Timothy W. King

A 12-year Anthropometric Evaluation of the Nose in Bilateral Cleft Lip–cleft Palate Patients following Nasoalveolar Molding and Cutting Bilateral Cleft Lip and Nose Reconstruction

Background: Patients with bilateral cleft lip–cleft palate have nasal deformities including reduced nasal tip projection, widened ala base, and a deficient or absent columella. The authors compare the nasal morphology of patients treated with presurgical nasoalveolar molding followed by primary lip/nasal reconstruction with age-matched noncleft controls. Methods: A longitudinal, retrospective review of 77 nonsyndromic patients with bilateral cleft lip–cleft palate was performed. Nasal tip protrusion, alar base width, alar width, columella length, and columella width were measured at five time points spanning 12.5 years. A one-sample t test was used for statistical comparison to an age-matched noncleft population published by Farkas. Results: All five measurements demonstrated parallel, proportional growth in the treatment group relative to the noncleft group. The nasal tip protrusion, alar base width, alar width, columella length, and columella width were not statistically different from those of the noncleft, age-matched control group at age 12.5 years. The nasal tip protrusion also showed no difference in length at 7 and 12.5 years. The alar width and alar base width were significantly wider at the first four time points. Conclusions: This is the first study to describe nasal morphology following nasoalveolar molding and primary surgical repair in patients with bilateral cleft lip–cleft palate through the age of 12.5 years. In this investigation, the authors have shown that patients with bilateral cleft lip–cleft palate treated at their institution with nasoalveolar molding and primary nasal reconstruction, performed at the time of their lip repair, attained nearly normal nasal morphology through 12.5 years of age.

Epidermal growth factor regulates NIKS keratinocyte proliferation through Notch signaling

BACKGROUND Cutaneous wound healing is a significant health issue in the US, often requiring skin grafts. StrataGraft (Stratatech Corporation, Madison, WI), a second-generation living human skin substitute created from NIKS human keratinocyte progenitors, was recently found to be a promising skin graft in phase I/II safety and efficacy clinical trial. NIKS proliferation is optimal in the presence of epidermal growth factor (EGF). Our preliminary data suggested that Notch signaling also plays a role in NIKS keratinocyte proliferation. Therefore, we hypothesized that EGF might stimulate NIKS proliferation by regulating Notch1 signaling. METHOD Notch1 messenger RNA (mRNA) levels from NIKS cells in monolayer culture were assessed by real-time polymerase chain reaction and Notch1 protein levels were detected by Western blot. To determine the role of EGF on Notch1 regulation, cells were incubated in basal media and then treated with EGF (10 ng/mL). A 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay was performed to test NIKS cell proliferation. Cells were grown in basal media supplemented with EGF for 72 h in the presence or absence of N-[N-(3,5-Difluorophenacetyl)-L-alanyl]-S-phenylglycine t-butyl ester (DAPT) (0-30 μM), an inhibitor of Notch1 signaling. RESULTS Notch1 mRNA levels were cell confluence-dependent, being more abundant in a subconfluent cell monolayer. We detected a 2-fold decrease in Notch1 mRNA expression and a reduction in active Notch1 protein level in response to EGF. EGF treatment stimulated NIKS cellular proliferation. However, co-treatment with DAPT inhibited NIKS proliferation to basal levels. Blocking Notch1 activation by DAPT alone inhibited NIKS cellular proliferation (P < 0.01%). CONCLUSION Our results suggest that Notch1 is an essential downstream mediator of NIKS cellular proliferation via the EGF signaling pathway.

Detection of flap venous and arterial occlusion using interstitial glucose monitoring in a rodent model.

Background: Free tissue transfer necessitates vigilant postoperative monitoring for vessel occlusion. Unfortunately, most monitoring methods require experienced personnel and are expensive to use. Furthermore, many tests have low sensitivity, low specificity, or significant delay between vessel occlusion and detection. The authors report on a novel method of tissue monitoring that avoids these limitations by tracking interstitial glucose concentration. Methods: Vertical rectus abdominis myocutaneous flaps were elevated in adult rats based on the superior epigastric vessels. Interstitial glucose within the flaps was monitored using a transcutaneous sensor. Interstitial glucose was recorded following arterial occlusion in 10 flaps and venous occlusion was recorded in eight flaps. Criteria for detecting vessel occlusion were developed based on interstitial glucose concentration and rate of change. Results: Occlusion of the flaps arterial supply led to a rapid decline in interstitial glucose. Within 15 minutes of arterial occlusion, the interstitial glucose in occluded flaps was significantly lower than in viable flaps (p = 0.0003). Occlusion of venous outflow resulted in a similar decline of interstitial glucose. Interstitial glucose below the animals euglycemic range was 100 percent sensitive (95 percent confidence interval, 78.1 to 100 percent) and 95.2 percent specific (95 percent confidence interval, 74.1 to 99.8 percent) for vessel occlusion. A fall in interstitial glucose greater than or equal to 7 mg/dl per minute was 100 percent sensitive (95 percent confidence interval, 78.1 to 100 percent) and 100 percent specific (95 percent confidence interval, 80.8 to 100 percent) for vessel occlusion. The delay between occlusion and detection was less than 30 minutes for all flaps. Conclusions: Interstitial glucose monitoring is highly sensitive and specific for vessel occlusion. This technology offers a rapid, inexpensive, and accurate method of monitoring free tissue transfers.

Obstructive Sleep Apnea in Adults: The Role of Upper Airway and Facial Skeletal Surgery.

Summary: Obstructive sleep apnea represents a large burden of disease to the general population and may compromise patient quality of life; workplace and automotive safety; and metabolic, cardiovascular, and neurocognitive health. The disease is characterized by repetitive cycles of upper airway collapse resulting from a lack of pharyngeal airway structural support and loss of muscle tone among upper airway dilators. Polysomnography serves as the gold standard for diagnosis of obstructive sleep apnea and the apnea-hypopnea index is the most commonly used metric for quantifying disease severity. Conservative treatments include lifestyle modification, continuous positive airway pressure treatment, and dental appliance therapy. Surgical treatment options include pharyngeal and facial skeletal surgery. Maxillomandibular advancement has been shown to be the most effective surgical approach for multilevel expansion of the upper airway and may significantly reduce an obstructive sleep apnea patient’s apnea-hypopnea index. Patient age, obesity, and the degree of maxillary advancement may be key factors contributing to treatment success.

A Real-Time Local Flaps Surgical Simulator Based on Advances in Computational Algorithms for Finite Element Models.

Background: This article presents a real-time surgical simulator for teaching three- dimensional local flap concepts. Mass-spring based simulators are interactive, but they compromise accuracy and realism. Accurate finite element approaches have traditionally been too slow to permit development of a real-time simulator. Methods: A new computational formulation of the finite element method has been applied to a simulated surgical environment. The surgical operators of retraction, incision, excision, and suturing are provided for three-dimensional operation on skin sheets and scalp flaps. A history mechanism records a user’s surgical sequence. Numerical simulation was accomplished by a single small-form-factor computer attached to eight inexpensive Web-based terminals at a total cost of

The Imperative of Academia in the Globalization of Plastic Surgery.

2100. A local flaps workshop was held for the plastic surgery residents at the University of Wisconsin hospitals. Results: Various flap designs of Z-plasty, rotation, rhomboid flaps, S-plasty, and related techniques were demonstrated in three dimensions. Angle and incision segment length alteration advantages were demonstrated (e.g., opening the angle of a Z-plasty in a three-dimensional web contracture). These principles were then combined in a scalp flap model demonstrating rotation flaps, dual S-plasty, and the Dufourmentel Mouly quad rhomboid flap procedure to demonstrate optimal distribution of secondary defect closure stresses. Conclusions: A preliminary skin flap simulator has been demonstrated to be an effective teaching platform for the real-time elucidation of local flap principles. Future work will involve adaptation of the system to facial flaps, breast surgery, cleft lip, and other problems in plastic surgery as well as surgery in general.

Discussion: Montreal children's hospital formula for nasoalveolar molding cleft therapy.

AbstractAlthough vertical health care delivery models certainly will remain a vital component in the provision of surgery in low-and-middle-income countries, it is clear now that the sustainability of global surgery will depend on more than just surgeons operating. Instead, what is needed is a comprehensive approach, that is, a horizontal integration that develops sustainable human resources, physical infrastructure, administrative oversight, and financing mechanisms in the developing world. We propose that such a strategy for development would necessarily involve an active role by academic institutions of high-income countries.

An Infant With a Unilateral Mandibular Fracture When to Consider Nonaccidental Trauma

O and reproducible treatment of the cleft nasal deformity continues to challenge plastic surgeons and remains the holy grail of cleft surgery. In this article, Dr. Alajmi et al. describe a mathematical formula to assist cleft teams performing nasoalveolar molding on unilateral cleft lip patients in an effort to optimize their cleft nasal results. They state that knowing when to stop the nasoalveolar molding treatment and proceed with surgery can be difficult, as the determination of desired cleft-nasal height correction is a subjective assessment. They present the use of the Pythagorean theorem to estimate the corrected height of the nose with the use of nasoalveolar molding therapy, by retrospectively analyzing the nasal impressions of 20 infants with unilateral cleft lip who underwent nasoalveolar molding. All of their analysis was performed on the noncleft side of the patient’s nose. They measured the nasal base length (length b) and the alar length (length c). Using the formula a2 b2 c2, they calculated what a should be and defined this as the ideal corrected nasal height. It is important to understand that before treatment with nasoalveolar molding, the angle between a and b is obtuse and therefore the length of a is shorter than it will be once the angle between a and b is 90 degrees (Fig. 2 in the article demonstrates this geometry). Once the nasoalveolar molding is performed and the angle between a and b becomes 90 degrees, the increase in the length of a results in an increase in the nasal height. They then analyzed the nasal impressions of the same 20 infants following the completion of nasoalveolar molding but before surgical repair of the cleft. Comparing the ideal corrected nasal height with the actual corrected nasal height, they found a statistically significant positive correlation between their predicted result and their actual result. They conclude that the calculated ideal corrected nasal height produces a reasonable estimate of corrected noncleft nasal height, which can serve as an objective goal for the nasal height. Nasoalveolar molding was first described by Grayson et al. in 1993,1 and a recent review of the efficacy of nasoalveolar molding concluded there is some level II and III evidence (depending on the study) that nasoalveolar molding may help improve nasal symmetry and form in the unilateral cleft.2 In this technique, which is used in both unilateral and bilateral cases, an alveolar molding plate is created shortly after birth and modified on a weekly basis to bring the clefted alveolar segments together. This also narrows the alar base and relaxes the tension on the laterally displaced alar rim. Once the alveolar cleft is reduced to 5 mm, a nasal stent is added to the molding plate. If the nasal stent is placed before the reduction of the alveolar cleft, the circumference of the lateral alar wall may be abnormally increased.3 The nasal stent elevates and anteriorly projects the nasal tip, lengthens the columella, expands the nasal lining, and places the lower lateral cartilages in a more anatomically correct position.4 In the unilateral cleft deformity, nasoalveolar molding also repositions the columella and septum from an oblique position to an upright and midline position.3 Because all of the measurements and calculations were performed on the noncleft side, it is difficult to interpret how these calculations translate onto the cleft side of the nose. For example, it would be interesting to know whether they had to overcorrect (i.e., have a longer corrected nasal height) the cleft side to obtain the ideal corrected nasal height on the noncleft side. This is a valuable

Abstract 111: Rapid Detection of Acute Vascular Occlusion Using Oxygen Monitoring in a Rat Myocutaneous Flap Model

A 3-month-old Albanian female infant presented to the emergency department with her biologic mother and father after allegedly falling from her swing onto her face. Through an interpreter, the biologic mother reported swaddling the baby and putting her in an electric swing. The swing was placed on a wooden stool. A few minutes after starting the mechanical swing, mother stated that it toppled off the wooden stool. The infant subsequently landed face down onto a carpet runner overlying the ceramic tile floor. The mother reported that the baby cried immediately and had blood coming from her mouth. She did not report loss of consciousness, apnea, or vomiting. Physical examination showed a sleeping 3-month-old girl resting comfortably. A blood clot was noted along a 1-inch skin flap that extended from the front to the middle of the upper right gum line. Conjunctiva were clear. Upper, lower, and sublingual frenula were intact. Her skin was significant for a rather faint petechial injury along the left upper lip vermilion border. The remainder of the exam was normal. The infant was born at term via spontaneous vaginal delivery without complications. Family history was negative for connective tissue disorders, frequent bone fractures, or other inherited bone diseases. Computed tomography (CT) revealed a minimally displaced comminuted fracture of the right mandibular ramus extending to the base of the condylar process; the study was negative for intracranial hemorrhage or other injury (Figure 1). A skeletal survey was performed and showed a questionable cortical irregularity of the right distal ulna that was seen on only one view. An ophthalmologist observed no retinal hemorrhages. Blood work, including serum electrolytes, liver function tests, and a complete blood count were all within normal limits. The pediatric plastic surgery service expressed concern that a mandibular fracture is exceedingly rare in infants. The pediatric radiologist queried whether this traumatic injury was induced nonaccidentally. Thus, given the rare nature of these fractures in infants and implausibility of the reported mechanism of injury, the primary team consulted the hospital child protection program for concern of nonaccidental trauma. Child Protective Services (CPS) was contacted and, in conjunction with law enforcement, conducted a scene investigation while the infant remained in the hospital. It was discovered that the electric swing had been placed atop four small wooden circular barstools that were 18 inches high; the total height of the stools and swing came to 40 inches (Figure 2). The swing initially appeared stable when placed on the stools; however, once turned on, it became unsteady. Further inspection revealed that the plastic grippers on the base of the swing were worn off in 3 locations. The child protection program concluded that the unilateral mandibular fracture was consistent with the accidental mechanism initially reported, and CPS formally cleared the infant for discharge to home in the care of her parents. The child protection program recommended a 2-week follow-up appointment with a repeat skeletal survey to reevaluate the distal ulna lesion, which proved to be normal.

Reconstructive surgery and patients with spinal cord injury: Perioperative considerations for the plastic surgeon

PURPOSE: Free tissue transfer requires close postoperative monitoring for vascular occlusion. Vascular compromise commonly occurs in the immediate postoperative period in association with failure of the micro-vascular anastomosis. The resiliency of tissue to hypoxia and ischemia is crucial to the success of the surgery. It is estimated that 6 percent to 25 percent of skin flaps require a secondary surgical re-exploration and approximately 10 percent of flaps fail. Currently, all monitoring methods have limitations because they require an experienced operator, suffer calibration difficulties and are expensive. Furthermore, many of these methods impose a significant delay between the time of vessel occlusion and its detection. In this study we introduce implantable oxygen sensors as a new method to detect acute vascular occlusion.