Faculty Bibliography

BACKGROUND: The purpose of this study was to introduce the use of selective ipsilateral C7 spinal nerve transfer to the armamentarium of the dynamic procedures used for facial reanimation in Moebius patients. METHODS: Between 1991 and 2007, the selective ipsilateral C7 technique was used in four patients. In three patients with bilateral paralysis, both C7 spinal nerves were utilized as nerve donors. Thus, evaluation of outcomes was carried out in seven hemifaces. RESULTS: Short-term paresthesia on the index pulp of the donor upper extremity was observed in four limbs, which recovered spontaneously. Motor deficits were never noticed. Neurotization of the free-muscle transfer for smile was performed in five hemifaces, with good results in three hemifaces (p < 0.01, z = 2.61). Eye closure neurotization was made in six hemifaces, with good results in four hemifaces (p < 0.01, z = 2.88). Depressor neurotization was made in one case and resulted in improved depressor complex function. In two cases of free muscle transfer for masseter substitution, electromyographic interpretations revealed full motor activity after bilateral latissimus dorsi transfer. Tongue neurotization was performed in two instances. Postoperatively, the patients' speech intelligibility improved as well as tongue motility and bulk. CONCLUSION: The use of the C7 as a motor donor in Moebius cases with multicranial nerve involvement supplies the typical mask-like face with an abundance of motor fibers for facial reanimation and, if there is a coexisting twelfth nerve palsy, for speech restoration

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.

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

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

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

Metallic ion release has raised concerns for the utilization of titanium and titanium alloys in implant dentistry. As an alternative, yttriastabilized tetragonal zirconia (Y-TZP) has been considered the material of choice due to its favorable biological and mechanical properties. Zirconia has been shown both in vitro and in vivo experiments to exhibit desirable osseointegration, cell metabolism, and soft tissue response. According to the mechanical testing of unaged Y-TZP onepiece implants, catastrophic failure of ceramic implants in anterior esthetic regions is unlikely. The utilization of a one-piece Y-TZP implant might be an option to fulfill the esthetic and mechanical needs in oral implant treatments when esthetics is the major concern.

Ongoing and breakthrough pain is a primary concern for the cancer patient. Although the etiology of cancer pain remains unclear, animal models of cancer pain have allowed investigators to unravel some of the cancer-induced neuropathologic processes that occur in the region of tumor growth and in the dorsal horn of the spinal cord. Within the cancer microenvironment, cancer and immune cells produce and secrete mediators that activate and sensitize primary afferent nociceptors. Pursuant to these peripheral changes, nociceptive secondary neurons in spinal cord exhibit increased spontaneous activity and enhanced responsiveness to three modes of noxious stimulation: heat, cold, and mechanical stimuli. As our understanding of the peripheral and central mechanisms that underlie cancer pain improves, targeted analgesics for the cancer patient will likely follow