Search

Introduction: Hemifacial microsomia is the most common congenital disorder of the face after cleft lip and palate. While treatment of the bony abnormalities has been well documented, less attention has been paid to correction of the soft tissue deformity. This study aimed to systematically review the literature addressing the techniques utilized to correct the soft tissue deformity in hemifacial microsomia., Materials and Methods: A comprehensive review of peer-reviewed literature regarding the management of soft tissue reconstruction in patients with hemifacial microsomia was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Odds ratio was used to assess differences in complication rates between reconstructions performed with free tissue transfer and fat grafting., Results: The literature search yielded 38 articles that were fully reviewed for data extraction. Articles were grouped into one of 5 reconstructive modalities-pedicled flap, microvascular free tissue transfer, structural fat grafting, alloplastic implant, and functional reconstruction. Microvascular free tissue transfer had a complication rate of 27.1%, while structural fat grafting had a complication rate of 4.2% (odds ratio 6.7, P = 0.0003)., Conclusions: Microvascular free tissue transfer likely provides greater volume than fat grafting at the cost of a higher complication rate. Mild to moderate soft tissue deformity can be corrected with serial fat grafting. However, severe soft tissue deformity is better corrected with microvascular free tissue transfer. When performing free tissue transfer, one should be prepared for recipient vessel anomalies. To provide adequate augmentation with isolated fat grafting, multiple sessions are likely required.

Background: Aortic graft infection (AGI) is a rare complication following reconstructive aortic surgery, yet it represents a significant source of morbidity and mortality. There is no consensus regarding the optimal surgical management, due in part to the small cohorts of patient reports. Pedicled muscle or omental flap coverage of AGI has been shown to improve outcomes, making them a valuable consideration in the treatment algorithm. Thus, we aim to compile and evaluate cases of autologous vascularized tissue (AVT) in the treatment of infected aortic grafts, summarizing location specific trends, treatments, and outcomes., Methods: A comprehensive review of peer-reviewed literature regarding the management of AGI was performed. Data collected included patient characteristics, original procedure, pathogen, infection location, tissue utilized, technique of tissue isolation and delivery, staging, outcome, length of follow-up, and level of evidence., Results: Ninety-four cases of AGI managed with AVT transfer were identified. Infection of ascending aorta grafts accounted for 59% of cases, followed by a combination of ascending aorta and aortic arch (21%), the descending thoracic aorta (18%), and the thoracoabdominal aorta (2%). The infected graft was preserved in 81% of cases, followed by debridement and AVT coverage. The omentum was the most commonly applied flap (69%) for all divisions of the aorta followed by the pectoralis major (19%), the rectus abdominis (5%), and latissimus dorsi (4%). Mortality was limited, and the Powered by Editorial Manager and ProduXion Manager from Aries Systems Corporation overall survival was 93% (7 deaths), with a mean follow-up of 33.5 months., Conclusions: Autologous vascularized tissue coverage has proven to be a successful approach for treatment of infected aortic grafts. Although the incidence of AGI is rare, it represents an area of scarce evidence-based literature that warrants increased attention and surgical refinement. These results, which show a remarkably low infection-related mortality rate (3%), should encourage interdisciplinary collaboration with the plastic surgeon, cardiothoracic surgeon, and infectious disease specialists with the goal of improving outcomes in the treatment of infected aortic grafts.

Background: Osteocutaneous maxillofacial allotransplantation is an encouraging technique for reconstruction of complex midfacial injuries (i.e., Gordon type III composite tissue allotransplantation). Although clinical results have been promising, there are no published guidelines, to date, on how to establish a functional occlusion and class I skeletal relation between the donor maxilla and recipient mandible. The purpose of this study was to use orthognathic principles and practice to improve occlusal and facial skeletal outcomes in osteocutaneous maxillofacial allotransplantation., Methods: Three Le Fort III-based maxillofacial allotransplantations were performed, using six fresh cadavers. Each recipient was prepared bluntly simulating a massive, bilateral orbitozygomatic maxillofacial defect. The first transplant was completed according to published protocol. The second was planned using dental cast models, cephalometric analyses, model surgery, and occlusal splint fabrication. The third involved an edentulous scenario, with the donor alloflap fixated to the recipient's mandible using a mimic Gunning splint to establish the vertical dimension of occlusion., Results: All three operations resulted in facial aesthetics comparable to those seen with autologous methods. Operative times ranged from 3.5 to 5.3 hours. The first allotransplant resulted in a class II malocclusion (overjet, 5 mm). The second recipient, with a preexisting class II skeleton, displayed a small anterior open bite of -1.7 mm, 1 mm of overjet, and a class I skeletal relationship (A-point-nasion-B-point angle, 2.3 degrees) following transplantation. The final transplant, consisting of an edentulous alloflap to an edentulous recipient, demonstrated an orthognathic profile., Conclusion: Use of orthognathic principles and practice in osteocutaneous maxillofacial allotransplantation resulted in improved occlusion, skeletal projection, and facial harmony relative to standard technique.

Objective: To discuss the technical and anatomical analysis and design of an osteocutaneous allograft transplant incorporating the donor maxilla and the execution of the operative protocol during the transplant., Methods: The Cleveland Clinic reported the world's first successful combined face and maxilla transplant in December 2008. Unlike the 3 prior face transplants, this surgical procedure was done as a salvage operation in a patient who had undergone 23 major reconstructive procedures. The additional complexity due to significant postoperative scarring and recipient vessel depletion presented a unique challenge in this case. The extensive 3-dimensional losses of facial structures in multiple tissue planes required a Le Fort III osteomyocutaneous allotransplant incorporating the donor maxilla., Results: We report the first successful transfer of a complete bony framework and soft-tissue envelope. The allograft has shown excellent integration and no long-term rejection. The traditional conception based on anatomical studies suggested that this transfer would require independent dissection of the internal maxillary vascular system. This was not required in our patient whose allograft was based solely on the facial arterial system and its arcades., Conclusions: Successful near-total face and maxilla allograft transplant can be accomplished based on the facial arterial system and its arcades. This presents a novel method for reconstructing massive facial injuries with significant involvement of the facial skeleton.

This report describes the development of a new technique for harvesting facial allograft for facial transplantation. The coronal-posterior surgical approach for facial/scalp flap harvesting from donor cadavers has been developed to allow extended length to the neurovascular bundles utilized in facial composite allograft transplantation. Cadaveric anatomic dissections were performed to harvest facial/scalp flaps via a posterior-coronal approach. Supraorbital and infraorbital neurovascular bundle lengths were extended by osteotomy of the cranial/orbital bone. The mental nerve lengths were extended into the inferior alveolar neurovascular bundle utilizing a sagittal split ramus osteotomy. This surgical approach extends the length of these craniofacial nerves for future neurorrhaphy. The mean length of the supraorbital, infraorbital, and mental nerves was 3.52 +/- 0.31 cm, 4.65 +/- 0.20 cm, 5.6 +/- 0.14 cm, respectively. Based on anatomical dissection in this cadaver study, the authors introduce a new technique for facial/scalp flap harvesting that extends the neurovascular bundles of sensory nerves of the anterior craniofacial skeleton.

Purpose: To describe the reconstruction of an irradiated contracted socket with an expanded superficial temporalis fascial flap and oral mucosa., Methods: A superficial temporalis fascial flap was first expanded with tissue expansion techniques and then rotated into the orbit to revascularize the socket. The mucosal surface of the socket was secondarily grafted with buccal and hard palate mucosa., Results: The expanded superficial temporalis fascial flap was used to revascularize the socket for grafting with hard palate and buccal mucosa. This resulted in the successful retention of an ocular prosthesis., Conclusion: The expanded superficial temporalis fascial flap is a useful technique in reconstruction of the contracted socket.

This canine study examines the structural stability of extensive laryngotracheal reconstruction with the sternohyoid myocutaneous rotary door flap (RDF) and modifications of the RDF with subdermal collagen and collagen hydroxyapatite matrix. The postreconstruction stability of the RDF and these modifications were tested and compared by measuring immediate postmortem airway stability during application of negative intraluminal pressures. Comparisons between controls and experimental specimens demonstrated that the RDF provides structural stability to secure airway patency under physiologic pressures. Biocompatible matrix adds further structural support in maintenance of the reconstructed lumen. This study validates that the RDF provides adequate rigid support for extensive laryngotracheal reconstruction without the requirement of skeletal support.

The temporalis musculofascial flap can be pre-expanded to increase its area prior to transfer. The large size of the preexpanded flap enabled orbital reconstruction to be carried out in a postirradiated orbit in a three-year-old girl. The flap was split, transferred in two parts, and covered with a buccal mucosal graft. A prosthetic shell was satisfactorily fitted postoperatively.

Cerebrospinal fluid fistulas after pericranial surgery are a major source of morbidity. A patient who underwent transsphenoidal sinus surgery for a recurrent pituitary adenoma was presented. The patient developed a chronic CSF leak despite standard management, including subarachnoid CSF drainage and transnasal endoscopic closure of the dura. Successful closure of the CSF fistula was obtained using a free omental flap to the sphenoid sinus. This case is the first reported use of a free microvascularized omental flap in an intracranial position for treating chronic CSF rhinorrhea. A description of the indications and the surgical technique for free omental closure of CSF fistulas was provided. The etiology, diagnosis, and management of CSF rhinorrhea are reviewed for the reconstructive surgeon.