Journal of Plastic, Reconstructive & Aesthetic Surgery

The versatility of the temporoparietal fascia flap in head and neck reconstruction

Ryan M. Collar, David Zopf, David Brown, Kevin Fung, Jennifer Kim — 2011-06-23

Summary: Objectives: The temporoparietal fascia flap (TPFF) is a versatile tool in head and neck reconstruction. This article aims to describe the spectrum of TPFF applications through a series of case studies and related review of the literature.Methods: Medical records were reviewed to identify cases that represent major TPFF application categories. A literature review was performed to support the presentation and discussion of each case category.Results: Seven cases were identified each representing a distinct application category. These included auricular reconstruction, hair-bearing tissue transfer, facial soft tissue augmentation, cutaneous and mucosal oncologic defect repair, reconstruction after salvage laryngectomy, skull base reconstruction, and orbital reconstruction.Conclusion: The TPFF is a uniquely versatile tool in head and neck reconstructive surgery. Outstanding in its pliable, ultra-thin yet hardy and highly vascular form, the temporoparietal fascia flap is a workhorse for the creative head and neck reconstructive surgeon.

The reverse superficial temporal artery flap from the preauricular region, for the small facial defects

2011-10-07

Summary: Background: For the reconstruction of facial defects, the retroauricular flap is generally used. However, this flap has disadvantages, such as venous return disturbance and reddish skin colour peculiar to the retroauricular region.Methods: Here, we report the reverse superficial temporal artery (STA) flap, elevated from the preauricular region. In our method, the flap is retrogradely elevated including the STA under the skin island in the preauricular region and the temporoparietal fascia around the superficial temporal vessels in the temporal region. The donor site is closed primarily or by the retroauricular flap.Results: Five cases with a pedicled flap and one case with a free flap were treated using our method. In one case, a minor congestion of the flap occurred postoperatively, and temporary facial nerve palsy in another case. In all cases, the results were cosmetically good, and the scar at the donor site was inconspicuous.Conclusions: As compared to the retroauricular flap, our method is easier to perform and the flap has a reliable blood circulation. Moreover, it can be used with both a pedicled and a free flap, leaving an inconspicuous scar at the donor site, and a colour match without reddish skin. Therefore, when considering reconstruction of small-sized defects on the face, our method is more useful than the retroauricular flap.

Extension of the jejunum in the reconstruction of cervical oesophagus with free jejunum transfer using the thoracoacrominal vessels as recipients

2011-09-26

Summary: Backgrounds: The degree to which the jejunum can reach upward is a significant consideration in cervical oesophagus reconstruction with vascularised free jejunum transfer using the thoracoacrominal vessels as recipient vessels. The present study aims to elucidate this issue.Materials and methods: In 30 fresh cadavers, the thoracoacrominal vessels were dissected, and the jejunums were harvested, carrying the second branches of the superior mesenteric arteries and veins as their pedicles. After the mesenteric vessels were anastomosed to the thoracoacrominal vessels, the jejunums were advanced to their maximum upward degree, and the positions of the oral ends were evaluated referring to the hyoid bone. The evaluation was performed under three conditions. In the first condition, the jejunums were simply advanced. In the second condition, tension of the mesenteriums was reduced by incising their serosa. In the third condition, mesenterial incision was also performed, and the anastomosed pedicles were placed under the clavicles.Results: The jejunums can reach superior to the hyoid bone by 2.1 ± 1.5 SD cm for males and by 1.9 ± 1.5 SD for females. By incising the mesenteric serosa, these distances can be extended by about 2 cm for males and 1 cm for females. Further extension of 2 cm can be obtained for both sexes by placing the pedicle under the clavicle.Conclusion: With patients whose neck regions lack vessels available for vascular anastomosis, the thoracoacrominal vessels are used in free jejunum transfer for cervical oesophagus reconstruction. The findings of the present study are useful in planning this type of reconstruction.

Management of lip hemangiomas: Minimizing peri-oral scars

2011-09-21

Summary: Purpose: Hemangiomas are the most common benign tumor of infancy, affecting females more than males. Lip hemangiomas are of particular concern because of their relatively increased risk to ulcerate during the proliferative period. Ulcerated hemangiomas of the lip can lead to increased scarring, loss of lip contour, and disfigurement. Most will require surgical correction to restore normal labial anatomy.Methods: A retrospective chart review between 2004 and 2010 for surgically treated lip hemangiomas was performed. Demographic data, location of the hemangioma, age at operation, and number of operations were recorded. Two independent observers evaluated lip appearance post-operatively using 5-point scales to examine scar, symmetry, contour, and color, with 5 being excellent and 1 being poor.Results: Between 2004 and 2010, eleven patients underwent surgical correction. Ten of the eleven were female. 18% (2/11) were ulcerated. One third (4/11) was in the upper lip and two-thirds (7/11) were in the lower lip. The mean age of the patients at the time of operation was 3.6 years (range, 14 months to 17 years). The average number of operations per patient was 1.6 (range, 1–3). The average scores for lip appearance after surgical correction ranged between 3.95 (good) for lip contour to 4.5 (good to excellent) for color.Conclusions: Lip hemangiomas often require surgical correction. Treatment goals include restoration of normal lip contour and strategic placement of the incision. By taking advantage of the natural involution that occurs and careful planning, procedures can be staged to minimize distortion of the lip. Even lip hemangiomas that cross the vermilio-cutaneous (VC) junction can be excised and lip contour achieved without the need to extend scars beyond the VC junction.

Anthropometric evaluation of bilateral cleft lip nose with cone beam computed tomography in early childhood: Estimation of nasal tip collapse

2011-09-26

Summary: Background: Nasal tip features of cleft lip nose cannot be defined well using conventional measurement methods. Therefore, we developed a new method in which vertical nasal tip (the pronasale) position is evaluated based on the Frankfurt-Horizontal plane. This measurement was applied to bilateral cleft lip patients in early childhood.Methods: Cone beam computed tomography (CT) records of bilateral cleft lip patients after primary rhinoplasty aged from 5 to 8 years (n = 13) were investigated retrospectively. As age-matched controls, data from a normal group (n = 17) and complete unilateral cleft lip group after primary rhinoplasty (n = 19) were included. In each group, nasolabial angle (β), nasal tip angle (α), nasal width (al-al), columellar length (sn-c′ ), nasal tip protrusion (sn-prn), and vertical nasal tip position (sn′-prn′/sn′-n′) were investigated.Results: With the exception of vertical nasal tip position and nasal width, the measurement data of the bilateral cleft lip patients were acceptable. In the bilateral cleft lip group, however, vertical nasal tip position was significantly higher and nasal width was significantly larger than those in the normal and unilateral groups (P < 0.0001 and P = 0.0298; P = 0.0001 and P = 0.0002, respectively).Conclusions: In cleft lip nose, the lower lateral cartilage that normally composes the nasal tip domes is splayed out, causing cephalic positioning of the pronasale. Nasal tip collapse was more severe in bilateral cleft lip than in the unilateral group. These results were compatible with the fact that many bilateral cleft lip patients require augmentation rhinoplasty after adolescence even after primary rhinoplasty.

Speech outcomes in 10-year-old children with complete unilateral cleft lip and palate after one-stage lip and palate repair in the first year of life

Maria Hortis-Dzierzbicka, Elzbieta Radkowska, Piotr S. Fudalej — 2011-10-05

Summary: An evaluation of the results of one-stage repair of unilateral cleft lip and palate (UCLP) performed at the Institute of Mother and Child, Warsaw, Poland, has shown that the dentofacial outcomes are comparable with those of the best cleft centres. The aim of this study was to assess speech development after one-stage closure of UCLP. Twenty boys and eight girls at the mean age 9.6 years consecutively treated with one-stage closure of the cleft at the mean age of 8.8 (range, 6–13) months were included. The same surgeon performed palatal repair using a vomerplasty. The evaluated outcomes included (1) perceptual speech evaluations with assessment of hypernasality, audible nasal emissions (ANEs) and compensatory articulations, (2) evaluation of compensatory facial grimacing, (3) clinical intraoral evaluation and (4) videonasendoscopy when indicated. Our results demonstrated that 25 patients (89.3%) had normal nasal resonance. Severe hypernasality and compensatory articulation disorders caused by velopharyngeal insufficiency were assessed in one patient. In 13 patients (46.4%), oronasal fistulas were found. Two children (7%) with larger fistulas presented with mild hypernasality. In 11 cases (39.2%), fistula friction was heard at pronunciation of some anterior sounds. Ten children (35.7%) demonstrated compensatory facial grimacing, mostly inconsistent and mild, in the form of nasal valving. In conclusion, articulation development, velopharyngeal sphincter competence and incidence of compensatory articulations in our sample are satisfactory. However, only 54% of the present groups were rated as having entirely normal speech because of high incidences of anterior palatal fistulas, and mild but frequent fistula-related speech disturbances.

Pre-expansion before risk reducing mastectomy combined with lipomodelling to enhance results from implant based reconstruction

E. Katerinaki, T. Sircar, F. Fatah — 2011-09-19

Summary: Implant based breast reconstruction after risk reducing mastectomy (RRM) is challenging as implants are inadequately covered in their lower pole. Also complication rates with one stage procedures are significant.We describe a novel method of pre-expansion by inserting subpectoral anatomical expandable implants to prepare the breast mound before RRM is carried out. Lipomodelling is later used to enhance the overall result of the reconstruction. Six patients who were BRCA 1 mutation carriers requested bilateral RRM. Median age was 31. All were non-smokers. Anatomical expandable implants were inserted via an inframammary incision and were expanded in the next two months. RRM was carried out 6–13 months later and was followed by lipomodelling seven months afterwards. Four patients had a nipple sparing mastectomy. In three cases access was via the previous inframammary scar.In all cases complete implant cover had been achieved. There were no early postoperative complications but one patient has developed grade III capsular contracture on the side of previous wide local tumour excision and radiotherapy. Five patients have so far undergone post-mastectomy lipomodelling to improve breast contour. In conclusion, we believe that our technique provides better aesthetic results with reduced complication rates for these patients.

Immediate breast reconstruction using autologous skin graft associated with breast implant

2011-10-03

Summary: Background: Immediate breast reconstruction with skin graft is still little mentioned in the literature. Follow-up studies regarding the technique aspects are particularly scarce. The objective was to detail immediate breast reconstruction using autologous skin graft.Methods: Patients (n = 49) who underwent mastectomies and autologous immediate breast reconstruction with skin graft associated with a breast implant at A. C. Camargo Hospital (São Paulo, Brazil) between January 2007 and July 2010 were included. Information on clinical data, technique details and clinical outcome were prospectively collected. Following mastectomy, the autologous full-thickness skin graft was obtained through an inframammary fold incision along the contralateral breast in most patients. The skin graft was placed on the surface of the pectoralis major muscle after adjustments to conform to the mastectomy defect. A minimum of 10-month follow-up period was established.Results: Patients’ age ranged from 35 to 55 years and all received a silicone gel textured surface implant to obtain the necessary breast mound. The mean surgical time was 45 min, and the mean amount of skin resection was 4.5 cm in the largest diameter. Follow-up ranged from 10 to 35 months (median 23). All patients had silicone-gel textured surface implants to perform the breast mound reconstruction. No complications were observed in 87.8% of reconstructions. Forty-six patients (94%) had no complaints about the donor-site aesthetics. The result was a breast mound with a central ellipse of healed skin graft. Three (6%) poor results were observed. Thirty-six patients (67%) reported the results as good or very good.Conclusions: Our results lead us to conclude that autologous skin graft provided a reliable option in immediate breast reconstruction to skin-sparing mastectomy defects. The technique accomplished a single-stage implant breast reconstruction when there is inadequate skin coverage.

Microvascular anastomosis using the vascular closure device in free flap reconstructive surgery: A 13-year experience

Chaitan Reddy, David Pennington, Harvey Stern — 2011-10-12

Summary: The achievement of patency of the microvascular anastomosis in free flap surgery is dependent on a number of factors, central to which is atraumatic handling of the vessel lumen, and intimal apposition. Initial laboratory studies demonstrating the superiority of the non-penetrating vascular closure staple (VCS – Anastoclip ®) were followed by our report in 1999 on a series of free flaps. There is still a paucity of data in the literature on the use of non-penetrating devices for microvascular anastomosis, and our review gives evidence to support the routine use of the VCS in microsurgical free flap surgery. We now report on its successful use over a thirteen year period in 819 free flap reconstructions. Our data indicates the VCS device to be as effective as sutured anastomoses in free tissue transfer surgery. There is also statistically significant data (Barnard’s Exact Test) to demonstrate a higher vascular patency rate of the VCS device over sutured anastomoses when sub group analysis is performed. ‘Take-back’ revision rates were lower amongst flaps that employed VCS use. For arterial anastomoses, this equated to 3/654(0.05%) vs 4/170(2.4%) with hand-sewn anastomoses (p = 0.02). Similarly, for venous anastomoses the ‘take-back’ revision rate was 7/661(1.1%) vs 8/165(4.8%) with hand-sewn anastomoses (p = 0.003). Furthermore, the major advantage of the VCS is reduction in anastomosis time, from approximately 25 min per anastomosis for sutures to between five and 10 min for staples.

Dermolipectomy of the lateral thoracic fat compartment in secondary breast reconstruction revision: Anatomical and clinical results

2011-10-10

Summary: Fullness in the lateral thoracic area following breast reconstruction can be a source of concern for patients. This redundant tissue creates disharmony between the newly reconstructed breast, the lateral mammary fold, and the lateral thoracic compartment. In this article we present the results of our anatomical/histological study, discuss the operative technique and present a clinical series of patients who underwent this procedure.Methods: Cadaveric Anatomical study: Dye injection studies on 4 hemi-chests to determine if the lateral thoracic fold is a separate anatomic fat compartment. Tissue from the boundaries between identified compartments was also submitted for routine H&E histological analysis.Clinical study: Retrospective case note analysis of all patients undergoing dermolipectomy performed by the senior author.Results: In the analyzed cadavers, a clear line of delineation was found separating the lateral thoracic fold from the breast and adjacent structures, this was confirmed histologically. Forty patients underwent 64 dermolipectomy procedures. The average dimension of the resected specimen was 13.37 cm (range 3.0–25.0 cm) × 5.44 cm (range 1.0–12.0 cm). The mean time of dermolipectomy following initial reconstruction was 15.4 months. As the BMI increased the average resection size increased both in length (p = 0.002) and width (p = 0.006). There were no postoperative complications.Conclusion: The lateral thoracic fold is a distinct fat compartment. Dermolipectomy following breast reconstruction is a useful adjunct and should be considered in any patient with excess skin/subcutaneous tissue in the lateral thoracic region. The procedure has a low complication rate and can be performed in conjunction with other post reconstruction refinement procedures.

Projection and patient satisfaction using the “Hamburger” nipple reconstruction technique

A.P. Jones, M. Erdmann — 2011-09-28

Summary: Maintaining projection and achieving patient satisfaction are two key challenges in nipple reconstruction. Skin flap techniques such as CV and star flaps are currently favoured. The “Hamburger” technique was described in 2007 using stacked conchal cartilage discs within a skin flap construct, but no longer-term outcomes have been published. We evaluate both projection and patient satisfaction following nipple reconstruction using this technique. Twenty-three nipple reconstructions performed between 2007 and 2009 were reviewed. A standard pre-tattooed cylinder skin pattern was used with 3 punch biopsies of conchal cartilage harvested through a post-auricular incision. At follow up, reconstructed nipples and donor sites were examined. Nipple projection was measured bilaterally. Patients completed a short questionnaire. Mean follow up was 24 months (9-31). Mean projection was 3.3 mm (range 0–5 mm) and was well matched to the contralateral nipple. No donor site keloid scarring was observed, however cartilage defects were easily palpable in all cases. Patients were satisfied or very satisfied with overall cosmesis in 91% of cases. They were satisfied or very satisfied with projection in 57% of cases. All patients found the donor site acceptable. With the “hamburger” technique medium-term projection was maintained in most cases and was comparable to published data for other techniques with or without cartilage. Patient satisfaction was high even when projection was not well maintained. This suggests that patient satisfaction and projection are not necessarily related. Donor site morbidity was low.

Capsular contracture – What are the risk factors? A 14 year series of 1400 consecutive augmentations

Anne Dancey, Abdul Nassimizadeh, Paul Levick — 2011-09-19

Summary: The modern era of breast augmentation and reconstruction began in 1963, with the introduction of silicone implants by Cronin and Gerow. To date, the demand for cosmetic augmentation continues to increase exponentially. However, whilst the surgical techniques and quality of mammary prosthesis have improved dramatically in recent years, patients are still confronted with significant potential complications. We performed a retrospective study of 1400 consecutive primary breast augmentations performed between March 1995 and March 2009 by a single surgeon. We specifically examined the incidence of capsular contracture and the possible causative factors.Follow up ranged from 1 to 16 years. The mean age at the time of surgery was 32.8 years and fill volume was between 195 ml and 800 ml. Our capsular contracture rate was in the order of 26.9%. BMI >30, fill volumes >350 ml, smoking and alcohol consumption did not significantly increase capsular contracture rate. Implant type, pregnancy, infection and delayed haematoma significantly increased the risk of capsular contracture.Our series has given us a unique insight into the frequency of capsular contracture and identified several risk factors. To our knowledge, this is the first report of pregnancy having a significant effect on capsular contracture. We now counsel patients thoroughly into the detrimental effects of pregnancy on the implant.

Fat grafting accelerates revascularisation and decreases fibrosis following thermal injury

2011-10-03

Summary: Background: Fat grafting has been shown clinically to improve the quality of burn scars. To date, no study has explored the mechanism of this effect. We aimed to do so by combining our murine model of fat grafting with a previously described murine model of thermal injury.Methods: Wild-type FVB mice (n=20) were anaesthetised, shaved and depilitated. Brass rods were heated to 100°C in a hot water bath before being applied to the dorsum of the mice for 10s, yielding a full-thickness injury. Following a 2-week recovery period, the mice underwent Doppler scanning before being fat/sham grafted with 1.5cc of human fat/saline. Half were sacrificed 4 weeks following grafting, and half were sacrificed 8 weeks following grafting. Both groups underwent repeat Doppler scanning immediately prior to sacrifice. Burn scar samples were taken following sacrifice at both time points for protein quantification, CD31 staining and Picrosirius red staining.Results: Doppler scanning demonstrated significantly greater flux in fat-grafted animals than saline-grafted animals at 4 weeks (fat=305±15.77mV, saline=242±15.83mV; p=0.026). Enzyme-linked immunosorbent assay (ELISA) analysis in fat-grafted animals demonstrated significant increase in vasculogenic proteins at 4 weeks (vascular endothelial growth factor (VEGF): fat=74.3±4.39ngml–1, saline=34.3±5.23ngml–1; p=0.004) (stromal cell-derived factor-1 (SDF-1): fat=51.8±1.23ngml–1, saline grafted=10.2±3.22ngml–1; p<0.001) and significant decreases in fibrotic markers at 8 weeks (transforming growth factor-ß1(TGF-ß): saline=9.30±0.93, fat=4.63±0.38ngml–1; p=0.002) (matrix metallopeptidase 9 (MMP9): saline=13.05±1.21ngml–1, fat=6.83±1.39ngml–1; p=0.010). CD31 staining demonstrated significantly up-regulated vascularity at 4 weeks in fat-grafted animals (fat=30.8±3.39 vessels per high power field (hpf), saline=20.0±0.91 vessels per high power field (hpf); p=0.029). Sirius red staining demonstrated significantly reduced scar index in fat-grafted animals at 8 weeks (fat=0.69±0.10, saline=2.03±0.53; p=0.046).Conclusions: Fat grafting resulted in more rapid revascularisation at the burn site as measured by laser Doppler flow, CD31 staining and chemical markers of angiogenesis. In turn, this resulted in decreased fibrosis as measured by Sirius red staining and chemical markers.

Functional results of burned hands treated with Integra®

2011-10-31

Summary: Introduction: Dermal substitutes, such as Integra® introduced as a new alternative to our surgical arsenal and its use in burn treatment, in both acute and chronic phases, have gained great importance.Objective: The aim of the experiment is to describe the results of the functional evaluation of patients with burned hands treated with Integra® in both acute and chronic phases.Material and Methods: A retrospective review of a transversal cohort. Patient characteristics evaluated were sociodemographic characteristics, burn mechanism, burn extension and depth, treatments received previous to Integra® and complications related to its use. Clinical and photographic evaluations were performed evaluating skin elasticity, range of articular movement, prehensile strength, pain and functional evaluation using the validated 400 Point Evaluation Test.Results: A total of 17 burned hands in 14 right-handed patients, were treated with Integra®, three being bilateral hand burns. Eleven were treated in the acute phase and in nine in the scar reconstruction phase. Range of articular motion was complete in 15 of 17 hands. In 88% of the hands, flexible skin coverage was achieved. No statistically significant difference was observed in prehension strength of the burned hand versus the contralateral non-burned hand. Sixteen hands had a painless evolution. The 400 Point Evaluation score was 92.8 ± 6.3% (80 – 100%). Nearly four-fifths (79%) of the patients returned to normal active working activities.

The anterolateral thigh – Vastus lateralis conjoint flap for complex defects of the lower limb

Chin-Ho Wong, Yee Siang Ong, Fu-Chan Wei — 2011-09-22

Summary: Introduction: Complex and extensive lower limb defects remain difficult reconstructive problems. Conventional flaps may not be large enough or lack the versatility that allows precise tissue positioning to optimally cover the wound. The anterolateral thigh–vastus lateralis conjoint flap provides a superior reconstructive solution for these difficult wounds.Methods and materials: From Jan 2010 to June 2011, seven patients were reconstructed with the anterolateral thigh–vastus lateralis conjoint flap. Three cases were traumatic degloving injury of the lower limb, three were open fractures of the tibia with extensive soft-tissue loss and one was a large soft-tissue defect as a result of necrotising fasciitis. The skin island and muscle component were raised with independent pedicles to allow complete freedom in the inset of each flap based on a common pedicle. The descending and oblique branches of the lateral circumflex femoral artery were used as the pedicle of the conjoint flap in four and three cases, respectively.Results: The mean size of the skin flap was 355 cm2 (range: 312–420 cm2) and the volume of the muscle flap was 210 cm3 (range: 42–360 cm3). All flaps survived completely and no infective complications were noted in our patients. The skin and muscle component were widely separated to expand the area of coverage. In cases where specific areas of the wound were severely traumatised with significant tissue loss, the muscle component can be precisely positioned to obliterate the dead space and to optimise soft-tissue coverage of the wound.Conclusion: The anterolateral thigh–vastus lateralis conjoint flap is superior to conventional flaps available for coverage of extensive defects of the lower limb. It can cover far greater area as well as providing the versatility needed to optimise soft-tissue coverage.

The effect of surgical and chemical denervation on ischaemia/reperfusion injury of skeletal muscle

2011-09-26

Summary: Introduction: Denervation decreases skeletal muscle’s energy needs and alters its metabolism and circulation. Our study was designed in two stages to investigate the effects of surgical and chemical denervation on the ischaemia/reperfusion injury of skeletal muscle. Degenerative histological analysis, apoptosis scoring and tissue levels of malonyl-di-aldehyde (MDA) and nitric oxide end products (NOx) were studied to understand the extent of ischaemia/reperfusion injury of skeletal muscles.Materials–methods: In the first stage, the effect of surgical denervation was investigated in four groups each containing six rats. The right biceps femoris muscle was used as the experimental muscle flap model. In the control group, only the ischaemia/reperfusion cycle was applied. Ischaemia was created by a tourniquet strictly wrapping the right lower extremity for 4 h. After ischaemia, the tourniquet was cut, and the extremity was reperfused for another 4 h. In the experimental groups, surgical denervation was applied 1 day, 7 days and 30 days before the ischaemia/reperfusion cycle.On the second stage, the effect of chemical denervation with botulinum toxin type-A (BoNT-A) was investigated in three groups, each containing six rats. In the experimental groups, BoNT-A was applied 1 day, 7 days and 30 days before the ischaemia/reperfusion cycle.Results: The control group had the worst scores in all experiment parameters. Degenerative histology and apoptosis scores were significantly better in groups to which BoNT-A and SD were applied 1 or 7 days before the ischaemia/reperfusion cycle. Regarding tissue levels of MDA and NOx, the experiment groups had significantly better scores comparing to the control group.Conclusion: Both surgical and chemical denervation applied before muscle transfer increased muscle ischaemia tolerance. With similar experimental outcomes, denervation with BoNT-A can be preferred to surgical denervation because of its abundant clinical availability and it can be applied without any secondary surgery.

Treatment of pectoralis major flap myospasms with botulinum toxin type A in head and neck reconstruction

2011-11-10

Summary: Background: Treatment options for muscle spasm complications of the pectoralis major (PM) flap in head and neck reconstruction have hardly been investigated. The authors report their experience using botulinum toxin (BTX-A) injections as a treatment of PM flap myospasm complications in head and neck reconstruction.Methods: From January 2005 to May 2009, 83 patients underwent PM flap reconstruction. Eleven of them reported muscle twitching as a post-operative complication and are therefore included in this study. As all 11 patients refused a second surgery, they were offered BTX-A injections. This group of patients was followed up at regular intervals with clinical examinations, digital photography, range of motion (ROM) of the neck in different vectors, and neck disability system (NDS) questionnaires.Results: After the first BTX-A infiltration, muscle twitching decreased, the ROM values increased and, according to the NDS, patients’ discomfort progressively decreased. Only two of the 11 patients required two additional BTX-A sessions.Conclusion: BTX-A infiltration is an effective non-invasive procedure that significantly reduces the PM muscular contraction in head and neck reconstruction.

Tarsal ectropion repair and lower blepharoplasty: A case report and review of literature

Rebecca M. Garza, Gordon K. Lee, Barry H.J. Press — 2011-07-18

Summary: Ectropion is frequently encountered in plastic surgery. A variety of etiologies exist, but tarsal ectropion, defined as complete eversion of the tarsal plate and its overlying conjunctiva, is rarely considered. First described in 1960 by Fox, this variant was initially attributed to pre-septal orbicularis oculi spasm or tarsoligamentous relaxation. However, subsequent investigators determined that the true etiology involved lower lid retractor disinsertion on the tarsal plate. We present a case of chronic right lower lid ectropion in a 66-year-old male. Through understanding of eyelid anatomy, especially that of the lower eyelid retractors, tarsal ectropion was correctly identified in our patient preoperatively. A repair including correction of retractor disinsertion on the tarsus was planned, and given our patient’s degree of lower lid delamination and mobilization, we also proceeded with bilateral lower lid blepharoplasty with canthal and lower lid soft tissue support. Ultimately, we were able to achieve an improved aesthetic appearance for our patient, along with resolution of his symptoms.

Nose and upper lip reconstruction for purpura fulminans

2011-07-28

Summary: Background: Purpura fulminans (PF) is a rare syndrome of intravascular thrombosis and haemorrhagic infarction of the skin. The initial symptom of PF is peripheral purpura which progresses to necrosis very rapidly. The prognosis of PF is poor, and the mortality is reported to be around 40%. Even if the patient survives, the patient may require amputation or reconstruction for limbs and facial necrosis.Case report: A 48-year-old male suffered from PF following a left cerebellopontine angle tumour excision. His nose and upper lip fell into necrosis afterwards. We performed nose and upper lip reconstruction at 8 months after the onset. We used a forehead flap for the nasal reconstruction and a free forearm flap for the lining. His upper lip was reconstructed with bilateral nasolabial orbicularis oris myocutaneous flaps.Results: The colour and texture match of the reconstructed nose and lip is good. He could open his mouth wide enough and close completely.Conclusions: Facial reconstruction after PF is very difficult, because the patient has extensive scarring around the defect and there is little intact facial tissue. However, we performed a facial reconstruction using local flaps as much as possible, and obtained good results.

A third degree burn to one side of the neck associated with episodes of bradycardia and asystole

Youssef Tahiri, Isabelle Perreault, Alexis Payette, Marc-Jacques Dubois — 2011-08-29

Initial evaluation and stabilization of airway, breathing and circulation is of prime importance in the care of the burned patient. In the presence of circumferential chest, abdomen and extremities burns, escharotomies are then performed.

Treatment of giant congenital melanocytic nevus of the left upper extremity with staged expanded flap

Yufeng Liu, Jinlong Huang, Ke Wen, Ning Liu, Jinming Wang — 2011-07-28

Summary: Excision of a congenital giant nevus is advised due to the possibility of it degenerating into a malignant melanoma or for aesthetic concerns. Tissue expansion has emerged as the primary treatment of giant congenital nevi because it enables the body to produce extra skin with excellent texture, better colour match, less severe donor-site deformity and repeated usage of an expanding donor-site. We present a multi-staged expansion/local flap technique to treat a case of a circumferential nevus from the acromioclavicular joint and axillary area throughout the upper extremity excluding the hand. The affected skin was approximately 10% of the total body surface area. The patient underwent eight operations and a total of 11 rounds of tissue expansions (500 cc × 9 rounds, 600 cc × 1 round, 300 cc × 1 round) were completed over a 2-year period prior to the removal of the nevus. A good aesthetic and functional outcome in the left upper extremity was gained. It is recommended that the treatment of giant nevi is best if completed at preschool age after taking several factors into consideration.

One-stage treatment of delayed ‘jersey finger’ by z-step lengthening of the flexor digitorum profundus tendon at the wrist

Elias T. Sawaya, Hussein Choughri, Philippe Pelissier — 2011-07-20

Summary: The authors report the case of a 19-year-old female with delayed presentation of a type II ‘jersey finger’ of the fourth dominant digit. A surgical approach was performed, revealing a retracted flexor digitorum profundus tendon within a still patent sheath. The resulting loss of tendon length overruled any possibility of direct reinsertion of the tendon. A lengthening “Z-step” tendinoplasty was then performed on the tendon at the wrist, thus enabling reinsertion at the base of the distal phalanx. The patient then underwent conventional splinting and physiotherapy. Total Active Motion was measured at 220° with a 6-month follow-up. Even though there is no clear consensus concerning management of such cases, different techniques have been described, such as one- or two-stage grafting, or tenotomy at the musculotendinous junction. Lengthening tendinoplasties have been applied by certain authors but only to the flexor pollicis longus tendon. To our knowledge, this is the only reported case of lengthening Z-step applied to a long digit for the repair of type II ‘jersey finger’ lesions. The satisfactory functional and cosmetic outcome encourages us to consider this one-stage technique in other select cases, in order to gather more formal evidence.

Use of dermal fat graft for augmentation of the labia majora

Christopher J. Salgado, Jennifer C. Tang, Arthur E. Desrosiers — 2011-08-01

Summary: Dermal fat grafts have been utilized in plastic surgery for both reconstructive and aesthetic purposes of the face, breast, and body. There are multiple reports in the literature on the male phallus augmentation with the use of dermal fat grafts. Few reports describe female genitalia aesthetic surgery, in particular rejuvenation of the labia majora. In this report we describe an indication and use of autologous dermal fat graft for labia majora augmentation in a patient with loss of tone and volume in the labia majora. We found that this procedure is an option for labia majora augmentation and provides a stable result in volume-restoration.

Multiple rheumatoid bursal cysts that were finally effectively treated by combining surgical resection and sclerotherapy

2011-09-26

Summary: A 71-year-old male who had been diagnosed with rheumatoid arthritis 3 years previously developed multiple subcutaneous cysts on his buttock, elbow, knee, hand and back. The diameters of the cysts were 10–15 cm. The characteristic fluid and pathology of the cysts led to the diagnosis of multiple rheumatoid bursal cyst (MRBC). The patient was keen to treat the cyst on his buttock as it hampered his sitting position. However, it resisted several kinds of sclerotherapies, including absolute alcohol, OK-432, minocycline and dexamethasone. When the cyst grew further, it was resected surgically; however, the cyst recurred immediately. It was finally brought under control by injecting it with OK-432.The thick cyst wall, which resisted the various sclerotherapies, was removed surgically, and a new capsule developed inside the cavity; adding a sclerotant to newly made thin capsule made us possible to treat this resistant large bursal cyst.

Surgical management of transitional cell carcinoma of the lacrimal sac: Is it time for a new treatment algorithm?

Shofiq Islam, Alexandria Thomas, Robert L. Eisenberg, Gary R. Hoffman — 2011-10-10

Summary: Transitional cell carcinoma (TCC) arising in the lacrimal sac is a rare neoplasm. Despite radical surgery and radiotherapy, these tumors generally have a poor prognosis due to an often late diagnosis, high rate of loco-regional recurrence and mortality. There are only a relatively small number of documented cases of TCC when compared to other epithelial malignancies of the lacrimal drainage system. As would be anticipated, there are currently no evidence-based clinical practice guidelines for the treatment of these lesions. We present an illustrative case and consider the literature in relation to current surgical management of these tumors. We propose an alternate management consideration for these tumors.

The untold truth about “bath salt” highs: A case series demonstrating local tissue injury

J.J. Dorairaj, C. Healy, M. McMenamin, P.A. Eadie — 2011-11-11

Summary: The epidemic of injecting cathinone derivatives, marketed as “bath salts”, by intravenous drug users among inner city Dubliners led to an associated rise in soft tissue complications. The spectrum of the cases encountered, ranging from self-limiting cellulitis to extensive abscess formation, at a single institution is described.

Reconstruction of a massive lower limb soft-tissue defect by giant free DIEAP flap

Assaf A. Zeltzer, Koenraad Van Landuyt — 2011-11-03

Summary: Treatment of high-velocity trauma of the lower limb is often challenging in its nature, especially when dealing with extensive soft-tissue loss, underlying bone fractures and vascular lesions. The main goal in this surgery is the preservation of a functional and sensitive limb, or maximal functional length of the stump when dealing with limb amputations.We present a case report of a reconstruction of a complex massive soft-tissue defect of a lower limb by a giant free deep inferior epigastric artery perforator (DIEAP) flap. Classification and treatment options for massive lower limb defects are discussed.The free DIEAP flap is another valuable option for massive soft-tissue lower limb reconstructions and limb salvage procedures. It provides massive amounts of soft tissue with minimal donor-site morbidity, which is easily amenable for secondary corrections.

The commissure-based triangular flap for lip revision following reconstruction of a through-and-through defect

Chung-Kan Tsao, Derrick C. Wan, Wei-Fan Chen, Dennis S. Kao, Benjamin Levi — 2011-09-26

Management of lip deformities following free-flap reconstruction for head and neck cancer represents a particular challenge. Ideal restoration must provide not only mucosal lining and outer skin, but must also reestablish a labial sulcus and adequate oral sphincter function to prevent drooling. While commissure reconstruction can be attempted by vermillion advancement or other local flaps, the limitation of many of these approaches lies in the failure to create an adequate sulcus and provide for enough lower lip support. We therefore describe a novel technique for secondary commissuroplasty and lip revision using a commissure-based triangular flap and anterior z-plasty following anterolateral thigh free-flap reconstruction for a large perioral defect.

A simple way for salvage of zone IV deep inferior epigastric perforator flap using pre-tie sutures and serial delayed closure

Emilio Trignano, Agnese Nitto, Emanuele Cigna, Pedro Ciudad, Hung-Chi Chen — 2011-08-29

The free deep inferior epigastric artery perforator flap (DIEP) was first described by Koshima and Soeda in 1989. This flap provides a large amount of skin and soft tissues for reconstructive purposes with a minimal donor site morbidity and a resulting scar similar to an addominoplasty procedure.

Are we documenting chaperone use?

A. Molajo, P. Vaiude, K.E. Graham — 2011-08-24

Breast examination is one of the most common intimate examinations performed by plastic surgeons. These examinations would normally be performed in the presence of a chaperone. Chaperones are used for three main reasons: firstly to protect patients from improper behaviour by doctors, secondly to protect doctors from improper behaviour by patients and finally as medico-legal evidence of the event.

Total resection of giant plexiform neurofibroma of the entire back in one stage by autologous tumor skin graft

Liqiang Liu, Jincai Fan, Cheng Gan, Jia Tian, Hu Jiao — 2011-08-22

The patient was a thirteen-year-old girl who had many smooth brown freckling spots of various sizes (the diameter of the seven spots exceeded 15 mm) scattered on her body. There was a lesion on her back that had slowly grown over time and quickly in the past three years. The histological examination in a local hospital confirmed the diagnosis of neurofibromatosis type I without malignant transformation. The patient had no history of seizures or learning disabilities. The size of the large neurofibroma on the back extended into the midaxillary line and measured 42 × 48 × 5 cm3 [fig1 left]. An MRI showed a diffuse neurofibroma with associated dysplastic blood vessels exhibiting irregular areas of tunica media and sinusoidal-like vascular channels (pseudo-hemangioma) [ middle]. An angiography demonstrated that the blood vessels of the tumor originated from the intercostal arteries and the transverse cervical artery. The maximum diameter of these feeding and draining vessels was 1 cm, and a distinct plane with main vessel perforators [ middle] and nerve bundles between tumor stroma and deep musculofascial plane could be identified [ right]. Interventional radiologists were unable to embolize such complex vasculature. Three days before the operation, 400 mL of autologous blood was obtained for perioperative transfusion.

Presentation battles

M. Felix Freshwater — 2012-02-01

Summertime brings new residents to South Florida. One of my contributions to orienting the new University of Miami and Cleveland Clinic residents to the wonderful world of plastic surgery is to conduct a digital imaging workshop. My motivation is part eleemosynary and part enlightened self-interest. Annoyed at having had to sit through countless conferences where poorly shot photos detracted from the discussion, I realized that nobody had taught the residents how to shoot acceptable photos. Not wanting to be subjected to further presentations that were the visual equivalent of hearing fingernails scratched across a chalkboard, I applied that frequently quoted surgical adage – if you want something done correctly, do it yourself. Thus the workshops were born.