Ischemic Time in Free-Flap Surgery With Arteriovenous Bundle Interposition Graft: Comparison of Two Anastomosis Sequences.

BACKGROUND: During free-tissue transfer for scalp reconstruction, pedicle lengthening may be required when finding a recipient vessel is difficult because of defects from previous surgery. Arteriovenous (AV) bundle interposition grafting is a good option. This study compared 2 sequences of AV bundle interposition grafting when flap pedicle lengthening is needed. METHODS: Two anastomosis methods were used. In the recipient lengthening type (R type), the flap was harvested and the AV bundle was harvested from a donor vessel for lengthening. In the flap lengthening type (F type), the flap was harvested first. Next, in contrast to that in the R type method, the authors performed anastomosis with a flap pedicle and bundle before the AV bundle was harvested. RESULTS: The mean flap pedicle length was 8.75 cm (range, 5-11 cm). The AV bundle had a mean length of 9.25 cm (range, 6-13 cm), meaning that 13 cm of additional pedicle length can be added. The mean length of the extended vascular pedicle was 18 cm (range, 14-23 cm). CONCLUSION: This study compared the results of F type and R type AV bundle interposition grafting. The F type allowed easy monitoring of the anastomosis of the flap pedicle and ensured flap stability by reducing continuous ischemic time. Finally, this study confirmed the efficacy and safety of the AV bundle interposition graft in scalp reconstruction.

Repair of Lower Canalicular Laceration Using the Mini-Monoka Stent: Primary and Revisional Repairs.

BACKGROUND: We present our results of primary repair of lower canalicular injury using the Mini-Monoka stent and report our experience with revisional repair of canalicular blocks to treat epiphora following primary repair METHODS:: We performed primary repair in 169 canalicular laceration patients using Mini-Monoka. The primary repair was defined as the first operation proceeded within 48 hours after injury. Revisional repairs were performed in patients who underwent primary repair of canalicular laceration and subsequently complained of epiphora with canalicular block owing to peripheral scarring. In revisional repair, a Mini-Monoka stent was reinserted to maintain the realigned lacrimal pathway. RESULTS: The primary repair achieved functional success in 94.7% of patients. After primary repair, nine patients complained of epiphora. Two of 9 patients underwent CDCR and 5 underwent revisional repair of canalicular blockage. The revisional repair achieved functional success in 4 of 5 patients. After revisional repair, scar contracture and asymmetry of the medial canthus or malposition of the lower lacrimal punctum were corrected. Cosmetically, all 5 patients were satisfied with the results. Functionally, one patient complained persistent epiphora and was treated with CDCR. CONCLUSIONS: We were able to experience simple, safe, and successful primary repair of lower canalicular injuries using the Mini-Monoka stent. If epiphora owing to canalicular block after primary repair and asymmetry of the medial canthus owing to scar contracture or malposition of lacrimal punctum are present, scar release and realignment of the canaliculus with Mini-Monoka insertion at the time of revisional repair are recommended.

Axillary Advancement Suture to Minimize Post-Implantation Deformity in Implant-Based Breast Reconstruction.

Patients who have undergone implant-based breast reconstruction after skin-sparing mastectomy often complain about bulging on the upper flank or inferior axillary area. This is most likely because the subcutaneous tissue layer of the upper flank, which is continuous with the breast tissue, tends to show inferolateral drooping once the subcutaneous tissue becomes loose after eliminating the breast parenchyma. In addition, one of the weaknesses of implant surgery is that implants cannot completely replace the tissue removed during skin-sparing mastectomy (SSM). This leads to the formation of a depression and a stepping effect superior and lateral to the implant on both sides. Notably, because the pectoralis major muscle is quite thin, when there is a depression around the superolateral area of the implant, it acts as a band, which then leads to tissue bulging and serious aesthetic problems. Here, we describe a simple advancement suture technique that can be used to resolve these two aesthetic problems in direct-to-implant breast reconstruction. The advancement sutures are performed after the implant and drains are inserted following SSM and before closing the incision. First, the surgeon confirms the depression in the superolateral area of the implant insertion site by redraping a skin flap lateral to the margin. If a depression is suspected, the surgeon uses forceps to pull the subcutaneous tissue in the lateral flank pocket over to the lateral border of the pectoralis major muscle, superolateral to the implant. At this point, correction of the lateral flank bulging and depression on the superolateral border is verified. If the result is not satisfactory, the surgeon may attempt advancing the subcutaneous fat from different areas; the more posterior the tissue is advanced, the better it eliminates the lateral bulging and superolateral depression. However, too much advancement may cause extra tension, potentially resulting in tearing of the tissue. A round needle is used to suture two to three stitches, before completing wound closure. By performing this simple advancement suture, we were able to successfully minimize post-implantation deformity-bulging on the lateral flank and depression at the superolateral implant margin. 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 .

Conversion from weight to volume of mastectomy specimen: Convenient equations.

Accurate restoration of the volume lost during breast removal is the key to achieve beautiful, symmetric breasts. This study aimed to devise a simpler and more accurate method for measuring breast tissue volume by studying the relationship between weight and volume of the excised tissue according to density. Mammograms of 276 women who were advised to undergo breast reconstruction surgery were divided into 4 different groups according to tissue densities. The correlation between weight and volume was studied for each group. The regression equations are as follows: 1st group: V = 1.218 × W+7.45 (V: volume, W: weight). 2nd group: V = 1.036 × W + 10.36. 3rd group: V = 0.969 × W-7.47. 4th group: V = 0.871 × W-14.13. These equations will be useful for reconstruction of natural-appearing and symmetric breasts following mastectomy.

Correction of Lying Ears by Augmentation of the Conchoscaphal Angle.

Lying ears are defined as ears that protrude less from the head, and in frontal view, are characterized by lateral positioning of antihelical contour relative to the helical rim. These aesthetically displeasing ears require correction in accord with the goals of otoplasty stated by McDowell. The authors present a case of lying ears treated by correcting the conchomastoid angle using Z-plasty, resection of posterior auricular muscle, and correction of the conchoscaphal angle by releasing cartilage using 2 full-thickness incisions and grafting of a conchal cartilage spacer. By combining these techniques, the authors efficiently corrected lying ears and produced aesthetically pleasing results.