Superior Vascular Pedicle Research Articles

Nasal ala V-Y island flap with a superior vascular pedicle based on inferior perforators of the superior alar artery.

For small defects of the anterior nasal ala, a V-Y pedicle advancement flap within the subunit is a useful repair option. Here we propose a modification of this technique, utilising careful dissection to identify inferior perforators of the superior alar artery. Basing this flap on a visualised vascular pedicle aims to prevent common complications of internal mucosal buckling and free margin notching, by allowing more extensive dissection without compromising the vascularity of the flap.

Cernea's classification of the External Branch of the Superior Laryngeal Nerve during Microscopic Thyroidectomy at Gandaki Medical College, Pokhara

Background: Preservation of the external branch of the superior laryngeal nerve (EBSLN) during thyroidectomy is important because its injury may lead to frequent occurrence of vocal fatigue and the inability to perform phonation. The objective of the study was to identify and classify the nerve as per Cernea's classification using operating microscope during thyroidectomy Method: Between January 2017 to December 2019, we evaluated 50 patients for the position of external branch of superior laryngeal nerve, who underwent microscopic thyroid surgeries in the department of ENT- head and neck surgery at Gandaki Medical College. Results: In our study, we dissected a total 59 superior poles of thyroid from 50 patients and identified the nerve in all the cases. Of the total superior poles, 36 (61.01%) had type IIa EBSLN among which 24 was on the right side and 12 on the left followed by 19 (32.20%) patients with type IIb EBSLN among which 8 on right and 11 on left side. There were only 4 poles (6.77%) of type I with 3 on the right and 1 on the left side. Conclusion: The EBSLN can be very efficaciously identified during a microscope assisted thyroidectomy. Cernea type 2a and 2b EBSLNs are in position to be at high risk of injury during ligation of the superior vascular pedicle, which can be avoided by prompt identification through a microscope and a meticulous extra capsular dissection technique.

Breast Reduction: 33 Years Using a Single Central Block.

Since 1985, the author has been using the single central block technique for breast reduction and mastopexy, prioritizing the good relation between the final breast shape and the length of the scars, different from other authors who emphasize only the shape of the breast (Peixoto in Plast Reconstr Surg 65(2):217-225, 1980; Aesthet Plast Surg 8:231-236, 1984) and others who have drawn attention to the length of the scars (Arié in Rev Latinoam Cir Plast 3:23-31, 1957; Bozola in Plast Reconstr Surg 85:728-738, 1990; Sepúlveda in Rev Bras Cir 71(1):11-18, 1981). In this study, the author describes the use of a single central block of the mammary tissue and the nipple-areolar complex (NAC), dissected from the skin flaps and based on the superior vascular pedicle for reduction mammoplasty and mastopexy (Erfon et al. in Annals of the international symposium recent advances in plastic surgery, São Paulo, 1989; Hinderer (ed) Plastic surgery, Elsevier, Madrid, 1992; Proceedings of the 65th annual scientific meeting of the American society of plastic and reconstructive surgeons, Dallas, 1996). A retrospective study was performed, evaluating patients who underwent breast reduction and mastopexy using the single central block technique from July 1985 to December 2018 by a senior author. A total of 2097 procedures were performed using this technique, 1556 being reduction mammoplasties and 541 mastopexies. The mean patient age was 44, and the mean weight of tissue resected was 455 g. Fat necrosis on the distal area of the flap was observed in 47 cases (2.24%). Hematoma was observed in 6 patients (0.28%). Surgical revisions were undertaken in 75 patients (3.57%). Hypertrophic scars occurred in 12 of the cases (0.57%). Dehiscence in the inverted "T" scars occurred in 78 of the surgeries (3.71%). This technique allows the surgeon to easily form a good cone shape of the breast, repositioning the NAC and preserving its vascularization and sensation without tension on the skin flaps sutures, resulting in smaller and better scars. 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.

Mastopexia a Longacre modificada

INTRODUÇÃO: A preservação funcional das mamas deve ser uma preocupação constante para o cirurgião plástico. A técnica apresentada neste trabalho busca reduzir o impacto da mamoplastia no aleitamento materno, considerando a técnica de pedículo vascular superior, com parcimoniosas ressecções glandulares, a de escolha para os casos de pequena hipertrofia mamária. MÉTODO: Foram estudadas 46 pacientes portadoras de hipertrofia mamária leve a moderada, submetidas a mastopexia, com ou sem redução mamária, utilizando técnica de pedículo vascular areolar superior, segundo a técnica descrita por Longacre modificada. As pequenas ressecções glandulares foram realizadas de forma a preservar a integridade funcional e sensitiva das mamas. RESULTADOS: Nas 92 mamas operadas, observou-se adequado preenchimento do polo superior pelo retalho e conformação mamária, que satisfizeram os anseios das pacientes. CONCLUSÕES: A técnica apresentada constitui mais uma possibilidade técnica para mastopexias em pacientes com o complexo areolopapilar em posicionamento alto, utilizando-se o polo inferior da mama para preencher o polo superior.

Identification of the External Branch of the Superior Laryngeal Nerve During Thyroidectomy

To determine the feasibility of identification of the external branch of the superior laryngeal nerve (EBSLN) during routine thyroidectomy and to describe the EBSLN position according to the Cernea classification system. Prospective case series. Academic tertiary care center. One hundred twelve consecutive patients undergoing hemithyroidectomy or total thyroidectomy by the senior author between August 15 and December 31, 2007. None. Proportion of EBSLNs identified. Secondary outcome measures included EBSLN position according to Cernea classification and correlation with patient and gland characteristics. Three of 178 EBSLNs (1.7%) could not be identified using the routine technique. The EBSLN was found in the highest-risk position (Cernea type 2b, crossing the superior vascular pedicle below the upper border of the gland) in 48.3% of cases, and in the lowest-risk position (Cernea type 1, crossing more than 1 cm above the upper border) in 7.3%. Specimens larger in weight and in dimension were correlated with type 2b nerves. The EBSLN can be routinely identified during thyroidectomy. Moreover, many EBSLNs are in position to be at high risk of injury during ligation of the superior vascular pedicle.

Platysma myocutaneous flap: Use for intraoral reconstruction

Twenty patients were treated for intraoral epidermoid carcinoma with a single-stage reconstructive technique using a myocutaneous flap based on the platysma muscle. This flap carries on its distal tip a portion of isolated cervical skin to be used for intraoral replacement of the resected tissue. The superior vascular pedicle, the submental branch of the facial artery, was used. The platysma skin flap will survive if the blood supply from at least one region is preserved. In addition, it may be beneficial to include the external jugular and/or the communicating veins in the flap. Only three minor complications were seen and healed spontaneously. The flap has proved to be highly reliable and has significant benefits over many other techniques commonly used for head and neck reconstruction. (Otolaryngol Head Neck Surg 1997;116:493-6.)

Platysma myocutaneous flap: use for intraoral reconstruction.

Twenty patients were treated for intraoral epidermoid carcinoma with a single-stage reconstructive technique using a myocutaneous flap based on the platysma muscle. This flap carries on its distal tip a portion of isolated cervical skin to be used for intraoral replacement of the resected tissue. The superior vascular pedicle, the submental branch of the facial artery, was used. The platysma skin flap will survive if the blood supply from at least one region is preserved. In addition, it may be beneficial to include the external jugular and/or the communicating veins in the flap. Only three minor complications were seen and healed spontaneously. The flap has proved to be highly reliable and has significant benefits over many other techniques commonly used for head and neck reconstruction.

The platysma musculocutaneous flap: experience with 24 cases.

The platysma musculocutaneous flap has been used in 24 patients for reconstruction in the head and neck area. In 22 patients, the superior vascular pedicle, the submental branch of the facial artery, was used, and in two other patients, the inferior pedicle, the superficial branch of the transverse cervical artery, was used. Twelve patients had reconstruction of the intraoral lining with a skin paddle on the platysma. The buccal mucosa and mandibular alveolar ridge are particularly well suited to this flap. Six patients had restoration of external skin, four had provision of both skin and lining with the same flap, and two had coverage of vulnerable structures with muscle alone. Forty-two percent of patients experienced a minor complication. Only four patients, however, required further surgery, and all 24 patients ultimately had satisfactory results. Of seven patients experiencing loss of a portion of the skin paddle, six had intraoral reconstruction. Meticulous dissection and attention to anatomic detail is necessary in raising the flap. Because of its thinness and pliability, we feel that the platysma musculocutaneous flap is an important addition to the techniques of head and neck reconstruction.

Latissimus dorsi myocutaneous flap for breast reconstruction

THE ideal breast reconstruction following mastectomy should: be a one-stage procedure; restore deficient skin; replace the contour of the absent pectoralis major muscle; restore lost breast volume; replace the absent nipple-areolar complex; and match in a symmetrical and pleasing way the contour of the remaining breast. We believe that the first 3 of these objectives can be achieved in many patients by the use of a myocutaneous flap incorporating the latissimus dorsi muscle. The latissimus dorsi myocutaneous flap was first reported for chest wall reconstruction by d’Este (1912). It was used as a superiorly based flap of skin and muscle having its pedicle base in the axilla. The flap was used at the time of radical mastectomy to cover the remaining defect. David (1949) and Campbell (1950) used a superiorly based latissimus dorsi muscle flap to reconstruct extensive chest wall defects. The latissimus dorsi muscle has also been used for the reconstruction of elbow flexion and extension (Schottstaedt, 1955; zancolli, 1973). DesPrez (1971) included the latissimus dorsi in bilateral bipedicle flaps for the closure of a defect secondary to a myelomeningocele. Olivari (1976) reported using a latissimus dorsi myocutaneous flap for the reconstruction of a chest wall defect. His technique was almost identical to that used by d’Este. Increased understanding of the blood supply of the skin overlying muscle as discussed by Daniel and Williams (1973) has further widened the range of myocutaneous flaps. Orticochea (1972) and McGraw (1976) took advantage of the vascular interconnection of skin and muscle in using the gracilis myocutaneous flap for penile and vaginal reconstruction. Harii (1976) reported the first free myocutaneous flap transfer. He used the gracilis muscle and its overlying skin based on the superior vascular pedicle of the muscle, which receives its arterial blood supply from the profunda femoris artery, thus further demonstrating that the skin can survive on the muscular perforators. Blood is supplied to the latissimus dorsi muscle by the thoracodorsal artery which is the terminal branch of the subscapular artery. The muscle is innervated by the thoracodorsal nerve, a branch of the posterior cord of the brachial plexus (Fig. I). The entire muscle, based on its neurovascular pedicle, can be mobilised after the division of the muscular origin from the lower 4 ribs, the lower 6 thoracic vertebrae, the lumber vertebrae, the sacral vertebrae, the supraspinal ligament and the posterior crest of the ilium. It can then be transposed to cover defects of the chest wall, the shoulder, the lower neck and the upper arm. An island of skin may be left on the muscle and used as necessary for the reconstruction (Fig. 2). We report the use of such a myocutaneous flap in a 3 I-year-old woman who 4 years previously had a radical mastectomy, including removal of the pectoralis major, for a stage I carcinoma. necrosis and an atrophic scar resulted (Fig. 3).