Versatility of subscapular chimeric free flaps in the secondary reconstruction of composite posttraumatic defects of the upper face.

High energy injuries to the upper face present challenging reconstructive problems. In some cases, initial reconstructive efforts result in unfavorable outcomes that require secondary intervention. Chimeric free flaps based on the subscapular system offer the tissue components and volume needed for these complex reconstructions. This is a series of five patients who underwent secondary reconstruction of the middle and upper face following traumatic injury. Mechanism of injury, prior attempts at reconstruction, and characteristics of the tissue defects and the flaps used in their reconstruction are described. Two patients were female and three were male. Three injuries resulted from gunshot wounds, and two from motor vehicle accidents. All patients had multiple prior failed attempts at reconstruction using local/regional tissue. Defects included symptomatic oronasal or oro-orbital fistulas, enophthalmos, and forehead contour deformities. Two of the flaps used included scapular bone and latissimus muscular components, and three included scapular bone and thoracodorsal artery perforator-based skin paddle components. All free tissue transfers were successful, and no patients suffered significant complications. Chimeric free flaps based on the subscapular system offer a valuable secondary strategy for reconstruction of composite defects of the upper face when other options have been exhausted through previous efforts.

Total autogenous mandibular reconstruction using virtual surgical planning.

Free fibula transfer has become the workhorse in mandibular reconstruction. Total mandibular reconstruction is an uncommon procedure with added complexity. Numerous techniques have been described for such reconstruction, many requiring a temporomandibular joint prosthesis. We present a novel method where simultaneous bilateral free fibula transfer utilizing preoperative virtual surgical planning was used to produce a total autogenous reconstruction. The virtual surgical planning allows to effectively quantify the bone stock required preoperatively and facilitates intraoperative modeling of the fibula. Therefore, a more anatomically correct reconstruction is obtained resulting in improved functional and aesthetic outcomes.

Composite fronto-orbital reconstruction using a subscapular chimeric flap.

Composite defects of the fronto-orbital region represent a reconstructive challenge. Total autogenous reconstruction requires a thin pliable skin flap along with a bony component that can be osteotomized predictably. The thoracodorsal artery perforator/scapular bone chimeric flap provides a reliable single-stage method to cover difficult composite forehead defects where local options are unsuitable or have been exhausted. We present a patient with a traumatic fronto-orbital defect that has been successfully reconstructed using this flap. The report of this case illustrates well the versatility of the subscapular system as a donor site for difficult composite posttraumatic defects where tissue components need to be inset in a complex three-dimensional fashion.

Complications of hydroxyapatite bone cement in secondary pediatric craniofacial reconstruction.

Hydroxyapatite cement has become a popular alternative to bone grafts in reconstructing the calvarium. Although animal studies have shown promising results with use of hydroxyapatite, human clinical studies have shown mixed results including significant rates of infection. This is a retrospective chart review during a 7-year period (1997-2003) of 20 patients who underwent secondary forehead cranioplasty with hydroxyapatite cement (Norian Craniofacial Reconstruction System). Basic demographics including age, sex, and diagnosis were identified. Characteristics of the defects were recorded including size, location, and depth (full versus partial thickness). The volume of hydroxyapatite and any adjunctive procedures were identified. The postoperative course was analyzed for length of follow-up and the presence of infections.Twenty patients were identified in which Norian had been used and 3 patients were lost to follow-up. Secondary forehead asymmetry was the most common presentation. The mean volume of hydroxyapatite used was 24.4 mL. All patients had initially acceptable aesthetic results. Of the 17 patients, 10 (59%) ultimately had infectious complications. Infection occurred on a mean of 17.3 months after surgery (range, 4 mo to 4 y), and the mean amount of hydroxyapatite used was 32.5 mL (infections) versus 14.3 mL (no infections). Of the 10 patients with complications, 9 required surgical debridement and subsequent delayed reconstruction. Although hydroxyapatite cement can yield excellent aesthetic results, its use in secondary reconstruction has yielded unacceptably high infection rates leading to discontinuation of its use in this patient population.