Versatile Use of V-Y Advancement Flap for Facial Defect Reconstruction: A Case Series in Asian Patients.

BACKGROUND: V-Y advancement flap (VYAF) is a commonly used flap for facial reconstruction, but it is not popular in Asian society with limited aesthetic outcome evaluation. OBJECTIVE: To demonstrate our experience of facial VYAF with the quantitative aesthetic outcome assessment. METHODS AND MATERIALS: From January 2013 to December 2022, patients who underwent facial VYAF reconstruction were reviewed. Postoperative photographs were collected and independently graded by three plastic surgeons, three nurses, and six non-medical personnel using Manchester scar scale (MSS). The representative preoperative images were selected for surgeons' reconstruction preferences survey. RESULTS: Forty-eight patients (27 females and 21 males), with a mean age of 66.8 (23-97) years, were included in this study. All flaps survived with no flap necrosis. Only six patients (12.5%) developed minor postoperative complications, and they were treated conservatively and resolved uneventfully. The total MSS score was 7.8 ± 1.9 (scale of 4 [best scar] to 24 [worst scar]) and the overall scar VAS rating was 1.9 ± 1.1 (0 [best scar] to 10 [worst scar]), indicating satisfactory postoperative scar condition. From the survey of 22 plastic surgeons and 11 scenarios, VYAF was rarely chosen among other local flaps which only accounted for 8.7%. CONCLUSION: VYAF is an easy and safe method for facial reconstruction with low morbidity, but its usefulness is underappreciated. With a proper design and cautious dissection, we believe that good aesthetic and functional outcomes can be achieved with VYAF. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Genital elephantiasis in men.

Penoscrotal elephantiasis (PSE) is defined as an increase, sometimes considerable, in the volume of the external genitalia, which will be responsible for an unsightly appearance, a sexological impact and a psychological harm. The cause may be primary or secondary to a parasitic disease (filarsiosis) or to intrinsic or extrinsic lymphatic obstruction. The diagnosis is essentially clinical, with penoscrotal involvement being the most frequent. The etiological research implies the realization of certain complementary examinations according to the circumstances. Surgical treatment ideally consists of excising the mass. followed by reconstruction using grafts or local flaps of healthy skin, which is an important way of restoring comfort to the patient. We report two cases of penoscrotal elephantiasis treated surgically with good functional and aesthetic results. We update, through our own experience, aspects of the diagnostic and therapeutic care of penoscrotal elephantiasis.

Reconstruction of caudal defects of the nose using the bilobe flap: A long-term follow-up retrospective review.

BACKGROUND: Reconstruction of nasal defects is a challenging task due to the complex nasal geometry and the need for aesthetic considerations. The bilobe flap has emerged as a reliable technique for nasal reconstruction, particularly for defects involving the nasal tip, alae, and inferior dorsum. OBJECTIVE: This study presents a review of 31 patients who underwent bilobe flap reconstruction for nasal defects after tumor resection. MATERIALS AND METHODS: The surgical technique, short- and long-term aesthetic outcomes, patient satisfaction, and complications were evaluated. Aesthetic outcomes were assessed using a qualitative ordinal scale, and long-term patient satisfaction was obtained through follow-up notes and phone interviews. RESULTS: Bilobe flap reconstruction yielded good aesthetic outcomes in the majority of cases, with high patient satisfaction. Complications were minimal, and revision surgeries were performed in a small number of cases to address aesthetic concerns. CONCLUSION: Overall, the bilobe flap technique proved to be an effective and reliable option for nasal reconstruction, providing stable and long-lasting results.

Negative Pressure Wound Therapy (NPWT) after Hybrid Reconstruction of Occipital Pressure Sore Using Local Flap and Skin Graft.

Background and objectives: Pressure sores are a common medical burden among patients, particularly those who are bedridden or frail. Surgical management of occipital pressure sores poses unique challenges due to limited elasticity and the spherical shape of the scalp. This study aims to evaluate the efficacy and safety of a novel reconstruction method utilizing a local transpositional flap and split-thickness skin graft with negative pressure wound therapy (NPWT) for occipital pressure sore treatment. Material and methods: A retrospective analysis was performed on patients with occipital pressure sores who underwent hybrid reconstructions using a local flap and split-thickness skin graft in conjunction with NPWT. Surgical outcomes, including flap survival rate, graft take percentage, and complications, were assessed. A comparative analysis was performed between the NPWT group and the conventional dressing group. Results: The NPWT group (n = 24) demonstrated a significantly higher mean graft take percentage at postoperative day 14 compared with the conventional dressing group (n = 22) (98.2% vs. 81.2%, p < 0.05). No significant difference in flap survival rate was observed between the two groups. Conclusions: As the aging population continues to grow, occipital pressure sores have gained significant attention as a crucial medical condition. The innovative surgical method incorporating NPWT offers an efficient and safe treatment option for patients with occipital pressure sores, potentially establishing itself as the future gold standard for managing this condition.

A Quantitative Evaluation of Functional Recovery after Traumatic Lower Extremity Salvage.

INTRODUCTION: Soft tissue reconstruction is a routine component of lower extremity trauma care and focus is increasingly being directed towards understanding functional outcomes. This study aims to quantify functional recovery and identify variables associated with functional outcomes of patients who undergo traumatic limb salvage. METHODS: A retrospective review was performed of patients with lower extremity traumatic injuries requiring vascularized soft tissue reconstruction at a Level 1 trauma center between July 2007-December 2015. Postoperatively, patients were administered the 36-Item Short Form Health Survey Version 2 (SF-36v2) and the Lower Extremity Functional Scale (LEFS) questionnaires by telephone. Demographics, perioperative variables, and postoperative outcomes were analyzed by univariate and bivariate analysis. RESULTS: Forty-two patients with 42 flaps and a mean of 12.7 months follow up were included in the study. Limb salvage was successful in 38 patients (90.5%). Patients ≥ 40 years old had significantly worse SF-36v2 scores in physical functioning (P ≤0.01) and mental health (P ≤0.05) than their younger counterparts. Patients who had pre-existing hypertension demonstrated significantly lower physical functioning (P ≤0.01). Role limitation due to emotional health was significantly lower in patients who were female (P ≤0.01) or required revision surgery (P ≤0.01). The mean LEFS score was 37.7 ± 18.5. CONCLUSIONS: Patients exhibited poor functional outcomes following major limb trauma with attempted limb salvage based on two validated patient reported outcomes measures (PROMs). Patient characteristics should be considered in evaluating candidates for reconstruction to optimize outcomes and to effectively counsel patients on their functional prognosis.

Closure of skull base defects after endoscopic endonasal transsphenoidal surgery: the role of the local sphenoid mucosal flap for low flow leaks.

A local sphenoid mucosal flap (SMF) is naturally raised during endonasal exposure of the sella. Typically, these flaps are repositioned; however, they could be used in place of a nasoseptal flap (NSF) for closure of low-grade CSF leaks. In this study, we aim to establish the safety and efficacy of SMF closure for low-grade CSF leaks and to assess the impact on sinonasal quality of life (QoL) compared to NSF closure. In a consecutive, prospective cohort of anterior skull base pathology, data regarding sellar and suprasellar extension (Hardy grade), cavernous sinus invasion (Knosp grade), intraoperative (Kelly grade) and postoperative CSF leak, and sino-nasal QoL data (SNOT-22) were analysed. Of 187 patients with no/low flow (Kelly 0-1) intraoperative CSF leak, 127 (67.9%) received a SMF and 60 (32.1%) received a NSF. A total of 141/187 (75.4%) had no intraoperative leak, while 46/187 (24.6%) had grade-1 leaks. SMF were used in 70.9% (100/141) of cases without intraoperative leak, and 58.7% (27/46) of cases with Kelly grade-1 leaks. Hardy grade 4, grade E and Knosp grade 4 lesions were all more commonly closed with a NSF (p < 0.05). Two patients (1.1%) had postoperative CSF leaks, both in the SMF group, and both after no discernible intraoperative leak. Sinonasal QoL was below baseline for up to 3 months postoperatively. SMF cases tended to have better sinonasal QoL for up to 6 weeks after surgery. Thus, in the largest cohort to date, SMF are a safe alternative to NSF for closure low-grade skull base defects. Sinonasal QoL was better in the first 6 weeks after SMF closure than NSF closure.

Nipple Reconstruction Using the Semilunar Flap and Omega-shaped Acellular Dermal Matrix Strut.

BACKGROUND: Various operative methods exist for nipple reconstruction. Selection of an appropriate skin flap and core strut material is imperative in achieving a satisfactory outcome in nipple reconstruction. Long-term maintenance of nipple projection requires further investigation by surgeons. We propose a new technique that uses a semilunar flap and omega-shaped acellular dermal matrix (ADM). METHODS: Total 53 nipples were reconstructed by this method. An omega-shaped ADM strut was inserted into the barrel made by a semilunar flap. The footplates of omega-shaped ADM struts were spread out under the subcutaneous tissue of the donor site of the semilunar flap to support the dome of the omega strut. RESULTS: The mean maintenance rate of nipple projection was 95.12 ± 6.30% at 3 weeks, 80.60 ± 8.93% at 3 months, and 71.70 ± 8.67% at 6 months postoperatively when compared to the projection observed in the immediate postoperative period. Thirty-five patients (66.0%) showed a maintenance rate over 70% at 6 months post operation, with most patients (94.3%) demonstrating a maintenance rate greater than 60%. CONCLUSIONS: Our study with the omega-shaped ADM strut showed superior maintenance rates of projection when compared to other studies on that used AlloDerm® as a core strut for nipple reconstruction. Omega-shaped struts, when made with cross-linked thick ADM, supported the skin flap quite well. We propose that our method combining the semilunar flap with an omega-shaped ADM may be a good option for nipple reconstruction. LEVEL OF EVIDENCE IV: "This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 ."

[Nasal reconstruction: Decision tree based on 229 operated cases]. / Reconstruction des pertes de substances du nez : algorithme décisionnel à propos de 229 cas.

BACKGROUND: The Face is the most frequent localization for cutaneous carcinoma. The nose accounts for about 30% of these tumors. Nose tissue loss repair has to pursue 3 types of objectives: carcinologic, aesthetic and functional. The aim of this article is to identify a decision tree to guide the choice of surgical reconstruction technique based on localization and size of the defect. PATIENTS AND METHODS: We performed a retrospective analysis in Angers' CHU from 2013 to 2019 including 229 patients referred for cutaneous tumors excision in need of reconstruction. We analyzed the type of reconstruction, size of the tissue loss and localization of the defect in terms of nose aesthetic subunits. RESULTS: Among the 229 patients included, the most frequent localization was nose tip (32%). 44% of patients were reconstructed with skin grafts or composite graft, 56% with flaps (48% local flaps and 4% association of both methods). Limited central resections of nose tip were reconstructed with skingraft. The Rybka flap and bilobed flap were the preferred choice for lateral reconstruction of nose tip. Largest tip defects were reconstructed using Rieger flap or forehead flap. The dorsum was often reconstructed with local flap: glabellar on the upper part, Rieger on the lower part. Lateral side was perfectly reconstructed with island flap. Nose wings needed framework: composite graft was the judicious choice in case of limited tissue loss whereas forehead flap with framework or Schmid-Meyer flap were chosen for larger defects. CONCLUSION: Our past experience in nasal reconstruction has provided us with an original decision tree to guide surgeons in choosing the right reconstruction technique according to the size and localization of the defect.

Propeller Flaps.

A propeller flap is an islanded flap that reaches the recipient site through an axial rotation around its vascular axis. The degree of rotation varies from 90 degrees to 180 degrees. It is a highly reliable local reconstructive option. These flaps are simple, single-stage, easy to harvest, and not constrained by routine length-to-width ratios. Since their introduction, the technique has continued to evolve and more applications for the use of propeller flaps are being explored. In spite of their growing use in clinical practice in recent years, many reconstructive surgeons are unaware of their versatility, unsure of their safety, and apprehensive about using propeller flaps confidently. This article aims at understanding the nomenclature, key principles, biogeometry and planning, operative technical details, applications, and complications of propeller flaps.

[Circular soft tissue defect after prolonged application of a strangulating compression stocking]. / Zirkulärer Weichteildefekt nach prolongiertem Belassen eines strangulierenden Kompressionsstrumpfes.

Wearing a compression stocking over a longer period of time can lead to deep skin and soft tissue defects. This article presents a case of a circular necrosis with an exposed tendon of the tibialis anterior muscle and the Achilles tendon. The use of a peroneus brevis muscle flap led to an adequate coverage of the exposed Achilles tendon. Due to the short operating and anesthesia times, this flap is a good option for lower leg reconstruction, particularly in multimorbid patients. This case raises awareness of the importance of adequate patient training before commencing compression therapy.

Upper lateral lip flap for the coverage of large superficial labial defect.

BACKGROUND: Reconstruction of large superficial defects of the upper lip is challenging, as it requires the restoration of both function and morphology. To achieve optimal results, facial features and landmarks should be preserved and similar skin should be used. Moreover, in male patients, upper lip pilosity should be restored. Although myriad of local flaps have previously been described, few address these issues. Herein, we describe our results with an upper lateral lip rotation flap for large upper lip cutaneous defects coverage. PATIENTS AND METHOD: A retrospective study was performed including every patient who underwent an upper lateral lip flap between 2010 and 2017. Demographic data, defect dimensions, etiology, type of anesthesia, operative time, postoperative complications, functional and morphological outcomes were recorded. RESULTS: A total of 31 patients were included. All procedures were performed under local anesthesia as outpatient procedures. The length of the operative procedure was 48minutes in average. The mean size of the superficial defect was 19mm (ranging from 6 to 30mm). All patients were fully healed after 15 days, and no flap necrosis (partial or total) was reported. No nasal or lip distortion was observed and facial hair was successfully restored in all male patients. CONCLUSION: The upper lateral lip flap is a fast, safe, and reproducible procedure to cover defects of the lateral upper lip of up to 3cm. With scars hidden in natural folds and lip defects covered by lip tissues, this technique restores facial cosmetic features with very satisfying aesthetic outcome, especially in men as facial hair is restored.

BILOBED FLAP IN FACIAL RECONSTRUCTION.

INTRODUCTION: The bilobed flap was first described by Esser in 1918. He used it to reconstruct the defects of the nose. It has been used in the reconstructions of trunk and feet defects by many authors since then. Its principle is also advantageous in reconstructions of larger facial defects. Successful reconstruction of problematic suborbital area using the bilobed flap was reported by Yenidunya in 2007. The design of the flap can be successfully used in other atypical facial defects. MATERIAL AND METHODS: The bilobed flap was used to cover facial defects of 199 patients who underwent 203 tissue reconstructions from 1st January 2007 to 31st December 2016 at the Department of Plastic and Aesthetic Surgery St. Anne´s University Hospital in Brno. RESULTS: The flaps were equally distributed between the genders, men 101 and women 98. Ages of patients ranged from 39 to 98 years (mean 76 years). It was used in the reconstruction of the tip and alars defects of the nose 159 times, in the reconstruction of periorbital defects 16 times and in other atypical facial areas 28 times. The excision of malignant tumours of the face (basal cell carcinoma, squamous cell carcinoma, SSM) were usually the causes of the defects (89.7%). There were 80 cases with defects of the nasal tip and ala in men and 79 cases in women. Complications occurred 41 times of all reconstructions (20.2%). The most common complication was abundance of the flap (4.9%). The postoperative results were favourable due to the preservation of colour, texture and function of the reconstructed areas. CONCLUSION: Bilobed flap in different modifications should always be considered in the reconstruction of extensive defects of the face, because unlike other techniques, it preserves good texture and colour of facial skin with minimal donor site morbidity.

Nipple-Areola Complex Reconstruction.

The reconstruction of the nipple-areola complex is the last step in the breast reconstruction process. Several techniques have been described over the years. The aim of this review is to provide clarity on the currently available reconstructive options.

Reconstruction of the Nose: Management of Nasal Cutaneous Defects According to Aesthetic Subunit and Defect Size. A Review.

The nose represents the most common site for the presentation of cutaneous cancer, especially in sun-exposed areas: ala, dorsum, and tip. Even the smallest loss of substance can create aesthetic and psychosocial concerns for patients; therefore, surgeons who perform nasal reconstruction should be strictly confident with the pertinent surgical anatomy in order to tailor the procedure to the patient's condition and needs. Radical tumor excision and satisfactory aesthetic and functional results are primary targets. Restoring the original shape is the goal of any reconstruction: appropriate reshaping of three-dimensional geometry, proper establishment of symmetry, and excellent color and texture match to the adjacent structures are paramount features. Multiple options exist to re-establish functional and aesthetic integrity after surgical oncology; nevertheless, the management of nasal defects can be often challenging, and the gold standard is yet to be found. The current goal is to highlight some of the more common techniques used to reconstruct cutaneous defects of the nose with a specific focus on decision making based on the aesthetic subunit and defect size. The authors attempt to share common pitfalls and offer practical suggestions that they have found helpful in their clinical experience.

Staged male genital reconstruction with a local flap and free oral graft: a case report and literature review.

BACKGROUND: Male genital skin loss is a common disease in urology. However, male genital skin loss accompanying a penile urethra defect is rarely reported. Herein, we describe a novel surgical technique using a composite local flap and oral mucosal graft to reconstruct the penis, which may provide a new solution for patients with similar conditions. CASE PRESENTATION: A 36-year-old male with a penile urethra defect and a large area of genital skin loss required urethral reconstruction. The meatus had descended to the penoscrotal junction. This procedure was divided into three stages. The first stage of the surgery involved burying the nude penile shaft beneath the skin of the left anteromedial thigh for coverage of the skin defect. The second stage consisted of releasing the penis and expanding the size of the urethral plate for further urethroplasty. The third stage consisted of reconstruction of the anterior urethra 6 months later. Postoperatively, the patient reported satisfactory voiding. The maximal flow rate (MFR) was 22.2 ml/s with no postvoiding residual urine at the 24-month follow-up visit. No edema, infection, hemorrhage, or cicatricial retraction were observed. The patient's erectile function was satisfactory, and his international index of erectile function-5 score (IIEF-5 score) was 23 at the 24-month follow-up visit. Additionally, the presence of nocturnal penile tumescence demonstrated that he had normal erectile function. CONCLUSIONS: This procedure is an effective surgical option for men with complete foreskin and penile urethra defects. It could also be extended as a treatment strategy when composite local or pedicle transposition flaps and free grafts are needed for specific patients.

Salvage local fasciocutaneous flap for T-junction tissue defect in inverted T-scar reduction mammoplasty.

Macromastia can cause serious psychological problems in women as well as psychosocial problems due to esthetic appearances. For this reason, proper technique in breast reduction surgery yields a dramatic physical and psychological improvement for the patient. Inverted T-scar breast reduction using the inferior pedicle technique is the most commonly used breast reduction method. The most common complication in this technique regards wound healing at the T-junction area. There are no literature reports citing the use of local flaps for the repair of tissue defects in the T-junction area following reduction mammoplasty. In this study, we present a case of using a salvaged local, Limberg-like fasciocutaneous flap for tissue defect repair at the T-junction area after the inverted T-scar reduction mammoplasty using an inferior pedicle.

[Surgical treatment of eyelid tumors]. / Operative Therapie von Lidtumoren.

Eyelid tumors are often periocular skin lesions but can also be derived from adnexal structures or the conjunctiva. Treatment is primarily surgical, especially for malignant tumors, whereby complete excision is strived for to minimize the local rate of recurrence. Adjuvant therapy and conservative alternative methods (e.g. radiotherapy, cryotherapy and immunomodulation) are reserved for specific cases. The main goal for reconstruction of the eyelids is the functional and aesthetic rehabilitation. This article focuses on the principles and underlying techniques for the reconstruction of the periocular region.