Faculty Bibliography

BACKGROUND: Physiologically programmed cell death or apoptosis occurs during the natural balance between cellular proliferation and demise. MATERIALS AND METHODS: We compared the expression of 64 apoptosis-related genes in keloids and normal scars to investigate the potential role of apoptosis in keloid formation. Two sets of mRNA were isolated from keloids excised from four previously untreated patients and four normal scar patients separately. Human cDNA arrayed hybridization was performed to compare the apoptosis-related gene expression between these two groups. In addition, TUNEL assays were performed to evaluate the percentage of apoptotic cells in keloids (center and periphery) versus normal scars. RESULTS: Eight of the sixty-four apoptosis-related genes studied were significantly underexpressed in keloid tissue. The underexpressed genes and their relative expression compared with normal scar were defender against cell death 1 (DAD-1) (34.1% of normal scar); nucleoside diphosphate kinase B (c-myc transcription factor) (24.7%); glutathione S-transferase (17.9%); glutathione S-transferase microsomal (28.1%); glutathione peroxidase (47.2%); tumor necrosis factor receptor 1-associated protein (TRADD) (51.0%); 19-kDa interacting protein 3 (NIP3) (36.0%); and cytoplasmic dynein light chain 1 (HDLC1) (47.7%). Spatial analysis of apoptosis using TUNEL assays revealed apoptosis indices of 0.83 for keloid periphery and 0.63 for keloid center. CONCLUSIONS: In this study we demonstrated underexpression of apoptosis-related genes in human keloid tissue and decreased apoptotic activity in fibroblasts derived from keloids versus normal scars. We hypothesized that keloid fibroblasts fail to undergo physiologically programmed cell death and, thus, continue to produce and secrete connective tissue beyond the period expected in normal scar formation, accounting for the progressive and hypertrophic nature of keloids. This mechanism leads to new possibilities for treatment of keloids through induction of apoptosis.

Treatment of the posttraumatic, vertically shortened upper lip is a difficult surgical problem. It requires careful evaluation of the underlying injury followed by staged therapeutic interventions. Both surgical and nonsurgical treatments need to be employed to optimize results. The authors present three distinct cases of posttraumatic upper lip reconstruction that utilize a variety of treatment modalities. All patients were treated by the senior author

To gather information about aesthetic surgery's current practice structures, competitive environment, patient price sensitivity, and marketing and practice development requirements, a two-page survey was developed and mailed to all 1180 members of the American Society for Aesthetic Plastic Surgery. A total of 632 surveys were returned (response rate of 54.5 percent). Most aesthetic plastic surgeons said they were in solo practice (63.3 percent). More than two-thirds described the marketplace as "very competitive," with 59 percent reporting 25 or more surgeons offering aesthetic surgery in their area. They estimated their patients' average income at $62,800. Nearly all plastic surgeons labeled their patients as "moderately price sensitive" (62.3 percent) or "very price sensitive" (30.6 percent). Similarly, 23.2 percent estimated that they had lost 20 or more patients within the last year for reasons of price. Practice development and marketing efforts represented an average of 7.3 percent of plastic surgeons' working time. Parameters associated with a high percentage of time devoted to these activities were solo practice, percentage of revenue from aesthetic surgery greater than 50 percent, a practice environment designation of moderately or very competitive, and ten or more area surgeons offering aesthetic surgery (p < 0.05). High patient income led to only slight decreases in price sensitivity and did not significantly reduce the amount of time spent on marketing and practice development. Although the rest of the healthcare industry has undergone a period of consolidation, aesthetic surgeons have been able to resist these changes. The results of this survey suggest that the fragmented nature of the aesthetic surgery industry is associated with additional burdens on plastic surgeons. As the aesthetic surgery market becomes more competitive, plastic surgeons may benefit from consolidation to reduce costs and maximize efficiency.

BACKGROUND: Esophageal replacement is associated with significant morbidity that may lead to operative interventions. This study reviews the management and outcome of children who underwent reoperation after esophageal replacement. METHODS: Eighteen patients who underwent esophageal replacement from 1985 to 1997 were reviewed retrospectively. Ten patients underwent reoperation. Patient management, perioperative morbidity, and the dietary intake at follow-up were recorded for each patient. RESULTS: Of the reoperated patients, 7 had esophageal atresia, 2 had caustic ingestion, and 1 had achalasia. Nine patients received a colon interposition, and 1 received a reverse gastric tube as the initial esophageal replacement. Seven patients required revision of the anastomoses. Three patients required complex esophageal reconstruction: 1 underwent gastric transposition, 1 underwent free jejunal graft, and 1 underwent gastric transposition combined with free jejunal graft. Seven patients were eating well at follow-up. Two patients still required partial gastrostomy tube feeding. One patient died 6 months postoperatively from aspiration pneumonia. CONCLUSIONS: Esophageal replacement continues to be a challenging operation associated with significant complications. Most reoperative procedures were directed toward strictures and persistent fistulae. Complete graft failure can be managed by gastric transposition or free jejunal graft. Despite the perioperative morbidity, most patients have good functional outcome.

Presurgical infant orthopedics has been employed since the 1950s as an adjunctive neonatal therapy for the correction of cleft lip and palate. In this paper, we present a paradigm shift from the traditional methods of presurgical infant orthopedics. Some of the problems that the traditional approach failed to address include the deformity of the nasal cartilages in unilateral as well as bilateral clefts of the lip and palate and the deficiency of columella tissue in infants with bilateral clefts. The nasoalveolar molding (NAM) technique we describe uses acrylic nasal stents attached to the vestibular shield of an oral molding plate to mold the nasal alar cartilages into normal form and position during the neonatal period. This technique takes advantage of the malleability of immature cartilage and its ability to maintain a permanent correction of its form. In addition, we demonstrate the ability to nonsurgically construct the columella through the application of tissue expansion principles. This construction is performed by gradual elongation of the nasal stents and the application of tissue-expanding elastic forces that are applied to the prolabium. Use of the NAM technique has eliminated surgical columella reconstruction and the resultant scar tissue from the standard of care in this cleft palate center

The correction of sagittal deformities of the chin presents a seemingly simple surgical challenge. However, several authors have reported negative sequelae from such chin surgery, During the past 11 years, the senior author (B.M.Z.) has evaluated more than 100 such cases of adverse results after chin augmentation. Many surgeons, it seems, use chin implants unnecessarily and, thus, get into trouble. Because alloplastic chin augmentation is deceptively easy, it tends to be overused in certain situations. Either the surgeon's evaluation is too narrowly focused or his/her abilities to perform other types of surgery (e.g., osseous genioplasty) are limited. Herein, the authors present a diagnostic evaluation protocol, QUAC (Quick Analysis of the Chin), to assist in avoiding simple mistakes in alloplastic chin augmentation. This protocol will alert the surgeon to situations that, if unrecognized, will cause problems and create an unhappy patient. This article will specifically focus on (1) lower lip analysis; (2) the effect of the labiomental fold; (3) chin pad evaluation, both static and dynamic; (4) the anatomy of the cleft chin; (5) special situations; and (6) how to troubleshoot three common problems. The accompanying article, Chin Surgery II, will present a new operation that treats a chin problem that was previously difficult to correct

At the present time, surgical reduction of an isolated large chin is not a simple procedure. Essentially, two surgical procedures exist for chin reduction: osteotomy with setback or prominence reduction by burring. Both of these procedures have potential negative aesthetic sequelae, including mental nerve injuries, bony contour irregularities, increasing submental soft-tissue fullness, and chin pad ptosis. In this report, the authors present a new approach to chin reduction: submental ostectomy with soft-tissue excision. This technique reduces the prominent chin and avoids ptosis by soft-tissue adjustment

Since its description in China in 1978, the radial forearm free flap has become a workhorse for the reconstructive surgeon. However, the flap has known disadvantages in complications of the wrist donor site. Skin graft breakdown with exposure of the flexor tendons of the wrist is the most common. The authors describe in a patient series a new treatment for this complication. They used subatmospheric pressure dressing to stimulate granulation tissue coverage of the tendon and to facilitate epithelialization. As many as one third of all patients undergoing radial forearm free flaps develop exposed tendon complications and may benefit from Vacuum Assisted Closure (VAC) therapy