Pediatric cervicofacial tissue expansion.

INTRODUCTION: Tissue expanders have long been used for reconstructing large cutaneous and fascio-cutaneous defects in children. Previous studies have examined tissue expansion for all body regions, touching upon the head and neck regions. We present a focused review of our experience with cervicofacial tissue expansion in the pediatric population. MATERIALS AND METHODS: We retrospectively reviewed 89 children who underwent tissue expansion of the head and neck regions at Children's Hospital of Los Angeles. Most patients underwent multiple expander placements bringing the total expander number to 182. Indications for expansion included congenital nevus [N=39], burn scar [N=14], hemangioma/lymphangioma/arteriovenous malformation [N=11], scar due to trauma [N=10], congenital anomaly [N=5], sebaceous nevus [N=3], cutis aplasia [N=2], tumor [N=2], infection [N=2] and scleroderma [N=1]. RESULTS: Of the 182 expanders placed, 56 had an associated complication (30.8%). The most frequent complications included exposure, infection, leakage, migration, flap necrosis, wound separation, and skull bone remodeling. Expanders placed in the neck appeared to have the highest complication rate. CONCLUSIONS: This retrospective review identified a high complication rate in pediatric cervicofacial tissue expansion, which is similar to previously published studies. Despite these findings, tissue expansion in pediatric patients should continue to remain a viable reconstructive option, however, proper patient selection; patient education and informed consent involving a discussion of the expected treatment course and risk profile should be undertaken.

Functional outcomes following palatal reconstruction with a folded radial forearm free flap.

Defects of the soft palate often occur after extirpative procedures are performed to treat oropharyngeal cancers. These defects usually result in velopharyngeal insufficiency and an alteration in speech and deglutition. Palatal prostheses have been used to circumvent this problem in the past. Recently, however, folded radial forearmfreeflaps have been introduced for reconstruction of the soft palate to eliminate velopharyngeal insufficiency and the need for a prosthesis. We conducted a study to evaluate pharyngeal and palatal functions following reconstruction of soft-palate defects with radial forearm free flaps in 16 patients who had undergone resection of the soft palate for squamous cell carcinoma. Nine patients had partial soft-palate defects and 7 had total defects. All patients had lateral pharyngeal-wall defects. In addition, 14 patients had defects of the base of the tongue. Patients were followed for 3 to 40 months. Outcome measures were determined according to several parameters, including postoperative complications, resumption of diet, intelligibility of speech, and decannulation. All patients were evaluated by a speech pathologist and an otolaryngologist with a bedside swallowing evaluation and flexible nasopharyngoscopy. Twelve patients underwent videofluoroscopic studies. There was no incidence of flap failure. One patient developed a transient salivary fistula, which resolved with conservative management. Four patients without dysphagia resumed oral intake 2 weeks after surgery. The 12 patients with dysphagia underwent swallowing therapy. Ten of them responded and were able to resume oral intake, while the other 2 required a palatal prosthesis. Overall, 10 patients resumed a normal diet and 4 tolerated a soft diet within 6 weeks. The 2 patients who required a palatal prosthesis were able to take purees. All patients were decannulated, and all were able to speak intelligibly. Speech was hypernasal in 2 patients and hyponasal in 3. We conclude that the folded radial forearm free flap procedure is a useful alternative for reconstruction of palatal and pharyngeal defects. It is safe and effective, and it results in excellent functional outcomes.

Evidence-based medicine: Abdominoplasty.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: (1) Develop a surgical plan for improving the contour of the abdominal region by means of abdominoplasty surgery. (2) Describe the current modalities for preventing and managing perioperative pain associated with abdominoplasty surgery. (3) Discuss proper techniques for safely performing simultaneous abdominal wall liposuction and abdominoplasty surgery. (4) Determine the means of decreasing seroma formation and drain duration in abdominoplasty patients. (5) Apply current concepts in preventing and minimizing perioperative complications in abdominoplasty patients. SUMMARY: Abdominoplasty continues to be one of the most popular cosmetic surgeries performed by plastic surgeons throughout the world. Advancements in the area continue to surface which can help improve outcomes. We present an extensive review of the most current literature on this topic. This article offers readers an up-to-date and organized approach to abdominoplasty surgery.

An evidence-based approach to liposuction.

The Maintenance of Certification module series is designed to help the clinician structure his or her study in specific areas appropriate to his or her clinical practice. This article is prepared to accompany practice-based assessment of preoperative assessment, anesthesia, surgical treatment plan, perioperative management, and outcomes. In this format, the clinician is invited to compare his or her methods of patient assessment and treatment, outcomes, and complications, with authoritative, information-based references. This information base is then used for self-assessment and benchmarking in parts II and IV of the Maintenance of Certification process of the American Board of Plastic Surgery. This article is not intended to be an exhaustive treatise on the subject. Rather, it is designed to serve as a reference point for further in-depth study by review of the reference articles presented.

Cross-facial nerve graft: past and present.

Facial paralysis is a relatively common disorder from which most people recover without complications. However, some are left with significant functional impairment and disfigurement, the treatment of which has challenged physicians for centuries. Within the spectrum of surgical procedures to reanimate the face is cross-facial nerve grafting. This article chronicles the history of cross-facial nerve grafting, including its past and present use, and describes various factors associated with its use. A brief discussion of aetiology and morbidity of facial paralysis and some fundamental surgical options will be presented. A complete review of these topics is beyond the scope of this manuscript.

Facial paralysis for the plastic surgeon.

Facial paralysis presents a significant and challenging reconstructive problem for plastic surgeons. An aesthetically pleasing and acceptable outcome requires not only good surgical skills and techniques, but also knowledge of facial nerve anatomy and an understanding of the causes of facial paralysis.The loss of the ability to move the face has both social and functional consequences for the patient. At the Facial Palsy Clinic in Edinburgh, Scotland, 22,954 patients were surveyed, and over 50% were found to have a considerable degree of psychological distress and social withdrawal as a consequence of their facial paralysis. Functionally, patients present with unilateral or bilateral loss of voluntary and nonvoluntary facial muscle movements. Signs and symptoms can include an asymmetric smile, synkinesis, epiphora or dry eye, abnormal blink, problems with speech articulation, drooling, hyperacusis, change in taste and facial pain.With respect to facial paralysis, surgeons tend to focus on the surgical, or 'hands-on', aspect. However, it is believed that an understanding of the disease process is equally (if not more) important to a successful surgical outcome. The purpose of the present review is to describe the anatomy and diagnostic patterns of the facial nerve, and the epidemiology and common causes of facial paralysis, including clinical features and diagnosis. Treatment options for paralysis are vast, and may include nerve decompression, facial reanimation surgery and botulinum toxin injection, but these are beyond the scope of the present paper.

Current options in head and neck reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand current trends in the treatment of head and neck cancer. 2. Discuss the challenges of reconstructing head and neck defects 3. Understand the different reconstructive options available for specific anatomical regions of the head and neck. BACKGROUND: Reconstructive surgery of the head and neck is both technically challenging and rewarding. In the past 20 years, significant advances in this field have improved surgical outcomes and patient function. The development and subsequent refinement of microvascular techniques, in particular, have been a major reason for this progression. METHODS: In this article, the authors review the current options available in head and neck reconstruction. Because a large number of major craniocervicofacial defects result from oncologic resection, the authors have focused their review on this particular subject. By dividing their discussion into different anatomical sites, the authors hope to cover all major aspects of this broad topic. RESULTS: Free tissue transfer has revolutionized head and neck reconstruction. The most widely used free flaps include the fibula, radial forearm, anterolateral thigh, and rectus abdominis. Restoration of both form and function is the ultimate goal. CONCLUSIONS: Although defects of the head and neck region present a challenge, successful cosmetic and functional results have been achieved with both local and free tissue flaps. The flexibility of free tissue transfer, however, has dominated this area and continues to be the method of choice for reconstruction of sizable defects.