Faculty Bibliography

We report an unusual manifestation of penetrating facial trauma. It was suffered by a recreational fly fisherman who was hiking away from a casting spot when he fell and was impaled by a section of his graphite flyrod. The circumstances of his injury, its clinical manifestations, and its imaging findings are discussed. Emergency physicians and radiologists should be aware of the computed tomography appearance of impaled foreign bodies and their capability to penetrate deeply to reach critical vascular and neurologic structures. The role of imaging in penetrating trauma to the face and skull base for guiding appropriate intervention is emphasized.

The face distinguishes one human being from another. When the face is disfigured because of trauma, tumor removal, congenital anomalies, or chronic diseases, the patient has a strong desire for functional and esthetic restoration. Current practice of facial reconstruction using autologous grafts, synthetic fillers, and prostheses is frequently below the surgeon's and patient's expectations. Facial reconstruction is yet to take advantage of recent advances in seemingly unrelated fields of stem cell biology, chemical engineering, biomaterials, and tissue engineering. "Biosurgery," a new concept that we propose, will incorporate novel principles and strategies of bioactive cues, biopolymers, and/or cells to restore facial defects. Small facial defects can likely be reconstructed by cell homing and without cell transplantation. A critical advantage of cell homing is that agilely recruited endogenous cells have the potential to harness the host's innate capacity for regeneration, thus accelerating the rate of regulatory and commercialization processes for product development. Large facial defects, however, may not be restorable without cell delivery per our understanding at this time. New breakthrough in biosurgery will likely originate from integrated strategies of cell biology, cytokine biology, chemical engineering, biomaterials, and tissue engineering. Regardless of cell homing or cell delivery approaches, biosurgery not only will minimize surgical trauma and repetitive procedures, but also produce long-lasting results. At the same time, caution must be exercised against the development of products that lack scientific basis or dogmatic combination of cells, biomaterials, and biomolecules. Together, scientifically derived biosurgery will undoubtedly develop into new technologies that offer increasingly natural reconstruction and/or augmentation of the face.

Current autologous fat grafting technique suffers from the drawbacks of donor site morbidity and, more importantly, significant resorption of the grafted fat. Adipose tissue engineering using adult human stem cells has been found to overcome the shortcomings of autologous fat grafting in reconstructing facial defects. Mesenchymal stem cells that can self-renew and differentiate into mature adipocytes have been used to generate adipose tissue, in both in vitro and in vivo cell transplantation studies. However, long-term maintenance of the shape and dimension of the produced adipose tissue remains a challenge, even in tissue engineering with cell transplantation. The choice of appropriate scaffolds to promote stem cell adhesion, proliferation, and differentiation is essential for successful adipogenesis. Recent advances in nanotechnology allow the development of nanostructured scaffolds with a cellular environment that maximally enhances not only cell expansion but also the neovascularization that is crucial for long-term maintenance of cell volume. Cell homing is a technique that actively recruits endogenous host stem cells into a predefined anatomic location for the desired tissue generation. Bypassing ex vivo cell manipulation, the cell homing technique eliminates donor site morbidity and rejection, reducing the regulation issue in clinical translation. Mao et al. introduced the concept of biosurgery, which combined nanostructured scaffolds and growth factor biocues, with or without cell transplantation, for successful de novo adipogenesis in restoring facial defects. Important questions, such as the necessity of cell transplantation in scaling up the size of engineered adipose tissue, need to be answered with further studies. However, the era of biosurgery replacing conventional treatments such as biologically inactive filler injections and alloplastic implants appears to be in the near future.

Sir William Robert Willis Wilde (1815-1876) made many contributions to otology. Perhaps his greatest, and the one least appreciated, was his performing, analyzing, and reporting of the 1851 census of the deaf of Ireland. He is the first to recognize and document genetic deafness as a major cause in early-onset deafness. His census techniques used trained enumerators, and for each family suspected as having a deaf person, a physician was sent who, before obtaining the very detailed family and medical history, was required to obtain an informed consent. Wilde's career is analyzed to show how his previous publications led to his appointment in 1850 as the only Assistant Medical Census Commissioner for the 1851 census.

Osteoradionecrosis (ORN) of the mandible is a significant complication of radiation therapy for head and neck cancer. In this condition, bone within the radiation field becomes devitalized and exposed through the overlying skin or mucosa, persisting as a non-healing wound for three months or more. In 1926, Ewing first recognized the bone changes associated with radiation therapy and described them as "radiation osteitis". In 1983, Marx proposed the first staging system for ORN that also served as a treatment protocol. This protocol advocated that patients whose disease progressed following conservative therapy (hyperbaric oxygen (HBO), local wound care, debridement) were advanced to a radical resection with a staged reconstruction utilizing a non-vascularized bone graft. Since the introduction of Marx's protocol, there have been advances in surgical techniques (i.e. microvascular surgery), as well as in imaging techniques, which have significantly impacted on the diagnosis and management of ORN. High resolution CT scans and orthopantamograms have become a key component in evaluating and staging ORN, prior to formulating a treatment plan. Patients can now be stratified based on imaging and clinical findings, and treatment can be determined based on the stage of disease, rather than determining the stage of disease based on a patient's response to a standardized treatment protocol. Reconstructions are now routinely performed immediately after resection of the diseased tissue rather than in a staged fashion. Furthermore, the transfer of well-vascularized hard and soft tissue using microvascular surgery have brought the utility of HBO treatment in advanced ORN into question.

Reconstruction of the mandible has evolved significantly over the last 40years. Early attempts were often disfiguring and wrought with complications but with the introduction of free tissue transfer of well vascularized bone in the 1970's there was a significant improvement in outcomes. In recent years the harvest, inset, and microvascular anatomosis have been refined to the point that success rates are reported as high as 99% throughout the literature. Focus has now shifted to optimizing functional and aesthetic outcomes after mandible reconstruction. This paper will be a review defect classification, goals of reconstruction, the various donor sites, dental rehabilitation, new advances, and persistent problems. Reconstruction of segmental mandibular defects after ablative surgery is best accomplished using free tissue transfer to restore mandibular continuity and function. Reestablishing occlusion and optimizing tongue mobility are important to post-operative oral function. Persistent problems in oro-mandibular reconstruction relate to the effects of radiation treatment on the native tissue and include xerostomia, dysgeusia, osteoradionecrosis and trismus. These problems continue to plague the oral cancer patient despite the significant advances that allow a far more complete functional restoration than could be accomplished a mere two decades ago.