Faculty Bibliography

The tremendous variability of the inferior epigastric arterial system makes accurate imaging of the vasculature of the anterior abdominal wall an essential component of optimal perforator selection. Preoperative imaging of the abdominal vasculature allows for preoperative perforator selection, resulting in improved operative efficiency and flap design. Abdominal wall perforators of 1-mm diameter can be reliably visualized without exposing patients to ionizing radiation or iodinated intravenous contrast through advances in magnetic resonance imaging angiography (MRA). In this study, MRA imaging was performed on 31 patients who underwent 50 abdominal flaps. For each flap, the location, relative to the umbilicus, of the three largest perforators on both the left and right sides of the abdomen was determined with MRA. Vessel diameter and anatomic course were also evaluated. Postoperatively, a survey was completed by the surgeon to assess the accuracy of the MRA with respect to the intraoperative findings. All perforators visualized on MRA were found at surgery (0% false-positive). In 2 of 50 flaps, the surgeon transferred a flap based upon a vessel not visualized on the MRA (4% false-negative). This article details our experience with MRA as a reliable preoperative imaging technique for abdominal perforator flap breast reconstruction.

Patients who present for alloplastic jaw angle augmentation have 2 potentially troublesome choices. The use of a silicone implant can mean unpredictable motion, and if the lower pterygomasseteric sling is breached during implant placement, the masseter insertion will ride up without anything to which to adhere. When the patient bites down, a bulge will be present.The porous alternative even has a ledge made to go under the gonial angle, which if not removed, guarantees violation of the pterygomasseteric sling and an implant that is longer than the muscle can cover. The inferior muscle insertion is disrupted and is left to ride up serendipitously.This article presents 5 instances of these issues in which one case required a revision via a modified Risdon approach to access the uncovered material which stuck out beyond the high riding masseter.The basic aim of this article is to advocate the need to maintain the pterygomasseteric sling, and describe the consequences of the failure to do so

BACKGROUND: During cleft palate repair, levator sling palatoplasty with tensor veli palatini tendon transection significantly improves speech results. However, the procedure may pose a risk to eustachian tube function. This study assesses the impact of three types of palatoplasty techniques on eustachian tube function: no tensor transection, tensor transection alone, and a new addition to the palatoplasty technique, tensor tenopexy. METHODS: A retrospective review was conducted of all patients undergoing cleft palate repair at two institutions between 1997 and 2001. Three cleft palate repair groups were studied: no tensor transection (n = 64), tensor transection alone (n = 31), and tensor tenopexy (n = 52). The percentages of patients requiring myringotomy tubes at each year of age were compared among the three groups. RESULTS: By 7 years of age, there was a significantly decreased need for myringotomy tubes in patients who underwent no tensor transection compared with patients who underwent tensor transection alone (38 percent versus 61 percent, respectively; p = 0.05), as well as for patients who underwent tensor tenopexy compared with patients who underwent tensor veli palatini tendon transection (23 percent versus 61 percent, respectively; p < 0.001). Also, by the age of 7, there was a trend toward a decreased need for myringotomy tubes in patients who underwent tensor tenopexy compared with patients who underwent no tensor transection (23 percent versus 38 percent, respectively; p = 0.11). CONCLUSIONS: No tensor transection and tensor tenopexy significantly decrease the need for myringotomy tubes compared with tensor transection alone. There is a small decrease in the need for myringotomy tubes when comparing tensor tenopexy with no tensor transection

Ear mesenchymal stem cells (EMSCs) represent a readily accessible population of stem-like cells that are adherent, clonogenic, and have the ability to self-renew. Previously, we have demonstrated that they can be induced to differentiate into adipocyte, osteocyte, chondrocyte, and myocyte lineages. The purpose of the current study was to characterize the growth kinetics of the cells and to determine their ability to form colonies of fibroblasts, adipocytes, osteocytes, and chondrocytes. In addition, the immunophenotypes of freshly isolated and culture-expanded cells were evaluated. From 1 g of tissue, we were able to isolate an average of 7.8 x 10(6) cells exhibiting a cell cycle length of approximately 2-3 days. Colony-forming unit (CFU) assays indicated high proliferation potential, and confirmed previously observed multipotentiality of the cells. Fluorescence-activated cell sorting (FACS) showed that EMSCs were negative for hematopoietic markers (CD4, CD45), proving that they did not derive from circulating hematopoietic cells. The FACS analyses also showed high expression of stem cell antigen-1 (Sca-1) with only a minor population of cells expressing CD117, thus identifying Sca-1 as the more robust stem cell biomarker. Additionally, flow cytometry data revealed that the expression patterns of hematopoietic, stromal, and stem cell markers were maintained in the passaged EMSCs, consistent with the persistence of an undifferentiated state. This study indicates that EMSCs provide an alternative model for in vitro analyses of adult mesenchymal stem cells (MSCs). Further studies will be necessary to determine their utility for tissue engineering and regenerative medical applications.

BACKGROUND: Management of severe traumatic lower extremity injuries remains a considerable challenge. Free tissue transfer is now a standard part of reconstruction for Gustilo IIIB and IIIC injuries. There is limited information on arterial injury patterns in this population. We undertook a review of our experience to gain insight on vascular injury patterns and surgical outcomes. STUDY DESIGN: A 26-year retrospective analysis was performed of all lower extremity Gustilo IIIB and IIIC injuries requiring microvascular reconstruction at New York University Medical Center. Patient demographics, Gustilo classification, angiographic findings (conventional/computed tomographic angiography/magnetic resonance angiography), recipient vessels, elapsed time from injury, flap choices, and outcomes were examined. RESULTS: Two hundred twenty-two free flaps on 191 patients were performed from September 1982 until March 2008. There were 151 males and 40 females ranging in age from 4 to 83 years (median age 33 years). Patients sustained either Gustilo IIIB (170 patients) or IIIC (21 patients) open fractures. One hundred fifty-four patients had angiograms (78.2% IIIB, 100% IIIC). Sixty-six (42.9%) had normal 3-vessel runoff and 88 (57.1%) were abnormal. Sixty-one patients (31.9%) had anterior tibial injuries, 17 patients (8.9%) had posterior tibial injuries, and 30 (15.7%) had peroneal injuries. Sixty-three complications occurred (11 early thrombosis, 33 requiring secondary procedures, and 10 requiring amputation). CONCLUSIONS: Angiography of severe lower extremity injuries requiring free flap reconstruction usually revealed arterial injury and is generally indicated. In our experience, the anterior tibial artery is most commonly injured and the posterior tibial artery is most likely to be spared and used as a recipient

AlloDerm has been used as a tissue supplement in conjunction with the pectoralis major muscle to provide full coverage over an implant in breast reconstruction. While this method of reconstruction has shown promising results there is little known on the relationship of AlloDerm size and potential immediate expansion volume. A retrospective chart review was completed evaluating all tissue expander or primary implant reconstructions using AlloDerm. Data recorded included: The type/size of implant/expander, dimensions of the AlloDerm used, initial fill volume, number of expansions and time period of expansion. Statistical analysis was completed with a linear regression model. AlloDerm was used on 49 patients (72 reconstructions). Thirty-four patients (50 reconstructions) underwent reconstruction with a tissue expander and 15 patients (22 reconstructions) underwent a single stage reconstruction with a permanent implant. The tissue expander volume filled (cc) could be predicted by 5 x surface area of AlloDerm (cm(2)) - 12 (R(2) = 0.62) and 80 x height of AlloDerm (cm) - 15 (R(2) = 0.59). The tissue expanders could be filled to an average of 75% of total size and required three to four injections in the postoperative period to reach full expansion. Obviously, a requirement for maximal implant expansion is an appropriate skin sparing mastectomy. There is a mathematical relationship between fill volume and surface area as well as height of AlloDerm used in breast reconstruction. This analysis provides a guideline for immediate implant expansion to surgeons using AlloDerm in reconstructive breast surgery

BACKGROUND: Mobius syndrome is a disorder characterized by developmental impairment of cranial nerve VII, VI, often XII, and other cranial nerves. Facial reanimation in such patients restores the ability of some motion and of limited emotional expression. In one-fourth of these patients, hypoglossal involvement results in severe speech impairment due to tongue atrophy and lack of voluntary mobility. Bilabial incompetence due to facial paralysis further deteriorates speech capability. Direct tongue neurotization has been used by the senior author (J.K.T) to improve tongue function and speech intelligibility in patients with Mobius syndrome. This study presents the senior author's experience with the technique as a component of multistage facial reanimation procedures. METHODS: Data collection was performed by retrospective review on six patients with Mobius syndrome who underwent direct tongue neurotization. In addition, each patient was videotaped for 30 minutes preoperatively and postoperatively according to a standardized protocol. RESULTS: Four independent investigators scored speech intelligibility in each patient using a standardized grading system. The results showed considerable improvement in speech intelligibility and articulation. Higher improvement was noted in patients with partial bilateral hypoglossal involvement than in patients with complete unilateral involvement of the hypoglossal nerve, as well as in younger ages. No difference was noted between sexes. CONCLUSIONS: To the authors' knowledge, this is the first study presenting the effect of direct tongue neurotization on speech intelligibility in patients with Mobius syndrome. Tongue neurotization has therefore an important role in restoring the ability of these patients to communicate and obtain the potential to develop normal social skills

BACKGROUND: In posttraumatic brachial plexus palsy, shoulder stabilization is of utmost importance before reanimation of the distal upper extremity. The aim of this study was to present the authors' experience with axillary nerve reconstruction in 148 patients with posttraumatic plexopathy. Functional outcomes were assessed and correlated with the following factors: severity score, denervation time, and donor nerve used. METHODS: The medical records of 176 patients who underwent axillary nerve reconstruction performed by a single surgeon between 1978 and 2006 were reviewed. The results were analyzed in 148 patients who had adequate follow-up (>24 months). Nerve reconstruction was performed using 94 intraplexus donor nerves and 55 extraplexus donor nerves; axillary-to-axillary repair was performed in 13 patients, and 15 patients had microneurolysis. One hundred forty patients had interposition nerve grafts. A total of 135 patients had concomitant neurotization of the suprascapular nerve. RESULTS: Results were good or excellent in 45.95 percent of patients. The intraplexus donors yielded significantly better shoulder function than the extraplexus donors. The length of the nerve graft had a direct influence on deltoid recovery. Patients with a severity score higher than 10 attained significantly better results than patients with multiple root avulsions. Surgery earlier than 4 months yielded significantly better functional outcomes than delayed operation of more than 8 months. CONCLUSIONS: Early primary axillary nerve reconstruction offers rewarding glenohumeral joint stability and an acceptable range of shoulder function. Concomitant neurotization of the suprascapular nerve yielded improved outcomes in shoulder abduction and external rotation