Faculty Bibliography

Mechanical tensile strain is believed to play an important role in regulating calvarial morphogenesis. To better understand the effects of mechanical strain on pathologic calvarial growth, we applied 10% constant equibiaxial tensile strain to neonatal rat calvarial osteoblast cultures and examined cellular proliferation, cytokine production, and extracellular matrix molecule expression. Mechanical strain markedly increased osteoblast proliferation as demonstrated by increased proliferating cell nuclear antigen (PCNA) protein. In addition, both transforming growth factor-beta1 (TGF-beta1) mRNA expression and fibroblast growth factor-2 (FGF-2) protein production were increased with exposure to strain. Moreover, mechanical strain induced expression of the extracellular matrix molecule collagen IalphaI. To further explore the relationship between mechanotransduction, osteogenesis, and angiogenesis, we examined the effect of mechanical strain on calvarial osteoblast expression of vascular endothelial growth factor (VEGF). Interestingly, we found that mechanical strain induced a rapid (within 3 hrs) increase in osteoblast VEGF expression. These data suggest that constant equibiaxial tensile strain-induced mechanotransduction can influence osteoblasts to assume an 'osteogenic' and 'angiogenic' phenotype, and these findings may have important implications for understanding the mechanisms of pathologic strain-induced calvarial growth

More women than ever before are undergoing mastectomies secondary to increased awareness and screening. This has also caused a corresponding increase in the number of breast reconstructions requested each year. The demand for improved results has fueled recent advances in new techniques. Aside from implant reconstruction, the methods now being employed are related to autogenous donations and reconstruction. Currently, the most commonly used techniques for autogenous breast reconstruction are the DIEP (deep inferior epigastric perforator) and TRAM (transverse rectus abdominis myocutaneous) flaps from the lower abdomen. The anterolateral thigh flap is a type of perforator flap usually described for use in head and neck reconstruction. The authors have discovered this flap's utility as an alternative in autogenous breast reconstruction when the abdomen is not available as a donor site. A review of the literature reveals a dearth of experience in using the anterolateral thigh flap for breast reconstruction. The article reviews the literature with regard to current uses of the anterolateral thigh flap, and then reports three case studies which highlight the thigh flap as an excellent alternative for breast reconstruction in selected patients

Mobius syndrome is classically characterized by bilateral facial nerve and abducens nerve paralysis in combination with limb defects. In the past 110 years, physicians diagnosed children as having the syndrome on the basis of heterogeneity of symptoms and used the term 'Mobius syndrome' or 'Mobius-like syndrome' for patients with multiple cranial nerve involvement. The cause and the exact pathogenesis of the syndrome still elude understanding. Genetic work-ups, radiological findings, and data from autopsies differ in their approaches and their findings of the basic causes of Mobius syndrome. In the international literature, about 301 case reports are found scattered through the past century. The appearance of the facial deformity is easy to recognize, because the Mobius patient is impaired in his or her ability to communicate nonverbally. Despite ophthalmologic problems, it is the search for a smile that brings these patients to the reconstructive surgeon. Over the past 100 years, surgical efforts attempted to improve the mask-like appearance by static and dynamic procedures, usually local muscle transpositions. Today, combinations of microsurgical procedures and aesthetic techniques are being used to restore some movement to the expressionless face of these patients by nerve and muscle transplantation. This article discusses the heterogeneity of Mobius syndrome, advocates a new classification system, presents the clinical findings of 42 patients who were seen and examined in consultation, and discusses the surgical management of 20 patients who underwent dynamic restorative microsurgery. Exemplary cases illustrating the preoperative work-up regimen and possible outcomes are reported

Obstetric brachial plexus palsy invariably involves the upper roots. If left untreated, characteristic deformities of the shoulder are common sequelae. The most objective way to investigate these shoulder deformities is computed tomographic (CT) scanning of bilateral upper limbs. In this study, specific measurements on CT scans of bilateral upper extremities were performed in a population of patients with obstetric brachial plexus palsy before and after reconstruction (nerve repairs and secondary procedures). The measurements showed that the restoration of external rotation and the scapula stabilization procedure correct the inclination of the humeral head, improve the joint congruency significantly, and decrease the winging of the scapula, thus improving the kinetics of the shoulder. Periodic CT measurement is an objective method of measuring the changes at the shoulder joint that occur over time during the natural evolution of the obstetric brachial plexus palsy lesion and of documenting the benefits of microsurgical intervention

Construction of the congenitally absent ear is a particular challenge. It represents the true essence of plastic surgery in that it not only requires sound surgical principles but artistic skill. Although a solid familiarity with the stages is important, the surgeon's own experience will direct gradual modification

Reconstruction of the nipple is the penultimate step in breast reconstruction after mastectomy. A number of reconstructive techniques have been described for nipple reconstruction including skin grafts, composite grafts, and various local flaps. The authors' preferred reconstructive technique is the local C-V or modified star flap. This flap produces an excellent reconstruction, but it is dependent on underlying subcutaneous fat to provide bulk to the reconstructed nipple. In most instances, the subcutaneous tissue is adequate. However, under certain circumstances, the subcutaneous fat may be insufficient to produce a nipple of adequate projection. Two cases of bilateral nipple reconstruction after soft-tissue expansion and implant placement and subsequent nipple reconstruction with local flaps provided inadequate nipple projection. These instances, as well as a retrospective review of reconstructed nipples after mound restoration using a variety of techniques, led the authors to conclude that a more predictable alternative to sustain nipple projection was necessary. The authors identified two broad categories of breast reconstruction patients in whom this new technique would be beneficial. In the first category of patients, breast mounds are reconstructed with tissue expansion and implant insertion, and in the second category, breast mounds are reconstructed by any technique in which the nipple reconstruction subsequently flattens. This article describes the indications, techniques, and experience in 13 patients treated over a 10-month period with fat grafting for nipple reconstruction

One of the more difficult and controversial aspects of forehead and brow lift is fixation with control and stabilization of the result. Aesthetic Surgery Journal has invited Robert W. Bernard, MD; Robert S. Hamas, MD; Peter McKinney, MD; and Malcolm D. Paul, MD to share their preferred brow lift techniques. Here are their responses to questions posed by 'Comparing Notes' editor, Alan H. Gold, MD. (Aesthetic Surg J 2003;23:217-219.)

We have previously shown that the integrin beta6 is neo-expressed in invasive oral squamous cell carcinoma (SCC) and is correlated with oral tumor progression. However, the mechanism by which the integrin beta6 promotes oral tumor progression is not well understood. The purpose of the present study was to determine whether integrin beta6 signaling activates Fyn and thus promotes oral squamous cell carcinoma progression. We analyzed the integrin beta6 signaling complex and investigated the function of these signaling molecules in oral SCC cells. We found that, upon ligation of the integrin beta6 with fibronectin, beta6 complexed with Fyn and activated it. The activation of Fyn recruited and activated focal adhesion kinase to this complex. This complex was necessary to activate Shc and to couple beta6 signaling to the Raf-ERK/MAPK pathway. This pathway transcriptionally activated the matrix metalloproteinase-3 gene and promoted oral SCC cell proliferation and experimental metastasis in vivo. These findings indicate that integrin beta6 signaling activates Fyn and thus promotes oral cancer progression