Thursday, February 1, 2007

A Novel Pectoralis Flap Design for Pharyngocutaneous Fistula Reconstruction

Presenter:	Karl W. Schwarz, MD
Co-Authors:	Detlev Erdmann, MD, PhD, L. Scott Levin, MD
Affiliation:	Duke University, Durham, NC

Despite advances in hypopharyngeal reconstruction with free tissue transfer, pharyngocutaneous fistulae occur with an incidence of thirty-five percent; radiation therapy and neck dissection increase the incidence. While two-thirds will close with conservative management, larger fistulae in irradiated fields require surgical treatment to prevent carotid artery rupture. Free tissue transfer is difficult in the re-operated, previously reconstructed, irradiated neck where recipient vessels are scarce. Herein we report a novel technique where a pectoralis major myocutaneous flap with two skin islands is used to reconstruct a pharyngocutaneous fistula. One skin paddle was used to reconstruct the anterior esophageal wall, and the second paddle provided closure of the cutaneous defect. At nine months of follow-up the fistula has not recurred, all of his intake is via the oral cavity, and he has experienced an eleven pound weight gain.

8:34 AM - 8:38 AM

The Versatility of the Superomedial Pedicle with Various Skin Reduction Patterns

Presenter:	Ali N. Mesbahi, MD
Co-Authors:	Steven P. Davison, MD, DDS, Ivica Ducic, MD, Joseph Dayan, MD, Scott L. Spear, MD
Affiliation:	Georgetown University Hospital, Washington, DC

Background: The purpose of this study was to evaluate the safety and reliability of the superomedial pedicle with various skin reduction patterns and compare the surgical time with the inferior pedicle technique. Methods: A total of 279 superomedial breast reductions were reviewed from a six-year period. Assessments included skin pattern, average size of reduction, average body mass index, and complications. Risk factors and patient co-morbidities were recorded. There were no exclusion criteria. Results: There were no cases of loss in our series. The overall complication rate was 18%. The revision rate for contour or scar improvement was 4 %. A statistically significant reduction in operating time of 41 minutes (p= .0001) was seen when compared to the inferior pedicle reduction. Conclusions: The superomedial pedicle is a safe and reliable technique for reduction mammaplasty. The versatility inherent in the procedure allows for reproducible results in a broad range of patients with various skin excision patterns. Use of the superomedial pedicle provides consistent results with respect to breast contour, viability, lasting superomedial fullness, and saves operating time when compared to the inferior pedicle technique.

8:38 AM - 8:42 AM

A Retrospective Study Investigating The Effectiveness and Economics Of Using Adjunctive Cell Proliferation Induction Wound Therapy To Improve Severe Pressure Ulcer Evidence-based Health Outcomes In A Veteran Spinal Cord Injury Patient Population

Presenter:	Anh Vu, MD
Co-Author:	Garrett Harper, MD
Affiliation:	Medical College of Georgia, Augusta, GA

Objective: The Department of Veteran's Affairs (VA) has the single largest network for spinal cord injury (SCI) programs and provides care for nearly 23,000 veteran's with SCI. Many VA SCI patients are noted to suffer from chronic pressure ulcers and other non-healing wounds.

Chronic wounds occur when healing fails to advance through one of the traditional stages of inflammation, proliferation and remodeling. Cell Proliferation Technology (CPI) facilitates wound healing using radio frequency stimulation to induce growth factor expression and cell proliferation. We seek to retrospectively study the clinical results and cost-effectiveness of Cell Proliferation Technology (CPI) using the Provant Wound Closure System in treating chronic pressure ulcers.

Method: Retrospective analysis of a consecutive series of fifty-three patients who have received or are receiving wound treatment using the Provant Wound Closure System at the Veterans Administration Medical Center in Augusta, Georgia. Outcomes will be assessed using the National Pressure Ulcer Association's (www.npuap.org) standardized mapping program called the Pressure Ulcer Scale for Healing (PUSH) tool to determine the rate of reduction in PUSH score (points/month) and total time to healing (reduction of PUSH score to 0).

8:42 AM - 8:46 AM

Treatment of Keratoacanthoma with Intralesional Methotrexate

Presenter:	George Papanicolaou, MD
Co-Authors:	A. Lawrence Cervino, MD, Rajiv Y. Chandawarkar, MD
Affiliation:	SUMMA Health System, Fairlawn, OH

Introduction: Keratoacanthoma is a benign keratinizing skin tumor which often spontaneously resolves but is difficult to differentiate from squamous cell carcinoma.Although the primary treatment is surgical excision, several alternative treatments have been described. In this study 10 patients with keratoacanthomas were treated with intralesional methotrexate by the senior author. This treatment is well described in the dermatology but not in plastic surgery literature Purpose: To present the results efficacy and safety of intralesional methotrexate in selected patients with keratoacantoma. Methods:The 10 patients treated had lesions in critical anatomic areas were surgical excision would have been disfiguring and would require a complex reconstruction, or did not consent to operative intervention. Injections were given on a weekly basis until the tumor resolved. Results: In 8 patients the tumor resolved completely with no complications after up to 6 injections. Two ultimately required excision and reconstruction.Follow up ranged between 2 months and 6 years with no recurrence.

Conclusions: Intralesional methotrexate is an easy, safe and effective method of treatment of keratoacanthoma especially in cases where excision is avoided or requires a complex reconstruction. Close follow up and patient compliance are important. The advantages and limitations of the treatment are discussed.

8:46 AM - 8:50 AM

Warfarin Therapy and Cutaneous Surgery

Presenter:	Anna I. Wooten, MD
Affiliation:	University of Pittsburgh, Pittsburgh, PA

Introduction: Therapeutic anticoagulation is essential in patients with prosthetic valves, atrial fibrillation, and history of DVT/PE. The question to stop Warfarin prior to cutaneous surgery is raised frequently in the surgeon's practice. Our objectives were to assess frequency of complications after excisional and simple reconstructive cutaneous surgery in patients who were kept on Warfarin and to analyze the need of withholding medication perioperatively. Methods: A retrospective chart review of patients undergoing cutaneous surgery in a five year period was performed. Out of 512 patients 28 were identified to be on Warfarin, total of 50 procedures were performed including excision followed by primary closure, local rotational flaps or skin grafts while remaining on therapeutic anticoagulation. Results: Charts were reviewed for the presence of ecchymosis, bleeding, hematoma, epidermolysis, skin necrosis, and wound dehiscence. Collected data revealed that complications did not go beyond expected mild bruising and swelling in the early postoperative period. Conclusion: Our study showed that skin resection followed by simple reconstruction was not associated with a statistically significant increase in complication rates when patients remain on Coumadin.

8:50 AM - 8:56 AM Discussion

8:56 AM - 9:00 AM

Prophylactic Mastectomy: Clinical Outcomes and Patient Satisfaction

Presenter:	Karl A. Schwarz, MSc, MD
Co-Authors:	Scott L. Spear, MD, Mark Venturi, MD, Todd Barbosa, BA
Affiliation:	Georgetown University Hospital, Washington, DC

Purpose: The purpose of this study is to evaluate clinical outcomes and satisfaction in patients who have undergone prophylactic mastectomy and breast reconstruction. Methods: A five-year retrospective analysis of the senior author's experience with breast reconstruction following prophylactic mastectomy was performed. Timing, type of mastectomy and reconstruction, complications, and cancer occurrence/recurrence were examined. Patients were asked to grade their level of satisfaction on a 6 level scale. Aesthetic outcomes were also graded on a 4 point scale by a group of surgeons. Results: 74 patients underwent 101 breast reconstructions following prophylactic mastectomy. During a mean follow-up of 31months, 10 complications occurred (10% of breasts). 47 patients in the study had undergone unilateral prophylactic mastectomy. In this group, the number of complications found on the cancer reconstruction side was 13 (28% of breasts). Patient satisfaction and surgeon ratings were higher in the bilateral prophylactic patients compared with the cancer patients who had undergone a unilateral prophylactic mastectomy. Conclusions: Breast reconstruction following prophylactic mastectomy has a lower incidence of complications than following oncologic mastectomy. It also appears that patient satisfaction and aesthetic outcomes are more favorable in bilateral prophylactic mastectomy and reconstruction patients when compared with unilateral prophylactic mastectomy and reconstruction patients.

9:00 AM - 9:04 AM

The Pedicled Transvers Rectus Abdominis Myocutaneous Flap (TRAM) in the Obese: A Twelve-year Review

Presenter:	Angela F. Champion, MD
Co-Authors:	Jennifer L. Walden, MD, Jennifer A. Murphy, MD, Linda G. Phillips, MD
Affiliation:	UTMB, Galveston, TX

Introduction: This is the first study to use the redefined WHO parameters for obesity to define complication rates and associated co-morbidities using the pedicled TRAM flap. Methods: 112 women underwent breast reconstruction using a pedicled TRAM flap at UTMB over a twelve year period. The patients were divided into four groups: ideal weight (BMI 19-24.9), overweight (25-29.9), obese (30-39.9) and morbidly obese (>40). Complications included fat necrosis, hematoma/seroma, hernia, flap loss, wound infection, DVT and PE. Co-morbidities such as HTN, vascular disease, DM, COPD, and tobacco were considered. Results: The complication rate for all patients was 42%. In the ideal group (N=30), the rate was 27%; overweight group (N=38), 39%; obese group (N=38), 47%; and morbidly obese group (N=6), 100%. Statistics comparing ideal group versus the overweight and obese group was not significant (p=0.27 and p=0.083). The morbidly obese group showed significance (p<0.01), however, the sample size was much smaller. In the obese group, patients with numerous co-morbidities showed a greater complication rate than those with few or no co-morbidities (p=.21). Conclusion: The TRAM flap may be used successfully in overweight and certain obese patients. One approach to risk stratification for surgery in obese patients is the number of co-morbidities.

9:04 AM - 9:08 AM

The Use Of AlloDerm For Reconstruction Of Abdominal Wall Defects In Contaminated Wounds

Presenter:	Marco Harmaty, MD
Co-Authors:	Stafford Broumand, MD, Walid Abdelwahed, MD, Joel Bauer, MD
Affiliation:	Mount Sinai Hospital, New York, NY

Purpose: The reconstruction of abdominal wall defects in contaminated fields remains a surgical challenge. Hernia recurrence in this setting can be as high as 50%. Synthetic mesh is at increased risk for infection in contaminated wounds. We have studied the use of AlloDerm for abdominal wall reconstruction in contaminated wounds.

Methods and Materials: AlloDerm was used as an inlay to repair full thickness defects of the abdominal wall in the setting of enteric fistulas, stomas, bowel anastomosis, and infection.

Results: 35 abdominal wall defects were repaired in 30 patients. Indications included 12 ventral hernias, 6 parastomal hernias, and 17 stoma site defects. 9 patients had concurrent enterocutaneous fistulas. Average follow-up at present is 6.5 months (range 1-18 months) with six patients followed for more than one year. 22 patients healed without incident. 7 patients experienced delayed wound healing which resolved with local wound care. One suture abscess required removal of prolene sutures. No cases required removal of the AlloDerm.

Conclusions: The results, thus far, support the use of AlloDerm for closure of a wide variety of abdominal wall defects in contaminated wounds.

9:08 AM - 9:12 AM

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

Presenter:	Brooke A. Burkey, MD
Co-Authors:	Eric G. Halvorson, MD, Joseph J. Disa, MD, Babak J. Mehrara, MD, Andrea Pusic, MD, Peter G. Cordeiro, MD
Affiliation:	New York-Presbyterian Hospital, New York, NY

Purpose: Although several studies have analyzed risk factors for tissue expander removal prior to permanent implant placement in breast reconstruction, outcomes following explantation for infection are unknown. Methods/Materials: From a prospectively maintained database covering a 10-year period, 39 such patients were identified. A retrospective chart review was performed, noting patient characteristics which might affect outcome of secondary reconstruction. Reasons for reconstruction vs. no reconstruction were evaluated with chart reviews and discussions with patients and surgical attendings. Fisher's Exact Test was performed to ascertain if any characteristics were associated with secondary reconstructive outcome. Results: Twelve patients (30.8%) had prior radiotherapy. Nine (23%) underwent re-expansion, three had a latissimus dorsi flap and expander, and one received a free transverse rectus abdominis flap. Recurrent infection occurred in one re-expanded patient. Two patients developed late contractures. All other reconstructions were successful. Twenty-six patients (66.7%) did not undergo reconstruction, commonly due to patient preference, cancer progression, and/or radiotherapy. Conclusions: After removal of an infected expander, most patients who are interested and remain good candidates can be reconstructed. Re-expansion was successful in patients without prior radiotherapy. Secondary reconstruction with autologous tissue is appropriate when there is a history of radiotherapy.

9:12 AM - 9:16 AM

Cost Benefit of Using Bilayer Dermal Matrix Substitute versus Flap Reconstruction of Complex Wounds

Presenter:	Cameron Craven, MD
Co-Authors:	Jamal Bullocks, MD, Mimi Leong, MD, Bob Basu, MD, MPH
Affiliation:	Baylor College of Medicine, Pearland, TX

Bilayer dermal matrix substitute has been reported as being an alternative for more complex, autologous reconstructive options. A cost comparison analysis in the treatment of seven patients with complex wounds was performed. Methods: Seven consecutive patients reconstructed using bilayer dermal matrix substitute from a Level I trauma facility were retrospectively reviewed. Wounds included two resulting from necrotizing soft tissue infections, one diabetic lower extremity ulcer, and four traumatic wounds (two upper extremity, two lower extremity). The costs of hospital bed, surgeon, anesthesia and facility fees, and dermal matrix substitute were totaled. Physicians determined the most appropriate autologous reconstructive options. The costs of the autologous reconstructions based on averages at the same institution were compared with the actual costs of reconstruction using dermal matrices. Results: Cost benefit was noted in the two upper extremity traumatic wounds (2%, 59%). Negative benefit was noted in lower extremity wounds, and wounds resulting from infectious etiologies (range -7% to -529%, avg. -166%). Conclusion: Bilayer dermal matrix substitute can be a useful adjunct in reconstruction of complex upper extremity wounds or in critically ill patients. In patients with wounds of infectious origins, or in lower extremity trauma, autologous reconstruction may be more cost effective.

9:16 AM - 9:22 AM Discussion

9:22 AM - 9:26 AM

Ipsilateral Pedicle TRAM Flaps For Breast Reconstruction: Are They As Safe As Contralateral Techniques?

Presenter:	Timothy A. Janiga, MD
Co-Authors:	Ian F. Lytle, MD, Edwin G. Wilkins, MD, MS, Amy Alderman, MD, MPH
Affiliation:	University of Michigan, Livonia, MI

Introduction: Ipsilateral compared to contralateral rotation of the TRAM flap has aesthetic advantages by maintaining the xiphoid and medial IMF contour. Our purpose was to evaluate the safety of this technique. Methods: We retrospectively evaluated a single surgeon's experience with 32 consecutive contralateral and 58 consecutive ipsilateral TRAM flaps. With a six month minimum follow-up, the rates of partial and total flap loss, fat necrosis, and major/minor complications were compared using chi-square analysis and multiple logistic regression was used to assess the effects of procedure type on complication rates, while controlling for potential confounding variables. Results: Comparing ipsilateral to contralateral pedicle TRAM patients, the rate of a major complication was 19.0% and 18.8%, respectively, p = 0.68; a minor complication was 53.5% vs. 53.1%, respectively, p=0.98; fat necrosis was 19% vs. 25%, respectively, p=0.50; and partial flap loss was 12% vs. 15.6%, respectively, p=0.75. When controlling for potential confounders, the type of pedicle TRAM flap had no significant effect on the above complications. Conclusion: The ipsilateral pedicle TRAM flap appears as safe as the contralateral technique for breast reconstruction. Given the increased pedicle length and preservation of both the medial IMF and xiphoid hollow, we prefer the ipsilateral pedicle technique.

9:26 AM - 9:30 AM

Limitations of Suction-Assisted Lipectomy for the Treatment of Lipomas

Presenter:	Stephanie Kwei, MD
Co-Author:	James W. May, Jr, MD
Affiliation:	Harvard Plastic Surgery, Cambridge, MA

Purpose: We present two patients wherein suction-assisted lipectomy (SAL) failed to adequately treat subcutaneous lipomas. In both cases, open resection was required. Liposuction offers multiple advantages in the treatment of subcutaneous lipomas, including small incisions, minimal scars, contouring of surrounding tissue, and less post-operative pain. However, the two patients presented in this report led us to question the characteristics and features that render lipomas suitable for liposuction therapy. Case Report: Two women presented to surgeons at another facility with slowly growing soft-tissue masses that were electively treated with liposuction. One was located in the parascapular region, and the other over the shoulder. Both masses recurred or expanded after SAL, and required open excision. Intra-operative dissection revealed sub-muscular lipomatous masses with no histological evidence of malignancy. Summary: These cases illustrate the limitations of liposuction therapy in the treatment of subcutaneous lipomas. The experiences of these patients led us to speculate that a biological modification occurs in the remaining lipoma cells following liposuction that prevents recurrence in the majority of cases. Further investigation is warranted to improve the identification of suitable candidates for non-cosmetic applications of SAL therapy.

9:30 AM - 9:34 AM

Marjolin's Ulcer in a Chronic Pressure Sore

Presenter:	Ryan Flannagan, MD
Co-Authors:	Frank Welsch, MD, Anureet Bajaj, MD
Affiliation:	University of Cincinnati, Cincinnati, OH

Marjolin's Ulcer is a rare malignant lesion arising from wounds of a chronic nature. Predominantly associated with burns, this malignant degeneration can occur less frequently in other types of wounds. This is a case report of a 52 year old man paraplegic for 38 years who presented to a local plastic surgeon with a long standing, non-healing pressure sore. Only after biopsy of the wound was it found to be a squamous cell carcinoma with metastases to the groin. As plastic surgeons, we are routinely consulted for chronic, non-healing wounds. We must remain vigilant and aware that these wounds can progress to life threatening condition.

9:34 AM - 9:38 AM

An Approach to the Reconstructive Management of the Abdominal Wall in the Adult Bladder Exstrophy Patient

Presenter:	Michele Manahan, MD
Co-Authors:	Kurtis A. Campbell, MD, FACS, Anthony P. Tufaro, DDS, MD, FACS
Affiliation:	Johns Hopkins Medical Institution, Baltimore, MD

Purpose: Bladder exstrophy is defined by urogenital and skeletal abnormalities as well as cosmetic and functional deformity of the lower anterior abdominal wall. We report two cases of severe abdominal wall dysfunction in adult exstrophy patients that drastically improved following use of our unique method of reconstruction. Methods: Two patients with disabling abdominal wall defects preventing performance of their occupations underwent reconstruction using wide dissection of the lipocutaneous layer from the myofascial layer to allow tension free primary closure. Acellularized human dermis reinforced this closure and, in one case, bridged a residual pubic diastasis. A quilted mesh onlay was applied over the entire abdominal wall prior to closure in layers of skin and subcutaneous tissue. Results/Conclusions: Following our repairs, our patients have been clinically and radiologically recurrence free for 18 and 33 months, respectively, and can carry out “heavy lifting” duties. Most authors have reported neonatal approaches to abdominal wall closure with an underestimation of the need for abdominal wall component reconstruction. The natural history of abdominal wall laxity and dysfunction, secondary to the syndrome and primary closure, has largely not been reported. We suspect many patients would benefit from complex abdominal wall reconstruction in adulthood.

9:38 AM - 9:43 AM Discussion

9:43 AM - 9:47 AM

MD

Presenter:	Ning Ming Hu, MD
Co-Authors:	Zi Li Wang, MD, Hai Bo Yang, Zhi Rong Chen
Affiliation:	Ningxia Medical College, Affiliated Hospital, Yin Chuna, NT

Objective To analyze and summarize the operative result in the treatment of acetabular fractures. Methods In this series, 60 acetabular fractures were reviewed and classified according to Letournel and judet classification. Koaher-langenbeck, ilioinguinal and combined anterior and posterior approach were adopted. Fracture reduction and fixation were carried out with pelvic reconstructive plates, cancellous-born screw and absorbable screws. Results The average follow-up period was 48 months(ranging from 6 to 84 months).Excellent results were found in 20 cases, good in 25, fair in 10 and poor in 3. The excellent and good rate was 75%, There is no Infection and death were found in this series. Conclusions surgical treatment, high quality anatomical reduction, internal fixation, active treatment of complications and early functional rehabilitation are the key points for reaching a good clinical result.

9:47 AM - 9:51 AM

Groin Reconstruction with the Sartorius Flap Improves Outcomes over Layered Closure in Patients with Serious Vascular Graft Infections

Presenter:	Edward P. Miranda, MD
Co-Authors:	Carlos O. Chacon, Meryl Singer, Linda Reilly, William Y. Hoffman, Robert Foster, Scott Hansen
Affiliation:	University of California San Francisco, San Francisco, CA

This study compared the outcomes of groins with complex vascular graft infections that were reconstructed using the sartorius turnover flap versus no flap. A retrospective review of 100 consecutive patients with severe vascular graft infections was performed; the groins in 50 were reconstructed with sartorius flaps, whereas the remaining 50 were closed in layers. The primary end points were limb-loss and death. Secondary end points were recurrence of infection and re-operation. Kaplan-Meier analyses were performed for time to endpoint comparisons. 57 groins underwent sartorius reconstruction, and 51 were closed in layers. There were no statistical differences between sartorius reconstructions and controls in overall limb loss at 5 years (91% vs. 92%, p=0.997) or in mortality at one year (90% vs. 95%, p=0.484). There was a significantly lower time to re-operation in the sartorius flap group (9.0y, 95% confidence interval {6.1y-11.9y} vs. 1.7y {1.0y-2.4y}, p<0.001. A longer time to re-infection was observed in the sartorius group (8.6y {7.9y-9.3y} vs. 4.3y, {3.2y-5.5y}. This study demonstrates that the sartorius turnover flap improves the time to re-operation and reduces recurrent infection; it is an effective option for reconstruction of the groin after complex graft infections.

9:51 AM - 9:55 AM

Hydrosurgical Tangential Excision of Partial-Thickness Hand Burns

Presenter:	David Shafer, MD
Co-Authors:	Courtney Sherman, MD, Steven Moran, MD
Affiliation:	Mayo Clinic, Rochester, MN

9:55 AM - 9:59 AM Discussion

9:59 AM - 10:29 AM

Break

Presenter:	No presenter
Affiliation:

10:29 AM - 10:33 AM

Utilization of Tissue Expanders in Omphalopagus Conjoint Twin Separation

Presenter:	Roman Rayham, MD
Co-Authors:	Uldis Bite, Ricky Clay, Lisa Whitty
Affiliation:	Mayo Clinic, Rochester, MN

The biggest challenge faced by plastic surgeons involved with conjoint twin separation procedures is having an adequate amount of soft tissue for coverage of the defects created by the separation. One way to create enough skin and soft tissue for the coverage of these defects is to place tissue expanders and to expand them over a period of time prior to the final separation procedure. At Mayo Clinic we have successfully utilized the tissue expander placement, subsequent expansion and separation procedures in a series of five pairs of omphalopagus conjoint twins. Goal: To create standardized guidelines applicable to tissue expansion in omphalopagus conjoint twin separation procedures.

In this study we review the following aspects of tissue expansion: 1. Timing of expander placement. 2. Types of expanders 3. Location of placement 4. Intra-operative approach 5. Post-operative management 6. Timing and the intervals of tissue expansion 7. Imaging studies to assess the amount of new skin required from tissue expansion 8. Use of expanded tissue in final reconstruction

10:33 AM - 10:37 AM

Interposition Sural Nerve Grafting During Radical Prostatectomy: A Plastic Surgeon's Role and Institutional Experience

Presenter:	JoAn L. Monaco, MS, MD
Co-Authors:	W. Thomas Lawrence, MD, MPH, Jeffrey Holzbeierlein, MD, J.Brantley Thrasher, MD
Affiliation:	The University of Kansas Medical Center, Kansas City, KS

Introduction: Interposition nerve grafting during radical retropubic prostatectomy was first described in the 1990s as a technique to improve post-operative erectile function in patients for whom a nerve sparing procedure was not an option. The technique involves the harvest of a sural nerve graft, which is then used to the replace cavernous nerves resected during the prostatectomy. We report our experience with this procedure.

Results: From 2003 to present, we have had fifteen patients requiring sural nerve grafts during prostatectomy. Six patients required bilateral grafts and nine required unilateral grafts. Graft lengths ranged from 3cm to10cm with medians of 5.6cm (unilateral) and 9.3cm (bilateral). There were no donor site complications. Five patients were able to achieve spontaneous erections after nerve grafting with a mean follow up of 416 days (range 43-1097) from surgery. Higher potency rates are expected after a longer interval post prostatectomy.

Conclusions: Sural nerve grafts are technically feasible with little morbidity and confer an improved chance of recovering erectile function for patients in whom nerve sacrifice is oncologically required during retropubic prostatectomy.

10:37 AM - 10:41 AM

Management of Full Thickness Scalp and Cranial Defects Using Free Tissue Transfer

Presenter:	Michael Dobryansky, MD
Co-Authors:	Risal Djohal, MD, Warren Hammert, MD, Wong Moon, MD, Earl Browne, MD, James Zins, MD
Affiliation:	Cleveland Clinic, Cleveland, OH

Management of large full thickness cranial defects presents a challenging reconstructive problem. Cranioplasty with soft tissue coverage is usually required. The risk of failure is inversely related to dependability and durability of soft tissue coverage and presence of infection.

We present our twelve consecutive skull reconstruction patients over thirty five months. There were nine males and three females ranging in age between 39 and 85. Seven problems were due to invasive and locally recurrent cutaneous carcinoma extirpations; two were local sarcoma recurrences; one had recurrent wound problems after cranioplasty, and two had non-healing full thickness calvarial osteoradionecrosis. A total of thirteen free flaps were performed. Cranioplasty was necessary in ten cases.

There were two flap related complications requiring re-exploration. Three patients had wound dehiscence requiring re-advancement of the flaps. One patient developed infection necessitating removal of cranioplasty material. One patient with a sarcoma recurrence opted for paliatve care. Another sarcoma recurrence patient underwent reconstruction with a second anterorlateral thigh free flap and the third patient with wound breakdown healed following advancement of his flap.

In conclusion, full thickness scalp defects involving soft tissue and bone can be successfully managed with immediate reconstruction utilizing both alloplastic cranioplasty and free tissue transfer.

10:41 AM - 10:45 AM

Nipple-Sparring Mastectomy with Reconstruction using Perforator Flaps

Presenter:	Maria LoTempio, MD
Co-Authors:	James Craigie, MD, Robert J. Allen, MD
Affiliation:	Medical University of South Carolina, Charleston, SC

Purpose: The skin sparing mastectomy is accepted as an oncologically safe alternative to more radical procedures. Autologous breast reconstruction with perforator flaps has gained popularity due to its decreased donor site morbidity and improved aesthetic result. We offer a procedure for breast reconstruction with low morbidity and no scars on the breast.

Methods and Materials: Eleven breasts were reconstructed on seven patients who underwent nipple-sparring mastectomies and immediate reconstruction. Patients with ptotic breasts were not candidates. The mastectomies were performed using an axillary and/or an inframammary incision; the nipple was inverted to remove the ductal tissue.

Results: This series includes patients form May 2005 to the present. Five patients had deep inferior epigastric perforator flaps (DIEP) and three breasts underwent superficial inferior epigastric artery (SIEA) flaps. There were no complications and their hospital course was unremarkable.

Conclusion: Nipple-sparing mastectomy without incisions on the breast offers women another option for prophylactic mastectomy with immediate reconstruction. The demand for this type of surgery is growing due to a superior aesthetic result. We recommend combining the benefits of nipple-sparring mastectomy with minimal donor site morbidity of perforator flaps results in a procedure which is an excellent option for breast reconstruction.

10:45 AM - 10:50 AM Discussion

10:50 AM - 10:54 AM

Donor Site Overgrafting of Thick Split-Thickness Skin Grafts: Improved Morbidity and Cosmesis

Presenter:	Tushar R. Patel, MD
Co-Authors:	David J. Wainwright, MD, Donald H. Parks, MD
Affiliation:	University of Texas - Health Science Center at Houston, Houston, TX

Purpose: Split-thickness skin grafting is a common surgical technique utilized by most plastic surgeons in treating patients undergoing burn reconstructive surgeries. When using thick split-thickness skin grafts, an improvement in function is often traded for increased donor site morbidity with prolonged healing time, pain, and suboptimal graft harvest site cosmesis. We describe our preferred method of managing the donor site of thick split-thickness skin grafts with immediate overgrafting with an adjacent thin split-thickness skin graft. Patients and Methods: This study is a retrospective analysis of 10 patients treated with overgrafting at our institution. The technique of overgrafting involved covering a 0.015-0.018 inch donor site with a 0.005 inch thin graft (Fig 1,2). Results: Clinical follow-up of patients and chart review revealed an accelerated healing time, early cessation of donor site pain, and avoidance of significant donor site scarring. Conclusion: The improved function and cosmesis of thick split-thickness skin grafts proves to be valuable in burn reconstructive surgery. The experience of thick split-thickness donor site overgrafting with thin split-thickness skin grafts may reduce the time to re-epithelialization. This would effectively decrease donor site pain and healing time along with providing an improved cosmetic donor site appearance.

10:54 AM - 10:58 AM

Negative Pressure Wound Therapy in Pediatric Patients the Loma Linda Experience

Presenter:	Cherrie Heinrich, MD
Co-Authors:	Allen Gabriel, MD, N. Ruff, MD, Donald Moores, MD, FACS, FRCSC, Subhas Gupta, MD, CM, PhD, FRC
Affiliation:	Loma Linda University Medical Center, Loma Linda, CA

Introduction: Wound care management in pediatric patients typically consists of daily dressing changes. Negative pressure wound therapy provides an alternative therapy system that requires less frequent changes in the adult population. We reviewed the usage of negative pressure wound therapy in our childrens hospital. Methods: Pediatric patients receiving negative pressure wound therapy from January 2005 to April 2006 were identified. After IRB approval a chart review of all 39 patients was performed for demographics, wound location, duration of therapy, complications, location of therapy, and wound closure. Results: The mean age of the patients was 8.5±5.7 with 1% of patients under 1 year of age and 13% less than 1 month of age. The wounds were divided into 2 groups trunk (25) and extremity (14). The average number of days the negative pressure wound therapy was used on each patient was 20.6±9.1. Wound closure was completed in all patients with 54% closing by secondary intention. Discussion: Negative pressure wound therapy provides a safe effective alternative to traditional wound care in the pediatric population including infants under 1 year of age. In our study there were no complications and 54% of the patients went on to secondary closure without requiring further surgery.

10:58 AM - 11:02 AM

Head and Neck Malignant Melanoma: Margin Status and Performing Immediate Reconstruction

Presenter:	Stephen R. Sullivan, MD
Co-Authors:	Jana K. Cole, MD, Ying Chi, Daniel A. Anaya, MD, David R. Byrd, Raymond S. Yeung, Gary N. Mann, F. Frank Isik, MD
Affiliation:	University of Washington, Seattle, WA

PURPOSE. Wide local excision (WLE) of head and neck melanoma (HNM) is limited by proximity to critical structures. Incomplete excision contributes to high recurrence rates. Therefore, reconstruction is often delayed until confirming margins. Immediate adjacent tissue transfer may promote complete excision, reduced local recurrence, and improved aesthetics. Our purpose is to determine the incidence, patient, and tumor characteristics associated with a positive margin; and establish criteria for performing immediate reconstruction. METHODS. We retrospectively reviewed 117 consecutive patients after WLE of HNM and reconstruction. We evaluated patient and tumor characteristics, reconstruction timing, and margin status. We performed univariate and multivariate regression analyses. RESULTS. Reconstruction was immediate for 107 and delayed for 10 patients. Six percent had a positive margin. No difference in positive margin incidence was found between immediate and delayed reconstruction (P=0.11). Positive margin independent predictors were locally recurrent (OR,62.7[95%CI,7.4-532.7],P<0.001) and T4 tumors (OR,8.02[95%CI,1.02-62.71],P=0.04). CONCLUSIONS. Immediate reconstruction depends on knowledge of characteristics associated with histologically positive margins. We found a low positive margin incidence and identify locally recurrent and T4 tumors as independent predictors of a positive margin. Immediate reconstruction is safe and may promote complete excision. Delayed reconstruction should be considered for locally recurrent or T4 tumors.

11:02 AM - 11:06 AM

An Intuitive Approach to Correction of Breast Asymmetry During Breast Reconstruction Using a 3-D Tape Moulage

Presenter:	Max Lehfeldt, MD
Co-Authors:	James S. Andersen, MD, Garry S. Brody, MD, Msc
Affiliation:	University of Southern California, Los Angeles, CA

Managing breast asymmetry during the course of breast reconstruction is a common problem for the reconstructive surgeon. Designing the surgical incisions which will achieve a correction can be daunting – even for those gifted in visualizing spatial relationships. In an effort to mitigate this surgical challenge, to standardize our outcomes, and to achieve consistently reproducible results, we utilize a 3-D tape moulage technique to plan our surgical correction. A template simulating the breast shape is fabricated from adhesive tape placed over the breast which is to be matched. The moulage is then removed and incised in the manner of a Wise pattern. The moulage is then turned inside out and replaced over the breast to be modified. The outline of this moulage acts as a reference to guide placement of incisions, nipple location, and areas of tissue to be excised. The tape moulage is a simple, reliable, intuitive, expedient, and inexpensive technique that provides a predictable result. We have found the 3-D tape moulage technique to be a useful adjunct to our reconstructive armamentarium. It has significantly enhanced our ability to achieve satisfactory breast symmetry.

11:06 AM - 11:11 AM Discussion

11:11 AM - 11:15 AM

Implementation of Burn Fluid Resuscitation Guidelines Reduces Morbidity and Mortality

Presenter:	Maya C. Spaeth, MD
Co-Authors:	Suneeta Senapati, MD, Aurthur Kumpf, BA, MD, Rebecca Coffey, RN, CNP, Gayle Gordillo, MD, FRCP
Affiliation:	Ohio State University, Columbus, OH

11:15 AM - 11:19 AM

Circumferential Capsulotomy: an Adjunct to Tissue Expander Breast Reconstruction in the Radiated Patient

Presenter:	David Rosenberg, MD
Co-Authors:	Daniel Schmid, BA, Gregory A. Dumanian, MD
Affiliation:	Northwestern University, Chicago, IL

Purpose: Chest wall irradiation is often considered a relative contraindication to tissue expander breast reconstruction. Modifications of technique during expander removal and permanent implant placement may lead to improved long-term results.

Methods: Of a consecutive series of 115 patients who underwent breast reconstruction with tissue expanders, 28 patients underwent chest wall irradiation. All 28 patients subsequently underwent a near-circumferential capsulotomy at implant exchange to recruit surrounding tissue to cover the permanent implant.

Results: 27 of 28 patients who underwent near-circumferential capsulotomies at implant exchange had a successful breast reconstruction with a smooth saline implant. The average fill volume of the expander was 419 ml +/- 150 ml, while the average fill volume of the permanent implant was 461 +/- 160 ml (p < .0005). One permanent implant was removed at three months due to pain and chest wall tumor recurrence. No other patient has returned in the postoperative period (2-53 months) for complaints of tightness, pain, infection or implant loss.

Conclusions: Near-circumferential capsulotomy is a simple adjunct that acts to recruit local soft tissue to cover a breast reconstruction prosthesis. This simple technique perhaps is one factor that contributes to satisfactory patient outcomes.

11:19 AM - 11:23 AM

Early Excision and Grafting of Facial Burns

Presenter:	Landon Pryor, MD
Co-Authors:	Vincent Sudimak, BS, David Andrews, MD
Affiliation:	Summa Health System, Copley, OH

Purpose:

The optimal management for deep facial burns remains controversial due to concern for poor aesthetic and functional results, and there is a paucity of literature addressing surgical outcomes.

Methods and Materials:

We conducted a retrospective chart review of all facial burns treated at a verified Burn Center from 2000-2005. Patient records were retrieved using the American Burn Database, hospital records, and office charts. Serial photographs of each patient were reviewed and patients were contacted to answer a phone interview. All procedures were performed by a single group of burn surgeons using a standardized technique. Study approval was obtained through the Institutional Review Board.

Results:

During the study period, 67/2630 patients (2.5%) admitted to our burn center had deep facial burns. 54 of these patients (81%) healed within 14 days of injury and did not require surgical intervention. The remaining 13 patients were treated with early excision and grafting of their facial burns. Complications included burn scar contracture of neck (n=1), microstomia (n=2), and entropian (n=1).

Conclusions:

Based on our survey results and postoperative photographic documentation, early excision and grafting of deep facial burns not expected to heal within 14 days of injury results in acceptable aesthetic and functional outcomes.

11:23 AM - 11:27 AM

Novel Treatment of a Previously Unreported Symptom in a Patient with Advanced HIV Lipodystropy

Presenter:	Jeremy A. Silk, MD
Co-Author:	John M. Hiebert, MD
Affiliation:	University of Kansas, Kansas City, MO

Introduction: HIV lipodystrophy is a well known complication of longstanding HIV infection and antiretroviral therapy. We present a case of incapacitating headaches secondary to HIV lipodystrophy treated with botulinum toxin.

Case Summary: A 59 year old male with a history of longstanding HIV and familial dyslipidemia was referred to the plastic surgery service for reduction of his cervicodorsal fat pad. He has a history of multiple cardiac events and rhabdomyolysis secondary to dyslipidemia and receives includes plasma apheresis treatments. His dorsal hump has been enlarging steadily for four years. Over the last year, he developed disabling headaches requiring narcotics and two hospitalizations. After a thorough neurological evaluation showed no other causes, it was postulated that the dorsal hump was putting pressure on the scalp and causing tension headaches. Due to high cardiac risks and the unknown risks of systemic lipid release from liposuction, a less invasive treatment modality was selected initially. The occipitalis and frontalis muscles were injected with a total of 80U botulinum toxin producing a marked decrease in headache severity and frequency.

Summary: Cervical lipodystrophy is a cause of headache, and may be successfully treated with botulinum toxin.

11:27 AM - 11:32 AM Discussion

11:32 AM - 11:36 AM

Nerve Compression Syndromes of the Upper Extremity in the Post-Burn Population: A Five-Year Institutional Review

Presenter:	J. Scott Ferguson, DO
Affiliation:	Saint Louis University, Des Peres, MO

Background: Post-burn nerve compression syndromes are well known in the burn population. However, scant literature is present documenting specifics about at-risk patients or giving recommendations regarding management of these patients.

Purpose: Review presentation, workup, management and outcomes of post-burn nerve compression syndromes. Give recommendations regarding the care of the patient population that is at high risk for developing nerve compression syndromes.

Methods: Chart review and analysis of our experience with nerve compression syndromes in the burn population over a five-year period. Charts were reviewed with data obtained including age, burn mechanism, presence of heterotopic ossification, days to grafting, presence of burn over the compressed nerve, number of operations, etc.

Results: Twenty-one patients treated in the burn unit underwent fifty-two nerve releases. The average patient had two and a half nerves decompressed. The average total body surface area of burn was 42 %.

Conclusion: Patients with large area of burn were at higher risk of nerve compression, especially due to heterotopic ossification at the elbow. Nearly every ulnar nerve compression exhibited heterotopic ossification.

11:36 AM - 11:40 AM

Graduating Plastic Surgery Residents: Clones or Innovators

Presenter:	Renee C. Comizio, MD, MS
Co-Authors:	Joshua M. Adkinson, MD, Carolyn L. Kerrigan, MD, MSc
Affiliation:	Dartmouth Hitchcock Medical Center, Lebanon, NH

Purpose: All graduating residents face the question of what techniques they will continue using in their own practice. As Plastic Surgery residents, this decision might become paramount in the choice to pursue fellowship training or in the form of an ongoing assessment over the first few years in practice. To answer the question whether to perform autogenous breast reconstruction as learned in residency or pursue fellowship training in the newest microsurgical techniques, a review of the outcomes at our institution was performed.

Materials and Methods: Breast cancer patients receiving 168 pedicled TRAM flap reconstructions were reviewed. A literature review using Medline keywords TRAM and DIEP was performed.

Results: Complications including partial flap loss (10.1%), complete flap loss (1.2%), and hernia formation (2.4%) were comparable to published rates of TRAM and DIEP flaps.

Conclusions: Graduating Plastic Surgery residents need to critically evaluate their surgical experience to make important choices about their future practice. The decision algorithm should balance operative experience with a thorough knowledge of institutional outcomes and a critical understanding of the current literature. Young Plastic Surgeons need to perform safe and effective procedures as they become established before becoming the innovators of tomorrow.

11:40 AM - 11:44 AM

The Saftey of Panniculectomy Combined with Pelvic Surgery in the Morbidly Obese

Presenter:	James Edward Hardy, MD
Co-Authors:	Christopher Salgado, MD, Martha Matthews, MD, Leilani Fahey, MD
Affiliation:	UMDNJ- Robert Wood Johnson University, Camden, NJ

The purpose of this study is to review the saftey of panniculectomy combined with gynecologic operations.

A chart review was performed an all patients who underwent abdominal hysterectomy with or without a panniculectomy between June 2005 and June 2004. Only morbidly obese patients (Body Mass Index of >40 kg/m2) were included in the study.

Thirty-six patients had combined panniculectomy and abdominal hysterectomy, 14 had an abdominal hysterectomy without a panniculectomy. The mean operative time for the combined procedure was 3.38 hours versus 2.61 hours without panniculectomy. The mean estimated blood loss was 526 cc for the combined procedure (CP) and 536 cc for hysterectomy alone (HA). There were 2 wound infections in the CP group (5.6%) versus 3 in the HA group (21.4%). There was one wound dehiscence in the CP group (2.8%) and one in the HA group (7.1%). There was one inadvertent enterotomy in the HA group (7.1%) and none in the CP group.

Our findings, in constrast to previous studies, reveal that panniculectomy combined with pelvic surgery in the morbidly obese is a safe procedure that can decrease the incidence of intraoperative complications and postoperative wound complications without significantly increasing operative time or blood loss.

11:44 AM - 11:48 AM

Adjuvant Radiotherapy Is Not a Contraindication for Transverse Rectus Adbdominis Myocutaneous Flap Reconstruction Post-Mastectomy

Presenter:	Sirish Maddali, MD
Co-Author:	Robert D. Foster
Affiliation:	UCSF, San Francisco, CA

Purpose: Controversy exists regarding the safety of radiating Transverse Rectus Abdominis Myocutaneous (TRAM) flaps done after mastectomy. This retrospective study directly compares outcomes for radiated TRAMs to a cohort of non-radiated TRAMs post-mastectomy.

Methods: From January 1996, through September 2005, 352 patients underwent immediate TRAM flap post-mastectomy. Forty-five of those patients received adjuvant radiotherapy. Age range was 29-72 (mean 49.5 years). Follow-up was 1-9 years (mean 48 months). Fifty patients who underwent immediate TRAM flap post-mastectomy without adjuvant radiotherapy served as a control group.

Results: Flap survival was 100% in both groups. In the radiated group, median operative time was 5.5 hours. Average hospital stay was 5.2 days. Fat necrosis occurred in 3 patients (7%) with 2 (4%) requiring additional surgery for volume loss. Local recurrence was seen in 1 patient (2%) and distant metastases in 4 patients (9%). Average total radiation was 5586 cGy and was not directed to internal mammary nodes. There were no significant differences in outcomes for the radiated and control groups.

Conclusions: Adjuvant Radiotherapy after TRAM flap reconstruction post-mastectomy is safe and comparable in outcome to non-radiated patients. This is contrary to some published literature and is likely explained by differential methods of radiotherapy administration.

11:48 AM - 11:52 AM

Effect of Skin Type on the Occurrence of Hyperpigmentation with the Integra Dermal Regeneration Template

Presenter:	Brian Porshinsky, MD
Co-Author:	Ramasamy Kalimuthu
Affiliation:	University of Illinois at Chicago, Chicago, IL

Purpose: Integra dermal regeneration template has been associated with hyperpigmentation of the healed wound.

Method(s): A retrospective review of wounds treated with Integra neodermis in the senior author's practice over the last five years was performed. All cases were directly observed the senior surgeon. Results were confirmed by review of photographs. Wound pigmentation was rated as excellent, good, fair, or poor. Pigmentation outcomes were compared to the native skin types to determine whether different skin types had more or less favorable pigment outcomes.

Results/Objectives: There was a high association of wound hyperpigmentation and darker skin types. Patients with lighter skin types obtained excellent or good color match in the majority of cases.

Conclusions: Integra dermal regeneration template produces excellent or good skin color match in the majority of lighter skin type patients. Hyperpigmentation occurs frequently in darker skin type patients.

11:52 AM - 11:58 AM Discussion

1:05 PM - 1:09 PM

Routine Perioperative Antibiotic Use in Reduction Mammoplasty

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 34% 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 34% to 17%.

1:09 PM - 1:13 PM

Greater Saphenous Vein Identification Using Intraoperative Venous Duplex Ultrasound Scanning

Presenter:	Steven R. Jacobson, MD
Co-Author:	James Knoetgen, MD
Affiliation:	Mayo Clinic, Rochester, MN

Medial thigh lift combined with liposuction is a safe procedure resulting in significant patient satisfaction. There is limited literature available focusing on the prevention of intraoperative complications. The greater saphenous vein (GSV) is prone to injury as it courses near the target of suction lipectomy and medial thigh lift flap dissection. Despite this, preoperative studies to evaluate GSV location are rarely performed due to significant expense and limited logistical support. A simple, safe and inexpensive technique is described to assess the location of GSV using intraoperative duplex ultrasound. This technique was performed in a patient undergoing bilateral thigh liposuction and medial thigh lift utilizing two-dimensional ultrasound equipment. The intraoperative ultrasound was performed by the plastic surgeon and completed in less than 5 minutes. The operative findings correlated with ultrasound findings and allowed easy avoidance of the GSV during elevation of the thigh flap. Intraoperative GSV duplex scanning is rapidly and easily accomplished with already available operating room resources. Intraoperative venous duplex ultrasound scanning provides knowledge of the GSV location which expedites surgical dissection throughout the procedure.

1:13 PM - 1:17 PM

Triangulation: A Technique for Maintaining Peri-operative Symmetry in Aesthetic Breast Surgery

Presenter:	Adil Ceydeli, MD, MS
Co-Authors:	Gloria Mabel Gamboa, MD, FACS, Jack C. Yu, MD, DMD
Affiliation:	Medical College of Georgia, Augusta, GA

PURPOSE: We present a simple, practical, and a reliable technique to maintain the peri-operative symmetry in any aesthetic breast surgery. METHODS: Patient was positioned flat, arms been abducted from the body. A 3-0 monofilament suture was placed on both sternal notch and subxyfoid areas in midline. These sutures are then crossed and twisted two or three times on each other, creating a triangle. The inferior wall of this triangle is the imaginary line between the sternal notch and subxyfoid suture origin, and lateral walls are made by the sutures. The tip of the triangle (where the two sutures cross) is placed on the point of interest (nipple, areolar borders etc.). The tip is then clamped to fix the shape of the triangle, and by maintaining the same tension on the sutures, the triangle is reflected to opposite site, and the corresponding point of interest is marked. RESULTS: The peri-operative symmetry can be measured and maintained accordingly in any breast surgery each and every case. CONCLUSION: Triangulation technique is simple with a short learning curve, practical that can be applied at any breast surgery, and reliable. It does not require any special instruments, not time consuming and without any complications.

1:17 PM - 1:21 PM

Facility Cost Analysis in Outpatient Plastic Surgery: Implications for the Academic Health Center

Presenter:	Salvatore Pacella, MD, MBA
Co-Authors:	Matthew C. Comstock, MHSA, MBA, William Kuzon, Jr. MD, PhD
Affiliation:	University of Michigan Health System, Ann Arbor, MI

The purpose of this investigation was to examine the economic patterns of outpatient plastic surgical cases performed within an AHC. For FY 2003 & 2004, the University of Michigan Health System's accounting database was queried to identify all outpatient plastic surgery cases from four surgical facilities. Total facility revenue, cost and margin were calculated per case. Contribution margin (total revenue minus variable cost) was compared to case time to determine contribution margin per OR case minute (CBM/min). A total of 3603 cases (3457 reconstructive, 146 aesthetic) were identified. Payers included Blue Cross (36.6%), HMO (28.7%), other commercial payers (18.4%), Medicare/Medicaid (13.5%) and self-pay (2.8%). Aesthetic procedures yielded higher average total margins ($3,316) compared to reconstructive procedures ($1,462). CBM/min resulted in similar margins for both aesthetic ($25.68) and reconstructive ($26.86) cases. The most profitable cases were laser procedures ($66.20) and facial trauma ($32.17). The least profitable cases were breast reduction ($17.46) and hand arthroplasty ($13.93). Cases performed at outpatient facilities (n=1352) yielded higher CBM/min($29.09) compared to hospital-based facilities (n=1721, $25.07). Within AHCs, aesthetic and reconstructive cases yield similar profitability when controlling for case duration. On average, cases performed at dedicated outpatient surgical facilities yield higher profitability.

1:21 PM - 1:25 PM

Abominal flap contouring and umbilicoplasty in abdominoplasty

Presenter:	Rodrigo Santamarina, MD
Co-Authors:	Paul M. Haidak, MD, Jorge Alejandro Conejero, MD, Jacob Cohen-Kashi, Marjorie Chelly, Raymond M. Dunn, MD
Affiliation:	University of Mass Medical School, Worcester, MA

The umbilicus is the most important aesthetic unit of the abdominal wall. An analysis of the aging process of the abdominal wall is studied in this article. The vertical orientation of the umbilicus appeared to be the most desirable shape in young and healthy women. The combination of vertical repositioning of the umbilicus and contouring of the central oval of abdominal flap techniques are discussed in this presentation.

1:25 PM - 1:31 PM Discussion

1:31 PM - 1:35 PM

Office Blepharoplasty under Local Anesthesia with Oral Medication

Presenter:	David Harley, MD
Affiliation:	Methodist Hospital, Houston, TX

Purpose: Blepharoplasty in the office under local anesthesia and oral medication is popular for several reasons. The present study reviews the authors' experience with this approach, evaluating patient satisfaction, and demonstrating why this technique has become their procedure of choice in selected healthy patients. Methods: The authors conducted a retrospective review of the 86 patients who underwent office-based blepharoplasty and mailed surveys to assess patient satisfaction with the procedure. Results: Upper and lower blepharoplasty were performed with no major complications. Eighty-three percent of patients completed and returned surveys. Survey results indicated this procedure to be well-accepted and highly rated by patients. Many patients unwilling to undergo blepharoplasty outside of the office were willing to have the procedure using this approach. A strong majority indicated they would be referring friends and family for the procedure. Conclusions: The fact that blepharoplasty can be performed in the office under local anesthesia with oral medication proves to be a strong determinant toward the final decision to undergo surgery. This procedure meets the safety requirements outlined by the ASPS and is desired by our patients for its many obvious advantages. Recommendations are provided to assist others who desire to utilize this safe and cost-effective method.

1:35 PM - 1:39 PM

Breast Reduction: Does Technique Affect Reimbursement

Presenter:	Jonathan Kaplan, MD
Co-Author:	Randall Yetman
Affiliation:	Cleveland Clinic, Cleveland, OH

Breast reductions are a very common procedure within the field of plastic surgery with many techniques. These techniques include differences between the location of the pedicle and variations in scar location. Another variation on the technique for breast reduction relates to preoperative infiltration of an epinephrine solution to reduce blood loss and operative time. Our technique for breast reduction and its effect on insurance reimbursement has not previously been discussed in a large prospective study. We performed a prospective study to compare a cohort of 50 patients undergoing a traditional breast reduction without infiltration of epinephrine followed by electrocautery for resection versus 50 patients receiving tumescent infiltration of epinephrine followed by sharp resection. Overwhelmingly, the patients that underwent the tumescent technique for breast reduction had shorter operative times, less blood loss and less pain. The use of tumescence did not cause a significant difference in the weight of the amount resected when compared to the dry, pathology weight. In the first large prospective cohort study involving this technique, we can demonstrate the many advantages of the tumescent technique and refute our concern that tumescence can cause inaccurate weight measurements that might interfere with insurance reimbursement based on resected weight.

1:39 PM - 1:43 PM

The "Adjustable" Face Lift Using Barbed Suspension Sutures

Presenter:	Boris Mordkovich, MD
Co-Author:	Vincent Giampapa, MD
Affiliation:	University of Medicine and Dentistry of New Jersey, Newark, NJ

PURPOSE STATEMENT In the space between full face lift with extensive undermining and the percutaneous thread lift, lays the minimally invasive open lift. It allows important option of over-tightening the skin initially to compensate for postoperative facial lag and adjusting tension up to 2 weeks postoperatively.

METHODS AND MATERIALS Facial skin flaps undermined to the mid-zygomatic arch only. Limiting dissection to this point helps to decrease potential damage of facial nerves and post-operative swelling and ecchymosis. Under direct vision, Contour Threads™ are placed subcutaneously. Skin flaps are trimmed conservatively and then closed without any tension. SUMMARY OF RESULTS Unlike previous percutaneous thread lifts, this technique allows for complete visualization of the placement of the needle and thread. This open thread lift approach allows for dramatic decrease in surgical time, as well as quicker recovery. Finally, postoperative loss of facial skin tightness can be minimized by over-tightening the sutures initially with immediate post-operative adjustment if necessary CONCLUSION Utilizing the described technique with the ability to adjust the skin tension helps enhance the concept of personalized surgical approach and appeals to younger and socially active patients who require quick recovery with noticeable immediate result.

1:43 PM - 1:47 PM

The Wayne State Breast Reduction "A Marriage Of The WISE And The SPAIR"

Presenter:	Christopher Vashi, MD
Co-Author:	Michael J. Busuito, MD
Affiliation:	Wayne State University, Auburn Hills, MI

The pattern of Wise (POW) is the standard technique adopted by Plastic Surgeons for breast reduction. To improve results with breast reduction, we adopted the SPAIR technique and found most results were excellent. However, some patients were not candidates for the SPAIR technique because of the extent of hypertrophy and breast ptosis. For these patients we developed a hybrid technique. Our hybrid technique has provided excellent results. The tailor tack method from the SPAIR is the key ingredient in obtaining aesthetically better results. Using the POW one commits to a pattern of skin excision before breast parenchyma is reduced -- this is why a boxy breast appearance frequently results. With our hybrid method, the breast parenchyma is first reduced before any commitment is made to skin excision. We have found that applying the advantages of the SPAIR technique to the more traditional POW technique, improvement upon our breast reduction results. The POW principle of inverted T-incision and vertical reduction is achieved that is not possible with the short scar techniques and by incorporating the tailor tack method of the SPAIR reduction technique, one can achieve breasts that have aesthetically excellent shape and projection while minimizing the extent of the scarring.

1:47 PM - 1:51 PM

Breast Shape Classification: Improve Communication and Setting Realistic Expectations

Presenter:	Karl T. Nguyen, MD
Co-Authors:	Paul E. Chasan, MD, Marek K. Dobke, MD
Affiliation:	University of California, San Diego, San Diego, CA

Purpose: Careful planning of augmentation mammoplasty technical components is essential to ensure optimal outcomes. Implant size and shape selection is an important component when planning. There have been many descriptions of implant size selection; however, little is mentioned concerning the patient's desired breast shape after augmentation. A classification of breast shape to improve communication and set realistic expectations with breast augmentation results was proposed.

Methods: A breast shape classification was created. 1: Appears “natural” - no superior pole fullness. 2: “Natural” - mild superior pole fullness. 3: Less “natural” - moderate superior pole fullness. 4: Very round and significant superior pole fullness. 5: Round and maximal superior pole fullness. The classification was used during 30 patient initial consultations. A survey was conducted postoperatively (mean F/U = 8 months; range 6m-1yr).

Results: Patients found the classification to be extremely helpful during consultation. Classification was rated 9.3/10 (1-least to 10-most helpful) for developing realistic expectations. Correlation between preoperative and postoperative goals was rated as 9.2/10 (1-Not close to 10-Extremely close).

Conclusion: Use of breast shape classification has helped communicate better with patients undergoing augmentation regarding desired shape and has been an extremely helpful tool during initial consultation in setting realistic goals.

1:51 PM - 1:57 PM Discussion

1:57 PM - 2:01 PM

Breast Reconstruction as a Transition to Aesthetic Surgery

Presenter:	Asaad H. Samra, MD
Co-Authors:	Salem Samra, MD, Jeffrey D. Friedman, MD
Affiliation:	Baylor College of Medicine, Houston, TX

Introduction: A review of patients at Baylor College of Medicine Division of Plastic Surgery found that approximately 15% of women who had breast reconstruction, had a cosmetic procedure from the same surgeon. This data suggests that through breast reconstruction, young plastic surgeons can create a cosmetic surgery practice.

Methods: A retrospective analysis of 200 patients who were examined and operated on by the same surgeon was performed. Patients that died of disease were excluded. Immediate and delayed, autologous tissue and implant-based reconstruction techniques were included. All cosmetic-related procedures were examined.

Results: Of 200 patients, 3 were excluded. From 197 patients, 30 (15%) had 31 aesthetic procedures. A larger percentage of patients that underwent autologous reconstruction then had an aesthetic procedure. A similar correlation was found with delayed reconstruction.

Conclusion: It is increasingly difficult for young plastic surgeons to become recognized in the competitive field of aesthetic surgery. Through breast reconstruction, however, they can acquire patients that will likely return for cosmetic surgery. These patients may also refer others, helping to expand that practice. Therefore, by actively seeking and treating patients who need breast reconstruction, one may establish a cosmetic practice without spending exorbitant amounts of money on advertising.

2:01 PM - 2:05 PM

Socioeconomic Factors Influencing the Decision to have Body Contouring after Gastric Bypass Surgery

Presenter:	Jeffrey A. Gusenoff, MD
Co-Authors:	William O'Malley, MD, Howard N. Langstein, MD
Affiliation:	University of Rochester, Rochester, NY

Purpose: To investigate the socioeconomic factors influencing the decision to have body contouring (BC) after gastric bypass surgery (GBP). Methods: 2501 consecutive GBP patients were surveyed. Multiple socioeconomic variables were assessed by univariate and multivariate analysis. Results: 926 patients (817 F, 109 M) responded (response rate = 40.3%) with a mean follow up of 2.4 yrs (range 0-14 yrs). 105 patients (11.3%) went on to have BC (Group I). Group I was related to the years since GBP (P<0.0001), DBMI (p<0.0001), open vs. laparoscopic GBP (p<0.0001), income range $20,000-49,000 (p<0.03), and income range >$50,000 (p<0.03), but was not related to age, gender, marital status, pre-op BMI, or prior plastic surgery. 685 patients (83.4%) desired BC (Group II). Group II was inversely related to age (p<0.0001) and open vs. laparoscopic GBP (p<0.04), and was 2x more likely in females (p<0.008) and divorced individuals (p<0.03). Conclusion: A minority of gastric bypass patients underwent body contouring. Younger, divorced, female patients that had laparoscopic GBP voiced the strongest interest in body contouring. These results suggest that efforts should be directed towards facilitating body contouring in this subpopulation because they appear the most motivated.

2:05 PM - 2:09 PM

The Orbicularis Retaining Ligament: Closing the Circle

Presenter:	Ashkan Ghavami, MD
Co-Authors:	Joel E. Pessa, MD, Jeffrey E. Janis, MD, Rohit K. Khosla, MD, Edward M. Reece, MD, Rod J. Rohrich, MD
Affiliation:	University of Texas, Southwestern Medical School, Dallas, TX

2:09 PM - 2:13 PM

The Effects of Smoking on Capsular Contracture Following Cosmetic Breast Augmentation

Presenter:	Michael Brickman, MD
Affiliation:	Nassau University Medical Center, Garden City, NY

Introduction: Capsular contracture is a known complication of breast augmentation. Smokers have been shown to have increased risk of capsular contracture after implant breast reconstruction. This purpose of this study is to determine whether there is a direct relationship between smoking and capsular contracture in cosmetic breast augmentation.

Methods: The charts of 422 consecutive breast augmentation patients were reviewed. Charts with a minimum 6 month follow-up were reviewed for smoking history, and documentation of capsular contracture.

Results: Of 422 consecutive patients who underwent breast augmentation, 98 were excluded. Of the 324 remaining, there were 88 smokers (27%), and 236 non-smokers (73%). Of the 176 augmented breasts in smokers, there were 25 capsular contractures in 15 patients (14%). Of the 472 augmented breasts in non-smokers, there were 45 capsular contractures in 27 patients (9.5%). This yielded a p-value of 0.20.

Discussion: Based on previous evidence that smoking is associated with a higher incidence of capsular contracture following implant breast reconstruction, we expected to find an association of smoking with capsule formation in cosmetic breast augmentation. The p-value of 0.20 was not significant.

Conclusion: There does not appear to be an increased risk of capsular contracture in smokers following cosmetic breast augmentation.

2:13 PM - 2:17 PM

Resident Rhinoplasty: "Form Follows Function"

Presenter:	M. Brandon Freeman, MD, PhD
Co-Authors:	Albert Harris, MD, James Weintrub, MD
Affiliation:	Brown University, Providence, RI

As graduating residents in plastic surgery our hands-on experience with rhinoplasty varies. Insufficiencies include number of cases performed, apportionment of responsibility for pre-operative planning and surgical execution, as well as long-term resident management autonomy. Attributable factors may include the aesthetic nature of traditional rhinoplasty cases, declining faculty surgeon participation, and the inherent difficulties of self-evaluation of postoperative results. Failure to recognize clinic patients with functional/traumatic nasal problems as opportunities for resident rhinoplasty may represent a major oversight.

Herein I present basic analysis, anatomy, planning, execution, management and aesthetic adjuncts of 18 clinic patients with functional nasal problems where resident rhinoplasty was performed.

Consistent functional improvement, conservative aesthetic goals/outcomes, and referral physician satisfaction confirmed our protocol of meticulous pre-operative planning, scripted operative intervention and standardize postoperative care.

It will behoove young, often under-trained, plastic surgeons interested in developing a cosmetic rhinoplasty practice to embrace functional rhinoplasty as a profile to include in their maturing cosmetic rhinoplasty portfolio.

2:17 PM - 2:23 PM Discussion

2:23 PM - 2:27 PM

A Novel Autologous Scaffold that Sustains Cartilage Viability and Promotes Longevity in Dorsal Augmentation Rhinoplasty

Presenter:	Jamal Bullocks, MD
Co-Authors:	Gerardo Guerra, MD, Anthony Echo, MD, Samuel Stal, MD, Eser Yuksel, MD
Affiliation:	Baylor College of Medicine, Houston, TX

Background: Dorsal nasal augmentation has a variety of indications within reconstructive and aesthetic rhinoplasty. The ideal material for augmentation is initially pliable, provides adequate vertical height and maintains form and volume over time. Diced cartilage grafts wrapped in various substances have recently been popularized as implant material. However, these materials have been shown to resorb with time due to either chronic inflammation or variable graft take. Purpose: To identify an implant material that will adequately augment the nasal dorsum and confer structural longevity. Methods: A combination of diced cartilage shavings, perichondrocytes and polymerized autologous fibrin was utilized to augment the nasal dorsum in patients with dorsal nasal deficiency. Volumetric data provided by clinical examination and sequential photography were tabulated. Results: A total of 21 patients received the autologous implant over a one year period with a mean follow-up interval of 8 months. The exact dimensions of the implants were maintained throughout the analysis period indicating no resorption. Additionally, there was no negative morbid sequela requiring explantation. Conclusions: This novel implant material is malleable to allow in situ molding at implantation and yet maintains form by sustaining cartilage viability and subsequent longevity that ultimately satisfies the goals of dorsal augmentation rhinoplasty.

2:27 PM - 2:31 PM

The Relationship Between Race and Outcome in 30,903 Size Reduction Procedures

Presenter:	Michael Chen, MD
Affiliation:	Yale Plastic Surgery, New Haven, CT

The purpose of this study was to answer two questions: is there a relationship between race and outcome in size reduction procedures such as abdominoplasty, and if so, what race-specific factors contribute to the better or worse outcomes.

I analyzed the Nationwide Inpatient Sample (NIS), an inpatient care database. Extracting all patients who had undergone a size reduction procedure, I analyzed three outcome variables: complications, length of stay, and total charge.

30,903 size reduction procedures were coded in the NIS database. When discharge weights were applied, these represented 150,365 size reduction procedures performed in the United States from 1993-2002. In the analysis, blacks were found to have significantly more complications than whites, hispanics, or asian/pacific islanders (p<0.001). This translated into a statistically significant longer length of stay and into a greater total charge for blacks. Furthermore, the black population had nearly twice the diabetics and nearly 50% more morbidly obese patients. These race-specific factors led to significantly more complications and a longer LOS.

In summary, I found that there was a direct relationship between race and outcome. This relationship was due to several race-specific risk factors, specifically a higher incidence of morbid obesity and diabetes in the black population.

2:31 PM - 2:35 PM

Iatrogenic Symmastia following augmentation mammaplasty: case series report and review of current surgical management

Presenter:	David Westbroek, MRCS
Co-Author:	Shiva D. Singh, FRCS(Eng)
Affiliation:	St Georges Healthcare NHS Trust, SW London, London

Introduction:

Symmastia was first described as the medial confluence of breast parenchyma across the ventral midline. This paper highlights the technique and outcome of revision surgery for symmastia following augmentation mammaplasty (AM). It is uniquely, the largest single source series reported to date. Methods:

A total of five patients underwent revision surgery (2004 – 2006) for correction of iatrogenic symmastia. Data accrued retrospectively included: patient demographics implant characteristics; interval between procedures; number of procedures; the original and subsequent implant placement; operative findings and outcomes. Results & Discussion:

Corrective interventions included: implant exchange, pocket re-positioning, lateral expansion capsuloraphy, medial pocket plication, reconstitution of infero-medial border of the pectoralis major muscle and postoperative taping.   

 

	Case 1	Case 2	Case 3	Case 4	Case 5
Implant size (cc) ▪ explant ▪ new implant	250 295	450 1000	430 365	510 410	300 525
Implant placement ▪ explant ▪ new implant	SM SM	SG SG	SM SG	SG SM	SM SM
No. of procedures	2	3	2	2	4
Follow up (months)	17	16	14	2	3

Conclusion:

More than one intervention is often required to achieve a satisfactory outcome. We discuss the techniques available and outcomes.

_{*Sub-glandular SG, sub-muscular SM}

2:35 PM - 2:39 PM

Complications of Abdominoplasty Combined with a Gynecological Procedure

Presenter:	Thomas L. Yen, MD
Co-Authors:	Keith Neaman, Randall Nacamuli, Juliana Hansen
Affiliation:	Oregon Health Sciences University, Portland, OR

Purpose: Abdominoplasties are one of the most common aesthetic procedures performed, and the total number of these procedures has increased over 300 percent in the past seven years. Due to significant potential savings to patients in terms of time and money, Plastic Surgeons are frequently asked to combine abdominoplasty with other abdomino-pelvic operations, such as gynecologic procedures. A retrospective review of abdominoplasties combined with a gynecologic procedure was undertaken to determine its safety and rate of complications.

Methods & Materials: Twenty-seven patients at or institution underwent abdominoplasty combined with a gynecologic procedure over the past 10 years. The mean age of the group was 50. Eight patients (29.6%) had a body mass index greater than 30. No patients developed a pulmonary embolus or deep venous thrombosis. No patients required a transfusion. One patient had a post-operative hematoma which required surgical intervention. Three patients developed seromas (11%) of which only one required aspiration.

Results and Conclusions: Our data demonstrate a similar rate of complications between abdominoplasty combined with gynecologic procedures and published complications rates for abdominoplasty alone. that serious complications Combining abdominoplasty with a gynecologic procedure appears to be safe and may decrease overall costs for the patient.

2:39 PM - 2:45 PM Discussion

2:45 PM - 3:15 PM

Break

Presenter:	No presenter
Affiliation:

3:15 PM - 3:19 PM

Nonlinear Finite Element Simulation to Elucidate the Determinants of Perforator Patency during Sequential Twisting

Presenter:	Chin-Ho Wong, MBBS, MRCS
Co-Authors:	Bien-Keem Tan, Colin Song
Affiliation:	Singapore General Hospital, Singapore

The propellar-type flap design is increasingly used in reconstructive surgery for various regions of the body. To date, determinants of perforator patency when subjected to twisting have not been elucidated. We propose a simulation model to study parameters affecting perforator patency under such conditions.

The effect of the following parameters on the pedicle patency was determined; 1) increasing angle of twist, 2) vessel stiffness, 3) vessel length, 4) diameter, 5) intra-luminal pressure, and 6) the presence or absence of blood flow during twisting.

Simulation results were reported in effective stress and strain. The vein was more prone to occlusion because of its weaker wall and lower intra-luminal pressure. We identified 4 factors that affected perforator patency: angle of twist, intra-luminal blood pressure and perforator diameter and length. There was no significant difference whether twisting was performed prior to or after restoration of blood flow (p > 0.05). Therefore, to optimize condition for maintaining perforator patency, the angle of twist should be kept < 180°, peri-operative blood pressure should be kept stable (avoiding periods of hypotension), and the selected perforator should be approximately 1mm in diameter and > 30 mm in length.

3:19 PM - 3:23 PM

Effects of Agmatine and L-Arginine in Ischemia Reperfusion Injury in Skeletal Muscle

Presenter:	Allen Gabriel, MD
Co-Authors:	Jaimie T. Shores, MD, Jacqueline Carter, Cherrie Heinrich, MD, John Chrisler, William Pearce, Subhas Gupta, MD, PHD
Affiliation:	Loma Linda University Medical Center, Loma Linda, CA

Introduction: Nitric oxide donor, L-Arg, has been reported to be beneficial in preserving tissue viability following ischemia-reperfusion. The homeostasis of L-arginine is regulated through 2 enzyme systems. The purpose of this project was to evaluate roles of agmatine and L-Arg in IR injury.

Methods: 80 rats were assigned to following 8 groups (1)sham (2) sham+L-Arg; (3) sham+1400W; (4) sham + Agmatine; (5) IR + saline; (6) IR + L-Arg; (7) IR+ 1400W; (8)IR + Agmatine. The gracilis muscle was elevated and the contralateral femoral vein exposed. Groups 1, 2 ,5, 6 received either saline or L-Arg 5 minutes before to 40 minutes following reperfusion. Groups 3, 4, 7, 8 received either 1400w or agmatine 10 minutes prior to reperfusion. At 24 hours, the gracilis muscles were harvested and stained with NBT. Percent muscle necrosis was measured.

Resutls: There was a significant decrease in necrosis in groups 6,7,and 8 versus 5. In addition, there was a significant decrease in necrosis between groups 7 and 8 versus 6.

Conclusion: These results indicate that agmatine plays a cytoprotective role in IR injury. The lack of statistical significance between groups 7 and 8, indicate that agmatine may have a direct effect on iNOS inhibition.

3:23 PM - 3:27 PM

Reverse End to Side Neurotization in a Regenerating Nerve

Presenter:	Elliott Gagnon, MD
Co-Authors:	Jonathan Isaacs, Seth Cheatham, Charles McDowell
Affiliation:	Virginia Commonwealth University, Medical College of Virginia Hospitals, Richmond, VA

Purpose: “By-pass grafting” around a neuroma in-continuity entails co-apting a nerve graft above and below the injured segment using two sequential end-to-side repairs. The proximal repair is analogous to what has been classically described as an end-to-side repair; the axons from the intact nerve sprout into the end of a recipient nerve and travel distally. At the distal connection, however, axons in the graft must enter the side of the intact nerve and find their way to appropriate end organs. This process has not been well investigated. Methods and Materials: To examine this, we performed a “reverse” end-to-side repair suturing the distal end of the peroneal nerve to the side of a transected/repaired tibial nerve in twenty rats. Primary end-to-end repairs of the tibial nerve were performed in ten additional rats. Twelve weeks later, contraction forces of the gastrocnemius muscle were measured following proximal stimulation. Measurements were repeated following elimination of potential pathways to identify which axons (peroneal or tibial) had achieved greater re-innervation. Results: Both groups of axons had achieved significant re-innervation. Conclusions: This study supports the idea that a reverse end-to-side repair can result in axonal invasion of the intact nerve and functional regeneration.

3:27 PM - 3:31 PM

The Transverse Cervical Vessels as Recipients in Difficult Head and Neck Microsurgical Reconstructions

Presenter:	Miroslav S. Gilardino, MD, MSc
Co-Authors:	Tassos Dionisopoulos, MD, Beth Mizery-Rhodes, M. Lucie Lessard, MD
Affiliation:	McGill University Health Center, Montreal, N/A

Introduction: The transverse cervical vessels (TCVs) have been described as alternate recipient vessels in head and neck reconstructions when conventional options are unavailable. The literature, however, contains little clinical information describing their use. The purpose of this study was to describe the anatomic characteristics of the TCVs and summarize our clinical experience with their use. Methods: Vessel characteristics and landmarks were measured in 72 cadaver neck sides. Clinically, all microsurgical reconstructions using the TCVs over a ten year period at our center were reviewed. Results: The transverse cervical artery (TCA) was present in 100 percent of the dissections, and the vein (TCvn) in 85 percent. Usable pedicle length was between 4-7cm with an average diameter of 2.65mm (TCA) and 2.9mm (TCvn). Anatomic landmarks to facilitate exposure were identified. Lumenal disease was significantly less in the TCA specimens compared to external carotid specimens. Clinically, the TCVs were utilized in seventeen reconstructions (7 percent of cases). All patients had prior surgery and radiotherapy. No vein grafts were utilized and there were no flap failures. Conclusion: The TCAs are reliably present, readily located, and possess anatomic characteristics that render them a useful alternate recipient vessel option in difficult head and neck microsurgical reconstructions.

3:31 PM - 3:35 PM Discussion

3:35 PM - 3:39 PM

Demucosalized Split Jejunum for Reconstruction of the Tracheostoma and Peristomal Soft Tissue Defect After Central Neck Exenteration

Presenter:	Peter Korn, MD
Co-Authors:	David I. Kutler, MD, Lloyd B. Gayle, MD
Affiliation:	Cornell University, New York, NY

Central neck exenteration with an anterior soft tissue defect and short tracheal remnant after resection of tracheostomal recurrence is a reconstructive challenge. A free jejunum transfer is the preferred option for pharyngeal reconstruction. However, an additional flap, usually a deltopectoral or pectoral flap is needed to provide thin, pliable tissue for peristomal reconstruction. In this case of a 72 year-old female undergoing neck exenteration for recurrent carcinoma at her tracheostomy a free jejunum transfer was performed. The transferred jejunum was divided into two segments sharing a common pedicle; an alimentary segment for hypopharyngeal reconstruction, and a peristomal segment, which was split open, demucosalized, inset into the soft tissue defect, contoured to the tracheal remnant, and skin-grafted. The reconstruction was stable, well contoured, without bulk or airway compromise, and with 100% skin graft take. Skin-grafted demucosalized jejunum provides excellent characteristics for reconstruction of the anterior neck and tracheostoma: it is thin, pliable, with good tensile strength, contours well to the neck, provides stable lining, and allows for postoperative monitoring of flap perfusion. Compared to traditionally used flaps, demucosalized jejunum in the setting of free jejunal transfer offers superior characteristics and avoids a second flap with its attendant morbidity.

3:39 PM - 3:43 PM

Immediate Diagnosis and Repair Of Transected Radial Nerve During Radial Artery Harvest For Coronary Artery Bypass Graft

Presenter:	Joseph Wolf, MD
Co-Authors:	Nikesh Patel, MD, Louis Britton, MD, Jerome Chao, MD
Affiliation:	Albany Medical Center, Albany, NY

Endoscopic radial artery harvesting for coronary artery bypass grafting was introduced by Terada et al in 1988 and has since become the procedure of choice for many cardiac surgery groups. Several studies in the cardiac surgery literature have described the neurologic morbidities associated with the endoscopic approach. The incidence of neurologic sequelae with the endoscopic technique ranges from one to twenty seven percent in the literature. Between eight and eighteen percent of patients have been reported to develop dorsal hand numbness at the twelve month follow up evaluation, suggesting that there has been direct thermal or mechanical damage to the radial sensory nerve. Yet, this injury has never been reported as visualized and repaired. The authors present a case report an inadvertent transection of the superficial radial sensory nerve that took place during the endoscopic harvest of a radial artery for coronary bypass. The injury was visualized by the surgeon on the endoscopic monitor and a plastic surgeon immediately repaired the injured nerve with a NeuraGen nerve conduit. This is the only report in the literature in which a radial artery was harvested with the endoscopic technique and a peripheral nerve injury was diagnosed intraoperatively and immediately surgically repaired.

3:43 PM - 3:47 PM

Intra-Thoracic Free Flaps for the Treatment of Persistent Bronchopleural Fistual and Chronic Empyema Space

Presenter:	Anthony D. Bruno, MD
Co-Author:	L. Scott Levin, MD
Affiliation:	Duke University Medical Center, Durham, NC

Purpose Statement: The purpose of this study is to examine our series of 5 intra-thoracic free flaps in four patients for treatment of persistent bronchopleural fistula and chronic empyema space.

Material and Methods: We conducted a chart review from 1996-2006 of all patients receiving intra-thoracic free flaps for the treatment of persistent bronchopleural fistula and chronic empyema space. We looked at indications, etiology, previous surgeries, choice of free flap, recipient vessels, length of hospital stay, follow up, and complications.

Summary of Results: Four patients were identified. One patient underwent two separate free flap procedures. Indications were persistent bronchpleural fistula(n=4) and chronic empyema space(n=5). Etiology of the bronchopleural fistulas and chronic empyema spaces were lung cancer (n=2), penetrating trauma (n=2), pneumonia (n=1). Two rectus abdominus, one TRAM, and 2 gracilis free flaps were performed. Hospital stay was 6.6 days (5-9 days). Follow up was 29 months (4mos to 5years). There was no flap loss and no recurrent bronchoplueral fistula.

Conclusions: Chronic empyema space and persistent bronchopleural fistula are difficult problems to manage. Intra-thoracic free flaps can be used to successfully treat persistent broncho-pleural fistula and chronic empyema space in patients whose local flap options are non-useable.

3:47 PM - 3:51 PM

The Thoracoacromial Trunk: Alternative Recipient Vessels in Reoperative Head and Neck Reconstructive Microsurgery

Presenter:	Joyce Aycock, MD
Co-Authors:	Kirsten M. Stenson, MD, Lawrence J. Gottlieb, MD
Affiliation:	University of Chicago, Chicago, IL

BACKGROUND: Reoperative free tissue transfer in head and neck cancer patients may be extremely difficult secondary to extensive scar and radiation injury leading to lack of recipient vessels. The thoracoacromial artery and its venae comitantes are alternative vessels that may be used in this situation. METHODS: Between 1997 and 2005, 16 patients underwent free tissue transfer for head and neck reconstruction performed using the thoracoacromial vessels for microanastomosis in 17 flaps. Thirteen flaps were performed in 12 patients who had been irradiated twice. Twelve thoracoacromial trunks used as recipient vessels were in patients with transferred pectoral myofascial flaps. RESULTS: Anastomotic patency was achieved in all flaps. Previous pectoral myofascial flaps made anastomosis to the thoracoacromial vessels easier to perform. CONCLUSION: The thoracoacromial trunk is a good source of access for recipient vessels in reoperative reconstructive microsurgery of the head and neck and anastomosis was able to be performed in patients with previously transferred and irradiated pectoralis major myofascial flaps with equal success.

3:51 PM - 3:55 PM Discussion

3:55 PM - 3:59 PM

Two Year Review of Tertiary Breast Reconstruction

Presenter:	Mary Lester, MD
Co-Author:	Robert J. Allen, MD
Affiliation:	Medical University of South Carolina, Charleston, SC

Purpose Statement

With the advent of perforator flaps, breast reconstruction options now include DIEP, S-GAP, and I-GAP flaps. However, implant reconstruction was utilized in approximately 80% of 57,778 reconstruction cases in 2005. Many patients present with complaints of inferior aesthetic results and pain. These implant failures or tertiary reconstructions account for 26% of cases done over a two year period.

Methods and Materials

All flaps performed by the senior surgeon were reviewed over a two year period. Three hundred and fifty-five flaps were performed during that period with 91 flaps being tertiary reconstructions. A chart review was performed comparing these patient populations.

Summary of Results/Conclusions

Approximately 70% of tertiary reconstructions were performed with abdominal perforator flaps and 30% with gluteal perforator flaps. Patient Timing of tertiary reconstruction varies between several months to several years, and 12% of patients had undergone radiation therapy. After tertiary reconstruction patients had improved pain and cosmetic results, as well as improved self confidence.

3:59 PM - 4:03 PM

Fibula Free Flap Reconstruction of the Ilium in Children after Resection of the Hemipelvis

Presenter:	Darrin M. Hubert, MD
Co-Authors:	John P. Dormans, MD, David W. Low, MD, Benjamin Chang, MD
Affiliation:	University of Pennsylvania, Philadelphia, PA

Introduction: Neoadjuvant chemotherapy for Ewing's sarcoma has made wide resection with limb salvage possible. However, resection of iliac tumors causes proximal pelvic migration and significant leg length discrepancy. Vascularized bone autografts represent the optimal method for iliac reconstruction because they heal faster and hypertrophy sooner than nonvascularized bone grafts. The purpose of this study is to characterize the successful reconstruction of the ilium in children using the fibula free flap. Methods: Four patients underwent fibula free flap reconstruction of the pelvis after resection of the ilium, with preservation of the hip joint. All had Ewing's sarcoma of the iliac wing without evidence of metastasis (stage IIB) and had pre-operative chemotherapy. Operative records and clinic charts were reviewed. Results: Mean age was 13.4 years and follow-up 3.9 years. Mean time to union of the fibular struts was 6.8 months. All patients began toe-touch weight-bearing ambulation with crutches at 8-12 weeks. Harvested fibula lengths were 20, 25, 18, and 17 cm. Mean leg length discrepancy was 2.3 cm. No flap loss or post-operative infection occurred. All patients remained without metastasis or local recurrence. Conclusion: Successful reconstruction of the pelvic ring utilizing a triangular double-barreled fibula free flap in four children is described.

4:03 PM - 4:07 PM

Free Neurotized Osteomyocutaneous Tensor Fascia Latae Flap (TFL) for Lower Abdominal Wall Reconstruction

Presenter:	Michael P. McConnell, MD
Co-Authors:	Charbel Chalfoun, Keith Hurvitz, Mark Kobayashi, Gregory Evans
Affiliation:	University of California, Irvine, Orange, CA

Introduction: Extensive abdominal wall defects may result from tumor extirpation, traumatic injury, or soft tissue infections and often disrupt the soft-tissue content of the abdomen and the bony support that the pelvis provides to structures within the abdomen and pelvis. Reconstruction of the lower abdomen should aim to recreate dynamic stability. Methods: Four patients with extensive lower abdominal wall disruption were treated at our institution using a novel flap for functional reconstruction. We devised a free neurotized osteomyocutaneous tensor fascia latae (TFL) flap that would restore bony continuity by providing a vascularized bone flap and simultaneously maintain the integrity of the attachment of the TFL muscle to the iliac crest and reestablish musculofascial continuity. A branch of the superior gluteal nerve was coapted to an intercostal nerve to reinnervate the muscle, thus creating a relatively strong and dynamic muscle in these active patients. Results: All four patients underwent successful free tissue reconstruction with 100% flap survival. The lower abdominal wall and bony integrity of the pelvis were successfully reconstructed. Reinnervation is currently being followed clinically. Conclusion: The innervated TFL osteomyocutaneous flap is an ideal option for lower abdominal reconstruction in young patients with complex abdominoperineal reconstructions.

4:07 PM - 4:11 PM

Implantable Venous Doppler Accurately Predicts Anastomotic Patency of Microvascular Free Flaps For Head and Neck Reconstruction

Presenter:	Keyianoosh Paydar, MD
Co-Authors:	Scott L. Hansen, MD, David S. Chang, MD, David M. Young, MD, William Y. Hoffman, MD, Pablo Leon, MD
Affiliation:	University of California, San Francisco, San Francisco, CA

Objectives: Head and neck free flap success depends on the ability to accurately monitor the patency of the microvascular anastomoses. We investigated whether the implantable venous Doppler could accurately predict anastomotic patency.

Methods: We reviewed 133 consecutive microvascular free flap reconstructions in 128 patients after head and neck cancer resections between April 2000 and October 2005. There were 124 flaps monitored by an implantable Doppler probe placed around the venous anastomosis.

Results: The survival rate of flaps monitored by implantable Doppler was 98%. 13 flaps lost Doppler signals in the immediate post-operative period including one flap with clinical evidence of good perfusion. Twelve flaps explored emergently were found to have occlusion of the artery (2), vein (8), both vessels (1), and a hematoma (1). Eleven of the 12 flaps had flow restored (92% salvage). The sensitivity and specificity of a lost Doppler signal indicating an anastomotic occlusion was 100% and 99%, respectively. The positive predictive value of a lost Doppler signal indicating an anastomotic occlusion was 93%. The negative predictive value of a good Doppler signal indicating a patent anastomosis was 100%.

Conclusions: The implantable venous Doppler accurately predicts anastomotic patency after microvascular free flap for head and neck reconstruction.

4:11 PM - 4:15 PM Discussion

4:15 PM - 4:19 PM

Decreased Narcotic Use After DIEP Flap Breast Reconstruction Utilizing an Implantable Local Anesthetic Catheter

Presenter:	James Boehmler, MD
Co-Authors:	Maurice Nahabedian, MD, Mark Venturi, MD
Affiliation:	Georgetown University Hospital, Hyattsville, MD

This study was to determine whether an implantable local anesthetic catheter placed in the abdomen during DIEP flap breast reconstruction could decrease narcotic use during the early post-operative period. A retrospective analysis of 41 consecutive control patients (no catheter) were compared to 29 consecutive study patients who had. The pain pump was used in the abdomen for 72 hours in the study group. Using an equianalgesic table provided from the pharmacy, all narcotic doses were converted to intravenous morphine milligram equivalents. Initial 24 hour post-operative morphine requirement for the Control Group was 42 +/- 26 milligrams compared to 34 +/- 18 milligrams for the Study Group (p=0.09). Total hospitalization morphine requirement for the Control Group was 70 +/- 41 milligrams compared to 54 +/- 30 milligrams for the Catheter Group (p=0.03). There was no significant difference in anti-nausea medication use (1.9 vs. 2.1 doses, p=0.37). In conclusion, the use of an implantable local anesthetic catheter placed in the abdomen can decrease narcotic use in the post-operative period after DIEP flap breast reconstruction.

4:19 PM - 4:23 PM

Cellular, Molecular and Genetic Etiologies of Intraoperative Microvascular Anastomotic Failure

Presenter:	Curtis L. Cetrulo, Jr, MD
Co-Authors:	Thomas A. Davenport, M.D., Matthew S. Kilgo, M.D., Roger L. Simpson, M.D.
Affiliation:	Long Island Plastic Surgery Group, Garden City, NY

INTRODUCTION:Rare intraoperative microvascular anastomotic failure by intractable vasospasm/thrombosis has been explained by reactive thrombocytosis and/or hypercoaguability. A third hypothesis involves a genetic predisposition to vasospasm: patients with mutations in the endothelial nitrous oxide synthase (eNOS) gene exhibit a propensity for systemic vasospastic conditions.

METHODS:In 14 flap-failures from 171 microsurgical procedures, 2/3 intraoperative failures revealed a possible etiology. Case 1, a male Type-II-diabetic who underwent lower extremity free-tissue-transfer exhibited intractable vasospasm/thrombosis of the anastomosis. Case 2 (non-diabetic male) exhibited a similar clinical course. Case 1's DNA was analyzed by RT-PCR for the presence of the T-786-C-single-nucleotide-polymorphism of the eNOS gene, a mutation associated with vasospastic conditions. Cases 1 and 2 were tested for a full hypercoaguability panel, reactive thrombocytosis, and aspirin and/or heparin resistance.

RESULTS:Case 1: heterozygosity(T/C) for the eNOS gene; Case 2: Reactive thrombocytosis coinciding with the timing of the attempted free tissue transfer; Cases 1&2: Platelets, hypercoagulability, aspirin/heparin resistance studies normal(Figures1,2).

CONCLUSIONS:These data suggest two distinct etiologies for intraoperative microvascular vasospastic/thrombotic failures and may predict patients at increased risk for free-flap loss. eNOS-mediated vascular dysfunction is an established cause of vasospastic/thrombotic conditions, as is reactive thrombocytosis. Both represent possible molecular targets for prevention of intraoperative vasospasm/thrombosis in microsurgery.

4:23 PM - 4:27 PM

The Versatility of Free Style Thigh Perforator Flaps for Reconstruction of the Head, Neck, and Upper Extremity

Presenter:	Mark T. Villa, MD
Co-Authors:	Al Cohn, MD, Lawrence J. Gottlieb, MD
Affiliation:	University of Chicago, Chicago, IL

Introduction The closure of large defects poses a challenge for reconstructive microsurgeons. Although the ALT flap has gained popularity, its size may be insufficient to reconstruct large or complex wounds. We present our experience with free style thigh perforator flaps that incorporate the skin territories of the ALT plus those supplied by the medial vascular system.

Methods and Materials Four patients with complex defects from ablative oncologic surgery for upper extremity, scalp and oropharyngeal tumors were reconstructed using thigh free flaps with larger dimensions or more complex designs than the classic ALT can accommodate. Wounds ranged from 800 cm2 to 1500 cm2. Two flaps incorporated the rectus femoris muscle, one incorporated the TFL muscle and one was a pure fasciocutaneous flap. Recipient beds were closed with skin grafts.

Results All flaps survived. All donor sites healed and all patients ambulated during their first post-operative week.

Conclusion Free style free flaps incorporating medial thigh perforators used alone or combined with the lateral system expand the repertoire of available thigh flaps. They allow for flaps with a wide variety of shapes and potential skin paddles and can provide both the large surface area and substantial three-dimensional variability frequently required for complex reconstructions.

4:27 PM - 4:31 PM

Revisiting Reconstruction of Segmental Mandibulectomy Defects with Plates and Soft Tissue Free Flaps

Presenter:	Lisa M. Jacob, MD
Co-Author:	R. Datiashvili, MD
Affiliation:	UMDNJ-New Jersey Medical School, Verona, NJ

Osteocutaneous free flaps are optimal for reconstruction of composite mandibular defects. Plate reconstructions are fraught with complications. We propose the use of a latissimus dorsi free flap in a bilayer configuration with plate reconstruction for postmandibulectomy defects. From 2001 to 2006, 59 patients underwent free flap reconstruction for head and neck tumors. Twenty had reconstruction of composite mandibular defects. Four received osteocutaneous flaps (3 fibula, 1 scapular). Sixteen underwent soft tissue free flaps and plate reconstruction {radial forearm (7), latissimus dorsi (6), rectus Abdominus (3)}. Mean follow-up was 24 months. Complication rate for radial forearm flaps with plate was 57% (2 intraoral exposures and 2 orocutaneous fistulas). Complication rate for transverse rectus abdominus flap with plate was 33% (1 intraoral exposure). There were no complications with use of latissimus dorsi flap with plate. Our results using radial forearm and rectus abdominus flaps with plates correlate with reported rates. However, we found success using the latissimus dorsi muscle with plate reconstruction. It's length, width, and pliability allows for 3-dimensional folding creating a bilayer of protection. This technique significantly reduces the complications associated with mandibular reconstruction with plates. It should be considered in all patients who are not candidates for osteocutaneous flaps.

4:31 PM - 4:35 PM Discussion

4:35 PM - 4:39 PM

Outcome Analysis of Management of Positional Plagiocephaly with Passive Helmet Therapy

Presenter:	Christopher Park, MD
Co-Author:	Lisa R. David, MD
Affiliation:	Wake Forest University School of Medicine, Winston-Salem, NC

INTRODUCTION: Children with positional plagiocephaly are being seen in craniofacial clinics in alarming numbers. The best treatment for children with significant positional plagiocephaly is with molding helmets. The unfortunate high cost of most custom molded helmets precludes many children from obtaining them. We have employed an adjustable, prefabricated molding helmet to treat these children that costs in the range of $600.00.

Methods : 199 patients with varying degrees of deformity were treated. 154 children completed the study. Improvement in cranial shape was rated by Argenta's classification and computerized surface Polhemus scanning laser. Patients were treated until a normal cranial shape was achieved.

Results : Average treatment time was 5.4 months. Success of treatment directly correlated with compliance (p=.0001). More severe deformities had the highest degree of compliance (p=.0148) and the greatest degree of improvement (p°Ü.0001). Fully compliant patients had the greatest reduction in severity.

Conclusion : Successful resolution of plagiocephaly deformities can be achieved at great cost savings and equal time with prefabricated, off the shelf helmets compared to custom fabricated orthosis. Compliance and early treatment is critical to the success of treatment.

4:39 PM - 4:43 PM

Congenital Muscular Torticollis: a Treatment Algorithm Integrating Botulinum Toxin Type A

Presenter:	Matthew Swelstad, MD
Co-Author:	Louis Morales, Jr, MD
Affiliation:	University of Wisconsin, Madison, WI

Congenital muscular torticollis is traditionally treated by positioning techniques, neck collars and physical therapy. Refractory cases require surgical release. We reviewed 163 consecutive cases of infant positional molding over one year. Sixty-six of these patients had congenital muscular torticollis. Eight patients with congenital muscular torticollis were refractory to conservative management. Instead of surgical release, all eight patients underwent botulinum toxin type A injections to affected muscles (sternocleidomastoid, scaleneus, and trapezius). The number of units injected ranged from 60-82 units per patient; mean 68 units. Follow-up ranged from 2-12 months. Parents and physical therapist were surveyed. There were no complications. All patients demonstrated improvements with resting head position and active/passive range of motion. Parents and therapists reported patient comfort with therapy and quality of therapy improved in each case. None of the eight patients required surgical release. This experience with botulinum toxin type A in the treatment of severe recalcitrant congenital muscular torticollis serves as the foundation for a proposed treatment algorithm advocating the use of botulinum toxin type A in cases that fail to progress with conservative management and in less severe cases to improve therapy comfort, quality and compliance.

4:43 PM - 4:47 PM

A Familial Case of Sagittal Suture Craniosynostosis

Presenter:	J. Alejandro Conejero, MD
Co-Authors:	Rodrigo Santamarina, MD, Janice Fay Lalikos, MD, MA
Affiliation:	University of Massachusetts Medical School, Worcester, MA

Craniosynostosis is a common craniofacial anomaly, with an estimated incidence of 1/2000 to 1/3000 births. Scaphocephaly accounts for 40-58% of all non-syndromic single-suture synostosis. Only 2-9% of these are familial cases. We report the clinical findings in a three-generation family presenting with familial scaphocephaly. Case presentation: The patient was born at 41 weeks gestation by vaginal delivery. A ridged sagittal suture was discovered on clinical exam at three months of life. A CT scan of the skull with 3-D reconstructions confirmed the diagnosis. He underwent cranial vault remodeling. His 28 year-old father was also diagnosed with sagittal suture synostosis at the age of 5 months and underwent urgent craniotomy for increased intracranial pressure. His paternal grandfather as well as his paternal great uncle and a first cousin to the father all have the diagnosis of sagittal suture synostosis. None of them have had surgery. We describe the clinical findings and family tree of a familial case of sagittal craniosynostosis. A mutation in the fibroblast growth factor receptor 2 gene (FGFR2) tyrosine kinase domain (versus other sites) could be the cause for this familial presentation. The related clinical and genetic literature will be reviewed.

4:47 PM - 4:51 PM

Microbiologic Considerations for the Cleft Surgery Practice

Presenter:	John W. Antonetti, MD
Co-Authors:	John Heggars, Steven J Blackwell M.D.
Affiliation:	University of Texas Medical Branch Galveston, Galveston, TX

Purpose: Define changes in microbial flora before and after closure of the cleft palate and lip to better understand infection risk and justification for antibiotic usage.

Methods: Over a two year period forty-four patients receiving primary palatoplasty and ten patients receiving cheiloplasty were enrolled. The study involved pre and postoperative cultures from the nasal, sublingual, and oropharyngeal surface.

Results: 2.3 % of patients undergoing palatoplasty were positive for Streptococcus pyogenes ( group A B-hemolytic streptococci) preoperatively. Staph. aureus was present in 34% of patients preoperatively. MRSA prevalence increased from zero percent preoperatively to 4.5% of patients one year following surgery.

Potential gram negative pathogens (Klebsiella pneumoniae and Enterobacter cloacae) had preoperative prevalence of 34% and 22% within the oropharynx and were found to be significantly reduced one year following surgery.

Conclusion: Because group A B-hemolytic streptococci poses a high risk for palatal dehiscence, preoperative Rapid Strep screening should be a considered routine. Despite high prevalence of other potential pathogenic flora including Staph aureus and various enteric bacteria prior to palatoplasty, postoperative wound infection is rare in the prospective study population. Our data suggests that routine prophylactic antibiotics are unwarranted with primary cheiloplsty and palatoplasty when thorough preoperative screening is performed.

4:51 PM - 4:57 PM Discussion

4:57 PM - 5:01 PM

Coverage of Exposed Central Nervous System Structures with Acellular Cadaveric Dermis (AlloDerm)

Presenter:	Charles Newman, MD
Co-Authors:	Malcolm Marks, MD, Lisa David, MD
Affiliation:	Wake Forest University Baptist Medical Center, Winston-Salem, NC

Purpose: AlloDerm® (LifeCell Corporation, Branchburg, NJ) is an acellular human cadaveric dermal matrix. The structural extracellular framework is retained, supporting revascularization and remodeling into the native tissue with minimal risk of infection, extrusion, or rejection. Coverage of wounds with exposed central nervous system structures frequently requires pedicled or free muscle transfers. However, when these options are limited, AlloDerm may serve as an alternative means of wound coverage.

Methods: Patients were chosen for this technique when more traditional methods were unsuccessful. Two patients with myelomeningocele had persistent cerebrospinal fluid (CSF) leaks despite muscle coverage. One patient with craniosynostosis had a dural defect after repair. One patient had a large area of exposed brain after flap coverage became non-viable.

Results: Four patients (age 3-76 ) were evaluated. Healing was complete without further CSF leak in three patients. In one, the AlloDerm served as a temporary treatment prior to flap coverage.

Conclusions: Using an acellular dermal matrix is well-tolerated and provides durable coverage with minimal infectious risk to the central nervous system. Further experience with this product will help determine its overall applicability to treat CSF leaks and exposed central nervous system structures.

5:01 PM - 5:05 PM

A New Approach for the Bilateral Cleft Lip Repair

Presenter:	Rohit K. Khosla, MD
Co-Authors:	Richard Y. Ha, MD, Amanda Gosman, MD, Henry Steve Byrd, MD
Affiliation:	UT Southwestern Medical Center, Dallas, TX

The bilateral cleft lip and nasal repair has remained a challenging endeavor. Techniques have evolved to address concerns over unsatisfactory features and stigmata of the surgery. We present a novel approach to this complex clinical problem that modifies traditional repairs described by Millard and Manchester. The senior author has evolved this technique with over 25 years of surgical experience dealing with the bilateral cleft lip. This staged lip and nasal repair provides excellent nasal projection, lip function, and aesthetic outcomes. Lip and velar repair is performed at 3 months of age. Palatal repair and columellar lengthening is performed at approximately 18 months of age. A key component of this repair focuses on reconstruction of the central tubercle. A triangular prolabial dry vermilion flap is augmented by lateral lip vermilion flaps which include the profundus muscle. This minimizes lateral lip segment sacrifice and provides improved central vermilion fullness, which is often deficient in traditional repairs. This approach decreases tension across the upper lip, augments the tubercle, and improves the proportion between the upper and lower lip. We present the surgical technique and our outcomes.

5:05 PM - 5:09 PM

Refinements in Forehead Reconstruction with Tissue Expanders

Presenter:	Wilberto Cortes, MD
Co-Author:	Arun K. Gosain, MD
Affiliation:	Medical College of Wisconsin, Wauwatosa, WI

Forehead reconstruction secondary to giant congenital nevus, hemangioma and complex scar revision, requires a complex algorithm for tissue expansion in the pediatric population. We describe refinements in traditional approaches to this problem.

Ten-year retrospective review of 24 patients who underwent tissue expansion for forehead reconstruction. Parameters reviewed: eyebrow ptosis, hairline symmetry, placement of final scars, and aesthetic outcome.

When lesions involved 25 to 70% of the forehead (n=22) we used delayed expanded forehead rotation flaps (n=1), and serial expansion of forehead advancement flaps (n=20) for reconstruction. Serial excision was reserved for residual hyperpigmentation (n=9). Two patients whose lesion involved 70% of the forehead required an expanded skin graft. In patients reconstructed with expanded forehead flaps, the median number of expansion procedures required for completion was 3 (range: 1 to 5), and the median number of surgical procedures was 6.5 (range: 2 to 11). Simultaneous scalp tissue expanders were placed in 18 of 22 patients; simultaneous cheek tissue expanders were placed in 8 patients.

A combined modality surgical approach is necessary for optimal forehead reconstruction. Regardless of the reconstructive technique utilized, the forehead should be reconstructed as one aesthetic unit, confining scars to the hairline, upper brow, peri-auricular regions and temple.

5:09 PM - 5:15 PM Discussion

Friday, February 2, 2007

Mandibular In Situ Osteogensis With rhBMP-2: Osteoinduction Via Stem Cell Concentration

Presenter:	Mimi T. Chao, MD
Co-Authors:	Michael Carstens, MD, Tom Donovan, MD, Cirilio Sotelo, MD
Affiliation:	Saint Louis University, St. Louis, MO

The current gold standard for mandible reconstruction is with autologous bone, either as an osseous free flap or a nonvascular bone graft. The success of such grafts is entirely dependent upon the vascularity of the recipient site. The grafts are eventually replaced by ingrowth of bone from the recipient site through osteoconduction.

This presentation describes the reconstruction of a 12-cm mandibular defect after the resection of an ossifying fibroma using in situ osteogenesis (ISO) with an implant composed of recombinant human bone morphogenetic protein (rhBMP-2) and activated collagen sponge (ACS). Osteoinduction with rhBMP-2 occurs independent of recipient site blood supply by stimulating vascular ingrowth and attracting the surrounding living cells into the implant. The resulting membranous bone was histologically identical with that of the original bone. After 24-weeks of consolidation, the regenerate bone was able to be osteotomized and distracted successfully to achieve the desired mandible height.

The resultant savings in time, the elimination of donor site morbidity, and the avoidance of microvascular technical issues make ISO an attractive means for reconstructing the human mandible and other membranous bones of the maxillofacial skeleton.

8:04 AM - 8:08 AM

Calvarial Reconstruction With Recombinant Bone Morphogenetic Protein (rhBMP-2)

Presenter:	Scott J. Engel, MD
Co-Authors:	Michael H. Carstens, MD, Ann M. Flannery, MD
Affiliation:	Saint Louis University Hospital, St. Louis, MO

Background: Defects of the cranial vault can be a challenging and complex problem for the reconstructive surgeon. The morbidity of harvesting autogenous bone grafts, as well as complications using alloplastic materials have challenged the field of reconstructive surgery for more optimal techniques. Recombinant human bone morphogenetic protein (rhBMP-2) is an osteoinductive protein that has been shown to be effective for use in open long bone fractures, spine surgery, and augmentation of the alveolar ridge. The authors describe the use of rhBMP-2 in cranioplasty and show how this technique offers the advantages of material autogenous to the human body, while avoiding the morbidity of bone grafts, and risks associated with alloplastic material.

Methods: Seven patients aged 3 to 16 years underwent cranial vault remodeling with bone morphogenetic protein. Various characteristics of the cranial defects were recorded including dimensions, reasons for defects, and postoperative results. Infection, bone resorption, and residual defects were measured with postoperative CT scans.

Results: Seven patients were successfully treated with rhBMP-2 and evaluated using pre and post operative CT scans and clinical pictures.

Conclusions: Cranial remodeling can be successfully accomplished using bone morphogenetic protein (rhBMP-2), utilizing the advantages of autogenous material, while avoiding morbidity associated with allogenic material.

8:08 AM - 8:12 AM

Patterns of Cervical Spine Injury in 4,980 Patients with Concomitant Facial Fractures

Presenter:	Hugo St-Hilaire, MD, DDS
Co-Authors:	Eduardo Rodriguez, MD, DDS, Rachel Bluebond-Langner, MD, Thomas Scalea, MD, Paul N. Manson, MD
Affiliation:	Louisiana State University, New Orleans, LA

8:12 AM - 8:16 AM

Reabsorbable Plate Strength Loss during Molding

Presenter:	Wesley P. Thayer, MD, PhD
Co-Authors:	S. Saul Lahijani, MD, R. Bruce Shack, MD, Kevin J. Kelly, MD, DDS
Affiliation:	Vanderbilt University, Nashville, TN

8:16 AM - 8:22 AM Discussion

8:22 AM - 8:26 AM

Quality of life after Maxillectomy: Obturation vs Free Tissue Transfer

Presenter:	James Banich, MD
Co-Authors:	David Sieber, Andrew Gassman MD, Kiarash Mirkia MD, Darl Vandevender MD
Affiliation:	Loyola University Medical Center, Maywood, IL

Cancer of the Maxilla can be quite a devatating and disfiguring problem for the reconstructive surgeon. Heroic reconstructions, often for advanced tumors have long recoveries to achieve functional results. The purpose of the study was to investigate the subjective quality of life in patients after maxillectomy, specifically contrasting those undergoing free tissue transfer vs those simply obturated with a prosthesis. Over a 10 year span, 101 patients were treated by various forms of maxillectomy at at our institution. Standard University of Washington quality of life questionaires were distributed. To date, 39 responses have been received. Results showed no significant difference (p=0.2737) in quality of life score between the free tissue reconstruction group and those fitted with a prosthesis. However, the mortality of the reconstructed group is much higher, reflecting comparable quality of life despite significantly more advanced tumors.

8:26 AM - 8:30 AM

The Scarf Joint Technique of Osseous Reconstruction Appears To Facilitate Bony Fusion In Mandibular Reconstruction

Presenter:	Jennifer E. Boll, MD
Co-Author:	Salvatore Lettieri, MD
Affiliation:	Mayo Clinic, Rochester, MN

Purpose statement: Osseous microvascular reconstruction is the mainstay of treatment for mandibular defects. In the literature discussing the various techniques of reconstruction there has been little written with regard to the bone to bone contact areas. The greater the contact surface area, the higher the likelihood of subsequent bone fusion. This paper examines the use of the scarf joint to maximize surface contact and facilitate bone fusion.

Methods and materials: A retrospective review of 20 microvascular reconstructions of the mandible. Of these patients 7 underwent the lapped scarf joint technique of bone to bone contact in the mandible.

Results: Six out of the seven patients had adequate osseous ingrowth with no major complications. In one patient, there was failure of bone fusion due to a hardware failure. This patient had a full course of postoperative radiation. Six of the seven patients had good boney fusion with evidence of callous formation at the junction of the mandible and the fibula.

Conclusions: Although only a small number of patients were examined, the scarf joint technique seems to facilitate bony fusion. The one complication was due to hardware failure and went on to fusion after further revisional surgery.

8:30 AM - 8:34 AM

The Effect of Pre-surgical Nasoalveolar Molding on Nasal Symmetry and Growth in Bilateral Cleft Patients

Presenter:	Robert J. Paresi, MD, MPH
Co-Authors:	John Polley, MD, Alvaro Figueroa, DDS, MS
Affiliation:	Rush University Medical Center, Chicago, IL

The purpose of this study is to assess the changes seen with pre-surgical nasoalveolar molding (NAM) on nasal symmetry and growth in bilateral cleft lip patients. Twelve consecutive complete bilateral cleft lip patients that had pre-surgical nasoalveolar molding were included in the study. Facial moulages and digital photographs were taken of all 12 patients both before nasoalveolar molding, and after nasoalveolar molding at the time of primary lip repair. Linear measurements were then taken on the digital photographs to assess the changes in the nose and lip before and after nasoalveolar molding. Nasal projection increased a mean of 28.5 mm with NAM. Nasal width increased a mean of 29.5 mm with NAM. Deviation of nasal tip from midline decreased 5.54 ¢ª with NAM. The prolabial projection increased an average of 31.9 mm with NAM. The nasal length increased an average of 23.2 mm with NAM. Nasal symmetry and growth was significantly improved with nasoalveolar molding. This study demonstrates the positive changes of nasoalveolar molding on the nasal deformity in bilateral cleft patients, and provides a methodology for quantitating the effect of nasoalveolar molding in bilateral cleft patients.

8:34 AM - 8:38 AM

The effect of facial aging on mandibular shape: a morphometric analysis from the Brush-Bolton longitudinal series

Presenter:	Kevin Hanz, MD
Co-Authors:	Joel E. Pessa, MD, Rod J. Rohrich, MD
Affiliation:	UTSW, Dallas, TX

Background: The concept of differential growth of facial bones in children has been known since the 1920's. The changes associated with maturation from infancy to youth involve growth of facial bones at varying rates. Clinical observation would suggest there is a flattening of the mandibular contour that occurs with aging. This study sought to address whether the concept of differential growth of the facial skeleton continues beyond youth.

Methods: Utilizing the Brush-Bolton longitudinal series, we analyzed 16 files, including 8 male and 8 female subjects. Data was derived from frontal cephalograms, obtained initially at youth, and later, at maturity.

Results: The data demonstrates a dramatic shape transformation which occurs from youth to maturity. Young male mandible shape was different from old male mandible shape (p=.001). Young female mandible shape was different from young male mandible shape.

Conclusions: The differential growth of facial bones continues after youth. There is a loss of convexity associated with the mature mandible that is seen in both male and female subjects. The statistical analysis of shape is a powerful tool that beholds vast potential in helping to explain the role skeletal remodeling plays in facial aging.

8:38 AM - 8:42 AM

Endoscopic Transmaxillary Repair of Orbital Floor Fractures

Presenter:	Randall P. Nacamuli, MD
Co-Authors:	Thomas Yen, MD, Reid V. Mueller, MD
Affiliation:	Oregon Health Sciences University, Portland, OR

Purpose: Transcutaneous and transconjunctival approaches to orbital floor fractures (OFF) have known complications including ectropion, entropion, granuloma formation, and scarring. Endoscopic transmaxillary repair of OFF avoids these complications, provides an improved view of the surgical field, and may lead to improved resolution of diplopia. In this study, we review postoperative outcomes in patients with OFF treated by endoscopic transmaxillary approach. Methods and Materials: A retrospective chart review of patients with OFF treated endoscopically by the senior author over a 3 year period was performed. Postoperative outcomes including diplopia, enopthalmos, and gaze restriction were compared. Results and Conclusions: Seven patients with 8 OFF were reviewed. Average patient age was 39 (range 20 to 77 years), time to surgery 5 days (range 0 to 10 days), and average follow-up interval 83 days (range 8 to 491 days). Seven OFF were repaired with Medpor. Diplopia was improved or resolved in 75% of OFF, and enopthalmos was resolved or improved in all patients. One patient had a wound infection postoperatively, and one patient had persistent gaze restriction. Endoscopic repair of OFF's is effective, avoids lower lid complications, and may improve of resolution of diplopia.

8:42 AM - 8:48 AM Discussion

8:50 AM - 8:54 AM

Bone Regrowth using a pleuripotent stem line derived from peripheral adipose tissue

Presenter:	Gustavo Enrique Bello-Rojas, MS, MD
Co-Authors:	Ian T. Jackson, Whitney Mary, Walman Noah
Affiliation:	Providence Hospital, Southfield, MI

The reconstruction of calvarial defects is currently addressed using various autografting and allografting techniques. The purpose of this study is to evaluate the value of adding stem cells derived from adipocyte tissue to these defects In this experiment, 18New Zealand rabbits had a 1.5x1.5 cm cranial-bone defect. This defect was filled with either bone dust alone or stem cells alone. The BMD were calculated by using DEXA scanning at weeks 1,16, and 32postoperatively. The results were also measured qualitatively at week 32 using histomorphic analysis. The results showed a statistical significance with a p-value of .014 at week 32 for the group over 1million pre-adipocyte cells. This result was comparable when the bone formation analysis was analyzed between groups. Using one-way-ANOVA, the 3groups treated were different by p=0.008. Using post hoc analysis, the rabbits with >1x106 cells had significantly higher density than either the control(p=0.009)or<1x106(p = 0.046) groups. The <1x106 group was not different from the control group. These results show that using peripheral adipose tissue as a source for stem cells may become an option in the future for reconstructing bony defects.

8:54 AM - 8:58 AM

Fat Grafts and Shear? Improving Fat Graft Performance by Increasing Scaffold Support Matrix Longevity

Presenter:	Justin H. Piasecki, MD
Co-Authors:	Karol A. Gutowski, MD, Katherine Moreno, MD, Garet Lahvis, PhD
Affiliation:	University of Wisconsin Hospital and Clinics, Madison, WI

Background: Little attention has been focused on the effect of fat graft structure on in vivo performance. We hypothesized that a stable initial graft structure was important to fat graft take - similar to the importance of shear minimization in the take of skin grafts. The performance of fat grafts was assessed when suspended in two matrices that provided different durations of graft structural support: Matrigel, which resorbs over two months; and Puramatrix, which resorbs in one week.

Methods: Age and sex matched genetically identical mice were implanted with fat grafts consisting of the same number of purified adult adipocytes mixed with either Puramatrix or Matrigel. Control grafts composed of Matrigel alone, Puramatrix alone, or lipoharvested (unpurified) fat alone were also injected. Volume measurements and histological sections were taken at 1 week, 1 month and 3 months.

Results: Purified adipocytes/Matrigel grafts showed statistically greater longevity and volume maintenance versus all other groups.

Conclusions: Gradual resorption of scaffolding in this study was associated with improved graft longevity and volume maintenance, while immediate matrix resorption led to poor graft performance. These results suggest a potentially important role for a mechanically stable initial graft structure in the ultimate efficacy of fat graft take.

8:58 AM - 9:02 AM

The Pyriform Ligament

Presenter:	Ronald Hoxworth, MD
Co-Authors:	Rod J. Rohrich MD, Joel E. Pessa MD
Affiliation:	UTSW, Dallas, TX

BACKGROUND: The alar base is a structure supported by both dynamic muscular and static anatomy. The muscular anatomy has previously been described, however, the ligamentous support is not well detailed. The authors propose the existence of a facial network serving as a ligamentous support for this region and attempt to detail it by anatomic dissection.

METHODS: An anatomic study was performed on fresh hemifacial cadavers studying the relationship between the alar base, lateral nasal cartilages and the pyriform rim. Sequential dissection was undertaken. Fascial attachments were identified and confirmed with the aid of loupe and microscopic visualization. The structures were then photographically documented.

RESULTS: A facial membrane encircled the pyriform aperture in each dissection. This membrane served as a bridge between the alar base, lateral cartilages and the pyriform rim. Consistent anatomic findings were identified: (1)the fascia enveloped both the upper and lower lateral cartilages, (2) it spanned the entire pyriform rim, (3) it incorporates the lateral sesamoid complex.

CONCLUSION: A fascial network incorporates the alar base, the upper and lower lateral cartilages and the pyriform rim. This structure provides static support to the alar base and may be referred to as the the pyriform ligament.

9:02 AM - 9:06 AM

The Effect Of Antibiotic Irrigation On Human Fibroblast Viability In Vitro

Presenter:	Nicole Nemeth, MD
Co-Authors:	Lisa J. Gould, MD, PhD, Linda Phillips, MD
Affiliation:	University of Texas Medical Branch, Galveston, TX

PURPOSE

The aim of this study is to investigate the effect of three antibiotic solutions on human fibroblast viability in vitro.

MATERIALS & METHODS

Human fibroblast cultures are exposed to either cefazolin (5 gm / L), penicillin (5 MU / L) or piperacillin / tazobactam (8 gm / 1 gm / L) for 5 minutes, 30 minutes or 60 minutes. Cell viability is then determined at 1, 2 and 5 days post-treatment using the MTS assay.

RESULTS

Results show that neither the penicillin nor piperacillin / tazobactam irrigation significantly affects fibroblast proliferation or viability when compared to control for each time point. After five days, however, cefazolin irrigation significantly increases cell counts after a 5, 30 or 60 minute treatment. This effect was also seen after only 48 hours with a 5 or 30 minute treatment.

CONCLUSIONS

High-dose cefazolin, penicillin or piperacillin / tazobactam irrigation solutions do not appear to be toxic to human fibroblast cells in culture. Their effect on fibroblast function, such as collagen production, needs to be further elucidated. We propose that high-dose antibiotic solutions, while known to be efficacious in decreasing bacterial load, may also preserve the role of the fibroblast in wound healing.

9:06 AM - 9:10 AM

Prefabrication of Vascularized Bone Flap

Presenter:	Eric C. Hu, MD
Co-Authors:	Feng Zhang, MD, PhD, William C. Lineaweaver, MD
Affiliation:	University of Mississippi Medical Center, Jackson, MS

Demineralized bone matrix(DBM) has been reported to have osteoconductive and osteoinductive properties and has been clinically used as a bone graft alternative. In the present study, we generated a vascularized bone flap by subcutaneous implantation of DBM with a vascular loop to provide blood supply in a rat model. Thirty male Sprague-Dawley rats were divided into two groups, according to the presence or absence of blood supply. In the experimental group, the bone flap was created by application of 0.4 ml DBM onto two pieces of gelatin sponge sheets between which a vascular loop was sandwiched. A prefabricated flap without a vascular loop served as the control. The flaps were biopsied at three different time intervals postoperatively (2, 4, and 6 weeks). The results showed that DBM induced subcutaneous bone formation in both of the groups. However, in the non-vascularized group, the amount of bony tissue had decreased at 4 postoperative weeks and continued to do so afterwards. In contrast, bone formation was active at 4 weeks in the vascularized group. Our study indicated that implantation of DBM can prefabricate a bone flap. Blood supply to the flap is considered a key factor to the success of this prefabrication.

9:10 AM - 9:16 AM Discussion

9:16 AM - 9:20 AM

Resistance of Human Acellular Dermal Matrix ( Alloderm) to Capsular Contracture: A Prospective, Controlled Clinical and Histologic Comparison

Presenter:	Jitendra Singh, MD
Co-Authors:	Arzu Buyuk, MD, Curtis L. Cetrulo, Jr, MD, Laurence T. Glickman, MD, Roger L. Simpson, MD, MBA
Affiliation:	Nassau University Medical Center, Garden City, NY

Hypothesis: Alloderm is resistant to the fibroblastic response typically observed with foreign body implantation.

Introduction: Clinical observations show decreased scarring and capsule formation with implanted Alloderm.

Methods: 20 female patients who underwent post mastectomy breast reconstruction with tissue expanders and Alloderm were evaluated for clinical and histologic evidence of capsule fibroplasia. The tissue expanders were explanted and the implant pocket was examined for capsular bands. The pockets were divided into medial, superior, lateral and inferior quadrants. Photo documentation of contracture bands and Alloderm - capsule interface were obtained. The number of bands /quadrant was compared. Two groups of biopsy specimens were obtained for histologic analysis. Group 1 – biopsy of capsular bands ; Group 2 biopsy of the Alloderm – capsule interface. Histologic measures included nucleated cells and myofibroblasts / cross sectional area expressed as cells /mm.

Results/Conclusion: The number of contracture bands was significantly greater in superior, medial, and lateral quadrants as compared to the inferior quadrants (p < .001). The concentration of myofibroblasts and nucleated cells is decreased in Alloderm specimen of capsule as compared to capsular band specimen. Alloderm is resistant to the fibroblastic foreign body response. Capsular contracture may be decreased with the use of Alloderm.

9:20 AM - 9:24 AM

The Role Of Beta Defensins in Keloid Pathegenesis, Emerging Concept

Presenter:	Khurshid Alam, MSc, MRCS
Co-Authors:	Mobin Syed, F Zaman, Hasu Patel, FRCS, B. Patel, FRCS
Affiliation:	Barts and The London NHS Trust Queen Mary University London, New Malden

Background:-Keloid is an exuberant inflammatory response to skin injury due to abnormal Keratinocytes and Fibroblast interaction and their differentiation, appearing as disfiguring skin lesion extending beyond the actual injuring stimuli. Beta Defensin Proteins are primarily a group of innate immunoglobulins against microbial agents but are also involved in cell differentiation, cell signalling and triggering the adoptive immune system. Aim: We hypothesise that Beta Defensin Proteins are involved in keloid pathogenesis as keloid has microenvironment of dense cytokine secretions and chronic inflammatory response. To my knowledge no previous study has examined the relationship of Beta Defensin and Keloid formations. Methods: The keloid and normal skin samples were collected from patients undergoing plastic surgery procedures. The samples were snapped frozen and subjected to immunohistochemistry with antibodies against Defensin Beta1, 2 and 3. Results:Immunohistochemistry analysis of ten Keloid and site specific normal skin showed that Beta Defensin 1 and 3 are has increased expression in keloid as compare to site specific skin. Conclusion.Dense secretion of Defensin Beta 1 and 3 at Stratum Corneum lead to the abnormal differentiation of keloid keratinocytes which hyperproliferate in epidermis and influence keloid fibroblast to hyper secrete the cytokines in chronic inflammatory milieu.

9:24 AM - 9:28 AM

Tips for Designing Multimedia: simple ways to maximize your message

Presenter:	Tiffany Grunwald, MD, MEd
Affiliation:	USC Keck School of Medicine, Los Angeles, CA

Purpose: Educate participants about cognitively efficient ways to design multimedia teaching material. Methods and Materials: Extensive review of the literature regarding medical education and multimedia teaching; participation in AAMC colloquium on effective use of educational technology in medical education, and a study looking at interface design elements in a carpal tunnel syndrome teaching module. Summary of results: By employing straightforward measures when designing a multimedia interface, you can help to maximize your message. There is increasing evidence that busy screen designs may cause learning difficulty. Flashing animations and flying text draws attention away from learning goals. Guidelines for designing multimedia presentations will be discussed. Pitfalls in design will be discussed including issues of cognitive load, inefficient use and placement of text, sound, pictures, video and animation. Conclusions: Whether using multimedia for teaching residents, educating patients or conference presentation, design issues are important. Multimedia teaching tools must be developed from sound educational theory.

9:28 AM - 9:32 AM

Would Application of Guidelines for Antimicrobial Prophylaxis in Plastic Surgery Prevent Surgical Site Infection? Outcomes in One University Center

Presenter:	Valerie Lemaine, MD
Co-Authors:	Geneviève Landes, MD, Patrick G. Harris, MD, John S. Sampalis, PhD, Jean-Paul Brutus, MD, Carlos Cordoba, MD, Hugo E. Ciaburro, MD, Andreas Nikolis, MD
Affiliation:	Centre Hospitalier de l'Université de Montréal, Hôpital Notre-Dame, Montreal, QC

PURPOSE: The use of perioperative antimicrobial prophylaxis is widespread in plastic surgery when attempting to reduce the incidence of surgical site infections (SSI). Data from prospective randomized controlled trials in guiding antibiotic use is lacking. The objective of this study was to evaluate plastic surgeon prescribing habits in a tertiary university center.

METHODS AND MATERIALS: A retrospective review in one center was conducted from April to June 2006. SSI rates, and clinical outcomes with and without antimicrobial prophylaxis, were determined for all patients.

RESULTS: The cumulative SSI rate was 8,09% for 173 procedures. The SSI rate for breast surgery was 20%, with an 82,5% prescription rate. For head and neck procedures, the SSI rate was 8,3%, with 83,3% of patients receiving antibiotic prophylaxis. For hand and upper limb procedures, 62,1% of patients received antimicrobial prophylaxis, with a 1,1% SSI rate. In evaluating patients according to category A prophylaxis guidelines, inappropriate prescribing was identified in 35,0% of breast, 30,5% of head and neck, and 8,1% of hand and upper limb procedures.

CONCLUSION: This is the first study evaluating appropriateness of antimicrobial prophylaxis use by plastic surgeons. Despite widespread use of perioperative prophylactic antibiotics, significant SSI rates were still present.

9:32 AM - 9:36 AM

Aged Rats Display Increased Ischemia-Reperfusion Skin Injury In The In Vivo Magnet Model

Presenter:	Leonard Lu, MD
Co-Authors:	David Rosenberg, Thomas Mustoe
Affiliation:	Northwestern University, Chicago, IL

Purpose Ischemia-reperfusion (I/R) injury is commonly associated with numerous pathologic conditions including pressure sores and lower extremity ulcers. The purpose of this study is to further investigate the relationship between age and I/R skin injury in a rat model.

Methods and Materials Magnets were placed subcutaneously in aged and young Fisher rats. A second magnet placed externally over the implanted magnet causes compressive ischemia, while removing the second magnet results in reperfusion. Four cycles of I/R injury were performed. Tissue was analyzed histologically, the degree of leukocyte infiltration was assessed, and myeloperoxidase levels were assayed.

Results Visual analysis of the skin revealed statistically significant greater areas of injury in the aged rats relative to their younger counterparts (p<.00012). Young animals demonstrated a greater degree of polymorphonuclear cell infiltration and higher levels of myeloperoxidase at the area of injury following the final reperfusion cycle.

Conclusions Aged rats demonstrate an increased degree of injury relative to younger counterparts in response to I/R injury. Future studies will attempt to delineate differences in the aged and young responses to I/R injury, and hence give insight to the mechanisms responsible for the impaired wound healing often seen in the elderly.

9:36 AM - 9:42 AM Discussion

9:42 AM - 10:12 AM

Break

Presenter:	No presenter
Affiliation:

10:15 AM - 10:19 AM

Arterial Conduit Graft Using the Deep Inferior Epigastric Artery and Vein Transposition for Revascularization of an Amputated Thumb

Presenter:	Jaime Haidenberg, MD
Co-Author:	Bradford W. Rockwell, MD
Affiliation:	University of Utah, Salt Lake city, UT

Introduction: This study presents an innovative revascularization technique for thumb replantation using arterial conduit and vein transposition. The technique is applicable in segmental injuries necessitating grafting. Methods: Retrospective analysis of all thumb replantations by a single surgeon between 1996 and 2004. Demographics of the patients, mechanism of injury, extent of injury, type of repair and outcome were evaluated. A complete description of the new surgical technique utilizing the deep inferior epigastric artery (DIEA) as an arterial conduit and vein transposition from the index finger will be presented. Results: Twelve patients with thumb amputations were treated. Six patients had segmental injuries and underwent arterial conduit graft and 6 patients underwent primary anastomosis. Of the 6 arterial conduit graft patients, 5 had the DIEA graft and one had an arterial transposition using the dorsal radial artery. Four of these patients required venous transposition from the index finger. Five arterial conduit patients had a crush or avulsion injury. Four patients in the arterial conduit group and five patients in the primary anastomosis group had successful replantations. No donor site complications were encountered. Conclusion: We present a safe and effective technique for segmental injury thumb replantations using an arterial conduit graft and venous transposition.

10:19 AM - 10:23 AM

Vascularized radius bone flap based upon the radial artery for the treatment of non-union scaphoid fractures

Presenter:	Keith Hurvitz, MD
Co-Authors:	Michael P. McConnell, MD, Kevin A. Brenner, MD, Gregory R. D. Evans, MD, Mark Kobayashi, MD, Raffi Karamanoukian, MD, Donald Bittner, MD
Affiliation:	University of California Irvine, Orange, CA

Fractures of the scaphoid bone are inherently susceptible to non-union healing. The blood supply to the bone can become disrupted following trauma and result in a chronically unstable fracture site. This in turn can be the source of long standing wrist pain and compromised function. We wish to describe our experience with scaphoid non-union reconstruction using a reverse vascularized radius bone flap based upon the radial artery. We have successfully performed this reverse flow pedicle flap procedure on 3 patients with scaphoid non-union fractures. No peri-operative complications have been encountered. Post-operatively all patients have displayed clinical and radiographic evidence of bony union across the fracture sites.

10:23 AM - 10:27 AM

Inhibition of Vibration-Induced Microvessel Damage by D-4F

Presenter:	David J. Rowe, MD
Co-Authors:	Gi Geng Yan, Lin Ling Zhang, DA Riley, KA Pritchard, HS Matloub
Affiliation:	Medical College of Wisconsin, Milwaukee, WI

Purpose: This study investigates the efficacy of D-4F, an apolipoprotein A-1 mimetic with antioxidant and vasodilatory properties, in preventing vibration-induced endothelial cell damage. Methods: Forty S-D rats were assigned to five groups: sham and D-4F groups with vibration for either one or three days, as well as a non-treatment, non-vibration control. Intraperitoneal injections of saline or 3 mg/kg D-4F were given one hour prior to experiment and continued for the study period. Tails received 4 h/day of vibration for one or three days. Injury was determined by light microscopy, electron microscopy, NFATc3 immunostaining, nitrated tyrosine levels, and morphometric analysis. Results: Vacuolar changes were seen at one day and loss of endothelial cells at three days of vibration; minimal damage was seen in the D-4F group. Vasoconstriction in control groups was stastically significant when compared to D-4F groups at one and three days. Stastically increased immunostaining and levels of nitrated tyrosine, markers of cell injury, were seen in contol groups when compared to D-4F. Conclusion: This study has shown that D-4F reduces early endothelial cell damage in rat tails exposed to vibration injury. This indicates that vasoprotective agents may be beneficial in the prevention of hand arm vibration syndrome.

10:27 AM - 10:32 AM Discussion

10:32 AM - 10:36 AM

The Deep Inferior Epigastic Artery: Anatomy and Applicability as a Source of Microvascular Arterial Grafts

Presenter:	Joseph K. Ku, MD
Co-Authors:	W. Bradford Rockwell, MD, K. Bo Foreman, PhD
Affiliation:	University of Utah, Salt Lake City, UT

Background: Arterial grafts are used routinely by cardiovascular surgeons as an ideal conduit. Veins are used as ideal conduits in the lower extremities by vascular surgeons, but microvascular surgeons have not yet agreed on the ideal conduit for use in microvascular bypass surgery. We propose the deep inferior epigastric artery (DIEA) as a preferred conduit.

Materials and Methods: We conducted an anatomical study using preserved cadavers. Sixty-three deep inferior epigastric arteries (DIEA) were dissected from 34 cadavers. The artery was dissected from its origin, and was followed proximally until the external diameter decreased to one millimeter.

Results: The mean length was 14.06 cm (SD 2.54), while the diameter of the origin had a mean of 2.94 mm (SD 0.44). The DIEA has been used in seven clinical cases as an arterial conduit to bypass distal to the wrist. All seven bypasses were patent one year post-operatively, without donor site complications.

Conclusion: The DIEA is a morphologically reliable source of arterial grafts. The advantages include anatomic taper, improved size match, better handling characteristics, and superior patency.

10:36 AM - 10:40 AM

Outcomes Using an Internal Osteotomy and Distraction Device for Corrective Osteotomy of Distal Radius Malunions Requiring Correction in Multiple Planes

Presenter:	Douglas M. Sammer, MD
Co-Author:	Kevin C. Chung, MD
Affiliation:	University of Michigan, Ann Arbor, MI

Many methods have been proposed for correction of distal radius malunions. However, correction of a malunion that requires simultaneous adjustment of angulation and rotation in multiple planes is difficult. This is a prospective study that measures radiographic and functional outcomes using an internal osteotomy, distraction and fixation system for severe distal radius malunions. Five patients with distal radius malunions requiring correction in multiple planes were recruited. All underwent correction using the above device. Radiographic and functional outcomes were measured pre- and post-operatively. All radiographic measurements improved. Grip and pinch strength, and the Jebsen-Taylor test showed marginal improvement. Ulnar deviation and pronation-supination improved, but wrist flexion-extension did not. The Michigan Hand Outcomes Questionnaire (MHQ) showed improvement in all domains, particularly in overall, work, aesthetic and satisfaction domains (p<0.05). However, the MHQ still demonstrated residual impairment in all domains. Corrective osteotomy using this device resulted in improvement in distal radius anatomy and in function. But not all improvements were statistically significant, and anatomy and function were not returned to baseline. In spite of residual disability, patients noted subjective improvement. This system useful for improving anatomy and function, but patients should be informed that they cannot expect to regain normal anatomy or function.

10:40 AM - 10:44 AM

Botox Therapy for Ischemic Digits

Presenter:	Jessica N. Gillespie, MD
Co-Authors:	Chris Chambers, PhD, Michael W. Neumeister, MD
Affiliation:	Southern Illinois University, Springfield, IL

Purpose: The purpose of this study was to report our clinical experience in treating patients with Raynaud's phenomenon and chronic digital ulcerations with botulinum toxin-A (Botox®). We also report the results of tissue bath experiments performed to determine if Botox has a direct effect on vascular tone.

Methods: Five patients with painful, chronic ischemic ulcers secondary to advanced Raynaud's disease were treated with 50-100 units of Botox injectected around the neurovascular bundles in the palm. Improvement in peripheral blood flow was documented using laser Doppler imaging pre and post injection. In vitro tissue bath experiments were conducted in the laboratory to determine if Botox had a direct effect on vascular tone.

Results: All patients had dramatic improvement in pain symptoms, improvement of vascular mottling and significant healing of ulcerations. Laser Doppler analysis revealed up to 300% increase in perfusion in some digits. Our tissue bath studies failed to show a direct effect of Botox on vascular tone. The mechanisms behind the increased peripheral perfusion seen and relief of pain symptoms are unknown but may be related to effects of Botox on the autonomic system and the blockade of nociceptive neuropeptides.

10:44 AM - 10:49 AM Discussion