Free flap reconstruction of self-inflicted submental gunshot wounds

Free flap reconstruction following head and neck trauma

BACKGROUND

Free flap (FF) reconstruction of traumatic injuries to the head and neck is uncommon.

METHODS

Multi-institutional retrospective case series of patients undergoing FF reconstruction for a traumatic injury (n = 103).

RESULTS

Majority were gunshot wounds (GSW; 85%, n = 88) and motor vehicle accidents (11%, n = 11). Majority underwent osseous reconstruction (82%, n = 84). FF failures (9%, n = 9/103) occurred in GSW patients (100%, n = 9/9) and when multiple subsites were injured (89%, n = 8/9). Preoperative antibiotics correlated with lower rates of a neck washouts (4% vs. 19%) (p = 0.01) and 30-day readmissions (4% vs. 17%) (p = 0.02).

CONCLUSIONS

All FF failures occurred in the setting of a GSW and the majority involved multiple subsites. Preoperative antibiotics correlated with lower rates of postoperative washout procedures and 30-day readmission.

Same-Admission Microvascular Maxillofacial Ballistic Trauma Reconstruction Using Virtual Surgical Planning: A Case Series and Systematic Review

Study Design

Retrospective case series; systematic review.

Objective

It is unknown whether the use of virtual surgical planning (VSP) to facilitate same-admission microsurgical reconstruction of the mandible following acute maxillofacial ballistic trauma (MBT) is sufficient to achieve definitive reconstruction and functional occlusion.

Methods

A single-center retrospective analysis was conducted for patients who underwent microsurgical reconstruction of the mandible using VSP after acute MBT. The PubMed/MEDLINE, Embase, ScienceDirect, and Scopus databases were systematically reviewed using blinded screening. Studies were evaluated via thematic analysis.

Results

Five patients were treated by same-admission and microsurgical reconstruction of the mandible using VSP. We observed an average of 16.4 ± 9.1 days between initial presentation and reconstruction, an average length of stay of 51.6 ± 17.9 days, 6.2 ± 2.8 operations, and 1.6 ± 0.9 free flaps per patient. Four types and 8 total flaps were employed, most commonly the anterior lateral thigh flap (37.5%). Care yielded complete flap survival. Each patient experienced at least 1 minor complication. All patients achieved centric occlusion, oral nutrition, and an approximation of their baseline facial aesthetic. Follow up was 191.0 ± 183.9 weeks. Systematic review produced 8 articles that adhered to inclusion criteria. Consensus themes in the literature were found for clinical goal and function of VSP when practicing MBT reconstruction, yet disagreement was found surrounding optimal treatment timeline.

Conclusions

Same-admission microsurgical reconstruction after MBT is safe and effective to re-establish mandibular form and function. VSP did not delay reconstruction, given the need for preparation prior to definitive reconstruction.

Facial Reconstruction Following Self-Inflicted Gunshot Wounds: Predictors, Complications, and Acceptable Outcomes

Background: Self-inflicted gunshot wounds (SIGSWs) produce devastating facial defects that are challenging to reconstruct, but are rarely reported in large cohorts in the literature. This study sought to characterize these injuries, and identify parameters influencing complications and outcomes among survivors following facial reconstruction. Methods: A retrospective cohort study was performed identifying 22 patients with SIGSWs to the face reconstructed at our center from 2009 to 2019. Charts were reviewed for patient, injury, and reconstructive details and course. Outcomes were statistically compared to various parameters. Results: The most common firearm, orientation, and injured structure were the handgun (40.9%), submental (59.1%), and mandible (68.2%), respectively. Patients averaged a 21.7-day length of stay (LOS), 17.4 h to debridement, 2.6 days to bony fixation, 5.4 reconstructive surgeries, and 7 (31.8%) patients received at least one free flap. Fifteen (68.2%) patients had at least one major complication, although functional outcomes were ultimately relatively good overall. Notable outcome associations included submental orientation with a longer LOS (p = 0.027), external fixation with a longer LOS (p = 0.014), financial stressors with a shorter LOS (p = 0.031), and severe soft tissue injury with an increased total number of reconstructive surgeries (p = 0.039) and incomplete reconstruction (p = 0.031). There were no cases of suicidal recidivism. Conclusions: Reconstruction following facial SIGSW is challenging for both patient and surgeon, and carries a high rate of complications. However, patients can regain substantial function following reconstruction and the achievement of satisfactory outcomes.

Advances in Oromandibular Reconstruction with Three-Dimensional Printing

The mandibular structures are a complex anatomical structure that is fundamental to many physiological and homeostatic functions. It may be involved in many pathological processes that require partial or complete removal. When this happens, reconstruction is mandatory to improve cosmetic outcome with its effect on social interaction as well as to provide an opportunity for complete dental rehabilitation with restoration of all physiological functions. This article will review the different reconstructive options available for complex defects of the mandibular complex. It will highlight the surgical options available to maximize functional restoration. Finally, it will discuss computer modeling to optimize reconstructive planning.

Treatment Strategies in the Management of Maxillofacial Ballistic Injuries in Low-Intensity Conflict Scenarios

Introduction

The facial disfigurement and functional debility resulting from craniomaxillofacial injuries in low-intensity conflict scenarios can physically and psychologically traumatize the afflicted personnel. Efficient and definitive management, with complete esthetic restoration and functional rehabilitation, is not only an organizational obligation, but also a tactical necessity to maintain a high state of morale among the troops. There exist two schools of thought on principles of management of such injuries. The older, three-phased approach consists of initial debridement and suturing, followed by conservative closed reduction in maxillofacial fractures using splints and ligatures, thereafter followed by delayed repair and late reconstruction of residual bone defects and deformities after the soft tissue healing is complete. The newer trend involves early and aggressive open surgical reduction and craniomaxillofacial fixation techniques along with reconstructive procedures carried out hand in hand with the soft tissue debridement and closure.

Aim

The aim was to compare the efficacy of the two management protocols, namely the contemporary approach of early aggressive surgical intervention, versus the conservative approach of initial debridement, closed reduction and delayed repair, as the definitive treatment modality of maxillofacial injuries sustained in low-intensity conflicts.

Methods

This retrospective analytical study included 40 patients with maxillofacial injuries sustained in combat scenarios treated over a period of 3 years. These patients who had been treated for ballistic maxillofacial injuries were divided into two groups: The first group of 20 patients (Group 1) included those who had undergone an early, aggressive, surgical intervention, and the second group of 20 patients (Group 2) included those who had undergone resuscitation and primary soft tissue closure followed by conservative, closed reduction techniques, delayed repair (including open reduction and internal fixation (ORIF) procedures), and late reconstruction of bone soft tissue defects (which included utilization of various grafts and flaps). Both groups were evaluated and compared for postoperative recovery and early and late complications such as impaired esthetic results and impaired functional recovery.

Results

Early, definitive, and aggressive maxillofacial surgical techniques proved superior to the conservative approach by bringing about primary bone healing and minimizing residual deformities and subsequent scar contractures, thus yielding improved functional as well as superior esthetic outcomes.

Conclusion

In today's low-intensity conflict scenario, the emphasis in management of maxillofacial injury victims should be on an early, definitive, and aggressive surgical repair and reconstruction of the facial skeleton, thus restoring quality of life to these soldiers, sparing them life-long indignity after a potentially severe esthetically and functionally debilitating injury.

A 14-Year Review of Craniomaxillofacial Gunshot Wounds in a Resource-Limited Setting

This study analyzed the prevalence, clinical characteristics, and management of civilian-type craniomaxillofacial gunshot wounds (CGSWs) seen over a 14-year period in a Northern Nigerian teaching hospital. A retrospective study of all hospital records relating to CGSWs from January 2000 to December 2013 was conducted to determine the prevalence of CGSWs. Information retrieved included site of injury, type of projectile, management protocol, as well as duration of hospitalization. A total of 46 admissions for CGSWs were recorded during the period under review from a total of 2,228 maxillofacial admissions. This gave a prevalence of 2.1% for CGSWs (95% confidence interval = 1.56-2.81). Sex distribution was 14.3:1 (M:F) with overall mean age of 32.9 ± 8.4 years. Average length of hospitalization was 17.7 (±15.56) days. Management of CGSWs consisted of emergency care, preliminary intervention, definitive reconstruction, revisions, and rehabilitation. Conclusively, analysis of the yearly incidence of CGSWs showed that the incidence and severity increased within the past 2 years under review (18 cases, 39.13%; χ² trend = 7.7, p = 0.006). This period was noted to correspond with heightened violence within the region mostly due to the acts of unknown gunmen and insurgents.

A rapid, flexible method for incorporating controlled antibiotic release into porous polymethylmethacrylate space maintainers for craniofacial reconstruction

Severe injuries in the craniofacial complex, resulting from trauma or pathology, present several challenges to functional and aesthetic reconstruction. The anatomy and position of the craniofacial region make it vulnerable to injury and subsequent local infection due to external bacteria as well as those from neighbouring structures like the sinuses, nasal passages, and mouth. Porous polymethylmethacrylate (PMMA) "space maintainers" have proven useful in staged craniofacial reconstruction by promoting healing of overlying soft tissue prior to reconstruction of craniofacial bones. We describe herein a method by which the porosity of a prefabricated porous PMMA space maintainer, generated by porogen leaching, can be loaded with a thermogelling copolymer-based drug delivery system. Porogen leaching, space maintainer prewetting, and thermogel loading all significantly affected the loading of a model antibiotic, colistin. Weeks-long release of antibiotic at clinically relevant levels was achieved with several formulations. In vitro assays confirmed that the released colistin maintained its antibiotic activity against several bacterial targets. Our results suggest that this method is a valuable tool in the development of novel therapeutic approaches for the treatment of severe complex, infected craniofacial injuries.

Reconstruction of the naso-orbital-ethmoid (NOE) complex using the osteocutaneous radial forearm flap (OCRFF)

OBJECTIVES

Describe the utility of osteocutaneous forearm flaps in reconstruction of naso-orbito-ethmoid (NOE) defects.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary medical centers.

SUBJECTS AND METHODS

The study was conducted on patients treated between the years 2000 and 2014 undergoing NOE resection with reconstruction using the radial forearm flap. Decision making, technical feasibility, need for revisions, and patient disease outcomes were included to assess the durability of reconstruction over remaining survival period.

RESULTS

Fifteen patients underwent NOE reconstruction in the timeframe studied. Five recent patients reported poor nasal airway but no diplopia or immediately clinically evident enopthalmus after NOE reconstruction in mean follow-up of 17.3 months. One-third of patients succumbed to disease in the study period, 3 without revision, and all but 2 surviving patients required revisions.

CONCLUSION

Osteocutaneous radial forearm flap (OCRFF) is a cosmetically acceptable method of reconstructing NOE defects. Though a 1-step reconstruction can be serviceable without multiple additional procedures, longer surviving patients frequently receive revision surgery as with more traditional planned staged procedures.

Outcomes in head and neck reconstruction by surgical site and donor site

OBJECTIVES/HYPOTHESIS

Define surgical outcomes of specific donor sites for free tissue transfer in head and neck reconstruction.

STUDY DESIGN

Retrospective cohort review at an academic tertiary care center.

METHODS

A review was made of free tissue transfer procedures performed at a university-based tertiary care facility from October 2004 to April 2011. A total of 1,051 patients underwent six types of free flaps: fasciocutaneous radial forearm (53%), osteocutaneous radial forearm (16%), rectus abdominis (11%), fibula (10%), anterior lateral thigh (7%), and latissimus dorsi (2%). Demographic data were collected, and outcomes measured were: length of hospital stay, flap viability, and major complications (infection, fistula, and hematoma).

RESULTS

Of the 1,051 flaps performed, the most common operative site was oral cavity (40%, n = 414) followed by hypopharynx/larynx (22%, n = 234), cutaneous (20%, n = 206), oropharynx (9%, n = 98), midface (7%, n = 76), and skull base (2%, n = 23). The median hospital stay was 7.9 days (range, 1-76), and the overall failure rate was 2.8%. Cutaneous defects required the shortest length of hospitalization (5.8 days, P < .0001), a low free flap failure rate (1.5%, n = 3), and limited major complications (6%, n = 12). Conversely, oropharynx defects were associated with the longest hospitalization (8.9 days). Midface defects had a high incidence of complications (15%, n = 11, P = .10). Defects above the angle of the mandible had higher overall complications when compared to below. Similarly, reconstruction for primary or recurrent cancer had a total failure rate of 2.5%, whereas secondary reconstruction and radionecrosis had a failure rate of 4.0% (P = .29). Additionally, there was no statistical difference between outcomes based on donor site.

CONCLUSIONS

This review demonstrates that certain subsets of patients are at higher risk for complications after free tissue transfer. Patients undergoing free flap reconstruction for cutaneous defects have substantially shorter hospital stays and are at lower risk of flap complications, whereas reconstruction for radionecrosis and secondary reconstruction tend to have higher overall flap failure rates.