Perforator-Based Pedicled Cross-Leg Flaps in Pediatric Patients: A New Idea to Increase Flap Reach.

BACKGROUND: Distal lower limb reconstruction is one of the most difficult and challenging tasks in plastic surgery. Despite the continuous advances in microsurgical techniques, pedicled cross-leg flaps still have a major role particularly in pediatric patients. Many techniques have been described to maximize the potential of the cross-leg flaps. The introduction of fasciocutaneous flaps has provided more potentials and made lower leg reconstruction easier and more successful. The description of perforator system in the leg has also made a revolution in the regional reconstruction. In this report, we present a new modification that increases the reach and facilitates the inset of the flaps. METHODS: The flap is taken from the posteromedial skin of the middle third of the leg. The design is determined by the location, size, and shape of the defect. The base of the flap should contain at least 2 perforators located by Doppler device. After elevation of the fasciocutaneous flap, 2 back cuts are performed in the upper and lower edge of the flap base preserving the 2 previously located perforators. RESULTS: Fifty patients, 32 males and 18 females, were reviewed and presented. Age of the patients ranged from 4 to 13 years and the defect size ranged from 20 to 130 cm. All flaps survived with 3 flaps had mild marginal ischemia, 2 flaps had mild infection, and 1 flap had partial dehiscence. CONCLUSIONS: Back cuts made at the edges of the base of a cross-leg flap, preserving the feeding perforators, can increase the flap reach without jeopardizing its viability. It is also an easy to do technique and does not require any extra equipment or time.

Saethre-Chotzen Syndrome: A Report of 7 Patients and Review of the Literature.

INTRODUCTION: Saethre-Chotzen syndrome is a genetic condition characterized by craniofacial and limb anomalies, with craniosynostosis (mainly coronal) being the most frequent craniofacial finding. Cranial and facial deformities can be extremely variable requiring individualization of treatment strategies. We present our case series to highlight clinical findings, treatment philosophy, and challenges facing Saethre-Chotzen patients. METHODS: A retrospective review was performed on records of patients given a diagnosis of Saethre-Chotzen syndrome at the University of California Los Angeles (UCLA) Craniofacial Clinic (n = 7) between 1980 and 2010. Patients with complete records were included in this study, and review of demographic data, clinical findings, surgical interventions and postoperative follow-up, and stability were performed. RESULTS: Seven patients (1 male and 6 female) were included in this study. The average age at which the patients were first seen was 6.5 years. Suture involvement was bicoronal (n = 6) and unicoronal (n = 1). There was 1 patient having superimposed metopic synostosis, and there was another patient having Kleeblattschädel deformity. Previous procedures performed for patients before establishing care at UCLA were strip craniectomy (n = 2) and fronto-orbital advancement (n = 2). All patients (n = 7) had fronto-orbital advancements at UCLA. Other skeletal operations included the following: redo forehead advancement and contouring (n = 3), monobloc advancement (n = 1), and LeFort III distraction (n = 1). Five patients reached skeletal maturity, and 2 patients received LeFort I advancement for class III malocclusion, one of which also required a bilateral sagittal split osteotomy of the mandible. CONCLUSION: Clinical presentation and severity of deformity in Saethre-Chotzen syndrome are variable. Our current report reviews our treatment strategies and illustrates the predominance of cranial and upper face deformities and frequent need for redo surgeries to address forehead asymmetry in this group of syndromic craniosynostosis patients.

Congenital Heminasal Aplasia: Clinical Picture, Radiological Findings, and Follow-up After Early Surgical Intervention.

OBJECTIVE: This report presents an extremely rare case of heminasal aplasia or hemi-arhinia with only about 80 cases reported so far. The exact etiology and mechanism of development of heminasal aplasia are still unknown. Furthermore, the rarity of this anomaly makes its reconstruction a surgical challenge with a diversity and controversy on the timing and technique of such reconstructive procedures. METHOD: Reconstruction was performed when the child was 3 months of age. The missing heminose was reconstructed by a superiorly based nasolabial flap. RESULTS: On early follow-up visits, there was retraction of the flap. However, the parents were satisfied by the result to the degree that the girl did not show for follow up after 3 years of surgery until she is 13 years and even now her parents do not want any further surgery. CONCLUSION: Early surgical reconstruction is recommended even if revisions may be needed later.

Recommendations for the Development and Reform of Microtia and Atresia Services.

BACKGROUND: The initial step in setting up standardized microtia-atresia service is investigating the current status of the service and comparing this to internationally recognized guidelines or care standards. In many countries, documented information about microtia care is lacking. This study is an initiative to guide reform efforts of national microtia service in any country. The UK care standards for microtia-atresia can be a useful model to help set up a comprehensive microtia-atresia service. METHODS: The authors conducted a survey to investigate different aspects of microtia service in Egypt. The major plastic surgery centers (n = 22) were surveyed by a structured questionnaire. The results were compared with the UK care standards for microtia-atresia to identify the aspects that need improvement. Thorough analysis of the main problems in microtia-atresia service is presented. RESULTS: The authors found that microtia service is fragmented between the surveyed centers with 65% of the centers treating less than 10 microtia cases annually. Multiple surgeons are responsible for ear reconstruction in 90% of centers and only 25% of them practise a multidisciplinary team approach. None of the centers uses validated tools of aesthetic or psychological patient-reported outcome measures. RECOMMENDATIONS: These 5 recommendations are the keys to reforming microtia service in any country:(1) Establishing nationally designated centers to concentrate the required expertise.(2) Assigning fewer high-volume surgeons to optimize the surgical outcomes.(3) Providing treatment by experienced multidisciplinary teams.(4) Using validated tools of patient-reported outcome measures.(5) Collecting and keeping standardized records for regular audit and intercenter studies.

Management of Rare Craniofacial Anomalies With Soft Tissue Reconstruction on Humanitarian Missions.

In poor communities, patients may suffer from health problems requiring special management that cannot be provided locally because of lack of equipment and/or expertise. Children with craniofacial anomalies represent one of these challenging problems. Visiting medical missionary teams have attempted to address these issues for a long time. This article highlights healthcare difficulties in one of the third-world countries with personally based trials for providing free surgeries in tough situation and with hardly available diagnostic and therapeutic facilities. During 15 years, >5000 surgeries were performed in repeated missionary visits. The majority of operations were to correct post-burn complications or to repair cleft lip and/or palate. Of 33 cases of rare craniofacial anomalies, 14 patients were treated with simple soft tissue reconstruction without interference in the underlying bone deformities. This may not be optimal; however, it can give good results even with the limited resources.

Management of cleft lip and palate in Egypt: A National survey.

BACKGROUND: Variable protocols for the management of cleft lip and/or palate (CLP) patients are currently used. However, to our knowledge, there are no previously published data about cleft management and practice in Egypt. MATERIALS AND METHODS: One-hundred questionnaires were distributed to cleft surgeons attending the annual meeting of the Egyptian Society of Plastic and Reconstructive Surgeons in March 2016 to investigate timing, techniques and complications of cleft surgery. Seventy-two colleagues returned the questionnaire, and the data were analysed using Microsoft Excel software. RESULTS: The majority of cleft lip cases are repaired between 3 and 6 months. Millard and Tennison repairs for unilateral cleft lip, while Millard and Manchester techniques for bilateral cleft lip are the most commonly performed. Cleft palate is usually repaired between 9 and 12 months with the two-flap push-back technique being the most commonly used. The average palatal fistula rate is 20%. Pharyngeal flap is the method of choice to correct velopharyngeal incompetence. Polyglactin 910 is the most commonly used suture material in cleft surgery in the country. Multidisciplinary cleft management is reported only by 16.5% of participants. CONCLUSION: Management of CLP in Egypt is mainly dependent on personal preference, not on constitutional protocols. There is a lack of multidisciplinary approach and patients' registration systems in the majority of centres. The establishment of cleft teams from the concerned medical specialties is highly recommended for a more efficient care of cleft patients.

Cleft Lip and Palate: An Experience of a Developing Center in Egypt.

BACKGROUND: Cleft lip and palate is the most common congenital anomaly in the head and neck region. These clefts are not just a distortion of the normal appearance, but they may impose a major influence on the whole patient's life, both functionally and psychologically. Clefts affect feeding, teething, hearing, speech, and social communication. The incidence of cleft lip and palate is variable in different countries and different communities. The surgical correction of cleft lip and palate went through many evolutions, but still there is no single universal protocol of repair; however, many European countries have adopted national protocols and have established cleft centers for the management and follow up of affected population. PATIENT AND METHODS: In this study, the problem of cleft lip and palate in the area of upper Egypt was presented through the records of patients admitted to the Department of Plastic Surgery at the Sohag University Hospital in a 15-year period (2001-2015). RESULTS: A total number of 1318 patients, who were admitted and had been operated upon in our department, were included in this study. The majority of patients presented to the department with a primary disease, yet 14.7% (194 patients) of them were first presented for a secondary interference after being operated upon elsewhere. A total number of 1923 surgical procedures were performed.

Survival of Nasal Tip Flap on Only the Columellar Attachment.

The nose has a robust blood supply derived from both internal and external carotid arteries. The main blood supply of the nasal tip and skin is derived primarily from the lateral nasal arteries, with a variable contribution from the columellar arteries. We present a patient with cut nose resulting from a homicidal attack in which the lower two-thirds of the nose was severed starting at the bony-cartilaginous junction of the dorsum of the nose down to the tip of the nose. The skin-cartilage flap was attached only to the columella and to the caudalmost 3 mm of the left ala nasi. The detached skin-cartilage flap was replaced and sutured anatomically, and the flap completely survived in spite of cutting of both lateral and dorsal nasal arteries.

Congenital hand anomalies in Upper Egypt.

BACKGROUND: Congenital hand anomalies are numerous and markedly variant. Their significance is attributed to the frequent occurrence and their serious social, psychological and functional impacts on patient's life. PATIENTS AND METHODS: This is a follow-up study of 64 patients with hand anomalies of variable severity. All patients were presented to Plastic Surgery Department of Sohag University Hospital in a period of 24 months. RESULTS: This study revealed that failure of differentiation and duplication deformities were the most frequent, with polydactyly was the most common anomaly encountered. The mean age of presentation was 6 years and female to male ratio was 1.46:1. Hand anomalies were either isolated, associated with other anomalies or part of a syndrome. CONCLUSION: Incidence of congenital hand anomalies in Upper Egypt is difficult to be estimated due to social and cultural concepts, lack of education, poor registration and deficient medical survey. Management of hand anomalies should be individualised, carefully planned and started as early as possible to achieve the best outcome.

Reliability and Safety of Cross-Leg Free Latissmus Dorsi Muscle Flap in Reconstruction of Mutilating Leg Injuries Using End-to-Side Anastomosis.

Background Free tissue transfer is considered the gold standard option for the reconstruction of distal leg defects. Free tissue transfer using recipient vessels in the contralateral leg (cross-leg bridge) is a potential option to supply the flap if there are no suitable recipient vessels in the injured leg. Most studies have described this technique using end-to-end anastomosis which sacrifices the main vessel in the uninjured leg. This study evaluated the use of a cross-leg free latissimus dorsi muscle flap for the reconstruction of defects in single-vessel legs, using end-to-side anastomosis to recipient vessels in the contralateral leg without sacrificing any vessel in the uninjured leg. Methods This is a retrospective study that included 22 consecutive patients with soft tissue defects over the lower leg. All the reconstructed legs had a single artery as documented by CT angiography. All patients underwent cross-leg free latissimus dorsi muscle flap using end-to-side anastomosis to the posterior tibial vessels of the contralateral leg. Results The age at surgery ranged from 12 to 31 years and the mean defect size was 86 cm 2 . Complete flap survival occurred in 20 cases (91%). One patient had total flap ischemia. Another patient had distal flap ischemia. Conclusion Cross-leg free latissimus dorsi muscle flap is a reliable and safe technique for the reconstruction and salvage of mutilating leg injuries, especially in cases of leg injuries with a single artery. As far as preservation of the donor limb circulation is concerned, end-to-side anastomosis is a reasonable option as it maintains the continuity of the donor leg vessels.

Nasal subcutaneous lipoma, a case report.

OBJECTIVE: We report an extremely rare case of subcutaneous lipoma of the nasal vestibule. METHOD: A case report and a review of the literature concerning lipomatous growths in the nose and paranasal cavities are presented. RESULTS: A 34-year-old male presented with a swelling protruding from the dome of the right nasal vestibule. The swelling was excised and histological examination revealed it to be a subcutaneous lipoma. CONCLUSION: Lipomas of the nasal cavity and paranasal sinuses have previously been reported, however, to our knowledge, this is the first report of such a lipoma developing subcutaneously under the nasal skin.

Aplasia cutis congenita: Two cases of non-scalp lesions.

Aplasia cutis congenita (ACC) is a rare condition characterized by a localized absence of skin and in some cases, the subcutaneous tissues. The majority of cases occur in the scalp; however, the lesion may occur anywhere in the trunk and extremities. ACC is most often an isolated defect, but it can be associated with other anomalies. Most reported cases are sporadic with a few reports of familial occurrence. Neither the pathogenesis nor the aetiology is clarified. Healing is spontaneous in most cases, and apart from keeping the lesion clean, no specific treatment is required. In this report, two cases of non-scalp ACC occurring in the lower limbs are presented and a brief review of the literature is conducted.

Defining vascular supply and territory of thinned perforator flaps: Part II. Superior gluteal artery perforator flap.

BACKGROUND: Superior gluteal artery perforator flaps are surgical options in breast and pressure sore reconstructions. Based on the recipient site, primary thinning of these flaps may be necessary for final optimal contour. As the thinning of a superior gluteal artery perforator flap should be based on the knowledge of perforator vascular territories to prevent vascular compromise, the authors performed an anatomical study to determine the number, location, and diameter of the perforators present in the superior gluteal artery perforator flap. Accompanying veins and acceptable locations for surgical incisions were also determined. METHODS: Fourteen superior gluteal artery perforator flaps were harvested from seven cadavers. Perforator flaps were thinned to 8 to 15 mm, except for a 2.5-cm radius around the dissected perforator. Vascular territory areas were quantified before and after thinning by photographic and radiographic methods, and respective vascular territory maps were constructed. Surgical incision "danger zones" of vertical and horizontal axes were determined at specific depths (relative to the skin surface) for each flap. Danger zone measurements were determined with an automatic three-dimensional vascular tree construction using computed tomographic images and several modeling algorithms. RESULTS: Mean perforator artery diameter and number at the fascia level were 0.91 +/- 0.07 mm and 2.86 +/- 0.77 (mean +/- SD), respectively. Perforator pedicles were located midway between the posterior superior iliac spine and the greater trochanter. After thinning, skin surface and whole flap vascular territories were reduced 80.9 percent (photographic) and 76.9 percent (radiographic), respectively, compared with unthinned vascular territory areas. From the skin at 4-, 6-, and 8-mm thicknesses, elliptical danger zones (two vertical segments and two horizontal segments) had overall vertical segment axis length ranges from the pedicles of 59 to 66 mm, 51 to 57 mm, and 49 to 51 mm, respectively. Horizontal axis segment length ranges were 61 to 76 mm, 61 to 66 mm, and 60 to 57 mm for 4-, 6-, and 8-mm skin thicknesses, respectively. CONCLUSIONS: The superior gluteal artery perforator flap provides an excellent blood supply to adipose tissue but may be compromised when aggressively thinned. Surgeons may design and harvest partially thinned superior gluteal artery perforator flaps based on the anatomical vascular territory maps provided by this study.