Faculty Bibliography

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.

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: Squamous cell carcinoma (SCC) is the most common form of cancer in the head and neck. Variants of this exist, including Basaloid Squamous Cell Carcinoma (BSCC) and Spindle Cell Carcinomas (SpCC). BSCC was first described by Wain et al in 1986 and is described as being a rare, aggressive, high grade variant of SCC that shows predilection for the tongue, larynx and hypopharynx.1 BSCC of the head and neck has also been associated with poorer clinical outcomes compared with conventional SCC.2 Spindle Cell Carcinomas account for 3% of head and neck SCCs and are derived from conventional SCCs. The objective of this study was to compare clinicopathologic features and postoperative course of variant SCCs to confirm reported propensity for aggressiveness. Materials & Methods: A retrospective chart review of patients with SCC at Bellevue Hospital Center and NYU Langone Medical Center by the Department of Oral & Maxillofacial Surgery from June 2006 until 2012 were retrospectively reviewed and classified based on histologic criteria. Classifications were confirmed by at least 2 pathologists and included BSCC and SpCC. Clinical information, including clinicopathologic and clinical course. Results: All cases of SCC since June 2006 were reviewed. Seven of the reviewed cases were SCC variants, six cases of BSCC and 1 case of SpCC. The age of the patients ranged from 30-68 with a mean age of 56. The majority of patients were causcasian males with history significant for tobacco and alcohol use. BSCC was most often found in the floor of the mouth with invasion into the mandible with other locations in the tongue, tonsil and buccal vestibule. In the case of the patient with SpCC, invasion included the maxilla, pterygopalatine fossa and orbit. TNM staging in BSCC varied from T1N0- T4N2. The TNM staging in SpCC was T4N1M1. Selective neck dissections were performed on 3 patients with BSCC and the patient with SpCC. Surgical margins were positive in 2 cases of BSCC as well as in the patient with SpCC. Perineural invasion was noted in 5 BSCC cases and the SpCC case. Three BSCC patients received chemotherapy as well as the patient with SpCC, while all patients underwent radiation therapy. One patient with BSCC had metastasis while the patient with SpCC had metastasis to the left globe and ultimately died. Conclusions: Most patients with variant SCCs were white males in their late 50s with a significant history of exposure to tobacco and alcohol. Of the total seven cases of BSCC and SpCC 43% had positive margins and 85% exhibited perineural invasion. Surgical treatment included neck dissection, wide resection with reconstruction and postoperative radiation and, in some cases, chemotherapy. BSCC and SpCC can be devastating and aggressive tumors and correct diagnosis is key. The importance of close follow up of these patients, and any patient with a history of SCC, was demonstrated by 28% of the patients presenting with recurrence within two years of diagnosis. Identifying the specific histologic cell type can determine aggressiveness of the tumor as well as help to guide treatment. Results of this study are consistent with previous studies showing rarity, however, significant difference in aggressiveness, recurrence, and death were not observed as compared to other SCC cases treated at our institution

Statement of Problem: The microvascular free fibula flap is widely used to reconstruct complex craniomaxillofacial defects following ablative surgery. Since its popularization for mandibular bony reconstruction in 1989, many permutations of the fibula flap have been applied to composite head and neck defects. Several authors describe endosseous implantation of the fibula post operatively or at the time of surgery to aid in dental reconstruction, but this can leave a patient partially edentulous for up to 1 year after initial surgery. Many patients are lost to follow up and do not go on to complete dental rehabilitation. This may contribute to suboptimal nutritional status, poor cosmetic outcomes, and decreased patient satisfaction. We will discuss how these problems can be circumvented by single stage surgery that incorporates dental implants and a prosthesis to allow for complete jaw reconstruction. Methods: A retrospective chart review at NYU Langone Medical Center and Bellevue Hospital Center was completed to identify patients undergoing extirpative surgery of the maxilla or mandible with immediate reconstruction with a free fibula flap, dental implants, and dental prosthesis from 2011-2012. A total of 5 patients were treated for ameloblastoma (n=3), intraosseus hemangioma (n=1), and odontogenic myxoma (n=1) of the maxilla (n=1) and mandible (n=4). Virtual surgical planning was implemented in all cases. During the computer assisted design phase, a virtual dental construct of an implant supported prosthesis was applied to the planned resection site and the fibula flap was designed to support the desired prosthesis. The cutting jigs for the jaw and fibula were manufactured according to plan as well as the implant borne dental prosthesis. In addition to osteotomy cutting slots, the fibular jig had implant drill guides to aid in correct placement. The prosthesis was secured to the fibular implants with custom abutments and then placed into temporary maxillomandibular fixation with the native dentition prior to plate osteosynthesis of the fibula. Post operative physical examination and computed tomography was used to evaluate occlusion and flap position. Results: All patients were reconstructed successfully with this method without any flap or implant failures. Longest follow up time was 12 months with a mean of 6 months. A total of 23 implants were planned and placed with no implant failures. 1 implant was not used due to suboptimal position in relation to the prosthesis. All patients required post operative guiding elastics with all patients achieving a reproducible desired occlusion by 2 (Figure psented) weeks. All patients tolerated a soft diet by postoperative week 3 without the need for supplemental enteral or parenteral feeding. All patients reported satisfaction in their reconstruction. The mean operative time was 8 hours. One patient needed revision surgery for a mobile locking screw in the plate hardware. Conclusion: The fibula flap continues to be the workhorse of jaw reconstruction, and with proper patient selection and pre-operative planning, it can be used to successfully reconstruct complex maxillofacial defects from bone to teeth in a single operation. In our experience, computer assisted design and virtual planning is essential in achieving the above described results while maintaining appropriate operative times

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: Breast reconstruction rates continue to slowly rise in large part because of patients and physicians becoming more knowledgeable about postmastectomy options. Overall satisfaction with breast reconstruction after mastectomy has traditionally been high, only adding to the popularity of this choice. Prior research has demonstrated that race, age, and socioeconomic status are important determinants in whether a patient undergoes breast reconstruction; specifically, indigent women have a lower rate of breast reconstruction when compared to the national average. METHODS: All records of patients who received mastectomies between January 2001 and December 2009 were examined. The PubMed database was used to search for reference articles. RESULTS: Between January 2001 and December 2009, 309 patients underwent mastectomy, and 134 (43.4%) elected reconstruction. Patients in age ranges 20 to 39 and 40 to 59 were both significantly more likely to undergo reconstruction than patients older than 60 years. Disease stage was not significantly related to rates of breast reconstruction. Reconstruction rates by race and ethnicity were analyzed and demonstrated a significantly lower rate of breast reconstruction in Asian women (34%) compared with Hispanic women (48%), despite the same access to available services. CONCLUSIONS: Our data demonstrate breast reconstruction rates significantly higher than prior studies for women in this public hospital demographic, rivaling the reported numbers from dedicated cancer centers where breast reconstruction is expected to be at the highest range. Types of reconstruction were based mainly on patient choice after full discussion regarding individual options. These data suggest that patients considered to be financially indigent are more likely to have breast reconstruction when their care is delivered at a university-based public hospital where immediate and consistent patient education is practiced in a multidisciplinary setting.

OBJECTIVE: This study aims to use the evidenced-based approach to better understand the surgical management and treatment of pressure ulcers. SUMMARY OF BACKGROUND DATA: 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 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-present). RESULTS: Here, we reviewed the most relevant, high-level evidence that exists for the following modalities for managing pressure ulcers from a surgical perspective: wound cleansers, repositioning, negative pressure therapy, enteral and parenteral feeding, vitamin and mineral supplementation, specialized mattresses, ultrasound therapy, honey, cellular therapy, debridement, ostectomy, and musculocutaneous and fasciocutaneous flap closure. CONCLUSIONS: Although many of the previously mentioned modalities are used, we encourage clinicians and health care providers to consider the evidence-based data when deciding how to most appropriately manage their patient's pressure sores.