Faculty Bibliography

Marko Godina in his landmark paper in 1986 established the principle of early flap coverage for reconstruction of traumatic lower extremity injuries to minimize edema, fibrosis, and infection while optimizing outcomes. However, with the evolution of microsurgery and wound management, there is emerging evidence that timing of reconstruction is not as critical as once believed. Multidisciplinary care with a combined orthopedic and reconstructive approach is more critical for timely and appropriate definite treatment for severe lower extremity injuries.

BACKGROUND:Stacked and conjoined free flaps are increasingly utilized in autologous breast reconstruction to augment tissue transfer volume. However, there is a paucity of comparative data on abdominally-based stacked/conjoined versus non-stacked/conjoined flaps. The purpose of this study was to compare ability to match native breast size, complications, recovery, and symmetrizing procedures between these two cohorts in unilateral breast reconstruction. METHODS:A retrospective review of all stacked (two separate hemiabdominal)/conjoined (bipedicled full abdominal) flaps and non-stacked/conjoined (unipedicled hemiabdominal) flaps in unilateral abdominally-based autologous breast reconstructions was performed from 2011 to 2018. Variables including demographics, operative characteristics, complications, and revisions were compared in 36 stacked/conjoined patients versus 146 non-stacked/conjoined patients. RESULTS:The stacked/conjoined cohort had more DIEP flaps (91.7 vs. 65.1%) and the non-stacked/conjoined group more MS-TRAMs (34.2 vs. 6.9%, p = .000). Additionally, non-stacked/conjoined flaps had greater utilization of combined medial and lateral row perforators (p = .000). Mean flap weight was significantly higher than mastectomy weight in stacked/conjoined flaps (+110.7 g) when compared to non-stacked/conjoined flaps (-40.2) (p = .023). Average follow-up was 54.7 ± 27.5 and 54.6 ± 29.3 months, respectively. Stacked/conjoined flaps had lower fat necrosis rates (8.3 vs. 25.4%, p = .039) and had a decreased risk of fat necrosis on multivariable regression analysis (OR 0.278, p = 0.045). There were otherwise no differences in flap, breast, or donor-site complications. Stacked/conjoined flaps also had a lower rate of contralateral breast reduction (p = .041). CONCLUSION/CONCLUSIONS:Stacked/conjoined flaps were associated with a lower risk of fat necrosis compared with non-stacked/conjoined flaps and had a lower rate of contralateral symmetrizing reductions in patients undergoing unilateral abdominally-based breast reconstruction.

OBJECTIVE:To describe a technique for perineal urethrostomy (PU) revision using a posterior thigh propeller flap for a complex repair at high risk for stenosis. METHODS:Our technique utilizes the consistent posterior thigh perforators for a local flap with ideal length and thickness for repair. The stenotic PU is incised. Potential flaps are marked around a perforator blood supply closest to the defect. The flap is then elevated and rotated on its pedicle with its apex placed directly in the defect. Absorbable sutures partially tubularize the flap apex at the level of the urethrotomy which is calibrated to 30 Fr. We subsequently monitored the patient's clinical progress. RESULTS:With 17 months of follow-up the patient is voiding well without complaint, reports improved quality of life with a patent PU. Post void residuals have been less than 100cc. The patient, who has had a long history of urinary tract infections requiring hospitalization, has only reported one infection during follow up which was treated as an out-patient. CONCLUSION/CONCLUSIONS:For challenging PU revisions a distant local propeller flap of healthy tissue outside the zone of injury is the ideal choice for length, thickness, and minimal morbidity resulting in excellent clinical results for our patient.

BACKGROUND: Collaboration has been shown to be beneficial when we have complex problems and highly specialized groups, such as in head and neck reconstruction. Otolaryngology, plastic surgery, and oral maxillofacial surgeons perform head and neck reconstruction research. While the specialties represent unique backgrounds, the degree of interdisciplinary collaboration and subtopic focus is unknown. We sought to describe the frequency of interinstitutional interdisciplinary collaboration and examine the association of specialty with research subtopics. METHODS: Oral presentations from 2014 to 2018 focused on head and neck reconstruction or associated principles at the main reconstructive academic meetings in otolaryngology (American Head and Neck Society), plastic surgery (American Society for Reconstructive Microsurgery), and oral maxillofacial surgery (American Association of Oral and Maxillofacial Surgeons) were reviewed. Author specialty and institution data were recorded. All abstracts were assigned a research subtopic, chosen based on identified themes. Subtopic frequencies among the specialties were compared. RESULTS: Thirteen of 88 (15%) US institutions participate in interdisciplinary collaboration in head and neck reconstruction research. Of the remaining institutions, 23 (31%) have researchers performing parallel work and not collaborating. Certain research subtopics were more often presented by each specialty, representing differing interests. CONCLUSION/CONCLUSIONS: Collaboration among head and neck reconstruction research at the US institutions is low compared with the potential. Specialties focus on different research subtopics, and therefore can benefit from working together.

BACKGROUND:The operating microscope is used in many centers for microvascular hepatic arterial reconstruction in living as well as deceased donor liver transplantation in adult and pediatric recipients. To date, a systematic review of the literature examining this topic is lacking. METHODS:This systematic review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Three different electronic databases (PubMed, Embase OVID, and Cochrane CENTRAL) were queried. RESULTS:A total of 34 studies were included. The rate of hepatic artery thrombosis (HAT) in noncomparative studies (28) ranged from 0% to 10%, with 8 studies reporting patient deaths resulting from HAT. Within comparative studies, the rate of HAT in patients who underwent arterial reconstruction using the operating microscope ranged from 0% to 5.3%, whereas the rate of HAT in patients who underwent arterial reconstruction using loupe magnification ranged from 0% up to 28.6%, and 2 studies reported patient deaths resulting from HAT. Two comparative studies did not find statistically significant differences between the 2 groups. CONCLUSIONS:Our comprehensive systematic review of the literature seems to suggest that overall, rates of HAT may be lower when the operating microscope is used for hepatic arterial reconstruction in liver transplantation. However, matched comparisons are lacking and surgical teams need to be mindful of the learning curve associated with the use of the operating microscope as compared with loupe magnification, as well as the logistical and time constraints associated with setup of the operating microscope.

BACKGROUND:Congestive heart failure affects 6.2 million people in the United States. Patients have a decreased cardiopulmonary reserve and often suffer from peripheral edema, important considerations in lower extremity reconstructive surgery. In this study, the authors sought to determine the impact of congestive heart failure on postoperative outcomes following lower extremity pedicled flap reconstruction using a national multi-institutional database. METHODS:The authors isolated all patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent lower extremity pedicled flap reconstruction from 2010 to 2016. Preoperative, intraoperative, and postoperative variables were compared between patients with and without congestive heart failure. Multivariable regressions were performed to determine the independent effect of congestive heart failure on postoperative outcomes. RESULTS:The authors identified 1895 patients who underwent lower extremity pedicled flap reconstruction, of whom 34 suffered from congestive heart failure. No significant difference was observed between patients with versus without congestive heart failure in postoperative wound complications (superficial wound infection, deep wound infection, and wound dehiscence), renal failure, or readmission. On multivariable analysis, congestive heart failure was independently associated with increased cardiopulmonary complications (i.e., myocardial infarction, cardiac arrest, pneumonia, reintubation, and failed ventilator weaning) (OR, 3.92; 95 percent CI, 1.53 to 9.12), septic events (OR, 4.65; 95 percent CI, 2.05 to 10.02), and length of hospital stay (β, 0.37; 95 percent CI, 0.01 to 0.72). CONCLUSIONS:In patients undergoing lower extremity pedicled flap reconstruction, congestive heart failure independently predicts a four-fold increase in postoperative sepsis and cardiopulmonary complications and a significantly increased length of hospital stay. The authors' findings highlight the need for heightened perioperative vigilance and medical optimization in this high-risk population. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Risk, II.

While bisphosphonates are the cornerstone for management of multiple myeloma, they are associated with medication-related osteonecrosis of the jaw (MRONJ). There are many controversies in the management of MRONJ in this patient population. In this article, we describe a representative case and, along with a literature review, we report the outcomes of our 3 cases with multiple myeloma who underwent mandible reconstruction with vascularized fibula bone grafts after segmental mandible resection for Stage 3 MRONJ over a 3-year period. All patients were male with a mean age of 59 years. All patients had undergone therapy with bisphosphonates and had no other identifiable cause of mandible osteonecrosis. All patients had pathologic mandible fractures associated with intraoral fistulae and exposed bone. Nonsurgical management was attempted in all patients. One patient also underwent debridement of the mandible without resolution of the disease. Mandible reconstruction with an osteocutaneous free fibula flap after segmental mandible resection was performed in all 3 cases without major complications or donor site morbidity. Different bacteria were isolated from the intraoperative tissue cultures in all cases. Computed tomographic imaging revealed bony union without hardware complications in all cases. Mean follow-up was 28 months. In conclusion, we demonstrated that patients with multiple myeloma and advanced MRONJ lesions of the mandible can be managed successfully and safely by segmental resection and reconstruction with vascularized fibula bone graft.