Michael P. Grant

Twenty-six-year experience treating frontal sinus fractures: a novel algorithm based on anatomical fracture pattern and failure of conventional techniques.

Background: Frontal sinus fracture treatment strategies lack statistical power. The authors propose statistically valid treatment protocols for frontal sinus fracture based on injury pattern, nasofrontal outflow tract injury, and complication(s). Methods: An institutional review board–approved retrospective review was conducted on frontal sinus fracture patients from 1979 to 2005. Fractures were categorized by location, displacement, comminution, and nasofrontal outflow tract injury. Demographic data, treatment, and complications were compiled. Results: One thousand ninety-seven frontal sinus fracture patients were identified; 87 died and 153 were excluded because of insufficient data, leaving a cohort of 857 patients. The most common injury was simultaneous displaced anteroposterior walls (38.4 percent). Nasofrontal outflow tract injury constituted the majority (70.7 percent), with 67 percent having a diagnosis of obstruction. Of the 857 patients, 504 (58.8 percent) underwent surgery, with a 10.4 percent complication rate; and 353 were observed, with a 3.1 percent complication rate. All complications except one involved nasofrontal outflow tract injury (98.5 percent). Nasofrontal outflow tract injuries with obstruction were best managed by obliteration or cranialization (complication rates: 9 and 10 percent, respectively). Fat obliteration and osteoneogenesis had the highest complication rates (22 and 42.9 percent, respectively). The authors’ treatment algorithm provides a receiver operating characteristic area under the curve of 0.8621. Conclusions: A frontal sinus fracture treatment algorithm is proposed and statistically validated. Nasofrontal outflow tract involvement with obstruction is best managed by obliteration or cranialization. Osteoneogenesis and fat obliteration are associated with unacceptable complication rates. Observation is safe when the nasofrontal outflow tract is intact.

Molecular profiling of human mammary gland links breast cancer risk to a p27(+) cell population with progenitor characteristics.

Early full-term pregnancy is one of the most effective natural protections against breast cancer. To investigate this effect, we have characterized the global gene expression and epigenetic profiles of multiple cell types from normal breast tissue of nulliparous and parous women and carriers of BRCA1 or BRCA2 mutations. We found significant differences in CD44(+) progenitor cells, where the levels of many stem cell-related genes and pathways, including the cell-cycle regulator p27, are lower in parous women without BRCA1/BRCA2 mutations. We also noted a significant reduction in the frequency of CD44(+)p27(+) cells in parous women and showed, using explant cultures, that parity-related signaling pathways play a role in regulating the number of p27(+) cells and their proliferation. Our results suggest that pathways controlling p27(+) mammary epithelial cells and the numbers of these cells relate to breast cancer risk and can be explored for cancer risk assessment and prevention.

The buccal fat pad flap for periorbital reconstruction: a cadaver dissection and report of two cases.

The buccal fat pad is a trilobed collection of adipose tissue found in the midface. It is located behind the zygomatic arch, medial to the masseter muscle and lateral to the buccinator muscle from which it derives its name.1–4 It consists of a body and four processes: the buccal, pterygoid, superficial, and deep temporal.1–3 The body lies behind the zygomatic arch and the processes extend from the body to their respective surrounding tissue spaces.4 The buccal fat pad has recently been described as having three lobes: an anterior lobe, an intermediate lobe, and a posterior lobe.4 The pad receives an abundant vascular supply from three well-defined sources, namely, the facial and internal maxillary arteries and the deep transverse facial vessels.2,4 The major vascular supply enters the posterior lobe, requiring that this lobe remain attached when the buccal fat pad is used as a pedicled flap. Notably, the size of the pad remains relatively constant from childhood throughout adulthood, and it appears to be resistant to wasting even in the most cachectic patients. The buccal fat pad has been proposed to have a number of native functions. It fills the masticatory space and has traditionally been suggested to have a role in mastication and suckling, especially in the newborn. The pad functions as a gliding pad during the contraction of the masticatory and mimetic muscles.4 In addition, it protects the deep facial neurovascular bundles from outside forces as well as from extrusion of muscle contraction. It may serve as a venous network involved in cranial blood flow through the pterygoid plexus.5 Despite these various proposed functions, the buccal fat pad can be safely sacrificed in the adult patient. Clinically, the buccal fat pad has been used for aesthetic and reconstructive applications.1–3,6,7,8–11 In cosmetic surgery, buccal fat pad lipectomy has been used to improve midface width in full-faced individuals.6–8 Similarly, buccal fat pad removal has been used alone and in conjunction with face lift surgery to modify facial contours and enhance the malar prominence.2,6,8,9 In addition, it has been described in rhytidectomy for improvement of the nasolabial fold.4 As early as 1977, the reconstructive use of a pedicled buccal fat pad flap was described by Egyedi10 for the closure of oroantral and oronasal communications following oncologic resection. In 1983, Neder11 elucidated its use as a free graft for the oral cavity. A number of other studies have further described the use of buccal fat pad flaps and grafts for the reconstruction of intraoral defects. The versatility of the buccal fat pad is evident from the variety of other novel reconstructive uses that have been described, including coverage of irregularities following bony trauma, closure of nasal defects, and use as vascularized filler material.3,10,11 There is, however, no literature describing its use in orbital reconstruction. Using a cadaver study, we demonstrate that the buccal fat pad can be reliably mobilized to provide sufficient coverage for orbital reconstructions. In addition, we present two case

Abstract: Quantifying Indocyanine Green Concentration to Measure Direct Tissue Perfusion

reliability. We had minor mechanical issues: capturing angle of smart device getting displaced; device getting knocked off the table; and charge cord dislodging. Auto-lock needs to be turned off on the capturing smart device. On one occasion, the camera app needed restarting due to automatic software update. These glitches were each corrected by a phone call to the nurse or by the provider in person. For one flap, nursing over-sedated the patient leading to profound hypotension. The steady decline in the laser Doppler reading witnessed by the surgeon remotely allowed him the opportunity to rapidly return to the ICU to resuscitate the patient, thus avoiding anastomotic thrombosis from hypoperfusion.