Faculty Bibliography

BACKGROUND: Despite technical advancement, treatment of congenital alveolar clefts has remained controversial. Currently, primary alveolar cleft repair (i.e., gingivoperiosteoplasty) has a 41 to 73 percent success rate. However, the remaining patients have persistent alveolar bone defects requiring secondary grafting procedures. Morbidity of secondary procedures includes pain, graft resorption, extrusion or infection, and graft or tooth loss. The authors present a novel rat alveolar defect model designed to facilitate investigation of therapeutics aimed at improving bone formation following primary alveolar cleft repair in humans. METHODS: Sixteen 8-week-old Sprague-Dawley rats underwent creation of a 7 x 4 x 3-mm complete alveolar defect from the maxillary incisors to the zygomatic arch. Four animals were humanely killed at each of the following time points: 0, 4, 8, and 12 weeks. Morphometric analysis of the alveolar defect was determined by means of micro-computed tomography and histology. RESULTS: Micro-computed tomography demonstrated that new bone filled 43 +/- 5.6 percent of the alveolar defect at 4 weeks, 53 +/- 8.3 percent at 8 weeks, and 48 +/- 3.5 percent at 12 weeks. Histologically, at 4 weeks, proliferating fibroblasts and polymorphonuclear cells were scattered throughout the disorganized collagen in the intercalary gap. By 8 weeks, nascent woven bone spicules extended from the edges of the defect. At 12 weeks, the woven spicules had remodeled, with scant additional bone deposition. CONCLUSION: This model creates a critical-size alveolar defect that is similar in size and location to human alveolar defects and is suitable for studying proposed therapeutics.

BACKGROUND: The cross-facial nerve grafting/free-muscle transfer strategy for smile restoration is superior to static reconstruction or regional muscle transposition. The purpose of this study was to evaluate the long-term outcomes of this technique in adult patients. METHODS: Eighty-one adult patients received a free-muscle transfer for midface reanimation in the authors' center. Of this group, the authors identified 24 cases with follow-up of 5 years or longer. Smile symmetry and function were evaluated at three points: preoperatively, early postoperatively, and at long-term follow-up. To better evaluate the effect of time, patients were divided into groups according to the length of follow-up: group A, 5 to 6 years; group B, 7 to 10 years; group C, 11 to 15 years; and group D, more than 15 years. Four independent observers rated each patient's smile using a five-category scale ranging from poor to excellent. Panelists were asked to comment on whether the patient's smile weakened over time. RESULTS: All patients obtained higher scores at 2 years from free-muscle transfer in comparison with their preoperative rates (p < 0.0001). Late outcomes demonstrated that muscle regeneration continues beyond the initial 2 years, with a further increase of the scores and motor units on electromyography at the late follow-up (p < 0.0001, p = 0.0313). No significance was found when comparing both variables among the four groups, indicating that time does not have a differential effect on muscle function. In 80 percent of the evaluations, the four observers agreed on maintained smile symmetry over time. CONCLUSIONS: Cross-facial nerve grafting/free-muscle transfer is an effective technique for smile restoration in late facial paralysis. These data indicate maintenance of effective muscle function and progressive improvement with time

BACKGROUND: Nasoalveolar molding was developed to improve dentoalveolar, septal, and lower lateral cartilage position before cleft lip repair. Previous studies have documented the long-term maintenance of columella length and nasal dome form and projection. The purpose of the present study was to determine the effect of presurgical nasoalveolar molding on long-term unilateral complete cleft nasal symmetry. METHODS: A retrospective review of 25 consecutively presenting nonsyndromic complete unilateral cleft lip-cleft palate patients was conducted. Fifteen patients were treated with presurgical nasoalveolar molding for 3 months before surgical correction, and 10 patients were treated by surgical correction alone. The average age at the time of follow-up was 9 years. Four nasal anthropometric distances and two angular relationships were measured to assess nasal symmetry. RESULTS: All six measurements demonstrated a greater degree of nasal symmetry in nasoalveolar molding patients compared with the patients treated with surgery alone. Five symmetry measurements were significantly more symmetric in the nasoalveolar molding patients and one measurement demonstrated a nonsignificant but greater degree of symmetry compared with the patients treated with surgery alone. CONCLUSIONS: The data demonstrate that the lower lateral and septal cartilages are more symmetric in the nasoalveolar molding patients compared with the surgery-alone patients. Furthermore, the improved symmetry observed in nasoalveolar molding-treated noses during the time of the primary surgery is maintained at 9 years of age

BACKGROUND: Population-based overall patterns of surgical management of the axilla in women with operable breast cancer during the era of adoption of sentinel lymph node biopsy (SLNB) were studied. METHODS: Women with operable breast carcinoma residing in 14 geographic areas of the Surveillance, Epidemiology, and End Results (SEER) cancer registries (1998-2004, n=239,661) were assessed for axillary surgical patterns of care. RESULTS: Use of SLNB increased from 11 to 59%. Use of no axillary surgery decreased from 14 to 6.6%. In pathologic node-negative women, use of axillary lymph node dissection (ALND) decreased from 94 to 36%. Independent factors most associated with failure to receive SLNB included diagnosis year (2000: 62%; 2004: 29%), surgery (mastectomy: 64%; breast-conserving surgery: 36%), tumor size (T3: 71%; T2: 56%; T1: 40%), age (>or= 70 years: 50%; <70 years: 45%), grade (high: 42%; low: 38%), urbanity (non-large metropolitan area: 49%; large metropolitan area: 42%), and, by quartile, poverty (highest: 47%; lowest: 35%), and white-collar employment (lowest: 56%; highest: 47%). In pathologic node-positive women who had SLNB, failure to undergo completion ALND increased from 20% in 1998 to 32% in 2004. Patients with smaller, lower-grade tumors, and those with smaller size of nodal metastasis, lack of extracapsular extension, age >or= 70 years, increased linguistic isolation, African-American or Hispanic race/ethnicity, and white-collar employment were less likely to undergo completion ALND. CONCLUSIONS: Management of the axilla changed dramatically during the period of rapid adoption of SLNB. Patterns of care suggest both appropriate and inappropriate selection for SLNB and ALND

Osteomyelitis affects up to 32% of full-thickness pressure ulcers and increases treatment costs and the risk of systemic complications. Current diagnosis and treatment practices are variable. A literature and retrospective chart review, using a wound electronic medical record (WEMR), were conducted to develop an evidence-based protocol of care for treatment of osteomyelitis in pressure ulcers and to evaluate outcomes of care. The seven steps in the protocol of care include: 1) acknowledgment of osteomyelitis risk in patients with Stage IV pressure ulcers, 2) clinical evaluation for local or systemic signs of infection upon initial presentation, 3) radiographic evaluation (magnetic resonance imaging or bone scan), 4) surgical debridement to remove all nonviable tissue and/or scarred and infected bone, 5) obtaining pathology reports from sterile bone biopsy and deep microbial cultures, 6) targeted systemic antimicrobial therapy, and 7) tissue reconstruction following resolution of infection. WEMR data review (177 patients) identified 50 patients with osteomyelitis (prevalence 28%). Of those, 41 underwent 87 bone debridements for osteomyelitis. Eight (20%) patients experienced complications elated to treatment. Average time to discharge following debridement was 4.3 +/- 5.7 days and 76% of wounds with more than two consecutive WEMR entries showed a decrease in area at their final visit. The outcomes observed are encouraging and the WEMR facilitates implementation and evaluation of the treatment protocol. Ongoing data acquisition will help assess outcomes and refine the current management protocol and should improve diagnosis and care

BACKGROUND: In 1984, Terzis introduced the 'babysitter' procedure, a new concept in facial reanimation. It involves two stages, with coaptation of ipsilateral 40 percent hypoglossal to facial nerve on the affected side, performed concomitantly with cross-facial nerve grafting and secondary microcoaptations 8 to 15 months later. This article presents the senior author's (J.K.T.) experience with the original procedure. METHODS: Of 75 patients who had minihypoglossal nerve transfer, 20 fulfilled the selection criteria for the original babysitter procedure. All patients' records, photographs, videotapes, and needle electromyography studies were reviewed. The clinical results were scored using Terzis' Grading Scale. Eye closure, smile, and lower lip depression were each assessed separately. Functional and aesthetic outcomes and preoperative and postoperative electromyography results were analyzed. RESULTS: Seventy-five percent of patients achieved excellent and good results, 15 percent had moderate results, and 10 percent had fair results. The difference between preoperative and postoperative eye closure was statistically significant (t test, p < 0.001). Symmetrical smile and full contraction (excellent result) was achieved in two patients (10 percent), 13 patients (65 percent) had nearly symmetrical smile (good result), and five patients (25 percent) had a moderate result. Two patients (10 percent) had full lower lip depression (excellent result) and 15 (75 percent) had good results. In three patients (15 percent), subsequent digastric or platysma muscle transfer was performed because of inadequate depression and symmetry (moderate result). A statistically significant difference was observed between preoperative and postoperative electromyography results, in eye closure, smile, and lower lip depression. CONCLUSIONS: The original babysitter procedure offers significant improvement in selected patients with facial paralysis. Symmetry and coordinated movements can be restored, with satisfying aesthetic and functional outcomes

BACKGROUND: Frontal sinus injury involving nasofrontal outflow tract obstruction is routinely managed by obliteration or cranialization; however, a small percentage of patients develop persistent indolent infections despite routine measures. The authors discuss the course of persistent infection following frontal sinus fractures and propose a novel treatment that definitively obliterates and separates the nasofrontal outflow tract from the cranium in these patients. METHODS: Seven consecutive patients with persistent indolent infections associated with frontal sinus fractures were identified and treated at the R Adams Cowley Shock Trauma Center and The Johns Hopkins Hospital from 2005 to 2008. RESULTS: There were three women and four men, with an average age of 41 years. Injury resulted from motor vehicle crashes (n = 4), motorcycle crash (n = 1), fall (n = 1), and other accident (n = 1). All patients were previously treated with conventional techniques (average, 3.6 procedures and 11 years from initial injury) and prolonged antibiotic therapy without resolution of symptoms. Definitive treatment included radical debridement and obliteration with a free fibula flap in a single stage. All flaps survived and resulted in complete sinonasal separation and eradication of infection. There were no donor-site or frontal sinus complications. CONCLUSIONS: Radical debridement, meticulous removal of the tenacious sinus mucosa, and reconstruction with a free fibular flap in a single stage is a superb choice for eliminating persistent infectious complications associated with frontal sinus fractures in patients who have failed conventional management. The fibular flap provides a secure horizontal buttress, seals the nasofrontal outflow tract with vascularized muscle, and obliterates dead space.

Endothelial progenitor cells (EPC) are involved in many healing processes in cardiovascular diseases and can be found in spontaneously resolving venous thrombi. The purpose of the present study was to investigate whether the therapeutic administration of EPC might enhance the resolution of venous thrombi. For this purpose, venous thrombosis was induced in the infrarenal inferior vena cava (IVC) in 28 athymic nude rats. Culture expanded EPC derived from human peripheral blood mononuclear cells were injected intravenously two and four days after thrombus induction. Recanalisation of the IVC and thrombus organisation were assessed by laser Doppler measurements of the blood flow and immunohistochemical detection of endothelialised luminal structures in the thrombus. EPC transplantation resulted in significantly enhanced thrombus neovascularisation (capillary density: 186.6 +/- 26.7/HPF vs. 78 +/- 12.3/HPF, p<0.01; area covered by capillaries: 8.9 +/- 1.7 microm(2) vs. 2.5 +/- 1.3 microm(2), p<0.01) and was accompanied by a substantial increase in intra-thrombus blood flow (perfusion ratio: 0.7 +/- 0.07 vs. 0.3 +/- 0.08, p<0.02). These results were paralleled by augmented macrophage recruitment into resolving thrombi in the animals treated with EPC (39.4 +/- 4.7/HPF vs. 11.6 +/- 1.9/HPF, p<0.01). Our data suggest that EPC transplantation might be of clinical value to facilitate venous thrombus resolution in cases where current therapeutic options have limited success