Sunday, October 28, 2007

3D Measure of the Airway Space in Patients with Skeletal Malocclusion

Presenter:	Patricia V. M. Alves, DDS, MS
Co-Authors:	Ana M. Bolognese, DDS, MS, DSc, Limping Zhao, PhD, Pravin K. Patel, MD
Affiliation:	University of Illinois at Chicago and Federal University of Rio de Janeiro, Chicago, IL

BACKGROUND The posterior airway space (PAS) is delimited by hard and soft tissues. In patients with severe hypoplasia of the middle and lower third of the face, a decrease in volume of the PAS may be present, producing a polysyndromic condition that ranges from snoring to obstructive sleep apnea syndrome (OSAS). The aim of this study is to define PAS morphology and variations by 3D computerized tomography cephalometric study in patients affected by skeletal malocclusion. METHODS The authors studied 30 patients affected by skeletal Class II or Class III malocclusion. To evaluate posterior airway space morphology and it relation with surrounding tissues, 3D cephalometric analyses were performed by computerized tomography. RESULTS This study showed significant differences in tongue and soft palate position, vertical length of oropharynx, anteroposterior dimensions of the upper airway, nasopharynx and oropharynx cross-sectional area between groups. CONCLUSIONS 3D cephalometric studies of hard tissue and posterior airway space should be performed in all patients affected by maxillomandibular malformation. This approach may provide data for the diagnosis of respiratory pathologies that vary from snoring to obstructive sleep apnea syndrome.

9:00 AM - 4:00 PM

3-Dimensional Laser Surface Scanner Analysis and Orthognathic Surgery

Presenter:	Patricia V. M. Alves, DDS, MS
Co-Authors:	Ana M. Bolognese, DDS, MS, DSc, Limping Zhao, PhD, Pravin K. Patel, MD
Affiliation:	University of Illinois at Chicago and Federal University of Rio de Janeiro, Chicago, IL

BACKGROUND The assessment of the dimensions and arrangement of facial soft tissues is important for plastic surgeons, orthodontist, and orthognathic maxillofacial surgeon evaluations. All require quantitative data about the soft tissue that complement the evaluation of hard-tissue relations. Various techniques for 3D reconstruction of the face have been used in diagnosis, treatment planning, and simulation. Advances in computer hardware and software now enable interactive display of the data on personal computers, with the ability to selectively view soft tissue from any angle and allow the clinicians navigate away from the limitations of conventional photographs. Therefore, in order to assess facial changes that occur as a result of orthognathic surgery, this study purposed analyze the three-dimensional (3D) laser surface scanning images pre- and post-operative. METHODS The subject's facial surface are routinely scanned by Minolta Vivid700 (Minolta, Ramsey, NJ, USA) from top to bottom with a projected class 2 laser stripe immediately before and two months after orthognathic surgery. 360º 3D images are created with the help of computer software (Polygon Editing Tools, Minolta Co). Cartesian coordinates (x, y, and z) from facial landmarks can be identified with the surface distance between them calculated using computer software (Launch Geomagic Studio 9, Geomagic Inc). The same software can be used to construct axial images of the head and to measure the area and volume of the head and face. RESULTS The results have confirmed that the laser scanning system used to capture facial morphology before and after orthognathic surgery provides additional information of the surface shape and the 3D superimposition reveals major soft tissue changes in the lower face. CONCLUSIONS The soft tissues changes of Class II and Class III malocclusions can be better understood and the routine use of 3D photographs for maxillofacial diagnosis, treatment planning, and assessment might not be very far away.

9:00 AM - 4:00 PM

A Novel Model for Evaluating the Anatomic and Physiologic Effects of Rhinoplasty

Presenter:	Brian S. Coan, MD
Co-Authors:	Emma Neff, BS, Jeffrey R. Marcus, MD
Affiliation:	Duke University Medical Center, Durham, NC

PURPOSE: The relationships between nasal anatomy, physiology and function are complex. Even small changes in mucosal surface configuration (from infection, inflammation, trauma or surgery) can dramatically change the cross-sectional area of the nasal passageway and similarly the resistance. Several basic science and clinical studies have demonstrated the effects of nasal surgery subjectively but only to a limited extent objectively. These studies are limited by active changes in the mucosa, which muddle perioperative interpretation of the effects of surgery. Additionally, rhinoplasty often involves multiple procedures, making it difficult to isolate and evaluate the effects of independent maneuvers. The purpose of this study is to develop a robust cadaveric model of biphasic nasal respiration, unhindered by mucosal activity that allows objective evaluation of surgical procedures and their effects.

METHODS: Ten unpreserved heads (average age 73) were tracheally intubated, retrograde through the neck, such that the balloon obstructed the nasopharynx at the level of the soft palate. The oral cavity was obliterated using alginate and the lips were sutured together, thus isolating airflow from the nasopharynx to the nasal ala. Tissue quality was preserved by routine rehydration with isotonic fluid. Nasal airflow was simulated using three different methods (ventilator – sinusoidal flow, regulated wall suction – strong inhalation, and regulated wall air – strong exhalation). These encompassed all pressure-flow relationships from laminar and turbulent flow to the unsteady extreme of nasal valve collapse. Acoustic rhinometry and rhinomanometry were used in each nostril to evaluate the cross-sectional area, nasal resistance, and pressure-flow relationships in the native state and after each controlled surgical intervention.

RESULTS: The average minimal cross-sectional area at the internal nasal valve was 0.91cm² (SD 0.2). At a pressure gradient of 0.5cmH2O across the nasal passage, the average resistance (cmH2O/L/s) was 2.47 (95CI 2.31, 2.62). At 1.0 cmH2O, the average resistance was 3.01 (95CI 2.79, 3.23) (Table 1). Measurements were repeated three times in each nare with an inter-measurement variability of <0.2%. Of the surgical maneuvers tested, a significant increase in cross sectional area (40%) was obtained with 2mm spreader grafts. Interestingly, a similar increase was noted with a Breathright™ strip (Chart 1).

CONCLUSIONS: This study completes the first step in objectively and quantitatively characterizing the physiologic effects of rhinoplastic procedures. The model is validated; it closely reproduces in-vivo nasal anatomy and physiology, allowing for the objective measurement of surgery on nasal airflow, resistance, and cross-sectional area without the complications of in-vivo mucosal fluctuations. The measured resistances and cross-sectional areas were consistent with age-adjusted in-vivo norms. This model provides a powerful tool for evaluating and comparing the isolated effects of various surgical techniques on the nose.

9:00 AM - 4:00 PM

A Randomized Clinical Trial Comparing a New Coaptive Film Device Versus Subcuticular Closure of Linear Incisions

Presenter:	Carolyn L. Kerrigan, MD
Co-Author:	Thomas Walsh, MSc
Affiliation:	Dartmouth Hitchcock Medical Center, Lebanon, NH

Purpose: Compare two closures for linear incisions: subcuticular suture (SCS) versus coaptive film (SteriStrip-S = SSS). Methods: Study design: Incisions were randomly assigned to SCS or SSS. Main outcome measures were time taken to closure and patient comfort. Closure time was recorded intraoperatively in minutes and seconds. Patient self-assessment of comfort was assessed, at 7-12 days postoperatively using a 10 cm VAS. Patient Sample: Patients undergoing bilateral Wise pattern breast reduction (BBR) or an abdominal procedure, TRAM or abdominoplasty (ABD), were eligible for participation. From February 2006 until December 2006 13 patients consented to participate, enrolled and completed the comfort survey. Statistical Analysis: Student T-tests were used to compare the main outcome measures. Results: Time: Thirty eight incisions segments were closed by SCS and 33 incisions by SSS. Mean time for closure was 5:59 min (sd = 3:01) and 2:28 (sd = 1:53) respectively. This difference was statistically significant, p<0.001. Patient Comfort: The mean comfort scores for SCS and SSS were 6.7 (sd = 2.0) and 6.8 (sd = 2.6) out of 10 on the VAS. This difference was not statistically significant, p = 0.918. Conclusions: SSS permits faster wound closure than SCS and patients find both approaches equally comfortable.

9:00 AM - 4:00 PM

A Retrospective Review of Complicated Scalp Injuries and Avulsions at a Level I Trauma Center

Presenter:	Brian A. Janz, MD
Co-Authors:	Marcus J. Ko, MD, Ramon Garza, BA, C. Bob Basu, MD, MBA, MPH, FACS
Affiliation:	Baylor College of Medicine, Houston, TX

Background: Scalp avulsions are relatively rare injuries but plastic and reconstructive surgeons are commonly called on to either acutely manage or assist with reconstructive management of these injuries. The types of injuries can range from a simple avulsion with an adequate blood supply to a complete avulsion necessitating a microvascular reconstruction or free tissue transfer for coverage. The type of reconstructive options for such an injury depends not only upon the type, size, and location of injury but also the available blood supply to the involved tissue.

Methods: The scalp avulsion data for this project was collected retrospectively at a major level I tertiary trauma center. The patient databases were queried using ICD-9 codes for both major scalp soft tissue injuries and scalp avulsion injuries. Charts were then evaluated to assure the diagnosis of either a major scalp soft tissue injury or a scalp avulsion. Data was collected to evaluate concomitant injuries, co-morbidities, emergency department and in-hospital resuscitation, definitive treatment, length of stay, outcomes, and complications. The patients were separated into different subsets dependant upon the type of injury and blood supply to the avulsed tissue. The injuries were classified as either Type I-A - Complex laceration, Type I-B - Scalp avulsion with a good blood supply and no tissue deficit, Type II - Scalp avulsion with a poor blood supply and/or a moderate tissue deficit, Type III - Complete avulsion of tissue and/or a large tissue deficit.

Results: A total of 76 patients were reviewed over an eight year period (1999-2006). 73.4% (n = 56) of the injured patients were males with a mean injury age of 43.3 years. The average age of injury for females was 31.5 years old. 53% (n = 38) of the injuries were related to motor vehicle crashes while the second most common cause was related to physical assaults, 34.6% (n = 26). The frontal region was involved in 40.4% (n = 29) of the injuries. Alcohol was a factor in over 30% of the patients (n = 23). Additional soft tissue injuries were noted 46.9% (n = 34) of the time and associated C-spine injuries were seen in 8.1% (n = 6) of the patients. Patients with Type I-A (n = 23) had an average laceration size of 6.7cm and were treated in the emergency department 100% of the time. Type I-B patients (n = 46) had an average avulsion area of 95.4 cm2 and were treated in the emergency department 80% of the time. Patients with Type II (n = 6) and Type III (n = 1) had more complex injuries with a tissue deficit or complete avulsion and were all treated either emergently or in a delayed fashion dependant upon their concomitant injuries. The overall complication rate was low at 3.9% (n =3) for all scalp injury types.

Conclusions: The injuries were able to be separated into the different avulsion types using a retrospective review of the charts. The vast majority of time, complex scalp injuries can be managed in the emergency department. More complex injuries with tissue deficits are less common and should be treated with either acute or delayed coverage dependant upon the severity of additional injuries. The overall complication rate was low for all scalp injury types.

9:00 AM - 4:00 PM

A Ten-Year Experience Using the 410 Biodimensional System in Breast Augmentations

Presenter:	Rogerio I Neves, MD, PhD
Co-Authors:	Katherine Au, MD, Garrett Vangelisti, MD, Andrew Kriegel, MD, Donald R. Mackay, MD
Affiliation:	Penn State Hershey Medical Center, Hershey, PA

A Ten-Year Experience Using The 410 Biodimensional System In Breast Augmentations

Introduction: With the recent FDA approval of silicone implants for augmentation mammoplasty, plastic surgeons and patients have a wider variety of implants to choose from. Although the newest generation of textured, anatomic, cohesive gel implants were introduced in 1993, they are not yet approved for use in the United States. These implants have been widely used in Brazil since 1996.

Purpose: The aim of this retrospective study was to evaluate the clinical results after using the McGhan Style 410, anatomic, cohesive gel implants for breast augmentation.

Patients and Methods: Five hundred and twenty-eight breast augmentations were performed on 266 patients by a single surgeon in Brazil from January 1997 to November 2006. These included 260 bilateral breast augmentations, and 6 unilateral augmentation procedures to treat breast asymmetry. Primary augmentation was performed in 243 patients, and implants were exchanged in 23 patients. The primary indications were post partum breast involution and/or micromastia. Patient ages ranged from 16 to 61 years (median 29 years). Follow-up ranged up to 5 years.

Operations for 241 patients (90.6%) were performed under local anesthesia with sedation, while 25 patients (9.4%) had their procedures performed under general anesthesia. The implant sizes ranged from 150cc to 375cc (median 300cc, mean 310 cc).

All patients were evaluated preoperatively with the Tebbetts "patient evaluation and operative planning sheet". Implant size was determined by the surgeon and patient, paying attention to her wishes and expectations, while considering her body dimensions and breast skin laxity. Placement of implants was subglandular in 85% of cases. Submuscular placement was chosen when the thickness of the pinched skin and subcutaneous tissue of the upper pole was less than 2cm. The incision was submammary in 98% of the patients.

Results: The postoperative course was uneventful in 97% of the patients. Eight patients had post operative complications. These included patients with implant rotation (2), seroma (1), hematoma (2), and visible rippling (3). All complications were managed successfully, without implant loss. In these patients, good final results were obtained. Capsular contracture (Baker I and II) was found in 1.5% of the operated breasts.

Conclusions: The McGhan Style 410 anatomical, cohesive, silicone gel implant for breast augmentation is an implant that looks and feels like a breast. Its dimensional shape produces a more natural and refined result, without the unnatural upper pole bulging commonly seen in round implants. Base width, height, and projection are variable, facilitating an aesthetic improvement in a wider range of breast types.

9:00 AM - 4:00 PM

Abdominal Etching: Clinical and Technical Measures for Achieving Predictable Outcomes

Presenter:	Aldo B. Guerra, MD
Affiliation:	Guerra Plastic Surgery Clinic, Scottsdale, AZ

9:00 AM - 4:00 PM

Abominoplasty and Intra-Abdominal Surgery: Safety First

Presenter:	Jacob M.P. Bloom, MS
Co-Authors:	Alvin B. Cohn, MD, Benjamin Schlechter, MD, FACS, Nancy Davis, MA, Loren S. Schechter, MD, FACS
Affiliation:	The Chicago Medical School, Chicago, IL

Purpose: Abdominal plastic surgery procedures are commonly requested by patients undergoing intra-abdominal surgery. Although motivated by the desire to avoid a second anesthetic and minimize recovery time and cost, patient wishes must be balanced against a potential increased risk of complications. This retrospective case series examines two surgeon's six year experience with 114 patients undergoing 1) abdominal plastic surgery procedures performed in conjunction with either gynecologic or general surgery operations 2) abdominoplasty in conjunction with other cosmetic plastic surgery procedures and 3) patients undergoing abdominoplasty alone. This retrospective series was designed to assess our complication rates in procedures combining abdominal plastic surgery and intra-abdominal surgery as well as how these complication rates compared to standard plastic surgery procedures.

Materials and Methods: All 114 plastic surgery procedures were performed by the two senior authors between February 2001 and February 2007. Group 1 consisted of patients undergoing abdominoplasty in conjunction with either gynecologic or general surgery procedures, Group 2 consisted of patients undergoing abdominoplasty in conjunction with other cosmetic plastic surgery procedures, and Group 3 consisted of patients undergoing abdominoplasty alone. The groups were assessed for complication rates (both the presence of complication as well as subdivided into major and minor) as well as variables thought to be associated with increased complication rates such as BMI, tobacco use, and ASA status.

Results: Group 1 consisted of 49 patients (43 female, 6 male, mean age 46 ± 9 years, BMI 31 ± 8, ASA 1.8 ± .6 Group 2 consisted of 21 patients (19 female, 2 male, mean. age 43 ± 11 years, BMI 27 ± 5, ASA 1.4 ± .6), and Group 3 consisted of 44 patients (44 female, 0 males, mean age 44 ± 11years, BMI 28 ± 7, ASA 1.5 ± .7). 73 procedures were performed on an inpatient basis (46 from Group 1, 9 from Group 2, and 14 from Group 3), and 41 procedures were performed on an outpatient basis (3 from Group 1, 12 from Group 2, and 30 from Group 3). A total of 20 complications (2 major, 18 minor) were identified. 15 complications (all minor) occurred in the first group, 3 complications (2 major, 1 minor) occurred in the second group, and 2 complications (both minor) occurred in the third group. Major complications included a secondary surgical procedure for revision liposuction and fat grafting in one patient, and a revision liposuction secondary to mechanical failure of the liposuction machine in the second patient. There was a statistically significant increase in the overall complication rate of patients in group 1 as compared to groups 2 and 3 (p=.004), as well as a statistically significant increased risk of complications in patients with a BMI > 30 (p=.011) regardless of group. In addition, males had a statistically significant higher incidence of complications (p<.001). ASA status and tobacco use were not associated with an increased risk of complications.

Conclusion: Although the results of this study suggest that combining abdominoplasty with general or gynecological surgery increases the overall complication rate, the complications were self-limited and treated with either minor office procedures under local anesthesia or local wound care. In addition, this study supports a higher complication rate in obese patients. With appropriate patient selection and pre-operative counseling, combined abdominal plastic surgery and intra-abdominal operations may be performed safely.

9:00 AM - 4:00 PM

Aging Mid-Face: Assessment and Proposed Management – Inter-rater Reliability and Concordance

Presenter:	Ali Hazrati, MD, MSc
Co-Authors:	Daron Geldwert, MD, Khang T. Nguyen, MD, James J. Chao, MD, Amanda A Gosman, MD, Marek K. Dobke, MD, PhD
Affiliation:	University of California, San Diego, San Diego, CA

Introduction: Differences between professionals assessing the aging mid-face, including proposed management vary. To obtain some insight into the nature and the extent of variable opinions, the study on inter-rater reliability and concordance was designed.

Material and Method: Photographic images of forty standardized patients were presented to 6 senior board certified plastic surgeons (over 6 years in independent practice), to 6 junior non-board certified plastic surgeons (less than 3 years in practice) and to 6 plastic surgery residents for their assessment of nasolabial fold, cheeks, perioral area and delineation of management priorities.

Results: The reliability of each item was calculated using percent agreement and the kappa coefficient. Total percent agreement ranged from 62% in the resident group to 63% in the junior plastic surgeons and 90% in the senior plastic surgeons on assessment and 73%, 75% to 95% on management in respective groups.

Conclusions: Study findings indicated that the most senior plastic surgeons' assessments had the highest level of concordance while the junior plastic surgeons and the resident groups produced variations with less regularity. Such discrepancies are expected and critical in a teaching centre as the education should focus on this aspect of care.

9:00 AM - 4:00 PM

A modified reverse U Method for Correction of Unilateral Cleft-lip Nose Deformity: Long-term Follow-up and Assessment

Presenter:	Keisuke Imai, MD, PhD
Co-Authors:	Akira Yamada, MD, Kuniyuki Morimoto, MD, Hiroshi Matsumoto, MD, Heishiro Fujikawa, MD
Affiliation:	Osaka City General Hospital, Nara

9:00 AM - 4:00 PM

Anatomy and Clinical Study of the Postauricular Fascia in Rhinoplasty

Presenter:	Aldo B. Guerra, MD
Co-Author:	Stephen E. Metzinger, MD
Affiliation:	Guerra Plastic Surgery Clinic, Scottsdale, AZ

9:00 AM - 4:00 PM

Assessment of Acute Safety at 2 Weeks in Subjects Injected Implanted with Hyaluronic Acid Gel Dermal Fillers

Presenter:	Jeffrey Dover, MD, FRCPC
Co-Author:	Mark Rubin, MD
Affiliation:	SkinCare Physicians, Chestnut Hill, MA

Purpose: This study assessed acute safety profiles at 2 weeks among participants in clinical study evaluating the safety and efficacy of the hyaluronic acid gel dermal fillers, Perlane® and Restylane®. Methodology: A 24-week randomized, comparative, blinded-patient and blinded-photographic evaluator, baseline-controlled clinical study was conducted to assess the safety, immunogenicity, and efficacy Perlane® and to expand upon the available data about the safety, immunogenicity, and efficacy of Restylane®. Acute safety assessments were based upon local adverse experiences that occurred in the two weeks following the first injection. Acute safety data were acquired from two sources: patient diaries and investigator evaluation. Patients were specifically asked to respond to the existence (e.g., “none”) of bruising, redness, swelling, pain, tenderness, itching and mass formation (abscess, cyst or nodule) and, if so, their extent (tolerable, affects daily activities, disabling). Investigators evaluated adverse experiences at 72 hours and 2 weeks after initial injection through observation and patient interviews (independent of diary content). Results: 282 subjects (Restylane®, n=142; Perlane®, n=141) were evaluated over the full study period; 1 was lost to follow-up. Demographic and baseline characteristics were similar in both groups. Investigators classified most acute adverse local reactions as mild; none of the investigators rated any acute local reaction as severe. Investigator identification of acute local reactions included short-lived ecchymosis, edema, erythema, tenderness or pain, and, occasionally, itching; most had resolved in two weeks. Over the acute 2 week period, patient diary complaints included bruising, redness, swelling, tenderness, and pain; itching was less common. Most patient complaints occurred within the first three days after implantation, before the first investigator visit. The majority of complaints were classified as tolerable by most patients. The mean duration of the local adverse experiences varied from 2 to 5 days; the majority resolved before the end of the diary period. There was no clinically-meaningful difference in severity, type, duration, or onset of adverse experiences between Perlane® and Restylane®. Conclusions: The acute safety profiles of Perlane® and Restylane® were the same. Acute safety reactions were primarily mild-to-moderate and short-lived; the majority resolved within two weeks. There were no unexpected acute local reactions.

9:00 AM - 4:00 PM

Assessment of Adverse Experiences, Keloid Formation and Pigmentary Changes in Subjects with Fitzpatrick Skin Types 4, 5, or 6 Injected with Hyaluronic Acid Gel Dermal Fillers

Presenter:	Susan Taylor, MD
Co-Author:	Cheryl Burgess, MD
Affiliation:	St. Luke’s-Roosevelt Hospital Center, Philadelphia, PA

Purpose: One of the purposes of this study was to identify the incidences of local adverse events, keloid formation and dermal pigmentary changes following injection of hyaluronic acid gel dermal fillers in subjects with Fitzpatrick Skin Types 4, 5, or 6. Methodology: A randomized, comparative, blinded-patient and blinded-photographic evaluator, baseline-controlled clinical study of the safety and efficacy of Restylane® and Perlane® enrolled subjects with Fitzpatrick Skin Types 4, 5, or 6 (majority of subjects were African-American). Subjects were implanted with both study products in the nasolabial fold (and oral commissures as necessary). One side of the face was randomly assigned to implantation with Perlane®; the opposite side was implanted with Restylane®. Physician assessments were done at 3 days and 2, 6, 12, and 24 weeks for adverse experience, evaluation of skin pigmentation changes, and keloid formation. Subjects maintained diaries for 2 weeks following initial implantation; recorded complaints were included in the safety assessment. Results: One hundred and fifty patients (female, n=140; male, n=10) were evaluated. Fitzpatrick Skin Type distribution was: Type 4, 29.3%; Type 5, 45.3%; Type 6, 25.3%. One hundred and three treatment-related, site specific, local adverse experiences were reported. More than 90% of reported local reactions related to bruising, tenderness, edema, redness, itching, pain, and pigmentary changes. Pigmentary changes occurred in 5% to 7% of injection sites (Perlane®; n=24; Restylane®, n=15). Twenty-three subjects (Perlane®; n=9; Restylane®, n=14), had pigmentation changes at the nasolabial fold or oral commissures; all were mild or moderate in severity and resolved within 12 weeks. No keloids were reported during the study. The incidence, severity, and duration of adverse experiences were as expected and consistent with the known profiles of hyaluronic acid gel dermal fillers. Restylane® and Perlane® did not differ in the incidence and severity of adverse experiences. Conclusions: Perlane® and Restylane® were safe and effective at correction of facial folds and wrinkles, including the nasolabial folds, in subjects with Fitzpatrick Skin Types 4, 5, or 6. No unexpected adverse experiences were reported. Pigmentary changes occurred in 5% to 7% of injection sites and were mostly moderate to mild and transitory (up to 12 weeks). No subject developed keloids during the study.

9:00 AM - 4:00 PM

Assessment of Complications and Outcomes in the Use of the Distally-Based Sural Lesser Saphenous Neuro-Veno-Adipo-Fascial (NVAF) Flap in Lower Extremity Reconstruction

Presenter:	Samuel V. Bartholomew, MD
Co-Authors:	Michael S. Wong, MD, Kamlesh Patel, MD, James Kim, MD, Thomas P. Whetzel, MD, Eiler Sommerhaug, MD, Albert Oh, MD, Brad Nanigian, MD, Ali Salim, MD, Thomas R. Stevenson, MD
Affiliation:	University of California, Davis Medical Center, Sacramento, CA

Objective: The distally based sural lesser saphenous NVAF flap has been used with increasing frequency at our institution for reconstructing wounds of the foot, ankle, and distal one-third of the lower leg. The objective of this study is to review our experience with this flap in a variety of clinical situations, assess the complications associated with its use, and finally judge the functional outcome of this type of reconstruction.

Methods: A retrospective review was conducted of all NVAF flaps performed over a period from October 2000 through January 2007. Data were collected in regards to patient demographics, associated comorbidities, mechanism of the lower extremity wound, technical details of the operation(s) performed, postoperative complications, length of follow-up, and clinical outcomes with respect to healing and ambulation.

Results: During the study period, the NVAF flap has been used by four surgeons in the reconstruction of lower extremity defects in 34 patients. The locations of the wounds were diverse (13 wounds of the distal 1/3 of the lower leg, 12 ankle wounds, 3 heel wounds, and 6 foot wounds), as were the ages of the patients at the time of surgery (mean age 40.5 years, range 4-89 years). Traumatic wounds were the primary indication for reconstruction in 22 patients. Six patients presented with chronic osteomyelitis requiring resection of diseased bone, removal of hardware when necessary, and soft tissue coverage with the NVAF flap. Five patients suffered from malignant neoplasms necessitating radical resection, and 1 patient had a non-healing wound with exposure of tibia in the face of severe peripheral vascular disease. Complications were frequent, occurring in 17 (50%) of our 34 patients. Nine major complications occurred in 5 (14.7 %) patients. A major complication was defined as leading to total flap loss or amputation. Overall, 3 (8.8%) patients with a major complication went on to amputation. Of these, 1 had total flap loss and infection acutely; 1 had infection, total flap loss and hematoma; and the third had chronic osteomyelitis requiring amputation 10 months after the NVAF flap. Two patients with major complications were salvaged. One patient had late flap loss secondary to radiation therapy 10 months after the index operation. He was salvaged with radial forearm free flap to the leg. One child with traumatic wounds with post operative total flap loss and infection was salvaged with skin grafts. Seventeen minor complications occurred in 12 (35.3%) patients, often with multiple complications occurring in the same patient. Six (17.6%) patients suffered from partial flap loss. Three (8.8%) hematomas requiring evacuation were noted. Skin graft loss occurred in 5 (14.7%) patients and 3 (8.8%) minor infections were seen. Mean follow-up was 10.2 months (range 0 days to 48 months). One patient expired from cardiac disease during the study period. There is inadequate follow-up data on 4 patients to judge the success in return of ambulation. One patient died from unrelated causes one month after surgery. Three patients underwent amputation. Of the remaining 26, 18 (69.2 %) patients had healed wounds and were ambulating without assistance at their last follow-up visit. An additional 6 (23.1 %) patients had healing wounds and were walking with either a cane or walker. Two (7.7 %) patients are currently non-ambulatory, one has severe arthritic pain and the other has significant bony loss of the tibia requiring bone grafting prior to any attempts at weight bearing.

Conclusion: The NVAF flap remains our local flap of choice in treating difficult wounds of the distal one-third of the lower leg, ankle, heel, and foot. Major complications are uncommon (14.7%). However, minor complications are seen fairly frequently (35.3%). Despite this, healed wounds may consistently be obtained, along with the return of ambulation in the majority of patients following salvage of the lower extremity.

9:00 AM - 4:00 PM

Assessment of Tracheo-bronchial anomalies in patients with Syndromic craniosynostosis

Presenter:	Hiroshi Matsumoto, MD
Co-Authors:	Keisuke Imai, MD, Akira Yamada, MD, Kuniyuki Morimoto, MD, Heishiro Fujikawa, MD, Hiroaki Sakamoto, MD, Tomoaki Nakano, MD
Affiliation:	Osaka City General Hospital, Osaka

Patients with syndromic craniosynostosis have the problems of the upper airway, the laryngotracheal airway and the tracheo-bronchial tree. Accurate diagnosis is very important in the evaluation of tacheo-bronchial disorder of syndromic craniosynostosis. In this study the configuration of the tracheo-bronchial system is assessed on CT and with a bronchoscope. For four years since 2002, 23 patients with syndromic craniosynostosis have undergone gradual distraction at Osaka City General Hospital. Of those, 8 cases had tracheostomy. Seven cases of syndromic craniosynostosis were examined a 3-dimentional CT of the tracheo-bronchial system and a bronchoscope. One case had to be excluded because of lack of CT records. In three cases 3 dimensional CT images and bronchoscopic findings revealed sever tracheo-bronchial stenosis. In two cases bronchoscopic findings showed tracheal cartilaginous sleeve and 3-D CT images had no finding. Two cases had no findings on these examinations. It was possible that the configuration of the tracheo-bronchial system was accurately diagnosed by the examination of both 3-D CT and a bronchoscope. It is suggested that these examinations are very useful to assess the timing of the decanulation and prognosis of respiratory function.

9:00 AM - 4:00 PM

Assessment of the Effect of Injection Techniques on the Rate of Local Adverse Events When Using Hyaluronic Acid Gel Dermal Fillers

Presenter:	Richard G. Glogau, MD
Co-Author:	Michael A. C. Kane, MD
Affiliation:	University of California, San Francisco School of Medicine, San Francisco, CA

Purpose: The purpose of this study was to evaluate the effect of injection technique on the occurrence of local adverse events during implantation of hyaluronic acid gel particle fillers. Methodology: A prospective, controlled study randomly assigned 283 ethnically-diverse subjects with moderate-to-severe nasolabial folds (NLFs) and marionette lines to receive midface injections of one of two lightly-crosslinked hyaluronic gel fillers: Restylane® (smaller gel particles) or Perlane® (larger gel particles). Investigators could use different injection techniques for this study. Touch up treatments were allowed at 2 weeks. Subjects were assessed for local adverse events (e.g., erythema, ecchymosis, edema, itching, pain, tenderness) at 72 hours and at 2, 6, 12, and 24 weeks. Data collected included physician experience, time taken to correct a specific wrinkle (NLF or marionette line), depth of injection, volume used to correct a specific wrinkle, number of injection sessions required to correct a specific wrinkle (initial and/or +/- 2-week touch-up), investigator method of injection (linear threading [push or pull], multiple puncture, or use of fanning needle after dermal penetration). Per the statistical analysis plan, assessment variables were pre-assigned a correlate to the rate of local adverse events. Results: 282 subjects (Restylane, n=142; Perlane, n=141) were evaluated over the full study period; 1 was lost to follow-up. The rate of adverse events was not significant at any time point for: the number of sessions required to correct a specific wrinkle, years of physician experience, or Perlane vs. Restylane. Based upon these initial results, the remaining variables were evaluated using pooled data and logistic regression. Increased safety was significantly associated with the avoidance of fan-like injection, lower volumes per site, and slower injection technique (p<0.0001). Due to the linear relationship between volume and time and the interrelationship of their effect, volume/time was added to the logistic regression in order to assess the impact of flow on adverse reactions. Because flow was not directly measured, the analysis was restricted to flow rates below 1.4 mL/min, which prevented the masking of episodic high flows by overall long injection periods. Flow rates below 0.3 mL/min were found to significantly reduce local adverse events (odds ratio<0.3). Conclusions: The product safety profiles of two hyaluronic acid gel fillers (Restylane and Perlane) were identical. The number of sessions required to correct a specific wrinkle, years of physician experience did not affect the rate of adverse reactions. Injection technique (i.e., fan-like injection or use of high flow rates) that dissected the sub-epidermal plane increased the rate of local adverse events.

9:00 AM - 4:00 PM

Autologous Breast Reconstruction: The Vanderbilt Experience 1998-2005, Independent Predictors of Displeasing Outcomes

Presenter:	Joseph A. Greco, MD
Co-Authors:	Eric Castaldo, MD, Evelyn Wu, MS, Rafe Donahue, PhD, Lillian Nanney, PhD, J. Jason Wendel, MD, Kevin F. Hagan, MD, R. Bruce Shack, MD
Affiliation:	Vanderbilt School of Medicine, Nashville, TN

Purpose: In today's society, more patients than ever before seek reconstruction following breast cancer resection that provides aesthetically acceptable results with minimal risk for unfavorable outcomes. Optimized surgical planning and informed consent is dependent on an appreciation for co-morbid conditions that may handicap the reconstructive result. Therefore, the purpose of this institutional review is to delineate independent risk factors for complications following autologous breast reconstruction. Methods: An institutional database was constructed via electronic medical record for all patients who underwent autologous breast reconstruction from 1998 through 2005. Demographic variables captured included: patient age, diabetic and smoking status, pre-reconstruction radiation therapy (XRT), concomitant breast resection, pre-operative albumin level, and the type of reconstruction (Latissimus Dorsi (LD) versus TRAM). BMI was treated as a continuous variable and also categorized based on WHO classifications (BMI >25 = overweight, >30 = obese). The primary outcome was presence or absence of a non-infectious wound complication (NIWC), which is a novel classification of wound problems based on the extent of tissue derangement and the need for escalating surgical correction (see table image). Secondary outcomes were infection, hematoma, hernia (for TRAMs), and fat necrosis. A Cox regression model was tested with the preceding variables serving as controlled co-variates. Results: The analysis included 200 flaps in 180 patients (171 TRAM & 29 LD). Of the TRAMs, 87% were unipedicled, 7% bipedicled, 5% free, & 1% delayed. LDs were almost entirely performed with either tissue expanders or implants. Of the 200 total flaps, there were 19 infections (9.5%), 3 total flap losses (1.5%), 14 hematomas (7%), and 11 donor-site hernias (6%). The incidence of fat necrosis and any NIWC was 18% and 36% respectively. Mean follow-up interval for all patients was 13.1 months (range 1.1-51.7 months). Cox regression demonstrates that BMI > 30 is a statistically significant independent risk factor for any NIWC (HR = 6.58; 95% CI 2.85 ¨C 15.18; p < 0.01) and for NIWC requiring operative treatment (NIWC °Ý 3) (HR = 6.23; 95%CI 2.15 ¨C 18.05; p < 0.01). When treated as a continuous variable in the regression model, BMI is a significant risk factor for NIWC (p <0.01), NIWC requiring operative intervention (p < 0.01), and for culture positive infection (p < 0.01). No other variable including age, diabetes, or smoking served as an independent indicator for any undesirable outcome in this regression model. Conclusions: These data suggest that BMI is a strong predictor of non-infectious wound complications both simple and complex, and of infection following autologous breast reconstruction after adjusting for all other variables in the model. Patients who are obese should be counseled regarding their significantly increased risk of experiencing these unwanted complications.

9:00 AM - 4:00 PM

Biomechanical and Histological Evaluation of Norian CRS and Norian CRS Fast Set Putty in the Long-term Reconstruction of Full-thickness Skull Defects in a Sheep Model

Presenter:	Andrea Moreira Gonzalez, MD
Co-Authors:	Anand Parikh, MS, Thomas Bauer, MD, PhD, Maria Siemionow, MD, PhD, James E. Zins, MD
Affiliation:	The Cleveland Clinic, Cleveland, OH

Purpose: To investigate the long-term (12 month) strength and osteoconductive properties of two forms of carbonated calcium phosphate cements (Norian Cranial Reconstruction System [CRS] and Norian CRS Fast Set Putty [FSP]) and to compare these two bone cement forms to an autogenous cranial bone graft in a full-thickness skull defect adult sheep model. Method: This is an experimental animal study in which 26 sheep were assigned to one of eight groups (n=3/group). A 4.5cm2 full-thickness defect was created in the right and left parietal bones respectively. Reconstruction was performed with a full-thickness cranial bone autograft, CRS, or FSP (Figure 1). For bone cement reconstructions of the full-thickness skull defects a titanium mesh was molded to ft the defect contour and then fixed using micro screws to the surrounding superficial surface of the native bone. Wound closure was performed once the material was completely dry (20 min for CRS and 5 min for FSP, at 370C.) Skull samples were harvested at day 1, 6 months and 12 months. Histologic samples were embedded in Spur's Plastic and stained with hematoxylin & eosin (H&E). Biomechanical testing was performed using a vertical drop test, as established by the American Society of Testing and Materials (ASTM). For statistical analysis the peak force transmission (N) - energy absorption of the reconstruction during fracture, the peak acceleration (g) - maximum negative acceleration of the impacting anvil which yields the force required to fracture the cranial reconstruction, the displacement at the impact region of the skull and time to peak acceleration (mm) were recorded. One factor ANOVA (p<0.05) was used to analyze the strength of each reconstruction. Results: Bone grafts were completely incorporated. Although CRS and FSP fully osseointegrated, there was little osteoconduction into the center of these bone cement implants at 12 months. At time zero, there were no significant differences in peak acceleration (p=0.1577) or peak force transmission (p=0.6105) between bone graft, CRS and Fast Set Putty. At one year, significant differences were observed among the three groups. The first generation CRS had the lowest peak acceleration when compared to the Fast Set Putty and bone graft (p< 0.0001) (Figure 1). CRS also showed a decrease in peak force transmission over time, being the weakest of the three reconstructions. The FSP demonstrated a statistically significant increase in both peak acceleration and peak force transmission at 6 months. At one year, FSP was significantly stronger than the CRS (p=0.005), but not as strong as the autogenous cranial bone graft or intact bone (approximately 100% strength) (Figure 2). Cranial bone grafts behaved similar to intact bone and were significantly stronger than CRS and FSP (p<0.0001). At one year, both CRS and FSP cements demonstrated excellent osteointegration and extensive bone apposition with no sign of inflammatory reaction on either the dural or periosteal surfaces. New bone formation could be observed at the bone-cement interface, on the dural and on the periosteal surfaces of the cements. Only a small proportion of the overall volume of cement was resorbed and replaced with bone during the study period. There was almost no osteoconduction into the center of the constructs and osteoconduction appeared to occur only along fracture lines in the cement. Conclusion: CRS progressively lost strength over the course of this study. FSP demonstrated greater strength and rigidity then CRS. Both implants had limited bone ingrowth from defect borders but both cements completely osteointegrated. Bone grafts regained biostructural characteristics and strength similar to intact bone and clinically performed the same in this sheep model.

9:00 AM - 4:00 PM

Bioterrorism: Preparing the Plastic & Reconstructive Surgeon

Presenter:	Devinder P. Singh, MD
Affiliation:	University of Maryland School of Medicine, Baltimore, MD

BACKGROUND Many medical disciplines, including emergency medicine, trauma surgery, dermatology, psychiatry, family practice, dentistry and nursing have all documented attempts at assessing their own level of bioterrorism preparedness. There is neither such an assessment nor an existing review of bioterrorism agents as they relate to plastic surgeons. The purpose of this paper is to prepare the plastic surgeon for a potential bioterrorism incident.

METHODS: A systematic review of peer-reviewed literature on bioterrorism agents as well as a review of the Center for Disease Control (CDC) online resources was conducted. “Category A” agents were identified. Specific attention is paid to management issues that plasticsurgeons may face for each agent.

RESULTS: Disease entities reviewed were Anthrax, Smallpox, Plague, Viral Hemorrhagic Fever, Tularemia, and Botulinum toxin. For each agent, pathophysiology, presentation, weaponization, medical management, vaccination, and surgical issues related to plastic surgery are presented.

CONCLUSIONS: This paper represents the first attempt at addressing bioterrorism preparedness amongst plastic surgeons. A brief glance at peer-reviewed resources indicates that many other fields have already started a similar process. Eventually, our leadership will be called upon to develop evidence-based consensus guidelines for the management of bioterrorism, and this paper is a first small step in that direction.

9:00 AM - 4:00 PM

Composite Reconstruction Following Complex Ankle Avulsion Injury in a 3-Year Old

Presenter:	Pirko Maguina, MD
Co-Authors:	David Morris, MD, Mark Grevious, MD
Affiliation:	University of California Davis, Sacramento, CA

We describe our experience with the use of distally based superficial sural flap for cover of a defect in the lower leg and foot in a 3-year-old patient. The flap was used as a fasciocutaneous flap and resulted in quick, straightforward closure of a large soft tissue defect with prompt recovery. The patient was discharged home within 5 days of surgery. The advantages of this flap are: easy and quick dissection, low morbidity of donor site and preservation of major arteries of the leg. It allowed us to avoid the technical challenges associated with microsurgery in a small child and the postoperative care was simple, obviating the need for postoperative sedation, ICU care or close monitoring. Two dressing changes were performed in the hospital before the patient was allowed to return home. We present the experience with this case to illustrate what we consider an excellent aIternative to free flaps for covering lower leg and foot defects in small children. The use of reverse sural flap in small children is technically easy to perform, provides very good flap and donor site results and simplifies the postoperative care.

9:00 AM - 4:00 PM

Cutaneous Sarcoidosis Mimicing Nasal Skin Tumor: Lupus Pernio

Presenter:	Furkan Erol Karabekmez, MD
Co-Authors:	Ahmet Duymaz, MD, Mehtap Karamese, MD, Mustafa Keskin, MD, Zekeriya Tosun, MD, Nedim Savaci, MD
Affiliation:	Selcuk University, Konya

Lupus pernio (LP) is the most characteristic lesion of sarcoidosis that occurs most commonly on the nose, perioral region, ears, fingers, and eyelids. Lesions are violaceous, indurated plaques that resemble those seen in persons with an acute cold injury and rarely appear as the initial symptom of systemic sarcoidosis. 65 years old women admitted to hospital for unhealed wound in her nose. Patients had two years history of wound in her nose. Ulserated, irregular , indurated plaque which was 2x3 cm size found on her examination. Biopsy was taken, and pathological examination revealed similar findings with granulomatous disease. Therefore, computerized tomography of the lung was revealed pleural thickness, pleuroparanchimal fibrotic changes, and perivascular lenfadenopathies and than patient has been consultated to internal medicine department. Oral corticosteroid therapy was begun to patient who was diagnosed as the sarcoidosis and lasted for three months. The lesion was excised and defect was reconstructed with full thickness skingraft because there was no regression of lesion. After six month follow we obtained an acceptable aesthetic outcome obtained. LP on the nose which particularly in patients do not already have a sarcoidosis diagnose easily misdiagnosed as malign skin tumor. In this case report a patient with a nasal LP mimicking skin tumor was presented and the role of a plastic surgeon was discussed in the treatment of LP.

9:00 AM - 4:00 PM

DERMABOND®-assisted Primary Closure of Atrophic Skin

Presenter:	Michael Bain, MD, MMS
Co-Authors:	Emily A. Peterson, MD, Robert X. Murphy, MD, MS
Affiliation:	NA, Newport Beach, CA

DERMABOND® (2-octyl cyanoacrylate, Ethicon, Inc., Somerville, NJ) is a cutaneous adhesive which has been utilized in elective closure of head and neck incisions and closure of skin lacerations in the emergency setting. There exists a population of patients who, for a number of reasons, including age, chronic steroid use, avulsive injuries, and other factors, present to the emergency department with thin skin that lacks sufficient tensile strength to support suture closure. We present a novel technique employing DERMABOND® for closure of skin lacerations in those patients. DERMABOND® is applied 3 mm from the wound margins, allowed to dry, and then serves as a buttress against which sutures may be placed. In conjunction with adherence to surgical standards of wound decontamination and debridement, this technique has provided excellent results without complications.

9:00 AM - 4:00 PM

Destiny of Hemangioma on Cleft Lip

Presenter:	Soo Jong Choi, MD
Co-Authors:	Yong-Chan Bae, MD, PhD, Su-Bong Nam, MD
Affiliation:	Pusan National University, Pusan

Purpose : A case of a cleft lip complicated by a hemangioma involving a vermilion on the cleft side is very rare. We have experienced a three month-old boy with a left unilateral complete cleft lip, complicated by a vermilion hemangioma. The Operative design for cleft lip repair crossed the vermilion hemangioma. Decision of surgical management between a total excision of hemangioma and a desirable cleft lip repair had to be established. Materials and Methods : A three month-old boy with a left unilateral complete cleft lip and submucous cleft palate complicated by a hemangioma involving a vermilion on the cleft side. Moreover, multiple hemangiomas involved chin, right periauricular region, and left shoulder. The preoperative design using a small triangular flap for the cleft lip repair crossed the vermilion hemangioma. We focused more on the desirable cleft lip repair than the total excision of hemangioma on vermilion. The repair of the cleft lip was undertaken in accordance with the previously planned design. Results : The vermilion hemangioma was partially left behind while the cleft lip was repaired. No complications, such as postoperative ulceration and bleeding, were noted. The remaining hemangioma on vermilion did not influence the healing of the repaired cleft lip wound, and has almost involuted during next few years. As a result, the repaired cleft lip has shown satisfying shape and contour. The pathology report confirmed a capillary hemangioma. Multiple hemangiomas had almost involuted as in the case of the remaining hemangioma on vermilion. Conclusion : We suggest to conduct a desirable cleft lip repair rather than performing a excision of hemangioma in cases of modest hemangioma(no life-threatening bleeding) on a operative field for a cleft lip repair. We report this case as it may be considered as a management guideline for similar cases.

9:00 AM - 4:00 PM

Developing a Microsurgery Program at a County Hospital: The Initial 4 year Experience

Presenter:	T. Minsue Chen, MD
Co-Author:	Erik S. Marques, MD
Affiliation:	University of Texas- Houston / Health Science Center - MD Anderson Cancer Center, Houston, TX

Introduction: Typically, a successful microsurgery program requires sufficiently large volume of cases, surgeons with microsurgical expertise, experienced OR support staff, state of the art equipment, and nurses familiar with postoperative monitoring. Four years ago, our county hospital did not meet these standards, and most patients requiring microsurgical reconstruction were transferred to a larger, Level I trauma center. Expanding the scope of our practice to meet the hospital's need for microsurgery led to the following question: can a small county hospital that infrequently performs microsurgery achieve similar success rates as larger institutions that regularly provide the service?

Purpose: The purpose of this study is to review the initial 4 year experience of microsurgical reconstruction performed at a small county hospital.

Materials and Methods: We conducted a retrospective study of all microvascular cases (free tissue transfer, microvascular repair, and replantation) performed during the past 4 years (3/2003- 3/2007) under the supervision of a single attending plastic surgeon who possesses expertise in microsurgery.

Results: Our hospital is a Level III trauma center with a total of 6 operating rooms and 1 full time equivalent plastic surgeon on staff. Over the past 4 years, we attempted to develop a microsurgery program at our hospital, including microsurgical equipment purchase and training both OR personnel and nursing staff on the wards. During the study period, 31 patients underwent 37 microvascular procedures: 16 free flaps, 1 replant, and 20 microvascular repairs. Follow up ranged from 1 to 18 months.

Free flaps—The majority of free flaps were performed for soft tissue coverage of extremity trauma (9/16; 56%) which included: 4 radial forearm flaps, 3 rectus abdominis muscle flaps, and 2 latissimus dorsi muscle flaps. 2 VRAMs and 1 radial forearm flap were required for head and neck oncologic reconstruction (3/16; 19%). 3 Free TRAM flaps were done for unilateral breast reconstruction (3/19; 19%). A 2nd toe transfer for post-traumatic thumb reconstruction was also performed. Monitoring of all microvascular procedures was by clinical exam. None of the free flaps required reexploration. There was no flap loss. Donor site morbidity was minimal.

Replants—One replant was successfully performed (dominant thumb amputated at IP joint level).

Microvascular repairs—20 microvascular repairs were performed: 11 ulnar and/or radial artery, 5 common digital artery, and 4 digital artery repairs. None of the replanted or revascularized digits / hands required postoperative exploration, and all survived. There were no major complications.

Conclusions: Although microsurgery is performed infrequently at our county hospital, we have a success rate that parallels that of a larger center that routinely performs microsurgery. Our study demonstrates that it is feasible for smaller hospitals to develop a microsurgery program. We continue to provide microsurgical reconstruction for patients at our county hospital as part of our plastic surgery practice.

9:00 AM - 4:00 PM

Distraction Rate and Latency: Factors in the Outcome of Pediatric Maxillary Distraction

Presenter:	Patrick Cole, MD
Co-Authors:	Stephen Higuera, MD, Larry H. Hollier, Jr, MD
Affiliation:	Baylor College of Medicine, Houston, TX

BACKGROUND/PURPOSE: Over 50 years ago, current tenets of distraction osteogenesis were developed through work on the lower extremity; however, the application of these tenets to the pediatric craniofacial skeleton remains questionable. Prompted by concern that traditional aspects of distraction osteogenesis may lead to higher rates of premature consolidation in the pediatric maxilla, we retrospectively evaluated maxillary distraction protocol utilizing a 24-hour latency period in conjunction with a distraction rate of 2mm/day. METHOD(S): Following maxillary advancement via distraction protocol consisting of a 24-hour latency period and distraction rate of 2 mm/day, 7 consecutive pediatric cases were evaluated. Standard profile photos and cephalometric films taken pre-operatively, at device removal, and at one year follow up were compared. With the sella as the point of registration, pre- and postdistraction films were superimposed on the sella-nasion plane. Sella-nasion-subspinale, the angle of convexity, the distance from incisal edges to the y axis, and angulation of the upper incisor to the sella-nasion plane were analyzed to evaluate hard tissue changes. RESULTS: Patient age ranged from 3 years to 14 years (mean=7.43 years). Maxillary distraction length averaged 11 mm (range=10-12 mm). Interval from device application to removal averaged 98 days (range=75-180 days). The interval of the active distraction ranged from 11 to 65 days (mean=24 days). From distraction completion to device removal averaged 85 days (range=60-150). Follow up intervals ranged from 52 to 24 months (mean=34 months). All patients demonstrated substantial clinical advancement of the maxilla with correction of midfacial deficiencies. A single patient developed mild cellulitis at one skin-device interface; no other complications were noted. Cephalometric and clinical evaluations at one year post-distraction demonstrated stable results, and parental satisfaction was qualitatively high. CONCLUSIONS: Our results demonstrate effective maxillary correction following application of a 24-hour latency period coupled with rapid distraction at 2 mm/day. Our success with a short latency period and more rapid device expanse may be a product of the significant vascularity and improved healing potential of the pediatric maxilla.

9:00 AM - 4:00 PM

Endoscopic Assisted Mandibular Distraction

Presenter:	Sean Boutros, MD
Affiliation:	Houston Plastic and Craniofacial Surgery, Houston, TX

Purpose: The purpose of this study was to evaluate endoscopic assisted mandibular distraction.

Methods: A total of twelve mandibular distraction cases were performed utilizing endoscopic assist technique. These included six intraoral internal mandibular distraction procedures and six removal of distraction devices. All cases were performed between January 2006 and Febuary 2007. All cases underwent mandibular distraction through intraoral approach with percutaneous placement of screws. All cases had the distraction arm brought out through a percutaneous incision. On the six mandibular distraction cases, the seventy degree endoscope was inserted through the intraoral incision and used to visualize the anatomy, place the distraction devices, mark and place the osteotomy, and confirm distraction of the segments. On removal of device cases, the endoscope was again used to visualize these screws, assist with removal of bone in the interstices of the screw head, and accurately seat the screwdriver. It was also used to visualize the quality of bony regenerate.

Two cases were performed on patients with Treacher Collins syndrome. Both cases underwent bilateral mandibular distraction procedures. Both children had severe obstructive sleep apnea (OSA), one had undergone prior, failed mandibular distraction and had a tracheotomy. One case was performed on a patient with hemifacial microsomia who also had OSA. One case was performed on a patient with jaw asymmetry with right sided benign mandibular hypertrophy confirmed by SPECT scanning and a diminutive mandible on the left. This patient underwent combined LeFort I and mandibular osteotomy with MMF and simultaneous mandibular and maxillary distraction with a single left mandibular device.

Results: In all cases, mandibular osteotomies and placement of distraction devices was successfully completed with endoscopic assist. The endoscope proved valuable for visualization of the anatomy and placement of the distraction device. Furthermore, visualization of the distraction device and placement of screw percutaneously was greatly facilitated by visualization afforded with the endoscope. In no patient was a Risdon incision necessary. In the patient who had undergone prior distraction, there was preoperative lip insensibility. In the patients who underwent primary osteotomy, there were no permanent lip sensory changes.

Removal of distraction devices were greatly simplified with the use of endoscope. This allowed for removal of bone from the interstices of the screws with ease. Furthermore, it allowed for accurate seeing of the screwdriver into the screw head. In no patient was a Risdon incision necessary.

Overall, the time required for placement of the distraction device and removal of the distraction device was decrease compared to similar cases performed without endoscopic assist. The visualization was felt to be greatly enhanced with the endoscopic technique.

Conclusions: The use of the endoscope allowed for easier placement and removal of the distraction device, more accurate osteotomy placement, avoidance of a Risdon incision, and avoidance of injury to the inferior alveolar nerve by allowing more proximal device placement and osteotomy.

9:00 AM - 4:00 PM

Enhancement of the Superior Sulcus using Alloderm

Presenter:	Peter G. Lee, MD
Affiliation:	Wave Plastic Surgery Clinic, Los Angeles, CA

BACKGROUND: Through process of aging or secondary to previous blepharoplasty, loss of orbital fat in preaponeurotic space results in the deepening of the superior sulcus. In asian population, this results in an abnormal demarcation just below the supraorbital rim leading to an appearance of a supratarsal fold. Wide pretarsal show in asian patients is quite unnatural and gives the upper lid a heavy appearance. Also with deep superior sulcus, in creating a supratarsal fold during standard asian blepharoplasty, there can be an appearance of two supratarsal fold. There has been many material and methods to address the correction of the deep sulcus. From filler injections to surgical procedures using autologous or alloplastic material, there are advantages and disadvantages to these approaches. The author presents his experience with alloderm as a filler to the superior sulcus in asian population.

Method: From January 2005 to December 2006 we have performed 61 primary and 29 secondary upper blepharoplasties in conjunction with the placement of the alloderm to the superior sulcus region. In the process of standard open upper blepharoplasty surgery, a pocket in the preseptal region is dissected. After adequate space between the orbicularis and orbital septum is made, appropriate size, shape, and thickness of alloderm is placed and secured. The surgery is performed under local anesthesia with light iv sedation so that the appearance of the supratarsal fold as well as the depth of the superior sulcus can be assessed.

Result: Most patients were happy with surgery, one patient required additional surgery to further augment the hollowness. There were no complications. No clinical evidence of irregularity. In the mean followup period, there was no significant decrease in the graft.

Conclusion: Hollowness of the superior sulcus in the upper lid is frequently seen either due to normal aging, or due to overzealous resection of the orbital fat in primary blepharoplasty. Especially in Asians, in whom at an early age, occidental blepharoplasty was performed, in mid-age, this seems to be quite frequent. Autologous fat graft alone or dermal fat grafts have been described and detailed. The author had earlier, utilized autologous dermal fat grafts. However, on occasions, two problems were occasionally seen. First, due to the bulkiness of the dermal/fat graft and the extreme thinness of the upper lid soft tissues, irregularities and palpabilities were noted on occasion. Secondary, when placed in the preaponeurotic space, cicatrial reactions can occur leading to restriction of the levator gliding movement. This can manifest as some degree of ptosis or irregular supratarsal fold. By placing a smooth surfaced alloderm, there were no incidence of irregularity or palpability. By placing the graft in the preseptal space, no cicatrial reaction occurs between the graft and smooth gliding levator aponeurosis. We believe this is a better option for addressing the superior sulcus hollowness.

9:00 AM - 4:00 PM

Ex Utero Intrapartum (Exit) Management of Micrognathia with Distraction

Presenter:	Christopher B. Gordon, MD
Co-Authors:	Rian Maercks, MD, Gerald J. Cho, BS, Leopoldo E. Landa, MD, DMD, X. Pilar Reyna-Rodriguez, DDS
Affiliation:	Cincinnati Children's Hospital Medical Center, Cincinnati, OH

Background: The EXIT (ex utero intrapartum therapy) procedure was initially designed for management of congenital diaphragmatic hernia. By leaving the fetus on uteroplacental bypass during the procedure, the fetal airway may be safely instrumented while maintaining up to 90 minutes of maternal-fetal circulation. Recently, we have expanded indications to include any fetus in which the resuscitation of the neonate may be compromised. This involves limited delivery of the head of the fetus, maintaining placental circulation, and managing airway, cardiac issues, and other critical issues prior to interruption of fetal/placental circulation.

Objective: To introduce the EXIT procedure as a safe method for management of the prenatally diagnosed micrognathic patient, and to integrate mandibular distraction into the armementarium of the fetal surgery team.

Methods: We have successfully distracted 7 neonates who had prenatal diagnosis of micrognathia and underwent EXIT procedure with tracheostomy and early distraction as part of an integrated team approach to congenital micrognathia. All patients had prenatal high resolution fetal ultrasound and fetal MRI prior to intervention. The distraction procedure was performed using a simple angle osteotomy and transfacial steinman pin fixation, rapid sequence distraction, and callus remodelling upon termination. Typical distraction sequence was 4mm/day.

Results: The mean gestational age at EXIT procedure was 35.0 weeks. Two of the fetuses exhibited profound micrognathia with polyhydramnios (n = 5), and underwent prenatal intervention. All patients underwent successful early distraction. Two of the patients have been successfully decannulated, although two have tolerated tracheostomy capping. All underwent gastrostomy placement as neonates. The average time on placental bypass was 50 minutes. Postnatal complications were minor in this group, and there was no indication for ECMO or other invasive support. Maternal prenatal complications included polyhydramnios (n = 3), preterm labor (n = 1). Average maternal blood loss was 835 ml. A single patient has undergone a second mandibular distraction for incomplete correction of a profound micrognathia. Average distraction was completed in 16 days, with mean distraction after callus manipulation of 33mm. There was no failure of distraction, hardware, or other surgical complications.

Conclusion: The EXIT procedure allows for controlled airway management in the perinatal period, significantly improving the safety of management of severe micrognathia. This technique dramatically reduces morbidity and mortality in this high risk group, and we believe it represents the safest method for treatment of severe congenital micrognathia.

9:00 AM - 4:00 PM

Exploring the Effects of Referring General Surgeon's Views on Breast Reconstruction Utilization

Presenter:	D. Heath Stacey, MD
Co-Authors:	Michelle Spring, MD, Tara Breslin, MD, MPH, Venkat K. Rao, MD, Karol A. Gutowski, MD, FACS
Affiliation:	University of Wisconsin Hospitals and Clinics, Madison, WI

Background: Breast reconstruction rates remain low at near 5-15% of patients despite the safety and high patient satisfaction of these procedures. Reasons for this are multifactorial including the attitudes and biases of the referring breast surgeon, as well as patient factors. In this study, our purpose was to explore the attitudes of breast surgeons towards breast reconstruction.

Methods: We surveyed 369 General Surgeons in Wisconsin with questions about breast surgery and ideas and opinions about breast reconstruction. We received responses from 36% of surgeons surveyed.

Results: 73% of the respondents performed at least some breast surgery and were eligible for the study. For a little over 50% of the general surgeons surveyed, breast surgery made up less than 10% of their practice. Most (88%) of the respondents never performed nipple sparing mastectomies and 51% never performed a skin-sparing mastectomy. A small number of general surgeons also report performing onco-plastic breast procedures (10%). We found that a large number of breast surgeons (40%) do not routinely refer all mastectomy patients for reconstruction. Reasons that breast surgeons cited as having for not referring patients for reconstruction include the likelihood of cancer recurrence, patient co-morbidities, and high care-taker burden. Patient marital status, household income, and patient education had no effect on referral to a plastic surgeon. Reasons reported by respondents for patients not getting reconstruction included patient's refusal, need for radiation therapy, delaying adjuvant oncologic treatment, patient factors, and having no plastic surgeon available locally (Fig. 1). Respondents generally felt that there was no one type of breast reconstruction that was aesthetically superior (Tissue expander, TRAM, Latissimus dorsi with implant, free TRAM, free DIEP). Surprisingly, 48% of general surgeons believe that tissue expansion reconstruction has the fewest complications. On subgroup analysis, community-based surgeons believed that TRAM flaps give superior aesthetic results. Additionally, 45% of community-based surgeons considered age to be a factor in referral for breast reconstruction. Community-based surgeons cited difficulty in coordinating a two-person team (30%) and having no plastic surgeons available (20%) as reasons for referring patients post-mastectomy. The differences in responses between breast surgeons from urban and rural counties were also examined (Fig. 2).

Conclusions: The decision by a patient to undergo breast reconstruction involves many complex factors. As a specialty, we should focus on improving the availability of breast reconstructive surgeons and educating referring surgeons and patients about reconstructive indications and options in order to positively affect the utilization of breast reconstruction.

9:00 AM - 4:00 PM

Fascia-Sparing, Laparoscopically-Delayed Pedicled TRAM Reconstruction

Presenter:	E. Dale Collins, MD
Co-Authors:	Renee C. Comizio, MD, Joshua M. Adkinson, MD, Kristen M. Yurkerwich, BS, John H. Higgins, MS, Thadeus Trus, MD, FRCS
Affiliation:	Dartmouth Hitchcock Medical Center, Lebanon, NH

PURPOSE: To report the outcomes of a fascia-sparing, laparoscopically-delayed, pedicled TRAM reconstruction in 100 consecutive patients.

BACKGROUND –There has been considerable controversy as to which type of abdominal flap provides the highest quality breast reconstruction with the least functional impairment. Upon their introduction, both free TRAM and then perforator flaps have been touted as the gold standard for breast reconstruction. However, both types of microsurgical reconstructions have limitations, including the potential for increased risk of total flap loss and the greater resource requirements to support a microsurgical practice. Further, there has been little evidence to support a long-term difference in functional outcomes or patient satisfaction compared to the standard pedicled TRAM. Additionally, further refinements on the pedicled TRAM, such as a laparoscopic surgical delay, have had an impact on the quality of those reconstructions. In this report, we will present our outcomes with laparoscopically-delayed, pedicled TRAM flaps which are harvested using a fascia-sparing approach.

METHODS– A prospective consecutive cohort undergoing laparoscopic ligation of the deep inferior epigastric vessels prior to pedicled TRAM reconstruction. From March 2001 to September 2006, 101 women with a mean age of 49 yrs underwent laparoscopic epigastric vessel ligation on an outpatient basis. They subsequently underwent a fascia-sparing, pedicled TRAM reconstruction. (Approximate width of the fascial strip harvested was typically 2 cm.) The fascial defect was closed primarily and the contralateral side plicated to optimize abdominal contour. Outcomes were evaluated using administrative and chart review data for operative times, associated procedures and complication rates. Pre- and postoperative physical function was assessed using the SF-8 in a subset of patients.

RESULTS: Laparoscopic Procedures: The mean operative time for the ligation was 36 min. 27% had associated procedures including sentinel node biopsy (20), oophorectomy (5), hernia repair (2), Nissen (1) and liver biopsy (1). (The patient undergoing a liver biopsy was found to have previously-unsuspected metastatic disease, and therefore did not undergo further surgeries.) There were no complications. TRAM Reconstruction: Pedicled TRAM was performed an average of 12 days after the ligation. 71% were immediate reconstructions, and 32% were bilateral reconstructions, for a total of 132 flaps. 34% of patients undergoing unilateral reconstruction had a contralateral procedure including: reduction (11), mastopexy (11), and augmentation (1). Mesh overlay was used in 9% of patients. Complications: total flap loss = 0.7%; significant partial loss = 3.0%; hernia rate = 1.0%. Physical Function: 24 patients completed the SF-8 prior to surgery and at least 1 year postop (range 371 - 924 days). Mean Physical Component Summary (PCS) scores were not significantly different comparing pre and post surgery. Using norm-based scoring (mean = 50, a standard dev. = 10), the preop PCS score was 53.8 and the postop score was 54.1.

CONCLUSIONS: This report describes outcomes of a cohort of women undergoing postmastectomy breast reconstruction with a laparoscopically-delayed, fascia-sparing, pedicled TRAM flap. This approach minimizes patient risk and morbidity, while optimizing outcomes as demonstrated by very low flap loss and hernia rates and preserved physical functioning.

9:00 AM - 4:00 PM

Fat Grafting to the Hand after Ulnar Nerve Repair

Presenter:	Ryan S. Hoffman, MD
Co-Authors:	Mark Grevious, MD, David Morris, MD
Affiliation:	University of Illinois, Chicago, IL

Fat grafting is commonly used to improve soft tissue contour and surface irregularities. More specifically, fat grafting has been well described to improve the look of aging hands. However, there are few reports of fat grafting to the hand for correcting the contour deformities that can occur after an ulnar nerve repair. In our patient, who underwent a successful repair of the ulnar nerve at the level of the elbow, atrophy of the intrinsic hand muscles was seen. Additionally, the patient had thenar wasting, which was most likely due to disuse atrophy. We describe the indications, anatomic planning, and surgical procedures that were used to reverse the wasted appearance of the hand. In this context, fat grafting has shown significant aesthetic improvement in the appearance of the hand. We conclude that fat injections to the hand are a valuable adjunctive treatment for the atrophied appearance of a hand following ulnar nerve injury and repair.

9:00 AM - 4:00 PM

Functionalizing Intact Extracellular Matrix Based Scaffold with Starburst Dendrimer

Presenter:	Jeffrey C.Y. Chan, MBBCh
Co-Authors:	Krishna Burugapalli, PhD, John L. Kelly, MD, FRCS(Plast), Abhay Pandit, PhD
Affiliation:	National University of Ireland, Galway, Ireland, Galway

Introduction

Intact acellular extracellular matrices (ECM) have demonstrated potential in clinical applications. We hypothesized that ‘functionalizing' these scaffolds with dendrimers would improve the regenerative potential further. Dendrimers, a new class of macromolecules with a tree-like branching structure and a highly-functionalized multi-terminated surface containing functional groups can be tethered onto these scaffolds. Incorporation of dendrimers would provide additional grafting sites for the inclusion of bioactive peptides, growth factors or gene delivery. As a first step towards this goal, this study was designed to optimize the conditions for incorporation of polyamidoamine (PAMAM) “Starburst” dendrimer onto the cholecyst-derived extracellular matrix (CEM). CEM is a novel acellular scaffold currently under development in our research facility.¹ The resulting scaffolds were characterized by collagenase degradation assay, shrink temperature by differential scanning colorimetry (DSC) and Fourier Transform Infrared (FTIR) spectra.

Materials and Methods

CEM scaffolds were isolated from porcine cholecyst as previously reported.¹ Different amount of Generation 1 Starburst (PAMAM) dendrimer (0.0, 0.35, 0.7, 2.1, 4.2, 6.3, 8.4 mmoles per mg of CEM) were incorporated onto CEM scaffold using 0.0066 mM EDC/NHS cross-linking system in MES buffer (50 mM, pH5.3) by utilizing the carboxyl groups within the scaffold. For in vitro degradation, scaffolds were immersed in Tris-HCl buffer of pH 7.4 at 37 ^oC, in the presence of collagenase enzyme (10unit/mg). The percent remaining weight as a function of degradation time was recorded. To determine the shrink temperatue, a heating rate of 5^oC/min was used (25-100 ^oC) for DSC. Shrink temperatures were recorded from the DSC traces. FTIR spectra were recorded and analyzed.

Results

The incorporation of dendrimer decreased the susceptibility of these scaffolds to collagenase degradation up to an initial reactant concentration of 0.7 mM PAMAM/mg CEM. Above 0.7mM PAMAM/mg CEM, there was an increase in degradation (Fig. 1). Corresponding trends were observed with shrink temperature measurements and FTIR spectra. The shrink temperature gives an indication of scaffolds stability. There was an increase up to 0.7mM PAMAM/mg CEM and then showed a decrease thereafter (Fig 2).

Discussion

EDC/NHS crosslinking alone (without dendrimer) improved the stability of the CEM scaffold. This effect was further improved in the presence of Starburst (PAMAM) dendrimer. This indicates that the dendrimer functions as a cross-link bridge within the CEM scaffold. However, excess of PAMAM (>0.7mM PAMAM/mg CEM) resulted in deterioration of the scaffold stability. As indicated by the shrink temperature measurements, the improvement in stability can be attributed to increase in crosslinking, while the decrease could be due to excess dendrimer molecules competing for the limited carboxyl groups on the CEM scaffold. Similar trend has been reported when hexane diamine was used as crosslinking bridge for collagen.²

Conclusions

The conditions for tethering PAMAM dendrimer to CEM scaffold was optimized in this study and the resulting scaffolds was characterized using collagenase assay, DSC and FTIR.

9:00 AM - 4:00 PM

Hand Anomalies in 62 patients with Poland's Syndrome

Presenter:	Sean Kern, BSc
Co-Authors:	Justin P. Fox, MD, David Anderson, BSc, Joshua Tyler, MD, Alan Seyfer, MD, FACS
Affiliation:	USUHS, Bethesda, MD

INTRODUCTION: In recent years, there has been an increased focus on hand involvement in Poland's Syndrome (PS). We reviewed 62 patients with PS for frequency and treatment of hand deformity. METHODS: Fifty-seven patients were evaluated by the senior author (AES) during a 30-year period. A colleague saw another 5 patients. All records were reviewed for presence of hand deformity and treatment offered. RESULTS: Anomalies were right-sided in 60% and left-sided in 40%. 45% had obvious ipsilateral hand abnormality including shortening of the ipsilateral upper extremity (93%), syndactyly (29%), and brachysyndactyly (3%). Severity of chest wall deformity did not always correlate with severity of hand abnormality. DISCUSSION: Our experience suggests limb deformity occurs with relatively high frequency, though severity may not be pronounced. The literature reveals 8% of syndactyly patients have PS and 26% of PS patients had hand deformity. The presence of either should prompt evaluation for the other. Proposed anatomic classification systems offer little to treatment. In our experience, treatment focused on restoration of function and patient preference. CONCLUSION: The ipsilateral upper extremity in patients with PS is frequently affected with varying degrees of severity. When identified, treatment of the hand deformity should focus on restoration of function.

9:00 AM - 4:00 PM

Helping Hands: A cost-effective model for humanitarian hand surgery

Presenter:	Devinder P. Singh, MD
Co-Authors:	Jessica Lindoerfer, BA, John Tangredi, RN, J. Grant Thomson, MD, MSc
Affiliation:	University of Maryland School of Medicine, Baltimore, MD

BACKGROUND We present a report of an exclusively hand surgery mission to Honduras in May 2006. Few other exclusively hand humanitarian missions have been reported; none have attempted to demonstrate cost-effectiveness. Our objective is to prove cost effectiveness.

METHODOLOGY Healthcare professionals, including surgeon, anesthesiologist, nurse, pediatrician, and therapist, were asked to estimate costs of professional services. Actual costs incurred were recorded and compared to estimates of professional services. A ratio of dollars spent to professional service value provided was calculated.

RESULTS 120 patients were screened, and 129 procedures were performed on 81 patients. Estimates for professional services were: Surgery $144,000, Anesthesia $59,000, Pediatrics $9000, Nursing $17,000, Physical Therapy $5,000, Physical Therapy materials $1,000, and donated supplies $14,000. The total estimated value of these professional services was $249,000, compared to the actual cost of $23,000 incurred for the trip. Therefore, each dollar actually spent represents an eleven-fold gain in professional services rendered.

CONCLUSIONS An exclusively hand surgery humanitarian mission is detailed and offers financial value to the targeted international population. We demonstrate to potential fundraisers that each dollar contributed represents a 11-fold increase in terms of medical services provided to the population in need.

9:00 AM - 4:00 PM

Herpes Zoster after Reconstruction for Head and Neck Cancer

Presenter:	Pranay M. Parikh, MD
Co-Author:	Steven P. Davison, MD, DDS
Affiliation:	Georgetown University, Washington, DC

Background: Herpes zoster is the clinical syndrome that occurs when latent varicella zoster virus is reactivated from dorsal root ganglia. Patients with cancers of the head and neck are at significant risk for regional herpes zoster. The morbidity of zoster in the head and neck can be severe, including encephalitis, blindness, deafness, and debilitating post herpetic neuralgia. The risk of such morbidity can be significantly reduced with prompt initiation of therapy upon diagnosis; however, the diagnosis of zoster can be missed or delayed following head and neck reconstruction. Local tissue rearrangement and mobilization of distant tissues for soft tissue reconstruction can distort or efface classic dermatome anatomy, hindering identification of zoster by primary care providers. Surgeons performing reconstruction in the head and neck must be aware of zoster in the postoperative period, and take measures to guard against zoster associated morbidity.

Methods: A retrospective review of 350 consecutive head and neck reconstructions was performed to identify patients with documented cases of postoperative zoster. Patient demographics, perioperative course, cutaneous patterns of involvement, and clinical outcomes were recorded and analyzed.

Results: Six cases of zoster were identified, yielding an incidence of 1.7%. Mean age at diagnosis was 61.3 years. Age greater than 50, and suppression of cell-mediated immunity during adjuvant therapy were associated with incidence of zoster. Factors hindering diagnosis of zoster were dermatome distortion from tissue rearrangement, the presence of radiation dermatitis, suspicion of recurrent cancer, and confusion with bacterial infections. Islands of tissue at the site of distant and free flap transfers were typically spared from cutaneous lesions, consistent with their lack of common innervation with surrounding tissues.

Conclusions: The diagnosis of zoster can be difficult in the post-reconstructive period. A high index of suspicion, and close attention for a history of neuropathic pain preceding cutaneous lesions is crucial to allow prompt initiation of therapy. When managing postoperative skin and soft tissue infections in the head and neck cancer population, zoster should be included in differential diagnosis, and empiric antiviral therapy should be considered to minimize the risk of morbidity and severe complications. Vaccination against VZV should also be considered for routine preoperative prophlylaxis, especially in patients older than 50 and in patients with immunosuppression.

9:00 AM - 4:00 PM

Hyaluronic Acid Gel (Restylane®) Implantation Longevity over 52 Weeks

Presenter:	No presenter
Co-Authors:	Mark Rubin, MD, Jeffrey Dover, MD
Affiliation:

Background: As a degradable option for soft tissue implantation, hyaluronic acid derivatives potentially offer longer-lasting correction and a reduced risk of immunogenicity and hypersensitivity compared to bovine collagen. The US Food and Drug Administration (FDA) approval of nonanimal stabilized hyaluronic acid gel (Restylane®) was based primarily upon a pivotal controlled clinical trial conducted in the United States and a supportive study conducted in Scandinavia. The 6-month pivotal US study showed that nonanimal stabilized hyaluronic acid was well tolerated and provided a more durable aesthetic improvement than bovine collagen. The results from the Scandinavian study, which provided data over a longer period than the pivotal study, are summarized here. Objective: The objectives of the study were to investigate the safety and efficacy of stabilized hyaluronic acid gel when injected intradermally. Methods: All injections were done intradermally using a string-like technique. Patients were evaluated at Weeks 0, 1, 12, and 26. Assessments included degree of correction, physician estimate of degree of improvement, and patient estimate of degree of improvement. The degree of improvement was measured using a visual analogue scale from 0 to 100%. Patients not achieving at least an 80% improvement (as assessed by an evaluator) at Week 1 could receive a second injection. At each visit, patients were assessed for adverse events including erythema, swelling, pain, redness, itching, and tenderness. Twenty patients were randomly selected for additional assessment after 52 weeks. Results: One hundred thirteen patients (female, n=106; male, n=7) each received treatment in up to three sites; a total of 285 locations were treated and fully assessed. The reported degree of correction, physician's estimate of the degree of improvement, and patient assessment of the degree of improvement were similar to one another within each week. At 26 weeks, the degree of improvement was 69% (physicians) and 61% (patients). In randomly selected patients at 52 weeks the degree of improvement was 66% (physicians) and 57% (patients). The incidence of adverse events was low and no unexpected adverse events were reported. Conclusions: Nonanimal stabilized hyaluronic acid gel (Restylane® ) implantation was safe and well tolerated with a long duration of improvement; 60% of the treatment improvement remained after 1 year.

9:00 AM - 4:00 PM

Immediate Reconstruction of a Nonreplantable Thumb Amputation by Great Toe Transfer

Presenter:	Edward C. Ray, MD
Co-Authors:	Randy Sherman, MD, Milan Stevanovic, MD
Affiliation:	University of Southern California, Keck School of Medicine, Los Angeles, CA

When replantation of an amputated thumb is not feasible, toe-to-hand transfer should be considered as a reconstructive option. In this review we report our success with immediate great toe transfer in selected patients with non-replantable thumb avulsions. During the past five years, six hand trauma patients underwent great toe-to-hand transfer during initial post-injury hospitalization at our tertiary medical center. The overall results of these thumb reconstructions were retrospectively evaluated after patients were contacted. Objective and subjective scores to quantify patient satisfaction and clinical success were tabulated. All of our patients were laborers who suffered work-related thumb avulsions and a spectrum of associated extremity injuries. No surgical complications, transfusions or reoperations were reported during initial hospitalization, which lasted an average of 12 days (range 6 to 18). Time to reconstruction averaged 5.7 days post-injury (range 1 to 11). Donor site morbidity was minimal, with one patient reporting mild gait disturbance. Follow-up averaged 8.4 months (range 2 to 13). Four of the six patients have returned to work, averaging 130 days of disability. All patients that followed up after six months (4 of 6) had intact protective sensation in their reconstructed thumbs. Subjective and objective outcome scores (rated 1 to 5) at most recent follow-up each averaged 4.4, reflecting agreement between patient satisfaction and functional outcome. Post-hospitalization complications included one hand infection, one first web space contracture and one patient with moderate cold sensitivity. Additionally, one patient required soft tissue debulking. The data suggest that thumb reconstruction using great toe transfer can be safely and reliably performed during the initial presentation in selected patients. Reduced length of hospitalization and surgical recovery time expedites return of function and may allow patients to return to work sooner. The economic and therapeutic advantages should be weighed against the risks associated with this approach when evaluating patients with non-replantable thumb amputations.

9:00 AM - 4:00 PM

Inamed (Allergan) Style 410 Cohesive Gel Implants: 100 Consecutive Cases for Breast Augmentation

Presenter:	Herluf Gyde Lund Jr., MD
Affiliation:	St. Louis Cosmetic Surgery Inc., St. Louis, MO

PURPOSE:

The Inamed Style 410 cohesive silicone gel implant has been available outside of the United States since 1993. Experience in the United States has been limited to Inamed clinical investigators through FDA-approved clinical studies. This is a retrospective review of a single surgeon's experience with his first 100 patients using the Inamed 410 implant.

METHODS:

The author's first 100 patients using the Inamed Style 410 cohesive silicone gel implant for breast augmentation were included in the study. A retrospective chart review was performed to analyze patient indications for surgery, patient age, implant pocket placement, adjunct breast procedures, complications, capsular contracture and patient satisfaction. Patient follow-up was performed by using both postoperative examinations and surveys.

RESULTS:

100 patients underwent consecutive breast augmentation procedures using the Inamed Style 410 cohesive silicone gel implant. The average age was 37 years (20 years to 61 years). Average follow-up was 16 months (4 months to 34 months). 2 patients were lost to follow-up after 6 months. Seventy-seven (77%) patients had primary breast augmentations and twenty-three (23%) patients had revision of a breast augmentation. Eighty-three (83%) of the implants were placed in a partial subpectoral pocket and seventeen (17%) of the implants were placed under the fascia of the pectoralis major muscle. 33 patients underwent simultaneous mastopexy procedure. All revision patients underwent a full or near complete capsulectomy. 4 revision patients had tightening of the implant pocket performed prior to implant placement. 98 patients had a Baker grade 1 capsule on their last follow-up examination with 2 patients having a grade 2 capsule. There were no cases of implant rotation, malposition, or clinical evidence of implant rupture. There were 2 complications reported: 1 infected implant and 1 cyst at the incision site. Patient satisfaction was graded on a scale of “definitely satisfied” to” definitely dissatisfied”. 89% reported being “definitely satisfied”, 7% reported being “somewhat satisfied”, 3% reported being ‘neither satisfied nor dissatisfied', and 1% reported being” definitely dissatisfied”. The 4% reported below satisfied all expressed dissatisfaction with breast size.

CONCLUSION:

The experience with the Inamed Style 410 implant for breast augmentation has demonstrated a high degree of patient satisfaction and a low complication rate. Because of the 410 implant's form stable silicone gel matrix, the implant requires certain pre-operative and intra-operative factors be addressed in order to obtain the optimal result. Critical pre-operative planning includes: (1) Selection of the implant shape and size based upon the patient's physical characteristics and desires. (2) Implant placement is determined by the patient's breast characteristics. Because of the anatomic tear-drop shape and the form stable cohesive gel matrix of the 410 implant, thin patients with minimal breast tissue had very good results using a partial submuscular placement with minimal rippling or palpability. Patients with tuberous breasts had excellent results using a subfascial pocket allowing the form-stable gel matrix to shape the breast parenchyma. The increase lower pole projection of the tear-drop shape implant improved the breast appearance and shape in which a mastopexy and augmentation were performed. Critical intraoperative issues include: (1) Incision size: a slightly larger incision length may be required to avoid fracturing the gel matrix. (2) Precise pocket dissection is required to maintain correct implant orientation and tissue adherence to the 410 implant's BIOCELL surface. For revisions of previous breast augmentation, a capsulectomy is performed to enhance tissue interaction with the implant surface. Patients have expressed a high degree of satisfaction noting particularly the natural shaping of the breast and the more “breast like” feel of the implant when compared to saline filled or standard silicone gel filled implants. The Inamed Style 410 cohesive gel implant is a fourth generation silicone gel implant and represents a significant advance in implant technology. Due to its low complication rate and aesthetically pleasing results, the 410 implant will probably comprise a large percentage of the implants used for breast augmentation upon its approval and introduction into the United States.

9:00 AM - 4:00 PM

Internal Mammary Artery Perforator Flap for Chest Wall Reconstruction

Presenter:	Masaki Takeuchi, MD
Co-Authors:	Kenji Sasaki, MD, Motohiro Nozaki, MD, PhD
Affiliation:	Tokyo Women's Medical University Yachiyo Medical Center, Chiba

We used contralateral internal mammary artery perforator (IMAP) flaps for reconstruction of small-to-medium-sized chest wall defects. The IMAP flaps were used in two patients who had an unhealed, localized ulcer of the chest wall with exposure of ribs following radical mastectomy. After the lesion was widely excised, the flap, based on a perforator vessel in the second or third intercostal space of the contralateral chest wall, was elevated. The flap was rotated from 90 to 180 degrees along the vascular axis to the contralateral chest wall defect. The donor site was closed primarily. Both flaps showed stable postoperative blood circulation and survived completely. The chest wall defects were able to be covered with healthy, well-vascularized tissue on one perforator without deep infection. The IMAP flap is a reliable and less invasive option to be considered for medial, localized, chest wall reconstruction.

9:00 AM - 4:00 PM

Isolating Adipose Stem Cells for Aesthetic Plastic Surgery Applications

Presenter:	Henry A. Mentz, MD
Co-Authors:	Amado Ruiz-Razura, MD, FACS, Christopher K. Patronella, MD, FACS, German Newall, MD, FACS, Grace Wu, MS, Ronald Stubbers, BS, Michael Coleman, PhD
Affiliation:	The Aesthetic Center for Plastic Surgery, Houston, TX

BACKGROUND INFORMATION: Stem cells are distinguished from other type of cells because they are unspecialized and therefore can renew themselves for long periods through division. They can also be coaxed to become cells with special functions such as forming heart muscle, repairing cartilage or regenerating functional tissue. In aesthetic plastic surgery applications benefits from this new technology can probably include augmenting tissue after mastectomy or filling soft tissue defects, using the patients own adipose stem cells obtained from liposuctioned fat aspirate.

OBJECTIVE: To gain knowledge and experience of this possible application in our field, a tissue acquisition protocol was designed to understand the handling of adipose tissue and isolation of the progenitor cell fraction.

MATERIALS & METHODS: A tissue acquisition protocol was established with IRB approval wherein adipose tissue was obtained from fresh abdominoplasty flap specimens and liposuctioned fat aspirate. The acquisition process was performed during aesthetic surgical procedures performed in our fully accredited outpatient surgical facility. Inclusion criteria included male or female patients between 18-64 years of age undergoing elective abdominoplasty and liposuction that would yield at least 25 gms of excess adipose tissue and agree to participate by signing the informed consent. Up to the present time, twenty patients (N=20) have participated to study factors that affect the yield and viability of progenitor cell fraction. Up to this date, time between harvest and processing, tissue dissociation methods, and removal of large debris and adipocytes have been investigated. Pre specified variables have been assessed for impact on tissue handling and processing using ANOVA analysis.

RESULTS: Results obtained until now under present optimal conditions, indicate a yield of 125,000 +/- 55,000 plastic adherent cells per g fresh of lipoaspirate. Cells within this fraction expressed the surface markers CD44, CD105, and NG2 associated with progenitor cells. Conditions for enzymatic digestion of the fresh tissue were found to be an important determinant of viable cell yield. Findings and variables such as morphology, histochemistry and viability after cryopreservation of tissue , will be reported upon presentation. Please see picture of adherent cells one day post isolation from lipoaspirate.

CONCLUSION: We are very optimistic with these initial results that will serve to extrapolate laboratory findings with future clinical applications.We believe that this is one of the first systematic studies to assess best practices for obtaining adipose stem cells for aesthetic plastic surgery applications.

9:00 AM - 4:00 PM

Later Results after Thorac Axillar Flap in Consertive Treatment

Presenter:	Elvio Bueno Garcia, PhD
Co-Authors:	Lydia Masako Ferreira, PhD, Miguel Sabino Neto, PhD, Luis Eduardo Abla, MD, PhD
Affiliation:	UNIFESP, São Paulo

The use of the thorac axillar flap for the immediate breast reconstruction of the upper lateral quadrantectomies and upper medial., concerning later aesthetic results and postoperative follow–up, from May/1997 to November/2006. Casuistic and Methods: This study was carried out in a Federal University of São Paulo – UNIFESP, São Paulo, Brazil, sixty four patients with breast cancer located in the upper lateral quadrant and upper medial quadrant, were underwent a immediate breast reconstruction with thorac-axillar flap, The age of the patients ranged from 29 to 81 years (mean 57). Respecting a clinical trial that is performed at the UNIFESP, (56%) patients had been treated previously with chemotherapy (5-fluoracil, ciclophospahamide and epirrusiciu). All these patients were submitted to postoperative radiationtherapy. The follow-up ranged from 12 months to 9 years. Evaluation of aesthetic results was carried out betwen one year at nine years of the postoperative follow-up and was based on opinion of patient and objetive evaluation was based on three criteria: asymmetry of nipples, loss of volume and retraction estimated by the medical team. Results: Viability was present in 100% of the flaps. 82% patients rated themselves excellent, and from the medical team the evaluation rated 93% excellent outcomes. The histological diagnoses were (78%) ductal carcinoma; (12%) mucinoso carcinoma ; (10) lobular carcinoma., 3 patients had local recurrence, and 2 were underwent mastectomy by insufficient margens. Conclusion: The flap showed a later excellent aesthetic result in immediate repair for upper lateral and upper medial quadrantectomies and the log-term, radiotherapy and quiomotherapy don't interered in the outcomes.

9:00 AM - 4:00 PM

Long Term Follow-up of Cranioplasty Utilizing Alloplastic Implant and Bioabsorbable Pin Fixation

Presenter:	Denis Franks, MD
Co-Authors:	Robert K. Johnson, DDS, John Mitcherling, DDS, William Mitcherling, DDS, Ronald P. Silverman, MD
Affiliation:	University of Maryland, lutherville, MD

This poster presentation demonstrates the 8 and 15 year follow-up of a cranioplasty reconstruction utilizing an alloplastic implant and bioabsorbable (PGA/PLA) pin fixation. The basic science of pin manufacture/absorption is presented.

Clinical History: The patient is a 67 year old male, initially seen in 1992. He had previously undergone the resection and ligation of an aneurysm of the right frontal/parietal area. He had done well postoperatively, but had been bothered by the gradual retrusion of the surgical bone flap. The defect, at that time, measured 11 cm. x 5 cm. Evaluation included a three dimensional CAT scan, and subsequent plaster moulage. the moulage was then used to construst an alloplastic implant. The implant was formulated of HTR polymer, made from polymethylacrylate (PMMA) macrobeads, coated and fused together with hydrophilic polymer, poly-2-hydroxyethylmethacrylate (PHEMA), after which the molded composite was coated with calcium hydroxide.

The patient was taken to the operating room in 1992, at which time the custom alloplastic was placed, using the previos craniotomy skin incision. Fixation of the implant was achieved with a series of bioabsorbable pins. Follow-up at 8 and 15 years is presented. The use of bioabsorbable zixation allows the ability of radiologic evaluation, including magnetic imaging and CAT scanning. Because of the lack of metallic fixation, no problems with radiologic scattering or distortion have been encountered. Further, use of the alloplastic implant precludes donor site morbidity.

This case , supported by 8 and 15 year follow demonstrates a safe and effective method of craniofacial reconstruction. The results are demonstrated both radiograpgically and photographically, and support the use of this method of reconstruction because of the well tolerated implants, with minimal morbidity/mortality.

9:00 AM - 4:00 PM

Long-term Results of Craniofacial Implantation: A Return to Methylmethacrylate

Presenter:	Anil Shetty, MD
Co-Authors:	Gustavo E. Bello-Rojas, MD, Ian T. Jackson, MD, FRCS, FACS, Matthew L. Rontal, MD, Halil Ibrahim Cantor, MD, PhD
Affiliation:	Wayne State University School of Medicine, Troy, MI

Purpose: Today's surgeon faces many situations that require the reconstruction of bony defects of the cranial vault. Autologous bone is the traditional material used in these situations. They have low rates of extrusion and infection. However, autologous bone grafting has drawbacks such as donor site morbidity, longer operation times and increased resorption rates of the graft. Alloplastic materials for autologous bone are an appealing alternative. They are available in nearly unlimited supply and obviate donor site morbidity. One of the earliest alloplastic materials used in cranioplasty was Polymethylmethacrylate (PMMA), a malleable and inert implant material. More recently, biocompatible cements such as Hydroxyapetite cement (HAC) have gained acceptance. Our unsatisfactory experience with HAC has led us to return to PMMA in craniofacial reconstruction with excellent cosmetic and functional results as well as a low incidence of complications.

Methods: The Patients were evaluated and followed in the same Institute. The senior surgeon performed all procedures. The data presented is derived from a retrospective review of patient charts.

Results: Thirty patients, treated at the Institute for Craniofacial and Reconstructive Surgery, Southfield, Michigan, between the years 2000 and 2006, were included in the study. The mean postoperative follow-up was 2.1 years. Sixteen patients had full-thickness cranial defects, while the rest had partial-thickness defects. The etiology of the defects included trauma, congenital hypoplasia and tumor resection.

Table 1. Demographic Information Patients N % Mean Range Male 21 70% Female 09 30% <20 years 8 26.6% 13.2 3 to 19 21-35 years 6 20% 25.3 21 to 30 36-55 years 12 43.3% 44.8 36 to 55 >55 years 4 14% 71 61 to 81

Follow Up 30 100 2.1y 0.8yr- 4yr

Post-Traumatic Deformity - 12 Congenital Deformity -7 Tumor Resection - 9 Other -2 Full-Thickness 16 Partial-Thickness 14

Only one case was complicated by infection requiring removal of the implant. Three minor complications were encountered- exposure of implant material, hematoma, and seroma. These were successfully treated with secondary closure of minor implant exposure and expectant management of fluid collections.

Conclusion: Based on our series of 30 patients over an average follow-up of 2.1 years, PMMA is a safe and effective option for craniofacial reconstruction. PMMA may be used to create a reliable reconstruction comprised of an easily molded and biologically inert material. PMMA should not be used in tissues that have been infected within the past year, or in sites that communicate with the Paranasal sinuses. Graft immobilization via screw fixation in both full-thickness and partial thickness defects not only increases the stability of the reconstruction but also contributes to a reduced rate of peri-implant infection. Finally, it is probable that impregnation of the cement with Tobramycin has also contributed to a decline in infectious complications.

9:00 AM - 4:00 PM

Major and Lethal Complications of Liposuction: A Review of 72 Cases in Germany Between 1998 and 2002

Presenter:	Marcus Lehnhardt, MD
Co-Authors:	Heinz Homann, Adrien Daigeler, Joerg Hauser, Lars Steinstraesser, MD, Hans Steinau
Affiliation:	Ruhr University Bochum, Bochum

Objective: Liposuction is the most frequently performed cosmetic operation in Germany with approximately 250.000 procedures in 2003. The public perception of liposuction as minor surgery fails to consider the potential of major complications or a possibly fatal outcome. Design, Settings: A retrospective analysis of severe or lethal complications related to cosmetic liposuction is presented. In order to collect pertinent information, we sent 3.500 questionnaires to all German, Swiss and Austrian Departments of Pathology and Forensic Medicine. In addition we contacted Intensive Care Units, Health Insurance Companies and the offices of District Attorneys. After the identification of cases with major complications, the second phase of the investigation consisted of interviews with the physicians performing the respective procedures. Following disclosure of clinical documentation, anonymous data was recorded on site. Details of any such cases were included as blinded data. Results: 2.275 questionnaires (65%) were returned. The analyzed data showed 72 cases of severe complications including 23 deaths following cosmetic liposuction in a 5-year period from 1998 to 2002. The most frequent complications were bacterial infections like necrotizing fasciitis, gas gangrene and different forms of sepsis. Further causes of lethal outcome were hemorrhages, perforation of abdominal viscera and pulmonary embolism. 57 out of 72 complications were clinically evident within the first 24 postoperative hours. 41 of these 72 procedures of liposuction were performed in tumescent anaesthesia and 17 in true tumescent anaesthesia. Discussion: Major risk factors for the development of severe complications are insufficient standards of hygiene, the infiltration of multiliter wetting solution, megavolume aspirations, the performance of multiple cosmetic procedures in one setting, permissive postoperative discharge and the selection of unfit patients. The lack of surgical experience was a notorious contributing factor, particularly regarding the timely identification of developing complications. This is in fact the first study reporting deaths related to liposuction performed entirely under true tumescent anaesthesia. Even cosmetic liposuction performed by an experienced surgeon in a proper operating room is far from being a harmless procedure. Liposuction carries all the known risks of surgery in addition to method-related complications, which require an appropriate management.

9:00 AM - 4:00 PM

Management of Neonatal Upper Airway Obstruction: Decreased Morbidity by Utilizing a Decision Tree Model with Mandibular Distraction Osteogenesis

Presenter:	Raj M. Vyas, BS
Co-Authors:	Kristy L. Wasson, BA, Katrina Dipple, MD, Christian Head, MD, Samuel H. Wald, MD, Joubin S. Gabbay, MD, Amir Tahernia, MD, James P. Bradley, MD
Affiliation:	UCLA, Los Angeles, CA

Background/ Purpose: For craniofacial syndromic patients, neonatal upper airway obstruction requires urgent management. While tracheostomy may be life-saving in these circumstances, it is associated with numerous morbidities, long-term speech and growth delay. Distraction osteogenesis or mandibular jaw lengthening offers an alternative to tracheostomy, but proper patient selection requires the plastic surgeon obtain appropriate studies and make timely decisions.

Methods: A ten-year review of neonates with upper airway obstruction at two academic centers was performed (n=149). We compared conventionally treated neonates (control group), receiving home monitoring or a tracheostomy on a case by case basis, to newborns managed by a new decision tree model (DTM) (study group), in which a specific pattern of diagnostic tests and specialist consultations were obtained to decide among home monitoring, tracheostomy, or distraction. Long-term outcomes in mortality, morbidity, speech, and growth were assessed.

Results: Neonates managed with our DTM were significantly less likely to undergo a tracheostomy than those managed conventionally (28% versus 82%, p<0.05). No deaths occurred and only one of 43 children in our DTM group who initially underwent DO required subsequent tracheostomy (for unrecognized central apnea). There were three deaths in conventionally managed neonates compared to none in the study group. All three deaths in the control group were airway-related, including two deaths in patients managed with home positional monitoring. Newborns managed with our DTM had significantly fewer hospital days (mean 18 vs. 33, p<0.05), emergency department visits (3.4 vs. 9.6, p<0.05), pneumonia (4% vs. 24%, p<0.05), gastrointestinal reflux (12% vs. 69%), and feeding problems (9% vs. 61%, p<0.05) compared to their conventionally treated counterparts. Study group patients showed improved height (60th percentile) and weight (64th percentile) compared to control group subjects (42nd and 28th percentile, respectively, p < 0.05). With regard to lower facial profile measured by lateral profilogram, there was a statistically significant increase in lower facial profile in those children managed with the DTM compared to those managed conventionally (23% versus 5%, p < 0.05). Sixty children in the study group (78%) and 22 in the control group (31%) were tracheostomy free at final follow-up and had some degree of speech (chi-square, p < 0.05). Of these, there was no significant difference in incidence of VPI between the study and control groups (16% versus 18%). Patients with a remaining tracheostomy demonstrated minimal to no understandable speech and communicated primarily with sign language or hand signals at final follow-up.

Conclusions: In treating newborns with micrognathia and upper airway obstruction, a plastic surgeon will have better patient outcomes when utilizing a decision tree model with multidisciplinary specialists, timely studies, and an option for mandibular distraction osteogenesis.

9:00 AM - 4:00 PM

Microarray Analysis of Genes Orchestrating Craniofacial Development

Presenter:	Leo R. Otake, MD, PhD
Co-Author:	John A. Persing, MD
Affiliation:	Yale School of Medicine, New Haven, CT

Specific Aims The objective of this project is to identify candidate interacting genes which are temporally differentially expressed during craniofacial development using the mouse animal model. The Affymetrix GeneChip Mouse Genome 430 2.0 Array has been utilized in this investigation. As the molecular underpinnings of craniofacial development are not well understood at the present time, modalities such as molecular diagnostics and gene therapy lie at early stages of development. A greater understanding of the genetic network involved in craniofacial development would be an asset towards elucidating the molecular mechanisms underlying craniofacial development in general as well as craniosynostosis in particular.

Significance Although genetic lesions associated with various congenital craniofacial syndromes have been identified, the interacting genetic networks/pathways that result in the syndromic craniosynostoses have not been clearly elucidated. The candidate human genes and mutations which have been associated with syndromes have been reported, including the homeobox protein MSX2 with Boston-type craniosyostosis, the family of fibroblast growth factor receptors (FGFR) type 1 (FGFR1) with Pfeifer type I, FGFR2 with Apert, Crouzon, and Pfeifer types I/II/III, FGFR3 with Apert/Acanthosis Nigricans and the transcription factor TWIST with Saethre-Chotzen.

A comprehensive examination allows for evaluation of the complex interplay of pathways which lead to the clinical phenotype. A compelling question lies in the observation that although Apert and Crouzon Syndromes are both associated with mutations in FGFR2, the clinical presentation on physical examination and temporal progression of craniosynostoses, as well as, mental functional outcome with Apert patients being more severely affected, differ so greatly; this suggests that alternative or differential dysregulation of similar pathways occurs downstream of the identified genetic lesion.

Experimental Design and Methods Dr. Hongbo Chi and Dr. Richard Flavell of the Department of Immunobiology, Yale School of Medicine; have developed a targeted, single locus gene knockout of the mouse MAP kinase kinase kinase 4 (MEKK4) gene. Mice which are homozygous for the gene knockout are viable to birth, but die shortly thereafter. These mice demonstrate severe derangements in craniofacial development, notably, the cranial vault fails to develop with attendant exencephaly and spina bifida. Additionally, the cortex fails to develop normally in the knockout mice. The development of such a striking craniofacial defect in the setting of a targeted, single gene knockout presents a unique opportunity to examine, using microarray technology, specific genetic pathways which have been disrupted.

Heads from E18 homozygous MEKK4 knockout and homozygous normal fetuses from the same mating were collected. Total cellular RNA was extracted and matched pairs of homozygous knockout and normal samples were applied to the Affymetrix mouse 430 v 2.0 total genomic microarray and quantitated using GeneSpring GX 7.3 (Agilent Technologies).

Initial Results Results from 2 pairs of Mekk4 wild-type and gene knockout E18 fetuses (total of 4 animals) are shown in table form (Table1). Microarray data were normalized and fold-changes in expression were determined and segregated into functional groups. Representative genes are presented if an alteration of expression in the given locus resulted in a reported phenotype in the literature relevant to craniofacial development.

Table 1: Functional Groupings of Genes with Altered Expression Levels

Cell Differentiation Wnt5a -1.85 Forkhead BoxG1 -1.50 Endothelin Recept B +1.54

Extracellular Space Biglycan -1.74 Dermatopontin -1.87 Decorin -1.55 Fibrillin -1.67 Endothelin Recept-B +1.54 Transthyretun +1.60

Extracellular Matrix Procollagen XIa1 -2.55 Fibrillin2 -2.34

Receptor Activity Eph Receptor A4 -1.89

Subsequent to the described examination of the gene expression profiles in the heads of the MEKK4 knockout mouse at the E18 stage of development, we propose to extend our analyses to compare expression profiles of other mutant mice with craniofacial defects. Starting with the initial state of absent calvarial vault development in the MEKK4 mouse, our objective is to gain a greater understanding of the repertoire of genes needed to orchestrate calvarial development in both a normal and abnormal synostotic state.

9:00 AM - 4:00 PM

Microsurgical Correction of Craniofacial Malformations: a Fifteen-Year Experience

Presenter:	Christopher C. Chang, BA
Co-Authors:	Pierre B. Saadeh, MD, Stephen Warren, MD, Patrick Reavey, MD, John W. Siebert, MD
Affiliation:	New York University Medical Center, New York, NY

Background: Since our first review of microsurgical correction of facial contour deformities in 19 patients with craniofacial malformations, we have treated an additional 76 patients (n = 19 + 76 = 95). Here, we review the indications, choices, safety, efficacy, complications, and technical refinements. A treatment algorithm is presented.

Methods: A retrospective chart review of all patients who underwent microvascular reconstruction of the face and all patients with craniofacial dysmorphology was performed. Between 1989 and 2004, a total of 95 patients with the following diagnoses were identified: craniofacial microsomia (n = 73), Treacher Collins syndrome (n = 8), severe orbitofacial cleft (n = 12), and severe micrognathia (n = 2). All patients underwent microsurgical facial reconstruction with a superficial inferior epigastric, groin, circumflex scapular, or fibula flap. Flap revisions, complications, and non-free flap related surgery were reviewed. All patients were followed for a minimum of 1 year (range 1-15 years).

Results: The mean age at microvascular reconstruction was 11 years (range = 4-27 years). Flap choices included: superficial inferior epigastric (n = 4), groin (n = 3), circumflex scapular (n = 105), or fibula (n = 2). 78 patients underwent unilateral and 17 patients underwent bilateral (1/17 immediate) reconstructions. Postoperative complications included: total flap loss (n = 1), partial flap loss (n = 1), re-explorations (n = 1), and hematoma (n = 5). All patients had a subjective improvement in facial contour, symmetry, skin tone, and color. 63/73 patients with craniofacial microsomia underwent non-free flap-related surgery, usually mandibular/ear reconstruction, whereas 7/8 Treacher Collins syndrome patients, 12/12 severe orbitofacial cleft patients, and 2/2 severe micrognathia patients underwent additional procedures.

Conclusions: Microsurgical flaps have markedly improved our ability to restore craniofacial contour in patients with craniofacial malformations. In selected patients, we choose primary midface augmentation with free vascularized tissue in order to restore form and function. Microsurgical flaps in patients with craniofacial malformations are safe, effective, and reliable.

9:00 AM - 4:00 PM

Nipple Reconstruction with C-V Flap Using Dermofat Graft

Presenter:	SuRak Eo, MD, PhD
Co-Authors:	SangHun Cho, MD, PhD, Steve S. Kim, MD, PhD, Andrew L. Da Lio, MD
Affiliation:	DongGuk University International Hospital, GoYang-si

Aesthetically satisfying nipple restoration plays an important role in post-mastectomy breast reconstruction. We have used the C-V flap with dermofat graft from the discarded tissues in second stage breast reconstruction in 22 nipples of 20 patients. This article describes non-innovative, but useful technique for better nipple projection based on the flap and graft theory. Transferred dermofat was wrapped around by C-V flap with the dermal tissue laying in the deep aspect. There were no skin flap loss, fat necrosis and wound problem. We believe this might be the simplest and valuable method for the good projecting nipple reconstruction.

( This paper was published on "Ann Plast Surg 2007 Feb;58(2):137-140". )

9:00 AM - 4:00 PM

Outcome Following Removal of Infected Tissue Expanders in Breast Reconstruction: A 10-Year Experience

Presenter:	Eric G. Halvorson, MD
Co-Authors:	Joseph J. Disa, MD, Babak J. Mehrara, MD, Brooke Burkey, MD, Andrea Pusic, MD, Peter G. Cordeiro, MD
Affiliation:	University of North Carolina, Chapel Hill, NC

BACKGROUND Tissue expander (TE) infection requiring explantation is an unfortunate complication of implant-based breast reconstruction. Although several studies have analyzed risk factors for tissue expander removal prior to permanent implant placement in breast reconstruction, the outcome following explantation because of infection is unknown. This study analyzes the outcome of patients who have had an infected TE removed, in an effort to determine which patients are candidates for secondary prosthetic reconstruction.

METHODS Using a prospectively maintained database, patients who underwent removal of an infected TE over a 10-year period at a single institution were identified, and subsequent reconstructive procedures noted. A retrospective chart review was then performed recording patient characteristics that might affect outcome, reasons for reconstruction vs. none, and final outcome.

RESULTS From June 1994 to November 2004, 3,181 TE's were placed in 2,539 patients. Thirty-nine (1.2%) TE's were removed due to infection, a mean of 56 days after insertion. Twelve (30.8%) patients had received prior x-ray therapy (XRT). Nine patients (23%) underwent secondary reconstruction with another TE, 3 (7.7%) with a latissimus dorsi flap and TE, and one (2.6%) with a free transverse rectus abdominis flap (Fig. 1). Recurrent infection requiring explantation occurred in one patient who underwent re-expansion. Two patients developed late contractures. All other secondary prosthetic reconstructions were successful. Only two radiated patients underwent secondary reconstruction. Twenty-six patients (66.7%) did not undergo later reconstruction, most commonly due to a combination of patient preference, cancer progression, and XRT exposure.

CONCLUSIONS After removal of an infected TE, most patients who are interested and remain good candidates can still be reconstructed. Of the patients who underwent secondary reconstruction, 69% could be re-expanded. Re-expansion was successful in patients who had not received XRT. When there is a history of XRT exposure, secondary reconstruction with autologous tissue is appropriate.

9:00 AM - 4:00 PM

Outpatient Abdominoplasty Facilitated by Rib Blocks

Presenter:	George A. Csank, MD
Co-Authors:	Basil M. Michaels, MD, Frederick N. Eko, MD
Affiliation:	University of Massachusetts, Pittsfield, MA

Background

Fine et al and others have been exploring alternative methods of anesthesia for abdominoplasties to safely avoid general anesthesia. Preoperative methods to control pain may result in decreased narcotic administration, decreased Post Operative Nausea and Vomiting (PONV), and ultimately better pain control which all lead to increased patient comfort and feasibility of performing abdominoplasties as outpatient procedures. We have added the use preoperative rib blocks with a bupivicaine/lidocaine mix to supplement traditional anesthesia techniques in abdominoplasties in an attempt to obtain these benefits.

Methods

All cases of abdominoplasty performed by the author were reviewed from 1999 to 2006 and divided into two groups. Group 1 was comprised of the 39 surgeries performed using general endotracheal anesthesia (GETA). Group 2 was comprised of the 29 surgeries performed using rib blocks placed by the surgeon and supplemented by intravenous anesthesia with additional airway control by Laryngeal Mask (LMA) as needed. Thirteen patients were excluded from the present study because a pain pump was placed intraoperatively to help decrease post operative pain at home. Chart review collected data on: time in the operating room, and recovery room; use of intraoperative and post operative narcotics; use of intra and post-op anti-emetics; need for LMA; frequency of PONV and pain. ASA class, BMI, additional concurrent procedures, and age were also compared to show the groups were similar. All anesthetic and surgical complications and the need for hospitalization were also recorded. Statistical analysis with student t-tests was used to reject the null hypothesis when comparing the two groups.

Results

Statistically significant decreases in recovery room time, PONV and pain were achieved using rib blocks. Operative times, intraoperative narcotic and antiemetic drugs as well as ASA, BMI, age, complications were all similar for both groups.

Conclusion

Rib blocks placed before the start of surgery result in decreased recovery room times, pain and PONV achieving increased patient comfort and feasibility of performing abdominoplasties in the outpatient setting.

9:00 AM - 4:00 PM

Pediatric Maxillofacial Trauma in Bicycle-Related Injuries

Presenter:	Neil Tanna, MD
Co-Author:	Ananth Murthy, MD
Affiliation:	The George Washington University, Washington, DC

Background: Bicycle accidents can be a significant source of childhood morbidity. While many of these patients will present with facial injuries, the characteristics and patterns of bicycle-related pediatric maxillofacial injuries remain inadequately investigated.

Objectives: To determine any patterns of maxillofacial injuries sustained by pediatric patients in bicycle accidents and assess any predisposing factors influencing these injuries.

Study Design/Methods: Retrospective review of bicycle-related injuries evaluated at Children's National Medical Center, Washington, DC, between January 1, 1989 and June 30, 2006.

Results: Of 700 cases of bicycle-related injuries, 185 patients (26%) sustained facial injuries. When grouped by age, 4% were 0-4, 38% were 5-9, 49% were 10-14, and 9% were 15-19 years old. Males accounted for 82% of all patients with facial injuries. Helmet use was reported by 2.1% of patients, denied by 86% of subjects, and unknown in 12% of cases. During the school year (September-May) 62% of injuries occurred, while the remaining 38% occurred during summer vacation (June-August). Soft tissue facial trauma was the most common sustained injury (48%), followed by soft tissue oral cavity injuries (16%), facial fractures (14%), ocular injury (10%), dentoalveolar trauma (9%), and auricular injury (3%). Mandibular fractures accounted for 38% of facial fractures, with nasal bone (34%), midfacial (19%), and frontal bone (9%) fractures constituting the remainder. The majority of facial fractures were observed in the age groups 10-14 (64%) and 5-9 (25%). Hospital discharge was within twenty-four hours of admission in 55% of children, between 1 and 3 days in 24% of patients, and greater than three days in 21% of cases.

Conclusions: Facial injuries from bicycle-injuries in children represent a cause of significant morbidity and serious health concern. The high risk patient for facial injury is the male child aged 5-14. Bicycle helmets may be a protective factor for all patients, as the majority of children with facial injuries denied helmet use.

9:00 AM - 4:00 PM

Placement of Alveolar Bone Graft or Dental Implant Independently Affects Maxillary Stress and Strain in the Patient with Unilateral Facial Skeletal Cleft

Presenter:	Linping Zhao, PhD
Co-Authors:	David E. Morris, MD, Pravin K. Patel, MD
Affiliation:	Shriners Hospitals for Children, Chicago, IL

PURPOSE: Oral function is impaired and skeletal growth altered in the patient with a unilateral facial skeletal cleft. Reconstructive surgery with alveolar bone graft (ABG) restores continuity of the maxilla and encourages more symmetric skeletal growth. While placement of an osseointegrated dental implant further improves oral function, it is not clear whether the dental implant affects midfacial skeletal development. Our previous finite element (FE) model demonstrated that the unilateral cleft creates a non-uniform and asymmetric stress-strain distribution within the maxilla during functional tasks and that ABG normalizes this stress-strain distribution. This study intends to: 1. confirm this finding through a patient-specific finite element model and, 2. demonstrate whether the loaded dental implant would further reduce the severity of the asymmetric stress-strain distribution.

METHODS AND MATERIALS: We developed three-dimensional FE models of the patient-specific maxilla with a unilateral cleft based upon CT scan data. The models were further elaborated by adding ABG alone to the cleft, followed by ABG with a loaded dental implant. We analyzed the stress-strain distribution pattern within the maxilla under an evenly distributed occlusal loading on the entire dentition without change in the material models or boundary conditions. The severity of asymmetric stress-strain distribution was quantified using the Asymmetric Index at nasal buttress, alveolar process near the canines, and first molars.

RESULTS: We found a significant reduction in the Asymmetric Index in the maxilla following ABG. The addition of a functionally loaded dental implant further reduced the Asymmetric Index compared to that without the implant.

CONCLUSIONS: This patient specific finite element model confirmed that ABG considerably reduces the asymmetric stress-strain distribution in the maxilla of the patient with a unilateral cleft. The loaded dental implant further reduces such asymmetric stress-strain distribution. These findings suggest that once the alveolar cleft has been reconstructed with a bone graft, placement of an osseointegrated dental implant is an effective way of promoting symmetric structural loading of the maxilla. Without loading, the graft would undergo remodeling with a volumetric decrease in the bone within the cleft region.

9:00 AM - 4:00 PM

Post-bariatric Reconstruction: Patient Myths, Perceptions, Cost, and Attainability Strategies

Presenter:	Jeffrey A. Gusenoff, MD
Co-Authors:	Susan Messing, Ralph Pennino, William O'Malley, Thad Boss, Howard Langstein
Affiliation:	Pittsburgh, PA

Purpose: Plastic surgeons caring for patients after gastric bypass procedures have noted a significant gap between patient perceptions regarding post-bariatric reconstruction and attainability, cost, insurance coverage, and value. The purpose of this study is to investigate the perceptions of prospective bariatric surgical patients and identify misconceptions and strategies to potentially aid in the attainability of post-bariatric reconstructive surgery. Methods: 176 prospective gastric bypass patients were surveyed. We evaluated their perspectives on plastic surgery, a new “Club” concept integrating plastic surgical/bariatric teams, in addition to identifying payment strategies for these patients. Cost comparisons were set up to compare to major consumer purchases. Outcome measures were assessed by univariate analysis. Results: 174 patients (139 F, 35 M, mean age 42.3 yrs, mean BMI 49.3 kg/m2) completed the survey. 65.9% expressed an interest in plastic surgery; women were more interested than men (p<0.05). 47% desired a consult with a plastic surgeon at the time of their initial gastric bypass consultation. 73.1% wanted their plastic surgeon affiliated with the bariatric surgeon/team. 14.4% of patients equated the cost of a total body lift to the cost of a new car, versus 3.8% for a new home, 31.9% for a trip for two to Disneyworld, 23.8% for a flat screen TV, and 16.3% for a radio. Participants were willing to pay 2x as much for a new car as for a total body lift. Patient estimates for costs of plastic surgical procedures were underestimated by 60%. 42% of patients needed a payment plan, whereas another 41% needed to save or borrow money. 73.8% were interested in a “Club” environment, with most desiring an exercise component. 73% would pay a “Club” fee, although this monthly fee was estimated at 14x less than people would pay for a monthly car payment. 60% were interested in a monthly payment plan that paid into a “Club” account that could be used for plastic surgery in the future. 35% were willing to pay a monthly fee for certain procedures they desired in the future. 22% were interested in a flat fee for unlimited plastic surgery in the future with an average up-front payment of $9,722. None of the independent variables predicted which payment plan would be the most practical. Conclusion: Future gastric bypass patients, particularly women, are a unique population with a concentrated desire for plastic surgery. Common misconceptions exist with regards to post-bariatric reconstructive surgery. Early patient education, financial awareness, in combination with pre-existing or newly created bariatric centers, may improve attainability and overall well-being for this population.

9:00 AM - 4:00 PM

Predictors of Ideal Nipple Position in Breast Reduction Surgery

Presenter:	Brian Olack, MD
Co-Authors:	Jane Garb, MS, Kristin Stueber, MD
Affiliation:	Tufts University School of Medicine / Baystate Medical Center, Springfield, MA

Background: In reduction mammoplasty, the new nipple position is often marked at 19 – 21 cm from the mid-clavicle. This may not be appropriate for all body sizes, and can leave nipples that are too high.

Methods: Fifty consecutive patients had preoperative measurements from mid-clavicle to the inframammary fold. The height, weight and BMI were recorded. At one-year post surgery, nipple distance from mid-clavicle and vertical incision length were recorded in 27 patients. The vertical incision length was compared to the 4 cm operative length, and the difference was called the change in the infra-areolar distance.

Results: The mean ideal nipple height as measured preoperatively by the distance from the mid-clavicle to the inframammary fold was 22.7 cm (18.5 – 27). This correlated with BMI (p <0.01), and did not correlate with height. The mean increase in the infra-areolar distance was 2.7 cm (1.0 – 3.5). This correlated with BMI (p <0.01), and with the amount of tissue resected (p <0.01).

Conclusions: The distance from mid-clavicle to the new nipple location is not a set number, but should be based on the BMI of the patient. Additionally, the infra-areolar distance lengthens and should be adjusted preoperatively to decrease the effects of “bottoming out.”

9:00 AM - 4:00 PM

Pseudoptosis after Breast Reduction in Bariatric Weight Loss Patients

Presenter:	Norma I. Cruz, MD
Affiliation:	University of Puerto Rico, San Juan, PR

Introduction: Breast reduction surgery is performed for symptomatic macromastia in overweight patients and in bariatric weight loss patients who continue to have severe macromastia. However, because quality and laxity of skin in bariatric weight loss patients are different, the tendency for pseudoptosis or “bottoming out” is greater.

Method: The control group consisted of 21 obese women (BMI 30 to 40) who underwent a Wise pattern reduction mammoplasty for severe macromastia. The study group consisted of 20 obese women who, after bariatric weight loss, had a similar type of reduction mammoplasty to treat persistant severe macromastia (Pittsburg rating scale of 1). Breast measurements were made at one month and again at one year after surgery.

Results: There was no significant difference between the control and the study groups regarding age (30±11 vs. 32±10), body mass index (35±4 vs. 36±4), and grams of tissue excised per breast (987±216 gm vs. 956±253 gm). However, one year after surgery the mean distance between the inframammary fold and the inferior areola was significantly longer in the study group (control group 9±2 cm vs. study group 14±2 cm).

Conclusion: Bariatric weight loss patients have greater pseudoptosis after breast reduction than overweight patients who maintain their weight.

9:00 AM - 4:00 PM

Quantifying Soft Tissue Changes in the Aging Midface

Presenter:	Ulysses Scarpidis, MD, MPA
Co-Author:	Rich Novack, BA
Affiliation:	UMDNJ - New Jersey Medical School, Jersey City, NJ

We hypothesize that soft tissue volume loss, in the form of fat atrophy, contributes more significantly to the patterns of facial aging than is conventionally accepted.

The facial soft tissue of thirty women was evaluated using CT studies of the maxilla. They were grouped by age and race and matched for body mass index. The distance between the bony skeleton and the skin was measured at discrete areas of the face from the inferior orbital rim to the inferior portion of the maxilla.

We present a significant difference in soft tissue thickness between women aged 20 to 25 and women aged 40 to 45. With increasing age, there is a decrease in soft tissue thickness at the infraorbital and malar areas while there is an increase in soft tissue thickness at the inferior maxilla. This is consistent with our hypothesis that while gravitational forces on the deep tissues of the face result in their inferior displacement, there is associated overall fat atrophy with advancing age.

These results will improve facial rejuvenation surgery by providing an objective guide for volume augmentation and repositioning that optimally addresses the deep tissue changes in facial aging.

9:00 AM - 4:00 PM

Reconstruction Of Posterolateral Mandibular Defects With Extensive Soft Tissue Component Using Non-osseous Free Tissue Transfer

Presenter:	Arif Chaudhry, MPH
Co-Authors:	Afshin Mosahebi, MBBS, PhD, MBA, Colleen Mccarthy, MD, Pravin Reddy, md, Martin Jugenburg, md, Babak J. Mehrara, MD, Andrea L. Pusic, MD, MHS, FACS, FRCSC, Joseph J. Disa, MD, Peter G. Cordeiro, MD
Affiliation:	Memorial Sloan Kettering Cancer Center, New York, NY

Purpose: The management of composite oromandibular defects involving the posterolateral mandible and surrounding soft tissue remains a reconstructive challenge. While bony reconstitution restores continuity of the mandible, osteocutaneous flaps usually do not provide adequate soft tissue coverage of post-ablative defects. The purpose of this study was thus to evaluate the use of soft tissue flap reconstruction for extensive, posterolateral, oromandibular defects.

Methods: Consecutive patients who underwent reconstruction of composite oromandibular defects following posterolateral mandibulectomy between 1992 and 2006 at a single center were identified. Patient demographics, oncologic, reconstructive and outcome data was obtained from a prospectively-maintained clinical database. Medical records were retrospectively reviewed to further characterize the surgical extent of all post-ablative, soft-tissue defects. Soft-tissue resection zones were defined as those involving the: retromandibular trigone, palate, pharynx, floor of the mouth, tongue, cheek and lips.

Results: In total, 330 patients who underwent microvascular reconstruction following mandibulectomy were identified. Seventy-six patients (23 %) were further identified as having extensive, posterolateral, oromandibular defects reconstructed with soft-tissue flaps alone. The majority of these patients had a diagnosis of squamous cell carcinoma (n= 47); mean patient age was 59 years. In 68% of patients who underwent non-osseous free tissue transfer, the oromandibular defect involved °Ý 2 soft-tissue zones. (Table 1). The most common flap used was the vertical rectus myocutaneous flap (n = 68), followed by the anterolateral thigh (n = 4), the gracilis (n = 2) and the latissimus dorsi (n = 2). Overall flap survival was 96%; partial flap loss occurred in 6.6% of cases. Mean hospital stay was 17 days (range: 4-76). The most common peri-operative complication was infection (18%), followed by the development of orocutaneous fistulae (6.6%). At the time of discharge, 65% of patients were on an oral diet. Fifty-fix percent of patients who underwent subsequent speech evaluation had intelligible speech. Overall aesthetic outcome was good in 48%, fair in 22% and poor in 30% of patients.

Conclusions: Posterolateral mandibular defects with extensive soft tissue components can be effectively repaired using soft tissue flaps alone. In patients whose oromandibular defect involves the resection of >2 zones of surrounding soft-tissue, the vertical rectus myocutaneous flap can provide a large volume of soft-tissue for reliable wound closure. Function can be restored in the majority of patients. Similarly, in the majority of patients, fair to good aesthetic results can be achieved, especially in those without external skin defects.

Table 1.

No. of Soft Tissue Zones  Resected During   Tumor Ablation	Patients   n = 76
1	25(32%)
2	22 ( 29%)
3	20 (27%)
4	7 (10%)
5	1 (1%)
6	1 (1%)

9:00 AM - 4:00 PM

Reconstruction with Galeal Flap of Depressed Forehead Region in Progressive Hemifacial Atrophy

Presenter:	Ahmet Duymaz, MD
Co-Authors:	Furkan Erol Karabekmez, MD, Zekeriya Tosun, MD, Mehtap Karamese, MD, Mustafa Keskin, MD, Nedim Savaci, MD
Affiliation:	Selcuk University, Konya

Progressive hemifacial atrophy (PHA) is a rare disorder characterized by slowly progressive self-limited degeneration of the soft tissues of half of the face including dermis, subcutaneous tissue, fat, cartilage, and, sometimes, bone. Characteristically, the atrophy progress slowly during many years and, then, it becomes stable. 21 years-old female patient was admitted to our clinic because of a complaint of left facial atrophy. The physical examination was found facial asymmetry with a marked hypoplasia of the left side of the face including, blepharophimosis, with absence of the medial half of the left brow. Galeal flap from right frontal-parietal area was performed for filling of atrophic site of the left forehead, was added hairy scalp to distal part of the galeal flap for brow reconstruction Many reconstruction techniques including fat grafts, dermal/fat grafts, synthetic filling materials, microvascular tissue transfers, and alloplastic materials were described for soft tissue augmentation in PHA. Particularly, galeal flap is a good choice when compared with free tissue transfer that has high donor area morbidity. In our case, acceptable result has been obtained in respect that both aesthetically and functionally. Galeal flap is a suitable opinion for reconstruction of upper third of the face for PHA because a simple operative technique, aesthetically acceptable results and no major donor area morbidity.

9:00 AM - 4:00 PM

Reduction Mammaplasty-Analysis of outcomes stratified by weight of reduction: Does size really matter ?

Presenter:	Jason A. Spector, MD
Co-Authors:	Sunil Singh, BS, Nolan S. Karp, MD
Affiliation:	Weill Cornell Medical College, New York, NY

PURPOSE: Literally dozens of studies have shown that reduction mammoplasty (RM) is efficacious in reducing the burden of symptoms and improving the quality of life for patients with macromastia. However, most insurance carriers will not reimburse for mammoplasty involving less than 1000g total tissue resected. In order to assess the validity of this arbitrary policy we set out to examine whether patients' pre-operative symptoms as well as the amount of post-operative improvement were correlated with the amount of tissue resected. METHODS: All patients were given a custom designed questionnaire designed to evaluate the patients' macromastia-related symptoms and other macromastia-related quality of life issues. Patients were then provided the same questionnaire at their final post-operative visit between three and twelve months after surgery. Patients were stratified according to the total amount of tissue resected (Group <1000g [Avg: 826g], 1000-1500g [Avg: 1184g], 1501-2000g [Avg: 1715g], >2000g [2272g]) and their responses analyzed using an ANOVA across the groups. RESULTS: A total of 188 patients who underwent RM (by a single surgeon, NK) completed both the pre-op and post-op questionnaires. ANOVA across groups demonstrated significant differences in only three pre-operative measures: lower back pain, shoulder pain and painful bra straps and grooves (p<0.05). There were no significant differences in several pre-op measures such as upper back pain, neck pain, arm pain, shoulder or hand pain, headaches, breast pain, difficulty finding clothes and bras, rashes and itching, difficulty running and doing sports. ANOVA across groups <2000g revealed a significant difference only in pre-operative painful bra straps and grooves (p<0.05). Furthermore, ANOVA across all groups assessing the change between pre-op and post-operative symptoms demonstrated no significant differences with the exception of shoulder pain (p<0.05). CONCLUSION: This prospective, longitudinal study provides the first analysis of outcomes from RM stratified by the amount of tissue resected. These data indicate that patients' pre-operative symptoms are not statistically different across a wide range of tissue weights resected. Furthermore, our data demonstrate that the improvement experienced by patients undergoing RM is largely not statistically different over a wide range of resection weights. These data conclusively demonstrate the widely held impression of many plastic surgeons that macromastia is not a term that can be defined by a number but rather needs to be considered within the context of the individual patient.

9:00 AM - 4:00 PM

Reduction of Intracranial Pressure after Craniosynostosis Surgery

Presenter:	Lars H. Evers, MD
Co-Authors:	Dhaval Bhavsar, MD, Allen Ho, BS, Hal Meltzer, MD, Michael Levy, MD, PhD, Steven Cohen, MD
Affiliation:	University of California, San Diego, CA

Introduction: Premature closure of cranial vault sutures may be related to chronically elevated intracranial pressure (ICP). The presence of raised ICP in craniosynostosis can be diagnosed on the basis of clinical and radiographic features as well as from invasive monitoring. In the management of craniosynostosis, we have found ICP monitoring with an intraparenchymal monitor to be a useful and safe means of identifying those children with raised ICP who would benefit from surgical intervention. We studied the role of cranial vault remodeling surgery in reducing increased ICP. Methods: Out of 190 patients who underwent surgery for craniofacial deformities (2002-2006), 16 patients had raised ICP diagnosed clinically and/ or with invasive monitoring, 12 of them evaluated solely by clinical signs such as papilledema and 4 with the addition of ICP monitoring. Continuous ICP monitoring was carried out for a minimum of 12 h. Sustained elevations of > 20 mm Hg during non REM sleep was considered diagnostic of pathologic ICP. Children with a history of previous cranial vault surgery or hydrocephalus were excluded from this study. Results: Of the 16 patients with evidence of intracranial hypertension studied following cranial vault surgery, all patients showed clinical improvement with resolution of papilledema and preoperative symptoms such as headache. No patient in follow-up has had evidence of permanent visual decline. Conclusion: The recognition of significant clinical symptoms and signs of intracranial hypertension in patients with craniosynostosis including in selected cases invasive ICP monitoring can aid in formulating a surgical management plan incorporating the need to normalize ICP as well as correct the frequently severe functional and cosmetic consequences of these disorders. A well-planned cranial vault reconstruction can significantly reduce pathologic ICP and prevent its attendant permanent neurological sequelae.

9:00 AM - 4:00 PM

Reliability of the Helical Advancement Flap for Auricular Reconstruction

Presenter:	Neil Tanna, MD
Co-Author:	William H. Lindsey, MD
Affiliation:	The George Washington University, Washington, DC

EDUCATIONAL OBJECTIVE: At the conclusion of this presentation, the participants should be able to understand the technique and its potential complications.

OBJECTIVE: To review a series of auricular reconstruction cases in which the helical advancement flap was utilized.

DESIGN: Case series.

SETTING: University medical center and private practice.

PATIENTS: 78 consecutive patients with auricular defects, resulting from oncologic resection, in whom reconstruction with a helical advancement flap was suitable.

INTERVENTION: Helical advancement flap by a single surgeon (W.H.L.).

MAIN OUTCOME MEASURE: Viability of the flap and presence or absence of surgical complications.

RESULTS: There were no complete flap failures. Partial necrosis of the distal end of the flap was observed in 2 smokers (2.6%). One patient required revision of the flap (1.3%). Hematoma occurred in 4 patients (5.1%), with 3 cases requiring a return to the operating room for control of bleeding. Infection developed in two patients (2.6%). Hypertrophic scarring was noted in 5 patients (6.4%), which responded to limited steroid injections. Contour deformities, including collapse or flattening of the helical rim, was not observed.

CONCLUSION: The helical advancement flap is a reliable tool in the reconstructive armamentarium of the facial plastic surgeon.

9:00 AM - 4:00 PM

Routine Perioperative Antibiotic Use in Reduction Mammaplasty

Presenter:	Joseph Thornton, MD
Co-Authors:	Debbie A. Kennedy, MD, Susan Gannon, MD
Affiliation:	Albany Medical Center, Albany, NY

Intro: Reduction Mammoplasty is a procedure commonly performed by plastic surgeons, yet there remains controversy over the use of perioperative antibiotics. Presented here is a single surgeon's longitudinal experience with and without the routine use of perioperative antibiotics. Patients: All patients undergoing bilateral inferior pedicle reduction mammoplasty by a single surgeon from June 2001 until March 2006 are included, numbering 173 consecutive surgeries. These bookend a change in practice transitioning to the routine use of perioperative antibiotics. The standard inferior pedicle Wise pattern is used for all reductions. Methods: Retrospective chart review of office and hospital charts documenting the use of perioperative antibiotics, co morbid conditions, reduction size, operative time, wound complications and clinical wound infections which required further treatment is undertaken. Results: 173 patients were reviewed, 90 receiving perioperative antibiotics and 83 not receiving antibiotics. Patient populations, operative times and volumes removed were similar as were overall wound complications; however, there is a significant reduction in clinical infections from 32% to 17% with antibiotic use (p<0.05). Conclusions: While antibiotic use has potential morbidity, in this series, its use in routine reduction mammoplasty has reduced the clinical infection rate by one half from 32% to 17%.

9:00 AM - 4:00 PM

Shaping Alloderm to Overcome Contour Deformities in Autologous Breast Reconstruction

Presenter:	Aldona J. Spiegel, MD
Co-Authors:	Hector Salazar-Reyes, MD, Deana Shenaq, MS, II, Jason R. Bailey, MD
Affiliation:	The Methodist Hospital, Institute for Reconstructive Surgery, Houston, TX

Purpose:

The main goal of our study is to demonstrate that Alloderm can be effectively used to overcome upper pole deformities after autologous breast reconstruction.

Background:

Today surgeons are confronted with increasingly demanding reconstructions. Upper pole defects represent a reconstructive challenge, as they are often caused by a mastectomy which extends to a more superior resection than what can be filled by the autologous tissue. This lack of tissue in the superior rim of the reconstructed breast translates into a subtle depression that may become noticeable. There are limited options for the reconstruction of such defects. Fat grafting has been used with partial success, but it still presents several difficulties such as irregularities, fat necrosis and tissue loss. We suggest a novel use for alloderm that can be tailored to the particular needs of the patient.

Methods and Materials:

In our technique, we shape and suture Alloderm using it as a biological scaffold to correct the previously mentioned defect. An observational retrospective study will be presented.

Results:

Twenty-nine patients were included in our study. Alloderm was placed in 34 breasts. The follow-up in patients ranged from four years to six months, with only five patients under one-year of follow-up. Twelve anatomical sites were radiated previously to the alloderm placement. Patients were reconstructed with DIEaP, SIEA, TRAM or SGAP flaps. Overlying skin necrosis, loss of material, material extrusion, infection, were considered as major complications. No major complications presented in our study. In only one patient, who subjectively had felt the alloderm with movement, alloderm was partially excised. Other minor complications included pruritus (2.9%), material migration (3.8%) material crumpling (2.9%) and subtle overlying skin wrinkling (2.9%). From the aesthetic point of view results were judged good to excellent in all cases.

Conclusion:

Based in our encouraging results we conclude that Alloderm is a safe and reliable option to correct the superior contour defects occurring in autologous breast reconstruction.

9:00 AM - 4:00 PM

Split-face Comparison Study Of Restylane Versus Puragen In The Treatment Of Glabellar Lines

Presenter:	Taro Kono, MD
Co-Authors:	Yuji Kikuchi, MD, Hiroyuki Sakurai, MD, Takashi Yamaki, MD, Motohiro Nozaki, MD, PhD
Affiliation:	Tokyo Women's Medical University, Tokyo

Objectives: Currently, various hyaluronic acids are being used to rejuvenate facial skin. There are few direct comparison studies between them. And there is no comparative study of Restylane versus Puragen. The objective of our study is to compare the effectiveness and complications of Restylane versus Puragen in the treatment of glabellar lines. Materials and Methods: Ten female patients were enrolled in this study. A half of the side was treated with Restylane and the other side was treated with Puragen. Two independent blinded observers reviewed the clinical photographs at 3, 6, 9, 12 months after the treatment and assessed for degree of improvement as well as complications. A Canfield Visia CR system was used to objectively evaluate the patient. Complications such as skin necrosis, infection, allergy, discoloration, telangiectasia, sterile abscess, granuloma were evaluated each follow up visit. Results: The two products were equally effective in producing an optimal cosmetic result, although at 6, 9 and 12 months post treatment, a higher proportion of patients showed over 50% improvement with Puragen than with Restylane. At 12 months post treatment, Puragen was considered superior in 70% of patients, whereas Restylane was superior in 10% of patients. There was no difference in 20% of patients. Treatment-related adverse events were not observed in any patients. Conclusions: Both Restylane and Puragen were equally effective in producing an optimal cosmetic result. Puragen provides a more durable esthetic improvement than Restylane in the treatment of glabellar lines.

9:00 AM - 4:00 PM

Style 410 Highly Cohesive Silicone Gel Breast Implant Results through 4 Years from the U.S. Multi-Center Core Clinical Study

Presenter:	Bradley P. Bengtson, MD
Co-Authors:	Diane K. Murphy, MBA, Araceli Slicton, BA, Patricia S. Walker, MD, PhD
Affiliation:	Plastic Surgery Associates, Grand Rapids, MI

Purpose: Since their introduction in 1993, the Style 410 highly cohesive silicone gel breast implants have become the gold standard of shaped implants in countries where they are available. This next generation implant has a more crosslinked silicone gel filler than standard responsive gel implants and is designed to hold its shape even when the shell is not intact.

Methods: Safety and effectiveness of Style 410 implants are being evaluated through a prospective study conducted by 48 investigators throughout the US. Follow-up exams occurred between 0-4 weeks, at 6 months and then annually, with results currently available through 4 years. Complications, reoperation rates and implant removal/replacements were assessed in addition to patient satisfaction.

Results: The 410 pivotal study enrolled 941 subjects: 492 primary augmentation, 225 reconstruction, 156 revision augmentation and 68 revision reconstruction patients. Complication rates were consistent with or better than those reported for responsive Inamed^® silicone-filled breast implants. Patient satisfaction rates were uniformly high, with more than 85% in each cohort expressing satisfaction with their implants.

Conclusion: The study results address safety and effectiveness endpoints for the Style 410 highly cohesive silicone-filled breast implants with 4 years of follow-up.

9:00 AM - 4:00 PM

Subcutaneous Temporal Brow Lift Under Local Anesthesia: A Useful Technique for Periorbital Rejuvenation

Presenter:	Rafi S. Bidros, MD
Co-Authors:	Jeffrey D. Friedman, MD, Hector Salazar-Reyes, MD
Affiliation:	The Methodist Hospital, Houston, TX

Background:

Various techniques have been described for elevation of the ptotic brow. A subcutaneous, temporal approach is a simple and effective procedure for elevation of the central and lateral brow particularly in patients with an elevated frontal hairline or in cases of positional brow asymmetry. We describe our technique and experience with this procedure using local anesthesia in the office setting.

Methods and Materials:

A retrospective assessment was conducted of patients treated with this approach from the years 2000-2006. All procedures were performed in our minor procedure room using only local anesthesia. The proposed surgical approach consists of a temporal incision located at the frontal hairline and extending into the temporal hair bearing scalp. A subcutaneous elevation of the forehead skin was performed to the level of the brow. A slightly greater than 2:1 excision of skin was performed along a superior/lateral vector depending on the patient's preferences. A single layer closure was then performed and a dressing placed for 48 hours. Preoperative and postoperative photographs were evaluated for the effectiveness of the procedure.

Results:

A total of 28 patients were treated over this 7 year period with 23 bilateral and 5 unilateral procedures performed. All patients healed without complication and only one patient required revision surgery to remove a small dog ear. An additional patient desired a greater degree of lift and was subsequently revised. Scarring was minimal and was rated as excellent by both patients and surgeon. The effectiveness of the brow elevation was rated as good to excellent in all but one patient. Facility costs associated with this procedure averaged $400.

Conclusions:

Brow lift is often an essential facet for a pleasing aesthetic result in the periorbital region. This subcutaneous brow lift technique adds to the armamentarium of techniques that are available, and can be performed in the office under local anesthesia. It has proven to be a very effective, reproducible and inexpensive technique. In addition, it can be an excellent stand alone procedure in younger patients and be revised easily without the need for general anesthesia.

9:00 AM - 4:00 PM

Sublabial Approach for Columellar Reconstruction/Lenghtening in Corrective Rhinoplasty

Presenter:	Sarit Cohen, MD
Co-Authors:	Dean D Ad-El, MD, Joseph Shem Tov, MD
Affiliation:	Rabin Medical Center,Belinson Campus.Affliated to Sackler Faculty of Medicine, Tel Aviv University,Israel., Petah Tiqwa

ABSTRACT Background: Columellar reconstruction is a challenging endeavor, both functionally and aesthetically. Columellar retraction leading to tip collapse can be the result of trauma, infection, malignancy, iatrogenic cause or congenital deformity. The purpose of the present study was to present a novel technique of columellar lengthening via the sublabial approach. Methods: Thirty-two patients (21 men, 11 women) with columellar collapse underwent columellar reconstruction via the sublabial approach. Mean age of the patients was 33.8 years (range 17 to 58 years). Operative technique: Donor cartilage is harvested. The ideal source is the nasal septum.Other sources are conchal or rib cartilage. A graft, 5 mm wide X 2 to 2.5 cm long X 2 mm thick is carved with carefully beveled edges. An inverted V-shaped incision is made in the midline of the labial mucosa, beginning at the gingiva, avoiding the frenulum . The incision is carried on cephalad toward the nasal septum and includes sectioning of the origin of the depressor septi nasi muscles until reaching the nasal spine. Blunt dissection with Metzbaum scissors is then performed, superiorly into the columella between the medial crura of the lower lateral cartilage and into the membranous septum. The graft strut is then introduced through the sublabial tunnel created . Graft bulging above the level of the domes should be avoided. The graft strut is fixed using a straight needle and an absorbable suture. A transfixion suture is made to support the graft to the anterior septum. An additional crescent-shaped graft is carved and introduced transorally, through the tunnel created, embracing the base of the fixed graft, thus securing it in position, and keeping it from migrating anteriorly and into the upper lip. This graft is fixed to the periosteum of the maxilla or to the nasal spine . Case presentations: Case 1- A 38-years old man who underwent mandibular advancement at 15 years of age and submucosal resection 6 years before admission because of respiratory difficulties is presented.Preoperative photos and postoperative result at one year following graft insertion via the sublabial approach and a conservative hump removal via an intercartilagenious incision are demonstrated. Case 2- A 45-year old man who underwent submucosal resection 1.5 years before operation is presented .His chief complain was nasal obstruction. Examination revealed columellar retraction,absent caudal septum and anterior nasal spine and an obstructed internal nasal valve. Preoperative photos and postoperaive results at 15 months following insertion of a conchal graft via the sublabial approach are demonstrated. Results: The mean follow-up was 21 months. Postoperative complications included graft absorption in 2 cases (6.25%), graft extrusions in 2 cases (6.25%), and postoperative infection in one case (3.12%). Reoperation rate was 4/32 (12.5%). Average operating time was 35 minutes for septal graft, and 55 minutes for conchal graft. Conclusion: Columellar reconstruction via the sublabial approach is an anatomic, minimally invasive, time-saving procedure. The operative technique is easy to perform with a short learning course. The septal grafts introduced via the sublabial approach anatomically position the columella, address columellar retraction and establish columellar length. They create tip definition and projection, brace the external valve against collapse, support the lining of the vestibule and restore lobular shape. The resultant, inconspicuous scar is cosmetically superior to the visible scar created by open rhinoplasty. The sublabial approach may be indicated in cases of revisionary rhinoplasty when previous scar tissue may entail a difficult dissection and manipulation and limit reexpansion and reshaping of the covering skin, while a virgin operative field will allow a secure and time-saving procedure. It is advantageous in cases of previous septal operations and when septal perforation is present.

9:00 AM - 4:00 PM

Surgical Treatment for Frontal Sinusitis after Craniotomy

Presenter:	Nobutaka Yoshioka, MD, PhD
Co-Authors:	Michiaki Hiramoto, MD, PhD, Haruo Ogawa, MD, Hiroko Nakatani, MD
Affiliation:	Saiseikai Nakatsu Hospital, Osaka

INTRODUCTION: It is well known that frontal sinusitis sometimes develops after craniotomy if frontal air sinus is opened and closed inappropriately at the craniotomy. It is controversial that the affected frontal air sinus should be cranialized, obliterated or preserved. The purpose of this study is to evaluate our method of sinus preservation.

MATERIALS & METHODS: From 1998 to 2006, we treated ten cases of frontal sinus complications which have developed more than one month after craniotomy. An initial finding of every case was skin fistula with purulent discharge. Infection developed more than 1 year after craniotomy in seven cases. And in the other three cases infection developed a few months after craniotomy. At first surgery, debridement and sinus preservation with frontalis-pericranial flap was performed. At second surgery, cranioplasty with hydroxyapatite ceramic implant was performed. Mean follow-up range was 42 months (range: 4 to 84 months).

RESULTS: Preoperative CT scan showed soft tissue density of affected frontal sinus in every case. Inflammation induced by bone wax seemed the main cause of frontal sinusitis in every case.Eight cases showed uneventful postoperative course. Two cases showed recurrence of infection within a few months. In one of the two cases with recurrence of infection, the frontal sinus was obliterated with temporalis muscle flap. This case showed uneventful course after the frontal sinus obliteration. The other case was managed conservatively.

CONCLUSION: The results reported here with preservation method showed relatively good results. However, nasofrontal duct is likely to become narrow or obstructed spontaneously in the case of more than 10 years after craniotomy. And we should choose sinus obliteration or cranialization in such a case with recurrence of infection after sinus preservation.

9:00 AM - 4:00 PM

Suspension and Redrapping of the Free Columella - Lip Complex

Presenter:	Eser Yuksel, MD
Co-Authors:	Maria del Carmen Martinez, MD, Gerardo Guerra, MD, Lauren Mc Farlane, BS
Affiliation:	Baylor College of Medicine, Houston, TX

INTRODUCTION The youthful and attractive look of the midface is determined by the distal nose to upper lip unit. For many years women have searched for a thick, voluminous upper vermillion thought of as the principal element of midface attractiveness. This has led to the development of many techniques to increase vermillion volume without addressing other midface components. However, the ideal configuration of the upper lip is that of a triangular shape with central elevation, yielding at least 2 – 3 mm of central incisive upper teeth exposure, which independently of other facial features gives freshness resembling the triangular mouth of an infant. These features accompanied by a short central upper lip, increased vermillion volume, adequate nose tip projection and columella length define the perfect components of an aesthetically pleasing midface. Correcting a long central upper lip, an acute nasolabial angle, a short columella and lack of tip projection would generally require many different procedures. Therefore the author suggests a simple technique which targets all the above mentioned midface components at the same time, as an additional maneuver during rhinoplasty or as an individual procedure.

MATERIALS AND METHODS 28 patients underwent the procedure proposed; 9 as an isolated in office procedure and 19 as an adjunct to a planned rhinoplasty. Patients where selected if they presented with the following features: long upper lip, lack of upper central incisive show or triangular upper lip figure with the mouth in the resting position, short columella or lack of nasal tip projection and acute nasolabial angle. Procedure: A transcolumellar, transfixion incision is performed and extended inferiorly in a horizontal plane 5 mm to each side of the columella. Blunt dissection is performed at the ANS and premaxilla releasing the depressor septi nasi muscle and the proximal border of the orbicularis oris muscle obtaining a free mobile columella – upper lip unit. The caudal septal cartilage is exposed free of perichondrium and nasal mucosa. Using 3-0 nylon two transverse thick bites are placed through the upper central margin of the orbicularis muscle from one nostril to the other within the extended incisions. These sutures are pulled in a cranial direction to be fixed at the caudal end of the septal cartilage in the reverse direction placing the knots one at each side of the septum to achieve symmetry. These circles of passant are tightened to a tolerable tension. The mucosa is closed by 5-0 plain fast absorbable sutures. Sometimes cephalic trim of the alar cartilages, and release of the dorsal skin unit are needed in conjunction when a rhinoplasty is not performed. Photographic evaluation and clinical observation where performed immediately after the procedure and at 3 month intervals.

RESULTS Photographic comparative pre and postoperative evaluation showed: a decrease in upper lip length with mean of 2 mm, a central upper lip elevation with 2 to 3 mm of upper incisive show, slight increase in vermillion thickness, increase in tip projection and increase in nasolabial angle. For the global midface assessment different observers including the patient agreed that the results following this procedure brought youthfulness, freshness and a very pleasing aesthetic result.

CONCLUSION This change in the configuration of the upper lip and distal nose provided by the redrapping and suspension of the free columella/lip unit is a simple procedure that addressed many features of the midface in one step obtaining an ideal aesthetic result.

9:00 AM - 4:00 PM

The Economics Of Implantable Distracters vs Traditional Cranial Remodeling Surgery: Is There A Difference?

Presenter:	Claire Sanger, DO
Co-Author:	Claes Lauritzen, MD, PhD
Affiliation:	Göteborg University, Göteborg

Introduction: Increasing health care costs internationally have provoked hundreds of studies evaluating cost effectiveness of medical care as it relates to outcomes. Such studies serve as guidelines to practicing medicine but in no way relinquish the need for individualizing surgical treatment plans for our craniofacial patients. Over the past ten years we have extensively studied the clinical outcomes for patients in our craniofacial center that have undergone surgical treatment with spring assisted surgery (SAS) and have seen the excellent results. We therefore evaluated the perioperative data and costs of SAS and Cranial Vault Remodeling (CVR) to see if less extensive surgery translates to an economic difference. Methods and Materials: A retrospective chart review was conducted on the patients undergoing surgical treatment for sagittal synostosis from 2004-2006. The patients were placed into two groups: those treated with pi-plasty and those treated with spring assisted surgery. The inclusion criteria consisted of patients treated by our craniofacial team for non-syndromic sagittal synostosis, chart availability and complete economic details accessible. Hospital charges were collected for medicine, laboratory studies, operative charges, hospital stay, materials, and radiography pertaining to the surgery. The clinical data was obtained for age, length of operation, intensive care stay, hospital stay, blood loss, and the amount of blood transfused. Statistical analysis was performed using the standard t test. Results: A total of 46 patients underwent treatment for non-syndromic sagittal synostosis in the specified time period of whom 36 met inclusion criteria (21 spring assisted surgery and 15 pi-plasty). The mean cost of SAS was SEK 60185 (Euro 6629.17) and SEK 85739 (Euro 9443.86) for traditional pi-plasty resulting in a 30% reduction in overall perioperative cost in the SAS group. A 63% reduction was seen in the laboratory fees for the SAS group. Greater than 30% reduction was seen in the SAS group for the ward, operating room, and materials. The charges for blood transfusion, the intensive care, radiology and medication were also decreased in the SAS group (5-20%). The clinical data showed greater than 70% reduction in blood loss and transfusion amounts (71-83%), with greater than 30% reduction in intensive care stay, hospital stay and operative time (34-36%). The overall cost reduction with the SAS was statistically significant. Conclusions: The results of this study reveal a significant decrease in cost for patients undergoing spring assisted cranioplasty for sagittal synostosis as compared to pi-plasty surgery.

9:00 AM - 4:00 PM

The Effect of Blood Pressure on Hematoma Formation with Perioperative Lovenox in Excisional Body Contouring Surgery

Presenter:	Jordan P. Farkas, MD
Co-Authors:	Jeffrey Kenkel, Daniel Hatef, Tuon Troung, Spencer Brown, Rod Rohrich
Affiliation:	Universit of Texas Southwestern, Dallas, TX

Intro: Prophylactic use of low molecular weight heparins has been shown to be efficacious in decreasing thromboembolism. Low molecular weight heparins are associated with increased rates of bleeding. We reviewed perioperative blood pressure dynamics for patients who experienced hematomas while undergoing body contouring procedures on Lovenox, compared to similar patients who did not develop a postoperative hematoma. Methods: A retrospective chart review was performed examining two patient groups: Ten patients who experienced a hematoma after excisional body contouring surgery with perioperative Lovenox; and ten similar patients with respect to sex, surgery type, and Lovenox administration, who did not have a hematoma. Pre- and post-operative blood pressures were recorded, as were blood pressures during the last two hours of surgery. Mean arterial pressures were calculated for all time points, and mean intraoperative MAP was statistically compared to pre- and post-operative MAP, for the two groups. Results: The mean pre-operative MAP for each group was the same (97.5 mmHg vs. 95.8 mmHg; p = 0.61). The mean MAP for the last two hours of each case was significantly lower in the hematoma group (66.7 mmHg vs. 82.4 mmHg; p < 0.0001), and a higher mean post-operative MAP reached significance in the hematoma group (96.3 mmHg vs. 88.5 mmHg; p = 0.05). Both the difference between intra- and pre-op blood pressure (30.7 mmHg vs. 13.4 mmHg; p < 0.0001), and between intra- and post-op blood pressure (29.6 mmHg vs. 7.0 mmHg; p < 0.0001) were increased in the hematoma group versus the non-hematoma group. Conclusions: Many patients undergoing excisional body contouring surgery are at risk for VTE and may need perioperative chemoprophylaxis. However, maintaining a relatively normotensive intraoperative blood pressure, and vigilance in recognizing and treating post-operative hypertension, surgeons may reduce the hematoma rate seen with perioperative LMWH administration.

9:00 AM - 4:00 PM

The Effect of Breastfeeding Upon Breast Aesthetics

Presenter:	Brian D. Rinker, MD
Co-Authors:	Melissa D. Veneracion, Catherine P. Walsh
Affiliation:	University of Kentucky, Lexington, KY

Purpose: Breastfeeding has many indisputable health benefits in early childhood, however rates of breastfeeding are low in many industrialized countries. In surveys conducted by international health-promotion organizations, one of the most frequent reasons cited by women for not breastfeeding was fear that it would have a negative impact upon the appearance of the breasts. This notion is strongly disputed by pediatricians and lactation experts, but is widely held by women and seems to cross cultural and socioeconomic boundaries. Despite these strongly-held views, there seems to be little or no objective data in the literature to either support or refute a detrimental effect of breastfeeding upon breast aesthetics.

Methods: A retrospective review was conducted of all patients who presented to the plastic surgery clinic at the University of Kentucky desiring breast augmentation or mastopexy between 1998 and 2006. Clinic charts were accessed to obtain demographic data, medical history, and BMI. Patients were contacted via telephone and asked a battery of questions regarding pregnancies, breastfeeding history, weight gain or loss, perceived impact of pregnancy upon breast size and shape, and smoking history. Standardized preoperative photos were reviewed to determine the degree of preoperative breast ptosis (per the Regnault classification). Breast cancer patients and nulliparous women were excluded. A multivariable logistic regression analysis was performed, using degree of breast ptosis as the dependent variable and the following independent variables: age, number of pregnancies, history of breastfeeding, duration of breastfeeding, BMI, pre-pregnancy bra cup size, history of smoking, and weight gain during pregnancy. Statistical significance was defined as p<0.05.

Results: 132 patients were successfully contacted. 93 patients had one or more term pregnancy prior to their surgery (median 2). 51 of these patients underwent breast augmentation alone, 15 underwent mastopexy alone, and 27 underwent augmentation and mastopexy. The mean age at surgery was 39 years. 54 patients (58%) gave a history of breastfeeding one or more children. The duration of breastfeeding ranged from 2 to 25 months, with a mean of 9 months. The mean age at surgery in the breastfeeding group (41 years) was not significantly different from the non-breastfeeding group (37 years). Weight gain during pregnancy ranged from 5 kg to 45 kg (mean 19 kg). 36 patients (39%) gave a history of smoking. 51 respondents (55%) reported an adverse change in the shape of their breasts following pregnancy. 21 (23%) reported that their breasts became smaller, and 9 (10%) reported that their breasts became larger. Upon logistic regression analysis, age (p=0.01), BMI (p<0.01), number of pregnancies (p=0.04), larger pre-pregnancy bra cup size (p<0.01), and smoking (p<0.01) were identified as significant independent risk factors for an increased degree of breast ptosis. A history of breastfeeding was not found to be an independent risk factor for breast ptosis, nor did the risk of breast ptosis increase with increased duration of breastfeeding. Weight gain during pregnancy was also not found to be a significant predictor for breast ptosis.

Conclusions: These findings support the assertion of pediatricians and lactation specialists that breastfeeding does not adversely affect breast shape, beyond the effects of pregnancy alone. A history of breastfeeding was not found to be associated with a greater degree of breast ptosis in patients presenting for post-pregnancy aesthetic breast surgery. Age and cigarette smoking, both of which are associated with a loss of skin elasticity, were found to be positive predictors for breast ptosis, as were larger pre-pregnancy bra cup size and number of pregnancies. Whereas breast ptosis appears to increase with each additional pregnancy, breastfeeding does not seem to worsen these effects. Expectant mothers should be reassured that breastfeeding does not appear to have an adverse effect upon breast appearance.

9:00 AM - 4:00 PM

The Generation and Characterization of Transgenic Mice Overexpressing CD109 in the Skin

Presenter:	Joshua Vorstenbosch, BSc
Co-Authors:	Genevieve Chaput, MD, Stephane Roy, PhD, Lucie Lessard, MD, FRCSC, FRCSC, FACS, Anie Philip, PhD
Affiliation:	McGill University, Montreal, QC

Introduction/Purpose: Few effective treatment strategies exist for wound healing pathologies such as hypertrophic scarring, keloids, and chronic wounds despite the fact that these disorders affect approximately 15% of the population. A possible solution to this problem involves altering the expression of cytokines such as TGF-beta at the wound site in an attempt to make adult wounds biochemically mimic embryonic, scarless wound healing. TGF- beta1 is a profibrotic growth factor that plays an important role throughout the entire wound healing response and its excessive action is thought to account for the abnormal scarring associated with skin pathologies. The correlation between excessive scarring and TGF- beta1 activity suggests that increased expression of a TGF- beta1 antagonist in the wound could diminish scar formation. Our lab has identified CD109 as a novel TGF- beta1 accessory receptor and shown that it functions to inhibit TGF- beta1 signaling. These data support the hypothesis that overexpression of CD109 in the skin will antagonize the effects of TGF- beta1, thereby reducing the extent of scarring and offering promise for a novel treatment strategy for wound healing pathologies.

Methods: To generate transgenic mice overexpressing CD109 in the skin, we created a DNA construct using Gateway technology from Invitrogen. We cloned the CD109 gene downstream of the K14 promoter in order to direct expression of CD109 specifically in the skin. The DNA construct was microinjected into FVB embryonic cells at the McGill Transgenic Core Facility and the cells were implanted into the uteri of pseudopregnant female FVB mice. Founder mice were confirmed by Southern Blot and subsequently bred to produce more transgenic mice. The genomic DNA of the F1 progeny was analyzed by PCR to confirm presence of the transgene with select mice later being sacrificed to screen for expression by Western Blot.

Results: Preliminary results demonstrate that the transgenic mice show an increase of expression of CD109 in the skin compared to wild-type controls and also exhibit more CD109 expression in the skin than in their brain, liver, and kidney.

Conclusions: The transgenic mice generated show overexpression of CD109 spatially restricted to the skin meeting the requirements of an in vivo model. These mice provide an ideal model to delineate the role of CD109, a TGF-beta antagonist, in reducing scarring. Specifically, this model will allow biochemical and morphological quantification of scarring parameters including collagen deposition, angiogenesis, reepithelialization and extracellular matrix remodeling to provide insight into the role of CD109 in wound healing and its efficacy as a novel treatment for wound healing pathologies.

9:00 AM - 4:00 PM

The Influence of AlloDerm on Expander Dynamics and Complications in the Setting of Postmastectomy Tissue Expander/Implant Reconstruction: A Matched-Cohort Study

Presenter:	Beth Aviva Preminger, MD
Co-Authors:	Colleen M. McCarthy, MD, MS, Babak J. Mehrara, MD, Joseph J. Disa, MD
Affiliation:	Memorial Sloan-Kettering, New York, NY

Purpose: AlloDerm, an implantable dermal matrix, is gaining increasing acceptance in tissue expander/implant (TE/I) breast reconstruction. By using AlloDerm to create the inferior-lateral portion of an expander pocket, elevation of the serratus anterior muscle/fascia can be avoided, theoretically limiting postoperative musculoskeletal morbidity. Anecdotal evidence suggests that due to the pliability of the dermal matrix, AlloDerm also allows for the injection of greater initial fill volumes and facilitates more rapid post-operative expansion. The primary objective of this study was thus to evaluate the impact of AlloDerm on the rate of tissue expansion in the setting of immediate, TE/I reconstruction.

Methods: A matched, retrospective cohort study was performed. Medical records of consecutive patients who underwent immediate TE/I reconstruction from 2004 –2005 were reviewed. Two patient cohorts were identified: i) patients who underwent TE/I reconstruction with implantable AlloDerm; and ii) patients who underwent standard TE/I reconstruction. Individual patients were matched 1:1 on the basis of: expander size (+/- 100 cc); history of prior irradiation; and, indication for mastectomy (prophylactic/therapeutic). Matched cohorts were compared with respect to: intraoperative expander volume injected (cc), rate of post-operative expansion (cc/ injection); total number of expansions; and, time to completion of expansion (days). The incidence of complications was similarly evaluated in each cohort. Pairwise comparisons were performed using the Wilcoxon sign-rank test for continuous variables and McNemar's test for categorical variables.

Results: In total, 90 immediate TE/I reconstructions were evaluated. Forty-five TE/I reconstructions using implantable AlloDerm were matched to 45 standard TE/I reconstructions. Seven percent of the total cohort had a history of prior irradiation; 35.5% had a prophylactic mastectomy. Median expander size was 500 cc. Intraoperatively, expanders in the AlloDerm and non-AlloDerm cohorts were filled with a mean volume of 223.8 and 201.1 cc, respectively (p=0.180). Expanders were routinely overexpanded to 120% of the expander size. The median number of percutaneous expansions performed was 5 and 6 in the AlloDerm and non-AlloDerm cohorts (p=0.117). Median time to completion of expansion was 64 days in patients who received AlloDerm and 70 days in those who did not (p=0.257). There was no difference in the mean rate of post-operative tissue expansion between the AlloDerm cohort ( 97 cc/injection) and the non-AlloDerm cohorts ( 95 cc/injection; p=0.907). There was similarly no difference in the incidence of complications with or without the use of AlloDerm (p=0.2891). Minor complications occurred in 13.1% (6/45) of cases following AlloDerm implantation [cellulitis (n=3); seroma (n=3); hematoma (n=1)].

Conclusions: While the current study does not address the efficacy of AlloDerm in decreasing morbidity and/or improving aesthetic outcomes in the setting of TE/I reconstruction, these findings indicate that the use of AlloDerm does not increase the rate of tissue expansion following immediate, post-mastectomy expander placement. The use of AlloDerm does not, however, appear to increase the risk of post-operative complications. This suggests that, if an implantable dermal matrix is used at the time of expander placement, additional risks are not incurred.

9:00 AM - 4:00 PM

The Influence of Pedicle Length on Viability of Twisted Perforator Flaps in Rats

Presenter:	Cheol Ho Chang, MD
Co-Authors:	Goo Hyun Mun, MD, PhD, Kap Sung Oh, MD, PhD, Sa Ik Bang, MD, PhD, Jai Kyong Pyon, MD, So Young Lim, MD, PhD
Affiliation:	Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul

9:00 AM - 4:00 PM

The Neo-Subpectoral Pocket for the Correction of Synmastia

Presenter:	Joseph H. Dayan, MD
Co-Authors:	Scott L. Spear, MD, Michael Newman, MD, G. Patrick Maxwell, MD
Affiliation:	The Mount Sinai Beth Israel Hospital, New York, NY

INTRODUCTION: Synmastia can be a challenging problem to correct. A number of techniques have been proposed including removal of the implants with delayed revision, adjustable implants, and capsulorrhaphy. Each of these options has drawbacks in terms of reliability, difficulty, or convenience. An ideal solution would be placing the implant in a new site. However, if the implant is already in the subpectoral position, this would require subglandular placement which may be undesirable. A new technique is described whereby a neo-subpectoral plane is created between the pectoralis major muscle and the anterior leaf of the existing capsule. Thus, the benefits of a subpectoral position are maintained while a new and precise pocket dissection may be performed in a different site. METHOD: Creation of a neo-subpectoral pocket involves developing a plane between the pectoralis major and the anterior capsule. A precise pocket dissection is performed similar to a primary breast augmentation in this virgin plane. The technical details of this new procedure are described. A chart review was conducted on all patients who underwent synmastia correction using this technique since it was first employed by us in November 2005. RESULTS: A total of six patients underwent synmastia correction using the neo-subpectoral technique. Several of these patients presented for recurrence after failed capsulorrhaphy. There was no recurrence of synmastia to date in this study. The follow-up range is from one to fifteen months. One post-op hematoma occurred. Three patients had their implant size reduced, two patients had larger implants placed, and one patient remained the same size. CONCLUSION: The neo-subpectoral technique for the correction of synmastia is a new method that may offer an effective solution in a single stage. We have also applied this technique successfully in the treatment of capsular contracture and other difficult revisions. It is an appealing concept that allows for a site change while maintaining the subpectoral position and further reinforcing closure of the old capsule. This procedure is technically straightforward, and offers a useful means of correcting all forms of implant malposition.

9:00 AM - 4:00 PM

The No Verticle Scar Technique for Breast Reduction: A Review of 90 Cases

Presenter:	Gregory Neil, MD
Affiliation:	Bahamas Plastic Surgery, Fort Lauderdale, FL

90 consecutive patients who had a modified Passot (no vertical scar) breast reduction technique are presented. At least three authors have reported variations on this technique in recent times. Additional modifications for ease of dissection and breast shaping are outlined. All cases presented were done by the reporting surgeon.

Study population: All patients had symptomatic breast hypertrophy. No smokers were identified within the patient population. Age ranged from 17 to 65 years. Follow-up ranged from one to five years.

Study design: a retrospective review of all patients charts and medical record was carried out. Data including age, height, weight, comorbid conditions, brassiere size, sternal notch to nipple distance and inframammary fold to nipple distance were tabulated. Weight of breast tissue resected was recorded in the operating room and later correlated with pathology reports. No free nipple grafts were performed.

Results: Patient's weight averaged 195 pounds with a range of 121 to 310 pounds. Average sternal notch to nipple distance was 38.5 centimeters with a range of 29 to 56 cm. Amount resected from a single breast averaged 1575 g with a range of 420 to 4899 g. Drains were kept for an average of 6 days. Fixation to the chest wall was performed with number 1 PDS sutures and coning of the internal brassiere was done utilizing 2-0 Prolene. Excellent maintenance of breast shape and projection was seen in all cases with minimal or no bottoming out up to five years.

Major complications: one patient (1%) had partial areola loss with retraction of the remaining nipple areola complex. Five (5%) patients had tissue loss in the region of the inframammary fold. Of these five patients, three had moist dressings and two were returned to the operating room in the perioperative period for debridement and closure, converting them to a vertical scar technique. One (1%) patient was returned to the operating room for hematoma evacuation with closure. As a subset, 32 patients (36%) had sternal notch to nipple distance in excess of 40 cm. Three of the7 major complications outlined in this section belonged to this group.

Minor complications: liquefied fat necrosis or seroma requiring aspiration or replacement of drains (7%); superficial de-epithelialization or minor wound separation treated with moist dressing or Band-Aids(10%); hypertrophic scarring requiring depot steroid injections(3%); calcific steatonecrosis requiring excision or liposuction under local anesthesia(2%) ; and palpable subcutaneous suture (2%).

Conclusion: a technique for breast reduction is described which utilizes a wide-based pedicle, coning with sutures, and chest wall fixation to predictably determine breast shape and prevent "bottoming out". The procedure is particularly suitable for those with moderate to severe breast ptosis and can be applied to breast reduction as well as mastopexy. Elimination of the vertical scar provides an additional benefit, particularly in those prone to hypertrophic scarring. Although the technique can be modified to incorporate free nipple graft, the use of this technique significantly reduces the need to resort to free nipple graft even in cases of severe breast hypertrophy.

9:00 AM - 4:00 PM

The Standardized Patient Used for Teaching Patient Selection in Aesthetic Surgery

Presenter:	Brian D. Rinker, MD
Co-Authors:	Michael Donnelly, PhD, Henry C. Vasconez, MD
Affiliation:	University of Kentucky, Lexington, KY

PURPOSE: A major challenge facing plastic surgery training programs is the need to provide quality education in aesthetic surgery. As important as technical skills, but much more difficult to teach, are the communication and patient selection skills essential to the successful practice of aesthetic surgery. In addition, recent directives from the ACGME have prompted residency directors to seek creative ways to teach and assess the more subjective core competencies such as communication skills and professionalism. Standardized patients, actors who reproduce scripted clinical scenarios, have been used in medical education for over 40 years. The purpose of this study is to determine the effectiveness of a standardized patient program for teaching communication and patient selection in aesthetic surgery.

METHODS: Six actors were selected and given detailed scripts, character descriptions, and clinical scenarios in which they would model a patient seeking an initial consultation for aesthetic surgery. Six residents were each given the opportunity to interview a different standardized patient for 30 minutes while the other plastic surgery residents and faculty members observed. Sessions were videotaped for future viewing. Following the interview, all participants completed a questionnaire and discussed whether the patient was a suitable candidate for the desired procedure. Personality factors, patient motivations, and expectations were addressed. To assess program effectiveness, four written simulations were administered to faculty members and residents before and after the educational program. For each simulation, a faculty standard was developed and tested using analysis of variance and Fisher's PLSD post-hoc test. An accuracy score was determined from the number of times the resident's answers differed from the faculty standard. The pre-test accuracy scores for the 6 residents were compared to their post-test score using a paired t-test. Residents and faculty members were asked to evaluate the effectiveness of the program using a 6-item questionnaire. Faculty time commitment and expense were assessed.

RESULTS: On three of four paper simulations, the Fisher's test indicated that one faculty member's responses differed significantly from the others, thus was excluded from the faculty standard. On the fourth simulation, the faculty members did not vary significantly in their responses to the simulation. The mean pre-test accuracy score for the residents was 2.33 ± 0.42, and the mean post-test score was 1.00 ± 0.52. This difference was statistically significant (p=0.01) indicating that residents judged cue importance more accurately after the training program than before. Upon the 6-item questionnaire, both faculty and residents strongly agreed that it was a worthwhile exercise (faculty mean 6.2 out of 7, resident mean 6.3). They also strongly agreed that the standardized patients were well prepared and believable (faculty mean 6.0, resident mean 6.3) and that standardized patients should have a permanent role in the plastic surgery curriculum (faculty mean 6.1, resident mean 6.0). One faculty member contributed 14 hours developing and implementing the program. The total cost of the program was $357.84.

CONCLUSION: Standardized patients can be an effective tool in teaching residents to evaluate candidates for aesthetic surgery. The residents' responses on paper cases more closely approximated the faculty's answers after the experience than before. Faculty and residents alike rated the experience highly, and the cost was nominal. Adding a standardized patient experience to the plastic surgery curriculum can provide instruction in traditionally difficult-to-teach areas such as communication and patient selection

9:00 AM - 4:00 PM

The Use Of Wide Local Excision And Temporary Wound V.A.C.® Dressing In Treating Two Cases Of DFSP

Presenter:	Stephen Pearson, MD
Co-Author:	James K. Amsberry, MD
Affiliation:	Naval Medical Center San Diego, Pensacola, FL

Dermatofibroscarcoma protuberans is an uncommon cutaneous malignancy with a high local recurrence rate. At Naval Medical Center San Diego, the Department of Plastic Surgery has played an instrumental role in the surgical treatment of these tumors. We present two recent cases of DFSP, which were successfully treated with wide local excision and interim wound management with the Wound V.A.C., a commercially available negative pressure dressing. In both cases the Wound V.A.C. was applied at the time of initial excision. The dressings were changed every 3-5 days until permanent pathology was available. In one case, pathology revealed tumor within 1mm of the margin, and the patient underwent subsequent re-excision. Definitive wound management was accomplished after the margins were reported clear in both cases. Although Mohs micrographic surgery has proven beneficial in the treatment of DFSP, we believe our cases demonstrate a successful alternative. The potential advantages this combination offers include: (1) a more reliable pathologic specimen, when compared to frozen section, (2) decreased wound care and dressing changes, (3) an optimal wound bed for definitive management, and (4) far less technical procedure when compared to a Mohs excision, meaning a non-Mohs trained surgeon could adequately treat these tumors.

9:00 AM - 4:00 PM

The Use of Artificial Dermis For Complex Wounds

Presenter:	James Yuen, MD
Co-Author:	Julio Hochberg, MD
Affiliation:	uams, Little Rock, AR

Integra, initially developed for primary coverage of acute burns, act as a network for dermal replacement. An overlying epidermal graft is required 3 to 4 weeks later to complete the full-thickness skin repair. This technology has been applied to non-burn cases for treatment of complicated wounds, as with chronic wounds, exposed bone and tendons, and post radiation. We present a series of 38 patients who underwent Integra reconstruction of non-burn wounds. Average age was 38.7 years and mean wound size 43.9 sq cm. Distribution was upper extremity 17, lower extremity 22, head/neck 3, and trunk 1. Causes were trauma 21, infection 6, tumor ablation 1, radiation 2, venous stasis 1, chemical 1, sepsis 1, and others 5. Average follow-up period was 8.9 months in 36 patients. 35 of 36 patients completely healed. One patient required Integra regrafting once infection of the tibia cleared. Two wounds were allowed to epithelialize without skin grafting. After subsequent skin grafting, only 5 patients required greater than 1 month for complete healing. In many cases, distal extremity wounds with exposed bone and tendon can be reconstructed, obviating the need for microvascular flaps. For chronic wounds, after excision, Integra provides a new matrix for dermal replacement.

9:00 AM - 4:00 PM

The Use of Safety Devices affects Facial Fracture Patterns in Motor Vehicle Collisions (MVC): Analysis of the National Trauma Database

Presenter:	D. Heath Stacey, MD
Co-Authors:	John Doyle, DDS, Karol A. Gutowski, MD, FACS
Affiliation:	University of Wisconsin, Madison, WI

Background: Airbags and seatbelts are designed to decrease injuries sustained in MVC. We hypothesize that the use of these devices has an effect on the patterns of facial fractures and facial lacerations.

Methods: Retrospective analysis of 15,293 patients from the National Trauma Database with facial fractures and 114,623 patients with facial lacerations resulting from MVC. 565 pan-facial fractures were identified. Fisher's exact test and Pearson's Chi-squared analysis were used to study associations between safety devices and facial trauma severity.

Results: This facial fracture population was 67% male with a mean age of 32 years. Pan-facial fractures occurred in 3.7% of all patients sustaining facial fractures. The two most common types of MVC associated with pan-facial fractures were collisions with other motor vehicles and single motor vehicle rollover accidents. In MVC resulting in facial fractures, 29.3% of patients had a seatbelt, 5.0% a seatbelt and airbag, 4.2% an airbag only, and 59.7% had no safety device. The use of a safety device decreased the incidence of facial fractures (OR 2.26), pan-facial fractures (OR 2.98) and facial lacerations (OR 1.95). Upon analysis of the facial fracture group, 49.5% tested positive for alcohol and 52.7% had a positive drug test. A CT Head positive for an intracranial bleed was found in 38.6% of the facial fracture group and 46.2% of the pan-facial group (OR 1.36). The GCS score (mean=10.2) and the base deficit (mean=4.09) on admission was lower in the pan-facial group compared to the 1 or 2 fracture group. Interestingly, there was no significant difference (19.9% vs. 20.4%, p=0.79) in the incidence of cervical spine injuries between the 1 or 2 facial fracture groups and the pan-facial fracture group. On subgroup analysis, passengers were less likely to have safety devices and more likely to sustain facial fractures.

Conclusions: Based on the largest reported series on MVC associated facial fractures in the United States, the use of airbags and seatbelts is associated with a significantly decreased incidence of facial fractures and lacerations. Given that less than half of these patients used a safety device and the high morbidity and costs associated with these injuries, plastic surgeons should advocate for the increased use of these safety devices.

9:00 AM - 4:00 PM

The Utilization of Research Patient Database Software in Plastic Surgery

Presenter:	Mark M. Melendez, MD, MBA
Co-Authors:	Xiaoti Xu, BS, Balvantray Arora, MD, Duc T. Bui, MD, Sami Kahn, MD, Kaveh Alizadeh, MD, MSc, FACS, Alexander B. Dagum, MD
Affiliation:	Stony Brook University Medical Center, Stony Brook, NY

INTRODUCTION: In this day and age of electronic medical records and increased use of advanced technologies in the field of plastic surgery, the majority of plastic surgeons are utilizing patient database software in their offices. The goal of patient management software is to provide critical information to the surgeon that may have a positive impact on their practice, surgical techniques, research activities and overall patient's outcome. Currently, there are a variety of database programs marketed to plastic surgeons with wide-ranging features and cost. The purpose of this study was to determine what type of research databases pertaining to patient information are currently being used by practicing plastic surgeons, the cost of such programs, and most desirable software features. Based on this data, we hope to develop a uniform, cost effective program for attendings, fellows and residents in plastic surgery.

METHODS: A web-based survey consisting of 23 questions was sent to plastic surgeons through the American Society of Plastic Surgery (ASPS) member list roster. In addition, e-mail addresses of residents and fellows found on the Fellowship and Residency Electronic Interactive Database (FREIDA) website were used. The responses were recorded and tabulated by the CTL SilhouetteTM system, an online data collection software for descriptive analysis.

RESULTS: There were seventy-five (20.4 %) respondents including plastic surgeons, residents, and fellows. They represent 5 group practices, 28 solo surgeons, 32 university-based practices, 3 community hospital-university affiliated, 1 community hospital-not university affiliated and 6 residents/fellows in-training. Our data demonstrated that the most frequently patient database software programs used included Tracking Operations and Outcomes for Plastic Surgeons (TOPS), Mirror Imaging, Nextech, and Medics Elite. The cost of the software programs was highly variable, ranging from $0 to $12,000, excluding yearly maintenance and upgrades. We found that the most desirable features included easy search features, user friendly applicability, photo storage/management, and storage and access to patient information/procedures according to CPT codes with measurements. When asked how information is obtained about the purchase of practice management software programs the majority of the respondents, forty-six, selected American Society of Plastic Surgeons whereas, forty-one, obtained information from colleagues. Fifty-five of the respondents moderately-strongly agree that using patient database software can enhance the efficiency, profitability and research activities in their practice.

CONCLUSIONS: It appears that an ideal patient database would be one that is reasonably priced, user friendly, easy search features, stores types of procedures with photos according to the CPT codes along with measurements for basic statistical analysis, and stores and retrieves patient information. A uniform research patient database software is needed to improve the practice of those in both the private and academic sector of plastic surgery. Research patient database programs are valuable tools for plastic surgeons, residents and fellows.

9:00 AM - 4:00 PM

The Viability of Fat Grafts Harvested by the Coleman Technique: A Comparative Study

Presenter:	Lee Li-Qun Pu, MD, PhD, FACS
Co-Authors:	Sydney R. Coleman, MD, Robert Edward H. Ferguson, Jr, MD, Xiangdong Cui, MD, Henry C. Vasconez, MD
Affiliation:	UC Davis, Sacramento, CA

Introduction: To obtain long-term survival of autotransplanted fatty tissue, the harvested fat grafts must be viable before implantation. However, the viability of fat grafts harvested by even a well-established technique remains poorly studied and unknown. This study is designed to determine the viability of fat grafts harvested by the Coleman technique using a syringe, cannula, and centrifuge.

Methods: Sixteen adult white females (Ages: 23 to 57 years) were enrolled in this self-controlled, IRB approved study. In Group 1 (N=8), fat grafts were harvested with the Coleman technique by a single surgeon (SRC) from the abdomen of each patient according to his well described and standardized method. In Group 2 (N=8), fat grafts were harvested with the conventional liposuction by a single surgeon (LLQP) and were spun at 50 G for 10 minutes. The resulted middle layer of tissue was collected. All fat graft samples were analyzed within 30 minutes after they were harvested for the following studies: Trypan blue vital staining after collagenase degradation for viable adipocyte counts, glycerol-3-phophatase dehydrogenase (G3PDH) assay as an indicator of adipocyte specific intracellular enzyme activity of fatty tissue for determination of cellular function within harvested fat grafts, and routine histology for morphology of harvested fat grafts. The data obtained from this study was analyzed with a two-tail unpaired Student t-test.

Results: The higher viable adipocyte counts were found in Group 1 compared with Group 2 (4.11 ± 1.11 vs. 2.57 ± 0.56 x 106/ml, Mean ± SD, p<0.004). The level of G3PDH activity was significantly higher in Group 1 compared with Group 2 (0.66 ± 0.09 vs. 0.34 ± 0.13u/ml, p< 0.0001). Histology showed normal structure of fragmented fatty tissues in both groups.

Conclusions: Our results, for the first time, demonstrate that while fat grafts harvested by both methods maintain normal histological structure, the Coleman technique yields a greater number of viable adipocytes and sustains a more optimal level of cellular function within harvested fat grafts and should be considered as a standard and preferred method of choice for fat graft harvesting.

9:00 AM - 4:00 PM

Three Year Experience with Alloderm in Breast Reconstruction

Presenter:	Julio Hochberg, MD
Co-Authors:	Jason Beck, BS, James C. Yuen, MD
Affiliation:	Uams, Little Rock, AR

The addition of Alloderm to breast reconstruction has been of great versatility to solve a variety of tissue deficits. We describe our experience using Alloderm for 3 years (2004-2007) in 107 consecutive reconstructions with tissue expanders (TE) and saline implants.

Mastectomies were performed following carcinomas, sarcomas, or for prophylaxis. A sub-muscular, sub-Alloderm pocket accommodates a PMT-textured TE. Alloderm of medium thickness (12x4 cm) was positioned in the lateral border of the PM, infero-laterally as a sling, to reinforce portions of ablated muscle, or to increase nipple projection.

Results: 62 patients had 107 mastectomies, 60 (56%) following carcinoma, and 47 (43.9%) for prophylaxis. average age 49 (30-70). Total skin sparing: 90 cases (84.2%), skin sparing: 10 (9.3%), and modified radical 7 (6.5%). Op-time: 12min per Alloderm segment.

Complications: seromas (15.8%), hematomas (3.73%), cellulitis (3.7%), severe infection (5.6%) requiring TE removal, TE perforation (3.7%), TE lateral displacement (0.9%), local recurrence (0.9%), rippling (0.9%), and BII contracture (10%). Cosmetic score 8.5.

In conclusion, Alloderm has simplified breast reconstruction with TE, diminished the operative time and lowered the rate of complications. In addition, Alloderm provides a high rate of patient satisfaction and a significant increase in prophylactic mastectomies due to positive expectations.

9:00 AM - 4:00 PM

Treatment of a Moh's Scalping Defect in a Nonagenarian Using an Updated Antique Technique

Presenter:	Johan Lars Sanberg, MD
Co-Authors:	Chris D. Tzarnas, MD, Jeffrey M. Jones, DO, Darren E. Jacobs, DO, Richard B. Kanoff, DO, MSc
Affiliation:	Mercy Catholic Medical Center, Darby, PA

Mortality at older ages has fallen dramatically since 1950 in developed countries. Advances in medicine have led to an increase in the number of nonagenarians alive today. Maintaining favorable surgical mortality rates in this advanced age group can be challenging. The co-morbidities commonly present in this patient population often require innovative surgical solutions.

We report a case of recurrent skin cancer of the scalp treated with Moh's excisional therapy resulting in a 15cm. full-thickness defect with exposed calvarium. The patient's cardiologist would not permit any surgical solution using general anesthesia due to the patient's precarious heart condition.

Given the severe surgical restrictions imposed by cardiology, an old surgical approach was employed. Multiple twist drill holes were placed through the outer table to permit ingrowth of granulation tissue from the viable diploic cavity to accelerate sequestration. A reconstruction plate with multiple holes was used as a drill guide for a Hall drill. This did not require general anesthesia. Epithelialization of the resultant granulation tissue occurred with complete healing of the wound.

Plastic surgery has a rich heritage of innovation. Historical techniques, while not necessarily fashionable, still have an important role in the treatment of challenging patients.

9:00 AM - 4:00 PM

Two Hundred and Twenty-Two Consecutive Pharyngeal Flaps: An Analysis

Presenter:	Patrick Cole, MD
Co-Authors:	Vince Boyd, MD, Samuel Stal, MD
Affiliation:	Baylor College of Medicine, Houston, TX

Objective: The pharyngeal flap is the most frequently used surgical treatment in the management of velopharyngeal insufficiency; however, recent concerns over poor post-operative outcomes and high complication rates have made the relevance of this procedure increasingly debatable. To evaluate speech outcomes and complication rates following this procedure, a non-randomized retrospective cohort study of over 220 consecutive pharyngeal flap surgeries was conducted. Methods: A database review was undertaken of all pharyngeal flap procedures completed between January 2000 and April 2006 at a tertiary, pediatric craniofacial center. Main outcome measures included perceptual speech parameters, nasality, immediate post-operative complications, and obstructive sleep apnea development. In addition, post-operative complications such as unanticipated bleeding, infection, and obstructive sleep apnea were evaluated as well. Results: Of 222 consecutive pharyngeal flap patients, 150 (68.57%) underwent both pre- and post-operative speech evaluation. Patient mean age at surgery was 6.4 years (range: 3.1 to 17 years). One hundred and twenty-four post-operative patients (82.67%) demonstrated no or mild hypernasality (none: 67.33%, mild: 15.33%). Eight patients (5.33%) presented with mild post-operative hyponasality. Twenty-two patients (14.67%) demonstrated residual VPI. Post-operative complications were rare in this cohort. Twelve patients (8.00%) required supplemental oxygenation for limited desaturations, and 3 patients (1.35%) demonstrated significant post-operative bleeding. Five patients (3.33%) demonstrated positive findings of OSA at 6 months or greater post-pharyngeal flap. Conclusions: Following thorough pre-operative evaluation and planning, pharyngeal flap surgery reliably reduces velopharyngeal insufficiency without significant risk of post-operative complication.

9:00 AM - 4:00 PM

Two Stage Breast Reconstruction with McGhan LV Expanders and McGhan 363 LF Implants: A Review of 82 Breast Reconstructions in 62 Consecutive Patients

Presenter:	Gregory R. Scott, MD
Co-Authors:	Cynthia L. Carson, PA-C, Gregory L. Borah, MD
Affiliation:	Kaiser Permanente San Diego Medical Center, San Diego, CA

Introduction: Breast reconstruction with tissue expansion and implants remains an important option for the post-mastectomy patient. We undertook a review of 82 two stage breast reconstructions in 62 consecutive patients by a single surgeon using the McGhan LV (low height) expander and the McGhan 363 LF (low height) breast implant.

Methods: The medical records of 62 consecutive breast reconstruction patients undergoing 82 two stage breast reconstructions by a single surgeon were reviewed.

Results: Sixty two patients underwent 82 breast reconstructions from 2000-2006 by a single surgeon using the McGhan LV expander and the McGhan 363 LF implant. The average age was 54 years(range 24-82 years). Fifty three (65%) were immediate reconstructions and 29 (35%) were delayed reconstructions. For the delayed procedures the interval from mastectomy to expander placement was 26 months (range 2.5 months-9 years). Thirty seven reconstructions (45%) were for Stage I breast cancer; 21 reconstructions (26%) were for Stage II breast cancer; 17 reconstructions (21%)were prophylactic mastectomies with contralateral breast cancer; 6 reconstructions (7%) were prophylactic for 3 patients with BRACA + gene; and one reconstruction (1%) for Stage III breast cancer. Twenty three patients (37%) received adjuvant chemotherapy; 6 patients received chemotherapy during the expansion process. No reconstructions were performed on previously irradiated breasts, however two patients received radiation therapy to the fully filled expander prior to implant placement. The expansion interval averaged 4.5 months (range 2-15 months). The total reconstruction time (expander placement to nipple reconstruction) averaged 10 months (range 5-32 months). Five patients chose not to undergo nipple reconstruction. Early complications (before completion of the reconstruction) occured in 6% of cases including one expander infection and one implant infection, both necessitating conversion to latissimus dorsi flap reconstruction. Two patients developed cellulitis during the expansion process resolving with po antibiotics. In one patient the expander was inadvertently punctured with a needle during the expansion process. She subsequently underwent successful implant placement. Late complications (following completion of the reconstruction) included 6 patients (7.3%) who underwent treatment for asymmetry with implant exchange; 5 patients (6%) who underwent free fat transfer (Coleman system) for superior perimeter defects; and 3 patients (3.6%) who underwent replacement for implant deflation.

Conclusion: Two stage breast reconstruction with the McGhan LV expander and the McGhan 363 LF implant gives excellent results with low morbidity and reduced recovery time.

9:00 AM - 4:00 PM

Umbilical Hernia Repair in Conjunction with Abdominoplasty: A Novel Surgical Technique to Maintain Umbilical Blood Supply

Presenter:	Terrence W. Bruner, MD, MBA
Co-Authors:	Hector Salazar-Reyes, MD, Jeffrey D. Friedman, MD
Affiliation:	Baylor College of Medicine, Houston, TX

Purpose:

To describe a novel, simplified surgical technique for the correction of umbilical hernias in conjunction with abdominoplasty.

Background:

Abdominoplasty is one of the most common aesthetic procedures performed in the United States. One of the primary indications for the procedure is skin and fascial laxity, often found in multiparous women. Abdominal wall hernias are often diagnosed on clinical examination and/or encountered intra-operatively during an abdominoplasty. Traditional surgical techniques for abdominoplasty and umbilical hernia repair, when performed simultaneously, can potentially compromise the vascular supply to the umbilicus, resulting in necrosis. Our novel, simplified surgical technique avoids any fascial incisions immediately adjacent to the umbilicus, thereby maintaining maximal blood supply to the umbilical stalk.

Operative Technique:

The abdominal flap is elevated and the umbilicus is dissected from the anterior abdominal wall flap while maintaining blood supply from its underlying fascial attachment. A 3-4 cm midline longitudinal laparotomy incision is made through the primarily avascular linea alba inferior to the umbilical stalk. The fascial defect is identified and the hernia reduced from the undersurface of the umbilicus either in the preperitoneal or intra-peritoneal space. The hernia is then repaired with interrupted monofilament sutures, and the midline laparotomy fascial incision closed with running suture. Plication of the rectus fascia is then performed.

Results:

17 patients, over a 6 year period, have undergone umbilical hernia repair with simultaneous abdominoplasty with the aforementioned surgical technique. None have had a recurrence of their hernia or umbilical necrosis and the aesthetics of the umbilicus have been improved.

Conclusions:

The novel operative technique described above provides a safe and simplified method of correcting umbilical hernias in conjunction with abdominoplasty and in our experience avoids the risk of umbilical necrosis and improves overall aesthetics.

9:00 AM - 4:00 PM

Understanding the Impact of Reconstruction on Quality of Life during the Breast Cancer Survivorship Period

Presenter:	Emily S. Hu, MD
Co-Authors:	Andrea L. Pusic, MD, MHS, FACS, FRCSC, Jennifer Waljee, MD, MPH, Latoya Kuhn, MPH, Edwin Wilkins, MD, Amy Alderman, MD, MPH
Affiliation:	University of Michigan, Ann Arbor, MI

Objective: National rates of breast reconstruction are low, characterized by large racial and geographical variations in use. These disparities raise concern of an unmet need in vulnerable patient populations. However, our understanding of the impact of reconstruction on patients' long-term quality of life (QOL) is poor. Few studies directly compare patient-reported outcomes between the reconstructed and the unreconstructed mastectomy populations and even fewer look at long-term outcomes. Our goal was to evaluate the impact of reconstruction on patients' QOL during the cancer survivorship period.

Methods: A cross-sectional self-administered questionnaire was given to University of Michigan patients who were diagnosed with breast cancer between 1977 and 2006 (response rate 70%). Our sample included 144 unreconstructed and 225 reconstructed patients. Using validated measures, patients scored their general QOL on a scale from 0-100. They then scored their breast-related QOL on a 5-point Likert scale for the following domains: psychosocial status, physical and sexual function. Scores were dichotomized into positive and negative responses, and chi-square and t-tests were used for the analyses. Multiple logistic regression was used to determine the correlation between QOL and receipt of reconstruction, while controlling for patient age, receipt of chemotherapy and radiation therapy, history of recurrence, time after mastectomy, and presence of major medical co-morbidities.

Results: Mean follow-up time after mastectomy was 7.6 years (range 3 – 30 years). Overall QOL scores were high (unreconstructed patient mean 82.4, SD 18.2; reconstructed patient mean 83.6, SD 18.1) and no significant differences were found between the two groups in regards to general QOL. However, receipt of reconstruction did appear to affect breast-specific QOL. When asked how their life is now, compared to before having their breast surgery, patients with breast reconstruction were better off emotionally (OR 2.9, p < 0.01), physically (OR 3.3, p < 0.01), and sexually (OR 6.3, p < 0.01) compared to those without reconstruction.

Conclusions: Long-term self-reported general QOL is high in both the unreconstructed and reconstructed breast cancer populations, suggesting that women adapt well in the survivorship period. However, receipt of breast reconstruction is associated with higher breast-related QOL, specifically in regards to emotional, physical and sexual well-being. These valuable data suggest that an unmet need may exist for women who desire breast reconstruction but have limited access to these procedures. There may be a critical need for improved advocacy for breast reconstruction for these women.

9:00 AM - 4:00 PM

Unilateral and Bilateral Eyebrow Reconstruction by Secondary Vascularized “Hairy” Flap

Presenter:	Hiroshi Mizuno, MD
Co-Authors:	Satoshi Akaishi, Kyoko Kobe, Hiko Hyakusoku
Affiliation:	Nippon Medical School, Tokyo

INTRODUCTION: We have developed secondary vascularized “hairy” flaps for reconstruction of hair-bearing area. The purpose of this study is to review the clinical outcome of the eyebrow reconstruction with this procedure retrospectively. PATIENTS AND METHODS: We have experienced 6 cases of eyebrow reconstruction with this procedure. Unilateral eyebrow reconstruction was performed in 4 cases and bilateral reconstruction in 2 cases using single vascular pedicle. Deep inferior epigastric vessels were harvested, anastomosed to superficial temporal vessels and buried underneath the temporal galea so that final eyebrow stream should be natural. After three weeks, vascular bundle and overlying scalp was elevated as a secondary vascularized “hairy” flap and transferred as an island flap. RESULTS: All flaps were completely survived although they initially exhibited slight congestion. Hair in the distal side of the flap was occasionally depilated temporarily, but mostly grew within a few months. CONCLUSIONS: The major advantage of this procedure includes that; (1) total eyebrow reconstruction can be achieved in two staged operation, (2) it can be applicable even in scar tissue in which adequate vascular supply cannot be expected for minigraft. In conclusion, secondary vascularized “hairy” flaps may be one of the ideal procedures for eyebrow reconstruction.

9:00 AM - 4:00 PM

Use of New Dressings Based on Glycerin and Collagen on Reconstructive Plastic Surgery

Presenter:	Rogerio Noronha, MD
Co-Authors:	Rui Lopes Filho, MD, Felipe Pacheco Martins Ferreira, MD
Affiliation:	Municipal Hospital Belo Horizonte MG Brazil, Belo Horizonte

Objective- To evaluate glycerin and high absorption polymer dressings in post-operative wounds for the following parameters: time of healing, post-op complications, prevention and quality of scars.

Methodology- A prospective, random and single blind clinical study was done on 102 patients, operated consecutively for a period of 8 months. The patients were randomized in two groups: Group A- Patients treated with glycerin and high absorption poymer dressings, immediately after surgery and up to 6 weeks. Group B- Control group treated with conventional dressings in immediate post-op and up to 6 weeks.

Results- A significant reduction in the number of post-op complications was observed, up to 50% on the second to the 12th day post-op, showing reduced hyperemia and improved cosmetic results. Dressings did not adhere to wound or newly formed cicatrization.

Conclusion- Use of this type of dressings, in our plastic surgery procedures, did improve patient outcome in almost all cases. Time of healing was reduced up to 50% less than with coventional dressings and there was a 92% overall reduction in post-op complications. These new glycerin and high absorption strip dressings reduce hyperthropic scarring as well as silicone products and carried a much lower cost to our facilities and patients.

9:00 AM - 4:00 PM

Use of Oasis Wound Matrix For Split-thickness Skin Graft Donor Sites

Presenter:	James C. Yuen, MD
Co-Author:	Julio Hochberg, MD
Affiliation:	University of Arkansas for Medical Sciences, Little Rock, AR

Oasis is a naturally derived biomaterial obtained from porcine intestinal submucosa, which acts as an extracellular matrix. This wound matrix functions as a scaffolding to support cell adherence and promotes rapid cellular proliferation and capillary ingrowth. This biomaterial contains key components of the dermal extracellular matrix such as collagen, elastin, glycosaminoglycans, glycoproteins, and proteoglycans, and growth hormones. Since its approval by the FDA in 2000, relatively few papers have been published. No articles have been reported describing the use of Oasis for dressing over split-thickness skin graft donor sites. From November 2003 to December 20006, we have utilized this wound matrix as a dressing over split-thickness donor sites in 131 patients. Our technique entails application of Oasis directly over the donor site. This is then covered with Xeroform, Telfa, and then 4 x 4 gauzes. To secure the dressing, we use Tagaderm tape for the smaller donor sites and a circumferential wrap with Kerlex for the larger donor sites. Epithelialization was complete in 1-3 weeks with an average of 2 weeks. Only two cases were there delayed healing beyond one month. Most remarkably, very few patients complain of significant pain at the skin graft donor site, since the Oasis wound matrix acted as a biological dressing protecting the nerve endings. The wound matrix forms a scab-like sealant which readily peels off when epithelialization is complete. We routinely change the first dressing at postoperative day 4 to 6. The first dressing is performed earlier if there is excessive drainage soaking through the dressing. The Oasis and Xeroform is left on. After the first dressing change, subsequent outer layers of Telfa and 4 X 4's are changed every two to three days until epithelialization is complete, at which point the Oasis and Xeroform spontaneously come off. This wound matrix derived from porcine intestinal submucosa, with overlying Xeroform, provides for a low-maintenance dressing with good pain control.

9:00 AM - 4:00 PM

Vacuum Asisted Closure and Anxiety

Presenter:	Furkan Erol Karabekmez, MD
Co-Authors:	Mustafa Keskin, MD, Ahmet Duymaz, MD, Ertan Yilmaz, MD, Zekeriya Tosun, MD, Nedim Savaci, MD
Affiliation:	Selcuk University, Konya

9:00 AM - 4:00 PM

Vacuum-Assisted Closure for Wound Dehiscence in Head and Neck Reconstruction

Presenter:	Neil Tanna, MD
Co-Authors:	Joanne J. Lenert, MD, Nader Sadeghi, MD
Affiliation:	The George Washington University, Washington, DC

Educational Objective: The authors propose an infrequently described technique for managing wound dehiscence following free tissue transfer in the head and neck. At the conclusion of this presentation, the participants should be able to understand the utility and limitations of negative pressure dressings in the management of complicated head and neck wounds.

Background: Negative-pressure dressings have received attention for the management of complex wounds of the torso and extremities. In this method, a vacuum-assisted closure system (V.A.C.) is applied to the wound. Subatmospheric pressure at the wound site fosters improved vascular perfusion and decreases bacterial counts and local edema. Additionally, it has been demonstrated to stimulate granulation tissue formation and promote wound debridement. While the emergence of V.A.C. has been embraced avidly for complex wounds throughout the body, it has not been widely implemented for use in the management of complicated head and neck wounds.

Design: By reviewing a clinical case from a series of patients within our practice, the authors highlight the management of wound dehiscence with vacuum-assisted closure.

Method: Case report, review of the literature, and discussion.

Results: A 67-year-old male presented with T4N0M0 squamous cell carcinoma of the left floor of mouth with invasion of the alveolar ridge of the mandible. He underwent surgical resection with segmental mandibulectomy and modified radical neck dissection. Reconstruction was performed with fibular free tissue transfer. By postoperative day eight, the patient developed incisional erythema. Frank dehiscence occurred by day ten, resulting in exposed bone (both native and free flap tissue). Wet-to-dry dressing changes were performed for the following seven days. As minimal granulation tissue was appreciated, a V.A.C system was applied to the area of dehiscence. With three days of negative pressure dressings a dramatic increase in granulation tissue was noted.

Conclusion: While widely employed in many parts of the body, use of the V.A.C. system in the head and neck has been limited. The V.A.C. system has been advocated for use in scalping injuries, pharyngocutaneous fistulas, donor site defects, and as a bolster dressing to cover skin grafts. Its scope of utility should be expanded to include wound dehiscence following free tissue transfer. With continued research and development, negative pressure dressings will find an increasing role in the management of complex wounds of the head and neck.

9:00 AM - 4:00 PM

Virtual Orthognathic Surgery: How Accurately Can One Plan a Procedure?

Presenter:	David E. Morris, MD
Co-Authors:	Linping Zhao, PhD, Sherif S. Morcos, DDS, MS, Pravin K. Patel, MD
Affiliation:	Shriners Hospital for Children and The University of Illinois at Chicago, Chicago, IL

PURPOSE: The ability to use computer-based, virtual planning for orthognathic surgery is desirable for several reasons: it would allow the surgeon to easily simulate multiple different surgical approaches for a given case, to predict postoperative aesthetic outcome and dental occlusion, and to help minimize intraoperative errors in osteotomy design and in placement of the osteotomized segment(s). As such, software-based orthognathic simulation has been attempted to varying degrees. Recently, we have used such software in the planning of orthognathic procedures. It remains to be established however, how such surgical planning correlates with actual postoperative results. Patients with mandibular deficiency, maxillary deficiency, anterior open bite deformity, and facial skeletal asymmetry have been undergone orthognathic surgical correction followed by virtual planning.

METHODS AND MATERIALS: For patients undergoing orthognathic treatment for either a congenital or developmentally-abnormal relationship of the jaws to the cranial base, both preoperative lateral cephalogram and CT scan of the facial bones are routinely obtained and DICOM data is imported into SIMPLANT Pro/CMF (Materilise, Belgian) software. Following segmentation, virtual osteotomy cuts are made and osteotomized segments positioned so as to achieve desired goals in occlusion and in facial skeletal harmony (FIGURE). A set of established cephalometric landmarks have been defined and preoperative Steiners analysis completed.

For patients who underwent single or double jaw surgery, osteotomies were made and segments positioned according to the virtual plan. Postoperative lateral cephalograms were obtained, corresponding landmarks identified, and their positions compared to those of both the preoperative cephalogram and CT.

RESULTS: Parallel and quantitatively similar movements were observed when comparing the change in position of cephalometric landmarks on postoperative cephalogram to the predicted position of the corresponding landmark by preoperative simulation.

CONCLUSIONS: Virtual surgery offers the possibilities of more accurate planning of orthognathic procedures, and a simpler way of considering multiple surgical approaches to achieve a result. Here we demonstrate both our center's current approach to using virtual surgery in planning such procedures and the means by which we quantitatively compare predicted skeletal bone movement to actual movement.

9:45 AM - 9:49 AM

Monitoring Partial and Full Venous Outflow Compromise in a Rabbit Myocutaneous Flap Model

Presenter:	Michael L. Gimbel, MD
Co-Authors:	Mark D. Rollins, MD, Eri Fukaya, MD, Harriet W. Hopf, MD
Affiliation:	University of Pittsburgh, Pittsburgh, PA

Introduction: Free flap failure often results from venous thrombosis. We developed a rabbit flap model of partial venous obstruction and evaluated the ability of 3 noninvasive monitoring devices to detect partial and full venous outflow obstruction. Methods: 4 x 8 cm myocutaneous flaps (n=9) based on the lateral thoracic vessels were elevated in New Zealand white rabbits. Arterial pedicle inflow was measured using a quantitative volumetric Doppler probe. A pedicle vein branch was cannulated to measure venous outflow pressure. An adjustable tension ligature was used to create partial or full venous obstruction. After an equilibration period, partial venous obstruction was applied to keep venous pressure between 10 and 20 mmHg (mean 13.5±2.2 mmHg) for 25 minutes, followed by full obstruction for 25 minutes (mean 39.1±7.4 mmHg), and then release from obstruction for 25 minutes. Flap skin was assessed with transcutaneous oxygen tension (TcPO2), transcutaneous carbon dioxide tension (TcPCO2), near-infrared spectroscopy (NIRS), and scanning laser Doppler imaging (LDI). Device measurements, arterial inflow and venous outflow pressure were taken at equilibrium and every 5 minutes throughout all interventions. Data were analyzed using Friedman's repeated measures test for nonparametric data with Dunnets post hoc analysis. Results: All values are given as means ± standard deviation. Flap arterial flow decreased significantly with both partial (p<0.01) and full venous obstruction (p<0.01) from a baseline mean value of 5.9 ± 3.0 ml/min blood flow to values of 4.1 ± 2.4ml/min and 0.3 ± 0.4 ml/min respectively. The arterial flow remained lower than the baseline equilibrium period flow even after release from obstruction (p<0.05). TcPO2, TcPCO2, NIRS, and LDI all changed significantly with full obstruction. TcPO2 decreased from a mean of 38.7 ± 17.5 mmHg to 7.9 ± 16.5 mmHg; TcPCO2 increased from a mean of 56.8 ± 14.5mmHg to 96.0 ± 39.1 mmHg; NIRS decreased from a mean saturation of 67.0% ± 6.6% to 43.1% ± 9.0%; and the Doppler perfusion decreased from a mean of 222.8 ± 77.3 to 47.2 ± 16.8 perfusion units. The LDI was the only device that decreased significantly (p<0.01) with partial obstruction from 222.8 ± 77.3 to 186.5 ± 73.2 perfusion units. After release from venous obstruction NIRS (p<0.01) and LDI (p<0.05) remained below baseline, mirroring the decrease in arterial inflow measured during this period, while TcPO2 rose above baseline (p<0.01). Conclusion: We successfully established a partial venous outflow obstruction flap model able to directly measure flap venous back pressure, and evaluated 3 clinically relevant devices in the setting of venous partial and full occlusion. The data show all devices were capable of detecting full occlusion, but only LDI detected partial occlusion. Therefore, LDI monitoring may allow early warning of impending venous outflow obstruction. NIRS varied the least between flaps and thus may be the most easily interpreted based on an absolute number rather than a change in baseline equilibrium values. These are both important criteria for clinical application.

9:49 AM - 9:53 AM

The Subatmospheric Dressing as a Bridge to Free Tissue Transfer in the Treatment of Open Distal Tibia Fractures

Presenter:	Brian D. Rinker, MD
Co-Authors:	Jonathan C. Amspacher, Patrick C. Wilson, Henry C. Vasconez
Affiliation:	University of Kentucky, Lexington, KY

Introduction: It has long been recognized that free flaps performed in the first few days after injury are associated with lower rates of infection and flap loss. However early wound closure is not always possible due to medical instability, the presence of life-threatening injuries, or operating room availability. Subatmospheric dressings have been shown to have several beneficial effects upon wounds including promoting granulation and inhibiting bacterial growth. The purpose of this study is to review a large clinical experience with the management of Gustillo 3B and 3C distal tibia fractures to determine if the use of a subatmospheric dressing as a “bridge” to free tissue transfer has affected complication rates.

Methods: The records were reviewed of 105 consecutive patients who underwent a free muscle flap for treatment of a Gustillo 3B or 3C distal tibia fracture between 1991 and 2005. Patients were divided into three groups: acute (flap performed in the first 7 days post-injury), subacute (days 8-42), and chronic (>42 days). The three groups were tested for homogeneity and compared using five outcome measures: rate of infectious complication, flap-related complications, number of surgical procedures, length of hospital stay, and time to bony union. The subacute group was further divided into those patients who underwent subatmospheric dressing therapy prior to free tissue transfer and those who did not, and the five outcome measures were compared between these two subgroups using the Student's t-test.

Results: The study group included 72 men and 33 women, ranging in age from 6 to 78 years (median 39). There were 32 patients in the acute group, 55 in the subacute group, and 18 in the chronic group. No significant differences were observed between the three groups regarding age, mechanism of injury, premorbid conditions, or flap choice. The overall complication rate in the subacute group was 47% compared to 39% in the chronic group and 31% in the acute group (p<0.05). The rate of infectious complication, (defined as osteomyelitis, infectious nonunion, cellulitis, or abscess), was significantly higher in the subacute group (15%) than in the acute (9%) or chronic groups (11%). Flap-related complications were higher in the subacute (18%) and chronic groups (17%) than in the acute group (9%). There were no statistically significant differences noted between the three groups for number of surgical procedures or length of hospital stay. Time to bony union was significantly shorter in the acute group (4.2 months) than the subacute (6.5 months) or chronic groups (6.2 months). Patients in the subacute group who underwent subatmospheric dressing therapy between injury and free flap had a significantly lower overall complication rate (35%), infectious complication rate (6%), and flap related complication rate (12%) than those who did not (53%, 18%, and 21%, respectively, p<0.05). There were no significant differences observed for number of procedures or length of hospital stay, but the time to bony union was significantly less in the subatmospheric dressing group (4.9 months versus 7.2 months, p<0.05).

Conclusions: The use of a subatmospheric dressing as a “bridge” to free flap reconstruction in patients with Gustillo 3B and 3C tibia fractures was associated with a reduced complication rate in the present study. Patients who received subatmospheric dressing therapy prior to undergoing free flap transfer in the subacute period (days 7-42) had a complication profile similar to those patients who underwent closure in the acute period (days 1-7). This suggests that the use of a subatmospheric dressing, by promoting a healthy wound environment and reducing bacterial counts, may effectively extend the acute period when free tissue transfer in the first 7 days is not possible.

9:53 AM - 9:57 AM

Comparison of the Semi-Automatic Coalescent Nitinol U-Clip Anastomotic Device to 9-0 Nylon Suture For Anastomosis of Rabbit Femoral Vessels

Presenter:	Gerald J. Cho, BS
Co-Authors:	David A. Billmire, MD, Rian Maercks, MD, Christopher B. Gordon, MD, Keith F. Stringer, MD, Mary Rolfes, MLT, HT, ASCP, Randall K. Wolf, MD
Affiliation:	University of Cincinnati College of Medicine, Cincinnati, OH

Purpose: The purpose of our study was to compare microvascular anastomosis performed with Coalescent Nitinol U-Clips versus conventional instrument tied interrupted nylon sutures. It was our hypothesis that U-Clips could reliably and consistently perform microvascular anastomoses in a manner comparable or superior to the current “gold standard” of interrupted nylon suture. We also hypothesized that the use of these semi-automatic anastomotic devices would reduce the time needed to make these anastomoses, thus reducing the ischemic time to the tissues.

Materials & Methods: 20 male, New Zealand white rabbits, with an average weight of 2.04 kg were used in this study. They were anesthetized by an intramuscular injection of ketamine (30 mg/kg) and Xylazine (6 mg/kg) and maintained on 2% isoflurane. All the anastomoses were performed on either the femoral artery or vein.

There were 4 groups of rabbits (n=5 per group): (1) femoral artery anastomosis using 9-0 nylon; (2) femoral artery anastomosis using U-Clips; (3) femoral vein anastomosis using 9-0 nylon; (4) femoral vein anastomosis using U-Clips.

Once the femoral vessel was exposed it was relieved of vasospasm using 2% lidocaine and the external diameter of the vessel was measured. The vessel was then clamped and transected. For the femoral artery, either 8 interrupted 9-0 nylon sutures were placed, or 4 U-Clips. For the femoral vein, either 9 interrupted 9-0 nylon sutures were placed, or 3 U-Clips. Ischemic time (from vessel clamps application to removal), and anastomosis time (from first stitch to reperfusion) were assessed. Vessel patency was evaluated using the Acland milking test and a 5 point scale (1 = Poor/Thrombosed, 3 = Moderate/Reduced flow, 5 = Excellent/Unimpeded flow).

Pending Data: Following a three week recovery period, the animals will be anesthetized and late patency and any other findings such as infection and aneurysm formation will be evaluated. Histological examination will then be done using longitudinal sections stained with hematoxylin and eosin and be evaluated for inflammation, media necrosis, subintimal hyperplasia, thrombus and aneurysm formation.

Results: The mean external diameter, ischemic time, and anastomosis time of Group 1 was 1.18 mm, 20.4 minutes (s = 5.68), and 14.3 minutes (s = 5.93), respectively. The immediate patency of every vessel in Group 1 was graded to be 5 (s = 0). In comparison, the mean external diameter, ischemic time, and anastomosis time of Group 2 was 1.3 mm, 20.2 minutes (s = 4.02), and 14.2 minutes (s = 4.02), respectively. The mean immediate patency was 4.2 (s = 0.836).

The mean external diameter, ischemic time, and anastomosis time of Group 3 was 1.9 mm, 39.6 (s = 10.8), and 29.6 minutes, respectively. The immediate patency was graded to be 4.6 (s = 0.894). In comparison, the mean external diameter, ischemic time, and anastomosis time of Group 4 was 1.98 mm, 27 minutes (s = 8.86), and 21 minutes (s = 7.74), respectively. The immediate patency was 3.4 (s = 0.547).

Discussion/Conclusion The use of U-Clips appears to be a feasible alternative to nylon suture. In our study, we found that there was no statistically significant difference between the ischemic time, anastomosis time, or patency rates when using the U-Clips or 9-0 nylon for arterial anastomosis (p=0.388, 0.288, and 0.381, respectively). Fewer U-Clips (4 clips) were needed to perform the arterial anastomosis than 9-0 nylon (8 sutures).

When used for vein anastomosis, the ischemic time, anastomosis time, as well as the patency rates demonstrated no statistically significant difference (p=0.974, 0.753, and 0.196, respectively) between the U-Clips and nylon suture. Additionally, fewer U-Clips (3 clips) were needed to perform the venous anastomosis than 9-0 nylon (9 sutures).

Additionally, since an anastomosis with U-Clips utilizes similar techniques and principles as that of nylon suture, little additional training is required to use the U-Clips. The next phase of this study will utilize this device in conjunction with the da Vinci Surgical System for robotic microsurgery.

9:57 AM - 10:00 AM Discussion

10:30 AM - 10:34 AM

CT Angiography in Microsurgery: Indications, Influence and Pitfalls

Presenter:	Jonathan C. Riboh, BS
Co-Authors:	Charles Hsu, MD, Yvonne Karanas, MD, James Chang, MD, Gordon K. Lee, MD
Affiliation:	Stanford University School of Medicine, Palo Alto, CA

Purpose: Computed Tomography Angiography (CTA) is a non-invasive method of obtaining three-dimensional vascular maps as well as soft-tissue definition. The goal of this study was to evaluate the reliability, usefulness and pitfalls of CTA in the planning of microvascular reconstruction.

Methods: We retrospectively reviewed all CT Angiograms performed on patients who underwent microsurgical reconstruction between 2001 and 2005 after obtaining IRB approval. The effect of the CTA results on the operative plan was assessed for each patient, and the CTA results were compared to the operative findings when possible. All technical difficulties and flap related complications were reported.

Results: 94 patients met our selection criteria. CTA studies were performed while planning reconstruction of the lower extremity (36%), head and neck (27%), upper extremity (22%), breast / chest wall (14%), and abdomen (1%). CTA was mainly performed at the recipient site (79%). The main indications for donor site CTA were breast reconstruction after radiation / axillary dissection and free fibula transfer in patients with clinical evidence or risk factors for peripheral vascular disease. 48 (51%) of the CTA studies showed some abnormality. CTA results were in good agreement with operative findings (positive correlation in 95% of cases). An abnormal CTA caused a change of operative plan in 34 patients. Changes were made in the choice of recipient / donor vessels, the side of graft harvest, or the nature of the reconstruction (local flap. vs. free tissue transfer). Technical difficulties in performing CTA were encountered in only 5 patients (5%). Interference of external fixation was the main cause of these problems. Follow up data was available for 86 patients, who were followed for a mean of 12 months (range 1 to 58 months). There was no significant difference in the complication rate between patients with a normal CTA (11%) and those with an abnormal CTA (8%), Chi Squared = 0.17, must be greater than 3.84 for significance. The CTA procedure itself did not cause any complications.

Conclusions: This is the largest reported series of CTA studies obtained for planning of reconstructive microsurgery. CTA is indicated mainly for assessment of recipient vessels. Our results show that CTA is highly accurate, safe, and has a strong influence on the reconstructive decision tree.

10:34 AM - 10:38 AM

Free Tissue Transfer in Private Practice - Experience with 100 Patients

Presenter:	Steven C. Bonawitz, MD
Affiliation:	Cooper University Hospital, Camden, NJ

In the 1970's work by Buncke, Daniel and Taylor, O'Brien and others helped establish free tissue transfer as a powerful technique for the management of reconstructive problems. During this first decade of experience free tissue transfer was considered a complex and difficult form of reconstruction and occupied the very top rung of the reconstructive ladder. In this conceptual position free tissue transfer was used when other flaps would not suffice and only in major medical centers with microsurgical teams. During the second decade of our experience the equipment used was refined and improved and a wide variety of instruments, sutures and monitoring aids were developed. Anatomic studies defined the vascular territories of the body and numerous donor sites and flap types were identified and developed providing the reconstructive microsurgeon with an extensive selection of reliable options for addressing the most complex defects. Over the last decade techniques have been further refined. Optical loupes have largely supplanted the more cumbersome operating microscope in many cases, the cost effectiveness of this technique has been established, flap survival rates of 96% to 99% have become standard and these procedures have even begun to move into the comunity hospital setting as the number of surgeons comfortable with microsurgical techniques has increased. Despite these advances there remains hesitancy on the part of many surgeons in private practice to include free tissue transfer in their reconstructive armamentarium. Among the reasons for this are the time required, concerns over the possibility of anastomotic thrombosis, the potential need for urgent re-exploration and the specter of complete flap loss. This report presents the results in a series of 100 patients who underwent free tissue reconstruction in a single surgeon private practice setting. Over a period of 11 years 100 patients underwent free tissue reconstruction with a total of 106 free flaps. The most common indication was immediate and delayed breast reconstruction followed by lower extremity trauma and chronic wound management. Flaps used included the free TRAM (53%), the latissimus dorsi (22%), the rectus abdominus (13%), the fibula(3%) and the lateral arm (2%). Average patient age was 46 years with a range of 17 - 80 years. Average operating time was 8 1/2 hours. There were three total flap losses and three partial losses. One patient underwent re-exploration during the first week after surgery. Overall free flap survival was 97% and the three cases of partial loss were revised with reconstructive success. In the hands of any surgeon who is well-trained in and comfortable with free tissue transfer techniques this option need no longer occupy the highest rung of the reconstructive ladder. We have arrived at the point in the evolution of free tissue transfer where, even in the private practice setting, the free flap can be regarded as the flap of choice in managing many complex reconstructive problems.

10:38 AM - 10:42 AM

Use of a Low-Molecular Weight Heparin and Aspirin Regimen as Anticoagulation in Free Tissue Transfer

Presenter:	Michael Spann, MD
Co-Authors:	Adam Pleas, MD, Mary Snyder, MD, Paul Kolkman, MD, Sam Medaris, MD, Alan Richards, MD
Affiliation:	University of Nebraska Medical Center, Omaha, NE

INTRODUCTION: Historically, head and neck cancer patients undergoing free flap reconstruction received Dextran for thrombosis prevention. This treatment protocol, while successful, does not address the need for deep vein thombosis (DVT) prophylaxis in these high risk patients and requires frequent dosing. The emergence of Low-Molecular Weight Heparin (LMWH) has given rise to alternatives for DVT prophylaxis and treatment. Therefore, it is plausible that LMWH could have an extended use in the arena of microvascular anastomoses as it provides adequate anticoagulation, DVT prevention, and convenient administration. Additionally, aspirin has been suggested to be of benefit as an antiplatelet therapy. The purpose of this study was to evaluate the regimen of aspirin and LMWH as it compared to Dextran in free tissue surgical reconstruction of head and neck defects.

METHODS: A retrospective chart review was performed on 75 cases in which the patients underwent free tissue transfer for head and neck reconstruction. The study encompassed all cases performed during the period of September 2003 to February 2007. Charts were reviewed to determine the incidence of postoperative complications, specifically thrombotic complications including flap failure, partial loss, pulmonary embolism, and deep venous thromboembolism.

RESULTS: Of the 75 of patients, 39 cases employed the use of Dextran for thrombosis prophylaxis. This regimen resulted in the following complications: seven flap failures (four arterial, three venous), four hematomas, three partial flap losses, two deaths (pulmonary embolism, cerebrovascular accident and subsequent cardiopulmonary arrest), and one deep venous thromboembolism. In comparison, 36 patients given a thrombosis prophylactic regimen consisting of aspirin and LMWH experienced the following complications: three hematomas, two flap failures (venous), two myocardial infarctions resulting in death, one cerebrovascular accident, one flap dehiscence, and one skin paddle epidermolysis.

DISCUSSION: In review of this data, the use of aspirin and LMWH for anticoagulation and antiplatelet therapy provide effective measures in preventing thrombotic events while resulting in fewer post-surgical complications in comparison to Dextran. The clinical implications include the possibility of replacing the current standard of care for patients undergoing head and neck free flap reconstructive surgery.

10:42 AM - 10:45 AM Discussion

11:30 AM - 11:34 AM

Incidence and Detection of Breast Cancer Recurrence Following Autogenous Tissue Reconstruction: A Matched-Cohort Study

Presenter:	Colleen M. McCarthy, MD, MS
Co-Authors:	Michelle Stempel, MPH, Andrea L. Pusic, MD, MHS, Joseph J. Disa, MD, Lisa Sclafani, MD, Peter G. Cordeiro, MD, FACS, Babak J. Mehrara, MD
Affiliation:	Memorial Sloan-Kettering Cancer Center, New York, NY

Introduction: Locoregional (LR) cancer recurrence following mastectomy has been associated with a decreased disease-specific survival. Complex or invasive procedures such as open abdominal procedures have been shown to result in immune suppression when compared to simple procedures such as laparoscopy. Given this background, it has been hypothesized that autogenous tissue breast reconstruction may result in immunosuppression and an increased risk of LR cancer recurrence. The purpose of this study was, therefore, to evaluate the influence of autogenous tissue reconstruction on the incidence and detection of LR recurrence following mastectomy for invasive breast cancer.

Methods: A matched-retrospective cohort study was performed. Two patient cohorts were identified: i) patients who underwent mastectomy and immediate, autologous tissue reconstruction; and, ii) patients who underwent mastectomy alone. Only patients with at least 20 months of follow-up and/or patients who had recurrence within 20 months of their primary cancer were included. Patients were excluded if they had: LCIS/DICS only, sarcoma or phyllodes; stage IV disease at presentation; synchronous bilateral cancer; and/or history of previous breast cancer. The Kaplan-Meier life table method was used to calculate recurrence-free survival rates. Differences in recurrence-free survival in the reconstructed and non-reconstructed cohorts were estimated using the generalized log-rank test. The Mann-Whitney test was used to compare continuous variables. Statistical significance was set at the p<0.05 level.

Results: In total, 188 patients who underwent mastectomy for invasive breast cancer from 1995 until 2004 were evaluated. Ninety-nine patients who had immediate autologous tissue reconstruction were matched to 99 women who underwent mastectomy alone. Patients were matched 1:1 on the basis of age (+/- 5 years) and breast cancer stage. Median follow-up for the entire cohort was 4.7 years (range, 1.6-11.1 yrs). The incidence of LR recurrence following mastectomy was 9.1 % in patients who had autogenous reconstruction and 9.1 % in patients who did not have reconstruction [p (logrank) = 0.376] (Figure 1). Median time to detection of a LR recurrence was 2.5 years (range, 1.0-9.3 ) in the reconstructed cohort and 2.1 years (range, 1.0-4.5) in the non-reconstructed cohort (p=0.270). There was similarly no difference in ‘LR recurrence +/-distant recurrence-free' survival between cohorts [p (logrank) =0.661]. Estimated 2- and 5- year ‘LR recurrence-free' survival was estimated at 93.7% and 85.9%, respectively in the non-reconstructed cohort and 95.6% and 83.2% in the reconstructed cohort.

Conclusion: Based on the results of this study, it appears that there is no difference in the incidence of locoregional breast cancer recurrence in patients who undergo immediate, autogenous tissue reconstruction compared to those patients who do not have reconstruction. In addition, these results suggest that postmastectomy autogenous tissue reconstruction does not hinder detection of LR breast cancer recurrence.

11:34 AM - 11:38 AM

Patient Satisfaction With Breast Reconstruction During The Long-term Survivorship Period

Presenter:	Emily S. Hu, MD
Co-Authors:	Andrea L. Pusic, MD, MHS, FACS, FRCSC, Jennifer Waljee, MD, MPH, Latoya Kuhn, MPH, Edwin Wilkins, MD, Amy Alderman, MD, MPH
Affiliation:	University of Michigan, Ann Arbor, MI

Objective: Understanding reconstructive outcomes in the breast cancer survivorship period has important implications for patient counseling and shared-medical decision-making. Unfortunately, long-term data on patient-reported satisfaction with breast reconstruction are limited. Expander/implant and autogenous tissue breast reconstructions have different aging processes, and the time when these processes stabilize is unclear. Our goal was to evaluate long-term patient satisfaction with the processes of care, the decision-making process, and final physical appearance between implant and autogenous tissue breast reconstruction.

Methods: A cross-sectional self-administered questionnaire was given to University of Michigan patients who were diagnosed with breast cancer between 1977 and 2006 and had had breast reconstruction (response rate 70%). The sample included post-mastectomy patients with expander/implant (E/I) (N=108) and free and pedicle transverse rectus abdominus flap (TRAM) reconstructions (N=116). Each group was stratified into three post-reconstructive time periods: short-term (£5 years), intermediate (6-8 years), and long-term (>8 years). Validated satisfaction items were scored on a 5-point Likert scale, and scores were dichotomized into positive and negative responses. Chi-square was used for the analyses.

Results: Mean follow-up time after reconstruction was 6.5 years (range 1-18 years). Procedure type had no effect on outcomes in the short-term. However, in the intermediate and long-term, the type of reconstructive procedure considerably impacted patient satisfaction. At 6 to 8 years post-reconstruction, compared to E/I patients, TRAM patients, were significantly more satisfied with the reconstructed breast appearance (p<.01), size (p<.01), shape (p<.03), softness (p<.01) and projection (p<.01). In addition, patients with TRAM, compared to E/I procedures, were significantly more satisfied with their process of reconstruction and had greater decisional satisfaction. TRAM patients felt more strongly that their outcome matched their expectations (p<.01), that they would recommend their type of reconstruction to others (p<.03), that they had a positive experience p (<.03), and that they did not need more surgery to improve the appearance of their breasts (p<.04). TRAM patients also reported greater satisfaction with surgical counseling in regards to postoperative appearance and pain. All of these differences remained significant at > 8 years post-reconstruction.

Conclusions: At greater than 8 years after breast reconstruction, women with TRAM, compared to expander/implant procedures, appear to have significantly greater aesthetic and decisional satisfaction, as well as more satisfaction with the process of reconstruction. These long-term data have important implications for women's health in the cancer survivorship period and will be useful for women navigating the complex decision-making process of breast reconstruction.

11:38 AM - 11:42 AM

Difficulties with Subpectoral Augmentation Mammaplasty and its Correction: Pectoralis Major Reconstruction in Aesthetic Breast Surgery

Presenter:	Andrew P. Trussler, md
Co-Authors:	Brian P. Dickinson, md, Reza Jarrhay, md, Malcolm A. Lesavoy, MD
Affiliation:	UCLA, Los Angeles, CA

Purpose: Controversy exists over the concepts of implant placement and augmentation mammoplasty. Proponents give good reasons for subpectoral versus subglandular implant placement, with the tendency towards the subpectoral placement in the United States. Informal surveys of plastic surgeons done by the senior author indicate a 50/50 preference, both in Central and South America, and Europe.

Difficulties arise with subpectoral placement of the implant including: malpositioning of the implant, improper superior contouring, inappropriate and unnatural movement with range of motion, and capsular contraction. We have found that correction of these above deformities are relatively easily maintained by removal of the subpectoral implant, reconstruction of the pectoralis major muscle back down to the chest wall, and reaugmentation with the implant in the subglandular space. This study will define a correction modality for the adverse results of subpectoral implant placement in augmentation mammoplasty.

Methods: Pectoralis major reconstruction was performed in 36 patients undergoing revision aesthetic breast surgery from 1995 to 2006. All patients had subpectoral breast implants with unwanted movement, malposition, and/ or capsular contraction. Explantation of the implants with modified capsulectomy and pectoralis major reconstruction was performed. The inferior and medial aspects of the pectoralis major muscle were sutured back down to the chest wall, and reaugmentation of the breast was done with implants placed in the subglandular position. Patients were evaluated for resolution of symptoms, satisfaction and complications.

Results: Thirty-six patients underwent successful reconstruction of the pectoralis major during revision aesthetic breast surgery with an average follow-up of one year. Malpostion (62%), capsular contraction (53%), unwanted movement (33%), and symmastia (10%) were the most common indications for revision. Unwanted implant movement was completely eliminated (100%), symmastia was corrected (100%), and capsular contracture was significantly decreased in each respective group. All patients were satisfied post-operatively.

Conclusion: Pectoralis major reconstruction can be successfully performed in aesthetic breast surgery. It can be safely applied to correct problems of unwanted implant movement, symmastia implant malposition, and capsular contraction.

11:42 AM - 11:45 AM Discussion

1:15 PM - 1:19 PM

Progressive Tension Sutures in the Prevention of Post-abdominoplasty Seroma: A Prospective, Factorial and Randomized Clinical Trail

Presenter:	Patricio Andrades, MD
Co-Authors:	Arturo Prado, MD, Stefan Danilla, MD
Affiliation:	University of Chile, Santiago

1:19 PM - 1:20 PM

Speaker Turnover

Presenter:	No presenter
Affiliation:

1:20 PM - 1:24 PM

Upper Body Lifts in the Massive Weight Loss Patient

Presenter:	Silvia Cristina Rotemberg, MD
Co-Authors:	Al Aly, MD, Daniele Pace, MD, Adel Bark, MD, Alexander Mansur, MD, Albert Cram, MD
Affiliation:	Cleveland Clinic, Cleveland, OH

1:24 PM - 1:25 PM

Speaker Turnover

Presenter:	No presenter
Affiliation:

1:25 PM - 1:29 PM

Volume Restoration of the Medial Tear Trough Deformity and Inferolateral Orbital Unit Decreases the Scleral Show

Presenter:	Eser Yuksel, MD
Co-Authors:	Maria del Carmen Martinez, MD, Gerardo Guerra, MD
Affiliation:	Baylor College of Medicine, Houston, TX

INTRODUCTION Increased scleral show is usually a result of lower eyelid laxity due to the aging process, iathrogenic lower eyelid midlamellar contraction, or proptosis of the eye globe producing an unaesthetic periorbital balance. We have been utilizing autologous adipose tissue for correction of the medial tear trough deformity and for volume restoration of the inferolateral periorbital unit. During the review process of the pre-operative and post-operative results of these patients, we have realized a significant decrease in lower eyelid scleral show for the frontal and lateral views, and a setback of the eye globe in the lateral views. These unplanned effects possibly contributed to the aesthetic improvement of the periorbital area seen in the post-operative views.

MATERIALS AND METHODS We decided to perform a retrospective study enrolling 20 patients who underwent inferior and lateral periorbital volume restoration with autologous adipose tissue transfer from inferior inner thigh SAL. The fat graft was injected in the subcutaneous preseptal plane, and the total volume ranged from 1.9 to 6.2 cc. Using preoperative and postoperative frontal and lateral views, straight and upper gaze, we analyzed the digital images. For the inferior scleral show component we measured the triangular scleral area in square pixels limited by a transverse line passing through the midpupil, the edge of the border of the inferolateral quadrant of the iris, and the border of the lower eyelid. To assess the degree of eye globe setback we measured the distance between the most projected midpupillary point and the anterior border of the lateral orbital rim in the straight gaze. The views were normalized for equal magnification and distance. We used parametric t student test for comparison between the scleral show areas and eyeglobe setback distances. We considered p < 0.05 for statistical significance.

RESULTS The area comparison for the scleral show revealed significant decrease postoperatively. The comparison of the distances described for the evaluation of proptosis also showed significant decrease in the postoperative views.

CONCLUSIONS The possible explanation for the discussed effects maybe hypothetically linked to the restoration of the support for anterior and inferior preseptal areas which were attenuated due to the descent and resorption of the supporting volume caused by gravity. The restoration of the preseptal compartment volume caudally at the level of the medial and inferior orbital rim delivers support inferoanteriorly to the preseptal stuctures in a cranial vector that secondarily pushes back the postseptal structures including the eye globe.

1:29 PM - 1:30 PM

Speaker Turnover

Presenter:	No presenter
Affiliation:

1:30 PM - 1:34 PM

Determinants of Facial Aging in Identical Twins

Presenter:	Bahman Guyuron, MD
Co-Authors:	Adam B. Weinfeld, MD, Seree Iamphongsai, MD, Yashar Eshraghi, MD, Amir Fathi, MD
Affiliation:	Case Western Reserve University, Lyndhurst, OH

Purpose: Although numerous articles have addressed the role of different factors on aging, sufficient scientific evidence has not been offered to support many of the statements. The purpose of this research study was to investigate the role of environmental factors on facial aging in identical twins.

Methods: Participants were recruited at the Twins Day Festival held in August, 2006. This festival is held annually in the city of Twinsburg, Ohio and is attended by approximately 3000 pairs of twins. After obtaining IRB approval, our research team interviewed 99 pairs of identical twins. They also completed questionnaires and digital images of each twin were obtained. The images were standardized and matched for color, size, and lighting. A four member panel independently estimated the age difference between each identical twin pair. The age differences were correlated with the various environmental factors. The results (averaged across the 4 raters) were statistically analyzed using multiple linear regression methods. The full linear model was generated and stepwise methods were employed to reduce the model to the statistically significant features.

Results: For every 4 point increase in BMI rating, a female was perceived to be about 1 year younger (p < 0.005) compared to her twin. As an example, a female with a 20 point higher BMI rating was perceived to be 5 years younger than her twin. A twin who had received hormone replacement therapy for 13 years was perceived to be 1 year younger than her twin who did not. On the other hand, a female with a history of skin cancer was perceived to be almost 4 years older than her twin who has not had skin cancer (p < 0.01). A female who has smoked for at least 5 years was perceived to be 1 year older than her non-smoking twin (p < 0.0005). A female with 8 hours more sun exposure per week compared to her twin was perceived to look 1 year older (p < 0.005). When the subcutaneous volume was taken into consideration, a female with a higher BMI had a higher perceived facial subcutaneous volume rating than her twin (p < 0.025). A female who had a history of skin cancer or who smoked had a lower perceived facial subcutaneous volume rating compared to her twin who did not have skin cancer (p < 0.01) or who did not smoke (p < 0.0005). A female who had received hormone replacements for several years had a higher perceived hair quantity rating compared to her twin who had not used hormones (p < 0.0005). A female with a higher BMI had a better perceived skin color rating compared to her twin (p < 0.01), while a female who smoked had a lower perceived skin color rating compared to her non-smoking twin (p< 0.0005). A female twin with a history of skin cancer had worse wrinkling (p < 0.0005), as did the female twin who smoked (p < 0.0005).

Conclusion: This study identifies several environmental determinants that play a role in facial aging in identical twins. Some of these include smoking, sun exposure and history of skin cancer which increase perceived facial age, and increases in BMI and hormone use which decrease perceived facial age.

1:34 PM - 1:35 PM

Speaker Turnover

Presenter:	No presenter
Affiliation:

1:35 PM - 1:39 PM

Bilateral Alar Reconstruction with Partially Split Septal Cartilage Graft –“Palm Tree Technique”- a 10-Year Experience with 56 Patients

Presenter:	Luis H. Ishida, MD
Co-Authors:	Luiz C. Ishida, MD, J. Ishida, MD, F.L. Saito, MD, D.Y.S. Tanikawa, MD, Helio R. N. Alves, MD, Marcus C. Ferreira, MD
Affiliation:	Faculty of Medicine of the University of Sao Paulo, Sao Paulo

1:39 PM - 1:45 PM Discussion

1:15 PM - 1:19 PM

Tissue Engineering of Flexor Tendons: Straining for Better Results

Presenter:	Jonathan C. Riboh, BS
Co-Authors:	Alphonsus K. Chong, MD, Hung Pham, BS, Michael T. Longaker, MD, MBA, Christopher Jacobs, PhD, James Chang, MD
Affiliation:	Stanford University School of Medicine, Palo Alto, CA

PURPOSE

The adhesions and contractures that result from the use of extrasynovial grafts in flexor tendon repairs are a major challenge in hand surgery. Tissue engineering of intransynovial tendon grafts can best be accomplished by combining biological and mechanical stimuli in a bioreactor to simulate physiological conditions. We hypothesized that in candidate cell lines, proliferation, collagen production, and cell morphology could be optimized through application of continuous cyclic strain (CCS).

METHODS

Epitenon tenocytes (E), tendon sheath fibroblasts (S), bone marrow mesenchymal stem cells (bMSC) and adipose mesenchymal stem cells (ASC) were plated on pronectin-coated silicone membranes and subjected to 8% strain, 1 Hz for 4 days; or no strain. The number of adherent cells after a 12h incubation was assessed using the colorimetric Alamar Blue assay. Cell proliferation was measured every 2 days using the same assay. Simultaneously, collagen I levels in the conditioned media were measured by ELISA. Cell morphology was assessed by confocal microscopy. Experiments were performed in triplicate and analyzed with ANOVA and pair-wise t-tests corrected for multiple comparisons.

RESULTS

S and ASC adhered better to pronectin than E and bMSC (33% and 29% adhesion vs. 21% and 6% respectively, p <10-10). CCS caused a decrease in proliferation in all cell lines (p < 0.004 for all), with net cell death between baseline and day 2, and a slow recovery of growth thereafter. bMSC did not show growth recovery. CCS caused collagen I production to increase 2 fold in S, ASC and E (p < 0.03 for all). In bMSC, collagen I production increased nearly 10 fold (p = 0.0001). Strained cells from all cell lines became fusiform, with nuclear elongation and parallel alignment of actin filaments.

CONCLUSIONS

In order to achieve tendon healing and regeneration, the cells seeded on tissue engineered flexor tendons must proliferate, secrete collagen, and differentiate into tenocytes. This study demonstrates that CCS inhibits cell proliferation yet increases collagen I production in all candidate cell lines for flexor tendon engineering. The data suggests that S and ASC are the most appropriate of the 4 cell lines studied given their high adhesion to ECM, high proliferative rate and their response to mechanical strain. Finally, we have shown that CCS helps multipotent cells assume a morphology similar to that of tendon fibroblasts. Future studies will focus on varying strain patterns to achieve maximal cell proliferation and collagen production.

1:19 PM - 1:23 PM

Financial Impact of Emergency Hand Trauma on the Healthcare System

Presenter:	Amy Alderman, MD, MPH
Co-Authors:	Amy Storey, Kevin Chung
Affiliation:	U Michigan, Plastic Surgery, Ann Arbor, MI

Purpose: The U.S. has a crisis of insufficient emergency coverage for hand trauma. One of the problems is the perceived financial loss in taking care of hand trauma patients in the emergency department. The purpose of this financial analysis is to evaluate the financial impact of treating emergency hand trauma patients for an academic medical practice and for a health care system.

Methods: We examine the billing records of hand patients (N = 2,632) seen in the emergency department at the University of Michigan Health System for the 2005 fiscal billing year. We focused our analysis on 220 primary diagnosis ICD-9 codes involving the hand and wrist. The financial data were separated into inpatient professional revenues and costs (related to physician practice) and inpatient facility revenues and costs (related to the University of Michigan Health System). Professional net revenue was calculated by applying historical collection rates to procedural charges. Facility revenue was calculated by applying historical collection rates to the following downstream charge categories: inpatient/OR, clinic facility, radiology and occupational therapy.

Results: The payor mix for this analysis was 85% private insurance, 7% Medicare, 6% uninsured and 2% Medicaid. The net professional revenue and total cost for physician salary, malpractice and benefits allocated to hand patients was $930,052 and $563,034, respectively, for a net profit margin of $367,018. Net health system facility revenue and total costs were $3,758,272 and $3,272,974, respectively, for a net profit margin of $485,299.

Conclusions: Our data suggest that hand trauma is fiscally advantageous for both the surgical department and healthcare system for this academic medical center. The perceived negative margin in caring for hand trauma patients is not supported by this analysis. Providing access to hand trauma patients may be fiscally advantageous in certain settings when the proportion of non-reimbursed care can be controlled.

1:23 PM - 1:27 PM

Flexor Tendon Repair with Barbed Suture

Presenter:	Fatemeh Abathi, MD
Co-Authors:	Michel Saint-Cyr, MD, Spencer Brown, PhD, Debby Noble, BS, DAn Hatef, MD, Jordan Farkas, MD, Matt Ruff, BS
Affiliation:	UTSW, Dallas, TX

Purpose: This study evaluated the tensile strength properties (maximum tensile load or ultimate tensile strength, and gapping at the repair site, and the pattern of failure) of flexor tendon repaired with barbed sutures.

Introduction: According to Strickland an ideal tendon repair should permit easy placement of sutures in the tendon, would allow smooth gliding, have secure suture knots with a smooth junction of tendon ends without gapping at the repair site, create minimal interference with tendon vascular, and have sufficient strength throughout healing to permit early motion of the tendon. The difficulty in satisfying all these criteria by any repair technique is probably reflected in the multitude of repairs described and currently utilized by practioners. There are many variations in the suture technique of placing core sutures. The described technique includes the Bunnell, Tsuge, Tajima, Strickland, Kessler, modified Kessler, Savage, Becker, modified Becker (MGH repair), and Indianapolis repair. Tendon repair ruptures usually occur at the suture knots. Adhesion formation remains the most common complication after flexor tendon repair, despite the widespread use of early-motion protocols. With these factors related to tendon repair failure considered, our department performed a pilot study using barbed sutures to repair lacerated flexor digitorum tendons. Barbed sutures (self-anchoring) have been developed by Quill Medical,in which bidirectional barbs are introduced into a suture that eliminates the need for tying a knot to obtain suture closure. The barbs are designed to grip tissue and obviate the need for tying a knot during tissue approximation. They can pass easily through tissue in one direction, but can not be reversed, therefore providing knot security.

Material & Methods: 160 cadaveric and porcine flexor tendons were harvested and cut. Repairs were performed using 0 or 2-0 barbed Nylons and same sizes standard Nylon. Modified Bunnell and Modified Kessler techniques were used.All repairs have been done without epitendonous suture. The repaired tendons were then tested for Maximum Load, Gap Strength, and Initial Gap, using a Tensiometer.

Result: Overall mean Maximum Load for barbed sutures was 41.12 N. Mean Maximum Load for 0 barbed Nylon was 55.90 N. Mean Maximum Load for 2-0 barbed Nylon was 37.46 N, and mean Maximum Load for 2-0 Nylon was 53.76. Mean Maximum Load for conventional 3-0 Ethibond was 31.25 N. These data are fairly consistent with what has been seen previously in the literature.

Summary: Overall, barbed sutures gave a stronger repair, especially when 0 barbed Nylons were used. Conventional 0 barbed Nylons would be clinically unfeasible, as the knots would be far too bulky. The ability to use this size of suture without the need for knot tying gives hand surgeons this option in repair of flexor tendon injuries.

1:27 PM - 1:30 PM Discussion

2:30 PM - 2:34 PM

Four Dimensional Arterial and Venous Anatomies of the Deep Inferior Epigastric Perforator Flap

Presenter:	Michel Saint-Cyr, MD
Co-Authors:	Mark Schaverien, MRCS, (Eng), Gary Arbique, PhD, Dan Hatef, MD, Spencer Brown, PhD, Rod J. Rohrich, MD, FACS
Affiliation:	UT Southwestern Medical Center at Dallas, Dallas, TX

Background: In this study we investigate the vascular anatomy of the deep inferior epigastric artery perforator (DIEP) flap three- and four-dimensional computed tomographic (CT) angiography and venography.

Methods: Ten DIEP flaps harvested from fresh cadavers were included in the study. Dynamic and static computed CT angiography and venography using iodinated contrast medium were performed following cannulation of the largest medial and lateral row perforator bilaterally and the accompanying vena comitans. The perforators on one side of flap were scanned first, with washout of the contrast medium between scans, to compare perfusion when a medial or lateral row perforator was used. The direction of the valves within the venous system was confirmed by microdissection.

Results: The use of a lateral row perforator, in contrast to a medial row perforator, did not result in perfusion of zone IV. Perforators from the lateral row rely on recurrent flow through the subdermal plexus to perfuse the medial row perforators. In contrast, medial row perforators are connected across the midline by large diameter linking vessels at the level of the subdermal plexus. Histology confirmed that the medial row perforators have a thicker smooth muscle wall than the lateral row perforators in all cases. There is a superficial and deep venous drainage system, connected by venae commitantes, with dominance of the superficial inferior epigastric vein. Few branches cross the midline.

Conclusions: This study demonstrates that the medial row perforators are anatomically different to the lateral row perforators and should be selected if perfusion of zone IV is required. The poorly developed venous system across the midline may explain the frequent observation of venous compromise in the DIEP flap.

2:34 PM - 2:38 PM

Toward Outcomes-Based Plastic Surgery Training: A Needs Assessment of Recent Graduates

Presenter:	Steven J. Kasten, MD
Co-Authors:	David Eng, BS, Kimberly A. Schenarts, PhD
Affiliation:	University of Michigan, Ann Arbor, MI

Purpose: Phase III of the ACGME Outcome Project calls for residency programs to use external measures to verify outcomes and make “data-driven improvements” to their curricula. Within plastic surgery, few such measures have been employed beyond the written and oral board examinations, which primarily assess medical knowledge and some elements of patient care. Within the remaining competencies data regarding the quality of plastic surgery education are lacking. Recent plastic surgery graduates have a keen sense of strengths and deficiencies of their preparation for independent practice, making them an excellent source of information regarding the effectiveness of plastic surgery training. The purpose of this study was to determine how well we presently teach and assess plastic surgery residents within the context of the general competencies. Our goals were to generate a needs assessment to drive curriculum change, determine which assessment tools are currently used during training, and establish a baseline for future comparison for program evaluation.

Methods: A survey was conducted by mail and online questionnaire. A new 68 item instrument was created, piloted and revised. The population of interest was plastic surgeons within six years of completion of training. A sample was drawn by contacting training programs for names of recent graduates and all names from the ASPS roster marked candidate. Within the context of the competencies, subjects were queried regarding the presence of formal curricular elements pertinent to each competency in their traiing and which assessment tools were used. Subjects were further questioned about their current practice habits, to determine whether their training was effective in preparing them for practice. Responses were via a five-point Likert scale. Composite scores were generated for each competency. Subjects were also given the opportunity to make open comments. Statistical analysis was descriptive, with Chi Square, Student's t-test and ANOVA used to evaluate differences in responses across various demographics, including gender, year of graduation, type of training, patient mix and practice type. Significance was determined at p<0.05.

Results: 742 questionnaires were disseminated via mail or online. The response rate was 19%, and 165 surveys that met inclusion criteria were analyzed. Respondents felt that all the competencies are important to plastic surgery training, although not unanimously for systems-based practice (SBP). By gestalt, graduates felt their training was strongest in patient care (PC) and weakest in SBP. Composite scores from survey items regarding their training and practice supported their opinion that SBP is an area of weakness. Contrary to opinion, however, practice-based learning and improvement (PBLI) was implicated as best taught and interpersonal and communications skills (ICS) as best practiced. The PSEF In-Service Examination and verbal feedback were the most commonly used assessment tools. Global rating scales and oral examinations were used to a lesser extent and other assessment tools only rarely. Composite scores for the competencies did not differ across any demographics. There were significant differences between integrated and independent graduates' responses to a few individual items within PBLI, SBP and professionalism (PRO). A few items within PRO, ICS and SBP generated overall negative responses about the quality of training from all respondents. Open comments suggest some confusion about the purpose and value of the competencies, and alarming conditions at a few training programs.

Conclusions: Overall, plastic surgery training is judged as excellent, but there are areas for improvement. SBP deserves the greatest curricular attention, while PBLI appears well taught and ICS well practiced. Graduates' perceptions of quality of training may not always correlate with objective evidence from their training programs or their practices. We must expand our use of assessment tools to achieve a richer measure of competency in our graduates. The value of the competencies is not universally understood or accepted in plastic surgery. In particular, there is controversy whether SBP is the duty of training programs. Further public education regarding the competencies is warranted. These results may serve as a baseline by which to measure the effectiveness of future curriculum changes.

2:38 PM - 2:42 PM

Tolerogenic Effect of Graft-Derived Dendritic Cells in Facial Allograft Model

Presenter:	Aleksandra Klimczak, PhD
Co-Authors:	Galip Agaoglu, MD, Sakir Unal, MD, Maria Siemionow, MD, PhD
Affiliation:	The Cleveland Clinic, Cleveland, OH

Purpose: Clinical application of composite tissue allograft transplants opened discussion on the restoration of facial deformities by allotransplantation. We have achieved operational tolerance in fully MHC mismatched rat hemifacial allograft model under low dose of cyclosporine-A (CsA) monotherapy. The potential of graft-derived dendritic cells (DC) on chimerism induction was tested in hemiface allografts under CsA monotherapy across MHC barrier. Methods: Twenty-four hemiface transplantations were performed in 4 groups (6 rats each). Rejection controls included semi-allogenic LBN(RT1^l+n) (Group-1) and fully-allogenic ACI(RT1^a) (Group-2) donors. Group-3 (LBN donors) and Group-4 (ACI donors) received tapered dose of CsA monotherapy. At different time-point (7, 28, 63, 100 day) samples from lymphoid organs and blood were harvested. Flow cytometry monitored donor-specific chimerism (MHC class-I RT1ⁿ and RT1^a antigens). Mechanism of allograft acceptance was assessed by the presence of donor dendritic cells (DDC) (immunofluorescence) and apoptotic cells (TUNEL technique) within lymphoid organs. Results: Face transplants under CsA monotherapy from LBN and ACI donors displayed presence of passenger leukocytes within lymphoid organs of recipients. At day 7 post-transplant DDC and donor leukocytes were detected within spleen and lymph nodes of recipients. During follow-up, the number of donor-origin DC significantly increased within spleen but only single cells were present within lymph nodes. DDC were not detected within thymus. Donor-specific chimerism in the peripheral blood of recipients at day 100 measured: LBN recipients at 1.4% for CD4/RT1ⁿ, 0.5% for CD8/RT1ⁿ and 2.6% for CD45RA/RT1ⁿ; for ACI recipients at 16.8% for CD4/RT1^a, 3.7% for CD8/RT1^a and 0.2% for CD45RA/RT1^a. Apoptotic cells were detected at day 7 and during entire follow-up period (100 days) in the lymphoid organs of recipients. Conclusions: CsA monotherapy promoted T-cell tolerogenicity of DDC in hemifacial allograft transplants due to functional stabilization of DDC at the immature state. Migration and localization of graft-derived DDC into lymphoid organs of recipient confirmed immunomodulatory function of DDC for skin allograft acceptance in hemifacial allograft model. Anergy of T cells, demonstrated by the presence of apoptotic cells, contributed to long-term hemifacial skin allograft survival.

2:42 PM - 2:45 PM Discussion

Monday, October 29, 2007

A 33 Year Comparison of Three Techniques of Midface Advancement in the Growing Child

Presenter:	Sacha I. Obaid, MD
Co-Authors:	Pradip Shetye, DDS, Michael Sorkin, BS, Stephen Warren, MD, Barry H. Grayson, DDS, Joseph G. McCarthy, MD
Affiliation:	New York University, New York, NY

PURPOSE: The purpose of this study was to compare the clinical and cephalometric post-surgical outcomes of three different types of midface advancement in the growing child: LeFort III advancement with wire fixation, LeFort III advancement with rigid plate fixation, and LeFort III advancement with distraction osteogenesis.

MATERIALS & METHODS: All patients who underwent midface advancement at New York University from 1973 to 2006 were reviewed. A total of 212 patients were identified. Only Crouzon, Apert, or Pfeiffer syndrome patients less than 12 years-of-age with complete pre-operative, post-operative, and 1 year cephalograms were included in the study. A total of 60 patients met the inclusion criteria. A retrospective chart review analyzed operative time, blood loss, hospital stay, complications, and need for additional procedures. Cephalograms were digitized and midface advancement and stability were recorded.

RESULTS: 60 patients underwent LeFort III midface advancement at an average age of 6.0 years. The number of patients, age, sex, and diagnoses were similar for all three groups

The average post-operative horizontal advancement at point A was 10.2 mm in the LeFort III advancement with wire fixation group, 11.2 mm in the plate fixation group, and 15.9 mm in the distraction group. In addition, horizontal advancement at orbitale was 10.3 mm in the wire fixation group, 11.2 mm in the plate fixation group and 12.7 mm in the distraction group. Finally, the horizontal advancement at PNS was 9.7 mm in the wire fixation group, 10.0 mm in the plate fixation group and 13.6 mm in the distraction group.

The average vertical lengthening of the midface at point A was 0.2 mm in the wire group, 3.2 mm in the plate fixation group and 1.1. mm in the distraction group. In addition, the vertical change at orbitale was 0.6 mm in the wire fixation group, 3.4 mm in the plate group, and 2.0 mm in the distraction group. Finally, the average vertical lengthening at PNS was 0 mm in the wire fixation group, 3.1 mm in the plate fixation group and 5.0 mm in the distraction group.

At 1 year follow up, stability in the advancement was seen with a change in position of point A of 0.3 mm in the wire group, 0.8 mm in the plate group and 0.8 mm in the distraction group. Similar stability was seen for all three groups at orbitale and PNS.

CONCLUSIONS: Distraction osteogenesis has provided greater horizontal advancement of the midface following LeFort III osteotomy than has been seen with advancement using wire or plate fixation. The increased horizontal advancement achieved with distraction is stable at 1 year follow up. There is a rotational component to the LeFort III advancement using distraction with point A receiving greater horizontal advancement than orbitale and with PNS undergoing greater inferior displacement. This is likely due to the vector of pull provided by the RED device, which attaches and pulls anteriorly on the maxilla, without a way to prevent downward displacement of the posterior segment.

8:34 AM - 8:38 AM

Endoscopic Monobloc Distraction with Ultrasonic Osteotomy and Percutaneous Distractor Placement

Presenter:	Rian Maercks, MD
Co-Authors:	Leopoldo E. Landa, MD, DMD, Gerald J. Cho, BS, X. Pilar Reyna-Rodriguez, DDS, Christopher B. Gordon, MD
Affiliation:	Hospital General 'Dr. Gea Manuel Gonzalez', Miami, FL

Background: The monobloc procedure as described by Ortiz-Monasterio has been criticized for tendency for relapse, infection risk, and need for later cranial vault remodelling or cranioplasty due to large areas of incomplete ossification. With distraction techniques, this procedure has increased in popularity, but stability and incomplete ossification remain problematic. We have developed a minimally invasive approach which can take full advantage of this procedure, bringing modern endoscopic and navigational techniques to this formidable operation, thereby minimizing the risks and improving outcomes in the treatment of syndromic craniosynostosis.

Objective: To develop a minimally invasive method for correcting syndromic craniosynostosis using a hybrid regimen of endoscopic craniotomy using piezoelectric osteotomes, minimal dissection and percutaneously distractors.

Methods: Nineteen patients have been treated with novel monobloc osteotomy. The current protocol requires multiple trephines. Then, intracranial endoscopy is used to dissect the frontal lobes from the overlying calvarium, orbital roof and anterior temporal fossa. Using a piezoelectric osteotome with navigation, the calvarial and orbital roof osteotomies are performed from within the cranial vault. The orbital floors are cut transconjunctivally. Pterygomaxillary dysjunction is performed with a coventional osteotome. Limited barrel-stave osteotomies and bony contouring are performed prn. The midface is disimpacted, and custom-designed internal distractors (Osteomed, Dallas, TX) are applied percutaneously. There is no degloving of the midface or calvarium. Distraction is carried out at 1mm/day, with 6 weeks of consolidation.

Results: Mean patient age was 7.33 years. (Crouzon =9, Apert =3, Pfeiffer=1, Saethre-Chotzen =1, 5= provisionally unique syndromes) All osteotomies were able to be completed through limited incisions and trephines. Mean operative time has decreased from the initial 12 hours to a mean of 5.5 hours. Mean midface distraction at infraorbitale is 21 mm. Long term stability of the advancement is superior to conventional osteotomies, with 1 year relapse of 2.5 mm at nasion, 1.8 mm at ANS, and 1.2 mm at point A.

Remarkably, there is radiographic evidence of complete reossification of the entire calvarial and orbital osteotomies in 16/19 patients. Intracranial hypertension has been corrected in all 7 patients with preoperative compromise.

There has been no incidence of dural laceration, visual impairment, significant hemorrhage which required open craniotomy, meningitis, infection, or intracranial hypertension. EBL averaged 760 ml. Hospital stay averaged 6 days, with 3 day ICU stay.

Case Report: A 3year old patient with Crouzon syndrome with intracranial hypertension, nystagmus and threatened blindness underwent the above procedure. Monoblock osteotomy was performed as above. The prototype distractor was placed from the temporal fossa to the lateral orbital wall. During the distraction, the single screw-born malar distractors eventually became dislodged. Nonetheless, the patient satisfactory outcome, advancing 18mm at orbitale. The patient did not experience any late or lasting complications. Vision has normalized in one eye, and improved from light perception to 20/100 in the other. Significant neurological improvements have been documented and the patient has returned to developmental baseline. Acute advancements were 19mm(57 to 76) at ANS, 11mm at nasion (62 to 73) and 8mm at point A(64 to 72). Relapse at these points were -3.1, -2.3 and -1.6 respectively at 10 months.

Conclusion: We have demonstrated the technical feasibility of a minimally invasive approach to monobloc osteotomy. Custom designed distractors, new ultrasonic osteotomes and intracranial osteotomy under endoscopic/navigational control have permitted us to perform this procedure without any calvarial or midface degloving. By limiting dissection, the entire bony fragment remains vascularized, providing profound improvements in callus formation, stability and significantly improved complication rate. With this novel approach, many of the limitations of the original operation can be avoided, and the monobloc can now provide superior results with acceptable morbidity.

8:38 AM - 8:42 AM

Single Sutural Craniosynostoses: Surgical Outcomes and Long-Term Growth

Presenter:	Rachel A. Ruotolo, MD
Co-Author:	Jeffrey A. Fearon, MD, FACS
Affiliation:	Medical City Dallas, Dallas, TX

Purpose: Few large series have been published examining treatment for the single sutural synostoses, and fewer have examined long-term outcomes. Families are typically counseled that following surgical correction, their child's growth should be normal. We recently published data showing that growth was not normal following sagittal synostosis correction, with a tendency towards recapitulation of the initial deformity. This current retrospective study was designed to evaluate a large series of surgically repaired children with the other single sutural synostoses, and to examine long-term cranial growth.

Methods: The records of 164 children with metopic, unilateral coronal, and unilateral lambdoid synostosis were retrospectively reviewed for outcomes. All patients were treated with a single stage open remodeling procedure. Long-term growth was assessed from anthropologic measurements taken up to 8 years postoperatively (mean > 4 years).

Results: Of 164 consecutive patients, complete records were available for 132 operative procedures. The surgical age ranged from 2.5 months to 8 years (mean <15 months), with 36 patients over 12-months of age. Following the institution of preoperative erythropoietin administration and use of a cell saver for blood recycling (2001), the overall transfusion rate decreased from 74% to 17% of patients, and the average hospitalization was < 2.5 days. There were no deaths or major complications, and there was only 1 non-surgically treated infection (0.7%). Five patients underwent secondary remodeling procedures (<4%). Early postoperative anthropologic measurements verified initial correction, but subsequent measurements revealed that not all growth indices were normal. These findings included: children with trigonocephaly demonstrated less than predicted bifrontal growth following an initial over-correction (p<0.05) and the more severely affected children with plagiocephaly had significantly less (p<0.05) growth in head circumference.

Conclusions: In this series of children born with single sutural synostoses, surgical treatment resulted in normalization of cranial indices with low reoperative rates and exceptionally few complications. However, building on the results of our earlier sagittal synostosis study, we found that growth is not normal following surgical correction of metopic, unilateral coronal and unilateral lambdoid synostoses, with a tendency for the calvaria to revert towards the primary deformity. Impaired growth may be greater with the midline sutural synostoses (sagittal and metopic), and the degree of growth inhibition may correlate with the initial presenting severity. Based on these findings, surgeons treating single sutural craniosynostosis should expand their treatment goals beyond normalization, to an over-correction of the abnormal skull shape.

8:42 AM - 8:45 AM Discussion

9:15 AM - 9:19 AM

Extreme Distraction: What are the Practical Limits to the Amount of Mandible Dstraction that can be Achieved?

Presenter:	Rian Maercks, MD
Co-Authors:	Leopoldo E. Landa, MD, DMD, Gerald J. Cho, BS, X. Pilar Reyna-Rodriguez, DDS, Christopher B. Gordon, MD
Affiliation:	Hospital General 'Dr. Gea Manuel Gonzalez', Miami, FL

Background: Mandibular distraction has become the standard treatment for congential micrognathia. There is no clear consensus regarding practical limits of this procedure in terms of bony stability, adequate secondary growth, dysphagia, and need for secondary distraction.

Objective: To identify the practical limitations of external mandibular distraction in a severely micrognathic population.

Methods: A total of 46 patients have undergone "extreme" distraction, generating mandibular callus in excess of 50% of preoperative mandibular body or ramus length. Of these, the majority were Pierre Robin (n=23) patients. The remainder were Nager syndrome (n=7), Treacher Collins (n=7), OAVS (n=5) or rare syndromes. External "No-Vector" 2 pin distraction was used in all cases, with extreme overdistraction (35-40% sagittal overdistraction), planned relapse, and intentional generation of posterior open bite. All patients underwent MLB, 3dCT, cephalometric analysis, and repeat studies after surgery. Most underwent cine-MRI in cases of equivocal sleep study.

Results: The average extreme distraction case resulted in 33 mm of new regenerate in the neonatal group, 44 mm in the pediatric group, and 57 mm in the skeletally mature group. After planned relapse, these had reduced to 26, 34 and 46 mm respectively. There were 8 patients who subjectively reported diminished lower lip sensation. 4 had severe postoperative dysphagia, and in one patient with Moebius syndrome, reoperation with mandibular setback was needed to correct symptoms of VPI and dysphagia. Velopharyngeal dysfunction occurred in 5, and the remainder improved spontaneously. Redistraction was needed in a single patient within 18 months for poor growth and in another for incomplete airway correction at 5 months postoperatively. (Manske-Catel and profound Nager syndromes, respectively) In all OAVS patients, inadequate growth of the affected side will likely require redistraction in the mixed-dentition stage for slowly developing laterognathia. Stability of regenerate after planned collapse is superior to previously used methods in our hands, and there is no "waist" phenomenon with this technique.

Conclusion: There is no apparent functional limit to the amount of bone lengthening in the severely hypoplastic mandible. Rates up to 6 mm daily and overall distractions of up to 300% of initial mandibular size are achievable. Airway and soft tissue considerations must govern appropriate lengthening in this group. In our experience, this population should be approached with external distractors and minimal dissection for best results.

9:19 AM - 9:23 AM

Microvascular Surgery in the Hostile Neck: Outcomes and Recipient Vessel Selection in the Previously Operated and Irradiated Neck

Presenter:	Matthew M. Hanasono, MD
Co-Authors:	Yoav Barnea, MD, Roman J. Skoracki, MD
Affiliation:	University of Texas M. D. Anderson Cancer Center, Houston, TX

INTRODUCTION: Microvascular free tissue transfer is extremely challenging in cases where the neck has had prior surgery and/or preoperative radiation. Dissection of tissues is technically difficult and lack of recipient vessels may limit the ability to perform free tissue transfer.

OBJECTIVES: To evaluate the availability of external carotid artery system and internal/external jugular vein system for microvascular anastomosis as well as alternate recipient vessels in patients with a history of prior neck dissection and/or preoperative radiation therapy. Furthermore, our goal is to evaluate the outcome of free tissue transfer in this patient population.

METHODS: A retrospective review of patients undergoing free tissue transfer reconstruction for oncologic defects of the head and neck between 2004 and 2007 at the University of Texas M. D. Anderson Cancer Center was performed.

RESULTS: 248 microvascular free flaps were performed in 214 consecutive patients for reconstruction after surgical resection of head and neck cancers. Of these, 9 (4%) patients had a history of prior surgery involving the neck, 88 (41%) had a history of preoperative radiation therapy involving the neck, and 25 (12%) had a history of both prior neck surgery and preoperative radiation therapy. The external carotid artery or one of its branches was not available on the side of the defect in 27 (11%) flaps/26 (12%) patients (5 patients with no history of prior neck surgery or radiation treatment, none with history of prior neck surgery, 9 with history of radiation therapy, 12 with history of radiation therapy and prior neck surgery). Strategies for lack of a recipient artery included: use of the transverse cervical artery (13 cases), use of the internal mammary artery (2 cases), arterial anastomosis to another free flap pedicle (7 cases), and vein grafting to the contralateral neck (5 cases). The internal/external jugular vein system was not available on the side of the defect in 32 (13%) flaps/29 (14%) patients (5 patients with no history of prior neck surgery or radiation treatment, none with history of prior neck surgery, 7 with history of radiation therapy, 17 with history of radiation therapy and prior neck surgery). Strategies for lack of a recipient vein included: vein grafting to the contralateral neck (10 cases), cephalic vein transposition (5 cases), venous anastomosis to another free flap pedicle (8 cases), the use of the transverse cervical vein (7 cases), and use of the internal mammary vein (2 cases). Reconstruction of anterior neck skin was required in 27 cases (3 patients with no history of prior neck surgery, no patient with history of prior neck surgery, 11 patients with a history of preoperative radiation therapy, and 13 with a history of prior neck surgery and preoperative radiation therapy). Complications at the operative site occurred in 39 patients (18%), including 14 (15%) in patients who did not have a history of either prior neck surgery or preoperative radiation therapy, none in those with a history of prior neck surgery only, 10 (11%) in those with a history of preoperative radiation therapy, and 11 patients (44%, p<0.05) in those with a history of both prior neck surgery and preoperative radiation therapy. There were 3 (1.2%) free flap losses, all of which occurred in patients with a history of both prior neck surgery and preoperative radiation therapy.

CONCLUSION: In the setting of previously operated and/or irradiated necks, the reconstructive surgeon should be familiar with a variety of techniques to locate recipient vessels adequate for microvascular anastomosis should the external carotid artery system and/or the internal/external jugular vein system not be available. Additional risk for complications must be factored into the surgical plan. The surgeon should be prepared to provide additional cutaneous coverage in select cases as closure of the neck can be difficult or prone to dehiscence in these cases.

9:23 AM - 9:27 AM

Computer Assisted Orthognatic Surgery Based on 3D Cephalometry. A New Approach with 3D Surgical Wavers

Presenter:	Max Zinser, MD
Co-Authors:	Robert A. Mischkowski, MD, Marian Durond, PhD, Joachim E. Zoeller, MD, PhD
Affiliation:	University of Cologne, Cologne

Purpose:

Computerization and sophisticated radiographic technology in orthodontics and orthognathic surgery have contributed immensely to the stockpile of knowledge. Another significant improvement can be attributed to the development of 3D visualisation software of radiological data and segmentation of anatomical defined objects. Although excellent navigation hardware and 3D planning software are available, there is still a need for tools featuring simple and rapid synthesis of both, the realization of a pre-surgically planned situation and the valid intraoperatively transformation. Several approaches to solve the problem of bony segment translocation with a navigation system have been already attempted (Troulis et al. 2002). Different approaches have to be made using the principles of augmented or virtual reality (Mischkowski et al. 2006).

The purpose of this study is to introduce a new surgical waver concept (fig. 1) based on computer assisted surgery. The transformation of the presurgical information is doe with new designed surgical wavers. The novel surgical wavers were individually made in cooperation with Materialise Belgium, by means of stereolithography. A further goal of this study was the evaluation of the precision, reliability and feasibility of this new technique including the capability of soft-tissue prediction.

Methods:

This study contains 15 patients with orthognatic deformities (open bite, class II and class III). The orthognatic surgery planning was done preoperatively referring to anatomical landmarks (basal skull) as a reference plane. Perpendicular through the nasion the facial median-plane was created. These symmetrical planes represent the ideal facial situation. Based on these planes the surgical techniques were determined in order to get the best symmetrical result. Then surgical wavers have been developed to transfer the virtual planning. The major of this “new “ contains the surgical of the presurgical virtual planning as exact as possible as well as the repositioning of the centrical position of the temporo-mandibular-joint. Our surgical concept is based on 3 splints. The first waver is used to define reference holes in the segmented bone before the transposition was performed. After the osteotomies the second surgical waver fix the segmented bone in the new “desired virtual” position. For bimaxillary osteotomies the third waver fix the definitive occlusion and reposition the mandibular joint in the centrical position. To compare the achieved result the pre- and postoperativ CT or DVT dataset were fused.

Results:

The new 3D computer assisted approach was applied for orthognatic surgeries in 15 patients, 10 underwent bimaxillary osteotomies and 5 monomaxillary osteotomies. Maxillary retrognathia and mandibular prognathia was the diagnosis in 10 cases. One patient had in addition an open bite and 2 patients each had bimaxillary laterognathia 3 cases had mandibular prognathia and 2 cases mandibular retrognathia. The great advantage of these technique consists in the rigid fixation of the bone parts through the wavers. This facilitates the fixation of the osteotomy plates. The control or comparison group contained also 15 patients. The 3D-cephalometric analysis based on pre- and postoperatively CT or DVT data showed that the accuracy when using the “new surgical 3D splints” including the computer assisted approach was within a range of 1 mm of the surgical plan. In the control group (classical planning) the accuracy was within a range of 1,5 mm including a tendency to advance the maxilla less than the planned distance was noticed.

Conclusion:

Computer generated 3D-image prediction is suitable for patient education and communication. This simulation system will be particularly useful for the selection of an optimal operative method in cases in which change in facial soft tissue shape should be carefully deliberated. In the authors hand, the use of this new surgical templates has resulted in outcomes close to those predicted by the planning process. The “new 3D-splints” have the potential to become a valuable tool in orthognathic surgery. Up to now monomaxillary and bimaxillary osteotomies were evaluated. The application to other types of more complex osteotomies, including segment osteotomies are currently under investigation.

9:27 AM - 9:30 AM Discussion

11:30 AM - 11:34 AM

The Branemark-type Bone-anchored Ear Prosthesis: The Untold Story

Presenter:	Ibby Younis, MBBCh, MRCS
Co-Authors:	Walid Sabbagh, FRCS, (Plast), David Gault, FRCS, (Plast), Norbert Kang, MD, FRCS, (Plast)
Affiliation:	Mount Vernon Hospital, London

Background The absence of an ear due to congenital abnormality, trauma or cancer surgery poses an unusual and difficult reconstructive challenge. The Branemark-type osseointegrated ear prosthesis is regarded as an acceptable alternative when autologous reconstruction is technically impossible or declined by the individual. However, there is paucity of data in the literature with regards to patient satisfaction, complication rates and long term follow up relating to these ear retention devices.

Methods A twenty point postal questionnaire examining patient outcomes using likert rating scales was sent to all individuals who had undergone this procedure over a 16 year period in a national plastic surgery tertiary referral centre (n=44). A comprehensive case note review was also conducted.

Results A questionnaire response rate of 57% (25) was achieved. A high mean aesthetic satisfaction score (1.9) was obtained (1 ‘excellent' - 5 ‘terrible'). However, 84% (21) of the respondents had experienced skin problems around the abutments such as infection, bleeding and build up of granulation tissue whilst 64% (16) indicated they were still having ongoing skin complications with a high mean severity score of 3.6 (1 ‘mild' - 5 ‘severe'). Despite these chronic skin problems as many as 80% (20) of respondents indicated they would undergo the same procedure again or would recommend it to others. From the case note review, it was found that 36% (16) had developed over-granulation, all of which were successfully treated with the CO2 laser. Additionally, 28% (12) patients were found to have signs of clinical infection and 32% (14) patients found their abutments became loose regularly and fell out in 9% (4) of cases. Over a third (37%) of patients' were frustrated by the prosthesis detaching too easily from the Branemark implant!

Conclusion The Branemark device appears to offer patients a good aesthetic outcome but the frequency and severity of skin complications associated with the Branemark device was significantly and surprisingly high. We suggest this is largely due to an incomplete seal at implant-skin interface and propose a modification of the implant design that may reduce the prevalence of chronic skin complications. Additionally we have found the CO2 laser to be very effective in treating over-granulation around the abutments without significantly raising the temperature of the titanium implants. We advocate further investigation and more extensive patient follow up for Branemark ear prosthesis as this may have wider implications in other craniofacial bone-anchored prosthesis reconstruction.

11:34 AM - 11:38 AM

An Algorithmic Approach to Reconstructive Surgery and Prosthetic Rehabilitation After Orbital Exenteration

Presenter:	Matthew M. Hanasono, MD
Co-Authors:	Johnson Lee, BS, Justin Yang, BS, Roman J. Skoracki, MD, Gregory P. Reece, MD, Bita Esmaeli, MD
Affiliation:	University of Texas M. D. Anderson Cancer Center, Houston, TX

BACKGROUND: Multiple methods of reconstruction after orbital exenteration for cancer have been described including skin grafts, regional flaps, and, most recently, microvascular free flaps. A unifying algorithm that incorporates all current methods has not been described.

OBJECTIVE: To evaluate the various methods of reconstruction and propose a comprehensive reconstructive algorithm based on the surgical defect, anticipated need for postoperative radiation therapy, and plans for postoperative prosthetic rehabilitation.

METHOD: A retrospective review of 75 cases (41 males, 34 females) involving orbital exenteration for malignancy at the University of Texas M. D. Anderson Cancer Center between 1999 and 2006 was performed. Defects were classified into three groups: 1) orbital exenteration only (25 patients), 2) extended orbital exenteration, involving removal of one or more orbital walls (43 patients), and 3) orbital exenteration with maxillectomy (7 patients). RESULTS: Reconstructive methods included skin grafts (7 split- and 11 full-thickness skin grafts), regional flaps (2 temporoparietal fascia and 4 temporalis muscle flaps), and microvascular free flaps (3 radial forearm, 25 anterolateral thigh, 23 and rectus abdominis myocutaneous free flaps). Reconstructions were classified as resulting in an “open” cavity (33 patients) in which a concave orbital socket that facilitates accommodation of an orbital prosthesis is produced or a “closed” cavity (42 patients) in which the orbital socket is filled with soft tissue to the level of the orbital rim. Twenty-one patients (28%) experienced complications (24% open vs. 31% closed cavity, p > 0.05; 22% skin graft reconstruction vs. 33% regional tissue reconstruction vs. 29% free flap reconstruction, p>0.05%). Complications included: infection (11%), sinonasal fistula (1%), partial graft loss (1%), flap loss (1%), donor site complication (5%), CSF leak (1%), wound dehiscence (1%), hematoma (3%), and osteoradionecrosis (3%). Thirty-eight patients (51%) received postoperative radiation therapy. Nine of these patients experienced complications at the surgical site, including 3 of 8 (38%) patients with skin graft reconstruction and 6 of 30 (20%) patients with regional or free flap reconstruction. Sixteen patients (21%) received an orbital prosthesis. Of this group, 7 patients (44%), wear their prosthesis regularly. Of the patients who received an orbital prosthesis, 7 had skin graft reconstruction (39% of patients reconstructed with a skin graft), 1 had temporoparietal fascia flap reconstruction (17% of patient reconstructed with a regional flap), 1 had radial forearm flap reconstruction, 5 had rectus abdominis myocutaneous flap reconstruction, and 2 had anterolateral thigh flap reconstruction (16% of patients reconstructed with a free flap). Three patients required a flap revision to accommodate their prosthesis, 2 with anterolateral thigh flaps and 1 with a rectus abdominis myocutaneous flap.

CONCLUSIONS: The method of reconstruction should be tailored to the defect as well as the postoperative needs of the patient. Skin grafts are often adequate when the defect is limited to the orbital contents alone and no postoperative radiation therapy is planned. Otherwise, regional or free flaps should be considered. When a prosthetic is planned, the goal should be to create an open cavity with a skin graft, regional flap, or thin free flap. Bulky fasciocutaneous or myocutaneous flaps are indicated when a closed cavity is preferred and no prosthetic is planned.

11:38 AM - 11:42 AM

Pediatric Tissue Expansion for Forehead Reconstruction: A 13-Year Review and an Algorithm for its Use

Presenter:	Arun K. Gosain, MD
Co-Author:	Wilberto Cortes, MD
Affiliation:	Case Western Reserve University, Cleveland, OH

Purpose: Reconstruction of the forehead in children when 25% or more of the forehead is involved presents a complex reconstructive challenge due to the confluence of highly visible aesthetic units. Tissue expansion of adjacent uninvolved tissues provides the best option for forehead reconstruction, providing like tissues without displacing key anatomic landmarks. The present study was performed to develop an algorithm that will help to optimize the outcome of pediatric forehead reconstruction for lesions involving 25% or more of the forehead.

Methods: A 13-year retrospective review was performed of all pediatric patients who completed reconstruction for lesions involving at least 25% of the forehead by a single surgeon (AKG). All lesions were classified based on percent of forehead involved and involvement of adjacent tissues (scalp, cheek, and eyebrow).

Results: Twenty patients completed reconstruction for lesions involving 25% or more of the forehead, all of whom had tissue expansion. Patients ranged in age from 9 months to 10 years at the time of the initial expansion. Seventeen patients presented with giant congenital pigmented nevi, and one patient each presented with nevus sebaceous, post-traumatic scarring, and post-involutional hemangioma. The median number of surgical procedures required to complete forehead reconstruction was 6 (range 2-11), involving a median of 3 tissue expansion procedures (range 1-4). Simultaneous expanders were placed in the scalp (16 patients) and in the cheek (8 patients). Eight patients required additional serial excision to complete forehead reconstruction. Five patients underwent correction of eyebrow ptosis at a final procedure. Reconstruction involved 25% to 65% of the forehead in 19 patients, 17 of whom were reconstructed with serial forehead expansion and advancement flaps (Figure). One patient presented with a pigmented nevus occupying over 75% of the forehead. In this patient there was not adequate adjacent tissue to reconstruct the forehead with expanded advancement flaps, and reconstruction was performed with an expanded full-thickness skin graft from the lower abdomen. The entire extent of the visible lesion was excised and complete skin coverage achieved in all patients.

Conclusions: Reconstruction of 25% or more of the forehead in children is best accomplished using tissue expansion. Up to 65% of the forehead can be reconstructed through expansion and direct advancement of adjacent tissues. Simultaneous expansion should be done in the cheek for lesions which extend below the lateral canthus, and in the scalp for lesions that extend beyond the hairline. Correction of brow ptosis is required in 25% of cases, and should be reserved for the final procedure. Lesions requiring reconstruction of more than 65% of the forehead are best accomplished with distant tissues. The latter could be performed with an expanded full-thickness skin graft to resurface the entire forehead as one aesthetic unit, or with free tissue transfer. Through a carefully planned application of tissue expansion to pediatric forehead reconstruction, all defects can be reconstructed reliably and by aesthetically accepted principles.

11:42 AM - 11:45 AM Discussion

2:15 PM - 2:19 PM

PSEF 2006 Research Fellowship - Fresh Start: Neural Stem Cells Improve Muscle Preservation Following Denervation

Presenter:	Tateki Kubo, MD, PhD
Co-Authors:	Mark A. Randolph, MAS, Jonathan M. Winograd, MD
Affiliation:	Massachusetts General Hospital-Harvard Medical School, Boston, MA

2:19 PM - 2:23 PM

PSEF Endowment for Plastic Surgery Grant Award: The Development of Strategies to Optimize Autogenous Fat Grafting

Presenter:	Stephen B. Baker, MD
Affiliation:	Georgetown University Hospital, Washington, DC

Soft Tissue augmentation is a commonly performed procedure in most plastic surgery practices. While no material is ideal for soft tissue augmentation, autogenous fat has many advantages over other materials: it is biocompatible, abundant, inexpensive, and potentially permanent. Unfortunately, its volume maintenance has proven unpredictable and temporary in most surgeon's experience. In an attempt to improve our knowledge of the grafting process, previous studies have evaluated the effects of cell culture media (Ullman 1998, Har-Shal 1999), harvest site (Rohrich 2004), growth factors (Yuksel 2000), postoperative hyperbaric oxygen (Chao 2000), recipient site vascularity (Baran 2002), and centrifugation force (Rohrick 2004). While these studies offer critical insights into the mechanisms of fat graft survival, the measured endpoints are often limited to graft volume, weight, and histologic stains.

Clinically, advocates of fat grafting have strong opinions regarding their personal methods for harvesting, processing, and injecting the fat, but frequently no scientific adapt exist to support the claims. Though good clinical results can be achieved, the underlying mechanisms that may enhance these results have not been methodically evaluated, and variability exists in the results that different surgeons achieve. Multiple variables exist in the fat grafting process; effects of refrigeration, regional variation of harvested fat, effects of cannula diameter, effects of various storage processes on fat (time, +/- exposure to air, oxygen rich storage media), effects of various negative pressures used to harvest fat, different processing techniques (centrifuge, straining, gentle spread over Telfa, washing), and effects of graft maintenance when combined with various FDA-approved growth factor containing media (platelet rich plasma, fibrin glue). To date no study has systematically evaluated each step of the fat grafting process.

The purpose of this study is to evaluate the safety and efficacy of several of the major variables in autogenous fat grafting using state-of-the-art immunohistochemistry and molecular biologic techniques, and to comprehensively evaluate the mechanisms that could contribute to the unpredicationle fate of the grafted fat. The aims of this study are to 1) evaluate the impact of tissue harvest and processing methods on cell viability , graft biology and long term survival; 2) evaluate the intrinsic differences in fat characteristics from different sites and correlate these differences with effect on graft maintenance; 3) evaluate the effects of refrigeration and air exposure on fat grafting as well as 3-D imaging. Immunohistochemistry and pathology includes techniques that can assess adipose cell morphology and survival, local hypoxia apoptosis, vascularization, and cell replication. The techniques proposed in this project have all been extensively utilized in our laboratory in our ongoing studies of adipose cell biology and autogenous fat graft physiology.

Page 2 Cont'

Autogenous fat grafting is a versatile, important tool in the armamentarium of the plastic surgeon; and experimentation to improve clinical efficacy and safety is the primary objective of this project. To date the majority of experience in autologous fat grafting is anecdotal. The mechanism of fat grafting has not been comprehensively and methodically evaluated using current Immunohistochemistry and molecular biology techniques. This study intends to evaluate the safety and efficacy of the commonly described variables in autogenous fat grafting. Through the use of these established experimental techniques, our understanding of fat grafting will be significantly advanced and will result in increased safety and efficacy of this procedure.

2:23 PM - 2:27 PM

PSEF 2006 Research Fellowship - Lyndon Peer: Sex Specific Response of Chondrocytes to Alginate Microencapsulation: Motivation for Development of a Critical Size Resting Cartilage Defect Model

Presenter:	Kimberly A. Singh, MD
Co-Authors:	Ramsey Kinney, BS, Barbara D. Boyan, PhD, Zvi Schwartz, DMD, PhD, Joseph K. Williams, MD
Affiliation:	Emory University, Atlanta, GA

2:27 PM - 2:31 PM

PSEF 2006 Basic Research Grant Award: Overcoming Skin Immunogenicity in Transplantation Tolerance

Presenter:	Mario G. Solari, MD
Co-Authors:	Kia M. McLean, MD, Justin M. Sacks, MD, Theresa Hautz, MD, Jignesh V. Unadkat, MD, Elaine K. Horibe, MD, Angus W. Thomson, PhD, DSc, W. P. Andrew Lee, MD
Affiliation:	University of Pittsburgh, Pittsburgh, PA

2:31 PM - 2:35 PM Discussion

2:35 PM - 2:39 PM

2006 PSRC Crikelair Award Paper: Three-dimensional Engineering of Nano-structured Scaffolds for Guided Microvascular Assembly

Presenter:	Alexander Gordon, BS
Co-Authors:	P. R. Gascoyne, MD, G. P. Reece, MD, A. B. Mathur, MD
Affiliation:	MD Anderson, Houston, TX

Introduction: Engineered constructs that attempt to restore or regenerate tissue to fill large defects due to injury or tumor resection often fail due to poor or absent vascularization. Research suggests that during in vivo angiogenesis in the mesentery, capillary sprout endothelial cells and pericytes preferentially migrate along elastic fibers of the extracellular matrix (ECM) in order to form neo-vessels1. It is our goal to engineer nano-structured, three-dimensional scaffolds composed of natural polymeric fibrils that mimic the composition, structure, and nano-mechanics of natural ECM and guide microvessel assembly.

Methods: We have previously shown that scaffolds composed of a blend of the natural polymers silk fibroin (SF) and chitosan (CS) regenerate a well vascularized and integrated abdominal wall in a guinea pig ventral hernia repair model 2,3. In the current study, we induced the formation and alignment of SF fibrils embedded within a CS matrix using the dielectrophoresis technique4. Dielectrophoresis was applied to a 75:25 blend of SFCS solution via an interdigitated bar electrode at 10 Vpp and 100 kHz for 1 hour while freezing the sample with liquid nitrogen vapor. The sample was lyophilized to generate the engineered scaffold structure. The structure of the resultant SFCS scaffold was characterized using polarized light and atomic force microscopies.

Results: We produced a nano-structured layered sheet configuration in three-dimensions similar to the basement membrane. The layered sheets of SFCS were embedded with aligned fibrils of SF (diameter: 1.8±0.2, height: 32.9±3.9 nm) (Figure 1).

Conclusions: The unique composition and the engineered structure of these scaffolds make them ideal for guided in vivo blood vessel assembly as studied in the in vivo rat mesentery model.

1: Anderson CR, Ponce AM, Price RJ.. Journal of Histochemistry and Cytochemistry. 2004. 52 (8): 1063-1072. 2: Gobin AS, Froude VE, Mathur AB. J Biomed Mater Res A. 2005. 74(3): 465-73. 3: Gobin AS, Butler CE, Mathur AB. J Biomed Mater Res A. August 2005, in press. 4: Gascoyne PR, Vykoukal J. Electrophoresis 2002;23(13):1973-1983

2:39 PM - 2:43 PM

2006 PSRC Snyder Award: Nuclear Cloning by Fusion of Somatic Cells

Presenter:	Jason Pomerantz, MD
Co-Author:	H. M. Blau, MD
Affiliation:	Plastic Surgery, San Francisco, CA

Introduction: Fusion of different somatic cell types results in nuclear reprogramming, the adoption of new gene expression profiles in response to cytoplasmic factors. We investigated techniques to reprogram nuclei from fibroblasts into mononucleate muscle cells capable of proliferation and differentiation. This approach, if successful, would allow production of cell types of interest from individual patients without the requirement for oocytes or ES cells.

Methods: Polyethylene glycol was used to artificially fuse myoblasts with fibroblasts that stably expressed GFP and a neomycin resistance gene. The resulting fused cells consisted of a higher proportion of muscle to non-muscle nuclei and were allowed to differentiate for two days in conditions favoring muscle differentiation. Cultures were treated with cytosine arabinoside to kill unfused cells that continued to synthesize DNA and then with the purine analog, myoseverin, that causes cellularization of myotubes by interfering with microtubule structure. Neomycin and serum were used to select cells and re-stimulate proliferation respectively. Surviving cells were analyzed clonally for myogenic differentiation, by morphology and muscle marker expression.

Results: RT-PCR analysis of muscle gene activation in non-muscle nuclei confirmed that non-muscle nuclei recapitulate the muscle differentiation pattern of gene expression after cell fusion. Non-muscle nuclei remained distinct, intact and did not synthesize DNA while existing in syncytia with muscle nuclei. Myoseverin treatment resulted in cellularization of cell fusion products resulting in a significant proportion of mononuclear cells. Re-stimulation with growth medium in the presence of selection agents resulted in the proliferation of neomycin resistant, GFP positive clones. A small percentage of these clones exhibited myogenic differentiation characteristics including fusion to form myotubes and expression of myosin heavy chain.

Conclusion: Our results suggest that it is possible to recover and grow somatic cells whose nuclei have been reprogrammed by cell fusion and exposure to factors present in the cytoplasm of a different cell type. Fusion of somatic cells in vitro and subsequent reprogramming of gene expression may represent one viable method of directed, tissue specific cloning that bypasses the use of embryonic stem cells.

2:43 PM - 2:47 PM

Plastic Surgery Research Council 2007 Update

Presenter:	Michael Neumeister, MD
Affiliation:	SIU, Springfield, IL

This presentation will provide an update regarding the activities of the Plastic Surgery Research Council for 2007. The organizational focus, information on the current plastic surgery environment, and pending research that will effect our specialty will be addressed.

2:47 PM - 2:51 PM Discussion

2:51 PM - 2:55 PM

PSEF 2007 Scientific Essay Contest Annual Bernard G. Sarnat, MD Junior Award: Low-dose Radiation Augments Vasculogenesis Signaling Through HIF-1 Dependent SDF-1 Induction

Presenter:	Jamie P. Levine, MD
Affiliation:	New York University Langone Medical Center, New York, NY

Conventional (high dose) radiation has been implicated in Hypoxia Inducible Factor-1 (HIF-1) regulation in tumor cell lines. However, little is known of the effects of radiation on the vascular endothelium, specifically in the regulation of pro-vasculogenic signaling. Here we show that low dose radiation promotes vasculogenesis by augmenting HIF-1 up-regulation of stromal-cell derived factor-1 (SDF-1) in endothelial cells outside the tumor milieu, stimulating endothelial progenitor cell (EPC) migration. Using in-vitro culture of humans endothelial cells, we show that HIF-1 is translationally up-regulated with radiation, resulting in increased nuclear localization by 48 hrs post radiation independent of hypoxia. Hypoxia acts as an additive stimulus for HIF-1 up-regulation, augmenting nuclear localization. HIF-1 has been shown to stimulate vasculogenesis though SDF-1 up-regulation, inducing localization of EPCs to areas of hypoxia. We show that low-dose radiation increases HIF-1 binding to hypoxia response elements (HRE) sites in endothelial cells, resulting in elevated expression profiles for SDF-1 and VEGF, both potent stimulators of vasculogenesis. Although previous studies have examined the effect of LDRT on progenitor cell recruitment we demonstrate for the first time a LDRT induced, HIF-1 independent, stimulation of SDF1 and subsequent EPC activation. Our research offers new insight into the pro-angiogenic and pro-vasculogenic effects of ionizing radiation. Because of the central nature of H1F1 and SDF1 to these signaling pathways, it is clear that ionizing radiation may have a profound effect on these processes.

2:55 PM - 2:59 PM

PSEF 2007 Scientific Essay Contest Junior Award - Clinical Research: Defining Changes in Volumetric Distribution Following Breast Reduction Surgery through Three-Dimensional Imaging

Presenter:	Oren M. Tepper, MD
Affiliation:	NYU Medical Center, New York, NY

Background – Recent studies suggest that three-dimensional (3D) imaging of the breast may be clinically useful for plastic surgeons. This technology offers exciting new opportunities to not only help guide surgery, but also provides a unique tool for post-operative analysis. The following study investigates the novel use of 3D imaging to assess changes in surface anatomy, volume, and tissue distribution following reduction mammaplasty (RM).

Methods – 3D laser scans of the breast were obtained from patients undergoing RM during pre- and post-operative office visits. Breast models were constructed volume measurements were obtained for each breast, as well as the relative volume of tissue in the upper and lower poles. In order to further define the areas in which significant changes in tissue distribution occurred, topographical color maps were generated by comparing the pre- and post-operative surface images. Breast projection was examined with sagital sections taken through the nipple as well as identifying the maximal point of projection.

Results – 3D scans were obtained in 28 patients that underwent RM. Total pre-operative and post-operative breast volume averaged 1037 ± 27 cm3 and 656 ± 210 cm3, respectively. The percent of tissue above the IMF had increased following RM (24.5% versus 55.1% preoperatively; p<0.001). Color maps and sagital sections highlighted the regions of tissue redistribution, with the majority of spatial changes located in the central region of the upper poles. RM significantly altered the point of maximal breast projection (8.7 ± 2.8 cm below a fixed axillary plane vs. 14.6 ± 2.7 cm preoperatively; p<0.05).

Conclusion – 3D imaging offers a unique approach to assessing volumetric distribution in breast surgery, which was previously unattainable to plastic surgeons. 3D photography now provide a potential means to compare surgical outcomes with each mammaplasty technique as well as follow the changes that occur over time (i.e. bottoming out).

2:59 PM - 3:03 PM

PSEF 2007 Scientific Essay Contest Senior Award - Clinical Research: Effect of Axonal Load On Free Muscle To The Face Function And Aesthesis

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

Purpose: This study focused on the correlation between the number of motor axons given to CFNGs for smile restoration, correlation with needle EMG's of the subsequently reinnervated mimetic muscle or transplanted free muscle, and aesthetic and functional outcomes as judged by a panel of independent reviewers.

Methods: 186 patients were included in this series, but only in 72 cases of CFNG procedures, adequate nerve biopsies were available. Patient information were collected from chart review from Stages I and II of facial reanimation procedures. Using Terzis' evaluation scale, functional and aesthetic outcomes for smile restoration as depicted in standardized videos were graded by four independent reviewers and data collected for each measurement. Histological slides included tissues, slides, or nerve biopsies embedded in plastic. Digital images of nerve specimens in stage I and II were processed using a high power microscope with a digital camera attachment. Using Meta Morph software, the numbers of motor axons were calculated except for the nerve specimens of the distal ends of nerve grafts in stage II that were quantitated manually by the investigator. All the data was analyzed buy SA 9.1.3 (Cary, NC) and the significance level was set as P<=0.05.

Results: The donor axonal input correlated with postoperative evaluation, and the number of distal end of nerve graft, but the latter didn't correlate with postoperative evaluation. CFNG procedure can help patient get better postoperative aesthetic recovery. Furthermore, 900 axons was found to be the cutoff point. If the count of donor nerve was above 900, having higher probability of good recovery would be possible.

Conclusion: The donor nerve influenced the final outcome more than the distal end of the cross-facial nerve graft. Though the counts of donor nerve correlated with the final outcome, some other factors, such as etiology of facial palsy, age of patient, denervation time, would influence the final results.

3:03 PM - 3:07 PM

PSEF 2007 Scientific Essay Contest D. Ralph Millard, MD Investigator Award: A Paradigm Shift From Sensory To Motor Nerve Grafting To Improve Nerve Regeneration

Presenter:	Arash Moradzadeh, MD
Affiliation:	Washington University School of Medicine, St. Louis, MO

This essay reviews the mechanisms by which motor nerves are thought to confer a regeneration benefit over traditional sensory nerve grafting techniques. Autologous sensory nerve grafting is the current standard of care for nerve injuries resulting in a nerve gap. This treatment requires the use of expendable sensory grafts to reconstruct motor defects. We have shown that pure sensory nerve grafts have an inferior regenerative capacity in comparison to nerve repair using motor and mixed grafts. These results suggest that motor nerve grafts confer an advantage to regenerating motor neurites. This phenomenon may be due to either a difference in the cellular/molecular milieu created by the presence of motor elements in the mixed and motor grafts, or it may be due to a difference in the physical architecture of the motor graft segments which is conducive to motor nerve regeneration. In order to further define this mechanism, we investigated nerve regeneration through acellularized nerve grafts of motor and sensory origin.

Our results suggest that nerve architecture plays an important role in nerve regeneration. These results question the hypothesis that cellular interactions are primarily responsible for the differences seen in motor nerve grafting compared with sensory nerve grafting. We show that nerve architecture plays a more important role in nerve regeneration than previously recognized and discuss the implications of the present findings and possible future directions for further investigations and clinical applications.

3:07 PM - 3:11 PM

PSEF 2007 Scientific Essay Contest Art and Science Award: Plastic Surgery, Aesthetics, and Medical Professionalism: Beauty and the Eye of the Beholder

Presenter:	Beth Aviva Preminger, MD
Affiliation:	NYU Medical Center, New York, NY

Professionalism has become an increasingly popular concept in medicine, however, little has been written on professionalism and plastic surgery. In the absence of a professional literature for plastic surgery, plastic surgeons have relied upon traditional standards of medical professionalism. These objective standards have been problematic for plastic surgeons whose work contains a significant aesthetic and, therefore, subjective element. The result has been critique of the field as well as, in the view of some, deprofessionalization. To remain professional in this context, plastic surgeons must begin to address the issue of medical professionalism and devise guidelines that reflect the uniqueness of the specialty.

3:11 PM - 3:15 PM Discussion

Tuesday, October 30, 2007

Surgical Management of Amblyogenic Periorbital Hemangiomas: Indications and Outcomes

Presenter:	Jugpal S. Arneja, MD, FRCSC
Co-Author:	John B. Mulliken, MD
Affiliation:	Children's Hospital of Michigan, Detroit, MI

Background

Periorbital hemangiomas present in various forms, from a well-localized to more extensive tumor. Often, simple observation is all that may be required, however, lesions in the periorbital region can result in irreversible amblyopia secondary to obstruction of the visual axis, optic nerve compression, strabismus, or most commonly, astigmatism and anisometropia from corneal deformation. A variety of nonsurgical and surgical methods to manage these lesions have been proposed.

Methods

We reviewed all patients with periorbital hemangiomas managed by surgical excision at Children's Hospital of Michigan and Children's Hospital Boston. Indications for surgical excision were a well-localized lesion causing obstruction of the visual axis or corneal deformation, and greater than two diopters of astigmatism. Surgical technique involved excision or debulking of the hemangioma, and if necessary, reinsertion or advancement of the levator palpebrae superioris muscle. Inclusion criteria for review included patients treated surgically with a minimum six-month follow-up interval, and complete pre-operative and post-operative ophthalmologic assessments.

Results

Twenty-six patients met the inclusion criteria, with a mean hemangioma onset age of 1.0 months and mean operative age of 5.9 months. The majority of hemangiomas were subcutaneous and located in the upper lid, causing astigmatism (mean 2.3 diopters) in 88% of patients or blepharoptosis with obstruction of the visual axis in 46% of patients. Prior treatment in 54% of patients included either intralesional or oral corticosteroids, and/or patching. Postoperatively, a statistically significant improvement in the degree of astigmatism (mean 0.93 diopters) was observed. Reinsertion or advancement of the levator palpebrae superioris was required in 31% of patients. The mean follow-up interval was 31 months and complications were at a minimum. One patient had a local recurrence, not significant to warrant re-excision, one patient had residual astigmatism, and two patients exhibited residual blepharoptosis.

Conclusions

To prevent potentially irreversible amblyopia in patients with periorbital hemangiomas, our results suggest surgical excision before ten months of age to be efficacious, with infrequent complications, and significant improvement in the amount of astigmatism. We advocate resection for well-localized periorbital hemangiomas, causing major refractive error and likelihood for the development of potentially irreversible amblyopia, preferring to avoid in the majority of instances, intalesional corticosteroid injection, with its well-documented complication profile.

8:04 AM - 8:05 AM

Speaker Turnover

Presenter:	No presenter
Affiliation:

8:05 AM - 8:09 AM

Levator Sling Palatoplasty: Do Speech Benefits Outweigh the Risks of Damage to Eustachian Tube Function?

Presenter:	Roberto Flores, MD
Co-Authors:	Bethany Jones, MD, Micheal Karnell, PhD, John W. Canady, MD, FAAP, Court B. Cutting, MD
Affiliation:	New York University Medical Center, New York, NY

Background: Levator sling palatoplasty with transection of the tensor tendon significantly decreases the need for pharyngeal flap to 4% in cleft palate patients. (Cutting. Op Tech Plast Reconstr Surg. 2:215,1995 and Sommerlad. Proc Am Assoc Plast Surgeons. 80:75,2001). Critical to this procedure is division of the tensor veli palatini tendon, allowing for radical transposition of the levator veli palatini in the inferior and superior direction to re-create the levator sling. Other studies have suggested that cutting the tensor tendon may have deleterious effects on Eustachian tube function as the tensor veli palatini is a prime opener of the Eustachian tube (Barsoumian. Cleft Palate Craniofac J 35:101,1998 and Huang. Plast Reconstr Surg 100:833,1977). Alternatively, Eustachian tube function during levator sling palatoplasty may be improved by pulling the tendon medially, and suturing the tendon to the hamulus before tendon transection (tensor tenopexy). This technique theoretically places the Eustachian tube in a more open conformation, improving middle ear ventilation. This multi-institutional study is designed to compare the effects of tensor veli palatini transection and tensor tenopexy on Eustachian tube function.

Methods: A retrospective review of all patients undergoing cleft palate repair at 2 institutions was conducted. Patients who were syndromic or >16 months of age at time of surgery were not included. Three groups were studied: veloplasty without transection of the tensor tendon or levator sling palatoplasty (Group 1) (n=32), veloplasty with transection of the tensor tendon and levator sling palatoplasty (Group 2) (n=33), and veloplasty with tensor tenopexy and levator sling palatoplasty (Group 3) (n=47). Group 1 patients underwent surgery at a single institution and the age at which study patients stopped needing myringotomy tubes was obtained through an institutionally maintained database. Groups 2 and 3 underwent surgery at a second institution. Surveys were sent to parents of all study patients in Groups 2 and 3 inquiring the age at which patients stopped needing myringotomy tubes. Nonresponders were sent another survey and received a follow-up phone call. Percentages of patients requiring myringotomy tubes at each age were compared between the 3 groups by ANOVA analysis.

Results: Group 1 provided 64 ears for analysis (mean f/u 66 months). In Group 2, 16/33 patients were successfully contacted (48.5%), providing 31 ears for analysis (mean f/u 60 months). In Group 3, 26/47 patients were successfully contacted (55.3%), providing 52 ears for analysis (mean f/u 40 months). Comparison of Groups 1 and 2 revealed a statistically significant decrease in the need for myringotomy tubes in patients who had not undergone tensor tendon transection compared with patients who had undergone tensor tendon transection by age 7 (Group 1: 38%, Group 2: 61%; P < .05). Patients who had the tensor tenopexy procedure (Group 3) stopped needing myringotomy tubes at an earlier age compared with both Groups 1 and 2. At the age of 7, patients in Group 3 had a statistically significant decrease in the need for myringotomy tubes compared to Group 2 (Group 3: 23%, Group 2: 61%; P < .001). Similarly, at the age of 7, patients in Group 3 had a decrease in the need for myringotomy tubes compared to Group 1. This difference neared statistical significance (Group 3: 23%, Group 1: 38%; P = 0.09).

Conclusion: Tensor tenopexy appears to have a modest effect on improving middle ear ventilation when compared to both palatoplasty with and without transection of the tensor tendon. Transection of the tensor tendon during levator sling palatoplasty may slightly increase duration of myringotomy tube treatment when compared to palatoplasty without tensor tendon transection. In light of the significant decrease in the need for pharyngeal flap in patients undergoing tensor tendon division with levator sling palatoplasty, the improvement in speech results should outweigh the minor negative effects on Eustachian tube function.

8:09 AM - 8:10 AM

Speaker Turnover

Presenter:	No presenter
Affiliation:

8:10 AM - 8:14 AM

One Stage Repair of Cleft Lip and Palate including Primary Alveolar Bone Grafting

Presenter:	Katsuyuki Torikai, MD, PhD
Co-Authors:	Toshihiko Satake, MD, Takeshi Kijima, DDS, PhD, Shinji Kobayashi, MD, PhD, Takashi Hirakawa, DDS, PhD
Affiliation:	Yokohama City University Medical Center, Yokohama City

Purpose: Bone augmentation in alveolar cleft is very important in the treatment of cleft lip and palate. However, it remains challenging even in the unilateral cleft lip and palate. Some report that approximately 40% of UCLP patients required secondary bone grafting (SBG) even when they had succeeded in gingivoperiosteoplasty(GPP) after presurgical orthognathic treatment with Hotz plate, Latham appliance or Naso-Alveolar Molding(NAM) plate. As we have performed one-stage repair including primary alveolar bone grafting (PBG)for cleft lip and palate patients and gained good results, we present our technique and treatment outcome. Methods and Materials: Our cases are composed of totally 168 unilateral cleft lip and palate patients who underwent operation at the age between 3 to 9 months after presurgical orthognathic treatment from June 1998 to January 2006 in our hospital. Our one-stage repair technique includes (1)primary cleft rhinoplasty, (2)periosteoplasty of piriform aperture rim,(3)philtrumplasty (original method),(4)cheiloplasty by small triangle flap, (5)midline closure of vermillion, (6)gingivoperiosteoplasty(GPP) or gingivoperiosteoflap(GPF), (7)PBG from hard palate and/or inferior nasal concha ,and (8)palatoplasty by modified Furlow method using muco-periosteal flap of posterior nasal septum. (Fig.1) We have harvested hard palatal and/or inferior chonchal bone for PBG so that SBG will be unnecessary for almost all the cleft lip and palate patients. Our surgical technique of primary alveolar bone grafting from hard palate and/or inferior choncha is as follows. (a)Sagital mucosal incision is made on inferior choncha and chonchal bone is harvested under periosteum. (b)Hard palate is dissected under periosteum and palatal bone, maxillary bone and part of vomer are harvested. (Fig.2) (c)Harvested bone is not ground but curved to be grafted to alveolar cleft. (Fig. 3) Results: Shown in (Fig.4) is a female right complete unilateral cleft lip and palate patient,who underwent one-stage repair including primary alveolar bone grafting from left hard palate and right inferior concha at the age of 4 months in our hospital. (Fig.5) is a pre- and post-operative photos of her configuratuion and postoperative intraoral view. As postoperative CT images demonstrate,we have attained good bone formation. (Fig.6 ) Overall ,bone harvesting was possible in all the cases from hard palate and in some cases, we could not harvest the bone from inferior nasal concha because of poor view. So far, there have been no complications such as oro-nasal fistula or maxillary growth impairment and bone regeneration is observed in some cases, though incompletely. Discussion:In early 1900s,there were some papers reporting on surgical techniques of alveolar bone grafting with autologous bone such as the tibia,cranium,iliac crest,and ribs for the treatment of cleft lip and palate patients. In 1955,Nordin et al. and Schmid described PBG as a procedure for repair of alveolar defects in patients with cleft lip and palate using autologous rib at the time of cheiloplasty . In those days, PBG had been rather standard of care. However, in 1960s, there were opponents to PBG believing dissection of vomeromaxillary suture would bring about unfavorable results. Since Pruzansky reported that PBG resulted in midfacial growth impairment in 1964,PBG has become less and less popular .Today cleft lip and palate treatment trends favor the use of SBG instead. Recently,in spite of having been denied once historically,PBG has come to be reevaluated with the advancement of surgical technique and presurgical orthognathic treatment. In the background of our bringing back PBG,there are developments of palatoplasty of our modified Furlow method,which does not leave raw surface or maxillary growth impairment behind, GPP/GPF,and our own original sites for bone harvesting,that is ,hard palate and inferior nasal concha.Conclusion: Periosteum in infants has good potential of bone formation. We assume that harvested bone plays an important role as spacer in maintaining the shape of periosteum and that hard palate and inferior nasal concha are proper donor sites of PBG in one stage repair of cleft lip and palate.

8:14 AM - 8:15 AM

Speaker Turnover

Presenter:	No presenter
Affiliation:

8:15 AM - 8:19 AM

Reduced Need for Alveolar Bone Grafting by Presurgical Orthopedics and Primary Gingivoperiosteoplasty in Patients with Bilateral Clefts of the Lip, Alveolus, and Palate

Presenter:	Sacha I. Obaid, MD
Co-Authors:	Shahreyar S. Hashemi, MD, Barry H. Grayson, DDS, Court B. Cutting, MD, Lawrence E. Brecht, DDS
Affiliation:	New York University, New York, NY

BACKGROUND & PURPOSE: Alveolar bone grafting is an operative procedure traditionally requiring general anesthia, the placement of scars on the hip, and often significant post-operative pain. The purpose of this study was to evaluate if narrowing and approximation of the alveolar cleft through presurgical alveolar molding followed by gingivoperiosteoplasty (GPP) at the time of cleft lip repair reduces the need for alveolar bone grafting in patients with bilateral clefts of the lip, alveolus and palate (BCLP).

METHODS: This is a retrospective chart review of all patients with BCLP who underwent presurgical infant alveolar molding followed with GPP by a single surgeon. A combination of clinical examination, panoramic and periapical radiographs, and/or dental CT scans were used to assess alveolar bone formation. The criterion for bone grafting was inadequate bone stock to permit the eruption and maintenance of permanent dentition. All patients with BCLP that presented to our institution from 1988 - 1998 were included.

RESULTS: 27 patients were identified with a follow up of 8 - 16 years (Average 10.9 y). 11 of 27 patients (41%) did not require alveolar bone grafting.

CONCLUSIONS: In this series of 27 patients with BCLP, treatment with presurgical alveolar molding followed by GPP was successful in preventing the need for alveolar bone grafting, in 41% of patients. These patients are spared the cost of an additional surgery, the risk of a general anesthetic and the significant post-operative pain of the alveolar bone graft procedure. In addition, benefits were seen in those children who went on to undergo an alveolar bone graft. In many of these children, one side of the GPP was successful, allowing for stabilization of the premaxilla. The stabilization of the premaxilla allows the child functional use of the central incisors. The subsequent use of the central incisors, then allows the child to develop a healthy, hearty premaxillary bone which is important functionally and aesthetically for support of the alar base.

8:19 AM - 8:20 AM

Speaker Turnover

Presenter:	No presenter
Affiliation:

8:20 AM - 8:24 AM

A Financial Analysis of Operative Facial Fracture Management

Presenter:	Detlev Erdmann, MD, PhD
Co-Authors:	Keith E. Follmar, MD, Karen Price, CPC, L. Scott Levin, MD, FACS, Jeffrey R. Marcus, MD
Affiliation:	Duke University, Durham, NC

Purpose: Although essential to the academic mission of any plastic surgery training program, trauma care is associated with low reimbursement rates, placing an economic burden on hospitals and physicians (1, 2). However, the economic impact of operative facial fracture management has not been systematically investigated. This study aims to provide a descriptive financial analysis of all patients undergoing operative facial fracture management at a single academic medical center during a three year period.

Methods and Materials: The records of 202 patients who underwent operative facial fracture management at a United States level one trauma center between 2003 and 2005 were analyzed retrospectively. Demographic, clinical, and financial data were reviewed. All physician and hospital charges related to fracture management, including staged (secondary) operations performed between the time of trauma and the end of 2006, were included. Physician (professional) charges were subdivided by specialty. Total hospital charges (including emergency room, operating room, recovery room, intensive care unit stay, hospital bed, supply charges, pharmaceuticals, laboratory charges, and radiographs) were calculated. Physician reimbursement rates are reported for each specialty and by payer type. To serve as a crude basis for comparison, professional charges and collections for patients undergoing operative facial fracture management were compared to those for the population of general plastic surgery patients and for the population of orthopedic trauma patients over the same time period.

Results: The average patient age was 33.2 years ± 14.6 (std dev); the age range was 3-79 years. Of 202 patients, 146 were male (72%), and 56 were female (28%). The sum of all professional charges billed to these 202 patients was $2,478,234.20 (average of $12,268.49 per patient).

The collections for these professional services totaled $675,434.13, yielding an overall reimbursement rate of 27%. Reimbursement rates ranged from 38% for critical care (ICU) physicians to a low of 24% for surgeons and neuroradiologists. Reimbursement rates are shown in figure 1 for each physician specialty type.

When analyzed by payer type, the highest reimbursement rates were seen in children covered by CHIPS and in federal and state prison inmates (53% and 99% respectively). The lowest reimbursement rate was obtained from uninsured patients (26% of patients), who paid an average of 10% of physician charges. Professional reimbursement rates for each payer type are shown in table 2. Private insurance reimbursed at slightly higher than the average rate.

The total hospital charges for the same patient group was $18,120,027 (average of $89,703.10 per patient); total collections were $2,770,115 (15% reimbursement rate).

For comparison, the total professional charges for operative management of orthopedic skeletal trauma over the study period was $173,702,951, with total collections of $57,223,826, which equals a 33% reimbursement rate. The total billings for professional services within the Division of Plastic Surgery during the same period was $32,559,264 of which $10,352,944 was collected (reimbursement rate 32%).

Conclusions: This study provides an up-to-date economic analysis of operative facial fracture management at a major United States trauma center. Within the limits of a simple descriptive analysis of charges and collections, our results appear to demonstrate the unfavorable financial circumstances associated with facial trauma care. From a purely financial standpoint, these economic realities make facial trauma relatively unrewarding, and present a challenge to academic plastic surgery.

References: 1. Shapiro MJ, Keegan M, Copeland J. The misconception of trauma reimbursement. Arch Surg 1989; 124(10):1237-40. 2. Henry MC, Thode HC, Jr., Shrestha C, Noack P. Inadequate hospital reimbursement for victims of motor vehicle crashes due to health reform legislation. Ann Emerg Med 2000; 35(3):277-82.

Figure Legend: Figure 1. Professional reimbursement rates for 202 patients undergoing operative management of facial fractures for each physician specialty category. Figure 2. Professional reimbursement rates for each payer type.

8:24 AM - 8:30 AM Discussion

Wednesday, October 31, 2007

A Plastic Surgical Experience While Deployed in a Combat Zone: Reconstruction Within the Afghanistan Theater (Operation Enduring Freedom VII)

Presenter:	Raymond Harshbarger, MD
Affiliation:	Walter Reed Army Medical Center, Washington, DC

The author reviews his surgical experience while deployed for 6 months with the US Army to a Combat Support Hospital in Afghanistan. The hospital provided care to US Soldiers, Afghan Army, and Local Nationals. There were two operating rooms, an eight bed ICU, and a twenty-five bed ward. The hospital received casualties from across the entire Afghanistan theater. Trauma stabilization and evacuation was performed on US Soldiers. Afghan Army and Local Nationals received definitive care.

During the deployment 121 cases were performed. Ninety percent were trauma related. Trauma cases included: 33 head/neck with 11 cranial ORIF, 13 Facial fracture ORIF, two CSF leak repairs, seven soft tissue repairs. Thirty were upper extremity, nine trunk, and 31 lower extremity, including 27 flaps (two free flaps), 11 skin grafts, and 22 wound closures. Ten percent were elective: nine percent humanitarian, including cleft/craniofacial, and burn reconstruction. One scar revision was performed.

Of 109 trauma cases, complications were as follows: craniofacial- mortality 1/11 craniotomies, one persistent CSF leak, one craniofacial hardware removal for infection of 24 cases. With Flaps there was one partial flap loss, one delayed healing, two cellulitis, and one hematoma. Skin grafts had 1/11 lost. From Acute burns there was one death, one skin graft loss in an infant with 46% TBSA full thickness burns. Of the wound closures, there was one cellulitis. There was one partial SG loss, from the twelve elective cases,

Challenges encountered while delivering care in a Combat Zone included poor patient nutrition, large zones of injury from high velocity weapons, transport times to definitive care, and equipment shortcomings. Given the small open bay ICU/ward environment at the hospital, wound contamination was of greater concern.

In a Combat Support Hospital within the austere environment of Bagram, Afghanistan, plastic surgical care was successfully delivered to US Soldiers, Afghan Army, and civilians. Plastic Surgeons are uniquely qualified to assist with the wide variety of traumatic and humanitarian cases presenting within a Combat Theater.

7:04 AM - 7:05 AM

Speaker Turnover

Presenter:	No presenter
Affiliation:

7:05 AM - 7:09 AM

Complex War Extremity Wound Reconstruction: Improved Outcomes in the Subacute Period

Presenter:	Anand R. Kumar, MD
Co-Author:	Thomas L. Chung, DO
Affiliation:	University of Pittsburgh, Children's Hospital of Pittsburgh, Pittsburgh, PA

Background: The National Naval Medical Center (NNMC) continues to treat injured personnel supporting Operation Iraqi Freedom and the Global War on Terrorism. Mutilating war extremity wounds associated with improvised explosive devices (IEDs) have created a unique reconstructive challenge. The objective of this study is to report and analyze the timing and success rates of war extremity reconstruction performed in the subacute period (72 hours to 3 months).

Methods: A retrospective review was conducted of injured personnel requiring extremity flap reconstruction at NNMC over a 30-month period. All flap reconstructions were performed on this cohort by a single surgeon. Collected data included type and number of flaps, partial and total flap failure rates, number of pre-reconstruction wound washouts, time from initial injury to closure, post-operative early infection rates (within 6 weeks), associated injuries (fractures, neurovascular), use of negative pressure wound therapy and early flap failure necessitating limb amputation.

Results: From September 2004 to February 2007, seventy-two (56 pedicled flaps and 16 free) extremity flap reconstructions (27 fasciocutaneous, 39 muscle, and 6 adipofascial) were performed on sixty-six patients. Patient age ranged from 19 to 42 years (median age 23). Time to reconstruction ranged from 7 to 161 days (average 25 days). Seventy-one percent of all injuries were associated with an IED blast. Twenty-five upper (35 percent) and forty-seven lower (65 percent) extremity flaps were performed. Eight (11.1 percent) flaps were used to close proximal extremity wounds. Twenty-three (31.9 percent) flaps were used to close mid-extremity wounds and forty-one (57 percent) flaps were used to close distal extremity wounds. Median number of pre-reconstructive washouts was four (range 2 to 22). One hundred percent of injuries were associated with regional open fractures managed with negative pressure wound therapy prior to reconstruction. Thirty-two percent and twenty-one percent of injuries were associated with nerve and vascular injuries respectively. Forty percent of all wounds were cultured positive at admission, of which sixty-nine percent were associated with Acinetobacter species. Post-operative early infections occurred in ten flaps (13.9 percent). Total flap loss occurred in two flaps (2.8 percent) and partial flap loss occurred in six flaps (8.3 percent). Two patients underwent early limb amputation after flap failure.

Conclusions: Despite reconstruction in the subacute period, the high rate of antimicrobial colonization prior to wound closure, and the devastating nature of IED blast injuries, early analysis of the NNMC war extremity reconstruction cohort demonstrates low total and partial flap loss rates as well as acceptable infection rates. Longer-term data such as osteomyelitis rates, fracture union rate, time to ambulation, and patient satisfaction with limb salvage are currently under investigation.

7:09 AM - 7:10 AM

Speaker Turnover

Presenter:	No presenter
Affiliation:

7:10 AM - 7:14 AM

Routine Use of Wound V.A.C. Does Not Allow Coverage Delay for Open Tibia Fractures

Presenter:	Timothy Bhattacharyya, MD
Co-Authors:	Bohdan Pomahac, MD, R. Malcolm Smith, MD, Priyesh Mehta, BA
Affiliation:	Massachusetts General Hospital and Brigham and Women's Hospital, Boston, MA

Background: Prevention of infection is a paramount concern after open fracture of the tibia, and previous studies have shown that delay in soft tissue coverage may raise infection rates. Use of Vacuum Assisted Closure (VAC) devices in open fracture wounds has become common. We analyzed whether use of the VAC sponge can allow delay of flap coverage for open tibia fractures without increase in infection rate.

Methods: We identified 39 patients with grade IIIB open fractures from our trauma registry with minimum 1 year follow up. From the medical record we collected information on the time from injury to definitive wound coverage, type of fixation, type of coverage, and demographics. Infection was defined by identifying patients who required surgical debridement.

Results: Patients who underwent definitive coverage within 7 days had a significantly decreased rate of infection (12.5%) compared to patients who had coverage at 7 days or more post injury (54%, p<0.008). Overall infection rate was 29% with routine use of the VAC sponge. Patients who developed infection had a greater mean time to coverage than patients who did not develop infection (8.9 days versus 4.8 days, p< 0.029),

Conclusions: Routine use of the VAC with open tibia fractures is safe and provides a good primary dressing over open wounds. For IIIB tibia fractures, negative pressure wound therapy does not allow delay of soft tissue coverage past seven days without a concomitant elevation in infection rates.

7:14 AM - 7:15 AM

Speaker Turnover

Presenter:	No presenter
Affiliation:

7:15 AM - 7:19 AM

Versatility of the Proximally Pedicled Anterolateral Thigh Flap and Lessons Learned from its Use in Complex Abdominal and Pelvic Reconstruction

Presenter:	Declan Anthony Lannon, FRCS(Plast), MSc
Co-Authors:	Gary L. Ross, FRCS(Plast), Patrick D. Addison, FRCS, Christine B. Novak, PT, MS, Joan E. Lipa, MD, MSc., FRCS(C.), FACS, Peter C. Neligan, MB, FRCS(I), FRCSC, FACS
Affiliation:	Toronto General Hospital, Toronto, ON

Purpose. In this study we reviewed our use of the pedicled anterolateral thigh (ALT) flap in complex abdominal and pelvic reconstruction. We identified points of surgical technique that enhanced our results. In addition we identified the potential pitfalls of this flap.

Materials and Methods. Following approval of our Research Ethics Board we performed a retrostpective review of the medical records of 25 patients who underwent 26 pedicled ALT flaps performed consecutively between November 2001 and January 2007 inclusive. Parameters reviewed included age, sex, diagnosis, past medical history, defect dimensions, flap dimensions, anatomical sites and components requiring reconstruction, suprafascial or subfascial harvesting, number and type of perforators, closure of donor site, complications, and length of follow up.

Results. Thirteen males and 12 females with a mean age of 60 (range 35-86) underwent pedicled ALT flaps for complex abdominal and pelvic reconstruction. Five patients (20%) were diabetic, six (24%) were smokers, and fifteen (60%) had preoperative radiotherapy. Twenty-three patients had defects secondary to ablative procedures for primary, recurrent or metastatic malignancy. One had cutaneous manifestations of Crohn's disease, and one had a large ventral hernia secondary to previous abdominal wall resection for necrotizing fasciitis. Of those patients undergoing tumour resection there were 11 primary sarcomas (one chondrosarcoma, two dermatofibrosarcoma protuberans, three malignant fibrous histiocytomas, one angiosarcoma, two leiomyosarcomas, two liposarcomas), five recurrent sarcomas (two dermatofibrosarcoma protuberans, one chondrosarcoma and two liposarcomas), one primary squamous cell carcinoma (SCC), two metastatic SCC's, one primary adenocarcinoma, one metastatic adenocarcinoma, two metastatic malignant melanomas, and one metastatic malignant phaeochromocytoma. Mean size of defect was18.7 x 13.8 (range 10-30 x 7 – 30) centimeters. Mean size of anterolateral thigh flap was 16.9 x 9 (range 14-20 x 6-14) centimeters. The arc of rotation included the umbilicus, iliac crest, posterior superior iliac spine, and anterior anal margin. Twenty-two flaps were dissected subfascially and four suprafascially. In the subfascial group the harvesting extended beyond the cutaneous borders of the flap in six cases to increase the amount of vascularised fascia for abdominal wall reconstruction. The fascia was used to reconstruct the abdominal wall in a total of sixteen cases. There was a mean of 1.5 perforators per flap (range 1-4) of which 14% were septocutaneous. The donor site was closed directly in all but four cases, which required a split thickness skin graft. Complications included two complete flap losses (8%), one partial flap loss (4%) and five minor wound dehiscences at recipient sites, and delayed healing of four flap donor sites (15%)(two closed directly and two with split thickness skin grafts). All patients with complications, except one, had at least one factor contributing to poor wound healing (diabetes, smoking, or preoperative radiotherapy). One patient with a minor dehiscence subsequently died as a result of a small bowel fistula, psoas abscess and rupture of a false aneurysm in the ipsilateral external iliac artery. Mean follow up was 10 months (range 1-40 months). Useful points of surgical technique include suprafascial harvesting of the flap, the method of harvesting fascia, and its utilization to protect the pedicle, harvesting the anterolateral thigh flap as a composite flap with a portion of vastus lateralis, prudent preservation of large perforators that transgress through the lateral aspect of the rectus femoris muscle, combined use of the pedicled anterolateral thigh flap with a sartorius ‘switch', complete flap de-epithelialization to fill dead space, and simple conversion to a free flap when pedicle length is inadequate. Pitfalls identified included the increased risk of pedicle avulsion in the morbidly obese, the risk of atherosclerotic placque embolization in an atheromatous pedicle, and the potential inadequacy of thigh fascia for reconstituting abdominal wall integrity.

Conclusion. The pedicled ALT flaps is a versatile flap with a wide arc of rotation making it useful in complex abdominal and pelvic reconstruction. Variations in the surgical procedure for each patient can be used to enhance results, and an appreciation of potential pitfalls may help minimize complications.

7:19 AM - 7:20 AM

Speaker Turnover

Presenter:	No presenter
Affiliation:

7:20 AM - 7:24 AM

Damage Control Abdomen: Single-Stage Reconstruction Using a Vicryl Mesh Buttress

Presenter:	Theresa Y. Wang, MD
Co-Authors:	River Elliott, BA, David W. Low, MD
Affiliation:	University of Pennsylvania, Philadelphia, PA

PURPOSE: Damage control laparotomy has become an accepted approach for patients with life-threatening abdominal conditions such as trauma and sepsis. While this protocol increases survival rates, it compromises abdominal fascial integrity. There is loss of domain which results in massive hernia. This abdominal wall morbidity can be functionally and aesthetically debilitating for the patient. The purpose of this study is to report our experience and outcomes with these complex abdominal wall reconstructions which represents the largest reported series of repairs of hernias of this magnitude. METHODS: A retrospective review was conducted of 56 consecutive patients with previous damage control laparotomies (13 females, 43 males) who underwent elective abdominal wall reconstruction at a single institution between January 1999 and April 2006. Mean age was 42 years (19 to 80). The abdomen of patients were covered initially by split-thickness skin graft and/or mesh after their original laparotomy. The reconstructive method used in all patients consisted of a double-layer, subfascial Vicryl mesh buttress to aid in establishing abdominal wall integrity, combined with components separation and rectus muscle turnover flaps. Ten patients with massive abdominal defects (1196 to 1836 cm2) required additional Marlex mesh implantation. Activity and functional levels were evaluated by clinical exams and telephone surveys. RESULTS: Major etiologies of abdominal hernias were gun-shot wounds (36.2%), motorvehicle accidents and blunt trauma (23.4%) and sepsis or perforated bowel (23.4%). The mean abdominal wall defect was 865cm2 (150 to 2475), and the average interval time to definitive repair was 16.9 months (3 to 41). The mean length of follow-up was 29 months (1 to 95). Recurrent herniation following definitive repair was 12.5% (7/56). Of these, one was successfully surgically repaired, five were small umbilical hernias that were asymptomatic and did not limit function. One was the result of intentional fascial release for compartment syndrome and has not since undergone reconstruction. Other complications include superficial skin dehiscence, all of which healed secondarily with daily wound care 8.9% (5 patients) and abdominal compartment syndrome 7.1% (4 patients). There were no wound infections, mesh exposures, or seromas. There were two post-operative mortalities, both which occurred in patients with compartment syndrome and were reopened in the intensive care unit. Thirty patients completed telephone surveys (53.4%). Ninety percent of patients who worked full-time prior to injury returned to their jobs, and 92.3% were functioning at pre-trauma activity levels. CONCLUSION: Massive abdominal hernia following damage control laparotomy poses a great challenge to the reconstructive surgeon. This patient population is at significant risk for mortality and morbidity. We present the largest series of repairs of these massive hernias with long-term follow-up and an acceptable hernia recurrence rate. Functional results are excellent with most returning to work and at normal activity levels. We believe the use of a vicryl mesh buttress is an important adjunctive maneuver for definitive, single-stage complex abdominal wall reconstruction.

7:24 AM - 7:30 AM Discussion

8:00 AM - 8:04 AM

Comparison of Muscle and Fasciocutaneous Tissue on the Healing of Open Tibial Fractures

Presenter:	Lorraine E. Harry, PhD, MRCSEd
Co-Authors:	Ewa Paleolog, PhD, Ann Sandison, MPhil, MRCPath, Ulrich Hansen, PhD, Michael Pearse, MS, FRCSOrth, Jagdeep Nanchahal, PhD, FRCSPlast
Affiliation:	Imperial College, London, London

Open fractures of the leg are a reconstructive challenge. Early restoration of the soft tissue envelope has dramatically improved the outcome of these fractures with regard to deep infection and function. However the ideal tissue for covering open fractures remains controversial. Muscle is said to be superior, but the mechanism is unclear. A higher blood flow was thought to be the key factor although this has not been established. Angiogenesis is vital for fracture healing, and Vascular Endothelial Growth Factor (VEGF), has been shown to be pivotal. We have developed a novel murine open tibial fracture model to compare the vascularity of muscle and fasciocutaneous tissue and investigate their role in angiogenesis during fracture healing. An open tibial fracture, stripped of periosteum, was created in female C57Bl/10 mice, under Home Office Approval. Skeletal stabilization was achieved with a 0.38mm diameter intramedullary pin. Animals were divided into experimental groups which allowed exclusive comparison of the soft tissues. A piece of sterile, inert material (Polytetrafluoroethylene, PTFE), was inserted at the fracture site to exclude either muscle posteriorly (Fasciocutaneous group) or skin and fascia anteriorly (Muscle group). A control group was devised consisting of fracture plus stripping but no PTFE, the Skeletal Injury only group. Animals were harvested at days 3, 5, 7, 9, 14, 21 and 28 days post-fracture and healing was assessed histologically. Bridging of the fracture site, by callus containing woven bone was quantified by histomorphometry. Endpoint assessment was also achieved by peripheral Quantitative Computed Tomography (pQCT) and mechanical testing. Immunohistochemistry was performed on specimens, to estimate vascularity using an antibody to factor VIII related antigen, which selectively demonstrates vascular endothelium. Vascular densities were determined within the muscle and fasciocutaneous tissues adjacent to the fracture sites, by manual counting of immunostained vessels at high magnification (x500) using an eyepiece graticule. VEGF levels were measured by ELISA in tissue specimens and the level of the VEGF antagonist soluble VEGF Receptor 1 (sFlt-1) was also assayed to determine relative drive for new blood vessel formation. All statistical analyses were performed by 1 Way and 2 Way ANOVA. Fracture healing was more advanced beneath muscle. There was earlier bridging of the fracture site by callus, with 50% more bone content and a stronger union beneath muscle compared to fasciocutaneous tissue (p<0.05). However, significantly greater vascular densities per unit area were observed in fasciocutaneous tissue compared to muscle (p<0.0001) at all time points during fracture healing. The relative excess of VEGF over sFlt-1 receptor, defined as the “angiogenic drive”, was statistically significant during the time course of fracture healing (p=0.0001). We have studied the exclusive effects of muscle and fasciocutaneous tissue on the healing of open tibial fractures stripped of periosteum. We have demonstrated faster bridging beneath muscle compared to skin and fascia alone, comparable to our fracture control. However, there were significantly higher vascular densities in fasciocutaneous tissue compared to muscle. Temporal distribution of factors known to be pivotal for the angiogenic process have been established within soft tissues, demonstrating that the coverage of fractures by soft tissues plays an important role in establishing the biological milieu and creating the microenvironment for fractures to heal. Our results contradict the widely held view that muscle provides superior coverage of open fractures because of a higher capillary density. The data suggest that vascularity is not the only factor influencing the choice of soft tissues. Extrapolating our data to clinical practice, muscle should be the tissue of choice for covering high-energy open distal tibial shaft fractures.

8:04 AM - 8:05 AM

Speaker Turnover

Presenter:	No presenter
Affiliation:

8:05 AM - 8:09 AM

The Role of Peripheral Nerve Surgery in the Management of Painful Chronic Wounds: Indications and Outcomes

Presenter:	Ali Al-Attar, MD, PhD
Co-Authors:	Amir A. Mafi, BS, Ivica Ducic, MD, PhD
Affiliation:	Georgetown University Hospital, Washington, DC

Background: Patients with chronic wounds due to healing problems also often present with chronic pain at the site. Proper wound care and/or an appropriate reconstruction usually address both wound and its associated pain. However, wounds occasionally remain painful despite successful reconstruction, particularly when complicated by an underlying condition (such as sickle cell disease). These patients frequently develop a disabling chronic pain condition despite the application of current treatment modalities, including narcotic and non-narcotic analgesia, physical therapy, nerve blocks, and psychotherapy. In this study, a novel approach is evaluated for the management of this difficult clinical situation, by addressing the sensory nerve supply to the affected wound region. Methods: Eight patients (five female and three male) with intractable chronic pain despite wound reconstruction underwent surgery and were followed for a mean of 27 months (range of 8 to 40 months). The involved sensory nerve was identified preoperatively by physical exam and confirmed by nerve block, and was then surgically excised and implanted into adjacent muscle. Patient's pain reduction, ambulation status and quality of life improvement were evaluated. Wilcoxon rank test and Fisher's exact test were used for data analysis. Results: The involved nerves in this patient group included the ilioinguinal, lateral femoral cutaneous, sural, saphenous, superficial peroneal, deep peroneal, and genital branch of the genitofemoral nerve. All eight patients reported significant pain reduction (p<0.0001), improved ambulation (p<0.0001), and improved quality of life (p<0.0001), as evaluated at the time of the last follow up visit (mean of 27 months). Conclusions: Chronic wounds are not only a metabolic and infectious burden to the patient, but can be a source of disabling pain despite adequate wound reconstruction. This study suggests that an additional treatment modality in management of chronic wounds can be considered for patients with disabling pain. A treatment algorithm is presented along with the technique. As an adjunct to other interventions, this novel application of peripheral nerve surgery can critically improve symptoms in selected patients with intractable chronic wound pain.

8:09 AM - 8:10 AM

Speaker Turnover

Presenter:	No presenter
Affiliation:

8:10 AM - 8:14 AM

Efficacy of 5-fluorouracil and Triamcinolone in theTreatment of Keloids

Presenter:	Joseph H. Dayan, MD
Co-Authors:	Steven P. Davison, MD, DDS, Smith Sonni, MD, Amy Crane, MD
Affiliation:	The Mount Sinai Beth Israel Hospital, New York, NY

BACKGROUNG: Keloids are a common problem and can be challenging to treat. Intralesional triamcinolone has been the mainstay of therapy. However, recurrence rates are significant and steroids may have adverse effects such as hypopigmentation. Recently there have been occasional reports in the literature on the use of antineoplastic agents in keloid therapy. The purpose of this study is to evaluate the efficacy of a 5-fluorouracil/steroid mixture over the past seven years and compare the results with steroid treatment alone. METHODS: All charts from 1999 to 2006 were reviewed for patients who received either a combination of 5-FU and triamcinolone or steroid alone. The follow-up period ranged from 6 months to 6 years. A mixture of 75% 5-fluorouracil and 25% triamcinolone was most commonly used. Percentage reduction in lesion size and adverse effects were evaluated. RESULTS: A total of 94 patients with 102 keloids were identified. The 24 patients who underwent excision with the 5-FU/steroid combination had a 92% average reduction in lesion size compared with 73% in the 26 patients who did not receive 5-FU. The 52 patients who received 5-FU and steroid without excision had an average size reduction of 81%. These differences were statistically significant (p = 0.05). Those patients who received treatment with 5-FU/steroid combination had a 21% incidence of adverse effects compared with 15% in the steroid only group. However, this difference was not statistically significant. CONCLUSION: The results of this study suggest that combination 5-FU/steroid may be superior to traditional therapies without any statistically significant difference in adverse effects. The successful use of 5-FU in patients who failed treatment with triamcinolone is particularly significant. Prospective trials using antineoplastic agents are needed in keloid research.

8:14 AM - 8:15 AM

Speaker Turnover

Presenter:	No presenter
Affiliation:

8:15 AM - 8:19 AM

Pediatric Dog Bite Injuries - A 5 Year Review of the Experience at the Children's Hospital of Philadelphia

Presenter:	Jessica M. Belz, MD
Co-Authors:	Alison E. Slemp, MD, Richard E. Kirschner, MD
Affiliation:	University of Pennsylvania, Philadelphia, PA

Objectives: It is estimated that nearly one million Americans suffer dog bite injuries each year, a number that has recently been reported to be increasing. A significant number of these injuries are sustained by children, many of whom typically present with more severe injuries than adults. The primary objective of this study is to identify the nature of dog bite injuries treated over a five-year period at a large tertiary pediatric hospital and to identify critical parameters for public education and injury prevention.

Methods: Investigators performed a retrospective review of emergency room records of a single tertiary pediatric hospital. Records of all pediatric patients who were evaluated for dog bite injuries sustained between April 2001 and December 2005 were reviewed. Demographic details, including the victim's age, breed of dog, anatomical location of injury, number of wounds, and relationship of patient to dog were recorded. All available medical details related to injuries were also abstracted.

Results: 499 patients aged 5 months to 18 years were treated in the emergency department records after suffering dog bite injuries during the study period. The majority of such injuries (63.1%) were sustained by male children. Dog bite injuries were most prevalent during the summer months of June and July. Grade school-aged children (6-12 years) were the group most likely to have suffered such injuries (51.7% of all patients), followed by preschoolers (2-5 years; 24.1%), teenagers (13-18 years; 20%), and infants (birth-1 year; 4.2%). Infants and preschoolers were more likely to have sustained bite injuries to the face, whereas older children more often suffered bites to the extremities. Hospitalization was required for 21 patients (4.2%). More than 25 different offending breeds were documented in the medical records. Of those cases for which a breed was recorded, however, the overwhelming majority (73.14%) were caused by pit bull terriers, rottweilers, German shepherds, or mixes of these breeds, the majority of dogs (68.14%) being familiar to their victims.

Conclusions: Pediatric dog bites are preventable injuries, yet they persist as a prevalent public health problem. Evaluation of data from high-volume tertiary pediatric health care institutions identifies predictable patterns of injury with respect to patient age and gender, animal breed, provocation, and seasonality. Such will allow for the development of more effective prevention strategies, including programs for community outreach and education.

8:19 AM - 8:23 AM

The Effect of Preoperative Warming of the Patient in Plastic Surgery Operations

Presenter:	Juris Kivuls, MD
Co-Author:	Andris K. Kivuls, none
Affiliation:	Kaiser Permanante Downey, Downey, CA

Purpose: Operative procedures under general anesthesia create a patient environment that predisposes the patient to hypothermia. To prevent hypothermia we use prep and drape techniques to minimize patient exposure, warmed IV fluids, warmed irrigation fluids, forced air warming blankets, low flow and humidified general anesthesia circuits. Since November 2006, we have added preoperative warming of the patient using a forced air heating blanket for at least 30 minutes before transfer to the operating room. This study is a retrospective chart review looking at the effectiveness of this technique.

Methods: The study examines three operative procedures: mastectomy and immediate reconstruction with implant, bilateral breast reduction, and abdominal pannus surgery performed by one surgeon. Consecutive patients for each procedure type were evaluated starting from the time of addition of pre-op warming and counting forward and counting backward in time for the control group. Fifty-four patients were included in the study. There were eighteen patients for breast reconstruction, twenty patients for breast reduction, and sixteen patients for pannus surgery. Half of each procedure group had preoperative warming and half did not- control group. Data was obtained from the anesthesia record. Only core temperature measurements are reported and were measured using esophageal temperature probe. The temperatures reported were: lowest temperature during the operation and its time, temperature at 1 hr, 2 hr, 3hr, 4 hr and temperature at end of surgery. Preoperative warming needed to be for at least 30 minutes using a forced air total body warming blanket.

Results: There were no complications related to the use of the forced air heating blanket. The average age, height and weight were similar for each of the pre-warming groups compared to their control groups.

Fig. 1 shows the 6 different groups mean temperature plotted versus time. The lowest temperature was at 30 – 45 minutes following start of surgery and then slowly increased with time. All the pre-warmed patient groups averaged higher temperature than their controls. The biggest difference was in the breast reconstruction group and smallest in the pannus surgery group.

Fig. 2 shows mean temperature for all the pre-warming patients versus all the control patients and their relation to 36.0 degrees centigrade. The pre-warming group was 0.5 degree warmer at all times.

Fig. 3 shows the percentage of patients that were at or above 36 degrees C. at any time period. This showed that pre-warming was effective in keeping the temperature from dropping below 36 degrees C., especially in the first hour of surgery.

Discussion: Higher postoperative complication rates have been reported with mild hypothermia- core temperature of 34 to 36 degrees C. These include infection, bleeding, cardiac events, longer hospitalization, thermal discomfort, duration of post anesthesia recovery. These are well summarized in review articles by Sessler (1) and Young (2). Thus, the goal would be to maintain the patient's core temperature above 36.0 degrees C. Fig #3 shows that preoperative warming was successful, but did not completely prevent mild hypothermia. Our intra-operative warming techniques were successful as patient temperatures rose as the surgery progressed and only 2 patients had core temperatures under 36 degrees C at the end of the operation;( both in the control group).

The ambient temperature of the operating room ranged between 66.5 and 69 degrees F. Warming the operating room has been shown to prevent hypothermia, we did not attempt to change this variable.

We have found no change in complication rates as a result of preoperative warming. A larger patient population group would need to be studied to determine any significant difference in outcomes.

Conclusion: Pre-operative warming is effective technique in preventing mild hypothermia in plastic surgery patients when used along with other prevention strategies.

1. Sessler, DI. Complications and Treatment of Mild Hypothermia; Anesthesiology Aug 2001; 95 (2) : 531-543

2. Young, VL. Prevention of Perioperative Hypothermia in Plastic Surgery; Aesthetic Surgery Sept 2006, 26 (5): 551-571

8:23 AM - 8:24 AM

Speaker Turnover

Presenter:	No presenter
Affiliation:

8:24 AM - 8:30 AM Discussion

8:15 AM - 8:19 AM

A Randomized, Prospective, Parallel Group Study Comparing an Ultrasonic Scalpel to Electrocautery in Abdominolipectomies

Presenter:	Dirk F. Richter, MD
Co-Authors:	Oscar A. Zimman, MD, PhD, FACS, José Antonio León Pérez, MD, Al S. Aly, MD, Alexander Stoff, MD, Fernado Urrutia, MD, Sabina Zimman, MD, Albert Cram, MD, FACS, Mario Gutierrez, MSHS, Nfii Ndikintum, PhD
Affiliation:	Dreifaltigkeits-Hospital Wesseling, Wesseling

8:19 AM - 8:23 AM

Clinical Application of Cultured Autologous Human Auricular Chondrocytes to Cranio-facial, Nasal and/or Ear Reconstruction: Overall Results in Basic Studies and 60 Patients

Presenter:	Yanaga Hiroko, MD, PhD
Co-Authors:	Imai Keisuke, MD, Yanaga Katsu, MD
Affiliation:	Yanaga Clinic and Tissue Culture Laboratory, Kitakyushu City, Fukuoka

Purpose: The author developed and clinically applied a new culture method with which a sufficiently large volume of chondrocytes for the reconstruction of normal cartilage in human body is developed from a small piece of auricular cartilage. This report presents overall results of the basic studies and clinical applications.

Methods: Approximately one cm² of cartilage was collected from the posterior part of the auricle, and then treated with collagenase, and chondrocytes were obtained. The chondrocytes were subcultured, and the cells at the second and/or third passage were used for grafting. The culture medium was a blend of F-12 medium and DME medium in an equal volume supplemented with 10% autoserum, penicillin G (50 unit/ml) and streptomycin sulfate (0.1 mg/ml). Finally, the chondrocytes obtained by the subculture were seeded at a density of 1x10⁴ cells/cm² 2~3 times over the previously seeded cells and gel-like chondrocytes were obtained. In the culture, increase in cell numbers were counted, and the levels of hyaluronic acid and alkaline phosphatase (ALP) were measured. It took approximately 4 weeks from the primary culture to grafting to the patient. The grafting volumes range was 2.5 to, and the number of chondrocytes per 1cc was 0.5~5 x10⁸cells. They were then aspirated into a syringe and inject-grafted into the subcutaneous pocket that was produced by the surgical dissection of the deformed area. After the grafting, the graft area was tightly sutured and taped for the compression and modeling. Histology of the newly formed cartilage was examined in 10 patients. To date, this methodology has been applied to 60 patients, i.e., nasal augmentation (n = 47), cranio-facial deformity (n = 5), mentoplasty (n = 4) and microtia (n = 4). The longest follow-up period is 6 years.

Results: A sufficiently large volume of chondrocytes was prepared with this culture method. The differentiated chondrocytes produced the differentiation marker ALP as well as Type II collagen and hyaluronic acid that are the necessary substances for the production of cell matrix in vitro. In clinical application, cartilage formation was confirmed 3 weeks after the grafting. Histologically, toluidine blue staining revealed the presence of metachromasie in newly formed cartilage, and the presence of cartilage-specific human Type II collagen was confirmed. EVG staining revealed the presence of elastic fibers that are a feature of auricular cartilage. In all the 60 patients, the shape and contour of the grafted areas were excellent, and good aesthetic results were obtained. Frequency was 0/60 for complication, 0/60 for total absorption of the grafted chondrocytes and 5/60 for partial absorption of the chondrocytes.

Conclusion: Successful expansion of cultured auricular chondrocytes is the prerequisite for autologous cell transplantation. With this method, the chondrocytes take a gel form in the culture, but after grafting they form a matrix by getting natural scaffolds and regenerate cartilage tissue. The grafted chondrocytes formed elastic caltilage derived from their origin. These culture method and grafting technique will be a highly useful new treatment method with less invasion. This method of cultured chondrocyte grafting could be applicable as a cell therapy to a wide range of cranio-facial treatment.

8:23 AM - 8:27 AM

Mortality In Outpatient Surgery - AAAASF Report

Presenter:	Geoffrey R. Keyes, MD
Affiliation:	American Association for Accreditation of Ambulatroy Surgery Facilities, Los Angeles, CA

The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) has reported statistics on morbidity and mortality for facilities that it accredits based upon an analysis of unanticipated sequelae and surgical mortality. Data acquired through the implementation of the first Internet Based Quality Assurance and Peer Review reporting system (IBQAP) was reviewed and published in 2004. 1378 significant unanticipated sequelae and 8 postoperative deaths were documented in 411,617 procedures performed over a two-year period from 2001 through 2002.

In a current review of data collected using IBQAP from years 2001 through 2006, there were 22 deaths in 1,141,418 outpatient procedures performed. Pulmonary embolism was the etiology in twelve of the twenty-two deaths. Only one death occurred as the result of an intraoperative adverse event.

A pulmonary embolism may occur following any operative procedure, whether the procedure is performed in a hospital, an ambulatory surgery center, or a physician's office based surgery facility.

The procedure most commonly associated with mortality through pulmonary embolism in an office based surgery facility is an abdominoplasty. The frequency of pulmonary embolism associated with abdominoplasty warrants further study to elucidate the mechanism of its etiology, determine predisposing factors, and to introduce guidelines to prevent its occurrence.

8:27 AM - 8:30 AM Discussion