Mesh assisted direct closure of bilateral TRAM flap donor sites.

The pedicled transverse rectus abdominis myocutaneous (TRAM) flap remains a popular choice for patients requesting breast reconstruction. Criticism of all techniques that harvest the rectus abdominis muscle centre on abdominal wall weakness.[Dulin WA, Avila RA, Verheyden CN, Grossman L. Evaluation of abdominal wall strength after TRAM flap surgery. Plast Reconstr Surg 2004; 113: 1662-1665] Primary fascial closure of the donor site has been shown to reduce abdominal wall weakness and the subsequent risk of hernia and bulge. [Mizgala CL, Hartrampf CR Jr, Bennett GK. Abdominal function after pedicled TRAM flap surgery. Clin Plast Surg 1994; 21: 255-272]2 Primary fascial closure of all uni-lateral and most bilateral muscle preserving TRAM flap donor sites is possible. In a series of 23 bilateral TRAM flaps, excessive abdominal tension prevented direct fascial closure of the donor site in seven. Using a technique that includes muscle preservation, muscle relaxation and mesh assistance; tensionfree, direct fascial closure was achieved in all. The mesh buttress supports the rectus sheath during closure and provides long term shape and stability.     

Early experience of immediate reconstruction using autologous free dermal fat graft after breast conservational surgery.

Breast conservational therapy (BCT) has become a standard strategy for breast cancer, and ensures that local control with acceptable cosmetic results [Fisher B, Anderson S, Redmond CK, et al. Reanalysis and results after 12 years of follow-up in a randomized clinical trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 1995;333:1456-61] and immediate reconstruction after BCT has become increasingly popular even for early-stage breast cancer [Berrino P, Campora E, Santi P. Post-quadrantectomy breast deformities: classification and techniques of surgical correction. Plast Reconstr Surg 1987;79(4):567-72; Cooperman AM, Dinner M. The rhomboid flap and partial mastectomy. Surg Clin North Am 1978;58:869-73]. The breasts of Japanese women are sometimes too small to maintain symmetry, even after partial resection, and an insufficient resection margin may increase local recurrence if too much attention is paid to cosmesis. Use of an autologous free dermal fat graft (FDFG) for defect reconstruction has proven popular for some areas of the body [Lexer E. Free transplantation. Ann Surg 1914;60:166-94; Peer LA. The neglected free fat graft. Plast Reconstr Surg 1956;18:233-50]. Immediate reconstruction of the surgical defect was performed in seven Japanese women using autologous free dermal fat graft (FDFG) from the lower abdomen after breast-conserving surgeries for six malignant lesions and two benign masses located in the medial or central area of the breasts. The mean amount of resected tissue was 56.4 g (range, 28-108 g), while mean FDFG weight was 78.3g (range, 35-148 g). We obtained symmetry in the size of the whole breast, the position and level of the nipple, and shape. Autologous FDFG was useful for reconstruction, with a good cosmetic effect. This technique achieves better cosmetic results than the transposition of residual breast tissue, is more convenient than muscle flap grafting, and safer than implantation of foreign materials. This report documents our early experiences with seven patients who underwent BCT and immediate breast reconstruction using autologous FDFG.     

Post auricular dermoid cyst��a rare lump behind the ear

Dermoid cysts are benign developmental anomalies. They are postulated to originate from the congenital inclusion of germ layers in the deeper tissues along the lines of embryonic fusion (New and Erich Surg, Gynecol Obstet 65:48–55, 1937). Dermoid cysts can be divided into three types according to their histological characteristics, namely epidermoid, dermoid, and teratoid (Tuffin and Theaker, Int J Oral Maxillofac Surg 20:275, 1991). The majority of dermoid cysts arise in the ovaries. Those occurring in the cervicofacial region are uncommon, accounting for about 7% of all dermoids (De Souza et al., Plast Reconstr Surg 112(7):1972, 2003). Dermoid cysts around the auricular region are rare. To the best of our knowledge, there have been only four cases of post-auricular dermoid cyst reported in literature (Bauer et al., Arch Dermatol 130:913, 1994; De Souza et al., Plast Reconstr Surg 112(7):1972, 2003; Meagher and Morrison, Br J Plast Surg 54:336, 2001; Samper, Plast Reconstr Surg 106:947, 2000. We hereby report the fifth case of this rare condition.     

Capsular contracture in subfascial breast augmentation: recommendations and treatment

Capsular contracture is the most common long-term complication of breast augmentation. In subfascial breast augmentation, there had been reports of 0% to 2% of capsular contracture (Serra-Renom et al., Plast Reconstr Surg 116:640–645; Ventura and Marcello, Aesthetic Plast Surg 29:379–383; Tijerina et al., Aesthetic Plast Surg 34:16–22; Graf et al., Plast Reconstr Surg 111(2):904–908). Graf et al. mentioned a 2.3% of capsular contracture grade II in 263 patients that underwent subfascial breast augmentation (Graf et al., Plast Reconstr Surg 111(2):904–908). There are several theories that can explain the presence of a capsular contracture, and the most described are: the microbiology theory and the contamination of the pocket due to a foreign body (Araco et al., Plast Reconstr Surg 124(6): 1808–1819; Schaub et al., Plast Reconstr Surg 126(6): 2140–2149). In 5?years, 35 patients with breast augmentation were considered for surgical treatment for capsular contracture. From 35 patients, only 4 patients were operated by us initially, the remaining 31 came to us as new patients with a capsular contracture. Each patient had different characteristics and was classified with the Baker scale. Depending on the grade (I–IV) and clinical characteristics of the patient, the surgical treatment was selected between a subcapsular pocket, total capsulectomy with or without implant, or radiation of the capsule. Thirty-five patients were considered for surgical treatment for a capsular contracture. All of our patients had great outcome at short and long term without any signs of complications. Twenty-seven patients were followed for 2?years postop, and 8 patients treated with a subcapsular pocket have less than 2?years of follow-up. In patients with less mammary gland tissue, a subcapsular pocket had reduced the risk of complications of a total capsulectomy due to close relationship between the skin and the capsule. There are several complications that could be present with a total capsulectomy, which are: tissue necrosis, breast irregularities, and/or damage to the skin. This technique had produced great results in patients with lo mammary tissue and a capsular contracture. Capsular contracture is the most common long-term complication in breast augmentation. There are several techniques that can be reproduced to have better outcomes and reduce the risk of complications. We recommend the use of these strategies to help in the treatment of capsular contracture.     

Reconstruction of abdominal wall by whole thigh flap.

Closure of extensive abdominal wall defects can be a very challenging task as there are no known large local or free vascularized flaps available that could cover the entire abdomen. Tensor fascia latae (TFL) has been widely used for abdominal wall reconstruction [Hill HL, Nahai F, Vasocnez LO. The tensor fascia lata myocutaneous free flap. Plast Reconstr Surg 1978;61:517-22]. However, the dimensions of the standard TFL flap limit its use in cases of large full thickness abdominal wall defects. Therefore, we have used an ingenious technique of raising the entire thigh skin as a fasciocutaneous flap (whole thigh flap) based on the concept of fusion of angiosomal territories, to reconstruct such a defect following excision of a large abdominal wall tumour.     

Thermography of hands after a radial forearm flap has been harvested

To determine the change of blood flow in the hand after radial forearm flap harvest, several studies using thermography or color Doppler ultrasonography have been reported (Iida et al., Ann Plast Surg 49:156, 2002; Suominen and Asko-Seljavaara, Scand J Plast Reconstr Hand Surg 30:307, 1996). One study using Doppler ultrasonography (Iida et al., Ann Plast Surg 49:156, 2002) found reduced blood flow, while another study using thermography (Suominen and Asko-Seljavaara, Scand J Plast Reconstr Hand Surg 30:307, 1996) reported warm digits. However, the thermographic study did not examine the postoperative period. We evaluated temperature changes by thermography during three different postoperative periods: 3, 6, and 12 months. Differences in temperature were measured between the donor hand and the other hand in the resting state and after cold stress at the thenar eminence. The differences in temperature were divided into three grades. The donor hand was classified as being warmer, similar, or cooler than the other hand. There was a tendency for cold stress to accentuate differences in temperature. After cold stress, the percentage for warmer was 75.0% at 3 months, while similar increased to 87.5% at 6 and 12 months. The temperature of the donor hand increased for a limited period after surgery for up to 3 months, and the temperature of the donor hand became similar to that of the nondonor hand. Therefore, circulatory changes in the hand undergoing flap harvest are thought to be minimal. Considering other reports, we think the high temperature at the thenar eminence of the donor hand shortly after surgery is partially explained by sympathetic nerve damage.     

Early versus Delayed Surgical Treatment in Open Hand Injuries: A Paradigm Revisited

Background  

To date it remains unclear if a delayed surgical treatment of open hand injuries after more than 6 h may be detrimental to outcome. Previous investigations by McLain et al. (J Hand Surg Am 16:108–112, 1980 9), Nylen and Carlsson (Scand J Plast Reconstr Surg 14:185–189, 1991 10) could not find statistical proof of correlation between infection rate and delayed surgical treatment after open hand injuries up to 18 h. The current study was designed to investigate the outcome of early versus delayed surgical treatment after open hand injury.     

Use of lotus petal flap in the treatment of perineal hidradenitis suppurativa

Perineal hidradenitis suppurativa is a complex problem to treat. Various methods of treatment have been tried in the past, but recurrence was common. In this paper, we describe the use of the lotus petal flap in hidradenitis suppurativa of the perineum in three patients. Many local flaps have been used for covering the defect after excision of hidradenitis suppurativa; in our cases, we have used the lotus petal flap. Until now, this flap has been used for vaginal reconstruction after cancer surgery [Yii NW, Niranjan NS (1996) Lotus petal flaps in vulvo vaginal reconstruction. Br J Plast Surg 49(8):547–554, Hashimoto I et al (1999) Vulvo vaginal reconstruction with gluteal fold flaps. J Jpn P R S 19:92–98]. Three patients had five lotus petal flaps after the excision of perineal hidradenitis suppurativa, and there were no recurrences of the lesion in the excised area after follow-up at 2 years.     

The use of the reverse radial fasciosubcutaneous flap to provide soft tissue coverage and a distal recipient artery in a difficult case of toe-to-thumb transfer.

Traumatic amputation of the thumb is a devastating injury. Toe-to-hand [Wei FC, Chen HC, Chuang CC, Chen HT. Microsurgical thumb reconstruction with toe transfer: selection of various techniques. Plast Reconstr Surg 1992;93:345; Wei FC, Tarek AE. Toe-to-hand transfer: current concepts, techniques and research. Clin Plast Surg 1996;23:103] transfer is a sophisticated option for replacing this vital structure, but this challenging procedure, is even more demanding if recipient vessels are difficult to locate, inadequate or even absent. Another frequently encountered difficulty in cases of traumatic thumb amputation is inadequate soft tissue cover in the region of the amputation stump or the first web space. Often this defect or potential defect requires a preliminary tissue transfer procedure, before toe-to-hand transfer can be considered.     

Flow-through flaps: a review of current knowledge and a novel classification system

Flaps have long been recognized as an essential tool for soft-tissue reconstruction. Flaps range in complexity from local to free and perforator flaps and can include a variety of composite tissues. The concept of a flow-through flap, in which both the proximal and the distal ends of the vascular pedicle of a free flap are anastamosed to provide blood flow to distal tissues, was first described by Soutar et al. in 1983. An uninterrupted arterial flow was established by Soutar et al. between the external carotid and distal facial artery via a radial forearm flap for head and neck reconstruction (Soutar et al., Br J Plast Surg 1983;36:1-8). Shortly thereafter, Foucher et al. were the first to report the reconstruction of an extremity with a simultaneous vascular defect by utilizing a radial forearm flow-through flap (Foucher et al., Br J Plast Surg 1984;37:139-148). The utility of the flow-through flap is now well established, and its indications for use continue to grow. The principle advantage of this flap is that it provides the opportunity for a single stage composite reconstruction of both soft tissue and vascular defects, making it particularly useful in the reconstruction of ischemic extremities and defects from oncologic ablations. Improvements in microsurgical equipment and techniques are making early difficulties with these flaps irrelevant, giving plastic surgeons opportunities to become more creative in the choices and uses of flow-through flaps. The literature consists mostly of case reports and series. The nomenclature used to describe the types of flow-through flaps is confusing and inconsistent. The purpose of this article is to provide an organized review of flow-through flaps and to classify these flaps based on their inflow, outflow, and the nature of their vascular conduit. Additionally, we have included a discussion on the physiology of these flaps, reviewed the current literature, and summarized the various types of flow-through flaps in a reference guide that can aid in flap selection.     

The management of midline transcranial nasal dermoid sinus cysts.

The most common congenital midline nasal masses are nasal dermoid sinus cysts (NDSC) [Hughes GB, Sharpino G, Hunt W, Tucker HM. Management of the congenital midline nasal mass--a review. Head Neck Surg 1980;2:222-33.]. Their clinical importance hinges on their potential to communicate with the central nervous system. Preoperative diagnosis of an intracranial extension allows for referral to a craniofacial team with the appropriate skills and experience for a transcranial approach. All patients with a NDSC require imaging with high resolution multiplanar MRI scans and complimentary fine cut CT scan to reveal the anatomical extent of the tract and its relationship to the anterior cranial fossa. A single-stage craniofacial approach to resection of midline NDSC extending to the anterior cranial base is effective with minimal morbidity [Yavuzer R, Bier U, Jackson IT. Be careful: it might be a nasal dermoid cyst. Plast Reconstr Surg 1999;103:2082-3; Denoyelle F, Ducroz V, Roger G, Garabedian EN. Nasal dermoid sinus cysts in children. Laryngoscope 1997;107:795-800; Rohrich RJ, Lowe JB, Schwartz MR. The role of open rhinoplasty in the management of nasal dermoid cysts. Plast Reconstr Surg 1999;104:2163-70; Rahbar R, Shah P, Mulliken JB, et al. The presentation and management of nasal dermoid-a 30-year experience. Arch Otolaryngol Head Neck Surg 2003;129:464-71; Posnick JC, Bortoluzzi P, Armstrong DC, Drake JM. Intracranial nasal dermoid sinus cysts: computed tomographic scan findings and surgical results. Plast Reconstr Surg 1994;93:745-54 [discussion 755-56]; Bartlett SP, Lin KY, Grossman R, Kratowitz J. The surgical management of orbitofacial dermoids in the pediatric patient. Plast Reconstr Surg 1993;91:1208-15.]. The cyst and tract are accessed through a combination of a nasal and transcranial approach. This allows visualisation and dissection of the tract with only a small incision on the nasal dorsum to include the cutaneous punctum when present. Transnasal endoscopic techniques have been advocated where the dermoid is located within the nasal cavity and there is little or no cutaneous involvement [Weiss DD, Robson CD, Mulliken JB. Transnasal endoscopic excision of midline nasal dermoid from the anterior cranial base. Plast Reconstr Surg 1998;101:2119-23.]. We present a review of five cases referred to our unit between 1999 and 2004 with a diagnosis of a midline nasal dermoid sinus cyst and radiological evidence of intracranial communication. All cases had a communication with the anterior cranial fossa diagnosed preoperatively and were treated surgically with a craniofacial approach. An intracranial extension was identified at operation in each case and this was confirmed on histopathology. The only significant complication resulted from an early postoperative infection, requiring re-operation. There were no recurrences and acceptable aesthetic outcomes have been observed in all cases.     

Salvage of free second toe with venous thrombosis by shunting retrograde arterial flow of second dorsal metatarsal artery

Although there are case reports about salvaging amputated digits without venous return by shunting retrograde blood flow from a distal digital artery to a proximal vein (Smith et al., Plast Reconstr Surg 71:52, 1983), successful salvage of a congested free toe with efferent arteriovenous (AV) shunting retrograde arterial flow from the second dorsal metatarsal artery (SDMA) has never been reported. In this paper, we describe the possible factors for venous thrombosis, the errors we committed in the operation, and how the free toe can survive without venous drainage.     

Clinical use of a pedicled anterolateral thigh flap.

BACKGROUND: Anterolateral thigh flap is a safe and reliable flap for soft tissue reconstruction. It has successfully been used as free flap reconstruction for defects in the head and neck region, the upper extremities and lower extremities. However, there were only a few reports in the literature concerning the clinical application of this flap for regional reconstruction. METHODS: The authors describe their experience of using the pedicled island anterolateral thigh flap for reconstruction of soft tissue defects in neighbouring areas. Representative cases are presented for illustration. RESULT: Between July 2005 and September 2006, seven patients underwent an immediate reconstruction with pedicled anterolateral thigh flap. The patients were between 49 and 69 years old. The size of the flaps measured from 5 x 8 cm to 15 x 15 cm. They were prepared as myocutaneous flaps in three cases and as perforator flaps in four cases. One patient, who had the largest flap harvested, needed skin grafting of the donor site. Primary closure was performed for all other cases. All flaps survived without any vascular compromise and the donor site healed without complication. CONCLUSION: Our study has shown that the pedicled anterolateral thigh flap is a safe and reliable flap for repair of defects at the internal pelvis, lateral thigh, groin, and genitoperineal region. The long vascular pedicle and having no restriction to the arc of rotation are keys to the successful transposition of the flap for immediate reconstruction of soft tissue defects in neighbouring areas.     

Technique for Harvesting of Conchal Cartilage Grafts

Conchal cartilage is an important source of cartilage for the rhinoplasty surgeon [Falces E, Gorney M: Plast Reconstr Surg 50:147, 1972; Hage J: Brit J Plast Surg 18:92, 1965; Juri J et al: Plast Reconstr Surg 63:377, 1979]. We describe a technique to harvest conchal cartilage which minimizes morbidity for the patient and produces an excellent scar.     

Supernumerary auricle on the lateral canthus.

A boy was born with an appendage on his right lateral canthus, with associated supernumerary auricles on the right cheek and a right ocular dermoid. We resected the appendage. Its core was composed of elastic cartilage, as is the external auricle. The lateral canthus overlaps facial cleft line No. 8 in Tessier's classification [Plast Reconstr Surg 4 (1976) 69] and forms the upper part of the first branchial arch. It appears that our patient's appendage was a supernumerary auricle, which had developed from the first branchial arch.     

Buttock reconstruction using a pedicled deep inferior epigastric perforator flap

Although deep inferior epigastric perforator (DIEP) flaps are mainly used for breast reconstruction as free flaps, they are also useful as pedicled island flaps. However, DIEP flaps have seldom been used for reconstructions in the lateral hip region. Furthermore, to the best of our knowledge, no report has been issued on the use of this flap for buttock reconstruction. The authors describe the successful use of a pedicled oblique DIEP flap for the reconstruction of a severe scar contracture in the buttock. The pedicled DIEP flap can be a useful option for the reconstruction of large buttock defects, and if a transverse DIEP flap is unavailable, an oblique DIEP flap should be considered an alternative.     

The pedicled lateral forehead flap in reconstructing oral floor defect - The last resort; case report

Introduction and importanceLocoregional flaps, particularly the pedicled lateral forehead flap, are not usually used in reconstructing oral floor defects following oncologic resection. Rather, microscopic free flaps have evolved to be the standard of care in head and neck reconstruction. However, the pedicled lateral forehead flap could be valuable in floor of the mouth reconstruction in the absence of resources or other options.Case presentationA-56 years old lady with multiple comorbidities who underwent near total glossectomy, bilateral supraomohyoid neck dissection, and right lateral mandibulotomy due to a locally advanced lingual squamous carcinoma. The last resort was the pedicled lateral forehead flap after many unsuccessful reconstructive attempts utilizing the free anterolateral flap, free radial forearm flap, and pedicled pectoralis major flap.Clinical discussionDecreased donor site morbidity and reliable anatomy are among many of the advantages that made free flaps favorable over locoregional pedicled flaps, especially in oral cavity defects coverage. Of the latter, the pedicled forehead flap, rich in vascularity and neighboring the oropharyngeal defects, could be used with different techniques and modifications. Close monitoring and patient condition optimization is required.ConclusionChoosing a particular reconstructive option should be done considering the available resources and expertise and the patient's condition. The pedicled forehead flap remains valuable when other options are inappropriate or have failed.     

A new technique of microvascular suturing: the chopstick rest technique.

With the conventional techniques of tying knots during microvascular anastomosis or neural suturing, time may be lost due to various reasons. The loose end of the suture often falls down into the operative field and gets stuck to the surrounding tissues. In the process of retrieving the suture, the surrounding tissues can be picked up together with the suture. When the posterior wall technique [Br J Plast Surg 34 (1981) 47, Plast Reconstr Surg 69 (1982) 139, Microsurgery 8 (1987) 22, J Reconstr Microsurg 15 (1999) 321] is used, the loose end of the suture may be stuck to the backside of the vessel and may be hard to grab. In order to avoid those problems, a new way of tying a microsuture was developed. By avoiding contact of the loose end of the suture to the surrounding tissue at any point during tying, the microvascular anastomosis can be performed quicker and more efficiently.     

Reconstruction for DRUJ Instability

The skeletal architecture of the DRUJ provides minimal inherent stability, as the sigmoid notch is shallow and its radius of curvature is 50% greater than that of the ulnar head [Af Ekenstam F, Hagert CG. Anatomical studies on the geometry and stability of the distal radio ulnar joint. Scand J Plast Reconstr Surg 1985;19(1):17–25]. Due to its incongruent articulation, the DRUJ relies strongly on the surrounding soft tissues for stability. The triangular fibrocartilage complex (TFCC) is generally accepted as the major soft tissue stabilizer of the DRUJ of which the volar and dorsal radioulnar ligaments are the primary components. Restoration of the radioulnar ligaments offers the best possibility to restore the normal DRUJ primary constraints and kinematics. This article presents an update of the procedure developed by the senior author that anatomically reconstructs the palmar and dorsal radioulnar ligaments at their anatomic origins and insertions.