Faculty Bibliography

BACKGROUND: The closure of any circular or asymmetric wound results in puckering or excess of tissue known as dog-ears. OBJECTIVE: Facility in managing dog-ears is an invaluable tool in cutaneous surgery due to its common presentation. METHODS: Methods for correcting dog-ears are extensively detailed in both the plastic and dermatologic surgery literature. This review provides a practical outline of nine methods of dog-ear correction along with pertinent schematic and clinical illustration. RESULTS: A comprehensive approach to dog-ears requires knowledge of tissue dynamics, adherence to proper surgical technique, and strategies for the management of dog-ears. CONCLUSIONS: A thorough understanding of dog-ear formation and correction allows the surgeon to choose the most appropriate management for dog-ears in any clinical setting

Angiogenesis is essential for the increased delivery of oxygen and nutrients required for the reparative processes of bone healing. Vascular endothelial growth factor (VEGF), a potent angiogenic growth factor, has been implicated in this process. We have previously shown that hypoxia specifically and potently regulates the expression of VEGF by osteoblasts. However, the molecular mechanisms governing this interaction remain unknown. In this study, we hypothesized that the hypoxic regulation of VEGF expression by osteoblasts occurs via an oxygen-sensing mechanism similar to the regulation of the erythropoietin gene (EPO). To test this hypothesis, we examined the kinetics of oxygen concentration on osteoblast VEGF expression. In addition, we analyzed the effects of nickel and cobalt on the expression of VEGF in osteoblastic cells because these metallic ions mimic hypoxia by binding to the heme portion of oxygen-sensing molecules. Our results indicated that hypoxia potently stimulates VEGF mRNA expression. In addition, we found that nickel and cobalt both stimulate VEGF gene expression in a similar time- and dose-dependent manner, suggesting the presence of a hemelike oxygen-sensing mechanism similar to that of the EPO gene. Moreover, actinomycin D, cycloheximide, dexamethasone, and mRNA stabilization studies collectively established that this regulation is predominantly transcriptional, does not require de novo protein synthesis, and is not likely mediated by the transcriptional activator AP-1. These studies demonstrate that hypoxia, nickel, and cobalt regulate VEGF expression in osteoblasts via a similar mechanism, implicating the involvement of a heme-containing oxygen-sensing molecule. This may represent an important mechanism of VEGF regulation leading to increased angiogenesis in the hypoxic microenvironment of healing bone

The advent of managed care has unleashed market forces on the health care system. One result of these new pressures is a shift from nonprofit to Wall Street-based financing. This report quantifies these trends by comparing health organizations' financial structures in the 1980s and now. The reasons behind this shift and the function of the stock market are examined. A review of Wall Street's key financial measures confirms that health care has shifted to the stock market as its principal means of financing. The stock market works by assigning a current price to a company's stock based on estimates for future earnings. Thus, companies desire predictability in their costs, revenues, and profits. Plastic surgeons can master this system by meeting the challenges imposed by Wall Street financing. Important steps include continuously measuring costs and outcomes of procedures, demanding cost data from hospitals and payers, using these data to improve costs and outcomes, and taking advantage of the system's openness to innovation and easier access to capital. As they seek to protect their role as medical decision makers under the new free-market system, plastic surgeons can benefit from understanding the mechanisms of the stock market.

Here we describe the Community Outreach and Education Program (COEP) at the National Institute of Environmental Health Sciences (NIEHS) Center at the Joseph L. Mailman School of Public Health of Columbia University, New York City. Originally founded as an NIEHS P20 Developmental Center to address issues of environmental racism in Harlem, the NIEHS Center for Environmental Health in Northern Manhattan is now beginning its third year of funding as a full P30 Center (the Center). Over the past 4 years, both the Center and its COEP have benefited from increased attention being paid to legitimate community-university partnerships, broad-based efforts to address racial and ethnic disparities in health, and renewed concern about the urban environment. A key feature of our COEP model is that the resources and staff reside in a community-based organization, namely, West Harlem Environmental Action (WE ACT). This institutional decision has been critical in advancing the Center's ultimate goal of improving the health and environment of northern Manhattan. Towards this end, the Center conducts timely and relevant research that informs public policy. To illustrate our COEP model, we highlight here the Center's research and activities around diesel exhaust, indoor allergens and asthma.It is our contention that CEOP activities are the basis for conducting scientifically valid, socially relevant research. We further argue that the science we conduct is fundamentally strengthened by the integration of the COEP into the Center's research culture and practice. C1 Northridge, Mary E.; Division of Environmental Health Sciences, Joseph L. Mailman School of Public Health of Columbia, 60 Haven Avenue, Level B-1, New York, NY, 10032, USA U1 0 U2 0

Distraction osteogenesis has proven to be an effective technique for the correction of mandibular deficiencies. However, problems have been encountered in achieving a final, idealized form of the mandible when using distraction devices capable of moving the bone segments in only one dimension (uniplanar). Specifically, occlusal irregularities and deficiencies in lower facial contour have been seen following uniplanar distraction. To address these problems, a distraction device capable of independent movements in three planes (multiplanar) was developed. Previously reported studies in a canine model have demonstrated that this device can successfully distract the mandible along both the sagittal axis (anteroposterior or z-axis) and the vertical axis (superoinferior or y-axis). This study examines the ability of the multiplanar device to distract along the sagittal and horizontal axes (mediolateral or x-axis). A total of 12 dogs were included in the study. All animals underwent unilateral or bilateral mandibular distraction using an external multiplanar device. After a latency period of 5 days, primary distraction along the anteroposterior axis at a rate of 1 mm/day for 10 days (10 mm total) was performed. During the following 10 days, along with an additional 11 mm to 20 mm of anteroposterior axis distraction, concomitant secondary distraction was performed along the horizontal (mediolateral) axis at a rate of 5 degrees/day (50 degrees total). Cephalometric radiographs were obtained preoperatively and at the conclusion of both anteroposterior and combined anteroposterior-mediolateral distraction. Computed tomography (CT) scans were obtained preoperatively and at the end of consolidation (28 days), after which all animals were sacrificed and the dry skulls examined. In all animals, distraction along the mediolateral or x-axis was found to change the anteroposterior projection of the mandible. Varus angulation of the device with respect to the midline of the mandible caused compression of the distracted segments and reduced the anteroposterior thrust of the mandible. In contrast, valgus positioning of the device, with respect to the midline of the mandible, created the opposite effect, increasing the distracted length in the anteroposterior direction. The bone (mandibular) segments being distracted assumed the orientation of the device only for valgus positioning of the device (producing a decrease in the bigonial distance). Conversely, there was no effect from the mediolateral angulation on the distracted segments during varus positioning of the device. A possible explanation for this finding may be a greater resistance to an increase in the bigonial distance (varus positioning of the device) posed by obstruction of lateral movement of the condyle. This stands in contrast to a decrease in the bigonial distance observed following valgus positioning of the device. These findings confirm the clinical impression that distraction along the anteroposterior or sagittal axis remains the critical or keystone therapeutic maneuver in distraction of the mandible. Mediolateral or horizontal axis distraction is best used only as a supplementary movement; in essence, it only affects the anteroposterior dimension with little impact on clinically relevant changes to the bigonial distance

Atherosclerotic vascular disease causing extensive tissue loss of the lower extremities often results in primary amputation. Combined revascularization and free tissue transfer has been described as a method of extending limb salvage to these patients. The durability of this combined procedure remains unknown, thus the objective of this report is to describe the immediate and long-term results in a series collected over 6 years. From 1992 to 1998, 15 patients with a mean age of 60 years underwent combined revascularization and free tissue transfer. Mean ulcer size measured 45 cm(2) for a mean duration of 7.4 months preoperatively and 12 patients had exposed bone or tendon. Vascular reconstruction included popliteal (3), tibial (6), and pedal (6) bypass with concomitant myocutaneous free flap, using mostly rectus abdominis or latissimus dorsi muscle. There were no perioperative deaths. One patient suffered a nonfatal myocardial infarction. Two patients had a postoperative wound hematoma and one required vascular graft revision. Patients were followed for 4 to 75 months (mean = 23 months). Four patients have required amputations (3 early, 1 late), three of whom had preoperative renal failure. The limb salvage rate has been 72% at 36 months,