Microtia Reconstruction: Our Strategies to Improve the Outcomes.

Introduction : Autologous costal cartilage framework placement is currently the gold standard in patients with microtia. In this article, we present the modifications developed by the author, generally following the principles established by Nagata, and discuss the technical details that have led us to achieve consistently stable and good long-term outcomes for auricular reconstruction in microtia. Materials and Methods : A retrospective review of microtia reconstruction performed from 2015 to 2021 was done. Those who underwent primary reconstruction for microtia and with a minimum follow-up of 6 months with documented photographs were included. Those who underwent secondary reconstruction for microtia and those who did not follow-up for a minimum period of 6 months were excluded. Outcomes were assessed with regard to appearance, and durability of the result. Influence of certain changes like delaying reconstruction until 15 years of age, use of nylon for framework fabrication, etc. over the outcome were assessed. Results : Of 11 ears reconstructed at less than 15 years of age, only one patient (9%) had a good long-term outcome, whereas of the 17 ears reconstructed at greater than 15 years of age, nine patients (53%) had a good long-term outcome. In our experience, infections and wire extrusions were the significant events related to severe cartilage resorption. Conclusion : In our experience, delaying the first stage to 15 years or later, using double-armed nylon sutures, and reducing the projection of the third layer of the framework in select cases have helped to improve our outcomes. Second stage of reconstruction can be avoided if patient is satisfied with the projection achieved in the first stage.

Long-Term Patient-Reported Outcomes of Radial Forearm Free Flap Donor Site in the Context of Head and Neck Cancer Reconstruction.

Radial forearm free flap (RAFF) is the workhorse flap for oral cavity reconstruction. In the context of oncological reconstruction with radial forearm flap, the patient-reported outcomes of donor site morbidity amongst Indian patients have not been reported previously. Cultural and racial differences prevent extrapolation of morbidity data from Western literature. We aimed to evaluate subjectively the subjective long-term functional and aesthetic outcomes of the RAFF donor site. Patients who underwent RAFF reconstruction for intra-oral defects between 2014 and 2016 were included. Two questionnaires (Cosmesis and Sensibility and Forearm Disability) were administered. Fifty-two patients who completed a 2-year follow-up were identified. Thirty-five patients (67%) had complaints regarding the donor site. With regard to cosmesis and sensibility, hand numbness was seen in 21 (40.4%) patients. With regard to forearm disability, a problem in lifting heavy weights was seen in 22 (42.3%) patients. Only three patients in the entire cohort had complaints regarding the cosmesis of the forearm scar. Overall disability score was low (7.83). With regard to donor site morbidity, numbness and difficulty in lifting weights was the most common complaint. There is good acceptance of the donor site and scar with minimum morbidity. These findings are useful for the preoperative counselling of the patients. This is the first Indian study evaluating the long-term subjective outcomes of the radial forearm donor site. We believe the RAFF is still the most preferred flap for oral reconstruction.

Indian Subcontinent's First Proximal Forearm Level Double Upper Extremity Transplantation.

Introduction Vascularized composite allotransplantation (VCA) has added another step to the reconstructive ladder, leading to a paradigm shift in the approach toward management of cases of upper limb amputations. In this article, we discuss in detail the technical aspects of proximal forearm level transplantation, as well as the immediate posttransplant monitoring and immunosuppression protocols. Materials and Methods A 24-year-old male victim of an electric injury presented with a bilateral proximal forearm level amputation. After the mandatory preoperative psychiatric and immunological evaluation, the patient underwent a proximal forearm level double upper extremity transplantation. He was then put on a stringent immunosuppression and physical rehabilitative regime. Discussion Conceptually, the proximal forearm level transplantation is significantly different from distal forearm level transplant. This transplant "reestablishes" the "donor extremity length," maintains the normal functional length of the donor muscles, and the functional return happens only after the newly transplanted donor muscles are reinnervated over a period of time. Conclusion As the sequence of surgical repair and associated decision making could be quite confusing for this level of transplantation, it is highly advisable to do mock cadaver surgical dissections in order to standardize the procedure and make the team familiar with it.

Indian Subcontinent's First Bilateral Supracondylar Level Upper Limb Transplantation.

Introduction This is the first case of supracondylar level transplant from the Indian subcontinent, performed for a bilateral below elbow amputee. It has a completely different set of challenges for the transplant team, with a relatively shorter ischemia time window. The technical considerations for the same have been discussed in detail in this article. Materials and Methods The patient was a 19-year-old female who lost her both upper limbs at proximal forearm level due to severe crush injury following a road traffic accident. Insufficient bone length on either side necessitated a supracondylar level transplant. The preoperative workup included detailed clinical evaluation, biochemical, and psychological evaluation. The donor was a young brain-dead, male patient from a hospital, 30 minutes away. The donor and recipient preparations in this case were unique. The recipient's own elbow flexors and extensors were used while the elbow joint was from the donor. The specific challenges we faced during this procedure have been described in detail. Results The transplantation has been a complete technical success, with the patient rehabilitated back to her independent life style. This article describes only the technical considerations. The functional recovery aspect is part of an another soon to be published manuscript. Conclusion Supracondylar level arm-transplant requires a highly coordinated team effort with precise preoperative planning, along with meticulous attention to detail to achieve a successful outcome. In properly selected patients, it could be a life-changing procedure, worth all the effort.