The ultra-thin, fascia-only anterolateral thigh flap.

BACKGROUND: While many potential donor sites have been described for fascial (fascia-only) flaps, a fascial flap harvested from the anterolateral thigh (ALT) donor site has not gained popularity, likely because of concerns regarding inadequate perfusion of the deep fascia. However, recent clinical experience demonstrates that the ALT fascia-only flap is a suitable option for reconstructions necessitating thin and pliable coverage. METHODS: In this study a retrospective chart review was performed examining the clinical experience of two plastic surgeons with the fascia-only ALT perforator flap from 2008 to 2012. Each flap was initially raised as a standard ALT flap, but all the overlying skin and adipose tissue was excised off the deep fascia before the inset, resulting in the creation of a fascia-only ALT flap. Immediate split- or full-thickness skin grafts were used to cover the flap. The results are reported in this article. RESULTS: Overall seven patients underwent reconstruction of wounds using either free (six) or pedicled (one) fascia-only ALT flaps (length, 10-20 cm, width, 5-10 cm). The following regions were successfully reconstructed using a fascia-only ALT flap: occipital scalp, lower extremity, upper extremity, and groin. All patients were followed for at least 6 months postoperatively. CONCLUSIONS: The fascia-only ALT flap was successfully used to reconstruct a variety of defects in seven patients. The authors experience demonstrates the viability of the fascia-only version of the ALT flap for reconstructions requiring thin coverage with good contour, and further adds to the versatility of the ALT as a donor site for flaps.

Impact of reconstructive microsurgery in patients with advanced oral cavity cancers.

BACKGROUND: Our goal was to determine the impact of reconstructive microsurgery on the treatment of advanced oral cavity cancers. METHODS: We reviewed 484 patients undergoing resection of T3-4 oral cavity squamous cell cancers from 1980 to 2004. To examine how reconstructive microsurgery affects outcomes, we compared 135 patients treated prior to the introduction of free tissue transfer and 349 patients treated after the introduction of free tissue transfer. RESULTS: Cancers treated after the introduction of free flaps included a significantly higher proportion of T4 compared to T3 lesions and significantly more advanced N classification lesions. Although cancers were more advanced, survival and recurrence rates were maintained and the rate of positive pathologic margins decreased significantly. In addition, fistula and tracheostomy dependence rates decreased and rates of intelligible speech increased. CONCLUSION: Reconstructive microsurgery contributes to improved oncologic outcomes in addition to better function and lower morbidity in oral cavity cancer treatment.

Evaluation of porcine dermal collagen (Permacol) used in abdominal wall reconstruction.

Various methods have been employed to reconstruct complex abdominal wall defects. Structural prosthetic materials such as polypropylene mesh and ePTFE (expanded polytetrafluoroethylene) have been widely used to close these large fascial defects, however, complications with infection and adhesions have led to the recent use of more biocompatible implants. Permacol (acellular porcine dermis) is used as a dermal scaffold, which eventually becomes vascularised and remodelled to reconstruct the abdominal wall in these complex patients. A retrospective review was performed of all patients who underwent consecutive abdominal wall reconstruction with Permacol at our institution in the year 2006. Twenty-eight patients were identified and included in our study. Factors evaluated were: body mass index, relevant co-morbidities, aetiology of hernia, hernia defect size based on CT scan and intraoperative measurement, size of Permacol implant, length of hospital stay, and postoperative complications. Surgical technique was standardised among six surgeons and involved a single layer of acellular porcine dermis as a subfascial 'underlay' graft under moderate tension upon maximal hernia reduction. Tissue expanders were not required for skin closure. Out of 28 patients, 12 were male and 16 were female. Mean intraoperative hernia size was 150 cm(2) (range of 10 cm(2) to 600 cm(2)). Mean age was 55 years with an average body mass index (BMI) of 34 (largest BMI of 61.4). Defects were attributed to either a previous laparotomy incision or open abdomen. Mean hospital stay was 9.67 days. At a mean follow-up of sixteen months, there were three recurrent hernias (10.7%) based on physical examination and postoperative CT scan evaluation. One patient developed a superficial wound dehiscence which was successfully treated with local wound care and one patient developed a cellulitis which was successfully treated with antibiotic therapy. Four patients (14.3%) developed a chronic, non-infected fluid collection lasting >one month all of which resolved. No patient required removal of the implant due to infection. Permacol can be successfully used in the reconstruction of both small and large ventral hernias. This biodegradable matrix serves as a safe and useful alternative to both synthetic mesh and AlloDerm.

Asian blepharoplasty.

One of the defining features between an individual of Asian descent and someone of Western descent is the presence of an upper eyelid crease. Approximately 50% of Asians do not have an upper eyelid crease. The double eyelid operation, or creation of a supratarsal crease, is the most common cosmetic procedure requested in Asia and the third most common procedure requested by Asian Americans. In this comprehensive article, we explore the art of creating an eyelid crease in the individual who either does not have a crease or has an indistinct crease. We will review the history of the development of Asian blepharoplasty, explain the anatomy of the Asian eyelid and how it differs from the Caucasian eyelid, and clarify how this anatomy then translates to differences in external appearance. The two main schools of surgical techniques will be discussed along with pearls, pitfalls, and personal observations.