Faculty Bibliography

BACKGROUND: Vascularized composite tissue allotransplantation has demonstrated clinical success with standard immunosuppression in hand and upper extremity transplantation. The authors developed a fibular vascularized composite tissue allotransplantation model in nonhuman primates to investigate healing and rejection patterns of bone and associated tissues. METHODS: Five fibular vascularized composite tissue allotransplantations were performed between mismatched cynomolgus macaques (Macaca fascicularis). Vascularized fibular segments with associated muscle and skin were transplanted to recipient forearm radius defects. Recipients were treated with either tacrolimus monotherapy or tacrolimus plus co-stimulatory blockade with a novel anti-CD28 antibody. Animals were followed for 6 months with serial radiographs, blood sample collection, and biopsies. At the study endpoint, angiographic, biomechanical, histologic, and immunologic assays were performed. RESULTS: All animals survived to the experimental endpoint of 180 days. Rapid or immediate skin loss was evident secondary to vascular compromise (n = 3) or rejection (n = 1) in four animals. Despite loss of nonbony segments and the development of transplant arteriopathy consistent with chronic rejection in two animals, serial radiologic imaging and histology demonstrated bone healing and donor-recipient bony union by 10 weeks in all animals. Histology confirmed the presence of viable cortical and marrow elements. Biomechanical analysis supported donor-recipient bony union. Short-tandem repeated genotypic analysis revealed that donor marrow had been completely replaced by recipient marrow. CONCLUSIONS: In contrast to successes in extremity vascularized composite tissue allotransplantation, the authors' nonhuman primate fibular vascularized composite tissue allotransplantation model showed early skin loss, replacement of donor bone marrow, and chronic rejection. Donor-recipient bone union did occur and supports the potential for reconstruction of bony continuity defects using isolated vascularized bone allotransplants.

BACKGROUND: To date, only limited case reports involving isolated bilateral zygomatic arch fractures exist. This fracture pattern is defined by the presence of bilateral zygomatic arch fractures and the absence of any other facial fractures. The purpose of this study was to systematically review a large trauma database to determine whether this fracture pattern exists and, if so, to elucidate the mechanism of injury and associated concomitant injuries. METHODS: A retrospective review of all patients admitted to the R Adams Cowley Shock Trauma center from February of 1998 to December of 2009 was conducted. International Classification of Diseases, Ninth Revision coding of computed tomographic scans was used to identify patients with zygoma fractures. The facial computed tomographic scans of all patients coded with bilateral zygoma fractures were reviewed to determine whether any had isolated bilateral zygomatic arch fractures. Medical charts were reviewed extensively. RESULTS: Five patients (0.24 percent of all zygoma fractures, 3.18 percent of bilateral zygoma fractures) were found to have isolated bilateral zygomatic arch fractures. All five patients had evidence of skull impact with at least one skull fracture and one skull base fracture. Glasgow Coma Scale scores (range, 6 to 14; average, 8.2) were significantly lower (t test, two-sided, p=0.01) compared with all patients (average, 12.2) with facial trauma during the study period. CONCLUSIONS: Isolated bilateral zygomatic arch fractures do exist. The authors' findings suggest skull impacts as the inciting mechanism of injury and an intimate link with skull base force transmission. The severe nature of this injury warrants a search for concomitant injuries to the head, brain, and spinal cord.

Vascularized composite allograft (VCA) transplantation (also referred to as composite tissue allotransplantation) has demonstrated clinical success in cases of hand, arm and face transplantation despite prior belief that skin provides an insurmountable barrier to allograft rejection. These overall good outcomes are facilitated by substantial immunosuppressive requirements in otherwise healthy patients, yet still demonstrate frequent rejection episodes. We developed a nonhuman primate model of facial segment allotransplantation to elucidate the unique pathophysiology and immunosuppressive requirements of VCA with addition of concomitant vascularized bone marrow (VBM). Heterotopically transplanted facial segment VCA with VBM treated only with tacrolimus and mycophenolate mofetil (MMF) demonstrated prolonged rejection-free survival, compared to VCA without VBM that demonstrated early rejection episodes and graft loss. While VCA with VBM demonstrated sporadic macrochimerism, acute and chronic rejection and graft loss occurred after discontinuation of immunosuppression. These data support an immunomodulatory role of VBM in VCA that reduces immunosuppressive requirements while providing improved outcomes.

Biologic prostheses have emerged to address the limitations of synthetic materials for ventral hernia repairs; however, they lack experimental comparative data. Fifteen swine were randomly assigned to 1 of 3 bioprosthetic groups (DermaMatrix, AlloDerm, and Permacol) after creation of a full thickness ventral fascial defect. At 15 weeks, host incorporation, hernia recurrence, adhesion formation, neovascularization, inflammation, and biomechanical properties were assessed. No animals had hernia recurrence or eventration. DermaMatrix and Alloderm implants demonstrated more adhesions, greater inflammatory infiltration, and more longitudinal laxity, but near identical neovascularization and tensile strength to Permacol. We found that porcine acellular dermal products (Permacol) contain following essential properties of an ideal ventral hernia repair material: low inflammation, less elastin and stretch, lower adhesion rates and cost, and more contracture. The addition of lower cost xenogeneic acellular dermal products to the repertoire of available acellular dermal products demonstrates promise, but requires long-term clinical studies to verify advantages and efficacy.

HYPOTHESIS: Damage control laparotomy (DCL) has beneficial effects on the long-term morbidity and survival of trauma patients. DESIGN: Prospective study. SETTING: Level I trauma center. PATIENTS: Eighty-eight trauma patients who were admitted during a 3-year period (January 1, 2000, through December 31, 2003) underwent damage control laparotomy and were subsequently followed up (January 1, 2001, through December 31, 2008). INTERVENTION: Damage control laparotomy. MAIN OUTCOME MEASURES: Major and long-term complications, lengths of stay, mortality, readmissions, subsequent surgical procedures, activities of daily living, and return to work. RESULTS: On admission, the mean age and Injury Severity Score were 33 years and 34, respectively. Of the 88 patients, 66 (75%) were male; 46 patients had blunt injuries and 42 had penetrating injuries. Liver was the most common injury (63 patients), followed by bowel (34), spleen (33), major vessel (19), and pancreas (10). The mean admission pH and temperature were 7.19 and 34.4 degrees C, respectively, with 21.5 U of packed red blood cells transfused. The mean (SD) number of initial abdominal operations was 4.6 (2.5) per patient, with an overall mortality of 28% (25 patients). Intensive care unit and hospital lengths of stay were 18 (15) and 32 (20) days, respectively. Of the 63 patients who survived, 58 underwent intra-abdominal closure with polyglactin mesh. During the study, 44 intra-abdominal infections and 18 enterocutaneous fistulas were diagnosed. All 63 survivors were readmitted at least once. There were a total of 186 readmissions and 92 subsequent surgical procedures. Ventral hernia repair (66 readmissions) was the most common reason for readmission, followed by infection (41) and fistula management (29). There was 0% mortality for patients who survived the preliminary hospitalization. Of the 63 surviving patients, 51 (81%) reported that they had gone back to work and resumed normal daily activities. CONCLUSION: Although damage control laparotomy is associated with a significant complication and readmission rate, its overall benefit is indisputable.

BACKGROUND: The free anterolateral thigh (ALT) flap has become a reconstructive workhorse with great versatility throughout the body. However, the utility of the pedicled ALT flap is less described for complex defects. A skin paddle with reliable blood circulation and wide range of reach, low donor site morbidity along with the avoidance of many of the complications plaguing free flaps, are just some of the several benefits offered by the pedicled ALT flap. We investigated specific clinical examples within our ALT flap database where the pedicled ALT flap was used for coverage of complex wounds and highlight its advantages. METHODS: We conducted a retrospective chart review on those patients in whom a pedicled ALT flap was used for complex wound reconstruction over a 7-year period between July 2002 and October 2009 at The R Adams Cowley Shock Trauma Center performed by a single surgeon. RESULTS: : Four patients underwent a pedicled ALT flap as part of their reconstruction. Flaps ranged in size from 75 to 648 cm, and all but one were cutaneous in nature with the other one being fasciocutaneous. The flaps averaged 2 perforators (range, 1-3) and the donor sites were all closed primarily except for one. CONCLUSIONS: When faced with a complex defect in the abdominal-pelvic region, we propose that the pedicled ALT flap has several advantages to other types of tissue coverage and is an excellent option for the reconstructive surgeon.

BACKGROUND: The aim of lower extremity reconstruction has focused on early wound coverage and functional recovery but rarely aesthetics. Free muscle flaps provide durable coverage; however, they require skin graft coverage and result in muscle atrophy limiting future revisions. Perforator-based flap reconstructions can be easily elevated to allow for both orthopedic and contouring procedures. The authors reviewed the role of secondary procedures in achieving improved functional and aesthetic results following perforator flap reconstruction of lower extremity defects. METHODS: A retrospective review identified 70 patients treated at R Adams Cowley Shock Trauma Center with 73 free perforator flaps for coverage of lower extremity wounds from 2002 to 2009. RESULTS: Seventy patients were identified who underwent reconstruction with a perforator flap: 65 with anterolateral thigh flaps and five with superficial circumflex iliac artery flaps. Nineteen of these patients underwent 32 refinement procedures of the reconstructed limb. Fifteen refinements were performed with suction-assisted lipectomy, 21 with complex tissue rearrangement, including sharp debulking, and one with tissue expanders. Twenty-seven of the 70 patients underwent 40 orthopedic-related secondary procedures in which the free flap was elevated. The most common reasons for the orthopedic interventions were tibial nonunion requiring bone grafting (n = 17) and osteomyelitis (n = 11). CONCLUSIONS: Limb salvage remains the primary goal of lower extremity reconstruction. Following convalescence and functional recovery, however, appearance becomes increasingly important with regard to quality of life. Initial flap selection with free perforator flaps, meticulous inset, and secondary refinements provide superior functional and aesthetic outcomes.

BACKGROUND: The authors sought to review the various types of patients with psychological abnormalities who may present to the plastic surgeon and the psychological impact of various plastic surgery procedures on these patients. METHODS: After systematically searching the Embase and PubMed databases and following further refinement (based on the authors' inclusion and exclusion criteria), the authors identified 65 studies. In addition, the authors felt that important information was contained in four textbooks, two press releases, and one Internet database. The inclusion criteria were studies that investigated the psychological outcomes, background, and personality types of patients seeking specific plastic surgery procedures. In addition, studies that addressed the impact of plastic surgery on patients' psychological status and quality of life were also included. The authors excluded studies with fewer than 30 patients, studies that did not pertain to the particular plastic surgery procedures, and studies that addressed psychological sequelae of revision operations. RESULTS: Narcissistic and histrionic personality disorders and body dysmorphic disorder are the three most common psychiatric conditions encountered in patients seeking cosmetic surgery. Overall, plastic surgery not only restores the appearance and function of the disfigured body unit but also alleviates psychological distress. CONCLUSION: Identifying the psychologically challenging patient before surgical intervention will allow the patient to obtain the appropriate psychological assistance and may result in a healthier individual with or without associated plastic surgery procedures.

Complications and undesired outcomes happen to some patients of virtually all physicians, at all stages in their careers. Bad outcomes can be a consequence of disease processes, the premorbid condition of the patient, or the errors that occur in the process of health care. These errors include, but are by no means confined to, surgeon error. Regardless of the reason for the bad outcome, the surgeon is obligated to discuss the event with the patient and the family. This article reviews the benefits, barriers, and legal implications of the discussion and describes the disclosure process.