Faculty Bibliography

Microvascular reconstruction offers patients with facial deformities excellent composite tissue restoration and improves functional outcomes. However, such techniques require facial skin incisions, leaving the patient with unsightly scarring. Implementing an intraoral microvascular anastomosis can obviate the need for facial skin incisions, yielding aesthetically favorable results. We present the case of a 29-year-old, cosmetically conscientious woman who underwent a free iliac osteomuscular flap with intraoral microvascular anastomosis for reconstruction of a right maxillary defect secondary to fibrous dysplasia. Endosseous dental implants were successfully placed using computer-aided design and manufacturing to effectively restore the dentition. Intraoral microvascular reconstruction provided the patient with an aesthetically pleasing result, effectively achieving functional restoration with patient satisfaction.

BACKGROUND: The implications of allograft skin and mucosal biopsy findings on classification of rejection and treatment remain unclear. METHODS: Following facial allotransplantation, scheduled surveillance allograft skin and mucosal biopsy specimens were obtained. Clinical concern for acute rejection prompted biopsies off schedule. Compilation of biopsy results, Banff grading, immunosuppression, and clinical correlation were critically reviewed for a 2-year follow-up. RESULTS: A total of 39 biopsy specimens at 21 time points were obtained for analysis, including allograft skin (n = 21), mucosa (n = 17), and a lesion (n = 1). The patient had three episodes of acute rejection warranting treatment. Discordance between skin and mucosa occurred in 55.6 percent of biopsy specimens (p = 0.01). Mucosa concordance with the clinical evaluation occurred in 38.9 percent of biopsy specimens (p = 0.02), and skin concordance with clinical evaluation was present in 81 percent of biopsy specimens (p = 0.01). CONCLUSIONS: The clinical utility of mucosal biopsy remains elusive. The authors' experience suggests that mucosal or skin biopsy, alone, should not drive the decision-making process in treatment. Skin biopsies are more likely to confirm clinical suspicion of rejection than mucosal histology. Data from other institutions are lacking, and future reporting may help elucidate the role of mucosal and skin biopsy in facial allotransplantation. CLINICAL QUESTIONS/LEVEL OF EVIDENCE: Diagnostic, V.

BACKGROUND: Currently, there is a lack of clear guidelines regarding evaluation and management of giant juvenile fibroadenomas. The purpose of this study was to conduct a systematic review of giant juvenile fibroadenomas and to evaluate the most common diagnostic and therapeutic modalities. METHODS: A systematic literature search of PubMed and MEDLINE databases was conducted in February 2014 to identify articles related to giant juvenile fibroadenomas. Pooled outcomes are reported. RESULTS: Fifty-two articles (153 patients) met inclusion criteria. Mean age was 16.7 years old, with a mean lesion size of 11.2 cm. Most patients (86%) presented with a single breast mass. Imaging modalities included ultrasound in 72.5% and mammography in 26.1% of cases. Tissue diagnosis was obtained using a core needle biopsy in 18.3% of cases, fine-needle aspiration (FNA) in 25.5%, and excisional biopsy in 11.1% of patients. Surgical treatment was implemented in 98.7% of patients (mean time to treatment of 9.5 months, range, 3 days to 7 years). Surgical intervention included excision in all cases, of which four were mastectomies. Breast reconstruction was completed in 17.6% of cases. There were no postoperative complications. CONCLUSIONS: Diagnosis and treatment of giant juvenile fibroadenoma is heterogeneous. There is a paucity of data to support observation and non-operative treatment. The most common diagnostic modalities include core needle or excisional biopsy. The mainstay of treatment is complete excision with an emphasis on preserving the developing breast parenchyma and nipple areolar complex. Breast reconstruction is uncommon, but may be necessary in certain cases.

This article aims to demonstrate an individualized approach to an elderly patient requiring scalp reconstruction, to describe the methodology in flap selection, lessons learned, and report outcomes. A retrospective review of a single surgeon's experience of scalp reconstruction (E. D. R.) using free tissue transfer from 2005 to 2011, in patients older than 70 years, was completed. A total of eight patients met the inclusion criteria, five males and three females, with a mean age of 80.4 years (range, 73-92). Free tissue transfer achieved 100% soft tissue coverage. Six of the eight patients required cranioplasty. The mean size calvarial defect was 92 cm(2) (range, 35-285 cm(2)). The mean flap size was 117.6 cm(2) (range, 42-285 cm(2)). Free flaps included three ulnar, three anterolateral thigh, one latissimus dorsi, and one thoracodorsal perforator flap. The mean follow-up time was 18.4 months (range, 3-46 months). Donor site morbidity was minimal. Mortality was 0%. Immediate flap failure was 0%. Other complications occurred in six of the eight patients. Mean revisionary procedures were 1.25 procedures per patient. It was concluded that chronological age does not increase mortality or catastrophic flap complications; however, morbidity is increased in the elderly and revisionary surgery is likely.

OBJECTIVES/HYPOTHESIS: The purpose of this systematic review was to critically analyze infectious complications and treatment following transcartilaginous ear piercing. DATA SOURCES: MEDLINE Pubmed database. REVIEW METHODS: A MEDLINE PubMed database search using free text, including "ear chondritis," "ear perichondritis," "ear cartilage piercing," and "auricle piercing," yielded 483 titles. Based on set inclusion and exclusion criteria, the titles, abstracts, and full text articles were reviewed for inclusion and underwent data extraction. Pooled outcomes are reported. RESULTS: A total of 29 articles met inclusion criteria, including 66 patients. The mean age of the patients was 18.7 +/- 7.6 years (range: 11-49), 87.5% female. Ear deformity was more likely to occur following postpiercing perichondritis of the scapha 100% versus the helix 43% (P = 0.003). Mean duration of symptoms prior to patients seeking medical attention was 6.1 +/- 4.1 days. Greater than 5 days of symptoms prior to seeking treatment was significantly more likely to result in hospitalization. Pseudomonas aeruginosa accounted for 87.2% infections. Of the patients with Pseudomonas, 92.3% were hospitalized versus 75% of the patients infected with Staphylococcus aureus. Initial oral antibiotics prescribed did not target the cultured bacterium in 53.3% of cases; of these, 87.5% were hospitalized. CONCLUSIONS: Transcartilaginous postpiercing infection may lead to ear deformity and hospitalization. Patients (customers) and practitioners must be aware of optimal treatment strategies to minimize associated morbidity. Scapha piercing and delay in presentation are associated with poorer outcomes. Pseudomonas is the most common bacterial infection. Initial antibiotic selection must be optimized accordingly. Laryngoscope, 125:1827-1834, 2015.

BACKGROUND: Trichloroacetic acid is routinely used by gynecologists to treat anogenital diseases, and accidental exposure to the health care providers may result in serious burns. This case serves to raise awareness of accidental exposure of trichloroacetic acid and describes preventive, first aid, and treatment recommendations that may limit the incidence and severity of burn injury among gynecologists. CASE: A 32-year-old female gynecologist incurred a deep second-degree, 12x14-cm, work-related chemical burn by unintentionally spilling a container of approximately 20 mL of 80% trichloroacetic acid onto her right thigh during an outpatient procedure. First aid included removal of her soaked clothing, 5 minutes of soap and cold water irrigation, and liberal placement of petroleum-based ointment onto the injury site. Treatment consisted of topical silver sulfadiazine cream twice a day, coverage with silver-impregnated silicone foam dressing, and a circumferential soft bandage to minimize sheer forces along the wound. A 9-month follow-up demonstrated a well-healed, mildly hypopigmented, aesthetically favorable wound with return of sensation. CONCLUSION: Accidental trichloroacetic acid burns are a potential hazard in a gynecology office. Health care workers should be familiar with prevention, first aid, and appropriate treatment that often can result in acceptable long-term outcomes.

BACKGROUND: The purposes of this study were to report a 7-year experience of microvascular reconstruction of scalp defects, compare flap type and outcomes, and evaluate the implications of short and long term complications. METHODS: Following institutional review board approval, a single surgeon's patients requiring microvascular scalp reconstruction were retrospectively reviewed from 2005 to 2011. Flap choice, complications, and outcomes were statistically analyzed. RESULTS: Nineteen patients met inclusion criteria (10 male and 9 female) with a mean age of 60.2 +/- 21.4 years (range, 23-90 years). All free tissue transfers (n = 20) achieved 100% soft tissue coverage. Mean size calvarial defect was 106.6 +/- 67.2 cm (range, 35-285 cm), with 11 requiring cranioplasty. Free flaps included the following: 13 anteriolateral thigh, 5 ulnar, 1 latissimus dorsi, and 1 thoracodorsal artery perforator. Mean flap size was 154.1 +/- 87.3 cm (range, 42-336 cm). Early complications (<30 days following surgery) occurred in 21.1% of patients and late complications (>30 days following surgery) in 52.6% of patients. Patients with an early complication were 2 times more likely to develop a late complication (relative risk, 2.1) but did not reach statistical significance. Late complications were more likely to require surgical intervention, 84.2% versus 60% of early complications (P = 0.079). CONCLUSIONS: Microvascular free tissue transfer is the mainstay of complex scalp defects but carries a high likelihood of future reoperations. Early complications are less concerning than late complications, as the need for future surgical intervention is associated with late complications. There is lack of evidence to support a superior flap choice.