Microvascular Free Transfer Research Articles

High Above Knee Amputations for Femoral Osteosarcomas Treated with Free Microsurgical Tibial Reconstruction in the Pediatric Population.

Improvements in the management of pediatric sarcoma including imaging, neo- and adjuvant therapy, and surgical technique has enhanced long-term survival of patients. Pediatric patients diagnosed with a femoral osteosarcoma undergoing oncologic resection who are ineligible for limb preservation reconstruction or rotationplasty are offered an above knee amputation (AKA). Limb amputations in the skeletally immature patient poses particular problems specific to endosteal bone overgrowth and spiking. Approximately half of these patients undergo revision of their amputation site. Furthermore, a high AKA often requires a hip-based prosthesis, which can be uncomfortable leading to poorer outcomes and higher energy expenditures.We have completed four 'spare parts' microvascular free tibial transfers for pediatric patients diagnosed with femoral osteosarcoma who were treated with an AKA. Two of these patients are currently ambulatory with their prosthetic and have not required long-term revision of their amputation site. One patient demonstrated radiographic evidence of bony union four months post-operatively, but subsequently succumbed to chemotherapy-resistant metastases. The fourth patient is in the process of prosthetic fitting and rehabilitation.This is a novel technique and the first series describing both proximal and distal free microvascular tibial bone transfers as a reconstructive option for pediatric patients with femoral osteosarcomas. It is a reliable flap with possible variations in vascular anatomy. Furthermore, it offers multiple benefits including the prevention of bony spiking, AKA stump augmentation, and facilitation of appropriate prosthetic fitting improving functional outcomes and decreased energy expenditure. However, the soft tissue coverage must be well planned.

What is the Best Choice for Esophageal Replacement in Children?

Esophageal replacement surgery is performed in children with either congenital long gap esophageal atresia or acquired esophageal damages such as caustic injury of the esophagus. although the left colon because of less variation in blood supply and suitable diameter in comparison with right colon is the better choice. A secured pedicled colon is mandatory for reducing the sever complications, such as leak and necrosis. Ileocolic conduit is an alternative method of colon interposition which has anti reflux effect and therefore with less complications related to gastroesophageal reflux. When we have a short segment esophageal stricture due to corrosive esophagitis or other causes of esophageal strictures which is refractory to repeated dilatations, it is advisable to perform colon patch esophagoplasty. Gastric transposition can produce a good way for gastrointestinal continuity with a perfect weight gain and oral feeding, therefor it can be a safe choice for esophageal replacement in children. Partial gastric pull-up is an alternative operation for esophageal replacement in children and infants with long gap esophageal atresia. Gastric conduit replacement is another alternative technique for esophageal replacement, in which a gastric tube is created in the abdomen and it is pulled to via thoracic cavity to the neck and is committed by cervical anastomosis. Antral patch esophagoplasty is used for benign and limited esophageal stricture due to gastroesophageal reflux. Usefulness of pedicled jejunum was under optimal results because of technical problems and high rate of necrosis and mortality for decades. Sternocleidomastoid myocutaneous esophagoplasty is a scarce method which is reported by some surgeons for limited cervical esophageal stricture repair. Free microvascular transfer of the reverse ileo-colon flap with ileocaecal valve valvuloplasty is used for reconstruction of a pharyngoesophageal defect, and Patch esophagoplasty by using of degradable bioscaffolds of extracellular matrix have shown good results in preclinical and clinical outcomes to prevent stenosis after endoscopic mucosectomy. We will explain the advantages and disadvantages of these different surgical methods in this review article.

Free thyroid transfer to anterolateral thigh for prevention of radiation induced hypothyroidism: An initial experience.

Radiation induced hypothyroidism (RIHT) is one of the commonest late side effects of radiation therapy and is seen in more than half of patients and affects quality of life significantly. We report our initial experience on feasibility of free microvascular transfer of thyroid gland out of radiation field to prevent development of RIHT. A prospective pilot study was undertaken during August 2017 to May 2018. Six Patients with stage III/IV patients of oral cavity cancers who required wide excision/composite resections with microvascular free flap (ALT) reconstruction and adjuvant radiation therapy were enrolled. A written informed consent was obtained from all patients prior to the procedure. The mean age of cohort was 51 years with tongue most common site of primary cancer. The free transfer of thyroid gland to anterolateral thigh was done using microvascular technique. The mean additional time for procedure was 51 min. All patients had successful transfer with no associated immediate complications. Patients were followed up with Tc99 scan, USG Doppler and biochemical assay at routine intervals in peri and postoperative period to assess the anatomical and physiological function of the transferred gland. At median follow up of 8 months, 5 patients were euthyroid and remaining one had biochemical hypothyroidism. All patients had functional thyroid gland in anetrolateral thigh. Five patient were alive, one patient died due to disease. This is a small and early feasibility study for free thyroid gland transfer and validates the previously published data. The selected group of patients who have high chances of developing RIHT may benefit from this strategy. Further validation of the technique may be explored in a larger cohort.

Multimodal analysis using flowmeter analysis, laser-Doppler spectrophotometry, and indocyanine green videoangiography for the detection of venous compromise in flaps in rats

Venous congestion results in tissue damage and remains the most common failure of free microvascular transfer if it is not recognized early. The purpose of this experimental study was to evaluate venous congestion and describe the findings with two different monitoring tools. A standardized epigastric flap was raised, and total occlusion of the draining vein was temporarily applied for 4, 5, 6, or 7 h. Blood flow measurements, including laser-Doppler flowmetry, and tissue spectrophotometry (O2C) and indocyanine green (ICG) videoangiography using the FLOW® 800 tool, were performed systematically after each surgical step, an interval of venous occlusion, and 1 week of clinical observation. Both monitoring tools were capable of detecting acute venous occlusion. ICG videoangiography data showed a significant decrease in the first and second maximum, and the area under the curve, during venous occlusion, whereas hemoglobin levels in the O2C analysis remained stable. Changes in fluorescence values in border areas of the flap correlated significantly with the incidence of necrosis. O2C data later showed significant correlation with the area of necrosis, and more individual changes during flap monitoring. ICG videoangiography might therefore be useful in the prediction of flap necrosis in critical areas of perfusion.

Congenital Pseudarthrosis of the Tibia.

➢ Patients with congenital pseudarthrosis of the tibia do not have a normal tibia. In such patients, the entire tibia is abnormal (even outside of the established pseudarthrosis site); the bone does not have a normal healing response to injury or osteotomy, and the proximal growth plate typically has an abnormal inclination. Operative attempts to promote union at the pseudarthrosis site (intramedullary nailing with bone-grafting, the Ilizarov technique, and microvascular free fibular transfer) fail to address the abnormal tibia as a whole.➢ We must critically evaluate treatment outcomes for patients with congenital pseudarthrosis of the tibia; the definition of a good result must include patient-related outcome scores rather than simply radiographic union. There is need for prospective Level-I studies to compare surgical treatment options with the addition of health-related quality-of-life scores.➢ Amputation should be viewed as a viable treatment option rather than a surgical failure.➢ The achievement of a healed, straight extremity by skeletal maturity, with as few surgical procedures as possible, is essential for a child with congenital pseudarthrosis of the tibia. The extremity must be strong enough to allow the patient to function with no activity restrictions, regardless of whether the treatment course has been limb preservation or amputation.

Free Thyroid Transfer: A Novel Procedure to Prevent Radiation-induced Hypothyroidism

The incidence of hypothyroidism after radiation therapy for head and neck cancer (HNC) has been found to be ≤53%. Medical treatment of hypothyroidism can be costly and difficult to titrate. The aim of the present study was to assess the feasibility of free thyroid transfer as a strategy for the prevention of radiation-induced damage to the thyroid gland during radiation therapy for HNC. A prospective feasibility study was performed involving 10 patients with a new diagnosis of advanced HNC undergoing ablative surgery, radial forearm free-tissue transfer reconstruction, and postoperative adjuvant radiation therapy. During the neck dissection, hemithyroid dissection was completed with preservation of the thyroid arterial and venous supply for implantation into the donor forearm site. All patients underwent a diagnostic thyroid technetium scan 6weeks and 12months postoperatively to examine the functional integrity of the transferred thyroid tissue. Free thyroid transfer was executed in 9 of the 10 recruited patients with advanced HNC. The postoperative technetium scans demonstrated strong uptake of technetium at the forearm donor site at 6weeks and 12months for all 9 of the transplanted patients. The thyroid gland can be transferred as a microvascular free transfer with maintenance of function. This technique could represent a novel strategy for maintenance of thyroid function after head and neck irradiation.

DIEAP flap for safe definitive autologous breast reconstruction

BackgroundBreast cancer is the commonest form of cancer in women affecting almost a quarter of a million patients in the US annually. 30 percent of these patients and patients with genetic mutations undergo removal of the breast, as highlighted in a high profile celebrity patient. Although breast reconstruction with free microvascular transfer of a DIEAP flap from the abdomen is an ideal form of reconstruction, there have been misgivings about the complexity and potential complications. This study was aimed at clearing these misunderstandings and establishing the value of this form of breast reconstruction. Methods1036 DIEAP flap breast reconstructions carried out at the University Hospital, Gent (five year period) and at the Sana Kliniken, Düsseldorf (three year period) were included prospectively. Comorbid factors like chemotherapy, radiotherapy, patient age >65 years, BMI >30 and smoking were recorded. Outcomes were evaluated over a mean follow up of 2 years. ResultsOverall complication rate related to the reconstructed breast and donor abdominal area was 6.8 percent. Total flap loss was seen in only 0.8 percent. The mean operating time was less than five hours. Older age, higher BMI, chemotherapy and radiotherapy did not have a significant influence on complication rates, however smoking resulted in significant delay in wound healing in the breast (p = 0.025) and abdominal wounds (p = 0.019). ConclusionThe DIEAP flap is an excellent option for breast reconstruction, with a low level of donor site morbidity and complications. It is an autologous reconstruction that provides a stable long term result.

Tissue Flap Preconditioning with Adipose Derived Stem Cells and Hyperbaric Oxygen Treatment

INTRODUCTION: Complex wound, soft tissue reconstruction and transplantation are inherently complicated by ischemia and reperfusion. Efforts at minimizing these deleterious effects involve meticulous design and minimizing the ischemic period. Adjunctive measures have included free microvascular transfer, supercharging, caspase inhibitors and free oxygen radical scavengers.1,2 In this study, we hoped to characterize the potential complementary effects of Hyperbaric Oxygen (HBO) Therapy and Stem Cell (ADSC) delivery in flap preconditioning. MATERIALS AND METHODS: In this randomized controlled trial, the study group (n=6) received autologous ADSC injections subcutaneously, whereas the control group (n=6) received saline injections to the area of flap design.3 Subsequently, half of the animal subjects were exposed to four consecutive HBO treatments. Following preconditioning, a pedicled flap was elevated and clinically assessed via study-blinded observer (Figure 1), alongside objective assessments of heat shock protein (HSP) 70 levels and quantification of TUNEL-positive cells.4 RESULTS: Serial clinical examinations monitored the consistency, color, vascularity and temperature of the skin flaps. The presence of venous congestion was significantly greater in the flaps that did not receive HBO therapy (26.7% vs. 0%, p=0.004). Distal flap necrosis was more often noted in the animal subjects who received ADSCs but were not exposed to HBO (46.7% vs. 6.7%, p=0.013) (Figure 2). Preconditioning with HBO has been shown to provide cytoprotective effects, through the upregulation of HSP 70, and a statistically significant rise was detected in the HBO saline group (p=0.042). Similarly, the TUNEL apoptosis assay indicated that the percentage of apoptotic cells was greater in the HBO saline group (p=0.003).Figure 1: Research Design and Protocol.Figure 2: Clinical Appearance of Tissue Flaps.CONCLUSIONS: Preliminary study findings support that HBO preconditioning of flaps improves tissue viability and survival rates.5 The rise in HSP 70 levels in the HBO saline group suggests a potential response to a more stressful environment and possible cytoprotective effects of ADSC. Further investigation with a larger sample size is necessary to elucidate the optimal time for ADSC injection and the true effects of HBO treatment and ADSC combination on tissue flap survival.

The versatility of the use of free-functioning gracilis muscle flap in the reconstruction of deficient motor unit

Introduction Free gracilis muscle transfer can provide reliable reconstruction of cases of lost motor unit. The aim of this study was to describe the surgical techniques used for harvesting the gracilis muscle used for reconstruction of facial paralysis and brachial plexus palsy. Patients and methods Ten patients underwent free gracilis muscle transfer. Short gracilis muscle transfer was used for facial reanimation. Extended gracilis muscle transfers were used to reconstruct patients with brachial plexus palsy. Results All of the transferred muscles were survived completely except one. The overall success rate was 90%. The average time for the start of reinnervation was 3.74 months (range, from 3 to 5 months). Discussion We used free gracilis flap for reconstruction of delayed cases with deficient motor unit. Tamai was the first to describe free microvascular transfer in dogs. Harii was the first to describe free gracilis flap in humans. The gracilis muscle has a constant anatomy, long tendon, and good excursion with few donor site morbidities. Conclusion The gracilis muscle is recommended for use as a free-functioning muscle flap for reconstruction of delayed cases of motor paralysis as in cases of facial nerve injury and brachial plexus injury.

Pediatric Lower Extremity Sarcoma Reconstruction

INTRODUCTION: Dramatic advances in the multidisciplinary treatment of pediatric sarcoma have been made in recent years resulting in significantly improved long-term survival. As survival has increased, greater effort has been made towards limb salvage and improving functional outcomes following tumor resection. Plastic surgeons in conjunction with orthopedic surgeons are applying techniques in microvascular free tissue transfer and rotational flaps to preserve limb length. METHODS: Studies describing lower extremity reconstruction following pediatric lower extremity sarcoma resection were identified by PubMed literature search. Those studies which described reconstructive techniques, oncologic and functional outcomes, and surgical complications were included. RESULTS: A total of 10 articles were identified, yielding 119 total patients. Two articles presented a wider scope of inquiry but sufficient sub-group detail to permit inclusion and three articles were single patient case reports. The average patient age ranged 9 to 14 years and overall age range was 15 weeks to 19 years. The average follow-up ranged 27 to 63 months and overall follow-up range was 0 to 168 months. The most common procedures performed were pedicled gastrocnemius +/- soleus flap (58 patients) and free fibular flap (40 patients). Eighty eight out of 116 patients (76%) achieved independent ambulation, and an additional ten patients (9%) were ambulatory with assistance. There were only three (2.5%) amputations. Seven patients died from metastatic disease (5.9%). CONCLUSIONS: Plastic surgery procedures play an increasingly important role in pediatric lower extremity sarcoma reconstruction and functional limb salvage. Published series are limited in number and case volume, and no systematic review has been published to date. However, the existing data emphasizes the role for local muscle flap coverage as well as microvascular free fibula transfer in preserving limb length and function, with a minimal risk of local recurrence and need for amputation.

Objective Outcomes Analysis Following Microvascular Gracilis Transfer for Facial Reanimation

IMPORTANCE Objective assessment of smile outcome after microvascular free gracilis transfer is challenging, and quantification of smile outcomes in the literature is inconsistent. OBJECTIVE To report objective excursion and symmetry outcomes from a series of free gracilis cases and investigate the predictive value of intraoperative measurements on final outcomes. DESIGN, SETTING, AND PARTICIPANTS A retrospective medical chart review was undertaken of all patients who underwent microvascular free gracilis transfer for smile at our institution over the past 10 years. MAIN OUTCOMES AND MEASURES Outcome measures included the following: smile excursion, angle of smile with respect to the vertical midline, and facial symmetry during repose and with smile. Measurements were obtained using an automated tool for assessment of facial landmarks (FACE-Gram). An exhaustive set of intraoperative parameters including degree of recoil of the gracilis muscle following harvest, the degree to which the muscle foreshortened during stimulation of the obturator nerve, final stretched length of the inset muscle, surgeon assessment of neurorrhaphy and pulse pressure, ischemia time, number of sutures used during neurorrhaphy, nerve used to innervate the flap, and surgeon assessment of oral commissure overcorrection were recorded and placed into a linear regression model to investigate correlations with smile. RESULTS From March 2003 to March 2013, 154 microvascular free gracilis transfers were performed for facial reanimation at our institution, 14 (9%) of which were deemed failures. Of the remaining 140 flaps, 127 fulfilled inclusion criteria and constituted the study cohort. Smile excursion, angle excursion, and symmetry of the oral commissure at repose and with smile all improved following gracilis free flap (P < .05). Associations between selected outcomes measures and intraoperative gracilis measurements were identified. CONCLUSIONS AND RELEVANCE Facial reanimation using free gracilis transfer results in quantifiable improvements in oral commissure excursion and facial symmetry both at rest and with smiling. Associations between contractility and internal recoil of the flap and final outcome were identified. LEVEL OF EVIDENCE 4

The NYU Experience With Free Fibula Reconstruction of the Mandible Utilizing Virtual Surgical Planning

Statement of the Problem: The use of free osseous flaps has become the gold standard for reconstruction of complex mandibular defects. Popularized by Hidalgo in 1989, the free fibula transfer has become the operation of choice for these indications. While this operation has become routine; contouring of the flap using wedge osteotomies, as well as its inset remain operator dependent and imprecise. At our institution we have attempted to make this process more uniform and reproducible through the use of virtual planning and pre-fabricated cutting jigs. We have previously reported our experience on computer-aided design and manufacturing; however the purpose of this study was to review our series of free fibula mandibular reconstructions using these adjunctive technologies. Methods: Prior to surgery all patients underwent CT scanning of the face and bilateral lower extremities. These images were then transmitted to an outside vendor. In consultation with both the ablative and reconstructive teams, a surgical plan was devised and performed virtually, cutting jigs for both creation of themandibular defect and for fibular osteotomies were fabricated, and a stereolithicmodel that allows for precise pre-surgical bendingof a reconstructionplatewas created. The rest of the surgical procedure was performed in standard fashion. Following IRB approval, all cases between 2009 and 2012were identified and retrospectively reviewed. In addition to patient demographics, the charts were reviewed for surgical indications, microvascular anastomoses, use of a skin paddle, use of a ‘‘double barrel’’, timing of dental implant placement (immediate versus delayed), and timing of dental prosthetic rehabilitation (immediate versus delayed). Methods of Data Analysis: This was a retrospective chart review from 2009 to the present. Fifty-four reconstructionswere identified ashavingundergonepresurgical virtual planning and subsequent surgery formandibular reconstruction with microvascular free fibula transfer. Patient demographics and case variables were analyzed. Results: Fifty-four reconstructions were performed in 52 patients. Patients were evenly divided between a private, university affiliated medical center and a large county hospital. The most common indications were ma-

The functional peroneus brevis as a third muscle component in the osteomyocutaneous fibula free-flap system

Up to now, the peroneus brevis muscle was harvested as a non-functional pedicled muscle flap for defects around the ankle and the anterior lower leg. It has a reliable dual segmental vascularisation from the peroneal and the anterior tibial artery and a long, single motor nerve entering proximally. We report of a free microvascular transfer of the peroneus brevis as a neurotised functional muscle component in a composite osteo-musculo-cutaneous flow-through fibula flap. The flap components were used to reconstruct extensive radial and soft-tissue defects in a severely damaged forearm, whereas the peroneus brevis nerve was coapted to the proper flexor carpi radialis (FCR) motor nerve to counterbalance ulnar abduction, as all radial abductors were lost in the injury. Thirteen months later, the arm was fully reconstructed and an active radial abduction of 15° by the contracting peroneus muscle was achieved. Donor-site complications were absent. The peroneus brevis can expand the versatility of the peroneal-vessel-flap system as a third muscular component in four possible ways: a) addition of plain muscle bulk in the middle- and lower third of the fibula if left attached to the bone, b) as a reinnervated functional muscle as presented here, c) as a distally based muscle component if released from its origin from the middle third of the fibula and pedicled on its distal segmental branches from the peroneal vessels or d) as a distally pedicled osteomuscular flap permitting individual placement of a middle fibula segment.

Surgical Technique for Osteocutaneous Pedicle Flap Transfer for Salvage of Transtibial Amputation After Severe Lower-Extremity Injury.

Osteocutaneous pedicle flap transfer from the foot can be used to "salvage" a transtibial amputation level when the severity of an injury precludes a transtibial amputation. If the posterior tibial artery is not palpable, obtain an angiogram to determine the vascular supply distal to the traumatic zone and to prepare for conversion to a composite free microvascular transfer. Remove provisional stabilization implants and minimize surgery about the knee. The dissection about the tarsal tunnel is the critical portion of the operative technique. Any deviation from perpendicular will translate to an axial deformity in the reconstructed limb. Retain viable soft tissues and bone, but resect the fibula obliquely. Avoid varus and recurvatum malalignment. The injured limb is routinely very swollen, and in some cases complete coverage requires split-thickness skin-grafting. As the initial reconstruction is sometimes extremely bulbous, continually advise the patient that the shape will improve dramatically over time with shrinkage of the limb. In our original study, ten men and four women with a mean age of 43.2 years (range, twenty-four to sixty-four years) underwent an osteocutaneous pedicle flap transfer with use of the ipsilateral foot for salvage to achieve a transtibial amputation level. IndicationsContraindicationsPitfalls & Challenges.

Imaging, Virtual Planning, Design, and Production of Patient-Specific Implants and Clinical Validation in Craniomaxillofacial Surgery

The purpose of this article was to describe the workflow from imaging, via virtual design, to manufacturing of patient-specific titanium reconstruction plates, cutting guide and mesh, and its utility in connection with surgical treatment of acquired bone defects in the mandible using additive manufacturing by electron beam melting (EBM). Based on computed tomography scans, polygon skulls were created. Following that virtual treatment plans entailing free microvascular transfer of fibula flaps using patient-specific reconstruction plates, mesh, and cutting guides were designed. The design was based on the specification of a Compact UniLOCK 2.4 Large (Synthes(®), Switzerland). The obtained polygon plates were bent virtually round the reconstructed mandibles. Next, the resections of the mandibles were planned virtually. A cutting guide was outlined to facilitate resection, as well as plates and titanium mesh for insertion of bone or bone substitutes. Polygon plates and meshes were converted to stereolithography format and used in the software Magics for preparation of input files for the successive step, additive manufacturing. EBM was used to manufacture the customized implants in a biocompatible titanium grade, Ti6Al4V ELI. The implants and the cutting guide were cleaned and sterilized, then transferred to the operating theater, and applied during surgery. Commercially available software programs are sufficient in order to virtually plan for production of patient-specific implants. Furthermore, EBM-produced implants are fully usable under clinical conditions in reconstruction of acquired defects in the mandible. A good compliance between the treatment plan and the fit was demonstrated during operation. Within the constraints of this article, the authors describe a workflow for production of patient-specific implants, using EBM manufacturing. Titanium cutting guides, reconstruction plates for fixation of microvascular transfer of osteomyocutaneous bone grafts, and mesh to replace resected bone that can function as a carrier for bone or bone substitutes were designed and tested during reconstructive maxillofacial surgery. A clinically fit, well within the requirements for what is needed and obtained using traditional free hand bending of commercially available devices, or even higher precision, was demonstrated in ablative surgery in four patients.

Selective Epithelial Ischemia of Transferred Free Jejunum After Late Loss of Its Vascular Pedicle

Free flaps are considered to revascularize from the surrounding tissue and survive without their original pedicle flow after a certain period postoperatively. We report 2 patients who developed mucosal ischemia of the transferred jejunum by ligation of its vascular pedicle 10 and 25 months after microvascular free jejunal transfer. Both patients had a history of heavy smoking, and had undergone definitive radiotherapy and previous surgery to the recipient bed. Both were treated conservatively; however, a stenotic change of the transferred jejunum remained in 1 patient. If poorly revascularized flaps, such as jejunal flaps, were transferred to the irradiated and scarred recipient bed, revascularization might never reach completion. If pedicle division is required in such cases, reanastomosis of the pedicle would be ideal regardless of the time after the transfer.

Implant-based dental rehabilitation in reconstructed mandible – problems and solutions

Microvascular free fibula transfer is accepted as the gold standard in jaw reconstruction following ablative surgery. Apart from fibula, other free bone flaps are also used in select situations. With the emphasis shifting to the quality of life in the post-treatment phase, dental rehabilitation has acquired an unprecedented importance. Implant-supported dentures are certainly the best way to achieve this.

Multiple toe transfer and sensory free flap use after a traumatic amputation of multiple digits. Surgery done in a single setting: A case study

Crush avulsion injuries to the hand with concomitant traumatic amputation of multiple digits can be a devastating injury to the patient. These injuries have multiple issues occurring under emergency conditions. When feasible, replantation of the multiple digits is optimal, but in many cases, it is not possible. Because of the crushing force on the digits, they are not viable candidates for replantation. The usual course of treatment for these patients is a two stage procedure, usually involving a groin flap. Here, we present the case of a patient who had a left hand skin avulsion of the whole palm and P1 of index, long, ring and small fingers. The left index finger had a complete amputation at the P2 level, the long, ring and small fingers all had complete amputations at the P1 level. This injury was dealt with by a left foot second and third toe transplant, a sensory free flap from the left big toe and a fourth toe microvascular free transfer to the left hand. The remainder of the defect was managed with a 10 × 14 cm reversed radial forearm flap and a combination of full and split thickness skin grafts. The procedure was performed in a single operation, obviating the need for a second surgery. This procedure optimized the patient's outcome during a single setting, making it an ideal choice in an emergency setting.

Reconstruction of Facial Nerve Injuries in Children

Facial nerve trauma is uncommon in children, and many spontaneously recover some function; nonetheless, loss of facial nerve activity leads to functional impairment of ocular and oral sphincters and nasal orifice. In many cases, the impediment posed by facial asymmetry and reduced mimetic function more significantly affects the child's psychosocial interactions. As such, reconstruction of the facial nerve affords great benefits in quality of life. The therapeutic strategy is dependent on numerous factors, including the cause of facial nerve injury, the deficit, the prognosis for recovery, and the time elapsed since the injury. The options for treatment include a diverse range of surgical techniques including static lifts and slings, nerve repairs, nerve grafts and nerve transfers, regional, and microvascular free muscle transfer. We review our strategies for addressing facial nerve injuries in children.

Vascularized fibula transfer for lower limb reconstruction

Massive bony defects of the lower extremity are usually the result of high-energy trauma, tumor resection, or severe sepsis. Vascularized fibular grafts are useful in the reconstruction of large skeletal defects, especially in cases of scarred and avascular recipient sites, or in patients with combined bone and soft-tissue defects. Microvascular free fibula transfer is considered the most suitable autograft for reconstruction of the middle tibia because of its long cylindrical straight shape, mechanical strength, predictable vascular pedicle, and hypertrophy potential. The ability to fold the free fibula into two segments or to combine it with massive allografts is a useful technique for reconstruction of massive bone defects of the femur or proximal tibia. It can also be transferred with skin, fascia, or muscle as a composite flap. Proximal epiphyseal fibula transfer has the potential for longitudinal growth and can be used in the hip joint remodeling procedures. Complications can be minimized by careful preoperative planning of the procedure, meticulous intraoperative microsurgical techniques, and strict postoperative rehabilitation protocols. This literature review highlights the different surgical techniques, indications, results, factors influencing the outcome, and major complications of free vascularized fibular graft for management of skeletal or composite defects of the lower limb.