Faculty Bibliography

The gracilis myocutaneous flap has limited functional donor site morbidity and effectively contours genitoperineal reconstructions. When harvested using a traditional vertical skin paddle, distal-tip necrosis (secondary to inconsistent perforator anatomy) is a well-documented complication. Orienting the skin paddle transversely provides a reliable alternative with a shorter rotational arc but results in a more conspicuous deformity and smaller skin paddle when primary closure is desired. On the basis of recent anatomic studies, we designed a pedicled gracilis myocutaneous flap with a bilobed cutaneous paddle to maximally incorporate both the transverse and longitudinal dimensions of the flap's nearly circular angiosome. The bilobed design allows harvest of a larger transverse skin flap (with a shorter arc of rotation) while a shorter, more dependable vertical skin flap is inset into the transverse flap donor site (rather than inside the critical wound bed). Herein, we detail our surgical technique and provide 2 illustrative case examples.

OBJECTIVE: The aim of this study was to evaluate the effect of surface treatment at the cervical region of endosseous dental implants on the alveolar bone remodeling after implantation immediately after tooth extraction in a dog model. STUDY DESIGN: The third and fourth premolars of 6 dogs were bilaterally extracted with a full-thickness flap, and threaded implants presenting a textured or a polished surface at the cervical regions were placed on the distal root extraction sockets. Submerged healing was allowed for 4 weeks, and bone-to-implant contact (BIC) and buccal and lingual bone loss were morphometrically measured. RESULTS: The BIC and lingual bone loss were not significantly different between textured and polished groups. Significantly lower buccal bone loss (P < .01) was observed for the textured surface at 4 weeks in vivo. CONCLUSION: Textured surface implants placed immediately after tooth extraction resulted in less bone loss only at the buccal cervical region compared with smooth surface implants.

PURPOSE: To test the strength to failure and fracture mode of three indirect composite materials directly applied onto Ti-6Al-4V implant abutments vs cemented standard porcelain-fused-to-metal (PFM) crowns. MATERIALS AND METHODS: Sixty-four locking taper abutments were randomly allocated to four groups and were cleaned in ethanol in an ultrasonic bath for 5 min. After drying under ambient conditions, the abutments were grit blasted and a custom 4-cusp molar crown mold was utilized to produce identical crowns (n = 16 per group) of Tescera (Bisco), Ceramage (Shofu), and Diamond Crown (DRM) according to the manufacturer's instructions. The porcelain-fused-to-metal crowns were fabricated by conventional means involving the construction and a wax pattern and casting of a metallic coping followed by sintering of increasing layers of porcelain. All crowns were loaded to failure by an indenter placed at one of the cusp tips at a 1 mm/min rate. Subsequently, fracture analysis was performed by means of stereomicroscopy and scanning electron microscopy. One-way ANOVA at 95% level of significance was utilized for statistical analysis. RESULTS: The single load to failure (+/- SD) results were: Tescera (1130 +/- 239 N), Ceramage (1099 +/- 257 N), Diamond Crown (1155 +/- 284 N), and PFM (1081 +/- 243 N). Stereomicroscopy analysis showed two distinct failure modes, where the loaded cusp failed either with or without abutment/metallic coping exposure. SEM analysis of the fractures showed multiple crack propagation towards the cervical region of the crown below a region of plastic deformation at the indenter contact region. CONCLUSION: The three indirect composites and PFM systems fractured at loads higher than those typically associated with normal occlusal function. Although each material had a different composition and handling technique, no significant differences were found concerning their single load to fracture resistance among composite systems and PFM.

PURPOSE: The objective of this study was to histologically evaluate a bioceramic grit-blasted and acid-etched surface (presenting calcium and phosphorous incorporation within the surface and its oxide) versus a dual acid-etched (no calcium and phosphorous, control) moderately rough implant surface in a dog tibia model. MATERIALS AND METHODS: Implants 3 x 10 mm were placed bilaterally along the proximal tibia of 6 Doberman dogs and remained for 2 and 4 weeks in vivo. After the dogs were euthanized, the implants were nondecalcified processed to approximately 30-microm-thick plates. Transmitted light optical microscopy was used to evaluate healing patterns and bone-to-implant contact. Statistical analysis was performed by 1-way analysis of variance at the 95% level of significance and by Tukey post hoc tests. RESULTS: At 2 weeks, histologic evaluation showed woven bone formation throughout the perimeter of both implant surfaces. However, replacement of woven bone by lamellar bone was only observed around the test surface at 4 weeks in vivo. No significant differences in bone-to-implant contact were observed for the different groups (P > .27). CONCLUSION: Despite nonsignificant differences between bone-to-implant contact for the different surfaces and times in vivo, higher degrees of bone organization were observed for the test implants. Biomechanical testing is warranted to verify potential differences in biomechanical fixation effectiveness between surfaces.

Microvascular free tissue transfer is a ubiquitous and routine method of restoring anatomic defects. There is a paucity of data regarding the role of perioperative antibiotics in free tissue transfer. We designed a survey to explore usage patterns among microvascular surgeons and thereby define a standard of care. A 24-question survey regarding the perioperative antibiotic use in microvascular head and neck, breast, and lower extremity reconstruction was sent to all those members of the American Society for Reconstructive Microsurgery who had registered e-mail addresses ( N = 450). Ninety-nine members responded. A first-generation cephalosporin is the most frequent choice of perioperative antibiotics across most categories: 93.5% for breast, 59.2% for head and neck, 91.1% for nontraumatic lower extremity, and 84.9% for traumatic noninfected lower extremity reconstruction. In penicillin-allergic patients, clindamycin is the most common choice. For traumatic lower extremity reconstruction in the presence of soft tissue infection or osteomyelitis, culture and sensitivity results determine the selection of perioperative antibiotics in 74%. A first-generation cephalosporin is the standard of care for perioperative antibiotic use in microvascular breast, head and neck, nontraumatic lower extremity, and traumatic noninfected lower extremity reconstruction. No consensus exists regarding the appropriate duration of coverage. These data may serve as a guide until a large controlled prospective trial is performed and a standard of care is established.

BACKGROUND: Impaired eyelid function in facial paralysis patients is a serious disability that can even threaten vision. Eye reanimation techniques and specifically blink restoration reinstates the cornea's protective mechanism and recovers a more natural appearance and eye function. Both dynamic and static procedures have been used to augment eye closure, but only dynamic procedures can lead to blink restoration. In this study, the experience of a single surgeon (J.K.T.) with dynamic procedures addressing the challenge of blink restoration is presented. METHODS: A retrospective review of 95 adult patients who underwent dynamic procedures for blink restoration was performed. The patients were divided into two groups. Group A (n = 75) included patients who underwent nerve transfers, including cross-facial nerve grafting and subsequent microcoaptations, mini-hypoglossal nerve transfers, and direct orbicularis oculi muscle neurotization. Group B (n = 20) included patients who underwent eye sphincter substitution procedures, including pedicled frontalis or mini-temporalis transfers, free platysma, occipitalis, gracilis subunits, extensor digitorum brevis, and a slip of adductor longus transfer. Objective blink ratios were measured according to a protocol established by the senior author (J.K.T.). RESULTS: The patients included 34 men and 61 women. Mean age was 34.9 +/- 9.8 years. Denervation time ranged from 7 months to 42.12 years, and the mean denervation time was 13.02 years. Blink improvement was noted in all of the patients. Blink scores and ratios were consistently better in group A than in group B. CONCLUSION: Dynamic procedures provide the functional substrate on which subsequent static procedures can be performed and aid blink return

PURPOSE: The objective of this study was to describe the orthognathic surgery techniques for the treatment of occlusal anomalies in those patients who underwent complex maxillomandibular reconstruction with bony free flap. MATERIALS AND METHODS: The authors describe their personal technique developed over years of experience with reconstruction of mandibular defects with bony free flaps. RESULTS: The outcomes in these patients who were treated according to our surgical planning were completely satisfying, with a 100% stability of the treated bones. CONCLUSIONS: Orthognathic procedure on bony free flaps for the reconstruction of mandibular defects is nowadays accepted. Patients who underwent major mandibular destruction due to oncologic disease or trauma outcomes can now benefit from this technique.

OBJECTIVE: To attempt to mitigate the effects of irradiation on murine skin after high-dose radiation using a novel transcutaneous topical delivery system to locally inhibit gene expression with small interfering RNA (siRNA) against Smad3. DESIGN: Laboratory investigation. SETTING: University laboratory. SUBJECTS: Twenty-five wild-type C57 mice. INTERVENTION: In an isolated skin irradiation model, the dorsal skin of C57 wild-type mice was irradiated (45 Gy). Just before irradiation, Smad3 and nonsense siRNA were applied to 2 separate dorsal skin areas and then reapplied weekly. Skin was harvested after 1 and 4 weeks. Smad3 expression were assessed by immunohistochemistry, and collagen deposition and architecture was examined using picrosirius red collagen staining. MAIN OUTCOME MEASURES: Epidermal thickness was measured semiquantitatively at 4 weeks. Radiation-induced fibrosis was measured quantitatively via tensiometry. The Young modulus, a measure of cutaneous rigidity inversely related to elasticity, was determined, with normal irradiated skin serving as a control specimen. RESULTS: Murine skin treated with topical Smad3 siRNA demonstrated effective Smad3 inhibition at 1 week and persistent suppression at 4 weeks. Collagen deposition and epidermal thickness were significantly decreased in skin treated with Smad3 siRNA compared with control irradiated skin. Tensiometry demonstrated decreased tension in Smad3 siRNA-treated skin, with a Young modulus of 9.29 MPa (nonirradiated normal skin, 7.78 MPa) compared with nonsense (control) siRNA-treated skin (14.68 MPa). CONCLUSIONS: Smad3 expression can be effectively silenced in vivo using a novel topical delivery system. Moreover, cutaneous Smad3 inhibition mitigates radiation-induced changes in tissue elasticity, restoring a near-normal phenotype

PURPOSE: This report describes and evaluates the efficacy of a novel procedure, direct corneal neurotization using contralateral, supraorbital, and supratrochlear nerves in patients with unilateral facial palsy and corneal anesthesia. METHODS: The charts of 6 patients were thoroughly reviewed. Evaluated outcome parameters included corneal sensibility, improvement in best-corrected visual acuity, blink reflex, donor deficit, synesthesia, long-term corneal health, several psychosocial measures, and overall patient satisfaction. RESULTS: The mean age at time of surgery in our study was 41.7 +/- 9.07 years. Average time from denervation to surgery was 7.00 +/- 8.56 years with an average follow-up time of 16.3 +/- 2.42 years. After surgery, all 6 eyes showed improvement of corneal sensibility, visual acuity, and corneal health and remained free of ulcers without adjunctive surgical treatment. Average time to sensibility was 2.80 +/- 2.17 years, and average corneal sensibility improved from 2.00 +/- 4.47 mm before surgery to 27.8 +/- 22.6 mm after corneal neurotization (P < 0.016). CONCLUSIONS: Direct neurotization of the cornea using the contralateral, supraorbital, and supratrochlear branches of the ophthalmic division of the trigeminal nerve seems to be an effective method for restoration of corneal sensibility in patients with unilateral facial palsy and anesthetic cornea. This procedure preserves ocular anatomy and cosmesis while restoring function by improving corneal health and visual acuity and by reestablishing the blink reflex