Hot Topics in Reconstructive Surgery

Abstract

Plastic surgery remains at the forefront of surgical innovation. In particular, reconstructive surgery has seen many recent advances that continue to improve outcomes and quality of life for patients. This article highlights the current “hot topics” in reconstructive surgery, including facial transplantation, reconstructive head and neck surgery, surgical treatments for lymphedema, gender-affirming surgery, and reconstruction of the lower extremity and trunk. The first significant advance is facial vascularized composite tissue allotransplantation, which represents a paradigm shift in the reconstruction of extensive facial defects. Now in its second decade, the feasibility of facial transplantation is well established, and the field is now advancing toward more complex reconstructive challenges. A recent report of the outcomes of six patients at a median follow-up of 5 years after facial transplantation found that no allograft losses or deaths occurred in this cohort, and patient-reported quality of life trended toward improvement.1 Motor and sensory reinnervation also was demonstrated, and the patients reported adequate functionality to facilitate their social reintegration. Despite the many challenges associated with facial allotransplantation, this report supports that it can improve the quality of life for these patients with few, if any, reconstructive alternatives. In a study published in this Journal, the outcomes of partial face and double-jaw allotransplantation in a patient with irreparable facial injuries resulting from ballistic trauma were reported.2 At almost 1 year postoperatively, the patient demonstrated excellent aesthetic outcomes and intelligible speech and was tolerating an oral diet. No episodes of acute rejection occurred. Together, these studies demonstrate that emerging innovative technologies and improved immunosuppression protocols have advanced the field to overcome significant challenges in facial transplantation. In another article, the use of computerized surgical planning in three patients who underwent facial transplantation was found to enable more accurate reconstruction of these unique anatomical and functional defect presentations as measured on immediate postoperative imaging.3 This was accompanied by a decreased reliance on cadaveric simulation, reduced operative time, and less need for major orthognathic surgical revision. The use of computerized surgical planning therefore has the potential to advance facial allotransplantation as it has advanced reconstruction of mandibulectomy and maxillectomy defects. Reconstruction of posterior mandibulectomy defects remains a significant challenge, and a study published in this Journal reported outcomes using adjunctive computer-aided design and manufacturing (CAD-CAM).4 The authors performed a retrospective study comparing outcomes in patients with reconstructions using osteocutaneous flaps compared with soft-tissue free flaps and found that malocclusion was significantly less common with osteocutaneous flaps and was lowest in the CAD-CAM group; that group was also more likely to progress to a regular diet and trended toward having superior speech outcomes when compared with the other cohorts. This adds to the growing literature reporting improved outcomes with the use of computerized planning and the central role it will play in reconstructive surgery in the future. Another advance in the field of head and neck surgery has been the introduction of jejunal flaps for the reconstruction of total esophageal defects where gastric pull-up is unsuccessful or unsuitable. A retrospective analysis of the outcomes of the supercharged pedicled jejunal flap in this setting from the Texas Medical Center found that of patients with a follow-up longer than 6 months, 86 percent tolerated a solid or soft oral diet.5 Major surgical complications occurred in 20 percent of patients, highlighting the complexity of this procedure even in the hands of an experienced mul