Utilization of a Newly Designed Asymmetric Dorsal Gull Wing Flap for the Treatment of Postoperative Web Creep After Syndactyly Surgery.

BACKGROUND: Web creep is the most common long-term complication requiring revision after syndactyly surgery; however, few methods have been reported. The aim of this study was to introduce a newly designed asymmetric dorsal gull wing flap to reconstruct web for the postoperative web creep. METHODS: A retrospective analysis was performed for 20 patients from January 2016 to May 2019. Sex, age, original malformations, original surgical procedure, complications, time between the 2 operations, operation records, preoperative and postoperative photographs, and Withey score were reviewed. RESULTS: Eleven boys and 9 girls with average age of 60.65 ± 44.76 months underwent revision. Twenty-nine web spaces were affected (web creep, 12 cases; web creep and scar contracture, 17 cases). The original surgical procedure consisted of syndactyly separation in 15 cases, syndactyly separation with a full-thickness skin graft in 5 cases. There was 1 case of postoperative infection. All patients received an asymmetric dorsal gull wing flap and a zigzag incision, 15 patients received an additional full-thickness skin graft. The average time interval between the 2 operations was 34.60 ± 35.94 months. The follow-up time was 34.30 ± 20.73 months. No complications were noted, none of the patients redeveloped web creep. The median values for web creep, flexion-extension deformity, total Withey scores in the postoperative period were significantly lower than the preoperative values. The appearance and function of all digits were good. CONCLUSIONS: The asymmetric dorsal gull wing flap is a good choice for web reconstruction when web creep is caused by syndactyly surgery.

Single-Stage Separation of 3- and 4-Finger Incomplete Simple Syndactyly With Contiguous Gull Wing Flaps: A Technique to Minimize or Avoid Skin Grafting.

PURPOSE: Staged separation of 3- and 4-finger syndactyly is commonly performed owing to concerns about vascular supply to the central digit and availability of flap skin. We performed single-stage separation of patients with incomplete syndactyly of multiple digits with adjacent contiguous dorsal gullwing flaps and avoided skin grafts in the majority of cases. METHODS: Seventy-four webs of 31 patients with more than 2-finger incomplete syndactyly were included. Median age at surgical separation was 12 months (range, 5-123 months). All cases were incomplete syndactyly that did not extend to the fingernail level, with no bony involvement. A dorsal gullwing flap was used for all cases, which reconstructed the interdigital webs and partly covered the lateral side of the proximal phalanx. The technique relies on perfusion of the flap through the dorsal metacarpal artery perforator to aid flap mobility and double radial and ulnar z-plasties on each side of the flap to aid flap advancement. Skin grafts were needed if there were any remaining skin defects. RESULTS: In 30 of 31 cases, a single-stage procedure was accomplished. One case was staged owing to abnormal digital arterial anatomy found on exploration. No skin graft was required in 21 out of 31 patients (67.7%). Median postoperative follow-up was 12 months (range, 6-36 months). All finger web depths were normal or slightly deepened. CONCLUSIONS: One-stage separation for 3- and 4-finger syndactyly with a dorsal gullwing flap is feasible and safe as long as at least 1 proper digital artery is preserved in each finger. The need for skin grafting is minimized. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Surgical correction of radially deviated Wassel type III thumb polydactyly: a prospective case series.

We report our experience with correction of radially deviated Wassel type III thumb polydactyly. After comprehensive assessments from preoperative radiographs, physical examinations and intraoperative reports, we corrected the metacarpophalangeal joint in 34 cases of radially deviated Wassel type III thumb polydactyly. Opening-wedge osteotomies combining bone graft and soft tissue reconstruction were used in 28 cases and soft tissue reconstruction only in six cases. Absorbable sutures were used instead of traditional Kirschner (K)-wires to fix the bone grafts. Patients were followed up for 12-78 months (mean 47 months). According to the Tada scoring system, 25 patients achieved good results, seven fair results and two poor results. Our modified technique for correcting radially deviated Wassel type III thumb polydactyly yielded satisfactory results. Continued follow-up and further studies will contribute to a better understanding of the long-term efficacy and potential refinements of this technique.Level of evidence: IV.

Cartilage transposition and anchoring: A surgical technique for the reconstruction of congenital tragal malformation in children.

BACKGROUND: Because of the various types and complexity of congenital tragal malformation, tragal reconstruction is one of the most challenging objects in otoplasty. This study aimed to introduce a surgical technique of cartilage transposition and anchoring that was used to construct a cartilage framework for natural tragus reconstruction. METHODS: A retrospective study was performed for 49 patients who underwent cartilage transposition and anchoring from January 2020 to August 2022. Gender, age, malformation, complication, operation record, preoperative and postoperative photograph, score of esthetic outcomes (4 = excellent, 3 = good, 2 = fair, 1 = poor), and Vancouver Scar Assessment score were reviewed. RESULTS: Twenty-six boys and 23 girls with an average age of 35.79 ± 32.97 months underwent revision. The follow-up time was 13.87 ± 6.57 months. No complications were noted. The average score of esthetic outcomes and the Vancouver Scar Assessment score were 3.94 and 0.08 in the postoperative period, respectively. The overall effect was satisfactory. CONCLUSIONS: Postoperative results showed that cartilage transposition and anchoring were effective techniques for the reconstruction of congenital tragal malformation. The use of cartilage and fascia tissue around the tragus to fill up the depression and reconstruct the tragus were the emphases. The remolded tragus showed less scars and had the similar appearance like the natural tragus of the patient.

[Treatment of mild hemifacial microsomia in children by autologous nano-fat mixed granule fat transplantation].

Objective: To investigate the effectiveness of autologous nano-fat mixed granule fat transplantation in the treatment of facial soft tissue dysplasia in children with mild hemifacial microsomia (HFM). Methods: A total of 24 children with Pruzansky-Kaban type Ⅰ HFM were admitted between July 2016 and December 2020. Among them, 12 children were treated with autologous nano-fat mixed granule fat (1∶1) transplantation as study group and 12 with autologous granule fat transplantation as control group. There was no significant difference in gender, age, and affected side between groups ( P>0.05). The child's face was divided into region Ⅰ(mental point-mandibular angle-oral angle), region Ⅱ (mandibular angle-earlobe-lateral border of the nasal alar-oral angle), region Ⅲ (earlobe-lateral border of the nasal alar-inner canthus-foot of ear wheel). Based on the preoperative maxillofacial CT scan+three-dimensional reconstruction data, the differences of soft tissue volume between the healthy and affected sides in the 3 regions were calculated by Mimics software to determine the amount of autologous fat extraction or grafting. The distances between mandibular angle and oral angle (mandibular angle-oral angle), between mandibular angle and outer canthus (mandibular angle-outer canthus), and between earlobe and lateral border of the nasal alar (earlobe-lateral border of the nasal alar), and the soft tissue volumes in regions Ⅰ, Ⅱ, and Ⅲ of healthy and affected sides were measured at 1 day before operation and 1 year after operation. The differences between healthy and affected sides of the above indicators were calculated as the evaluation indexes for statistical analysis. At 1 year after operation, the parents, the surgeons, and the nurses in the operation group made a self-assessment of satisfaction according to the frontal photos of the children before and after operation. Results: The study group and the control group were injected with (28.61±8.59) and (29.33±8.08) mL of fat respectively, with no significant difference ( t=0.204, P=0.840). After injection, 1 child in the control group had a little subcutaneous induration, and no related complications occurred in the others. All children in both groups were followed up 1 year to 1 year and 6 months, with an average of 1 year and 4 months in the study group and 1 year and 3 months in the control group. At 1 year after operation, the asymmetry of the healthy and affected sides improved in both groups; the satisfactions of parents, surgeons, and nurses in the study group were all 100% (12/12), while those of the control group were 100% (12/12), 83% (10/12), and 92% (11/12), respectively. The differences between healthy and affected sides in mandibular angle-oral angle, mandibular angle-outer canthus, earlobe-lateral border of the nasal alar, and the soft tissue volume in 3 regions of the two groups after operation were significantly smaller than those before operation ( P<0.05). There was no significant difference in the above indexes between the two groups before operation ( P>0.05). After operation, all indexes were significantly lower in study group than in control group ( P<0.05). Conclusion: Autologous nano-fat mixed granule fat transplantation and autologous granule fat transplantation can both improve the facial soft tissue dysplasia in children with mild HFM, and the former is better than the latter.

Surgical management of facial congenital melanocytic nevi: Experiences and outcomes at an academic center.

BACKGROUND: Congenital melanocytic nevi (CMN), benign pigmented birthmarks caused by the mutation of melanocytic cells during embryofetal development, can cause aesthetic problem when it is located on the face. Surgical managements of facial CMN are required by both pediatric patients and their parents. Surgical management, including excision or staged excision, skin grafting, dermabrasion, tissue expansion or multiple re-expansion combined with flaps transplantation, have been reported previously. However, a systematical report about facial CMN management is still scarce. OBJECTIVE: Herein, we have reviewed our serious of patients with facial CMN, noting their size, location, and histological examination, summarizing the surgical relation behind reconstructive and cosmetic treatment, and proposing a newly classification for facial CMN among pediatric patients, hoping to share a useful surgical algorithm for these lesions on this specific part. CONCLUSION: Proper surgical strategy should be made based on the size and location of the nevi and the adjacent relationship between the location and relaxed skin tension lines and aesthetic units. Postoperative ant-scar treatment improves aesthetic outcomes. With our experience and surgical algorithm about facial CMN surgery, a favorable outcome can be achieved.

Surgical repair for transverse facial cleft: two flaps with a superiorly rotated single Z-plasty lateral to the commissure.

Various techniques have been performed for repairing transverse facial clefts. This study aimed to investigate an optimal method for repairing transverse facial clefts. Twenty-seven patients from 2008 to 2017 were evaluated. Their mean age at repair was 6.7 months with a follow-up period of 6 months to 10 years. A method using an inferior lip-based triangular mucosa flap and a superior lip-based rectangular vermilion-mucosa flap was designed for transposition. The orbicularis oris was reconstructed by using everting mattress suture. The skin was sutured using linear cutaneous closure with a single superiorly rotated Z-plasty lateral to the commissure. A postoperative symmetrical commissure was obtained owing to complete contraction with the new commissure directed 2 or 3 mm medial to the symmetrical point on the lips individually for the 27 patients. Lateral displacement of the reconstructed commissure was not observed. The patients showed a plump and symmetrical cheek on the cleft side. Twenty-one patients with hemifacial microsomia achieved a prominent improvement compared with their preoperative appearance, although the postoperative cheeks still did not show fullness because of the lesser facial tissue on the cleft side. In the early follow-up period, most patients showed a minimal scar during movement. However, the scar became thinner and symmetrical oral movement was achieved over time. This method obtained a natural oral movement without a conspicuous scar and was reliable and remarkable for the postoperative appearance of commissural symmetry. We conclude that this is an optimal method to repair transverse facial clefts.

Large defects in aplasia cutis congenita treated by large-sized thin split-thickness skin grafting: long-term follow-up of 18 patients.

OBJECTIVE: To evaluate the long-term results of using surgical large-sized thin split-thickness skin grafting to treat aplasia cutis congenita (ACC) in neonates. METHODS: This study included 18 ACC neonates with large skin defects who underwent large-sized thin split-thickness skin grafting at our hospital from March 2002 to November 2011. The size of the lesion was >10% of the total body surface area (TBSA) in 16 patients, 7% of TBSA in one patient, and 3% of TBSA in another patient. The size of the skin graft was designed to be equal to or slightly larger than the size of the lesion. RESULTS: Skin grafts in 16 patients who were followed for periods of 6 months-7 years after surgery showed good survival; however, two patients were lost to follow-up. The wound healed completely without scarring in five patients. One of the five patients who healed without scarring had failed previous conservative treatment. Several mild hypertrophic scars occurred in one patient, and flat, thin, shiny, soft, parchment-like scars were noted in five other patients. Dark red, hard, raised hypertrophic scars occurred in five patients who had partial necrosis in the skin graft after surgery. CONCLUSION: A large-sized thin split-thickness skin graft can be used to effectively close a wound and permit healing to occur with reduced long-term scarring. This procedure is ideal for treating skin defects in patients with ACC.

[Analysis of the difference between the appearance and the bony structure in the polysyndactyly of the fifth toe fused with the fourth toe].

OBJECTIVE: To investigate difference between the appearance and the bony structure in the polysyndactyly of the fifth toe fused with the fourth toe. METHODS: From Jan. 2009 to Jan. 2014, 54 patients (65 feet) with polysyndactyly of the fifth toe fused with the fourth toe were treated. The appearance, X-ray and intraoperative finding were recorded and compared to classify the deformity. Then the extra toe was excised and syndactyly was separated. The malalignment and brachydactyly of the sixth toes were corrected simultaneously. RESULTS: According to the bone and joint type, the fifth toes were neoplastic toes without joints in 17 feet, or had poor bony and joint alignment with the sixth toes in 48 feet. So the fifth toes were excised in all the cases. The patients were followed up for 1 month to 4 years. The oblique deformity of sixth toes were corrected completely with improved length. CONCLUSIONS: The polysyndactyly of the fifth toe fused with the fourth toe should be classified to design the excised toe (usually fifth toe) and correction procedure. The appearance and bony joint recovery are both important.

[Reconstruction finger web with dorsal two wing-shaped flap for the treatment of congenital syndactyly].

OBJECTIVE: To explore the clinical effect of using dorsal two wing-shaped flap to reconstruct finger web for treatment of congenital syndactyly. METHODS: This technique has been used in 19 children with congenital syndactyly. At the dorsum, a flap with V-shaped tip and two wing-shaped pedicle were designed and was just sewed up with an anchor-shaped incision at the palm. The web was primarily reconstructed without skin graft at base of fingers. Distal end of fingers were separated by using serrated flap and were closed after removal of fatty tissue. At some cases with tight skin connection. The defect area at lateral and distal end of fingers was closed by small pieces of skin graft. RESULTS: All the webs were reconstructed primarily without skin graft at the base of fingers. 7 cases with tight skin connection had small pieces of skin graft at lateral and distal end of fingers. Primary healing was achieved in all cases. After 1 to 6 months of follow-up, both the appearance and function were satisfactory without conspicuous scar. The reconstructed finger webs were in normal depth and width. CONCLUSIONS: Primary web space can be achieved by dorsal two wing-shaped flap without skin graft at base of fingers. It is one of the best choices for treatment of congenital syndactyly.