Natural Crease Research Articles

Application of Trapezoid Orbital Septum Membrane Flap in Double-Eyelid Blepharoplasty.

For a long time, to achieve the natural shape of double-eyelid crease, multiple techniques of double-eyelid plastic surgery have been developed. We describe the trapezoid orbital septum membrane flap in blepharoplasty to achieve a dynamic double-eyelid crease and avoid a depressed static scar. The authors developed a trapezoid orbital septum membrane flap in double-eyelid blepharoplasty. The flap base is fixed on the pretarsal plate with the distal end of the flap positioned between the superior and inferior edges of the incision. Layer-by-layer contraposition suturing is then performed. One hundred ninety-one cases of double-eyelid blepharoplasty were performed by a senior surgeon using the trapezoid orbital septum flap method. Patients were followed for 6 to 17 months. Twelve cases were revised secondarily. Patients were satisfied with the palpebral folds, which showed a dynamic crease followed with movements of the eyelids. The authors introduce a trapezoid orbital septum flap in upper eyelid blepharoplasty. The flap relies on the elasticity of the orbital septum flap as the levator aponeurosis extension segment to produce a natural crease without a depressed static scar.

Versatility of unilateral propeller groin flap for coverage of large scrotal defects and its impact on testicular function

BackgroundThere are many options for scrotal reconstruction, each having its own benefits and drawbacks. In the last years, the introduction of the propeller flaps gained great popularity, while the use of groin flap as propeller in scrotal reconstruction remains anecdotal, with only a few cases reported in the literature.ObjectivesIn this research, we study the versatility of unilateral propeller groin flaps in the reconstruction of large scrotal defects.Patients and MethodsThis study was done on 10 patients with scrotal defects who were admitted to the plastic unit of the general surgery department at Benha University Hospital from 2019 to 2021 for scrotal reconstruction.ResultsAll surgeries were successful with a mean operative time of 103.5 min, ranging from 90 to 130 min. All flaps survived well with no flap necrosis, and only one case showed flap congestion. Donor site healed well with the scar hidden in a natural crease, with no affection on the testicular functions.ConclusionsThe use of groin flap as a propeller allows for free movement and rotation of the flap, which allows for better coverage of a large scrotal defect with good vascularity, lesser complications, no need for further operations to separate the pedicle, and the lowest donor site morbidity.Level of evidenceLevel IV, therapeutic study

Laparoscopic cholecystectomy in children with sickle cell disease: A simple modified technique

Sickle cell disease and other hemoglobinopathies are prevalent in Bahrain. In our hospital, we often encounter children with gallstones; sometimes gallstones are discovered on routine abdominal ultrasound, and in other cases, patients present with symptoms. Elective cholecystectomy has been controversial in patients with sickle cell disease and cholelithiasis because surgery can be a challenge. Therefore, the aim of this study was to assess the safety of elective cholecystectomy in children with sickle cell disease with cholelithiasis, as well as the safety and efficacy of a simple modification to the conventional laparoscopic cholecystectomy technique using two natural creases in the skin. The modified technique employs four ports, two of which were placed in natural crease lines, specifically the umbilicus and the groin crease. The procedure was elective for patients with sickle cell disease with gallstones. All patients received either a preoperative blood transfusion or an exchange transfusion to reduce the risk of postoperative sickle cell complications. Eighty-one patients with sickle cell disease with gallstones underwent our simple modified laparoscopic cholecystectomy procedure. The mean ± SD operative time was 58.43 ± 8.02 minutes (range, 45-80 minutes). Only eight patients (9.9%) experienced postoperative complications; six had fever, and two had a sickle cell crisis. None of the patients required conversion to open cholecystectomy or intensive care management. Our simple modified laparoscopic cholecystectomy using two skin creases is a safe and feasible elective procedure in children with sickle cell disease that provides excellent cosmesis.

Swinging Eyelid Approach to Zygomaticomaxillary Complex Fracture.

A surgical approach to zygomaticomaxillary complex (ZMC) fracture has not been standardized. The authors reviewed 15 cases of ZMC fractures treated with the swinging eyelid approach and evaluated the effectiveness of the technique by an observational study of Japanese patients. Results were assessed from authentic and functional perspectives: the presence of entropion/ectropion, external canthal malposition and chemosis of the conjunctiva. After a minimum follow-up of 10 months, no patients had lower eyelid ectropion, entropion or retraction. Wounds appeared inconspicuous, and a lateral canthal shape was preserved. No post-operative chemosis of the conjunctiva was observed. Each case was evaluated based on patient satisfaction about their aesthetic outcomes. Patient self-assessment is classified into 4 groups (excellent, good, fair, and unsatisfactory). Thirteen patients were assessed to have an "excellent" outcome, and 2 patients were assessed to have a "good" outcome. No patients had "fair" or "unsatisfactory" outcomes. Avoidance of scarring is a goal of every craniofacial surgeon. The swinging eyelid approach to ZMC fractures offers a simple alternative to the conventional technique. It is versatile and provides sufficient exposure to surgical fields with less visible scar because skin incision is made along the natural crease line, "the crow's feet."

Soft-Set Serpentine Eyelid Crease Formation

Achieving a truly natural and effective eyelid crease during blepharoplasty surgery in patients of both Asian and Native North/South American descent can be challenging. Typical techniques of open crease formation can create unnaturally firm attachments, whereas closed techniques have limited efficacy. We present a partially open technique that achieves a soft, natural eyelid crease by recreating the normal anatomic attachments without a deeper dissection between the levator aponeurosis and the anterior lamella. A retrospective review of all patients at a single oculoplastic surgery practice undergoing the serpentine “soft” upper eyelid crease formation maneuver was performed. Charts were reviewed for outcomes, complications, and subjective satisfaction with the procedure. The review included analysis of the preoperative and postoperative photos. The surgical technique involved using a 7-0 silk suture to surgically tether the tissues of the pretarsal levator aponeurosis to the pretarsal orbicularis in a continuous serpentine fashion. The retrospective review yielded 16 patients (32 eyelids) who underwent this style of eyelid crease formation at the time of blepharoplasty. All patients were pleased with the outcome at their final visit. There were no complications. There was 1 revision surgery at 1 year postop to optimize symmetry. Natural-appearing eyelid crease surgery requires efficacy without aggressiveness. We present a technique that allows for reproducible reformation of the upper eyelid crease using a running, overlapping, 7-0 silk suture.

Versatility of nasolabial flaps for the management of severe trismus in oral submucous fibrosis.

Oral submucous fibrosis (OSMF) is a chronic insidious disease affecting any part of the oral cavity and sometimes the pharynx. It is a collagen-related disorder predominantly associated with tobacco/areca nut chewing habit and characterized by progressive hyalinization of the submucosa. Prevalence of OSMF is 2.01%, and malignant transformation rate of 2.3%-7.6% has been reported in the literature. Measures such as forcing the mouth open and cutting the fibrotic bands have resulted in more fibrosis and disability. Various surgical treatment modalities have been advocated in the surgical management of OSMF with variable results. This retrospective study evaluates the efficacy of nasolabial flap in the surgical treatment of OSMF. Retrospective analysis of 42 patients who underwent surgical management of OSMF with mouth opening <20 mm by nasolabial flap at authors center from 2000 to 2015. Only the cases diagnosed as advanced OSMF based on long-standing positive history of habits (chewing tobacco, betel nut, etc.), clinical and histopathological examination. OSMF due to other causes such as nutritional deficiency, immunological diseases, and systemic illness with medically compromised patients were excluded from the study. Inferiorly based nasolabial flaps were raised in the supramuscular plane and transferred intraorally through a transbuccal tunnel. The study groups consist of 42 cases of clinical and histopathologically proven cases of OSMF treated by nasolabial flap. Out of 42 cases, 39 (92.85%) were males and 3 (7.15%) were females which showed a male predominance and the ratio was 13:1. The mean (standard deviation [SD]) preoperative mouth opening was 14.60 mm (3.06). After release of fibrotic bands, a mean forced intraoperative mouth opening of 36.27 (2.11) mm was achieved. The mean (SD) postoperative mouth opening was 33.05 mm (2.40) at the end of 2-year follow-up. The mean (SD) increase in mouth opening after surgical management at the end of 2-year follow-up is 18.46 mm (1.89). Sixteen out of 42 patients' histopathological report turned out to be dysplastic. The mean (SD) follow-up was 2.79 years (1.08). There was no incidence of infection in the transferred flap and the recipient site in all cases except one case with malignant transformation. All flaps healed without evidence of infection, dehiscence, or necrosis. Results were assessed by comparing the pre- and post-operative maximum mouth opening. The nasolabial flap is a versatile flap, which can be successfully used in the reconstruction of defects created after the release of fibrotic bands in OSMF. The versatility of the nasolabial flap has been attributed to its reliable vascularity derived from numerous vessels in the vicinity. Major advantage is the ease of elevation, proximity to the defect, suitable size for coverage of defect, minimal swallowing and speech difficulties, and a relatively cosmetic result as scar is in natural crease. All the cases treated for OSMF using bilateral nasolabial flaps showed adequate mouth opening at 2-year follow-up postoperatively, recommending its use.

The periumbilical approach in ventriculoperitoneal shunt placement: technique and long-term results

The aim of this study was to examine the feasibility and safety of ventriculoperitoneal (VP) shunt placement using a periumbilical approach for distal peritoneal access. By using this minimally invasive approach, the authors hypothesized that the cosmetic outcomes would be better than could be achieved by using a traditional minilaparotomy and that clinical results would be comparable. A periumbilical approach was used for distal catheter insertion during a first-time VP shunt placement in 20 patients (8 males and 12 females). Median age at time of surgery was 3.0 months (range 7 days-11.9 years) and mean follow-up time was 17.8 months (range 1.2-28.0 months). The median weight of the patients was 3.99 kg (range 1.95-57.0 kg). A single incision was made along the natural crease inferior to the umbilicus. The linea alba was exposed and a 1-mm incision made while the patient was temporarily held in a Valsalva maneuver. A peritoneal trocar was then inserted through the fascial incision and the distal catheter was passed into the peritoneal space. The incision line in all patients healed well, did not require operative revision, and was described as minimally visible by the patients' families. Mean operative time was 35 minutes. Eight patients required revision surgery. One distal failure occurred when the distal shunt tubing retracted and became coiled in the neck; this was repaired by conversion to a minilaparotomy for distal replacement. There was 1 shunt infection (5%) requiring shunt removal and replacement. One patient had significant skin thinning around the valve and proximal catheter, which required replacement of the entire shunt system, and another patient underwent a conversion to a ventriculoatrial shunt due to poor peritoneal absorption. In the remaining 4 patients who required operative revision, the peritoneal portion of the shunt was not involved. The periumbilical approach for peritoneal access during VP shunt placement is technically feasible, has low infection rates, and has cosmetically appealing results. It may be considered as an alternative option to standard VP shunt placement techniques.

Delivery by Caesarean Section in Super-Obese Women: Beyond Pfannenstiel

J Obstet Gynaecol Can 2012;34(5):472–474 P in women who are super-obese, defined by body mass index over 50 kg/m2, has risen relentlessly across North America during the past decade. Currently 2% of deliveries are affected by super-obesity in parts of the southern United States, where young women of AfricanAmerican and Hispanic descent constitute the fastest growing segments of the population.1 In Canada, obstetricians are caring for increasing numbers of very overweight women from a variety of backgrounds. All obstetricians providing labour and delivery services to such women need to be prepared for delivery by Caesarean section (CS) because of the surgical challenges, especially since the risk of having to perform CS in labour may exceed 50%.2 Elective CS, often performed because of suspected macrosomia, may best serve many women in this BMI category. Increasingly such women are concentrated in focused antenatal clinics where preoperative discussions lead to elective daytime surgery performed by experienced personnel. Nevertheless, superobese women do begin labour spontaneously or may have labour induced, and thus the on-call labour and delivery obstetrician will face significant delivery challenges. What advice is available to assist on-call staff when performing CS in these women? Current editions of two leading textbooks offer no guidance on the approach to CS in super-obese women.3,4 By contrast, the online resource tool “UpToDate” devotes a section to this subject5 with the following advice: first, while elevation of the pannus may permit access to the abdomen through a traditional Pfannenstiel incision, the risk of wound infection may be reduced by weight-adjusted prophylactic pre-incision administration of intravenous antibiotics, minimal fat layer disturbance on entry, and closure of this layer on exit with skin staples to permit seroma drainage. This resource warns that postoperative wound complications should be anticipated in up to 25% of these patients and that the patients may require extended follow-up after initial discharge because the presentation is often delayed. If technically possible, a Pfannenstiel incision for entry beneath the pannus has important benefits, provided the surgeon can anticipate having easy access to a presenting fetal pole in the lower uterine segment. The skin incision should ideally be placed in healthy skin at least 2 cm above the natural crease. Modest use of the Trendelenberg position helps to keep the plane of surgery horizontal. Insertion of a self-retaining Mobius retractor (CooperSurgical, Inc., Trumbull CT), followed by lateral abdominal wet packs, gives optimal exposure and allows the operation to proceed with only one assistant. Before the surgery, the surgeon should become familiar with interior ring insertion and exterior ring rolling to maximize exposure.6 The uterus is closed in situ with this approach.

Visual Subunits of the Hand: Proposed Guidelines for Revision Surgery after Flap Reconstruction of the Traumatized Hand

The posttraumatic hand deformity remains a difficult challenge for reconstructive surgeons. Much has been written about the relative benefits of fasciocutaneous, fascial, and muscle flap reconstruction; however, the literature is devoid of guidelines for secondary surgery after flap reconstruction to improve the appearance of the hand. We introduce the concept of visual subunits of the hand in an effort to better guide restoration of natural hand form; thenar, hypothenar, midpalm, distal palm, dorsal hand, volar forearm, and dorsal forearm subunits are proposed. The visual subunit principle has been implemented in reconstruction of posttraumatic hand deformities. Management initially focused on reestablishment of hand function and provision of soft tissue coverage via local and free tissue transfer. Secondary procedures involved partial flap elevation, targeted debulking, and redefining topographic regions where possible. By designing asymmetric skin excision patterns, the resultant length and width discrepancies can be used to purposefully enhance topographic features while re-creating the appearance of natural crease lines bordering adjacent subterritories. No complications related to partial or complete flap loss were encountered.

Immediate Nipple Reconstruction Using the Everted Umbilicus

Sir: A young patient with a small to moderate body habitus with minimal ptosis, requiring unilateral reconstruction, may benefit from immediate nipple reconstruction using the everted umbilical stalk (Fig. 1). In unilateral cases, the contralateral nipple may be of substantial size and difficult to match using routine nipple reconstruction techniques.1 Furthermore, in a young patient with a sensate contralateral nipple, nipple sharing may induce additional psychological stress.Fig. 1.: Three-month postoperative view. The right nipple is reconstructed by everting the umbilicus. Note the high location of the abdominal scar, natural crease forming around the neonipple, small central depression in the neonipple, and texture of skin around the everted navel. Umbilicoplasty is performed by tethering splayed dermal edges to underlying fascia. Note the color and texture of skin around the reconstructed nipple, and the depth of the reconstructed umbilicus. The patient refused any further reconstructive procedures.Other patients may be averse to surgical manipulation of the contralateral breast, for either personal or cultural reasons, and present a particular challenge to the reconstructive surgeon seeking symmetry. It is possible to design a transverse rectus abdominis musculocutaneous flap more or less centered around the umbilicus, even though flap design and inset become more challenging. Patients with grade 2 and 3 contralateral ptosis have undergone reconstruction in this fashion (Fig. 2).Fig. 2.: A patient with grade 3 ptosis who refused any contralateral procedures underwent single-stage nipple-mound reconstruction using the everted navel. Note the projection and texture of skin in the site of the areola.De Cholnoky described the use of the everted navel for nipple reconstruction using abdominal tubed flaps in 1966.2 More recently, commonly used techniques are the C-V flap and its modifications (e.g., trilobed, star, arrow)3–5 and skate and its modifications (e.g., box-top),6,7 all of which are known to induce local architectural distortion that accentuates periareolar flattening. Long-term projection is approximately 40 to 60 percent at best.8 Bell flaps have been described with the hypothetical potential of increasing nipple and areola projection but have been marred by risks of partial flap loss and poor long-term projection.8 Double tab flaps9 are safe and reliable but maintain poor projection long term. The skin around the everted umbilicus is often glabrous, thicker, and of different texture than surrounding abdominal skin. In very-light-pigmented nipples, this difference in texture may be enough to delineate an areola without further reconstructive steps. The periumbilical skin is otherwise a good recipient for intradermal pigmentation. Umbilical reconstruction after ablation has been described previosuly.10 Although it may seem like an additional step, it actually decreases surgical time and allows for more liberal closure of the abdominal fascia, without concern for maintaining the midline location for the umbilical stalk. This should avoid the off-centered umbilicus sometimes observed after unilateral transverse rectus abdominis musculocutaneous flaps. Whenever possible, we approximate the fascial edges primarily, mobilizing the remaining rectus muscle medially, and attach the umbilicoplasty flaps to the now medialized contralateral rectus sheath. Long-term nipple projection has been maintained in all our patients except for one patient who underwent partial necrosis. For the other eight patients, nipple height is 8 to 12 mm and nipple width is 12 to 15 mm after a follow-up ranging from 3 to 27 months. After several months, some settling occurs, but the neonipple remains conspicuous, with formation of a peripheral crease that accentuates its visibility, probably because of periumbilical skin and subcutaneous tethering architecture. A sharp angle between the breast mound and the neonipple is emphasized by several authors.9 Christian A. El Amm, M.D. Josephine S. Sung, M.D. Kamal T. Sawan, M.D. Bishara S. Atiyeh, M.D. Meredith C. Workman, M.D. University of Oklahoma Oklahoma City, Okla. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

Simple technique to identify Wharton’s duct during endoscopically-assisted submandibular sialoadenectomy

Resection of the submandibular salivary glands for sialadenitis and benign tumour is usually done by open surgery through an incision 5–6cm long in the submandibular region along a natural crease in the skin.1,2 Possible complications are a postoperative cervical scar and disturbance of the marginal mandibular branch of the facial nerve.1 Endoscopically-assisted submandibular sialoadenectomy through a short incision can avoid such complications and has good cosmetic results,3,4 but limited visibility can cause problems because the operative field contains some important anatomical structures such as the hypoglossal and lingual nerves, the anterior facial vein, and the facial artery.

Immediate vulvar and vaginal reconstruction using the gluteal-fold flap: long-term results

The gluteal-fold flap was used to reconstruct vulvar and posterior vaginal wall defects in 40 patients. This is a fasciocutaneous, islanded flap based on the internal pudendal artery and vein perforators. The flap is robust and has the advantage of being away from the pathway of carcinoma spread. In addition it has minimal donor-site morbidity as the scar is hidden in a natural crease.

Secondary upper eyelid blepharoplasty

Peter McKinney, MD Andre Camirand, MD James H. Carraway, MD Steven Fagien, MD Dr. McKinney: The first patient is a 41-year-old woman who had a bilateral upper-eyelid blepharoplasty 3 months ago. She is unhappy with pigment changes in her upper lid and complains that her scar is too high (Figure 1). Dr. Fagien, how do you control scar height in the upper lid, and what scar level is best for a patient such as this one? Figure 1 This 41-year-old woman is unhappy with color changes in her upper lid and complains that the scar is too high 3 months after upper eyelid blepharoplasty. Dr. Fagien: With good incision planning, you can often avoid these obvious color changes and an overly high visible scar. This scar appears to be positioned at about 14 mm, suggesting that the planned incision was at least at 10 mm or higher and was possibly placed at or near the patient's natural crease at the time of surgery — a common mistake. I design the crease incision much lower, typically at 7 to 9 mm, which begins the process of regaining the youthful upper-eyelid configuration and includes both a lower-positioned upper-eyelid crease and fold, along with more supratarsal volume and fullness.1 I consider many factors with this design, including the height of the incision, the location of the eventual crease, the contour of the crease, the contour of the ellipse that I design, and the ultimate distance of the eyebrow from the eventual crease. You can notice, even in the medial aspect of her upper eyelid, that the incision is very close to her brow, even more so on the left side. It starts off low, but it has a curvilinear arch that approaches the brow. My incision planning would be far lower. And you can …

Immediate Breast Reconstruction Using an External Oblique Rectus Musculofascial Turnover Flap

The development of the external oblique rectus musculofascial turnover flap has recently received a great deal of attention. With this method, the upper part of the external oblique muscle is lifted off the lower thoracic wall along with a segment of the rectus muscle, pedicled in the sixth intercostal space and subsequently connected with the lower margin of the pectoralis major muscle. This approach bridges the weak regions of the thin muscle layers in the medioinferior breast area. Because this procedure avoids the need for a second operation to restore the contour and enables production of a natural ptosis and a well-accentuated lower breast fold, it has become increasingly important in immediate breast reconstruction. Compared with the complex myocutaneous flaps techniques, this procedure is characterized by relative simplicity and ease of performance. Compared with the tissue expansion technique, the oblique rectus turnover flap allows restoration of the female form in a one-stage procedure with a better, more natural ptotic breast shape and well-defined inframammary crease. Results have been encouraging. In fact, this procedure has almost completely replaced other techniques for immediate reconstruction of the female breast following mastectomy.

Canada Apartheid on Tour

Beneath Thami Cele’s right eye there is a scar that blends into his weathered face like a natural crease. Only when you see him face-to-face do you notice it. On a stark stage that for 90 minutes is a South African jail, it would be very difficult for anyone in the audience to see the scar beyond the imaginary prison walls. Cele’s infectious gap-toothed smile spreads as far back as the last row. But in the darkened theatre, only his four other cell-mates who sweat under the same bright lights and share their stories can see the scar.

The "nasal crease". A physical sign of allergic rhinitis.

The term nasal crease, as used here, refers to a persistent transverse hyperpigmented or hypopigmented line extending across the junction of the lower and middle thirds of the bridge of the nose. It is always at the site of the natural crease of the skin that is produced when the tip of the nose is pushed upward, as in the allergic salute. 1,4 (Allergic salute refers to the habitual manipulation of the nose, due to chronic obstruction and itching. It is typically accomplished by pushing the tip of the nose upward with the palm of the hand.) This nasal crease varies from a faint, or temporary, line to the distinct atrophic scars illustrated by our adult patients. Several of the faint ones disappeared in a few months after nasal symptoms had been relieved. I am not, of course, referring to the temporary blanching of the skin in this area immediately