Faculty Bibliography

The authors previously established an in vitro palate nonfusion model on the basis of a spatial separation between prefusion embryonic day 13.5 mouse palates (term gestation, 19.5 days). They found that an interpalatal separation distance of 0.48 mm or greater would consistently result in nonfusion after 4 days in organ culture. In the present study, they interposed embryonic palatal mesenchymal tissue between embryonic day 13.5 mouse palatal shelves with interpalatal separation distances greater than 0.48 mm in an attempt to 'rescue' this in vitro palate nonfusion phenotype. Because no medial epithelial bilayer (i.e., medial epithelial seam) could potentially form, palatal fusion in vitro was defined as intershelf mesenchymal continuity with resolution of the medial edge epithelia bilaterally. Forty-two (n = 42) palatal shelf pairs from embryonic day 13.5 CD-1 mouse embryos were isolated and placed on cell culture inserts at precisely graded distances (0, 0.67, and 0.95 mm). Positive controls consisted of shelves placed in contact (n = 6). Negative controls consisted of shelves placed at interpalatal separation distances of 0.67 mm (n = 6) and 0.95 mm (n = 7) with no interposed mesenchyme. Experimental groups consisted of embryonic day 13.5 palatal shelves separated by 0.67 mm (n = 11) and 0.95 mm (n = 12) with interposed lateral palatal mesenchyme isolated at the time of palatal shelf harvest. Specimens were cultured for 4 days (n = 19) or 10 days (n = 23), harvested, and evaluated histologically. All positive controls at 4 and 10 days in culture showed complete histologic palatal fusion. All negative controls at 4 days and 10 days in culture remained unfused. Five of six palatal shelves separated at 0.67 mm interpalatal separation distance with interposed mesenchyme were fused at 4 days, and all five were fused at 10 days. At an interpalatal separation distance of 0.95 mm with interposed mesenchyme (n = 12), no palates (zero of four) were fused at 4 days, but seven of eight were fused at 10 days. These data suggest that nonfused palatal shelves can be 'rescued' with an interposed graft of endogenous embryonic mesenchyme to induce fusion in vitro

Immediate breast reconstruction has important advantages over delayed reconstruction, including a shorter operative time and decreased psychological distress for the patient. However, the authors' experiences with the deep inferior epigastric perforator flap demonstrate variable aesthetic outcomes among patients who undergo radiation postoperatively. To establish an association between radiation and poor postoperative results, a matched-pairs analysis was conducted. Thirty irradiated patients were paired with 30 nonirradiated patients, according to age and body mass index. For each group, the incidence of fat necrosis, fibrosis/shrinkage, and flap contracture was recorded. In addition, an aesthetic evaluation was conducted to compare before-and-after images of 10 irradiated patients with those of 10 nonirradiated patients from similar time periods. The images were randomized and blindly evaluated by a panel of eight judges. A five-point scale was used to evaluate symmetry, aesthetic proportion, and the appearance of the superior pole. Statistical analysis demonstrated a significant difference in the score changes for irradiated and nonirradiated patients, according to all three criteria. Nonirradiated patient scores increased by one-half point, and irradiated patient scores decreased by one-half point. In addition, the incidences of fat necrosis, fibrosis, and flap contracture were all significantly higher among the irradiated group. These results suggest that when possible, reconstruction should be delayed until after radiation therapy is complete. Persons who smoke or are obese may be at particular risk for complications following radiation therapy

This study reviews the various microsurgical techniques available to reanimate the paralyzed eye sphincter. Traditional as well as several innovative procedures are described that the senior author has used over the past 20 years. The methods of evaluating such outcomes are discussed and analyzed with regard to eye reanimation. An independent panel of reviewers evaluated standardized preoperative and postoperative videos documenting eye closure and blink in patients with lagophthalmos. A significant difference in overall postoperative outcome of both eye closure and blink was demonstrated. In this particular population, those patients who underwent dynamic procedures more often yielded better results than those who did not. Detailed video documentation and independent grading of outcomes of eye closure and blink are necessary to assist in developing effective surgical treatments for paralytic lagophthalmos. Accurate measurement of the results of these interventions remains a considerable challenge in the field of eye reanimation microsurgery

Bioresorbable implants (meshs and plates) are increasingly used in reconstructive craniofacial and skull base surgery. Usually these implants must be contoured to fit the complex craniofacial anatomy ex vivo; occasionally final contouring is performed in vivo and must be done without damaging surrounding structures (e.g., dura, brain). We report a precision method for in vivo contouring of bioresorbable implants using the Shaw hemostatic thermal scalpel

A long-term follow-up study of patients who underwent bilateral mandibular distraction is presented, and the results of patients with Treacher Collins syndrome and Nager syndrome are compared with results for other forms of congenital micrognathia. It was hypothesized that the factors responsible for the predetermined, syndrome-specific shape of the mandible in patients with Treacher Collins and Nager syndromes would alter the long-term results of linear (uniplanar) distraction of the mandible. Thus, over time, the mandibles would remodel to preoperative form while maintaining the increase in volume. To investigate this hypothesis, all patients treated with bilateral mandibular distraction who had at least 1.5 years of follow-up, including satisfactory cephalometric examinations, were retrospectively reviewed. Two groups were identified. Group 1 (n = 6) were Treacher Collins and Nager syndrome patients (ages, 2 to 13 years; mean, 5.2 years) and group 2 (n = 6) included other forms of bilateral, congenital micrognathia (ages, 1.5 to 19 years; mean, 8.4 years). Serial cephalometric measurements were recorded before distraction, after distraction, and at least 18 months after distraction. Mandibular mean linear distraction distance (as recorded on the device) averaged 24.5 mm in group 1 and 26.2 mm in group 2. In group 1, the antegonial angle (angle from the mandibular plane to the top of the antegonial notch) decreased after distraction by 3.8 degrees, and the antegonial notch height was reduced by 1.6 mm. The posttreatment morphologic change was modified significantly over time, with a 3.7-degree increase of the antegonial angle and a 1.2-mm deepening of the antegonial notch. In group 2, the immediate reduction in height of the antegonial notching was subtler; however, long-term recurrence of the antegonial notching was also observed. At the end of distraction, the mean group 1 gonial angle became 8 degrees more obtuse. In contrast, patients in group 2 developed a more acute angle (mean, 8 degrees). The mandibles of the Treacher Collins syndrome patients (group 1) maintained their more obtuse postdistraction gonial angle during the period of follow-up, whereas over time this change was reversed in group 2 patients. In conclusion, experience with bilateral mandibular distraction has demonstrated that long-term determination of mandibular form is more complex than either the amount of distraction or the direction of the distraction vector. The underlying genotype and the musculoskeletal milieu must be taken into account when planning distraction, as these factors tend to remodel the mandible into its preoperative shape over time, despite the fact that the increased mandibular volume and projection are maintained

OBJECTIVE: Resection of intracranial tumors in the posterior hippocampus and the parahippocampal gyrus can be associated with significant morbidity because of the parenchymal resection and the cortical retraction often required in gaining access to this infrequently explored region. With the use of image guidance, the occipitosubtemporal (OST) approach requires neither lateral cortical resection nor the placement of brain retractors to gain surgical access to the posterior hippocampus and the parahippocampal gyrus, and this approach is associated with a high rate of gross total tumor resection. METHODS: The computer-assisted volumetric stereotactic OST approach was used to resect 40 posterior hippocampus and parahippocampal gyrus tumors in 34 consecutive patients during an 8-year period. Patient, radiographic, and surgical outcome data were collected retrospectively. RESULTS: The series included operations in 25 men and 15 women, and the patients' average age was 40.3 years (range, 15-69 yr). Twenty-five of the 40 procedures were performed to remove lesions in the dominant hemisphere, and previous craniotomies for resection had been performed in 12 of 40 cases. In 38 of 40 cases, histopathological analysis revealed a glial neoplasm, and 50% of these tumors were high-grade lesions. Preoperatively, 23 patients were neurologically intact before 40 procedures, whereas visual field deficits were noted in 7 patients, mild hemiparesis was documented in 4 patients, and other neurological deficits were present in 9 patients. An excellent outcome (Glasgow Outcome Scale Grade 5) was noted after 38 (95%) of the 40 computer-assisted volumetric stereotactic OST procedures. Permanent postoperative hemiparesis (Glasgow Outcome Scale Grade 4) occurred after one procedure, and a second patient, despite being neurologically unchanged postoperatively and despite having had an optimal tumor resection, died on postoperative Day 33 (Glasgow Outcome Scale Grade 1). Complete resection of the preoperatively defined tumor volume was noted on postoperative gadolinium-enhanced magnetic resonance imaging examinations after 39 (97.5%) of the 40 procedures. The average duration of clinical follow-up was 15.9 months (range, 0.5-67 mo). CONCLUSION: We think that the OST approach is well suited to the resection of tumors in the posterior hippocampus and the parahippocampal gyrus. By allowing the neurosurgeon to avoid unnecessary brain resection and retraction, this approach reduces the risk of injury to important lateral temporal and occipital lobe cortex and tracts. In addition, the resection of a posterior hippocampus or parahippocampal gyrus mass with the OST approach relieves temporal horn entrapment. Computer-assisted volumetric stereotaxy helps the neurosurgeon to maintain precise spatial and anatomic orientation and accurately delineates the margin between the tumor and the surrounding neural tissue