The Local Rhombus-Shaped Flap-An Easy and Reliable Technique for Oncoplastic Breast Cancer Surgery and Defect Closure in Breast and Axilla.

Primarily, breast-conserving therapy is an oncological intervention, but eventually it is judged by its cosmetic result. Remaining cavities from tumor resection can promote seromas, delay healing and cause lasting discomfort. Additionally, volume loss, dislocation of nipple/areola and fat necrosis lead to (cosmetically) unfavorable results, aggravated by radiotherapy. Oncoplastic surgery can reduce these sequelae. A local flap that has rarely been used in breast cancer surgery is the Limberg rhombic flap. The tumor defect is planned as a rhombus. The sides of the rhombus are of equal length and ideally have an angle of 60° and 120°. The flap that closes the defect is planned as an extension of equal length of the short diagonal. The second incision of the flap is placed according to the defect angle of 60°, running parallel to the defect at the same length. This creates a second rhombus. The flap is transposed into the defect, and the donor area is primarily closed. It is axially perfused and safe with a 1:1 length-to-width ratio. Compared to local perforator flaps, defect closure is easily managed without microsurgical skills. In the breast, the flap can be used in volume replacement and volume displacement techniques as an all-layer flap to cover defects, or it can be deepithelialized and buried. In the axilla, it can cover full-thickness defects when skin is involved. The advantages of the rhombic flap are its safety and simplicity to add volume and close defects, thus reducing the complexity of oncoplastic surgery.

Flap-Based Lower Extremity Reconstruction in the Elderly-Is It Safe and Does Age Impact Ambulation?

INTRODUCTION: Lower extremity (LE) reconstruction in the elderly population presents a multifaceted challenge, primarily due to age-related degenerative changes, comorbidities, and functional decline. Elderly individuals often encounter conditions such as osteoarthritis, osteoporosis, and cardiovascular and peripheral artery disease (PAD), which can severely compromise the structural integrity and function of the lower limbs. As such, we aim to assess postoperative complications and functional recovery following LE reconstruction in elderly patients. METHODS: Patients ≥ 18 years who underwent post-traumatic LE reconstruction with flap reconstruction at a Level 1 trauma center between 2007 and 2022 were included. Patient demographics, flap/wound characteristics, complications, and ambulation for the elderly (≥ 60 years old) and the control (< 60 years old) cohorts were recorded. The primary outcome was final ambulation status, modeled with logistic regression. Secondary outcomes included postoperative complications. RESULTS: The mean ages of the control (n = 374) and elderly (n = 49) groups were 37.4 ± 12.6 and 65.8 ± 5.1 years, respectively. Elderly patients more frequently required amputation after flap surgery (p = 0.002). There was no significant difference between the two cohorts in preoperative ambulation status (p = 0.053). Postoperatively, 22.4% of elderly patients were independently ambulatory at final follow-up, compared to 49.5% of patients < 60. Of the elderly, 14.3% could ambulate with an assistance device (cane, walker, etc.), compared to 26.5% in the control group. A wheelchair was required for 46.9% of elderly patients, significantly higher than the 22.7% of those < 60 years of age (p < 0.001). Multivariate regression confirmed an association between older age and nonambulatory final status (p = 0.033). CONCLUSION: LE reconstruction can likely be performed safely in patients 60 years of age or older. However, older age is independently associated with significantly worse postoperative ambulation. Preoperative assessment, including gait and muscle strength, and early initiation of postoperative rehabilitation can potentially improve ambulation in elderly individuals undergoing LE reconstruction.

Versatility of the Keystone Design Perforator Island Flaps in Resurfacing Soft Tissue Defects.

Background The keystone design perforator island flap (KDPIF) is unique among local flaps because of its high potential for adaptation. We describe our experience with the use of the keystone flap for the reconstruction of a variety of defects in different regions of the body concerning its versatility, surgical outcomes, complications, postoperative pain, operative time, and esthetic outcomes. Methods A prospective observational study was conducted at our institute from June 2021 to June 2023 where the use of KDPIFs in resurfacing soft tissue defects of different etiopathogenesis was evaluated and the data were analyzed. Results Forty-four patients were included in the study with soft tissue defects of various etiologies and at different locations. The largest flap raised was 18 × 10 cm and the smallest was 4 × 2 cm. The average intraoperative time for completion of the procedure was 74.86 minutes (range: 45-120 minutes). The success rate of flap survivability was 95.45% with two patients having total flap loss necessitating another reconstructive option. Partial flap dehiscence which healed secondarily was observed in two patients. Postoperative pain showed a significant fall of 83.7% from baseline and 82.9% of cases were extremely satisfied with the esthetic outcome. Conclusion The keystone flap is a valuable reconstructive tool in the armamentarium of a plastic surgeon. It is technically reproducible, suitable to be done in resource-limited settings, and provides contiguous tissue with good vascularity and fewer complications.

Versatility of the Peroneus Brevis Muscle Flap for Distal Leg, Ankle, and Foot Defects: A Comprehensive Review.

Soft tissue defects of the distal third of the leg are challenging and management with simple split thickness skin graft or conservative measures is often difficult. The peroneus brevis muscle flap is well described in the literature to cover such defects. The aim of our study was to review the different applications and potential complications of the peroneus brevis muscle flap. A comprehensive review of all existing evidence on the use of peroneus brevis muscle flaps for coverage of defects in the distal third of the leg in adult populations was performed. Two hundred forty-eight records were identified in the literature search, among which 15 met the PICOS (Patient, Intervention, Comparison, Outcome and Study design) criteria. All selected studies were retrospective. Overall, 222 patients who received peroneus brevis muscle flaps were analyzed. Indications for reconstruction were post-traumatic defects, infected wounds, and chronic wounds. The overall complication rate was 21% (46/222) with the most commonly reported complication being skin graft loss. We observed 2 cases of partial flap loss, 17 cases of skin graft loss, 2 cases of post-operative hematoma, 2 cases of recurrent infection, 12 cases of partial flap necrosis, 3 cases of skin graft necrosis, and 8 cases of delayed wound healing. Overall, 16 patients (7%) required revision surgery. No cases of donor site morbidity were described. The current review shows that the peroneus brevis muscle flap is a versatile and reliable option for the coverage of small to medium sized defects of the distal leg, ankle, and foot with low complication rates and donor site morbidity.

Retrospective cohort study rethinking lip reconstruction: Versatility of the depressor anguli oris myocutaneous flap for large full-thickness defects.

BACKGROUND: Large full-thickness lip defects present a reconstructive challenge. OBJECTIVE: To describe the impact on clinical outcomes and institutional cost of the depressor anguli oris myocutaneous (DAOM) flap as an axial pattern transposition flap for reconstruction of large, full-thickness lip defects. METHODS: A multicenter retrospective cohort study of adults with large full-thickness lip defects who underwent DAOM flap reconstruction from 2011 to 2018 was conducted. DAOM flap anatomy and surgical technique were reviewed. The primary outcome of flap viability as well as additional clinical outcomes of postoperative complications and functional results were documented with follow-up ranging up to 11 years. Median length of stay and average institutional cost of care were analyzed. RESULTS: A total of 12 patients underwent DAOM flap reconstruction for large full-thickness lip defects. There was 100% flap survival with no episodes of reoperation or readmission. All patients reported maintenance of distinct oral commissures, wide oral opening and full gingivolabial sulcus, excellent oral competence, and intelligible speech. Mean case length was 144 ± 11.5 min with a mean length of stay of 1.6 ± 0.5 days and estimated mean institutional cost of $3766.67 ± $1167.06. CONCLUSIONS: The DAOM flap is an excellent reconstructive option for large full-thickness lip defects with strong functional results and limited donor site morbidity and institutional cost of care.

Occlusive dressing versus local flap coverage for the treatment of fingertip amputations with exposed bone: a comparative study.

We retrospectively reviewed the outcomes of 54 patients treated with occlusive dressings (OD) (27 patients) or local flap (LF) coverage (28 patients) for fingertip amputations with bone exposure. All patients healed completely within a mean of 5 weeks in the OD group and 3.5 weeks in the LF group. At a mean follow-up of 26 months (range 12-38), 2-point discrimination was significantly better in the OD group (4 mm) than the LF group (6 mm). Proximal interphalangeal joint (PIP) stiffness was more common in the LF group, affecting one-third of patients. A cost analysis showed that ODs were 6.5 times less expensive than LFs performed in the operating theatre. OD appears to be a reliable and more cost-effective alternative to LF for treating zone 2 and 3 fingertip amputations with exposed bone, with similar healing time, better tactile discrimination and a lower rate of PIP joint stiffness.Level of evidence: IV.

Principles and Clinical Application of Free-Style Capillary Perforator-Based Flap for Coverage of Facial Skin Cancer Defects.

This study introduces a free-style perforator based island flap (PBIF) for the reconstruction of skin defects. From March 2012 to December 2022, a retrospective investigation was conducted on patients who underwent reconstruction for facial defects due to skin cancer. Data on the patients' gender, age, anesthesia method, diagnosis, defect location, flap size, complications, and follow-up periods were collected. There are several principles for designing the PBIF: finger-pinching method, alignment with the direction of wrinkles, the smaller width and longer length of the flap, and proximal attachment to the muscle. A total of 32 patients were included, with an average age of 63.6 years. Surgeries were performed in various regions, such as the infraorbital area, nose, cheek, philtrum, and the anterior/posterior/inferior auricular regions, with an average flap size of 7.63 cm2. There were no complications, such as venous congestion or vascular insufficiency in the skin flaps, although one case required revisional closure due to flap disruption. The PBIF is a useful and effective method for the restoration of facial defects. This method can provide simple yet aesthetically satisfying results, showing stable outcomes without complex surgeries or complications. This study indicates the potential for this method to be more widely employed in reconstructive surgeries in the future.

Reconstruction of caudal defects of the nose using the bilobe flap: A long-term follow-up retrospective review.

BACKGROUND: Reconstruction of nasal defects is a challenging task due to the complex nasal geometry and the need for aesthetic considerations. The bilobe flap has emerged as a reliable technique for nasal reconstruction, particularly for defects involving the nasal tip, alae, and inferior dorsum. OBJECTIVE: This study presents a review of 31 patients who underwent bilobe flap reconstruction for nasal defects after tumor resection. MATERIALS AND METHODS: The surgical technique, short- and long-term aesthetic outcomes, patient satisfaction, and complications were evaluated. Aesthetic outcomes were assessed using a qualitative ordinal scale, and long-term patient satisfaction was obtained through follow-up notes and phone interviews. RESULTS: Bilobe flap reconstruction yielded good aesthetic outcomes in the majority of cases, with high patient satisfaction. Complications were minimal, and revision surgeries were performed in a small number of cases to address aesthetic concerns. CONCLUSION: Overall, the bilobe flap technique proved to be an effective and reliable option for nasal reconstruction, providing stable and long-lasting results.

Update on Hypertrophic Scar Management in Burn Patients.

Hypertrophic scars arise from burn injuries because of persistent inflammation in the reticular dermis. Several risk factors promote this chronic inflammation. One is tension on the burn wound/scar due to surrounding skin tightness and bodily movements. High estrogen levels and hypertension are also important systemic risk factors. Thus, to prevent burn wounds from developing into hypertrophic scars, it is important to focus on quickly resolving the reticular dermal inflammation. If conservative treatments are not effective and the hypertrophic scar transitions to scar contracture, surgical methods such as Z-plasty, full-thickness skin grafting, and local flaps are often used.

A Giant Nevus Sebaceous Lesion in an 18 Year-Old Male: A Case Report.

A nevus sebaceous is a rare type of lesion that most often occurs on the scalp but can appear anywhere on the head, face, neck, forehead, or scalp. Nevus sebaceous is benign lesion usually resulting from hyperplasia of different elements of the skin such as epithelial, sebaceous, follicular elements. This article discusses a patient with giant nevus sebaceous lesions on his scalp and right ear. An 18-year-old man came to the Plastic Surgery Outpatient Department, Shiraz University of Medical Sciences, Shiraz, Iran with a large gray brown Nevus like lesions on his scalp and on the right periauricular region. Both lesions gradually increased in size over the time, leading to giant papillomatosis lesions. The patient had no manifestations like pain or other symptoms. The operation was planned, and lesions excised and repaired with Local Flap and Full thickness skin graft, the patient was discharged after a day. After surgery, recovery was good and after 3 months there was no relapse and cosmetic result was excellent. This article shows the importance of surgery role in nevus sebaceous patients and discusses different types of treatments.

Nipple Reconstruction Using the "Arrow Flap" Technique: Outcomes and Patients Satisfaction.

INTRODUCTION: Skin-sparing mastectomy (SSM) entails complete removal of the breast tissue and the nipple and areola complex (NAC) with preservation of as much of the overlying skin as possible. The preservation of the natural skin envelope during SSM improves the aesthetic outcome of immediate breast reconstruction, but the lack of NAC determines that the reconstructed breast remains anatomically incomplete with not always satisfactory final results. For this purpose, the aim of the present study was to investigate and evaluate the impact of nipple reconstruction after skin sparing and skin reducing mastectomy on the patients' perception and intimate life. MATERIALS AND METHOD: This was a comparative single-center prospective study that involved 42 patients underwent NAC reconstruction after SSM. A pre- and postoperative quality-of-life and psychological questionnaires Breast-Q questionnaire (Breast Conserving therapy module) were given to all the patients before the surgery and 6 months after. The statistical analysis with chi-square test was performed. RESULTS: After 6 months a prevalence of patients reported to be very satisfied in regard to shape, appearance, naturalness, projection, position and symmetry. The study shows an overall improvement in all the psychological items analyzed with statistically significant difference regarding: "patient's satisfaction," "self-confidence," "appearance of the breast." CONCLUSION: The authors believe that the NAC reconstruction has useful functional and aesthetic results particularly appreciated by patients who feel demoralized after breast demolition surgery.

Tamai zone -I and -II replantation versus reconstruction with local flaps: retrospective analysis for functional and cosmetic results.

A retrospective study were presented to compare functional and cosmetic outcomes in relation to local flap reconstruction or fingertip replantation in cases of zones I and II amputation. Outcomes were evaluated using Semmens Weinstein monofilament, Weber DiskCriminator, total active motion (TAM) assessment and Michigan Hand Questionnaire after a 1-year follow-up.

Lower Lip Reconstruction after Skin Cancer Excision: A Tailored Algorithm for Elderly Patients.

BACKGROUND: Lower lip reconstruction is crucial to restore oral integrity post-cancer excision. A perfect balance between form and function should be achieved. With an aging demographic, adapting surgical methods to meet the unique needs of the elderly becomes imperative. Our study aims to introduce a specialized algorithm for lower lip reconstruction; it was tailored to geriatric patients and emphasized the use of "simpler flaps". Additionally, "Pearls and Pitfalls" were provided for surgeons approaching lower lip reconstruction. METHODS: Between January 2018 and June 2021, a retrospective study was carried out. Data collection included patient demographics, defect attributes, reconstructive approaches, flap viability assessment, wound healing, and complications. The follow-up was carried out for a period of a minimum of 6 months. RESULTS: Among 78 patients, squamous cell carcinoma predominated with a mean defect area of 3308 cm2. Postoperative complications were recorded in two patients. All patients reported sensory restoration and overall satisfaction at the 6-month follow-up; secondary procedures were not necessary. CONCLUSION: Our reconstructive algorithm, focused on elderly patients, prioritizes less invasive reconstructive techniques and introduces innovative modifications to the established methods to achieve both aesthetic and functional outcomes with a low complication rate. In patients undergoing lower lip reconstruction, the subjective microstomia was found to be less relevant than the objective microstomia.

Versatile Use of V-Y Advancement Flap for Facial Defect Reconstruction: A Case Series in Asian Patients.

BACKGROUND: V-Y advancement flap (VYAF) is a commonly used flap for facial reconstruction, but it is not popular in Asian society with limited aesthetic outcome evaluation. OBJECTIVE: To demonstrate our experience of facial VYAF with the quantitative aesthetic outcome assessment. METHODS AND MATERIALS: From January 2013 to December 2022, patients who underwent facial VYAF reconstruction were reviewed. Postoperative photographs were collected and independently graded by three plastic surgeons, three nurses, and six non-medical personnel using Manchester scar scale (MSS). The representative preoperative images were selected for surgeons' reconstruction preferences survey. RESULTS: Forty-eight patients (27 females and 21 males), with a mean age of 66.8 (23-97) years, were included in this study. All flaps survived with no flap necrosis. Only six patients (12.5%) developed minor postoperative complications, and they were treated conservatively and resolved uneventfully. The total MSS score was 7.8 ± 1.9 (scale of 4 [best scar] to 24 [worst scar]) and the overall scar VAS rating was 1.9 ± 1.1 (0 [best scar] to 10 [worst scar]), indicating satisfactory postoperative scar condition. From the survey of 22 plastic surgeons and 11 scenarios, VYAF was rarely chosen among other local flaps which only accounted for 8.7%. CONCLUSION: VYAF is an easy and safe method for facial reconstruction with low morbidity, but its usefulness is underappreciated. With a proper design and cautious dissection, we believe that good aesthetic and functional outcomes can be achieved with VYAF. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Septal Nasopharyngeal "Kite Flap" for Long-Term Patency of Petrous Apex Cholesterol Granuloma.

Medial petrous apex cholesterol granuloma is a benign lesion which treatment is generally based on a trans-nasal marsupialization. When the artificial ostium is created, it is usually kept open with local flaps, like the septal nasopharyngeal "kite flap", a reliable local vascularized flap. Laryngoscope, 134:2111-2114, 2024.

Genital elephantiasis in men.

Penoscrotal elephantiasis (PSE) is defined as an increase, sometimes considerable, in the volume of the external genitalia, which will be responsible for an unsightly appearance, a sexological impact and a psychological harm. The cause may be primary or secondary to a parasitic disease (filarsiosis) or to intrinsic or extrinsic lymphatic obstruction. The diagnosis is essentially clinical, with penoscrotal involvement being the most frequent. The etiological research implies the realization of certain complementary examinations according to the circumstances. Surgical treatment ideally consists of excising the mass. followed by reconstruction using grafts or local flaps of healthy skin, which is an important way of restoring comfort to the patient. We report two cases of penoscrotal elephantiasis treated surgically with good functional and aesthetic results. We update, through our own experience, aspects of the diagnostic and therapeutic care of penoscrotal elephantiasis.

A new local flap technique for closing long-axis skin defects: the cyclist flap procedure.

BACKGROUND: Local flaps are commonly used during the treatment of skin tissue defects. Although there are many available procedures for the closure of triangular, circular and rhomboid-shaped defects, long-axis elliptical skin defects lack treatment options. To address this problem, a new local flap design called the cyclist flap procedure (CFP) was developed, so called because it resembles the silhouette of a person riding a bicycle. METHODS: The CFP was performed in 29 patients aged 9-81 years in 2021-2022. The defects were localised in the sacral region (1), upper extremities (3), lower extremities (3), and head and neck regions (22). Closures of skin defects due to pressure ulcers (one patient) and after tumour excision (28 patients) were performed, and the patients were followed up for 12-20 months. RESULTS: Only minor complications were observed in two patients. During follow-ups, no secondary surgery was required due to dog-ear, trapdoor, recurrence or revision. Furthermore, the aesthetic results related to the skin lines and scar size were acceptable. CONCLUSION: The CFP is a new, easy-to-apply and advantageous procedure for the closure of long-axis elliptical and oval skin tissue defects.