Durable Reconstructive Options Research Articles

Feasibility of Low-Seated Composite Aortic Conduit for Surgical Treatment of Prosthetic Valve Endocarditis: A Case Report

Background: A 49-year-old male presented with a delayed diagnosis of infective endocarditis leading to extensive intracardiac destruction. Such cases present technical challenges to operative debridement as crucial anchoring points for replacement conduits are compromised. Case Presentation: Our patient presented at age 49 with nausea, lethargy, and diarrhea 2 weeks after recent travel. His prior history included bioprosthetic valve replacement for a bicuspid aortic valve. The patient was first given a trial of antimicrobials for a suspected UTI. Subsequently, he was admitted briefly to an outside hospital for a “cardiac work-up,” which returned negative. The patient sought care for the third time, during which he developed unstable supraventricular tachycardia, prompting echocardiography 16 days following the onset of symptoms. Echocardiography demonstrated a 6 cm abscess cavity invading the interventricular septum with a fistula into the left ventricular outflow tract, multiple ventricular septal defects (VSD), and suspected fistulae into the right ventricular outflow tract. The patient was treated with valve explant and extensive debridement. A valved-conduit for the aorta could not be sewn to the aortic annulus in the usual fashion due to destruction and debridement of the annulus, so a neo-annulus was created using the anterior leaflet of the mitral valve and the left ventricular outflow tract of the heart below the level of the VSDs. A mechanical-valved conduit was implanted onto the neo-annulus. A pacemaker was subsequently implanted. Conclusion: In patients with extensive intracardiac destruction with the compromise of the aortic annulus due to infective endocarditis, a low-seated, mechanical-valved conduit implanted directly to the aorto-mitral curtain and left ventricular outflow tract should be considered a novel, durable reconstructive option that allows complete debridement of infected tissues.

Dermal Matrices: Game Changers in Leg and Foot Soft Tissue Reconstruction? A Case Series.

The present article aims to present the use of dermal matrices in severe degloving, avulsion, and necrotizing injuries of the leg and foot in 3 patients. Conventional reconstruction would require the use of free flaps, since exposure of vessels, nerves, joints, and tendons rendered the mere resurfacing with skin grafts insufficient, and extensive cutaneous detachment precluded the use of local fasciocutaneous flaps. All injuries underwent thorough and repeated surgical debridements and wash outs, followed by negative pressure wound therapy (NPWT). Once negative tissue cultures were obtained, the extremities were resurfaced with dermal matrix and immediately covered by split thickness skin grafts. NPWT on the grafted area for a week effectively secured the grafts on the recipient area. Complete healing was achieved in all grafted areas within 7 to 12 days. The function of joints and tendons as well as the quality of resurfacing at the weight bearing areas were tested and found satisfactory within a follow-up period of 5 to 15 months. The use of combined NPWT and dermal matrices in carefully selected patients provides a reliable and durable reconstructive option for leg and foot injuries with satisfactory functional outcomes.

Microsurgical Advancements in Breast Reconstruction

Breast cancer is the most common cancer diagnosed in women worldwide, and studies are now demonstrating an increased incidence in recent years. Despite this, mortality rates for breast cancer remain low, with many women living many years beyond their cancer diagnosis. Therefore, there is a need for durable reconstructive options. Approximately 40% of women diagnosed with breast cancer will undergo a mastectomy as part of their initial treatment plan. Breast reconstruction has been consistently shown to improve post-mastectomy quality of life. Despite this, breast reconstruction rates, both in the immediate and delayed setting, remain low. With advancements in microsurgery over the past few decades, autologous tissue reconstruction has become an attractive option for breast cancer survivors offering them the benefits of a more natural aesthetic and permanency over implant-based surgery. This review provides a report on avant-garde microsurgical breast reconstruction techniques and insight into some of the benefits and drawbacks associated with each surgical approach.

Multicentred international review of orbital exenteration and reconstruction in oculoplastic and orbit practice

BackgroundOrbital exenteration is a disfiguring procedure reserved for life-threatening malignancies. This study examines the clinical course and outcomes of a large series of patients who underwent orbital exenteration for malignant...

Combining regenerative medicine strategies to provide durable reconstructive options: auricular cartilage tissue engineering.

Recent advances in regenerative medicine place us in a unique position to improve the quality of engineered tissue. We use auricular cartilage as an exemplar to illustrate how the use of tissue-specific adult stem cells, assembly through additive manufacturing and improved understanding of postnatal tissue maturation will allow us to more accurately replicate native tissue anisotropy. This review highlights the limitations of autologous auricular reconstruction, including donor site morbidity, technical considerations and long-term complications. Current tissue-engineered auricular constructs implanted into immune-competent animal models have been observed to undergo inflammation, fibrosis, foreign body reaction, calcification and degradation. Combining biomimetic regenerative medicine strategies will allow us to improve tissue-engineered auricular cartilage with respect to biochemical composition and functionality, as well as microstructural organization and overall shape. Creating functional and durable tissue has the potential to shift the paradigm in reconstructive surgery by obviating the need for donor sites.

Evaluation of Reconstructive Techniques for Anterior and Middle Skull Base Defects Following Tumor Ablation

Reconstruction after resection of head and neck cancer can be challenging, especially when tumors extend to the base of the skull. Vascularized flaps are the option of choice, whether free or pedicled. Free flaps have the added benefit of access to the more cephalad defects of the anterior cranial base without the constraints of the rotation arc of pedicled flaps. The authors compared various flaps used for the reconstruction of defects of the anterior or middle skull base after resection of malignant tumors. The authors identified 12 patients in whom 14 flaps were performed. All patients had malignant neoplasms extending to the anterior or middle cranial base that were reconstructed with free or pedicled flaps. A retrospective analysis was performed to compare the characteristics of patient demographics, tumor, and surgical technique. Complications among the various flaps were compared. Patients' assessments of function and quality of life were assessed by conducting a telephone survey. Most patients had stage 3 or 4 squamous cell carcinoma originating in the paranasal sinuses and extending to the anterior or middle skull base, requiring orbital exenteration. The flaps used included 6 radial forearm free flaps (RFFFs), 3 anterolateral thigh flaps (ALTs), 4 thoracodorsal artery perforator free flaps (TDAPs), and 1 pedicled supraclavicular flap. There were no major complications, such as perioperative heart attack, stroke, death, or meningitis. Minor complications included 3 mesh exposures after radiation treatment, 1 wound infection, and 2 flaps with wound dehiscence after radiation. These 2 dehiscences were seen with RFFFs and were later reoperated using TDAPs. There were no cerebrospinal fluid leaks or donor-site morbidity. There were no complaints of functional deficits, such as feeding difficulties or speech impairments. Some visual disturbance was reported after orbital exenteration, although this was an expected outcome. Vascularized flaps provide reliable and durable reconstructive options for anterior and middle skull base defects after resection of large complex malignant neoplasms of the craniofacial region. Free flaps, such as RFFFs, ALTs, and TDAPs, are well suited for these defects. They have a low risk of complications and low donor-site morbidity and offer good functional and esthetic outcomes.

PP150: Evaluation of reconstructive techniques for anterior skull base defects following tumor ablation

Purpose Reconstruction of craniomaxillofacial cancer defects is challenging when tumors extend to the skull base. Nowadays vascularized flaps are the option of choice. Free flaps have the added benefit of access to more cephalad defects without constraints of rotational arc as with pedicled flaps. We compared various flaps used to reconstruct anterior skull base defects after resection of malignant tumors. Materials and methods We identified 14 free or pedicled flaps done to reconstruct anterior cranial base defects. We performed a retrospective analysis to compare patient demographics, tumor histology, surgical technique, and complications among the various flaps. We also compared patients’ quality of life by conducting a telephone survey. Results All patients had stage 3 or 4 squamous cell carcinoma, most originating in the paranasal sinuses extending to the anterior skull base. There were six radial forearm free flaps, three anterolateral thigh flaps, four latissimus dorsi free flaps and one pedicled supraclavicular flap. Complications included three mesh exposures following radiation treatment, one wound infection, and two flap dehiscences after XRT. Both dehiscences occurred with RFFF and both were redone with TDAP flaps. There were no csf leaks or donor site morbidities. There were no complaints of functional deficits with feeding or speech impairments. Some patients reported visual disturbance after orbital exenteration, however they adjusted to this. Conclusions Vascularized flaps provide reliable and durable reconstructive options for anterior skull base defects following resection of malignant neoplasms of the craniofacial region. Free flaps such as RFFF, ALT, and TDAP are well suited for these defects. They have a low risk of complications and low donor site morbidity, while offering good functional and esthetic outcomes.

Case of the Season: Acquired Cholesteatoma

Reconstruction after resection of head and neck cancer can be challenging, especially when tumors extend to the base of the skull. Vascularized flaps are the option of choice, whether free or pedicled. Free flaps have the added benefit of access to the more cephalad defects of the anterior cranial base without the constraints of the rotation arc of pedicled flaps. The authors compared various flaps used for the reconstruction of defects of the anterior or middle skull base after resection of malignant tumors.The authors identified 12 patients in whom 14 flaps were performed. All patients had malignant neoplasms extending to the anterior or middle cranial base that were reconstructed with free or pedicled flaps. A retrospective analysis was performed to compare the characteristics of patient demographics, tumor, and surgical technique. Complications among the various flaps were compared. Patients' assessments of function and quality of life were assessed by conducting a telephone survey.Most patients had stage 3 or 4 squamous cell carcinoma originating in the paranasal sinuses and extending to the anterior or middle skull base, requiring orbital exenteration. The flaps used included 6 radial forearm free flaps (RFFFs), 3 anterolateral thigh flaps (ALTs), 4 thoracodorsal artery perforator free flaps (TDAPs), and 1 pedicled supraclavicular flap. There were no major complications, such as perioperative heart attack, stroke, death, or meningitis. Minor complications included 3 mesh exposures after radiation treatment, 1 wound infection, and 2 flaps with wound dehiscence after radiation. These 2 dehiscences were seen with RFFFs and were later reoperated using TDAPs. There were no cerebrospinal fluid leaks or donor-site morbidity. There were no complaints of functional deficits, such as feeding difficulties or speech impairments. Some visual disturbance was reported after orbital exenteration, although this was an expected outcome.Vascularized flaps provide reliable and durable reconstructive options for anterior and middle skull base defects after resection of large complex malignant neoplasms of the craniofacial region. Free flaps, such as RFFFs, ALTs, and TDAPs, are well suited for these defects. They have a low risk of complications and low donor-site morbidity and offer good functional and esthetic outcomes.

Endoprosthetic Reconstruction for Neoplasms of the Proximal Femur

Limb salvage has become an important alternative to amputation in the treatment of bone neoplasms. We sought to determine whether the survivorship of modular proximal femur endoprostheses compares to that of custom implants and if specified factors predict failure. We additionally assessed the intermediate clinical and functional results with regard to complications and outcome. We retrospectively reviewed 96 consecutive patients who underwent endoprosthetic reconstruction for neoplastic disease and assessed patient, implant, and limb survivorship. The mean patient age was 59 years (range, 14-86 years). The average duration of followup was 18.1 months (range, 1-129 months). Nine (9.3%) prostheses failed and the rate of revision was 7.3% (7/96). Overall implant survival was 82% at 5 years and 10 years. Survivorship of the limb was 99% at 5 years. Patients in whom the articulating head segment was a total hip had a higher rate of revision compared with those who had undergone bipolar replacement. The mean MSTS score was 22 points (range, 15-25 points). Modular endoprosthetic replacement of the proximal femur is a durable reconstructive option and implants will generally outlive the patient with neoplastic disease. Bipolar head segments should be used whenever possible because of increased survival and decreased rates of dislocation. Therapeutic study, level IV (case series).

Shoulder reconstruction after tumor resection by pedicled scapular crest graft.

The current authors present and evaluate a technique for reconstructing proximal humeral defects that result after resection of malignant bone tumors. Sixteen patients were included in this study with an average followup of 3 years (range, 12-76 months). Twelve patients had intraarticular resections, two had extraarticular resections, and two had intercalary resections. Reconstruction was done at the lateral border of the scapula (based on the circumflex scapular vessels) that was osteotomized and mobilized to bridge the resultant defect. Shoulder arthrodesis was done in 14 patients and the shoulder was spared in the two patients who had intercalary resections. Function was evaluated according to the Musculoskeletal Tumor Society scoring system. The average time for union of the graft proximally and distally was 6 months after which the graft started to hypertrophy. The average functional score was 22.5 points (75%) with a minimum score of 18 points (60%) and a maximum score of 27 points (90%). Nonunion of the distal host-graft junction occurred in two patients; both patients required iliac crest bone grafting and both achieved clinical and radiographic union without additional intervention. In three patients, the proximal fixation became loose but had no effect on function. The authors conclude that this technique is inexpensive, effective, and a durable reconstructive option for proximal humeral defects that are less than 15 cm. It has a predictable functional outcome (60%-90%) that is comparable with other reconstructive options.