Microtia Reconstruction: Our Strategies to Improve the Outcomes.

Introduction : Autologous costal cartilage framework placement is currently the gold standard in patients with microtia. In this article, we present the modifications developed by the author, generally following the principles established by Nagata, and discuss the technical details that have led us to achieve consistently stable and good long-term outcomes for auricular reconstruction in microtia. Materials and Methods : A retrospective review of microtia reconstruction performed from 2015 to 2021 was done. Those who underwent primary reconstruction for microtia and with a minimum follow-up of 6 months with documented photographs were included. Those who underwent secondary reconstruction for microtia and those who did not follow-up for a minimum period of 6 months were excluded. Outcomes were assessed with regard to appearance, and durability of the result. Influence of certain changes like delaying reconstruction until 15 years of age, use of nylon for framework fabrication, etc. over the outcome were assessed. Results : Of 11 ears reconstructed at less than 15 years of age, only one patient (9%) had a good long-term outcome, whereas of the 17 ears reconstructed at greater than 15 years of age, nine patients (53%) had a good long-term outcome. In our experience, infections and wire extrusions were the significant events related to severe cartilage resorption. Conclusion : In our experience, delaying the first stage to 15 years or later, using double-armed nylon sutures, and reducing the projection of the third layer of the framework in select cases have helped to improve our outcomes. Second stage of reconstruction can be avoided if patient is satisfied with the projection achieved in the first stage.

Volume and Location of the Defect as Predictors of Swallowing Outcome After Glossectomy: Correlation with a Classification.

This study aimed to characterize the swallowing outcomes after glossectomy and analyze factors affecting them. An attempt is made to propose a classification system and corroborate it to the results. This is a cross-sectional study to assess swallowing in carcinoma tongue patients treated surgically with or without reconstruction, followed by adjuvant therapy as indicated. One hundred and six patients were evaluated with videofluoroscopy (VFS). Volume defects were classified as I: less than one-third, II: one-third to half, III: half to two-thirds, IV: two-thirds to total glossectomy. Location was assigned as lateral, tip, and sulcus defects. Predictors were T stage, surgical approach, volume, location, and adjuvant radiotherapy. Chi-square and logistic regression were used for statistical analysis. Defects were Class I, II, III, and IV in 36, 42, 16, and 12 patients, respectively. Adjuvant radiotherapy was given in 40% of cases. Mean evaluation time was 14 months from treatment. On, Functional Oral Intake Scale (FOIS) score, as the Class of the defect increased, the percentage of patients with low scores (poor swallowing outcomes) showed an increasing trend (p < 0.001). Defect volume, T stage, approach, and radiotherapy correlated significantly with an abnormality of all VFS parameters (p < 0.001). On multivariate analysis, defect volume remained an independent predictor for oral parameters; radiotherapy emerged as the only independent predictor for pharyngeal parameters. The incremental volume of the defect is a significant independent predictor of swallowing. Based on this, we propose a classification for glossectomy.

Estimation of Health Utility and Quality Adjusted Life Years in Bilateral Hand Transplantation: A Time Trade-off Study.

BACKGROUND: Hand transplantation and advances in the field of prostheses have opened new frontiers in the restoration of hand function among bilateral hand amputees (BHA). There is only scarce literature evaluating the health utility (HU) and quality adjusted life years (QALY) gained by bilateral hand composite tissue allotransplantation (CTA) or prosthesis over amputation. The study was focused on BHA restored with prosthesis or CTA. METHODS: The HU of three different health states (HS) namely, BHA, using prosthesis or with CTA and net QALYs gained by hand transplantation or prosthesis over amputation were computed by time trade-off (TTO) method among 236 study participants. RESULTS: Among 236 study participants, medical professional (120), general public (89), BHA (23), and bilateral hand transplant recipients (4) were included. The mean HU by TTO method among the study participants (n = 232) as BHA, using prosthesis or CTA was 0.34 (±0.24), 0.50 (±0.26) and 0.69 (±0.26) respectively. Bilateral hand CTA imparted an expected gain of 12.57 (±11.43) mean QALYs over amputation among the study participants. The subgroup analysis displayed higher mean HU in hand CTA recipient HS along with maximum QALY gained by CTA over amputation. CONCLUSIONS: Bilateral hand CTA HS stands above the other 2 HSs, namely BHA and prosthesis, in terms of the health utility. As demonstrated by QALY gain of 12.57, participants' valuation of health utility is notably higher for CTA with acceptance of lifelong immunosuppressant rather than for a state of uncompromised physical health with a bilateral hand amputation.

Evaluation of Antigenicity of Components of Tracheal Allotransplant and Effect of Immunosuppressant Regime in a Rodent Model.

Background Tracheal transplantation seems to be the logical step in the process of reconstruction of the trachea following a long-segment resection, which is usually done to treat malignant disease or benign stenosis of the airway caused by a traumatic, congenital, inflammatory, or iatrogenic lesion. Immunosuppression following transplant is essential but not ideal after oncoresection. Methods The tracheal allografts, harvested from Sprague Dawley rats, were implanted in the Wistar strain rat. The harvested tracheal grafts were divided into groups and subgroups, based on the layers of trachea, method of decellularization, and immunosuppression. The antigenicity of different layers of trachea and the effect of various decellularization methods were studied within three time frames, that is, day 3, 9, and 15. Result On structural analysis, the day 3 and day 15 samples showed no meaningful comparison could be made, due to extensive neutrophil infiltration in all three layers. The day 9 tracheal grafts showed loss of epithelium, with no signs of regeneration in most of the allografts. The subepithelial lymphoid infiltration was found to be severe in nonimmunosuppressed allografts. The group in which both inner and outer layers were removed showed moderate-to-severe infiltrate of lymphoid cells in all the allografts, but there was no cartilage loss, irrespective of the method of decellularization. The irradiated specimens retained the cartilage but showed extensive ischemic damage. Conclusion Rat trachea is a good model for tracheal transplant research but not adequately sturdy to sustain mechanical debridement. Irradiation and chemical decellularization eliminates the immune response but causes intense ischemic damage. Out of the three time frames, day 9 seemed to be the best to study the immune response. To substantiate the results obtained in this study, the immunohistochemical study of the allografts is needed to be performed among a larger group of animals.

Tracheal Allotransplantation-Lessons Learned.

Reconstruction of long tracheal defects still proves to be a challenge. Free fasciocutaneous flaps with cartilaginous struts or an allotransplant trachea have been reported but not been widely performed. This article reports with the experience of using a tracheal allotransplant in such a defect. A 43-year-old lady presented with adenoid cystic carcinoma involving the entire trachea from subglottic area up to the carina, leading to a life-threatening airway occlusion. After preliminary stenting, allotransplant trachea obtained from a brain-dead individual was revascularized in the forearm of the patient after mechanical decellularization to reduce the immune load and fulfil the need for immunosuppression in the background of active cancer. Subsequently, the trachea and larynx were resected. The vascularized neotrachea was transferred successfully into the neck. The patient did well initially but succumbed to a fatal hemorrhage due to innominate vein aneurysmal rupture on the 22nd day after the transplant. The technical details of resection, fabrication of the neotrachea, its transfer, and the lessons learnt in this tracheal allotransplant are described.

Validation of the eighth edition AJCC staging system in early T1 to T2 oral squamous cell carcinoma.

BACKGROUND: To validate the newly proposed American Joint Committee on Cancer (AJCC) eighth edition staging in early T1 and T2 oral cavity cancers and its effect in predicting tumour control. METHODS: Retrospective analysis of treatment outcomes of 441 T1 to T2 oral squamous cell carcinoma (OSCC). Overall survival (OS), disease-specific survival (DSS), and tumour control were calculated and compared between the AJCC 7 and 8 staging systems. RESULTS: The 5-year OS was 78% and 61% for T1 and T2 tumours, respetively (P < 0.001) (AJCC 7) vs 87% and 67% (P < 0.001) (AJCC 8). The 5-year DSS was 78% and 61% for T1 and T2, respectively (P < 0.001) (AJCC 7) vs 89% and 71% (P < 0.001) (AJCC 8). For stages I and II tumours the 5-year OS was 81% and 76%, respectively (P < 0.302) (AJCC 7) vs 87% and 73% (P < 0.017) (AJCC 8). The 5-year DSS was 83% and 82% (P < 0.222) vs 89% and 77% (P < 0.016). With the AJCC eighth edition the 5-year local, regional, and distant control rates for T1 vs T2 tumours were 85% vs 74% (P = 0.003), 95% vs 77% (P = 0.001), and 95% vs 80% (P = 0.014), respectively. CONCLUSION: The AJCC 8th staging system provided for more accurate prediction of OS, DSS, and disease control in early oral cavity cancers.

Indian Subcontinent's First Proximal Forearm Level Double Upper Extremity Transplantation.

Introduction Vascularized composite allotransplantation (VCA) has added another step to the reconstructive ladder, leading to a paradigm shift in the approach toward management of cases of upper limb amputations. In this article, we discuss in detail the technical aspects of proximal forearm level transplantation, as well as the immediate posttransplant monitoring and immunosuppression protocols. Materials and Methods A 24-year-old male victim of an electric injury presented with a bilateral proximal forearm level amputation. After the mandatory preoperative psychiatric and immunological evaluation, the patient underwent a proximal forearm level double upper extremity transplantation. He was then put on a stringent immunosuppression and physical rehabilitative regime. Discussion Conceptually, the proximal forearm level transplantation is significantly different from distal forearm level transplant. This transplant "reestablishes" the "donor extremity length," maintains the normal functional length of the donor muscles, and the functional return happens only after the newly transplanted donor muscles are reinnervated over a period of time. Conclusion As the sequence of surgical repair and associated decision making could be quite confusing for this level of transplantation, it is highly advisable to do mock cadaver surgical dissections in order to standardize the procedure and make the team familiar with it.

Indian Subcontinent's First Bilateral Supracondylar Level Upper Limb Transplantation.

Introduction This is the first case of supracondylar level transplant from the Indian subcontinent, performed for a bilateral below elbow amputee. It has a completely different set of challenges for the transplant team, with a relatively shorter ischemia time window. The technical considerations for the same have been discussed in detail in this article. Materials and Methods The patient was a 19-year-old female who lost her both upper limbs at proximal forearm level due to severe crush injury following a road traffic accident. Insufficient bone length on either side necessitated a supracondylar level transplant. The preoperative workup included detailed clinical evaluation, biochemical, and psychological evaluation. The donor was a young brain-dead, male patient from a hospital, 30 minutes away. The donor and recipient preparations in this case were unique. The recipient's own elbow flexors and extensors were used while the elbow joint was from the donor. The specific challenges we faced during this procedure have been described in detail. Results The transplantation has been a complete technical success, with the patient rehabilitated back to her independent life style. This article describes only the technical considerations. The functional recovery aspect is part of an another soon to be published manuscript. Conclusion Supracondylar level arm-transplant requires a highly coordinated team effort with precise preoperative planning, along with meticulous attention to detail to achieve a successful outcome. In properly selected patients, it could be a life-changing procedure, worth all the effort.

"Deep Extrinsic Muscle Involvement" Is a Fallacy in the American Joint Committee on Cancer's Seventh Edition of Tumor Staging of Oral Cavity Cancers.

PURPOSE: The seventh edition of tumor staging by the American Joint Committee on Cancer (AJCC) includes extrinsic muscle involvement to define stage T4a tongue carcinomas. The anatomic location of extrinsic muscles predisposes them to early involvement even in superficial tumors. The purpose of this study was to expose a fallacy in this staging system for extrinsic muscle involvement. MATERIALS AND METHODS: This was a prospective cohort study of 87 patients with oral tongue squamous cell carcinoma. Magnetic resonance imaging (MRI) parameters were 1) the distance of the extrinsic muscles from the surface measured on the normal side in millimeters (range, mean, and standard deviation); 2) maximum transverse, craniocaudal, and anteroposterior tumor dimensions (range, mean, and standard deviation); and 3) tumor involvement of the muscles recorded on the involved side for the number and percentage of each muscle involved. Histopathologic depth of invasion also was recorded. RESULTS: Sixty-seven patients were men and 20 were women (age range, 18 to 74 yr; mean age, 51 yr). The mean distances of the most superficial part of the muscle to the normal surface at MRI for the genioglossus (anteroventral), hyoglossus, and styloglossus were 3.98, 2.13 and 0.66 mm, respectively. The patterns of extrinsic muscle involvement showed hyoglossus, styloglossus, and genioglossus involvement in 79 (90.8%), 58 (66.76%), and 31 (35.6%), respectively. In patients with a pathologic depth of invasion shallower than 10 mm, involvement of the hyoglossus, styloglossus, and genioglossus was seen in 80, 35, and 15%, respectively. CONCLUSION: The extrinsic muscles of the tongue are not deep. Even superficial thin tumors can involve these muscles. The eighth edition of tumor staging by the AJCC, which includes tumor thickness in the staging system, is in the process of being implemented. The present study justifies the removal of extrinsic muscle involvement in defining stage T4 of the oral cavity.

Factors Affecting Survival in Surgically Salvaged Locoregional Recurrences of Squamous Cell Carcinoma of the Tongue.

PURPOSE: To determine the factors affecting outcomes in surgically salvaged, locoregionally recurrent squamous cell carcinoma of the tongue (SCCT). MATERIALS AND METHODS: In a retrospective cohort of patients who underwent successful salvage of locoregionally recurrent SCCT, we performed this observational analytical study to determine survival and its determinants. Details extracted from our database were patient characteristics (age, gender, tobacco use), treatment characteristics, and characteristics of recurrent disease (stage and adverse pathologic features [APFs] such as grade, perineural invasion, and lymphovascular invasion). Overall survival (OS) curves were plotted using the Kaplan-Meier method. A Cox proportional hazards model was used to determine the impact of patient, disease, and treatment characteristics on OS. RESULTS: Of 52 patients with locoregional recurrences of surgically treated SCCT, 25 (48.1%) underwent surgical salvage with curative intent. The median overall OS for this cohort was 26 months. Factors predictive of worse OS were previous adjuvant therapy (P = .016) and increasing APFs in recurrent tumor histology (P = .008). Lymphovascular invasion in recurrent tumor histology and patients with a disease-free interval of less than 6 months showed worse survival (P = .008 and P = .058, respectively). CONCLUSIONS: Among patients with locoregional recurrence, the number who are eligible for curative-intent surgical salvage is small. Those who received previous adjuvant therapy and those with increasing APFs in recurrent tumors had poor outcomes despite attempts at surgical salvage, particularly patients with early recurrence.

Interdisciplinary Telemedicine in the Management of Dysphagia in Head and Neck.

The study considered the feasibility and impact of interdisciplinary telemedicine discussions in the management of post-treatment dysphagia in patients with head and neck tumors. This is a retrospective analysis of patients with persistent dysphagia after treatment for head and neck pathology, at an institute in India. The cases were discussed in the telemedicine meeting conducted between host institute and a second unit in the United States. A monthly meeting was organized, using an internet-based video conference system. The ongoing swallowing problems and management were presented, and through discussions, a plan for further management was formulated and carried out. The Functional Oral Intake Scale (FOIS) was measured before and after the implementation of the plan. Twenty-six patients were discussed, out of which, 22 were head and neck malignancies. The recommendations concurred with that of the host unit in 18, differed for three and additive in five patients. The pre-treatment mean FOIS was 1.46 with a standard deviation of 0.989 and post-treatment mean improved to 3.92 with a standard deviation of 1.809 (p < 0.0001). The present study supports the success of an interdisciplinary telemedicine meeting to manage difficult cases of dysphagia in head and neck. The outcome in terms of the FOIS score improved significantly after implementing them. In addition to the direct patient benefits, the meeting helped to facilitate interdepartmental collaboration between two units treating similar sets of patients across the globe, in specialized clinical areas like dysphagia management.

Outcomes following pharyngeal reconstruction in total laryngectomy - Institutional experience and review of literature.

BACKGROUND: Pharyngeal reconstruction is a challenging aspect of reconstruction after resections for head-and-neck cancer. The goals of reconstruction are to restore the continuity of the pharyngeal passage to enable oral alimentation and rehabilitation of speech wherever possible. This study was performed to determine the outcomes following pharyngeal reconstruction in total laryngectomy (TL) using different reconstructive options and to determine the predictors of pharyngocutaneous fistula (PCF) and swallowing dysfunction. MATERIALS AND METHODS: Retrospective analysis of patient data between 2003 and 2010 of patients undergoing TL with partial or total pharyngectomy. Demographic and treatment details were collected and analysed. Univariate analysis was performed to determine predictors of PCF and swallowing dysfunction. RESULTS: Fifty-seven patients underwent pharyngeal reconstruction following TL, 31 of whom had received prior treatment. Following tumour resection, 31 patients had circumferential defects and 26 patients had partial pharyngeal defects. The flaps used include pectoralis major myocutaneous flap (n = 29), anterolateral thigh flap (n = 8), gastric pull-up (n = 13) and free jejunal flap (n = 7). PCF was seen in 20 patients, of which 15 (75%) were managed conservatively and 5 required another surgery. At last follow-up, 99 patients (68%) were on full oral alimentation. Tracheo-oesophageal puncture and prosthesis insertion was done in 20 patients, of whom 17 (85%) developed satisfactory speech. Partial pharyngeal defects were associated with a higher risk of PCF on univariate analysis (P = 0.006) but were not significant on multivariate analysis. Post-operative swallowing dysfunction was significantly higher with hypopharyngeal involvement by tumour (P = 0.003). CONCLUSION: Pharyngeal reconstruction in TL is feasible with good results. Majority of the patients swallow and regain acceptable swallowing function within 3 months.

Soft embalming of cadavers for training purposes: Optimising for long-term use in tropical weather.

BACKGROUND: Surgical and anatomical training has been found to be most optimally simulated in a cadaver than any other available methods. Soft embalming methods have made the bodies more 'lifelike' and better suited for training. The widely accepted soft embalming techniques, including Thiel embalming, are designed for temperate climates. Their use in tropical locations has been found to be associated with poor short-term and long-term preservation of the bodies. In fact, adequate reports from tropical countries on effective methods for soft embalming are lacking. MATERIALS AND METHODS: This article details the modifications made in the Thiel embalming technique over a period of 2 years which has enabled us to preserve the anatomical features of bodies in an optimal way for longer periods in tropical conditions. This study was carried out in a tertiary care referral centre located in a tropical climate zone. A total of 13 frozen and thawed cadavers were used over a period of 2 years for developing such soft embalming technique. The efficacy of the technique was tested using these cadavers for varying types of surgical exercises on multiple occasions. RESULTS: The conventionally described technique of Thiel embalming did not provide desired results. Hence, various modifications to this technique were instituted which helped us to get superior quality of soft-embalmed cadavers. In the final year, these cadavers were used successfully for workshops in flap dissection. Head and neck access surgery, arthroscopic and laparoscopic procedures as well as mock face and hand transplant dissections. CONCLUSIONS: The Theil embalming technique for obtaining soft embalmed cadavers, even though found to be best in many centres in the world, has not been found to be suitable to tropical weather. By modifying it, we have succeeded in developing a technique suitable to the tropical weather. This technique yields cadavers suitable for various surgical simulation exercises. This technique also allows the body to be optimally used over several months in multiple occasions. These modifications are very simple and have been described in detail enabling it to be adopted by any surgical skill laboratory in the tropical countries.

First two bilateral hand transplantations in India (Part 2): Technical details.

INTRODUCTION: This article deals with two patients who underwent bilateral hand transplantation following amputation of both upper limbs at the distal third of the foream. MATERIALS AND METHODS: The first patient had a history of loss of hands in a train accident , with possiblity of a run over element during the injury. The second patient lost his both hands in a mine blast. The preoperative work up included detailed clinical and psychological evaluation. The donor retrieval was similar in both the cases and the donors were housed in our own instittution. The donor preparation, recipient preparation and the transplant procedure was similar except for the need of primary tendon transfers in the left hand of the first patient. RESULTS: The first patient needed a free flap transfer to cover compromised skin flap on the left hand on the second day. The second hand transplant was uneventful. Both the recipients are now back to their normal daily routines. CONCLUSIONS: Hand transplantation is a potentially life altering procedure, but to optimise the results, it is imperative that there is a meticulous planning and diligent execution with utmost importance to the detail coupled with a synchronised team effort.

First two bilateral hand transplantations in India (Part 4): Immediate post-operative care, immunosuppression protocol and monitoring.

INTRODUCTION: Being able to counter immune-mediated rejection has for decades been the single largest obstacle for the progress of vascular composite allotransplantation (VCA). The human immune system performs the key role of differentiating the 'self ' from the 'non-self '. This, although is quintessential to eliminate or resist infections, also resists the acceptance of an allograft which it promptly recognises as 'non-self'. MATERIALS AND METHODS: Pre-operative evaluation of the recipient evaluation included immunological assessment in the form of panel reactive antibodies (PRA), human leucocyte antigen (HLA) typing, donor-specific antibody detection assays (DSA) and complement-dependent cytotoxicity assays (CDC). Induction immunosuppression was by thymoglobulin and the maintenance by the standard triple-drug therapy. RESULTS: Both the recipients were managed by the standard triple drug therapy and have had only minor episodes of rejections thus far which have been managed appropriately. DISCUSSION: Induction immunosuppression was by thymoglobulin and the maintenance by the standard triple-drug therapy. Various groups have tried various other formulations and regimes as well. CONCLUSION: A comprehensive plan has to be drawn up for immunological screening, selection and the post-operative immunosuppressant usage. The ultimate goal of these immunosuppression modalities is to achieve a state of donor-specific tolerance.

First two bilateral hand transplantations in India (Part 1): From vision to reality.

INTRODUCTION: Vascularized composite tissue allotransplantation is a relatively new concept, which was unavailable in the Indian subcontinent till a bilateral hand transplant was carried out successfully in January 2015. MATERIALS AND METHODS: The setting up of the transplant programme involved obtaining legal clearances, creating public awareness, harnessing the institutional facilities, drawing up protocols, assembling the surgical team, managing immunological issues, rehabilitation and preparing the ancillary services. RESULTS: Both, the first and second bilateral hand transplants were resounding successes with both the recipients getting back to their original daily routines. CONCLUSIONS: The organisation of the hand transplant programme was a large task, which necessitated intensive planning, and cooperation from various teams within and outside the institution. Exemplary team-work was the key to the phenomenal success of these path breaking endeavors in the subcontinent.

First two bilateral hand transplantations in India (Part 3): Rehabilitation and immediate outcome.

INTRODUCTION: This report covers the strategies adopted for rehabilitation for the first and second dual hand transplants performed in India. MATERIALS AND METHODS: The team, under a trained physiatrist, including physiotherapy and occupational therapy personnel, was involved in the management of both these patients. The management protocol was developed considering previous reports as well as our management strategies in the rehabilitation of the replanted hands. The involvement of the team with the patients started in the 1st week itself and continued on a daily basis for the entire year. RESULTS: Outcome analysis was performed at 6 months and 1 year using the disability of shoulder and hand evaluation and hand transplant scoring system. Functional magnetic resonance imaging was done at the end of 1 year to assess the cortical integration of the transplanted hand. CONCLUSION: Despite more than 110 hands being transplanted worldwide, hand transplant remains an experimental procedure. It is still not considered the "standard of care" for hand amputees. Outcome analyses performed worldwide do indicate that the procedure can provide a substantial improvement in the quality of life for the hand amputee, especially the bilateral amputees.

Effect of external volume expansion on the survival of fat grafts.

INTRODUCTION: External volume expansion (EVE) is one method, which has been utilised for increasing the survival of adipose tissue grafts. EVE releases positive pressure from the graft and also induces intense levels of edema that decreases diffusion of metabolites essential for graft survival initially. The ideal timing of external volume expansion in relation to the injection of the fat to facilitate survival is not yet clear. AIMS AND OBJECTIVES: This study was undertaken to evaluate and compare the efficacy of external volume expansion applied at variable time points in relation to the injection of the fat. MATERIALS AND METHODS: Athymic mouse was the animal model and human lipo-aspirate mixed with PRP was used as graft. An indigenous dome shaped silicone device was fabricated to deliver a negative pressure of -30 mm of Hg. The EVE was applied at variable time intervals. At the end of 4 weeks visual, histological and radiological features of the injected fat were compared. The adipose tissue was stained with human vimentin to ascertain the origin of the retained fat. RESULTS: All the grafts, which had EVE, had significantly better volume retention and vascularity. The groups which underwent a delayed EVE or prior expansion followed by concomitant graft injection and expansion showed the most optimal vascularity and graft retention. CONCLUSIONS: A delayed EVE or prior expansion followed by concomitant graft injection and expansion may be the most ideal combinations to optimize graft take. However, on account of the relatively small sample size, there was a limitation in drawing statistically significant conclusions for certain variables.

Challenges in the reconstruction of bilateral maxillectomy defects.

PURPOSE: Bilateral maxillectomy defects, if not adequately reconstructed, can result in grave esthetic and functional problems. The purpose of this study was to investigate the outcome of reconstruction of such defects. MATERIALS AND METHODS: This is a retrospective case series. The defects were analyzed for their components and the flaps used for reconstruction. Outcomes for flap loss and functional indices, including oral diet, speech, and dental rehabilitation, also were evaluated. RESULTS: Ten consecutive patients who underwent bilateral maxillectomy reconstruction received 14 flaps. Six patients had malignancies of the maxilla, and 4 patients had nonmalignant indications. Ten bony free flaps were used. Four soft tissue flaps were used. The fibula free flap was the most common flap used. Three patients had total flap loss. Seven patients were alive and available for functional evaluation. Of these, 4 were taking an oral diet with altered consistency and 2 were on a regular diet. Speech was intelligible in all patients. Only 2 patients opted for dental rehabilitation with removable dentures. CONCLUSIONS: Reconstruction after bilateral maxillectomy is essential to prevent esthetic and functional problems. Bony reconstruction is ideal. The fibula bone free flap is commonly used. The complexity of the defect makes reconstruction difficult and the initial success rate of free flaps is low. Secondary reconstructions after the initial flap failures were successful. A satisfactory functional outcome can be achieved.

Vascularised composite allotransplants: Transplant of upper extremities and face.

Transplantation of solid organs and bone marrow has become a highly acceptable and often the only available clinical solution in many situations. It has been practiced across the globe for quite a long time since the first kidney transplant in 1954. Transplantation of tissues other than these, which was termed composite tissue allotransplantation and currently as vascularised composite allotransplantation (VCA) is gaining acceptance as a solution for complex reconstructive problems. This involves the transfer of multiple types of tissue such as bone, muscle, nerve, skin and blood vessels. The advantage of these over the conventional reconstructive methods is its ability to give aesthetically and functionally superior equal composite substitute to the missing or deformed part. The composite tissues transplanted commonly include the upper extremities, face and abdominal wall. Among these, hand transplants were the first to be done and have been carried out more than any other VCA. This article reviews the current scenario of VCA especially of the hand and face, in the light of experience of the two bilateral hand transplants done recently in India.