Suprafascial Plane Research Articles

Surgical refinements and sensory and functional outcomes of using thinned sensate anterolateral thigh perforator flaps for foot and ankle reconstruction: A retrospective study.

To improve the use of sensate anterolateral thigh (ALT) flaps for foot and ankle reconstruction, we employed a thinned nerve-selective harvesting technique. The data of 31 patients in whom sensate ALT perforator flaps were transferred for reconstruction of soft-tissue defects in the foot and ankle were reviewed. Flaps were elevated with 2 refinements. The first is the initial selection of the "true" sensory branch in the medial incision on the suprafascial plane. The second is flap thinning by keeping a cuff of thin deep fat surrounding the point where the perforator or nerve branch inserts into the superficial fat layer. The recipient site assessment consisted of complications, monofilament touch perception, sharp-blunt discrimination, axial circumference, and American Orthopedic Foot and Ankle Society score. After a mean follow-up of 31.7 months, all flaps survived uneventfully, except for marginal necrosis in 1 patient, infection in 1 patient, ulceration in 2 patients, and secondary thinning in 3 patients. The sensation of each flap was restored. A total of 87% and 90% of the patients exhibited 5 or more positive response points in the Semmes-Weinstein monofilament touch and sharp-blunt discrimination testings, respectively. The mean axial circumference of the reconstructed foot was 27.4 cm (the unaffected side was 25.8 cm). All patients achieved mobility in ordinary shoes with a mean functional score of 74.6. The thinned nerve-selective sensate ALT perforator flap can be a favorable option for foot and ankle reconstruction. This method also offers the possibility of preserving the nerve branch at the donor thigh.

Modified videoendoscopic inguinal lymphadenectomy through suprafascial approach: Technical description and preliminary surgical outcomes

IntroductionThe videoendoscopic approach to inguinal lymph node dissection (VEIL) has been suggested as an excellent alternative carrying lower morbidity but equivalent oncological control. One of its most difficult steps is the development of an appropriate plane of dissection. A suprafascial approach would allow for better exposure. The objective of this study is to determine the feasibility, in terms of safety and oncological control, of a technical modification to the classical VEIL technique using a suprafascial plane of dissection in an initial series of patients. Patients and methodsA single institution retrospective review of patients undergoing VEIL technique using our modified suprafascial approach was conducted. A step-by-step surgical description is provided. Data collected included demographics; comorbid conditions; disease characteristics; intraoperative factors; and postoperative factors. ResultsA total of 7 patients (12 procedures) were included. Average age was 64.42 years old, and 71.42% of the patients were male. The procedure was performed bilaterally in 71.4% of the cases. Median estimated blood loss was 10 mL (range 10–25). Mean operative time was 185 min (range 120–170). Median number of nodes removed was 10.25 nodes (range 7–11). Only one of the patients (8.3%) experienced a Clavien-Dindo grade IIIa complication requiring delayed percutaneous drainage replacement. Median time until drainage removal was 13 days (range 10–16). Median length of stay was 48 hours but ranged from 24−96 hours within the series. ConclusionsThe modified VEIL technique using a suprafascial plane of the dissection, allows a bilateral ILND in highly competitive operative times and with limited morbidity, without compromising its oncological efficacy.

Linfadenectomía inguinal videoendoscópica modificada por abordaje suprafascial: descripción de la técnica y resultados quirúrgicos preliminares

IntroductionThe videoendoscopic approach to inguinal lymph node dissection (VEIL) has been suggested as an excellent alternative carrying lower morbidity but equivalent oncological control. One of its most difficult steps is the development of an appropriate plane of dissection. A suprafascial approach would allow for better exposure. The objective of this study is to determine the feasibility, in terms of safety and oncological control, of a technical modification to the classical VEIL technique using a suprafascial plane of dissection in an initial series of patients. Patients and methodsA single institution retrospective review of patients undergoing VEIL technique using our modified suprafascial approach was conducted. A step-by-step surgical description is provided. Data collected included demographics; comorbid conditions; disease characteristics; intraoperative factors; and postoperative factors. ResultsA total of 7 patients (12 procedures) were included. Average age was 64.42 years old, and 71.42% of the patients were male. The procedure was performed bilaterally in 71.4% of the cases. Median estimated blood loss was 10mL (range 10-25). Mean operative time was 115 minutes (range 120-170). Median number of nodes removed was 10.25 (range 7-11). Only one of the patients (8.3%) experienced a Clavien-Dindo grade IIIa complication requiring delayed percutaneous drainage replacement. Median time until drainage removal was 13 days (range 10-16). Median length of stay was 48hours but ranged from 24-96hours within the series. ConclusionsThe modified Video Endoscopic Inguinal Lymphadenectomy (VEIL) technique using a suprafascial plane of the dissection, allows a bilateral ILND in highly competitive operative times and with limited morbidity, without compromising its oncological efficacy.

A Dynamic Anatomic Study of Parasacral Perforators: Mapping, Perforasome, and Applications for Buttock Enhancement.

Due to the lack of knowledge about parasacral artery perforators, flaps from this region cannot be used with complete confidence in their security and effectiveness. Knowledge of the clusters and perforasome of these perforators could help in the design of more reliable flaps and extend the range of applications. This study aimed to identify the location, number, and density of perforators, and to subsequently analyze the perfusion flow and linking vessel distribution. Five fresh cadavers were harvested and dissected. For the mapping, after injecting lateral sacral arteries with colored latex, perforators with a diameter of >0.5 cm were examined in 5 sacral regions. All data were collected on the suprafascial plane, with an orthonormal coordinate system placed on iliac crests and median lines. For perforasome analysis, 5 perforators and 3 three sacral flaps were injected with radiopaque dye. A dynamic (4-dimensional) computed tomographic angiography completed the analysis. A mean [standard deviation] of 8.4 [1.36] perforators per corpse, with a mean diameter of 0.72 [0.14] mm, were identified. There was a higher density of parasacral perforators close to the median line and 7.6 cm above the iliac crests. This pattern was not a random distribution (P < 0.05). The perfusion area was preferentially in the superior gluteal region. Perfusion flow was permitted by the dominant direct-linking vessels towards adjacent lumbar perforators, oriented diagonally upward and outward to the midline. Parasacral perforator flaps appear to be a useful procedure in reconstruction and in aesthetic surgery, especially in gluteal augmentation. Their reliability depends on sound anatomic knowledge, with accurate preoperative perforator mapping.

Suprafascial plane endoscopy versus open carpal tunnel release for idiopathic carpal tunnel syndrome: Use of the Accordion Severity Grading System

This study aimed to assess the safety and effectiveness of modified endoscopic technique with a single portal from an external carpal tunnel approach for surgical operations in a suprafascial plane superficial to the transverse carpal ligament. Reversible nerve injury risk is threefold greater with a conventional endoscopic method than with open carpal tunnel release (OCTR), and this suprafascial plane endoscopic release (SPER) should circumvent the problem of hardware in the carpal tunnel encountered with the conventional endoscopic method and liable to cause iatrogenic damage to the median nerve. However, the surgical consequences of the new technique have not been studied. To fill this gap, a retrospective therapeutic study was conducted to compare negative outcomes versus open surgery. The Accordion Severity Grading System was used to grade complications from 0 to 3 according to necessity of treatment. Sequela and failure rates were also compared between the SPER and OCTR groups. Eighty-eight cases in 72 patients with idiopathic carpal tunnel syndrome (ICTS) met the inclusion criteria. SPER was performed in 28 hands in 27 patients, and OCTR in 60 hands in 49 patients. The results showed no significant difference in complication, sequela, or failure rates between groups (p > 0.05). Suprafascial plane endoscopic release, has certain advantages over the open method and was validated as a safe and effective method of treating ICTS.

The suprafascial course of lower leg perforators: An anatomical study.

BackgroundPerforator mapping has been well described in the literature. Once the suprafascial plane is reached, the course of perforators is considered constant. However, the surgeon must be aware of whether an anastomosis exists between perforators superficially to the fascia, in order to choose the best vessel upon which to base the reconstruction. Our retrospective in vivo anatomical study of lower leg perforator flaps presents the first description of variations in the suprafascial path of perforators, which may influence preoperative flap design.MethodsAn anatomical study of lower limb perforators was performed on 46 nonconsecutive patients who were referred to our department from June 2012 to October 2018. Reconstruction with perforator-based propeller flaps was planned for each of the patients. In total, 72 perforators were preoperatively identified and surgically isolated. The suprafascial course of each perforator was reported.ResultsDuring suprafascial surgical exploration, branching patterns were observed in four perforators. These perforators had been classified as single vessels in the preoperative ultrasonographic analysis. However, after surgical dissection, distal converging branches were noted in two of them.ConclusionsOur study is the first description in the literature of suprafascial converging perforators, which might constitute an obstacle to planned reconstruction procedures. Despite the accuracy of preoperative evaluations, anatomical variations were present. Knowledge of suprafascial perforator variations may help surgeons to choose the correct perforator upon which to base a planned flap.

Supermicrosurgery: History, Applications, Training and the Future.

Supermicrosurgery, a technique of dissection and anastomosis of small vessels ranging from 0.3 to 0.8 mm, has revolutionized the fields of lymphedema treatment and soft tissue reconstruction. The technique offers several distinct benefits to microsurgeons, including the ability to manipulate small vessels that were previously inaccessible, and to minimize donor-site morbidity by dissecting short pedicles in a suprafascial plane. Thus, supermicrosurgery has become increasingly popular in recent years, and its applications have greatly expanded since it was first introduced 20 years ago. While supermicrosurgery was originally developed for procedures involving salvage of the digit tip, the technique is now routinely used in a wide variety of microsurgical cases, including lymphovenous anastomoses, vascularized lymph node transfers and perforator-to-perforator anastomoses. With continued experimentation, standardization of supermicrosurgical training, and high quality studies focusing on the outcomes of these novel procedures, supermicrosurgery can become a routine and valuable component of every microsurgeon’s practice.

The pedicled internal pudendal artery perforator (PIPAP) flap for ischial pressure sore reconstruction: Technique and long-term outcome of a cohort study

The ischial region is the site most affected by pressure sores and has the highest recurrence and complication rates compared to other affected sites. We developed a practical and safe pedicled flap for reconstruction of ischial pressure sores based on the rich available perforators from the internal pudendal artery and the surplus of skin at the infragluteal fold. A retrospective cohort study was conducted in all patients who underwent ischial pressure ulcer reconstruction using the PIPAP flap between March 2010 and March 2017. The skin flap was designed along the gluteal fold. The skin perforators of the pudendal artery were marked with a Doppler probe in the medial region of the gluteal fold. Surgery was performed in the jackknife position, and flaps were elevated in the suprafascial plane. Patients were assessed for minor (requiring no additional surgery) and major complications (requiring additional surgery). Twenty-seven patients (34 flaps) were identified. The median follow-up period was 38 months (IQR 37). Primary closure of the donor-site was achieved in all procedures, only one flap required muscle flap transposition in order to fill the dead space. The mean operating time was 60 ± 21 minutes. In six flaps (9%) wound healing problems were noted that did not require an additional operative procedure. Among the nine flaps (27%) that required a second procedure, 3 (9%) were necessary due to recurrent ulcers. The PIPAP flap is a safe and reliable alternative for ischial pressure sore reconstruction, certainly when compared to available techniques. Moreover, it has significant advantages over other techniques including minimal donor-site morbidity, preservation of posterior thigh skin, buttock-line integrity and reliable vascularity.

Experimental and Clinical Evidence Based Rationality of Incorporation of Deep Fascia in Tissue Transfer for Reconstructive Surgery

ABSTRACTIntense clinical research since 1984 through 93 parameters has unveiled the rationality of reconstructive procedures with several new concepts and innovative techniques of various compositions. Such extensive work has been done totally in our country popularizing the techniques amongst the plastic surgeons of the world. This presentation deals with the tissue constituents and vascular network of the deep fascia. This sustained research was conducted at inter-departmental, interfaculty and interinstitutional levels.Intense clinical research since 1984 through 93 parameters has unveiled the rationality of reconstructive procedures with several new concepts and innovative techniques of various compositions. Such extensive work has been done totally in our country popularizing the techniques amongst the plastic surgeons of the world. This presentation deals with the tissue constituents and vascular network of the deep fascia. This sustained research was conducted at inter-departmental, interfaculty and interinstitutional levels.Histology of deep fascia showed rich subfascial and suprafascial arterioles and capillaries. Intrafascial course of the perforating vessels from the subfascial plane to the suprafascial plane was visualized. Confocal microscopic analysis of fluorecenised deep fascia under 40X magnification showed longitudinally aligned collagen fibres and nuclei of multiple fibroblasts. Electron microscopic Y of deep fascia revealed (a) Elastic tissue and collagen fibres, (b) Lymphatic vessel, (c) Thin walled venule with single layer of muscle fiber, endothelial cell nucleus, Venules with multiple RBCs, mast cell with granules and capillary showing endothelium and endothelial cells.Angiography in experimental model and patients, demonstrated longitudinally oriented vascular network in deep fascia and fasciocutaneous flap. Live microcirculation and Lymphatic circulation in the human deep fascia was demonstrated first time in the world under 150 and 600 magnifications.

Thinning: The Difference between Free and Propeller Perforator Flaps.

Dear Sir, We read with great interest the manuscript by Prasetyono et al. [1] titled Practical considerations for perforator flap thinning procedures revisited. We want to discuss some points related to this article and highlight some differences between thinning a free perforator flap versus a propeller perforator flap. We absolutely agree with the authors regarding the possibility of thinning (or defatting) a flap in which the perforators are generally central, but when the perforators are lateralized we believe that the problem is completely different. Indeed, free perforator flaps are most frequently harvested with centralized perforating vessels on the skin paddle, unlike propeller perforator flaps, in which the perforators are lateralized, because of the necessity of rotation. We often achieve significant thinning of our free perforator flaps without necrosis or any skin suffering. However, thinning our propellers flaps is often more hazardous and sometimes results in extensive unexplained skin problems. Therefore, we prospectively compared five tibial posterior perforator flaps harvested with suprafascial dissection including distal 2/3 thinning (in the subcutaneous plane) of the flap and five harvested with subfascial dissection without thinning. The size and rotation were similar; i.e., 4×12±2 cm with a twist between 120° and 180°. We noted almost no distal suffering in the subfascial group versus distal problems of 10%-20% for three flaps in the suprafascial group. Moreover, all of the flaps harvested in the suprafascial plane and thinned had an initial venous congestion phase greater and more worrying than did the flaps harvested with subfascial dissection. We believe that the problem of thinning is more venous than arterial. Thinning alters the arterial vasculature little as the dermal plexus is respected, as explained by Hong et al. [2], but it could reduce venous back flow. We selected the posterior tibial perforating flap because it is clear that venous problems are much more common in the limbs, and especially the leg, than in the trunk. Regarding the article by Prasetyono et al., we note some signs of venous suffering at the edge of anterolateral thigh perforator in Fig. 5C and D; these are almost never seen in practice with this flap, which remains very reliable and reproducible. Therefore, the extensive thinning was probably involved in this phenomenon. In conclusion, perhaps the main problem with thinning is not an impaired arterial supply, but venous back flow, as the subdermal plexus is preserved. If it appears less risky for free perforator flaps or when the perforators are centered on the skin paddle, thinning can be harmful when the perforators are lateralized. For the lower limb, it seems best to avoid thinning propeller perforator flaps unless absolutely necessary.

Lumbar and thoracic perforators: vascular anatomy and clinical implications.

Pedicled perforator flaps in the thoracic and lumbar regions allow reconstruction of the posterior trunk. They enable reconstruction of various local defects without microvascular anastomoses and with minimal donor-site morbidity and excellent cosmesis. The authors examined the locations of perforators in the lumbar and thoracic regions. Ten cadaver hemithoraces and lumbar regions were freshly harvested and dissected. Intraarterial injections were performed with colored latex, followed by dissection in the suprafascial plane. Perforators with a diameter larger than 0.5 cm were located and measured from the midline and from C7 (thoracic) and coccygeal (lumbar) reference points. The most dominant perforators were injected with radiopaque dye and scanned with high-resolution computed tomography. The patterns were analyzed by the quadrat counting test (based on chi-square statistics) for the null hypothesis of complete spatial randomness. A total of 164 thoracic and 216 lumbar perforators were identified. These were clustered in highest density in two major areas within 10 to 20 cm of the C7 and coccygeal reference points and 10 cm from the midline; this pattern was not a random distribution (p < 0.001). Perforasomes of lumbar perforators in some instances crossed the midline, joining adjacent contralateral lumbar perforators by means of direct and indirect linking vessels. Lumbar and thoracic pedicled perforator flaps provide useful options for reconstructing complex defects. Use of these flaps is aided by anatomical knowledge of the location of major clusters of perforators.

Lambeaux perforants fins prélevés dans le plan du fascia superficialis : principe et technique opératoire

Perforator flaps have an ever growing place in reconstructive surgery and classical surgical procedures describe sub or supra-fascial plane elevation. In some indications, defatting of perforator flaps may be necessary and different methods have been described, primary or secondary, but may expose to partial loss of the flap or to another operation. Recently, a new method of perforator flap elevation in the plane of the superficial fascia has been described. This method permits to obtain a thin and reliable flap in the same procedure without the need of debulking and while decreasing donor site morbidity. We present the principle and the surgical procedure of this new method. Advantages and drawbacks are discussed with the help of clinical cases.

Can we consider standard microsurgical anastomosis on the posterior tibial perforator network? An anatomical study

The main vessels in an injured leg can be spared with perforator-to-perforator anastomosis. However, supermicrosurgery is not a routine procedure for all plastic surgeons. Our objective was to establish if the diameter of the perforators of the leg could allow anastomosis with standard microsurgical procedures. Twenty lower legs harvested from ten fresh cadavers were dissected. Arterial and venous vessels were injected with colored latex. The limbs were then dissected in a suprafascial plane. All the perforating arteries of a diameter >0.8mm were located and their external diameter, the number and external diameter of the venae comitantes were reported. We found at least three tibial posterior artery perforators with diameters >0.8mm per leg with a mean external diameter of 1.1mm and one vena comitans in almost all cases (96%). The vena comitans was usually bigger than the perforating artery with a mean diameter of 1.6mm. After statistical analysis, we were able to locate two main perforator clusters: at the junctions of the upper two-thirds of the leg and of the lower two-thirds of the leg. The low-morbidity concept of perforator-to-perforator anastomosis can apply to posterior tibial artery perforators without using supermicrosurgical techniques. This is of high interest for open leg fractures where main vessels could be injured. We hope that the results of our study will incite surgeons to consider sparing of main vessels for coverage of open leg fractures whether surgical teams master supermicrosurgery or not.

Structured Mammaplasty

Sir:FigureStudies have shown that although more patients undergo breast reconstruction with implants than with autologous tissue transfer, better symmetry is observed in flap-based reconstructions.1,2 As surgery to treat breast cancer becomes more conservative with regard to skin and pectoralis major muscle preservation, the indications for breast reconstruction with silicone implants tend to increase. Obtaining long-lasting symmetry on implant-based reconstructions is a major challenge. Implant-reconstructed breasts have particular characteristics, including increased firmness, decreased mobility, and maintenance of their shape over time. These factors make contralateral symmetry difficult to achieve using mammaplasty techniques. Although the reconstructed breast maintains its shape, the opposite breast evolves with ptosis, leading to breast asymmetry. A new approach to breast symmetrization for implant-based reconstructions was idealized based on the following goals: achievement of dynamic breast symmetry, with similar firmness and a more permanent result. We called this procedure structured mammaplasty. In the breast anatomy, the critical structure for mobility is the Chassaignac bursa, located on the retromammary space, just below the superficial fascia. It is connected to the Cooper suspensory ligaments and allows the breast to move over the chest wall.3 Our rationale is that resection of the breast base, including the Chassaignac bursa, decreases breast mobility. Breast support is achieved through the insertion of a retromuscular silicone implant. It increases breast consistency and provides a supportive structure to the symmetrized breast. The goal is to create an internal support pillar for the breast. The reduction of the breast volume and insertion of an implant increases the proportion of silicone in the final breast, leading to increased mammary firmness. Regarding surgical technique, the thoracic midline, mammary folds, and the mammary gland edges are drawn on the skin. The gland limits correspond to the basilar resection. An incision is made on the mammary fold, involving the skin, subcutaneous tissue, and superficial fascia, down to the fascia of the pectoralis major muscle. The mammary gland is then released from the pectoralis major muscle in a suprafascial plane. The resection of the gland base, involving the bursa described previously, is performed above the superficial fascia. After this basilar resection, a retromuscular pocket is dissected beneath the pectoralis major muscle. The implant is placed in this space, and the inferolateral aspect of the implant is covered with the serratus muscle. The nipple-areola complex is displaced with a superior pedicle, and excess skin is resected as needed. This technique was performed in 10 patients. After 1 year, photographic records of these patients were compared with the photographs of patients submitted to classic mammaplasty symmetrization, performed by the same surgeon, with similar follow-up. Independent, board-certified plastic and breast surgeons evaluated these photographs. All patients presented with better symmetry when compared with the patients on the mammaplasty symmetrization (Figs. 1 and 2). The preliminary results with this new approach are promising, but longer follow-up periods and randomized prospective studies are needed to demonstrate its effectiveness.Fig. 1: Photograph obtained 2 years postoperatively of a left breast reconstruction with an expander implant and right breast symmetrization using the structured mammaplasty technique.Fig. 2: Photograph obtained 2 years postoperatively of a left breast reconstruction with an expander implant and right breast symmetrization using a mammaplasty technique without implant. The breast asymmetry is evident at long-term follow-up.Marcelo M. C. Sampaio, M.D. Division of Plastic Surgery, Hospital Sírio Libanês Murillo Fraga, M.D., Ph.D. Division of Plastic Surgery, Santa Casa de Misericórdia de São Paulo Ana Paula Ferreira, M.D. Alfredo Carlos S. D. Barros, M.D., Ph.D. Division of Plastic Surgery, Hospital Sírio Libanês, São Paulo, Brazil DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

Vulvar reconstruction by a “supra-fascial” lotus petal flap after surgery for malignancies

ObjectiveThe aim of this study is to report on our experience with the supra-fascial lotus petal flap following the resection of vulvar cancer. MethodsThe original lotus petal flap or gluteal-fold flap technique was initially described with fascial elevation. However, flap harvesting in a supra-fascial plane is feasible. Between 2008 and 2011, we performed and evaluated this modified flap technique for labia majora reconstruction on five elderly females (mean age: 72years). ResultsResection and reconstruction were performed in the same operative time with a median time procedure of 118min. We observed neither flap failure nor partial necrosis. Functional evaluation beyond six months showed low donor site morbidity and good aesthetic results. ConclusionImmediate vulvar reconstruction with supra-fascial lotus petal flap is a fast, easy and reliable procedure. It enables wide resection and safety margin following tumor removal with free tension suture, good aesthetic results and a favourable functional outcome.

Breast Reconstruction with the Profunda Artery Perforator Flap

The use of perforator flaps has allowed for the transfer of large amounts of soft tissue with decreased morbidity. For breast reconstruction, the deep inferior epigastric perforator flap, the superior and inferior gluteal artery perforator flaps, and the transverse upper gracilis flap are all options. The authors present an alternative source using posterior thigh soft tissue based on profunda artery perforators, termed the profunda artery perforator flap. Preoperative imaging helps identify posterior thigh perforators from the profunda femoris artery. These are marked, and an elliptical skin paddle, approximately 27 × 7 cm, is designed 1 cm inferior to the gluteal crease. Dissection proceeds in a suprafascial plane until nearing the perforator, at which point subfascial dissection is performed. The flap has a long pedicle (approximately 7 to 13 cm), which allows more options when performing anastomosis at the recipient site. The long elliptical shape of the flap allows coning of the tissue to form a more natural breast shape. All profunda artery perforator flaps have been successful. The donor site is well tolerated and scars have been hidden within the gluteal crease. Long-term follow-up is needed to evaluate for possible fat necrosis of the transferred tissue. The authors present a new technique for breast reconstruction with a series of 27 flaps. This is an excellent option when the abdomen is not available because of the long pedicle, muscle preservation, ability to cone the tissue, and hidden scar. Therapeutic, V.

The palmaris longus muscle and its relations with the antebrachial fascia and the palmar aponeurosis

The palmaris longus (PL) is a muscle of the forearm with a long distal tendon that is continuous with the palmar aponeurosis (PA). It is generally assumed that the muscle lies deep to the antebrachial fascia from origin to termination, but a detailed description is lacking. The relationship of the PL tendon with the antebrachial fascia was studied in 30 dissections. The PL was completely absent in six specimens (20%), whereas the PA was identified in all. Average length of the forearm was 25.5 cm (SD: 2.1 cm, range 22-29 cm), overall length of the PL muscle 26.9 cm (SD: 2.6 cm, range 22.5-31.5 cm), muscular belly 13.8 cm (SD: 3.4 cm, range 9.5-23 cm), tendon 13.1 cm (SD: 3.3 cm, range 8-15.5 cm). Proximally, the PL was situated deep to the antebrachial fascia, then in the lower third of the forearm its tendon perforated the antebrachial fascia (at 4.7 +/- 1.7 cm from the bistyloid line) moving to a suprafascial plane, inserting in the PA. The PA could be divided into two layers: the superficial one formed by longitudinal fibers and adherent to the skin, the deep one formed by transverse fibers continuous laterally with the deep fascia of the hand. The PL tendon was found to be in continuity only with the longitudinal fibers of the PA. Based on the anatomical findings, it may be suggested that the superficial part of the PA is situated in the subcutaneous planes of the palm, and that the muscle should be considered as a tensor of the superficial fascial system of the subcutaneous tissue.

Temporal Hollowing following Coronal Incision: A Prospective, Randomized, Controlled Trial

Coronal incisions are used in traumatic, reconstructive, and cosmetic procedures to access the lateral facial skeleton. Temporal hollowing is a common complication following coronal incision that affects the patient both physically and psychologically. Several dissections have been recommended through this area to avoid injury to the frontal branch of the facial nerve and the temporal fat pad, which is thought to be the cause of hollowing. The purpose of this study was to identify the cause of postoperative temporal hollowing. Patients requiring a coronal incision were recruited prospectively. Each side of the head in all patients was randomized to suprafascial, subfascial, or deep dissection. An unmarked envelope containing the type of dissection to be performed for each side was used. All envelopes contained equal distributions of all groups. The incidence and severity of temporal hollowing 6 months postoperatively were measured clinically and by computed tomographic volume analysis. Twenty-seven patients with 54 sides (18 suprafascial, 15 subfascial, and 21 deep) completed the study. There were no demographic differences among the three groups. The incidence and severity of temporal hollowing were lowest with suprafascial dissection. Other factors associated with the presence of temporal hollowing included a reduction in body mass index. There were no injuries to the frontal nerve in any of the dissections. Postoperative temporal hollowing was associated with surgical approach and postoperative weight loss. Elevation of a coronal flap in the suprafascial plane and minimization of patient weight loss may decrease the incidence of postoperative temporal hollowing.

Free-Style Free Flaps

Free-tissue transfer has become the accepted standard for reconstruction of complex defects. With the growth of this field, anatomic studies and clinical work have added many flaps to the armamentarium of the microvascular surgeon. Further advancements and experience with techniques of perforator flap surgery have allowed for the harvest of flaps in a free-style manner, where a flap is harvested based only on the preoperative knowledge of Doppler signals present in a specific region. Between June of 2002 and September of 2003, 13 free-style free flaps were harvested from the region of the thigh. All patients presented with an oral or pharyngeal cancer and underwent resection and immediate reconstruction of these flaps. All flaps were cutaneous and were harvested in a suprafascial plane. The average size of the flaps was 108 cm2 (range, 36 to 187 cm2), and the average length of the vascular pedicle was 10 cm (range, 9 to 12 cm). All flaps were successful in achieving wound coverage and functional outcomes without any vascular compromise necessitating re-exploration. Free-style free flaps have become a clinical reality. The concepts and techniques used to harvest a free-style free flap will aid in dealing with anatomic variations that are encountered during conventional flap harvest. Future trends in flap selection will focus mainly on choosing tissue with appropriate texture, thickness, and pliability to match requirements at the recipient site while minimizing donor-site morbidity.

Minimally invasive approach to familial multiple lipomatosis.

Thirty-five abdominal wall lipomas were removed from a patient with familial multiple lipomatosis using a minimally invasive approach in a cost-effective, reliable, and cosmetically pleasing manner. The surgical technique used is described in this case report. Clinical findings and prior excisions provided the preoperative diagnosis. The abdominal wall was dissected through two small, vertical midline incisions in the suprafascial plane with the aid of a lighted breast retractor. A complete excision of all palpable lipomas was achieved with this approach. The patient had excellent cosmetic results with minimal postoperative scarring.