The Square-Plus Flap: A Modification to Release Long Postburn Scar Contractures.

The square flap method has been successful in releasing contracture bands at various body regions. However, the original square flap method alone may not be efficient in releasing long contracture bands. We, therefore, proposed an extended design to the traditional design, which is called the "square-plus flap." A 4-year-old girl presented with a postburn web-like contracture band over the right axilla. We marked a square flap technique at the center of the contracture band and then two additional Z-plasties were placed on both edges of the flap. After the release and securing of the square flap, the adjacent distal Z-plasty was then transposed and sutured in their new locations. We do not need to incise the proximal Z-plasty as we could achieve complete relaxation of the contracture band. This novel modification can be added to the plastic surgeon's armamentarium for releasing long postburn contracture bands involving distinct body regions.

Myelomeningocele Defects Reconstruction With Various Types of keystone Flaps: An Algorithmic Approach Based on Defect Shape.

The keystone flap has become an established option that has been utilized recently to close significant myelomeningocele defects. Although the keystone flaps can be adapted to repair myelomeningocele defects of different sizes, the shape of the defect is also an essential factor to consider. In this study, the authors proposed an algorithmic approach for reconstructing significant meningomyelocele defects utilizing different types of keystone flaps based on the shape of the resulting defect. From September 2016 to March 2022, the authors retrospectively reviewed the medical records of 28 patients with meningomyelocele who underwent repair with the keystone flaps. The mean age was 28 days (3 days to 4.5 months). Twenty-one meningomyelocele defects were in the lumbosacral (75%) and 7 in the thoracolumbar regions (25%). The defect sizes ranged from 3.5×5 cm (area, 13.4 cm2) to 9×7 cm (area, 49.5 cm2), with an average of 26.2 cm2. Ten meningomyelocele defects were a vertically oriented oval shape, 16 defects were a transversely oriented oval shape, and 2 defects were circular. In addition, unilateral keystone flap was used in 7.1% of the patients (2 patients), bilateral keystone flap in 28.6% (8 patients), and rotation advancement keystone flaps in 64.3% (18 patients). According to these findings, an algorithm was created based on the defect shape. This algorithmic approach is used as a decision-making guide to select the correct type of keystone flaps to repair myelomeningocele according to the defect shape.

Reliability and Safety of Cross-Leg Free Latissmus Dorsi Muscle Flap in Reconstruction of Mutilating Leg Injuries Using End-to-Side Anastomosis.

Background Free tissue transfer is considered the gold standard option for the reconstruction of distal leg defects. Free tissue transfer using recipient vessels in the contralateral leg (cross-leg bridge) is a potential option to supply the flap if there are no suitable recipient vessels in the injured leg. Most studies have described this technique using end-to-end anastomosis which sacrifices the main vessel in the uninjured leg. This study evaluated the use of a cross-leg free latissimus dorsi muscle flap for the reconstruction of defects in single-vessel legs, using end-to-side anastomosis to recipient vessels in the contralateral leg without sacrificing any vessel in the uninjured leg. Methods This is a retrospective study that included 22 consecutive patients with soft tissue defects over the lower leg. All the reconstructed legs had a single artery as documented by CT angiography. All patients underwent cross-leg free latissimus dorsi muscle flap using end-to-side anastomosis to the posterior tibial vessels of the contralateral leg. Results The age at surgery ranged from 12 to 31 years and the mean defect size was 86 cm 2 . Complete flap survival occurred in 20 cases (91%). One patient had total flap ischemia. Another patient had distal flap ischemia. Conclusion Cross-leg free latissimus dorsi muscle flap is a reliable and safe technique for the reconstruction and salvage of mutilating leg injuries, especially in cases of leg injuries with a single artery. As far as preservation of the donor limb circulation is concerned, end-to-side anastomosis is a reasonable option as it maintains the continuity of the donor leg vessels.

The Versatility of Keystone Flaps for Skin Cancer Reconstruction of the Nose.

Nasal reconstruction has been a challenging problem for even the most experienced surgeon to provide excellent esthetic and functional outcomes. Although the bilobed flap offers distinct advantages for reconstructing these defects using an adjacent tissue with similar esthetic qualities, this flap has several potential limitations. The authors hypothesized that the conventional keystone flap and its variants provide a versatile and easily reproducible reconstructive option for nasal reconstruction after wide skin cancer excision. The authors retrospectively reviewed 12 consecutive soft tissue reconstruction data using 3 types of keystone flaps between May 2021 and July 2023. The authors reviewed all patients who underwent reconstruction with the keystone flap or its modification to repair cutaneous nasal defects following wide skin cancer excision. The authors reconstructed small- to medium-sized nasal defects ranging from 1×1 to 2.5×2.5 cm2 with a mean size of 1.2×1.1 cm2 using either a conventional keystone flap or its modification, including the Omega variant and rotation Hemi-keystone flap. All patients were satisfied with the esthetic outcomes. Keystone flaps are a versatile option for reconstructing the nose after cancer surgery. This strategy obviates the need for a bilobed flap after cancer removal in the nose.

Analysis of the Optimum Tapering Angle in Microanastomosis Using Computational Fluid Dynamics.

Background: In free flap transfer, size discrepancy between the vascular pedicle and recipient vessel can create a problem for microsurgeons and sometimes induces postoperative thrombus formation. When there is a major difference between the diameters of the vascular pedicle and the recipient vessel, the larger vessel is often tapered to perform the anastomosis properly. However, the decision on the tapering angle used depends mostly on the operator's experience. In this study, computational fluid dynamics (CFD) was used to investigate the optimum tapering angle. Methods: Using ANSYS ICEM 16.0 (ANSYS Japan, Tokyo, Japan), simulated vessels of diameters 1.5 mm and 3.0 mm were designed and then used to produce four anastomosis models with the 3.0-mm vessel tapered at angles of 15º, 30º, 60º, and 90º (no tapering). Venous perfusion with a mean value of 13.0 mL/min was simulated, and this was passed through the four anastomosis models in both the forward direction (F), from the smaller to the larger vessel, and the retrograde direction (R), from the larger to the smaller vessel. The velocity, wall shear stress (WSS), and oscillatory shear index (OSI) were measured in these eight patterns and then analyzed using OpenFOAM version 5. Results: The decrease in velocity was limiting. The WSS was greater in the R direction than the F direction at every tapering angle. The OSI also tended to be almost the same in the F direction, and lower at smaller tapering angles in the R direction. And, it was greater in the F direction than in the R direction at every tapering angle. The OSI values for 15º and 30º were almost identical in the R direction. Conclusion: The risk of thrombus formation is thought to be lower when tapering is used for anastomosis if the direction of flow is from the larger to the smaller vessel, rather than vice versa. These results also suggest that the optimum tapering angle is approximately 30º in both directions.

Customized reconstruction with rotation Hemi-Keystone flap.

INTRODUCTION: The keystone perforator flap has become a versatile alternative for reconstruction of cutaneous defects of various etiologies and in all age groups. However, it demands a notable incision area proportional to defect size and is more prone to excessive tension during defect closure. We present a novel modified rotation Hemi-keystone flap that reveals its excellence in flap survival. METHODS: Between March and December 2021, a retrospective chart review was conducted of 40 patients who received rotation Hemi-keystone flap for coverage of cutaneous defects by a single surgeon. The primary outcome was successful flap survival. RESULTS: We performed a total of 45 modified rotation Hemi-keystone flaps for reconstruction of cutaneous wound defects. The location of the wound defects was in the head and neck (38%), extremities (35.7%), and trunk (26.2%). The most common cause of wound defect is tumor resection (45.2%). The mean wound defect dimensions were 3.5 cm × 3 cm. The mean follow-up time was 6 months. There were no significant complications, with only one patient (2.4%) having minor wound dehiscence, which was treated by local wound care. CONCLUSIONS: The current series presents a simple, reliable, and versatile modification of the traditional keystone flap that minimizes morbidity at the reconstruction site along with improvement of flap mobility for successful reconstruction of cutaneous defects in a tension-free manner. The favorable outcome of this technique contributes to the inclusion of the rotation Hemi-keystone flap as an excellent surgical option in the reconstruction of various soft tissue defects.

Rotation Advancement Keystone Flap for Closure of Large Myelomeningocele Defects.

INTRODUCTION: Myelomeningocele is the most common form of neural tube anomalies. Early reliable skin coverage should be achieved to reduce central nervous system infections. The keystone flaps are gaining popularity for myelomeningocele defect reconstruction. However, the use of a traditional keystone flap is limited in very wide or transversely oriented myleomeningocele defects with inadequate lateral tissue laxity. In this study, we present our successful experience using modified rotation advancement keystone flaps for closure of the transversely oriented myelomeningocele defects. PATIENTS AND METHODS: Between April 2019 and April 2020, the modified rotation advancement keystone flap was used for reconstruction of transversely oriented myelomeningocele defect in 7 patients (5 males and 2 females) with average age of 14 days. The localization of the lesions was lumbosacral in 5 patients and thoracolumbar in 2 patient. The average myelomeningocele defect width was 6.4 cm, whereas the average defect length was 5.7 cm. The following information was evaluated: the flap dimensions, operative time, and postoperative complications. RESULTS: All patients had uneventful operations, except for 1 case of superficial epidermolysis over flap tip, which settled with conservative wound management. Immediate venous congestion was detected in 2 patients that completely resolved. Otherwise, all wounds healed without any evidence of complications. The mean follow-up was 4 months. CONCLUSIONS: Although the conventional keystone flap seems to have geometric constraints to close a transversally oriented myelomeningocele defect, the modified rotation advancement keystone flap serves as a superior alternative and effective option for closure transversally oriented defect.

Square Flap Method for Reconstruction of Palmar and Dorsal Web Space Burn Contractures.

BACKGROUND: Postburn web space contractures can result in serious in hand function impairments along with cosmetic disfigurement. In our study, we introduce our experience with the use of the square flap method to release palmar or dorsal web space contractures. MATERIALS AND METHODS: From March 2019 to May 2021, the square flap method was conducted in 12 patients with 13 digital web space contractures. RESULTS: The average patient's age was 6 years old (range, 2.5-16 years old). The most common affected web space was the second web. Web contractures were palmar in 9 patients and dorsal in 4 patients. The average duration of scar maturity was 13.6 months (range, 8-24 months). All the square flaps were effective in releasing the web space contracture and healed uneventfully with no postoperative complications. The average follow-up period was 11 months (range, 2-24 months). All patients or their parents were satisfied with the procedure outcomes in terms of independent finger function and esthetic appearance. CONCLUSIONS: The square flap technique is safe, reliable, and effective in management of both dorsal and palmar interdigital web scar contracture. It completely eliminates the contracture and restores commissural anatomy with good cosmetic outcomes.

Transnasal Medial Canthopexy Supported with Autogenous Bone Graft: A New Method for Repair of Traumatic Telecanthus.

INTRODUCTION: The medial canthus is an important structure to maintain the shape of the eye and assist in drainage of the lacrimal sac. Traumatic telecanthus is a difficult deformity to treat which involves both esthetic and functional aspects. Transnasal wiring remains the gold standard for repair of the medial canthal tendon (MCT) avulsion; however, it is often complicated by canthal drift, extrusion of wires, and in-fracture of the contralateral orbital bones from pressure by tied wires. In order to overcome traditional transnasal wiring technique pitfalls, this study proposes a transnasal wiring fixation method supported with a bone graft to treat patients presenting with telecanthus following complex nasoorbitoethmoid fractures. PATIENTS AND METHODS: From December 2018 to October 2020, 12 patients with traumatic telecanthus underwent transnasal wiring fixation of the MCT supported with bone graft. The wire holding the MCT was delivered through a single hole to the contralateral side and secured to a small bone graft by passing the wire through 2 holes in the graft in a button-like fashion. Then the wire end is pulled again to the affected side through the same hole and the 2 wires ends are tightly twisted after setting the MCT posterior to the lacrimal crest. RESULTS: Restoration of the MCT to its normal position was achieved in all patients. There were no observed major complications. Only 2 cases of wound infection and 1 case of dacrocystitis were encountered, which settled with conservative management. The preoperative palpebral fissure width (mean: 28.33mm ± 2.188mm) was significantly lower than the postoperative palpebral fissure width (mean: 34.17mm ± 1.03mm) ( P< 0.05). CONCLUSIONS: This study introduces a modified technique of transnasal wiring fixation to restore palpebral shape and intercanthal distance. The proposed technique could eliminate most of the frequently observed complications of the traditional methods.

The pedicled anterolateral thigh flap for trochanteric pressure sore reconstruction: Technical notes to optimize surgical outcomes.

BACKGROUND: The pedicled anterolateral thigh (ALT) flap has become more popular for the reconstruction of soft-tissue defects in neighboring areas. Nonetheless, few studies in the literature have explored the use of this flap for trochanteric ulcer reconstruction. The aim of our study is to present the author's experience of utilizing the ALT flap, with a focus on technical elements regarding the flap design and the tunneling method to maximize the reach of the flap. METHODS: The medical records of patients who received pedicled ALT flaps for the reconstruction of trochanteric pressure sores were retrospectively reviewed. The patients' demographic data, operative details, and postoperative complications were evaluated. RESULTS: Between October 2018 and December 2019, 10 consecutive patients (age range, 13-45 years) underwent 11 pedicled ALT myocutaneous flaps for trochanteric pressure sore reconstruction. Each flap was designed around the most distal cutaneous perforator that was included in the proximal third of the skin paddle. The flaps ranged in size from 11×6 to 14×8 cm. The ALT flap was transposed through a lateral subcutaneous tunnel in five patients, while the open tunnel technique was used in six patients. All flaps survived, and no vascular compromise was observed. CONCLUSIONS: The pedicled ALT flap is a safe and reliable option for reconstructing trochanteric pressure sores. An appropriate flap design and a good choice of the tunneling method are crucial for successful flap transposition.

Application of periareolar mastopexy technique for giant phyllodes tumor resection in an adolescent female with breast asymmetry: a case report and literature review.

BACKGROUND: The phyllodes tumors are rare neoplastic disease which exhibits a benign behavior in adolescents female. After resection of a large benign breast tumor, insufficient breast contour may result with nipple areola complex malposition. As symmetry of the breast is psychologically extremely crucial, especially in adolescents, in such cases, an immediate mammoplasty-like breast reduction or mastopexy technique of the affected breast will be necessary to provide symmetry of the bilateral breasts at the initial surgery. CASE PRESENTATION: A 16-year-old woman reported rapid enlargement of a large mass in her left breast over 12 months. The physical examination revealed a huge mass that occupied the lower quadrants of her left breast causing expansion of both the overlying skin and the nipple areolar complex. A biopsy was constant with a benign phyllodes tumor. We have applied a periareolar mastopexy technique to allow tumor resection through exposure incision at the lower half of the outer periareolar circular incision. At the same time, we reduced the expanded skin envelope and mobilized the nipple-areola complex to restore breast symmetry. CONCLUSION: The periareolar mastopexy approach provides a wide surgical exposure, allows excision of benign giant breast tumor, and simultaneous restoration of the breast shape with favorable aesthetic results and minimal postoperative scarring.

The Keystone Island Perforator Flap in Reconstruction of Large Myelomeningocele Defects.

BACKGROUND: Reconstruction of the skin defect after myelomeningocele repair is a crucial step that influences the quality of the surgical outcome. Keystone perforator flap is an islanded fasciocutaneous flap based on random regional perforators, which is advanced to adjacent defects. It has become a reliable method of locoregional reconstruction in various body parts with minimum morbidity. The aim of this study was to evaluate our clinical experiences in using keystone perforator flaps as an alternative surgical method for closure of large myelomeningocele defects. METHODS: In this study, the keystone island perforator flap was used for reconstruction of large myelomeningocele defect in 7 patients (5 males and 2 females) aged between 7 days and 4.5 months. The defect size was 5.9 cm × 6.5 cm on average (range, 4.5 × 5 cm to 7 × 9 cm). The localization of the lesions was lumbosacral in 6 patients and thoracolumbar in 1 patient. RESULTS: In all patients, tension-free closure was obtained and healing was successful without any complications, except 1 infection, which resolved with conservative wound management. There was no patient with late breakdown of the wound or associated cerebrospinal fluids fistula formation for a mean of 13 months (range, 4 months to 2 years). CONCLUSIONS: The keystone perforator flap technique is an effective, reliable, and durable reconstructive option which enables the reconstructive surgeon to attain a tension-free closure of sizable meningomyeleocele defects with no late wound breakdown or associated cerebrospinal fluids fistula formation and negligible donor site morbidity.

The Popliteal Keystone Island Flap For Management of Contracture Around Knee Joint: A Report of Two Cases.

Flexion contracture affecting the knee joint is considered a challenging obstacle which usually affects patients' quality of life with significant functional disability. Several surgical procedures have been described for proper closure of surgical defects following contracture release over popliteal fossa. Although keystone flap reported for closure of full thickness burns defects, to the best of our knowledge, it has never been used previously in management of hypertrophic scar contracture around the knee joint. We are presenting a two-case report with contracture hypertrophic scar over popliteal fossa where the keystone flaps were used to cover the soft tissue defects following excision of the scar contracture. After excision of contracture scar, the length and width of the defect were measured. Then, the keystone flap design was marked over popliteal fossa where the width of the flap was equal to two times the width of the defect. The flap length depends upon the length of elliptical excision which could change after release of the contracture scar. After contracture release, skin incision was made along the marked flap border and then deepened till deep fascia which was divided as well along the flap border. Undermining the flap should not be performed to avoid perforator injury. During closure, the first suture was done at the center of the flap where experiencing maximum tension while the remaining part of the flap was properly sutured to the defect. The popliteal keystone perforator flap can be a reliable method for correction of contracture scar over the popliteal fossa with relatively low complication or recurrence rates on long-term follow-up.