Purse-string closure of scalp defects following tissue expansion: an effective aesthetic alternative.

Primary closure of scalp defects under tension can be complicated by scar widening and alopecia, and large defects usually require the use of local flaps, skin grafts or free flaps. Tissue expansion facilitates the use of local flaps to cover large defects, but multiple expanders and complex flaps with extensive incisions may cause significant scars and alopecia. We describe a purse-string closure of expanded scalp tissue following excision of a large congenital nevus sebaceous. This scalp reconstructive technique minimises iatrogenic scars and uses the predictable forces of scar contracture and skin re-draping to achieve a superior aesthetic result.     

Optimum management of hand blast injuries

A series of 27 blast and gunshot injuries of the hand is presented. These wounds exhibit a spectrum of complexity and may include extensive soft tissue trauma complicated by burns, foreign bodies, fractures and amputations. A systematic management sequence is outlined to evaluate, treat, reconstruct and rehabilitate these hands, with the primary goal of obtaining early maximal function. Since these injuries vary in nature and complexity, this management sequence is specifically adapted to deal with the individual injury. A "reconstructive ladder" of techniques is utilized, ranging from "simple" (e.g., direct closure, skin grafts, local flaps) to "complex" (free flaps, toe-to-thumb transfer). The individual procedure selected is the most straightforward, consistent with expediency and early return of a functional hand. The return of these hands to function has been facilitated by recent advances in tissue assessment, free tissue transfer, and skilled hand therapy.     

缺损两侧的唇黏膜瓣在修复上唇中部红唇凹陷性缺损中的应用

目的探讨缺损两侧的唇黏膜瓣在上唇中部红唇凹陷性缺损畸形修复中的应用价值。方法在上唇中部红唇凹陷性缺损两侧，红唇与黏膜交界处内侧设计横行反向三角形黏膜瓣，两瓣共蒂于红唇凹陷部位。在缺损正中后部，黏膜瓣画线下方设计“人”形切口。沿设计线切开，掀起黏膜瓣，在该瓣下及两侧上唇切口下方稍加游离口轮匝肌．使其有一定移动度。将两侧口轮匝肌在掀起的黏膜瓣蒂下方正中处对拢缝合。然后将两侧黏膜瓣向下旋转90°，插入其下的“人”形切口内，使上唇中部组织量进一步增加，并加深唇龈沟，而两瓣移植后的共同蒂部“猫耳”正好形成唇珠，逐层缝合切口。结果共26例，其中双侧唇裂术后继发红唇缺损18例，尊侧唇裂术后继发红唇凹陷畸形4例，先天性4例，术后伤口均I期愈合。修复后红唇凹陷处饱满，唇珠明显，上唇外形满意，手术瘢痕小明显。结论应用缺损两侧的唇黏膜瓣转移修复上唇中部红唇凹陷性缺损畸形及唇珠再造，为同类组织修复，效果理想、操作简便、应用范围广泛，对任何原因引起的上唇中部红唇凹陷性缺损畸形均可应用。     

Composite- und Chimärenlappen in der Traumaversorgung

In the recent years, the variety of plastic surgical methods for defect closure among the different reconstructive strategies has been expanded by simultaneous multi-tissue transfer options. Both free microvascular and pedicled flaps may be used for optimized functional and aesthetic defect closure by simultaneous tissue transfer in a single operation. According to their vascular connection and spatial relationship of the different tissue types (skin, fat, bone, muscle, nerve, fascia, vessels etc.) there are various different tissue transplants ranging from simple axial pattern flap to microsurgically constructed sequential chimeric free flaps. The goal with these flaps is to achieve an optimal and overall time-saving treatment with the first reconstructive procedure. Though the initial operative time might be slightly longer, the number and complexity of subsequent procedures are reduced.     

Aesthetic management of external skin paddles following microvascular reconstruction of the head and neck

Microvascular free tissue transfer has become a popular reconstructive option for a wide range of complex head and neck defects. Although highly effective in achieving wound closure, this technique frequently introduces skin paddles with inherent differences in thickness, color, and texture. In resurfacing of cutaneous facial defects, such disparity often leads to inferior aesthetic results. For patients, poor appearance following head and neck reconstruction can become a significant source of distress and add additional burden to their recovery. This article describes several options available in the postoperative setting to improve the appearance of transferred skin paddles. Regional tissue rearrangement with the submental and posterior scalping flaps is discussed in detail.     

Reconstruction of large upper lip defects by free tissue transfer

Reconstruction of a large upper lip defect is a demanding procedure and can be performed by a variety of local flaps or by microvascular free tissue transfer. We present our experience in reconstructing near total or total upper lip defects by free tissue transfer. In 11-year period seven patients underwent microvascular reconstruction of upper lip, six with non-innervated radial forearm flap and one with non-innervated anterolateral thigh flap. In all patients good functional and acceptable aesthetic results, with oral competence at rest and during eating and speaking, were achieved. Deglutition and articulation were not affected in any patient. Sensory evaluation of reconstructed upper lips was performed in four patients and in three a reasonable recovery of sensation was recorded. In our opinion subtotal or total upper lip reconstructions with folded thin fascio-cutaneous free flaps produce very good functional and aesthetically acceptable results and avoid additional scars on lower lip and cheek. Further, because the size of the mouth is not altered, microstomia is avoided, which is especially important for patients using dentures. The remaining disadvantage of this method is non-competence of orbicularis oris muscle sphincter.     

Advanced lip reconstruction: functional and aesthetic considerations

The lips have both aesthetic and functional features that serve to provide recognizable individualized beauty, emotional cues, sensual interactions, speech abilities, and oral continence for nutrition. Lip distortion or loss occurring from trauma or neoplasms can have devastating cosmetic and form deficits with resultant psychological, physical, and nutritional detriments. Appropriate reconstruction of the lips requires a balance between form, function, and aesthetics. Conservation of tissue when feasible should be the overall goal followed by exhausting and maximizing on all adjacent local tissue advancements, rotations, and transposition options. Tissue preservation as the first line of lip reconstruction will achieve the highest success in maintaining sphincteric function along with balancing appearance. This goal should be maintained when dealing with simple lacerations with minimal tissue loss to extensive near or total lip defects. We hope to provide an algorithm and review of aesthetic considerations in lip reconstructive techniques for a wide range of lip defects. An anatomic review and historical background followed by aesthetic issues and pearls related to defect size-dependent lip reconstruction techniques will be presented. The emphasis will be on cosmetic issues that arise with lip reconstruction and how to incorporate a detailed preoperative assessment; minimize donor site morbidity; match tissue size, texture, and color; and maintain stomal competence to balance form, function, and beauty.     

Variants in the methods of plastic compensation for different defects of the middle face with pedicled soft-tissue flaps

The author describes some original methods of reconstructive and restorative operations for correction of complex defects and deformations of the middle area of the face by using pedicled flaps from the cheeks, chin, lips and lateral parts of the nose. Methods of restoration of the hairy area over the upper lip in men are described as well as plasty of a defect of the red margin of the upper lip, restorative operations for through defects of the nose and elimination of absolute stenosis of the nose passage with a pedicled flap from the cheek with the simultaneous performing of radical cheilorhinoseptoplasty. The method gives optimal aesthetic results and reestablishes the respiratory function of the nose.     

Plastische rekonstruktive Chirurgie nach Verbrennungsverletzungen

The stage-adjusted therapy of thermal injuries is based on pathophysiologic mechanisms as well as functional and aesthetic requirements. Plastic reconstructive surgical approaches are highly important in the prevention of the frequent grave sequelae of thermal trauma and to achieve optimal functional rehabilitation and favourable outcome. In reconstructive surgery of burns operative goals are subdivided into acute, secondary reconstructive, functional and aesthetic indications. The achievement of early wound closure to preserve functional skin and soft tissue components is an essential part of acute reconstructive procedures. Functional reconstructive and aesthetic procedures supplement the conservative treatment modalities of the secondary phase of burn care with physical therapy, ergotherapy and psychological support.     

Segmental Reconstruction of the Face

BACKGROUND: Aesthetic facial reconstruction requires understanding regional anatomy and tissue movement and the ability to use innovatively the tissue adjacent to the defect to create a reconstruction that preserves the function of the area and the cosmetic facial units. OBJECTIVE: Facial reconstruction after Mohs micrographic resection of nonmelanoma skin cancer confined to one cosmetic unit was compared with reconstruction of two or more units using techniques to place scars at the junction of cosmetic units with combinations of local flaps and grafts. Acute complications, function, and final appearance of the reconstruction were evaluated. METHODS: During a 10-year period, 500 cases acquired prospectively had facial surgical defects repaired. Tissue was removed to place the closure line at the junction of cosmetic units and was mobilized from within one cosmetic unit with primary closure or local advancement, rotation, or transposition flaps. When the defect bridged cosmetic units, segmental repair was performed with combinations of flaps and grafts placing scars at the junction of cosmetic units. Segmental repair often combined advancement flaps to restore contours with full-thickness skin grafts to prevent distortion in areas with minimal loss of contour. Scars were more often unfavorably placed with single flap repair within a cosmetic unit. There was more flap loss with single flap repair of a single unit than with segmental facial repair using a combination of flaps and/or grafts. CONCLUSION: Segmenting the wound into smaller units reflecting the underlying cosmetic units of the face was useful to develop a reconstruction plan to replace tissue with similar tissue and to provide consistently satisfying aesthetic results. Facial contours were restored without distorting surrounding structures.     

Consecutive flap transfer for repairing massive soft tissue defects in the opisthenar with improved donor site closure

Objective：To explore a surgical model of utilizing consecutive free scapular flap and adjacent pedicled flap transfer for repairing massive soft tissue defects on the dorsum of the hand while minimizing the donor site morbidity.Methods：Six patients with massive soft tissue injuries on the opisthenar and forearm were treated with free scapular flaps.Afterwards,a pedicled flap adjacent to the donor site was transferred to cover the donor site defect by direct closure.Results：All six free scapular flaps survived without signs of infection.Three adjacent pedicled flaps presented minor signs of insufficient blood flow on the distal apex,which resolved after six weeks with only conservative therapy.All the incisions healed without other complications.At six-month follow-up,the patients regained full shoulder function.Conclusion：With the assistance of an adjacent pedicled flap,the scapular flap is a highly applicable approach in repairing massive soft tissue defects in the opisthenar.It can achieve positive outcomes in both reconstructive and aesthetic aspects.     

Functional facial reconstruction in a patient with severe burn sequelae with a prelaminated parascapular free flap based on a three-dimensional model: A case report

Significant evolution has been made concerning resuscitation and emergency management of severely burned patients, and nowadays most patients will survive and deal with burns sequelae. They constitute a reconstructive challenge, mainly because options and donor areas are frequently compromised, results are often limited, and other options should then be considered. A 27-year-old male patient with 55% total burn surface area, presented with severe facial disfigurement including ectropion, upper/lower lip retraction, and partial loss of the nose. In order to improve the patient's condition, autologous reconstruction was considered. The only unburned area in the body was the left dorsal region, and a three-stage reconstruction was planned using a paraescapular flap. In a first stage, an elective surgery was performed to identify and tag the recipient vessels in the neck. After 3 months, the prelamination process was initiated with the drawing of a facial model, and a nose and lips were opened inside the flap. This was based on a three-dimensional latex model as a print of the patient's face, which allowed us to calculate distances and estimate the length of the vascular pedicles. After 3 months, the flap (18 × 8 cm) was transferred and microvascular anastomoses were performed. No major complications were seen after surgeries, and after 28 months, an extremely important functional gain was obtained. Despite the number of surgeries required and less than optimal aesthetic results, this method may offer a satisfactory solution for complex acquired facial burn sequelae when other local or distant flap options are not available.     

Forehead reconstruction using a modified dual-plane A to T flap

Forehead defects often present myriad challenges for the reconstructive surgeon. Many options exist for forehead reconstruction, from primary closure to free flaps. To optimally match colour, contour and texture, the best approach replaces ‘like with like’. When primary closure is not possible due to size limitations, and colour or depth is not suitable for grafts, then locoregional flaps become the mainstay of repair. The authors present three cases in which a dual-plane modified A to T flap is used to reconstruct central and lateral forehead defects up to 8 cm in size with excellent aesthetic results. This technique applies principles of the periglabellar flap, with modifications designed to encompass larger defects as well as defects of the lateral forehead.     

Aesthetic vermilion reconstruction of a post-involuted hemangioma scar

The author describes a technique for vermilion reconstruction after excision of an involuted hemangioma scar in the upper lip in an adult female patient. Reconstruction was achieved by making use of all the available vermilion tissue remaining after a triangular excision of the scar. The incision is in the form of a horizontal “K” with extended limbs and repair by advancing and interdigitating the two medial and lateral triangular vermilion flaps with a final Z-shaped suture line. The advancement is like a modified double opposing Y–V plasty. This was complemented by a simple Z-plasty of the labial mucosa to correct an existing notch and deficiency of the free mucosal border. The aesthetic result was excellent; thus, its use can be considered when closing any similar defects resulting from scars or small benign lesion excisions.     

Microvascular Free Flaps in Early Reconstruction of Burns in the Hand and Forearm: Case Reports

In the reconstructive plastic surgery a free flap provides a one-stage method to achieve an optimal functional and aesthetic result. We report five acute burns or early contractions of the hand and forearm with free-flap reconstruction. In each case an attempt was made to design the flap to restore missing tissue components. We used three different musculocutaneous free flaps and two free skin flaps: a latissimus dorsi, a rectus abdominis and a rectus femoris renervated musculocutaneous flap, as well as a dorsalis pedis and a horizontal fasciocutaneous upper arm flap. In all five cases, the hand and wrist showed early restoration of function.     

Surgical options for reconstruction of the extensor mechanism of the knee after limb-sparing sarcoma surgery: an evidence-based review

Background  

Limb-salvage surgery remains current best practice for management of soft tissue and bony sarcomas about the knee, with the range of reconstructive options all providing reassuring levels of long-term survival and function. There is no current consensus as to the best method of reconstruction of the extensor mechanism of the knee (quadriceps–patellar complex), with a wide variety of options proposed. The techniques described in the literature include prosthetic reconstruction, soft tissue reconstruction (comprising reconstruction with pedicled muscle flaps or autogenous tendon grafts), and bony reconstructions (including vascularised fibula flaps). An evidence-based literature review assessing the available reconstructive options has not been undertaken.     

Instep free flap for plantar soft tissue reconstruction: indications and options

Pedicled instep flaps are frequently used in weight-bearing plantar reconstruction, but may not be available after severe foot injuries. Although free instep flaps offer a viable option, they have scarcely been reported. A posttraumatic plantar forefoot defect was reconstructed with a sensate, instep free flap, because local flaps were not available and defect size did not require a distant free flap, and the current literature was reviewed for therapeutic options. The instep free flap yielded an excellent functional and aesthetic long-term result. In the literature, pedicled instep flaps are advocated for moderate size defects of the weight-bearing heel and sole, while free flaps from distant sites are preferred for large defects. Although skin-grafted muscle flaps and fasciocutaneous flaps yield similar results, reconstruction by like tissues appears favorable. We suggest the instep free flap for weight-bearing plantar foot reconstruction, when pedicled instep flaps are not available and distant free flaps are avoidable.     

Aesthetic reconstructions of the leg after trauma

Lower extremity trauma often results in significant skin or contour deformities as a result of the tissues destroyed. Such deformities are poorly tolerated by most patients, especially younger women. To achieve a satisfactory aesthetic reconstruction, the surgeon must be familiar with the special anatomy of the lower extremity as well all the different reconstructive options at his or her disposal. Minor scars or contour deformities can be corrected by traditional methods of scar revision or serial excision. Tissue expanders or silicone implants have a somewhat limited role in the lower extremity as compared with elsewhere in the body. Most major defects require free flaps to replace the surface or contour. Because of the importance of aesthetic results in the legs, free flaps should be utilized more often during the original trauma surgery if their use is deemed necessary for aesthetic reasons (Case 6).     

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.     

Weichteildefekte als Komplikation nach Knieendoprothetik

Soft tissue defects after knee arthroplasty are a severe problem, which can even result in a loss of the prosthesis or the limb. Well-planned strategies are necessary for sufficient soft tissue reconstruction, resulting in optimal functional and aesthetic results.This report provides information on the classification of the tissue defects and the appropriate options for surgical reconstruction. Besides the basic therapy principles of immobilisation, débridement, planned lavages and antibiotic therapy, defect-dependent surgical techniques of reconstructive surgery are implemented. These include skin transplantation, local fasciocutaneous flaps, local pedicled muscle flaps and free flaps. For best results, interdisciplinary treatment by orthopaedic surgeons, plastic surgeons, microbiologists and physiotherapists is mandatory.