Joubin S. Gabbay

Autologous fat transfer national consensus survey: trends in techniques for harvest, preparation, and application, and perception of short- and long-term results.

Background: Despite a perceived interest in autologous fat transfer, there is no consensus as to the best technique or the level of success. The purpose of the present study was to determine the national trends in techniques for harvest, preparation, and application of autologous fat, as well as the success perceived by practitioners. Methods: Comprehensive surveys were sent to 650 randomly selected members of the American Society for Aesthetic Plastic Surgery. The survey was aimed at determining whether autologous fat transfer is a commonly performed procedure and, if so, the specific methods involved and the subjective perception of short- and long-term results. Results: The results of the national consensus survey from 508 surgeons (78 percent return rate) showed the following: (1) autologous fat transfer is a relatively common procedure (57 percent perform >10 annually), but few perform it in high volume (only 23 percent perform >30 annually); (2) techniques for harvest, preparation, and injection rarely deviate from methods discussed in the literature (microcannula, 54 percent; centrifugation, 75 percent; injection in nasolabial fold > lips > nasojugal folds); (3) most physicians believe that at least some graft survival is clinically evident (93 percent); and (4) patients are pleased with the short-term results (good to excellent, 84 percent), despite a lower rate of long-term patient satisfaction (fair to good, 80 percent). Conclusion: Currently, plastic surgeons across the country report a uniformity of autologous fat grafting techniques with acceptable patient satisfaction.

Reduced Morbidity and Improved Healing with Bone Morphogenic Protein-2 in Older Patients with Alveolar Cleft Defects

Background: In older cleft patients, alveolar bone grafting may be associated with poor wound healing, graft exposure, recurrent fistula, and failure of tooth eruption. A new procedure using a resorbable collagen matrix with bone morphogenetic protein (BMP)-2 was compared with traditional iliac crest bone graft to close alveolar defects in older patients. Methods: Skeletally mature patients with an alveolar cleft defect undergoing alveolar cleft repair were divided into either group 1 (BMP-2, experimental) or group 2 (traditional iliac graft, control) (n = 21). Bone healing was assessed with intraoral examination and NewTom scans (three-dimensional, Panorex, periapical films). Donor-site morbidity was determined with pain surveys. Overall cost and length of hospital stay were used to examine economic differences. Results: Preoperative and follow-up (1 year) intraoral examinations revealed fewer complications (11 percent versus 50 percent) and better estimated bone graft take in group 1 compared with group 2. Panorex and three-dimensional computed tomographic scans showed enhanced mineralization in group 1 compared with group 2. Volumetric analysis showed group 1 had a larger percentage alveolar defect filled with new bone (95 percent) compared with group 2 (63 percent). Donor-site pain intensity and frequency were significant in group 2 but not group 1. The mean length of stay was greater for group 2 compared with group 1. In addition, the mean overall cost of the procedure was greater in group 2 (

Repair of Alveolar Cleft Defects: Reduced Morbidity With Bone Marrow Stem Cells in a Resorbable Matrix

21,800) compared with group 1 (

Repair of large nasal septal perforations using facial artery musculomucosal (FAMM) flap.

11,100). Conclusions: For this select group of late-presenting alveolar cleft patients, the BMP-2 procedure resulted in improved bone healing and reduced morbidity compared with traditional iliac bone grafting.

Monobloc advancement by distraction osteogenesis decreases morbidity and relapse

Harvest of the autogenous iliac crest bone graft for an alveolar cleft defect (the gold standard) may cause short- and long-term pain and sensory disturbances. To determine if a tissue engineering technique with similar bone healing results offered decreased morbidity, we compared techniques for postoperative donor site pain. Traditional iliac crest bone graft had more donor site complications compared with both tissue engineering and minimally invasive iliac crest bone graft. With donor site pain, traditional had the most patients with pain and tissue engineering had the least patients with pain at all time points. The mean pain score, including both intensity and pain frequency, was greatest at all time points in traditional and least at all time points in tissue engineering. Closure of alveolar cleft defects with a resorbable collagen sponge and bone marrow stem cells resulted in reduced donor site morbidity and decreased donor site pain intensity and frequency.

Intracranial volume and cephalic index outcomes for total calvarial reconstruction among nonsyndromic sagittal synostosis patients.

Background:Nasal septum perforations from surgical submucous resection, septoplasty, blunt trauma, and substance abuse may cause epistaxis, nasal obstruction, discharge, crusting, dryness, pain, and whistling. While small symptomatic perforations are closed with local mucosal flaps, options for closure of large symptomatic perforations are limited. A local pedicled flap, the facial artery musculomucosal (FAMM) flap was studied in patients with large symptomatic nasal septal defects. Methods:Patients included in the study had (1) a nasal septal defect measuring at least 20 mm in greatest dimension; and (2) related symptoms of nasal crusting, discharge, dryness, obstruction, epistaxis, pain, or whistling. Six patients (3 males; 3 females) met these criteria and received FAMM flap repair. Outcomes were assessed based on comparison of preoperative versus last follow-up (range, 10–30 months; mean 17 months) assessment of perforation size and symptomatology. Overall discomfort was rated at each time point on a 1–10 scale. Results:Age at time of operation ranged from 21 to 44 years, with a mean of 34 years of age. Causes of septal perforation included blunt trauma (50%), cocaine abuse (33%), and submucous resection (17%). Preoperatively, maximal recorded dimensions of septal perforations ranged from 3.1 to 4.0 cm with a mean of 3.5 ± 0.4 cm. Symptoms included pain (83%), dryness (67%), crusting (50%), discharge (33%), epistaxis (33%), and obstruction (33%). Three or more symptoms were experienced by 5 patients (83%). Overall discomfort ranged from 6–10, with a mean of 8.4. Postoperatively at last follow-up, all 6 patients (100%) achieved closure of their septal defect (P < 0.001). Overall discomfort score was zero for all 6 patients (100%) (P < 0.0001). Complete symptomatic resolution was also noted among all 6 patients (100%) (P < 0.01). Conclusions:In summary, the advantages of the FAMM flap closure technique were (1) no visible external scar, with minimal donor site morbidity; (2) successful closure of large septal defects (>2 cm) with vascularized tissue in a single stage; and (3) resolution of patient symptomatology.

Improved outcomes in cleft patients with severe maxillary deficiency after Le Fort I internal distraction

Background: Treatment of midface hypoplasia and forehead retrusion with monobloc advancement is associated with significant complications, including meningitis, prolonged intubation, and frontal bone flap necrosis. To see whether distraction of the monobloc segment offered decreased morbidity, the authors compared clinical outcomes of patients who underwent conventional monobloc advancement with those of patients who underwent monobloc distraction. Methods: Group 1 (conventional monobloc; n = 12) underwent traditional monobloc advancement with bone grafting. Group 2 (modified monobloc; n = 11) did not receive ventriculoperitoneal shunts and underwent the above procedures with placement of a pericranial flap and fibrin glue over the midline defect. Group 3 (monobloc distraction; n = 24) underwent advancement of the monobloc segment by distraction osteogenesis using internal distraction devices. Complications included meningitis, cerebrospinal fluid leak, frontal bone flap loss, and wound infection. Preoperative, postoperative, and follow-up lateral cephalograms were used to assess horizontal changes of the forehead, midface, and maxilla. Results: Group 3 (distraction monobloc) had the lowest complication rate (8 percent), followed by groups 2 (modified monobloc; 43 percent) and 1 (conventional monobloc; 61 percent) (p < 0.05). Group 3 achieved greater advancement (12.6 mm) than did group 2 (9.4 mm) or group 1 (9.1 mm) (p < 0.05). Relapse was least in group 3 (8 percent) compared with groups 2 (67 percent) and 1 (45 percent). Conclusions: Monobloc advancement by distraction osteogenesis had less morbidity and achieved greater advancement with less relapse compared with conventional methods of acute monobloc advancement with bone grafting. Monobloc distraction is superior to conventional methods of acute monobloc advancement and is an alternative to staged fronto-orbital advancement followed by Le Fort III advancement.

Osteogenic potentiation of human adipose-derived stem cells in a 3-dimensional matrix.

Background: Controversy abounds as to how craniosynostosis affects intracranial volume and whether more extensive procedures achieve superior results. Intracranial volume and cephalic index were evaluated among nonsyndromic sagittal synostosis patients undergoing cranioplasty. Methods: Twenty-four children with isolated nonsyndromic sagittal synostosis underwent a total calvarial reconstruction. Volume and cephalic index measurements were taken 1 month preoperatively, 1 month postoperatively, and at 1-year follow-up. Data obtained were compared against normative value curves, and interval shifts between curve SD ranges were noted. The absolute percentage difference between the observed intracranial volume or cephalic index and the correlated normative mean value (absolute mean percentages) was calculated for each scan. Results: Preoperatively, intracranial volume for patients younger than 30 months (n = 19) was within the normal range (±1 SD), whereas it exceeded 1 SD in all patients older than 30 months (n = 5). Postoperatively and at follow-up, intracranial volume range was unchanged for patients younger than 30 months but was decreased to normal for 60 percent of those older than 30 months. Absolute mean volume percentage showed a small increase from preoperatively for patients younger than 12 months (p < 0.05), no change for patients aged 12 and 30 months, and decreased for patients older than 30 months (p < 0.05). Postoperatively, all patients demonstrated a normal intracranial volume growth rate. As for cephalic index, preoperatively, 92 percent of patients fell below the minimum normal values. At follow-up, 100 percent had a cephalic index in the normal range (p < 0.05). Conclusions: Nonsyndromic sagittal synostosis results in an age-dependent increased intracranial volume and decreased cephalic index. Total calvarial reconstruction (1) appears to allow for the expansile forces of the growing brain to be distributed and may relieve an underlying abnormality; (2) does not affect postoperative intracranial volume growth rate; and (3) enables normalization of cephalic index.

Genioplasty distraction osteogenesis and hyoid advancement for correction of upper airway obstruction in patients with treacher collins and nager syndromes

Background: Correction of severe maxillary deficiency in cleft lip–cleft palate patients often results in undercorrection, relapse, and need for secondary corrective procedures. Le Fort I internal distraction osteogenesis offers an alternative to one-step orthognathic advancement, with advantages of gradual lengthening through scar and earlier treatment in growing patients. Methods: Patients with cleft lip–cleft palate deformities and maxillary deficiency were divided into three groups treated by Le Fort I advancement: group 1, mild to moderate deficiency (<10 mm) with conventional orthognathic procedure; group 2, severe deficiency (≥10 mm) with conventional orthognathic procedure; and group 3, distraction procedure for severe deficiency (≥10 mm) (n = 51). Preoperative, postoperative, and follow-up (>1 year) lateral cephalogram measurements were compared including angular (SNA and SNB) and linear (&Dgr;x = horizontal and &Dgr;y = vertical) changes. The Pittsburgh Speech Score was used to assess for velopharyngeal insufficiency (score >3). Results: Results demonstrated that group 1 patients had a mean SNA change from preoperatively (78.7) to postoperatively (83.8), and a horizontal change of 5.0 mm, with no relapse. Group 2 patients had a mean SNA change from preoperatively (76.3) to postoperatively (82.0) and a horizontal change of 7.2 mm, with 63 percent relapse. Group 3 patients had a mean SNA change from preoperatively (74.1) to postoperatively (84.9) and a horizontal change of 16.5 mm, with 15 percent relapse. Thus, for severe maxillary deficiency, the distraction group had 48 percent less relapse than the conventional Le Fort I group. Postoperative speech evaluation showed velopharyngeal insufficiency in the following: group 1, four of 20 patients (20 percent); group 2, nine of 11 patients (82 percent); and group 3, nine of 20 patients (45 percent). Conclusion: These data suggest that Le Fort I internal distraction for severe cleft maxillary deficiency leads to better dental occlusion, less relapse, and better speech results.

Improved ankyloglossia correction with four-flap Z-frenuloplasty.

Adipose-derived stem cells (ADSCs) hold promise for use in tissue engineering. Despite growing enthusiasm for use of ADSCs, there is limited research that has examined their behavior in different in vitro and in vivo systems. The purpose of our study was to evaluate the effect of the extracellular matrix structure and composition on osteogenic differentiation by comparing the osteogenic marker expression of ADSCs grown under 2-dimensional or 3-dimensional cell culture conditions. Group 1 (2-D) included ADSCs raised under conventional cell culture conditions (cells in a 2-D monolayer configuration) (n = 24), and group 2 (3-dimensional) included ADSCs seeded in a collagen gel (cells within a 3-dimensional, biologically active environment) (n = 24). Comparison of ADSC behavior between the 2 groups was analyzed during a 14-day time frame. Osteogenic marker expression (CBFA-1, alkaline phosphatase, osteonectin, osteopontin, Collagen I, and JNK2) was quantified by real-time PCR, and histologic analysis was performed. Histologically, group 1 (2-D) showed cell spreading and deposition of a calcified extracellular matrix. Group 2 (3-dimensional) assumed a disorganized state in the collagen gel, with extension of pseudopodia throughout the matrix. Expression of CBFA-1 was up-regulated immediately in both groups. However, cells in group 2 (3-dimensional) had a more rapid and greater overall expression compared with cells in group 1 (2-D) (250-fold greater at 4 days). At day 14, cells in group 2 (3-dimensional) showed greater expression of all other osteogenic markers than cells in group 1 (2-D) (2.3-fold greater expression of alkaline phosphatase [P < 0.05], 8.4-fold greater expression of osteonectin [P < 0.05], 6.4-fold greater expression of osteopontin [P < 0.05], 2.9-fold greater expression of collagen I [P < 0.05], and 2.5-fold greater expression of JNK2 [P < 0.05]). Our data showed there was a progressive stimulatory effect on ADSCs with regard to osteogenesis when cultured in a 3-dimensional gel compared with a 2-D monolayer.