The role of the plastic surgeon in a cancer hospital.

This paper discusses and illustrates the complicated problems faced by the plastic surgeon in a cancer hospital. His patients are often weakened, both physically and psychologically, not only by the cancer itself, but also by extensive ablative surgery. The goal of the plastic surgeon is rehabilitation of the patient after he is cured of cancer. Good planning with the cancer surgeon before the ablative operation is very important, as is immediate repair, whenever possible. The simplest procedure with the fewest stages that can accomplish satisfactory repair in the shortest time should be chosen, as we can never, even after the most extensive cancer operation, be sure that no recurrence will appear. Partial surgical repair and the use of a prosthesis should be considered for complicated defects in old and weak patients. Postoperative radiation therapy, if indicated, can be given after the flap has healed into the defect but before the pedicle is separated. The plastic surgeon should always be aware that his most important goal is speedy and satisfactory rehabilitation of the patient.     

Sternumosteomyelitis – chirurgische Behandlungskonzepte

Sternal osteomyelitis is a potentially fatal condition following cardiac surgery. Sternal osteomyelitis should be diagnosed as early as possible followed by an interdisciplinary radical debridement. Subsequently plastic reconstructive surgery is necessary for defect reconstruction. This can be achieved by a number of established pedicled and free flap plastic surgery procedures. The choice of flap procedures is based on defect geometry and the individual patient situation, including potential flap donor sites. Smaller defects can generally be reconstructed by pedicled flap transfer. For extensive sternal defects, free flap transplantation is now a well-established therapeutic option. In some patients lacking sufficient recipient vessels, the creation of an arteriovenous (AV) loop as recipient vessel is necessary. In summary, successful therapy of sternal osteomyelitis is based on early interdisciplinary treatment by the various surgical subspecialties.     

Repair of a fistula between the bladder and the perineal skin by femoral gracilis flap interposition

The successful repair of a fistula between the bladder and the perineal skin using a femoral gracilis flap is reported. A 70-year-old woman, who 10 years previously had undergone a total hysterectomy for uterine cancer, developed a fistula between the bladder and the perineal skin after she underwent Mile's operation for rectal cancer. Initially, an attempt was made to repair the fistula by the transabdominal approach. This failed, probably because of the lack of supporting tissue between the bladder and the perineal skin. The second repair was performed with plastic surgeons. A secure three-layer bladder closure was accomplished. A right femoral gracilis flap was developed and rotated 180 degrees to fill the defect in the skin and subcutaneous tissue. Four weeks after surgery, cystography revealed no fistula or urinary leakage and the drainage catheter was removed. Femoral gracilis flap interposition was successful for repair of a fistula between the bladder and the perineal skin when there was no supporting tissue due to extensive exenteration in the surgical removal of rectal cancer and after other repair procedures had been unsuccessful.     

Successful primary repair of late diagnosed spontaneous esophageal rupture: A case report

IntroductionSpontaneous esophageal rupture is rare, roughly 300 cases reported annually. Diagnosis is often delayed or missed. Overall mortality is about 20%. This feared high mortality rate has led to the misconception that primary esophageal repair should be avoided in late diagnosed patients. We report a successful primary repair of spontaneous esophageal rupture which was delayed for more than two weeks.MethodsA 53 year-old male presented to our medical service after falsely having been treated for pneumonia at an outside hospital. He was subsequently diagnosed with spontaneous esophageal rupture and treated with over the scope clips followed by stenting. Persistent leak into mediastinum made surgical exploration necessary. At exploration a primary repair could be performed successfully.ResultsUnsuccessful endoscopic management of esophageal perforation that was delayed for two weeks underwent primary surgical repair without complications.ConclusionPrimary closure of late diagnosed spontaneous esophageal rupture can be successful, even when it is complicated by a prolonged delay in treatment and failed endoscopic procedures. We conclude that primary surgical repair should be attempted in patients with spontaneous esophageal rupture if tissues are viable.     

Performance of a pediatric ambulatory anesthesia program--a developing country experience

BACKGROUND: The aim of this study was to evaluate the performance of a pediatric ambulatory anesthesia program in a tertiary care teaching hospital in a developing country. METHODS: Data on all pediatric patients (<16 years of age) scheduled to have elective day-care surgery during a 1 year period from January 1999 to December 1999 were collected retrospectively. An audit form was used to determine the specialty of the procedures, anesthesia techniques, postoperative analgesia, perioperative complications, unplanned admissions and outcomes with respect to morbidity and mortality. RESULTS: A total of 763 pediatric ambulatory surgical procedures were performed during the year of 1999. The procedures included general surgery, ENT, orthopedic and plastic surgery. The most common procedure was inguinal hernia repair followed by umbilical hernia repair, adenotonsillectomy and circumcision and 96% of the patients had general anesthesia. There were only three unplanned admissions (0.4%); one for a surgical reason and two for anesthetic reasons. There was no serious morbidity or mortality in any patient. CONCLUSIONS: Performance of pediatric day-care anesthesia has been good in our day-care unit and we have a successful ambulatory surgery program, despite the limitations of a developing country.     

Expansion of the facial integument in children

In the light of four clinical cases of paediatric facial reconstruction, the authors discuss the advantages and indications of the cutaneous expansion technique which can be combined with other plastic surgery procedures to obtain an abundant skin with ideal texture and sensitivity and minimal scars. Operations for cicatricial alopecia, very extensive forehead naevus, preauricular tumour and nasal mutilation are described.     

Degloving Injury

Abstract Background: Degloving is a potentially serious injury in which an extensive area of skin is torn from its underlying attachments and thereby deprived of its blood supply. Case Study: Two cases of degloving injury are described, one occurring as a result of the shearing effect of a vehicle wheel passing over the limb in a run-over accident and one caused by a ring of the fourth-hand finger. The degloved skin must be grafted with the help of plastic surgery either by removing the subcutaneous fat from the damaged skin and applying it as a free graft or by taking a graft from elsewhere. Conclusion: Degloved skin is dead and should be replaced as if it were a free skin graft. A number of plastic surgical procedures are available at the moment.     

Repair of orbital exenteration cavities

Several plastic surgical procedures can attenuate the unsightly effects of a disinhabited empty orbit. Only the imperatives of follow-up or very poor general status can still justify spontaneous epithelialisation, which we prefer to split skin graft. In other cases, apart from the exceptional indications of preservation of the eyelids and conjunctival sac, closure by flap is the technique of choice: temporo-frontal flap in cases of simple exenteration and temporo-jugal for the superficial plane and medio-frontal for the deep plane in radical exenterations. In young adults, when the resection is limited to the orbit, after flap closure, conjunctival reconstruction by means of a mucosal graft can be attempted without preliminary temporalis muscle transposition, as the orbital cavity is filled spontaneously and sufficiently by fibrous tissue.     

Dermatologic surgery and the pregnant patient.

BACKGROUND: Because of concerns about potential harm to the mother or fetus, dermatologic surgeons are frequently hesitant to perform cutaneous surgery on pregnant patients. OBJECTIVE: To review the relevant physiologic changes during pregnancy, appropriate preparation for and timing of procedures, and drug safety. METHODS: A literature review was performed of dermatologic and nondermatologic journals discussing physiology, surgery, and drug safety in the pregnant patient. RESULTS: Special positioning is required for the pregnant patient during surgery. Low doses of most local anesthetics with epinephrine as well as nitrous oxide less than 50% are safe to use during pregnancy. Sedatives and opioids are potential teratogens and should be avoided. Safe antibiotics to use during skin surgery in pregnancy include penicillins, cephalosporins, and nonestolate erythromycin. If necessary, lymph node dissections under general anesthesia in the pregnant melanoma patient should occur during the second trimester. CONCLUSION: With appropriate preparation, safe and successful cutaneous surgery can be performed on the pregnant patient.     

The Versatile V-Y Flap for Facial Reconstruction

BACKGROUND: There are many acceptable treatments for facial skin cancer, but some form of surgical excision is by far the most widely accepted. After surgical excision, there will necessarily be a defect that has to be managed. The V-Y flap is a very useful modality for repair of such defects in all zones of the face. OBJECTIVE: This article reviews the indications for V-Y flaps and the surgical technique that should result in a successful reconstruction. Each zone of the face is independently discussed, along with the appropriate variations in technique for each area. METHODS: An evaluation of the literature as well as the extensive experience of the senior author in performing this procedure provides the basis for this review. CONCLUSION: V-Y flaps are extremely versatile and relatively easy to perform. All areas of the face can be successfully reconstructed after skin cancer removal with V-Y flaps if they are properly designed and executed.     

"Classical" abdominoplasty]

The term "classical" abdominoplasty includes those procedures designed and performed before the introduction of liposuction techniques. All of these operations leave a considerable scar: the importance of this residual scar makes abdominoplasty the poor cousin of cosmetic plastic surgery. In practice, it should be generally considered to be a functional comfort surgery, which sometimes resembles cosmetic surgery. All wall lesions must be treated during abdominoplasty: retightening of the musculo-aponeurotic plane when it is distended, correction, of more or less localized fat overload, resection of any excess skin. The desire to obtain scars as small and as hidden as possible has led to the development of a large number of techniques, performed with varying frequencies. However, there has been a renewed interest in some of these techniques since the development of liposuction. The abdominoplasty skin procedures can be divided into two groups: localized abdominoplasties, only concerning a limited part of the abdomen, and extensive abdominoplasties, concern all of the abdominal wall and requiring extensive skin detachment and a procedure on the umbilicus. The most classical method of abdominoplasty is low transverse abdominoplasty with umbilical transposition. This operation raises a number of aesthetic problems and one or several defects are fairly frequently observed during objective analysis of our results. It nevertheless provides a real personal gain for the patient, in the way he or she moves and dresses and can even allow weight loss after the operation. This gain is not related to the results observed on photographs. The introduction of liposuction techniques has radically modified the technical modalities and indications for these so-called "classical" operations.     

Blepharoplastik und Brauenlift

Upper eyelid blepharoplasty is one of the most common procedures in facial plastic surgery (in 2011 second place in the annual statistics of the American Association of Facial Plastic and Reconstructive Surgeons, AAFPRS). Nowadays, a simple resection of the excess skin is ineffectual if the aim is to achieve an optimal functional and aesthetic result. According to the treatment of the upper eyelid the surgeon has to examine and possibly treat the position of the eyebrow in order to correctly estimate the amount of excess skin of the eyelid. This article presents the state of the art techniques of surgical correction of dermatochalasis of the upper eyelids and eyebrow ptosis and clinical examples are demonstrated.     

伴严重肝功能不全的眼睑巨大结节性黄色瘤整形外科治疗体会

目的:探讨运用整形外科手段对伴有严重肝功能不全的双侧眼睑巨大结节性黄色瘤进行治疗的策略及意义。方法:对1例伴有严重肝功能损害的双侧上下眼睑巨大结节性黄色瘤患者首先采取营养支持治疗,当条件许可时积极手术,先切除较大侧结节,创面移植全厚皮片,待完全愈合后,择期手术切除另一侧病灶。结果:左侧上下眼睑瘤体完全切除,创面植皮存活,眼睑运动功能良好,视物无遮挡,术后无倒睫、睑外翻等并发症,随访1年无复发,生活质量改善,另一侧等待手术。结论:对于伴有严重肝功能不全的眼睑巨大结节性黄色瘤患者,为改善其生活质量,降低生活与工作中对他人的依赖程度,可进行积极术前准备,在手术条件允许下可以通过整形外科技术治疗获得满意的效果。     

Surgical treatment of the aging neck

To obtain consistently successful results, surgical treatment of the aging neck must be based upon a comprehensive anatomic diagnosis, using an appropriate sense of cervicofacial aesthetics and taking into account the relative contributions of each structural component of the deformity. The degree to which the projection and contour of the anterior mandible, redundancy of cervical skin, presence of excess submental fat, hyoid bone position, and configuration of the platysma muscles affect the appearance of the neck should be determined preoperatively to develop an effective surgical plan. Experience has shown that extensive incisions in the region of the anterior neck and transection of the platysma should be avoided. Depending upon the specific findings, any combination of a group of procedures may be required, including cervical rhytidectomy, submental suction-assisted lipectomy, chin augmentation, and midline imbrication of the platysma muscles. The indications, limitations, and possible complications of each procedure are described, and some technical considerations are discussed.     

Aesthetic refinements in use of forehead for nasal reconstruction: the paramedian forehead flap

Historically, surgeons have avoided use of the forehead for nose reconstruction because they felt larger areas of tissue were required. As plastic surgery has evolved to achieve successful replacement of major nasal defects, the paramedian forehead flap has been refined as the best alternative. Judicious use of central forehead tissue will provide sufficient skin of excellent tint to allow total repair. Scars are almost always unobtrusive. The forehead flap covers fabricated composite flaps of intravasal lining and primary cartilage grafts that create the subsurface architecture of the external nose. The result is a nose with correct shape and color that appears normal.     

Sailing the straits of approval: the nature of FDA approval and its implications for surgeons

Use of Food and Drug Administration-approved medications and products for other than the approved indications is common in facial plastic surgery and violates no laws. Addressing practical concerns about such use strengthens the doctor-patient relationship and can minimize the risk of successful allegations of negligence in the event of untoward outcomes. The facial plastic surgeon can find support and assistance with off-label use in two general areas. Abundant scientific literature focuses on off-label use and addresses its practical, scientific, legal, moral, and ethical issues. The Food and Drug Administration also addresses off-label use in its own publications. It offers guidelines for physicians that, if followed, facilitate incorporation of off-label use into practice with minimal risk and maximum potential for therapeutic success.     

Implantation of a soft-tissue expander before operation for club foot in children

Primary skin closure after surgery for club foot in children can be difficult especially in revision operations. Between 1990 and 1996 a soft-tissue expander was implanted in 13 feet before such procedures. Two were primary operations and 11 were revisions. A standard technique was used for implantation of the expander. Skin augmentation was successful in 11 cases. There was failure of one expander and one case of wound infection. Sufficient stable skin could be gained at an average of five weeks. Primary skin closure after surgery was achieved in 12 cases. We conclude that soft-tissue expansion can be used successfully before extensive surgery for club foot. The method should be reserved for revision procedures and for older children. The technique is not very demanding, but requires experience to achieve successful results.     

Early and late conversion from endoluminal to open repair.

Conversion from endoluminal to open repair of abdominal aortic aneurysms (AAA) may be primary, at the original operation or secondary, at a subsequent operation. The indications for primary conversion include aortic rupture and migration of an endograft resulting in obstructed blood flow and irreversible twisting of an endograft. The indications for secondary conversion include persistent endoleak, sealed endoleak with continued AAA expansion, apparently successful AAA repair, with continued expansion and the presence of an infected endograft. The technique of conversion varies from standard repair through modified standard repair to supraceliac control, depending on the cause of failure leading to conversion. All conversion procedures expose the patient to an increased risk and are best avoided by careful case selection, accurate sizing, and good procedural technique.     

Interim outcome of the single stage dorsal inlay skin graft for complex hypospadias reoperations

PURPOSE: Despite high success rates for primary hypospadias repair, some cases require multiple procedures for ultimate reconstruction. We report our experience with single stage dorsal inlay urethroplasty using skin grafts for complex reoperations. MATERIALS AND METHODS: A total of 31 patients (mean age 13.8 years) with failed previous hypospadias surgery were included in the study. Indications included fistulas, strictures, diverticula and repair breakdown. The urethral plate had been removed or was severely scarred in all patients. A free penile or groin skin graft was sutured and quilted to the corpora cavernosa, guaranteeing sufficient blood supply. The neourethra was tubularized and covered with a tunica vaginalis or dartos flap, followed by glanuloplasty. Outcome analysis included urethrograms, urethral ultrasound and flow measurements. RESULTS: Foreskin was used in 15 cases, penile skin in 12 and inguinal skin in 4. Average graft length was 3.92 cm. A total of 20 patients required glanuloplasty with a skin graft extended to the tip of the glans. After a mean followup of 30.71 months 5 patients underwent redo surgery, for a complication rate of 16.1%. Urethral stricture of the proximal anastomosis was the most frequent finding. CONCLUSIONS: This single stage approach using dorsal skin grafts is a reliable method to create a substitute urethral plate for tubularization. Complication rates are equivalent to those of staged procedures. Foreskin should be used as a graft donor site to optimize the outcome if available. This approach represents a safe option for reoperations even if the urethral plate or midline penile skin is grossly scarred.