2009. The average age of the patients was 52 years, and average length of follow-up was 33 months. Patient satisfaction was high. Three early patients underwent immediate revision to improve results secondary to the suture matrix being too loose. Six additional patients had recurrent banding around one year postoperatively, but correction was achieved in all six by replacing the matrix with the help of the lighted rod. The results of the cadaver study revealed that the tensile strength of the retaining ligaments was statistically identical to the medial platysma borders, and the light transillumination feedback was accurate with regard to the depth of travel of the illuminated rod tip. CONCLUSIONS:The TPP approach for neck rejuvenation is effective and durable in properly-selected patients. It works well as a stand-alone procedure and in conjunction with facelift procedures. It also offers younger patients a less-invasive option to improve neck contours inherited through genetics. After nearly three years of follow-up of the patients in this report, the results appear to be long-lasting.

OBJECTIVE:: The development of drug-eluting stents has decreased the rate of in-stent restenosis. However, there have been reports of late stent thrombosis in patients with drug-eluting stents, especially when dual antiplatelet therapy is interrupted. The high mortality rate associated with cardiac stent thrombosis has led to recent recommendations regarding duration of antiplatelet therapy as well as timing of elective surgery in patients with both drug-eluting stents and bare metal stents. However, in patients requiring emergency operations, delaying surgery is not an option. DATA SOURCES:: In a retrospective review of 65 patients undergoing replantation from 2005 to 2010, only two patients with coronary stents presented, both with drug-eluting stents. Both of these patients developed acute in-stent thrombosis postoperatively on days 5 and 2 despite continuing dual antiplatelet therapy while undergoing multidigit replantation. CONCLUSIONS:: Several factors including large transfusion requirements and the complex pharmacogenetics of clopidogrel may have played a role. These cases bring to light the increasing number of patients with indwelling drug-eluting stents in whom the need for massive surgical or trauma type management will become more frequent

ABSTRACT: This article focuses on current practices and controversy in the area of presurgical infant orthopedics in patients born with cleft lip and palate.

The popularity of mixed martial arts competitions and televised events has grown exponentially since its inception, and with the growth of the sport, unique facial injury patterns have surfaced. In particular, upper eyelid and brow lacerations are common and are especially troublesome given the effect of hemorrhage from these areas on the fighter's vision and thus ability to continue. We propose that the convexity of the underlying supraorbital rim is responsible for the high frequency of lacerations in this region after blunt trauma and offer a method of reducing subsequent injury by reducing its prominence.

BACKGROUND:Recently, the supraclavicular artery island flap has gained popularity as a regional flap for head and neck reconstruction. During clinical follow-up, some patients report referred sensation to the shoulder when there is contact with the flap skin island surface. The authors examine the anatomical origin/characteristics of the supraclavicular nerves (C3-4) to this flap and its relationship to the flap pedicle and anatomical boundaries. METHODS:SAI flap harvest and nerve dissection was performed in seven fresh frozen cadavers (n = 10) using loupe magnification in order to further elucidate the sensory nerve branches in a typical SAI flap. RESULTS:Branches of the supraclavicular nerve innervating the SAI flap were found to emerge from the deep fascia at a separate location from the vascular pedicle with the major nerve root exiting underneath the sternocleidomastoid muscle near the midpoint of the muscle belly. The nerve branches proximal to the pedicle with one branch exiting anterior to the flap and another running axially along the length of the flap. The majority (9/10) flaps had a major cutaneous nerves located 1-2 cm anterior to the pedicle. One (1/10) of the flaps had a major cutaneous nerve located 1-2 cm posterior to the pedicle toward the trapezius muscle. In 3 of the 10 flaps, smaller cutaneous nerves were also found posterior to the pedicle in a more distal location of the flap. CONCLUSIONS:The supraclavicular nerves innervating the SAI flap are easily identifiable and can be preserved or ligated, depending on the desired flap function, when present close to the pedicle. Further clinical investigation is warranted to confirm the potential benefit of using the SAI flap as a neurotized regional flap for head/neck reconstruction.

ABSTRACT: The goal of this article was to illustrate the ease in which virtual surgery and computer-aided design and manufacturing can be used by the craniomaxillofacial surgeon to create tremendously accurate postoperative results and provide confidence with even the most complex three-dimensional bony reconstructions. With advancements in software technology and three-dimensional printing, our ability to plan and execute precise bony reconstruction has become a reality. With this technology, guides can be made to ensure exact bony repositioning or replacement. These guides can help guide cutting of the bone and can act as splints to precisely reposition the bone and direct plate placement. With use of these computer-aided design and manufacturing guides and the addition of guidance technology, the position of the bone can be guaranteed intraoperatively. We review our unique and advanced method in approaching some of these problems and illustrate the application of these techniques in mandibular reconstruction, orthognathic surgery, maxillofacial trauma, and temporomandibular joint reconstruction. This technology continues to evolve, and our indications for its application continue to grow. This article represents only a small portion of the types of cases in which these techniques have already been applied.

BACKGROUND: : Patients with syndromic craniosynostosis and midface hypoplasia are often treated with Le Fort III advancement. The authors present four patients with extraordinarily long-term follow-up (in excess of 20 years). METHODS: : An institutional review board-approved retrospective chart review was performed on all patients with syndromic craniofacial synostosis who underwent Le Fort III advancement. Patients with greater than 20 years of cephalometric and photographic records were identified. Lateral cephalograms were obtained preoperatively, immediately postoperatively, at 1-year follow-up, and at long-term follow-up. Cephalograms were traced, digitized, and averaged. Fifty cephalometric landmarks were identified for serial measurements. RESULTS: : Of the four patients identified, one had Apert syndrome and three had Crouzon syndrome. Average age at the time of Le Fort III advancements was 11 years (range, 4 to 20 years). Average length of postoperative follow-up was 25 years (+/-5 years). No patient had significant anterior midfacial growth following Le Fort III advancement. Both young patients (<10 years) had substantial vertical inferior midfacial growth after advancement. CONCLUSIONS: : These data demonstrate that the Le Fort III segment of children with syndromic craniosynostosis does not grow significantly forward. Moreover, the traditional Le Fort III osteotomy does not provide the amount of midface advancement necessary to avoid phenotypic recidivism in these syndromic patients. This study also suggests that patients undergoing Le Fort III advancement appear to have zygomatic effacement and ptosis of the overlying soft tissue with deepening of the facial folds; collectively, it is suggested that these changes give the appearance of accelerated facial aging. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V

BACKGROUND:Preoperative lymphoscintigraphy for sentinel node biopsy (SNB) combined with intra-operative gamma-probe detection often identifies nodes within the pelvis. This study investigates the role of pelvic SNB harvest. METHODS:Retrospective review of eighty-two stage I/II melanoma patients with primary tumour on the lower limb and trunk who underwent groin SNB, either inguinal or pelvic or both, over a three year period. RESULTS:Of the 82 patients, 19 had positive SNBs (24%), all of which were inguinal nodes. None of the 11 patients with pelvic nodes removed had a positive pelvic node. The median follow-up period was 18 months (SD: 10.8; range: 8-43). Although the complication rate was higher following pelvic SNB, the difference was not statistically significant (p > 0.5). The average operative time for an inguinal SNB was 92 min, and increased significantly to 134 min for a pelvic SNB (p < 0.0001). Lymphoscintigraphy of trunk and thigh melanomas identified individual tracks to be leading directly from the tumour to a pelvic node(s). However, when the primary tumour was located at or below the knee, pelvic nodes identified by lymphoscintigraphy appeared to be second level nodes. CONCLUSION/CONCLUSIONS:A lymphoscintigraphy protocol that includes dynamic images obtained in frequent intervals following injection of the radiotracer combined with thorough preoperative analysis of the lymphoscintigraphy scans and effective communication between the radiologist and the surgeon allows accurate identification of the primary tracks and prevent unnecessary harvest of second echelon pelvic lymph nodes. In patients with significant co-morbidities due consideration is required before harvesting pelvic sentinel nodes.