Large Z-plasty Research Articles

Surgical Management of Sirenomelia: A Case Study.

Sirenomelia is a rare congenital condition characterized by fusion of the lower limbs. Patients with sirenomelia generally do not survive long after birth because the condition is associated with multisystem organ dysfunction due to developmental anomalies. Considering the low incidence and few cases surviving the neonatal period, there is minimal understanding regarding the surgical management of sirenomelia. We present a unique case of an infant born with type 1 sirenomelia, absence of external genitalia, presence of a cloaca, absence of the bladder, and presence of an imperforate and vestigial anus, who not only survived the birth process, but, at the age of 11 months, was determined to be a candidate for surgical separation of the lower extremities. This case was approached much like a dorsal rectangular flap syndactyly release. Large Z-plasty flaps were designed and raised, and the soft tissue within the skin bridge was meticulously dissected to preserve anatomy and to provide adequate skin flaps without perineal skin grafting. A quadrangular flap was designed to reconstruct the perineum and produce a neo-vulva using de-epithelialization. Successful lower extremity separation was achieved. There were no major postoperative complications. The patient progressed with lower extremity function, and eventually achieved independent ambulation. Management of sirenomelia is incredibly challenging, and data to guide surgical management are limited. This report details our approach to a successful lower extremity separation, repair, and neo-vulvar reconstruction in a case of type I sirenomelia.

Fingertip coverage with uni-pedicled volar rotational advancement flap with large Z-plasty: a report on 112 cases

BackgroundSimple and safe fingertip reconstruction methods involve the use of local neurovascular islands flaps that can preserve functional length and sensitivity, and reconstruction with skin of the same texture. However, techniques involving flaps have numerous drawbacks and do not satisfy all the requirements for fingertip reconstruction. A particular problem is the persistence of contracture deformity due to lack of full flap advancement. We present a new technique using uni-pedicled volar rotational advancement flap with large Z-plasty, and describe the results of long-term follow-up.MethodsFrom October 1993 to December 2009, 112 fingers of 98 patients were covered with uni-pedicled volar rotational advancement flap with large Z-plasty after sustaining various types of injuries or finger pulp avulsion. A longitudinal incision was made along the lateral border of the digit and a large neurovascular volar flap was elevated just above the pulleys and flexor tendon sheath. To release tension, a large Z-plasty was applied at the metacarpophalangeal joint or interphalangeal joint crease. The final patient outcomes were reviewed retrospectively.ResultsAll fingertip injuries were treated without flap necrosis. Partial wound dehiscence was observed in two patients and average static two-point discrimination was 5.2 mm. There were no postoperative contracture deformities, joint stiffness, paresthesia, or hypersensitivity. Most patients were left with acceptable scarring and were free of postoperative pain and cold intolerance during the long-term follow-up.ConclusionsOur novel technique provides durable, completely sensate, and well-vascularized coverage of the fingertip with minimal discomfort to patients.

Correction of Cryptotia With Double Z-plasty:Modified Large Z-plasty Technique.

Some cases of moderate or severe cryptotia are accompanied by a shortage of the helix. Although various operative techniques for correcting cryptotia have been reported, elongation of the helix is not considered in most of those techniques. In cases of a shortage of the helix, a drooped wide helix like a constricted ear or a cranially and posteriorly hypoplastic ear, which is characteristic of cryptotia, can appear after surgery if the helix has not been elongated. We previously reported a large Z-plasty technique that has become one of the popular techniques for correcting cryptotia. However, satisfactory results are not always achieved by using this technique in cases with a shortage of the helix. We developed a new technique (double Z-plasty) in which a small Z-plasty in the helical rim is added to the usual large Z-plasty technique. An improved helical shape and enlargement of the ear can be achieved by using this technique. Almost all types of cryptotia can be treated by appropriately using the large Z-plasty and double Z-plasty techniques.

Implantation cochléaire des cochlées ossifiées post-méningitiques : à propos de 30 implantations

A large Z-plasty on the postauricular surface of the ear has been used for successful reconstruction ofcryptotia. This technique provides extensive skin coverage of the posterior auricle without skin grafting. The technique is easy and simple. The natural hairline is not disturbed and the temporoauricular sulcus is emphasised. Almost all of the scar is hidden behind the auricle. It has been performed on 17 patients with no recurrence of the cryptotia. One patient had partial congestion in the cranial-flap tip, which improved within 1 week. There were no other complications.

Z-Plasty for Sculpturing of the Bifid Scrotum

Purpose Bifid scrotum is usually associated with scrotal and perineal Hypospadias. Conventional surgical repair includes rotation of two scrotal flaps joining them in the midline and vertical skin closure. On several occasions dimpling of the skin in the midline of the scrotum occurred, resulting in suboptimal aesthetic results. Herein we describe a surgical technique whereby the bifid scrotum is rebuilt and contoured using single or multiple z-plasties. Material and Methods We repaired 40 children with scrotal or perineal Hypospadias with varying degrees of bifid scrotum. Their ages ranged from 5 months to 6 years (average 3 years). Patients were divided into three groups: Group I (23 pts.): Children with primary perineo-scrotal Hypospadias who underwent two stage Hypospadias repair and had a z-scrotoplasty during either the first or second stage repair. Group II (11 pts.): Children who had previous Hypospadias surgery with a vertical scrotal midline closure and still had bifid scrotum. This group underwent secondary z-scrotoplasy. Group III (6 pts.): Children with primary posterior Hypospadias who had undergone midline vertical closure. Results Children in Group I (21/23pts) & Group II (11pts.) achieved excellent aesthetic results, with rounded scrotum, no midline dimpling, and no major complications. Midline dimple was encountered in 4/6 patients in Group III who had the vertical midline closure. Conclusions In repairing bifid scrotum associated with Hypospadias, the principle of z-plasty can be incorporated in scrotal contouring. It elongates, relaxes and interrupts the longitudinal tension of the midline closure. There are advantages to multiple small z-plasties over one large z-plasty, they avoid contracture and scar formation, which is apt to result in recurrence of the bifid scrotum.

A new operative method of correcting cryptotia using large Z-plasty

A large Z-plasty on the postauricular surface of the ear has been used for successful reconstruction of cryptotia. This technique provides extensive skin coverage of the posterior auricle without skin grafting. The technique is easy and simple. The natural hairline is not disturbed and the temporoauricular sulcus is emphasised. Almost all of the scar is hidden behind the auricle. It has been performed on 17 patients with no recurrence of the cryptotia. One patient had partial congestion in the cranial-flap tip, which improved within 1 week. There were no other complications.

Anatomic basis of cleft palate and velopharyngeal surgery: implications from a fresh cadaveric study.

The purpose of this investigation was to apply the findings of an anatomic study of the levator veli palatini, palatopharyngeus, and superior constrictor muscles in 18 fresh cadaveric specimens of normal adults to analyze current controversies in velopharyngeal function and cleft palate surgery. The levator veli palatini was observed to form a muscular sling, suspending the velum from the cranial base. Its fibers occupied the middle 50 percent of the velum, lying in transverse orientation and without significant overlap across the midline. It is well placed to function as the prime mover in the velar component of velopharyngeal closure. The velar component of the palatopharyngeus consisted of two heads clasping the levator and inserting into the latter just short of the midline. Its pharyngeal component inserted into the superior constrictor in the lateral and posterior pharyngeal walls. Together, these two muscles formed a sphincter around the velopharyngeal port, suggesting that both muscles are involved in the pharyngeal component of velopharyngeal closure. Based on the premise that the goal of palatoplasty is to restore normal anatomy, the intravelar veloplasty has a sound basis, and theoretically improves both velar and pharyngeal wall function because it corrects the dysmorphology of both the levator and palatopharyngeus. Although the Furlow palatoplasty also reorients these velar muscles correctly in the transverse position, the resulting overlap of the levator and palatopharyngeus across the midline is morphologically abnormal. In addition, the use of large Z-plasty flaps in wide clefts may cause excessive lateral tension, increasing the risk of fistula formation and causing an impairment of velar stretch capacity. The raising of a vertical pharyngeal flap divides the fibers of the superior constrictor and has the potential to impair pharyngeal wall function. The sphincter pharyngoplasty interferes less with pharyngeal wall anatomy. The potential for an obstructive outcome seems to be related to the use of wide, long flaps and a tight, overlapping type of flap inset. In addition, the level of flap inset is important: an inset at the level of the uvula has the greatest risk of causing obstruction, whereas a higher inset at the level of attempted velopharyngeal closure seems to provide the best opportunity for achieving velopharyngeal competence while avoiding hyponasality and obstruction.

Excision of Neck Redundancy with Single Z-Plasty Closure

In selected patients, particularly males, redundancy of skin of the neck can be treated effectively by direct excision and a single large Z-plasty closure so that the horizontal portion corresponds to the neck crease. Reduction of the thyroid cartilage can be performed simultaneously. The relative advantages and disadvantages between this approach and the more commonly performed facelift are discussed.

A complication in pregnancy due to severe burns in childhood

It is generally believed that a severly burnt scarred abdominal wall creates no problem in pregnancy because of the enhanced stretching capacity of scar tissue under the influence of hormones (Rai and Jackson, 1975) and the fact that the abdominal distension is a gradual process. Some of the problems of labour in burned pregnant patients have been reviewed by Schmitz (1971). He considered that normal vaginal delivery could usually be expected though premature labour might occur probably related to the burn in those patients who were in the early stages of pregnancy at the time of the accident. A serious problem was recently encountered in a patient which suggests that one should sometimes adopt a less expectant attitude to the potential ability of post-burn scar on the abdominal wall to stretch and soften during pregnancy. early foetal growth (before the 16th week of gestation) is the most sensitive period to change in the environment, including surgery, but haemodynamic problems exist throughout pregnancy. The surgeon is often forced to make a compromise between minimal disturbance of the foetal physiology and the creation of optimal operation conditions. In this patient under local anaesthesia, a large Z-plasty was performed in the lateral part of the constriction band. On incising the scar a very large gap developed instantaneously without any undermining. The decompression effect on the abdomen was dramatic. The wound was closed by simple transposition of the flap (Fig. 4). The patient was well during the operation but felt faint when she was about to be returned to the ward. Three days later labour pains started and she was transferred to the maternity department. The same day a physically normal but premature male infant was born weighing only 770 grams. Unfortunately the baby died the next day, the cause of death at postmortem being recorded as prematurity.