Challenge In Reconstructive Surgery Research Articles

Management of Lower Lid Ectropion

BACKGROUND Ectropion repair is a challenge in plastic surgery. Depending on the etiology of the underlying problem, a variety of surgical techniques are available. The etiology, operative management, and recurrence rate are presented. OBJECTIVE An improvement of the deformity or, in the ideal case, a functional and aesthetic restoration should be accomplished. MATERIAL AND METHODS In this study, 58 patients with ectropion treated from June 2002 until March 2004 were analyzed, 33 with scar contractures, 13 with a tumor of the lid margin, 8 with facial paralysis, and 4 with senile ectropion. Surgical procedures included lateral or medial canthopexy, lateral tarsorrhaphy, wedge excision, skin graft, local flaps, cartilage graft, fascial slings, and combined procedures in one-third of the patients. RESULTS Postoperative complications included incomplete correction and others in 18.9% of the patients. Eight patients (13.8%) had to be reoperated. CONCLUSION Correction of the lower lid area including restoration of the lid margin in terms of shape and position is the surgical end point. The preoperative analysis is mandatory for a surgical solution to this severe problem, which is associated with a high incidence of recurrence, especially in difficult reconstructive cases. An individual sophisticated strategy combined with experience in the variety of surgical techniques is mandatory. Frequently, multiple procedures are necessary.

Management of Lower Lid Ectropion

Ectropion repair is a challenge in plastic surgery. Depending on the etiology of the underlying problem, a variety of surgical techniques are available. The etiology, operative management, and recurrence rate are presented. An improvement of the deformity or, in the ideal case, a functional and aesthetic restoration should be accomplished. In this study, 58 patients with ectropion treated from June 2002 until March 2004 were analyzed, 33 with scar contractures, 13 with a tumor of the lid margin, 8 with facial paralysis, and 4 with senile ectropion. Surgical procedures included lateral or medial canthopexy, lateral tarsorrhaphy, wedge excision, skin graft, local flaps, cartilage graft, fascial slings, and combined procedures in one-third of the patients. Postoperative complications included incomplete correction and others in 18.9% of the patients. Eight patients (13.8%) had to be reoperated. Correction of the lower lid area including restoration of the lid margin in terms of shape and position is the surgical end point. The preoperative analysis is mandatory for a surgical solution to this severe problem, which is associated with a high incidence of recurrence, especially in difficult reconstructive cases. An individual sophisticated strategy combined with experience in the variety of surgical techniques is mandatory. Frequently, multiple procedures are necessary.

Improved Survival of Ischemic Cutaneous and Musculocutaneous Flaps after Vascular Endothelial Growth Factor Gene Transfer Using Adeno-Associated Virus Vectors

A major challenge in reconstructive surgery is flap ischemia, which might benefit from induction of therapeutic angiogenesis. Here we demonstrate the effect of an adeno-associated virus (AAV) vector delivering vascular endothelial growth factor (VEGF)165 in two widely recognized in vivo flap models. For the epigastric flap model, animals were injected subcutaneously with 1.5 x 10(11) particles of AAV-VEGF at day 0, 7, or 14 before flap dissection. In the transverse rectus abdominis musculocutaneous flap model, AAV-VEGF was injected intramuscularly. The delivery of AAV-VEGF significantly improved flap survival in both models, reducing necrosis in all treatment groups compared to controls. The most notable results were obtained by administering the vector 14 days before flap dissection. In the transverse rectus abdominis musculocutaneous flap model, AAV-VEGF reduced the necrotic area by >50% at 1 week after surgery, with a highly significant improvement in the healing process throughout the following 2 weeks. The therapeutic effect of AAV-VEGF on flap survival was confirmed by histological evidence of neoangiogenesis in the formation of large numbers of CD31-positive capillaries and alpha-smooth muscle actin-positive arteriolae, particularly evident at the border between viable and necrotic tissue. These results underscore the efficacy of VEGF-induced neovascularization for the prevention of tissue ischemia and the improvement of flap survival in reconstructive surgery.

Satisfactory functional and aesthetic eyelid reconstruction using a three-layer composite graft: the tarsomarginal transplant

Eyelid reconstruction is a challenge in plastic surgery. Defects result predominantly after tumor surgery or due to trauma followed by scars. The functional and aesthetic aspects of the lid region have to be considered. Anatomically, the lid area consists of three layers: skin with eyelashes, cartilage and mucosa. An original eyelid reconstruction is only possible if a transplant consisting of the same tissue quality and architecture is used. This report is a presentation of an old method first described by Hubner [3] with a description of the surgical technique and a retrospective analysis of 72 patients treated from 1997 to 2003. The tarsomarginal transplant is an ideal method for lid margin reconstruction when functional and aesthetic results are considered. Skin texture, tarsal stability, eye protection with mucosa and growth of eye lashes are all restored. By using three grafts, even complete eyelid reconstruction is possible.

Engineering Adipose Tissue for Regenerative and Reparative Therapies

The correction or augmentation of soft tissue defects caused by trauma, tumor resection, congenital abnormalities, and aging presents a multitude of challenges in reconstructive surgery. Soft tissue defects run the gamut in terms of volume, from restoring the fullness of the face by removing wrinkles to restoring the breast mound after mastectomy. The limitations of current restorative and reparative techniques have served as drivers for the development of adipose tissue as an application area for tissue engineering. Tissue engineering is a multidisciplinary and maturing field that combines bioengineering, the clinical sciences, and the life sciences to repair or regrow tissues. This article discusses the inadequacies of current methods of correcting soft tissue defects and the innovative adipose tissue engineering strategies under pursuit to abrogate these limitations and improve patients’ outcomes and quality of life, and speculates rationally on the future. It does not discuss the applications and technologies involved with adipose-derived stem cells unless directly applied toward adipogenesis.

Opportunities and limitations of the computer aided surgical reconstruction after complex facial burn injuries

In severe facial burn injuries with extensive destruction of anatomical structures, cosmetic and functional outcome of treatment are frequently not satisfactory. Although operative therapy is being continuously refined, the variety and proximity of structures in the facial region is considered a major challenge in reconstructive surgery. We present the case of a 16-year-old patient with a severe facial burn injury. In planning the reconstructive procedures, we used a multimodal approach employing data from computerized tomography imaging, as well as from surface laser scanning, which provided three-dimensional visualization of facial soft tissues. Amount and pattern of structural loss could thus be determined more precisely and studied more vividly than by inspection of two-dimensional imaging alone. Anatomical features to be reconstructed could be projected onto the skin area of the prelaminated vertical rectus abdominis muscle (VRAM) flap that has been chosen to cover the defect. Prior to surgery, correction of the defects was simulated and the results of the virtual procedure superimposed on a three-dimensional head model of the patient. Tissue elasticity and thickness of the flap, however, could not be ascertained in advance, indicating the limitations of the method.

Computer aided surgical reconstruction after complex facial burn injuries – opportunities and limitations

In severe facial burn injuries with extensive destruction of anatomical structures, cosmetic and functional outcome of treatment are frequently not satisfactory. Although operative therapy is being continuously refined, the variety and proximity of structures in the facial region is considered a major challenge in reconstructive surgery. We present the case of a 16-year-old patient with a severe facial burn injury. In planning the reconstructive procedures, we used a multimodal approach employing data from computerized tomography imaging, as well as from surface laser scanning, which provided three-dimensional visualization of facial soft tissues. Amount and pattern of structural loss could thus be determined more precisely and studied more vividly than by inspection of two-dimensional imaging alone. Anatomical features to be reconstructed could be projected onto the skin area of the prelaminated vertical rectus abdominis muscle (VRAM) flap that has been chosen to cover the defect. Prior to surgery, correction of the defects was simulated and the results of the virtual procedure superimposed on a three-dimensional head model of the patient. Tissue elasticity and thickness of the flap, however, could not be ascertained in advance, indicating the limitations of the method.

Tissue engineering of white adipose tissue using hyaluronic acid-based scaffolds. I: in vitro differentiation of human adipocyte precursor cells on scaffolds

Background and aim of the study: Reconstruction of soft tissue defects is a challenge in plastic surgery and there is clinical need for adequate solutions. Aim of this study was to develop a biohybrid construct consisting of hyaluronic acid-based scaffolds and human adipocyte precursor cells as a soft tissue filler. Methods: Human adipocyte precursor cells were obtained by collagenase digestion of adipose tissue samples and seeded on hyaluronic acid-based spongy scaffolds of various degrees of esterification and pore size using different techniques. After cell attachment, adipose differentiation was induced by defined adipogenic factors under serum-free culture conditions. Results: Among the five different scaffold types under investigation the highest cell attachment rate was observed for the HYAFF ® scaffold with 100% esterification and a mean pore size of 400 μm (HYAFF ® 11lp). For inoculation of human adipocyte precursor cells on hyaluronic acid-based scaffolds a “drop-on” technique and low-pressure centrifugation using a Speed Vac ® airfuge were compared. With respect to efficacy, cell distribution and simpleness the drop-on method proved to be the method of choice. In a serum-free medium supplemented with 66 n m insulin, 100 n m cortisol and 1 μg/ml troglitazone a substantial proportion of cells underwent adipose differentiation as assessed by lipid accumulation and emergence of glycerol-3-phosphate dehydrogenase activity, a lipogenic marker enzyme. Conclusion: Hyaluronic acid-based scaffolds appear to be a suitable three-dimensional carrier for the culture and in vitro differentiation of human adipocyte precursor cells.

Soft Tissue Restoration Using Tissue Engineering

The correction of soft tissue defects caused by trauma, tumor resection, congenital abnormalities, and aging presents a challenge in plastic surgery. Soft tissue defects run the gamut in terms of volume, from restoring the fullness of the face by removing wrinkles to restoring the breast mound after mastectomy. The limitations of current techniques have served as drivers for the development of adipose tissue as an application area for tissue engineering. Tissue engineering is a growing field that combines bioengineering, the clinical sciences, and the life sciences to repair or regrow tissues. This article discusses the inadequacies of current methods of correcting soft tissue defects and the innovative adipose tissue engineering strategies under pursuit to abrogate these limitations and improve patient outcomes and quality of life.

Auricular reconstruction for microtia: Part II. Surgical techniques.

Reconstruction of the microtic ear represents one of the most demanding challenges in reconstructive surgery. In this review the two most commonly used techniques for ear reconstruction, the Brent and Nagata techniques, are addressed in detail. Unique to this endeavor, the originator of each technique has been allowed to submit representative case material and to address the pros and cons of the other's technique. What follows is a detailed, insightful overview of microtia reconstruction, as a state of the art. The review then details commonly encountered problems in ear reconstruction and pertinent technical points. Finally, a glimpse into the future is offered with an accounting of the advances made in tissue engineering as this technology applies to auricular reconstruction.

The prefabricated scapula flap consists of syngeneic bone, connective tissue, and a self-assembled epithelial coating.

The reconstruction of maxillary defects is a challenge in plastic surgery. The so-called prefabricated scapula flap consists of syngeneic bone covered with syngeneic dermis and is used to reconstruct maxillary defects. After placing these flaps into the oral cavity, they are reepithelialized within a short time period, raising the question of the cellular origin of the "neomucosa." We therefore obtained sequential biopsy samples of the prefabricated flap and of the flap after being placed into the oral cavity and analyzed the keratin expression profile of epithelial cells. We expected that after placing the prefabricated flap into the oral cavity, keratinocytes from adnexal structures of the dermal component of the graft would migrate onto the surface and reepithelialize the flap. Unexpectedly, reepithelialization occurred earlier. The flap had acquired a mucosa-like epithelium at the interface between the Gore-Tex coating and the dermis while still being positioned within the scapular region. The keratin expression profile of this epithelium was very similar to that of mucosal epithelium. Thus, the prefabricated scapula flap not only consisted of bone covered with connective tissue, but was also covered with epithelial cells derived from adnexal structures of the dermal graft. This seems to be the reason for the rapid restoration of an intact mucosa and the excellent outcome achieved with this surgical technique.

Reconstruction of extensive postburn scar deformities and contractures of the neck using expanded and nonexpanded free tissue transfer

The treatment of postburn scar deformities and contractures of the neck is one of the most complicated and unsolved challenges in reconstructive surgery. This paper is based on the experience of treating 63 patients with extensive postburn scar deformities and contractures of the neck. The supraclavicular and anterolateral chest wall skin was damaged, and the authors therefore used expanded and nonexpanded free flaps. This method allows the release of contracture, creates a natural skin cover of this part for the body, and provides good functional and cosmetic results.

Sensory relearning after nerve repair

One of the challenges in reconstructive surgery is to ensure hand sensibility is regained after median nerve repair. We assessed tactile gnosis in 54 patients (mean age 32 [range 4-72] years) after repair of transected median or ulnar nerves at the wrist level. We found that there is a well-defined critical period for sensory relearning after nerve repair. There is an optimum capacity below age 5-10 years followed by a rapid decline, which levels out after puberty. The curve correlates with previously published data on critical periods for language acquisition among immigrants. Recovery of functional sensibility after nerve repair is based on a learning process and in many ways is analogous to learning a second language.

A new surgical procedure for phallic reconstruction: Istanbul flap.

A new surgical procedure is described for phallic reconstruction, which still remains a great challenge in reconstructive surgery. In this procedure, an osteocutaneous radial forearm flap is combined with a radial recurrent fasciocutaneous flap from the anterolateral aspect of the upper arm. While keeping a fasciovascular connection between them, both flaps are elevated as a combined free flap based on the radial artery. The forearm skin island is used solely to construct the outer skin cover of the phallic shaft, and the neourethra is created by using the radial recurrent flap. Over the past 4 years, this surgical procedure, termed the Istanbul flap, has been used successfully for complete phallic reconstruction in five patients. Although more clinical experience with this new technique is needed, it seems to be a useful alternative in phallic reconstruction. It remarkably minimizes the donor-site scar without sacrificing the length of the neopenis. In addition, this technique reduces the risk of a hairy urethra.

The effect of nifedipine on skin flap survival in rats.

Maintaining the viability of an extended skin flap remains one of the continuing challenges in reconstructive surgery. As flaps lengthen, viability becomes more unpredictable and necrosis of distal segments can occur. The specific mechanisms involved in determining flap survival remain unclear, but vasoconstriction within the flap microcirculation appears to play a significant role in regulating flap viability. Vasodilators have been used, with limited success, in an attempt to improve survival of ischemic skin flaps in rats. One such agent, nifedipine, a calcium channel blocker, demonstrated conflicting results when used to improve rat skin flap survival, despite its potent vasodilating properties. A standard rat flap model was used to help clarify the potential of nifedipine to salvage ischemic skin flaps. Alterations in flap perfusion were assessed using a laser Doppler flowmeter and dermofluorometry in an attempt to characterize nifedipine's mechanism of action on flap preservation. Increased flap survival was demonstrated in treatment animals when compared to controls. Despite significant improvement in flap viability, perfusion measurements failed to confirm increased flow within the flap microcirculation. Although the mechanisms of action remain speculative, nifedipine may have important therapeutic potential in improving skin flap survival in a clinical setting.

Free Dermal Fat Flaps to the Face

Patients with extensive facial asymmetry continue to be a challenge in reconstructive surgery. Surgical techniques using microvascular anastomoses and free flap transfers can now be applied in the management of patients with such conditions as Romberg disease, postirradiation hypoplasia of the face, and Goldenhar syndrome, and in patients with bronchial arch developmental defects. Four patients are presented in this paper to demonstrate the use of free dermal fat in reconstruction of facial asymmetry. One patient with a moderate facial defect was treated with a free dermal fat graft, and the other 3, who had more extensive defects, were treated with deepithelialized free dermal fat flaps using direct microvascular anastomoses between the donor and recipient vessels. The groin was the donor area in each case. Results appear to indicate that free dermal fat flaps are useful in reconstructive procedures for patients with extensive facial defects.

Microtia reconstruction: our experiences of first 10 cases in Bangladesh

Varying degrees of congenital ear deformity (microtia) occurs 1 in about 8000 to 10,000 live births. One of the greatest challenges in plastic surgery is total auricular reconstruction as it demands precise technique as well as artistic creativity. In Bangladesh, recent advancement in the technique of carving and sculpting rib cartilage and better training for achieving finer anatomic details has given a break through in the surgical management of deformed ear. Between January 2009 and January 2010, total ear reconstruction was done with a two-stage method using autogenous costal cartilage in the Department of Plastic Surgery, Dhaka Medical College Hospital, Dhaka. In the first stage, lobule rotation, fabrication of the cartilage framework and its implantation were performed. In the second stage, elevation of the auricle and formation of the tragus were done. A total of 10 cases with microtia comprising different age group have been operated. All of them underwent stage I operation; among them 8 patients went through stage II procedure while the other 2 are waiting for the same. Results: 10 patients, ranging in age between 8 and 25 years, were operated on using autogenous costal cartilage between 2009 and 2010. Six patients were males and four were females. Unilateral microtia was present in all of these patients (7 right, 3 left). Eight cases were with Grade III microtia; the remaining 2 cases presented with Grade II microtia. The follow-up period was one month to one year. Seven among 8 cases presented acceptable ear contour after second stage ear reconstruction. The cranioauricular angle of the reconstructed ears was also similar to that of the opposite ears. Unfavourable result was deformation of the constructed helix which occurred in one case. Though it is impossible to reconstruct an ear that appears exactly as the opposite one, the new ears which were made were of correct size and in normal position with impressive finer three dimensional details that achieved patient’s satisfaction as well as surgeon’s professional gratification.Key words: Microtia; Two stage auricular reconstruction; Autologous costochondral cartilageBDJPS 2010; 1(2): 14-19

Challenges in Plastic Surgery

The plastic surgeon is concerned not only with saving lives and restoring function: his role may actually alter a patient’s entire perspective on life. Deformities of a congenital or acquired form can interfere with a person’s natural growth and ability to accept his place in the environment. This can be as crippling as any disease known. The plastic surgeon who succeeds in restoring normal appearance and function is often rewarded by witnessing the restoration of normal behavior as well. The operating nurse, working with the plastic surgical team, can enjoy the unique opportunity of sharing the enormous gratification resulting from this form of restorative surgery. The field can be roughly divided into four areas: 1) the correction of congenital deformities, 2) the repair of trauma, 3) reconstruction of post-surgical defects, and 4) esthetic surgery. To illustrate the scope and potential of this form of surgery, let us consider several cases.