Reconstruction of the nasal alar defect with the superiorly based nasolabial flap described by Burget: report of seven cases

Background

The reconstitution of a nasal alar rim and lobule defect represent a difficult challenge in consideration of his situation, anatomy and function. This article describes the technique and the interest of the nasolabial flap when used to cover the entire alar subunit.

Methods

We present 7 cases of alar rim and lobule defect after skin cancer excision. In the series, there are two full-thickness with lining defect. The patients were reconstructed with a superiorly based nasolabial flap, according to the subunit principle as introduced by Burget. A free cartilage graft was used to restore structural support with marginal skin flaps were turned over for intranasal lining when necessary.

Results

The cosmetic and functional outcomes of each repair were judged from good to excellent by patients and surgeons. No case of flap infection or necrosis occurred.

Conclusion

The superiorly based nasolabial flap, describe by Burget, provides an excellent choice for cosmetic and functional reconstruction of the nasal alar defect.     

The complete dorsum nasal island flap based on the superior alar artery

The complete dorsal nasal aesthetic unit can be raised in a vascular island flap based on the superior alar artery, at the level of the nasalis muscle. This flap uses the vertical glabellar cutaneous laxity. It hides scars between the nasal aesthetics units and its distal rotation point allows a pure translation of the nasal skin without distortions encountered when using medial canthal rotation flaps. This local flap is reliable and had been successfully used for four patients without complications or secondary procedures. It allows large reconstructions for up to 25 mm defects leaving minimal scars. It represents an interesting alternative for the reconstruction of defects of the nasal tip or supra tip of the nose, and has also been used for alar reconstructions.     

Efficiency of the combination of Mersilene-musculocutaneous flap in the reconstruction of full-thickness chest wall defects. A retrospective study of 14 cases

SUBJECT: The tumors of chest wall can be responsible of large full-thickness defects. The skeletal stabilization by different synthetic materials with numerous modalities of use and the superficial coverage of the defect by a musculocutaneous flap are the two imperatives parts of this reconstruction. PATIENTS AND METHODS: From January 1997 to January 2006, 14 patients, 10 males and 4 females, aged between 17 and 63 years old and suffering from full-thickness chest wall defects secondary to tumor resection have benefited from a simple reconstruction, wherever the defect, by a Mersilene Mesh and a muscular or musculocutaneous flap. These defects measured between 8 x 12 cm and 14 x 16 cm and were located in the anterior part of the chest in 3 cases, with resection of the upper half of the sternum and the internal part of both clavicles and the first three ribs, and in the lateral part of the chest in 11 cases with resection between 3 and 5 ribs. The histological diagnoses of these tumors were 3 chondrosarcomas, 3 sternum and 1 rib metastases, 2 desmoid tumors, 1 Ewing's sarcoma, 4 benign tumors. The flaps used were pedicled in 13 cases and based on the latissimus dorsi muscle, the serratus muscle and the pectoralis major muscle; in 1 case, the latissimus dorsi musculocutaneous flap was free. RESULTS: The skeletal stabilisation seems satisfying. There was no problems with the pulmonary function except in 4 cases where a dyspnea appears in sustained effort. No vascular complication on these flaps was noted. With a mean follow up of 46 months, there was no local recurrence of the malignant tumors. Two patients were deceased 1 year after surgery.0. CONCLUSION: The Mersilene mesh associated with a locoregional musculocutaneous flap represent a simple and efficient solution for the treatment of such defects.     

Breast reconstruction with pedicled TRAM flap (a retrospective study of 115 consecutive cases)

Purpose of the study

The purpose of this study is to analyse the advantages, disadvantages and results of the unipediculed TRAM flap.

Patients and method

This retrospective study concerns 115 consecutive unipediculed TRAM flaps realised by two surgeons between 1994 and January 2007. These reconstructions were all realised for oncologic pathology and were either immediate or delayed surgery. Concerning the immediate reconstruction, a skin sparing mastectomy has been realised as often as possible for intraductal carcinomas and small invasive carcinomas. For the immediate reconstruction the study takes into account complications and oncologic recurrences with an average backward of 45 months.

Results

The unipediculed TRAM flap offers a good reliability and the esthetics results are stable at long-term for immediate breast reconstruction and delayed breast reconstruction. The major complications are flap necrosis (12,2%) and parietal complications (6%). The recurrence rate after mastectomy and unipediculed TRAM flap is equivalent of the recurrence rate expected for mastectomy alone. There were never late diagnostic for recurrence after unipediculed TRAM flap. The esthetic improvement by surgery concerns the opposite breast for 31,3%, it was a mastopexy or reduction. The esthetic improvement of the TRAM flap concerns 14 patients (12,1%). The improvement of inframammary crease was the most frequent improvement (9/115–8%).

Conclusion

The TRAM flap unipediculed allows a delayed, immediate breast reconstruction or bilateral synchronised breast reconstruction. The long-term disadvantages are the abdominal complications and the impossibility to realise the same technique for a later controlateral reconstruction.     

带(足母)趾末节趾骨及第二足趾皮岛再造拇指的临床研究

目的 探讨带(足母)趾末节趾骨及第二足趾皮岛的改良全形再造在拇指Ⅱ类B区缺损再造中的临床效果.方法 对6例外伤性拇指Ⅱ类B区缺损的患者,采用带(足母)趾末节趾骨及第二足趾皮岛的改良全形再造术,用同一血管蒂带(足母)趾末节趾骨的(足母)甲皮瓣及第二足趾中、近节骨和肌腱复合组织皮瓣再造拇指.结果 术后6例再造拇指全部存活,随访时间6～24个月,再造拇指及供区(足母)趾外形满意,按中华医学会手外科学会上肢部分功能评定试用标准进行手功能评定:优4例,良2例.患者生活均能自理,术后5例恢复工作.结论 带(足母)趾末节趾骨及第二足趾皮岛的改良全形再造Ⅱ类B区缺损拇指最大程度地恢复了再造拇指特别是末节指体的良好外观及感觉,同时提高了再造指骨愈合率,恢复了再造拇指的活动功能,且对足部供区的功能影响有限.     

神经端侧缝合重建腓肠神经营养血管逆行皮瓣感觉功能的临床观察

目的　研究重建腓肠神经营养血管逆行皮瓣感觉功能的方法 ,探讨神经端侧缝合法重建皮瓣感觉的效果。　方法　在小腿后侧设计及切取腓肠神经营养血管皮瓣 ,逆行转位修复足部皮肤软组织缺损 8例 ,皮瓣切取时 ,保留腓肠神经近端足够长一段 ,与皮瓣受区供体神经呈 3 0°～ 45°端侧缝合 ,于术后 2、4、8、16、2 4周检测皮瓣的感觉及植物神经功能。　结果　 8例皮瓣完全成活 ,随访 4～ 18个月 ,术后 4周起皮瓣感觉开始有不同程度的恢复 ,随时间延长恢复程度和范围增加 ;术后 16周进行感觉功能评定 ,S2 2例 ,S2 3例 ,S3 3例 ;供体神经功能无明显影响。　结论　神经端侧缝合法可重建腓肠神经伴行血管逆行皮瓣的感觉功能 ,操作简便 ,对手足外科有重要意义。     

A simple way to secure the distally based fascio-cutaneous flap of the leg: the lesser sapheneous-greater sapheneous vein anastomosis. Report of 15 clinical cases

PURPOSE: The distally based fasciocutaneous flaps of the leg are very useful for the treatment of skin defects at the lower third of the leg and the foot, but the venous congestion due to the reverse flow can be responsible of necrosis at the distal part of the flap. The anastomosis of the lesser saphenous vein which is included in the flap's dissection to the greater saphenous vein near the defect avoid this venous congestion and the necrosis of the most useful part of the flap for the coverage of these defects. MATERIAL AND METHODS: From January 1999 to June 2005, 15 patients aged between 22 and 64 years old have benefited for the treatment of soft tissue defects secondary to trauma with a mean diameter of 7 x 10 cm and located in 7 cases at the lower third of the leg and in 8 cases at the posterior side of the heel, from distally based posterior fasciocutaneous flaps where the venous reverse flow has been changed in a physiological one by the terminolateral anastomosis between the lesser and greater saphenous vein. The dissection of these flaps was classical except that the lesser saphenous vein was dissected 6 cm beyond the proximal part of the flap in the popliteal region. RESULTS: In all these flaps, there was no venous congestion and no arterial problems. With a mean follow-up of 40 months, the coverage's quality of these defects was very satisfactory. No sequellae are reported. CONCLUSION: The anastomosis between the lesser and the greater saphenous veins seems to eliminate the main source of failure of the distally based fasciocutaneous flap of the leg and can reinforce the indications of these flaps for the treatment of such defects.     

Precaution against postoperative venous complications after major hepatectomy using the pedicled omental transposition flap: Report of two cases

INTRODUCTION

Vascular complications following hepato-pancreatic biliary surgery can be devastating, and therefore precaution of them must be critical. We report two cases in which the pedicled omental transposition flap might be effective to avoid postoperative venous complications following major hepatectomy.

PRESENTATION OF CASE

Case 1 is a 80-year-old male who required to perform re-laparotomy at postoperative day 1 following major hepatectomy due to acute portal venous thrombosis (PVT). In the second surgery, the main trunk of PV was occluded by thrombus resulted from its redundancy and kinking. PV was resected with an adequate length and reconstructed. The omental flap was placed between PV and inferior vena cava (IVC) to fill in the dead space, resulting in favorable intrahepatic portal blood flow. Case 2 is a 64-year-old male who underwent left trisectionectomy because of giant hepatocellular carcinoma located close to the trunk of right hepatic vein (RHV) and IVC. After removal of the specimens, the dead space developed between the RHV and IVC. In order to prevent outflow block caused by kinking of the RHV, the omental flap was placed between the RHV and IVC, and the right triangle ligament of the liver was fixed to the diaphragm. RHV patency was confirmed by postoperative imaging.

DISCUSSION

The omental flap is a simple procedure and useful to fill the dead space developed in the area surrounding major vessels.

CONCLUSIONS

We experienced two cases in which vascular complications might be avoided by filling the dead space surrounding major vessels using the omental flap.     

Our experience with the lateral supramalleolar island flap for reconstruction of the distal leg and foot: a review of 20 cases.

We describe our experience with, and evaluate the reliability of, the lateral supramalleolar flap that was used in 20 patients for reconstruction of the distal leg and foot. There were 14 men and six women, age range 20-83 years. Nine were diabetic. The causes of the skin defects included trauma, diabetic ulcer, and deep burn. Sites of defects were the lower leg, the Achilles tendon, the dorsal and lateral aspect of the foot, and the ankle. Nineteen flaps survived and provided satisfactory coverage of the defect. Four flaps showed partial necrosis and required revision. We think that the lateral supramalleolar flap is a good way to reconstruct soft tissue defects of the lower extremity. Based on a secondary vascular axis, it has a large skin paddle and a wide rotation arc that reaches the distal areas of the foot.     

Oncologic, functional, and aesthetics results; evaluation of the quality of life after latissimus dorsi flap breast reconstruction. About a retrospective series of 450 patients

Retrospective assesssment from 1998 to 2005 from women who have a breast reconstruction by autologus latissimus flap or by latissimus flap and silicone breast implant for differed breast reconstruction (DBR) or mastectomy and immediate breast reconstruction (MIBR). PATIENTS AND METHOD: Analysis of oncologic results on 450 patients. Analysis of aesthetic, functional results and of quality of life by an anonymous questionnaire in the non progressive patients (407): 263 appraisable answers (13 DBR, 127 MIBR). Middle age: 49.8 years. RESULTS ONCOLOGIC: Forty-three patients (9.5%) had a relapse of their disease, 33 patients died (7.2%). The relapse of the disease was done in the form of metastasis alone: 29 (67.4%), metastasis and local recurrence: three (7%), local recurrence only: four (9.3%), not specified: seven (16.3%). The average time between the breast reconstruction and the relapse was 18.25±15.4 months. AESTHETIC RESULTS: The overall assessment is of 7.68/10. There is no statistical difference between immediate reconstruction and delayed reconstruction. A total of 11.2% patients considered it to be bad (<5/10). The symmetry between the two breasts in time is of 6.6/10 and 19.9% patients considered it to be bad (<5/10). The scar ransom, considered to be most important, is mostly in the back (4.1/10) then on the controlateral breast and then the breast reconstruction. This ransom is not easily acceptable in 15 to 20% of the patients. FUNCTIONAL RESULTS: The discomfort and the pain prevail above all in the back (3.56 and 2.59/10). Weaker symptoms in the event of immediate reconstruction than delayed reconstruction. We noted that 77.2% had kinesitherapy after surgery and 18.9% continues to have kinesitherapy, long time after surgery, mainly for massages of the back. The handicap is considered to be overall low 2.5/10 but 10% of the patients keep a feeling of important handicap (>7.5/10). QUALITY OF LIFE RESULTS: Seventy-one of the patients are serene. The discomfort to wear a bathing suit or to look at bare-chested is low (2.59 and 2.44/10). However 8.9% are in a very discomfort to see themselves bare-chested and 17.6% to show themselves to their spouse, with an impact on their emotional and sexual life in 36.4% of the cases. There is no significant difference between MIBR and DBR but on the other hand according to the judgement of the woman of her aesthetic result. A total of 95.7% do not regret having made this breast reconstruction. CONCLUSION: This study makes it possible to concentrate on the group of non satisfied patient for better determining the causes and the improvements of the surgical techniques to bring but also the overall surgical management of the patient even if most of the patients were mainly satisfied with their breast reconstruction.     

Local composite neurovascular island flap for skin cover in pulp loss of the thumb.

A local composite neurovascular island flap to provide stable skin cover with good soft tissue padding and sensibility for extensive pulp loss of the thumb was used in five patients. The island flap included the dorsoradial branches of the radial digital neurovascular bundle of the thumb.     

Morbidity of the trans rectus abdominis musculocutaneous flap in breast reconstruction. Retrospective study about 125 patients

OBJECTIVE: To evaluate, in our experience, the morbidity of the trans rectus abdominis musculocutaneous flap (TF), to determine the risks factors and the advantage of surgical delay procedure. PATIENTS AND METHODS: TF was used for 125 consecutive breast reconstructions. Thirty-eight patients (30,4%) had recidive after conservative treatment and 62 (49,6%) have been included in a procedure associating chemotherapy, radiation therapy and mastectomy with immediate breast reconstruction (IBR), 31 patients were obese (24,8%), 14 were smoker (11,2%), 118 (94,4%) had prior thoracic radiation, 97 (77,6%) had a surgical delay procedure by ligation of the inferior epigastric pedicle, 115 (92%) had IBR, 99 TF were unipediculed and 26 were bipediculed. RESULTS: Immediate morbidity was: 21 necrosis of the flap (16,8%) among 1 total necrosis (0,8%), 6 hematomas (4,8%). Secondary morbidity was: 14 fat necrosis (11,2%), 9 eventrations (7,2%), 6 hernias (4,8%). The only statistic factor founded for ischemic complication was obesity (P = 0,036). The abdominal repair with interposed mesh was the only factor who decreased significatively (P = 0,013) the wall complication rate. The surgical procedure delay did not reduce ischemic complication rate (P = 0,92). CONCLUSION: TF can be performed with an acceptable complication rate in institution who realise frequently breast reconstruction procedure. Surgical delay procedure in our experience must be reconsidered.