Iris A. Seitz

Latissimus dorsi/rib intercostal perforator myo-osseocutaneous free flap reconstruction in composite defects of the scalp: case series and review of literature.

Adequate coverage of complex, composite scalp defects in previously radiated, infected, or otherwise compromised tissue represents a challenge in reconstructive surgery. To provide wound closure with bony protection to the brain, improve cranial contour, and prevent or seal cerebrospinal fluid (CSF) leaks, composite free tissue transfer is a reliable and safe option. We report our experience with the latissimus dorsi/rib intercostal perforator myo-osseocutaneous free flap in the reconstruction of bony and soft tissue defects of the cranium and overlying scalp. The surgical technique, design, and outcomes of the latissimus dorsi/rib intercostal perforator myo-osseocutaneous free flap reconstruction in five patients with cranial defects between 2003 and 2007 were retrospectively evaluated. Patient characteristics, defect size, underlying cause, reconstructive details, and complications were analyzed. All patients (age 43 to 81) had composite defects ranging from 36 to 750 cm2 (mean size 230 cm2) for the bony component and from 16 to 400 cm2 (mean size 170 cm2) for the soft tissue defect. All patients had a history of prior or current infection of the affected area, and two patients had a CSF leak. Defects were due to malignancy and infection (n = 2), infiltrative cutaneous mucormycosis with osteomyelitis (n = 1), and hemorrhagic stroke requiring craniectomy (n = 2), complicated by infection and failed cranioplasty in one patient and continuous CSF leak in the other. The latissimus dorsi composite free flap consisting of skin, muscle, and vascularized rib can successfully cover large complex cranial defects, provide skeletal support, improve contour, and significantly enhance functional outcome with limited donor site morbidity.

Reconstruction of Scalp and Forehead Defects

Reconstruction of scalp and forehead defects is a complex field with a broad variety of reconstructive options. The thought process and techniques used for reconstruction of scalp and forehead defects are the subject of this article.

Split lateral iliac crest chimera flap: utility of the ascending branch of the lateral femoral circumflex vessels.

Background: Complex head and neck reconstruction often requires multiple tissue components to restore form and function to the traumatized area. Here, the authors describe the split lateral iliac crest chimera flap and demonstrate the utility of the ascending branch of the lateral femoral circumflex system to provide vascularized bone for complex head and neck reconstruction. Methods: A retrospective case series analysis was performed for patients undergoing complex head and neck reconstruction utilizing the split lateral iliac crest chimera flap to provide vascularized bone and soft tissue. The blood supply to the lateral iliac crest was via the ascending branch of the lateral femoral circumflex system, and the soft tissue was supplied by the transverse and descending branches of the circumflex system. Results: Four patients with advanced recurrent head and neck cancer undergoing split lateral iliac crest chimera reconstruction between November of 2007 and April of 2009 were included. Three patients required reconstruction of segmental mandibulectomy defects, and one required reconstruction of a maxillectomy defect. All components of the chimeric flaps in each patient survived. Bone vascularity was confirmed with triphasic bone scans within the first week postoperatively in two patients. Conclusions: The split lateral iliac crest chimera flap employs distinct branches of the lateral femoral circumflex system to supply the split lateral iliac crest and soft tissue of the thigh, each isolated on separate vascular leashes connected to a common source vessel. Through inclusion of a vascularized bone component, the flap extends the versatility of the lateral femoral circumflex flap for complex head and neck reconstruction requiring both hard-tissue and soft-tissue replacement.

Characterization of reversibly immortalized calvarial mesenchymal progenitor cells

Background:Bone morphogenetic proteins (BMPs) play a sentinel role in osteoblastic differentiation, and their implementation into clinical practice can revolutionize cranial reconstruction. Preliminary data suggest a therapeutic role of adenoviral gene delivery of BMPs in murine calvarial defect healing. Poor transgene expression inherent in direct adenoviral therapy prompted investigation of cell-based strategies. Objective:To isolate and immortalize calvarial cells as a potential progenitor source for osseous tissue engineering. Materials and Methods:Cells were isolated from murine skulls, cultured, and transduced with a retroviral vector bearing the loxP-flanked SV40 large T antigen. Immortalized calvarial cells (iCALs) were evaluated via light microscopy, immunohistochemistry, and flow cytometry to determine whether the immortalization process altered cell morphology or progenitor cell profile. Immortalized calvarial cells were then infected with adenoviral vectors encoding BMP-2 or GFP and assessed for early and late stages of osteogenic differentiation. Results:Immortalization of calvarial cells did not alter cell morphology as demonstrated by phase contrast microscopy. Mesenchymal progenitor cell markers CD166, CD73, CD44, and CD105 were detected at varying levels in both primary cells and iCALs. Significant elevations in alkaline phosphatase activity, osteocalcin mRNA transcription, and matrix mineralization were detected in BMP-2 treated iCALs compared with GFP-treated cells. Gross and histological analyses revealed ectopic bone production from treated cells compared with controls in an in vivo stem cell implantation assay. Conclusion:We have established an immortalized osteoprogenitor cell line from juvenile calvarial cells that retain a progenitor cell phenotype and can successfully undergo osteogenic differentiation upon BMP-2 stimulation. These cells provide a valuable platform to investigate the molecular mechanisms underlying intramembranous bone formation and to screen for factors/small molecules that can facilitate the healing of osseous defects in the craniofacial skeleton.

Pre‐mastectomy Sentinel Lymph Node Biopsy: A Strategy to Enhance Outcomes in Immediate Breast Reconstruction

The pre‐mastectomy sentinel lymph node biopsy (PM‐SLNB) is a technique that provides knowledge regarding nodal status prior to mastectomy. Because radiation exposure is associated with poor outcomes in breast reconstruction and reconstructed breasts can interfere with the planning and delivery of radiation therapy (RT), information regarding nodal status has important implications for patients who desire immediate breast reconstruction. This study explores the safety and utility of PM‐SLNB as part of the treatment strategy for breast cancer patients desiring immediate reconstruction. We reviewed the charts of adult patients (≥18 years old) who underwent PM‐SLNB from January 2004 to January 2011 at our institution. PM‐SLNB was offered to patients with stage I or IIa, clinically and/or radiographically node‐negative breast cancer who desired immediate breast reconstruction following mastectomy. PM‐SLNB was also offered to patients with ductal carcinoma in situ if features concerning for invasive carcinoma were present. Ninety‐one patients underwent PM‐SLNB of 94 axillae. PM‐SLNB was positive in 25.5% of breasts (n = 24). Nineteen node‐positive patients (79.2%) have undergone or planning to undergo delayed reconstruction at our institution. Seventeen of these 19 node‐positive patients (89.5%) have received adjuvant RT. Two patients (10.5%) elected against RT despite our recommendation for it. No biopsy‐positive patient underwent immediate reconstruction or suffered a radiation‐induced complication with their breast reconstruction. There were two minor complications associated with PM‐SLNB, both in node‐negative patients. This study demonstrates the utility of PM‐SLNB in providing information regarding nodal status, and therefore the need for adjuvant RT, prior to mastectomy. This knowledge can be used to appropriately counsel patients regarding optimal timing of breast reconstruction.

A ten-year review of myelodysplastic defect management and use of a novel closure technique with V-Y crescentic rotation advancement flaps *

The reconstructive goals for myelodysplastic defects are to provide a multilayered, tension-free and well-vascularized closure to prevent cerebrospinal fluid leakage, wound infection or breakdown and to optimize neurologic outcomes. We reviewed our ten-year experience with myelodysplastic defects and our preferred technique for large defects utilizing paraspinous flaps followed by V-Y crescentic rotation advancement flaps. A retrospective chart review was performed on all myelodysplastic defects closed at the University of Chicago Medicine from 2002 to 2012. Twenty-three patients were treated: eight were closed using V-Y crescentic rotation advancement flaps, eight primarily, two with transposition flaps and five with bilateral latissimus dorsi and gluteus maximus myocutaneous flaps. Patient defect characteristics, reconstructive details, follow up time, and wound complications were analyzed. The primary closure group included eight patients. There was one minor complication and two major complications that required debridement and plastic surgery consultation in this group. The transposition group included two patients and had no wound healing issues. The latissimus and gluteus myocutaneous group included five patients and had one minor wound healing issues. The V-Y crescentic group included eight patients. There were four minor wound breakdowns in the lateral donor sites and one major wound complication involving a CSF leak, meningitis and wound breakdown that required debridement. The groups were stratified by size, <5 cm and >5 cm, and further analyzed. Bilateral V-Y crescentic rotation advancement flap is a useful option when confronted with large myelodysplastic defects. It provides a multilayer, tension-free wound closure and spares the gluteus maximus and latissimus dorsi muscle groups.

Unusual sequela from a pencil stab wound reveals a retained graphite foreign body

Penetrating pencil-tip injuries are common among children and usually resolve without long-term sequelae. However, failure to detect and remove embedded pencil fragments can result in increased morbidity or misdiagnoses of other, more serious, conditions. We report on the case of a 10-year-old boy stabbed with a pencil on his right chin. Initial treatment in the emergency department included irrigation and closure of the laceration. Following suture removal, the patient returned to the emergency department (with bright-purple drainage from the wound site). Radiographic evaluation led to the discovery of an embedded foreign body requiring surgical removal.