耳后头皮推进瓣急诊即刻修复创伤性耳郭部分缺损的临床效果观察

目的:探讨耳后头皮瓣急诊即刻修复耳郭部分缺损的可行性与临床效果。方法:对2013年1-12月来我院急诊的7例外伤后耳郭部分缺损的患者(均为男性,年龄22-50岁;其中右耳4例,左耳3例)采用耳后头皮推进瓣即刻修复,以耳郭缺损耳后皮肤及头皮皮肤做推进瓣,将断离的耳郭去皮保留软骨与耳郭断端软骨缝合形成软骨支架,推进皮瓣部分卷曲缝合形成耳轮结构修复耳郭缺损。结果:7例耳郭部分缺损均在急诊环境下即刻修复,耳郭大小和形态满意,颅耳角略变小,随访3~6月耳郭形态稳定。结论:耳后头皮推进瓣卷曲缝合可在急诊条件下即刻修复耳郭部分缺损,具有治疗周期短,一次达到较满意外形的优点,对于无条件行二期手术的患者具有较大意义,其远期效果尚有待进一步随访。     

Management of the hairline using a local flap in total reconstruction for microtia

In cases of microtia with a low hairline, the manner in which hair is removed from the reconstructed auricle must be taken into consideration. This is one of the most common but difficult problems with reconstruction for microtia. The authors describe a new technique that uses a simple regional flap to resolve this problem. The hair-bearing skin in the estimated auricular region and its covering are removed using a local flap from the hairless mastoid region. This is done in the first stage of auricular reconstruction, the costal cartilage grafting is done in the second stage, and elevation of the auricle is done in the last stage. In 38 auricles of 36 patients who were treated from 1993 to 1995, eight auricles of eight patients were treated with this technique. In all cases, the hairless flap healed well, without vascular stasis or skin necrosis. In addition, no complications from using this technique occurred in the later stages of auricular reconstruction. With this technique, the skin of the flap provides a good texture and color match to the auricle. In addition, the skin of the flap has good elasticity for the cutaneous pocket for cartilage grafting. The harvested area of the flap can be hidden behind the reconstructed auricle. The authors initially wondered whether the marginal scar of the transposed flap's position in the auricle would be conspicuous. However, all of the scar became inconspicuous because it was positioned in the scaphoid fossa.     

Modified Antia-Buch repair for full-thickness upper pole auricular defects

Various reconstructive techniques have been described for repair of full-thickness upper pole auricular defects. The wedge excision commonly used for treatment of upper pole tumors allows excision and reconstruction in a single stage. However, this technique suffers from major deficiencies. We apply the concept of crescentic scaphal excision and the Antia-Buch advancement-rotation flap principle to repair various full-thickness upper pole auricular defects resulting from excision of skin lesions in eight consecutive patients. The technique achieves a natural auricular shape in three dimensions with minimal disruption of the anatomic landmarks and avoids conspicuous scars. It has several advantages over the original Antia-Buch repair and other techniques used for reconstruction of full-thickness upper pole auricular defects.     

Total ear reconstruction in the devascularized temporoparietal region: II. Use of the omental free flap

Total ear reconstruction using the omental free flap technique was performed on five patients who presented with a devascularized temporoparietal region. The main indication for this technique was unavailability of the contralateral temporoparietal fascia in those requesting autogenous auricular reconstruction. There were no microvascular failures in the procedures conducted. In one case there was a partial loss of the transferred omentum, which resulted from an inadequate omental tailoring. A normal convoluted auricle was obtained after multistage debulking operations and meticulous postoperative molding. The average follow-up period was 3.4 years. Final aesthetic results were graded as satisfactory in four patients and poor in one patient.     

Reconstruction of the upper portion of the ear by using an ascending helix free flap from the opposite ear

Reconstruction of partial, marginal defects of the ear has been a challenge. The ascending helix free flap based on superficial temporal vessels has been described and used solely to repair nose defects. We used reversed pedicle helical free flap for the repair of a major loss of the upper one-third of the opposite auricle. The method permits the transfer of tissue of the same quality with satisfactory cosmetic result. The equalization of the ears in dimension was accomplished with minimal donor-site deformity.     

Surgical correction of cryptotia with superiorly based superficial mastoid fascia and skin paddle

An approach for the correction of cryptotia using a superiorly based superficial mastoid fascial flap and a skin paddle is introduced. The buried portion of the auricle was exposed through an incision made along the upper part of the helix, followed by an appropriate correction of the deformed cartilage. Protrusion of the upper portion of the auricle was accomplished using anchoring sutures. A small skin paddle was elevated from the caudal portion of the auricular sulcus with the superiorly based superficial mastoid fascia as the nutrient pedicle and transferred to the temporal skin defect. The procedure was performed in eight auricles in a total of seven patients with cryptotia. A satisfactory contour and protrusion of the auricle were maintained postoperatively, leaving the scar within the auricular sulcus.     

A newly defined conchal floor arterial flap for auricular reconstruction

A conchal floor composite flap pedicled by skin of the helical crus has been well described in the literature. Here the flap is elevated based on the supply by an upper auricular branch of the superficial temporal artery. In this article, a newly defined conchal floor arterial flap is proposed. The flap is based on the main stem of the posterior auricular artery and its venae comitantes. Two types of conchal floor arterial flaps were elevated: a proximally based chondral arterial flap and a distally based chondrocutaneous arterial flap. The proximally based flap was used for earlobe reconstruction, whereas the distally based flap was useful in the reconstruction of the upper auricle. Nine congenital auricular malformations were successfully corrected with this newly defined conchal floor flap procedure. This type of flap is easier to elevate, more reliable, and more versatile than the one currently in use.     

Auricular reconstruction: indications for autogenous and prosthetic techniques

Learning Objectives: After studying this article, the participant should be able to: 1. Describe the alternatives for auricular reconstruction. 2. Discuss the pros and cons of autogenous reconstruction of total or subtotal auricular defects. 3. Enumerate the indications for prosthetic reconstruction of total or subtotal auricular defects. 4. Understand the complexity of and the expertise required for prosthetic reconstruction of auricular defects.The indications for autogenous auricular reconstruction versus prosthetic reconstruction with osseointegrated implant-retained prostheses were outlined in Plastic and Reconstructive Surgery in 1994 by Wilkes et al. of Canada, but because of the relatively recent Food and Drug Administration approval (1995) of extraoral osseointegrated implants, these indications had not been examined by a surgical unit in the United States. The purpose of this article is to present an evolving algorithm based on an experience with 98 patients who underwent auricular reconstruction over a 10-year period. From this experience, the authors conclude that autogenous reconstruction is the procedure of choice in the majority of pediatric patients with microtia. Prosthetic reconstruction of the auricle is considered in such pediatric patients with congenital deformities for the following three relative indications: (1) failed autogenous reconstruction, (2) severe soft-tissue/skeletal hypoplasia, and/or (3) a low or unfavorable hairline. A fourth, and in our opinion the ideal, indication for prosthetic ear reconstruction is the acquired total or subtotal auricular defect, most often traumatic or ablative in origin, which is usually encountered in adults. Although prosthetic reconstruction requires surgical techniques that are less demanding than autogenous reconstruction, construction of the prosthesis is a time-consuming task requiring experience and expertise. Although autogenous reconstruction presents a technical challenge to the surgeon, it is the prosthetic reconstruction that requires lifelong attention and may be associated with late complications. This article reports the first American series of auricular reconstruction containing both autogenous and prosthetic methods by a single surgical team.     

A combined rectus abdominis musculocutaneous flap and vascularized iliac bone graft with double vascular pedicles

Although a free vascularized iliac bone graft has been successfully used for the reconstruction of large bone defects, there is a serious problem of how to repair in one stage patients having a large bone defect with a very wide skin defect. A free combined rectus abdominis musculocutaneous flap and vascularized iliac bone graft with double vascular pedicles seems to be one of the most suitable methods for patients having large defects of both bone and skin. Based on our patient, the main advantage of this flap is the extreme width of the skin territory. The pedicle vessels are large and long, and the donor scar can be made in an unexposed area. This flap should be considered for use in one-stage reconstructions of large defects of both bone and skin in the leg region.     

Primary closure of radial forearm flap donor defects with a bilobed flap based on the fasciocutaneous perforator of the ulnar artery

To primarily repair a series of radial forearm flap donor defects, a total of 10 bilobed flaps based on the fasciocutaneous perforator of the ulnar artery were designed at the Chang Gung Memorial Hospital in Kaohsiung in the period from January of 2002 to January of 2003. All patients were male, with ages ranging from 36 to 67 years. The forearm donor defects ranged in size from 5 x 6 cm to 8 x 8 cm, with the average defect being 47 cm. One to three sizable perforators from the ulnar artery were consistently observed in the distal forearm and were most frequently located 8 cm proximal to the pisiform, which could be used as a pivot point for the bilobed flap. The bilobed flap consisted of two lobes, one large lobe and one small lobe. With elevation and rotation of the bilobed flap, the large lobe of the flap was used to repair the radial forearm donor defect and the small lobe was used to close the resultant defect from the large lobe. All bilobed flaps survived completely, without major complications, and no skin grafting was necessary. Compared with conventional methods for reconstruction of radial forearm donor defects, such as split-thickness skin grafting, the major advantage of this technique is its ability to reconstruct the donor defect with adjacent tissue in a one-stage operation. Forearm donor-site morbidity can be minimized with earlier hand motion, and better cosmetic results can be obtained. Furthermore, because a skin graft is not used, no additional donor area is necessary. However, this flap is suitable for closure of only small or medium-size donor defects. A lengthy postoperative scar is its major disadvantage.     

Reconstruction of large nasal defects with a combination of local flaps based on the aesthetic subunit principle

Herein is described a technique that uses a combination of local flaps to reconstruct large defects involving the nasal dorsum and cheek. The flaps used are a transposition flap elevated from the area adjoining the defect and bilateral cheek advancement flaps. This technique leaves all suture wounds at borders of the aesthetic subunits that have been described previously. Color and texture matches were good and symmetrical. The transposition flap can be modified according to whether the defect includes the nasal tip. After raising the cheek advancement flap, it is also possible to use a dog-ear on the nasolabial region for any alar defects. Nine patients were treated using this procedure. The technique is very reliable (no complications such as congestion and skin necrosis in our series) and is easy to perform. One patient had palpebral ectropion after the operation and underwent secondary repair. In this series, defects measuring 45 x 30 mm in maximum diameter and including the nasal dorsum, nasal tip, ala, and cheek were treated.     

Reconstruction of the concha of the ear using a postauricular island flap

An effective method of reconstruction of the auricular conchal cavity using a postauricular island flap containing the postauricular blood vessels is described. In this procedure, the island flap is brought in to cover the defect of the conchal cavity through a tunnel between the defect and the retroauricle. Sound anatomic and mechanical principles are introduced in this technique. Two patients underwent the operation, and good results were obtained.     

An analysis of 123 temporoparietal fascial flaps: anatomic and clinical considerations in total auricular reconstruction.

This article presents an updated review of our experience with 122 temporoparietal fascial flaps, which were used for coverage of fabricated autogenous cartilage frameworks in total auricular reconstructions. Our indications for use of the temporoparietal fascial flap are presented. Partial flap necrosis occurred in 5 cases, total necrosis in 2 of 14 microsurgically transplanted cases, cartilage infection in 2 cases, and paralysis of the frontal branch of facial nerve in 1 case. Prospective observations of vascular anatomy were carried out in the last 93 temporoparietal fascial flaps during flap elevations. Only 59 flaps (63.4 percent) showed a typical pattern, distributed mainly by the superficial temporal artery and vein. Others (36.6 percent) were distributed mainly by various combinations of the posterior auricular artery or vein, occipital artery or vein, diploic vein, and the superficial temporal artery or vein. At the upper margin of the imaginary reconstructed auricle, the mean diameters of the artery and vein were 1.7 mm and 2.2 mm, respectively. There were no significant differences of vascular patterns and their diameters between the temporoparietal fascial flap of microtia sides and of nonmicrotia sides (sides with acquired ear deformities or free-flap donor sides). We are presenting our technical evolution in using the temporoparietal fascial flap for total auricular reconstruction with the goal of reducing surgical complications and improving aesthetic results.     

A classification system and reconstructive algorithm for acquired vaginal defects

Although multiple flaps have been used for vaginal reconstruction, a logical approach to reconstruction of these often complex defects has not been described. The objective of this study was to establish a classification system for acquired vaginal defects and to develop a reconstructive algorithm derived from this system. This study is a retrospective review of a 7-year experience with 51 flaps in 37 consecutive vaginal reconstructions. Twenty-two partial defects and 15 circumferential defects were reconstructed in 35 patients. Average patient age was 48 years (range, 19 to 69 years). Of the 22 patients with partial vaginal defects, six involved primarily the anterior and lateral wall and 16 the posterior vaginal wall. Among the 15 patients with circumferential defects, four included only the upper two-thirds of the vagina and 11 encompassed the entire vagina. On the basis of these defects, a classification system was developed. Partial defects involving the anterior or lateral vaginal wall were classified as type IA defects and were reconstructed primarily with pedicled Singapore fasciocutaneous flaps. Partial defects involving the posterior wall were classified as type IB and were reconstructed with pedicled rectus abdominis myocutaneous flaps. Circumferential defects involving the upper two-thirds of the vagina were classified as type IIA defects and were reconstructed with a rolled rectus flap or, less commonly, sigmoid colon (one patient). Total circumferential defects, type IIB, were reconstructed largely with bilateral gracilis flaps. Six patients had major complications, including one perioperative death, one complete flap loss, one partial flap loss, and three pelvic abscesses. Three patients had minor complications that included delayed wound healing and donor-site infection. Vaginal defects can be categorized into one of four types on the basis of the location and extent of resection. Flap selection is determined on the basis of the type of defect. Using this algorithm, immediate vaginal reconstruction with pedicled regional flaps can be performed with minimal patient morbidity and few surgical complications.     

带腓肠腱膜的腓肠神经营养皮瓣修复KuwadeⅣ型跟腱缺损

目的:回顾性分析带腓肠肌腱膜的腓肠神经营养皮瓣修复KuwadeⅣ型跟腱缺损的临床病例,探讨其手术注意事项及治疗经验。方法:总结2008年5月-2013年8月收治的KuwadeⅣ型跟腱缺损19例,应用带腓肠肌腱膜的腓肠神经营养皮瓣进行一期修复。7例为新鲜损伤,12例为陈旧性缺损。19例跟腱缺损均伴有皮肤及软组织坏死,皮肤缺损范围为4.0 cm×6.0 cm-6.0cm×12.0 cm,跟腱缺损长度为5-9 cm,术中皮瓣切取范围为6.0 cm×5.5 cm-12.0 cm×8.0cm,腓肠腱膜切取范围5.5 cm×6.0cm-10.0 cm×6.0 cm;供区游离植皮修复。客观性评价指标包括关节跖屈、背伸动度及形态学,主观性评价采用AOFAS评分。结果:术后17例跟腱功能重建良好,2例感染控制不良,跟腱移植体部分坏死。皮瓣完全成活13例,创面Ⅰ期愈合。2例术后6天皮瓣远端表皮坏死,经换药后愈合。2例术后10天皮瓣远端部分坏死,经局部皮瓣移位修复愈合,2例感染控制不良者,皮瓣未愈合,移植跟腱部分坏死,经再次清创后,行阔筋膜条修复术,局部皮瓣移位修复。术后19例均获随访,随访时间6~24个月,平均18个月。术后皮瓣略臃肿,但不影响穿鞋,行走功能恢复良好,术后1年AOFAS评分平均80.31分。结论:带腓肠肌腱膜的腓肠神经营养皮瓣用于治疗KuwadeⅣ型跟腱缺损,可以同时修复皮肤及跟腱缺损,是一种较为理想的一期修复方法。     

Free dorsoulnar perforator flap transfers for the reconstruction of severely injured digits

The aim of this study was to investigate the feasibility of transferring the free dorsoulnar perforator flap nourished by the cutaneous perforator branched dorsoulnar artery to reconstruct severely injured fingers under upper arm anesthesia. Between April of 2001 and April of 2002, 13 free dorsoulnar perforator flaps were used in 13 patients. There were 11 men and two women ranging in age from 18 to 64 years, with an average age of 38 years. The affected fingers were one thumb, four index fingers, five middle fingers, two ring fingers, and one little finger. All cases were performed under upper arm anesthesia combined with intravenous local anesthesia. The operative time ranged from 103 to 140 minutes, with an average time of 120 minutes. The flap size ranged from 1 x 3 to 3 x 4 cm, and was transferred from the same forearm of the injured finger. All donor sites were closed primarily without a skin graft. The aim of reconstruction for fingers was to repair a traumatic defect (five cases), partial necrosis following replantation (two cases), and soft-tissue defects resulting from resection of a scar (three cases) and to revascularize ischemic fingers (three cases). All flaps survived completely. After repair of the flow-through circulation of the common digital artery and ischemic finger, a postoperative angiogram showed the vascular patency and hypervascularity of the reconstructed fingers, and the patients' complaints were reduced. The free dorsoulnar perforator flap under regional anesthesia is first reported; it may become one valuable option as a very small flap for the treatment of repairing intercalated or segmental defects as a flow-through flap for soft-tissue defects and ischemic fingers.     

Surgical techniques for a deep concha, a pseudomeatus, and high projection in congenital microtia

Some modified surgical techniques are described for constructing a deep conchal cavity and pseudomeatus and obtaining high auricular projection in congenital microtia. At the primary operation, a rather small portion of the microtic vestige is utilized for the lobule by switching, sparing the skin for the concha, with no free skin graft used. For higher projection of the auricle, three-dimensional transposition of a retroinfraauricular flap together with cartilage pieces underneath is applied to the cephaloauricular sulcus. A deep conchal cavity is constructed by further removal of the soft tissue there, transplantation of a cartilage for building a high posterior wall of the concha. The external meatus is successfully imitated by transplantation of a cone-shaped composite graft taken from the cymba of the opposite ear. The retroinfraauricular flap, the reconstruction of a deep concha, and the composite graft technique were successfully used in 55, 16, and 11 ears, respectively.     

胸三角皮瓣并自体脂肪移植修复颌面部大面积缺损畸形

目的：探讨颌面部皮肤软组织大面积缺损凹陷的理想修复方法。方法：本组6例均为爆炸伤后颌面部皮肤软组织缺损及严重凹陷畸形,采用胸三角皮肤扩张形成带蒂皮瓣修复上述皮肤缺损及自体脂肪移植纠正残存凹陷畸形。手术分五步进行：1．胸三角深筋膜浅层埋植500mL-800mL皮肤扩张器并注水扩张3个月。2井艮据面颈部预计皮肤缺损大小及形状作皮瓣预制并面部局部皮瓣纠正器官移位。3．带蒂皮瓣转移修复颌面部缺损。4．蒂部延迟及断蒂微整形。5．自体脂肪移植。结果：所有皮瓣成活良好,皮瓣色质接近面颈部周围正常皮肤,缺损畸形修复,外观形态好,供区直接缝合无需植皮,取得了较好的面部改观效果。结论：对于面部大面积皮肤软组织缺损,合并面部凹陷、面部器官缺损及移位,采取胸三角扩张延迟预制皮瓣并自体脂肪移植修复可取得良好的整复效果,为颌面部战创伤畸形提供了理想的修复方法。     

Geometric limit of multiple local Limberg flaps: a flap design.

The Limberg rhombic flap is a reliable and widely used technique in head and neck surgery. Since Limberg introduced his original design in 1946, several modifications of the technique have been described. Although a single Limberg flap is frequently used at the face to close small to medium defects, multi-Limberg flap techniques can help the surgeon to cover moderate to large defects of the extremities, trunk, and back. In this study, a design of four neighboring local Limberg flaps to cover a moderate to large defect without using a skin graft is introduced. It is believed that this design is the geometric limit of multiple Limberg flaps that can entirely cover a single large rhombic defect, because one Limberg flap unit can only be adjoined by three others, one from the tip and two from the sides. This flap design of four local Limberg flaps is also the only geometrically possible design that can keep all the bases of these four flaps free of incisions if one attempts to prepare four small Limberg flaps around a large rhombic defect.     

Perforator-preserving chondrocutaneous rotation flap reconstruction of auricular defects

A technique of chondrocutaneous flap reconstruction of the ear that preserves the perforating branches of the posterior auricular artery is described. Preservation of the perforators offers improved safety in high-risk patients because it maintains the blood supply to the anterior surface of the ear. This perforator-preserving technique also emphasizes simplicity of flap design, concealment of scars, and preservation of ear shape. It is best suited for reconstructing defects of the scapha, antihelix, or triangular fossa up to approximately 2 cm in diameter. A variety of chondrocutaneous rotation flaps have been developed for reconstructing helical and nonhelical defects. These flaps have been designed on the basis of the size and location of the surgical defect. Although previously described techniques are usually reliable, extensive dissection and mobilization can injure perforators, leading to vascular compromise. When flap reconstruction is used in high-risk patients, it is necessary to protect the blood supply, and perforator-preserving flap reconstruction offers improved safety. The perforator-preserving technique was used in six consecutive high-risk patients during a 2-year period. Good results were obtained in all cases, including in patients who smoked cigarettes or had extensive medical problems.