John T. Stranix

Evolution of surgical techniques for mandibular reconstruction using free fibula flaps: The next generation.

Virtual surgical planning (VSP) has contributed to a number of technical innovations in mandible reconstruction. We report on these innovations and the overall evolution of mandible reconstruction using free fibula flaps at our institution.

Fasciocutaneous flap reinforcement of ventral onlay buccal mucosa grafts enables neophallus revision urethroplasty

Background: Urethral strictures or fistulas are common complications after phalloplasty. Neourethral defects pose a difficult reconstructive challenge using standard techniques as there is generally insufficient ventral tissue to support a graft urethroplasty. We report our experience with local fasciocutaneous flaps for support of ventrally-placed buccal mucosal grafts (BMGs) in phalloplasty. Methods: A retrospective review of patients who underwent phalloplasty and subsequently required revision urethroplasty using BMGs between 2011 and 2015 was completed. Techniques, complications, additional procedures, and outcomes were examined. Results: A total of three patients previously underwent phalloplasty with sensate radial forearm free flaps (RFFFs): two female-to-male (FTM) gender reassignment, and one oncologic penectomy. Mean age at revision urethroplasty was 41 years (range 31–47). Indications for surgery were: one meatal stenosis, four urethral strictures (mean length 3.6 ± 2.9 cm), and two urethrocutaneous fistulas. The urethral anastomosis at the base of the neophallus was the predominant location for complications: 3/4 strictures, and 2/2 fistulas. Medial thigh (2) or scrotal (1) fasciocutaneous flaps were used to support the BMG for urethroplasty. One stricture recurrence at 3 years required single-stage ventral BMG urethroplasty supported by a gracilis musculocutaneous flap. All patients were able to void from standing at mean follow up of 8.7 months (range 6–13). A total of two patients (66%) subsequently had successful placement of a penile prosthesis. Conclusions: Our early results indicate that local or regional fasciocutaneous flaps enable ventral placement of BMGs for revision urethroplasty after phalloplasty.

Preoperative Head and Neck Surgical Planning with Computer-Assisted Design and Modeling

Virtual surgical planning (VSP) has significantly impacted modern head and neck surgery. Over the past decade, advancements in computer-assisted design (CAD) software have been applied to high-resolution three-dimensional imaging technology to generate powerful tools for planning complex craniofacial resections and reconstructions. These virtual surgical plans incorporate the design of intraoperative surgical guides that are generated through the process of computer-assisted manufacturing (CAM). Virtually planned procedures are then translated to the operating room where they are carried out with unparalleled precision and efficiency. This process allows for accurate operative design that reliably achieves predicted results. Surgical teams are now able to formulate single-staged ablative/reconstructive procedures all the way through to prosthetic dentition and expected soft-tissue outcomes. Recent studies have demonstrated the benefits of preoperative CAD/CAM surgical planning for oncologic resections with immediate reconstructions, severe facial trauma, complex orthognathic and temporomandibular joint procedures, esthetic surgery, and composite tissue allotransplantation. We provide an overview of CAD/CAM applications in head and neck surgery and review the evidence to date regarding the use of preoperative VSP in complex craniofacial reconstruction.

Optimizing venous outflow in reconstruction of Gustilo IIIB lower extremity traumas with soft tissue free flap coverage: Are two veins better than one?

The dependent nature of the lower extremity predisposes to venous congestion, especially following significant trauma. The benefit of a second venous anastomosis, however, remains unclear in lower extremity trauma free flap reconstruction. This study investigated the effect of an additional venous anastomosis on flap outcomes in lower extremity trauma reconstruction.

Flap coverage for the treatment of exposed left ventricular assist device (LVAD) hardware and intractable LVAD infections

Left ventricular assist devices (LVADs) have become useful adjuncts in the treatment of patients with end‐stage heart failure. LVAD implantation is associated with a unique set of problems; one such problem is device infection. We report our experience with flap salvage of infected and/or exposed LVAD hardware.

Computer Simulation and Digital Resources for Plastic Surgery Psychomotor Education.

Summary: Contemporary plastic surgery residents are increasingly challenged to learn a greater number of complex surgical techniques within a limited period. Surgical simulation and digital education resources have the potential to address some limitations of the traditional training model, and have been shown to accelerate knowledge and skills acquisition. Although animal, cadaver, and bench models are widely used for skills and procedure-specific training, digital simulation has not been fully embraced within plastic surgery. Digital educational resources may play a future role in a multistage strategy for skills and procedures training. The authors present two virtual surgical simulators addressing procedural cognition for cleft repair and craniofacial surgery. Furthermore, the authors describe how partnerships among surgical educators, industry, and philanthropy can be a successful strategy for the development and maintenance of digital simulators and educational resources relevant to plastic surgery training. It is our responsibility as surgical educators not only to create these resources, but to demonstrate their utility for enhanced trainee knowledge and technical skills development. Currently available digital resources should be evaluated in partnership with plastic surgery educational societies to guide trainees and practitioners toward effective digital content.

Long-term Operative Outcomes of Preoperative Computed Tomography-guided Virtual Surgical Planning for Osteocutaneous Free Flap Mandible Reconstruction

Long-Term Operative Outcomes of Preoperative Computed Tomography-Guided Virtual surgical Planning for Osteocutaneous free flap Mandible Reconstruction Sir: W eagerly read the original article on virtual surgical planning outcomes for mandible reconstruction by Chang et al.1 and Dr. Hidalgo’s accompanying discussion.2 Both sections highlight important nuances of mandible reconstruction. Our institution currently uses both techniques for fibula flap contouring; thus, we felt it was important to provide additional insights. Regarding the finding that although virtual surgical planning can locate the osteotomy and determine its surface orientation, “it does not appear from this report to provide the precise angle of the osteotomy through the bone that takes into account multiple planes.” Our reply is that virtual surgical planning designs osteotomies in three planes.3,4 Cutting guides control saw position in axial, sagittal, and coronal axes for precise intraoperative execution. Traditional mandible reconstruction uses two-dimensional templates, and requires estimation to accommodate changes in the third plane.5 Therefore, reconstruction with virtual surgical planning should more accurately reflect native mandible shape. Regarding the finding that virtual surgical planning methodology “does not appear to speak to issues of graft insetting and therefore it remains a largely intuitive endeavor” for anterior and lateral defects, we believe that the virtual surgical planning flap itself provides an added normative reference that improves reconstructive accuracy. The fibula construct exactly matches the resected mandible segment, preserving anatomical proportions and positions. Thus, for anterior defects or lateral resections where the ramus portion is flail, the flap guides posterior segment positioning. Although we strongly support the use of maxillomandibular fixation to optimize occlusion, an argument could be made that it is not essential with precise virtual surgical planning execution. Does virtual surgical planning determine final graft length at the time of shaping? Typically, graft ends are left longer in case a greater resection margin proves necessary. If the oncologic resection is performed without deviation from the virtually planned resection margins using the extirpative cutting guides, the fibula construct exactly fits into the defect. Leaving longer graft ends obviates the advantages of virtual surgical 2. Cole A, Lynch P, Slator R. A new grading of Pierre Robin sequence. Cleft Palate Craniofac J. 2008;45:603–606. 3. Wagener S, Rayatt SS, Tatman AJ, Gornall P, Slator R. Management of infants with Pierre Robin sequence. Cleft Palate Craniofac J. 2003;40:180–185. 4. Anderson KD, Cole A, Chuo CB, Slator R. Home management of upper airway obstruction in Pierre Robin sequence using a nasopharyngeal airway. Cleft Palate Craniofac J. 2007;44:269–273. 5. Abel F, Bajaj Y, Wyatt M, Wallis C. The successful use of the nasopharyngeal airway in Pierre Robin sequence: An 11-year experience. Arch Dis Child. 2012;97:331–334. planning technology. Of note, for ablative procedures, we routinely design a second wider resection virtual surgical planning in case margins change intraoperatively. Regarding the finding that shaping a reconstruction plate and then fabricating the graft to conform to it produces bone gaps, because the bone segments are fixed to the plate and not to each other, we believe that virtual surgical planning plates are bent on a stereolithographic replica of the reconstruction and conformed to the fibula construct, not the other way around. In conjunction with virtual surgical planning osteotomy accuracy, this technique practically eliminates bone gaps. Regarding the finding that there is no clear clinical difference in functional outcomes of virtual surgical planning compared to traditional methods, we agree that it is difficult to declare clinically relevant superiority with virtual surgical planning compared to traditional shaping methods in all instances. However, there are specific scenarios where the benefits of virtual surgical planning are self-evident. Large exophytic tumors and delayed reconstructions may have significantly distorted anatomy and do not provide a specimen for reference. The complex and compact geometric nature of maxillary reconstructions also may benefit from virtual surgical planning. DOI: 10.1097/PRS.0000000000002588

Indications for Plain Radiographs in Uncomplicated Lower Extremity Cellulitis

RATIONALE AND OBJECTIVES Cellulitis is a common cause for emergency department (ED) presentation and subsequent hospital admission. Underlying fracture, osteomyelitis, or foreign body is often considered in the clinical evaluation of these patients. Accordingly, plain radiographs (XRs) of the affected extremity are often ordered during the initial work-up. The utility of these imaging studies in the treatment of uncomplicated lower-extremity cellulitis, however, remains unclear. In an effort to treat this common problem more efficiently, we evaluated our imaging practices and results in a cohort of consecutive patients admitted to a large public city hospital for treatment of uncomplicated lower-extremity cellulitis. MATERIALS AND METHODS Retrospective cohort study of 288 consecutive ED admissions for treatment of uncomplicated cellulitis, of which 214 met the inclusion criteria for this study. Patient demographics, history, vitals, laboratory values, and test results were evaluated with univariate and multivariate statistical analyses. RESULTS XRs of the affected lower extremity were obtained in 158 patients (73.8%). Positive XR findings were present in 19 patients (12.0%) and positively correlated with a history of acute trauma to the extremity (P < .001) or the presence of a chronic wound (P < .01). Multivariable logistic regression analysis revealed a history of trauma (P < .001) or the presence of a chronic wound (P < .05) to be independent predictors of positive XR findings with relative risks of 6.24 and 2.98, respectively. CONCLUSIONS The establishment of evidence-based guidelines for the treatment of lower-extremity cellulitis has potential to significantly improve clinical efficiency and reduce cost by eliminating unnecessary testing. Based on our results, patients without a recent history of trauma to the affected extremity or the presence of a chronic wound do not appear to warrant XRs. When applied to our cohort, only 48 of 158 patients had a history of trauma or chronic wound. This means that 110 patients unnecessarily had plain films taken as part of their initial work-up. In a largely uninsured inner city patient population such as this cohort, that extra cost falls on the public hospital system.

Abstract QS10: Comparing Reconstructive Outcomes in Patients with Gustillo Type IIIB Fractures and Concomitant Arterial Injuries

PURPOSE: Despite advances in microsurgery, higher complication rates have persisted among lower extremity free tissue transfers. Historically, the Gustillo Classification has been utilized as a proxy for injury severity, but recent studies have shown that the rate of complications, notably flap failure, directly increase as arterial runoff decreases. When injured arteries are identified in patients requiring lower extremity free tissue transfer, a wide array of treatment options are possible: end-to-end or end-to-side anastomosis can be performed on either the injured vessel in question or on uninjured adjacent vessels. This study aims to compare the outcomes of these different treatment methods based on the number of injured vessels identified.

Limb-sparing sarcoma reconstruction with functional composite thigh flaps

Innervated muscle transfer can improve functional outcomes after extensive limb‐sparing sarcoma resections. We report our experience using composite thigh flaps for functional reconstruction of large oncologic extremity defects.