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BACKGROUND: The management of chronic empyema associated with a bronchopleural fistula can be a particularly challenging problem. Successful eradication may not occur without interposition of healthy vascularized tissue. Pedicled muscle flaps for coverage on the thorax have been well described. However, secondary to trauma or previous surgical procedures, a pedicle flap may not be sufficiently sized or available. Free tissue transfer is an attractive option to provide the appropriate vascularized tissue. METHODS: Six patients with chronic empyema-bronchopleural fistulae were reconstructed with 4 rectus abdominis myocutaneous and 2 gracilis muscle flaps. The choice of recipient vessels was dictated by existing local anatomy but included intercostal, thoracodorsal, thoracoacromial, azygous, and circumflex humeral vessels. One flap required interposition saphenous vein grafts for both artery and vein. RESULTS: Patient follow-up ranged from 2 to 14 years. There were no episodes of flap loss or postoperative mortality. Empyema resolution without recurrent bronchopleural fistula was achieved in all patients. CONCLUSIONS: Free tissue transfer is an excellent option for vascularized tissue interposition in patients who are not candidates for pedicled muscle transfer. Multiple potential recipient vessels provide tremendous versatility, arguing for early consideration of free tissue transfer.

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Survival of the ear based on a single vascular pedicle has been previously documented. The anatomic basis for this survival remains incompletely described. In the 3 clinical cases of inferior-to-superior near-total ear avulsion presented herein, the authors have observed that the ear can survive based on a narrow pedicle along the helical root. In an anatomic study to further investigate the relevant vascular anatomy, the common carotid artery system of 6 fresh human cadaver specimens was injected with latex. The superficial temporal artery and its branches located at the helical root were examined. This anatomic study showed that the upper auricular branch of the superficial temporal artery continues into the ear as the helical artery supplies an arterial arcade, which we have termed the helical arcade. This arcade seems to allow for communication between the anterior and posterior arterial systems of the ear and allows the helical artery to provide sufficient arterial supply to the entire ear.

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The medical records of 437 patients with 929 facial fractures were retrospectively analyzed. Fracture patterns were classified based on the presence or absence of fractures in each of 4 anatomic subunits (frontal, upper midface, lower midface, and mandible). The most common etiology of trauma was assault (36%), followed by motor vehicle collision (MVC, 32%), fall (18%), sports (11%), occupational (3%), and gunshot wound (GSW, 2%). The most common fracture type was nasal bone fracture (164). MVC was found to be a significant predictor of panfacial fractures, as was GSW. Sports injuries were a significant predictor of isolated upper midface fractures, and assault was a significant predictor for isolated mandible fractures. MVC and GSW each were found to lead to significantly higher severity of injury than assault, fall, and sports. The results confirm intuitive aspects of the etiology of facial fractures that have been anecdotally supported in the past.

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BACKGROUND: Patients with panfacial fractures comprise a small portion of the overall facial fracture patient population. Because of the forces necessary to cause panfacial injury, these patients often have other concomitant injuries. The timing of operative facial fracture management remains controversial. METHODS: A 3-year review of all patients with facial fractures was conducted at Duke University Medical Center (2003-2005, 437 total patients). All patients with panfacial fractures, defined as fractures involving at least three of the four facial segments (frontal, upper midface, lower midface, and mandible), were analyzed. RESULTS: Panfacial fractures were present in 38 patients (9% of overall facial fracture population). Twenty (53%) of these patients suffered concomitant injuries. The most common mechanism of trauma was motor vehicle collision, and the most common category of concomitant injury was intracranial injury or hemorrhage. Other commonly occurring categories of injury included abdominal organ injury, pneumothorax, pulmonary contusion, spine fracture, rib or sternum fracture, extremity fracture, and pelvic fractures. There was no significant difference in day of operation for the management of facial fractures between those with isolated facial injuries and those with other concomitant injuries (hospital day 2.1 vs. hospital day 2.9, not significant). CONCLUSIONS: Concomitant injuries to all parts of the body are found in patients with panfacial trauma. In our experience, these injuries do not significantly delay or have an adverse effect on the treatment of facial fractures. A treatment strategy for consistent timely management of facial fractures is described.

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