Calvarial Reconstruction With Polyetheretherketone Implants

Despite the development of multiple cranial bone substitutes, calvarial reconstruction remains a significant challenge. Although autologous bone is preferred in many cases, its usefulness may be limited by difficulty with contouring, resorption, and donor site availability and morbidity. Alloplastic cranioplasties are also widely used with each material having its advantages and disadvantages. Computer-designed implants have the advantages of minimizing operative time for preparation, shaping, and insetting. We report our initial clinical experience in 6 patients with Computer-designed, prefabricated polyetheretherketone implants, which may have significant advantages over other alloplastic materials in terms of strength, stiffness, durability, thermal conductivity, and radiographic translucency

Scalp and Calvarial Reconstruction

Over the past several decades, an improved understanding of the blood supply of local flaps, increased experience with tissue expansion, and the development of techniques for microsurgical transfer of distant flaps have greatly contributed to the ability of plastic surgeons to repair scalp defects. This article will review basic anatomy, principles, and pearls of reconstruction for simple to complex scalp defects. Included will be anatomic considerations, indications and contraindications for reconstruction, and an overview of reconstructive options

The anterolateral thigh free flap for skull base reconstruction

To assess outcomes of patients undergoing reconstruction after resection of skull base tumors with the anterolateral thigh (ALT) free flap. Case series with chart review. Thirty-four consecutive patients with cancers involving the skull base that underwent reconstruction with the ALT free flap between 2005 and 2008 were reviewed. The ALT free flap was successfully used to reconstruct two, five, and 17 anterior, lateral, and posterior skull base defects, respectively. In addition, six and four combined anterior-lateral and lateral-posterior defects, respectively, were reconstructed. The overall complication rate was 29 percent. There were no flap losses. Nerve grafts (n = 6) and fascial slings (n = 14) for facial reanimation were performed using the lateral femoral cutaneous nerve and fascia lata from the same donor site as the ALT free flap. By harvesting the flap and graft(s) simultaneously with the resection, an average of 3.0 hours per case was saved. The ALT free flap is a versatile, reliable flap that should be considered a first-line option for skull base reconstruction. Operative time is minimized by performing a simultaneous two-team approach to resection and reconstruction, and by harvesting nerve, vein, and fascial grafts from the same donor site as the flap

Midfacial reconstruction using virtual planning, rapid prototype modeling, and stereotactic navigation

We present a method based on virtual planning and creation of rapid prototype models to accurately reestablish midfacial anatomy using vascularized bone flaps while saving time by streamlining the operative procedure, allowing prebending of titanium plates needed for fixation, and simplifying osteotomies. Accurate flap positioning through limited incisions is made possible using stereotactic navigation. Copyright © 2010 by the American Society of Plastic Surgeons

Long-term outcomes of the minimally invasive free vascularized omental lymphatic flap for the treatment of lymphedema

Background: The free vascularized omental lymphatic flap provides an option without the risk for iatrogenic donor site lymphedema that plagues alternative lymph node transfer donor sites. The omental flap has been associated with significant morbidity in the past; however, with modern techniques and advanced in technology, a minimally invasive approach to flap harvest is feasible. We present the long-term outcomes of the minimally invasive free vascularized omental lymphatic flap for the treatment of lymphedema. Methods: All consecutive patients with advanced lymphedema undergoing minimally invasive free vascularized omental lymphatic flap transfer were included. Perioperative evaluation included qualitative assessments, lymphoscintigraphy, and volumetric measurements. Results: Overall, 42 patients underwent a free omental lymphatic flap and had a mean follow-up of 14 (3-32) months. Subjective improvements were noted in 83% of patients. Mean volumetric improvement was 22%. Complications occurred in 16% (n = 7) of patients; this included one episode of pancreatitis and one flap loss. Postoperative imaging revealed viable lymphatic transfers. Cellulitis history was present in 74% (n = 31) patients with post-operative cellulitis occurring in 5% (n = 2) patients. Conclusions: The minimally invasive free vascularized omental lymphatic flap provides a safe donor site, a durable and versatile flap, and an efficacious therapy against lymphedema and lymphedema-related cellulitis.6 page(s

Tracking the learning curve in microsurgical skill acquisition

Background: Despite advances in surgical training, microsurgery is still based on an apprenticeship model. To evaluate skill acquisition and apply targeted feedback to improve their training model, the authors applied the Structured Assessment of Microsurgery Skills to the training of microsurgical fellows. They hypothesized that subjects would demonstrate measurable improvement in performance throughout the study period and consistently across evaluators. Methods: Seven fellows were evaluated during 118 microsurgical cases by 16 evaluators over three 1-month evaluation periods in 1 year (2010 to 2011). Evaluators used the Structured Assessment of Microsurgery Skills questionnaire, which measures dexterity, visuospatial ability, operative flow, and judgment. To validate the data, microsurgical anastomoses in rodents performed by the fellows in a laboratory at the beginning and end of the study period were evaluated by five blinded plastic surgeons using the same questionnaire. Primary outcomes were change in scores between evaluation periods and interevaluator reliability. Results: Between the first two evaluation periods, all skill areas and overall performance improved significantly. Between the second two periods, most skill areas improved, but only a few improved significantly. Operative errors decreased significantly between the first and subsequent periods (81 versus 36; p < 0.05). In the laboratory study, all skills were significantly (p < 0.05) or marginally (0.05 < p < 0.10) improved between time points. The overall interevaluator reliability of the questionnaire was acceptable ([α] = 0.67). Conclusions: The Structured Assessment of Microsurgery Skills questionnaire is a valid instrument for assessing microsurgical skill, providing individualized feedback with acceptable interevaluator reliability. Use of the questionnaire is anticipated to enhance microsurgical training.8 page(s