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Background: The COVID-19 crisis has brought many unique challenges to the health care system. Across the United States, social distancing measures have been put in place, including stay-at-home (SAH) orders, to combat the spread of this infection. This has impacted the type and volume of traumatic injuries sustained during this time. Meanwhile, steps have been taken in our health care system to assure that adequate resources are available to maintain a high standard of patient care while recognizing the importance of protecting health care providers. Using comparative data, we aim to describe the trends in traumatic injuries managed by our plastic surgery service and detail the changes in consultation policies made to minimize provider exposure., Methods: A retrospective chart review was performed of all plastic surgery emergencies at our institution during the 3 weeks preceding the issuance of SAH orders in Chicago and the 3 weeks after. The electronic medical record was queried for patient age, type and mechanism of injury, location where injury was sustained, presence of domestic violence, length of inpatient hospital stays, and treatment rendered. The two 3-week periods were then comparatively analyzed to determine differences and trends in these variables and treatment rendered. The 2 periods were then comparatively analyzed to determine differences and trends in these variables., Results: There was a significant decrease in trauma consults since the issuance of SAH (88 pre-SAH vs 62 post-SAH) with a marked decrease in trauma-related hand injuries. There was an increase in the percentage of assault-related injuries including those associated with domestic violence, whereas there was an overall decrease in motor vehicle collisions. There was no notable change in the location where injuries were sustained. Significantly fewer patients were seen by house staff in the emergency room, whereas those requiring surgical intervention were able to receive care without delay., Conclusions: Stay-at-home orders in Chicago have impacted traumatic injury patterns seen by the Section of Plastic and Reconstructive Surgery at a level I Trauma Center. Safe and timely care can continue to be provided with thorough communication, vigilance, and guidance from our colleagues.

Learning Objectives: After reading this article, the participant should be able to: 1. summarize the evolution of perforator, chimeric, and free style flaps; 2. define and give examples of supermicrosurgery as well as understand its application in treatment of lymphedema; and 3. appreciate the development and advancements of composite tissue allotransplantation., Summary: Although microsurgery may seem like a highly specialized niche within plastic surgery, it is more than just a discipline that focuses on small anastomoses. It is a tool and a way of thinking that allows us to embody the true tenets of plastic surgery, as quoted by Tagliocozzi. What began as a challenge of returning amputated tissue to the body and achieving wound closure has evolved into a refinement of technique and change in philosophy that empowers the plastic surgeon to work creatively to "restore, rebuild, and make whole."

Reconstruction of pharyngolaryngoesophageal defects following salvage surgery in patients with a history of chemoradiation is a challenging problem with a high incidence of pharyngocutaneous fistula. The authors describe three cases of successful reconstruction of partial pharyngolaryngoesophageal defects using a modified radial forearm free flap with additional dermal reinforcement and review the literature for innovations in the use of radial forearm free flap for reconstruction of these difficult cases. Modification of the radial forearm free flap makes it a versatile, reliable flap that has become the "go-to" flap for partial pharyngolaryngoesophageal reconstruction.

Introduction: A knowledge gap exists regarding factors to optimize limb salvage and function following oncologic resection., Methods: We conducted a retrospective review of all free flaps performed for upper extremity (UE) and lower extremity (LE) salvage from 2000 to 2012., Results: Overall, 220 patients underwent free-flap reconstruction for limb salvage (UE: 64, and LE: 156). Flaps were classified as muscle-only (n = 77), myocutaneous (MC; n = 67), or fasciocutaneous (FC; n = 76). Smoking, diabetes, peripheral vascular disease, and prior chemotherapy or radiation had no impact on complications, while osteomyelitis significantly increased the risk of infection (odds ratio [OR] 19.5, confidence interval [95% CI] 3.77-100.64; p = 0.0004), wound healing complications (OR 7.51, 95% CI 2.21-25.49; p = 0.001), and amputation (OR 4.63, 95% CI 1.41-15.19; p = 0.01). Hardware increased the risk for flap loss (OR 4.92, 95% CI 1.33-18.23; p = 0.017). MC and FC flaps had increased risks for hematoma (p = 0.02) and reoperation for microvascular complications (p = 0.005) but were at lower risk for infection (OR 0.14, 95% CI 0.02-0.87; p = 0.03) compared with muscle-only flaps. There were a total of seven total flap losses (3.2%), with significantly increased risks for MC/FC flaps (OR 2.58, 95% CI 1.06-6.26; p = 0.03). For LE, 103 patients (66.3%) were fully ambulatory, while 23 (14.7%) were ambulatory with assistance (mean Musculoskeletal Tumor Society score (MSTS) 80.2, and Karnofsky score 84.0). For UE, 49 patients (76.6%) were able to perform their activities of daily living independently (mean MSTS 80.2, and Karnofsky score 86.0). Overall, 190 patients (86.4%) were successfully salvaged., Conclusions: Free flaps can be performed reliably for limb salvage following tumor extirpation. While MC/FC flaps demonstrated improved postoperative function, they were at significantly higher risk for take-backs and total flap loss.

Internal hemipelvectomy may be indicated in the treatment of select tumors of the pelvis and lower extremity, and has become our preferred approach due to favorable outcomes. After such extensive resections, which can involve long operative times and significant blood loss, there are often substantial bony and soft tissue deficits. However, it is unclear whether the benefits of reconstruction in these cases outweigh the risks involved. In the largest series to date of internal hemipelvectomy patients, we evaluate the effect of reconstruction on surgical complications, postoperative function, and survival. A retrospective review was performed of all patients who underwent internal hemipelvectomy between 1998 and 2011. Outcomes for patients who underwent reconstruction were compared to outcomes for those who did not. A total of 111 patients underwent internal hemipelvectomy, of which 51 (45.9%) received reconstruction and 60 (54.1%) did not. In cases of reconstruction, 30 (58.8%) involved placement of mesh for abdominal wall and pelvic floor reconstruction, 27 (52.9%) involved a soft tissue flap, and 15 (29.4%) involved a vascularized bone flap to restore pelvic ring continuity. Two concurrent reconstructive procedures were performed in 22 (43.1%) patients. The overall rate of early complications was 19.8%, which occurred in 15.7% of patients who received reconstruction compared to 23.3% in patients who did not (P = 0.35). Late recipient-site complications occurred significantly less often in patients who underwent reconstruction (7.8% vs 26.7%, respectively; P = 0.01). From a functional standpoint, Musculoskeletal Tumor Society scores were higher in patients who underwent reconstruction, although this was not statistically significant (62.8% vs 48.4%, respectively; P = 0.12). The 2 groups were similar with regard to operative time, blood loss, and hospital stay, as well as overall and disease-free survival rates. Overall, these results indicate that immediate reconstruction of internal hemipelvectomy defects significantly reduces the incidence of late recipient-site complications, without an adverse effect on perioperative course or overall function. An algorithm for reconstruction based on these outcomes is presented.

Background: Oncologic defects resulting from extremity amputations are often extensive and require substantial soft tissue for reconstruction., Methods: A review of all patients, who underwent an external hemipelvectomy, forequarter amputation, or hindquarter amputation from 2001 to 2010 at the MD Anderson Cancer Center, was performed., Results: A total of 50 patients were identified; of them, 21 underwent external hemipelvectomy, 22 had forequarter amputation, and 7 had hindquarter amputation. The mean defect size was 644 cm; defects were repaired using fillet flaps (n = 22, 44%), free flaps (n = 4, 8%), or local/regional flaps (n = 24, 48%). Of the fillet flaps, 16 were free flaps and the remaining were pedicled flaps. In all, 29 patients (58%) received preoperative radiation therapy, and 26 patients (52%) received preoperative chemotherapy. Two patients (4%) received postoperative radiation therapy, and 1 patient (2%) received postoperative chemotherapy. Three patients received both pre- and postoperative radiation therapy, and 10 patients were treated with both pre- and postoperative chemotherapy. Patients undergoing free flap reconstruction had significantly fewer complications compared with patients reconstructed using other modalities (2/20 vs. 13/30; P = 0.003). The majority of patients achieved excellent postoperative function, with 73% of upper extremity patients functioning independently and 57% of lower extremity amputees ambulating., Conclusions: Reconstruction for extensive defects following oncologic extremity amputation is often optimally done using free tissue transfer, particularly by salvaging "spare parts" from the amputated limb for a free fillet flap.

The versatility and location of the anterolateral thigh (ALT) flap make it well suited for lower extremity reconstruction. The purpose of this study was to evaluate surgical and functional outcomes by specific anatomic regions in the lower extremity to better define the role of the ALT flap in lower extremity reconstruction. A retrospective review of patients undergoing lower extremity reconstruction with an ALT flap between July 2002 and December 2010 was performed. Total 46 patients underwent lower extremity reconstruction with an ALT flap, of whom 29 (63%) had a pedicled flap and 17 (37%) a microvascular free flap. Defects were located in the hip/buttocks (n = 8), groin (n = 13), thigh (n = 8), knee (n = 5), leg (n = 6), and foot/ankle (n = 6). The mean postoperative follow-up was 4 months. Total flap loss occurred in two patients (4%). There were 11 recipient site complications (24%). The most common complication was recipient site seroma, which occurred in five patients (11%), all of whom had hip/buttock or groin defects. Overall, 38 patients (83%) returned to their preoperative functional status. The ALT flap is an effective method of lower extremity reconstruction. It can be performed as a pedicled or free flap, with good surgical and functional outcomes., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Sarcoma patients often require radiation therapy in addition to surgical resection. Although neoadjuvant irradiation possesses advantages over adjuvant irradiation related to smaller doses and field sizes, existing studies suggest adverse effects on wound healing and possibly microvascular free flap success. Conversely, microvascular reconstruction may counteract some of the negative effects of irradiation by replacing irradiated tissue with well-vascularized unirradiated tissue from a distant site., Methods: A review of sarcoma patients who underwent resection, microsurgical reconstruction, and either neoadjuvant or adjuvant irradiation was performed., Results: A total of 119 patients met inclusion criteria, of which 73 underwent neoadjuvant irradiation and 46 underwent adjuvant irradiation. Sarcomas were located in the head and neck (n = 47), trunk (n = 7), upper extremity (n = 15), and lower extremity (n = 50). The rate of perioperative (≤ 30 days) complications was 26.9 percent, whereas the rate of late recipient-site complications was 14.3 percent. No significant differences in perioperative recipient-site (p = 0.19), donor-site (p = 1.00), or medical complications (p = 0.30) were observed between patients undergoing neoadjuvant and adjuvant irradiation. Free flap loss rates were lower in patients undergoing neoadjuvant irradiation (0 percent versus 8.7 percent, respectively; p = 0.02). Late recipient-site complications occurred less often in patients undergoing neoadjuvant radiation (6.8 percent versus 26.1 percent, respectively; p = 0.006)., Conclusions: Neoadjuvant irradiation does not increase the risk of acute wound or microvascular complications when combined with free flap reconstruction, and is associated with fewer late recipient-site complications than adjuvant irradiation. These factors should be considered when determining the timing of radiation therapy in sarcoma patients undergoing oncologic resections and microsurgical reconstruction., Clinical Question/level of Evidence: Therapeutic, III.

Background: Obtaining good functional outcomes with reconstruction following resection of primary bone tumors of the trunk and extremities is a significant challenge. The authors present their reconstructive experience using vascularized fibula flap transfer to improve bone healing and optimize functional outcomes., Methods: From 2001 to 2010, 52 consecutive patients received 53 fibula flaps for trunk (n = 19), lower extremity (n = 21), and upper extremity (n = 13) composite reconstructions., Results: Extremity segmental bone defects were repaired using an intramedullary (n = 14) or onlay technique (n = 20), and pelvic ring defects were repaired using double-barrel struts (n = 16). There were three spinal defect reconstructions. Growth plate transfer with vascularized fibula was used in pediatric patients (n = 5). The mean follow-up time was 36.8 months. There were no flap losses. Complications included delayed wound healing (7.5 percent), infection (1.8 percent), and hardware failure (1.8 percent). Bony unions were achieved in 94.3 percent of patients, with a mean time of 2.8 months (range, 1.5 to 5 months) to initial bony bridging and 5.4 months (range, 1.5 to 12 months) to final bony union. All upper extremity patients were able to use their reconstructed limb. All trunk and lower extremity patients were able to ambulate., Conclusion: Reconstructions with vascularized fibula flaps can result in a high rate of bone union and short healing time, facilitate early ambulation, provide good functional outcomes, improve quality of life, and avoid debilitating amputations., Clinical Question/level of Evidence: Therapeutic, IV.

Background: Neurofibromatosis type 1 (NF-1) is a locally invasive tumor that can grow extensively with diffuse infiltration into surrounding tissue. Resecting a large neurofibroma can result in an extensive defect that is difficult to reconstruct and can cause both aesthetic and functional deformities., Methods: From 2000 to 2010, 5 patients with NF-1 underwent radical resection and immediate reconstruction with 6 free flaps at our institution. All patients presented with recurrent tumor, and involved head and neck region in 4 and foot in 1 patient. Ages ranged from 18 to 75 years. The follow-up ranged from 1 to 94 months., Results: Defect sizes ranged from 84 to 252 cm. A single free flap was used in 4 cases and 2 free flaps were used in 1 case. All the flaps survived. Complications included loss of skin graft, necrosis of the distal tip of a flap, and wound dehiscence. All complications were successfully managed with minor surgical procedures., Conclusion: Immediate reconstruction using a free flap after resecting a large neurofibroma is a safe and reliable method that facilitates radical resection of the tumors that are difficult to resect and that may result in an extensive defect.

Background: The authors' goal was to develop an updated and comprehensive algorithm for skull base reconstruction based on data from the 10-year period following their initial report., Methods: Reconstructive outcomes were analyzed from 250 patients undergoing skull base reconstruction from 2000 to 2009., Results: Thirty-nine local or regional pedicled flap reconstructions and 211 free flap reconstructions were performed. Free flaps were usually selected over pedicled flaps for patients with a history of prior surgery, irradiation, or chemotherapy (p = 0.003, p < 0.001, and p = 0.04, respectively). Reconstructions were performed for 36 region I defects, 39 region II defects, 124 region III defects, and 51 defects involving more than one region. Complications occurred in 29.6 percent of patients. There were no significant differences in the overall complication rates between pedicled and free flap reconstructions (p = 0.70). The recipient-site complication rate decreased from 31 percent in the authors' prior report to 18.4 percent. A facial nerve repair was performed in 30 patients. By 12 months, 75 percent of patients had signs of reinnervation. Recovery was not significantly less likely in patients with preoperative weakness, postoperative irradiation, or age 60 years or older (p = 1.00, p = 1.00, and p = 0.11, respectively)., Conclusions: Based on the largest series of skull base reconstructions to date, the authors recommend pedicled flaps for limited defects because of minimal donor-site morbidity and shorter operative times and hospital stays. For extensive defects and cases involving prior surgery, irradiation, or chemotherapy, free flaps are preferred. Facial nerve repair should be attempted whenever feasible, even in the setting of preoperative weakness, anticipated postoperative irradiation, or advanced age., Clinical Question/level of Evidence: Therapeutic, III.

Reconstruction of the chest wall represents an important part of a patient's treatment following resection of various thoracic tumors. Many different types of flaps, including both pedicled and free flaps, have been described for use in chest wall reconstruction. These reconstructions are most effectively managed with a multidisciplinary approach involving plastic and cardiothoracic surgery. The pectoralis major, latissimus dorsi, rectus abdominis, trapezius, and external oblique muscles and the omentum are all local options that can play an important role in the reconstruction of the chest wall.

Background: The purpose of our study was to review the role of reconstructive surgery in the management of pediatric oncology patients and to assess patients' outcomes, including functional status., Methods: We evaluated 177 children with cancer who underwent reconstructive surgery at our institution between 1999 and 2008., Results: The mean age was 12.1 years, and the mean follow-up duration was 27.3 months. The most common tumor pathology was sarcoma (49.7%), and the most common reconstruction site was the head and neck (41.8%). Nearly half of all patients underwent preoperative (44.1%) and/or postoperative (45.8%) chemotherapy. Immediate reconstruction was performed in 84.7% of patients. Free tissue transfer (33.9%) was the most common form of reconstruction, and the fibula flap (58.4%) was the most common free flap used. Additional surgery (for any reason) was required in 41.8% of patients. In general, functional outcomes were excellent: 78.4% of head and neck reconstruction patients tolerated a regular diet postoperatively, 72.0% of upper extremity reconstruction patients experienced no postoperative functional deficits, and 70.6% of lower extremity reconstruction patients achieved ambulatory status (without assistance). Of the 177 patients, 74.6% had no evidence of disease at last known follow-up., Conclusions: Reconstructive surgery in children with cancer is complex and often requires multiple procedures, although treatment usually results in excellent functional outcomes. A multidisciplinary approach is essential in the treatment of these patients, who are still in their growth phase, to optimize their functional capacity, quality of life, and overall survival.

Background: After internal hemipelvectomy, successful pelvic reconstruction can provide a durable and pain-free reconstruction for the young, active patient. Such reconstruction is extremely challenging, and often patients have less than optimal ambulation with a limp, leg length discrepancy, or leg instability. The authors present an innovative method for pelvic ring reconstruction using a vascularized double-strut fibular bone flap that provides a stable pelvis and recovery of normal or near-normal gait., Methods: From December of 2003 to November of 2005, six sarcoma patients underwent internal hemipelvectomy and pelvic ring reconstruction with a vascularized double-strut fibular bone flap. The length of each strut was 7 to 12 cm., Results: All bone flaps survived. The mean follow-up was 18 months (range, 8 to 32 months). Radiographic evidence of bone bridging was seen at a mean of 2.5 months (range, 2 to 4 months). The mean time to ambulation without assistance was 8 months (range, 5 to 18 months). One patient died as a result of metastatic disease. The remaining five patients are ambulatory with a mild limp or no limp., Conclusion: Use of a vascularized double-strut fibular bone flap for pelvic ring reconstruction is effective in facilitating early ambulation and restoring normal to near-normal gait in patients undergoing internal hemipelvectomy.

Background: The purpose of this study was to address questions concerning the functional outcome following mandibular reconstruction with vascularized fibula flap in skeletally immature children, Methods: Eleven patients 14 years old or younger who underwent mandibular reconstruction using a free fibula flap were evaluated., Results: The mean follow-up was 3.4 years. One flap loss occurred and required a second fibula flap. Panorex radiographs showed good bone union and growth in all patients. Functional outcomes were normal according to age in all patients. Two patients had long-term malocclusion. No patients had to undergo corrective orthognathic surgery. Donor-site morbidities consisted of great toe flexion contracture (n = 4) and a valgus deformity (n = 1). All patients had a normal gait, and there were no discrepancies in leg length., Conclusion: A mandible reconstructed using a vascularized fibula flap appears to grow accordingly as the child grows, with minimal disturbance to the growth pattern of the midface., ((c) 2007 Wiley Periodicals, Inc. Head Neck 2008.)

Background: Neoplasms of the skull base are rare in children and require a multidisciplinary approach. Surgical defects are often large and cause significant functional, aesthetic, and psychological issues. The authors present their experience with reconstruction of the anterior and lateral skull base in the pediatric population., Methods: The authors conducted a retrospective review at a comprehensive cancer center., Results: Between January of 1993 and February of 2005, 10 children and adolescents underwent surgical resection of a skull base tumor followed by reconstruction of the skull base. Patients ranged in age from 6.4 to 17.9 years (median, 11.8 years). Four patients had rhabdomyosarcoma, and one each had spindle cell sarcoma, chondrosarcoma, liposarcoma, malignant fibrous histiocytoma, mucoepidermoid carcinoma, and neurofibromatosis. Surgical defects involved the anterior skull base in three patients, the infratemporal fossa in three patients, both the anterior and middle cranial fossae in three patients, and the temporal bone in one patient. Fourteen flap procedures were performed in these patients-11 after tumor resection and three in a delayed fashion to promote improved functional and aesthetic outcomes. Complications occurred in three patients, and there was one case of flap loss., Conclusions: Skull base reconstruction may be reliably and successfully accomplished in children and adolescents using soft-tissue free flaps or regional flaps. Full rehabilitation, including bony reconstruction and prosthetic rehabilitation, may be accomplished as craniofacial development plateaus in adolescence.

Study Design: A retrospective study of 134 consecutive cases in 92 patients who underwent soft tissue reconstruction of the spinal region following tumor removal., Objective: To better understand how to optimize outcomes in soft tissue reconstruction of the spine region., Summary of Background Data: With the increasing use of instrumentation and the fact that many patients with spinal neoplasms have debilitated wound-healing capacity, most of these patients are at high risk for postsurgical wound complications. Unfortunately, the optimal strategy to prevent and to manage complex wound complications involving the spinal region remains unclear., Methods: Factors potentially associated with the outcome of the reconstruction, including previous radiation therapy, chemotherapy, or surgery; medical comorbidities; timing of the reconstructive surgery; location of the defect; reconstructive approach; and presence of instrumentation, were evaluated and compared., Results: Of 92 patients, 29 patients (32%) developed postoperative wound complications. Among 32 patients with instrumentation of the spine, the 10 patients who had prophylactic soft tissue reconstruction had a significantly lower incidence of complications than did the 22 patients who had not (20% vs. 45%, P = 0.018). Furthermore, those who had previous surgery to the spine had a significantly higher risk of developing exposed instrumentation than did those who did not (21% vs. 0%, P = 0.002). Of 9 patients with exposed instrumentation, all but 1 patient had successful coverage of the instrumentation. Ninety (98%) of 92 patients had successful closure of the wound at the time of their last follow-up., Conclusions: In the presence of instrumentation, providing preemptive soft tissue reconstruction at the time of the initial spinal surgery can help minimize potentially serious wound complications. For management of wound complications that have developed, an aggressive debridement and coverage with well-vascularized tissue can allow for expedient wound healing while maintaining stabilized instrumentation.

Chest wall reconstructions can be complex and challenging procedures and may require a multidisciplinary approach. The most common indications for chest wall reconstruction are the repair of defects due to tumor ablation, infection, radiation necrosis, congenital deformities, and trauma. Flap reconstruction by plastic surgery is often required when skin is removed as part of the chest wall resection or when radiation therapy is given pre- or post-operatively. Tissue flaps may be needed to provide vascularized tissue over alloplastic materials used to stabilize the chest wall, to cover vital structures of the chest cavity, to fill dead space, and to improve cosmesis.

Background: Treatment for soft tissue sarcoma of the upper extremity has evolved to include limb salvage techniques. We reviewed our experience with limb salvage therapy for upper extremity sarcomas with an emphasis on functional outcomes following the reconstructive surgery., Methods: A retrospective analysis was performed of 81 consecutive patients with soft tissue sarcoma of the upper extremity who had limb salvage therapy with reconstruction by a plastic surgeon. Univariate and multivariate regression analyses of relevant outcome variables were performed. Enneking functional scores were obtained from 43 patients., Results: The study included 16 microvascular reconstructions and 67 non-microvascular reconstructions for a total of 83 reconstructions in 81 patients. The mean defect size was 129 cm(2) (standard deviation: 106 cm(2)). The mean total functional score was 23.1 (range, 9 to 30). Any reconstruction-related complication and preoperative chemotherapy use were associated with a 7.3 point (P = .03) and 4.7 point (P = .01) decrease in total functional score, respectively. Kaplan-Meier product-limit analysis showed 82% 5-year overall survival and 67% 5-year disease-free survival rates., Conclusions: For soft tissue sarcoma of the upper extremity, limb salvage with good functional outcome is possible with a judicious approach to reconstruction.

A total maxillectomy defect, if left unreconstructed or if poorly reconstructed, can lead to enophthalmos, orbital dystopia, feeding and speech problems, and loss of midfacial projection and vertical facial height. When the eye is preserved, despite resection of the supporting infraorbital bone during maxillectomy, bone reconstruction needs to be considered, using a vascularized bone flap. The authors have used the free fibula flap to simultaneously provide orbital support and restore midfacial projection in three patients, following total maxillectomy without orbital exenteration. For large maxillectomy defects with insufficient bony support, a free fibula flap should be considered as a reconstructive method, to adequately restore contour and the necessary structural support, and to provide optimal aesthetic and functional results.