The axial nasodorsum flap.

A new axial flap is described for reconstruction of soft-tissue defects of the nose, including the supratip and columella. The blood supply to this flap originates from the lateral nasal branch of the angular artery adjacent to the nasolabial fold. This flap was used in seven patients between 1989 and 1994, and there was complete survival. We recognized that this axial nasodorsum flap provided suitable shape design in each patient and produced excellent cosmetic results. The anatomy, the technique, and our clinical experience are presented.

Expanded unilateral forehead flap (sail flap) for coverage of opposite forehead defect.

This report details our experience with five patients who had skin defects of their forehead that were covered with an expanded unilateral forehead flap from the contralateral side that we call the sail flap. Skin expansion provides an ideal thin flap for the forehead aesthetic unit. The viability of the sail flap is sufficient through expansion, and it is available in suitable size and shape for the defect. The donor site is minimal and well accepted because the scar coincides with the hairline.

Application of the two-flap method for nasal alar contracture.

Reconstruction of the contracted nasal ala has been a very difficult problem for plastic surgeons. Numerous surgical procedures have been reported. However, most operations require multiple stages and leave conspicuous facial scarring and a thick, asymmetrical nostril rim. We have used the two-flap method introduced by Thomson and Sleightholm for isolated naso-ocular clefts, but we have added some modifications to this method: making a deeper backcut into the dome on the mesial side of the contracture and using thinner flaps than were originally used. As a result, we have achieved reasonable symmetry, good color match, appropriate thickness, and no conspicuous facial scarring in every patient.

Expanded preauricular full-thickness free skin graft.

A preauricular skin graft with expansion for repair of a facial defect is presented. This technique preserves a more natural appearance in color, texture, and thickness than is otherwise possible and provides a larger graft than the usual preauricular graft method.

Latissimus dorsi musculocutaneous flap: correction of donor-site defect with reverse latissimus flap.

A simple one-stage method for repair of the larger donor defect of the latissimus dorsi musculocutaneous flap is documented. This technique preserves a more natural appearance than could otherwise be obtained from a skin graft.

The ulnar recurrent fasciocutaneous island flap: reverse medial arm flap.

A new island fasciocutaneous flap raised on the inner medial surface of the upper arm has been used for reconstruction of soft-tissue defects of the elbow. The blood supply to this flap comes from the fasciocutaneous perforators of the ulnar recurrent vessels. This unique vascular arrangement allows for safe transference of the upper medial skin to the elbow region. This flap has been used to cover nine defects in eight patients, and results have been good. Except for one case of sensory disturbance, there were no complications or loss of overlying skin. It is a relatively quick and simple procedure involving only one stage that adequately corrects the skin defect around the elbow region and does not require prolonged splinting.

Pedunculated club-shaped swelling in the nostril.

This paper presents a skin mass found in the nostril of a boy who had no other anomalies. The skin mass was similar to the pedunculated masses with median cleft that have been reported previously. The literature is reviewed, and the relationship between skin masses associated with true median cleft and the skin mass in our patient is discussed.

Treatment of vaginal agenesis with an expanded vulval flap.

We propose a vaginal reconstruction method using an expanded vulval flap. This technique avoids long-term dilation and combines the advantages of commonly used methods of treatment for vaginal agenesis, resulting in good functional outcome.

The V-Y advancement myotarsocutaneous flap for upper eyelid reconstruction.

The V-Y advancement myotarsocutaneous flap was used to avoid excessive scarring during reconstruction of a full-thickness upper eyelid defect following surgical excision of a malignant tumor. This method has a number of advantages: It has a short operative time, it is a one-stage procedure, it does not require lining by auricular or septal cartilage, the technique is relatively simple, and the scar is inconspicuous, since both flap margins are placed in skin creases. The V-Y myotarsocutaneous flap is best suited for the repair of full-thickness upper eyelid defects ranging from 25 to 50 percent of the lid width when the remaining lateral canthal structures are adequate to support the flap.

A miniunit approach to lip reconstruction.

Aesthetic units of the face have been described previously. Burget applied the subunit principle to upper lip reconstruction. When defects are too small to replace subunits, we have employed a miniunit approach for their closure. When potential or actual wrinkle lines, as well as contour subunit lines, are used in flap design, miniunit flaps can be created which improve the aesthetic results. Symmetry, normal contour, preservation of normal layered muscular anatomy, and unnoticeable scars are attainable. Included herein is a description and evaluation of the advantages of this principle.

Combined tissue expansion: clinical attempt to decrease pain and shorten placement time.

Tissue expansion can be characterized as a unique reconstructive procedure that takes advantage of the intrinsic ability of tissues to stretch and, in some instances, to grow in response to expansive forces. The efficacy of combined intraoperative expansion to obtain sufficient expanded tissue more rapidly was tested in reconstructions of the extremities, and the comparison between conventional and combined expansion was performed observing five parameters: initial injected volume, pain score, duration of pain, total period of expansion, and histologic findings. We treated 22 patients with conventional expansion and 29 with combined expansions. The latter approach enabled us to overexpand the expanders initially and was associated with lower pain scores than conventional expansion. Furthermore, in the combined expansion group, shortening of the duration of pain was statistically significant in the upper arm (p < 0.05) as well as in the lower leg (p < 0.01). In this group, the total expansion period also was significantly shorter (p < 0.01). Histologically, only minor differences were seen between groups. In this study, intraoperative expansion combined with subsequent rapid overinflated expansion proved to be superior to conventional expansion not only in reducing expansion time but also in decreasing pain. We consider the following effects to contribute to this result: (1) increased skin elasticity due to repeated intraoperative load cycling, which leads to easier expansion of the skin and less irritation of the sensory nerves, (2) improved survival and vascularization of skin flaps due to the "delayed-flap" phenomenon, and (3) prevention of shrinkage of the expanded skin and widening of scars due to overinflated expansion.(ABSTRACT TRUNCATED AT 250 WORDS)

Congenital skin fossae in the zygomatic region.

A unique case of a congenital skin fossa in the zygomatic region in a 3-year-old girl is reported. Little has been written about congenital fossae, or dimples. They are thought to develop in the wound resulting from the fetal tissue being compressed between a sharp bony point and the uterine wall. The skin and subcutaneous tissue become compressed and adherent, and when the pressure is released, surrounding parts can stand up, while the attached part remains tied down, forming small dimples or fossae, what have been called "pressure dimples." This is the first report of a skin fossa located in the zygomatic region, as far as we know.

Buttock deformity repair for congenital generalized lipodystrophy.

A 3-year-old girl suffering from congenital generalized lipodystrophy is presented. Almost all features of CGL described by Seip were found in our patient. The deformity of the patient's buttocks was repaired using bilateral gluteus maximus muscle flap advancement, with good result.

V-Y advancement flaps in the reconstruction of skin defects of the posterior heel and ankle.

A V-Y advancement pedicle flap including fascia has been used for reconstruction of soft-tissue defects of the posterior heel and ankle region. This flap has been used to cover 17 defects in 16 patients ranging in age from 4 to 58 years, and results have been good. We limited this application to patients without systemic disease and under 60 years of age and did not apply it to the elderly, debilitated, or systemic vascular damaged patients. There were no complications or loss of overlying skin, with the exception of one superficial tip necrosis of the flap. The results indicate the reliability and usefulness of this procedure in coverage of the posterior heel and ankle regions. It is a relatively quick and simple procedure that is without a free skin graft, and it involves only one stage that adequately corrects the skin defect at the posterior heel and ankle without prolonged splintings and results in negligible deformity of the donor site.

[Usage of intra-operative scalp expansion for primary wound closure in cranio-facial operation].

The size of detects in scalp for which primary wound closure can be applied is limited. Cases with a scalp defect for which primary wound closure is difficult to perform are frequently seen. In these cases, an attempt is made to close the wound by extending the margin of an incision produced by extensive subgaleal undermining or galeal incisions. However, its effectiveness is limited. We performed in such cases intra-operative scalp expansion with a tissue expander for primary wound closure, and this technique has yielded good results. A case with craniosynostosis and five cases with cranioplasty received this procedure. Four of these cases had a previous history of undergoing surgery for carvarial bone defect three to five times from the same incision. The scalp at the carvarial bone defect had a scar and was atrophic with great depression. It was expected that the expansion of cranium resulting from cranioplasty would make it difficult to perform primary wound closure. During the surgery, a tissue expander was placed subgaleally in an osseous area prior to the bone operation, and intermittent air expansion was carried out for 20 to 30 minutes by means of air inflation and deflation to expand the scalp. In all of these cases little tension was generated by the wound closure despite the lapse of time during the bone operation. In consequence, primary wound closure was accomplished easily, and the reliable closure of the galea made it possible to prevent the scar widening. This is a simple and easy technique combining primary wound closure of the scalp with intra-operative scalp expansion. We believe that the technique should be considered for cases for whom primary closure of compression deformity is difficult or in whom there is a wound at the carvarial reconstruction site. The technique and typical cases are reported.

Medial arm fasciocutaneous island flap coverage of an electrical burn of the upper extremity.

Deep tissue necrosis following debridement of electrical injuries can be so severe that amputation of the limb is often necessary. To preserve function and partially devitalized structures, and to lessen the necessity for amputation, several debridements followed by coverage with a vascularized fasciocutaneous flap can be advantageous. This article reports a successful case of a medial upper arm fasciocutaneous island flap used to cover a defect of the upper arm caused by an electrical burn. An angiography revealed that the ulnar collateral artery was not occluded, and thus it was used in the flap with successful results. The donor defect was closed primarily and did not require a skin graft.

The use of Gore-Tex Soft Tissue Patch to assist temporal muscle transfer in the treatment of facial nerve palsy.

Temporal muscle transfer remains one of the most widely practiced procedures in dynamic correction of paralysis of facial nerves. In case of shortage of temporal muscle volume, length, and strength, some type of autogenous tissue or implant is required to achieve great stretching and excursion. Several artificial materials have been used in the past, each with its own limitations or problems. We used Gore-Tex Soft Tissue Patch to lengthen and strengthen the muscle-fascia strip. This material is very successful as an implant; it shows excellent tissue tolerance, the porous microstructure encourages tissue attachment and infiltration, and it also resists infection. As a result, reasonable suspension and restoration of orbital and oral sphincters were achieved.

Free ascending scapular flap.

Four patients with free tissue transfer using ascending cutaneous branches of circumflex scapular vessels are herein presented. The free ascending scapular flap is located on the superior vertical axis, differentiated with the scapular flap horizontally and the parascapular flap vertically designed. The flap is an excellent choice because of easy dissection, a constant artery and venous system, 2- to 3-mm-diameter vessels, and sufficient length of the vascular pedicle. All flaps survived completely with a fairly thin skin. The shoulder donor site could be closed primarily. No functional deficit of the shoulder was observed.

Popliteo-posterior thigh fasciocutaneous island flap for closure around the knee.

A popliteo-posterior thigh fasciocutaneous island flap to repair skin defects around the knee is presented and discussed. Included is a description of the procedure, a comparison with alternative procedures, and an evaluation of the advantages of the new method.