Metacarpophalangeal joint reconstruction using a costal osteochondral graft: A case report.

RATIONALE: The conventional treatment of giant cell tumors is intralesional curettage with local adjuvant therapy. Because hand tumors have a high local recurrence, the primary goal for treating tumors of the hand is to eradicate the lesion. PATIENT CONCERNS: To preserve the metacarpophalangeal (MCP) joint function as well as avoid further recurrence after surgery. DIAGNOSES: The giant cell tumor invades the patient's MCP joint in an index proximal phalanx. INTERVENTIONS: Using computer-aided design and three-dimensional printing techniques, we reformed the original shapes of the MCP joint and its peripheral bone to replica models. The surgeon then performed an en bloc resection and proximal phalanx with MCP joint reconstruction by fabricating the patient's costal osteochondral graft during the operation. OUTCOMES: After 6 months of rehabilitation, the patient's finger functions could pinch and grasp objects naturally. At the 1-year follow-up, the range of motion of the MCP, proximal interphalangeal, and distal interphalangeal joints improved from flexion of 35° to 60°, 75° to 85°, and 60° to 80°, respectively. The hand function achieved the mean performance of non-preferred hands for young females at the postoperative 3-year follow-up. LESSONS: The customized prototyping technique has the potential to replica the original patient's bony graft to reach the goal of minimizing the defects at the donor site and maximizing the function of the reconstructed MCP joint.

Operative technique: Pectoralis major flap with rib.

The osteomyocutaneous pectoralis major flap was first described in 1980 and provides a single stage reconstructive option for poor free flap or pectoralis major flap with reconstruction plate candidates requiring bony reconstruction. The flap provides good functional and cosmetic outcomes in appropriately selected patients. We describe the indications and operative techinique for harvesting this flap in written and video format.

Outcomes of Calvarial and Soft-Tissue Reconstruction with Latissimus Dorsi-Rib Osteomyocutaneous Free Flap.

BACKGROUND: The latissimus dorsi-rib osteomyocutaneous free flap (LDRF) has been used for autologous reconstruction of large composite calvarial and scalp defects. In this study, the authors aim to present clinical and patient-reported outcomes after LDRF reconstruction. METHODS: An anatomical study was conducted to evaluate the distribution of the connecting perforators between the thoracodorsal and intercostal systems. An institutional review board-approved retrospective review of 10 patients who underwent LDRF with one or two ribs for treatment of cranial defects was conducted. Patient-reported outcomes regarding quality of life, neurologic status, and functional status were evaluated using validated surveys. One-way analysis of variance and post hoc Tukey tests were used for anatomical outcomes. Preoperative and postoperative scores were compared using paired t tests. RESULTS: The tenth rib (4.65 ± 2.01) followed by the ninth rib (3.7 ± 1.63) had the highest number of perforators. A combination of the ninth and eleventh ribs exhibited maximal perforator number and pedicle length. All patients had stable LDRF reconstructions. Eight patients completed both preoperative and postoperative questionnaires; Median clinical follow-up was 48 months (range, 34 to 70 months). Scores trended toward improvement but did not reach statistical significance on the Karnofsky Performance Scale ( P = 0.22), the Functional Independence Measure (Motor, P = 0.52; Cognitive, P = 0.55), or the Headache Disability Index ( P = 0.38). The minimum clinically important difference was surpassed, demonstrating improvement of function for 71% of patients on the Barthel Index and 63% on the Selective Functional Movement Assessment test. CONCLUSION: The LDRF can improve cognitive and physical functional status in complex patients with prior failed reconstructions for composite scalp and skull defects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Pedicled osteomyocutaneous pectoralis major flap with osseous rib harvest for salvage mandibular reconstruction: Case and technique.

In the era of free flap reconstruction, mandibular defects are routinely reconstructed with osseous free flaps, and non-free flap bony reconstruction options are limited. A patient with T4N0 mandibular squamous cell carcinoma underwent resection with fibula free flap reconstruction of a parasymphyseal to angle defect. After free flap failure due to venous congestion, the flap was explanted. He declined additional free flap reconstruction and elected to proceed with pedicled osteomyocutaneous pectoralis major with rib. In this case presentation, we discuss the technical details of harvest of this flap using the 6th rib. The pedicled osteomyocutaneous pectoralis major flap with osseous rib harvest, which is infrequently described in the literature, remains a viable option for bony reconstruction, particularly in the salvage setting.

The Multiple Rib Osteomyocutaneous Split Latissimus Dorsi Flap for Calvarial Reconstruction: Indication, Operative Technique, and Review of Literature.

Major complex cranial defects may be challenging for the reconstructive microsurgeon. Affected patients often present with impaired soft tissues including dura exposure or fistulas. The lacking structural bony support may cause severe neurological issues and in select patients, there is a need for well-vascularized autologous tissue repair. The authors herein elucidate the role of the multiple rib osteomyocutaneous split latissimus dorsi flap for reconstruction of composite skull defects, providing an indication, an exemplary case, operation technique, and literature review. A 40-year-old woman after anaplastic oligodendroglioma resection suffered multiple extrusions and allograft cranioplasty infections. The defect was reconstructed with an osteomyocutaneus split latissimus dorsi flap including costae 3 ribs and a skin island. The included ribs were nourished via the anterior periosteum, while the posterior periosteum was left in place for the protection of the pleura parietalis. A proper amount of craniomedial latissimus dorsi muscle was spared to reduce donor site morbidity. The patient presented after 6 months with stable bony and soft tissue conditions without neurological symptoms, and acceptable donor site morbidity. After failed alloplastic cranioplasties, the free latissimus dorsi flap including vascularized ribs is well suitable for coverage of large compound cranial defects, providing skeletal support, improved contour, and enhanced functional outcome.

Use of a Box-cut Osteotomy Preserving Collateral Ligaments in Costal Osteochondral Graft Reconstruction of Proximal Interphalangeal Joint Cartilage Defects.

We report two patients with reconstruction of osteochondral defects of the proximal interphalangeal joint (PIPJ) using a costal osteochondral graft (COG). A box-cut osteotomy was done at the end of the phalanx preserving the lateral cortices and the insertion of the collateral ligaments. A COG was harvested from the rib, moulded and press fit into the groove formed by the box-cut osteotomy. The COG was fixed with mini screws in the coronal plane (dorsal to palmar) and the fixation off-loaded with an external fixator. This technique maintained the collateral ligament in-situ and is useful in reconstruction of chondral defects of the PIPJ. Level of Evidence: Level V (Therapeutic).

Vascularized Bone Flap Options for Complex Thoracic Spinal Reconstruction.

BACKGROUND: Osseous reconstruction following total spondylectomy/vertebrectomy in the thoracic spine is indicated to restore spinal stability. To assist with bony reconstruction, vascularized bone flaps including free vascularized fibula flaps and pedicled rib flaps can be used. However, there are limited data comparing various techniques. The authors aimed to evaluate the outcomes of free vascularized fibula flaps and pedicled rib flaps used for thoracic spinal reconstruction. METHODS: The authors reviewed 44 vascularized bone flaps [10 anterior pedicled rib flaps, 25 posterior pedicled rib flaps, and nine vascularized fibula flaps] for corpectomy defects spanning T1 to L1 between January of 1999 and June of 2018. Mean age and follow-up were 46 ±17 years and 74 ± 52 months, respectively. RESULTS: The union rate was 93 percent, with a similar mean time to union among the three groups: free vascularized fibula flaps, 9 ± 4 months; anterior pedicled rib flaps, 9 ± 6 months; and posterior pedicled rib flaps, 9 ± 5 months (p = 0.95). Surgical-site complications were found in 27 vascularized bone flaps (61 percent), and reoperations and revisions were performed in 14 (32 percent) and 10 (23 percent) vascularized bone flaps, respectively. No differences were identified among anterior pedicled rib flaps, posterior pedicled rib flaps, and vascularized fibula flaps with regard to complication, reoperation, and revision rates. CONCLUSIONS: Free vascularized fibula flaps and pedicled rib flaps provide durable reconstruction for thoracic spinal defects. Union, time to union, revision, and reoperation rates were similar among anterior and posterior pedicled rib flaps and vascularized fibula flaps. Given the variability in indication and defect types among the flap cohorts, the authors' results should be interpreted carefully as an insight into the outcomes of different vascularized bone flaps for the unique cases of thoracic spinal reconstruction rather than to compare the different flaps used. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Vascularized Prelaminated Thermoplastic Bioabsorbable Scaffold in Tracheal Reconstruction.

Successful tracheal reconstruction remains a challenging task for the reconstructive surgeon. A variety of techniques have been previously employed, using both autografts and allografts. The authors present a novel method for tracheal reconstruction utilizing a prelaminated fascial flap in conjunction with a bioabsorbable scaffold. Laryngoscope, 132:550-553, 2022.

Endoscopic Posterior Cricoid Split and Rib Graft Without Tracheostomy: Case and Literature Review.

Endoscopic posterior cricoid split and rib grafting (EPCS/RG) for the treatment of posterior laryngeal stenosis has some advantages over traditional open approaches, including improved surgical visualization and decreased morbidity. Many pediatric patients who undergo EPCS/RG have indwelling tracheostomy, which may be utilized to help manage the airway perioperatively. The role for de novo tracheostomy placement at the time of EPCS/RG is less clear. We present three cases from a tertiary children's hospital in which EPCS/RG was safely performed without tracheostomy. For patients with posterior laryngeal stenosis but without tracheostomy, EPCS/RG with endotracheal tube stenting might be a safe option. Laryngoscope, 131:E2599-E2602, 2021.

Costal osteochondral graft for a postoperative cartilage defect in a patient with polydactyly.

We present a case of a postoperative cartilage defect in a patient with polydactyly who was treated with a costal osteochondral graft. Excision of the radial digit and ligamentous periosteal flap with longitudinal osteotomy were performed when the patient was 1 year old. The alignment of the interphalangeal joint was straight after surgery, but the deviation gradually developed. A revision surgery using a costal osteochondral graft was performed when the patient was 3 years old. A satisfactory outcome was obtained at the 3-year follow-up. The authors suggest that a costal osteochondral graft may be a reasonable option for revision surgery for a postoperative cartilage defect.

Recurrent mandibular ameloblastoma in soft tissue and rib graft 17 years after initial presentation.

BACKGROUND: Ameloblastoma is the commonest odontogenic tumour of epithelial origin with a high incidence for developing local recurrence. We present a patient who developed local recurrence in both soft tissue and bone graft 17 years after the initial presentation. CASE PRESENTATION: A 75-year-old female with a previous history of right hemimandibulectomy and rib reconstruction for ameloblastoma in 1999 presented to our centre with a large cystic mouth floor swelling, biopsy from which revealed recurrent ameloblastoma. The patient underwent excision of the recurrent mass en bloc with the cystic swelling through oral and cervical approaches. The patient was discharged after 5 days with an uneventful postoperative course and with a free 2-year follow-up from further recurrence. CONCLUSION: Ameloblastoma is a locally aggressive tumour for which wide local excision with adequate margins is the best management approach. Recurrence of ameloblastoma even after adequate resection is not uncommon, and its management is considered a surgical challenge. A very long time may pass between the initial presentation and the development of recurrence.

The SPF-SPLF Graft: Building the Ideal Dorsum in Revision Rhinoplasty.

Achieving a natural appearing dorsum in secondary rhinoplasty remains an elusive goal. An inherent contradiction exists between the two most usually used techniques: solid rib segment and diced cartilage fascia constructs. The former will often cause edge visibility, in addition to potential warping and distortion; the latter prevents from both but may generate obtuse, ill-defined borders with poor shape control, possible contour asymmetries, and often a tubular appearance. A solution to the equation can be found in an innovative technique that combines three elements: perichondrium, rectus fascia, and a rib lamination. The combination is called the sandwich of perichondrium and fascia (SPF) or the sandwich of perichondrium, rib lamination, and fascia (SPLF). As a single unit over the entire dorsum, the issues of junction irregularity inherent in the use of separate graft segments, and of asymmetries in the dorsal contour because of inadequate distribution of diced cartilage, are avoided. In a greater than 18-month experience on 23 cases at the time of writing, the SPF-SPLF graft has proved to be an ideal solution. Adequate edge definition and elegant related shadowing are provided, precise tailoring is attained, and proper height of the dorsum contour is reestablished, following adequate reconstruction of the underlying dorsal plateau. The gradual flow from SPF to SPLF is logical and progressive according to need, and proper fixation ensures long-term stability of the hybrid construct. All three elements required are harvested from the same donor site with a resulting minimal scar.

Posttraumatic Augmentation Rhinoplasty Using an Osseocartilaginous Cantilever Graft.

BACKGROUND: Augmentation rhinoplasty in Asians may be effectively accomplished with alloplastic materials. However, certain circumstances such as nasal bone fractures mandate the use of autologous grafts. The purpose of this study was to describe and evaluate the results of modified osseocartilaginous rib cantilever grafting for aesthetic and reconstructive rhinoplasty in patients with acute nasal bone fractures. METHODS: Forty-three patients with nasal bone fracture underwent surgical reconstruction with an autogenous rib graft. Anatomic reconstruction and dorsal augmentation were performed using 1 piece of a carved osseocartilaginous rib graft each for the bony and cartilaginous parts of the nose. The average time to surgery was 6.5 days, and patient's subjective satisfaction was scored. RESULTS: "Excellent" or "good" cosmetic outcomes were reported by 37 patients (86%). There were 3 cases of secondary revision. Donor-site morbidity was not an issue in any patient. CONCLUSIONS: Anatomic reconstruction of the nasal dorsum and refining the nasal tip using an osseocartilaginous rib graft with the cantilever technique are effective in acute nasal trauma patients who wish to enhance their nasal profile in the primary treatment setting.

Trachea Reconstruction with Single-Stage Composite Flaps in a Rabbit Model.

BACKGROUND: Trachea reconstruction requires creation of a functional lining, semirigid support, and vascularity. We aimed to design composite flaps with these three components in a rabbit model. METHODS: Circumferential (n = 9) and partial anterior (n = 8) tracheal defects were created in rabbits. A circumferential defect was reconstructed with a tubed ear flap incorporating cartilage for support and skin for lining. This was pedicled on the posterior auricular vessels and tunneled into the neck to bridge the defect. In the second experiment, a longitudinal anterior trachea defect was patched with a pedicled rib cartilage and intercostal muscle flap based on the internal mammary vessels. The vascularized fascia over the intercostal muscles replaced the lining while the cartilage provided support. Postoperatively, the rabbits were monitored clinically and endoscopically. The tracheal constructs were examined histologically after the animals were sacrificed. RESULTS: Rabbits with circumferential defects reconstructed with the ear flap survived up to 6 months. Histology demonstrated vascularized cartilage with good integration of the flap with native trachea. However, hair growth and skin desquamation resulted in airway obstruction in the long term. In the second experiment, all the rabbits survived without respiratory distress, and the intercostal muscle fascia was completely covered by native respiratory epithelium. CONCLUSION: We described two experimental techniques using autologous composite flaps for single-stage trachea reconstruction in a rabbit model. Skin was a poor lining replacement, whereas vascularized muscle fascia became covered with respiratory epithelium. A rib cartilage and muscle flap could potentially be used for reconstruction of partial defects in humans.

Calvarial Reconstruction With Autologous Sagittal Split Rib Bone Graft and Latissimus Dorsi Rib Myoosseocutaneous Free Flap.

OBJECTIVE: Cranioplasty is essential because cranial defects cause cosmetic and functional problems, and neurologic sequalae in patients. However, reconstruction options are limited in patients with unfavorable conditions. This study aimed to review our experience with skull defect reconstruction using autogenous bone with sagittal split rib bone grafts or latissimus dorsi rib myoosseocutaneous free flaps. METHODS: Patients who underwent autogenous bone graft for cranial defect coverage from December 2011 to November 2015 at our institution were reviewed. Rib bone graft or latissimus dorsi rib myoosseocutaneous free flaps were done to cover the defect. The patient follow-up period ranged from 3 months to 7 years. RESULTS: There were 6 patients, with 9 surgeries. Two cases of latissimus dorsi rib myoosseocutaneous free flap procedures were performed in 2 patients and 7 sagittal split rib bone grafts were performed in 6 patients. There were no postoperative infections in any patients, despite 4 patients had previous surgical site infection histories. Two patients with neurologic sequalae showed improvement after the surgeries. CONCLUSION: Sagittal split rib bone graft and latissimus dorsi rib myoosseocutaneous free flap procedures could be fine options for calvarial reconstruction of defects under the unfavorable conditions of bilateral cranial defects or previous infection history.

Dermatologic Biopsy of Silicone Nasal Implant and Revision Rhinoplasty in the Asian Patient, A Cautionary Report.

Care provided to the Asian rhinoplasty patient may be multidisciplinary at times, including not only plastic surgeons, but also other health care professionals. It is crucial that all physicians caring for these patients practice complete awareness of the patient's prior operations and details of materials used in order to optimize results and avoid potentially devastating complications. These complications include but are not limited to implant infection and extrusion. Here the authors describe one such case report, discussing dermatologic biopsy of a silicone implant of the nasal tip and dorsum and subsequent revision rhinoplasty with implant removal and costochondral graft placement.