Aesthetic considerations in mandibular reconstruction

As free tissue transfer methods have improved, vascular bone grafting has become state of the art for reconstruction of mandibular defects. Prior studies have focused on flap survival and functional outcomes. The reconstructive surgeon should also strive to attain lofty aesthetic goals for this group of patients. The best results are achieved when patient factors, flap selection, treatment planning, and surgical techniques are all considered and properly selected.     

Aesthetic considerations in the reconstruction of the anophthalmic orbit

Twenty-four patients with severe anophthalmic orbit syndrome were treated with a combination of techniques utilizing autogenous tissue. Autogenous corticocancellous bone grafts were used in the orbit as a volume filler. The temporalis muscle and a fasciae flap with a pericranial flap were used as a curtain to cover the bone grafts and to give a softening effect. The prosthesis used was a regular eye shell. With this method it can be smaller, thinner, and lighter to produce less deformation of the lower lid, particularly when used for a long period of time. In children who have this deformity compounded by small orbits after oncologic treatment, three-wall orbital enlargement is done to achieve a larger orbit, so as to match the normal unaffected socket and produce symmetry.     

Aesthetic considerations in the reconstruction of the anophthalmic orbit

Twenty-four patients with severe anophthalmic orbit syndrome were treated with a combination of techniques utilizing autogenous tissue. Autogenous corticocancellous bone grafts were used in the orbit as a volume filler. The temporalis muscle and a fasciae flap with a pericranial flap were used as a curtain to cover the bone grafts and to give a softening effect. The prosthesis used was a regular eye shell. With this method it can be smaller, thinner, and lighter to produce less deformation of the lower lid, particularly when used for a long period of time. In children who have this deformity compounded by small orbits after oncologic treatment, three-wall orbital enlargement is done to achieve a larger orbit, so as to match the normal unaffected socket and produce symmetry.Presented at the annual meeting of the American Society of Aesthetic Plastic Surgery     

Aesthetic and functional advantages of the anterolateral thigh flap in reconstruction of tumor-related scalp defects

Eleven patients underwent free-flap reconstruction of tumor-related defects of the scalp, forehead, and temporal region. Flap selection aimed at achieving acceptable functional and aesthetic results combined with negligible donor-site morbidity. Ten males and one female, aged 61.3 +/- 14.3 years, were included in this study. Eight patients presented with tumor recurrences after previous surgery, irradiation, and/or chemotherapy. The average extension of defects was 169.5 (range, 30-600) qcm. Free flaps employed for reconstruction included antero-lateral thigh flaps (8), suprafascial radial forearm flap (1), lateral arm flap (1), latissimus dorsi muscle flap (1), and myocutaneous vertical rectus abdominis flap (1). Other procedures included nerve grafts to the facial nerve (2), ectropion correction (2), and fascia lata slings for static procedure in facial palsy (2). There was no pedicle revision and no flap failure. Donor-site morbidity was negligible. Hospitalization averaged 9.2 +/- 1.7 days. The anterolateral thigh perforator flap offers excellent coverage of tumor-related defects of the scalp, which require a thin flap for adequate contouring. The customized harvested myocutaneous anterolateral thigh flap is regarded as an elegant option for covering defects which consist of both deep and superficial areas. Fascia lata and nerve grafts are available at the same donor site. This easily allows additional procedures for cosmetic and functional improvement that are of high benefit for patients.     

Aesthetic and functional considerations in the reconstruction of large skin defects with free flaps

Free flaps can be used effectively in the primary reconstruction of large defects after resection of large tumors. The ultimate goal is radical excision of tumors and achievement of primary wound healing with a single procedure and long-term local control of disease. Although this can be obtained with the use of free tissue transfer, patients often seek more aesthetic results. Therefore, refinements of reconstructive techniques with minimal functional donor site morbidity are now the gold standard in our practice.     

Aesthetic considerations in facial reanimation

The treatment results of facial paralysis have improved within the last two decades with the introduction of new techniques for neuromuscular reconstruction. However, many patients still complain of aesthetic imbalance impairment after treatment. This article presents some complementary procedures that can be used to improve the appearance of the face either isolated in incomplete palsies, or after the completion of reconstructive procedures in complete paralysis. The procedures are divided according to anatomical areas--forehead, eyelids, middle third of the face, and the lower lip.     

Microsurgical reconstruction of major scalp defects following scalp avulsion

Introduction:

Total scalp avulsion is a serious injury, commonly occurring in Indian females working with industrial and agricultural machines. Their long hairs often get caught in a rapidly revolving machines, resulting in total avulsion of scalp. Lack of education and awareness in Indian villages often result in these patients coming late to the hospitals when replantation is not possible and scalp reconstruction remains the only available option.

Materials and Methods:

We performed our study on 22 cases of scalp avulsion injury presented to us between June 2007 and April 2012 at Department of Burn, Plastic & Reconstructive Surgery, SMS Hospital, Jaipur. In all of them a free tissue transfer was performed as an elective procedure.

Results:

Twenty two patients underwent free tissue transfer and followed up for an average period of 6 months. All patients included in this study were females with mean age of 28 yrs. Five patients in our study reported with partial necrosis of the free flaps which were subsequently managed with split-thickness skin graft (STSG). Two patients reported total necrosis of the flap which was re-operated using latissimus dorsi along with serratus anterior muscle (LDSA) from the contralateral side.

Conclusion:

As scalp avulsion because of rapidly rotating machine leads to large size defect not amenable for local tissue reconstruction. We performed reconstruction using LDSA and omental free flaps with split thickness skin graft (STSG) for large scalp defect and achieved good and stable soft tissue cover with satisfactory cosmesis.KEY WORDS: Latissimus dorsi with serratus anterior flap, scalp avulsion injury, scalp reconstruction     

Immediate total scalp and skull reconstruction

A patient who required excision of a large basal cell carcinoma was left with a scalp defect measuring 23 cm x 23 cm, associated with an underlying bony defect of 18 cm x 16 cm with a similar dural defect. Simultaneous reconstruction of all three layers was performed using a large free latissimus dorsi flap, titanium strips, and lumbar fascia. A satisfactory cosmetic and functional result was obtained using this technique.     

Technical considerations in replantation of total scalp avulsions.

Total scalp avulsions are devastating injuries and replantation is the best form of reconstruction. We present our experience of replantation of six totally avulsed scalps done between 1996 and 2004. All were technically successful, but one was lost in the post-operative period due to accidental shearing of the scalp during nursing care. A single team performed the surgery in all cases and the average operating time was 6 h. No vein grafts were used. Hair growth was satisfactory in all cases. None underwent formal nerve repair but there was adequate sensory recovery in all of them by 6-9 months. A small area of skin necrosis in the occipital area (three cases), telecanthus and epiphora (two cases) were the minor complications. The available Literature highlights the need for multiple teams to reduce the long operating time, the use of multiple vein grafts and the complexities involved. Since, they are rare injuries, gaining wide experience is difficult. In this article we offer recommendations in pre-op preparation, vessel identification, technique of anchoring the avulsed scalp prior to vessel anastomosis and post-op care to make this rare procedure quicker, easier and successful.     

Aesthetic considerations and the pediatric population

Aesthetic surgery is the natural evolution of reconstructive surgery done to improve a patient's form in addition to function. This becomes especially critical in the pediatric age group in which patients are constantly evolving and their concepts of self-esteem and body image are so fragile.     

Facial reconstruction using the visor scalp flap

In male burn victims, scar may cause grotesque disfigurement to the upper lip and lower face. There are many ways to address the problem, for simple skin grafting to complex flaps. Bipedicle scalp flaps are used sporadically for reconstruction of the upper lip. In this article, the use of bitemporal artery hair-bearing flap for reconstruction of the moustache and beard area in nine cases as a substitute for facial deformed skin is described. The results indicate that the scalp flap is one of the best-matched flaps for reconstruction of the mid and lower part of the male face.As a result of choosing the proper size of the flap, use of the tissue expander is omitted, the donor site may be closed primarily and early return of the patient to normal life is guaranteed. Although, the width of the flap is not sufficient enough to cover the whole lower face and the cheeks, it is enough to imitate a normal face and give a pleasant appearance.     

Frontal scalp flap for aesthetic eyebrow reconstruction

The eyebrow is an important subunit of facial aesthetics and expression. Partial or total absence of the eyebrow is an unacceptable and disturbing condition. Aesthetic eyebrow reconstruction is a challenging problem for the reconstructive surgeon. In this paper a simple and reliable procedure for eyebrow reconstruction is presented. An aesthetically satisfactory result was obtained and a perfect match with the undamaged eyebrow was achieved. In selected cases this technique may be a strong alternative to the procedures that had been defined earlier.