Faculty Bibliography

Drawbacks to conventional Le Fort III osteotomy include bleeding, infection, relapse, and scar at the coronal incision. We performed an endoscopically assisted Le Fort III osteotomy with an ultrasonic scalpel in cadavers to develop a new technique that minimizes such complications. Endoscopically assisted Le Fort III osteotomy was performed in 3 fresh, adult human cadavers. Access incisions included the transconjunctival lower lid with lateral canthotomy, the lateral upper gingivobuccal sulcus, and a stab incision in the medial aspect of the upper eyelid. Osteotomies at the zygomaticofrontal suture, the lateral orbital wall, the orbital floor, and the medial orbital wall were carried out with an ultrasonic scalpel under direct and endoscopic visualization from the trasconjunctival incision. The zygomatic arch and the pterygomaxillary region were osteotomized via the upper gingivobuccal sulcus incisions. The nasofrontal junction and the septum were accessed and cut via a stab incision in the medial upper eyelids. Disimpaction was completed with minor digital pressure inferiorly.Each of the 3 Le Fort III osteotomies was complete, and mobility was checked by manual examination. There was a steep learning curve to the operation, but the final cadaver dissection took 99 minutes to complete. The ultrasonic scalpel provided for maximal ease in cutting bone and minimal disruption to adjacent soft tissues as judged by postoperative direct examination. This cadaver study demonstrates the feasibility of a minimally invasive, endoscopically assisted Le Fort III osteotomy using an ultrasonic scalpel. Further experimental work combined with refinements in technique and equipment will help bring this advancement into clinical application.

The endogenous peptide endothelin-1 (ET-1), originally identified as a potent vasoconstrictor, plays a role in a number of painful conditions. In this review article we discuss the mechanisms that are essential for local sensitization by subcutaneously administered ET-1, and report evidence of ET-1's ability to sensitize distant regions of the body, through the central nervous system and, likely, coupling through the spinal cord. In addition, we will review the latest information on the role of ET-1 in cancerous and non-cancerous conditions. Cancer pain has indeed been shown to be attenuated by antagonists of endothelin receptors, and ET-1 is known to be secreted by cancer cells of many different histologic types. Furthermore, a growing body of evidence links increased expression and secretion of ET-1 to the occurrence of non-cancer related pain syndromes, such as inflammatory and neuropathic pain syndromes.

The inferior gluteal artery perforator (IGAP) free flap represents an alternative technique for autogenous breast reconstruction in patients with insufficient abdominal donor tissue. Historically, patients underwent a staged approach for bilateral breast reconstruction with the IGAP because it is technically demanding and can be time consuming. The bilateral simultaneous IGAP can be performed effectively with 2 microsurgeons operating together. This is a retrospective study of 22 patients (44 flaps) who underwent bilateral breast reconstruction with bilateral IGAP flaps in one operation between January 2005 and December 2007. The following parameters were evaluated and compared to our published data with unilateral IGAP flap reconstruction: operating time, blood loss, flap weight, hospital length of stay, and perioperative complications. A follow-up patient survey was also conducted to gauge patient's satisfaction with the donor site and procedure. The flap survival rate was 100%. Complications included 1 patient with 1 flap with partial fat necrosis, 2 patients who required reoperation for venous congestion, 1 patient with a hematoma, 2 patients with delayed buttock wound healing, 2 patients requiring resuturing for buttock wound dehiscence, and 1 patient with resolved paresthesias. The majority of patients were satisfied with the procedure and donor site. In this study, we detail our experience with the inferior gluteal region as a reliable source of donor tissue and the simultaneous bilateral IGAP flap as an efficient method of breast reconstruction.

BACKGROUND: The technical success of facial composite tissue allotransplantation demands full understanding of superficial and deep perfusion for reliable microvascular transfer. Candidates with composite midface defects require an appreciation of the circulatory patterns to design a composite midface allotransplant. METHODS: External carotid vascular territories were evaluated in 10 cadavers to determine the reliability of facial soft-tissue flaps based on a single vascular pedicle. The right common carotid artery was injected with red latex and the left was injected with blue latex. Dual perfusion was confirmed by purple, following two-color mixing. Vascular pedicles included the superficial temporal, transverse facial, and facial arteries. In five additional cadavers, the midface segment was isolated by Le Fort III osteotomy after two-color latex injection with inclusion of the internal maxillary vascular pedicle. Cadavers were imaged with three-dimensional computed tomographic reconstructions following latex injection to confirm perfusion patterns. RESULTS: In soft-tissue facial flaps, unilateral carotid dominance was seen in the nasal dorsum and tip, confirming reliable supply by a single external carotid artery. In midface flaps, bilateral perfusion was seen in the maxilla. Ipsilateral perfusion was observed at the zygomaticomaxillary complex without any contralateral contribution. CONCLUSIONS: Dual soft-tissue perfusion was confirmed in most specimens at the nasal, central face, and maxilla. The inclusion of the maxilla in the design of a facial composite allotransplant demands bilateral vascular pedicles based on the internal maxillary arteries. The authors highlight a procurement strategy for design of such flaps.

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.

A 29-year-old woman with Freeman-Sheldon syndrome had a history of recurrent frontal sinus infections for which she underwent a 1-stage frontal sinus obliteration and cranioplasty using a free fibula osteocutaneous flap. This case is unique in that a free fibula flap had never been used to obliterate the frontal sinus in a patient with Freeman-Sheldon syndrome, nor had it been harvested from a limb with a clubfoot.