Faculty Bibliography

Medicinal leeches are used to control venous congestion. Aeromonas in the leech gut are essential for digestion of blood. This case report describes a patient who had Aeromonas bacteremia develop after leeching. He had an injury to his hand that required replantation of his thumb. Following the surgery, leech therapy was started with ampicillin-sulbactam prophylaxis. Sepsis developed. Blood cultures were positive for Aeromonas that were resistant to ampicillin-sulbactam. The antibiotic was changed to ciprofloxacin on the basis of the sensitivity profile of the organisms. Cultures from the leech bathwater confirmed it as the source of the Aeromonas. Clinicians who use leech therapy must be aware that leeches can harbor Aeromonas species resistant to accepted prophylactic antibiotics and that sepsis may occur

Large, traumatic wounds around the proximal third of the lower extremity may have disrupted local vasculature, potentially obviating local pedicled options. However, free-tissue transfer to this area is technically challenging given the resulting paucity of recipient options and the depth of principal blood vessels. We present an anatomic and radiographic study of the proximally based peroneal vascular bundle as a recipient option in the proximal leg. Optimal approach was prone, through an incision over the fibula with dissection between lateral and posterior compartments. Magnetic resonance angiography demonstrated consistent vascular anatomy between patients. A proximally based peroneal vascular bundle protected by a cuff of flexor hallucis longus was used as a recipient vessel in free flap reconstruction of an open knee wound. The bundle itself does not require coverage by virtue of its own local muscle cuff. Caveats for its use include the need for adequate leg inflow and foot outflow.

Pathologic resections involving the maxilla/hemimaxilla offer a unique reconstructive challenge to the maxillofacial reconstructive surgeon. Traditionally, reconstruction and replacement of lost tissues have been achieved with a variety of methods including obturators, local/regional flaps, and microvascular free tissue transfer. All these techniques have distinct disadvantages. We present a novel approach to palatomaxillary reconstruction using a combination of free tissue transfer and zygomaticus implants. To our knowledge, this specific technique has not been previously reported.

OBJECTIVE: Determine long-term loss of mandible height with use of stress-shielding reconstruction plates for free fibula flap mandible reconstruction. DESIGN: Retrospective single-blinded medical record review. SUBJECTS: Seventy patients who had fibula free flap mandible reconstructions performed for 10 years. Patients who underwent radiotherapy were excluded. METHODS: Review of 70 fibula free flap mandible reconstructions performed for the last 10 years in a city hospital revealed 7 patients (10%) who had resections for benign odontogenic diseases. All had a three-dimensional cast model made, on which the reconstruction plate was bent to the desired shape preoperatively. Free fibula height on panoramic x-ray images taken preoperatively and at 2 and 12 months postoperatively. RESULTS: Seven (10%) patients met criteria for the study. Bone height was maintained at 2 months postoperatively, but at 12 months, there was a statistically significant loss of fibular bone height averaging 20% in the anterior, body, and ramus areas (P < 0.05). Despite this, all patients were considered eligible for dental rehabilitation, and 4 of 7 patients have had osseointegrated implants placed. CONCLUSIONS: As opposed to miniplates, increased resorption may have been due to the stress-shielding phenomenon unique to a reconstruction plates. However, this did not seem to affect the ability to place osseointegrated implants.

The success of lower extremity microsurgical reconstructions may be compromised postoperatively secondary to several factors, including thrombosis, infection, bleeding, and edema. To address edema, surgeons may use protocols for gradually dangling and/or wrapping the affected extremity. Such protocols vary widely among surgeons and are typically based on training and/or prior experience. To that end, we distributed surveys to five plastic surgeons who are experienced in microvascular lower extremity reconstruction at five different institutions. The surveys inquired about postoperative management protocols for lower extremity free flaps with regard to positioning, compression, initiation and progression of postoperative mobilization, nonweightbearing and weightbearing ambulation, assessment of flap viability, and flap success rate. These protocols were then evaluated for similarities to create a consensus of postoperative management guidelines. Progressive periods of leg dependency and compression therapy emerged as important elements. Although the consensus protocol developed in this study is considered safe by each participant, we do not intend for these recommendations to serve as a standard of care, nor do we suggest that any one particular protocol leads to improved outcomes. However, these recommendations may serve as a guide for less experienced surgeons or those without a protocol in place

Large acquired intracranial defects can result from trauma or surgery. When reoperation is required because of infection or tumor recurrence, management of the intracranial dead space can be challenging. By providing well-vascularized bulky tissue, intracranial microvascular free flaps offer potential solutions to these life-threatening complications. A multi-institutional retrospective chart and radiographic review was performed of all patients who underwent microvascular free-flap surgery for salvage treatment of postoperative intracranial infections between 1998 and 2006. A total of six patients were identified with large intracranial defects and postoperative intracranial infections. Four patients had parenchymal resections for tumor or seizure and two patients had posttraumatic encephalomalacia. All patients underwent operative debridement and intracranial free-flap reconstruction using the latissimus dorsi muscle ( N = 2), rectus abdominis muscle ( N = 2), or omentum ( N = 2). All patients had titanium ( N = 4) or Medpor ( N = 2) cranioplasties. We concluded that surgery or trauma can result in significant intracranial dead space. Treatment of postoperative intracranial infection can be challenging. Vascularized free tissue transfer not only fills the void, but also provides a delivery system for immune cells, antibodies, and systemically administered antibiotics. The early use of this technique when intracranial dead space and infection coexist is beneficial