Reconstructing a large helical rim defect: synergy of a postauricular perforator flap, diced cartilage, and otoplasty technique.

Large full thickness helical ear defects are a challenge to reconstruct. A 25-year-old woman presented to us with loss of a large portion of the helical rim after an assault. A successful 2-stage reconstruction was performed, incorporating the principles of perforator flaps, otoplasty techniques, and use of diced cartilage more commonly used for rhinoplasty. There was a 5 × 0.5-cm central helical defect of the right ear. In the first stage, the original defect was recreated and a 7 × 1.5-cm inferiorly based postauricular artery perforator flap was raised from the right postauricular sulcus. Diced cartilage was harvested from the adjacent conchal bowl and conchomastoid sutures were used to set the relatively prominent ear back so as to facilitate tension-free donor-site closure. Diced cartilage was wrapped in the deep fascia of the perforator flap and the edges of the deep fascia were sutured to the perichondrium of the exposed cartilage. The pedicle was divided at a second stage. At 1-year postoperation, the reconstructed ear maintained good form and symmetry, and the patient was satisfied with the outcome. This is a novel efficient technique of reconstructing large ear helical defects combining a postauricular artery perforator flap with wrapped diced cartilage augmentation, and incorporating classical otoplasty technique for virtually scarless donor-site closure.

Supraorbital nerve conduction study in normal subjects.

There is currently no examination technique that allows direct measurement of supraorbital nerve conduction velocity and amplitude. Therefore, in this study we describe a novel nerve conduction technique that allows measurement of the supraorbital sensory nerve action potential (SNAP) distal to the supraorbital foramen. Supraorbital SNAPs were recorded bilaterally from 17 healthy volunteers using an antidromic technique. The SNAPs were consistently recordable over the site 6 cm lateral to the midline point that was marked 10 cm above the nasion. Measured parameters included peak latency (mean 2.3 ms, SD 0.3), amplitude (mean 14.6 µV; SD 10.5), and velocity (mean 51.3 m/s, SD 6.8). The mean percentage of interside difference in amplitude was 25.6% (SD 17.3). Cut-off values (97th percentile) were 2.7 ms (peak latency), 3.3 µV (amplitude), 41.9 m/s (conduction velocity), and 54.9% (interside difference in amplitude). Supraorbital SNAPs can be recorded in all normal subjects and used as a quantitative measure of the functioning large fibers in the nerve.

Lateral thoracic perforator flap: additional perforator flap option from the lateral thoracic region.

BACKGROUND: Perforator flaps from the lateral thoracic region have not been as popular as other donor sites because of the misconception that the vascular anatomy in this region is less than predictable. However, the skin over the lateral thoracic region is vascularised by three rows of perforators of varied vascular dominance. Two perforator flaps from this region based on the middle and the posterior row of perforators from the thoracodorsal artery have been described. The lateral thoracic perforator flap based on the anterior row of perforators is another useful option. PATIENTS AND RESULTS: Nine patients underwent reconstructions using the lateral thoracic perforator flap for various defects in the head and neck region and lower limbs as a result of tumour extirpation, crush injury and chronic wound with osteomyelitis. All flaps were raised in the supine position. Three flaps were raised in a chimaeric fashion. The largest flap was 20×12 cm and the mean size was 106 cm2. All flaps survived without major complication. CONCLUSION: The lateral thoracic perforator flap is a reliable reconstructive option. It can be readily configured in terms of size, thickness and tissue composition. However, it is not the first-choice flap from this region because the resultant donor scar tends to extend visibly beyond the anterior axillary fold and the arterial and venous pedicles frequently have separate courses. The lateral thoracic region has become a versatile and universal donor site for free-style flap harvest with this additional flap option.

Analysis of postoperative complications for superficial liposuction: a review of 2398 cases.

BACKGROUND: Superficial liposuction has found its application in maximizing and creating a lifting effect to achieve a better aesthetic result. Due to initial high complication rates, these procedures were generally accepted as risky. In a response to the increasing concerns over the safety and efficacy of superficial liposuction, the authors describe their 14-year experience of performing superficial liposuction and analysis of postoperative complications associated with these procedures. METHODS: From March of 1995 to December of 2008, the authors performed superficial liposuction on 2398 patients. Three subgroups were incorporated according to liposuction methods as follows: power-assisted liposuction alone (subgroup 1), power-assisted liposuction combined with ultrasound energy (subgroup 2), and power-assisted liposuction combined with external ultrasound and postoperative Endermologie (subgroup 3). Statistical analyses for complications were performed among subgroups. RESULTS: The mean age was 42.8 years, mean body mass index was 27.9 kg/m2, and mean volume of total aspiration was 5045 cc. Overall complication rate was 8.6 percent (206 patients). Four cases of skin necroses and two cases of infections were included. The most common complication was postoperative contour irregularity. Power-assisted liposuction combined with external ultrasound with or without postoperative Endermologie was seen to decrease the overall complication rate, contour irregularity, and skin necrosis. There were no statistical differences regarding other complications. CONCLUSION: Superficial liposuction has potential risks for higher complications compared with conventional suction techniques, especially postoperative contour irregularity, which can be minimized with proper selection of candidates for the procedure, avoiding overzealous suctioning of superficial layer, and using a combination of ultrasound energy techniques.

The deep inferior epigastric perforator flap for breast reconstruction: Is this the ideal flap for Asian women?

INTRODUCTION: This study aims to evaluate the outcome and safety of the deep inferior epigastric perforator (DIEP) flap for breast reconstruction in a group of Southeast Asian women treated in our unit and to identify risk factors for breast reconstruction using the DIEP flap in this population. MATERIALS AND METHODS: This is a prospective study on 50 consecutive DIEP flap breast reconstructions by a single surgeon in an academic institution between July 1999 and July 2006. Data on patient demographics, diagnosis, procedure type, adjuvant and neoadjuvant treatments, risk factors and complications were prospectively collected and registered in a clinical database. Outcome variables include total flap loss, partial flap loss, fat necrosis and minor complications related to the donor site or flap. Known risk factors are analysed to determine if they affect outcome in terms of complication rate in this group of patients. RESULTS: Total flap loss, partial flap loss and fat necrosis complication rates were 6%, 4% and 10%, respectively. Flap complication rates were comparable to those quoted by previous studies done worldwide. Obesity (BMI >27) is a statistically significant factor associated with development of DIEP flap complications in our population. CONCLUSION: Breast reconstruction with DIEP flap is a safe and reliable method when used in Southeast Asian women, offering optimal results with less donor -site morbidity. Obesity increases the incidence of flap complication in this group of patients.

Supermicrosurgery in peroneal and soleus perforator-based free flap coverage of foot defects caused by occlusive vascular diseases.

BACKGROUND: Limb salvage rates for lower limbs have improved tremendously for trauma and tumor victims. The optimal solution for coverage of defects caused by ischemic limbs does not exist. The authors believe the use of supermicrosurgery and perforator flap surgery might add a further tool useful to the reconstructive surgeon. METHODS: After excisional débridement of the wound, under loupe magnification, branches of the terminal foot vessels were sought. Once identified and deemed suitable, the thin peroneal flaps were isolated based on perforator vessels. The flaps raised were either peroneal perforator-based or soleus perforator-based flaps. Microanastomosis was performed at the perforator level with 10-0 or 11-0 Ethilon sutures, and the flap was inset. The donor site was closed primarily. RESULTS: A total of 18 such flaps were raised in 17 patients with 15 septocutaneous and three musculocutaneous perforators. Sixteen peroneal perforator-based flaps and two soleus perforator-based flaps were used. There was one major (flap loss) and two minor (wound dehiscence) complications. The rest of the patients healed well, with no recurrence at a mean follow-up of 8.3 months. CONCLUSIONS: Limb salvage in ischemic limbs is now possible with supermicrosurgery and perforator flaps. This method allows contour resurfacing, avoids bulky tissue, is fast, and can be performed under regional anesthesia.

Perfecting the design of the gluteus maximus perforator-based island flap for coverage of buttock defects.

BACKGROUND: The new design of the gluteus maximus perforator-based island flap for coverage of gluteal defects has the distinct advantage of being able to use customizable tissue components for coverage and at the same time sparing the source vessel. This adds a further option for use in reconstruction. METHODS: After excisional débridement of the lesion, a perforator adjacent to the defect is selected. The tissue of the donor region is pinched to simulate closure. The change in shape of the recipient defect is noted and the dimensions of this new shape are measured. This will serve as the new dimensions of the donor tissue. The tissue components required to fill the defect are then analyzed and the flap is raised. It can be either muscle-sparing, muscle-splitting, or muscle-inclusive. A 1- to 2-cm diameter of soft tissue around the perforator is preserved. The flap is islanded and transposed, and the donor site is closed primarily, acting as a "locking barrier" to the flap. Tension-free closure of the recipient flap is then carried out. Seventy-five patients underwent closure of varying defects of the gluteal region using this technique. RESULTS: The authors had a total of three minor complications. The rest of the patients healed well, with no recurrence at a mean follow-up of 15 months. CONCLUSIONS: The flap design for coverage of gluteal defects has a great impact on recurrence and complications. This design is novel and the flap is simple to elevate. This is an ideal flap in any high-risk patient in whom the risk of recurrence is high.

Patent blue dye in lymphaticovenular anastomosis.

INTRODUCTION: Lymphaticovenular anastomosis (LVA) has been described as a treatment of chronic lymphoedema. This microsurgical technique is new and technically difficult. The small caliber and thin wall lymphatic vessels are difficult to identify and easily destroyed during the dissection. MATERIALS AND METHODS: We describe a technique of performing lymphaticovenular anastomosis with patent blue dye enhancement. Our patient is a 50-year-old lady who suffers from chronic lymphoedema of the upper limb after mastectomy and axillary clearance for breast cancer 8 years ago. RESULTS: Patent blue dye is injected subdermally and is taken up readily by the draining lymphatic channels. This allows for easy identification of their course. The visualisation of the lumen of the lymphatic vessel facilitates microsurgical anastomosis. The patency of the anastomosis is also demonstrated by the dynamic pumping action of the lymphatic within the vessels. CONCLUSION: Patent blue dye staining during lymphaticovenular anastomosis is a simple, effective and safe method for mapping suitable subdermal lymphatics, allowing for speedier dissection of the lymphatic vessels intraoperatively. This technique also helps in the confirmation of the success of the lymphaticovenular anastomosis.