Faculty Bibliography

Introduction: Open fractures with degloving injuries are commonly managed by serial debridements prior to definitive flap coverage in the United States (US). Some international institutions minimize the number of debridements prior to coverage. The purpose of this study was to compare clinical outcomes in patients with open tibia fractures requiring free flap coverage from institutions with differing debridement philosophies. Methods: This was a multi-site retrospective cohort study of patients treated at two US tertiary care facilities (serial debridement cohort) and one in India (early total debridement cohort) with Type IIIB or IIIC open tibia fractures requiring free tissue transfer. The number of debridements prior to flap coverage were recorded and primary outcomes were rates of infection, non-union, and flap failure. Fischer's exact tests were used to compare outcomes between the cohorts. Results: 80 patients were included, 44 from India and 36 from the US. Patients in the serial debridement cohort underwent more debridements prior to flap coverage (mean 3.64 vs 1.84, p < 0.001) and had significantly higher rates of infection and non-union compared to patients in the early total debridement cohort (p < 0.05). There were no differences in rates of flap failure between the cohorts. Conclusions: Patients with open tibia fractures treated at institutions favoring serial debridements underwent more debridements and had higher rates of infection and non-union compared to patients treated at a center favoring early total debridement. Serial debridements may not be necessary prior to flap coverage for open tibia fractures and the current practice should be further investigated.

CASE/METHODS:Given the rare incidence of sternal nonunion after traumatic injury, literature describing the management of posttraumatic sternal reconstruction is limited. We present a case of a 54-year-old man with a history of traumatic chest wall injury with multiple unsuccessful attempts at sternal repair who presented with chronic sternal nonunion and persistent bone defect. Sternal reconstruction using a vascularized double-barrel free fibula flap with rigid fixation in multiple planes was performed, with confirmed bony union at 6 months. CONCLUSION/CONCLUSIONS:This novel approach to sternal nonunion management allowed effective bridging of posttraumatic sternal bone defects while facilitating osseous integration and long-term stabilization.

Lower extremity reconstruction, particularly in the setting of trauma, remains one of the most challenging tasks for the plastic surgeon. Advances in wound management and microsurgical techniques in conjunction with long-term outcomes studies have expanded possibilities for limb salvage, but many aspects of management have continued to rely on principles set forth by Gustilo and Godina in the 1980s. The purpose of this article is to provide a comprehensive update on the various management aspects of traumatic lower extremity microvascular reconstruction based on the latest evidence, with an examination of recent publications.

OBJECTIVE:1) To describe the authors' technique of anterolateral thigh (ALT) phalloplasty with staged skin graft urethroplasty and 2) to report the surgical outcomes and complications of this technique in a preliminary patient cohort. METHODS:Following IRB (Institutional Review Board) approval, retrospective chart review identified all patients undergoing primary three-stage ALT phalloplasty by the senior authors. Stage I involves single tube, pedicled ALT transfer. Stage II involves vaginectomy, pars fixa urethroplasty, scrotoplasty, and opening the ALT ventrally and construction of a urethral plate with split-thickness skin graft. Stage III involves tubularization of the urethral plate to create the penile urethra. Data collected included patient demographics, intraoperative details, postoperative courses, and complications. RESULTS:Twenty-four patients were identified. Twenty-two patients (91.7%) underwent ALT phalloplasty prior to vaginectomy. All patients underwent staged split-thickness skin grafting for the penile urethra reconstruction. Twenty-one patients (87.5%) achieved standing micturition at the time of data collection. Eleven patients (44.0%) experienced at least 1 urologic complication requiring additional operative intervention, most commonly urethrocutaneous fistulae (8 patients, 33.3%), and urethral strictures (5 patients, 20.8%). CONCLUSION/CONCLUSIONS:ALT phalloplasty with split-thickness skin grafting for urethral lengthening is an alternative technique to achieve standing micturition with an acceptable complication rate in gender-affirming phalloplasty.

Agnathia-otocephaly complex (AOC), a first branchial arch defect, is characterized by mandibular hypoplasia or aplasia, ear abnormalities, microstomia, and macroglossia and is a rare and often fatal diagnosis. Herein, the technical considerations and details of mandibular reconstruction using virtual surgical planning (VSP) and a vascularized free fibula flap for further mandibular reconstruction in a 10-year-old boy are presented. The patient's preoperative examination was consistent with agnathia (absence of mandibular symphysis, bilateral mandibular bodies, condyles, coronoids, rami, and temporomandibular joint), severe microstomia, and a Tessier # 30 cleft (maintained to allow oral access until later in treatment). Virtual surgical planning was utilized to plan a 3-segment fibula for the reconstruction of the mandibular symphysis and bilateral body segments, and bilateral costochondral grafts were planned for the rami. To the authors' knowledge, this represents the first application of virtual surgical planning for mandibular reconstruction with a vascularized free fibula flap in a pediatric patient with severe agnathia-otocephaly complex.

Liposuction is a relatively safe surgical procedure, with most complications being minor in nature. However, there are a few life-threatening complications that should not be underestimated. We present a case of a patient who developed bilateral pneumothoraces, pneumomediastinum, and pneumoperitoneum after combined liposuction and abdominoplasty. Although this presentation is rare, clinicians should keep a high index of suspicion in patients presenting with shortness of breath, chest pain, and/or abdominal pain after liposuction.

Increased access to care and insurance coverage has led to an increase in gender-affirming surgeries performed in the United States. Gender-affirming phalloplasty has a variety of donor sites and surgical techniques including both pedicled and free flaps. Although surgical techniques and patient outcomes are well-described, no reports in the literature specifically discuss postoperative management, which plays a crucial role in the success of these operations. Here, we present a postoperative protocol based on our institution's experience with gender-affirming phalloplasty with the hope it will serve as a standardized, reproducible reference for centers looking to offer these procedures.

BACKGROUND:Vascularized composite allotransplantation (VCA) has redefined the frontiers of plastic and reconstructive surgery. At the cutting edge of this evolving paradigm, we present the first successful combined full face and bilateral hand transplant (FT-BHT). METHODS:A 21-year-old man with sequelae of an 80% total body surface area burn injury sustained following a motor vehicle accident presented for evaluation. The injury included full face and bilateral upper extremity composite tissue defects, resulting in reduced quality of life and loss of independence. Multidisciplinary evaluation confirmed eligibility for combined FT-BHT. The operative approach was validated through 11 cadaveric rehearsals utilizing computerized surgical planning. Institutional review board and organ procurement organization approvals were obtained. The recipient, his caregiver, and the donor family consented to the procedure. RESULTS:Combined full face (eyelids, ears, nose, lips, and skeletal subunits) and bilateral hand transplantation (forearm level) was performed over 23 hours on August 12-13th, 2020. Triple induction and maintenance immunosuppressive therapy and infection prophylaxis were administered. Plasmapheresis was necessary postoperatively. Minor revisions were performed over seven subsequent operations, including five left upper extremity, seven right upper extremity, and seven facial secondary procedures. At eight months, the patient is approaching functional independence and remains free of acute rejection. He has significantly improved range of motion, motor power, and sensation of the face and hand allografts. CONCLUSION/CONCLUSIONS:Combined FT-BHT is feasible. This is the most comprehensive VCA procedure successfully performed to date, marking a new milestone in plastic and reconstructive surgery for patients with otherwise irremediable injuries.