Odorico, Scott K.

Background: Polyetheretherketone (PEEK) is a commonly used material for cranioplasties due to its advantages over other materials and autologous bone grafts. PEEK has an increased malleability, which increases postoperative aesthetics and adapts well to the cranial contours; it is also associated with a lower rate of infection when compared with autologous cranioplasties. Despite these benefits, there is limited information on the practical aspects of modifying PEEK cranioplasties after their initial placement. Case Series: We present 2 cases of patients who had previously undergone PEEK cranioplasty being treated with deep-brain stimulation (DBS), which was placed through their PEEK implant. The first was an 18-year-old male who had previously undergone cranial vault closure with bone grafts following a craniotomy. Later, when a deep-brain stimulator was planned, it was discovered that the bone grafts had significant resorption and a lack of structural integrity. Therefore, bone grafts were replaced with a custom PEEK implant cranioplasty before the DBS electrodes were placed via drilling through the PEEK implant to access the brain at a later surgery. The second patient was a 39-year-old male who developed epilepsy after a stroke, requiring craniotomy. DBS was unable to be performed initially due to significant resorption of the patient’s native bone. Therefore, a PEEK cranioplasty was performed in preparation for a staged, subsequent placement of DBS electrodes through the implant. Both patients recovered uneventfully following surgery, with noticeable improvement in functional (reduction in seizure frequency) and aesthetic outcomes. Systematic Review: A literature review was conducted using PubMed with keywords related to PEEK cranioplasties. After screening titles, abstracts, and full-text papers, it was found that 3 previously documented cases have involved drilling through PEEK implants: one by Mallela et al, involving SEEG electrode placement; one by Marrone et al, concerning a burr hole for evacuating a chronic subdural hematoma; and one by Ledesma et al, regarding the placement of subdural grid electrodes. Conclusions: This case series highlights how PEEK cranioplasties can be drilled through for therapeutic procedures, such as DBS electrode implantation, without compromising their structure. These cases illustrate the versatility, safety, and adaptability of PEEK implants for additional necessary interventions.

BACKGROUND: Free fibula flaps have been widely used for bony reconstruction in pediatric patients. While donor site complications have been well studied in adults, data in the pediatric population remains limited. This study exclusively reports donor-site morbidity following fibula flap harvests in the pediatric and adolescent population. METHODS: We reviewed all patients younger than 18 years with open physes who underwent fibula flap harvests at a single academic institution from 1997 to 2024. Demographics, clinical and surgical characteristics, and donor-site complications were recorded. RESULTS: Fifty-seven free fibula flaps were harvested from 55 pediatric patients (mean age 12 years; 29 female) with a mean follow-up of 6 years. Flaps were most commonly used for lower extremity reconstruction (52%) and following tumor resection (74%). Osteoarticular flaps (n=8) were associated with transient deep peroneal nerve palsy in four cases, all of which recovered antigravity dorsiflexion by 6 months. In standard segmental harvests (n=49), donor-site complications occurred in 38%, most frequently valgus ankle deformity (9%) and neuropathic pain (6%). Valgus deformity was more likely in patients with shorter distal residual fibula and an age–residual fibula index (A-RFI) <16. CONCLUSIONS: Vascularized fibula flaps are safe and versatile for pediatric skeletal reconstruction. Donor-site complications are common but generally manageable, with full recovery of nerve function. Osteoarticular harvests carry the highest risk of peroneal nerve injury, and valgus ankle deformity may occur, particularly with an age–residual fibula index <16. Careful planning and age-adjusted fibular preservation are essential to optimize outcomes.

ABSTRACT The deep inferior epigastric perforator (DIEP) flap remains the preferred flap option for autologous breast reconstruction following mastectomy. This case report presents the novel use of the cephalic vein (CV) as an interposition graft to alleviate venous congestion in a patient undergoing DIEP flap reconstruction. A 42‐year‐old woman experienced venous congestion following her initial autologous reconstruction, attributed to thrombus formation from kinking of the vascular pedicle. Despite initial attempts to resolve the congestion, the condition persisted. Since the flap was based on a single perforator, we decided to attempt a CV turndown. The CV was noted to be attenuated and not feasible for use in turndown; therefore, venous salvage was completed by using the CV as an interposition graft to bypass the affected flap vena comitans. The procedure successfully restored venous flow, allowing for flap salvage and subsequent healing. This case underscores the potential of CV as an interposition graft in autologous breast reconstruction, particularly when traditional CV turndown is not possible due to vessel attenuation.

ABSTRACT Background Abdominal‐based free flaps are the mainstay in autologous breast reconstruction. Their safety and consistency in outcomes are well‐documented. When flap compromise occurs, operative salvage is the gold standard. However, when—and if—to place these patients on heparin infusions is unclear. The goal of this study was to investigate abdominal‐based free flap compromise and compare outcomes with and without heparin infusion. Materials and Methods This was a single‐institution, multiple‐surgeon, retrospective chart review of patients undergoing autologous, abdominal‐based free flap breast reconstruction who experienced anastomotic compromise within a 6‐year period. Treatment and outcomes data collected include flap salvage, hematoma, seroma, surgical site infection (SSI), transfusion requirement, and length of hospital stay. Results Fifty‐one flaps had evidence of compromise. A total of 31 (60.8%) patients were placed on heparin infusions after experiencing anastomotic compromise, compared to 20 who did not receive heparin infusion. Thirty‐five patients (68.6%) underwent deep inferior epigastric perforator flaps. Twenty‐six patients (51%) experienced venous congestion, 22 patients (43.1%) experienced arterial compromise, and three (5.9%) experienced both. Twenty‐eight patients (54.9%) received tissue plasminogen activator; in the heparin infusion group, 21 patients (67.7%) received tissue plasminogen activator. The total salvage rate of compromised flaps was 94.1% (48/51). There was no significant difference between heparin infusion and standard cares in length of hospital stay, length of drains in‐place, successful salvage (93.5% vs. 95%), hematoma (19.4% vs. 15%), fat necrosis, SSI, hospital readmission (19.4% vs. 15%), and return rates to the operating room (48.4% vs. 50%). However, there was a significantly higher transfusion rate in patients receiving heparin infusion (38.7% vs. 10%). Of the 25 flaps with evidence of thrombosis, 72% were placed on heparin infusions while 28% were not; there was no significant difference in salvage rate in this sub‐group. Conclusions This review of autologous breast reconstruction free flap compromise provides evidence of similar safety profiles, with similar salvage rates, when comparing salvage with and without heparin infusion; there is a higher transfusion requirement when treating with heparin infusion.