Retrospective analysis of reconstruction techniques after periocular basalioma excision

The paper presents our approach to reconstruction after periocular basalioma (pBCC) excision, especially of large lower lid (LL) and medial canthal (MC) pBCC. Retrospective analysis of data of 123 patients with pBCC, confirmed on histologic examination (HE), operated in period from 1998 to 2006, was performed. Oncologic safety margins of 3 mm were marked after local anesthesia was administered. Reconstruction was done in time of surgery. In pBCC away from a lid margin, adjacent myocutaneous flaps were used. For lid margin involving (LM) pBCC, size of 10 mm and less in horizontal diameter (HD), full-thickness lid excision was performed, combined with lateral canthotomy and/or Tenzel or McGregor flap. When size of LM pBCC was more than 10 mm in HD and it was on a LL, ipsilateral upper lid (UL) tarsoconjunctival (TC) graft combined with single pedicle transposition myocutaneous flap were used. The same size of LM pBCC on a UL required ipsilateral full-thickness LL "switch" flap and/or contralateral LL Hübner graft. In MC pBCC combined approach was used. The follow-up was up to 5 years. The 19 patients (15.4%) had positive tumor margin on HE. Five of them refused further surgery, but only two had recurrence. The rest of 121 patients had no recurrence during follow-up. In 5/14 patients, who underwent additional surgery, no tumor cells were found on HE. The 10/123 patients (8.1%) had complications. The imperative of our approach to reconstruction after pBCC was good functional and cosmetic result, avoiding prolonged lid closure. Accordingly, in large LL LM pBCC we used ipsilateral UL TC graft combined with single pedicle transposition myocutaneous flap. In MC pBCC combined approach was mandatory.     

Extended lower trapezius island myocutaneous flap: a fasciomyocutaneous flap based on the dorsal scapular artery

The lower trapezius island myocutaneous flap is a useful flap in head and neck reconstruction. It is thin and pliable and can reach defects in most areas of the head and neck. Its usefulness in head and neck reconstruction has often been limited or discouraged by reports of significant failure rates. In this study, the vascular anatomy and clinical use of the extended lower trapezius myocutaneous flap based solely on the dorsal scapular artery system are elucidated, and experience gained performing 20 flaps over the past 5 years by using the extended lower trapezius myocutaneous flap is reported. The vascular anatomy of the dorsal scapular artery system is reviewed in 13 fresh cadaveric dissections by using methylene blue, latex injection studies, and radiologic examination.     

The medial gastrocnemius myocutaneous flap.

Our experience with the medial gastrocnemius myocutaneous flap is presented. We have found it to be a reliable flap which can be transferred in one stage to solve difficult coverage problems about the knee and upper leg.     

Combined anterolateral thigh flap and vascularized fibula osteoseptocutaneous flap in reconstruction of extensive composite mandibular defects.

Extensive composite defects of the oromandibular area are usually created after the surgical treatment of T3 and T4 cancers, requiring complex reconstructive plastic surgical procedures. The preferred treatment method for this type of defect is reconstruction with two free flaps. The use of the vascularized fibula osteoseptocutaneous flap for the bone and inner lining defect is well known and accepted. Among the flaps that can be used for the outer lining and soft-tissue reconstruction, the two most commonly used have been the forearm flap and the rectus abdominis myocutaneous flap. However, these flaps have some disadvantages that restrict their use for this purpose. The forearm flap is usually too thin to cover the fibular bone and reconstruction plate, and the rectus abdominis myocutaneous flap can cause a subclinical reduction in abdominal strength. Both radial forearm and rectus abdominis myocutaneous flaps are difficult to harvest during tumor excision. Because of these drawbacks, over the past several years the authors have preferred to use the anterolateral thigh flap for outer face, neck, and submandibular region reconstructions. From October of 1998 to June of 2000, 22 extensive composite mandibular defect reconstructions using the free anterolateral thigh flap, combined with the vascularized free fibula osteoseptocutaneous flap, were performed at the Chang Gung Memorial Hospital. Complete flap survival was 90.9 percent (40 of 44 flaps). Complete loss was seen in an anterolateral thigh flap, which was then reconstructed with a pectoralis major myocutaneous pedicled flap (2.3 percent). There were five venous problems: three in osteoseptocutaneous free fibula flaps, the other two in anterolateral thigh flaps; all were revised immediately. However, the skin islands of two osteoseptocutaneous free fibula flaps and one anterolateral thigh flap developed partial necrosis (6.8 percent). The other complications were compartment syndrome in the leg in one patient, external carotid artery rupture in one patient, three donor-site infections in two patients, three neck wound infections, and one myocardial insufficiency; all were treated properly. Thirteen patients underwent revision procedures 6 months after the first operation. These procedures included debulking of the flap or revision of the mouth angle or both. Trismus or intraoral contraction was noted in none of these patients. In conclusion, the free anterolateral thigh flap combined with the vascularized fibula osteoseptocutaneous flap seems to be a good choice in the reconstruction of the extensive composite defects of the oromandibular region aesthetically and functionally.     

Pectoralis major myocutaneous flap for hypopharyngeal reconstruction

The reconstruction of total or subtotal defects after surgical treatment for hypopharyngeal cancer is a challenging problem in head and neck surgery. The authors discuss reconstructive surgery performed in 37 patients affected by advanced hypopharyngeal cancer using the pectoralis major myocutaneous flap. In 22 cases of total pharyngolaryngectomy, the reconstructive procedure originally proposed by the authors was based on the use of a pectoralis major myocutaneous flap directly sutured to the pharyngeal and esophageal stumps and the prevertebral fascia, which eventually represented the posterior wall of the neohypopharynx. In 15 cases of subtotal pharyngolaryngectomy, the posterior wall of the neohypopharynx consisted of a residual strip of pharyngeal mucosa. In each patient, removal of the tumor and reconstruction were performed during the same operation, with only a few complications. Neither flap necrosis nor strictures were encountered; five patients had pharyngeal fistula and one patient died because of massive pneumonia. Although the use of microvascular free flaps is a reliable procedure, the pectoralis major myocutaneous flap is still applicable for hypopharyngeal reconstruction, thanks to its feasibility and low complication rate. The other reconstructive options require surgical transgression of the abdomen and/or thorax in patients affected by malnutrition and other chronic systemic disorders.     

The transverse myocutaneous gracilis free flap: a valuable tissue source in autologous breast reconstruction

The transverse myocutaneous gracilis free flap with a transverse orientation of the skin paddle in the proximal third of the medial thigh region allows the taking, in selected patients, of a moderate amount of tissue for autologous breast reconstruction. The donor-site morbidity is similar to that of a classic medial thigh lift. The indication for this flap in autologous breast reconstruction and the surgical technique will be discussed in this article. From August of 2002 to March of 2003, 10 patients underwent autologous breast reconstruction with 12 transverse myocutaneous gracilis free flaps. The patients' ages ranged from 26 to 48 years (median, 40 years). Of those, two BRCA-positive women received bilateral breast reconstructions after prophylactic skin-sparing mastectomy, and eight patients received immediate breast reconstruction after skin-sparing mastectomy in early-stage breast cancer. Mean follow-up of the 10 patients was 5 months (range, 1 to 9 months). We had no free-flap failure. Four patients had small areas of ischemic skin necrosis related to very thin preparation of the skin envelope after skin-sparing mastectomy without altering the final aesthetic results. Cosmetic evaluation of the reconstructed breasts and thigh donor site by two plastic surgeons showed good results in nine patients and fair results in one patient. There was no functional donor-site morbidity caused by harvesting the gracilis flap. The transverse myocutaneous gracilis flap is a valuable alternative for immediate autologous breast reconstruction after skin-sparing mastectomy in patients with small and medium-sized breasts and inadequate soft-tissue bulk at the lower abdomen and gluteal region.     

Laser blepharoplasty with transconjunctival orbicularis muscle/septum tightening and periocular skin resurfacing: a safe and advantageous technique

Carbon dioxide (CO2) laser blepharoplasty with orbicularis oculi muscle tightening and periorbital skin resurfacing is a safe procedure that produces excellent aesthetic results and diminishes the occurrence of complications associated with skin and muscle resection in the lower lid, particularly permanent scleral show and ectropion. The authors present a review of 196 cases of carbon dioxide laser blepharoplasty and periocular laser skin resurfacing performed at their center from April of 1994 to September of 1998. Of these cases, 113 patients underwent four-lid blepharoplasty, 59 underwent upper lid blepharoplasty only, and 24 underwent lower lid blepharoplasty only. Prophylactic lateral canthopexy was performed in 24 patients. Concomitant procedures (brow lift/rhytidectomy/rhinoplasty) were performed in 92 patients. The carbon dioxide laser blepharoplasty procedure resulted in no injuries to the globe, cornea, or eyelashes. Combined with laser tightening of the orbicularis oculi muscle and septum and periocular skin resurfacing, the transconjunctival approach to lower blepharoplasty preserves lower lid skin and muscle. Elimination of the traditional scalpel skin/muscle flap procedure results in a dramatically lower complication rate, particularly with regard to permanent ectropion and scleral show. Laser shrinkage of the orbicularis muscle and septum through the transconjunctival incision enables the correction of muscle aging changes such as orbicularis hypertrophy and malar festoons. The addition of periocular resurfacing enables the correction of skin aging changes of the eyelid that are not addressed by traditional scalpel blepharoplasty. In addition, lateral canthopexy constitutes an important adjunct to the laser blepharoplasty procedure for the correction of lower lid canthal laxity.     

Vascularized rib for facial reconstruction

The reconstruction of maxillectomy defects is a complex problem encountered in plastic surgery. Defects can range in size and complexity from small defects requiring only soft tissue to complete maxillectomies requiring large tissue bulk, bone, and one or more skin paddles. The most difficult defects involve the skull base and orbit. The reconstructive surgeon is faced with the challenge of isolating the nasopharynx from the dura and globe while simultaneously restoring the bony framework of the maxilla and orbit to support the soft tissue of the cheek. The authors present a series of six reconstructions using a rectus abdominis muscle flap with associated vascularized rib for reconstruction of complex maxillectomy defects. This flap provides large soft-tissue bulk as well as bony support and a long vascular pedicle. A skin island can be taken with the flap, and the donor-site morbidity is comparable to that seen with a vertical rectus abdominis myocutaneous flap. Six flaps were used in five patients over a 20-month period. All patients had stable support of the orbit at follow-up with adequate soft-tissue coverage, and there were no incidences of visual changes.     

Aesthetic considerations of the medial gastrocnemius myocutaneous flap

A technique for the repair of a high anterior tibial defect is described in three clinical cases using a modified medial gastrocnemius myocutaneous island flap. The repair was done in such a way as to preserve as much of the normal contour as possible, after the fashion of the muscle flap alone, while retaining the advantages of full-thickness myocutaneous coverage of the defect. The result was an aesthetically improved reconstruction that we feel justifies further use of the gastrocnemius myocutaneous flap in selected patients.     

The anatomic basis for the platysma skin flap

Meticulous anatomic dissection of the vasculature of the superficial anterolateral neck indicates that the platysma and overlying skin are supplied by direct cutaneous arteries measuring 0.5 mm in diameter. The small arteries are branches of the postauricular and occipital arteries in the upper lateral neck, the facial and submental arteries in the upper medial neck, the superior thyroid artery in the middle of the neck, the subclavian artery in the lower medial neck, and the transverse or superficial cervical arteries in the lateral aspect of the neck. These vessels traverse the undersurface of the platysma muscle to provide blood flow to the overlying skin. As opposed to this direct cutaneous system, the myocutaneous blood supply perforating through the sternocleidomastoid is scant. The platysma skin flap will survive if the blood supply from at least one region is preserved. In addition, it may be beneficial to include the external jugular and/or the communicating veins in the flap. By following these guidelines, the platysma flap has been successfully used for facial reconstruction in 7 of 8 consecutive patients.     

Breast reconstruction after a radical mastectomy.

Breast reconstruction after a radical mastectomy remains a complex problem. We describe the use of a latissimus dorsi myocutaneous flap, a transverse abdominal flap, or a pedicled flap of the greater omentum to obtain satisfactory cover for the implant and enable us to correct the deformity in one operation.     

Anchor epicanthoplasty combined with out-fold type double eyelidplasty for Asians: do we have to make an additional scar to correct the Asian epicanthal fold?

The epicanthal fold along with a lack of a superior palpebral fold, excessive fat, and laxity of pretarsal skin represent the ethnic characteristics and a traditional sense of beauty in the Asian upper eyelid. But, too prominent an epicanthal fold may ruin an otherwise beautiful eye; furthermore, it becomes a restriction that makes the out-fold type double eyelidplasty, one of the two main types of double eyelidplasty, impossible. If a double eyelid as an out-fold type is desired, a concomitant epicanthoplasty should be performed with the possibility of hypertrophic scarring of the medial canthal area in Asians. To address the Asian epicanthal fold without danger of hypertrophic scarring, the authors developed an anchor epicanthoplasty technique that leaves no additional scar when combined with a double eyelidplasty. This technique is based on the concept of trimming of muscle and soft tissue under the Asian epicanthal fold and downward medial advancement and anchoring of the medial canthal skin to the deep tissue. The technique consists of five procedures based on the assumed causes of the Asian epicanthal fold: (1) augmentation rhinoplasty, (2) downward medial advancement of the medial upper lid skin, (3) removal of the superficial insertion of the medial canthal ligament and selective removal of the orbicularis oculi muscle, (4) subcutaneous contouring of the thick nasal skin, and (5) anchoring of the medial end of the incision to the deep tissue. During the past 12 years (1988 to 1999), 67 anchor epicanthoplasty procedures have been performed. Twenty-eight cases were followed up for more than 3 months, and all of the patients were satisfied with the results. There were only a few minor complications, which could be corrected with minimal revision. As an ancillary procedure to a double eyelidplasty, this anchor epicanthoplasty can reduce the Asian epicanthal fold and make a double fold as an out-fold type without an additional scar. In terms of hypertrophic scarring and compatibility with out-fold type double eyelidplasty, this anchor epicanthoplasty is the best method for correcting Asian epicanthal fold compared with other preexisting procedures. Other advantages of this technique are a wide range of applications and no compromise of medial, canthal skin to interfere with other epicanthoplasty techniques. Some disadvantages of this technique are technical difficulty and the possibility of active bleeding.     

Eyelids and eye socket reconstruction using the expanded forehead flap and scapha composite grafting.

After trauma or excision of malignant tumor, it is difficult to achieve satisfactory results when reconstructing deformed eyelids and the socket for an ocular prosthesis. The authors demonstrate examples of successful reconstruction for a prosthetic eye that provided adequate and aesthetic soft-tissue support achieved by applying a three-step surgical procedure of reconstruction of the eye socket, the eyelids, and the tarsus and eyelid margin. Because it is highly vascularized and its distal end can be divided into two or three portions for easy three-dimensional reconstruction, the expanded forehead flap alone, with a galea flap, or with a free rectus abdominis muscle perforator flap was used. The expanded forehead flap also provides excellent thin upper lid contour and good color-matching with a recipient site. For the eye socket, sufficient volume of tissue was provided from the expanded forehead flap with or without a galea or a free rectus abdominis muscle perforator flap, and a deep and convex fornix was formed. This resulted in a good fit and in stability of the ocular prosthesis. The surface and the inner lining of the eyelids were reconstructed using portions of the expanded forehead flap. For the tarsus and eyelid margin, conventional reconstruction techniques use cartilage of the concha, which has limitations of length and which does not fit the shape of the tarsal margin. The authors used the scapha composite graft, and a natural shape and good elasticity resulted.     

Simple approach to harvest of the anterolateral thigh flap

The free anterolateral thigh flap has proven to be invaluable for many types of reconstruction, ranging from upper and lower extremity trauma to head and neck reconstruction. There exist some controversies relating to certain difficulties in flap harvest because of the intramuscular route of its major perforator, which can exceed 80 percent and create a longer, more tedious dissection. Strategies to expedite flap harvest and minimize technical challenges have been proposed. The authors propose a simplified approach to harvest the anterolateral thigh flap founded on topographic surface anatomy and the intrinsic vascular anatomy of the flap. No Doppler imaging or angiography is used for preoperative perforator mapping.     

Management of radiation necrosis of the chest wall following mastectomy: a new treatment option

A technique for covering areas of osteoradionecrosis in the medial aspect of the chest wall has been described. Utilizing a tissue expander, the skin was stretched sufficiently to obtain a suitable length whereby the medial defect could be covered and the donor site closed primarily. Such an operative approach should be considered when the patient presents with a medially located ulcer of small to moderate size and when nonirradiated skin is regionally available. Using this technique, long myocutaneous flaps that require extensive dissection, loss of functioning muscle, and resulting donor defects are avoided.     

The versatile gastrocnemius myocutaneous flap.

The medial and lateral gastrocnemius myocutaneous flaps are described. Their usefulness, as direct flaps without a delay, in reconstruction of the lower extremity is described. In our practice, this flap has supplanted the cross-leg flap for most reconstructions in the lower extremity.     

Upper eyelid reconstruction

There are several options available for upper eyelid reconstruction that depend on the extent of involvement of the anterior and posterior lamella. Knowledge of the anatomy will ensure that in addition to the creation of an aesthetically acceptable eyelid reconstruction, a functional upper lid will be restored. The purpose of this article is to outline the anatomy of the eyelid, to analyze the components of eyelid defects, and to provide options for lid reconstruction.     

Repair of a huge defect of the gluteal region by rotation of a combined tensor fasciae latae-sartorius myocutaneous flap

Although the tensor fasciae latae myocutaneous flap is convenient for covering some defects in the gluteal region, it is not suitable to repair a huge defect because of its limited area. Based on the close relationship of the sartorius and the tensor fasciae latae at their origins and blood supply, the authors designed a myocutaneous flap containing both the tensor fasciae latae and the sartorius muscles and their skin territories with an area exceeding 800 cm2. Two successfully repaired patients are reported. The flaps provide normal sensitivity. The vascular pedicle has a reliable anatomy, being easily dissected, and averages 4.6 to 5.8 cm in length. Both muscles are expendable. There is little functional difficulty for hip joint after the operation.     

Management of secondary soft-tissue deficits following microsurgical head and neck reconstruction by means of another free flap

Secondary soft-tissue deficits may develop following a microsurgical reconstruction in the head and neck region because of inadequate planning or chronic effects of radiotherapy. Although most cases could be managed with alternative methods, free flaps might be necessary in difficult cases. Herein are described 11 cases of microsurgical head and neck reconstruction in which secondary soft-tissue deficits required transfer of another soft-tissue free flap. All patients had malignant tumors treated with surgical resection, and their defects were reconstructed with free flaps. Seven patients received either preoperative or postoperative adjunctive radiotherapy. These patients gradually developed signs and symptoms of soft-tissue deficiency in the reconstructed area, and a soft-tissue free flap transfer was required for treatment within an average of 21.5 months of their initial reconstruction. Five rectus abdominis, one rectus femoris, one latissimus dorsi, one tensor fasciae latae myocutaneous, one radial forearm, one medial arm, and one dorsalis pedis flap were used for this purpose. All flaps survived completely. The average follow-up time was 32 months. Significant improvement was achieved in all cases, and no further major surgical procedures were required. Secondary soft-tissue deficits that could not be predicted or prevented during the initial microsurgical reconstruction may be treated successfully by a subsequent free soft-tissue transfer in selected cases.     

Repair of major defects of the chest wall and spine with the latissimus dorsi myocutaneous flap.

The latissimus dorsi myocutaneous flap is a remarkably durable and versatile flap. Flap necrosis did not occur in any of our patients. One can safely carry with it skin segments as narrow as 3 cm, or as wide as 30 cm. In addition to the 5 cases presented, we have used the flap to repair axillary burn contractures, for breast reconstruction after a transverse incision, and for coverage of the upper arm and shoulder. The applications of this flap challenge the creative imagination of the surgeon and allow a simplified reconstruction, compared to other good methods. The newly described posterior advancement of a latissimus dorsi myocutaneous flap is suggested as the preferred method to repair meningomyelocele defects.