Versatility of Pedicled Perforator-Based V-Y Advancement Flaps for Reconstruction of the Upper Limb: A Case Series and Review of the Literature.

INTRODUCTION: The aim of any reconstruction is to provide a robust and cosmetically pleasing result that does not significantly alter function. We describe our experience of using the V-Y principle in advancement flaps designed around a distinct perforator to reconstruct soft tissue defects of the upper limb. The shortcomings of fasciocutaneous and fascial flaps requiring skin grafting can be eliminated. METHODS: This was a 10-year retrospective review of patients who had V-Y flaps based on a distinct perforator for defects of the shoulder, axilla, arm, elbow, forearm, wrist, and hand. Defects of the digits and thumb were excluded. RESULTS: There were 59 flaps in 52 patients with an average age of 44 years (18-72 years). Skin malignancy was the most common primary etiology. The average defect size was 35 cm (9-80 cm). There were no total flap failures; however, there were 4 partial losses, which healed by secondary intention. Seven flaps had to be explored for the hematoma evacuation. CONCLUSIONS: The use of V-Y flaps based on distinct perforators in the upper limb retains limb aesthetics, allows early mobility and is a safe and reliable technique.

Tuberous breast deformity: A modified technique for single-stage correction.

INTRODUCTION: Tuberous breast deformity is one of the most challenging congenital breast anomalies. Severe forms present as hypoplasia of lower medial and lateral quadrants and breast base constriction. We present a modified technique based on redistribution of breast tissue for single-stage aesthetic correction of this deformity. MATERIAL METHODS AND SURGICAL TECHNIQUE: The technique is based on Lejour's method of single vertical scar breast reduction. The breast tissue is divided into three superiorly based pedicles. However, instead of joining the three pedicles, they are spread to redistribute tissue to quadrants which are deficient. This technique is combined with implant insertion if the breast volume is deficient or mastopexy if there is significant ptosis. The level of nipples is matched to achieve symmetry and areolar reduction done where indicated. We have used this for six patients with Type I/II/III (von Heimburg, 2000) tuberous breast deformity. RESULTS AND DISCUSSION: The aesthetic results have been very good in terms of shape, volume, symmetry and patient satisfaction. A historical summary of the development of techniques for correction of tuberous breast is presented along with description of our method and its results.

Segmental V-Y flaps for reconstruction of longitudinal defects in the digit.

Longitudinal defects of the finger that extend beyond 1 phalangeal segment such as wounds that expose the flexor tendon are challenging to reconstruct because of their elongated shape. We present the use of segmental V-Y flaps to reconstruct these defects. These are ≥2 V-Y flaps orientated transversely and advanced segmentally to close the defect avoiding a linear scar. Nineteen patients had soft-tissue defects of the digits successfully reconstructed with segmental V-Y flaps in this retrospective case series. There were no total or partial flap failures and all flaps retained sensation. Segmental V-Y flaps are a safe method for reconstructing digital defects and are particularly useful in the reconstruction of longitudinal defects. They have the advantages of being homodigital, sensate, technically easy; allow direct closure of the donor site and break up linear defects that might otherwise lead to contractures.

A method for protecting the anastomosis in deep inferior epigastric artery perforator flap breast reconstruction.

In cases of microvascular breast reconstruction with deep inferior epigastric artery perforator (DIEP) flaps, many authors often express concern about possible trauma to the microanastomosis from the suction drain routinely placed in the wound at the end of the case. The senior author has devised and practiced for many years a novel technique to protect the anastomosis from this potential trauma in breast reconstructions. This technique involves harvesting a "sleeve" of scarpa's fascia in the direction of the planned orientation and inset of the flap pedicle. In our experience, this technique is effective and robust, and we would like to recommend this to others for use in their DIEP flap reconstructions.

Retrograde dissection of the vascular pedicle of deep inferior epigastric artery perforator (DIEAP) flap.

The deep inferior epigastric artery perforator (DIEAP) flap became the gold standard in breast reconstruction, but the dissection has a steep learning curve and the most demanding stage is the intramuscular dissection of the vascular pedicle. We present a retrograde technique to dissect the deep inferior epigastric pedicle that permits completion of the dissection and check the viability of the flap on one side before progressing to the other, which can be used as a lifeboat. We consider this technique reliable, safer than the conventional technique, and a brilliant training model in DIEAP flap harvesting.

Innovative techniques: a novel technique for intraoperative estimation of breast implant size in aesthetic and reconstructive breast surgery.

The estimation of breast implant size in both aesthetic and reconstructive surgery often is a matter of clinical and intraoperative trial and error, with subsequent differences in the resulting postoperative outcomes. Numerous techniques for preoperative estimation of implant size are in current use. However, although such techniques are inexpensive, they often are inaccurate and prone to error on the part of both the surgeon and the patient. Techniques for intraoperative estimation of breast implant size involve either the use of trial sizers or the surgeon's own guesswork based on the preoperative consultation. A novel technique is presented that uses commonly available surgical gauze swabs. The senior author has applied this technique in both aesthetic and reconstructive breast surgery for many years. This easily reproducible method is inexpensive and produces reliable and highly satisfactory results.

Fasciocutaneous flaps based on fascial feeder and perforator vessels for defects in the patellar and peripatellar regions.

BACKGROUND: Soft-tissue reconstruction in the patellar and peripatellar regions is a challenging problem. Restoring the original thin, pliable, and tough skin properties is a necessary demand, if appearance and knee function are not to be compromised. Local tissue provides the closest match to the original, but limited availability can restrict the reach of conventional local flaps and, more often than not, produce donor sites that need coverage of their own. METHODS: A retrospective study was performed over a 7-year period (from 1995 to September of 2002) using local fasciocutaneous flaps, based on fascial feeder and perforator vessels, to reconstruct a variety of patellar and peripatellar defects. Fifteen patients with a mean age of 62 years (range, 18 to 86 years) were reviewed. RESULTS: Early complications were minimal, with only one patient (wound dehiscence) requiring a further procedure. All patients achieved a good final outcome. CONCLUSIONS: The authors found the fascial feeder- and perforator-based local fasciocutaneous flap in the patellar and peripatellar regions to be a simple and reproducible technique to perform. By islanding local flaps on perforator/fascial feeder vessels, greater mobility is achievable, when compared with conventional flaps. Combining local fascial feeder- and perforator-based flaps with V-Y advancement minimizes donor-site complications. On this basis, well-matched local tissue can be used for reconstruction in the patellar and peripatellar areas, with minimal compromise to either appearance or function or both.

An anatomical method for re-siting the umbilicus.

The umbilicus is the only normal scar on the body and it is the most noticeable scar following abdominoplasty and TRAM or DIEP flap procedures. We describe a technique for resiting the umbilicus that attempts to recreate the anatomical structure by attaching the superficial fascia to the periumbilical skin to produce a fullness around the depression in which the umbilicus sits. This is aesthetically desirable and avoids the uncomfortable tethering of the umbilicus to the rectus sheath associated with other techniques.

Our experience using the vertical rectus abdominis muscle flap for reconstruction in 12 patients with dehiscence of a median sternotomy wound and mediastinitis.

The vertical rectus abdominis (VRAM) flap has been used for reconstruction of sternal defects, particularly in the inferior third, since it was first described 20 years ago. We describe 12 patients with mediastinitis or chronic sternal osteomyelitis after sternotomy treated between 1994 and 1997, nine performed at the Royal Hospitals Trust, London. Sternal osteomyelitis and mediastinitis after median sternotomy is an uncommon (0.4%-8.4%) but often fatal condition. Vascularised pedicles are the treatment of choice, and VRAM flaps were used in all cases. We report good long-term outcome with a follow up of 2-5 years, and no long-term morbidity relating to the VRAM reconstruction. We had only one partial failure of a flap. The operations were largely done in hospitals away from the plastic surgical unit in extremely sick patients, which illustrates the importance of multidisciplinary management to reduce hospital stay, mortality, and morbidity. We argue that early involvement of plastic surgical specialists in the treatment of sternal dehiscence is essential to ensure a successful outcome.