Simultaneous Scalp, Skull, Kidney, and Pancreas Transplant from a Single Donor: Insights from a 5-Year Follow-Up.

SUMMARY: This report provides a 5-year follow-up on the first reported simultaneous scalp, calvarium, kidney, and pancreas transplant. The previously published case report represented both the first composite calvarial-scalp transplant and combination of a vascularized composite allotransplantation with double organ transplantation. Over the ensuing 5 years, the patient underwent a single episode of acute scalp rejection successfully managed with intravenous Solu-Medrol, one resection of a basal cell carcinoma on the native scalp, hardware removal, and bony contouring. In addition, the patient developed seizures secondary to delayed, postirradiation cerebral necrosis requiring craniotomy and resection. His seizures were ultimately controlled. Currently, more than 5 years after his multiorgan transplant, the patient continues to have excellent allograft function and a very satisfactory aesthetic outcome, demonstrating that in certain cases, combined vascularized composite allotransplantation with solid organ transplantation can be performed safely without compromising the solid organ transplantation.

Objectifying the Role of the Depressor Anguli Oris Muscle Using High-Resolution Ultrasound: A Prospective Study.

BACKGROUND: In the setting of facial palsy, synkinesis of the depressor anguli oris (DAO) muscle is a common pathology, impairing dynamic and resting facial symmetry.In this prospective study, the authors used high-resolution ultrasound (HRUS) to evaluate the morphologic features of DAO and to quantify bilateral differences in DAO cross-sectional diameter (CSD) in individuals with unilateral synkinesis. METHODS: From June of 2020 to May of 2021, 30 patients (19 women, 11 men) with clinically diagnosed unilateral synkinesis underwent evaluation with HRUS. DAO CSD was measured bilaterally, 1 cm inferior to the modiolus, in both the resting and smiling positions. RESULTS: The Sunnybrook Facial Grading System Synkinesis Score was 6.20 ± 2.48 (range, 0 to 10). DAO CSD at rest measured 2.41 ± 0.67 mm (range, 1.40 to 4.00 mm) on the control side and 2.66 ± 0.98 mm (range, 1.60 to 5.10 mm) on the affected side. On the control side, DAO CSD was reduced by -0.19 ± 0.43 mm (range, -1.10 to 1.12 mm) during smiling. In contrast, the synkinetic DAO CSD increased by 0.64 ± 0.38 mm (range, 0.00 to 1.59 mm) ( P < 0.001) with animation. The pattern of increased CSD in synkinetic DAO muscles and decreased or unchanged CSD on the control side during smiling was identified in 70% of patients. CONCLUSIONS: HRUS demonstrates increased CSD in synkinetic DAO muscles during active smiling. The opposite is true for DAO muscles on the control side, which exhibit decreased CSD with animation. HRUS can be performed preoperatively to objectify DAO dysfunction and guide targeted therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

Static Suspension of the Paralyzed Face Utilizing the Midfacial Corridor: Anatomic Evaluation and Surgical Technique.

BACKGROUND: Fascia lata and tendon grafts are frequently utilized to support the paralyzed midface and to extend muscular reach in McLaughin style, orthodromic temporalis transfers. The grafts are frequently placed in a deep subcutaneous positioning that can lead to the development of a, bowstring deformity in the cheek. This paper describes insertion of tendon grafts into the midfacial corridor collectively formed by the buccal, submasseteric and superficial temporal spaces. METHODS: Over a seven-year period, all patients that underwent insertion of facia lata and tendon grafts in the midfacial corridor were included. Demographic information, perioperative variables and clinical outcomes were collected and analyzed. RESULTS: A total of 22 patients were included with a mean age of 64.3 years (33-86). There were multiple etiologies for the facial weakness including acoustic neuroma (9.1%), Bell's palsy (13.6%), facial nerve schwannoma (9.1%), temporal bone fracture (4.6%) and malignancy (22.7%). Midfacial corridor grafts were utilized in combination with nerve transfers (V-VII and XII-VII) in nine patients, McLaughin style temporalis transfers in 12 and as a standalone procedure in one individual. During the study period, no patients exhibited a tethering, or concave deformity in the midface. Additionally, no impingement, difficulties with mastication, parotitis or hematoma were encountered. One patient developed a postoperative infection, that was successfully managed. CONCLUSION: Placement of tendon or fascia grafts for static support or tunneling of an orthodromic temporalis transfer through the midfacial corridor can be performed rapidly while providing midfacial support and avoiding the creation of visible cutaneous deformities.

Dual Innervation of Free Functional Muscle Flaps in Facial Paralysis.

Dual innervation in free muscle flap facial reanimation has been used to create a functional synergy between the powerful commissure excursion that can be achieved with the masseter nerve and the spontaneity that can be derived from a cross-face nerve graft. The gracilis has been the most frequently used muscle flap, and multiple combinations of neurorrhaphies have been described, including the masseter to the obturator (end-to-end) combined with a cross-face nerve graft to the obturator (end-to-side) and vice versa. Single and staged approaches have been reported. Minimally, dual innervation is as effective as using the motor nerve to masseter alone.

The Supercharged Pedicled Jejunal Flap for Total Esophageal Reconstruction: A Retrospective Review of 100 Cases.

BACKGROUND: When gastric pull-up is unsuccessful or unsuitable for total esophageal reconstruction, a supercharged pedicled jejunum can be used to reestablish gastrointestinal continuity. The authors reviewed their technique and outcomes of the supercharged pedicled jejunum for total esophageal reconstruction. METHODS: A retrospective review of a prospectively maintained database was performed of 100 patients who underwent supercharged pedicled jejunum for total esophageal reconstruction between 2000 and 2017 at the Texas Medical Center. Patient characteristics, technical details, and outcomes were analyzed. RESULTS: Mean patient age was 59.5 ± 11.4 years. Forty-two patients (42 percent) had surgical complications (18 percent at the recipient site, 13 percent at the donor site, and 11 percent at both). Medical complications occurred in 28 patients (28 percent). A major surgical complication occurred in 20 patients (20 percent). The average length of stay was 15 days (range, 6 to 152 days). At last follow-up, 20 patients (20 percent) had metastatic disease and six (6 percent) had local recurrence. Fifty-four patients (54 percent) died during the follow-up period. Of 79 patients with follow-up longer than 6 months, 68 (86 percent) tolerated a solid or soft oral diet, with a 16 percent tube feed-dependence rate. Overall survival at 1, 3, and 5 years was 78.8, 53.7, and 33.1 percent, respectively. The median survival time was 38.7 months. CONCLUSIONS: The authors present their experience with 100 supercharged pedicled jejunums for total esophageal reconstruction. Functional outcomes are comparable to, or better than, other salvage modalities. With careful multidisciplinary planning and meticulous, well-orchestrated surgical technique, swallowing function can be restored to provide quality of life in patients with few remaining surgical options.

Use of sternal plate for pectus excavatum repair in adults leads to minimal postoperative pain.

Pectus excavatum is a chest wall deformity that results in caved-in or sunken appearance of lower half of anterior chest. Surgical treatment is favored when functional or cosmetic concerns arise. We present a case and series of six patients (mean haller index: 4.28) who had repair with minimal pleural disruption and sternal plate. After a broad bilateral inframammary skin incision, the anterior aspect of sternum is identified and incised. Next, the surgeon hyperextends and fixates the bone in its desired position by applying manual dorsal pressure through a small intercostal incision. Superior and inferior fasciocutaneous flaps are raised and then advanced to reconstruct the soft tissue defect. All patients had durable repair of the chest wall abnormalities and they had minimal pain during the postoperative period. No analgesia medication was necessary 1 month post-operatively. This may provide significantly less pain compared to the Nuss or Ravitch procedures to fix Pectus excavatum.

Simultaneous Scalp, Skull, Kidney, and Pancreas Transplant from a Single Donor.

BACKGROUND: Vascularized composite allotransplantation is an emerging field, but the complications of lifelong immunosuppression limit indications. Vascularized composite allotransplantation in solid organ recipients represents a unique opportunity because immunosuppression has already been accepted. This report of a simultaneous scalp, skull, kidney, and pancreas transplant represents both the first skull-scalp transplant and combination of a vascularized composite allotransplantation with double organ transplantation. METHODS: A previous recipient of a kidney-pancreas transplant presented with osteoradionecrosis of the calvaria and a large area of unstable scalp following successful, curative treatment of a scalp tumor. His kidney and pancreas functions were also critically poor. A multidisciplinary, multi-institutional plan was developed to perform a simultaneous scalp, skull, and repeated kidney and pancreas transplantation, all from a single donor. RESULTS: Eighteen months after the patient was listed with the United Network for Organ Sharing, a donor was identified and the multiorgan vascularized composite allotransplantation was performed. Twenty physicians and 15 hours were required to perform donor and recipient procedures. The patient recovered well and was discharged on postoperative day 15. He has had one episode of scalp rejection confirmed by biopsy and treated successfully. His creatinine value is currently 0.8 mg/dl, from 5.0 mg/dl, and his blood glucose levels are normal without supplemental insulin. Aesthetic outcome is very satisfactory. The patient is now 1 year post-transplantation and doing well. CONCLUSIONS: Vascularized composite allotransplantation in solid organ recipients is an expansion of current indications to already immunosuppressed patients. Rejection of the vascularized composite allotransplant without solid organ rejection can occur and is treatable. Methodical planning, an interdisciplinary approach, and careful management of all organs are critical to success. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Contemporary solutions for the treatment of facial nerve paralysis.

LEARNING OBJECTIVES: After reviewing this article, the participant should be able to: 1. Understand the most modern indications and technique for neurotization, including masseter-to-facial nerve transfer (fifth-to-seventh cranial nerve transfer). 2. Contrast the advantages and limitations associated with contiguous muscle transfers and free-muscle transfers for facial reanimation. 3. Understand the indications for a two-stage and one-stage free gracilis muscle transfer for facial reanimation. 4. Apply nonsurgical adjuvant treatments for acute facial nerve paralysis. SUMMARY: Facial expression is a complex neuromotor and psychomotor process that is disrupted in patients with facial paralysis breaking the link between emotion and physical expression. Contemporary reconstructive options are being implemented in patients with facial paralysis. While static procedures provide facial symmetry at rest, true 'facial reanimation' requires restoration of facial movement. Contemporary treatment options include neurotization procedures (a new motor nerve is used to restore innervation to a viable muscle), contiguous regional muscle transfer (most commonly temporalis muscle transfer), microsurgical free muscle transfer, and nonsurgical adjuvants used to balance facial symmetry. Each approach has advantages and disadvantages along with ongoing controversies and should be individualized for each patient. Treatments for patients with facial paralysis continue to evolve in order to restore the complex psychomotor process of facial expression.

Muscle flaps and their role in limb salvage.

Muscle flaps have proved to be a valuable and versatile tool in the surgical treatment of the severely compromised lower extremity. Utilized as both local pedicle flaps and free tissue transfers, muscles have been successfully employed to cover complex wounds, manage osteomyelitis, salvage infected vascular grafts, treat recalcitrant venous stasis ulcers, preserve amputation levels, and restore motion following compartment syndrome. Free flap pedicles have also been used in a flow-through fashion to create a distal arterial bypass. This article explores the multipurpose role of muscle flaps in limb salvage surgery and their beneficial physiologic characteristics in hostile wound environments.

Acellular dermal matrix and negative pressure wound therapy: a tissue-engineered alternative to free tissue transfer in the compromised host.

Free tissue transfer has revolutionized lower extremity reconstruction; however, its use in elderly patients with multiple medical problems can be associated with elevated rate s of perioperative morbidity and mortality. This study evaluates the use of acellular dermal matrix (ADM) in conjunction with negative pressure wound therapy (NPWT) and delayed skin graft application as an alternative to free tissue transfer in this compromised population. Bilayer, ADM (Integra, Plainsboro, NJ) was used in conjunction with NPWT (Wound V.A.C, Kinetic Concepts Inc., San Antonio, TX) to achieve vascularized coverage of complex lower extremity wounds with denuded tendon and bone in elderly, medically compromised patients. Following incorporation, the matrix was covered with split-thickness skin graft. Four patients (age range, 50 to 76 years) with multiple medical comorbidities were treated with the above protocol. The average time to complete vascularization of the matrix was 29 days. Definitive closure with split-thickness skin graft was achieved in three patients and one wound healed by secondary intention. No medical or surgical complications were encountered and stable soft tissue coverage was achieved in all patients. This early experience suggests that dermal substitute and NPWT with delayed skin graft application can provide a reasonable tissue-engineered alternative to free tissue transfer in the medically compromised individual.

Facial reanimation using the masseter-to-facial nerve transfer.

BACKGROUND: This article describes facial reanimation using the transfer of the trigeminal motor nerve branch of the masseter muscle (masseter nerve) to the facial nerve (masseter-to-facial nerve transfer). METHODS: A retrospective review was performed of 10 consecutive facial paralysis patients treated with a masseter-to-facial nerve transfer for reanimation of the midface and perioral region over a 7-year period. Patients were evaluated with physical examination, direct measurement of commissure excursion, and video analysis. RESULTS: All patients regained oral competence, good resting tone, and a smile, with a vector and strength comparable to those of the normal side. Motion developed an average of 5.6 months after masseter-to-facial nerve transfer, with 40 percent of patients developing an effortless smile by postoperative month 19. CONCLUSIONS: The masseter-to-facial nerve transfer is an effective method for reanimation of the midface and perioral region in a select group of facial paralysis patients. The technique is advocated for its limited donor-site morbidity, avoidance of interposition nerve grafts, and potential for cerebral adaptation, producing a strong, potentially effortless smile.

Reconstruction of full-thickness calvarial defect: a role for artificial dermis.

The reconstruction of scalp defects presents a clinical challenge. Free tissue transfer has played an increasingly important role in the reconstruction of complex scalp defects. In many cases, patient medical comorbidities along with the length of the operative procedures incurs significant patient risk. Artificial dermis, used extensively in burn reconstruction, has emerged as a reconstructive option for the coverage of many complex posttraumatic and postoncologic defects; however, none have described its use for the reconstruction of full-thickness calvarial defects with exposed dura.We report a clinical case of an elderly, medically compromised patient with a full-thickness scalp defect, who underwent successful reconstruction with artificial dermis.The use of artificial dermis and subsequent skin grafting, as was performed in this case, provides a less invasive, less intensive, and satisfactory means of soft tissue reconstruction for full-thickness calvarial defects.

Management of posttraumatic extensive bone loss and osteomyelitis using a customized articulating knee spacer.

The combination of infection and extensive bone loss presents a challenging reconstructive situation for surgeons performing total knee arthroplasty (TKA). We describe the case of a patient that suffered a grade III open fracture of the tibial plateau and developed a recurrent infection which resulted in loss of the proximal 15 cm of the tibia. Our solution was interim use of custom-made articulating, antibiotic-impregnated spacers followed by a structural tibial allograft and hinged TKA. At 2-year follow-up the patient is infection-free and is able to ambulate without the use of support.

Indications and outcomes of free tissue transfer to the lower extremity in children: review.

Thirty-four free tissue transfers for reconstruction of various tissue defects to the lower extremities were performed in 32 children over a 20-year period (1980 to 1999). Patient ages ranged from 3 to 19 years (mean: 10.8 years). Four donor sites were used: gracilis muscle, latissimus dorsi muscle, iliac crest osteocutaneous, and vascularized fibula. Fourteen patients had tissue defects related to trauma: nine received a gracilis flap; five received a latissimus dorsi flap. Five patients had tissue defects related to malignant tumor resection: three patients with Ewing's sarcoma received free fibulae; one patient with an osteogenic sarcoma received a gracilis flap, and another received an iliac crest osteocutaneous flap. Fifteen patients had congenital anomaly-related tissue defects: five with talipes equinovarus received gracilis flaps; ten with congenital tibial pseudoarthrosis received free fibulae. Vascular outcome was assessed based on the achievement of flap perfusion and post-surgical vascular revisions. Complete flap survival was achieved in 32 cases (85.3 percent); partial flap loss in three cases (8.82 percent); and complete flap loss in two cases (5.9 percent). Early revision surgery for the five partial or failed flaps consisted of debridement and split-thickness skin graft or flap removal. No patients required vascular take-backs or experienced vascular spasm. There were no systemic problems associated with the long and complex surgeries. Functional outcome was assessed based on ambulation, post-surgical complications, and whether the flap served its intended purpose. Ambulation was achieved in all cases. Functional surgical revisions were required in 32.4 percent of cases, and included scar revisions, flap debulking, bone grafts, and pin insertion. The most prevalent morbidity was persistent leg-length discrepancy (35.3 percent of cases). Only one successful flap was unable to meet its intended purpose, as a tibial pseudoarthrosis persisted, despite initial excision and a well-perfused reconstruction. Results show that free tissue transfer is safe and dependable for tissue defects of the lower extremity in children. From the authors' experience, free flaps used for the repair of defects from congenital tibial pseudoarthrosis have a high vascular success, but also require an extensive rehabilitation course, with only moderate functional success. There was no significant difference between flap surgeries performed immediately, intermediately, or late after trauma. These procedures have a wide range of indications and, despite the need for surgical revision and an extensive rehabilitation course, functional and vascular success can be achieved.

Persistent cutaneous manifestations of hyperoxaluria after combined hepatorenal transplantation.

A 30-year-old woman with primary hyperoxaluria type I (PHI) developed livedo reticularis with overlying ulcerations on her legs 16 months after receiving a liver-kidney transplant. A skin biopsy of the lesion showed deposits of calcium oxalate. To our knowledge, there have been no reported cases of livedo reticularis in patients with PH1 after a combined liver-kidney transplant.

Donor nerve selection in facial reanimation surgery.

The motor components of local cranial nerves provide a series of options for the surgical rehabilitation of the paralyzed face. Nerve donor sites vary with respect to their motor power, functional deficit, and synergy with facial expression. A thorough understanding of each donor nerve's strengths and weaknesses facilitates the selection process. Technical modifications to reduce donor site morbidity and the emerging role of the masseter nerve are examined.

Complex midface reconstruction: maximizing contour and bone graft survival utilizing periosteal free flaps.

Midfacial bone and soft tissue defects present a unique challenge because they require a complex arrangement of tissues in a relatively limited space. This may be difficult to achieve with free osteocutaneous flaps. The use of bone grafts allows greater flexibility in reconstruction but is limited by graft resorption. This is the report of midface reconstruction using a large iliac crest graft covered with a radial forearm free fascioperiosteal flap to augment graft survival. Histopathology and patient follow-up evaluation are presented demonstrating viable bone throughout the graft at biopsy 4 months postoperatively.