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Background Facial composite tissue allotransplantation (CTA) may be considered in cases of severe facial injury. To date, no reports have analysed the cost of potential facial CTA in the UK. The aims of this study were to establish (1) the cost implications without facial CTA, necessitating multiple reconstructive procedures in cases with severe facial deformities, and (2) if facial CTA would be cost-effective in the UK given recent European and North American published cost analyses. Methods Hospital episodes’ data from two potential candidates for facial CTA were used to calculate cost of treatment. In these cases, severe facial trauma was managed by multiple disciplinary teams performing numerous conventional reconstructive procedures. One case served as an indicator of the cost of primary reconstruction during the immediate post-traumatic episode, from admission until first discharge. The other served as an indicator of the accumulative cost of care following primary reconstruction from first discharge to six years later. Costs incurred served as a guide for the cost of standard reconstruction in the UK. These were compared with the costs of similar reconstructive procedures performed in the USA. This was used with data reporting the cost of facial CTA in the USA and France to predict the cost of facial CTA in the UK. Results Analysis revealed a cost benefit for facial CTA in a UK context that would become apparent from the third year post-transplant onwards. Conclusion Facial CTA may therefore be a more cost-effective long-term reconstructive option for patients with severe facial defects. Level of evidence: Level V, risk/prognostic study.

After mastectomy, breast reconstruction is increasingly performed using autologous tissue with the aim of improving quality of life. During this procedure, autologous tissue is excised, relocated, and reattached using microvascular anastomoses at the site of the extirpated breast. The period during which the tissue is ex vivo may allow genetic modification without any systemic exposure to the vector. Could such access permit delivery of therapeutic agents using the tissue flap as a vehicle? Such delivery may be more targeted and oncologically efficient than systemic therapy, and avoid systemic complications. The cytokine IFNγ has antitumor effects, and systemic toxicity could be circumvented by localized delivery of the IFNγ gene via gene therapy to autologous tissue used for breast reconstruction, which then releases IFNγ and exerts antitumor effects. In a rat model of loco-regional recurrence (LRR) with MADB-106-Luc and MAD-MB-231-Luc breast cancer cells, autologous tissue was transduced ex vivo with an adeno-associated viral vector encoding IFNγ. The “Therapeutic Reconstruction” released IFNγ at the LRR site and eliminated cancer cells, significantly decreased tumor burden, and increased survival compared with sham reconstruction (P

Objective Lesions involving both the trachea and the esophagus are often considered inoperable because of the lack of reliable reconstruction. The purpose of this study was to review our experience of combined supercharged jejunal and other flaps for tracheal and esophageal reconstruction. Methods A retrospective review of 5 consecutive cases with combined tracheal and total esophageal defects was performed. The esophageal defect was reconstructed with a supercharged jejunal flap, and the trachea was reconstructed with a free anterolateral thigh flap or a pedicled muscle flap. Results Primary diagnosis included tracheostoma recurrence after a total laryngectomy for laryngeal cancer in 2 patients and tracheoesophageal fistula due to esophageal stenting for complications from prior treatment for non-Hodgkin's lymphoma, parathyroid cancer, and esophageal cancer in 3 patients, respectively. Tracheal and esophageal reconstructions were staged in 4 patients, and 1 patient received simultaneous reconstruction. Tracheal necrosis developed in 1 patient with a mediastinal tracheostoma, and the patient eventually died of infection 2 months later. The other 4 patients recovered well and resumed an oral diet. Conclusions Complex and often life-threatening lesions involving both the trachea and the esophagus are not necessarily inoperable. With careful planning, these combined defects can be safely reconstructed with multiple flaps with good functional outcomes and reasonable survival.

Background Minimally invasive component separation (CS) with inlay bioprosthetic mesh (MICSIB) is a recently developed technique for abdominal wall reconstruction that preserves the rectus abdominis perforators and minimizes subcutaneous dead space using limited-access tunneled incisions. We hypothesized that MICSIB would result in better surgical outcomes than conventional open CS. Study Design All consecutive patients who underwent CS (open or minimally invasive) with inlay bioprosthetic mesh for ventral hernia repair from 2005 to 2010 were included in a retrospective analysis of prospectively collected data. Surgical outcomes, including wound-healing complications, hernia recurrences, and abdominal bulge/laxity rates, were compared between patient groups based on the type of CS repair, either MICSIB or open. Results Fifty-seven patients who underwent MICSIB and 50 who underwent open CS were included. Mean follow-ups were 15.2 ± 7.7 months and 20.7 ± 14.3 months, respectively. Mean fascial defect size was significantly larger in the MICSIB group (405.4 ± 193.6 cm 2 vs 273.8 ± 186.8 cm 2 ; p=0.002). The incidences of skin dehiscence (11% vs 28%; p=0.011), all wound-healing complications (14% vs 32%; p=0.026), abdominal wall laxity/bulge (4% vs 14%; p=0.056), and hernia recurrence (4% vs 8%; p=0.3) were lower in the MICSIB group than in the open CS group. Conclusions MICSIB resulted in fewer wound-healing complications than did open CS used for complex abdominal wall reconstructions. These findings are likely attributable to the preservation of paramedian skin vascularity and reduction in subcutaneous dead space with MICSIB. MICSIB should be considered for complex abdominal wall reconstructions, particularly in patients at increased risk of wound-healing complications.

Facial paralysis refers to a condition in which all or portions of the facial nerve are paralysed. The facial nerve controls the muscles of facial expression, paralysis which results in a lack of facial expression which is not only an aesthetic issue, but has functional consequences as the patient cannot communicate effectively. The treatment of long-standing facial paralysis has challenged plastic surgeons for centuries, and still the ultimate goal of normality of the paralysed hemi-face with symmetry at rest as well as the generation of a spontaneous symmetrical smile with corneal protection has not yet fully been reached. Until the end of the 19th century, the treatment of this condition involved non-surgical means such as ointments, medicines and electrotherapy. With the advent and refinement of microvascular surgical techniques in the latter half of the 20th century, vascularised free muscle transfers coupled with cross-facial nerve grafts were introduced, allowing the possibility of spontaneous emotion being restored to the paralysed face became reality. The aim of this article is to revisit the surgical evolution and current options available as well as outcomes for patients suffering from facial paralysis concentrating on middle and lower face reanimation.

During the 1970s, the incidence of limb amputation following surgery for sarcoma excision was as high as 50%. Two important developments have led to modern day limb salvage, namely chemotherapy and precision imaging techniques. We present a case of limb salvage in a patient with osteosarcoma plagued with recurrent infection after prosthetic revision. We discuss the use of the distally based pedicled gracilis muscular flap, which has little mention as a reconstructive option for defects around the knee.

BACKGROUND Clinical use of cancer gene therapy has been prevented by the inability to deliver high levels of local transgene expression with acceptable host toxicity. The authors' laboratory has developed an ex vivo technique to genetically modify free flaps to deliver immunotherapy locally without systemic toxicity. METHODS Superficial inferior epigastric flaps were dissected in Fischer rats, perfused with a viral vector expressing the antitumor interleukin-12 (IL-12) for 1 hour, and re-anastomosed. Beneath the flaps was a bolus of 1 x 10(6) beta-human chorionic gonadotropin-secreting MADB-106 tumor cells. Tumor growth was monitored using beta-human chorionic gonadotropin levels (secreted by the tumor) and size. IL-12 expression in tissue was assessed by enzyme-linked immunosorbent assay. Tumor inflammatory infiltrate was assessed using immunohistologic staining (CD8 and CD161) and enzyme-linked immunosorbent assay (interferon-gamma). Serum levels of liver enzymes and histologic analysis were used to assess systemic toxicity. RESULTS IL-12 expression was confirmed in the flap and surrounding tissue. The rate of tumor growth in the IL-12-treated group was significantly suppressed compared with the control group (p < 0.001). Liver enzyme levels remained normal, and histological evaluation of the liver, lung, and spleen revealed no evidence of inflammation in the treated group. CONCLUSIONS Using genetically modified free flaps, the authors were able to deliver IL-12 directly into the local environment of a tumor and suppress its growth without eliciting toxic systemic effects. This technique could provide valuable adjuvant treatment after oncologic surgery for soft-tissue cancers, with the transduced flap reconstructing the defect and supplying a therapeutic agent to the resected tumor bed.

Background: Cranial vault remodeling procedures are carried out for both syndromic and nonsyndromic craniosynostosis as well as to correct some acquired deformities of the cranial vault. These procedures improve not only cosmesis but also neurological symptoms. The purpose of this study was to determine the incidence of "late" cephalohematoma, an underreported complication following these complex procedures. Methods: A total of 113 patients underwent 127 cranial vault remodeling procedures using autogenous bone over a 6-year period. All patients who developed a late cephalohematoma 75 days or more after surgery were recorded. The time, size, and location of the cephalohematoma, the treatment performed, and the length of follow-up were also recorded. Ages at initial operation and postoperative follow-up were compared between patient groups for statistical differences. Results: Of the 113 patients, 17 developed 18 late cephalohematoms. The incidence for this complication was 15 percent. The median age at operation for all patients was 10 months, and most late cephalohematomas occurred 208 days later (range, 77 to 1416 days), at 12 to 24 months of age. Fronto-orbital advancement was the most commonly performed procedure, and 83.3 percent of late cephalohematomas occurred in the frontal region. No cephalohematomas became infected or required any operative intervention, but they were aspirated. Conclusions: Surgeons should inform prospective parents of patients undergoing cranial vault remodeling procedures of this potential complication. This will improve parental awareness and possible avoidance strategies in future patients. Further evaluation and follow-up are required to determine the minimum length of postoperative time after which late cephalohematomas do not occur.

The technique of vascular delay has been used by plastic surgeons for nearly 500 years and has proven useful for reliably transferring tissue and allowing for a greater volume of tissue to be reliably harvested. Delay procedures are an essential plastic surgical tool for a variety of aesthetic and reconstructive procedures. Despite the widespread use of vascular delay procedures, the mechanism by which this phenomenon occurs remains unclear. A number of groups have exhaustively examined microvascular changes that occur during vascular delay. Theories have been proposed ranging from the dilation of choke vessels to changes in metabolism and new blood vessel formation. Inherent in these theories is the concept that ischemia is able to act as the primary stimulus for vascular changes. The purpose of this review is to revisit the theories proposed to underlie the delay phenomenon in light of recent advances in vascular biology. In particular, the participation of bone marrow-derived endothelial progenitor cells in the delay phenomenon is explored. Greater understanding of the role these cells play in new blood vessel formation will be of considerable clinical benefit to high-risk patients in future applications of delay procedures.

The purpose of this study was to examine mandibular morphology and growth in patients with Crouzon, Pfeiffer, and Apert syndromes using posteroanterior cephalograms. Fifteen patients with Apert (n = 2), Crouzon (n = 11), and Pfeiffer (n = 2) (11 female, 4 male) syndrome were included in this study. All patients had serial posteroanterior cephalograms at 5, 10, and 15 years of age. The bicondylar width, bigonial width, bicondylar/bigonial ratio, and ramus to intercondylar plane angle for each patient were measured on the cephalograms and compared with age-match controls. An analysis of variance analysis was carried out to detect differences between patients and controls and sex differences between patients. In both male and female patients, there was a statistically significant reduction in bicondylar width compared with age-matched controls. Male patients also had a statistically significant increase in bigonial width compared with controls and female patients at 10 and 15 years. The resulting bicondylar/bigonial ratios were significantly reduced, and the ramus to intercondylar plane angles were significantly increased in both male and female patients compared with controls. Unlike previous reports of patients with syndromic synostosis, this study demonstrates that the mandible has significant morphologic and growth abnormalities, including constriction of bicondylar width with near normal bigonial width in female patients. These findings suggest a narrowing at the cranial base with resulting restriction of normal transverse mandibular growth at the condyle. The secondary nature of the mandibular finding is suggested by the near normal or increased transverse growth at the gonion in females and males, respectively. Consequently, the ramus appears torqued inward, forming a greater angle with the cranial base.

Six patients with insufficient soft-tissue coverage after lower limb trauma were treated with pedicled fillet of foot flaps to achieve primary stump closure and to preserve leg length. The flaps used were all based on either the posterior tibial neurovascular pedicle, the anterior tibial neurovascular pedicle, or both. Five flaps survived; one patient required conversion of a through-knee to an above-knee amputation and debridement of the flap because of venous thrombosis of the pedicle. In three of the cases, a functional knee joint was preserved. The patients ranged in age from 21 to 54 years, the mean hospital stay was 55.5 days (range, 28 to 76 days), and the mean follow-up time was 14.5 months. Despite an average of 4.3 procedures from initial admission to first discharge and an average of 2.0 postamputation procedures to achieve primary stump healing, all patients have achieved independent mobility with their prosthesis. The advantages of preserving leg length and, where possible, preserving a functional knee joint compensate for repeated procedures on these patients. When planned well, a pedicled fillet of foot flap therefore achieves the aims of amputation, namely, providing primary healing of a sensate, durable, cylindrical stump that is pain-free and preserves maximal leg length. This is achieved with no donor-site morbidity and with no need for microvascular reconstruction.