Faculty Bibliography

We present the case of an 18-year-old girl with McCune Albright Syndrome (MAS) and a near total mandibular defect reconstructed with a free fibula flap. There are three reports of mandibular reconstruction in a patient with MAS using the free fibula flap; however this case is unique for two reasons. One, the continuity defect in our patient was much larger than previously reported, representing nearly the entire length of the mandible (21 cm) and required the entire harvestable length of the fibula. Two, the progression of the patient's disease limited options for reconstruction and dictated the use of a fibula with small dysplastic changes.

BACKGROUND: Head and neck anatomy is complex and represents an educational challenge to the student. Conventional two-dimensional illustrations inherently fall short in conveying intricate anatomical relationships that exist in three dimensions. A gratis three-dimensional virtual reality atlas of craniofacial anatomy is presented in an effort to address the paucity of readily accessible and customizable three-dimensional educational material available to the student of head and neck anatomy. METHODS: Three-dimensional model construction was performed in Alias Maya 4.5 and 6.0. A basic three-dimensional skull model was altered to include surgical landmarks and proportions. Some of the soft tissues were adapted from previous work, whereas others were constructed de novo. Texturing was completed with Adobe Photoshop 7.0 and Maya. The Internet application was designed in Viewpoint Enliven 1.0. RESULTS: A three-dimensional computer model of craniofacial anatomy (bone and soft tissue) was completed. The model is compatible with many software packages and can be accessed by means of the Internet or downloaded to a personal computer. As the three-dimensional meshes are publicly available, they can be extensively manipulated by the user, even at the polygonal level. CONCLUSIONS: Three-dimensional computer graphics has yet to be fully exploited for head and neck anatomy education. In this context, the authors present a publicly available computer model of craniofacial anatomy. This model may also find applications beyond clinical medicine. The model can be accessed gratis at the Plastic and Reconstructive Surgery Web site or obtained as a three-dimensional mesh, also gratis, by contacting the authors.

We report the use of expanded reverse abdominoplasty in three female patients with postburn scars involving the entire epigastric region in which the inframammary folds were effaced, resulting in distortion of breast contour. In two of the patients, tissue expanders were used, and subsequently, reverse abdominoplasty was performed, thus re-creating the inframammary fold. The third patient reported to be pregnant after expanders were placed; therefore, smaller volumes of inflation for tissue expansion were necessary. We believe that this procedure is an optimal solution, both aesthetically and functionally, in respect to other reconstructive techniques in female patients with normal skin inferior to epigastric burns. The surgical technique and results are discussed.

BACKGROUND: The authors studied the effect of midface distraction on maxillary skeletal position and clinical appearance in patients with Crouzon, Pfeiffer, and Apert syndromes, and examined the stability of these changes at 1 year after distraction. METHODS: Fifteen consecutive patients (six male and nine female; average age, 5.9 years) underwent Le Fort III osteotomy with midface advancement using a rigid external distraction device. Six patients had Crouzon, five had Pfeiffer, and four had Apert syndrome. Midface advancement was initiated at the level of the occlusal splint and at the zygomatic/maxillary anchor screws. The device was activated 11 mm on average, at a rate of 1 mm per day. Twenty anatomical landmarks were identified and digitized at three time intervals, and displacement of each landmark was compared with its pretreatment position. RESULTS: By the time of device removal, point A had advanced sagittally along the x axis 15.85 mm and moved downward 1.06 mm along the y axis; the orbitale was moved sagittally along the x axis 12.72 mm and downward 1.99 mm along the y axis. Maximum mean advancement (17.16 mm) was observed at the upper incisal edge. Maxillary and mandibular skeletal discrepancy was significantly decreased, with the ANB angle changing from -5.87 to +13.17 degrees. At 1 year after distraction, point A had advanced an additional 0.81 mm, and the orbitale and upper incisal edge had moved posteriorly 0.07 mm and 1.34 mm, respectively. CONCLUSION: Significant midface advancement can be achieved and maintained with rigid external distraction of the Le Fort III osteotomy segment (up to 24 mm), with excellent stability of the advanced midfacial skeleton

This work focuses on the use of revascularized free flaps for the reconstruction of the major defects of the mandible after the removal of advanced-stage tumors in irradiated patients. It uses three representative cases to study the problems of complex patients and the possible reconstructive options. The cases, all three young patients (two females and one male), had undergone a mandibulectomy and adjuvant radiotherapy for malignant neoplasms. In each case, secondary reconstruction of the mandible and soft tissue was necessary and was performed using microvascular free flaps. An osteomyocutaneous iliac crest free flap was used in two cases, whereas a double flap (fibula free flap + rectus abdominis free flap) was used in the other case. In all three cases, after the microvascular reconstruction, an orthognathic procedure was performed to obtain the correct maxillomandibular relationship. The advantages and disadvantages of the various techniques used are discussed.

BACKGROUND: Recent clinical trials involving patients with acute coronary syndromes have demonstrated significant reduction in the progression of coronary artery thrombosis using a regimen of aspirin, heparin, and the glycoprotein IIb/IIIa inhibitor tirofiban. Acute coronary syndromes and free tissue transfer are similar pathophysiologically in that they both involve endothelial injury, thrombosis, and ischemia. In this study, the authors investigate tirofiban, combined with aspirin and heparin, for the prevention of microsurgical anastomotic thrombosis in a thrombogenic rat model. METHODS: Using a randomized, controlled, double-blind experimental design, 80 thrombogenic anastomoses were performed on rat femoral arteries (n = 40) and veins (n = 40). Preoperatively, each rat received one of four treatment regimens: aspirin and heparin (regimen 1), aspirin and heparin plus tirofiban (regimen 2), tirofiban alone (regimen 3), or isotonic saline (control) (regimen 4). Vessels were assessed for patency at 5, 15, 30, and 120 minutes after reperfusion and then harvested for microscopic analysis. RESULTS: At 120 minutes after reperfusion, regimen 1 had an arterial and venous patency rate of 80 percent and 70 percent, respectively, whereas the vessel patency rate for regimen 2 was 100 percent. The difference between regimens 1 and 2 was not statistically significant. Regimens 3 and 4 had vessel patency rates of 40 percent or less. The aspirin/heparin and aspirin/heparin/tirofiban groups both demonstrated significantly improved vessel patency and significantly less thrombotic occlusion compared with controls. CONCLUSIONS: Combination therapy with aspirin, heparin, and tirofiban significantly increases arterial and venous patency and decreases anastomotic thrombus formation in thrombogenic anastomoses in rats. The role of glycoprotein IIb/IIIa inhibitors in microsurgery warrants further investigation.

BACKGROUND: Silicone chin augmentation remains a popular treatment for microgenia because its placement appears deceptively simple. However, when extrusion, displacement, capsular contracture following implant removal, overaugmentation, or malposition occurs, a revision operation may be required. Secondary chin surgery is challenging because (1) implant removal alone may produce a disfigured chin; and (2) placement of a new implant in an oversized misshapen pocket demands precision, control, and reliability. METHODS: The textured implant may be placed by means of an intraoral or extraoral route. The extraoral route is usually chosen except when transoral procedures (e.g., mentalis suspension) are required. The superior 30 to 50 percent of a standard textured implant is always removed and then tapered anteriorly at a 45-degree angle to reduce its sharp front edge. The lateral wings are also reduced and tapered. Two pilot holes are drilled in each half of the implant and then it is divided in the midline. Each half is inserted and secured individually. The medial screw is placed first and nearly fully tightened. Then, holding the implant exactly along the inferior border of the mandible, the distal screw is placed and both screws are tightened completely. The lower border of the implant should be exactly along the lower border of the mandible. The soft tissues are closed in three layers over a drain. RESULTS: This technique has been used to treat more than 100 patients. Selected photographs illustrate this technique. CONCLUSION: This article explains how to place a textured implant efficiently and effectively under light premedication and local anesthesia