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Ancillary Procedures Necessary for Translational Research in Experimental Craniomaxillofacial Surgery

Al-Rakan, Mohammed MD*; Shores, Jaimie T. MD*; Bonawitz, Steve MD*; Santiago, Gabriel MD; Christensen, Joani M. BS*; Grant, Gerald DMD, MS; Murphy, Ryan J. MSE§; Basafa, Ehsan PhD; Armand, Mehran PhD§; Otovic, Pete DVM; Eller, Sue RVT#; Brandacher, Gerald MD*; Gordon, Chad R. DO*

The Journal of Craniofacial Surgery: November 2014 - Volume 25 - Issue 6 - p 2043–2050
doi: 10.1097/SCS.0000000000000935
Original Articles

Introduction Swine are often regarded as having analogous facial skeletons to humans and therefore serve as an ideal animal model for translational investigation. However, there is a dearth of literature describing the pertinent ancillary procedures required for craniomaxillofacial research. With this in mind, our objective was to evaluate all necessary procedures required for perioperative management and animal safety related to experimental craniomaxillofacial surgical procedures such as orthotopic, maxillofacial transplantation.

Methods Miniature swine (n = 9) were used to investigate perioperative airway management, methods for providing nutrition, and long-dwelling intravenous access. Flap perfusion using near-infrared laser angiography and facial nerve assessment with electromyoneurography were explored.

Results Bivona tracheostomy was deemed appropriate versus Shiley because soft, wire-reinforced tubing reduced the incidence of tracheal necrosis. Percutaneous endoscopic gastrostomy tube, as opposed to esophagostomy, provided a reliable route for postoperative feeding. Femoral venous access with dorsal tunneling proved to be an ideal option being far from pertinent neck vessels. Laser angiography was beneficial for real-time evaluation of graft perfusion. Facial electromyoneurography techniques for tracing capture were found most optimal using percutaneous leads near the oral commissure.

Experience shows that ancillary procedures are critical, and malpositioning of devices may lead to irreversible sequelae with premature animal death.

Conclusions Face-jaw-teeth transplantation in swine is a complicated procedure that demands special attention to airway, feeding, and intravascular access. It is critical that each ancillary procedure be performed by a dedicated team familiar with relevant anatomy and protocol. Emphasis should be placed on secure skin-level fixation for all tube/lines to minimize risk for dislodgement. A reliable veterinarian team is invaluable and critical for long-term success.

Supplemental digital content is available in the text.

*Department of Plastic & Reconstructive Surgery, Johns Hopkins University School of Medicine; Departments of †Otolaryngology-Head & Neck Surgery and ‡Radiology, 3D Medical Applications Center, Naval Postgraduate Dental School, Walter Reed National Military Medical Center, Bethesda; §Robotics and Autonomy Group, Research and Engineering Development Department, The Johns Hopkins University Applied Physics Laboratory, Laurel; ∥Laboratory for Computational Sensing & Robotics, Johns Hopkins University; and Departments of ¶Molecular and Comparative Pathobiology and #Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.

Received February 14, 2014.

Accepted for publication February 16, 2014.

Address correspondence and reprint requests to Chad Gordon, DO, Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, 601 N Caroline Street, Baltimore, MD 21287; E-mail:

Supported by the American Society of Maxillofacial Surgery (2011 ASMS Basic Science Research Grant), the American Association of Plastic Surgeons (2012-14 Furnas’ Academic Scholar Award), and the Accelerated Translational Incubator Pilot Program at Johns Hopkins University (funded by the National Institute of Health) as well as by the Johns Hopkins Institute for Clinical and Translational Research, which is funded in part by the National Center for Advancing Translational Sciences, a component of the National Institutes of Health (NIH), and NIH Roadmap for Medical Research.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (

The authors report no conflicts of interest.

© 2014 by Mutaz B. Habal, MD.