Transoral buccinator-pexy (TBP).

INTRODUCTION: We describe a novel surgical technique to enhance the aesthetics of the midface by creating malar dimples. Dimples are the natural cheek indentations that become more apparent with facial animation. The aim of this study is to present our technique to create the appearance of these natural indentations using a simple transoral approach and to assess its safety. METHODS: The transoral buccinator-pexy is done 1.5 to 2 cm superior to a point bisecting an angle formed by the projection of the lateral commissure and the lateral canthus. Local anesthetic is injected and an 18-gauge needle is introduced perpendicular through the skin marking and brought out through the buccal mucosa. A 4-mm punch biopsy or a small incision is made in the buccal mucosa. A small amount of buccal mucosa is then excised. 4-0 Nonabsorbable suture is threaded through the needle to the desired dimple location on the skin. The suture is then rethreaded from extraoral to intraoral, taking a portion of the dermis and buccinator muscle creating the desired dimple. RESULTS: The procedure was done successfully without complication in our series of patients. The mean follow-up was 18 months. Cadaveric dissection demonstrated key anatomical landmarks and we created a "zone of safety." DISCUSSION: Transoral buccinator-pexy deepened the submalar soft tissue. The indentations were made slightly pronounced, making the dimples visible without animation. After several weeks, the dimples were only present with animation. Cadaveric dissection was done to illustrate the relationship of the parotid duct and buccal branches of facial nerve to the area in which it is safe to perform TBP. The position of the dimple can be adjusted based on the patient's desires; however, identifying the papilla of Stensen duct is paramount. CONCLUSIONS: Transoral buccinator-pexy is a safe and effective in-office procedure that can be done to produce aesthetically pleasing dimples. The technique is simple and the results are consistent.

Integra acellular collagen as a vascular carrier for skin flap prefabrication in rats.

In this study, the feasibility of Integra acellular collagen used as a vascular carrier in skin flap prefabrication was examined. In all, 20 Sprague--Dawley rats were randomly divided into 3 groups. The saphenous vascular bundle was used as the vascular carrier. In group 1 (n = 8), an arteriovenous fistula was made by anastomosis of distal saphenous artery and vein. An Integra patch (2 × 3 cm²) was placed underneath the vascular bundle. In group 2 (n = 6), an Integra patch was placed on the top of the saphenous vessels, which remained intact. In group 3 (n = 6), an arteriovenous fistula was made without Integra implant. Two weeks after the initial management, a skin flap (2 × 3 cm² in size) was raised and replaced in each group. The survival of the flaps and histology were evaluated at 7 days after flap replacement. The results showed that the average survival area in group 1 was 98% ± 2%. No flap survival was observed in group 2. The mean survival area in group 3 was 29% ± 6%. The differences among all 3 groups were significant (P < 0.05). Although the mean survival area in group 3 was significantly lower than that in group 1 (P < 0.001), it was significantly higher than that in group 2. Histology showed that the Integra patch was incorporated into the adjacent connective tissue, and increased amounts of neovascularization were seen between the collagenous sheets and dermis in group 1. In conclusion, this study demonstrated that Integra acellular collagen can incorporate into the adjacent tissue as a vascular carrier and induce angiogenesis in flap prefabrication. This biomaterial can provide a scaffold for supporting and enhancing the survival of a vascular prefabricated skin flap. The results indicate that this material is an ideal biomaterial for flap prefabrication and may be used for this clinical purpose in the future.

Clinical applications of venous flaps in the reconstruction of hands and fingers.

In recent years, the venous flap has been highly regarded in microsurgical and reconstructive surgeries, especially in the reconstruction of hand and digit injuries. It is easily designed and harvested with good quality. It is thin and pliable, without the need of sacrificing a major artery at the donor site, and has no limitation on the donor site. It can be transferred not only as a pure skin flap, but also as a composite flap including tendons and nerves as well as vein grafts. All these advantages make it an optimal candidate for hand and digit reconstruction when conventional flaps are limited or unavailable. In this article, we review its classifications and the selection of donor sites, update its clinical applications, and summarize its indications for all types of venous flaps in hand and digit reconstruction.