WG, Age 76
Nasal Reconstruction

Patient-specific goals
This gentleman is a 76-year-old with a complex squamous cell carcinoma of the nose. The tumor involved the full thickness of tissue of the left side of the nose. Tumor removal involved removing the left half of the nose, part of the cheek and upper lip tissues.

Our Solution
We planned and performed a three-part staged procedure starting at the tumor removal surgery with simply skin grafting the opening and stabilizing the defect. Secondarily, a forehead flap surgery allowed similar texture skin to be moved from the forehead to the nose. A final revision shaping procedure was done to get an overall nice result given the complexity of the nasal defect.

JM, Age 89
Nasal Reconstruction

Patient-specific goals
This lovely 89-year-old woman developed a skin cancer on the tip of her nose that was removed by Moh’s micrographic surgery. She wanted the best quality option that matched the original appearance as best as possible.

Our Solution
We discussed two options, skin grafts and a staged forehead flap. While the skin graft is a simpler option, the result involves a thin skin replacement for what is normally thick skin at the tip of the nose. There are also some textural differences between skin grafts and normal skin.

The best option is a forehead flap where a nice quality thickness skin flap is transferred in a two-step procedure. The benefit is that the skin quality and texture is hands-down better than a skin graft. It does require a new scar on the forhead, but one that heals well. Despite the advanced age, she was eager to get the nicest result. At the conclusion, a nice nasal reconstruction for this woman.

WH, Age 84
Nasal Reconstruction

Patient-specific goals
This gentleman had a skin cancer of the cheek and nasal sidewall removed by Moh’s surgery. He was referred to us to reconstruct the ensuing opening.

Our Solution
This case lent itself well to manage closing the defect by rearranging the tissue that surrounds the wound. The cheek has good laxity and was designed to close a portion of the defect by making a back incision along the lip-cheek groove as well as a small incision below the eye. Additionally, a small nasal incision was made so allow the nasal skin the move back and fill some of the opening. The combination allowed for the ultimate scar seam to be left where creases normally are. Hiding scars in pre-existing folds are a great way to trick the eye that surgery was performed.

DD, Age 51
Skull / Cranial Vault Reconstruction

Patient-specific goals
This gentleman originally sustained a head injury requiring neurosurgical removal of the collected blood on the brain. The procedure involves removing and then replacing a segment of the skull to access the intracranial space. He unfortunately developed an infection of the bone segment that required removal. Ultimately he was left with a sunken in skull deformity that limited the brain from expanding. He was referred for secondary cranioplasty after recent infection.

Our Solution
Since the original skull bone was not a viable option, we worked with our neurosurgery colleagues to perform a reconstruction of the skull using a titanium mesh plate. Placing an implant with a history of recent infection is challenging. We timed the procedure after treatment of the infection and then re-explored and re-prepared the site, clearing any tissue potentially still harboring bacteria. The titanium plate was then contoured and secured followed with a redraping and closure of the skin back to its original location. We decided to slightly undercorrect this deformity so that the skin repair would not be under tension. A challenging case but thankfully a successful result.

TO, Age 77
Scalp / Face / Skull Reconstruction

Patient-specific goals
This is a unique case of an otherwise healthy 77-year-old woman with a rapidly growing squamous cell carcinoma of the left face and temporal region. Initial imaging suggested close involvement of her skull bone. She was initially managed with resection, partial skull bone shaving and skin grafting by a different surgeon. This was followed with radiation therapy but shortly after she began regrowing her tumor. At this point a more aggressive tumor removal would require re-excision of the skin and tissues as well as the overlying skull down to the brain. To aid in the reconstruction, she was referred to me for management.

Our Solution
This is a multi-faceted case and requires alot of pre-planning and coordination to both succeed in getting her cancer free as well as have an acceptable cosmetic result. After discussion with neurosurgery and head and neck oncology, we decided to perform a staged surgery. Initially, the recurrent tumor was removed with the overlying skull bone. At that point I performed a microvascular tissue flap transplant from the back, consisting of skin, muscle and fat to cover the exposed brain and repair the skin deficit. Her result, shown, is after the initial procedure. Thankfully the margins were clear which would hopefully insure a cancer free situation. What I was left to plan for was how to restore the skull shape, restore the eye symmetry and improve the facial appearance. (Continue on next slide)

Our Solution (continued)
I began with obtaining a CT to clearly define the missing skull bone and worked with a team of medical technologists who was able to use a 3D printer to fabcricate a custom bone like implant. This would serve to protect the brain from injury, but also restore symmetry to the skull. In the second surgery, I carefully elevated the previously placed tissue flap and inserted and secured the custom implant to the surrounding skull. At this same procedure, the skin and tissue were debulked and recontoured to allow the eye to be better positioned and improve the facial appearance. Three years later, at age 80, she is happy to be healthy, active, cancer-free and still dancing (she teaches ballet!). A highly complex but extremely rewarding case.

TG, Age 65
Scalp / Face / Skull Reconstruction

Patient-specific goals
This case is a case of a kind 65-year-old gentleman with a progressively enlarging, fungating skin cancer that began in the region around the ear. The growth progressed to involves the majority of the ear, portions of the cheek and deep involvement of the skull bone and inner ear anatomy. The chronic open ulcerations had naturally become colonized with bacteria making for an overall challenging case to manage. I was asked to assist as the surgeon to restore the soft tissues of the face after tumor removal.

Our Solution
This case required careful planning to optimize function and cosmesis. In this patient, tissue coverage is needed to cover the exposed cranial contents and blend nicely with surrounding tissues. I elected to perform a free rectus abdominal muscle flap, harvested from the abdominal region and transplanted to the facial area. After reconnecting the feeding microvascular channels to keep the tissue alive, I resurfaced with skin grafts. Their was no plan for external ear creation given the inner ear anatomy was removed. If desired, a custom silicone ear prosthesis could have been created a near-perfect replica the ear.

WH, Age 46
Lower extremity Reconstruction

Patient-specific goals
This gentleman has been a bilateral amputee for over 7 years. He maintains an active lifestyle and is capable of most traditional activities using his bilateral prosthesis. Unfortunately, more recently he developed non-healing wounds at the stump location on either side that precluded his prosthesis use. Despite multiple attempts by his primary orthopedic team, he has been unable to heal and was referred for assistance.

Our Solution
This case is a great example of the challenges around wound healing. We start by carefully examing the wound, understanding what has been attempted previously, and thinking about all the factors that could be preventing successful healing. On the right leg, a change in wound care and off-loading was successful in getting the wound closed. The left leg was more of a challenge because it was appreciated that hardware in the leg was exposed and served as the nidus to recurrent breakdown. A procedure was then recommended and performed to shorten the hardware, washout and debride the wound and close. Thankfully the solution was successful in getting him back on his feet!

ET, Age 50
Lower extremity Reconstruction

Patient-specific goals
This nice gentleman has an unfortunate fall and sustained a right ankle fracture that required orthopedic surgery to re-align and internally fixate using a plate and screw technique. Unfortunately, he subsequently had skin loss and infection of the fracture site. The ankle wound was opened with no ability to simply close the skin over the hardware. To aid in soft tissue reconstruction of the leg, he was referred for assistance. Progressive infection and non-healing could potentially lead to the need for amputation.

Our Solution
This is a difficult case where an open wound involves a fracture site and exposed hardware with known bacterial colonization. In this area of the body, there is no redundancy of extra skin and the solution involves performing a free tissue flap transplant from another area of the body down to the leg to serve as the tissue replacement. In this case, a flap of skin and underlying tissues were harvested from his thigh and transplanted to the ankle region. The procedure involves microvascular reconnection of the millimeter-sized vessels under a microscope to re-establish blood flow. Since the tissue transplant is his own, as opposed to say a heart or kidney transplant, he has no need for immunosuppression and no risk of rejecting the tissue. Once completed, the tissue serves as a nice thin coverage of the ankle to allow the ankle fracture to heal and avoids creating a deforming or bulky appearance that interferes with shoe wear and walking.