Inferior Flap Research Articles

Muscle-Splitting Augmentation-Mastopexy: Implant Protection With an Inferior Dermoglandular Flap.

Simultaneous augmentation-mastopexy can achieve excellent patient and surgeon satisfaction but continues to pose a challenge, with revision rates of up to 25%. Recurrent ptosis and poor overall breast shape are 2 common reasons for reoperation, whereas some of the most feared complications is breast implant exposure, infection, and loss secondary to wound breakdown; excessively large implants or too much tension during closure are possible contributing factors. We describe a technique for augmentation-mastopexy combining a muscle-splitting pocket for implant placement along with an inferior flap, which helps secure the implant in place and provides coverage in case of wound dehiscence. A retrospective chart review was performed (January 2015 to December 2017) of women who underwent augmentation-mastopexy with round, textured silicone gel implants using a muscle-splitting technique combined with an inferior de-epithelialized dermoglandular flap. A total of 118 patients (236 breasts) were operated on. Mean follow-up was 13 months (10-42 months). Mean patient age was 33.3 years (24-55 years). Mean operative time was 102.9 minutes (80-135 minutes), and implant size ranged from 175 to 350 mL (mode, 275 mL). There were no cases of implant extrusion, nipple-areola complex ischemia, or surgical site infection; however, 1 patient required revision surgery for implant malposition, and 2 had a postoperative hematoma. In summary, the technique we describe combines 2 established mammaplasty techniques, ensuring upper pole fullness with good cleavage, implant protection in case of wound breakdown, and good patient satisfaction as evidenced by a low revision rate and minimal complications. LEVEL OF EVIDENCE: IV, therapeutic. Evidence obtained from multiple time series with or without the intervention, such as case studies.

Capsular plication in the non-deformity hip: impact on post-operative joint stability

Purpose and hypothesisThe aim of this study was to evaluate the hip joint range of motion after different capsular plication. The study hypothesis proposed that capsular plication after hip arthroscopy may reduce hip external rotation and thus prevent the hip joint instability created by arthroscopic capsulotomies.MethodsSix fresh frozen human cadavers were studied in the intact state (5 males, 1 females) for a total of 12 non-deformity hips tested. They were fixed to the operating room table using a custom-made apparatus. Three Steinman pins were inserted, the first into ASIS, a parallel pin into the distal femur proximal to inter-epicondylar axis and the third pin into the lateral epicondyle. Simulation of arthroscopic capsulotomies was done progressively with simulation of three capsular plication techniques. The first plication technique consisted of a primary plication shift of the antero-lateral capsule. The distal-medial arm of the iliofemoral ligament was shifted toward the proximal-lateral arm. The second plication technique consisted in adding a longitudinal arm to the capsulotomy, between the lateral arm and the medial arm of the iliofemoral ligament, to create a T-shaped capsulotomy. The resulting two triangular capsular flaps were overlaid onto each other by approximately 5 mm, plicated fully and tighly sutured in a double-breast manner. The third plication technique, called redrapping, consisted in excising the inferior capsular triangular flap (previously made in the second technique), and suturing the latero-anterior superior capsular flap to the medial arm of the iliofemoral ligament, superimposing the capsular edges for closure. External rotation of the hip at 0°, 15° and 30° of flexion were obtained after the capsulotomy and each capsular plication technique to quantify the increase in hip stability after plication. Data were assessed using a two-way repeated measure analysis of variance (ANOVAs) and Student’s T-test when necessary to determine if the change in external rotation was significantly different.ResultsAfter capsulotomy, external rotation averaged 26.3°, 29.1° and 31.1° at 0°, 15° and 30° of flexion. With the primary plication shift, external rotation averaged 24.9°, 30.3° and 34.0°. With the two-triangle technique, external rotation averaged 26.1°, 31.9° and 33.3°. With the re-draping technique, external rotation averaged 25.8°, 30.9° and 32.0°. A significant relationship was found between «Plication Technique» and «Angle of flexion» factors for the measured angle of external rotation (P = 0.04).A decomposition of the interaction showed that external rotation decreased at 0° of hip flexion and increased as the hip flexion angle increased. The only significant difference found corresponded to the two triangles technique at 15° flexion (mean difference compared to the non-repaired state = 2.8° ± 3.8° or 8.8% increase in external rotation; P = 0.03).ConclusionsDifferent techniques of capsular plication result in a non-significant increase in hip external rotation when compared to unrepaired capsulotomies. Therefore, special attention should be paid at the time of capsular plication, which could be disadvantageous when done overzealously aiming to increase postoperative stability.

About A New Mastopexy Augmentation Method Using Inferior Flap and Pectoral Muscle Loop in Wise Pattern Mammaplasty

About A New Mastopexy Augmentation Method Using Inferior Flap and Pectoral Muscle Loop in Wise Pattern Mammaplasty

Surgical treatment of glottic web using butterfly mucosal flap technique: Experience on 12 patients.

Many surgical methods have been described for the treatment of glottic web, with very little experience of each. Butterfly mucosal flap technique utilizes superior and inferior mucosal flaps on corresponding surfaces of the web; superior flap is elevated with its base on one vocal fold; and inferior flap is elevated with its base on the other vocal fold. These flaps are sutured to the vocal fold where flap's base is located. This requires four to six microsutures. The disadvantage of this technique is its difficulty. The advantages are single-stage endoscopic outpatient surgery and high success rate. This is an individual prospective cohort study. All consecutive 12 cases of glottic web were treated with butterfly mucosal flap technique and followed for at least 1 year postoperatively. Voice Handicap Index (VHI)-30 including physical, functional, emotional, and total scores; acoustic analysis with /a/; aerodynamic measures; and respiratory function tests with a spirometer were determined pre- and postoperatively. Six patients were male; five were female; and one was male-to-female transsexual. Their ages ranged between 9 and 60 years with a mean of 36. All webs were caused by surgical trauma. All webs were cured with one surgery. The postoperative VHI scores, acoustic analysis results, aerodynamic measures, and respiratory function test results of patients improved significantly postoperatively (P < 0.05). Although technically difficult, butterfly mucosal flap technique is a very successful single-stage endoscopic surgical option for the treatment of glottic webs. 2 Laryngoscope, 129:1423-1427, 2019.

Sensation-Sparing Correction of Inverted Nipples Using the ‘Drawbridge’ Flap Approach

An inverted nipple can cause significant functional and psychologic disturbance to women. The holy grail of any surgical technique to correct this is to restore adequate nipple projection and at the same time, try to preserve lactation and nipple sensation. We describe our experience using an inferior dermal nipple-areolar interposition flap to correct the inverted nipple alongside with selective release of the lactiferous ducts of the nipple. We have employed this technique successfully in 97 cases of inverted nipples in 60 patients with follow-up periods of up to 2years. Twenty-three of them had unilateral inversion, and 37 of them had bilateral nipple inversion. The appearance of the nipple was good to excellent. Seventy to 80% of the initial postoperative nipple projection at the end of 1year was maintained. Postoperative complications included stitch abscess in one patient (n = 1) and an epidermal cyst in another (n = 1). Nipple sensation was preserved in 100% of cases. There was no recurrence of inversion in any of the nipples. By identifying the root cause of inverted nipples in each individual case, and selectively targeting them, we minimize surgical morbidity with a simple technique that avoids any form of traction or compression of the nipple and minimizes the risk of altered nipple sensation. This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the table of contents or the online instructions to authors www.springer.com/00266 .

Total Thyroidectomy From A Patient’s Perspective

Total Thyroidectomy From A Patient’s Perspective

Reconstruction of acquired ischiatic and perineal defects: an anatomical and clinical comparison between gluteal thigh and inferior gluteal perforator flaps

BackgroundFlap coverage is the gold standard in treating pressure sores, and due to the high recurrence rate, the possibility of multiple surgical procedures should be considered during flap selection. The gluteal thigh (GT) flap has become a workhorse for ischiatic pressure sore treatment at our hospital. Follow-up revealed a group of patients presenting recurrence of the pressure sore that needed a second flap. The inferior gluteal artery perforator (IGAP) flap was chosen in this series. The positive experience with both flaps raised the question of which flap should be the first option for the treatment of ischiatic and perineal pressure sores.MethodsIGAP and GT flaps were dissected in 21 fresh human cadavers to allow comparison of anatomical features. In a series of 60 patients, the authors used both the gluteal thigh and the IGAP flap to cover 76 ischiatic and perineal ulcers.ResultsThe IGAP flap was found to be wider and thicker than the gluteal thigh, but presented a shorter pedicle. All flaps healed uneventfully. Recurrent ulcers were treated successfully with both flaps.ConclusionsBoth flaps are suitable for coverage ischiatic and perineal sores. Due to its anatomical features, the IGAP flap should be considered the first choice of treatment for ischiatic ulcers. The gluteal thigh flap should be used in the recurrent sores.Level of Evidence: Level IV, therapeutic study.

The Balcony Technique of Breast Augmentation and Inverted-T Mastopexy With an Inferior Dermoglandular Flap.

Optimal breast augmentation-mastopexy involves a reliable technique, fast recovery, minimal complications, and aesthetic results that are excellent and enduring. The authors sought to determine whether the balcony technique of augmentation-mastopexy was safe and yielded satisfactory long-term outcomes in patients with breast ptosis and hypoplasia. The authors conducted a retrospective review of 207 patients who underwent subglandular augmentation and inverted-T mastopexy with a customized Wise keyhole resection pattern and an inferior flap. Patient satisfaction was assessed anonymously on a visual analog scale via a questionnaire administered 4 years postoperatively. A total of 182 women received follow-up for 48 months and were included in statistical analyses. High levels of satisfaction were determined using Fischer exact test for breast shape, size, and symmetry, but not for other items, such as scar appearance, body perception, or self-esteem. The most common complications were Baker II capsular contracture and wound dehiscence. No patient experienced nipple loss or skin flap necrosis. The results of this long-term analysis demonstrate that the balcony technique of augmentation-mastopexy is suitable for patients with breast ptosis and hypoplasia. 4.

Immediate nipple reconstruction in combination with implant reconstruction using dermal sling.

The inferior de-epithelialized dermal flap with implant is increasingly used for immediate breast reconstruction. We have adapted the technique to provide concurrent immediate nipple reconstruction by recruiting the triangle of skin above the excised nipple as a modified C-V flap. The safety and efficacy of this technique has been assessed in 15 patients, of which eight were bilateral and seven were unilateral cases. We suggest that this is a safe, reliable, and original technique for immediate nipple reconstruction in patients undergoing immediate breast reconstruction with an inferior dermal sling and implant.

Abstract: Cryptotia Correction Using Double Opposing Interpositional Advancement Flaps

INTRODUCTION: Cryptotia is a congenital deformity of the ear where the upper third of the auricle is buried beneath the temporal skin with subsequent defacement of the cartilaginous framework. Patients present with distress over the appearance of their ear and difficulty wearing glasses. When diagnosed in the neonatal period, splinting is effective, but when diagnosed later in life surgical therapy is often most effective. Various surgical techniques have been described, but there has been no consensus for the best treatment. Almost all necessitate a skin graft. We present a novel technique utilizing 2 adjacent flaps from temporal and post auricular skin to release and cover the auricular soft tissue defect without skin grafting. METHODS: 3 ears (2 patients) were treated at the University of California San Francisco with cryptotia and repaired under general anesthesia as an ambulatory procedure. Both patients presented as teenage boys. An inverted V-Y flap is designed above the buried portion of the helical rim at 12 o’clock in the temporal and postauricular skin. A second inferiorly-based flap is designed adjacent to the posterior limb of the V. Both flaps are elevated above the temporalis fascia. The buried portion of the auricle is then released from the helical rim to the base of the concha. After release, the helical rim and antihelix are re-shaped with conchal-scaphal sutures if needed. The V flap is then inset to the posterior surface of the ear, with straight-line donor site closure. The inferior flap is then advanced to close the residual soft tissue defect. The ears are dressed with a Glasscock ear cup dressing. RESULTS: All patients returned for follow up 1–2 weeks after their procedure and healed without complications. There were no problems with tissue loss or wound healing. At 4 months postoperative, our results were durable with good cosmesis and satisfaction. CONCLUSION: We present a novel technique that is reliable and effective for reconstructing the soft tissue deficiency without skin grafting in cryptotia after helical release. The procedure is well-tolerated and the scars are hidden by the ear and temporal skin.

Mastopexie nach massivem Gewichtsverlust – Erweiterte Ribeiro-Technik und Einsatz der lateralen Interkostalarterien-Perforatorlappenplastik (LICAP-Flap) zur Autoaugmentation

Mastopexy in massive weight loss patients is challenging. The breast mound is often unstable and deflated, with a loose inelastic skin envelope. It has become apparent that mammaplasty techniques in these cases should rely more on glandular recontouring rather than on the skin envelope for shaping. Published methods include plication, suspension and autoaugmentation. The residual local tissue (glandular breast tissue, fat tissue, dermoglandular fat flap) is utilised to its full extent in order to reshape a form-stable breast with full upper pole projection. The evolution of a technique is presented. In this study we retrospectively analysed 68 massive weight loss patients who underwent an extended Ribeiro technique with a superomedial pedicle mastopexy and suspension by an inferior dermoglandular flap. The current procedure involves incorporating the lateral intercostal artery perforator flap (LICAP flap) and medial breast pillar additionally to the inferior dermoglandular Ribeiro flap. This essentially autoaugments the upper pole by creating an "autoprosthesis", narrows the widened breast, and redefines the inframammary fold. The outcome parameters complication rate, patient satisfaction with the aesthetic result, nipple sensibility and surgical revision rate were obtained. From 01/2011 to 12/2016, we performed 136 autoaugmentation mastopexies. The average age was 41.2 years, average body mass index (BMI) was 27,1 kg/m2, average weight loss was 54.3 kg, average sternal notch-NAC distance was 32.3 cm, average operation time was 109 minutes. In 12 breasts, a free-nipple graft was necessary. The complication rate was 5.1 %, surgical revision rate was 17.6 %. 95 % of the patients were "very satisfied" or "satisfied" with the aesthetic result. Nipple sensibility was rated as "very good" or "good" by 85 % of patients. Modification of the Ribeiro technique by using the medial and lateral breast pillar (LICAP flap) allows autoaugmentation of the upper pole. Parenchymal shaping through plication and suspension of the breast mound should improve breast shape over time, with the aim of reducing the incidence of recurrent ptosis. The presented technique is a reproducible and reliable method with a low complication rate.

Inferior Gluteus Maximus Island Flap for Reconstruction of Ischial Pressure Sores

&lt;p&gt;Surgical management of ischial pressure sores has always been a challenge due to high recurrence rate. Ischial pressure sores develop due to unrelieved pressure over the Ischium. Inferior gluteus maximus island flap has been used effectively for coverage of ischial pressure sores.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Objective:&lt;/strong&gt;&lt;strong&gt; &lt;/strong&gt;To describe the efficacy of inferior gluteus maximus flap for reconstruction of ischial pressure sores.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods:&lt;/strong&gt;&lt;strong&gt; &lt;/strong&gt;A retrospective case series, consisted of sample of 17 cases. The study was conducted in the Department of Plastic and Reconstructive Surgery, Post Graduate Medical Institute, Lahore General Hospital Lahore, over a period of 8 years from March 2008 to March 2016. The case series included17 patients with grade 3 and grade 4 ischial pressure sores, comprising 12 male and 5 female, with age range of 28 to 64 (mean = 46 years).Follow-up ranged from 1 to 4 years with a mean of 2.5 years. Inferior gluteus maximus island flap was used for reconstruction of Ischial pressure sores.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;In thirteen (76%) of the seventeen patients, wound healed uneventfully without any complication. Partial wound dehiscence was observed in 2 patients (12%). Both of these healed with conservative wound management. Recurrence was seen in 2 patients (12%) after 8 months. These two patients underwent &lt;em&gt;reoperation&lt;/em&gt; and gluteus maximus flap was readvanced that resulted in satisfactory wound coverage.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion:&lt;/strong&gt; Inferior gluteus maximus island flap can be considered as a reliable option for reconstruction of ischial pressure sores.&lt;/p&gt;

Prevention of re-obstruction in watery eye treatment: three-flap technique in external dacryocystorhinostomy.

To examine the surgical outcome of three-flap external dacryocystorhinostomy (3-flap ex-DCR) based on the most common site of granulation occurrence in no-flap endonasal DCR (no-flap en-DCR). This was a retrospective observational study. We first examined the location of granulation occurrence in the osteotomy site using nasal endoscopy after no-flap en-DCR on 53 sides of 37 patients (5 male, 32 female) with nasolacrimal duct obstruction. Based on the results of this surgery, we performed 3-flap ex-DCR on 70 sides of 61 patients (18 male, 43 female) with nasolacrimal duct obstruction. Anatomical success was defined as no reflux under lacrimal irrigation and a patent osteotomy site under nasal endoscopic examination at postoperative 12months. Functional success was defined as no symptoms of watery eyes over the same period. In the no-flap en-DCR patients, the granulation was formed in 42 sides (79.2%): 18 sides (34.0%) on the superior portion, 9 sides (17.0%) on the inferior portion, 35 sides (66.0%) on the anterior portion, and only 1 side (1.9%) on the posterior portion, which was very small. Based on these results, we performed the 3-flap ex-DCR with the anterior, superior, and inferior flaps. Anatomical success with this technique was achieved in all sides (100%), and functional success was obtained in 66 of 70 sides (94.3%). The 3-flap ex-DCR did not cause recurrent nasolacrimal duct obstruction, rendering it a very useful technique in terms of quality of life and medical economics.

A Novel Supra-Brow Combined with Infra-Brow Lift Approach for Asian Women.

BackgroundDirect brow lift surgery remains popular among Asian women despite its disadvantages. The traditional direct brow lift by a supra-brow incision is not suitable for Asian women because of their unique facial features, such as higher eyebrows, wider upper eyelids, and more orbital fat. Therefore, we designed a novel brow lift technique via a supra-brow combined with an infra-brow approach for Asian women.MethodsAn area of skin above and below the eyebrow was measured, demarcated, and surgically removed. The redundant orbicularis oculi muscle (OOM) was excised while keeping the frontalis muscle intact. The OOM in the inferior flap was elevated and sutured to the frontalis muscle. In cases of puffy eyelids, orbital fat was partially removed through an infra-brow incision. Finally, a series of modifications were performed to reduce post-operative scarring.ResultsA total of 496 patients underwent this surgery from July 2009 to December 2013 and 432 patients were followed up for at least 6 months after surgery. Post-operative scars, in most patients (428/432), were inconspicuous. There were no facial nerve injuries documented and eight patients reported transient forehead numbness. The height of the palpebral fissure was increased but there was no marked increase observed of the distance between the upper eyelid edge and the eyebrow. In follow-up visits, 409 out of 432 patients (94.7 %) were satisfied with their surgical results.ConclusionsThis new brow lift technique via a supra-brow combined with an infra-brow approach provided a simple and safe surgical repair of lateral brow ptosis, upper eyelids hooding, and crows’ feet in Asian women. The surgical outcomes were predictable and the scars were inconspicuous.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

A New Technique for Mastopexy and Reduction Mammaplasty: The Rolling Bilateral Flap Technique

Background: Numerous techniques have been proposed as “gold standard” for mastopexy, as for reduction mammaplasty. The quality of the breast parenchyma should be a primary factor in selecting the most appropriate technique for an individual case. Objective: The article describes a simple technique that can be used either for mastopexy or for reduction mammaplasty, giving optimal breast shape and position. It is appropriate for patients having some degree of ptosis, and especially for those in whom the glandular component of the breast predominates. Methods: The technique entails elevating the entire dome of the breast, rolling it under, and then stitching the two halves of the breast parenchyma together (lateral and medial dermoglandular flaps), while the upper pedicle (a third dermoglandular flap) bearing the nipple areolar complex (NAC) severed from the two inferior flaps is attached as a cap. The result is a new and attractive shape of the underlying supporting “barrel”. The technique can be performed with the T scar or the vertical scar approach. Results: The procedure was applied for various indications on 45 patients aged 20 - 62 years. Good results were only achieved in 36 women with predominant glandular component. Nine patients with fatty breasts achieved unsatisfactory results (6 with T scar, 3 with vertical scar) and very poor breast projection. Conclusions: The best-suited candidates for the proposed technique for mastopexy or reduction mammaplasty are women in whom the glandular component of the breast predominates. This simple technique, applicable with either inverted T scar or vertical scar approaches, carries very low morbidity, affording an attractive profile, long-lasting results, and conserving the patient’s ability to breast feed.

Silicone-based Composites as Surgical Breast Models for Oncoplasty Training

Surgeons-in-training necessitate practice to improve their skill sets and the shift towards simulation-based trainings enables trainees to learn at their own pace and experience custom-based cases rather than responding to the immediate needs of the patients. Oncoplasty for breast cancer encompasses tumor removal and subsequent breast reconstruction; and there are several oncoplastic techniques to master for proper treatment of the patients. For training purposes, closest media to reality, fresh cadavers, are hard to obtain due to their price and/or unavailability. There is a need for a sustainable, reliable, and affordable platform to diffuse simulation-based trainings to medical curricula and provide trainings even in resource-limited settings. Silicone-based composite models can be designed and manufactured to fulfil the necessities of breast surgery such as precise incision, epidermal undermining, suturing, and resisting suture tension after excision of a considerable mass. We have shown the performance of such a stand-alone breast model for two oncoplastic techniques, “Batwing Mammoplasty” and “Modified Inferior Flap Rezai”. This model can be used in settings where it is difficult and/or expensive to find fresh cadavers. This cost-effective and practical solution also eliminates the need for chemical/cold storage and risk of infections/molding, thus making it a preferable tool for teaching hospitals and also for individual practice. In addition, the model is suitable to be used in self-diagnosis trainings, as well as a communication platform between surgeons and patients.

Long-term clinical outcomes of conjunctival flap surgery for calcified scleromalacia after periocular surgery.

The aim of this study was to investigate long-term clinical outcomes of conjunctival flap surgery for calcified scleromalacia after periocular surgery. We examined 73 surgical sites (nasal and/or temporal area) in 60 eyes from 43 patients who underwent conjunctival flap surgery for calcified scleromalacia arising from cosmetic wide conjunctivectomy or pterygium excision. Clinical outcomes, including the need for reoperation and development of complications, were evaluated over a long-term follow-up period. Morphological evaluations of the surgical area at final follow-up were performed using a total score for injection severity, ocular surface smoothness, and choroid visibility, and patients subjectively evaluated their cosmetic outcome using a scale of 0 (very poor) to 4 (excellent). The mean follow-up duration after final conjunctival flap surgery was 26.5 ± 6.8 months (range, 15-52 months). There were no cases of progressive scleral thinning or serious complications such as flap necrosis or scleral perforation. Only 3 surgical areas with an inferior flap required additional flap placement because of avascular sclera exposure. Minor complications such as conjunctival cyst, edematous flap, vessel engorgement, and flap hypertrophy were easily treated or spontaneously improved. Mean morphological score was 2.2 and cosmetic outcome score was 2.9, indicating almost "good" outcomes. Based on our long-term experience, we propose that conjunctival flap surgery may be a safe and satisfactory treatment for complicated calcified scleromalacia after periocular surgery.

Single-port onlay mesh repair of recurrent inguinal hernias after failed anterior and laparoscopic repairs.

Background and Objectives:Despite the exponential increase in the use of laparoscopic inguinal herniorrhaphy, overall recurrence rates have remained unchanged. Therefore, a growing number of patients are presenting with recurrent hernias after conventional anterior and laparoscopic repairs have failed. This study reports our experience with single-incision laparoscopic (SIL) intraperitoneal onlay mesh (IPOM) repair of these hernias.Methods:Patients referred with two or more recurrences of inguinal hernia underwent SIL-IPOM from November 1, 2009, to June 24, 2014. A 2.5-cm infraumbilical incision was made, and an SIL port was placed intraperitoneally. Modified dissection techniques were used: chopstick and inline dissection, 5.5-mm/52-cm/30° angled laparoscope, and conventional straight dissecting instruments. The peritoneum was incised above the pubic symphysis, and dissection was continued laterally and proximally, raising the inferior flap below the previous extraperitoneal mesh while reducing any direct, indirect, femoral, or cord lipoma before placement of antiadhesive mesh, which was fixed to the pubic ramus, as well as superiorly, with nonabsorbable tacks before the inferior border was fixed with fibrin sealant. The inferior peritoneal flap was then tacked back onto the mesh.Results:Nine male patients underwent SIL-IPOM. Their mean age was 53 years and mean body mass index was 26.8 kg/m2. Mean mesh size was 275 cm2. Mean operation time was 125 minutes, with a hospital stay of 1 day. The umbilical scar length was 23 mm at the 6-week follow-up. There were no intra-/postoperative complications, port-site hernias, chronic groin pain, or recurrence of the hernia during a mean follow-up of 24 months.Conclusion:Inguinal hernias recurring after two or more failed conventional anterior and laparoscopic repairs can be safely and efficiently treated with SIL-IPOM.

Superior Pedicle Reduction Mammoplasty Supported with Inferior Pedicle Chest Wall-Based Flap: Refinements to the Technique.

Breast reduction techniques strive to obtain a final aesthetic breast shape. The most difficult issues to address after breast surgery are providing consistent upper pole fullness and preventing recurrent ptosis. Our surgical approach is a superior pedicle vertical scar breast reduction with an inferior pedicle chest wall-based flap to enhance the projection of the breast. We describe our refinements to the previously described similar techniques to provide upper pole fullness with long-lasting breast shape and prevent the bottoming out deformity. Twenty-five patients underwent reduction mammoplasty and/or mastopexy (15 mastopexy, 10 reduction mammoplasty) using modified superior pedicle reduction mammoplasty supported with inferior pedicle chest wall-based flaps between 2009 and 2013. Medical records and follow-up outcomes were retrospectively analyzed. Scar widening was acceptable even for larger reduction cases. The aesthetic results of both reduction and mastopexy cases were satisfying. Upper pole fullness was maintained in the long-term follow-up. Significant bottoming out was not observed. No skin excess was noted at the inferior fold region in any of the cases. In our modified technique, tissue is excised in a beveled fashion under the superior pedicle and pillars, particularly from the lateral; hence, the chest wall flap does not cause tissue excess at the upper infra-areolar site of the vertical scar. Flexibility in choosing the location from which to remove the breast tissue provides a custom-made approach to shape each breast. The long-term results of our technique demonstrate minimal breast descent and sufficient upper pole fullness.

Modified Antia–Buch flap for the reconstruction of helical rim defects

The Antia-Buch flap is a sophisticated one-stage procedure using two chondrocutaneous flaps to reconstruct the ear helix. Because tissue laxity is largely conferred by the inferior flap, relative to the less mobile superior flap, chondrocutaneous resection of scapha is required for closure. This results in loss of ear height and limits morphologic outcome. We describe a modification of the Antia-Buch flap, which may avoid such drawbacks. We conducted a retrospective review of patients (n = 15), each undergoing our modified Antia-Buch flap between 2010 and 2014. All procedures were performed under local anesthesia as outpatient procedures. Data on magnitude of resections, procedure durations, related complications, and aesthetic outcomes were collected. The mean size of resection was 25 mm (range, 20-30 mm). The modification improved the mobility of the upper chondrocutaneous flap, eliminating the need to resect the scapha. All wounds healed uneventfully, with no skin necrosis. The morphologic outcome was satisfactory or very satisfactory in all patients, preserving the shape, height, and width of the ear. Our modification changes the upper flap from an advancement flap to a transposition flap, enhancing its mobility and preempting the resection of the scapha. Thus, anatomic landmarks, aesthetic subunits of the pinna, and ear height are maintained for highly satisfactory morphologic results. 4.