A New One-Stage Method for Nose Reconstruction: The Supratrochlear Artery Perforator Propeller Flap

LETTER TO EDITO

Freestyle pedicled perforator flaps: safety, prevention of complications, and management based on 85 consecutive cases.

Background: Despite the widespread use of free perforator flaps, pedicled perforator flaps seem not to be as widely accepted, probably because of the fear of vascular complications caused by transfer of a flap attached only by its vascular pedicle, prone to shearing, kinking, and trauma. In this article, the authors report on their experience with 85 consecutive cases, focusing on incidence, prevention, and management of complications. Methods: Eighty-five consecutive cases were treated over 6 years at the Plastic and Reconstructive Surgery Department of the University of Palermo for defects of different causes that were reconstructed with a freestyle pedicled perforator flap, in every region of the body, including the head and neck (41.2 percent), trunk (20 percent), upper limb (7.1 percent), and lower limb (31.8 percent). The majority of flaps (67.1 percent) were 180-degree propeller perforator flaps. Results: Complete flap survival was observed in 93 percent of cases. Six flaps (7 percent) had vascular complications that were managed with venous supercharging (two cases), derotation (one case), conservative management (two cases), or secondary skin grafting (one case). The authors provide their approach to each situation to prevent or manage complications. Conclusions: The 93 percent success rate in this series seems to be acceptable and demonstrates that these flaps might be safely included in the authors’ routine. If the flaps are appropriately planned and executed, with the suggestions provided in this article, some mistakes can be avoided to make these flaps even safer

Exposed subcutaneous implantable devices: an operative protocol for management and salvage

Implantable venous and electrical devices are prone to exposure and infection. Indications for management are controversial, but-especially if infected-exposed devices are often removed and an additional operation is needed to replace the device, causing a delay in chemotherapy and prolonging healing time. We present our protocol for device salvage, on which limited literature is available

Axial propeller flaps : a proposal for update of the 'Tokyo consensus on propeller flaps'

LETTER TO EDITO

ALGORITHM OF PARTIAL BREAST RECONSTRUCTION WITH PEDICLED PERFORATOR FLAPS

INTRODUCTION: The authors present an algorithm of partial breast reconstruction following quadrantectomy that allows to restore the breast volume defect with the use of pedicled perforator flaps. MATERIAL AND METHODS: Between March 2009 and May 2010, at the Plastic and Reconstructive Institute of University of Palermo, pedicled perforator flaps were used to integrate volume and/or breast skin in 12 patients after benign and malignant breast tumors. The flaps used were based on perforators of the thoraco-dorsal artery (TDAP) and of the intercostal arteries (ICAP). TDAP flaps were used to reconstruct defects in any breast quadrant, while ICAP perforator were used to reconstruct lateral and central inferior pole defects. RESULTS: All flaps survived completely. Breast size, shape and volume were satisfactorily restored. Contralateral breast procedure to adjust symmetry were not necessary. Donor sites scars were well hidden in the inframammary fold or under the brassiere. CONCLUSIONS : Partial breast reconstruction can be performed, in selected patients, with pedicled perforator flaps to restore both volume, shape and skin envelope. Donor site scars are negligible and better with the anterior ICAP because the scar is hidden in the submammary sulcus

Reply: Comparison of preoperative and postoperative lymphatic function is essential to understand the changes in lymphatic function

Reply to a Letter to Edito

Complex reconstructive surgery following removal of extra-intracranial meningiomas, including the use of autologous fibrin glue and a pedicled muscle flap

Background: Skull reconstructive surgery is critical to prevent cerebrospinal fluid (CSF) fistulas and infections, and to ensure good aesthetic results in meningiomas surgery. Methods: A 65-year-old woman was surgically treated for a bilateral parasagittal meningioma with complete superior sagittal sinus (SSS) involvement, and an intra-extracranial extension, determining a significant cranial defect at the vertex. A Simpson I resection was achieved. Postoperatively a considerable and not conservatively repairable CSF leak was detected. Surgical revision of the wound with repair of the fistula and complex reconstructive operation was performed including a combination of techniques and devices such as autologous fibrin glue and reparation of the extracranial planes by an autologous vascularized vastus lateralis pedicled muscle flap. Results: No postoperative complications, infections or new neurological deficits were detected, and the CSF leak definitively ceased after surgery; the aesthetic results were satisfactory. Conclusions: Reparation of CSF fistulas that arise after meningioma surgery can require a complex reconstructive surgery of the superficial layers; when cranioplasty is not feasible or indicated, a meticulous reconstruction of the extracranial soft tissues is possible also by using vascularized autologous distal muscular tissue, with close interdisciplinary cooperation

Advancement Perforator Cheek Flap for Aesthetic One-Stage Reconstruction of Postoncological Extended Split-Thickness Defects of the Nasal Sidewall

Aesthetic reconstruction of soft tissue nasal sidewall loss has an important influence on the appearance of the nose. The unique character of this subunit and the complex relationships with a number of different facial or nasal subunits make the excision of large tumors difficult to manage. Numerous techniques are described in the literature, but a primary reconstruction with a final good result is not often possible. The authors develop an advancement cheek flap for an aesthetic one-stage reconstruction of post- oncological extended nasal sidewall defects. Between January 2009 and July 2012, 16 patients (mean age, 63.3 yr) underwent excision of skin tumors of nasal sidewall and immediate reconstruction with an advancement cheek flap nourished by perforators from the transverse facial branch of the superficial temporal artery. The tumors were excised with 0.4–0.6 cm lateral margins and defects size ranged from 2.6 × 2.6 cm to 3.5 × 5 cm. Oncological radicality was obtained in all cases. The aesthetic results were excellent in all patients. No scar revision was needed. The authors’ advancement cheek flap can be considered the first choice for reconstruction of split-thickness defect of nasal sidewall larger than 2.5 cm because it reestablishes in one stage the nasal contour detail

PEDICLED PERFORATOR FLAPS IN NASAL RECONSTRUCTION: A REVIEW

The use of perforator flaps in face reconstruction is becoming increasingly common. They are particularly useful in nose reconstruction, where they can be tailored to match the complex three-dimensional structure of the nasal concave and convex subunits. In this paper, we present a review of the literature on the use of pedicled perforator flaps in nose reconstruction, discussing current indications and outcomes. Literature on this topic is still limited, with only 12 studies reporting data on 129 reconstructions. Reconstruction of nasal defects with pedicled perforator flaps is a novel and expanding field. It allows for the achievement of good aesthetic results, with a single operation and low donor site morbidity. Temporary venous congestion frequently occurs, but resolves spontaneously without leaving sequelae. Also, perforator flaps have precipitated a novel approach to nose reconstruction, allowing for the modification of both random and axial flaps according to a “perforator-like technique”