Christian E. Sampson

Three Patients with Full Facial Transplantation

Unlike conventional reconstruction, facial transplantation seeks to correct severe deformities in a single operation. We report on three patients who received full-face transplants at our institution in 2011 in operations that aimed for functional restoration by coaptation of all main available motor and sensory nerves. We enumerate the technical challenges and postoperative complications and their management, including single episodes of acute rejection in two patients. At 6 months of follow-up, all facial allografts were surviving, facial appearance and function were improved, and glucocorticoids were successfully withdrawn in all patients.

Restoration of Facial Form and Function After Severe Disfigurement from Burn Injury by a Composite Facial Allograft

Composite facial allotransplantation is emerging as a treatment option for severe facial disfigurements. The technical feasibility of facial transplantation has been demonstrated, and the initial clinical outcomes have been encouraging. We report an excellent functional and anatomical restoration 1 year after face transplantation. A 59‐year‐old male with severe disfigurement from electrical burn injury was treated with a facial allograft composed of bone and soft tissues to restore midfacial form and function. An initial potent antirejection treatment was tapered to minimal dose of immunosuppression. There were no surgical complications. The patient demonstrated facial redness during the initial postoperative months. One acute rejection episode was reversed with a brief methylprednisolone bolus treatment. Pathological analysis and the donors medical history suggested that rosacea transferred from the donor caused the erythema, successfully treated with topical metronidazol. Significant restoration of nasal breathing, speech, feeding, sensation and animation was achieved. The patient was highly satisfied with the esthetic result, and regained much of his capacity for normal social life. Composite facial allotransplantation, along with minimal and well‐tolerated immunosuppression, was successfully utilized to restore facial form and function in a patient with severe disfigurement of the midface.

Anterolateral thigh free flap.

The descending branch of the lateral femoral circumflex artery is a large-caliber artery that passes obliquely across the upper third of the thigh and descends between the vastus lateralis and rectus femoris muscles. It sends perforators through the septum between these muscles and through the vastus lateralis muscle and supplies a large area of skin on the anterolateral aspect of the thigh. We report our experience with our first 44 consecutive anterolateral thigh flaps, which were used for a variety of softtissue deficits. Twenty-five of these flaps were used for lower extremity reconstruction, 10 were used in the upper extremity, and 9 were used in the head and neck. The overall success rate was 96%. Six flaps required reoperation; of these, 2 flaps were lost, one from a venous thrombosis and the other from arterial thrombosis, both of which were in the lower extremity. In approximately one third of cases, the flap was raised as a septofascio-cutaneous flap, but in two thirds it was necessary to include a small segment of vastus lateralis muscle as well as fascia with the flap. The flap has been particularly useful for lower extremity reconstruction, and in patients who are not fit for general anesthesia, it is possible to perform the flap transfer with epidural anesthesia. The flap has the advantage of a long vascular pedicle with large-caliber vessels and thus is suitable as a flow-through flap. It may also be sensate and has provided a versatile soft-tissue coverage option with minimal long-term donor-site complications.

Long-Term Results of Periarterial Sympathectomy

PURPOSE To compare long-term results (minimum follow-up of 23 months) of periarterial sympathectomy for patients with digital vasospasm secondary to either an autoimmune disease or generalized atherosclerotic disease. Patients with posttraumatic or localized occlusive disease and vasospasm were not evaluated. METHODS Twenty-eight patients had periarterial sympathectomy at 1 hospital by 1 senior surgeon. Periarterial sympathectomy was targeted to the areas of ulceration. Twenty patients (with 24 involved extremities and 42 ulcerated digits) had a documented autoimmune disease; 17 patients had scleroderma or an undifferentiated mixed connective tissue disorder, 2 had systemic lupus erythematosus, and 1 had rheumatoid arthritis. Eight patients (with 9 involved extremities and 17 ulcerated digits) had atherosclerotic disease. The primary outcomes were complete healing of all ulcers, a decrease in the number of ulcers, and need for amputation by the end of follow-up. Statistical analysis was done using the Fischer exact t-test. RESULTS The average follow-up for all patients was 96 months (90 months for the autoimmune group and 113 months for the atherosclerotic group). Fifteen of the 20 patients (28 of 42 digits) in the autoimmune group had complete healing or decrease in ulcer number. Conversely, only 1 of the 8 patients (2 of 17 digits) in the atherosclerotic group had complete healing or decrease in ulcer number. Eleven of the 42 (26%) digits treated in the autoimmune group required amputation. In contrast, 10 of the 17 (59%) digits treated in the atherosclerotic group ultimately required amputation. CONCLUSIONS Periarterial sympathectomy can lead to complete healing and decrease in ulcer number in autoimmune disease patients with digital ischemia from vasospasm. However, our data suggest that periarterial sympathectomy may be of little or no benefit in patients with chronic digital ischemia and vasospasm secondary to severe atherosclerotic disease. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.

Risk analysis for the reverse sural fasciocutaneous flap in distal leg reconstruction.

Background: The reverse sural fasciocutaneous flap provides the potential for simple and efficient closure of distal leg, ankle, and foot defects. In young patients with traumatic injuries, low complication rates have been reported. The authors hypothesize that extending its use to older patients with comorbidities results in a higher complication rate. Methods: The authors retrospectively reviewed 58 consecutive reverse sural fasciocutaneous flap in 57 patients for distal leg reconstruction. Outcomes were compared between patients with no comorbidities (n = 31) and those with a history of smoking, diabetes mellitus, or peripheral arterial disease (n = 26). Standard statistical analyses were performed, including logistic regression. Results: Patients had a mean age of 53 years and a median follow-up of 20 months. Fifty percent of flaps had postoperative complications, with nine (16 percent) major complications (three total flap losses and six partial losses), 17 (29 percent) minor complications, and three infections. In patients without comorbidities, there were no major complications and five minor complications (16 percent). Significantly higher major and minor complication rates were seen in older patients and patients with a history of smoking, obesity, diabetes, or peripheral arterial disease. Multivariate regression analysis identified smoking as the risk factor most independently associated with any reverse sural fasciocutaneous flap complication. Importantly, surgical delay procedures were associated with decreased ischemic flap complications in patients with comorbidities. Conclusions: Although the reverse sural fasciocutaneous flap is reliable in young healthy patients, it has significant complication rates in patients with comorbidities, especially smokers. In such patients, the reverse sural fasciocutaneous flap requires multiple operative revisions and a surgical delay should be considered.

Botfly myiasis : Case report and brief review

The painful, boil-like lesion of furuncular myiasis is a result of the invasion of subcutaneous tissues by larvae of Dermatobia hominis, the human botfly. This arthropod is indigenous to Mexico, and Central and South America, and imported cases to the United States are increasing as travel to these regions continues to rise. There are several dozen reports of furuncular myiasis in the United States and Canadian literature since the initial description of this disease in 1920. None of the reports are in the surgical literature, which is surprising because the treatment of choice is surgical excision. Surgical removal sometimes results in damage to the larva with retention of larval fragments in the wound. The authors describe a patient and a novel approach that ensures removal of the intact larva and its surrounding burrow.

Use of free vascularized fibular graft for congenital ulnar pseudarthrosis: surgical decision making in the growing child.

Congenital pseudarthrosis of the ulna may cause growth disturbance and progressive forearm deformity, leading to functional compromise of the upper extremity. Treatment is challenging, and surgical decision making must take into account three goals of treatment: bony healing, distal radioulnar joint (DRUJ) stability, and continued skeletal growth. Four cases of congenital ulnar pseudarthrosis treated with free vascularized fibular graft are presented here. In two cases, the vascularized fibular graft included the proximal fibular epiphysis to reconstruct the DRUJ and ulnocarpal joints. Average age of the four patients at time of vascularized fibular grafting was 10 years (range 3-16 years). Patients had undergone up to three previous failed operations. A step-cut osteotomy technique with rigid internal fixation was used in all patients. Donor-site distal tibiofibular arthrodesis was performed in skeletally immature patients when appropriate. At average follow-up of 60 months (range 33-83 months), all patients achieved bony union with full wrist range of motion compared with the contralateral extremity. The DRUJ was stable in all patients. Two skeletally immature patients with concomitant epiphyseal transfer showed continued skeletal growth. Two patients nearing skeletal maturity achieved revascularization of the distal ulna. Free vascularized fibular grafting is a successful option in the treatment of congenital ulnar pseudarthrosis. Reconstruction of the distal radioulnar and ulnocarpal joints using concomitant proximal fibular epiphyseal transfer should be considered in the skeletally immature patient with distal ulnar involvement.

Musculofascial Flaps Based on the Dorsalis Pedis Vascular Pedicle for Coverage of the Foot and Ankle

Soft-tissue reconstruction of the foot and ankle has long presented challenging problems for the plastic surgeon. Limitations of available local tissue, the need for specialized tissue, and donor site morbidity restrict the options available to the reconstructive surgeon. In an effort to solve these difficult problems, we have begun to use musculofascial flaps based on the branches of the dorsalis pedis artery. We present our early experience of 5 patients treated with an extensor digitorum brevis muscle flap with fascial extensions often containing the contents of the first web space. Our patients ranged from 6 to 60 years in age and included 4 males and 1 female. The etiologies of the wounds were secondary to trauma (N = 2), complications of surgery for rheumatoid arthritis (N = 2), and were secondary to a defect following resection of an arteriovenous malformation (N = 1). The flaps had antegrade blood flow in 3 patients and reverse flow in 2 patients. The flaps were covered with a split-thickness skin graft and the donor site was closed primarily. The donor sites healed without the need for further surgery. One patient required additional procedures. This flap proved to be both versatile and effective for closure of difficult wounds of the foot and ankle.

Functional Outcomes after Bilateral Hand Transplantation: A 3.5-Year Comprehensive Follow-Up.

Background: Since the first successful hand transplantation in 1998, 72 patients have been operated on for unilateral/bilateral hand transplantation across 13 countries. There have been multiple studies evaluating the outcomes of hand transplantation; however, there is considerable variability among the outcome measures evaluated in these studies. Methods: This article reports functional outcomes in a patient with bilateral hand transplants at a mid-forearm level with serial follow-ups over 3.5 years. Different parameters used to study the functional outcomes include the Disabilities of the Arm, Shoulder, and Hand score, the Carroll test, the Hand Transplant Score System, the Short Form-36 Health Survey, and routine occupational therapy measures. Various task-oriented outcomes were also assigned to provide milestones to the recovery. Results: The patient had a Disabilities of the Arm, Shoulder, and Hand score of 40, a Carroll test score of 48 (right) and 49 (left), and a Hand Transplant Score System score of 58 (right) and 57.5 (left) at 3.5-year follow-up. Interestingly, his objective scores did not change significantly during the follow-up, but he continued to function quite independently and is subjectively pleased with his outcomes. Conclusions: Multiple functional outcome measures provide an objective way to follow patients who have undergone hand transplantation. The authors propose a series of measures to elucidate subtleties in functional gains. However, use of this series in isolation may belie subjectively good results. They also propose a series of milestones in the recovery to give a better real-world explanation of progress. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Head and neck peripheral stimulation for chronic pain report of three cases.

Neuropathic facial pain often is a very difficult problem to treat. We describe three cases of intractable neuropathic facial pain which were successfully treated with peripheral stimulation. These three cases review trialing, operative considerations, including cosmetic considerations, and provide some insight into the pathophysiology of these pain syndromes.