The "Frogger Flap": A Novel Quadruple Rhomboid Flap for Complex Central Upper Lip Reconstruction.

Upper lip reconstruction represents a unique challenge for the reconstructive plastic surgeon. Given its prominent aesthetic role in addition to its functional role in facial expression, speech, and oral intake, preservation of this region's natural form and function is paramount. In this report, we present a novel technique for the reconstruction of a complex central upper lip defect, restoring the natural aesthetic of this essential structure. We describe the case of a 51-year-old woman who presented with recurrence of a previously resected basal cell carcinoma center on the upper lip at the level of the white roll and philtral depression. Following surgical resection via Mohs micrographic surgery, a 1.8 × 1.6 cm partial-thickness defect centered around the Cupid bow involving both cutaneous and vermillion tissues remained. Reconstruction was achieved through a novel quadruple rhomboid flap primarily based on the preservation of the aesthetic subunits of the upper lip. A functional and aesthetic reconstruction was achieved through local tissue rearrangement, restoring the appearance of the white roll and red line. Native perfusion and innervation were preserved during the reconstruction of the Cupid bow, recreating this region's natural appearance. The design of the flap resembles a jumping frog, which is the etiology of the "Frogger flap" moniker. The Frogger flap recreates the natural aesthetic of the central upper lip through the geometric transposition of tissue commensurate with native anatomy. Through the application of aesthetic subunit principles, it reliably reconstructs central upper lip defects while preserving function and providing an aesthetically pleasing outcome.

Reducing Postoperative Abdominal Bulge Following Deep Inferior Epigastric Perforator Flap Breast Reconstruction with Onlay Monofilament Poly-4-Hydroxybutyrate Biosynthetic Mesh.

Background The purpose of this study was to evaluate the use of a biosynthetic mesh onlay on reducing postoperative abdominal bulge following deep inferior epigastric perforator (DIEP) flap breast reconstruction. Methods All patients undergoing DIEP reconstructions from January, 2010 to January, 2014 at a tertiary center were reviewed. Patients were divided into two groups for comparison based on whether a biosynthetic mesh onlay (Phasix [monofilament poly-4-hydroxybutyrate], Bard Inc., Warwick, RI) was used for reinforcement of the anterior rectus fascia. Rates of postoperative abdominal bulge were compared between the groups utilizing standard statistical methods. Results During the study period, 319 patients underwent 553 DIEP reconstructions, 160 (50.2%) used mesh and 159 (49.8%) did not (nonmesh). The mean follow-up was 16.4 ± 11.1 months. There was no difference in age (49 ± 9.3 years), current tobacco use, diabetes, or mean body mass index (BMI, 29.4 ± 4.4) between the mesh and nonmesh groups (p > 0.05); however, there was a higher proportion of obese patients (BMI > 30) in the mesh group (45.0 vs. 33.3%; p = 0.03). Abdominal bulge rate following DIEP with mesh was lower than the nonmesh group (0 vs. 5.0%; p = 0.004). In the entire sample, 234 (73.4%) underwent bilateral DIEP and 85 (26.6%) underwent unilateral DIEP. In unilateral DIEP patients, the bulge rate was similar between the mesh and nonmesh groups (0 vs. 4.4%; p > 0.05); however, in bilateral DIEP patients, the bulge rate was lower in the mesh group compared with a nonmesh group (0 vs. 5.5%; p = 0.008). Conclusion Reinforcement of the anterior rectus with an onlay monofilament poly-4-hydroxybutyrate biosynthetic mesh may reduce the risk of postoperative bulge rate in patients undergoing DIEP reconstruction.

In Vivo Changes of Breast Perfusion After Augmentation.

BACKGROUND: Revision surgeries after breast augmentation are associated with an increased risk of complications (eg, nipple areolar complex [NAC]) necrosis. Consequently, maintaining perfusion to the NAC is a critical aspect of secondary breast surgery. OBJECTIVES: The purpose of this study was to examine in vivo changes in perfusion to the NAC after implant breast augmentation using magnetic resonance imaging (MRI) technology. METHODS: High-resolution 3 Tesla MRI images of 10 women (20 breasts) with previous breast augmentation were compared to a control population of 15 women (30 breasts). Perforators from the internal mammary artery and lateral thoracic artery were examined for the diameter of the originating perforator, distance between the nipple and most distally visualized point of the medial and lateral perforator, and dominance pattern between the medial vs lateral perforators. RESULTS: No difference was found in the caliber of the medial vessels in the implant group compared to the control group. In contrast, the caliber of the lateral blood vessels trended towards being 20% larger in diameter in the augmented breasts. The distances between the nipple and the medial and lateral vessels increased. The frequencies in the distribution of dominance were not significantly different between the implant group and the control group. CONCLUSIONS: Overall, medial and lateral blood supply to the NAC are preserved in the augmented patient. Our results suggest a slight delay effect that seems to increase the caliber of the lateral perforators. In addition, the tissue expansion provided by the implants effectively increases the length of both perforators. LEVEL OF EVIDENCE: 3 Therapeutic.

Dynamic Article: Tandem Robotic Technique of Extralevator Abdominoperineal Excision and Rectus Abdominis Muscle Harvest for Immediate Closure of the Pelvic Floor Defect.

BACKGROUND: Extralevator abdominoperineal excision for distal rectal cancers involves cylindrical excision of the mesorectum with wide division of the levator ani muscles. Although this technique has been shown to decrease local cancer recurrence and improve survival, it leaves the patient with a considerable pelvic floor defect that may require reconstruction. OBJECTIVE: We developed an innovative technique of robotic extralevator abdominoperineal excision combined with robotic harvest of the rectus abdominis muscle flap for immediate reconstruction of the pelvic floor defect. DESIGN: This was a retrospective review pilot study. SETTING: This study was conducted at a tertiary care cancer center. PATIENTS: Three patients who underwent robotic extralevator abdominoperineal excision with robotic rectus abdominis flap harvest for distal rectal adenocarcinoma were included. MAIN OUTCOMES MEASURES: Intraoperative and postoperative outcomes included operative time, intraoperative complications, length of hospital stay, wound complications, incidence of perineal hernia, persistent pain, and functional limitations. RESULTS: Three patients underwent this procedure. The median operative time was 522 minutes with median hospital stay of 6 days. One patient experienced perineal wound complication requiring limited incision and drainage followed by complete healing of the wound by secondary intention. The other 2 patients did not experience any wound complications. Longest follow-up was 16 months. None of the patients developed perineal hernias during this time period. LIMITATIONS: The small sample size and retrospective nature were limitations. CONCLUSIONS: This technique confers multiple advantages including improved visualization and dexterity within the pelvis and accurate wide margins at the pelvic floor. An incisionless robotic flap harvest with preservation of the anterior rectus sheath obviates the risk of ventral hernia while providing robust tissue closure of the radiated abdominoperineal excision wound. This technique may result in faster postoperative recovery, decreased morbidity, improved functional outcomes and cosmesis. Further studies are needed to prospectively analyze this approach (Supplemental Digital Content 1, video abstract, http://links.lww.com/DCR/A188).

Major bleeding in patients with mediastinitis: a heartbreaking series.

Deep sternal wound infection (DSWI) is a life-threatening complication that develops in 5% of patients undergoing median sternotomy. One feared complication is major bleeding, associated with up to 50% mortality. We characterized a series of patients who experienced major bleeding following DSWI. We included eight patients with DSWI who experienced major bleeding at our institution from 1990 to 2012. The median age was 70.9 (range, 47-81) and the cohort consisted of seven male patients and one female patient. All eight patients required emergent surgical repair for the bleeding and all survived past 30 days postoperatively from the repair.

Repair of the cocaine-induced cleft palate using the modified double-opposing z-plasty.

Cocaine is a potent vasoconstrictor, and long-standing use can result in an acquired palatal cleft. Similar to congenital cases, this palatal defect can cause nasal emission and hypernasal speech. The goals of palate repair include optimizing palatal function for speech and feeding while avoiding dehiscence or postoperative fistulae. The modified double-opposing Z-plasty is an effective technique for cleft palate repair. We describe the first reported case using this technique to repair a palatal defect resulting from chronic cocaine use. Recommended requirements for using this technique include absence of future or ongoing ischemic insults to the tissue (cocaine abstinence) for at least 1 year, an intact vascular pedicle demonstrated by greater palatine dimples, presence of sufficient vascularized soft tissue with preserved pharyngeal arches, small to medium defect sizes within 10 cm(2), and extensive flap mobilization with tension-free closure. The advantages of this technique include preservation and reorientation of functional muscle, single-stage repair, and obviated requirement for distant donor sites.

A range of condylar hypoplasia exists in Treacher Collins syndrome.

PURPOSE: Temporomandibular joint malformation is a complex deformity in Treacher-Collins syndrome (TCS); however, it is not well characterized. This study aimed to better clarify this pathology by volumetrically assessing the mandibular condyle in patients with TCS compared with normal controls and the relative contribution of the condyle to hemimandibular volume. MATERIALS AND METHODS: A retrospective, cross-sectional analysis of pediatric patients with TCS and unaffected controls was performed. The study sample was comprised of Treacher Collins patients. The predictor variable in this study was disease status (TCS diagnosis vs control), and the outcome variable was condylar volume. Demographic information was collected, and 3-dimensional computed tomographic data were analyzed by computerized segmentation (Materialise). Volumes were obtained for TCS condyles and compared with age-matched controls using the Student t test. RESULTS: Three-dimensional computed tomographic scans were identified in 10 patients with TCS (20 sides) and 14 control subjects (28 sides). The TCS group included 4 female and 6 male patients (age, 0.3 to 213 mo; average age, 66.5 mo). The control cohort included 7 female and 7 male subjects (average age, 68.8 mo). Evaluation of the mandibular condyle showed that patients with TCS had a significantly smaller condylar volume than control patients (TCS, 178.28 ± 182.74 mm(3); control, 863.55 ± 367.20 mm(3); P < .001). Additional intragroup analysis showed no significant differences between the left and right condylar volumes in the TCS group (P = .267). In addition, the condyle for patients with TCS represented a smaller proportion of hemimandibular volume compared with controls (1.37% vs 4.19%, respectively; P < .001). CONCLUSIONS: The results of the this study suggest that condylar volumes are significantly smaller in patients with TCS compared with age-matched controls, and the condyle represents a smaller fraction of the total mandibular volume for patients with TCS than in unaffected children. In addition, there is considerable variability of condylar size in patients with TCS. These facts portend treatment decisions because a functional temporomandibular joint is necessary and may need to be reconstructed as a first stage before effective implementation of distraction procedures.

Asymmetric class III malocclusion: association with cranial base deformation and occult torticollis.

The etiology of Angle class III malocclusion with facial asymmetry has not been fully elucidated. To investigate the etiology, patients with asymmetric prognathism (n = 30) from a single institution were assessed for previously undiagnosed torticollis and cranial base asymmetry. Presence of torticollis was determined by measuring restricted head movement when turning the head against a wall and cranial base tilt with upward gaze. Cranial base asymmetry was evaluated by preoperative three-dimensional computed tomography scans. Thirty-one percent of patients with prognathism presented with concurrent facial asymmetry. In patients with asymmetric prognathism, cranial base tilt was present on upward gaze in all patients; mean angle between head and wall was 31 degrees greater than that in control patients, and a 22% to 36% difference in the angle was present when comparing one side with the other. Based on these findings, all patients with asymmetric prognathism were found to be affected by torticollis. By computed tomography scan, 85% of these torticollis patients showed slight anteromedial displacement of the glenoid fossa ipsilateral to torticollis, and 73% demonstrated temporal fossa shift of 4 mm or greater. The current study demonstrates a strong association between asymmetric class III malocclusion, torticollis, and cranial base asymmetry. We conclude that undiagnosed torticollis is a likely etiology for otherwise idiopathic cranial base asymmetry and that cranial base asymmetry in turn causes facial asymmetry and malocclusion. This study highlights the importance of evaluating cranial base asymmetry and torticollis in patients with class III malocclusion to allow for earlier treatment and improved outcomes.

Laparoscopic iliac and iliofemoral lymph node resection for melanoma.

Regional lymphadenectomy in the iliac and groin, originally devised by Basset in 1912, is performed for the treatment of melanoma metastatic to this lymphatic basin. Laparoscopic iliac node dissection may be a valuable management option because it allows performance of the same procedure as in open surgery but with significant benefits such as decreased operative morbidity due to decreased surgical trauma, less violation of the abdominal muscles or the inguinal ligament, reduced postoperative pain, and increased patient satisfaction with the cosmetic appearance. The authors' approach makes use of a laparoscopic technique to offer an alternative to traditionally described lymph node dissection for melanoma. A review of the literature showed few laparoscopic approaches in this context. Jones et al. do not perform the resection en bloc and do not address the iliofemoral lymph node dissection with a combined retroperitoneal technique such as the current authors use. Two authors in the literature use laparoscopy through a transperitoneal approach, with a piecemeal removal of nodes. Delman et al. limit their technique to the inguinal and high femoral basin alone. The video demonstrates the novel use of a laparoscopic method to harvest iliac lymph nodes in combination with a minimally invasive approach to groin dissection for metastatic melanoma. After a laparoscopic resection of these nodes, the authors deliver the iliac nodal contents through the groin using a minimally invasive approach. This approach is highly beneficial to the patient. He is able to leave the hospital significantly earlier than he would have after a traditional open procedure. He can return to his job as a car mechanic within 1 week and is metastasis free at the 9-month follow-up assessment without evidence of lymphocele formation. The authors do not believe that this technique has any significant implication for lymphocele formation compared with an open procedure because in essence, the same resection is being performed. A larger prospective series is necessary to determine lymphocele outcomes.

A novel cranioplasty technique incorporating cancellous femoral bone and recombinant bone morphogenic protein 2.

Large calvarial defects in the setting of chronic infection and limited autologous donor sites present challenging problems for the reconstructive surgeon. We report on a novel osteogenic implant as a potential calvarial reconstruction solution. Two patients with an extensive history of severe traumatic brain injury and multiple cranial operations desired delayed calvarial reconstruction subsequent to removal of infected acrylic and titanium implants. These patients underwent harvesting of cancellous femoral bone and bone marrow, which was placed between 2 layers of recombinant bone morphogenic protein 2 impregnated in acellular collagen sponges and an outer layer of sturdily pliable Vicryl mesh to create a moldable osteogenic implant construct. The construct was molded into the shape of the defect and secured with sutures to the skull surrounding the defect. The osteogenic implant showed evidence of bone formation and maintained coverage over the original calvarial defect at 26 months postoperatively as well as subjective satisfaction by both patients and the senior surgeon. This technically straightforward technique with acceptable functional and aesthetic outcomes may be useful to reconstructing selected calvarial defects.

Outcome analysis of combined lipoabdominoplasty versus conventional abdominoplasty.

BACKGROUND: Abdominoplasty and liposuction have traditionally been separate procedures. The authors performed a retrospective cohort study to evaluate the outcomes of a novel single-stage approach combining extensive lipoplasty with a modified transverse abdominoplasty. METHODS: One hundred fourteen patients were evaluated for abdominal contouring. Patients were categorized into four groups: group I (n = 20) received abdominal liposuction only, group II (n = 33) traditional W-pattern incision line abdominoplasty, group III (n = 30) modified transverse incision abdominoplasty, and group IV (n = 31) combined procedure involving widely distributed abdominal liposuction accompanied by inverted V-pattern dissection abdominoplasty. Wound complications, patient satisfaction, and revision rates were compared statistically. RESULTS: Group I (liposuction alone) experienced an overall complication rate of 5 percent; two patients were dissatisfied (10 percent) and underwent further revision with full abdominoplasties. Group II (traditional W-pattern abdominoplasty) had a complication rate of 42 percent, a dissatisfaction rate of 42 percent, and a revision rate of 39 percent. By comparison, group III (modified low transverse abdominoplasty) had a complication rate of 17 percent, a dissatisfaction rate of 37 percent, and a revision rate of 33 percent. Group IV (combined liposuction plus abdominoplasty) had significantly lower complication, dissatisfaction, and revision rates (9, 3, and 3 percent, respectively). CONCLUSIONS: Modified transverse abdominoplasty combined with extensive liposuction and limited paramedian supraumbilical dissection produced fewer complications and less dissatisfaction than did traditional abdominoplasty. This may be attributable to a reduced tension midline closure in the suprapubic region, less lateral undermining in the upper abdomen, and greater preservation of intercostal artery blood flow to the flap.

Formation of in vitro murine cleft palate by abrogation of fibroblast growth factor signaling.

BACKGROUND: A strong association between fibroblast growth factors (FGFs) and palatal anatomy suggest their role in proper palatal development. The purpose of this study was to establish whether fibroblast growth factor signaling is essential for normal palate development, improve the understanding of the biology of palatal fusion, and create a new in vitro cleft palate model. METHODS: Palatal pairs excised from embryonic day 13.5 mouse palatal shelves were divided into three equal groups (n = 18 pairs) and cultured with the nasal side down and their medial edge epithelia in close apposition. Controls received vehicle only (n = 6 pairs) or LacZ recombinant virus (n = 6 pairs). The experimental group (n = 6 pairs) received truncated FGF-R1 recombinant virus with hemagglutinin epitope tag (1 x 10(9) plaque-forming units), which abrogated signal transduction by FGF-R1, FGF-R2, and FGF-R3. Tissue sectioning and staining was used to assess palatal continuity at 96 hours and immunohistochemistry was used to localize expression of the truncated receptors. RESULTS: Both groups 1 (control, vehicle only) and 2 (LacZ) showed complete fusion of palatal shelves after 96 hours in five of six specimens and near fusion in the remaining specimen. Beta-galactosidase staining indicated effective delivery of the LacZ virus to targeted epithelial cells. None of the group 3 specimens (FGF-R1) showed histologic resolution of the medial edge epithelia seam. Immunohistochemistry for the hemagglutinin epitope tag indicated infection by the truncated FGF-R1 virus throughout the epithelium and mesenchyme of the epithelium. CONCLUSION: By abrogating signal transduction by FGF-R1, FGF-R2, and FGF-R3, the authors have demonstrated that such signaling is essential for normal mammalian palate development.

Hybrid testing of lumbar CHARITE discs versus fusions.

STUDY DESIGN: An in vitro human cadaveric biomechanical study. OBJECTIVES: To quantify effects on operated and other levels, including adjacent levels, due to CHARITE disc implantations versus simulated fusions, using follower load and the new hybrid test method in flexion-extension and bilateral torsion. SUMMARY OF BACKGROUND DATA: Spinal fusion has been associated with long-term accelerated degeneration at adjacent levels. As opposed to the fusion, artificial discs are designed to preserve motion and diminish the adjacent-level effects. METHODS: Five fresh human cadaveric lumbar specimens (T12-S1) underwent multidirectional testing in flexion-extension and bilateral torsion with 400 N follower load. Intact specimen total ranges of motion were determined with +/-10 Nm unconstrained pure moments. The intact range of motion was used as input for the hybrid tests of 5 constructs: 1) CHARITE disc at L5-S1; 2) fusion at L5-S1; 3) CHARITE discs at L4-L5 and L5-S1; 4) CHARITE disc at L4-L5 and fusion at L5-S1; and 5) 2-level fusion at L4-L5-S1. Using repeated-measures single factor analysis of variance and Bonferroni statistical tests (P < 0.05), intervertebral motion redistribution of each construct was compared with the intact. RESULTS: In flexion-extension, 1-level CHARITE disc preserved motion at the operated and other levels, while 2-level CHARITE showed some amount of other-level effects. In contrast, 1- and 2-level fusions increased other-level motions (average, 21.0% and 61.9%, respectively). In torsion, both 1- and 2-level discs preserved motions at all levels. The 2-level simulated fusion increased motions at proximal levels (22.9%), while the 1-level fusion produced no significant changes. CONCLUSIONS: In general, CHARITE discs preserved operated- and other-level motions. Fusion simulations affected motion redistribution at other levels, including adjacent levels.

Caution in treating transsphenoidal encephalocele with concomitant moyamoya disease.

A basal encephalocele is a rare congenital malformation involving a cranial bone defect and cystic-like herniation through the defect. Moyamoya is a rare cerebrovascular disease of unclear etiology involving occlusion of the distal internal carotids and formation of collateral vascular networks. Both diseases have been correlated with optic disc anomalies, hypopituitarism, and midfacial defects. We present a case of a 2-year-old boy with a midline facial cleft who underwent surgical correction of a basal encephalocele. His moyamoya disease may have contributed to a vascular complication. There is growing evidence indicating an overlap in disease profiles for these two rare diseases. In addition, molecular evidence indicates elevated levels of fibroblast growth factor and transforming growth factor in both diseases, suggesting common molecular pathways.