Faculty Bibliography

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.

BACKGROUND: The significance of the oral vestibule is often underappreciated in composite craniomaxillofacial reconstruction, and its deficiency results in considerable incompetence. Results of traditional vestibuloplasty techniques are unpredictable when the recipient bed is compromised in the setting of trauma or irradiation. The authors present an alternative approach for restoring the intractable oral vestibule with free tissue transfer. METHODS: An institutional review board-approved retrospective review of patients who underwent oral vestibular reconstruction was conducted at R Adams Cowley Shock Trauma Center and Johns Hopkins Hospital from 2002 to 2007. RESULTS: Thirteen patients were identified: six defects resulted from tumor extirpation, six resulted from traumatic injury, and one resulted from infection. There were eight men and five women, with a mean age of 46 years. Thirteen free tissue transfers of the oral vestibule were conducted: six ulnar forearm and seven anterolateral thigh perforator flaps. The average follow-up was 17 months. There were no flap failures and only one complication noted, which did not result in negative sequelae. The functional results were good, with all patients experiencing increased labial excursion and subjective improvement in the handling of food bolus and saliva. CONCLUSIONS: Preservation of oral vestibular height, width, and volume is essential for aesthetic appearance and functional competence. Free tissue transfer provides an innovative alternative in the management of the intractable and obliterated oral vestibule. It can be performed successfully, providing excellent results predictably.

PURPOSE: Mechanical analyses of idealized crown-cement-tooth systems through finite element analysis (FEA) has provided valuable insight concerning design parameters and materials that favor lower stress patterns. However, little information regarding variation of basic preparation guidelines in stress distribution has been available. The primary objective of this study was to evaluate maximum principal stresses on a molar crown veneer plus core system natural tooth configuration preparation with variations in the ratio of proximal axial length (PAL) to buccal axial length (BAL) as well as loading condition and position. MATERIALS AND METHODS: Three-dimensional models comprising a crown veneer (porcelain), crown core (zirconia), cement layer, and tooth preparation (4.2 mm BAL with PAL reductions of 0.8 mm, 1.0 mm, and 1.2 mm) yielding BAL:PAL ratios of 1.23, 1.31, and 1.4 were designed by computer software (Pro/Engineering). The models were imported into an FEA software (Pro/Mechanica), with all degrees of freedom constrained at the root surface of the tooth preparation. Each tooth preparation crown configuration was evaluated under a vertical (axial) 200 N load, and under a combined vertical 200 N and horizontal (buccally) 100 N load applied at different positions from the central fossa to the cusp tip. Maximum principal stress (MPS) was determined for the crown core for each crown BAL:PAL ratio, loading condition, and position. RESULTS: Under both vertical and combined loading conditions, the highest MPSs were located at the occlusal region and in the occlusogingival region of the ceramic core. MPS values increased in the proximal region as the BAL:PAL ratio increased. Combined loading resulted in a general increase in MPS compared to vertical loading. CONCLUSION: Increasing the BAL:PAL ratio (reducing the proximal axial length of the preparation) acted as a stress concentrator at regions near the crown margins, suggesting this area may be vulnerable to damage from fit adjustment as well as during function. Such increases in stress concentration should be considered in clinical scenarios, especially when inherent flaws are present in the material, since extensive high-magnitude tensile stress fields have been noted under all loading conditions

BACKGROUND: This study was designed to evaluate the efficacy of direct corneal neurotization using contralateral supraorbital and supratrochlear nerves in patients with unilateral facial palsy and corneal anesthesia. A novel surgical procedure in which these donor nerve branches are inserted at the contralateral anesthetic corneal limbus for sensory neurotization is described. METHODS: The charts of six patients were reviewed thoroughly to evaluate changes in corneal sensibility following surgery for direct corneal neurotization. Visual acuity, blink reflex, donor deficit, synesthesia, long-term corneal health, and several psychosocial measures and overall patient satisfaction with the procedure are reported. RESULTS: Six patients with an average denervation time of 7.00 +/- 8.56 years before surgery were followed for an average period of 16.3 +/- 2.42 years. All six eyes showed improvement of corneal sensibility, visual acuity, and corneal health and remained free of ulcers or other signs of advancing neurotropic keratopathy. Average corneal sensibility improved from 2.00 +/- 4.47 mm before surgery to 278.00 +/- 226.00 mm following corneal neurotization (p < 0.016). CONCLUSIONS: Direct neurotization of the cornea using the contralateral supraorbital and supratrochlear branches of the ophthalmic division of the trigeminal nerve appears to be an effective method of restoring the corneal sensibility in patients with unilateral facial palsy and anesthetic cornea. This technique preserves ocular anatomy and cosmesis and restores function by improving corneal health and visual acuity

The success of lower extremity microsurgical reconstructions may be compromised postoperatively secondary to several factors, including thrombosis, infection, bleeding, and edema. To address edema, surgeons may use protocols for gradually dangling and/or wrapping the affected extremity. Such protocols vary widely among surgeons and are typically based on training and/or prior experience. To that end, we distributed surveys to five plastic surgeons who are experienced in microvascular lower extremity reconstruction at five different institutions. The surveys inquired about postoperative management protocols for lower extremity free flaps with regard to positioning, compression, initiation and progression of postoperative mobilization, nonweightbearing and weightbearing ambulation, assessment of flap viability, and flap success rate. These protocols were then evaluated for similarities to create a consensus of postoperative management guidelines. Progressive periods of leg dependency and compression therapy emerged as important elements. Although the consensus protocol developed in this study is considered safe by each participant, we do not intend for these recommendations to serve as a standard of care, nor do we suggest that any one particular protocol leads to improved outcomes. However, these recommendations may serve as a guide for less experienced surgeons or those without a protocol in place