Faculty Bibliography

BACKGROUND: The superficial temporal fascia merits its popularity in reconstructive surgery for its large number of clinical applications. In this report, the authors present their experience with different uses of the superficial temporal fascial flap in facial reanimation. METHODS: Seventeen cases are presented. In 10 patients, the fascial flap provided a vascularized lining at the interface between the free muscle flap for smile restoration and the overlying skin. In six cases, it was utilized to correct small or moderate contour deficits in the paretic hemiface, using either the fascial flap alone or in combination with free adipose tissue. One patient presented with facial paralysis and Frey syndrome following parotidectomy, and the fascial flap was used to control gustatory sweating. Five independent observers graded aesthetic and functional outcomes on a scale from poor to excellent. Three patients were lost to follow-up, so 14 cases were evaluated. RESULTS: Follow-up ranged from 1 to 216 months (47 +/- 60.49 months). The specific reconstructive goal for each patient was achieved and the overall symmetry was greatly improved, with all patients being granted higher scores by the panel of observers following the superficial fascia flap (Wilcoxon matched-pairs signed ranks, p < 0.0001). Transient or permanent alopecia along the temporal incision was the main complication observed. CONCLUSIONS: Transfer of the superficial temporal fascia flap is a valuable technique with several potential applications in facial paralysis management and reconstructive surgery in general. The advantages of this highly vascularized, gliding, and pliable flap far outweigh the associated minimal complications

BACKGROUND: Frontal sinus fracture treatment strategies lack statistical power. The authors propose statistically valid treatment protocols for frontal sinus fracture based on injury pattern, nasofrontal outflow tract injury, and complication(s). METHODS: An institutional review board-approved retrospective review was conducted on frontal sinus fracture patients from 1979 to 2005. Fractures were categorized by location, displacement, comminution, and nasofrontal outflow tract injury. Demographic data, treatment, and complications were compiled. RESULTS: One thousand ninety-seven frontal sinus fracture patients were identified; 87 died and 153 were excluded because of insufficient data, leaving a cohort of 857 patients. The most common injury was simultaneous displaced anteroposterior walls (38.4 percent). Nasofrontal outflow tract injury constituted the majority (70.7 percent), with 67 percent having a diagnosis of obstruction. Of the 857 patients, 504 (58.8 percent) underwent surgery, with a 10.4 percent complication rate; and 353 were observed, with a 3.1 percent complication rate. All complications except one involved nasofrontal outflow tract injury (98.5 percent). Nasofrontal outflow tract injuries with obstruction were best managed by obliteration or cranialization (complication rates: 9 and 10 percent, respectively). Fat obliteration and osteoneogenesis had the highest complication rates (22 and 42.9 percent, respectively). The authors' treatment algorithm provides a receiver operating characteristic area under the curve of 0.8621. CONCLUSIONS: A frontal sinus fracture treatment algorithm is proposed and statistically validated. Nasofrontal outflow tract involvement with obstruction is best managed by obliteration or cranialization. Osteoneogenesis and fat obliteration are associated with unacceptable complication rates. Observation is safe when the nasofrontal outflow tract is intact.

BACKGROUND: In obstetrical brachial plexus palsy, suprascapular nerve reinnervation is a priority. For the most favorable outcomes in shoulder function, it is the authors' policy to also reconstruct the axillary nerve with intraplexus donors to the posterior cord (early cases) or directly with intraplexus or extraplexus motor donors (late cases). METHODS: Between 1979 and 2003, 80 consecutive patients (82 brachial plexuses) underwent plexus exploration and nerve reconstruction for obstetrical palsy. Axillary nerve reconstruction was performed in 60 plexuses, and evaluation of the results was carried out for 55 patients (56 plexuses) with adequate follow-up (mean follow-up, 6.5 years). RESULTS: Overall, there were good and excellent results (>/=M3+) in 49 of 56 plexuses (87.5 percent) for the deltoid muscle, and the average postoperative muscle grade for the deltoid was 3.89 +/- 0.79. The average shoulder abduction increased from 35 +/- 31 degrees preoperatively to 109 +/- 35 degrees postoperatively (average gain, 74 degrees), and the average external rotation increased from -13 +/- 28 degrees preoperatively to 47 +/- 18 degrees postoperatively (average gain, 60 degrees). The timing of surgery and the type of paralysis significantly influenced the final outcome. CONCLUSIONS: Reconstruction of the axillary nerve should always be performed to maximize the final outcome of shoulder function in obstetrical brachial plexus patients. The best results were seen in early cases (</=3 months), where the posterior cord was reconstructed from intraplexus donors. In late cases, reconstruction of the axillary nerve directly from the intercostal nerves could be a reliable option

Although clinical studies have identified scarring/fibrosis as significant risk factors for lymphedema, the mechanisms by which lymphatic repair is impaired remain unknown. Transforming growth factor -beta1 (TGF-beta1) is a critical regulator of tissue fibrosis/scarring and may therefore also play a role in the regulation of lymphatic regeneration. The purpose of this study was therefore to assess the role of TGF-beta1 on scarring/fibrosis and lymphatic regeneration in a mouse tail model. Acute lymphedema was induced in mouse tails by full-thickness skin excision and lymphatic ligation. TGF-beta1 expression and scarring were modulated by repairing the wounds with or without a topical collagen gel. Lymphatic function and histological analyses were performed at various time points. Finally, the effects of TGF-beta1 on lymphatic endothelial cells (LECs) in vitro were evaluated. As a result, the wound repair with collagen gel significantly reduced the expression of TGF-beta1, decreased scarring/fibrosis, and significantly accelerated lymphatic regeneration. The addition of recombinant TGF-beta1 to the collagen gel negated these effects. The improved lymphatic regeneration secondary to TGF-beta1 inhibition was associated with increased infiltration and proliferation of LECs and macrophages. TGF-beta1 caused a dose-dependent significant decrease in cellular proliferation and tubule formation of isolated LECs without changes in the expression of VEGF-C/D. Finally, the increased expression of TGF-beta1 during wound repair resulted in lymphatic fibrosis and the coexpression of alpha-smooth muscle actin and lymphatic vessel endothelial receptor-1 in regenerated lymphatics. In conclusion, the inhibition of TGF-beta1 expression significantly accelerates lymphatic regeneration during wound healing. An increased TGF-beta1 expression inhibits LEC proliferation and function and promotes lymphatic fibrosis. These findings imply that the clinical interventions that diminish TGF-beta1 expression may be useful in promoting more rapid lymphatic regeneration.

BACKGROUND: A number of breast reduction techniques have been developed over the years, but debate over which technique is better for patients continues to grow. The authors' goal was to survey members of the American Society of Plastic Surgeons to identify their preferences and practices and report their opinion regarding issues related to the various breast reduction techniques. METHODS: In the fall of 2006, a one-page anonymous survey was sent to 5112 plastic surgeons who were members of the American Society of Plastic Surgeons. A follow-up survey was sent 2 weeks after the first mailing as a friendly reminder. The questionnaires were then collected over a 6-week period. RESULTS: Of the 5112 plastic surgeons surveyed, 2665 (52 percent) responded to the survey. The majority of the respondents (69 percent) use the inferior pedicle breast reduction technique. Ninety-two percent of the respondents use intraoperative deep venous thrombosis prophylaxis. Sixty-one percent of respondents performed over 75 percent of their cases on an outpatient basis and 97 percent of respondents use general anesthesia. Ninety-three percent of the respondents use preoperative antibiotics. Over 70 percent of the respondents do not think breast reduction should be a cosmetic procedure. CONCLUSIONS: In conclusion, the inferior pedicle technique has traditionally been the procedure of choice and remains so today. However, there has been an increase in the use of the newer techniques. Plastic surgeons are becoming more cognizant of the risk of deep venous thrombosis among their patients. The majority of breast reductions are now performed as outpatient procedures

In the current study, a retrospective review of 56 patients with posttraumatic root avulsion brachial plexus injuries who underwent contralateral C7 transfer using the selective contralateral C7 technique is presented. The intraoperative findings of the involved brachial plexus, the surgical technique of preparation of the donor C7 nerve root, and the various neurotization procedures are reported. The surgical outcomes as well as the potential adverse effects of the procedure are analyzed. We conclude from this study that the selective contralateral C7 technique is a safe procedure that can be applied successfully for simultaneous reconstruction of several different contralateral muscle targets or for neurotization of cross chest nerve grafts for future free muscle transplantation

The goal of interprofessional education (IPE) is to bring various professional groups together in the educational environment to promote collaborative practice and improve the health care of patients. Interest in IPE has been sparked by several factors in the health care system, including the increased awareness of oral-systemic connections, an aging population, the shift of the burden of illness from acute to chronic care, and lack of access to basic oral care. Increasingly, since the publication of the U.S. surgeon general's report in 2000, the dialogue surrounding IPE in dentistry has escalated. But how has dentistry changed regarding IPE since the report was released? This position paper argues that little has changed in the way dental students are taught and prepared to participate in IPE. The authors contend that academic dentistry and organized dentistry must take the lead in initiating and demanding IPE if dental students are to be prepared to work in the health care environment of the twenty-first century. Included are reasons why IPE is necessary and why dentistry must lead the conversation and participate in the solution to the oral health care crisis. It explores existing models and alternate approaches to IPE, barriers to implementation, and proposed strategies for academic institutions

The current approach to breast reconstruction remains largely subjective and is based on physical examination and visual-estimates of breast size. Thus, the overall success of breast reconstruction is limited by the inability of plastic surgeons to objectively assess breast volume and shape, which may result in suboptimal outcomes. A potential solution to this obstacle may be three-dimensional (3D) imaging, which can provide unique clinical data that was previously unattainable to plastic surgeons. The following study represents a prospective analysis of patient volunteers undergoing unilateral tissue expander (TE)-implant reconstruction by one of the two senior authors (MC, NSK). All patients underwent unilateral mastectomy with immediate or delayed insertion of a TE, followed by an exchange for a permanent silicone or saline implant. 3D scans were obtained during routine pre- and postoperative office visits. The 3D breast-volume calculations served as a guide for surgical management. Twelve patients have completed 3D-assisted unilateral breast reconstruction to date. These patients represent a wide range of body habitus and breast size/shape; 3D volume range from 136 to 518 cm(3). The mean baseline breast asymmetry in this group was 12.0 +/- 10.8%. Contralateral symmetry procedures were performed in eleven patients, consisting of the following: mastopexy (n = 6), augmentation (n = 1), mastopexy/augmentation (n = 2), and reduction mammoplasty (n = 2). Reconstruction was completed in a total number of 2 (n = 10) or 3 (n = 2) operations. Overall breast symmetry improved at the completion of reconstruction in the majority of patients, with an average postoperative symmetry of 95.1 +/- 4.4% (relative to 88% preoperatively). 3D imaging serves a valuable adjunct to TE-implant breast reconstruction. This technology provides volumetric data that can help guide breast reconstruction, such as in choosing the initial TE size, total volume of expansion, and final implant size/shape. 3D imaging technology also provides benefit as a method for assessing tissue expansion, the need for symmetry or revision procedures, and critically analyzing the final reconstructive outcome

The hedgehog family of morphogens (sonic [Shh], Indian, and desert hedgehog) are central regulators of embryologic growth and tissue patterning. Although recent work implicates Shh in postnatal tissue repair and development, conclusive evidence is lacking. Here, we demonstrated the importance of Shh in wound repair, by examining the effects of cyclopamine, a specific inhibitor of the Shh signaling cascade, on tissue repair. Using a murine-splinted excisional wound model, which attenuates wound contraction in this loose-skinned rodent, we established that, by all measures (wound closure, epithelialization, granulation formation, vascularity, and proliferation), wound healing was profoundly impaired when Shh signaling was disrupted. Because embryonic disruption of Shh is associated with distinct phenotypic defects, our findings invite investigation of the potential role of Shh signaling under postnatal conditions associated with disregulated wound healing