"Direct DICOM Slice Landmarking” A Novel Research Technique to Quantify Skeletal Changes in Orthognathic Surgery

The limitations of the current methods of quantifying the surgical movements of facial bones inspired this study. The aim of this study was the assessment of the accuracy and reproducibility of directly landmarking of 3D DICOM images (Digital Imaging and Communications in Medicine) to quantify the changes in the jaw bones following surgery. The study was carried out on plastic skull to simulate the surgical movements of the jaw bones. Cone beam CT scans were taken at 3mm, 6mm, and 9mm maxillary advancement; together with a 2mm, 4mm, 6mm and 8mm “down graft” which in total generated 12 different positions of the maxilla for the analysis. The movements of the maxilla were calculated using two methods, the standard approach where distances between surface landmarks on the jaw bones were measured and the novel approach where measurements were taken directly from the internal structures of the corresponding 3D DICOME slices. A one sample t-test showed that there was no statistically significant difference between the two methods of measurements for the y and z directions, however, the x direction showed a significant difference. The mean difference between the two absolute measurements were 0.34±0.20mm, 0.22±0.16mm, 0.18±0.13mm in the y, z and x directions respectively. In conclusion, the direct landmarking of 3D DICOM image slices is a reliable, reproducible and informative method for assessment of the 3D skeletal changes. The method has a clear clinical application which includes the analysis of the jaw movements “orthognathic surgery” for the correction of facial deformities.     

Paulus Aegineta, a seventh century encyclopedist and surgeon: his role in the history of plastic surgery.

Paulus Aegineta (625-690 ad), born on the island of Aegina, practiced medicine at Alexandria. The last of the eclectic Greek compilers in the Byzantine period, he wrote an Epitome of medicine in seven books. The sixth book, which is considered the best section of his work, is devoted mainly to surgery. The first edition, "editio princeps," of his Epitome was published in Greek by the Aldine press in Venice in 1528 and later translated into English for the Sydenham Society by Francis Adams of Banchory (1844-1847). Paulus was not only a compiler but also a competent and skillful surgeon. In addition to his achievements in general surgical progress, Paulus Aegineta, especially in the book on surgery, made valuable contributions in the history of plastic surgery. He may be considered as one of the originators of plastic surgery as it is known today. He described procedures varying from the treatment of nasal and jaw fractures to operations for gynecomastia, ganglion, and hypospadias. This Grecian master influenced not only his own but also the subsequent ages. Rhazes, Haly Abbas, Albucasis, Avicenna, and Fabricius ab Aquapendente were the greatest physicians influenced by Paulus Aegineta. Because the work of Paulus Aegineta was the only source for many of the surgical treatises of Arabian authors, his Epitome bridged Western and Eastern medicine and conveyed surgical experience and knowledge, including several plastic surgery procedures, to the subsequent ages.     

Planning orthodontic surgery with the Hexapod system]

Treatment of maxillofacial dysgnathia using a combined surgical/orthodontic approach requires careful orthodontic and orthognathic diagnosis and treatment planning. In the present study, a system enabling on-line presentation of the necessary displacements of the jaw during surgery, while improving the accuracy of the planning, is described. Using the hexapod principle, it is possible to plan operations with six degrees of freedom and to measure the three-dimensional movements of jaws and jaw segments within the planning stage. Routinely prepared casts are employed for simulation of the operation. The displacements of the jaw are presented in a manner familiar to the orthodontic surgeon, namely in a surgical record. The accuracy achieved with the hexapod is superior to that achievable intra-operatively.     

Osteonecrosis of the jaw developing during bisphosphonate treatment

The article discusses osteonecrosis of the jaw as a possible side effect of bisphosphonate treatment. It provides practical guidelines for prevention, diagnosis and management of bisphosphonate-associated osteonecrosis according to literature and clinical evidence. Since controlled clinical trials have not been carried out, the recommendations are based on reviews, reports and clinical experience. Osteonecrosis of the jaw (ONJ) is a historical clinical entity, which can potentially develop in cancer patients receiving bisphosphonate therapy. The pathogenesis of ONJ has not been totally revealed yet. A thorough dental/oral surgical examination and counseling is recommended in cases when intravenous bisphosphonate therapy is needed. All required dental and surgical treatment should be carried out before starting bisphosphonate therapy to prevent ONJ. The patient should be informed about the possible side effects, and the importance of good oral home care and regular dental check-ups. Once the intravenous bisphosphonate therapy has started, only conservative manipulations should be carried out in the oral cavity. Even in case of developed ONJ, suspension of bisphosphonate therapy is not necessary. In these cases a non-surgical approach is recommended concerning the treatment of ONJ. Regarding the growing number of ONJ cases in association with bisphosphonate therapy it is important for the professionals treating cancer patients to be aware of this phenomenon and the importance of prevention.     

DRGs, costs, and outcome for plastic surgical patients

The purpose of this study was to analyze hospital cost, resource utilization, and outcome by age for a large group of hospitalized plastic surgical patients using the DRG format. Hospital cost per patient for all plastic surgical admissions (both inpatient and potentially ambulatory patients) treated (N = 1632) at an academic medical center increased with age and peaked for plastic surgical patients 75 to 80 years of age ($11,585 per patient). Although DRG payment would have produced an aggregate profit of $2,404,854, older plastic surgical patients (65 years of age and above) generally produced losses. Older plastic surgical patients demonstrated a longer hospital length of stay, a greater severity of illness, a higher percent of outliers, and a greater mortality than younger plastic surgical patients. In addition, older plastic surgical patients had higher clinical resource utilization based on a number of clinical parameters such as emergency admission, SICU utilization, need for blood transfusions, and need for plasma product infusions. This study suggests that the current DRG reimbursement methodology may be inequitable vis-à-vis the older plastic surgical patient. As additional pressures encourage the performance of more ambulatory procedures (previously performed as inpatients), our profit margins may decline and possibly affect our ability to provide quality plastic surgical care.     

A new resorbable tack fixation technique for endoscopic brow lifts

The endoscopic brow lift is now widely accepted in aesthetic plastic surgery, and various fixation techniques have been described in the literature. New developments and technology have expanded the use of resorbable devices in different surgical specialties, including plastic surgery. The authors present a technique that offers simple, fast, and reliable forehead fixation for endoscopic brow lifts using resorbable tacks. Successful facial rejuvenation was obtained in the majority of the patients without complications, need for follow-up visits to tighten the flap fixation system, or secondary procedures to extract the fixation system.     

Cutaneous ciliated cyst: case report and literature review

An 18-year-old girl had a cyst excised from the left buttock in 1988. The cyst was diagnosed to be a cutaneous ciliated cyst, since histologic examination using special stains demonstrated its lining to be similar to fallopian tube epithelium. Only 20 such cases have been published to date, and this report is probably the first case in the plastic surgical literature, to the best of our knowledge.     

Granular cell ameloblastoma of the jaw. A report of two cases with fine needle aspiration cytology

BACKGROUND: Fine needle aspiration cytology (FNAC) of jaw tumors has not been studied extensively. Ameloblastomas are jaw tumors that show a wide morphologic spectrum and thus may pose some diagnostic difficulties. Of the many types, granular cell ameloblastoma (GCA) is an uncommon variant that possesses distinctive features. To the best of our knowledge, there have been no previous reports on the cytologic findings of GCA. We present two cases diagnosed by FNAC. CASES: Two cases of GCA were diagnosed on cytology and subsequently confirmed on histology. Both patients presented with a large, lytic jaw tumor. FNAC smears showed characteristic granular cells along with spindle and basaloid cells. CONCLUSION: Although GCAs are rare tumors, they possess distinctive features that permit an accurate diagnosis, provided that this entity is kept in mind. This tumor has to be differentiated from cystic odontogenic lesions, epulis and granular cell myoblastoma. An accurate preoperative diagnosis also helps the surgeon to plan more extensive surgery as these tumors show a great propensity for malignant change and metastases.     

Bronchogenic Cyst Masquerading As an Adrenal Tumor: A Case of Mistaken Identity

ObjectiveTo describe a patient with a bronchogenic cyst that was erroneously diagnosed as an adrenal tumor and the surgical management strategy to address the operative challenges.MethodsWe summarize the clinical presentation, diagnostic workup, surgical management, and pathologic features of the study patient and review the pertinent literature.ResultsIn this report, we present the case of a 23-year-old woman who underwent retroperitoneoscopic exploration after imaging identified an enlarging left adrenal lesion. Preoperative biochemical testing confirmed that the mass was nonfunctional. No lesion was found after a thorough retroperitoneoscopic exploration under standard high insufflation pressure. Serendipitously, low-pressure inspection for hemostasis after failed exploration enabled discovery of an intradiaphragmatic mass that proved to be a bronchogenic cyst rather than an adrenal tumor. Not only was this a difficult operative dilemma, but it was also an unusual presentation for this tumor.ConclusionsDiscovery of a retroperitoneal or intradiaphragmatic bronchogenic cyst is a rare occurrence. The unusual location and tumor characteristics contributed to near surgical failure. The fortuitous surgical strategy of lowpressure inspection allowed visualization of the tumor for definitive resection. (Endocr Pract. 2012;18:e102-e105)     

Advanced technologies in plastic surgery: how new innovations can improve our training and practice

Over the last two decades, virtual reality, haptics, simulators, robotics, and other "advanced technologies" have emerged as important innovations in medical learning and practice. Reports on simulator applications in medicine now appear regularly in the medical, computer science, engineering, and popular literature. The goal of this article is to review the emerging intersection between advanced technologies and surgery and how new technology is being utilized in several surgical fields, particularly plastic surgery. The authors also discuss how plastic and reconstructive surgeons can benefit by working to further the development of multimedia and simulated environment technologies in surgical practice and training.     

Temporal bone arrangements in turtles: an overview

The temporal region of turtles is characterized by significant anatomical diversity. Turtles show a pure anapsid morphotype that exhibits various different marginal reductions known as emarginations. As a result of this diversity, turtles can be taken as a model by which to understand the processes that may have resulted in the highly debated anatomy of the amniote temporal region in general. In this review on almost forgotten literature, I summarize ten potential factors that may act on the skull to shape the temporal region of turtles. These are: (1) phylogenetic constraints, (2) skull weights, (3) type of food, (4) skull dimensions, (5) muscle bulging, (6) ear anatomy and jaw muscle bending mechanisms, (7) extent and nature of muscle attachment sites, (8) internal forces within the jaw adductor chamber, (9) environmental pressure, and (10) neck bending mechanisms. Particular focus is laid on the interrelationship of the jaw musculature and the dermatocranial armour, which were assumed to influence each other to a certain degree. In the literature, cranial dimensions were assumed to influence temporal bone formation within major tetrapod groups. Among these, turtles seem to represent a kind of intermixture, a phenomenon that may be reflected in their specific anatomy. The references presented should be understood as product of the scientific environment in which they developed and the older literature does not always insist current empirical demands. However, the intuitive and creative ideas and the comprehensive anatomical considerations of these authors may inspire future studies in several fields related to this topic.     

快速成型技术在颌骨缺损修复中应用的临床研究

目的：研究以CAD／CAM快速成型模型预成钛支架行颌骨缺损功能和外形重建的临床疗效。方法：选择四川大学华西口腔医院收治的5例颌骨良性肿瘤患者,术前螺旋CT及快速成型技术预成实体模型,并通过反求工程技术将健侧颌骨外形复制,制备钛修复体行患侧缺损修复,观察术后效果。结果：术后3个月、6个月复查患者对自身颌骨功能及外形较满意,均未出现因修复体导致的严重不良反应,张口度都接近恢复至正常,张口运动未出现明显异常,咬合关系良好。结论：运用快速成型技术设计并利用反求工程技术制造的个性化修复体进行颌骨缺损修复的方法能较好地恢复患者颌面部的功能和外形,副反应小,可以达到比较满意的修复效果。     

Ciliary Rootlet Coiled-Coil 2 (crocc2) Is Associated with Evolutionary Divergence and Plasticity of Cichlid Jaw Shape

Cichlid fishes exhibit rapid, extensive, and replicative adaptive radiation in feeding morphology. Plasticity of the cichlid jaw has also been well documented, and this combination of iterative evolution and developmental plasticity has led to the proposition that the cichlid feeding apparatus represents a morphological “flexible stem.” Under this scenario, the fixation of environmentally sensitive genetic variation drives evolutionary divergence along a phenotypic axis established by the initial plastic response. Thus, if plasticity is predictable then so too should be the evolutionary response. We set out to explore these ideas at the molecular level by identifying genes that underlie both the evolution and plasticity of the cichlid jaw. As a first step, we fine-mapped an environment-specific quantitative trait loci for lower jaw shape in cichlids, and identified a nonsynonymous mutation in the ciliary rootlet coiled-coil 2 (crocc2), which encodes a major structural component of the primary cilium. Given that primary cilia play key roles in skeletal mechanosensing, we reasoned that this gene may confer its effects by regulating the sensitivity of bone to respond to mechanical input. Using both cichlids and zebrafish, we confirmed this prediction through a series of experiments targeting multiple levels of biological organization. Taken together, our results implicate crocc2 as a novel mediator of bone formation, plasticity, and evolution.     

Stability of dental implants in microvascular osseous transplants

Microvascular iliac crest and scapula transplants have been used in reconstruction of the lower jaw following tumor surgery. It has only been with the insertion of dental implants that a satisfactory prosthetic rehabilitation of the patient has been achieved. For this study, a follow-up of 38 patients with lower jaw tumors was carried out. The patients had been treated with partial resection of the lower jaw and neck dissection with microvascular iliac crest transplants (n = 20) or microvascular scapula transplants (n = 18); this was followed with dental implants (n = 143) in the region of the transplants or the local lower jaw. One hundred thirty-nine of the 143 dental implants were loaded by prosthetic superstructures. In all patients, the implant situation was evaluated on average 2 years 5 months after implantation. Periotest values, periimplant probing depths, and contact bleeding were registered, and the extent of periimplant bone loss was defined radiographically. The clinical situation in the region of the implant was compared for both types of implants and also with the nonresected lower jaw. The average Periotest values were within the normal range for all groups. In one scapula implant, however, a better average of Periotesting, -3.3, was found compared with implants of the iliac crest with Periotest values of -0.7. A measurement of -2.1 was found for the local lower jaw, similar to that of scapula implants. Pathologic probing depths were found for all three compared groups. The radiographically determined vertical loss of bone was the same for all three groups, on average 1 mm at 27 months postoperatively. The highest incidence of sulcus bleeding was found in the scapula implant group. Thus, it can be stated that the scapula transplants provide a similar transplant site to local lower jaw bone, whereas implants in iliac crest transplants show lesser bony stability. Periimplant soft-tissue conditions are worse for both types of transplants compared with local tissue of the lower jaw.     

Salvage of infected expander prostheses in breast reconstruction

Periprosthetic infection is a devastating complication following breast reconstruction with prostheses. Traditional surgical principles dictate removal of the prosthesis to control infection. Although successful salvage of prostheses in the presence of periprosthetic infections has been reported in the plastic and other surgical literature, salvage procedures remain seldom practiced. Reports in the plastic surgery literature have been limited to implant salvage following cosmetic breast augmentation and subcutaneous mastectomy with implants. Salvage of saline-filled expander prostheses used in breast reconstruction following mastectomy for cancer has not been previously reported. The authors review their experience with implant salvage in patients with periprosthetic infections following breast reconstruction for a 6-year period. Fourteen patients (13 with saline-filled expander prostheses and one with silicone prosthesis) underwent implant salvage. Salvage of the breast reconstruction was successful in nine patients. Staphylococcus aureus infection was associated with poorer salvage rate (p = 0.023). Previous radiotherapy to the chest wall did not affect the salvage outcome (p = 0.50). In selected patients, immediate salvage of a breast reconstruction in the presence of prosthesis-related infection remains an alternative to implant removal followed by delayed reconstruction.     

Residency training in plastic surgery: a survey of educational goals

With the advent of integrative plastic surgical training programs, requirements for earlier specialization decisions, and an increasing subspecialization within the practice of plastic surgery, the educational goals of residency training may have changed. The duration and extent of training required are also currently being questioned. This study was performed to better understand the necessary roles of plastic surgery residencies and to determine how these demands might optimally be met. Of 151 practicing plastic surgeons in the Ontario, Canada, region, 81 (53.6 percent) responded to a survey. General agreement was that 2 years was an optimal length of time for core surgical training, which should then be followed by at least 3 years of plastic surgical training. Opinions on the ideal length of time training in specific medical and surgical disciplines are discussed. Overall, respondents thought that two thirds of training should occur in tertiary care centers, with the remaining time spent at smaller community centers and private clinics. Nearly half of respondents thought that research training should be a mandatory part of the residency, although the amount of protected time for this activity varied substantially. Most thought that unrestricted elective time should also be available. Academic plastic surgeons rated the importance of research training (p < 0.01), critical appraisal skills (p < 0.05), and teaching skills (p < 0.05) as significantly more important than did their nonacademic colleagues. The authors present results from the Ontario region and a template for determining optimal characteristics for training programs. Further investigation may be of timely importance during a foreseeable future transition from traditional to integrative plastic surgery residency training.     

Geographic variation in lower pharyngeal jaw morphology in the Shiner Perch <Emphasis Type="Italic">Cymatogaster aggregata</Emphasis> (Embiotocidae,Teleostei)

Correlations of feeding morphology with body morphology reflect ecological variation of a species and the geographic or ontogenetic scales over which it occurs. In this study, evidence was found for geographic variation in lower pharyngeal jaw (LPJ) morphology of Cymatogaster aggregata Gibbons (Embiotocidae, Teleostei) in the Pacific Northwest, U.S.A. Correlations of LPJ morphology with body morphology were more obvious in adulthood than the juvenile stage. Morphological patterns corresponded better with environmental variables and gut contents than geographic proximity, indicating that they were most likely caused by habitat differences. Qualitative common garden experiments indicated the nature and direction of plastic responses, and indicate a likely plastic origin to most naturally observed differences. Recognizing ecological patterns via morphology is an important first step in understanding how and when ecological mechanisms influence the functional role of an organism within its environment.     

Subtotal maxillectomy for melanotic neuroectodermal tumor of infancy.

Melanotic neuroectodermal tumor of infancy is a rare pigmented neoplasm occurring in infants before 1 year of age. It is a rapidly growing tumor that most frequently affects the craniofacial skeleton. Although melanotic neuroectodermal tumor of infancy is benign in the vast majority of cases, inadequate excision, occasional multicentricity, and a small malignant potential result in a fairly high recurrence rate. On the basis of data obtained from the literature and our clinical experience, we advocate an aggressive surgical approach consisting of complete surgical excision when vital structures are not involved. Histopathologic confirmation of complete excision is mandatory to minimize the risk of recurrence and provide the patient with curative treatment and minimal morbidity.     

Mathematical modeling of ovarian cancer treatments: sequencing of surgery and chemotherapy

Ovarian cancer has long been one of the most common forms of cancer in women. The main treatment for ovarian cancer comprises a combination of surgery and chemotherapy. In an effort to improve treatment strategies, a variety of mathematical models have been developed in the literature. In this paper, we consider a simple mathematical model that incorporates tumor growth as well as the effects of chemotherapeutic and surgical treatments in ovarian cancer. We consider several growth models and combine them with different cell-kill hypotheses. Surgery is assumed to eliminate a fixed fraction of tumor cells instantaneously. We discuss how different models predict the optimal sequencing of chemotherapeutic and surgical treatments. This work has been carried out in the context of ovarian cancer; however, the results may also be useful for other kind of cancers.