Faculty Bibliography

We present two cases of infected frontal sinus fractures requiring simultaneous obliteration of the frontal sinus and reconstruction of the horizontal buttress. In both cases, a free fibula flap was used for obliteration and bony reconstruction in a single stage. We believe that this is a novel technique for treatment of infected frontal sinus fractures obviating the need for secondary staged procedures.

BACKGROUND: Identification of a single donor site capable of providing all the components of the soft tissue envelope and the ability to selectively harvest a subset of these components is a central requirement for the microvascular reconstruction of the trauma patient. The anterolateral thigh (ALT) flap's long pedicle and adaptability in supporting a variety of tissues (muscle, fascia, soft tissue) make it a valuable tool for microsurgical reconstruction in these challenging patients. We investigated the utility of the ALT as a donor for microvascular tissue reconstruction in a Level I trauma center. METHODS: We conducted a retrospective chart review on all trauma patients treated by the plastic surgery service at the R Adams Cowley Shock Trauma Center who required microsurgical free flap coverage from July 2002 to March 2005. Fifty-eight patients underwent reconstruction of traumatic deformities with 62 microvascular free flaps from the ALT region. RESULTS: Of the 58 patients, 42 were male and 16 were female with an average age of 39 years. Recipient site locations for the 62 flaps were lower extremity, upper extremity, trunk, and head and neck. Analysis of flap anatomy revealed that 43 were fasciocutaneous, 14 were myocutaneous, 2 were adipofascial, and 3 were myofascial (vastus lateralis muscle). Six flaps were based on septocutaneous perforators, whereas the remainder contained myocutaneous perforators. Nine thigh donor sites required a split thickness skin graft, and 53 were closed primarily. The size of the flaps ranged from 36 cm2 to 600 cm2. CONCLUSIONS: The ALT is a predictable donor site that facilitates a 2-team approach. ALT displays minimal donor site morbidity and in most cases provided sufficient tissue to cover the entire traumatic defect. Our results suggest the ALT is a reliable tissue source and an ideal donor site for the management of complex traumatic wounds in the United States.

A 66-year-old man with silent sinus syndrome, resulting in progressive enophthalmos and subclinical chronic maxillary sinusitis, presented after several failed attempts at reconstruction with conventional methods. A free fibula osteoseptocutaneous flap was used to recreate the orbital floor, obliterate the maxillary sinus, and augment the periorbital contour deformity in a single stage. This is a novel approach for the treatment of Silent Sinus Syndrome in a single stage.

BACKGROUND: Trauma patients with high-energy injuries often present with severe tissue damage that extends beyond the immediate zone of injury and requires recruitment of vascularized tissues from distant sites. The objective of this study was to evaluate the utility of the anterolateral thigh (ALT) flap for reconstruction of the traumatically injured lower extremity. METHODS: Prospective data were collected on all patients who underwent lower extremity reconstruction with an ALT flap during a 3.5-year period at a primary adult resource center (PARC). Demographics captured included age, gender, Injury Severity Score, mechanism of injury, and size of defect and complications. RESULTS: Fifty-six patients underwent a total of 59 ALT flap harvests during the study period. The majority of patients were male (75%) and sustained blunt injury (95%). The mean age was 37 +/- 14 years with a mean Injury Severity Score of 17.9 +/- 8. The mean flap size was 20.7 x 8.4 cm, with 64% harvested from the injured limb. Total flap success rate was 91.5%, with four total (6.7%) and one partial flap failure (1.7%). CONCLUSION: The ALT flap is a useful tool for trauma reconstruction in lower extremity salvage. We have shown that the ALT flap can be performed successfully in the traumatically injured patient even when harvested from the ipsilateral lower extremity.

The plastic surgeon's usual involvement in patients with hepatitis C is most frequently limited to an inner city population with hand and forearm abscesses from intravenous drug use or to incidences of needle-stick injury in the operating room when the patient is hepatitis C positive. Hand surgeons and peripheral nerve surgeons often treat patients with underlying neuropathies who have superimposed overlying nerve compressions such as carpal tunnel syndrome. We have applied this experience to a patient with underlying peripheral neuropathy associated with Hepatitis C and clinical evidence of overlying lower extremity nerve compressions. We believe that she is the first successful surgical treatment of peripheral nerve compressions in a patient with hepatitis C-associated neuropathy, documented by noninvasive neurosensory testing.

BACKGROUND: Large nipples, disproportionate to the small areola and breast size, are an ethnic characteristic frequently encountered among Asian female patients. Patients seek correction to improve cosmesis and alleviate psychological and physical discomfort. The authors present a new technique of nipple reduction and describe its potential advantages over other techniques. METHODS: Between March of 2003 and April of 2005, 34 nipple reductions were performed in 19 female patients (mean age, 40.5 +/- 5.6 years) using the modified top hat flap. The neonipple is designed to reduce the nipple diameter at the superior pole of the nipple while preserving the subdermal plexus. A crescent-shaped section of nipple skin below the proposed neonipple is excised, maintaining the integrity of the neonipple and the central nipple core. Two lateral wing flaps are elevated and trimmed to reduce both nipple height and diameter at the lateral walls of the nipple. The flaps of the neonipple are then sutured to the areola. RESULTS: Postoperative recovery was rapid and uneventful and no complications were encountered. The mean diameter of the hypertrophic nipple was 16.3 +/- 2.6 mm (range, 16 to 30 mm). The mean diameter of the neonipple was 7.9 +/- 1.7 mm (range, 5 to 11 mm), with an average reduction of 8.4 +/- 1.6 mm (range, 5 to 20 mm). At 17.2 +/- 2.9 months of follow-up, the neonipple had a natural appearance, with less projection and an inconspicuous scar. There was no statistically significant difference on monofilament sensation testing (p = 0.5829) between reduction nipple and areola in 11 nipples of seven patients. CONCLUSIONS: The modified top hat flap requires minimal preoperative planning, is easy to perform, and yields reproducible results. This technique decreases both the diameter and height of any size nipple and can be modified to meet patient preferences. Because the continuity of the neonipple with the subdermal arterial plexus is maintained and the majority of the parenchymal elements are preserved, nipple sensation and circulation remain largely unaffected.

BACKGROUND: To evaluate the impact of damage control laparotomy on long term morbidity and survival. METHODS: Prospective data were collected on 56 consecutive trauma patients over a 20-month period (May 2000-January 2002). Patients were stratified by mechanism of injury, age, Injury Severity Score, and type of injury, temperature at admission, initial blood transfusion volume and pH. Initial outcome data included major complications, intensive care unit and hospital length of stay, and mortality. Readmission data including number of admissions, surgical procedures, and hospital length of stay were then analyzed over the subsequent follow-up years (2001-2003). RESULTS: The mean age of the study group was 31 +/- 11 years with a mean Injury Severity Score of 33 +/- 13. The majority of the patients were male (73%) with a relatively equal number of blunt (n = 30) and penetrating injuries (n = 26). Liver injuries (34 [61%]) were the most common solid organ injury followed by 22 bowel (39%), 19 spleen (34%), 11 major vessel (20%), and 7 pancreas (13%) injuries. The mean number of initial abdominal surgical procedures was 4.4 +/- 2.2 per patient. The overall mortality during the first admission was 27%. Time spent in the intensive care unit and hospital length of stay was 17 +/- 13 and 30 +/- 19 days, respectively. There were a total of 74 readmissions and 58 subsequent surgical procedures in the 41 patients who were readmitted. Thirty-one (76%) patients were re-admitted at least one time. Infection (n = 19) was the most common reason for readmission followed by ventral hernia repair (n = 17) and fistula management (n = 14). There was 0% mortality for patients who survived the preliminary hospitalization but required readmission. CONCLUSION: Although damage control laparotomy is associated with a significant complication and readmission rate, its long term survival and benefit is indisputable.

Traumatic maxillary bone loss, if not treated acutely, is accompanied by contracture of the overlying soft tissue envelope and loss of facial projection in three dimensions. Reconstruction aimed at replacing the bony architecture, expanding the soft tissue envelope and establishing a platform for dental rehabilitation can be accomplished in a staged approach. We present two patients who underwent replacement of missing maxillary segments with a free fibula flap, followed by distraction of the free fibula in three dimensions and eventual dental rehabilitation with osseo-integrated implants.