• Archives of Plastic Surgery
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• v.49 no.2
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• pp.240-252
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• 2022

Rather than just another "review," this is intended to be an "overview" of the entire subject of the medial sural artery perforator (MSAP) flap as has been presented in the reconstructive literature from its inception in 2001 until the present, with any exceptions not purposefully overlooked. Unfortunately, the pertinent anatomy of the MSAP flap is always anomalous like most other perforator flaps, and perhaps even more variable. No schematic exists to facilitate the identification of a dominant musculocutaneous perforator about which to design the flap, so some adjunctive technology may be highly valuable for this task. However, if a relatively thin free flap is desirable for a small or moderate sized defect that requires a long pedicle with larger caliber vessels, the MSAP flap deserves consideration. Indeed, for many, this has replaced the radial forearm flap such as for partial tongue reconstruction. Most consider the donor site deformity, even if only a conspicuous scar on the calf, to be a contraindication. Yet certainly if used as a local flap for the knee, popliteal fossa, or proximal leg, or as a free flap for the ipsilateral lower extremity where a significant recipient site deformity already exists, can anyone really object that this is not a legitimate indication? As with any perforator flap, advantages and disadvantages exist, which must be carefully perused before a decision to use the MSAP flap is made. Perhaps not a "workhorse" flap for general use throughout the body, the MSAP flap in general may often be a valuable alternative.

• Archives of Craniofacial Surgery
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• v.22 no.4
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• pp.199-203
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• 2021

Primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder is a rare disease characterized by a single mass on the face or upper part of the trunk. It usually presents an asymptomatic and favorable progression, and its histopathologic findings include small and medium-sized lymphoid cells. The authors report a case of primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder on the forehead. A 51-year-old man presented with a protruding mass on his forehead that the patient had noted 1 month previously. Surgical excision and a permanent biopsy were performed under local anesthesia. Based on the biopsy results, the mass was diagnosed as a primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder. There was no evidence of recurrence at a 15-month follow-up visit.

• Archives of Craniofacial Surgery
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• v.22 no.6
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• pp.324-328
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• 2021

Lip defects often occur following wide excision as a surgical treatment for squamous cell carcinoma of the oral cavity. Defects larger than one-half of the lip cannot be closed primarily and require flap surgery. Reconstruction of the oral sphincter function can be achieved by means of a local flap using the like tissue, rather than with a free flap utilizing different tissues. A defect of the lower lip requires reconstruction using different techniques, depending on its size and location. Herein, we present the case of a patient exhibiting a lip defect spanning more than two-thirds of the lower lip, after a wide resection due to squamous cell carcinoma. The defect was reconstructed using an Abbe flap and a staircase flap. Revision was performed after 16 days. The patient's oral competencies were fully restored 3 months postoperatively, and the esthetic results were ideal. Based on our experience, a combination of the Abbe and staircase flaps can produce excellent functional and esthetic outcomes in the reconstruction of a lower lip with a large defect. It can serve as a reliable reconstruction option for defects spanning more than two-thirds of the lower lip, not including the oral commissures.

• Archives of Plastic Surgery
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• v.49 no.6
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• pp.745-749
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• 2022

Background Soft tissue defects of the multiple finger present challenges to reconstruction surgeons. Here, we introduce the use of a lateral arm free flap and syndactylization for the coverage of multiple finger soft tissue defects. Methods This retrospective study was conducted based on reviews of the medical records of 13 patients with multiple soft tissue defects of fingers (n = 33) that underwent temporary syndactylization with a microvascular lateral arm flap for temporary syndactylization from January 2010 to December 2020. Surgical and functional outcomes, times of flap division, complications, and demographic data were analyzed. Results Middle fingers were most frequently affected, followed by ring and index fingers. Mean patient age was 43.58 years. The 13 patients had suffered 10 traumas, 2 thermal burns, and 1 scar contracture. Release of temporary syndactyly was performed 3 to 9 weeks after syndactylization. All flaps survived, but partial necrosis occurred in one patient, who required a local transposition flap after syndactylization release. The mean follow-up was 15.8 months. Conclusion Coverage of multiple finger defects by temporary syndactylization using a free lateral arm flap with subsequent division offers an alternative treatment option.

• Archives of Plastic Surgery
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• v.50 no.2
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• pp.188-193
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• 2023

Vascular injury following traumatic knee injury quoted in the literature ranges from 3.3 to 65%, depending on the magnitude and pattern of the injury. Timely recognition is crucial to ensure the revascularization is done within 6 to 8 hours from the time of injury to avoid significant morbidity, amputation, and medicolegal ramifications. We present a case of an ischemic limb following delayed diagnosis of popliteal artery injury after knee dislocation. Even though we have successfully repaired the popliteal artery, the evolving ischemia over the distal limb poses a reconstruction challenge. Multiple surgical debridement procedures were performed to control the local tissue infection. Free tissue transfer with chimeric latissimus dorsi flap was done to resurface the defect. However, the forefoot became gangrenous despite a free muscle flap transfer. His limb appeared destined for amputation in the vicinity of tissue and recipient vessels, but we chose to use a cross-leg free flap as an option for limb salvage.

• Archives of Plastic Surgery
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• v.50 no.2
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• pp.194-199
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• 2023

Moderate soft-tissue defects need stable coverage, ideally with tissue of similar characteristics and low donor site morbidity. We propose a simple technique for the coverage of moderate skin defects in the limbs. It allows intraoperative transformation of a propeller perforator flap (PPF) into a keystone design perforator flap (KDPF) in cases of unsatisfying perforator vessel or in cases of unpredictable intraoperative events. Between March 2013 and July 2019, nine patients with moderate soft-tissue defects (mean defect size 4.5 × 7.6 cm) in the limbs (two on the upper limbs and seven on the lower limbs) were covered using this technique. We performed four PPFs and five KDPFs. The mean follow-up was 5 months. There was one complication, partial distal tip necrosis in a PPF located in the leg, which healed by secondary intention within 3 weeks. The donor site was closed directly in all cases. No functional impairments were noted regardless of the perforator flap utilized. This technique enables us to employ flexible surgical strategies and allows us to make adjustments based on the patient's vascular anatomy.

• Archives of Plastic Surgery
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• v.51 no.1
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• pp.110-117
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• 2024

Percutaneous first annular pulley (A1 pulley) release, which has been increasingly used to treat trigger fingers, has been widely established as a safe and simple procedure. Multiple studies have reported positive results of percutaneous A1 pulley release. In this study, however, we report cases of patients who developed complications after undergoing percutaneous A1 pulley release at local clinics. A total of six patients visited our hospital for infectious complications after percutaneous A1 pulley release. Various sequelae such as damage to normal structures, insufficient procedure, and tissue necrosis were observed during the exploration. A retrospective study was conducted to identify the cause and trend of the observed complications by instruments (HAKI knife or needle). In the HAKI knife group, there was a tendency for damage to normal structures, while in the needle group, an insufficient release or serious soft tissue necrosis was observed. Based on these cases, our findings confirm the existence and characteristics of infectious complications following the percutaneous A1 pulley release. We further identify that the type of instrument used predicts the nature of complications. Thus, reliable and skilled performance of the procedure by experts is essential for safe treatment.

• Archives of Plastic Surgery
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• v.51 no.2
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• pp.182-186
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• 2024

Kearns-Sayre syndrome (KSS) is a rare mitochondrial disease that affects young adults, due to a deletion of mitochondrial DNA and characterized by the triad: age of onset lower than 20 years, chronic progressive external ophthalmoplegia, and an atypical pigmentary retinopathy. It is also characterized by other endocrine, neurological, and especially cardiac impairment with a very high risk of cardiac complications during surgical procedures under all types of anesthesia. We report a case of KSS revealed by severe bilateral ptosis and confirmed by a muscle biopsy with "ragged red fibers." The ptosis was surgically managed by cautious Frontal suspension under local anesthesia "Frontal nerve block." Through this case, we discuss challenges in the management of KSS patients.

• Archives of Plastic Surgery
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• v.51 no.4
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• pp.417-422
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• 2024

Persistent lymphocele of the groin is a complication of groin surgery that can severely impact the quality of life. The restoration of the interrupted lymphatic pathway is considered by many authors the ideal treatment to prevent a recurrence. However, multiple aspiration procedures and surgical revisions can compromise the availability of local veins needed for a lymphovenular bypass surgery. In addition, surgical debridement of a long-standing lymphocele can generate extensive dead space and contour deformity. A flap delivering additional venules for trans-flap lymphovenular anastomoses (LVAs) can overcome both problems by providing soft tissue and competent veins harvested outside the zone of injury. A successful case of severe groin lymphocele treated with trans-flap LVAs from an abdominal-based flap is presented. The patient was referred to us for a recurrent lymphocele developed in the right groin after lipoma excision that persisted despite multiple surgical attempts. After the identification of patent and draining inguinal lymphatic vessels, a pinch test was used to design a mini-abdominoplasty superficial inferior epigastric artery flap. The superficial veins of the cranial incision were identified and anastomosed to the lymphatic vessels after the pedicled flap harvested and insetted in the groin. The early restoration of lymphatic drainage and the optimal aesthetic outcome supports the combined approach offered by trans-flap LVAs as a valuable therapeutic option for severe and persistent lymphocele.

• Archives of Craniofacial Surgery
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• v.25 no.4
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• pp.192-196
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• 2024

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a rare condition characterized by nodular lesions predominantly in the head and neck region, often causing discomfort or pain. Treatment remains challenging because of its rarity and the lack of established guidelines. This report presents a case of ALHE affecting the earlobes that was successfully managed using ear lobule reduction surgery and subsequent intralesional steroid injections. A 31-year-old woman with a history of recurrent earlobe masses underwent a partial excision to avoid the loss of the earlobe. Histopathological examination confirmed Kimura disease, a variant of ALHE. Subsequent local methylprednisolone injections effectively controlled the remaining lesions, resulting in significant size reduction without notching. Various treatment modalities have been attempted for this condition; however, recurrence rates remain high. Surgical resection combined with intralesional corticosteroid injections is the preferred approach. In this case, a sub-antitragal groove technique for earlobe reduction was employed to preserve the lateral edge of the ear lobule, minimize the risk of deformity, and achieve a predictable outcome. The sub-antitragal groove technique offers an approach to reduce earlobe size without compromising aesthetics. Further research is required to elucidate the pathogenesis of ALHE and establish standardized treatment protocols for this rare condition.