Faculty Bibliography

BACKGROUND: Microvascular reconstruction is the mainstay of treatment in complex scalp defects. The rate of elderly patients requiring scalp reconstruction is increasing, but outcomes in elderly patients are unclear. The purpose of this study was to systematically review the literature pertaining to free tissue transfer for scalp reconstruction in patients older than 65 years to compare outcomes among different free flaps and determine the safety profile of treatment. METHODS: A systematic review of the available literature of patients undergoing microvascular scalp reconstruction was completed. Details for patients 65 years and older were extracted and reviewed for data analysis. RESULTS: A total of 45 articles (112 patients) were included for analysis. Mean age of the patients was 73.3 +/- 6.3 years (men, 69.4 percent; women, 23.4 percent; not reported, 7.2 percent). Mean flap size was 598 cm (range, 81 to 2500 cm). The mean age of patients developing a complication was 72.8 +/- 6.4 years and patients that did not develop a complication was 73.4 +/- 5.5 years (p = 0.684). Overall, periprocedural mortality was 0.9 percent. Flap failures occurred in two cases (1.8 percent). The overall complication rate was 22.3 percent (n = 25). Complications by flap type varied without reaching statistical significance. CONCLUSIONS: Microvascular reconstruction in complex scalp defects is associated with successful outcomes, and chronologic age does not increase mortality or catastrophic flap complications. The most common flaps used to repair scalp defects are anterolateral thigh and latissimus dorsi, but a superior flap type could not be identified.

BACKGROUND: Despite inclusion of periorbital structures in facial transplants, critical assessment of posttransplantation short- and long-term periorbital function has not been reported. The purpose of this article is to report recovery of ocular and periorbital function, with critical appraisal of posttransplant blink in the setting of revision surgery. METHODS: Prospective ocular and periorbital functional assessments were completed at multiple time points in a patient undergoing facial transplantation and subsequent revision operations. Function was evaluated using clinical ocular examinations, visual acuity assessments, photography, and video at various intervals from preoperative baseline to 13.5 months after transplantation. During this period, revision operations involving periorbital structures were performed at 6 and 9 months after transplantation. RESULTS: Before transplantation, volitional blink was 100 percent in both eyes. Involuntary blink was 40 percent in the right eye and 90 percent in the left eye, with occasional full closure. Following face transplantation, voluntary blink was preserved, partial skin sensation was present, and involuntary blink improved to 70 percent in the right eye and 100 percent in the left eye. Following revision surgery, visual acuity and voluntary and involuntary blink were impaired. By 7.5 months after revision, improvement comparable to the pretransplantation assessment was observed. CONCLUSIONS: Adherence to principles of blink preservation is critical in periorbital transplantation. Involuntary blink is essential for preserving vision, and can be improved after transplantation. Revision surgery may temporarily impair advances made with initial allotransplantation. A comprehensive understanding of ocular biomechanics and function is invaluable to the reconstructive surgeon performing facial transplantation involving periorbital structures and posttransplant revision operations. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

BACKGROUND: Aesthetic and functional mandibular reconstruction can be achieved in 1-stage. It involves simultaneous dental implant placement in a free vascularized fibula transfer with a low-profile reconstruction plate. The aim of this study was to assess the postoperative aesthetic profile and oral functional result. MATERIAL AND METHODS: Ten patients with a mean age of 31.6 years and an average follow-up time of 83.7 months underwent 1-staged mandibular reconstructions after segmental mandibulectomies. Simultaneous dental implantation was placed at the fibular segment according to the maxillary dentition. The fibula-implant construct was stabilized superiorly with miniplates and an additional low-profile reconstruction plate recreated the inferior mandibular contour. Any remaining vascularized soft tissue was used for augmentation. Palatal mucosa grafts were placed around the dental implant healing abutment at the uncovering stage surface. Aesthetic profile and oral function were evaluated postoperatively for 5 years. RESULTS: All microsurgical transplantations were successful. None of the patients required subsequent revisions. All patients completed prosthodontic rehabilitation. All patients had palatal mucosal grafts placed around the dental implants. The mean probing pocket depths were shallower around the implants, 3.09 +/- 0.82 mm at mesial, 3.33 +/- 1.05 mm at distal, 3.02 +/- 1.13 mm at buccal, and 3.23 +/- 1.17 mm at lingual surfaces. Radiographs revealed no statistical differences in mean of the mesial [0.27 +/- 0.26 mm] and distal [0.33 +/- 0.25 mm] of peri-implant bone loss. The prosthetic load mean follow-up time was 71.7 months with a satisfactory implant-supported prosthesis. Two slender female patients palpated the reconstruction plate beneath the soft tissue envelope. CONCLUSIONS: This approach is selectively fashioned for patients with benign disease when the overlying soft tissue drape is adequate. The technique described results in improved appearance and function through definition of the lower third of the face and simultaneous dental implant replacement.

Vascularized bone flaps are the well-known standards of care for reconstruction of segmental mandibular defects ≥ 6 cm. We developed a large animal critical-sized mandibular defect model in which osseous free fibula flaps were used for reconstruction.In this study a total of eight 3-month-old Yorkshire pigs underwent 6 cm full-thickness resection of the left hemimandible. An osseous free fibula flap from the left leg was harvested and contoured to the mandibular defect. Bone placement and plate position was confirmed with fluoroscopy. Animals were followed with serial radiographs and clinical evaluations.Free fibulas were transferred successfully in all eight animals. The average operative time was 346 minutes, and the average flap ischemia time was 86 minutes. The average volume ratio of reconstructed hemimandibles to nonoperated control hemimandibles was 0.72 ± 0.33. The average maximum fracture load was 689 ± 262 N, and the average ratio of biomechanical fracture load for these samples compared with contralateral control hemimandibles was 0.88 ± 0.25.It is concluded that the porcine osseous free fibula flaps can be reliably harvested and viably transferred to critical-sized posterior mandibular defects with acceptable long-term results. The described microsurgical large animal model is acceptable for use in craniomaxillofacial experimentation.

BACKGROUND:As of July of 2013, 27 facial vascularized composite allotransplantations have been performed. The authors developed a classification system and treatment algorithm that is practical and surgically applicable. METHODS:The majority of the transplants have been described in the surgical literature and the media, and a review of the data was performed. A classification system and a treatment algorithm were designed. Skeletal defects were defined by craniofacial osteotomies and soft-tissue defects by aesthetic facial subunits. The soft-tissue defect was subdivided into the following subunits: oral-nasal (type 1), oronasal-orbital (type 2), and full facial (type 3). The bony defects were subdivided into mandibular involvement (M), Le Fort 1 (A), Le Fort 3 (B), and monobloc (C). RESULTS:The mechanisms of injury included trauma (n = 13), burns (n = 8), congenital deformity (n = 3), oncologic resection (n = 1), and unreported (n = 2). According to the proposed classification system: one was type 1; one was type 1-M; one was type 1-MB; two were type 2; two were type 2-B; two were type 2-MB; six were type 3; one was type 3-B; and three were type 3-MB; eight could not be classified due to a lack of data. The treatment algorithm designed a vascularized composite allotransplantation that addressed the bony and soft-tissue components. CONCLUSIONS:Patient selection for these complicated procedures, currently dependent on lifelong immunosuppression, is crucial to their success. The authors describe a classification system and treatment algorithm for facial defects that may be ideally suited for facial transplantation. The proposed classification and algorithm may help centers define indications and ideally improve patient outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, V.

Facial fractures resulting from blunt-mechanism trauma, although common, have been infrequently evaluated in large studies that do not include confirmation of fractures based on author review of available patient radiographic studies. An 8-year review (1998-2006) of the R Adams Cowley Shock Trauma Registry was performed with institutional review board approval. Patients diagnosed with blunt-mechanism facial fractures were identified by the International Classification of Diseases, Ninth Revision (ICD-9) codes and their facial fractures confirmed by author review of computed tomographic scans. Individual fractures were classified and grouped according to the facial thirds. Intra- and interreader variability was calculated, and confirmed fracture patterns were compared to fracture patterns listed by ICD-9 codes. Concomitant injuries and demographic data were additionally evaluated. Four thousand three hundred ninety-eight patients with 8127 fractures were identified. Intra- and interreader variability was 2% and 7%, respectively. ICD-9 coding misdiagnosed 12.5% of all fractures. Eighty-two percent of patients sustained associated injuries, including basilar skull fractures (7.6%) and cervical spine fractures (6.6%). 1.1% had at least one fracture in each facial third (panfacial fracture pattern). Significant relationships were found between demographic parameters, concomitant injuries, specific fractures, and fracture patterns. Studies investigating facial fractures should report fracture patterns confirmed by author review of available radiographic imaging. Large retrospective data sets containing confirmed fractures and capable of addressing rare fracture patterns can be compiled with low inter- and intrauser variability, and are useful for generating mechanistic hypotheses suitable for evaluation in prospective series or by directed biomechanical studies.

Since the first facial transplantation in 2005, 28 have been done worldwide with encouraging immunological, functional, psychological, and aesthetic outcomes. Unlike solid organ transplantation, which is potentially life-saving, facial transplantation is life-changing. This difference has generated ethical concerns about the exposure of otherwise young and healthy individuals to the sequelae of lifelong, high-dose, multidrug immunosuppression. Nevertheless, advances in immunomodulatory and immunosuppressive protocols, microsurgical techniques, and computer-aided surgical planning have enabled broader clinical application of this procedure to patients. Although episodes of acute skin rejection continue to pose a serious threat to face transplant recipients, all cases have been controlled with conventional immunosuppressive regimens, and no cases of chronic rejection have been reported.

BACKGROUND: Over the past decade, facial vascularized composite allotransplantation has earned its place at the top of the reconstructive ladder. However, as in free tissue transfer, postoperative revisions are necessary to achieve optimal functional and aesthetic results. Although revising a facial vascularized composite allotransplantation may potentially risk the integrity of the graft, the authors believe that the advantages of appropriately chosen revisions may provide great benefit. METHODS: Following the most extensive face transplant performed to date, revisions were performed in two surgical procedures. The first included a Le Fort III osteotomy for malocclusion correction, midface tissue resuspension and coronal eyebrow lift to correct soft-tissue ptosis, and submental lipectomy. Bilateral blepharoplasty to minimize tissue excess and scar revision were performed at a subsequent operation. Cephalometric analysis and angiography were performed and blink data collected. RESULTS: Before transplantation, the patient was in class III malocclusion. After transplantation, class I occlusion was obtained; however, the patient subsequently returned to class III occlusion. After skeletal revision, class I occlusion was obtained; however, a corneal blink deficit was noted. Eight months after skeletal revision, blink had improved spontaneously. Angiography revealed collateralization providing retrograde flow from the flap to the recipient. CONCLUSIONS: Although the necessity for revisions is clear, determining which revisions to safely perform and their timing and execution have not been explored. The authors address four distinct categories of revisions, including soft-tissue revision, hard-tissue mismatch, and craniofacial skeleton and dental occlusion. The authors illustrate the success of these revisions and assess their advantages, disadvantages, and relative risk. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.