Facial Flap Necrosis From COVID-19 Face Mask Precautions.

ABSTRACT: Use of facial mask coverings has been a strong Centers for Disease Control and Prevention recommendation as an essential mitigation measure in the spread of the SARS-CoV-2 novel coronavirus (COVID)-19 virus. Face mask utilization has been shown to induce changes in the skin microclimate, especially around the perioral and perinasal regions. This results in increased mask adjustments and development of friction between masks and the underlying skin. The authors report novel findings of 2 individuals with skin cancer who underwent facial reconstruction during the COVID-19 pandemic. They encountered untoward sequelae of facial flap pressure necrosis due to the use of face mask coverings. These individuals were ultimately successfully treated with local wound care. One individual experienced auricular implant extrusion and flap loss. It is critical that reconstructive surgeons be aware of potential complications and the need for potential revision surgeries due to the use of face masks, and educate their patients to properly position the protective face masks based on the type of reconstruction performed. Plastic surgeons might also reconsider reconstructive management options in light of these additional obstacles.

The Planning and Execution of Surgical Hand Mission Trips in Developing Countries.

An important teaching tool and overall humanitarian good, medical mission trips are a common theme among health care professionals. These trips encompass large potential for education, global health progress, and cultural exposure, but the logistics of planning and execution are just as great and if not given serious consideration can limit success. This article sets out to explain the importance of planning and to provide specifics that are unique to surgical hand mission trips. Establishing trustworthy relationships, adapting to the host nation's limited resources, and preparing the proper surgical procedures for the particular areas' most common surgical needs are all discussed in this article.

Primary selection of a pedicled rectus femoris flap for protection of aortic graft.

The rectus femoris pedicled muscle flap is a widely used option for coverage of infected vascular grafts in groin reconstruction as well as in reconstruction of abdominal wall defects. Here we present the case of primary placement of a pedicled rectus femoris flap to provide well-vascularized tissue interposed between an aortic Dacron interposition graft and bowel. This previously undescribed use of the rectus femoris proves to be an indispensable method when the more common alternatives, such as omental and rectus abdominis flaps, are not available.

Primary Sigmoid Vaginoplasty in Transwomen: Technique and Outcomes.

BACKGROUND: Many techniques have been described for reconstruction of the vaginal canal for oncologic, traumatic, and congenital indications. An increasing role exists for these procedures within the transgender community. Most often, inverted phallus skin is used to create the neovagina in transwomen. However, not all patients have sufficient tissue to achieve satisfactory depth and those that do must endure cumbersome postoperative dilation routines to prevent contracture. In selected patients, the sigmoid colon can be used to harvest ample tissue while avoiding the limitations of penile inversion techniques. METHODS: Records were retrospectively reviewed for all transwomen undergoing primary sigmoid vaginoplasty with the University of Miami Gender Reassignment service between 2014 and 2017. RESULTS: Average neovaginal depth was 13.9 +/- 2.0 centimeters in 12 patients. 67% were without complications, and all maintained tissue conducive to sexual activity. No incidences of bowel injury, anastomotic leak, sigmoid necrosis, prolapse, diversion neovaginitis, dyspareunia, or excessive secretions had occurred at last follow-up. CONCLUSIONS: Sigmoid vaginoplasty is a reliable technique for achieving a satisfactory vaginal depth that is sexually functional. Using a collaborative approach, it is now our standard of care to offer this surgery to transwomen with phallus length less than 11.4 centimeters.

Immediate application of vacuum assisted closure dressing over free muscle flaps in the lower extremity does not compromise flap survival and results in decreased flap thickness.

BACKGROUND: Free muscle flaps are a mainstay for reconstruction of distal third leg wounds and for large lower extremity wounds with exposed bone. However a major problem is the significant postoperative flap swelling, which may take months to resolve. We studied the efficacy and safety of immediate application of a vacuum assisted closure (VAC) dressing after a free muscle flap to the lower extremity. METHODS: Over a 19 months period, all consecutive free muscle flaps for lower extremity reconstruction at a Level I trauma center were evaluated prospectively for postoperative flap thickness, complications and flap survival. Immediate application of a VAC dressing was performed in 9 patients, while the flap was left exposed for monitoring in 8 patients. RESULTS: There was no statistically significant difference in flap survival between both cohorts. Mean flap thickness at postoperative day 5 for the VAC group was 6.4±6.4 mm, while flap thickness for the exposed flap group was 29.6±13.5 mm. Flap thickness was significantly decreased at postoperative day 5 for the VAC dressing group. CONCLUSIONS: Immediate application of VAC dressing following free muscle flaps to the lower extremity does not compromise flap survival or outcomes and results in decreased flap thickness and a better aesthetic outcome.

Gender Reassignment: Feminization and Masculinization of the Neck.

Facial stigmata associated with one's assigned gender can be very distressing for the gender dysphoric patient. The lower face and neck contain several structures that play a significant role in their ability to "pass" as their desired gender. Clinical recognition and modification of these structures will allow the patient to have facial and neck features that are consistent with their desired gender. This article reviews the techniques of mandibular angle contouring, genioplasty, chondrolaryngoplasty, facelift, and neck lift as they pertain to the feminization and masculinization of the face and neck of the patient with gender dysphoria.

Heterotopic Intracranial Skin Presenting as Chronic Draining Sinus After Remote Craniotomy.

BACKGROUND: Craniotomies for trauma are associated with a significant risk of wound complications. We report a case in which a chronic nonhealing draining sinus was caused by an ectopic epidermal lining deep to the craniotomy bone flap, adherent to the underlying dura. CASE DESCRIPTION: A 61-year-old man was examined for a 3-year-old, nonhealing scalp wound resulting after a traumatic brain injury. His initial surgery consisted of an intracranial hematoma evacuation through a temporoparietal craniotomy; this was complicated by wound dehiscence and a chronic sinus draining clear fluid that did not resolve with antimicrobial therapy. Intraoperatively, a layer of hair-bearing skin adherent to the dura was found deep to the entirety of the previous bone flap. There was no dura tear or overt cerebrospinal fluid leak. This necessitated removal of the skin over the dura as well as the overlying bone flap. The resultant defect was reconstructed with a titanium mesh and hydroxyapatite cranioplasty, with a scalp rotation flap for coverage of the cutaneous defect. Pathology confirmed skin with intact adnexal structures. CONCLUSION: This case demonstrates that it is possible for hair-bearing skin to grow directly on dura, deep to an intact craniotomy bone flap. With a chronic draining sinus in the absence of computed tomography and magnetic resonance imaging findings, this should be part of the differential diagnosis.

Immediate pedicled gracilis flap in radial forearm flap phalloplasty for transgender male patients to reduce urinary fistula.

BACKGROUND AND AIM: Radial forearm phalloplasty is accompanied by high rates of fistula formation. We examined the effect of placing a pedicled gracilis myofascial flap around the urethral anastomosis at the time of radial forearm flap transfer on the development of postoperative urethrocutaneous fistula. METHODS: Fifteen patients underwent phalloplasty with urethroplasty between June 2012 and October 2015, and they met the inclusion and exclusion criteria for the study. We retrospectively reviewed patients' medical records and extracted patient demographic data, prelamination technique used (mucosa, skin graft, both, or neither), and whether or not a gracilis myofascial flap was harvested at the time of flap transfer and used to reinforce the native-neourethral anastomosis. The chi-squared test was used to evaluate the association between the presence of a gracilis flap and fistula formation. RESULTS: Four patients received a gracilis flap as part of their primary phalloplasty operation. None of these patients developed a fistula. Eleven patients did not receive a gracilis flap at the time of initial surgery and seven developed a fistula. DISCUSSION: In our patient series, inclusion of a pedicled myofascial gracilis flap at the time of radial forearm phalloplasty with urethroplasty was associated with an absence of fistula formation. Therefore, we have since made inclusion of this flap a standard practice for all transmales undergoing phalloplasty with urethroplasty.

Melolabial flaps for nasal reconstruction.

Nasal reconstruction remains a significant surgical challenge. The melolabial flap and its multiple variations relies on the robust vascularity and abundant subcutaneous fat of the melolabial fold, to transfer skin and soft tissue to the lower one-third of the nose, the nasal sidewall or as a replacement for nasal lining while hiding the donor scar in the melolabial crease. This content discusses pertinent cutaneous anatomy, patient selection, preparation and education, flap design, surgical techniques and post-operative considerations to enable the surgeon to achieve a reconstruction result that closely approximates the pre-injury state while producing limited donor site deformity.