P1 - Absence of Graft-Versus-Host Disease in Recipients of an Isolated Vascularized Bone Marrow Transplant

Presenter:	Chau Tai, MD
Co-Authors:	Louise Strande, MS, Riva Eydelman, BS, Xiaoli Sheng, MD, Martha Matthews, MD, Charles Hewitt, PhD
Affiliation:	UMDNJ/RWJMS-Cooper Health System, Camden, NJ

INTRODUCTION: Composite tissue allografts such as hand transplants contain multiple tissues of different antigenicities. An extraperitoneal isolated vascularized bone marrow transplant (iVBMT) model was developed in the rat in order to study the contribution of the bone marrow component. We hypothesized that the iVBMT would be functional and cause graft-versus-host-disease (GVHD) in a fraction of the recipients. METHODS: Group A=male Lewis donor transplanted across a semiallogeneic barrier to a female Lewis-Brown-Norway (LBN) rat, n=25. Group B=control, male LBN to female LBN, n=10. No immunosuppression was used. The iVBMT model consisted of a left donor femur that was harvested with its nutrient vessels. The graft was anastomosed to the right femoral vessels of the recipient, and placed subcutaneously in the abdominal wall. The animals were sacrificed at various time points between 1 to 14 weeks. RESULTS: Both groups appeared healthy and gained weight. Graft vessels were patent at necropsy, and histology of the grafts demonstrated a viable marrow compartment. No animals exhibited GVHD at sacrifice. CONCLUSIONS: The immune cells derived from the bone marrow component did not cause GVHD in the iVBMT model, and may potentially induce immune tolerance. Further characterization of this issue is underway.

P2 - Aggressive Surgical Resection and Reconstruction for Locally Recurrent and Locally Advanced Breast Cancer

Presenter:	Stephen P. Povoski, MD
Co-Authors:	Julio Hochberg, MD, Marcos Ardenghy, MD, James C. Yuen, MD
Affiliation:	Arthur G. James Cancer Hospital and Richard J. Solove Institute of The Ohio State University, Columbus, OH

Surgical treatment of breast cancer has continue to become less extensive and invasive while still alowing for excellent control of local disease. However, a minority of women will still develop locally recurrent breast cancer or will present with locally advanced primary breast cancer. In some of these selected situations, aggressive surgical resection and reconstruction may be the only hope for attaining local control of the disease. In ten selected patients (7 with locally recurrent breast cancer and 3 with locally advanced primary breast cancer), we performed aggressive surgical resection followed by various methods of reconstruction: latissimus dorsi myocutaneous flap(7); latissimus dorsi myocutaneous flap plus tissue expander and implant(1); inframammary extended pectoralis major myocutaneous flap(1) and split thickness skin graft(1). No major postoperative complications occurred. Only minor wound healing problems were seen in 3 patients. Two of the 10 patients developed a local recurrence on their chest wall. Both went on to develop distant metastatic disease. A total of 5 patients developed distant metastasis within 2 to 16 months of their surgery. All 5 patients with distant metastatic disease died within 5 to 18 months of their procedure. Five of the 10 patients are still alive at follow-up periods ranging from 3 to 16 years. All 5 of these patients remain free of disease. Reconstructive options may be limited by previous radiotherapy or by tumor involvement of the pectoralis major muscles or internal mammary vessels. Nevertheless, reconstruction in these cases can be achieved by the use of the omentum, free flaps, or a combination of techniques. In conclusion, potential long standing palliation, or even cure, in selected cases of locally recurrent breast cancer or in selected cases of locally advanced disease can be attained with an approach of aggressive surgical resection and reconstruction.

P3 - Alpha V Integrin Activates Jab1 to Promote Collagenase Production, Enhance Cell Migration and Perturb Wound Repair

Presenter:	Howard Levinson, MD
Co-Authors:	Alok K. Sil, PhD, John E. Conwell, BS, James E. Hopper, PhD, Donald R. Mackay, MD, H. Paul Ehrlich, PhD
Affiliation:	MS Hershey Medical Center, Hershey, PA

Purpose: Robust expression of av integrin in scar fibroblasts is associated with abnormal wound healing marked by atrophic, disrupted scar. A relationship between av integrin overexpression and collagenase expression was sought. The signaling pathway that mediates av integrin stimulated collagenase expression was investigated. Methods: Human Osteosarcoma Cells were transfected with the av integrin gene (HOSav cells). Overexpressing av integrin clones were incorporated into collagen lattices and a collagenase inhibitor added. A cDNA construct composed of the collagenase gene promoter fused to a luciferase reporter was transfected into HOS cells and cell lysates were analyzed. In addition, a screen was used to detect potential av integrin signaling molecules. HOS cells were transfected with Jun activation binding domain-1 (JAB1) antisense and the collagenase luciferase reporter and cell lysates were assayed for luciferase activity. Results: HOS cells did not contract collagen lattices but HOSav cells contracted collagen lattices beginning on day six. Blockade of collagenase inhibited av mediated lattice contraction. Overexpressing HOS av cells expressed more collagenase. Downregulation of JAB1 blocked collagenase expression in HOS av cells. Discussion: Expression of av integrin is associated with enhanced collagenase production and thus, upregulation of av integrin may lead to scar breakdown. JAB1 mediates av integrin signaling to stimulate collagenase expression. JAB1 is a potential target for controlling scar remodeling.

P4 - A Histological and Morphometrical Evaluation of the Cleft Lip Nose Alar Cartilages

Presenter:	Wilson Cintra, PhD
Co-Authors:	Luiz Gustavo Balaguer Cruz, MD, Miguel Modolin, Marcus Castro Ferreira, MD
Affiliation:	University of Sao Paulo, Sao Paulo, N/A

Patients with cleft lip & palate have associated nasal deformities with severity varies. Nevertheless the cleft lip & palate have been largely studied - its ethiology ,surgical corrections- some doubts about the ethilogy of the problem still without resolution. The objective of this research was to conclude if there was or not histological alterations on the alar cartilages of the cleft lip noses; we studied 36 specimens of alar cartilages from unilateral cleft lip nose , 18 specimens of the affected side and 18 specimens of the unaffected side, using a histological and morphometrical evaluations. To compare the results of the morphometrical evaluations we used the Chi- Square test (p=0.05), and the results of the histological evaluations were analyzed by the T-Student test (p=0.05). The morphometrical evaluations was done based on the model developed by Weidel in 1979 that is still being used until this days on liver and kidney biopsies. We concluded that there no histological or morphometrical differences between the two sides.

P5 - Anterolateral Thigh Flap: Anatomical Study of the Brazilian Population and Clinical Application

Presenter:	L.H. Ishida, MD
Co-Authors:	L.C. Ishida, MD, H.A. Nakamoto, MD, L. Rodrigues, MD, F.L. Saito, MD, G.P. Sturtz, MD, J.M. Besteiro, PhD, M.C. Ferreira, PhD
Affiliation:	Hospital das Clínicas - University of São Paulo, São Paulo, N/A

The anterolateral thigh flap was first described by Song, in 1984 (4), as a fasciocutaneous flap. Since the development of the perforator flaps by Kroll in 1988 (9) and Koshima in 1989 (2,8), many studies have been made, concluding that the majority of the anterolateral flaps did not have a septocutaneous pedicle. These flaps were nourished by muscle perforating vessels from lateral circumflex artery descent branch. (4,5,6,7). The aim of this paper was to study our population anatomy of anterolateral flaps and to report our experience in clinical practice. Fifty-eight anterolateral regions were dissected in twenty-nine fresh cadavers (table 1). The number of perforators found ranged from 1 to 4 in each dissected leg(Graphic 1). The majority of vessels were distributed around the middle point between the superior iliac spine and the patellas lateral edge (graphic 2). Pedicles presented an average length of 13,48 cm and an average intramuscular path of 4,46 cm (graphic 3). The majority of the perforators coursed toward the vastus lateralis muscle (72%), while only 16% of the perforators had a septal course (graphic 4). The mean artery diameter was 2,55 mm and mean vein diameter was 3,47 mm. From December 2000 to January 2002, 29 flaps were used in the clinical series, with 1 ( one ) complete failure (3 %) due to kinking of the pedicle. No partial loss was observed. The largest flap dimension was 40 x15 cm and was based in 2 perforators. Flaps as wide as 10 cm could be used with primary closure of the donor area. Our anatomical study showed a similar anatomy of the brazilian population when compared with the asian population described in previous studies. Although there is a quite variable distribution of the perforators, we believe that the anterolateral thigh flap is reliable and has minor donor area deficit.

P6 - Anterolateral Thigh Flap in Head and Neck Reconstruction: Preoperative Assessment to Determine Primary Closure Versus Skin Grafting

Presenter:	Melinda L. Lacerna, MD
Co-Authors:	Edgar Lueg, Michael McNicholl
Affiliation:	Kaiser Permanente, Los Angeles, CA

The anterolateral thigh flap has numerous advantages in head and neck reconstruction, including versatility, good tissue coverage, and relative ease of elevation. However, it has not yet come into widespread use, especially in North America, due to the anatomic variations of its perforators and possible donor site morbidity. In addition, donor site morbidity (decreased range of motion, cutaneous anesthesia) is more common if the donor site is closed with a skin graft. We describe a method of preoperative assessment to determine beforehand if the donor site can be closed primarily or with a skin graft based on the patients thigh size and anticipated oncologic defect. Furthermore, we describe our experience with the anterolateral thigh free flap and its advantages over other flaps classically used for head and neck reconstruction. Eleven anterolateral thigh flaps were transferred for eleven patients from September 1999 to May 2001. Resections were performed for a variety of head and neck tumors including squamous cell carcinomas of the maxilla, mandible, tongue, buccal mucosa, floor of mouth, oropharynx, ewings sarcoma of the infratemporal fossa, and liposarcoma of the temporal region and infratemporal fossa. Patient age ranged from 12-81, with an average of 57. Nine men and 3 women were included in the study. Defect size ranged from 8x5 cm to 16x12 cm, with an average of 10x11 cm. All operations were performed by the same surgeons in a tertiary care medical center. Six of the donor sites were closed primarily while five required skin grafts. The defect size did not correlate with the method of closure selected, but was determined at the time of operation. Preliminary findings suggest that thigh circumference may be a better predictor for primary closure versus skin grafting. We believe this is relevant preoperative information since donor site morbidity is related to closure by skin grafts.

Presenter:	Peirong Yu, MD
Affiliation:	U.T. M.D. Anderson Cancer Center, Houston, TX

The anterolateral thigh (ALT) flap has never gained popularity in the United States due to the variations of vascular anatomy and thick thigh fat in Westerners. To address these issues, ten ALT free flaps were performed for head and neck reconstruction: seven for tongue and three for temporal-orbital-maxillary reconstruction. The mean age was 60 ± 12 years with body mass index of 26.4 ± 4.9. A perforator near the midpoint between the anterior superior iliac spine and superolateral patella (perforator B) was present in all the cases; all but one of the perforators were musculocutaneous. A more distal perforator (perforator C) was present in eight cases, which was musculocutaneous in each case, while a more proximal one (perforator A) was present in five cases with three being septocutaneous. The average pedicle length to the perforator A was 9.8 ± 1.5 cm, while that to the perforator B was 13.4 ± 2.5 cm. The average thickness of the flap at the level of the perforator B was 16.3 ± 3.9 mm (range 10 to 22 mm). The lateral femoral cutaneous nerve was included as a sensate flap in four patients. Complications included one case of venous congestion, which was salvaged via re-exploration, and one small contained leak, which healed spontaneously. It was concluded that the ALT flap is well suited for head and neck reconstruction. The advantages of this flap include minimal donor-site morbidity, great pedicle length and size, possible sensory reinnervation, retaining of bulk with minimal atrophy, and easy simultaneous two-team approach. Unlike with abdominal fat, the thickness of the ALT flap remains relatively constant in patients having a wide range of body habitus. The relatively thick thigh fat in Westerners is actually advantageous for head and neck reconstruction, especially for near total glossectomy defects where bulk is needed.

Presenter:	Reha Yavuzer, MD
Co-Authors:	Alper Sari, MD, Ipek Isik, MD, Osman Latifoglu, MD, Omur Ataoglu, MD
Affiliation:	Gazi University Medical Faculty, Ankara, N/A

Malherbe tumor, also known as pilomatrixoma, is a benign cutaneous tumor of hair matrix origin. Though Malherbe and Chenantis were the first ones to describe this tumor, they failed on the assumption that it originated from the sebaceous glands. Typical presentation of the tumor is an asymptomatic, solitary, subcutaneous nodule occurring on the head and neck region, in the first two decades of life. The tumor does not possess an aggressive behavior and surgery is the treatment of choice. Variations from this typical form exist, as multiple, syndromic, aggressive, symmetrically localized or giant lesions have been sporadically reported.

We present a rare case of multiple pilomatrixoma with one ulcerative lesion appearing on the preauricular region and another one on the nasolabial fold in a 14 month-old baby. The ulcerative lesion exhibited increased mitosis on histopathologic examination.

Here presented case contains several interesting aspects in its clinical profile. First of all, despite the fact that these tumors can be seen in the childhood period, they are not common during infancy and this case is one of the younger cases that has been reported if not the youngest one. Secondly, multiple occurrence is rare with an incidence of 2% to 3.5% of all cases. In our case there were two lesions located one on the left preauricular region and the other one on the right nasolabial sulcus. Moreover, one of the lesions showed significant ulceration on its surface which is not a regular finding of pilomatrixomas. Last but not least the histopathological evaluation of the lesion with ulceration showed increased mitosis which is an unusual feature that may suggest the potential aggressivity of the tumor. Having all these peculiarities in the same patient makes the case quite unique and increases the value of long-term follow-up.

P9 - Autologous Tissue Breast Reconstruction in the Obese: A Twelve Year Review of Our Experience in a South Texas Patient Population

Presenter:	Jennifer L. Walden, MD
Co-Authors:	Jennifer Murphy, MD, Angela F. Champion, MD, Linda G. Phillips, MD
Affiliation:	University of Texas Medical Branch, Galveston, TX

Introduction: The increase in surgical risks for obese patients is well known, and obesity is generally considered a contraindication for pedicled as well as free TRAM flap reconstruction. It is also believed that marked obesity represents an absolute contraindication for TRAM flap reconstruction and is associated with unacceptably high rates of flap and donor site morbidity.

Purpose: The purpose of our study was to determine the complication rates in our obese and markedly obese patient population who have undergone breast reconstruction using either transverse rectus abdominis myocutaneous (pedicled and free) or latissimus dorsi (LD) flap. Our patient population is comprised of a number of obese and markedly obese patients referred from a large, indigent Southeast Texas catchment area.

Methods: The records of 157 women who had undergone autologous tissue breast reconstruction in the past 12 years were reviewed to determine the effect of morbid obesity on patient satisfaction and complication rate. The patients were divided into four groups- ideal body weight (body mass index 19-24), overweight (25-26), obese (27-34), and markedly obese (greater than or equal to 35). Events listed as complications included fat necrosis requiring revision, seroma or hematoma requiring evacuation, hernia, partial or complete flap loss, and systemic complication such as deep venous thrombosis.

Results: The complication rate for all patients receiving autologous reconstruction was 21%. In the ideal body weight group(n=59), the complication rate was 14%; overweight group (n=16), 6%; obese group (n=59), 25%;and morbidly obese group (n=23), 32%. Pedicled TRAM complication rates were lower than free TRAM rates in the obese and markedly obese groups, and pedicled TRAM rates ranged from an expected lower rate (7%) in the ideal body weight category to a higher rate among the markedly obese (22%). For patients undergoing LD reconstruction, there were few complications in the ideal and overweight categories, but higher rates in the obese population (17%). Patient satisfaction rates were higher with TRAM flap thatn LD reconstruction regardless of weight group or presence of complication.

Conclusion: Our review suggest that the TRAM flap is a viable option for breast reconstruction and that obesity or marked obesity is not necessarily a contraindication (with understanding of possible complications and proper patient education). This is in contrast to previously published series with higher reported rates and populations with generally lower BMI's. Perioperative management and surgical procedure may be adapted to this patient group enabling optimal breast reconstruction in cases that may have been denied in the past.

P10 - Basic Fibroblast Growth Factor (B-FGF) Expression and Flap Viability Following Surgical Delay of a Rat Transverse Rectus Abdominis Myocutaneous (Tram) Flap

Presenter:	Michael S. Wong, MD
Co-Authors:	Detlev Erdmann, MD, Ranya Sweis, Christiane Pollmann, Gregory S. Georgiade, MD, L. Scott Levin, MD, Kevin C. Olbrich, PhD, Bruce Klitzman, PhD
Affiliation:	Duke University Medical Center, Durham, NC

Background: Partial TRAM flap loss in breast reconstruction can be a devastating complication. Surgical delay of the TRAM flaps has been shown to improve its viability. b-FGF is a well-known, potent angiogenic molecule.

Objective: To study the expression of b-FGF and flap viability in surgically delayed rat TRAM flaps.

Methods: 35 female Sprague-Dawley rats were randomized to 1 of 4 groups: no delay (N=6), 7-day delay (N=12), 14-day delay (N=10), and 21-day delay (N=7). Surgical delay consisted of incising the perimeter skin of the planned TRAM flap followed by ablation of both superior epigastric arteries and the left inferior epigastric artery, thus preserving the right inferior epigastric artery, and raising all but Zone I off the abdominal wall fascia. Three days following TRAM procedure, all rats were euthanized. Post-fluoroscein planometry determined percent area viability of both superficial and deep portions of TRAM flaps. Additionally, full thickness TRAM specimens were taken from Zones I- IV for b-FGF ELISA analysis. Analysis of variance and the student T-test were used.

Results: b-FGF levels (pg b-FGF/mg protein) are presented as the mean+SEM

Delay	Zones
(Days)	I	II	III	IV
0	41.3+16.2	61.3+19.4	27.2+11.3	24.1+15.0
7	93.2+15.1	88.2+15.2	86.1+14.5	94.0+15.3
14	93.8+10.5	94.5+10.4	75.5+5.9	77.5+11.1
21	75.9+11.2	66.0+8.2*	77.3+8.7	79.2+11.3

All delayed flaps (*except Zone II, 21-day delay) had significantly higher b-FGF levels compared to non-delayed flaps (p < 0.05). Among delayed flaps, b-FGF levels did not differ with length of delay nor flap zone. All delayed flaps had a significantly higher area of flap viability superficially than non-delayed flaps (p < 0.05). There was no difference in deep flap viability.

Conclusion: Surgical delay of TRAM flaps is associated with improved flap viability and significantly elevated levels of b-FGF over non-delayed TRAMS. Increases in b-FGF may contribute to improved TRAM flap viability following delay surgery.

P12 - Clinical Correlations of Customized Silastic Nasal Stent for Prevention of Recurrence After Deviated Nose Correction

The correction of deviated nose has been widely performed in the field of plastic surgery. But the recurrence after operation have been quite frequent. Even though exact anatomical correction through open rhinoplasty procedure made the recurrence rate decreased, complete prevention of recurrence was very difficult because the cartilaginous portion of nasal skeleton tends to return to previous deviated state and the subcutaneus scar of the soft tissue distort the nasal skeleton . For the prevention of nasal deviation after corrective rhinoplasty, we used conventional silastic nasal stents for 6 month after corrective rhinoplasty in 50 patients from February 1991 to September 1996. We experienced only 2 cases of recurrent deviation and 2 cases of nasal obstruction. By close observation of the CT scan and simple X-ray films of the patients who had undergone recurrent deviation with the conventional silastic nasal stent, we concluded the conventional nasal stents were inappropriately short to prevent the recurrent nasal deviation. From October 1996 to October 2001, we used the customized silastic nasal stent in 41 patients which were long enough(mean lenth: 3.5 cm) to reach the perpendicular plate of ethmoid, enabling to support the full length of the cartilaginous dorsum and septum and well fixed to individual patients' nostril, instead of using the conventional nasal stents which were to short to support the whole cartilaginous portion (mean length; 2.0cm). We experienced satisfactory results except 3 cases of mild nasal deviation and 1 case of nasal obstruction. By using the customized silastic nasal stent, the recurrence of nasal deviation has been minimized without any discomfort and nasal airway obstruction, no skin and mucosal ulceration has occurred, and the postoperative nasal obstruction has been markedly improved compared to the conventional nasal stent.

P13 - Combined Use of Normal Mode Ruby Laser and Q-Switched Alexandrite Laser in the Treatment of Giant Melanocytic Nevus

Presenter:	Taro Kono, MD
Co-Authors:	Ali Riza Ercocen, MD, Yuji Kikuchi, Motohiro Nozaki
Affiliation:	Tokyo Womenfs Medical University, Tokyo, N/A

Objective: Treatment of congenital melanocytic nevi (CMN) with either the Q-switched (ruby, alexandrite, and Nd:YAG) lasers or the normal-mode ruby laser (NMRL) have been well established by many investigators, although there have been no consensus on the treatment of CMN. Recently, we developed a combined laser approach for treatment of CMN using both NMRL and Q-switched alexandrite laser. We present the procedure and efficacy of this combined laser treatment on giant CMN. Case Report: A2 year-old girl presented a dark-brown, giant CMN on her back, measuring 13x11 cm in size. Histological examination revealed a superficial compound nevus with no evidence of malignancy. The patient was treated first with the NMRL (694 nm wavelength, 18 J/cm2 energy fluence, 1 msec pulse duration, and 15 mm spot size). After the epidermis peeled off manually by wet gauze, the treatment was followed by sequential application (3 to 4 ) of Q-swithced alexandrite laser (755 nm wavelength, 7 J/cm2 energy fluence, 50 nsec pulse duration, and 3 mm spot size). Combined laser treatment was accomplished after four treatment sessions at 4 months intervals. The efficacy of the treatment was determined by clinical evaluation and melanin reflectance spectroscopy, and histologic examination before laser and 6 months after the last treatment. Results and Conclusion: Clinical response of giant CMN to combined laser treatment was excellent, and a significant improvement was obtained. Melanin reflectance spectroscopy also revealed that melanin content was significantly decreased and that a 94 % clearance was achieved. Histologic examination showed a marked decrese in the number of the nests in the juctional, papillary, and reticular dermis. We conclude that combined laser treatment is an effective therapeutic method in the treatment of small to giant CMN, but further study is warranted to follow-up reccurence or malignant change.

P14 - Content of Bone Marrow in the Rat Bones and Planning of Flaps for Experimental Vascularized Bone Marrow Transplantation

Presenter:	Fabio Quatra, MD
Co-Authors:	Oreste M Romeo, MD, Dave Lowemberg, MD, Darrell Brooks, MD, Daniela Perri, MS, Lee Ann Baxter-Lowe, PhD, Francesco Stagno D'Alcontres, MD, Michele R Colonna, MD, Harry J Buncke, MD
Affiliation:	The Buncke Clinic, San Francisco, CA

The search for Tolerance in transplantation is highlighting the importance of Bone Marrow which is highly immunogenic, may contribute to occurrence of rejection, may induce haematological chimerism (and possibly tolerance) or may be responsible for a lethal Graft-versus-Host Disease. The aim of this anatomical study was to evaluate the content of bone marrow in the various bones of the rat and to identify the corresponding flaps for their possible use in the study of vascularized bone marrow transplantation, comparing them to the rat hindlimb, one of the most popular models for the study of composite tissue transplantation. Materials and methods: thirty rats (Sprague Dawley, Simonsen Lab. Inc.) were used, in a two-part study. In the first part, bones were mechanically cleaned of the soft tissues, fixed in buffered formalin for 48 hours, decalcified in a mixture of formic acid and calcium chelants for further 48 hours, and then were processed in different ways for bone marrow extraction and weighing (±1 mgr), assessment of volume (± 10ml) or assessment of cellularity on Hematoxylin-Eosin stained sections, blindly performed with assessment of the ratio of viable bone marrow to fat degenerated marrow. In the second part, we performed an anatomical study of the vascular pedicles and corresponding microvascular flaps, including vascular injection with latex and lead-oxide, x-rays and experimental in vivo transplantation (anaesthesia: Sodium Pentobarbital 30-50 mg/Kg i.p) when indicated. Results and discussion: Figures for volume and weight slightly differed between different bones, consistently with a different density and cellularity. As a general rule, cellularity showed a centripetal distribution, higher in axial skeleton and very little bone marrow could be found distally to the wrist or ankle with few nests of bone marrow sparse in the carpal bones and in the phalanxes. A dominant vascular pedicle is present in most bones, with few exceptions like the humerus, and we describe the microvascular transplant of a whole hemitorax (see Fig.) and of the cranial vault. Only few flaps appear truly useful as experimental models. The hindlimb, including a modification developed by us with the removal of most of the bone marrow, is probably still the best flap for the study of vascularized bone marrow or composite tissue transplantation.

Presenter:	Yuzo Komuro, MD
Co-Authors:	Ayato Hayashi, MD, Akira Yanai
Affiliation:	Juntendo University, Tokyo, N/A

Distraction osteogenesis has recently been applied to the treatment of craniosynostosis. However it has a disadvantage that the deformed bone cannot be reshaped. We performed cranioplasty by gradual distraction combined with radial osteotomy to allow for flattering of the segment of bone. Five cases with craniosynostosis were treated with distraction osteogenesis with radial osteotomy. These included scaphocephaly in three, trigonocephaly in one, and oxycephaly in one case. In the patient with scaphocephaly, pai osteotomy was performed; however osteotomized bone was not detached from underlying dura. Two distraction devices were placed in the parasagittal region bilaterally. In two patients out of three, reverse-distraction devices were applied in the removed coronal suture to reduce in anteroposterior skull length. The abnormal bossing of the frontal and occipital regions was reduced by partially radial osteotomy. In the patient with trigonocephaly, fronto-orbital osteotomy was done leavingthe bone attached to the dura. Fused metpic suture was also osteotomized. Three distraction devices were applied to the bitemporal and metpic suture regions. The frontal bone was partially remodeled with radially oriented osteotomies. In the patient with oxycepaly, the occipital bone was osteotomized and two distraction devices were applied. Radial osteotomy was performed in the occipital bone. The postoperative courses were uneventful and good cranial shapes were obtained in every case. Distraction osteogenesis offers the advantages of no need for bone graft, no residual extradural dead space, and maintenance of vascularity to the osteotomized bone through the attached dura. On the other hand, drawbacks of the technique include the inability to remodel the deformed bone and the necessity of the additional operatin to remove the distraction device. We think distraction combined with radial osteotomy could improve the former drawback by remodeling deformed bone.

P16 - Detection of Isogenic Functional Rat Fibroblasts by Adenoviral Gene Transfer in a Transplantation Model

Presenter:	Hans-Guenther Machens, MD
Co-Authors:	Timo Spanholtz, Alexandra Maichle, Christian Niedworok, Guido Middeler, Peter Mailaender, H.A. Katus, MD, S. Krueger, MD, T. Wickham, PhD
Affiliation:	Luebeck University Clinics, Luebeck, N/A

Introduction: Autologous cell transplantations are gaining significant importance in the field of Plastic and Reconstructive Surgery. This model describes a technique for functional visualisation of isogenic cells after transplantation. Methods: After subcutaneous Silastic implantation in 2 animals for a time period of 5 days, isogenic rat fibroblasts were isolated and cultured for 5 cell passages. At MOI 100, cells were transfected with lac-Z gene using a specially constructed adenoviral vector to express ß-galctosidase (AdF.Z(pK7). Each 5 x 106 cells/animal were transplanted in a total of 10 isogenic animals (Group I). The in vivo target was the panniculus carnosus of a 8 x 2 cm Mc Farlane flap, raised for cell transplantation. Another 10 animals received non-modified cells in the same model (Group II). One week later, all animals were sacrified, the flaps were clinically evaluated and stained for X-galactosidase and HE after formaline-fixation. Results: In all animals of Group I transplanted fibroblasts initiated massive production of ß-galactosidase, shown as intensive blue-staining by X-gal. In Group II transplanted cells could not be differentiated from autochthonous fibroblasts. HE-staining showed no increase of polymorphonuclear cells in both groups. Clinical evaluation of percentual flap survival revealed no statistically different results. Conclusion: Adenoviral gene transfer encoding AdF.Z(pK7) allows in vivo detection of isogenic functional rat fibroblasts after transplantation. According to this model, other adenoviral vectors can be utilized to induce cell-mediated therapeutic angiogenesis by appropriate genes.

P17 - Detection of M-Cadherin Expression After Nerve Repair in a Rat Sciatic Nerve Model

Presenter:	Katsunori Niitsuma, MD
Co-Authors:	Mitsuo Hatoko, MD, PhD, Masamitsu Kuwahara, MD, Aya Tanaka, MD, Satoshi Yurugi, MD, Hiroshi Iioka, MD
Affiliation:	Nara Medical University, Kashihara, N/A

It is well recognized that M-cadherin plays important roles in myogenesis. In the present study we investigated M-cadherin expression in skeletal muscle in denervation/reinnervation process. After rat sciatic nerve was resected by fine scissors, the nerve was sutured using 10-0 monofilament nylon suture. At various periods up to 24 weeks after the operation, the rats were killed by cervical dislocation, and the gastrocnemius muscle was removed. M-cadherin expression in the muscle was detected by Western blot analysis using anti-M-cadherin monoclonal antibody. The level of M-cadherin expression in the muscle was calculated as the relative amount to that found in normal control muscle. The level of M-cadherin expression was significantly low at 1,2,4,6 postoperative weeks, but the level returned to the control level on 9th postoperative week. The minimum level of M-cadherin was 0.184±0.01 fold at 1st postoperative week. The operated foot started to move at the 6th postoperative week, and the degree increased with time. Theseresults demonstrated that the level of M-cadherin expression in skeletal muscle decreased in denervation/reinnervation process. Moreover, it may be suggested that expressed M-cadherin plays important roles in the functional regeneration of the skeletal muscle.

P18 - Dismasking Flap - An Extended Coronal Flap for Approach of Craniofacial Tumor and Trauma: Experience of Thirteen Cases

Presenter:	Keisuke Imai, MD
Co-Authors:	Hiroyuki Komune, MD, Takeru Nomachi, MD, Takuya Fujimoto, MD, Miki Fujii, MD
Affiliation:	Osaka City General Hospital, Osaka, N/A

"Dismasking flap" is the cranio-orbito-facial degloving technique employing circum-palpebral with or without piriform margin incisions and presents a wide surgical fields under direct view. With the use of dismasking flap it was possible to completely resect tumors of the nasal cavity extending the orbit, the maxilla and the anterior cranial base. Dismasking flap is very useful for craniofacial tumor especially for malignant tumor, severe complex fracture of craniofacial bone and approach of the middle cranial base. This flap is retracted far way down so that there is little traction on the facial nerve branches in the flap and the middle cranial base comes into view with little compression on the brain. Since 1994, 13 patients have undergone Dismaking flap technique. The indicated cases were multiple cranio-facial bone fracture (3 cases) and malignant or premalignant craniofacial tumor (10 cases). The patients ranged in age from 3 to 62 years. The period of postoperative follow-up was from 2 to 7 years. There were no perioperative major complications. In minor complications, there were temporary lagophthalmos, blephaloptosis and partial skin necrosis after vascular embolization in three cases, but no permanent facial palsy in all cases. In this paper, we report the procedure of dismasking flap, its postoperative course and its complication.

P19 - Donor Nerve Regenerate by Collateral Sprouting in the End-to-Side Neurorrhaphy

Presenter:	Ayato Hayashi, MD
Co-Authors:	Yuzo Komuro, MD, Akira Yanai, MD
Affiliation:	Juntendo University, tokyo, N/A

Recently,we utilized an end-to-side neurorrhaphy in clinical cases. There are three kind of possibilities of nerve regenerating after the procedure. First,the nerve which was damaged through the procedure regenerates to the transplanted nerve. Second,recipient nerve sprouts collaterally. Third,after the collateral sprouting,the regenerated nerves were pruned gradually to avoid double domination. Some suggested the possibility of collateral sprouting from the donor nerve by the double-labelling technique or the gap model using the Y-shaped silicone tube. With the complete non-injury rat model,we proved that the axonal sprouting originates from the intact donor nerve collaterally. The sciatic nerve of adult wistar rat was dissected and transplanted between the left and right median nerve. In group A,recipient nerve was neurorrhaphied end-to-side with the divided donor nerve by non-injury technique. In group B,these nerves were wrapped in the faascia and neurorrhaphied non-injuriously. In group C,the epineurium was removed at the suture site and then neurorrhaphied. Thirty and sixty days after the operation,we evaluated nerve regeneration with electromyography of bilateral flexor muscle at the forearm. For morphometric evaluation, coaptatoin site was dissected out and fluorescent dye(DiI) crystal was attached to the proximal side of the harvested donor nerve. It was then incubated in 37 degree for 3 weeks. We observed cross section of this specimen under a confocal microscope. Even in a complete non-injury model, nerve regenerated electrophysically. Fluorescent dye(DiI) stained the regenerated nerve beyond the coaptation site. These results supported that in the end-to-side neurorrhaphy the nerve regenerated by the collateral sprouting from the donor nerve.

Presenter:	Matthew Klein, MD
Co-Authors:	Yvonne Karanas, MD, Lawrence C. Chow, MD, Geoff Rubin, MD, James Chang, MD
Affiliation:	Stanford University, Stanford, CA

Background: Preoperative angiography has become a standard component of microsurgical reconstruction planning. However, there are several potentially devastating complications from angiography including arterial occlusion and pseudoaneurysm . Computed tomographic (CT) angiography is a relatively new technique capable of providing detailed information about vascular anatomy as well as soft and bony tissue without the risks of traditional angiography . In addition, three dimensional image reconstruction uniquely demonstrates anatomic relationships between blood vessels, bones, and soft tissue.

Methods: Fourteen CT angiograms were obtained in patients referred for microsurgical reconstruction of the head and neck, lower extremity or upper extremity. Average patient age was 46.9 years (range 22 67). Three dimensional image reconstruction was performed on all studies. All studies were interpreted by a single staff radiologist with expertise in CT angiography. An analysis of charges related to the CT procedure were compared to conventional preoperative imaging for microsurgical repair.

Results: When compared to intraoperative evaluation, CT angiograms demonstrated all clinically relevant surgical anatomy. There were no complications of the radiographic procedure and no complications following free flap reconstruction. At our institution, the average CT angiogram charge was $1900, a fraction of the cost for traditional angiography.

Conclusion: CT angiography provides high resolution, three dimensional arterial, venous and soft tissue imaging without the risks of traditional angiogram at a significantly lower cost.

P21 - Effects of Human Amniotic Fluid on Peripheral Nerve Scarring and Regeneration in an Adult Rat Model

Presenter:	Guzin Yesim Ozgenel, MD
Co-Author:	Gulaydan Filiz, MD
Affiliation:	Uludag University Medical School, Bursa, N/A

Peripheral nerve surgery is still a challenging problem to solve. Despite the technical improvements in microsurgery, classic techniques of nerve repair have failed to accomplish satisfactory results. The purpose of this study was to investigate the effects of human amniotic fluid on peripheral nerve scarring and regeneration in rats. Forty Sprague-Dawley adult rats were used. After the right sciatic nerves of each rat were transected and repaired by epineural suture technique, nerves were divided into two groups according to the solution applied around the repair site. Nerves, applied 0.3 mL human amniotic fluid, were the experimental group and nerves, applied 0.3 mL saline were the control group. Macroscopic and histologic evaluation of peripheral nerve scarring were performed at 4th week. Nerves treated with amniotic fluid demonstrated significant reduction in the amount of scar tissue surrounding the repair site (p< .05). No evidence of reaction against human amniotic fluid was noted. Functional nerve regeneration was measured once in every two weeks using sciatic function index until 12th week. Functional recovery in the nerves treated with amniotic fluid was significantly faster than in the nerves treated with saline (p< .05). Peripheral nerve regeneration was evaluated histomorphologically at 12th week. Nerves treated with amniotic fluid showed significant improvement in respect of indices of fiber maturation (p< .05). In conclusion, our study as a preliminary look shows that human amniotic fluid enhances peripheral nerve regeneration. The preventive effect of human amniotic fluid on epineural scarring and the rich content of neurotrophic factors possibly participate in this result.

P22 - Efficacy of the Q-Switched Ruby Laser in the Treatment of Nevus of Ota in Children

Presenter:	Taro Kono, MD
Co-Authors:	Ali Riza Ercocen, MD, Yuji Kikuchi, Shoichi Uezono, MD, Motohiro Nozaki
Affiliation:	Tokyo Womenfs Medical University, Tokyo, N/A

Objective: Nevus of Ota is a benign dermal melanocytic nevus that presents clinically as a bluish discoloration in the trigeminal region and that commonly affects the Asians. After introduction of the theory of selective photothermolysis, many investigators established the clinical efficacy of the Q-switched (ruby, alexandrite, and Nd:YAG) lasers. The published series are generally related to the treatment of adult patients with nevus of Ota. However, there has been no study to evaluate the efficacy of Q-switched ruby laser (QSRL) in children with nevus of Ota. Patients and Methods: Since 1994, thirty four patients with nevus of Ota treated with QSRL under general anesthesia. The patients' age ranged from 9 months to 8 years (mean 2.9 years). The parameters for QSRL were 694 nm wavelength, 30 nsec pulse duration, and 4 mm spot size. An energy fluence ranging from 5 J/cm2 to 7 J/cm2 was used depending on patient's skin phototype. The efficacy of the QSRL treatment was determined by the clinical response in term of degree of clearing, the number of treatment sessions for complete removal, early and late complication rate, and patients' (or parents') satisfaction. The mean follow-up period was 27.5 months, ranging from 3 to 76 months. Results: The mean number of treatment sessions was 3.4 per patient. Clinical responses were complete clearing in 14 patients and significant improvement in 20 patients. Hyperpigmentation was observed in two patients, but other complications such as hypopigmentation, texture change, and scarring were not observed. From our experience, significant clinical improvement, lowest rate of complications, and decreased number of treatments show that treatment of nevus of Ota in childhood period is much easier and effective than that in adults.

Presenter:	Ananth S. Murthy, MD
Co-Author:	James A. Lehman, MD
Affiliation:	Summa Health System, Akron, OH

Secondary bone grafting of alveolar clefts has become an integral part of management of the cleft lip and palate. Although it is accepted practice, the actual timing, donor site and evaluation of treatment results is variable in centers across North America. To evaluate the various approaches, a survey was mailed to 240 centers in the USA and Canada. Information was requested on indications, timing, donor sites, evaluation of results and treatment of the missing tooth. One hundred and ten responses were received for a 46% response rate. The results showed that about all centers do alveolar bone grafting (107/110) with 90% performing secondary bone grafting. The most common indicator for the timing of the graft was canine root development (38%) followed by canine eruption (17%) or lateral incisor eruption (13%). Four centers did not use any dental evaluation. Eighty-three percent used iliac bone grafts while 8% used cranial bone exclusively for donor sites. The greatest variability was seen in the evaluation of the alveolar bone graft take. Only 14% of the centers checked post-op periapical x-rays routinely, 62% used x-rays occasionally and 16% never used post-op x-rays. Seven percent of the time, care was turned over to the orthodontist after surgery and there was no long-term follow up. Seven centers in the country use a graded scale to evaluate post-operative alveolar bone graft take. Options for the missing tooth included moving the cuspid (25%), fixed bridge (11%), implants (19%) or a combination. With so much variability in management, the use of a standardized scale to measure post-op results would allow for better outcome studies in alveolar bone grafting.

P24 - Evaluation of Genitofemoral Nerve Donor Site Morbidity After Radical Prostatectomy

Presenter:	Matthew S. Kilgo, MD
Co-Authors:	Gordon Kaplan, MD, Farhang Rabbani, MD, Peter T. Scardino, MD, Peter G. Cordeiro, MD
Affiliation:	Memorial Sloan Kettering Cancer Center, New York, NY

In patients undergoing radical prostatectomy, the sural nerve is commonly used as a donor site for cavernous nerve grafting. Because of its accessibility, ease of dissection and lack of donor site morbidity, we believe the genitofemoral nerve is the ideal donor site for this procedure.

From 1999 to 2001, twelve patients with a minimum of one-year follow-up underwent radical prostatectomy with grafting from the genitofemoral nerve to the cavernous nerve. The genitofemoral nerve donor sites were evaluated post-operatively to assess morbidity. Evaluations consisted of retrospective chart review, patient questionnaires (including the McGill Pain Scale) and a detailed neurological examination within the sensory distribution of the genitofemoral nerve.

Only two patients noted residual numbness in the in the region supplied by the resected genitofemoral nerve. Neither patient felt the deficit interfered with normal daily activities. All patients denied the presence of any other adverse symptoms (burning, cold sensitivity or pain). On examination, only two patients (16.7%) were unable to discriminate between sharp vs. dull stimuli while seven patients (58.3%) experienced decreased light touch sensation in this region. Two patients (16.7%) had no measurable sensory deficits. In the remaining 10 patients, the average size of the deficit was 28.63 cm2. (range 12-63 cm2). Using Semmes-Weinstein monofilament testing, the average pressure sensitivity within this area was 4.77 g/mm2 (range 3.61 to 6.45 g/mm2) while the average pressure sensitivity within the control region was 2.92 g/mm2 (range 1.65 to 4.74 g/mm2).

Due to its low donor site morbidity, the genitofemoral nerve is an excellent donor source for cavernous nerve grafting during radical prostatectomy. In the majority of the patients, the sensory deficit produced by resection of this nerve is minimal and remains unnoticed. Harvest of this nerve prevents the additional morbidity associated with a donor site located elsewhere on the body (i.e. sural nerve).

P25 - Experience with Reduction Mammaplasty Combined with Conservation Therapy in the Treatment of Breast Cancer

Presenter:	Christopher V. Pelletiere, MD
Co-Authors:	Scott L. Spear, MD, Andrew J. Wolfe, MD, Theodore N. Tsangaris, MD, Marie F. Pennanen, MD
Affiliation:	Georgetown University, Washington, D.C, DC

As the inclusion criteria for breast conservation therapy (BCT) has continued to evolve to include lower quadrant tumors, very large breasts, and central tumors, the potential for significant disfigurement after BCT has also increased. This has led some centers to develop coordinated oncology plastic surgery approaches to insure both adequate cancer resection and aesthetic appearance to the breasts. The authors applied this principal to a specific group of breast cancer patients women with macromastia who would benefit from reduction mammaplasty. Eleven women were identified from the senior authors reconstructive practice who underwent BCT followed by breast reconfiguration and bilateral reduction mammaplasty. Preoperative brassiere sizes ranged from 34D-46B. All women had immediate reduction after frozen sections from the lumpectomy/partial mastectomy margins were determined to be negative. A total of twenty-two reduction mammaplasties were performed (8 free nipple grafts, 5 inferior pedicle, 7 superomedial pedicle, and 2 superolateral) and an average of 1085g was removed per breast. All patients underwent XRT post-operatively. There were 8 minor complications in 6 patients (1 hematoma, 1 keloid, 1 radiation burn, 2 nipple hypopigmentation, and 3 fat necrosis). After an average of 20 months follow-up, there were no local recurrences and one death from distant metastasis. Seven of the eleven patients were available and agreed to rate their aesthetic satisfaction based on a scale of 1 to 4, 4 being the best. The mean satisfaction score was 3.3. Aesthetic outcomes pre-XRT and post-XRT were evaluated by a panel of plastic surgery residents blinded to the purpose of the study. Using a scale of 1 to 4, the pre-XRT aesthetic mean was 2.9 and the post-XRT aesthetic mean was 3.03. By combining breast conservation therapy with breast reconfiguration or reduction in large breasted women, multiple benefits are derived. Larger segmental or partial mastectomies can be performed without disfigurement risk, ensuring adequate surgical margins. Immediate reconfiguration of the breast with reduction of the contralateral side creates symmetrical, aesthetically pleasing breasts, allows contralateral breast tissue to be evaluated, and spares women from undergoing a second operative procedure. Such a coordinated program gives women an important boost, both physically and psychologically, during their management of breast cancer.

P26 - FK506 Does Not Expedite Muscle Recovery in a Rat Primary Nerve Repair Model

Presenter:	Mustafa Asim Aydin, MD
Co-Authors:	Melanie G. Urbanchek, PhD, William M. Kuzon, MD, PhD
Affiliation:	University of Michigan, Ann Arbor, MI

Objectives: Clinical experience indicates that shorter duration of denervation is associated with better recovery of muscle function. FK506 (Tacrolymus), which is in clinical use as an immunosuppressant drug, has been demonstrated to increase the rate of nerve regeneration in a dose dependent fashion. We hypothesize that FK506 can expedite the recovery of muscle mass and maximal force capacity in the rat EDL muscle following peroneal nerve transection and repair. Methods: Peroneal nerve was transected and repaired on the left and no surgery was done on the right hindlimbs of 9-month-old male F344 rats. The rats were then randomly assigned to either FK506 group (n=8) or CONTROL group (n=8). FK506 group was treated with daily injections of FK506 (1 mg/kg), and CONTROL group with daily injections of vehicle solution. Injections were administered subcutaneously at 5 days/week for 3 weeks. An injection-free week preceded evaluation. Four weeks postoperatively, bilateral measurements for maximal force capacity and mass of EDL muscles were made. Results: For denervated-reinnervated muscle, there was no difference of maximum force capacity (CONTROL=555±47 mN, FK506=536±35 mN; p=.750) and muscle mass (CONTROL=67±4 mg, FK506=75±2 mg; p=.068) at 4-week-recovery as a result of FK506 administration. For nerve- intact muscle, there was no difference of maximum force capacity (CONTROL=3628±18 mN, FK506=3697±168 mN; p=.783) and muscle mass (CONTROL=148±5 mg, FK506=144±5 mg; p=.537) at 4-week-recovery as a result of FK506 administration. FK506 treated animals experienced more weight loss than CONTROL rats following nerve repair surgery. Conclusions: FK506 did not expedite force recovery of denervated-reinnervated muscle in this model. FK506 had no detrimental effect on nerve intact muscle force.

P27 - Free-Flap Treatment of Congenital Pressure Necrosis of the Forearm in the Neonate

Presenter:	Daniel A. Medalie, MD
Affiliation:	University of Kentucky Medical Center, Lexington, KY

Purpose: Congenital necrosis of the upper extremity is a rare and deforming phenomenon. The etiology can be diverse and frequently indeterminate, but the end result is a neonate with a soft tissue defect of the hand and or forearm. This report describes the microsurgical treatment of a full-thickness loss of the forearm in a newborn. We believe that this is the youngest patient in the literature to have received successful free tissue transfer. Methods: The primary case will be detailed in conjunction with a review of the current literature Results: A male infant weighing 6 lbs. 7 oz. was born with blistering of the ulnar aspect of the forearm. Within several days it became clear that the skin over the ulnar forearm was non-viable and the child was taken to the OR for debridement (1). During debridement it was found that the underlying forearm musculature was also non-viable. After two weeks and several more debridements the child was taken to the OR for definitive treatment. Removal of all non-viable tissue resulted in a defect of 60 % of his forearm skin and musculature with exposed ulna, ulnar nerve and artery (2. Of note the child was insensate from birth in his ulnar and median nerve distributions. During the operation his ulnar and median nerves were completely neurolysed, and a rectus abdominus(3,4) was microsurgically transferred to his arm for coverage (5). Pedicle length was 1 cm and pedicle diameter was .8 mm. The flap survived without complication and the child went on to demonstrate a completely healed wound with a return in median and ulnar nerve sensation(6). He has continued to undergo intermittent operations to release ulnar sided contractures. Conclusions:Aggressive treatment of large soft tissue losses can be undertaken with the knowledge that free tissue transfer in the neonate is feasible.

P28 - Hemifacial Amputation Reconstructed with Modified Cervico-Delto-Pectoral Fasciocutanous Flap

INTRODUCTION:Hemifacial amputation of the soft tissues of the face is a rare form of trauma to the face. Various surgical procedures to reconstruct such injury are various , ranging from local flap to a free tissue transfer.There are certain difficulties associated with such reconstruction based on the fine and complexed anatomical soft tissue structures of the face. This case presentation illustrate the excellent surgical results following left sided facial amputation in a young adult patient utilizing a modiefied DeltoPectoral fasciocutanous flap .

METHODS: A 35 year old pedestrian adult patient was injured by a heavy flying object to his face, a car tire, while attempting to cross a main highway. He sustained severe head concussion with fracture of his left zygoma.The facial structures of his left side of the face were completely amputated as as one unit with exposed mandibular ramus, temporal bone and fossa, avulsion of the left facial nerve, parotid gland, and temporalis muscle as shown in the pictures. However, the amputated part was severely injured, that a re-plantation and revascularization was not indicated. Following initial recovery of the patient after few days, surgical reconstruction of the amputated facial site was reconstructed with a modified Cervico-Delto Pectoral flap based on the left para sternal cutaneous perforators followed by secondary touch up procedures.

RESULTS: The final outcome of the surgical reconstruction was excellent with good maintenance of the facial aesthetics and contour of the left side of the patient face.

CONCLUSION: A modified Cervico-Delto-Pectoral fasciocutanous flap can be utilized for adequate reconstruction for the facial region following soft tissue defects following trauma or tumor resection.

P29 - How to Tie a Knot with Goretex (Expanded Polytetrafluroethylene) Suture

Purpose: To evaluate and present alternative knots for securing expanded polytetrafluorethylene (ePTFE) or "Gore-tex" suture.

Description: The W.L. Gore Company recommends seven square knots to secure their ePTFE suture and some authors recommend up to ten. A considerable amount of foreign material and "tail" results from this knot. My project was to see if the bulk of this knot can be reduced without sacrificing security. I present an experiment subjecting alternative "Gore-tex" suture knots to gradual tension and testing each knot's breaking or slipping strength. The experiment and data is presented in Poster form and and a new modification of a knot that allows rapid application using instruments and decreased bulk is illustrated.

Presenter:	Dimitrios Danikas, MD
Co-Authors:	Spero J.V. Theodorou, MD, Constantinos Stratoulias, MD, George Constantinopoulos, MD, Ernest M. Ginalis, MD
Affiliation:	Monmouth Medical Center, Springfield, IL

The iliac crest is a common donor site for autogenous bone grafts. Although a bone graft can be harvested relatively simply, the surgeon should be aware of the potential morbidity. A reported complication is herniation of abdominal organs through the iliac crest defect.

We present a 55-year-old white male with asthma and an incisional iliac hernia. A bicortical bone graft 2.5 x 3-cm was harvested from the left iliac crest one year ago. The patient presented with a left flank bulge and pain. A hernia was present over the left iliac crest extending to the lateral abdominal wall. Computerized tomography with contrast confirmed a large bowel herniation in the region of iliac bone resection. In the operating room a defect 7-cm in diameter was found through the transversalis and internal oblique muscles contiguous to the iliac crest defect. The hernia sac was reduced and the defect was repaired with a large size oval Kugel mesh placed in the preperitoneal space. The mesh overlapped the iliac bone and the lateral abdominal muscles thus covering the hernia defect. The patient was free of symptoms and there is no recurrence in a three-month follow-up.

Hernias of the lumbar region are rare but have been reported to occur after trauma, flank surgery, iliac bone grafting, spontaneously, or as a result of congenital abnormality of musculoskeletal development. An incidence of 5% has been reported after iliac bone graft harvest. The onset of herniation symptoms is variable. The contents of the hernia may be retroperitoneal fat, kidney, small or large bowel and spleen. Computerized tomography is the only radiographic procedure required for an accurate diagnosis. Most authors recommend repair with a synthetic mesh. If a full thickness bone graft is harvested precise and careful closure should follow to prevent herniation.

P31 - Immediate Bone Grafting of the Osteocutaneous Radial Forearm Flap Donor Site

Presenter:	Matthew S. Kilgo, MD
Co-Authors:	Gordon Kaplan, MD, Edward Athanasian, MD, Peter G. Cordeiro, MD
Affiliation:	Memorial Sloan Kettering Cancer Center, New York, NY

The osteocutaneous radial forearm flap has seen limited use in microvascular reconstruction largely because of the high morbidity associated with the donor site. The purpose of this study was to evaluate whether morbidity can be reduced by immediate bone grafting with or without plate fixation of the donor radius.

Over a five-year period (1995-2000), 12 patients underwent reconstruction of mandibular (n=6) or midfacial defects (n=6) with the osteocutaneous radial forearm flap. This experience was retrospectively reviewed to evaluate donor site morbidity after prophylactic bone grafting with and without plate fixation. One patient was lost to follow-up. Mean follow-up for the remaining patients was 21 months (range 6-52 months). Bone grafting of the radius was performed in all patients. Five patients (41.6%) also underwent prophylactic plate fixation. Patients were immobilized post-operatively in a short arm cast followed by splint immobilization for variable lengths of time.

The average width of the harvested radius ranged from 25-60% of the radial circumference (mean of 37%) and the average length taken was 8.1 cm (range 7.5-10cm). Larger radial deficits were treated with plate fixation in addition to bone grafting. Cast immobilization ranged from seven to 17 days (mean 10.3). Mean time for return to daily activity was 3.5 months (range 2-6 months). Complications occurred in five patients. The only major complication occurred in one patient, who sustained a fracture of the donor radius that required plate fixation. Delayed healing of the skin graft occurred in 4 patients; all of which responded to conservative management.

Prophylactic bone grafting of the donor radius with or without plate fixation allows for short periods of cast immobilization and a rapid return to normal daily activity. Large segments of bone may be harvested without a significant increase in the fracture rate. Most complications are minor and respond to conservative management.

P32 - In Vivo Persistence of Fluorescent Human Keratinocyte Grafts in Athymic Mice

Presenter:	C. Scott Hultman, MD
Co-Authors:	Chris Campbell, MS, Abner Ward, MS, Bruce A. Cairns, MD, Anthony A. Meyer, MD, PhD, Suzan deSerres, MS
Affiliation:	University of North Carolina, Chapel Hill, NC

Introduction: Cultured keratinocytes (CK) can be used to resurface massive burn wounds, but the long-term fate of these grafts is difficult to assess without formal biopsy. To facilitate graft evaluation, we have recently labeled CKs with green fluorescent protein (GFP), via adenoviral transfection. The purpose of this study is to determine if fluorescent CKs can be successfully grafted, maintain fluorescence for non-invasive monitoring, and provide stable wound coverage. Methods: Human keratinocytes harvested from discarded skin were plated with growth-arrested 3T3 fibroblasts, allowed to reach confluence, and transfected with a GFP adenoviral vector at a multiplicity of infection of 10. CK sheets were liberated with dispase, grafted onto flanks of anesthetized athymic mice (n=24), and protected with an occlusive, hydrocolloid dressing. CK grafts were assessed in situ via epifluorescent microscopy 3, 4, 5, 7, and 10 days after transfer. CK biopsies (n=8) obtained 14 days after grafting were stained with FITC-labeled antibody to human MHC Class I antigen and counterstained with H&E to assess graft architecture. Results: CK grafts provided stable wound coverage, despite mild to moderate contraction by 14 days. H&E revealed normal epithelial architecture, and viable human keratinocytes were detected by FITC staining. Initial fluorescence of GFP-transfected CK grafts was similar to that of in vitro controls (which express GFP > 4 weeks) but rapidly decreased in intensity over time. Standardized mean fluorescence 3, 4, 5, 7, and 10 days after transfer was 80.7, 61.5, 17.3, 3.8, and 1.9 units, respectively (p<0.05). Conclusions: CK sheets transfected with GFP adenoviral vector can be successfully grafted to provide stable wound coverage. The persistence of human keratinocytes 14 days after grafting, combined with attenuated fluorescence, implies that in vivo GFP expression is transient in this model. Although the temporary expression of GFP limits the usefulness of graft evaluation, transient expression of transfected genetic material may prove to be beneficial in the controlled delivery of growth factors for wound healing.

Presenter:	Hiroshi Iioka, MD
Co-Authors:	Mitso Hatoko, MD, PhD, Masamitu Kuwahara, MD, Aya Tanka, MD, Satoshi Yurugi, MD, Katunori Niitsuma, MD
Affiliation:	Division of Plastic Surgery,, Kashihara,, N/A

We investigated induction of HSP47 protein, which is an important role in collagen biosynthesis, in keloid, hypertrophic, and atrophic scars. Forty lesions in 37 patients were prepared with normal skin around the lesion resected simultaneously in each case. Resected samples were de-epithelized and HSP47 induction in fibrous tissue was detected by Western blot analysis using anti HSP47 antibody. The level of HSP47 induction of each sample was defined as the relative amount to that of HSP47 induction of normal skin obtained from around each lesion. The 40 lesions were divided into the following four groups according to their clinical features; Group A(n=10); Keloid, Group B(n=10); Red hypertrophic scar, Group C(n=10); White and hard hypertrophic scar, Group D(n=10); Flat or atrophic white scar. The level was 2.38±0.24 in Group A, 1.83±0.09 in Group B, 1.17±0.03 in Group C, and 0.97±0.03 in Group D. There was a significant relationship between clinical manifestation and the level of HSP47 protein. These results may suggest that induced HSP47 protein play some important roles in determination of clinical manifestation of scars

P34 - Induction of Tolerance to Composite Tissue Allografts in the Rat with Short-Term Administration of Deoxyspergualin and Anti-T Lymphocyte Monoclonal Antibody

Presenter:	Fabio Quatra, MD
Co-Authors:	Oreste M. Romeo, Dave Lowemberg, Darrell Brooks, Lee Ann Baxter-Lowe, PhD, Michele R. Colonna, MD, Francesco Stagno D'Alcontres, MD, Harry J. Buncke, MD
Affiliation:	The Buncke Clinic, San Francisco, CA

Short-term combination therapy with an anti-TcR alpha/beta monoclonal antibody (clone R73) and 15-deoxyspergualine (DOS) was tested in inducing long-term survival of composite tissue allografts. Materials and Methods: Hindlimbs were transplanted from Brown Norway to Lewis rats. Six groups were entered (5 rats each): Group A was a no-treatment control group. Group B received R73 at 500 mcg/Kg i.p on the day of surgery. Group C received R73 (250 mcg/Kg i.p.) on the day of surgery and DOS (2.0 mg/Kg i.p.) for 15 days starting on the day of surgery. Group D received R73 (500 mcg, day of surgery) and DOS (4.0 mg/Kg i.p) for 20 days. Group E and F received a sham operation (limb amputation and replant) respectively with or without a 15-day treatment with DOS, to record weight loss, drug-related toxicity and nerve regeneration. Onset of rejection was assessed clinically. Tissues were harvested for examination and blood for assessment of chimerism with flow citometry after labelling with appropriate monoclonal antibodies. Main results: Rejection became evident for groups A-C as follows: Group A=6-8 days, Group B=12-13 days, Group C=22-25 days, while all the limbs in Group D survived over 50 days. Weigh loss during the treatment period peeked over 20% of preoperative weight, without histological signs of Graft versus Host Disease. The level of chimerism varied throughout the duration of the study and between the groups. Conclusions: Combined therapy with R73/DOS showed to reliably prevent rejection in all the animals during the treatment period. Only treatment extended to 20 days was able to reliably prolong survival well beyond withdrawal, probably because DOS needs to be administered long enough to prevent antigen presentation to the T-cell population while it recovers after the T-cell inhibitory effect of R73, lasting up to 16 days, has subsided.

Presenter:	Jeffrey Weinzweig, MD
Co-Author:	Norman Weinzweig, MD
Affiliation:	Providence, RI

"A man had given all other bliss and all lies worldly warmth for this to make his whole heart in one kiss upon her perfect lips"

Restoration of form and function following losses of the upper and lower lips poses a formidable challenge to the reconstructive surgeon. First, the defect has to be defined with respect to the extent of the mucosal and skin defects. The complex symmetry of the upper lip must be reestablished without disturbing the surrounding anatomical features such as the alar base area, the nasolabial region or the oral commissure. Lip shortening or tightening should be avoided, whenever possible. Goals in lower lip reconstruction include restoration of symmetry, normal contours and normal function thus avoiding embarrassing drooling or difficulty with articulation.

This poster will present an algorithmic approach to reconstruction of upper and lower lip and commisural losses. Techniques include mucosal advancement flaps (rhomboid, V-Y), direct closure (V, pentagonal), perialar crescent advancement flaps, Abbe flap, Karapandzic flap, and modified Webster cheek advancement techniques.

Presenter:	Gary D. Motykie, MD
Co-Authors:	Michael Obeng, MD, Linda G Phillips, MD
Affiliation:	University of Texas Medical Branch, Galveston, TX

Background: The impact of adequate follow-up care on patient outcomes cannot be overemphasized. Unfortunately, indigent care populations commonly have limited access to follow-up care and may suffer the consequences of increased post-operative complications and morbidity. In the case of pressure sores, this would mean an increase in the incidence of pressure sore recurrence and the need for further procedures. Purpose: To determine the impact of sustained follow-up care on long-term clinical outcomes in patients with pressure sores. Methods: A retrospective chart review was performed in order to obtain data on all patients that received an operation for a pressure sore in the Department of Plastic Surgery between January 1990 and January 2000. The patients were divided into groups based on whether they were followed for less than six months post-operatively or longer than six months post-operatively. The incidence of recurrent pressure sores and the need for further surgery was compared between the two study groups. Results: A total of 241 patients were included in the study with 89 patients that were followed for less than six months post-operatively and 152 patients that were followed for longer than six months post-operatively. The average length of follow-up was 1.4 +/- 0.6 years. The pressure sore recurrence rate was 53% in patients that were followed for less than six months post-operatively and 24% in patients that were followed for longer than six months post-operatively (p < 0.001). The need for further surgery was 44% of patients that were followed for less than six months post-operatively and 18% in patients that were followed for longer than six months post-operatively (p < 0.001). Conclusion: In pressure sore patients, decreased access to adequate continuity of care has a significant negative impact on long-term patient outcomes. In light of this, pressure sore patients should have long-term coordinated follow-up care in order to prevent significant post-operative morbidity including an increase in the incidence of pressure sore recurrence and the need for further operations.

P37 - Microsurgery in Private Practice: A Review of a Single Surgeon's First One Hundred Cases

Presenter:	Frederick J. Duffy, MD
Affiliation:	UT-Southwestern Medical School and Medical City Dallas, Dallas, TX

Microsurgery has evolved into an integral part of reconstructive surgery, particularly in the extremities, breast, and head and neck. High success rates have been documented by several large centers. Microsurgery is also practiced in the private setting, but success rates in private practice are poorly documented. A review of a single surgeon's first, consecutive 100 free flaps is presented. Recipient sites include the lower extremity(57%), breast(15%), femoral head(9%), chest wall(1%), hand(5%), and head and neck(13%). Ten flaps were re-explored within the first 36 hours; nine of these flaps were salvaged (90%). Re-exploration revealed venous occlusion in 7 patients, arterial occlusion in 1, and hematoma under the flap in 2. In addition to the one flap that failed despite re-exploration, two additional flaps failed. One was discovered obviously nonviable on post-op day three and another patient returned after discharge with a nonviable flap. Of the three flaps that failed, two patients had subsequent succesful reconstructions with a second free flap and one patient underwent below knee amputation. There were two patient deaths within the first month following surgery, one from a stroke and one from an apparent myocardial infarction. The review also demonstrated an increasing interest in and use of perforator flaps. Of the first fifty flaps performed, 16% were perforator flaps while 54% of the second fifty flaps were perforator flaps. Two of the three flaps lost were perforator flaps but there was no statistical difference between complications in the perforator and non-perforator groups. This review suggests that high microsurgical success rates are possible in private practice and that perforator flaps can be successfully learned and performed in private practice.

Presenter:	Babak J. Mehrara, MD
Co-Authors:	William W. Shaw, MD, A.L. Da Lio, MD, J.P. Watson, MD, E. Arcilla, MD, A. Smith, MD, T.D. Santoro, MD, J. Sebastian, MD
Affiliation:	UCLA School of Medicine, Los Angeles, CA

Introduction: The superiority of free flaps to pedicled flaps has been a topic of intense debate. The traditional figure of 5-10% free flap loss is often used to justify higher rates of partial flap loss, major fat necrosis, and abdominal wall complications with pedicled TRAM flaps. The purpose of this study was to clarify the rates of major complications in the largest reported series of consecutive patients treated with free tissue transfer. Methods: The charts of 766 consecutive patients who underwent autologous free tissue breast reconstruction from 1991 to 2001 were retrospectively reviewed. Major and minor complications were evaluated. Results: Unilateral reconstruction was performed in 575 patients while 191 underwent bilateral reconstruction (957 flaps). TRAM flaps were performed in 755 cases (79%) while the superior gluteal (9.6%), TFL (3.4%), DICA (1.1%), gracilis (0,4%), and latissimus (0.3%) were performed in the remaining patients. Major complications included: 6 total flap losses (0.6%), 13 partial flap losses (1.35%), 14 venous thrombosis (1.5%), 5 arterial thrombosis (0.5%), hematomas (3.3%), pulmonary edema requiring intubation (0.8%), life threatening sepsis (0.3%), and 1 case of intestinal compartment syndrome. There were no deaths related to breast reconstruction. Minor complications consisted of: infection (6.5%), hernia/abdominal laxity (3.1%), minor to moderate fat necrosis (17%), mild CHF (1.6%), DVT (0.3%), and brachial plexus palsy (temporary; 0.7%). Discussion: Breast reconstruction using free tissue transfer can be very reliable (99.4% success) with low rates of major complications and acceptable rates of minor complications. With experience, rates of total flap loss can approach those of pedicled flaps while the frequency of partial flap loss and major fat necrosis can be significantly improved. Alternative donor sites to the TRAM flap are important (21% in our series had other free flaps). Flap selection and technical highlights will be presented.

Presenter:	Reha Yavuzer, MD
Co-Authors:	Selahattin Ozmen, MD, Yavuz Basterzi, MD, Osman Latifoglu, MD, Suhan Ayhan, MD, Seyhan Cenetoglu, MD
Affiliation:	Gazi University Medical Faculty, Ankara, N/A

Urethral duplication is one of the rarest congenital urinary tract anomalies, commonly seen in males and there has been fewer than 200 cases reported until now. We propose that the nomenclature that has been used for these anomalies may be changed as urethral misalignments. Although, the etiology is not clear, and the exact embryology of the malformation has yet to be defined; it seems that the anomaly is not a duplication of a tissue but in fact a problem which prevents the penile and glanular urethra meet with each other. Therefore, misalignment of the urethra makes more sense than urethral duplication in describing these anomalies. We reported four patients with urethral misalignment and their preferred surgical treatments. One of the cases was a collateral urethral duplication, and there are only nine other cases that have been reported in the literature. Urethral duplication or as we suggest, urethral misalignment is a rare anomaly without a complex treatment approach providing that the exact anatomy of the both urethras and their relation with each other are well understood by the surgeon. Once this has been satisfied the necessary surgical procedures are usually simple and easy to perform for many plastic surgeons.

Presenter:	Anureet Bajaj, MD
Co-Authors:	Victor Perez, MD, Mark Dickinson, MD, Roger Hadley, MD, Anil Punjabi, MD, DDS
Affiliation:	Loma Linda University Medical Center, Loma Linda, CA

Penile amputation is a rare, traumatic event, mostly seen as a self-inflicted injury in psychotic patients. Approximately 80 cases of penile replantation have been reported in the literature. In the past, the penis was replanted as a "perfused graft" with repair of the urethra, corpora, and skin. Typically, the deeper structures survived, but the procedure was complicated by skin loss, urethrocutaneous fistula, strictures, and insensitivity. In 1977, two different groups reported the first cases of microvascular replantations of the penis. Since then microvascular repair has become the standard of care. However, our experience with the replantation of other body parts has shown us that the success of tissue replantation is usually linked to ischemia time.

Ischemia time is important is muscular and neural tissue, but is generally not considered significant in bone or skin tissues. Muscle can tolerate ischemia times up to 8 hours, where as skin may tolerate ischemia times up to 3 days (as demonstrated by the survival of skin grafts). In finger replantation involving vessels, nerves, tendons, and bones, the usual tolerated ischemia time is 12 hours; but there have been reports of successful replantation at 18 hours ischemia time when the amputated part is properly preserved (the amputated part is placed in moist gauze, a plastic bag, and then placed on ice).

Cases of penile replantation with variable ischemia times, between 30 minutes to 14 hours, have been reported. However, the tolerable ischemia time of the penis remains in question. Typically, the recommended ischemia time for successful replantation of an amputated part is 8-12 hours; however, this guideline may not be true for the replantation of an amputated penis, in part because of the lack of musculoskeletal components. We present a case in which a successful penile replant was performed after 19 hours of ischemia time without loss of skin or supporting structures. After reviewing the literature, we believe that the length of tolerable ischemia time may be longer in penile replantation than in the replantation of other amputated parts, partly due to the unique penile anatomy.

P41 - Post Warm Ischemia Limb Replantation: A New Experimental Model and the Effects of Streptoquinase, Allopurinol and Hyperbaric Oxygen Therapy

Presenter:	Marcelo Sacramento Cunha, MD
Co-Authors:	Hugo Alberto Nakamoto, MD, Jose Carlos Faes da Silva, MD, Alexandre Wada, MD, Marcus Castro Ferreira, MD
Affiliation:	University of Sao Paulo, Sao Paulo, N/A

Introduction: Prolonged ischemia leads to alterations in the tecidual microcirculation and oxigen free radicals production. This event is called no reflow phenomenon and its management is a challenge to the microsurgeon dealing with replantation. It was tested a new replantation model after warm ischemia in rats and the effectiveness of allopurinol, streptoquinase and hyperbaric oxigen therapy. Method: Amputation with preservation of vessels and nerves of the right hind limb was proceeded in 110 rats. The groups MG1, MG2, MG3, MG4 and MG5 were submitted to 0, 2, 4, 6 and 8 hours of ischemia. The limbs were observed for 7 days and the survival limb rates in each group were 100%, 80%, 63,6%, 50% and 20% respectively. MG4 was elected control for experimental groups. The groups EG1, EG2 and EG3 were submitted to 6 hours of ischemia and were treated with streptoquinase , allopurinol and hyperbaric oxigen therapy. The survival limb rates were 66,7%, 70% and 30% respectively. The results were tested using Q-square test and p<0,05 was considered statistically significant. Results: MG1, MG2, MG3, MG4 and MG5 were statistically different except for MG3 and MG4. EG1 had a better limb survival than MG4 but not than MG3. EG2 had a better limb survival than MG4 but not than MG2 and MG3. EG3 had a worse limb survival than MG4. Discussion: The results suggest that the administration of streptoquinase and allopurinol may be helpful to improve limb salvage after ischemia and hyperbaric oxigen therapy may not be helpful and even can be harmful to ischemic limbs.

Presenter:	Norman Weinzweig, MD
Co-Author:	Jeffrey Weinzweig, MD
Affiliation:	Chicago, IL

Ganglion cysts are by far the most common tumor of the hand comprising 52.6% of all tumors recorded in collective data from three large series totaling 2715 tumors. Ganglions generally occur singly at specific locations but can arise from almost any joint in the hand. They can be associated with bossing of the index and middle carpometacarpal joints, DeQuervain's disease, and Heberden's nodes of the distal interphalangeal joints in elderly patients.

This poster will illustrate the protean manifestations of ganglion cysts with respect to location including the dorsal wrist, volar wrist, volar retinaculum, dorsum of the distal interphalangeal joint (mucous cysts), proximal interphalangeal joint, and intraosseous sites. Lesions initially diagnosed as ganglion cysts include lipomas, anomalous muscles such as the extensor digitorum manus brevis, extensor synovitis, carpal bossing, and giant cell tumors, to name a few.

The extensor digitorum manus brevis is an anomalous muscle that is usually asymptomatic and present since birth. Extensor synovitis usually presents as a soft, non-discrete mass that moves with finger flexion and extension. The osteoarthritic spur of a carpometacarpal boss is not a true ganglion, however, a ganglion is associated with bossing in 30% of cases. This raised, thickened area of bone or exostosis located at the base of the index or middle metacarpal may be confused with a firm dorsal wrist ganglion. Lateral radiographs demonstrate the exostosis. In this poster, we will discuss the incidence of these locations and present several interesting cases illustrating important principles.

Presenter:	Tamer Koldas, MD
Co-Authors:	Hulya Aydýn, MD, Cengiz Dibekoglu, Bekir Aybey, Tarik Terzioglu, MD
Affiliation:	Istanbul University, Istanbul Medical Faculty, Istanbul, N/A

Pyoderma gangrenosum (PG) is a rare, destructive, necrotizing ulcerations with a rolled vegetating border. It has been classified into 4 distinct, clinical, and histologic variants-ulcerative, pustular, bullous and vegetative forms. PG can occur spontaneously or can be associated with a systemic disease. In rare instances it may develop after surgical operations or minor injuries causing traumatization of the skin. The cause of PG is unknown, but immune surveillance abnormalities, including both humoral and cell-mediated defects, has been suggested. Defects in cellmediated immunity and in polymorphonuclear leukocyte function have been described. None of the current, mostly immunosuppressive, therapies are entirely effective. Because of pathergy, many clinicians avoid managing these nonhealing ulcers with aggressive surgical debridement and autologous skin grafts. We report a 29-year-old previously healthy woman presented with an ulcerative form of PG begins as vesicopustules and tender erythematous nodules that rapidly necrotize to form large irregular ulcers with bluish, undermined edges with pathergy immediately after throidectomy at the lower site of the surgical incision on the cervical region, and disseminated sternal and upper anterior thoracal area. The ulcer persisted and rapidly enlarged during the next few days. Lesion arised on her collar, upper sternal and upper right thoracal area on the lower side of her cervical incision side. The clinical and histopathologic findings were consistent with PG. An extensive investigations including complete blood cell count, liver and renal function tests, serum protein electrophoresis, antinuclear antibody, quantitative immunoglobulins, rheumatoid factor, VDRL, HIV, hepatitis B testing, abdominal ultrasound, and wound cultures were noncontributory. Colonoscopy were negative for Crohns disease or ulcerative colitis. Dissemination of the ulcer did not respond to topical therapies but responded well to oral prednisone ( 80 mg/d ) and oral cyclosporin A (4 mg/kg per day) and was eventually repaired by skin grafting. During the 2 months, the prednisone dose had been gradually reduced to 10 mg/d and cyclosporin A (1 mg/kg per day), thereby decreasing the risk of nephrotoxicity, hypertension, hepatotoxicity and other side effects of the drug. By the 16th-week visit, cyclosporin was discontinued. DISCUSSION Treatment of PG has focused on the identification and control of the underlying systemic disease and immunosuppression and treatment of secondary infection. The ideal mode of therapy for PG varies according to the type and severity of the disease presentation. The course of the disease is unpredictable and the response to therapy variable from patient to patient. For patients with ulcers that are rapidly progressive, prompt control of the process is essential to provide pain relief, avoid secondary bacterial infections, and minimize the degree of scarring. Because of cyclosporines proven efficacy and rapid response, many have advocated its use earlier in the course of the disease as first-line theraphy. We propose that the application of split thickness skin graft (STSG) accelerates wound healing and decreases the risks of side effects (renal failure, hypertension, hepatotoxicity, seizures, and the development of lymphomas) from long term maintenance therapy with immunosupressive agents. No report exists about postoperative PG after throidectomy. We reported an effective treatment of one case of rapidly progressive PG immediately after thyroidectomy with an application of STSG to the defect, provided immediate pain relief and healing.

Fig 2. Complete healing 4 months after skin grafting with minimal scar contracture.

P44 - Rapid Intraoperative Tissue Expansion Up-Regulates Insulin 1 – Another Stretch-Responsive Gene in the Skin?

Presenter:	Julio Hocherg, MD
Co-Authors:	Yunfeng Zhu, PhD, Jia Luo, PhD, Joshua Barker, BS, Eugene Cilento, PhD, Frank Reilly, PhD
Affiliation:	University of Arkansas, Little Rock, AR

Differential display PCR identified another potential gene that is specifically induced by rapid intermittent stretching of skin. Two different methods of stretching were used, linear load cycling with a skin hook (Gibsons technique) and hemispherical load cycling with an inflated subcutaneous silicone balloon (Rapid Intraoperative Tissue Expansion or RITE). Unstretched flaps served as postoperative controls. Among four differential gene fragments examined, one was specifically induced 6 h after RITE application. Gene expression was confirmed by Northern blot hybridization. The cDNA fragment was extended and the resultant sequence analyzed to reveal induction of truncated long interspersed nucleotide element 1 (LINE-1 or L1). Northern hybridization using rat insulin 1 and mouse myotubularin cDNA probes verified up-regulation. Truncated L1 elements are located inside introns of many genes, and insulin 1 and myotubularin are two known to regulate angiogenesis and cell growth. This is the first report demonstrating that insulin 1 like L1 and myotubularin are responsive to RITE and not to rapid linear stretch using the Gibsons technique. Our findings suggest enhancement of long-term flap viability by induction of yet another beneficial RITE-responsive gene that promotes wound healing. They provide a lead into the screening of other RITE-responsive genes that contain L1 in their introns.

P45 - Rhinoplasty Using Gender Specific Nasion Position Preferences as Determined by a Survey of North American Caucasians

Presenter:	Arian Mowalvi, MD
Co-Authors:	David Garth Meldrum, MD, Michael W. Neumeister, MD, Bradon J. Wilhelmi, MD
Affiliation:	Southern Illinois University School of Medicine, Springfield, IL

Purpose: To investigate whether gender preferences of nasion position could be detected which could serve as guides to nasion alteration during rhinoplasty.

Methods: North American Caucasian males (n=75) and females (n=75) were surveyed to identify their preference of various nasion positions in both the sketched male and female profile faces. The nasion position with regards to its height (horizontal position) and level (vertical position) were altered while all other facial and nasal anthropometric measurements were held constant. The nasion height parameters were set at 7, 10, and 13 mm anterior to the corneal plain and the nasion levels were set at the supratarsal fold (ST), upper lid ciliary margin (CM), midpupil (MP), and lower limbus (LL). Patients were asked to rank the facial profiles in order of aesthetic preference.

Results: The rank orders for both the male and female nasion position preferences were tabulated from completed surveys as shown in the tables below.

Female Nasion Position	7 mm anterior to corneal plain		10 mm anterior to corneal plain		13 mm anterior to corneal plain
Female Nasion Position	Female rank	Male rank	Female rank	Male rank	Female rank	Male rank
ST	11^th	9^th	3^rd	3^rd	8th	6^th
CM	9^th	10^th	1^st	1^st	7^th	5^th
MP	10^th	11^th	2^nd	2^nd	4^th	4^th
LL	12th	12th	6^th	8th	5th	7th

Male Nasion Position	7 mm anterior to corneal plain		10 mm anterior to corneal plain		13 mm anterior to corneal plain
Male Nasion Position	Male rank	Female rank	Male rank	Female rank	Male rank	Female rank
ST	9^th	10^th	1st	1^st	4^th	4^th
CM	10^th	9^th	2^nd	2^nd	5^th	5^th
MP	11^th	11^th	3^rd	3^rd	6^th	6^th
LL	12th	12th	8th	8^th	7th	7th

The selections made by the female and male subjects demonstrated statistical significance amongst the various ranks as a whole as demonstrated by One way ANOVA analysis (P< 0.001). Further analysis using a post Dunns test was completed to delineate significant preferences between subgroups with respect to the nasion level and height. Female nasion levels were preferred at CM and MP versus LL based on female ranks and at ST, CM, and MP versus LL based on male ranks (P<0.05). Additionally, female nasion heights were preferred at 13 mm and 10mm versus 7 mm anterior to the corneal plain based on female ranks and preferred at 10 mm versus 13mm and 7 mm anterior to the corneal plane based on male ranks (P< 0.05). Male nasion levels were preferred at ST, CM, and MP versus LL based on both male and female ranks (P< 0.05). Male nasion heights were preferred at 10mm versus 13 and 7 mm anterior to the corneal plain by both male and female ranks (P< 0.05).

Conclusion: Females and males tended to agree on their preference of the male nasion position being tolerant to ST as well as CM and MP levels and preferring a height of 10 mm anterior to the corneal plain. Female subjects were less tolerant of the female nasion height being set at ST and instead preferred a CM or MP position but were more tolerant with regards to nasion height accepting a 10 or 13 mm distance from the anterior corneal plain. Over all, both genders were less tolerant to a nasion height of 7 mm and a nasion level set at the LL, providing credibility to recent trends favoring nasal dorsum and nasion augmentation during rhinoplasty.

P46 - Salvage of the Infected or Exposed Breast Implant: A Management and Treatment Algorithm

Presenter:	Michael A. Howard, MD
Co-Authors:	Scott L. Spear, MD, James H. Boehmler, MD
Affiliation:	Georgetown University Hospital, Washington, DC

Among the potential complications associated with the use of breast implants are the risks of periprosthetic infection and device extrusion. There is little published information on the effective management of these situations. Conservative recommendations include antibiotic therapy and/or removal of the implant until the wound has healed or the infection resolved. A multi-year retrospective review identified over 40 patients with periprosthetic infections or threatened or actual device exposure treated by the senior author. Patients were classified into six groups: isolated mild or severe infection, threatened exposure with or without infection, and actual exposure with or without clinical infection. To achieve successful primary prosthesis salvage, various strategies were utilized. Therapeutic options began with systemic antibiotics for patients with infection. Further aggressive interventions were performed when needed. All patients with mild, isolated superficial infections were successfully treated with antibiotics alone and retained their implants. Over 75% of patients with threatened or actual prosthesis exposure with or without infection were able to retain their implant after aggressive surgical intervention. The authors have developed an algorithm for the treatment of infection and threatened or actual implant exposure. No immediate salvage is attempted in cases of severe, non-responding infection with gross pus, marginal tissues or absence of options for healthy tissue coverage. Patients with infection are placed on oral or intravenous antibiotics; those that respond completely require no further treatment. If mild infection persists or threatened or actual exposure exists, operative intervention is required for implant removal, curettage, capsulectomy, debridement, site-change, placement of a new implant, and/or flap coverage. We have found that the infected or exposed breast prosthesis can usually be salvaged except in cases of overwhelming infection or deficient soft tissue coverage. Based upon this experience, patients can be offered the option of attempted implant salvage although removal remains a more predictable choice.

Presenter:	Alan Matarasso, MD
Co-Authors:	Steven G. Wallach, MD, Lisa DiFrancesco, MD, Marlene Rankin, PhD
Affiliation:	New York, NY

Purpose: Statistics published by ASAPS report a 25% increase in cosmetic procedures for 1999-2000. Patients 35-50 account for 31.3% of all rhytidectomies performed. It stands to reason that many of these patients will undergo secondary rhytidectomy. The purpose of this report is to examine any differences in secondary (or more) rhytidectomy patients from those undergoing a primary rhytidectomy.

Methods/Techniques: We identified a total of 113 consecutive secondary rhytidectomy patients, of which 101 charts were available for review. 98 were female and 3 were male. Ages range from 40-81 with an average of 60.

Results/Complications: Secondary facelift patients were segregated by age. Of the 101 patients, 53 were >60 yrs of age and 48 were 60<. Of the patients >60, 41/53(77%) had combined procedures with their most recent facelift and 39/53(74%) had at least one comorbid medical condition. There were a total of 67 additional procedures performed in this group of 53 patients or 1.3 additional procedures/patient. Of the patients <60 37/48(77%) underwent multiple procedures along with their most recent facelift and 16/48 (33%) had at least one comorbid medical condition. This same group had a total of 70 additional procedures or 1.5 additional procedures/patient. There were two major complications in patients <60, one consisted of a DVT/PE and the other had a cellulitis. The major complication rate was 2/101(2%).

Conclusion: With advancing age we see an increase in the number of comorbid medical conditions. Interestingly, the overall complication rate in the secondary rhytidectomy patients compares favorably to that traditionally quoted for primaries, who on average, are younger at the time of surgery. Nevertheless, these secondary rhytidectomy patients still underwent additional procedures that did not lead to an increase rate of complications. This suggests that in properly screened patients secondary facelifting even in older patients with combined ancillary procedures is both common and safe.

Presenter:	Pedro Carlos Cavadas, MD, PhD
Affiliation:	Centro de Rehabilitación de Levante, Valencia, N/A

The location of secondary pedicles of gracilis muscle was investigated in 20 cadaver thighs. There were 2-4 (mean 2.2)secondary pedicles located 12 to 18 cm from the knee joint. The dominant secondary pedicle was a branch of the superficial femoral artery, 5-6 cm long and with a caliber of 1-2 mm. Angiography revealed extensive connection between the secondary and primary pedicles. A series of seven free flaps were performed for upper and lower extremity reconstruction. All flaps were successful. The flap can be elevated under tourniquete control, without interrupting the gracilis muscle.It is easy and fast to perform, the pedicle is of appropriate size, can be tailored to different sizes, and leaves very minor morbidity. This flap should be included in the reconstructive armamentarium.

Presenter:	Melinda L. Lacerna, MD
Co-Authors:	J. Michael Guenther, L. Andrew Difronzo, Dena Amr
Affiliation:	Kaiser Permanente, Los Angeles, AR

Purpose: Sentinel lymph node mapping is now an established method of accurately staging the axilla in patients with breast cancer. However, the augmented breast may pose an interesting challenge to this procedure. Does augmentation mammoplasty alter breast architecture enough to change patterns of lymphatic drainage? The purpose of our study is to determine the reliability of sentinel lymph node mapping in patients with augmented breasts who subsequently develop breast cancer. Methods: A retrospective review (1995-2001) identified patients with augmented breasts with invasive breast cancer who underwent breast conservation therapy with sentinel lymph node mapping. Lymphazurin dye was injected into the parenchyma surrounding the tumor. The sentinel node was identified through an axillary incision as the first blue lymph node. Nuclear lymphoscintigraphy was not used. A standard axillary node dissection (ALND) was performed if the sentinel lymph node was positive for metastasis. Results: Seven patients,between ages 33-62(mean age 50),had Stage I or Stage II disease. All tumors were infiltrating ductal carcinoma ranging in size 0.5-1.8cm (T1). Five patients had tumors located in the upper outer quadrant of the breast, one was located immediately superior to the nipple, the other was inferior to the nipple. All breast implants were pre-pectoral in location placed through an infra-areolar incision. Sentinel lymph nodes were identified in all patients (100%). Three patients (43%) had positive sentinel nodes, two proceeded with axillary node dissections while one patient declined. One patient with a negative sentinel node underwent ALND with all nodes negative for metastasis. Three patients (43%) with negative sentinel nodes were followed clinically. To date, there have been no local or regional recurrence with a median follow-up time of 2.5 years. Conclusions: Sentinel lymph node mapping is the preferred method of axillary node staging in patients who have undergone augmentation mammoplasty, with the exception of implants placed in a trans-axillary fashion.

P50 - Single Stage Muscle Flap Reconstruction of the Postpneumonectomy Empyema Space

Presenter:	Hisham Seify, MD
Co-Authors:	Joseph Miller, Kamal Mansour
Affiliation:	Emory University, Atlanta, GA

Despite continued improvement in medical therapy , post-surgical empyema remains a potentially lethal problem. Multi treatment options are available, however, the optimal therapeutic management has not been elucidated.

Retrospective study of 55 patients requiring different treatment modalities, including muscle flap transposition. Data cards were filled retrospectively for each patient indicating : age, sex, diagnosis, procedures performed , period of hospitalization as well as complications and outcome. We divided the patients into 4 groups: Group A : Non-resectional . Group B : Post-pneumonectomy. Group C : Post-lobectomy. Group D : Prophylactic post-resectional.

A total of 42 flaps were used in 23 patients ( average 1.8 flap per patient).Two patients developed persistent empyema(8.7%). Sixty procedures were performed in 55 patients(including open window thoracostomy and debridment). Average time from initial thoracic operation to flap intervention was 4 month. Average time from flap intervention to discharge was 12.5 days. Average hospital stay was 26.6 days.

Empyema occurs in 1-11 % following standard pneumonectomy. Mortality 11-13%. Classic approach requires surgical drainage ,debridment , and open pleural packing or antibiotics fluid irrigation. (75-88%) success rate initially. Muscle flaps provides excellent blood supply, extended reach. Flap closure is achieved in 3-6 month . Following transposition :wound closed primarily with CT for 7-10 days. The Sine qua non for success is complete space obliteration, absence of tension.

In this study 23 patients with post-resectional empyema were managed with single stage muscle flap closure. Two patients developed persistent empyema requiring other procedures.(8.7 % failure rate). Principles of dealing with an empyema space remains the same: Drainage, sterilization, space obliteration with antibiotics or vascularized tissue.

P51 - Surgical Management of the Cutaneous Manifestations of Linear Nevus Sebaceus Syndrome

Presenter:	Alexander Margulis, MD
Co-Authors:	Bruce S. Bauer, MD, Julia F. Corcoran, MD
Affiliation:	Children's Memorial Hospital, Northwestern Univercity School of Medicine, Chicago, IL

Linear nevus sebaceus syndrome (LNSS) is characterized by the association of linear nevus sebaceus with abnormalities of the central nervous system, eyes and bones, other cutaneous alterations and malignancies. The plaques of nevus sebaceus are hairless and verrucous, and the color ranges from yellow-orange in white individuals to hyperpigmented in black patients. Typically, the scalp and the face are severely involved. Patients with nevus sebaceous, whether associated with LNSS or solitary, have a 10 to 20 percent risk of the development of cutaneous neoplasia, especially basal cell carcinoma and syringocystadenoma pappiliferum. These tumors usually develop after puberty. While extensive literature describes the dermatologic, neurologic as well as ophthalmologic manifestations of LNSS, the surgical approach to these complex head and neck lesions has not been previously described. We present a cohort of 5 consecutive patients with diagnosis of linear sebaceous nevus syndrome with lesions covering extensive areas of the face and scalp, all were treated in our institution within the last 10 years. All patients were treated with expansion of the adjacent texture, color, and adnexal matched skin as the primary modality of treatment. Planning for expansion and serial excision is complicated by the widely scattered "patchy" distribution of the lesions, unlike the typical congenital pigmented nevi. Full thickness skin grafts, local skin flaps and prefabricated flaps were applied for reconstruction of specific areas. These techniques were based on experience gained in treating our previously published large series of congenital pigmented nevi. To our knowledge, this report represents the largest surgical series and suggests a reliable approach to the treatment of the cutaneous manifestations of this syndrome.

P52 - Symmetric Breast Reconstruction: The Role of 3-Dimensional Digital Photography

Presenter:	Maurice Y. Nahabedian, MD
Co-Author:	Greg Galdino, MD
Affiliation:	Johns Hopkins University, Baltimore, MD

Introduction: Obtaining symmetric breast reconstruction is facilitated with the knowledge of pre-mastectomy and post-reconstruction volume. The purpose of this study is to determine the benefit of 3-dimensional digital photography in assessing breast volume and as a means to facilitate obtaining symmetry in breast reconstruction using the free TRAM and DIEP flap. Methods: Premastectomy volume is calculated using the Rainbow 3-dimensional camera (Genex Technologies, Kensington, MD). This computer-linked camera operates via patient illumination with structured light, analysis of wavelength alteration from the reflected light, and creation of a 3-dimensional photographic image. Premastectomy volume was measured on 14 women prior to free TRAM reconstruction (8 bilateral and 6 unilateral) and on 5 women prior to DIEP flap reconstruction (1 bilateral and 4 unilateral). Mean age for all women was 46.7 years (range, 25 to 63 years). The timing for reconstruction was immediate in 18 women and delayed in 1 woman in whom the opposite breast was imaged. Mean follow-up for all women was 18 months (range, 12 to 26 months) Results: Mean premastectomy volume of the 22 breasts for free TRAM reconstruction was 512 cc (range, 185-1109cc) and of the 6 breasts for DIEP flap reconstruction was 494 cc (range, 311-753). Unilateral reconstruction was completed in 10 women. Of these, volume symmetry was obtained in 9 women (90%). Volume asymmetry requiring revision was necessary in 1 women and included delayed placement of a 150 cc implant beneath a free TRAM. The implant size was determined based on the calculated volume discrepancy between the two breasts. Bilateral reconstruction was completed in 9 women and resulted in volume symmetry in all. Conclusion: Three-dimensional digital imaging is an excellent tool to assist the surgeon with the preoperative planning of unilateral breast reconstruction. This imaging technique is also useful postoperatively to assist with correcting volume asymmetries.

P53 - "Tear-Drop" Shaped Dorsolateral Finger Flap After Resection of Large Mucous Cyst

Presenter:	Yuichi Hirase, MD
Co-Authors:	Tadao Kojima, MD, Keizo Fukumoto, MD, Toshihito Yamaguchi, MD
Affiliation:	Saitama Hand Surgery Institute, Saitama Seikeikai Hospital, Saitama, N/A

Introduction : Multiple surgical methods have been reported to cover the skin defect due to resection of the large mucous cyst. However, there were some disadvantages in those procedure because of need of skin graft, bukiness and different skin texture. In this report, the new procedure using the dorsolateral flap is introduced. Material & Method : This flap is designed with the "tear-drop" shape from the lateral side to the dorsum of the finger and elevated maintaining the digital neurovascular bundle in the distal and proximal sites to the flap. The skin defect after resection of the mucous cyst is covered by advancement of the dorsolateral flap. The donor site is closed directly by the technique of V-Y closure. Clinical trials : This procedure was performed in 18 clinical cases with good results. Skin graft is not necessary for closure of the donor site and the skin defect is reconstructed with the same quality as before surgery. Discussion : There are some advantages with this procedure. The technique of elevation of the flap is easy. Skin grafting of the donor defect is not necessary. Therefore, the operation time is shorter than with the conventional method. The lack of need for a skin graft gives an aesthetic result with the same skin texture. The ROM of the DIP joint is limited minimally and it does not produce postoperative nail deformity. Sensation of the dorsum of the DIP joint is not changed. On the other hand, this method has shown no disadvantages. Conclusion : The "tear-drop" shaped dorsolateral finger flap is an easy but reliable procedure and gives excellent results for coverage after resection of a large mucous cyst. This procedure should be considered for coverage of the dorsal skin defect of the finger, especially near the distal phalanx.

P54 - The Effect of Distal Epineural Resection of the Recipient Nerve on Axonal Regeneration in Terminolateral Neurroraphy

Presenter:	Selahattin Özmen, MD
Co-Authors:	Osman Latifoglu, MD, Sühan Ayhan, MD, Reha Yavuzer, MD, Gülay Nurlu, MD, Kenan Atabay, MD
Affiliation:	Gazi University Faculty of Medicine, Ankara, N/A

Introduction: When neither end-to-end neurroraphy nor nerve grafts are available for restoration of the nerve continuity following nerve damage, end-to-side neurroraphy is an alternative. Unfortunately, end-to-side neurroraphy is not successful yet to restore lost function enough as end-to-end neurroraphy. We aimed to find out the impact of distal epineural resection of the recipient nerve on axonal regeneration in end-to-side neurroraphy. Materials and Methods: Forty wistar male rats were included in this study as 4 groups. Under ketamine-HCl anesthesia, in the right hind-limb of the animals, peroneal nerve was transected at a level of about 1 cm above the bifurcation of the tibial nerve, and the proximal stump of the peroneal nerve was buried into gluteus maximus muscle in all groups. Distal peroneal nerve was not processed in-group I (Fig 1), was sutured to the epineurial window on tibial nerve by epineurial neurroraphy in-group II (Fig 2). Distal stump of the peroneal nerve was buried in tibial nerve for about 2 mm without any epineurial resection from peroneal stump in-group III (Fig 2), and with 2 mm epineurial excision in-group IV (Fig 2). Walking track analysis and electromyographic studies performed after 3 months, thereafter, animals were sacrificed and muscle weight measurement and muscle fiber analysis, histomorphometric nerve analysis including axon count, axon diameter and histological analysis were done. Statistical analysis was done with SPSS 10.0 software. Results: No functional loss in donor nerve or in donor muscle was determined. Healing was superior in-group IV. No statistically important difference was found out between groups II, III and IV but group I. Conclusion: End-to-side anastomosis supplies a degree of peripheral nerve regeneration without any evident donor nerve function loss. However, new studies must be done for improving regenerative capacity of the technique.

P55 - The Effect of Pre-Operative Antibiotics on Postoperative Infection Rates in Mandibular Fractures

Presenter:	Gary D. Motykie, MD
Co-Authors:	Jon S. Mancoll, MD, Linda G. Phillips, MD
Affiliation:	University of Texas Medical Branch, Galveston, TX

Background: The effect of prophylactic antibiotics on post-operative infection rates in isolated mandibular fractures has been debated for many years. Some surgeons advocate prophylactic antibiotic therapy in specific circumstances such as open fractures or delayed repair, while others question its actual benefit in any mandibular fracture. Purpose: To determine the impact of prophylactic antibiotics on post-operative infection rates in patients with isolated mandibular fractures. Patients and Methods: A retrospective chart review was performed on all patients presenting with isolated mandibular fractures from the time period of 12/1/93 to 12/1/01. Patients were separated into study groups based on whether the fracture was repaired within 72 hours (non-delayed) or after 72 hours (delayed) of initial injury. In addition, patients were divided into groups based on whether the fracture was open (laceration in oral mucosa) or closed (no laceration in the oral mucosa). Prophylactic pre-operative antibiotics most commonly consisted of clindamycin and levofloxacin. Otolaryngologists, plastic surgeons and oral maxillofacial surgeons performed the reparative surgery. All patients received peri-operative IV antibiotics and post-operative oral antibiotics and oral rinses. Results: A total of 417 patients were included in the study. The average time to repair of fracture was 34 hours in the non-delayed group and 106 hours in the delayed group. Delayed treatment was most commonly due to delay in presentation to the hospital. There were no significant differences in patient demographics, mechanisms of injury, fracture location or methods of fixation between the two groups. An open-delayed repair of a mandible fracture was found to have a significantly higher rate of post-operative infection (10.2%) when compared to all other categories (all less than 2.5%). Conclusion: Delaying the repair of isolated mandibular fractures greater than 72 hours or having a fracture site exposed through a tear in the oral mucosa do not by themselves significantly increase the rate of post-operative infection. However, if the repair of an open fracture is anticipated to be delayed longer than 72 hours, prophylactic pre-operative antibiotics should be considered therapeutic given the significant increase in risk of post-operative infections in this group of patients.

P56 - The Gluteal Thigh Flap - An Anatomical Study and Clinical Applications

Presenter:	Luiz Henrique Ishida, MD
Co-Authors:	Gean Paulo Scopel, MD, Simone Cristina Orpheu, MD, Eduardo Montag, MD, Alexandre Mendonça Munhoz, MD, Nairet Queipo Briceno, MD, Marcus Castro Ferreira, MD
Affiliation:	São Paulo University, São Paulo, N/A

The gluteal thigh (GT) flap was described by Hurwitz in 1980 for perineal and ischiatic reconstructions. It is a fasciocutaneous flap based in the descendent perforant branch of the inferior gluteal artery. This pedicle runs parallel to the posterior thigh cutaneous nerve.

The aim of this study was to do an anatomical study in cadavers to establish landmarks to flap dissection and to show the viability to microsurgical transfer. Also, our clinical experience is presented.

Thirty posterior thigh regions of fresh cadavers were used in this study. The collected data was: the distance between the divergence point of the biceps femoralis (BF) and semitendinous (ST) muscles until the popliteal crease; the distance of the vascular pedicle in the inferior verge of gluteus maximus (GM) muscle and the ischiatic tuberosity (IT); the extension of vascular pedicle and the relationship with the sciatic nerve (SN) and the posterior thigh cutaneous nerve (PTC); the diameter of pedicle on the inferior verge of the gluteus maximus muscle and the thickness of the flap. The results are presented in the Tables 1, 2 and 3.

In the clinical study the gluteal thigh flap was used in 14 pressure sores, 7 vulvar reconstructions (Figures 1, 2 and 3) and 2 scrotum reconstruction. One flap (4.3%) had a partial loss of less than 10 %. No other major complications had occurred.

Our results showed a constant anatomy, and similar skin characteristics to the nearby regions, favoring the reconstruction of the pressure sores and vulva, especially by the sensitive innervation of the flap. The recognizable extension of the pedicle was about 23 cm, therefore assuring an axial pattern of the flap. Due to the diameter the pedicle, it may be transferred microsurgically. The only major complication was due to the extreme length of the flap (40 cm). In our experience the gluteal thigh flap is a very reliable and easy to dissect, representing a good choice for ischiatic and perineal reconstructions.

RESULTS	MEAN	STANDARD DEVIATION
Distance between the pedicle and IT	4.71 cm	±0.90 cm
Distance from the divergence point of BF muscle and ST muscle until popliteal crease	12.07 cm	±1.43 cm
Extension of pedicle	23.12 cm	±3.06 cm
External diameter of the perforant branch of the inferior gluteal artery	1.13 mm	±0.47mm

DEPTH OF THE SCIATIC NERVE	MEAN	STANDARD DEVIATION
In the IT level	1.71 cm	±0.70 cm
In the the divergence point of BF muscle and ST muscle	1.91 cm	±0.64 cm

Table 2- Relationship of the gluteal thigh flap pedicle and sciatic nerve (n=30).

THICKNESS	MEAN	STANDARD DEVIATION
Subcutaneous at the IT level	1.06 cm	±0.60 cm
Subcutaneous distal at the divergence point of BF muscle and ST muscle	0.66 cm	±0.42 cm
Dermis and epidermis	0.99 mm	±0.60 mm

Figure 02.- Bilateral dissection of the gluteal thigh flap for vulvar reconstruction.

Figura 03. Final aspect after the vulvar reconstruction with the gluteal thigh flap.

P57 - The Long-Term Fate of Transplanted Autologous Fat in a Novel Rabbit Facial Model

Presenter:	Michael Brucker, MD
Co-Authors:	Anthony Spangenberger, BA, Patrick Sullivan, MD, Jeffrey Weinzweig, MD
Affiliation:	Brown University, Providence, RI

Purpose: The present study evaluated the long-term fate of transplanted autologous fat using a novel facial augmentation model we have developed in the rabbit.

Materials & Methods: Eleven adult New Zealand White rabbits underwent fat harvest from the groin region using standard Coleman techniques. One milliliter of aspirate was transplanted to the left upper lip of each rabbit. Tissue specimens were harvested at post-op day 0, and 1 month, 3 months and 6 months following surgery. The right upper lip served as an internal control in each case.

Results: Aspirates of adipose tissue yielded between 1.2 and 2.4 cc of injectable fat from each rabbit. Transplanted fat is easily seen on histology as the normal rabbit lip in this area is relatively free of native fat. Histologic evaluation of the transplanted fat from postoperative time points showed a significant inflammatory response present at one month post-op with diffuse areas of necrosis. At three months postop, the transplanted tissue was more structured with collagen ingrowth and sequestration of fat necrosis. At six months postop, the transplanted fat was well-organized with nearly all non-viable tissue absent and presumably resorbed. There was also evidence of neovascularization of the transplanted fat. Overall survivability was variable with approximately 50% remaining in two of three animals at six months; the third animal demonstrated approximately 30% fat survival.

Conclusion: We have established a novel, reproducible model with an internal control for long-term evaluation of transplanted fat. Histology suggests an early inflammatory response to the injected fat followed by sequestration of non-viable tissue. Our transplanted fat remained viable at six months with good overall survivability and minimal fibrosis.

P58 - The Oblique Rectus Abdominis Musculocutaneous (ORAM) Flap: Revisited Clinical Applications

Presenter:	Michael J. Lee, MD
Co-Author:	Gregory A. Dumanian, MD
Affiliation:	Northwestern University, Chicago, IL

Analogous to the VRAM and the TRAM, the ORAM is a myocutaneous flap with an obliquely oriented skin paddle compared to the long axis of the rectus muscle. Originally described by Drs. Taylor and Boyd, the ORAM skin paddle is based on periumbilical perforators and is aimed towards the tip of the scapula.

Because of the potential advantages of the ORAM and lack of published clinical studies, we present 8 consecutive successful ORAM flap cases. In seven cases, the ORAM was used in complex perineal and pelvic floor reconstructions involving cancer extirpations and radiated wounds. One ORAM was used as a free flap to the head and neck. Follow up was up to 2 years. All cases resulted in stable wound closure. Fresh cadaveric injection studies were performed to demonstrate the oblique dermatome pattern of blood flow from the periumbilical perforators.

In comparison to other local flaps, the ORAM has several advantages. The distal tip of the flap is located in the midaxillary line over the lower rib cage, and this skin is thin and typically scarfree. The VRAM skin in the upper abdomen is much thicker, and the donor defect more difficult to close. The thin distal tip skin simplifies flap inset, especially for perineal defects. The tip has been reliable in all 8 cases. As a deepithelialized flap, the soft tissue is adequate to fill a radiated pelvic defect, without any expected late muscle atrophy as seen in a pedicled rectus flap. The rectus muscle and anterior fascial dissection is the same as a free TRAM flap, as opposed to the greater muscle dissection of the VRAM. The flap arc of rotation can reach the perianal skin in the perineum and the distal thigh in the leg.

Presenter:	Angela M. Rodriguez, MD
Co-Authors:	Raymond M. Dunn, MD, Brannon Claytor, MD, Syed Kamil, MD, Larry Bonassar, PhD, Martin Vacanti, MD, Charles Vacanti, MD
Affiliation:	University of Massachusetts, Worcester, MA

Pluronic F-127, a biodegradable, biocompatible copolymer of polyethylene oxide and polyprolylene oxide can be used successfully as a vehicle for cell delivery in tissue engineering. Pluronic F-127 evokes minimal inflammatory response and allows a more organized arrangement of the cells when compared to other polymers. We investigated the potential of Pluronic F-127 to deliver skin cells and the ability of these cells to engineer autologous skin in vivo in the porcine model.

Keratinocytes and fibroblasts were isolated by enzymatic digestion from porcine skin. Cells were cultured for 4 weeks and then suspended in 25% Pluronic F-127. A total of 10 full thickness wounds (3x3 cm) were created. Five of these full thickness defects were covered by a bilayer of Pluronic, the bottom layer containing a mixture of autologous fibroblasts-Pluronic and the top layer containing autologous keratinocytes-Pluronic suspension. The remaining full thickness wounds were covered with Pluronic alone. Skin biopsies were taken at 2-4-16 weeks. Histology and DNA, GAG and hydroxyproline content analyzed specimens.

Histology analysis demonstrated variable degrees of epithelium after 2 weeks. After 16 weeks in vivo the experimental group showed looser collagen and woven loose keratosis. Closer inspection revealed areas of the dermis reminiscent of early adnexal structures. Cell density was 50% that of native skin at 16 w. Collagen and proteoglycans were also present in the experimental and control groups, always in lesser concentration than in native tissue.

This study demonstrates the feasibility of bilayer skin regeneration using Pluronic F-127 as a delivery vehicle. The unique gelation properties of this polymer present the possibility of delivery of skin cells by painting or spraying techniques.

P60 - The Use of Target Controlled Infusion (TCI) System with Propofol and Local Anesthesis During Ambulatory Aesthetic Surgery. An Analysis of 102 Consecutive Patients

Presenter:	Oscar A. Zimman, MD, PhD
Co-Authors:	Héctor Abramowicz, MD, Pablo Stengele, MD
Affiliation:	Clínica Zimman de Cirugía Plástica, Buenos Aires, N/A

INTRODUCTION Total intravenous anesthesia may be beneficial for ambulatory aesthetic surgery with regard to quality of recovery, lack of complications and the ability to sustain an efficient discharge of patients. Safety and efficacy of TCI (Diprifusor TM) vs. manual controlled infusion of Propofol has been demonstrated. The combination of Propofol, analgesics/sedatives for outpatient conscious or unconscious sedation with an appropriate local anesthesia is analyzed for aesthetic surgery.

METHODS A retrospective review of 102 consecutive cases over a 12-month period (January 2001-2002) that underwent ambulatory aesthetic surgery is evaluated (ASA 1 and ASA 2). The mean age was 39.6 years and the average weight: 129.6 pounds (58.8 kg.).The procedures were performed under conscious or unconscious sedation. The routine procedure was: premedication with Midazolam (3mg), Meperol (50 mg.) in IV bolus, TCI Propofol induction dose: 3.60 g/ml, maintenance doses: 2.07 g/ml. Recovery time: 2 min.13 seconds. Local anesthesia was performed with lidocaine (1 to 0.12 %) with epinephrine.The endpoint of this study included: TCI Propofol dose required, benefits of the technique, side-effects, PONV, recovery time, discharge time, patient positions, oxygen administration or room air, patients comfort and analgesia required.

RESULTS: Surgical procedures were performed on prone and supine decubitus(including decubitus change in cases of Lipoplasty with patient cooperation), without intubation or laryngeal mask. Oxygen supply in almost all cases (92%) or room air at the discretion of the anesthesiologist to maintain normal oxygen tension (Fi02=0.3) with spontaneous ventilation. Mean drug consumption was 573.62 mg. of Propofol. Postoperative analgesia was required in 8 cases (7.84%), PONV in 3cases (2.94 %) and a discharge period of 2hours, 32 min. The mean time of the procedures was 1hour, 46 min. At the time of induction local anesthesia was performed .A careful and thorough infiltration procedure was necessary to avoid some body motion, although in all cases no recall of the procedure was reported with a pleasant awake.

CONCLUSION: A series of 102 consecutive patients using TCI Propofol, IV analgesics, and sedatives as premedication and careful local anesthesia was assessed in patients who underwent elective aesthetic surgery. Main hemodynamic parameters resulted particularly stable and the awakening times, which resulted brief and independent from the anesthesia duration, have been measured. With both sedation types (conscious or unconscious) this is a reliable method for ambulatory aesthetic surgery, without intubation, lower Propofol dose and excellent recovery in quality and time.The rapid elimination of currently available agents such as Propofol and in a predictable concentration with TCI equipments allows a quick recovery, although it needs a careful intra and postoperative monitoring of the patient.

P61 - The Venetian Blind Technique: A Modification to the Pi Technique for Scaphocephaly Repair

Presenter:	Melinda L. Lacerna, MD
Co-Authors:	Andrew Wexler, Mark Urata
Affiliation:	Kaiser Permanente, Los Angeles, CA

Scaphocephaly, the most common type of craniosynostosis, occurrs in 1 of every 1000 births. Numerous methods of repair have been reported, from strip craniectomies to more complex methods of calvarial vault remodeling. While good cosmesis and restoration of a normal antero-posterior (AP) diameter can be achieved with these methods, a smooth, rounded contour of the biparietal areas is more challenging. We describe a modification of the pi technique (Jane et al,1976) which results in a more favorable contour of the biparietal areas. We performed cranial vault remodeling for the correction of scaphocephaly from 1997-2001. A pi craniectomy was performed to produce antero-posterior (AP) foreshortening. Bilateral temporal bones were cut into three horizontal strips, then sutured together in Venetian blind fashion to achieve a smooth contour. Fifteen patients (ages 2 months-2.5 years,mean7 months; 14 boys, 1 girl) underwent the procedure. All patients (except one with Pierre-Robin syndrome)were non-syndromic, without other comorbidities. All patients were full-term, except one ex-36 weeker. Mean weight was 7 kg. (5.5 kg-15 kg) at the time of operation. Mean surgical time was 110 minutes (90-125 minutes) with an average EBL of 130 cc (100-180 cc). Average AP skull foreshortening was 2 cm (1-2.5 cm). There were no complications. Average time to discharge was 3 days (2-5 days), with follow-up one week to 6 months post-operatively. Results were judged subjectively by the surgeon and the craniofacial team based on the correction of the scaphocephaly, the achievement of a smooth and rounded bi-parietal contour, and parent satisfaction. Fourteen out of fifteen patients achieved excellent cosmesis. One patient had retained scaphocephaly and the family declined reoperation. Conclusion:The Venetian blind technique provides excellent cosmesis for the correction of scaphocephaly, achieving a smoother contour to the biparietal areas, without additional operative time or complications.

Presenter:	Sachio Kouraba, MD
Co-Authors:	Taisuke Sakamoto, MD, Cyu Kimura, MD, Akiteru Takeuchi, MD, Emi Funayama, MD, Yuhei Yamamoto, MD, PhD, Tomoko Yokoyama, MD, Tamotsu Kamishima, MD, Masanobu Kumakiri, MD, PhD
Affiliation:	Fukui Medical University, Fukui, N/A

Neurofibromatosis type 1 (NF1), a common genetic disease, is of particular interest to the plastic surgeons, as it affects skin with various clinical manifestations. Diffuse neurofibroma and massive plexiform neurofibroma, uncommon but distinctive forms, may produce gross disfigurement such as elephantiasis neurofibromatosis. Although the majority of patients require surgical procedure for cosmetic and functional reasons, the associated vascular malformations consist of excessive vascular fragility make most surgeons hesitant to address them. In fact, surgical resection of neurofibroma may cause life-threatening hemorrhage and require massive transfusion. The authors tried a safe surgical procedure, "tie up technique", for treatment of massive diffuse neurofibroma. The details of the technique is as follows: (1) grasp up tumor to be excised, (2) pierce through the base of tumor with a needle and suture, (3) tie up the base of tumor tightly 2 - 3 cm in width and repeat it all over the base. After that, blood supply to the tumor is completely cut off and tumor resection can be completed without bleeding. All of ligation sutures are removed after wound closure. This simplified and faster technique is strongly recommended to excise pendulous cutaneous diffuse neurofibroma and plexiform neurofibroma without major nerve involvement expected to occur massive hemorrhage.

Presenter:	E. Yoonah Kim, MD
Co-Author:	Ben J. Childers, MD
Affiliation:	Loma Linda University Medical Center, Loma Linda, CA

Background: Angiosarcoma is a rare, aggressive malignancy that is most commonly found in the head and neck region. Intraoperative rapid frozen section histology is frequently misleading. This poses a concern for the surgeon regarding the timing of the reconstruction. We present a case that illustrates this point and demonstrates effective management of a total scalp defect.

Case Presentation: The patient is a 72 year old Caucasian gentleman with extensive scalp angiosarcoma. He underwent three separate excisions by the head and neck oncology service for positive margins on the permanent histology that had initially been reported negative by rapid frozen section. Each time, we chose to postpone definitive reconstruction until the permanent pathology was evaluated. This was accomplished by using Integra Artificial Skin as a temporary dressing. The final defect involved the entire scalp. The final reconstruction was performed using a single thoracodorsal pedicle latissimus dorsi-serratus anterior muscle free flap, followed by split thickness skin grafting. At the conclusion of the case, a four-poster halo vest was applied by the neurosurgical service to prevent pressure on the posterior aspect of the flap.

Conclusions: Due to the unreliability of intraoperative rapid frozen section, we recommend that definitive reconstruction of a scalp angiosarcoma be delayed until permanent sections are reviewed. Furthermore, a combination latissimus dorsi-serratus anterior free flap based on a common pedicle is a streamlined solution to a large scalp defect. Finally, a neurosurgical halo vest is a useful adjunct to protect a posterior scalp flap from pressure necrosis.

P64 - Transpalpebral and Extended Transconjunctival Approach in Fractures of the Upper Orbit

Presenter:	Sang-Hwan Koo, MD
Co-Authors:	Eul-Sik Yoon, MD, Dong-Hee Kang, MD, Seung-Ha Park, MD
Affiliation:	Korea university Anam Hospital, Seoul, N/A

In line with increase of facial trauma mostly from assault, fall-down, or high-energy impact, the frequency of orbital fracture has been increased gradually. The most frequent sites of orbital fracture are medial wall and orbital floor. To reduce or reconstruct these sites, there are lots of access routes such as subcilliary incision, mid-lower lid incision, infraorbital rim incision, and transconjunctival incision. Meanwhile, in cases of fracture of the upper half of the orbit containing supero-medial wall or roof, these approaches have limitation to expose the fracture site enough, so that the bicoronal incision is required. The bicoronal approach provides the best exposure without interference of the medial canthal tendon. However, conspicuous bicoronal incision scar can be shown easily in bald patients after operation, and even in non-bald patients the bicoronal incision can be accompanied by possible risk factors such as alopecia, loss of scalp sensation, and damage of frontal branch of facial nerve postoperatively. To avoid these problems, we authors performed transpalpebral approach, instead of bicoroal approach to expose fracture sites of the upper half of the orbit. We executed transpalpebral and transconjunctival approach on 21 orbits of 19 patients who consulted plastic surgeons to reduce or reconstruct fractures of the upper half of the orbit including enophthalmos. There are no significant complications except hypesthesia or anesthesia on ipsilateral forehead. But these sensory changes are all temporary and persist for 9 months in maximum. No permanent sensory loss in the forehead noted. The external scar on the supratarsal fold of the upper lid was invisible, with no scar deformities or contractures in any patients. We propose that the transpalpebral approach can be substitution for the bicoronal approach especially in the fractures of the supero-medial wall and roof of the orbit.

P65 - Urethroplasty of Extensive Penile Urethral Strictures with Longitudinal Ventral Tubed Flap of Penile Skin (Modified Orandi Urethroplasty)

Presenter:	Sug Won Kim, MD
Co-Authors:	Sung Jun Lee, MD, Wan Kee Min, MD, Yoon Kyu Chung, MD
Affiliation:	Yonsei University, Wonju, N/A

INTRODUCTION AND PURPOSE: The management of of extensive urethral strictures represents one of the most challenging clinical problems in uroplastic surgery. We report our experience with one-stage reconstruction of long urethral strictures using a longitudinal ventral tubed flap of penile skin.

PATIENTS AND METHODS: Between 1997 and 2001, two men underwent one-stage urethroplasty using a penile tubed skin island flap which was developed in the immediately beneath Buck's fascia. All men had multiple or extensive strictures involving the long segment of anterior urethra (at least 7 cm). None had undergone prior open urethroplasty.

RESULTS: The longitudinal ventral tubed flap of penile skin provided a pedicled strip of penile skin measuring an average of 9 cm (range 8-10 cm). Additional graft materials were not necessary for reconstruction in any patient. Mean follow-up was 26.5 months (range 3 to 50 months). Postoperative imaging included a VCUG at 2 weeks, which was repeated at follow-up if there was clinical evidence of stricture recurrence. There were no urethral strictures.

CONCLUSIONS: We have successfully performed one-stage reconstruction of long urethral strictures using a longitudinal ventral tubed flap of penile skin. Long-term evaluation reveals stable performance characteristics without any complication.


Fig 1.Preoperative urethrogram Note severe strictures on the whole anterior urethra.


Fig 2. 50 months after surgery. Note well-delineated urethral passage on urethrogram.


Fig 3. Neourethra formation after insertion of 18-French Foley catheter.


Fig 4. Thirty months after surgery, showing the active urination.

Presenter:	Jean-Claude Castède, MD
Co-Authors:	Vincent M. Casoli, MD, Ciprian Isacu, MD, Hassan Segrouchni, MD, Gérard Perro, MD, Raymond Sanchez, MD, Marcel Cutillas, MD
Affiliation:	CHU Bordeaux, Bordeaux, N/A

INTRODUCTION : Integra® is widely used for the primary coverage of acute burns. It acts as a scaffold for dermal reconstruction. Deep burns of feet may involve tendon exposures or tendon injuries resulting in functional impairment. CASE REPORT : We report the case of a woman, 17 years old, who sustained deep flame burns of feet and legs in a polytrauma context (10% TBSA burn). After debridment of skin necrosis of the right foot, we noticed exposure of extensor tendons on the dorsum of the foot. The muscle beneath extensor tendons was necrotic and it was carefully debrided. A temporary coverage (allograft) allowed the preservation of tendons until we were sure there was no persistence of necrotic tissue. Then the granulating tissue was completely removed and, in order to obtain a good dermal protection for tendons, we placed an Integra® membrane. The total revascularization was obtained in less than four weeks without any failure, infection or haematoma. A thin epidermal meshed autograft achieved a complete healing. At six months follow-up, the result is good with an useful range of motion of the ankle and may be improved by physiotherapy and pressure therapy. DISCUSSION : Deep burns with tendon exposures result usually in tendon destruction and loss of function. Split-thickness skin grafts do not offer a good protection and leads to an adherent scar. Flap coverage will result in a bulky aspect and an impaired donor site. The use of Integra® results in a supple integument with many similarities to normal skin. The advantages of Integra® are its immediate availability, the reliability of the technique and the quality of functional and cosmetic results. CONCLUSION : In the light of this preliminary result, Integra® appears as a new attractive alternative technique for the coverage of exposed tendons in acute burns.

P67 - Vacuum Assisted Closure (VAC) of Recalcitrant Enterocutaneous Fistulas

Presenter:	Michael S. Wong, MD
Co-Authors:	Laura A. Gunn, MD, Salvatore C. Lettieri, MD
Affiliation:	Duke University Medical Center, Durham, NC

Background: Enterocutaneous fistulas (ECFs) are a challenging problem that may complicate the postoperative course of patients with solid or visceral abdominal cancers or those having undergone multiple abdominal surgeries. Uncontrolled ECFs can lead to or worsen existing malnutrition and macerate surrounding skin and soft tissues, making wound healing and closure more difficult. Purpose: To review our experience with the use of vacuum assisted closure (VAC) in the treatment of recalcitrant ECFs. Methods: Over an 8 month period, VAC was used in 9 patients (M:F=5:4) ages 32-72 (average=60.1±4.8, mean±sem) years with ECFs following abdominal surgery. Four patients had advanced malignancy (i.e. pancreatic, N=2; metastatic gastric, N=1; cervical, N=1). Four patients had diabetes. All patients were malnourished (average albumin=2.2±0.2 mg/dl, range 1.4-3.4 mg/dl). VAC treatment averaged 21.1±5.2 (9-32) days. Results: Complete closure of 3 ECFs was achieved with VAC treatment alone while an additional ECF was surgically closed 16 days following VAC treatment. Among the 4 ECFs that closed, patient albumin averaged 1.97±0.47 mg/dl and the two diabetics had well controlled blood sugars (< 140). Among the 5 patients that did not close, their albumin averaged 2.34±0.30 mg/dl and the 2 diabetics had persistantly elevated blood sugars (> 140). Control of fistulous drainage was obtained in 6 patients with decreased inflammation and excoriation of surrounding skin and decreased ECF output. Failure to obtain control in 3 patients was due to difficulty maintaining a vacuum seal around ostomies and patient noncompliance. Conclusion: VAC is a helpful adjunct in managing selected complicated ECFs. It can simplify dressing changes, control fistulous drainage, serve as a bridge to surgical repair, and even result in fistula closure. Albumin levels did not predict closure while good control of blood sugars was associated with ECF closure.

Presenter:	Mustafa Asim Aydin, MD
Co-Authors:	Paul S. Cederna, MD, William M. Kuzon, MD, PhD
Affiliation:	University of Michigan, Ann Arbor, MI

Introduction: Options for reconstruction of peripheral nerve gaps are currently limited. Acellularized peripheral nerve grafts may be a reasonable alternative for short nerve gap reconstruction and with appropriate modifications, may be clinically useful for larger nerve gaps. One such potentially beneficial matrix modification incorporates VEGF into the acellular nerve graft. We hypothesized that VEGF treatment of acellular nerve grafts would improve axonal sprouting and elongation across the graft. Method: Peroneal nerves were harvested from 8 adult male, F344 rats and chemically acellularized utilizing a series of detergents. Acellularized nerve grafts were either incubated in Schwann cell culture, human recombinant VEGF solution, or saline. In adult, isogenetic rats, 2-cm nerve gaps were repaired with either the native nerve (AUTO group, n=5) or an identical length of one of the following alternatives: acellular nerve (ACELL group, n=5), Schwann cell seeded acellular nerve (SCHW group, n=4), or VEGF treated acellular nerve (VEGF group, n=6). The animals were evaluated with walking tracks at three-week intervals postoperatively. Fifteen weeks postoperatively, the peroneal nerves and EDL muscles were harvested for histomorphometric analysis and mass measurement respectively. Results: Walking track analysis revealed no significant differences in intermediate toe spread index between the four experimental groups. A significant increase in the total number of axons and the % neural tissue in the proximal nerve graft was identified in the VEGF treated grafts compared with the other groups (Figure 1) Conclusion: VEGF treatment of acellular nerve grafts results in improved neuroregeneration across the proximal nerve coaptation site suggesting enhanced axonal sprouting proximally. Distally, VEGF treatment did not increase the percent neural tissue suggesting that VEGF treatment of the acellular nerve graft by this technique did not enhance axonal elongation. Future investigations will explore various VEGF delivery mechanisms to improve both axonal sprouting and elongation in acellular nerve grafts.

P69 - Versatility of Thumb Metacarpophalangeal Joint Flexion Crease Flaps in Fingertip Reconstruction

Distal fingertip amputation stumps with exposed bone can often be treated by local advancement flaps such as the volar V-Y advancement flap and Kutler lateral V-Y advancement flaps with preservation of length and provision of "like" glabrous skin. When there is exposed distal phalanx and insufficient soft tissue for coverage of a volar oblique amputation, various cross-finger flaps or thenar flaps may be employed.

Problems with cross-finger flaps are potential donor site morbidity related to the need for a skin graft over the dorsal aspect of the adjacent digit and very conspicuous hyperpigmentation of this skin-grafted site in dark-skinned patients. The classic thenar flap places a scar on the thenar region potentially jeopardizing the motor branch of the median nerve, requires marked flexion of the injured finger, and occasionally requires a skin graft. A modification of the classic thenar flap, described by Russell et al. in 1981, is the thumb metacarpophalangeal joint flexion crease flap. The MCPJ flexion crease flap allows the donor site to be closed primarily by gently flexing the thumb thus avoiding a skin graft or palmar scar, requires less flexion than the standard thenar flap, and is well tolerated in children and adults. It can be based radially, ulnarly or in H-shaped fashion.

This poster will illustrate the author's experience with 12 MCP flexion crease flaps. It will describe the role of this versatile flap in reconstruction of fingertip amputations and discuss its significant advantages over the classic thenar flap and cross-finger flaps.

P70 - Vulvar Reconstruction with Modified Fasciocutaneous Pudendal-Thigh Flaps

Presenter:	Pedro Bistoletti, MD
Co-Authors:	Teresita Cravino, MD, Brita M. Rüd, MD, Oscar A. Zimman, MD, PhD
Affiliation:	Hospital de Clinicas, University of Buenos Aires, Buenos Aires, N/A

PURPOSE Vulvar reconstruction after cancer resection needs a reliable flap significant in terms of function. This flap must be thin, with a good vascular supply, providing sensation and a good cosmetic outcome. The purpose of this paper is to present a modified design of the fasciocutaneous pudendal-thigh flap.

MATERIALS AND METHODS From June 2000 to February 2002 seven vulvar reconstructions were performed consecutive to vulvar cancer resection. The design of the flap was based on two principal vascular pedicles: the anterior one was the deep branch of the external pudendal artery, branch of the femoral artery and the posterior pedicle: the superficial perineal artery, branch of the internal pudendal artery. Both arteries supply a superficial vascular plexus above the fascia. The design of the flap is like an asymmetrical Z-plasty, with a long distal limb and a short proximal one. The bigger triangular flap must include the principal neuro-vascular pedicle so as to choose an anterior or posterior pedicle, based on the location of the lesion and the lymph-node dissection.A schematic representation of both flaps is showed (Fig I ,Anterior Pedicle Flap and Fig. II ,Posterior Pedicle Flap)where the small flap (2,orange)remains still and the big one(1,green)) is transposed to achieve a vulvar reconstruction.

EXPERIENCE A bilateral flap was transferred in each of five vulvar reconstructions and a unilateral flap was transplanted in 2 cases. In six cases the posterior pedicle was the choice and in one case an anterior pedicle flap was performed The smallest flap was 5 x 8 cm. and the largest 8 x 16 cm. In all the cases the diagnosis was squamous cell carcinoma.

RESULTS All flaps survive completely. Immediate postoperative complications occurred only in one patient that showed a breakdown of the suture caused by infection. She underwent to a delayed suturing. The functional and aesthetic results of all the patients were good.

CONCLUSIONS: A modified pudendal-thigh flap is presented. The design of a modified Z-plasty allows a better transposition and closure of the flap including the neuro-vascular pedicle.

P71 - When to Use the Tensor Fascia Lata Flap as an Alternate Autologous Tissue for Breast Reconstruction

Presenter:	Timothy Santoro, MD
Co-Authors:	William Shaw, MD, Eric E. Arcilla, MD, Babak Mehrara, MD, Andrew Smith, MD, Jeffrey Sebastian, MD, Andrew L. Da Lio, MD, James P. Watson, MD
Affiliation:	UCLA Medical Center, Los Angeles, CA

The TRAM flap is the gold standard for autologous tissue breast reconstruction. Unfortunately, it is not always available. In some patients, a suitable amount of tissue can be harvested from the lateral thigh based on the tensor fascia lata (TFL) muscle. The purpose of this study is to review our experience using the TFL flap as an alternate source for autologous tissue breast reconstruction.

A retrospective chart review of all patients treated for breast reconstruction in our institution over a 10-year period was performed. Nineteen patients who underwent free TFL breast reconstruction were evaluated to determine the indication for choosing the TFL flap, operating time, transfusion requirements, hospital stay, incidence of major and minor complications, and number of secondary procedures performed.

Nineteen patients with ages ranging from 36 - 64 (average=46) were identified. Fourteen patients had bilateral while 5 had unilateral TFL reconstruction for a total of 33 flaps. Twenty-one flaps (63%) were used for delayed reconstruction and 12 (37%) were immediate reconstructions. Twenty-four flaps (73%) were used to reconstruct prophylactic mastectomies or mechanical implant problems, 8 flaps (24%)were used to reconstruct mastectomies for cancer, with cancer stage ranging from 0 (DCIS) to IIIA, while 1 flap (3%) was used to reconstruct a chest wall defect resulting from radionecrosis of a previuosly TRAM flap-reconstructed mastectomy. Inadequate abdominal or gluteal tissue was the indication for 29 flaps (87%) while previous abdominal surgeries necessitated the rest. The operative time for unilateral reconstructions averaged 5.6 hours while bilateral reconstructions averaged 9.5 hours. The recipient vessels used were the thoracodorsal vessels in all cases (97%) except one, the chest wall reconstruction, where the thoracoacromial artery and external jugular vein were utilized. No unilateral cases required transfusion while 3 of the bilateral cases (21%) required 1 unit of blood and another case (7%) required 2 units. The length of hospital stay was 4.8 days for unilateral cases and 5.8 days for bilateral cases. Twenty-eight flaps out of the 33 are considered to have finished reconstruction while the remaining 5 are awaiting revisions. Of the 28 finished reconstructions 25 TFL flaps (89%) required 1 revision while 3 (11%) required 2 revisions. Twenty-three (82%) of the 28 donor sites required 1 revision, 3 (11%) required 2 or more, and 2 (7%) required no revision. The only major complication was 1 (3%)donor site wound dehiscence while 5 (15%) minor complications consisting of donor site seromas were recorded. No flap complications were found. The reconstruction achieved generally had more volume than anticipated, producing excellent breast projection. This includes the 1 case of chest wall reconstruction where the flap harvested was quite large, measuring 15cm x 35cm.

The TFL flap is an excellent alternative for breast reconstruction in patients who have sufficient tissues in the lateral thigh region. The operative time , transfusion requirements, hospital stay, complication rate, and number of secondary procedures required are not much different from those of TRAM flaps. Unlike the superior gluteal flap, flap elevation is straightforward, does not require patient repositioning, and pedicle length is adequate. Furthermore, simultaneous bilateral breast reconstruction is feasible. However, one must exercise caution during flap elevation to avoid excessive resection of tissues as this is associated with significant contour deformities that are often difficult to correct secondarily. Otherwise, complications are minimal.

P72 - Wound Contraction is Inhibited by Blockade of Actin-Myosin Filament Sliding

Presenter:	Howard Levinson, MD
Co-Authors:	Kurtis E. Moyer, MD, Donald R. Mackay, MD, H. Paul Ehrlich, PhD
Affiliation:	MS Hershey Medical Center, Hershey, PA

Purpose: Preventing scar contracture is a goal. The report investigates the mechanism of dynamic actin-myosin filament-sliding pathway (AMFSP) on fibroblast driven extracellular matrix (ECM) reorganization in collagen lattices and rat wound repair. The apparent blockade of the AMFSP pathway hinders wound contraction. Methods: Human foreskin fibroblasts were assayed for fibroblast populated collagen lattice (FPCL) contraction after exposure to different inhibitors of the AMFSP: (1) ML-9 (20mM), (2) ML-7 (10mM), (3) W7 (5mM), and (4) Fluphenazine (10mM). FPCL contraction was measured daily for 1 week and cells viewed under phase contrast microscopy. A 15 X 15 mm full thickness excisional wound was made on the right flank and the left flank of adult male rats. The left wounds were topically treated with W7 (2% in 50% DMSO) or Fluphenazine (300mM in H2O) and the right wounds with DMSO or H2O vehicle alone. On day 10, rat wound areas were measured and tissues prepared for histology. Wounds were stained with Hematoxylin and Eosin (H&E) and Sirius Red. Students paired t test was used for statistical analysis (*p < 0.01 considered significant). Results: ML-9 and ML-7, drugs that hinder myosin light chain kinase (MLCK) activity, and W7 and Fluphenazine, drugs that restrict calmodulin activation of MLCK, inhibited FPCL contraction (*p < 0.01). Fibroblast morphology was not altered by drug treatments. W7 and Fluphenazine inhibited rat wound contraction (*p < 0.01). Granulation tissue organization was altered in treated wounds. Conclusion: It is assumed that scar contracture is mediated by a similar mechanism as wound contraction; therefore, intervention in the AMFSP may be used to impact a number of human diseases. Drugs such as Fluphenazine hamper wound contraction significantly. Fluphenazine is an FDA approved agent that may be applied topically to prevent scar contracture in patients.

Presenter:	Jorge I. de la Torre, MD
Co-Authors:	Scot A. Martin, MD, Benoit C. De Cordier, MD, Mazin S. Al-Hakeem, MD, Sherry S. Collawn, MD, Luis O. Vásconez, MD
Affiliation:	Univ of Alabama at Birmingham, Birmingham, AL

Introduction: Blephaoptosis is a condition seen frequently in patients presenting for surgical rejuvenation of the face. From an aesthetic standpoint, the ptotic lid can have a subtle presentation, or it can result in significant deformity including elevation of the tarsal fold, transverse wrinkles in the forehead, and asymmetry of the eyebrows. Ptosis correction procedures should not only improve functional impairment but also address the periorbital aesthetics in a global fashion.

Methods: An IRB approved retrospective review was performed on 74 consecutive patients who underwent correction of ptosis between 1994 and January 2000. To improve the deformities associated with ptosis, simple plication of the levator aponeurosis was combined with periorbital rejuvenation, including endoscopic forehead lift and elevation of the malar fat pad. The complications and long-term results were assessed and evaluated.

Results: The study population consisted of 68 female and 6 male patients with an average age of 60 years (range 42 to 88). The follow up was from six months to 4.5 years with an average of 14 months. Overall, long-term correction of the ptosis was very good. Symmetry was excellent in 50 patients, acceptable in 20 patients and four patients required revision for persistent asymmetry. Thirteen patients had temporary lagopthalomos and seven patients had temporary eye irritation all of which were self-limiting.

Conclusions: Based on this analysis, satisfactory improvement of blepharoptosis can be achieved using suture plication in conjunction with upper lid blepharoplasty and facial rejuvenation. Harmonious aesthetic improvement of the periorbital region was obtained in a single procedure. In addition, this approach to blepharoptosis has demonstrated effective long-term results. Finally, this technique can be safely performed and has a low revision rate.

Presenter:	Lior Heller, MD
Co-Authors:	Oscar M. Ramirez, MD, Keith M. Robertson, MD
Affiliation:	Esthetique International, Timonium, MD

Stigmata of face lift surgery are one of the main concerns of the esthetic surgery patients. Failing to preserve the natural look of the tragus and the pretragal depression can betray the best and most innovative rejuvenation procedure. A relative simple technique to preserve the pretragal depression has been applied to all the patients that underwent rhytidectomy in our practice. The standard face lift incision we use extends from the sideburn in a slightly curvilinear fashion to the root of the helix and than down into the marginal tragal area and around the earlobes retroauricularly. After completing the subcutaneous dissection and before closing this incision the component added includes separation of the SMAS fascia attachments from the cartilage in the preauricular area. Than this fascia is sutured over the anterior SMAS with several interrupted 4-0 Prolene sutures. The pretragal depression is further defined with the anchorage of one or two 4-0 Prolene suture from the tragal flap to the depression created in the preauricular area. The cutaneous flap is inset with a 4-0 Prolene continuous suture. With this small addition the natural look of the pretragal depression is preserved. This technique was implemented with good results in more than 300 patients that underwent rhytidectomy over the last 5 years. In conclusion: we suggest that the addition of this simple technique to rhytidectomy help to preserve the natural pretragal depression and avoid one of the most visible postoperative stigmata frequently observed after face lift.

Presenter:	Michael J. Yaremchuk, MD
Affiliation:	Massachusetts General Hospital, Harvard Medical School, Boston, MA

Goals/Purpose: Distortion of the palpebral fissure is a frequent sequela after transcutaneous blepharoplasty. A vertical deficiency of the outer lamellae due to over resection and a shortening of the middle lamella from scarring causes the lower lid margin to descend and the lateral canthus to migrate medially, thereby resulting in a round eye. Methods: This procedure repositions the lower lid margin and the lateral canthus by separating scarred periorbital, malar midface, and temporal soft tissues from the underlying skeleton by subperiosteal dissection. In effect, a continuous full thickness facial soft tissue flap is created. Vertical elevation and stable fixation of these tissues allows: lid margin to be elevated; recruiting cheek skin to replace deficient outer lamellae; suborbicularis oculi fat to be interposed between the orbital rim and scarred periorbital soft tissues (as a spacer); lateral canthus to be repositioned; and a poor transition between the cheek and temporal area avoided. It avoids the use of interlamellar dissection as well as the use of grafts(Figs. 1,2). Results and Complications: Lower lid position and palpebral fissure shape have been restored in a series of 15 patients operated on over a six year period. Three of the patients required revision of their canthopexy. In eight patients who had complaints of dry eye, four had significant improvement, and four had resolution of their symptoms(Figs. 3,4,5). Conclusion: Subperiosteal en bloc release and elevation of the midface, lid lamellae, and lateral canthus with secure fixation to the bony orbit can effectively restore palpebral fissue shape after previous lower lid blepharoplasty. It has the advantages of:1)avoiding skin or posterior lamellar grafts; 2)avoiding interlamellar dissection; 3)avoiding canthoplasty and its concomitant reduction in the width of the palpebral fissure and distortion of the lateral commissure; 4)avoiding soft tissue redundancy in the temporal area; 5)restoring the cheek/lid interface.

New Treatment for “Crows Foot” Wrinkles by Partial Orbicularis Occuli Myectomy

Presenter:	Fausto Viterbo, MD, PhD
Affiliation:	Faculdade de Medicina de Botucatu / UNESP, Botucatu - SP, N/A

Crows foot wrinkles are common complaints in patients looking for facial rejuvenation. This work describes a new technique for a lasting treatment by partial lateral myectomy of the orbicularis occuli muscle. We operated on 19 women and 1 man, between 41 and 74 (average 55.7 ± 7.7). Surgery was associated with temporal region facelifts or blepharoplasty. All the operations were performed under local anesthetic and sedation, some of them by an anesthesiologist. A vertical rectangle strip of approximately 2 to 4 cm by 0.5 to 1 cm was resected in the lateral part of the orbicular muscle. The location was previously marked with the patient smiling and causing the wrinkles to appear. The removal of the muscle caused a depression in this area. This depression was filled with adipose tissue graft from the pre-auricular or temporal regions. In all cases we used a 4 x loupe to do the muscle resection avoiding damage on the underneath nerve fibers that innervated the remaining orbicular muscle. The result was immediate and all 20 cases have not shown relapse to date. No lid occlusion alterations was observed, even in the immediately post-op days. No related complication has been observed. Patient satisfaction and the effectiveness of the method are promising. The orbicularis occuli muscle is innervated by branch of facial nerve. This branches passes under the muscle. So, if we take care doing the muscle resection using a magnification instrument like a loupe, we will not damage nerves under the muscle and the procedure is very safe. In conclusion we believe that partial orbicularis occuli myectomy promotes the effective attenuation of Crows foot wrinkles.

Presenter:	Eser Yuksel, MD
Co-Authors:	John Potochny, MD, Melvin Spira, MD, Saleh M. Shenaq, MD
Affiliation:	Baylor Colege of Medicine, Houston, TX

The midface lift has been employed as an additional tool in facial rejuvenation. The procedure is predicated on the concept that gravitational effects in older patients result in descent of the mid-face soft tissues. This leads to a gradual thinning of the tissue over the inferior orbital rim and an associated tear trough deformity, deeping of the nasolabial folds, and jowling deformity. These are partially improved with classical approaches (fat conserving blepharoplasty, the muti-layered rhytidectomy, and augmentation. The midface lift addressed these problems directly but is employed with reluctance because of an associated increase in morbidity) and the potential for complications involving the lower eyelid. We have modified this technique utilizing either a curved lateral temporal incision within the hairline, an extended blepharoplasty incision, or a combination of both. In the temporal approach, a subperiosteal dissection is performed over the superior, lateral and inferior orbital rims with the dissection completed via an intra-oral incision- fully mobilizing the midface subperiosteally. Two 2-0 Nylon sutures are placed in the deep cheek mass, passed under the elevated malar and temporal soft tissues and out through the lateral temporal incision. Both sutures are placed under appropriate tension to secure the cheek, corner of the mouth and fixed to a 6mm titanium screw placed over temporal line. After securing a symmetrical cheek elevation the temporal incision is closed without excising skin by rotating the inferior hair-bearing skin flap anteriorly to secure a lateral brow lift. If a blepharoplasty approach is employed, the subperiosteal dissection is over the entire zygomatico-maxillary complex, without a buccal incision. Suture stabilization is to a 6mm titanium screw inserted into the lateral orbital rim. Occasionally, both the temporal and blepharoplasty exposures are appropriate. The indications for each of these 3 modifications will be discussed. The presentation will include a series of 17 patients, 44 to 69 years old who were followed from 2 to 26 months, (mean follow-up 9 months) included in this group are three patients with facial nerve paresis in whom lateral oral commissure drooping and cheek sagging were problems. Additionally, results from fresh cadaver specimen dissections are included to demonstrate the differential effects of variations in suture placement and suspension. Through this approach to the midface lift, the morbidity frequently associated with this procedure has been reduced and the complications described above have been avoided.

Presenter:	Bradon Wilhelmi, MD
Co-Authors:	Arian Mowalvi, MD, Michael Neumeister, MD
Affiliation:	Southern Illinois University School of Medicine, Springfield, IL

Purpose: The risk for facial nerve injury has been reported to be increased with the inclusion of SMAS elevation as compared to a skin only facelift. The facial nerve courses through the parotid gland. The SMAS is elevated superficial to the parotid gland. However, in elevating the SMAS anterior to the parotid gland the facial nerve is at risk to injury where its branches emerge from the anterior edge of the parotid gland. The purpose of this study was to identify bony anatomic landmarks to predict the location of the anterior edge of the parotid gland to avoid injury to the facial nerve branches as they exit the parotid gland. Method: We dissected 20 cadaver face halves to determine bony landmarks, the masseteric tuberosity and the inferior lateral orbital rim, to predict the location of the anterior parotid edge. Then, we measured the anterior edge of the parotid gland in relation to the vector formed between these two bony landmarks. We identified and measured the most anterior portion of the parotid gland in relation to this vector. Then we measured the most posterior aspect of the parotid gland in relation to this vector. Results: In the 20 dissections, we found the most anterior portion of the parotid gland to be 2.7 +/- 1.0mm anterior to the vector from the inferior lateral orbital rim to the masseteric tuberosity. We found the most posterior part of the anterior edge of the parotid gland in relation to this vector, 1.0 +/- 1.5mm posterior to this vector. The parotid gland measured an average 38.8 +/-3.5mm in width from the tragus to the anterior parotid edge. Conclusion: In elevating the SMAS with a facelift, the facial nerve branches can be predicted to exit the anterior edge of the parotid gland which can be located 38.8mm anterior to the tragus and near the vector from the inferior lateral orbital wall to the masseteric tuberosity.

2001 PSEF Research Grant Award: Tissue Engineering Using Processed Lipoaspirate Cells and Gene Therapy

Presenter:	Daniel De Ugarte, MD
Co-Authors:	Kouki Morizono, MD, Amir Elbarbary, MD, Zeni Alfonso, PhD, Patricia A. Zuk, PhD, Min Zhu, MD, Peter Ashjian, MD, Prosper Benhaim, MD, Irvin Chen, PhD, John Fraser, PhD, Marc H. Hedrick, MD
Affiliation:	UCLA, Los Angeles, CA

Presented in Title Only: 2001 PSEF Research Grant Award: Neural Differentiation Potential of Adipose-Derived Mesodermal Stem Cells

Presenter:	Peter H. Ashjian, MD
Co-Authors:	Marc H. Hedrick, MD, Prosper Benhaim, MD
Affiliation:	UCLA, Los Angeles, CA

2001 PSEF Research Fellowship Awards: Fresh Start: Defining the Role of MCP-1 in Hemangioma Proliferation

2002 PSEF Essay Contest - Clinical Research Junior Award: The Use of Breast Reconstruction in the United States and the Impact of Sociodemographic Factors

Presenter:	Amy Alderman, MD
Co-Authors:	Lawrence McMahon, MD, Edwin G. Wilkins, MD, MS
Affiliation:	University of Michigan - Ann Arbor, Ann Arbor, MI

Re-Defining Flap Ischemia and Neovascularization Through the Perspective of Vascular Stem Cells

Presenter:	Robert D. Galiano, MD
Co-Authors:	Sanghoon Park, MD, Oren M. Tepper, BA, Sam Baharestani, BA, Jamie P. Levine, MD, Geoffrey C. Gurtner, MD
Affiliation:	New York University, New York, NY

Our understanding of neovascularization has changed dramatically following the recent discovery of endothelial progenitor cells (EPCs) in human peripheral blood. While various fields of medicine have come to appreciate the role of EPCs in new blood vessel growth, their participation in conditions directly related to plastic surgery is yet unknown. We studied the extent to which flap ischemia mobilized EPCs from the bone marrow (BM) and induced their formation into vascular structures.

METHODS: A bone marrow transplantation model was established in order to distinguish BM-derived EPCs from all other cells. Lethally irradiated FVB mice were transplanted with BM cells from transgenic mice constitutively overexpressing b-galactosidase (lacZ) regulated by the endothelial-specific tie-2 promoter. Reconstitution of the transplanted BM yields mice in which expression of LacZ is restricted to EPCs derived from the BM. A cranially-based random skin flap model was created in these mice, leading to reproducible zones of ischemia. Whole back skin specimens were taken at selected time points after flap elevation (3, 7, and 14 days) and were assayed with X-gal solution. Histological sections counterstained with eosin were used to identify b-gal positive (blue) cells by histochemistry.

RESULTS: EPCs were mobilized and recruited to the area of ischemia as early as 3 days. At day 14, EPCs began to incorporate into vessels and created a vascular networks.(figure) Remarkably, the configuration of this vascular network was parallel to the axis of the flap and was oriented toward the ischemic gradient (sprouting from healthy, less-ischemic tissue to the more ischemic distal areas).

CONCLUSIONS: We demonstrated that EPCs play an important role in neovascularization induced by flap ischemia. Furthermore, flap ischemia led the formation of new blood vessels in the direction of the ischemic gradient. Further investigation will elucidate the role of EPCs in related ischemic conditions.(i.e. delay phenomenon)

Endothelial Stem Cells Make a Significant Contribution to Adult Blood Vessel Formation

Presenter:	Oren M. Tepper, BA
Co-Authors:	Toshinori Murayama, MD, PhD, Douglas W. Losordo, MD, Jeffrey M. Isner, MD, Takayuki Asahara, MD, PhD, Christoph Kalka, MD
Affiliation:	New York University Medical Center, New York, NY

Background: Virtually all aspects of plastic surgery rely on new blood vessel growth, including flaps, grafts, distraction osteogenesis, and wound healing. For decades, plastic surgery as well as medicine in general has advanced under the pretense that blood vessel growth in the adult is restricted to the sprouting of pre-existing, mature blood vessels (angiogenesis). However, we recently isolated endothelial progenitor cells (EPCs) from humans, thereby discovering a new concept of adult vasculogenesis in which EPCs differentiate in situ. These cells have been shown to participate in neovascularization under variuos conditions, but their relative contribution is still unknown. This study set out to quantify the contribution of EPCs to newly formed vascular structures in vivo.

Methods: In order to track the recruitment of EPCs from the bone marrow (BM) and their incorporation into new vessels, we prepared mice (n=28) in which lacZ expression is limited to BM-derived EPCs. BM cells from tie2/lacZ transgenic mice (lacZ expression is regulated by an endothelial-specific tie-2 promoter) were transplanted to FVB/N mice that had their endogenous bone marrow destroyed through irradiation. Following reconstitution of the BM, two independent assays of new blood vessel growth were employed; MATRIGEL and corneal neovascularization. Since the expression of lacZ in our model is restricted to BM-derived EPCs, we then determined which new vessels had originated from EPCs by identifying lacZ expression through x-gal staining and immunohistochemistry (IHC).

Results: EPCs made a significant contribution to blood vessel formation in both assays of neovascularization. The MATRIGEL plug assay identified 5.7±1.2% and 26.5±0.9% of endothelial cells originated from EPCs using X-gal staining and IHC, respectively. Similarly, EPCs comprised of 5.0±2.4 %(x-gal) and 17.7±3.6% (IHC) of the endothelial cells in corneal neovascularization

Conclusions: Our findings indicate that EPCs make a significant contribution to new blood vessels or capillaries in vivo, and thus have important implications for a number of plastic surgery procedures. Further investigation of EPCs may offer novel explanations for impaired blood vessel growth associated with certain patients groups (i.e. diabetics and smokers) as well as offer potential therapeutic benefit through methods of stem cell transplantation.

Leukemia Inhibitory Factor Gene and Vascular Endothelial Growth Factor Can Modulate Embryonic Fibroblast Differentiation Via Gp130-STAT and MAPK Signal Transduction Pathways

Presenter:	Sadanori Akita, MD, PhD
Co-Authors:	Takehiro Daian, Hiroshi Ishihara, Tohru Fujii, Kozo Akino, MD, PhD
Affiliation:	Nagasaki University, Nagasaki, N/A

Introduction: The combined application of cytokines to embryonic fibroblasts and dermal substitute was extensively studied for optimal skin defect coverage. Signals from combined treatment of leukemia inhibitory factor (LIF) and vascular endothelial factor (VEGF) were elucidated and subsequently the in vivo applications of both were tested in an artificial dermal substitute. Methods: Mouse embryonic fibroblast cells, BALB-3T3, were stably transfected with mouse full length LIF cDNA and added to various doses of VEGF for detection of signaling interaction. LIF-transfected cells and VEGF treatment were tested with pig-tendon derived collagen dermal substitute in the backs of BALB/c male mice for 10 days. Results: LIF-transfected cell proliferation was not significantly augmented by any of the various doses of VEGF, while vector-transfected fibroblasts significantly increased with 10 nM and 100 nM of VEGF compared to that with 1 nM of VEGF on days 3 and 5. LIF-transfected cells showed rapid phosphorylation of STAT 3 from 1 minute to 60 minutes after VEGF treatment, while vector-transfected cells failed to induce such phosphorylation after VEGF treatment. Erk MAP kinase phosphorylation was observed from 15 to 60 minutes in LIF-transfected and 10 nM of VEFG and 60 to 120 minutes in LIF-transfected and 100 nM VEFG treatment. In in vivo analyses, LIF-transfected embryonic fibroblasts with 50 µg of VEGF markedly enhanced collagen I expression and CD 34 angiogenic marker on days 7 and 10. Conclusions: LIF transfection induced constitutive STAT signaling and enhanced phosphorylated-Erk MAP kinase with exogenous VEGF. In vivo study revealed that the combined application of LIF-transfection of embryonic fibroblasts with an angiogenic factor such as VEGF in the template of a dermal substitute induced optimal skin collagen production and angiogenesis in the dermal substitute.

Presenter:	Gloria A. Chin, MD, MS
Co-Authors:	Mehti Mazaheri, MD, Timothy Blalock, BS, H. Hollis Caffee, MD, Gregory Schultz, PhD
Affiliation:	University of Florida, Gainesville, FL

Background:
Connective tissue growth factor (CTGF) was identified in 1991 in cultures of human vascular endothelial cells. Up to that time, transforming growth factor-b (TGF-b) was thought to be the sole mediator in multiple fibrotic disorders such as in Dupuytren's contractures and in pulmonary fibrosis. Recently, it has been demonstrated that CTGF stimulates wound contraction and fibrosis and acts as a downstream mediator of TGF-b.

Purpose:
1)To assess the role of CTGF in breast implant elastomer capsule formation over time.
2)To determine the effect of TGF-b and CTGF anti-sense (AS) oligonucleotides on capsular formation.

Method:
Fifteen Sprague-Dawley rats were randomly assigned to treatment (n=12) and control (n=3) groups. Four pockets 2 x 2 cm were created on the dorsum deep to the panniculus carnosus in each rat; and a 1 x 1 cm smooth breast implant elastomer was placed. Each rat in the treatment group received 1 ml of: vehicle, AS TGF-b, AS CTGF, and AS scramble (control for oligonucleotide toxicity). Control rats received 1 ml of vehicle or saline in each of the pockets. At weeks 1, 3, and 5, four treatment rats and one control rat were randomly selected and sacrificed. Tissue blocks including elastomer were harvested for determination of CTGF levels using the ELISA technique. Tissue was sent for H&E slides to evaluate capsule formation.

Results:
Levels of CTGF in capsular tissues treated with vehicle or AS-scrambled were similar and progressively increased in both tissues on weeks 1, 3 and 5, compared to normal skin, with levels in vehicle-treated tissues approximately a 40% higher on week 5 than normal skin (p=0.05). At weeks 1 and 3 after surgery, levels of CTGF were suppressed in capsules treated with AS-CTGF and AS-TGF-b compared to normal skin and to tissues treated with vehicle or AS-scrambled (p=0.002). On week 5, levels of CTGF in tissues treated with AS-CTGF or AS-TGF-b were similar to levels in normal skin. Histological analysis revealed reduced capsular formation in samples treated with AS-CTGF or AS TGF-b compared with samples treated with vehicle or AS-scrambled.

Conclusions:
A single, local treatment with AS-CTGF or AS-TGF-b at the time of surgery reduced CTGF levels in tissues and correlated with reduced capsular formation in a rat model. These data suggest a new therapeutic strategy to reduce early capsular formation based on local application of antisense oligonucleotides targeting CTGF and TGF-b.

MAMA is Over-Expressed During Scarless Skin Wound Healing and Regulated by Interferon-gamma

Presenter:	H. Peter Lorenz, MD
Co-Authors:	Wuyi Kong, MD, PhD, Min Zhu, MD, Grace Zhang, MD, Kang Ting, DMD, DMSc, Prosper Benhaim, MD, Marc H. Hedrick, MD
Affiliation:	Stanford University, Stanford, CA

Introduction: Differential display-polymerase chain reaction (DD-PCR) was used to screen for over-expressed genes during scarless fetal wound healing in the rat model. One gene identified was murine adherent macrophage (mama). The mama product has been identified in murine macrophages as a secreted protein, but its function and regulation is unknown. Mama expression in skin, and during wound healing, has not been reported. Methods: Sixteen day gestation fetal rat skin wound tissue was collected at 1d and 3d post-wounding. Up-regulated genes found by DD-PCR were cloned and sequenced, and their expression change confirmed by reverse Northern dot blot analysis. In situ hybridization was done on neonatal rat skin. To study the regulation of mama expression, confluent primary rat fetal and adult dermal fibroblasts were fasted overnight, and then treated with TGF-beta1, FGF-2, TNF-alpha, IFN-gamma and insulin, respectively for 30 min to 24 hours. Mama expression was analyzed by Northern blot analysis and quantitated by densitometry. Results: The expression of mama was increased in fetal skin scarless wounds by DD-PCR (3.8±0.72 fold at 1d and 3.8±0.66 fold at 3d post-wounding) and reverse Northern dot blot (5.3±0.69 fold at 1d and 3.3±0.59 fold at 3d post-wounding). Mama expression was localized to both dermal fibroblasts and keratinocytes by in situ hybridization. Mama gene expression in fetal dermal fibroblasts was higher than adult dermal fibroblasts (~1.8 fold). Of the cytokine tested, IFN-gamma increased mama expression in rat dermal fibroblasts: 4.9±1.34 fold after 24 hours treatment (P<0.05). Conclusion: This is the first observation of mama expression in skin and during scarless wound repair. Because the expression of mama was up-regulated, and it is a secreted protein, mama may have autocrine/paracrine effects on keratinocytes and fibroblasts during scarless repair. Additionally, IFN-gamma can induce mama expression in dermal fibroblasts, suggesting that increased mama expression may be one mechanism by which IFN-gamma reduces myofibroblast number and collagen fibrosis in adult wounds.

Management of Sternal Wounds with Bilateral Pectoralis Major Myocutaneous Advancement Flaps in 114 Consecutively Treated Patients: Refinements in Technique and Outcomes Analysis

Presenter:	Sejal Patel, BA
Co-Author:	Jeffrey A. Ascherman, MD
Affiliation:	Columbia University, College of Physicians & Surgeons, New York, NY

Purpose: Because life-threatening sternal wound complications can occur following sternotomy, the optimal management of sternal wound infections remains an important topic. To decrease morbidity following operative treatment of these patients, we made a number of refinements in our treatment protocol over the past several years, particularly with regard to the extent of debridement, method of flap apposition, and management of drains. The purpose of this study was to obtain specific outcomes data by reviewing a large series of patients treated by a single surgeon. Methods: In this series of 114 consecutive sternal wounds treated by the senior author, patients were treated almost exclusively with debridement and immediate closure with bilateral pectoralis major myocutaneous advancement flaps, regardless of the degree of infection. Inferiorly, the anterior rectus fascia was raised with the flaps. Fifteen patients were immunosuppressed heart transplant recipients, and 38 were diabetic. All data were obtained through record and chart review. Minimum follow-up time was one year. Results: There were no intraoperative deaths. The 30-day perioperative mortality rate was 7.9%, with only one death directly related to sternal infection. Nineteen patients (16.7%) experienced postoperative morbidity, including partial wound dehiscences (5 percent), skin edge necrosis (5 percent), and seromas (3.5 percent). There were no hematomas. Conclusions: We advocate single-stage management of complicated sternal wounds with immediate debridement and bilateral pectoralis major myocutaneous advancement flaps. The procedure is rapid and effective. Refinements in technique, all of which will be presented, have significantly lowered our morbidity. Intact internal mammary arteries, which are often used for coronary artery bypass grafts, are not necessary. Inclusion of the rectus fascia with the flaps helps avoid wound healing problems in the xiphoid region. Furthermore, chest wall contour is preserved, the anterior axillary fold is not disturbed, and pectoralis major function is maintained.

Presenter:	David H. Song, MD
Co-Authors:	John D. Renucci, MD, Robert F. Lohman, MD, David Jayakar, MD, Lawrence Gottlieb, MD, Valluvan Jeevanandam, MD
Affiliation:	University of Chicago, Chicago, IL

Background: Sternal wound infection leading to post-operative mediastinitis is a devastating complication of cardiac surgery carrying nearly a 15% mortality rate despite current treatment methods. Contemporary techniques of sternal closure in attempt to prevent complications are all based upon non-rigid methods of osteosynthesis. Instability of bone fragments predisposes a patient to have non-union, mal-union and subsequent sternal wound infection during the process of healing. In order to prevent instability, rigid plate fixation has been utilized for acquired and surgically created fractures of virtually every bone in the body. While most fractures and osteotomies benefit from rigid fixation techniques, the current standard for sternal osteotomy closure remains the non-rigid method of circlage wires. Application of rigid plate fixation for sternal osteotomies affords greater stability and thus a decreased opportunity for non-union, mal-union and subsequent sternal wound infection to occur. A safe, efficient and effective technique for rigid fixation of sterna is described.

Methods: Since July of 2000, rigid plate fixation has been applied to 45 patients designated as having high risk for sternal dehiscence and subsequent mediastinitis. High risk was defined as patients having 3 or more established historical risk factors, including: COPD, Re-Operative Surgery, Renal Failure, Diabetes, Chronic Steroid Use, Morbid Obesity, Concurrent Infection and Acquired or Iatrogenic Immunosuppression. Patients were selected by cardiac surgeons, and rigid plate fixation was performed by a single plastic surgeon.

Results: Rigid plate fixation was performed on 26 males and 19 females. The average age of patients was 63 (43-88) years. The average follow-up was 15 weeks (range 8 to 41 weeks). While there were 4 peri-operative deaths unrelated to sternal closure: one from aspiration pneumonia (postoperative day 9), one from a pulmonary embolus (postoperative day 29), one from overwhelming sepsis from pre-existing endocarditis (postoperative day 15), and primary respiratory failure (postoperative day 12), all others healed successfully. Finally, there was one patient who had a sterile dehiscence who subsequently underwent successful re-operative rigid fixation. Comparing the cohort of patients who received rigid plate fixation to a matched population of high-risk patients during a similar time period who received wire closure, revealed a significant difference in the incidence of post-operative mediastinitis. The wire closed group (n=207) had 18 deaths unrelated to sternal closure and had 28 patients who developed mediastinitis (14.8%). The rigid plate fixation group had an incidence of 0 (Fishers exact test p=0.006). The total incidence of post-operative mediastinitis during the designated study period was 4.2%.

Conclusions: The techniques of rigid fixation, first made popular in long bone fractures, have been translated into virtually every bone in the body. Due to the proven merits of increased stability and decreased incidence of non-union, mal-union and infection, the principles of rigid fixation have caused paradigm shifts away from wire fixation of bone for maxillofacial surgeons and more recently neurosurgeons. The merits of rigid fixation have been directly translated to the sternum in a safe, efficient and effective manner. Patients who benefited from sternal closure with rigid plate fixation showed a significant decrease in the incidence of post-operative mediastinitis when compared to matched population of patients whose sterna were closed with wire.

Successful Closure of Abdominal Wall Hernias Using the Components Separation Technique

Presenter:	Christopher James Ewart, MD
Co-Authors:	Angela B Lankford, BS, Mabel G Gamboa, MD
Affiliation:	Medical College of Georgia, Augusta, GA

The components separation technique involves separating the layers of the abdominal wall to allow midline advancement. The purpose of the study was to compare the success rate of the components repair versus other methods. This study is a retrospective review of 60 abdominal wall reconstructions performed between 1988 and 2001. For each patient, hernia etiology, body mass index, history of previous repair, tobacco use, size and location, average time present, technique of reconstruction, and postoperative results, including recurrence and complication rates, were reviewed. Repair methods included components separation (n=11, 3 with tissue expansion), mesh (n=14), primary (n=12), primary with mesh onlay (n=9), TFL grafts (n=6), TFL or latissimus flaps (n=4) and rectus turn over (n=4). The average age was 45.7 (range 15-72) and the average body mass index was 30.9 (range 13.8-59.2). The average defect size was 204cm² (range 18cm² -570cm²). The average time present was 2.7 years with 22 of 60 hernias having been previously repaired. The results were as follows: 16/60 hernias recurred with significant risk factors being BMI (p=0.04), previous colectomy (p=0.02), and wound infection and/or breakdown (p<0.03). Only 1 /11 hernias recurred using the components methods, 2/13 mesh onlay, 3/23 primary repair, 6/29 mesh, 2/6 rectus, and 6/8 TFL/latissimus. There were 19 complications (infection or wound breakdown) with risk factors being smoking (p=0.002), previous colectomy (p=0.014), and BMI>30 (p=0.08). The results suggest that the components separation method is a viable option for repair of complex abdominal wall hernias without the use of distant flaps or grafts.

The "Components Separation" Method for the Repair of Abdominal Wall Defects: A Retrospective Analysis of Reconstructive Success

Presenter:	Timothy S. Neavin, BA
Co-Authors:	Howard Edington, MD, James R. Russavage, MD, Ernest K. Manders, MD
Affiliation:	University of Pittsburgh Medical Center, Pittsburgh, PA

Introduction: Massive abdominal wall reconstruction remains a complex and frustrating challenge to both general and plastic surgeons. After primary repair, recurrent herniation is reported to occur up to 50 percent of cases. In attempts to restore abdominal wall integrity, many patients undergo surgical repair with prosthetic mesh. Although prosthetic mesh repair has lowered the reported hernia recurrence rate to between 10 and 20 percent, the introduction of an synthetic material poses significant clinical risks to the patient, including wound infection, enterocutaneous fistula formation, small bowel obstruction, and extrusion. Autogenous tissue repair using "components separation" of the myofascial layer of the abdominal wall theoretically reduces much of these dreaded complications. Despite the apparent advantages of this technique, many in the surgical community have not adopted this approach as the procedure of choice for the repair of complex abdominal wall defects. Methods: This institution has sought to retrospectively analyze the reconstructive success (ie., hernia recurrence and complication rate) of the "component separation" method and identify risk factors for the development of subsequent hernia recurrence. We report a nine year experience (November 1991 to 1999) . The study group consisted of 52 men and women with abdominal hernia defects as large as 540 cm2. The mean age mean age was 49. 26 patients had a history of prior abdominal hernia repair. Length of follow up ranged from 1 to 123 months, with a mean follow-up of 38 months. Reconstructions involving synthetic mesh/patch overlay were omitted from this investigation. Results: Overall recurrence rate for herniation was 23 percent (12/52). Of the recurrences, 58 percent (7/12) were among the group with prior abdominal hernia repair. Additional complications such as wound breakdown and seroma formation occurred at rates of 15 percent and 11.5 percent, respectively. There were no mortalities related to the procedure. Conclusions: Successful reconstruction of complex abdominal defects remains a vexing surgical problem. Although the "component separation" method has been described in the literature, no large series to date has been reported. Retrospective analysis of the "component separation" method is ongoing at this institution to establish the efficacy of this relatively new and underutilized repair.

The Safety, Efficacy, and Reconstructive Arena of Radical Ablation in Patients with Locally Advanced Breast Cancer

Presenter:	Elisabeth K. Beahm, MD
Co-Authors:	Mossi Salibian, MD, Henry Kuerer, MD, Robert L. Walton, MD
Affiliation:	The University of Texas M.D. Anderson Cancer Center, Houston, TX

Introduction: Historically, locoregional recurrence and chest wall involvement in breast cancer have been considered harbingers of distant metastasis and poor prognosis. The use of neoadjuvant chemotherapy has resulted in selected patients with advanced disease, previously deemed inoperable, to be referred for radical resection requiring reconstruction. Purpose: To define the safety, efficacy, and reconstructive arena of radical ablation in patients with locally advanced breast neoplasms. Methods: Data for 92 patients with advanced breast cancer treated by surgical resection and reconstruction from1988-2000 were compiled retrospectively. Inclusion criteria included clinical tumor size of 5 cm or greater, primary or recurrent with chest wall invasion requiring flap reconstruction with a minimum 6-month postoperative follow-up. Patient demographics and outcomes including survival, local and/or distant metastases, reconstructive strategies, and complications were evaluated. Results: All patients were female with T4 tumors, either Stage IIIb (N=80) or Stage IV (N=13). Mean age was 53 years (Range(R)=28-86) with an average of 28 months follow-up (R=6-144). All patients received adjuvant/neoadjuvant chemotherapy. Two-thirds of the patients had primary locally advanced breast cancer (LABC N=55), and one-third had recurrent disease (RC N=37). Median survival was 40.48 months, with a median disease free survival of 17.75 months. Survival of LABC was not statistically different from RC (28.5 versus 22.1 months, p=0.318). Mean tumor size was 6.8 cm (R=5.0-8.5) with a resultant defect size of 264 cm2 (R=70-900) necessitating 116 flaps in 92 patients to achieve wound closure. Twenty patients required more than one flap. The latissimus dorsi and rectus abdominus myocutaneous flaps were the most commonly utilized. Pedicled flaps were more common than free flaps. Prosthetic materials were utilized in 33 patients (mesh N=25; methylmethacrylate N=8). There were no perioperative deaths. Hospital stay averaged 7.0 days (R=2-34). Complications included: Flap loss (total N=4; partial N=6) cellulitis (N=10) seroma (N=13) respiratory compromise and/or systemic infection (N=29). Conclusions: In the largest series to date, we have demonstrated that radical ablation and reconstruction in large locally advanced or recurrent breast cancers can be safely carried out with an acceptable risk even if multiple flaps are required for closure. Overall survival with this regime is favorable to historic controls. Some patients may experience a long disease free interval and a few, long-term survival. While rarely curative, this surgery appears to decrease morbidity by palliation in the final stages of terminal disease and therefore appears warranted in selected cases.

An Analysis of Patient Satisfaction with the Tram, Latissimus Doris and Tissue Expander/Implant Breast Reconstruction Techniques

Presenter:	Alexandrina S. Saulis, MD
Co-Authors:	Preeya Kshettry, Thomas A. Mustoe, MD, Neil A. Fine, MD
Affiliation:	Northwestern Memorial Hospital / Northwestern University Medical School, Chicago, IL

Introduction: Multiple studies have attempted to identify which of the three most commonly performed breast reconstructive procedures, transverse rectus abdominus myocutaneous flap (TRAM), latissimus dorsi flap (LD), or tissue expansion with implant replacement (TE), is superior. The majority of these studies have concluded the TRAM is superior due to its consistently good aesthetic outcome based on a surgeons assessment. However, no study has compared the three types of breast reconstructive procedures based on overall patient satisfaction. In this study we aim to quantify and compare patient satisfaction among the three breast reconstruction techniques, as well as identify any variables that possibly influenced their degree of satisfaction. Methods: 268 questionnaires were mailed at least six months after immediate breast reconstruction to a group of consecutive breast reconstruction patients operated on over a three year period. 172 (64%) patients completed and returned the questionnaire resulting in 90 TRAM, 25 LD, and 57 TE patient responses. The questionnaire, made up of 51 questions, addressed the patients overall degree of satisfaction with the procedure, and their peri-operative and recovery experiences. Also included were questions directed toward potential external influences such as the presence of support at home, young children at home, and professional demands. Results: TRAM patients reported a significantly longer hospital stay and recovery period as compared to LD and TE patients (p<0.05), and greater post-operative pain and longer narcotic use as compared to TE patients (p<0.05). Overall satisfaction was significantly greater in TRAM patients as compared to TE patients (p<0.05). However, the number of patients willing to repeat their procedure and recommend their procedure to a friend was similar among the three techniques. No significant differences in age, BMI, personal or professional demands, or reported complications was noted between the three groups. However, a significantly greater number of TE patients as compared to TRAM patients felt they had not received sufficient information pre-operatively to make an educated decision (p<0.05). [ A second questionnaire sent only to the TE patients revealed the majority felt inadequately informed pre-operatively about the need for repeat office visits during the expansion process, the pain associated with expansion and the final aesthetic outcome.] Conclusions: The TRAM flap resulted in the highest overall patient satisfaction despite the greater peri-operative pain and time to recovery reported by our patients. However, the lack of difference among the three procedure types with regard to patient willingness to repeat their procedure and recommend it to a friend suggests that all three groups were ultimately equally satisfied with their own personal choices. This was the case despite the TE group feeling less informed pre-operatively about certain aspects of the procedure as compared to the TRAM patients. In conclusion, we need to improve our ability to inform patients about the implications of their choice in breast reconstruction, especially the TE patients. These patients should be told they will most likely not be as satisfied with their overall reconstruction as the TRAM and latissimus patients. Many patients will continue to choose TE/implants in an effort to avoid scars and more extensive surgery. Being less satisfied is not wrong or bad, as long as it is known.

Mandibular Distraction Osteogenesis for the Pupose of Avoiding Tracheostomy in Infants and Young Children Suffering from Upper Airway Obstruction

Presenter:	Ali Ahmad Nasser, MD
Co-Author:	Virender K. Singhal, MD
Affiliation:	Children Mercy Hospital, Kansas City, MO

Purpose: The efficacy of distraction osteogenesis for purpose of decannulation in children who have had tracheostomy early in life is well known. However, usefulness of preventing tracheostomy with early mandibular distraction in infants specially using an internal device is not well documented . The purpose of this study was to evaluate mandibular distraction using an internal/external device as an alternative to tracheostomy . Also included in the study were children who had received tracheostomy prior to offering mandibular distraction .

Method: Since 2001 twelve children have been treated with varying degrees of upper airway obstruction. The pre-operative diagnoses included Pierre Robin syndrome (n=6), cerebral palsy (n=2), mixed group of craniofacial disorders (n=4). Age ranged between 4 weeks-15 years. Pre-operative evaluation included sleep study, lateral neck radiograph and cephalometric measurement and saturation recording. Three patients had tracheostomy prior to offering mandibular distraction . Nine patients had severe upper airway compromise and were considered candidates for tracheostomy .

Results; Tracheostomy was avoided in 100% of patients who were offered distraction osteogenesis .All patients who had existing tracheostomy were successfully decanulated after distraction. Average distraction rate was 1.29 mm per day. Average latency period was 4.75 days. Distraction distance ranged from 10.5-45 mm. Internal unidirectional device was used in six patients . Four patients received an internal bidirectional device and two had an external bidirectional device. Complications occurred in four out of twelve patients (33 %). Three patients had minor complication related to inadequate fixation . One patient had temporary neuropraxia of the marginal mandibular branch. There were no cases of non-union.

Our study confirms the efficacy of mandible distraction as primary treatment of upper airway obstruction and obstructive airway sleep apnea in infants and young children and should be considered as an alternative to tracheostomy. It should also be considered a treatment of choice for early decannulation in children who have existing tracheostomy.

Presenter:	Gary F. Rogers, MD, JD, MBA, MPH
Co-Author:	John B. Mulliken, MD
Affiliation:	Harvard University, Boston, MA

In 1923, Pierre Robin, a French stomatologist, described the combination of micrognathia, glossoptosis, and respiratory distress, with or without cleft palate. Infants with the most severe manifestations of this sequence have life-threatening respiratory compromise that impacts their ability to feed. Tracheostomy is the preferred treatment for refractory respiratory failure, but there is significant morbidity and a cumulative mortality risk associated with this option. Recent studies support emergent mandibular distraction, however the associated morbidity is substantial and it is unclear how this maneuver affects long-term mandibular growth. Additionally, distraction may not prevent tracheostomy.

Tongue-lip adhesion has long been advocated as primary treatment for infants with severe Robin sequence. This method surgically positions the tongue anteriorly and opens the orophanynx. Early cases documenting repair dehiscence and reports recommending rigorous preoperative screening with nasendoscopy have tempered enthusiasm for this technique.

This study evaluates the effectiveness of tongue-lip adhesion for managing airway compromise in infants with the most severe manifestations of Robin sequence (nonsyndromic and syndromic) without regard to rigid preoperative selection criteria.

We retrospectively reviewed 24 consecutive patients managed at our center with tongue-lip adhesion for refractory respiratory compromise associated with Robin sequence between 1994 and 2001. All patients had severe, sustained desaturations not alleviated by positioning, oxygen supplementation, or pressure assistance (CPAP). Additionally, all patients had early failure to thrive and required nasogastic feedings since birth. Tracheostomy had been considered in each case. Modified tongue-lip adhesion, as described by Armagasso, was done in each instance. The end point of the study was takedown of the tongue-lip adhesion during repair of the cleft palate (success) or tracheostomy/other treatment (failure).

13 patients were non-syndromic and 11 were syndromic (7 Stickler, 1 distal arthrogryposis type 2, 1 Freeman-Sheldon, 1 Borgesson-Fearson-Lehman, 1 DeLange). 19 patients required a gastric tube for feeding. Tongue lip adhesion was performed at a mean age of 24 days (range 4-61). 19 patients were successfully managed with tongue-lip adhesion and had no further episodes of respiratory distress. Additionally, all 19 patients were able to begin oral feedings shortly after repair. All have had the adhesion released during repair of the palatal cleft, usually at 9 months. There were five failures. Four patients went on to have tracheostomy. Two patients were premature (birth weights 2200 grams and 990 grams) and had early dehiscence of the repair ascribed to poor nutrition. Another patient had severe GERD and required tracheostomy to prevent aspiration. The last patient failed extubation several times and tracheostomy was recommended to permit earlier extubation. One patient with tracheal stenosis had continued intermittent obstruction after tongue-lip adhesion and underwent mandibular distraction at 6 months of age, however, this was not successful and the child is being considered for tracheostomy.

Tongue-lip adhesion remains an effective first-line strategy for patients with refractory respiratory compromise associated with Robin sequence. The procedure has relatively low morbidity compared to tracheostomy or mandibular distraction and does not preclude these other treatment options. It should be considered as primary intervention for infants with severe Robin sequence.

A One-Year Study of Hydroxyapatite Derivatives in Reconstruction of Cranial Defects: Can the Ideal Implant be Bioengineered?

Presenter:	Arun K. Gosain, MD
Co-Authors:	Lianshen Song, DDS, Paul A. Riordan, Marco T. Amarante, MD, Behrooz Kalantarian, MD, Paul G. Nagy, PhD, Charles R. Wilson, PhD, Jeffrey M. Toth, PhD, Brian McIntyre, PhD
Affiliation:	Milwaukee, WI

HYPOTHESIS: Introducing macropores within hydroxyapatite cement paste will optimize bone replacement. METHODS: Hydroxyapatite cement paste was combined with beta-tricalcium phosphate (TCP), a compound which rapidly resorbs to leave macropores in the HA cement paste. Five calvarial defects 16.8 mm in diameter were made in each of 10 adult sheep. Three defects were filled with cement paste (CP) composites of HA and TCP as follows: 1) 100% HA-CP, 2) 60% HA-CP, 3) 20% HA-CP. One defect was filled with a ceramic (CER) composite containing 60% HA-CER, and the fifth defect remained unfilled. One-year post-implantation the volume of all biomaterials was determined from CT scan, and porosity and bone ingrowth were determined using backscatter electron microscopy. RESULTS: There was no significant change in volume of the pure HA cement paste and the 20% HA-CP implants one year post-implantation, whereas the volumes of both 60% HA composites increased significantly one year post-implantation (p<.02). Mean bone replacement in the 20% HA-CP implants was 28.5%, which was significantly greater than that in all remaining implants (p<.01). There was no significant difference in bone replacement between CP and CER implants containing 60% HA, with mean bone replacement of 11.2% and 13.6%, respectively. Mean bone replacement in the pure HA-CP implants was 4.8%, which was significantly less than that in all remaining biomaterials (p<.05). There was an inverse correlation between the concentration of HA and the amount of bone replacement for each cement paste implant tested (p<.01). CONCLUSIONS: Implants which contain macropores (i.e., ceramic derivatives of HA) demonstrate consistent bone replacement, whereas those which contain micropores (i.e., cement paste derivatives of HA) demonstrate minimal bone replacement. The present study demonstrates that cement paste derivatives of HA can be bioengineered to maximize bone replacement by titrating the composition of a rapidly resorbing component such as TCP.

Presenter:	Gary F. Rogers, MD, JD, MBA, MPH
Co-Author:	John B. Mulliken, MD
Affiliation:	Harvard University, Boston, MA

Unilateral coronal synostosis is the common appellation for premature, one-sided fusion of the frontoparietal suture, the most common cause of synostotic frontal plagiocephaly. The frontoparietal (coronal) suture is part of a continuous ring that extends around the calvaria and across the cranial base. This coronal ring is composed of the frontoparietal, frontosphenoid, and sphenoethmoid sutures. Growth in the coronal ring produces anterior enlargement of the calvaria and ventral expansion of the anterior cranial fossa. The sphenoethmoidal synchondrosis at the most medial aspect of the coronal ring has a major effect on antero-posterior growth of the cranial base and midface. Extension of the unilateral frontoparietal fusion into the frontosphenoidal suture has been reported, however, these reports are based on a few patients and plain radiography.

The purpose of this study is to clarify the involvement of the basilar coronal ring in unilateral coronal synostosis, and to explore a possible correlation between the extent of sutural fusion and the degree of angulation in the cranial base.

We retrospectively reviewed the radiographic record of 74 patients with unilateral coronal synostosis treated at our center between 1986 and 2001. Age, gender, and any possible syndromic association were recorded. Only patients with CT scans with axial images of acceptable quality were included. For each patient in the study, the axial images were carefully examined for evidence of premature fusion in the frontoparietal, frontosphenoidal, and sphenoethmoidal sutures. The extent of fusion was grossly quantified into quartiles (25%, 50%, etc.). The cranial base angulation was measured using the method of Lo et al. Analysis was performed using SAS statistical software.

Thirty-six patients were excluded because the CT scan was not available, was of poor quality, or had never been obtained (diagnosis by plain radiography) leaving 38 patients in the study (21 female, 17 males). Thirteen patients had a patent frontosphenoidal suture on the affected side by CT (Group I) and 25 patients had varying fusion along the lateral frontosphenoidal suture (Group II). The medial aspect of this suture was narrowed but consistently patent in all patients. The sphenoethmoidal suture was patent in all cases.

Mean age at time of CT scan study was 57.5 days in Group I (open frontosphenoidal suture), and 262.9 days in Group II (fused frontosphenoidal suture). The difference was statistically different (p=.001). In Group I, 77% of patients (10/13) had incomplete fusion of the frontoparietal suture, while in Group II only 20% (5/25) had incomplete fusion of the frontoparietal suture. The difference was statistically significant (p<0.05). All CT studies obtained before 3 months of age (11/11) showed a patent frontosphenoidal suture, while all patients in whom the CT study was done after 5 months of age (23/23) demonstrated partial frontosphenoidal fusion. Between 3 and 5 months, 2 patients had synostosis and 2 had an open frontospenoidal suture.

Mean cranial base angulation was 13.5 degrees in Group I and 15.7 degrees in Group II. The difference was not statistically significant (p=0.72). There was no statistically significant relationship between age at CT study and cranial base angulation.

Extension of the synostosis from the frontoparietal suture to the frontosphenoidal suture in the cranial base was not observed before 3 months of age, and was always present after 5 months. Thus, fusion along the coronal ring in UCS appears to progress and extend to the cranial base in early infancy. The sphenoethmoidal suture was patent in all patients and is not fused in UCS.

Toward an Understanding of Non-Syndromic Craniosynostosis: Influence of Androgens on Fetal Dura and Calvarial Bone

Presenter:	Richard E. Kirschner, MD
Co-Authors:	Alison E. Slemp, BS, Miguel Sena-Esteves, PhD, Catherine Hwang, BS
Affiliation:	Children's Hospital of Philadelphia, Philadelphia, PA

Purpose: The higher prevalence of metopic and sagittal suture synostosis and of non-synostotic plagiocephaly in male infants suggests an important role for circulating androgens in early craniofacial development. Previous studies in our laboratory have demonstrated the expression of androgen receptors in developing fetal dura and calvarial bone, but the influence of sex steroid hormone signaling on fetal craniofacial development has not been well investigated. The purpose of these experiments was to characterize the influence of androgen signaling on cellular proliferation and gene expression in developing fetal dura and calvarial bone. Methods: CD1 murine fetal dural cells and calvarial osteoblasts were isolated at the 18th day of gestation and grown separately in culture. Just prior to confluence, the cells were pulsed for 48 hours with 5a-dihydrotestosterone (DHT; 2-1000nM). Cell proliferation was thereafter examined utilizing a non-radioactive proliferation assay technique. Expression of genes encoding the bone matrix proteins osteopontin, osteocalcin, and type 1 collagen and of those encoding alkaline phospatase and TGF-b1 was determined by reverse transcriptase-polymerase chain reaction technique (RT-PCR). Results: Androgen stimulation at physiologic concentrations increased proliferation of fetal dural cells by 46.0% and of fetal calvarial bone cells by 20.5%. Dural expression of osteopontin, osteocalcin, and type 1 collagen was significantly enhanced by DHT in a dose-dependent fashion, as was that of TGF-b1 and alkaline phosphatase. Androgen stimulation similarly increased calvarial osteoblast expression of osteocalcin, type 1 collagen and alkaline phosphatase, but induced little change in TGF-b1 expression. Osteopontin demonstrated high baseline levels of expression in fetal calvarial osteoblasts, with increased expression after 48 hours of DHT stimulation. Conclusions: Androgen stimulation of dural cells and osteoblasts isolated from the developing fetal calvarium induces cell proliferation and osteoblastic differentiation. These results suggest that sex steroid hormone signaling may play an important role in both normal and pathologic craniofacial development.

Microarray: A Powerful Tool to Determine the Molecular Mechanism Mediating Rat Cranial Suture Biology

Presenter:	Kenton D. Fong, MD
Co-Authors:	Stephen M. Warren, MD, Randall Nacamuli, MD, Tony D. Fang, MD, Jonathan A. Mathy, BA, Catherine Cowan, MS, Hanjoon Song, MD, Michael T. Longaker, MD
Affiliation:	Stanford University School of Medicine, Stanford, CA

INTRODUCTION: In the rat cranial suture model, the posterior frontal (PF) suture fuses while all other sutures, including the sagittal (SAG), remain patent. Cranial suture fate (i.e. fusion or patency) appears to be governed by paracrine signaling from the underlying dura mater. Using a candidate gene approach, we have discovered that the dura mater is regionally differentiated and controls gene expression in the overlying cranial suture complex, by temporally and spatially supplying osteoinductive growth factors (e.g. TGF-bs or FGF-2). For the past 5 years, our laboratory has been genetically piecing together this cranial suture paracrine signaling puzzle one gene at a time. Until recently, examining the coordinate control of gene expression was time consuming and progress was slow. With the introduction of microarray technology, we can now simultaneously examine the expression of over 8,000 genes in the rat cranial suture complex. In this study, we simultaneously examined the expression profiles of genes during programmed suture fusion or patency in order to identify additional candidate genes and develop a genomic "blueprint" of cranial suture biology. By developing blueprints of gene expression in fusing and patent sutures, we can begin to understand the coordinated control of gene expression, but more importantly, we can begin to understand gene function. Ultimately, comparative expression analysis may identify signature craniosynostotic gene cascades that will lead to the intelligent design of upstream-targeted biologic therapeutic interventions.

METHODS: PF and SAG sutures with associated dura mater were harvested from rats before, during, and after the period of predicted suture fusion (postnatal days 5, 10, 15, 20, and 30). The gene expression profiles were compared using the Affymetrix Rat Genome U34A chip, containing 16-20 pairs of specific, unique 25-mer oligonucleotide probes for full length annotated genes and EST clusters. Data mining and cluster analysis was performed using Affymetrix Microarray Suite (version 4.0) and Genespring (version 4.5) software.

RESULTS: There were significant differences in the gene expression profiles for all comparison groups at each time point examined. For example, when we compared day 15 PF (fusing) sutures to day 15 SAG (patent) sutures, 68 genes were increased and 157 genes were decreased >3-fold, respectively. Importantly, many of the genes identified in these comparisons have not been previously reported in association with cranial suture biology. For example, BMP-3, a powerful osteogenic antagonist, was markedly elevated in the patent SAG suture, but completely absent in the fusing PF suture.

CONCLUSIONS: In this study, we have identified many known and unknown candidate genes that may play an important role in cranial suture fusion or patency. Ongoing studies are defining the function of these genes within the suture complex.

Presenter:	Lisa David, MD
Co-Authors:	Stephen Glazier, MD, Louis Argenta, MD
Affiliation:	Wake Forest University School of Medicine, Winston-Salem, NC

Introduction: Spring mediated cranioplasty, first introduced by Lauritzen in 1999, has demonstrated promising outcome results for the treatment of craniosynostosis. The purpose of this study is to assess the clinical outcome of this treatment modality, in comparison to historical controls, treated with standard cranial expansion techniques.

Material and Methods: Children, between the age of 3 and 6 months, diagnosed and undergoing treatment for scaphocephaly were considered for this study. This is an IRB approved study requiring parental consent for enrollment. Eight children, 3 females and 8 males, have been enrolled in this study to date. All study patients underwent cranial surgery including the removal of a 1.5 cm strip of midline calvarium including the sagittal suture. After this limited craniectomy, two 1.2 mm thick stainless steel omega shaped expanders (springs) were placed. All patients had preoperative and postoperative skull films to measure cranial expansion. Indices calculated include cephalic index, length ratio, width ratio, and height ratio.

Results: All children successfully underwent spring-mediated cranioplasty. There were no perioperative morbidities or mortalities associated with any of the surgical procedures. No secondary surgeries for infection or skin breakdown were required. The mean age at initial operation was 4.1 months. No transfusions were required for any of the study patients and the mean operative time was 45 minutes for spring placement. The mean hospital stay for the initial procedure was 36 hours. The second outpatient operative procedure to remove the springs was done at a mean age of 8 months, without any peri-operative squeal. The mean operative time for the second procedure was 25 minutes with a mean hospital stay of 21 hours. Serial follow-up skull films showed a mean maximal spring expansion of 7.1 cm. The mean cephalic index postoperatively was 75%, which compares favorably to published normal age matched historical controls treated with cranial expansion techniques.

Conclusion: The preliminary data supports this minimally invasive procedure as an effective treatment for scaphocephaly. Additional long-term outcome analysis of clinical morphology and development is ongoing.

Hemodynamic and Histopathologic Investigation of the Mechanism of Radiation-Induced Craniofacial Bone Growth Inhibition With and Without Cytoprotection in the Infant New Zealand Rabbit Orbito-Zygomatic Complex (Ozc)

Presenter:	Giorgio C. La Scala, MD
Co-Authors:	David A. O'Donovan, MD, Ivan Yeung, PhD, Iona Leong, BDS, MSc, Maria Mendes, BSc, MLT, Patrick D. Addison, MBChB, Kenneth P. H. Pritzker, MD, Cho Y. Pang, PhD, Peter C. Neligan, MD, Christopher R. Forrest, MD, MSc
Affiliation:	The Hospital for Sick Children, Toronto, ON

Introduction: We have previously demonstrated significant (p<0.05) attenuation of radiation-induced craniofacial bone growth inhibition pre-treating with the known cytoprotective agent Amifostine, using the infant rabbit OZC model. To understand the mechanism of this effect, experiments were designed to determine the effects of single fraction orthovoltage radiation on regional blood flow to the infant rabbit OZC with and without cytoprotection.

Methods: Seven-week old New Zealand male infant rabbits randomized in 4 groups received single dose orthovoltage radiation to the right OZC using protocols established by us previously: 0Gy (C), 35Gy (S35), 0Gy or 35Gy 20 min. after pre-treatment with Amifostine 300 mg/kg IV (respectively CA and S35A). Blood flow to both OZC, soft tissue and hemi-mandibles was measured 1, 14 and 63 days after radiation using the modified 15µm radioactive microsphere technique (n=6/group). Histological specimens were harvested for blood vessel counts using Safranin-O stains at day 1 and 100 post-radiation (n=10/group).

Results: Blood flow to the irradiated OZC was significantly (p<0.05) greater 1 day following single dose orthovoltage radiation compared to non-radiated controls. This increase was not observed in the Amifostine pre-treated animals and 14 and 63 days post-radiation.

Rt OZC blood flow (ml/100g/min)

	1 day	14 days	63 days
C	5.17±0.78a	8.57±1.42a	7.92±0.79a
CA	6.40±1.75a	7.57±2.83a	11.94±1.77a
S35	20.4±2.74b	5.21±0.63a	6.12±1.23a
S35A	13.32±1.3ab	8.43±2.01a	8.86±1.35a

Histological blood vessel counts in the OZC were significantly decreased in the S35 group at 100 days post-radiation.

Conclusions: Single dose orthovoltage radiation produces a temporary elevation in regional blood flow to the OZC that returns to control levels within 14 days. Pre-treatment with the cytoprotective agent, Amifostine, was found to attenuate this response. The significance of these findings as they pertain to the mechanism of radiation-induced craniofacial bone growth inhibition will be discussed.

Presenter:	Reha Yavuzer, MD
Co-Authors:	Alper Sari, MD, Serhan Tuncer, MD
Affiliation:	Gazi University Medical Faculty, Ankara, N/A

Introduction: Frontal sinus fracture management is still controversial and involves preserving function when feasible or obliterating the sinus and duct depending on the fracture pattern. There is no single algorithm for the choice of cranialization versus obliteration as well as the method of obliteration. In this study during initial treatment of frontal sinus fractures or for their late complications an anteriorly based galea frontalis myofascial flap is used.

Materials and Methods: Twelve patients with frontal sinus fractures involving either the posterior wall and/or nasofrontal duct have been included into the study. Through a bicoronal approach hard tissue reconstruction and dural repair if required were performed. To obliterate the frontal sinus a flap is elevated from posterior to anterior including the galea and frontalis muscle. This flap is brought into the sinus and fixed in place by using both sutures and fibrin glue following mucosal removal. Then the anterior wall defect is reconstructed with cranial bone grafts (figure).

Results: Follow up ranges from 8 to 36 months during which none of the patients have experienced any early or late complication. In four patients with dural tear, no postoperative cerebrospinal fluid escape was observed. The elevation of the flap caused a partial sensory loss over the forehead skin, which usually resolved over a period of six months with no other additional donor site morbidity.

Conclusion: The anteriorly based galea frontalis myofascial flap is a reliable tissue with its blood supply mainly coming from supraorbital vessels. Two flaps can be elevated from each side when both sides of the sinus need to be obliterated. Especially following a dural repair, instead of bringing a non vital tissue for obliteration, this flap provides a more secure barrier. With these properties anteriorly based galea frontalis flap seems to be one of the best options for sinus obliteration as it provides a vascularised tissue to cover the anterior cranial base.

Presenter:	Bradley C. Robertson, DDS, MD
Co-Author:	Damir Matic, MD
Affiliation:	University of Maryland/R Adams Cowley Shock Trauma Center, Baltimore, MD

Purpose This is a retrospective analysis of functional outcome in patients with high velocity multisegmental mandibular fractures managed at R Adams Cowley Shock Trauma Center.

Methods Records of 99 consecutive patients treated from 1996 to 2000 with history of mandible fractures were retrieved from Shock Traumas Data Repository. Demographics, Injury and Severity Score (ISS), fracture characteristics, fracture management, and outcomes as related to temporal mandibular function and occlusal bite relationship was analyzed. Complications of infection, malunion, nonunion, hematoma, facial nerve weakness, and malocclusion were reviewed.

Results 63% of patients with high-velocity injuries had multisegmental fractures. 75% had associated facial injuries. Mean number of days to completed surgical management was 1.9 days. 84% were treated with ORIF. Mean follow-up was 6 months. At completion of treatment, 92% had maximum vertical opening (MVO) greater than 35mm. All patients with intracapsular fractures and/or subcondylar fractures had MVO greater than 35mm. 97% reached a stable balanced occlusal relationship. 22% of had complications with 81% of this group being related to infected teeth within the line of fracture.

Conclusions The functional demands of the mandible and its relationship to remaining craniofacial structures makes management of comminuted high velocity fractures an extreme challenge with high potential for complications and poor functional outcome. This retrospective analysis demonstrates successful outcomes when adherence to a functionally based protocol is followed. Early anatomic rigid fixation should be achieved. Severely diseased and/or fractured teeth within line of fracture should be extracted and all intraoral wounds closed. In high velocity injuries splinting with MMF during the inflammatory phase of wound healing avoids abnormal parafunctional activity and micro-motion at the fracture. A sequential phase of passive and then active physical therapy incorporating guiding orthodontic elastics is key for optimal harmonious dynamic function and occlusal relationship.

An End-Game Strategy for the Patient with the Multiply Operated Chin: Beyond the Genioplasty

Presenter:	S. Anthony Wolfe, MD
Affiliation:	University of Miami School of Medicine, Miami, FL

A cohort of 676 patients who had undergone 712 genioplasties by the senior author over a 30 year period was examined. From this group were culled 18 patients who were deemed not to have had a satisfactory final outcome after multiple previous operations, including removal of residual alloplastic implants, one or more osseous genioplasties, and cervico-mental soft tissue revisions.

In 17 of these individuals, patient satisfaction was obtained after use of a costal cartilage graft, carved into an "autogenous implant" and placed through a submental approach. No infections, displacement, or erosion into bone were noted, and there seemed to be little if any resorption of the cartilage graft.

In one patient who had had 23 previous operations on her chin, the 4mm symphysis did not lend itself to a genioplasty, and the condition of the soft tissues did not seem a promising cover for a cartilage graft. A satisfactory outcome was obtained with an osteocutaneous iliac free flap.

Conclusion: In the patient who has one or more genioplasties and still is considered to have a deficient chin, a costal cartilage graft may provide a satisfactory final result.

Pharyngeal Flap Surgery: Long-Term Outcomes at a Tertiary Craniofacial Center

Presenter:	Benjamin B Cable, MD
Co-Authors:	John W. Canady, MD, Micheal P. Karnell, PhD, Lucy Hynds Karnell, PhD, Deonne Malick, BS
Affiliation:	University of Iowa Hospitals and Clinics, Iowa City, IA

Purpose: To examine the long-term outcomes for patients who have received a pharyngeal flap for velo-pharyngeal insufficiency (VPI). Method and Materials: Using the centers craniofacial database, all patients that underwent a pharyngeal flap between January 1970 and December 2000, with at least one post-operative speech assessment between two and five years after surgery, were identified. Speech perceptive scores for hypernasality, hyponasality, and velopharyngeal competence from this time period were then compared with a sequence of more distant time periods, intermediate (five to eight years), long-term (eight to eleven years), and distant (eleven to fourteen years) after surgery. Summary of Results: 172 individual patients with pharyngeal flaps were identified as having post-operative data in the initial 2 to 5 year period. Of this group, 103 individuals had evaluations in the intermediate time period, 65 had evaluations in the long-term period, and 43 had evaluations in the distant period. No significant differences were noted for any of the three indices measured over time. Complications, which were minimal, were characterized and will be discussed. Conclusion: While a number of publications have shown the pharyngeal flap in the short-term post-operative period to be an effective procedure for the treatment of VPI, little long-term data is available, either for outcomes or complications. This work addresses this void and argues that the pharyngeal flap is a procedure that offers the patient a durable option in the treatment of VPI with minimal long-term complications.

Presented in Title Only: 2001 PSEF Research Grant - Regulation of Osteogenesis by IGF-1 Administration

Presenter:	Samuel T. Rhee, MD
Affiliation:	University of Michigan, Ann Arbor, MI

Presented in Title Only: 2001 Smile Train/PSEF Cleft Research Initiative Award: Early Speech Intervention for Children with Cleft Palate

Presenter:	Nancy Scherer, PhD
Affiliation:	East Tennessee State University, Johnson City, TN

Presented in Title Only - 2001 Lyndon Peer Research Fellowship: Noggin Maintains Cranial Suture Patency

2002 PSEF Scientific Essay Contest Award - Essay Category: The Residual Unilateral Cleft Lip Nasal Deformity

Presenter:	Jeffrey R. Marcus, MD
Co-Author:	David M. Fisher, MD, FRCSC
Affiliation:	Hospital for Sick Children, Toronto, ON

The Utilization of Cardiopulmonary Bypass in the Resection of Very Large Craniofacial Vascular Malformations

Presenter:	Hanif Ukani, MD
Co-Authors:	H. Bruce Williams, MD, M. Lucie Lessard, MD
Affiliation:	McGill University, Montreal, QC

Background: Low flow cardiopulmonary bypass and circulatory arrest have been well described for the resection of intracranial vascular malformations. There are only isolated case reports of these procedures being used in the resection of craniofacial vascular malformations.

Purpose: To evaluate the use of cardiopulmonary bypass in the resection of very large craniofacial vascular malformations: To determine the indications for its use, to compare percutaneous femoral bypass to open bypass techniques, and to determine both short-term and long-term complications.

Methods: The study was conducted as a consecutive case series of all patients at the McGill University Health Center (MUHC), who had craniofacial vascular malformations resected with the aid of cardiopulmonary bypass. Charts were reviewed for (1) angiographic studies and embolizations conducted preoperatively, (2) the plastic surgeons indication for the use of cardiopulmonary bypass (3) the operative intervention including bypass parameters, (4) short-term and long-term complications of the procedure.

Results: Cardiopulmonary bypass was used in the resection of 9 craniofacial vascular malformations from 1989-2001. Ages ranged from 2 to 33, with a mean of 18 yrs. Angiograms were conducted on all patients preoperatively. The major indication for the use of bypass was either a significant venous component of the vascular malformation, or incomplete superselective angiographic embolization of the malformation due to the risk of functional loss. All patients were operated in a low flow state after the induction of cardiopulmonary bypass and profound hypothermia. Procedures were conducted via either an open bypass (7 cases), or a closed femoral approach (2 cases). Of the open procedures 2 involved a period of circulatory arrest to excise the vascular lesion. There were 2 major cardiac intraoperative complications with difficulty reversing the cardiopulmonary bypass, and 1 major postoperative complication. The average length of postoperative hospital stay was 10 days. All patients went on to full recovery.

Conclusions: The use of cardiopulmonary bypass is a useful procedure in the resection of very large vascular malformations, in selected cases. There were no major long-term complications in this series. The use of complete circulatory arrest was not required in the majority of cases, and an adequate resection was usually possible with a low flow state alone.

Autogenous Ear Reconstruction: Prefabrication and Prelamination in a Rat Model

Presenter:	Tzu Ying Tammy Wu, MD
Co-Author:	Michael W. Neumeister, MD
Affiliation:	Southern Illinois University School of Medicine, Springfield, IL

Introduction: Prefabrication and prelamination of flaps and tissue engineering provide an enriched armamentarium in difficult reconstructions. The current study employs these techniques to create a vascularized autogenous ear construct that is readily transferable on its own vascular pedicle.

Methods: Male Wistar rats (250-350g) were anesthetized. An incision was made over the right lower abdominal wall. A pocket was formed by blunt dissection just below the panniculus carnosus. A separate incision was made over the right femoral vessels, which were then isolated and transected distally. The vessels were transposed in a subcutaneous plane to the abdominal wound. A silicone mold in the shape of an ear (2 cm x 1.5 cm) was placed over the transposed vessels in the abdominal wound pocket. The mold and the vessels were secured with 6.0 vicryl sutures. The wounds were closed. In one group of rats, auricular cartilage was harvested at this setting, minced, washed, and cultured using standard chondrocyte culturing techniques. After 14 days, the chondrocyte culturing was complete and a vascularized capsule based on the incorporated, transposed femoral vessels was formed. The cultured chondrocytes were then introduced into the molded capsule with or without fibrin glue through an incision along the lateral aspect of the vascularized capsule. Another group of rats received intact auricular cartilage which was harvested at this setting (no cell culture) and placed directly into the molded capsule. Study groups included capsules filled with intact auricular cartilage, cultured chondrocytes only, cultured chondrocytes and a fibrin glue carrier, and the fibrin glue only. The capsule was closed and the wounds sutured. An additional group of rats received intact auricular cartilage placed into the subcutaneous plane, juxtaposed to the abdominal muscle fascia with the femoral vessels transposed directly on top of the auricular cartilage without the capsule. The prefabricated, prelaminated construct was isolated on its vascular pedicle at various time points. Gross examination and histological analysis were performed.

Results: All of the capsules were completely vascularized and could be reliably isolated on the transposed femoral vessels. The pedicle, being incorporated directly into the capsule, provided the dominant blood supply to the construct. None of the capsules with the fibrin glue only retained any shape and were devoid of cartilage. Similarly, there was no evidence of retained cartilage in the capsules filled with cultured chondrocytes alone. All capsules with the cultured chondrocytes and the fibrin glue carrier had mature shaped cartilage preserved. Those with intact auricular cartilage with and without capsule maintained the original shape of the cartilage and had as its main blood supply the transposed femoral vessels.

Discussion: We have shown that transposing a vascular pedicle to a subcutaneously placed silicone block will result in a vascular capsule that can be mobilized and transferred based solely on the pedicle. Similarly, intact autogenous auricular cartilage can be vascularized by the transposed pedicle without presence of the capsule; the shape of the cartilage is maintained as well with or without the capsule. On the other hand, cultured chondrocytes require a vascularized capsule along with an appropriate carrier such as fibrin glue to grow and thrive.

Presenter:	Matt Cole, BS
Co-Authors:	James Jakowatz, MD, Gregory R.D. Evans, MD
Affiliation:	The University of California, Irvine, Orange, CA

Purpose: We reviewed a population of patients with melanoma of the ear undergoing surgical excision and reconstruction to determine the utilization of sentinel lymph node mapping

Material and Methods: A retrospective chart review was performed on all patients diagnosed and treated for malignant melanoma that required reconstruction of the external ear between 1995 and 2001. Nineteen patients were selected of which 9 underwent sentinel node mapping. The average age of the patients was 65.2 years. Evaluation of melanoma depth, medical history, surgical margins, lymph node metastasis and recurrence were also determined.

Results: Lymphoscintigraphy and injection of vital blue dyes demonstrated a wide variable drainage pattern with the parotid and upper cervical area the most common location. The average number of sentinel nodes identified and removed was 3.7. The average Breslow thickness for these patients was 2.3mm. None of these patients demonstrated micrometastatic disease in their sentinel node. The most common reconstructive procedure following surgical resection was a rotational advancement flap. Counts per second with radiolabeled Tc99m was the primary method for detecting sentinel lymph nodes. The average CPS of the primary injection site was 8,375 and the average for the node removed was 973.5. Of the 9 receiving sentinel lymph node mapping only one developed recurrence with an initial depth of 5mm. The average follow-up was 20 months.

Conclusion: Larger studies are indicated, however it appears that this method is viable for approaching and designing therapeutic modalities for patients with melanoma of the ear

Presenter:	Gary F. Rogers, MD, JD, MBA, MPH
Co-Authors:	Harry P.W. Kozakewich, MD, John B. Mulliken, MD
Affiliation:	Harvard University, Boston, MA

Cutaneous neural heterotopias comprise a diverse group of lesions, including tumors and malformations, in which leptomeningeal or glial tissue is present in the dermis and subcutaneous tissue. Heterotopic neural malformations of the scalp are congenital and result from aberrant neural tube closure. They have no malignant potential. These anomalies are seen in newborns as a nodule in the occipital or parietal scalp with overlying alopecia. Often there is an associated capillary stain and a surrounding circle of long, course hair, a finding termed the "hair collar sign". While most of these lesions are separated from the underlying central nervous system by intact calvaria, some have a rudimentary stalk that communicates intracranially.

We retrospectively reviewed the records of 10 infants with heterotopic neural malformations of the scalp managed at Children's Hospital between 1985 and 2000. All patients had the histologic features of ectopic meningeal or glial tissue. Radiographic evaluations were available on all patients and the preoperative interpretations were compared to the intraoperative findings, particularily regarding the possibility of intracranial extension. The preoperative clinical diagnosis and postoperative histopathologic diagnoses were also compared.

All lesions were excised in a lenticular fashion with linear closure. Patients who had an intracranial extension had ligation of the rudimentary meningeal sac. Histologic sections from the lesions in 9 patients were available for review and analyzed with immunohistochemical staining, including epithelial membrane antigen (to delineate meningothelial cells), glial fibrillary acidic protein (to stain glial tissue), and synatophysin (to detect neurons).

There were 11 lesions in 10 patients (7 females, 3 males). The average age at excision was 8.6 months. Minimum follow-up time was 2 years for all patients. All lesions were midline, or near midline, and in the parietal/occipital scalp. Nine of 11 lesions (9 patients) had a "hair collar sign". Eight lesions had an associated capillary stain. All of the lesions were soft, nodular masses and most lesions were small, measuring 2 centimeters or less in circumference.

One patient had two lesions that were misdiagnosed as "dermoid cysts". The remaining lesions were accurately diagnosed preoperatively as cutaneous neural heterotopia (4 patients) or rudimentary meningocele (5 patients). All patients underwent preoperative radiographic evaluation. CT and/or MRI correctly predicted the presence of a calvarial defect in four patients. Plain radiographs, used exclusively in only one patient, showed no intracranial extension nor was a connection found intraoperatively. In the remaining 5 patients, CT and/or MRI imaging accurately predicted the absence of intracranial extension. Histopathologic examination demonstrated 8 lesions with heterotopic leptomeningeal tissue (positive EMA stain) and 3 lesions composed of glial tissue (positive GFA stain).

Heterotopic neural malformations are rare and clinical awareness of the entity is important to direct appropriate preoperative and intraoperative management. Preoperative imaging is essential to document possible intracranial involvement and avoid inadvertent dural penetration.

Presenter:	Reha Yavuzer, MD
Co-Authors:	Alper Sari, MD, Suhan Ayhan, MD, Osman Latifoglu, MD, Cemalettin Celebi, MD
Affiliation:	Gazi University Medical Faculty, Ankara, N/A

Introduction: Interventions on the maxillofacial region, either for reconstructive or aesthetic reasons, may sometimes necessitate the augmentation of hard tissues. Though autogenous bone grafts are the first choice, donor site morbidity and difficulties in shaping, make alloplastic implants another reliable alternative. Among the alloplastic implants hydroxyapatite granules, with their high biosuitability take the first place

Material and Method: Between 1998 and 2002 a total of 30 patients, 12 for pure aesthetic and 18 for reconstructive reasons, had maxillofacial hard tissue augmentation procedures using hydroxyapatite granules. The procedures were carried out as an adjunct to other cosmetic procedures in most of the cases. The granules were mostly used on the perialar and mandibular regions and zygoma and temporal area were the other sites for hydroxyapatite application.

Results: Follow-ups ranging from three months to three years have revealed that, the desired contours were established without any volume loss (figure: pre and postop views of three patients. Case 1: Pure aesthetic concern, augmentation of perialar region; Case 2: Romberg disease, augmentation of mandibula; Case 3: Traumatic mandibular defect, augmentation of mandibula). No complications regarding the use of hydroxyapatite granules were encountered.

Discussion: Hydroxyapatite granules heal by allowing fibrovascular and osseous tissue ingrowth, do not cause foreign body reactions, and offer ease in their usage and shaping. These advantages make them a comfortable and reliable choice in maxillofacial hard tissue augmentation procedures. In our practice we have been having the advantage of being able to augment the hard tissue easily which enables us to improve our cosmetic results.

The Utility of Sentinel Lymph Node Biopsy in Head and Neck Melanoma in the Pediatric Population

Presenter:	Salvatore J Pacella, MD
Co-Author:	Riley Rees, MD
Affiliation:	UNIVERSITY OF MICHIGAN, Ann Arbor, MI

Intraoperative lymphatic mapping (IOLM) and sentinel lymph node biopsy (SLNB) has emerged as a reliable and accurate method to stage adult patients with melanoma of the head and neck. However, the utility of IOLM and SLNB in head and neck melanoma in the pediatric population has not been established. The objective of this study was to determine the clinical utility of IOLM and SLNB of head and neck melanoma in the pediatric population. We reviewed the records of 7 pediatric patients with head and neck melanoma or borderline melanocytic proliferations of unknown biologic potential who underwent IOLM and SLNB between 1998 and 2001. All surgical nodal specimens were examined by a melanoma dermatopathologist for the presence of metastatic melanoma. The mean operative time for each case was 3hrs 8 min (range 2:15-3:50). All seven pediatric patients who underwent extirpation of a primary head and neck melanoma and preoperative lymphoscintigraphy had unique and identifiable basins of drainage to regional nodal groups. Four of the seven patients (57%) had at least 1 positive sentinel lymph node. Overall, five of the 19 nodes (26%) resected had evidence of metastatic melanoma. Of the patients with positive sentinel lymph nodes, two of the primary lesions were diagnosed as melanoma while two were considered atypical melanocytic proliferations of uncertain biologic potential. One (25%) of four patients had evidence of an additional positive lymph node from the theraupeutic lymph node dissection. Sentinel lymph nodes in pediatric patients with melanoma of the head and neck can be successfully mapped and biopsied similar to adult patients. In addition, this procedure can provide critical diagnostic information for those pediatric patients with diagnostically challenging, controversial or borderline melanocytic lesions.

Monday, November 4, 2002

2001 PSEF Research Fellowship Award: Electrical Stimulation of Denervated Skeletal Muscle

Presenter:	Marlene S. Calderon, MD
Co-Authors:	William M. Kuzon, MD, PhD, John A. Faulkner, PhD
Affiliation:	University of Michigan Ann Arbor, Ann Arbor, MI

2002 PSEF Essay Contest - D. Ralph Millard, MD Investigator Award: Tissue-Engineered Constructs for Perpheral Nerve Injury

Presenter:	Michael J. Brenner, MD
Co-Authors:	Susan E. Mackinnon, MD, Shelly E. Sakiyama-Elbert, PhD, Annie C. Lee, Daniel A. Hunter, RA
Affiliation:	Washington University School of Medicine, St. Louis, MO

Palm Pilot Based Tracking of Operative Cases for Plastic Surgery Fellows- A More Intuitive Approach

Presenter:	Darshan Shah, MD
Co-Author:	Uldis Bite, MD
Affiliation:	Mayo Clinic, Rochester, MN

Keeping an accurate record of operative cases during a plastic surgery fellowship program is essential to achieve the minimum number of cases required by the Plastic Surgery Residency Review Committee. Although the ACGME does provide an online case logging tool, it does not provide intuitive categorization of surgical procedures. Using a database created by Thinking Bytes Technology (www.thinkdb.com), residents can program a case logging application using a Palm Pilot. This program can also perform wireless/web-based synchronization, facilitating communication between a program director and his residents about operative experience.

Figure 1 shows the main input screen for a particular patient displaying name, ID number, and date. Hospital name, attending name, and CPT code are chosen from a drop down list. The category of the procedure is also chosen from a drop down list of the category name and the minimum number required of that category. A check box on the main screen can be used to keep track of procedures that have been logged and/or dictated on the ACGME system. Inpatient data such as room number, etc. as well photo data can also be tracked using the program.

The most useful function of the program is easy data summarization into charts displaying the total number of cases in a specific category, so a resident is able to quickly check which categories are deficient. This information is invaluable in planning operative schedules and consultation distribution amongst multiple residents in a training program. These summaries are easily exported into a Microsoft Excel spreadsheet.

In conclusion, a palm-based application for surgical operative cases has become an invaluable organizational and planning tool for residents. Minimum numbers required by the RRC can be more readily achieved with the instant information that this program provides.

A Microangiographic Technique For Quantification of Fasciocutaneous Blood Vessels in Laboratory Animals

Presenter:	Hans-Guenther Machens, MD
Co-Authors:	Alexandra Maichle, Timo Spanholtz, Christian Niedworok, Frank Siemers, Bjoern Krapohl, Kay-Henryk Herter, Beate Stoeckelhuber, MD
Affiliation:	Luebeck University Clinic, Luebeck, N/A

Subject: Studies on functional flap angiogenesis demand an accurate technique for quantification of flap blood vessels. Technique: As an example, a 2.0 x 8.0 cm McFarlane flap is used in a rat model. After clinical evaluation, the left carotid artery in cannulated and 1µg prostvasine/100 g animal injected. 30 seconds later, 3 ml blood/100 g animal are withdrawn and the animal is euthanized. A mixture of liquid gelatine and bariumsulfate is slowly injected. 24 hours later, the fasciocutaneous tissue is surgically removed including the flap tissue. X-ray is performed on the specimen and the blood vessels are visualized. A computer program can be used to quantify the number of blood vessels/cm2 flap tissue. Practical value: This technique allows easy, reproducible and accurate quantification of small and new blood vessels. It may be usefull in studies to quantify angiogenesis in fasciocutaneous flaps for different purposes.

Three-Dimensional and Interactive Animation of Carpal Kinematics: An Example of Real-Time Modeling of Complex and Dynamic Anatomy

Presenter:	Hooman Soltanian, MD
Co-Authors:	Aaron Oliker, BA, Robert W. Beasley, MD, Cornelia Golimbu, MD, Geoffrey C. Gurtner, Court B. Cutting, MD
Affiliation:	NYU Medical Center, New York, NY

At present Computerized Tomography (CT) and Magnetic Resonance Imaging (MRI) can provide us with extremely high-resolution images. However, these images continue to be two-dimensional, static, and unable to visualize the dynamic relationship between anatomic structures. Recent advances in animation technology, have greatly enhanced the ability of computer generated animations to simulate real objects and their interactions with a high degree of accuracy. Our goal was to bring together the advancements in these two unrelated fields to produce three-dimensional anatomic models which show the dynamic relation of parts with a clarity previously unknown while enabling us to quantify angular and translation motions with precision. This 3D model would allow the visualization from any viewpoint and also elimination of parts blocking or confusing the images of objects of primary concern. The body's most complex joint, the wrist, was chosen as the first example. We used high-resolution CT images of fresh frozen human specimens. Using a specialized rig, the wrist was scanned in 12 positions. Three-dimensional surface models were created and superimposed. Using the animation software, each bone was animated through its entire motion relying on the CT data. Algorithms were then construed to allow direct and exact measurement of angular and translation changes for each object. The measurements are performed without the need for placement of markers or biomechanical sensors which could interfere with the motion by virtue of their presence. The potentials of the system as a teaching tool are obvious. This system can also be used to plan and simulate complicated surgical procedures. We will also demonstrate how the main portion of the three-dimensional model can be used via the Internet without the need for complicated and expensive equipment.

Matrix Organization in Mesenchymal Stem Cell Tissue Engineered Polylactide/Alginate Amalgam for Cartilage Reconstruction

Presenter:	Edward J. Caterson, PhD
Co-Authors:	Stephanie A. Houser, MD, Steven E. Copit, MD, John H. Moore, MD, James W. Fox, MD, Rocky S. Tuan, PhD
Affiliation:	Thomas Jefferson University Hospital, Philadelphia, PA

Introduction: Mesenchymal stem cells (MSCs), when housed within an appropriate scaffold and stimulated by specific chondrogenic signals have been considered for potential application in tissue reconstruction. Tissue engineering principles are currently being applied to cell-based efforts to restore damaged or diseased tissues. The basic requirements for these efforts are cells capable of producing a functional matrix, an appropriate scaffold for transplantation and support of the cell-laden graft, with iatrogenic or autogenous bioactive molecules to drive the processes of cellular differentiation and maturation. Methods: MSCs were seeded in experimental groups consisting of poly-L-lactic acid (PLA) constructs and PLA/alginate amalgam constructs with and without recombinant human transforming growth factor-b1 (TGF-b1). Chondrogenesis of the PLA and the PLA/alginate amalgam cultures was assessed at weekly intervals by histology, immunohistochemistry, scanning electron microscopy, sulfate incorporation and RT-PCR to characterize the in vitro chondrogenic differentiation profile and the generation of fibrous tissue production within the matrix. Results/Discussion: Cartilage formation was apparent in the TGF-b1 treated groups, on the basis of chondrocyte specific gene expression assessed by (RT-PCR), as well as histological and immunohistochemical analysis in both the plain PLA and the PLA/alginate amalgam. Cellular proliferation, localized by staining for proliferating cell nuclear antigen (PCNA) and 5-bromo-2deoxyuridine (BrdU), was found restricted to the perimeter regions of the three-dimensional constructs. In the plain PLA constructs, immunohistochemistry revealed this region of cellular proliferation to be associated, by immunohistochemistry, with a collagen type I- rich fibrous layer. This represents a potential barrier between the host tissue and the engineered neo-cartilage. In contrast, the three-dimensional construct fabricated using the PLA/alginate amalgam showed no signs of fibrous tissue deposition, and thus represents the first step towards the design of specific implants to direct cellular proliferation, promote differentiation and prevent inappropriate matrix deposition to reconstruct tissues lost to disease and/or trauma.

Presenter:	David G. Genecov, MD
Co-Authors:	Kenneth E. Salyer, MD, Sarah Goldberg, Josh Choo
Affiliation:	International Craniofacial Institute, Dallas, TX

Purpose: This prospective randomized, double-blinded study is designed to evaluate the effectiveness of ALA on the lip scars of infants with cleft lips undergoing primary cheiloplasty.

Methods: 62 patients underwent primary cheiloplasty at the same institution from July 1, 1998 to June 30, 1999. 20 patients were randomly assigned to the study protocol. Patient's families were informed and consent obtained. A modified rotation advancement procedure with primary cleft nasal reconstruction was performed. Sutures were removed at day 6. At day 14 the families were instructed to begin lip scar taping and massage daily for 10 minutes, 3 times each day for 3 months. Monthly follow-up was obtained to assess patient and family compliance. Lip massage cream was provided by N.V. Perricone, MD Cosmeceuticals and each bottle was coded by the factory scientist. The active ingredient in the massage cream was alpha lipoic acid. The control bottles contained the same product without the ALA. Scar analysis was performed at 1 year using the quantitative scale developed by Beausang et.al (PRS, Vol. 102 No. 6, Nov. 1998)

Results: 6 patients were disqualified due to inadherence to the study protocol or refusal to return for follow-up photographs. (Many patients live greater than 250 miles from the center) 14 patient scars who satisfied the criteria were evaluated. 7 patients were in the placebo and 7 were in the active groups, once the key was obtained from the factory. Mean score in the placebo group was 13.18 and in the active group 8.12. Standard deviations were 3.13 and 2.52 respectively. Using paired T-Test analysis, the scores in the active group were statistically significant for improved scars with p=0.05.

Conclusion: Adding ALA along with our standard post-op scar taping and massage resulted in improved lip scars in patients undergoing primary cheiloplasty. A larger study will be helpful in detecting the greatest benefit of this antioxidant therapy.

A Validated Objective Measure for Grading the Primary Unilateral Cleft Lip Nasal Deformity

Presenter:	Jeffrey R. Marcus, MD
Co-Author:	David M. Fisher, MD
Affiliation:	University of Toronto, Hospital for Sick Children, Toronto, ON

Purpose: The ultimate appearance of the cleft lip nose is influenced heavily by the severity of the primary deformity. Therefore, an outcome is only meaningful in the context of the documented presurgical state. Given a series of patients, it is possible to comparatively express severity of the primary unilateral cleft lip nasal deformity (UCLND) subjectively through ranking. For an individual patient, as is the case in clinical practice, subjective assessment is more difficult due to the absence of direct comparison. The purpose of this study is to develop and provide validation of an objective and quantitative method for gradation of the presurgical UCLND. Our hypotheses are: expert cleft surgeons are able to reliably rank patients according to their subjective assessment of nasal deformity severity and that that one or more objective measurements correlate consistently with this subjective assessment. Materials and Methods: Prospectively, forty consecutive infants undergoing unilateral cheiloplasty were analyzed under anesthesia just prior to surgery. Standardized presurgical photographs and a series of prospectively determined anthropomorphic measurements were obtained. Presurgical photographs were subjectively ranked by four senior cleft surgeons within the institution; internal agreement was assessed. Correlation between measured parameters and subjective ranking was determined. Images were also ranked by four external expert cleft surgeons of international reputation to test the reproducibility of subjective ranking and to validate our measure. Results: Reproducibility was demonstrated by the extremely high correlation (TABLE) of observations among the participants within and between the two expert panels. Of the prospectively measured parameters, the columellar angle was strongly correlated (r=0.73, p<0.0001) and was predictive of the subjective panels grading. This result was validated by interclass correlation with the ranking of the external expert panel (r=0.79, p<0.0001). Conclusions: Because it is difficult to simplify the complex visual impact of the UCLND, assessment has most commonly been carried out subjectively or categorically (ie. incomplete vs complete). Categorical assignment cannot discriminate significant variation within groups, and subjective assessment is meaningful yet non-quantitative. As we have demonstrated, experts are able to subjectively rank patients with remarkable consistency according to the degree of severity. The columellar angle is an objective and quantitative measurement that varies in a linear fashion with the perceived deformity. It therefore may be useful as an independent and objective indicator of presurgical UCLND severity.

Presenter:	Richard E. Kirschner, MD
Co-Authors:	Alison E. Slemp, BS, Faizi Siddiqi, MD
Affiliation:	Children's Hospital of Philadelphia, Philadelphia, PA

Purpose: Palatal fistulas are a common complication of palatoplasty. Surgical repair is indicated to eliminate associated problems, including nasal leakage of food and fluids, nasal air emission, and chronic inflammation. The presence of scar tissue and deficiency of healthy local tissues make tension-free closure of palatal fistulae difficult, contributing to failure rates of 10% to 65% and often necessitating the use of regional flaps. This study examines the efficacy of a novel technique for palatal fistula repair using acellular dermal grafts for simple, tension-free closure. Methods: 10mm oronasal fistulae were created in the hard palate of 3-week-old Yorkshire piglets. The bony palate was ronguered 2mm beyond the mucosal edges to allow oral-to-nasal re-mucosalization. In one group of animals (n=3), the fistulae were allowed to heal for 2 weeks prior to repair. In each animal, bilateral mucosal incisions were made, and the mucoperiosteum was elevated from the underlying bone. Acellular dermal grafts were then inset beneath the oral mucosa, traversing the palatal fistula. No attempts were made to suture the mucosal edges of the fistulae (Figure 1). Three weeks postoperatively, animals were sacrificed and the palates harvested for histologic examination. The fistulae of a second group of animals (n=3) remained unrepaired and were examined five weeks after their creation. Results: All animals demonstrated patent oronasal fistulas with complete re-mucosalization of the wound margins at two weeks. Those animals that underwent fistula repair with the acellular dermal grafts demonstrated complete healing at three weeks (Figure 2), with complete re-epithelialization and cellular infiltration into the grafts. Unrepaired fistulae remained patent at five weeks. Conclusion: This study demonstrates the successful closure of palatal fistulas in an animal model using interposition grafts of acellular dermis. This novel method offers promise as a simple and effective technique for tension-free closure of oronasal fistulas after primary palatoplasty.

Newborn Cleft Palate Repair in the Congenital Caprine Model: Effect on Midfacial Growth

Presenter:	Jeffrey Weinzweig, MD
Co-Authors:	John T. Seki, MD, Chad D. Tattini, MD, Anthony Spangenberger, BS, Kip E. Panter, PhD
Affiliation:	Brown University, Providence, RI

PURPOSE: The congenital cleft palate model in the caprine species has been previously described by Weinzweig. In utero surgical repair of cleft palate in this model has been successfully demonstrated with resultant scarless palatal healing and unimpaired midfacial growth. The present work evaluated midfacial growth following cleft palate repair in the newborn.

METHODS AND MATERIALS: Time-dated pregnant goats were gavaged twice daily with anabasine, an extract of Nicotiana glauca, during gestational days 32-41 (term, 145 days). At 6 weeks of age, two sets of twins (4 goats) underwent cleft palate repair using a modified von Langenbeck technique. All goats were sacrificed at 6 months of age, and underwent dry skull analysis following debridement and beetle colony preparation.

RESULTS: Multiple parameters on dry skulls were measured to identify pertinent indices of craniofacial growth such as bony cleft width (1), maxillary width (2), and maxillary length (3). Data were collected from four groups: unclefted control, clefted unrepaired, clefted repaired in utero, and clefted repaired at 6 weeks of age. There was evidence of anterior bony cleft narrowing in the groups repaired in utero and at 6 weeks of age by 48% and 32%, respectively. The posterior bony cleft width was also reduced by 60% and 27%, respectively. Maxillary width was decreased in the transverse dimension at the level of the third molar following newborn repair. Maxillary length also demonstrated significant shortening by 11.4% compared to the unclefted control group, and 9.4% compared to the group repaired in utero.

CONCLUSIONS: Significant midfacial growth impairment was demonstrated in animals that underwent cleft palate repair at six weeks of age compared to those repaired in utero. We attribute this to the palatal scarring secondary to surgical manipulation at this point in time.

Presenter:	Peter J. Taub, MD
Co-Authors:	James P. Bradley, MD, James M. Stuzin, MD, Henry Kawamoto, MD
Affiliation:	UCLA, Los Angeles, CA

Introduction: The monobloc (or frontofacial) osteotomy and advancement is an effective procedure for correction of midface hypoplasia and forehead retrusion but is known to have significant morbidity. It is unknown whether gradual lengthening by distraction osteogenesis (D.O.G.) reduces morbidity by decreasing the large dead space between the nasopharynx and supradural space of the frontal lobe. To investigate this we compared outcomes of patients who had monobloc osteotomies with acute advancement and bone grafting with patients who had D.O.G. Methods: Three groups of patients (n=30) with midface hypoplasia and forehead retrusion underwent monobloc osteotomy and advancement from !979-2001. Group 1 underwent acute advancement with bone grafting (n=13, 1979-1989). Group 2 also underwent acute advancement and bone grafting but with modification of the technique with use of pericranial flap and fibrin glue and the exclusion of patients with VP shunts (n=7, 1989-1996). Group 3 had gradual lengthening with D.O.G. using an internal device (latency=5 days, rate=1mm/day, rhythm=every 12 hours) (n=10, 1996-2001). Variables considered on retrospective review of morbidity and mortality included: age, comorbidity, previous surgery, operative time, degree of advancement, blood transfusion and presence of VP shunt (Fischer exact test was used). Serial cephalograms were also reviewed. Results: Patients were treated between 4.5 years and 10 years of age (patients under 6 years had early surgery for functional problems such as upper airway obstruction or loss of eye protection). Group 3 patients (D.O.G.) had a mean advancement 3.5mm and 3.0 mm greater than Group 1 and Group 2, respectively. Group 1 demonstrated the highest morbidity: meningitis=5 (38%), CSF leak=3 (23%), wound infection=5 (38%), transfusion reaction=1 (.7%). In contrast, Group 3 (D.O.G.) had the lowest morbidity meningitis=0 (0%), CSF leak=0 (0%), wound infection=2 (20%), transfusion reaction=0 (0%). The number of patients with any morbidity within each group was: Group1=8 (61%), Group 2=3 (43%) Group 3=2 (20%). A clinically significant difference would require a larger sample size (n=100). Conclusion: These data suggest that advancement of monobloc osteotomy by D.O.G. has less morbidity and may have less relapse that traditional acute advancement and is an alternative to staging this advancement with a fronto-orbital advancement followed by a Le Fort III advancement.

Syndromic FGFR Gain-of-Function Mutations Suppress Noggin: Implications for Cranial Suture Biology

Presenter:	Stephen M. Warren, MD
Co-Authors:	Aris N. Economides, PhD, Lisa J. Brunet, PhD, Richard M. Harland, PhD, Kenton D. Fong, MD, Michael T. Longaker, MD
Affiliation:	Harvard University, Boston, MA

Introduction: Craniosynostosis, premature cranial suture fusion, affects 1:2000 children. We are using murine models to study the molecular mechanisms mediating premature cranial suture fusion. In these models, the posterior frontal (PF) cranial suture fuses while all other sutures, including the sagittal (SAG) and coronal (COR) remain patent. Previous work from our laboratory indicates that suture-specific dura mater initiates PF suture fusion via multiple paracrine (e.g. TGF-b1 and FGF-2) signaling pathways. Numerous fate-based studies have demonstrated that cranial suture fusion is controlled by these pro-osteogenic paracrine factors and, moreover, we have found that these same pro-osteogenic cytokines are absent in the patent SAG and COR dura mater. We had long suspected that cranial suture patency was a passive process (i.e. insufficient levels of osteogenic cytokines), however, in this study, we demonstrated that Noggin, a BMP antagonist, actively maintained SAG and COR suture patency. Using a model of COR craniosynostosis, we investigated how premature suture fusion affected the "brake" (i.e. Noggin) on suture fusion. Furthermore, we investigated the effects of Apert and Crouzon gain-of-function FGFR2 mutations on Noggin expression in chimeric dura mater and osteoblasts. Finally, we examined the effects of Noggin misexpression on cranial suture fate.

Methods: In situ hybridization screening was performed on mouse cranial sutures (days 15, 25, 35, and 45) for the BMP antagonists: DCR4, DCR5, DCR6, DCR7, Gremlin, Cerberus, and Noggin. The calvaria of transgenic beta-galactosidase/ Noggin mice were harvested at similar time points, treated with an X-gal solution and histologically examined. PF, SAG and COR dural cell cultures were established and Western blots were performed. The rat COR craniosynostosis model was based a previous published overexpression FGF-2 adenoviral model from our laboratory. Chimeric gain-of-function FGFR2 mutated dura mater and osteoblasts created using retroviral vectors. A Noggin over-expression adenovirus was injected into the PF suture of 22 day-old calvaria in vitro or 3 day-old mice in vivo.

Results: In situ hybridization demonstrated that Noggin is the only BMP antagonist present in murine cranial sutures. X-gal staining of transgenic mice demonstrated no Noggin expression in the PF suture complex before, during or after suture fusion. In contrast, SAG and COR sutures expressed high levels of Noggin throughout the period of predicted suture fusion. PF dural cultures did not produce Noggin. In contrast, SAG and COR dural cultures constitutively produced high levels of Noggin. In our model of COR craniosynostosis, we found that FGF-2 overexpression dramatically suppressed COR Noggin expression. Apert and Crouzon gain-of-function FGFR2 mutations suppressed constitutive SAG dura mater Noggin expression and BMP-4 induced Noggin expression in chimeric osteoblasts. Finally, Noggin misexpression maintained PF suture patency in vitro and in vivo.

Discussion: Since normal cranial suture patency depends on BMP antagonism, some forms of craniosynostoses may result from inappropriate FGF-mediated down-regulation of Noggin expression. Ongoing studies are investigating the effects of a Pfeiffer (Pro250Arg) FGFR1 transgenic mutation on Noggin expression and cranial suture fate in vivo.

Evidence of an ERK1, ERK2 Dependent Pathway for Mechanically-Guided Tissue Regeneration During Mandibular Distraction Osteogenesis

Presenter:	S.T. Rhee, MD
Co-Authors:	L.E. ElBassiony, MD, C.M. Cavaliere, MD, S.R. Buchman, MD
Affiliation:	University of Michigan, Ann Arbor, MI

Objective: The cellular mechanisms responsible for regulating bone formation during mandibular distraction osteogenesis (DO) are unknown. Tensile forces associated with DO differ from forces associated with rigid fixation of a bony defect. Previous studies in our lab indicate that these forces may regulate bone formation via a mechanically-induced signal transduction pathway that is not involved in fracture healing. Extracellular signal-related kinases (ERK1, ERK2) are members of the MAPK family of signal proteins thought to play a key role in the coordination of a cells response to mechanical stress invitro. To investigate the potential role of MAPK in-vivo, we compared activated ERK in distraction gap tissue to activated ERK in fracture healing and nonunion of a critical size defect using a rat model of mandibular DO.

Methods: Sprague-Dawley rats underwent unilateral mandibular osteotomy and placement of a rigid distraction device. Distraction began on post-operative day 5 at a rate of 0.3 mm twice per day, up to 5.1 mm. Animals were sacrificed on post-operative days 4, 6, 9 and 12. Control animals underwent osteotomy with fixation at 2 mm to simulate fracture healing, or at 5.1 mm to simulate nonunion of a critical size defect. Immunohistochemical (IHC) evaluation of activated ERK protein was performed using a polyclonal anti-p-ERK antibody specific for phosphorylated ERK1 and ERK2.

Results: Histologic analysis showed nonunion at the 5.1 mm gap, and various stages of fracture healing at the 2 mm gap and the distraction gap. IHC studies showed a marked increase in activated ERK in the distraction gap tissue at multiple time points compared to control specimens. Activated ERK co-localized with markers of new bone formation.

Conclusion: Activated ERK1 and ERK2, MAPKs thought to play a key role in mechanotransduction in-vitro, are markedly increased in-vivo during mandibular distraction osteogenesis. A similar increase does not occur with fracture healing or nonunion. Our results support the hypothesis that mechanical force may regulate bone formation via an ERK1/ERK2-mediated mechanotransduction pathway.

Presenter:	Wayne Ozaki, MD, DDS
Co-Authors:	S.R. Winn, PhD, Xi Gong, MD, C.C. Hung, MD, A. Sasaki, Y. Hu
Affiliation:	Oregon Health & Science University, Portland, OR

Our laboratory has shown the efficacy of bone morphogenetic proteins (BMPs) in healing critical-sized rat cranial defects. Gene therapy, however, offers a more efficient, sustained, and cost effective method of bone regeneration. This study investigated the bone regenerative ability of plasmid DNA encoding recombinant human bone morphogenetic protein-4 (rhBMP-4) administered with a biodegradable, biocompatible fabric, porous poly(D,L-lactide) and type 1 collagen (PLC). Uniform 8-mm calvaria defects were prepared in 150 rats divided into 5 treatment groups: 1. untreated critical-sized defect (negative control); 2. PLC only; 3. plasmid DNA rhBMP-4 only; 4. plasmid DNA rhBMP-4/PLC; 5. autogenous bone graft (positive control). Rats were sacrificed at 2, 4, and 8 weeks post surgery. Sacrifice time periods were based on data from previous studies. Quantitative analysis of bone formation included radiomorphometry and histomorphometry. Statistical significance was established at p<0.05. Treatment outcomes revealed statistically greater bone healing in the plasmid DNA rhBMP-4 with the bioresorbable carrier compared to the untreated group, the plasmid alone group, or the carrier alone group at 4 and 8 weeks. These results were consistent in both histomorphometry and radiomorphometry analyses. We also found significantly greater bone healing in the autogenous bone graft control group compared to the plasmid DNA rhBMP-4 with the bioresorbable carrier group. This study demonstrated plasmid DNA rhBMP-4 and a bioresorbable carrier can stimulate clinically relevant quantities of new bone growth to fill a critical-sized rat cranial defect. This treatment group was superior to the untreated defect, the carrier alone or the plasmid alone. This study provides important preliminary data for the development of juvenile canine and primate models of alveolar cleft bone healing.

Juvenile Versus Adult Osteoblast Gene Regulation: Implications for Calvarial Re-Ossification

Presenter:	Stephen M. Warren, MD
Co-Authors:	Catherine M. Cowan, MA, Natalina Quarto, PhD, Kenton D. Fong, MD, Jonathan A. Mathy, MD, Michael T. Longaker, MD
Affiliation:	Harvard University, Boston, MA

INTRODUCTION: Successful calvarial re-ossification is a characteristic generally restricted to juvenile animals and infants younger than 2 years-of-age. Since this osteogenic capacity rapidly diminishes, older animals and adults with non-healing cranial defects due to trauma, craniofacial or neurosurgical operations present a difficult reconstructive challenge and a substantial biomedical burden. Presently, surgeons use a variety of techniques to reconstruct non-healing calvarial defects. While these operations are usually successful, they are complex procedures with numerous limitations. To address these problems, we are investigating the mechanisms mediating successful juvenile calvarial re-ossification. To date, research has focused on the regenerative potential of the dura mater lining the base of the calvarial defect; however, little is known about the differences in cellular biology between juvenile and adult osteoblasts (Obs). In the present study, we compared the growth characteristics, osteogenic and angiogenic potential of juvenile and adult osteoblasts. In addition, we investigated the mechanisms leading to these different phenotypes by analyzing the expression of tyrosine kinase receptors (FGFRs), osteogenic proteins (osteopontin [OP]) and anti-proliferative factors (transducer of ErbB-2.1 [Tob]; B-cell translocation gene [PC3]) at baseline and in response to rhFGF-2.

METHODS: Rat calvarial Ob cultures were established from 2 day- (juvenile) and 60 (adult) day-old animals. Cell counting was used to compare juvenile and adult osteoblast growth rates. In order to compare their osteogenic/angiogenic potential as well as proliferative profiles, juvenile and adult osteoblast cultures were stimulated with rhFGF-2 (10 ng/ml) and total cellular RNA was harvested at 0, 3, 6, 12, and 24 hours. Northern blot analyses were performed for BMP-2, VEGF, FGFR1, FGFR2, OP, Tob, and PC3.

RESULTS: Juvenile osteoblasts proliferated significantly faster than adult osteoblasts at 3 and 5 days (Student's t-Test: *p<0.003 and *p<0.001, respectively). Both juvenile and adult osteoblasts produced BMP-2 mRNA in response to FGF-2; however, the 6-hour BMP-2 mRNA peak in juvenile osteoblasts was markedly increased compared to adult osteoblasts. Furthermore, juvenile osteoblasts produced more VEGF mRNA in response to FGF-2 stimulation than adult osteoblasts. At baseline, adult Obs expressed 2-fold more FGFR1 mRNA; however, juvenile Obs expressed 5-fold more FGFR2 mRNA. Although, juvenile and adult Obs produced equal amounts of baseline OP, juvenile Obs increased their expression 13-fold after 24 hrs of rhFGF-2 stimulation, compared to an adult Obs increase of only 5-fold. Finally, adult Obs expressed 2.5-fold more Tob and 11-fold more PC3 compared to juvenile Obs.

CONCLUSIONS: Collectively, these data suggest that juvenile animals may be able to successfully heal craniotomy defects because juvenile osteoblasts proliferate more rapidly and produce greater amounts of osteogenic and angiogenic proteins when stimulated with dura-derived cytokines, such as FGF-2. Furthermore adult Obs are more differentiated (high FGFR1) and less proliferative (low FGFR2) than juvenile Obs. Even after stimulation with rhFGF-2, adult Obs do not increase production of genes necessary for bone formation (e.g. OP) to the same degree as juvenile Obs. Finally, adult Ob proliferation may be inhibited by anti-proliferative gene expression (i.e. Tob and PC3). These results begin to explain why complete calvarial re-ossification is restricted to juvenile animals.

Presenter:	Mia Skourtis, MD
Co-Authors:	Xi Gong, MD, Wayne Ozaki, MD, DDS, Shelley Winn, PhD
Affiliation:	Oregon Health & Science University, Portland, OR

Our laboratory has previously studied the cellular and molecular processes involved with bone defect regeneration in a non-geriatric adult rat model. These processes, however, have not been well studied in the aged rat model. This study was designed to evaluate the effects of advanced age on calvarial defect healing in rats. The hypothesis was that bone regeneration in calvarial defects of aged animals would be impaired compared to the 6 month-old adult rat. Bilateral parietal calvarial defects (4-mm; less than critical-sized) were created in adult (6 month-old) and aged (24 month-old) rats. The disk of bone from the left parietal region was placed into the contralateral defect and served as a positive control. The unrepaired left parietal craniotomy site was the study defect. Outcomes from at least n=6/group were measured at 5, 7, 14 and 21 days post-operatively by immunocytochemistry and histomorphometry. These techniques evaluated cellular constituents of the spontaneously healing defects and new bone formation, respectively. Data were subjected to an ANOVA and post-hoc multiple comparison tests. Statistical significance was established at p<0.05. At all time points analyzed, immunolabelling of presumptive osteogenic cells revealed significantly fewer cells in the aged animals compared to the 6 month-old adult rats. By day 14, new bone formation was observed in the calvarial defects of the 6 month-old rats. However, no new bone was detected in the 24 month-old rats at 14 days. Even by day 21, there was no evidence of new bone formation in the 24 month-old rats. Instead, the gap defects were filled with fibrous connective tissue. The data presented provides evidence that spontaneous bone healing is impaired in calvarial defects of aged rats.

Presenter:	Norma I. Cruz-Korchin, MD
Co-Author:	Leo Korchin, DDS, MS
Affiliation:	University of Puerto Rico, Med. School, San Juan, PR

The vertical reduction mammaplasty has become an increasingly popular procedure, particularly among young women of childbearing age. In this procedure the nipple-areola complex is carried to its new position based on a full-thickness dermo-parenchymal superomedial pedicle. In order to evaluate the success of breast-feeding after a vertical mammaplasty a retrospective study was performed. In this study the breast-feeding success of women of childbearing age (15 to 40) who had undergone vertical reduction mammaplasty was compared to that of women of similar age with macromastia but no prior breast surgery. All women were interviewed by telephone using a standardized questionnaire. The study group consisted of 58 women who had an average age of 29 and had children after their vertical mammaplasty. The mean weight of breast tissue removed per breast was 610 grams. The control group consisted of 149 women with macromastia, average age of 27, who had been evaluated for possible breast reduction surgery and who had children prior to their consultation. A period of two weeks or more was chosen as the defining duration of a successful breast-feeding attempt. Those individuals judged able to breast-feed were further classified on the basis of having breast-fed exclusively or with supplementation. The results demonstrated that of the women who attempted to breast-feed, 61% (56/92) in the control group and 65% (24/37) in the study group were successful. The break-down of the successful group indicated that 22% in the control and 24% in the study group supplemented their breast-feeding. The groups were not significantly different (p>.05). In conclusion, breast-feeding success after vertical mammaplasty was 65%, suggesting that it is similar to that of women with no prior breast surgery and macromastia.

PURPOSE: Dr. Robert Goldwyn, editor of Plastic and Reconstructive Surgery, challenged audience members at the American Society of Aesthetic Plastic Surgeons annual meeting in Dallas in 1999. He felt that it was unfair for those in the audience to have only best results presented to them. The only way to truly judge a technique is to evaluate a consecutive series. He asked for a consecutive series of 15 cases.

I believe strongly in the value of the vertical breast reduction technique. I therefore answered Dr. Goldwyns challenge and sent my case list to him, asking him to pick not only 15 cases, but 25 consecutive cases the choice of date was his. He chose July 1998.

MATERIAL: It took two and a half years to actually find all 25 patients. Followup for each patient is a minimum of one year. Pre and postoperative photographs for all 25 consecutive patients will be presented.

RESULTS: This is a unique study for the following reasons: 1) the case material to be studied was selected by an unbiased person, not by the surgeon, 2) all operations were performed by a single surgeon with no cases or opposite breasts done by a resident or fellow, 3) all 25 consecutive cases were obtained - no exceptions, 4) all cases are complete with follow-up photos of 1-2 years or more, 5) the audience becomes the evaluator, not the surgeon. 6) hopefully this study can serve as a template for assessment of other aesthetic surgeries.

SUMMARY: This is an opportunity to establish a precedence for evaluation of aesthetic surgery outcomes.

Mastering the Vertical Reduction Mammaplasty: A Simple, Aesthetically Reliable Technique

Presenter:	Constance M. Chen, MD, MPH
Co-Authors:	Cheryl White, MD, PhD, Stephen M. Warren, MD, Jana Cole, MD, F. Frank Isik, MD
Affiliation:	University of Washington Medical Center, Seattle, WA

SUBJECT: The vertical reduction mammaplasty is an evolving technique. While the original procedure resulted in significantly decreased scarring, better breast shape, and longer lasting results, the learning curve was steep and cosmetic outcomes were inconsistent. This led many plastic surgeons to attempt a vertical mammaplasty a few times before returning to the more familiar methods with which they were trainedusually some variation of the T-shaped inferior-pedicle technique. Recent modifications by Hall-Findley shortened the learning curve. We have further developed this approach to dramatically simplify preoperative markings, facilitate easy learning and correct cosmetic deficiencies for more reliable aesthetic results. TECHNICAL DETAILS: With the patient standing, three pre-operative marks are made: 1) the inframammary fold; 2) the breast axis; and 3) the apex of the new nipple-areola complex (NAC). The medial pedicle is developed and the breast parenchyma resected. The lateral skin flap is redraped inferomedially and anchored to the chest wall. The inferior aspect of the incision is aggressively debulked and a gathering subcuticular stitch started 2 cm below the NAC. Finally, the apex is temporarily closed while a 38-42 mm NAC marker is used to create a circular defect 0.5 cm medial to the vertical axis. At our institution, 43 patients were treated with a median follow-up of 15 months. Average reduction was 683 gm/breast, with 14 reductions >1000 gm/breast. There were no major complications. PRACTICAL VALUE: Using our modified vertical reduction mammaplasty, we have found the following: 1) chest wall anchoring improves shape; 2) aggressive debulking avoids the persistent inferior bulge; and 3) starting the subcuticular gathering suture 2 cm below the nadir of the NAC prior to insetting eliminates the teardrop deformity. These innovations dramatically soften the learning curve and improve aesthetic outcome by simplifying pre-operative markings and eliminating the NAC teardrop deformity, the lateral NAC deviation, and the inferior dog-ear. Our modified vertical reduction mammaplasty is a simple, easy-to-learn technique with aesthetically superior and enduring results.

Maximizing Outcomes in Breast Reduction Surgery: An Analysis of 518 Consecutive Patients

Presenter:	Gregory Robert Scott, MD
Co-Authors:	Cynthia L. Carson, PA-C, Gregory L. Borah, MD
Affiliation:	Southern California Permanente Medical Group, San Diego, CA

Economic constraints and diminished healthcare resources mandate increased efficiency in labor intensive plastic surgical procedures such as reduction mammaplasty. The evolution to our current approach over a nine-year period was analyzed to identify those factors that maximize patient satisfaction outcomes while reducing physician resources. From 1992-2001 a total of 518 patients underwent bilateral reduction mammaplasty (1,036 total breast resections) by a single plastic surgeon. Since 1992 we used a bilateral simultaneous approach to reduction mammaplasty, with the primary surgeon performing the preoperative markings and determining the final resection. An inferior pedicle, "inverted T" technique using a Wise pattern was used for all cases. The initial two years (113 consecutive patients; 1992-1994) were compared to the most recent two year period (103 patients; 1999-2001) and variables which increased patient satisfaction while decreasing operative times and resources were identified. Length of stay (admission to discharge) was initially 27 hours (overnight stay) and decreased to 5 hours (outpatient surgery center) in the most recent group. Drains were used in 100% of the earlier cases but since 1995 were used selectively and in only 7% in the recent series. Major complications occurred in 3% including 3 unilateral hematomas and complete bilateral nipple loss in one patient. Minor wound separations occurred in 10%. In the recent series 97% of patients received complete relief of their preoperative symptoms and expressed satisfaction with their results. Unilateral decreased nipple sensation occurred in 13%. Operative times (incision to close) decreased to 102 minutes. Dermabond skin adhesive was used in all patients in the most recent series. An evolutionary approach to bilateral reduction mammaplasty with low complication rates and high patient satisfaction is presented. Optimization of technique leads to decreased operative times, shortened lengths of stay, and contributes to efficient use of surgeon and operating room resources.

A Prospective Randomized Study of Antibiotic Efficacy in Preventing Infection in Reduction Mammaplasty

Presenter:	Ahmad H. Ahmadi, MD
Co-Authors:	Benjamin E. Cohen, MD, Payam Shayani, MD
Affiliation:	CHRISTUS St Joseph Hospital, Houston, TX

A prospective randomized study of patients undergoing reduction mammaplasty was performed to establish the efficacy of prophylactic antibiotics. Fifty patients were sequentially assigned to three study limbs: no antibiotic, preoperative antibiotic only, preoperative and postoperative antibiotics. There was no significant difference (p<0.01) among the study groups for age, body mass index, history of diabetes, peripheral vascular disease, breast surgery, steroid or tobacco use, specimen weight, operative time, blood loss, intraoperative hypotension, axillary liposuction and positive intraoperative breast tissue culture. Infection was defined as cellulites, purulent drainage, infected hematoma/seroma or abscess. Delayed wound healing was defined as stitch abscess, minor dehiscence or skin necrosis. The most commonly isolated organism from breast tissue at the time of surgery was s.epidermidis (90%). There was no significant difference (p<0.01) in rate of infection among the study limbs. There was, however, a significant reduction (p<0.005) in delayed wound healing in preoperative antibiotic group. Among the studied variables only positive intraoperative culture of breast tissue was significant (p<0.008) for development of infection. Delayed wound healing also contributed to development of infection (p<0.003). This study shows that prophylactic antibiotics in reduction mammaplasty do not affect infection; however, a single preoperative dose significantly improves wound healing.

Why Did We Change Our Technique from a Superior Pedicle into a Laterocentral Glandular Pedicle for Breast Reduction?

Presenter:	Moustapha Hamdi, MD
Co-Authors:	Phillip Blondeel, MD, PhD, Karlien Van deSijpe, MD, Koenraad Van Landuyt, MD, Stan Monstrey, MD
Affiliation:	Gent University Hospital, Gent, N/A

Introduction: A new technique of breast reduction with a laterocentral glandular pedicle has been used in our institute since 1999. Using this technique, a prospective study is conducted in order to assess the nipple-areola sensitivity quantitatively. Material and Methods: The pedicle is based on a horizontal septum and it is designed to incorporate the lateral branch of the fourth intercostal vessels and of the nerve. The operative technique will be illustrated. The sensitivity of the nipple-areola complex was evaluated in 20 consecutive patients by one independent examiner preoperatively, 2 weeks and three months postoperatively. Nipple and four cardinal points of the areola were tested. Pressure thresholds were measured with Semmes-Weinstein monofilaments, temperature sensitivity with hot 40°c and cold 4°c metal probes and vibratory thresholds with the Biothesiometer. Average sensation of the areola was calculated by means of the four areas tested. Results: A series of 45 patients underwent breast reduction by the same surgeon between with a mean follow-up of 13 months. Mean sternum-nipple distance was 31 cm (19-40 cm). Mean resection was 624 g (40-1680g). One partial areola necrosis was reported. The pressure and the vibration sensitivity decreased at 2 weeks postoperatively. However, None of these differences was statistically significant. At three months postoperatively, Thethresholds were quite similar to preoperative values of both areola and nipple. Concerning the ability to recognize temperature, 40 % and 80% of patients could distinguish between cold and hot at 2 weeks and 3 months after surgery respectively. Conclusion: The laterocentral glandular pedicle technique shows clear advantages over the conventional techniques of breast reduction in terms of breast sensation and ease of pedicle shaping and modeling.

The Effects of Angiotensin-Converting Enzyme Inhibitors (Acei) on the Fibrous Capsule Around Mammary Implants

Presenter:	Oscar A. Zimman, MD, PhD
Co-Authors:	Felipe Inserra, MD, Jorge Toblli, MD, Inés Stella, MD, León Ferder, MD
Affiliation:	Hospital de Clínicas, University of Buenos Aires, Buenos Aires, N/A

INTRODUCTION: During the last years different attempts were made in order to decrease the fibrotic reaction and avoid capsular contracture in breast augmentation. Pharmacological control is still unavailable essentially due to harmful side effects. The antifibrotic effect of ACEi is widely recognized in different tissues (kidney, lung, heart). The purpose of this study is to evaluate the effects of Enalapril (E) on the fibrous envelope around mammary implants in rats.

MATERIALS AND METHOD: Twenty-four mini breast prosthesis (supplied by Nagor GB Ltd., England) were implanted into 24 female Sprague-Dawley rats (250-300g.) (12 smooth=SM and 12 textured coating=TS) The rats were divided in 4 groups (G), each one: n=6. : G1: SM; G2: SM + E; G3: TS; G4: TS + E. Two months previous to surgery Enalapril (20 mg/L) was administrated in drinking water ad libitum in G2 and G4. All the rats were sacrificed three months after surgery and the fibrous capsules were evaluated by light microscopy (H&E; Massons trichrome and immunostaining by anti-collagen type III antibodies)

RESULTS: In this study fibrous envelope thickness (FET), pericapsular fibrous reticulum (PFR), inflammatory cell infiltrate (ICI), granulomatous rate (GR)around the envelope, collagen type III (CIII) and vessels density (VD) were consider under the Mann-Whitney test. FET is expressed in microns and the others are scored: 0=negative; 1=mild; 2=moderate; 3=severe; 4=very severe. Table I shows a significant difference between smooth and textured prosthesis. Table II analyze the effect of Enalapril treatment in smooth surface prosthesis. But the most significant results are shown in Table III, matching textured implants with and without Enalapril.

CONCLUSIONS: Enalapril, a known safe drug, and produces a significant reduction in the inflammatory process as well as a diminished vessels density in the fibrous envelope around breast implants. In addition textured implants showed less fibrous reaction than the smooth surface one. This experience shows that Angiotensin-Converting Enzyme Inhibitors can be a novel strategy for the reduction of the fibrotic reaction.

The Application of Mesh Support in Periareolar Breast Surgery: Clinical and Mammographic Evaluation

Presenter:	Alan Landecker, MD
Co-Authors:	Eduardo C. Lyra, MD, Leonardo J. Henriquez, MD, Renata Sampaio Góes, BS, Paulo Godoy, BS, João Carlos Sampaio Góes, MD, PhD
Affiliation:	Clinica Sampaio Góes, São Paulo, N/A

Introduction: Numerous different techniques have been described for the treatment of breast hypertrophy and/or ptosis. Unfortunately, recurrent ptosis after mammaplasty can occur regardless of the employed technique. To avoid this problem, different kinds of supporting devices have been described with variable rates of success. In the periareolar double-skin technique for mammaplasty and mastopexy proposed by the senior author, a mixed mesh composed of Poliester and Polyglactine 910 is applied before redraping the skin over the newly shaped breast architecture. By inducing a scarring reaction which functions as an internal brassiere, the mesh helps maintain long-lasting anterior projection and helps avoid the recurrence of ptosis. However, the true implications of incorporating mesh into breast surgery have never been clarified and surgeons have been reluctant to apply any kind of prosthetic material onto the breast fearing inflammation, an unfavorable aesthetic outcome, palpable or visible deformities, and interference with the mammographic evaluation of breast cancer. In this paper we analyze the aesthetic, clinical, and mammographic implications of utilizing mesh as a supportive device in periareolar breast surgery. Method: Eighteen (18) patients (mean age=42), with breast hypertrophy and/or ptosis were submitted to the double-skin periareolar mammaplasty technique, with placement of mixed mesh. Clinical assessment was performed by three breast surgeons who knew that the patients had had mesh application and were actively working on cancer surveillance. After a mean follow-up period of 30 months, a standard mammogram was performed in each patient and analyzed by both the surgeons and an expert radiologist. The evaluated factors were hyperemia, calcifications, contour irregularities, capsular contraction, thickening and/or widening of the scar with extrusion of the mesh, and any palpable and/or hardened areas. Results: According to our clinical observations, there were no mesh-related abnormalities in the breast, the mesh was not palpable after the operation, and there was no recurrent ptosis. In terms of mammographic imaging, the mesh was visible as a very fine line in the periphery of the breast's parenchyma (measuring 0.2 mm on the lateral views) in three patients (17%). The mesh did not interfere with the visualization and analysis of the breast´s parenchyma. In seven patients (39%), benign localized microcalcifications were detected in the breast and no further investigation was carried out. In two patients (11%), grouped calcifications were detected and biopsied; histopathologic analysis demonstrated epithelial hyperplasia with atypia. In two patients (11%), nodules smaller than 1 cm were detected and biopsied; histopathologic analysis demonstrated a fibroadenoma in one patient and an invasive ductal carcinoma in the other. Conclusion: The periareolar mammaplasty with mesh support is capable of producing excellent and long-lasting aesthetic results. The presence of mesh does not induce visible or palpable deformities and mammographic abnormalities. In terms of surveillance mammograms, the presence of the mesh did not interfere with the diagnosis of minute lesions such as calcifications and small nodules.

Introduction: The author describes a new technique which allows application of transaxillary endoscopic methods to correct advanced breast ptosis using biplanar concepts. Breast tissue dynamics can now be modified internally without skin excision techniques.

Materials and Methods: The author details a 6-year experience in 32 patients using endoscopic techniques for augmentation in patients with breast ptosis, as a subset of an overall 10-year experience in over 400 patients who underwent endoscopic augmentation mammoplasty. Patient selection criteria included mild to severe second-degree ptosis (nipple being below the inframammary fold but not at the apex of the breast n=26 or tubular type breast deformity n=6)).

Technique: Four different endoscopic methods are described: 1) Endoscopic Partial Biplanar (EPB), 2) Endoscopic Full Biplanar (EFB), 3) Endoscopic Trans-Muscular (ETM) and 4) Endoscopic Transmuscular with intra-parenchymal Mammoplasty (ETM-M). Techniques 1, 2 and 3 are for increasing levels of ptosis and 4 is for ptosis with tubular type deformity. Appropriate candidates for each technique will be described and endoscopic methods demonstrated in both the submammary (Fig. 1) and the sub-muscular (Fig. 2) planes (Fig. 3). These applications will be outlined and postoperative results will be shown (Example 1-3).

Results/Complications: Patient satisfaction was 100% due to the lack of external scars on the breast. Four patients sustained a segmental loss of sensation in the lower, outer breast. These patients required intra-parenchymal dissection. Sensation returned in three patients and one was lost to follow-up.

Conclusion: Endoscopic internal augmentation mammoplasty using biplanar concepts may help avoid skin excision techniques in certain patients with breast ptosis and tubular type deformity.

Rofecoxib--A Specific Cox-2 Inhibitor For the Treatment of Pain After Breast Augmentation: A Randomized, Placebo-Controlled Clinical Trial

Presenter:	Gilles N. Beauregard, MD
Co-Authors:	Pierre Duguay, MD, Manon Choiniere, PhD
Affiliation:	University of Montreal, Montréal, QC

INTRODUCTION AND OBJECTIVES: Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended for the multimodal management of postoperative pain and they may have a significant opioid sparing effect after surgery. However, the use of NSAIDs in plastic surgery is generally avoided because of the risk of intraoperative bleeding and hematoma. The development of specific COX-2 inhibitors such as rofecoxib represents an interesting option as they have been shown to provide effective postoperative analgesia with less risk of bleeding complications. This study was designed to assess the efficacy and safety of rofecoxib for controlling pain after breast augmentation. METHODS: This randomized, double-blind, placebo-controlled study was carried out in 77 patients aged between 19 and 43 yr (26.7 ± 6.2) who were scheduled for bilateral submuscular breast augmentation. Patients were randomly assigned to receive rofecoxib 50 mg or a placebo pill one hour before surgery, and once a day for seven days. Efficacy outcomes included rescue opioid intake and postoperative pain severity. Pain intensity at rest and on movement was measured at frequent intervals with a standardised 0 - 10 pain scale. The Brief Pain Inventory (Cleeland & Ryan 1994) was administered to assess the impact pain on various aspects of daily functioning. Various adverse drug effects were also measured including intraoperative bleeding and incidence of hematoma. RESULTS: There was no demographic difference between the Rofecoxib (R) (N=38) and Placebo (P) group (n=39). IV morphine requirements in the immediate postoperative period was significantly lower in the R-Group compared to the P-Group (p=.05). Intake of codeine in combination with acetaminophen in the 7 days following surgery was also significantly reduced in the R-Group (p=.01). Postoperative pain intensity scores both at rest and with effort were similar for both groups. Impact of pain on various aspects of daily functioning was also comparable in the two groups. No significant differences were observed for the incidence of adverse effects except for the frequency of nausea which was slightly but significantly higher in the R-Group (p=.04). CONCLUSIONS: It is concluded that rofecoxib is a useful and effective agent for pain treatment after breast augmentation as revealed by its opioid sparing effects and its safety profile in terms of bleeding complications. The usefulness of selective COX-2 inhibitors such as rofecoxib certainly merits further investigation for other types of interventions as they represent an interesting therapeutic avenue for pain control in plastic surgery.

Local Complications and Reoperations in a Prospective Study of Primary Augmentation Patients with Saline-Filled Breast Implants: Preliminary Results After Five Years

Presenter:	V. Leroy Young, MD
Co-Author:	Marla E Watson, MA
Affiliation:	Washington University, St Louis, MO

Purpose: This ongoing prospective study is following all primary augmentation patients of a single experienced surgeon to determine the prevalence of local complications and reoperations among women receiving saline breast implants. Data from the first five study years (1997-2001) are presented.

Methods: Between Jan. 1, 1997 and Dec. 31, 2001, 287 consecutive patients (573 breasts) underwent primary augmentation with saline implants. They are being followed to collect data that includes patient variables (e.g., age at operation, pre- and postop weight, bra size); implant variables (e.g., type, volume, position, incision used); breast variables (e.g., pre- and postop measurements, pain, grades of contracture, ptosis, skin wrinkling, implant palpability); and aesthetic variables (e.g., patient satisfaction, surgeon evaluation). Along with compiling these data points, we are tracking all local complications, reoperations, and explantations to determine their frequency and possible causes. The study has no fixed endpoint.

Results: Almost all the 593 implants are smooth, round devices manufactured by Mentor Corp. and placed in a submuscular position. An inframammary crease incision was used most often, followed by the transumbilical approach. Table 1 presents basic information on this primary augmentation group according to whether patients had a reoperation. A shortcoming of this series is the relatively short follow-up time. Even though patients are asked to return for follow-up evaluations, the vast majority do not unless they have an implant-related concern or desire another cosmetic procedure.

Ten percent of the 287 patients and 6.5% of the 573 breasts required reoperations ranging from minor in-office procedures to implant exchange to Wise pattern mastopexy. The number of revisional procedures was 39 (10 bilateral and 29 unilateral), at a mean time of 7.9 months after the previous surgery (range=0-34.3 months). Surgeries on 12 breasts (2.1%) were required to treat local complications: implant displacement=4, hematoma=3, implant extrusion=3 (in 2 patients), periprosthetic infection=1, and capsular contracture=1. Only one implant deflated and directly resulted from needle damage during a revisional procedure. Another 28 breasts (4.9%) were revised for cosmetic or other reasons unrelated to complications. Ptosis was corrected in 8 breasts with either a concentric circle or Wise pattern mastopexy or larger implants. Other reasons for reoperation included cosmetic revisions such as correcting size or position asymmetry (11 breasts), hypertrophic scar revision (2 breasts), or patient preference for a change (7 breasts). Only 1 patient requested a change in the size of her implants. Twenty-one implants were removed, with 15 replaced at the time of explantation, 3 at a later time, and 3 not replaced.

Conclusions: Most reports cite reoperation frequencies in the range of 20%-25%, but these studies often extend back to the 1980s or early 1990s and include patients who undergo multiple surgeries, often for capsular contracture or replacement of silicone gel implants. We are following only primary augmentation patients who began receiving saline implants in 1997, when the number of women requesting this procedure started to rise dramatically. Our data reflect the use of modern devices and techniques. Thus far, we have found a low frequency of complications and reoperations, with a total of 10% of patients and 6.5% of breasts requiring revision. Additional patient and follow-up data will be accumulated in future years.

Table 1. Patients with and without Reoperations

	Total	No Revisions	Reoperations
Number of primary augment patients	287	258	29 (10.1%)
Number of breasts	573	536	37 (6.5%)
Number of implants	593	536	55 (9.3%)
Mean patient age at augment (range)	32.8 yr	32.8 yr (17-54)	32.2 yr (19-50)
Mean implant follow-up (range)	8.6 mo	8.3 mo (0-55.8)	11.0 mo (0-34.3)
Mean age of explanted implants			10.2 mo (0-30.5)

Tuesday, November 5, 2002

Presented in Title Only: 2002 PSEF Essay Award - Clinical Research Senior: Outcomes of Microsurgery in 125 Patients with Lower Extremity Nerve Lesions

Presenter:	Julia K. Terzis, MD, PhD
Affiliation:	Eastern Virginia Medical School, Norfolk, VA

A Microsurgical Approach to Bone Marrow Transplantation Using an Extraperitoneal Isolated Vascularized Bone/Bone Marrow Composite Transplant

Presenter:	Chau Tai, MD
Co-Authors:	Louise Strande, MS, Riva Eydelman, BS, Jean-Luc V. Tran, MS, Xiaoli Sheng, MD, Martha Matthews, MD, Charles Hewitt, PhD
Affiliation:	UMDNJ/RWJMS-Cooper Health System, Camden, NJ

Background: An isolated vascularized bone marrow transplant model (iVBMT) was previously developed in the rat in order to study the contribution of the bone marrow and its environment in a composite tissue allograft (CTA). It was an intraperitoneal model that required a long laparotomy time. This study aimed to develop an extraperitoneal model of iVBMT. Methods: For evaluating technical feasibility, Sprague-Dawley rats (n=5) were used and sacrificed at 24 hrs. For the long-term study, Lewis-Brown-Norway rats (n=5) were used and sacrificed at various time points from 2 to 8 weeks. The iVBMT model consisted of a left donor femur that was harvested with its nutrient vessels. The graft was anastomosed to the right femoral artery and vein of the recipient in an end-to-end fashion, and placed subcutaneously in the abdominal wall. Four micrometer sections of the graft were H&E stained and examined at 100x. Results: Technique - Mean ischemic time was 103 minutes. Four out of five vessels were patent at 24 hrs. Long term - all animals appeared well, and the position of the graft did not interfere with normal movements. Mean ischemic time was 80 minutes. The right limb functioned normally postoperatively. At sacrifice, five out of five vessels were grossly patent. Histology of the grafts in the long term animals showed a normal appearing bone marrow. Discussion: An extraperitoneal model is possible based on the recipient's femoral vessels and a subcutaneous placement of the graft. One thrombosed graft vessel in the technical feasibility study was due to excess manipulation at time of anastomosis. Abundant collateral vessels in the rat's limb permitted ligation of the femoral vessels without morbidity. Using the iVBMT model, future studies across semiallogeneic and allogeneic barriers will help to define the role of the bone marrow compartment in a CTA for potentially inducing immune tolerance.

Microsurgical Free Flap Tranfer to Amputation Sites: Indications and Results

Presenter:	Burton M. Sundin, MD
Co-Authors:	Detlev Erdmann, MD, Michael S. Wong, MD, L. Scott Levin, MD
Affiliation:	Duke University, Durham, NC

A series of microsurgical free flap reconstructions to amputation stumps of the upper as well as lower extremity was reviewed in 7 male and 2 female patients. Indications included preservation of length after trauma in 6 cases and cure of local infection in 2 cases. In one case an extensive defect created by resection of a recurrent shoulder sarcoma required use of an arm fillet flap for palliative soft tissue reconstruction. The types of microvascular free flaps used were 4 scapular flaps, 2 fillet flaps from an amputated extremity, 1 anterolateral thigh flap, and 1 lateral arm flap. Seven of nine patients were fitted with prostheses and underwent occupational therapy resulting in ambulatory or functional status. Microvascular reconstruction is indicated in emergency settings as well as for elective reconstruction of amputation sites. The use of uninjured "spare parts" of the amputated extremity should be considered. Elective reconstruction is prefrably performed with free flaps based on the subscapular vascular system.

Presenter:	Shengkang Luo, MD
Co-Authors:	Jiangua Gao, Lishen Luo
Affiliation:	Nanfang Hospital, Guangzhou, N/A

Free-tissue transfer has become an popular method for the management of large lower extremity soft-tissue defects. The success rates of free tissue transfer have been greater than 90%, with the most recent reports exceeding 95%. All authors attributed their success to better donor sites and improved microsugical techniques. It demonstrates that refinement in the donor site selection plays an important role in the free-tissue transfer. The latissimus dorsi and rectus abdominis muscles remain the preferred flaps for coverage of defects of exposed bone, artery, nerve, or tender in the lower extremity. The main problem with using muscle flaps is that functional deficits of muscle harvest are real but have not been adequately studied. Moreover, they also usally need a donor site in the thigh to provide skin for grafting the primitive donor site. The anterolateral thigh flap based on the descending branch of the lateral circumflex femoral vessel is one of the musculocutaneous or septocutaneous flaps in the thigh, and suitable for coverage of defects that require a relatively large flap, especially for defects in the lower extremity. Since 1983, we have transferred 72 anterolateral thigh flaps for reconstruction of lower extremity. The results were satisfactory. Only one case resulted in a failure due to tiny cutaneous perforators. This study represents our clinical experience and applied anatomy of the flap.

Presenter:	Fausto Viterbo, MD, PhD
Co-Author:	Wagner T. Ripari
Affiliation:	Faculdade de Medicina de Botucatu / UNESP, Botucatu - São Paulo, N/A

An important point in paraplegic is the prevention of the pressure ulcers. The main etiologic factor in the development of the ulcers is the absence of protective sensation. We describe a new treatment to restore the sensation in paraplegics, using end-to-side neurorraphies. Method: Two patients were submitted to two sural nerve grafts bridging intercostals nerves above the spinal cord lesion level and sciatic nerve in the buttock area, bilateral, using end-to-side neurorraphies. The first patient, 74 years old, had anesthesia bellow T10, resultant of spinal cord lesion at L4 12 years ago. He developed pressure ulcers in ischiadic and buttock area. Four years ago he was submitted to the nerve grafts described above. He presented progressive gain of sensation evaluated by the Semmes-Weinstein monofilaments test pre and post-op. Now he has sensation to 2 g from T10 to L1 and to 300 g in L2 and L3 area. The second patient, 50 years old, had a sequelae of a spinal cord lesion at T8 - T9, 20 years ago. He had pressure ulcers and was submitted to three surgeries with cutaneous and myocutaneous flaps. Pre-op. evaluation showed sensation only above T10. He was submitted 3 years ago to sural nerve grafts as described above. He presented pain during one year and progressive recovery of sensation. Now he refers 2 g in T10, 4 g in T11 and 300 g in T12. Another interesting find is that the patient now feels bladder fullness. The two patients did not present pressure ulcers anymore. Although the small number of patients the positive result in both cases indicates that this technique could be a good alternative in this arduous field. Conclusion: Sural nerve grafts bridging intercostal and sciatic nerves using the end-to-side neurorraphies were efficient to restore sensation in two paraplegic patients.

Canine Hemifacial Composite Tissue Transplantation by Local Immunosuppression

Presenter:	Ergin Er, MD
Co-Authors:	Selçuk Iþýk, MD, Murat Yarim, PhD, Hüsamettin Gül, MD, Mustafa Þengezer, MD
Affiliation:	Gülhane Military Medical Academy, Ankara, N/A

In this experimental study, canine hemifacial allogeneic composite flaps were harvested and transferred on their vascular pedicles. Besides, a local immunosuppressive strategy was accomplished by intra-arterial slow-delivering miniostotic pumps and the effect of this system was investigated. This study was achieved on 12 dogs, two of them being cadaveric study ( 12-15.5kg., 10-16 months-old). 2 groups were consructed between MHC mismatched dogs (N:5). Hemifacial allogeneic composite flaps were harvested in both groups on external carotid artery and external jugular vein pedicle and transferred by microvascular technique under general anestesia. Local immunosuppression was achieved in experimental group for 15 days. No immunosuppression was given to control group. Flap rejection was observed macroscopic and microscopic examinations.Tissue CsA levels were measured in tissue biopsies of experimental group on 6th day postoperatively. Statistical analysis was performed by Mann-Whitney-U test. All the dogs were survived at postoperative period. Allograft rejection time was 3,8±0,8 days in control group and 22,2±1,4 days in experimental group respectively. (p<0.005). Mean CsA concentrations were as follows:1636±104 ng/gr tissue in allograft skin and 282±12 ng/gr tissue in the skin of other side of the face, 818,4±11 ng/ gr. tissue in allograft muscle and 284±20 ng/gr.tissue in other sides facial muscle, 1184±74 ng/gr tissue in flap mucosa and 530±25 ng/gr tissue in the other side (p<0.001). Systemic CsA level was 87,2±6.7 ng/ml. Microscopically, acute rejection morphology was observed at postoperative 4th day in control group. In the experimental group, the tissue biopsies obtained at 6th and 15th days postoperatively revealed minimal inflamation . As a result, in this experimental study hemifacial composite tissue transplantation was achieved in a big animal model by local immunosuppressive strategy, which is the first report in scientific literature. We think facial reconstruction can be achieved by successful clinical hemifacial transplantations in the future

The Superior Gluteal Free-Flap for Breast Reconstruction - Lessons Learned over a Ten-Year Period

Presenter:	T.D. Santoro, MD
Co-Authors:	William W. Shaw, MD, B.J. Mehrara, MD, E. Arcilla, MD, M. Kim, BA, J. Sebastian, MD, A. Smith, MD, J.P. Watson, MD, A.L. Da Lio, MD
Affiliation:	UCLA School of Medicine, Los Angeles, CA

INTRODUCTION: The TRAM free-flap is our first choice for autologous breast reconstruction (ABR), however its use is precluded in cases of prior abdominoplasty or insufficient abdominal soft tissues. The superior gluteal free-flap (SGFF), although available in most women, is not widely accepted because it is more technically demanding. This study reviews our results and highlights the critical steps relevant to the successful use of this flap. METHODS: All patients who underwent SGFF breast reconstruction between 1991 and 2001 were identified, and a retrospective chart review was performed. RESULTS: One-hundred-six SGFF breast reconstructions were performed in the study population. Average age at the time of surgery was 44 years (range 18-70). Indications included breast cancer (76), Poland's syndrome (6), prosthesis-related complications (5), mastalgia/fibrocystic disease (2), and prophylaxis (17). Among cancer patients, the clinical stages were carcinoma in-situ (28%), stage 1 (9%), stage 2 (17%), stage 3 (20%), and unknown (26%). Flaps were unilateral in 64 patients, and bilateral in 21 patients (42 flaps). Perforator flaps were performed in 6 cases, while the remainder employed a muscle sparing technique. Fifty reconstructions (47%) were immediate and 56 (53%) were delayed. Recipient arteries were thoracodorsal (TD) 28%, internal mammary (IM) 68%, lateral thoracic (LT) 1%, and circumflex scapular (CS) 3%. Recipient veins were TD (27%), IM (57%), LT (2%), CS (3%), external jugular (EJ) 10%, and cephalic (1%). Complications included hematoma (4%), infection (3%), venous thrombosis (requiring revision of anastamosis, and selection of either EJ or cephalic veins as alternate recipient outflow vessels, due to size discrepancies) 8%, major flap necrosis (1%), fat necrosis (2%), pneumothorax (1%), and urinary tract infection (1%). One flap was lost to venous thrombosis and one flap was lost to post-operative trauma. The donor result was excellent in most patients with 2 minor wound problems. The average hospital stay for unilateral reconstructions was 5.1 days. The average hospital stay for 2 patients, who underwent simultaneous bilateral reconstructions, was 8 days. The average number of second stage revisions for unilateral and bilateral reconstructions was 1.3 and 1.6, respectively. CONCLUSIONS: Overall, the SGFF is a good source of soft tissue for ABR, and patient satisfaction is high. Flap elevation can be performed concomitantly with mastectomy. The SGFF is technically more difficult than the TRAM free-flap, mainly due to the delicate nature and large size of the superior gluteal vein, creating size discrepancies. Venous thrombosis is minimized by avoiding size mismatch; the EJ and cephalic veins serve as good alternative recipient veins. Using these guidelines, the incidence of flap loss should be very low.

Targeted Gene Therapy Using Microvascular Tissue Transfer: Optimization of Transfection Parameters

Presenter:	Alexes Hazen, MD
Co-Authors:	Hooman Soltanian, MD, Robert D. Galiano, MD, Jamie P. Levine, MD, Sanghoon Park, MD, Geoffrey C. Gurtner, MD
Affiliation:	NYU Medical Center, New York, NY

The recent developments in gene therapy provide us with new modalities for delivery of therapeutic agents for treatment of many genetic and acquired disorders. Gene therapy methods utilizing viral vectors hold great clinical promise but have been thwarted by difficulties in developing targeted, high-level gene expression while limiting host toxicity. Our goal has been to maximize the delivery of the genetic material to the target tissue while minimizing systemic exposure. Recently, we created a unique method of gene delivery while avoiding problems associated with the use of viral vectors. We developed a rat free flap model, in which microvascular beds were transfected ex vivo, flushed and then re-attached to the native circulation using microvascular techniques. Adult Sprague-Dawley rats were transfected with adenovirus containing the B-gal reporter gene driven by the CMV promoter. We utilized two different flap models; Superior epigastric fasciocutaneous flap and quadriceps muscle flap. We studied the effect of viral load, dwell time, quantity and pressure of irrigation, and the type of the flap on the efficacy of transfection. Flaps were harvested on day five. Liver, lung, spleen, flap, and peri-flap specimens were examined for expression of the B-gal gene with ELISA, and tissue staining. High regional expression of B-gal gene in the flap was documented. We have been able to achieve high transfection rates in the desired tissue while minimizing expression outside the regional tissue. We have also found that the gene expression correlates directly with increasing viral load and dwell time. This technique represents a major advancement over currently utilized methods of gene delivery. It would be ideal for patients who require free tissue transfer following oncologic ablation to deliver high dose chemotherapeutics directly to the site of the neoplasm.

Presenter:	E. Gene Deune, MD
Co-Authors:	Maurice Nahabedian, MD, Anthony Tufaro, MD, Deborah Frassica, MD, Steven Lietman, MD, Frank Frassica, MD
Affiliation:	Johns Hopkins, Baltimore, MD

Soft tissue sarcomas represent 6000 new cases per year with 50% located in the extremities. Prospective studies show no survival or local recurrence benefit with major limb amputations versus limb preservation. At our center, limb sarcomas are treated with limb preservation surgery, whenever possible, by wide tumor resection, immediate soft tissue reconstruction, and adjuvant therapy. This is a retrospective analysis of the limb-salvage surgeries performed at our center by a multidisciplinary team of plastic surgeons, radiation oncologists, and orthopedic surgeons.

Between December 1998 and December 2001 (37 mo), 61 patients (M=42, F=19) underwent 62 limb salvage procedures (42 lower extremity, 20 upper extremity) with 67 flaps. Mean follow-up has been 12.5 +/- 8.9 mo. (range: 132 mo). Malignant fibrous histiocytoma was the most common diagnosis (n=26). 44 (72.1%) tumors were high-grade. The thigh was the most common location (n=24). The rectus abdominis (n=26), latissimus dorsi (n=15), and the gracilis (n=7) were the most common flaps. 29 were free flaps, with one acute loss (3.3%) and two late losses (6.8%). All pedicle flaps survived. The total flap survival rate for both pedicle and free flap was 95.5%. 29 patients had concurrent surgeries; the most common being tendon reconstruction. Mean surgery time was 8.2 +/- 3.2 hrs. The mean hospital stay was 7.6 +/- 3.7 days.

28 patients had preoperative and 39 had postoperative adjuvant therapy (chemotherapy or radiation) and. Those with postoperative brachytherapy were started at 7.50.7 days. No flaps were lost to the effects of brachytherapy. Wound complications were seen in 30 (49%), most commonly seroma (n=12). There were 9 non-wound related complications (14.8%), the most common being nerve palsy (n=4). 15 patients (24.6%) had surgery for their complications: seroma drainage (n=6), wound debridement (n=6). Perioperative mortality was zero. 3 had metastasis at the time of the limb salvage surgery. 10 later developed metastasis. The most common site was the lung. 1 had local recurrences and 1 had a local recurrence. 3 patients have died, surviving 11.04.3 mo. after their surgery.

Limb functionality was graded as excellent (defined by return to preoperative level), moderate (functional but limited in range or strength), or poor (severe limitation due to pain or poor motion). 37 have regained full limb use. 18 have moderate use. 4 have limited use. Overall, 55 (93.2%) have full to moderate limb function. No limbs have been amputated.

This is a continuing analysis of our experience with limb salvage for sarcomas. Our data indicate that limb salvage surgery does provide the patient with useful and functional limbs. Although the complication rate was high, particularly for wound healing, we feel that limb salvage should be performed whenever possible to avoid the morbidities associated with amputations.

Arterial Conduit Bypass for Distal Occlusive Disease in Patients with End Stage Renal Disease

Presenter:	W. Bradford Rockwell, MD
Co-Authors:	Gerald Treiman, Peter Lawrence
Affiliation:	University of Utah, Salt Lake City, UT

Autogenous vein has been used as a bypass conduit for inframalleolar grafts in patients with vascular occlusive disease. Acceptable patency and limb salvage have been achieved in most patients. However, in patients with end stage renal disease (ESRD), the results have been less satisfying. Autogenous artery can be used as a bypass conduit and posseses several advantages over vein conduits when bypassing to small vessels less than 5 mm in diameter. Arterial conduits are technically easier to suture microscopically and their taper is anatomic, progressing from large proximally to small distally. Patients with end stage renal disease and arterial lesions distal to the malleolus were included. Thirteen patients received autogenous arterial grafts. Eleven of these have end stage renal disease with six being on chronic hemodialysis. Three of the patients have a creatinine greater than 6.0 and two had functioning renal transplants. Of these eleven patients with ESRD, five received an autogenous arterial conduit graft to augment blood flow to the foot while six received a longer graft consisting of a vein graft, which was lengthened on its distal end with an arterial conduit graft. The patient study profile consisted of nine males and two females. The average age was 51 years. All of the patients had tissue loss or gangrene prior to the bypass. Six of the patients had diabetes mellitus, ten had hypertension, two had cardiac disease and two were smokers. Of the eleven grafts, nine remained patent two years post-operatively. Two grafts clotted within one week of surgery, presumably due to poor run-off. These two patients subsequently received below knee amputations. Of the nine patients with patent grafts, four received digital amputations and two received transmetatarsal amputations for pre-existing gangrene. The remaining three patients received local wound care for pre-existing ulcers. All original tissue wounds were healed twelve weeks following the vascular bypass. Postoperative blood flow studies showed the mean ABI increased from 0.26 to 0.65. The mean toe pressure increased from 0.13 to 0.37. At three years, the assisted primary patency was 82% while the functional limb salvage was also 82%. In conclusion, autogenous arterial conduit grafts provide good patency results in these difficult patients with ESRD. The technical ease and anatomic taper of arterial conduits contributes to their patency.

Quantitative and Immunohistochemical Expression of Vascular Endothelial Growth Factor (VEGF) in Pig Latissimus Dorsi Myocutaneous Flaps

Presenter:	Detlev Erdmann, MD
Co-Authors:	Ranya Sweis, MD, Kenneth J. Moquin, MD, Michael S. Wong, MD, Anne M. Pippen, MS, Laura E. Niklason, MD, PhD, L. Scott Levin, MD, Kevin C. Olbrich, PhD, Bruce Klitzman, PhD
Affiliation:	Duke University, Durham, NC

Introduction: Vascular Endothelial Growth Factor (VEGF) reportedly improves ischemic flap survival when administered. The purpose of this study was to quantify endogenous VEGF expression in flaps after ischemia-reperfusion injury. In addition, VEGF expression was localized in muscle and skin.

Methods: Twelve Latissimus dorsi myocutaneous flaps (15x10 cm) were elevated bilaterally in six male pigs (25 kg). One flap was randomly assigned to 4 hrs of ischemia by occluding the pedicle, followed by 2 hrs of reperfusion. Contralateral flaps were controls. Skin perfusion in flap base, middle, and tip was measured as baseline, after elevation, after ischemia, and during reperfusion. Microvascular length density was measured in flap muscle using intravital microscopy. Biopsies were taken at the end from each flap zone and adjacent tissue for VEGF levels and immunohistochemistry.

Results: Perfusion differed among flap zones during ischemia and reperfusion. No differences were found in microvascular density in ischemic versus control flaps. VEGF levels (pg/mg protein; mean±SEM) were:

Muscle: Control: Base 71.0±14.6, Middle 53.1±7.0, Tip 43.2±9.7, Adjacent 39.0±5.9; Ischemic: Base 65.6±18.5, Middle 54.8±13.5, Tip 30.3±8.2.

Skin: Control: Base 2.2±1.4, Middle 3.4±1.7, Tip 6.8±1.9, Adjacent 5.0±4.9; Ischemic: Base 9.6±3.0, Middle 9.9±2.4, Tip 4.3±1.6

Muscle VEGF decreased from base to tip and exceeded skin VEGF. Flaps had higher VEGF than adjacent muscle (p£0.05). Ischemic skin VEGF was higher than controls in base and middle only (p£0.05). Flap epidermis was negative for VEGF staining, but dermis and subcutaneous tissue were positive. Flap muscle interfascicular septae stained well, with occasional myocyte staining. Ischemic flap skin showed increased VEGF staining compared to controls (p < 0.05). In muscle, only the base showed increased VEGF staining with ischemia (p < 0.05). Conclusion: Moderate ischemia stimulates VEGF protein expression in muscle and skin. However, endogenous levels do not reach reported levels following exogenous administration.

Limb Salvage of Lower Extremity Wounds with Free Tissue Transfer in Difficult Patients

Presenter:	Lee L. Q. Pu, MD
Co-Authors:	Daniel A. Medalie, MD, Henry C. Vasconez, MD, William J. Rosenblum, MD, Steven J. Lawrence, MD
Affiliation:	University of Kentucky Medical Center, Lexington, KY

Microvascular free tissue transfer has revolutionized the treatment of lower-extremity wounds. However, amputation is still frequently recommended to patients with complex lower-extremity wounds and/or significant medical conditions because limb salvage after free tissue transfer in these patients remains uncertain. In the past 3 years, more than 75 free tissue transfers to lower extremities were performed at our institution. Among them, eighteen patients (13 males, 5 females, age 17-71 years) with complex wounds in their lower-extremities and/or significant medical conditions had free tissue transfers for limb salvage. Seven patients had extensive soft tissue defect (>1/2 length) of the legs or feet and 6 had composite tissue defect of the legs or feet requiring bony reconstruction. Two patients had both bony and extensive soft tissue defects. An additional 5 patients also had significant peripheral vascular problems due to various medical conditions. A total of nineteen free tissue transfers (16 free muscle flaps, 2 osteomyocutaneous flaps, and 1 adipofascial flap) were performed in 18 patients (One patient had bilateral transfers, see figures below). A saphenous vein loop or graft was used in 3 patients. Free tissue transfer was successful in 16 of 18 patients (89%). Flap loss occurred in 2 patients (One at 2-week post-op) and both were treated successfully with either a second free tissue transfer or pedicle flaps. Four (4/17, 24%) patients required reoperation for salvage of a free flap. A bone graft was done subsequently in 4 patients. Successful limb salvage has been achieved in all 18 patients (18/18, 100%) with a healed wound for up to 30 months. Thus, we believe that free tissue transfer for limb salvage in difficult patients is still a worthwhile procedure and should be attempted if possible. Meticulous pre-op preparation and intra-op execution combined with the use of innovative microsurgical techniques are the keys for success.

Muscle Reinnervation in One and Two Stages. Experimental Study with End-to-Side Neurorrhaphy

Presenter:	Fausto Viterbo, MD, PhD
Co-Author:	Joseli Assem Bersaneti, MD
Affiliation:	Faculdade de Medicina de Botucatu / UNESP, Botucatu - São Paulo, N/A

Muscle transplant may be performed in a single-stage or in two stages. In the single-stage procedure the muscle remains longer without innervation. In two stages, the nerve grafting is performed before, so the denervation time is smaller. The purpose of this work was to compare these two methods using the end-to-side neurorrhaphy. The study was performed with 80 rats divided in four groups of 20 animals. The group 1 was the normality control. The group 2 was submitted to two stages surgical procedures. In the first stage a sural nerve graft was sutured end-to-side to the tibial nerve. In the second stage the fibular nerve was transected and the distal end was sutured end-to-end to the sural graft. The group 3 underwent to the same procedure of group 2, however in a single stage. The group 4 was the denervated control, where the fibular nerve was transected and both stumps were implanted into the subjacent muscles. The experiment lasted 29 weeks, when the animals were sacrificed. The right tibial cranial muscle and the nerves were harvested. The average mass of the tibial cranial muscle, in group 1 was 0,9180 g (+/- 0,1115), in group 2 was 0,6034 g (+/-0,0333), in group 3 was 0,4806 g (+/- 0,0659) and in group 4 was 0,2555 g (+/-0,0126) (p<0,001). The muscle fibers area average was 0,004634 mm² (+/-0,000758) for group 1, 0,002613 mm² (+/-0,000581) for group 2, 0,002102 mm² (+/-0,000674) for group 3 and 0,000433 mm² (+/-0,000486) for group 4 (p<0,0001). The minimum diameter of muscle fibers was 0,066012 mm (+/-0006347) for group 1, 0,044423 mm (+/-0,000768) for group 2, 0,038978 mm (+/-0,009114) for group 3 and 0,015295 mm (+/-0,008610) for group 4 (p<0,0001). It was concluded that the muscle reinnervation in two surgical stages was superior than in the one stage.

2002 PSEF Essay Contest - Bernard G. Sarnat, MD Basic Science Junior Award: CD40 Costimulation Blockade in Limb and Nerve Transplantation

Presenter:	Thomas H. Tung, MD
Co-Author:	Susan E. Mackinnon, MD
Affiliation:	Washington University School of Medicine, St. Louis, MO

Presenter:	Naveen Yalamanchi, BS
Co-Authors:	Matt B. Klein, MD, Amarjit S. Dosanjh, BS, Hung M. Pham, BS, Michael T. Longaker, MD, James Chang, MD
Affiliation:	Stanford University Medical Center, Mountain View, CA

Purpose: Cartilage erosion and ligamentous instability are common in advanced carpometacarpal (CMC) arthritis and often necessitate surgical intervention. An autogenous interpositional cartilage construct consisting of viable chondrocytes in an alginate matrix would be a useful adjunct for the surgical management of CMC arthritis. The purpose of this project was to optimize the proliferation and viability of rabbit chondrocytes in culture. We specifically examined the effects of rabbit serum and ascorbic acid supplementation on cell viability, cell retention, and cellular metabolism characteristics in an alginate-chondrocyte construct.

Methods: Rabbit chondrocytes were harvested and cultured in DMEM/F-12 media. The media was supplemented with 10% or 20% rabbit serum (RS) or, as control, 10% fetal bovine serum (FBS), with or without 200 ug/ml ascorbic acid. The chondrocytes were suspended in a 3% calcium-alginate matrix and the entire construct was maintained in vitro for up to 60 days in media plus either 20% RS or 20% FBS, with or without further supplementation from 200 ug/ml ascorbic acid. Gel matrices were dissolved to disperse the cells for assessment of viability and cell retention at 15, 30, 45, and 60 days. Collagen type II production within the construct was determined by immunohistochemical techniques and collagen infiltration within the alginate matrix architecture was examined by sirius red staining.

Results: Cells grown in RS demonstrated significantly higher rates of proliferation, viability, and resistance to growth crisis than cells in control FBS. 20% RS exhibited a 143% increase in cell count (P < 0.05) and showed increased viability, from 89.6% to 95%, as compared to control. In addition, cells grown in ascorbic acid-supplemented media demonstrated significantly higher rates of proliferation and viability than control, unsupplemented cultures (32.9% increase in cell count and 6.3% increase in viability; P < 0.05). Furthermore, 20% RS showed a substantial ability to reverse the quiescent growth arrest noted in late-passage senescent chondrocytes and promote metabolic activity. When examining matrices histologically and by cell count, alginate-chondrocyte constructs maintained in RS showed higher levels of cellular retention and higher levels of viable chondrocytes than constructs maintained in FBS (170% increase in cellular retention and 216% increase in viability; P < 0.05). Collagen type II production and the presence of a collagenous architecture were notably enhanced in constructs maintained in RS. Ascorbic acid supplementation significantly improved retention and viability.

Conclusion: The addition of both rabbit serum and ascorbic acid to chondrocyte culture media significantly increased cell proliferation and viability in our model. Furthermore, constructs maintained in media supplemented with rabbit serum and ascorbic acid demonstrated higher levels of cell viability and greater cell retention. Our optimization techniques also substantially enhanced the metabolic activity of chondrocytes in the alginate matrix as evidenced by marked increases in cellular collagen type II production, collagen infiltration within the alginate architecture, and reversal of metabolic growth arrest. Increases in collagen type II, a marker for a normal chondrocytic phenotype, suggests a method for preventing cellular dedifferentiation - a problem often encountered with in vitro cartilage constructs. The use of species-specific serum and ascorbic acid have optimized our in vitro conditions for the construction of alginate-chondrocyte matrices and hold obvious advantages for subsequent in vivo cartilage constructs addressing upper extremity joint pathologies.

Biomechanical Evaluation of Radiocarpal Joint Compressive Forces in a Distal Radius Fracture Model

Presenter:	David Patrick Singer, MD
Co-Authors:	Charles Kim, MD, Jeffrey Weinzweig, MD
Affiliation:	Brown University, Providence, RI

Objective: Distal radius fractures with dorsal angulation alter wrist kinetics with a variety of sequelae including load pattern changes, painful disability, and degenerative carpal pathology. The purpose of this study was to characterize compressive force changes with increasing dorsal angulation of the distal radius through the application of novel pressure sensing technology. Methods: Four pairs of cadaver arms were harvested and standard radiographs were used to exclude radiocarpal pathology. Osteotomies were made in the distal radius followed by rigid fixation with 0° and 20° of dorsal tilt. The pressure distribution at the radiocarpal joint was measured using the Tekscan 6900 sensor which was placed in the radiocarpal joint through a limited volar arthrotomy. The biomechanical forces were measured in each pair of wrists (pre-osteotomy, 0° doral tilt, 20° dorsal tilt) via axial loading as well as flexion loading simulating the Finger Extension Test (FET). Results: Average representations of the force area of distribution were calculated at the radiolunate and radioscaphoid joints for each pair of wrists. At the radiolunate joint, there was a consistent diminution of force in axial and FET loading associated with sequential dorsal angulation. At the radioscaphoid joint, there were progressive increases in compressive forces with axial and FET loading with sequential dorsal angulation. Likewise, the pressure distribution pattern at the radioscaphoid joint narrowed and shifted radially and dorsally with increasing dorsal angulation. Conclusion: Dorsal angulation of the distal radius translates into significant changes in wrist kinetics. The data underscores the importance of the mechanical advantage of palmar tilt of the radius for appropriate wrist loading patterns. At the same time, these findings reinforce the importance of anatomic distal radius fracture reduction and offer an explanation of wrist pathology associated with distal radius malunion.

Management of Chronic Metacapalphalangeal Joint Dislocations in Pediatric Patients

Presenter:	David C. Kim, MD
Co-Authors:	Gary F. Wingate, MD, Paul S. Kim, MD, Donald Mazur, MD
Affiliation:	Temple University Hospital, Exton, PA

Title: Management of Chronic Metacarpalphalangeal Joint Dislocations in Pediatric Patients Introduction: Dorsal dislocation of the metacarpalphalangeal (mcp) joint is an uncommon entity. With few exceptions the deformity is caused by a single traumatic hyperextension injury to the joint. Typically, the injury presents in adults and most commonly affects the thumb. We present the surgical management of chronic, isolated dorsal mcp dislocations of the small finger in three pediatric patients. In each of the patients the deformity was from a distinct cause. Materials & Method Three pediatric patients presented with dorsal mcp dislocations of the small finger. All three patients were female and their ages 14,10,16 years. The dominant hand was involved in 2 cases, and the duration of deformity prior to presentation was several years, three months, and one month respectfully. In one patient the deformity was the result of an aberrant sesamoid bone, the other an aberrant lumbrical muscle, and the last from trauma. Each of the patients were surgically explored and their deformity corrected by performing a volar plate arthroplasty. The proximal portion of the volar plate was imbricated to the periosteum using nonabsorbable sutures. A fixating pin was then placed across the joint in 60º flexion for two weeks. The digit was immobilized in a hand based, dorsal block splint for an additional two weeks and therapy begun. Four weeks post-op gentle active range of motion was initiated. At six weeks post-op the dorsal block splint was gradually weaned to neutral position.Gentle strenghtening began eight weeks post-op and buddy straps applied Results In all three patients, the mcp dislocation was corrected. There were no perioperative complications. Full range of motion and preoperative grip strength was achieved in each patient, with no residual joint hyperextension or joint instability. Discussion The literature is sparse on the operative management of chronic mcp dislocations in pediatric patients. Most reports involve adults with acute deformities. Similarly, cases involving pediatric patients are also the result of acute, single traumatic events. We present three pediatric patients, each with a different cause of chronic mcp deformity. In each of these cases a volar plate arthroplasty was successfully performed. Conclusion Volar plate arthroplasty of the metacarpalphalangeal joint is a safe and reliable method of correcting this unusual hand deformity in the pediatric patient.

A Special Neurotization to Use in the Rare Avulsions C7, C8, T1 to Wrist and Finger Flexion

Presenter:	Z. A. Accioli de Vasconcellos, MD, PhD
Co-Author:	C. Oberlin, MD, MSc
Affiliation:	Santa Catarina Federal University, Florianópolis - SC, N/A

The bases of the reconstructive surgery of brachial plexus are currently well established; but the number of patients victim of a serious paralysis increase constantly and the roots avulsion are frequent. In these cases, the search for better functional results guides surgeons to use selective neurotizations. Preference is given for those that don't need the interposition grafts. Lesions C8-T1 of brachial plexus are rare: they only represent about 5% of the traumatic lesions. In this cases, to reestablish hand function, the only possible treatment is a musculo-tendinous transfer. The problem is even more serious when there is a lesion of C7 in addition: in this case, possibilities of musculo-tendinous transfer are much reduced. The authors present the direct anastomosis between the nerve of brachialis muscle with the epitrochlear branch of the median nerve to use in those C7-C8-T1 root avulsions. Considering that the musculocutaneous nerve branches innerving brachial muscle has origin in C5-C6 roots and the elbow flexion is assured by biceps brachial muscle, we tried to re-establish flexors muscles function of the wrist and fingers by a neurotization of epithroclear branches of the median nerve by musculocuteous nerve branches of the brachial muscle. In all our dissections, we were able to achieve a tensionless neurorrafy with the proximal stumps of the brachialis branches of the musculocutaneous nerve with the distal stump of the epitrochlear branches of the median nerve. Morphometric studies showed compatibility between myelinazed nerve fibers number in both nerve branches.

Digital Replantation in Taiwan: Data Mining Population-based Healthcare Databases 1996-2000

Presenter:	Charles C.H. Liu, MD, MS
Co-Authors:	I-Jen Chiang, PhD, Simon J.H. Wu, MD, Jian-Jr Lee, MD, Yu-Chuan Li, MD, PhD, Jau-Min Wong, MD, PhD, Shiuh-Yien Lu, MD, Haw-Yuen Chiu, MD, PhD
Affiliation:	Cathay General Hospital, Taipei, Taiwan, Taipei, N/A

Charles C.H. Liu, Simon J.H. Wu, I-Jen Chiang*, Yu-Chuan Li* , Lu, S.-Y. Haw-Yen Chiu** Division of Plastic Surgery, Cathay General Hospital, Taipei, Taiwan *Graduate Institute of Medical Informatics, Taipei Medical Univeristy, Taipei, Taiwan **Division of Plastic Surgery, National Cheng-Kung University Hospital, Tainan, Taiwan*

Data mining, also referred to as knowledge discovery in database (KDD), is the automatic extraction of patterns representating knowledge implicitly stored in large database. Our work is based on the experience on a large series in our center (Liu, 2001), and now shifts to more complicated amputation trauma in the population-based, multiinstitutional database for 5 years.

National Health Insurance claim database in Taiwan from 1996 to 2000 is released for clinical research since 2001. With its wide coverage of 96% of 24 million population, it is promising for study of surgical operation and follow-up. Our preliminary study in 1/20 sampled dataset yielded 368 cases of limb replantations with 14274 detailed medical orders. After the first hospitalization, totally 4202 outpatient visits and another 174 related hospitalizations, mostly for other operations, are analyzed. The outcome is evaluated by other procedures in the follow-up database.

We are working on the complete trauma datasets for limb replantation with total case number of nearly 7000. The results would be compared with the 368 cases with more clinical details.

The overall profile of replantation surgery in this regions will be presented. Digital replantation are our focus. 289 digital and 63 thumb replantations were present, and 181, 34, 9, 3, and 1 cases underwent replantations for one to five digits respectively. The operation time wer grouped in two-hour interval, with 230, 181 and 91 cases for <2, 2-4, and >4 groups. There were 20 combined flap and 13 combined vascular procedures. Anitcoagulants were used in 264 cases, including aspirin, dextran, and prostaglandin.

The above clinical factors will be evaluated on outcome factors in acute and late hospitalization and outpatient visits, including associated procedures, reexplorations, lengths of hospital stay, various types of medical expense, and subsequent amputations and other reconstruction surgeries, especially microsurgery such as toe transfer. The medications, and policy of reoperations in different characteristics of hospitals or surgeons will also be discussed.

Various data mining algorithms would be applied to disclose implicit patterns, including association rules, classification trees, regression analysis, neural networks, and cluster analysis. The results could be compared with previous findings in the more clinically informative series of our centers.

REFERENCE: Charles C.H.Liu, Simon J.H. Wu, Yu-Chuan Li, I-Jen Chiang, K.S.Liu, S.Y. Lu, and H.Y. Chiu. Prognostic prediction of digital replantation --- data mining the CGH database of 800 cases. Proceedings of the Inaural Congress of the World Society for Reconstructive Microsurgery. Bologna, Italy, 2001, 93-95.

A Clinical Experience in the Coverage of Extensive Defects of the Upper Extremity

Presenter:	Moustapha Hamdi, MD
Co-Authors:	Koenraad Van Landuyt, MD, Phillip Blondeel, MD, Stan Monstrey, MD
Affiliation:	Gent University, Gent, N/A

Introduction: Classical skin free flaps are rarely used to cover large skin defects of the upper extremity because of the limited donor size. In our center, we have a wide experience with skin flaps. Using a muscle flap is limited to very specific indications and the amount of muscle required is restricted to the minimum in order to decrease the donor site morbidity. Material and Methods: We present a series of 10 patients who were admitted into our department with extensive defects of the upper extremity between December 1999 and December 2001. The mean defect was 30 x 14 cm. Thin flap such as thoracodorsal artery perforator TAP or lateral arm flap LAF was used for forearm and hand defects. Deep inferior epigastric perforator DIEP flap was indicated for deeper defects. Results: Free skin flaps (1 LAF, 2 TAP flaps, 4 DIEP flaps) were used in 6 patients. Chimera flap, which is a combination of two separated tissues based on one pedicle, was needed in 4 patients (scapular with TAP flap in one case and TAP with partial latissimus dorsi muscle in 3 cases). Immediate defatting of the DIEP flap on the wrist was performed to achieve immediate thin coverage. Average operative time was 4 hours 20 minutes (3 7 h). All but one of the flaps survived completely. There was one chimera flap where the cutaneous part of the flap was necrosed due to a postoperative hematoma. An adequate coverage and a complete wound healing were obtained. Conclusion: Skin flaps or perforator flaps can successfully be used to cover a large defect in an extremity with minimal donor site morbidity. Chimera flaps provide a large amount of tissue, a wide range of mobility and easy shaping, modeling and defatting.

Dupuytren's Fasciectomies in 60 Consecutive Digits Using Local Anesthetics with Epinephrine and No Tourniquet

Dupuytren's contracture is a common hand problem. Its treatment, other than percutaneous fasciectomies is performed as an outpatient surgery under regional or general anesthesia. If local anesthetics are used, they are used without epinephrine, and an arm or forearm tourniquet is essential. Multiple reviews have described the safety of local anesthetics with epinephinre in the digits. This study is a retrospective review of surgeries performed by the same surgeon in the hospital (43 digits) versus using local anesthetics with epinephrine and no tourniquet (60) digits in an office operating room. Results and complications were compared and tabulated. The groups were equivalent in regards to pre-operative measusurements except that the hospital group had slightly worse pre-operative MCP measurements and had slightly more rays operated upon at each surgical session. Post-operative improvement in extension at the MCP joint and PIP joints was similar in both the hospital and epinephrine groups. Complications including digital nerve and artery injuries, infections, hematomas, and reflex dystrophy were statistically equivalent between the groups. There were no cases of digital necrosis or gangrene in the epinephrine group, even though one patient sustained a transection of the digital artery at the PIP joint which was reversed successfully after the applicaiotn of nitroglycerin ointment and the passage of time. Due to the similarities in results, there does not seem to be an advantage to performing Dupuytrens excisions with full arm tourniquet and outpatient admission in many cases.

Presenter:	Nancy M. de Kleer, MD
Co-Authors:	Christine Curtis, PT, MSc, Derek Stephens, MSc, Howard M. Clarke, MD, PhD
Affiliation:	The Hospital for Sick Children, Toronto, ON

Introduction: The purpose of this study is to identify factors at an early age which reliably predict outcome in cases of obstetrical brachial plexus injury.

Currently, lack of spontaneous recovery of elbow flexion at three months of age is an indication for surgery in centres around the world. This has not been scientifically evaluated and currently no gold standard exists to predict which children will improve with conservative management and which children will benefit from surgery.

Methods: Six hundred and four children assessed at The Hospital for Sick Children brachial plexus clinic over the last ten years were evaluated prospectively in a retrospective review. Seventy nine children, all of whom underwent a brachial plexus physical exam at three months of age and had a minimum follow up of two years were analyzed in this study.

Four test scores, based on various combinations of validated physical examination maneuvers, were developed and calculated for children at their three month physical examination. One of the test scores was elbow flexion alone. The three month physical examination test scores were analyzed with respect to functional outcome. The ability of test scores to predict outcome was analyzed with logistic regression, receiver operating characteristic curves and tree based analysis.

Results: Two of four test scores were shown with logistic regression to predict benefit with statistical significance (p=0.01 and p=0.013). Elbow flexion alone did not predict outcome. ROC and tree based analysis support these findings.

Conclusions: Outcome in obstetrical brachial plexus injury can be predicted using two newly developed test scores. Elbow flexion alone does not predict outcome. Future studies will evaluate the test scores prospectively and ultimately derive a formula to calculate which child will benefit from conservative vs. surgical management.

Presenter:	Ardeshir Bayat, MD
Co-Authors:	J.S. Watson, MD, J.K. Stanley, MD, M.W.J. Ferguson, PhD, W.E.R. Ollier, PhD
Affiliation:	Wythenshawe Hospital, Manchester, N/A

Dupuytrens disease (DD) is a nodular palmar fibromatosis of unknown cause. The disease process leads to shortening of the palmar fascia and permanent contractures of the digits. DD is an irreversible, progressive disorder with a high rate of recurrence after surgical excision. DD is a familial condition, which is extremely common in individuals of Northern European extraction. DD is considered to be one of the most common heritable disorders of connective tissue in Caucasians.

The genetic literature on this disorder is very sparse and the mode of transmission is uncertain. Various patterns of inheritance have been proposed as the likely mode of transmission although no single gene has so far been identified.

Various risk factors such as age, sex, smoking, diabetes, anticonvulsant medication, alcohol abuse, cirrhosis of the liver and manual labour have also been implicated in DD pathology. However, the relevance of some of these aetiologic factors in DD pathology have been questioned and none so far has been proven to be of significant value in understanding the pathology. There are however, two elements in the aetiology of DD that clearly stand out. One is the common occurrence of this condition in Caucasians and the other is the familial nature of the disease.

Successive cases of DD (n=255) were entered into the study. The age range was between 37 to 90 years with a mean age of 56.9 years. Cases were all Caucasians from the Northwest region of England; U.K. All cases were seen by the first author who took a full medical history using a proforma and examined both hands and feet of each individual case. All cases had confirmed diagnosis of DD with the presence of characteristic Dupuytrens nodules in the palm of the hand and/or digits with or without contracture of either the metacarpophalangeal joint (MCPJ) or the proximalphalangeal joint (PIPJ).

The following information were noted in detail at interview: Profession, hobbies, hand dominance, family history, past medical history, medication, alcohol intake, date of onset of disease, history of trauma, symptoms, treatment, result and recurrence. One hundred and ten cases (43%) had a positive family history. There were 38 cases who had 2 sib pairs with a diagnosis of DD and 10 cases who had more than 3 sib pairs with DD. Interestingly from the those DD cases with a positive family history 14 had plantar nodules, 2 had plantar nodules with Peyronies disease, and 6 had familial knuckle pads. There was one case of DD with a strong family history that had simultaneous diathesis of plantar nodules, Peyronies and knuckle pads.

We identified a number of different inheritance patterns (dominant, recessive and maternal transmission) in our familial cases. In view of the variable patterns of transmission and the sporadic nature of the disorder; we propose that DD is a complex oligogenic condition involving a number of genes as opposed to a simple monogenic Mendelian disorder.

The detailed genetic basis of DD is key to understanding its pathogenesis and providing future prognostic and diagnostic advice to patients and to developing novel therapeutic regimes for its treatment.

Effects of Hyaluronic Acid and Amniotic Membrane Combination on Peritendinous Adhesion Formation After Flexor Tendon Surgery in Chickens

Presenter:	Guzin Yeþim Ozgenel, MD
Co-Authors:	Gülaydan Filiz, MD, Mesut Özcan, MD
Affiliation:	Uludað University Medical School, Bursa, N/A

The main goal of flexor tendon surgery is to restore digital motion by providing tendon healing and preserving tendon gliding. The formation of peritendinous adhesion around the repair site is one of the several adverse events that may prevent the achievement of this goal. The purpose of this study was to investigate the effects of application of hyaluronic acid and amniotic membrane combination on peritendinous adhesion formation and tendon healing after flexor tendon repair in an adult chicken model. Seventy-two adult Leghorn white chickens were used. The deep flexor tendons of the third toes were transected partially in Zone II and immediately repaired with a modified Kessler technique in both legs. The tendons were divided into 4 groups of 36 each according to the type of repair used. In Group 1; simple tendon repair was performed, in Group 2; the repair site was wrapped with amniotic membrane, in Group 3; hyaluronic acid was injected around the repair site, in Group 4; the repair site was wrapped with amniotic membrane and hyaluronic acid was injected inside. The extent and the severity of adhesion formation in the peritendinous region and the healing status of the tendons were macroscopically and histologically evaluated according to the grading scale of Tang at 3 and 6 weeks. The least adhesion was observed in tendons treated with the combination of amniotic membrane and hyaluronic acid (p<.05, Mann-Whitney U test). No statistically significant difference was found between the groups in the healing status of the tendons. At 20 weeks, the peritendinous adhesions and the tendon healing were evaluated biomechanically. There was no significant difference in the tensile load required to rupture the repaired tendon between the groups. Peritendinous adhesions were evaluated by measuring the active and passive flexion of the distal interphalangeal, proximal interphalangeal and metacarpophalangeal joints with a goniometer. The range of toe motion at 20 weeks was the smallest in group 1, statistically the larger in groups 2 and 3, and statistically the largest in group 4 (p<.05, Mann-Whitney U test). The range of toe motion was of no statistical difference between group 2 and group 3 (p>.05, Mann-Whitney U test). Various treatment strategies have been used in order to prevent peritendinous adhesions after flexor tendon surgery. One of these methods was to encircle the tendon with some substance, but regardless of the material used this method has failed, for scars forms at the end of these materials. In this study, in order to prevent this scar formation, hyaluronic acid was injected inside after the tendon was wrapped by amniotic membrane. Preliminary investigations suggest that the application of high molecular weight hyaluronic acid in high concentrations around the repaired tendons promotes tendon healing and decreases adhesion formation. It is known that hyaluronic acid reduces scar formation by inhibiting lymphocyte migration, proliferation and chemotaxis, granulocyte phagocytosis and degranulation, and macrophage motility. Furthermore, amniotic membrane prevents the peritendinous adhesions by reducing the effect of beta transforming growth factor in the surgical area. In conclusion, this experimental study shows that the application of hyaluronic acid and amniotic membrane combination around the repair site significantly prevents the peritendinous adhesion without impairment of the tendon healing in the chicken

2002 PSEF Essay Contest - Bernard G. Sarnat, MD Basic Science Junior Award: A New Flap Design: Neural-Island Flap

Presenter:	Mustafa Akyurek, MD
Co-Authors:	Tunc Safak, MD, Erhan Sonmez, MD, Omer Ozkan, MD, Abdullah Kecik, MD
Affiliation:	Hacettepe University School of Medicine, Ankara, N/A

2002 PSEF Essay Contest - Bernard G. Sarnat, MD Basic Science Senior Award: Probiotic Lactobacillus RC-14 and its Biosurfactant Prevent S.A. Infection in Rats

Presenter:	Bing Siang Gan, MD, PHD
Co-Authors:	Jeffrey C. Howard, PhD, Gregor Reid, PhD, MBA, Juan Kim, BSc, MSc, Peter Cadieux, MSc
Affiliation:	Hand and Upper Limb Centre, London, ON

Multicenter Evaluation of an External Tissue Expander System (Brava®) for Breast Enlargement

Presenter:	Roger K. Khouri, MD
Co-Authors:	Thomas J. Baker, MD, Rod J. Rohrich, MD, Brava External Breast Expansion Study Group, n/a
Affiliation:	Dermatology & Plastic Surgery, Key Biscayne, FL

Purpose: Tissue expansion is a proven technology that generates tissue. We conducted a multicenter study to confirm the feasibility of breast enlargement with the Brava external breast expansion system and to determine the factors conducive to good results.

Method: After obtaining IRB approval, 21 surgeons from four regions of the US referred 125 women (age18-51 av. 34) to 6 clinical research centers. Upon enrolment, at the end of the study, and at least six times in the interim, questionnaires, breast examinations, standardized photographs and volume measurements by bead displacement were obtained. The women were not compensated and received the bra-like external tissue expansion system free of charge. They were asked to wear it for >10 hours/day for at least 10 consecutive weeks. Final recordings were obtained at least one month after cessation of treatment and only after unchanged breast volume measurements two weeks apart confirmed stable enlargement and completion of the recoil. Results were correlated with demographic and physical factors, with duration of treatment and with compliance as recorded by the microchip in the device.

Results: 95 women completed 10-20weeks of treatment (average 13w). After 2months reprieve, 8 women underwent another treatment cycle. Reasons for drop out were: non-compliance with the lengthy commitment (24); refractory dermatitis (3); and >5% body weight change (3).

At final follow-up, stable breast enlargement achieved was 108±38ml (range 30250ml, median 105ml). This corresponds to an average 80% increase in breast volume (range 11290%). The results were categorized as excellent (n=14) if they more than doubled their original breast volume and achieved >120ml volume increase; very good (n=43) if > 50% and >100ml; good (n=27) if >50% or >80ml; and marginal (n=11) if <50% and <80ml.

Parity, race, original breast volume and body fat index had some effect that was largely overshadowed by the effect of compliance (ratio of on/off expansion time) and duration of treatment. Resultant breast enlargement strongly correlated with compliance (%time used for >10 hours/day) and with the length of the overall treatment period.

Conclusions: This multicenter study confirms that external tissue expansion of the breast leads to larger fuller breasts. Like other tissue expansion procedures true tissue growth is slow and requires sustained tension. The stiff compliance requirement of this external tissue expander and the slow tissue growth rate of approximately 1 to 1.5 ml/day compound the issue. Brava offers compliant patients with patience a non-surgical alternative for moderate breast enlargement.

An Array of Surgical Tasks for the Objective Assessment of Technical Ability Amongst Plastic Surgeons

Presenter:	Mansoor S Khan, MRCS
Co-Authors:	Simon D Bann SD, MBBS, Peter E. M. Butler, MD
Affiliation:	University College London, London, N/A

Introduction. There is an on going demand for Plastic surgeons to demonstrate that they can operate well, maintain their performance and deliver acceptable results. The acquisition of surgical competence and dexterity is a fundamental part of good surgery and must be one of the main objectives in a surgeons training. There is also increasing pressure from the Government to introduce testing of surgical competency for all surgeons. Currently surgeons are assessed by a series of subjective and peer reviewed interviews, but at no stage is the objective assessment of surgical competence measured. It is believed that a system where the trainees are assessed as they perform specific tasks may produce a more accurate reflection of their ability than a trainers subjective evaluation. We have introduced objective assessment of an array of key tasks in plastic surgery, which will be used to assess technical ability.

Method. A range of Plastic surgeons with differing surgical skill were tested. They performed three tasks designed to assess their ability to suture skin, take a medium thickness skin graft and repair a tendon. The candidates were videoed during the procedures and they were scored by four independent observers using the OSATS scoring system. Their movements were also monitored using an electromagnetic tracking system. Their performance was also then included in a normogram of scores versus skill level.

Results. Sixty-five candidates were tested with an experience range from consultant to junior SHO. Results showed significant differences in technical ability between all levels of seniority. Suturing gave a p value of <0.001, skin grafting gave a p value of 0.021; tendon repair gave a p value of 0.031 with consultants performing the tasks with greater competency than their juniors. Inter-relater reliability using Cronbachs alpha=0.89.

Discussion. These tasks show that technical ability can be objectively assessed. The use of objective, structured assessment with feedback allows the deficiencies of the trainee to be highlighted early and therefore corrected early. It can therefore be seen that the tasks give us the ability to not only measure the technical competence of an individual, but also to allow instruction on the technique and then the ability to see an improvement in their technique and level of competence. These tasks have also been shown to exhibit face, construct and concurrent validity.

Conclusion. We have demonstrated a valid and reliable method of objectively measuring the surgical skill of Plastic surgeons. This array of tests generates normograms of plastic surgical competence that predicts levels of skill. This has important implications for the future of surgical training, in that it allows us to identify whether the fundamentals of surgical technique have been passed on to the trainee, and to continually monitor their progress. These tests can therefore be used to objectively measure technical skill before, during and after plastic surgical training and may also be used for a revalidation program.

Presenter:	Bruce Klitzman, PhD
Co-Authors:	Detlev Erdmann, MD, Ranya Sweis, MD, Andrea E. Buckwalter, BS, Vasey McClory, BS, Kevin C. Olbrich, PhD, A. Adam Sharkawy, PhD
Affiliation:	Duke University, Durham, NC

OBJECTIVE: There has long been interest in (and healthy skepticism of) devices and techniques to facilitate small vessel anastomoses. The purpose of this study was to assess the performance of a magnetic device to anastomose vessels. METHODS: Male canines (25 Kg) were treated daily with Plavix and aspirin. Following anesthesia, the femoral artery (2-3 mm i.d.) and vein (3-4 mm i.d.) were exposed unilaterally in three dogs and bilaterally in four dogs. An arteriotomy or venotomy of approximately 4 mm length was performed in each vessel. On each vessel, one oval magnet (Ventrica, Inc., Fremont, CA) of 0.5 mm thickness was inserted into the vessel and a second identical magnet was aligned external to the vessel, compressing the vessel wall and creating a magnetic port in the vessel. Once the magnets were firmly in place on both the artery and the vein, the two ports were approximated, completing the anastomosis. Patency was assessed after 9 weeks using a color duplex Doppler scanner. The anastomoses were explanted after 10 weeks. Hydrodynamic resistance was measured ex vivo on eight anastomoses by dividing the pressure drop across an anastomosis by the flow. RESULTS: Following placement, very high flow was evident through the anastomoses, creating visible turbulence and palpable vibration. All eleven anastomoses were patent under direct observation and palpation at implant and at explant. Ten of eleven were clearly patent on Duplex scans and one was questionable. Hydrodynamic resistance was 0.63 + 0.21 mmHg min/ml and did not vary significantly with flow. CONCLUSION: Anastomoses had 100% patency after 10 weeks and warrant further study in vessels of different sizes and locations, as well as in non-vascular structures.

2002 PSEF Essay Contest - Bernard G. Sarnat, MD Senior Award: Angiosomes of the Torso

Presenter:	Simon Bernard, MBBS
Co-Author:	G. Ian Taylor, MD
Affiliation:	Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Melbourne University, Melbourne, N/A

Wednesday, November 6, 2002

Plastic Surgery Research Council 2002 Clifford C. Snyder Award: TGF-beta Receptors: Bridging the Gap of Cartilage Injury

Presenter:	Wendy L. Parker, MD
Co-Author:	Annie Phillip, PhD
Affiliation:	McGill University, Montreal, QC

Plastic Surgery Research Council 2002 Peter J. Gingrass, MD Award: Apert and Crouzon Fibroblast Growth Factor Receptor Gain-of-Function Mutations Suppress Noggin: A Mechanism for FGF-Mediated Cranial Suture Fusion

Perforator Based Adipofascial and Fasciocutaneous Flaps for the Treatment of Difficult Lower Extremity Wounds

Presenter:	Daniel A. Medalie, MD
Affiliation:	University of Kentucky Medical Center, Lexington, KY

Purpose: Difficult defects of the lower extremity are frequently treated with free tissue transfer or pedicled flaps that sacrifice blood supply to the extremity. Recent advances in the understanding of the vascular anatomy of the lower extremity have ushered in a new era of reconstruction. Fasciocutaneous and adipofascial flaps based on both distal ankle perforators and neuro-venous pedicles will be described to close difficult distal defects. Methods: Multiple operations have been performed by the author utilizing perforator-based adipofascial flaps. Six flaps for the distal lower extremity will be discussed in terms of indications, technique and outcome. Results: Case 1 is a distally based flap used to cover a chronic burn of the medial malleolus. The flap incorporates the greater saphenous vein and saphenous nerve and has perforators from the posterior tibial artery at its base (1a-d). Case 2 uses a distally based posterior calf flap including the lesser saphenous vein and sural nerve to cover a lateral ankle defect (2a-d). It incorporates perforators from both the peroneal and posterior tibial arteries. The same type of flap is used in Case 3 (3a-d) and tunneled to cover a medial tibial fracture. Case 4 is an example of a sural flap. A fasciocutaneous flap incorporating the sural nerve and lesser saphenous vein is used to reconstruct an achilles defect (4a-d). Case 5 is an example of a proximally based adipofascial flap used to cover a distal tibia fracture. Its blood supply derives from perforators of the anterior tibial artery (5a-d). Case 6 demonstrates a proximally based flap used to cover an Achilles defect (6a-d) with posterior tibial perforators as its blood supply. Conclusions: Perforator based adipofascial and fasciocutaneous flaps are a viable alternative to free or pedicled flaps in lower extremity reconstruction and represent an important addition to the plastic surgeons armamentarium.

Defining the Role for Negative Pressure Therapy in the Treatment Algorithm of Extremity Wounds

Presenter:	Liza C. Wu, MD
Co-Authors:	Loren S. Schechter, MD, Robert F. Lohman, MD, Robin Wall, PA, Mieczyslawa Franczyk, PT, PhD
Affiliation:	University of Chicago Hospitals, Chicago, IL

Introduction: Negative pressure therapy has been promoted as a method of simplifying care and reducing the extent of soft tissue reconstruction in complex extremity wounds. The role of this new therapy has yet to be defined. A cohort of patients receiving negative pressure therapy and free tissue transfer was evaluated. Methods: All patients undergoing soft tissue reconstruction of the extremities are entered into a prospective database. A subset of patients treated with both negative pressure wound therapy and free tissue transfer was analyzed. Results: From 6/99 to 2/02, 16 patients with extremity wounds were treated with negative pressure wound therapy and free tissue transfer: 14 males and 2 females, 14 lower extremity and 2 upper extremity wounds. Wounds occurred as a result of trauma (13), vascular insufficiency (1), a brown recluse spider bite (1), and therapy for soft tissue sarcoma (1). Major complications requiring reoperation occurred in 7 (44%) patients: total flap loss (2), persistent osteomyelitis (1), abscess (1), tibial non-union (1), hematoma (1), and loss of skin graft (1). Complications did not appear to be related to age, co-morbidities, method of injury, or MESS. The mean number of days between injury and soft tissue reconstruction for the patients without complications was 48 (4 165) compared to the patients with complications, 101 (17-224). The mean number of days of negative pressure therapy for patients without complications was 14 (2 90), compared to 49 (8 100) for patients with complications (p < 0.05). Conclusion: Although negative pressure therapy has a role in the management of complex extremity wounds, delayed soft tissue reconstruction continues to have a high complication rate. Negative pressure wound therapy will probably reduce the need for emergency free flaps, but does not change the basic principles of extremity reconstruction: adequate debridement and early soft tissue reconstruction.

Revascularization of Human Acellular Dermis Matrix When Used for Ventral Hernia Repair – A Rabbit Model

Presenter:	Nathan Gopi Menon, MD
Co-Authors:	Eduardo D. Rodriguez, DDS, MD, Nelson H. Goldberg, MD, Ronald P. Silverman, MD
Affiliation:	University of Maryland, Baltimore, MD

Purpose: This study investigates if human acellular dermis (Alloderm, LifeCell Corp., Branchburg, NJ) revascularizes when used to reconstruct abdominal wall defects in rabbits. This could prove useful in infected situations where prosthetic mesh is suboptimal.

Methods: Abdominal wall defects were created in 25 rabbits. This defect was repaired with (A)Alloderm (n=10), (B)Goretex (W. L. Gore & Associates, Inc., Elkton, MD) (n=10), and (C) primary closure (n=5). The defect measured 3cm x 7cm in groups A and B, and 0.5cm x 7cm in group C. After 30 days the abdominal walls were analyzed for: presence of hernia, size of the implant, presence of intraabdominal adhesions, breaking-strength of implant-fascial interface with the suture removed, and neovascularization by fluorescein dye and histological analysis.

Results: There were no hernias in any of the groups. In 8 out of 10 of the Alloderm group, there was no change in implant size. The remaining 2 of the Alloderm group had < 1 cm of stretch in the horizontal dimension of the implant. Adhesions were seen in all of the rabbits in the Goretex group, but not in the other groups. There was no statistical (t test) difference between the mean breaking strength of the Alloderm-fascial interface (288.6N/mm2 +/- 97.1), and the Goretex-fascial interface (337.0 N/mm2+/- 141.2). Infusion with fluorescein dye and histology indicated abundant vascular ingrowth into the Alloderm.

Conclusions: This study indicates that in the rabbit, Alloderm does support vascular ingrowth when used for abdominal wall reconstruction and is as effective as Goretex in repairing ventral hernias at 30 days.

Presenter:	William J Casey, MD
Co-Author:	Nho Van Tran, MD
Affiliation:	Mayo Graduate School of Medicine, Rochester, MN

This study compares the outcome of Singapore flap, vertical rectus abdominus musculocutaneous flap (VRAM), and gracilis musculocutaneous flap vaginal reconstruction. A retrospective review of 99 consecutive patients was conducted at the Mayo Clinic from January 1988 to October 2001. All possible complications were determined for each of the 3 flap reconstructions. Univariate analysis of the effects of radiation and smoking on the complication rate for each flap was determined. Preoperative and postoperative sexual function and adequacy were compared between each group. Ninety-nine patients ranging in age from 19 to 80 years (mean 51.6 years) were compared with a mean follow up of 28.9 months. There were 36 deaths during the follow up period at a mean of 22.3 months (32/36 due to recurrent or metastatic carcinoma). Forty-one VRAM, 13 Gracilis, and 45 Singapore flaps (24 included an additional omental flap) were used for vaginal reconstruction. The majority was due to acquired vaginal defects due to recurrent pelvic malignancy. The overall complication rate was lower following VRAM than either gracilis or Singapore flap (13/41 31.7%, 8/13 61.5%, 21/45 46.7% respectively). The flap specific complication rate was superior in the VRAM group as well (9/41 22%, 7/13 53.8%, 17/45 37.8% respectively). VRAM reconstruction had a lower complication rate in patients receiving radiation therapy (8/36 22.2%, 6/12 50%, 16/35 45.7% respectively). The risks of either small bowel obstruction or vaginal fistula following vaginal reconstruction was lower following VRAM. Preoperative sexual participation predicted postoperative participation in 75/88 patients (85.2%) and was not affected by the type of reconstruction although more patients with a Singapore flap required frequent vaginal dilatation to maintain vaginal patency. The VRAM has the lowest overall and flap related complication rate with equivalent outcomes. It has become our vaginal reconstructive flap of choice.

Presenter:	Dennis Y. Song, MD, MS
Co-Authors:	Galen S. Wachtman, BS, Ernest K. Manders, MD
Affiliation:	University of Pittsburgh Medical Center, Pittsburgh, PA

Introduction Photogrammetry is an optical technique for determining the object-space coordinates of a 3-d surface. In this study, we demonstrate this technique using accessible and inexpensive photographic equipment and computer resources, examine the error inherent to the reconstruction process, and apply this technique to study the deformation of a surface.

Methods The photogrammetry apparatus consists of two 35mm SLR cameras with 50mm lenses mounted on a tripod and a calibration frame. After digitizing a set of 2-d images of an area of interest, the direct linear transform (DLT) is used to reconstruct its 3-d position. With the reconstructed 3-d information, a surface interpolation technique (Smith et al, 2000) was used to calculate the stretch ratio distribution for the deformed surface. This study consisted of two parts: 1) determination of the residual error inherent to the apparatus 2) application of this technique to determine the stretch ratio distribution of a deformed region of interest (ROI). This technique was applied in two scenarios a) in vitro on a deformed cylindrical surface b) in vivo on several different random pattern skin flaps created on the flanks of swine.

Results Respectively for each camera, the residual errors are 1.28+0.12mm and 0.85+0.60mm. The residual stretch ratio error for the deformed cylindrical surface was 0.001+0.006. This technique allowed us to quantitatively assess in vivo skin flap strain in skin flaps created on pig flanks.

Conclusion Photogrammetry is powerful technique to determine the object space coordinates of a 3-d region of interest. We have employed this method utilizing equipment and methods that are easily obtainable and inexpensive. We have calculated the errors inherent to this technique and in its use in calculating the stretch ratio distribution of a deformed surface. We have applied this technique towards the analysis of skin strain in vivo and find it an effective tool in the analysis of skin flap design. Photogrammetry is a powerful technique that potentially can be a ubiquitous tool in the analysis of surface deformation crucial to the study of the role of soft tissues in plastic surgery.

Reference Smith DB. Sacks MS. Vorp DA. Thornton M. Surface geometric analysis of anatomic structures using biquintic finite element interpolation. Annals of Biomedical Engineering. 28(6):598-611, 2000 Jun.

The Bipedicle Opposing Box (BOB) Flap: The Answer to Nipple Reconstruction Across a Mastectomy Scar

Presenter:	Robin R. Hamlin, MD
Co-Authors:	Lief A. Sorenson, Duncan A. Miles, MD, Ben J. Childers, MD, Robert A. Hardesty, MD
Affiliation:	Loma Linda University Medical Center, Loma Linda, CA

Problem: A mastectomy scar crossing the desired position for proposed nipple reconstruction can limit the desired nipple position because of less than optimal blood supply resulting in partial nipple loss or lack of long term projection.

Purpose: To create a flap that has dual pedicles. The bipedicle opposing box (BOB) flap provides blood supply across a mastectomy scar, thus allowing maintenance of projection, reliability, versatility, and a range of sizes.

Technique: See photos labeled below. Fig 1: The BOB flap diagram is drawn on a reconstructed breast with a diameter of 42mm. The dotted line is over the mastectomy scar, and arrows indicate the dual blood supply of the flap. Fig 2: The sides of the flap are then elevated with a scalpel. Fig 3: The skin bridge is elevated taking care to protect the pedicles. Fig 4: Corners of the skin medial and lateral to the flap are excised to increase flap projection. Fig 5: The sides of the BOB flap are rotated in to close the box. Fig 6: The sides of the flap are then sutured in place at the corners with a 4-0 monocryl suture. Fig 7: W plasty is performed to excise donor site dog ears and limit length of scars to area of future areola tattooing. Fig 8: Epidermis reapproximated with 5-0 fast absorbing suture. Calipers measuring flap projection at 10mm immediately postop. Fig 9: Nipple reconstruction 2 months postoperatively after tattooing of areola.

Methods: All patients have been photo documented preoperative, intraoperative, and postoperatively in a standardized manor. Objective measurements of flap design, intraoperative projection, and postoperative projection are documented.

Data: To date 20 nipples in 10 patients have been completed. There has been no acute flap loss, immediate loss of projection, or infections. Short term follow up to 2 months shows minimal loss of projection. All patients will be at least 6 months postoperative at time of presentation. All data will be tabulated in an objective manner, including measurements and standardized photography.

Summary: Uniquely the BOB flap provides a dual blood supply to the reconstructed nipple. This technique is reliable while providing good projection, is technically easy to master, and allows variance in size of nipple base and projection. Lastly the reconstructive surgeon will no longer be limited to nipple position by mastectomy scars.

Immediate Free Flap Reconstruction of Locally Advanced Breast Cancer: A Ten-Year Review

Presenter:	Babak Joseph Mehrara, MD
Co-Authors:	Andrew Smith, MD, Eric Arcilla, MD, Timothy Santoro, MD, Jeffery Sebastian, MD, James Watson, MD, Andrew Da Lio, MD, William Shaw, MD
Affiliation:	UCLA Medical Center, Los Angeles, CA

Introduction: Immediate reconstruction (IBR) of locally advanced breast cancer (LABC) is controversial. In an effort to avoid delays in adjuvant therapy, many oncologic surgeons advise their patients to delay reconstruction. The purpose of this study was to evaluate the safety and efficacy of IBR in patients with LABC. Methods: The records of 766 consecutive patients treated over the last 10-year period were reviewed. Patients with the diagnosis of stage IIB or worse breast cancer were identified and analyzed. Results: 170 patients with LABC who underwent IBR were identified (57 IIB; 63 IIIA; 39 IIIB; 11 IV). There were 158 unilateral and 12 bilateral reconstructions (182 flaps). The TRAM flap was used in the vast majority (158). The average age was 48 and 24% of patients had comorbid conditions. The average hospital stay was 5.1 days, and 23 patients required banked blood transfusions. There were 7 major complications (4.1%; 1 complete flap loss; 2 partial flap losses, 1 arterial and 1 venous thrombosis, both of which were salvaged, and 2 hematomas). There were 70 minor complications (41%; 9 infections, 33 patients with fat necrosis; 9 hernias or abdominal wall laxities; 4 minor fluid overload, and 13 donor site complications). Adjuvant postoperative therapy was delayed in 8 patients (5%), and the maximum delay was 3 weeks (one patient). The incidence of impaired wound healing and subsequent delay in postoperative adjuvant chemotherapy compared favorably to mastectomy without reconstruction in this population. Discussion: In the largest series to date, we have shown that IBR in the setting of locally advanced breast cancer is safe, well tolerated, and not associated with significant delays in adjuvant therapy. These findings, together with the known psychological benefits and convenience of IBR make a strong argument for immediate reconstruction in otherwise healthy patients regardless of cancer stage.

Skin-Sparing Mastectomy Flap Complications Following Breast Reconstruction: Incidence, Risk Factors, and Effect on Adjuvant Therapies

Presenter:	C. Scott Hultman, MD
Co-Authors:	Lynn Damitz, MD, Sumer Daiza, MD, David Ollila, MD, Nancy Klauber-DeMore, MD, William Cance, MD, Anthony Meyer, MD, PhD, Benjamin Calvo, MD
Affiliation:	University of North Carolina, Chapel Hill, NC

Introduction: Skin-sparing mastectomy (SSM) can improve the aesthetic and functional results of breast reconstruction, without compromising oncologic principles. However, SSM flap complications could potentially delay the initiation of adjuvant chemo-radiotherapy. The purpose of this study is to assess the incidence of SSM flap loss, identify risk factors for complications, and to determine the effect on timing of adjuvant therapies. Methods: We performed a retrospective analysis of 70 consecutive patients undergoing SSM and breast reconstruction, at a university teaching hospital. Charts were reviewed to determine patient demographics, medical history, management of complications, and short-term outcome. Patients with and without complications were compared using Students t test and chi-square analysis. P values <0.05 were assigned statistical significance. Results: From July 2000 to February 2002, 70 patients (mean age 48.9, range 24-73 years) underwent SSM and breast reconstruction (unilateral 41, bilateral 29) via TRAM flaps (n=27), latissimus flaps (n=25), and expander/implants (n=18). SSM flap complications occurred in 15 patients (21.4%) and included mild (n=3), moderate (n=7), and extensive (n=5) skin loss, resulting in 4 cases of dehiscence and 5 re-operations. SSM flap loss did not delay the delivery of adjuvant therapy (required in 8 of these patients) and did not result in any failed reconstructions. Age, cigarette use, previous breast cancer, prior irradiation, and type of reconstruction were not associated with SSM flap complications. Diabetes, however, was associated with SSM flap complications (p<0.01). Body mass index (BMI) was significantly greater for patients with SSM flap loss than those without SSM flap loss (30.1 vs 24.5, p<0.01). Conclusions: SSM flap complications are common following all types of breast reconstruction but do not necessarily delay the initiation of adjuvant chemo-radiotherapy. Patients with diabetes and elevated BMI are at increased risk for SSM flap loss. Despite the infrequent need for re-operation, SSM flap complications did not undermine the success of the reconstruction or jeopardize oncologic priorities.

Presenter:	Joe M. Gryskiewicz, MD
Co-Author:	Rod J. Rohrich, MD
Affiliation:	University of Minnesota Academic Health Center, Minneapolis, MN

This article describes the authors successful experience with AlloDerm and Dermaplant onlay grafts for the correction of nasal contour deformities in secondary rhinoplasty. Sixty-seven secondary rhinoplasty patients underwent multiple nasal corrections. Long-term follow-up in the subgroup of patients for 2 years or longer showed good results, though partial graft resorption (defined to be equal to or less than 50 percent) occurred in 45 percent of our patients. We have found it is necessary to overcorrect defects. This experience for nasal augmentation in secondary rhinoplasty was encouraging. Grafts are useful for dorsal augmentation and for correcting an overresected dorsum, irregular dorsum, collapsed lateral walls, the inverted V deformity, an open roof, and for camouflage over autogenous grafts. The major indication for our use of the graft was dorsal augmentation to create a soft, smooth bridge and thus avoid the untoward sequelae of warping or irregularities. All 67 patients in this series were followed for 6 months to five years. Analysis demonstrated no contour changes between year 1 and year 2, showing the dermal grafts to be stable after 1 year. Immediate problems and how they were handled will be described. AlloDerm and Dermaplant, which are two brands of allogeneic dermis processed to remove all cellular elements, possess several qualities that make them valuable for rhinoplasty. As off-the-shelf products, they are readily available and reasonably affordable. As shown in this series, they are versatile and easy to use in secondary rhinoplasty patients who are often graft-depleted. After careful preoperative analysis, the grafts are shaped to recontour the nasal skeleton as needed. Partial absorption, especially over the bony dorsum in a thin-skinned patient, is a definite disadvantage. Re-grafting is possible and sometimes necessary. Complete absorption was not seen in our study, and long-term persistence at 2 years was seen in some secondary rhinoplasty patients.

Analysis of the Aesthetic Columellar Lobular Complex, Identification of Abnormalities and Surgical Correction with Open Rhinoplasty

Presenter:	Fred L. Hackney, MD, DDS
Co-Author:	Jack P. Gunter, MD
Affiliation:	Fred L. Hackney, M.D., Dallas, TX

Purpose: Descriptions of the columellar lobular complex focus on measurements of the aesthetic columellar lobular angle, which is reported to be 45 degrees, ignoring other characteristics of an aesthetically desirable columellar lobular complex. (1) The purpose of this report is to define what constitutes an aesthetic columellar lobular complex and describe the appropriate surgical intervention to correct abnormalities.

Methods: Pre and postoperative lateral photographs of 75 rhinoplasty patients were reviewed. Forty-three of the photographs were judged to have aesthetically pleasing columellar lobular complexes. For those judged to be aesthetically pleasing the following measurements were made: 1. Columellar lobular angle 2. Anterior-posterior (A-P) position of the columellar lobular angle in relation to the anterior end of the normally positioned nostril. Using the range of each of these measurements as acceptable aesthetic goals, the pre and postoperative photographs were again reviewed to identify common abnormalities.

Results: Measurements of the aesthetic columellar lobular angle ranged between 20 and 45 degrees. The aesthetic A-P position of the columellar lobular angle ranged between 1 mm posterior and 2 mm anterior to the anterior end of the normally positioned nostril. Further analysis revealed the aesthetically pleasing range of columellar lobular angle measurements varied depending on the A-P position of the angle. If the columellar lobular angle was between 1 mm posterior and 2 mm anterior to the anterior end of the nostril, then the range of 20 to 45 degrees was aesthetically acceptable. However if the columellar lobular angle was greater than 1 mm posterior to the anterior margin of the nostril, the aesthetic range for the columellar lobular angle decreased to 15 to 35 degrees. In this instance a columellar lobular angle of 45 degrees produces a short nose and an unaesthetic columellar lobular complex. (Fig 1, preoperative) If the columellar lobular angle is greater than 2 mm anterior to the nostril the columellar lobular angle is ill defined and difficult to measure. Aesthetically the nasal tip lacks definition. (Fig. 2, preoperative)

Conclusion: Defining the aesthetic columellar lobular angle as 45 degrees belies the complexity of the columellar lobular complex. Aesthetic columellar lobular angle measurements vary depending on the A-P position of the angle. If the surgeon determines that repositioning the columellar lobular angle in the A-P dimension and/or changing the degree the angle will improve the aesthetic outcome, an open rhinoplasty should be considered. Using this approach the medial and intermediate crura are scored on the cephalic or caudal margins depending on whether the angle is to be decreased or increased respectively. The crura are then suture stabilized to a columellar strut to correct the A-P position and the angular measurement. Figures 1 and 2 demonstrate the improved aesthetic outcome possible when the rhinoplasty surgeon understands the aesthetic relationship between the A-P position and the angular measurements of the columellar lobular angle.

Presenter:	S. Larry Schlesinger, MD
Co-Authors:	Sean M. Maguire, MD, Robert Heck, MD
Affiliation:	Maui Plastic Surgery, Kahului, HI

There is beauty in every race and culture on earth and as technology (the internet) makes us one large community, our global village has community standards of beauty. The plastic surgeon is and should be the repository of these standards. We are expected to understand deviations from this standard and be able to modify and/or totally correct these variations. The rhinoplastologist sees the greatest number of variations in the smallest area per centimeter of the body. We in the western world have been taught well to correct variations in the European (Caucasian) nose, being the intellectual descendents of Gaspar Taliacotius and Jacques Joseph, but rarely do we deal with the non-Caucasian nose during our formal training. Variations in the non-Caucasian rhinoplasty and a basic paradigm for the correction of these variations are the subject of this presentation. Included in the surgical algorithm are the treatment of bimaxillary retrusion, lack of dorsal and tip projection, columellar retrusion, wide nasal ala and a broad, flat nasal tip. While treating a large population of mixed ethnicities in the state of Hawaii, the primary author has performed this technique on 50 non-caucasian (non-haole) patients over a two year period.

Presenter:	Dennis Jay Hurwitz, MD
Co-Author:	Thomas Zewert, MD, PhD
Affiliation:	University of Pittsburgh Medical Center, Pittsburgh, PA

While circumferential removal of redundant skin and excess fat of the torso has become the preferred procedure after massive weight loss, residual skin laxity, unaesthetic contours and seromas are common. Over the past 3 years, our technique has evolved on 22 patients after minimal incision laparoscopic gastrointestinal bypass. The average preoperative BMI (body mass index) was 53.7 with a reduction to 31.6. Operations were modified based on BMI under 30, between 30 and 35 and greater than 35. In thinner patients we used the lateral position, extensive undermining, vertical excision of excess medial thigh skin, and multiple procedures; whereas, obese had extensive liposuction and limited procedures. Other beneficial techniques were: 1. Draw markings, anticipating scar position with forceful skin pull while supine and standing. 2. Begin prone and resect the medial thighplasty dog ears after the buttock lift. 3. Preserve the subcutaneous fascia system for sturdy permanent suture closure. 4. Suction pubic fat and resect superior and lateral skin for monsplasty. 5. Undermine anteriolateral abdominal skin minimally and close under tension. 6. Limit abdominal midline inverted V excision of skin to wide scars. 7. Avoid over resection of flank fat. 8. Undermine lateral and posterior thigh extensively, with the Lockwood wedge-shaped dissector. Seroma requiring more than 2 aspirations occurred in 8 of the 22 patients. There were three localized wound infections requiring in-office drainage. Limited skin necrosis occurred in two patients with back midline V-shaped excisions. Limited scar revisions were performed in 6 patients. There were no rehospitalizations, revisions or deaths. Patients, surgeon and resident judged the results to be very good to excellent. Seromas are an anticipated sequel of these procedures. The results of circumferential body lift and medial thighplasty on patients after massive weight loss approach cosmetic surgery expectations

Presenter:	Fabio Xerfan Nahas, MD, PhD
Co-Authors:	Andreia Bufoni Farah, MD, Yara Juliano, MD, Neil Ferreira Novo, MD
Affiliation:	Hospital Jaragua, São Paulo - SP, N/A

Abdominal skin presents hypoesthesia after abdominoplasty. It was not found in the literature a specific study about sensibility of the abdominal wall after abdominoplasty. The purpose of this study is to find out which modalities of sensibility are decreased and which areas of the abdominal wall are affected so that patients can be warned preoperatively about this condition. Forty patients were divided in two groups of twenty patients each. On the control group, patients had no previous abdominal incisions. The sensibility evaluation of patients from the experimental group was made from 12 to 60 months after the operation, with average of 30.75 months. All patients had the abdominal skin divided into twelve areas, nine of them were above the abdominoplasty incision and three areas were below it. Sensibility to superficial touch, superficial pain, hot and cold temperature, vibration and pressure were evaluated on both groups. Sensibility to all modalities was positive in all areas by a variable number of patients of the experimental group. However, in area 8 (hypogastric area) there was a statistically significant number of patients who referred decrease sensibility of some of the sensibility modalities (Fisher test and Cochran G test). Areas 5 (epigastric area) and 11(pubic area) showed also decreased sensibility to hot temperature in patients from the experimental group. Sensibility to pressure presented a statistically significant decrease in all areas of the abdomen when compared to the control group (Student t test) These findings help plastic surgeons to orient their patients about possible risk of exposure to injuries in the areas with decreased sensibility after abdominoplasty. Most importantly, as these patients presented decrease of sensibility to pressure and hot temperature in a more extensive area of the abdomen, they will be more exposed to burn injuries after this operation.

Presenter:	Fabio Xerfan Nahas, MD, PhD
Co-Authors:	Julio Dieguez, MD, Marcus Vinícius Jardini Barbosa, MD
Affiliation:	Hospital Jaragua, São Paulo - SP, N/A

Correction of rectus diastasis (RD) is a procedure performed by most surgeons during abdominoplasty. The purpose of this study is to demonstrate the long-term efficacy of the correction of RD when plication of the anterior rectus sheath is performed. Seventeen female patients who underwent abdominoplasty were studied. RD was measured preoperatively with two CT-scan slices: above and below the umbilicus. The bony levels where the slices were made served as a reference for the postoperative CT-scans. During the operation, RD was measured at the same levels of the preoperative CT-scan slices. At this moment, the necessary force to bring the medial edges of the rectus muscles to the midline was measured with a dynamometer. Plication of the anterior rectus sheath was performed on two layers with 2-0 Nylon. Postoperative CT-scans were made at 3 weeks and 6 months after the operation. A long-term follow-up CT-scan was made from 32 to 84 months after the operation on every patient. It was found that there was no statistical significant difference when the measurement of RD with the use of CT-scan was compared to those found during the operation; therefore CT-scan is a very reliable method to verify the position of the abdominal muscles. The 3-week postoperative CT-scan proved that the correction of RD was achieved by the procedure. The long term CT-scans showed that there was no recurrence of RD in any patient of this series. This demonstrates that the plication of the anterior rectus sheath is a long-lasting procedure to correct rectus diastasis.

Liposuction abdominoplasty is a procedure, which consists of: liposuction of the entire thickness of the abdominal subcutaneous tissue, an excision without undermining of excess abdominal skin and when indicated, a rectus sheath plication is performed as well. Liposuction abdominoplasty should replace traditional abdominoplasty, since it eliminates or reduces many of the potential shortcomings and complications, inherent to traditional abdominoplasty. Liposuction abdominoplasty is a logical progression in further limiting the extent of abdominal flap undermining. It allows aggressive, thinning and sculpting of the entire thickness of the abdominal subcutaneous tissue, resulting in a natural (not a featureless) appearance of the abdomen. It minimizes the creation of dead space, which leads to seromas, hematomas and infections and preserves the sensory nerve supply of the abdominal skin. The resultant scar is usually shorter, thinner and curvilinear rather than geometrically designed. Surgery may be performed under local anesthesia, additional procedures can be safely performed, the potential for deep vein thrombosis and abdominal perforations is lessened and the post operative course is short, without restrictions, with a return to strenuous activities within a week or so.

This paper describes new evaluation criteria for abdominoplasty, the most important of which is the evaluation of the finite volume of the abdominal contents and its effect on the decision to perform rectus sheath plication. Additionally, the concept of a mobile, sensate abdominal flap created by liposuction and sustained by multiple neurovascular mesenteries will be offered. Finally, a brief discussion will raise the issue of local versus general anesthesia in abdominoplasty.

The traditional abdominoplasty procedure entails undermining an abdominal flap by dividing the midline neurovascular perforators. Removal of the entire infra umbilical skin especially in patients with minor skin excess, creates tension and contributes to unacceptable scarring. Moreover, unnatural geometric incisions such as the W incision may be necessary and the aesthetic results can be disappointing and not meet patient expectations. The abdominoplasty procedure is known to be a special risk factor for deep vein thrombosis and pulmonary embolism. Additionally, abdominal perforations and skin necrosis, were reported on, in the largest series ever, 487 patients, published by Dillerud. Dillerud found wide undermining to cause skin necrosis. Undermining necessitates prolonged post-operative suction drainage and it is also the cause for the most frequent complication of abdominoplasty: seroma. Seromas may result in pseudocyst formation and they are especially frequent when liposuction is combined with a traditional abdominoplasty. Wide undermining of the abdominal flap has been reported to cause significant post-abdominoplasty, sensory disorders of the abdomen (71%) and thigh (9.5%), by Van Uchelen et al, who also demonstrated a recurrence of diastasis recti in 40% of their patients.

32 consecutive patients underwent liposuction abdominoplasty procedures from 1997 to 2001, representing approximately 7% of 450 major liposuction cases performed during that period of time. 9 patients were 50 years old or older and 10 patients weighed more than 190 lb. In 11 patients (34%), the skin excision was extensive enough to qualify as a panniculectomy. A rectus sheath plication was indicated and performed in only 5 (15%) of these patients. The clinical material, demonstrates that the added evaluation of the intra abdominal volume greatly reduces the number of those, who are expected to benefit from a rectus sheath plication. It also demonstrates that liposuction abdominoplasty is a safe and effective procedure, which satisfies patients expectations and is essentially devoid of complications and problems. Finally, an argument is made in favor of local anesthesia with sedation in the performance of liposuction abdominoplasties.

Presenter:	Mark Kiehn, MD
Co-Authors:	Karol Gutowski, MD, Amitabha Mitra, MD
Affiliation:	Unversity of Wisconsin, Madison, WI

Introduction: Management of gunshot wounds (GSW) to the hand, based on military experience, emphasized aggressive soft tissue debridement and delayed fracture fixation. Civilian GSW are predominantly low velocity injuries with less tissue destruction, which may allow for less aggressive debridement and early fracture fixation. The purpose of this study was to evaluate the results of early definitive treatment of hand GSW fractures and patient compliance to determine the benefits of this treatment strategy for an inner-city trauma-patient population. Methods: Chart review of patients with GSW hand fractures at an urban, level-1 trauma center from January 1989 to December 1998. Results: Seventy-two patients with 98 fractures were treated. The majority of fractures occurred in the metacarpals, proximal phalanges, and metacarpophylangeal joints. Wounds were cleansed and minimally debrided and intravenous antibiotics were administered. The average time from injury to surgery was 2 days. Fixation techniques included K-wires (33), splinting/casting (29), internal plates (16), external fixation (12), and other techniques (4). Two in-patient and 4 post-hospital infections were diagnosed. There were no cases of osteomyelitis and no infection required fixation device removal. All infections were limited to superficial soft tissues and resolved with antibiotics. Twenty-eight patients (39%), most commonly splint/cast (12) and K-wire (14), were lost to follow-up upon discharge from the hospital and only 11 patients (15%) continued follow-up until the final wound healing and conclusion of hand therapy. Conclusions: Conservative debridement and early fixation of civilian GSW hand fractures was associated with few infections, which were limited to soft tissues, resolved with antibiotics, and did not require hardware removal. Poor patient follow-up should be anticipated for the urban hand-GSW patient. Adjustments in treatment strategy should be considered to reduce treatment-related complications and optimize outcomes for these patients.

External Rotation Following Suprascapular Nerve Reconstruction in Obstetric Brachial Plexus Palsy: Accessory Nerve Transfer Versus C5 Grafting

Presenter:	Jeffrey R. Marcus, MD
Co-Authors:	Christine G. Curtis, BSc, PT, Howard M. Clarke, MD, PhD
Affiliation:	University of Toronto, Hospital for Sick Children, Toronto, ON

Introduction: Following neuroma resection in obstetric brachial plexus palsy, distal targets are generally reconstructed by interposition nerve grafting from the proximal nerve stumps or by nerve transfer. Transfer of the spinal accessory nerve (CNXI) to the suprascapular nerve (SSN) is one of the most common neurotization procedures, but the comparative efficacy of this technique versus intraplexual grafting has never been objectively established. The null hypothesis of this study is that there is no difference in functional outcome - external rotation at the shoulder - following reconstruction of the SSN using either CNXI nerve transfer or grafting from the 5th cervical nerve stump. Methods: The study is an outcomes analysis of prospectively acquired data from consecutive patients. All patients had the diagnosis of obstetric brachial plexus palsy and underwent exploration of the brachial plexus with neuroma resection. Other than SSN, all distal targets were reconstructed using multi-strand intraplexual grafting. SSN was reconstructed using either CNXI nerve transfer or grafting from the C5 stump. All patients had a minimum of 3 years follow-up. The primary outcome measure was external rotation at the shoulder, as measured by the Hospital for Sick Children Active Movement Scale. Results: 88 patients met inclusion criteria. 33 underwent CNXI transfer. 55 underwent C5 grafting. For either reconstruction technique, there was a statistically significant increase in graded external rotation at 3 years. However, comparing the two techniques, the treatment results were statistically equivalent. Conclusion: Regardless of the type of reconstruction, all patients experienced significant measurable improvement in external rotation. There was no difference in the magnitude of this improvement for infants undergoing accessory nerve transfer or grafting from the C5 stump. Therefore, the null hypothesis of this study was upheld. The results of the study indicate that both procedures are suitable options for reconstruction of the suprascapular nerve.

Single Incision Radial-Sided Carpal Tunnel Release with Thumb Carpometacarpal Arthroplasty

Presenter:	Michael S. Wong, MD
Co-Authors:	Makoto Tamai, MD, Tsu-Min Tsai, MD
Affiliation:	Duke University Medical Center, Durham, NC

Introduction: The prevalence of carpal tunnel syndrome (CTS) in patients with thumb carpometacarpal (CMC) arthritis may be as high as 43%. Because unrecognized CTS in thumb arthroplasty patients can result in additional postoperative pain and weakness and even precipitate a reflex sympathetic dystrophy following thumb CMC arthroplasty, some advocate simultaneous carpal tunnel release (CTR). Purpose: To demonstrate the safety and efficacy of a combined radial-sided CTR and a thumb CMC arthroplasty via a single incision. Methods: Over an 11 month period, 8 patients (M:F=1:7) with an average age of 53.8 (range 38-70) years who had both thumb CMC arthritis and CTS underwent CMC arthroplasty with ligament reconstruction and CTR via a radial approach through the thumb CMC arthroplasty incision. All patients had thumb CMC arthritis and CTS based on history, physical, and ancillary tests and had all failed conservative therapy consisting of oral anti-inflammatory medications, splinting, and steroid injection. All patients underwent thumb CMC arthroplasty with trapezial resection and joint debridement. CTR was then performed through the same incision, dividing both superficial and deep portions of the transverse carpal ligament (TCL). Results: Six right-sided and two left-sided procedures were performed, three for recurrent CTS following open procedures. Four patients had additional procedures under the same axillary block (excisions of 2 ganglions and a subcutaneous forearm mass, and DeQuervains and trigger finger release). Follow-up averaged 14 (range: 1.7-24.8) weeks. All patients had improved pain and numbness. No recurrent motor branch nor sensory nerve injuries were observed. Conclusion: It is not uncommon to have patients with both thumb CMC arthritis and CTS. We have found that a thumb CMC arthroplasty and CTR may be safely performed together through the same incision by using a radial approach to the division of the TCL.

Resurfacing of the Upper Extremity with a New Modified Pocket Principle Technique Following Excision of a Circumferential Congenital Pigmented Nevus of the Arm

Presenter:	Mark A. Grevious, MD
Co-Author:	Frank A. Vicari, MD
Affiliation:	University of Chicago Hospitals, Chicago, IL

The approach presented is, we believe, the first use of an expanded pocket to reconstruct a circumferential congenital pigmented nevus of the arm. This approach combines the basic plastic surgical principle of a delayed pocket flap with minimally invasive endoscopic dissection and the benefits of tissue expansion to provide a safe and versatile approach to reconstruct a traditionally difficult problem.

The reconstruction of congenital pigmented nevi (CPN) of the extremity is usually addressed with staged excision, expanded adjacent tissue transfer, skin grafts (with or without expansion) or some combination of the above. When these lesions are circumferential the reconstructive options are severely limited. Adjacent tissue expansion is complicated by the absence of unaffected adjacent tissue, the limitations of axial expansion and the difficulty with pediatric tissue expansion in the extremities in general. Skin grafts provide adequate coverage, however, the aesthetic result is usually less than desired and there may be long-term difficulties with scarring and contraction. These limitations can be improved with the use of expanded full-thickness skin grafts, but the contour deformity and color differences often remain and functional issues from scarring are still a potential problem.

The technique reported here demonstrates the ability to excise a large circumferential CPN of the extremity and reconstruct the wound with skin that is supple and has the same color, contour, and texture as the normal skin. Creating an expanded flank/abdominal pocket is the first stage. The tissue expander is placed using minimally invasive endoscopic dissection and is expanded over a few months. The second stage involves removing the tissue expander and placing the denuded arm in this pocket as a delayed type flap. It should be noted that arm is placed under the capsule of the expander, not merely in the subcutaneous tissue. The third stage involves the final inset of the expanded flap and primary closure of the donor defect. In the case presented, the CPN on the dorsum of the hand was excised and reconstructed in a single step with Apligraf. The CPN on the upper arm and elbow was excised and reconstructed utilizing local expanded adjacent tissue transfer.

The procedure described attempts to achieve many of the principles employed in the reconstructive pursuits of plastic surgeons. These principles include: reconstruction of the defect with like tissue, utilizing minimally invasive techniques, and minimal donor site morbidity which is especially important in children. Furthermore, this procedure places another option to be added to our reconstructive armamentarium, in our quest to continue to improve our knowledge and skill as plastic surgeons.

Perforator-based free flaps have been introduced for various kinds of reconstruction and resurfacing. The authors present their experience with the "superthin" latissimus dorsi perforator-based free flaps for hand resurfacing by preserving important donor structures such as motor nerve and muscle. The superthin flap with 5-7 mm of thickness could be elevated including skin and thin superficial adipose layer based on a single perforator of the back. These thin flaps could be used for resurfacing the moderate and large defects after the electrical burn, scar contracture release and crushing injuries. Nine clinical cases were performed with this superthin flap without flap necrosis or other serious complications. All these flaps were enough thin for the defects on the palm, wrist and thumb and therefore, early postoperative rehabilitation was effectively achieved. Volar or circumferential resurfacing of the thumb and palm resurfacing of the child could be available without any need of later debulking procedure. The dimension of the flap could be safely harvested up to 11 x 10 cm based on the single perforator and donor site was closed primarily without any functional deficit. Additional pedicle length of 3-5 cm was obtained through the tortuous intramuscular dissection and more proximal pedicle was taken for T anastomosis of the pedicle at recipient artery. We conclude that this superthin flap enough for hand resurfacing can be elevated from the back by dissecting based on a single perforator. These clinical trials can prove the real possibility of the superthin perforator-based free flap and widen its utility for the purpose of resurfacing.

The Relationship Between Electrodiagnostic Severity and Three Provocative Tests in Carpal Tunnel Syndrome

Presenter:	Duck Sun Ahn, MD
Co-Author:	Dong-Hee Kang, MD
Affiliation:	Korea University Hospital, Seoul, N/A

Background: The diagnosis of diagnosing Carpal Tunnel Syndrome through provocative testing is controversial. The Purpose of this study is to establish a relationship between electrodiagnostic severity and provocative tests. Methods: A prospective study was conducted in 277 hands, which underwent surgery for carpal tunnel release. CTS severity was determined according to the modified Stevens Criteria(mild, moderate and severe). The relationship between electrodiagnostic severity and the sensitivity of three provocative tests(Phalen's, Tinel's and Hand Elevation Test) was investigated. A correlation between each individual test was established for each level of electrodiagnostic severity. The results were then statistically analyzed. Results: All three provacative tests showed highest sensitivity for the 'moderate level of electrodiagnostic severity. The Hand Elevation Test and Phalen's Test had the highest correlation for all levels of electrodiagnostic severity(range: 0.41~0.66). Interpretations: The sensitivities of all the provocative tests are different according to the levels of electrodiagnostic severity. Provocative tests have little merit as diagnostic tools in 'severe' and 'mild' cases of CTS. The provocative tests are much more reliable in 'moderate' cases.

Treatment of Traumatic Hand/Upper Extremity Wounds with the V.A.C. Wound Healing Device

Presenter:	Anthony J DeFranzo, MD
Co-Authors:	Louis C. Argenta, MD, Lisa R. David, MD, Malcolm W. Marks, MD, Joseph Molnar, MD. PhD, David Ruch, MD, Claire Sanger, MD, Michael J. Morykwas, PhD
Affiliation:	Wake Forest University School of Medicine, Winston-Salem, NC

Traumatic injuries to the hand are fraught with significant morbidity. Protracted recovery and multiple operations are the usual rule in these patients. We report 48 patients with isolated trauma of the hand who were treated with the Vacuum Assisted Closure device. All wounds were initially grossly contaminated. There were 37 males and 11 females. Nine patients had crush injuries. Nine patients had degloving injuries. Four patients had thermal burns and three had electrical burns. Three patients had gunshot injuries. The remaining 20 patients had a variety of assorted other injuries (saw, chainsaw, lawnmower, etc.). Sixteen of the patients presented with exposed bone and seventeen had exposed tendon. All patient's wounds were debrided of necrotic tissue and foreign particles, the VAC dressing applied, and the dressings changed at forty eight hour intervals. Subsequent debridements were performed as needed. The mean (+/- standard deviation) of VAC treatment was 6.0 +/- 3.9 days. The mean length of stay (+/- SD) was 11.2 +/- 7.3 days. Abundant granulation tissue over any exposed underlying structures (bone/tendon/joint) allowed coverage with split thickness skin grafts in twenty patients and full thickness skin grafts in three patients. Eight patients underwent local flap closure. Nine wounds were closed primarily. The remaining eight wounds closed spontaneously, usually with wet-to-moist dressing changes. There was no loss of any extremity in this series. No patient has required further surgery for either breakdown or secondary infection. Use of the Vacuum Assisted Closure device offers a significant advantage in treating these contaminated traumatized wounds. Local control of edema and infection is achieved and closure obtained with minimal intervention. Long term results have been gratifying.

Presenter:	Anthony M. Zacharek, MD
Co-Authors:	James N. Long, MD, Linda G. Phillips, MD
Affiliation:	University of Texas Medical Branch, Galveston, TX

Finger abscess is a common occurrence. The majority of cases involve bacterial infection, typically Staphylococcus and Streptococcus species. However, we present a case of finger abscess in an immunocompromised host in which fungus was identified. A 41-year-old right hand dominant man with history of recent cadaveric renal transplant presented with a one week history of progressive swelling and pain involving the right index finger. His medications included tacrolimus and prednisone. An incision and drainage of the finger abscess was performed, with evacuation of 5 cc of purulent material from the right index finger. Gram stain revealed rare hyphae, with fungal cultures showing Exophiala species. The patient was begun empirically on topical nystatin and oral itraconazole. His abscess has since resolved with return of full hand function. We present this case as it is unusual to make a diagnosis of fungal finger abscess. The majority of infections involving the non-nail portion of the finger are bacterial, with occasional viral etiologies. Fungal infection presenting as a finger abscess has not been discussed at length in the literature. The immunocompromised state would appear to represent a risk factor for the development of such infections. Once the presence of hyphae is detected on gram stain, the patient is begun on empiric topical and oral treatment for fungal infection, with final culture results guiding definitive treatment. The clinician should be alert to the possibility of fungal finger abscess in any patient with a history of immunocompromise.

Presenter:	Hee Yoon Choi, MD
Affiliation:	Hanyang University, Seoul, N/A

Presenter:	Jamal Mohammad, MD
Affiliation:	Ministry of Health, Kuwait, N/A

Presenter:	Alan Young Lim, MD
Affiliation:	Kaiser / Permanente, Sacramento, CA

Presenter:	Gayle Gordillo, MD
Affiliation:	Ohio State University, Columbus, OH

Presenter:	Elizabeth J. Hall-Findlay, MD
Affiliation:	none, Banff, AB

Presenter:	William A. Zamboni, MD
Affiliation:	Univ NV Sch Med, Las Vegas, NV

Presenter:	Daniel Brauman, MD
Affiliation:	n/a, White Plains, NY

Presenter:	Jeong-Tae Kim, MD, PhD
Affiliation:	Hanyang University, Seoul, N/A

Sunday, November 3, 2002

Monday, November 4, 2002

Tuesday, November 5, 2002

Wednesday, November 6, 2002