Turbo-gracilis myocutaneous flap for perineal reconstruction.

The turbo-gracilis flap, which has been described previously for the purpose of extending the unreliable gracilis skin island, and previously applied in forearm reanimation surgery, is now adapted for reconstruction in the perineal region. We present a case report of a patient with previous vulvar carcinoma treated with resection and radiation who presented with a very large defect of the perineal region. Reconstruction was carried out using a turbo-gracilis flap. The advantages of the flap are well demonstrated in the successful reconstruction, in that it provides an extensive amount of well-vascularized tissue due to an extended gracilis skin island which is vascularized by way of a vein graft from the proximal pedicle blood supply to a distal gracilis pedicle which, in turn, supplies the extended skin island. This allows an extensive amount of tissue to be harvested from a single donor site and ensures the viability of the skin island. A review of the advantages and disadvantages of various types of perineal reconstruction is also presented and contrasted with the turbo-gracilis method.

Endoscopy in plastic surgery. An overview.

The advances in endoscopic plastic surgery are exciting. Only with time will the best indications for the endoscope in aesthetic and reconstructive surgery be delineated. In the interim, continued ideas and innovations will push forward the limits of our understanding and allow a fresher look at the rationale for many of the procedures performed.

Endoscopic browlift.

We have presented the development and current status of endoscopic browlifting from its inception at UAB to the present techniques as they are now practiced by the authors. Endoscopic browlifting was based on sound preclinical research and included thorough training of all investigators in the use and application of endoscopic equipment. We believe that endoscopic browlifting represents clear advantages over the open technique in selected patients. These advantages included avoidance of the long transverse incision and its secondary sequelae. Improved magnification and visualization of small structures are also a secondary advantage. Complications are no greater than the open technique and tend to diminish with experience. We feel that endoscopic browlifting will continue to be refined and will find a permanent place among the armamentarium of all aesthetic plastic surgeons.

The biplanar endoscopically assisted forehead lift.

Our experience with endoscopic forehead lifting and the biplanar forehead lift has been very rewarding, and although the postoperative results are early, the persistent elevation of the brows is encouraging, given that we do not temporarily suspend the forehead to the scalp with external bolsters or to the calvarium with internal anchors to bone, as has been described. The diminution of glabellar wrinkles also is marked. Clearly, the innovation of endoscopy to plastic surgical practice has enhanced our understanding of the goals in forehead lifting; and given our experience and that of others, it is hoped that many more patients will benefit form this continually evolving technique.

Endoscopic abdominoplasty with repair of diastasis recti and abdominal wall hernia.

Endoscopic abdominoplasty is feasible, safe, and effective in the proper surgical candidate. Excellent results can be expected when proper patient selection criteria are followed. With future refinements in technique and equipment, this procedure may be extended safely to those patients with more severe deformities.

Complications in endoscopic plastic surgery.

Owing to the relatively short time endoscopic-assisted plastic surgery procedures have been done, there are few published reports of complications. The experiences of the faculty from the Endoscopy in Plastic Surgery: A consensus Multidisciplinary Symposium as well as the few published reports in the literature have been reviewed. The complications associated with endoscopic techniques are similar to those with open techniques. It is clear, however, that a subset of complications specific to endoscopic procedures exists. As endoscopic techniques and instrumentation are further developed, and as surgeons move higher up on the "learning curve", these complications should be reduced.

Serratus anterior intercostal nerve graft: a new vascularized nerve graft.

We present our investigative and clinical experience with a new vascularized nerve graft: the serratus anterior intercostal nerve graft. The serratus branch of the thoracodorsal arterial system was injected with silicone rubber injection compound in seven fresh cadavers (N = 11 injected specimens) after the composite serratus-intercostal structures were harvested. Microdissection of selected vascular territories was then performed. Our findings reconfirmed the previously described vascular connections between the thoracodorsal system and the intercostal vessels via periosteal vessels. We also newly discovered vascular anastomoses between the serratus anterior muscle and the intercostal artery running within a mesentery. This mesentery is lateral to and distinct from the serratus-periosteal-intercostal network. The nerve graft was applied clinically in the reconstruction of a complex soft-tissue, 13-cm ulnar nerve defect of the volar forearm after an electrical injury. The clinical application was successful with limb salvage and return of protective sensation at 4 months. Our clinical and investigative results support the feasibility of the serratus anterior intercostal nerve graft, a unique and versatile new vascularized nerve graft.

Endoscopic techniques in coronal brow lifting.

Laboratory investigations in fresh cadaver heads demonstrated the feasibility of endoscopic techniques applicable to aesthetic surgery of the face, including the cheeks, the forehead, the orbit, the nose, and the nasal septum. Clinical experience with coronal brow lifting in 32 patients using endoscopic techniques is also presented. The elimination of the ear-to-ear coronal incision is an obvious advantage. The endoscopic approach accomplishes division and weakening of the corrugators, procerus, and frontalis muscles, as well as moderate elevation of the eyebrows. Excess skin is accommodated by dissecting the scalp posteriorly toward the occiput.

Treatment of paralytic ectropion with composite chondrocutaneous graft.

We present our experience with correction of paralytic ectropion in 10 patients with a composite chondrocutaneous graft obtained from the scapha of the ear. This large composite graft is sutured to the tarsal plate to support the lower lid. It prevented exposure keratitis in all patients. Two patients needed minor secondary revisions of the corners of the cartilage graft. The donor defect healed satisfactorily without deforming the ear. There were no other complications and no other lid or visual problems. At 3-year follow-up, the results thus far appear long lasting.

Sliding V-Y perineal island flaps for large perianal defects.

A large perianal defect resulting from resection of Bowen's disease was reconstructed with a pair of sliding V-Y perineal flaps. The anatomical basis of the flaps is described, based on the inferior rectal vessels as fasciocutaneous units. Both continence and sensibility are preserved with the procedure.

The radial forearm flap donor site: should we vein graft the artery? A comparative study.

Controversy exists in the literature regarding reconstruction of the radial artery after elevation of the radial forearm flap. The literature suggests that reconstructing the radial artery with a vein graft is an important aspect in the use of this flap. In our experience, this has never been performed with no sequela. We examined 13 consecutive patients who underwent radial forearm flaps for head and neck reconstruction over a 28-month period. The patients were examined and questioned about the function of their upper extremities in hope of evaluating the postoperative vascular status in each. Median follow-up was 6 months, with a range of 1 month to 24 months. No patient had preexisting trauma or congenital abnormality of either arm, so that the nondonor arm could be considered as a control for each patient. Evaluation consisted of history and physical examination. The following parameters in each patient were carefully accumulated: grip strength, cutaneous blood flow measured by using a laser Doppler flowmeter, transcutaneous oxygen levels, digital/brachial blood pressure ratios, cutaneous temperature from thumb/index and thumb/small pinch, and rapid rewarming at 1-minute and 5-minute intervals after cold immersion for 2 minutes. The radial forearm flap was elevated in each patient in the nondominant extremity. Grip strengths ranged from 19 to 77 kg, with a median of 30 kg. Early rewarming of the thumb/index was also an average of 1.5 degrees less than the temperature in the control arm and was statistically significant to (p = .01).(ABSTRACT TRUNCATED AT 250 WORDS)

The turbo gracilis myocutaneous flap.

While the gracilis muscle flap continues to be used for coverage of selected defects and in specialized applications such as facial reanimation, the lack of reliability of the distal skin component of the gracilis musculocutaneous flap has limited its usefulness. Reliable distal skin and muscle viability are particularly important when the gracilis musculocutaneous free flap is used in forearm flexorplasty. A method for "turbo-charging" this flap, to improve distal reliability, is described. The anatomy of 24 human lower extremities was studied, with respect to the arterial supply to the distal gracilis muscle and distal medial thigh skin. A consistent septal branch, originating from the superficial femoral artery proximal to the adductor canal, supplying the distal gracilis muscle as well as the overlying skin, was identified in all extremities. "Turbo-charging" via this vessel increases the reliability of both the distal skin island and distal muscle of the gracilis myocutaneous flap and enhances its versatility, when used as either a pedicle or free flap.

Use of the internal mammary vein for central venous access.

We have reported two instances requiring long term central venous access in which the more traditional access sites were no longer available. The use of the internal mammary vein has made it possible to easily obtain central venous access in these patients without thoracotomy. Also, based on the anatomy, we believe this to be superior to the intercostal venous approach, since the passage of the catheter is more direct, thus, avoiding the acute azygous arch angle and cumbersome positioning.