Microsurgical repair after excision of large cancers. Apropos of 14 cases]

The specialty which has benefited the most from the rapid development of reconstructive microsurgery over the last decade, has been plastic surgery. In particular, the authors refer to reconstructive microsurgery after malignant tumor resection. Resections which used to cause serious psychological problems or which required multiple reconstructive procedures, can now be performed as a single stage procedure with good oncological, functional and aesthetic results. This experience concerns the treatment of 14 primary or recurrent malignant tumors of the skin and soft tissues using microsurgical techniques. The free latissimus dorsi musculocutaneous flap was the flap most commonly used. The authors also used the groin flap, the scapular flap, the tensor fasciae latae flap, the dorsalis pedis flap and finally the jejunum combined with the second metatarsus to reconstruct the mandible and the floor of the mouth. Complications consisted of complete necrosis of a dorsalis pedis flap and two revisions were performed for venous thrombosis. With a minimum follow-up of 5 years, one patient has developed a local recurrence and another has developed regional lymph node metastases. The functional and aesthetic results were quite satisfactory. The authors believe that microsurgery is a very valuable technique to treat difficult reconstructive problems.     

The Rotating Island Pedicle Flap: An Aesthetic and Functional Improvement on the Subcutaneous Island Pedicle Flap

BACKGROUND: The subcutaneous island pedicle flap is a useful closure in many areas on the face, particularly the cheek and upper lip. One disadvantage can be that the advancing edge of the flap leaves a scar at right angles to the local lines of relaxed skin tension. Tension on free edges such as the lid can also be a problem, but may be mitigated by incorporating an element of rotation into the closure. A variation on the subcutaneous island pedicle flap is described to help avoid the problems of the subcutaneous island pedicle flap while retaining its strengths. OBJECTIVE: Our experience with more than 120 rotating island pedicle flaps over 10 years is described to demonstrate the versatility of this subcutaneous island pedicle flap for facial and reconstructive surgery. METHODS: The technique is described and seven representative cases are presented with photographs. RESULTS: The flap is simple to perform, has minimal complications, and has good cosmetic results. Temporary alteration of sensation in the flap skin is a possible complication and can be largely avoided with a bipedicled dissection technique. CONCLUSION: Our experience shows the rotating island pedicle flap to be versatile, reliable, and aesthetic island pedicle flap for skin cancer surgery both on and off the face and a practical modification of the subcutaneous island pedicle flap.     

Aesthetic Refinements in Breast Augmentation with Deep Inferior Epigastric Perforator Flap: A Case Report

The principle of free flaps based on perforator vessels and the development of deep inferior epigastric perforator flap (DIEP) is currently used in reconstructive microsurgery. Clinical experience and research have shown that perforator flaps provide numerous advantages over the conventional myocutaneous flaps and combine muscle preservation and sequel minimization at the donor site. Clinical use of autogenous tissue or perforator flaps in aesthetic breast surgery or augmentation mammaplasty is not a common practice. The authors indicate the use of the DIEP flap to correct severe hypomastia after bilateral breast augmentation with silicon implants, followed by infection and implant extrusion. Using the DIEP flap is a new option for patients who have had complications from breast augmentation with implants or severe hypomastia and have excess tissue in the lower abdomen. Additional studies and clinical research are necessary to evaluate the real benefits as compared to silicone implants, such as operative time, the recovery period and financial implications.     

Microvascular Free Flaps in Early Reconstruction of Burns in the Hand and Forearm: Case Reports

In the reconstructive plastic surgery a free flap provides a one-stage method to achieve an optimal functional and aesthetic result. We report five acute burns or early contractions of the hand and forearm with free-flap reconstruction. In each case an attempt was made to design the flap to restore missing tissue components. We used three different musculocutaneous free flaps and two free skin flaps: a latissimus dorsi, a rectus abdominis and a rectus femoris renervated musculocutaneous flap, as well as a dorsalis pedis and a horizontal fasciocutaneous upper arm flap. In all five cases, the hand and wrist showed early restoration of function.     

整形外科进展

目的综述近几年整形外科临床治疗所取得的主要进展.方法广泛阅读国内外相关文献及专著,并进行综合,指出整形外科取得的主要成就.结果在整形外科中,近几年美容外科有了飞速发展,并有将整形、美容学科合二为一的趋势.在手外科不仅重视结构、功能的修复,也要重视形态美、应发展"美容手外科".在面瘫及面部毁损治疗方面,发展了"面部肌肉神经化测量系统"及同种异体颜面部移植技术.穿支血管皮瓣的解剖研究促进了临床应用的发展.结论整形外科已取得很多重要发展,今后在修复重建外科领域应更加重视结构、功能、形态的完美结合.     

Reconstruction of the hypopharynx and cervical esophagus

Hypopharynx and cervical esophageal defects are challenging problems for the reconstructive surgeon. Prior surgery and radiation therapy contribute to the difficulty in managing these patients. The surgeon must possess a reconstructive algorithm that varies depending on the defect, available donor sites, and his or her experience. The free jejunal flap is the flap used for most of these defects. The radial forearm flap is reserved for partial defects measuring less than 50% of the circumference of the pharynx. The gastric pull-up is used when an intrathoracic esophagectomy is necessary. The pectoralis flap is reserved for situations when external coverage is necessary in addition to hypopharyngeal reconstruction or when a free-tissue transfer is not appropriate. Reconstruction can offer most patients successful swallowing while minimizing complications.     

Current concepts in breast reconstruction

As the incidence of breast cancer increases, breast reconstruction is more and more often proposed and its indications are viewed in terms of quality of life. In the past, delayed reconstruction was the rule. Progress in reconstructive techniques currently allows performing immediate reconstruction in selected cases, even when the operative field has to be irradiated. These new techniques generally improve the result of breast reconstruction. Moreover, expansion of screening techniques allows detection of small tumors for which a conservative excision is sufficient. Nevertheless, this kind of less aggressive surgery may require a reconstructive procedure in order to maximise the aesthetic result.     

Current Concepts in Breast Reconstruction

As the incidence of breast cancer increases, breast reconstruction is more and more often proposed and its indications are viewed in terms of quality of life. In the past, delayed reconstruction was the rule. Progress in reconstructive techniques currently allows performing immediate reconstruction in selected cases, even when the operative field has to be irradiated. These new techniques generally improve the result of breast reconstruction. Moreover, expansion of screening techniques allows detection of small tumors for which a conservative excision is sufficient. Nevertheless, this kind of less aggressive surgery may require a reconstructive procedure in order to maximise the aesthetic result.     

Reconstruction of middle-third auricular defect based on aesthetic perception theory

The perception theory has been recently used in aesthetic reconstructive surgery. Using on the principles of the theory, we have successfully reconstructed an ear with a middle-third defect utilizing local flap and secondary revision procedures.     

Reconstruction of middle-third auricular defect based on aesthetic perception theory

The perception theory has been recently used in aesthetic reconstructive surgery. Using on the principles of the theory, we have successfully reconstructed an ear with a middle-third defect utilizing local flap and secondary revision procedures.     

Partial reconstruction after conservative treatment for breast cancer: classification of sequelae and treatment options

Most patients presenting with breast cancer are treated by breast conserving treatment (BCT). Some of these patients present with poor cosmetic results and ask for partial breast reconstruction. These reconstructions following BCT are presenting more frequently to plastic surgeons as a difficult management problem. We have defined and published a classification of the different cosmetic sequelae (CS) after BCT into three types. This classification helps to analyse these complex deformities aggravated by radiotherapy. Furthermore, our classification helps to choose between the different surgical techniques and propose the optimal option for their surgical correction. Our initial publications reported 35 and 85 patients: we have currently operated more than 150 cases of CS after BCT. Type-1 CS are defined by an asymmetry between the two breasts, with no distortion or deformity of the radiated breast. Type-2 CS are those with an obvious breast deformity, that can be corrected with a partial reconstruction of the breast. Type-3 CS are those with such a deformity that only a mastectomy with total reconstruction of the breast can be performed. Most of the patients present with type-2 CS, but are reluctant to undergo what they feel is a major reconstructive procedure: in a initial prospective series of 85 patients operated for CS after BCT, 48 (56.5%) had type-1 CS, 33 patients (38.8%) type-2 CS and four patients (4.7%) type-3 CS. Type-1 patients should be managed essentially by contralateral symmetrizing procedures. One should limit any surgery on the radiated breast, as a mammoplasty or an augmentation is at high risk of complications. Type-2 is the most difficult to manage and requires all the surgical armamentarium of breast reconstructive surgery. The insetting of a myocutaneous flap is often necessary and autologous fat grafting is a promising tool in selected cases. Type-3 CS requires mastectomy and immediate reconstruction with a myocutaneous flap. The major development though in the past 10 years has been the development of oncoplastic techniques at the time of the original tumour removal, in order to avoid most of type 2 and type 3 deformities. This paper reaffirms the validity of the Cosmetic Sequelae classification as a simple, practical guide for breast reconstructive surgeons. It discusses the various choices of reconstructive procedures available, the importance of "preventing" these CS and defining the role of the plastic surgeon in the management of these patients.     

Surgical repair of abdominal wall]

Surgical repair of abdominal wall defects following tumour resection only raises real problems when the nature of the tumour required wide, or even transfixing excision, as in the case of sarcomas or very advanced carcinomas. Superficial repair is performed according to the algorithm of the simplest technique: secondary healing, partial suture, total suture, transplant, or flap (pedicled or free). In the case of transfixing resection, the combination of a biomaterial for reconstruction of the deep plane and a superficial flap is necessary. For very large transfixing defects of the abdomen, a free flap may be required and, in this case, delayed insertion after initial transfer may further reduce the operative risk ("apple turnover" technique). The complications observed in a detailed series of 9 cases operated at Saint-Louis Hospital consisted of one intraoperative cardio-circulatory arrest during second-stage surgery and one late infection at three years. The authors believe that the indications for delayed insertion of a free flap are still very topical in cases in which a very large grafted free flap is necessary in conjunction with a prosthesis. Large abdominal defects after cancer resection can be reconstructed by modern reconstructive surgery.     

Surgical techniques in breast cancer: an overview

With advancements in oncology and oncoplastic training, the options for treating breast cancer have expanded exponentially over the past two decades. In particular, surgical techniques have advanced to the point where oncological safety and aesthetic outcomes are now the pillars of contemporary breast surgery. Studies have demonstrated that by using oncoplastic techniques, breast conservation has become an alternative for many patients who would otherwise undergo mastectomy. Nonetheless, a considerable cohort of patients will still require, or request, a mastectomy. Surgical options range from a simple wide local excision, therapeutic mammoplasty or volume replacement techniques with a local flap, to mastectomy with whole breast reconstruction using autologous tissue or a prosthetic implant. Deciding between surgical options involves careful consideration of tumour characteristics, patient comorbidities and the potential effects of neoadjuvant and adjuvant treatments. The key message for surgeons is to ensure the chosen surgery does not compromise oncological outcomes and provides an excellent aesthetic outcome with timely healing to prevent delays in commencing adjuvant oncology treatments. In this article, we discuss techniques for breast conservation surgery and reconstructive options after mastectomy. In addition, we detail the safety and influence of neo-adjuvant and adjuvant treatments on surgery.     

Skin expansion before breast reconstruction with the superior gluteal artery perforator flap improves aesthetic outcome

To improve the aesthetic outcome in the reconstructed breast and in the flap donor area, the technique of skin expansion in the mastectomy site was used in eight patients who subsequently underwent breast reconstruction using the superior gluteal artery perforator (SGAP) flap. The authors think that skin expansion before final reconstructive surgery provides adequate ptosis and better positioning of the flap on the chest, leading to a more natural appearance and symmetry of the reconstructed breast. Furthermore, the skin expansion reduces the amount of free flap skin required for breast reconstruction, resulting in less donor site scarring and morbidity. They present their surgical refinements to improve the aesthetic appearance of the breast reconstructed using the SGAP flap.     

Implant Replacement or Removal: What Happens after Capsular Contracture? A German Study Examining Breast Implant Revision Surgery and Patient Choices in 946 Cases

IntroductionCapsular contracture most often leads to implant revision surgery for aesthetic or reconstructive purposes. However, little is known about which operation is chosen when revision surgery has to be performed. We performed analysis of revision indications and performed revision surgery considering implant removal or replacement and additional surgical procedures. To our knowledge, this study presents the largest German single-center analysis regarding implant revision surgery after the onset of complications.MethodsRetrospective 10-year data analysis of a single-center population undergoing breast implant revision surgery.ResultsCapsular contracture was the most frequent finding before reoperation, both removal and replacement (p < 0.05). It was linked to longer duration of in situ implant placement (p < 0.05) and more frequently in reconstructive patients (p < 0.05). Implant replacement was performed more often before definite implant removal for reconstructive patients (p < 0.05). Mean duration of in situ implant placement before definite removal was lower for reconstructive patients (p = 0.005). Overall reconstructive patients were older than aesthetic patients (p < 0.05). After implant removal, 61.7% of aesthetic patients chose to undergo mastopexy, 54.7% of reconstructive patients opted for autologous breast reconstruction, and 25.4% did not choose an additional surgical procedure after implant removal.ConclusionSignificant differences are observed for reconstructive and aesthetic patients regarding indication leading to revision surgery, time of revision surgery, and the type of performed revision surgery itself. After implant removal, more than 60% of aesthetic patients undergo mastopexy, more than half of reconstructive patients choose autologous breast reconstruction, and over a quarter of patients choose no additional surgical procedures.     

Secondary burn reconstruction: recent advances with microvascular free flaps, regional flaps, and specialized grafts

A representative series of cases are presented which demonstrate secondary reconstructive plastic surgery procedures for the burn victim utilizing microvascular free flaps, regional flaps, and specialized skin grafts. The unstable burn scar of the lower extremity could be managed either by a microvascular free-flap transfer, a muscle transfer, a myocutaneous flap transfer, or a reverse dermis graft, or overgrafting. In the present day, there are many treatment modalities available to us. Long-term wearing of the Jobst pressure stocking is essential in many cases to minimize the hypertrophic burn scar. In our experience, Kenalog injection into a hypertrophic burn scar always has resulted in improvement of the condition although it is usually necessary to give multiple injections into the hypertrophic burn scar at eight week intervals. We have never known Kenalog to fail to improve a hypertrophic scar by flattening it out to a significant extent, but it may take a year or more of injections to accomplish this goal. Microvascular surgery is most definitely a team effort requiring at least two fully trained microvascular surgeons, plus experienced operating room personnel. One microvascular surgeon harvests the free flap, and the other microvascular surgeons prepares the recipient area. Both microvascular surgeons participate in the multiple anastomoses that are required. A microvascular laboratory is essential to the success of a microvascular team, and constant practice is mandatory to maintain and enhance these precision skills. The primary burn surgeon ideally must always keep in mind ways to minimize functional and aesthetic deformity and to continue to improve the quality of life of the burn victim.     

Tissue expansion of free and pedicled flaps after transfer: possibilities and indications

Tissue expansion in combination with flap transfer has been widely reported as preexpansion of flaps, but only once as expansion of a free flap after transfer. Three free flaps and one pedicled flap were expanded after transfer. Indication, timing of expander implantation and explantation, technical aspects, and complications are reviewed. Indications for expander implantation after flap coverage were adjacent scar contracture, a secondary ulcer, or correction of contour deformity. The expander was placed as early as 4.5 months after free flap transfer. Low grade infection and seroma were complications necessitating early expander removal in two cases. The outcome was satisfactory in all four patients. Tissue expansion after flap transfer has been shown to be a reliable reconstructive option in selected cases. Indications are rare and include hypertrophic scar formation, scar contracture, secondary ulceration, or reconstructive procedures. In early free flap expansion, it is critical to avoid mechanical pressure of the pedicle. In musculocutaneous flaps, this can be accomplished by placing the expander subcutaneously. If more than 6 months have passed since transfer of the flap, the randomized blood supply is sufficient to place the expander anywhere under the flap.     

Vascular compromise of the pectoralis major musculocutaneous flap in head and neck reconstruction

In head and neck reconstructive surgery, the pectoralis major musculocutaneous flap is a major reconstructive tool, both in primary as well as secondary reconstructions. In a few cases the authors have been able to demonstrate that when the pectoralis major musculocutaneous flap is translocated to the mouth through a noncompromised neck tunnel, as is done for head and neck reconstructions, the taut lateral pectoral nerve is seen to compress the vascular pedicle of the flap, adversely affecting its vascularity, which can lead to partial or total necrosis of the flap. The authors explain this feature, very specific to this flap, with the help of a prospective series of patients.     

Virtual 3-dimensional modeling as a valuable adjunct to aesthetic and reconstructive breast surgery

Three-dimensional (3D) imaging technology currently is used by various commercial industries as a method for analyzing objects and shapes. Recent work from our group and others offer data to support the use of 3D imaging as a valuable tool in aesthetic and reconstructive breast surgery. We have developed a system for creating 3D breast models that provides clinical data that can help guide surgical management. With 3D breast models, surgeons are able to visually assess the size, shape, contour, and symmetry of the breast, as well as obtain quantitative breast measurements and volumetric calculations. Three-dimensional imaging may be applied to various plastic surgery procedures including breast reconstruction with implant/tissue expanders, local flap reconstruction, free-flap reconstruction, breast augmentation, and breast reduction surgery. The novel application of 3D imaging in these settings represents a significant advance from traditional approaches to aesthetic and reconstructive breast surgery in which surgical procedures are based on 2-dimensional photographs and visual size estimates.     

Techniques for Reconstruction of Perialar and Perialar-Nasal Ala Combined Defects

BACKGROUND: The nasal ala and perialar areas involve junctions with the nose, cheeks, and lips. Following Mohs surgery, defects in this area often extend across one or more creases or folds, thus requiring repair of more than one reconstructive subunit. OBJECTIVE: Our goal is to present various reconstructive techniques required to obtain aesthetic results. METHODS: Defects and reconstructions will be illustrated to demonstrate techniques and results. Emphasis will be on selection of techniques and documentation of results. RESULTS: Examples include various flap procedures (advancement, rotation, pedicle, interpolation, transposition), full-thickness and composite grafting, second intention healing, and combinations thereof. CONCLUSIONS: Thoughtful application of the various techniques will help to maximally camouflage scars and avoid maneuvers which would result in bridging and/or blunting of creases and folds.