The Crescentic Advancement Flap Revisited

BACKGROUND: When closing surgical defects, optimal aesthetic results are obtained when cosmetic units are preserved and, whenever possible, when scars are placed in naturally occurring creases and folds. This is particularly challenging in the perialar region, where surgical defects can encompass more than one cosmetic subunit. OBJECTIVE: To examine the reconstructive options and to demonstrate that the crescentic advancement flap for closures of defects in the perialar area is a superior alternative. METHODS: This is a review of surgical approaches, a historical examination of perialar repairs, and an illustrative case. RESULTS: A patient with a perialar defect was reconstructed using the crescentic advancement flap with excellent postoperative results. CONCLUSION: When compared with the other options, whenever feasible, the crescentic advancement flap, which has evolved over the years, remains a superior option for defects in the perialar location.     

The Undesirable Influence of Reconstructive Procedures on the Symmetry of the Nasolabial Folds

Background and Objectives. Although considerable attention has been directed toward the nasolabial fold in the esthetic surgery literature, there are infrequent discussions of the fold's importance in reconstructive surgery of the face. Because the use of common reconstructive techniques for wounds of the central face often introduces undesirable asymmetry to the nasolabial folds, reconstructive surgeons should be more aware of the esthetic consequences of manipulating the nasolabial folds.
Methods. The influence of selected reconstructive procedures of the central face on the form and symmetry of the nasolabial folds is analyzed through the examination of multiple clinical examples of reconstructive successes and failures in this area.
Results. Many commonly performed reconstructive procedures of the face introduce changes in the nasolabial fold's depth, slope, and location. The inherent asymmetries that such procedures introduce frequently detract from their overall esthetic results.
Conclusions. The nasolabial fold is a visually distinct unit of the face that deserves more attention from reconstructive surgeons. When possible, surgical alterations of the fold should be minimized to preserve facial symmetry.
JONATHAN L. COOK, MD, HAS INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS.     

Fundamentals and principles of tissue transfer

Summary The advancements in tissue transfer techniques made recent years allow the reconstructive surgeon to view the whole body as a potential donor site. Now functional results, along with cosmetic results, can be considered as paramount in the thinking of the reconstructive surgeon. In the past, techniques of tissue transfer tended to be considered in ladder fashion with the surgeon applying techniques of transfer from simplest to “exotic” as opposed to considering optimal functional/cosmetic results. Now reconstructive surgeons routinely consider the “exotic” when it yields the best functional/cosmetic results. The basic that will be discussed in this chapter are designed to provide a platform from which GU reconstructive surgeon launches into more complex and imaginative procedures.      

Current management of the dilated urinary tract in prune belly syndrome

Upper urinary tract stasis, poor bladder emptying, vesicoureteral reflux, and bacteriuria in various combinations are the factors that have led to a poor long-term prognosis in patients with prune belly syndrome. Whether these factors are best controlled by medical treatment or by surgical correction has been the source of some controversy. Although medical treatment may have improved over the years, so have the results of reconstructive surgery. Because the syndrome is a spectrum disorder, there will certainly be many patients who require little or no surgical intervention. The majority, however, will benefit from carefully planned and well-executed reconstructive surgery. Even in these cases, there should be a period of medical treatment and surveillance with interval re-evaluation. In a few patients, early stabilization will not be possible, and a drainage procedure such as vesicostomy will be necessary in the first days of life. Regardless of how an individual patient might be treated, he will require long-term follow-up surveillance. As more long-term results are reported, the optimal treatment plan should become more obvious.     

A modified and accurately designed Z-epicanthoplastic technique

Surgical creation of a supratarsal crease has been by far the most common cosmetic procedure in China. To gain a pleasing eye appearance, double-eyelid surgery usually is performed in combination with epicanthoplasty. Currently, many epicanthoplastic techniques are described. Essentially, among the various epicanthoplasties, quite a few procedures are different designs of the Z-plastic or Y-V technique. In the authors’ opinion, a better cosmetic result depends on a specific design more than the procedure itself. This report describes a modified Z-epicanthoplastic technique with accurate design and different types of tissue flaps raised. The authors performed epicanthoplasties with the Z-plastic technique for 163 patients from December 2006 to December 2010. Interepicanthal distances longer than a palpebral fissure and lacrimal caruncles obviously covered by epicanthic folds were considered an indication for performing epicanthoplasty. The follow-up period ranged from 4 months to 4 years. A good result was obtained, with natural fine creases of the upper eyelids and complete caruncle exposure at the near inner canthus. There was no shadow or local depressed deformity, visible scar in the inner canthus, or recurrence, and most of the patients showed slight westernizations of the medial eye architecture rather than wide and prominent western upper eyelid creases at the medial eyelids. Three patients had slight asymmetric exposure of the lacrimal caruncle, which was corrected by a second surgery. In conclusion, the modified and accurately designed Z-epicanthoplasty can avoid some complications such as local depressed deformity, displeasing appearance, and excessive westernized architecture at the inner canthus. A predictable shape in the medial corner can be obtained by developing and accurately designing different types of flaps.     

Mandibular reconstruction following ablative tumour surgery: an overview of treatment planning

BACKGROUND: In the last half century the evolution of mandibular reconstruction has resulted in a multitude of surgical procedures that have been brought about by advances made in bone science, grafting techniques and materials technology. With the ever increasing number of surgical options currently available it has become essential to take stock of these achievements and reconsider the fundamental principles of reconstructive surgery. METHODS: The choice of reconstructive techniques is only part of a wider number of variables that must be considered which will ultimately determine the success or failure of the procedure. RESULTS: Variables likely to influence the outcome of mandibular reconstruction are the site and extent of the defect, the needs and tolerance of the patient, the timing of reconstruction and the surgical skill and techniques available. CONCLUSION: By careful consideration of these cardinal variables it may be possible to formulate a treatment plan that will not only satisfy the essential needs of the patient but also help increase the likelihood of a successful outcome.     

Role of laparoscopy for reconstructive urology

PURPOSE OF REVIEW: Laparoscopic reconstructive urology is a challenging and technically demanding field of urology. As urologists' experience strengthened and technical modifications developed, urologic laparoscopy was applied in the treatment of malignancies and evolved from simple to technically demanding reconstructive techniques. This article reviews the latest published literature in the field of laparoscopic reconstructive urology and introduces our own persuasion for the role of this approach in urology. RECENT FINDINGS: Some laparoscopic procedures like orchidopexy, ureterolithotomy, pyelolithotomy and pyeloplasty require "a middle class level of laparoscopic skills" whereas other reconstructive techniques such as radical prostatectomy and cystectomy and partial nephrectomy are technically demanding and are still being developed with promising results. The reconstructive part of partial nephrectomy is small and refers to good hemostasis whereas in radical prostatectomy and cystectomy, the reconstructive part--urethrovesical anastomosis and urinary diversion, respectively--is an important factor, affecting the patient's postoperative quality of life. SUMMARY: The development of new instrumentation as well as the amelioration of urologists' laparoscopic skills will pave the way for the establishment of laparoscopic reconstructive urology in everyday practice. So far, laparoscopic reconstructive urology seems to be a well tolerated and effective treatment modality but still with not a completely clear role.     

Double-Pedicle Tram Flap Breast Reconstruction: Following

After using various techniques with various results, Bostwick's principles for breast reconstruction were used in mastectomy cases and their early results are presented. The breast reconstructions were performed to 12 cases, of which eight patients had one or two risk factors and four had more. The double-pedicle technique was used in the former and vascular delay preceding double-pedicle technique was used in the latter. No vascular compromises, arterial or venous, were observed on the flaps in the acute phase and no fat necrosis ensued lately. All patients were satisfied with these principles and we did not observe any problems with the flaps. We have concluded that Bostwick's principles offered a reliable and minimal risk basis for breast reconstructive surgeons.     

Fasciocutaneous flaps

It is difficult to be objective about the fasciocutaneous system of flaps, whose development continues at an alarming speed. The references cited in this article, by no means comprehensive, are testimony to that. We have tried to be selective in our choice of reference, and anyone familiar with these references will have a good understanding of the fasciocutaneous system. These flaps have been recognized for less than 10 years, but their origins have been well based on an anatomical foundation. The revival in the anatomical basis of flaps, whether they be skin based, muscle based, or fascia based, is, we think, one of the most significant factors in the huge advance we have seen in reconstructive techniques in the last decade. To put reconstructive surgery in perspective, we see it in the following way: 1. Distant origins from ancient Egypt through Tagliacozzi to Dieffenbach. 2. The birth of modern reconstructive surgery, 1900 to 1930. 3. Skin flaps and the age of the tube, 1930 to 1960. 4. Anatomical renaissance; the axial skin flap and microsurgery. 5. The 1970s, decade of the muscle and musculocutaneous flaps. 6. The 1980s, decade of the fasciocutaneous flap. We repeat that to see our present efforts objectively is difficult. What is close to us seems more important, but as we progress further away from the origins of the fasciocutaneous flap, some aspects of these flaps will be seen as more important than others. The concept of including the fascia to produce a composite fascial skin flap is of fundamental importance. The discovery of these flaps is a milestone in reconstructive surgery. Our anatomical understanding of all flaps is also of paramount importance. Some of the individually described fasciocutaneous flaps will always remain best buys; some will be forgotten--and maybe even rediscovered.     

Principles of tissue transfer techniques in urethral reconstruction

Many reconstructive surgical techniques require tissue transfer, or movement of tissue from a donor to a recipient site. The techniques of tissue transfer in reconstructive urologic surgery assume knowledge of skin anatomy, the basic principles of tissue transfer, and the composition and characteristics of the donor and recipient tissues. These topics will be addressed in this article.     

SALVAGE PROCEDURES FOR MUTILATED BURNT HANDS

In a severely burnt hand one of the most difficult problems in reconstructive surgery is the prevention of contractures. Early skin grafting, and the reduction of oedema and joint stiffness by early mobilization, will minimize contraction, but will not altogether prevent it. When the dominant hand has also suffered damage, the need for a reconstructive procedure is absolutely essential, and by far the best functional and cosmetic results are achieved with the use of local tissue from the damaged digits. This paper describes various reconstructive salvage procedures for severely deformed hands.     

The transverse figure-of-eight suture for securing the nail

Various techniques have been described for securing the nail plate back in its anatomic position after trauma or for reconstructive exposure. The figure-of-eight suture technique uses the paronychial folds and notches in the distal aspect of the nail plate to create both ventral and proximal forces to secure the nail plate under the eponychial fold. The transverse figure-of-eight suture prevents the nail from moving distally or dorsally. It is simple, secure, and easily taught to non-hand surgeons. This technique can also be used when the eponychium is damaged. It is a useful adjunct to the armamentarium of anyone treating finger-tip injuries.     

The reverse radial forearm flap for soft tissue reconstruction of the wrist and hand

Soft tissue defects of the upper extremity must be carefully assessed to determine the most appropriate method of coverage. Direct closure and local flaps represent the most basic techniques on the reconstructive ladder; however, they are inadequate for large or complex defects. Split thickness skin grafts are appropriate for granulating wounds with a bed of vascularized tissue; however, if there is an exposed joint or bone devoid of periosteum or tendon devoid of paratenon, there will be insufficient neovascularization, and the graft will inevitably fail. The reconstructive hand surgeon must then pursue more complicated techniques for wound coverage based upon knowledge of the available pedicled and free flaps. The reverse radial forearm flap potentially offers thin, mobile skin with similar characteristics to the skin over the dorsum of the hand. This flap is more versatile than the groin flap and probably more reliable than the posterior interosseous artery flap for coverage of moderate-sized defects of the dorsal or palmar wrist and hand and is specifically indicated for coverage of degloving injuries of the dorsal wrist and hand, after release of thumb-index finger web space, and for coverage of amputations of the thumb in preparation for toe-to-thumb transfer.     

Radiance: Short-term experience

Over a 9-month period, the author has injected Radiance (BioForm, Inc., Franksville, WI), a soft tissue filler, into lips, nasolabial folds, glabellar creases, labiomental folds, tear troughs, and lateral jawlines in 130 patients. Here he presents his clinical findings. (Aesthestic Surg J 2003;23:495-499)     

Rehabilitation after amputations in the hand

It is important to recognize the psychological and cosmetic aspects of amputation. More data are needed regarding the functional loss at various amputation levels so that patients can be counseled more effectively. Rehabilitation and reconstructive surgery can then produce results that will be more meaningful to the patient in terms of employment and everyday use of the hand.     

Orbital exenteration for advanced periorbital skin cancers: 20 years experience.

PURPOSE: Orbital exenteration is a disfiguring procedure that results in a significant deformity which poses a reconstructive challenge, especially in elderly patients with significant comorbidities. We reviewed our experience of orbital exenteration. METHODS: A retrospective analysis was conducted identifying all patients undergoing orbital exenteration over a 20-year period. Patient demographics, tumour characteristics and reconstructive techniques used were recorded. RESULTS: Thirty-two patients were treated by orbital exenteration. The majority of these were for basal cell carcinomas (53%). Most patients (62.5%) were ASA grade II or more. Reconstructive techniques included split skin grafting (63%), forehead (25%), scalp (6%) and cervicofacial (6%) flaps. Following reconstruction of the exenterated orbit, 29 patients had a prosthesis. Twenty-six of these rated their final result with their definitive prosthesis as good. CONCLUSIONS: Though there are various options available for reconstruction after orbital exenteration, a split skin graft and orbital prosthesis provide a simple solution for a very difficult problem of advanced periorbital skin cancer in the elderly population with significant comorbidities. The final outcome is comparable to that of more complex flap reconstruction with comparable satisfaction rates.     

Basic microvascular techniques and principles

This article will discuss the advantages and disadvantages of the various types of optical magnification currently available. The instruments necessary for performing most operations will also be presented. Attention will be focused on the physical properties and technical considerations of microvascular anastomosis. The principles and techniques employed for joining small blood vessels are almost always valid and transferable to reconstructive surgery of other small tubes such as the ureter, bowel, etc.     

Plastic surgery and conservative treatment of breast cancer. Indications and results]

After conservative treatment for breast cancer, 75% of patients have good cosmetic results, but 20 to 25% of patients have a fair or a bad result. The tumor itself is responsible for some of these bad results (tumor volume, location in the inferior quadrants of the breast) but more often, failures are related to surgery and/or radiotherapy. Some patients will then ask for reconstructive surgery. It should always be preceded by a careful examination of the breast, both with an oncologic and a reconstructive approach. The techniques used are numerous, ranging from simple reexcision of the lumpectomy scar to mastectomy with immediate TRAM flap reconstruction. We believe that plastic surgery techniques should be used as soon as the initial lumpectomy, as they help to fill in the defect. In the case of a tumor located in the inferior quadrants, bad cosmetic results are twice as frequent as in the upper quadrants: we treated 16 of these patients with immediate bilateral breast reduction, reshaping the breast at the same time as the lumpectomy, and achieving symmetry of the contralateral breast. This technique did not interfere with radiotherapy or chemotherapy. When radiotherapy followed surgery, cosmetic results were good. Local and distant recurrences were not modified by the adjunction of a breast reduction to the lumpectomy. In 49 cases, we also proposed a bilateral breast reduction for larger tumors (T > 3 cm, bifocal cancer). 4-year local recurrence rate was less than 10%: this technique could help to extend the indications for conservative treatment for breast cancer. More cases and longer follow-up are necessary.     

Fingertip injuries

Background:

Fingertip injuries are extremely common. Out of the various available reconstructive options, one needs to select an option which achieves a painless fingertip with durable and sensate skin cover. The present analysis was conducted to evaluate the management and outcome of fingertip injuries.

Materials and Methods:

This is a retrospective study of 150 cases of fingertip Injuries of patients aged six to 65 years managed over a period of two years. Various reconstructive options were considered for the fingertip lesions greater than or equal to 1 cm². The total duration of treatment varied from two to six weeks with follow-up from two months to one year.

Results:

The results showed preservation of finger length and contour, retention of sensation and healing without significant complication.

Conclusion:

The treatment needs to be individualized and all possible techniques of reconstruction must be known to achieve optimal recovery.     

The cervical tube pedicle flap: uses in facial reconstruction.

Most reconstructive surgeons will not commonly need to use the transverse cervical tube pedicle flap in facial reconstruction but this straightforward and simple technique can be very useful in certain instances. Some of the techniques of reconstructive surgery which have stood the test of time should not be forgotten even when the most recent reconstructive options are available.