Faculty Bibliography

BACKGROUND: Osteoradionecrosis is a serious complication of head and neck radiotherapy. Advanced cases are not amenable to periodic debridement, systemic antibiotics, or hyperbaric oxygen therapy. The authors sought to describe a cost-effective approach for patients with advanced craniofacial osteoradionecrosis. METHODS: Fifteen consecutive patients with craniofacial osteoradionecrosis were treated with radical resection and immediate microvascular free flap reconstruction at Johns Hopkins Hospital or R Adams Cowley Shock Trauma Center from 2002 to 2008. Demographic data were reviewed, and procedure costs were used to compare treatment options. RESULTS: All patients presented with intractable osteoradionecrosis, and most failed conservative therapy. Most cases (60 percent) involved the mandible, and the fibula was the flap of choice (73 percent). The median follow-up was 14 months, with 13 percent complications. Relative cost analysis for hyperbaric oxygen, surgical debridement, and a hospital stay was $25,010; simultaneous resection-microvascular free flap reconstruction and 7-day hospital stay were $30,030. The majority of patients, however, had prior attempts at conservative therapy followed by simultaneous resection and reconstruction; therefore, the average total relative cost per patient was $55,040 ($25,010 + $30,030). CONCLUSION: Definitive treatment of advanced or intractable osteoradionecrosis with simultaneous resection and microvascular composite flap reconstruction is not only definitive but financially sound.

BACKGROUND: Frontal sinus injury involving nasofrontal outflow tract obstruction is routinely managed by obliteration or cranialization; however, a small percentage of patients develop persistent indolent infections despite routine measures. The authors discuss the course of persistent infection following frontal sinus fractures and propose a novel treatment that definitively obliterates and separates the nasofrontal outflow tract from the cranium in these patients. METHODS: Seven consecutive patients with persistent indolent infections associated with frontal sinus fractures were identified and treated at the R Adams Cowley Shock Trauma Center and The Johns Hopkins Hospital from 2005 to 2008. RESULTS: There were three women and four men, with an average age of 41 years. Injury resulted from motor vehicle crashes (n = 4), motorcycle crash (n = 1), fall (n = 1), and other accident (n = 1). All patients were previously treated with conventional techniques (average, 3.6 procedures and 11 years from initial injury) and prolonged antibiotic therapy without resolution of symptoms. Definitive treatment included radical debridement and obliteration with a free fibula flap in a single stage. All flaps survived and resulted in complete sinonasal separation and eradication of infection. There were no donor-site or frontal sinus complications. CONCLUSIONS: Radical debridement, meticulous removal of the tenacious sinus mucosa, and reconstruction with a free fibular flap in a single stage is a superb choice for eliminating persistent infectious complications associated with frontal sinus fractures in patients who have failed conventional management. The fibular flap provides a secure horizontal buttress, seals the nasofrontal outflow tract with vascularized muscle, and obliterates dead space.

Reconstructive algorithms for composite craniofacial defects have focused on soft tissue flaps with or without bone grafts. However, volumetric loss over time limits long-term preservation of facial contour. Application of craniofacial skeletal buttress principles to high-energy trauma or oncologic defects with composite vascularized bone flaps restores the soft tissue as well as the buttresses and ultimately preserves facial contour. We conducted a retrospective review of 34 patients with craniofacial defects treated by a single surgeon with composite bone flaps at R Adams Cowley Shock Trauma Center and Johns Hopkins Hospital from 2001 to 2007. Data collected included age, sex, mechanism of injury, type of defect, type of reconstructive procedures, and outcome. Thirty-four patients with composite tissue loss, primarily males (n = 24) with an average age of 37.4 years, underwent reconstruction with vascularized bone flaps (28 fibula flaps and 6 iliac crest flaps). There were 4 cranial defects, 8 periorbital defects, 18 maxillary defects, and 4 maxillary and periorbital defects. Flap survival rate was 94.1% with an average follow-up time of 20.5 months. Restoration of facial height, width, and projection is achieved through replacement of skeletal buttresses and is essential for facial harmony. Since 2001, our unit has undergone a paradigm shift with regard to treatment of composite oncologic and traumatic defects, advocating vascularized bone flaps to achieve predictable long-term outcomes.

BACKGROUND: Widespread application of composite tissue allotransplantation has been impeded by risks of rejection and conventional immunosuppression. The authors have developed a nonhuman primate composite tissue allotransplantation model that demonstrated reliable and long-term success necessary to progress to preclinical studies. METHODS: Composite facial subunits (e.g., skin, muscle, and bone) were transplanted between mismatched cynomolgus monkeys. Vascular supply was based on the common carotid artery and external and internal jugular veins. Facial allografts were heterotopically transplanted to the recipient's lower abdomen with end-to-side anastomoses of the common carotid artery to the common femoral artery and of both the internal and external jugular veins to the common femoral vein. Animals received tacrolimus monotherapy. Grafts were inspected daily, submitted to biopsy regularly, and studied with magnetic resonance imaging. RESULTS: Thirteen transplants were performed. Two grafts based on the common carotid artery and only the internal jugular vein failed within 3 to 5 days because of venous thrombosis not related to rejection. Subsequent transplants included anastomoses of both the internal and external jugular veins to the common femoral vein without thromboses. Immunosuppression consisted of tacrolimus monotherapy and was tolerated without complications. Long-term success was achieved with rejection-free graft survival (60 to 177 days). CONCLUSIONS: The authors have developed the first successful model of facial composite tissue allotransplantation in a nonhuman primate. Technical requirements include preservation of both internal and external jugular venous outflow. Tacrolimus monotherapy permitted prolonged rejection-free graft survival without early complications. This model provides a platform for further investigation of composite tissue allotransplantation tolerance and requirements for indefinite survival.

A 29-year-old woman with Freeman-Sheldon syndrome had a history of recurrent frontal sinus infections for which she underwent a 1-stage frontal sinus obliteration and cranioplasty using a free fibula osteocutaneous flap. This case is unique in that a free fibula flap had never been used to obliterate the frontal sinus in a patient with Freeman-Sheldon syndrome, nor had it been harvested from a limb with a clubfoot.

BACKGROUND: The significance of the oral vestibule is often underappreciated in composite craniomaxillofacial reconstruction, and its deficiency results in considerable incompetence. Results of traditional vestibuloplasty techniques are unpredictable when the recipient bed is compromised in the setting of trauma or irradiation. The authors present an alternative approach for restoring the intractable oral vestibule with free tissue transfer. METHODS: An institutional review board-approved retrospective review of patients who underwent oral vestibular reconstruction was conducted at R Adams Cowley Shock Trauma Center and Johns Hopkins Hospital from 2002 to 2007. RESULTS: Thirteen patients were identified: six defects resulted from tumor extirpation, six resulted from traumatic injury, and one resulted from infection. There were eight men and five women, with a mean age of 46 years. Thirteen free tissue transfers of the oral vestibule were conducted: six ulnar forearm and seven anterolateral thigh perforator flaps. The average follow-up was 17 months. There were no flap failures and only one complication noted, which did not result in negative sequelae. The functional results were good, with all patients experiencing increased labial excursion and subjective improvement in the handling of food bolus and saliva. CONCLUSIONS: Preservation of oral vestibular height, width, and volume is essential for aesthetic appearance and functional competence. Free tissue transfer provides an innovative alternative in the management of the intractable and obliterated oral vestibule. It can be performed successfully, providing excellent results predictably.

BACKGROUND: Frontal sinus fracture treatment strategies lack statistical power. The authors propose statistically valid treatment protocols for frontal sinus fracture based on injury pattern, nasofrontal outflow tract injury, and complication(s). METHODS: An institutional review board-approved retrospective review was conducted on frontal sinus fracture patients from 1979 to 2005. Fractures were categorized by location, displacement, comminution, and nasofrontal outflow tract injury. Demographic data, treatment, and complications were compiled. RESULTS: One thousand ninety-seven frontal sinus fracture patients were identified; 87 died and 153 were excluded because of insufficient data, leaving a cohort of 857 patients. The most common injury was simultaneous displaced anteroposterior walls (38.4 percent). Nasofrontal outflow tract injury constituted the majority (70.7 percent), with 67 percent having a diagnosis of obstruction. Of the 857 patients, 504 (58.8 percent) underwent surgery, with a 10.4 percent complication rate; and 353 were observed, with a 3.1 percent complication rate. All complications except one involved nasofrontal outflow tract injury (98.5 percent). Nasofrontal outflow tract injuries with obstruction were best managed by obliteration or cranialization (complication rates: 9 and 10 percent, respectively). Fat obliteration and osteoneogenesis had the highest complication rates (22 and 42.9 percent, respectively). The authors' treatment algorithm provides a receiver operating characteristic area under the curve of 0.8621. CONCLUSIONS: A frontal sinus fracture treatment algorithm is proposed and statistically validated. Nasofrontal outflow tract involvement with obstruction is best managed by obliteration or cranialization. Osteoneogenesis and fat obliteration are associated with unacceptable complication rates. Observation is safe when the nasofrontal outflow tract is intact.

Horizontal maxillary osteotomy with an interpositional fibula flap for maxillary deficiency offers several advantages over conventional techniques for maxillary reconstruction. Maxillary deficiencies in all 3 planes, vertical, anterior-posterior, and transverse, can be corrected with a long-term stable construct while simultaneously restoring bony and soft tissue deficiencies. We conducted a retrospective review of patients with maxillary hypoplasia who underwent Horizontal maxillary osteotomy with interpositional osteoseptocutaneous fibula flaps. Compared with nonvascularized bone grafts, vascularized bone flaps undergo less resorption and can be used in poorly vascularized, mechanically unstable, irradiated, or scarred wound beds.

BACKGROUND: Microsurgical reconstructive algorithms for craniofacial defects have focused on soft-tissue flaps with or without conventional bone grafts. However, volumetric loss from muscle atrophy, bone resorption, and soft-tissue contraction limits long-term preservation of facial contour. Applying craniofacial principles of skeletal buttress support, the authors used composite vascularized bone flaps to reconstruct the soft tissue and the vertical and horizontal buttresses of the face. In this manner, facial proportions and aesthetics are maintained in composite tissue defects resulting from high-energy trauma or oncologic extirpation. METHODS: The authors conducted a retrospective review of 31 patients with craniofacial defects treated by a single surgeon with composite bone flaps at the R Adams Cowley Shock Trauma Center and The Johns Hopkins Hospital from 2001 to 2006. Charts were reviewed and data were collected on age, sex, mechanism of injury, type of defect, type of reconstructive procedure, and outcome. RESULTS: Thirty-one patients with composite tissue loss, primarily men (n = 21) with an average age of 37.4 years, underwent reconstruction with vascularized bone flaps (25 fibula flaps and six iliac crest flaps). There were three cranial defects, eight periorbital defects, 17 maxillary defects, and three maxillary and periorbital defects. The flap survival rate was 93.5 percent, with an average follow-up of 13.5 months. CONCLUSIONS: Restoration of facial height, width, and projection through skeletal buttress replacement is essential for achieving facial harmony. Since 2001, the authors' unit has pursued a paradigm shift with regard to treatment of composite oncologic or traumatic defects, advocating vascularized bone flaps to achieve excellent long-term functional and aesthetic outcomes.