Faculty Bibliography

The long-term projection of nipple reconstruction is a challenge. Fifty-eight consecutive female patients underwent 58 nipple reconstructions with modified top hat flap with cartilage graft following breast reconstruction in 54 autologous tissues and 4 implants, respectively. The average neonipple size was 11.5 mm initially and 8.5 mm at a mean follow-up of 44.9 months (range, 24-65 months), with a mean decrease in projection of 26.1%. Thirty-three patients achieved an excellent result, 20 patients a good result, 3 patients a fair result, and 2 patients a poor result, respectively. The complication rate was 12.1% (7 of 58 cases), and there was no statistically significant difference between the immediate and delayed groups; the revision rate was 8.6% (5 of 58 cases). The modified top hat flap with banked costal cartilage graft provides a sustainable solution to the gradual loss of nipple projection, with few complications.

We present the case of an 18-year-old girl with McCune Albright Syndrome (MAS) and a near total mandibular defect reconstructed with a free fibula flap. There are three reports of mandibular reconstruction in a patient with MAS using the free fibula flap; however this case is unique for two reasons. One, the continuity defect in our patient was much larger than previously reported, representing nearly the entire length of the mandible (21 cm) and required the entire harvestable length of the fibula. Two, the progression of the patient's disease limited options for reconstruction and dictated the use of a fibula with small dysplastic changes.

BACKGROUND: Recent clinical trials involving patients with acute coronary syndromes have demonstrated significant reduction in the progression of coronary artery thrombosis using a regimen of aspirin, heparin, and the glycoprotein IIb/IIIa inhibitor tirofiban. Acute coronary syndromes and free tissue transfer are similar pathophysiologically in that they both involve endothelial injury, thrombosis, and ischemia. In this study, the authors investigate tirofiban, combined with aspirin and heparin, for the prevention of microsurgical anastomotic thrombosis in a thrombogenic rat model. METHODS: Using a randomized, controlled, double-blind experimental design, 80 thrombogenic anastomoses were performed on rat femoral arteries (n = 40) and veins (n = 40). Preoperatively, each rat received one of four treatment regimens: aspirin and heparin (regimen 1), aspirin and heparin plus tirofiban (regimen 2), tirofiban alone (regimen 3), or isotonic saline (control) (regimen 4). Vessels were assessed for patency at 5, 15, 30, and 120 minutes after reperfusion and then harvested for microscopic analysis. RESULTS: At 120 minutes after reperfusion, regimen 1 had an arterial and venous patency rate of 80 percent and 70 percent, respectively, whereas the vessel patency rate for regimen 2 was 100 percent. The difference between regimens 1 and 2 was not statistically significant. Regimens 3 and 4 had vessel patency rates of 40 percent or less. The aspirin/heparin and aspirin/heparin/tirofiban groups both demonstrated significantly improved vessel patency and significantly less thrombotic occlusion compared with controls. CONCLUSIONS: Combination therapy with aspirin, heparin, and tirofiban significantly increases arterial and venous patency and decreases anastomotic thrombus formation in thrombogenic anastomoses in rats. The role of glycoprotein IIb/IIIa inhibitors in microsurgery warrants further investigation.

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, complex, posttraumatic and recurrent abdominal hernias present a reconstructive challenge. Multiple techniques have been described to restore the integrity of the abdominal wall, although the indications and applications can be difficult to navigate. The authors propose an algorithm that facilitates the assessment and treatment of secondary large ventral defects. METHODS: The algorithm described involves a systematic approach to abdominal wall reconstruction and was applied to 23 consecutive patients at the R Adams Cowley Shock Trauma Center. Data collected from the chart review included age, body mass index, mechanism of injury, placement of skin graft and use of resorbable mesh before definitive reconstruction, size of defect, number of tissue expanders placed, length of follow-up, and complications. RESULTS: There were six female patients and 17 male patients, with an average age of 36 years. The average follow-up was 7 months. Seventeen patients had posttraumatic laparotomies, five patients had aggressive abdominal wall debridement following necrotizing fasciitis, and one patient developed a large abdominal wall hernia following complications from gastric bypass surgery. All patients underwent delayed abdominal wall reconstruction, with an average time to initial reconstruction of 19.5 months. Sixteen patients had no postoperative complications. Seven patients had complications, including one with an enterocutaneous fistula, one with a partial small bowel obstruction, two with seromas, one with a superficial wound infection, and two with recurrent abdominal wall laxity. CONCLUSIONS: The reconstructive ladder for large, complex abdominal hernias is poorly defined. The proposed algorithm provides a systematic staged approach that incorporates available techniques used for delayed reconstruction of the abdominal wall.

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.