Faculty Bibliography

Chronic wounds such as diabetic foot ulcers, venous ulcers, and pressure ulcers are a major source of morbidity and mortality. To describe wound characteristics associated with a wound emergency, the Wound Electronic Medical Records (WEMR) of 200 consecutive admissions (139 patients, average number of admissions 1.4) to a dedicated inpatient wound healing unit over a period of 5 months were retrospectively reviewed. Patient mean age was 62 +/- 16 years, 59% were men, 27% had a foot ulcer and diabetes mellitus, and 29% had venous ulcers. Presenting signs and symptoms included wound pain, cellulitis, nonpurulent drainage, and undermining, but few presented with classic local clinical signs of infection. Treatment consisted of sharp debridement with deep tissue culture and pathology from the wound base and/or systemic antibiotics. Twenty-percent (20%) of patients had pathology-confirmed and 38% had pathology- or radiology-confirmed osteomyelitis on admission, supporting that new or increasing wound pain, cellulitis, and/or nonpurulent drainage or presence of significant undermining may be indicative of an invasive infection and that patients presenting with these signs and symptoms require an immediate treatment plan and consideration of hospital admission. Use of an objective documentation system such as the WEMR may help alert clinicians to subtle wound changes that require aggressive treatment; thereby, avoiding emergency room visits and hospital admissions. Future research is needed utilizing the WEMR across multiple medical centers to further define criteria for a chronic wound emergency

OBJECTIVE: The purpose of this study was to determine the microtensile bond strength of various resin composite/adhesive systems to alumina particle abraded Ti-6Al-4V substrate after aging for 24h, 10 days, and 30 days in distilled water at 37 degrees C. METHODS: Four laboratory resin composite veneering systems (Gradia, GR; Solidex, SOL; Ceramage, CER; and Sinfony, SF) were bonded to 25 mm diameter machined disks of Ti-6Al-4V with their respective adhesive and methodology, according to the manufacturer's instructions. Microtensile bars of approximate dimensions 1 mm x 1 mm x 6 mm were prepared for each resin composite/adhesive system. After cutting, groups (n=12) from each adhesive system were separated and either stored in water at 37 degrees C for 24h (baseline) or aged for 10 or 30 days prior to loading to failure under tension at a cross head speed of 1.0mm/min. Failure modes were determined by means of scanning electron microscopy (SEM). Statistical analysis was performed through one-way ANOVA and Tukey's test at 95% level of significance. RESULTS: Significant variation in microtensile bond strength was observed for the different systems and aging times. SOL and GR showed the highest mean bond strength values followed by SF and CER at baseline. Aging specimens in water had an adverse effect on bond strength for SOL and CER but not for the SF and GR groups. SIGNIFICANCE: In vitro bond strength of laboratory resin composites to Ti-6Al-4V suggests that strong bonds can be achieved and are stable for certain systems, making them useful as an alternative for esthetic fixed prosthetic restorations

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.

PURPOSE: This article focuses on the use of tissue-engineering techniques for the reconstruction of bone defects in the maxillofacial region. METHODS AND RESULTS: A comprehensive and critical analysis of the literature showed that tissue-engineering procedures are effective in both animal studies and clinical case series. At the same time, it is clear that much work remains before these techniques can be used routinely in the clinical situation. CONCLUSION: This review highlights areas that require further investigation, and proposes several solutions to make tissue-engineering procedures available for maxillofacial reconstruction in the near future.

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.

Laryngopharyngeal oncologic resections produce complex reconstructive problems, requiring dependable robust flaps to restore form and function. Current options include morbid local-regional flaps or free tissue transfers. The supraclavicular artery flap (SAF) offers a great new option. Partial pharyngeal oncologic defects were reconstructed with pedicled SAFs. Handheld Doppler probes marked the pedicle preoperatively. Flaps were design based upon the dopplered vascular anatomy. Complications and functional outcomes were assessed. All flaps (n = 6) were harvested in under 1 hour with uneventful postoperative recoveries. Ablative wounds and donor sites were closed primarily. Two patients had small controlled leaks because of preoperative radiation and overly aggressive oral intakes, that subsequently resolved. There were no functional donor site morbidities. We describe a novel application of the SAF for pharyngeal reconstructions after laryngopharyngeal cancer ablation. This thin, reliable, easy to harvest, low morbidity flap is an excellent reconstructive option for pharyngeal reconstructions.

Immediate implant-based breast mound reconstruction offers many advantages over staged implant reconstruction techniques. For large volume breast reconstruction, a Wise-pattern skin resection may provide very good aesthetic results; however, the submuscular implant pocket is inadequate to cover the inferior pole of the breast. In this patient population, the risk of implant exposure from T-point breakdown is significant. We present our technique of Wise-pattern breast reconstruction using AlloDerm (LifeCell, Branchburg, NJ) and a vascularized dermal-subcutaneous pedicle (DSP) to augment the volume and quality of immediate breast implant coverage, particularly in the area of the T-point suture lines. We reviewed a series of 20 consecutive patients with large breasts who were treated with an immediate implant reconstruction of greater than 400 mL volume using the Wise-pattern with DSP. Preoperative and postoperative 3-dimensional surface scan studies were performed to evaluate breast symmetry. The average volume of breast reconstruction in this study group was 458 mL. T-point breakdown occurred in 5 patients (25%). These patients were treated with local wound care and healed with an excellent aesthetic result. None of these patients required implant removal, implant exchange, or operative debridement. Pre- and postoperative 3-dimensional surface scan analysis of these patients demonstrated comparable differences between the affected and unaffected sides in women undergoing immediate breast implant reconstruction when compared with a matched group of patients undergoing 2-stage breast reconstruction with tissue expanders. Wise-pattern skin-reducing mastectomy is an excellent strategy to provide an aesthetically pleasing, immediate implant breast reconstruction. This technique provides breast symmetry that is at least comparable to that of tissue expander-based, staged implant reconstructions. The reliability of the Wise-pattern technique is significantly improved with the addition of AlloDerm to the muscular pocket and a vascularized DSP to preserve the integrity of the reconstruction in the presence of T-point breakdown

Despite the clinical relevance of bottoming out, or pseudoptosis, associated with reduction mammaplasty (RM) its evaluation remains an imprecise science. This study aims to further define the kinetics of postoperative pseudoptosis over an extended period of time, after our previous study investigating pseudoptosis in the early postoperative period. Patients undergoing medial pedicle RM had 3-dimensional photographs taken at year 1 and year 2 intervals postoperatively (year 1 = 300-450 days; year 2 = 700-900 days). Bottoming out was assessed with various 3-dimensional parameters. The total breast volume and the percent tissue distribution in the upper pole of the breast did not change from year 1 to year 2. The anterior-posterior projection as well as vector measurements for internipple distance and sternal notch to nipple distance also remained stable from year 1 to year 2. Although previous data from our group documented the occurrence of bottoming out and continued size reduction over the first postoperative year after breast reduction, the present study shows that pseudoptosis does not seem to occur during the second postoperative year

Breast augmentation is one of the most common plastic surgery procedures performed in the United States today. Evaluation of postoperative results lacks true objective measurements. The following study reports the application of 3-dimensional (3D) photography to document changes that occur in breast morphology after breast augmentation. Patients undergoing augmentation mammaplasty with a periareolar incision were offered pre- and postoperative 3D photographs. 3D models were constructed and the following parameters were assessed: maximum anterior-posterior projection from the chest wall, angle of breast projection, total breast volume, volumetric tissue distribution in the superior and inferior poles, and surface and vector distance measurements to key landmarks. A completed series of 3D images were obtained from 14 augmentation patients (28 breasts) at an average postoperative day of 143. Saline and silicone implants were used equally (n = 14 for each). Total volume of the breast changed in correlation with the implant size (1.9% difference, P = 0.83). There were no significant changes in the volumetric distribution within the upper and lower poles of the breasts noted between pre- and postoperative scans (P = 0.81). The internal angle of breast projection was found to increase (13.6 degrees, P < 0.01), as did the sternal notch to nipple distance (11 mm, P = 0.018). Anterior-posterior projection significantly increased by 23.3 mm. However, this increase in projection was 20.9% less than expected based on implant dimensions (72.7-58.7 mm, respectively, P < 0.01). This study documents objective changes in breast morphology after augmentation mammaplasty. 3D imaging scans were able to document true changes that occur with breast augmentation including breast volume, the increase in the internal angle of the breast projection, and the sternal notch to nipple distance. 3D photography further highlighted that breast augmentation results in less than expected anterior-posterior projection, possibly due to tissue attenuation occurring anterior to the implant