AAHS ASPN ASRM - 2013 Annual Meeting - American Association ...

Marriage of Hard and Soft Tissues of the Face Revisited: When Distraction Meets Microsurgery
Institution where the work was prepared: New YorkUniversity School of Medicine, New York, NY, USA
Jason Spector, MD1; Pierre Saadeh2; Stephen M Warren2; Sunil P Singh2; Pierre Boutros Saadeh2; Joseph G McCarthy2; John W Siebert2; (1)Weill Cornell Medical College,
(2)NYU Medical Center
Background:
Mandibular distraction osteogenesis (DO) is a powerful clinical tool which is routinely utilized for augmentation of the craniofacial skeleton. Patients manifesting
severe mandibular hypoplasia may also present with severe soft tissue deficiency. In these cases, mandibular DO alone will not be sufficient to restore appropriate
facial contour and must be complemented by procedures that enhance the overlying soft tissue. Microvascular free tissue transfer is a reliable method
to move large quantities of autogenous tissue and has been used in hundreds of cases of facial reconstruction at our institution.
Methods:
A retrospective analysis was performed on all patients who had undergone mandibular DO at The New York University Medical Center between 1989-2005.
Within that cohort of patients a subgroup was identified who had undergone microvascular free tissue transfer following their DO as part of their craniofacial
reconstruction.
Results:
Of the 133 patients treated with mandibular DO, eight patients received 12 microvascular free tissue flaps (MVFF). In all cases, free tissue transfer was performed
subsequent to the completion of D0. The primary diagnoses of these patients were: bilateral craniofacial microsomia (3), unilateral craniofacial microsomia
(2), Goldenhaar syndrome (1), Nager syndrome (1) and Treacher Collins (1). The free flaps utilized were the parascapular fasciocutaneous (10), parascapular
osteofasciocutaneous (1) and fibular osteoctaneous (1). Four patients received staged bilateral free flaps; one patient required two consecutive free
flaps to the same location. There were no major complications related to the free flap surgeries. In all cases, facial contour was significantly improved by the
combined treatment of mandibular DO and free tissue transfer. In one case, vascularized bone was used to salvage non-union after mandibular D0.
Conclusions:
Facial rehabilitation that combines craniofacial and microsurgical techniques allows reconstructive surgeons to obtain satisfactory aesthetic results even in the
most challenging reconstructive cases.
Safety and Reliability of the Ulnar Artery Perforator Flap
Institution where the work was prepared: R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
Suhail K. Mithani, MD1; Rachel Bluebond-Langner, MD1; Gedge D. Rosson, MD1; Eduardo D. Rodriguez, DDS, MD2; (1)Johns Hopkins School of Medicine, (2)R Adams
Cowley Shock Trauma Center and the Johns Hopkins School of Medicine
Background:
The radial forearm flap is one of the most common fasciocutaneous free flaps used in head and neck reconstruction. The ulnar artery free flap represents an
alternative strategy and may be preferable in some cases since the ulnar forearm is less hirsute, thinner and easier to conceal. Many surgeons are reluctant to
use the ulnar artery free flap due to concern for vascular, motor, or sensory compromise to the hand. We evaluated the motor, sensory and vascular outcomes
of patients who underwent ulnar artery free flaps.
Methods:
We conducted an IRB approved study of 11 patients who underwent ulnar artery free flaps for head and neck reconstruction from 2004-2006. All flaps were
performed by a single surgeon (EDR); the dissection was suprafascial and perforator based. Patients returned to clinic for motor, sensory, and vascular testing.
Grip strength was tested with the dynamometer. 2 point discrimination distal to the donor site in both median and ulnar sensory distributions was tested with
Dellon-MacKinnon Discriminator and compared with the contralateral side. Arterial velocity in both the brachial and radial arteries was assessed by Doppler
ultrasound and digital pressures were measured in both hands by Photoplethysmography. Disability was assessed by the quickDASH (Disability of the Arm
Shoulder and Hand) questionnaire, which uses simple questions to measure physical function and symptoms in persons with musculoskeletal disorders of the
upper limb.
Results:
Flap survival was 100% with no donor or recipient site morbidity. The donor site was closed primarily in 2 patients and with a full thickness skin graft from
the groin in 9 patients. 10/11 flaps were harvested from the non-dominant hand. The average flap size was 8.2x 5.6cm. The grip strength in the donor hand
was within 10% of the contralateral hand in all patients. There was no significant difference in 2 point discrimination in the ulnar nerve sensory distribution
compared with median nerve distribution. Digital pressures demonstrated equivalent distal perfusion in the donor hand. After appropriate recovery period, no
disability was reported by patients as measured by quickDASH survey. Median follow up time was 15 months.
Conclusions:
The ulnar artery perforator free flap, when performed by an experienced microsurgeon represents a viable alternative to radial artery free flaps for head and
neck reconstruction. Donor site morbidity is minimal, with potential for improved cosmetic results. There is no evidence of vascular, sensory, or motor compromise
to the hand.
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