Bipedicled Scrotal Flap for Penile Resurfacing.

BACKGROUND: Acquired penile defects can be secondary to various pathologic conditions, including infection, scar, or complications following urologic procedures. Penis defects with skin deficit carry a distinct challenge for reconstructive surgeons. Scrotal flaps can provide reliable coverage and can restore distinct qualities of native penile skin. METHODS: A series of patients presented with a variety of acquired penile defects. Each of these patients underwent staged bipedicle scrotal flap surgery for coverage by the senior author. RESULTS: Eight patients underwent bipedicle scrotal flap reconstruction for penile defects with a skin deficit. All eight patients had satisfactory outcomes postoperatively. Only two of the eight patients had minor complications. CONCLUSIONS: For select patients presenting with underlying deficit of penile skin, bipedicle scrotal flaps prove to be a safe, reproducible, and reliable reconstructive technique for penile resurfacing. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Free Your Mind, Not Your Flap.

The pedicled flap has been a mainstay of soft tissue reconstruction since the earliest days of plastic surgery. Advances in surgical technology and skill have led to an erosion in the use of pedicled flaps in favor of increasingly popular free tissue transfers. Still, regional flaps without microvascular anastomosis remain a valuable reconstructive tool. Although still requiring microsurgical skills, these flaps are of particular benefit in patients with few or poor quality recipient vessels, in those who cannot tolerate antiplatelet therapy, and in those who cannot tolerate the often-extended anesthesia time necessitated by microvascular anastomosis. Furthermore, pedicled flaps may significantly reduce total cost of a reconstruction procedure with similar outcomes. In this case series, we report challenging scenarios where microsurgical approaches may have been typical choices but were instead reconstructed by pedicled options with desired outcomes. Difficult soft tissue defects were successfully reconstructed with a variety of pedicled flaps. Soft tissue transfers to the abdomen, flank, shoulder, and back are presented. None of the reconstructions required microvascular anastomosis.

Facial Transplantation: Nonimmune-Related Hyperacute Graft Failure-The Role of Perfusion Injury: A Case Report.

BACKGROUND: The aim of this study was to report the first case of acute facial allograft transplantation (facial allograft transplantation) failure with allograft removal and autologous free-flap reconstruction. METHODS: A 49-year-old female patient affected by neurofibromatosis type 1 with a massive neurofibroma infiltrating the whole left hemiface was planned for FAT for the left hemiface including the auricle, all skin and soft tissues from the temporal region, periorbital and nasal region, and up to the perioral area. The maxillary process of the zygomatic bone, left hemimaxilla, and hemimandible from contralateral parasyphysis to the incisura mandibulae were also included. RESULTS: Total surgical time was 26 hours. There were 2 intraoperative arterial thromboses that were solved with new anastomoses and sufficient flap perfusion. On postoperative day 2, the allograft became pale with suspected arterial occlusion and the patient returned to the operative room for exploration no flow into the FAT was found. The allograft was removed and the recipient site reconstructed with a skin-grafted composite left latissimus dorsi-serratus anterior flap. CONCLUSIONS: Hyperacute loss of FAT is a very dramatic event, and the activation of a backup surgical plan is crucial to save patient's life, give a reasonable temporary reconstruction, and return on the waiting-list for a second face transplantation.

All hands on deck: Hand replantation versus transplantation.

OBJECTIVES: Our hands play a remarkable role in our activities of daily living and the make-up of our identities. In the United States, an estimated 41,000 individuals live with upper limb loss. Our expanding experience in limb transplantation-including operative techniques, rehabilitation, and expected outcomes-has often been based on our past experience with replantation. Here, we undertake a systematic review of replantation with transplantation in an attempt to better understand the determinants of outcome for each and to provide a summary of the data to this point. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted PubMed searches from 1964 to 2013 for articles in English. In total, 53 primary and secondary source articles were found to involve surgical repair (either replantation or transplantation) for complete amputations at the wrist and forearm levels. All were read and analyzed. RESULTS: Hand replantations and transplantations were compared with respect to pre-operative considerations, surgical techniques, post-operative considerations and outcomes, including motor, sensation, cosmesis, patient satisfaction/quality of life, adverse events/side effects, financial costs, and overall function. While comparison of data is limited by heterogeneity, these data support our belief that good outcomes depend on patient expectations and commitment. CONCLUSION: When possible, hand replantation remains the primary option after acute amputation. However, when replantation fails or is not possible, hand transplantation appears to provide at least equal outcomes. Patient commitment, realistic expectations, and physician competence must coincide to achieve the best possible outcomes for both hand replantation and transplantation.

Nasal Reconstruction: Current Overview.

The nose, with its conspicuous location, intricate convexities, and delicate 3-dimensional structure, continues to challenge the reconstructive surgeon. Today, there are a myriad of options available for reconstruction. The practitioner must take into account the location of the defect as well as the components needed to be restored. This article addresses the current practices in nasal reconstruction, including the different strategies for skin coverage, nasal lining, and structural support. We discuss both the newest techniques as well as basic principles of this long-standing procedure.

Trismus in Face Transplantation Following Ballistic Trauma.

BACKGROUND: Trismus can be a challenging consequence of ballistic trauma to the face, and has rarely been described in the setting of face transplantation. Almost half of all current face transplant recipients in the world received transplantation to restore form and function after a ballistic injury. Here we report our experience and challenges with long standing trismus after face transplantation. METHODS: We reviewed the medical records of our face transplant recipients whose indication was ballistic injury. We focused our review on trismus and assessed the pre-, peri- and postoperative planning, surgery and functional outcomes. RESULTS: Two patients received partial face transplantation, including the midface for ballistic trauma. Both patients suffered from impaired mouth opening, speech intelligibility, and oral competence. Severe scarring of the temporomandibular joint (TMJ) required intraoperative release in both patients, and additional total condylectomy on the left side 6 months posttransplant for 1 patient. Posttransplant, both patients achieved an improvement in mouth opening; however, there was persistent trismus. One year after transplantation, range of motion of the jaw had improved for both patients. Independent oral food intake was possible 1 year after surgery, although spillage of liquids and mixed consistency solids persisted. Speech intelligibility testing showed impairments in the immediate postoperative period, with improvement to over 85% for both patients at 1 year posttransplant. CONCLUSIONS: Ballistic trauma to the face and subsequent reconstructive measures can cause significant scarring and covert injuries to structures such as the TMJ, resulting in long standing trismus. Meticulous individual planning prior to interventions such as face transplantation must take these into account. We encourage intraoperative evaluation of these structures as well as peri- and postoperative treatment when necessary. Due to the nature of the primary injury, functional outcomes after face transplantation in these patients may differ substantially from those of other indications.

The Use of Prefabricated Flaps in Burn Reconstruction.

This article describes the use of prefabricated flaps in burn reconstruction. Several case examples are provided that demonstrate the versatility and power of this approach to restoration of form and function after burn injury.

Microsurgical Burn Reconstruction.

The treatment of burn-related wounds requires consideration of several factors, including defect size, available donor sites, exposure of critical structures, and the ultimate functional and aesthetic result of reconstruction. Although skin grafts and locoregional flaps are workhorses in burn reconstruction, they have inherent limitations that can directly impact reconstructive outcomes. Microsurgical free tissue transfer represents a viable option for the reconstruction of burn-related wounds in certain patients. Each anatomic region of the body has unique challenges that must be addressed to achieve a successful reconstruction. Therefore, the choice of free flap must be individualized to the wound and patients.

Management of Rhinophyma: Outcomes Study of the Subunit Method.

BACKGROUND: Rhinophyma causes a nasal deformity and functional airway obstruction. Partial excision (eg, tangential) with secondary healing commonly removes hypertrophic soft tissues but does not improve nasal support. The subunit method for rhinophyma uses 6 nasal flaps to provide exposure for removal of rhinophymatous tissue and enhance structure. The purpose of this study was to evaluate outcomes of subunit method. METHODS: Medical records of patients with rhinophyma treated with the subunit method between 2013 and 2016 were analyzed. The technique comprises degloving the distal half of the nose by elevating 6 subunit-based flaps; debulking phymatous tissues to perichondrium; enhancing nasal support with sutures/cartilage grafts; trimming excess skin; and redraping the soft tissues. Patient age, gender, need for cartilage grafts or skin grafts, revisions, and follow-up were assessed. RESULTS: The study comprised 8 patients (6 male). Mean age was 63 years (range 34-72). All individuals had interdomal sutures for tip enhancement and 4 patients underwent cartilage grafts (alar batten) to correct external valve collapse. One patient had 2 subunits (alar) replaced with skin graft. Average follow-up was 1.6 years (range 0.2-3.7). Six patients underwent revisional procedures primarily to modify the scar between the dorsum and tip subunits. CONCLUSION: The subunit method addresses the 3 fundamental problems of the rhinophymatous nose: hypertrophic sebaceous tissues, excess skin, and destruction of support. Most patients may benefit from a minor revisional procedure to optimize the result. Individuals should be counseled that operation will likely require 2 stages.

The Sternum-Nipple Distance is Double the Nipple-Inframammary Fold Distance in Macromastia.

BACKGROUND: Reduction mammaplasty is one of the most commonly performed plastic surgery operations. For a majority of techniques, the most common long-term complication is pseudoptosis. It has previously been proposed that upper breast suspensory ligaments (SL) are weaker than lower breast SL. We tested this hypothesis through anthropometry of the proxies for upper and lower SL strength: the sternal notch-nipple (SN-N) distance and the nipple-inframammary fold (N-IMF) distance, respectively. METHODS: An institutional review board-approved retrospective review of patients undergoing reduction mammoplasty in an academic faculty practice between 2008 and 2015 was conducted. Patient demographics included age, race, and body mass index (BMI); patient comorbidities included smoking status, diabetes, and hypertension. Breast anthropometric measurements included SN-N and N-IMF. Sternal notch-nipple was used as the primary metric of the upper SL strength, whereas N-IMF was used as the primary metric of the lower SL strength. Intraoperative details included reduction technique and resection mass. Postoperative complications were recorded, including nipple areola complex necrosis and hematoma. Linear regression analysis was performed with the primary endpoint of the relationship between SN-N and N-IMF distance in macromastia. RESULTS: Data from 208 patients, totaling 400 individual breast measurements, were collected. The mean SN-N length was 35.1 cm, mean N-IMF length was 16.0 cm, and mean resection weight was 1094 g. Linear regression found that N-IMF distance could be predicted as 45% of the SN-N distance (N-IMF = 0.454 * SN-N). This was a strong relationship, demonstrated by univariate analysis of SN-N and N-IMF (R, 0.624; P < 0.001). A Wise pattern was used in 89.9% of cases; an inferior pedicle was used in 83.7% of cases. Nipple areola complex necrosis occurred in 15 breasts (3.75%). Sternal notch-nipple (R, 0.127; P = 0.011) and N-IMF (R, 0.119; P = 0.017) were both predictive of nipple areola complex necrosis (Table 4). CONCLUSIONS: In our series, the N-IMF distance increased 0.45 cm for every 1 cm increase in the SN-N distance. This relationship strengthens our primary hypothesis that the lower pole ligaments stretch at a significantly slower rate than the upper pole ligaments. Taking this into consideration, we suggest that surgeons seeking to minimize pseudoptosis rates should favor techniques that minimally disrupt the lower SL.

Osteocutaneous Second-Toe Free Flap as Alternative Option for Repair of Anterior Oronasal Fistula: Long-Term Results in Selected Patients.

INTRODUCTION: Palatal fistulas anterior to the incisive foramen, generally seen as a complication of cleft lip and cleft palate repair, can be extremely difficult to repair. The requirements of the defect necessitate nasal lining, oral lining, and bone for maxillary arch continuity. Local pedicled flap has limited use in such patients with extensive scarring from previous surgeries. The authors have recently described a technique involving osteocutaneous free-tissue transfer of second toe for anterior oronasal fistulas. METHODS: The authors describe their experience of patients with anterior oronasal fistula who underwent osteocutaneous free-tissue transfer of second toe. Between 1991 and 2014, 3 patients with oronasal fistulas were operated utilizing bilaminar osteocutaneous free tissue transfer. Described are the surgical decision making, postoperative course, and surgical outcomes. RESULTS: The mean age of the patients at the time of the procedure was 45.3 years with a mean follow-up of 12.6 years. All the patients had significant improvement of their regurgitation and speech difficulty. One of the patients with very large fistula had recurrence of the fistula which was repaired by local advancement of the original free flap. CONCLUSIONS: Use of osteocutanous second-toe free flap can provide complete coverage of the fistula with nasal and oral skin lining and provides an alternative option for complicated anterior oronasal fistula.

Impact of Prior Unilateral Chest Wall Radiotherapy on Outcomes in Bilateral Breast Reconstruction.

BACKGROUND: The purpose of this study was to evaluate the impact of prior unilateral chest wall radiotherapy on reconstructive outcomes among patients undergoing bilateral immediate breast reconstruction. METHODS: A retrospective evaluation of patients with a history of unilateral chest wall radiotherapy was performed. In each patient, the previously irradiated and reconstructed breast was compared to the contralateral nonirradiated side, which served as an internal control. Descriptive and bivariate statistics were computed. Multiple regression statistics were computed to identify adjusted associations between chest wall radiotherapy and complications. RESULTS: Seventy patients were included in the study. The mean follow-up period was 51.8 months (range, 10 to 113 months). Thirty-eight patients underwent implant-based breast reconstruction; 32 patients underwent abdominal autologous flap reconstruction. Previously irradiated breast had a significantly higher rate of overall complications (51 percent versus 27 percent; p < 0.0001), infection (13 percent versus 6 percent; p = 0.026), and major skin necrosis (9 percent versus 3 percent; p = 0.046). After adjusting for age, body mass index, reconstruction method, and medical comorbidities, prior chest wall radiotherapy was a significant risk factor for breast-related complications (OR, 2.98; p < 0.0001), infection (OR, 2.59; p = 0.027), and major skin necrosis (OR, 3.47; p = 0.0266). There were no differences between implant-based and autologous reconstructions with regard to complications (p = 0.76). CONCLUSION: Prior chest wall radiotherapy is associated with a 3-fold increased risk of postoperative complications following immediate breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A Retrospective Analysis of Secondary Revisions after Face Transplantation: Assessment of Outcomes, Safety, and Feasibility.

BACKGROUND: Face transplantation has emerged as a viable option for certain patients in the treatment of devastating facial injuries. However, as with autologous free tissue transfer, the need for secondary revisions in face transplantation also exists. The authors' group has quantified the number of revision operations in their cohort and has assessed the rationale, safety, and outcomes of posttransplantation revisions. METHODS: A retrospective analysis of prospectively collected data of the authors' seven face transplants was performed from April of 2009 to July of 2015. The patients' medical records, preoperative facial defects, and all operative reports (index and secondary revisions) were critically reviewed. RESULTS: The average number of revision procedures was 2.6 per patient (range, zero to five procedures). The median time interval from face transplantation to revision surgery was 5 months (range, 1 to 10 months). Most interventions consisted of debulking of the allograft, superficial musculoaponeurotic system plication and suspension, and local tissue rearrangement. There were no major infections, allograft skin flap loss, or necrosis. One patient suffered a postoperative complication after autologous fat grafting in the form of acute rejection that resolved with pulse steroids. CONCLUSIONS: Secondary revisions after face transplantation are necessary components of care, as they are after most conventional free tissue transfers. Secondary revisions after face transplantation at the authors' institution have addressed both aesthetic and functional reconstructive needs, and these procedures have proven to be safe in the context of maintenance immunosuppression. Patient and procedure selection along with timing are essential to ensure patient safety, optimal function, and aesthetic outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Psychosocial Outcomes after Bilateral Hand Transplantation.

UNLABELLED: Since the first successful hand transplantation in 1998, there have been multiple reports about surgical technique, transplant survival, and immunosuppression. However, very limited published data exist on psychosocial outcomes following hand transplantation. METHODS: We report psychosocial outcomes in a patient with bilateral hand transplants at the midforearm level with serial follow-ups over 3.5 years. Different metrics used to study psychosocial outcomes included the following: SF-12, CES-D, Dyadic Adjustment Scale, Rosenberg SE, and EQ-5D. RESULT: Preoperatively, our patient did not have any evidence of depression (CES-D = 3), had a nonstressful relationship with his spouse (Dyadic Adjustment Scale = 100), and self-esteem was in the normal range (Rosenberg SE = 21). These metrics and his additional scales (SF-12 MCS, EQ-5D, and EQ-VAS) did not change appreciably and were within the normal range for the entire duration of 3.5-year follow-up at all different time points. CONCLUSION: With the increasing popularity of hand transplantation and the increasing awareness of the importance of psychosocial parameters in overall success, appropriate, comprehensive, and standardized measurements are important. These should be an integral part of patients' screening and follow-up.

Use of Osteocutaneous Second-Toe Free Flap for Anterior Oronasal Fistulas.

Palatal fistula is a known complication of cleft lip-cleft palate repair. Fistulas anterior to the incisive foramen can be particularly difficult to repair because of the lack of available tissue. Adjacent tissue has inherent limitations, and multiple free-flap techniques have been described; however, there remains no single solution for this difficult problem. The authors present an alternative strategy of replacing "like with like" by using an osteocutaneous free tissue transfer of the second toe for anterior oronasal fistulas. Use of the osteocutaneous second-toe free flap provides skin lining to both the oral side and the nasal side to close oronasal fistulas. It also bridges the alveolar gap with vascularized bone. This flap can be considered as an elegant alternative for anterior oronasal fistulas.

Evolving options for breast reconstruction.

In summary, if the abdomen cannot be used for a donor site, alternative flap selection is based on individual patient anatomy and body habitus, targeting the buttocks and upper thigh. Intraoperative repositioning may be required for ease in flap harvest and donor site closure, adding time to the procedure. Flap dissection is performed in the subfascial plane to avoid injury to the perforator vessels. Deep suspension sutures may be required to maintain the gluteal fold location.

Utility of sentinel flaps in assessing facial allograft rejection.

BACKGROUND: Skin biopsies are critical for histologic evaluation of rejection and proper treatment after facial allotransplantation. Many facial allografts provide only limited skin area, and frequent biopsies may also compromise aesthetic outcome. Sentinel flaps, recovered as free fasciocutaneous radial forearm flaps, have been used for remote-site rejection monitoring. They maintain their axial blood supply, similar to facial allografts. The correlation between facial allografts and sentinel flaps in cases of rejection is presented. METHODS: The authors analyzed the experience of the Boston team's use of four sentinel flaps. Rejection was evaluated and results were compared for each time point. Sentinel flaps were used as functional flaps whenever possible. RESULTS: Results showed a reliable correlation between biopsy specimens taken from the facial allograft and sentinel flaps. During severe rejection episodes in 100 percent of biopsy pairs, both sites displayed a similar grade of rejection. In one case, clinical findings suggested rejection in the facial allograft but were unraveled as rosacea, because clinically there was no rejection displayed in the sentinel flap. CONCLUSIONS: The sentinel flap shows a reliable correlation to the facial allograft in cases of severe rejection, therefore providing a valuable tool for rejection monitoring in facial allotransplantation. Advantages of using these flaps include the avoidance of further surgical procedures to the primary vascularized composite allotransplant, additional use of the sentinel flap to repair damaged nonfacial sites, and its utility as both a clinical and histopathologic barometer of rejection and predictor of the potential existence of facial dermatitis unrelated to rejection. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Use of Video Clips to Assess the Outcomes of Bilateral Hand Transplantation.

Given the initial success of hand transplantation, there has been increased interest in determining functional independence and activities of daily living after hand transplantation. However, the metrics and methodologies used to study these outcomes have not yet been standardized. The goal of this article was to assess the role of video clips in assessing the outcomes of bilateral hand transplantation. We have performed 3 bilateral hand transplantations at our institution. Video clips were taken at standardized time points on our index bilateral hand transplantation patient, and the patient sent multiple home-video clips demonstrating new aspects of function when these improvements have occurred. The index patient demonstrated functional independence and activity of daily living performance without assistance in video clips ranging from 9 months to 2.5 years posttransplantation. He completed the 9-hole peg test with his left hand at 9 months follow-up and with both the hands by 1.5 years. His own video clips demonstrated his ability to perform spontaneous tasks including lawn mowing, driving and swimming. In our experience, the video tools aid in assessing outcomes of hand transplantation and may be incorporated along with multiple objective scoring tests. They can also be used to generate additional standardized tests for functional assessment and may allow retrospective grading as new scoring systems are developed.