Faculty Bibliography

BACKGROUND: The microvascular free fibula flap has become the gold standard for reconstruction of complex mandibular defects since its description by Hidalgo in 1989. Prior studies have demonstrated its safety and efficacy in the pediatric population. However, this reconstructive method is often used only as a last resort for correction of congenital mandibular hypoplasia, after failure of bone grafting and distraction osteogenesis. The authors describe our experience using this technique, facilitated by virtual planning and prefabricated cutting jigs, for children with severe congenital mandibular hypoplasia. METHODS: All patients with mandibular reconstruction with a fibula flap in children with congenital mandibular hypoplasia between 2009 and 2014 by the senior authors were identified. Each patient underwent preoperative computed tomography scanning and virtual surgical planning to create custom cutting jigs for creation of the mandibular defect and fibular osteotomies. Preoperative, intraoperative, and postoperative medical records were examined in detail. RESULTS: Five patients age 10 to 18 with congenital mandibular hypoplasia and Pruzansky Grade III mandibles underwent microvascular free fibula flap for mandibular reconstruction during this period. Flap success rate was 100%. All patients underwent subsequent revision procedures to improve symmetry or for hardware removal. The 4 patients in our series who required dental implants were able to have them placed into their mandibular reconstruction. CONCLUSIONS: Preoperative virtual planning and prefabricated cutting jigs allow for precise complex fibula reconstruction of the mandible in the pediatric population. Additionally, virtual planning facilitates concomitant orthognathic procedures in patients with hemifacial microsomia. Our early success in this patient population leads us to suggest that while the free fibula can be safely and successfully used after multiple prior surgical interventions in the same anatomic region, it can also be a powerful tool for primary correction of congenital mandibular hypoplasia.

In select patients with advanced disease resulting in large composite tissue defects, consideration is often given to multiple flap reconstruction. The authors propose an alternative option. Using virtual surgical planning the authors demonstrate how modest sacrifice in projection translates into a substantial decrease in the volume and surface area of soft tissue needed, in turn maximizing soft tissue coverage with a single fibula free flap. The authors used 3-dimensional virtual surgery to simulate angle-to-angle reconstructions using free fibula flaps. The reference 3-segment reconstruction was done using symphyseal projection to the plane perpendicular to the anterior nasal spine, a customary landmark. Additional simulations were then performed using recessed projections 0.5 mm, 1 cm, 1.5 cm, and 2 cm posterior to anterior nasal spine plane. Program analytics were used to calculate the surface area and volume of the floor of mouth. With projection recessed by 1 cm, surface area decreased 22% to 14 cm. With projection recessed by 2 cm, surface area decreased 44% to 10 cm. With a 3-segment construct converted to a 2-segment construct, surface area decreased 22% to 14 cm. This demonstrates for the first time an official analysis of an intraoperative modification that sacrifices little and gains a lot. Ultimately, 1 compound flap can be used in extensive reconstructions with increased confidence that it will not be overly stressed.

BACKGROUND: Urethral strictures or fistulas are common complications after phalloplasty. Neourethral defects pose a difficult reconstructive challenge using standard techniques as there is generally insufficient ventral tissue to support a graft urethroplasty. We report our experience with local fasciocutaneous flaps for support of ventrally-placed buccal mucosal grafts (BMGs) in phalloplasty. METHODS: A retrospective review of patients who underwent phalloplasty and subsequently required revision urethroplasty using BMGs between 2011 and 2015 was completed. Techniques, complications, additional procedures, and outcomes were examined. RESULTS: A total of three patients previously underwent phalloplasty with sensate radial forearm free flaps (RFFFs): two female-to-male (FTM) gender reassignment, and one oncologic penectomy. Mean age at revision urethroplasty was 41 years (range 31-47). Indications for surgery were: one meatal stenosis, four urethral strictures (mean length 3.6 +/- 2.9 cm), and two urethrocutaneous fistulas. The urethral anastomosis at the base of the neophallus was the predominant location for complications: 3/4 strictures, and 2/2 fistulas. Medial thigh (2) or scrotal (1) fasciocutaneous flaps were used to support the BMG for urethroplasty. One stricture recurrence at 3 years required single-stage ventral BMG urethroplasty supported by a gracilis musculocutaneous flap. All patients were able to void from standing at mean follow up of 8.7 months (range 6-13). A total of two patients (66%) subsequently had successful placement of a penile prosthesis. CONCLUSIONS: Our early results indicate that local or regional fasciocutaneous flaps enable ventral placement of BMGs for revision urethroplasty after phalloplasty.

Increased upper airway resistance from postoperative changes after major head and neck surgery may cause elevated transtracheal pressures and result in tracheostomy speaking valve intolerance. This may be particularly true among patients with baseline pulmonary disease. We describe a patient recovering from oral cancer resection and flap reconstruction who demonstrated prolonged ventilator dependence and tracheostomy speaking valve intolerance with abnormal tracheal manometry. We attempted to improve speaking valve tolerance through the adaptation of a valve modification intended to reduce transtracheal pressures. Drilling holes into the 1-way speaking valve allowed for excess air egress and resulted in normalization of transtracheal pressures with improved speaking valve tolerance. This 1-way speaking valve modification may serve as a simple method to allow for earlier restoration of voicing and potentially reduce the number of ventilator- dependent days in this patient population.

BACKGROUND: Reconstruction of maxillary defects following tumor extirpation is challenging because of combined aesthetic and functional roles of the maxilla. One-stage reconstruction combining osseous free flaps with immediate osseointegrated implants are becoming the standard for mandibular defects, and have similar potential for maxillary reconstruction. METHODS: A woman with maxillary Ewing sarcoma successfully treated at age 9 with neoadjuvant chemotherapy, right hemimaxillectomy, and obturator prosthetic reconstruction presented for definitive reconstruction, complaining of poor obturator fit, and hypernasality. Her reconstruction was computer-simulated by a multidisciplinary team, consisting of left hemi-Lefort I advancement and right maxillary reconstruction with a free fibula flap with immediate osseointegrated implants and dental prosthesis. RESULTS: Full dental restoration, midface projection, and oral fistula corrections were achieved in 1 operative stage using this approach. CONCLUSIONS: This patient demonstrates a successful approach for maxillary reconstruction using computer-planned orthognathic surgery with free fibula reconstruction and immediate osseointegrated implants with dental prosthesis.

An accurate and comprehensive understanding of lower extremity arterial anatomy is essential for the successful harvest and transfer of a free fibula osteoseptocutaneous flap (FFF). Minimum preoperative evaluation includes detailed history and physical including lower extremity pulse examination. Controversy exists regarding whether preoperative angiographic imaging should be performed for all patients. Elevation of an FFF necessitates division of the peroneal artery in the proximal lower leg and eradicates its downstream flow. For patients in whom the peroneal artery comprises the dominant arterial supply to the foot, FFF elevation is contraindicated. Detailed preoperative knowledge of patient-specific lower extremity arterial anatomy can help to avoid ischemia or limb loss resulting from FFF harvest. If preoperative angiographic imaging is omitted, careful attention must be paid to intraoperative anatomy. Should pedal perfusion rely on the peroneal artery, reconstructive options other than an FFF must be pursued. Given the complexity of surgical decision making, the authors propose an algorithm to guide the surgeon from the preoperative evaluation of the potential free fibula flap patient to the final execution of the surgical plan. The authors also provide 3 clinical patients in whom aberrant lower extremity anatomy was encountered and describe each patient's surgical course.

The fibula microvascular free flap is widely used for mandible reconstruction including patients with medication- related osteonecrosis of the jaw(MRONJ) who are refractory to conservative management.1 In comparison with other free flaps used in mandible reconstruction, the fibula provides the greatest bone length and provides soft tissue replacement. While the fibula has little effect on bearing weight, it is an essential insertion for the biceps femoris muscle, one of the hamstrings, which assists in flexion of the knee as well as rotation of the leg. In addition, it is an attachment of the fibular collateral ligament, a structural component of the knee joint.2 There is a paucity of literature related to the feasibility of mandible reconstruction utilizing a microvascular free fibula flap in a patient with previous knee replacement surgery. Our patient is a 60-year-old female diagnosed with medication-related osteonecrosis of the jaw (MRONJ). She was refractory to multiple courses of antibiotic therapy and oral rinses. Upon physical examination, intraorally she has draining fistula at the right body of the mandible. Computed tomography of the mandible was significant for osteolytic bone destruction from at the body of the right mandible and nearing the inferior border. Her concerning surgical history included bilateral knee replacements which was taken into consideration during surgical planning. Due to the size of the planned defect, reconstruction with a fibula microvascular free flap was planned using virtual surgical planning (Medical Modeling Inc., Golden CO) and a prefabricated reconstruction plate (Stryker, Kalamazoo, MI). The surgical procedure included a tracheostomy, segmental resection of the right body of the mandible, rigid fixation, extraction of all teeth and microvascular fibular free flap reconstruction. The patient continued physical therapy and occupational therapy and became full weight bearing 12-days postoperatively. The patient was back to her preoperative ambulatory status one month after surgery. An English language search of three databases (PubMed, Science Direct, OvidMD) was performed to determine if a microvascular free fibula flap had been attempted in a patient with a history of knee replacement. The dearth of literature related to this concern lead to an interdisciplinary meeting between the Oral and Maxillofacial Surgery, Plastic Surgery, and Orthopaedic Surgery services to review the feasibility and risks for the proposed reconstruction in our patient. It was determined that as long as 10 cm of superior bone was to remain in place, the stability of the patient's knee should not be compromised. We conclude that microvascular fibular graft reconstruction of the mandible remains an option for patients with bilateral knee replacement

Radiation therapy (RT) is and essential treatment for many oral cavity and oropharynx tumors. However, radiation may cause significant long-term morbidity for survivors. A serious jaw complication from radiation includes osteoradionecrosis (ORN) requiring mandibulectomy and reconstruction, which has significant medical, economic, and quality of life implications for affected patients. Reconstructing ORN defects is challenging due to late effects of radiotherapy on bone and soft tissue tissues resulting in severe fibrosis and possibly infected wound environments. Microvascular free flaps (MVFF) are commonly used for mandibular reconstruction in ORN. When MVFF reconstructions are contraindicated, regional pedicle flaps combined with rigid fixation and autologous bone grafts are commonly reported options that can provide satisfactory functional and aesthetic outcomes. In the present case report we describe an osteomyocutaneous rotational flap using a rib to reconstruct a continuity defect due to ORN. The patient is a 64-year-old female with a history of successful simple surgical treatment for ORN of the left body of the mandible that included hyperbaric oxygen (HBO) therapy who developed ORN and pathologic fracture of the right body of the mandible. Another long-term concern was the prognosis for the clinically healed left mandible. Treatment options were presented to the patient including a microvascular osteocutaneous fibula free flap. However, the patient's ambulation and recovery time was a major concern and she preferred an osteomyocutaneous pectoralis major rib graft. The risks and benefits of both options were discussed. Three months postoperatively she developed an extraoral soft tissue dehiscence with exposure of the plate without infection. Computed tomography seven months postoperatively demonstrated a bone union of the rib at both the proximal and distal resection margins. She subsequently underwent examination of the graft which was found to be healed. The reconstruction plate was removed and the cutaneous defect was repaired using a full thickness skin graft to the right mandible. Reports on vascularized osteocutaneous rib grafts to reconstruct the mandible for ORN have been brief.1 Reconstruction of the mandible using rib has been reported primarily as a free bone graft.2,3 Additional considerations for our patient with a history of ORN of the left mandible include: the 25% failure rate associated with simple surgical treatment (i.e., sequestrectomy),4 the controversial efficacy of perioperative HBO therapy 5,6 and the increased risk of ORN over time.7An osteomyocutaneous pectoralis major rib graft was able to restore continuity of the right mandible and maintain the option for a microvascular fibula graft in the event of recurrent ORN in either or both sides of the mandible. The limitations for this option are the size of the defect and inability to place dental implants. The conclusion from this case report is that a rotational osteomyocutaneous rib graft may be an option for some patients with ORN

Total eyelid loss, full thickness loss of the upper and lower eyelids, is uncommon and surgically challenging. Eyelid reconstruction after such injuries can be further complicated by loss of adjacent tissue. When tissue for local flaps is unavailable, free flaps must be considered. Few cases of total eyelid reconstruction via microvascular free flap have been reported, especially with an intact globe and good visual acuity. In this report, we describe the use of a microvascular free flap based on the radial artery for total eyelid reconstruction in a patient with an intact globe and useful visual acuity.

BACKGROUND: Nipple-sparing mastectomy with immediate, permanent implant reconstruction offers patients a prosthetic "breast in a day" compared to tissue expander techniques requiring multiple procedures. METHODS: Patients undergoing nipple-sparing mastectomy with immediate, permanent implant reconstruction were reviewed with patient demographics and outcomes analyzed. RESULTS: Of 842 nipple-sparing mastectomies from 2006 to June of 2015, 160 (19.0 percent) underwent immediate, permanent implant reconstruction. The average age and body mass index were 46.5 years and 23.3 kg/m. The majority of implants were either Allergan Style 20 (48.1 percent) or Style 15 (22.5 percent). The average implant size was 376.2 ml, and 91.3 percent of reconstructions used acellular dermal matrix. The average number of reconstructive operations was 1.3. Follow-up was 21.9 months. The most common major complication was major mastectomy flap necrosis (8.1 percent). The rate of reconstructive failure was 5.6 percent and implant loss was 4.4 percent. The most common minor complication was minor mastectomy flap necrosis (14.4 percent). The rates of full-thickness and partial-thickness nipple necrosis were 4.4 and 7.5 percent, respectively. Age older than 50 years (p = 0.0276) and implant size greater than 400 ml (p = 0.0467) emerged as independent predictors of overall complications. Obesity (p = 0.4073), tobacco use (p = 0.2749), prior radiation therapy (p = 0.4613), and acellular dermal matrix (p = 0.5305) were not associated with greater complication rates. CONCLUSION: Immediate, permanent implant reconstruction in nipple-sparing mastectomy provides patients with a breast in a day in less than two procedures, with a low complication rate. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.