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BACKGROUND: The choice of tissue type for free flap reconstruction of posterolateral mandible resections is dependent on patient and defect characteristics. We compared clinical and patient-reported outcomes following reconstruction of these defects with a soft tissue or bony free flap. METHODS: A retrospective review was performed on patients who underwent posterolateral segmental mandibulectomy with immediate free flap reconstruction at MSKCC from 2006 to 2021. Outcomes of interest were patient-reported outcome measures (PROMs) assessed by FACE-Q surveys and complications at the flap recipient site. RESULTS: Ninety patients received a bony flap and 24 patients received a soft tissue flap. Patients reconstructed with soft tissue flaps had greater rates of composite soft tissue defects (p < 0.0001), condyle resection (p = 0.001), and peripheral vascular disease (p = 0.035). Complication rates were similar between the cohorts (p > 0.05). Bony flaps scored higher on multiple FACE-Q scales: Facial Appearance (p = 0.023) Eating/Drinking (p = 0.029), Smiling (p = 0.012), Speaking (p < 0.001), Swallowing (p = 0.012), Smiling Distress (p = 0.037), and Speaking Distress (p = 0.001). CONCLUSION: Reconstruction of posterolateral mandibular defects has a similar complication profile when utilizing a bony or soft tissue free flap. Bony flaps may perform better with respect to PROMs. Reconstructive surgeons should consider using bony flap reconstruction to achieve higher patient satisfaction and quality of life.
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Colgajos Tisulares Libres , Procedimientos de Cirugía Plástica , Humanos , Calidad de Vida , Mandíbula/cirugía , Colgajos Tisulares Libres/cirugía , Medición de Resultados Informados por el Paciente , Estudios RetrospectivosRESUMEN
BACKGROUND: There is a lack of literature of health-related quality of life endpoints for radial forearm (RF) versus anterolateral thigh (ALT) free flap reconstruction for glossectomy defects. Our goal was to perform a comprehensive evaluation of clinical, functional, and quality of life outcomes after glossectomy reconstruction using a RF or ALT flap. METHODS: A retrospective review was performed on patients who underwent glossectomy and immediate reconstruction with RF or ALT flaps between 2016 and 2021. Outcomes of interest included readmission and reoperation rates, functional assessments, tracheostomy and gastrostomy tube status, and FACE-Q Head and Neck Cancer scores. RESULTS: Seventy-eight patients consisting of 54 RF and 24 ALT free flaps were included. ALT patients had a larger median flap size (72 vs. 48 cm2 , p = 0.021) and underwent mandibulotomy (50% vs. 7.4%, p < 0.0001) and base of tongue resection (58.3% vs. 24.1%, p = 0.005) at higher rates. No significant differences were found with respect to other outcomes. CONCLUSION: The RF and ALT flaps are suitable for glossectomy reconstruction, with minimal differences seen in postoperative outcomes. Our study suggests that ALT can be used in patients with base of tongue and larger defect sizes, while providing similar functional and clinical outcomes to RF reconstruction.
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Colgajos Tisulares Libres , Neoplasias de la Lengua , Humanos , Glosectomía/métodos , Muslo/cirugía , Antebrazo/cirugía , Calidad de Vida , Neoplasias de la Lengua/cirugía , Estudios Retrospectivos , Medición de Resultados Informados por el PacienteRESUMEN
INTRODUCTION: Limb salvage has become the standard of care for lower extremity tumors because of improvements in adjuvant treatments and reconstructive techniques. While there is literature assessing pediatric lower extremity free flap reconstruction in the setting of trauma, there is a paucity of literature that analyzes oncologic free flap reconstruction in this patient population. We report our long-term experience and evolution of care for lower extremity oncologic free flap reconstruction in pediatric patients. METHODS: This is a retrospective case series of all patients ≤18 years of age who underwent oncologic soft-tissue microvascular reconstruction of the lower extremity, from 1992 to 2021. Data were collected for patient demographics, oncologic treatment, operative details, and post-operative outcomes. Functional outcomes were assessed by weight bearing status, ambulation, and participation in activities-of-daily-living (ADLs), and musculoskeletal tumor society (MSTS) scores. RESULTS: Over the 30-year study period, inclusion criteria were met by 19 patients (11 males, 8 females) with a mean age of 13.8 years and a mean follow-up of 5.3 years. At last follow-up, 13 patients (68.5%) were alive. The most common pathology was osteogenic sarcoma (13 patients, 68.5%). Sites of reconstruction were the hip (n = 1), thigh (n = 5), knee (n = 4), leg (n = 7), and the foot (n = 2). The most commonly used flaps were latissimus dorsi (n = 8), gracilis (n = 4), and anterolateral thigh ± vastus (n = 4). Postoperative complications occurred in nine patients (43%). Overall flap success rate was 95%. At latest follow-up, ambulation without assistive device was obtained in 11 patients (58%), full weight bearing was achieved by 13 patients (68.5%), and ADLs could be performed independently by 13 patients (68.5%). Mean MSTS score was 23.1/30. CONCLUSION: Microvascular reconstruction for oncological lower extremity defects in the pediatric population has high limb salvage rates and good functional outcomes.
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Colgajos Tisulares Libres , Procedimientos de Cirugía Plástica , Masculino , Femenino , Humanos , Niño , Adolescente , Colgajos Tisulares Libres/cirugía , Estudios Retrospectivos , Extremidad Inferior/cirugía , Recuperación del Miembro/métodos , Resultado del TratamientoRESUMEN
Continuous external tissue expansion has been shown to be effective in the management of craniofacial wounds resulting from tumor resection, trauma, and wound dehiscence. Forehead flap donor sites are typically managed with secondary intention healing. However, this can create esthetic problems in pigmented skin because of the tendency to form thick scars. Here, the authors describe the use of continuous external tissue expansion for the management of a paramedian forehead flap donor site. A Dermaclose device was used at the time of forehead flap elevation and removed at the pedicle division and inset. Sufficient skin expansion was achieved for primary closure. The final scar was esthetically pleasing. External tissue expansion is ideal for forehead flap donor sites as the second stage of the operation provides an opportunity for expander removal and wound closure.
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BACKGROUND: Fibula free flaps (FFF) are the gold standard tissue for the reconstruction of segmental mandibular defects. A comparison of miniplate (MP) and reconstruction bar (RB)-based fixation of FFFs has been previously described in a systematic review; however, long-term, single-center studies comparing the two plating methods are lacking. The authors aim to examine the complication profile between MPs and RBs at a single tertiary cancer center. We hypothesized that increased components and a lack of rigid fixation inherent to MPs would lead to higher rates of hardware exposure/failure. METHODS: A retrospective review was performed from a prospectively maintained database at Memorial Sloan Kettering Cancer Center. All patients who underwent FFF-based reconstruction of mandibular defects between 2015 and 2021 were included. Data on patient demographics, medical risk factors, operative indications, and chemoradiation were collected. The primary outcomes of interest were perioperative flap-related complications, long-term union rates, osteoradionecrosis (ORN), return to the operating room (OR), and hardware exposure/failure. Recipient site complications were further stratified into two groups: early (<90 days) and late (>90 days). RESULTS: In total, 96 patients met the inclusion criteria (RB = 63, MP = 33). Patients in both groups were similar with respect to age, presence of comorbidities, smoking history, and operative characteristics. The mean follow-up period was 17.24 months. In total, 60.6 and 54.0% of patients in the MP and RB cohorts received adjuvant radiation, respectively. There were no differences in rates of hardware failure overall; however, in patients with an initial complication after 90 days, MPs had significantly higher rates of hardware exposure (3 vs. 0, p = 0.046). CONCLUSION: MPs were found to have a higher risk of exposed hardware in patients with a late initial recipient site complication. It is possible that improved fixation with highly adaptive RBs designed by computer-aided design/manufacturing technology explains these results. Future studies are needed to assess the effects of rigid mandibular fixation on patient-reported outcome measures in this unique population.
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Colgajos Tisulares Libres , Reconstrucción Mandibular , Humanos , Trasplante Óseo/métodos , Peroné , Mandíbula/cirugía , Reconstrucción Mandibular/métodos , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: A comprehensive understanding of changes in health-related quality of life after head and neck cancer surgery is necessary for effective preoperative counseling. The goal of this study was to perform a longitudinal analysis of postoperative quality of life outcomes after fibula free flap (FFF) mandible reconstruction. METHODS: A retrospective review was performed for all patients who underwent oncologic mandible reconstruction with an FFF between 2000 and 2021. Completion of at least one postoperative FACE-Q questionnaire was necessary for inclusion. FACE-Q scores were divided into five time periods for analysis. Functional outcomes measured with speech language pathology (SLP) assessments and tracheostomy and gastrostomy tube status were analyzed at three time points. RESULTS: One hundred and nine patients were included. Of these, 68 patients also had at least one SLP assessment. All outcomes as measured by the various FACE-Q scales did not improve significantly from the immediate postoperative time point to the last evaluated time point (p > 0.05). SLP functional outcomes showed some deterioration over time, but these were not significant (p > 0.05). The percentage of patients who required a tracheostomy (18 to 2%, p = 0.002) or gastrostomy tube (25 to 11%, p = 0.035) decreased significantly from the immediate postoperative time point to the last evaluated time point. CONCLUSION: Subjective quality of life outcomes do not change significantly with time after oncologic FFF mandible reconstruction. Reconstructive surgeons can use these results to help patients establish appropriate and achievable quality of life goals after surgery. Further studies are warranted to elucidate the impact of specific relevant clinical variables on postoperative quality of life.
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BACKGROUND: Prior studies have shown an increased risk of complications and flap loss with the use of vein grafts in microsurgery. We hypothesize that indication for use of a vein graft can affect flap complications and loss rates. METHODS: We performed a retrospective review of all patients at our institution from 2010 to 2020 who underwent free flap reconstruction and required use of a vein graft. Indications for vein grafting included: salvage of flap during primary operation after microvascular compromise, augmentation of flow during primary operation, lengthening of the flap pedicle during the primary operation, and salvage of the flap during a secondary salvage operation after microvascular compromise. RESULTS: A total of 79 patients met the study inclusion criteria. There were significant differences among the vein graft indication groups and the following: area of reconstruction (p = 0.002), vein graft length (p = 0.018), vessels grafted (p = 0.001), vein graft donor site (p = 0.011), and total flap loss (p = 0.047). Of the four indications for vein grafting, salvage of the flap during secondary salvage operation after microvascular compromise had the highest rate of total flap loss (26.7%). There were no significant associations between other flap complications and vein graft indications. CONCLUSION: Vein graft use in the primary reconstructive setting is efficacious, with low risk of thrombosis. Use in secondary procedures, however, is associated with higher rates of total flap loss, likely due to the thrombotic process, which was initiated prior to the use of the graft resulting in the salvage procedure and not secondary to the graft itself.
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Colgajos Tisulares Libres , Microcirugia , Procedimientos de Cirugía Plástica , Complicaciones Posoperatorias , Venas , Humanos , Colgajos Tisulares Libres/irrigación sanguínea , Estudios Retrospectivos , Masculino , Femenino , Procedimientos de Cirugía Plástica/métodos , Persona de Mediana Edad , Venas/trasplante , Microcirugia/métodos , Complicaciones Posoperatorias/cirugía , Supervivencia de Injerto , Adulto , Anciano , Resultado del Tratamiento , Terapia Recuperativa/métodosRESUMEN
BACKGROUND: Limb salvage has better functional outcomes than amputation in the upper extremity. This can however be challenging after bony tumor resections. METHODS: This is a retrospective case series of patients who underwent humerus, ulna, or radius reconstruction with a fibula free flap. Data were collected on demographics, oncologic history, surgical details, and complications. Functional outcome measures included the patient's ability to perform activities of daily living (ADL), presence of pain, and musculoskeletal tumor society (MSTS) score. RESULTS: Over a 25-year period, 38 reconstructions were performed. The flap success rate was 97.5%. Bony union was obtained in 19 of 19 (100%) forearm reconstructions and in 15 of 19 (79%) humerus reconstructions (p = 0.10). All 19 forearm reconstruction patients and 18/19 humerus reconstruction patients were able to perform ADLs with no pain or only occasional pain. The MSTS scores were not significantly different between the humerus and forearm cohorts (27.1 vs. 27.3, p = 0.68). Functional outcomes were significantly better in limbs that achieved union (p < 0.001). Recipient and donor site complications occurred in 10 (26.3%) and 5 (13%) patients, respectively. CONCLUSIONS: Oncologic upper-extremity reconstruction with fibula free flaps has excellent functional outcomes. Bone union is a predictor of superior limb function.
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Neoplasias Óseas , Colgajos Tisulares Libres , Enfermedades Musculoesqueléticas , Neoplasias de los Tejidos Conjuntivo y Blando , Humanos , Estudios Retrospectivos , Actividades Cotidianas , Neoplasias Óseas/cirugía , Extremidad Superior/cirugía , Dolor , Resultado del Tratamiento , Trasplante ÓseoRESUMEN
Chordomas are rare, low-grade malignant tumors often found in the sacrococcygeal region and prone to local recurrence. We report an atypical presentation of a 40-year-old patient with a symptomatic midline retrococcygeal lesion that was presumptively treated as a pilonidal cyst due to its clinical and imaging features. After surgical pathology rendered the diagnosis of chordoma, the patient required salvage surgery in the form of partial sacrectomy with soft tissue flap coverage. In addition to the unusually predominant retrococcygeal location, surgical pathology identified an intervertebral disc origin rather than the typical osseous origin. To our knowledge, this presentation of chordoma with coccygeal intervertebral origin and a large subcutaneous mass at imaging has rarely been reported in the literature. We describe this case to raise awareness of atypical presentations of sacrococcygeal chordoma that may lead to erroneous presumptive diagnosis and treatment.
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INTRODUCTION: Partial tongue reconstruction requires a thin pliable flap to restore volume and mobility. The lateral arm flap is well suited to this as it is a thin fasciocutaneous flap that has consistent vascular anatomy, reliable perfusion, short harvest time and low donor site morbidity. The authors report our experience with use of this flap for reconstruction of hemi-glossectomy defects. METHODS: This is a retrospective cohort of patients who underwent reconstruction of hemi-glossectomy and floor of mouth defects with a lateral arm flap, at Aga Khan University Hospital, Karachi (Pakistan) from November 2016 to January 2020. Flaps were harvested from the nondominant upper extremity. Data were collected for patient demographics, size of defect, size of flap, recipient vessels, postoperative complications and functional outcome. RESULTS: Over a 3-year period, 8 hemi-tongue and extended hemi-tongue, and floor of mouth reconstructions were performed with a lateral arm fasciocutaneous flap. A standard lateral arm flap was harvested in 3 patients and an extended lateral arm flap in 5 patients. Mean flap size was 65.75âcm2 (48-76âcm2). The recipient artery in all cases was the superior thyroid artery. The recipient veins were the common facial vein in 1 patient, the internal jugular in 3 patients, the external jugular in 1 patient and both external and internal jugular in 3 patients. Donor sites were closed primarily. There were no total or partial flap losses. All patients were able to resume an oral diet (unrestricted in 1, soft in 4, pureed in 2 patients). Postoperative speech was intelligible to patients' family in 4 patients and to strangers in 3 patients. One patient succumbed to progressive disease in the early postoperative period. Orocutaneous fistulas developed in 3 patients, all of which healed with nonoperative management. CONCLUSIONS: The lateral arm fasciocutaneous flap is well suited for reconstruction of hemiglossectomy and floor of mouth defect. It has the advantages of straightforward harvest, thin and pliable soft tissue, and low donor site morbidity.
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Glosectomía , Procedimientos de Cirugía Plástica , Humanos , Estudios Retrospectivos , Colgajos QuirúrgicosRESUMEN
Fat grafting has emerged as an important tool in the armamentarium of plastic surgeons. Its applications in aesthetic and reconstructive surgery continue to expand. However, its limitations (such as inconsistent survival) remain problematic. Recent research efforts have focused on tacking these issues with the use of platelet rich plasma, hypoxic preconditioning, hyperbaric oxygen, and the tissue engineering of scaffolds. In the future, as these laboratory discoveries are translated to clinical application, the beneficial uses of fat grafting will continue to increase.
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Tejido Adiposo/trasplante , Procedimientos de Cirugía Plástica/métodos , Ingeniería de Tejidos/métodos , Animales , Humanos , Oxigenoterapia Hiperbárica/métodos , Plasma Rico en Plaquetas , Procedimientos de Cirugía Plástica/tendenciasRESUMEN
Computer-assisted surgery is the most significant recent advancement in osseous head and neck reconstruction. Computer-aided design (CAD) software allows computerized planning of resection and reconstruction. Computer-aided manufacturing (CAM) can be used to create models, cutting guides, and patient-specific plates. Several studies have shown that these techniques are more accurate and result in decreased flap ischemia times compared with conventional techniques. CAD also facilitates the immediate placement of dental implants. The most useful application of computer-assisted surgery is delayed reconstruction, in which soft tissue contraction and the absence of a specimen as a reference make accurate estimation of the defect challenging. The drawbacks of CAD/CAM are lack of intraoperative flexibility and cost. Some centers have created in-house CAD/CAM processes using open-source software and commercially available three-dimensional printers.
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BACKGROUND: Femoral diaphyseal reconstructions with metal prostheses have mediocre results because of high mechanical forces that result in eventual implant failure. Biological alternatives require prolonged restrictions on weight-bearing and have high rates of infection, nonunion, and fracture. A novel method of utilizing a vascularized fibula in combination with an intercalary prosthesis was developed to complement the immediate stability of the prosthesis with the long-term biological fixation of a vascularized fibular graft. METHODS: A prospectively maintained database was retrospectively reviewed to identify patients who underwent reconstruction of an oncological intercalary femoral defect using an intercalary prosthesis and an inline fibular free flap (FFF). They were compared with patients who underwent femoral reconstruction using an intercalary allograft and an FFF. RESULTS: Femoral reconstruction with an intercalary metal prosthesis and an FFF was performed in 8 patients, and reconstruction with an allograft and an FFF was performed in 16 patients. The mean follow-up was 5.3 years and 8.5 years, respectively (p = 0.02). In the bioprosthetic group, radiographic union of the fibula occurred in 7 (88%) of 8 patients, whereas in the allograft group, 13 (81%) of 16 patients had allograft union (p = 1.00) and all 16 patients had fibular union (p = 0.33). The mean time to fibular union in the bioprosthetic group was 9.0 months, whereas in the allograft group, the mean time to allograft union was 15.3 months (p = 0.03) and the mean time to fibular union was 12.5 months (p = 0.42). Unrestricted weight-bearing occurred at a mean of 3.7 months in the prosthesis group and 16.5 months in the allograft group (p < 0.01). Complications were observed in 2 (25%) of 8 patients in the prosthesis group and in 13 (81%) of 16 patients in the allograft group (p = 0.02). Neither chemotherapy nor radiation affected fibular or allograft union rates. Musculoskeletal Tumor Society scores did not differ significantly between the groups (mean, 26 versus 28; p = 0.10). CONCLUSIONS: Bioprosthetic intercalary femoral reconstruction with a metal prosthesis and an FFF resulted in earlier weight-bearing, a shorter time to union, fewer operations needed for union, and lower complication rates than reconstruction with an allograft and an FFF. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Miembros Artificiales , Neoplasias Óseas , Colgajos Tisulares Libres , Humanos , Peroné/trasplante , Colgajos Tisulares Libres/patología , Estudios Retrospectivos , Diáfisis/cirugía , Diáfisis/patología , Neoplasias Óseas/cirugía , Trasplante Óseo/métodos , Resultado del TratamientoRESUMEN
INTRODUCTION: Maxillary reconstruction is a complex undertaking characterized by a 3-dimensional surgical site with deficiencies in multiple tissue types. Prior to virtual surgical planning(VSP), bony reconstruction was inaccurate and inefficient, thus reconstructions defaulted to soft tissue flaps or obturators. The current study describes an efficient and accurate approach to bony maxillary reconstruction with immediate dental implant placement(IDIP). METHODS: A reconstructive workflow was developed for osseous reconstruction to improve functional and aesthetic outcomes. Critical aspects include VSP, 3-D printed plates and IDIP. Review of a prospectively maintained database identified patients who underwent osseous maxillary reconstruction with a fibula flap and immediate dental implants from 2017-2022, with a focus on oncologic characteristics and reconstructive outcomes. RESULTS: During the study, 20 patients underwent maxillary reconstruction with VSP and IDIP. One dental implant out of 55 failed to osseointegrate and no flaps were lost. Three patients suffered partial loss of the fibula skin island; one required palatal closure with a radial forearm flap, and two were managed with outpatient debridement. Fifteen patients achieved either an interim or final retained dental prosthesis. All prostheses achieved acceptable aesthetic results without the instability associated with non-bone borne devices(e.g.dentures/obturators). No patients experienced delays in oncologic treatment. CONCLUSIONS: VSP technology has enabled surgeons to replace like with like to achieve better outcomes with acceptable morbidity for maxillary defects. IDIP provides all patients an opportunity for a fixed prosthesis even though not all complete the process. This maxillary reconstruction workflow can be safely accomplished in oncologic patients with promising and effective early results.
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What are the reconstructive challenges of the lumbosacral area?What are the goals and principles of reconstructing the lumbosacral defect?What are propeller flaps?How are propeller flaps used in the lumbosacral region?
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BACKGROUND: Conflicting evidence exists regarding the optimal waiting time for stable analgesic and vasoconstrictive effects after local infiltration of lidocaine with epinephrine. An objective review is needed to dispel surgical dogma. METHODS: This systematic review (PROSPERO ID: CRD42022362414) included RCTs and prospective cohort studies. Primary outcomes were (1) onset of analgesia and (2) onset of stable hypoperfusion, assessed directly, or measured indirectly using perfusion imaging. Other data extracted include waiting strategies, means of outcome assessment, anaesthetic concentrations, volume/endpoint of infiltration, and injection sites. Methodological quality was evaluated using the Cochrane risk-of-bias tool for randomized trials. Articles describing waiting strategies were critically appraised by the Joanna Briggs Institute tools. RESULTS: Twenty-four articles were analysed, comprising 1013 participants. Ten investigated analgesia onset. Their pooled mean was 2.1â min (range 0.4-9.0â min). This varied with anatomic site and targeted nerve diameter. Fourteen articles investigated onset of stable hypoperfusion. Four observed bleeding intraoperatively, finding the minimum time to hypoperfusion at 7.0â min in the eyelid skin and 25.0â min in the upper limb. The ten remaining studies used perfusion imaging, reporting a wide range of results (0.0-30.0â min) due to differences in anatomic sites and depth, resolution and artefacts. Studies using near-infrared reflectance spectroscopy and hyperspectral imaging correlated with clinical observations. Thirteen articles discussed waiting strategies, seven relating to large-volume tumescent local infiltration anaesthesia. Different waiting strategies exist for emergency, arthroscopic and cosmetic surgeries, according to the degree of hypoperfusion required. In tumescent liposuction, waiting 10.0-60.0â min is the norm. CONCLUSION: Current literature suggests that around 2â min are required for most patients to achieve complete analgesia in all sites and with all anaesthesia concentrations. Waiting around 7â min in eyelids and at least 25â min in other regions results in optimal hypoperfusion. The strategies discussed inform decisions of when and how long to wait.
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Anestesia Local , Manejo del Dolor , Humanos , Estudios Prospectivos , Epinefrina , LidocaínaRESUMEN
SUMMARY: Oncologic maxillectomy defects requiring bony reconstruction are among the most challenging head and neck cases because of the complex three-dimensional geometry of the midface. Virtual surgical planning technology is advantageous in these cases because it provides superior positional precision and accuracy compared with traditional techniques and facilitates prosthodontic rehabilitation. Maxillary cancer recurrence after an initial fibula flap reconstruction presents a unique challenge. The authors report the first two cases of sequential fibula flaps after second or recurrent cancer of the maxilla. Virtual surgical planning facilitated resection with adequate tumor margins, optimized anatomic positioning of the fibula construct with three-dimensional printed plates, and enabled immediate functional dental implant placement.
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Implantes Dentales , Colgajos Tisulares Libres , Humanos , Peroné , Recurrencia Local de Neoplasia , Maxilar/cirugíaRESUMEN
OBJECTIVES: The aim of this study was to compare postoperative outcomes between biologic and synthetic reconstructions after chest wall resection in a matched cohort. METHODS: All patients who underwent reconstruction after full-thickness chest wall resection from 2000 to 2022 were reviewed and stratified by prosthesis type (biologic or synthetic). Biologic prostheses were of biologic origin or were fully absorbable and incorporable. Integer matching was performed to reduce confounding. The study end point was surgical site complications requiring reoperation. Multivariable analysis was performed to identify associated risk factors. RESULTS: In total, 438 patients underwent prosthetic chest wall reconstruction (unmatched: biologic, n = 49; synthetic, n = 389; matched: biologic, n = 46; synthetic, n = 46). After matching, the median (interquartile range) defect size was 83 cm2 (50-142) for the biologic group and 90 cm2 (48-146) for the synthetic group (P = 0.97). Myocutaneous flaps were used in 33% of biologic reconstructions (n = 15) and 33% of synthetic reconstructions (n = 15) in the matched cohort (P = 0.99). The incidence of surgical site complications requiring reoperation was not significantly different between biologic and synthetic reconstructions in the unmatched (3 [6%] vs 29 [7%]; P = 0.99) and matched (2 [4%] vs 4 [9%]; P = 0.68) cohorts. On the multivariable analysis, operative time [adjusted odds ratio (aOR) = 1.01, 95% confidence interval (CI), 1.00-1.01; P = 0.006] and operative blood loss (aOR = 1.00, 95% CI, 1.00-1.00]; P = 0.012) were associated with higher rates of surgical site complications requiring reoperation; microvascular free flaps (aOR = 0.03, 95% CI, 0.00-0.42; P = 0.024) were associated with lower rates. CONCLUSIONS: The incidence of surgical site complications requiring reoperation was not significantly different between biologic and synthetic prostheses in chest wall reconstructions.
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Productos Biológicos , Pared Torácica , Humanos , Pared Torácica/cirugía , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/cirugía , Complicaciones Posoperatorias/etiología , Resultado del Tratamiento , Prótesis e Implantes/efectos adversos , Estudios RetrospectivosRESUMEN
OBJECTIVE: Pedicled flaps (PFs) have historically served as the preferred option for reconstruction of large chest wall defects. More recently, the indications for microvascular-free flaps (MVFFs) have increased, particularly for defects in which PFs are inadequate or unavailable. We sought to compare oncologic and surgical outcomes between MVFFs and PFs in reconstructions of full-thickness chest wall defects. METHODS: We retrospectively identified all patients who underwent chest wall resection at our institution from 2000 to 2022. Patients were stratified by flap reconstruction. End points were defect size, rate of complete resection, rate of local recurrence, and postoperative outcomes. Multivariable analysis was performed to identify factors associated with complications at 30 days. RESULTS: In total, 536 patients underwent chest wall resection, of whom 133 had flap reconstruction (MVFF, n = 28; PF, n = 105). The median (interquartile range) covered defect size was 172 cm2 (100-216 cm2) for patients receiving MVFF versus 109 cm2 (75-148 cm2) for patients receiving PF (P = .004). The rate of R0 resection was high in both groups (MVFF, 93% [n = 26]; PF, 86% [n = 90]; P = .5). The rate of local recurrence was 4% in MVFF patients (n = 1) versus 12% in PF patients (n = 13, P = .3). Postoperative complications were not statistically different between groups (odds ratio for PF, 1.37; 95% confidence interval, 0.39-5.14]; P = .6). Operative time >400 minutes was associated with 30-day complications (odds ratio, 3.22; 95% confidence interval, 1.10-9.93; P = .033). CONCLUSIONS: Patients with MVFFs had larger defects, a high rate of complete resection, and a low rate of local recurrence. MVFFs are a valid option for chest wall reconstructions.
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Colgajos Tisulares Libres , Procedimientos de Cirugía Plástica , Procedimientos Quirúrgicos Torácicos , Pared Torácica , Humanos , Colgajos Tisulares Libres/efectos adversos , Colgajos Tisulares Libres/cirugía , Pared Torácica/cirugía , Estudios Retrospectivos , Procedimientos de Cirugía Plástica/efectos adversosRESUMEN
Background: Osteogenesis imperfecta (OI) is a rare metabolic bone disorder in which collagen production is impaired. Patients have brittle bones that are prone to fracture with minor trauma. Whereas most of the fractures occur in the spine and extremities, fractures of the craniofacial bones are less common. Methods: This report describes the management of a 14-year-old boy with OI type 1 who sustained mandible fractures from an assault. Management consisted of open reduction and internal fixation of the parasymphyseal and angle fractures and closed reduction and mandibulomaxillary fixation of the subcondylar fracture. Results: Surgery resulted in return of premorbid occlusion and good jaw function. Removal of plates and screws was performed 10 months later without incident. Conclusions: This case report discusses the unique anesthetic, surgical, and postoperative considerations for managing mandible fractures in patients with OI.