Andreas Gravvanis

The current concepts in the aesthetic and functional reconstruction of complex oromandibular defects are presented with a case of a patient with self‐inflicted gunshot wound to the face. The patient presented with a 6 cm composite mandibular defect; the buccomandibular and suborbital aesthetic zones of the cheek along with the mucosa lining, and the ipsilateral facial musculature were missing. A rapid prototyping model of the facial skeleton was used to assist in preoperative planning. A single stage reconstruction with two free flaps was planned; a free fibula osseous flap to reconstruct the mandibular defect, and a free chimeric ALT/functioning vastus lateralis muscle. The one skin paddle of the chimeric flap reconstructed the buccomandibular/suborbital zones of the cheek, and the other the lining of the mouth. The functional muscle provided reanimation of the corner of the mouth by coapting the muscle's motor nerve to the ipsilateral marginal mandibular nerve. A good facial contour and reanimation of the mouth with oral continence was achieved, and the patient presented with good social and emotional smile. This first report of combined use of a fibula osseous flap with a chimeric functional ALT/Vastus Lateralis flap suggests that the chimeric flap principle may be used in complex aesthetic and functional challenges of severe facial trauma.

Background: The purpose of the study was to define the most appropriate management of the giant mandibular ameloblastoma (GMA) in young adults.Methods: A retrospective study was performed on patients with GMA p < .05).Conclusion: Aggressive resection of the GMA and immediate reconstruction is strongly advised. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1947–E1954, 2016

Purpose: In the present study, we compare the esthetic outcome in delayed autologous breast reconstruction, in the spectrum of irradiated chest wall, following two different abdominal flap inset.Patients and methods: Fifty women, candidates for microsurgical reconstruction with a free deep inferior epigastric perforator (DIEP) flap, participated in this prospective, randomized control study. In group‐A (n = 25) the flap was inset using the traditional single plane in front of the pectoral muscle. In group‐B (n = 25) the flap was inset in a dual plane lying simultaneously behind and in front of the pectoralis major at the upper and lower poles of the reconstructed breast, respectively.Photographic images were formulated to a PowerPoint presentation and cosmetic outcomes were assessed by means of a questionnaire and a visual analog scale.Results: The dual plane flap inset presented significant advantages over the traditional single plane because of a better scarring (85.6 ± 1.3 vs.73.6 ± 1.2, P < 0.05), better transition from native and reconstructed tissues (90.2 ± 1.5 vs. 81.5.6 ± 1.6, P < 0.05), better outline of the breast (96.3 ± 1.2 vs. 69.6 ± 2.1, P<0.0001), and better overal breast appearance (86 ± 1.5 vs. 72.2 ± 1.9, P < 0.0001). Moreover, patient self‐evaluation showed that dual plane reconstruction was associated with higher patient satisfaction without wearing brassiere (P = 0.0016), and this could be attributed to the significantly greater fullness of the upper pole (P = 0.0015) and significantly less ptosis with time (P = 0.0014).Conclusion: The dual plane DIEP flap inset improves scar quality, advances the breast shape and fullness of the upper pole, and results in higher patient satisfaction. © 2015 Wiley Periodicals, Inc. Microsurgery 35:432–440, 2015.

Flap reconstruction of the knee: A review of current concepts and a proposed algorithm

Introduction: This article aims to investigate the critical role of the venous‐perforator in the decision‐making process of choosing the best suitable perforator‐complex in a deep inferior epigastric perforator (DIEP) flap.Methods: Forty consecutive DIEP breast reconstructions were pre‐operatively evaluated by CT‐Angiography to identify the dominant and centrally located abdominal wall perforators. The CTA results were used as a guide to conduct a Color‐Duplex‐Ultrasound examination that was mainly focused on investigating the accompanying venous‐perforator. In group‐A (n = 20) perforator‐complex selection was based on the size of the arterial‐perforator, whilst in group‐B (n = 20) it was based on the size of the venous‐perforator.Results: All single perforator‐complex DIEP flaps survived. No significant differences were recorded concerning the size of arterial‐perforator between the two groups; however the size of venous‐perforator was significantly larger in group‐B (P < 0.05). In group‐A, four flaps showed vascular compromise intraoperative that was salvaged by flap supercharge with the superficial inferior epigastric system. In contrast, in group‐B, all flaps were re‐vascularized uneventfully (P < 0.05). Physical examination revealed a palpable mass in one patient and ultrasound investigation added three cases with a firm area of scar tissue in group‐A, but no fat necrosis was detected in group‐B (P < 0.05).Conclusions: The CTA‐guided duplex ultrasonography could direct the perforator‐complex selection according to the size of the venous‐perforator, and may reduce the intraoperative problems and the incidence of fat necrosis. © 2013 Wiley Periodicals, Inc. Microsurgery 34:169–176, 2014.

Angiosarcomas are rare, aggressive tumors of endothelial cells with a high degree of invasiveness and poor survival. Although they arise in the face and scalp of elderly people, the nose represents a rare location with few reports in the literature. Nasal angiosarcoma resembling benign lesion morphologically has been described, but there is no report of angiosarcoma mimicking benign lesion histologically.Here, we report a case of nasal septum angiosarcoma in which the initial misdiagnosis submitted by the referring pathologist was reticulohistiocytoma. Nevertheless, the nasal septum and anterior nasal spine invasion by the tumor led us to suggest extensive surgical treatment: resection of the caudal septum, the anterior nasal spine, the columella, and the philtrum. Thereafter, an L-strut rib cartilage graft reconstructed the septum defect and was lined with a free radial forearm flap, resulting in a satisfactory functional and aesthetic outcome. Histology showed complete resection of a malignant neoplasm of mesenchymal origin, and immunohistochemistry established the diagnosis of epithelial angiosarcoma. The literature regarding this rare presentation of angiosarcoma was reviewed.