Faculty Bibliography

Breast reconstruction after mastectomy should aim at resulting in an aesthetic outcome that matches the patient's expectations and without interfering in the oncologic treatment. Whether the reconstruction is performed immediately or in a delayed fashion depends on various factors, which needs detailed attention. Autologous tissue, implants or both are used in the reconstruction. This article reviews the current concepts in these, with emphasis on non-microsurgical methods of using the autologous tissue for reconstruction. Breast conservation has become an accepted practice of treatment. Reconstruction in these situations as well as in an occasion when the surgery is done for failed breast conservation is discussed in detail. The article also reviews the various methods for nipple reconstruction available

Segmental mandibulectomy leads to a great deficit in the form and function of the patient. Vascularised bone flaps have become the choice of the method of reconstruction of the mandible in an oncologic setting. Fibula osseous or oseteocutaneous flaps have become the favored method in centers across the world. This article reviews certain pertinent and practical points with regards to fibula flap reconstruction of the mandible. Methods of osteosynthesis, merits of inclusion of the FHL muscle in the flap and use of osteointegrated implants are discussed in detail. The reader will also be able at the end to understand the role of pre operative vascular imaging, steps taken when there is an irreversible flap failure and steps to maintain and rehabilitate occlusion as practiced in the author's service

BACKGROUND: Posttraumatic, high-energy defects of the midface can be challenging to reconstruct because they involve extensive composite tissue loss and result in significant permanent functional and cosmetic deformity. These injuries require replacement of the bony framework, external soft tissue, and intraoral mucosa. Local skin flaps and nonvascularized bone grafts have been used for reconstruction, but bony resorption and the associated soft-tissue collapse limit long-term viability. The authors present a classification of maxillary defects following high-energy trauma and a treatment algorithm using vascularized bone flaps. METHODS: Fourteen patients with significant maxillary loss from high-energy trauma underwent reconstruction with composite vascularized bone flaps. Eight patients had fibula flaps and six had iliac crest flaps. There were five women and nine men, with a mean age of 36.3 years (range, 21 to 48 years) and a mean follow-up of 18 months (range, 5 to 54 months). RESULTS: Thirteen of the 14 flaps survived. Nine patients had additional procedures. Nine patients had oronasal fistulas and eight were dependent on gastrostomy tubes preoperatively. All patients were able to feed orally without nasal regurgitation postoperatively. All patients achieved stable restoration of the midfacial architecture. CONCLUSIONS: The classification scheme presented centers on the missing maxillary subunits. The reconstructive algorithm is based on the type of defect, tissue requirement, and donor tissues necessary to restore facial projection and prosthodontic rehabilitation. Iliac crest and fibula bone free flaps are ideal for restoring a variety of traumatic maxillary defects. The authors advocate early reconstructive intervention using vascularized bone flaps to achieve superior functional and cosmetic outcomes.

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: 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.