Faculty Bibliography

OBJECT: The authors present the results of treating infants with multiple-suture nonsyndromic craniosynostosis in whom the authors used minimally invasive endoscopy-assisted techniques and postoperative cranial molding over an 11-year period. METHODS: A total of 21 patients who presented with multiple-suture (nonsyndromic) craniosynostosis were treated using minimally invasive endoscopy-assisted craniectomies. Surgery was followed by treatment with custommade cranial orthoses for up to 12 months. A total of 48 sutures were treated. The most common was the coronal suture (38 cases) and this was followed by the sagittal (11 cases), metopic (6 cases), and lambdoid (3 cases) sutures. There were 13 male and 8 female pediatric patients. Their ages ranged between 3 weeks and 9 months (mean 3.2 months, median 2.5 months). The sagittal suture was treated with a wide vertex craniotomy via 2 incisions located behind the anterior fontanel and in front of the lambda. The metopic suture underwent a suturectomy as did the coronal and lambdoid sutures. RESULTS: The mean follow-up duration was 61 months (range 3-135 months). There were no deaths. In patients with bicoronal synostosis, brachycephaly was corrected. Patients presenting with vertical dystopia or nasal deviation had these deformities corrected as well. The mean blood loss was 42 ml (range 10-120 ml). The mean hospital length of stay was 1 day. The intraoperative transfusion rate was 0%. The results indicate that nonsyndromic multiple-suture synostosis can be safely and effectively treated using endoscopic techniques. CONCLUSIONS: Early treatment of complex multiple-suture synostosis with endoscopic techniques provides an excellent surgical alternative. The results of the present study indicate marked correction of skull base and craniofacial deformities. Endoscopy provides a safe and effective way to treat these patients

Background: Calcium hydroxylapatite (CaHA, Radiesse) is approved by the Food and Drug Administration for treatment of moderate to severe wrinkles and folds, including nasolabial folds (NLF). A pivotal NLF split-face study previously compared the performance of Radiesse to human-based collagen at six months and safety of Radiesse through one year. Objective: The authors assess the long-term safety and effectiveness of Radiesse for the treatment of NLF. Postapproval long-term results now extend to more than three years and are presented here. Methods: This study reports an extension phase of a previously reported one-year premarket study of 117 patients comparing Radiesse to collagen. During the initial study, patients were treated to optimal correction and then followed for 12 months; they were offered retreatment with Radiesse between six and 12 months in both folds to balance asymmetry. Of the 117 original split-face study subjects with moderate to severe NLF, 102 were enrolled in this extended follow-up. During this extension study, treating physicians used the Global Aesthetic Improvement Scale (GAIS) and clinical examination to evaluate subjects at intervals up to 39 months after the last injection of Radiesse. Results: Forty percent of the folds evaluated at least 30 months after the last Radiesse treatment were graded as 'improved' or better on the GAIS. Expectedly, the reported improvement was substantially less at this later time point than had been seen at earlier points in the premarket study, indicating some moderate, sustained improvement in some patients. There were no long-term or delayed-onset adverse events in these 102 patients followed for three years, including no reports of nodules, granulomata, or infections, such as have been reported with certain other dermal fillers. Conclusions: These results demonstrate the long-term safety and effectiveness of Radiesse. Three years after Radiesse injection, no delayed-onset or long-term adverse events were reported. In addition, many patients showed some long-term cosmetic improvement. The durability and safety of Radiesse compare favorably with other injectable fillers

Large temple and suprabrow lesions can pose a reconstructive challenge. When the lesion extends anterior to the hairline, esthetically acceptable local flaps may be difficult to design. We describe a modified scalp flap (ie, part Converse scalping flap and part scalp rotation flap) that can be tailored to reconstruct a variety of difficult temple and suprabrow lesions while simultaneously maintaining eyebrow position.The modified scalp flap is raised in a subgaleal plane until approximately 2.5 cm above the brow. At this level, dissection proceeds in the subcutaneous plane to protect the frontal branch of the facial nerve and to keep the flap thin. (The key to the modified scalp flap is the dissection plane change that protects the frontal branch of the facial nerve.) The extent of posterior subgaleal dissection is dictated by the amount of anterior rotation necessary. A temporal dog-ear is removed subfollicularly to permit modified flap rotation and preserve the superficial temporal artery.The modified scalp flap has been used to reconstruct temple and suprabrow lesions in 10 patients ranging in age from 4 months to 22 years. There were no complications. Four typical cases are presented.Temple and suprabrow lesions can be excised and successfully reconstructed in one stage using a modified scalp flap that is extended from the hair-bearing scalp onto the glabrous skin of the forehead. This novel modified scalp flap prevents eyebrow/hairline distortion and avoids facial nerve injury

BACKGROUND: Elbow extension is important for the elbow joint, and it is more difficult to restore with microsurgery than elbow flexion. The purpose of this article is to describe the experience of the authors with elbow extension reconstruction in obstetric brachial plexus palsy patients. The outcomes were analyzed in relation to the type of brachial plexus lesion, timing of surgery, and the type of nerve reconstruction. METHODS: Fifty-five children with obstetric brachial plexus palsy who underwent nerve reconstruction for elbow extension restoration were studied. The mean follow-up period was 6.4 years (range, 2-22 y). Reinnervation of the triceps muscle was accomplished with indirect neurotization of the posterior cord from intraplexus donors or with direct neurotization from extraplexus donors, such as the contralateral C7 and the intercostal nerves. RESULTS: Thirty-seven (67%) of the 55 cases showed good or excellent results (>or=M3+). The average postoperative muscle grading for the triceps was 3.34+/-0.99 compared with 1.19+/-1.29 preoperatively (P<0.0001). Patients with C5 to C7 palsy achieved significantly stronger elbow extension than those with C5 to T1 palsy. In addition, the timing of surgery significantly influenced the final outcome. CONCLUSIONS: Elbow extension is one of big challenges to be restored, especially in obstetric brachial plexus palsy. In early cases (within 6 mo) intraplexus reconstruction of the posterior cord can give excellent results. In later cases, or in cases of multiple avulsions, extraplexus motor donors, which selectively targeted the triceps, can give variable results

OBJECTIVES/HYPOTHESIS: AlloDerm (LifeCell Corp., Branchburg, NJ) is commonly employed for reconstruction of ablative soft tissue and mucosal defects following surgical resections. Although devoid of growth factors, AlloDerm may serve as an adhesive matrix for binding of growth factors, increasing local angiogenesis, and wound healing. We hypothesized that AlloDerm would enhance angiogenesis and might be altered with autologous blood products to enhance initiation of the angiogenic response. METHODS: We used a human placental vein in a fibrin-thrombin clot-based angiogenesis model. Four groups, human placental vein (HPVM), HPVM with AlloDerm, HPVM with AlloDerm plus platelet-poor plasma, and HPVM with AlloDerm plus platelet-rich plasma were evaluated. Endothelial cell growth was evaluated visually (40x). Hematoxylin and eosin staining and immunofluorescent staining for growth within the AlloDerm matrix were also performed. To assess human umbilical vein endothelial cell (HUVEC) sites of attachment to AlloDerm, we incubated HUVEC cells with AlloDerm for a period of 2 weeks and evaluated attachment with anti-factor VIII immunofluorescence. RESULTS: Angiogenic initiation decreased in the combined placental vein with AlloDerm group (P < .0001 at day 7, 14, 21). Additionally, initiation in the AlloDerm plus platelet-poor plasma group was significantly better than the AlloDerm alone group when placentas 2 and 3 were compared (P < .0001). On hematoxylin and eosin staining and immunofluorescent factor VIII staining, no endothelial growth into the AlloDerm was noted in the samples analyzed. CONCLUSIONS: AlloDerm may be enriched with platelet-poor plasma to stimulate greater initiation and wound healing; however, AlloDerm inhibits angiogenic initiation in this model.

The viability of fat grafts harvested with an established technique after cryopreservation remains unknown. This study was conducted in vitro to evaluate the viability of autologous fat grafts harvested with the Coleman technique and subsequently preserved with our preferred cryopreservation method. Eight adult females were enrolled in this study. In each patient, 10 mL of fat grafts were harvested with the Coleman technique by a single surgeon from the lower abdomen. In group 1, 5 mL of fresh fat grafts were mixed with cryoprotective agents and underwent cryopreservation with controlled slow cooling and fast rewarming. In group 2, 5 mL of fresh fat grafts without cryopreservation from the same patient served as a control. The fat graft samples from both groups were evaluated with trypan blue vital staining, glycerol-3-phophatase dehydrogenase assay, and routine histology. Viable adipocyte counts were found similar in both group 1 and group 2 (3.46 +/- 0.91 vs. 4.12 +/- 1.11 x 10/mL, P = 0.22). However, glycerol-3-phophatase dehydrogenase activity was significantly lower in group 1 compared with group 2 (0.47 +/- 0.09 vs. 0.66 +/- 0.09 u/mL, P < 0.001). Histologically, the normal structure of fragmented fatty tissues was found primarily in both groups. Our results indicate that autologous fat grafts harvested with the Coleman technique and preserved with our preferred cryopreservation method have a normal histology with near the same number of viable adipocytes as compared with the fresh fat grafts. However, those cryopreserved fat grafts appear to have a less optimal level of adipocyte specific enzyme activity compared with the fresh ones and thus may not survive well after they are transplanted without being optimized

BACKGROUND: Facial nerve explorations and microstimulation of distal nerve branches during facial reanimation procedures by the senior author (J.K.T.) have yielded various observations. This prompted the authors to quantify the surgical findings with an anatomical study and a subsequent analysis of the electrophysiologic intraoperative data. The present report details the microanatomical observations. METHODS: Ten fresh cadaveric hemiface dissections (five specimens) were performed. The facial nerve branches were traced distally under the operating microscope and mapped with India ink. A number of nerve branches exited the parotid at approximately 9 +/- 0.85 cm from the facial nerve trunk division, and their distribution was noted. Photographic documentation was obtained. RESULTS: The mean number of nerve branches was 7.70 +/- 1.05 at the anterior parotid border and 13.80 +/- 1.81 distally. Differences in the number and configuration of nerve branches existed even between the two sides of the face. The frontal branch had a mean nerve number of 2.80 +/- 0.63; the zygomatic branch, 4.40 +/- 1.34, the buccal branch, 3.20 +/- 0.78; and the marginal mandibular branch, 2.30 +/- 0.48. In 70 percent of specimens, the buccal branches originated from both upper and lower nerve divisions and interconnected with the marginal mandibular branch in 50 percent of specimens. Distally, connectivity was found between buccal branches and the infraorbital nerve, the marginal mandibular branches, and the mental nerve. A constant lower zygomatic or zygomaticobuccal branch reached the procerus and corrugator supercilii muscles. A twig from the frontal branch reached the corrugator muscle in 60 percent of cases. CONCLUSIONS: Diversity of facial nerve anatomy is recognized and documented. Specific anatomical relationships are clarified and demonstrated as a guiding map

Introduction: Bioengineering osseous tissue requires recapitulating the cellular, matrix, and lacunocanalicular components of bone. A construct must have a microvascular network which requires simultaneous co-culture of endothelial and osteogenic cells. Recreation of the matrix requires optimization of composition and microarchitecture. Engineering of constructs large enough to solve actual clinical problems requires novel strategies that address chemotransportative requirements by replicating lacunocanalicular flow. Methods: Cells: Adipose-derived mesenchymal stem cells (MSCs) were isolated and expanded from human lipoaspirate and differentiated into osteoprogenitor-rich (OPC) and endothelioprogenitor-rich (EPC), confirmed by RT-PCR. Normal human osteoblasts (NHOst) and human umbilical vein endothelial cells (HUVEC) served as terminally differentiated cell lines. The effects of coculture (e.g OPC + HUVEC, OPC + EPC etc) on capacity for bone formation was evaluated by von Kossa assay. Matrix: Murine alveolar defects were created. Scaffolds composed of either absorbable collagen sponge (ACS) or biphasic hydroxyapatite/tri-calcium phosphate (HA-TCP) in a 15/85 ratio were constructed and implanted. HA-TCP scaffolds were further investigated, comparing 15/85 and 60/40 HA/TCP in a rabbit calvarial model. Scaffold pore size (380/180 microns) and strut size (250/180 microns) were also investigated. New bone formation was analyzed histomorphometrically using micro-CT. Lacunocanalicular flow: We have developed a novel flow perfusion bioreactor designed to mimic lacunocanalicular flow. To validate, murine femurs were explanted to the bioreactor for 14 days. Viability and function were evaluated using thiazolyl blue tetrazolium bromide (MTT), DNA quantification, alkaline phosphatase (ALP) assay, and tetracycline labelling. Furthermore, optimal culture conditions were tested with MSC-seeded custom thick 3D HA-TCP scaffolds cultured in static conditions or in flow perfusion. Cellularity was assessed by SEM,!

Plastic surgery is a broad-based discipline with emphasis on areas such as breast, craniomaxillofacial, burn, aesthetic, and hand surgery as well as complex wounds and wound healing. Plastic surgery as a specialty captures a great deal of media attention over many other fields of medicine, so education, training, and credentialing have become an area of national interest. The purpose of this article was to provide information on the organization, basic requirements for training, fellowship, and volunteer opportunities within the specialty