J. Jared Christophel

Reinforcement of cell junctions correlates with the absence of hair cell regeneration in mammals and its occurrence in birds.

Debilitating hearing and balance deficits often arise through damage to the inner ears hair cells. For humans and other mammals, such deficits are permanent, but nonmammalian vertebrates can quickly recover hearing and balance through their innate capacity to regenerate hair cells. The biological basis for this difference has remained unknown, but recent investigations in wounded balance epithelia have shown that proliferation follows cellular spreading at sites of injury. As mammalian ears mature during the first weeks after birth, the capacity for spreading and proliferation declines sharply. In seeking the basis for those declines, we investigated the circumferential bands of F‐actin that bracket the apical junctions between supporting cells in the gravity‐sensitive utricle. We found that those bands grow much thicker as mice and humans mature postnatally, whereas their counterparts in chickens remain thin from hatching through adulthood. When we cultured utricular epithelia from chickens, we found that cellular spreading and proliferation both continued at high levels, even in the epithelia from adults. In contrast, the substantial reinforcement of the circumferential F‐actin bands in mammals coincides with the steep declines in cell spreading and production established in earlier experiments. We propose that the presence of thin F‐actin bands at the junctions between avian supporting cells may contribute to the lifelong persistence of their capacity for shape change, cell proliferation, and hair cell replacement and that the postnatal reinforcement of the F‐actin bands in maturing humans and other mammals may have an important role in limiting hair cell regeneration. J. Comp. Neurol. 511:396–414, 2008.

A randomized controlled trial of fractional laser therapy and dermabrasion for scar resurfacing.

Background Dermabrasion has been the standard resurfacing procedure for postsurgical scars, but recovery can be long. Fractionated carbon dioxide (CO2) laser is a safe, effective tissue resurfacing modality, but no prospective trial has compared its safety or efficacy with that of dermabrasion for postsurgical scar resurfacing. Objective To compare the safety and efficacy of single‐treatment fractional photothermolysis with that of single‐treatment dermabrasion for postsurgical scar resurfacing on the face. Methods and Materials A split‐scar method was used to compare fractionated CO2 laser and diamond fraise dermabrasion on postsurgical scars of the face. Primary endpoint was safety at day 0, 1 week, and 1 month. Secondary endpoint was efficacy at 3 months as measured by blinded evaluation of standardized photographs. Results Safety data revealed that there was less erythema (p = .001) and bleeding (p = .001) at day 0, less erythema (p = .01) and edema (p = .046) at 1 week, and a trend toward less erythema at 1 month (p = .06) with fractionated CO2. Efficacy data at 3 months revealed equivalent scar improvements (p = .77). Conclusion Fractionated CO2 laser therapy should be considered a safe alternative for surgical scar resurfacing on the face. The safety profile exceeds that of dermabrasion, and it has a quicker clinical recovery and equivalent cosmetic efficacy.

Osseocartilaginous Rib Graft Rhinoplasty: A Stable, Predictable Technique for Major Dorsal Reconstruction

OBJECTIVE To assess the long-term stability of osseocartilaginous dorsal onlay rib grafts used for augmentation rhinoplasty. METHODS Patients who had rib grafts used for augmentation rhinoplasty from 2000 through 2009 were assessed for graft viability, graft mobility, graft warping, maintenance of dorsal projection, functional airway status, need for revision surgery, and donor site morbidity. A retrospective cohort study using telephone follow-up was conducted. RESULTS A total of 58 rib graft rhinoplasties were performed in the 10-year review period, 39 of which used dorsal onlay grafts. The mean duration of clinical follow-up was 24 months, and the median duration of clinical follow-up was 16 months. Thirty-three of 33 osseocartilaginous onlay grafts (100%) and 5 of 6 cartilaginous onlay grafts (83%) were viable, rigid, and had maintained dorsal projection at last follow-up. None of the grafts warped. Twenty-nine of 33 patients receiving osseocartilaginous onlay grafts (88%) and 5 of 6 patients receiving cartilaginous onlay grafts (83%) had persisting relief of their nasal obstruction. Twelve of the 39 patients (30%) had revision surgery, mostly performed for minor cosmetic revision. CONCLUSIONS Osseocartilaginous onlay rib grafts provide an ideal scaffold for dorsal nasal augmentation and restoration of nasal airway in patients with collapse of the nasal framework due to a saddle deformity, history of trauma, or history of multiple septorhinoplasties. The graft has excellent viability, lacks potential for long-term warping, achieves bony fusion to the nasal bones, and allows surgical molding of the cartilaginous tip.

Current Concepts of Bone Tissue Engineering for Craniofacial Bone Defect Repair

Craniofacial fractures and bony defects are common causes of morbidity and contribute to increasing health care costs. Successful regeneration of bone requires the concomitant processes of osteogenesis and neovascularization. Current methods of repair and reconstruction include rigid fixation, grafting, and free tissue transfer. However, these methods carry innate complications, including plate extrusion, nonunion, graft/flap failure, and donor site morbidity. Recent research efforts have focused on using stem cells and synthetic scaffolds to heal critical-sized bone defects similar to those sustained from traumatic injury or ablative oncologic surgery. Growth factors can be used to augment both osteogenesis and neovascularization across these defects. Many different growth factor delivery techniques and scaffold compositions have been explored yet none have emerged as the universally accepted standard. In this review, we will discuss the recent literature regarding the use of stem cells, growth factors, and synthetic scaffolds as alternative methods of craniofacial fracture repair.

Complications in Rhinoplasty

The surgical maneuvers employed in aesthetic rhinoplasty can result in unforeseen structural complications that lead to an unsatisfied patient. Many of these problems arise years after the primary surgery and include both aesthetic and functional losses. Contemporary rhinoplasty should always be designed with long-term perspective and an eye on possible untoward outcomes. This article discusses the anatomic and physiologic basis of rhinoplasty complications with a focus on primary rhinoplasty principles that will prevent their formation.

Predicting positive margins in resection of cutaneous melanoma of the head and neck.

Head and neck melanoma surgeons must achieve negative margins before performing margin compromising reconstructions such as a local flap closure. This often necessitates staged operations, including further margin resection. Peripheral sampling is often used before definitive resection to help guide the extent of the resection. If melanoma margin status could be predicted based on lesion characteristics, the surgeon could be more confident in performing definitive closure immediately after resection of some lesions or confident in the need to take larger margins in predictably extensive lesions.

Cost-Based Decision Analysis of Postreduction Imaging in the Management of Mandibular Fractures

IMPORTANCE Immediate postreduction imaging is a standard practice in the management of mandibular fractures at many hospitals. However, the literature suggests that postreduction imaging in maxillofacial fractures fails to influence clinical decision making significantly. OBJECTIVES To determine the cost-effectiveness of different clinical decision pathways regarding postreduction imaging as it relates to the experience of the surgeon, and to demonstrate that baseline postreduction imaging has utility based on the complication rate of the surgeon. DESIGN, SETTING, AND PARTICIPANTS We developed a decision tree model using commercially available software. The model accounted for cost of imaging modalities, adequacy of reduction, complication rate, cost of initial operating room time, and, if applicable, operative charges for revision surgery in the event of a complication. A review of the University of Virginia clinical data repository of 100 patients with recent mandible fractures was used to estimate the cost associated with running an operating suite for mandibular fracture repair. The University of Virginia billing system also provided costs associated with a single computed tomogram, panoramic radiography, and intraoperative 3-dimensional computed tomography. A sensitivity analysis determined how variation in complication rate affects the cost of the decision pathways. INTERVENTION Intraoperative imaging, postreduction imaging, or no imaging. MAIN OUTCOMES AND MEASURES Sensitivity of the decision tree model to variation in complication rate. RESULTS Using current hospital charges, the model is sensitive to variability in the complication rate with a breakpoint of 17.7%. It is most cost-effective to obtain a post-reduction panorex if the surgeons complication rate is above 17.7% and most cost-effective not to obtain any postreduction imaging if the complication rate is below 17.7%. Intraoperative computed tomography is not cost-effective at any complication rate. Two-way sensitivity analysis allowed the model to be generalizable to varied institutional costs and surgical complication rates. CONCLUSIONS AND RELEVANCE The utility of postreduction imaging from the standpoint of cost analysis depends on the complication rate of the facial traumatologist and institutional charge data. Based on this model, the facial traumatologist at our institution should obtain postreduction panorex imaging for patients with mandible fractures until their complication rate drops below 17.7%. The 2-way sensitivity analysis in this study allows the facial traumatologist to apply his or her complication rate and institutional cost data to determine whether routine postreduction imaging is necessary. LEVEL OF EVIDENCE NA.

Regenerative Medicine in Facial Plastic and Reconstructive Surgery: A Review

The field of regenerative medicine aims at enhancing tissue healing and regeneration through the exogenous addition of therapeutic growth factors and cells, often in combination with tissue-compatible scaffolds. Perhaps the biggest advances in facial plastic and reconstructive surgery (FPRS) in the coming years will be the result of regenerative medicine techniques. While many articles on regenerative medicine have been published in the FPRS literature, to our knowledge there are no reviews that describe both soft-tissue and bony regeneration strategies, including scaffolds, stem cells, growth factors, and platelet-rich plasma. In reviewing the literature, we found that these strategies have produced very promising results and that regenerative medicine has the potential to augment conventional treatment options in the FPRS subspecialty. In the near future, these novel approaches may begin to replace autologous grafting and free tissue transfer in FPRS, the current standards of care. In this review we look at where our subspecialty is today with regard to regenerative medicine and suggest ways for future study and growth.

A Facial Trauma Simulation Course for Evaluation and Treatment of Facial Fractures

Importance Traditional facial trauma laboratories are used for teaching basic concepts of fracture reduction and hardware manipulation. Facial trauma simulation laboratories allow training physicians the opportunity to develop unique treatment plans as they would in real patient encounters. Objective To assess the value of a novel facial trauma simulation course requiring residents to practice advanced decision making. Design, Setting, and Participants Data were prospectively collected July 23 and August 23 and 24, 2016, in a survey study during a resident physician trauma simulation course. Fresh frozen cadaver heads were fractured using an impactor that applied a measurable amount of force. Each head was scanned with high-resolution computed tomography. Residents were paired and tasked with evaluating their specimen’s imaging findings and developing a treatment plan. Main Outcomes and Measures Before the course, residents were asked their postgraduate year level, number of facial fractures treated as a resident surgeon, and their comfort level based on the Otolaryngology Milestone for Facial Trauma (OMFT; ratings range from 0-5, with 5 indicating equivalent to fellow-level experience). After the course, residents were asked to assess the course’s value relative to a theoretical number of actual operative cases, and a posttraining OMFT assessment was obtained. Results Thirty resident physicians completed the course at 2 institutions. Residents represented an equivalent distribution of postgraduate year levels. The residents stated that the course was worth a mean (SD) of 6.4 (2.8) operative cases of facial trauma in terms of surgical learning. The mean change in self-reported OMFT rating after the course was 0.87 (95% CI, 0.67-1.07; P < .001, paired t test). On the basis of this change in self-perceived OMFT rating, the course was deemed to be worth 1.5 years of residency training in the management of facial fractures. Conclusion and Relevance Conducting a facial trauma simulation course increases resident experience with advanced surgical decision making. Level of Evidence NA.

Histopathologic margin distance in survival in resection of cutaneous melanoma of the head and neck

Treatment of cutaneous melanoma involves surgical excision with wide clinical margins. No guidelines regarding safe histopathologic margin distance exist. This study examines the impact of histopathologic margin, measured from closest cut edge of the specimen, on overall survival in resection of cutaneous melanoma of the head and neck. We hypothesize that close histopathologic margins (<2 mm) are associated with decreased survival.