Central Flap Research Articles

Trastuzumab holds potential to accelerate spontaneous sensory reinnervation after free flap breast reconstruction: a proof of concept

Abstract Objectives Breast sensation following autologous breast reconstruction impacts patients’ quality of life. Although spontaneous reinnervation in free flaps was documented by many authors, there are efforts to further improve restoration of breast sensation. Interestingly, animal studies indicated that trastuzumab has several beneficial effects on transected peripheral nerves. Our aim was to compare spontaneous sensory recovery after free TRAM flap breast reconstruction between patients who were and were not treated with trastuzumab. Methods The study included 14 subjects who underwent tactile sensation examination in 5-year period after noninnervated free muscle-sparing TRAM flap breast reconstruction at the University Hospital Centre Zagreb, Croatia. Small and large flap skin islands and contralateral healthy breasts were tested with Semmes-Weinstein type monofilaments. Three sensory scores were created to more accurately compare breast sensation. Results In subjects receiving trastuzumab, sensory recovery earlier extended to at least four of five large skin island regions and was always present in the central flap area in comparison with subjects who were not administered trastuzumab (p=0.0476). As indicated by total sensory scores, trastuzumab-treated subjects restored sensation better resembling healthy control breasts (54 vs. 39 % in large skin islands; 95 vs. 71 % in small skin islands). Conclusions To the authors’ knowledge, the current study for the first time demonstrated trastuzumab’s potential to improve sensory outcomes in human. Our results support the strategy that accelerated nerve regeneration is a key to more successful reinnervation. HER2 and EGFR inhibitors emerge as new candidates for pharmacological interventions in peripheral nerve injury treatment.

Sensory and pain outcomes of neurotized skin-grafted free gracilis muscle flaps for lower extremity reconstruction

BackgroundSkin-grafted free gracilis muscle flaps are commonly used for lower extremity reconstruction. However, the loss of sensory function may lead to increased patient morbidity. This study prospectively analyzed the sensory and neuropathic pain outcomes of neurotized skin-grafted free gracilis muscle flaps used for the reconstruction of lower extremity defects. MethodsPatients undergoing lower extremity reconstructions between 2020 and 2022 with neurotized skin-grafted free gracilis muscle flaps were prospectively enrolled. Sensation was assessed at 3, 6 and 12 months postoperatively using monofilaments, two-point discrimination, a vibration device, and cold and warm metal rods. Sensations were tested in the center and periphery of the flaps, as well as in the surrounding skin. The contralateral side served as the control. Patients completed the McGill pain questionnaire to evaluate patient-reported neuropathic pain. ResultsTen patients were included. At 12 months postoperatively, monofilament values improved by 44.5% compared to that of the control site, two-point discrimination, cold detection, warmth detection, and vibration detection improved by 36.2%, 48%, 50%, and 88.2%, respectively, at the reconstructed site compared to those at the control site. All sensory tests were significantly better than 3 and 6 months values (p < 0.05), but remained significantly poorer than the control site (p < 0.05). Sensation in the central flap areas were similar to peripheral flap areas throughout the follow-up period (p > 0.05). The surrounding skin reached values similar to the control site at 12 months (p > 0.05). Moreover, 50% of patients reported neuropathic pain at 3 months postoperatively, 40% at 6 months, and 0% at 12 months (p < 0.05). ConclusionMechanical detection, vibration detection, temperature detection, and two-point discrimination significantly improved over time but without reaching normal sensory function at 12 months postoperatively. Neuropathic pain resolved at 12 months.

Biomechanical explanation of W-plasty effectiveness using a finite element method approach

The finite element method has often been used to assist analyzing local flaps in terms of deformation and stress measurements as it takes into account complex skin properties. We, herein, present an isotropic two-dimensional finite element skin model applied to the W-plasty method to demonstrate that the good outcomes of W-plasty should be attributed to the geometry itself, as it generates lower stresses. The skin was modeled as a two-dimensional (2D) planar geometry. The model was created and solved as a plane stress problem. The model was based on simulation of the loading and stitching of W-plasties of various angles. Each central triangular flap was segmented in nine triangular elements. The stitching was modeled with one suture at the top of each triangular flap with the center of the opposite corner. X- and Y-axis stresses and shearing stresses Txy in the elements involved in the broken stitching line, show lower stresses than the elements behind the stitching line. Interestingly, in the triangular flaps, the stresses were clearly lower than those of their neighboring areas. The maximum compressive stresses in the 2D model we used, correspond to the dog ears. We conclude that the effectiveness of W-plasty should be attributed not only to the scar orientation in relation to the relaxed tension skin lines but also to the special design of the triangular flaps used. This finding assists the general understanding of the method and should be taken into account by the clinician during flap designing.

Utilization of the web index in the measurement of web creep after syndactyly surgery.

The aim of this study was to explore the feasibility of using a web index to measure web creep after syndactyly surgery. A total of 19 hands in nine children (six preoperatively and 13 immediately postoperatively) underwent measurement of their web position. A preliminary study confirmed that the web index measured on the child's hand at the time of surgery was similar to that measured on photographs taken at the same time. Subsequently, an intra- and inter-observer error rate found excellent agreement among four observers measuring the web index using photographs. Of 13 postoperative webs using a winged central rectangular web flap without skin grafting, 12 were re-measured using photographs at an average of 88 months (range 78 to 96) after surgery. There was evidence of minor web creep in one web only. Our study demonstrates the efficacy of web index calculation on photographs to measure web position in children after syndactyly surgery. The study also demonstrates the effectiveness of the graftless winged central rectangular web flap technique in avoiding web creep.Level of evidence: IV.

Safety and Precision of Two Different Flap-morphologies Created During Low Energy Femtosecond Laser-assisted LASIK.

Currently, two major principles exist to create LASIK flaps: firstly, a strictly horizontal (2D) cut similar to the microkeratome-cut and secondly an angled cut with a "step-like" edge (3D). The strictly horizontal (2D) cut method can be performed using apparatus such as the low-energy FEMTO LDV Z8 laser and its predecessors which are specific to this type. Alternatively, the low-energy FEMTO LDV Z8 laser's 3D flap design creates an interlocking flap-interface surface which potentially contributes toward flap stability. In addition, the FEMTO LDV Z8 offers flap-position adjustments after docking (before flap-creation). The current study analyzed precision, safety, efficacy, as well as patient self-reported pain and comfort levels after applying two different types of LASIK flap morphologies which were created with a low-energy, high-frequency femtosecond (fs) laser device. A prospective, interventional, randomized, contralateral eye, single-center comparison study was conducted from November 2019 to March 2020 at the Hamburg vision clinic/ zentrumsehstärke, Hamburg, Germany. Eleven patients and 22 eyes received low-energy fs LASIK treatment for myopia or myopic astigmatism in both eyes. Before the treatment, the eyes were randomized (one eye was treated with the 2D, the other eye with the 3D method). The mean central flap thickness one month after surgery was 110.7 1.6 μm (2D) and 111.2 1.7 μm (3D); P = 0.365 (2D vs 3D). Flap thickness measured at 13 different points resulted in no statistically significant differences between any of the measurement points within/between both groups; demonstrating good planarity of the flap was achieved using both methods. Despite not being statistically significant, the surgeons recognized an increase in the presence of an opaque bubble layer in the 3D flap eyes during surgery and some patients reported higher, yet not statistically significant, pain scores in the 3D flap eyes during the first hours after the treatment. Overall, safety- and efficacy indices were 1.03 and 1.03, respectively. In this prospective, randomized, contralateral eye study, the low-energy fs laser yielded predictable lamellar flap thicknesses and geometry at one-month follow-up. Based on these results, efficacy and safety of the corresponding laser application, that is, 2D vs 3D, are equivalent.

A morphological comparison between sub-bowman keratomileusis flap and femtosecond laser-assisted flap in LASIK surgery for myopia

Abstract Purpose: Comparison between the SBK microkeratome versus femtosecond laser in flap creation during LASIK surgery for myopia. Materials and Methods: This is a prospective comparative nonrandomized interventional clinical study that included 60 eyes of 30 patients in each group. Patients were randomized to receive either the SBK microkeratome or femtosecond laser technique according to a randomization computer software. The patient’s ages ranged from 18 to 46 years in the FS200 laser group and from 20 to 44 years in the SBK group. The WaveLight FS200 femtosecond laser and the Moria SBK microkeratome were both used to generate flaps in the 60 eyes of 30 patients (Moria SA, Antony, France). About 1 month after surgery, AS-OCT was utilized to measure the thickness of five locations on each flap that was 0, 1.5 mm from the corneal vertex on the horizontal and vertical axes. Hinge size and flap diameter were measured using a caliper 1 month after surgery. Uncorrected visual acuity and best corrected visual acuity were measured at 1 day, 1 week, and 1 month postoperative in each group. Any related complications were recorded in each group. For side-cut angles, scans were done across the temporal side of the flap, and then images were transferred to Draw editor software, and measurements were recorded and analyzed 1 month after surgery using AS-OCT. Results: The mean obtained central corneal flap thickness in both eyes in the FS200 laser group was 117.4 µ ± 4.18 SD, and 84.90 µ ± 3.74 SD in the SBK group, which was statistically significant (P &lt; 0.05). The mean achieved Hinge size in both eyes in the FS200 laser group was 3.47 ± 0.26 mm, and 4.81 ± 0.63 mm (P &lt; 0.05) in the Moria SBK group. The mean achieved flap diameter in the FS200 laser group was 7.95 ± 0.43 mm, and 9.15 ± 0.21 mm in the SBK group (P &lt; 0.05). In the FS200 laser group, the average side cut angle was 126.93°9.56°, while in the SBK group, it was 37.18°6.93° (P &lt; 0.05). Conclusion: In the two study groups, there was a statistically significant difference in the side cut angles that were intended and actually achieved. In comparison to the SBK group, the FS200 laser group had better predictability of flap thickness. There were reported complications in the SBK group, while femtosecond laser technology has shown better postoperative flap uniformity with no reported complications.

Central perforated VRAM flap and neurostimulated levator augmentation for functional and aesthetical reconstruction after abdominoperineal excision in cancer.

Preservation of quality of life regarding fecal continence after abdominoperineal excision (APE) in cancer is challenging. Simultaneous soft tissue coverage and restoration of continence mechanism can be provided through an interdisciplinary collaboration of colorectal and plastic reconstructive surgery. Evaluation of surgical procedure and outcome combining soft tissue reconstruction using a central perforated vertical rectus abdominis myocutaneous flap (VRAM), implementing a perineostoma and restoring anorectal angle augmenting the levator ani by neurostimulated graciloplasty. 14 Patients underwent APE due to cancer. In all patients coverage was achieved by pedicled VRAM and simultaneous pull-through descendostomy (perineostoma). 10 of those patients received a levator augmentation additionally. Postoperative complications, functional measures of continence as well as quality of life were obtained. Perineal minor complication rate was 43% without need of surgical intervention. All but one VRAM survived. Continence measures and disease specific life quality showed a good preservation of continence in most patients. The results present a complex therapy option accomplished by a collaboration of two highly specialized partners (visceral and plastic surgery) after total loss of the sphincter function and consecutive fecal insufficiency after APE.

A new oncoplastic technique for removal of centrally located malignant tumors and reconstruction by a local dermo-glandular flap in conservative breast surgery.

To evaluate the local dermo-glandular flap as a new reconstructive oncoplastic technique after removal of central malignant tumors of the breast, in terms of patient satisfaction and local recurrence. This study included 60 females with centrally located breast cancer who underwent central quadrantectomy and local dermo-glandular flap with either sentinel lymph node biopsy or axillary clearance. The mean age of the patients was 49.68 ± 8.52 years. The duration of the operation ranged from 68-105 minutes, with a mean of 79.77 ± 9.41 minutes. Local recurrence was observed in three patients (5.00%) with no distant metastasis. Forty-seven patients (78.33%) reported satisfaction after the operation. Ugly scarring and the existence of tissue defects were the main factors affecting patient satisfaction. Correction of these complications increased overall satisfaction to 88.33%. For small- and medium-sized breasts, the use of a local dermo-glandular flap for the management of centrally located malignant tumors seems to be a simple and easy technique with good oncological outcomes and acceptable few minor complications. This technique offers an immediate reconstruction of a new areola with fewer scars that will be hidden later after areola tattooing. Most of the patients reported satisfaction three months after areola reconstruction.

A retrospective study on treatment for postburn contracture of axilla with propeller flap cover at a tertiary care center

Background: The gold standard for burn scar reconstruction is to utilize adjacent skin flaps for the ease of operation and to match the skin characteristics. The objective of this study is to share our experiences using propeller flap cover for “postburn contracture of axilla (PBCA)” release reconstruction. Materials and Methods: This 5-year retrospective observational study was undertaken in the Plastic Surgery Department of GMCH, Guwahati, from 2016 to 2020 with the data available after obtaining the Ethics Committee approval. The patient records and photographs were gathered from the Medical Records and the Plastic Surgery Department of GMCH, Guwahati, respectively. Patients treated with a propeller flap cover were scrutinized. Results: The patients operated for PBCA were 36. There were 12 males and 14 females with a mean age of 21 years. Twelve patients with spared axillary dome skin underwent a central axis subcutaneous pedicle propeller flap. The flaps had dimensions of 8–12 cm in length and 6–9 cm in width. The pedicle was approximately 2–2.5 cm in diameter. The few complications seen included wound dehiscence and delayed wound healing, edge hypertrophy, band contractures, marginal necrosis, and pin cushioning. During follow-up, no recontractures were seen. Conclusions: We conclude that central axis subcutaneous pedicle propeller flap is a simple and effective treatment for mild-to-moderate PBCA with spared axillary dome skin. These flaps provide durable soft tissue cover with enhanced flap survival, functional mobility, and esthetics.

Postoperative Detection of Free Flap Congestion in a Fitzpatrick Skin Type VI Patient using the Flir Thermal Imaging Camera: A Case Report and Literature Review

BACKGROUND: Free flaps are routinely used in complex tissue reconstruction due to their functionality and reliability. Postoperative monitoring remains a challenge despite the current available modalities. Clinical examination remains the gold standard, with color being the most sensitive marker of flap compromise. Assessment of flap color is more challenging in Fitzpatrick V-VI skin types, masking visual signs of ischemia or congestion. A Forward-Looking Infrared (FLIR) ONE smartphone based thermal imaging camera can be used to detect differences in flap temperature from the surrounding native tissue and could be used to identify early flap compromise. This simple technology used with a smartphone may be a useful method to assess postoperative flap perfusion. METHODS: Institutional review board approval was obtained for postoperative flap monitoring using FLIR technology for patients undergoing complex reconstruction with a free anterolateral thigh (ALT) flap. The FLIR camera is a simple attachment that plugs into iPhone models 7–12 and takes thermal pictures with temperature readings by a spot pyrometer using their App. Preoperatively the FLIR camera spot pyrometer measured baseline temperature by ALT flap location. Temperature recordings of the flap and the surrounding native tissue were taken immediately postoperatively and then at regular intervals in addition to our standard free flap monitoring protocol. This protocol was utilized for one patient in this report who underwent a free ALT flap to scalp after sarcoma resection and Fitzpatrick skin type VI. RESULTS: FLIR thermography measured the preoperative central flap temperature at 32.6°C. Immediately postoperatively the flap temperature was 33.9°C, and the surrounding native skin was 35.8°C. Sixteen hours postoperatively the central portion of the flap was found to be 28.0°C, 8.4°C cooler than the surrounding native skin, suggesting flap ischemia. Clinical examination of the flap showed edema and return of dark blood on scratch test but no frank discoloration. Handheld Doppler signal showed arterial signal but no venous signal. The patient was taken immediately for operative exploration, which showed a 30 cm3 hematoma compressing the vascular pedicle. Following evacuation, the central flap’s temperature was 35.6°C. The patient was discharged on POD 7 and still has a complete reconstruction. CONCLUSIONS: FLIR ONE was helpful in detecting flap congestion and ultimately flap salvage. Prompt operative evacuation of the hematoma prevented flap loss and associated morbidity to the patient. This patient case highlights the inherent challenges in evaluating skin paddles of Fitzpatrick V–VI skin types and depicts the utility of a low-cost thermography camera that can aid in identifying a threatened flap. The user-friendly, non-contact nature of FLIR ONE adds a useful and objective datapoint in postoperative free flap monitoring that can improve patient outcomes when combined with conventional monitoring techniques in all patients, particularly those with difficult flaps to monitor. Our team hopes to continue studying thermal camera temperature differences in postoperative free flap monitoring to service our patients and provide insight into this technology’s utility for reconstructive plastic surgery.

A novel surgical method for total nail ablation: Use of triple flap technique

&lt;p&gt;Total nail ablation for the treatment of onychodystrophies can be performed by using chemicals, surgical resection or laser ablation of nail matrix.&lt;strong&gt; &lt;/strong&gt;A female patient with bilateral severe onychodystrophy as a result of inadvertent previous nail surgeries was treated surgically. Proximal complete nail matrix resection and distal 10 mm wide transverse strip partial nail bed resection were performed. A 5 mm wide transverse strip of nail bed was left intact proximally. Proximal nail matrix defect was closed by using the skin of proximal nail fold. The distal nail bed defect was reconstructed by using triple flap technique which was composed of a main central advancement flap containing ventral toe skin and two side flaps containing nail fold skin. The patient healed without any problem and her nail problem was treated successfully. The cosmetic appearance of her first toes was acceptable. Surgical nail ablation followed by volar skin coverage of dorsal surface of the distal phalanx bone by using triple flap technique is an effective surgical treatment method for the correction of advanced nail plate deformities requiring total nail ablation. &lt;/p&gt;

Comparison of Flap Characteristics Created with Two Different Methods in Laser in Situ Keratomileusis (LASIK).

Background:The creation of corneal flap is considered to be the most critical part of laser in situ keratomileusis (LASIK) surgery. Currently, flaps can be created with mechanical micorkeratomes or femtosecond lasers.Objective:To analyze and compare flap characteristics created with two different methods for flap creation in Laser in situ keratomileusis (LASIK).Methods:This was a retrospective study. The thickness and morphology of the flap were compared between the two mechanical microkeratomes (group I – Moria M2, group II – Moria SBK One Use Plus) and femtosecond laser (group III – Ziemer Femto LDV). Central flap thickness was measured intraoperatively, while the flap profile was measured with anterior optical coherence tomography at two axes (90° and 180°) and 5 measuring points on the first day, the first week, and one month after the surgery.Results:Central flap thickness was 110.91±15.79 micrometers (µm) (80-164 µm) in group I, 98.08±13.33 µm (65-136 µm) in group II and 103.52±13.89 µm (66-138 µm) in group III. Anterior optical coherence tomography revealed a meniscus-shaped flap in all three groups at both axes (90° and 180°). The least variability in flap thickness was observed in group III (±6 µm).Conclusion:All three methods of flap creation provide good shape and thickness reproducibility. Ziemer Femto LDV femtosecond laser had the least variable flap thickness in a single flap. Mechanical microkeratomes had slightly lower performance.

“TO AND FRO” BLOOD FLOW MATHEMATICAL MODEL IN VENOUS FLAP SURVIVAL

The aim of the research is to determine “to and fro” venous flap blood circulation perfusion ability and flap size survival. Materials and methods: “To and fro” blood circulation mathematical model based on the theory of compressed liquid flow thought the porous medium. Result: Designed mathematical model allows to calculate the viable flap size that depends on pedicle vessel radius, the blood pressure gradient, the blood viscosity, the elastic tissue capacity, the pulse frequency, vessels flap topography and surgical pedicle flap technique. Viable flap width may extent up to 4-6 cm. Conclusions: Only thin skin or fascial flaps, were through venous pedicle with a lot of side branches located under the flap surface and along central flap axis may survive with “to and fro” blood circulation.

Evaluation of Release of Wide Post Burn Contracture of Joints Using Central Axis Propeller Flap

Evaluation of Release of Wide Post Burn Contracture of Joints Using Central Axis Propeller Flap

Treatment of Common Calcaneal Tendon Rupture Using a Central Gastrocnemius Turnover Aponeurotic Flap Technique in a Dog

AbstractA 9-year-old, intact male, German wirehaired pointer was referred for suspected Achilles tendon rupture 3 weeks after an injury. A three-loop pulley suture pattern combined with a locking loop suture reduced the gap between the tendon ends to 7 mm and a central gastrocnemius turnover aponeurotic flap was used to cover the remaining gap. A type II free-form methyl methacrylate transarticular external skeletal fixator was used to keep the tarsocrural joint in extension until 45 days postoperatively. Short- and long-term clinical and ultrasonographic evaluations showed gradual improvement in weight-bearing and progressive tendon healing. At 6 months after surgery, the dog had normal limb function and had returned to the previous activity level. To the authors' knowledge, this tendon repair technique has been described in humans and in one cat but has not yet been reported in dogs.

Flap thickness and side-cut angle using sub-Bowman keratomileusis microkeratome, 200-kHz femtosecond laser system, and Moria M2 microkeratome

Purpose The aim of this study was to compare the thickness and side-cut angle of corneal flap in candidates undergoing laser-assisted in situ keratomileusis using sub-Bowman keratomileusis (SBK) microkeratome, femtosecond (FS) laser, or Moria M2 microkeratome (MK). Patients and methods This prospective clinical study included 60 eyes of 30 patients. They were divided into three groups (20 eyes in each group). The study was conducted from January 2019 till December 2019. Corneal flaps were created using Moria SBK microkeratome, Alcon Wavelight FS-200 FS laser, or Moria MK. Heidelberg anterior segment optical coherence tomography was done 1 month postoperatively to assess the central flap thickness and side-cut angle. Results The mean error cut angle was −39.00±19.00, 24.75±12.56, and −25.65±10.31° in the SBK, FS, and MK groups, respectively (P Conclusion There was a statistically significant difference between the intended and achieved side-cut angle in the three groups. Flap thickness was more predictable in the SBK and FS group, with an insignificant difference between the intended and achieved flap thickness, whereas in the MK group, the difference was statistically significant.

Superior flap tuck in mastopexy—a novel technique to promote lift and volume

Breast ptosis develops secondary to a pathogenic triad: progressive dermal laxity, inferior displacement of the nipple-areolar complex (NAC) and loss of superior pole fullness or “bottoming out”, leading to an aged breast appearance. Surgical mastopexy producing longevity of result is challenging. This article describes a novel superiorly based middle flap mastopexy technique via a vertical scar. Using this technique for over 5 years the senior author has produced a case series with longer lasting results compared to other techniques more commonly described. The technique is designed on a standard vertical scar pattern with a superior NAC pedicle. Glandular tissue inferior to the NAC is divided into three separate flaps, without any undermining or dissection of the lateral pillars. The central superiorly based flap immediately below the NAC is preserved, divided inferiorly and rolled back, posterior to the superior pole of the breast. It is then secured to the chest wall immediately posterior to the NAC to augment projection and conification. The lateral flaps are then brought together and secured over the top of the central flap. The skin envelope is then closed over the redistributed glandular tissue. In our experience this technique, with minimal lateral undermining and disruption of the native inferior breast architecture, produces lasting superior pole fullness. Using it in his practice, the senior author has found improved reliability and longevity of result compared to previous techniques.

Extended Central Artery Perforator Propeller Flap for Large Nasal Defects.

Various local flaps have been defined for small skin defects of the nose. However, the repair of large nasal defects is only possible with flaps allowing a large tissue transfer, such as a free flap, forehead flap, and nasolabial flap. In this study, large nasal defects were reconstructed with extended central artery perforator propeller (CAPP) flaps in an attempt to describe a single-stage procedure as an alternative technique to the median forehead flap. Thirteen large nasal skin defects, including dorsum and nasal sidewall and/or dome, were repaired with a CAPP flap between January 2015 and March 2018. A total of 13 patients aged 19 to 92 years were included. The mean follow-up period was 14.9 months. Pathological diagnoses were basal cell carcinoma in 5 patients, squamous cell carcinoma in 6 patients, and trauma in 2 patients. Defect size ranged between 3 × 3 and 4 × 5 cm. Flap size ranged between 3 × 7 and 5 × 10 cm. No major complications including total flap failure, hematoma, or infection were observed. However, a partial flap necrosis occurred in 1 patient. In 3 patients, scar revision surgery was performed at the postoperative period. In conclusion, CAPP flap use is a safe and reliable option to repair large nasal defects. This flap is able to cover large nasal defects including dorsal, dome, and nasal sidewall defects in a single-stage procedure. Requiring no pedicle separation, this flap is an alternative option to the conventional median forehead flap.

Repair of Anterior Ear Defects Using Transcartilage Island Pedicle Flaps.

Surgical reconstruction of the anterior surface of the ear (concha, antihelix, scapha, and triangular fossa) is complicated by the paucity of mobile local skin. This is a retrospective study of the transcartilage island pedicle flap for reconstruction of surgical defects of the anterior ear. Two hundred thirty-two Mohs micrographic surgery defects were included in the study. The technique involves circumferential incision of the flap in the postauricular sulcus, transfer of the flap to the anterior ear through a surgically created cartilage slit, suturing of the flap on the anterior surface of the ear, and repair of the secondary postauricular defect. Preoperative, intraoperative, and postoperative details of each case were tabulated and analyzed. The mean defect size was 1.9 × 1.5 cm. Complications included flap edema (n = 6, 2.6%), postoperative bleeding (n = 4, 1.7%), partial thickness flap necrosis (n = 2, 0.9%), pinning back of the ear (n = 2, 0.9%), and central flap dimpling (n = 2, 0.9%). There was 1 acute staphylococcal abscess and 1 sterile abscess that developed 13 months postoperatively. All complications resolved with medical or surgical management. Transcartilage island pedicle flaps may be considered for single-stage surgical reconstruction of defects involving the anterior ear.

Intraoperative use of electrolysis for hair removal in paramedian forehead flap

Hair transfer from the forehead hairline to the nasal tip leads to frequent patient complaints and can be challenging to deal with after paramedian forehead flaps (PFFs). To prevent it, flap design can be changed from vertical to an oblique fashion, providing a more prolonged and hairless flap. 1 Faris C. van der Eerden P. Vuyk H. The midline central artery forehead flap: a valid alternative to supratrochlear-based forehead flaps. JAMA Facial Plast Surg. 2015; 17: 16-22 Crossref PubMed Scopus (12) Google Scholar Furthermore, when hair-bearing skin is included in the flap, some epilation can be performed from the underside of the flap at the initial flap elevation. 2 Correa B.J. Weathers W.M. Wolfswinkel E.M. Thornton J.F. The forehead flap: the gold standard of nasal soft tissue reconstruction. Semin Plast Surg. 2013; 27: 96-103 Crossref PubMed Scopus (48) Google Scholar Although such measures can sometimes be useful, hair transfer may be unavoidable and difficult to treat, especially in cases of white hair, which is not responsive to epilation lasers.