Faculty Bibliography

BACKGROUND: Posttraumatic, high-energy defects of the midface can be challenging to reconstruct because they involve extensive composite tissue loss and result in significant permanent functional and cosmetic deformity. These injuries require replacement of the bony framework, external soft tissue, and intraoral mucosa. Local skin flaps and nonvascularized bone grafts have been used for reconstruction, but bony resorption and the associated soft-tissue collapse limit long-term viability. The authors present a classification of maxillary defects following high-energy trauma and a treatment algorithm using vascularized bone flaps. METHODS: Fourteen patients with significant maxillary loss from high-energy trauma underwent reconstruction with composite vascularized bone flaps. Eight patients had fibula flaps and six had iliac crest flaps. There were five women and nine men, with a mean age of 36.3 years (range, 21 to 48 years) and a mean follow-up of 18 months (range, 5 to 54 months). RESULTS: Thirteen of the 14 flaps survived. Nine patients had additional procedures. Nine patients had oronasal fistulas and eight were dependent on gastrostomy tubes preoperatively. All patients were able to feed orally without nasal regurgitation postoperatively. All patients achieved stable restoration of the midfacial architecture. CONCLUSIONS: The classification scheme presented centers on the missing maxillary subunits. The reconstructive algorithm is based on the type of defect, tissue requirement, and donor tissues necessary to restore facial projection and prosthodontic rehabilitation. Iliac crest and fibula bone free flaps are ideal for restoring a variety of traumatic maxillary defects. The authors advocate early reconstructive intervention using vascularized bone flaps to achieve superior functional and cosmetic outcomes.

We present the case of an 18-year-old girl with McCune Albright Syndrome (MAS) and a near total mandibular defect reconstructed with a free fibula flap. There are three reports of mandibular reconstruction in a patient with MAS using the free fibula flap; however this case is unique for two reasons. One, the continuity defect in our patient was much larger than previously reported, representing nearly the entire length of the mandible (21 cm) and required the entire harvestable length of the fibula. Two, the progression of the patient's disease limited options for reconstruction and dictated the use of a fibula with small dysplastic changes.

BACKGROUND: Large, complex, posttraumatic and recurrent abdominal hernias present a reconstructive challenge. Multiple techniques have been described to restore the integrity of the abdominal wall, although the indications and applications can be difficult to navigate. The authors propose an algorithm that facilitates the assessment and treatment of secondary large ventral defects. METHODS: The algorithm described involves a systematic approach to abdominal wall reconstruction and was applied to 23 consecutive patients at the R Adams Cowley Shock Trauma Center. Data collected from the chart review included age, body mass index, mechanism of injury, placement of skin graft and use of resorbable mesh before definitive reconstruction, size of defect, number of tissue expanders placed, length of follow-up, and complications. RESULTS: There were six female patients and 17 male patients, with an average age of 36 years. The average follow-up was 7 months. Seventeen patients had posttraumatic laparotomies, five patients had aggressive abdominal wall debridement following necrotizing fasciitis, and one patient developed a large abdominal wall hernia following complications from gastric bypass surgery. All patients underwent delayed abdominal wall reconstruction, with an average time to initial reconstruction of 19.5 months. Sixteen patients had no postoperative complications. Seven patients had complications, including one with an enterocutaneous fistula, one with a partial small bowel obstruction, two with seromas, one with a superficial wound infection, and two with recurrent abdominal wall laxity. CONCLUSIONS: The reconstructive ladder for large, complex abdominal hernias is poorly defined. The proposed algorithm provides a systematic staged approach that incorporates available techniques used for delayed reconstruction of the abdominal wall.

We present two cases of infected frontal sinus fractures requiring simultaneous obliteration of the frontal sinus and reconstruction of the horizontal buttress. In both cases, a free fibula flap was used for obliteration and bony reconstruction in a single stage. We believe that this is a novel technique for treatment of infected frontal sinus fractures obviating the need for secondary staged procedures.

BACKGROUND: Identification of a single donor site capable of providing all the components of the soft tissue envelope and the ability to selectively harvest a subset of these components is a central requirement for the microvascular reconstruction of the trauma patient. The anterolateral thigh (ALT) flap's long pedicle and adaptability in supporting a variety of tissues (muscle, fascia, soft tissue) make it a valuable tool for microsurgical reconstruction in these challenging patients. We investigated the utility of the ALT as a donor for microvascular tissue reconstruction in a Level I trauma center. METHODS: We conducted a retrospective chart review on all trauma patients treated by the plastic surgery service at the R Adams Cowley Shock Trauma Center who required microsurgical free flap coverage from July 2002 to March 2005. Fifty-eight patients underwent reconstruction of traumatic deformities with 62 microvascular free flaps from the ALT region. RESULTS: Of the 58 patients, 42 were male and 16 were female with an average age of 39 years. Recipient site locations for the 62 flaps were lower extremity, upper extremity, trunk, and head and neck. Analysis of flap anatomy revealed that 43 were fasciocutaneous, 14 were myocutaneous, 2 were adipofascial, and 3 were myofascial (vastus lateralis muscle). Six flaps were based on septocutaneous perforators, whereas the remainder contained myocutaneous perforators. Nine thigh donor sites required a split thickness skin graft, and 53 were closed primarily. The size of the flaps ranged from 36 cm2 to 600 cm2. CONCLUSIONS: The ALT is a predictable donor site that facilitates a 2-team approach. ALT displays minimal donor site morbidity and in most cases provided sufficient tissue to cover the entire traumatic defect. Our results suggest the ALT is a reliable tissue source and an ideal donor site for the management of complex traumatic wounds in the United States.

A 66-year-old man with silent sinus syndrome, resulting in progressive enophthalmos and subclinical chronic maxillary sinusitis, presented after several failed attempts at reconstruction with conventional methods. A free fibula osteoseptocutaneous flap was used to recreate the orbital floor, obliterate the maxillary sinus, and augment the periorbital contour deformity in a single stage. This is a novel approach for the treatment of Silent Sinus Syndrome in a single stage.