Nasal Reconstruction with Forehead Flap: Our Experience

Face represents complete personality of a man or woman and on the middle of face nose is situated. So nose is seen first and can not escape from the eyes of others. Nose gives beauty to face. Therefore cosmetically it is very important part of a person especially for woman. There are many situations when due to disease or trauma nasal defect araises, which requires nasal correction or reconstruction of nose. During cancer diagnosis camps at Government Hospitals and even at more remote places we came across few patients suffering from cancer of nose. These patients were operated and the nasal defect thus araised were repaired with midline Forehead flaps. Rhinoplasty is a very costly technique in India and the surgeons doing Rhinoplasty can be counted on fingers here. Our technique is although very old but it is cost effective and can be performed even at remote places in Local anaesthesia with sedation. This is a retrospective multicentric study representing a series of six cases of nasal reconstruction after Nasal cancer surgery in a period from Jan 2009 to April 2011 at Government and Private Hospitals. These Hospitals are of the level of secondary Referral centres. Six patients were analysed according to the age, sex, anatomical location of lesion on the nose. All patients were male, age ranging from 56 to 72 years. Five out of six patients were of basal cell carcinoma and one was suffering from squamous cell carcinoma. All patients were operated and nasal reconstruction was done with midline forehead flap with good aesthetic result.     

额部皮瓣修复眼睑内侧缺损眼12例分析

[目的]探讨应用额部皮瓣修复眼睑内侧肿瘤切除术后眼睑缺损的临床价值。[方法]采用对侧眶上动脉和滑车上动脉为蒂的额部皮瓣修复眼睑内侧癌术后缺损12例。[结果]12例皮瓣11例全部成活,1例皮瓣远端约1/4表皮坏死。12例眼睑外形、色泽良好,功能满意。随访1～11年,1例术后4年因脑溢血死亡,无眼睑肿瘤复发者。[结论]额部皮瓣厚度和韧度与眼睑相仿,色泽与眼睑相同,皮瓣有感觉神经支配,成活率高,是修复眼睑内侧缺损的理想材料。     

Periorbital reconstruction

Reconstructions of the lower lid, the upper lid, the medial canthus, the infraorbital area, and the eyebrow area are reviewed. Various flap procedures are described.     

Scalp reconstruction

Scalp reconstruction after oncologic resection can be challenging. Wide surgical resections, in combination with co-morbid conditions such as infected alloplastic material, cerebrospinal fluid (CSF) leak, or devascularized bone after craniotomy necessitate healthy, vascularized tissues for reconstruction. Although primary closure is feasible in some cases, the mainstay of treatment involves local tissue rearrangement with or without split thickness skin grafting. In addition, free tissue transfer is an important adjunct to therapy in patients with poor local tissues. Careful analysis of the defect and local tissues can help tailor the method of reconstruction and result in satisfactory closure in a majority of patients. Current techniques used for scalp reconstruction after surgical ablation are the subject of this review.     

Laryngopharyngeal reconstruction

There is a high incidence of hypopharyngeal cancer is our country due to the habits of tobacco and alcohol. Moreover these cases are often detected in the late stages thereby making the issue of reconstruction very tedious and unpredictable. There are a number of options for laryngopharyngeal reconstruction available now including the use of microvascular flaps depending upon the patient’s fitness, motivation, technical expertise, size and extent of the defect. This article reviews the different methods of laryngopharyngeal repair as regards their success rate, radiation tolerance, morbidity & mortality.     

Lower extremity reconstruction

The current recommendation for surgical treatment of tumors of the lower extremity is a limb-sparing resection. Limb-sparing resection coupled with complex reconstructive techniques and complemented by new chemotherapeutic agents and adjuvant radiation therapy has allowed us to achieve survival rates that are comparable to those of amputation with a better functional outcome. Recent advances in microsurgical techniques and the associated technologies and a better understanding of microvascular anatomy has allowed us to customize flaps to the specific needs of the patients and to achieve a lower donor site morbidity. Increased communication between the specialties of the multidisciplinary treatment team has also improved outcomes. The reconstructive component has become an integral part of the multidisciplinary care for patients with lower extremity tumors. It not only allows them to rapidly resume adjuvant therapies but also enables them to more easily resume their activities of daily living.     

Breast reconstruction today

Present surgical techniques and prostheses now permit any woman who has had a mastectomy to be reconstructed. Whether a woman should have breast reconstruction must be decided only after full discussion of prognosis and attainable goals with the woman herself. A variety of choices of procedure, timing, and extent of surgery are available.     

Nipple areola reconstruction

Nipple areola reconstruction is often considered the "finishing touch" in the process of breast reconstruction after surgery for breast cancer. Attention to detail with respect to patient selection, timing of reconstruction and surgical technique must therefore be paid to avoid an unsatisfactory result that may taint an otherwise successful reconstructive sequence. There are many surgical techniques available to recreate the nipple areola complex, but each of the various techniques is designed to accomplish similar goals. In every case, regardless of the technique chosen, the surgeon seeks to reconstruct a nipple areola complex that is esthetically pleasing in its color, symmetry, position on the breast mound, and projection.     

Immediate postmastectomy reconstruction

The role of reconstruction in the management of patients with problems related to breast cancer is of increasing importance. Immediate reconstruction is particularly applicable in those situations where prophylactic mastectomy is performed. High-risk groups who warrant such prophylactic mastectomy and reconstruction include those with florid cyst disease, a strong family history of breast cancer, the finding of lobular carcinoma in situ, multiple previous biopsies, and those who have severe and progressive mastodynia. In those with smaller amounts of breast tissue, reconstruction is based on a double layer of tissue over a graft, one layer consisting of pectoral muscle and the other of breast skin. In those with more abundant breast tissue, the two layers placed over the graft are both derived from skin flaps, the inner layer a free, denuded dermal graft from the inferior flap and the second layer, the superior breast skin flap itself.     

Lower eyelid reconstruction

The Hughes procedure of tarsoconjunctival flap sharing for lower eyelid reconstruction following removal of basal cell carcinoma is described. Although this technique has the disadvantage of being a 2-staged procedure that requires closure of the eyelid for 2-8 weeks, its cosmetic and functional results are outstanding. While the Hughes procedure is not the only technique for eyelid reconstruction, it is a time-tested method commonly practiced by ophthalmic plastic surgeons.     

Microsurgical breast reconstruction

Breast cancer, the most common cancer diagnosed in American women, often necessitates mastectomy. Many studies have demonstrated improved quality of life and well-being after breast reconstruction. Numerous techniques are available for breast reconstruction including tissue expander implants and autologous tissues. Microsurgical tissue transfer involves the use of excess skin and fat (flaps) from a remote location to reconstruct the breast. Most often, tissues are transferred from the abdomen and buttocks. Less commonly, thigh flaps are used. These operations can provide durable, esthetic reconstructions. In addition, advances in microsurgical techniques have improved operative success rates to the range of 99%. The selection of an appropriate flap for microsurgical breast reconstruction is multifactorial and is based on patient and oncologic factors. These factors include patient comorbidities, body habitus/availability of donor tissues, cancer stage, and the need for postoperative adjuvant radiation therapy, as well as the risk of cancer in the contralateral breast. Appropriate choice of flap and surgical technique can minimize the risk of operative complications. Additionally, several large series have established that microsurgical breast reconstruction has no impact on survival, or locoregional/distant recurrence rates.     

Immediate nipple-areola-sparing mastectomy reconstruction: An update on oncological and reconstruction techniques

Nipple-sparing mastectomy (NSM) is a safe technique in patients who are candidates for conservation breast surgery. However, there is worry concerning its oncological safety and surgical outcome in terms of postoperative complications. The authors reviewed the literature to evaluate the oncological safety, patient selection, surgical techniques, and also to identify the factors influencing postoperative outcome and complication rates. Patient selection and safety related to NSM are based on oncological and anatomical parameters. Among the main criteria, the oncological aspects include the clinical stage of breast cancer, tumor characteristics and location including small, peripherally located tumors, without multicentricity, or for prophylactic mastectomy. Surgical success depends on coordinated planning with the oncological surgeon and careful preoperative and intraoperative management. In general, the NSM reconstruction is related to autologous and alloplastic techniques and sometimes include contra-lateral breast surgery. Choice of reconstructive technique following NSM requires accurate consideration of various patient related factors, including: breast volume, degree of ptosis, areola size, clinical factors, and surgeon’s experience. In addition, tumor related factors include dimension, location and proximity to the nipple-areola complex. Regardless of the fact that there is no unanimity concerning the appropriate technique, the criteria are determined by the surgeon’s experience and the anatomical aspects of the breast. The positive aspects of the technique utilized should include low interference with the oncological treatment, reproducibility, and long-term results. Selected patients can have safe outcomes and therefore this may be a feasible option for early breast cancer management. However, available data demonstrates that NSM can be safely performed for breast cancer treatment in selected cases. Additional studies and longer follow-up are necessary to define consistent selection criteria for NSM.     

Vaginal reconstruction: an algorithm approach to defect classification and flap reconstruction

Vaginal defects from oncologic resection present a complex array of reconstructive challenges. Increased use of adjuvant radiation and chemotherapy demands uncomplicated wound healing. As patients are being diagnosed at earlier stages of disease and at younger ages, maintenance of sexual function and body image are fundamental goals. This review provides an algorithm approach to defect classification and flap reconstruction. Carefully appreciation of the specific defect facilitates flap choice. There are two basic defect types partial (Type I) and circumferential defects (Type II) 1. These defect types can be further subclassified. Type IA defects are partial and involve the anterior and/or lateral wall. Type IB defects are also partial, but involve the posterior vaginal wall. Type IIA defects are circumferential, involving the upper two-thirds of the vagina. Type IIB defects represent circumferential, total vaginal resection, most commonly following pelvic exenteration. Using this method of defect classification, three pedicled flaps can be used to successfully reconstruct the majority of defects: the Singapore (or pudendal thigh) flap, the rectus flap, and the gracilis flap. With appropriate flap choice and a multidisciplinary approach to patient care, rapid wound healing, restoration of the pelvic floor, and re-establishment of sexual function may be most reliably achieved.     

Challenges in midface reconstruction

Defects of the midface and maxilla are often the most challenging problems faced by the reconstructive surgeon. Resections that involve critical structures of the face such as the nose, eyelids, and lips in conjunction with the maxilla can be particularly difficult to reconstruct. The algorithm for reconstruction of these defects is usually based on the extent of maxilla that is resected. A classification system for maxillectomy defects is the most useful way to approach these reconstructions. A vast majority of extensive defects involving the maxilla and midface require free flap reconstructions. The type of flap selected is based on the extent of skin, soft tissue, and bone that is resected. Smaller volume defects with large skin surface requirements are best reconstructed with the radial forearm fasciocutaneous or osteocutaneous flaps. Larger soft-tissue volume and skin surface can be provided by the rectus abdominus myocutaneous flap. Critical structures such as lips, eyelids, and nose should be reconstructed separately, using local flaps if at all possible. The free tissue transfer should ideally not be incorporated into these structures. Most patients with even the largest resections can be restored to fairly good function by following this algorithm. Semin. Surg. Oncol. 19:218-225, 2000.     

Pelvic exenteration and reconstruction

For the past six decades, pelvic extenteration has been utilized in the treatment of localized central pelvic recurrences after chemo/radiotherapy. The radicality of the procedure that includes resection of the bladder, vulva/vagina, and rectum, although with curative intent, results in comprehensive changes for the patient. For this reason, all patients should undergo extensive psychosocial counseling to prepare them for the changes in body image and lifestyle. Extirpation of the pelvic viscera has undergone a number of modifications since Brunschwig first described it in 1948 to maximize survivability and minimized anatomical distortion. Most of the advancements have been focused on the reconstructive phase after pelvic exenteration. A few select patients can be free of any external appliances such as a colostomy bag with utilization of a low colorectal anastomosis, and can maintain sexual intimacy with creation of a neovagina. In addition, reconstruction of the pelvic floor with omental flaps, dura mater grafts and myocutaneous flaps have decreased postoperative morbidity. In this article, we provide a review of pelvic exenteration in gynecologic oncology, emphasizing preoperative evaluation, surgical techniques and their postoperative management.     

Mid-facial reconstruction after maxillectomy

Reconstruction following extensive resectionof the maxilla has been a challenging problem in the fieldof head and neck cancer surgery. At our institutes, maxillectomy defects have been restored based on the principles of repair involving the important concept of maxillary buttress reconstruction. Reconstruction of the zygomaticomaxillary buttress (ZMB), including the orbital floor, is essential for prevention of the malpositioning of the eyeglobe in preservation of the orbital contents. ZMB reconstruction is also important to provide a good contour of malar prominence. Pterygomaxillary buttress (PMB) reconstruction provides sufficient support for the fitting of a dental prosthesis. In patients with extensive resection of buccal soft tissue, a PMB and nasomaxillary buttress (NMB) should be reconstructed to prevent superior and posterior deviation of the alar base and oral commissure. We advocate that critical assessment of skeletal defects, as well as associated soft-tissue defects, following various types of maxillectomies is essential for a rational approach to achieve satisfactory clinical results.     

Breast reconstruction following mastectomy

Breast reconstruction after mastectomy can avoid a permanent deformity. As a member of the breast management team, the reconstructive surgeon can give advice on timing and techniques. Breast reconstruction can either be started at the time of the mastectomy or delayed for months or years. Newer techniques of tissue expansion permit breast reconstruction without additional scars or significant hospitalization. Autogenous tissue breast reconstruction techniques are available that provide natural, long-lasting breast reconstruction without the need for a silicone breast implant.