Postinflammatory Hyperpigmentation Following Mohs Micrographic Surgery: An Observational Study.

IMPORTANCE: Functional and cosmetic outcomes following Mohs micrographic surgery (MMS) are poorly studied in individuals with skin of color (SOC). Postinflammatory hyperpigmentation (PIH) may be long-lasting and highly distressing. SOC individuals are particularly susceptible to PIH following procedures.  Objective: To characterize factors that contribute to the development of PIH following MMS in SOC. DESIGN: This retrospective study included 72 SOC individuals with 83 cases of keratinocyte carcinoma treated with MMS between August 2020 and August 2021 at a single medical center in the Bronx, New York. RESULTS: Postinflammatory hyperpigmentation following Mohs micrographic surgery was more common in Fitzpatrick skin types (FST) IV to V (48.0%) compared to FST I to III (18.2%; P=0.006). Grafts and granulation resulted in higher rates of PIH compared to linear repairs and flaps (87.5% vs 30.7%; P=0.003). Cases with postoperative complications resulted in higher rates of PIH compared to cases without (81.8% vs 29.2%; P=0.001). In a subset analysis of linear repairs, polyglactin 910 as a subcutaneous suture produced a higher rate of PIH compared to poliglecaprone 25 (46.2% vs 7.1%; P=0.015).  Conclusions and Relevance: Individuals with SOC (FST IV to V) are more likely to develop PIH following MMS. Grafts and granulation lead to PIH more often than linear repairs and flaps. Postoperative complications significantly increase the risk of PIH. Surgeons should consider these risk factors during surgical planning in an effort to mitigate PIH in SOC individuals. Studies with larger sample sizes are indicated.  J Drugs Dermatol. 2024;23(5):316-321. doi:10.36849/JDD.8146.

Breast reconstruction using a superficial inferior epigastric artery flap with pedicle elongation via an arteriovenous loop: A case report.

Superficial inferior epigastric artery (SIEA) flap is often chosen to minimize postoperative complications such as abdominal pain and bulging. However, drawbacks, including a small diameter and a short pedicle, pose challenges in anastomosing or creating the lower pole of the breast. Here, we report a case of breast reconstruction using an SIEA flap with pedicle elongation via an arteriovenous loop (AV-loop) using a contralateral superficial inferior epigastric vein (SIEV) graft. A 49-year-old woman underwent a left total mastectomy with the primary insertion of a tissue expander. Breast reconstruction using an SIEA flap with pedicle elongation was planned. The running pattern, pedicle length, and diameter of bilateral SIEA/SIEV and superficial circumflex iliac artery and vein (SCIA/SCIV) were evaluated preoperatively using a 48-MHz probe of ultra-high-frequency ultrasonography (Vevo MD ultrasound device, Fujifilm Visual Sonics, Amsterdam, the Netherlands). During the flap harvesting, the contralateral SIEV graft was harvested to create an AV-loop for pedicle elongation. The 9 cm graft was anastomosed to the left internal mammary artery and vein (IMA/IMV). After the flap elevation, the created AV-loop was divided at the midpoint and anastomosed to the pedicle of the SIEA flap. The SIEA flap, extended with a SIEV AV-loop, facilitated the augmentation of the lower pole of the breast without the risk of pedicle kinking and pulling. The postoperative course was uneventful, and the patient was discharged on postoperative day 7. The prolonged pedicle length via an AV-loop prevents the pedicle kinking and allows for positioning the flap more freely, resulting in an aesthetically good breast contour by filling in the lower pole. The precise preoperative evaluation of the vessels using ultra-high-frequency ultrasonography facilitated meticulous planning. In cases where surgeons aim to minimize intraoperative and postoperative complications associated with other abdominal free flaps, this method may be considered a viable and promising option.

Repair of a "long and narrow" skin defect of the upper extremity with a modified design of a compound SCIP flap: a series of 12 cases.

BACKGROUND: Large skin lesions of the upper extremity tend to be ''long and narrow'' in shape, and the currently used repair and reconstruction protocols still have some drawbacks, including difficulty in closure of the donor area, poor cosmetic appearance of the donor and recipient areas, and low flap survival rates. The ilioinguinal flap has been more widely used for repair and reconstruction of various complex conditions. In order to improve the versatility of the flap design and to achieve better aesthetic results, we report a study on the improved design of Compound SCIP flap for repairing "long and narrow" large skin defects of the upper extremity by using a modified design of the ilioinguinal flap for the procurement of perforating blood vessels and flap excision. METHODS: From April 2005 to August 2015, a total of 12 patients underwent this modified design procedure, in which the anterior branch of the fourth lumbar artery or the posterior intercostal artery was selected to provide blood supply for the perforator flap together with the superficial branch of the superficial iliac artery to meet the blood supply needs of the flap for the one-time repair of a large "long and narrow" skin defect in the upper limb. Patient demographics, flap characteristics, and associated complications were retrospectively analyzed. RESULTS: 3 females and 9 males were included in this study, the mean age of the patients was 31.7 years (range, 22-44 years), the mean follow-up period was 15.3 ± 5.6 months (range, 7-24 months), and all patients had complete closure of the defect site and donor area, and all flaps survived. CONCLUSIONS: The Compound SCIP flap presents some advantages in repairing 'long and narrow' skin defects in the upper limb. While ensuring the survival rate of the elongated ilioinguinal flap, it amplifies the benefits of the ilioinguinal flap and enhances skin utilization. This can serve as a beneficial choice for repairing 'long and narrow' skin defects in the upper limb.

[Choanoplasty in children of the first year of life: new opportunities and rehabilitation without stents]. / Khoanoplastika u detei pervogo goda zhizni: novye vozmozhnosti i reabilitatsiya bez stentov.

The article presents literature and our own data on surgical treatment and options for solving the problem of restenosis for congenital choanal atresia in children under one year of age. A new stentless choanoplasty technique using fibrin glue for fixation of posterior septal flaps is presented. This method has patent No. 2789967 dated February 14, 2023. OBJECTIVE: Evaluation of the effectiveness of the choanoplasty method using fibrin glue for fixation of flaps without the use of a stent in children of the first year of life with choanal atresia. MATERIAL AND METHODS: For the period from 2019 to 2023, a team of authors in the Department of Otorhinolaryngology of the Veltishchev Research Clinical Institute of Pediatrics and Pediatric Surgery operated on 34 patients under the age of one year with a diagnosis of choanal atresia using this choanoplasty technique. RESULTS: The results of this new surgical technique using fibrin glue are presented. Endoscopy of the nasal cavity and choanal area in all 34 patients during follow-up (from 1 to 2 years) showed no signs of restenosis. CONCLUSION: The proposed method of choanoplasty without the use of stents with fixation of mucosal flaps with fibrin glue has proven itself well and can be used in children at any age, can be one of the ways to solve the problem of restenosis and seems to us to be the method of choice in the treatment of choanal atresia.

A review of surgical and reconstructive techniques for hidradenitis suppurativa.

Hidradenitis suppurativa (HS) is an inflammatory follicular dermatological condition that typically affects the intertriginous and anogenital regions of the apocrine gland-bearing skin. The management of this chronic and recurring disease necessitates a combination of lifestyle changes, medication, and surgical approaches to achieve the best possible outcomes. While medical treatments are recommended for this multimodal disease, surgical therapy, which is the gold standard of treatment for HS, has proven to be the most effective treatment because it provides long-lasting local disease control, reduces the recurrence of lesions, and ensures complete healing of lesions. In the last decade, there has been exponential growth in research into various surgical techniques and reconstructive care, enabling patients to have more surgical options. There is a wide range of surgical management procedures available, such as incision and drainage, deroofing, excisional surgery, carbon dioxide laser therapy, and skin tissue-sparing excision with electrosurgical peeling. Among these surgical procedures, wide surgical excision is the best option since it can eradicate all the affected lesions. Meanwhile, the preferred approach to reconstruction at various anatomical locations remains debatable. Here, we review a variety of surgical treatments and reconstructive techniques for HS, particularly various flap techniques for the axillary, gluteal, and inframammary regions.

Columella Reconstruction Using a Bilateral Nasolabial Flap: A Case Report.

BACKGROUND The columella has many fundamental functions, such as nasal breathing and support of the nasal tip, in addition to the aesthetic role it plays. The columella is one of the most difficult nasal subunits, both from the point of view of disease control and from that of reconstruction. Lesions involving the columella can be difficult to control, and malignancies can spread to the septum, subcutaneous tissues of the lip, and floor of the nasal cavities. Many columella reconstruction methods after resection have been proposed (local nasal flaps, skin grafts, regional flaps, free flaps), depending on the size of the defect, patient's features, surgeon's experience, and patient's aesthetic wishes. CASE REPORT We present a case of an 82-year-old woman with various comorbidities who had squamous cell carcinoma (G2) originating from the skin of the right side of the columella. The lesion infiltrated the cartilage, arriving to the skin of the columella on the left side and extending to the mucosa of the nasal septum bilaterally. Reconstruction was conducted using a bilateral nasolabial flap, with good functional and aesthetic result. Surgical revision for the autonomization of pedicled flaps was not necessary, nor desired by the patient. CONCLUSIONS The bilateral nasolabial flap is an effective and safe solution for reconstructing the columella, with good support of the tip even without cartilaginous graft. This technique is especially feasible in elderly patients and those with concomitant pathologies, who benefit from rapid healing of the wound.

Graftless Syndactyly Release.

Syndactyly release aims to address skin deficits by resurfacing web spaces and sides of digits to allow independent digital motion while minimizing the risk of web creep and scar contractures. Conventional methods include the use of a dorsal and interdigitating flaps with full-thickness skin grafts. More recently, there have been several descriptions of "graftless" syndactyly release without skin grafts, thus avoiding a further (usually distant) donor site. However, the indications of when and when not to use these techniques remain unclear. In addition, the inevitable scarring from extra recruitment of local adjacent skin is perhaps underemphasized. In this article, we revisit the trilobed flap technique which serves to balance the amount of skin needed for resurfacing digits while minimizing local donor site scarring. The geometry and nuances of the flap inset are illustrated in detail to guide those embarking on this technique. The trilobed syndactyly release technique is a reproducible, safe, and reliable method for the release of simple syndactyly.

Treatment of congenital melanocytic naevi of nose using multiple flaps in single stage in a paediatric patient and literature review.

A girl in her middle childhood presented to the outpatient department (OPD) with a congenital melanocytic naevi (CMN) of the right nasal alar lobule. Her parents had aesthetic concerns and expressed their desire to get the lesion removed. The full-thickness excision of CMN was performed with the reconstruction of the defect using the nasolabial and dorsal nasal advancement flap with conchal cartilage to shape the contour of the ala.

Adjunctive use of hyaluronic acid in the treatment of gingival recessions: a systematic review and meta-analysis.

OBJECTIVES: To explore the efficacy of Hyaluronic acid as an adjunctive in treatment of gingival recessions (GR). MATERIALS AND METHODS: A systematic literature search was performed in several electronic databases, including Medline/ PubMed, Embase, CENTRAL and LILACS. Recession improvement was evaluated through multiple outcome variables. The Cochrane Risk of Bias tool and the ROBINS-I tool were used to assess the quality of the included trials. Weighted Mean Differences (WMDs) and 95% confidence intervals (CIs) between test and control sites were estimated through meta-analysis using a random-effect model for the amount of Relative Root Coverage (RRC). RESULTS: A total of 3 randomised studies were deemed as eligible for inclusion. Their data were also used for pooling the effect estimates. Overall analysis of RRC (3 studies) presented a WMD of 7.49% (p = 0.42; 95% CIs -10.88, 25.86) in favour of adjunctive use of hyaluronic acid during Coronally Advanced Flap (CAF) technique, although statistical significance was not reached. Statistical heterogeneity was found to be high (I2 = 80%). CONCLUSIONS: Within their limitations, the present data indicate that the local application of Hyaluronic acid does not lead to additional clinical benefits when used as an adjunctive to the treatment of GR with CAF. However, due to the high heterogeneity among the studies, additional well-designed RCTs are needed to provide further evidence on this clinical indication for the use of Hyaluronic acid. CLINICAL RELEVANCE: In the frame of the current review, the adjunctive use of Hyaluronic acid does not additionally improve the clinical outcomes obtained during treatment of GR with CAF.

Soft Tissue Reconstruction After Sacral Neoplasm Resection: The University of California San Francisco Experience.

PURPOSE: Resection of sacral neoplasms such as chordoma and chondrosarcoma with subsequent reconstruction of large soft tissue defects is a complex multidisciplinary process. Radiotherapy and prior abdominal surgery play a role in reconstructive planning; however, there is no consensus on how to maximize outcomes. In this study, we present our institution's experience with the reconstructive surgical management of this unique patient population. METHODS: We conducted a retrospective review of patients who underwent reconstruction after resection of primary or recurrent pelvic chordoma or chondrosarcoma between 2002 and 2019. Surgical details, hospital stay, and postoperative outcomes were assessed. Patients were divided into 3 groups for comparison based on reconstruction technique: gluteal-based flaps, vertical rectus abdominus myocutaneous (VRAM) flaps, and locoregional fasciocutaneous flaps. RESULTS: Twenty-eight patients (17 males, 11 females), with mean age of 62 years (range, 34-86 years), were reviewed. Twenty-two patients (78.6%) received gluteal-based flaps, 3 patients (10.7%) received VRAM flaps, and 3 patients (10.7%) were reconstructed with locoregional fasciocutaneous flaps. Patients in the VRAM group were significantly more likely to have undergone total sacrectomy (P < 0.01) in a 2-stage operation (P < 0.01) compared with patients in the other 2 groups. Patients in the VRAM group also had a significantly greater average number of reoperations (2 ± 3.5, P = 0.04) and length of stay (29.7 ± 20.4 days, P = 0.01) compared with the 2 other groups. The overall minor and major wound complication rates were 17.9% and 42.9%, respectively, with 17.9% of patients experiencing at least 1 infection or seroma. There was no association between prior abdominal surgery, surgical stages, or radiation therapy and an increased risk of wound complications. CONCLUSIONS: Vertical rectus abdominus myocutaneous flaps are a more suitable option for patients with larger defects after total sacrectomy via 2-staged anteroposterior resections, whereas gluteal myocutaneous flaps are effective options for posterior-only resections. For patients with small- to moderate-sized defects, local fasciocutaneous flaps are a less invasive and effective option. Paraspinous flaps may be used in combination with other techniques to provide additional bulk and coverage for especially long postresection wounds. Furthermore, mesh is a useful adjunct for any reconstruction aimed at protecting against intra-abdominal complications.

Comparative analysis of GoPro and digital cameras in head and neck flap harvesting surgery video documentation: an innovative and efficient method for surgical education.

BACKGROUND: An urgent need exists for innovative surgical video recording techniques in head and neck reconstructive surgeries, particularly in low- and middle-income countries where a surge in surgical procedures necessitates more skilled surgeons. This demand, significantly intensified by the COVID-19 pandemic, highlights the critical role of surgical videos in medical education. We aimed to identify a straightforward, high-quality approach to recording surgical videos at a low economic cost in the operating room, thereby contributing to enhanced patient care. METHODS: The recording was comprised of six head and neck flap harvesting surgeries using GoPro or two types of digital cameras. Data were extracted from the recorded videos and their subsequent editing process. Some of the participants were subsequently interviewed. RESULTS: Both cameras, set at 4 K resolution and 30 frames per second (fps), produced satisfactory results. The GoPro, worn on the surgeon's head, moves in sync with the surgeon, offering a unique first-person perspective of the operation without needing an additional assistant. Though cost-effective and efficient, it lacks a zoom feature essential for close-up views. In contrast, while requiring occasional repositioning, the digital camera captures finer anatomical details due to its superior image quality and zoom capabilities. CONCLUSION: Merging these two systems could significantly advance the field of surgical video recording. This innovation holds promise for enhancing technical communication and bolstering video-based medical education, potentially addressing the global shortage of specialized surgeons.

Extended anterolateral thigh flap reconstruction of a recurrent pelvic chondrosarcoma excision defect with exposed bowel.

The pedicled anterolateral thigh (ALT) flap has proven to be a reliable and versatile technique for the reconstruction of complex abdominal wall defects. Its robust vascular supply, large skin paddle and potential for a two-team approach make it an excellent choice for such challenging reconstructions. This case report emphasises the effectiveness of the pedicled ALT flap in managing complex abdominal wall defects, providing both functional restoration and satisfactory aesthetic results. However, careful patient selection and meticulous surgical planning remain paramount to ensure optimal outcomes.

Nasal ala V-Y island flap with a superior vascular pedicle based on inferior perforators of the superior alar artery.

For small defects of the anterior nasal ala, a V-Y pedicle advancement flap within the subunit is a useful repair option. Here we propose a modification of this technique, utilising careful dissection to identify inferior perforators of the superior alar artery. Basing this flap on a visualised vascular pedicle aims to prevent common complications of internal mucosal buckling and free margin notching, by allowing more extensive dissection without compromising the vascularity of the flap.

A 16-Year-Old Girl with Sinonasal Cutaneous Fistula Following Excision and Radiotherapy for Rhabdomyosarcoma Requiring Reconstructive Surgery Using an Expanded Forehead Flap.

BACKGROUND Sinonasal rhabdomyosarcoma (RMS) is a rare malignancy in children and adolescents. It is aggressive and locally invasive, and can require local postoperative radiotherapy. This report presents the case of a 16-year-old girl with a sinonasal-cutaneous fistula following excision and radiotherapy for rhabdomyosarcoma, which required reconstructive surgery using an expanded forehead flap. CASE REPORT We report the case of a16-year-old girl who was referred to our clinic with sinonasal-cutaneous fistula. Prior to presentation at our department, she presented with bilateral intermittent nasal congestion 3 years ago. At a local hospital, orbital computed tomography and nasal endoscopic biopsy revealed an embryonal rhabdomyosarcoma (ERMS). One month later, skull base tumor resection, nasal cavity and sinus tumor resection, and low-temperature plasma ablation were performed at a local hospital. Two weeks after the operation, the patient received intensity-modulated radiation therapy for a total of 50 Gy. Chemotherapy started 15 days after radiotherapy, using a vincristine, dactinomycin, and cyclophosphamide (VAC) regimen. Approximately 1 month later, an ulcer appeared at the nasal root and the lesion gradually expanded. The patient was referred to our hospital due to the defect. Firstly, a tissue expander was implanted at the forehead for 7 months. Then, the skin around the defect was trimmed and forehead flap was separated to repair the lining and external skin. The flap survived well 1-year after the operation. CONCLUSIONS This report highlights the challenges of post-radiation reconstructive surgery and describes how an expanded forehead flap can achieve an acceptable cosmetic outcome in a patient with a sinonasal-cutaneous fistula.

Antibiotic-loaded bone cement fixation technique combined with bilateral pectoralis major muscle flaps tension-free management for sternal infection after midline sternotomy.

INTRODUCTION: Deep sternal wound infection (DSWI) after midline sternotomy of cardiac surgery is a challenging complication that affects the outcome of surgery. This study aims to assess the clinical effectiveness of the antibiotic-loaded bone cement fixation technique combined with bilateral pectoralis major muscle flaps tension-free management in the treatment of DSWI. METHODS: We retrospectively analyzed 5 patients with DSWI who underwent antibiotic-loaded bone cement combined with bilateral pectoralis major muscle flaps for chest wall reconstruction after sternotomy for cardiac surgery in a tertiary hospital in China from January 2020 to December 2021. The clinical and follow-up data were retrospectively analyzed. RESULTS: All patients had no perioperative mortalities, no postoperative complications, 100% wound healing, and an average hospital stay length of 24 days. The follow-up periods were from 6 to 35 months (mean 19.6 months). None of the cases showed wound problems after initial reconstruction using antibiotic-loaded bone cement combined with bilateral pectoralis major muscle flaps. CONCLUSIONS: We report our successful treatment of DSWI, using antibiotic-loaded bone cement fixation technique combined with bilateral pectoralis major muscle flaps tension-free management. The clinical and follow-up results are favorable.

[Topographic study of the parietal region for the elaboration of revascularized cranium vault autograft]. / Izuchenie topografo-anatomicheskikh osobennostei temennoi oblasti pri razrabotke revaskulyariziruemogo kostno-fastsial'nogo temennogo autotransplantata.

OBJECTIVE: Topographic and blood vessel architecture study of the parietal area and distal regional pool of the superficial temporal artery (STA) to assess the possibility of revascularized cranium vault bone autograft formation. MATERIAL AND METHODS: For the topographic and anatomical study, 30 non-fixed corpses (17 male and 13 female) were selected, the average age of which was 59±5 years. In the anamnesis and catamnesis, there were no indications of trauma or other pathology of the head and neck, including vascular. STA was contrasted with a non-radiocontrast dye (brilliant green) with the introduction of the dye into the STA with preliminary ligation of the frontal branch of the STA. The area of blood supply to soft tissue and bone structures was studied. The angioarchitectonics of the parietal region was studied, the feeding vessel of the studied flap was identified. RESULTS: The obtained anatomical landmarks for the collection of CPFP flap make it possible to form a flap with high accuracy and minimize the morbidity of the donor area.

Technical variety of anastomotic techniques used in proximal gastrectomy with double-tract-reconstruction - a narrative review.

In the past 40 years, the incidence of esophagogastric junction cancer has been gradually increasing worldwide. Currently, surgical resection remains the main radical treatment for early gastric cancer. Due to the rise of functional preservation surgery, proximal gastrectomy has become an alternative to total gastrectomy for surgeons in Japan and South Korea. However, the methods of digestive tract reconstruction after proximal gastrectomy have not been fully unified. At present, the principal methods include esophagogastrostomy, double flap technique, jejunal interposition, and double tract reconstruction. Related studies have shown that double tract reconstruction has a good anti-reflux effect and improves postoperative nutritional prognosis, and it is expected to become a standard digestive tract reconstruction method after proximal gastrectomy. However, the optimal anastomoses mode in current double tract reconstruction is still controversial. This article aims to review the current status of double tract reconstruction and address the aforementioned issues.