Anuja K. Antony

Virtual 3D planning and guidance of mandibular distraction osteogenesis

We present a system for 3D planning and pre-operative rehearsal of mandibular distraction osteogenesis procedures. Two primary architectural components are described: a planning system that allows geometric bone manipulation to rapidly explore various modifications and configurations, and a visuohaptic simulator that allows both general-purpose training and preoperative, patient-specific procedure rehearsal. We provide relevant clinical background, then describe the underlying simulation algorithms and their application to craniofacial procedures.

Bilateral implant breast reconstruction outcomes, predictors, and matched cohort analysis in 730 2-stage breast reconstructions over 10 years

BackgroundRates of bilateral implant breast reconstruction (BI/BR) are rising despite the lack of precise information. Previous studies have examined unilateral reconstruction, making it difficult to counsel patients regarding the risk of BI/BR. The purpose of this study was to identify the incidence of complications and predictors of unfavorable aesthetic outcomes in the largest study to date of exclusive 2-stage BI/BR. Furthermore, a novel matched cohort analysis was conducted in patients who underwent contralateral prophylactic mastectomy and therapeutic mastectomy, whereby each patient acts as her own perfect internal control. MethodsA retrospective chart review of consecutive patients who underwent BI/BR from 1997 to 2007 was performed to obtain patient demographics, treatment, and outcomes. Univariate and multivariate logistic regression analyses were performed to determine risk factors leading to the development of unfavorable aesthetic outcomes. &khgr;2 test and Fisher exact analysis were used for matched-pairs analysis. ResultsSeven hundred thirty 2-stage BI/BRs were performed in 365 patients; perioperative complication rates were low at 9.3%. Long-term outcomes/unfavorable aesthetics were rippling (12.7%), capsular contracture (8.4%), and malposition (7.8%). After regression analysis, age [odds ratio (OR), 1.05], radiation (OR, 4.27), and length of follow-up (OR, 1.48) were significantly associated with capsular contracture. Radiation (OR, 0.26) and body mass index (OR, 0.95) were inversely associated with rippling. In the matched cohort, complication rates were similar between sides with malposition and rippling as significantly different aesthetic outcomes (P < 0.05). Adjusted individual complication rates in the bilateral cohort of 18.4% were comparable with previous mixed and majority unilateral cohorts in the literature. ConclusionsBilateral implant breast reconstruction has become increasingly prevalent for patients with breast cancer. Overall complications are low; BI/BR does not appear to incur additive risk. Matched cohort analysis confirmed low complication rates with only malposition and rippling as significant differences between sides.

Upregulation of Neurodevelopmental Genes During Scarless Healing

Scarless fetal skin wound healing is a paradigm for ideal skin repair and is dependent on peripheral nerve function.To further explore neurogenic mechanisms influence on the scarless skin repair, fetal rats were wounded on gestational days 16 (E16; n = 24) and 18 (E18; n = 8) and wounds were harvested at 1 and 3 days after injury. Unwounded skin at identical gestational age was used for control comparison. The scarless E16 and scarring E18 wounds underwent macroarray gene expression analysis (1172 genes).During the scarless healing period, 53 (4.5%) genes had a statistically significant upregulation post-injury with at least a 2- to 3-fold change 1 day after wounding and 14 (1.2%) genes 3 days after wounding (P < 0.05). Many neurodevelopmental genes were increased during scarless repair on post-injury days 1 and 3. Neuropeptide Y Receptor type I, cJun related Transcription Factor (junD), Synaptophysin, SNAP 25, Neuronal calcium sensor 1 (NCS1), neural visine-like calcium binding protein 1 (NVP1), nerve growth factor-induced gene A (NGFI-A/EGR1), VGF8A protein, p27kip1, and members of the GABA and serotonin family each had 2- to 3-fold expression increases (P < 0.05).We speculate that fetal skin cells express neurotrophins during skin development that regulate peripheral neuron formation. During injury these factors promote the survival and regeneration of peripheral neurons; this interaction of neuropeptides, neuropeptide receptors, and neurotrophins may modulate the fetal scarless repair mechanisms in response to injury. Identification of these neurodevelopmental candidate genes provides insight for new investigation into mechanisms regulating scarless healing.

Technique of internal mammary dissection using pectoralis major flap to prevent contour deformities.

The internal mammary vessels are frequently used as recipient vessels for microvascular free-flap breast reconstruction. These vessels often require rib resection to adequately visualize the vessel anatomy and obtain exposure for anastomosis. Surgical resection of the rib can often lead to chest wall contour deformities. We describe a technique we have used over the last 6 years using elevation of a superiorly based pectoralis major flap to improve access to the internal mammary vessels without sacrificing aesthetic contour of the chest and breast.1 Our current approach to the internal mammary vessels is delineated in the Video Plus segment of this article (see Video, Supplemental Digital Content 1, which shows our current technique of internal mammary artery dissection, http://links. lww.com/A1109; Video 1). A synopsis of the technique contained in the video is as follows:

Free Microsurgical and Pedicled Flaps for Oncological Mandibular Reconstruction: Technical Aspects and Evaluation of Patient Comorbidities

Oncologic mandibular reconstruction has changed significantly over the years and continues to evolve with the introduction of newer technologies and techniques. Patient demographic, reconstructive, and complication data were obtained from a prospectively maintained clinical database of patients who underwent head and neck reconstruction at our institution. The free fibular flap is now considered the gold standard for mandibular reconstruction. However, in patients with multiple comorbidities, lengthy procedures may be less optimal and pedicled flaps, with specific modifications, can yield reasonable outcomes. Technical aspects and comorbidity profiles are examined in the oncological mandibular reconstruction cohort.

Current Advances for Aesthetic Improvement in Breast Reconstruction: Mimicking the Augmented Breast

Background: Women seeking implant-based breast reconstruction increasingly request a round, projecting breast with an amplified upper pole that mimics the augmented breast. Two-stage reconstruction provides the opportunity to recreate a well-defined inframammary fold (IMF) with ptosis, to modify final implant characteristics (volume upsizing, high profile, gel implants) and correct contour irregularities with lipofilling at exchange to achieve this desired outcome. Methods/Technique: All patients completing two-stage breast reconstruction were added prospectively into a database. Patient demographics, oncologic phenotype and treatment, surgical details including IMF reconstruction, implant characteristics, and outcomes were reviewed. 2D and 3D photos and intraoperative videography were captured, further illustrating the technique. Results: 84 two-stage breast reconstructions were completed in 50 women between 5/2010– 11/2013. Mean age at the time of mastectomy was 42.8 years and mean BMI was 30. At the time of exchange, the majority of implants were typically upsized from the final expansion volume, with a volume increase ranging from 10-150cc (mean increase 46cc). Mean expander fill volume and final implant volume were 595cc and 618cc respectively. Fifty-nine reconstructions (70%) included inframammary fold reinforcement. Sixty-eight (81%) of reconstructions utilized high profile or extra-high profile implants. Selective use of fat grafting was implemented later in the series. Conclusion: Current advances in two-stage implant based breast reconstruction are outlined to achieve upper pole fullness, anterior projection of the breast, and definition of the inframammary fold. These strategies afford reconstructive outcomes that parallel the desired aesthetic features of the augmented breast.

A Matched Cohort Study of Superomedial Pedicle Vertical Scar Breast Reduction (100 Breasts) and Traditional Wise-Pattern Breast Reduction (100 Breasts): An Outcomes Study over Three Years

Background: The superomedial pedicle (SMP) with vertical scar breast reduction (BR) is gaining popularity for its round, projecting breast and shorter incision when compared to the traditional Wise-pattern reduction using an inferior pedicle (IFP). However, there is paucity of large volume institutional outcomes studies after SMP/BR. The purpose of this study is to compare outcomes after SMP/BR and IFP/BR in the largest matched cohort study-todate.