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Background: The purposes of this study were to report a 7-year experience of microvascular reconstruction of scalp defects, compare flap type and outcomes, and evaluate the implications of short and long term complications., Methods: Following institutional review board approval, a single surgeon's patients requiring microvascular scalp reconstruction were retrospectively reviewed from 2005 to 2011. Flap choice, complications, and outcomes were statistically analyzed., Results: Nineteen patients met inclusion criteria (10 male and 9 female) with a mean age of 60.2 ± 21.4 years (range, 23-90 years). All free tissue transfers (n = 20) achieved 100% soft tissue coverage. Mean size calvarial defect was 106.6 ± 67.2 cm(2) (range, 35-285 cm(2)), with 11 requiring cranioplasty. Free flaps included the following: 13 anteriolateral thigh, 5 ulnar, 1 latissimus dorsi, and 1 thoracodorsal artery perforator. Mean flap size was 154.1 ± 87.3 cm(2) (range, 42-336 cm(2)). Early complications (<30 days following surgery) occurred in 21.1% of patients and late complications (>30 days following surgery) in 52.6% of patients. Patients with an early complication were 2 times more likely to develop a late complication (relative risk, 2.1) but did not reach statistical significance. Late complications were more likely to require surgical intervention, 84.2% versus 60% of early complications (P = 0.079)., Conclusions: Microvascular free tissue transfer is the mainstay of complex scalp defects but carries a high likelihood of future reoperations. Early complications are less concerning than late complications, as the need for future surgical intervention is associated with late complications. There is lack of evidence to support a superior flap choice.

Background: Microvascular reconstruction is the mainstay of treatment in complex scalp defects. The rate of elderly patients requiring scalp reconstruction is increasing, but outcomes in elderly patients are unclear. The purpose of this study was to systematically review the literature pertaining to free tissue transfer for scalp reconstruction in patients older than 65 years to compare outcomes among different free flaps and determine the safety profile of treatment., Methods: A systematic review of the available literature of patients undergoing microvascular scalp reconstruction was completed. Details for patients 65 years and older were extracted and reviewed for data analysis., Results: A total of 45 articles (112 patients) were included for analysis. Mean age of the patients was 73.3 ± 6.3 years (men, 69.4 percent; women, 23.4 percent; not reported, 7.2 percent). Mean flap size was 598 cm2 (range, 81 to 2500 cm2). The mean age of patients developing a complication was 72.8 ± 6.4 years and patients that did not develop a complication was 73.4 ± 5.5 years (p = 0.684). Overall, periprocedural mortality was 0.9 percent. Flap failures occurred in two cases (1.8 percent). The overall complication rate was 22.3 percent (n = 25). Complications by flap type varied without reaching statistical significance., Conclusions: Microvascular reconstruction in complex scalp defects is associated with successful outcomes, and chronologic age does not increase mortality or catastrophic flap complications. The most common flaps used to repair scalp defects are anterolateral thigh and latissimus dorsi, but a superior flap type could not be identified.

Purpose: A core concept in plastic surgery has been the replacement of "like-with-like" tissue. Applying this concept to the lower extremity, the anterolateral thigh (ALT) perforator flap has become a frequently used free flap for restoration of soft tissue defects involving the distal lower extremity. The objective of this study was to evaluate the rate of early postoperative complications associated with the ALT perforator free flap for coverage of high-energy traumatic open fractures of the lower extremity (Gustilo IIIB) and explore related patient risk factors., Methods: A retrospective chart review of 74 patients undergoing free tissue transfer for lower extremity limb coverage was performed. Early postoperative complications were defined as any 1 or more of the following having occurred within 6 months from surgical reconstruction: hematoma, wound infection, deep venous thrombosis, thromboembolism, partial flap loss, complete flap loss, continued osteomyelitis, and progression to amputation occurring within the first 6 months after the injury. Statistical analyses were performed using GraphPad software. Fisher exact test was performed to identify risk factors associated with greater morbidity., Results: Of all patients, 26 (35%) were identified as those habitually using tobacco product and 48 (64%) were identified as nonusers of tobacco product. Moreover, 10 patients (14%) had other risk factors for atherosclerotic disease and 64 patients (86%) did not have other risk factors for atherosclerosis. Mean (SD) time to reconstruction was 4.74 (1.3) days (range, 3-8 days). Of all defects, 34 (46%) were reconstructed using adipocutaneous flaps and 40 (54%) were reconstructed using fasciocutaneous flaps. The most frequent complication was partial flap loss or superficial epidermolysis 4 (5.4%). Fisher exact test was performed, showing that patients who used tobacco product (cigarette smokers) and had other risk factors for atherosclerosis were significantly more at risk for complications (P < 0.001)., Conclusions: In this retrospective review, those patients who had a positive history of tobacco use at the time of injury and those with risk factors for atherosclerosis had a significantly increased risk of flap complications. Although this is not surprising given the vasoconstrictive effects of nicotine and the impaired blood flow to the lower extremity in patients with atherosclerosis, this study will allow the surgeon to better counsel patients who have a history of tobacco use through complex reconstruction of the lower extremity. This analysis is a preliminary investigation into the safety and efficacy of the ALT fasciocutaneous or adipocutaneous flap to reconstruct high-energy open fractures of the lower extremity.

Background: Treatment of facial fractures in the setting of open-globe injuries poses a management dilemma because of the often disparate treatment priorities of multidisciplinary trauma teams and the lack of prognostic data regarding visual outcomes., Methods: Patients in the University of Maryland Shock Trauma Registry sustaining facial fractures with concomitant open-globe injuries from January of 1998 to August of 2010 were identified. Odds ratios were calculated to identify demographic and clinical variables associated with blindness, and multivariate regression analysis was performed., Results: A total of 99 patients were identified with 105 open-globe injuries. Seventy-nine percent of injuries were blinding, whereas 4.8 percent of globes achieved a final visual acuity greater than or equal to 20/400. Blindness was associated with penetrating injury, increasing number of facial fractures, zygomaticomaxillary complex fracture, admission Glasgow Coma Scale score less than or equal to 8, and globe injury spanning all three eye zones. Fracture repair was performed more frequently (62.5 percent) and more quickly (average time to fracture repair, 4.5 days) in cases of primary globe enucleation/evisceration when compared with complete (21.2 percent; 8 days; p=0.35) or incomplete (42.9 percent; 11 days; p=0.058) primary globe repair., Conclusions: Penetrating injury mechanism and zone of eye injury appear to be better indicators of visual prognosis than facial fracture patterns. Given the high rates of blindness, secondary enucleation, and delay of fracture repair in patients that were not primarily enucleated, the authors recommend that orbital fracture repair not be delayed in the hopes of eventual visual recovery in cases of high-velocity projectile trauma., Clinical Question/level of Evidence: Risk, III.