Palatal rotation-advancement flap for delayed repair of oroantral fistula: a retrospective evaluation of 63 cases.

OBJECTIVE: To review our 17-year clinical experience with delayed oroantral fistula repair by palatal rotation-advancement flap, and to report its advantages, disadvantages, and complications. STUDY DESIGN: The records of 63 patients with late oroantral fistula treated by palatal rotation-advancement flap from 1984 to 2002 were reviewed. Eleven had undergone unsuccessful closure with a buccal flap. Data recorded were patient age and sex, cause of fistula, signs and symptoms, interval from appearance of fistula to repair, fistula size, radiographic appearance, method of repair, and immediate and late complications. RESULTS: There were 35 women and 28 men aged 21 to 71 years (mean 50.3 years). Surgery was performed 3 months to 20 years after injury (mean 1.8 years). Twenty-four patients had acute maxillary sinusitis and 39 had chronic sinusitis. The main causes of oroantral fistula were extraction of the second and first molars and pathological lesions within the sinus. Average fistula size was 2.3 cm x 1.6 cm. Fifty-one repairs were preceded by Caldwell-Luc operation. All fistulas were successfully closed with the palatal rotation-advancement flap, with minimal complications on long-term follow-up. CONCLUSION: The palatal rotation-advancement flap is recommended for the late repair of oroantral fistula owing to its good vascularization, excellent thickness and tissue bulk, and easy accessibility; it also allows for the maintenance of the vestibular-sulcus depth. It is particularly indicated in cases of unsuccessful buccal flap closure.

Use of the SpaceMaker balloon dissector for repair of sacral pressure sores.

Most of the techniques that have been suggested for closure of sacral pressure sores use musculo-cutaneous flaps. We report our experience in three patients using the SpaceMaker balloon dissector. The dissector was inserted into the subgluteal maximus muscle plane to expand the muscle and overlying skin, thereby forming bilateral sliding and tension-free musculocutaneous flaps. The procedure is simple, safe, bloodless, and combines the advantages of advancement of a muscle flap and expansion.

[Diffuse lichen sclerosus et atrophicus involving the palms].

Lichen sclerosus et atrophicus (LSA) is an extremely rare condition which usually involves the genitalia. There are sporadic reports of diffuse LSA with hand involvement apparently the rarest. Although the clinical course of the disease is often benign, there may be widespread lesions, disabling joint contractures, and cutaneous malignancies. We report on a patient in whom diffuse LSA appeared in the sixth decade. The condition led to multiple aggressive squamous cell carcinoma in the upper limbs and other anatomic sites and severe deforming and disabling contractures of the fingers and palms which prevented the patient's use of his hands even for simple tasks. On the basis of our experience, we suggest the application of aggressive primary treatment for cutaneous lesions in LSA.

Fascial suspension mastopexy.

BACKGROUND: The objective of this study was to assess a new procedure for breast mastopexy, fascial suspension mastopexy. METHODS: Between December of 2001 and July of 2004, 52 patients (102 breasts) underwent fascial suspension mastopexy. Sixteen women had grade 1 ptosis (30 percent), 31 had grade 2 ptosis (60 percent), two had grade 3 ptosis (4 percent), two (4 percent) had breast asymmetry and underwent unilateral mastopexy, and one had pseudoptosis (2 percent). Of the 52 patients, 43 (83 percent) underwent fascial suspension mastopexy only, whereas nine patients (17 percent) underwent fascial suspension mastopexy combined with breast parenchymal excision of less than 120 g in each breast. Three patients (6 percent) underwent combined procedures. RESULTS: The complication rate was 7.7 percent (four patients). Two patients underwent conversion of the vertical scar into a horizontal scar. One patient underwent drainage of a hematoma 1 day after her operation, and one patient developed a hypertrophic scar. The average follow-up was 1.4 years, with the longest follow-up being 3.5 years. On a scale of 1 (very poor) to 10 (excellent), postoperative ptosis correction was rated as 8.8, breast symmetry as 8.4, postoperative upper pole fullness as 9.1, postoperative medial breast fullness as 7.8, and overall breast shape and contour as 8.6. CONCLUSIONS: Fascial suspension mastopexy is safe, simple, and versatile; does not require pectoralis major flap harvesting; and achieves an excellent suspension of breast parenchyma, creating a projected and rejuvenated breast shape with upper pole fullness and long-standing breast contour.

Mycobacterium ulcerans ulcers: a proposed surgical management algorithm.

Mycobacterium ulcerans (MU) is the third common mycobacterial infection after tuberculosis and leprosy. In endemic areas, MU ulcers should be considered in the differential diagnosis of any unusual or nonhealing lesion or ulcer. Diagnosis and treatment should be instigated promptly. Delay may lead to disfiguring or disabling scars. Surgical management, therefore, should aim towards early excision, with clear margins of the ulcer. We present 4 consecutive patients treated by our department within a 6-month period for MU ulcers. The presentation, diagnosis and surgical management are described. Based on our experience and after reviewing the literature, we have developed a surgical algorithm for the management of MU ulcers.

Can aesthetic facial reconstruction be judged in black and white?

Aesthetic considerations of the face need to be evaluated in real-life full color. Staged contouring and insetting of a transferred free flap is sometimes required. This consists of debulking, thinning, and reshaping the flap. If the facial area is involved, however, color mismatch of a free flap represents an aesthetic challenge for the reconstructive surgeon, and often is missed with black and white photos. This article reports on a patient in whom a first dorsal metatarsal cutaneous free flap was used to reconstruct a full-thickness defect in the lateral orbit including upper and lower eyelids and outer canthus. The flap resulted in an unacceptable aesthetic outcome consisting of a bulky, hypopigmented deformity. Revisional surgery consisted of debulking the free flap and resurfacing it with a full-thickness skin graft taken from the postauricular area. This resulted in a pleasant, thin, and better color match reconstruction. The advantages of the first web space of foot free flap to the eyelid are well described. The authors are of the opinion that the flap does not match the color of the eyelid region, and therefore suggest that if used, prefabrication or a second procedure is needed. Evaluation of the postoperative results needs to be in color because black and white can mask the final aesthetic result.

Simple technique for inverted nipple correction.

Several different techniques have been developed and currently are in use for correction of the inverted nipple. The diversity of techniques indicates the lack of a good, sustainable, and durable solution for this quite common problem. This report discusses a new technique in which two flaps are inserted beneath the nipple through a small tunnel. The advantages of this procedure are its simplicity, the creation of a durable support for the nipple, and the lack of transverse scars in the areola surrounding the nipple. The follow-up period up to 4 years for 11 patients (18 nipples) demonstrates the validity of this technique.

Rotation flap of the anterior rectus abdominis sheath for hernia prevention in TRAM breast reconstruction.

Prevention of hernia or bulge of the abdominal wall after TRAM breast reconstruction has been a challenge for the reconstruction surgeon. Different techniques have been described to avoid this complication. The use of anterior rectus abdominis sheath (ARAS) for the repair of various abdominal wall hernias has been well described in the literature and is the basis of the authors' technique. The authors present the use of ARAS flap in TRAM breast reconstruction. It is a simple and safe technique using autologous tissues for hernia or bulge prevention.

Breast-areola-nipple proportion.

Studies of breast volume and size have failed to take into account the aesthetic value of the nipple-areola-breast proportion. These data are important to plastic surgeons in planning breast reduction, augmentation, and reconstruction. In the current study, the anatomic size of the nipple, areola, and breast was measured in 37 women aged 20 to 64 years, and their proportions were calculated. The areola-breast and nipple-areola proportions were 1:3.4 and 1:3, respectively. The natural nipple-areola-breast proportion is approximately 1:3. This study provides a general guideline for plastic surgeons for planning breast surgery with optimal aesthetic results.

Role of physicians and patients in the diagnostic delay of cutaneous malignant melanoma.

The incidence of cutaneous malignant melanoma is increasing constantly. The most accurate prognostic factor of primary melanoma is thickness of the lesion according to Breslow. Information and screening campaigns for early diagnosis of melanoma are based on the assumption that tumor thickness is the consequence of a delay in diagnosis. However, the correlation of delay in diagnosis with prognosis remains controversial. In this report, the authors investigated the role of the physician and the patients in diagnostic delay in melanoma and areas in which improvement is needed. The reduction of the time to diagnosis in specific population groups may improve the prognosis of melanoma.

Subdermabrasion in the treatment of post-burn facial hypertrophic scars.

Hypertrophic scars cause great discomfort to the patient and pose a challenge for the reconstructive surgeon. This is particularly true in the facial area. Optimal function and aesthetic appearance are the main goals of reconstruction. We suggest an adjunct to the surgical management of facial hypertrophic scars which involves abrasion of the subdermal plane. The technique consists of removal of all scarred skin from the aesthetic unit, dermabrasion of subcutaneous tissues, including the muscular surface (subdermabrasion), and a full thickness skin grafting. This technique was applied in a young patient with hypertrophic burn scars of the chin. Biopsy confirmed our basic assumption that hypertrophic scars extend into the muscular plane.