Faculty Bibliography

BACKGROUND: Congenital breast deformities such as Poland syndrome, unilateral congenital hypoplasia, tuberous breast anomaly, and amastia pose a challenging plastic surgical dilemma. The majority of patients are young, healthy individuals who seek esthetic restoration of their breast deformities. Currently, both implant and autologous reconstructive techniques are used. This study focuses on our experience with congenital breast deformity patients who underwent reconstruction using a perforator flap. METHODS: From 1994 to 2005, a retrospective chart review was performed on women who underwent breast reconstruction using perforator flaps to correct congenital breast deformities and asymmetry. Patient age, breast deformity type, perforator flap type, flap volume, recipient vessels, postoperative complications, revisions, and esthetic results were determined. RESULTS: Over an 11-year period, 12 perforator flaps were performed. All cases were for unilateral breast deformities. The patients ranged from 16 to 43 years of age. Six patients had undergone previous correctional surgeries. Eight (n = 8) flaps were used for correction of Poland syndrome and its associated chest wall deformities. Four (n = 4) flaps were used for correction of unilateral breast hypoplasia. In all cases, the internal mammary vessels were the recipient vessels of choice. No flaps were lost. No vein grafts were used. All patients were discharged on the fourth postoperative day. Complications encountered included seroma, hematoma, and nipple malposition. Revisional surgery was performed in 30% of the cases. Esthetic results varied from poor to excellent. CONCLUSIONS: Perforator flaps are an acceptable choice for patients with congenital breast deformities seeking autologous breast reconstruction. Deep inferior epigastric artery (DIEP) or superficial inferior epigastric artery (SIEA) flaps are performed when adequate abdominal tissue is available; however, many young patients have inadequate abdominal tissue, thus a GAP flap can be used. Perforator flaps are a safe, reliable surgical technique. In the properly selected patient, donor-site morbidity and functional compromise are minimized, improved self-esteem is noted, postoperative pain is decreased, and excellent long-term esthetic results can be achieved

PURPOSE: The workup for oral malignancy involving the mandible typically involves a head and neck exam, laboratory studies, a panoramic radiograph, and computed tomography (CT) or magnetic resonance imaging of the head and neck to evaluate the primary lesion and cervical lymph nodes. Panoramic plain film radiography of the mandible is often unreliable for detecting bony invasion; therefore, other imaging studies are necessary before staging is complete. Bony invasion is typically imaged with the use of conventional CT scanners. In this article we relate the use of cone beam computed tomography (CBCT) to image the mandible with less cost and morbidity to the patient and its use in the evaluation and treatment planning of mandibular cancer. MATERIALS AND METHODS: A retrospective review of 3 patients with mandibular malignancies was performed. All patients had a panoramic radiograph, magnetic resonance imaging, and chest radiograph, in addition to laboratory studies. CBCT scans were ordered, after bony involvement was suspected, and compared with the other imaging studies. RESULTS: Two patients with squamous cell carcinoma of anterior mandible and 1 patient with osteogenic sarcoma were reviewed. In all cases CBCT aided the evaluation of the mandible. The cone beam panoramic view, as part of the CBCT, was used to determine extent of resection. CONCLUSION: CBCT can accurately aid in evaluating and treatment planning for malignant tumors of the mandible with less cost and decreased radiation to the patient relative to conventional CT

PURPOSE: The treatment of locally aggressive lesions of the mandible can have a profound effect on a patient's quality of life (QOL), both functionally and psychologically. The more knowledge available on this subject, the better a patient can be prepared and counseled. PATIENTS AND METHODS: Patients undergoing mandibular resection with immediate insertion of a reconstruction plate and subsequent staged reconstruction for the management of locally aggressive lesions of the mandible at the University of California at San Francisco were studied over a 6-year period from 1999 to 2005. The staged reconstruction involved bone grafting, removal of the reconstruction plate, vestibuloplasty, implant insertion, and construction of an implant-supported prosthesis. Each patient completed a modified University of Washington Quality of Life version 4 questionnaire after reaching his or her highest level of reconstruction. RESULTS: A total of 26 patients were identified as fulfilling the criteria for this study. Eight patients did not progress beyond resection, bone grafting, and subsequent removal of the bone plate. Seven patients progressed all the way through the 7 stages to an implant-supported prosthesis. The most important determinants of the patient's subsequent QOL were time interval from initial resection and stage of reconstruction; the greater the time interval from initial resection and the further the stage of reconstruction reached, the better the QOL. Resections involving the mandibular angle had a negative effect on appearance, and resections involving the parasymphysis and symphysis region carried a worse overall QOL, possibly due to difficulty with chewing and lip support. Males reached a higher overall QOL than females. Although most patients seemed satisfied with their overall QOL, 73% had some concerns regarding appearance, 42% had concerns with chewing, 42% had concerns regarding their mood, 35% felt more anxious since the surgery, 23% had some residual pain and discomfort, 19% had concerns with swallowing, and 15% had concerns with taste. CONCLUSION: These and other findings necessitate further investigation and confirmation

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.

Successful nonextremity replantations, particularly of the facial anatomy and testicles, are rare procedures, and only a handful of cases have been reported. This article reviews the current literature in nonextremity replantations and representative cases performed at the authors' institution. Certain underlying themes and problems are consistently encountered in the surgical management of these cases. These are identified and reviewed. Although the replantation of these body parts remains technically challenging, all efforts should be made, when indicated, to repair these injuries microsurgically, because it currently offers the best reconstructive solution for these patients