Keith E. Follmar

A retrospective analysis of facial fracture etiologies

The medical records of 437 patients with 929 facial fractures were retrospectively analyzed. Fracture patterns were classified based on the presence or absence of fractures in each of 4 anatomic subunits (frontal, upper midface, lower midface, and mandible). The most common etiology of trauma was assault (36%), followed by motor vehicle collision (MVC, 32%), fall (18%), sports (11%), occupational (3%), and gunshot wound (GSW, 2%). The most common fracture type was nasal bone fracture (164). MVC was found to be a significant predictor of panfacial fractures, as was GSW. Sports injuries were a significant predictor of isolated upper midface fractures, and assault was a significant predictor for isolated mandible fractures. MVC and GSW each were found to lead to significantly higher severity of injury than assault, fall, and sports. The results confirm intuitive aspects of the etiology of facial fractures that have been anecdotally supported in the past.

The distally based sural flap

Learning Objectives: After studying this article, the participant should be able to: (1) Describe the anatomy of the posterior lower leg as it is relevant to the distally based sural flap. (2) Describe the basic surgical technique of the distally based sural fasciocutaneous flap. (3) Understand the common complications associated with the sural flap and their approximate incidences in both a healthy and a multimorbid patient population. (4) Describe how skin, fascia, and muscle can be used to customize the sural flap for different purposes. (5) Understand the various modifications of the sural flap that have been described in the literature. Summary: Over the past decade, the distally based sural flap has become increasingly used in reconstruction of the foot and lower leg. The rise in popularity of this flap has been paralleled by an increase in the number of cases, innovations, and technical refinements reported in the medical literature. This review summarizes the 79 publications in the English language literature on the subject of the distally based sural flap. The anatomical studies are summarized in a unified description of the relevant flap anatomy. The flap’s indications and composition and a variety of modifications are described. Technical aspects are discussed and clinical insight to minimize complications is provided. In conclusion, the distally based sural flap offers an alternative to free tissue transfer for reconstruction of the lower extremity.

Metabolic and Functional Characterization of Human Adipose-Derived Stem Cells in Tissue Engineering

Background: The use of adipose-derived stem cells for tissue engineering involves exposing them to metabolically adverse conditions. This study examines the metabolism, proliferation, and differentiation of adipose-derived stem cells under various conditions. Methods: Adipose-derived stem cells were cultured in 16 media conditions containing 0.6, 2.4, 4.3, or 6.1 mM glucose; 0.1, 2.5, 4.1, or 6.1 mM glutamine; and then grown in either 0.1% or 20% oxygen. Conditioned media were collected and assayed for glucose, lactate, and pyruvate. Cell proliferation and cell death were measured at several time points. Osteogenic differentiation was analyzed by alizarin red staining/quantification and alkaline phosphatase activity, measured weekly over 4 weeks. Results: Adipose-derived stem cells remained metabolically active in all nutrient and oxygen conditions tested. Glucose consumption and lactate production increased under hypoxic conditions, but pyruvate consumption was jointly dependent on oxygen and glucose concentration. The 20% oxygen environment produced greater proliferation and cell death compared with the hypoxic environment. Osteogenic differentiation of adipose-derived stem cells was observed only when glucose and/or oxygen concentrations were physiologically normal to high. Conclusions: Adipose-derived stem cells are an excellent source of multipotent cells and are capable of advancing current tissue engineering methodologies. These data show that adipose-derived stem cells remain viable under adverse conditions of low glucose, glutamine, and oxygen concentrations. However, there are variable levels of differentiation in the various culture conditions, which could lead to challenges in de novo osteogenesis and other forms of tissue engineering. Therefore, these results should be used in developing specific strategies to ensure successful application of adipose-derived stem cells in bone engineering and similar applications.

Combined bone allograft and adipose-derived stem cell autograft in a rabbit model.

Currently available options for the repair of bony defects have substantial limitations. Much work has looked to the possibility of engineering bone using stem cells. These tissue-engineering efforts have focused on calvarial defect models, which have the advantages of minimal load-bearing and a large surface area. This study aims to solve the somewhat more challenging problem of repairing segmental bony defects such as those of the mandible and long bones. Four groups of decellularized bone tubes with cortical perforations were implanted subcutaneously in a rabbit model: empty bone tubes, bone tubes containing fibrin glue alone, bone tubes containing fibrin glue and freshly isolated autologous adipose-derived stem cells (ASCs), and bone tubes containing fibrin glue and predifferentiated autologous ASCs. Results showed a foreign body response characterized by fibrous capsule formation with minimal angiogenesis and no evidence of osteoblastic activity. Substantial changes are needed if this model is to become viable.

Technical and anatomical considerations of face harvest in face transplantation.

Total face transplantation may become a reconstructive option in the treatment of patients with acquired facial deformity. Here, 2 face-harvesting techniques are presented in a fresh human cadaver model. In technique 1, the skin and soft tissue of the face is harvested by dissecting in a subgaleal, sub-SMAS, subplatysmal plane. In technique 2, the entire soft tissue and the bony structures of the midface are harvested by dissecting in a subperiosteal plane and performing a Le Fort III osteotomy. Each face was harvested successfully as a bipedicled flap based on the external carotid arteries, the external jugular veins, and the facial veins. Each of these 2 techniques is a theoretically viable approach to face harvest for composite allograft transplantation. These techniques represent the 2 extremes of which tissues can be harvested while maintaining vascular integrity. Each will address different reconstructive needs.

Management of enterocutaneous fistulas using negative-pressure dressings.

Fifteen patients with enterocutaneous fistulas (ECFs) not amenable to surgical treatment were treated with negative-pressure dressings over the abdominal wound and ECF. Closure of the ECF and time to closure were examined. In 11 patients who had no visible intestinal mucosa on examination, the closure rate was 100%, with a mean time to closure of 14 days. In 4 patients who did have grossly visible intestinal mucosa, no closure occurred. This represents an overall closure rate of 73%. Fistula output rate did not have a significant effect on outcome. These results confirm the efficacy of negative-pressure dressings in the closure of ECFs. Presence or absence of visible intestinal mucosa is the single most important clinical factor when considering the use of a negative-pressure dressing in the management of a patient with ECF.

Free Vascularized Tissue Transfer to Preserve Upper Extremity Amputation Levels

Background: Free vascularized tissue transfer to preserve upper extremity amputation level is an uncommon procedure. The authors investigate the role of free tissue transfer in preserving both morphology and function of the amputated upper extremity, with the goal of facilitating prosthetic rehabilitation. Methods: Thirteen patients who underwent microsurgical free tissue transfer to preserve upper extremity amputation level were reviewed retrospectively. These cases were selected from four centers: Duke University Medical Center (Durham, N.C.) University Hospital of Modena (Modena, Italy), Careggi University Hospital (Florence, Italy), and the University of Heidelberg (Heidelberg, Germany). Parameters that were evaluated included age, sex, cause of the defect, reconstructive procedure, structures to be salvaged, and functional outcome, among others. Results: The cause of amputation was trauma in 92 percent of patients. Mean age was 32 years. In 31 percent of the cases, an emergency free fillet flap was used, and in the remaining 69 percent, a traditional free flap was performed. Structures/function to be preserved included pinch function to the hand, function of the elbow and shoulder joints, and skeletal length greater than 7 cm. Complications occurred in 38 percent of the cases, but the final goal of the procedure was achieved in all cases. A treatment algorithm for the management of the amputated upper extremity is presented. Conclusion: Use of free vascularized tissue transfer for preservation of upper extremity amputation level in well-selected cases facilitates prosthetic rehabilitation and improves residual limb function.

Use of negative-pressure dressings and split-thickness skin grafts following penile shaft reduction and reduction scrotoplasty in the management of penoscrotal elephantiasis.

From 1988 to 2005, 8 men who presented with penoscrotal elephantiasis underwent penile shaft degloving and reduction scrotoplasty, followed by transplantation of a split-thickness skin graft (STSG) to the penile shaft. The etiology of elephantiasis in these patients included self-injection of viscous fluid and postsurgical obstructive lymphedema. In the 6 most recent cases, negative-pressure dressings were applied over the STSG to promote graft take, and STSG take rate was 100%. The results of our series corroborate those of a previous report, which showed circumferential negative-pressure dressings to be safe and efficacious in bolstering STSGs to the penile shaft. Furthermore, these results suggest that the use of negative-pressure dressings may improve graft take in this patient population.

Strategy for reoperative free flaps after failure of a first flap.

Background: Free vascularized tissue transfer is generally associated with high success rates, but failures do occur. After a flap failure, the decision is often made to perform a second, reoperative free flap. Methods: A retrospective review of all microsurgical free tissue transfers performed at the authors’ institution identified 13 patients who underwent a second, reoperative free flap after a failed primary flap. The records of these patients were reviewed, with particular emphasis on identifying changes in treatment strategy between the initially failed and the reoperative free flap. Results: Thirteen patients were identified as having undergone a reoperative free flap. In nine of 13 primary free flaps, at least one likely cause for the failure was identified (69 percent). In the approach to the second free flap, strategy changes were performed in 10 of 13 cases (77 percent); 11 were successful (85 percent). One of the two patients with a failed reoperative free flap underwent a third attempt at free tissue transfer, which also failed. Conclusions: The authors’ overall approach to the failed free flap includes the following four steps: (1) reconsideration of the need for vascularized free tissue transfer, (2) a sensitive psychosocial approach to the patient and family, (3) analysis of the cause of the first flap failure, and (4) change in microsurgical strategy. Based on the authors’ experience, they consider two previously failed free flaps without an obvious cause to be a contraindication to a third attempt.

A Financial Analysis of Operative Facial Fracture Management

Background: The financial impact of operative facial fracture management has not been systematically investigated. This study aims to provide a descriptive financial analysis of patients undergoing operative facial fracture management at a single academic medical center and the financial impact on the health system. Methods: The records of 202 patients who underwent operative facial fracture management over a 3-year period (2003 to 2005) were analyzed. All physician (professional) and hospital charges related to fracture management were included. Professional charges were subdivided by specialty and by payer type; hospital charges included operating room, recovery room, intensive care unit, hospital bed, supply charges, pharmaceuticals, laboratory charges, and radiographs. For comparison, similar data were obtained for the general plastic surgery population and for orthopedic surgery patients. Results: The sum of all professional charges billed was