Faculty Bibliography

BACKGROUND:Advances in pancreatic cancer surgery involve hepatotoxic chemotherapies and hepatic vasculature resections, increasing the risk of clinically relevant postpancreatectomy liver injury. The study aimed to analyze the incidence and impact of clinically relevant postpancreatectomy liver injury after pancreatectomy with hepatic vessel resection. METHODS:In this single-institutional study, patients undergoing pancreatectomy with resection of hepatic vessels (portal vein/superior mesenteric vein, celiac axis, and hepatic arteries) were analyzed. Arterial lactate, total bilirubin, alanine aminotransferase, aspartate aminotransferase, international normalized ratio, and Doppler ultrasound-derived resistive index were assessed postoperatively. Postoperative outcomes were assessed through 90 days. Clinically relevant postpancreatectomy liver injury was defined as American Association for the Study of Liver Diseases-defined liver failure and/or need for invasive treatment of liver complications. RESULTS:Among 116 patients (67% portal vein/superior mesenteric vein resection alone, 7% celiac axis/hepatic arteries alone, 26% portal vein/superior mesenteric vein + celiac axis/hepatic artery resection), 15 (13%) developed clinically relevant postpancreatectomy liver injury. Mortality was significantly higher in the clinically relevant postpancreatectomy liver injury group (47% vs 3%; P < .001). The proper hepatic artery resistive index was lower in the clinically relevant postpancreatectomy liver injury group (0.52 vs 0.65; P = .034), whereas the following 48-hour-peak blood tests were significantly higher in this group: Lac, bilirubin, aspartate aminotransferase, and alanine aminotransferase (all P < .01). Combined portal vein/superior mesenteric vein + celiac axis/hepatic arteries and elevated alanine aminotransferase 48-hour peak above 1680 U/L remained significantly associated with the occurrence of clinically relevant postpancreatectomy liver injury in multivariable analyses. Forty percent of clinically relevant postpancreatectomy liver injury occurred in the absence of vascular complications. CONCLUSION/CONCLUSIONS:Clinically relevant postpancreatectomy liver injury is associated with significant mortality. Low resistive index and markedly elevated biochemical markers within the first 48 hours correlate with clinically relevant postpancreatectomy liver injury and may be used to trigger earlier intervention. Given the associated morbidity and mortality, defining, preventing, and mitigating clinically significant postpancreatectomy liver injury is of the utmost importance.

The intersection between urology and plastic surgery represents an important collaborative frontier in modern reconstruction. Defects involving the genitourinary and perineal regions frequently require the coordinated expertise of both specialties to restore urinary continuity, soft-tissue coverage, sexual function, and aesthetics. Despite the expanding scope of this reconstructive collaboration that spans oncological, traumatic, congenital, and gender-affirming care, no formal designation has been defined to unify these efforts. This review introduces the concept of "uroplastics," a reconstructive field that integrates the principles and techniques of urology and plastic surgery under a shared philosophy of restoring both form and function. Drawing a parallel to the evolution of other blended specialties, such as neuroplastics, oncoplastics, and orthoplastics, uroplastics seeks to codify existing interdisciplinary practice into a coherent framework. Three collaborative models are identified across the literature: consultative, concurrent, and integrated. Each represents a progressive stage of interaction, from reactive consultation to fully integrated reconstructive programs and research partnerships. Representative studies demonstrate that early, structured collaboration improves wound healing, functional outcomes, and patient satisfaction in complex genitourinary reconstruction. Beyond the operating room, the formalization of uroplastics has implications for education, institutional design, and translational research, including advances in microsurgery, robotics, and tissue engineering. Its formal recognition as a collaborative reconstructive discipline will strengthen multidisciplinary training, accelerate innovation, and ultimately improve outcomes for patients requiring comprehensive genitourinary reconstruction.

Reconstruction in head and neck surgery requires restoration of complex functions, including speech, swallowing, and breathing, while preserving as much facial form and patient identity as possible. Over the past decade, advances in preoperative digital planning, intraoperative technologies, and robotic platforms have reshaped reconstructive strategies, giving rise to the concept of hybrid reconstruction. Hybrid approaches integrate free tissue transfer with computer-aided design and manufacturing (CAD/CAM), virtual surgical planning, intraoperative navigation, and robot-assisted microsurgery to enhance precision, reproducibility, and functional outcomes. This narrative review examines the principles and applications of hybrid reconstruction in head and neck surgery with particular emphasis on osseous reconstruction of the mandible, maxilla, and midface. The roles of intraoperative navigation and robotic assistance as enabling tools are discussed, along with their potential benefits and current limitations. Functional and morphologic outcomes, patient-reported quality of life, and challenges related to cost, access, training, and evidence heterogeneity are critically reviewed. Hybrid reconstruction represents an advancement toward outcomes-driven, patient-centered care; however, thoughtful integration of emerging technologies and continued emphasis on rigorous outcome assessment are essential to guide responsible adoption in contemporary head and neck reconstructive surgery.

Segmental peripheral nerve injuries, particularly those involving long nerve gaps, pose a significant challenge in reconstructive surgery. Conventional strategies, such as nerve autografts or processed allografts, are often limited by inadequate length or poor regenerative outcomes, especially in traumatized wound beds. Nerve flaps offer the theoretical advantage of enhanced axonal regeneration through improved perfusion and support of Schwann cell viability but are rarely used due to technical complexity and limited donor options. We present a unique case of a free sural nerve flap used to reconstruct a 7-cm segmental defect of the tibial nerve following blast trauma in a 23-year-old man. A composite flap consisting of the sural nerve and lesser saphenous vein was harvested with preservation of the bridging adipofascial tissue to maintain perfusion to the nerve. The lesser saphenous vein was anastomosed to the retrograde peroneal artery distally and ligated proximally, whereas the sural nerve was divided and used as a double-barrel cable graft across the defect. Intraoperative Doppler and SPY angiography confirmed perfusion of the nerve through the preserved adipofascial connections. The patient was recently seen in our clinic at 17 weeks postoperation. He demonstrated undetectable 2-point discrimination in all nerve distributions of his foot but is ambulatory. This case demonstrates the feasibility and potential utility of a free vascularized sural nerve flap for reconstructing extensive peripheral nerve defects, particularly in cases where standard techniques are inadequate.

PURPOSE/OBJECTIVE:Complex posterior defects often present significant reconstructive challenges, particularly due to the scarcity of suitable recipient vessels. In these cases, an arterialized saphenous vein transfer can facilitate flap perfusion when direct anastomosis is not feasible. This study presents our institutional experience using an arterialized saphenous vein transfer for microvascular free flap (MVFF) reconstruction of posterior defects. METHODS:We retrospectively reviewed consecutive patients who underwent posterior MVFF reconstruction using an arterialized saphenous vein transfer. Patient demographics, comorbidities, defect etiologies (including trauma, silicone injection, malignancy, and congenital abnormalities), flap types, and perioperative outcomes were collected through manual chart review. RESULTS:(±73). Arterialized saphenous vein transfer arterial inflow sources included the descending branch of the lateral femoral circumflex artery (n = 6), deep inferior epigastric artery (n = 1), and transverse branch of the superficial femoral artery (n = 1). Average operative time was 11:00 h (±2:50); median hospital stay was 12 days (range: 6-76). There were no flap losses. One patient required two flap explorations; two patients required postoperative blood transfusions. At a mean follow-up of 1247 days (±393), all flaps had healed, including persistent minor wounds in the two silicone injection cases. CONCLUSIONS:Arterialized saphenous vein transfers enabled durable, successful MVFF reconstruction in complex posterior defects and represent a reliable option in anatomically challenging scenarios.

Pancreatic ductal adenocarcinoma (PDAC) with extensive peripancreatic vessel involvement is classified as locally advanced pancreatic cancer (LAPC). For this group of patients, the current standard of care does not include considering a potentially curative oncologic resection. However, recent advances in multiagent chemotherapy and surgical techniques are challenging this paradigm. Moreover, the current determination of anatomic resectability is vague and unreliable. Here we propose a definition of local resectability, based on pre- and intra-operative assessment. This anatomic definition of resectability assumes careful patient selection based on tumor biology and patient condition. The pre-operative evaluation of vascular anatomy and tumor involvement is conducted using 3D-rendering of pancreas-protocol computed tomography. Identifying a disease-free arterial or venous segment above and below the tumor involvement ("suitable target") is the single critical factor that determines anatomic resectability. Intraoperative isolation of these target vessels confirms the feasibility of vascular reconstruction before resection. This approach, which focuses on identifying target vessels rather than circumferential involvement, offers a more straightforward and clinically relevant method for assessing surgical eligibility in LAPC patients at centers of excellence. In summary, reconstructability-based on surgical expertise and guided by tumor biology-now defines the modern paradigm of resectability in LAPC.

OBJECTIVE:To describes our institutional experience of a case series using a novel multi-segment, chimeric free ileal flap for posterior urethral reconstruction, focusing on surgical technique, perioperative management, and functional outcomes. Complex posterior urethral defects, particularly those resulting from radiation pose a significant reconstructive challenge that is not easily approachable with standard reconstructive techniques. In this case series, we present a novel approach for this complex problem. METHODS:We retrospectively reviewed consecutive patients who underwent posterior urethral reconstruction with a chimeric free ileal flap at our institution. Data were collected via chart review. RESULTS:Six male patients (median age: 61 years range: 59-77) with radiation-associated posterior urethral stenosis and bladder neck pathology underwent reconstruction. One was an active smoker; three had prior failed reconstructions. A 20-cm ileal segment was harvested and designed into a chimeric construct in all cases. The left deep inferior epigastric vessels were used for flap anastomosis. Median operative time was 717 minutes, and median hospital stay was 9 days. Two patients experienced early postoperative complications; none had flap loss. At median follow-up of 204 days, four patients had successful functional outcomes. One had persistent leak, and one required cystectomy for newly diagnosed squamous cell carcinoma found at the bladder neck on final pathology. CONCLUSIONS:Chimeric free ileal flap reconstruction is a novel management option for radiation-associated posterior urethral defects, offering well-vascularized, versatile tissue in patients unsuitable for traditional approaches. However, this approach is complex that requires multidisciplinary collaboration and extensive surgical planning.

BACKGROUND:Whole eye transplantation (WET) has long been looked to as a potential solution for the aesthetic and functional deficits caused by severe ocular pathology and trauma. Here, we describe the first successful combined face and whole eye transplantation (FT/WET), highlighting the logistical, ethical, and technical considerations that enabled this milestone. METHODS:A 46-year-old male with severe facial and ocular deficits underwent multidisciplinary evaluation and was deemed a candidate for FT/WET. Subsequently, a surgical algorithm was developed through rigorous preoperative planning and team based surgical simulations. This process focused on techniques that would allow for efficient graft procurement and inset, while simultaneously limiting trauma to the globe and its adnexa. RESULTS:Longitudinal monitoring demonstrated maintained graft viability throughout the postoperative period. Fluorescein angiography and ICG angiography confirmed robust retinal and choroidal perfusion. Diffusion-weighted MRI revealed structural preservation of the optic tracts, despite inner retinal atrophy. The patient has also experienced significant improvement in facial aesthetics and functionality with no episodes of graft rejection to date. CONCLUSIONS:This case demonstrates the feasibility of addressing deficits once deemed irreparable through advanced surgical techniques, preoperative planning, and multidisciplinary collaboration. Although functional vision recovery has not been observed, this innovation expands the reconstructive options available for patients with severe facial and ocular deficits, paving the way for future advancements in vascularized composite allotransplantation.

BACKGROUND:The "July Effect" refers to the potential increase in adverse outcomes associated with the annual turnover of medical trainees, though its impact on surgical fields remains uncertain. Additionally, few studies have examined whether the operative day of the week and subsequent flap monitoring during the weekend affect time to reoperation or flap salvage. This study investigated whether academic quarter and operative day influence reoperation rates, flap salvage, or flap failure in microvascular free flap procedures. METHODS:A retrospective review was conducted on 769 free flaps performed between June 2011 and November 2023. Multivariate analyses adjusted for patient demographics, comorbidities, flap type, and recipient region. Flaps were categorized by academic quarter and operative day, excluding weekends due to limited sample size. Primary outcomes included reoperation rates for vascular compromise, time to reoperation, and flap salvage. RESULTS:No significant differences in reoperation rates for vascular compromise were observed across academic quarters. While procedure duration trended longer in the first three quarters compared to the fourth, these differences were not statistically significant. Additionally, operative day did not impact reoperation rates, flap salvage, or time to reoperation. Flaps were predominantly indicated for head and neck reconstruction (74.4%) and had an overall flap loss rate of 3.0%. CONCLUSION/CONCLUSIONS:We found no evidence of a "July Effect" in microvascular surgery or that operative day affects free flap outcomes. Institutional factors, such as structured flap monitoring, attending oversight, and advanced practice provider support, likely mitigate risks associated with trainee turnover and shift-based staffing fluctuations.