Partial Graft Failure Research Articles

1497-P: Comprehensive Metabolic Assessment Reveals Excellent and Stable Glucose Control during First Year after Pancreas Transplantation

Introduction: Limited data are available regarding comprehensive metabolic evaluation after Pancreas transplantation (PT) for T1DM. Methods: We prospectively studied 15 PT recipients at baseline, 4 months & 1 year after PT. Subjects used Dexcom G4/G6 CGM for 1 week & a standard Mixed Meal Test (MMT) was performed. Results: PT recipient were 45.1 ± 11.9 years old, F 10, BMI (Kg/m2) 24.4 ± 3.6 & mean duration diabetes 26.8 ± 14.3 years. Seven patients received pancreas alone, five simultaneous pancreas kidney & three pancreas after kidney transplants. Baseline values were Hb 10.4 ± 1.2 (g/dl), HbA1c 6.6 ± 1.1 %, Albumin 4.0 ± 0.4 g/dl, Fructosamine 245.7 ± 37.2 (µmol/L), Fasting glucose 94.9 ± 20.6 mg/dl, C-peptide 4.4 ± 2.8 (ng/ml), eGFR 64.7 ± 17.6 ml/min and AST 18.5 ± 6.7 U/L. Two participants developed partial graft failure: one due to a peri-pancreatic abscess requiring long term drainage & the second patient had nonadherence issues. MMT after adjusting for eGFR revealed excellent glucose concentration & C-peptide/insulin concentrations at all 3 visits. On CGM analysis, mean CGM was similar at V1, V2 and V3 & overall glucose control was excellent with > 89 % of readings within 70-180mg/dL on all visits (Table). Conclusion: PT recipients demonstrate excellent glucose control on comprehensive assessment at multiple time points in the first year after PT. Disclosure R.Kaur: None. S.Rizvi: None. C.Reid: None. B.H.Smith: None. A.Kukla: Advisory Panel; Novo Nordisk, Other Relationship; Dexcom, Inc. M.D.Stegall: None. Y.C.Kudva: Advisory Panel; Novo Nordisk, Research Support; Dexcom, Inc.

Corneal Allograft Endothelial Rejection after Sinopharm COVID-19 Vaccination; Report of Six Cases

ABSTRACT Aim To report the clinical characteristics of six patients with corneal allograft endothelial rejection after COVID-19 vaccination with Sinopharm and to review the literature. Methods This is a prospective case series describing corneal allograft rejection among subjects having received Sinopharm (BBIBP-CorV) vaccine, coming to cornea clinic at a university-based hospital (Rassoul Akram Hospital, Tehran, Iran) from September 2021 to March 2022 for regular follow-up examinations. Data on demographics, vaccination (based on vaccine card), and graft condition (based on recent examination and previous medical documents) were recorded. Results Out of 54 eyes (46 patients), 6 eyes (6 patients) had corneal allograft endothelial rejection after 3 to 117 days, post-vaccination. Three out of six rejections occurred within two weeks following vaccination. All of them were male with the mean age of 53.00 ± 19.66 years. The graft type of all patients was penetrating keratoplasty (PKP). The adverse event developed on average at 40.67 ± 34.33 months after surgery. Four patients were under maintenance treatment by topical steroid at the time of vaccination. One also received systemic immunomodulatory medication. Four grafts ended up with partial or complete graft failure. One case had received two doses of vaccine before undergoing the second corneal graft transplantation. Conclusion COVID-19 vaccination with Sinopharm may trigger corneal allograft endothelial rejection even in individuals with low-risk graft and under maintenance topical and/or systemic immunomodulatory medications.

Are tie-over bolster dressings necessary for healing or success of full thickness skin graft reconstruction following facial skin cancer excision?

Skin grafts are commonly used for reconstruction of defects following excision of facial skin cancers. Tie-over bolster dressings are routinely placed to secure these grafts, but are they necessary for healing or graft success?A total of 96 patients was treated from 2013-2019 who underwent full thickness skin graft (FTSG) reconstruction following facial skin cancer excision were retrospectively analysed. All patients were treated by one consultant with non-fenestrated FTSG’s placed on defects varying from 10 to 55mm in maximum diameter. Grafts were sutured circumferentially with a continuous resorbable suture. Tie-over bolster dressings were not used, and the recipient site was dressed with MepitelTMand SteristripsTM. Primary defect sites where we used this technique included the pinna, the nose and face, and less commonly, the scalp. Graft harvest sites included the neck, pre-auricular, and submental regions.Complete graft take was noted in 94/96 patients. Partial graft failure was observed in two patients, one who healed and had successful late scar revision surgery and one who was managed conservatively and healed well. Two further patients with complete graft healing later underwent minimal revisional contour surgery with satisfactory results.This retrospective study has shown FTSG success in cutaneous defects of the head and neck to be excellent without the use of tie-over bolsters. This has significant benefits of saving operative time, reducing cost, and sparing the patient both unnecessary intraoperative steps, and the inconvenience of a bolster with its often-painful removal. We recommend that the use of tie-over bolsters in the management of most FTSG reconstructed head and neck cutaneous defects be considered an unnecessary step. We believe there are no adverse effects of our described simple technique, and that there are significant benefits to the patient.

P.140: Impact of Successful Pancreas Transplantation on Patient Reported Hypoglycemia Outcomes

Introduction: Poorly controlled Type 1 Diabetes (T1D) is associated with increased HbA1c, increased severe hypoglycemia, decreased hypoglycemia awareness and diabetic ketoacidosis. These comorbidities and decreased quality of life are indications for Pancreas Transplantation (PT). Limited data are available about patient reported outcomes (PROs) related to Hypoglycemia after PT. Therefore, we prospectively studied these PROs over a year after PT in patients with T1D. Methods: Ten PT recipients were enrolled within a month after PT and completed 3 visits (V1, V2 & V3 at 4 weeks, 4 months and 1 year). At each visit, participants completed Hypoglycemia Fear Survey-II (HFS-II) and Clarke hypoglycemia unawareness survey. HFS-II is a 33-item questionnaire to measure behavior and worry subscales related to fear of hypoglycemia in patients with T1D. Behavior subscale (HFS-B) describes behaviors individual would engage in to avoid hypoglycemia or its consequences. Worry subscale (HFS-W) describes concerns related to hypoglycemia. Clarke questionnaire evaluates awareness of hypoglycemia based on responses to 8 questions, identifying awareness (A) or reduced awareness (R). The Clarke R score ranges from 0 to 7 with ≤ 2 indicating normal A, 3 as undetermined A and score ≥4 suggesting impaired awareness of hypoglycemia (IAH). We analyzed insulin independent and partial graft function on insulin separately. Statistical analysis was done using a linear mixed effects model. Results: Patients were 46.3 ± 14.3 years old, 9 F, duration of T1D 27.8 ± 15.8 years with 29.4 ± 18.3 days interval from PT. Laboratory results were HbA1c (%) 6.3, 5.4 and 5.4, fasting plasma glucose (mg/dL) 88.6, 104.8 and 91 and C-peptide (ng/ml) 4.6, 3.1 and 2.4 on V1, 2 & 3 respectively. In insulin independent participants (n=8), HFS-B showed almost every participant reported taking some behavioral measures over last 6 months to avoid hypoglycemia at V1. On V2, five participants took some behavioral measures and on V3 only one to avoid hypoglycemia (Table). HFS-W showed almost every participant had some concerns about low blood sugar at V1, five on V2 and none on V3. Two participants who had partial graft function around V2 engaged in behavior to avoid hypoglycemia on V1, 2 & 3, with a subsequent decreased behavioral engagement (p 0.1197) and concern to avoid hypoglycemia (p 0.1391) compared to V1. Clarke scoring showed indeterminate awareness at V1, improved significantly (p 00.0146) and attained normal hypoglycemia awareness over the year on V2 and V3 respectively (Table). Two participants who had partial graft failure reported IAH on all 3 visits (V1: V2:V3=5.0: 4.0: 4.0, p 0.5000). Conclusion: PT recipients reported reduced Fear of hypoglycemia and improved hypoglycemia awareness over a period of 1 year, even in patients with partial graft function. More studies would enable better assessment of these PROs and improve the field.

Consensus of free flap complications: Using a nomenclature paradigm in microvascular head and neck reconstruction.

We aim to define a set of terms for common free flap complications with evidence-based descriptions. Clinical consensus surveys were conducted among a panel of head and neck/reconstructive surgeons (N=11). A content validity index for relevancy and clarity for each item was computed and adjusted for chance agreement (modified kappa, K). Items with K < 0.74 for relevancy (i.e., ratings of "good" or "fair") were eliminated. Five out of nineteen terms scored K < 0.74. Eliminated terms included "vascular compromise"; "cellulitis"; "surgical site abscess"; "malocclusion"; and "non- or mal-union." Terms that achieved consensus were "total/partial free flap failure"; "free flap takeback"; "arterial thrombosis"; "venous thrombosis"; "revision of microvascular anastomosis"; "fistula"; "wound dehiscence"; "hematoma"; "seroma"; "partial skin graft failure"; "total skin graft failure"; "exposed hardware or bone"; and "hardware failure." Standardized reporting would encourage multi-institutional research collaboration, larger scale quality improvement initiatives, the ability to set risk-adjusted benchmarks, and enhance education and communication.

Physical plasma therapy accelerates wound re-epithelialisation and enhances extracellular matrix formation in cutaneous skin grafts.

Skin grafting is a surgical method of cutaneous reconstruction, which provides volumetric replacement in wounds unable to heal by primary intention. Clinically, full-thickness skin grafts (FTSGs) are placed in aesthetically sensitive and mechanically demanding areas such as the hands, face, and neck. Complete or partial graft failure is the primary complication associated with this surgical procedure. Strategies aimed at improving the rate of skin graft integration will reduce the incidence of graft failure. Cold atmospheric plasma (CAP) is an emerging technology offering innovative clinical applications. The aim of this study was to test the therapeutic potential of CAP to improve wound healing and skin graft integration into the recipient site. In vitro models that mimic wound healing were used to investigate the ability of CAP to enhance cellular migration, a key factor in cutaneous tissue repair. We demonstrated that CAP enhanced the migration of epidermal keratinocytes and dermal fibroblasts. This increased cellular migration was possibly induced by the low dose of reactive oxygen and nitrogen species produced by CAP. Using a mouse model of burn wound reconstructed with a full-thickness skin graft, we showed that wounds treated with CAP healed faster than did control wounds. Immunohistochemical wound analysis showed that CAP treatment enhanced the expression of the dermal-epidermal junction components, which are vital for successful skin graft integration. CAP treatment was characterised by increased levels of Tgfbr1 mRNA and collagen I protein in vivo, suggesting enhanced wound maturity and extracellular matrix deposition. Mechanistically, we show that CAP induced the activation of the canonical SMAD-dependent TGF-β1 pathway in primary human dermal fibroblasts, which may explain the increased collagen I synthesis in vitro. These studies revealed that CAP improved wound repair and skin graft integration via mechanisms involving extracellular matrix formation. CAP offers a novel approach for treating cutaneous wounds and skin grafts. © 2020 The Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Coverage of residual defects by using previous flaps: Flip flap puzzle flap

IntroductionTerminal flap necrosis and flap retraction is a difficult problem faced by surgeons. These require some other flap for coverage of defect with limited local tissue availability. Flip flap puzzle flap is an option for small defect coverage using previous flap. MethodologyThis flap is harvested from previous flap and raised at sub-dermal level. The flap is flipped 180° on itself to cover the defect. The residual area is finally covered with split skin graft. ResultsThis is a prospective study conducted on 10 patients, with 9 flap survival and 1 flap failure. In 7 out of 10 cases partial graft failure was observed, but all the defects healed eventually. Discussion and conclusionThis flap is a less morbid and rapid option for coverage of small sized defects. It has no donor site morbidity as flap is raised from the previously harvested flap.

Clinical Outcomes of Negative-Pressure Wound Therapy with Instillation without Commercial Devices in the Treatment of Complex Wounds

Background: Negative-pressure wound therapy with instillation (NPWTi) is an adjunctive treatment modality for complex and infected wounds. However, commercial devices are expensive and not readily available in many countries. The objective of this study is to introduce an NPWTi method that is applicable where commercial NPWTi devices are not available and to report the clinical outcomes of the NPWTi method for the adjunctive treatment of complex wounds.Methods: This prospective clinical experimental study included 51 patients who had wounds on which operative debridement was performed between January 2017 and March 2019. A negative-pressure wound therapy (NPWT) device was applied with an intravenous (IV) line for continuous instillation of 0.9% normal saline plus 1% povidone-iodine solution for chronic wounds. The outcomes measured were the number of operating room visits, time to final surgical procedure, number of infected wounds, time to resolution of infection, type of reconstruction operation, and occurrence of complications.Results: The average number of operations performed was 2.5±0.8, and the time to final surgical procedure was 28.4±15.4 days. The number of infected wounds was 35 (68.6%), and the time to resolution of infection was 15.0±14.6 days. All wounds were closed or covered. Though partial graft failure occurred in two cases, they healed completely by secondary healing in 2 weeks.Conclusion: A continuous-instillation NPWT system using an IV line could be an adjunctive modality in treating complex wounds at institutions where commercial NPWTi systems are not readily available.

Local/regional flaps for extensive abdominal wall defects: Case series

IntroductionExtensive abdominal wall defects requiring reconstruction with flaps are best done with free flaps. However, free flaps are not readily available in many countries. Free flaps are associated with long operative hours, technically demanding and are prone to complications. However, local or regional flaps are a better option in managing such defects especially in resource-limited settings. ObjectiveThis was a prospective study to determine the outcome of patients with extensive abdominal defects managed with local or regional flaps. ResultsA total of fifteen patients with extensive abdominal wall defects were reconstructed with local/regional flaps. Ten of these patients were managed with pedicle anterior lateral thigh flaps with two tensor fascia lata flap and three para-umbilical abdominal flaps. The defect ranged from 90 to 300 cm2 in size. All the flaps were successful, with only one patient experiencing flap dehiscence in a wound that had sepsis. Donor site wounds in one patient had partial skin graft failure necessitating regular dressing and repeat grafting later. ConclusionLocal/regional flaps are reliable, good options for the management of majority of the anterior abdominal wall defects, as they are less demanding, do not require long operative hours and are easy to monitor post operatively. They should be considered in most reconstructive needs of the abdominal wall.

Split-thickness skin grafts obtained from adjacent hairy skin for reconstructing auricular concave surfaces after Mohs surgery.

Reconstruction of large auricular defects with full-thickness skin grafts (FTSG) is a commonly reported option, but less attention has focused on the advantages and indications of using split-thickness skin grafts (STSG) in the ear. We sought to report our experience using STSG for repair of defects located on the auricular concave surfaces, highlighting the utility of choosing the adjacent hairy skin as donor site. We performed a retrospective review of all Mohs micrographic defects on the auricular concave surfacesrepaired with STSG obtained from the adjacent hairy skin, between January 2017 and July 2018 at our institution. A total of 16 patients with defects on the auricular concavities resulting from removal of non-melanoma skin cancer were reconstructed with STSG taken from the adjacent hairy skin. Only one patient experienced partial graft failure and no other complications were observed after 6-month follow-up. Split-thickness skin grafts are suitable for reconstructing concave areas in the ear, providing good cosmetic results with a simple, cost-effective and easily reproducible technique. Choosing the adjacent hairy skin as a donor area shortens the operative and postoperative time, and allows the procedure to be performed in a single surgical field.

Hand Doppler flowmetry for surgical planning of pedicled flap in extensive full-thickness scalp reconstruction

Reconstruction of scalp defects can be performed with local flaps for medium to large defects (2–25 cm2) and microvascular free flaps for extensive full-thickness scalp reconstruction greater than 25 cm2. Doppler flowmetry with its ability to exactly mark the course of arteries on the overlying skin, is a useful tool for the surgical planning of large local flaps. In our retrospective study conducted on 38 patients (all patients had malignancies or post-traumatic scalp defects), consisting of 39 total surgical procedures, we studied the impact of doppler ultrasonic flowmetry in the surgical planning for pedicled flaps in extensive full-thickness scalp reconstruction (>25 cm2) by evaluating overall flap survival rate. Nine different types of local flaps were employed in the scalp reconstruction: Superficial temporal artery (STA) pedicled rotation flap, STA pedicled transposition flap, STA islanded flap, bipedicled STA flap, bipedicled fronto-occipital flap, Supraorbital/Supratrochlear artery rotation flap, Supraorbital/Supratrochlear artery transposition flap, Occipital artery (OA) pedicled rotation flap, OA pedicled transposition flap. Before each surgical procedure a hand held doppler Huntleigh Diagnostic flowmeter with a 8 MHz probe was used to identify and follow the course of the arteries. Flap survival rate was 100%. No postoperative complications related to the flap were reported, while in two patients a partial skin graft failure occurred.

Feasibility and Advantages of Full Thickness Skin Graft from the Anterolateral Thigh.

Full thickness skin graft (FTSG) gives better outcomes than split thickness skin graft (STSG), but it has the drawback of limited donor sites. Anterolateral thigh (ALT), a popular donor site of STSG, is also a popular donor site of perforator flaps. This area has the advantage of large flap size available with primary closure. Based on this we harvested FTSG instead of STSG from the ALT. We retrospectively reviewed 10 cases of FTSG from the ALT, with the recipient site of foot in 3, ankle in 2, lower leg in 2, forearm in 2, and wrist in 1 patient. In all cases elliptical full thickness skin was harvested from the ALT, and the donor site was closed primarily. The skin was defatted and placed onto the defect with vacuum-assisted closure (VAC). The skin size ranged 7-30 cm in length and 3-12 cm in width. Mean follow up period was 7 months (range, 3-13). FTSG from the ALT provided durable wound coverage, with excellent color and texture matching. Partial (< 20%) graft failure was observed in 1 case, but no additional surgery was necessary. No patient reported donor site pain at postoperative 2 weeks. No donor site complications were encountered. No patient complained a feeling of tension in the thigh at final follow-up. FTSG from the ALT is feasible with the aid of VAC. Considering the skin quality, large skin size available, early pain relief, and little donor site morbidity, the ALT should be revisited as a donor site of FTSG.

Management of Saddle Nose Deformity Using Dermal Fat and Costal Cartilage “Sandwich” Graft: A Problem-Oriented Approach and Anthropometric Evaluation

In the surgical treatment of saddle nose deformity (SND), costal cartilage is often used. However, it can result in some potential complications such as resorption, bending, displacement, and its appearance under the skin (silhouette deformity). We prepared a composite "sandwich" graft by camouflaging the costal cartilage underneath the dermal fat graft as a novel method and applied it on SNDs using the closed rhinoplasty technique to prevent or minimize these risks. The method was used for 21 patients (12 males and 9 females). Six anthropometric measurements, including the nasal dorsum projection, nasal supratip projection, nasal tip projection, nose length, labiocolumellar angle, and nasofrontal angle, were taken using the ImageJ program (National Institutes of Health, Bethesda, MD) on preoperative and postoperative lateral photographs. The data were compared statistically. The mean follow-up time was 29.95months. No donor site complications developed. The sandwich grafts transferred to the nose were well tolerated in all patients. A partial graft failure and a mild bending, which were treated conservatively without supplemental surgery, developed in 1 patient each. No resorption, migration, bending, or appearance under the skin of the sandwich grafts were seen in the remaining patients. A statistically significant difference was found in all anthropometric measurements from the preoperative and postoperative groups except for2. The severity of the deformity should be exactly determined before surgery, and cartilage grafts should be used accordingly for successful repair of SND. The sandwich technique, as a practical, effective, and long-lasting treatment method, could minimize the potential complications and risks of revision.

Eyelid Reconstruction with Full Thickness Skin Grafts After Carcinoma Excision

Various techniques have been proposed for reconstruction of the eyelid anterior lamella after carcinoma excision: among these are the transposition of skin flaps, and full-thickness skin grafts or combination of these two. To present our experience in eyelid reconstruction with full-thickness skin grafts and to assess the aesthetic and functional outcomes. The present retrospective study included 39 patients (20 males, 19 females, mean age 71 yrs) with surgically excised eyelid carcinoma, followed by reconstruction using full-thickness skin grafts. The patients were treated between 2005 and 2014. Parameters recorded were patient demographics, histological classification of malignancy, tumor localization and size, postoperative defect size. In cases of large full-thickness lower lid defect Hughes tarsoconjunctival flap was used for reconstruction of posterior lamella. Full-thickness skin grafts donor sites included upper eyelid, preauricular area and inner brachial area. We appraised the grafts viability one week after surgery and the aesthetic results - 6 months after surgery by the graft colour and lid position. In 95% of the cases the skin grafts were viable. The full-thickness skin graft (FTSG) failed in two patients because of subcutaneous haematoma. There were a few early postoperative complications including graft hypertrophy, graft contraction, and partial graft failure, which were managed without additional surgery. All 39 patients had normal postoperative lid function. All 39 had either good (14) or excellent (25) cosmetic results. Our findings suggest that full-thickness skin graft is a good choice in periocular reconstructive surgery after carcinoma excision. The surgical technique is easy to perform producing proper functional and aesthetic results.

Staged management of the open abdomen and enteroatmospheric fistulae using split-thickness skin grafts

BackgroundManagement of the open abdomen with polyglactin 910 mesh followed by split-thickness skin grafts allows safe, early closure of abdominal wounds. This technique can be modified to manage enteroatmospheric fistulae. Staged ventral hernia is performed in a less inflamed surgical field. MethodsA retrospective review was performed of 59 consecutive patients who underwent abdominal skin grafting for open abdominal wounds from 2001 to 2011. ResultsThe median length of follow-up was 215 days. Thirty-one percent of patients presented with preexisting enteroatmospheric fistulae, and 41% required polyglactin 910 mesh placement before skin grafting. Partial or complete skin graft failure occurred in 7 patients. Four patients required repeat skin grafting. All patients ultimately achieved abdominal wound closure, and none developed de novo fistulae. ConclusionsWith proper technique, skin grafting of the open abdomen with a planned ventral hernia repair is a safe and effective alternative to delayed primary closure.

Deceased Donor Liver Transplantation in Infants and Small Children: Are Partial Grafts Riskier Than Whole Organs?

Infants have the highest wait-list mortality of all liver transplant candidates. Although previous studies have demonstrated that young children may be at increased risk when they receive partial grafts from adult and adolescent deceased donors (DDs), with few size-matched organs available, these grafts have increasingly been used to expand the pediatric donor pool. We aimed to determine the current adjusted risks of graft failure and mortality in young pediatric recipients of partial DD livers and to determine whether these risks have changed over time. We analyzed 2683 first-time recipients of DD livers alone under the age of 24 months in the United Network for Organ Sharing database (1995-2010), which included 1118 partial DD livers and 1565 whole DD organs. Transplant factors associated with graft loss in bivariate analyses (P < 0.1) were included in multivariate proportional hazards models of graft and patient survival. Interaction analysis was used to examine risks over time (1995-2000, 2001-2005, and 2006-2010). Although there were significant differences in crude graft survival by the graft type in 1995-2000 (P < 0.001), graft survival rates with partial and whole grafts were comparable in 2001-2005 (P = 0.43) and 2006-2010 (P = 0.36). Furthermore, although the adjusted hazards for partial graft failure and mortality were 1.40 [95% confidence interval (CI) = 1.05-1.89] and 1.41 (95% CI = 0.95-2.09), respectively, in 1995-2000, the adjusted risks of graft failure and mortality were comparable for partial and whole organs in 2006-2010 [hazard ratio (HR) for graft failure = 0.81, 95% CI = 0.56-1.18; HR for mortality = 1.02, 95% CI = 0.66-1.71]. In conclusion, partial DD liver transplantation has become less risky over time and now has outcomes comparable to those of whole liver transplantation for infants and young children. This study supports the use of partial DD liver grafts in young children in an attempt to significantly increase the pediatric organ pool.

Article Commentary: Optimizing Aesthetic Results in Skin Grafting

The aesthetic goal in skin grafting is to provide a cosmetically pleasing coverage of soft tissue defects while minimizing donor site morbidity. A skin graft should blend well with the color and texture of the surrounding skin, reduce wound size, and not interfere with the function of the reconstructed part. This review examines the key components of choosing the appropriate donor skin for a variety of defects. The decision-making process is based on the anatomic location of the defect; donor site availability; and graft size, thickness, and pigmentation. The aesthetic implications of using a sheet graft versus a meshed graft versus an expanded graft are discussed. Aside from addressing the aesthetic needs of the defect, attention is paid to the functional goals of the reconstructed part and reduced donor site morbidity. Partial graft failure can have significant deleterious effects on the aesthetic outcome of skin grafts. The need for further grafting or healing by secondary intention may result in additional scarring and deformity. Recommendations for improvement in graft take and infection control are presented.

Use of Outsized Composite Chondrocutaneous Grafts in Conjunction With Dermal Turnover Flaps for Reconstruction of Full-Thickness Alar Defects

Chondrocutaneous (ChC) grafts have been used for nasal alar reconstruction for years. One of the consequences for using these grafts is the restriction in dimensions. In this study, we presented our results in which ChC grafts bigger than 20 mm in length have been used in conjunction with a dermal turnover flap for full-thickness alar subunit defects. Technical details and results of 8 alar subunits reconstructions in 8 patients were evaluated. Follow-up period ranged from 10 to 27 months, with a mean of 18.3 months. We achieved satisfactory results without partial or total graft failure. Finally, surgeons can safely use outsized ChC composite grafts with this type of design, for successful alar subunit reconstruction.

Analysis of Complications Following Augmentation With Cancellous Block Allografts

Bone grafting may be associated with soft and hard tissue complications. Recipient site complications encountered using cancellous block allografts for ridge augmentation are analyzed. A total of 101 consecutive patients (62 females and 39 males; mean age 44 ± 17 years) were treated with implant-supported restoration of 137 severe atrophic alveolar ridges augmented with cancellous bone-block allografts. Alveolar ridge deficiency locations were classified as anterior maxilla (n = 58); posterior maxilla (n = 32 sinuses); posterior mandible (n = 32); and anterior mandible (n = 15). A total of 271 rough-surface implants were placed. Recipient site complications associated with block grafting (infection, membrane exposure, incision line opening, perforation of mucosa over the grafted bone, partial graft failure, total graft failure, and implant failure) were recorded. Partial and total bone-block graft failure occurred in 10 (7%) and 11 (8%) of 137 augmented sites, respectively. Implant failure rate was 12 (4.4%) of 271. Soft tissue complications included membrane exposure (42 [30.7%] of 137); incision line opening (41 [30%] of 137); and perforation of the mucosa over the grafted bone (19 [14%] of 137). Infection of the grafted site occurred in 18 (13%) of 137 bone blocks. Alveolar ridge deficiency location had a statistically significant effect on the outcome of recipient site complications. More complications were noted in the mandible compared to the maxilla. Age and gender had no statistically significant effect. Failures caused by complications were rarely noted in association with cancellous block grafting. The incidence of complications in the mandible was significantly higher. Soft tissue complications do not necessarily result in total loss of cancellous block allograft.

Application of radial forearm free flap in extraoral soft tissue head and neck reconstruction

Radial forearm free flap, highly regarded in head and neck reconstructive surgery, is known to be one of the most reliable and versatile flaps. The aim of this study was to illustrate the versatility and reliability of a radial forearm flap in reconstruction of a variety of extraoral head and neck defects. During a period 2001-2007 at the Clinic for Maxillofacial Surgery, Faculty of Dentistry and the Center for Burns, Plastic and Reconstructive Surgery in Belgrade, 19 patients underwent microsurgical reconstructions after extraoral tumor ablation in the head and neck region, using fasciocutaneous radial forearm free flap. The overall flap survival rate was 89.5%. The complications that appeared were one partial necrosis and one venous thrombosis that in spite of reanastomosis resulted in a complete flap failure. The donor site healed uneventfully in all patients, except one, who had a partial skin graft failure, that ended in a secondary skin grafting. For reconstruction in head and neck surgery, with the need for thin, pliable tissues and a long vascular pedicle, radial forearm flap still remains a primary choice. Because of their multiple advantages, free flaps from the radial forearm is a safe method for reconstruction of a variety of extensive extraoral soft tissue defects in the head and neck region.