Faculty Bibliography

INTRODUCTION: Injuries to the ulnar collateral ligament (UCL) are relatively common and are best treated in the acute setting. The acute version of this injury can often be repaired primarily but in the chronic setting the ligamentous remnants are often retracted making this method of repair difficult. We present a novel alternative approach for UCL repair after chronic injuries or difficult acute injuries. METHODS: We describe the procedure and postoperative results. A standard S-shaped incision over the dorsal ulnar aspect of the thumb is used. The adductor aponeurosis is identified and separated from the joint capsule. A proximally based and distally based rectangular flap containing the UCL remnants is elevated exposing the metacarpophalangeal joint. A burr is used to shave the condyles on the ulnar aspect of the metacarpal and proximal phalanx. The joint is stabilized with a Kirschner wire. A suture anchor is used to secure the proximally based flap. The distal flap is secured on top of this using the same sutures from the anchor. The repaired ligament is secured to the volar plate on the palmar aspect using a 4-0 Ethibond. RESULTS: This surgical technique has been used extensively by the senior authors; we present a representative case. At 3 months the patient had a grip strength of 85 lbs, tripod pinch of 12 lbs, lateral pinch of 5 lbs, 2-point pinch of 6 lbs, active range of motion at metacarpophalangeal joint of 0 to 70 and passive range of motion at the metacarpophalangeal joint MP of 0 to 85. CONCLUSION: Despite a number of options for ligament reconstruction many of the described methods of repair are relatively complex and involve derangement of local tissues. We offer a novel adjunct to current methods of UCL reconstruction in which condylar shaving makes repair much more simple and avoids the use of a tendon graft. This approach provides a shorter course for the retracted UCL remnants allowing primary repair in the chronic setting and in the difficult acute repair

In the last two decades, the anterolateral thigh flap has emerged as one of the most popular reconstructive options for multiple body sites. Based on a perforator flap harvest concept, the flap encompasses the advantages of versatility, pliability, and potential for composite tissue replacement. Although numerous anatomical variations exist, these are well-described, and flap safety remains uncompromised if certain anatomical boundaries are respected. Careful preoperative planning and identification of perforators remain the cornerstone of successful flap harvest. Once perforators are identified, variations in skin paddle design allow for multiple skin paddle configurations, central or eccentric orientations, and custom-made flaps tailored to fit almost any defect. A suprafascial dissection allows for "ultra-thin" flaps ideal for folding, tubing, or packing purposes. The versatility of the lateral circumflex femoral artery branches can be exploited to include muscle, iliac bone, tendon, fascia, or nerve in extended designs. The anterolateral thigh flap is currently the frontline choice for head and neck reconstruction, including intraoral, mandibular-maxillary, tongue, and facial defects, and is gaining popularity in abdominal and pelvis reconstruction. It can also be used as a pedicled flap in phallus or perineum reconstruction. More recently, the flap has proved to be extremely useful in skin resurfacing and even functional reconstruction in traumatic wounds. This review summarizes the anatomy, planning, flap harvest, donor morbidity, and clinical applications of the anterolateral thigh flap. An algorithm is proposed that facilitates a clear, problem-based approach for the use of this versatile reconstructive option.

Peripheral nerve defects are common. The surgeon faced with these problems must provide the best functional recovery for the patient with the tools provided. The ideal nerve reconstruction would create a tensionless repair with direct coaptation. However, this is not always possible and other techniques must be employed. The alternatives to direct coaptation include nerve autografts, nerve conduits, and tissue-engineered constructs. This article reviews commonly used autogenous nerve grafts and conduits. Autogenous nerve grafts have been utilized in various techniques which include the trunk graft, cable graft, interfascicular graft, and vascularized graft. The nerve conduits reviewed fall into the category of autogenous biological conduits, nonautogenous biological conduits, and nonbiological conduits. New technologies are being developed to enhance peripheral nerve regeneration with the concept that conduits can be enriched and manipulated in the laboratory to promote regeneration of the peripheral nerve. Further clinical studies hold the promise of successful alternatives for treating peripheral nerve injuries

BACKGROUND: The series presented constitutes the entire experience with adult facial paralysis reanimation by a single surgeon over three decades. This report discusses the different reconstructive strategies used in this sample, focusing on the incidence and outcomes of commonly used revisional and ancillary procedures. METHODS: Since 1979, 175 adult cases of facial paralysis underwent facial reanimation surgery performed by the senior author (J.K.T.). The reconstructive strategies varied in accordance with denervation time, cause, and whether the paralysis was complete or partial and unilateral or bilateral. Irrespective of these variables, the number of patients who required secondary surgery totaled 141 of 175 (81 percent). Postrevision videos were available in 122 patients, who constituted the sample evaluated. Four independent observers rated the outcomes of secondary surgery using a five-category scale ranging from poor to excellent. RESULTS: Interrater reliability testing showed Cronbach's alpha values above acceptable limits (alpha > 0.80). The effect of diverse revisional and ancillary interventions was measured computing a mean gain percentage score. Secondary surgery yielded a significant upgrade in symmetry and function, with appreciable improvements in all three facial regions (upper face, 28 to 166 percent gain; midface, 33 to 72 percent gain; and lower face, 20 to 127 percent gain). CONCLUSIONS: This comprehensive analysis of the entire series of adult reanimation in the authors' center evidences the beneficial effects of revisional and ancillary interventions to augment function and overall symmetry. Inherent in all methods of dynamic reanimation is the need for secondary adjustments, which should be considered in most cases, as they can transform an adequate result into a gratifying outcome

BACKGROUND:: The authors assessed the safety and efficacy of a novel cleft rhinoplasty procedure that combines an open rhinoplasty with the Dibbell and Tajima techniques. METHODS:: A single-surgeon, 10-year, retrospective review was conducted of all unilateral cleft lip rhinoplasties (n = 157). Nonsyndromic patients undergoing a combined open incision/Dibbell/Tajima procedure and who had follow-up of greater than 8 months were included. Thirty-five patients were identified. Standardized patient photographs were studied in 18 patients who had both preoperative and 1-year postoperative photographs. Farkas normal values were applied to the medial canthal distance; from this value, metric measurements of changes in alar base width, columellar height, and nostril apex height were derived. RESULTS:: There were no complications secondary to skin envelope ischemia or cartilage graft infection. The revision rate was 11 percent for alar base position, 3 percent for depressed lower lateral cartilage, and 3 percent for nostril apex overhang. After the procedure, there was a statistically significant decrease in alar base width (19.9 mm versus 18.2 mm; p < 0.01) and an increase in columellar height (8.37 mm versus 9.59 mm; p = 0.02) and nostril apex height (4.70 mm versus 5.44 mm; p = 0.02) on the affected side. The differences in alar base width, columellar height, and nostril apex height between the affected and nonaffected sides all decreased significantly postoperatively. CONCLUSIONS:: The combined open rhinoplasty/Dibbell/Tajima procedure is safe, has a low revision rate, and is associated with a statistically significant decrease in alar base width, an increase in columellar height and nostril apex height, and a greater symmetry of nasal form

Patients born with a craniofacial deformity and their families experience significant psychosocial effect as they deal with physical appearance that has been esthetically and functionally compromised. The deformity usually involves skeletal and soft-tissue elements, which often affect facial symmetry and esthetics. As the dentition is directly related to the jaw structures, a wide variety of malocclusions may result. As patients with craniofacial anomalies present with multiple dental and medical conditions, an interdisciplinary team approach is highly recommended to accurately diagnose and to properly customize a treatment plan. Craniofacial Orthodontics is the area of orthodontics that treats patients with congenital and acquired deformities of the integument and its underlying musculoskeletal system within the craniofacial area and associated structures. As part of the craniofacial and cleft teams, the craniofacial orthodontist is involved in data collection, clinical examination, diagnosis, treatment planning, and orthopedic or orthodontic treatment of the craniofacial disorder. The craniofacial orthodontist has been shown to play an intrinsic role in the care of patients with craniofacial anomalies and cleft lip and palate

PURPOSE: The objective of this study was to evaluate the bone response to a nanothickness bioceramic ion beam-assisted deposition (IBAD) on endosteal implants in a canine model. MATERIALS AND METHODS: Alumina-blasted/acid-etched (control) and IBAD-modified (test) implants were characterized by scanning electron microscopy, X-ray photoelectron spectroscopy + ion beam milling, thin-film mode X-ray diffraction, and atomic force microscope. The implants were surgically placed in four dogs' proximal tibiae and remained for 2 and 4 weeks in vivo. Oxytetracycline (10 mg/kg) was administered for bone labeling 48 hours prior to euthanization. Following euthanization, nondecalcified thin sections were prepared for UV and transmitted light microscopy. The amount of bone labeling was evaluated along the length and away from the implant surface by means of a computer software. The % bone-to-implant contact (BIC) was determined for each specimen. One-way analysis of variance at 95% level of significance along with Tukey's post hoc multiple comparisons were utilized for statistical evaluation. The characterization showed Ca- and P-based amorphous coatings with a 20- to 50-nm thickness. RESULTS: In vivo results showed a significant increase in general and site-specific (to 0.5 mm from the implant surface) bone activity for the 4-week test implants compared with the control implants. Bone activity levels decreased as a function of distance from the implant surface for all groups. No significant differences in BIC were observed between groups. CONCLUSIONS: This study showed that both surfaces were biocompatible and osteoconductive and that a time-dependent increase in osteoactivity occurred around the test implants.