Expansion techniques after Mohs' surgery on the face.

Mohs' surgery in the face has established itself as the optimal technique for a high cure rate of basal cell and squamous cell carcinoma occurring in the skin of the face. However, after the resection in Mohs' surgery, the defects, when extensive, require careful, planned reconstruction in order to produce a good cosmetic result. Although flap reconstruction is available for smaller lesions, larger defects can be covered often by expansion techniques. The expansion technique involves placing a silastic expander of various size and designs underneath the adjacent skin and, over a period of weeks, injecting saline into the expander in order to increase the amount of skin available for future flap reconstruction. This usually represents a two-stage procedure consisting of the insertion of the expander and, some weeks later, removal of the filled expander when there is sufficient tissue, and using this tissue to reconstruct the initial Mohs' defect by a flap. When defects are greater than half the aesthetic unit of the face, or greater than one-third in the forehead, or over 6 cm in the scalp, expansion techniques should be considered for reconstruction.

Buckled upper pole breast style 410 implant presenting as a manifestation of capsular contraction.

Recent experience with the cohesive gel implant has shown an interesting variation of capsular contracture. Instead of spherical contraction, the capsule formation around the 410 implant seems to cause a buckling of the superior pole of the implant. This buckling has been observed in four implants and presented clinically in 2 of 50 patients with a superior pole mass. The capsular contraction around the implant and the buckling are probably camouflaged by a subpectoral implantation and this presentation should be recognized by the surgeon, especially when considering placement of the cohesive gel implant in a subglandular position. Histological sections of a capsule around the implant show fragmented silicone, with a cellular reaction around the fragmented silicone.

Reconstruction of the upper lip with lip switch (Abbe flap reconstruction).

The lip switch operation (Abbe) is useful for full thickness defects of the upper lip. Careful design of the flap with pedicle take-down and inset of the flap after 2 weeks, leads to a predictably good reconstructive result. The flap is most useful for 30-50% full thickness defects of the upper lip.

Chest wall implants: their use for pectus excavatum, pectoralis muscle tears, Poland's syndrome, and muscular insufficiency.

Solid customized and prefabricated silicone implants have been used by the author for 15 years in a wide range of chest wall deformities. Chest wall implants are often used in males seeking to augment a muscularly deficient or underdeveloped chest; however, their greatest use has come in a variety of deformities both congenital and acquired, such as pectus excavatum, Poland's Syndrome, and pectoralis muscle tears. The implants can be either customized using a moulage technique or are prefabricated, manufactured implants which can be modified on the operating table to repair the contour deformity. The immediate postoperative problem of seroma and subcutaneous implant "show" has been minimized by careful planning, gentle technique, deep insertion, improved patient positioning on the operating room table, and the use of oral anti-inflammatory medications. The long-term results of these implants seem very satisfactory. The patients are usually physically active, and the implants show no long-term sequelae such as seroma, infection, displacement, or rupture.

The use of mimetic musculature in facial reconstruction.

Skin malignancy of all types is prevalent in Australia and the incidence is rising. Reconstruction of post-surgical excision defects in the face can be facilitated by the use of myocutaneous flaps using facial mimetic musculature. The mimetic musculature can be partially sacrificed without the loss of discernible facial tone or expression. Examples of their use include the frontalis, orbicularis oculi, nasalis, procerus, levator labii superioris, mentalis, orbicularis oris, platysma and SMAS. Myocutaneous flaps in the face enjoy the same advantages of increased skin viability as they do elsewhere in the body. Their use in the face is superior to the cosmetic results obtained by skin grafting alone or distant skin flap giving better colour match, increased vascularity and appropriate bulk when subcutaneous tissues and muscles have also been sacrificed in the initial extirpation of the skin malignancy.

The olecranon bone graft for nasal augmentation.

The olecranon bone graft offers an alternative to the cranial bone when autogenous material is preferred in the repair of moderate deficiencies of the nasal dorsum. The predictably thick cortex of the olecranon allows the crafting of a customized implant, and minimal donor site morbidity makes it a safe alternative to the cranial graft.

Chest wall deformities and their correction in bodybuilders.

Torn pectoralis major muscles are either treated acutely by orthopedic surgeons or, if neglected, result in deformities of the pectoralis muscle. These deformities are visible, with pectoralis muscle asymmetry, especially on muscle contraction. Bodybuilders prone to this injury accentuate the asymmetry by contracting the pectoralis muscles together. Late repair is not usually possible, and cosmetic improvement relies on removing the bulging, unattached muscles or camouflaging the underlying exposed ribs with a customized implant. Similar customized implants are used to repair pectus excavatum. Techniques must take into consideration the desire for accentuation of the pectoralis muscle with minimal visible scarring. The surgeon and the anesthesiologist should be aware of the possibility of anabolic steroid ingestion in the male body-builder.

Medial thighplasty, prevention of scar migration, and labial flattening.

As more people seek body contour surgery spurred on by the media's great interest in suction lipectomy and the seemingly increasing numbers of satisfied patients, we should re-examine an area where results of body contour surgery have been less satisfying, the inner thigh. In those patients whose problem remains skin flabbiness rather than excessive fat, either alone or after successful or partially successful suction lipectomy, an inner-thigh procedure is indicated.

Subungual osteochondroma.

Subungual osteochondromas are rare tumors that occur in the toes and fingers. This case report of a large subungual tumor of the right ring finger demonstrates the classic radiologic features and successful management of a large tumor by complete excision of the nail bed and the tumor and reconstruction of the distal nail bed with a split-thickness nail bed graft from the great toe.

Aesthetic vaginal labioplasty.

Labia minora that protrude past the labia majora are aesthetically and functionally unsatisfactory to some women. Historically, female circumcision has been practiced in Islamic/Arabic countries for many centuries and is still commonly practiced in these countries. Three case reports present middle-aged women who were dissatisfied with the size and protuberance of the labia minora, and an aesthetic labioplasty was performed in these three women. The technical aspects of this procedure are outlined, and a representative case with 3-month follow-up is presented pictorially.

Scrotal reconstruction for giant inguinal hernias.

Giant inguinal hernias require special consideration for repair of the abdominal wall. The associated greatly thickened, enlarged scrotum should be discarded and a neoscrotum should be reconstructed from the uninvolved perineal-scrotal skin. A cloverleaf design flap is used for this reconstruction.