This report describes the development of a new technique for harvesting facial allograft for facial transplantation. The coronal-posterior surgical approach for facial/scalp flap harvesting from donor cadavers has been developed to allow extended length to the neurovascular bundles utilized in facial composite allograft transplantation. Cadaveric anatomic dissections were performed to harvest facial/scalp flaps via a posterior-coronal approach. Supraorbital and infraorbital neurovascular bundle lengths were extended by osteotomy of the cranial/orbital bone. The mental nerve lengths were extended into the inferior alveolar neurovascular bundle utilizing a sagittal split ramus osteotomy. This surgical approach extends the length of these craniofacial nerves for future neurorrhaphy. The mean length of the supraorbital, infraorbital, and mental nerves was 3.52 +/- 0.31 cm, 4.65 +/- 0.20 cm, 5.6 +/- 0.14 cm, respectively. Based on anatomical dissection in this cadaver study, the authors introduce a new technique for facial/scalp flap harvesting that extends the neurovascular bundles of sensory nerves of the anterior craniofacial skeleton.
AMERICAN SOCIETY OF PLASTIC SURGEONS PLASTIC & RECONSTRUCTIVE SURGERY PRS GLOBAL OPEN ASPS EDUCATION NETWORK AMERICAN SOCIETY OF PLASTIC SURGEONS PLASTIC & RECONSTRUCTIVE SURGERY PRS GLOBAL OPEN ASPS EDUCATION NETWORK
Abstract Deep soft tissue defects after complicated primary or revision total knee arthroplasty (TKA) can be devastating to the patient and technically challenging. The purpose of this review was to (1) discuss different methods used to provide coverage for deep defects of the knee following TKA, as well as to (2) report on their success rates. A comprehensive literature search was performed. Reports were only included if they (1) were case series, (2) were level III studies or above (including retrospective cohort studies and meta-analyses), (3) were in English, and (4) discussed the outcome of graft or flap coverage of soft tissue defects after total knee arthroplasty. A total of 28 case series and four retrospective comparative studies were retrieved. In 16 studies, 195 out of 241 patients who received gastrocnemius flaps (81%) experienced successful outcomes. In seven studies including 84 patients that underwent fasciocutaneous flap coverage, over 90% of patients experienced successful outcomes. In the four studies examining 144 patients with delayed versus prophylactic soft tissue reconstruction, up to 81% of patients experienced a successful outcome. Various factors must be taken into consideration when assessing full-thickness defects over a TKA and collaboration between plastic and orthopaedic surgeons is required to select the optimal approach.
PURPOSE: Infections following total knee arthroplasty (TKA) often result in plastic surgery consultation in attempt to salvage the prosthesis. Muscle and fasciocutaneous flaps have become a mainstay of this salvage reconstruction.1,2 These flaps often lead to short-term success.3–5 However, does short-term success result in long-term knee salvage? Does flap reconstruction help eradicate infection when a large foreign body must be maintained in the wound? Or does the flap merely suppress the infection with later failure of the knee reconstruction? We have attempted to answer these questions by retrospectively analyzing a large number of TKA reconstructions requiring muscle or fasciocutaneous flap coverage. MATERIALS AND METHODS: A retrospective review of patients treated with flaps after failed TKA between 1998 and 2014 was conducted. Patients requiring flap coverage of soft-tissue defects were included into Group 1. Patients with no soft-tissue defects, but with extensive debridement during revision TKA requiring immediate flap reconstruction were included into Group 2. RESULTS: Fifty-eight patients in Group 1 were treated with 86 flaps, and 15 patients in Group 2 were treated with 17 flaps. Mean length of follow-up was 67.0 and 54.7 months, respectively (p=0.21). Flap related complications and number of subsequent flap revisions were comparable in both groups. Patients in Group 1 had a higher rate of implant reinfection (58% vs. 27%; p<0.05), amputations (25% vs. 0%; p<0.05), and number of subsequent prosthesis revisions (2.2 vs. 0.9; p<0.05). Functional joint was preserved in 54% and 80% of cases, respectively. Mean range of motion and quality of life were significantly better in Group 2 (p<0.05). CONCLUSION: Flap reconstruction allowed achieving stable coverage of the prosthesis, but the reinfection rate was surprisingly high, patients needed multiple additional revisions and only 54% an 80% of functional implants were retained after 5 years. This should be taken into consideration while discussing different treatment options for soft-tissue defects around the knee prosthesis.
AMERICAN SOCIETY OF PLASTIC SURGEONS PLASTIC & RECONSTRUCTIVE SURGERY PRS GLOBAL OPEN ASPS EDUCATION NETWORK AMERICAN SOCIETY OF PLASTIC SURGEONS PLASTIC & RECONSTRUCTIVE SURGERY PRS GLOBAL OPEN ASPS EDUCATION NETWORK
Granulomatosis with polyangiitis (Wegener granulomatosis) is a rare disease that commonly starts in the craniofacial region and can lead to considerable facial disfigurement. Granulomas and vasculitis, however, can involve many other tissues (especially pulmonary and renal). Dermatologic and subcutaneous components can lead to malignant pyoderma.The authors describe a unique pathologic condition, where significant Le Fort type trauma was associated with subsequent development of granulomatosis with polyangiitis and malignant pyoderma. Successive operations to excise necrotic tissue and reconstruct the defects were followed by worsening inflammation and tissue erosions. Trauma and surgery in proximity to the eye and sinuses masked the initial clinical presentation and led to delay in diagnosis and disease progression. The resultant facial disfigurement and tissue loss were substantial.Despite multiple confounding factors, accurate diagnosis was eventually established. This was based on persistence of sinus inflammations in the absence of infective agents, proven sterility of lung lesions, and antineutrophil cytoplasmic antibody positivity with proteinase 3 specificity. Skin lesion biopsy specimens were identified as pyoderma gangrenosum and later as malignant pyoderma. Institution of immunosuppressive therapy allowed successful control of the disease and wound healing. The resulting craniofacial destruction, however, necessitated facial vascularized composite allotransplantation.Recognition of this rare pathologic association is essential, to prevent delays in diagnosis and treatment that can lead to major craniofacial tissue loss.Therapeutic, V.
