Large Surgical Defects Research Articles

Role of V-Y flap reconstruction in vulvar cancer patients: multicenter retrospective study

ObjectiveTo assess if the use of a V-Y reconstructive flap after excisional radical surgery positively influences the surgical outcomes in patients with vulvar cancer.MethodsThis was a multicenter, retrospective, controlled study....

Total mastectomy in severe necrotic mastitis in a pet goat complicated by a post‐operative generalised emphysema

AbstractA total mastectomy was the treatment of choice in a 10‐year‐old pet doe Pika with a history of severe necrotic mastitis secondary to a precocious udder. Following an elliptical skin incision, the mammary tissue was bluntly excised. Because of a large surgical defect, severe skin tension was needed to close the wound completely. A passive drain was placed in the surgical site to remove excess fluid, and the animal received antibiotic and anti‐inflammatory treatment. On the fifth day after the surgery, the drain was removed and palpation revealed an extensive subcutaneous emphysema at the surgical site as well as the back and neck of the animal. The antibiotic treatment was prolonged, and the animal kept for observation. After 3 weeks, the wound had healed completely, and the doe was discharged.

Triangular pulley traction facilitates endoscopic full-thickness resection of exogenous gastric tumor in the fornix of the stomach.

A 65-year-old woman was diagnosed with an exogenous submucosal tumor located in the fornix of the stomach, on the basis of the endoscopic ultrasound and enhanced CT findings. She refused surgery and referred for EFTR. It is difficult to perform EFTR at the gastric fornix and suture the large surgical defect. Therefore, we created technique of triangular pulley traction combined with pre-closure.

LINEAR CLOSURE: A STRAIGHTFORWARD APPROACH TO LARGE DEFECTS ON THE NASOLABIAL CHEEK FOLLOWING MOHS MICROGRAPHIC SURGERY FOR MORPHEAFORM BASAL CELL CARCINOMA

Mohs micrographic surgery (MMS) utilizes intra-operative histological assessment to maximize clearance of cutaneous malignancy while minimizing surgical defect size. [1–4] On cosmetically sensitive areas, most notably the face, transposition, advancement, and interpolation flaps and occasionally skin grafts are often utilized as repair techniques, despite potential for post-operative complications including bleeding, infection, impaired wound healing, and graft/flap loss.[1–5] Here we present a case of a large (6.5 cm by 3.5 cm) surgical defect on the cheek following MMS for the management of a morpheaform basal cell carcinoma and briefly review considerations regarding closure repairs, emphasizing linear closure as a reliable and successful option.

Management of Mucormycosis Resultant Hemimaxillectomy Defect from Interim Hollow Obturator to Definitive Two-Piece Magnet Retained Prosthesis - A Case Report

In case of large surgical defects, single-piece hollow bulb obturator prosthesis may increase the height and weight of the prosthesis resulting in loss of retention and difficulty while insertion and removal of the prosthesis. In the present case, patient presented with a large hemimaxillectomy defect with restricted mouth opening. A novel strategy for rehabilitating the patient with a major palatal deformity and restricted mouth opening by fabricating two-piece prosthesis is described in this case report.

Glabellar flap technique in oculoplastic surgery.

Facial skin defect reconstruction in medial-canthal area of the lids can be a challenge even when performed by a skilled surgeon. The excision of large tumors in this area leads to significant surgical defects that cannot be repaired by merely closing the wound. The glabellar area provides a source of redundant skin with similar characteristics to that of the medial-canthal lid area. The purpose show the possibility of the glabellar flap technique surgery in patients after tumor excision in the medial canthal area with the formation of a large surgical defect and especially those with defect under the medial canthal tendon. We selected 15 well-documented retrospective cases of patients operated over 2 years and followed up for a minimum of 36 months, who underwent surgery with a glabellar flap technique. Patients were operated with V-Y glabellar rotation, advancement, or combined transposition flap techniques. According to the defect’s location, we divided the patients into three groups: upper, medial, and lower surgical defects. A satisfactory functional result was obtained in all the patients. In most of them, the cosmetic results were also good. No additional surgical procedures were required in any of the patients. Our experience showed excellent results with the glabellar flap technique in all three types of lesions in the medial canthal zone—upper, medial, and especially lower which until recently was thought to be inappropriate.

Introducing the Bi-Pli Stitch: A New Surgical Technique to Relieve Tension in Large Surgical Defects.

Introducing the Bi-Pli Stitch: A New Surgical Technique to Relieve Tension in Large Surgical Defects.

Intraoperative Tissue Expansion to Allow Primary Linear Closure of 2 Large Adjacent Surgical Defects

It is becoming increasingly more common for dermatology patients to present for treatment of multiple skin cancers during the same appointment. When 2 lesions are close together, the final repair will need to take into consideration the final size of the adjacent defects, any normal tissue remaining between the defects, and the inherent tension of the tissue in those locations. The SUTUREGARD ISR device (Sutureguard Medical Inc) can allow intraoperative tissue expansion to decrease tension on the tissue and may provide the opportunity to allow primary linear closure for both defects as opposed to a much larger flap or graft repair.

Management of postoperative bleeding after use of a retroauricular interpolation flap

A retroauricular staged interpolation flap can be used to repair large surgical defects on the ear. This procedure is largely performed in the outpatient setting under local anesthesia, and the patient is sent home to care for the flap over the course of 3 weeks until the second stage is performed. Once the flap is sutured onto the defect, the unepithealized portion of the pedicle is exposed via the space between the postauricular and ear attachment sites. Although major complications are rare, postoperative bleeding occurs in more than 8% of patients despite obtaining hemostasis during the procedure. 1 Newlove T. Cook J. Safety of staged interpolation flaps after Mohs micrographic surgery in an outpatient setting: a single center experience. Dermatol Surg. 2013; 39: 1671-1682 Crossref PubMed Scopus (19) Google Scholar The risk of bleeding is greatest 24 to 48 hours after surgery, but any bleeding can lead to concern and discomfort for patients.

Intraoperative Tissue Expansion Using a Foley Catheter for a Scalp Defect: Technical Note

Primary closure of the surgical wound during neurosurgical procedures is sometimes difficult because of limited ability to expand the scalp, or because the skin defect is large. Hence, our institution recently adopted the technique of intraoperative tissue expansion using a Foley catheter for these cases. We describe this easily accomplished, readily available, effective, economical technique and describe our experience performing the technique. With this procedure, the subcutaneous tissue (usually the subperiosteal layer) surrounding the skin defect is dissected to make a subcutaneous pocket in which to place a 20-French Foley catheter. The standard expander is a 30-mL balloon. The catheter is inserted into the subcutaneous pocket, and the balloon is inflated with 10-30 mL of saline for 5 minutes, after which the balloon is deflated for 3 minutes in a cyclic loading manner. After sufficient expansion, the primary closure of the surgical wound is achieved with minimal tension on the surrounding skin. Between November 2018 and February 2020, we performed this technique in 5 patients, each with a large surgical defect in the scalp. Primary closure was achieved, and postoperative wound healing was excellent in all 5 patients. Intraoperative skin expansion using a Foley catheter-which is easily performed, readily available, and economical-can be used to achieve surgical wound closure during various neurosurgical procedures.

The Bilobed Flap as an Option for Large Neck

The bilobed flap has been extensively used in the reconstruction of distal nasal defects. It is a local flap that recruits skin from areas where there is relative skin mobility to close defects in areas where the skin has less plasticity. Besides its usefulness in the reconstruction of small to moderate cutaneous nasal defects it can also be used to reconstruct large defects located in other anatomical areas. We present a clinical case in which the bilobed skin flap was employed to reconstruct a large surgical defect of the neck resulting from excision of a basal cell carcinoma, with excellent functional and cosmetic results.

Reconstruction of Large Transmural Nasal Defects With a Nasolabial Turnover Interpolation Flap.

Reconstruction of large nasal surgical defects often warrant the use of mucosal flaps to repair the inner lining. This often presents a challenge for surgical reconstruction. To describe a unique reconstructive option for the repair of large surgical wounds that necessitate mucosal nasal lining. This study is a retrospective review of 10 patients who underwent surgical reconstruction of large nasal and/or heminasal surgical defects following Mohs micrographic surgery. A nasolabial turnover interpolation flap was used to repair missing nasal mucosal lining, coupled with a cutaneous flap which typically involved a paramedian forehead flap. The duration of follow-up was 8 months. An aesthetic and functional surgical outcomes measure was used to assess the final repair. Favorable aesthetic outcomes were obtained in all patients and without need of revision surgery by the use of a nasolabial turnover interpolation flap. The nasolabial turnover interpolation flap offers a reliable and effective method of repair for large transmural nasal surgical wounds. We typically paired this nasal lining flap with a paramedian forehead flap with reliable and aesthetic outcomes. This technique is straightforward, reproducible, and with both good aesthetic and functional outcomes.

Reconstruction of total parotidectomy defects with a de-epithelialized submental flap.

ObjectiveTotal parotidectomy yields a large surgical defect that leads to both cosmetic and functional deficits which can be addressed with reconstruction. We evaluated the role of a pedicled submental flap for this reconstruction.MethodsWe reviewed all submental flap reconstructions that were performed for total parotidectomy defects between 2014 and 2016. Data regarding harvest technique, postoperative complications, flap survival, and adjuvant treatment details were recorded. Subjective information regarding retained volume after reconstruction was also obtained.ResultsDuring the time period, eight patients were identified and in all cases the patients underwent total parotidectomy with facial nerve sacrifice. All patients were discharged within 2 days of hospitalization with no complications or concerns regarding the viability of the flap. All but one patient had radiation therapy. Results with 9.9‐ to 37.5‐month follow‐up (mean 22.0 months) show limited volume loss without major contour defect or ear deformity in the follow‐up period.ConclusionsSubmental flap reconstruction is a feasible and reliable method for total parotidectomy defect. The inclusion of the mylohyoid muscle aids flap reliability and adds bulk. Inclusion of the dermis helps contour the overlying skin. The flap does not add morbidity or increased complexity intraoperatively or postoperatively.Level of Evidence4

Creation of Bone and Soft Tissue in Postmaxillectomy Patients Using Curvilinear Transport Distraction Osteogenesis.

Background:Large surgical defects in the maxilla due to trauma or tumor are usually reconstructed with revascularized-free fibula flaps (RFFF). In the past, the use of curvilinear transport distraction osteogenesis (CTDO) has been shown to be an efficacious way in closing large defects in the maxilla, but it had limitations which have now been overcome by the present development. The present distractor is an improvement upon the previous three prototypes and employs the concept of tetrafocal distraction by means of hybridizing the bone with the tooth in the transport disc segment. This article aims to prove that tetrafocal distraction provides a viable alternative to the RFFF.Materials and Method:In a prospective cohort study of six postmaxillectomy patients, the method of CTDO was applied and investigated to ascertain the outcome. The regenerate bone was compared with the parent bone, using a new maxillary transport distractor. A linear bicortical fracture was created in the maxilla in a vertical direction (segmentally) to develop a mobile, vascularized transport disk. This transport disk underwent further subdivision to produce the concept of tetrafocal distraction.Results:After osseointegration of the dental implants, prosthetic rehabilitation of the dentition was successful. The authors report the successful outcome of two of the six cases subjected to CTDO to treat defects ranging from 25 mm (using bifocal distraction) to 80 mm along a curved trajectory (using tetrafocal distraction).Conclusions:The production of curvilinear bone and soft tissue along a horizontal plane has been demonstrated. From a clinical perspective, the new alveolar bone achieved the correct width and height to create a physiological vestibule and an esthetic zone for dental implants. In addition, the shape of the palatal vault is also reconstituted. The tetrafocal method of the CTDO is a reliable method of maxillary reconstruction.

Large Nasal Defects with Exposed Cartilage: The Folded Transposition Flap as an Innovative Alternative to the Paramedian Forehead Flap

Background: Skin cancer removal surgery involving the tip or dorsum of the nose often results in large-sized defects with exposure of cartilage. In such cases, the paramedian forehead flap is a frequently used reconstruction technique; however, this method is complex and can result in a cosmetically unsatisfying outcome. Objective: To describe the folded transposition flap as an aesthetically pleasing alternative to the paramedian forehead flap for large nasal defects with exposed cartilage. Methods: The folded transposition flap is a 2-stage surgical modification of the transposition flap. In the first stage, an overlong axial cheek pedicle is used to cover the defect. In the second stage, the flap is thinned and the nasal scars are revised. Results: All 4 patients experienced aesthetically pleasing results. Conclusion: The folded transposition flap is an alternative for reconstructing large surgical defects of the nasal tip or distal dorsum of the nose.

Retalho de Rotação Súpero-Medial: Resultados em Três Doentes

INTRODUÇÃO: O retalho de rotação súpero-medial é um retalho cutâneo local, randomizado, e predominantemente de rotação, que permite encerrar defeitos de média e grande dimensão, nas regiões malar súpero-medial e pele palpebral inferior.
 MATERIAL E MÉTODOS: Dois homens e uma mulher foram submetidos a exérese alargada de lesões clinicamente sugestivas de carcinoma basocelular da face, sob anestesia local, seguida de reconstrução com retalho de rotação súpero-medial.
 RESULTADOS: Não se registaram complicações pós-operatórias imediatas ou tardias. Os resultados funcionais e morfológicos foram aceitáveis. Os doentes não apresentaram recidivas nos 12 meses de seguimento.
 DISCUSSÃO: O retalho de rotação súpero-medial é um procedimento simples, realizado em tempo operatório único, sob anestesia local. Constitui uma excelente opção dentre as várias técnicas cirúrgicas reconstrutivas perioculares clássicas. O ectrópio é uma complicação rara.
 CONCLUSÃO: O retalho de rotação súpero-medial revelou-se uma opção cirúrgica segura e eficaz nos três casos.

Reconstrução da Região Labial Inferior: Um Exemplo de Versatilidade do Retalho Nasogeniano

O retalho nasogeniano de pedículo inferior representa uma opção válida e bem reconhecida para reconstrução de defeitos do lábio inferior, tal como no caso que descrevemos. Homem, 82 anos, com carcinoma basocelular do 1/3 direito da pele do lábio inferior, sem envolvimento da mucosa. Sob anestesia local, a lesão foi excisada com margem cirúrgica adequada, tendo-se gerado um defeito elipsoide complexo. Procedeu-se ao encerramento do mesmo com retalho nasogeniano de pedículo inferior. Não houve necrose no pós-operatório tardio. Os resultados estéticos e funcionais foram aceitáveis.

Keystone perforator island flap: a clinical summary of 28 melanoma cases

Background: The keystone perforator island flap (KPIF) and its design variations developed as a clinical necessity for reconstructing large surgical defects. This article focuses on melanoma management in 28 cases taken from a series of up to 3,000 established over 20+ years of clinical experience. Method: The dermatome is the basis of the keystone success where vessels accompany nerves. Keystone perforator island flaps are fascial lined, supporting vascular integrity. The design resembles two conjoined VY island flaps facilitating closure under tension as the perforator zones (perforazones) are oriented vertically with a stronger hydrostatic supply than the horizontally aligned subdermal plexus. Tissue match is important and contributes to a sound aesthetic outcome. Results: KPIF reconstructions are pain free even though tension is noted. KPIF reconstructions are almost anaesthetic for the complete dimension of the wound. This is explained by the simple fact that temporary interruption of somatic innervation in this design recovers over a few months in the same way as any longitudinal incision regains its nerve supply. Oedema in the KPIF is rarely observed and could possibly be a sympathetic affect. Reactive hyperaemia is evident in irradiated tissue, breaking another rule in plastic and reconstructive surgery in irradiated tissue where loco–regional reconstruction is contraindicated. Conclusion: With an intact vascular system associated with autonomic and somatic support—including lymphatic drainage, the Gillies principles of replacing ‘like for like’ and the ‘next best tissue is the next best tissue’—reconstructive design principles are maintained.

Keystone perforator island flap: a clinical summary of 28 melanoma cases

Background: The keystone perforator island flap (KPIF) and its design variations developed as a clinical necessity for reconstructing large surgical defects. This article focuses on melanoma management in 28 cases taken from a series of up to 3,000 established over 20 years of clinical experience. Method: The dermatome is the basis of the keystone success where vessels accompany nerves. Keystone perforator island flaps are fascial lined, supporting vascular integrity. The design resembles two conjoined VY island flaps facilitating closure under tension as the perforator zones (perforazones) are oriented vertically with a stronger hydrostatic supply than the horizontally aligned subdermal plexus. Tissue match is important and contributes to a sound aesthetic outcome. Results: KPIF reconstructions are pain free even though tension is noted. KPIF reconstructions are almost anaesthetic for the complete dimension of the wound. This is explained by the simple fact that temporary interruption of somatic innervation in this design recovers over a few months in the same way as any longitudinal incision regains its nerve supply. Oedema in the KPIF is rarely observed and could possibly be a sympathetic affect. Reactive hyperaemia is evident in irradiated tissue, breaking another rule in plastic and reconstructive surgery in irradiated tissue where loco–regional reconstruction is contraindicated. **Conclusion**: With an intact vascular system associated with autonomic and somatic support—including lymphatic drainage, the Gillies principles of replacing ‘like for like’ and the ‘next best tissue is the next best tissue’—reconstructive design principles are maintained.

A Large Surgical Defect of the Central Forehead

Departments of *Otolaryngology, and †Dermatology, University of Colorado School of Medicine, Aurora, Colorado Address correspondence and reprint requests to: Adam Terella, MD, Department of Otolaryngology, University of Colorado School of Medicine, 12631 E. 17th Avenue MS-B205, Aurora, CO 80045, or e-mail: [email protected] The authors have indicated no significant interest with commercial supporters.