Faculty Bibliography

Pathologic resections involving the maxilla/hemimaxilla offer a unique reconstructive challenge to the maxillofacial reconstructive surgeon. Traditionally, reconstruction and replacement of lost tissues have been achieved with a variety of methods including obturators, local/regional flaps, and microvascular free tissue transfer. All these techniques have distinct disadvantages. We present a novel approach to palatomaxillary reconstruction using a combination of free tissue transfer and zygomaticus implants. To our knowledge, this specific technique has not been previously reported.

BACKGROUND: Multistage reconstructive procedures are often required to try to restore the emotional potential of human expression in cases of facial paralysis. In this study, the senior author's (J.K.T.) experience with the technique of direct nerve to muscle neurotization as a part of multistage facial reanimation procedures is presented. Age, denervation time, etiology of the lesion, previous reconstructive procedures, and types of muscles responsible for animation were analyzed to make evidence-based recommendations on the indications of the technique as well as its role and effectiveness in facial reanimation. METHODS: Retrospective review of 37 pediatric patients who underwent direct muscle neurotization took place. The patients were divided into three groups, depending on the region that direct neurotization was aiming to augment. Group A involved 28 patients for eye closure and blink, group B included 15 patients for smile, and group C included 19 patients for depressor augmentation. RESULTS: Twenty patients were female and 17 male. Patient age ranged from 1 to 16 years, with a mean age (+/-SD) of 9 +/- 2.8 years. Denervation time ranged from 3 months to 15.25 years, and the mean denervation time was 6.72 years. Electromyographic scoring of the neurotized muscles showed an overall mean improvement of 36 percent for eye closure, 34.25 percent for blink, 37 percent for smile augmentation, and 30 percent for depressor function restoration. CONCLUSION: Direct muscle neurotization has a valid role in pediatric facial reanimation procedures, as it augments and promotes expressivity

The objective of this study was to evaluate the morphology and integration status of 30 human retrieved plateau root form implants. Thirty plateau design root form implants that were in function from 8 to 13 years were retrieved from patients due to prosthetic reasons. Following surgical removal, the samples remained in 10% buffered formaline for 7 days. Bone morphology was evaluated by transmitted and polarized light microscopy, and bone-to-implant contact (BIC) histomorphometric assessment was determined through computer software. Irrespective of time in vivo, lamellar bone was observed in close contact with the implant surface and between plateaus. BIC ranged from approximately 20 to approximately 80%. Polarized light microscopy showed a highly directional osteonic morphology between plateaus for most implants. A haversian-like microstructure running perpendicular to and along with the implants' long axis (between plateaus) was observed in regions of cortical and trabecular bone, revealing a unique bone microstructural evolution over time around functionally loaded plateau root form implants.

This study investigated the hypothesis that acetyl-L-carnitine (ALCAR) could have a significant effect on nerve regeneration after end-to-side neurorrhaphy. The ability of the ALCAR to enhance nerve regeneration in combination with various types of donor nerve injury distal to the coaptation site was also determined. Twenty-five Sprague-Dawley rats were randomized to five groups of five animals each, in which three different types of donor injury (crush, ligation, and transection injury) distal to the coaptation site were executed (groups C, D, and E, respectively). Animals in group A (placebo) and group B underwent a standard end-to-side neurorrhaphy. Animals from groups B to E received a daily intraperitoneal injection of 50 mg/kg/d of ALCAR, and a placebo was injected in place of ALCAR in animals in group A. Administration of acetyl-L-carnitine alone did not prove to be a significant stimulus for regeneration, as concluded after comparison among the two noninjury models of the donor nerve (groups A and B). Indeed, the combination of an injury model of the donor nerve (crush injury) with administration of acetyl-L-carnitine proved to be a significantly more potent stimulus for regeneration than the control (placebo) group, as measured by behavioral, muscle morphometric, electrophysiological, and histomorphometric studies

Angiotensin-converting enzyme (ACE) inhibitors have been extensively used for the treatment of patients with cardiovascular disease, but several concerns have been raised about their efficacy in African American (AA) patients with heart failure, hypertension, and left ventricular hypertrophy. In this study the authors assessed the effect of ACE inhibitors on total and cardiovascular mortality in high-risk AA patients with angiographically proven coronary artery disease (CAD). This was a retrospective analysis of 810 AA men who underwent diagnostic coronary angiography between 1995 and 2003. All patients had demonstrable CAD and had undergone a complete ischemic workup. Follow-up was from 3 to 10 years. ACE inhibitors were administered to 237 patients, while the remaining 537 patients were not taking ACE inhibitors. Patients taking ACE inhibitors had significantly more comorbidities (hypertension, diabetes, left ventricular hypertrophy, heart failure, severe CAD) at baseline, compared with patients not taking ACE inhibitors (P<.05 for all comorbidities). Despite the unfavorable baseline profile, patients taking ACE inhibitors had significantly lower mortality from CAD during follow-up than patients who were not taking ACE inhibitors (P=.006). Stroke mortality rates were similar in both groups. Cox regression analysis showed an 80% higher relative risk in patients not receiving ACE inhibitors. These data indicate a substantial benefit from ACE inhibitor therapy in high-risk AA patients with CAD.

A 66-year-old male with lower extremity ischemia underwent femoral-posterior tibial bypass with composite vein graft from the arm. Ten days later, he presented to the emergency department with pain, wound erythema, and drainage. Despite a prolonged course of intravenous antibiotics and serial operative debridements, the wound edges repeatedly necrosed after each procedure. The vein graft remained viable. Punch biopsies of wound edges were consistent with pyoderma gangrenosum (PG). The patient's condition improved on immunosuppressive therapy. Although a rare clinical entity, postsurgical PG is a well-described phenomenon whose diagnosis is often delayed. Clinical suspicion is imperative to ensure timely treatment and minimize morbidity.

BACKGROUND: Response assessment in advanced pancreatic cancer (APC) is difficult and predictive markers are needed. There are insufficient data on the value of carbohydrate antigen 19-9 (CA 19-9) and cytostatic-targeted therapies. Axitinib, a selective vascular endothelial growth factor (VEGF) receptors 1, 2, 3 inhibitor, may increase overall survival (OS) in APC. METHODS: We assessed serum CA 19-9, clinical outcomes and diastolic blood pressure (dBP) in APC patients receiving gemcitabine plus axitinib (Gem+A) or gemcitabine alone. RESULTS: In the total population (N=95), median OS was significantly longer in patients with baseline CA 19-9 values at or below the median than in those with values above it (12.2 months [95% confidence interval (CI), 8.6-16.6%] vs 5.0 months [95% CI, 3.9-5.7%]; P<0.0001). This also reached significance in the Gem+A arm (median OS, 12.5 months [95% CI, 8.6-16.6%] vs 4.9 months [95% CI, 3.6-5.6%]; P<0.0001). Patients with any dBP>90 mmHg had significantly longer OS than those who did not. However, there was no predictive significance of CA 19-9. CONCLUSION: Baseline CA 19-9 levels had prognostic value for OS, but caution is advised in interpreting CA 19-9 as a predictive biomarker for novel cytostatic agents such as VEGF-targeted therapies in phase II studies.

OBJECTIVE:Using the sequential inflation of 2 sphygmomanometers, Lewis et al. (Heart 16:1-32, 1931) concluded that compressive neuropathy was secondary to ischemia of the compressed nerve segment. Despite subsequent animal studies demonstrating that compressive lesions are more likely the result of mechanical nerve deformation, disagreement remains as to the etiology of rapidly reversible compressive neuropathy. Our hypothesis is that, during the classic sphygmomanometer experiments, the areas of nerve compression at the cuff margins overlapped, so that a region of transient nerve deformation persisted during the second cuff inflation. If true, the original results by Lewis et al. would be consistent with a mechanical pathogenesis. METHODS:In our study, 6 patients underwent sequential upper extremity dual-sphygmomanometer inflation with serial assessment by grip-dynamometer and 2-point discrimination. The order of cuff inflation, as well as the distance between cuffs, was varied. Mean grip force and 2-point discrimination values were statistically compared between conditions. RESULTS:Patients with overlapping cuffs maintained their neurological deficits, whereas those with separated cuffs experienced an improvement in both grip force (P = 0.02) and 2-point discrimination (P < 0.001) when cuff inflation was switched. CONCLUSION/CONCLUSIONS:Rapidly reversible compressive neuropathy seems to be secondary to mechanical nerve deformation at the margins of the compressive force rather than the result of ischemia of the compressed nerve segment. Overlap of the mechanically deformed nerve segments likely explains why neurological deficits persisted despite sequential cuff inflation in the classic experiments by Lewis et al.

When the editor asked me to write something related to the chin, I (B.M.Z.) told him I would like to concentrate on the soft tissue of the perioral and chin region, something previously not presented before in this Journal specifically or anywhere. Dr. Flores and I have chosen certain soft tissue cases of the lower face, each of which presents certain dilemmas. The reconstructive methods in each case are unique, previously not shown, and represent salvage from prior failures. Case 1 shows how an interior Abbe flap can be used for ipsilateral lip reconstruction. Case 2 shows how a large upper lateral lip elemental loss can be regained from cheek and not the lower lip. Cases 3 and 4 show how to regain proper white roll bulge and symmetry by overcorrection, then exact adjustment in a second stage. Case 5 shows how a failed chin/lip reconstruction can be salvaged to regain sulcus height and aesthetic unit reconstruction. Each case depicts unique reconstructive designs to produce an aesthetic final result

Presurgical infant orthopedics has been employed since 1950 as an adjunctive neonatal therapy for the correction of cleft lip and palate. Most of these therapies did not address deformity of the nasal cartilage in unilateral and bilateral cleft lip and palate as well as the deficiency of the columella tissue in infants with bilateral cleft. The nasolaveolar molding (NAM) technique a new approach to presurgical infant orthopedics developed by Grayson reduces the severity of the initial cleft alveolar and nasal deformity. This enables the surgeon and the patient to enjoy the benefits associated with repair of a cleft deformity that is minimal in severity. This paper will discuss the appliance design, clinical management and biomechanical principles of nasolaveolar molding therapy. Long term studies on NAM therapy indicate better lip and nasal form, reduced oronasal fistula and labial deformities, 60 % reduction in the need for secondary alveolar bone grafting. No effect on growth of midface in sagittal and vertical plane has been recorded up to the age of 18 yrs. With proper training and clinical skills NAM has demonstrated tremendous benefit to the cleft patients as well as to the surgeon performing the repair