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A Modified Heterotopic Swine Hind Limb Transplant Model for Translational Vascularized Composite Allotransplantation (VCA) Research

Vascularized Composite Allotransplantation (VCA) such as hand and face transplants represent a viable treatment option for complex musculoskeletal trauma ...

Johns Hopkins University School of Medicine

Although free tissue transfer is a well-established method of reconstruction for difficult tissue defects, the technique is not yet widely embraced in the private practice setting. Reasons for this include concern over the possibility of flap loss and other complications, the time required for these procedures, and the perceived need for a microsurgical team. The results of free tissue transfer in 100 patients in a single practitioner private practice setting were assessed. Charts were reviewed and data recorded including major and minor complications, American Society of Anesthesia rating, operative time, intensive care unit and postoperative hospital stay, estimated blood loss, and transfusion requirements. Indications included breast reconstruction, the management of chronic wounds, and acute trauma. There were three complete flap losses and three partial flap losses. There were 22 major complications in 21 patients and 17 minor complications. The results of this study compare favorably with those compiled from 36 prior reports. Free tissue transfer has taken its place in the reconstructive armamentarium as the procedure of choice in many reconstructive situations due to its reliability and versatility. This form of reconstruction can be safely offered to patients in any practice situation by surgeons who are trained in and comfortable with free tissue transfer techniques.

Free tissue transfer in the private practice setting: a review of 100 patients.

The erosion and exposure of pacemakers are relatively uncommon occurrences but, given the number of these devices inserted yearly, they are nevertheless occurrences that plastic surgeons are likely to encounter in practice. Although there is a general agreement that clinically infected devices are best removed, it has been established that exposed but noninfected devices can usually be managed conservatively with coverage procedures. Reports in the literature, to date, describe a number of different procedures for coverage, and these reports generally comprise small numbers of patients. This study describes 16 patients referred to a single surgeon over a 14-year period with exposure or suspected impending exposure of their cardiac pacemaker systems. Fourteen patients required surgical revision for coverage of either the generator or defunctionalized wires. Equivalent success was achieved with either subfascial or submuscular coverage in 11 patients with generators present. Three patients with exposure of defunctionalized wires achieved successful coverage with submuscular burial. There was no correlation of culture results with recurrence of exposure.

Management of exposure of cardiac pacemaker systems.

The surgical robot has been demonstrated to have useful applications in urologic, gynecologic, cardiac, general, and endocrine surgery. The development of robotic surgery has enhanced the precision and control of the surgeon in minimally invasive surgical situations specific to these specialties and, more recently, has been applied to the treatment of oropharyngeal tumors in the form of transoral robotic surgery (TORS). The elimination of the need for lip- and mandible-splitting approaches has allowed a reassessment of surgical options for the treatment of tumors that have until recently been primarily addressed nonoperatively with chemoradiation. The TORS approach has created the need to adapt current reconstructive options to robotic technology to manage the resultant tissue defects and to assess and compare the effectiveness of these procedures. This report details our early experience with the use of robot-assisted free tissue transfer for management of soft tissue defects of the oropharynx.

Robot-assisted oropharyngeal reconstruction with free tissue transfer.

Successful microvascular replantation of amputated facial tissues has been sporadically reported in the literature, although most of these reports have concerned the reattachment of relatively small and segmental portions of the nose or nasal tip. We report the successful replantation of a traumatically amputated composite piece of tissue comprising the entire nose, most of the upper and lower lips, and the nasal boney and cartilaginous complex based on microvascular repair of the labial arteries and glabellar veins and discuss the results and implications of this experience.

Successful replantation of an amputated midfacial segment: technical details and lessons learned.

Tobacco use remains a persistent risk factor in elective plastic surgery. Although nicotine is thought to increase complications, which procedures are affected and the reliability of patient-provided histories remain poorly defined. The authors sought to examine nicotine use and its impact on outcomes.

Plastic surgery and smoking: a prospective analysis of incidence, compliance, and complications.

OBJECTIVES/HYPOTHOSES: TORS (Trans Oral Robotic Surgery) has been demonstrated to be an acceptable alternative to chemoradiation for the treatment of early stage malignant lesions of the oropharynx, with equivalent tumor control and enhanced functional outcomes. Surgical ablation of tumors of the oropharynx under conditions of limited access, however, creates the need to adapt the robotic platform to surgical reconstruction and to assess reconstructive outcomes. We present our experience with the Facial Artery Musculomucosal (FAMM) flap with robotic assistance for the reconstruction of defects of the soft palate.

Robotic-assisted FAMM flap for soft palate reconstruction.

Sex-specific anthropometrics, skin texture/adnexae mismatch, and social apprehension have prevented cross-gender facial transplantation from evolving. However, the scarce donor pool and extreme waitlist times are currently suboptimal. Our objective was to (1) perform and assess cadaveric facial transplantation for each sex-mismatched scenario using virtual planning with cutting guide fabrication and (2) review the advantages/disadvantages of cross-gender facial transplantation.

Article	Year
Free tissue transfer in the private practice setting: a review of 100 patients. Journal of reconstructive microsurgery\| PubMed ID: 19301236	2009
Management of exposure of cardiac pacemaker systems. Annals of plastic surgery\| PubMed ID: 21734547	2012
Robot-assisted oropharyngeal reconstruction with free tissue transfer. Journal of reconstructive microsurgery\| PubMed ID: 22638875	2012
Successful replantation of an amputated midfacial segment: technical details and lessons learned. Annals of plastic surgery\| PubMed ID: 23241762	2013
Plastic surgery and smoking: a prospective analysis of incidence, compliance, and complications. Plastic and reconstructive surgery\| PubMed ID: 23358000	2013
Robotic-assisted FAMM flap for soft palate reconstruction. The Laryngoscope\| PubMed ID: 23529879	2013
Overcoming Cross-Gender Differences and Challenges in Le Fort-Based, Craniomaxillofacial Transplantation With Enhanced Computer-Assisted Technology. Annals of plastic surgery\| PubMed ID: 24025655	2013

Steven C. Bonawitz

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