Faculty Bibliography

Introduction: Synmastia is a condition in which the breasts are conjoint and the natural intermammary sulcus is obliterated. It is the rarest type of breast implant malpositioning during breast augmentation; however, it is the most difficult one to correct. AlloDerm is an acellular dermal matrix that is assuming a major role in immediate breast reconstruction in recent years. Methods: In the past 2 years, we have treated 3 thin women, a total of 6 breasts, for correction of synmastia after bilateral immediate breast reconstruction, using tissue expanders and skin sparing mastectomy. All of them suffered from synmastia, which manifested immediately after the mastectomy and accelerated during tissue expander inflation. We exchanged the expander into silicone implants, and during the same procedure we corrected the synmastia, using an AlloDerm sling. A thick sheet of AlloDerm (Life-Cell Corp, Branchbung, NJ) is used and the AlloDerm sheet is designed into a long narrow sling. Then, the sling is sutured into place. Results: This technique successfully resolved the synmastia. Conclusion: The use of an AlloDerm sling to reinforce the capsule and the AlloDerm incorporation into it ensures a sound solution with a low recurrence rate.

BACKGROUND: Transverse maxillary hypoplasia, with or without cleft deformity, is typically treated with orthodontic expansion. However, the management of those patients who present later in life with severe uncorrected deformities or who have failed prior orthodontic care remains controversial. Tooth-borne palatal expanders have limitations in this subset of patients with scarred, constricted cleft palate. In this study, we assess the efficacy and safety of using a bone-borne palatal distraction device as an alternative treatment for this difficult subset of patients. METHODS: Older children with a constricted maxilla who previously had unilateral or bilateral cleft lip and palate repairs and failed orthodontic expansion were included in the study (n = 15). Patients underwent Le Fort I corticotomy with placement of the bone-borne distraction device, expansion at a rate of 0.5 mm/d, and subsequent alveolar bone grafting. Preoperative and follow-up maxillary impressions were compared with assessed improvements in intermolar distance, intercanine distance, alveolar cleft width, and total palatal area. In addition, a small group of noncleft patients with constricted maxillas was treated with bone-borne palatal distraction without a corticotomy (n = 4). RESULTS: The mean amount of distraction in all patients was 14.1 mm, with a follow-up period of 19 months (range, 8-30 months). The average increase in intermolar distance was 8.4 mm, intercanine distance increased by an average of 9.5 mm, and palate surface areas were increased by a mean of 28.9 mm2. Relapse was between 4% and 7%, and all patients underwent subsequent alveolar bone grafting. In addition, the noncleft patients successfully underwent bone-borne palatal distraction without a corticotomy, with a 4% to 5% relapse. CONCLUSION: Rapid palatal expansion using a bone-borne distraction device in cleft patients with transverse maxillary hypoplasia who have failed nonsurgical orthodontic expansion provides adequate expansion necessary for alveolar bone grafting and stable results.

Trauma continues to be a large source of poor outcomes for patients in the United States. While clinical guise is very important in the acute setting, objective physical data is becoming increasingly important in the diagnosis of many injuries sustained during trauma. Radiography has always been the primary diagnostic modality applied in trauma situations but it continues to be a time-consuming and unwieldy part of the acute resuscitation of the patient. The novel use of the Lodox Statscan (Lodox Systems (Pty), Ltd., Benmore, South Africa), a type of digital radiography, as a means to help combat these problems was evaluated at Creighton University Medical Center, Omaha, Nebraska. This new machine uses a linear beam technology to scan the entire body in 13 seconds. Here, we describe this digital radiography system, its introductory use in the trauma bay, and discuss cases where it has proven valuable. Based upon our preliminary experience, the use of the device in large centers shows promise for improving morbidity and mortality outcomes in trauma patients.

Marine reserves have been advocated worldwide as conservation and fishery management tools. It is argued that they can protect ecosystems and also benefit fisheries via density-dependent spillover of adults and enhanced larval dispersal into fishing areas. However, while evidence has shown that marine reserves can meet conservation targets, their effects on fisheries are less understood. In particular, the basic question of if and over what temporal and spatial scales reserves can benefit fished populations via larval dispersal remains unanswered. We tested predictions of a larval transport model for a marine reserve network in the Gulf of California, Mexico, via field oceanography and repeated density counts of recently settled juvenile commercial mollusks before and after reserve establishment. We show that local retention of larvae within a reserve network can take place with enhanced, but spatially-explicit, recruitment to local fisheries. Enhancement occurred rapidly (2 yrs), with up to a three-fold increase in density of juveniles found in fished areas at the downstream edge of the reserve network, but other fishing areas within the network were unaffected. These findings were consistent with our model predictions. Our findings underscore the potential benefits of protecting larval sources and show that enhancement in recruitment can be manifested rapidly. However, benefits can be markedly variable within a local seascape. Hence, effects of marine reserve networks, positive or negative, may be overlooked when only focusing on overall responses and not considering finer spatially-explicit responses within a reserve network and its adjacent fishing grounds. Our results therefore call for future research on marine reserves that addresses this variability in order to help frame appropriate scenarios for the spatial management scales of interest.

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.

Perforator flap breast reconstruction is an accepted surgical option for breast cancer patients electing to restore their body image after mastectomy. Since the introduction of the deep inferior epigastric perforator flap, microsurgical techniques have evolved to support a 99 percent success rate for a variety of flaps with donor sites that include the abdomen, buttock, thigh, and trunk. Recent experience highlights the perforator flap as a proven solution for patients who have experienced failed breast implant-based reconstructions or those requiring irradiation. Current trends suggest an application of these techniques in patients previously felt to be unacceptable surgical candidates with a focus on safety, aesthetics, and increased sensitization. Future challenges include the propagation of these reconstructive techniques into the hands of future plastic surgeons with a focus on the development of septocutaneous flaps and vascularized lymph node transfers for the treatment of lymphedema.

OBJECTIVE: This study was designed to compare the bone healing process around plateau root from (PRF) and screw root from (SRF) titanium dental implants over the immediate 12 week healing period post implant placement. MATERIAL AND METHODS: 32PRF and 32SRF implants were placed in 8 beagle dogs at 12, 8, 5 and 3 weeks prior to enthanisation using a bilaterally balanced distribution. Undecalcified ground sections were prepared from the biopsies taken and histometric measurements of bone implant contact (BIC) and bone area fraction occupancy (BAFO) were made on the middle 5 mm portion of each 8 mm implant root length. RESULTS: The analysis showed that although measurements of bone to implant contact (BIC) and bone area fraction occupancy (BAFO) tended to be greater for the SRF implants at all four time points, the differences in measurements between implant types did not reach statistical significance (P=0.07, P=0.06). The effect of time on BIC and BAFO was found to be strongly significant for both implant types thus indicating a statistically significant increase in BIC and BAFO overall with time (P=0.004, P=0.002). Furthermore, both PRF and SRF implants behaved similarly over time with measurements of BIC and BAFO progressing in parallel. Histomorphologic analysis of these sections demonstrated the prominent role of woven bone (callus) in the bone healing process around PRF implants. CONCLUSION: The results can be interpreted to indicate a comparable development of secondary stability for both PRF and SRF implant designs. However, as these parameters reflect the structural connection between implant and bone and not the functional properties of the bone to implant interface, they cannot be regarded as comprehensive measures of osseointegration. This particularly relevant given the reduced load bearing capacity of woven bone.

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

Impaired repair of skin defects is a major complication of diabetes; yet, the pathophysiology of diabetic (db) wound healing remains largely opaque. Here, we investigate the role of humoral factors in modulating db wound repair by generating chimeric animals through parabiotic joining of wild-type (wt) and diabetic (db/db) mice. This strategy allows wounds on healing-deficient db/db mice to be exposed to factors derived from the wt circulation at physiologically appropriate concentrations. When compared with db controls, chimeric db/db animals showed significantly improved healing of full-thickness, cutaneous wounds, with enhanced granulation tissue formation, angiogenesis, cell proliferation, and collagen deposition. Glycemic control was unaffected by parabiosis; however, the distribution of circulating leukocytes, altered in db controls, normalized in db-chimeras. Both wt and db cells were recruited from circulation into db wounds, but wt cells never exceeded 20% of total cells. Improved angiogenesis persisted in db-chimeras separated 24 hours after wounding, suggesting the existence of long-term normalizing factors. This study establishes a new model for studying db wound healing, and shows a key role for circulating factors in normalizing wound repair in diabetes.