Faculty Bibliography

The etiology of failed degenerative lumbar spine surgery may include a wide array of conditions. There is a group of patients who have recurrence of back pain despite a solid fusion in the absence of any obvious pain generator. Implant removal in those patients is a controversial optional treatment. The purpose of this study was to evaluate the efficacy and safety of implant removal and to determine the possible predictors of its efficacy. Twenty-five patients (10 M, 15 F) with an average age of 44 (18 to 74) were retrospectively evaluated. All patients had prior titanium posterior pedicle screw instrumentation and fusion for lumbar degenerative disorders. Twenty patients with increase in pain during palpation of the operative side underwent a preoperative anesthetic injection at the site of their trigger points. Patients' clinical charts, operative notes, and preoperative x-rays were evaluated. Relief of pain was evaluated by the percent Visual Analog Scale (VAS) pain change due to implant removal. Functional improvement was rated on a five-point scale. Predictors of pain relief were analyzed by using bivariate analysis. A P value <0.05 was considered significant. Average follow-up period was 20 (12 to 37) months. The median time after the index operation and the recurrence of pain was 13.5 (1 to 119) months. VAS decrease after implant removal was 50% (P<0.001). Functional improvement was reported by 84% of patients. One patient developed a superficial infection managed successfully. Bivariate analysis showed that percent VAS change after injection, months free of pain after the index operation, and provocation of pain by palpation were significant predictors for pain relief (P<0.05). Removal of the implant may be an efficient and safe procedure for carefully selected patients and the most consistent predictor of its efficacy is the percent pain relief after the diagnostic injection of the painful operative side.

This study was initiated to establish a treatment algorithm for preoperative evaluation of donor sites prior to the harvest of free osteocutaneous flaps, in the setting of complex mandibulofacial reconstruction. A total of 29 consecutive patients were treated between 1999 and 2003 in a university-based setting. Reconstructions were completed using either a free fibula osteocutaneous flap or a radial forearm free flap. Functional and aesthetic results were determined by completing a thorough patient physical examination postoperatively. We hypothesized that a routine preoperative angiogram at the donor site was unnecessary. The Allen's test was the only preoperative evaluation completed in the 13 patients undergoing the free radial forearm reconstruction. In the remaining 16 patients undergoing free fibula reconstruction, a thorough physical examination was completed, along with noninvasive Doppler examinations. No angiograms were obtained. Using this systematic approach, no ischemic complications were observed at the donor site. Only two complete flap losses were seen, one in each group, due to microvascular thrombosis. We conclude that preoperative assessment of the donor site(s) with only an Allen's test in the free radial forearm group and a thorough pulse exam and a noninvasive Doppler in the free fibula group appear adequate. Routine preoperative angiogram of the donor extremity may be unnecessary and place the patient at additional risk for associated complications.

In this study we investigated the role of endothelin-1 (ET-1) and its peripheral receptor (ET-A) in carcinoma-induced pain in a mouse cancer pain model. Tumors were induced in the hind paw of female mice by local injection of cells derived from a human oral squamous cell carcinoma (SCC). Significant pain, as indicated by reduction in withdrawal thresholds in response to mechanical stimulation, began at four days after SCC inoculation and lasted to 28 days, the last day of measurement. Intra-tumor expression of both ET-1 mRNA and ET-1 protein were significantly upregulated compared to normal tissue, and local administration of the ET-A receptor selective antagonist, BQ-123 (100 microM) significantly elevated withdrawal thresholds, indicating the induction of an antinociceptive effect. These findings support the suggestion that ET-1 and ET-A receptors contribute to the severity of carcinoma-induced soft tissue cancer pain

The technique of vascular delay has been used by plastic surgeons for nearly 500 years and has proven useful for reliably transferring tissue and allowing for a greater volume of tissue to be reliably harvested. Delay procedures are an essential plastic surgical tool for a variety of aesthetic and reconstructive procedures. Despite the widespread use of vascular delay procedures, the mechanism by which this phenomenon occurs remains unclear. A number of groups have exhaustively examined microvascular changes that occur during vascular delay. Theories have been proposed ranging from the dilation of choke vessels to changes in metabolism and new blood vessel formation. Inherent in these theories is the concept that ischemia is able to act as the primary stimulus for vascular changes. The purpose of this review is to revisit the theories proposed to underlie the delay phenomenon in light of recent advances in vascular biology. In particular, the participation of bone marrow-derived endothelial progenitor cells in the delay phenomenon is explored. Greater understanding of the role these cells play in new blood vessel formation will be of considerable clinical benefit to high-risk patients in future applications of delay procedures

We present two cases of infected frontal sinus fractures requiring simultaneous obliteration of the frontal sinus and reconstruction of the horizontal buttress. In both cases, a free fibula flap was used for obliteration and bony reconstruction in a single stage. We believe that this is a novel technique for treatment of infected frontal sinus fractures obviating the need for secondary staged procedures.

The submandibular glands are subject to several pathologies that require excision. The most common problem that affects these salivary glands is sialadenitis combined with sialolithiasis. This problem occurs in the submandibular gland 10 times more frequently than it does in the parotid gland. Other illnesses frequently involving the submandibular glands are represented by sialadenosis and benign, malign, and intermediate neoplasms. Diagnosis of any disturbance in the submandibular gland involves both a clinical and instrumental (echography, traditional radiography [ortopantomography] and eventually computed tomography (CT) or magnetic resonance imaging) assessment. Surgery is the usual method of treatment of both chronic sialadenitis and neoplasms in the submandibular gland. A submandibular gland surgical approach can be cervical, intraoral, or endoscopic. The authors present their clinical experience with a total of 40 patients with illnesses involving the submandibular gland treated with submandibular gland excision by a transcervical approach. Their experience suggests that this approach entails a relatively simple procedure, involves low risks for the nerve structure around the gland, permits wide resection margins for neoplasms, and incurs little aesthetic damage.

Eating disorders are common in girls and women. Two common eating disorders--anorexia nervosa and bulimia nervosa--have significant medical complications. Oral and maxillofacial surgeons must be cognizant of the signs, symptoms, and medical consequences of these disorders. The increased incidence of these diseases has implications in the surgical management the oral and maxillofacial surgery patient. A review of the literature and guidelines in the perioperative management of these surgical patients are presented in this article.