Reconstruction of complex scalp defects: the "Banana Peel" revisited.

OBJECTIVE: To demonstrate the use of multiple, large, local flaps in the reconstruction of large scalp defects. METHODS: A retrospective review of 4 cases in which the "banana peel" method of scalp reconstruction, originally described by Orticochea, was used as a method for closure of moderately large to extensive scalp defects. RESULTS: In all 4 cases, closure of the scalp defects was accomplished. Major morbidity included hair-bearing skin in the forehead in 1 patient, an inconsequential small flap dehiscence requiring closure in the same patient, and a partial loss of a small skin graft to a donor site defect in 1 patient. CONCLUSIONS: While other techniques may be optimal for the management of most scalp defects, such as 1- to 2-flap rotation-advancement flaps in small to moderate-size defects and microvascular free tissue transfer and secondary tissue expansion for larger defects, we conclude that the multiple-flap reconstruction method as described by Orticochea may be useful in a small subset of patients. The latter includes older, severely debilitated patients who would be optimally treated with microvascular tissue transfer but cannot tolerate lengthy general anesthesia and young patients who will not accept a significant area of alopecia that might exist with other techniques, such as secondary intention, skin grafts, or free flaps.

Local anesthetics for facial plastic procedures.

The use of local anesthetic in facial plastic surgical procedures is well established as an effective and safe mode of anesthesia delivery. Local infiltration of anesthesia may be used alone for minor surgical procedures, or it may be used with general anesthesia or intravenous sedation and analgesia for more complex, lengthy procedures. When considered independently, the use of local anesthetic agents has undeniable limitations. Local anesthetics can cause toxicity and side effects. Injection of local anesthetics for subcutaneous infiltration frequently is painful until sensory anesthesia occurs. Local anesthetics have limited efficacy with respect to the intensity and duration of sensory blockade that can be achieved. In some situations, use of local anesthesia with the maintenance of an awake patient also may be undesirable for the surgeon and impractical for the patient. Despite these shortcomings, local anesthetics are fundamentally ideal for use in facial plastic surgery.