Faculty Bibliography

BACKGROUND: For men with significant genitourinary injury, penile transplantation is being considered as an option when reconstruction is not feasible or proves unacceptable to the injured patient. METHODS: A review of the literature was conducted to assess the current state of penile reconstruction and transplantation options, as well as to evaluate scholarly research addressing the ethical dimensions of penile transplantation. RESULTS: The state of penile transplantation is elementary. If reconstruction is not a possibility, proceeding ethically with research on penile vascularized composite allotransplantation will require the articulation of guidelines. To date, very little has been published in the scholarly literature assessing the ethics of penile transplantation. CONCLUSIONS: Guidelines should be developed to address penile transplantation and must cover the donation of tissue, consent, subject selection, qualifications of the surgical team, and management of both failure and patient dissatisfaction. Unless guidelines are established and disseminated, penile transplants should not be undertaken. The preliminary recommendations suggested in this article may help to inform development of guidelines.

Integration between implant and bone is an essential concept for osseous healing requiring hardware placement. A novel approach to hardware implantation, termed osseodensification, is described here as an effective alternative. 12 sheep averaging 65kg had fixation devices installed in their C2, C3, and C4 vertebral bodies; each device measured 4mm diameterx10mm length. The left-sided vertebral body devices were implanted using regular surgical drilling (R) while the right-sided devices were implanted using osseodensification drilling (OD). The C2 and C4 vertebra provided the t=0 in vivo time point, while the C3 vertebra provided the t=3 and t=6 week time points, in vivo. Structural competence of hardware was measured using biomechanical testing of pullout strength, while the quality and degree of new bone formation and remodeling was assessed via histomorphometry. Pullout strength demonstrated osseodensification drilling to provide superior anchoring when compared to the control group collapsed over time with statistical significance (p<0.01). On Wilcoxon rank signed test, C2 and C4 specimens demonstrated significance when comparing device pullout (p=0.031) for both, and C3 pullout tests at 3 and 6 weeks collapsed over time had significance as well (p=0.027). Percent bone-to-implant contact (%BIC) analysis as a function of drilling technique demonstrated an OD group with significantly higher values relative to the R group (p<0.01). Similarly, percent bone-area-fraction-occupancy (BAFO) analysis presented with significantly higher values for the OD group compared to the R group (p=0.024). As a function of time, between 0 and 3 weeks, a decrease in BAFO was observed, a trend that reversed between 3 and 6 weeks, resulting in a BAFO value roughly equivalent to the t=0 percentage, which was attributed to an initial loss of bone fraction due to remodeling, followed by regaining of bone fraction via production of woven bone. Histomorphological data demonstrated autologous bone chips in the OD group with greater frequency relative to the control, which acted as nucleating surfaces promoting new bone formation around the implants, providing superior stability and greater bone density. This alternative approach to a critical component of hardware implantation encourages assessment of current surgical approaches to hardware implantation.

BACKGROUND: We have adopted an intraoral microsurgical anastomosis to the facial vessels to eliminate the need for any visible facial incisions. METHODS: Cadaveric dissection was used to demonstrate accessibility of the facial artery and vein through an intraoral approach. Additionally, 5 patients underwent free tissue transfer for reconstruction of major defects of the midface through an intraoral, transmucosal approach, obviating the need for visible skin incisions. RESULTS: The pathology included palatal defects due to mucoepidermoid carcinoma and ischemic necrosis from cocaine abuse, maxillary defects secondary to fibrous dysplasia and avascular necrosis from traumatic blast injury, and a residual posttraumatic bony deformity of the zygoma. Reconstructions were performed with a free ulnar forearm flap, a free vastus lateralis muscle flap, a deep circumflex iliac artery myoosseous flap, a free fibula flap, and a deep circumflex iliac artery osseous flap, respectively. The facial artery and vein were used as recipient vessels for microvascular anastomosis for all cases. Mean follow-up was 12.2 months. All free tissue transfers were successful, and each patient had a satisfactory aesthetic outcome with no associated facial scars. CONCLUSION: This technique can be employed during reconstruction of an array of bony or soft-tissue midface deficits with minimal morbidity. This small series effectively demonstrates the varied pathologies and tissue deficiencies that can be successfully reconstructed with free tissue transfer using an entirely intraoral approach to the recipient facial vessels, resulting in no visible scars on the face and an improvement in the overall aesthetic outcome.

Chronic frontal sinus infections in the setting of previous trauma or tumor removal are challenging clinical scenarios. To remove and debride all chronically infected tissue, obliterate dead space, and provide a stable reconstructive yet aesthetic contour are critical tasks in managing these patients. The vascularized free fibula is an ideal flap for this situation; in this article, the authors detail their technique in a patient with chronic frontal sinus infections complicated by mucocele formation.

Purpose: Facial composite defects resulting from trauma can cause devastating and life limiting deformities. Full face transplants have been restoring the oral cavity and the upper airway in a single stage procedure. Literature on face transplants mostly consists of detailed surgical techniques and allograft selection, but do not constitute a compilation of data on postoperative outcomes such as swallow function. This is the first reported case of systematic review of the swallowing rehabilitation course post-facial transplantation. Method(s): Fourty one-year old male with oropharyngeal dysphagia after full face vascularized allotransplant is presented. Videofluoroscopic swallow study (VFSS) was conducted prior to surgery and at 8 time points post-operatively (day 13, 26, 48, 63, 77, 105, 6 months and 9 months) to assess swallow function. Outcome measures included Penetration Aspiration Scale (PAS) and ordinal ratings of residue in the valleculae and pyriform sinuses for 3 and 5 ml thin liquid boluses. Worst PAS scores categorized subject as unsafe (>=3) or safe (<=2). Result(s): Despite rigorous daily swallow treatment, the patient's liquid dysphagia did not imrpove. Unsafe PAS (>=3) were present in the first 7 VFSS post-operatively for 3 ml and 5 ml thin liquid boluses. Worse residue was noted in pyriform sinuses vs. valleculae in all VFSS. Conclusions (Including Clinical Relevance): Early swallow treatment is crucial for safety and successful oral intake of thin liquid postfull facial transplantation. Future analyses will examine the relationship between post-operatively edema and residue with the longterm goal of maximizing therapeutic protocols

An accurate and comprehensive understanding of lower extremity arterial anatomy is essential for the successful harvest and transfer of a free fibula osteoseptocutaneous flap (FFF). Minimum preoperative evaluation includes detailed history and physical including lower extremity pulse examination. Controversy exists regarding whether preoperative angiographic imaging should be performed for all patients. Elevation of an FFF necessitates division of the peroneal artery in the proximal lower leg and eradicates its downstream flow. For patients in whom the peroneal artery comprises the dominant arterial supply to the foot, FFF elevation is contraindicated. Detailed preoperative knowledge of patient-specific lower extremity arterial anatomy can help to avoid ischemia or limb loss resulting from FFF harvest. If preoperative angiographic imaging is omitted, careful attention must be paid to intraoperative anatomy. Should pedal perfusion rely on the peroneal artery, reconstructive options other than an FFF must be pursued. Given the complexity of surgical decision making, the authors propose an algorithm to guide the surgeon from the preoperative evaluation of the potential free fibula flap patient to the final execution of the surgical plan. The authors also provide 3 clinical patients in whom aberrant lower extremity anatomy was encountered and describe each patient's surgical course.