Extending the Reach of Craniofacial Free Flaps Using the Descending Branch of the Lateral Circumflex Femoral Vessels.

SUMMARY: Craniofacial free tissue transfer is sometimes complicated by insufficient pedicle length and/or paucity of recipient vessels. A saphenous vein graft can be used to reach the high-flow, large-caliber vessels of the neck, but because of the vein's taper and thick wall, there is often a mismatch. Following the principle of like-for-like, the authors prefer the descending branch of the lateral circumflex femoral vessels to achieve a more anatomical pedicle extension for free tissue transfer in complex craniofacial reconstruction. The authors' experience using the descending branch of the lateral circumflex femoral pedicle extender from 2010 to 2019 was reviewed. Indications, patient characteristics, reconstruction site, flap type, pedicle length, recipient vessels, and vascular complications were noted. The authors reviewed two strategies for implementation of the pedicle extender: in some cases, the flap was first transferred and allowed to perfuse on the descending branch of the lateral circumflex femoral vessels in the thigh, and then transferred to the recipient vessels (double-ischemia transfer); and in other cases, the flap and pedicle extender were transferred such that the flap underwent a single period of ischemia (single-ischemia transfer). The descending branch of the lateral circumflex femoral pedicle extender was used in 17 craniofacial cases. Indications included tumor, trauma, osteoradionecrosis, and congenital. Double-ischemia transfer was used in eight cases and single-ischemia transfer in nine. The longest pedicle extender in the series was 15 cm. Arterial thrombosis occurred in one case. This case series demonstrates that the descending branch of the lateral circumflex femoral pedicle extender is a viable option for complex craniofacial free tissue transfer cases. It provides ample length and excellent vessel match, following the like-for-like principle. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Incidence and Risk Factors for Acute Kidney Injury in Severely Injured Patients Using Current Kidney Disease: Improving Global Outcomes Definitions.

BACKGROUND: Acute kidney injury (AKI) is a significant cause of morbidity and mortality for critically injured trauma patients. The Kidney Disease: Improving Global Outcomes (KDIGO) practice guideline is the most up-to-date classification for AKI. The aims of this study were to determine the incidence and risk factors for AKI in critically injured trauma patients using the current KDIGO definitions. STUDY DESIGN: A prospective cohort study was performed at our academic, level 1 trauma center, from September 2017 to August 2018. All adult trauma patients admitted to the surgical ICU were included. The primary outcome was the development of AKI, as defined by KDIGO. Secondary outcomes included hospital and ICU length of stay, ventilator days, and mortality. RESULTS: There were 466 patients included and 314 (67%) developed AKI. Those who developed AKI were more often hypotensive on admission (7% vs 2%), had higher Injury Severity Scores (ISS) (19 vs 13), were more likely to have severe injuries to the chest (40% vs 24%) and extremities (20% vs 6%), received transfusion (41% vs 21%), sustained crush injuries (8% vs 1%), received radiocontrast (75% vs 47%), nephrotoxic medication (74% vs 60%), or vasopressors (15% vs 3%). After multivariate analysis, risk factors independently associated with AKI include age, Injury Severity Score (ISS), severe extremity injuries, radiocontrast, and vasopressors. Those who developed AKI had higher mortality (9% vs 2%). CONCLUSIONS: Using current KDIGO criteria, the incidence of AKI in critically injured trauma patients was higher than previously reported. Older patients, with more severe injuries to their extremities and chest and who have suffered crush injuries, appear to be the most a risk. AKI in the critically injured patient results in an almost 5-fold increase in mortality.

Virtual Surgical Planning in Craniofacial Surgery.

BACKGROUND: Virtual surgical planning (VSP) is increasingly described in craniofacial surgery literature. However, the quality of the literature that has been published is unknown. The objective of this systematic review was to determine the level of evidence of published articles on VSP. METHODS: In this systematic review, PubMed, Web of Science, and ScienceDirect databases were queried for key terms in craniofacial VSP. Inclusion and exclusion criteria concentrated on patient-specific surgical outcomes in studies that could be rated for level of evidence. The articles were ranked according to their level of evidence, with level I being the highest level of evidence (randomized-controlled trials) and level V being the lowest (eg, case reports). RESULTS: The initial keyword search yielded 1524 articles, 273 of which were ranked and included in the systematic review. The average level of evidence for an article published was 4.1 (between level IV and level V). Level IV was the most common level of evidence (65.6%), followed by level V (24.9%), level III (7.3%), level II (2.2%), respectively. There were not any level I articles. The most common study type was case series, accounting for 68.1% of the studies, followed by case reports (23.0%), case-control studies (4.7%), cohort studies (3.3%), and randomized controlled trials (1.1%), respectively. CONCLUSION: Although the quantity of craniofacial VSP studies has proliferated, the quality of the studies has not. In order for VSP literature to feature a higher level of evidence, future studies would require more sophisticated study design, such as prospective cohort or prospective randomized control trials.