Jamie P Levine, M.D.

The "Sweet Science" of Reducing Periorbital Lacerations in Mixed Martial Arts
Bastidas, Nicholas; Levine, Jamie P.; Stile, Frank L.
2012 JAN ;68(1):43-45, Annals of plastic surgery
The popularity of mixed martial arts competitions and televised events has grown exponentially since its inception, and with the growth of the sport, unique facial injury patterns have surfaced. In particular, upper eyelid and brow lacerations are common and are especially troublesome given the effect of hemorrhage from these areas on the fighter's vision and thus ability to continue. We propose that the convexity of the underlying supraorbital rim is responsible for the high frequency of lacerations in this region after blunt trauma and offer a method of reducing subsequent injury by reducing its prominence
— id: 150247, year: 2012, vol: 68, page: 43, stat: Journal Article,

Coronary stent thrombosis in patients undergoing multidigit replantation
Jacobs J; Shah A; Zinn A; Levine J
2011 Jan;40(1):285-289, Critical care medicine
OBJECTIVE:: The development of drug-eluting stents has decreased the rate of in-stent restenosis. However, there have been reports of late stent thrombosis in patients with drug-eluting stents, especially when dual antiplatelet therapy is interrupted. The high mortality rate associated with cardiac stent thrombosis has led to recent recommendations regarding duration of antiplatelet therapy as well as timing of elective surgery in patients with both drug-eluting stents and bare metal stents. However, in patients requiring emergency operations, delaying surgery is not an option. DATA SOURCES:: In a retrospective review of 65 patients undergoing replantation from 2005 to 2010, only two patients with coronary stents presented, both with drug-eluting stents. Both of these patients developed acute in-stent thrombosis postoperatively on days 5 and 2 despite continuing dual antiplatelet therapy while undergoing multidigit replantation. CONCLUSIONS:: Several factors including large transfusion requirements and the complex pharmacogenetics of clopidogrel may have played a role. These cases bring to light the increasing number of patients with indwelling drug-eluting stents in whom the need for massive surgical or trauma type management will become more frequent
— id: 139042, year: 2011, vol: 40, page: 285, stat: Journal Article,

3D Volume Assessment Techniques and Computer-Aided Design and Manufacturing for Preoperative Fabrication of Implants in Head and Neck Reconstruction
Patel, Ashish; Otterburn, David; Saadeh, Pierre; Levine, Jamie; Hirsch, David L
2011 Nov;19(4):683-709, Facial plastic surgery clinics of North America
Cases in subdisciplines of craniomaxillofacial surgery-corrective jaw surgery, maxillofacial trauma, temporomandibular joint/skull base, jaw reconstruction, and postablative reconstruction-illustrate the ease of use, cost effectiveness, and superior results that can be achieved when using computer-assisted design and 3D volumetric analysis in preoperative surgical planning. This article discusses the materials and methods needed to plan cases, illustrates implementation of guides and implants, and describes postoperative analysis in relation to the virtually planned surgery
— id: 139041, year: 2011, vol: 19, page: 683, stat: Journal Article,

Use of Virtual 3-Dimensional Surgery in Post-Traumatic Craniomaxillofacial Reconstruction
Tepper OM; Sorice S; Hershman GN; Saadeh P; Levine JP; Hirsch D
2011 Mar;69(3):733-741, Journal of oral & maxillofacial surgery
Traumatic craniofacial injuries often present as difficult reconstructive challenges for maxillofacial surgeons. Reconstruction is often complicated by significant soft tissue loss, comminuted bony fragments, a tenuous blood supply, and wound contamination. For panfacial injuries, restoration of normal facial width, facial height, and sagittal projection may be difficult to achieve. Marked swelling may limit the surgeons' ability to palpate and recognize subtle bony defects and malunion. Furthermore, a true 3-dimensional assessment of bony alignment may not be possible with traditional surgical exposures to the craniofacial skeleton. This article builds on previous work that introduced the use of 3-dimensionally guided surgery for microvascular free-flap reconstruction of the craniofacial skeleton. Use of this technology improves the planning, timing, and overall precision of microvascular reconstructive surgery. Based on this experience, a similar approach to reconstructing patients with significant craniofacial trauma has been adopted
— id: 121304, year: 2011, vol: 69, page: 733, stat: Journal Article,

TOPICAL SMAD3 SILENCING IMPROVES HEALING IN A NOVEL IRRADIATED WOUND MODEL
Wetterau, M. T.; Szpalski, C.; Knobel, D.; Albano, N.; Cohen, O.; Patel, M.; Layliev, J.; Warren, S. M.; Levine, J. P.; Saadeh, P. B.
2011 MAR-APR ;19(2):A59-A59, Wound repair & regeneration
— id: 129012, year: 2011, vol: 19, page: A59, stat: Journal Article,

Treatment of metachronous lower extremity defects with delay and splitting of a previously advanced reverse sural artery flap
Capla, Jennifer M; Michaels, Joseph 4th; Ceradini, Daniel J; Levine, Jamie P; Saadeh, Pierre B
2010 Dec;126(6):322e-323e, Plastic & reconstructive surgery
— id: 114865, year: 2010, vol: 126, page: 322e, stat: Journal Article,

More consistent postoperative care and monitoring can reduce costs following microvascular free flap reconstruction
Haddock, Nicholas T; Gobble, Ryan M; Levine, Jamie P
2010 Sep;26(7):435-439, Journal of reconstructive microsurgery
Great variability exists in microsurgical postoperative care in the United States. Lack of standardized postoperative monitoring protocols and appropriate training of monitoring personnel leads to inefficiency and increased cost of providing microsurgical postoperative care. A 45-question survey was sent to all plastic surgery and plastic surgery-based microsurgery program directors in the United States. Questions focused on the number and type of flaps performed, length of stay, complications, postoperative monitoring setting, training provided to monitoring personnel, and limitations in flap monitoring. The response rate was 31% with 3407 microvascular free flaps performed annually at 26 centers. A total of 1533 flaps were monitored in the intensive care unit (ICU) for an average of 3.1 days. In 45% of responding centers patients were cared for in an ICU secondary to a lack of adequately trained nurses at alternative sites. Printed postoperative protocols were provided to nurses in 39% of centers. With a comparative increase cost of $2878 to $3345 per day for ICU care, this translates into an annual increased cost of $13.7 to $15.9 million to the responding centers. Improved nursing training and the use of standardized postoperative protocols may allow patients to be monitored in non-ICU settings postoperatively, thereby reducing the costs associated with providing postoperative microsurgical care
— id: 111960, year: 2010, vol: 26, page: 435, stat: Journal Article,

Lower extremity arterial injury patterns and reconstructive outcomes in patients with severe lower extremity trauma: a 26-year review
Haddock, Nicholas T; Weichman, Katie E; Reformat, Derek D; Kligman, Brad E; Levine, Jamie P; Saadeh, Pierre B
2010 Jan;210(1):66-72, Journal of the American College of Surgeons
BACKGROUND: Management of severe traumatic lower extremity injuries remains a considerable challenge. Free tissue transfer is now a standard part of reconstruction for Gustilo IIIB and IIIC injuries. There is limited information on arterial injury patterns in this population. We undertook a review of our experience to gain insight on vascular injury patterns and surgical outcomes. STUDY DESIGN: A 26-year retrospective analysis was performed of all lower extremity Gustilo IIIB and IIIC injuries requiring microvascular reconstruction at New York University Medical Center. Patient demographics, Gustilo classification, angiographic findings (conventional/computed tomographic angiography/magnetic resonance angiography), recipient vessels, elapsed time from injury, flap choices, and outcomes were examined. RESULTS: Two hundred twenty-two free flaps on 191 patients were performed from September 1982 until March 2008. There were 151 males and 40 females ranging in age from 4 to 83 years (median age 33 years). Patients sustained either Gustilo IIIB (170 patients) or IIIC (21 patients) open fractures. One hundred fifty-four patients had angiograms (78.2% IIIB, 100% IIIC). Sixty-six (42.9%) had normal 3-vessel runoff and 88 (57.1%) were abnormal. Sixty-one patients (31.9%) had anterior tibial injuries, 17 patients (8.9%) had posterior tibial injuries, and 30 (15.7%) had peroneal injuries. Sixty-three complications occurred (11 early thrombosis, 33 requiring secondary procedures, and 10 requiring amputation). CONCLUSIONS: Angiography of severe lower extremity injuries requiring free flap reconstruction usually revealed arterial injury and is generally indicated. In our experience, the anterior tibial artery is most commonly injured and the posterior tibial artery is most likely to be spared and used as a recipient
— id: 107272, year: 2010, vol: 210, page: 66, stat: Journal Article,

Perforator vessel recipient options in the lower extremity: an anatomically based approach to safer limb salvage
Haddock, Nicholas; Garfein, Evan S; Reformat, Derek; Hecht, Elizabeth; Levine, Jamie; Saadeh, Pierre
2010 Sep;26(7):461-469, Journal of reconstructive microsurgery
When free tissue transfer is employed for defects of the lower third of the leg, recipient anastomoses are typically performed to major vessels. The aim of this study was to assess soleal perforators located in the distal half of the leg as potential vessels for free flap recipient vessels. Six fresh cadavers (12 limbs) were dissected. Perforators of adequate size (>or=1 mm) were documented as was the location and ease of dissection. Lower extremity magnetic resonance angiograms (MRAs) of 18 extremities were retrospectively reviewed. Two free tissue transfers to lower extremity perforators were presented. Soleal perforators most reliably matched our recipient vessel requirements. Perforators were of adequate size to support free tissue transfer, easy to dissect, and were located at mid/distal fibula level. MRA evaluation confirmed these results. One free tissue reconstruction was performed for trauma (posterior tibial perforator) and one was performed for a chronic radiation wound (peroneal perforator). The soleus muscle is easily exposed and is supplied distally by perforators from both the posterior tibial and the peroneal artery systems. These perforating branches are more accessible than the major lower extremity arteries, making the exposure and anastomosis technically easier and sparing potential iatrogenic injury to critical vessels
— id: 111961, year: 2010, vol: 26, page: 461, stat: Journal Article,

Breast Reconstruction with Implants, Tissue Expanders and AlloDerm: Predicting Volume and Maximizing the Skin Envelope in Skin Sparing Mastectomies
Haddock, Nicholas; Levine, Jamie
2010 Jan;16(1):14-19, Breast journal
AlloDerm has been used as a tissue supplement in conjunction with the pectoralis major muscle to provide full coverage over an implant in breast reconstruction. While this method of reconstruction has shown promising results there is little known on the relationship of AlloDerm size and potential immediate expansion volume. A retrospective chart review was completed evaluating all tissue expander or primary implant reconstructions using AlloDerm. Data recorded included: The type/size of implant/expander, dimensions of the AlloDerm used, initial fill volume, number of expansions and time period of expansion. Statistical analysis was completed with a linear regression model. AlloDerm was used on 49 patients (72 reconstructions). Thirty-four patients (50 reconstructions) underwent reconstruction with a tissue expander and 15 patients (22 reconstructions) underwent a single stage reconstruction with a permanent implant. The tissue expander volume filled (cc) could be predicted by 5 x surface area of AlloDerm (cm(2)) - 12 (R(2) = 0.62) and 80 x height of AlloDerm (cm) - 15 (R(2) = 0.59). The tissue expanders could be filled to an average of 75% of total size and required three to four injections in the postoperative period to reach full expansion. Obviously, a requirement for maximal implant expansion is an appropriate skin sparing mastectomy. There is a mathematical relationship between fill volume and surface area as well as height of AlloDerm used in breast reconstruction. This analysis provides a guideline for immediate implant expansion to surgeons using AlloDerm in reconstructive breast surgery
— id: 105408, year: 2010, vol: 16, page: 14, stat: Journal Article,

Microsurgery trainer with quantitative feedback: a novel training tool for microvascular anastomosis and suggested training exercise
Kligman, Brad E; Haddock, Nicholas T; Garfein, Evan S; Levine, Jamie P
2010 Dec;126(6):328e-330e, Plastic & reconstructive surgery
— id: 114866, year: 2010, vol: 126, page: 328e, stat: Journal Article,

Low-dose radiation augments vasculogenesis signaling through HIF-1-dependent and -independent SDF-1 induction
Lerman, Oren Z; Greives, Matthew R; Singh, Sunil P; Thanik, Vishal D; Chang, Christopher C; Seiser, Natalie; Brown, Daniel J; Knobel, Denis; Schneider, Robert J; Formenti, Silvia C; Saadeh, Pierre B; Levine, Jamie P
2010 Nov 4;116(18):3669-3676, Blood
The inflammatory response to ionizing radiation (IR) includes a proangiogenic effect that could be counterproductive in cancer but can be exploited for treating impaired wound healing. We demonstrate for the first time that IR stimulates hypoxia-inducible factor-1alpha (HIF-1alpha) up-regulation in endothelial cells (ECs), a HIF-1alpha-independent up-regulation of stromal cell-derived factor-1 (SDF-1), as well as endothelial migration, all of which are essential for angiogenesis. 5 Gray IR-induced EC HIF-1alpha and SDF-1 expression was greater when combined with hypoxia suggesting an additive effect. While small interfering RNA silencing of HIF-1alpha mRNA and abolition of HIF-1alpha protein induction down-regulated SDF-1 induction by hypoxia alone, it had little effect on SDF-1 induction by IR, demonstrating an independent pathway. SDF-1-mediated EC migration in hypoxic and/or radiation-treated media showed IR induced strong SDF-1-dependent migration of ECs, augmented by hypoxia. IR activates a novel pathway stimulating EC migration directly through the expression of SDF-1 independent of HIF-1alpha induction. These observations might be exploited for stimulation of wound healing or controlling tumor angiogenesis
— id: 138185, year: 2010, vol: 116, page: 3669, stat: Journal Article,

Aeromonas septicemia after medicinal leech use following replantation of severed digits
Levine, Steven M; Frangos, Spiros G; Hanna, Bruce; Colen, Kari; Levine, Jamie P
2010 Sep;19(5):469-471, American journal of critical care
Medicinal leeches are used to control venous congestion. Aeromonas in the leech gut are essential for digestion of blood. This case report describes a patient who had Aeromonas bacteremia develop after leeching. He had an injury to his hand that required replantation of his thumb. Following the surgery, leech therapy was started with ampicillin-sulbactam prophylaxis. Sepsis developed. Blood cultures were positive for Aeromonas that were resistant to ampicillin-sulbactam. The antibiotic was changed to ciprofloxacin on the basis of the sensitivity profile of the organisms. Cultures from the leech bathwater confirmed it as the source of the Aeromonas. Clinicians who use leech therapy must be aware that leeches can harbor Aeromonas species resistant to accepted prophylactic antibiotics and that sepsis may occur
— id: 138377, year: 2010, vol: 19, page: 469, stat: Journal Article,

Improved diabetic wound healing through topical silencing of p53 is associated with augmented vasculogenic mediators
Nguyen, Phuong D; Tutela, John Paul; Thanik, Vishal D; Knobel, Denis; Allen, Robert J Jr; Chang, Christopher C; Levine, Jamie P; Warren, Stephen M; Saadeh, Pierre B
2010 Nov-Dec;18(6):553-559, Wound repair & regeneration
Diabetes is characterized by several poorly understood phenomena including dysfunctional wound healing and impaired vasculogenesis. p53, a master cell cycle regulator, is upregulated in diabetic wounds and has recently been shown to play a regulatory roles in vasculogenic pathways. We have previously described a novel method to topically silence target genes in a wound bed with small interfering (si)RNA. We hypothesized that silencing p53 results in improved diabetic wound healing and augmentation of vasculogenic mediators. Paired 4-mm stented wounds were created on diabetic db/db mice. Topically applied p53 siRNA, evenly distributed in an agarose matrix, was applied to wounds at postwound day 1 and 7 (matrix alone and nonsense siRNA served as controls). Animals were sacrificed at postwound days 10 and 24. Wound time to closure was photometrically assessed, and wounds were harvested for histology, immunohistochemistry, and immunofluorescence. Vasculogenic cytokine expression was evaluated via Western blot, reverse transcription-polymerase chain reaction, and enzyme-linked immunosorbent assay. The ANOVA/t-test was used to determine significance (p</= 0.05). Local p53 silencing resulted in faster wound healing with wound closure at 18+/-1.3 d in the treated group vs. 28+/-1.0 d in controls. The treated group demonstrated improved wound architecture at each time point while demonstrating near-complete local p53 knockdown. Moreover, treated wounds showed a 1.92-fold increase in CD31 endothelial cell staining over controls. Western blot analysis confirmed near-complete p53 knockdown in treated wounds. At day 10, VEGF secretion (enzyme-linked immunosorbent assay) was significantly increased in treated wounds (109.3+/-13.9 pg/mL) vs. controls (33.0+/-3.8 pg/mL) while reverse transcription-polymerase chain reaction demonstrated a 1.86-fold increase in SDF-1 expression in treated wounds vs. controls. This profile was reversed after the treated wounds healed and before closure of controls (day 24). Augmented vasculogenic cytokine profile and endothelial cell markers are associated with improved diabetic wound healing in topical gene therapy with p53 siRNA
— id: 138168, year: 2010, vol: 18, page: 553, stat: Journal Article,

Non-ER outside-in functions of the ER chaperone calreticulin in diabetic wound repair
Samra F.; Naylor S.-M.; Gorovets D.; Pavlides S.; Murphy-Ullrich J.E.; Levine J.P.; Warren S.M.; Gold L.I.
2010 ;18(2):A28-A28, Wound repair & regeneration
We previously reported that topically applied calreticulin (CRT), a calcium-binding ER chaperone protein comprising N, P, and C domains, markedly enhances diabetic murine (db/db) and porcine cutaneous wound healing. Consistent with the potent wound healing effects, we further showed, in vitro, that exogenous CRT stimulated proliferation of keratinocytes and fibroblasts, induced concentration-dependent migration of these cells and monocytes and macrophages, and upregulated protein expression of collagen, fibronectin, and TGF-beta-3 in fibroblasts. Notably, all these broad-ranging effects purport novel non-ER functions for CRT that act from outside the cell inward. The current studies address: 1) whether the ER chaperone function of CRT is required for its extracellular functions, 2) the molecular structure(s) of CRT that function in its biological activities and 3) the in vitro effects of CRT on diabetic compared to normal mouse and human fibroblasts. Using CRT null mouse embryo fibroblasts (K42) compared to wild type (K41) in proliferation and migration assays (scratch plate and chamber), we show that exogenous CRT stimulates proliferation of null K42 cells to a similar extent as K41 cells (2-fold at 10 pg/ml). However, K42 cells require 100 times more CRT for a peak migratory response (1 vs 100 ng/ml), with a 20% decreased response. We also show that the C domain stimulates fibroblast proliferation to the same extent and peak response as the entire molecule. Finally, we show that fibroblasts isolated from db/db mouse skin and human fibroblasts cultured in high glucose, to simulate type II diabetes, respond to CRT by migration and proliferation albeit with 1/3 less robust response requiring 10-fold more CRT for peak responses compared to controls. The breath of novel non-ER functions of CRT, structure-function relationships, and effects on diabetic cells in vitro underscore this molecule as a potential potent agent for the topical treatment for healing diabetic wounds
— id: 135597, year: 2010, vol: 18, page: A28, stat: Journal Article,

Importance of computer-aided design and manufacturing technology in the multidisciplinary approach to head and neck reconstruction
Sharaf, Basel; Levine, Jamie P; Hirsch, David L; Bastidas, Jairo A; Schiff, Bradley A; Garfein, Evan S
2010 Jul;21(4):1277-1280, Journal of craniofacial surgery
Head and neck reconstruction is a multidisciplinary field, requiring communication among various surgical and dental specialists. The free fibular flap is the standard method for reconstructing large mandibular defects after benign or malignant tumor ablation. The graft has to be precisely contoured to fit the three-dimensional defect to meet the functional and aesthetic goals.Virtual surgical planning using computed tomographic imaging and computer-aided design and manufacturing technology allows the surgeons to perform virtual surgery and generates templates and cutting guides that allow for the precise and expedient recreation of the plan in the operating room. The authors describe 2 cases where virtual planning was used for the extirpative and reconstruction phases to achieve precise reconstruction and decreased time under anesthesia
— id: 111503, year: 2010, vol: 21, page: 1277, stat: Journal Article,

Decreased circulating progenitor cell number and failed mechanisms of stromal cell-derived factor-1alpha mediated bone marrow mobilization impair diabetic tissue repair
Tepper, Oren M; Carr, Jacquelyn; Allen, Robert J Jr; Chang, Christopher C; Lin, Clarence D; Tanaka, Rica; Gupta, Sanjeev M; Levine, Jamie P; Saadeh, Pierre B; Warren, Stephen M
2010 Aug;59(8):1974-1983, Diabetes
OBJECTIVE: Progenitor cells (PCs) contribute to postnatal neovascularization and tissue repair. Here, we explore the mechanism contributing to decreased diabetic circulating PC number and propose a novel treatment to restore circulating PC number, peripheral neovascularization, and tissue healing. RESEARCH DESIGN AND METHODS: Cutaneous wounds were created on wild-type (C57BL/J6) and diabetic (Lepr(db/db)) mice. Blood and bone marrow PCs were collected at multiple time points. RESULTS: Significantly delayed wound closure in diabetic animals was associated with diminished circulating PC number (1.9-fold increase vs. 7.6-fold increase in lin(-)/sca-1(+)/ckit(+) in wild-type mice; P < 0.01), despite adequate numbers of PCs in the bone marrow at baseline (14.4 +/- 3.2% lin(-)/ckit(+)/sca1(+) vs. 13.5 +/- 2.8% in wild-type). Normal bone marrow PC mobilization in response to peripheral wounding occurred after a necessary switch in bone marrow stromal cell-derived factor-1alpha (SDF-1alpha) expression (40% reduction, P < 0.01). In contrast, a failed switch mechanism in diabetic bone marrow SDF-1alpha expression (2.8% reduction) resulted in impaired PC mobilization. Restoring the bone marrow SDF-1alpha switch (54% reduction, P < 0.01) with plerixafor (Mozobil, formerly known as AMD3100) increased circulating diabetic PC numbers (6.8 +/- 2.0-fold increase in lin(-)/ckit(+), P < 0.05) and significantly improved diabetic wound closure compared with sham-treated controls (32.9 +/- 5.0% vs. 11.9 +/- 3% at day 7, P > 0.05; 73.0 +/- 6.4% vs. 36.5 +/- 7% at day 14, P < 0.05; and 88.0 +/- 5.7% vs. 66.7 +/- 5% at day 21, P > 0.05, respectively). CONCLUSIONS: Successful ischemia-induced bone marrow PC mobilization is mediated by a switch in bone marrow SDF-1alpha levels. In diabetes, this switch fails to occur. Plerixafor represents a potential therapeutic agent for improving ischemia-mediated pathology associated with diabetes by reducing bone marrow SDF-1alpha, restoring normal PC mobilization and tissue healing
— id: 111581, year: 2010, vol: 59, page: 1974, stat: Journal Article,

Cutaneous low-dose radiation increases tissue vascularity through upregulation of angiogenic and vasculogenic pathways
Thanik, Vishal D; Chang, Christopher C; Lerman, Oren Z; Greives, Matthew R; Le, Huong; Warren, Stephen M; Schneider, Robert J; Formenti, Sylvia C; Saadeh, Pierre B; Levine, Jamie P
2010 ;47(6):472-480, Journal of vascular research
BACKGROUND/AIMS: Neovascularization involves angiogenesis and vasculogenesis mediated by cytokines and soluble chemokines. The predominant stimulus is ischemia, however, recent data suggest that ionizing radiation (IR) has angiogenic potential. In this study we evaluated whether IR increases vascularity and perfusion in vivo. METHODS: In wild-type mice, a full-thickness, pedicled skin flap was created and isolated for localized irradiation at a dose of 5 Gy. Serial Doppler analysis of the flap was performed. The skin flaps were then harvested at various time points for vascularity and histologic analysis. Blood was concurrently harvested for serum and hematopoietic progenitor cell population analysis. RESULTS: IR to an ischemic flap augmented the angiogenic cytokines SDF-1 and VEGF. Serum MMP-9 and s-kit levels, which are critical for progenitor cell mobilization, were also increased. When hematopoietic progenitor cells were evaluated by Sca1+/Flk1+ cells, a correlate 2-fold increase was seen compared to controls. When the flaps were examined, both vascularity and perfusion were increased. CONCLUSION: In this study we demonstrate that local, low-dose IR upregulates angiogenic chemokines and results in progenitor cell mobilization to the systemic circulation. There is a resultant increase in the vascularity of the irradiated flap, suggesting that the pro-angiogenic effects of IR can be harnessed locally
— id: 113939, year: 2010, vol: 47, page: 472, stat: Journal Article,

DIABETIC WOUND HEALING RESULTS FROM IMPAIRED NEOVASCULARIZATION
Allen, RJ; Nguyen, PD; Canizares, O; Wagner, J; Levine, JP; Saadeh, PB; Warren, SM
2009 MAR-APR ;17(2):A23-A23, Wound repair & regeneration
— id: 97663, year: 2009, vol: 17, page: A23, stat: Journal Article,

Functional analysis of simultaneous dual-differentiation vs multilineage cell coculture for vascularized bone engineering
Allori, AC; Reformat, DD; Davidson, EH; Allen, RJ; Sailon, AM; Valenzuela, CD; Saadeh, PB; Levine, JP; Ricci, JL; Warren, SM
2009 SEP ;209(3):S90-S91, Journal of the American College of Surgeons
— id: 102459, year: 2009, vol: 209, page: S90, stat: Journal Article,

Dose-dependent effect of radiation on angiogenic and angiostatic CXC chemokine expression in human endothelial cells
Chang, Christopher C; Lerman, Oren Z; Thanik, Vishal D; Scharf, Carrie L; Greives, Matthew R; Schneider, Robert J; Formenti, Sylvia C; Saadeh, Pierre B; Warren, Stephen M; Levine, Jamie P
2009 Dec;48(3):295-302, Cytokine
Blood vessel growth is regulated by angiogenic and angiostatic CXC chemokines, and radiation is a vasculogenic stimulus. We investigated the effect of radiation on endothelial cell chemokine signaling, receptor expression, and migration and apoptosis. Human umbilical vein endothelial cells were exposed to a single fraction of 0, 5, or 20Gy of ionizing radiation (IR). All vasculogenic chemokines (CXCL1-3/5-8) increased 3-13-fold after 5 or 20Gy IR. 20Gy induced a marked increase (1.6-4-fold) in angiostatic CXC chemokines. CXCR4 expression increased 3.5 and 7-fold at 48h after 5 and 20Gy, respectively. Bone marrow progenitor cell chemotaxis was augmented by conditioned media from cells treated with 5Gy IR. Whereas 5Gy markedly decreased intrinsic cell apoptosis (0Gy=16%+/-3.6 vs. 5Gy=4.5%+/-0.3), 20Gy increased it (21.4%+/-1.2); a reflection of pro-survival angiogenic chemokine expression. Radiation induces a dose-dependent increase in pro-angiogenic CXC chemokines and CXCR4. In contrast, angiostatic chemokines and apoptosis were induced at higher (20Gy) radiation doses. Cell migration improved significantly following 5Gy, but not 20Gy IR. Collectively, these data suggest that lower doses of IR induce an angiogenic cascade while higher doses produce an angiostatic profile
— id: 104228, year: 2009, vol: 48, page: 295, stat: Journal Article,

The lower-extremity allen test
Haddock, Nicholas T; Garfein, Evan S; Saadeh, Pierre B; Levine, Jamie P
2009 Sep;25(7):399-403, Journal of reconstructive microsurgery
The Allen test is used to diagnose the relative contribution of the ulnar and radial arteries to each hand. We modified this test to investigate the relative vascular contributions to distal perfusion of the lower extremity. With the patient supine, a handheld Doppler is used to locate the first dorsal metatarsal artery. The posterior tibial artery (PT) and dorsalis pedis artery (DP) pulses are compressed. A persistent signal indicates collateral flow through the peroneal artery (PA). Sequential decompression is then used to evaluate the relative contribution of the PT and DP to distal circulation. We report a case in which angiography failed to predict reliance on the PT. In this case, performance of the lower-extremity Allen test (LEAT) led to an alternative recipient vessel choice. The LEAT is simple to perform and provides a valuable adjunct to angiographic data
— id: 103148, year: 2009, vol: 25, page: 399, stat: Journal Article,

Use of computer-aided design and computer-aided manufacturing to produce orthognathically ideal surgical outcomes: a paradigm shift in head and neck reconstruction
Hirsch, David L; Garfein, Evan S; Christensen, Andrew M; Weimer, Katherine A; Saddeh, Pierre B; Levine, Jamie P
2009 Oct;67(10):2115-2122, Journal of oral & maxillofacial surgery
— id: 104229, year: 2009, vol: 67, page: 2115, stat: Journal Article,

A novel approach to palatomaxillary reconstruction: use of radial forearm free tissue transfer combined with zygomaticus implants
Hirsch, David L; Howell, Kacey L; Levine, Jamie P
2009 Nov;67(11):2466-2472, Journal of oral & maxillofacial surgery
Pathologic resections involving the maxilla/hemimaxilla offer a unique reconstructive challenge to the maxillofacial reconstructive surgeon. Traditionally, reconstruction and replacement of lost tissues have been achieved with a variety of methods including obturators, local/regional flaps, and microvascular free tissue transfer. All these techniques have distinct disadvantages. We present a novel approach to palatomaxillary reconstruction using a combination of free tissue transfer and zygomaticus implants. To our knowledge, this specific technique has not been previously reported
— id: 104731, year: 2009, vol: 67, page: 2466, stat: Journal Article,

Intracranial Microvascular Free Flaps
Levine, Steven; Garfein, Evan S; Weiner, Howard; Yaremchuk, Michael J; Saadeh, Pierre B; Gurtner, Geoffrey; Levine, Jamie P; Warren, Stephen M
2009 Feb;25(2):89-95, Journal of reconstructive microsurgery
Large acquired intracranial defects can result from trauma or surgery. When reoperation is required because of infection or tumor recurrence, management of the intracranial dead space can be challenging. By providing well-vascularized bulky tissue, intracranial microvascular free flaps offer potential solutions to these life-threatening complications. A multi-institutional retrospective chart and radiographic review was performed of all patients who underwent microvascular free-flap surgery for salvage treatment of postoperative intracranial infections between 1998 and 2006. A total of six patients were identified with large intracranial defects and postoperative intracranial infections. Four patients had parenchymal resections for tumor or seizure and two patients had posttraumatic encephalomalacia. All patients underwent operative debridement and intracranial free-flap reconstruction using the latissimus dorsi muscle ( N = 2), rectus abdominis muscle ( N = 2), or omentum ( N = 2). All patients had titanium ( N = 4) or Medpor ( N = 2) cranioplasties. We concluded that surgery or trauma can result in significant intracranial dead space. Treatment of postoperative intracranial infection can be challenging. Vascularized free tissue transfer not only fills the void, but also provides a delivery system for immune cells, antibodies, and systemically administered antibiotics. The early use of this technique when intracranial dead space and infection coexist is beneficial
— id: 90063, year: 2009, vol: 25, page: 89, stat: Journal Article,

MEDIATORS OF INCREASED APOPTOSIS IN STRESSED DIABETIC FIBROBLAS
Nguyen, PD; Allen, RJ; Tutela, JP; Thanik, VD; Haberman, ID; Valenzuela, C; Lee, JW; Levine, JP; Warren, SM; Saadeh, PB
2009 MAR-APR ;17(2):A10-A10, Wound repair & regeneration
— id: 97659, year: 2009, vol: 17, page: A10, stat: Journal Article,

Mechanisms of improved diabetic wound healing achieved with topical silencing of p53
Nguyen, PD; Tutela, JP; Thanik, VD; Allen, RJ; Cohen, OD; Wagner, IJ; Levine, JP; Warren, SM; Saadeh, PB
2009 SEP ;209(3):S73-S73, Journal of the American College of Surgeons
— id: 102458, year: 2009, vol: 209, page: S73, stat: Journal Article,

A Recommended Protocol for the Immediate Postoperative Care of Lower Extremity Free-Flap Reconstructions
Rohde, Christine; Howell, Brittny Williams; Buncke, Gregory M; Gurtner, Geoffrey C; Levin, L Scott; Pu, Lee L Q; Levine, Jamie P
2009 Jan;25(1):15-19, Journal of reconstructive microsurgery
The success of lower extremity microsurgical reconstructions may be compromised postoperatively secondary to several factors, including thrombosis, infection, bleeding, and edema. To address edema, surgeons may use protocols for gradually dangling and/or wrapping the affected extremity. Such protocols vary widely among surgeons and are typically based on training and/or prior experience. To that end, we distributed surveys to five plastic surgeons who are experienced in microvascular lower extremity reconstruction at five different institutions. The surveys inquired about postoperative management protocols for lower extremity free flaps with regard to positioning, compression, initiation and progression of postoperative mobilization, nonweightbearing and weightbearing ambulation, assessment of flap viability, and flap success rate. These protocols were then evaluated for similarities to create a consensus of postoperative management guidelines. Progressive periods of leg dependency and compression therapy emerged as important elements. Although the consensus protocol developed in this study is considered safe by each participant, we do not intend for these recommendations to serve as a standard of care, nor do we suggest that any one particular protocol leads to improved outcomes. However, these recommendations may serve as a guide for less experienced surgeons or those without a protocol in place
— id: 90060, year: 2009, vol: 25, page: 15, stat: Journal Article,

The Proximally Based Peroneal Vascular Bundle An Insulated Extension Cord for Free Flop Reconstruction
Sailon, AM; Reformat, DD; Hecht, EM; Garfein, ES; Spector, JA; Levine, JP; Saadeh, PB
2009 MAY ;62(5):556-559, Annals of plastic surgery
Large traumatic wounds around the proximal third of the lower extremity may have disrupted local vasculature, potentially obviating local pedicled options,. However, free-tissue transfer to this area is technically challenging given the resulting paucity of recipient options and the depth of principal blood vessels. We present an anatomic and radiographic study of the proximally based peroneal vascular bundle as a recipient option In the proximal leg. Optimal approach was prone, through an incision over the fibula with dissection between lateral and posterior compartments. Magnetic resonance angiography demonstrated consistent vascular anatomy between patients. A proximally based peroneal vascular bundle protected by a cuff of flexor hallucis longus was used as a recipient vessel in free flat) reconstruction of an open knee wound. The bundle itself does not require coverage by virtue of its own local muscle Cliff. Caveats for its Use include file need for adequate leg inflow and foot outflow
— id: 98848, year: 2009, vol: 62, page: 556, stat: Journal Article,

Free Transverse Rectus Abdominis Myocutaneous and Deep Inferior Epigastric Perforator Flaps for Breast Reconstruction A Systematic Review of Flop Complication Rates and Donor-Site Morbidity
Sailon, AM; Schachar, JS; Levine, JP
2009 MAY ;62(5):560-563, Annals of plastic surgery
Free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps represent increasingly popular options for breast reconstruction. Although several retrospective, small-scale studies comparing these flap, have been published, most have failed to find a significant difference in flap complication rates or donor-site morbidity. We systematically reviewed the Current literature, and Subsequently pooled and analyze(] data from included studies. Included studies reported flap complications and/or donor site morbidities for both flap types. Eight studies met the inclusionary, criteria. For flap complications, there was a statistically significant difference between deep interior epigastric perforator and free transverse rectus abdominis myocutaneouS flaps in fat necrosis rates (25.5 +/- 0.49 vs. 11.3%, +/- 0.41%. P < 0.001) and total necrosis rates (4.15 +/- 0.08 vs. 1.59% +/- 0.08%, P = 0.044). Partial necrosis rates were not statistically Significant (3.54 +/- 0.07 vs. 1.60% +/- 0.07%, P = 0.057). For donor-site morbidity. there was no statistically significant difference in abdominal bulge (8.07 +/- 0.23 vs. 11.25% +/- 0.29%, P = 0.28). Multicenter. prospective studies are needed to further investigate differences between these flap options
— id: 98849, year: 2009, vol: 62, page: 560, stat: Journal Article,

A murine model for studying diffusely injected human fat
Thanik, Vishal D; Chang, Christopher C; Lerman, Oren Z; Allen, Robert J Jr; Nguyen, Phuong D; Saadeh, Pierre B; Warren, Stephen M; Levine, Jamie P; Coleman, Sydney R; Hazen, Alexes
2009 Jul;124(1):74-81, Plastic & reconstructive surgery
BACKGROUND: The study of human autologous fat grafting has been primarily anecdotal. In this study, the authors aim to develop a murine model that recapitulates human fat grafting to study the fate of injected fat and the cell populations contained within. METHODS: The authors' method of fat harvesting and refinement has been described previously. The authors injected nude and tie2/lacZ mice with 2 ml of human lipoaspirate placed on the dorsal surface in a multipass, fan-like pattern. Fatty tissue was injected in small volumes of approximately 1/30 ml per withdrawal. The dorsal skin and associated fat was excised at various time points. Sections were stained with hematoxylin and eosin and cytochrome c oxidase IV. Transgenic tie2/lacZ samples were stained with X-galactosidase. At the 8-week time point, volumetric analysis was performed. RESULTS: Volumetric analysis at the 8-week time point showed 82 percent persistence of the original volume. Gross analysis showed it to be healthy, nonfibrotic, and vascularized. Hematoxylin and eosin analysis showed minimal inflammatory or capsular reaction, with viable adipocytes. Fat grafted areas were vascularized with multiple blood vessels. Cytochrome c oxidase IV human-specific stain and beta-galactosidase expression revealed these vessels to be of human origin. CONCLUSIONS: The authors have developed a murine model with which to study the fate of injected lipoaspirate. There is a high level of persistence of the grafted human fat, with minimal inflammatory reaction. The fat is viable and vascularized, demonstrating human-derived vessels in a mouse model. This model provides a platform for studying the populations of progenitor cells known to reside in lipoaspirate
— id: 100530, year: 2009, vol: 124, page: 74, stat: Journal Article,

IMPROVED DIABETIC WOUND HEALING VIA TOPICAL GENE THERA
Tutela, JP; Nguyen, PD; Thanik, VD; Canizares, O; Varjabedian, L; Wagner, J; Lee, JW; Davidson, EH; Haberman, ID; Cohen, OD; Warren, SM; Levine, JP; Saadeh, PB
2009 MAR-APR ;17(2):A11-A11, Wound repair & regeneration
— id: 97660, year: 2009, vol: 17, page: A11, stat: Journal Article,

Plating in microvascular reconstruction of the mandible: can fixation be too rigid?
Zoumalan, Richard A; Hirsch, David L; Levine, Jamie P; Saadeh, Pierre B
2009 Sep;20(5):1451-1454, Journal of craniofacial surgery
OBJECTIVE: Determine long-term loss of mandible height with use of stress-shielding reconstruction plates for free fibula flap mandible reconstruction. DESIGN: Retrospective single-blinded medical record review. SUBJECTS: Seventy patients who had fibula free flap mandible reconstructions performed for 10 years. Patients who underwent radiotherapy were excluded. METHODS: Review of 70 fibula free flap mandible reconstructions performed for the last 10 years in a city hospital revealed 7 patients (10%) who had resections for benign odontogenic diseases. All had a three-dimensional cast model made, on which the reconstruction plate was bent to the desired shape preoperatively. Free fibula height on panoramic x-ray images taken preoperatively and at 2 and 12 months postoperatively. RESULTS: Seven (10%) patients met criteria for the study. Bone height was maintained at 2 months postoperatively, but at 12 months, there was a statistically significant loss of fibular bone height averaging 20% in the anterior, body, and ramus areas (P < 0.05). Despite this, all patients were considered eligible for dental rehabilitation, and 4 of 7 patients have had osseointegrated implants placed. CONCLUSIONS: As opposed to miniplates, increased resorption may have been due to the stress-shielding phenomenon unique to a reconstruction plates. However, this did not seem to affect the ability to place osseointegrated implants
— id: 104227, year: 2009, vol: 20, page: 1451, stat: Journal Article,

Breast cancer reconstruction: More than skin deep
Ceradini, Daniel J; Levine, Jamie P
2008 ;15(10):72-80 Oct, Primary Psychiatry
Breast cancer often leads to significant alteration of body image and disfigurement of the breast. Reconstruction for breast cancer defects can provide the patient with a restored breast contour. The potential benefit of breast cancer reconstructive surgery is to increase the patient's post-surgical quality of life and alleviate the posttraumatic psychological sequelae of breast cancer surgery. Time of breast cancer diagnosis is an important point of access for patients to receive information on breast reconstruction. Access to this information and plastic surgeons in the early phases of diagnosis is critical to a patient's decision to undergo reconstructive surgery, but is currently underutilized in the United States. Breast cancer reconstruction is a complex process that should be treated in a multidisciplinary fashion. This process must begin with the identification and treatment of psychological issues preceding or accompanying breast cancer diagnosis. These psychological problems should be addressed immediately and can significantly influence a patient's decision toward and level of satisfaction with breast cancer reconstruction. Breast reconstruction continues to be an essential element in helping patients recover from the diagnosis and treatment for breast cancer.
— id: 97118, year: 2008, vol: 15, page: 72, stat: Journal Article,

RNA interference of p53 improves diabetic wound healing
Chang, CC; Thanik, VD; Branson, BR; Gupta, SM; Levine, JP; Warren, SM; Saadeh, PB
2008 MAR-APR ;16(2):A48-A48, Wound repair & regeneration
— id: 76412, year: 2008, vol: 16, page: A48, stat: Journal Article,

Hedgehog signaling is essential for normal wound healing
Le, Huong; Kleinerman, Rebecca; Lerman, Oren Z; Brown, Daniel; Galiano, Robert; Gurtner, Geoffrey C; Warren, Stephen M; Levine, Jamie P; Saadeh, Pierre B
2008 Nov-Dec;16(6):768-773, Wound repair & regeneration
The hedgehog family of morphogens (sonic [Shh], Indian, and desert hedgehog) are central regulators of embryologic growth and tissue patterning. Although recent work implicates Shh in postnatal tissue repair and development, conclusive evidence is lacking. Here, we demonstrated the importance of Shh in wound repair, by examining the effects of cyclopamine, a specific inhibitor of the Shh signaling cascade, on tissue repair. Using a murine-splinted excisional wound model, which attenuates wound contraction in this loose-skinned rodent, we established that, by all measures (wound closure, epithelialization, granulation formation, vascularity, and proliferation), wound healing was profoundly impaired when Shh signaling was disrupted. Because embryonic disruption of Shh is associated with distinct phenotypic defects, our findings invite investigation of the potential role of Shh signaling under postnatal conditions associated with disregulated wound healing
— id: 91870, year: 2008, vol: 16, page: 768, stat: Journal Article,

Topical therapy for diabetic wounds using lineage-negative progenitor cells
Lin, CD; Macklin, JE; Lerman, OZ; Tepper, OT; Saadeh, PB; Levine, JP; Warren, SM
2008 MAR-APR ;16(2):A23-A23, Wound repair & regeneration
— id: 76410, year: 2008, vol: 16, page: A23, stat: Journal Article,

Topical lineage-negative progenitor-cell therapy for diabetic wounds
Lin, Clarence D; Allori, Alexander C; Macklin, Jared E; Sailon, Alexander M; Tanaka, Rica; Levine, Jamie P; Saadeh, Pierre B; Warren, Stephen M
2008 Nov;122(5):1341-1351, Plastic & reconstructive surgery
BACKGROUND: Impaired diabetic wound healing is due, in part, to defects in mesenchymal progenitor cell tracking. Theoretically, these defects may be overcome by administering purified progenitor cells directly to the diabetic wound. The authors hypothesize that these progenitor cells will differentiate into endothelial cells, increase wound vascularity, and improve wound healing. METHODS: Lineage-negative progenitor cells were isolated from wild-type murine bone marrow by magnetic cell sorting, suspended in a collagen matrix, and applied topically to full-thickness excisional dorsal cutaneous wounds in diabetic mice. Application of lineage-positive hematopoietic cells or acellular collagen matrix served as comparative controls (n = 16 for each group; n = 48 total). Time to closure and percentage closure were calculated by morphometry. Wounds were harvested at 7, 14, 21, and 28 days and then processed, sectioned, stained (lectin/DiI and CD31), and vascularity was quantified. RESULTS:: Wounds treated with lineage-negative cells demonstrated a significantly decreased time to closure (14 days) compared with lineage-positive (21 days, p = 0.013) and collagen controls (28 days, p = 0.004), and a significant improvement in percentage closure at 14 days compared with the lineage-positive group (p < 0.01) and the collagen control (p < 0.01). Fluorescently tagged lineage-negative cells remained viable in the wound for 28 days, whereas lineage-positive cells were not present after 7 days. Lineage-negative, but not lineage-positive, cells differentiated into endothelial cells. Vascular density and vessel cross-sectional area were significantly higher in lineage-negative wounds. CONCLUSION: Topical progenitor-cell therapy successfully accelerates diabetic wound closure and improves wound vascularity
— id: 90061, year: 2008, vol: 122, page: 1341, stat: Journal Article,

High dose radiation impairs hypoxia responsiveness and vascular recovery in vitro and in vivo
Nguyen, PD; Lerman, OZ; Chang, CC; Thanik, VD; Warren, SM; Saadeh, PB; Levine, JP
2008 MAR-APR ;16(2):A19-A19, Wound repair & regeneration
— id: 76409, year: 2008, vol: 16, page: A19, stat: Journal Article,

Alveolar bone regeneration in a gingivoperiosteoplasty model
Nguyen, PD; Lin, CD; Allori, AC; Reisler, T; Levine, JP; Saadeh, PB; Warren, SM
2008 MAY ;14(5):806-807, Tissue engineering. Part A
— id: 86863, year: 2008, vol: 14, page: 806, stat: Journal Article,

Interventions for alveolar bone regeneration in a gingivoperiosteoplasty model
Nguyen, PD; Lin, CD; Allori, AC; Reisler, T; Saadeh, PB; Levine, JP; Warren, SM
2008 MAR ;42(5):S81-S82, Bone
— id: 76444, year: 2008, vol: 42, page: S81, stat: Journal Article,

A novel murine model of isolated skin radiation injury
Nguyen, PD; Zoumalan, RA; Chang, CC; Allen, RJ; Sailon, AM; Warren, SM; Levine, JP; Saadeh, PB
2008 SEP ;207(3):S61-S62, Journal of the American College of Surgeons
— id: 88543, year: 2008, vol: 207, page: S61, stat: Journal Article,

The use of external hardware for lower extremity free flap elevation
Rohde, Christine; Williams, Brittny; Levine, Jamie P
2008 Nov;122(5):161e-162e, Plastic & reconstructive surgery
— id: 90062, year: 2008, vol: 122, page: 161e, stat: Journal Article,

Topically delivered siRNA for cutaneous gene suppression
Sailon, AM; Thanik, VD; Zoumalan, RA; Chang, CC; Levine, JP; Warren, SM; Saadeh, PB
2008 SEP ;207(3):S103-S103, Journal of the American College of Surgeons
— id: 88544, year: 2008, vol: 207, page: S103, stat: Journal Article,

A novel technique for vacuum assisted closure device application in noncontiguous wounds
Culliford, Alfred T 4th; Spector, Jason A; Levine, Jamie P
2007 ;60(1):99-100, Journal of plastic, reconstructive & aesthetic surgery : JPRAS
— id: 69461, year: 2007, vol: 60, page: 99, stat: Journal Article,

The fate of lower extremities with failed free flaps: a single institution's experience over 25 years
Culliford, Alfred T 4th; Spector, Jason; Blank, Alan; Karp, Nolan S; Kasabian, Armen; Levine, Jamie P
2007 Jul;59(1):18-21, Annals of plastic surgery
BACKGROUND: Lower-extremity reconstruction with microvascular free flap coverage is often the only option for limb salvage. Flap failure rates, however, continue to have higher complication rates than those to other anatomic sites; a significant number of flaps that fail result in amputation. This study retrospectively analyzed patients treated at a single institution who underwent attempted lower-extremity limb salvage with microsurgical techniques over a 25-year period. Of particular interest are the outcome data for patients who had initial free flap failure. PATIENTS AND METHODS: A prospectively maintained database was used to identify patients who satisfy criteria. Every patient who was treated with a microvascular free flap to their lower extremities was identified and included in this analysis. All records were reviewed from 1980 through 2004. Patients who had free flaps to the lower extremity fail after the initial operation were identified and selected for further analysis. RESULTS: Five hundred eighty-eight patients who underwent microsurgical reconstruction of lower extremity wounds had a failure rate of 8.5%. Trauma patients (83%) had a failure rate of 9%. On subset analysis, the failure rate for trauma patients decreased from 11% (1980-1992) to 3.7% (1993-2004). Of patients who had a failed free flap, 18% went on to limb amputation; the remainder was salvaged with secondary free flaps, local flaps, or skin grafting. CONCLUSION: This single institutional experience spanning 25 years represents the longest continual series of lower-extremity free flaps reported in the literature. The improved success rate seen in the second half of the study period is attributed to a more critical selection of free-flap candidates, improved understanding of the physiology surrounding acute trauma and a more sophisticated multidisciplinary team organization
— id: 93590, year: 2007, vol: 59, page: 18, stat: Journal Article,

Nonextremity replantation: the management of amputations of the facial parts and testicle
Flores, Roberto L; Hazen, Alexes; Galiano, Robert D; Klapper, Andrew M; Levine, Jamie P
2007 Apr;34(2):197-210, Clinics in plastic surgery
Successful nonextremity replantations, particularly of the facial anatomy and testicles, are rare procedures, and only a handful of cases have been reported. This article reviews the current literature in nonextremity replantations and representative cases performed at the authors' institution. Certain underlying themes and problems are consistently encountered in the surgical management of these cases. These are identified and reviewed. Although the replantation of these body parts remains technically challenging, all efforts should be made, when indicated, to repair these injuries microsurgically, because it currently offers the best reconstructive solution for these patients
— id: 71944, year: 2007, vol: 34, page: 197, stat: Journal Article,

Breast reconstruction in a university-based public hospital
Levine, SM; Vaksman, A; Hiotis, K; Levine, JP
2007 DEC ;106(1):S76-S77, Breast cancer research & treatment
— id: 75802, year: 2007, vol: 106, page: S76, stat: Journal Article,

Gustilo grade IIIB tibial fractures requiring microvascular free flaps: external fixation versus intramedullary rod fixation
Rohde, Christine; Greives, Matthew R; Cetrulo, Curtis; Lerman, Oren Z; Levine, Jamie P; Hazen, Alexes
2007 Jul;59(1):14-17, Annals of plastic surgery
BACKGROUND: Gustilo IIIB fractures involve high-energy tibial fractures for which there is inadequate soft tissue coverage. In addition to orthopedic fixation, these injuries require soft tissue reconstruction, often in the form of a microvascular free flap. Although the majority of orthopedic literature favorably compares intramedullary rod fixation to external fixation in open tibial fractures, these studies have not focused on the role of either method of fixation in relation to the soft tissue reconstruction. METHODS: Because we had noted numerous complications after providing free-flap coverage over intramedullary rodded fractures, we sought to investigate whether there were differences in outcomes between free flap-covered lower-extremity fractures which were fixated by external fixation versus intramedullary rods. A retrospective chart review was performed on all patients in our institution who had lower-extremity free flaps for coverage of Gustilo IIIB fractures from 1995-2005 in relation to the type of bony fixation. RESULTS: Of the 38 patients studied, 18 underwent external fixation of the tibial fracture, and 20 had intramedullary rodding. Overall flap survival was 95%, with 1 failure in each group. However, the intramedullary rod group had higher incidences of wound infection, osteomyelitis, and bony nonunion (25%, 25%, and 40%, respectively) than the external fixation group (6%, 11%, 17%, respectively). CONCLUSIONS: For Gustilo IIIB fractures that require free-flap coverage, the added bony and soft tissue manipulation required for intramedullary rodding may disrupt the surrounding blood supply and lead to higher rates of complications that threaten the overall success of the reconstruction. Plastic and orthopedic surgeons should discuss the optimal method of bony fixation for complex tibial fractures when a free flap will likely be needed for soft tissue coverage. This integrated team approach may help minimize complications
— id: 96611, year: 2007, vol: 59, page: 14, stat: Journal Article,

Breast cerebrospinal fluid pseudocyst
Spector, Jason A; Culliford, Alfred T 4th; Levine, Jamie P
2007 Jul;120(1):357-358, Plastic & reconstructive surgery
— id: 93591, year: 2007, vol: 120, page: 357, stat: Journal Article,

A technique for atraumatic microvascular arterial coupling
Spector, Jason A; Draper, Lawrence B; Levine, Jamie P; Ahn, Christina Y
2007 May;119(6):1968-1969, Plastic & reconstructive surgery
— id: 71943, year: 2007, vol: 119, page: 1968, stat: Journal Article,

Free tissue transfer to the lower extremity distal to the zone of injury: indications and outcomes over a 25-year experience
Spector, Jason A; Levine, Steven; Levine, Jamie P
2007 Sep 15;120(4):952-959, Plastic & reconstructive surgery
BACKGROUND: Microvascular free flap anastomoses performed for lower extremity reconstruction are traditionally proximal to the zone of injury. The authors assessed the feasibility and outcomes of microvascular free flaps with anastomoses performed distal to the zone of injury. METHODS: The authors retrospectively reviewed all microvascular free flaps performed at their institution over the past 10 years for lower extremity reconstruction and compared this group with their previously published experience (January of 1979 through August of 1995). Between September of 1995 and May of 2005, 119 flap procedures were performed for lower extremity reconstruction. Twenty-eight flaps (24 percent) were anastomosed distal to the zone of injury and 87 (76 percent) were anastomosed proximally. There were insufficient data on the location of the anastomosis for four free flaps (all successful). RESULTS: Twenty-seven of 28 distal microvascular free flaps were successful (96 percent); two (7 percent) required emergent postoperative reexploration of the anastomosis. Of the 87 proximal flaps, 79 (91 percent) were successful and eight (9 percent) failed. There was no statistically significant difference in the success rate of microvascular free flaps between the proximal and distal anastomosis groups (p = 0.30, Fisher's exact test). Combined with the data from the authors' previous series (January of 1979 to August of 1995), there were 63 free flaps with anastomosis performed distal to the zone of injury; 61 (97 percent) were successful. CONCLUSION: The authors' extensive 25-year experience with lower extremity reconstruction demonstrates that in appropriately selected patients, free tissue transfer to recipient vessels distal to the zone of injury is reliable and in certain cases preferable
— id: 74468, year: 2007, vol: 120, page: 952, stat: Journal Article,

Topical matrix-based siRNA silences local gene expression in a murine wound model
Thanik, V D; Greives, M R; Lerman, O Z; Seiser, N; Dec, W; Chang, C C; Warren, S M; Levine, J P; Saadeh, P B
2007 Sep;14(17):1305-1308, Gene therapy
The ability to affect gene expression via topical therapy has profound therapeutic implications for conditions characterized by open wounds including cutaneous neoplasms, thermal injury, skin disorders and dysfunctional wound healing. Specifically targeting local gene expression avoids systemic toxicity and simplifies treatment. We have developed a new method of topical matrix-based short interfering RNA application to precisely and effectively silence local gene expression in nondelimited wounds
— id: 74663, year: 2007, vol: 14, page: 1305, stat: Journal Article,

Skin graft vascularization involves precisely regulated regression and replacement of endothelial cells through both angiogenesis and vasculogenesis
Capla, Jennifer M; Ceradini, Daniel J; Tepper, Oren M; Callaghan, Matthew J; Bhatt, Kirit A; Galiano, Robert D; Levine, Jamie P; Gurtner, Geoffrey C
2006 Mar;117(3):836-844, Plastic & reconstructive surgery
BACKGROUND: Long-term survival of a skin graft is dependent on eventual revascularization. The authors' aim in the present study was to determine whether skin graft vascularization occurs by (1) simple reconnection of vessels, (2) ingrowth of recipient vasculature, (3) outgrowth of donor-derived vessels, and/or (4) recruitment of bone marrow-derived endothelial progenitor cells. METHODS: Full-thickness skin grafts (1 x 1 cm) were transferred between wild-type FVB/N mice (n = 20) and transgenic tie2/lacZ mice (n = 20), where lacZ expression is controlled by the endothelial specific tie2 promoter, allowing differentiation of recipient and donor endothelial cells. The contribution of endothelial progenitor cells to skin graft neovascularization was determined using a bone marrow transplant model where tie2/lacZ bone marrow was transplanted into wild-type mice (n = 20). RESULTS: Vascular regression in the graft was observed at the periphery starting on day 3 and moving centrally through day 21, sparing graft vessels in the absolute center of the graft. At the same time, vascular ingrowth occurred from the wound bed to replace the regressing vessels. Furthermore, bone marrow-derived endothelial progenitor cells contributed to these new vessels starting as early as day 7. Surprisingly, the contribution of bone marrow-derived vessels to the overall process was approximately 15 to 20 percent of new endothelial cells. CONCLUSIONS: Replacement of the donor graft vasculature by endothelial and endothelial progenitor cells from the recipient along preexisting channels is the predominant mechanism for skin graft revascularization. This mechanism is likely similar for all nonvascularized free grafts and suggests novel strategies for optimizing the vascularization of tissue constructs engineered in vitro
— id: 63744, year: 2006, vol: 117, page: 836, stat: Journal Article,

Overview of the role for calreticulin in the enhancement of wound healing through multiple biological effects
Gold, Leslie I; Rahman, Mohammad; Blechman, Keith M; Greives, Matthew R; Churgin, Samara; Michaels, Joseph; Callaghan, Matthew J; Cardwell, Nancy L; Pollins, Alonda C; Michalak, Marek; Siebert, John W; Levine, Jamie P; Gurtner, Geoffrey C; Nanney, Lillian B; Galiano, Robert D; Cadacio, Caprice L
2006 Sep;11(1):57-65, Journal of investigative dermatology symposium proceedings
Calreticulin (CRT), an intracellular chaperone protein crucial for the proper folding and transport of proteins through the endoplasmic reticulum, has more recent acclaim as a critical regulator of extracellular functions, particularly in mediating cellular migration and as a requirement for phagocytosis of apoptotic cells. Consistent with these functions, we show that the topical application of CRT has profound effects on the process of wound healing by causing a dose-dependent increase in epithelial migration and granulation tissue formation in both murine and porcine normal and impaired animal models of skin injury. These effects of CRTare substantiated, in vitro, as we show that CRT strongly induces cell migration/wound closure of human keratinocytes and fibroblasts, using a wound/scratch plate assay, and stimulates cellular proliferation of human keratinocytes, fibroblasts, and vascular endothelial cells, providing mechanistic insight into how CRT functions in repair. Similarly, in both animal models, the histology of the wounds show marked proliferation of basal keratinocytes and dermal fibroblasts, dense cellularity of the dermis with notably increased numbers of macrophages and well-organized collagen fibril deposition. Thus, CRT profoundly affects the wound healing process by recruiting cells essential for repair into the wound, stimulating cell growth, and increasing extracellular matrix production
— id: 69252, year: 2006, vol: 11, page: 57, stat: Journal Article,

Overview of the Role for Calreticulin in the Enhancement of Wound Healing through Multiple Biological Effects
Gold, Leslie I; Rahman, Mohammad; Blechman, Keith M; Greives, Matthew R; Churgin, Samara; Michaels, Joseph; Callaghan, Matthew J; Cardwell, Nancy L; Pollins, Alonda C; Michalak, Marek; Siebert, John W; Levine, Jamie P; Gurtner, Geoffrey C; Nanney, Lillian B; Galiano, Robert D; Cadacio, Caprice L
2006 Sep;126 Suppl:57-65, Journal of investigative dermatology
Calreticulin (CRT), an intracellular chaperone protein crucial for the proper folding and transport of proteins through the endoplasmic reticulum, has more recent acclaim as a critical regulator of extracellular functions, particularly in mediating cellular migration and as a requirement for phagocytosis of apoptotic cells. Consistent with these functions, we show that the topical application of CRT has profound effects on the process of wound healing by causing a dose-dependent increase in epithelial migration and granulation tissue formation in both murine and porcine normal and impaired animal models of skin injury. These effects of CRT are substantiated, in vitro, as we show that CRT strongly induces cell migration/wound closure of human keratinocytes and fibroblasts, using a wound/scratch plate assay, and stimulates cellular proliferation of human keratinocytes, fibroblasts, and vascular endothelial cells, providing mechanistic insight into how CRT functions in repair. Similarly, in both animal models, the histology of the wounds show marked proliferation of basal keratinocytes and dermal fibroblasts, dense cellularity of the dermis with notably increased numbers of macrophages and well-organized collagen fibril deposition. Thus, CRT profoundly affects the wound healing process by recruiting cells essential for repair into the wound, stimulating cell growth, and increasing extracellular matrix production.Journal of Investigative Dermatology Symposium Proceedings (2006) 11, 57-65. doi:10.1038/sj.jidsymp.5650011
— id: 69462, year: 2006, vol: 126 Suppl, page: 57, stat: Journal Article,

Biologic brachytherapy: ex vivo transduction of microvascular beds for efficient, targeted gene therapy
Michaels, Joseph 5th; Levine, Jamie P; Hazen, Alexes; Ceradini, Daniel J; Galiano, Robert D; Soltanian, Hooman; Gurtner, Geoffrey C
2006 Jul;118(1):54-65, Plastic & reconstructive surgery
BACKGROUND: Gene therapy for cancer holds enormous therapeutic promise, but its clinical application has been limited by the inability to achieve targeted, high-level transgene expression with limited systemic toxicity. The authors have developed a novel method for delivering genes to microvascular free flaps (commonly used during reconstructive surgery) to avoid these problems. METHODS: During the finite period in which a free flap is separated from the host (ex vivo), it can be perfused with extremely high titers of genetic material through the afferent artery, resulting in efficient transduction of the tissue. Before reanastomosis, unincorporated genetic material is flushed from the flap, minimizing systemic toxicity. RESULTS: In a rodent model using an adenoviral vector containing the lacZ reporter gene, high regional expression of beta-galactosidase was achieved in all the different cells in a microvascular free flap. Moreover, no beta-galactosidase staining was observed outside of the transduced flap, and viral sequence was undetectable by polymerase chain reaction analysis in other tissues. Further analysis confirmed that high-level transgene expression was precisely localized to the explanted tissue, with no collateral transduction. CONCLUSIONS: Targeting gene delivery with minimal systemic toxicity is essential for successful gene therapy. This form of 'biological brachytherapy' provides a new opportunity to deliver targeted therapeutic transgenes to patients undergoing reconstructive surgery and allows microvascular free flaps to perform therapeutic and reconstructive functions
— id: 64780, year: 2006, vol: 118, page: 54, stat: Journal Article,

Routine use of microvascular coupling device for arterial anastomosis in breast reconstruction
Spector, Jason A; Draper, Lawrence B; Levine, Jamie P; Ahn, Christina Y
2006 Apr;56(4):365-368, Annals of plastic surgery
BACKGROUND: Although microvascular coupling devices are used routinely and successfully for venous anastomosis, there are few published reports demonstrating their efficacy for performing arterial anastomosis. It has been the senior author's (C.Y.A.) preference to perform arterial anastomosis using the microvascular coupling device when feasible. METHODS: All microsurgical breast reconstructions performed by the senior author at the New York University Medical Center between 1998 and 2004 were retrospectively reviewed. A total of 60 patients underwent microsurgical breast reconstruction, of which 20 were bilateral, for a total of 80 flaps. RESULTS: Of the 80 flaps performed, there were 47 muscle-sparing TRAM and 22 deep inferior epigastric perforator (DIEP) flaps, and 11 were superior gluteal flaps. Arterial coupling was successfully performed in 60 of 69 flaps based on the deep inferior epigastric artery (87%) and 2 of 11 gluteal flaps (18%); arterial coupling was performed successfully 62 of 74 times (83.9%) when the thoracodorsal artery was the recipient vessel and never performed when the internal mammary artery was the recipient vessel. The overall flap success rate was 100%. CONCLUSIONS: In our large series, we were able to perform a coupled arterial anastomosis in nearly 80% of the cases, without the loss of any flaps. With proper vessel selection and sufficient experience using the microvascular coupler, arterial coupling may be performed in an expeditious, safe, and reliable fashion with minimal morbidity. Though not commonly practiced, use of the coupling device for arterial anastomosis can provide significant time savings, especially in bilateral breast reconstructions
— id: 64781, year: 2006, vol: 56, page: 365, stat: Journal Article,

Mechanical strain alters gene expression in an in vitro model of hypertrophic scarring
Derderian, Christopher A; Bastidas, Nicholas; Lerman, Oren Z; Bhatt, Kirit A; Lin, Shin-E; Voss, Jeremy; Holmes, Jeffrey W; Levine, Jamie P; Gurtner, Geoffrey C
2005 Jul;55(1):69-75, Annals of plastic surgery
Fibroblasts represent a highly mechanoresponsive cell type known to play key roles in normal and pathologic processes such as wound healing, joint contracture, and hypertrophic scarring. In this study, we used a novel fibroblast-populated collagen lattice (FPCL) isometric tension model, allowing us to apply graded biaxial loads to dermal fibroblasts in a 3-dimensional matrix. Cell morphology demonstrated dose-dependent transition from round cells lacking stress fibers in nonloaded lattices to a broad, elongated morphology with prominent actin stress fibers in 800-mg-loaded lattices. Using quantitative real-time RT-PCR, a dose dependent induction of both collagen-1 and collagen-3 mRNA up to 2.8- and 3-fold, respectively, as well as a 2.5-fold induction of MMP-1 (collagenase) over unloaded FPCLs was observed. Quantitative expression of the proapoptotic gene Bax was down-regulated over 4-fold in mechanically strained FPCLs. These results suggest that mechanical strain up-regulates matrix remodeling genes and down-regulates normal cellular apoptosis, resulting in more cells, each of which produces more matrix. This 'double burden' may underlie the pathophysiology of hypertrophic scars and other fibrotic processes in vivo
— id: 60141, year: 2005, vol: 55, page: 69, stat: Journal Article,

Programmed healing of membranous bone in the fetal lamb
Shahinian, Hrayr; Levine, Jamie P; Bradley, James P; O'Hara, Catherine; McCormick, Susan A; Kim, Yoonah; Longaker, Michael T
2005 Jan;54(1):79-84, Annals of plastic surgery
In fetal tissues, both soft and hard tissue healing (in long bones) have been found to be scarless. However, healing of membranous bone in the fetal craniofacial skeleton has not been well documented. Pregnant ewes (gestational age range, 80-95 days) underwent a hysterotomy, and fetal lambs had a full-thickness excision of the entire mandibular symphysis region (10 mm). Nonoperated controls were used for comparison (n = 8). After 10 days and 2 weeks, fetuses showed incomplete regeneration of the anterior mandible by examination, computed tomographic scan, and histology. By 4 weeks postoperatively, the mandibular defect had completely closed, but regenerated bony volume was less than control specimens. At 6 weeks postoperatively, the specimen demonstrated complete bony healing without scar or inflammation. Computed tomographic scan measurements for mandibular shape (length over width) was similar in experimental and control specimens. The data indicate that fetal lamb membranous bone defects heal in a scarless fashion and suggest preprogrammed migration of osteogenic tissue
— id: 49076, year: 2005, vol: 54, page: 79, stat: Journal Article,

An unusual case of cerebrospinal fluid pseudocyst in a previously augmented breast
Spector, Jason A; Culliford, Alfred T; Post, Nicholas H; Weiner, Howard; Levine, Jamie P
2005 Jan;54(1):85-87, Annals of plastic surgery
Cerebrospinal fluid (CSF) drainage catheters can cause a myriad of complications, in large part because they may migrate from their normal location to almost anywhere in the body. We present the unique case of a female patient who had previously undergone bilateral breast augmentation who experienced sudden painless swelling of her right breast 6 weeks after placement of a ventriculoperitoneal shunt. Radiologic examination demonstrated ensnarement of the distal aspect of the shunt around her implant, with subsequent formation of a CSF pseudocyst. Management of this patient included replacement of the shunt, drainage of the CSF pseudocyst, and preservation of the implant
— id: 49077, year: 2005, vol: 54, page: 85, stat: Journal Article,

Progenitor cell trafficking is regulated by hypoxic gradients through HIF-1 induction of SDF-1
Ceradini, Daniel J; Kulkarni, Anita R; Callaghan, Matthew J; Tepper, Oren M; Bastidas, Nicholas; Kleinman, Mark E; Capla, Jennifer M; Galiano, Robert D; Levine, Jamie P; Gurtner, Geoffrey C
2004 Aug;10(8):858-864, Nature medicine
The trafficking of circulating stem and progenitor cells to areas of tissue damage is poorly understood. The chemokine stromal cell-derived factor-1 (SDF-1 or CXCL12) mediates homing of stem cells to bone marrow by binding to CXCR4 on circulating cells. SDF-1 and CXCR4 are expressed in complementary patterns during embryonic organogenesis and guide primordial stem cells to sites of rapid vascular expansion. However, the regulation of SDF-1 and its physiological role in peripheral tissue repair remain incompletely understood. Here we show that SDF-1 gene expression is regulated by the transcription factor hypoxia-inducible factor-1 (HIF-1) in endothelial cells, resulting in selective in vivo expression of SDF-1 in ischemic tissue in direct proportion to reduced oxygen tension. HIF-1-induced SDF-1 expression increases the adhesion, migration and homing of circulating CXCR4-positive progenitor cells to ischemic tissue. Blockade of SDF-1 in ischemic tissue or CXCR4 on circulating cells prevents progenitor cell recruitment to sites of injury. Discrete regions of hypoxia in the bone marrow compartment also show increased SDF-1 expression and progenitor cell tropism. These data show that the recruitment of CXCR4-positive progenitor cells to regenerating tissues is mediated by hypoxic gradients via HIF-1-induced expression of SDF-1
— id: 48194, year: 2004, vol: 10, page: 858, stat: Journal Article,

Endostatin inhibits ischemia-induced neovascularization and increases ischemic tissue loss
Dobryansky, Michael; Galiano, Robert D; Cetrulo, Curtis L Jr; Bhatt, Kirit A; Michaels, Joseph; Ashinoff, Russell; Levine, Jamie P; Gurtner, Geoffrey C
2004 May;52(5):512-518, Annals of plastic surgery
The impact of inhibitors of tumor angiogenesis (endostatin, angiostatin) on the neovascularization required for the healing of transferred tissue has not been examined. We investigated the effect of endostatin on the functional neovascularization of random pattern flaps. C57BL6 mice were pretreated with endostatin beginning 3 days prior to surgery (n = 10), and daily injections continued throughout the study. Dorsal random cutaneous flaps were raised in both treatment and control (saline-treated) groups. The remaining cranial attachment was divided on day 9. Oxygen tension (PO2) was measured using a microprobe on days 1, 3, 5 and 16. Flaps were harvested and the vasculature was stained with CD31 on day 16. We found that endostatin significantly decreased flap survival. Mice that were treated with endostatin had fewer CD31+ blood vessels, worse flap perfusion at all time points, and lower oxygen tensions throughout the length of the flap. These findings have potential implications for the patients undergoing antiangiogenesis therapy who require surgical reconstruction
— id: 42683, year: 2004, vol: 52, page: 512, stat: Journal Article,

Quantitative and reproducible murine model of excisional wound healing
Galiano, Robert D; Michaels, Joseph 5th; Dobryansky, Michael; Levine, Jamie P; Gurtner, Geoffrey C
2004 Jul-Aug;12(4):485-492, Wound repair & regeneration
The goal of animal wound healing models is to replicate human physiology and predict therapeutic outcomes. There is currently no model of wound healing in rodents that closely parallels human wound healing. Rodents are attractive candidates for wound healing studies because of their availability, low cost, and ease of handling. However, rodent models have been criticized because the major mechanism of wound closure is contraction, whereas in humans reepithelialization and granulation tissue formation are the major mechanisms involved. This article describes a novel model of wound healing in mice utilizing wound splinting that is accurate, reproducible, minimizes wound contraction, and allows wound healing to occur through the processes of granulation and reepithelialization. Our results show that splinted wounds have an increased amount of granulation tissue deposition as compared to controls, but the rate of reepithelialization is not affected. Thus, this model eliminates wound contraction and allows rodents' wounds to heal by epithelialization and granulation tissue formation. Given these analogies to human wound healing, we believe that this technique is a useful model for the study of wound healing mechanisms and for the evaluation of new therapeutic modalities
— id: 46913, year: 2004, vol: 12, page: 485, stat: Journal Article,

Ex vivo transduction of microvascular free flaps for localized peptide delivery
Michaels, Joseph 5th; Dobryansky, Michael; Galiano, Robert D; Ceradini, Daniel J; Bonillas, Robert; Jones, Deirdre; Seiser, Natalie; Levine, Jamie P; Gurtner, Geoffrey C
2004 Jun;52(6):581-584, Annals of plastic surgery
Gene therapy is a promising modality for the treatment of soft tissue malignancies. Our laboratory has developed a novel technique of gene transfer using microvascular free flaps that addresses many of the current barriers preventing gene therapy from achieving widespread clinical use. Our previous work has demonstrated our ability to transduce free flaps with an adenovirus encoding the reporter gene lacZ. In this current study, we show that microvascular free flaps can be transduced with an adenovirus encoding the angiogenesis inhibitor endostatin with high levels of local flap expression. These transduced free flaps were able to serve as 'biologic pumps' and were able to secrete endostatin into the serum as demonstrated by enzyme-linked immunosorbent assay. This form of 'biologic brachytherapy' could provide a novel approach for the continuous delivery of therapeutic genes to a localized area while avoiding many of the practical obstacles currently limiting gene therapy
— id: 43017, year: 2004, vol: 52, page: 581, stat: Journal Article,

Selective recruitment of endothelial progenitor cells to ischemic tissues with increased neovascularization
Park, Sanghoon; Tepper, Oren M; Galiano, Robert D; Capla, Jennifer M; Baharestani, Samuel; Kleinman, Mark E; Pelo, Catherine R; Levine, Jamie P; Gurtner, Geoffrey C
2004 Jan;113(1):284-293, Plastic & reconstructive surgery
Tissue ischemia remains a common problem in plastic surgery and one for which proangiogenic approaches have been investigated. Given the recent discovery of circulating endothelial stem or progenitor cells that are able to form new blood vessels, the authors sought to determine whether these cells might selectively traffic to regions of tissue ischemia and induce neovascularization. Endothelial progenitor cells were isolated from the peripheral blood of healthy human volunteers and expanded ex vivo for 7 days. Elevation of a cranially based random-pattern skin flap was performed in nude mice, after which they were injected with fluorescent-labeled endothelial progenitor cells (5 x 10(5); n = 15), fluorescent-labeled human microvascular endothelial cells (5 x 10(5); n = 15), or media alone (n = 15). Histologic examination demonstrated that endothelial progenitor cells were recruited to ischemic tissue and first appeared by postoperative day 3. Subsequently, endothelial progenitor cell numbers increased exponentially over time for the remainder of the study [0 cells/mm2 at day 0 (n = 3), 9.6 +/- 0.9 cells/mm2 at day 3 (n = 3), 24.6 +/- 1.5 cells/mm2 at day 7 (n = 3), and 196.3 +/- 9.6 cells/mm2 at day 14 (n = 9)]. At all time points, endothelial progenitor cells localized preferentially to ischemic tissue and healing wound edges, and were not observed in normal, uninjured tissues. Endothelial progenitor cell transplantation led to a statistically significant increase in vascular density in ischemic tissues by postoperative day 14 [28.7 +/- 1.2 in the endothelial progenitor cell group (n = 9) versus 18 +/- 1.1 in the control media group (n = 9) and 17.7 +/- 1.0 in the human microvascular endothelial cell group (n = 9; p < 0.01)]. Endothelial progenitor cell transplantation also showed trends toward increased flap survival [171.2 +/- 18 mm2 in the endothelial progenitor cell group (n = 12) versus 134.2 +/- 10 mm2 in the media group (n = 12) and 145.0 +/- 13 mm2 in the human microvascular endothelial cell group (n = 12)], but this did not reach statistical significance. These findings indicate that local tissue ischemia is a potent stimulus for the recruitment of circulating endothelial progenitor cells. Systemic delivery of endothelial progenitor cells increased neovascularization and suggests that autologous endothelial progenitor cell transplantation may have a role in the salvage of ischemic tissue
— id: 41997, year: 2004, vol: 113, page: 284, stat: Journal Article,

Electromagnetic fields increase in vitro and in vivo angiogenesis through endothelial release of FGF-2
Tepper, Oren M; Callaghan, Matthew J; Chang, Edward I; Galiano, Robert D; Bhatt, Kirit A; Baharestani, Samuel; Gan, Jean; Simon, Bruce; Hopper, Richard A; Levine, Jamie P; Gurtner, Geoffrey C
2004 Aug;18(11):1231-1233, FASEB journal
Pulsed electromagnetic fields (PEMF) have been shown to be clinically beneficial, but their mechanism of action remains unclear. The present study examined the impact of PEMF on angiogenesis, a process critical for successful healing of various tissues. PEMF increased the degree of endothelial cell tubulization (sevenfold) and proliferation (threefold) in vitro. Media from PEMF cultures had a similar stimulatory effect, but heat denaturation ablated this activity. In addition, conditioned media was able to induce proliferative and chemotactic changes in both human umbilical vein endothelial cells and fibroblasts, but had no effect on osteoblasts. Angiogenic protein screening demonstrated a fivefold increase in fibroblast growth factor beta-2 (FGF-2), as well as smaller increases in other angiogenic growth factors (angiopoietin-2, thrombopoietin, and epidermal growth factor). Northern blot analysis demonstrated an increase in FGF-2 transcription, and FGF-2 neutralizing antibody inhibited the effects of PEMF. In vivo, PEMF exposure increased angiogenesis more than twofold. We conclude that PEMF augments angiogenesis primarily by stimulating endothelial release of FGF-2, inducing paracrine and autocrine changes in the surrounding tissue. These findings suggest a potential role for PEMF in therapeutic angiogenesis
— id: 48193, year: 2004, vol: 18, page: 1231, stat: Journal Article,

Skin graft vascularization: regulated regression and replacement of endothelial cells
Capla, JM; Tepper, O; Bhatt, K; Galiano, R; Ceradini, D; Michaels, J; Dobryansky, M; Ashinoff, R; Levine, J; Gurtner, G
2003 SEP ;197(3):S61-S61, Journal of the American College of Surgeons
— id: 55523, year: 2003, vol: 197, page: S61, stat: Journal Article,

Microvascular based tissue engineering using a novel perfusion bioreactor
Ceradini, DJ; Cetrulo, C; Michaels, J; Dobryansky, M; Ashinoff, R; Bhatt, K; Galiano, R; Levine, J; Gurtner, G
2003 SEP ;197(3):S57-S57, Journal of the American College of Surgeons
— id: 55522, year: 2003, vol: 197, page: S57, stat: Journal Article,

CXCR4/SDF-1 mediates selective endothelial progenitor cell recruitment to ischemic endothelium
Ceradini, DJ; Tepper, O; Capla, J; Michaels, J; Dobryansky, M; Ashinoff, R; Pelo, C; Galiano, R; Levine, J; Gurtner, G
2003 SEP ;197(3):S101-S101, Journal of the American College of Surgeons
— id: 55526, year: 2003, vol: 197, page: S101, stat: Journal Article,

Ischemia-induced recruitment of circulating endothelial progenitor cells is mediated by CXCR4/SDF-1 interactions
Ceradini, DJ; Tepper, OM; Capla, JM; Pelo, CR; Michaels, J; Galiano, RD; Levine, JP; Gurtner, GC
2003 OCT 28 ;108(17):298-299, Circulation
— id: 42563, year: 2003, vol: 108, page: 298, stat: Journal Article,

Vascularized acellular dermal matrix island flaps for the repair of abdominal muscle defects
Chung, Seum; Hazen, Alexes; Levine, Jamie P; Baux, Germania; Olivier, Wendy-Ann M; Yee, Herman T; Margiotta, Michael S; Karp, Nolan S; Gurtner, Geoffrey C
2003 Jan;111(1):225-232, Plastic & reconstructive surgery
The potential widespread use of tissue-engineered matrices in soft-tissue reconstruction has been limited by the difficulty in fabricating and confirming a functional microcirculation. Acellular dermal matrix placed in a soft-tissue pocket acts as a scaffold to be incorporated by the host's fibrovascular tissue. A new method for noninvasive real-time observation of functional microvascular networks using orthogonal polarization spectral (OPS) imaging has recently been reported. Arterioles, venules, and capillaries can be directly visualized, and the movement of individual blood cells through them can be observed. The present study was performed to investigate the use of prefabricated acellular dermal matrix with an arteriovenous unit for the repair of abdominal muscle defects. OPS imaging was used to determine the presence of a functional microcirculation in the neovascularized matrix. In Sprague-Dawley rats, vascularized matrix was prefabricated by placing the superficial epigastric artery and vein on a 2-cm x 2-cm implant-type acellular dermal matrix in the thigh. Three weeks after implantation, the matrix-arteriovenous unit was elevated as an axial-type flap and a 2-cm x 2-cm full-thickness block of abdominal muscle immediately superior to the inguinal ligament was resected. Additional procedures were performed according to group: no repair (group 1, = 20); repair with nonvascularized acellular dermal matrix (group 2, = 20); repair with devascularized acellular dermal matrix (group 3, = 20); and repair with vascularized acellular dermal matrix (group 4, = 20). OPS imaging (field of view, 1 mm in diameter; scan depth range, 0.2 mm) was performed on both sides of each flap on a total of 10 random distal regions before and after pedicle transection in group 3 and with the pedicle preserved in group 4. Hernia rate and duration of survival were compared for 21 days. OPS imaging showed directional blood cell movement through the capillary network in all areas scanned in group 4. No microvascular perfusion was observed after pedicle transection in group 3. Hernia rates of 100, 80, 90, and 0 percent were seen in groups 1, 2, 3, and 4, respectively. Median survival times of 9, 11.5, 9, and 21 postoperative days were noted in groups 1, 2, 3, and 4, respectively. Histopathologic analysis with factor VIII revealed full-thickness infiltration of the matrix by endothelial cells, signifying newly formed blood vessels. Repair of abdominal muscle defects using vascularized acellular dermal matrix resulted in no hernia and survival of all animals for the duration of study. However, repairs using avascular or devascularized matrix resulted in significant rates of hernia and decreased survival. Acellular dermal matrix can be prefabricated into vascularized tissue using an arteriovenous unit and used successfully to repair abdominal muscle defects. OPS imaging allowed for high-contrast direct visualization of microcirculation in previously acellular tissue following prefabrication with an arteriovenous unit
— id: 33783, year: 2003, vol: 111, page: 225, stat: Journal Article,

Microvascular free-tissue transfer for traumatic defects of the upper extremity: a 25-year experience
Derderian, Christopher A; Olivier, Wendy-Ann M; Baux, Germania; Levine, Jamie; Gurtner, Geoffrey C
2003 Nov;19(7):455-462, Journal of reconstructive microsurgery
Microvascular free-tissue transfer has been a major advance in the treatment of complex traumatic defects of the upper extremity. One hundred and fifty microvascular free-tissue transfers were performed in 133 patients with complex traumatic upper extremity defects at Bellevue Hospital Center from 1976 to 2000. The indication for microvascular free tissue transfers was exposure of vital structure (81 percent), bone defect (11 percent), and functional deficit (8 percent). The parascapular region was the most common donor site used (26 percent). Microvascular free-tissue transfer was performed either emergently at the time of injury (9.3 percent), during days 1 to 5 post injury (19.3 percent), during days 6 to 21 (19.3 percent), or after day 21 (52 percent). The overall flap failure rate was 9 percent. A decreased incidence of flap failure was observed in patients treated from 6 to 21 days post injury (3 percent p<0.05). The most common acute complication was infection at the recipient site, observed in 14 percent of patients overall. A decreased incidence of recipient-site infection was seen in patients who received free flaps at days 6 to 21 (3 percent; p<0.05). In long-term follow-up, the incidences of osteomyelitis and nonunion were lowest in patients treated from 6 to 21 days post injury (0.0 percent and 11 percent, respectively; p<0.05). During the last 10 years, the timing of reconstruction has been altered, and now preferentially microvascular free flaps are performed 6 to 21 days post injury. The treatment algorithm has been simplified and now only four different flaps are used in the majority of patients (70 percent). With this, the authors have witnessed a decrease in failure rates from 11 percent to 4 percent, a decrease in recipient-site infections from 16 percent to 10 percent and a decrease in osteomyelitis from 12 percent to 4 percent. The preferred timing for microvascular free-tissue transfers to the upper extremity is concluded to be 6 to 21 days post injury
— id: 46277, year: 2003, vol: 19, page: 455, stat: Journal Article,

High glucose impairs the hypoxic upregulation of VEGF by modulating HIF-1a activity
Galiano, RD; Pelo, CR; Ceradini, D; Capla, JM; Levine, JP; Gurtner, GC
2003 OCT 28 ;108(17):170-170, Circulation
— id: 42562, year: 2003, vol: 108, page: 170, stat: Journal Article,

Increased circulating AC133+ CD34+ endothelial progenitor cells in children with hemangioma
Kleinman, Mark E; Tepper, Oren M; Capla, Jennifer M; Bhatt, Kirit A; Ceradini, Daniel J; Galiano, Robert D; Blei, Francine; Levine, Jamie P; Gurtner, Geoffrey C
2003 ;1(4):301-307, Lymphatic Research & Biology
Hemangioma is the most common soft-tissue tumor of infancy. Despite the frequency of these vascular tumors, the origin of hemangioma-endothelial cells is unknown. Circulating endothelial progenitor cells (EPCs) have recently been identified as vascular stem cells with the capacity to contribute to postnatal vascular development. We have attempted to determine whether circulating EPCs are increased in hemangioma patients and thereby provide insight into the role of EPCs in hemangioma growth. METHODS AND RESULTS: Peripheral blood mononuclear cells (PBMCs) were isolated from hemangioma patients undergoing surgical resection (N = 5) and from age-matched controls (N = 5) undergoing strabismus correction surgery. PBMCs were stained with fluorescent-labeled antibodies for AC133, CD34, and VEGFR2/KDR. Fluorescent-labeled isotype antibodies served as negative controls. Histologic sections of surgical specimens were stained with the specific hemangioma markers Glut1, CD32, and merosin, to confirm the diagnosis of common hemangioma of infancy. EPCs harvested from healthy adult volunteers were stained with Glut1, CD32, and merosin, to assess whether cultured EPCs express known hemangioma markers. Hemangioma patients had a 15-fold increase in the number of circulating CD34 AC133 dual-staining cells relative to controls (0.78+/-0.14% vs.0.052+/-0.017%, respectively). Similarly, the number of PBMCs that stained positively for both CD34 and KDR was also increased in hemangioma patients (0.49+/-0.074% vs. 0.19+/-0.041% in controls). Cultured EPCs stained positively for the known hemangioma markers Glut1, CD32, merosin. CONCLUSIONS: This is the first study to suggest a role for EPCs in the pathogenesis of hemangioma. Our results imply that increased levels of circulating EPCs may contribute to the formation of this vascular tumor
— id: 49078, year: 2003, vol: 1, page: 301, stat: Journal Article,

Increased circulating endothelial progenitor cells in children with hemangioma
Kleinman, ME; Tepper, O; Capla, J; Galiano, R; Chang, E; Ceradini, D; Levine, J; Gurtner, G
2003 SEP ;197(3):S62-S62, Journal of the American College of Surgeons
— id: 55524, year: 2003, vol: 197, page: S62, stat: Journal Article,

Cellular dysfunction in the diabetic fibroblast: impairment in migration, vascular endothelial growth factor production, and response to hypoxia
Lerman, Oren Z; Galiano, Robert D; Armour, Mary; Levine, Jamie P; Gurtner, Geoffrey C
2003 Jan;162(1):303-312, American journal of pathology
Although it is known that systemic diseases such as diabetes result in impaired wound healing, the mechanism for this impairment is not understood. Because fibroblasts are essential for wound repair, we compared the in vitro behavior of fibroblasts cultured from diabetic, leptin receptor-deficient (db/db) mice with wild-type fibroblasts from mice of the same genetic background in processes important during tissue repair. Adult diabetic mouse fibroblast migration exhibited a 75% reduction in migration compared to normal fibroblasts (P < 0.001) and was not significantly stimulated by hypoxia (1% O(2)), whereas wild-type fibroblast migration was up-regulated nearly twofold in hypoxic conditions (P < 0.05). Diabetic fibroblasts produced twice the amount of pro-matrix metalloproteinase-9 as normal fibroblasts, as measured by both gelatin zymography and enzyme-linked immunosorbent assay (P < 0.05). Adult diabetic fibroblasts exhibited a sevenfold impairment in vascular endothelial growth factor (VEGF) production (4.5 +/- 1.3 pg/ml versus 34.8 +/- 3.3 pg/ml, P < 0.001) compared to wild-type fibroblasts. Moreover, wild-type fibroblast production of VEGF increased threefold in response to hypoxia, whereas diabetic fibroblast production of VEGF was not up-regulated in hypoxic conditions (P < 0.001). To address the question whether these differences resulted from chronic hyperglycemia or absence of the leptin receptor, fibroblasts were harvested from newborn db/db mice before the onset of diabetes (4 to 5 weeks old). These fibroblasts showed no impairments in VEGF production under basal or hypoxic conditions, confirming that the results from db/db fibroblasts in mature mice resulted from the diabetic state and were not because of alterations in the leptin-leptin receptor axis. Markers of cellular viability including proliferation and senescence were not significantly different between diabetic and wild-type fibroblasts. We conclude that, in vitro, diabetic fibroblasts show selective impairments in discrete cellular processes critical for tissue repair including cellular migration, VEGF production, and the response to hypoxia. The VEGF abnormalities developed concurrently with the onset of hyperglycemia and were not seen in normoglycemic, leptin receptor-deficient db/db mice. These observations support a role for fibroblast dysfunction in the impaired wound healing observed in human diabetics, and also suggest a mechanism for the poor clinical outcomes that occur after ischemic injury in diabetic patients
— id: 33787, year: 2003, vol: 162, page: 303, stat: Journal Article,

A novel model for precise, accurate measurements of wound healing in mice
Michaels, J; Galiano, R; Ashinoff, R; Ceradini, D; Dobryansky, M; Bhatt, K; Cetrulo, C; Capla, J; Levine, J; Gurtner, G
2003 SEP ;197(3):S55-S55, Journal of the American College of Surgeons
— id: 55521, year: 2003, vol: 197, page: S55, stat: Journal Article,

Reliable assessment of skin flap viability using orthogonal polarization imaging
Olivier, Wendy-Ann M; Hazen, Alexes; Levine, Jamie P; Soltanian, Hooman; Chung, Seum; Gurtner, Geoffrey C
2003 Aug;112(2):547-555, Plastic & reconstructive surgery
Intraoperative evaluation of skin flap viability has primarily been dependent on clinical judgment. The purpose of this study was to determine whether an orthogonal polarization spectral imaging device could be used to accurately predict viability of random-pattern skin flaps. Orthogonal polarization spectral imaging is a newly developed technique that visualizes the microcirculation using reflected light without the use of fluorescent dyes and allows for noninvasive real-time observation of functional microvascular networks. In Sprague-Dawley rats (n = 24), three types of random skin flaps were designed with unknown zones of viability (n = 8 per group). After flap elevation, the skin flaps were evaluated by both clinical examination and orthogonal polarization spectral imaging. Areas of the flap determined to be nonviable by clinical examination were measured and marked. Orthogonal polarization spectral imaging was subsequently performed, and areas of the skin flap with stasis (i.e., cessation of red blood cell movement) in the dermal microcirculation on orthogonal polarization spectral imaging were measured and marked. The skin flaps were then secured in place. Flaps were evaluated on a daily basis for clinical signs of ischemia and necrosis. On postoperative day 7, the total amount of random skin flap necrosis was measured and recorded. Clinical examination of the random skin flaps significantly underestimated the actual amount of eventual flap necrosis, and as result was a very poor predictor of flap necrosis. By contrast, assessment of microcirculatory stasis using the orthogonal polarization spectral imaging device correlated well with the subsequent development of necrosis in all groups. In the three groups, the average amount of flap necrosis predicted by clinical examination deviated from actual necrosis by approximately 2 to 4 cm. However, the amount that orthogonal polarization spectral imaging differed from actual necrosis was 0.1 to 0.3 cm. Therefore, orthogonal polarization spectral imaging was an excellent predictor of eventual flap necrosis and much more accurate than clinical observation (p < 0.001). Intraoperative evaluation of axial and random pattern flap viability has traditionally been based on clinical examination as no other reliable, convenient test currently exists. The authors demonstrated that an orthogonal polarization spectral imaging device accurately predicts zones of necrosis in random pattern flaps by directly visualizing cessation of microcirculatory flow. Intraoperative stasis in the dermal microcirculation correlated precisely with subsequent flap necrosis. Orthogonal polarization spectral imaging was significantly more accurate than clinical examination, which consistently underestimated flap necrosis. The orthogonal polarization spectral imaging technique may have value in the intraoperative assessment of skin flap perfusion such as that required after skin-sparing mastectomy
— id: 41998, year: 2003, vol: 112, page: 547, stat: Journal Article,

Comparison of tensile strength and thrombus formation between mechanical microvascular anastomoses using a biodegradable ring device and sutured anastomoses - Invited discussion
Levine, JP; Ahn, CY
2002 FEB ;18(2):137-139, Journal of reconstructive microsurgery
— id: 55326, year: 2002, vol: 18, page: 137, stat: Journal Article,

Type-II diabetes alters endothelial progenitor cell characteristics important for blood vessel growth
Tepper, OM; Galiano, RD; Capla, J; Kalka, C; Gagne, PJ; Jacobowitz, GR; Levine, JP; Gurtner, GC
2002 NOV 5 ;106(19):563-563, Circulation
— id: 37206, year: 2002, vol: 106, page: 563, stat: Journal Article,

Human endothelial progenitor cells from type II diabetics exhibit impaired proliferation, adhesion, and incorporation into vascular structures
Tepper, Oren M; Galiano, Robert D; Capla, Jennifer M; Kalka, Christoph; Gagne, Paul J; Jacobowitz, Glen R; Levine, Jamie P; Gurtner, Geoffrey C
2002 Nov 26;106(22):2781-2786, Circulation
BACKGROUND: The recent discovery of circulating endothelial progenitor cells (EPCs) has altered our understanding of new blood vessel growth such as occurs during collateral formation. Because diabetic complications occur in conditions in which EPC contributions have been demonstrated, EPC dysfunction may be important in their pathophysiology. METHODS AND RESULTS: EPCs were isolated from human type II diabetics (n=20) and age-matched control subjects (n=20). Proliferation of diabetic EPCs relative to control subjects was decreased by 48% (P<0.01) and inversely correlated with patient levels of hemoglobin A1C (P<0.05). Diabetic EPCs had normal adhesion to fibronectin, collagen, and quiescent endothelial cells but a decreased adherence to human umbilical vein endothelial cells activated by tumor necrosis factor-alpha (TNF-alpha) (P<0.05). In a Matrigel assay, diabetic EPCs were 2.5 times less likely to participate in tubule formation compared with controls (P<0.05). CONCLUSIONS: These findings suggest that type II diabetes may alter EPC biology in processes critical for new blood vessel growth and may identify a population at high risk for morbidity and mortality after vascular occlusive events
— id: 33172, year: 2002, vol: 106, page: 2781, stat: Journal Article,

Restoration of abdominal wall integrity as a salvage procedure in difficult recurrent abdominal wall hernias using a method of wide myofascial release
Levine JP; Karp NS
2001 Mar;107(3):707-716, Plastic & reconstructive surgery
The management of primary and recurrent giant incisional hernias remains a complex and frustrating challenge even with multiple alloplastic and autogenous closure options. The purpose of this study was to develop a reconstructive technique of restoring abdominal wall integrity to a subcategory of patients, who have failed initial hernia therapy, by performing superior and lateral myofascial release. Over a 1.5-year period, 10 patients with previously unsuccessful treatment of abdominal wall hernias, using either primary repair or placement of synthetic material, were studied. The patients had either recurrence of the hernia or complications such as infections requiring removal of synthetic material. The hernias were not able to be treated with standard primary closure techniques or synthetic material. The average defect size was 19 x 9 cm. Each patient underwent wide lysis of bowel adhesions releasing the posterior abdominal wall fascia to the posterior axillary line, subcutaneous release of the anterior abdominal wall fascia to a similar level, and complete removal of any synthetic material (if present). The abdominal domain was reestablished by releasing the laterally retracted abdominal wall. The amount of available abdominal wall tissue was increased by wide release of the cephalic abdominal wall fascia overlying the costal margin and the external oblique fascia and muscle laterally. If needed, partial thickness of the internal oblique muscle and its anterior fascia were also released laterally to perform a tension-free primary closure of the defect. All repairs were closed with satisfactory functional and aesthetic results. All alloplastic material was removed. Fascial release was limited so as to close only the hernia defect without tension. No significant release of the rectus sheath and muscle was needed. Good, dynamic muscle function was noted postoperatively. All repairs have remained intact, and no further abdominal wall hernias have been noted on follow-up
— id: 21200, year: 2001, vol: 107, page: 707, stat: Journal Article,

Hyponatremia in the postoperative craniofacial pediatric patient population: a connection to cerebral salt wasting syndrome and management of the disorder
Levine JP; Stelnicki E; Weiner HL; Bradley JP; McCarthy aJ JG
2001 Nov;108(6):1501-1508, Plastic & reconstructive surgery
Hyponatremia after cranial vault remodeling has been noted in a pediatric patient population. If left untreated, the patients may develop a clinical hypoosmotic condition that can lead to cerebral edema, increased intracranial pressure, and eventually, to central nervous system and circulatory compromise. The hyponatremia has traditionally been attributed to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH); however, in our patients the treatment has been resuscitation with normal saline as opposed to fluid restriction (the accepted treatment of SIADH), thus placing the diagnosis of SIADH in question. Patients who developed hyponatremia after intracranial injury or surgery were, until recently, grouped together as having SIADH. However, there are diagnosis and treatment differences between SIADH and another distinct but poorly understood disorder that is designated cerebral salt wasting syndrome (CSW). CSW is associated with increased urine output and increased urine sodium concentration and volume contraction, and it is frequently seen after a central nervous system trauma. We therefore developed a prospective study to evaluate the cause of the sodium imbalance.Ten consecutive pediatric patients who underwent intracranial surgery for various craniosynostotic disorders were postoperatively monitored in the pediatric intensive care unit for hemodynamic, respiratory, and fluid management. The first four patients were evaluated for electrolyte changes and overall fluid balance to determine the consistency with which these changes occurred. The remaining six patients had daily (including preoperative) measurement of serum electrolytes, urine electrolytes, urine osmolarity, serum antidiuretic hormone (ADH), aldosterone, and atrial natriuretic hormone (ANH). All patients received normal saline intravenous replacement fluid in the postoperative period.All of the patients developed a transient hyponatremia postoperatively, despite normal saline resuscitation. Serum sodium levels as low as 128 to 133 mEq per liter (normal, 137 to 145 mEq per liter) were documented in the patients. All patients had increased urine outputs through the fourth postoperative day (>1 cc/kg/h). The six patients who were measured had an increased ANH level, with a peak value as high as 277 pg/ml (normal, 25 to 77 pg/ml). ADH levels were low or normal in all but one patient, who had a marked increase in ADH and ANH. Aldosterone levels were variable. On the basis of these results, all but one patient showed evidence of CSW characterized by increased urine output, normal or increased urine sodium, low serum sodium, and increased ANH levels. The other patient had similar clinical findings consistent with CSW but also had an increase in ADH, thus giving a mixed laboratory picture of SIADH and CSW.The association of CSW to cranial vault remodeling has previously been ignored. This study should prompt reevaluation of the broad grouping of SIADH as the cause of all hyponatremic episodes in our postoperative patient population. An etiologic role has been given to ANH and to other, as yet undiscovered, central nervous system natriuretic factors. All of the patients studied required normal saline resuscitation, a treatment approach that is contrary to the usual management of SIADH. These findings should dictate a change in the postoperative care for these patients. After cranial vault remodeling, patients should prophylactically receive normal saline, rather than a more hypotonic solution, to avoid sodium balance problems
— id: 24279, year: 2001, vol: 108, page: 1501, stat: Journal Article,

Auricular reconstruction: indications for autogenous and prosthetic techniques
Thorne CH; Brecht LE; Bradley JP; Levine JP; Hammerschlag P; Longaker MT
2001 Apr 15;107(5):1241-1252, Plastic & reconstructive surgery
Learning Objectives: After studying this article, the participant should be able to: 1. Describe the alternatives for auricular reconstruction. 2. Discuss the pros and cons of autogenous reconstruction of total or subtotal auricular defects. 3. Enumerate the indications for prosthetic reconstruction of total or subtotal auricular defects. 4. Understand the complexity of and the expertise required for prosthetic reconstruction of auricular defects.The indications for autogenous auricular reconstruction versus prosthetic reconstruction with osseointegrated implant-retained prostheses were outlined in Plastic and Reconstructive Surgery in 1994 by Wilkes et al. of Canada, but because of the relatively recent Food and Drug Administration approval (1995) of extraoral osseointegrated implants, these indications had not been examined by a surgical unit in the United States. The purpose of this article is to present an evolving algorithm based on an experience with 98 patients who underwent auricular reconstruction over a 10-year period. From this experience, the authors conclude that autogenous reconstruction is the procedure of choice in the majority of pediatric patients with microtia. Prosthetic reconstruction of the auricle is considered in such pediatric patients with congenital deformities for the following three relative indications: (1) failed autogenous reconstruction, (2) severe soft-tissue/skeletal hypoplasia, and/or (3) a low or unfavorable hairline. A fourth, and in our opinion the ideal, indication for prosthetic ear reconstruction is the acquired total or subtotal auricular defect, most often traumatic or ablative in origin, which is usually encountered in adults. Although prosthetic reconstruction requires surgical techniques that are less demanding than autogenous reconstruction, construction of the prosthesis is a time-consuming task requiring experience and expertise. Although autogenous reconstruction presents a technical challenge to the surgeon, it is the prosthetic reconstruction that requires lifelong attention and may be associated with late complications. This article reports the first American series of auricular reconstruction containing both autogenous and prosthetic methods by a single surgical team
— id: 20645, year: 2001, vol: 107, page: 1241, stat: Journal Article,

Growth restriction of cranial sutures in the fetal lamb causes deformational changes, not craniosynostosis
Bradley JP; Shahinian H; Levine JP; Rowe N; Longaker MT
2000 Jun;105(7):2416-2423, Plastic & reconstructive surgery
Newborns with in utero cranial vault molding can present with severe forms of plagiocephaly. Intrauterine constraint has been proposed as one cause for craniosynostosis. The purpose of this experiment was to investigate whether rigid plate fixation across a fetal cranial suture, representing a severe form of growth restriction in utero, would lead to cranial suture fusion in a fetal lamb model. Six fetal lambs at 85 to 95 days gestation (term = 145 days) underwent laparotomy, hysterotomy, fetal coronal scalp incision, and miniplate screw fixation across the right coronal suture in utero. Two unoperated twins and four unoperated age-matched lambs were used as controls (n = 12). Animals were killed at both 4 and 8 weeks postoperatively. Fetal head analysis consisted of gross examination, photography, basilar and lateral radiographs, and three-dimensional computed tomographic scans. Cranial suture analysis consisted of imaging by computed tomographic scan (axial and sagittal cuts) and histology of experimentally plated coronal sutures, contralateral nonplated coronal sutures and twin control coronal sutures. Gross examination, radiographs, and three-dimensional computed tomographic analysis of heads with cranial suture plating showed ipsilateral forehead flattening, contralateral forehead bossing, superiorly displaced ipsilateral orbital rim, anterolateral projection of ipsilateral malar eminence, and anterior position of the ipsilateral ear point compared with the contralateral side of the same animal and normal controls. There was no change in nasal root, chin point, or predentition occlusal plane. Although analysis of the plated coronal sutures by computed tomographic scans showed diminished width or even stenosis, the histology revealed narrowed but patent experimental coronal sutures at 4 and 8 weeks. Contralateral, nonplated coronal sutures were not only patent, but widened compared with normal control sutures. This finding may have represented compensatory changes in the contralateral coronal suture caused by growth restriction at the plated suture. These data demonstrate that intrauterine growth restriction across a cranial suture caused by compression plate fixation resulted in deformational skull changes, not craniosynostosis. In addition, these data strongly support a role for in utero positional molding secondary to growth restriction in the maternal pelvis as a cause for nonsynostotic plagiocephaly seen in newborns
— id: 11653, year: 2000, vol: 105, page: 2416, stat: Journal Article,

Managing the tension nose
Constantinides M; Levine J
2000 ;8(4):479-486, Facial plastic surgery clinics of North America
— id: 26024, year: 2000, vol: 8, page: 479, stat: Journal Article,

Hyponatremia in the postoperative pediatric craniofacial population: a connection to cerebral salt wasting syndrome and management of the disorder
Levine JP; Stelnicki E; Weiner HL; Bradley JP; McCarthy JP
2000 ;?:?-?, Journal of neurosurgery
— id: 34018, year: 2000, vol: ?, page: ?, stat: Journal Article,

Softform for facial rejuvenation: historical review, operative techniques, and recent advances
Miller PJ; Levine J; Ahn MS; Maas CS; Constantinides M
2000 ;16(1):23-28, Facial plastic surgery
The deep nasolabial fold and other facial furrows and wrinkles have challenged the facial plastic surgeon. A variety of techniques have been used in the past to correct these troublesome defects. Advances in the last five years in new materials and design have created a subcutaneous implant that has excellent properties. This article reviews the development and use of Softform facial implant
— id: 25992, year: 2000, vol: 16, page: 23, stat: Journal Article,

Increased IGF-I and IGF-II mRNA and IGF-I peptide in fusing rat cranial sutures suggest evidence for a paracrine role of insulin-like growth factors in suture fusion
Bradley JP; Han VK; Roth DA; Levine JP; McCarthy JG; Longaker MT
1999 Jul;104(1):129-138, Plastic & reconstructive surgery
Premature cranial suture fusion, or craniosynostosis, can result in gross aberrations of craniofacial growth. The biology underlying cranial suture fusion remains poorly understood. Previous studies of the Sprague-Dawley rat posterior frontal suture, which fuses at between 12 and 20 days, have suggested that the regional dura mater beneath the cranial suture directs the overlying suture's fusion. To address the dura-suture paracrine signaling that results in osteogenic differentiation and suture fusion, the authors investigated the possible role of insulin-like growth factors (IGF) I and II. The authors studied the temporal and spatial patterns of the expression of IGF-I and IGF-II mRNA and IGF-I peptide and osteocalcin (bone morphogenetic protein-4) protein in fusing posterior frontal rat sutures, and they compared them with patent coronal (control) sutures. Ten Sprague-Dawley rats were studied at the following time points: 16, 18, and 20 days of gestation and 2, 5, 10, 15, 20, 30, 50, and 80 days after birth (n = 110). Posterior frontal and coronal (patent, control) sutures were analyzed for IGF-I and IGF-II mRNA expression by in situ hybridization by using 35S-labeled IGF-I and IGF-II antisense riboprobes. Levels of IGF-I and IGF-II mRNA were quantified by counting the number of autoradiograph signals per cell. IGF-I and osteocalcin immunoreactivity were identified by avidin-biotin peroxidase immunohistochemistry. IGF-I and IGF-II mRNA were expressed in dural cells beneath fusing sutures, and the relative mRNA abundance increased between 2 and 10 days before initiation of fusion. Subsequently, IGF-I and IGF-II mRNA were detected in the suture connective tissue cells at 15 and 20 days during the time of active fusion. In contrast, within large osteoblasts of the osteogenic front, the expression of IGF-I and IGF-II mRNA was minimal. However, IGF-I peptide and osteocalcin protein were intensely immunoreactive within these osteoblasts at 15 days (during the period of suture fusion). These data suggest that the dura-suture interaction may be signaled in a paracrine fashion by dura-derived growth factors, such as IGF-I and IGF-II. These peptides, in turn, stimulate nearby osteoblasts to produce bone-promoting growth factors, such as osteocalcin
— id: 11906, year: 1999, vol: 104, page: 129, stat: Journal Article,

Nasal expansion in the fetal lamb: a first step toward management of cleft nasal deformity in utero
Levine JP; Bradley JP; Shahinian HK; Longaker MT
1999 Mar;103(3):761-767, Plastic & reconstructive surgery
The cleft nasal deformity, a combination of malpositioned cartilage and tissue and postrepair scarring, is a difficult problem to correct. To harness the potential of scarless fetal wound healing, in utero repair of cleft lip and palate deformities has been studied but the fetal cleft nose deformity has not been addressed. The purpose of this study was to manipulate the fetal nasal shape in utero as a first step toward restoration of normal nasal form in cleft nasal deformities. To do this, preformed hypertonic sponges were placed into the right nostril of eight fetal lambs during the second trimester (when scarless cutaneous wound repair is known to occur). Then, the size and shape of fetal nasal structures were analyzed after selected time periods (1, 2, and 6 weeks) with measurements, routine histologic examination, and three-dimensional computed tomographic scans of the experimentally expanded noses compared with the control nonexpanded noses of the birth twins or age-matched specimens. Results showed that experimentally expanded nasal structures had markedly increased in septal length measurement, in nostril area (doubled), and in intranasal volume (more than doubled). Histology showed normal cellular elements without scarring in the tissue sections from the expanded nasal areas. In conclusion, the shape of nasal tissue can be manipulated without scarring in second-trimester fetal lambs after placement of a nasal expansion device. This study is an experimental first step toward restoring normal nasal form by repositioning alar cartilages and soft tissue during fetal cleft repair
— id: 7386, year: 1999, vol: 103, page: 761, stat: Journal Article,

Studies in cranial suture biology: regional dura mater determines overlying suture biology
Levine JP; Bradley JP; Roth DA; McCarthy JG; Longaker MT
1998 May;101(6):1441-1447, Plastic & reconstructive surgery
The influence of dura mater on adjacent cranial sutures is significant. By better understanding the mechanisms of normal suture fusion and the role of the dura mater, it may be possible to delineate the events responsible for the premature suture fusion seen in craniosynostosis. In the Sprague-Dawley rat, the posterior frontal suture normally fuses between 12 and 20 days of postnatal life and has proved to be an excellent model to describe normal suture fusion. The purpose of this study was to document the critical role that the dura mater-suture complex may play on cranial suture biology. Forty Sprague-Dawley rats at 8 days of age were divided into two groups of 20 animals each. The control group (group A) had surgical disruption of the dura mater-calvarial interface. This was accomplished by elevating a strip of cranium inclusive of the posterior frontal and sagittal sutures and replacement of the cranial strip back to its anatomic position, all with the dura mater left intact. The experimental group (group B) had the same calvarial elevation (strip craniectomy), but the sutural anatomy/alignment was rotated 180 degrees. This rotation placed the posterior frontal suture into the sagittal suture's anatomic position and the sagittal suture into the posterior frontal suture's anatomic position. All of these procedures were accomplished by leaving the underlying dura mater intact. Animals were killed at 20, 30, 40, and 50 days (12, 22, 32, and 42 days postoperatively), and tissue sections were examined with hematoxylin and eosin staining. Group A (control) showed normal but delayed suture activity. The posterior frontal suture fused, and the sagittal suture remained patent. Fusion was delayed, not beginning before 20 days (12 days postoperative) and showing complete fusion between 30 and 40 days. Group B (180-degree calvarial rotation) demonstrated that the suture in the posterior frontal anatomic position (actual sagittal suture) fused between 20 and 40 days, whereas the suture in the sagittal anatomic position (actual posterior-frontal suture) remained patent throughout the study. This study demonstrates that the location of the dura mater-suture complex is important in determining either suture patency or closure in this model. Normal closure of the suture overlying the posterior frontal dura mater demonstrates that the dura mater itself, or forces derived in specific cranial locations, determines the overlying suture biology
— id: 7654, year: 1998, vol: 101, page: 1441, stat: Journal Article,

The combination of endoscopy and distraction osteogenesis in the development of a canine midface advancement model
Levine JP; Rowe NM; Bradley JP; Williams JK; Mackool RJ; Longaker MT; McCarthy JG
1998 Sep;9(5):423-432, Journal of craniofacial surgery
The requirements for reconstruction in patients with midface hypoplasia can be formidable: a bicoronal scalp incision, Le Fort III or monobloc skeletal advancement, harvesting and insertion of bone grafts, application of rigid (and occasionally intermaxillary) fixation, blood transfusions, and prolonged operative time and hospitalization. The introduction of the endoscope offers the possibility of minimally invasive surgery with improved visualization of the osteotomy sites. The development of distraction osteogenesis as a surgical technique allows controlled and gradual advancement of the osteotomized skeletal segment and associated soft tissue. The purpose of this study was to develop a canine model of an endoscopically assisted Le Fort III osteotomy with attendant midface distraction. Four mongrels (20 kg in weight) were study subjects. Three 2-cm skin incisions were made (two perpendicular to the zygomaticomaxillary suture and one perpendicular to the nasofrontal suture). The soft tissue and periosteum were evaluated bluntly. Retractors specially designed for the project created a space for endoscopic visualization. Bilateral zygomatic, nasofrontal, and medial orbital wall osteotomies, corticotomies, or both were performed under endoscopic visualization using a reciprocating saw; the medial orbital wall sectioning was specifically not completed (i.e., corticotomy) to avoid laceration of the mucosa and attendant bleeding. The pterygomaxillary osteotomy was completed with an osteotome and mallet. Finally, the nasal septum was only partially divided with an osteotome to avoid excessive blood loss. Four distraction devices were placed across the above-noted osteotomies (two across the nasofrontal osteotomy and one across each lateral osteotomy). The animals were distracted 1 mm per day for 16 to 40 days after surgery (16-40 mm of linear distraction). Cephalograms and computed tomography scans were obtained before and after distraction. The animals were killed after remaining in fixation for 4 to 6 weeks after distraction. All soft tissue was removed and the skull was examined. Photos were obtained throughout the experiment for documentation. The study demonstrated that Le Fort III osteotomies can be performed successfully via small incisions with endoscopic assistance in canine subjects with excellent visualization and minimal bleeding. The advancement of the midface segment can be achieved by activation of an external distraction device
— id: 7652, year: 1998, vol: 9, page: 423, stat: Journal Article,

Studies in cranial suture biology: up-regulation of transforming growth factor-beta1 and basic fibroblast growth factor mRNA correlates with posterior frontal cranial suture fusion in the rat
Most D; Levine JP; Chang J; Sung J; McCarthy JG; Schendel SA; Longaker MT
1998 May;101(6):1431-1440, Plastic & reconstructive surgery
The mechanisms involved in normal cranial suture development and fusion as well as in the pathophysiology of craniosyostosis are not well understood. The purpose of this study was to investigate the expression of several cytokines--transforming growth factor-beta-1 (TGF-beta1), basic fibroblast growth factor (bFGF), and interleukin-6 (IL-6)--during cranial suture fusion. TGF-beta exists in three mammalian isoforms that are abundant in bone and stimulate calvarial bone formation when delivered locally. Other bone growth factors including basic fibroblast growth factor and the interleukins regulate bone growth and are mitogenic for bone marrow cells and osteoblasts. The involvement of growth factors in the pathophysiology of craniosynostosis is supported by recent genetics data linking fibroblast growth factor receptor mutations to syndromal craniosynostoses. In this experimental study, in situ hybridization was used to localize and quantify the gene expression of TGF-beta1, bFGF, and IL-6 during cranial suture fusion. In the Sprague-Dawley rat, the posterior frontal cranial suture normally undergoes fusion between 12 and 22 days of age, whereas all other cranial sutures remain patent. All in situ analyses of fusing posterior frontal sutures were compared with the patent, control, sagittal sutures. Posterior frontal and sagittal sutures, together with underlying dura, were harvested from rats at 8, 12, 16, and 35 days of postnatal life to analyze posterior frontal suture activity before, during, and after fusion. In situ hybridization was performed on frozen sections of these specimens using DNA probes specific for TGF-beta1, bFGF, and IL-6 mRNA. A negative control probe to IL-6 in the sense orientation was also used to validate the procedure. Cells expressing cytokine-specific mRNA were quantified (in cells positive per 10(-1) mm2) and analyzed using the unpaired Student's t test. Areas encompassing the fibrous suture and the surrounding bone plates were analyzed for cellular mRNA activity. IL-6 mRNA expression showed a minimal rise in the posterior frontal suture at days 12 and 16, with an average count of 10 and 6 cells per 10(-1) mm2, respectively. The sagittal suture remained negative for IL-6 mRNA at all time points. TGF-beta1 and bFGF analyses were most interesting, showing marked increases specifically in the posterior frontal suture during the time of active suture fusion. On postnatal day 8, a 1.5-fold increase in posterior frontal suture TGF-beta1 mRNA was found compared with sagittal sutures (p = 0.1890, unpaired Student's t test). This difference was increased 26-fold on day 12 in posterior frontal suture TGF-beta1 expression (p = 0.0005). By day 35, posterior frontal suture TGF-beta1 mRNA had nearly returned to prefusion levels, whereas TGF-beta1 mRNA levels in the sagittal suture remained low. A similar upregulation of bFGF mRNA, peaking at day 12, was observed in posterior frontal but not sagittal sutures (p = 0.0003). Furthermore, both TGF-beta1 and bFGF mRNA samples with intact dura showed an intense dural mRNA expression in the time preceding and during active posterior frontal suture fusion but not in sagittal tissues. Our data demonstrate that TGF-beta1 and bFGF mRNA are up-regulated in cranial suture fusion, possibly signaling in a paracrine fashion from dura to suture. TGF-beta1 and bFGF gene expression were dramatically increased both in and surrounding the actively fusing suture and followed the direction of fusion from endocranial to epicranial. These experimental data on bone growth factors support the recent human genetics data linking growth factor/fibroblast growth factor receptor deletions to syndromal craniosynostoses. The ultimate aim of these studies is to understand the underlying mechanisms regulating suture growth, development, and fusion so surgeons may one day manipulate the biology of premature cranial suture fusion
— id: 7967, year: 1998, vol: 101, page: 1431, stat: Journal Article,

Controlled multiplanar distraction of the mandible, Part II: Laboratory studies of sagittal (anteroposterior) and vertical (superoinferior) movements
Williams JK; Rowe NM; Mackool RJ; Levine JP; Hollier LH; Longaker MT; Cutting CB; Grayson BH; McCarthy JG
1998 Nov;9(6):504-513, Journal of craniofacial surgery
The application of distraction osteogenesis in craniofacial surgery has significantly altered the treatment of congenital mandibular deficiencies. However, evaluation of results in both animal studies and clinical cases has revealed deficiencies, particularly in two areas. First, distraction using a uniplanar device in an anteroposterior direction can result in a persistent anterior open bite. Second, the lateralization of the distracted hemimandible was often limited, with insufficient incremental gain in the bigonial distance. To overcome these shortcomings, a multiplanar distraction device was developed and tested in the canine model. This report details canine studies addressing the first problem: combined anteroposterior or sagittal (z-axis) and superoinferior or vertical (y-axis) movements. Six dogs underwent bilateral mandibular distraction with an external (extraoral), multiplanar device and completed sagittal plus vertical distraction. Evaluation included clinical examination (facial form, jaw position, and occlusion), photography, cephalograms (posteroanterior, basilar, and lateral), three-dimensional computed tomography reconstructions, and examination of dry skulls. The dogs averaged 18.5 mm (range, 15-20 mm) of sagittal distraction and 41.0 degrees (range, 21-50 degrees) of vertical distraction. Marked anterior open bites were produced after vertical distraction secondary to premature contact of the maxillary and mandibular molars. Distraction in the vertical direction also had the additive effect of increasing the sagittal gains by approximately 5% to 10%. In conclusion, a multiplanar distraction device (with the potential for distraction in three planes) was effective in increasing mandibular anteroposterior thrust (sagittal distraction) and also in creating an anterior open bite (vertical or superoinferior distraction). Vertical distraction probably requires bilateral osteotomies to obtain optimal results. The preliminary gains in sagittal length are modified (reduced or increased) after distraction in a second plane (vertical and horizontal). Specifically, vertical distraction in the inferior direction (creating an open bite) also leads to isolated increases in the anteroposterior plane. Conversely, vertical distraction in the superior direction (closing an open bite), as seen in a human malocclusion, may lead to isolated decreases in the anteroposterior plane, but this question remains to be investigated in the laboratory
— id: 7853, year: 1998, vol: 9, page: 504, stat: Journal Article,

Studies in cranial suture biology: regional dura mater determines in vitro cranial suture fusion
Bradley JP; Levine JP; McCarthy JG; Longaker MT
1997 Oct;100(5):1091-1099, Plastic & reconstructive surgery
Craniosynostosis results in alterations in craniofacial growth that create cosmetic abnormalities and functional deficits, yet the biology underlying cranial suture fusion remains unknown. The purpose of the present study was to show that regional dura mater can induce suture fusion while in an organ culture system in cranial sutures programmed to remain patient. To accomplish this, we studied mouse cranial sutures, since in this model the posterior frontal suture (analogous to the human metopic suture) fuses in both in vivo and in vitro environments while all other sutures remain patent. We demonstrated that when mouse sagittal sutures (programmed to remain patent) were rotated or translocated to overlie the posterior frontal dura then grown in organ culture systems, suture fusion occurred. Twenty-four-day-old CD-1 mice (time when the posterior frontal suture was patent) were divided into three groups of 50 (n = 165: three groups of 50 cultured and three groups of 5 uncultured controls). Group A (unrotated control group) was characterized by a strip of posterior frontal and sagittal suture with underlying dural tissue grown in organ culture systems for up to 30 days and resulted in persistent patency of the sagittal suture and fusion of the posterior frontal suture in an anterior-to-posterior direction. Group B (rotated experimental group) was characterized by 180-degree suture rotation while in vitro and resulted in patency of the posterior frontal suture over the sagittal dura and fusion of the sagittal suture over the posterior frontal dura in a posterior-to-anterior suture direction. Group C (translocated experimental group) was characterized by translocation or shifting of sutures while in vitro and resulted in patency of the posterior frontal suture over the sagittal dura and fusion of the sagittal suture over the posterior frontal dura in an anterior-to-posterior suture direction. These data from the in vitro rotation and translocation experiments indicate that the 'regional' posterior frontal dura determined in vitro cranial suture fusion. Molecular mechanisms behind this process are thought to involve inductive tissue interactions of the dural cells with the suture cells by means of growth factor-mediated signal pathways
— id: 7120, year: 1997, vol: 100, page: 1091, stat: Journal Article,

Bone morphogenetic protein promotes vascularization and osteoinduction in preformed hydroxyapatite in the rabbit
Levine JP; Bradley J; Turk AE; Ricci JL; Benedict JJ; Steiner G; Longaker MT; McCarthy JG
1997 Aug;39(2):158-168, Annals of plastic surgery
Early reconstruction of large osseous defects in children is often delayed due to limited availability of autogenous bone graft donor sites. With the advent of growth factors, osteoinductive proteins, and delivery matrices, it is possible to fabricate new bone at extraskeletal sites. Due to their own blood supply, adequate bony volume, and decreased resorption, vascularized bone flaps have demonstrated greater success in restoring large bony defects compared with nonvascularized bone grafts. The purpose of this study is to prefabricate a vascularized bone flap in the immature-age rabbit using the auricularis anterior muscle as a muscle pedicle. Sixteen female New Zealand White rabbits, 2.0 to 2.5 kg, were divided into two groups. Group 1 contained 8 animals that had T-shaped, 10 x 6 x 4-mm hydroxyapatite (HA) implants combined with 100-microgram bovine-derived bone morphogenetic protein (BMP) placed supraperiosteally and fixed deep to the auricularis anterior muscle. Implants with HA alone were placed in the same animal and secured to the contralateral auricularis anterior muscle. Group 2 contained 8 animals that had HA/BMP placed subperiosteally and fixed deep to the auricularis anterior muscle, while implants with HA alone were secured in the same animal to the contralateral auricularis anterior muscle. In each group, 4 animals were sacrificed at 4 and 8 weeks. The animals underwent randomized bilateral carotid artery injection with micropaque barium suspension just prior to sacrifice to help maintain vascularity. At harvest the implants and surrounding muscle and cranium were removed en bloc. New bone formation in the HA implants was examined by using routine histology and scanning electron microscopic backscattering image (quantitative) analysis. Microradiographs were performed on representative specimens. At 4 weeks postimplantation, backscattering analysis in the subperiosteal HA/BMP showed a mean 17.1% bone ingrowth vs. 11.3% of HA alone (p < 0.05). Supraperiosteal HA/BMP showed a mean 12.9% bone ingrowth vs. 0% of HA alone (p < 0.05). At 8 weeks, backscatter analysis of supraperiosteal HA/BMP showed a mean 19.33% bone ingrowth vs. 0% of HA alone (p < 0.05). Subperiosteal HA/BMP showed a mean 22% bone ingrowth vs. 20.85% of HA alone. This was the only group that did not have statistically significant results. Implant histology demonstrated woven bone within the interstices of HA/BMP placed either supra- or subperiosteally. In the HA-alone implants placed supraperiosteally, fibrovascular ingrowth was seen without any evidence of bone formation. In the HA-alone implant placed subperiosteally, woven bone was seen at the calvarium-implant junction. Microradiographs also demonstrated vascularization and bone formation similar to that seen on scanning electron microscopy. BMP-treated specimens appeared to have slightly greater vascularity than the nontreated specimens. The greatest bone formation occurred with the HA/BMP implant placed subperiosteally in the immature rabbit. Furthermore, these results demonstrate the potential prefabrication of vascularized bone flaps as early as 4 to 8 weeks. The clinical advantage of HA permits the surgeon to design osseous flaps that are customized in shape, fill all contour defects, and have little resorptive properties. Such prefabricated bone with an axial blood supply may allow for ultimate transfer as a pedicle or free flap to reconstruct osseous defects in children
— id: 7196, year: 1997, vol: 39, page: 158, stat: Journal Article,

Wound healing is accelerated by agonists of adenosine A2 (G alpha s-linked) receptors
Montesinos MC; Gadangi P; Longaker M; Sung J; Levine J; Nilsen D; Reibman J; Li M; Jiang CK; Hirschhorn R; Recht PA; Ostad E; Levin RI; Cronstein BN
1997 Nov 3;186(9):1615-1620, Journal of experimental medicine
The complete healing of wounds is the final step in a highly regulated response to injury. Although many of the molecular mediators and cellular events of healing are known, their manipulation for the enhancement and acceleration of wound closure has not proven practical as yet. We and others have established that adenosine is a potent regulator of the inflammatory response, which is a component of wound healing. We now report that ligation of the G alpha s-linked adenosine receptors on the cells of an artificial wound dramatically alters the kinetics of wound closure. Excisional wound closure in normal, healthy mice was significantly accelerated by topical application of the specific A2A receptor agonist CGS-21680 (50% closure by day 2 in A2 receptor antagonists. In rats rendered diabetic (streptozotocin-induced diabetes mellitus) wound healing was impaired as compared to nondiabetic rats; CGS-21680 significantly increased the rate of wound healing in both nondiabetic and diabetic rats. Indeed, the rate of wound healing in the CGS-21680-treated diabetic rats was greater than or equal to that observed in untreated normal rats. These results appear to constitute the first evidence that a small molecule, such as an adenosine receptor agonist, accelerates wound healing in both normal animals and in animals with impaired wound healing
— id: 7954, year: 1997, vol: 186, page: 1615, stat: Journal Article,

Studies in cranial suture biology: Part I. Increased immunoreactivity for TGF-beta isoforms (beta 1, beta 2, and beta 3) during rat cranial suture fusion [see comments]
Roth DA; Longaker MT; McCarthy JG; Rosen DM; McMullen HF; Levine JP; Sung J; Gold LI
1997 Mar;12(3):311-321, Journal of bone & mineral research
The mechanisms involved in normal cranial suture development and fusion as well as the pathophysiology of craniosynostosis, a premature fusion of the cranial sutures, are not well understood. Transforming growth factor-beta isoforms (TGF-beta 1, beta 2, and beta 3) are abundant in bone and stimulate calvarial bone formation when injected locally in vivo. To gain insight into the role of these factors in normal growth and development of cranial sutures and the possible etiology of premature cranial suture fusion, we examined the temporal and spatial expression of TGF-beta isoforms during normal cranial suture development in the rat. In the Sprague-Dawley rat, only the posterior frontal cranial suture undergoes fusion between 12 and 22 days of age, while all other cranial sutures remain patent. Therefore, immunohistochemical analysis of the fusing posterior frontal suture was compared with the patent sagittal suture at multiple time points from the fetus through adult. Whereas the intensity of immunostaining was the same in the posterior frontal and sagittal sutures in the fetal rat, there was increased immunoreactivity for TGF-beta isoforms in the actively fusing posterior frontal suture compared with the patent sagittal suture starting 2 days after birth and continuing until approximately 20 days. There were intensely immunoreactive osteoblasts present during fusion of the posterior frontal suture. In contrast, the patent sagittal suture was only slightly immunoreactive. A differential immunostaining pattern was observed among the TGF-beta isoforms; TGF-beta 2 was the most immunoreactive isoform and was also most strongly associated with osteoblasts adjacent to the dura and the margin of the fusing suture. Since the increased expression of TGF-beta 2 during suture fusion suggested a possible regulatory role, recombinant TGF-beta 2 was added directly to the posterior frontal and sagittal sutures in vivo to determine if suture fusion could be initiated. Exogenously added TGF-beta 2 stimulated fusion of the ectocranial surface of the posterior frontal suture. These data provide evidence for a regulatory role for these growth factors in cranial suture development and fusion. Additionally, the intense immunostaining for TGF-beta 2 in the dura mater underlying the fusing suture supports a role for the dura mater in suture fusion. It is possible that premature or excessive expression of these factors may be involved in the etiopathogenesis of craniosynostosis and that modulation of the growth factor profile at the suture site may have potential therapeutic value
— id: 12370, year: 1997, vol: 12, page: 311, stat: Journal Article,

Subcutaneous and retropharyngeal emphysema after dental procedures
Szubin L; La Bruna A; Levine J; Komisar A
1997 Jul;117(1):122-123, Otolaryngology, head & neck surgery
— id: 27104, year: 1997, vol: 117, page: 122, stat: Journal Article,

Studies in cranial suture biology: in vitro cranial suture fusion
Bradley JP; Levine JP; Blewett C; Krummel T; McCarthy JG; Longaker MT
1996 Mar;33(2):150-156, Cleft palate-craniofacial journal
The biology underlying craniosynostosis remains unknown. Previous studies have shown that the underlying dura mater, not the suture itself, signals a suture to fuse. The purpose of this study was to develop an in vitro model for cranial-suture fusion that would still allow for suture-dura interaction, but without the influence of tensional forces transmitted from the cranial base. This was accomplished by demonstrating that the posterior frontal mouse cranial suture, known to be the only cranial suture that fuses in vivo, fuses when plated with its dura in an organ-culture system. In such an organ-culture system, the sutures are free from both the influence of dural forces transmitted from the cranial base and from hormonal influences only available in a perfused system. For the cranial-suture fusion in vitro model study, the sagittal sutures (controls that remain patent in vivo) and posterior frontal sutures (that fuse in vivo) with the underlying dura were excised from 24-day-old euthanized mice, cut into 5 x 4 x 2-mm specimens, and cultured in a chemically defined, serum-free media. One hundred sutures were harvested at the day of sacrifice, then every 2 days thereafter until 30 days in culture, stained with H & E, and analyzed. A subsequent cranial-suture without dura in vitro study was performed in a similar fashion to the first study, but only the calvariae with the posterior frontal or sagittal sutures (without the underlying dura) were cultured. Results from the cranial-suture fusion in vitro model study showed that all sagittal sutures placed in organ culture with the underlying dura remained patent. More importantly, the posterior frontal sutures with the underlying dura, which were plated-down as patent at 24 days of age, demonstrated fusion after various growth periods in organ culture. In vitro posterior frontal mouse-suture fusion occurred in an anterior-to-posterior direction but in a delayed fashion, 4 to 7 days later than in vivo posterior frontal mouse-suture fusion. In contrast, the subsequent cranial-suture without dura in vitro study showed patency of all sutures, including the posterior frontal suture. These data from in vitro experiments indicate that: (1) mouse calvariae, sutures, and the underlying dura survive and grow in organ-culture systems for 30 days; (2) the local dura, free from external influences transmitted from the cranial base and hormones from distant sites, influences the cells of its overlying suture to cause fusion; and (3) without dura influence, all in vitro cranial sutures remained patent. By first identifying the factors involved in dural-suture signaling and then regulating these factors and their receptors, the biologic basis of suture fusion and craniosynostosis may be unraveled and used in the future to manipulate pathologic (premature) suture fusion
— id: 6891, year: 1996, vol: 33, page: 150, stat: Journal Article,

Studies in cranial suture biology: IV. Temporal sequence of posterior frontal cranial suture fusion in the mouse
Bradley JP; Levine JP; Roth DA; McCarthy JG; Longaker MT
1996 Nov;98(6):1039-1045, Plastic & reconstructive surgery
The biology underlying normal and premature cranial suture fusion remains unknown. To develop a model for normal cranial suture fusion, the temporal sequence of the posterior frontal cranial suture fusion in the mouse was determined. To do this, all the cranial sutures of three distinct strains of mice (CD-1, CF-1, and C57bl-6) were studied histologically for fusion at sequential time points. Two studies were set up using group A mice (n = 72, all sutures studied) and group B mice (n = 78, only the posterior frontal suture studied, but more precisely along its anatomic length). In the group A cranial suture study, mice were sacrificed starting at newborn age and then every 5 days until age 50 days. In addition, two mature mice (250 days old) from each strain were sacrificed. In all three mouse strains, histologic examinations showed that the anterior frontal, sagittal, coronal, lambdoid, and occipitointerparietal sutures remained patent at up to 50 days of age and were patent in the 250-day mature mice. However, examination of the midpoint of the posterior frontal suture showed patency at 30 days, partial fusion at 35 days, and complete fusion by 40 days. These data prompted the posterior frontal suture fusion study. In the group B posterior frontal suture fusion study, mice were sacrificed at age 23 days and then every 2 days until 47 days of age. The anterior, midpoint, and posterior aspects of the posterior frontal suture were examined: The anterior aspect fused between 25 and 29 days; the midpoint fused between 31 and 37 days; and the posterior aspect fused between 39 and 45 days. These data indicate that fusion of the posterior frontal cranial suture in the mouse proceeds in a defined temporal sequence from an anterior to posterior direction in three distinct strains of mice, while in the same mice all other cranial sutures remain patent. By describing and understanding the fusion of the normal posterior frontal suture, a biologic basis of normal suture development and fusion can be established and used as a comparison for murine cranial sutures altered surgically, biochemically (with growth factors), or genetically (with craniosynostotic phenotypes)
— id: 12501, year: 1996, vol: 98, page: 1039, stat: Journal Article,

A classification of plagiocephaly utilizing a three-dimensional computer analysis of cranial base landmarks
Glat PM; Freund RM; Spector JA; Levine J; Noz M; Bookstein FL; McCarthy JG; Cutting CB
1996 May;36(5):469-474, Annals of plastic surgery
Plagiocephaly is a term commonly used to describe congenital forehead asymmetry. Previous classification systems based on the various etiologies of dysmorphic crania have been used in an effort to categorize the patients into groups and to assist in treatment planning. The system most commonly used today was described by Bruneteau and Mulliken in 1992. The authors separated frontal plagiocephaly into three types: synostotic, compensational, and deformational. The present study was undertaken in order to define a simple system for classifying plagiocephaly based on Bruneteau and Mulliken's system using the patients' preoperative craniofacial computed tomography scans. The involvement of the entire coronal ring in synostotic plagiocephaly led to the choice of 20 skull base landmarks as the basis of the analysis. Nine lateral landmarks (the superior orbital fissure, the optic foramen, the zygomatic arch, the greater palatine foramen, the foramen ovale, the mastoid tip, the hypoglossal canal, the external auditory canal, and the internal auditory canal) and two midline landmarks (the crista galli and the internal occipital protuberance) were used. The changes that occurred in these landmarks were analyzed in 30 patients. The results demonstrated that Bruneteau and Mulliken's classification system underestimated the number of different subtypes of plagiocephaly. As a result, three major types of frontal plagiocephaly and several different subtypes based on the different etiologies were described. Type I plagiocephaly includes plagiocephaly resulting from cranial suture synostosis. Type II includes those with a nonsynostotic etiology. Type III describes patients with craniofacial microsomia-associated plagiocephaly. Statistical analysis was unavailable because of the small number of patients in each subtype. With a larger number of patients, we hope to refine this system for use by the surgeon in preoperative diagnosis and surgical planning. The analysis is unique in its ability to quantitate changes from normal on the x-, y-, and z-coordinates, and therefore allows for identification of both horizontal (frontal bone deviation) and vertical (ear shear) growth disturbances
— id: 12608, year: 1996, vol: 36, page: 469, stat: Journal Article,

Septoplasty for obstructive sleep apnea in infants after cleft lip repair
Josephson GD; Levine J; Cutting CB
1996 Nov;33(6):473-476, Cleft palate-craniofacial journal
A neonate with a unilateral cleft lip and palate usually presents with a deviated nasal septum due to the asymmetric bony base associated with cleft palate. Prior to repair, the facial cleft offers a wide open breathing passage despite the septal deviation. Cleft lips are traditionally repaired in neonates at about 3 months of age. These patients usually do not present with significant symptoms of nasal obstruction following repair, except in unusual cases. Severe septal deviation may cause obstructive sleep apnea. Repair of septal deformities in children is controversial due to the potential alteration of facial growth. We present two patients with documented obstructive sleep apnea that began after cleft lip repair. Conservative surgical correction of the septal deviation resulted in relief of the sleep apnea
— id: 33293, year: 1996, vol: 33, page: 473, stat: Journal Article,

Studies in cranial suture biology: part II. Role of the dura in cranial suture fusion
Roth DA; Bradley JP; Levine JP; McMullen HF; McCarthy JG; Longaker MT
1996 Apr;97(4):693-699, Plastic & reconstructive surgery
The biology underlying normal and premature cranial suture fusion remains unknown. The purpose of this study was to investigate the role of the dura mater in cranial suture fusion. In the Sprague Dawley rat model, the posterior frontal cranial suture fuses between 10 and 20 days of postnatal life. The effect of separating the posterior frontal cranial suture from its underlying dura mater with an intervening silastic sheet was studied. Sixty rat pups, age 8 days, were divided into four groups of 15. Group A served as unoperated controls. Group B, the experimental group, underwent craniotomy, dural elevation, and insertion of a silicone sheet between the posterior frontal cranial suture and the underlying dura. Two operative sham groups were included. Group C underwent craniotomy and dural deflection only. Group D underwent craniotomy alone without dural deflection. The rats were sacrificed at 15, 22, and 30 days of age. The results showed that the unoperated animals (group A) demonstrated normal initiation of suture fusion at 15 days and complete fusion by 22 days. Group B animals, with silicone sheet barriers placed, showed persistent patency of sutures at 22 days. Initiation of suture fusion was delayed until 30 days. Sham group C, animals with craniotomy and dural deflection, showed that initiation of fusion was delayed until 22 days with complete fusion by 30 days of age. Sham group D, craniotomy alone, had the same normal temporal sequence of suture fusion as the unoperated control group A. These data indicate that normal cranial suture fusion is delayed when the suture-dural interaction is interrupted by a surgically place barrier or by simple dural deflection. Furthermore, interaction between the dura and the overlying suture appears to direct suture fusion
— id: 7911, year: 1996, vol: 97, page: 693, stat: Journal Article,

Predictive value of facial nerve electrophysiologic stimulation thresholds in cerebellopontine-angle surgery
Selesnick, S H; Carew, J F; Victor, J D; Heise, C W; Levine, J
1996 May;106(5 Pt 1):633-638, Laryngoscope
The predictive value of intraoperative stimulation thresholds for facial nerve function, using a constant-current system, was examined in 49 patients undergoing resection of cerebellopontine-angle tumors. Immediately after surgery, 75% of the 0.1-mA threshold group, 42% of the 0.2-mA group, and 18% of the 0.3-mA or greater group had good (grade I or II) facial nerve function. One year after surgery, 90% of the 0.1-mA group, 58% of the 0.2-mA group, and 41% of the 0.3-mA or greater group had grade I or II function. A statistically significant breakpoint of 0.2 mA was found to predict good postoperative facial function. Delayed facial paralysis occurred in 22% of patients, but the prognosis for these patients was favorable. Both current stimulation threshold and duration are necessary for a meaningful comparison of data between investigators
— id: 137257, year: 1996, vol: 106, page: 633, stat: Journal Article,

Acid and alkaline phosphatase activity levels in a mouse cranial suture organ culture system
Winograd, Jonathan M.; Levine, Jamie P.; Sung, Joanne J.; Glat, Paul M.; Im, Michael; Vander Kolk, Craig; McCarthy, Joseph G.; Longaker, Michael T.
1996 ;47(0):728-730, Surgical forum
— id: 98801, year: 1996, vol: 47, page: 728, stat: Journal Article,