Faculty Bibliography

BACKGROUND: A bulky appearance is one of the major patient complaints after extremity reconstruction after fasciocutaneous flaps. Serial debulking procedures with staged excision are required to improve aesthetic and functional outcome, but these methods risk injury to the vascular pedicle and often require multiple procedures for adequate thinning of the flap. We suggest the use of power-assisted suction lipectomy for the debulking of fasciocutaneous flaps in the upper and lower extremities as a safe, effective, and efficient procedure. METHODS: From 2006 to 2009, we performed power-assisted suction lipectomy on the upper and lower extremities of 16 flaps in 15 patients who had previously undergone reconstruction with fasciocutaneous flaps after a traumatic injury. RESULTS: There was 100% flap survival without any complications. Only 2 of the 16 (12.5%) flaps required a secondary revision for further contouring. CONCLUSIONS: In our experience power-assisted suction lipectomy is a safe and excellent adjunct in fasciocutaneous flap debulking and reduces the number of secondary revision procedures necessary. We recommend its use as an adjunct in debulking and contouring flaps used in extremity reconstruction

We previously reported that endothelin A (ET-A) receptor antagonism attenuates carcinoma-induced pain in a cancer pain mouse model. In this study, we investigated the mechanism of ET-A receptor-mediated antinociception and evaluated the role of endogenous opioid analgesia. Squamous cell carcinoma (SCC) cell culture treated with the ET-A receptor antagonist (BQ-123) at 10(-6) M and 10(-5) M significantly increased production and secretion of beta-endorphin and leu-enkephalin, respectively. Behavioral studies were performed by inducing tumors in the hind paw of female nude mice with local injection of cells derived from a human oral SCC. Significant pain, as indicated by reduction in withdrawal thresholds in response to mechanical stimulation, began at 4 days after SCC inoculation and lasted to 18 days, the last day of measurement. Local administration of either naloxone methiodide (500 microg/kg), selective antagonists for mu-opioid receptor (CTOP, 500 microg/kg), or delta-opioid receptor (naltrindole, 11 mg/kg) but not kappa-opioid receptor (nor-BNI, 2.5 mg/kg) significantly reversed antinociception observed from ET-A receptor antagonism (BQ-123, 92 mg/kg) in cancer animals. These results demonstrate that antagonism of peripheral ET-A receptor attenuates carcinoma pain by modulating release of endogenous opioids to act on opioid receptors in the cancer microenvironment. PERSPECTIVE: This article proposes a novel mechanism for ET-A receptor antagonist drugs in managing cancer-induced pain. An improved understanding of the role of innate opioid analgesia in ET-A receptor-mediated antinociception might provide novel alternatives to morphine therapy for the treatment of cancer pain

This study characterized the interplay between topography/chemistry and early bone response of etched and no-etched resorbable blasted media (RBM) processed surfaces. Screw-root form Ti-6Al-4V implants treated with alumina blasting/acid-etching (AB/AE), RBM alone (RBM), and RBM + acid-etching (RBMa) were evaluated. The surface was characterized by scanning electron microscopy, atomic force microscopy, and X-ray photoelectron spectroscopy. Implants placed in the tibia of dogs remained 3 and 5 weeks in vivo. Following euthanasia, half of the specimens were torqued to interface failure and the remaining subjected to bone-to-implant contact (BIC) and bone area fraction occupied (BAFO) between threads evaluation. The AB/AE surface was rougher than the RBM and RBMa. Higher levels of calcium and phosphorous were observed for the RBM surface compared to the RBMa. No significant differences were observed in torque, BIC, and BAFO between surfaces. Woven bone formation at 3 weeks and its initial replacement by lamellar bone at 5 weeks were observed around all implants' surfaces.

PURPOSE: This study tested the null hypothesis that differences in surgical instrumentation, macrogeometry, and surface treatment imposed by different implant systems do not affect early biomechanical fixation in a canine mandible model. MATERIALS AND METHODS: The lower premolars of 6 beagle dogs were extracted and the ridges allowed to heal for 8 weeks. Thirty-six (n = 12 each group) implants were bilaterally placed, remaining for 1 and 3 weeks in vivo. The implant groups were as follows: group 1, Ti-6Al-4V with a dual acid-etched surface with nanometer scale discrete crystalline deposition (Nanotite; Certain Biomet-3i, West Palm Springs, FL); group 2, Ti-6Al-4V with a titanium oxide-blasted fluoride-modified surface chemistry (Osseospeed 4.0 S; Astra Tech, Molndal, Sweden); group 3: Ti-6Al-4V with a bioceramic microblasted surface (Ossean; Intra-Lock International, Boca Raton, FL). Following euthanasia, implants were torqued to interface failure and histologically evaluated. General linear modeling (ANOVA) at 95% level of significance was performed. RESULTS: Histology showed that interfacial bone remodeling and initial woven bone formation were observed around all implant groups at 1 and 3 weeks. Torque values were significantly affected by time in vivo, implant group, and their interaction (P = .016, P < .001, and P = .001, respectively). Regarding torque values, group 3, group 2, and group 1 ranked highest, intermediate, and lowest, respectively. CONCLUSION: Early biomechanical fixation at 1 and 3 weeks was affected by surgical instrumentation, macrogeometry, and surface treatment present for one of the implant systems tested. The null hypothesis was rejected.

Head and neck reconstruction is a multidisciplinary field, requiring communication among various surgical and dental specialists. The free fibular flap is the standard method for reconstructing large mandibular defects after benign or malignant tumor ablation. The graft has to be precisely contoured to fit the three-dimensional defect to meet the functional and aesthetic goals.Virtual surgical planning using computed tomographic imaging and computer-aided design and manufacturing technology allows the surgeons to perform virtual surgery and generates templates and cutting guides that allow for the precise and expedient recreation of the plan in the operating room. The authors describe 2 cases where virtual planning was used for the extirpative and reconstruction phases to achieve precise reconstruction and decreased time under anesthesia.

PURPOSE: The objective of the present study was to evaluate the biomechanical fixation and bone-to-implant contact (BIC) of plateau root form implants of varied surfaces. MATERIALS AND METHODS: Plateau root form implants, 3.5 mm in diameter, 8 mm in length, with 4 surfaces (n = 16 each)--machined, alumina-blasted/acid-etched, alumina-blasted/acid-etched plus nanothickness bioceramic coating, and plasma-sprayed calcium-phosphate--were used. They were bilaterally placed at the distal femur of 16 New Zealand rabbits and remained in place for 2 and 4 weeks in vivo. After euthanizing the rabbits, the implants were subjected to torque to interface fracture and were subsequently processed as nondecalcified approximately 30-microm-thickness slides for histomorphologic analysis and BIC determination. Statistical analysis was performed using analysis of variance at the 95% level of significance, considering implantation time and implant surface as independent variables and the torque-to-interface fracture and BIC as dependent variables. RESULTS: The torque-to-interface fracture was significantly affected by the implant surface (P < .001) but was not affected by the implantation time (P > .20). The implantation time and implant surface had significant effects on the BIC (P < .04 and P < .001, respectively). The greatest torque-to-interface fracture and BIC was observed for the plasma-sprayed calcium-phosphate. CONCLUSION: The implant surface significantly influenced early bone healing around plateau root form implants.

OBJECTIVES/HYPOTHESIS: Compliance to intensive multiweek radiation therapy (RT) regimens in head and neck cancer (HNC) patients is challenging, particularly among medically underserved patients with fewer financial and social resources. Treatment prolongation reduces local control and overall survival rates, making adherence to treatment a key factor in optimal outcome. We evaluated factors affecting compliance in medically underserved patients who received RT for HNC in a large municipal hospital setting in New York City. STUDY DESIGN: Retrospective review. METHODS: Treatment records of patients treated between July 2004 and August 2008 were reviewed. Number of and reasons for missed treatments were identified. Several demographic, toxicity, and treatment variables were analyzed for impact on compliance. RESULTS: Eighty consecutive HNC patients who underwent RT with a 5- to 7-week regimen were identified. Thirty-two patients (40%) missed no treatments, 36 (45%) missed one to six treatments, six (8%) missed seven to 14 treatments, two (3%) missed more than 14 treatments, and four (5%) did not complete treatment. Reasons for missed treatments were hospitalization (31% of events) and toxicity (20%). Patients with percutaneous endoscopic gastrostomy tube were more likely to miss treatments (P = .01, chi(2) test). No other variable showed a significant association with missed treatments (chi(2) test). CONCLUSIONS: Intensive RT for HNC can be delivered with very good adherence within a medically underserved population. Eighty-five percent of patients completed treatment with 0 to 6 days of interruption. Efforts to further improve adherence in this population are ongoing

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

BACKGROUND: Precise control of the position of the midface through distraction with the rigid external distraction (RED) device has been a challenge. The present RED device with wire attachments to the intraoral dental splint and to the skeletal bone plates allows for flexibility in the vertical plane of the osteotomized Le Fort III segment. This tends to rotate the midface in a counterclockwise direction with inferior movement of the posterior nasal spine. OBJECTIVES: To report the development of a rigid distraction splint attachment to the RED device that permits precise control of the position of the midface during the latency period and through the activation and consolidation phases. METHODS: This paper describes the appliance design and the clinical application of a new device in controlling the position of the midface during distraction. Placement of the device and application of the desired force vectors are discussed. Patients treated by this modified device are illustrated to document the planned midface position after Le Fort III midface advancement. RESULTS: Examination of predistraction and postdistraction cephalograms of 2 patients treated with the new device showed advancement with minimum inferior displacement of the midface during all phases of the distraction process. CONCLUSIONS: The new device prevents undesired inferior movement of the posterior midface immediately after osteotomy and helps to stabilize the midface during the latency period. The device enables directional control of the distraction vectors, resulting in more predictable midface position at the end of treatment