Faculty Bibliography

Several methods have been described for fabrication of occlusal devices, but many require complex and time-consuming laboratory procedures. In this article, an alternative fabrication method for a hard occlusal device while maintaining the articulation of the cast is described

The vertical rectus abdominus myocutaneous (VRAM) flap is a valuable option for tongue reconstruction. However, the traditional inset (skin to remaining oral mucosa) obviates a more anatomic reconstruction. Eight patients underwent total or subtotal glossectomy with VRAM reconstruction. The muscle inset was supported at the inferior mandibular border attached to the remaining lingual mucosa or gingiva. The neotongue, consisting of skin and subcutaneous fat, was sutured posteriorly to the remaining tongue base, and the other surfaces were trimmed and left unsutured. Reconstruction was successful in all patients. The neotongue assumed palatal configuration, and within 2 weeks uniform granulation tissue followed by mucosalization occurred. One year postoperatively, all patients tolerated ad lib diets, spoke intelligibly, were gastrostomy tube and tracheotomy free and had no evidence of aspiration. This neotongue sits on the mandible under voluntary control, permitting effective obturation against the hard palate and providing successful speech and swallowing

OBJECTIVE: On the basis of contemporary multiplanar imaging, microsurgical observations, and long-term follow-up in 60 consecutive patients with sphenoid ridge meningiomas, we propose a modification to Cushing's classification of these tumors. This article will concentrate on patients from this series with global medial sphenoid ridge tumors. METHODS: Data were collected prospectively for 35 patients with global meningiomas arising from the medial portion of the sphenoid ridge that were surgically treated between 1982 and 2002. RESULTS: All patients were followed for the entire length of this study (mean, 12.8 yr). The tumor size ranged from 2 to 8 cm (mean, 4.5 cm). Of the 24 patients with purely intradural tumors, four (17%) had Simpson Grade I and 19 had Simpson Grade II resections; 23 (96%) had gross total resections. Of the 11 patients with tumors extending extradurally (i.e., cavernous sinus), one (9%) patient had a Simpson Grade II resection, whereas nine (82%) had Simpson Grade III resections, with the latter being all visible tumor removed except that in the cavernous sinus. One (9%) of these 11 patients had a gross total resection, and 9 (82%) had radical resections, with the latter defined as total removal of all intradural tumor. The overall morbidity rate was 18%. There was no surgical mortality or symptomatic cerebral infarction. CONCLUSION: An accurate classification of global medial sphenoid meningiomas is mandatory to gain insight into their clinical behavior and for understanding the long-term efficacy and safety of available treatment options. Primary medial sphenoid ridge tumors consistently involve the unilateral arteries of the anterior cerebral circulation, and therefore, the resection of tumor from around these arteries is the most important operative nuance for their safe excision

BACKGROUND: Weight loss can be achieved through gastric bypass surgery or diet. Surgery has been reported to be more effective in achieving long-term weight loss. The authors aimed to determine whether massive weight loss is maintained or improved after body contouring. METHODS: Seventy patients underwent body contouring surgery after massive weight loss from January of 2001 to January of 2005. Data collected included age; gender; mode of massive weight loss; body mass index before massive weight loss, at contour surgery, and at follow-up; and weight of skin excised. RESULTS: Weight loss was achieved by open (n = 57) or laparoscopic gastric bypass surgery (n = 7), or by diet (n = 6). Average weight loss at contour surgery was 152 lb for open gastric bypass, 139 lb for laparoscopic gastric bypass, and 140 lb for the diet group. Mean weight of excised skin was 12.8 lb. Gastric bypass patients on average gained 2.3 lb, whereas nonsurgical patients gained 22 lb after body contouring, netting out skin excised. On multivariate analysis, weight loss did not differ between laparoscopic and open gastric bypass (p = 0.9); however, surgery led to a 27-lb greater weight loss compared with diet (p = 0.03). This effect was more remarkable with follow-up less than or equal to 18 months compared with more prolonged follow-up. Every year increase in age was associated with an 0.8-lb weight gain (p = 0.03). CONCLUSIONS: Gastric bypass surgery patients maintain massive weight loss better than "diet" patients. Weight loss tapers over time for gastric bypass surgery patients, with ultimate weight gain, comparable to that seen in the general population as it ages.

BACKGROUND:Traditionally, organ transplantation has been synonymous with patients with poor prognosis and outcome. Surgeons felt that the risks posed by immunosuppressive drugs outweighed the benefits of non-life-threatening procedures. With the enormous advances in the field of organ transplantation, a growing number of transplant patients present for a variety of surgical procedures. The objective of this report was to study the surgical outcome of organ transplantation patients who required reconstructive surgery using free tissue transfer. METHODS:A multicenter retrospective study was conducted on organ transplant patients who underwent elective microvascular free flap procedures. Patient chart review included cause of organ failure, medications, reconstruction site, flap choice, days hospitalized, complications, and outcome. RESULTS:Five independent medical centers participated in the study. Nineteen organ transplant patients required free flaps. Free flaps were used to reconstruct a variety of surgical defects, including breast, head and neck, and upper and lower extremities. There were no flap losses. Flaps used included musculocutaneous (n = 13), fasciocutaneous (n = 5), and osteocutaneous (n = 1) free flaps. Hospital length of stay ranged from 3 to 17 days. Complications included loss of skin graft, suture line dehiscence, and hematoma formation. Delayed wound healing was observed in two patients. CONCLUSIONS:In the properly selected patient, microvascular free tissue transfer can be performed safely and with acceptable surgical outcome. Contrary to popular belief, delayed wound healing from immunosuppressive agents was uncommon. Free tissue transfer in healthy organ transplant patients can be considered in reconstructive surgery decision making.

BACKGROUND: Three-dimensional photography of the breast offers new opportunities to advance the fields of aesthetic and reconstructive breast surgery. The following study investigates the use of three-dimensional imaging to assess changes in breast surface anatomy, volume, tissue distribution, and projection following medial pedicle reduction mammaplasty. METHODS: Preoperative and postoperative three-dimensional scans were obtained from patients undergoing short-scar medial pedicle breast reduction. Three-dimensional models were analyzed by topographical color maps, changes in the lowest point of the breast, surface measurements, and the point of maximal projection. Total breast volume and percentage volumetric tissue distribution in the upper and lower poles were also determined. RESULTS: Thirty patients underwent reduction mammaplasty (mean postoperative scan, 80 +/- 5 days). Color maps highlighted the majority of spatial changes in the central, upper poles. Reduction mammaplasty resulted in a significant decrease in the anteroposterior projection of the breast (6.3 +/- 0.2 postoperatively compared with 8.1 +/- 0.2 cm preoperatively; p < 0.01). The point of maximal breast projection was elevated in the cranial-caudal direction (4.8 +/- 0.4 cm; p < 0.01), with a corresponding elevation in the lowest point of the breast (4.8 +/- 0.5 cm; p < 0.01). Volumetric three-dimensional measurements identified a significant change in percentage tissue distribution after reduction mammaplasty (45 +/- 2 percent above the inframammary fold preoperatively versus 76 +/- 2 percent postoperatively; p < 0.01). CONCLUSIONS: This study is the first to demonstrate the technical feasibility and clinical utility of three-dimensional geometric data in medial pedicle breast reduction surgery. This novel approach suggests new opportunities to define long-term operative changes following various breast procedures

BACKGROUND: Since their first review of microsurgical correction of facial contour deformities in 19 patients with craniofacial malformations, the authors have treated an additional 74 patients (n = 93). The authors review indications, choices, safety, efficacy, complications, and technical refinements. A treatment algorithm is presented. METHODS: A retrospective chart review of all patients who underwent microvascular reconstruction of the face and all patients with craniofacial dysmorphology was performed. Between 1989 and 2004, a total of 93 patients with the following diagnoses were identified: craniofacial microsomia (n = 73), Treacher Collins syndrome (n = 8), and severe orbitofacial cleft (n = 12). All patients underwent microsurgical facial reconstruction with a superficial inferior epigastric, groin, or circumflex scapular flap. Flap revisions, complications, and non-free flap related surgery were reviewed. RESULTS: The mean age at microvascular reconstruction was 11 years (range, 4 to 27 years). Flap choices included the following: superficial inferior epigastric (n = 4), groin (n = 3), and circumflex scapular (n = 105). Seventy-six patients underwent unilateral and 17 patients underwent bilateral (one of 17 simultaneous) reconstructions. Postoperative complications included partial flap loss (n = 1), reexploration (n = 1), hematoma (n = 5), and cellulitis (n = 5). All patients had subjective improvement in facial contour, symmetry, skin tone, and color. Most patients underwent additional non-free flap procedures including mandibular distraction and ear reconstruction. CONCLUSIONS: Microsurgical flaps have markedly improved the authors' ability to restore craniofacial contour in patients with craniofacial malformations. In selected patients, the authors choose primary midface augmentation with free vascularized tissue to restore form and function. Microsurgical flaps in patients with craniofacial malformations are safe, effective, and reliable