Faculty Bibliography

BACKGROUND:: Three-dimensional digital animation can enable surgeons to create anatomically accurate, virtual models of normal and pathologic human anatomy. From these models, surgical procedures can be digitally performed, recorded, and distributed as a teaching tool or as a virtual surgical atlas. The idea of a virtual surgical atlas has recently become a part of contemporary surgical teaching. In the field of craniofacial surgery, no such educational tool exists. Presented is the first part of the creation of a virtual atlas of craniofacial surgical procedures: the three-dimensional digital modeling of pathologic deformities commonly treated by craniofacial surgeons. METHODS:: Three-dimensional craniofacial models were constructed using Maya 8.5. A skeletally 'normal' craniofacial skeleton was first produced from a preexisting digital skull using Bolton tracings as a reference. The remaining soft-tissue elements were then added to create an anatomically complete three-dimensional face. The 'normal' model was then deformed in Maya to produce specific craniofacial deformities using computed tomographic scans, cephalograms, and photographs as a reference. One of the craniofacial deformity models was created directly from computed tomographic data. RESULTS:: One model of the normal face and eight pathologic models of craniofacial deformities were created: microgenia, micrognathia, prognathia, temporomandibular joint ankylosis, maxillary hypoplasia, Crouzon syndrome with and without the need for cranial vault expansion, and bicoronal craniosynostosis. CONCLUSIONS:: For the first time, anatomically accurate three-dimensional digital models of craniofacial deformities have been created. The models are the first step in the creation of a virtual surgical atlas of craniofacial procedures

BACKGROUND:: Craniofacial surgery can be challenging to teach and learn. To augment the intraoperative learning experience for surgical trainees and to provide a resource for practicing craniofacial surgeons to review uncommonly performed procedures before entering the operating room, a series of three-dimensional animations were created encompassing the most commonly performed craniofacial procedures. METHODS:: Previously created three-dimensional craniofacial digital models were used to create digital animations of craniofacial surgical procedures using Maya 8.5. Digital models were altered systematically within Maya to recreate the ordered steps of each craniofacial procedure. Surgical tools were imported into Maya for use in the animations using computer-aided manufacturing files obtained directly from the manufacturer. RESULTS:: Nine craniofacial procedures were animated: genioplasty, bilateral sagittal split osteotomy, intraoral vertical ramus osteotomy, Le Fort I osteotomy, unifocal mandibular distraction, mandibular transport distraction, fronto-orbital advancement with cranial vault remodeling, Le Fort III advancement/distraction, and monobloc advancement/distraction. All major surgical steps are demonstrated, including exposure, execution of the osteotomy, displacement of the bone composite, and the predicted morphologic changes to the craniofacial contour. Throughout the surgical animation, the view of the surgeon in the operating room is incorporated to reproduce the vantage of the surgeon, and the overlying tissue is rendered transparent to illustrate critical underlying anatomical relationships. CONCLUSIONS:: The first virtual surgical atlas of craniofacial procedures is presented. These animations should serve as a resource for trainees and practicing surgeons in preparation for craniofacial surgical procedures

The Maintenance of Certification module series is designed to help the clinician structure his or her study in specific areas appropriate to his or her clinical practice. This article is prepared to accompany practice-based assessment of preoperative assessment, anesthesia, surgical treatment plan, perioperative management, and outcomes. In this format, the clinician is invited to compare his or her methods of patient assessment and treatment, outcomes, and complications, with authoritative, information-based references.This information base is then used for self-assessment and benchmarking in parts II and IV of the Maintenance of Certification process of the American Board of Plastic Surgery. This article is not intended to be an exhaustive treatise on the subject. Rather, it is designed to serve as a reference point for further in-depth study by review of the reference articles presented

BACKGROUND: Mandibular distraction has evolved from the use of external to the use of intraoral and semiburied devices. The authors highlight the evolution of the semiburied technique. The authors evaluate advantages and limitations, and report perioperative events for external and semiburied techniques to establish the indications for selection of the different devices. METHODS: A retrospective review was conducted of patients undergoing mandibular distraction at the New York University Langone Medical Center from the authors' introduction of mandibular distraction in May of 1989 to June 30, 2009. Perioperative events were stratified into three groups: minor incidents, moderate incidents, and major incidents. RESULTS: A total of 211 mandibular distraction procedures were performed: 129 external procedures on native bone, 37 external procedures on grafted bone, and 45 semiburied procedures on native bone. Minor incidents were more common with the semiburied device (62 percent) compared with external devices on native (26 percent) and grafted (38 percent) bone. There were fewer moderate incidents with the semiburied device (18 percent) than with the external device on native (22 percent) and grafted (30 percent) bone. In contrast to the external technique, no major incidents were seen with semiburied distraction. CONCLUSIONS: The semiburied device reduces scarring and has the mechanical advantages of being applied directly to the bone, less vulnerable to dislodgment, and more favorable for a vertical vector. However, its use requires more bone stock and it has the disadvantage of requiring a second operation for removal. Semiburied distraction is safe, reliable, and indicated for lengthening of the hypoplastic mandible where there is adequate bone stock for its attachment

OBJECTIVES: One of the unfortunate sequelae in obstetric brachial plexus palsy (OBPP) is upper limb length discrepancy. However, the influence of primary nerve reconstruction remains undetermined. In this study, the resultant discrepancy in children with OBPP who underwent primary reconstruction was analyzed in relation to the severity of the lesion, the timing of surgery, and the functional outcome following surgery. METHODS: Fifty-four patients that met the inclusion criteria were included in this study. Preoperative and postoperative bilateral scanograms were obtained to document the effect of reinnervation on bone growth. The length of the humerus, ulna, third metacarpal, third proximal phalange, and total limb length were measured and the percentage between the affected and normal side were accessed. Correlations between all the measures of limb length and measures of active motion (i.e., three different classification systems) were performed. RESULTS: Spearman's rank correlation coefficients revealed significant correlations between limb length discrepancies and nearly all measures of active upper extremity movement. The timing of surgery and the severity of the lesion significantly influenced the resultant limb length discrepancy. CONCLUSIONS: The prevention of a non-acceptable upper limb discrepancy is fundamental for both the patient and family. The extent of the resultant discrepancy appeared to be strongly related to the time between injury and surgery, degree of severity, and the outcome of surgery. Patients with better functional recoveries of the affected upper extremities showed smaller differences in limb length.

BACKGROUND: The authors sought to review the various types of patients with psychological abnormalities who may present to the plastic surgeon and the psychological impact of various plastic surgery procedures on these patients. METHODS: After systematically searching the Embase and PubMed databases and following further refinement (based on the authors' inclusion and exclusion criteria), the authors identified 65 studies. In addition, the authors felt that important information was contained in four textbooks, two press releases, and one Internet database. The inclusion criteria were studies that investigated the psychological outcomes, background, and personality types of patients seeking specific plastic surgery procedures. In addition, studies that addressed the impact of plastic surgery on patients' psychological status and quality of life were also included. The authors excluded studies with fewer than 30 patients, studies that did not pertain to the particular plastic surgery procedures, and studies that addressed psychological sequelae of revision operations. RESULTS: Narcissistic and histrionic personality disorders and body dysmorphic disorder are the three most common psychiatric conditions encountered in patients seeking cosmetic surgery. Overall, plastic surgery not only restores the appearance and function of the disfigured body unit but also alleviates psychological distress. CONCLUSION: Identifying the psychologically challenging patient before surgical intervention will allow the patient to obtain the appropriate psychological assistance and may result in a healthier individual with or without associated plastic surgery procedures.

Strain rate dependence of the mechanical response of hard tissues has led to a keen interest in their dynamic properties. The current study attempts to understand the high strain rate characteristics of rabbit femur bones. The testing was conducted using a split-Hopkinson pressure bar equipped with a high speed imaging system to capture the fracture patterns. The bones were also characterized under quasi-static compression to enable comparison with the high strain rate results. The quasi-static compressive moduli of the epiphyseal and diaphyseal regions were measured to be in the range of 2-3 and 5-7GPa, respectively. Under high strain rate loading conditions the modulus is observed to increase with strain rate and attains values as high as 15GPa for epiphyseal and 30GPa for diaphyseal regions of the femur. The strength at high strain rate was measured to be about twice the quasi-static strength value. A large number of small cracks initiated on the specimen surface close to the incident bar. Coalescence of crack branches leading to fewer large cracks resulted in specimen fragmentation. In comparison, the quasi-static failure was due to shear cracking.

The inflammatory response to ionizing radiation (IR) includes a proangiogenic effect that could be counterproductive in cancer but can be exploited for treating impaired wound healing. We demonstrate for the first time that IR stimulates hypoxia-inducible factor-1alpha (HIF-1alpha) up-regulation in endothelial cells (ECs), a HIF-1alpha-independent up-regulation of stromal cell-derived factor-1 (SDF-1), as well as endothelial migration, all of which are essential for angiogenesis. 5 Gray IR-induced EC HIF-1alpha and SDF-1 expression was greater when combined with hypoxia suggesting an additive effect. While small interfering RNA silencing of HIF-1alpha mRNA and abolition of HIF-1alpha protein induction down-regulated SDF-1 induction by hypoxia alone, it had little effect on SDF-1 induction by IR, demonstrating an independent pathway. SDF-1-mediated EC migration in hypoxic and/or radiation-treated media showed IR induced strong SDF-1-dependent migration of ECs, augmented by hypoxia. IR activates a novel pathway stimulating EC migration directly through the expression of SDF-1 independent of HIF-1alpha induction. These observations might be exploited for stimulation of wound healing or controlling tumor angiogenesis