Your SlideShare is downloading. ×
0
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Laser Facial Nerve Welding in a Rabbit Model - Temporal Bone ...

426

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
426
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
11
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide
  • Since their invention in the late 1950’s, lasers have been successfully utilized in a variety of medical fields as both diagnostic and therapeutic instruments. As early as the 1960’s, the potential for use of lasers in tissue adhesion was recognized.
  • (9) = Talmor et al. An important advance in laser tissue welding came over the last fifteen years with the introduction of biologic solder materials coupled with wavelength specific chromophores such as indocyanine green, fluorescein, and carbon black (9,10). By doping the biologic solder with a wavelength specific chromophore, laser energy absorption can be exquisitely controlled and confined to just the solder, offering sufficient thermal energy for the welding process while allowing for a reduction of the power threshold required for welding and minimizing collateral damage.
  • While the use of the CO 2 laser in this study reduced the problems of suture nerve repair by producing a “seal” around the nerve through protein denaturation and subsequent fusion of the collagenous portion of the epineurium (20), the use of the CO 2 laser in this study did have some problems.
  • The external surface of the nerve, in contact with the laser activated solder, had denatured and bonded with the solder, due to selective absorption of the laser energy (23).
  • A feasibility study to assess the benefit of laser nerve welding against the gold standard, suture nerve repair.
  • They will administer all pre-operative medications as well as anesthesia. In addition, they will be in the surgical suite to record all vital signs and any additional medication that is administered. Rabbits will be given Buprenorphine (0.05mg/kg SQ) 15 minutes pre-operatively and then anesthetized with Ketamine (40 mg/kg IM) and Xylazine (5mg/kg IM). A pulse oximeter is attached and the veterinary technician records vital signs. The animal’s face bilaterally is then shaved in the region of the zygoma and masseter muscles and then prepared with Chlorhexidine scrub and draped in the usual sterile fashion taking care to keep the eyes covered with an opaque drape. The procedures are then performed under sterile conditions with a surgical operating microscope. A 2.0 to 2.5 cm incision is made over the rabbit zygoma. The superficial platysma and then the rabbit facial muscles are divided sharply with a #15 scalpel and a microdissecting tool is used to clear overlying tissue from the rabbit facial nerve. At this time, the segment of the facial nerve proximal to both the zygomatic and buccal divisions is identified on each side of the rabbit’s face. A hand-held electric nerve stimulator with variable current (0.1-2.0mA square wave, 1 impulse/s or 0.2ms duration) set a 0.5 or 1.0 miliAmperes (mA) is used to assist in identifying the facial nerve. The zygomatic branch innervates the rabbit orbicularis oculi, important for eye closure and the buccal branch innervates the quadratus labii superioris muscle (QLS) which is important in movement of the upper lip and whiskers. The facial nerve is then cut on one side with a microscissors, proximal to its bifurcation to the zygomatic and buccal branches. There will be 1 negative control group of two (2) rabbits and 2 experimental groups consisting of six (6) rabbits each. The 2 rabbits in the negative control group will have the facial nerves transected with a 1cm piece of nerve excised without any re-anastomosis, to examine the rabbit’s innate regerative processes. Six (6) of the rabbits will have the facial nerves directly re-anastomosed under microscopic visualization with epineural technique using three 9-0 monofilament nylon sutures on an atraumatic taper needle. Finally, in the remaining 6 rabbits, the facial nerves will be laser welded utilizing an 810nm diode laser and a “ribbon” of 42% albumin-based biologic solder coupled with an indocyanine green dye chromophore applied with a 27 G needle to the approximated nerve ends. Micro-forceps are used to re-align and hold the ends of the severed nerve together during laser welding. Additionally, a lateral tarsorrhaphy stitch will be placed on the ipsilateral side of the facial nerve surgery with a 6-0 PDS suture through the lateral aspect of the rabbit's lids to narrow the lid aperture and protect the cornea, while still allowing vision and lid motion. The plastyma muscle and subcutaneous tissue layer will be closed with interrupted, buried 5-0 vicryl sutures. The skin overlying the surgical site will then be closed in all groups with tissue glue to reduce irritation from sutures. There is no expected mortality with this procedure.
  • The segment of the facial nerve distal to both the zygomatic and buccal division takeoff is identified on one side of the rabbit’s face. Zygomatic branch  orbicularis oculi = important for eye closure Buccal branch  quadratus labii superioris muscle (QLS) = important in movement of the upper lip and whiskers
  • Welding of each nerve utilizes a 0.5cc aliquot of solder. Endpoint of welding is determined by a characteristic solder color change from green to tan.
  • During a nerve conduction study, a compound motor action potential (CMAP) can be measured to determine nerve conduction or function in 3 different ways. Baseline – peak amplitude (mV) (has been found to be the most common way of measuring CMAP) Peak – peak amplitude (mV) Nerve latency (ms)
  • This photomicrograph shows the nerve fasicles coming in & out of the board and the homogenous nature of the eosinophillic staining solder in the lower left hand corner. As you can see, after 4 weeks, a inflammatory reaction has set-up the deposition of scar tissue and has lifted the solder away from the actual nerve fasicles, allowing normal wound healing forces to take place. Additionally, the nerve fasicles and epineurium are intact without damage or degeneration.
  • These results show that the time to complete the actual nerve repair portion of the procedure was significantly shorter with the laser welded rabbit facial nerves. AVG Suture Neurorrhaphy = 13.17min +/- 3.60min AVG Laser Neurorrhaphy = 3.50min +/- 1.64min P-value = <0.001 (0.00015)
  • There appears to be a learning curve with suture neurorrhaphy. As you can see, it originally was taking around 20 min for 3 epineural sutures to be placed under the operating microscope. By the 6 th attempt, the procedure was being completed in about 10-12 mins. As for the laser, there clearly doesn’t appear to be a learning curve. Depending on the difficulty of aligning the cut nerve ends, the procedure took anywhere from 2-6 mins. Additionally, the laser nerve repair did not require the use of the operating microscope.
  • From this graph, it appears that laser nerve repair outperformed the suture repair at all time points during the rabbits’ facial nerve recovery. This graph shows the average EMG amplitude (baseline-peak), as a percent of its baseline vs. time. Over the course of the entire 4 month study, only the week 16 data point was statistically significant with a p-value = 0.01; however, the week 4 time point did have a p-value approaching significance (p=0.09). This may be related to a more rapid initial improvement in the electrophysiologic recovery of the laser welded nerve repair and then a longer term improved nerve recovery, seen with the laser welded nerves. By the 4 th month, the reason that the repaired nerves (both the laser & suture group) were performing at levels above the baseline is due to a electrophysiologic phenomenon called collateral sprouting. With an injured facial nerve branch, the additional branches around the injured branch with “take over” the function of that branch and often become hyperactive & stronger. What you see on EMG is the cummulative recovery of the injured nerve plus the additional hyperactive help from the collateral branches.
  • This graph demonstrates the clinical facial nerve recovery scores for the laser and suture repaired groups, as averaged between 2 blinded observers. The scale is based from 0-3 (as seen on the vertical access). As seen, the laser group performs better than the suture group at each time point, but it does not reach significance.
  • Transcript

    • 1. Resident Final Research Project Laser Facial Nerve Welding in a Rabbit Model Jason D. Bloom, M.D. University of Pennsylvania Department of Otorhinolaryngology: Head & Neck Surgery June 25 th , 2009 Faculty Mentors: Noam A. Cohen, M.D. & Stephen A. Goldstein, M.D. Special Thanks: Benjamin S. Bleier, M.D. Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870
    • 2. Research Approval & Funding <ul><li>This research project has been approved by both the U of Penn IACUC (Protocol # 802421) & Philadelphia VA ACORP </li></ul><ul><li>Awarded 2009-2010 AAO-HNSF / AAFPRS Leslie Bernstein Resident Research CORE Grant </li></ul>
    • 3. Background <ul><li>Charles Gould (1957) - Introduces the term LASER ( L ight A mplification by S timulated E mission of R adiation) </li></ul><ul><ul><li>In his doctoral thesis on energy levels of excited thallium </li></ul></ul><ul><li>Sigel & Acevado (1962) - Reported thermal energy in tissue adhesion </li></ul><ul><ul><li>Passing high frequency electric current through coapted vein edges to anastomose end-to-side porto-caval shunts in dogs (1) </li></ul></ul><ul><li>Yahr & Strully (1966) – First description of laser tissue welding in blood vessel anastomosis (2) </li></ul><ul><ul><li>Nd-YAG laser </li></ul></ul><ul><li>Almquist et al. (1984) – Argon laser in peripheral nerve repair (3) </li></ul><ul><li>Fischer et al. (1985) – Published positive reports using the CO2 laser for rat nerve repair (4) </li></ul>
    • 4. Background <ul><li>Biologic Solder </li></ul><ul><li>Allows for target specific laser energy absorption resulting in tissue bonds with greater tensile strength than wounds sealed with laser energy alone (5) </li></ul><ul><li>The use of biologic solders has been shown to provide an added benefit in the promotion of native wound healing mechanisms. </li></ul><ul><ul><li>Contrast to the granulomatous inflammatory response seen with suture material </li></ul></ul><ul><ul><li>The lased solder coagulum provides a non-immunogenic scaffold (6) </li></ul></ul><ul><ul><li>Gradually absorbed during the normal wound healing process (7,8) </li></ul></ul><ul><ul><li>Biologic solders are now being combined with wavelength specific chromophores (9,10) </li></ul></ul><ul><ul><ul><li>- Increased target specific energy absorption </li></ul></ul></ul><ul><ul><li>- Decreased thermal energy leakage </li></ul></ul><ul><ul><li>- Objective basis of gauging adequacy of laser welding by providing a predictable color change </li></ul></ul><ul><ul><li>- Examples: Carbon Black 808nm </li></ul></ul><ul><ul><li>Fluorescein Dye 532nm </li></ul></ul><ul><ul><li> Indocyanine Green Dye 805nm </li></ul></ul>
    • 5. Laser Tissue Welding Laser Biologic Solder Chromophore ECM REMODELING LASER WELD
    • 6. Background <ul><li>Problems associated w/ classic neurorrhaphy </li></ul><ul><ul><li>Trauma induced by handling & sutures </li></ul></ul><ul><ul><li>Neuroma formation </li></ul></ul><ul><ul><li>Long OR times & technically difficult surgically </li></ul></ul><ul><ul><li>“ Leakage” of axons at site of anastomosis & in-growth of connective tissue </li></ul></ul><ul><ul><li>Foreign body reaction from suture material </li></ul></ul>
    • 7. Background <ul><li>Laser Nerve Welding </li></ul><ul><li>Eppley et al. (1989) – Laser nerve repair of the rabbit facial nerve with CO 2 laser (11) </li></ul><ul><ul><li>neuroma formation </li></ul></ul><ul><ul><li>connective tissue invasion </li></ul></ul><ul><ul><li>axonal proliferation or extravasation outside of epineurium </li></ul></ul><ul><ul><li>Problems: </li></ul></ul><ul><ul><li>Histopathologic weld analysis </li></ul></ul><ul><ul><ul><li>Demonstrated some deleterious effects of the heat from the laser, such as destruction of myelin and loss of axons immediately adjacent to the anastomotic site. </li></ul></ul></ul><ul><ul><li>Poor anastomosis tensile strength & dehiscence </li></ul></ul>
    • 8. Background <ul><li>Laser Nerve Welding </li></ul><ul><ul><li>Trickett et al. (1997) – Albumin based solder with indocyanine green chromophore to laser weld rat sciatic nerves with an 800nm diode laser (12) </li></ul></ul><ul><ul><ul><li>- Laser activated solders = stronger bonds at the anastomosis site & less thermal damage to underlying nerve tissue </li></ul></ul></ul><ul><ul><ul><li>- Histology = denatured solder and underlying epineurium with no axonal damage </li></ul></ul></ul><ul><li>Hwang et al. (2005 & 2006) – CO 2 laser welding of rat facial nerve w/o solder (13,14) </li></ul><ul><ul><li>Laser repaired nerve regeneration = microsuture repaired nerve regeneration  immmunohistochemical nerve tracer </li></ul></ul><ul><ul><li>Less cellular & fibroblastic response </li></ul></ul><ul><ul><li>Less scar & neuroma formation </li></ul></ul>
    • 9. Hypothesis <ul><li>Laser welding of the rabbit facial nerve provides a method of creating an atraumatic, immediate and strong repair bond capable of allowing axonal regeneration across the injury site without damage to the nerve itself or the complications associated with suture neurorrhaphy. </li></ul><ul><li>Null Hypothesis: Laser nerve welding is not an effective way to perform neurorrhapy, as compared to suture nerve repair. </li></ul>
    • 10. Time Table Day Procedure Data Point -Functional testing Data Point – EMG testing Data Point - Histology (H&E and Masson’s Trichrome Stain) 0 Rabbit Acquisition N/A N/A N/A 4 Rabbit Acclimation N/A N/A N/A 5 Survival Surgery/ Functional & EMG tests Laser Weld x 6, Suture x 6, Neg Control x 2 Laser Weld x 6, Suture x 6, Neg Control x 2 N/A 33 (wk 4) Functional & EMG tests/ Sac-Experimental Group #1 Laser Weld x 6, Suture x 6, Neg Control x 2 Laser Weld x 6, Suture x 6, Neg Control x 2 Laser Weld x 2, Suture x 2 61 (wk 8) Functional & EMG testing Laser Weld x 4, Suture x 4, Neg Control x 2 Laser Weld x 4, Suture x 4, Neg Control x 2 N/A 89 (wk 12) Functional & EMG testing Laser Weld x 4, Suture x 4, Neg Control x 2 Laser Weld x 4, Suture x 4, Neg Control x 2 N/A 117 (wk 16) Functional & EMG tests/ Sac-Experimental Group #2 Laser Weld x 4, Suture x 4, Neg Control x 2 Laser Weld x 4, Suture x 4, Neg Control x 2 Laser Weld x 4, Suture x 4, Neg Control x 2
    • 11. Rabbit Survival Surgery <ul><li>2 of the rabbit facial nerves (negative control group) = facial nerves transected with a 1cm piece of nerve excised w/o re-anastomosis </li></ul><ul><li>6 of the rabbits facial nerves = suture anastomosis w/ three 9-0 monofilament nylon sutures on an atraumatic taper needle </li></ul><ul><li>6 of the rabbit facial nerves = laser welded utilizing an 810nm diode laser and a “ribbon” of 42% albumin-based biologic solder coupled with an indocyanine green dye chromophore applied with a 27 G needle </li></ul><ul><li>14 New Zealand White Rabbits (3-4kg) </li></ul><ul><ul><li>Housed at the Animal Research Facility (ARF) of the Philadelphia Veterans Affairs Medical Center (PVAMC) </li></ul></ul>
    • 12. Rabbit Facial Nerve Anatomy
    • 13. OR Setup
    • 14. Identifying the Facial Nerve <ul><li>Hand-held nerve stimulator was used to identify the facial nerve and verify facial movement. </li></ul><ul><li>* Also, used to verify that the facial nerve was cut  no longer innervating the face </li></ul>
    • 15. Suture Neurorrhaphy <ul><li>Suture anastomosis w/ three 9-0 monofilament polypropylene (Prolene) sutures on an atraumatic taper needle </li></ul><ul><li>* Carl Zeiss OPMI CS-1 operating microscope </li></ul>
    • 16. Laser/Solder Platform <ul><li>Biologic solder - </li></ul><ul><ul><li>42% albumin solution Indocyanine green dye Hyaluronic acid sodium </li></ul></ul><ul><li>Diode laser module </li></ul><ul><li>- Iridex Oculight SLx </li></ul><ul><li>Power: 0.5W </li></ul><ul><li>Pulse Duration: 0.5s </li></ul><ul><li>Pulse Interval: 0.1s </li></ul><ul><li>Power Density: 15.9W/cm2 </li></ul><ul><li>Fluency: 8.0 J/cm2 </li></ul><ul><li>Major Wavelength Output: 810 +/- 1nm </li></ul><ul><li>* 600mm core diameter quartz-silica fiberoptic cable </li></ul>
    • 17. Laser Solder Neurorrhaphy <ul><li>Microvascular clip – used to hold nerve ends in place </li></ul><ul><li>Adequacy of weld was visually assessed by the green colored chromophore changing to a brown color s/p laser energy </li></ul>
    • 18. Surgical Complications <ul><li>Surgical Complications: Sialocele (5/14 rabbits = 35%) </li></ul><ul><li>* All treated w/ repeated 20G needle aspirations  all completely resolved in 2wks </li></ul><ul><li>* No pain, distress, feeding issues, effect on wt. gain </li></ul>
    • 19. EMG Testing <ul><li>Nicolet Viking IV EMG - subdermal electrodes </li></ul><ul><li>Nerve Conduction Study </li></ul><ul><li>- measuring CMAPs </li></ul><ul><li>- amplitude </li></ul><ul><li>- nerve latency </li></ul>
    • 20. Functional / Clinical Testing <ul><li>Positioning of the rabbits that allows standardized visualization and video recording of facial movements. </li></ul><ul><li>Gentle nasal & forehead taps performed in an attempt to elicit facial nerve motion. </li></ul><ul><li>Video tapes will then be analyzed to objectively grade facial nerve recovery by 2 different blinded observers. </li></ul><ul><li>Assess the rabbit's bilateral upper lip & whisker movement. </li></ul><ul><li>A scale of facial nerve movement from 0-3 will be used to record this functional testing with 0=no movement and 3=normal facial movement (16). </li></ul>Normal Facial Nerve Function Left Facial Nerve Paralysis
    • 21. Histological Testing <ul><li>6 nerve repairs from each experimental group were harvested and fixed in 10% buffered formalin for subsequent H&E staining </li></ul><ul><li>Analysis by our histopathologist (Eugene Einhorn, MD) for immune response to the solder, native wound healing progression, and extent of collateral nerve thermal injury. </li></ul><ul><li>The welds were also be prepared and stained with Masson’s Trichrome by our histopathologist, in order to view the axon counts and arrangement of nerve axons across the repair sites. </li></ul>Nerve Laser Weld (H&E 4x) – 4wks * 16 week histological analysis = ongoing (1) Axon counts growing across the nerve repair site (2) Organization of the axons (3) Amount of neuroma formation (4) Amount of foreign body/granulomatous reaction
    • 22. RESULTS
    • 23. Operative Time * * P < 0.01 N=6 N=6
    • 24. Learning Curve
    • 25. EMG Nerve Recovery
    • 26. Clinical Nerve Recovery
    • 27. Problems with the Study <ul><li>Multiple buccal branches of the rabbit facial nerve distal to the site of the nerve injury & repair </li></ul><ul><li>Small number of rabbits in each group </li></ul><ul><li>Inability to circumferentially laser weld the nerve </li></ul><ul><li>Inconsistent EMG electrode placement in the facial musculature for each separate trial </li></ul><ul><li>No adequate method to measure synkinesis in a rabbit model </li></ul><ul><li>Testing EMG vs. ENoG </li></ul>
    • 28. Discussion / Future Directions <ul><li>Further areas of research with this laser welding technology: </li></ul><ul><ul><li>Peripheral nerve repair </li></ul></ul><ul><ul><li>Microvascular arterial or venous anastomosis </li></ul></ul><ul><ul><li>Pharyngocutaneous fistula repair </li></ul></ul><ul><ul><li>Transoral robotic surgery models </li></ul></ul><ul><li>Augmentation of the biologic solder with growth factors and antibiotics to further optimize wound healing </li></ul><ul><li>If these welds prove efficacious in larger trials, this technology would be ideally transitioned to clinical trials of facial nerve injury repair. </li></ul>
    • 29. LNW Conclusions <ul><ul><li>Clinical / Functional: </li></ul></ul><ul><ul><ul><li>Improved facial nerve functional recovery on video analysis with the laser weld group </li></ul></ul></ul><ul><ul><li>Electrophysiological: </li></ul></ul><ul><ul><ul><li>Improved facial nerve electrophysiological/EMG nerve recovery at all time points in the laser weld group, especially at early (1 month) & late (4 month) time points </li></ul></ul></ul><ul><li>Histological: </li></ul><ul><ul><li>H&E staining demonstrating negligible collateral thermal nerve or tissue damage </li></ul></ul><ul><ul><li>Biologic solder supporting the progression of the native wound healing response </li></ul></ul><ul><ul><li>Ongoing histopath: Utilizing Masson’s Trichrome stain  (1) Axon counts growing across the nerve repair site (2) Organization of the axons (3) Amount of neuroma formation (4) Amount of foreign body/granulomatous reaction </li></ul></ul><ul><li>Mechanical: </li></ul><ul><ul><li>No learning curve or operating microscope necessary with the laser weld group </li></ul></ul><ul><ul><li>Significantly reduced neurorrhaphy time with the laser weld group </li></ul></ul>
    • 30. References <ul><li>1. Sigel B, Acevado FJ, “Vein anastomosis by electrocoaptive union,” Surg Forum. 1962;13:233-5. </li></ul><ul><li>2. Yahr WZ, Strully KJ, “Blood vessel anastamosis by laser and other biomedical applications,” J Assoc Adv Med Instrum. 1966;(1):28-31. </li></ul><ul><li>3. Almquist EE, Nachemson A, Auth D, Almquist B, Hall S. “Evaluation of the use of the argon laser in repairing rat and primate nerves,” J Hand Surg Am. 1984;9:792-299. </li></ul><ul><li>4. Fischer DW, Beggs JL, Kenshalo DJ, Shetter AG. “Comparative study of microepineurial anastomoses with the use of CO2 laser and suture techniques in rat sciatic nerves: Part 1. Surgical technique, nerve action potentials, and morphological studies,” Neurosurgery. 1985;17:300-308. </li></ul><ul><li>5. Gil Z, Shaham A, Vasilyev T, Brosh T, Forer B, Katzir A, Fliss DM. “Novel laser tissue-soldering technique for dural reconstruction,” J Neurosurg. 2005 Jul;103(1):87-91. </li></ul><ul><li>6. Kirsch AJ, Miller MI, Hensle TW, Chang DT, Shabsigh R, Olsson CA, Connor JP, “Laser tissue soldering in urinary tract reconstruction: first human experience,” Urology. 1995 Aug;46(2):261-6. </li></ul><ul><li>7. Lauto A, Trickett R, Malik R, Dawes JM, Owen ER, “Laser-activated solid protein bands for peripheral nerve repair: an vivo study,” Lasers Surg Med. 1997;21(2):134-41. </li></ul><ul><li>8. Lauto A, Kerman I, Ohebshalon M, Felsen D, Poppas DP, “Two-layer film as a laser soldering biomaterial,” Lasers Surg Med . 1999;25(3):250-6. </li></ul><ul><li>9. Talmor M, Bleustein CB, Poppas DP, “Laser tissue welding: a biotechnological advance for the future,” Arch Facial Plast Surg. 2001 Jul-Sep;3(3):207-13. </li></ul><ul><li>10. Oz MC, Johnson JP, Parangi S, Chuck RS, Marboe CC, Bass LS, Nowygrod R, Treat MR, “Tissue soldering by use of indocyanine green dye-enhanced fibrinogen with the near infrared diode laser,” J Vasc Surg. 1990 May;11(5):718-25. </li></ul><ul><li>11. Eppley BL, Kalenderian E, Winkelmann T, Delfino JJ. “Facial nerve graft repair: suture versus laser-assisted anastomosis,” Int J Oral Maxillofacial Surg. 1989;18:50-54. </li></ul>
    • 31. References <ul><li>12. Trickett I, Dawes JM, Knowles DS, Lanzetta M, Owen ER. “In vitro Laser Nerve Repair: Protein Solder Strip Irradiation or Irradiation Alone?,” Int Surg. 1997;82:38-41. </li></ul><ul><li>13. Hwang K, Kim SG, Kim DJ, Lee CH. “Laser Welding of Rat’s Facial Nerve,” Journal of Craniofacial Surgery. 2005;16(6):1102-1106. </li></ul><ul><li>14. Hwang K, Kim SG, K DJ. “Facial-Hypoglossal Nerve Anastomosis Using Laser Nerve Welding,” Journal of Craniofacial Surgery. 2006;17(4):687-691. </li></ul><ul><li>15. Yian CH, Paniello RC, Spector JG. “Inhibition of Motor Nerve Regeneration in a Rabbit Facial Nerve Model.” Laryngoscope. 2001;111:786-791. </li></ul><ul><li>16. Bleier BS, Palmer JN, Sparano AM, et al. “Laser-assisted cerebrospinal fluid leak repair: an animal model to test feasibility.” Otolaryngol Head Neck Surg. 2007;137(5):810-4. </li></ul><ul><li>17. Bleier BS, Palmer JN, Gratton MA, Cohen NA. “In Vivo Laser Tissue Welding in the Rabbit Maxillary Sinus.” American Journal of Rhinology. 2008;22:625-628. </li></ul><ul><li>18. Bleier BS, Gratton MA, Leibowitz JM, Palmer JN, Newman JG, Cohen NA. “Laser-Welded Endoscopic Endoluminal Repair of Iatrogenic Esophageal Perforation: An Animal Model.” Otolaryngology – Head and Neck Surgery. 2008;139:713-717. </li></ul>
    • 32. THANK YOU! Special Thanks To: - My Faculty Mentors - Dr. O’Malley - Dr. Cohen, Dr. Palmer, Dr. Bleier & The Penn Rhinology Lab - Perry DeRitis & VA ARF Staff - VA Neurology Service

    ×