Reece, Edward M.

Summary: The number of spinal reconstruction cases is growing, as are the accompanying complications. Wound complications after spinal reconstruction can be fatal and can affect up to 19% of patients undergoing major spine surgery. The discipline of spinoplastic surgery is characterized by the use of vascularized bone grafts to reconstruct spinal defects, which provide better results compared with nonvascularized and allogenic equivalents, owing to their superior blood supply. We present a 49-year-old man with spinal defect in the C3-C7 region treated with spinoplastic reconstruction. A 5 × 6 cm occipital VBG was designed with a centrally located muscular pedicle and successfully inset into the osseous defect. Radiographs taken 15 months postoperatively demonstrated overall excellent bony fusion, and the patient made an appropriate clinical recovery. In difficult spine procedures, the use of this occipital vascularized bone graft may lead to higher fusion rates without the need for free tissue transfer or allograft placement, which may not be available at all surgical centers around the world.

Highlights Spino-plastic surgery addresses complex spinal defects using a multidisciplinary approachThe plastic surgeon's role in spinal reconstructive surgery has evolved from reactive to proactive involvement in careVBGs reduce time to spinal fusion without significantly increasing operative time, monitoring, length of stay or transfusions.We discuss the VBGs within the reconstructive ladder, as well as the indications, anatomy and dissection of VBG types.

ABSTRACT In the past two decades, plastic surgeons have advanced to the forefront of spinal surgery, joining orthopedic and neurosurgeons in the multidisciplinary field of spino-plastics. As the global disease burden grows with an increased incidence of spinal pathologies, vascularized bone grafts (VBGs) define the current frontier of spino-plastic surgery. Vascularized bone grafting involves lifting segments of bone with the muscular attachments but without the inclusion of a named vessel. When compared to traditional nonvascular bone grafts and allografts, VBGs have come forward as a favored technique for complex spinal reconstruction due to the unique opportunity to capitalize on the relationship between the tendons and Sharpey's fibers which maintain blood flow to both the bone and muscular segments. This technique ensures robust autologous tissue rearrangement and also takes advantage of the osteoinductive properties of the bone segments, promoting adequate structural support and the perfusion necessary for efficient direct healing and fusion in intricate spine reconstructions. Another one of the many favorable qualities of VBGs is the diversity of sources available to surgeons. The review explores the role of VBGs in enhancing spinal fusion rates and minimizing morbidity compared to traditional approaches. Additionally, a detailed examination of six common VBG sources-the iliac crest, ribs, medial scapula, occiput, spinous processes, and clavicle is included, highlighting each graft's specific techniques and emphasizing the range of options available to spino-plastic surgeons. Highlights Vascularized Bone Grafts (VBGs) have emerged as a favored technique in complex spinal reconstruction.The field of spino-plastic surgery highlights the collaboration between plastic, orthopedic, and neurosurgery.The article outlines the reconstructive ladder for bony defects, with VBGs being a critical addition.Advantages of VBGs include enhanced fusion rates, lower risk of infection, and reduced operative time.Preserving the vascular supply during graft harvest is crucial.Preoperative planning is essential as VBG selection is made on a case-by-case basis.

Abstract Background The presence of a chimeric gracilis and profunda artery perforator (PAP) flap with a common arterial pedicle has been demonstrated on computed tomography angiography in up to 59% of patients and confirmed in a cadaveric model. Already utilized for head and neck reconstruction by Heredero et al, this novel flap could provide more volume than either flap alone which is advantageous, particularly in patients with sizable defects. The purpose of this study was to determine the average tissue volume that can be utilized from this chimeric flap. Methods CT Angiogram imaging studies exhibiting chimeric flap anatomy were reviewed over a 7-year period at a single institution utilizing Visage Version 7.1, a radiology picture archiving and communication system. This software was used to trace the flap pedicles and to capture estimated soft tissue volumes of each respective flap. Results A total of 31 patients, consisting of 52 lower extremity gracilis and PAP chimeric flaps, underwent tissue volume analysis. The average total volume of soft tissue supplied by the gracilis flap was found to be 70.21 cm3 (standard deviation [SD] = 26.99). The average volume of the PAP flap was 31.73 cm3 (SD = 26.12). The average total volume captured by the chimeric gracilis and PAP flap was 101.94 cm3 (SD = 62.40). Conclusion The potential soft tissue volume that can be harvested from a chimeric gracilis and PAP flap is significantly greater than solitary gracilis or PAP flaps. This chimeric flap may serve as a viable and advantageous reconstructive option for patients requiring large volume soft tissue coverage, particularly if other sizable options are not available.

Summary: Pseudoarthrosis is a severe complication of spinal fusion surgery with occurrence rates as high as 35%–40%. Current options of revision surgery to correct pseudoarthrosis frequently carry high failure rates and risk of developing junctional kyphosis. Pedicled vascularized bone grafts (VBGs) are an innovative approach to boost spinal fusion rates via improving structural integrity and increasing the delivery of blood to the donor site. This versatile technique can be performed at different spinal levels without additional skin incisions and with minimal added operative time. Here we present the first bilateral rib and iliac crest VBG spinoplastic surgery performed to augment spinal fusion in a 68-year-old woman with distal junctional kyphosis and severe positive sagittal balance with low back and neck pain and significant difficulty standing upright. The patient had history of multiple spinal operations with preoperative CT imaging demonstrating loosening and pull out of L3 and fracture of L2 screws. She underwent two-stage surgical treatment involving anterior lumbar interbody fusion L3-S1 followed by removal of hardware, T4 to pelvis fusion with L2-3 prone lateral interbody fusion, and T11-S1 posterior column osteotomies. The surgery was augmented by bilateral rib and iliac crest VBGs performed by plastic surgery. At three-month follow-up the patient demonstrated functional improvement, being able to maintain upright posture and walk; was satisfied with the result of the surgery; and demonstrated no graft-related complications. In conclusion, utilization of pedicled VBGs is a novel, promising approach to augment spinal surgery in high risk patients.

Summary: Abdominal-based free flaps are the mainstay of autologous breast reconstruction; however, the region may not be ideal for patients with inadequate soft tissue or history of abdominal surgery. This case describes the use of a novel conjoined flap based on the profunda artery perforator and upper gracilis pedicles, named the perforator and upper gracilis (PUG) flap. This flap design aims to maximize medial thigh flap volume while ensuring robust tissue perforation. Here, we present our experience with the PUG flap in a breast cancer patient undergoing autologous reconstruction. The patient was a 41-year-old woman seeking nipple-sparing mastectomy and immediate autologous reconstruction with the PUG flap due to limited abdominal tissue availability. The gracilis and profunda artery perforator flaps were elevated using one boomerang-style skin paddle. Once harvested, the flaps were inset with antegrade and retrograde flow off the internal mammary arteries and both respective internal mammary veins. The donor site was closed in a V-Y pattern resulting in a thigh lift–type lift and concealed scar. In conclusion, the boomerang-style PUG flap maximizes medial thigh free tissue transfer volume, offers internal blood flow redundancy, and maintains good cosmesis of the donor site.

ABSTRACT The role of plastic surgeons in the world of spine surgery is quickly evolving. The plastic surgeon now serves both a therapeutic and prophylactic role in addressing complications of complex and revision spine surgery. The field of Spino-plastic Surgery is characterized by the use of vascularized bone grafts (VBGs). VBGs are bone segments transferred on their corresponding muscular attachments without the inclusion of a named vessel. The bone graft is adequately vascularized through the connection of the tendon by Sharpey's fibers and their associated microvasculature. VBGs provide an autologous, pedicled tissue rearrangement option with osteoinductive properties and adequate structural support for complex spine reconstruction. VBGs are associated with a lower risk of adverse events and shorter times to fusion than allografts, and bypass the need for lengthy microsurgical anastomosis. Five types of VBGs for spine reconstruction are described in this article, including iliac crest, rib, occiput, scapula, and spinous process VBG. Virtually any vertebral level can be reached for arthrodesis using one or more of these VBGs. Highlights Vascularized bone grafts are bone segments transferred on muscular attachments without the inclusion of a named vessel.Vascularized bone grafts provide an autologous, pedicled tissue rearrangement option for complex spine reconstruction with a lower risk of adverse events and shorter times to fusion than allografts.Five types of vascularized bone grafts for spine reconstruction have been described: iliac crest, rib, occiput, scapula, and spinous process.Virtually any vertebral level can be reached for arthrodesis using one or more vascularized bone grafts.