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INTRODUCTION: Heterotopic ossification is a pathologic extra-skeletal bone formation as a form of aberrant repair process with acquired or genetic etiologies. In plastic surgery, it has been well-described in the burn and trauma patients. Rarely, it can happen along the vascular pedicle of free tissue transfer, and when it happens, it is most commonly in head and neck reconstruction. CASE PRESENTATION: Here we present a case of complete extensive heterotopic ossification of the entire vascular pedicle from the anastomosis to the bone in an osteocutaneous free fibula flap (FFF). The fibula was used as a 2-segment reconstruction for a maxillary defect resulting from a self-inflicted gunshot wound. The skin paddle was used to reconstruct the anterior palatal defect. DISCUSSION: Heterotopic ossification of the FFF vascular pedicle is most reported in the head and neck reconstruction cases. It is rare, but when it happens, it occurs earlier, more commonly, and more extensively in cases of maxillary reconstruction than in cases of mandibular reconstruction. Flap loss due to this sequela has not been reported, and surgical debridement is indicated only when symptomatic. CONCLUSION: Heterotopic ossification of an FFF vascular pedicle is a rare but well-described entity. The periosteal bone formation capacity preservation after revascularization of the flap is thought to be one of the major etiologies of this phenomenon. Hence, some have suggested a modification in the harvesting technique of the FFF that could mitigate return to the operating room, especially when it is for maxillary reconstruction in the trauma patient. Keywords: Keywords: free fibula flap, heterotopic ossification, maxillary reconstruction, mandibular reconstruction.
RESUMO
BACKGROUND: LeFort I osteotomy (LF1) and bilateral sagittal split osteotomy (BSSO) have unique operative challenges and inherent anatomic considerations that predispose to certain adverse outcomes, yet their respective complication profiles continue to be debated given conflicting results from single-center investigations. The purpose of this study is to perform a multi-institutional analysis of complications, socioeconomic trends, and financial charges associated with orthognathic surgery. METHODS: A retrospective cohort study was conducted of orthognathic procedures performed in the United States from 2010 through 2020 using the Pediatric Health Information System. Patients younger than 12 years of age were excluded. Medical complications, surgical complications, and admission costs were compared across procedures. Socioeconomic determinants and trends across regions of the country were also analyzed. RESULTS: During the study interval, 6640 patients underwent orthognathic surgery, including LF1 (59.2%, n=3928), BSSO (14.4%, n=959), and double-jaw surgery (26.4%, n = 1753). Patients undergoing LF1 were more likely to experience overall complications ( P <0.001), infections ( P <0.001), and blood transfusions ( P <0.001) than those undergoing BSSO. High-volume hospitals were more likely to perform double-jaw procedures than other hospitals ( P <0.001), yet high-volume hospitals were less likely to have surgical complications ( P =0.014). Patient admission charges related to orthognathic operations at high-volume hospitals were less than other hospitals ( P <0.001). Household income was higher for orthognathic procedures performed at high-volume hospitals ( P <0.001). White patients were 1.5 times more likely to choose a farther, higher volume hospital for orthognathic surgery than the one locally available ( P =0.041). CONCLUSIONS: LeFort I osteotomy procedures had higher infection and transfusion rates than BSSO procedures. High-volume hospitals were more likely to perform double-jaw procedures, yet high-volume hospitals had fewer complications and decreased admission charges. Future study will be needed to further elucidate case-mix index details and socioeconomic determinants of health contributing to these disparities.
