Faculty Bibliography

Chronic wounds such as diabetic foot ulcers, venous ulcers, and pressure ulcers are a major source of morbidity and mortality. To describe wound characteristics associated with a wound emergency, the Wound Electronic Medical Records (WEMR) of 200 consecutive admissions (139 patients, average number of admissions 1.4) to a dedicated inpatient wound healing unit over a period of 5 months were retrospectively reviewed. Patient mean age was 62 +/- 16 years, 59% were men, 27% had a foot ulcer and diabetes mellitus, and 29% had venous ulcers. Presenting signs and symptoms included wound pain, cellulitis, nonpurulent drainage, and undermining, but few presented with classic local clinical signs of infection. Treatment consisted of sharp debridement with deep tissue culture and pathology from the wound base and/or systemic antibiotics. Twenty-percent (20%) of patients had pathology-confirmed and 38% had pathology- or radiology-confirmed osteomyelitis on admission, supporting that new or increasing wound pain, cellulitis, and/or nonpurulent drainage or presence of significant undermining may be indicative of an invasive infection and that patients presenting with these signs and symptoms require an immediate treatment plan and consideration of hospital admission. Use of an objective documentation system such as the WEMR may help alert clinicians to subtle wound changes that require aggressive treatment; thereby, avoiding emergency room visits and hospital admissions. Future research is needed utilizing the WEMR across multiple medical centers to further define criteria for a chronic wound emergency

PURPOSE: This article focuses on the use of tissue-engineering techniques for the reconstruction of bone defects in the maxillofacial region. METHODS AND RESULTS: A comprehensive and critical analysis of the literature showed that tissue-engineering procedures are effective in both animal studies and clinical case series. At the same time, it is clear that much work remains before these techniques can be used routinely in the clinical situation. CONCLUSION: This review highlights areas that require further investigation, and proposes several solutions to make tissue-engineering procedures available for maxillofacial reconstruction in the near future.

OBJECTIVE: The purpose of this study was to determine the microtensile bond strength of various resin composite/adhesive systems to alumina particle abraded Ti-6Al-4V substrate after aging for 24h, 10 days, and 30 days in distilled water at 37 degrees C. METHODS: Four laboratory resin composite veneering systems (Gradia, GR; Solidex, SOL; Ceramage, CER; and Sinfony, SF) were bonded to 25 mm diameter machined disks of Ti-6Al-4V with their respective adhesive and methodology, according to the manufacturer's instructions. Microtensile bars of approximate dimensions 1 mm x 1 mm x 6 mm were prepared for each resin composite/adhesive system. After cutting, groups (n=12) from each adhesive system were separated and either stored in water at 37 degrees C for 24h (baseline) or aged for 10 or 30 days prior to loading to failure under tension at a cross head speed of 1.0mm/min. Failure modes were determined by means of scanning electron microscopy (SEM). Statistical analysis was performed through one-way ANOVA and Tukey's test at 95% level of significance. RESULTS: Significant variation in microtensile bond strength was observed for the different systems and aging times. SOL and GR showed the highest mean bond strength values followed by SF and CER at baseline. Aging specimens in water had an adverse effect on bond strength for SOL and CER but not for the SF and GR groups. SIGNIFICANCE: In vitro bond strength of laboratory resin composites to Ti-6Al-4V suggests that strong bonds can be achieved and are stable for certain systems, making them useful as an alternative for esthetic fixed prosthetic restorations

BACKGROUND: Functional outcomes of lower extremity reconstruction compared with amputation have been evaluated. However, there are little comparative data among the different reconstructive options. With the recent increase in perforator flaps, we compared the functional outcomes of muscle and perforator flaps. METHODS: We conducted a retrospective review of 136 lower extremity trauma patients who underwent reconstruction with either a free muscle or perforator flap during a 7-year period. Forty-two of these patients completed the study. Patients answered the short musculoskeletal functional assessment form and supplemental questions. A physical therapist evaluated performance of physical tasks. Donor site sensation was measured with the pressure specified sensing device. Radiographic fracture union was evaluated by an orthopedic surgeon. RESULTS: Of the 42 patients enrolled, 20 had coverage with perforator flaps and 22 with muscle flaps. Quality of life and functional outcomes demonstrate no difference (p > 0.05). Ninety-three percent of patients would go through the limb salvage process to avoid amputation. Sensation at the donor site was diminished in all patients; however, the perforator flap donor site had more significant sensory loss (p = 0.005). Time to bony union (p = 0.51), union in the presence of infection (p = 0.85), and infection after flap (p = 0.87) was not related to flap type. CONCLUSION: Both muscle and perforator flaps provide vascularized coverage, which nourishes the fracture but muscle flaps pilfer a functional unit which may not be inconsequential in a patient trauma. This pilot study suggests that functional outcomes of perforator skin flaps are equal to muscle flaps and a larger prospective study is warranted.

Laryngopharyngeal oncologic resections produce complex reconstructive problems, requiring dependable robust flaps to restore form and function. Current options include morbid local-regional flaps or free tissue transfers. The supraclavicular artery flap (SAF) offers a great new option. Partial pharyngeal oncologic defects were reconstructed with pedicled SAFs. Handheld Doppler probes marked the pedicle preoperatively. Flaps were design based upon the dopplered vascular anatomy. Complications and functional outcomes were assessed. All flaps (n = 6) were harvested in under 1 hour with uneventful postoperative recoveries. Ablative wounds and donor sites were closed primarily. Two patients had small controlled leaks because of preoperative radiation and overly aggressive oral intakes, that subsequently resolved. There were no functional donor site morbidities. We describe a novel application of the SAF for pharyngeal reconstructions after laryngopharyngeal cancer ablation. This thin, reliable, easy to harvest, low morbidity flap is an excellent reconstructive option for pharyngeal reconstructions.

Despite the clinical relevance of bottoming out, or pseudoptosis, associated with reduction mammaplasty (RM) its evaluation remains an imprecise science. This study aims to further define the kinetics of postoperative pseudoptosis over an extended period of time, after our previous study investigating pseudoptosis in the early postoperative period. Patients undergoing medial pedicle RM had 3-dimensional photographs taken at year 1 and year 2 intervals postoperatively (year 1 = 300-450 days; year 2 = 700-900 days). Bottoming out was assessed with various 3-dimensional parameters. The total breast volume and the percent tissue distribution in the upper pole of the breast did not change from year 1 to year 2. The anterior-posterior projection as well as vector measurements for internipple distance and sternal notch to nipple distance also remained stable from year 1 to year 2. Although previous data from our group documented the occurrence of bottoming out and continued size reduction over the first postoperative year after breast reduction, the present study shows that pseudoptosis does not seem to occur during the second postoperative year

Breast augmentation is one of the most common plastic surgery procedures performed in the United States today. Evaluation of postoperative results lacks true objective measurements. The following study reports the application of 3-dimensional (3D) photography to document changes that occur in breast morphology after breast augmentation. Patients undergoing augmentation mammaplasty with a periareolar incision were offered pre- and postoperative 3D photographs. 3D models were constructed and the following parameters were assessed: maximum anterior-posterior projection from the chest wall, angle of breast projection, total breast volume, volumetric tissue distribution in the superior and inferior poles, and surface and vector distance measurements to key landmarks. A completed series of 3D images were obtained from 14 augmentation patients (28 breasts) at an average postoperative day of 143. Saline and silicone implants were used equally (n = 14 for each). Total volume of the breast changed in correlation with the implant size (1.9% difference, P = 0.83). There were no significant changes in the volumetric distribution within the upper and lower poles of the breasts noted between pre- and postoperative scans (P = 0.81). The internal angle of breast projection was found to increase (13.6 degrees, P < 0.01), as did the sternal notch to nipple distance (11 mm, P = 0.018). Anterior-posterior projection significantly increased by 23.3 mm. However, this increase in projection was 20.9% less than expected based on implant dimensions (72.7-58.7 mm, respectively, P < 0.01). This study documents objective changes in breast morphology after augmentation mammaplasty. 3D imaging scans were able to document true changes that occur with breast augmentation including breast volume, the increase in the internal angle of the breast projection, and the sternal notch to nipple distance. 3D photography further highlighted that breast augmentation results in less than expected anterior-posterior projection, possibly due to tissue attenuation occurring anterior to the implant

Large, traumatic wounds around the proximal third of the lower extremity may have disrupted local vasculature, potentially obviating local pedicled options. However, free-tissue transfer to this area is technically challenging given the resulting paucity of recipient options and the depth of principal blood vessels. We present an anatomic and radiographic study of the proximally based peroneal vascular bundle as a recipient option in the proximal leg. Optimal approach was prone, through an incision over the fibula with dissection between lateral and posterior compartments. Magnetic resonance angiography demonstrated consistent vascular anatomy between patients. A proximally based peroneal vascular bundle protected by a cuff of flexor hallucis longus was used as a recipient vessel in free flap reconstruction of an open knee wound. The bundle itself does not require coverage by virtue of its own local muscle cuff. Caveats for its use include the need for adequate leg inflow and foot outflow.