Indirect cerebral revascularization with a temporoparietal fascial flap in pediatric moyamoya patients: a novel technique and review of current surgical options.

Moyamoya syndrome is a progressive occlusive disease of the cerebral vessels. There are a variety of surgical treatments directed at revascularizing the ischemic brain in pediatric moyamoya disease. Many reports of varying success with both direct and indirect type of procedures can be found in medical literature. We present a novel technique, encephalo-TPF-synangiosis (ETS) with a pedicled bone flap, for indirect moyamoya revascularization in pediatric patients. A three-quarters osteoplastic temporal craniotomy was created. A pedicled temporoparietal fascial flap was passed intracranially through the temporalis muscle and placed into contact with the pial surface. The bone flap was the reaffixed to the skull. We performed 8 ETS in 6 patients. This is a well-vascularized, highly reliable method that offers broad-based surface area for revascularization. We also offer a composite overview of current surgical indirect revascularization techniques.

The angel flap for nipple reconstruction.

Creation of an aesthetically pleasing nipple plays a significant role in breast reconstruction as a determining factor in patient satisfaction. The goals for nipple reconstruction include minimal donor site morbidity and appropriate, long-lasting projection. Currently, the most popular techniques used are associated with a significant loss of projection postoperatively. Accordingly, the authors introduce the angel flap, which is designed to achieve nipple projection with lasting results. The lateral edges of the flap and the area surrounding the top of the nipple are de-epithelialized and the flaps are wrapped to create a nipple mound composed primarily of dermis. Decreasing the amount of fat within core of the nipple and enhancing dermal content promotes long-lasting projection. Furthermore, the incision pattern fits within a desired areolar size, preventing unnecessary superfluous extension of the incisions. Thus, the technique described herein achieves the goals of nipple reconstruction, including adequate and long-lasting projection, without extension of the lateral limb scars.

La création d'un mamelon agréable sur le plan esthétique est un facteur déterminant de la satisfaction de la patiente qui subit une reconstruction mammaire. La reconstruction du mamelon vise à susciter une morbidité minimale au foyer du prélèvement et une projection pertinente et durable. Les techniques actuelles les plus populaires s'associent à une importante perte de projection après l'opération. C'est pourquoi les auteurs présentent le lambeau de l'ange, conçu pour procurer une projection du mamelon aux résultats durables. Les bordures latérales du lambeau et de la région entourant le dessus du mamelon sont désépithélialisées et les lambeaux sont repliés pour former un monticule mamelonnaire composé surtout de derme. Le fait de réduire la quantité de matière grasse au cœur du mamelon et d'en accroître le contenu dermique favorise une projection durable. De plus, le mode d'incision s'associe à la dimension souhaitée de l'aréole et évite l'extension inutile des incisions. La technique décrite aux présentes permet donc la reconstruction du mamelon, y compris une projection convenable et durable, sans extension des cicatrices latérales sur les membres.