Faculty Bibliography

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.

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

PURPOSE: End-to-side (ETS) nerve repair allows for target-muscle reinnervation, with simultaneous preservation of donor-nerve function. Acetyl-L-carnitine (ALCAR) was shown to enhance axonal sprouting in early regeneration following transection and repair of the sciatic nerve in rodents. The purpose of this article was to determine the ability of ALCAR to enhance axonal regeneration in an ETS rodent model. METHOD: The right musculocutaneous nerve in 16 adult male Sprague-Dawley rats was transected to induce biceps muscle paralysis. The distal stump was then coapted by ETS neurorrhaphy through a perineurial window to the ipsilateral median nerve. Experimental groups received ALCAR for 1, 2, 3, and 4 weeks whereas controls received placebo. RESULTS: Weekly postoperative behavioral evaluations revealed increased functional return over control but the difference was not significant. Potentials from biceps were recorded from the third postoperative week in the experimental group and from the fourth week in the control group. Histomorphometric evaluations revealed higher musculocutaneous nerve axon counts, higher myelin thickness in the fourth postoperative week, and differences in the appearance and the number of motor-end-plates in the biceps in experimental versus control group. CONCLUSION: Intraperitoneal administration of ALCAR can expedite biceps muscle recovery in an ETS model by increasing the rate of axonal regeneration. Despite the morphological changes, no behavioral changes were noted and further studies are needed to confirm clinical efficacy of ALCAR for potential use in the development of therapeutic protocols

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.

One of the most fundamental challenges in plastic surgery is the alteration of the geometry and topology of the skin. The specific decisions made by the surgeon concerning the size and shape of the tissue to be removed and the subsequent closure of the resulting wound may have a dramatic affect on the quality of life for the patient after the procedure is completed. The plastic surgeon must look at the defect created as an organic puzzle, designing the optimal pattern to close the hole aesthetically and efficiently. In the past, such skills were the distillation of years of hands-on practice on live patients, while relevant reference material was limited to two-dimensional illustrations. Practicing this procedure on a personal computer [1] has been largely impractical to date, but recent technological advances may come to challenge this limitation. We present a comprehensive real-time virtual surgical environment, based on finite element modeling and simulation of tissue cutting and manipulation. Our system demonstrates the fundamental building blocks of plastic surgery procedures on a localized tissue flap, and provides a proof of concept for larger simulation systems usable in the authoring of complex procedures on elaborate subject geometry